QUEST : A COMPREHENSIVE GUIDE TO UG

Surgery, Orthopedics
& Anesthesiology
MBBS Q. & A. from 2020 - 2008 including regular, supplementary & semester papers

l
r-

I
Dr. Debanjan Kundu MBBS
M.D. Post Graduate Trainee at Dept. of Radiation Oncology,

'
R. G. Kar Medical College and Hospital, Kolkata

Dr. Simantini Sircar MBBS

M.S., Obstetrics and Gynaecology, Kasturba Hospital, Delhi,
Senior Resident, Dept. of Obstetrics and Gynaecology,
CK Birla Hospital, Gurgaon.

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MBBS questions and answers of regular & supplenzentary
CONTENTS
QUEST : A COMPREHENSIVE GUIDE TO UG QUEST: A COMPREHENSIVE GUIDE TO UG

ANATOMY PHYSIOLOGY
SECTION : 1 SURGERY

QUEST : A COMPREHENSIVE GUIDE TO UG 1 SEGMENT- A 1 -100

QUEST : A COMPREHENSIVE GUIDE TO UG
. a t·,ons of Final MBBS 2008-2020 (Paper -1)
Solved Long ues 101-215
BIOCHEMISTRY FORENSIC MEDICINE &
Solved Long
Q
ues
t ·,ons of Final MBBS 2008-2020 (Paper -11)
TOXICOLOGY
2. SEGMENT - B 216 -251
QUEST : A KEY TO UG QUEST : A COMPREHENSIVE GUIDE TO UG Solved Long Questions of Semesters (Paper - I) 252-273
PHARMACOLOGY PATHOLOGY Solved Long Questions of Semesters (Paper - II)

3 SEGMENT-C 274-346
. Solved Short Notes of Final MBBS 2008-2020 (Paper - I) 347-466
QUEST : A COMPREHENSIVE GUIDE TO UG QUEST : A COMPREHENSIVE GUIDE TO UG
Solved Short Notes of Final MBBS 2008-2020 (Paper - II)
MICROBIOLOGY OTORHINOLARYNGOLOGY
(ENT) 4. SEGMENT - D 467- 579
Solved Short Notes of Semesters
QUEST : A COMPREHENSIVE GUIDE TO UG QUEST : A COMPREHENSIVE GUIDE TO UG
5. SEGMENT - E 580 -613
COMMUNITY MEDICINE COMMUNITY MEDICINE Solved Shorts Notes of Investigations
(THEORY) (ORAL & PRACTICAL)
SECTION : 2 ORTHOPEDICS
QUEST : A COMPREHENSIVE GUIDE TO UG QUEST : A COMPREHENSIVE GUIDE TO UG

OPHTHALMOLOGY (EYE) MEDICINE 1. GROUP -1 614 -693

Solved Short Notes of Final MBBS 2008 - 2020

QUEST : A COMPREHENSIVE GUIDE TO UG
SURGERY, ORTHOPAEDICS
& ANESTHESIOLOGY
QUEST : A COMPREHENSIVE GUIDE TO UG
PAEDIATRICS '
2 GROUP-- II s
694-750
QUEST : A COMPREHENSIVE GUIDE TO UG . Solved Short Notes of Semesters of Various College
OBSTETRICS & GYNAECOLOGY
SECTION : 3 ANESTHESIOLOGY
751 - 772
Solved Short Notes
ESSENTIAL MATHEMATICS
FOR POSTGRADUATE MEDICAL
ENTRANCE EXAMINATIONS (PGMEE)

on line available with www.flipkart.com & www.academicpublishers.in

T2
 2011

Q.1 : A 45 yr old female patient presents with acute upper abdominal pain. Discuss the differential diagnosis and
management. - Ans. (See Page No. 33)
SECTION 1 - SURGERY ~ · Enumerate c~use~ of intestinal _obstruction in infants. Write clinic.al featums, irvestigations an~ management of
~ - - · intussuscept1ons 1n 7 yr old child. - Ans. (See Page No. 37) . , \ · ·
SEGMENT A (PAPER - I)
2011 Supplementary
2008
Q.1 : Define shock. What are its different types? Outline the management of a patient presenting with features of
0.1 : Define and classify shock. How will you assess and treat a case of haemorrhagic shock? Mention complications ~ p t i c shock. - Ans. (See Page No. 38)
of blood transfusion. - Ans. (See Page No. 3)
~ : Describe__the clinical features, investigations and management of acute pancreatitis. - Ans. (See Page
_9,2</ Enumerate the causes of bleeding per rectum. Mention how it is diagnosed. Outline the management for .No 38) \"h ., :, 1• .\; • •
j)leed1ng hemorrhoids. - Ans. (See Page No. 7) ,, • ' ...
L,9Z:., Wh~t are the causes of lump i~ R. I. F in a .~al_e pati~nt ?f 40 year old? How do you investigate and manage such
~ / What are the causes of obstructive jaundice? How do you establish the diagn.osis? Di~cuss various options in a patient? - Ans. (See Page No. 38) / )•
· management of choledocholithiasis. - Ans. (See Page No. 10) , .\ J11 Ii · 1
2012

~
~ 2008 Supplementary ,
Classify burn. How will you assess and manage a 35 year old woman weighing 60 kg admitted with 40% burn.
-···
~ What are the types of haemorrhage? What are.the methods of determining acute blood loss? How will you treat
J)aemorrhage? - Ans. (See Page No. 40) f ·,o/,• .
,> - Ans. (See Page No. 13) J.) 1t9,v., ~ , . Middle aged patient presented with a big tense cystic lump in upper abdomen following an att~~,k of acu\e
. . 0.2: Enumerate the causes of upper GI blee,ding. Discuss how a patient with this should be diagnosed and abdomen. How would you investigate and plan the management? - Ans. (See Page No. 42) (' t. 1 ·
managed. - Ans. (See Page No. 13) ) · ·' , ;, · · , Q3: · What are the causes of benign biliary stricture,s? Discu,ss the man<;¼gement of retained stones in common bile
.. QS': · A_40 year old patient has come to emergency with acute pain in right hypochondrium, How will you make a ~ duct. - Ans. (See Page No. 46) • · r t · ' · '
clinical d1agnos1s? Outline the treatment strategy in such a patient.. - Ans. (See Page No. 13). 1
I • _< i j ,~· i .,...... 2012 Supplementary
2009
Q.1: \__,,9A··:/Define shock. Describe the pathophysiology of septic shock. How would you manage a patient suffering from
Define and cl2ssify wounds. Discuss various factors influencing wound healing. Discuss management of
Diabetic foot. - Ans. (See Page No. 13) ,septic shock? - Ans. (See Page No. 47) C,, (rv', . . . ..
'· g2:' How would you proceed to investigate and manage a 50 ye~r _old m_an who presentea with lump ,n left iliac fossa
__92( ~ mid?le aged male patient presents with .a~ epig'.3-stric lurrp. Discuss differential diagnosis. How would you - /·and irregular bowel habit? - Ans. (See Page No. 47) f', ,· •l . l. . .
1nvest1gate? - Ans. (See Page No. 16) f , , · t__.,fa:3: A male patient presented with irreducible inguinal hernia on t~~ right.side of 6 hours duration. How will you
0,3-:/ What are the causes of weeping urr7bilicus\ ,Discuss the pr?blems related to VID and their remedies. - Ans. proceed to manage the patient? - Ans. (See Page No. 47) ~·{'J- ,; /,
(See Page No. 18) · , ,.1 • ·· •.'

2013
2009 Supplementary
Q.1 : Discuss assessment of burn wound. Write in short pathophysiology of burn. How will you treat 30% burn in 50
Q.1 : Classify haemorrhage. How will you determine the amount of blood loss and treat it? - Ans. (See kg body weight female patient. - Ans. (See Page No. 49)
__Page No. 20)
\ ___9,2': , Classify colonic tumours. 1How will y~u rran~ge a 60 yr old man presenting with fresh bleeding per rectum. -
J}.-2: Giye an account of pathogenesis, clir,iical features and management of acute pancreatitis. - Ans. (See Page Ans. (See Page No. 54) ! · ,
/N'o. 20) ,. · · . · : '
~: Define and classify intestinal obstruction. How will xou diagnose and treat small intestinal obstruction. - Ans.
\-9·3: Describe clinical features, diagnosis and management of choledocolithiasis. - Ans. (See P~.~e ~C:>/,1,)J
(See Page No. 20)r\. .' , ·-; . i 2013 Supplementary
2010
~:.---What are the normal values of different body electrolytes? What are the electr_olyte changes in a ~atient of ~ong
Q.1: What are coagulation factors? Write in detail about mechanism of homeostasis. - Ans. (See Page No. 22) standing pyloric stenos is? How do they occur? How do you prepare such a patient before an elective operation?
0 ..2: What are the causes of upper GI bleed? How will you manage acute variceal bleeding? - Ans. (See ,= Ans. (See Page No. 61) ,1
g/ .
P:f'ge No. 23) 1 ·; • ,~,0:2":· What are the causes of lump in right Hif1C fossa? Outline diagnosis and management of append1cular lump. -
0.3: What are the causes oi obstructi,ve jaundit:;e? Write the management of CA head of pancreas. - Ans. (See Ans. (See Page No. 63) ~ ' , ·' L. . ·
Page No. 26) ..• · • · · Q.3 : A 30 yr old lady presented with severe abdominal pain and shock. Discuss differential diagnosis and management.
- Ans. (See Page No. 64)
2010 Supplementary
2014
0.1 : Define claudication. What are the grades of claudication? How will you manage a case of Buergers disease with
.• dry gangrene of foot? - Anz. (See Page No. 29) c,o:<ciassify shock. Discuss the patho - physiology and management of septic shock. - Ans. (See Page No. 66) 0;'.i'/v"
, ~ - Enumerate the differential diagnosis of painiess fresh bleeding per rectum. Plqn the investigation and treatment Q.2: Describe t~ t'\n,i,cal ~~atures, investigations and management of carcinoma of stomach. - Ans. (See Page
of carcinoma of sigmoid colon. - Ans. (See Page No. 29) V • · r • . No.71) ~,r,,, ,.
9.3: How will you evaluate, grad\ and manage a case of blunt splenic trauma? - Ans. (See Page No. 31) '-..0~3 :
A 50 years old patient present~. wit,h bleedi_n9 pe~ rect~m. How w_ill you investigate and manage the patient?
-<-; - Ans. (See Page No. 73) ~< () t -"'·'"- · ''

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 2014 Supplementary
i _ ~ t i o n the causes of nipple discharge~ How w~uou investigate? How will you manage fibrocystic disease of
Q:f: What are the diseases of umbilicus? What are the presentation and treatment of Meck 1, d" rt" 1 ? A · . breast? - Ans. (See Page No. 93) l:.,eieo..i' -

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1
;~~~uN:;s:~s :·~;~:~; ;jmp' in an e1~3y w~~an'? ·O~tlin~ the treatment optionseofsa~:ear::::e:~t: ns.
woman of 50 years. - Ans. (See Page No. 78 ) ~_;:;t-
0

ancer
. fa2: Describe the clinical features of Gastric Outlet Obstruction. How will you investigate and treat a 60 year old
· man presenting with Gastric Outlet Obstruction? - Ans. (See Page No. 93)

L . ~ What are the in_dications of blood transfusion? What are its co~plications? What do you understand by • 2018
blood transfusion? - Ans. (See Page No. 78) C-~~ massive /~
~: A 40 year old man presents with a non-healing ulcer over the lower part of his inferior extremity. What are the
- 2015 causes? How will you investigate the case? What are the surgical considerations of diabetic foot ulcer? (No
~ ~ c r i b e the biological process of wound healing. What are the factors affecting wound healing? Treatme t operative details) - Ans. (See Page No. 93-94)
options for presternal keloid. - Ans._(S~e Page No. 79) C-,-e,y,~ · n Q.2: A 25 years old female, recently married, presents with sudden pain over the right lower abdomen. How will you
\ ~ A 45 ~ears old gentleman ~resen!s with intractable anemia and a painless lump in right iliac fossa of 3 months take up the case to come at a diagnosis? Outline the management of Acute Appendicitis. (No operative details) .
•.....-Ans. (See Page No. 94) l'f·l • · ,.,
duration. How would you investigate the case to confirm}h,e diagnosis? Briefly outline a comprehensive
management of the problem. - Ans. (See Page No. 81) cuy n r , I ), . , L%: Wh 9t are the causes of Intra abdominal lump in the re~ion of epigastrium? Discuss the management of Hydatid
cyst of the liver. - Ans. {See Page No. 95) " ti • , ·,
0.3: A 50 ye~rs old male comes to you with_painless progressive jaundice and on clinical examination the gall
bladder I_s palpable. ~ow will _you InvestIgate the patient to come to a diagnosis? Describe the preoperative
preparations of Jaundiced patients. - Ans. (See Page No. 84) ,: . r ,. .\. · · ~. 2018 Supplementary
:~Define Claudication. What are the grades of Claudication? How will you manage a case of Buerger's disease
2015 Supplementary L,,., with dry gangrene of the foot? - Ans. (See Page No. 95) Ul-e-Y\
\ __,):l:2: Wha~ are t~e common causes of Lower GIT bleeding? Describe in bri,ef ~ow will y~u in~estigate and manage
•--~;::§i~cuss the etio~athogenesis and management of acute pancreatitis. - Ans. ~;ee ~~ge No. 86). · ,a patient with acute lower GIT bleeding. - Ans. (See Page No. 95)kc: 1 ·· - ·
y: LJefme burns. Discuss the management of 40% burns in a 22 years female patient of 50 kg body weight \ 0:3:· Discuss the etiopathogenesis of Chronic Pancreatitis. What are the imaging characteristics of Chronic
... carrying 12 week~ pregnancy. - Ans. (S~e- Page No. 86) \;Sin 8 '
~ Classify ulcers. Discuss the pathology, clinical features, investigations and management of venous ulcer
.--- Pancreatitis? Mention the operation done for Chronic Pancreatitis. ·, • ...;,\ ' i • .1

- Ans. (See Page No. 86) {/\ ·£'.AA ·

2019
~~- 2016 ,0:1:
Define shock. Give the etiological classification of shock. Describe the pathogenesis and the management of
, __y.i: Classify _hemorrhage. Discuss briefly the management of hemorrhagic shock. Mention complications of blood ·· ~eptic shock. - Ans. (See Page No. 95) ·"
/ transfusion. - Ans. (See Page No. 87) 0, 'E'/',1'\. ~ A 45 year old lady, known to be having USG evident cholelithiasis, admitted with the complaints of severe pain
9.2 : A 50 year old man prnsents with ~lternate constipation and diarrhea. He has a lump in left iliac fossa. abdomen radiating to the back, out of proportion to any of the signs present and her laboratory values showed
How would you, invest1Qate, and diagnose the case. Outline the treatment of such case _ Ans (See a significant serum hyperamylasemia (3 times the normal value). How would you proceed to investigate
/Page No. 87) ., .. - · , , · · further, prognosticate and manage (principles only). - Ans. (See Page No. 95) r'• , l ,
t._ )):-3: A 45 y~ar old m~n prese~ted w!th a re?ently d!~covered lump in the epigastrium with rapidly developing 0.3: ·A 54 year old gentleman presents in the OPD with a history of dull, vague epigastric pain with persistently and
ano~ex1a, asthen1a, anemia and IncreasIng vomItIng. How would you investigate to arrive at the diagnosis? steadily progressive yellow discoloration of eyes and urine for last 4 months with intermittent rise of temperature
Outline the management of the case. - Ans. (See Page No. 87) r,. \::, )
~ 'N ,'-v\11- l ,, 1,1 v. 1, · with chills and rigor for last 15 days. He also gives a history of recently developed anorexia and gross weight
I
loss. On examination, his gall bladder is palpable as soft cystic swelling. How would you proceed to have a
2016 Supplementary detailed work-up of the patient, prepare him for general anesthesia for a major operation an.d give the outline of
his treatment (principles only including palliation). - Ans. (See Page No. 95) · , · ·'< 1,1 Lie,
\,)t
' ~ h a t · is gangrene? What ar~ the different types and causes of gangrene? Discuss briefly the management of ..;
. a you~g m~le of 32 years with d~y gangrene on his left great toe? - Ans. (See Page No. 88) C,,-r, . 2019 Supplementary .
0.2. Classify_ salivary tumours. Describe the pathology, clinical features and management of pleomorphi'c~~noma
of parotId gland. - Ans. (See Page No. 89) L 0 o w would you estimate the extent & depth of burns in a flame burn victim? How would you calculate the
~What is triple assessment of breast lump? Discuss how will you manage a patient with early breast cancer _ quantity of fluid with the type of fluid & dose distribution of fluid necessary for resuscitation of a 40 Kg lady with
Ans. (See Page No. 90) Ge,~~ · _40% TBSA (Total Body Surface Area) burn, according to Purkland Formula? - Ans. (See Page No. 95). C,,.., 91V\
Q.2:' A 50 year old gentleman, severely anemic, anorexic & cachectic, presents with the history of epigastric
2017
fullness & vomiting for last 4 months with the appearance of an irregular epigastric lump for last one month. How
D~scribe th~ sign_s, s_ymptoms, prevention and treatment of tetanus. - Ans. (See Page No. 91) c:;$'YI would you proceed to diagnose, prognosticate & manage the patient? - Ans. (See Page No. 96) l , /, 1 '
Di_scuss the I_nvest1gat1ons of a 50 year old_ male prese_nting with obstructive jaundice and palpable gall bladder. Q:3( A 25 year old young lady, married for last 3 months presents at the ER with severe right iliac fossa pain. How
'---·
Give the outhn~ ?f management of \hf patient. How will you prepare liver for operation if needed? - Ans. (See would arrive at a clinical diagnosis? What are the differentials diagnosis? What are the investigations you need
_____ Page No. 93) :. , .·· , ~· . ·. . , to undertake to confirm your diagnosis? - Ans. (See Page No. 96) r,1,.,1 ·
~ Discuss the pathophysiology of aci.;te intestinal obstruction. H. ow will you manage a case of intussusception?
- Ans. (See Page No. 93) '1'\Ai-e.s1'v,oJ (t;,~~1.9t,,.{..-l,.,,> 1-._,\ • December-January 2020

~- 2017 Supplementary
\ _✓w-h~t
·-
are Hospital Acquired Infections (HAI) and Surgical site Infections (SSI)? Define Bacteremia and Systemic
Inflammatory Response Syndrome (SIRS)? How would you prevent infectio:is (broad outline only) - Ans.
,,,.,01: Descri_b? th~ clinical methods of assessing surface area of burns wound. Describe the management of 40% (See Page No. 96) '1\e'I\
burns 1nJury 1n a 60 kg female patient. - Ans. (See Page No. 93)ri · _,Q:2:--- A middle aged gentleman presents with profuse hematemesis following analgesic intake. How will investigate
y•f..O'\V'- and manage this patient? What are the complications of chronic peptic ulcer? - Ans. (See Page No. 98)
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 ~ a c t a t i n g women presents to emergency with painful 1 • h ·
rn~~t
• .
~ l ~ s s i f y renal neoplasms. How will you diagnose and rn3r129e a case of renal cell carcinoma? - Ans. (See

~=-
Write down the clinical examination, investigation and tr~:i~~ br~ast which is associated with fever.
n o 1s patient. - Ans. (See Page No. 99) PageNo.139) LJ.9wfoq,9
B:r,~-r- · 06 2011 Supplementary
- ~ June-July 2020 ·

l,_.-0':1: ~:s:~r Write in details about wound healing and factors affecting wound healing._ Ans. (See Page ~ ~ : ) t~f\~~~a~f;ent of a lady of 35 years presenting with toxic mul!inodular goitre. - Ans. (See Page

0.2: A 60 year old man presenting with palpable lump in ri ht h h · · • ~ O year old m'a~ presents with acute retention of urine. How would you investigate the patient? Outline the
is your diagnosis? Discuss the etiopathogenesis, in~esti~~~no:'~1~r~~~~~~~f:?1scolouration of eye. What management in brief of benign hyperplasia of prostate. -· Ans. (See Page No. 143)
No. 99) 1s case. - Ans. (See Page
0.3: Classify burns How will you manage a c f 30°/c b · 2012
(See Page No: 100) ase o o urns with a short note on post burns sequelae. - Ans.
~ l a s s i f y thyroid neoplasms. Write clinical features, investigations and management of papillary carcinoma of
- ~ e thyroid gland ( A lady of 25 years old). - Ans. (See Page No. 143) 'T1.A.~g.,r·/o
SEGMENT A (PAPER - II) 02: A 40 years old gentleman presented with bilateral knobby renal ,ump in the abdomen. How do you investigate
. 2008 and treat such a patient (operation details not requ;red). - Ans. (See Page No.145)0.91 0 I~~

;~umerate the causes of haematuria. How will ou

- ,.... ~ ~i~gnosed to have carcinoma of urinary bladder/- J~;_r r~~h;a~:g~~s~~~)~~~II
· · · · ·
you do for a patient
2012 Supplementary
~ are the different types of nipple discharges with their clinical importance? How w1':lld you manage Stage-
~ ~iscuss the pathogenesis of multinodular goiter M
manage such a patient? - Ans. (See Page No. 1oar~:; h • •. cf'6.·0
~~?'1cat1ons of such a goiter. How do you I carcinoma breast in a lady aged 40 years? - Ans. (See Page No.147) f>~~
I ·
~ 5 year old man presents to the emergency with acute retention of urine. How would you investigate & manage
,J
U.9-ia~i; .
-
__ 2008 Supplementary the patient? - Ans. (See Page No.147)

(~'"Enumerate the causes of acute retention of uri Wh t h ·

. ('\ ,:),.,,.J,~pertrop~y? How will you manage such a p;f~nt? a_ a:nt/(~~:~~g1c~ changes ass°?iated with prostratic ~ f i n e hydronephrosis. Discuss the causes and management of unilateral hydronephrosis. - Ans. (See Page
.. ~ - Discuss clinical features of pheochromocytoma Ho . ge ~-113) oey- l!Y-P
. _ ~o.148) \)9,oloav..r--
~ manage ii? - Ans. (See Page No. 114 ,--1\\j.S. ~ ~ ~ ~~:~t;~~"n'ore ~h;~ cond1t1on? Wtiat will you do to ,_.,,,.9='2: ~ascribe lymphatic o'rainage of breast. Mention tile risk factors of breast carcinoma. How to manage a 52 year
• r _gld,female patient with locally advanced breast carcinoma? - Ans. (See Page No. 150) Q,, E',f;r
2009 (,J
~ A 50 year old gentleman presented with painless haematuria. What may be the possible causes? How would

-,,___~ 35 year old lady presents with a solitary thyroid nodule in ri h ob you investigate the case? Give an outline of the management. - Ans. (See Page No. 160) '.)3, : i ( ~
. .,.mana~e s~ch a patient? - An~. (See Page No. 114) 11r!.~0 id
How would you come to a diagnosis and 2013 supplementary
- . . ~ Classify kidney tumours. Mention different modes f "" ·
management of such a patient._ Ans. (See Page N~. ~;~elJ~f~;;:'....Adenocarcinoma. Outline the ~ o w do you classify goiter? Give an outline of investigations and management of a solitary nodular goiter.
..,..,.,.-Ans. (See Page No. 168) '1'17'
o!'d
~ 2009 Supplementary Lfo2: Classify renal neoplasms. Write clinical features, investigations and management of renal cell carcinoma in a
~.AO years old male patient. - Ans. (See Page No. 173) U:r,o/ o.f};f,:·
',,...0:< Define hydronephrosis. What are the causes of unilat
".',,-patient with stone in middle third of water. - Ans. (Se:~:g: ;~~;f
Ih d · ·
;)r0Us1s ? p1scuss the management of a
~~ ~f~
~ Discuss the clinical features of phaeochromocytoma. How will you aiagnose this condition? Give an outline of
management. - Ans. (See Page No. 174) ~-'--19' , <;
i~~ ~~tfu.:~~~!.. v
0'.2. A 56 year old lady presents with a lum in
management of such a patient. _ Ans. (see~~~ 1 ngh reast. Discuss briefly the 2014
// 2010 ~ c u s s the clinical features, investigations and treatment of thyrotoxicosis. - Ans. (See Page No. 1n) '11,•"~J'' .~•. ,
•. ·-t{; : ~ Describe the pathophysiology of BHP. Mention the medical and surgical management of BHP. - Ans. (See
What are the functions of thyroid and
~ a t m ~ n t of ~ype_rparat~ymidism. _ p:~:. ;:;:;:~~~
th · · ·
;~~;t~I ~-~~~~ 1~~nical features, investigations and - _yage No. 183) U9'd~
~ Classify testicular tumours. Discuss investigations necessary to plan the treatment for a suspected testicular .
· · ~ : :::~e~~~\~~f~P;;r0s~al swelling. Write in detail about manage,:;,ent of testicular tumour. _ Ans. tumour. What are the treatment options available? - Ans. (See Page No. 188) U:3 ; ' ... 2M
cc- ,.,--,------- 2014 supplementary
r ("'
'-- . ,
2010 Supplementary
\_Jr.f;.
Discuss causes, investigation & management of haematuria. - Ans. (See Page No. 195)U·, .1 "P*·
0.1: Classify thyroid malignancies How ·11 ~2: What are the different types of renal calculi ? Discuss the clinical features & management of renal'cafouli. -
/Page No.123) -rA-1c,,.,: . w1 you manage a case of follicular carcinoma of thyroid? - Ans. (See
_,..A11"s. (See Page No. 195) L/.Ci-, ol 0f)tf''
_1

.
y A 40 year old patien(presents with hae t · E · · ·
and treatment. - Ans. (See Pag'e Nom1a2u4r)1~. h nuterate the d1fferent1al diagnosis, plan the investigations
~ What are the clinical features of prnnary hyper parathyroidism ? Discuss the investigation & managemt of
, v;;tQ.c,;;"y · primary hyperparathyroidism. - Ans. (See Page No. 197) "1"1,_"-t..,.'oH
f

/.,/" 2011 2015 "'

~Q;f : Classify carcinoma of breast H ·11 · · · C ass1fy goiter. How will you investigate and treat a 30 years old man with clinically discrete nodule of 3 cm
- year old lady. - Ans. (See Pa~:~~- ~~~)nvi::;nd manage a case of early carcinoma of breast in a 40
diameter in right lobe of thyroid? - Ans. (See Page No. 197)

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 .,,,,.
1~1assify renal injury. Discuss clinical features and management of patient having injury to left kidney following
~ t h e etiopathogenesis of Multinodular Goiter. Describe its_ management. - Ans. (See Page No. 211)
uni trauma in left loin. - Ans. (See Page No. 197) J J-:o 1/')Jf.l!r-
1

: iscuss the clinical features , complications and managemMif of undescended testis. - Ans. (See Page 0 VDiscuss the etiopathology of acute extradural hematoma. Mention the symptoms and the signs. Outline the
'l
No. 201) v·">1
. ..7 principle of its management. - Ans. (See Page No. 211) ,'1

· 2015 Supplementary 2019

" ~ i b e the pathology, investigations and treatment of differentiated thyroid carcinoma. - Ans. (See Page / , : m e r a t e the causes of anuria. How would you differentiate between prere~al anp renal anuria. Give the
~:~~~~2) ' ~ -agement of calculus anuria. (principles only) - Ans. (See Page No. 211) )}· 0 ~.u: . .
-~ Mention common causes of lump in left upper quadrant of abdomen. Describe the clinical features and manage- . . What are the anatomical and pathophysiologica_l ~hanges that lead to the development oNhe primary varicose
U
,,,ment of renal cell carcinoma. - Ans. (See Page No. 203) fro' '.l f:)4 veins of the lower limbs? How would you test clinically the competence of the valves of the sapheno-femoral,
,Y Mention the sites of narrowing of ureter. Describe the clinical feature\f, complications and treatment of ureteric sapheno-popliteal junctions and the _leg p_erforators? - Ans. (See Page No. 214) .
stones. - Ans. (See Page No. 204) ''J!:r o/ r&4o Give the management of a patient with primary varicose vein with sapheno-femoral 1ncor:ipet_enc~. .
~ Define thyrotoxicosis. Enumerate the grade-wise presentation of t_he eye signs In thyrotox1cosIs. Give the brief
~ 2016 v- · outline of the diagnosis and options of management of Graves Disease. - Ans. (See Page No. 214)
• ~ Enumerate the causes of painless hematuria. Discuss the investigation and treatment in a patient of 65 years
2019 Supplementary
~sented with painless hematuria. - Ans. (See Page No. 205) I, )s· ,,l ~"'
~ Classify thyroid cancer. Discuss the management of FNAC proved folliculAfneo~asm of Right lobe of thyroid , ~~I are the differ_ent types of_ renal calculus? How does a pal/ent 9t renal calculus present? How would you
).rrfi lady of 45 years. - Ans. (See Page No. 205) investigate to confirm d1agnos1s? - Ans. (See Page No. 214) J<r,, Y·;::: . .
_O.Z-:
What are the etiologies of pancreatitis? How will you investigate and treat a case of acute pancreatitis? - Ans. , ~What are the principal symptoms of peripheral arterial occlusive dis~ase? How would you p~oceed to 1nvest1gate
(See Page No. 205) 1...,-T"- · such a case? What are the conservative management you advice in for a lower leg distal smaller vessel
2016 Supplementary · ease? - Ans. (See Page No. 215) (r,--PJ,. .
45 year old lady presents with rapidly developing lump in the upper outer ~uadrant of th~ right breast of the
, Q~cuss the clinical features and management of primary thyrotoxicosis. - Ans. (See Page No. 205) size 4 cm x 5 cm with a palpable, mobile enlarged central group lymph node in the same ax1lla. How would you
~(:;lassify adrena~mou~s. D~scribe the investigation and treatment of adrenal incidentaloma. - Ans. (See confirm your diagnosis? How would you stage & prognosticate? How would you manage? - Ans. (See Page
_,,,,Page No. 205) · ' v\,.1,:::i19 •a-
No. 215) B':l"'eD.?):-·
, ¥:
~w--
Enumerate the cause~of relation of urine in different age groups. How will you investigate a case of relation of

-
urine? How will you treat retention of urine? - Ans. (See Page No. 206) tJj-,J.>
2017

-~Jlisscuss the causes of haemoperitoneum and its management. - Ans. (See Page No. 207)
,
,. .
t0:2: What are the clinicarteatures of renal cell carcinoma ? How will you investigation and treat a case of renal cell
/'
December-January 2020

\ ~Write down the effect of prostatic hypertrophy on urethra and urinary bladder. ~ention the medical and surgical
t atment of benign prostatic hypertrophy. - Ans. (See Page No. 215) , ~"_;_:. . . . .
30 year old lady presents wit~ 3 cm size solitary nodule on right ti:x;oid lobe: Give the d1fferent1al d1agnos1s.
- -~rcinoma? - Ans. (See Page No. 210) IJ~bJ;rg-- How will you manage such patient? - Ans. (See Page No. 215) I_ 11',:j :'r o .c . .
~ : ~I_scuss the clinical features, investigations anamanagement of pheochromocytoma. - Ans. (See Page ~ middle-aged bus conductor presents with non healing ulc~r and pIgmentatIon in left lower leg near medial
No. 210) malleolus. How will you examine, investigate and manage this patient? - Ans. (See Page No. 215) C., e..v'\.
2017 Supplementary
June-July 2020
~ ~ s c u s s the patholo.gy of tumors of. Salivary gland and management of Pleomorphic adenoma. - Ans. (See
/Page No. 210) -,S::;,JJ•10cl'::;:: 8'.~ i . ~ i n e gangrene. Discuss etiopathogenesis, clinical features, investigations and management of gas gangrene.
\.~: 20 year old male presenting with right testipular mass - how will you proceed to investigate and manage this - .Ans. (See Page No. 215) Ci. e"r . . . .
, case? - Ans. (See Page No. 210) UJi o' t;}J,··· ~lassify testicular tumours. How will you manage a 60 year old man presenting with semInoma testis. - Ans.
~ 30 year young adult complaining of colicky pain from right loin to groin with vomiting - how will you investigate (See Page No. 215) ·c'~
and manage this case?. - Ans. (See Page No. 21 0) U9·1 0lo a.~ Q.3: Describe the clinical features ·and management of Thyrotoxicosis. - Ans. (See Page No. 215)
0()
2018 ,
----
0.1<"\~hat are the different forms of Renal calculi? Discuss the clinical presentation and management of a stone in
SEGMENT B (PAPER - I)
the Renal pelvis. - Ans. (See Page No. 210) V9',oia.¥Jr Q.1: Discuss briefly the D/D of right iliac Iossa pain in a young adult male. How will you treat a case of appendicular
, 0:2: What is ANDI to classify benign lesion~e the breast?Oiscuss the management of discharge from the nipple. mass? - Ans. (See Page No. 216) · . . .
~ Ans. (See Page No. 211) t)f,·•r,c,.>;> -- Q.2: Discuss briefly the difforent diagnostic blood fractions commonly used for surgical patients. Discuss the
- ~ : Classify thyroid neoplasms. Discuss the management of solitary thyroid nodule, 3 cm in size of a 30 years old complications of whole blood transfusions in brief. - Ans. (See Page No. 219)
female. - Ans. (See Page No. 211) 0.3: Define ulcer. Describe the clinical exam. Of an ulcer. Write down the treatment of venous ulcer. - Ans. (See
Page No. 222) . . .
2018 Supplementary Q.4: Define and classify intermittent claudication. Describe the pathogenesis of Buerger's disease. How will you
.../ ·
Q. v.· Discuss the presenting symptoms of Benign Hyperplasia of Prostate. How will you manage a 65 year old male
Q.5:
treat a case of Buerger's disease without gangrene? - Ans. (See ~age No. _224) . . .
A 32 yrs old male patient attends the surgery OPD with chief complaints of pain in the r!ght_ calf, while walking,
., patient with acute retention of urine in emergency and subsequently? - Ans. (See Page No. 211)
I )o I for 2 months. He had been a chronic smoker for 1O yrs. On examination, he has reduction In peripheral pulses
\... /!0\1)11/ ..
'-'c (16)
T3 (17)
 2010
in the affected lower limb. What are the D/D? What investigations will you do in this case? What procedures can
be done for improving the lower limb circulation? - Ans. (See Page No. 226) · Hemangioma - Ans. (See Page No. 285)
0.1:
0.6: Define and classify cysts. Discuss the management of a surgically relevant parasitic cystic disease. Write a carotid body tumor - Ans. (See Page No. 286)
0.2:
brief account on pseudocyst of pancreas. - Ans. (See Page No. 231) Branchial sinus - Ans. (See Page No. 287)
0.3:
0.7: A 60 yrs old lady has presented with jaundice, pruritus, pale stools and a palpable mass in the right upper Carcinoid tumor - Ans. (See Page No. 288)
0.4:
quadrant of abdomen. Enumerate the D/D. Which radiological investigations will you recommend? Outline the
operative management of periampullary CA. - Ans. (See Page No. 236) 2010 Supplementary
0.8: Enumerate the endocrine tumors of pancreas. Discuss C/F, investigations and treatment of any 2 of such
Q.1: Melanoma - Ans. (See Page No. 289)
tumors. - Ans. (See Page No. 239)
Q.2: Blood substitutes - Ans. (See Page No. 289)
0.9 : A 45 yrs old man presented with rapidly developing anorexia, asthenia and fatigue with increasing
Q.3: Trophic ulcer - Ans. (See Page No. 289)
vomiting. How would you investigate to confirm the diagnosis? How would you stage and manage the
0.4: Systemic inflammatory response syndrome - Ans. (See Page No. 289)
patient? - Ans. (See Page No. 241) ,
0.10: A 55 yrs old male, chronic alcoholic, complains of severe, agonising, acute abdominal pain persisting for 2011
several hours, radiating to the back and a little relief on stooping. How would you investigate to confirm the
diagnosis, prognosticate and manage? - Ans. (See Page No. 247) 0 _1 : Pre operative preparation of a case of obstructive jau~dice - Ans. (See Page No. 289)
~pigastric hernia - Ans. (See Page No. 290) J ,
0.3: Deep vein thrombosis - Ans. (See Page No. 290)
SEGMENT B (PAPER - 11) 0.4: Active immunisation against tetanus - Ans. (See Page No. 291)

0.1: A 20 yrs old actress has presented with a small goitre involving right lobe and ipsilateral lymphaden- 2011 Supplementary
opathy. How will you establish a diagnosis? Discuss the surgical management and complications. -
Ans. (See Page No. 252) 0.1 : Marjolin's ulcer - Ans. (See Page No. 292)
0.2: A 70 yrs old male patient complains of inability to pass urine for past 8 hrs. How will you differentiate this from 0.2: Preoperative preparation of a patient of Pyloric stenosis - Ans. (See Page No. 292)
anuria? Outline the subsequent management of the case. - Ans. (See Page No. 256) - 0.3 : Blood fractions - Ans. (See Page No. 292)
0.3: What are the common surgical causes of haematuria? Discuss the diagnosis and management of haematuria Q.4: Hyponatremia - Ans. (See Page No. 292)
due to carcinoma of urinary bladder. - Ans. (See Page No. 264) 2012
0.4: A 48 yrs old female presented with a 4 cm lump in Right breast. Discuss the D/D and diagnostic approach to the
condition. - Ans. (See Page No. 267) 0.1 : Post operative pain management - Ans. (See Page No. 294)
Q.2_;..,.-Greating pneumoperitoneum in laparoscopic surgery. - Ans. (See Page No. 294)
~ : __aurst abdomen - Ans. (See Page No. 296)(/\'B,,v\.
SEGMENT C (PAPER -1) ~ Decubitus ulcer - Ans. (See Page No. 296) Vi~-
2008 2012 Supplementary
0.1: Methods of sterilisation - Ans. (See Page No. 274) 0.1 : Lipoma - Ans. (See Page No. 297)
0.2 : Biochemical abnormality in pyloric stenosis - Ans. (See Page No. 275) Q.2: Metabolic acidosis - Ans. (See Page No. 297)
0.3: Universal precaution - Ans. (See Page No. 275) · Q.3: TPN - Ans. (See Page No. 297)
~ · Nipple discharge - Ans. (See Page No. 276) !::) 9-ieo}.:-\- 0.4: Prophylactic antibiotics - Ans. (See Page No. 299)

2008 Supplementary 2013

~broadenoma of breast - Ans. (See Page No. 27~
~ Meckel's diverticulum - Ans. (See Page No. 278) ::.:,.1j(:\')\<,
0.3: Keloid - Ans. (See Page No. 278)
1_.Q:3:.-/Anal Fissure - Ans. (See Page No. 278) , .\
2009
0.1 : Arteriovenous fistula - Ans. (See Page No. 279)
0.2 : Basal cell carcinoma - Ans. (See Page No. 280)
0.3: Pre-operative preparation of a patient of pyloric stenosis - Ans. (See Page No. 282)
0.4: Autotransfusion - Ans. (See Page No. 282)
2009 Supplementary
0.1: Intermittent claudication - Ans. (See Page No. 283)
..~ - OPSI - Ans. (See Page No. 283)'~ (
o,a:-· Oesophageal var ices - Ans. (See Page No. 285) Qc:,;;
&~3it ~ , w ; ~ s and treatment of metabolic acidosis - Ans. (See Page No. 300)
1 ~ e n o u s ulcer - Ans. (See Page No. 301) Lil~--
\ Q.~oumier's gangrene - Ans. (See Page No. 302) v,,SI\/\
~ ~ectal malformations - Ans. (See Page No. 303) cA: ·
~ orticollis - Ans. (See Page No. 304) V• '(;"./\_
2013 Supplementary
~;omplications of splenectomy - Ans. (See Page No. 305)
Q.2: Pilonidal sinus - Ans. (See Page No. 306)
· Q.3 ·_ lntercostal drain - Ans. (See Page No. 307) ·
~ Core needle biopsy - Ans. (See Page No. 309) V'-~~--
2014
'-~Breast biopsy - Ans. (See Page No. 309)
L_9.2": Incarcerated hernia - Ans. (See Page No. 310) \

(19)
(18)

~ ; ; o d substitutes - Ans. (See Page No. 312)
_OA-~·yolvulus neonatorum - Ans. (See Page No. 313) ..
__0,8:"· Amoebic liver abscess - Ans. (See Page No. 314) U" e.9•
2014 Supplementary
0.1 : CT Scan - Ans. (See Page No. 316)
Q.2 ~leomorphic adenoma - Ans. (See Page No. 316)
~ : - ~heochromocytoma - Ans. (See Page No. 316)-,.,.:•:>
.Jl.4:.>Gallstone ileus - Ans. (See Page No. 316) .. : . -:\
..G:S: Femoral hernia - Ans. (See Page No. 316)
2015
Q.1 :_ Ludwig's angina - Ans. (See Page No. 318) . . ,
. ~ : Appendicular Lump - Ans. (See Page No. 318) f Y .
\_~1ypes of anorectal abscess - Ans. (See Page No. 318) , \ ··.-' •·
\~_MODS - Ans. (See Page No. 319) './'$/-/'.
~ Estrogen & Progesterone Receptors - Ans. (See Page No. 321) B.'J,'(,.?>~·-·
2015 Supplementary
i__9•-~··c:Juxoa~enoma - Ans. (See Page No. 322) ~- v e~i·
~ . Branch1al cyst - Ans. (See Page No. 322) U\ •&-".
. 0:-3': __ Compli~ations of splenectomy - Ans. (Sec Pa~e No. 322) 1.
,__...Q-,r. Warth,n s tumor - Ans. (See Page No. 322)1( f ' ~ ' . J -, :#
Q.5: Colostomy - Ans. (See Page No. 323)
2016
....O:r:::Pancreatic pseudocyst - Ans. (See Page No. 324)
_.0:2':· Liver abscess - Ans. (See Page No. 324) r. :·•
1
, pr: Marjolin's ulcer - Ans. (See Page No. 324) 1/'·'f:/',,,\
0.4 : F_emoral hernia - Ans. (See Page No. 324) '· ·
Q,a-< Hydatid cyst of liver - Ans. (See Page No. 324)
2016 Supplementary
· !~Thyroglossal cyst - Ans. (See Page No. 327) <l'vv~.o; ·
' - ~ - Basal cell carcinoma - Ans. (See Page No. 327)u·C½"·.
, ... O:q.~ FNAC - Ans. (See Page No. 327) {.,, BN'--
A:14;_ .. Pelvic abscess - A_ns. (See Page No. 327) (j9wl0::,;;;
- ~ : Closed loop obstruction - Ans. (See Page No. 328) ·. , \
2017
0.1 : _.Alvar~do Score - Ans. (See Page No. 332) ( r. \ . \3fr./
~ - Parot1d abscess - Ans. (See Page No. 332) o1~1
Q~:,.,...Gastnnoma - Ans. (See Page No. 332) ·:•1•1·1 •• ,. / \
\~.Sentinel node biopsy - Ans. (See Page No. 333) 8y::P-!:.:J:-
. · QY," Mesenteric cyst - Ans. (See Page No. 333) ~- .' .
2017 Supplementary
,.,.---- •,
L0ct: Sigmoid volvulus - Ans. (See Page No. 334) \, , ' · , <-
0.2: Tuberculous cervical lymphadenopathy - Ans. (See Page No. 334)
~ Keloid - Ans. (See Page No. 334) u-r-f.r-.
0.4 : ~anula - Ans. (See Page No. 334)
,,__Q.,&-<c;holedochal cyst - Ans. (See Page No. 334)
(20)
2018
\.Q;1{piagnostic peritoneal lavage - Ans. (See Page No. 334) ~ e,·v\
; ! _Q;f:. Colostomy - Ans. (See Page No. 334) ' •• .· '· •.
1 ~-~Molecular su~types of Breast carcinoma - A'!s, (S~ Pag_e No~ 331) Bs,e~--\-
~intussusceptlon - Ans. (See Page No. 334) . 1 ,\ ·.. • • •. • , • • •
..-Er.D: Amebic liver abscess - Ans. (See Page No. 334) ; : •. • , ' ·
2018 Supplementary
\~entinel Node Biopsy - Ans. (See Page No. 335) o~·~p ~_.:;:':-
; ~--surgicalemphysema .::r·•
· ~fleomorphic adenoma - Ans. (See Page No. 335) 0.crs.0J
, ~~.anterior resection of Carcinoma rectum - Ans. (s_ ee Page No. 335)
~Malignant melanoma - Ans. (See Page No. 335) c., '(}'v'l.
2019
.
, · O,Y. . . 9ubphrenic abscess - Ans. (See Page No. 336) ! ·
~/_complications of splenectomy - Ans. (See Page No. 337)
~ - Femoral Hernia - Ans. (See Page No. 338) \: •, ·,
~-1'.denomatous polyps of colon - Ans. (See Page No. 338) ·,
Q.5: Tuberculous Cervical Lymphadenopathy - Ans. (See Page No. 338)
2019 Supplementary
· ~ o e b i c liver abscess - Ans. (See Page No. 338) 1 , '· \
Ans. (See Page No. 338) S p1 ·, YY'-'
,.. .0:t·: Rupture of the Spleen -
~Pseudocyst of the pancreas - Ans. (See Page No. 338) P·~ /
-~-Diagnosis of acute small bowel obstruction - Ans. (See Page No. 338)' ' .· \ .
,0:5: Umbilical Hernia - Ans. (See Page No. 338) ',' ·
. December-January 2019-2020
~arotid fistula. - Ans. (See Page No. 339) )::::h:;J
\__ ..0:2: Cold abscess -
Ans. (See Page No. 339) u,
_0:a;· Volvulus - Ans. (See Page No. 339) ~1 •· \c ~ • · .•
0.4: Idiopathic Thrombocytopenic Purpura (ITP) - Ans. (See Pa~e No. 339)
a&-"- Acute Necrolising Pancreatitis - Ans. (See Page No. 341) r"t• · · r •·.'
_ June-July 2020
'-~;:;wig's Angina - Ans. (See Page No. 343) C) 'r.O!) ,
,I \_...-,0:2:/ Fibroadenoma- Ans. (See Page No. 343) B:=rt:::J'.>Y:1
0.3: Liver abscess - Ans. (See Page No. 343)
0.4: Thyroglossal cyst - Ans. (See Page No. 344)
Keloid- Ans. (See Page No. 344) O·(Y!'-cJ-• t?J
SEGMENT C (PAPER - II)
2008
· 0.1: Venous ulcer - Ans. (See Page No. 347)
0.2 : Epididymal cyst - Ans. (See Page No. 347)
, , 0.3: Tetany - Ans. (See Page No. 347)
0.4 : Thyroglossal cyst - Ans. (See Page No. 348)
0.5 : Dermoid cyst - Ans. (See Page No. 349)
(?1)
 '~Ar.6:/Exomphalos - Ans. (See Page No. 350)
0.7: Sk~n grafting - Ans. (See Page No. 351) '-'
0.8: Spinal anesthesia - Ans. (See Page No. 353)
0,9: Double contrast enema - Ans. (See Page No. 353)
0.1 O : Brachytherapy - Ans. (See Page No. 353)
0.11: De~tal cyst - Ans. (See Page No. 353)
0.12 : Flail chest - Ans. (See Page No. 354)
0.13: Glasgow coma scale - Ans. (See Page No. 355)
0.14 : Therapeutic use of ultrasound - Ans. (See Page No. 356)
0.15 : Patent Ductus Arteriosus - Ans. (See Page No. 356)
2008 Supplementary
0.1 : Carcinoid tumour - Ans. (See Page No. 358)
0.2: Ranula - Ans. (See Page No. 358)
0.3 : Abdomi,nal compartment syndrome - Ans. (See Page No. 358)
0.4 -:/ D~s_mo1d tumour - ~ns. (See Page No. 358)
._.05. Clinical features of H1rschsprung's disease - Ans. (See Page No 358) /
0.6: Cleft hp management in children - Ans. (See Page No 358)
0,7: Tetanus prophylaxis - Ans. (See Page No. 359) · 0.10: Lumbar puncture - Ans. (See Page No. 380)
0.8: Empyema thoracis - Ans. (See Page No. 359)
0.9. Epul1s - Ans. (See Page No. 359)
0.10: Wax bath - Ans. (See Page No. 359)
0.11 : Extradural haematoma - Ans. (See Page No. 359)
0.12 : Raynaud'.s phenomenon - Ans. (See Page No. 359)
0.13. D1~gnost1c use of ultrasound - Ans. (See Page No. 360)
0.14 : Axial flap - Ans. (See Page No. 360)
0.15: Care of a paraplegic patient - Ans. (See Page No. 361)
2009
0.1 : Salivary calculi - Ans. (See Page No. 361)
0.2: _Fournier's gangrene - Ans. (See Page No. 362)
- ~ Breast.ab~cess - Ans. (See Page No. 362) ~p~d
0.4: Compl1cat1ons of undescended testis - Ans. (See Page No. 363)
0.5 .. MEN Syndrome - Ans. (See Page No. 364)
9'6: Anorectal malformations - Ans. (See Page No. 365)
0.7: Extr~dural hematoma - Ans. (See Page No. 365)
0.8: Cardiopulmonary Resuscitation - Ans. (See Page No. 367)
0.9. MRI - Ans. (See Page No. 367)
0.10: Complications of radiotherapy - Ans. (See Page No. 367)
0.11: Fat embolism - Ans. (See Page No. 368)
0.12: Odontomes - Ans. (See Page No. 369)
0.13 : Shor~ wave diathermy - Ans. (See Page No. 370)
0.14: Tension pneumothorax - Ans. (See Page No. 370)
0.15 : Hypokalaemia - Ans. (See Page No. 371)
2009 Supplementary
0.1: Hypospadius - Ans. (See Page No. 372)
0.2: Marjolin's ulcer - Ans. (See Page No. 372)
0.3: Collar stud abscess - Ans. (See Page No. 372)
0.4: Venous ulcer - Ans. (See Page No. 372)
0.5: Cleft p~lat~ - Ans. (See Page No. 372)
Q.6: Co~pllcat1ons of radiotherapy - Ans. (See Page No. 372)
0.7: Regional anaesthesia - Ans. (See Page No. 372)
0.8: Empyema thoracis - Ans. (See Page No. 372)
(22)
~mmography - Ans. (See Page No. 373) (::;~-(>-9<'..-T
0' 10: Nerve injury - Ans. (See Page No. 373)
:·;; YManagement of Hirschsprung's disease - Ans. (See Page No. 373)
~ ; T;rget FNAC - Ans. (See Page No. 373)
0 ' 13: Ultrasonic therapy - Ans. (See Page No. 373)
a: 14: Adamantinoma - Ans. (See Page No. 373)
~olitary thyroid nodule - Ans. (See Page No. 373)
2010
0.1: Ectopic vesicae - Ans. (See Page No. 373)
0.2: Neurofibromatosis - Ans. (See Page No. 375)
~ g e t ' s disease of nipple - Ans. (See Page No. 3?6) ,L).91'€8~
~ Fistula in ano - Ans. (See Page No. 376) (,>· ,Ji , ·, , . •. .
0.5: Varicocele - Ans. (See Page No. 377)
0.6: Subdural hematoma - Ans. (See Page No. 378)
0.7: Muscle relaxants - Ans. (See Page No. 379)
O.8: 1131 scan - Ans. (See Page No. 379)
~ongenital hypertrophic pyloric stenosis - Ans. (See Page No. 379).' .\ · \
· ·
O.11 : Ludwig's angina - Ans. (See Page No. 380)
O.12: Meningomyelocele - Ans. (See Page No. 381)
Q.13: Empyema thoracis - Ans. (See Page No. 381)
Q.14: Patent Ductus Arteriosus - Ans. (See Page No. 381)
O.15: Referred pain - Ans. (See Page No. 383)
201 0 Supplementary
O.1: Mixed salivary tumour - Ans. (See Page No. 384)
~econium ileus - Ans. (See Page No. 384) .•\ '• ·
O.3: Post burn contracture - Ans. (See Page No. 384)
0.4: FAST - Ans. (See Page No. 384)
0.5: Tension pneumothorax - Ans. (See Page No. 384)
0.6: Epulis - Ans. (See Page No. 384)
0.7: Glasgow coma scale - Ans. (See Page No. 384)
0.8: Gas gangrene - Ans. (See Page No. 384)
0.9 :~!ravenous anaesthetics - Ans. (See Page No. 385)
I...Q:1'(): Primary hyperparathyroidism - Ans. (See Page No. 385) ':'/".,,1:?·
,_Q,:11: Hypersplenism - Ans. (See Page No. 386) :S,(r:,·O,'"' '--'
0.12: Hydrocephalus - Ans. (See Page No. 387)
\ ..~entinel lymph node biopsy - Ans. (See Page No. 388) ~~1·
0.14: Hospice - Ans. (See Page No. 389)
0.15: Differential diagnosis of intracranial space occupying lesions - Ans. (See Page No. 389)
2011
0.1: Flail chest - Ans. (See Page No. 392)
0.2: £,ost - operative pyrexia - Ans. (See Page No. 392)
~ Brain death - Ans. (See Page No. 394) Nev"'r• 0
0.4: Split thickness skin graft - Ans. (See Page No. 394)
. ~-~,Spinal anesthesia - Ans. (See Page No. 394)
. ~ : Omphalocele - Ans. (See Page No. 394) ri
~ Retrosternal goitre - Ans. (See Page No. 394) "t"tj9"'0
0.8 :. Parotid abscess - Ans. (See Page No. 395)
~ Alvarado score of acute pancreatitis - Ans. (See Page No. 396)
9,10: TURP - Ans. (See Page No. 397) '
(23)
 · .Q.11: Oxalate stone - Ans. (See Page No. 397) !)
Q.12 : Wax bath - Ans. (See Page No. 398)
Q.13 : Epulis - Ans. (See Page No. 399)
Q.14: MRI scan in surgery - Ans. (See Page No. 401)
Q.15 : Radiation dermatitis - Ans. (See Page No. 401)
Q.16: Spinal anesthesia - Ans. (See Page No. 401)
2011 Supplementary
~ - Paraphimosis - Ans. (See Page No. 401) .o
Q.2 : .Parotid fistula - Ans. (See Page No. 401)
' - ~ Hypospadius - Ans. (See Page No. 401) U1·
7 ",,)t) ...
Q.4: Local anaesthesia - Ans. (See Page No. 402)
y-:' Oschner - Sherren regimen - Ans. (See Page No. 402) ',. ·
cc·
Q.6 : Stove-in-chest - Ans. (See Page No. 402)
Q.7: Hydrocephalus - Ans. (See Page No. 402)
Q.8: Ulnar nerve injury - Ans. (See Page No. 402)
Q.9: Bedsore - Ans. (See Page No. 404)
~ o o d y discharge per nipple - Ans. (See Page No. 404) f,3.'rc.:~\·
,~Hydronephrosis - Ans. (See Page No. 405)!)9, 0
Q.12 : Adamantinoma - Ans. (See Page No. 405)
Q.13 :JlJachytherapy - Ans. (See Page No. 405)
J).-M: USG for hepatobiliary diseases - Ans. (See Page No. 405)
Q.15 : Cervical traction - Ans. (See Page No. 405)
2012
\ ~ a s t biopsies - Ans. (See Page No. 406)
~ Causes of hematuria - Ans. (See Page No. 406) ·
•.::,_,e:j: ... Antegrade pyelography - Ans. (See Page No. 406)
....-0:-tr: Stress gastritis - Ans. (See Page No. 406) <. ' ' '
• ~ P.S.A - Ans. (See Page No. 406) 1
0~ 6 ,
• ~ : . Parap_himosis - Ans. (See Page No. 408) l/9 · yi4
o
Jr.7: Lucid interval - Ans. (See Page No. 408) IJ1'f!/V' '--✓
Q.8 : Chest drain - Ans. (See Page No. 408)
\_9,.8-'.'Jorsion of testi_s - Ans. (See Page No. 408)
\____p,-tO: Tissue expansion - Ans. (See Page No. 409)
Q.11: Anesthetic monitoring devices - Ans. (See Page No. 410)
Q.12: Radiotherapy in treatment of '::,A breast - Ans. (See Page No. 410).B'.\<?9
Q.13 : Ameloblastoma - Ans. (See Page No. 411)
Q.14: Transluminal USG - Ans. (See Page No. 412)
Q.15: Short wave diathermy - Ans. (See Page No. 412)
2012 Supplementary
Q.1 : Extradural haemorrhage - Ans. (See Page No. 412)
Q.2: DVT - Ans.(See Page No. 412)
Q.3: Epididymal cyst - Ans. (See Page No. 41,2)
1 ~ ESWL - Ans. (See Page No. 412) :)_">;o ~!;']" , 0.2: Patient ductus arteriosus - Ans. (See Pag'1 No. 431)
\,..-0:5~ Causes of haematuria - Ans. (See Page No.4Y2) \)'Ju?'
Q.6: Dentigerous cyst - Ans. (See Page No. 412)
Q.7: Epidural anaesthesia - Ans. (See Page No. 413)
~-~A3rachytherapy - Ans. (See Page No. 413)
~ : _Nephroblastoma - Ans. (See Page No. 413)
_.Q:10: Bladder changes in BHP - Ans. (See Page No. 413) .,,
,_9,.1-t,·::Yariants of melanoma - Ans. (See Page No. 414) 'i r ·
_a-ti: CABG - Ans. (See Page No. 415) '!\,. 0 i:,· o y
(24)
0 _13: small bowel enema - Ans.(SeePageNo.4~. . .
\.Q,1,-4:Tracheostomy - Ans. (See Page No. 416) 1 .,r '.) ~ 0
0 _15: Frozen shoulder- physiotherapy - Ans. (See Page No. 416)
2013
Q.1 : Cleft lip - Ans. (See Page No. 417)
Q.2: Thyroglossal cyst - Ans. (See Page No. 419)
Q.3: Spinal anesthesia - Ans. (See Page No. 419)
Q.4: Types of skin graft - Ans. (See Page No. 419) .
~ Role of ERCP in obstructive jaundice - Ans. (See Page No. 419) h
Q.6: Oral submucous fibrosis - Ans. (See Page No. 419)
0.7: Wax bath - Ans. (See Page No. 420)
a.a : j,ubdural hematoma - Ans. (See Page No. 42. 0)
~ lntussusception - Ans. (See Page No. 420) . 1. · .: \
a:
10: Marjolin's ulcer - Ans. (See Page No. 421)
2013 Supplementary
.~p~~terior urethral valve - Ans. (See Page No. 421)
~_lj_lJtchinson's pupil - Ans. (See Page No. 422)
~ Empyema thoracis - Ans. (See Page No. 422)
Q.4: PCNL - Ans. (See Page No. 422) .
~J,Ypes of renal stone - Ans. (See Page No. 422) 1)910' t'>(yc'
-QK Causes of scrotal swelling - Ans. (See Page No. 424)~er,.o I"·
~ressure sore - Ans. (See Page No. 424) C, 0',/\_
~ Hypospadius - Ans. (See Page No. 425) \)91.0\
Q.9: Keloid - Ans. (See Page No. 426) 1
'c:o
Q.10: Tension pneumothorax - Ans. (See Page No. 427)
2014
~ a g e t ' s disease of nipple - Ans. (See Page No. 427) 69-'·ee>.i\
~ l e c t r i c burns - Ans. (See Page No. 427)0, fYV'·
Q.3: Dentigerous cyst - Ans. (See Page No. 428)
\YC Lucid interval - Ans. (See Page No. 429) 0,()lv',._
~j;istula in ano - Ans. (See Page No. 429) Vrn\ · ·
~ Penile carcinoma - Ans. (See Page No. 429) U9'10 !oJz-
0.7: Muscle relaxant - Ans. (See Page No. 430)
a.a: Flail chest - Ans. (See Page No. 430)
0.9: __Epidural anesthesia - Ans. (See Page No. 430)
\9-1'(1: Compartment syndrome - Ans. (See Page No. 430) V'"0/A..
2014 Supplementary
0.1 : Parotid abscess - Ans. (See Page No. 431)
~=-.chordee - Ans. (See Page No. 431) \.k 0
.o 102 v,
~ Chronic subdural haematoma - Ans. (See PageNo. 431) 'l o
0.5 : _Jlentigerous cyst - Ans. (See Page No. 431)
. \j),8":" Venous ulcer - Ans. (See Page No. 431) Crei,, ..
0.7: Transluminal USG - Ans. (See Page No. 431)
0.8: Local anaesthesia in inguinal hernia surgery - Ans. (See Page No. 431)
~ - ~adioactive iodine - Ans. (See Page No. 432) "T'~ 4 ·
~QUART - Ans. (See Page No. 433) b_o/\roi°\'-
T4 (25)
 2015
~ Breast abscess - Ans. (See Page No. 434)
~ : Meconium ileus - Ans. (See Page No. 434) . }
~,_Basal cell carcinoma - Ans. (See Page No. 434)
~ J?remalignant conditions of penile carcinoma - Ans. (See Page No. 434)
~ - Acute pancreatitis - Ans. (See Page No. 436) , ·· \ ,
\_Q&; Glasgow Coma Scale - Ans. (See Page No. 438) ~·
0. 7 : Badiofrequency ablation of tumors - Ans. (See Page No. 438)
· ~ension pneumothorax - Ans. (See Page No. 440) (JI.,-, ·A?'f'ci>
0.9: Epulis - Ans. (See Page No. 440)
0.10: Complications of spinal anesthesia - Ans. (See Page No. 440)
2015 Supplementary
\_,Ot':-Testicular torsion - Ans. (See Page No. 440) U.CJ1c!opv ..
___.0..-2-';-E:xtradural hematoma - Ans. (See Page No. 440) 'i ·
0.3 : Flail chest - Ans. (See Page No. 440)
h»
· ~-Ameloblastoma - Ans. (See Page No. 440) c)}•p~
~ · §ubmandibular sialolithiasis - Ans. (See Page No. 440) ,)s,·,~)
.~Pyloric stenosis in infant - Ans. (S::_e Page No. 441) J-,/ \ c,;: ·
__Q.-r.· PDA - Ans. (See Page No. 441) ", c":>·•o-
. ~ W a x bath - Ans. (See Page No. 441) rt}'/
0.9: Telecobalt therapy - Ans. (See Page No. 441)
2016
0.1 : _ Epidural anesthesia - Ans. (See Page No. 441) ~.
• ___,ef: ,Venous ulcer of lower leg - Ans. (See Page No. 441) U()N-.~..
J).-a-:" Spina bifida - Ans. (See Page No. 441) ·f l (/
·_~MEN syndrome - Ans. (See Page No. 441) f':1•Ne;• · L,0:-!f: Triage ()- (}v\.
\ ...,0,.-8-:' Principle of skin grafting - Ans. (See Page No. 4l1}.<P•(o/v-. ·
,__J}:6:· Post burn contracture - Ans. (See Page No. 441) '/". ~
__.SY.r. Hydrocephalus - Ans. (See Page No. 441_) f-k,.1/ ,'J
~Hamartoma - Ans. (See Page No. 441) 0\'(:Jv,_
0.9.>lonising radiation - Ans. (See Page No. 442)
.filO: Bleeding from gum - Ans. (See Page No. 443) O'f'.a.},
2016 Supplementary
0.1 ~ PET Scan - Ans. (See Page No. 444)
,..Q-:2'": Undescended testis - Ans. (See Page No. 444)
. __.er.£ Intermittent claudication - Ans. (See Page No. 444)
0.4: Brachytherapy - Ans. (See Page No. 444)
0.5: Dental cyst - Ans. (See Page No. 444)
\ ~ Fournier's gangrene - Ans. (See Page No. 444) !N{)/'--1',
0.7: __Begional anaesthesia - Ans. (See Page No. 444)
~~hest drain after chest injury - Ans. (See Page No. 444) <l
t___.,Q:9"': ___Different types of nerve injuries - Ans. (See Page No. 444) C,.,. '0'-"---
....o.-ffi: Pre-malignant condition of oral cavity - Ans. (See Page No. 444) t ) ~
2017
/''
. Q'(.. Subdural haemorrhage ~ Ans. (See Page No. 446) f
\ ~ PCNL - Ans. (See Page No. 446) "'}''
0.3: Complications of spinal anaesthesia - Ans. (SE!e Page No. 446)
· ~ D V T - Ans. (See Page No. 446) C, o,,,,..
0.5: Ludwig's angina - Ans. (See Page No. 446)
(26)
~~transfusion - Ans. (See Page No. 446) (,,, >:Y,,... ,
uir:::J>ulmonary embolism - Ans. (See Page No. 446) ··
~ -~yocutaneous flap - Ans. (See Page No. 448) v-,y;;r0.
;-~~I - Ans. (See Page No. 449) 0, -e,1/\..
1 ~ongue ulcers - Ans. (See Page No. 450) C)91...01J
2017 Supplementary
~ g l o s s a l cyst - Ans. (See Page No. 450) "'00-f'r
Q.2: MRCP - Ans. (See Page No. 451) U
Q.3: Complications of Radiotherapy - Ans. (See Pc1ge No. 451)
~ lmperforate anus - Ans. (See Page No. 451) J,; c \ · · . --~-
l.,.Q:S': Flail chest - Ans. (See Page No. 451) '1\... _o3· :,-
~lasgow coma scale - Ans. (See Page No. 451) ~,
~ !VU - Ans. (See Page No. 451) \).9 LD / '.J ~e:--
~Marjolin's ~leer - Ans. (See Page No. 451_) ';:I;; ,p,•v\.
~ypospad1as - Ans. (See Page No. 451) \)&--0: '>"'/r
~ngrowing toe nail - Ans. (See Page No. 451) &-~
2018
~ ; i d interval - Ans. (See Page No. 451)
~_;fbyroid storm - Ans. (See Page No. 451) ~,~,)
~ ~~nu/a - Ans. (See Page No. 452)0 -e,<,-,. CJ
0.4 : ERCP - Ans. (See Page No. 452)
,~esticular torsion - Ans. (See Page N_o; 452)
~ ~SA - Ans. (See Page No. 452) U.s-,o: c,q \.A _
0.7: Brachytherapy - Ans. (See Page No. 45~
0.8 :_,,J3i?markers
0.10: Regional anesthesia - Ans. (See Page No. 452)
2018 Supplementary
~~ssification of nerve injury - Ans. (See Page No. 452) {A'{?/./\_
~anagement of pneumothorax '!¼o9-v> x-
1._,.Q:3: Criteria of brain death - Ans. (See Page No. 452) V°'J~?J, 'T 0
~ y p e s of skin grafting - Ans. (See Page No. 452) 0, e,'V'--
~ Chemotherapy of testicular cancer - Ans. (See Page No. 452)
0.6: Use of LASERs in surgery
0. 7: Cleft lip - Ans. (See Page No. 452)
~lasgow coma scale - Ans. (See Page No. 452) 1:Je--<,,_9.-
~f=>reoperaiive assessment of pulmonary function "f'\.,.,,o.:r "'"·
\jMO:Dentigerous cyst - Ans. (See Page No. 452) •eM v,,
2019
0.1 : Magnetic resonance cholangio-pancreatography (MRCP) - Ans. (See Page No. 453)
0.2: Epidural Anesthesia - Ans. (See Page No. 453)
~-~_Split-thickness skin graft- Ans. (See Page No. 453)
~ : Choledochal Cyst - Ans. (See Page No. 453) L.
· , ~ .. Gomplications of external beam radiation therapy - Ans. (See Page No. 453)
'-'"Q.t> : OM
Epulis - Ans. (See Page No. 455)
, Q. 7: _l,!ltrasound wave therapy - Ans. (See Page No. 455)
~ F l a i l chest with paradoxical respiration- Ans. (See Page No. 455) '>'\.,~9•,>".
. ~•. Secondary brain injury - Ans. (See Page No. 455) N,:s,.,•7·,.o.'.:>9- ·
l.,.)df. 1u : Diabetic foot - Ans. (See Page No. 457)
(27)
 2019 Supplementary
Q, 1 : Endoscopic Retrograde Cholangiopancreatography (ERCP) - Ans. (See Page No. 457) 0 ,16: Trea~ment of urinary bladder tumor - Ans. (See Page No. 478)
Q.2 : Spinal Anaesthesia - Ans. (See Page No. 457) a.17 : carcinoma of tongue - Ans. {See Page No. 481)
~ u l l thickne_ss skin _graft - Ans. (See Page No. 457) ·:; o/if\&--...::iJ 0,18: Massive blood transfusion - Ans. {See Page No. 483)
\ ..9-Ar. Hypertr?ph1c pylo~1c stenosis of infancy- Ans. (See Page No. 457}":- : \ ., Q. 19: Blood fractions - Ans. ~See Page No. 484)
0.5 : Neo-adJuvant Radiotherapy - Ans. (See Page No. 457) Q.20: causes of buttock swelhng - Ans. {See Page No. 484)
[__J).&-;Tiental Cyst - Ans. (See Page No. 459) ('_)7 , 7 J Q.21: Frost-bite - Ans. {See Page No. 485)
· ____o..:r.-___.PosHraumatic pneumothorax - Ans. (See Page No. 459) ""'!1-..og-, o, x Q.22: Tendon transfer - Ans. (See Page No. 486)
,.___o..8': lntercostal chest tube drainage - Ans. (See Page No. 459) 7'.r ,<i, ,::- .. Q.23: Ubiquitous tumor or Universal tumor or Lipoma - Ans. (See Page No. 486)
0.9: ~xtradural hemorrhage - Ans. (See Page No. 459) Q.24: lnvertogram - Ans. (See Page No. 487) ·
'-..0:-ta:Venous ulcer - Ans. (See Page No. 459) D-\·<Yv\ Q.25: Barrett's esophagus - Ans. (See Page No. 488)
Q.26: Tenesmus - Ans. (See Page No. 488)
Q.27: ANDI - Ans. (See Page No. 489)
_.,,.- .. December-January 2019-2020
Q.28: Volume overload - Ans. (See Page No. 490)
\...Q;1:' Branchial fistula - Ans. (See Page No. 459) ,--·: \, 0; · o :,., Q.29: Qsteogenesis imperfecta - Ans. (See Page No. 491)
~ Regional Anesthesia_- Ans. {See Page No. 460) f'•v~J •~.~ ,' "'- Q.30 : 1opercent tumor - Ans. {See Page No. 492)
0.3: Endotracheal Intubation - Ans. {See Page No. 460) Q.31: Whipple's triad - Ans. (See Page No. 494)
QA:-· Undescended Testis - Ans. (See Page No. 460) U5-t.,0 i ""' v1 . Q.32 : Post operative pulmonary complications - Ans. (See Page No. 495)
0.5: __ Complications of Chemotherapy- Ans. (See Page No. 460)6 0.33 : Complications of blood transfusion - Ans. (See Page No. 495)
_,.0:6; IVU - Ans. {See Page No. 462) U.5-1..0 ~ ?'J'J • QJM : Mismatched blood transfusion-Management - Ans. (See Page No. 496)
0.7: Lucid interval- Ans. (See Page No. 462) ~- c; Q.S5 : Myopectineal orifice - Ans. (See Page No. 497)
l_,0:8:_.P.left Palate - Ans. (See Page No. 463) 0) 1.e>-.) Q.36 : laometric exercise - Ans. (See Page No. 498)
_o..e:-___. Warthin's tumour - Ans. (See Page No. 463) Q.37 : Saphena varix - Ans. (See Page No. 498)
,__.,,0:1"0: Varicocele - Ans. (See Page No. 463) -~·oJ Q.38 : Blood component therapy - Ans. (See Page No. 499)
Q.39: Treatment of hypercalcemic crisis In a patient of hypothyroidism - Ans. (See Page No. 499)
June-July 2020 0.40: Hirschprung'1 disease - Ans. (See Page No. 499)
Q.41: Neurogenic bladder - An1. (See Page No. 501)
- ~ Epidural Anaesthesia - Ans. (See Page No. 463) IF..f' !).}~}t-•.G-'.l, e;,..,_. Q.42 : Choledochal cyst - Ane. (See Page No. 501)
0.2: lmperforate Anus - Ans. (See Page No. 463) Q.43 : Mucocele of gall bladder - Ans. (See Page No. 502)
~Breast abscess - Ans. (See Page No. 4 6 3 ) ~ Q.44 : Cholesterosis - An1. {See Page No. 503)
~ Ba~al C~!I Carcinoma - Ans. (See Page No. 463). o, -e,.'I' 'f'.9u.>J Q.45 : Meckel'• diverticulum - Ans. {See Page No. 503)
i...-,-1«--': Sp1na_B1f1da - Ans. (See Page No. 463) N'::'1A..9-,9_s•, 'h-0\'E'!>v.f\ Q.48 : Preparation fot large bowel surgery - Ans. (See Page No. 505)
0.6: Bleeding from gum - Ans. (See Page No. 463) 0 Cf 0.47 : Familial adenomatous polyposis - Ans. (See Page No. 505)
, . J:Y.I: Hydrocephalus - Ans. (See Page No. 463) N:':?J..-\9Q'C:,v.9•,:>.'-QJ-;_...\ 0.48 : Fibroadenoma - An1. (See Page No. 506)
0.8: Glasgow Coma Scale - Ans. (See Page No. 463) -..:...) ........:1 0.49: Phyllode's tumor - An1. (See Page No. 507)
0.9: . P.E.T. Scan - Ans. (See Page No. 463) Q,50: Stages of CA breast - Ans. (See Page No. 508)
- ~ Cleft Lip - Ans. (See Page No. 463) C810') Q.51: Etiologic factors in the development of breast carcinoma - Ans. (See Page No. 509)
Q.62: Adjuvant chemotherapy in breast carcinoma - Ans. (See Page No. 510)
SEGMENT D Q.53: Inflammatory carcinoma - Ans. (See Page No. 511)
0.1: Q.54 : Gynecomaatla - Ans. (see Page No. 512)
Paradoxi~ aciduria/Metabolic changes following gastric outlet obstruction - Ans. (See Page No. 487) Q.55: Medullary carcinoma of thyroid - Ans. (See Page No. 514)
0.2: Euthanasia - Ans. {See Page No. 467)
0.3: 0.56: Hashimoto's thyroiditis - Ans. (See Page No. 515)
Bezoar - Ans. (See Page No. 467) Q.57: Prevention and treatment of simple goiter - Ans. {See Page No. 516)
0.4: Wound debridement - Ans. (See Page No. 467) Q.58: Preoperative preparation in Grave's disease - Ans. (See Page No. 518)
0.5: Virchow's node - Ans. {See Page No. 468)
0.6: 059 : Complications of total thyroidectomy - Ans. (See Page No. 519)
Cystic hygroma - Ans. (See Page No. 468) 0.60 : Metabolic and neuromuscular manifestations in Grave's disease - Ans. (See Page No. 520)
0.7: Pharyngeal pouch - Ans. (See Page No. 469)
0.8: 0.61: Gallstone ileus - Ans. (See Page No. 521)
Catheterisation - Ans. (See Page No. 470) 0.62 : Laparoscopic cholecystectomy - Ans. (See Page No. 521)
0.9: Surgical drains - Ans. (See Page No. 471)
Q.10: 0.63 : Hiatus hernia - Ans. (See Page No. 522)
Preparation of jaundice patient for surgery - Ans. (See Page No. 472) 0.64 : Cavernous hemangioma - Ans. (See Page No. 523)
Q.11: Laryngocele - Ans. (See Page No. 472) 0.65 : Acute appendicular lump - Ans. (See Page No. 523)
Q.12: Chordee - Ans. (See Page No. 473)
Q.13: 0.66 : Pseudocyst of pancreas - Ans. {See Page No. 524)
Thoracic outlet syndrome - Ans. (See Page No. 474) 0.67: Abdominal compartment syndrome - Ans. (See Page No. 525)
Q.14: Cervical rib - Ans. {See Page No. 475)
Q.15: 0.68 : Ranula - Ans. (See Page No. 526)
Cleft palate - Ans. {See Page No. 477) 0.69 : Tourniquet - Ans. {See Page No. 527)
0.70: Blood transfusion - Ans. (See Page No. 528)
(28)

(29)
Q.71: Melanoma - Ans. (See Page No. 529) . Barium follow through X~Ray - Ans. (See Page No. 583)
Q.72 : Radiological features of various causes of intestinal obstruction - Ans. (See Page No. 531) o. 5 : Barium enema X-Ray - Ans. (See Page No. 584)
Q.73: lmperforate Anus - Ans. (See Page No. 532) o. 7 · ouble contrast barium enema - Ans; (See Page No. 585)
Q.74: Spread of carcinoma - Ans. (See Page No. 532) MRCP _ Ans. (See Page No. 586) L, 'IQ},
Q.75: Squamous cell carcinoma - Ans. (See Page No. 533) 1
10 : ERCP - Ans. (See Page No. 586)
Q.76 : Rhinophyma - Ans. (See Page No. 535) 0 ·1 : MRI - Ans. (See Page No. 587)
Q.77: Web space infection - Ans. (See Page No. 535)
Q.78: Paronychia - Ans. (See Page No. 536)
g· 1
12 : Therapeutic ultrasound - Ans. (See Page No. 589)
0 ·13 . CT Scan _ Ans. (See Page No. 590)
Q.79: SIRS - Ans. (See Page No. 536) 0 ·14 ; DRE _ Ans. (See Page No. 591)
Q.80: H.Pylori eradication regime - Ans. (See Page No. 537) 0 · 15 : TURP _ Ans. (See Page No. 591)
Q.81 : Acute limb ischemia - Ans. (See Page No. 538) o· 16. Investigations of LUTS - Ans. (See Page No. 592)
Q.82: Collar stud abscess - Ans. (See Page No. 539) 0 ·17 : Retrograde pyelography - Ans. (See Page No. 593)
Q.83 : Critical limb ischemia - Ans. (See Page No. 540) a· 18: Antegrade pyelogram - Ans. (See Page No. 594)
Q.84 : Intermittent claudication - Ans. (See Page No. 540) 0 ·19 : Intravenous urethrogram - Ans. (See Page No. 595)
Q.85: Raspberry tumor - Ans. (See Page No. 541) 0 :20 ; Cystoscopy - Ans. (See Page No. 595) .
Q.86: Buerger's disease - Ans. (See Page No. 541) 0 21 . Suprapubic cystostomy - Ans. (See Page No. 596)
0.87 : Complications of varicose veins - Ans. (See Page No. 544) 0 ·22 '. PCNL - Ans. (See Page No. 597)
Q.88: Horse-shoe kidney - Ans. (See Page No. 545) 0 ·23 : ESWL - Ans. (See Page No. 598)
Q.89 : Polycystic kidney - Ans. (See Page No. 547) 0 :24 ; Bone scan - Ans. (See Page No. 598)
Q.90 : Desmoid tumor - Ans. (See Page No. 548) 0 25 . Thyroid scan - Ans. (See Page No. 599)
Q.91 : Trachea-esophageal fistula - Ans. (See Page No. 549) 0 ·26 : Mammography - Ans. (See Page No. 600)
Q.92: Mallory-Weiss syndrome - Ans. (See Page No. 550) 0'21: Lumbar puncture - Ans. (See Page No. 600)
0.93 : Sebaceous cyst - Ans. (See Page No. 550) 0·28: Duplex ultrasound - Ans. (See Page No. 602)
Q.94 : Phimosis - Ans. (See Page No. 552) 0'29: Esophagoscopy - Ans. (See Page No. 602)
Q.95 : Unilateral hydronephrosis or Causes of bilateral hydronephrosis - Ans. (See Page No. 552) 0·30: Tracheostomy - Ans. (See Page No. 604)
Q.96 : Staghorn calculus - Ans. (See Page No. 555) 0'31 : Bronchoscopy - Ans. (See Page No. 606)
Q.97 : Carcinoma of cheek - Ans. (See Page No. 556) a:32 ; Colonoscopy - Ans. (See Page No. 607)
Q.98: Classification of nerve injury - Ans. (See Page No. 558) 0.33 : Cholangiography - Ans. (See Page No. 608)
Q.99 : Venesection - Ans. (See Page No. 559) 0.34: Pet scan - Ans. (See Page No. 611)
0.100 :Wilm's tumor - Ans. (See Page No. 560) 0.35: USG for Hepatobiliary diseases - Ans. (See Page No. 612)
Q.101: Cysts - Ans. (See Page No. 561)
Q.102: Testicular tumor markers - Ans. (See Page No. 562)
Q.103: Primary hydrocele - Ans. (See Page No. 563) SECTION - 2 (ORTHOPEDICS)
Q.104: Congenital hydrocele - Ans. (See Page No. 564)
Q.105: Encysted hydrocele of cord - Ans. (See Page No. 565)
GROUP I
Q.106: Secondary hydrocele - Ans. (See Page No. 565) 2008
Q.107: Post-burn contracture - Ans. (See Page No. 566)
Q.108: Volvulus - Ans. (See Page No. 567) 0.1: Frozen shoulder - Ans. (See Page No. 61~ (S p e No 617)
Q.109: Paralytic ileus - Ans. (See Page No. 568) Q.2 : Complications of supracondylar fracture)- ns. ee ag •
Q.11 0: Meconi um ileus - Ans. (See Page No. 569) O.3 : Sequestrum - Ans. (See Page No. 618
Q.111: Surgical site infection - Ans. (See Page No. 570) O.4: Volkmann's ischaemic contracture - Ans. (S) ee Page No. 620)
Q.112: Abscess - Ans. (See Page No. 571) Q.5: Talipes equines - Ans. (See Page No. 621
Q.113: Pyogenic abscess - Ans. (See Page No. 571) 0.6: Bladder problem in spinal paraplegia - Ans. (See Page No. 624)
Q.114: Cold abscess - Ans. (See Page No. 573)
Q.115: Necrotising fasciitis - Ans. (See Page No. 573) 2008 Supplementary
Q.116: Parotid fistula - Ans. (See Page No. 574)
Q.117: Frey's syndrome - Ans. (See Page No. 575) 0.1 : Fracture of patella - Ans. (See Page No. 625)
Q.118: Adenolymphoma - Ans. (See Page No. 576) 0.2: Celle's fracture - Ans. (See Page No. 625)
0.3: Clinical features of spinal tuberculosis - Ans. (See Page No. 625)
SEGMENT E 0.4: Bone cyst - Ans. (See Page No. 626)
0.5: Gibbus - Ans. (See Page No. 626)
Q.1: F.A.S.T - Ans. (See Page No. 580)
Q.6: Stress Fracture - Ans. (See Page No. 626)
Q.2: Diagnostic peritoneal lavage - Ans. (See Page No. 580) 2009
Q.3: SPECT Scan - Ans. (See Page No. 581)
Q.4: Barium swallow X-Ray - Ans. (See Page No. 582) Q.1 : Myositis ossificans - Ans. (See Page No. 627)
0.5: Barium meal X-Ray - Ans. (See Page No. 582) Q.2: Pathological fracture - Ans. (See Page No. 628)

(30) (31)
!1! '
rilr
If~

.\
:j
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2012 Supplementary
Q.3: Carpal tunnel syndrome - Ans. (See Page No. 629)
Q.4: Fracture neck femur- types & complications - Ans. (See Page No. 630) compartment syndrome - Ans. (See Page No. 656)
Q.5: Aetiopathogenesis of acute osteomyelitis - Ans. (See Page No. 631) Q.1:
sequestrum - Ans. (See Page No. 656)
Q.6: Spina bifida - Ans. (See Page No. 633) a.2:
Q.3: Radiological features of osteosarcoma - Ans. (See Page No. 656)
Q.4: Indications of limb amputation - Ans. (See Page No. 656)
2009 Supplementary
Q.5: Fracture decranon - Ans. (See Page No. 657)
Q.1 Non-union of closed fracture - Ans. (See Page No. 634) Q.6: Slipped disc - Ans. (See Page No. 658)
Q.2: Complications of supracondylar fracture of humerus - Ans. (See Page No. 635) 2013
Q.3: Paget's disease of bone - Ans. (See Page No. 635)
Q.4: Tension band wiring - Ans. (See Page No. 635) Q.1: Volkmann's ischaemic contracture - Ans. (See Page No. 661) \ l..
Q.5: Indication for amputation - Ans. (See Page No. 635) 0.2: E~stumor - Ans. (See Page No . .66-tJ t;..<: '
Q.6: Management of osteosarcoma - Ans. (See Page No. 635) Q.3: Core needle biopsy - Ans. (See Page No. 661)
Q.4: Colles' fracture - Ans. (See Page No. 662) ____.- i< B> 'c '3
2010
Q.5: ________
Bone graft - Ans. (See Page No. 663) .___.--
Q.1 Exostosis - Ans. (See Page No. 637)
Q.2: Brown's tumor - Ans. (See Page No. 638) 2013 Supplementary
Q.3: Ewing's sarcoma - Ans. (See Page No. 639) CTEV- anatomical changes - Ans. (See Page No. 664)
Q.1:
Q.4: Spondylolisthesis - Ans. (See Page No. 640) Monteggia fracture - Ans. (See Page No. 664)
Q.5: Bone scan - Ans. (See Page No. 641)
0.2:
0.3: Carpal tunnel syndrome - Ans. (See Page No.,_665)- ~~ _: , ls:: ls:'> C'.:>
Q.6: TB spine - Ans. (See Page No. 642)
0.4: Ncm-unTon of fracture - Ans. (See Page No. 665) le\'..•' '1 ~
0.5: External fixation - Ans. (See Page No. 667)
2010 Supplementary
Q.6: Recurrent dislocation of shoulder - Ans. (See Page No. 668)
Q.1 Tuberculosis of hip joint - Ans. (See Page No. 646)
Q.2: 2014
Volkmann's ischaemic contracture - Ans. (See Page No. 646)
Q.3: Club foot - Ans. (See Page No. 646) Fractures occurring due to fall on outstretched h9illi- Ans. (See Page No. 669) ~----·
] 0.1:
Q.4: Dupuytren's contracture - Ans. (See Page No. 646) Osteochondrmna - Ans. (See Page N o . ~ ,;::y Cl S'"'T Jc;:;'.:. .::. ' h c_;: ·::,, ' le' ts ·, Cl \
i Q.5: Giant cell tumour - Ans. (See Page No. 646)
0.2:
!
I Q.6: Avascular necrosis of femoral head - Ans. (See Page No. 646)
0.3: Greenstick fracture - Ans. (See Page No. 669) ...___-----

l l
l
2011
Q.4: - ~ l a - Ans. (See Page No.-6'10) ~-f-
0.5: Sp)_r,a b[fida - Ans. (See Page NoJiJSr 6 3 2,.
2014 Supplementary
: Q.1 Trigger finger - Ans. (See Page No. 646)
i Q.2: Ewing's tumor - Ans. (See Page No. 647)
Q.3: Mechanism of fracture patella - Ans. (See Page No. 647) Q.1: Frozen shoulder - Ans. (See Page No . ..G-?05 S \ 6
;
Brodie's abscess - Ans. (See Page No.~ G4 €;'

,I
j Q.4: Brodie's absess - Ans. (See Page No. 648) 0.2:
I 0.3: Carpal tunnel syndrome - Ans. (See Page No..616) (',,'7 .--:,.:, . :. '2· 50
Q.5: Carpal tunnel syndrome - Ans. (See Page No. 648)
Q.6: Shoulder dislocation - Ans. (See Page No. 648) 0.4: ~ (See Page No. 670) S':: .:.
0.5: Compound fracture - Ans. (See Page No. 670) ----
2011 Supplementary
~
2015
Q.1 Sequestrum - Ans. (See Page No. 650)
Q.2: Frozen shoulder - Ans. (See Page No. 650) 0.1: Ring sequestrum - Ans. (See Page No. 671) .---
Q.3: DO disease - Ans. (See Page No. 650) 0.2: Exostosis of bone - Ans. (See Page No._6.11'J "(637 ; KS 10 I
Q.4: Codman's triangle - Ans. (See Page No. 650) 0.3: voikmann's ischemic contracture - Ans. (See Page No. 671) \< t; · 't.. 'S
Q.5:

Q.1
S-P Nail - Ans. (See Page No. 651)

2012
Fracture of clavicle - Ans. (See Page No. 651)
0.4:
0.5: Ideal
,-~- ____
Pathological fracture - Ans. (See Page No ..611') G2-r:,
amputation
--~~~,__, stump - Ans. (See Page No. 673) /

2015 Supplementary
Q.2: Tennis elbow - Ans. (See Page No. 652)
Q.3: Supracondylar fracture of humerus - Ans. (See Page No. 653) 0.1: Nonunion of fractures - Ans. (See Page No. ,£w4'J \< \::> \ 0 ::S , ·';l_ '.,, , :.:.a
Q.4: Dupuytren's contracture - Ans. (See Page No. 654) 0.2: Mallet finger - Ans. (See Page No. 674)
Q.5: Ruptured tendoachilles - Ans. (See Page No. 655) 0.3: Baker's cyst - Ans. (See Page No. 674)
Q.6: Mallet finger - Ans. (See Page No. 656) 0.4: Wrist drop
Q.7: Pyogenic osteomyelitis - Ans. (See Page No. 656)
0.5: ~ - Ans. (See Page No. 675) ~

(32)
TS (33)
 2016 2019 Supplementary
V-\:l/;;!"J ..
Q.1: Carpal tunnel ~ndrome - Ans. (See Page No.-675) Complications ofCollgs frc!9Jure- Ans. (See Page No. 680] "',-:., · 1
• r • L.
0.1:
0.2: Tardy ulnar n~~~~y - Ans. (See Page No.-875) ! .. Diagnosis of Vo!~_r11_cl!7n is_£~_e_rrii_a - Ans. (See Page ~.'?.'....,686)"" ·.,:: \' ·
0.2:
0.3: ]upra con~ylar fracture of humerus__-: Ans. (See Page No . .815) 0.3: ~.sitis ossifi<2_ans - Ans. (See Page No.-680)' G <' 7
0.4: •Gian~I tumor - Ans~·{SeePage No.PSJ -=:;,zq_ 1 \<.£:, 9: ::;:. o.4: CubillJS varus - Ans. (See Page No. 681) 6'6 ! , \< t'.:,G \
0.5: ~cJl3.!§l!l~a:Lt~.:i!Jor hip joint - Ans. (See Page No. 675) .__,- 0.5: Pathological fracture - Ans. (See Page No.~ 6 ~

2016 Supplementary December-January 2019-2020

Q.1: Ewing's tumor - Ans. (See Page No. 676) 0.1: Sequestrum - Ans. (See Page No.-6&2(
0.2: Genu varum - Ans. (See Page No. 676) 0.2: ~offs-paraplegia - Ans. (See Page No. 682,) .----:-
0.3: Frozen shoulder - Ans. (See Page No.-61'6) 0.3: Tennis elbow - Ans. (See Page No ...687f 1 ") · ""'·
0.4: _Osteosarcoma ·_ Ans. (See Page No.~ 0.4: Avascular necrosis - Ans. (See Page No.,68'7) 73,;:,,
0.5: External fixation - Ans. (See Page No. 677) 0.5: Dupuytren's Contracture - Ans. (See Page No ..~ , .'.

2017 June-July 2020

Q.1: Volkmann's ischaemic contracture - Ans. (See Page No.-671)- )< 12:: 0.1: Volkmann's ischaemic contracture - Ans. (See Page No..e8"1J· ') ,<•~ .
0.2: Pathological fracture - Ans. (See Page No ...&ny _:,':z.L.7 0.2: Non union of fracture - Ans. (See Page No ..-6&1) I< E, ''J 3 r "--
<J
0.3: Q_e>ri_gl3!)it 91tc1lip~.:>_(39..uinovarus - Ans. (See Page No ..611} r..;;,,, · Q.3: Rozenshoulder - Ans. (See Page No . .68'7') :::; ':~
Q.4: ~~~ - Ans.(SeePageNo.JRr~.1 ! 1 ¥'.'.G\4\ Q.4: E'l.'.ing's Sarcoma - Ans. (See Page No.~ >-:,
Q.5: ~~~~l~erveinj~ry due to fracture - Ans. (See Page No. 677) Q.5: 1=.1:§ctu_i:_~~~~Ans. (See Page No ..,68-7)
GROUP - II
2017 Supplementary
Q.1 : Scaphoid fracture - Ans. (See Page No. 694)
Q.1: Injuries sustained by fall on outstretched hand - Ans. (See Page No.-67'8) O.2: Sudeck's osteodystrophy - Ans. (See Page No. 695)
0.2: Compffcatio·ns of~c:on~yl_~rfrc19t_ure ·: Ans. (See Page No.Ji.78f ' : 0.3: Garre's sclerosing osteomyelitis - Ans. (See Page No. 695)
0.3: ~~!r_U!:!l___-:: Ans. (See Page No . .6J3r' ( Q.4: Blood supply of femoral head - Ans. (See Page No. 696)
0.4: ~ f r a c t u r e - Ans.(SeePageNo.-6'1'8)'«G- '·'7' 0.5: Congenital dislocation of hip - Ans. (See Page No. 696)
0.5: Ewing's sarcoma - Ans. (See Page No. 678) 0.6: Physiotherapy in orthopedics - Ans. (See Page No. 698)
0.7: Elbow dislocation - Ans. (See Page No. 699)
2018 Q.8: Plaster of Paris bandage (POP) - Ans. (See Page No. 700)
0.9: Paget's disease - Ans. (See Page No. 701)
0.1: M.}:'ositis ossificans - Ans. (See Page No. 6]6) ,c.;27
Q.10: Tardy ulnar nerve palsy - Ans. (See Page No. 701)
Q.2: -Fracture palelia . :.... Ans. (See Page No~) f:tF+ 0.11: Prolapsed intervertebral disc - Ans. (See Page No. 702)
0.3: Complications of Colles' fracture - Ans. (See Page No.678) Q.12: Osgood- Schlatter's disease - Ans. (See Page No. 703)
0.4: Pathological fracture - Ans. (See Page No.,6?8') Q.13: Gout - Ans. (See Page No. 704)
0.5: Giant cell tumor - Ans. (See Page No. 6?8f · Q.14: Tension Band Wiring (TBW) - Ans. (See Page No. 704)
-015: Genu val gum and Genu varum - Ans. (See Page No. 705)
2018 Supplementary Q.16: Fracture healing - Ans. (See Page No. 706)
Q.17: De-Quervan's disease - Ans. (See Page No. 706)
Q.1: Pathogenesis of Chronic Osteomyelitis - Ans. (See Page No. 678) Q.18: Osteoarthritis - Ans. (See Page No. 707)
Q.2: Pott's Paraf)!~_glc1 - Ans. (See Page No ..67.S, v::fi:/L 0.19: Septic arthritis - Ans. (See Page No. 709)
Q.3: Classification of fracture neck femur - Ans. (See Page No. 678) 0.20: Classification of fractures - Ans. (See Page No. 710)
Q.4: Spin1!._b_ifi9g - Ans. (See Page No. Ei78f S 3 ::: 0.21 : Benett's dislocation - Ans. (See Page No. 710)
Q.5: ~equestrum - Ans. (See Page No. _9)81' .,:, l O.22: Traumatic paraplegia - Ans. (See Page No. 711)
0.23: lntramedullary nail - Ans. (See Page No. 712)
2019 0.24: Tom - Smith arthritis - Ans. (See Page No. 712)
Q.25: Fracture head of radius - Ans. (See Page No. 713)
0.1: 9!till~ Ans. (See Page No. 679) Q.26: Wrist drop - Ans. (See Page No. 714)
0.2: Fracture healing - Ans. (See Page No.-688)' 0.27: Cock-up splint - Ans. (See Page No. 715)
0.3: Osteosarcoma-: Ans. (See Page No_;JiiO) ·:::i 2 S 1 \< :JS £i 0.28: Below knee amputation - Ans. (See Page No. 715)
0.4: Club foot - Ans. (See Page No.,,680) C 'T [ ·1 rc, <; 1 Q.29: Thomas test - Ans. (See Page No. 716)
0.5: §.l:!Qr?~J'@.r:_~r~c:ttJ~__<)J_~lJ~LJs - Ans. (See Page No.~ c ·;, 0.30: Perthes disease - Ans. (See Page No. 717)

(34) (35)
 Q.31 : Calcaneum fracture - Ans. (See Page No. 720)
Q.32: Osteoid osteoma - Ans. (See Page No. 721)
Q.33: Simple bone cyst - Ans. (See Page No. 721)
Q.34 : Aneurysmal bone cyst - Ans. (See Page No. 722)
Q.35: Fibrous dysplasia - Ans. (See Page No. 723)
Q.36 : Osteoclastoma - Ans. (See Page No. 724)
Q.37: Osteosarcoma - Ans. (See Page No. 725)
Q.38: Crush syndrome - Ans. (See Page No. 727)
Q.39: Arthroplasty - Ans. (See Page No. 728)
Q.40: Arthroscopy - Ans. (See Page No. 728)
Q.41 : Arthrodesis - Ans. (See Page No. 729)
Q.42 : McMurray's osteotomy - Ans. (See Page No. 730)
Q.43 : Galeazzi fracture - Ans. (See Page No. 731)
Q.44: Foot drop - Ans. (See Page No. 731)
Q.45: Kyphosis - Ans. (See Page No. 732)
Q.46: Scoliosis - Ans. (See Page No. 733)
Q.47: Golfer's elbow - Ans. (See Page No. 734)
Q.48 : Malunion - Ans. (See Page No. 735)
Q.49: Avascular necrosis - Ans. (See Page No. 736)
a.so: Smith's fracture - Ans. (See Page No. 737)
Q.51 :
Q.52:
TB hip - Ans. (See Page No. 737)
Ingrowing toe-nail - Ans. (See Page No. 739)
Section 1
Q.53: Osteogenesis imperfecta - Ans. (See Page No. 740)
Q.54: Madelung deformity - Ans. (See Page No. 741)
Q.55: Student's elbow - Ans. (See Page No. 741)
Q.56: Claw hand - Ans. (See Page No. 742)

SECTION 3 - ANESTHESIOLOGY
SURGERY
0.1 : Spinal anesthesia - Ans. (See Page No. 753)
0.2 : Post spinal headache - Ans. (See Page No. 755)
Q.3: Muscle relaxants - Ans. (See Page No. 757)
Q.4: Monitoring in anaesthesia - Ans. (See Page No. 759)
Q:5: Pulse oxymetry - Ans. (See Page No. 761)
Q.6: Preanesthetic check-up - Ans. (See Page No. 761)
~Epidural anesthesia - Ans. (See Page No. 763)
Q.8 : Regional anesthesia/Local anesthesia - Ans. (See Page No. 764)
Q.9: CPR - Ans. (See Page No. 766)
. ~ Endotracheal intubation - Ans. (See Page No. 768)
·· Q.11 : Intravenous anaesthetics - Ans. (See Page No. 770)

(36)
 SEGMENT-A
SOLVED LONG QUESTIONS OF FINAL MBBS
Paper - I

// 2008
~ ~ - a n ~ classify shock. How will you assess and treat a case of hemorrhagic shock ? Mention
complications of blood transfusion. [2 +2 +5+3 +3 ]

SHOCK
Section - 1
Definition : Shock may be defined as a state of depression of the vital functions of the body due to
SURGERY inadequate tissue perfusion of the vital organs, resulting from insufficient microcirculation.

Classification -

1. SEGMENT - A
SHOCK
Solved Long Questions of Final MBBS 2008-2015 (Paper- I)
Solved Long Questions of Final MBBS 2008-2015 (Paper - II) Hypovolemic or Cardiogenic
Oligaemic or Vasogenic
2. SEGMENT - B Hematogenic Refer to next page for
Refer to next page for details
details
Solved Long Questions of Semesters of Various Colleges (Paper - I)
Hemorrhagic Non-
Solved Long Questions of Semesters of Various Colleges (Paper - II) Hemorrhagic
Due to systemic
Bleeding from Bleeding into sepsis by
3. SEGMENT - C injury site injury site Loss of fluid and f-------, 1. E. Coli
plasma e.g. Burn 2. Klebsiella
Solved Short Notes of Final MBBS 2008-2015 (Paper -1) Loss of fluid 3. Pseudomonas
1. External 1. Into the intestine e.g.
2. Internal 4. Staphylococcus
Solved Short Notes of Final MBBS 2008-2015 (Paper - II) 1. Fractured rib Vomiting, Diarrhea aureus
2. Acute pancre- 2. Into the peritoneum 5. Bacteroides
4. SEGMENT - D atitis e.g. Peritonitis

Solved Short Notes of Semesters of Various Colleges

5. SEGMENT - E

Solved Shorts Notes of Investigations

ASSESSMENT OF HEMORRHAGIC SHOCK :

1. Symptoms -
\
Mild shock-(< 20% blood loss)
(a) Pale cold clammy extremities
(b) Thirst
Moderate shock - (20-40% blood loss)
(a) Reduced urine output(< 0.5 ml/kg/hr)
Severe shock - (> 40% blood loss)
(b) Restlessness, anxiousness giving way to apathy, exhaustion

3
 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 5
4

2. Signs-
Spinal injury Mild shock-
(a) Superficial veins coilapse making insertion of infusion needle difficult
Neurogenic
Moderate shock-
Spinal Anesthesia Due to loss (a) Oliguria
of sympa- (b) Hypotension
Sudden fright thetic tone (c) Tachycardia

Psychogenic
Severe shock -
(a) Rapid pulse
Vasogenic Acute pain (b) Low BP
Shock (c) Anuria
(excessive pooling of (d) Unconsciousness
blood in peripheral circu-
lation) Due to pooling of Signs of significant blood loss -
blood in limb muscle (a) Pulse > 100/min
Vasovagal and dilated splanch-
(b) SBP < 100 mm Hg
nic vessels
(c) DBP drop on sitting or standing > 10 mm Hg
(d) Pallor/ sweating
Peripheral vasodila- (e) Shock index (pulse rate : BP) > 1
tation due to release
Anaphylactic 1------1 of NO, histamine, 3. Measurement of blood loss :
Slow Release Ana-
phylactic Substance (a) Clot size of a clenched fist = 500 ml
A (SAS-A) (b) Blood loss in closed tibial fracture = 500-1500 ml, in fracture femur= 500-2000 ml
(c) Weighing the swab before and after use
Rains factor:
Total amount of blood loss = Total difference in swab weight*1.5 (for smaller wounds)
Total amount of blood loss = Total difference in swab weight*2 (for larger wounds)
(d) Hb% and PCV estimation
(e) Blood volume estimation using radioiodine technique or microhaematocrit method
Intrinsic 1.MI
(f) Measurement of CVP or PCWP
(Decreased myocardial 2. Arrhythmia (g) Investigations specific for cause :
contractility)
(i) USG abdomen
(ii) FAST
(iii) Diagnostic peritoneal lavage
(iv) Doppler and angiogram
Cardiogenic
/-'1v) CT scan
Compressive
Shock 1. Cardiac tamponade ATMENT OF HEMORRHAGIC SHOCK :
(Compression of
2. Pneumothorax
(Defective pump
mechanism)
cardiac chambers) 1. Resuscitation - Ab C
This should begin immediately as soon as the patient is admitted.
(a) Establishment of clear airway
Pulmonary (b) Maintenance of adequate ventilation and oxygenation - lowering of head (increases cerebral
e.g. pulmonary circulation, prevents stasis of blood in leg muscles thereby preventing Edema), support of
Obstructive embolism jaw, moist oxygen administration
(Increased peripheral (c) Endotracheal intubation and mechanical ventilation may be needed in case of airway
vascular resistance) obstruction
Systemic
e.g. Obstruction of 2. Immediate arrest of Hemorrhage :
aorta (a) External bleeding - raising footend
- compression bandage
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 7
6 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

2. Transmission of infections :
(b) Internal bleeding - surgical exploration (a) Bacterial: Syphilis, Yersinia
(c) Bleeding from GIT - decompression of stomach and other specific measures (b} Viral :_HIV, HBV, CMV, EBV 1
(c) Parasite: T. cruzi, Malaria_
3. Extracellular fluid replacement :
□ 2 wide bore cannula inserted and intravenous infusion is started 3. Reactions caused by massive transfusion : ?7
□ Ringer lactate is ir,itially used(@ 1-2 It in 45 mins) till arrangement for whole blood is made. (a) Acid-Base imbalance - Mainly metabolic acidosis because most of the citrate in the
anticoagulant solution is present as sodium citrate, which becomes sodium bicarbonate as
It is better to withhold administration of blood until surgical control of bleeding is obtained or
atleast until just before induction of Anesthesia .. Rapid r~cement_ol1res.b..il[QQ1 after control citrate is consumed.
of Hemorrhage will lead to fewest complications. At times when bleeding has been severe, (b) Hyperkalaemia - Due to shift of potassium out of RBC due to low temperature of storage
blood should be given before surgical control of Hemorrhage. (c) Citrate toxicity- Its main effect is to consume ionized calcium from the patient's body.
□ Non sugar crystalloid solution is used; sugar is avoided because it induces osmotic diuresis. (d) Hypothermia
□ Colloid solutions should not be used as in cases of severe shock, there is generalised (e) Failure of coagulation - The caubative factors are
damage of capillary endothelium and colloids may come out into interstitial tissues causing (i} DIC
pulmonary embolism. (ii) Dilution of clotting factors
(iii) Dilutional thrombocytopenia
4. Drugs:
4. Complications of overtransfusion :
(a) Sedatives - used to alleviate pain (a) Congestive cardiac failure - Mainly seen if whole blood transfusion is given to chronic anaemic
- Morphine for adults, barbiturates for children
patients and elderly individuals
(b) . ChronotI,qpic - used in patients having slow heart rate
(b) Circulatory overload causing heart failure
_ag_e_nts - ~!rgpJ_rie most widely used, followed by lsoprenaline
(c) lonotropic - used to improve myocardial contractility 5. Complications of general i.v. fluid administration:
_a9(!_nJs - QQpamine, Dobutamine (a) Thrombophlebitis
(d) Vasodi/ators
~· ·-
- used in septic, "traumatic cardiogenic" shock (b) Air embolism
(e) Vasoconstrictors - used in neurogenic shock
6. Due to transfusion components :
(f) Beta blockers - used in cardiogenic shock
-·------··- - mainly used is fropranolQL (a),lron overload
(g) Jl_it}_!fl_t~s - sometimes used in cardiogenic shock (b) Haemochromatosis
(h} Sc,_cJju{fl_bic.9!bE_nate - used if metabolic acidosis occurs
Q .2;, Enumerate the causes of bleeding per rectum. Mention how it is diagnosed. Outline the
_ / · management for bleeding hemorrhoids. [ 5 +5+5 ]
COMPLICATIONS OF BLOOD TRANSFUSION
BLEEDING PER RECTUM
1. Transfusion reactions :
CAUSES:
(a) Incompatibility- There are 3 causes :
(i) lncompatit@ transfusion (A) Local causes :
(ii) Transfusion with blood which is already haemolysed by heating or freezing or over 1. In rectum and anal canal -
shaking · (a) Hemorrhoids
(iii) Transfusion of blood after expiry date (b) Anal fissure
(b) Pyrexial reactions - The causes are : (c) CA Rectum
(i) lmproper~d transfusion sets (d) Rectal polyp
(ii) ~~ C>(PJ.r:9Jl~_ns in the donor apparatus (e) Ruptured perianal hematoma
(iii) f ransfusion of infected blood (f) Others - ulceration, trauma, ruptured anorectal abscess, skin excoriation
(iv) Very ra(llil transfusionotbiood 2. lncolon-
(c) Allergic reactions - Due to allergic reaction ·io plasma products in the donors blood (a) CA Colon
(d) Sensitisation__!g_!f!l!.fOCVtes aQJ[~ts - This occurs where many blood transfusions (b) Ulcerative colitis
have been given in the recent past. Antibodies are developed against WBC or platelets of (c) Crohn's disease
donated blood, which causes reactions. (d) Angiodysplasia of colon
(e) lmm~11!'logica/ sensitisation
 8 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 9

(e) Amoebic ulcers (c) At times other than during defecation - Prolapsed piles, polyp, CA, ulcerative colitis, Crohn's
(f) Diverticular disease disease, angiodysplasia, etc.
(g) Bacillary dysentery
(h) lschaemic colitis 6. Nature of blood -
3. In small intestine - (a) Blood alone - Polyps, Villous adenoma, Diverticulosis
(b) Blood mixed with mucus - Ulcerative colitis, Crohn's disease, lntussusception, lschaemic
(a) Meckel's diverticulum
colitis, CA colon
(b) lntussusception
(c) Blood streaked on stool - CA rectum, Anal fissure
(c) Mesenteric artery obstruction/ mesenteric ischaemia
(d) Fresh blood as splashes in pan - Hemorrhoids
(d) Small bowel Tumor
(e) Maroon coloured stool - Meckel's diverticulum
(B) General causes : (f) Red currant jelly in stool - lntussusception
(g) Bright red blood in stool - Rectal polyp
(a) Blood dyscrasia
(b) Liver failure 7. Associated pain -
(c) Renal failure (a) Present in - Anal fissure
(d) Drugs - NSAIDs, steroids (b) Absent in - CA, polyp
(All pathological conditions above Hilton's line are painless, below Hilton's line are painful
DIAGNOSIS: except CA)
[Lower G.I bleeding can be divided into three types - 8. Associated symptoms -
(a) Occult blood loss - Alleast 10 ml blood loss per day which is detected only by chemical tests. (a) Change in bowel habit (constipation followed by Diarrhea), constant colicky pain, distended
(b) Slow bleeding - Recognisable blood loss either altered or fresh per anum in a stable patient. abdomen, palpable lump - Left sided colonic CA
(c) Rapid/ severe bleeding - Rapid blood loss per anum reflected by hemodynamic instability.] (b) Paleness + dull pain in right lower abdomen + palpable mass - Right sided colonic CA
(c) Tenesmus, bladct,er symptoms, palpable mass - Sigmoid colon CA
(A) History :
(d) Spurious Diarrhea, tenesmus, bloody slime - Rectal CA
1. Age - (e) Something coming out per rectum - Hemorrhoids, polyp
(a) More common in children - Rectal polyp, lntussusception, Bacillary dysentery (f) Diarrhea - Ulcerative colitis, Crohn's disease, dysentery
(b) More common in middle age - Hemorrhoids, Anal fissure
(c) More common in old age - CA Colon, CA Rectum (B) Clinical examination:

2. Onset- 1. General survey -

Acute bleed occurs in Pallor in CA, ulcerative colitis, Crohn's disease, bleeding diathesis
(a) Mesenteric ischaemia 2. Abdominal examination -
(b) Angiodysplasia of colon (a) Lump in right or left iliac fossa - CA colon
(c) lschaemic colitis
(b) Sausage shaped, smooth, firm, mobile, resonant mass with emptiness in right iliac fossa -
(d) Meckel's diverticulum
Intussusception
(e) lntussusception
(f) Acute episodes of ulcerative colitis (c) Distended abdomen - Ulcerative colitis
In rest conditions there is chronic bleed. 3. Inspection of anal opening - For Hemorrhoids, fissure
3. Amount of blood loss - 4. Digital per rectal examination -
(a) Very small amount- Anal fissure (streak of fresh blood on stool) Not done in Anal fissure as painful
(b) Profuse - Hemorrhoids, acute bleeding conditions Hemorrhoids is not palpable unless thrombosed
4. Colour of blood - CA rectum, polyp may be palpated
(a) Bright red - from rectum or anal canal 5. Proctoscopic examination -
(b) Dark red - from colon Visualisation of Hemorrhoids, Rectal polyp, Ca rectum
(c) Black - (melaena) from small intestine or higher up
(C) Investigations :
5. Relation of bleeding to defaecation -
1. Colonoscopy
(a) At the time of passing hard stool - Anal fissure
2. Endorectal USG
(b) At the time of passing stool, or just after defecation - Hemorrhoids

2
 10 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 11

3. Barium enema ( when not much scope for colonoscopy )

4. Biopsy 2. Age-
5. For staging - X-ray chest, USG abdomen, CT abdomen (a) Young age - Biliary atresia, Choledochal cyst
6. Routine investigations for pre-anaesthetic check up - Hb, TLC, ESR, blood urea, serum creati- (b) Middle age - Choledocholithiasis
nine, blood sugar, Chest X-ray, ECG. [Management of Bleeding Hemorrhoids - See page 57]. (c) Elderly - CA
3. Sex-
. ~ r e the causes of obstructive jaundice ? How do you establish the diagnosis ? Discuss (a) CA head pancreas, periampullary CA more common in males
/~,,,./various options in management of choledocholithiasis. [ 5 + 5 + 5] (b) Choledocholithiasis, Cholangiocarcinoma, Choledochal cyst more common in females

OBSTRUCTIVE JAUNDICE 4. Associated symptoms -

(a) Classical triad of recurrent attacks of right upper abdominal pain+ slowly progressive jaundice
CAUSES: + palpable abdominal mass - Choledochal cyst
(b) Intermittent jaundice+ weight loss+ fever+ pain - Sclerosing cholangitis
Biliary atresia (c) Biliary colic+ Charcot's triad ( Fluctuating jaundice+ Intermittent pain in right upper abdomen
+ Fever with rigor ) [sometimes Reynaud's pentad = Charcot's triad + shock + mental
Congenital
obtundation] - Choledocholithiasis
Choledochal cyst (d) Weight loss + asthenia + anorexia in all CA
Painless progressive jaundice in CA head of pancreas. Intermittent jaundice + Silvery stool
(due to mixing of undigested fat with metabolised blood derived ) + Diarrhea with pale, foul
Ascending
cholangitis smelling stool in periampullary CA.
Inflammatory
(B) Clinical Examination :
Sclerosing
cholangitis 1. General survey -
(a) Pallor in CA
(b) Jaundice
Choledocholithiasis (c) Enlarged Virchow's node in CA head of pancreas
CAUSES OF
OBSTRUCTIVE Obstructive Biliary stricture 2. Abdominal examination -
JAUNDICE (a) Smooth, non tender, globular mass with well defined lower, medial and lateral margins,
Parasitic infestation moving with respiration palpable in right hypochondriac region i.e. Gall bladder - CA head of
pancreas, periampullary CA, Choledochal cyst (according to Courvoisier's Law, in a patient
with jaundice, if there is palpable gall bladder, ii is not due to stones)
CA head pancreas, (b) Hepatomegaly - in CA head of pancreas, periampullary CA, Cholangiocarcinoma, Klatskin
periampullary CA Tumor (if soft - due to hydrohepatosis, if hard, nodular - due to secondaries)
Neoplastic Cholangiocarcinoma (c) Trousseau's sign (migratory superficial thrombophlebitis) in CA pancreas
(C) Investigations :
Klatskin Tumor (a) LFT-
Extrinsic (i) Increased total bilirubin
compression by (ii) Conjugated bilirubin raised
lymph node,
(iii) ALP, GGT highly raised
Tumor
(iv) AST, ALT raised
(v) Albumin : globulin ratio normal or may be altered with reduced albumin
DIAGNOSIS: (b) Prolonged prothrombin time
(c) USG abdomen
(A) History
(d) ERCP - 'double duct' sign in CA head of pancreas
1. Chief complaint - (e) Barium meal - 'Pad' sign in CA head of pancreas, 'Reverse 3' sign in periampullary CA
(a) Yellowish discolouration of urine, eyes and skin (f) MRCP
(b) Intense pruritus (g) CT Scan
(c) Clay coloured stool
(h) CA 19-9 in CA head of pancreas, periampullary CA
 12 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - I 13

(i) PET
(j) EUS 2008 Supplementary
(k) Urine tests - (i) Fouchet's test (for bile pigments)
(ii) Hay's test (for bile salts) ~ i f y burn. How will you assess and manage a 35 year old woman weighing 60 kg admitted
(iii) Ehrlich's test (for urobilinogen) with 40% burn. [3 + 5 + 7]
A: See Section - 1, Segment A, Paper- I, 2013, Os. 1 (Page No. 49) .
MANAGEMENT OF CHOLEDOCHOLITHIASIS
.-, ✓
-~:nerate the causes of upper GI bleeding. Discuss how a patient with this should be diagnosed
~-~~d managed. [5 + 5 + 5]
1. Preoperative preparation for obstructive jaundice A: See Section 1, segment A, Paper I, 2010, Os. 2 (Page 23-24).
(a) Immediate hospitalisation
(b) Diet - high carbohydrate, low protein, no fat diet along with vitamin and calcium supplements Q.3: A 40 year old patient has come to emergency with acute pain in right hypochondrium. How will
you make a clinical diagnosis? Outline the treatment strategy in such a patient. [5 + 10]
(c) Adequate hydration with oral and intravenous fluid
(d) i.v mannitol - 10% 200ml before, during or after surgery or lnj Furosemide 40mg i.v A: See section 1, Segment A, Paper I, 2011, Os. 1 (Page 33) "ACUTE PAIN IN RIGHT
HYPOCHONDRIUM".
(e) lnj Dopamine 2 ug/kg/min
(f) lnj Vitamin K 10mg for 3 days to correct prothrombin time ➔ if still no improvement, fresh frozen
plasma is used 2009
I ,-" ,./
(g) Blood transfusion if severe anaemia
(h) Broad spectrum antibiotics ~ ci:JJoeime and classify wounds. Discuss various factors influencing wound healing. Discuss
(i) If preoperative bilirubin > 10mg%, ERCP stenting or PTBD done, else MRCP done management of diabetic foot. [ 5 +5 +5J

2. Ideal treatment - Endoscopic sphincterotomy by ERCP and bile duct stone removal by Dormia WOUNDS
basket catheter or Fogarty balloon catheter followed by laparoscopic cholecystectomy not within the
1st 24 hours of ERCP(as chance of ERCP pancreatitis) but in the same hospital admission. Definition : Break in the integrity of the skin or tissues, often associated with disruption of the structure
If laparoscopic facilities not available, then open cholecystectomy to be done. and function.
3. If ERCP not possible, laparoscopic choledocholithotomy followed by laparoscopic cholecystectomy Classification :
done.
1. Classification of surgical wounds:
4. If laparoscopic facilities not available, then open cholecystectomy '. per operative chol~ngiogram ➔ (a) Clean - e.g. herniorraphy, excision
choledocholithotomy ➔ T tube insertion ➔ within 7-10 days T tube 1s clamped, and patient ob~erved
(b) Clean contaminated - e.g. appendicectomy, bowel surgery
for development of pain, jaundice and fever ➔ free flow of dye is confirmed by T tube cholang1ogram
(c) Contaminated - e.g. acute abdominal condition, open fresh accidental wound
➔ T tube removed by smart pull
(d) Dirty infected - e.g. abscess drainage, empyema gall bladder
5. Management of retained CBD stones i.e. detected within 2 years of choledocholithotomy :
2. Rank and Wakefield classification :
(a) Small stones may spontaneously pass down . . .
(a) Tidy - e.g. surgical incision
(b) Heparinised saline or bile acid flushing through T Tube( 250 ml normal saline with 25000 units
i.v. Heparin) (b) Untidy - e.g. crushing, tearing, avulsion
(c) Contact dissolution with monooctanoin or methyl terbutyl ether 3. On basis of covering :
(d) Burrhene technique - After 6 weeks once T tube track gets matured, track if needed is dilated
(a) Open - e.g. incised wound, lacerated wound
using graduated dilators. Then using Fogarty catheter or Dormia bas~et c~theter or (b) Closed - e.g. abrasion, contusion
choledochoscope, stone is removed through T tube track under fluoroscopic guidance (C-
ARM) 4. On basis of severity :
(e) ERCP and stone removal in 3 weeks (a) Simple (only skin involved)
(f) Transduodenal sphincteroplasty or choledochojejunostomy (b) Complex (vessels, nerve, bones, tendons involved)
(g) ESWL with endoscopic sphincterotomy
(h) Through percutaneous transhepatic route, cholangioscope is passed and CBD visualised, stone 5. On basis of involvement of underlying viscera :
is identified and removed using Dormia basket catheter or Fogarty catheter (a) Penetrating - e.g stab wound, gun shot wound
(i) Laparoscopic choledocholithotomy {b) Non penetrating - e.g. abrasion, bruise
(j) Open choledocholithotomy often with open choledochojejunostomy 6. On basis of velocity of inflicting object:
(a) Low velocity
{b) High velocity
14 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 15

7. On basis of part of body involved:

(a)
(b)
(c)
(d)
Skin
Mucosa
Bone
Brain
3.
-
Diseases -
(a)
(b)
(c)
_t,_na~miJL_
Uraemia .•
~.a.1,1ndice
(d) _Diabetes __
8. On basis of clinical appearance : (e) Blood dyscrasia
(a) Puncture (f) Malignant disease
(b) Bruise
(c) Abrasion
4. Steroids - ~J:.laX h,aling
(d) Incision 5. Cytotoxic drug~= Qela~ pealin~
(e)
(f)
Laceration
Avulsion . /;;;7
\___,,/-/ MANAGEMENT OF DIABETIC FOOT
Factors influencing wound healing :

(A} LOCAL FACTORS : taain problems in diabetic foot.:

1. _J}is_position - Skin wounds made in direction parallel to lines of Langer heal faster than those 1. Callosities
made across these lines, because skin is less stretchable along these lines because of arrange- 2. Trophic Ulcer
ment of collagen bundles in the dermis 3. Abscess
4. Infection
2. _VasculariJy- Wounds heal faster in areas with high vascularity like scalp, face etc
5. Gangrene - dry gangrene in old diabetics, wet gangrene in young diabetics
3.. LyT11ph, and _vf!_flous drainage - Edematous tissues heal slowly. Impaired lymphatic and venous 6. Osteomyelitis, arthritis
drainage delays.healing
4. f\Jecrosis - Delays healing Investigations :
5. .Tension - Delays healing 1. Blood -
6. Presence of f1Jceign_f2qgies - Delays healing as phase of granulation tissue formation cannot (a) Sugar
start unless tissue reaction induced by the foreign body ceases (b) Urea, creatinine
7. Infection - Delays healing as the granulation tissue formation cannot begin till active inflamma- (c) HbA1c
tion persists 2. Urine - Ketone bodies
8. Movements - Damage newly growing granulation tissue 3. Doppler study of lower limb to assess arterial patency
9. Anchorage - Delays healing by impairing wound contraction 4. Angiogram to look for proximal blockage
5. Pus - for culture and sensitivity
10 .. Radiation - Delays healing
6. X-ray if osteomyelitis is suspected
11. UV light - increases rate of healing
7. USG abdomen - to see status of abdominal aorta
12. Faulty technique of wound closure delays healing
Treatment:
(B} SYSTEMIC FACTORS: (A) Conservative treatment :
1. Age - Healing is faster in young age 1. Diabetes to be controlled by- (a) diet (b) drugs (c) insulin
2. Nutrition - 2. Control of obesity
(a) j'rq_t_~Jn. - High level of protein is required as 3. Drugs-
(a) Pentoxiphylline (improves blood circulation by reducing blood viscosity)
(i) All proliferating cells demand protein
(b) Cilostazole (Phosphodiesterase inhibitor which improves microcirculation)
(ii) Collagen formation requires hydroxyproline and hydroxylysine
(iii) Protein loss of catabolic phase has to be made for (c) Low dose aspirin
(d) Dipyridamole
(b) Vitamins -
4. Care of foot -
(i) Vitamin C - For collagen synthesis (a) Avoid injury
(ii) Vitamin A - For epithelialisation (b) Keep it clean and dry especially toe webs
(iii) Vitamin D - For new bone formation (c) Regular dressing
(c) Minerals - (d) MCA (Micro Cellular Rubber) footwear to be used (farmers are advised to wrap the foot with
~inc, calcium-'rn~nganese, ma~~~sium and co~_1:.~r are required for wound healing polythene packet and then work in the fields)
5. Antibiotics used if infection
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 17
a'·
16 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

2. Ab.d_ominal examination -
(B) Surgical treatment : (i) Liver mass -
(a) Site - epigastric region
1. Infection -
(b) Movement with respiration - present _ .
(a) Early cases - wide spread incision and drainage with debridement of wound removing all (c) Margins - upper border not felt, extends to left hypochondriac region
necrotic tissue
(d) Consistency - hard, nodular
(b) Severe cases - amputation above knee or below knee
(e) Percussion - dull
2. Trophic ulcer -
(ii) Stomach mass -
If superimposed infection, then local debridement with proper antibiotic administration
(a) Site - epigastric region
3. Gangrene -
(b) Movement with respiration - present
(a) Localised dry gangrene - postpone operation and allow autoamputation to take place over (c) Margins - globular, ill defined
a period of weeks (d) Consistency - hard, nodular
(b) Spreading gangrene - amputation (level to be determined based on investigations) (e) PeFcussion - resonant/ impaired resonant
/"' ,,-c'""/~ I
(f) Succusion splash - audible
q2·:,A'middle aged male patient presents with an epigastric lump. Discuss differential diagnosis.
(g) Auscultopercussion
/ /. How would you investigate? [ 8 + 7]
(iii) Pseudocyst -
EPIGASTRIC LUMP (a) Site - epigastric region
(b) Movement with respiration - absent/slight
L X ; ~ ; a l diagnosis : (c) Mobility - restricted
1. Palpable left lobe of liver - (d) Retroperitoneal mass
(a) Hepatoma (e) Margins - lower border well palpable, upper border ill defined
~) Liver secondaries (f) Consistency - smooth, soft
(c) Amoebic liver abscess (g) Percussion - resonant
(d) Hydatid cyst of left lobe (h) Baid test positive
2. Stomach mass (iv) Cystadenocarcinoma pancreas -
3. Pseudocyst of pancreas (a) Site - epigastric region
4. Cystadenocarcinoma of pancreas (b) Movement with respiration - absent
5. Colonic mass - CA transverse colon (c) Mobility - restricted
6. Para-aortic lymph node enlargement - (d) Retroperitoneal mass . .
(a) Lymphoma (e) Margins - lower border well palpable, upper border 111 defined
(b) Secondaries (f) Consistency - soft
(c) Tuberculosis (g) Percussion - resonant
7. Aortic aneurysm (v) Para-aortic lymph node mass -
Diagnosis: (a) Site - deep in epigastrium
(b) Movement with respiration - absent
(A}((ii~ (c) Mobility - restricted
f-_.,.Age - CA commonly in elderly (d) Percussion - resonant
2. History of r1roiectile vomit containing food taken 12 hours ago+ feeling of something moving from (vi) Aortic aneurysm -
left to right - Stomach mass
(a) Site - deep in epigastrium
3. History of constipation followed by Diarrhea (change in bowel habit) + abdominal pain + vomit -
(b) Movement with respiration - absent
Colonic mass --
(c) Mobility - restricted
4. History of y~[§_IJ discolourati,cin of urine and eyes, itching, pale coloured stool - CA pancreas
(d) Percussion - resonant
5. History of acute attack of. sti!g_l:liQ_g abdominal pain radiating to the flanks and back + profuse (e) Consistency- soft, smooth
vomiting+ retching, all occurring about 3 days before lump being palpable - Pancreatic pseudocyst
(f) Pulsatile (expansile)
6. History of evening rise ofJe.r.mi.eratu_re, cough, haemoptysis - TB
7. Ascites - Hepatic cause (C(lnvestigation~'
8. Losi~of weight, anorexia, asthenia - in CA and TB 1.-- Routin/- (i) Hb - reduced in CA, TB (ii) TLC raised i~ infection (iii) ES_~ increased in TB, infection
(B)<i!~~~;;~ (iv) Blood urea, Serum creatinine (v) Blood sugar (v1) Chest X-ray (v11) ECG

1. Gengral survey - Pallor in CA and TB

3
! 1

18 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED.LONG QUESTIONS OF FINAL MBBS □ Paper.:'f "i9

2. Special -
(i) Tubercul~eritonitis .
(i) USG abdomen - 0) Acquired intestinal fistula in Crohn's Disease .
(a) Liver mass - hyperechogenic mass, mosaic pattern with thin halo and lateral shadows (k) Acquired intestinal fistula from secondary_ carqfilQ!fla
(b) Liver abscess - hypo/anechogenic mass, site, size, number, location
PROBLEMS RELATED TO VID AND THEIR REMEDIES
(c) Hydatid cyst - rosettes of daughter cysts, double contoured cyst membrane, cyst wall
calcification
Anatomy:
(d) Pseudocyst - size and thickness
the head fold and the tail fold, the embryo becomes constricted by right and left lateral folds. The
(e) To see spread in ovary and other organs
.Between·ng dorsal portion of the yolk sac constitutes the m1dgut.
· At f.irst t h e m,·d gut communica
· t es fre el Y
interveni . I · ·
(ii) CT abdomen - CECT useful in hepatic mass, pseudocyst pancreas. Cart wheel appearance . h th rest of the yolk sac on its ventral aspect, but the continued growth of the folds resu ts in narrowing
Wit e . // . t· I d t
in hydatid cyst. Spiral CT shows portal vein infiltration, retroperitoneal lymph node, size of of the connection, which becomes drawn out as the ~!~.CJ~::..!!l~l!L~ __ l!,f.
Tumor
(iii) LFT, PT - altered in hepatic mass, pancreatic CA NAMES ANOMALIES CLINICAL FEATURES INVESTIG- TREATMENT
SI.
(iv) Upper GI endoscopy - to detect stomach mass and take biopsy No. ~✓J.~ ATIONS
(v) Barium meal - Intestinal fistula VID comple~~!Y 1) Faecal/tirinary dis- 1) Fistulogram + 1) Fistulectomy
1,
CT and resection
(a) CA Stomach - (1) Irregular filling defect; (2) Loss of rugosity; (3) Delayed emptying; (4) _J2~_tent char11.~ from umbili-
GUS
--
2) Discharg_e of bowel seg-
Dilatation of stomach in CA pylorus; (5) Carmann's meniscus sign i.e., margin of lesion ment and patent
projects outward from ulcer 2) Recurrentyi_tectiOD .5-!.tJdY
VID followed by
(b) Pancreatic CA - 'pad' sign 3) Pain/tenderness and 3) ~SG abdome.n
anastomosis of
ei"xcoriation in and
(vi) Gastroscopy with biopsy - CA stomach bowel
around umbilicus
(vii) Tumor markers -
2, Umbilical ~~n__tJ_s_ _§__ri:i.all portion of Pain, swelling, dis~. 1) Discharge 1) Treatment of
(a) CA 72-4 : CA stomach study '.':.J> ·N<,;) the cause
VID near umbili- "tende rnes§JHOund um-
0

(b) CEA: CA stomach 2) Sinusogram 2) Antibiotics

cus remains bilicus
(c) CA 19-9 : CA pancreas patent 3) USG, CTabdo- 3) Umbilectomy
(d) CA 12-5 : CA stomach men
(e) Alphafetoprotein : Liver mass
3. Umbilical~a Partially unobli- 1) Red swelling JJ_rg- If pedunculated,
(viii) ERCP with pancreatic juice cytology or brush biopsy teratedVID near trud_es out n.eacum-
OR Enteroterato- firm ligature tied
(ix) MRCP - to see biliary tree ma OR Umbilical umbilicus and J2ili.c.us around it, so that
(x) Coeliac and superior mesenteric angiogram polyp OR Rasp- the mucosa pro- 2) It is moist with mu- Tumor falls of. If
(xi) MRI abdomen berry Tumor lapses through GUS reappears,~
umbilicus 3) Tends to bleed
- -••~--ca-- ••• on
~ lectom:ii done
.~.,.✓-· touch
/6.3":What are the causes of weeping umbilicus? Discuss the problems related to VID and their VID closed on Assymptomatic USG abdomen ~xcis_ion
4. Intra abdominal
remedies. [ 5 +5 +5 ] _C}:'.St OR Enterocy- either side but
stoma intervening por-
CAUSES OF WEEPING UMBILICUS tion remains
patent
1. Congenital :
5. Meckel's diverticu- VID patent near Assymptomatic, tea- 1) Technitium 99 Excision of Me<;:~~-~
(a) Intestinal fistula tu res anse onl{ due to (Tc99) radio diverticulum along
lum its attachment
(b) Patent uracfius- complications : isotope scan with its base and a
to terminal ileum
(c) Umbilical adenoma 2) X-ray abdo- short segment of
------- giving rise to
congenital diver-
1) §J~~d_in_g_
men ileum followed by
2. Acquired : 2) Littre's hernia
ticulum 3) Barium meal end to end anasto-
(a) Umbilical dermatitis 3) l!Jl!,S_ti@l.obstruction follow through mosis
(b) Umbilical...9.@!luloma _ 4) l\leopla~m 4) CT Scan
(c) Umbilical calculus or omphalith 5) f'§:J.ti_c:: ulcer.
(d) Umbilical abscess 6) Perforation
(e) Endometrioma
6. Vitellointestinal VID obliterated Volvulus, intestinal ob- USG abdomen Excision
(f) Pilonidal sinus
cord OR lntraab- but a band per- struction may occur
(g) Secondarycarcinoma
dominal band sists
(h) Sister Mary Joseph's nodule
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- I 21

Anomalies: A) Depending on site -

Sometimes the vitello - intestinal duct may persist completely or partially to give rise to the following 1) Proximal small bowel obstruction
conditions :
2) Distal small bowel obstruction
3) L.arge bowel obstruction
2009 Supplementary
B) Depending on aetiopathogenesis -

Q.1 : Classify haemorrhage. How will you determine the amount of blood Joss and treat it? Depending on aetiopathogenesis
[3+5+7]
f;,: See Section 1, Segment A, Paper I, 2012 (Page 40)
/

02; G~ii~ account of pathogenesis, clinical features and management of acute pancreatitis. Dynamic Adynamic
[5 + 5 + 5) I
/< ,///
./ //
A: ACUTE PANCREATITIS
,

I I I
•
•
Postoperative
Cessation of peristalsis
In lumen In wall Outside wall • Spinal injuries
• Pathogenesis -
• Tuberculous • Adhesions • Uraemia
Pancreatic enzymes in the pancreatic acini remain as pro-enzymes (inactivated form). When the •Roundworm
stricture • Hernias • Diabetes mallitus
proenzymes are activated, they produce series of changes which are characteristic of acute • Gallstones
pancreatitis. The main causes of activation are - • Malignancy • Volvulus • Retroperitoneal haematoma/
• Meconeum
• Crohn's • lntussuscep- surgery
(i) Epithelial break (ii) Mixing up of infected bile and the pancreatic proenzymes. ileus
• lnspissated disease lion • Pseudo-obstruction
Following are the changes -
faeces • Mesenteric ischaemia
(1) The Kinins cause vasodilation and there is passage of fluid from the blood vessels into • Electrolyte imbalance
pancreatic tissue causing oedema of pancreas and finally hypovalaemia with hypovolaemic
shock
(2) Co/Jagenase and Jecithinase act on collagen fibres of blood vessels and destroy them C) Depending on type -
causing Haemorrhage Blood collects in the pancreas, retropancreatic space and even the 1) Acute obstruction
peritoneal cavity. It may finally lead to paralytic ileus and collection of blood in loin (when 2) Subacute obstruction
patient lies down) and peri umbilical region (via falciform ligament) 3) Chronic obstruction
(3) Lipase will act over the fat specially greater omentum. Fat is split into fatty acids and glycerol. 4) Closed loop obstruction
Fatty acids combine with calcium to form soap. These are white looking like pearl. These are
scattered over the omentum (fat necrosis) SMALL INTESTINAL OBSTRUCTION
(4) Amylase absorbed through peritoneal surface into blood. So there is rise of serum amylase,
□ Clinical features :
(5) Destruction of p cells ➔ lack of insulin ➔ hyperglycaemia
(6) As Ca 2+ is mobilised to produce soap, there is hypocalcaemia. A) Symptoms -
(7) Finally, there is diminished excursion (movement) of diaphragm and lungs, particularly in lef • Abdominal pain
side as tail of pancreas is in close contact with diaphragm. This leads to hypoventilation an Nature - Initially colicky, later continuous
finally partial pressure of 0 2 falls and partial pressure of CO 2 rises. Severity - Intense
(8) Lasny, superadded infection on the necrotic pancreas leads to pancreatic abscess and Onset - Sudden
septicaemia, which finally may lead to renal failure, hepatic failure, respiratory failure and Site - Begins around umbilicus and then spreads to whole abdomen
even multiorgan failure. ·
Frequency - Recurring episodes occurring as short crescendo/decrescendo episodes
• Rest- See Section 1, Segment B, Paper I, Os. 10 (Page No. 247). (lasting about 30 seconds)
~·b ne and classify intestinal obstruction. How will you diagnose and treat small intestina Abdominal distension -
/4/ obstruction. [5 + 5 + 5] Minimal or absent in jejuna! obstruction
- A: INTESTINAL OBSTRUCTION Associated with visible intestinal peristarsis and borborygmi sounds in ileal obstruction
(step ladder paralysis)
• Definition - • Absolute constipation - No passage of flatus or faeces
Obstruction to the peristaltic movements of intestine • Vomiting -
• Classification -
 22 QUEST : A Comprehensive Guic'e to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 23

Early and persistent in jejuna! obstruction Mechanism:

Recurrent (initially bilious, later faeculent) in ileal obstruction

j
B) Signs - INTRINSIC PATHWAY EXTRINSIC PATHWAY
• Tachycardia, tachypnoea

t
• Fever Inactive Factor XII Inactive Factor VII

• Bowel sounds increased initially, later absent if gangrene sets in Collagen High mol. Wt. Kininogen,
T;s,~
I
I
I• • Dehydration ➔ Renal failure thromboplastin
i I ~
• Rebound tenderness if strangulation occurs, along with guarding and rigidity Kallikrein Factor VIia
I; P/R Exam ➔ Empty, dilated rectum often with tenderness.
□ Investigations:
• Blood investigations -
Complete haemogram (TLC may be increased)
Activated Factor XII (Xlla) I
Factor 'vlla, TTh (tissue
Inactive Factor XI -T~h-ro-m-bi-n ► Factor Xia
* LFT thromboplaatin) PP, Ca 2 •
KFT
Serum electrolytes
Inactive Factor IX
-- Factor IXa, PP

•
• USG-
Blood sugar
Straight X-ray Abdomen - } See Section 1, Segment C, Paper I, 2016
supplementary, Os. 5 (Page No. 328)
I Inactive Factor VIII ~

Thrombin '
Factor VIiia, Ca 2 •

□ Treatment :
See Section 1, Segment C, Paper I, 2016 supplementary, Os. 5 (Page No. 328) lnactive Factor X I -
,. Factor Xa, Ca 2 •

Factor Va, PP
lnactive Factor V ,.
~

2010 Thrombin

Q.1: What are coagulation factors? Write in detail about mechanism of homeostasis. [ 5 + 10] Prothrombin I ,. Thrombin
~

Fibrin monomer ◄lll(f--------'I_____ Fibrinogen

Coagulation factors :
HOMEOSTASIS

Blood coagulation is a complex process involving 13 coagulation factors in a specific cascading sequence
i Polymerisation

Fibrin threads form loose, friable meshwork with blood corpuscles

resulting in formation of fibrin meshwork which entangles formed elements of blood and blood clot is.
formed. Inactive Factor XIII .
Thromb1n
► Factor Xllla, Ca 2• ----►--►IY
The factors are -
1. Factor I - Fibrinogen Stable clot
2. Factor II - Prothrombin
3. Factor Ill - Tissue thromboplastin
4. Factor IV - Ca2+
.o; 2: What are the causes of upper GI bleed ? How will you manage acute variceal bleeding ? [8 + 7]
5. Factor V - Proaccelerin
6. Factor VI - does not exist
UPPER GI BLEED
7. Factor VII - Proconvertin
8. Factor VIII - Antihaemophilic globulin When the source of bleeding lies above the duodenojejunal flexure, it is referred to as upper G.I. tract
9.
10.
Factor IX - Christmas factor
Factor X - Stuart - Prower factor
bleed O='L- J1¥'ti\B,"~ ~ \the\ t.'.2-
11. Factor XI - Plasma thromboplastin antecedent 0
12 Factor XII - Hageman factor
13. Factor XII I - Fibrin stabilising factor
24 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 25

(d) Clinical examination to check for hepatosplenomegaly, ascites

CAUSES OF UPPER GI BLEED (e) Cirrhotics to be graded on Child - Pugh score immediately
(f) _ Ryle's tube passed for aspiration of blood coJ!~~ted in G.1.T, also helps to know if there is any
- ~ bleeding
LOCAL CAUSES SYSTEMIC CAUSES (g) i.v fluid started
(h) Moist 02 inhalation
(i) In-dwelling catheter to measure urine volume to maintain input-output chart
Oesophagus Stomach and Small intestine
Duodenum (j) Till blood becomes available, plasma volume expanders used. Then blood transfusion when
blood is available
Hemorrhagic (k) lnj Vit K 10 mg i.m twice daily for 2 days ➔ if no improvement in Prothrombin time ➔ FFP
Gastro-oesoph- disorders (I) Platelet transfusion if possible
ageal varices Chronic duodenal Peutz-Zegtier's thrombocyt-
ulcer syndrome openia, DIC, (m) Dopamine/ Dobutamine 2ug/kg/day may be used to restore BP
Hemophilia, liver (n) H2 receptor antagonists to prevent stress ulcer
diseases, etc. '-"1o) In cirrhotics with hepatic encephalopathy - Lactulose 30 ml 8 hourly + Neomycin 1g 6 hourly
Reflux
oesophagitis Chronic gastric Polyps '--{pJ If ascites - Spironolactone ➔ not improve ➔ Furosemide ➔ not improve ➔ combination ➔ not
ulcer improve ➔ Ameloride/ Bumetanide
Drugs salicylates,
steroids, NSAIDs If refractory ascites, careful paracentesis and salt-free albumin infusion
Multiple erosions (q) Antibiotics to prevent spontaneous bacterial peritonitis
Hiatus hernia Vascular
and acute peptic (r) Monitoring of vital signs, fluid and electrolyte balance, input-output chart
malformations
ulcer (s) When patient becomes stable, upper GI endoscopy is done to look for the cause - confirm the
Alcohol oesophageal varices as the cause.
Mallory-Weiss
syndrome Polyps and Tumors
(B)Ei.!I~_f portal venous pressure :
carcinoma Any one of the following is used -
(a) Vasopressin - 20 units in 100ml of 5% dextrose i.v over 10 mins, repeated if necessary 3-4 times
at hourly intervals
Barret's ulcer Meckel's (b) }"erlipressin - 2mg i.v 6 hourly till bleeding stops ➔ 1mg 6 hourly for further 24 hours
diverticulum
(c) _Somatostatin and its synthetic analogue Octreotide - 50ug bolus dose ➔ 50ug in 24 hour
✓-~~
Polyps and (C):_L~-l~eas~E;,_~_J
""~ ...... ········-·---·
carcinoma (a) Balloon tamponade -
1. Using Sengstaken Blakemore tube - with 3 lumens
2. Using Minnesota tube - with 4 lumens
Achalasia and
foreign bodies These tubes have 2 balloons, oesophageal and gastric. Tube introduced into the stomach
preferably through the mouth ➔ gastric balloon inflated and pulled back into cardia of stom-
ach ➔ still bleeding does not stop ➔ oesophageal balloon inflated

MANAGEMENT OF ACUTE VARICEAL BLEEDING (b) f=:r1!!_oscopic procedures -

1. Endoscopic sclerotherapy :.... 5cc Ethanolamine oleate injected into the varices
(A){.General measures ·
·~-------"" 2. Endoscopic variceal band ligation (EVBL)
(a) Immediate hospitalisation
(b) Blood sample drawn for investigations
(D) ;Surgic_~Uneasures : ~ ro~-\ c,.,·~,,v-s~g
(c) Quick history taken to assume the cause -
(a) Jra_nsjugular intrahepatic portosystemic shunt (TIPSS) _r-
(b) ~~rtoiystemTc" sliTimTngandOesophage..alstap~ection
1. H/0 peptic ulcer symptoms, anti-ulcer drug, endoscopy
2. Intake of alcohol, drugs causing bleeding (E) Prev~~-t~f recurrent bleeding (secondary prophylaxis):
3. H/0 cirrhosis (a) Medical treatment - Beta-blockers + Nitrates f- r \',,,),Vi ·« \.-,,,. \:
. ·c/ i
4
 26 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - I 27

(b) Endoscopic sclerotherapy - sclerosants like Ethanolamine oleate, Sodium morrhuate, Sodium MANAGEMENT OF CA HEAD OF PANCREAS
tetradecyl sulphate 2 ml per varix every 2 weekly
(c) Endoscopic variceal band ligation Diagnosis:
(d) Transjugular intrahepatic{portosystemic shunt - done if patient can afford liver transplantation as
it may result in hepatic encephalopathy --r•_:
'f SS (A)~
(e) Porto-systemic shunt surgery - ~~fole~~ progressive yellowish disc?!?~L".l~?_n_C>f_EJ_ye~ an~ urine(~:, 1, k+ /; r ,..,.. -t
(b) Intense pruritus ·
1. Non-selective shunts which decompress the entire portal venous system -
(c) Clay coJg_ured stool
(i) End to end portocaval shunt
(d) W~ight loss, ari()!Elxia, reduced appetite
(ii) Side to side portocaval shunt
(iii) Proximal splenorenal anastomosis (B) tt'ff;;;~-~ination )
(iv) Mesocaval shunt (aj(jenera survey -
\
2. Selective shunts which decompress only the varices 1. Pallor
2. .Jaundice
Failure of aj:JOve require liver transplantation which is the definitive treatment
3. Virchow's lymph node may be enlarged (Troissier's sign)
O. ✓~i';;~ the causes of obstructive jaundice ? Write the management of CA head of pancreas. 4. Migratory superficial thrombophlebitis (Trousseau's sign)
7>
..
/',/
7
[5+10] (b) Abdominal examination -
1. Enlarged palpable liver (due to hydrohepatosis)
OBSTRUCTIVE JAUNDICE 2. A soft, non-tender, smooth, globular, intraabdominal lump palpable in right hypochondriac
and right lumbar region, moving up and down with respiration, whose lateral, medial and

Biliary atresia
(C
-----
estigations :)
.,
lower margins are well palpable.

........ ··-•-•-"'·-~-·""'
,

Congenital □ Routine - (i) Hb - reduced in CA, TB (ii) TLC raised in infection (iii) ESR increased in TB, infection
Choledochal cyst (iv) Blood urea, Serum creatinine (v) Blood sugar (vi) Chest X-ray (vii) ECG
□ Special -
(a) LFT-
Ascending
cholangitis 1. Increased total bilirubin
Inflammatory 2. Conjugated bilirubin raised
3. ALP, GGT highly raised
Sclerosing 4. AST, ALT raised
cholangitis
5. albumin : globulin ratio normal or may be altered with reduced albumin
(b) Prolonged prothrombin time
Choledocholithiasis (c) USG abdomen
CAUSES OF (d) ERCP -
OBSTRUCTIVE Obstructive Biliary stricture 1. 'Double duct' sign in CA head of pancreas
JAUNDICE
2. Abrupt block of pancreatic duct with irregular stricture
Parasitic infestation 3. Parenchymal filling
4. Scrambled egg appearance
(e) Barium meal - 'Pad' sign in CA head of pancreas
CA head pancreas, (f) MRCP
periampullary CA
(g) CT Scan
Neoplastic Cholangiocarcinoma (h) CA 19-9 raised
(i) PET
(j) Endosonography and EUS guided biopsy
Klatskin Tumor
Extrinsic (k) Urine tests - (i) Fouchet's test (for bile pigments)
compression by (ii) Hay's test (for bile salts)
lymph node,
(iii) Ehrlich's test (for urobilinogen)
Tumor
(I) Coeliac and superior mesenteric angiogram
 28 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I ' 29

Pre-operative preparation : pc,st-operative management :

PrtJ-operative preparation for obstructive jaundice - 1. Maintenance of proper fluid and electrolyte balance
(a) Immediate hospitalisation 2. Observation for bleeding; controlled by blood transfusion, FFP

\ (b) Diet - high carbohydrate, low protein, no fat diet along with vitamin and calcium supplements
(c) Adequate hydration with oral and intravenous fluid
3.
4.
lnj Vit K 10mg i.m for 5 days
Mannitol 200ml after surgery
_) (d) i.v mannitol - 10% 200ml before, during or after surgery or lnj Furosemide - 40mg i.v 5.
a.
lnj Octreotide infusion for 5 days
Antibiotics
) (e) lnj Dopamine 2 ug/kg/min
(f) lnj Vitamin K 10mg for 3days to correct prothrombin time ➔ if still no improvement, fresh frozen
plasma is used
7.
a.
Nasogastric aspiration
Respiratory care

l (g) Blood transfusion if severe anaemia

·- ....... (h) Broad spectrum antibiotics
_

(i) If pre-operative bilirubin >10mg%, ERCP stenting or PTBD done, else MRCP done
9.
Pain control :
1.
Monitoring of vitals

CT guided 50% of 20 ml ethanol injection into celiac ganglion

2. Epidural Anesthesia
Treatment:
3. Opioids
(a) Operable cases - 4. Transthoracic splanchnicectomy
vv, 1ppIet>_
IA/h" ' opera t',on c-:::,
T-)1 (J. ,, \'
· . 5. Palliative radiotherapy
'l':..: . .,,,, - (pain is caused due to retropancreatic nerve involvement and pancreatic duct obstruction caus-
(i) Following removed -
ing stasis in the !Jland)
1. Tumor
2. Head and neck of pancreas
3. C-loop of duodenum 2010 Supplementary
4. 40% of distal stomach
5. 10% of proximal jejunum Q.1: Define c/audication. What are the grsd•• of c/audication? How will you manage a case of
6. Lower end of CBD Buergers disease with dry gangrene of foot? [2 + 4 + 9]
7. Gall bladder A: See Section 1, Segment 8, Paper-I, Os. 4 (Page 224) and Os. 5 (Page 226).
8. Lymph nodes -
• Peripancreatic Q.2: Enumerate the differential diagnosis of painless fresh bleeding per rectum. Plan the investigation
• Pericholedochal and treatment of carcinoma of sigmoid colon. [3 + 5 + 7]
• Paraduodenal A : Differential diagnosis - See Section 1, Segment A, Paper I, Os. 2, (Page 7) - All causes except
• Perihepatic Anal Fissure.
(ii) Continuity maintained by - ,
1. ~~9.l~.9.9£~~Jejunostomy ( CARCINOMA OF SIGMOID COLON
2. r-ancreaticojejunostomy (
3. Q_astrojejunostomy __) Cl Clinical feature• :
(iii) Types - • More common in males
1. Original Whipple's operation was 2-staged procedure - initial bypass and a 2nd stage resection • Generalised features - Anorexia, Weight loss, Pallor, Cachectic look.
with closure of pancreatic stump
2. Trimble's 1-staged procedure • Colicky abdominal pain
3. Traverso - Longmire pylorus preserving pancreaticoduodenectomy • Altered bowel habits (alternating constipation and diarrhoea)
4. Fortner's regional pancreatectomy (extended Whipple's) • Abdominal distension sometimes, due to obstruction
5. Total pancreatectomy • Tenesmus
(b) Inoperable cases - • Passage of blood and mucus per rectum
(i) Roux-en-Y choledochojejunostomy + gastrojejunostomy + cholecystectomy • If metastasis occurs - liver enlarged, hard
(ii) ERC.P. + stent
- palpable left supraclavicular lymph nodes.
(iii) Chemotherapy - Gemcitabine
(iv) lrnmunotherap_y □ Investigations:
(v) Radioactive-iodine is on trial • Routine blood investigations
(c) Other types of neoplasms in head of pancreas - - Complete hemogram with ESR
(i) Large neoplastic cyst in head of pancreas - Cystoduodenostomy - LFT
(ii) Cystadenocarcinoma of pancreas - Distal/ central/ total pancreatectomy - depending on extent
KFT
and size of Tumor
 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - I 31
30

Blood sugar lrinotecan

Serum electrolytes • Radiotherapy - No role
• CEA (Carcino-E~-~~yogy,nic Antigen) • lmmunotherapy -
Level > 5 ng/ml is significant ► .Bevacizumab (VEGF)
Preoperative level > 7.5 ng/ml indicates poor prognosis ► Cetuximab (EGFR)
• . Ba~jur:!uinema - "Apple core lesion" • Secondary mets -- Liver mets can be resected (There is role of metastatectomy in colorectal
• Colonoscopy and biopsy - confirms diagnosis carcinoma)
• .Fallow-up - CEA levels are assessed.
•
•
•
Virtual colonoscopy is a recently developed useful investigation to visualise entire colon.
USG Abdomen - to detect secondaries in liver, .lymph node, etc
CT s~an Abdomen - to see local spread, determine stage, nodal status and liver secondaries
#; /

will you evaluate, grade and manage a case of blunt splenic trauma? [3 + 4 + BJ

• fNAQ_of palpable left supraclavicular lymph nodes. Ans: BLUNT SPLENIC TRAUMA
□ Treatment : ATLS guideline to be followed.
• Preparation for large bowel surgery - See Section 1, Segment D, Os. 46 (Page No. 50$)
'ABCDE' steps to be done, for evaluation and management
• Antibiotic prophylaxis (Metronidaole + Cefoxitin / Ceftriazone / Profloxacin) - to be started 1-
□ Grading:
2 hours before incision.
• Pulmonary function tests and pulmonary exercise pre and post operatively "Splenic Organ Injury Scale" -
• Urinary catheterisation Grade I : Non expanding subcapsular haematoma< 10% surface area. Non-bleeding capsular
laceration with < 1 cm depth
• Mesogastric tube placement
Grade II : Non expanding subcapsular haematoma 10-50% surface area. Non expanding
• Surgery
intraparenchymal haematoma < 2 cm
(a) Position -~~t~r modified lithotomy position.
Grade Ill : Expanding subcapsular or intraparenchymal haematoma. Bleeding subcapsular
(b) Incision ~ haematoma or subcapsular haematoma> 50% area or intraparenchymal haematoma
(c) Procedure - > 2 cm or parenchymal laceration > 3 cm depth
Abdomen explored systematically after peritoneal cavity is entered Grade IV : Ruptured intraparenchymal haematoma with active bleed; laceration involving
,!. segmental or hilar vessels with > 25% devascularisation
Special attention given to liver, peritoneum to evaluate distant metastasis Grade V : Shattered or avulsed spleen; hilar disconnection with entire spleen devascularisation.
,!. □ Evaluation :
Duke's staging followed • Detailed history about injury - mode, time, place
(d) Resection - Rectosigmoid resection preferred. • History about medical or surgical conditions of patients, any coagulation disorder or previous
~adical hemi~yd~ne (left½ of transverse colon and descending trauma
colon removed along with lymph nodes) or s~~-~<:.i~y d2ne if localised • Patient will be having following clinical features
tumour. ► Features of shock (pallor, tachycardia, hypotension)
(e) Safety margin - 5 cm ► Pain in upper abdomen
(f) Reconstruction/diversion - Bowel ends may be reanastomosed or proximal ends may ► Abdominal distension due to haemoperitoneum
be brought out as colostomy ► Dullness in left flank which does not shift due to clotting of the collected blood
(g) Drains - placement is optional (Ballance's sign)
• Chemotherapy - ► Referred pain in left shoulder due to irritation of phrenic nerve and left side of
► FOLFOX Regimen diaphragm by the collected clot (Kehr's sign)
Folinic acid ► Delayed presentation because of formation of subcapsular haematoma which later
5-Fluorouracil gives way. (The interval is called 'latent period of Bandet')
Oxiplatin ► Muscle guard, rigidity if peritonitis occurs
► FOLFRI Regimen ► Grey Turner's sign (blackish discolouration over flanks)
Folinic acid ► Cullen's sign {blackish discolouration over umbilicus)
5-Fluorouracil ► Saegesser's tender point between left sternocleidomastoid and scalenus medius.
 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 33
32

', Bag-mask ventilation may be given

□ Investigations:
► Moist oxygen inhalation
• Blood investigations
► Mechanical ventilation if endotracheal tube inserted.
► Complete hemogram D - Nervous system dysfunction to be assessed
► Grouping and cross matching E - Proper exposure and evaluation of other injuries along with eliciting history
► LFT
B) Specific measures -
► KFT
BT, CT, CRT I) Non-operative measures - (done in Grade I, 11, Ill injuries)
►
PT, aPTT • Close observation clinically
►
Blood sugar • Absolute bed rest
►
► Serum electrolytes • Sedation
• X-ray abdomen • Serial CT Abdomen / USG 'Abdomen
► Obliteration of splenic outline • Vitals and 1/0 charting
► Obliteration of psoas shadow • Angiographic embolisation sometimes
► Indentation of fundic gas shadow II) Operative measures - (done in Grade IV, V injuries)
► Elevation of left side of diaphragm • Splenorraphy - done in clean incised wound, where spleen is spleen is salvaged by
► Fracture of left lower ribs suturing wound with placement of gel foam, absorbable mesh wrap over the wound,
(done in Grade I, II, Ill injuries of haemodynamically unstable patient)
► Free fluid in abdomen
• Partial splenectomy
USG Abdomen/ FAST - investigation of choice in unstable patients
• • Emergency splenectomy
CT Scan Abdomen - investigation of choice in stable patient
• [Post-splenectomy pneumococcal vacci,1e, meningococcal vaccine and influenza vaccine
Diagnostic peritoneal lavage - significant if aspirated fluid contains
• are administered to prevent OPSI]
► Gross blood > 1O ml
► RBC > 100,000/mm3
► WBC > 500/mm3
. i/"'~ 2011
► Amylase > 175 units/di
l--d:t:1i4;year old female patient presents with acute upper abdominal pain. Discuss the differential
► Bile/bacteria/food fibres diagnosis and management. [ 7+8J
D Management :
A) General measures - ACUTE UPPER ABDOMINAL PAIN
C - Circulation to be ascertained
Differential diagnosis -
► 2 16G cannula to be inserted
► i.v. fluid to be administered
(A) Surgical causes :
► blood to be drawn while inserting cannula 1. Biliary - (a) Acute cholecystitis (b) Acute cholangitis
2. Stomach - (a) Acute peptic ulcer (b) Peptic ulcer perforation
► central venous line if required
3. Pancreas - Acute pancreatitis
► blood to be transfused when arranged 4. Liver - Liver abscess
► urinary catheterisation 5. Intestine - Acute intestinal obstruction
► input-output chart to be maintained (B) Non - surgical causes :
A - Airway to be ascertained 1. Heart - Acute myocardial infarction
► sucking of blood/secretions/foreign body by 'two finger' sweep and suction under 2. Lung - (a) Basal pneumonia (b) Empyema thoracis
vision. 3. Sickle cell disease
► Chin-lift and jaw-thrust manouvre to prevent tongue fall back 4. Acute intermittent porphyria
► Endotracheal intubation /Cricothyrotomy/Emergency tracheostomy may be required 5. Diabetes mellitus
6. Due to epilepsy
sometimes.
B - Breathing to be ascertained Manage~1--:
► Rate of respiration to be checked after proper exposure / " ~

5
34 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 35

• Pain - 6. USG abdomen -

(i) Sudden onset, colicky pain in the right upper abdomen, often radiating to the right shoulder (i) Presence of gallstone (acoustic shadow), thickened GB wall, pus in lumen, pericholecystic
- Acute cholecystitis collection - Acute cholecystitis
(ii) Sudden onset pain almost in midline in upper abdomen - Acute peptic ulcer (ii) Edematous pancreas, peripancreatic fluid collection - Acute pancreatitis
(iii) Sudden onset severe pain in mid upper abdomen then moving towards right side of (iii) Dilated bowel and fluid - Acute intestinal obstruction
abdomen, then becoming generalised - Peptic ulcer perforation
7. CT Scan abdomen - if suspected Acute pancreatitis
(iv) Sudden onset, stabbing, upper abdominal pain, radiating to the flanks and back and
relieved on leaning forward (Mohameddan prayer position) - Acute pancreatitis a. Peritoneal tap - if suspected Acute pancreatitis, Peptic perforation
(v) Sudden onset pain, initially severe colicky, later continuous severe pain -Acute intestinal 9. Upper GI endoscopy(if not available then Barium meal X-ray - Acute peptic ulcer
obstruction 10. ECG - ST elevation, Pathological Q wave in Acute myocardial "infarction"
(vi) Sudden onset retrosternal oppressive/ crushing pain - Acute myocardial infarction
• Associated features- Management :
(i) Nausea, vomit, fever - Acute cholecystiti13 □ ACUTE CHOLECYSTITIS
(ii) Hematemesis, vomit - Acute peptic ulcer
Conservative treatment followed by elective cholecystectomy at interval of 8-10 weeks. Conservative
(iii)Fever, vomit, dehydration, oliguria, shock - Peptic ulcer perforation
treatment consists of :
(iv) Nausea, persistent vomit, retching - Acute pancreatitis
(v) Vomit, abdominal distension, absolute constipation, dehydration - Acute intestinal (a} Hospitalisation
obstruction (b) Nothing per mouth
(vi) Severe sweating, no relief by rest or aspirin - Acute myocardial infarction (c) Nasogastric aspiration for 3-5 days
• History of peptic ulcer disease (dyspepsia, belching, etc.), alcohol intake, similar attack (d) Intravenous fluid initially, later soft fat free diet
in past (e) Analgesic, antispasmodic
(f) Broad spectrum antibiotic
(b) Clinical examination :
(g) Observation and regular follow up using USG
• General survey :
Features of shock -Acute pancreatitis, Peptic ulcer perforation, Acute intestinal obstruction □ ACUTE PEPTIC ULCER
• Abdominal examination : (a) Control of hematemesis
(i) Tenderness, Murphy's sign positive, Boas' sign positive -Acute cholecystitis (b) H2 blockers or PPI
(ii) Tenderness - Acute peptic ulcer □ PEPTIC PERFORATION
(iii)Tenderness, rebound tenderness (Blumberg's sign), card-board rigidity, later abdominal
(a) Hospitalisation
distension, dullness over flanks, obliterated liver dullness, absent bowel sounds - Peptic
ulcer perforation (b) Nothing per mouth
(iv) Tenderness, Grey Turner's sign positive, Cullen's sign positive, Fox sign positive -Acute (c) Nasogastric aspiration for 3-5 days
pancreatitis (d) Intravenous fluid initially, later soft fat free diet
(v) Tenderness, rebound tenderness, initially hi'gh pitched metallic sounds, later silent• (e) Catherisation
abdomen - Acute intestinal obstruction · (f) Broad spectrum antibiotic
(g) Emergency laparotomy followed by closure with omental patch
(c) Investigations :
* Manheim peritonitis index or APACHE II scoring system used to assess patient properly
1. Complete Hemogram - Raised TLC in Acute cholecystitis, Acute pancreatitis
2. Serum amylase, lipase, LOH raised in Acute pancreatitis □ ACUTE PANCREATITIS
3. LFT (a) Hospitalisation
4. Chest skiagram(PA view) - (b) Nothing per mouth
(i) To rule out basal pneumonia (c) CVP line
(ii) Free gas under right dome of diaphragm - Peptic perforation, or any hollow viscus . (d) Total parenteral nutrition
perforation (e) Intravenous fluid
5. Skiagram abdomen (AP view) - (f) Fresh frozen plasma
(i) 10% gallstones are radioopaque - Acute cholecystitis (g) Nasogastric aspiration
(ii) Sentinel loop, colon cut sign, obliteration of psoas shadow - Acute pancreatitis (h) Catheterisation
(iii) Multiple air fluid levels (> 3) - Acute intestinal obstruction (i) Electrolyte management with monitor
36 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 37

(j) Hemodialysis if required

(k) Pethidine to relieve pain numerate causes of intestinal obstruction in infants. Write clinical features, investigations
· and management of intussusceptions in 7 years old child. [ 3 +4 + 3 +5 ]
(I) Broad spectrum antibiotics
(m) Proton pump inhibitor to relieve stress ulcer
(n) Calcium gluconate - 10% 10 ml/kg i.v 8 hourly INTESTINAL OBSTRUCTION
(o) Somatostatin/Octreotide to reduce pancreatic secretion
(p) Protease inhibitor/ Acetylcholine/ Calcitonin causes of intestinal obstruction in infants :
(q) Steroids
1. Hirschsprung's disease
(r) Nebulisation, Bronchodilator 2. Meconium ileus
0 ACUTE INTESTINAL OBSTRUCTION 3. Meconium plug syndrome
4. lntussusceptions (most common cause in children)
(a) Immediate hospitalisation
5. Heal/colonic atresia/stenosis (duodenal atresia is most common cause in neonates)
(b) Nasogastric aspiration - decompression of small bowel by Miller Abbott's tube or Cantor tube
6. Neonatal small left colon syndrome
(c) Intravenous fluid
(d) Broad spectrum antibiotics INTUSSUSCEPTION
(e) Fresh frozen plasma
(f) CVP Define:
(g) PCWP Acute intestinal obstruction where telescoping or invagination of one segment of bowel into adjacent
(h) Dopamine/ dobutamine if severe hypotension segment occurs (mostly occurring due to hypertrophy of Peyer's patches in ileum)
(i) Emergency laparotomy Clinical features :
(A) Symptoms -
Caecum identified History of child crying intermittently (during an episode of acute attack) and sleeps peacefully
once it gets reduced
✓ '\._ 1. Sudden onset severe colicky abdominal pain
Caecum collapsed Caecum distended 2. Vomiting

t
Small intestinal obstruction
t
Lar9.e intestinal obstruction
3.
4.
5.
Abdominal distension
Absolute constipation
Passage of red currant jelly stool

~ / (8) Signs -
1. Tenderness
A junction between the distended and collapsed part is reached 2. Abdominal distension
3. On palpation, a sausage shaped, smooth, firm, resonant lump palpable with concavity looking
+
This is the site of obstruction
towards umbilicus, which does not move with respiration, is mobile in all directions, contracts
under palpating fingers, appears and disappears
4. Emptiness in right iliac fossa (sign de dance)
t
bbstruction relieved
5. Step ladder peristalsis
Investigations :
1. Routine investigations - Hb, TLC, ESR, Chest X-ray, ECG
Viability of gut checked 2. Straight)H~X abdomen -
(a) Distended intestinal shadow
✓ ~ (b) Multiple .filf fluid lev!;!ls
Viable Not viable
(c) Target sign - soft tissue mass with concentric area of luscency due to mesenteric fat
t
Gut kept inside, abdomen closed
t
Resection and anastomosis
(d) Meniscus sign - crescent of gas within colonic lumen that outlines apex of intussuscep-
tions
3. Barium enema -
t
Abdomen closed after peritoneal wash
'(afc1aw~sign- rounded apex of intussusceptions protrudes into contrast column
(b) Qoiled spring sign (Pincer sign) - Edematous mucosa! folds of returning limb outlined by
contrast. "rriateiTal
 38 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 39

4. USG abdomen - 0 History to be taken -

(a) Target sign • Details about lump - onset
(b) Pseudokidney sign - progress
(c) Bull's eye sign
- rapid increase in size
Treatment: • Details about associated features
1. Conservative -
(a) Immediate hospitalisation
pain abdomen
fever
J
(appendicular abscess)
(b) Nasogastric aspiration - decompression of small bowel by Miller Abbott's tube or Cant
tube
altered bowei habits
weight loss
J .
(carcinoma caecum)
(c) Intravenous fluid
(d) Broad spectrum antibiotics dysentery (amoeboma)
(e) Fresh frozen plasma paraspinal muscle spasm (psoas abscess)
(f) CVP o Clinical examination - Nature of mass in right iliac fossa
(g) PCWP
• Smooth, tender, non-mobile mass, does not move with respiration, well-localised with distinct
(h) Dopamine/ dobutamine if severe hypotension
borders, resonant on percussion ➔ Appendicular mass
(i) Reduction by hydrostatic pressure by passing normal saline or barium enema
• Smooth, soft, tender, dull mass with indistinct borders ➔ Appendicular abscess
2. Surgical - • Nodular, hard mass, mobile, resonant or impaired resonance ➔ .Carcinoma caecum
After laparotomy under Gt>-, intussusception reduced_ ~:t:.9~DUY flld_Shing it from apex (NEVER • Smooth, hard, resonant, non-tender, does not move with respiration, restricted mobility ➔
PULL). Jhen viability ch~~ed -~- lleocaecal TB
Signs of non-viability : • Smooth, soft, non-mobile, localised mass, with associated tenderness, gibbus in spine ➔
(a) Blackish in colour Psoas abscess.
(b) Lustreless
(c) No peristaltic movement □ Investigations -
(d) No bleeding on needle prick • Blood investigations
(e) No pulsation of mesenteric artery Hb, Platelet
If viable ➔ gut kept inside and abdomen closed TLC
If non-viable ➔ hot mop applied + 100% 02 ➔ still no improvement ➔ resection an DLC
anastomosis ESR

2011 Supplementary
LFT
Serum electrolytes
Q.1: Define shock. What are its different types? Outline the management of a patient presentin Blood sugar
with features of septic shock. [2 + 4 + 9] Mantoux test
• USG Abdomen - to ascertain nature of lump
A: SHOCK • CT Abdomen - to evaluate retroperitoneal mass
□ Definition - See Section 1, Segment A, Paper-I, 2008, Os. 1, Page No. 3 • Colonoscopy - to rule out carcinoma caecum
• IVU - to rule out renal lesions
□ Types - See Section 1, Segment A, Paper-I, 2008, Os. 1, Page No. 3
□ Management -
□ Septic shock - See Section 1, Segment A, Paper-I, 2014, Os. 1, Page No. 68
• Appendicular lump - See Section 1, Segment A, 2013 supplementary, Os. 2, Page No. 64
Q.2: Describe the clinical features, investigations and management of acute pancreatitis. • Appendicular abscess - Incision and drainage of abscess cavity under general anaesthesia,
[5 + 5 + 5] followed by interval appendicectomy after 3 months.
A: See Section 1, Segment B, Paper-I, Os. 10 (Page No. 247) • Amebiasis - Medical management
p:s,,; What are the causes of lump in R.I.F in a male patient of 40 year old? How do you investigate an • lleocaecal TB
/// manage such a patient? [5 + 5 + 5] Antitubercular drug
Surgery (limited ileocaecal resection / stricturopasty) if severe haemorrhage,
A: LUMP IN RIGHT ILIAC FOSSA IN MALE
presentation of acute abdomen, intestinal obstruction
□ Causes - See Section 1, Segment A, Paper-I, 2013 supplementary, Os. 2, Page No. 63 (except • Psoas abscess - Incision and drainage under GA (only lateral approach advised)
Ovarian disease and Twisted ovarian cyst) • Carcinoma caecum - Right radical hemicolectomy after proper bowel preparation.
 40 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 41

2012 (B) SIGNS:

Q. yiv; are the types of Hemorrhage ? What are the methods of determining acute blood loss ? (a) Mild shock -
, }/ ow will you treat Hemorrhage? [3 + 6 + 6] (i) ?up_erficial veins collapse making insertion of infusion needle difficult
\/---- (b) Moderate shock-
HEMORRHAGE (i) Oliguria
Types of Hemorrhage :
(ii) ~tension
(A) Based on visibility: (iii) i:a.9_t,ycardia
(a) External - bleeding t!iat is revealed (c) Severe shock -
e.g. incised wound, lacerated wound (i) _Rapid pulse
(b) Internal - bleeding that is concealed (ii) Low BP

-
e.g. liver injury, spleen injury (iii) Anuria
(c) Initially concealed, later revealed (iv) Unconsciousness
e.g. hematemesis, melaena
Signs of significa.E1t blood loss :
(B) Based on source : ----~•·-'- ~--•.· ---,.
1. Pulse > 100/min
(a) Arterial - bright red, spurting like jet 2. SBP < 100 mm Hg
(b) Venous - dark red, steady and continuous 3. DBP drop on sitting or standing > 10 mm Hg
(c) Capillary - bright red, rapid 4. Pallor/ sweating
(C) Based on duration: 5. Shock index (pulse rate : BP) > 1
(a) Acute - sudden, severe ~) MEASUREMENTOFBLOODLOSS:
e.g. after trauma, surgery
(a) Clot size of a clenched fist == 500 ml
(b) Chronic - bleeding occurring for prolonged period
(b) !3l~Qd loss in closed tibial fracture= 500 - 1500 ml, in fracture femur== 500 - 2000 ml
e.g. hemorrhoids, bleeding peptic ulcer
(c) Weighing the swab before and after use
(c) Acute on chronic - sudden onset severe bleeding occurring in people who are already anaemic -••- •-•"'---"-----•~-~•~<~~-~ G ·---~~~,,~~~~

Rains factor :
(D) Based on onset: Total amount of blood loss == Total difference in swab weight*1.5(for smaller wounds)
(a) Primary - bleeding at time of surgery or injury Total amount of blood loss == Total difference in swab weight*2(for larger wounds)
(b) Secondary - bleeding occurring within 24 hours of surgery or injury (d) Hb% and PCV estimation - normal in acute blood loss
Cause is mostly slipping of ligature (e) Blood volume estimation using radioiodine technique or microhaematocrit method
(c) Tertiary - bleeding occurring in 7-14 days after surgery (f) Measurement of CVP or PCWP
Cause is mostly infection (g) Investigations specific for cause :
(E) Based on possible intervention : (i) USG abdomen
(ii) FAST
(a) Surgical - can be corrected by surgical intervention
(iii) Diagnostic peritoneal lavage
(b) Non-surgical - cannot be corrected by surgical measures, mainly due to bleeding diathesis
(iv) Doppler and angiogram
Methods of determining acute blood loss : (v) CT Scan
(A) SYMPTOMS :
Treatment of Hemorrhage :
(a) _Mild~J!':!ck- (< 20% blo~~-!g1>s)
(A) §to.e_glood {!iss :
(i) Pale cold clammy extremities
(ii) Thirst 1. Rest-
(b) Moderate shock- (20;-40% blood loss) (i) Absolute rest
(ii) Pethidine may be used
(i) i::ieduced ~rine output(< 0.5 ml/kg/hr}
(iii) Position of patient -
(c) ~~6ock-:- (> 40% bl.o.od loss) (a) Hemorrhage from thyroidectomy - head end of bed raised (reverse Trendelenburg posi-
(i) Restlessness, anxiousness giving way to apathy, exhaustion tion)
(b) Hemorrhage from varicose veins - foot end of bed raised (Trendelenburg position)

6
 42 QUEST : A Comprehensive Gi.:ide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 43

2. Pressure and packing from outside - (c) Dermoid cyst

Sterile pieces of gauge and bandage are generally us_ed for external compression (d) Fibrocystic disease (mucoviscidosis)
3. Operative methods - (B) Acquired -
(i) Bleeding vessels during operation - (a) Retention cyst
• Haemostatic forceps are applied to the bleeding vessels. Then the vessel is ligated. (b) Parasitic cyst -
• Smallest vessels can be coagulated using diathermy (i) Hydatid cyst
• Larger vessels - transfixation suture used with silk (ii) Amoebic cyst
(iii) Cysticercosis
(ii) Hemorrhage in the form of oozing -
(c) Neoplastic cyst -
• Oxycel or gelatine sponge
• Gauge soaked in adrenaline solution (i) Cystadenoma - * Serous * Mucinous
• Bone wax in case of oozing from bone (ii) Cystadenocarcinoma
(iii) Cystic teratoma
(iii) Bleeding vessel cannot be detected - (iv) Secondary cavitation of solid Tumor
Rolls of gauge used to pack the wound ➔ after 5 min, gauge pack removed ➔ slight bleeding (v) Cystic islet cell Tumor
from spurting vessel identified ➔ vessel held by haemostat forceps ➔ vessel ligated
2. Simple cyst of liver
(iv) Profuse bleeding from rupture of solid viscus -
3. Hydatid cyst of liver
Whole or part of the viscus should be excised
4. Mesenteric cyst
(B) fJ_EJstCJ[fl:t{qr,_9!_ blood volume : 5. Retroperitoneal cyst
(i) For chronic Hemorrhage - packed cells are used 6. Aortic aneurysm
(ii) For acute Hemorrhage -
Blood sample sent for grouping and cross-matching ➔ by the time the report is received,
infusion of crystalloid ➔ when blood becomes available, blood transfused
~
(a} Patient will give a history of sudden onset severe pain in central part of upper abdomen, radiating to
flanks and back, relieved slightly on attaining Mohameddan prayer position. Pain was associated
□ Haemostasis during laparoscopy -
with severe nausea and vomiting. He was completely relieved after receiving i.v fluid and parenteral
1. Electrocoagulation medication. After about weeks of the attack, patient noticed a small swelling in the central part of
2. Monopolar electrosurgery abdomen which was gradually increasing in size and often associated with dull aching pain - Pancreatic
3. Bipolar electrosurgery pseudocyst
4. Laser coagulation (b) Epigastric discomfort, weight loss, anorexia - Neoplastic cysts
5. LigaSure (c) History of painless progressive jaundice along with weight loss, anorexia - Pancreatic CA
--~,''".:::::~·.;:;,__ ""'-~..;..~;,,.~

6. Enseal vessel fusion (~~?f,eJ1JiJ1!tiory2)

7. Harmonic scalpel (a) General survey - Pallor and jaundice in CA
8. Mechanical clips (b) Abdominal examination -
(i) Pseudocyst -
, L zf
....._ '~~
Q. ~die aged patient presented with a big tense cystic lump in upper abdomen following an '
attack of acute abdomen. How would you investigate and plan the management ? [8 + 7] ;
1. Site - epigastric region
2. Movement with respiration - absent/slight
3. Mobility - restricted
BIG TENSE CYSTIC LUMP IN UPPER ABDOMEN
4. Retroperitoneal mass
Differential diagnosis : 5. Margins - lower border well palpable, upper border ill defined
6. Consistency - smooth, soft
Most probable diagnosis of big tense cystic lump in upper abdomen following an attack of acute abdomen
is PANCREATIC PSEUDOCYST. 7. Percussion - resonant
8. Said test positive ·

I
Other differential diagnosis:
(ii) Cystadenocarcinoma pancreas -
1. True cysts of pancreas :
1. Site - epigastric region
(A) Congenital - 2. Movement with respiration - absent
(a) Sequestration cyst
3. Mobility - restricted
(b) Enterogenous cyst
4. Retroperitoneal mass
 44 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 45

5. Margins - lower border well palpable, upper border ill defined a,,,agement:
6. Consistency - soft f, pSEUDOCYST OF PANCREAS :
7. Percussion - resonant Indications of surgery-
(iii) Liver mass - (a) Size > 6 cm
1. Site - epigastric region i (b) Cyst persisting for > 6 week
2. Movement with respiration - present (c) Infected cyst
3. Margins - upper border not felt, extends to left hypochondriac region (d) Multiple
4. Consistency - cystic (e) Due to trauma
5. Percussion - resonant
(f) Thick wall
(iv) Mesenteric cyst -
Options for surgery -
1. Site - umbilical region
2. Movement with respiration - absent (a) Ideal operation if only pseudocyst in lesser sac - Cystogastrostomy (Anterior wall of stomach
3. Margins - well defined incised ➔ incision on posterior wall of stomach ➔ capsule of pseudocyst opened ➔ fluid sucked
4. Consistency - soft out ➔. fluid sent for cytology,culture sensitivity,cyst wall biopsy ➔ cyst cavity washed with normal
5. Fluctuant saline after breaking septae ➔ posterior wall of stomach sutured along with cyst wall so that
6. Painless contents of cyst wall will now drain into stomach ➔ anterior wall of stomach closed in layers)
7. Smooth (b) Laparoscopic cystogastrostomy
8. Percussion - band of resonance in front of cyst (c) If pseudocyst + chronic pancreatitis - Cystogastrostomy + lateral pancreaticojejunostomy
9. Freely mobile in direction perpendicular to mesentery (d) If pseudocyst in head of pancreas - Cystoduodenostomy
{(1-7)+(8)+(9)= Tillaux's triad} (e) If pseudocyst in tail or body of pancreas or pseudocyst extending beyond epigastrium -
(v) Aortic aneurysm - .Q}'.stojejunostomy
1. Site - deep in epigastrium (f) USG guided aspiration in small pseudocysts
2. Movement with respiration - absent (g) If gross infection/ rupture/ Hemorrhage - Cystogatrostomy + external drainage
3. Mobility - restricted (h) If infection/ acutely progressing/ patient unfit for surgery or refuses surgery/ pseudocyst in unusual
4. Percussion - resonant location not fit for internal drainage - Percutaneous drainage
5. Consistency - soft, smooth
6. Pulsatile ( expansile) 2. HYDATID CYST OF PANCREAS :
, ..•. -~~,~

(a) Ideal treatment is enucleation

.!!!!_:EJ~'!i) (b) If cyst is large and involves body or tail of pancreas, distal pancreatectomy with splenectomy to be
1. Routine- (a) Hb- reduced in CA, TB (b) TLC raised in infection (c) ESR increased in TB, infection (d)
done
Blood urea, Serum creatinine (e) Blood sugar (f) Chest X-ray (g) ECG
2. Special - 3. NEOPLASTIC CYST OF PANCREAS :
(a) USG abdomen - (a) Large cyst in head of pancreas - Cystoduodenostomy
{i) Liver mass - hyperechogenic mass, mosaic pattern with thin halo and lateral shadows (b) Large cyst in body of pancreas - Cystogastrostomy
(ii) Hydatid cyst - rosettes of daughter cysts, double contoured cyst membrane, cyst wall calcifi- (c) Large cyst in tail of pancreas - Distal pancreatectomy
cation
4. CYSTADENOCARCINOMA OF PANCREAS:
(iii) Pseudocyst - size and thickness
(iv) Mesenteric cyst detected Distal/ central/ total pancreatectomy - depending on extent and size of Tumor
(v) To see spread in ovary and other organs 5. HYDATID CYST OF LIVER :
{b) CT abdomen - CECT useful in hepatic mass, pseudocyst pancreas. Cart wheel appearance in
(a) Medical - Albendazole/ Praziquantel/ Mebenaazole
hydatid cyst. Spiral CT shows portal vein infiltration, retroperitoneal lymph node, size of Tumor.
Mesenteric cyst detected (b) Surgical -
(c) LFT, PT - altered in hepatic mass, pancreatic CA (performed after albendazole used for 21 days ➔ gap of 21 days - for 3 cycles)
(d) Tumor markers - (i) Peritoneal cavity packed with mops soaked in scolicidal agents ➔ fluid from cyst aspirated
CA 19-9 : CA pancreas ➔ scolicidal agents injected ➔ wait for 10 mins ➔ excision of hydatid cyst using natural
(e) ERCP with pancreatic juice cytology or brush biopsy cleavage plane between endocyst and pericyst
(f) MRCP - to see biiiary tree (ii) Laparoscopic pericystectomy
(g) Coeliac and superior mesenteric angiogram (iii) PAIR (Puncture - Aspiration - Injection - Reaspiration)
(h) MRI abdomen

llllliL
 46 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 47

6. MESENTERIC CYST: (i) Laparosc~£ic c~oledocholithg1QJTIY

(a) Cholelymphatic cyst ➔ enucleation (j) Op~n choJedocholithotomy often with open choledochojejunostomy
(b) Enterogenous cyst ➔ removal of cyst with resection of adjacent segment of bowel
7. AORTIC ANEURYSM :
., ,, 2012 Supplementary
,,/ ~

If aneurysm > 5.5 cm. then surgery is the treatment of choice -
(a) Open surgical aneurysm repair using PTFE or Dacron graft
(b) Endoluminal stent graft procedure using interventional radiology with Seldinger's technique
(c) Massive blood transfusion and emergency surgery if ruptured aneurysm
Q.~ Wh~re the causes of benign biliary strictures? Discuss the management of retained stones
/ ' ,),rcommon bile duct. [5 + 10]
· ../ BILIARY STRICTURE
\C!:JJ;.,;f)etf;(e shock. Describe the pathophysiology of septic shock. How would you manage a patient
suffering from septic shock? [2 + 6 + 7]
A: Definition - See Section 1, Segment A, Paper-I, 2008, Os. 1, Page No~
Septic shock - See Section 1, Segment A, Paper-I, 2014, Os. 1, Page No.~
Q.2 :.//'fWiwould you proceed to investigate and mana ea 50 ear old man who resented with lump
//:··1n left iliac fossa and irregular bowel habit? \<': 6 'r·I , · [6 + 9]

A: LUMP IN LEFT ILIAC FOSSA

Causes of benign biliary stricture :
1. Traumatic -
0 <""'·,_.,,,,,,,,.,e•
/The probable causes are -
During cholecystectomy or bile duct surgery, the following may lead to stricture : • Carcinoma sigmoid or descending colbn
(a) When cystic artery bleeds, haemostat may be blindly applied to the common hepatic duct causing • Psoas abscess
injury and stricture • Ectopic kidney
(b) In fundus-first operation, excessive pull to the gall bladder may lead to clamping of both common • Undescended testis
hepatic and common bile duct • Lymph node mass
(c) Ignorance of anomalies of bile duct and cystic duct Now in a 50 year old man, with irregular bowel habit, the probable cause seems to be - Carcinoma
(d) Distal bile duct injury caused by dilators used for exploration of stones or to dilate sphincter of sigmoid I descending colon
Oddi For details, See Section 1, Segment A, 2010 supplementary, Os. 2, Page No 29.
c~/r,
(e) Rarely after partial gastrectomy, liver surgery, duodenal and pancreatic surgery
ty3•r.A male patient presented with irreducible inguinal hernia on the right side of 6 hours duration.
2. Inflammatory - ·· How will you proceed to manage the patient? [15]
,_.-- ··-"""'·,~--,
(a) Due to accumulation of bile around the common bile duct when cystic duct is not properly ligated
during cholecystectomy
~··-···- ~ • • ··-·· Ans: IRREDUCIBLE INGUINAL HERNIA
(b) Ignored cholecystohepatic duct
(c) Sclerosing cholangitis Patient has to be identified by appropriate clinical features. Necessary investigations to be done
(d) Recurrent CBD stones and treatment to be done immediately.
(e) Parasites - Ascaris lumbricoides, Clonorchis sinensis □ Clinical features -
3. F~fJ!.~~~.!!!-<?E!!!_ • Swelling in groin which is better seen during straining, coughing and standing
• Sudden onset severe pain over pre-existing hernia, which later becomes generalised
MANAGEMENT OF RETAINED STONES IN COMMON BILE DUCT • Persistent vomiting
• Absolute constipation
Management of retained CBD stones i.e. detected within 2 years of choledocholithotomy: • Distension of abdomen
(a) Small stones may spontaneously f@.SS down • Features of toxicity - fever, dehydration 'r'\O
(b) Heparinised saline· or 6ile acid flushing through T Tube (250 ml normal saline with 25000 units • Reduced urine output
i.v. Heparin) - D On examination -
(c) Contact dissolution with monooctanoin or methyl terbutyl ether • Swelling in inguinal region which is
(d) Burrhene technique - After 6 weeks once T tube track gets matured, track if needed is dilated
- tense
using graduated dilators. Then using Fogarty catheter or Dormia basket catheter or
choledochoscope, stone is removed through T tube track under fluoroscopic guidance (C-ARM) tender
(e). ERCP and stone removal in 3 weeks irreducible___.,
(f) Transduodenal sphincteropl~ or choledochojejunostomy has no impulse on coughing ,_,....
(g) ESWL with endoscopic sphincterotomy • Hypotension
(h) Through percutaneous transhepatic route, cholangioscope is passed and CBD visualised, stone • Tachycardia
is identified and removed using Dormia basket catheter or Fogarty catheter • Oliguria
48 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 49

• Rebound tenderness (iv) Pulsation of mesenteric artery

• Abdominal distension with guarding and rigidity (v) Bleeding from wall on needle prick
□ Investigations -
✓ '\
• Routine blood investigations If viable If non-viable
Hb, Platelet
TLC (increased generally) t
Gut kept inside
t
Resection and anastomosis done
DLC abdomen with placement of drain
LFT
KFT
- ~ or,,,TT /PP'6G-,.., Bassini's repair done by placing
Serum electrolytes interrupted non-absorbable sutures (NEVER USE MESH)
Blood for grouping and crossmatching □ Post-operative care -
• Plain X-ray Abdomen - shows multiple air fluid levels • Intravenous antibiotics to be continued
• USG Abdomen
•
•
ECG
CXR (PA view)
J pre-anaesthetic evaluation
•
•
•
Maintenance intravenous fluid
Oral diet started after bowel sounds become audible
Drain rem ved after 4-5 days .
□ Management -
• High rish consent to be taken after admission 2013
• i.v. cannula to be inserted and blood sample to be taken simultaneously for investigations.
,<:J. 1 · cuss assessment of burn wound. Write in short pathoph ysiology of burn. How will you treat
• Intravenous fluids to be started
30% burn in 50 kg body weight female patient? [ 3 +6 +6]
• Ryle's tube to be inserted
• Catheterisation to be done BURN WOUND
• Maintain 1/0 chart
• Monitor vitals Assessment of burn wound :
• Intravenous antibiotics This can be done in three ways -
• Emergency surgery - (A) Depending on layers of skin involved:
Steps are as follows :
Groin incision made which extends into the most prominent area of swelling Characteristics First degree Second degree Third degree Fourth degree
, ( j,
Layers involved Superficial lay- a) Superficial type - Upto subcutaneous All layers involved
of\,{) , Sac exposed
,,_,, / j,
ers of epidermis Deeper layers of epi-
dermis
tissue along with muscles,
bones
f / Constrictfon ring and superficial injuinal ring are cut and released
r b) Deep type - Epidermis
.... _,_~·
j, and dermis
Sac opened without allowing spillage of fluid
j,
Pain Present Present Absent
·, ) \~bsent. )

Fluid sucked by suction machine Appearance H;teeraemia 2f Vesicles/blisters are hall- Ch~ parcbment Same as third de-
j, _§_fuwith slight mark; mottled, red ap- like with eschar for- gree with muscle
Edema of epi- pearance mation with throm- and bone involve-
In the meanwhile bowel is held with fingers to prevent it from getting reduced dermis, no blis- 6osed superficial ment
j, ter veins
Viability of bowel is checked
Healing Without scar- a) Superficial type - by By epithelialisation Secondary healing
(i) Pinkish colour from wound edge -
~ pignierifation ·
(ii) Normal lustre secondary healing
b) Deep type - by scar-
(iii) Peristaltic movements present ring
I

7
 SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - I 51
50 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

(B) Depending on thickness of skin involved:

1. ~ thickness - Severe hypovolaemia
• Involves superficial layers of skin J,
• Reddish appearance with blisters Reduced cardiac output ➔ Decreased myocardial function
• Painful ➔ Decreased renal blood flow ➔ Oliguria
• Spontaneous regeneration of epithelium is expected, skin grafting is not necessary
J,
2. Full thickness -
Altered pulmonary resistance
• Whole thickness of skin destroyed
J,
• Charred appearance
• Insensitive Pulmonary Edema
• Spontaneous regeneration of epithelium cannot occur, skin grafting required
(C) Depending on severity of burns : Infection

Severity Full thickness

:r: •' . ~'·c"
Partial thickness
Systemic inflammatory Response Syndromel(SIRS) )
Adults Children I ,, /
'V ~-·-
Mild <2%) <15%) <10o/o Multi Organ Dysfunction Syndrome (MODS)
Moderate ( 2 - 10o/~J v15- 25°/o) 10-20%
Changes in different systems :
Severe ( > 10%) (>25% J > 20%
1 . ~ ~
(D) Rule of NINE (depending on % of burns): (a) Shock stage - reduced cardiac output, increased peripheral resistance, reduced ventricular end
The patient's palm is considered as 1% of TBSA (total body surface area) - diastolic volume
In adult patients, the surface areas of different body parts as a % of TBSA is as follows • Cause of shock -
1. Head + Face+ Neck= 9% Direct and chemical mediated vascular injury ~ increased vascular
2. Anterior chest wall = 9%
permeability
3. Posterior chest wall = 9% ~
4. Anterior abdominal wall = 9% , Loss of fluid into the third space
5. Posterior abdominal wall = 9%
6. Each upper limb = 9%
/
7. Anterior part of each lower limb= 9% Redistribution of blood to the burnt areas
8. Posterior part of each lower limb = 9% (b) Resuscitation stage - cardiac output increased, peripheral resistance decreased, plasma volume
9. Groin + Perineum = 1% restored, pP.rfusion of vital organs restored
• Fallacy - This. rule is not applicable in children upto 14-15 years, electric burn, inhalation injury (c) _Hypermetabolic stage - increased BMR due to physiological demand for tissue regeneration
for children, Lund and Browder Charts used. (d) t(J'J)ercatabolic stage - due to infection/septicaemia/end stage organ failure, cardiac output
Pathophysiology : increased, BP falls, peripheral resistance reduced, generalised vasodilatation,liberation of toxic
chemical mediators
Types of shock in burn - l
• Hypovolaemic shock I
/ • Neurogenic shock /
~ e p t i c shock __J
2.rPUL~
Release of vasoactive peptide (a) Increased ventilation, respiratory rate, pulmonary vascular resistance
J, (b) Formation of circular eschar in chest - impairs respiration
(c) Pulmonary E;gema
Altered capillary permeability
(d) !::!i'.P.oxia, atelectasis, lung abscess
' ,1,
(e) .AfillS
Loss of fluid (f) Inhalation injury
 QUEST: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS O Paper - I 53
52

3.~ . . . . CATEGORY OF BURNS AGE AND WEIGHT ADJUSTED FLUID RATES

(a) Renal blood flow and glomerular filtrat~on rate both are redu~!d m 1mmed1ate post-burn penod
Flame or scald Adults and older children (more 2 ml RL~body weight (in kg)*

________________
(b) Renal failure and acute tubular necrosis
(c) Electric burn may lead to myonecrosis, leading to renal failure than and equal to 14 years old) %TBSA
,.,,,,,,,--......_,.,~ Children (less than 14 years old) 3 ml RL,'X.body weight (in kg)*
4. ( GASTROINTESTINAL TRACT AND LIVER - Flame or scald
%TBSA
(a) Hypomotility of GIT
(b) Paralytic ileus ~ctrical iniu!Y All ages 4 ml RL?<,_body weight (in kg)*
(c) Acute gastric dilatation . . .

~--
%TBSA
(d) Increased hepatic enzymes and cholestatIc Jaundice
ARKLAND REGIME - [This is most commonly used]
5. / ENDOCRINE SY:S t EM -)
'~tio;-~Tafdosterone and vasop.r:,~_ssin ➔ increased renal retention <>! ~alt an~ water Amount of fluid (in ml)=% of burnXbody weight (in kg)X4
(b) Secretion of epinephrine, cortisol, gluoagon ➔ increas.ed extracellular concentration of glucose, Half amount given in 1st 8 hours, rest given in next 16 hours
(c) MUIR AND BURCLAY REGIME -
mobilisation of fat
(c) Release of endorphins 1 Ration = {% of burns * body weight (in kg)}/2
(d) BAASJIQtiv~!1 ➔ vasoconstriction ➔ maintains renal blood flow 3 Rations given in 1st 12 hours
2 Rations given in 2nd 12 hours
6. , ·1MMUNOLOGIC~ . 1 Ration given in 3rd 12 hours
l~munostim~lau;,· or imm~~osuppression (varies) (d) GALVESTON REGIME - (For paediatric cases)
--~---··•' 5000ml/m2 burned area + 1500ml/m2 total body surface area
7 .. ____
HAEMATOP0IETIC SYSTEM-- -
,,..,,_ _,,,,,,,,-~~..--""""""''~'-c<
(e) MODIFIED BROOKE REGIME -
(a) Anaemia - due to blood loss, haemolysis
First 24 hours - 4ml/kg/ % of burns R.L (first half in 1st 8 hours), no colloid
(b) Serum erythropoietin level increased
Second 24 hours - Crystalloids to maintain urine output, Colloids (Albumin in R.L solution) -
Treatment of 30% burn In 50kg body weight female patient: 0.3-0.5ml/kg/% of burns
(A) First aid : (f) EVAN'S REGIME -
- ~ the burning process and keep the patient away from the burning area First 24 hours - Normal saline 1ml/kg/% of burns, Colloids 1ml/kg/% of burns, 5% dextrose in
2. Cool the area with tap water by continuous irrigation for 20 mins. 200ml water
Second 24 hours - Half of the volume used in 1st 24 hours
(8) Indications for hospitalisation :
4. Fluids used -
1. Any moderate and severe burn
(a) Ringer Lactate (fluid of choice)
2. Airway burns of any type
(b) Normal Saline
3. Burns in extremes of age
(c) Hartmann fluid
4. All electrical/deep chemical burn
(d) Plasma
(C) Initial care in emergency ward: 5. Route - Central vein by large bore intravenous cannula
1. Patient admitted 6. Monitor - Pulse, BP, urine output
2. Maintenance of airway, breathing, circulation
(E) General treatment :
3. Clothing removed
4. Cooling by running water for 20 mins
1. 02 inhalation, endotracheal intubation may be needed sometimes
2. CVP line
5. Cleaning the parts to remove dust, mud, etc.
3. Total Parenteral Nutrition
6. Assessment of % of burn using Rule Of Nine
4. Catherisation
7. Sedatives, analgesics used 5. Antibiotics
8. Patient shifted to Burn Care Unit or a clean isolated room 6. Anti-ulcer drugs (H2 blocker) - lnj Ranitidine i.v 50ml 8 hourly
(D) Fluid resuscitation : 7. Diuretics (Mannitol 1 ampoule) - used in following cases
1. When to start - As early as possible (a) high voltage electric burn
2. Indications - Burns involving 25% TBSA (b) with associated mechanical soft tissue injury
3. Quantity - (c) deep burns involving muscles
(d) extensive burns
~ A T L S 10th edition updates
(e) oliguria persists in spite of large volume of fluid
 rf
SOLVED LONG QUESTIONS OF FINAL MBBS O Paper I 55
54 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

COLONIC TUMORS
8. Tetanus prophylaxis -
(a) Patient immunised and last booster dose taken within last 5 years - Nothing required
(b) Patient immunised and last booster dose taken between last 5-10 years -1 booster dose of l
POLYPS CARCINOMA
tetanus toxoid
t
(c) Patient not immunised or immunisation status unknown or last booster taken > 1O years ago
- 1 tetanus toxoid + lnj Human Tetanus Globulin 250 units Inflammatory Hamartoma Neoplastic Hyperplastic
~gp.i:;rof bum wound :
\A~ First degree burn - IJQ dressing or topical antibiotic required Benign -j Juvenile polyp Tubular adenoma
lymphoid polyp (Adenomatous
2. TShe?dond degree burn -_~Li!nti~ + ~~.E'.l!~ padded dressing polyp)
3
. ir degree burn - Peutz-Jegher's
(a) Debridemen!._- Escharotomy if eschar formation Pseudopolyp polyp
Villous adenoma
(b) Dressing_ (Ulcerative colitis)
(Papilloma)
(c) Topical antibio~
(d) yvound excision and skin grafting after 3 weeks, MESH split skin graft for wider area
Familial polyosis coli
General rules of local management -
1. Dressing at regular intervals under general Anesthesia using
(a) paraffin gauze · (b) Anal fissure
(b) hydrocolloids (c) CA Rectum
(c) plastic films (d) Rectal polyp
(d) vaseline impregnated gauze
(e) Ruptured perianal hematoma
(e) fenestrated silicone sheet
(f) biological dressing like amniotic membrane, synthetic biobrane (f) Others - ulceration, trauma, ruptured anorectal abscess, skin excoriation
2. Open method - without dressing, only topical agent used; generally done for burns in head, face 2. In colon -
and neck (a) CA Colon
3. Closed method - with dressing and topical agent (b) Ulcerative colitis
4. Topical agents are used after cleaning with povidone iodine solution (c) Crohn's disease
5. Topical agents used are - (d) Angiodysplasia of colon
(a) Silver sulfadiazine 1% (e) Amoebic ulcers
(b) Sulfamylon 5% (f) Diverticular disease
(c) Silver nitrate 0.5% (g) Bacillary dysentery
6. Tangential excision -0f burn wound with.skin grafting done after granulation tissue formation, but (h) lschaemic colitis
may be done within 48 hours in patients with < 25% burns (B) General causes :
(G) Post - resuscitation period : (a) Blood dyscrasia
1. Prevention and treatment of infection (b) Liver failure
2. Proper nutrition (c) Renal failure
3. Fluid infusion - Glucose in water or R.L or colloid used i.v or orally (d) Drugs - NSAIDs, steroids
Amount of fluid (in ml)= 1500ml/m2 of body surface area+ evaporative fluid loss (i.e 25* % of burn
* m2 of body surface area) Diagnosis:
4. Wound resurfacing + Splintage
5. Physiotherapy
/ / ,.
. ,~;/1t 2: Classify colonic Tumors. How will you manage a 60 year old man presenting with fresh bleeding
~-
"'Acute bleed occurs in
,/• per rectum. [ 5 + 1O] (a) Angiodysplasia of colon
Classification of colonic Tumors : See page 55. (b) lschaemic colitis
(c) Acute episodes of ulcerative colitis
BLEEDING PER RECTUM IN 60 YEAR OLD In rest conditions there is chronic bleed.
2. Amount of blood loss -
Causes of fresh bleeding per rectum : - iQ4···'"·£.,,J!!'!::::;,;,,.;.~.w,,••••~~-~-~-
(a) Very small amount-. Anal fissure (streak of fresh blood on stool)
(A) Local causes : (b) Profuse - Hemorrhoids, acute bleeding conditions
1. In rectum and anal canal -
(a) Hemorrhoids
 56 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 57

3. Colour of blood - 3. Barit:T enema (when not much scope for colonoscopy)
(a) Bright red - from rectum or anal canaj 4. _Biopsy
(b) Dark red - from color} 5. For staging - X-ray chest, USG abdomen, CT abdomen
(c) Black - (melaena) from small intestine or higher up
Routine investigations for pre-anaesthetic check up - Hb, TLC, ESR, blood urea, serum creatinine,
4. Relation of bleeding to defecati?n - blood sugar, Chest X-ray, ECG
(a) At the time of passing hard stool - Anal fissure
Management:
(b) At the time of passing stool, or just after defecation - Hemorrhoids , ~- ~
(c) At times other than during defecation - Prolapsed piles, polyp, CA, ulcerative colitis, Crohn's 1.. (t!!_morrhoid5.j
disease, angiodysplasia, etc.
5. Nature of blood -
(a) Blood alone - Polyps, Villous adenoma, Diverticulosis
MANAGEMENT OF BLEEDING HEMORRHOIDS
(b) Blood mixed with mucus - Ulcerative colitis, Crohn's disease, lschaemic colitis, CA colon
(c) Blood streaked on stool - CA rectum, Anal fissure
(d) Fresh blood as splashes in pan - Hemorrhoids
(e) Bright red blood in stool - Rectal polyp
6. Associated pain -
(a) Present in - Anal fissure Milli_gan Morgan Pro-
Preventing constipa- lr:ii~_cti_on sclerosant cedure (Ligation and
(b) Absent in - CA, polyp therapy (sclerosants
tion by- excision of piles)
(All pathological conditions above Hilton's line are painless, below Hilton's line are painful i) drinking lots of fluid like-ethanolamine ole-
except CA) ii) high fibre diet ate injected using
iii) no high quality pro- Gabriel syringe, 3-5 Park's Submucosal
7. Associated s~~ - haemorrhoidectomy
tein ml per piles, repeated
(a) Change in bowel habit (constipation followed by Diarrhea), constant colicky pain, distended 6 weekly)
abdomen, palpable lump - Left sided colonic CA Hill-Fergusson
(b) Paleness + dull pain in right lower abdomen + palpable mass - Right sided colonic CA ciosea method
Local application to
(c) Tenesmus, bladder symptoms, palpable mass - Sigmoid colon CA reduce pain
(d) Spurious Diarrhea, tenesmus, bloody slime - Rectal CA
Barron's band ligation
(e) Something coming out per rectum - Hemorrhoids, polyp (bands plffr;ea 2 cm
(f) Diarrhea - Ulcerative colitis, Crohn's disease, dysentery above dentate line,
only 2 piles banded at
(B)J Clinical ·examination . a time)
1. General survey - _ f i l ~ (sit in warm
Pallor in CA, ulcerative colitis, Crohn's disease, bleeding diathesis water with anal region
dipped in water for 20
2. Abdominal examination - mins, 2-3 times a day)
(a) Lump in right or left iliac fossa - CA colon
(b) Distended abdomen - Ulcerative colitis Infra red coagulation
3. Inspection of anal opening - for Hemorrhoids, fissure
Lord's dilatation (man-
4. Digital per rectal examination - . ual stretching of anal
Not done in Anal fissure as painful canal in permanently Laser therapy
Hemorrhoids is not palpable unless thrombosed prolapsed piles)
CA rectum, polyp may be palpated
5. Proctoscopic examination - DGHAL
Visualisation of Hemorrhoids, Rectal polyp, Ca rectum (Doppler Guided Hemorrhoidal
Artery Ligation
(C) Investigations ·
1. Colonoscopy__ _
2. Endorectal USG

8
58 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 59

2. Anal fissure -
• Bowel wash using normal saline for 2-3 days before surgery
• Total gut irritation
TREATMENT OF ANAL FISSURE • Antibiotics
(i) Abdomino - Perinea! Resection (APR) - sigmoid, descending colon and upper rectum is
mobilised per abdominally; anal canal with perianal and perirectal tissues are dissected per
GENERAL anally; retained colon is brought out as end colostomy in left iliac fossa.
(j) APR is the treatment of choice when
(i) Mesorectum is involved
Preventing constipa- Bed Rest Lateral anal (ii) Poorly differentiated Tumor
tion by - ~Qb.ir.icterotQ!!!Y (iii) Nodes involved
i) drinking lots of fluid
ii) high fibre diet (k) Criteria for anterior resection -
Nifedipine ointment Dorsal fissurectomy
iii) no high quality pro- (i) Upper and middle third rectal growth
tein wlth~~!c:,tomy (ii) Above peritoneal reflection
(ii) Well - differentiated Tumor
Lord's dilatation under
GA --- - ..... (iv) < 4cm size Tumor
J:QP.l~ (v) T1 N0/T2N0 Tumor
Bulk forming agents, nitroglycerine
stool softeners (vi) Tumor without lymphatic or venous spread
Laxative, xylocaine (I) Hartmann's operation - excellent palliative procedure done in elderly people who are not fit
used lorma]or surgery, and in locally advanced Tumors.
Botulinum toxin
(m) ~reoE~!ative and postoper~!ive radiotherapy
Sitz bath (sit in warm
water with anal region (n) Chemotherapy -
dipped in water for 20 Diltiazem • Neoadjuvant
mins, 2-3 times a day) • Adjuvant
• Palliative
4. Rectal polyps :
Once recovers, regu-
Transanal endoscopic microsurgery
lar anal dilatation
5. CA colon:
(a) "'f:!i.9hl - sided : ~i-~ht radical hemic;:Q\ectQffiY with ilea-transverse anastomosis. In inoperable
3. Rectal carcinoma -
(a) Surgeryjs the main method of treatment.
cases, ilea-transverse anastomosis Is done as a by-pass procedure.
(b) Left-sided: Left radical hemicolectQmy
(b) .AruiQmJ.09-Perineal Resecti.on(APR) is the gold standard. ' _,.-...,_,,_.,,.,.-,_~
(c) But if Tumor is well differentiated and if there is adequate margin above the anal canal, a 6. Crohn's disease, Ulcerative colitis:
__$pb_i_n9J_1:3,r__~avin_g./•inl@.rl9r..B~§.!3-QtiQQ.{AR) may be done. ---(ar Steroids
(d) Total Mesorectal Excision (lMt;l should be the goal. ' ·-(15f Azathioprine
(e) Principles of surgery - ,. ~er· 5-ASA
• Distal margin - 2 cm away from the lesion ' ('d) .Antibiotics
• Proximal margin - 5 cm away from the lesion ' •-ttif Metronidazole
• Radial margin - 3 cm of mesorectum to be removed ._(!)-· Surgery if medical methods fail
(f) Laparosco.p_Lc.AeJ3LAB.. is becoming popular. 7. Angiodysplasia:
(g) For carcinoma rectum presenting with obstruction, an initial proximal colostomy is done. Bipolar coagulation along with angiography is the treatment : embolisation may be done.
,Neoadjuvant chenJQifilllation is given. Patient is reassessed for operability. Then APR is
done with permanent colostomy.
(h) Proper preoperative bowel preparation - rO. :,..rt:i~i:irlbe clinical features, diagnosis and management of choledocolithiasis. (4 + 4 + 7]
~,/'~_., ..,-·•'
• Low residue diet for 48-72 hours before surgery, only clear liquid on day before surgery,
no feed on day of surgery /• .... - CHOLEDOCHOLITHIASIS
• Elemental diet for 3-5 days before surgery
Definition :
• Single dose of oral polyethylene glycol dissolved in 2It of water on day before surgery
Stones in common biliary duct a~iliary tree
60 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-'+ ''iS1

Clinical features : the 1st 24 hours of ERCP(as chance of ERCP pancreatitis) but in the same hospital admission.
If laparoscopic facilities not available, then open cholecystectomy to be done.
1. _Assymp_tomatic
3. If ERCP not possible, laparoscopic choledocholithotomy followed by laparoscopic cholecystec-
2. ~i!i"!D:'._~gllc:::::: right hypochondria! pain, radiating to the right shoulder, sudden onset, precipitated
tomy done.
by fatty heavy meal, peaks ➔ sustained for sometime ➔ gradually subsides spontaneously
4. If laparoscopic facilities not available, then open cholecystectomy ➔ per operative cholangio-
( not a true colic as little smooth muscle in wall of common bile duct)
gram ➔ choledocholithotof!]y ➔ T-Tube insertion ➔ within 7-10 days T tube is clamped, and
Charcot's triad of ascending cholangitis - ~ 0 ..J__ • 1 .t J' patient observed fordevelopment ofpain,
jaundice and fever ➔ free flow of dye is confirmed by
(a) Fluctuating jaundice ..LWf:!fiYIA(tbNIJ GV'iV(
T tube cholangiogram ➔ T tube removed by smart pull
(b) Intermittent pain in right upper quadrant of abdomen . )? P,c,)v\
(c) Fever with rigor L-- .
,,
1. ,
dJc e
5. Management of retained CBD stones i.e. detected within 2 years of choledocholithotomy :
Raynaud's pentad of acute obstructive jaundice(suppurative cholangitis) - (a) Small stones may_ sponJg_neguslyQc:!S_s clown
(a) Fluctuating jaundice {b} Heparinised saline or bile acid flushing through T Tube (250 ml normal saline with 25000
(b) Intermittent pain in right upper quadrant of abdomen units i.v. Heparin)
(c) Feverwithrigor
(d) Shock
r,,,...__.,v,--· l'r, q,,,u-' .I :::-
t<l»'i' ~.::, n:;::;,,,toc, A (c) Contact dissolution with monooctanoin or methyl terbutyl ether
(d) Burrhene technique -After 6 weeks once T tube track gets matured, track if needed is dilated
(e) Mental obtundation v using graduated dilators. Then using Fogarty catheter or Dormia basket catheter or
5. . Features of obstructive jaundice - , choledochoscope, stone is removed through T tube track under fluoroscopic guidance (C-
(a) Mustard coloured urine ARM)
(b) Pale clay coloured stool, steatorrhoea (e) E:J3CP and stone removal in 3 weeks
(c) Intense pruritus {f) Transduodenal sphincteroplasty or choledochojejunostomy
6. Pain and tenderness in epigastrium and right hypochondrium (g) ESWL with endoscopic sphincterotomy
(h) Through percutaneous transhepatic route, cholangioscope is passed and CBD visualised,
Diagnosis:
stone is identified and removed using Dormia basket catheter or Fogarty catheter
1. Liver function test : (i) Laparoscopic choledocholithotomy
(a) Total serum bilirubin - raised (j) Open choiedo~holithotomy often with open choledochojejunostomy
{b} Conjugated bilirubin - raised
,.-·
(c) Serum protein - albumin, globulin normal
(d} AST, ALT - slightly raised 1 Supplementary 2013
(e) ALP, GGT - highly raised
'(f} PT - prolonged ,Q..t-('{ e normal values of different body electrolytes ? What are the electrolyte changes
2. U~G abdomen - CBD diameter> 1cm indicates biliary obstruction) In a patient of long standing pyloric stenosis ? How do they occur ? How do you prepare such
3. ERCP - gold standard as stones in retroduodenal part of CBD missed in USG a patient before an elective operation ? [ 5+5 +5 ]
4. MRCP
Normal values of different body electrolytes :
5. Routine investigations - Hb, TLC, ESR, Chest X-ray, ECG
(a) Na+ 130-150 mmol/lt
Management :
(b) K+ _3.5-5.5 _l]mQJL!l
1. Preoperative preparation for obstructive jaundice
(a) Immediate hospitalisation
(c) c1- 98-106 mmol/lt
( 24-28 mmol/lt
(b) Diet - high carbohydrate, low protein, no fat diet along with vitamin and calcium supplements (d) HC03 ~---··"-~"'"~-· ~,._,,_,_...=--!"

\ (c) Adequate hydration with oral and intravenous fluid (e) Ca2+ J:_1__1_~/.gL
) (f) p
{d) i.v mannitol - 10% 200ml befor~uring or after surgery }·4:?. . .'!!9!.9L
(e) lnj Dopamine 2 ug/kg/min r
Q.JCO -,- ® t<~ e,.i ,'.YI(\ ,t{o c.) (g) Mg ?.-.~ -n.:ig/9.I
(f) lnj Vitamin K 10mg for 3days to correct prothrombin time ➔ if still no improvement, fresh (h) pH 7.3-7.4
frozen plasma is used
(g) Blood transfusion if severe anaemia
(h) Broad spectrum antibiotics
PYLORIC STENOSIS

Electrolyte changes :
2. Ideal treatment - Endoscopic sphincterotomy by ERCP and bile duct sto e removal by Dormia
Hypochloraemi~ hypo\(alaemic _metaboli~ al_k_~osis with hypocalcaer:r::i_i_i.3:_~,e.e.!.~d~($LC§!I aci!:J.,YJ.~§
basket catheter or Fogarty balloon catheter followed by laparoscopic cholecystectomy not within "'"'"""">f"''"'...,,,,,«<M!'r""""-••--•••"'"''"/"i,\ .,_,_~_,,...___,, .,.,,,~-•• ' "-~~-~•W•'-""i •''', •

\~co'b~
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 63
/ /

·•'Basis of electrolyte changes : ,0 y~t /·//

are the causes of lump in right iliac fossa ? Outline diagnosis and management of
appendicular lump. [3 +6+6l
Projectile vomit ➔ loss of fluid and hydrochloric acid

i
Loss of H+, K+, Cl- Causes:
LUMP IN RIGHT ILIAC FOSSA

i
Hypochloraemic, hypokalaemic metabolic alkalosis
(A) Parietal swelling -
(a) Lipoma
(b) Desmoid Tumor

/ ~
(B) lntraabdominal lump -
(a) Appendicular lump
Kidney tries to compensate by excreting Alkalosis leads to hypocalcaemia (b) Appendicular abscess
(c) lleocaecal tuberculosis
Low amounts of c1- , high amounts of HCO 3 (Gastric tetany) (d) Crohn's disease
(e) CA caecum
t (f) Ovarian disease
While excreting Hco 3, Na+ lost (g) Twisted ovarian cyst
(h) Actinomycosis
t
Hyponatremia develops
(i) Mesenteric lymphadenitis
(j) Lymphoma

t
RAAS activated ➔ Aldosterone released
and K+ which are excreted in urine
➔ Na+ retained in distal tubule in exchange of H+
(C) Retroperitoneal lump -
(a) Hydronephrosis - right sided or bilateral
(b) Tumor in unaccended or dropped kidney

t
Kidney passes acidic urine (H+)
(c) Tumor in undescended right testis
(d) Retroperitoneal sarcoma
(e) lliopsoas abscess

t
Paradoxical aciduria (as in the background of metabolic acidosis, kidney should have excreted
APPENDICULAR LUMP
alkaline urine)
Definition :
Also called Periappendicular phlegmon.
Pre- operative preparation of patient:
!tis the .to_calisatior:tQf_Lr::iJ~QtiQD v:rbi9hQQ9lJt~ ~:_Q_dc;J,ys_1i.f!El.ran attac~ of acute appElndiciti~.,
1. Correction of dehydration - i. v normal saline (not Ringer lactate) Its contents are -
2. Correction of electrolyte imbalance - i.v normal saline. Once urine output becomes normal, (a) Jnflamed appendix.
potassium supplemented (b) J3re1:1.J._eJgrrrenturn
3. Correction of hypoproteinemia - (c) Edematous caecum
(a) Oral high protein diet (d) J>Uat.ed .ileu.fl!
, (b) Amino acid (e) Parietal peritoneum
(c) Fresh frozen plasma (f) Exudates which binds them all
(d) Human albumin transfusion
Diagnosis:
4. Correction of anaemia - by blood transfusion ______,/
(A) History : .
5. Correction of hypocalcaemia - Calcium gluconate 10% 1O ml/kg i. v
Sudden onset severe periumbilical pain which gradually shifted to the right lower abdominal
6. Gastric lavage -
region, associated with vomit and fever
Done before each feed for 4-5 days prior to surgery
Its advantages - (B) Clinical examination :
(a) Removes food residues in stomach A tender, smooth, firm, well localised mass palpable 3-5 days after the attack, which is resonant
(b) Reduces mucosa! Edema on percussion, immobile and not moving with respiration ·
(c) Recovery of gastric tonicity
~ce-- ~ °'~~ ~ j's. ~j~•eo.:h~
&~ 64'?ff:~d£cec:t-n,vv../\
QUEST : A Co~p~e'~ Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 65

(C) Investigations : (b) Small gut perforation - typhoid ulcer, tubercular ulcer, Crohn's disease
(a) TLC - raised (c) Large gut perforation - colonic ulcer
(b) USG abdomen - confirms the mass, shows any pus if abscess 2. Inflammations -
(a) Acute pancreatitis
Management : (b} Meckel's diverticulitis
If lump palpable, but not abscess (no fever, no rising TLC, increasing tenderness), then conservative 3. Obstetric causes -
management is done as nature has already localised the infection to prevent spread in peritoneum, which
(a) Ruptured ectopic pregnancy
if distulj)ed, may lead to faecal fistula.
(b) Uterine perforation/injury during abortion or termination of pregnancy
i
~ e r - Sherren regif"{l_gfl; ~.:.:;;;,.- \ I ~, j
4. Intestinal obstruction with strangulation
I (a) Nothing per mouth 5. Penetrating or blunt trauma abdomen
[ (b) Intravenous fluid 6. Perforation during surgery
· (c) Analgesics 7. Septicaemia
(d) Antibiotics 8. Dissecting aortic aneurysm rupture
(e) Nasogastric aspiration for initial 2-3 days
(f) Monitoring everyday - (A) History :
(i) Temperature, BP, Pulse (a) Sudden onset, stabbing, upper abdominal pain, radiating to the flanks and back and relieved on
(ii) TLC
leaning forward (Mohameddan prayer position) - Acute pancreatitis
"~- (iii) Palpation of lump to observe the size
(b) Sudden onset severe pain in mid upper abdomen then moving towards right side of abdomen,
(A) If mass reduces in size, temperature and pulse becomes normal, TLC reduces, appetite improves ➔ then becoming generalised - Perforation
patient discharged and advised to come after 6 weeks for interval appendicectomy
(c) Severe pain abdomen + amenorrhoea for 4-6 weeks + vomit or mild bleeding per vagina ➔
(B) Criteria to discontinue the regimen - Ruptured ectopic pregnancy
(a) Patient becomes more toxic (tachycardia, temperature rises)
(b) Persistent vomit (B) Clinical examination :
(c) Increasing size of lump 1. Features of shock - tachycardia, tachypnoea, drowsiness, decreased urine, hypotension
(d) Pain becomes more intense 2. Abdomen - tenderness in all quadrants, IPS may be sluggish or not audible if perforation occurs
(e) Rising TLC or in case of ruptured ectopic pregnancy, tense in consistency if perforation occurs
(f) Appendicular abscess formation 3. Grey Turner's sign, Cullen's sign, Fox's sign in acute pancreatitis
In these cases, immediate surgery is done. Drainage if appendicular abscess. 4. Severe pain abdomen + vomit + absolute constipation + abdominal distension ➔ Intestinal ob-
(C) Contraindications to the regimen - struction
(a) Doubtful diagnosis 5. Chills, elevated temperature, pain abdomen ➔ Septicaemia
(b) .~~!J.t.e 9:ppe_ndlcitis in ch.ild1en.a.nc:l elc:Jerjy 6. Features of perforation may also be present in blunt trauma
(c) Burst, gangrenous appendicitis
(C) Management :
(d) Diffuse peritonitis
Even before going for investigations, our prime concern should be the management of shock. 2 wide
(D) Patient of appendicitis taken for appendicectomy and palpation of right iliac fossa under general
bore cannula should be inserted and i.v infusion started. Ringer's lactate is used initially till arrangement
Anesthesia revealed a mass -
for whole blood is made. Non-sugar crystalloid solution may be used.
(a) If symptoms present for 3-5 days, appendicectomy performed as scheduled
While canulla is inserted, blood is collected for fo~wing investigations -
(b) If symptoms present for longer duration (> 7 days) and a firm lump is palpable, surgery postponed
and conservative management done followed by interval appendicectomy · Hb%, TLC, DC, PCV, ESR, Platelets, ABO and rH gjouping, Serum Amylase and Lipase.
Arrangement for whole blood or packed cell is made in the meanwhile. Nasogastric aspiration is done.
a. 3: A 30 year old lady presented with severe abdominal pain and shock. Discuss differential Patient's status reevaluated. When patient becomes stable than before, necessary radiological
diagnosis and management. f6 + 9} investigations may be done if emergency setup present - USG whole abdomen, FAST, CT scan
abdomen, MRI abdomen.
SEVERE ABDOMINAL PAIN AND SHOCK Prophylactic antibiotics started.
Differential diagnosis : Morphine, Dobutamine, Dopamine, Noradrenaline are to be kept ready for use if the situation demands.
Blood transfusion is started when arranged.
This occurs in diffuse peritonitis which may be due to :
1. Perforation of GIT - In case of acute pancreatitis (as detected by raised Serum Amylase and Lipase, USG/CT findings
showing Edematous pancreas with peripancreatic fluid) conservative management done. [for details
(a) Gastric cause - benign or malignant gastric ulcer ·
refer to page 35]

9
 66 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 67

In other cases, following management done

(a) Ruptured ectopic pregnancy - Salpingectomy. If ovary is adhered or non-viable, then
salpingo-oophorectomy done Spinal injury

(b) Blunt trauma - Diagnostic Peritoneal Lavage (DPL) done. Emergency laparatomy done if Neurogenic
positive lavage signs present such as -
Spinal Anesthesia Due to loss
1. 10 ml or more gross amount of blood
of sympa-
2. Amylase level in fluid> 175 IU/ DL thetic tone
Sudden fright
3. WBC count > 500/mm /\ 3
4. ABC count > 1 lakh/mm /\ 3 Psychogenic
5. Presence of bile, bacteria, foreign body or food particle in fluid Vasogenic Acute pain
Specific surgical procedures (which are carried out if conservative treatment is not enough) Shock
are as follows: (excessive pooling of
• Duodenal injury - lacerations sutured surgically with a stenting or gastrojejunostomy blood in peripheral circu-
lation) Due to pooling of
• Colonic injury - resection and anastomosis. lleostomy/ hemicolectomy may be done if
required blood in limb muscle
Vasovagal and dilated splanch-
• Pancreatic injury - Whipple's operation/ total pancreatectomy nic vessels
• Splenic injury - splenorrhapphy/ splenectomy
Peripheral vasodila-
• Liver injury - small tear is sutured; for large tear Pringle's manoeuvre is applied (by
talion due to release
compressing porta hepatis near Foramen of Winslow)
Anaphylactic of NO, histamine,
Slow Release Ana-
phy'lactic Substance
// 2014 A (SAS-A)
~sify shock. Discuss the patho-physiology and management of septic shock. [3 + 6 + 6]

~ SHOCK
(Classification) :

Intrinsic 1. Ml
(Decreased myocardial 2. Arrhythmia
contractility)
SHOCK
•
Hypovolemic or
Oligaemic or Vasogenic Cardiogenic
Hematogenic Cardiogenic
Refer to next page for Compressive
Refer to next page for details Shock 1. Cardiac tamponade
details (Compression of 2. Pneumothorax
Hemorrhagic Non- (Defective pump cardiac chambers)
Hemorrhagic mechanism)

Bleeding from Bleeding into Due to systemic

injury site injury site Loss of fluid and
plasma e.g. Burn
1------- sepsis by
1. E. Coli Pulmonary
2. Klebsiella e.g. pulmonary
1. External Loss of fluid
3. Pseudomonas Obstructive embolism
2. Internal 1. Into the intestine e.g.
1. Fractured rib Vomiting, Diarrhea 4. Staphylococcus
(Increased peripheral
2. Acute pancre- aureus
2. Into the peritoneum vascular resistance)
atitis e.g. Peritonitis 5. Bacteroides Systemic
e.g. Obstruction of
aorta
 68 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 69

SEPTIC SHOCK Most blood pooled in cutaneous vascular bed ➔ skin red and hot
.j,
Pathogenesis :
Diminished circulating blood volume
Causative organisms - .j,
Both Gram positive and Gram negative organisms - mainly Reduced blood supply to the vital organs and other areas
(a) E.coli
(b). i<Tebsiella (B) Stage of white/cold shock :
(c) .·Pro1eu·s- Bacterial toxins cause an intravascular inflammatory process
(d) Pseudomonas .j,
(e) .. Bacterioids
· Release of inflammatory factors
• Gram positive sepsis and shock - caused by dissemination of a potent exotoxin liberated .j,
from the organism, without evidence of bacteria; arterial resistance falls but there is no
reduction in cardiac output with normal urine output ' Damage of lining wall of capillaries
• Gram negative sepsis and shock - caused by .j,
(i) operation or instrumentation in the genitourinary system Exit of fluid from intravascular space into interstitialtissues
(ii) respiratory system infections .j,
(iii) gastrointestinal tract infection Sharp fall in total blood volume
.j,
Toxins/ endotoxins from organisms
.j, Hypoperfusion of vital organs
.j,
Inflammation, cellular activation of macrophages, neutrophils, monocytes
.j, Activation of cutaneous pressor mechanism
.j,
Release of cytokinesis, free radicals
.j, Blood diverted from less es~I skin to important vital organs ___,,,,_-·
.j,
Chemotaxis of cells, endothelial injury, altered coaiulat[on cascade - SIAS Skin becomes cold and pale
.j, ((;{t:S' WN·c ' r
Reversible hyperdynamic warm stage (Z-e,tp:i /, ;9'VN e This sequence of red and white shock, however, occurs only when the patient is normovolaemic prior
.j, - . to the onset of systemic sepsis. In contrast, if systemic sepsis develops in a subject who is already
Sev7e circulatory failure with DIC - MODS ( ~i}Jtti L}}ff' 'I' hypovolaemic, the patient passes straightaway to the stage of cold shock.
Another important component of septic shock is marked oxygen desaturation of tissues, affected by -

Hypodynamic, irreversible cold stage 1. Progressive pulmonary dysfunction -

Stages of septic shock:
Septic shock is usually a combination of vasogenic and hypovolaemic shock.
The vasogenic component - consists of pooling of a large volume of blood in the skin reducing the
circulatory blood volume. . '
The hypovolaemic component - due to generalised leakage of intravascular fluid into the interstitial
tissue through the capillary walls, which suffer widespread damage due to bacterial toxins.
(a) Primary cause is leakage of proteinaceous fluid through the damaged capillary walls into the
interstitial tissues of the lungs and then into the alveolar spaces, causing gradual loss of
alveolar function.
(b) The condition is worsened by superimposed bacterial infection.
2. Decreased oxygen utilisation by the tissues due to -
(a) Arteriovenous shunting
(b) Inability of the cells to utilise 0 2 as a direct effect of sepsis

(A) Stage of red shock : Management :

Systemic sepsis . (A) TREATMENT FOR SEPSIS -
.j, (a) Identification of the source - Bacterial blood culture, USG, CT, MRI may be ~elpful if source is not
Hypermetabolic state and heat production increases evident
.j, Diminution of arteriolar resistance (b) Antibiotics - Combination of Cefazolin + Gentamicin/ Amikacin + Metronidazole started as generally
the source is GIT. Later antibiotic therapy according to culture sensitivity report
Heat loss accomplished by diversion of blood to skin by ~ (c) Surgery- Drainage of abscess, surgical debridement, removal of retained products of conception,
~
etc.
J, Opening of cutaneous arteriovenous shunts
 /

70 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - I 71

(8) GENERAL SUPPORTIVE MEASURE - 6. ECG

Resuscitation : 7. Chest X-ray
This should begin immediately as soon as the patient is admitted. 8. Serum electrolytes
(a) Establishment of clear airway 9. Blood gas analysis at regular intervals
(b) Maintenance of adequate ventilation and oxygenation - lowering of head (increases cerebral
circulation, prevents stasis of blood in leg muscles thereby preventing Edema), support of jaw, Q, 2: Describe tt,e clinical features, investigations and management of carcinoma of stomach.
moist oxygen administration [ 4 + 4 +7]
(c) Endotracheal intubation and mechanical ventilation may be needed in case of airway obstruction
CARCINOMA OF STOMACH
(C)~_~ATMENT FOR SHOCK -
.Clinical features :
(a) Extracellular fluid replacement:
(A) SYMPTOMS:
(i) 2 wide bore cannula inserted and intravenous infusion is started .
1. New onset dyspepsia
(ii) _i=l~L@Q!file is initially used (@ 1-2 It in 45 mins) till arrangement for whole blood is made.'
It is better to withhold administration of blood until surgical control of bleeding is obtained or 2. Anorexia, nausea and loss of weight along with fatigue
atleast until just before induction of Anesthesia. Rapid replacement of fresh blood after con- 3. Continuous upper abdominal pain or discomfort without periodicity, not relieved by food
trol of Hemorrhage will lead to fewest complications. At times when bleeding has been 4. If gastric outlet obstruction occurs -
severe, blood should be given before surgical control of Hemorrhage. (a) Sensation of fullness after meals or early satiety
(iii) Non sugar crystalloid solution is used; sugar is avoided because it induces osmotic dieresis. (b) Belching
(iv) Colloid solutions should not be· used as in cases of severe shock, there is generalised (c) Projectile vomiting - Vomitus is yellowish in colour (non-bilious), contains food material
damage of capillary endothelium and colloids may come out into interstitial tissues causing consumed more than 12 hours ago, leaving a sour taste in mouth
pulmonary embolism. (d) Feeling of a rolling mass moving from left to right in the abdomen (due to peristalsis)
5. Lump in abdomen
(b) Drugs: 6. Due to metastasis -
(i) _S__E:!_d_~iyg_s - used to alleviate pain (a) Abdominal swelling (due to ascites from hepatic or peritoneal metastasis)
- Morphine fqr adults, barbiturates for children (b) Breathlessness (due to pleural effusion from pulmonary involvement)
(ii) Chronc)!ropic agents - used in patients having slow heart rate (c) Yellowish discolouration of eyes and urine (due to enlarged lymph node obstructing porta
- Atropine most widely used, followed by lsoprenaline hepatis)
(iii) _lonotropic <'l:~~~s - used to improve myocardial contraclility (d) Backache (due to metastasis to vertebrae)
- Dopamine, Dobutamine
(8) SIGNS:
(iv) Vasoc_onstrictors - Norepinephrine i~~-~.!. choice
1. General swvey-
(v) E.~eroids may be used if no response with adequate fluid replacement
(a) Cacheclic look may be present
(vi) Sodium bicarbonate - used if metabolic acidosis occurs (b) Pallor
(c) Jaundice may be present
(D) M(:)Nl"[QBJl':,lG. -
(d)~ged Virchow's lymph node (left supraclavicular) - Troissier's sign
1. Vital signs - (e) Enlarged Irish nodes in left axilla
(a) Pulse - Progressive tachycardia and irregular pulse indicate deterioration (f) Superficial migratory thrombophlebitis - Trousseau's sign
(b) BP - Better indication is MAP > PP> DBP or SBP (g) Due to paraneoplastic syndrome -
(c) Respiration - Persistent rapid and deep respiration and presence of cyanosis are unfavourable • Dermatomyositis
• Acanthosis nigricans
signs
• Circinate erythema
(d) Temperature - Cold clammy skin is unfavourable, hyperpyrexia in septic shock is dangerous
2. Sensorium - Restlessness is unfavourable 2. Systemic examination -
3. Urine output - MOST RELIABLE AND EASIEST GUIDE OF ADEQUATE PERFUSION. Urine (a) Abdominal examination -
output< 0.5 ml/kg/hr is insufficient (i) Nodular hard mass, with impaired resonance, moves up and down with respiration is
4. CVP (Central Venous Pressure) - Best way is to raise the rate of transfusion till CVP rises to 10- palpable
15cm of water (ii) In cases of gastric outlet obstruction -
5. PCWP (Pulmonary Capillary Wedge Pressure) - Indicates left ventricular function; Swanganz • stomach is distended
Pulmonary Artery Floatation Catheter (SPAFC) is the best technique • succusion splash audible
• greater curvature of stomach below umbilicus on ausculto-percussion
 72 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - I 73

(iii) Sister Mary Joseph's nodule looked for(due to infiltration of umbilicus) (b) Adjuvant therapy : (chemotherapy after surgery)
(iv) Ascites is looked for Purpose - to increase survival rate
(b) Rectal exa.mination - • Regimens which may be used -
To detect metastasis in pelvis and to exclude Krukenberg's Tumor 1. 5-Fluorouracil + Leucovarin
(c) Skeletal system examination - 2. 5-Fluorouracil + Adriamycin + Mitomycin C (FAM regime)
To look for sternal tenderness and bony tenderness 3. Cisplatin, Epirubicin, Adriamycin, Oxalilatin, Capecitabine are other drugs used

Investigations: (C) Radiotherapy -

1. Routine blood examination - low Hb, high ESR No role

2. Routine stool examination - occult blood present in 80% cases (D) Lymph node dissection -
3. Gastric function tests - gross hypochlorhydria or achlorhydria and blood in basal secretion Group I (perigastric) nodes and Group II (along root of major vessels) nodes are removed generally
4. Upper GI endoscopy (is the Gold Standard) and 1O quadrant biopsy
5. Barium meal X-ray(if Endoscopy not possible) - (E) Palliative procedures -
(a) irregular filling defect (a) Palliative partial gastrectomy - best method
(b) loss of rugosity (b) Palliative anterior gastrojejunostomy
(c) delayed emptying (c) Devine's antral exclusion operation
(d) dilated stomach (d) SEMS (Self Expanding Metal Stents)
(e) margin of lesion projects outward from lesion into gastric lumen(Carmann's meniscus sign) (e) Laser recanalisation
6. For staging - (f) Palliative chemotherapy - FAM regime
(a) Chest skiagram(P.A view) 1. Adherent to pancreas or colon or mesocolon
(b) CT Scan abdomen, chest, pelvis 2. Ascites
(c) MRI abdomen, chest, pelvis 3. Para-aortic lymph nodes
(d) Endoscopic ultrasound 4. Secondaries in liver
5. Blummershelf lymph nodes
7. Others -
6. Enlarged Virchow's node
(a) LFT 7. Sister Mary Joseph nodule
(b) PT 8. Irish node
(c) FNAC left supraclavicular lymph node /~:
(d) Laparoscopy for staging Q. »::A 50 year old patient presents with bleeding per rectum. How will you investigate and manage
(e) Tetracycline fluorescence test \._..,/· the patient ? [ 7+8]
(f) Tumor markers - CA 72, CEA, CA 19-9, CA 12-5
(g) Combined PET
(h) Sentinel node biopsy BLEEDING PER RECTUM IN 50 YEAR OLD
Management :
Causes of bleeding per rectum :
(A) Surgery -
(A) Local causes :
{Treatment of choice)
1. In rectum and anal canal -
(a) If early growth involving pylorus region - Lower radical gastrectomy + Billroth II anastomosis (a) Hemorrhoids
(b) If growth in oesophago-gastric junction or upper part of stomach - Upper radical gastrectomy + (b) Anal fissure
Oesophagogastric anastomosis (c) CA Rectum
(c) If growth in body of stomach - Total radical gastrectomy + Oesophagojejunal anastomosis (d) Rectal polyp
(d) EMR (Endosr.opic Mucosa! Resection) is done in Japan (e) Ruptured perianal hematoma
(B) Chemotherapy - (f) Others - ulceration, trauma, ruptured anorectal abscess, skin excoriation

(a) Neoadjuvant therapy : {chemotherapy before surgery)

2. In colon -
Purpose - (a) CA colon
1. to increase reducability {b) Ulcerative colitis
2. to reduce recurrence (c) Crohn's disease
3. to determine chemotherapy sensitivity {d) Angiodysplasia of colon
(e) Amoebic ulcers

10
74 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 75

(f) Diverticular disease (B) Clinical examination :

(g) Bacillary dysentery 1. General survey -
(h) lschaemic colitis Pallor in CA, ulcerative colitis, Crohn's disease, bleeding diathesis
(8) General causes : 2. Abdominal examination -
(a) Lump in right or left iliac fossa - CA colon
(a) Blood dyscrasia (b) Distended abdomen - Ulcerative colitis
(b) Liver failure 3. Inspection of anal opening - for Hemorrhoids, fissure
(c) Renal failure 4. Digital per rectal examination -
(d) Drugs - NSAIDs, steroids Not done in Anal fissure as painful
Diagnosis: Hemorrhoids is not palpable unless thrombosed
CA rectum, polyp may be palpated
(A) History : 5. Proctoscopic examination -
1. Onset- Visualisation of Hemorrhoids, Rectal polyp, Ca rectum
Acute bleed occurs in
(a) Angiodysplasia of colon (C) Investigations:
(b) lschaemic colitis 1. Colonoscopy
(c) Acute episodes of ulcerative colitis 2. Endorectal USG
In rest conditions there is chronic bleed. 3. Barium enema ( when not much scope for colonoscopy )
2. Amount of blood loss - 4. Biopsy
(a) Very small amount - Anal fissure (streak of fresh blood on stool) 5. For staging - X-ray chest, USG abdomen, CT abdomen
(b) Profuse - Hemorrhoids, acute bleeding conditions Routine investigations for pre-anaesthetic check up - Hb, TLC, ESR, blood urea, serum creatinine,
3. .Colour of blood - blood sugar, serology, Chest X-ray, ECG
(a) Bright red - from rectum or anal canal
Management :
(b) Dark red - from colon
(c) Black - (melaena) from small intestine or higher up 1. Hemorrhoids - (See chart on the next page no. 76)
4. Relation of bleeding to defecation - 2. Anal fissure -
(a) At the time of passing hard stool - Anal fissure
(b) At the time of passing stool, or just after defecation - Hemorrhoids TREATMENT OF ANAL FISSURE
(c) At times other than during defecation - Prolapsed piles, polyp, CA, ulcerative colitis, Crohn's
disease, angiodysplasia, etc.
5. Nature of blood - GENERAL ACUTE CASES CHRONIC CASES
(a) Blood alone - Polyps, Villous adenoma, Diverticulosis
(b) Blood mixed with mucus - Ulcerative colitis, Crohn's disease, lschaemic colitis, CA colon
Preventing constipa-
(c) Blood streaked on stool - CA rectum, Anal fissure Bed Rest Lateral anal
tion by-
(d) Fresh blood as splashes in pan - Hemorrhoids sphincterotomy
i) drinking lots of fluid
(e) Bright red blood in stool - Rectal polyp ii) high fibre diet
6. Associated pain - iii) no high quality pro- Nifedipine ointment Dorsal fissurectomy
tein with sphincterotomy
(a) Present in - Anal fissure
(b) Absent in - CA, polyp
Bulk forming agents, Lord's dilatation under
(All pathological conditions above Hilton's line are painless, below Hilton's line are painful GA
except CA) stool softeners Topical
nitroglycerine
7. Associated symptoms -
(a) Change in bowel habit (constipation followed by Diarrhea), constant colicky pain, distended Sitz bath (sit in warm Laxative, xylocaine
abdomen, palpable lump - Left sided colonic CA water with anal region used
dipped in water for 20 Botulinum toxin
(b) Paleness+ dull pain in right lower abdomen + palpable mass - Right sided colonic CA mins, 2-3 times a day)
(c) Tenesmus, bladder symptoms, palpable mass - Sigmoid colon CA
(d) Spurious Diarrhea, tenesmus, bloody slime - Rectal CA
(e) Something coming out per rectum - Hemorrhoids, polyp Once recovers, regu- Diltiazem
lar anal dilatation
(f) Diarrhea - Ulcerative colitis, Crohn's disease, dysentery
ii
76 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Pape/- ·1· • , 77 -
'
I

MANAGEMENT FOR BLEEDING HEMORRHOIDS

I
I (h) Proper preoperative bowel preparation -
• Low residue diet for 48-72 hour before surgery, only clear liquid on day before surgery,
I T I
no feed on day of surgery
GENERAL
l I LOCAL
I SURGICAL I LATEST OPTION l •
•
Elemental diet for 3-5 days before surgery
Single dose of oral polyethylene glycol dissolved in 2It of water on day before surgery

Preventing constipa-
tion by-
Injection sclerosant
therapy (sclerosants
>--
Milligan Morgan Pro-
cedure (Ligation and
excision of piles)
L Stapling
(minimally inva-
sive method)
•

i) drinking lots of fluid
L--
ii) high fibre diet
iii) no high quality pro-
tein
Local application to
- reduce pain
H Antibiotics, laxatives
Sitz bath (sit in warm
water with anal region
L--
dipped in water for 20
mins, 2-3 times a day)
•
Bowel wash using normal saline for 2-3 days before surgery
• Total gut irritation
Antibiotics
like ethanolamine ole-
L--
ate injected using
Gabriel syringe, 3-5
ml per piles, repeated
H Park's Submucosal
haemorrhoidectomy
(i) Abdomino - Perinea! Resection (APR) - sigmoid, descending colon and upper rectum is
mobilised per abdominally; anal canal with perianal and perirectal tissues are dissected per
anally; retained colon is brought out as end colostomy in left iliac fossa.
6 weekly)
Hill-Fergusson
closed method
I (j) APR is the treatment of choice when
• Mesorectum is involved
• Poorly differentiated Tumor
• Nodes involved
Barron's band ligation
(bands placed 2 cm (k) Criteria for anterior resection -
,____ above dentate line,
• Upper and middle third rectal growth
only 2 piles banded at
a time) ,
• Above peritoneal reflection
• Well - differentiated Tumor
• < 4cm size Tumor
~ Cryosurgery • T1 N0/T2N0 Tumor
• Tumor without lymphatic or venous spread
-i Infra red coagulation
(I) Hartmann's operation - excellent palliative procedure done in elderly people who are not fit
for major surgery, and in locally advanced Tumors.
(m) Preoperative and postoperative radiotherapy

L--
Lord's dilatation (man-
ual stretching of anal
canal in permanently
H Laser therapy
(n) Chemotherapy -
• Neoadjuvant
prolapsed piles) • Adjuvant
OGHAL • Palliative
'-- (Doppler Guided Hemorrhoidal 4. Rectal polyps :
Artery Ligation Transanal endoscopic microsurgery
5. CA colon:
(a) Right - sided : Right radical hemicolectomy with ilea-transverse anastomosis. In inoperable
3. Rectal carcinoma -
cases, ilea-transverse anastomosis is done as a by-pass procedure.
(a) Surgery is the main method of treatment.
(b) Left-sided : Left radical hemicolectomy
(b) Abdomino-Perineal Resection (APR) is the gold standard.
(c) But _if Tumor is well differentiated and if there is adequate margin above the anal canal, a 6. Crohn's disease, Ulcerative colitis :
sphincter saving Anterior Resection (AR) may be done. (a) Steroids
(d) Total Mesorectal Excision (TME) should be the goal. (b) Azathioprine
(e) Principles of surgery - (c) 5-ASA
• Distal margin - 2cm away from the lesion (d) Antibiotics
• Proximal margin - 5cm away from the lesion (e) Metronidazole
• Radial margin - 3cm of mesorectum to be removed
(f) Surgery if medical methods fail
(f) Laparoscopic APR/AR is becoming popular.
(g) For carcinoma rectum presenting with obstruction, an initial proximal colostomy is done. 7. Angiodysplasia :
Neoadjuvant chemoradiation is given. Patient is reassessed for operability. Then APR is Bipolar coagulation along with angiography is the treatment : embolisatiom may be done.
done with permanent colostomy.
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 79

2014 Supplementary • Active blood loss > 100 ml/h

• Age > 70 year
Q.1 : What are the diseases of umbilicus? What are the presentation and treatment of Meckel's Hemoglobin > 7 g/dl with :
diverticu/um? [2 + 6 + 7]
Comorbid disease states or Hemodynamic instability
A: • Diseases of umbilicus - See Section 1, Segment A, Paper-I, 2009, Os. 3 (Page No. 18) [BP= Blood pressure; HR= heart rate; Sv 0 = mixed venous saturation of hemoglobin in oxygen;
• Meckel's diverticulum - See Section 1, Segment D, Os. 45, Page No. 503 BE= base excess.] 2

□ complications -
Q.2: How will you assess a breast lump in an elderly woman? Outline the treatment options of an
See Section 1, Segment D, Os. 33 (Page No. 495)
early breast cancer in a woman of 50 years. [6 + 9]
□ Massive blood transfusion -
A: See tion 1, Segment A, Paper-II, 2011, Os. 1, Page No. 128. See Section 1, Segment D, Os. 18, (Page No. 483)
./'
Q.3,,f.(. at are the indications of blood transfusion? What are its complications? What do you
\ _ y / understand by massive blood transfusion? {3 + 8 + 4] 2015
\ __,.,
_

Ans : BLOOD TRANSFUSION a. 1 : Describe the biological process of wound healing. What are the factors affecting wound healing?
Treatment options for pre sternal keloid. [ 5 + 5 + 5 = 15 ]
□ Indications -
• Severe blood loss from trauma/bleeding ulcer/any pathological lesion WOUND HEALING
• During major operative procedures
• Severe burns • Wound:
• Severe anaemia pre and post operatively Wound occurs when integrity of any tissue is compromised ( e.g. skin breaks, muscle tears, burns
• Surgery of haemophilia patients or in thrombocytopenia or bone fractures), leading to disruption of the strucJure andJunction of the skin and/or its under-
* Special indications - ' lying tussue.
/ /
• Whole Blood : • Slo/oglcal process of wound hj(;J}{h!! :/,..,...----
-
-
Acute blood loss
Shock
fr '<. "'-' _, ound heali~~r~re ....: .,"_
I. _:.;,;,_.,~c;;;.:;,~ /f·
- Exchange transfusion in neonate II.
• Packed red blood cells : Ill. __,________ -< _ ;j
00
- Chronic severe anemia
IV ::::..::.:::.;.:.,a~~=:.:.. sue fOrmalTon (
- Leukemia V ------.
- Thalassemia • wni J!! , ~

• Platelets concentrate : I. In ation -

- Thrombocytopenia i:>,la{e1ets adhesion and aggregation
Bleeding due to platelet dysfunction - J,
Malignancy
Form haemostatic plug along with clotting factors
- Major surgery
J,
* Transfusion indications -
Transcient vasoconstriction followed by vasodilatation of blood vessels
Hemoglobin ::; 7 g/dl
Hemoglobin > 7 g/dl with one or more of the following : l
• Systolic BP < 90 mm Hg Increased permeability of blood vessels due to histamine and other chemical mediators
• HR> 100 beats/min J,
• Cardiac index< 2.21. min-1 .m-2 Stasis of blood flow
• Sv0 < 65% J,
2
• Arterial lactate > 2 mm/I Margination of the polymorphonuclear leucocytes
• · Base excess ::; 8 mEq/I :r
• Oxygen delivery < 600 ml/min Rolling (mediated by selections) along vessel surface
80 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

,j,
Adhesion to vessel surfacei (mediated by integrins) Fibrocytes secrete tropocollagen
,j,
Diapedesis / Transmigration of WBC through vessel wall (mediated by PECAM-1)
,j, Tropocollagen Condense Reticulin fibres

Chemotoxis (main chemoattractant - Csa) j,. Condense

,j, Collagen
Opsonisation (main opsonin - C3b)
,j, • Collagen formation begins by Day 5
• Maximum collagen formation on Day 20-21
Phagocytosis of b..~£t~~Lll}icrol:>e l:>y WBC
B) Stage of devascularisation :
Clinically, inflammation represented as
• redness • Granulation tissue looks pale as some vessels undergo atrophy or their lumen get oblit-
erated due to intimal proliferation.
• warm
• Nerve fibre and lymphatics formed.
• tender
• Mast cells appear and then disappear
• swelling
• Finally scar tissue formed (Process called cicatrization)
• loss of function
II. Wound contraction -
V. Scar remodelling -

After an initial lag period of 14 days, wound contraction occurs, when wound is reduced to almost • Central scar remodels itself after complete synthesis of scar tissue
80% of its size. It occurs due to - • Collagen remodelling increases tensile strength of tissue, by effective cross-linking
• Collagen contraction
• Action of myofibroblasts
Ill. Epithelialisation -
Basal cells on wound edges lose their attachment to underlying dermis, and migrate into the
n
Wound
Contraction
wound
J,
Fixed basal cells near wound edge proliferate
,j, ,,\ ..
.41\'.•:··:

__
Entire wound re-epithdialised within 36-48 hours.

-~__;::..__;__ ___ _____________

Layering of epithelium
J,
begins
_:_

IV. Scar I Granulation tissue formation -

and cells on surface become keratinised
..,.,........... .

0.1 0.3 3 10 30 100

(A) Stage of vascularisation : Days
After 72 hours, neutrophils are replaced by macrophages
-l, • Factors affecting wound healing -
See Section 1
They move towards centre of wound
-l, • Treatmen, options for pre-sternal keloid -
Capillary loops and fibroblasts organise themselves into granulation tissue ~13'3 .secti~n 1; segment C; paper 2; 2013 supplementary; Question No 9 (Page 420).
-l,
I Cl. 21"/45 year old gentleman presents with intractable anaemia and a painless lump in right iliac
Capillary loops differentiate into arterioles and venules i · ../ fossa of 3 months duration. How would you investigate the case to confirm the diagnosis.
-l, Briefly outline a comprehensive management of the problem. [ 8 + 7 = 15 ]
Fibroblasts fibrocytes

11
82 QUES1 ':'AComprehensive Guide to UG Surgery, Orthopedics & Anesthe~,iolocy, SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 83

ANAEMIA AND PAINLESS LUMP IN RIGHT ILIAC FOSSA ,__

(C(.... lnv2,~ti~!ions
•
__
-~..,,.-" : )
Blood investigations -
• Age - 45 years
• Sex - Male Complete blood count - Reduced hemoglobin
• Chief complaint - Anaemia + painless lump in right iliac fossa * CEA (Carcino Embryogenic Antigen) - Level > 5 ng/ml is significant
LFT (to check hepatic metastasis)
The above history clearly indicates a probable Right sided colon cancer. For confirmation, we
n!'led to take some other history, examine clinically and concfuae wTth certain investigations. Guaiac test - for occult blood in stool
• Radiological -
<~i=~~ • Diet - Red meat intake
Colonoscopy and biopsy (to confirm)
Virtual colonoscopy may be done
Saturated fat intake
Low fibre in diet • Others to determine spread of lesion -
Vitamin A, C, E deficiency FNAC of palpable lymph nodes
All these are dietary risk factors. For staging and operability ➔ PET CT > CECT Abdomen
• Addiction - For 'T' stage / depth ➔ USG
Sm9_king, ?lcohol - increase risk • Treatment -
• Comorbid medical conditions - Staging (Duke's Staging) Treatment
Intestinal bowel disease (Ulcerative colitis > Crohn's disease) - Long standing diarrhea,
abdominal discomfort and pain, severe malnutrition increase the risk A Restaicted to Mucosa + Submucosa (Surgery);

• . ~-Family flisto.ry of -
·~:_;; ·"::... . ~.,.~ ..-~. ·-
,_,., ,.,

- FAP
- Gardner's syndrome
] High cisk
- Turcot's syndrome

-
-
HNPCC
Pentz-Jeghers syndrome
Junenile polyposis syndrome
J Less risk
C2 - B2 + lymphadenopathy

;
Neoadjuvant chemotherapy
J,
su7e~
"

)
\

• Associated clinical features -

•, Adjuvant chemotherapy _,,,/ ··-~.
- ~le~~!r.:!9 per rectum - Early feature
Distant metastasis
- Anorexia
Maiaise
- Abdominal discomfort ] More in left • Surgery-
Recent change in bowel habit Sided colon CA Ju.rnor in caecum ➔ ~..fil!l9§!.Lrl9~Ll:1.~.micolectomy
(Removal of terminal 1O cm ileum, caecum, ascending colon, right 1/3 transverse colon
(8) ::§~~!:~~~;~
• 'General - * Severe pallor
and ligating right branch of middle colic artery)
Tumor in ascending -9.olqnJ.hiw.atLc;;JL~~Y.re ➔ Extended right hemicolectomy
* Cachectic look (Radical right hemicolectomy with removal of right 2/3 transverse colon and ligation
beyond left branch of middle colic artery)
• Abdominal - Mass in right iliac fossa with following features :
These are followed by ilea-transverse anas tumor
Non-tender
• Chemotherapy -
Mobile C -:"+- F \F
Hard
Localised
(1) Folinic acid .. r:·:r: r\,t C·r--
I·r·-7""
(2) 5-Fluoro uracil
Impaired resonant sound
·cr :5:" FD1
;/ ~
Does not move with respiration
• Systemic - * Any hepatomegaly
~7 rr"t·'\
* Lymphadenopathy Oniplatin lronetecan
* Ascites J, J,
* Bladder abnormality FOLFOX FOLFORI
Regimen Regimen
84 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 85

(due to mixing of undigested fat with metabolised blood derived ) + Diarrhea with pale, foul
• lmmunotherapy-
smelling stool in periampullary CA.
Bevacizumab
Cetuximab
(l>C§~~~~~
• Liver metastasis - 1. · General survey -
Resection of involved segment (a) Pallor in CA
(b) Jaundice
• Follow-up-
(c) Enlarged Virchow's node in CA head of pancreas
CEA levels
2.Abdominal examination -
Colonoscopy
USG - Abdomen
LFT
} every 6 monthly
(a) Smooth, non tender, globular mass with well defined lower, medial and lateral margins,
moving with respiration palpable in right hypochondriac region i.e. Gall bladder - CA head of
pancreas, periampullary CA, Choledochal cyst (according to Courvoisier's Law, in a patient
• Pre-operative preparation - with jaundice, if there is palpable gall bladder, it is not due to stones)
Bowel preparation (See Page No. 58-59) (b) Hepatomegaly - in CA head of pancreas, periampullary CA, Cholangiocarcinoma, Klatskin
• Blood transfusion (if HB < 10 g%) Tumor (if soft - due to hydrohepatosis, if hard, nodular - due to secondaries)
Antibiotic prophylaxis ? ~ e a u ' s sign (migratory superficial thrombophlebitis) in CA pancreas

9,.,a:'
Catheterisation

A 50 year old male comes to you with painless progressive jaundice and on clinical examina-
·--.-~
(C) ef,westigatior,i~
(a) LFT-
tion the gall bladder is palpable. How will you investigate the patient to come to a diagnosis? (i) Increased total bilirubin
Describe the preoperative preparation of jaundiced patients. [ 10 + 5 = 15] (ii) Conjugated bilirubin raised
(iii) ALP, GGT highly raised
PAINLESS PROGRESSIVE JAUNDICE WITH PALPABLE GALL BLADDER (iv) AST, ALT raised
(v) Albumin : globulin ratio normal or may be altered with reduced albumin
• foLJ,_ryoisier~J_aw - In a case of painless progressive jaundice with palpable gall bladder, the (b) Prolonged prothrombin time
cause is unlikeiy to be gall stones. (c) USG abdomen
• Based on this, choledocolithiasis is ruled out. (d) ERCP - 'double duct' sign in CA head of pancreas
• When gall bladder is palpable, the jaundice is likely to be obstructive type, which needs to be (e) Barium meal - 'Pad' sign in CA head of pancreas, 'Reverse 3' sign in periampullary CA
confirmed from history and investigations. --·--•.. ·· (f) MRCP
• Now from the knowri causes of obstructive jaundice (See Question No. 3, Page 10), the congenital (g) CT Scan
causes can be ruled out due to the given age of the patient.
(h) CA 19-9 in CA head of pancreas, periampullary CA
• Inflammatory causes may be ruled out due to absence of fever, pain abdomen.
(i) PET
• So, the most likely D/D are -
(j) EUS
(1) CA h~ad 2!_e.1mcreas
(k) Urine tests - (i) Fouchet's test (for bile pigments)
(2) .Periampullary _GP.. (ii) Hay's test (for bile salts)
·'··'""''~ .Cholangiocarcinoma_ (iii) Ehrlich's test (for urobilinogen)
(A) History.~;)
PRE-OPERATIVE PREPARATION OF JAUNDICED PATIENT
·~·r.-"chief complaint -
(a) Yellowish discolouration of urine, eyes and skin (a) Immediate hospitalisation
(b) Intense pruritus (b) Diet - high carbohydrate, low protein, no fat diet along with vitamin and calcium supplements
(c) Clay coloured stool (c) Adequate hydration with oral and intravenous fluid
2. Sex- (d) i.v mannitol - 10% 200ml before, during or after surgery or lnj Furosemide 40mg i.v
(e) lnj Dopamine 2 ug/kg/min
(a) CA head pancreas, periampullary CA more common in males; Cholangiocarcinoma more
(f) lnj Vitamin K 10mg for 3 days to correct prothrombin time ➔ if still no improvement, fresh frozen
common in females
plasma is used
3. Associated symptoms - (g) Blood transfusion if severe anaemia
Weight loss + asthenia + anorexia in all CA (h) Broad spectrum antibiotics
Painless progressive jaundice in CA head of pancreas. Intermittent jaundice + Silvery stool (i) If preoperative bilirubin > 10mg%, ERCP stenting or PTBD done, else MRCP done.
 86 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 87
_,, , .~·~ _,.,,.,..,,,,.
/ _,,,,..

2015 Supplementary ~ ; , ; ; grading of ulcer-

r-------------
i Grade O - preulcerative lesion / healed uJser
Q.1 : Discuss the etiopathogenesis and management of acute pancreatitis [7+ BJ 1 Grade 1 - superficial ulcer
A: See Section 1, Segment B, Paper-I, Os. 10, Page No. 247. Grade 2 - ulcer deeper to subcutaneous tissue exposing soft tissues or bone
Q.2: Define burns. Discuss the management of 40% burns in a 22 year female patient of 50 kg body Grade 3 - abscess formation underneath/osteomyelitis
weight, carrying 12 weeks pregnancy. [3 + 12] : Grade 4 - gan_~!~f part of the tissues/ limb / foot
A: BURNS Grade 5 - gangrene of entire one area/foot

□ Types of burns : VENOUS ULCER

A) Thermal injury
- Scald See Section 1, Segment C, Paper-I, 2013, Os. 2, Page No. 301. _
Flame burn
Flash burn /,,,,,,,,,. 2016
- Contact burn
B) Electrical injury ~:-i1-~ sify haemorrhage. Discuss briefly the management of haemorrhagic shock. Mention
complications of blood transfusion. [5 + 5 + 5]
C) Chemical burns
- Acid Ans: CLASSIFICATION OF HAEMORRHAGE
- Alkali
D) Sun burns See Section 1, Segment A, Paper-I, 2012, Qs. 1 (Page No. 40)
E) Ionising radiation
F) Co!d injury - Frost bite MANAGEMENT OF HAEMORRHAGIC SHOCK
Rest--::/s'ee Section 1, Segment A, Paper-I, 2013, Qs. 1, Page No. 49.
// / See Section 1, Segment A, Paper-I, 2008, Os. 1, (Page No. 3)
a.~;A5ta§,Sify ulcers. Discuss the pathology, clinical features, investigations and management of
~---efnous ulcer. [5 + 2 + 2 + 2 + 4] COMPLICATIONS OF BLOOD TRANSFUSION

A: ULCERS See Section 1, Segment A, Paper-I, 2008, Os. 1, (Page No~

CLASSIFICATION ,a.~<k-Sifyear old man presents with alternate constipation and diarrhoea. He has a lump in left iliac
V - fossa. How will you investigate and diagnose the case? Outline treatment of such a case
[6+ 4 + 5]
Clinical Ans: See Section 1, Segment A, Paper-I, 2012 Supplementary, Qs. 2, (Page No. 40)
Pathological
Spreading I 0.1/'A ~;; old man presented with a recently discovered lump in the epigastrium with rapidly
(Edge inflammed and oedematous) \___,,,/ _,,,~veioping anorexia, asthenia, anaemia and increasing vomiting. How would you investigate to
arrive at a diagnosis? Outline the management of the case. [8 + 7]
Healing Specific Non-specific Malignant
(Sloping edge + Healthy granu- + Serous • Syphilitic • Traumatic • Carcinomatous Ans: LUMP IN EPIGASTRIUM
lation tissue discharge) • Tuberculous • Venous • Melanotic
Callous • Meleney's • Arterial • Rodent □ Symptoms -
(lndurated + Unhealthy granu- + Difficult ulcer • Trophic • Lump in epigastrium
edge lation tissue to heal) • Actinomycosis • Bazin's
• Rapidly developing anorexia, asthenia, anaemia, increasing vomiting.
• Tropical
• Infective All these symptoms favour the diagnosis ''.Gastri~!£lnoma leading to gastric outlet__
• Diabetic obstruction"
• Cortisol SeeSection 1, Segment A, Paper-I, 2009, Qs. 2, Page No. 16
ulcer See Section 1, Segment A, Paper-I, 2014, Os. 2 Page No. 71
• Martorell's See Section 1, Segment C, Paper-I, 2009, Os. 3 Page No. 282.
hypertensive
ulcer
 88 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - I 89

// 2016 Supplementary □ Investigations:

/ /
• Blood - Complete hemogram
:. p:f~at is gangrene? What are the different types and causes of gangrene? Discuss briefly the
- LFT
~ / management of a young male of 32 years with dry gangrene on his left great toe? [2 + 5 + BJ
- KFT
A: GANGRENE - Blood sugar
• Arterial Doppler
□ What is it:
• USG Abdomen - to know about status of aorta
Macroscopic death of tiss~.e_!n situ with g_r:.~~hout putrefaction
□ Treatment :
□ Types:
A) Limb saving methods -
• Dry
• Wet
Limb saving methods
□ Causes:

Traumatic < Direct

Indirect Treatment of Surgeries to improve

1
underlying Care of feet Drugs limb perfusion
Secondary to arterial occlusion Buerger's disease cause (as per need}
To be kept dry Antibiotics
Raynaud's disease Management
➔ Lumbar sympa-
Atherosclerosis of diabetes Injury to be avoided Pentoxiphylline . thectomy
Diabetes Use of proper foot- Vasodilators
Emboli wear (Microcellular
➔
___ __
Omentoplasty
---~~----- ~--~--,..
,

Low dose aspirin

rubber footwear- ➔ Profundoplasty
-....------~·--~---.-
Venous gangrene MCR) Dipyridamole

1
➔ Arterial. graft by-
Limb not to be pass
Infective Gas gangrene Ticlopidine
warmed
Fournier's gangrene ➔ Femoropoplite.EI
Praxilene
Cancrum eris Pressure areas to thrombectom_y or
be protected -~_ndarterectomy
Boil
Carbuncle Pus to be drained
Measures to relieve
Physical Burn pain
Scald
Nutritional supple-
Chemicals mentation
Irradiation
Electrical
B) Life saving methods - Limited amputation is sufficient for dry gangrene.
Frost-bite
Different types are -
MANAGEMENT OF DRY GANGRENE • Above knee amputation
• Below knee amputation
□ Diagnosis by examination: • Ray amputation
• Colour changes - pale, greyish, brownish black • Gritti-Stokes tangenital amputation
• Loss of pulsation
• Loss of sensation Q,2: Classify salivary tumours. Describe the pathology, .clinical features and management of
pleomorphic adenoma of parotid gland. [5 + 3 + 3 + 4]
• Loss of function
• Dry mummified Ans: SALIVARY TUMOURS
• Line of demarcation between viable and non-viable tissues

12
 90 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 91

~~1fication - TRIPLE ASSESSMENT

,----------------------------------------,
Salivary tumours
Triple assessment

Epithelial Secondary
Lymphoma tumours
Non-Epithelial (common in from head Clinical Imaging Pathology
parotids) &neck

Lipoma
Adenoma Acinar cell L,ymphoepithelial

J
Pleomorphic
J,
I
Monomorphic
tumour

Muco
epidermoid
Angioma
Neurofibroma
Sarcoma
t Benign
Malignant
Age Mammography Corecut

tumour Haemangioma
Adeno
Mixed Confident diagnosis in 99.9% of cases
lymphoma
parotid
Carcinoma
tumour Oncocytoma
Adenocarcinoma
Oxyphil EARLY BREAST CANCER
tumour Adenoid cystic carcinoma (least malignant)
Mucoepidermoid carcinoma (commonest) See Section 1, Segment A, Paper-II, 2011, Os. 1 (Page No. 128)
Basal cell
adenoma Anaplastic carcinoma (highly malignant)
Squamou~ cell carcinoma i. / / 2017
Pleomorphic adenoma changing into
malignancy
\q. : ' ~ b e the signs, symptoms, prevention and treatment of tetanus. [15]

Ans: TETANUS

PLEOMORPHIC ADENOMA □ Symptoms:

See Section 1, Segment C, Paper-II, 2012, Os. 5 (Page No 406)

• Stiffness of muscles in jaw, neck and back
• ---------
Pain in muscles
1 .·· /aj:· an;;;;
is triple assessment of breast lump? Discuss how will you manage a patient with early • _f1eadache
) /~~~=:t cancer. [5 + 10] • Anxiousness
• Delirium
/' ~e•

Ans: TRIPLE ASSESSMENT OF BREAST LUMP • Dysphagia

• Dyspnoea
□ lncludes-
• Drowsiness
1) Clinical assessment
□ Signs:
2) Radiological imaging
• t:Jeck rioictit'.:l....
3) Cytological / histological analysis
• Spasm_of all rTl~~cle~--
• Tonic clonic convulsions
• _Trismus_~ ~-l:~. to spasm of masseter and pterygo~~s
• Risus sardonicus - due to spasm of zygomaticus major
• Postures - (i) Opisthotonus (backward)
92 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 93

(ii) Emprosthotonus (forward)

\
Q.2: Discuss the investigations of a 50 year old male presenting with obstructive jaundice and
(iii) Pleur~~~rafl5end) palpable gall bladder. Give the outline of management of the patient. How will you prepare liver
• __ljyperreflexia for operation if needed? [5 + 5 + 5]
• Abdominal wall rigidity + haematoma Ans: See Section 1, Segment A, Paper-I, 2015, Os. 3, (Page No. 84)
• Urinary retention
Q.3 : Discuss the pathophysiology of acute intestinal obstruction. How will you manage a case of
• Constipation
intussusception? [5 + 10]
• Respiratory problems - Dyspnoea
• Features of carditis Ans: ACUTE INTESTINAL OBSTRUCTION
• Fever
□ Symptoms:
• Tachycardia
□ Prevention: See Section 1, Segment C, Paper-I, 2016 Supplementary, Os. 5, (Page N o . ~..
See "Active Prophylaxis" - Section 1, Segment C, Paper-I, 2011, Os. 4 (Page N o ~
INTUSSUSCEPTION /
□ Treatment:
A) General measures - See Section 1, Segment A, Paper-I, 2011; Os. 2, (Page No. 37)
• Admission in hospital - kept in isolation in dark, quiet room, away from noise and light
• ATG (Anti Tetanus lmmunoglobulin) - 3000 IU intramuscular
~ 2017 Supplementary
• lfATG not available/not affordable - AT.S{Anti Tetanus Serum) - after initial intravenous test
dose - 50000 IU intramuscular or 50,000 IU intravenous 03,Yf!..~5._c!~~e the clinical methods of assessing surface area of burns wound. Describe the
• lnj Tetanus toxoid - 0.5 ml intramuscular ( (J/ '· 1 G ) management of 40% burns injury in a 60 kg female patient. [10 + 5]
1st dose initially Ans : See Section 1, Segment A, Paper I, 2013, 0 1, (Page No. 49)
- 2nd dose after month
Q.2: Mention the causes of nipple discharge. How will you investigate? How will you manage
- 3rd dose after six months
fibrocystic disease of breast? [3 + 5 + 7]
• Wound debridement
• Drainage of pus Ans: See Section 1, Segment C, Paper I, 2008, 0 4, (Page No. 276)
,,-,··
• Local instillation of ATG 250-500 IU O,J-:-1Jescribe the clinical features of Gastric Outlet Obstruction. How will you investigate and treat
• Oxygen inhalation V a 60 year old man presenting with Gastric Outlet Obstruction? [5 + 5 + 5]
• Catheterisation '
Ans : CA stomach - See Section 1, Segment A, Paper I, 2014, 0 2, (Page No. 71)
• Intravenous fluids + Electrolyte balance maintenance I \ 0
\ ! ,-'
• Ryle's tube insertion - for decompression initially and later for feeding
.. / 2018
• Regular throat suction //·/
• Antibiotics - lnj. Penicillin 20 lac IU 6 hourly, lnj. Gentamicin, lnj. Metronidazole "Q} (4a year old man presents with a non-healing ulcer over the lower part of his inferior extremity.
\, ..
• Prevention of bed sore What are the causes? How will you investigate the case? What are the surgical considerations
• Prevention of DVT of diabetic foot ulcer? (No operative details) _________ [3 + 7 + 5]
• Proper back and bowel, bladder care
Ans: ULCER
• Chest physiotherapy
□ Specific measures : □ Definition :
• lnj. Diazepam - 20 mg - 6 hourly It is a break in the continuity of the covering epithelium (skin or mucus membrane)_clue JQ...cell
• lnj.-ChlorpromazLnE:! - 25 mg - 6 hourly death.
• lnj. Phenobarbitone - 30 mg - 6 hourly □ Classification of ulcer :
• Bronchodilators See Section 1,Segment A, Paper I, 2015 supplementary, 0 2, (Page No. 86)
• Steroids
□ Clinical examination of an ulcer :
• Endotracheal intubation / Tracheostomy if required
1. Site
• Ventilator support if required
• Tuberculous ulcer - Neck (over cervical lymph nodes)
 \ SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 95

• Syphilitic ulcer - Penis Q.3: What are the causes of Intra abdominal lump in the region of epigastrium? Discuss the
• Rodent ulcer - Forehead, face management of Hydatid cyst of the liver. [5 + 1OJ
• Venous ulcer - Leg (above the medial malleolus) Ans: EPIGASTRIC LUMP - See Section 1, Segment A, Paper I, 2009, 0 2, (Page No. 16).
2. Number HYDATID CYST OF LIVER - See Section 1, Segment C, Paper I, 2016, 0 5, (Page No. 324)
• Single - Syphilitic ulcer, rodent ulcer, carcinomatous ulcer, venous ulcer
• Multiple - Tuberculous ulcer
2018 Supplementary
3. Size l .//•·

4. Shape rQ.tJ: beflne Claudication. What are the grades of Claudication? How will you manage a case of
5. Margins - May be regular or irregular, oval or rounded ' · Buerger's disease with dry gangrene of the foot? [3 + 4 + BJ
• Tuberculous ulcer - Thin bluish margins Ans: See section 1, Segment B, Paper I, 0 4, (Page No. 224).
6. Edge of the ulcer- It is useful in diagnosis of ulcer as well as assessment of healing
• Tuberculous ulcer - Undermined edge Q.2: What are the common causes of Lower GIT bleeding? Describe in brief how will you investigate
and manage a patient with acute lower GIT bleeding. [5 + 1OJ
• Syphilitic ulcer - Punched out edge
• Rodent ulcer - Raised and beaded edge Ans : BLEEDING PER RECTUM - See Section 1, Segment A, Paper I, 2013, 0 2, (Page No. 54).
• Carcinomatous ulcer - Rolled out and everted edge
Inflamed and edematous edge signifies spreading ulcer.
2019
Sloping edge is seen in a healing ulcer. /< /
~Define shock. Give the etiological classification of shock. Describe the pathogenesis and the
lndurated edge is a feature of non healing/ callous ulcer.
7. Floor of the ulcer __,,, management of the septic shock. [2 + 3 + 5 + 5]
• Tuberculous ulcer - Pale granulation tissue Ans : See Section 1, Segment A, Paper I, 2008, 0.1 (Page No3. & See Section 1, Segment A,
• Syphilitic ulcer - Wash leather slough Paper I, 2014, 0.1 (Page No.~.
• Rodent ulcer - scab (made of epithelial cells and dried serum)
Q.2: A 45 year old lady, known to be having USG evident cholelithiasis, admitted with the complaints
• Carcinomatous ulcer - covered by necrotic tumor, blood and serum of severe pain abdomen radiating to the back, out of proportion to any of the signs present and
• Venous ulcer - Healthy pink/ red granulation tissue her laboratory values showed a significant serum hyperamylasemia (3 times the normal value).
8. Base of the ulcer How would you proceed to investigate further, prognosticate and manage (principles only).
• No induration - Venous ulcer [5 + 5 + 5]
• lndurated - Syphilitic ulcer, rodent ulcer, carcinomatous ulcer, tuberculous ulcer Ans : This clinical picture is suggestive of Acute Gall Stone pancreatitis. See Section 1, Segment B,
9. Any discharge from the ulcer Paper I, 0.10 (Page No. 247).
• Serous - healing ulcer
Q.3: A 54 year old gentleman presents in the OPD with a history of dull, vague epigastric pain with
• Purulent - infected ulcer persistently and steadily progressive yellow discoloration of eyes and urine for last 4 months
• Bloody - Carcinomatous ulcer with intermittent rise of temperature with chills and rigor for last 15 days. He also gives a
• Yellowish - Tuberculous ulcer history of recently developed anorexia and gross weight loss. On examination, his gall bladder
10. Whether the ulcer extends to the normal tissue or not is palpable as soft cystic swelling. How would you proceed to have a detailed work-up of the
11. Examination of regional lymph nodes patient, prepare him for general anesthesia for a major operation and give the outline of his
treatment (principles only including palliation). [5 + 5 + 5]
• Rodent ulcer, venous ulcer - No involvement
• Tuberculous ulcer, syphilitic ulcer, carcinomatous ulcer - lymph node involved Ans: See Section 1, Segment A, Paper I, 2015, 0.3 (Page No. 84)
12. Examination of distal pulses, sensations, joint movements, function of the limb

DIABETIC FOOT ULCER - See Section 1, Segment A, Paper I, 2009, 0 1, (Page No. 13). . / / 2019 Supplementary
Q.2 : A 25 years old female, recently married, presents with sudden pain over the right lower abdomen. eYJ:!°.w ~~uld you estimate the extent & depth of burns in a flame burn victim? How would you
How will you take up the case to come at a diagnosis? Outline the management of Acute , · calculate the quantity of fluid with the type of fluid & dose distribution of fluid necessary for
Appendicitis. (No operative details) [10 + 5J resuscitation of a 40 Kg lady with 40% TBSA {Total Body Surface Area) burn, according to
Purkland Formula? [5 + 5 + 5]
Ans: See Section 1, Segment B, Paper I, 0 1, (Page No. 216)
Ans : See Section 1, Segment A, Paper I, 2013, 0.1, (Page No. 49).
 SOLVED LONG QUESTIONS OF FINAL MBBS O Paper - I 97

Q.2 : A 50 year old gentleman, severely anemic, anorexic & cachectic, presents_ with the hi~tory ~f g, Role of hospital pharmacist :
epigastric fullness & vomiting for last 4 months with the appearance of an irregular ep1gastnc a) Storing and distributing pharmaceutical preparations using practices which limit transmission
Jump for last one month. How would you proceed to diagnose, prognosticate & manage the of infections agents
patient? [5 + 5 + 5]
b) Maintaining records of antibiotics distributed to medical department
Ans : See Section 1, Segment B, Paper I, 0.9, (Page No. 241 ).
□ Role of nursing staff:
Q.3: A 25 year old young lady, married for last 3 months presents at the ER with severe right iliac a) Participating in Infection Control Committee
fossa pain. How would arrive at a clinical diagnosis? What are the differentials diagnosis? What
b) Promoting development and improvement of nursing technique
are the investigations you need to undertake to confirm your diagnosis? [5 + 5 + 5]
c) Ongoing review of aseptic nursing policies
Ans: See Section 1, Segment B, Paper I, 0.1 (Page No. 216).
□ Central sterilisation service :
a) Oversee use of different methods
/' __ December-January 2020 b) Ensure technical maintenance of the equipment
/" . .,,--
□ Role of food service : Maintain cleanliness and hygiene
y ~ a t are Hospital Acquired Infections (HAI) and Surgical site Infections (SSI)? Define Bacteremia
\. . / / "-·· and Systemic Inflammatory Response Syndrome (SIRS)? How would you prevent infections □ Joint effort of housekeeping and laundry services :
(broad outline only) [2½ + 2½ + 2½ + 2½ + 5]
□ Universal I standard precautions for infection control:
Ans: See Section 1, Segment D, Short Notes 0. 79 (Page No._mSystemic Inflammatory Response a) Hand hygiene - follow all steps at following points
Syndrome (SIRS). i) before patient contact
ii) before aseptic task
PREVENTION OF INFECTION (BRIEF OUTLINE) 5 marks iii) after patient contact
Guidelines by National Center for Disease Control (NCDC) - iv) after body fluid exposure risk
v) after contact with patient surroundings
□ Infection control committee to be established consisting of :
b) Personal protective equipment
• Chairper~Q!l.
• Member secretary i) Gloves
ii) Disposable plastic apron
• Members
iii) Mask
• ReTeva."nt ~edica.1 faculties
iv) Eye protection
• Support._services
•
• -
Infection control nurse
Infection control officer
c)
d)
Safe handling and disposal of sharps
Follow needle stick injudy protocol
i) irrigate mucous membrane by washing under running water
□ Aim of sterilisation : Asepsis
ii) never rub/ squeeze the injury site
□ General guidelines for disinfection : iii) wash with soap and water
a) Critical instruments ➔ undergo sterilisation before and after use iv) apply antiseptic lotion to injury site
b) S;critical instruments ➔ high level disinfection before use and intermediate level v) contact emergency room medical officer for management
disinfection after use · vi) complete incident report
c) Non.critical instruments ➔ only intermediate or lo~_level disinfection before and after use e) Safe handling and disposal of waste
□ Role of physician : f) Managing blood and bodily fluids
a) Provide direct patient care practices which minimise infection g) Disinfection of equipment
b) Follow appropriate hygiene practice h) Disinfection of environment
c) Protecting own patients from other infected patients and infected hospital staff
i) Immunization
d) Comply with practices approved by Infection Control Committee
j) Isolation
e) Obtain appropriate microbiological specimen when infection present or suspected
f) Notifying cases of hospital acquired infection

13
98 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- I 99

Q.2: A middle aged gentleman presents with profuse hematemesis following analgesic intake. How ► Progressive weight loss
will investigate and manage this patient? What are the complications of chronic peptic ulcen ► On examination
[5 +5 +5] - epigastric fullness
Ans: See Section 1, Segment A, Paper I, Q. 2 (Page No. 23-24) - outlines of enlarged stomach
- succussion splash
- dehydration
COMPLICATIONS OF CHRONIC PEPTIC ULCER
• Investigations -
□ Most common complications :
► CBC
/--ajPerto;;iio;~", \ ► Serum electrolytes
b) Bleeding ► Renal function test
c) Obstruction ► Barium meal
d) Malignancy ► Oesophago gastroduodenoscopy - dilated stomach with atrophic gastritis
□ ,!~ • Treatment -
• Incidence - 4 - 14 cases per 1 lakh individual a) Conservative - fluid and electrolyte replacement
• . CHn~ca_l _f_ea_tLire -Acute onset abdominal pain which begins in epigastrium, gradually becomes b) Medical - Gastric antisecretory agent

•
generalised (when associated with diffuse peritonitis)
Diagnosis -
□
c) Surgical -
---
Truncal v~otomy and gastrojejunostomy
·-·--· .
Malignancy : Peptic ulcer can give rise to gastric carcinoma in 1% cases mostly adenocarcinoma.
► Chest X-ray (upright posture) - Pneumoperitoneum ~~ See Page No;,?'li. @
► USG - decreased peristalsis and free fluid
Q.3: A lactating women presents to emergency with painful lump in her right breast which is associated
► CECT - identify site of perforation and presence of ongoing leakage
with fever. Write down the clinical examination, investigation and treatment o(this patient.
► Test for H. Pylori infection [5 + 5 + 5]
• Management -
Ans: See Section 1, Segment C, Paper II, Q. 3 (Page No. 362-363) Breast Abscess.
► Nasogastric suction
► Fluid resuscitation
► Antibiotics
June-July 2020
► Surgery - If failure to improve within 24 hours
- Omental patch closure Q, l : Classify wounds. Write In details about wound healing and factors affecting wound healing.
' . [5+5+5]
- Highly selective vagotom~
- Truncal vagotomy Ans: See Section 1, Segment A, Q. 1 (Page No. 13-14) and Page (79-81) "Wound Healing".
- Vagotomy with antrectomy
Q,2: A 60 year old man presenting with palpable lump In right hypochondr/um with yellow
□ ~er: discolouration of eye. What is your diagnosis? Discuss the etiopathogenesis, investigation and
• Clinical features - treatment of this case. [3 + 4 + 4 + 4]
► Melaena Ans:
► Hematemesis
► Features of shock - cold clammy extremit hypotension, tachycardia PALPABLE LUMP IN RIGHT tlVPOCHONDRIUM
• Management - See page 24
□ Obstruction by peptic ulcer:
.□ Diagnosis :
~. • Most common cause CARCINOMA HEAD OF PANCREAS
• Clinical features -
•• •" •w•"-~••-~•--•~•-•--•• • Other causes may be ductal carcinoma
► ~omiting --p~~-~~.!!.l.~, yellow col2.l:!. ~~~ (not bile stained), foul odour - Cholangiocarcinoma of mid portion of common bile duct
► Epigasfric pain - gastric carcinoma with para aortic lymph node metastasis
 100 QUEST: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

SEGMENT-A
□ Etlopathogenesls:
• Risk factors SOLVED LONG QUESTIONS OF FINAL MBBS
Paper- II
Demographic factors Environment / lifestyle Genetic factors & medical conditions
2008
Age (peak incidence Cigarette smoking Family history
65-75 years i) Two first-degree relatives with a, 1 • erate the causes of hematuria. How will you confirm the diagnosis? What will you do for a
Male gender pancreas cancer; relative risk • patient diagnosed to have carcinoma of urinary bladder? [5 + 5 + 5)
Black ethnicity increases 18 - 57-fold
CAUSES OF HEMATURIA
ii) Germiline BRCA2 mutations in some
rare high-risk families ttematuria is defined as abnormal presence of RBCs in urine.
Hereditary panoreatitis (50- to 70-fold i is of 2 types : (1) gross (2) microscopic ( > 5 RBC/hpf).
increased risk) The causes of hematuria are as follows :
Chronic pancreatitis (5- to 15-fold A. Kidney cause :
increased risk) (a) Glomerular hematuria
Lynch syndrome (HNPCC) (i) Primary causes -
1. Acute post streptococcal glomerulonephritis (APSGN)
Ataxia telangiectasia
2. lgA nephropathy
Peutz-Jeghers syndrome 3. Membranous glomerulonephritis
Familial breast-ovarian cancer syndrome 4. Membrano-proliferative glomerulonephritis

I Familial atypical multiple mole melanoma

Familial adenomatous polyposis - risk of
5. Focal segmental glomerulosclerosis
6. Alport syndrome

I ampullary/duodenal carcinoma 7. Benign familial hematuria

(ii) Secondary causes -
Diabetes mellitus
1. SLE
2. Subacute bacterial endocarditis (SABE)
□ Pathology: 3. Henoch Schonlein purpura (HSP)
• Tumors arising in head pancreas are mostly ductal adeno c~rcinoma 4. Hemolytic uraemic syndrome (HUS)
• Solid, scirrhous tumours characterised by neoplastic tubular glands within a markedly 5. Wegener's granulomatosis
desmoplastic fibrous stroma 6. Polyarteritis nodosa
• Infiltrate locally, typically along nerve sheaths, along lymphatics and into blood vessels - 7. Exercise induced hematuria
liver and periton~al mets are common (b) Non-glomerular hematuria
• Often preceded by pancreatic intraepithelial neoplasia 1. Tumors -Wilm's tumor, Renal cell carcinoma (RCC)
• Tumors arising from ampulla or distal CBD can·pr~sent as a mass in head of pancreas 2. Trauma- Stab/ Blunt injury
3. Renal vascular disorders- Renal vein thrombosis, Renal artery embolism, Renal aneurysm,
• lntraductal papillary mucinous neoplasms common in pancreatic head
Arterio-venous fistula
• Jaundice occurs due to obstruction of distal bile duct by the tumour
4. Infections- Pyelonephritis, Tubule-interstitial nephritis
For Investigation and treatment See Section 1, Segment A,. Raper I, Q. 3 (Page No. 27-28) 5. Anatomical abnormalities- Polycystic kidney disease, Multicystic renal disease,
"Management of CA head of pancreas". Hydronephrosis
6. Kidney stone
0.3: Classify bums. How will you manage a case of 30% bums with a short note on post bums
7. Kidney TB
seque/ae. .
8. Idiopathic hypercalciuria
[5+5+5]
B. Ureter cause :
Ans : See Section 1, Segment A, a. 1 (Page No. 49) "Burn Wound" and See Section 1, Segment D, 1. Ureteric stone
a. 107 (Page No. 566) "Post-Burn Contracture". 2. Tumor

101
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 103
102 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

2. Evaluation of gross hematuria -

C. Bladder cause :
(a) Colour of urine :
1. Cystitis
2. Tumor- Papilloma, Urothelial cell CA
• Cola coloured- Hematuria of glomerular or upper urinary tract origin ~
• Bright red coloured- Hematuria of bladder or low~-llii-~ary tract origin ~
3. Tuberculosis
(b) Pattern of hematuria :
4. Vesical calculus
• Hematuria throughout the stream- Hematuria can be of upper or lower urinary tract origin
5. Urinary Bilharziasis
• Hematuria in the later part of voiding- Bladder pathology
D. Urethra cause :
• Hematuria in the initial part of voiding- Hematuria of lower urinary tract origin (Urethral
1. Trauma
pathology)
2. Stone (c) Recurrent hematuria- seen in lgA nephropathy, Alport syndrome, Benign familial hematuria,
3. Tumor Idiopathic hypercalciuria, Exercise induced hematuria, Urolithiasis
E. Prostate cause : 3. Associated features -
1. Benign prostatic hyperplasia (BPH) (a) Pain:
2. Prostate CA • Colicky pain- kidney stone, ureteric stone
F. Miscellaneous causes : • Dull aching pain- Vesical calculus, cystitis
1. Drugs - Analgesics (NSAIDs), Anticoagulant therapy • Painless hematuria- RCC, Bladder CA, BPH, urinary bilharziasis, APSGN, leukemia,
2. Blood dyscrasias - Sickle cell anaemia, ITP, Leukemia anticoagulant overdose, snake bite
3. Coagulation disorders - Hemophilia, DIC (b) Fever- APSGN, pyelonephritis, cystitis, urinary bilharziasis, SABE
4. Snake bite (c) Facial puffiness, hypertension- seen in APSGN
(d) Symptoms suggestive of Lower urinary tract symptoms (LUTS) / bladder outlet obstruction
DIAGNOSIS OF HEMATURIA
(Hesitancy, urgency, frequency, poor stream of urine, dribbling, inadequate emptying) - BPH,
Prostatic CA, bladder/urethral pathologies
Freshly passed urine is (e) Night fever, weight loss- Genitourinary TB
I collected in a test tube (f) H/O sore throat (2-3 weeks back)/ pyoderma (3-6 weeks back) - seen in APSGN
I (g) Deafness, visual problems- Alpert syndrome
I l (h} Urticaria for a few days, fever after 4-8 weeks-Urinary bilharziasis
'
Naked eye/gross examination Microscopic 4. Occupational history :
of Centrifuged urine on examination • Aniline dye factory workers- Bladder carcinoma
standing for some time
Long distance runners (> 10 km) - Exercise induced hematuria
I
I
I
I •
• Fresh water swimmers - Urinary bilharziasis
1. RBCs with/without ABC 5. Family history-
Red or reddish
Uniformly pink casts - Hematuria • Hematuria with non-progressive renal disorder - Benign familial hematuria
brown deposit of
coloured urine with 2. No ABC + Anaemia and
intact RBCs with • Hematuria, deafness, visual problems, progressive renal disorder - Alport syndrome
no deposit reticulocytosis present -
clear supernatant
Haemoglobinuria • Hematuria, renal stone- Idiopathic hypercalciuria
I I 3. No ABC + No anaemia 6. H/O drug intake - Analgesics, Anticoagulants
or reticulocytosis -
Indicates Indicates Myoblobinuria 7. H/O snake bite - Snake bite induced hematuria
Hematuria Haemoglobinuria
□ General examination :
1. Pallor - seen in malignancy (RCC, Bladder CA), tuberculosis, HUS, leukemia
Confirmation of hematuria : 2. Jaundice - seen in HUS, coagulopathy with hepatic failure
□ History: 3. Edema - Pitting edema is seen in APSGN
4. Lymph node - Cervical lymphadenopathy may be seen in Genitourinary TB
1. Age-
5. Pulse rate - Tachycardia is seen in rapid blood loss due to renal injury (kidney/ bladder)
• Children - Vesical calculus
6. Blood pressure - Hypertension is seen in APSGN, Polycystic kidney disease
• Young adults - Kidney stone, Kidney TB
7. Temperature - elevated in APSGN, pyelonephritis, cystitis, SABE, urinary bilharziasis
• Adults - Polycystic kidney disease (Onset at 30-40 years of age)
8. Purpuric spots - seen in ITP, leukemia, anticoagulant therapy
• Elderly - RCC, BPH, Prostate CA
 104 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS O Paper - 11 105

9. Osier's nodes - seen in SABE (c) Culture and sensitivity :

10. Butterfly rash, arthritis - SLE • Gram staining - useful in UTI
11. Lymphadenopathy, hepatosplenomegaly - Acute lymphoblastic leukemia • AFB staining - AFB may be observed in genitourinary TB
□ Systemic examination : (d} Special diagnostic investigations :
1. Abdominal lump - • 24 hour urinary calcium, uric acid, oxalate excretion - for urolithiasis, nephrolithiasis
• Kidney lump - seen in RCC, Wilm's tumor, polycystic kidney disease • 24 hour urinary calcium > 4 mg/kg, Spot Urinary calcium : creatinine ratio > 0.2 (in
• Distended bladder - seen in prostatic CA, BPH children > 1 year) - seen in idiopathic hypercalciuria
2. Abdominal tenderness - 2. Blood profiles -
• Renal angle tenderness - kidney injury, polycystic kidney disease (PCKD}, pyelonephr' • Complete hemogram
• Suprapubic tenderness - cystitis, vesical calculus • Serum urea, creatinine
3. PIR examination - • Serum total protein, albumin
• Enlarged smooth prostate, free overlying rectal mucosa - seen in BPH • Serum cholesterol
• Enlarged, hard, irregular prostate, fixed overlying rectal mucosa - seen in prostate CA • Serum electrolytes
4. Examination of genitalia - • Serum C3- Low serum C3 level seen in :
► APSGN
• Varicocele - seen in RCC
► Membranoproliferative GN
• Craggy epididymis, beaded vas deferens, hard and thickened seminal vesicles - seen
Genitourinary TB ► SLE nephropathy
5. Changing murmur in heart - seen in SABE ► SABE nephropathy
□ Investigations : • Serum ASO titre- Increased ASO titre is seen in APSGN
• Serum calcium, uric acid- for Urolithiasis, nephrolithiasis
1. Urine examination -
• 20 minute whole blood clotting test (WBCT)- Clotting time >20 mins indicates snake bite
(a) Routine examination :
3. Renal biopsy- lmmunofluorescent and electron microscopic study is done only when indicated
• Specific gravity
4. Renal function tests -
• Protein
(a) DTPA (Diethylene triamine pentaacetic acid) scan,
• Sugar
(b) DMSA (Di mercapto succinic acid) scan,
• Blood
(c) MAG-3 (Mercapto Acetyl Glycine) scan
• Ketone
5. Radiological investigations -
(b) Microscopic examination :
(a) Straight X-ray of KUB region :
• Phase contrast microscopy - to detect dysmorphic RBC
• Radio-opaque shadows - kidney, ureteric and bladder stones
Glomerular Hematuria Non glomerular Hematuria • Enlarged kidneys - Polycystic kidney disease
(b) Intravenous urethrography (IVU) :
• Clinical features- edema, hypertension~ • Clinical features - edema, hypertension are ' • Filling defects in ureter or bladder - Tumor (if irregular), stone (if regular)
common ~JJltPWWPD • Spider leg deformity of calyces - seen in PCKD
• . Uri7i'e e,Z-~mination - (i)RBC casts - present • Urine examination - (i) RBC casts - absent
• Irregular calyces - seen in RCC
(ii) Albumin - 2+ or more (iii)Phase contrast (ii)Albumin - Trace or 1+ (iii) Phase contrast
microscopy - Deformed/dysmorphic RBC microscopy - Dysmorphic RBC < 15%, • Missing calyces - seen in Kidney TB
> 15%, Acanthocytes > 5%, G-1 cells Acanthocytes < 5%, G-1 cells< 5% (c) USG of abdomen:
(Doughnut shaped cells with blebs) > 5% • enlarged kidney - seen in RCC, Wilm's tumor, PCKD
(d) CT scan:
• Exercise induced hematuria- Glomerular in origin, RBC casts are sometimes present in urine, does (e) Cystoscopy:
satisfy other criterias of glomerular hematuria • Indications are -
• Worm like clots - seen in ureteric tumor ► H/0 Lower urinary tract symptoms (LUTS)
• Flat disc like clots - seen in urethral pathology ► Hematuria with normal IVU
• Pieces of tumor - seen in papilloma of bladder ► Malignant cells found in cytology of urine
• Ova of Schistosoma haematobium - seen in urinary bilharziasis • may be followed by brush biopsy.
• Exfoliative cytology (by Papanicolau staining) • bladder tumor, stone and tuberculosis can be diagnosed.
106 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 107

• bilharzia! pseudotubercles, bilharzia! nodules, sandy patches, ulceration,

granuloma, papilloma (presence of any 1 or more) - suggestive of urinary
MANAGEMENT OF CARCINOMA OF URINARY BLADDER
bilharziasis
A. For noninvasive bladder tumor
(f) Retrograde pyelography - to diagnose bladder and ureteric pathology 1.- Endoscopic resection of bladder tumor
(g) Urethrography - to diagnose urethral pathology 2. Helmstein balloon degeneration and cystoscopic resection :
(h} Transrectal Ultrasound - to diagnose prostate CA, BPH • Done for large papillary tumor
(i) Echocardiography - to diagnose SABE
Algorithm for evaluation of hematuria :
Remaining part
Balloon is Pressure
of the tumor is
passed into Balloon is necrosis of the
IVU resected
urinary inflated summit of the
through
bladder tumor
cystoscopy
Normal Abnormal
3. lntravesical chemotherapy :
• Used especially for carcinoma in situ
Cystoscopy Filling defect in • BCG is mostly used.
and biopsy Renal stone Tumor
the renal pelvis • Dose- 120 mg of BCG in 150 ml of normal saline weekly for six weeks
~=E=~-.=-=...I....=-=-,:::;--;::=:::::i,__---, • A/E- BCG provocation (fever, joint pain, granulomatous prostatitis, disseminated
Normal Bladder Lateralising Retrograde
Renal CT/USG tuberculosis)
tumor ureteric pyelography/
bleeding** Brush cytology • Contraindication- hematuria
• Mitomycin C, adriamycin, epirubicin, metrotrexate, thiotepa can also be used.
Renal CT/USG 4. Systemic chemotherapy :
Solid lesion Cystic lesion • Cisplatin, Adriamycin, 5-FU and mitomycin are used.
(probably (probably
malignant) benign) B. For invasive bladder tumor
1. Radiotherapy :
Normal Tumor
Cystoscopy (a) Interstitial radiotherapy
and biopsy • Often curative.
• Implantation of radioactive gold grains (Au 198, half-life =2.5 days) I radioactive
tantalum wires (Ta 182, half-life = 4 months) is done.
(b) Radical deep external beam radiotherapy
** Lateralising
ureteric bleeding • Dose- 45 Gy
• Cobalt 60 is used
• Advantage- Normal act of micturition can be maintained
Retrograde
pyelography • Complication- Thimble/Systolic bladder
2. Surgery:
• Indications :
Normal Tumor (a) Multiple tumors
(b) Recurrent tumors
Renal CT/USG (c) Sessile tumors
(d) Poorly differentiated tumors
(e) Adenocarcinoma
Normal Tumor (f) Squamous cell carcinoma
(g) Carcinoma in situ
Renal angiography - To rule out renal aneurysm,
arterio-venous fistula, renal vein thrombosis, renal • Modalities :
artery embolism (a) Partial cystectomy-
► Indication- single tumor, tumor confined to fundus of bladder
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 109

► 2.5 cm margin of clearance is mainfainea □ complications :

► Surgery is followed by external beam radiotherapy and chemotherapy. 1. Tracheal obstruction -
(b) Radical cystectomy - • by retrosternal extension of the goiter.
► Removal of urinary bladder, urethra, paravesical tissues, pelvic lymph nodes • may follow hemorrhage into a nodule impacted in the thoracic inlet.
is done. Hyterectomy with removal of part of vagina is done in females. 2. Secondary thyrotoxicosis - Transient episodes of mild hyperthyroidism (30%)
► Urinary diversion is done by ureterosigmoidostomy or continent ileal conduit 3. Carcinoma - Increased incidence of Follicular CA of thyroid reported from endemic areas.
or rectal urinary pouch.
3. Chemotherapy : □ Management:
• The term Multinodular goiter describes an enlarged, diffusely heterogeneous thyroid gland.
(a) lntravesical chemotherapy
• Done by BCG, mitomycin C, adriamycin, interferons. • Multinodular goiter is essentially of 2 types -
(b) Systemic chemotherapy - 1.# Simple (Non-toxic) Multinodular goiter
• Regimen for adjuvant therapy : (i) Cisplatin, adriamycin, mitomycin, vinblastin 2. :fox!S Multinodular goiter
(ii) Methotrexate, vinblastin, adriamycin, cisplatin (MVAC) • Multinodular goiter may present as :
• Neoadjuvant chemotherapy : Cisplatin is used (improves survival by 7%)

Non toxic Multi nodular Goiter Toxic Multinodular Goiter

\ e pathogenesis of multinodular goiter. Mention the complications of such a goiter.
1
How do you manage such a patient? [5 + 5 + 5] • Usually middle aged - 40 to 60 years of age
• More common in middle aged females (10: 1)
• Most patients are asymptomatic • F>M
MULTINODULAR GOITER
• Swelling of neck, dysphagia, dyspnea • Secondary thyrotoxicosis
□ Pathogenesis : • Distension of cervical veins due to pressure • Features of hyperthyroidism- Wt. loss, diarrhea,
effect fatigue and muscle weakness, tremor, oligo -
Persistent TSH stimulation • Dysphonia - Rare and suggests neoplastic le- or amenorrhoea, excessive appetite, emo-
sion tional !ability

I
•
Diffuse hyperplasia Active follicles • Sudden pain with increase in size of gland- • Cardiovascular manifestaions - Palpitation,
due to large hemorrhage within a cyst or a de- Shortness of breath, Angina, Irregular heart
generative nodule or sometimes due to infec- rate
tion. • Dysphagia, dyspnoea
Fluctuating stimulation

I
•
Mixed pattern develops Areas of active and inactive lobules Wayne's Clinical Diagnostic Index -

Signs Present Absent

Palpable thyroid +3 -3
Active lobules
Exophthalmos +2
Become more vascular and Hemorrhage Central necrosis Lid retraction +2
hyperplastic Finger tremor +1

t Bruit over thyroid

Atrial fibrillation
+2
+4
-2

I
Necrotic lobules coalesce to form nodules filled with either iodine-
Pulse Rate:
free colloid or a mass of new but inactive follicles.

•
Centre of the nodule is inactive. Only margin is active
I i.e. internodular tissue is active.
I
I
90/min
80/min
Hands:
hot
moist
+3

+2
+1
-3

t Hyperkinetic movement +4 -4
Continual repetition of this process - formations of many I Lid lag +1
nodules and hence Multinodular goiter.
I
11 O QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 111

Symptoms Present Absent

Non toxic goiter - Often shows patchy uptake with areas of hot and cold nodules.
Palpitation +2 Toxic goiter- "Hot" areas
Excessive sweating +3 7. Indirect laryngoscopy-
Increased appetite +3
To assess vocal cord movements prior to surgery (mainly for documentation and medicolegal
Reduced appetite -3 purpose).
Increased weight -3 8. ECG - To detect cardiac abnormalities
Reduced weight +3 9. Baseline investigations -
Preference for cold +5 a) Complete hemogram: Hb%, TC, DC, ESR
Preference for heat -5 b) Blood for sugar, urea and creatinine
► Index> 19 = Toxic goiter c) Urine and stool routine examination
► Index 11 - 19 = equivocal □ Treatment :
► Index< 11 =Nontoxic goiter (euthyroid) A. Non toxic goiter
1) Most patients with multinodular goiter are asymptomatic and do not require operation.
□ Investigations:
2) Surgery -
T_hyroid function test -
1.
• It is preferred as MNG is an irreversible stage.
a) TSH, FreE:i.!4-~o detect hyperthyroidism.
• Indications -
• Serum Thyroid-Stimulating Hormone (Normal 0.5-5 micro IU/mL)
a) Cosmetic reason
• Total T4 (Reference Range 55-150 nmol/L) and T3 (Reference Range 1.5-3.5 nmol/L)
b) Retrosternal prolongation
• Free T4 (Reference Range 12-28 pmol/L) and Free T3 (3-9 pmol/L)
c) Compressive symptoms
Non-toxic goiter- Usually euthyroid with normal TSH 11ndlow-normc1l or normal free T4 levels. If
some nodules develop autonomy, suppressed TSH levels or hyperthyroidism d) MNG suspected to be neoplastic
Toxic goiter- free T4 - very_hlgt!,. T~H- low or.undetectable • Options -
b) Thyroid Antibodies assessment - to differentiate from autoimmune thyroiditis (TPO and a) Subtotal thyroidectomy-
Thyroglobulin antibodies) and Grave's disease (LATS). ► 2 x subtotal lobectomy + isthmusectomy
2. X-ray neck and chest - to detect tracheal deviation or compression or sometimes calcification. ► 8 g thyroid tissue is retained in tracheo-oesophageal groove on both sides
3. Ultrasound of neck - ► Surgery of choice
• To Identify impalpable nodules (<2-3 mm in diameter) b) Total thyroidectom_y- 2 x total lobectomy + isthmusectomy
• Gives Information about size and multicentricity. c) Hartley-Dunhill procedure - Total lobectomy on the more affected side +
• Distinguishes solid from cystic lesion isthmusectomy + Subtotal lobectomy on the less affected side
• To guide FNAC • Post operative complications - In 7-10 percent cases
4. CT/MRI- • Postoperative levo-thyroxine (0.1 mg daily) - to prevent recurrence
• To evaluate Retrosternal extensions. • Recurrence - 10-20 percent within 10 years
• To detect impalpable nodules
B. Toxic goiter
5. FNAC-
(a) GENERAL MEASURES
• recommended in patients who have a dominant nodule or one that is painful or
enlarging 1. Rest
• Done as carcinomas have been reported in 5 to 10% of multinodular goiters. 2. Sedation
• Most experts have recommended 3-6 aspiration per nodule. Satisfactory specimen (b) SPECIFIC MEASURES
contains atleast 5-6 groups of cells, each group containing 10-15 well preserved
1. Anti - thyroid drugs
cells
• Initially given to make patient Euthyroid before surgery
6. Radioisotope study (Isotope used - I 123 [Half life- 12-13 hrs] or Tc99[Half life-6 hrs))
• Carbimazole 10mg 6-8 hrly- Euthyroid state may be achieved by 6-8 wks
• "Hot" nodule - Toxic
• '.'Warm" nodule - Euthyroid; • Prop~a,n()I()(. 20-40. mg. BD(TDS- To ameliorate cadiovascular symptoms
Warm nodule in Tc99 scan, but cold nodule in RAI scan- Discordant nodule • J. yg..QLsJggir,~ .10-30.c!.rQQ§(c!ay for 10 days prior to surgery - To reduce -..ascularity of
(Malignancy) gland
• "Cold" nodule - 20% malignant, 80% benign 2. Radioiodine therapy
 112 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 113

□ Indications : • Failed radioiodine therapy

• Patient with cardiac complications • Those who require rapid resolution at thyrotoxic state
• Elderly ( initially 40yr age ,however now more than 10 yr age eligible ) □ Options:
□ Contraindication : Pregnancy • Total thyroidectomy (Surgery of choice)
□ Adjuvant: Pretreatment with lithium, rhTSH leads to increased effectiveness of uptake • Near total thyroidectomy - < 2 g of thyroid thyroid tissue is kept only to preserve parathyroid
glands, near lower pole on one or both sides
□ Isotope used: I 131 (half life= 8 days)
• Subtotal thyroidectomy
□ Dose : 300-600 MBq or, 12-14 milicurie or, 160 microcurie/g of thyroid orally
□ Advantages :
❖ Substantial improvement b/w 8-12 wks.
• Rapid cure and High cure rate
□ Disadvantages :
• Recurrent thyrotoxicosis {5%)
Antithyroid therapy until
eumetabolic state (2-8 wk) • Permanent hypothyroidism (20-45%)
• RLN injury
I □ Pre operative :
Medication discontinued for 4 • CT scan, MRI
days • Restoration of euthyroidism

I □ Post operative : ..
\ ~ Carbimazole-10mg, 6-8 hourly
.. 12-14 mCurie rc1_dioiodine is deposited into the
gland based on pretreatment RAIU test
:r-··
No clinical improvement for 7-14 days
I j,
7 days thereafter, antithyroid drug is Euthyroid state achieved in 6-8 weeks
reinstituted for 3 months j,
Maintenance dose - 5mg, 8 hourly for 12-18 months
I
I
If size reduces ] [ No improvement ) / / 2008 Supplementary

~ e r a t e the causes of acute retention of urine. What are the pathological changes associated
Dose of Antithyroid with prostratic hypertrophy? How will you manage such a patient ? [5 + 5 + 5]
Second course of
- drugs is tapered - therapy/Surgery Ans: ACUTE RETENTION OF URINE
gradually

□ Causes:
A) Prostatic causes -
□ Adverse effects :
(i) Benign hyperplasia of prostate
• Low level exposure to radiation
• Hypothyroidism (ii) Prostatitis
• Radiation induced thyroiditis (4% cases) (iii) Carcinoma of prostate
• Therapeutic dosing dilemma B) Bladder causes -
• Orbitopathy (i) Bladder calculus
3. Surgery (ii) Bladder neck muscular hypertrophy
(iii) Bladder neck fibrosis
□ Indications :
(iv) Carcinoma of bladder
• Young patients
C) Urethral causes -
• Mid trimester pregnancy
(i) Urethral calculus
• One or more large nodule with obstructive symptoms

15
114 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 115

(ii) Urethral stricture (Often patient found writhing in distress and pacing about trying to find a comfortable
(iii) Urethral tumour position, whereas patient with peritoneal irritation remains motionless to minimise
(iv) Urethritis discomfort)
D) Other causes - ► Mimics - Appendicitis, cholecystitis, tubal or ovarian disease
(i) Rupture urethra due to trauma • Nausea, vomiting, sweating (due to pain and reflex pylorospasm)
(ii) Phimosis • Increased frequency and urgency of micturition
} mainly in children
(iii) Meatal stenosis • Strangury is fre·q-uently present
(iv) Post-operative cases • Dysuria
(v) Spinal injury • Haematuria
(vi) Following spinal anaesthesia • Tenderness of costo-vertebral (renal) angle or, in iliac Iossa may be found associated
(vii) Faecal impaction sometimes.
□ Investigations -
PROSTATIC HYPERTROPHY • Urine - Routine Examination
A: See Section 1, Segment A, Paper-II 2014, Os. 2, (Page No. 183) Microscopic Examination
- Culture and sensitivity (to be done before starting antibiotics and repeated after
Q.2: Discuss clinical features of pheochromocytoma. How do you diagnose this condition? What treatment)
will you do to manage it?
• !'~~n radiograeh of kidney, ureter and bladder (X-ray KUB)
A: See Section 1, segment A, Paper 11, 2013 supplementary, Os. 3 (Page No. 174) ► detects radioopaque stones in 90% cases
► helps to assess size, shape and location of calculi
2009 ► sensitivity 45-60%
Q.1: A 35 year old lady presents with a solitary thyroid nodule in right lobe. How would you come to a ► cannot visualise radioluscent stones (10% cases)
diagnosis and manage such a patient? [8 + 7) • . Ultrasonography_abdomen..,_
Ans: See Sec 1 Segment-A Paper-I; 2013 Supplementary 0.1, (Page No. 61) ► direct demonstration of stones
► difficult to identify stones between PUJ and VUJ.
Q.2: Classify kidney tumors. Mention different modes of presentation of Renal Adenocarcinoma.
• lntr{!yenous urogra(?hy -
Outline the management of such a patient. [3 + 5 + 7)
► traditional 'gold-standard'
Ans: See Sec 1 Segment-A Paper-I; 2011 0.2, (Page No. 37) --~
► structural and functional information
► only radioopaque stones detected
2009 Supplementary ► contraindicated in contrast reaction, risk of nephrotoxicity
► Metformin to be discontinued at time of IVU and to be withheld for subsequent 48
Q.1 : Define hydronephrosis. What are the causes of unilateral hydronephrosis ? Discuss the hours or when renal function normalises.
management of a patient with stone in middle third of water [2 + 4 + 9] • Non-contrast enhanced CT abdomen -
Ans: HYDRONEPHRO~S \l 1
/
►
►
high sensitivity (96%) and specificity (100%) than IVU
no use of contrast medium
/See Section 1, Segment A, Paper-II, 2013, Os. 1 (Page No@ ~ ► the diagnostic test
·7 ' - • Blood investigation_s -
STONE IN MIDDLE THIRD OF URETER ► Routine (Hb, Platelet, TLC, DLC)
□ Diagnosis - A patient with stone in middle third of ureter will have following clinical presentation. ► Blood urea
• Ureteric colic - ~ with following features - ► Serum creatinine
► Nature - Colicky ► Serum uric acid
► Intensity - Severe ► Serum electrolytes
► Radiation - From loin to groin may extend to genitalia □ Management -
► Increases with - Exercise • Plenty of fluids/water orally
• Medical expulsive therapy - mainly for stones less then 5 mm
 116 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 117

The combination therapy includes - · 1. Effect on general growth and development

1) NSAID - has ureteric relaxing effects • Synthesis of somatomedins
2) Corticosteroid - to reduce local edema through its anti-inflammatory action • Stimulate secretion of growth hormones
3) Antibiotics - to prevent/treat UTI • Potentiate the action of GH
4) Calcium antagonists - suppresses fast component of ureteric contraction, leaving • Increased synthesis of structural proteins
peristaltic rhythm unchanged
2. Calorigenic action
5) a 1 adrenergic blockers - inhibit basal tone, peristaltic wave frequency and ureteric
contraction in intramural parts • • Increase BMR 6) . ,~
• Acute pain to be relieved by pethidine (NOT Morphine)
• Increase body temperature 't;
• Increase 02 consumptioJ.J,._·
. • in all tissues except brain, anterior pituitary, spleen, lymph
• Injection Furosemide along with i.v. fluids for fast relief
nodes and testes I!) .
• Surgical interventions -
3. Metabolic actions
Indications - i) Size of stone more than 5 mm (a) Carbohydrate metabolism :
ii) Impaction for 6-8 weeks • Increased absorption of glucose from gut
iii) Pain comes and goes without further descent of stone • Increased glycogenolysis
iv) IVU shows hydronephrosis/hydroureter • Increased gluconeogenesis
v) Infection superveoos with fever, chills, pyaemia • Inhibitory role on insulin action
Surgeries done - • Increased peripheral utilisation of glucose
i) Uretero-Renosc~pic Stone Removal (URS) (b) Lipid metabolism
ii) Shock Wave Lithotripsy · ·-·· • Stimulates synthesi3, mobilisation and degradation of lipids
iii) Open ureterolithotomy • Lower serum cholesterol level (increases no. of LDL receptors in liver)
Prevention of recurrence - (c) Protein metabolism
• Advise adequate hydration (3-4 lit fluid/day) · · --~-- Normal level of thyroid hormones leads to positive nitrogen balance
•. Avoid diets rich in calcium, vitamin C, oxalate sodium } • High level leads to protein catabolism
Advise dietary fibre and diet rich in magnesium - to reduce oxalate stones (d) Mineral metabolism
··· • Lead to osteoporosis (negative balance of ?alcium and phosphate)
• Allopurinol may be prescribed - to reduce urate stones
• Penicillamine - to reduce cystine stones (e) Vitamin metabolism
' ··-~---Help in conversion of beta-carotene to vitamin A
• Aluminium or ammonium hydrochloride - to reduce phosphate stones
• Acetohydroxamic acid - to reduce bacterial originated stone • Absorption of vitamin 812 from gut
4. Effects on nervous system
Q.2: A 56 year old ladypresents with a lump in upper and outer quadrant of right breast. Discuss • Development and maturation of neurons
briefly the management of such a patient. [15]
• Help in myelinogenesis
Ans: LUMP OF RIGHT BREAST • Maintain a normal reaction time of the jerks
• Increase activity of RAS
See section I, segment B, Qs. 4, Page 267. • High level produces fine tremor
5. Effects on CVS
□ Treatment -
• P'asitive_ino!!:Q.ei.9, chronotropic, bathmotropic and dromotropic effects due to incre~sed
• Early carcinoma - See section I, segment A, Paper-II, 2011, Qs. 1, Page No. 125 nu-mber of beta adrenerg1c receptors and their increased sensitivity to catecholamines
• Locally advanced carcinoma - See section I, segment A, Paper-II, 2013, Qs. 2, Page No. 150. • IQ~Contractility of the myocardium due to increased alpha-Myosin heavy chain in
heart muscles
/,// 2010 • High level produces peripheral vasodilation and hyperdynamic circulation
~ /

· . \c~ What are the functions of thyroid and paratho~mone? Write in detail about clinical features, 6. Effects on musculoskeletal system
\._.,,/ Investigations and treatment of hyperparathyroidism. [3 + 4 + 4 + 4] • .Growth and mainterianceof skeletal muscle
Ans: • Maturation and differentiation of cartilages
• Fusion of epiphyses and growth of bones both in length & girth
Functions of thyroid hormones -
• High level leads to Thyrotoxic myopathy
118 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - II 119

7. Effects on digestive system 6. Kidney - Bilateral, multiple renal stones or nephrocalcinosis may occur
• Mairrt~ins the ~~!-~LJDE~igns of the digestive system 7. Associations - Peptic ulcer, pancreatitis, MEN I syndrome
• Increased level causes increased appetite, increased motility of gut and diarrhea - Band keratopathy, skin necrosis, myalgia, arthralgia, pseudogout, polyuria, glycosuria,
• Decreased level causes decreased appetite and constipation hypertension (33%)
8. Effects on skin 8. The combination of symptoms is known as "Bones, stones, abdominal groans and psychic
moans" _...,..,..._,._ .........__ -
• Normal metabolism of skin proteins like p_~accharI2es, hyaluronic acid, chondroitin
polysulphuric acid etc. ------ 9. Acut;-hyperparathyroidism (crisis)
• Low level leads to retention of these substances along with retention of water in the skin • rare but dangerous presentation
resulting in the edematous look (Myxedema) • Abdominal pain, vomiting, dehydration, oliguria, muscle weakness and death

•
•
-
9. Effects on other functions
Stimulates erythropoiesis
Increases _milk production
□
•
Investigations:
Serum calcium is very high (>12% or> 3.5mmol/L)

1. Serum levels -
• Maintains normal reproductive function • High calcium (> 10mg/dL)
• Has permissive action to some hormones e.g. catecholamines • Decreased phosphorus
• Increased Alkaline phosphatase
□ Functions of parathormone :
• Increased PTH (> 0.5 mg/L) - Diagnostic f
Primarily PTH increases the plasma calcium level for which it acts as follows :
2. Urinary levels -
1. Action on kidneys --· <t.)(_9'L-+
• Increased calcium (> 250mg/24 hr)
• Increases calcium_reabsorp1io_r, in Distal convoluted tubules
• Increased cAMP level in 90% cases
• Formation of calcitriol from 25-hydroxycholecalciferol by direct stimulation of alpha
3. X-ray features -
hydroxylas·e enzyme
• Inhibits reabsorption of phosphate in kidney @ • Salt-pepper appearance of skull
• High level maintains a high plasma calcium level and thus increases the filtered load of • Sub-periosteal erosion of radial side of middle phalanx (specific)
calcium leading to calciuria • Calcification in bones
2. Action on gut 4. Thallium - Technetium scan shows hot spots which are diagnostic of parathyroid adenoma
• 1-:felps absorption of calci!:!__m from the gut through formation of calcitriol in kidney 5. Technetium-99m labelled Sestamibi scan
3. Action on the bones • More sensitive than Thallium-Technetium scan (80%)
• Increases calcium permeability of the osteoclasts, osteoblasts and osteocytes • Very expensive
• Increases osteoclastic activity and bone destruction \ • used in parathyroid re-exploration
• Low concentration stimulates osteoblastic activity (bone remodelling) • Often combined with Single Photon Emission Computerised Tomography (SPECT)
• Overall effect is mobilisation of calcium from bone 6. USG abdomen - to detect problems in pancreas, kidneys
4. Action on serum calcium 7. USG neck and CT/MRI scan of neck and mediastinum
• Increases flow of calcium into blood by- 8. Other investigations - Angiography, Venous sampling (Selective sampling for PTH)
► Mobilisation from bone □ Treatment :
► Increased reabsorption in kidney
A. Medical treatment
► Increased absorption in gut
• Usually ineffective for primary hyperparathyroidism
HYPERPARATHYROIDISM • Occasionally advocated for Acute hyperparathyroidism crisis
► Forced diuresis - 3-5 L of normal saline with Frusemide
□ Clinical features : ► Rehydration - Normal ss!lin.e @300mUhr
1. Common in middle aged women ► To inhibit effects of vitamin D - SteroLds...400mg i.v. for 5 days
2. Asymptomatic in > 50% cases ► Pamidronate (90 mg i.v. slowly in 4 hrs)
3. Nonspecific and psychiatric symptoms (Neurotics) I Zoledronic acid (4 mg initially, 8 mg later)
4. Behavioural problems ► To reduce serum calcium level - Mithramycin, calcitonin, ~[§12_hosQbQ!Jfil~s. Cinacalet
5. Bones - Osteitis fibrosa cystica (von Recklinghausen disease) in 5% cases, which shows (Calcium receptor agonist), Gallium nitrate (inhibits osteoclast resorption of calcium
single or multiples cysts or pseudotumour in jaw, skull or middle phalanges. The first bone to at the dose of 200rng/m2/day)
show these changes is the lamina dura of tooth. ► _estrogens, pro_gElsterons, r~loxifene (Selective estrogen receptor modulator)
 120 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper -11 121

B. Surgical treatment 1O. Filariasis of scrotum

• Indication for .e__arathyroidectomy- 11. Lipoma of the cord
► Severe symptoms 12. Lymphangioma of the cord ' I,
► Serum calcium > 11 mg% \ Inguinal H e ~
;>- I f '
Q
c'-!Y'//•/-'/
t ~-€.91 'I\J O I
► Urinary calcium > 400mg/24 hrs
□ Definition : Hernia is abnormal protrusion of a part or whole of a viscus through the wall of its
► Young age group containing cavity.
► Markedly reduced bone density
□ History:
► Urinary calculi • The swelling reduces in size or disappears when the patient lies down.
► Neuromuscular presentations • The swelling reappears when the patient stands and increases in size on coughing, walking,
• Subtotal parathyroidectomy is the treatment of choice - Surgical removal of the parathyroid straining during defaecation.
"glan.ds ana 1mpTanlalionoTffieglandlissue in forearrrfmuscle mass (Brachioradialis) or neck
□ On examination :
(Sternomastoid). At the transplantation site, marker stitch is plac ed. 100 mg of parathyroid
0

gland or one-third of one gland is auto transplanted. • Expansile impulse on coughing over the swelling observed during both inspection and
• Parathyroid carcinoma - Additional hemithyroidectomy with Lymph node dissection and palpation.
post operative radiotherapy may be required · • On palpation, it is not possible to get above the swelling.
• Parathyroid adenoma of one gland with normal other glands - Removal of that gland with • Anatomically the swelling lies above and medial to the pubic tubercle.
adenoma only • Skin over the swelling is normal.
• Mediastinal parathyroid adenoma - After proper localisation, thoracoscopic removal may be • There is visible peristalsis over the swelling. The swelling feels elastic and soft on palpation,
sufficient is resonant on percussion and bowel sounds are audible over the swelling on auscultation.
• When all four glands are diseased - Total parathyroidectomy along with transcervical • Test for reducibility, lnvagination test, Deep ring occlusion test, Zieman's test etc are done to
thymectomy confirm the diagnosis.
• Familial and MEN syndromes - Total parathyroidectomy is done Vaginal Hydroc~;>- ~C:9'lQ ,>Q)'f' cks~
• Complications of parathyroidectomy -
□ Definition: It is a condition characterised by accumulation of fluid in the tunica vaginalis sac of testis.
► Permanent hypoparathyroidism
□ History:
► ~er~i~t~nt hyperparathyroidism {5%) • No change in size of the swelling with lying down or during standing, walking, strenuous
► _Recu_n:e.ot ~perparathyroidism (12 months after the first parathyroid surgery,
activities.
hypercalcemia recurs)
• No pain over the swelling.
► Rec::~!!~a~al nerve i~fury (1%)
► Hungry bone syndrome (Sudden drop in calcium level after surgery due to increased □ On examination :
- absorption of calcium by bones) • No expansile impulse on coughing.
• It is possible to get above the swelling on palpation.
Q.~rential diagnosis of scrotal swelling. Write in detail about management of testicular • The swelling is soft and cystic in feel.
/ ../ tumor. [5 + 10]
• The swelling is fluctuant and initially transilluminant.
SCROTAL SWELLING • Testis cant be palpated separately from the swelling.
• The swelling is dull on percussion.
□ Differential diagnosis:
1. Inguinal hernia Encysted hydrocele of the cord
2. Vaginal hydrocele □ Definition : It is a condition characterised by accumulation of fluid in the unobliterated intermediate
3. Encysted hydrocele of the cord segment of the~processus vaginalis.
4. Testicular tumor □ History:
5. Hematocele • No change in size of the swelling with lying down or strenuous activities.
6. Chylocele
□ On examination :
7. Varicocele
• No expansile impulse on coughing.
8. Spermatocele
• Swelling feels soft and cystic on palpation.
9. Epididymal cyst
• Fluctuation and Transillumination tests are positive.

16
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 123
122 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

front, the patient is asked to bow. Varicocele gets reduced in size (due to decreased blood
• Swelling is mobile from above downward and from side to side.
flow through pampiniform plexus of veins).
• Traction test - the swelling becomes less mobile on gentle traction to the testis (as it is.fixed
to the spermatic cord). Spermatocele

Testicular Tumor □ Definition: It is an acquired unilocular retention cyst a,•ising due to blockag~_of some portion of sperm
conducting mechanism of epididymis.
□ History:
□ on examination :
• The swelling was initially gradually increasing in size and lately rapidly increasing in size . • Swelling is at the head of epididymis, above and behind the upper pole/body of the testis.
• No change in size of the swelling during daily activities . • It looks like "third testis".
• Vague discomfort or a feeling of heaviness in the ipsilateral scrotum . The swelling feels soft and cystic on palpation.
• There may be acute pain in the scrotum (due to hemorrhage or infarction), abdominal pain •
It is fluctuant, but poorly transilluminant (due to barley water like fluid which contains
(due to retroperitoneal metastasis), flank pain (due to ureteric obstruction), back pain (due to •
involvement of psoas muscle and nerve roots). spermatozoa)
□ On examination : Epididymal Cyst
• It is possible to get above the swelling on palpation . □ Definition : It is a condition arising due to cystic degeneration of the epididymis _(paradidymis/
• Swelling feels firm on palpation . appendix of the epididymis/ appendix of the testis/ the vas aberrans of Haller).
• Loss of testicular sensation . □ History:
• There may be abdominal mass (bulky retroperitoneal metastasis) , extremities edema (due • Occurs in middle age.
to compression of Inferior Venacava). • Swelling is often bilateral.
Hematocele □ On examination :
• Swelling feels tensely cystic on palpation.
□ Definition: !3leeding into the tunica vaginalis sac due to rupture of one of the vessels in the tunica
• Swelling feels like "bunch of tiny grapes" (due to its lobulated surface)
following aspiration from a hydrocele or trauma to the testis.
• ft is brilliantly transilluminant, appear as "chinese lantern pattern" (due to its clear fluid and
□ History:
finely tessellated numerous septae)
• After an history of trauma there is sudden onset of pain and swelling. • Testis can be felt separately from the swelling.
□ On examination :
Filariasis of Scrotum
• Recent hematocele - Swelling is tender, fluctuant, nontransilluminant.
• Old hematocele - Swelling is nontender, nonfluctuant, nontransilluminant with loss of testicular □ History:
sensation. • Gradually progressive thickening and swelling of the skin of scrotum and penis.
• Watery discharge from the skin of scrotum occasionally.
Chylocele
• Recurrent attacks of fever with chill and rigor.
□ Definition : 11 is a type of hydroceJe characterised by lymphatic obstruction of the scrotal contents. ft • Recurrent episodes of pain in the groin and scrotum. ·
usually occurs following multiple attacksofTfiarial e·p1didymoorchitis. The fluid contains fat which is
rich in cholesterol and is derived frorn ruptured lymphatic varyx into the tunica. □ On examination :
• Fissured, hyperkeratotic , rough skin overlying the scrotum and penis.
Varicocele • Testis, epididymis, spermatic cord are not easily palpable.
□ Definiton : It is a condition characterised by dilatation and tortuosity of the pampiniform plexus of
_veins of the spermatic cord. MANAGEMENT OF TESTICULAR TUMOR
□ History : ·· ·· · · Ans: See Sec 1, Segment - A, Paper - II; 2014 0.3, (Page No. 188).
• Swelling usually disappears on lying doi,<,n and reappears on standing and walking.
• Dull aching/ dragging pain in the groin or scrotum. 2010 Supplementary
□ On examination :
• Swelling is at the root of the scrotum. 0.1 : Classify thyroid malignancies. How will you manage a case of follicular carcinoma of thyroid?
[5 + 10]
• No expansile impulse on coughing .
• "Bag of worms" feeling (due to a mass of dilated vein) and thrill observed on palpation . Ans: See Section 1, Segment A, Paper-II, 2012, Os. 1 Page No. 143.
• Bow sign - After holding the swelling between index and middle finger behind and thumb in
 124 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 125

FOLLICULAR CARCINOMA OF THYROID 2011

□ Clinical presentation - .1: Classify carcinoma of breast. How will you investigate and manage a case of early carcinoma
See Section 1, Segment A, Paper-II, 2012, Os. 1 Page No. 143 of breast in a 40 year old lady. [4 + 5 + 6]
Associated features -
• Tracheal compression causing stridor CLASSIFICATION OF CARCINOMA OF BREAST
• Dyspnoea
• Chest pain Ductal CA in
• Haemoptysis situ (DCIS)
In situ/non invasive
• Hoarseness of voice due to Recurrent Laryngeal Nerve involvement
carcinoma
□ Investigations - Lobular CA in
)f • FNAC IS INCONCLUSIVE - fails to differentiate follicular adenoma and follicular carcinoma,
situ (LCIS)
because main features of carcinoma like angioinvasion and capsular invasion cannot be
detected by FNAC_
• Frozen section biopsy is useful
• Trucut biopsy may be done but risk of haemorrhage and injury to vital structure reduces its
use.
• Rest - See Section 1, Segment A, Paper 11, 2012, Os. 1, Page No. 143. No Special Type (NST)/
□ Treatment- Not otherwise Specified
• Current NCCN guidelines recommend Lobectomy along with lsthmusectomy as initial sur2_ery; (NOS)- 70%
followed by frozen section biopsy. If histologic section confirms follicular carcinoma, total
thyroidectomy is advised.
Medullary - 5%
• NCCN recommends total thyroidectomy as initial procedure only if invasive cancer or Breast carcinoma
metastatic disease is apparent at the time of surgery or if patient wishes to avoid a second
surgery
• Therapeutic neck dissection of involved compartments to be done for clinically apparent/ Tubular - 2%
biopsy proven disease.
• Maintenance dose of Tab. L-thyroxine 0.1 mg once daily or T 3 80 µg/day lifelong following
total thyroidectomy. Invasive Colloid - 2%
ductal CA
□ Follow-up - See Section 1, Segment-A, Paper-II, 2012, Os. 1, Page No. 144.
/ .,,-
l ~~ year old patient presents with haematuria. Enumerate the differential diagnosis, plan the
·- ' · investigations and treatment. [4 + 7 + 4] Invasive Invasive cribriform - 2%
lobular CA
Ans: HAEMATURIA 10%

Inflammatory Invasive papillary - 1%

□ Differential diagnosis - See Section 1, Segment-A, Paper-II, 2008, Os. 1, Page No. 94.
breast
□ Investigations - See Section 1, Segment-A, Paper-II, 2008, Os. 1, Page No. 94.
CA-2%
□ Treatment - Invasive
carcinoma Adenoid cystic - 1%
A) Glomerular causes - Steroids (Details - refer to medicine books) Mixed connective
8) Tumor - and epithelial
tissue tumor
• Renal cell carcinoma - See Section-1, Segment-A, Paper-II, 2011, Os. 2 Page 139 Metaplastic - 1%
• Wilm's Tumour - See Section-1, Segment-D, Os. 100, Page No. 560.
C) Ureteric stone - See Section 1, Segment-A, Paper-II, 2009 supp, Os. 1, Page No 114.
D) Bladder carcinoma - See Section 1, Segment-A, Paper-II, 2008, Os. 1, Page No. 107 Carcinosarcoma Angiosarcoma
E) Benign prostatic hyperplasia - See Section 1, Segment-A, Paper-II, 2014, Os. 2, .Page 183
[Refer to Section 1, Segment-A, Paper-II, 2013, Os. 3, Page No. 163]
126 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 127

□ DCIS: • Microscopically-Malignant cells in a background of infiltrate mainly composed of lymphocytes.

• Proliferation of malignant mammary ductal eRitheliaLcells contained within .intact basement • Medullary variant/Basal like breast CA -
membrane without any access to lymphatics or vascular channel. ► Uniformly High grade tumor.
•
·----
Incidence -,k?.Q~
I

\ ► Triple negative status - Negative ER, PR and HER-2/Neu receptors.

• 5 Histological types - ► Express molecular markers of basal or myoepithelial cells.
► Solid - High grade □ Tubular CA :
► Comedo (with necrosis) - ...tfulb.JJL?.clE:l (Most dangerous due to high chances of
• Microscopically - Single cell layer lined tubular structures and open central space.
microinvasion)
• It has best prognosis among all types of ductal CA.
► Cribriform - Low grade
► Papillary - Low grade □ Colloid CA :
► Micropapillary • Microscopically - Malignant cells in a pool of abundant mucin.
• Rarely may present as swelling in breast or solitary duct discharge (nipple discharge) □ Invasive Papillary CA :
• On clinical examination, often there is no palpable abnormality • Microscopically - Malignant cells with papillae having multilayered epithelium and
• On mammography, Clustered microcalcification (5-7 areas of polymorphic, linear or branching fibrovascular stalks.
clusters of calcification) is seen in 75% of cases.
□ Adenoid cystic CA :
• Ultrasound assisted FNAC may be needed for diagnosis.
• Microscopically- Glandular spaces + dense mucoid material.
• Treatment options - a) Breast Conservative Surgery (BCS) with .R~giotherapy.(!:F) to the
breast + Axillary dissection after Sentinel Lynijffi"Node Biopsy (SLNB), if it is positive. □ Paget's disease of the nipple :
► Wide local excision or even Total mastectomy may be needed in some cases followed • It is a superficial manifestation of an intraductal CA with infiltration along excretory ducts
by adjuvant hormonal therapy. leading to early involvement of nipple and areola.
• Prognostic indices for DCIS - • Unilateral eczema-like lesion with distinct edges in perimenopausal women with characteristic
► Van Nuy's prognostic index (Size, Clearance, Grade and necrosis) absence of itching and vesicles.
► Nottingham prognostic index (0.2*tumor size in cm+ lymph node stage+ tumor grade) • Underlying lump is often present. The hard nodule ulcerates causing destruction of the nipple.
□ LCIS: • Microscopically - Presence of Paget's hyperchromatic malignant cells (with a clear halo in
cytosol due to intracellular mucopolysaccharides)
• Arises in terminal duct lobular unit
• Treatment - Modified Radical Mastectomy (MRM)
• Incidence - 3-5%. Common in perimenopausal white females.
• Poses high risk towards causing invasive cancer. □ Invasive lobular CA :
► 65% - invasive ductal CA (lpsilateral or contralateral breast) • Multicentric, multifocal, bilateral tumor.
► 35% - invasive lobular CA (ipsilateral or contralateral breast) • Microscopically - Lobule shows clustered tumor cells within the acini.
• It is Bilateral (50%), multifocal. • Shows Indian file pattern/single file pattern.
• Clinically, no lump is palpable.
□ Inflammatory breast CA :
• On mammography, no calcificatio.!1~-~n.
• Known as Mastitis carcinomatosis/ Lactating carcinoma.
•
• Treatment - Hormonal therapy (Tamoxifen I Raloxifene) ' ,,_
lmmunohistochemistry with_E~::.Qadheriri .anUl:>gcly .~.. F'ositi1,1e
+ Bilateral total mastectomy
"
•
•
Common in pregnant or lactating women.
Rapidly progressive tumor, diffusely involving entire breast tissue, sometimes even extending
□ Invasive ductal CA NOS : to the skin of chest wall.
• Also known as Scirrhous CA. • Clinically - (a) Painful, warm lesion with peau d' orange appearance (b) Diffuse ( due to
• Macroscopically - hard, irregular, whitish yellow, non capsulated mass with cartilaginous obstruction of dermal lymphatics with tumor emboli)
consistency. • It is a clinical diagnosis.
• Microscopically - small clusters of malignant cells between collagen bundles with an intensive • Mimics acute mastitis.
stromal reaction (fibrous stroma). • Microscopically - Ductal or lobular type of malignant cells are seen in dermal lymphatics.
• Atrophic scirrhous CA- Seen in elderly females, slow growing tumor, better prognosis, IOC- • Mammography is inconclusive.
FNAC, TOC- mastectomy or curative brachytherapy. • FNAC confirms the diagnosis (shows undifferentiated cells).
• It is a Stage Ill B (T4d) carcinoma
□ Medu/lary CA :
• Treatment - External radiotherapy and chemotherapy + Salvage surgery, if feasible.
• Also known as Encephaloid type (due to its brain like consistency macroscopically).
• It has got worst prognosis.
• Most BRCA 1 associated ductal carcinoma
 128 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 129

► Findings suggestive of malignant lesion -

~ ~ A R L Y CARCINOMA OF BREAST IN A 40 YEAR OLD LADY
1. Distorted architecture of the breast parenchyma (irregular soft tissue shadow).
- □ Diagnosis : 2. Micro calcifications (< 5 mm) with spiculations.
3. Focal dilatations of ducts.
4. !nc__r-~~l3_e_cl __r,_1J_r:i:,~er and thickening o_f Cooper's ligaments.
Triple assessment 5. J:i~t~rog~n,9JJs,, poly_rnorp_hic_,__high density_ opa~ity -with irregular margin/
for breast satellite lesion. ·
carcinoma ► American College of Surgeons (ACS) guidelines -
A Woman with average risk of breast CA should undergo regular screening
mammography, starting from 45 years age, annually to 54 yrs age, then biennially for
Histopathological/ as long as the woman is in good health and has a life-expentancy of at least 10
History + Physical Radiological years.
Cytological
examination imaging
analysis ► Usual views taken -
1. ~----"-,__,_,,,
Medio-lateral-oblique
.~~=----(MLO)
'""' view
\Y \_,,- 2. Cranio cau9filC.fL'{!~~
□ . · I assessment :
Cl,mca ',
I,, MR, '7~ .,, " ► Amount of radiation exposure during mammography - 0.1-0.2 cGy (this amount of
40
•
•
_
!:Jard lump ___________ 40
_:,_ in the breast which is most ,,.,,,,.,--~""
commonC painless.
The second most common presentation ~~_ipple discharg~
__
,.,.,.,,,,

• USG -
radiation being not enough to cause malignant changes in breast itself)

• Ulceration and funga!Jon of nipple areolar complex and /or surrouding skin. ► Done mainly in young females < 40 yrs of age in whom mammography is less
• _Ly_mPttnode_ E3Dlarge~! - ~xi~_~ry, ~praclavicular.
sensitive due to dense-breast tissue.
~~-~,/"~,~•~•.#"'",_,,,,w"' ,,~, •"_.~•~
r
--••~ ,,,,.-.,,_.
·-·-~--~-~-------~
► It is a preferred method for screening in pregnancy and early lactation.
• Pai11 on the lesion (10% cases).
► Purpose -
• Qh~st pain, ~~en.1optysjs, t:Jone p_aj_11 and tenderness, pathological fracture, ascites, pleural
~ffusion --- 1. To know whether the lesion is solig_O!E~tic.
• Symptoms due to secondaries in Jl~er, secondary ovarianJl!IJ!9r. 2. To define__~_?.e, _fil(tent and texture_9f._!~e lesion.
► Findings suggestive of malignant lesion -
□ Radiological imaging :
1. Irregular internal echoes:
• First investigation to be done in a case of early breast CA is always a radiological imaging, as - 2. Irregular posterior acoustic__~~adow.
)&7 -> ► These are non-invasive investigations. 3. !!!~g}Jl~r margin.
<2"'0- -:,,.. ► FNAC/ Open biopsy , if done first, may cause hematoma, which will alter the findings 4. Non compressibility.
on imaging. ~~-~v-/"-
5. Ratio between anteroposterior to lateral/horizontal dimensions is >1.
• MAMMOGRAPHY - 6. Hypoechoic, more vertical mass.
► Done in females > 40 years of age. 7. High frequency signals with continuous flow on doppler.
► It is the only reliable means to detect non-palpable breast CA. 50% of breast CA may ► Disadvantage - ,Lesions< 1 cm n:,ay _!>g_ffiissed.
be seen on mammography before they are palpable. Further, it can identify breast ► Can guide FNAC, cheaper, easily available and has no risk of radiation.
CA at least 2 years before the mass becomes palpable.
► Indications - • MRI -
1. To evaluate suspicious breast lump, nipple discharge. ► Purpose -
2. To identify multicentricity, to know size and location of the masses. 1. To idef!t!fY ml!lti!ocaL(> 1 foci in one quadrant) and n.1ulticentric breast. tumor
(MRI is even betfer than USG). ... - - - .
3. To screen contralateral breast for additional masses in a patient undergoing
definitive surgery. 2. To image breasts with breast implants.
4. To screen both breasts before any cosmetic surgery. 3. To detect local recurrence or scar after mastectomy.
5. Screening before Breast Conservative Surgery (BCS). 4. To assess axillary metastasis.
6. Follow-up after BCS / Radiotherapy/ Neo-adjuvant chemotherapy. 5. To assess dermal extension.

17
 130 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 131

► Indications - □ Histopathological/ Cytological analysis -

1. Screening of yo!Jng worn en and. worn13n in high risk group (History of
therapeutic radiation in age < 30 yrs, Strong family history of breast CA, A) BREAST BIOPSY
BRCA 1/2 mutation, Personal history of DCIS/ Invasive breast CA, family
history of beast and ovarian CA)
\ □ Types:

l
2. Suspected DCIS (MRI is the most sensitive investigation for DCIS)
► There is no risk of ionising radiation. Biopsy of bre~st
► IOC for imaging breasts in pregnant female. tussue
► It is a better modality than other investigations for dense breasts. I
I I
► Findings suggestive of malignant lesion -
For palpable For non-palpable
1. Mass with irregular intensity and spiculations
2. Thickened skin, changes in nipple.
tumor
I tumor I
I
3 .. Lymphedema. I I I I
Minimally
► Disadvantages - I
FNAC Core needle Frozen section Excision al invasive
1. Costly, not available easily. biopsy biopsy biopsy breast biopsy
\
2. Not accurate, if done within 9 months of radiotherapy for breast CA. _.._j I .
~
3. Cannot be done in patients with incompatible metal prosthesis like cardiac
pacemaker.
~'()~i~J I

Stereotactic
I

Ultrasound/
I
Needle localised
, ...;;::: Bl RADS (Breast Imaging Reporting and Data based Scoring system) : "'\~9~ncl. Mammographic MRI guided excisional

►
biopsy (NLEB)
\/,x::/ • This is a scoring system based on different investigations.
► Based on this, advice can be given regarding further investigations and diagnosis.

□ FNAC:
• Fine needle aspiration cytology is the first, simplest and least invasive technique for obtaining
Grade 0 Grade 1 Grade 2 a cell diagnosis in breast cancer

• Inadequate/Incomplete
assessment
-
• Normal / Negative
-·~--..--
• Continue annual
• Btmigri_
• Continue annual
•
•
Mininum 6 aspirations are done using 21-30 G needle
Giemsa, hematoxylin and eosin, papanicolaou stains used
• As breast tissue is dense, mammography mammography • It can be repeated 2 times
mammogram cant interprete • Advantages : (1) least painful (2) cheap (3) reliable (4) can be done on Out patient basis (5)
• Needs additional study no evidence of malignant deposits along FNAC track
• Disadvantages : (1) Receptor study cant be done (2) Invasive cancer cant be differentiated
from in situ disease (3) False negative results do occur, mainly due to sampling errors
□ Core needle biopsy :
.Grade 3

• Possible/Probably
benign
Grade 4

• Suspicious lump
• Chance of CA =
Grade 5

• Highly suggestive of
malignancy
Grade 6

• Biopsy provEm
r:nalignancy
•
•

• Chance of CA = 1-2%
• Repeat imaging after • Biopsy recommended
3-6 months
•
---
It is the preferred method for diagnosis of palpable or non-palpable breast abnormalities
Permits analysis of breast tissue architecture to give clear histological evidence and definitive
preoperative diagnosis
Can confirm DCIS and invasive lesion
25-50% • Chance of CA = • Known carcinoma
75-90% • Can comment about grade and receptor status of tumor
• Biopsy required 0 Frozen section biopsy:
• Not usually practiced now-a-days
• Indication : when FNAC fails even after 2 trials or is negative
• Disadvantage: Shows 20% false negative results
132 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 133

□ Exclslonal biopsy: • Sensitivity - ~ue dye : 90%, Radioisotope · 98%

• Also known as open biopsy • ~est_l!leth.o.d.ls.. combined pce0Ritf_!:!ti11~u.!!.c:IJ.Q.!~~ope injectiQn inJ9 peritumouL~~~a+
• It is the best and definitive investigation for breast cancer per~e~~tive patent blue dye inj~2!iQr:ilnJh!t!.U.bru.e2J~LI~.9lQ!1,.
• Incision is planned in such a way that it will be included in the eventual mastectomy incision • Positive SLNB - (a) Macrometastasis (> 2 mm) (b) Micrometastasis (< 2 mm)
at a later date • Contraindicated in -
• Should give no false negative and no false positive results ► Pregnancy
► Inflammatory carcinoma of breast
□ Needle localised excisions/ biopsy (NLEB):
► Patients allergic to vital blue dye or radio-colloid
• Procedure: (1) Through an incision under local anesthesia, a hook is placed adjacent to the
suspected lesion, using needle sheath over the tumor (2) Excision biopsy is done under • Complications -
mammographic guidance ► Anaphylaxis
• Indication : When core needle biopsy fails to localise non-palp,able tumor ► Seroma formation
► Blue tattooing of skin
B) SENTINEL LYMPH NODE BIOPSY (SLNB) ► Passage of blue-green urine and stool for a small period

• The first lymph node draining the breast CA is referred to as Sentinel lymph node. C) AXILLARY SAMPLING
• It is the first lymph node to be involved by tumo/cells-:· . -··----
• Not commonly used now.
• The incidence of skip lesion (involvement of other lymph nodes skipping the sentinel node) is as
• Done by separate adequate curved incision, 6 cm below the apex of axilla, between the outer
Iowas 3%.
border of pectoralis major and latissimus dorsi.
• It is done in all cases of early breast CA (stage T 1 and T 2) without clinically palpable lymph nodes,
, About 10-15 lymph nodes (Level I) are sampled.
before wide local excision of the primary tumor.
, If Level I lymph nodes are not palpable, then only level II and level Ill lymph nodes are sampled.
• Markers used :
, At least 4 largest lymph nodes are removed and sent separately for histological examination.
► Blue ~Y_!- lsosulphan vital blue dye (2.5-7.5 ml)
• Can detect skip metastasis in level II or level Ill lymph nodes.
Meth_yl~11e blue dye
► Radioisotope - 99Tc radioisotope l_abelled albumin (1 mCi) □ Other Investigations :
99Tc tagged sulphur colloid • Triple receptor assessment-
□ Procedure : ► Estrogen ReceptorjER} Sti;!dY
• Estrogen sensitive cytosolic glycoprotein level > 10 units per gram of tissue is
known as ER +ve status.
Preoperative (12 hours prior to surgery) or peroperative injection of .the marker at the peritumour
-~-~~ or into· the subdermal plexus around nipple. Breast Is massagecfio Increase the uptake * ER +ve status indicates good response to hormone therapy and good
I prognosis.
T ► Progesterone receptoJJ,eBL~udy
Marker in sentinel node can be seen visually as blue staining or with a gamma camera

' '
I
Small incision Is made over the sentinel node. Blue dye stained lymphatics can be traced to f •
2-3 lymph nodes. Hand held radloprobe may"be used to identify the sentinel node
► HER 2/Neu receptor study
• Human epidermal growth receptor 2 Neu oncogene, also ltnown as cErb 82,
is a tyrosine kinase receptor.
• Positivity indicates high grade tumor and poor prognosis.
Cytological analysis of nipple discharge
► Sample is obtained through ductal lavage.

I • Tumor markers
► CA 15/3 (Normal serum value <40 U/ml)
Sentinel node along with 2-3 nodes are removed. Frozen section biopsy / Touch Imprint
cytology/Paraffin section histology is done.
' I •
►
►
CA27
CA29
Metastatic work up
► Chest X-ray I CT thorax
-If biopsy report is negative, immunohistochemistry is done to confirm the diagnosis
' ► USG /CT abdomen
 134 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 135

► X-ray/ MRI spine and pelvis

► LFT
► Complete hemogram
\ lpsilateral, mobile, a-More than or
ging:
\
discrete Axiliary a-Fixed/matted
equal to 1O axillary
lymph node axillary LN (4-9 LN
I -------------------------------------. LN +ve/lpsilateral
\ involvement involved) lnfraclavicular LN
TNM STAGING clinically +ve
(1-3 in no.) b-lnternal mammary
LN +ve clinically in b-lpsilateral Internal
the absence of mammary LN
T x - Primary tumor can't be To - No evidence of primary
axillary LN
assessed tumor involvement +
involvement Axillary LN
involvement

c-lpsilateral
supraclavicular LN
Tis - Carcinoma in situ (DCIS/ Tis - Paget's ds. of nipple with involvement
LCIS) no tumor

T 1 - Tumor size less than or Metastases

T 1 mic - Microinvasion < 0.1 No Distant
equal to 2 cm in greatest could not be
metastasis metastases
cm diameter (T 1a - 0.1-0.5 cm, T 1b assessed
- 0.5-1 cm, T 1c - 1-2 cm)

• Stage I - T 1 NO
• Stage lla-T 0 N 1 , T 1N 1 , T 2N0
T 2 - Size > 2 cm but less than • Stagellb-T 2N 1 ,T 3 N0
T 3 - Size > 5 cm
or equal to 5 cm • Stage llla-T0 N 2 , T 1 N2 , T 2N2 , T 3 N 1 , T 3 N2
• Stage lllb-T 4N0 , T 4N1, T4N2
• Stage Ille -Any T, N 3
• Stage IV - Any T, Any N , M 1
T 4 - Tumor of any size fixed to
the chest wall or skin (T 4a - N.B.-
Fixed to chest wall*, T 4b - 1. All other stages except Stage IV - M 0
Fixed to skin**, T 4c - T 4a + T 4b, 2. Any N 2 except T 4 tumor- Stage Illa
T 4d - Inflammatory breast (CA)
3. Any T 4 except N 3 node- Stage lllb
4. Any N 3 - Stage Ille
* Chest wall involvement - except pectoralis major muscle 5. Early breast Cancer - T 1 / T 2 lesion + N0 / N 1 node (Breast tumor less than or equal to 5 cm in
** Skin involvement - Ulceration/edema/Satellite nodule size, without chest wall or skin involvement, with or without lymph node involvement < 4 in
no.)
6. Locally advanced breast cancer (LABC) - T 3 N0 , Stage Illa, Stage lllb
7. Metastatic breast cancer - Stage IV

0 Treatment :
Lymph nodes • Aims of treatment:
cant be No nodes Node with
micrometastasis ► To achieve likely cure
assessed
► Control of local disease in breast and axilla
 136 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 137

► Conservation of local formations and function of breast Ideal choice - Patey's modified radical mastectomy (Total / simple mastectomy may also be
•
► Prevention of recurrence done)
► Prevention or delaying of distant metastases Skin sparing mastectomy (SSM)- Through limited skin incision, excision of nipple areolar complex
•
with very limited skin removal is done here. It does not alter the recurrence rate and is cosmetically
• Modalities of treatment:
superior.
► Control of disease in breast - Breast Conservation Surgery (BCS) OR Mastectomy
□ Sentinel lymph nodes biopsy:
► Treatment to axilla - Sentinel lymph node biopsy (SLNB) OR Axillary dissection/
clearance • Done when axillary nodes are not clinically palpable.
► Post operative radiotherapy □ Axillary dissection/ clearance :
► Adjuvant chemotherapy
• Done when clinically lymph nodes are palpable OR sentinel lymph node biopsy is positive
► Adjuvant hormonal therapy force3,rcinoma. ___ _
► Regular follow up - Tumor marker CEA, Radiosiotope 'bone scan • Removal of fat, fascia and nodes (level I and II) in the axilla is done.
BREAST CONSERVATION SURGERY (BCS): ~ : I ~YV\ • Dissection is done - (a) through a separate transverse incision in axilla, when advocated
with BCS and (b) by extension of breast incision, when advocated with MAM/total mastectomy/
► Wid~ local excision of unicentric tumor with normal breast Ussue cleJ!Lan_cEl_QL1 cm is ideaUy
SSM
_done. Curvilinear non radial incisions are used and skin flaps are not raised.Tumor clearance is
confirmed by frozen section biopsy of the specimen(for adequacy, at least 1 mm clearance is □ Post operative radiotherapy (RT) :
needed). Along with this, axillary dissection (level I and II nodes) is done through a separate • Indications -
► (~5~
incision and radiotherapy (4500 cGy) to breast and chest wall is given.
► Ouadrantectomy as a part of QUART therapy (Quadrantectomy + Axillary dissection of level 1 ► High grade turr!Qr
and II nodes through a separate incision + radiotherapy to breast [5000 cGy] and axilla [1000
► _Po_sit[1,1e surgical margin
c~y] areas) may be used in some patients. Here removal of the entire quadrant of breast along
► Pectoralis fascia involvement
with the ductal system, with normal breast tissue clearance of 2-3 cm, is done
► More than or equal to 4 axillary nodes are positive
• Indications : ---.__
►
►~ -)
Internal mammary LN +ve
• _External radiotherapy to chest wall is a must after BCS. Here adjuvant RT decreases the risk
► Clinically negative_ axiUary nodes of recurrence after 10-15 yrs from 30% to 7%. Total dosage is 5000 cGy (200 cGy 5 days a
►
►
Mammographically detected lesio_n
Well-differentiated lesion with low S phase
- •
week for 5 weeks).
After total mastectomy, external RT to axilla can be give in patients if axillary dissection is not
► Breast of adequate size and volume to allow proper radiotherapy done OR more than or equal to 4 axillary nodes are positive. Internal mammary and
supraclavicular lymph node areas may also be irradiated.
• High chance of recurrence in cases of:
• Adverse effects of RT -
► Young female ► Skin necrosis
► Inadequate surgery ► Chest wall myosilis
► High grade tumor ► Interstitial pneumonitis
► Lymphovascular invasion ► Pleural effusion
MASTECTOMY: ► Pulmonary fibrosis
• lndicatio_fl_: _____~ ► Angiosarcoma (delayed complication)
► \ Tumor size> 4 cm_ ) □ Adjuvant chemotherapy :
► Tumor margin is not.~ of tumor after BCS • Indications -
► Multicentric tumor ► :-Any_t_u_m_o_r_>---=-1-c-m---=-inygv ,._------
► Poorly differentiated tumor ► lAII LN +ve patien~~--
► Centr~ltumor beneath the nipple ► RTgh grade tumor - higher rate of proliferation, aneuploidy, microinvasicn
► Extensive intraductal carcinoma ► Lymphovascular invasion
► History of earlier breast irradiation ► Her 2/ Neu +ve ER -ve PR -ve tumor

18
138 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 139

• Assessment for need of chemotherapy - • Letrozole -

~ -

► Oncotype Dx ► 2.5 mg OD for~ years (Latest data - 10 years dosage)

* Done in Stage I and II ER/ PR +ve patients ► A/E : vaginal dryness, night sweats, osteoporosis.
* 21 gene assay \ en;,·neoplasms. How will you diagnose and manage a case of renal cell carcinoma?
* Calculates recurrence score ~
\ [4+5+6]
* Score < 18 : No chemotherapy required '

* Score 18-31 : Role of chemotherapy is equivocal CLASSIFICATION OF RENAL NEOPLASMS

* Score> 31 : Chemotherapy is required A. Benign lesions
► Mammaprint • Adenoma
* Done only for T 1 / T 2 lesion with ER/PR +ve / -ve • Oncocytoma
* 70 gene assay • Angiomyolipoma (AML)
• Chemotherapy regimens - B. Malignant lesions
► First line drugs - CMF (cyclophosphamide, Methotrexate, 5-fluorouracil) in monthly • Wilm's tumor/Nephroblastoma
/ 3 weekly cycles for 6 months - Most commonly used • Renal cell carcinoma/Hypernephroma
OR, CAF (Cyclophosphamide, ~driyamycin /doxorubicin,~) ► Clear cell CA (70-80%)
OR, CEF ((_?~clophosphamide, Epirubicin, ~-FU) - better regimen * Most common Renal cell CA
► Second line drugs - ~!!~s (Paclitaxel, docetaxel) * Highly vascular
Cyclophosphamide with Anthracyclin (doxorubicin, epirubicin) for 4-8 cycles + * Associations :
Paclitaxel thrice weekly i) Loss of chr. 3p (associated with Von Hippel Lindau syndrome)
► Third line drugs - _Q_emcitabi!J.e
ii) Loss of chr. Bp, 9p, 14q
• Adverse effects of chemotherapy - iii) Gain of chr. 5p
► Bone marrow suppression ► Papillary CA (15-20%)
► Cardiotoxicity * Mostly seen in acquired cystic renal disease
► Alopecia * Hypovascular
► GI side effects * Associations :
□ Adjuvant hormonal therapy: i) Loss of chromosome 14 and Y
• Indication - ER/ PR +ve patients in all age groups ii) Trisomy of chr. 7 and 17
• Endocrine manipulations - ► Chromophobe cell CA (3-5%)
► Ovarian ablation by surgery or radiation_ * Associations :
► Pituitary ablation or adrenalectomy i) Birt Hogg Dube syndrome
ii) Loss of chr. 1,2,6, 10, 13
► SEAM
iii) Gain of chr. 7,12,16,20
► Aromatase inhibitors
► Collecting duct cell CA(< 1%)
► LHRH agonists - Goserelin 3.6 mg every 28 days cycle for 2 years (Medical
oophorectomy) ► Renal medullary CA
► Aminoglutethimide (Medical adrenalectomy) * Seen in Sickle cell trait
• Protocol - * More in young (30-40 yrs)
► For premenopausal patients - Selective estrogen receptor modulator (SEAM) like • Transitional cell CA of pelvis
tamoxifen, raloxifene • Squamous cell CA of pelvis
► For post menopausal patients - Aromatase inhibitors like letrozole, anastrozole,
exemestane. DIAGNOSIS OF RENAL CELL CARCINOMA
• Tamoxifen - □ Presentation :
~

► 1O mg BD or ~O mg_ BD for 5 years (Latest data - > 10 yrs dosage is more beneficial) • Usually in the 6th-7th decade
► A/E : Hot flushes, Deep vein thrombosis, endometrial hyperplasia • M:F=3:2
• Usual presentation is hematuria
 140 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 141

• Dragging discomfort in loin _► DTPA scan (Diethylene triamine pentaacetic acid)- for renal function
• ~able flank mass • Chest X-ray - to rule out pulmonary metastasis
• Few patients may present with Pelviureteric junction obstruction without evidence of infection • Liver function test - to detect hepatic dysfunction
• Sudden onset. of Left sided varicocele i.n male patie.:_:n.:.:,ts~------- • Blood studies - elevated ESR, decreased Hb, Increased Calcium, decreased LOH
• Typical triad (9%) - Gross hematuria + Flank pain + Palpable renal mass • Bone scan - Done only when ALP is raised or bone pain is present
- indicates advanced disease.
• Features of advanced Renal cell CA (8) Treatment :
► Bilateral pedal edema due to compression of IVC by the mass □ Staging : TNM staging
► Weight loss
► Night sweat
► Fever
► Palpable supraclavicular lymph node T1 T2 T3 T4
► Cough and haemoptysis
► Paraneoplastic syndrome T1A- < 4 cm, T2A- > 7 cm, T3A- Invasion Invasion of
* 20% cases
* Most commonly : Ra(sed ESR (55%)
confined to
kidney -- and < 10 cm,
confined to
kidney
- into peri-
nephric fat
and renal vein
- Gerota's
fascia and
adrenal gland
* Other features : T1B- > 4 cm,
a) Hypertension - 36% confined to T2B- > 10cm, Tumor
b) Anaemia - 35%
c) Cachexia - 34%
kidney
- confined to
kidney
- thrombus in
IVG below the
diaphragm
d) Hypercalcemia - 13%
e) Polycythaemia - 4%
Tumor
f) Amyloidosis - 2% thrombus in
~

g) Stauffer syndrome - (i) Hepatic dysfunction associated with RCC; (ii) 3. IVC above the
20% cases; (iii) elevation of ALP (100%); (iv) Elevation of P Time (67%); diaphragm
(v) Elevated bilirubin (20-30%)

MANAGEMENT OF RENAL CELL CARCINOMA

(A) Investigations:
• Renal USG - Solid/cystic mass Single regional
> 1 Lymph node
Lymph node
• Plain X-ray abdomen - Calcified renal mass with irregular outline involvement
involvement
• CECT - Contrast enhanced lesion in the kidney (RCC until proven otherwise)
► May show multilocular cyst with thickened septa and enhancement within the cyst
► Local staging
► Tumor extension into perinephric fat/lymph node/ renal vein/ IVC Mo
• MRI - It is the best test to recognise tumor thrombus in renal vein or IVC
• No metastasis • Distant metastasis
► It is also useful to evaluate a renal mass poorly defined in CT scan
► Can be done in contrast allergy, renal insuffiency, pregnancy
• MRA (Magnetic resonance angiography) - Done for blood vessel mapping in patients in
whom partial nephrectomy is to be done Stage I Stage II Stage Ill Stage IV
• Nucleotide scan
• T1-2N1-2Mo • T4 any N
► DMSA scan (Dimercapto succinic acid)
• T3 any N Mo • Any T Any N M1
* for renal anatomy
* Increased uptake indicates Pseudotumour/Hypertrophic column of Bartini
* Decreased uptake indicates tumor or cyst
142 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 143

□ Treatment: 2011 Supplementary

• For T 1 _ 2 tumor
a 1: Describe the management of a lady of 35 years presenting with toxic multinodular goitre.
. ~+~
T 1 _ 2 tumor Ans : See Section 1, Segment A, Paper-II, 2008, Os. 2, Page 108.
-20%benign
- 60% indolent
0 .2 : A 70 year old man presents with acute retention of urine. How would you investigate the patient?
outline the management in brief of benign hyperplasia of prostate. [7 + BJ
- 20% aggressive
Ans: ACUTE RETENTION OF URINE

Surveillance See Section 1, Segment-8, Paper-II, Os. 2, Page 256.

Surgery BENIGN HYPERPLASIA OF PROSTATE

Thermal ablation See Section 1, Segment-A, Paper-II, 2014, Os. 2, Page 183.

2012
Partial nephrectomy Q.1: Classify thyroid neoplasms. Write clinical features, investigations and management of papillary
carcinoma of the th roid gland ( A lady of 25 years old). [3 + 4 + 3 + 5]

THYROID NEOPLASMS

Indication - Thyroid
a) Small tumor< 10-12 cm Indication - neoplasm
b) No such renal vein involvement a) Tumor < 7 cm
c) No/minimal local invasion b) Renal cell CA in solitary kidney
d) Manageable lymphadenopathy c) Bilateral RCC
d) Familial RCC Benign Malignant

• For T 3 tumor
Follicular Hurthle cell Primary Secondary
adenoma type/Oncocytic From
4-10% cases - Tumor IVC thrombus below the level of IVC thrombus extending above
adenoma 1. CA colon
thrombus in venous system main hepatic vein the level of main hepatic vein-
2. Renal cell CA
Requires aggressive approach
• Isolation of vessels followed 3. Melanoma
• 45-75% cases - managed by
Nephrectomy + Thrombectomy by thrombectomy • Venovenous bypass/ Foetal Colloid Simple Embryonal 4. CA breast
Cardiopulmonary bypass
• Hypothermic cardiac arrest

Well-differentiated -
• For T 4 tumor- Best option is En Bloc resection of all involved structures From Follicular 1. Papillary CA
• For bulky lymphadenopathy - Surgical resection if feasible epithelial cells 2. Follicular CA
• For local recurrence of RCC (Adjuvant treatment for RCC) Carcinoma
► for local recurrence after radical nephrectomy (2-4%) From parafollicular C Poorly differentiated-
* localised - Re-resection (ii) Systemic - Radiotherapy cells-Medullary CA Anaplastic CA
► for local recurrence after partial nephrectomy (1-10%) Primary malignant Lymphoma
* Completion nephrectomy / Repeat partial nephrectomy / thermal ablation
► for local recurrence after thermal ablation
Sarcoma
* Repeat thermal ablation / Salvage surgery (Partial or Radical nephrectomy)
144 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 145

PAPILLARY CA OF THYROID
c. Prognosis :
□ Clinical features :
• Symptoms AMES scoring AGES scoring
► Swelling in lower part of anterior aspect of neck which doesnot move with protrusion
A: Age - < 20 yrs has better prognosis A: Age - < 20 yrs has better prognosis
of tongue
M: Distant metastasis has worse prognosis G: Pathologic grade of the tumor
► Hoarseness of voice- may occur
E: Extent of primary tumor • Well differentiated - better prognosis
• Signs • Poorly differentiated - worse prognosis
• Invasion to capsule/blood vessels-
► Swelling is fixed to surrounding tissue worse prognosis E : Extent of primary tumor
► Irregular surface with firm consistency • Non invasive - better prognosis • Invasion to capsule/blood vessels-
► Rapid onset/ Recent rapid growth s: Size of the tumor- Size < 4 cm has better worse prognosis
► Palpable neck lymph nodes prognosis • Non invasive - better prognosis
□ Investigations : S : Size of the tumor - Size < 4 cm has better
prognosis
• FNAC of thyroid nodule - Confirms diagnosis
• USG neck - Hypoechoic lesion with poorly defined margin, with microcalcification, with high
vascularity, without any surrounding halo (Malignant lesion) ' " L'./a10uyears old gentleman presented with bilateral knobby renal lump in the abdomen. How do
you investigate and treat such a patient (operation details not required). [7 + 8]
• Radioisotope study - shows '.'Cold nodule'.'
• Thyroid function test - Increased TSH level Ans : Bilateral knobby renal lump in the abdomen in a 40 years old gentleman indicates towards the
diagnosis of Autosomal Dominant Polycyslic Kidney Disease (ADPKD).
• Metastatic work up :
► CT scan of neck - ADPKD
• To detect impalpable nodules
• To assess for lymphadenopathy □ Clinical features :

► FNAC of lymph node Typical presentation in a young adult -

► X-ray/CT scan of chest - to assess for lung metastasis • Age of onset - 30-40 yrs
• Principal symptom - Hypertension (60% cases)
► USG/ CT abdomen
• Hematuria (40-50% cases) - gross or microscopic
► Liver Function Test
• Bilateral palpable renal lump - almost always
□ Management: • Flank pain - colicky (due to clot/calculus)/acute {due to infection /hemorrhage)/chronic (due
to stretching of the capsule)
A. Treatment:
Surgery. Extent of surgery depends on the size of thyroid swelling. • Gastrointestinal symptoms - Anorexia, nausea
• Infection - Renal angle tenderness + Pyuria + Fever with chill and rigor
• < 1 cm - Hemithyroidectomy.
For extremes of ages- Near total thyroidectomy + Modified radical neck dissection type 111 (if • Renal insufficiency
lymph nodes are involved) □ Causes:
•
•
·--.,
> 2 cm - Total thyroidectomy
-----,--,. , ~~,~- - "- ~-·-----· -
1-2 cm - Controversial (Hemithyroidectomy/ Near total thyroidectomy/ Total thyroidecJomy) •
•
Compression of non-dilated nephron by cyst
Hypertension
Suppressive dose of levo-thyroxine 0.3 mg OD will be conti~ued lifelong. • Prominence of renal epithelial apoptosis
8. Follow-up : ·o Associated abnormalities :
• By measurement of Thyroglobulin level. Thyroglobulin >1-2 microgram/L after total • Liver cyst {18%)
thyroidectomy indicates residual disease. ► more in adult, more in female
• Recurrence - Completion thyroidectomy + LN dissection + radioiodine therapy (in elderly ► usually asymptomatic
subjects only radioiodine therapy is advocated) ► may develop portal hypertension
• Berry's aneurysm (10-30% cases)
• Splenic cyst

19
 146 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 147

• Pancreatic cyst
• Arachnoid cyst Hemodialysis
• Pineal gland cyst
• Others - Colonic diverticula, Mitra! valve prolapse, Aortic aneurysm, Lung cyst
□ Diagnosis : Bilateral nephrectomy

3 generation involvement + Bilateral renal cyst on USG

OR,
The presumptive diagnosis of ADPKD without any family history requires : ( Renal transplantation )
Bilateral renal cyst on USG + 2 or more of the following -
• Liver cyst more than or equal to 3
• Pancreatic cyst .//~ 2012 Supplementary
• Splenic cyst 1

• Solitary cyst of arachnoid or pineal gland ~ a t are !!'e different types of nipple discharges with their clinical importance? How would you
• Aneurysm of cerebral artery manage Stage-I carcinoma breast in a lady aged 40 years? r,\ "" 'Y'$:~~. [6 + 9]
f\7 / ,~
□ Investigations: ( (.
Ans: NIPPLE DISCHARGE \, L · ./
,,

• USG of whole abdomen - Bilateral renal cyst

• Intravenous urethrogram (IVU) -
Types Clinical conditions
i) Enlargement of kidney
Blood stained i) Duct papilloma (commonest)
ii) Distortion of calyceal system/ elongated compressed calyces - Spider leg appearance
ii) Ductal carcinoma
iii) Appearance of bubble in Nephrogram phase (due to stasis of dye within the cyst)
iii) Duct ectasia
• CT scan - It is the ideal investigation to detect hemorrhage within the cyst (50-90 Hounsfie
unit) Serous i) Fibroadenosis
• MRI - indicated in patients with renal insufficiency, contrast allergy, pregnancy ii) Retention cyst
• Blood urea, Serum creatinine iii) Duct ectasia
• Decreased maximal osmolality of urine (Due to hampered concentrating capacity of kidn
• Urine RE/ME - Low specific gravity Types Clinical conditions
□ Treatment :
Milky i) Hyperprolactinaemia
• Presymptomatic stage-Wait and watch policy ii) Hypothyroidism
- ~onitor BP and renal function iii) Pituitary tumour like prolactinoma
• tt_ inf:.?~~ cy_§_t - Lipid soluble antibiotics are advocated Purulent i) Infection
► Quinolones
ii) Malignancy (rare)
► Cefoperazone/Cefuroxime
Greenish i) Duct ectasia (commonest)
► Cotrimoxazole
ii) Fibrocystic disease (rare)
► _Chloramrhe_ri_Lcol
• ..E~n.
If there is hemorrhage and infection due to overdistension of cysts, ~urgical interventioni Serosanguinous i) Infection
is required.- Rovsing's deroofing of the cyst with marsupialisation of the cut edge (pain
decreased in 90% of cases) :"f
iii ii) Carcinoma

• U1SGh_gu1 ided perc~!~n:~:l_s aspiration of cysl!Yith/without instillation of sclerosing agent like!•i·• STAGE - I BREAST CARCINOMA
aco o ··•
• Laparoscopic/retroperitoneoscopic aspiration/ deroofing of renal cyst " See Section-1, Segment-A, Paper-II, 2011, Os. 1, Page No. 128.
• When_End Stage Renal Disease (ESRD) sets in (According to National Institute of Diabete&i 0.2: 65 year old man presents to the emergency with acute retention of urine. How would you
and Kidney DTseaseguideline, GFR < 10ml/min and Serum creatinine > 8mg/dl oA& investigate & manage the patient ? [7 + BJ
according to WHO criteria, GFR < 15 ml/min) - Renal Replacement Therapy (ART) is"
recommended \ ·
'V Ans : See Section 1, Segment-B, Paper-II, Os. 2, Page 257.
 148 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

_/ /"/

~
• Intravenous pyelography (IVP)
i 2013 ► Dye (Sodium diatrizoate or Meglumine iothalamate) is injected into the ante cubital vein
/ /oefine hydronephrosis. Discuss the causes and management of unilateral hydronephrosis. ► Films taken at 1 min (Nephrogram), 5 min, 15 min, 20 min
► Shows i) dense nephrogram ii) enlarged kidney iii) flattened, club shaped, broadened
' [2 + 5 + 8)
calyces iv) hydroureter
HYDRONEPHROSIS
► Late films (4 hrs, 8 hrs, 24 hrs) can be taken to see bladder pathology as well as
□ Definition : It is the aseptic dilatation QfJ:>._~lvic calyceal system with or without obstruction of the residual urine.
outflow tract. ► Contraindication - Iodine sensitivity, toxic thyroid, multiple myeloma
□ Causes of unilateral hydronephrosis: • CT scan
A. Congenital - ► Good anatomical and functional evaluation
• Pelvi-ureteric junction obstruction • Isotope renography/ Nucleotide scan
• Retrocaval ureter ► Individual kidney function is measured by Gamma camera
• Ureterocele ► Also includes anatomical evaluation and perfusion study
• Ureteric stricture
► Can be of 3 types - i) DTPA scan (using Diethyl Triamine Penta Acetic acid) ii) DMSA
• Aberrant renal vessels (vein or artery)-common on left side
scan (using Dimercapto Succinic Acid) iii) MAG 3 scan (using Mercapto Acetyl
B. Acquired - Triglycerine)
• lntraluminal ► Shows - i) split renal function in vascular phase, secretory phase and excretory
► Stone in renal pelvis or ureter phase ii) site of obstruction
► Papillary necrosis (sloughed papilla) ► Secretion less than 20% hails bad prognosis
• Intramural • Whitaker test
► Neoplasm of ureter ► Fine needle is pushed into the renal pelvis through loin followed by saline perfusion
► Stricture of ureter following pelvis surgeries, removal of ureteric stone, TB ureter at 10 ml/min
► Infection e.g. UTI ► Persistent increase in pressure suggests the diagnosis of hydronephrosis
• Extramural B) Treatment - It is done according to the cause of hydronephrosis.
► Compression by growth e.g. CA cervix, ovarian tumor • Congenital PUJ obstruction
► Retroperitoneal fibrosis
► Retroperitoneal CA Dismembered pyeloplasty
□ Management of unilateral hydronephrosis : (Anderson-Hyne's
A patient with unilateral hydronephrosis usually presents with - operation) - A new pelvis
is created following
• Dull aching pain in loin with dragging sensation or heaviness
excision of spasmodic
• Mass in the flank which is smooth, ballotable, mobile, moves with respiration with a band of
segment and redundant
colonic resonance in front
pelvis. Cut end of new
• Dietl's crisis - Following an attack of acute renal colic, swelling in the flank is seen. It
pelvis is anastomosed to
disappears after sometime following evacuation of large volume of urine
ureter in dependant
• Infected hydronephrosis - Fever + Chill and rigor + Renal angle tenderness
position.
A. Investigations -
• Urine RE, ME and culture
► Done to detect UTI Pyeloplasty
• Blood biochemistry
► Creatinine - to detect azotemia Congenital PUJ
obstruction
► Urea
• USG of KUB (Kidney ureter bladder) with post void residual (PVR) urine Endopyelosis (Done in Nondismembered
► Shows "loss of central echogenicity with dilatation of pelvic calyceal system", case of very small pyeloplasty (Foley's YV
associated hydroureter, any stone disease stricture in PUJ) plasty) - Reconstruction
is done without PUJ
► False negative in about 35% cases
transaction
► False positive in - Parapelvic cyst, capacious extrarenal pelvis, vesico-ureteric reflux
► Disadvantage - It cant evaluate kidney function
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 151
150 Q\JE$ I"--: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthe.stclc,g~•

• Retrocaval ureter - Anderson-Hyne's operation 0 s,x:

F:M = 150:1
• Ureterocele - Cystoscopic ureteric meatotomy with removal of the cyst wall. Ureteric •
< 0.5% cases are seen in males.
reimplantation may be needed. •
• Stricture urethra - Dilatation, Urethrotomy, urethroplasty 0 Race:
• Aberrant renal vessels - Hamilton-Stewart operation • Seen in white > black
• Retroperitoneal fibrosis - 0 Diet:
► Drugs - Tamoxifen, Corticosteroids, Cyclophosphamide • Alcoholism
► Omental wrapping of ureter following release of fibrous tissue • High fatty diet
• Obesity l\
i , , ~ b e lymphatic drainage of breast. Mention the risk factors of breast carcinoma. How to
~-- manage a 52 year old female patient with locally advanced breast carcinoma? [ 4 + 3 + 8)
• High dose of estrogen for prolo1_1ged therqQyjljfil) [!?I.O d:) €;;e °";
0 Menstrual history:
LYMPHATIC DRAINAGE OF BREAST • Early menarche(< 12 yrs)- 2 xearsdelay_lowers the risk ofbreastCA.QYJQ%
• · Late menopause (> 50 yrs)·_::: Doubles the risk of breast CA
A. Into the Axillary lymph nodes (75%) ---·---~-'r'---- -
□ Berg's levels of axillary lymph nodes :
□ Obstetrfc~nd Gynaecological history:
• Late first pregnancy (> 30 yrs) - 2 fold increased risk of breast CA
• Level I (Belo~ and~! to pectoralis minor muscle)
► Anterior/ pectoral/ external mammary group - This is the principal draining lymph node □ Family history: 1_'
of the breast. The nodes in this group are situated along lateral thoracic vessels. • H/O breast CA in 2 first degree relatives - 2-3 times increased risk of breast CA
► Lateral group - Rarely involved in breast carcinoma. Nodes are situated along axillary • H/O breast CA and ovarian CA
vein.
□ Personal history :
► ~ r / subscapular group- Rarely involved in breast carcinoma.
• H/O contralateral breast CA - Increased risk of 3-4 times in cases of lobular CA
• Level II (Behind pectoralis minor muscle)
-· ·--"· ··- ----------~--~-------~-~
• H/O endometrial CA
Central group - This is the 2nd most common lymph node group involved in breast carcinoma.
This group is most easily palpable clinically. • H/O fibrocystic disease of breast with atypical proliferation
• Level Ill (Above and medial to the pectoralis minor muscle) • H/O previous irradiation to breast
~ c u l a r / Halsted lymph node group - Not commonly involved in breast CA. □ Genetic factors :
' ► lnterpectoral~ - It lies between the pectoralis major and the pectoralis • BACA 1 and BACA 2 mutation - 50-70% risk lifelong
minor muscle. When involved, it indicates retrograde spread of the tumor.
► ~aclavicular lymph nodes - Finally the lymphatics from axillary lymph nodes
• . i:>§3 9,ene mutation
drain here. • pT~ gene mutation
_
►· _Axillary Reverse Mapping (ARM - Injection of blue dye in upper part of the medial • Ataxia telengiectasia
aspect of the arm) is done now-a-days to map the axillary lymph node drainage.
• Cowden' s syndrome ....:;,- ~ ~ e, ~h Y\I\ 09""):o ')/Y'O,. Sod~p "YYI e
B. Into the Internal mammary lymph nodes (25%) 0/
"fIA VY! q_2,.
----··"--"•"------.,--·--------------~<>----·-·------ --
r • These nodes are situated in lntercost_al spaces (2nd, 3rd and 4th) 1-2 cm lateral to the sternal Very high risk
Mild to moderate risk Moderate to high risk
' margin and placed vertically parallel to internal mammary vessels.
• Lymphatics from the ~~9.jc11)1altQfJh? 1Jre_c1.st mainly drain here. • Nulliparity • Age> 60 yrs • Therapeutic radiation (Age
• LCIS > 30 yrs)
• The efferent lymphatics from here drain into subclavicular nodes. • Early menarche, late
• Atypical hyperplasia • BRCA 1 / BRCA 2 mutation
C. Into the contralateral axillary lymph nodes menopause
• Personal H/O DCIS/invasive • Family H/O breast CA and
• Obesity, alcohol, HRT
• Negligible amount of lymphatics drain here. .✓-:::=.~= breast CA (> 40 yrs) ovarian CA
• Family H/O breast CA (first • Personal H/O DCIS/invasive
[See Figure 1.2.1 (Page Nd:202~~
degree relative, < 50 yrs) breast CA (< 40 yrs)
• Family H/O breast CA (2
RISK FACTORS OF BREAST CARCINOMA first degree relatives)
□ Age:
• Increased incidence of breast carcinoma usually after 30 years.
• Unusual in < 20 yrs and > 90 yrs aged.
152 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 153

MANAGEMENT OF LOCALLY ADVANCED BREAST CARCINOMA IN A 52 YR OLD ► Findings suggestive of malignant lesion -'-
1. Distorted architecture of the breast parenchyma (irregular soft tissue shadow).
FEMALE
2. Micro calcifications (< 5 mm) with spiculations.
❖ Diagnosis : 3. Focal dilatations of ducts.
4. Increased number and thickening of Cooper's ligaments.
5. Heterogenous, polymorphic, high density opacity with irregular margin/
satellite lesion.
Triple assessment ► American College of Surgeons (ACS) guidelines -
for breast A Woman with average risk of breast CA should undergo regular screening
carcinoma mammography, starting from 45 years age, annually to 54 yrs age, then
l biennially for as long as the woman is in good health and has a life-expentancy
I I I of at least 10 years.
► Usual views taken -
Histopathological/
History + Physical Radiological 1. Medio-lateral-oblique (MLO) view
Cytological
examination imaging
analysis 2. Cranio caudal (CC) view
► Amount of radiation exposure during mammography - 0.1-0.2 cGy (this amount of
radiation being not enough to cause malignant changes in breast itself)
• MRI-
□ Clinical assessment :
► Purpose -
• Hard lump in the breast which is most commonly painless. 1. To identify multifocal ( > 1 foci in one quadrant) and multicentric breast tumor
• The second most common presentation is nipple discharge. (MRI is even better than USG).
• Ulceration and fungation of nipple areolar complex and /or surrouding skin. 2. To image breasts with breast implants.
• Lymph node enlargement - axillary, supraclavicular. 3. To detect local recurrence or scar after mastectomy.
• Pain on the lesion (10% cases). 4. To assess axillary metastasis.
• Chest pain, haemoptysis, bone pain and tenderness, pathological fracture, ascites, pleural 5. To assess dermal extension.
effusion ► Indications -
• Symptoms due to secondaries in liver, secondary ovarian tumor. 1. Screening of young women and women in high risk group (History of
therapeutic radiation in age < 30 yrs, Strong family history of breast CA,
□ Radiological imaging: BRCA 1/2 mutation, Personal history of DCIS/ Invasive breast CA, family
• First investigation to be done in a case of early breast CA is always a radiological imaging, as - history of breast and ovarian CA)
2. Suspected DCIS (MRI is the most sensitive investigation for DCIS)
► These are non-invasive investigations.
► FNAC/ Open biopsy , if done first, may cause hematoma, which will alter the findings ► There is no risk of ionising radiation.
on imaging. ► IOC for imaging breasts in pregnant female.
• MAMMOGRAPHY (bilateral) - ► It is a better modality than other investigations for dense breasts.

► Done in females > 40 years of age. ► Findings suggestive of malignant lesion -

► It is the only reliable means to detect non-palpable breast CA. 50% of breast CA may
be seen on mammography before they are palpable. Further, it can identify breast
CA at least 2 years before the mass becomes palpable.
► Indications -
1. To evaluate suspicious breast lump, nipple discharge.
2. To identify multicentricity, to know size and location of the masses.
3. To screen contralateral breast for additional masses in a patient undergoing
definitive surgery.
4. To screen both breasts before any cosmetic surgery.
5. Screening before Breast Conservative Surgery (BCS).
6. Follow-up after BCS / Radiotherapy/ Neo-adjuvant chemotherapy.
1. Mass with irregular intensity and spiculations
2. Thickened skin, changes in nipple.
3. Lymphedema.
► Disadvantages -
1. Costly, not available easily.
2. Not accurate, if done within 9 months of radiotherapy for breast CA.
3. Cannot be done in patients with incompatible metal prosthesis like cardiac
pacemaker.
• BIRADS (Breast Imaging Reporting and Data based Scoring system) -
► This is a scoring system based on different investigations.
► Based on this, advice can be given regarding further investigations and diagnosis.

20
 154 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 155

j Grade 0

• Inadequate/Incomplete
Grade 1

• Normal / Negative • Benign

Grade 2 • Disadvantages : (1) Receptor study cant be done (2) Invasive cancer cant be differentiated
from in situ disease (3) False negative results do occur, mainly due to sampling errors.

assessment (b) Core needle biopsy:

• Continue annual • Continue annual
,[ I
I
• As breast tissue is dense,
mammogram cant interprete
• Needs additional study
mammography mammography •
•
It is the preferred method for diagnosis of palpable or non-palpable breast abnormalities
Permits analysis of breast tissue architecture to give clear histological evidence and definitive
preoperative diagnosis
• Can confirm DCIS and invasive lesion
ii1, • Can comment about grade and receptor status of tumor
fl Grade 3 Grade 4 Grade 5 Grade 6 (c) Frozen section biopsy:
I • Possible/Probably • Suspicious lump • Highly suggestive of • Biopsy proven • Not usually practiced now-a-days
benign • Chance of CA = malignancy malignancy • Indication : when FNAC fails even after 2 trials or is negative
• Chance of CA = 1-2% 25-50% • Chance of CA = • Known carcinoma • Disadvantage : Shows 20% false negative results
• Repeat imaging after • Biopsy recommended 75-90% (d) Excisions/ biopsy:
3-6 months • Biopsy required • Also known as open biopsy
• It is the best and definitive investigation for breast cancer
D Histopathological/ Cytological analysis - • Incision is planned in such a way that it will be included in the eventual mastectomy incision
at a later date
BREAST BIOPSY • Should give no false negative and no false positive results
► Types: (e) Needle localised excisions/ biopsy (NLEB):
• Procedure: (1) Through an incision under local anesthesia, a hook is placed adjacent to the
Biopsy of breast suspected lesion, using needle sheath over the tumor (2) Excision biopsy is done under
tussue mammographic guidance
• Indication : When core needle biopsy fails to localise non-palpable tumor
I
I I
□ Other Investigations :
For palpable For non-palpable • Triple receptor assessment -
tumor tumor I
I a) Estrogen Receptor (ER) study
I
I I I I ► Estrogen sensitive cytosolic glycoprotein level > 10 units per gram of tissue
Minimally is known as ER +ve status.
FNAC Core needle Frozen section Excisional invasive
► ER +ve status indicates good response to hormone therapy and good
biopsy biopsy biopsy breast biopsy
prognosis.
I b) Progesterone receptor (PR) study
I I I
c) HER 2/Neu receptor study
Stereotactic Ultrasound/ Needle localised
► Human epidermal growth receptor 2 Neu oncogene, also known as cErb 82,
Mammographic MRI guided excisional is a tyrosine kinase receptor.
biopsy (NLEB)
► Positivity indicates high grade tumor and poor prognosis.
• Cytological analysis of nipple discharge
(a) FNAC: a) Sample is obtained through ductal lavage.
• Tumor markers
• Fine needle aspiration cytology is the first, simplest and least invasive technique for obtaining
a cell diagnosis in breast cancer a) CA 15/3 (Normal serum value <40 U/mL)
• Minimum 6 aspirations are done using 21-30 G needle
b) CA 27
c) CA 29
• Giemsa, hematoxylin and eosin, papanicolaou stains used
• Metastatic work up
• It can be repeated 2 limes
► Chest X-ray/ CT thorax - To look for pleural effusion, secondaries in lung (cannon
• Advantages : (1) least painful (2) cheap (3) reliable (4) can be done on Out patient basis (5)
ball opacities on X-ray), mediastinal lymph nodes, secondaries in ribs.
no evidence of malignant deposits along FNAC track
► USG /CT abdomen - To look for secondaries in liver, ascites, Krukenberg tumor.
rr
156 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 157

► X-ray/ MRI spine and pelvis - To look for osteoly_tic sec?ndar!es in_ bones. Pla!n X-ray
will only detect the lesion when 60% of bone Is demmerahsed in metastatic bone
disease.
► LFT
► Complete hemogram Lymph nodes
cant be No nodes Node with
► Metabolic panel - Increased Alkaline phosphatase along with increased serum micrometastasis
assessed
Calcium level and bone pain is an indication of bone scan.
► Radioisotope bone scan - To look for secondaries in bone in advanced cases. A
positive bone scan will confirm the diagnosis of Metastatic carcinoma of breast, not
LABC.
► PET scan - To look for bone, soft tissue or visceral metastases.
lpsilateral, mobile,
□ Staging: a-More than or
discrete Axillary a-Fixed/matted
equal to 1O axillary
lymph node axillary LN (4-9 LN
LN +ve/lpsilateral
TNM STAGING involvement involved)
lnfraclavicular LN
clinically +ve
(1-3 in no.) b-lnternal mammary
LN +ve clinically in b-lpsilateral Internal
T x - Primary tumor can't be To - No evidence of primary the absence of mammary LN
axillary LN involvement +
assessed tumor
involvement Axillary LN
involvement
c-lpsilateral
supraclavicular LN
involvement
Tis - Carcinoma in situ (DCIS/ Tis - Paget's ds. of nipple with
LCIS) no tumor

Metastases
T 1 - Tumor size less than or could not be No Distant
T 1 mic - Microinvasion < 0.1 equal to 2 cm in greatest assessed metastasis metastases
cm diameter (T 1a - 0.1-0.5 cm, T 1b
- 0.5-1 cm, T 1c - 1-2 cm)
• Stage I - T 1 NO
• Stage lla-T 0N1 , T1N 1 , T2No
• Stage llb-T 2N1 , T3No
T 2 - Size > 2 cm but less than
T 3 - Size > 5 cm • Stage llla-T0 N2 , T 1N2 , T2N2, T3N1, T3N2
or equal to 5 cm
• Stagelllb-T 4N 0 ,T4N1 ,T4N2
• Stage Ille-Any T, N 3
• Stage IV - Any T, Any N , M 1
T 4 - Tumor of any size fixed to N.B.-
the chest wall or skin (T 4a - 1. All other stages except Stage IV - M0
Fixed to chest wall*, T 4b -
2. Any N2 except T 4 tumor- Stage Illa
Fixed to skin**, T 4c - T 4a + T 4b,
T 4d - Inflammatory breast (CA) 3. Any T 4 except N 3 node - Stage lllb
4. Any N 3 - Stage Ille
5. Early breast Cancer- T 1 /T 2 lesion+ N0 / N1 node (Breast tumor less than or equal to 5 cm in size,
* Chest wall involvement - except pectoralis major muscle
without chest wall or skin involvement, with or without lymph node involvement < 4 in no.)
** Skin involvement - Ulceration/edema/Satellite nodule
6. Locally advanced breast cancer (LABC) - T 3N0 , Stage Illa, Stage lllb
7. Metastatic breast cancer - Stage IV
158 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 159

□ Treatment : (b) For non-responders and patients with progressive disease

A. For non-inflammatory breast CA ► Radiotherapy to breast, chest wall, axilla and supraclavicular region
• Objectives of management - ► Hormonal therapy
► To achieve local control of the disease ►
Surgery, if operable tumor
► To prevent or delay the distant metastasis 3. Approach to relapse after adjuvant chemotherapy
• Protocol of treatment -
► Initial neoadjuvant chemotherapy -
Adjuvant chemotherapy of remaining
• Purpose: 3-4 cycles following palliative surgery
► To achieve cytoreduction {downstaging of tumor)
► To convert inoperable tumor to operable one/ to convert a tumor needing mastectomy
to a tumor manageable by Breast Conservation Surgery (BCS)
► To target possible micrometastases Local recurrence Distant spread
► To assess chemosensitivity
► Better cosmesis Excision of
• Given for 3-4 cycles tumor Disease free Disease free
interval > 2 yrs interval < 2 yrs
• Regimen -J2.MEJcyclophosphamide, Methotrexate, 5-fluorouracil) in monthly/3 weekly cycles
OR, CAF (Cyclophosphamide, Adriyamycin /doxorubicin, 5-FU)
~
Radiotherapy Hormonal therapy Hormonal therapy
OR, fil (Cyclophosphamide, Epirubicin, 5-FU) may be effective is ineffective
1. Assessment for response to chemotherapy
► The patients who underwent neoadjuvant chemotherapy are divided into 4 categories
based on reponse - • Hormonal therapy -
* Complete responders without palpable tumor ► For ER/ PR +ve tumor - Tamoxifen 20 mg OD for 5 years
* Partial responders with > 50% decrease in tumor size ► For HER 2/ Neu +ve tumor - Trastuzumab (Herceptin) 4 mg/kg loading dose followed
* Non-responders with < 50% decrease in tumor size by 2 mg/kg as maintenance dose for 1 year
* Progressive disease with > 25% increase in tumor size • Purpose of palliation is to control pain, to prevent bleeding or fungation.
• Usually there are no role of BCS and axillary dissection in LABC.
2. (a) For responders (complete and partial)
• 5 year survival - 40-45%, 1O year survival - < 25%
a. For inflammatory breast CA
Palliative surgery - Total mastectomy/ Modified Radical Mastectomy/ occasionally BCS • Known as Mastitis carcinomatosis/ Lactating carcinoma.
• Common in pregnant or lactating women.
• Rapidly progressive tumor, diffusely involving entire breast tissue, sometimes even extending
to the skin of chest wall.
Remaining chemotherapy (3-4 cycles) • Clinically -
► Painful, warm lesion with peau d' orange appearance
► Diffuse lymphedema (due to obstruction of dermal lymphatics with tumor emboli)
• It is a clinical diagnosis.
Adjuvant radiotherapy • Mimics acute mastitis.
• Microscopically - Ductal or lobular type of malignant cells are seen in dermal lymphatics.

i
Hormonal therapy
•
•
•
Mammography is inconclusive.
FNAC confirms the diagnosis (shows undifferentiated cells).
It is a Stage Ill B (T4d) locally advanced breast carcinoma.
• Treatment -
• It has got worst prognosis. 5 year survival - 25-30%
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 161
160 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Initial chemotherapy or radiotherapy Freshly passed

urine is collected in
a test tube
I
I I
If cytoreduction is achieved, total mastectomy with axillary clearance
Naked eye/gross
examination of Microscopic
Centrifuged urine examination
on standing for

[ Chemotherapy
] I
some time

I
I
I
1. RBCs with/without
Red or reddish RBC casts-Hematuria
Uniformly pink
brown deposit of 2. No RBC + Anaemia
Hormonal therapy - Tamoxifen coloured urine
intact RBCs with and reticulocytosis
with no deposit
clear supernatant present -
I I Haemoglobinuria
3. No RBC + No
./1[/ A 50 year old gentleman presented with painless hematuria. What may be the possible causes? Indicates Indicates
anaemia or reticulocyto-
How would you investigate the case? Give an outline of the management. [5 + 5 + 5) Hematuria Haemoglobinuria
sis-Myoglobinuria

PAINLESS HEMATURIA IN A 50 YEAR OLD MAN

,- Hematuria in the initial part of voiding- Hematuria of lower urinary tract origin (Urethral
D Possible causes : pathology)
Hematuria is defined as abnormal presence of RBCs in urine. 2. Associated features -
It is of 2 types - (1) gross (2) microscopic ( > 5 RBC/hpf). • Fever - APSGN, urinary bilharziasis
Causes of painless hematuria in a 50 year old gentleman are - • Facial puffiness, hypertension - seen in APSGN
• Renal cell carcinoma (RCC) • Dragging discomfort in loin - RCC
• Bladder tumor - Papilloma, Urothelial cell CA • Symptoms suggestive of Lower urinary tract symptoms (LUTS)/ bladder outlet obstruction
• Benign prostatic hyperplasia (BPH) (Hesitancy, urgency, frequency, poor stream of urine, dribbling, inadequate emptying) -
Bladder tumor, BPH
• Urinary bilharziasis
• H/0 sore throat (2-3 weeks back)/ pyoderma (3-6 weeks back) - seen in APSGN
• Acute post-streptococcal glomerulonephritis (APSGN)
• Urticaria for a few days, fever after 4-8 weeks-Urinary bilharziasis
• Leukemia
3. Occupational history -
• Anticoagulant overdose
• Aniline dye factory workers - Bladder carcinoma
• Snake bite
• Fresh water swimmers - Urinary bilharziasis
D Diagnosis :
4. H/0 drug intake - Anticoagulants
Confirmation of hematuria - (see the chart on next page) 5. H/0 snake bite - Snake bite induced hematuria
□ History: □ General examination :
1. Evaluation of gross hematuria - • Pallor - seen in malignancy (RCC, bladder CA), leukemia
• Colour of urine : • Edema - Pitting edema is seen in APSGN
► Cola coloured - Hematuria of glomerular or upper urinary tract origin • Blood pressure - Hypertension is seen in APSGN
► Bright red coloured - Hematuria of bladder or lower urinary tract origin • Temperature - elevated in APSGN, urinary bilharziasis
• Pattern of hematuria : • Purpuric spots - seen in leukemia, anticoagulant overdose
► Hematuria throughout the stream - Heinaturia can be of upper or lower urinary tract □ Systemic examination :
origin
1. Abdominal lump -
► Hematuria in the latter part of voiding - Bladder pathology • Kidney lump- seen in RCC

21
162 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 163

• Distended bladder - seen in BPH *

Malignant cells found in cytology of urine
2. Examination of genitalia - ►
may be followed by brush biopsy.
• Varicocele - seen in RCC , bladder tumor can bo ciiagnosed.
3. P/R examination -
► bilharzia! pseudotubercles, bilharzia! nodules, sandy patches, ulceration,
• Enlarged smooth prostate, free overlying rectal mucosa - seen in BPH granuloma, papilloma (presence of any 1 or more) - suggestive of urinary
□ Investigations :
1. Urine examination -
• Routine examination :
► Specific gravity
•
•
bilharziasis
Retrograde pyelography - to diagnose bladder tumor
Transrectal Ultrasound - to diagnose BPH
I.
n
I'
ij
IJ Management :
► Protein
(i} MANAGEMENT OF RENAL CELL CARCINOMA
t
►
►
►
Sugar
Blood
Ketone
• Staging : TNM staging I
• Microscopic examination :
►
►
Phase contrast microscopy - to detect dysmorphic ABC
Pieces of tumor - seen in papilloma of bladder
T1 T2 T3 T4
►Ova of Schistosoma haematobium - seen in urinary bilharziasis
T1A- < 4 cm, T2A- < 7 cm, T3A- Invasion Invasion of
►Exfoliative cytology (by Papanicolau staining)
• Culture and sensitivity
confined to
kidney
...... and < 10cm,
confined to - into peri-
nephric fat - Gerota's
fascia and
► Gram staining kidney and renal vein adrenal gland
► AFB staining T1B- < 4 cm,
2. Blood profiles - confined to T2B- < 10cm, Tumor

• Complete hemogram
kidney
- confined to
kidney
t--
thrombus in
IVC below the
• Serum urea, creatinine diaphragm
• Serum total protein, albumin
• Serum cholesterol Tumor
•
•
Serum electrolytes
Serum C3 - Low serum C3 level is seen in APSGN
- thrombus in
IVC above the
diaphragm
• Serum ASO titre - Increased ASO titre is seen in APSGN
• 20 minute whole blood clotting test (WBCT)- Clotting time > 20 mins indicates snake bite
3. Renal biopsy - lmmunofluorescent and electron microscopic study is done only when indicated
4. Renal function tests
Single regional
• DTPA (Diethylene triamine pentaacetic acid) scan, > 1 Lymph node
Lymph node
involvement
• DMSA (Di mercapto succinic acid) scan, involvement
• MAG-3 (Mercapto Acetyl Glycine) scan
5. Radiological investigations -
• Intravenous urethrography (IVU) :
Mo
► Irregular Filling defects in bladder-'- Tumor
► Irregular calyces - seen in RCC • No metastasis • Distant metastasis
• USG of abdomen :
► Enlarged kidney - seen in RCC
• CT scan Stage I Stage II Stage Ill Stage IV
• Cystoscopy :
• T2 No Mo • T1-2N1-2Mo • T4 any N
► Indications are -
• T3 any N Mo • Any T Any N M 1
* H/O Lower urinary tract symptoms (LUTS)
* Hematuria with normal IVU
164 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS O Paper - II 165

□ Treatment : (II) MANAGEMENT OF CARCINOMA OF URINARY BLADDER

A. ForT1-2 tumor
, Endoscopic resection of bladder tumor
, Helmatein balloon degeneration and cystoscopic resection -
T1-2 tumor
-20%benlgn ► Done for large papillary tumor
- 60% indolent
- 20% aggressive
Balloon is passed pressure necrosis remaining part of the
balloon is inflated of the summit of the tumor is resected
Into urinary bladder
tumor through cystoscopy
Surveillance

Surgery • lntravesical chemotherapy -

Thermal ablation ► Used especially for carcinoma in situ
► BCG is mostly used.
► Dose : 120 mg of BCG in 150 ml of normal saline weekly for six weeks
► A/E : BCG provocation (fever, joint pain, granulomatous prostatitis, disseminated
Partial nephrectomy tuberculosis)
► Contraindication : hematuria
► Mitomycin C, adriamycin, epirubicin, metrotrexate, thiotepa can also be used.
• Systemic chemotherapy -
► Cisplatin, Adriamycin, 5-FU and mitomycin are used.
0 For invasive bladder tumor
Indication - • Radiotherapy
a) Small tumor< 10-12 cm Indication -
a) Tumor ► Interstitial radiotherapy
b) No such renal vein involvement
c) No/minimal local invasion b) Renal cell CA In solitary kidney • Ofte11 curative.
d) Manageable lymphadenopathy c) Bilateral RCC • Implantation of radioactive gold grains (Au 198, half-life = 2.5 days)/ radioactive
d) Familial RCC tantalum wires (Ta 182, half-life= 4 months) is done.
► Radical deep external beam radiotherapy
• Dose: 45 Gy
D. For bulky lymphadenopathy - Surgical resection if feasible
• Cobalt 60 is used
4-10% cases - Tumor IVC thrombus below the level of IVC thrombus extending above • Advantage : Normal act of micturition can be maintained
thrombus in venous system main hepatic vein the level of main hepatic vein- • Complication : Thimble/Systolic bladder
Requires aggressive approach • Surgery
• 45-75% cases - managed by • Isolation of vessels followed
► Indications :
Nephrectomy + Thrombectomy by thrombectomy • Venovenous bypass/
Cardiopulmonary bypass * Multiple tumors
• Hypothermic cardiac arrest * Recurrent tumors
B. For T3 tumor * Sessile tumours
C. For T4 tumor - Best option is En Bloc resection of all involved structures * Poorly differentiated tumors
D. For bulky lymphadenopathy - Surgical resection if feasible * Adenocarcinoma
E. For local recurrence of RCC (Adjuvant treatment for RCC) * Squamous cell carcinoma
• for local recurrence after radical nephrectomy (2-4%) * Carcinoma in situ
► localised - Re-resection (ii) Systemic - Radiotherapy ► Modalities:
• for local recurrence after partial nephrectomy (1-10%) * Partial cystectomy -
► Completion nephrectomy / Repeat partial nephrectomy / thermal ablation ❖ Indication : single tumor, tumor confined to fundus of bladder
• for local recurrence after thermal ablation ❖ 2.5 cm margin of clearance is maintained
► Repeat thermal ablation / Salvage surgery (Partial or Radical nephrectomy) ❖ Surgery is followed by external beam radiotherapy and chemotherapy.
166 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 167

* Radical cystectomy - Alpha 1 adrenergic blockers -

❖ Removal of urinary bladder, urethra, paravesical tissues, pelivic lymph no
• Act on dynamic component - Inhibit contraction of smooth muscle of prostate
is done. Hyterectomy with removal of part of vagina is done in females. • Reduce bladder neck resistance thereby improving urine flow
❖ Urinary diversion is done by ureterosigmoidostomy or continent ileal cond • Short acting drugs : Prazosin, lndoramin
or rectal urinary pouch. • Long acting drugs : Terazosin, Doxazosin
• Chemotherapy • Selective Alpha 1A receptor blocker :
► lntravesical chemotherapy a) Tamsulosin - 0.4-0.8 mg daily for 12 weeks
* Done by BCG, mitomycin C, adriamycin, interferons. b) Alfuzosin - 10mg daily
• Systemic chemotherapy - c) Silozosin - 4-Smg daily
► Regimen for adjuvant therapy : (i) Cisplatin, adriamycin, mitomycin, vinblastin ( • Selective Alpha 1D receptor blocker
Methotrexate, vinblastin, adriamycin, cisplatin (MVAC) Naftodipil-improves nocturia (25-75 mg daily)
► Neoadjuvant chemotherapy : Cisplatin is used (improves survival by 7%) • Adverse effects -
a) Floppy iris syndrome
(iii) MANAGEMENT OF BPH b) Postural hypotension
□ IPSS: c) Retrograde / dry ejaculation
• International Prostate Symptom Score/ American Urologic Association Score d) Flushing
• 7 questions regarding symptoms in the past month 2. 5 alpha reductase inhibitors -
• Act on static component : Inhibit conversion of testosterone to DHT
• 1. Incomplete emptying 2. Frquency 3. lntermittency 4. Urgency 5. Weak stream 6. Straini
7. Nocturia • Effective in palpable enlarged prostate
• Maximum score - 7*5 = 35 • Drugs used :
• Mild symptoms - Score Less than or equal to 7 ► Finasteride : 5mg daily for 6-8 months

• Moderate symptoms - Score 8-19 ► Dutasteride : 0.5 mg daily

• Severe symptoms - Score 20-35 3. Anticholinergics -
• Drugs used :
A. Medical treatment :
► Tolterodine - 2-4 mg
► Solifenacin - 5-10 mg
► Darifenacin - 7.5-15 mg
IPSS-More than or equal to 8,
- Patient chooses non-invasive therapy 4. Phosphodiesterase 5 inhibitors -
• Drugs used :
I ► Sildenafil
I I
► Tadalafil
Prostate < 30 g Prostate > 30 g
PSA < 15 ng/ml PSA > 15 ng/ml ► Vardenafil

I I B. Surgical treatment :
Start Alpha Alpha blocker + 5 alpha reductase • Indications of surgery -
blocker inhibitor ► Prostatism (frequency, dysuria, urgency)
► Acute retention of urine

C
I
► Refractory/ chronic urinary retention with residual urine > 200mL
No response For better responce - Add
Anticholinergic ► Recurrent UTI
Surgery
► Recurrent hematuria
I
► Bladder stone
If erectile dysfunction - Add
► Bladder diverticula
Phosphodiesterase 5 inhibitor
► Hydroureter, Hydronephrosis

C If no response, then -
Surgery
• Minimal Invasive Therapy -
► Transurethral resection of prostate (TLJRP)
* Most common and popular method as quicker recovery and early discharge are
possible
 168 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 169

* No suprapubic incision is needed

* Done using resectoscope with high frequency diathermy current Goiter
* Continuous postoperative irrigation with glycine solution is needed for 72 hours
► Holmium LASER enucleation of prostate (HOLEP)
► Trans urethral needle ablation (TUNA) using high frequency radiowaves
► Trans urethral vaporisation (TUVP)
► Trans urethral Microwave therapy (TUMT)
Non toxic Toxic Neoplastic Thyroiditis Others
► Trans urethral incision of prostate (TUIP}
► Trans urethral balloon dilatation of prostate
► Prosthetic stents (lntraurethral / extraurethral}
Bacterial Amyloidosis
► High intensity ultrasound energy therapy
► Water induced thermotherapy
• Surgery: Diffuse Colloid Multi nodular
Solitary
* Millin's retropubic prostatectomy hyper- nodule
► Not commonly practiced plastic
► Done without opening of bladder
* Young's perinea! open prostatectomy
Freyer's suprapubic transvesical open prostatectomy
► It was the procedure of choice for enlarged prostate before the advent of TURP
Hashimoto's
► Indication : Bladder pathology + Large median lobe Diffuse-Grave's autoimmune
disease thyroiditis
• Complications of surgical procedures :
* Water intoxication with congestive cardiac failure - TURP syndrome
* Retrograde ejaculation - 65%
de-quervain's
* Recurrent late UTI - 20% Multinodular-
Thyroiditis autoimmune
* Need for re-TURP/ Surgery in 10 years - 15% Plummer's disease
thyroiditjs
* Failure/ Recurrence of symptoms - 10%
* Severe sepsis - 6%
* Erectile dysfunction - 5%
* Postoperative hematuria Toxic nodule Riedel's
(solitary) thyroiditis
* Perforation of bladder or prostatic capsule

(iii) MANAGEMENT OF URINARY BILHARZIASIS

1) Medical treatment - Long term Praziquantel or Metrifonate
2) Surgical treatment -
• For sequelae or complications of urinary bilharziasis Carcinomas ,,,.
► for thimble bladder - ileocystoplasty/ cecocystoplasty 1, papillary
Malignant 2, follicular
► for papilloma of bladder - cystoscopic diathermy fulgaration 3. anaplastic
► for squamous cell carcinoma of bladder - radical cystectomy 4, medullary

2013 (supplementary) Neoplastic

Lymphoma
Ho do you classify goiter? Give an outline of investigations and management of a solitary
odular goiter. - [5 + 5 + 5]
GOITER Adenomas -
Benign Follicular,
□ Classification - The term Goiter (Latin "gutter"-throat) is used to describe generalised enlar;g_emen~ Hurthle cell type
of the thyroid gland,-~ -~- '

22
 170 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 171

□ Investigations:
1. Thyroid function test- TSH, Free T4 (to detect hyperthyroidism)
[ Diffuse hyperplastic goiter ) • Serum Thyroid-Stimulating Hormone (Normal 0.5-5 U/ml)

I
I
I I
• Total T 4 (Reference Range 55-150 nmol/L) and T3 (Reference Range 1.5-3.5
nmol/L)
Physiological - Primary iodine • Free T 4 (Reference Range 12-28 pmol/L) and Free T3 (3-9 pmol/L)
Secondary iodine
1. Puberty deficiency - deficiency Non-toxic nodule - Usually euthyroid with normal TSH and low-normal or normal free T 4
2. Pregnancy endemic (dietary intake levels. If some nodules develop autonomy, suppressed TSH levels or hyperthyroidism
< 100 microg/day) Toxic nodule - Free T4 - very high, TSH - low or undetectc:_bJe

I Dyshormonogenetic :
I 2.
3.
X-ray neck and chest - to detect tracheal deviation or compression or sometimes calcification.
Ultrasound of neck -

II
• To ~rri£alpable nodules(< 2-3 mm in diameter)
• Gives Information about size.and multicentricity.
Drugs-PAS thiocyanate, • Distinguishes solid from cystic lesions
lithium • To guide FNAC
• To assess for cervical lymphadenopathy.
Goitrogens-cabbage, • Colour Doppler USG helps in visualisation of small vessels within the gland
soyabean etc 4. CT/MRI -
• To evaluate Retrosternal extensions .
To assess for lymphadenopathy
To detect impalpable nodules
SOLITARY THYROID NODULE
It is a single palpable nodule in an otherwise impalpable thyroid gland. It may be toxic (3-5%) or non-toxic. 5.~-
□ Causes/Differential diagnoses : • Recommended in patients who have a dominant nodule or one that is painful or
enlarging · ---- - - ..
(i) Toxic nodule (single/ one palpable nodule of a multinodular goiter) [most common]
• Can detect colloid nodule, thyroiditis, thyroid cyst, thyroid carcinoma (papillary and
(ii) Thyroid adenornas (Follicular, Hurthle cell type) - 20%
medullary)
(iii) Papillary carcinoma of thyroid - 20%
• Cant differentiate between follicular adenoma and adenocarcinoma
(iv) Thyroid cyst - 10%
• Most experts have recommended 3-6 aspiration per nodule. Satisfactory specimen
(v) MedullaTv"carcinoma of thyroid
contains atleast 5-6 groups of cells, each group containing 10-15 well preserved
□ Solitary thyroid nodule may present with the following features : cells
• .,§_welling in the anterior aspect of lower part of neck, which moves with deglutition anddoesnot • Grading - Thy1 (nondiagnostic),Thy2 (noneoplastic),Thy3 (follicular),Thy4
~ove with protrusion of t(?!!9,1Je ··-··-··~~ (suspicious of CA),Thy5 (Malignant)
• Tracheal deviation towards opposite side is common (Trail's sign, Two finger test) 6. FNAB/ True cut biopsy -
• History and clinical features suggestive of.malignan·cy : • Fo[diagnosis of ca_i:~t!l9ma mainly- unresectable tumor, anaplastic CA, lymphoma
► Nodule in extremes of age group (child/> 60 yrs aged) 7. Radioisotope study (Isotope used - I 123 [Half life- 12-13 hrs] or Tc99[Half life-6 hrs])
► Nodule in a ~ patient • "Hot" nodule - Toxic
► History of radiation on neck • '.~War_!!I~' nodule - Euthyroid (Non t ~ ;
► _Family history of papillary/medullary CA of thyroid Warm nodule in Tc99 scan, but cold nodule in RAI scan - Discordant nodule
► Hoars~ess of voice/stridor/dyspnea/dysphagia (Malignancy)
► ~ e with firm consistency • '.'Cold" nodule - 20% mal~J!0%J2enign
► fixity to surrounding structure 8. f:_ower Doppler -
► ~ s e t / recent rapid growth in size • ]"o know vascularity of the glafld
► Pain in.Jh; swelling • Resistive index> 0.7 (N = 0.65-0.7) indicates malignancy
► Palpab~ lymph node

.
172 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 173

9. Indirect lary!1go~py;::::,
To assess vocal cord movements prior to surgery (mainly for documentation and medicolegal
FNAC
purpose). ·
10. ECG - To detect cardiac abnormalities
11. Baseline investiga~
• Complete hemogram : Hb%, TC, DC, ESR Hurthle cell Follicular Papillary CA Medullary CA
• Blood for sugar, urea and creatinine adenoma adenoma

• Urine and stool routine examination

Hemi Near total thy-
□ Treatm~nt : thynoidectomy Total thyroidec-
Hemithyroidectomy roidectomy ***
Indications for surgery in solitary nodule of thyroid - tomy with lymph
followed by levo-
node dissection
i) Malignant nodule/ Nodule suspicious of malignancy thyroxine 0.3 mg
Histology - Hurthle (upto level 6)
cell carcinoma
OD
ii) Follicular neoplasm
Histology Follicular
iii) Nodule with obstructive symptoms
carcinoma
iv) Toxic nodule in children Total thyroidectomy
v) Complex cyst + routine central
neck node removal Completion
vi) Cosmetically bothersome nodule thyroidectomy
+ modified radical
Treatment options - neck dissection within 7 days or
when lateral neck after 3 weeks
• Non-toxic nodule - Hemithyroidectomy (Unilateral lobectomy+isthmusectomy) Total thyroidec-
nodes are palpable
• Toxic nodule - · · · tomy (if Frozen
section biopsy
proves carcinoma)
with lymph node
Treatment of toxic dissection
nodule

• Colloid nodule -
Age < 45 years Age > 45 years Oral levo-thyroxine
J,
Therapy failed- Progressive enlargement/ recurrent nodule
Antithyroid drugs • Radio iodine J,
until euthyroid th~~ 5 rnilicurie
status is achieved .a.rally Hemithyroidectomy
Anti - thyroid drugs :
□ Initially given to make patient Euthyroid before surgery
Surgery □ Carbimazole 10mg 6-8 hrly - Euthyroid state may be achieved by 6-8 wks
Hemithyroidectomy ••
□ Propranolol20-40 mg BD/TDS - To ameliorate cadiovascul.ar symptoms
□ Lugol's iodine 10-30 drops/day for 10 days prior to surgery - To reduce vascul~ELtl .c:>f gland
·-~~·- -,, ~---""'·' ·- ' .. -··-~--·•-•-
•• Hemithyroidectomy - Lobectomy (unilateral) + lsthmusectomy
• Thyroid cysts - *** Near total thyroidectomy - < 2 g of thyroid tm,TQisLU§,sue..ls..ke.QLQ!llYJQ preserve parathyroid glands,
near lower pole on one or both sides. ·
► Cyst..~ i n size ]
► gomplex cy_s_t (Cyst containing both solid and cystic areas) Surgery indicated 0.2 :Classify renal neoplasms. Write clinical features, investigations and management of renal cell
► Recurrent thyroid cyst carcinoma in a 40 years old male patient. (3 + 5 + 3 + 4]
• Thyroid neoplasms - (see chart on next page) Ans : See Sec-I, Segment-A, Paper-II; 2011 Os. 2 (Page 139-140) .
 174 prehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - II 175

f"' ~ s s the clinical features of pheochromocytoma. How will you diagnose this condition? Give • Polyuria
\j
7:itline of management.
'°
[5 + 5 + 5) • Diarrhea (Due to elevated Basal Metabolic rate)
PHEOCHROMOCYTOMA • Weight loss (Due to elevated BMR)
• Constipation
□ Clinical Features : • Raynaud's phenomenon
1. Age of onset - 4th-5th decade • Cushingoid features
2. Typical features - 6. Rule of 10 for phaeochromocytoma -
a)
• 10% familial

Classical
• 10% extra-adrenal

Triad • 10% malignant

• 10% calcified
• 10% multiple
Headache
Palpitation Perspiration • 10% bilateral
(30%) • 10% hypotension
• 10% in children

b) Anxiety 0 Investigations for diagnosis :

c) Sense of impending doom 1. Blood studies -
d) Facial pallor • elevated Total leucocyte count
e) Tremor • elevated ESR
f) Cyanosis • elevated Blood glucose
3. Cardiac manifestations - • decreased Renin
• Hypertension - Most common manifestation (90%) 2. Urinary metanephrine - Sensitivity > 97%(1.3mg/day)
- 60% sustained hypertension, 40% paroxysmal hypertension 3. Urinary Vanillyl mandelic acid (VMA) - Sensitivity 89%
• Angina - More than? mg/24hrs
• Myocardial infarction 4. Plasma free metanephrine - Screening test of choice
• Supraventricular tachycardia 5. Serum chromogranin A - increased in 80% cases
• Ventricular premature beats 6. Imaging studies -
• Cardiomyopathy • CT scan - Gives better anatomical delineation
• Myocardial fibrosis • MRI - Investigation of choice {IOC)
• Congestive cardiac failure ► More sensitive (>90%)
• Non-cardiogenic pulmonary edema (Pulmonary capillary wedge pressure/PCWP < ► Light bulb appearance
18mmHg) • Metaiodo Benzyl Quinidine (MIBG) scan with Iodine 123 radioisotope
4. Crisis - ► To locate extra-adrenal phaeochromocytoma
• Sudden onset • Somatostatin Receptor Scintigraphy (SAS)
• Anorexia, Nausea, vomiting ► By using lndium-111 Octreotide
• Chest pain, Abdominal pain ► to locate occult phaeochromocytoma
• Hypertension, Tachycardia, Tremor • Positron Emission Tomography (PET) scan with 18-Fluorodeoxyglucose (FOG)
• Sense of impending doom ► Besttest
• Perspiration, Headache ► Highly sensitive
5. Other features - □ Management:
• Confusion
Algorithm for management of Phaeochromocytoma :
• Psychosis
• Fever (elevated IL6)
176 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS O Paper - II 177

0 Treatment of Operable phaeochromocytoma :

Hypertension, Headache, Perspiration, Preoperative Preparation -
Palpitation, Weight loss, Tremor
A.
1. Alpha blocker - Given 4 weeks prior to the surgery

Plasma free metanephrine

Phenoxybenzamine 20 mg BO initially

Negative Positive
Increase the dose every 3rd day

Observe Confirmatory test-Urinary

metanephrine/catechola'.mines
Maintenance dose - 40-160 mg daily

Negative Positive Suppression is indicated by -

• BP in supine posture <90/60 mmHg
Repeat urinary metanephrine • BP in erect posture <160/90 mmHg
CT/MRI**
2. Beta blocker - Propranolol 40mg BO (Given 1 week prior to the surgery only after the patient is
fully alpha blocked)
3. Newer Calcium Channel Blocker like Felodipine
Negative Mildly elevated Positive
B. /ntraoperative Treatment -
1. Hypertensive crisis - Drug of choice (DOC) is Sodium Nitroprusside (0.5-10 Microgram/kg/min)
Observe CT/MRI** 2. Fatal arrhythmia - DOC is Esmolol (5 mg titrating dose, Half life is 10 mins)
Clonidine suppression test*
· C. Adrenalectomy -
• Adrenal vein is ligated first
• To avoid breach in the capsule of tumor during surgery
• Clonidine • Rupture and spillage of the tumor should be prevented
suppression test
• In case of bilateral presentation of phaeochromocytoma, the opposite side can be operated
at a later date
□ Treatment of Inoperable pheochromocytoma :
Urinary Metanephrine Urinary Metanephrine
suppressed not suppressed Catecholamine Synthesis Inhibitor - Metyrosine 250 mg ODS
□ Treatment of Metastatic pheochromocytoma :
Observe CT/MRI** • Chemotherapy - Cyclophosphamide, Vincristine, dacarbazine
• High dose MIBG therapy with Iodine 123 and Iodine 131
**CT/MRI

!//~~ 2014
Age < 50 years, Age > 50 years, a:~~&ss the clinical features, investigations and treatment of thyrotoxicosis. [5 + 5 + 5]
Multicentric Solitary lesion
THYROTOXICOSIS
MIBG Scan Preoperative prepara- Thyrotoxicosis refers to the symptom complex due to raised levels of thyroid hormones.
tion and Surgery ,- w,"¥§1{'-); ~-~- r ~ • ~

(Adrenalectomy) Can occur in any age group. ,

Preoperative preparation and Sex predisposition - £ : M = ,§: 1 f (" tt\
Surgery (Adrenalectomy) It is of two principal types - (i) Primary (ii) Secondary

23
 178 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 179

□ Clinical features : , Ectopic beats/ Extrasystoles

A. Symptoms ► Pulsus paradoxus
i) ~ascular system , Paroxysmal atrial tachycardia
► Palpitation ► Paroxysmal atrial fibrillation
► Angina , Persistent atrial fibrillation not responding to digoxin
► Dyspnea iii) Thyroid dermopathy
ii) Gastrointestinal system ,. Pretibial myxedema - Skin around both ankles and feet become shiny, reddish,
, Diarrhea thickened with coarse hair. Occurs due to deposition of mucin like materials
► Weight loss (although appetite is increased) (Glycosaminoglycans) in skin and subcutaneous tissue.
iii) Genitourinary system ► Pruritus
► Oligomenorrhea/amenorrhea ► Palmar erythema
► Urinary frequency (occasionally) ► Dupuytren's contracttJre
iv) Skin iv) Thyroid acropachy
Hair loss► ► Clubbing of fingers and toes
Pruritus ► ► Hypertrophic pulmonary osteoarthropathy may occur
► Gynecomastia
v) Musculoskeletal system PRIMARY THYROTOXICOSIS SECONDARY THYROTOXICOSIS
\. •'

► Undue fatigue 1. Symptoms are followed by thyroid st'E(lljng. 1. Symptoms follow thyroid swelling.
► Muscle weakness 2. Goiter is diffuse, smooth , 2. Swelling is large, nodular
r Increase in linear growth (seen in children) 3. Features are more severe 3. Features appear late , are less severe and
vi) Neurological system 4. Eye signs are common slowly progressive
► Tremor 5. Cardiac manifestations are uncommon 4. Eye signs are not common
► Irritability 6. Occurs in young 5. Cardiac features are common
► Nervousness 7. Entire thyroid gland is overactive 6. Occurs in adults and elderly
7. lnternodular tissues are overactive
► Insomnia
8. Signs
i) Eye signs □ Investigations :
► Stellwag's sign - Absence of normal blinking resulting into staring looks. It is the first 1. Thyroid function test
eye sign to appear. (a) TSH, Free T4 - to detect hyperthyroidism.
► Lid retraction (Dalrymple's sign) - Visible upper sclera due to higher upper eyelid ► Serum Thyroid-Stimulating Hormone (Normal _0.5-5 micro IU/mL)
with normal lower eyelid. .·
► Total T4 (Reference Range 55-150 nmol/L) and T3 (Reference Range 1.5-3.5 nmol/L)
► Lid lag (von Graefe's sign) - Upper eyelid is unable to keep pace with the eyeball ► Free T4 (Reference Range 12-28 pmol/L) and Free T3 (3-9 pmol/L)
when it looks downwards while following examiner's finger.
Non-toxic goiter- Usually ~ o i d with normal TSH and low-normal or normal free T4 levels. If
► Joffroy's sign - Absence of wrinkling on forehead when patient looks upwards. some nodules develop autonomy, suppressed TSH levels or hyperthyroidism
► Moebius's sign - Lack of convergence of eyeball resulting in diplopia.
Toxic goiter - Free T4 - very hig~, TSH - low or undeteqtable
► Exophthalmos - Visibility of lower sclera initially followed by visible upper sclera(due (b) Thyroid Antibodies assessment -
to spasm of upper eyelid and infiltration of retrobulbar tissues with fluid).
► to differentiate from autoimmune thyroiditis (TPO_ and Thyroglobulin antibodies)
► Grading of exopththalmos -
► to detect Grave's disease (LATS).
* Mild- Stellwag's sign + Dalrymple's sign + von Graefe's sign
► TSHRAb found in all Primary thyrotoxicosis
* Moderate - Joffroy's sign
(c) TRH stimulation test - "No response" (No change is TSH level after 20 mins following
* Severe - Moebius's sign, diplopia, ophthalmoplegia
intravenous TRH 200 microg) suggests hyperthyroidism
* Malignant (misnomer)/Progressive - Chemosis, corneal ulceration, papilledema 2. X-ray neck and chest - to detect tracheal deviation or compression or sometimes calcification.
ii) Cardiac manifestations
3. Ultrasound of neck -
► Tachycardia and increased sleeping pulse rate (as per Crile's grading)
• To Identify impalpable nodules (<2-3 mm in diameter)
 180 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 181

Gives Information about size and multicentricity.

* P!opran_c:il_ol 20-40 mg BD/TDS - To amelio_r~te cadiovascular symptoms
Distinguishes solid from cystic lesion
* Lug_ol's iodine 10-30 drops/day for 10 days prior to surgery- To reduce vascularity
To guide FNAC
of gland
To assess for cervical lymphadenopathy.
• Colour Doppler USG helps in visualisation of small vessels within the gland ► Disadvantages -

4. CT/MRI - * High recurrence rate

* Adverse effects - thrombocytopenia, agranulocytosis, hair loss, liver damage
• To evaluate Retrosternal extensions.
• To assess for lymphadenopathy • Radioiodine therapy
► lndicatior.s -
• To detect impalpable nodules
5. FNAC- i) Patient with cardiac complications
• Recommended in patients who have a dominant nodule or one that is painful or enlarging ii) Elderly (initially 40yr age, however now more than 10 yr age eligible)
• Done as carcinomas have been reported in 5 to 10% of multinodular goiters. iii) Autonomous toxic nodule
• Most experts have recommended 3-6 aspiration per nodule. Satisfactory specimen contains ► Contraindication - Pregnancy
atleast 5-6 groups of cells, each group containing 10-15 well preserved cells ► Adjuvant- Pretreatment with lithium, rhTSH leads to increased effectiveness of uptake
6. Radioisotopestudy (Isotope used-I123 [Half life -12-13 hrs] or Tc99 [Half life-6 hrs)) ► Isotope used - I 131 (half life= 8 days)
• "Hot"nodule - TC:xic ► Dose - 300-600 MBq OR 12-14 milicurie OR 160 microcurie/g of thyroid orally
• ~'-'Y~rm" nodule - Euthyroid; ► Suhsln.ntial improvement b/w 8-12 wks.
Warm nodule in Tc99 scan, but cold nodule in RAI scan - Discordant nodule (Malignancy)
• "Cold"-~-~~~~-::_?0% malignant, 80% b~!gn
Grave's diease (Primary thyrotoxicosis) - Diffuse uniform overactivity r

Secondary thyrotoxicosis - Heterogenous overactivity (only internodular areas show increased uptake) Antithyroid therapy until
eumetabolic
7. Indirect laryngoscopy - state (2-8 wk)
To assess vocal cord movements prior to surgery (mainly for documentation and medicolegal purpose).
8. ECG - To detect cardiac abnormalities
9. Baseline investigations - Medication discontinued
• Complete hemogram : Hb%, TC, DC, ESR for 4 days
• Blood for sugar, urea and creatinine
• Urine and stool routine examination
12-14 m Curie radioiodine is
□ Treatment : _99.posIted into the 1iland based on
A. GENERAL MEASURES pretreatment RAIU test
1) Rest
2) Sedation
7 days thereafter, antithyroid drug
B. SPECIFIC MEASURES is reinstituted for 3 months
1) Anti - thyroid drugs
► Indications - I I
i) Initially given to make patient Euthyroid before surgery I No improvement I
ii) Soon after starting radioiodine therapy I If size reduces I
►
iii) Thyrotoxicosis in children and in young adults
iv) Thyrotoxicosis in pregnant women (preferred drug-Propylthiouracil)
Drugs -
L Dose of Antithyroid
drugs is tapered
gradually
L Second course of
therapy/Surgery
* _9arbimaz.ole 10mg 6-8 hrly
OR Propylthiouracil 200 mg 8 hourly
- EL7thyroTdstate may be achieved by 6-8 wks
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - 11 183
182 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

* Adverse effects -
· ·lf: Describe the pathophysiology of BHP. Mention the medical and surgical management of BHP.
· [6 + 4 + 5]
i) Low level exposure to radiation
ii) Hypothyroidism BENIGN PROSTATIC HYPERPLASIA
iii) Radiation induced thyroiditis (4% cases) Q pathophysio/ogy:
iv) Therapeutic dosing dilemma • Benign Prostatic Hyperplasia is involuntary hyperplasia of prostat~ du_e to disturbance of
v) Orbitopathy r,~al_@_tio and quantity of circuLatin.9- androgens and estro~_i:,_ri_s_:.
• Surgery • It is actually a benign neoplasm, also known as Fibromyoadenoma.
► Indications -
i) Young patients
ii) Mid trimester pregnancy Pulsatile release of LHRH from hypothalamus
iii) Autonomous toxic nodule
iv) Toxic multinodular goiter
v) Grave's ophthalmopathy Release of LH from anterior pituitary

vi) One or more large nodule with obstructive symptoms

vii) Failed radioiodine therapy
LH stimulates Leydig cells of testis
viii) Failed/ Prolonged treatment with antithyroid drugs (> 2 yrs)
ix) Those who require rapid resolution at thyrotoxic state
Options -
Leydig cells release Testoterone
a) _i:otal thyroidE:9~0!:!1y (Surgery of choice)
b) --~~¥.IQ!flUbY.[.Q[sJ~C~r:!}Y- ~~£D~hyroid tissue is kept only to preserve
parathyroid glands, near lower pole on one or both sides
c) Subtotal thyroidectomy - 2_i:<.J.':1,~~~i!_?EE:J_St9_my + j§!h.J!!!,l~~Y- 8 g thyroid Prostate release 5 alpha reductase type II which converts Test-
tissue is retained in trachea-oesophageal groove on both sides osterone to Dihydrotestosterone (DHT)
► Advantages -
* Rapid cure and High cure rate
• DHT is five times more potent than Testosterone. With increasing age, the level of testosterone
Disadvantages - drops slowly. When the concurrent fall of the level of estrogen is not equal, prostate enlargement
a) Recurrent thyrotoxicosis (5%) occurs through Intermediate peptide growth factor.
b) Permanent hypothyroidism (20-45%) • BPH usually arises from submucosal glands of periurethral transitional zone and enlarges
c) RLN injury as lateral lobes narrowing the urethra. BPH may also arise from subcervical glands of central
zone and enlarges as middle (median) lobe projecting up into the bladder.
Pre operative -
* CT scan, MRI
M~9iaJ1 lobe of prostate enlarges into the bladd~r Lateral lobes of prostate narrow the urethra
* Restoration of euthyroidism
► Post operative -
Tab Carbimazole - 10mg, 6-8 hourly 1. Detrusor muscle hypertrophy (lengthening of 1. Urethra above verumontanum gets narrowed
J, muscle fibres) occurs - Trabeculation 2. Lengthening of prostatic urethra - Alteration of
No clinical improvement for 7-14 days 2. Sacculations and diverticula formation in bladder posterior curvature
J, 3. Compression of prostatic venous plexus leading 3. External sphincter dysfunction
to congestion - Vesical piles resulting in hema- 4. Severe obstruction may lead to obstructive
Euthyroid state achieved in 6-8 weeks turia uropathy and renal failure
J, 4. Progressive increase in bladder pressure - In- 5. Impotence
Maintenance dose - 5mg, 8 hourly for 12-18 months creased Post Void Residual (PVR) 5-12 ml
5. Backpressure causes hydroureter and hydro-
nephrosis
6. Secondary ascending infection- Pyelonephritis
.I
184 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 185

Management of BPH
Algorithm for evaluation:
!PSS-more than or equal to 8
A I
IPSS-~ Iha n or equal to 71
History suggestive of Bladder outlet obstruction (BOO) / I
Lower urinary tract syndrome (LUTS) A. Urof/owmetry

Watchfu I waiting
j 1. Normal voided volume > 150 ml
2. Normal Maximum flow > 10 mUsec
3. Normal average flow < 10 mUsec
Suggestive history B. Post Void Residual
1. Voiding symptoms - Hesitancy, poor '
stream, dribbling, inadequate empty-
~
I
ing, retention Discussion for patient opinion about
2. Symptoms of storage - Frequency, ur- treatment modality
gency, nocturia, urge incontinence
I
Patient chooses non-invasive Patient chooses invasive
therapy therapy

I Digital rectal examination

I j
I
1. UsG
r--- Watchful waiting 2. Urodynamic study

I Urine analysis - RE, ME, CS

I

I Serum Prostate specific antigen (PSA) level (Normal - 4 ng/mL)

I
y Medical treatment
*·
I
r--
Minimal invasive
therapy
,1,
I Nex\-. ~O.O'Q.,

I
\...
IPSS (International Prostate Symptom Score)
I ~
Surgery

□ /PSS:
Less than or equal to 7-Mild • International Prostate Symptom Score I American Urologic Association Score
" symptoms • 7 questions regarding symptoms in the past month
• 1. Incomplete emptying 2. Frquency 3. lntermittency 4. Urgency 5. Weak stream 6. Straining
7. Nocturia
• Maximum score - 7*5 == 35
• Mild symptoms - Score Less than or equal to 7
More than or equal to • Moderate symptoms - Score 8-19
8-Moderate to severe symptoms
• Severe symptoms - Score 20-35

24
 186 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 187

5 alpha reductase inhibitors -

• Act on static component- Inhibit conversion of testosterone to DHT
• Effective in palpable enlarged prostate
IPSS - More than or equal to 8 Patient >-
chooses non-invasive therapy • Drugs used -
a) Finasteride - 5mg daily for 6-8 months
I b) _Dutasteride - 0.5 mg daily
I I
Anticholinergics -
Prostate < 30 g Prostate > 30 g
• Drugs used -
PSA < 15 ng/mL PSA > 15 ng/mL
a) ~ - 2 - 4 m g
I I b) ~?lifenacin - 5-10 mg
Alpha blocker+ 5'alpha c) Darifenacin - 7.5-15 mg
Start Alpha blocker reductase inhibitor 4. Phosphodiesterase 5 inhibitors-
I • Drugs used -
For better responce - Add a) Sildenafil
Anticholinergic b) TadalafiL
If no response -
- Surgery I c) Y~L
If erectile dysfunction - Add o Surgical treatment :
phosphodiesterase 5 • Indications of surgery -
inhibitor 1) Prostatism (frequency, dysuria, urgency)
2) Acute retention of urine
3) Refractory/ chronic urinary retention with residual urine > 200mL
~
If no response - 4) Recurrent UTI
Surgery
5) Recurrent hematuria
6) Bladder stone
7) Bladder diverticula
□ Medical treatment : 8) Hydroureter, Hydronephrosis
1. Alpha 1 adrenergic blockers - • Minimal Invasive Therapy -
• Act on dynamic component - Inhibit contraction of smooth muscle of prostate ► Transurethral resection of prostate (TURP)
• Reduce bladder neck resistan_ce thereby improving urine flow *' Most common and poeular method as quicker recovery and early discharge are
• Short acting drugs - Prazosin, lndoramin possible
• Long acting drugs - Terazosin, Doxazosin * No suprapubic incision is needed
• Selective Alpha 1A receptor blocker - * Done using resectoscope with high frequency diathermy current
a) Tamsulosin - 0.4-0.8 mg daily for 12 weeks * Continuous postoperative irrigation with glycine solution is needed for 72 hours
b) Alfuzosin - 10mg daily ► .l::!.olmium LASER enucleation of prostate (HOLEP)
c) Silozosin - 4-8mg daily ► Trans urethral needle ablation (TUNA) using high frequency radiowaves
• Selective Alpha 1D receptor blocker - ► Trans urethral vaporisation (TUV!;>)
Naftodipil - improves nocturia (25-75 mg daily) ► Trans urethral Microwave therap~ Q'U~J)
• Adverse effects - ► T·rans· urethral incision of prostate (TUIP)
a) Floppy iris syndrome ► Dans urethral balloon dilatation of prosta!e
b) Postural hypotension ► Prosthetic stents (lntraurethral / extraurethral)
c) Retrograde/ dry ejaculation ► .t!.!~h intensity ultrasound energy therapy
d} Flushing ► yV~~~r induced thermotherapy
 188 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 189

• Surgery - 5. Tumors of rete testis

► Millin's retropubic prostatectomy > • Adenoma
* Not commonly practiced • Adenocarcinoma
* Done without opening of bladder 6. Adnexal and paratesticular tumors
► Young's perinea! open prostatectomy • Mesothelioma
► Freyer's suprapubic transvesical open prostatectomy • Adenoma
* It was the procedure of choice for enlarged prostate before the advent of TURP • Sarcoma
*Indication : Bladder pathology + Large median lobe 7. Others -
• Complications of surgical procedures - • Carcinoid
► Water intoxication with congestive cardiac failure - TURP syndrome • Secondaries
:,. Retrograde ejaculation - 65°;~ • Soft tissue tumor
► Recurrent late UTI - 20% • Unclassified
► Need for re- TURP/ Surgery in 10 years - 15% Cl Investigations :
►
►
Failure/ Recurrence of symptoms - 10%
Severe sepsis - 6%
Tumor markers
a) Beta HCG
* CN 31'.i',c.,-r
tbv. 't¼:~Jv1v<r
Y Erectile dysfunction - 5% • Half-life - 18-36 hrs
► Postoperative hematuria • Secreted by syncytiotrophoblasts Gte>-,,'VV1 Ce,,fJ ~;
/.,, / ► Perforation of bladder or prostatic capsule • Elevated in -
i) Choriocarcinoma (100% cases)
\,.. 4.ssify testi:ular tumors. Discuss investigations necessary to plan the treatment for a
/~--~~spected testicular tumor. What are the treatment options available? [5 + 5 + 5] ii) Embryonal CA (65% cases)
iii) Advanced seminoma (15% cases)
TESTICULAR TUMORS • Also elevated in -
Hepatocellular CA, Cholangio CA, Pancreatic CA, Renal cell CA, Breast CA,
□ Classification : (\ on!.•·
.· Lung CA, Bladder CA, Gastric CA
1. Germ cell tumor (95<iaS b) ~p.!Ja fetoprotein (AFP)
• Seminomatous (52-56%) - (i) Classic (ii) Spermatocytic (iur-Anaplastic
• Half-life - 5-7 days
• Non-seminomatous/ NSGCT (44-48%) - . • Elevated in -
► Teratoma-Mature, Immature, Dermoid i) Yolk sac tumor
► Yolk sac tumor/ endodermaJ sinus tumor ii) Embryonal CA
►Embryonal carcinoma • Not elevated in seminoma and Chorio CA
► Choriocarcinoma • Also elevated in -
2. Sex cord stromal tumors i) Pancreatic CA, Gastric CA, Cholangio CA, Lung CA
• Leydig cell tumor
r ii) Alcoholic liver disease, Auto immune liver disease, Drug induced hepatitis,
• Sertoli cell tumor Infectious liver disease
• Granulosa cell tumor ii.i) Ataxia telecgiectasia, Tyrosinemia
• Thecoma
c) LOH
• Fibroma
• Half-life - 24 hrs
3. Combined/ Mixed germ cell and sex cord stromal tumors - Gonadoblastoma
• Elevated in -
4. Lymphoid/ Hematopoietic tumors
► Advanced seminoma (80% cases)
• Leukemia
► NSGCT (65% cases)
• Lymphoma
• Also elevated in - Lymphoma
• Plasmacytoma
d) Placental Alkaline Phosphatase (PLAP)
• Elevated in - Seminoma
190 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 191

>
/ L . : : r markers (S - Beta MCG, AFP, LOH) TNM classification

......
.• Tx-T staging not • Tumor Confined • Tumor Confined • Tumor invading • Tumor invading
done to testis/epididy- to testis/epididy- into spermatic into scrotum
Marker Normal
• T0 -No evidence mis mis cord • With or without
study Marker
not done study of tumor • No vascular/lym- • With vascular/ • With or without vascular/lym-
phatic invasion lymphatic inva- vascular/lym- phatic invasion
• Tis-Carcinoma in
• Involvement of tu- sion phatic invasion
situ
nica albuginea, • lnvolvementoftu-
but not tunica nica vaginalis
vaginal is

Beta HCG -
< 5000 mlU/mL
Beta HCG -
5000-50000 mlU/mL
Beta HCG -
> 50000 mlU/mL
[ Nx, No N1 N2 N3

• Nx•Lymph node • Single/Multiple LN • Single/Multiple LN • Regional node

AFP- study not done • Not more than • More than 2 cm > 5 cm
AFP - < 1000 ng/mL AFP - 1000-10000
ng/mL > 10000 ng/mL • No-No lymph node 2 cm in greatest but less than or
involvement dimension equal to 5 cm
LDH - < 1.5* ULN
(upper limit of normal LOH - 1.5-10 *ULN LOH - > 10• ULN

No distant Distant spread to Distant spread to any

2. USG of abdomen and scrotum metastasis nonregional lymph area except non re-
nodes gional LN or lungs
• 5-1 O mega Hz
Distant spread to
• Shows hypoechoic area within testis lungs
• Microlithiasis is testis may be present
• NSGCT may appear as heterogenous lesion
• Any T

(______
• Teratoma may show ectodermal tissue
• No
3. CT abdomen Stage 1
• Mo
• To look for retroperitoneal mass / secondaries, lymphadenopathy/ iliac and
aortic lymph nodes
JI • So

[
• Correct staging can be done • Any T
4. Chest X-ray • N1
Stage2A
• Mo
5. MRI
•

•
To rule out pulmonary secondaries

Superior to CECT
JI • So I 81

Any T

(_
•
6. Sperm cryopreservation
• N2
• Done for future fertility concern Stage2B
• Mo
• Testicular tumor shows oligospermia (52% cases) and azoospermia (10% cases)

Scrotal FNAC/ Transcrotal incisi~~..~iopsy is C?~aindicaJed beq_('!M,~e - ,

JI • So I 81

• Any T

(_____
It leaves inguinal part of the spermatic cord & alters the lymphatic drainage of testis increasing risk of
local re·cu·rrence, pelvic and inguinal metastasis. - • N3
Stage2C
• Mo
JI • So I 81
 192 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 193

• Any T ~ 3 and 1s:

( Stage3

JI
• Any N
• M1
• S1.3
l Chemotherapy
(Cisplatin based)
• Any T

( Stage 1s

JI
• No
• Mo
• S1.3
I
I
Residual mass

• Low grade tumor - Stage 1, Stage 2A, Stage 28 I

• High grade tumor - Stage 2C, Stage 3, Stage 1s I I
□ Treatment : >3cm
® '1) (For se~oma {it is radiosensiti~
<3cm

Stage 1:
~- I
PET Scan ~
Observe
High inguinal orchidectomy
I
9 I

Positive Negative
Surveillance

Tumor markers - at regular intervals for 5 Imaging studies - CT abdomen and chest once
years, then annually a year
- Surgical
resection - Observe

v @~r-NSGCT (it is not radios~~sitive, Teratoma is not even chemosensi~Lv~

Primary radiotherapy OR Primary chemotherapy
Stage 1:
~

Primary radiotherapy/Dog leg radiotherapy 20- Primary chemotherapy - Cisplatin based (1-2
30 Gray to paraaortic + ipsilateral pelvis cycle) High inguinal
orchidectomy

Stage 2A and 2B : I
~
1. Dog leg radiotherapy
Surveillance
• If LN mass< 3 cm
• 20-35 Gray
I
2. Chemotherapy
I I
• If bulky retroperitoneal LN (> 3 cm) or multiple LN metastasis
Primary Primary
• BEP (Bleomycin + Etoposide + Cisplatin) for 3 cycles OR, EP (Etoposide + Cisplatin) for
chemotherapy RPLND
4 cycles

25
 I

194 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

1. Primary chemotherapy - 2014 Supplementary

• Criteria:
i) Bulky retroperitoneal LN (> 3cm)
Q.1: Discuss causes, investigation & management of haematuria. [4 + 3 + BJ
Ans : See Section 1, Segment-A, Paper-II, 2008, Os. 1, Page 94 & 2013, Os. 3, Page 165.
ii) Distant mets
iii) Post orchidectomy tumor marker elevation w1vr1'A't'e the different types of renal calculi ? Discuss the clinical features & management of
nal calculi. [3 + 4 + BJ
• BEP for 2 cycles
2. Primary Retro Peritoneal Lymph Node Dissection (RPLND) Ans: RENAL CALCULI
• Criteria :
o Types-
i) Small LN ( < 3cm)
Also Response to Predisposing
Type Features X-Ray finding
ii) Localised disease called Lithotripsy factors
• Nerve sparing RPLND is ideal, Modified RPLND is advocated to retain ejaculation Oxalate Mulberry , Brown Radioopaque Moderately ✓ Hypercalciuria
stone stone • Viliffishar12 12rojections responsive ✓ Hyperoxaluria
• Complications : Hemorrhage, Injury to major vessels/bowel/ureter, retrograde ejaculati , Show envelope crystals in
chylous ascites, lymphocele urine
, Generally made of calcium
Stage 2A and 2B : oxalate
~ ·
1. Chemotherapy , Most common type
Phosphate Staghorn , Made of calcium magnesium or Radioopaque Moderately ✓ Alkaline urine
• Given to patients suspected to have occult metastasis
stone calculus ammonium phosphate responsive ✓ Excess alkali
• - Criteria - Elevated tumor marker/ Bulky retroperitoneal LN metastasis , §°'mooth - consumption
• BEP for 3 cycles OR, EP for 4 cycles , White ✓ Urine infected
, Coffin-lid shape with proteus sp.
2. RPLND , Usually solitary, takes up
shape of renal calyces
~J!~~.?/!-!1:'3(3 : Cystine , Extremely hard Radioopaque Most resistant ✓ Acidic urine
stone , Hexagonal snape ✓ Inherited
cystinuria
Induction
chemotherapy Uric acid , Smooth Radio opaque Most ✓ Acidic urine
stone • Yellowish responsive ✓ Gout
(Cisplatin based)
, Multiple ✓ Hyperuricaemia
I Xanthine • Smooth Radio opaque ✓ Deficiency of xan-
stone , Brick red thine oxidase
Relapse
Indigo/ • Blue Radio opaque ✓ Due to indinavir
lndinavir use
I stone
I I
Triamterene ✓ Due to
I stone Triamterine use
I,.
Early (within 2 years Late ( after 2 years as antihyperten-
of chemotherapy) of chemotherapy) sive

I I □
- Clinical features -
• Pain:
Second line
Surgical resection
chemotherapy with ✓ Site- i) Renal angle
of all tumors, if
VIP (Vinblastine + ii) Hypochondrium
feasible
ifosfamide + Cisplatin)
iii) Lumbar region
for 4 cycles
✓ Nature - i) Dull (due to stretching of capsule)
ii) Colicky (due to movement of small stone)
✓ Intensity - Severe
 SOLVED LONG QUESTIONS OF FINAL MBBS O Paper- II 197
196 OUES'l' :,:( Comprehensive Guide to UG Surgery, Orthopedics & Anestt(esiolo~y

✓ Worsens on - Movement
b. For lower pole renal caluli ---~l
•
✓ Associated with - Vomiting (due to pylorospasm - renogastric reflex)
Haematuria < 1 cm
~ t
1-2 cm
t
>2cm
• :rend~!!l~-~~-!!1,L~Dal_filill)e
t I t ~
(j)
• Fever with chills due to secondary bacterial infection
□ Investigation - HU< 1000 HU > 1000 Is PCNL
SSD < 10 cm SSO > 10 cm Contraindicated
• Blood investigations -
i) Complete haemogram with ESR
ii) Blood urea ESWL
~
FlexibleI~~
l No '{e$

Retrograde PCNL
iii) Serum creatinine
lntrarenal Surgery
iv) Serum electrolytes - sodium, potassium, calcium, phosphate ,
v) Uric acid
vi) PTH level 3. If endouralogical surgery fail
• Urine investigation - Surgeries
i) Routine & microscopy i) Pyelolithotomy - For stones in extrarenal pelvis
ii) Culture & sensitivity ii) Extended Pyelolithotomy - lntrarenal pelvis
• Plain X-Ray KUB iii) Nephrolithotomy - Incision at most convex surface (Brodel's line)
• 1vu/"r;
,,
-"'"', ,\ iv) Nephrophyelo lithotomy - Incision both on kidney & pelvis [For staghorn calculus]
• USG Abdomen v) Partial nephrectomy - Multiple stones occupy a pole
□ Treatment - vi) Others - (a) Bench surgery
1. For stones < 0.5 cm (b} Anatrophic Pyelolithotomy
Conservative (c) Coagulum Pyelolithotomy
i) i.v. fluids
ii) Antispasmodic & anti-inflammatory agents Q.3: What are the clinical features of primary hyper parathyroidism ? Discuss the investigation &
managemt of primary hyperparathyroidism.[6 + 5 + 4]
iii) Ing. Furosemide 60-80mg i.v.
iv) Flush therapy Ans : See Section 1, Segment-A, Paper-I I, 2010, Os. 1, Page No. 118.
v) Alkalinising agent, acidifying agent (for chronic cases)
vi) Relief of obstruction by double-J stent. 2015
2. Stones > 0.5 cm
Endourological surgery Q.1: Classify goiter. How will you investigate and treat a 30 years old man with clinically discrete
nodule of 3 cm diameter in right lobe of thyroid? [5 + 5 + 5]
a. For non-lower pole renal calculi
A. See Section 1 Segment A Paper II 2013 (supplementary) Q.1, Page No. 168.

<2cm
{, t
>2cm ~ " r e n a l injury. Discuss clinical features and management of patient having injury to left
I kidney following blunt trauma in left loin. [4 + 5 + 6]
~
>1cm CLASSIFICATION OF RENAL INJURY

t
Uretero
American Association for the Surgery of Trauma (AAST) grading for renal trauma is as follows -
:::,H.3,2 .~·'-' Ji-62 ,JJA~,.--•<,, 41 ,,!!;,At,.. ux:s ,i '~·? '~ ; "

Renoscopic stone
Lithotripsy

•
fu;e~----- PCNL

(~~
 198 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 199

[ Grade-I J • Contusion-Microscopic/Gross hematuria (Urologic study is normal)

• Hematoma-Subcapsular, non-expanding
C. Local examination of abdomen
a)
b)
Inspection ·- Any abrasion, ecchymosis, fullness of flanks or abdominal swelling
Palpation - Tenderness, muscle guard or rigidity, any palpable mass
c) Percussion - Any shifting dullness (suggestive of free fluid in abdomen), obliteration of

[ Grade- II J • Hematoma-Perirenal, non-expanding

• Laceration:Cortical, < 1 cm of parenchymal depth, without urinary
extravasat,on
d)
liver dullness (suggestive of free gas under diaphragm)
Auscultation - JPS (absent bowel sounds in hemoperitoneum or peritonitis), any bruit
e) Digital rectal examinatbn-Any doughy feeling (suggestive of blood clot), any tenderness

m J
3. Algorithm of renal trauma rnanagement
[ Grade - • Laceration-Cortical, > 1 cm of parenchymal depth, no urinary
extravasation
RENAL TRAUMA

[ Grade-IV J • Laceration-Extends through cortex, medulla and collecting system

with extravasation of urine
• Vascular-Main renal artery/vein injury, contained hemorrhage
'
Blunt Trauma Penetrating Trauma

[ Grade-V J • Laceration-Shattered kidney

• Vascular-Renal pedicle avulsion, devascularising kidney
Microscopic hematuria
( > 5 RBC/hpf) without
features of shock
Gross hematuria with
features of shock
Microscopic or
gross hematuria

Observation
Hemodynamically Hemodynamically
INJURY TO LEFT KIDNEY FOLLOWING BLUNT TRAUMA TO LEFT LOIN Unstable Stable
Selective renal
□ Clinical features : staging
Exploratory CECT (IVP is
1. Hematuria-mild, moderate or severe depending on the grade of the injury Clinical laparotomy optional)
2. Features of shocls follow-up
3. Single shot IVP Renal exposure
Sudden delayed_J~-~~e hemorrhage- may occur between 3rd day to 3rd week after trauma in the on table
form of hematuna.
4. Clot colic Abnormal/ Done if:
5. Pain and _
swellinn in the loin inconclusive 1. Grade V injury
- _ _v.,"'""''•""-•<>•

6. 2. Expanding/ pulsatile hematoma

Abdom~nal distension with paralytic ileus (due to implication of the splanchnic nerves by
retroperitoneal hematoma) Selective renal 3. Patient becomes unstE!ble with features of shock
exposure 4. Ureteropelvic junction obstruction
□ Management:
1. Primary survey and resuscitation
2. Secondary survey □ Investigations :
A. History 1. Intravenous pyelography (IVP)
a) Time of injury, type of injury, site of injury • Investigation of choice
b) Hematuria-Microscoµic/ gross, progression : decreasing/ increasing • Single shot IVP- 2 mUkg BW radiocontrast injection into ante-cubital vein. After 10 mins,
c) Pain-Site, duration, character, radiation single film is taken.
d) Any other symptoms • Purpose -
B. General survey (i) To observe contralateral kidney (functional or not)
a) Vitals-Pulse rate, BP, RR, temperature, urine output (ii) To perform intraoperative staging of the injury
b) Head to toe examination-to exclude any other injury 2. CECT
• Gold standard test (highly sensitive and specific).
 200 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS D Paper - II 201

• Provides most definitive information about grading of renal trauma. Ill. If polar tear - Partial nephrectomy is done
• Absence of uptake of dye indicates injury to renal artery. IV. If hilar injury, severe laceration - Total nephrectomy__is done, provided the contralateral
• Shows extent of injury, can evaluate other organ injuries. kidney is functioning normally
3. USG abdomen
• Done to see amount of hematoma, type of injury and other associated injuries in the abdomen. ~z;r·------
1
.a._~~he clinical features, complications and management of undescended testis. [5 + 5 + 5)

• Can be repeated at regular intervals {12-24 hourly) to assess progress.

4. Urine RE/ME UNDESCENDED TESTIS
• Volume D What is undescended testis: Testis has failed to descend to scrotum
• Cytology D Incidence : Mostly in premature infants {30%)
• Albumin D Laterality : Right (50%) » left (30%) > bilateral (20%) [this is because right sided testis descends
5. Blood examination later than the left sided one]
• Blood urea, serum ~reatinine D Etiology:
• Serum electrolytes a) Familial
• Hb% b) Gubernacular dysfunction
• Blood grouping and cross-matching c) Short vas deferens

□ Treatment :
d)
e)
Lack of Calcitonin Gene Related Peptide (CGRP)
Lack of HCG
(
1. Conservative management f) Altered hypothalamo-pituitary gonadal axis
• Indications - g) Retroperitoneal adhesions
I. Patient is hemodynamically stable h) Prune-Belly syndrome
II. Decreasing hematuria □ Types/ Clinical presentations :
111. Perinephric hematoma is not increasing I. Lumbar testis - complete failure of descent
IV. No evidence of contrast extravasation on CECT II. Iliac testis - testis remains just deep to deep ring
• Modalities - Ill.Inguinal testis - testis in inguinal canal
I. Bed rest IV. In superficial inguinal poucb - testis in space between external oblique and Scarpa's fascia
II.
Ill.
Catheterisatio.n
Intravenous fluid
V. Scrotal
.,_,,.,.,..,---
testis - testis in upper part of scrotum
The condition with bilateral undescended testes which are clinically impalpable is known as
IV. Blood transfusion (if needed) Cryptorchidism.
V. Sedation, analgesics In undescended testis, testis cannot brought down manually to the bottom of the scrotum.
VI. Antibiotics □ Complications: "TESTIS" (PNEMONIC)
VII. Monitoring of patient 1. Torsion
2. Surgery (Done only in 10-20% of patients) 2. Epididymo-orchitis
•· Indications - 3. Seminoma (Malignant transformation in undescended testis is 20 times more common than
I. Persistent bleeding normal testis)
4. Trauma
II. Expansile or pulsalile perirenal hematoma
Ill. Hilar injury 5. Inguinal hernia (Indirect inguinal hernia - 70%)

IV. Urinary extravasation

6. Sterility
7. Atrophy
V. Segmental arterial injury
• Modalities - □ Management :
I. Renorrhaphy (Transperitoneal approach) A. Investigations:
II. If kidney is friable - Cabot's Nephrostomy _is done 1. USG abdomen
2. CT scan

26
 202 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- II 203

3. Assessment of FSH, LH. HCG Papillo folicular carcinoma ---'t behaves like papillary carcinoma
•
Hurthle cell carcinoma ---'t behaves like Follicular carcinoma except with more bone spread.
4. Gonadal venogram •
5. Laparoscopy □ Patho/ogy-
B. Treatment: A. Papillary thyroid carcinoma -
1. Always surgery - done between 2-4 years of age, 6 months gap in case of bilateral involvement • Soft I firm_! h!3-rd / cysti~
2. Principles of surgery - • Solit~y / 12:1_ultinod_LJJ_c1r
• Mobilisation of spermatic cord • Contains blackish brown fluid
-••-v-•-------•
• Repair of associated hernia • White cut surface
• Creation of scrotal pouch and fixation of testis into the scrotum • On microscopy, shows -
• Orchidectomy done if testis is completely atrophied i) Cystic spaces
3. Hormone therapy used in following cases - ii) Papillary projections
• Doubtful retractile testis iii) Subtle irregularities in nuclear contour with deep nuclear grooves & pseudoinclusions
(Orphan Annie eye nuclei)
• Bilateral cases + hypogenitalism + obesity
iv) Psammoma bodies
4. Laparoscopic approach - orchidopexy is becoming popular
• Slowly progressive
• No blood spread
• Spread via lymphatics
8. Follicular thyroid carcinoma -
• -~apsular invasion
a - Lateral • Angioin~~~~~
b - Central • S_e_~~-~ds via blood / occassionally bones &_lymph node
c - Pectoral
C. Hurthle cell carcinoma -
d-Apical
• S~f?.E:i_g!J_gHicular thi'.rQJ_c:j_ carcinoma
e - Supraclavicular
• Presence of oncocytes rich in mitochondria (Hurthle cell)
• Appear brown on cut surface
Pectoralis minor
For Rest, See Sector 1, Segment-A, Papter-11, 2012, Qs. 1, Page 144 &
See Sector 1, Segment-A, Papter-11, 2010 Supplementary, Qs. 1, Page 123.
Level I - Below lateral
Level II - Behind a:e • /
~ommon causes of lump in left ~pper quadrant of abdomen. Describe the clinical
Level Ill - Above medial · ~ : : : ~< management of renal cell carcmoma. [5 + 5 + 5]
Axillary vein
Ans: LUMP IN LEFT UPPER QUADRANT OF ABDOMEN
/ / F i g . 1.2.1 : Surgical levels of lymph nodes in the axilla draining the breast.
□ Causes -
• Splenic neoplasm
· / /✓" 2015 Supplementary • Left sided renal causes -
i) Renal neoplasm
~ r i b e the pathology, investigations & treatment of differentiated thyroid carcinoma. ii) Polycystic kindney
[4 + 3 + BJ iii) Hydronephrosis
• Gastric outlet obstruction
Ans: DIFFERENTIATED THYROID CARCINOMA
• Carcinoma of pancreatic body & tail
□ Type- Retroperitoneal tumour -
•
•
•
Papillary thyroid carcinoma
Follicular thyroid carcinoma
\ i) Lipoma
ii) Neurofibroma
 204 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 205

~~~~.
iii) Liposarcoma
ii) ESWL (for stones> 5 to< 2.5 cm)
iv) Biomyosarcoma

•
v) Lymphoma
vi) Secondaries
Left sided adrenal tumour
y-
c_; af:// 1t
"""f~viC
1
.
iii) PCNL (for stones> 2.5 cm)
iv) Uretero - Renoscopic Removal
v) Open Ureterolithotomy
B. Mid Ureter -
• Left sided carcinoma colon I '->- ~ls,! C CY',J v'-"
i) Flush
__,,...----- RENAL CELL CARCINOMA /_...,
/ ·~
1 ll
v1.e:ttQVOSuv'
J , ii) Uretero - Renoscopic Removal
( See Se~tion 1, ~egment A, Paper-II, 2011, Os. 2, Page 139. 1 >·'-"• f iii) Open Ureterolithotomy
C. Lower Ureter Flush
- ~ : o n t_he sites of narrowing of ureter. Desctibe the clinical features, complication & treatment
-- - of ureter,c stones , [3 + 4 + 3 + 5] i) Uretero - Renoscopic Removal
ii) Open Ureterolithotomy
Ans: SITES OF NARROWING OF URETER
iii) Ureteric meatotomy }
1, Pelvi-ureteric junction \J~~-P ,·c ~ r)
peJ·; for stones at ureteric orifice
2. A ~ o f lesser pelvis i.e. as ureter enters pelv;;' & 6rosses over l fe) 1 ·' ts·•;, iv) Dormia basket for single stone < 10 mm ..---

3. Along passage through bladder wall i.e. at common vesicoureteric junction ( ~0cj) 2016
URETERIC STONES \ ,/ .,,.---
---\."-V I.::.. Q.1 : Enumerate the causes of painless haematuria. Discuss the investigation and treatment in a
See Section ,1, Segment A, Paper-II, 2009, Supplementary, Os. 1, P a g ~ <EE:- patient of 65 years presented with painless haematuria. [5 + 5 + 5]

□ Radiation of pain ~7' ~ Ans: See Section 1, Segment-A, Paper-II, 2013, Os. 3, Page 160.

Q.2: Classify thyroid cancer. Discuss the management of FNAC proved follicular neoplasm of Right
Location Radiation site Nerve involved
lobe of thyroid in a lady of 45 years. [5 + 10]
Stone in upper ureter Testicles T 10 .11 _12 through les4er & lower
splanchnic nerves~ Ans:
Stone in mid-ureter Right side Mc Burney's point llohypogastric or ilio inguinal □ Classification - See Section 1, Segment-A, Papter-II, 2012, Os. 1, Page 144.
(simulates appendicitis) nerve (T 12 , L 1) □ Follicular neoplasm- See Section 1, Segment-A, Papter-II, 2010, Supplementary, Os. 1, Page 124.
Left side Left lower quadrant
Q.3: What are the etiologies of pancreatitis ? How will you investigate and treat a case of acute
(simulates diverticulitis)
pancreat/tis ? (5 + 5 + 5]
Stone in lower portion of ureter Inner side of thigh or groin Genitofemoral nerve (L1' L 2 )
(proximal to orifice) Ans: See Section 1, Segment-C, Papter~f 2015, Os. 5, Page 436 &
See Section 1, Segment-8, Papter-I, Os. 10, Page 247.
□ Complications -
✓ Obstruction 2016 Supplementary
✓ Infection
Q.1 : Discuss the clinical features and management of primary thyrotoxicosis. [5 + 10}
✓ Hydronephrosis, hydroureter
✓ Ureteral stricture Ans: See Section 1, Segment-A, Paper-II, 2014, Os. 1, Page 177.
✓ Stone impaction
Q.2: Classify adrenal tumours. Describe the investigation and treatment of adrenal incidentaloma.
□ Treatment - _.,,-.,,,. - [5 + 10]
See Section 1, Segment-A, Paper-II, 2009, Supplementary, a(;, Page 114. ADRENAL TUMOURS
Sugeries for different sites '<_ Ans:

A. Upper ureter -
i) Flush

t
 206 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS O Paper - 11 207

D Classification - ✓ Imaging -
✓ Diagnostic algorithm

Rest See Section 1, Segment-A, Paper-II, 2013, Supplementary, Os. 3, Page 174.
Tumour of Cortex Tumour of Medulla Juxta Adrenal Masses
✓ Adrenocortical ✓ Neuroblastoma ✓ Leiomyosarcoma of vena cova
adenoma ✓ Phaechromocytoma ✓ Retroperitoneal liposarcoma ' ~-/ 2017
✓ Adrenocortical ✓ ✓
Ganglioneuroblastoma Retroperitoneal schwannoma
carcinoma <J.4·:-~the causes of haemoperitoneum and its management. [5 + 10]
✓ Neuroendocrine
carcinoma Ans: HAEMOPERITONEUM

G,,.. ~re ~
Miscellaneous
✓
✓
Primary adrenal lymphoma
Massive macronodular adrenal
hyperplasia
D Causes -
✓

✓
Penetrating_ and deep abdominal_!_r'~L!m~
St~~---~.QJJnd
w~'ch- .blood.
~t;,b~ OA>J
r~
\~V\o.l

'tJ.
\o\ee::L~ t''V\_
\Y\. ~
✓ Blunt traum~ to abdominal organs
✓ Hamartoma ✓ Spleen ruptLJr~----
✓ Teratoma ✓ Bowel laceration
✓ Angiomyolipoma ✓ Pancreas laceration
✓ Myelolipoma ✓ l::!ver rupture
✓ Amyloidosis ✓ Aorta or vascular rupture like abdominal aortic aneurysm
✓ Plexiform neurofibroma ✓ Uterine _rupjure
✓ R1,1Q_ture ecJopjc pregnancy
ADRENAL INCIDENTALOMA
✓ Perforated gastric ulcer
D Differential diagnosis - ✓ Ut1:irine rt11>ture
✓ Adenoma ✓ _Ovarian c:y§_!J:l,filture (
✓ Metastasis ✓ Rupture of malignant tumour in abdomen
✓ Lymphoma ✓ Bleeding disorders
✓ Phaeochromocytoma □ Management-
✓ Neuroblastoma ATLS protocol is to be followed -
✓ Adrenocortical carcinoma A - Airway maintenance with cervical spine care
✓ Haematoma B - Maintenance of ~
✓ Myelolipoma C - Maintenance of..Qi.rculati.on after proper assessment
✓ Adrenal hyperplasia (2 wide bore cannula 14G or 16G inserted, blood drawn for investigations and cross-
✓ Adrenal cyst matching and then intravenous fluids administered)
✓ Granulomatous disease D - Dysfunction of central nervous system excluded.
E - E_l(po~~of patient to look for external injuries.
0.3: Enumerate the causes of relation of urine in different age groups. How will you investigate a
case of relation of urine ? How will you treat retention of urine ? {5 + 5 + 5] Then secondary survey done which includes following -
D History-
Ans: See Section 1, Segment-A, Paper-II, 2008, Supplementary, Os. 1, Page 113 and
✓ Date and time of injury
See Section 1, Segment-8, Paper-II, Os. 1, Page 257.
✓ Mode of injury
□ Diagnosis -
✓ LMP & menstrual history in case of suspected ectopic pregnancy
✓ Most common presentation of adrenal masses is incidental observation on cross-section imaging
performed for other reason ✓ Type of impact for vehicular accidents
208 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 209

✓ Type of weapon in case of penetrating injuries

B. For blunt injury
✓ Details about clinical features -
I
a) Pain -i) site
ii) intensity
t
Patient stable
t
Patient unstable
iii) character
iv) radiation
t
CECT Abdomen
t
ATLS protocol of initial
v) aggravating and relieving factors resuscitation
b) Vomiting
c) Haematemesis
t
Evaluate
d) Haematuria I
e) Abdominal swelling t
Patient responsive
t
Patient non-responsive
✓
✓
Other injuries at other parts of body
Past history FAST/e-FAST
t t
Laparotomy
✓ Personal history about chronic disease - mainly bleeding disorder (Founed Assessment by Sonagraphy for
✓ Significant family history trauma/Extende~Fast)

□ Examination -
I t
No minimal collection
i
Collection present
•t
Inconclusive
t
Inspection
t
Palpation
t t t t
Percussion Auscultation Conservative management Laparotomy Diagnostic peritoneal
✓ Abdominal distension ✓ Temperature ✓ Obliteration of ✓ Bowel sounds aspiration
I

•t
✓ Bruise around ✓ Tenderness liver dullness ✓ Per-rectal

✓
umbilicus/flanks
Movement of
✓ Rebound
tenderness
✓

✓
Splenic dullness
Shifting dullness ✓
examination
Per-vaginal •
t
> 10ml blood Inconclusive
abdomen with ✓ Kehr's sign in examination in • Presence of food/bile/
respiration case of splenic females faecal matter Diagnostic peritoneal lauage
✓ Bleeding from any site injury
t
Laparotomy
(DPL - most sensitive investigation
for haemoperitoneum
□ Specific management -
I
A. For penetrating injury

tl
Patient stable
~
Patient not stable
t
• > 10 5 RSC/ml
• > 500 WBC/ml
• > Food/bile/faecal matter
•t
No collection

Conservative
t
Check features of peritonitis
t
Laparotomy
t
Laparotomy
management

t I
~
Present Absent □ Conservative management -
t
Laparotomy
t
CECT Abdomen
• Routine blood investigation - Hb
- TLC
- DLC
- LFT

27
 210 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 211

- KFT
2018
- Blood Suger
- PT/aPTT Q.1 : What are the different forms of Renal calculi? Discuss the clinical presentation and management
- BT/CT/CRT of a stone in the Renal pelvis. [5 + 1OJ
- ABO, Rh grouping Ans : See Section 1, Segment A, Paper II, 2014 supplementary, 0 2, Page 195.
• Blood to be arranged for transfusion if required
Q.2: What is ANDI to classify benign lesions of the breast? Discuss the management of discharge
• l.v., cannulation
from the nipple. [7 + BJ
• Catheterisation
Ans: ANDI - See Section 1 , Segment D, Q 27, Page 489.
• Intravenous fluids
MANAGEMENT OF NIPPLE DISCHARGE - See Section 1, Segment C, Paper I, 2008, 0 4,
• i.v. antibiotics Page 276 .
• Bowel, bladder care
Q.3 : Classify thyroid neoplasms. Discuss the management of solitary thyroid nodule, 3 cm in size of
0.2: What are the clinical features of renal cell carcinoma ? How will you investigation and treat a a 30 years old female. [5 + 10]
case of renal cell carcinoma ? [8 + 4 + 3J Ans: CLASSIFICATION OF THYROID NEOPLASMS - See Section 1, Segment-A, Paper-II, 2012,
Q 1, Page 143.
Ans: See Section 1, Segment-A, Paper-II, 2011, Os. 2, Page 139.
SOLITARY THYROID NODULE - See Section 1, Segment A, Paper II, 2013 supplementary, 0 1,
0.3: Discuss the clinical features, investigations and management of pheochromocytoma. Page 168.
[5 + 5 + 6J
Ans: See Section 1, Segment-A, Paper-II, 2013 supplementary, Qs. 3, Page 174.
2018 Supplementary

2017 Supplementary Q.1 : Discuss the presenting symptoms of Benign Hyperplasia of Prostate. How will you manage a
,/
~
~- 65 year old male patient with acute retention of urine in emergency and subsequently? [5+5+5]
\. _/~·<f).;. efi;cuss the pathology of tumors of Salivary gland and management of Pleomorphic adenoma. Ans : BHP - See Section 1, Segment A, Paper II, 2014, Q 2, Page 183.
[5 + 10J
ACUTE RETENTION OF URINE - See Section 1, Segment 8, Paper 11, Q 2, Page 257.
Ans: CLASSIFICATION OF SALIVARY TUMORS - See Section 1, Segment A, Paper 1, 2016
supplementary, Q 2, Page 89. Q.2: Outline the etiopathogenesis of Mu/tinodular Goiter. Describe its management. [5 + 10]

PLEOMORPHIC SALIVARY ADENOMA - See Section 1, Segment C, Paper 11, 2012, Q 5, Page 406. ~ :J>ee Section 1, Segment A, Paper 11, 2008, Q 2, Pag~ \ C)?;

Q.2: 20 year old male presenting with right testicular mass - how will you proceed to investigate . ~~cuss the etiopathology of acute extradural hematoma. Mention the symptoms and the signs.
and manage this case? [7 + BJ \•. /. Outline the principle of its management. [ 5 + 5 + 5]

Ans: See Section 1, Segment A, Paper II, 2010, Q 2, Page 120. Ans: See Section 1, Segment C, Paper II, 2009, Q 7, Page 365.

MANAGEMENT OF TESTICULAR TUMOR - See Sec 1, Segment-A, Paper-II, 2014, Q 3, Page 188.

0.3: 30 y~ar yo~ng adult complaining of colicky pain from right loin to groin with vomiting - how will -~/ 2019
you mvest,gate and manage this case? [7 + BJ
a.i/4~ate the causes of anuria. How would you differentiate between prerenal and renal
Ans : Colicky pain from right loin to groin in a young adult is suggestive of a diagnosis of "Stone in · anuria. Give the management of calculus anuria. (principles only) [5 + 5 + 5]
Ureter".
Ans:
See Section 1, Segment A, Paper II, 2009 supplementary, Q 1, Page 114.
See Section 1, Segment A, Paper 11, 2015 supplementary, Q 3, Page 204. ANURIA

□ Anuria : Urine output less than 100 ml/24 hours

 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 213
212 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
r. ;1
□ P'-f'pf,,oJ J
Management of calculus anuria : (
□ Causes of anuria :
► Investigation-
• Blood invesligaiions -
Pre-renal Renal Post renal i) Complete haemogram with ESR
(Sudden & severe drop in BP (Direct damage to kidneys by (Sudden obstruction of urine Ii) Blood urea
or interruption of blood flow to inflammation, toxins, drugs, flow due to enlarged prostate, iii) Serum creatinine
the kidneys from severe injury infection or reduced blood kidney stones, bladder iv) Serum electrolytes - sodium, potassium, calcium, phosphate
or illness) supply) tumour or injury)
v) Uric acid
➔ Hypovolaemia ➔ Acute tubular necrosis ➔ Prostatic hypertrophy
vi) PTH level
➔ Dehydration • lschaemia ➔ Blocked catheter
• Urine investigation -
➔ Hypotension • Toxins (antibiotics, ➔ Ma!ignancy
contrast media) i) Routine & microscopy
Impaired cardiac function • Bladder cancer
ii) Culture & sensitivity
➔ Advanced liver disease ➔ Acute interstitial necrosis • Prostate cancer
• Inflammation • Plain X-Ray KUB
➔ Renal vascular disease
• Edema • IVU
• Drugs (Furosemide, • USG Abdomen
Penicillin) Treatment-
►
➔ Glomerulonephritis 1. For stones < 0,5 cm
• Post-infectious Conservative
• SLE i) i.v. fluids
• ANCA associated
ii) Antispasmodic & anti-inflammatory agents
• Anti-GBM disease
iii) Ing. Furosemide 60-BOmg i.v.
• Henoch-Schonlein
purpura iv) Flush therapy
• Cryoglobulinaemia v) Alkalinising agent, acidifying agent (for chronic cases)
• Thrombotic microangio- vi) Relief of obstruction by double-J stent.
pathy 2. Stones> 0.5 cm
► TTP Endourological surgery
► HUS
a. For non-lower pole renal calculi - - - ,

□ Differentiation between prerenal and renal anuria :

<2cm
t i
>2Cm
I
Test

Urine specific gravity > 1.020

Prerenal AKI

~ 1.010
Intrinsic AKI
t
<1Cm
i
>1Cm

Urine ..§.Q.Q!!!_m, mEq/L

Fractional excretion of sodium
< 20 @
< 1% (neonates < 2%)
> 40 {"1')
> 2% (neonates > 2.5%)
t
Uretero
Fractional excretion of urea < 35% > 50% Renoscopic stone
Lithotripsy
Urine osmolality, mOsm/kg > 500 ffi < 350 (~)
Urea nitro._gen-creatin!_r:le ratio 10-15 g i
> 20
® Filure ------➔
 214 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS D Paper- II 215

b. For lower pole renal caluli - - - - ~ Q.2: Whet,, --

the principal symptoms of peripheral arterial occlusive disease? How would you

< 1 cm
I
t
1-2 cm >2cm
'~a/4ceed to investigate such a case? What are the conservative management you advice in for
a tower leg distal smaller vessel disease?

Ans : See Section 1, Segment B, Paper I, 0.5 (Page No. 226).

[5 + 5 + 5]

~
HU< 1000
t
HU> 1000
~
Is PCNL
Q.3: A 45 year old lady presents with rapidly developing Jump in the upper outer quadrant of the right
breast of the size 4 cm x 5 cm with a palpable, mobile enlarged central group lymph node in the
SSD < 10 cm SSD > 10 cm Contraindicated

7
same axil/a. How would you confirm your diagnosis? How would you stage & prognosticate?
t Fle±ble .LNo How would you manage? [5 + 5 + 5]

~ PCNL
ESWL
Retrograde See Section 1, Segment A, Paper II, 2011, 0.1 (Page No. 125).
lntrarenal Surgery

December-January 2019-2020
3. If endouralogical surgery fail
Surgeries Q.1: Write down the effect of prostatic hypertrophy on urethra and urinary bladder. Mention the
medical and surgical treatment of benign prostatic hypertrophy. [5 + 5 + 5]
i) Pyelolithotomy - For stones in extrarenal pelvis
ii) Extended Pyelolithotomy - lntrarenal pelvis Ans: See Section 1, Segment A, Paper II, 2014, 0.2 (Page No.183-188).
iii) Nephrolithotomy - Incision at most convex surface (Brodel's line) Q.2: A 30 year old lady presents with 3 cm size solitary nodule on right thyroid lobe. Give the
iv) Nephrophyelo lithotomy - Incision both on kidney & pelvis [For staghorn calculus] differential diagnosis. How will you manage such patient? [5 + 10]
v) Partial nephrectomy - Multiple stones occupy a pole
Ans : See Section 1, Segment A, Paper II, (Page No. 170 & 172-173).
vi) Others - (a) Bench surgery
n 11 • ~ ~ g e d bus conductor presents with non healing ulcer and pigmentation in left lower leg
(b) Anatrophic Pyelolithotomy
(c) Coagulum Pyelolithotomy
11/Z~u::,;~;~, malleo/us. How will you examine, investigate and manage this patient?[5 + 5 + 5]

Ans: See Section 1, Segment A, Paper I, (Page No. 93) & Section 1, Segment C, Paper I, (Page No.
a-3,;,w:::z::,~ anatol1}ical and pathophysiological changes that lead to the development of the 301 "Venous Ulcer").
_,>< .-1!!- ry vancose vems of the lower limbs? How would you test clinically the competence of the
- v~lves of the sapheno-femoral, sapheno-poplitea/ junctions and the leg perforators?
~ive the management of a patient with primary varicose vein with sapheno-femora/ June-July 2020
incompetence. [ 5 + 5 + 51

Ans: See Section 1, Segment D, 0. 37 (Page No. 498) Saphena 'Varix'. Q.1 ~ ~ e . Discuss etiopathogenesis, clinical features, investigations and management
_,, o"tgas gangrene. [3 + 3 + 3 + 3 + 3]
Q.3: D:fine thyr?toxic~sis. Enumerate the grade-wise presentation of the eye signs in thyrotoxicosis.
Ans : See Section 1, Segment C, Paper II, 0.8 (Page No. 384).
Give the bnef out/me of the diagnosis and options of management of Graves Disease. [5 + 5 + 5]
Ans : See Section 1, Segment A, Paper II, 2014, 0.1 (Page No. 177); Q.2: Classify testicular tumours. How will you manage a 60 year old man presenting with seminoma
testis. [5 + 10}
Sectin 1, Segment D, 0.58, (Page No. 518) & Section 1, Segment D, 0.60, (Page No. 520).
Ans: See Section 1, Segment A, Paper 11, 0.3 (Page No. 188).

Q.3: Describe the clinical features and management of Thyrotoxicosis. [8 + 7]

2019 Supplementary
Ans: See Section 1, Segment A, Paper II, 0.1 (Page No. 177).
0.1: What are the difterent_types of renal calculus? How does a patient of renal calculus present?
How would you mvestIgate to confirm diagnosis? [5 + 5 + 5]

Ans: See Section 1, Segment A, Paper II, 2014 Supplementary, 0.2 (Page No. 195).
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 217

SEGMENT-B 3. Crohn's disease

4. lleocecal tuberculosis (TB)
SOLVED LONG QUESTIONS OF SEMESTERS 5. Acute intestinal obstruction
Paper- I 6. Perforated peptic ulcer
7. Acute pancreatitis
Q. 1 : Discuss briefly the DID of right iliac fossa pain in a young adult male. How will you treat a case 8. Acute pyelonephritis
ofappendicularmass? [10 + 5] 9. Ureteric stone
Keeping the above differential diagnosis in mind, the approach to this case would be through proper
a. 2: Discuss briefly the different diagnostic blood fractions commonly used for surgical patients.
Discuss the complications of whole blood transfusions in brief. [7 + 8] history taking, clinical examinations and relevant investigations.
□ History:
Q.3 : Define ulcer. Describe the clinical exam. of an ulcer. Write down the treatment of venous ulcer.
[2 + 8 + 5] 1. Pain:
• Vague pain at right iliac fossa- Acute appendicits
Q.4 : Define and classify intermittent claudication. Describe the pathogenesis of Buerger's disease.
• Cramping/colicky pain- Acute typhlitis, Ureteric stone
How will you treat a case of Buerger's disease without gangrene? [2 + 4 + 4 + 5]
• Sudden onset pain, initially severe colicky, later continuous severe pain - Acute intestinal
Q. 5: A 32 yrs old male patient attends the surgery OPD with chief complaints of pain in the right calf, obstruction
while walking, for 2 months. He had been a chronic smoker for 10 yrs. On examination, he has • Sudden onset severe pain in mid upper abdomen then moving towards right side of abdomen,
reduction in peripheral pulses in the affected lower limb. What are the DID? What investigations then becoming generalised - Peptic ulcer perforation
will you do in this case? What procedures can be done for improving the lower limb circulation? • Sudden onset, stabbing, upper abdominal pain, radiating to the flanks and·back and relieved
[5 + 5 + 5] on leaning forward (Mohameddan prayer position) - Acute pancreatitis
0.6: Define and classify cysts. Discuss the management of a surgically relevant parasitic cystic 2. Associated features :
disease. Write a brief account on pseudocyst ofpancreas. {1 + 4 + 4 + 5]
• Nausea, vomiting, fever - Acute appendicitis
0.7: A 60 yrs old lady has presented with jaundice, pruritus, pale stools and a palpable mass in the • watery diarrhea with mucus in stool with or without blood - Acute typhlitis, Crohn's disease
right upper quadrant of abdomen. Enumerate the DID. Which radiological investigations will • Pallor, loss of appetite, weight loss, lump in right iliac fossa - lleocecal TB
you recommend? Outline the operative management of periampul/ary CA. [3 + 3 + 4] • Vomiting, abdominal distension, absolute constipation, dehydration - Acute intestinal
obstruction
0.8: Enumerate the endocrine tumors of pancreas. Discuss CIF, investigations and treatment of
• Fever, vomiting, dehydration, oliguria, shock - Peptic ulcer perforation
any 2 of such tumors.
• Nausea, persistent vomiting, retching - Acute pancreatitis
0.9: A 45 yrs old man presented with rapidly developing anorexia, asthenia and fatigue with Burning sensation during micturition, frequency; urgency - Acute pyelonephritis
increasing vomiting. How would you investigate to confirm the diagnosis? How would you •
stage and manage the patient? [5 + 5 + 5] 3. Past history :
• H/O peptic ulcer disease (dyspepsia, belching) - Peptic ulcer perforation
0.10 : A 55 yrs old male, chronic alcoholic, complains of severe, agonising, acute abdominal pain
• H/O alcohol intake - Acute pancreatitis
persisting for several hours, radiating to the back and a little relief on stooping. How would you
investigate to confirm the diagnosis, prognosticate and manage? [5 + 5 + 5] □ Clinical examinaton :
1. General survey :
/ SOLUTIONS • Pallor - lleocecal TB, Crohn's disease
• Elevated temperature - Acute appendicitis, acute typhlitis, ileocecal TB, acute pancreatitis,
~ u s s br~efly the DID of right iliac fossa pain in a young adult male. How will you treat a case acute pyelonephritis
· .../£.>,..
of append1cular mass? [10 + 5] • Rapid and feeble pulse, reduced urine output - Acute intestinal obstruction, Peptic ulcer
perforation, acute pancreatitis
DIFFERENTIAL DIAGNOSIS OF RIGHT ILIAC FOSSA PAIN 2. Abdominal examination :
• Mass in right iliac fossa, non tender, non mobile, with impaired resonance - lleocecal TB
Causes of right iliac fossa pain in a young adult male : • Tender soft to firm mass - Acute typhlitis, Crohn's disease
1. Acute appendicitis • Tenderness, rebound tenderness, initially high pitched metallic sounds, later silc,,,t abdomen
2. Acute typhlitis / Neutropenic enterocolit:s - Acute intestinal obstruction

216
28
 218 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- I 219

• Tenderness, rebound tenderness (Blumberg's sign), card-board rigidity, later abdominal Ochsner - Sherren regimen :
distension, dullness over flanks, obliterated liver dullness, absent bowel sounds - Peptic 1) Nothing per mouth
ulcer perforation
2) Intravenous fluid
• Tenderness, Grey Turner's sign positive, Cullen's sign positive, Fox sign positive - Acute
3) Analgesics
pancreatitis
4) Antibiotics
3. Per rectal examination :
5) Nasogastric aspiration for initial 2-3 days
• Perianal fistula - suggests Crohn's disease
6) Monitoring everyday -
vestigations : a) Temperature, BP, Pulse
\, 1. Complete hemogram : b) TLC
• Raised TLC - Acute pancreatitis c) Palpation of lump to observe the size
• Raised ESR - lleocecal TB A) If mass reduces in size, temperature and pulse becomes normal, TLC' reduces, appetite improves
2. Serum amylase, lipase, LOH- raised in acute pancreatitis ~ patient discharged and advised to come after 6 weeks for interval appendicectomy

3. ADA (Adenosine deaminase activity) : Serum value> 42 IU/L and/or ascitic fluid value> 33 IU/L B) Criteria to discontinue the regimen -
is sensitive and specific for ileocecal TB. i) Patient lJecomes more toxic (tachycardia, temperature rises)
4. Urine for RE/ME/CS - Increased number of pus cells with bacterial growth seen in acute ii) Persistent vomit
pyelonephritis iii) Increasing size of lump
5. Stool for ova, parasite, cyst; stool for occult blood iv) Pain becomes more intense
6. Chest skiagram (PA view): v) Rising TLC
• To look for primary focus of ileocecal TB vi) Appendicular abscess formation
• Free gas under right dome of diaphragm/Pneumoperitoneum (feature of hollow viscus In these cases, immediate surgery is done. Drainage if appendicular abscess.
perforation) - Peptic ulcer perforation
C) Contraindications to the regimen -
7. Skiagram abdomen (AP view in erect posture):
i) Doubtful diagnosis
• Sentinel loop, colon cut sign, obliteration of psoas shadow - Acute pancreatitis
ii) Acute appendicitis in children and elderly
• Multiple air fluid levels (> 3) - Acute intestinal obstruction
iii) . Burst, gangrenous appendicitis
8. USG abdomen :
iv) Diffuse peritonitis
• Edematous pancreas, peripancreatic fluid collection - Acute pancreatilis D) Patient of appendicitis taken for appendicectomy and palpation of right iliac fossa under general
• Dilated bowel and fluid - Acute intestinal obstruction anesthesia revealed a mass -
9. Barium follow through X-ray : i) If symptoms present for 3-5 days, appendicectomy performed as scheduled
• Increased transit time, hypersegmentation (chicken intestine), lleal stricture (String sign}, ii) If symptoms present for longer duration (> 7 days) and a firm lump is palpable, surgery
Pulled up cecum, conical cecum, Thickened ileocecal valve (Inverted umbrella sign/ postponed and conservative management done followed by interval appendicectomy
Fleischner sign), obtuse ileocecal angle (>150 degree), straightening of ileocecal junction
with goose neck deformity, ulcers in terminal ileum (napkin lesion) - lleocecal TB o. 2 : Discuss briefly the different diagnostic blood fractions commonly used for surgical patients.
• Cicatrisation of ileum (String sign of Kantor), rose thorn appearance of bowel wall, straightening Discuss the complications of whole blood transfusions In brief. [7+8]
of valvulae conniventes - Crohn's disease
10. CECT abdomen - if suspected acute pancreatitis, intestinal obstruction DIFFERENT BLOOD FRACTIONS
11. Peritoneal tap - if suspected acute pancreatitis, peptic ulcer perforation
BLOOD SUBSTITUTES
12. Sigmoidoscopy, colonoscopy - to confirm Crohn's disease
□ What are they - Substances which can be used instead of blood to replenish the blood loss.
t-\c,\ '11/'0 \} 61')1_ APPENDICULAR@
□ ,
Treatment: flri,''1 :-
"•. 'l::'' - V•'?
°'f:(J·fh/) __,. t-\ 11 -C..\
□ Types-
1 (A) Plasma and its derivatives
If lump palpable, but not abscess (no fever, no rising TLC, increasing tenderness), then conservative (B) Synthetically prepared solutions
management is done as nature has already localised the infection to prevent spread in peritoneum,
□ Plasma and its derivatives -
which if disturbed, may lead to faecal fistula.
See "Blood Fractions" on the next page -
220 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- I 221

BLOOD FRACTIONS (B) GELATINE -

Name Preparation Storage Indications • Mal-wt 20000 - 40000
• Less effective than dextran as plasma volume expander
• Packed cell Centrifuging whole blood @ 2000-30009 1-6°C for • Chronic anaemia
for 15 mins 35 days • Old age (C) FLUOROCARBONS-
• Children
• What is it - Hydrocarbons in which hydrogen atoms have been replaced by fluorine
• Platelet rich plasma -do- • Burn
• Hypovolemia • Features -
• Severe protein loss Colourless
cirrhosis odourless
• Human albumin (4.5%) Repeated fractionation of plasma 4°C Several
months Edema ( chemically inert
nephrotic syndrome dense liquid
(Used as volume expander) poorly soluble
• Fresh frozen plasma Fresh plasma rapidly frozen (contains clot- -40°C for • Severe liver disease • Advantage -
(FFP) ting factors) 2 years • DIC Considered red cell substitute as it binds and releases oxygen rather than passively trans-
[1 unit FFP = 3% rise in clotting factors] • Congenital clotting factor porting dissolved oxygen.
deficiency
• Precaution -
• Following warfarin therapy Patient has to be kept in hyperbaric environment during this transfusion.
• Cryoprecipitate Visible white supernatant fluid when FFP -do- • Haemophilia A
thawed at 4°C (factor VIII+ Fibrinogen) • Von Willebrand's disease (0) HYDROXYETHYLSTARCH(HES)-
• Fibrinogen Organic liquid fractionation of plasma Dried form • DIC • Composition = Starch + Sodium hydroxide + Ethylene oxide
• Afibrinogenaemia
• Mol-wt: 60000 - 4,50,000
• Platelet concentrate • Thrombocytopenia
Centrifugation of platelet rich plasma
• Drug induced hemorrhage COMPLICATIONS OF BLOOD TRANSFUSION
• Prothrombin complex From pooled plasma which contains tac- • Reversal of warfarin over-
concentrate tors 11, IX, X dose 1. Transfusion reactions :
a) Acute hemolytic reactions -
□ Synthetically prepared solutions - • There are 3 causes :
► Incompatible transfusion
(A) DEXTRAN - ► Transfusion with blood which is already haemolysed by heating or freezing or over
• What is it - Polysaccharide polymer shaking
• Production - Polysaccharide compound derived from bacterium Leuconostoc Mesenteroides, ► Transfusion of blood after expiry date
to which yeast extraction is added • It is considered as criminal negligence in the court of law.
• Disadvantages - • lntravascular destruction leads to hemoglobinemia, hemoglobinuria, acute renal failure and
disseminated intravascular coagulation (DIC)
(i) induces rouleaux formation of RBC
• Features - Dyspnea, tachycardia, hypotension, sweating, jaundice, smoky urine
(ii) interferes with platelet function
• Management -
(iii) interferes with blood grouping & cross matching
(i) lnj. Hydrocortisone/ dexamethasone i.v. stat
• Function - Restore plasma volume (ii) Alkalization of blood (sodium bicarbonate, sodium lactate)
• Types- (iii) Fluid therapy
(i) Low molecular weight dextran (mol. wt. 40000) - also known as rheomacrodex or dextran 40 (iv) Inf. mannitol
(ii) High molecular weight dextran (mol. wt. 70000) - also known as dextran 70. (v) lnj. furosemide i.v.
• It occasionally can be fatal.
• Indications -
b) Pyrexial reactions (most common complication) -
(i) DIC
• The causes are :
(ii) Burn (i) Improperly sterilised transfusion sets
• Precautions - (ii) Presence of pyrogens in the donor apparatus
(i) Not used > 1000 ml (iii) Transfusion of infected blood
(iv) Very rapid transfusion of blood
(ii) Blood sample for grouping & cross-matching to be drawn before introducing this solution.
c) Allergic reactions - Due to allergic reaction to plasma products in the donor's blood
 222 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 223

d) Sensitisation to leucocytes and platelets - This occurs where many blood transfusions have □ Clinical examination of an ulcer:
been given in the recent past. Antibodies are developed against WBC or platelets of donated
1. Site
blood, which causes reactions.
• TRALI (Transfusion related acute lung injury) : • Tuberculous ulcer - Neck (over cervical lymph nodes)
Y Cause - It is mostly due to antibody against HLA and leucocyte specific antigens of the • Syphilitic ulcer - Penis
recipient in the donor plasma. It may also be due to antibody against donor's leucocytes • Rodent ulcer - Forehead, face
in recipient's plasma. • Venous ulcer - Leg (above the medial malleolus)
,- Symptoms - Breathlessness, fever (approx. 4 hrs after transfusion) 2. Number
,- Signs - Hypotension, Drop in oxygen saturation • Single - Syphilitic ulcer, rodent ulcer, carcinomatous ulcer, venous ulcer
,- May require ventilatory support. Recovery is usually complete. • Multiple - Tuberculous ulcer
e) Immunological sensitisation 3. Size
• Transfusion related graft versus host disease (TGVH) - 4. Shape
► A rare and serious complication 5. Margins - May be regular or irregular, oval or rounded
► Cause - It is due to reaction against recipient's tissues by donor lymphocytes. • Tuberculous ulcer - Thin bluish margins
,- Commonly seen in immunocompromised, leukemia, lymphoma 6. Edge of the ulcer - It is useful in diagnosis of ulcer as well as assessment of healing
,- Features- Pancytopenia, toxic epidermal necrolysis (TEN), liver dysfunction • Tuberculous ulcer - Undermined edge
,- Mortality is more than 90%. • Syphilitic ulcer - Punched out edge
2. Transmission of infections: • Rodent ulcer - Raised and beaded edge
a) Bacterial : Syphilis, Yersinia • Carcinomatous ulcer - Rolled out and everted edge
b) Viral: HIV, HBV, CMV, EBV ,- Inflamed and edematous edge signifies spreading ulcer.
c) Parasite : T.cruzi, Malaria , Sloping edge is seen in a healing ulcer.
► lndurated edge is a feature of non healing/ callous ulcer.
3. Complications caused by massive transfusion :
7. Floor of the ulcer
a) Acid-Base imbalance - mainly metabolic acidosis because most of the citrate in the anticoagulant
solution is present as sodium citrate, which becomes sodium bicarbonate as citrate is consumed. • Tuberculous ulcer - Pale granulation tissue
b) Hyperkalemia - due to shift of potassium out of RBC due to low temperature of storage • Syphilitic ulcer - Wash leather slough
c) Citrate toxicity - Its main effect is to consume ionized calcium from the patient's body resulting in • Rodent ulcer - scab (made of epithelial cells and dried serum)
hypocalcemia and bradycardia. • Carcinomatous ulcer - covered by necrotic tumor, blood and serum
d) Hypothermia • Venous ulcer - Healthy pink/ red granulation tissue
e) Failure of coagulation - The causative factors are : 8. Base of the ulcer
• DIC • No induration - Venous ulcer
• Dilution of clotting factors • lndurated - Syphilitic ulcer, rodent ulcer, carcinomatous ulcer, tuberculous ulcer
• Dilutional thrombocytopenia 9. Any discharge from the ulcer
• Serous - healing ulcer
4. Complications of general intravenous fluid administration: • Purulent - infected ulcer
a) Thrombophlebitis • Bloody - Carcinomatous ulcer
b) Air embolism • Yellowish - Tuberculous ulcer
5. Miscellaneous : 10. Whether the ulcer extends to the normal tissue or not
a) Iron overload 11. Examination of regional lymph nodes
b) Hemochromatosis • Rodent ulcer, venous ulcer - No involvement
c) Congestive cardiac failure - mainly seen if whole blood transfusion in large quantities is given to • Tuberculous ulcer, syphilitic ulcer, carcinomatous ulcer - lymph node involved
chronic anemic patients, pregnant females, patients with cardiac problems and elderly individuals. 12. Examination of distal pulses, sensations, joint movements, function of the limb

0.3 : Define ulcer. Describe the clinical exam. Of an ulcer. Write down the treatment of venous ulcer. TREATMENT OF VENOUS ULCER
[2+8+5]
□ Conservative :
ULCER BISGARD REGIMEN
□ Definition : • Elevation of the affected lower limb
It is a break in the continuity of the covering epithelium (skin or mucus membrane) due to cell death. • Massage of the indurated area and the calf
 224 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 225

•
•
Passive and active exercise
Pressure bandage - applied spirally from base of toes upto knee joint over a piece of felt r
- ·-···· -·--··-····--·--

placed on the ulcer

I
0ngestion/inhalation of smoke )
•
•
"Four layer" bandage - developed by Charring Cross Hospital, London
Regular cleaning of the ulcer using povidone iodine
Carbon monoxide_
- Nicotinic acid
•

•
Dressing with EU SOL (Edinburg University Solution of Lime - contains sodium hypochlorite,
calcium hydroxide and boric acid)
Antibiotics (depending on culture and sensitivity report of the discharge)
,,
• Topical steroids ( Carbon monoxide binds with hemoglobin )
□ Surgical:
• Definite procedure for varicose vein (Trendelenburg operation etc} after ulcer heals by
conservative treatment
\. •
··•.,.
Formation of Carboxyhemoglobin
..
·-
/
•
•
Valve replacement
Kistner's valvuloplasty
~ r ..

.~ b e ·
e and classify intermittent claudication. Describe the pathogenesis of Buerger's disease.
(Results in...J
· / / ow will you treat a case of Buerger's disease without gangrene? [ 2 + 4 + 4 + 5]
Vasop~s;1:1 Hyperplasia of intima ___
"',,_,,.,....,,_~.,,~,.,,,-, ,

□
INTERMITTENT CLAUDICATION
Definition:_ It can be defined as cramping pain in the muscle of limbs. -
i

~
,
• Arterial occlusion leads to accumulation of metabolites like lactic acid and substanc.eY in the Thrombosis and obliteration of vessels (usually medium sized vessels)
muscle, which causes the pain.
• , ~ i t e - calf muscle (due to block in femoropopliteal segment) Panarteritis Usually segmental involvement
• Other sites-foot (lower tibial and plantar vessels), thigh (superficial femoral artery), buttock
(common iliacor aortoiliac segment) --
0 Classification:
BOYD'S CLASSIFICATION OF CLAUDICATION
Eventually involvement of artery, vein and nerve
• Grade I : Patient complain_s of pain after walking a distance
(The distance at which pain develops is known as "Claudication distance". If patient continues
walking, increased perfusion in the muscle washes away the metabolites and pain is subsided)
• Grade II : Pain still pesfets 0ILC.ontinuin~\¥cl~k,but patient can walk with effort
----
Rest pain due to nerve involvement Features of ischemia in the affected limb

• Grade Ill : Patient has to take rest to relie~e the pain_:_

."1 ;w \ :\. B1UERGER'S.DISEASE _J . ....
-.,,., -~~ "-"""""'-""' -""-~"'
Following blockage, plenty of collaterals open up (around kn~Joint/around buttock)
l.,, • fO I ")':: '")) • ,, . ve))''.;C._I ' ,cJ\ ______.,,--~-----.,..,--~---~
□ ~
~~~-_,,..,---,....,____..,.,..__..._
Pathogene~is: VV-'"'_c,11 0.i-d 1 ;\.: i~v"l h ~pc. 1: ~;'.:. >,':'(lp,,:,
_Buerger's d1seg§E3, also known as thro~oangiti~~~i~ElEc:iil.!3, is ali:ric:i~t__E:Jl<Ci!:!_~l~E31y_seen in~~ung\ Blood supply to the ischemic area is mainta[ned Known as "Compensatory peripheral vascular disease"
mc1_l13_::._ who are smokers and/or tobacco (See chart on the next page) ~
□ Treatment :
1. Advise patient TO STOP SMOKING
2. Care of the limbs :
(a) Buerger's position - To improve circulation head end of the bed is raised and foot end is
lowered. --
Decompensatory peripheral vascular disease a/k/a "Critical limb ischen,ia" (Ulceration, rest pain,
(b) _E3~EJ-~gElr's exercise -
gangrene)
• Leg is elevated and lowered alti:irnatively, each for 2 minLJJe.s for several minutes at a time.
Regular graded exercises are to be done upto the point of claudication

29
 226 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 227

(c) Care of the foot (Chiropady) -

3. Diabetes mellitus
To avoid trauma (even nail pairing) or pressure at pressure points in feet.
4. SQJeroderrn.a.....
To avoid exposure of feet to more warm or cold temperature.
5. Autoimmune diseases - Rheumatoid arthritis, SLE
To avoid dryness of feet and legs.
Regular application of oil to feet and legs. □ Atherosclerosis :
To wear socks with footwear. Chronic inflammatory condition of elastic and muscular arteries.
Heel raise by 2 cm. • Risk factors - (1) Hypercholesterolemia/ Dyslipidemia ( Serum cholesterol> 200 mg%, Serum
3. Drugs: LDL > 100 mg%, Serum HDL < 35 mg%) (2) Hypertension (3) Diabetes mellitus (4) Cigarette
smoking (5) Hypertriglyceridemia (6) Elderl_y age group (7) Obesity / Sedentary lifestyle
► Nifedipine - vasodilator
")-- ~C)"'{Sh0
► Low dose aspirin (75 mg once daily) - Anti-thrombin activity □ Buerger's disease :
► (;Jopidogrel (75 mg) • Inflammatory disorder involvi~ di!>tal mediuf'!l sized vesselswith ceU medi_ated sensitivity ts,
► .Atorvastatin (10 mg) ~}'£E;_l.9.I1dJll£()IJc19~n. /:SO '/.''.h'.,
► Qilostaz()J~ {100 mg BO) - Phosphodiesterase inhibitor (improves circulation) • Risk factors - (1) ~ ~ a l e s (2) Cigarette/ tobacco use (3) Recurrent minor feet injuries
(4) Lower socioeconomic group (5) Poor hygiene
► Pentoxiphylline - Increases oxygenation by increasing the flexibility of RBCs
► Graded injection of Xanthine nicotin.ate{?Q00 mg on day 1 to 9000 mg on day 5) - promotes □ Diabetes mellitus :
ulcer healing • DiabEJ!i.C: ne!Jrgpathy -~esults in higher risk for injuries and subsequent infection of foot. Diabetic
4. Chemical... sympathectomy- microan£li9path\1causes blockade in microcirculation resulting in hypoxia. Diabetic
► Jn,.jElgtion of lignocaine 1% paravertebrally (L2, L3, L4) in front of the lumbar fascia. atherosclerosTsreduces the blood supply leading to gangrene.
► For long term efficacy, 5 ml
phenol in.. watercan be~sed. □ Sc/eroderma :
► Done under C-Arm guidance.
• .ELqg r~ss ive v ascu Iiti s c~'"~~~ 1.~gJLg_r_g_~J~.~91-~~!!), . .QCL__L~D.9~~,,--,~~-?~.¼~-~5!~~~-~ys •
► Advantage - Feet become warm immediately after injection
• Common in females (M : F= 1 : 4) in 4th-5th decade
► Disadvantage - Risk of Spinal cord ischemia, risk of injury to IVG/aorta.
• Association - CREST syndrome (Calcinosis cutis, Raynaud's phenomenon, Esophageal
5. ~ h e . 1 ~ -
hypomotility, Sclerodactyly, Telengiectasia)
l_llt@_1!!~§£LlJc1r injection of VEGF (vascular endothelial growth factor) promotes angiogenesis.
6. Surgery - INVESTIGATIONS
► Omentoplasty - To revascularise the affected limb
1. Blood investigations:
► _Profundopla~.!}'. - To open more collaterals across the knee joint (in blockage of profunda
femoris) • Hb%, Platelet count, ESR, Peripheral Blood Smear
► Lumbar sympathectomy - To improve the cutaneous perfusion in the affected limb. • Lipid profile
► llizarov method of bone lengthening - Causes neo-osteogenesis, improves overall blood • Blood urea, serum creatinine
supply, decreases rest pain and claudication. • Blood sugar, Urine ketone bodies
► Am2..utations - Below-knee or Above-knee amputation based on site and severity of vessel • lgG, Antinuclear and Anticentromere antibodies
.••· . ycclusion. 2. _segmental Blood Pressure measurements :
(a,..$//~yrs old male patient attends the surgery OPD with chief complaints of pain in the right calf. • Measured at multii:@Jevel~:::- l}pper and lower thigh, upper calf, ankle.
_ / " -"~;;e walking, for 2 months. He had been a chronic smoker for 1Oyrs. On examination, he ha~ • ~bloo_d pres~ure increases as we go further down the leg.
re~uction i~ per!pheral pulses in the affected lower limb. What are the DID? What investigations • > 20 mm Hg gradient is abnormal. Pressure reductions between levels_ help_ to localise the
will you do m this case? What procedures can be done for improving the lower limb circulation? o·cclusTori-:-" -
[5+5+5] 3. Arteria/Doppie,";--Provides information about the following :
(a) arterial diameter (b) blood flow rate (c) velocity of flowing blood (d) assessment of stenosed
DIFFERENTIAL DIAGNOSIS segment

A c~se of 32 yrs o!d male presenting with pain in right calf, while walking, for 2 months and reduction in 4. Duplex scan :
~enp_heral p_ulses 1n the a!fected lower limb, on examination, indicates towards the Eathology of lower •Combination of Ultrasound (B mode) and Doppler study.
,l~.1sch9..,rr11a d41:J<1. l!E~~c1l-2£clusior:!,: ~-- ' •Provides information about the following- (a) site, extent and severity of occlusion (b) collaterals
Differential diagnosis of this case is as follows - (c) pulse wave tracing (d) blood pressure at various levels
1. . Atherosclerosis 5. USG abdomen: to see block or aneurysm in abdominal aorta/ other vessels and other organs.
2. Thromboangitis obliterans (TAO)/ _§_Ll_~!.~er's dis~ase 6. ECG/ Echocardiography/ Treadmill test: to assess the status of coronary circulation.
 SOLVED LONG QUESTIONS OF SEMESTERS O Paper-I 229
228 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

c) Care of the foot (Chiropady) -

7. Angiography: • To avoid trauma (even nail pairing) or pressure at pressure points in feet.
• Retrograde transfemoral angiography by Seldinger technique is most commonly done. It is To avoid exposure of feet to more warm or cold temperature.
done only when femoral pulsation can be felt. To avoid dryness of feet and legs.
• Shows site, extent and severity of blockade • Regular application of oil to feet and legs.
• Cork screw appearance of vessel (due to dilatation of vasa vasorum), Spider leg/ inverted To wear socks with footwear.
tree collaterals, corrugated/ rippled artery (due to severe vasospasm) - suggestive of TAO/ Heel raise by 2 cm.
Buerger's disease 4. Care of the foot and toes in diabetics :
• Distal run off through the collaterals is important to judge whether the ischemia is compensated ► To avoid any injury or pressure at pressure points.
or not. ► To keep the foot clean and dry.
8. Digital Subtraction Angiography (DSA) : ► The limb should not be warmed.
• Here vessels and vascular anomalies are well delineated as other tissues are eliminated ► To use Microcellular Rubber (MGR) footwear.
from the image using computer softwares. a. Drugs:
• Done to exclude arteriovenous malformations, hemangioma, vascular tumors. • Nifedipine - vasodilator
9. CT /MR angiogram : • Low dose aspirin (75 mg one~ daily) - Anti-thrombin activity
10. Ankle Brachia/ Pressure Index (ABPI): • Clopidogrel (75 mg)
• Normal value is 1 • Atorvastatin (10 mg)
• Cilostazole (100 mg BQl - Phosphodiesterase type Ill inhibitor (improves circulation)
• Value less than 0.9 - lschemia is present
• P~ntoxiphylline - Increases oxygenation by increasing the flexibility of RBCs
• Value less than 0.3 - severe ischemia with gangrene
• Graded injection of Xanthine nicotinate (3000 mg on day 1 to 9000 mg on day 5) - promotes ulcer
11. Brown's vasomotor index: healing
• (Rise in skin temperature - Rise in oral temperature) / Rise in oral temperature. • Vitam_ir:U~s.gmp~ including Folic ac_id - reduces homocysteine level
• Specific nerve of the ischemic limb (like posterior tibial nerve for lower extremities) is • Inositol, L-carnitine, Magnesium, Vitamin E, Vitamin C - Used to improve walking distance
anesthetised. If ischemia is at vasospasm stage, the nerve block will relieve the vasospasm • _Prost~glandins, VEGF (intramuscular injection promotes angiogenesis), E2F decoy (blocks intimal
and skin temperature will rise. and smooth muscle proliferation), Mesoglycan (breaks blood clot)
• Value more than 3.5 means the disease is due to vasospasm (can be relieved by • Heparin - only used in embolism or acute phase
sympathectomy). • Oral anticoagulants - only used if there is H/0 embolism or atrial fibrillation
• Value less than 3.5 means sympathectomy would not be beneficial. • Drugs for scleroderma: D penicillamine, Para aminobenzoic acid, Colchicine, Dimethyl sulfoxide.
12. Transcutaneous oximetry: C. Surgery:
•Oxygen tension (tcP02) is measured by placing polarographic electrodes over skin at thigh, 1. Percutaneous transluminal balloon angioplasty (PTA) -
leg and foot. tcP02 reflects underlying tissue perfusion. ► Following Transfemoral retrograde angiography by Seldinger approach, PT A is done under
• Normal value is 50-60 mmHg. fluoroscopic guidance. PTA with stenting, using self-expandable or non-expandable stents,
Value less than 40 mmHg - Inadequate wound healing. may also be done.
Value less than 10 mm Hg - Critical ischemia. ► Types - (a) Conventional (b) Subintimal
13. Xenon 133 isotope method: Done to study muscle blood flow. ► Indication - Done when the stenosis is less than 5 cm
► Advantages -(a) Stent, if needed, can be placed at a later date (b) Done under local anesthesia
PROCEDURES FOR IMPROVING LOWER LIMB CIRCULATION ► Complications - Arterial dissection, thrombosis, embolism, pseudoaneurysm, retroperitoneal
hematoma, bleeding
A. General measures:
2. ~!~ - Removal of atheromatous plaque from the wall of the vessels by open surgery or
1. Stop smoking, Regular exercise through percutaneous route.
2. Control of diabetes, hypertension 3. Thro111_~~ - Removal of thrombus through an arteriotomy. Done in larger vessels (For
3. Care of the limbs : aortoiliac, femoropopliteal blocks).
a) Buerger's position - To__irriprove circulation head end of the b~...i~ raised and foot end is 4. Endartere<::_tomy -
lowered. ·-··-··--·-··········· -· ► -·Removal of thrombus along with diseased intima of t~l3_vessel through an arteriotomy.
b) Buerger's exercise - ► Done in carotid, aortoiliac, aortofemoral blocks.
Leg is elevated and lowered alternatively, each for 2 minutes for several minutes at a ► 3 methods - (a) Open method (b) Semi closed method (c) Wiley's eversion endarterectomy
time. ► Disadvantage - Reocclusion
Regular graded exercises are to be done upto the point of claudication
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 231
230 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Define and classify cysts. Discuss the management of a surgically relevant parasitic cystic
5. Profundoplasty : 0 ·6 : disease. Write a brief accow1i on pseudocyst of pancreas. [1+4+4+5]
',- Done when there is a localised block in the opening of profunda femoris.
',- Lateral angiogram view is -used to identify the-orifice of profunda femo~is. CYSTS
► Endarterectomy at the junction and closure with venous or synthetic (Dacron or PTFE) grafts
are done. □ Definition : Cyst< KUSTIS (Greek word, which means "Bladder")
-,., Advantage - Allows collaterals across knee joint to open through profunda femoris thereby Cyst is defined as a collection of fluid in a sac lined by epithelium or endothelium. .
providing good blood supply to below-knee level. These are usually hemispherical sw0!iings which are smooth, well defined, fluctuant and sometimes
6. -~ass grafting procedures : transilluminant.
', Aortofemoral !2YP~. J1E9.ft"t~. th~_,,gqJ9 . .~t~r'LQ. e,r:d procedure for Type I and type II aortoiliac
atherosclerotic occlusive disease with a long term patency rate of 70-80%. CLASSIFICATION OF CYSTS
-,., Grafts used can be arterial/ venous/ synthetic :
[A] ~_!!:ietLc - Dacron woven graft, Dacron knitted graft, PolytetraflUO[Oethylene (PTFE) graft
Thyroglossal
[Bl Natural - Internal mammary artery, Long saphenous vein (reverse OR, in situ), Umbilical
cyst
vein graft (with minimum 3 mm diameter) Dermoid cysts
► Other bypass grafting procedures are : lleofemoral, Femorofemoral, Femoropopliteal, Ependymal
Femorodistal, Axillofemoral. Congenital cyst
► Disadvantage : Leak, infection, reblock, thrombosis. cysts
7. __ Lumbar _sympathectomy: Urachal cyst
I Cysts of embry-
r Removal of L2 1 La_~ L4, Ls_ganglia from the lumbar syrhpathetic chain with retention of L1 on onic remnants Postnatal

►
one side in bilateral cases.
Advantage: Increased cutaneous blood flow for 2-4 weekf:i (due to absence of constriction of
I dermoid

arterioles and precapillary sphincters) resulting in improved nutritive distal perfusion, better
ulcer healing, reduced pain.
/ Retention cysts
Sebaceous cyst

-,., Complications : Bartholin's cyst

Injury to IVC or aorta Acquired cysts
Injury to bowel, ureter Distension cysts
Bursitis
Bleeding lumbar veins
Paraplegia due to lschemia of spinal cord
Exudation cysts Hydrocele
Dry ejaculation due to damage to B/L L 1 ganglion CYSTS
Post- sympathetic neuralgia
Pseudocyst of
Wound infection
pancreas
Paradoxical gangrene of opposite lower extremity
Traumatic cysts f----1 Hematomas
8. Chen,ical sympathectomy :
-, lnieGtio_n_of lig_nocaine_ 1% 12.,arave.rtebra]ly (12, L3,4} in front of the lumbar fascia.
► For long term efficacy, 5 ml phenol in water can be used. Degenerative
Hydatid cysts
cysts
► Done under C-Arm guidance.
, Advantage - Feet become war,:i:i_i_r_rimec:liately after_Lr:ij_(,_ction Cysticercosis
',- Disadvantage - Risk of Spinal cord ischemia, risk of injury to IVG/aorta. Parasitic cysts
9. Omentoplasty: Trichiniasis
► Retaining one of the pedicles, omentum with its arcade of vessels can be mobilised in order
to reach the lower limb to maintain the circulation. Dermoid cyst of
>-- Advantage : Control of ischemia, reduced pain, better ulcer healing. ovary
Cystic tumors
► Complications : Abdominal sepsis, lncisional hernia, Intestinal obstruction.
Cystadenomas
10. -~or Buergt3_!'.~._?i_5-~ase :
llizarov method of bone lengthening- Causes neo-osteogenesis, improves overall blood supply,
decreases rest pain and claudication.
11. For diabetic foot : Surgical debridement of the wound.
-·=· ·~-=..-.,,,,"''-'=•·
 232 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 233

MANAGEMENT OF A SURGICALLY RELEVANT PARASITIC CYSTIC DISEASE 2. Mebendazole

-,, Dose - 600 mg daily
Hydatic cyst of liver is caused by dog tapeworm, Echinococcus granulosus, a parasite.
-,, Duration - 4 weeks
Its definitive host is dog, intermediate host is sheep and accidental host is man.
3. Praziquantel
□ Investigations for hydatid cyst of liver: ► Dose - 60 mg/kg (along with albendazole)
1. USG: ► Duration - 2 weeks
► It is diagnostic. B. PAIR (Puncture -Aspiration - Injection - Reaspiration):
► Findings - (a) Double contoured membrane of the cyst • Indications -
(b) Rosettes of daughter cysts (cart wheel appearance) ► Inoperable patients
(c) Calcification of cyst wall ► Infected cysts
► Hassen Gharbi's USG based classification for hepatic hydatid cyst - ► Relapsed cysts
Type 1 : Pure fluid collection ► Gharbi type 1 and type 2 cysts
Type 2 : Fluid collection with split wall ► Pregnant women
Type 3 : Fluid collection with septa ► Children < 3 years of age
Type 4 : Heterogeneous appearance • It is done under ultrasound/ CT guidance.
• Procedure -
Type 5 : Reflecting thick walls
2. CT scan abdomen :
Cyst is punctured with Cholangiography 22 gauge needle through the thickest
a) It is the radiological investigation of choice for hydatid cyst of liver.
part of the cyst wall, under local anesthesia.
b) More accurate than ultrasound in identifying cyst characteristics.
c) Old hydatid cysts show Serpent sign/ Crumpled membrane sign.
3. MRI:
a) Done to look for cystobiliary communication, biliary hydatids (in common bile duct and hepatic 50% of cyst fluid is aspirated. Radio opaque dye is injected to look for any
ducts). communication.
4. Serological tests :
a) lmmunoelectrophoresis - 80-95% sensitivity
b) ELISA Scolicidal agent (15-20% Hypertonic saline) is injected.
c) Indirect hemaglutination test
d) Latex agglutination test
e) lmmunofluorescence antibody test
5. Other laboratory tests :
Reaspiration is done after 20 minutes.
a) PCR - useful in extrahepatic hydatid cyst and calcified hepatic hydatid.
b) lmmunoblotting
c) Detection of precipitation line
6. Casoni's test :
Alcohol (a sclerosant) is injected.
a) lntradermal test of historic importance.
b) Sensitivity is 75%.
□ Treatment of hydatid cyst of liver:
• Contraindications of PAIR -
A. Drugs:
a) Dead/ calcified cyst
1. Albendazole. b) Deep seated/ Inaccessible cyst
► 4 week cycles. c) Muliloculated cyst/ honeycomb cyst
► Started at least 2 weeks before any intervention. d) Cyst with cystobiliary communication
► To be continued till 2 weeks after any intervention. e) Extra hepatic hydatid cyst

30
 234 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 235

C. Surgery: c) Contents
• It is the gold standard therapy for hepatic hydatid cyst. d) Extent of necrosis in pancreas
• During open surgery, the peritoneal cavity is packed with mops soaked in povidone iodine (black e) Calcification and atrophy
in colour) to identify white scolices so as to prevent any spillage. Fluid from the cyst is aspirated. f) Regional vessels and their abnormalities
Scolicidal agent (hypertonic saline/ cetrimide/ chlorhexidine/ 10% povidone iodine/ Hydrogen 3. MRCP - demonstrates ductal anatomy and its abnormality,
peroxide) is injected into the cyst cavity followed by reaspiration 20 minutes later.
cystopancreatic communication.
• Other surgical options - (a) Laparoscopic pericystectomy (b) Liver resection
4. ERCP - To look for communication/ fistula.
• Procedures to correct cystobiliary communications -
5. Barium meal (Lateral view) - Shows widened vertebrogastric angle with displaced stomach.
a) Pericystectomy and marsupialization
6. LFT, Serum amylase (Amylase level in cyst fluid is> 5000 units/ ml)
b) Suturing of the communication with Vicryl / PDS with T tube placement in the common bile
D Treatment -
duct
• Majority of pancreatic pseudocysts are resolved spontaneously.
c) Capitonnage (spiral suturing of the bottom of the cyst cavity upward from the base of cavity to
the edge of cyst wall); lntroflexion (inverting the rim of the cyst edge without apposition); • Indications for intervention/ surgery -
omentoplasty a) Size> 6cm
d) Bipolar drainage b) Cyst with wall thickness > 6mm
e) Perdomo procedure c) Cyst persisting for > 6 weeks
f) Pericystojejunostomy d) Communicating cyst
e) Infected cyst
PSEUDOCYSTOFPANCREAS • Procedures -
• Most common complication of Pancreatic pseudocyst surgery - Hemorrhage
D It is a localised collection of sequestrated pancreatic fluid, which occurs usually 3 weeks after an
attack of acute pancreatitis .. ffmaials'o occ·u,-·aftercnromcpa-rlcreciITtTs-.-·····--··· -··· ...
□ lt.iscalled''ps·e·udocyst" becausErnfs-,i;,e·xudation cyst lin.:.:!.EX granulc!tion tissLJe, not epithelium.
□ Sites - Surgical intervention for
• Lesser sac - Most common I Pseudocystofpancreas
• Duodenum I
• Jejunum I I

• Colon External drainage Internal drainage

• Splenic hilum
□ D'Egidio classification - I I
I I
Type I : After an attack of acute pancreatitis. Normal duct anatomy. No fistula I communication. Done for infected cyst,
Type II : After an attack of acute on chronic pancreatitis. Abnormal duct anatomy without stricture. hemorrhagic cyst Cystogastrostomy Cystojejunostomy
50% chance of fistula.
Type Ill: After an attack of chronic pancreatitis. Abnormal duct anatomy with stricture. Always I
I I
communicating.
□ C/F -
Open (Jurasz Endoscopic
operation)
1. Epigastric swelling which is hemispherical, smooth, soft, non-mobile, not moving with respiration,
with well-defined lower margin and diffuse upper margin, with transmitted pulsation, confirmed
by knee-elbow positioning of the patient.
2. Baid's test - Ryle's tube passed can be felt per abdominally.
□ Complications of pseudocyst -
□ Investigations -
• Infection - Most common (20%)
1. USG abdomen : Shows size and thickness of the cyst.
• Bleeding from splenic vessels (7%)
2. CT scan:
• Rupture (3%)
► CECT is the investigation of choice.
• Cholangitis
► It shows -
• Duodenal obstruction
a) Number, Size, shape, wall thickness
□ Pancreatic pseudocyst mimics cystic neoplasm of pancreas, although the former can be :'ifterentiated
b) Pancreatic duct size
from the latter by CT findings and CEA level.
 236 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS D Paper - I 237
Q.7: A 60 yrs old lady has presented with jaundice, pruritus, pale stools and a palpable mass in the
right upper quadrant of abdomen. Enumerate the DID. Which radiological investigations will
6. ERCP with pancreatic juice cytology or brush biopsy
you recommend? Outline the operative management of periampullary CA. [3 + 3 + 4]
, Shows the site of obstruction in CBD with proximal dilatation
DIFFERENTIAL DIAGNOSIS • Any growth can be biopsied.
• Bile may be collected and exfoliative cytology can be done from the sample. This, along with
A clinical picture of jaundice, pruritus and pale stools in a 60 years old lady is suggestive of Obstructive/ brush cytology, may be helpful in the diagnosis of cholangiocarcinoma of distal CBD.
surgical jaundice. • If serum bilirubin is very high (>10mg%), stent may be placed in the bile duct during ERCP to
A palpable mass in the right upper quadrant of abdomen in this patient is suggestive of gall bladder bring down the level of bilirubin.
enlargement, which necessitates consideration of Courvoisier's law. • Findings suggestive of carcinoma of the head of pancreas :
Courvoisier's law states that- "In a patient with jaundice, if there is palpable gall bladder, then it is not due i) Abrupt block in the pancreatic duct with irregular stricture
to stones". The law has following exceptions :
ii) Pancreatic duct encasement
(a) Double impaction of stone (one is CBD and another in cystic duct)
iii) Double duct sign- both pancreatic duct and CBD are cut off/ constricted
(b) Empyema gall bladder with primary CBD stone
iv) Scrambled egg appearance
(c) Distended gall bladder due to huge stone load
v) Parenchymal filling
Hence, the following differential diagnosis can be considered in this patient :
7. MRCP
1. Periampullary carcinoma
• It is preferred when serum bilirubin level is < 10mg% and preoperative stenting is not being
, Carcinoma of the head of pancreas contemplated.
, Ampullary carcinoma arising from ampulla of Valer
• It is a noninvasive diagnostic tool with 96% sensitivity and 99% specificity.
, Cholangiocarcinoma of distal common bile duct (CBD)
• II provides with delineation of the entire biliary tree and pancreatic duct along with any lesion.
, Duodenal adenocarcinoma
2. Carcinoma of gall bladder
a. Percutaneous transhepatlc cha/angiography (PTC)

3. Lymph node mass in the porta causing biliary obstruction (Due to metastasis/ lymphoma/ tuberculosis) • It is useful when ERCP fails to detect and assess the site of lesion and the patient is deeply
jaundiced.
RELEVANT RADIOLOGICAL INVESTIGATIONS • Percutaneous transhepatic biliary drainage (PTBD) with a fine catheter left in situ, to
decompress the biliary system, may be done in these cases.
1. USG abdomen
, Can delineate the anatomy of gall bladder, liver, any growth, size of CBD (Normal diameter OPERATIVE MANAGEMENT OF PERIAMPULLARY CARCINOMA
is < 10 mm), lymph node status, portal vein, ascites.
If there is no symptoms or clinical signs of disseminated disease, and investigations don't reveal any
, Can detect any stone in gall bladder and common bile duct.
spread, Whipple's pancreaticoduodenectomy is the surgery of choice.
2. Endoscopic Ultrasound (EUS)I Endosonography
Cl Preoperative preparation :
, More accurate in assessment of pancreatic mass, staging of the disease (T and N), to identify
involvement of portal venous system, CBD stones. 1. Oral and intravenous fluid for adequate hydration (Patients with obstructive jaundice usually
, Useful for EUS guided FNAC, Celiac axis neurolysis, EUS guided immunotherapy. have dehydration and impaired renal function. Adequate rehydration is indicated by good
urine output).
3. Barium meal X-ray
2. Intravenous mannitol 200 ml twice daily for 3 days prior to surgery (Patient is prone to develop
• Not routinely done now-a-days. hepatorenal syndrome postoperatively which may result in renal failure due to blockage of
, Rose thorn appearance of medial border of duodenum, Reverse 3 sign (due to filling defect) renal tubules by deposition of bile salts or due to gram negative septicemia).
- suggestive of periampullary carcinoma. 3. Adequate oral or intravenous glucose (Due to associated hepatocellular dysfunction, the
, Pad sign (widened C loop of duodenum), gastric distension due to gastric outlet obstruction glycogen reserve in liver is reduced in these patients).
- suggestive of Carcinoma of the head of pancreas. 4. lnj. Vitamin K 1O mg IM for 5 days prior to surgery (Prothrombin Time may be prolonged due
4. Spiral CT to decreased absorption of vitamin K).
• To assess operability, size and extent of growth. 5. Broad spectrum antibiotics like 2nd generation cephalosporin and aminoglycoside
• To detect portal vein invasion, lymph node status. combination for 1-2 days prior to surgery (Patients have increased risk of infection and are
, CECT is the investigation of choice in periampullary carcinoma. prone to gram negative septicemia).
6. Total parenteral nutrition [TPN] (If patient is malnourished).
5. CTI MR angiogram
7. Evaluation of pulmonary function by Chest X-ray and Pulmonary function test. Pulmonary
• To assess vascularity, portal venous system.
physiotherapy is to be started.
, Angiographic appearance of occlusion of celiac, superior mesenteric vessels or portal vein
8. Preoperative biliary drainage by either ERCP stenting or PTBD in cases where preoperative
suggests nonresectability.
serum bilirubin levels are >10mg%. Surgery is done after 3 weeks once bilirubin level drops
down adequately.
238 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS D Paper - I 239

□ Operative Procedures in operable cases : a.B: Enumerate the endocrine tumors of pancreas. Discuss CIF, investigations and treatment of
1. Whipple's operation any 2 of such tumors. [ 3 +6 +6 ]
,, Removal of tumor+ Head and neck of pancreas including uncinate process + C loop of
ENDOCRINE TUMORS OF PANCREAS
duodenum + 1O cm proximal jejunum + Distal 40% stomach + Lower end of CBD + Gall
bladder + Pericholedochal, paraduodenal and perihepatic lymph nodes
-,.. Continuity is maintained by choledochojejunostomy, pancreaticojejunostomy and lnsulinoma
gastrojejunostomy
► Mortality is 2-8%.
► Complications- Delayed gastric emptying, pancreatic fistula, bile leak, infection. Gastrinoma • G Cells
2. Traverso-Longmire pylorus preserving pancreaticoduodenectomy • Multiple recurrent refractory peptic ulcer
-,.. Here distal part of the stomach is not removed. Duodenum is __ cut 2 cm distal to the
pylorus.
Glucagonoma
• Alpha Cells
► It avoids the dumping syndrome, a complication of Whipple's operation. • Necrolytic migratory erythema
3. Fortner's regional pancreatectomy / Extended Whipple's operation
, Resection of a segment of superior mesenteric vessels and dissection of adjacent lymph
VIPoma • Pancreatic cholera/ Verner-Morrison syndrome
nodes with maintenance of continuity of portal vein by a synthetic vascular graft. • Watery Diarrhea, Hypokalemia, Achlorhydria (WDHA syndrome)
4. Total pancreatectomy
',- It may be done in growth involving head and body of pancreas. • S cells or Delta cells
',- It is preferred because - SomatostaUnoma [
• Diabetes mellitus, steatorrhea, cholelithiasis
a) Pancreatic growth may be multicentric.
b) There is higher chance of local recurrence after Whipple's operation.
c) Viable malignant cells may be present in the pancreatic duct. INSULINOMA
d) Morbidity by postoperative pancreatic fistula or pancreatitis.is not seen here. • Most common pancreatic endocrine tumor.
► Disadvantages - • Majority are benign (85%).
a) Mortality is higher than Whipple's operation 10-20%. • Usually solitary.
b) Severe resistant diabetes mellitus is seen postoperatively which needs lifelong insulin • Arises from Beta cells of islets of Langerhans.
therapy. • Can be sporadic or associated with MEN syndrome type I.
c) Permanent pancreatic enzyme deficiency which needs pancreatic enzyme
replacement therapy lifelong. □ Clinical features :
1. Abdominal discomfort, sweating, trembling, dizziness, diplopia, hallucinations. Convulsions and
□ Features of unresectability:
unconsciousness may occur.
1. Multiple liver metastasis 2. The patients usually are overweight.
2. Peritoneal metastasis
Whipple's triad is a feature of lnsu.linoma.
3. Malignant ascites
4. Extensive lymph node metastasis
' ' : • An attack of hypoglycemia in fasting state
5. Invasion of the growth into IVC
WHIPPLE'S TRIAD • Blood sugar level below 40 mg/dl during the attack
6. Invasion of the growth into superior mesenteric vessels, portal vein of celiac axis
• Reversal of symptoms on administration of glucose.
□ Operative procedures in inoperable cases :
In these cases, palliative surgery is to be undertaken - □ Investigations:
1. For relief of jaundice - Roux en Y choledochojejunostomy following cholecystectomy 1. Insulin radioimmunoassay following 72 hours fasting :
2. If the patient has gastric outlet obstruction - gastrojejunostomy

l
3. For relief of pain-celiac plexus blockade with absolute alcohol • Plasma insulin level > 7 microunit/ml
4. For steatorrhea - Enzymes Findings in • Plasma insulin to glucose ratio > 0.3
5. Control of diabetes mellitus lnsulinoma • Proinsulin level > 24% of total insulin level
• C peptide level > 1.2 pg/ml with glucose level < 40 mg/dl
240 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 241

► Proinsulin level > 40% of total insulin level is suggestive of malignant insulinoma. Hypergastrinemia
2. Insulin provocation test using Calcium gluconate or tolbutamide.
3. MRI - to localise the tumor.
4. Celiac angiogram.
5. lntraoperative USG - It is the best modality to localise the tumor. Increased acid secretion

D Treatment :
• Benign insulinoma are treated by enucleation. Distal pancreatectomy (spleen; tail and the body
of pancreas are removed) may also be done. pH of duodenum becomes acidic
• To decrease insulin secretion - Octreotide.
• To control hypoglycemia - Diazoxide, Beta blockers, phenytoin, verapamil
• To treat metastatic insulinoma (when secondaries are present in liver or elsewhere)-Streptozocin Pancreatic enzymes don't get activated

GASTRINOMA
• Second most common pancreatic endocrine tumor. Malabsorption
• Most common pancreatic endocrine tumor seen in MEN syndrome type I.
• Common in males.
•
•
It causes Zollinger Ellison syndrome type II.
Majority of gastrinoma lie in Gastrinoma triangle/ Passaros triangle.
( Diarrhea

• Most common location - 1st part of duodenum

• Majority are malignant (85%) 4. Secretin provocation test - On injection of secretin 2 units/kg i.v., assessment of blood samples
before and every 5 minutes after injection of secretin for 30 minutes, will show a gastrin level
more than or equal to (Baseline gastrin value + 200 pg).
5. Basal acid output (> 15 meq/hour)
6. PH of stomach(< 4)
7. CT, MRI, lntraoperative USG - to localise the tumor.
8. Angiogram
9. Gastroscopy
□ Treatment :
• As majority of gastrinoma are malignant, radical surgery Whipple's operation
(pancreaticodudenectomy) is usually done.
• Enucleation of tumor or Distal pancreatectomy may be done sometimes.
• To treat metastatic gastrinoma - High dose octreotide is used.

Q.S,✓r" ~5 yrs old man presented with rapidly developing anorexia, asthenla and fatigue with
,/increasing vomiting. How would you investigate to confirm the diagnosis? How would you
stage and manage the patient? ~-e. v,~"' 01) [ 5 + 5 + 5 ]
,y-
D Features: Ans : A 45 years old man presented with rapidly developing anorexia, asthenia and fatigue with
increasing vomiting - this clinical picture is suggestive. of the diagnosis of Gastric carcinoma.
1. Multiple, recurrent, refractory/resistant peptic ulcers in unusual sites (2nd/3rd/4th part of duodenum,
jejunum).
CLINICAL FEATURES OF CARCINOMA STOMACH
2. [See chart on the next page].
□ Investigations:
A. Symptoms: (¼sJ~~)
i) Most common symptom - ~ h t loss
1. Gastrin assay (Normal level 100-150 pg/ml) : Gastrin >1000 pg/ml
ii) Earliest symptom - Post prandial heaviness. Continuous upper abdominal pain or discomfort
2. Calcium provocation test
without periodicity, not relieved by food
3. Pentagastrin provocation test

31
242 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 243
1$3/i~<~·'.:;.·- - - - - - - - - - - - - - - - ' - - - - - - - - - - - - - - - - - - - - - - -

iii) Anorexia, rJilJ:l~a, asthenia (weakness + fatigue) 4. Routine stool examination - occult blood present in 80% cases
iv) If _gastric outlet obstruction occurs - · s. Gastric function tests - gross hypochlorhydria or achlorhydria and blood in basal secretion
► Sensation of fulln~~ after meals or early satiety 6. Upper GI endoscopy (is the Gold Standard) and 10 quadrant biopsy
► Belching 7. Barium meal X-Ray (if Endoscopy not possible) -
► Projectile vomiting - vomitus is yellowish in colour (non-bilious), contains food material i) irregular filling defect
consumed more than 12 hours ago, leaving a sour taste in mouth ii) loss of rugosity
► Feeling of a rolling mass moving from-.left to right in the abdomen (due to peristalsis) iii) delayed emptying
v) ~ in abdomen
iv) dilated stomach
vi) Due to metastasis -
v) margin of lesion projects outward from lesion into gastric lumen (Carmann's meniscus sign)
► Abdominal swelling (due to ascites from hepatic or peritoneal metastasis)
8. For staging -
► Br~~t.hJessness (due to pleural effusion from pulmonary involvement) i) Chest skiagram (PA view)
► Yellowish discolouration of eyes and urine (due to enlarged lymph~node obstructing porta ii) CT Scan abdomen, chest, pelvis
hepatis)
iii) MRI abdomen, chest, pelvis
► Backache (due to metastasis to vertebrae)
iv) Endoscopic ultrasound
B. Signs: ( <zxo 'l'N\r-c,J< uVI) 9. Others -
a) General survey - i) LFT
i) Cachectic look may be present
. ii) PT
ii) Pallor
iii) FNAC from left supraclavicular lymph node
iii) Jaundice may be present
iv) Laparoscopy for staging
iv) Enlar9ed Virchgtt:_.~l!lQ.b,.node (left supraclavicular LN) - Troisier's sign
v) Tetracycline fluorescence test
v) Enlarged Irish nodes in left axil la
vi) Tumor markers - CA 72, CEA, CA 19-9, CA 12-5
vi) Superficial migratory thrombophlebitis - Trousseau's sign
vii) Due to paraneoplastic syndrome - vii) Combined PET
Dermatomyositis viii) Sentinel node biopsy
Acanthosis nigricans
TNM ST AGING OF CARCINOMA STOMACH
Circinate erythema
b) Systemic examination - T status-
1) Abdominal examination :
► Nodular hard mass, with impaired resonance, moves up and down with respiration on
palpation
► In cases of gastric outlet obstruction -
stomach is distended
succusion splash audible Tumor can not be No evidence of pri- Carcinoma in situ
greater curvature of stomach below umbilicus on ausculto-percussion assessed mary tumor (intraepithelial tumor
without invasion)
► Sister Ma.ry Joseph's nodule looked for (due to infiltration of umbilicus)
► Ascites is looked for
2) Rectal examination -
To detect metastasis in pelvis and to exclude Krukenberg's tumor
3) Skeletal system examination -
To look for sternal tenderness and bony tenderness

RELEVANT INVESTIGATIONS
Invasion of lamina Invasion of Invasion of muscu-
1. Routine blood examination - low Hb, high ESR propria or muscularis laris propria
submucosa
2. Serum Electrolytes mucosa
3. Blood Sugar, blood urea, serum crnatinine
244 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

,,,,,.,, nod• 1t11tlons In Gastric Carcinoma (JEGC) -

A. oroup I I N1 tier (Per/gastric LN)
, Station 1 : Right paracardiac
Invasion of subserosal Invasion of visceral lhvasiofl of adjacent 1 Station 2 : Left paracardiac
connective tissue and peritoneum 11tructutes 1 Station 3 : Along lesser curvature
serosa 1 Station 4 : Along greater curvature
.
► 4a - Along short gastric vessels
N status - ► 4b - Along left gastroepiploic vessels
► 4c - Along right gastroepiploic vessels
, Station 5 : Suprapyloric
, Station 6 : lnfrapyloric
. 8, Group Ill N2 tier (LN along the intermediate arterial trunks)
, Station 7 : Along left gastric artery
, Station 8 : Along common hepatic artery
Primary LN No evidence of , Station 9 : Along celiac trunk
status can not be lymph node 1-2 regional LNs 3-6 regional LNs
involved involved , Station 10 : At splenic hilum
assessed spread
, Station 11 : Along splenic artery
a. Group /Ill N3 tier (LN along the great vessels)
, Station 12 : At hepatoduodenal ligament
• Station 13 : Retroduodenal/ retropancreatic LNs
, Station 14 : At the root of mesentery
► 14a - Along superior mesenteric artery
► 14v - Along superior mesenteric vein
7-15 regional > 15 regional • Station 15 : Around middle colic artery
LNs involved LNs involved • Station 16 : Para aortic LNs
• Station 17 : Around lower esophagus
M status- • Station 18 : Supradiaphragmatic
D. Group IV/ N4 tier-Distant lymph nodes beyond these stations

MANAGEMENT
1, .c,§ur9_!ry (Treatment of choice) -
No distant spread Proximal resection margin is to be at least 6 cm to achieve microscopically negative margin.
Distant metastasis
► 1t early growth involvin~ pylorus region - ~~~~-~ !~-~!~~1 ..11~.~-tr.~p~o_~y/ Distal gastrectomy +
8 i11roth II anastomosis · ·· ·
..... ----· ···-·-
► If growth in_esophago-gastric junction or upper part of stomach - Upper radical gastrectomy/
Nodal spread as per Japanese Classification of Gastric Carcinoma (JEGC) -
Esophagogastrectomy + esophagogastric cervical/ thoracic anastomosis
► If growth in. body of stomach - lQ!~I radical gastrectomy +~e.s.Qp.lJ.~.g.Qi~_anastomosis
► EMR (Endoscopic Mucosal Resection) is done in Japan
R status (Tumor status after resection) :
Ro resection - No residual gross/macroscopic or microscopic tumor in tumor bed +
Negative resection margin.
LN stations 1-6 LN stations 7- LN stations 12- R 1 resection - No residual gross/macroscopic tumor in tumor bed_+ Positive resection
Nodes can't be No nodal ........
assessed - spread (Group I) 11 (Group II) 18 (Group Ill) margin
involved involved involved R2 resection - Residual gross/macroscopic tu·mor
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 247
246 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

2. Lymph node dissection -

.~;;:5 yrs old male, chronic alcoholic, complains of severe, agonising, acute abdominal pain
persisting for several hours, radiating to the back and a little relief on stooping. How would you
► D 1 dissection : Done when LN status is No. Removal of Group I LNs/ LN stations 1~6.
-"
'~ ~-,_.,,- investigate to confirm the diagnosis, prognosticate and manage? [ 5 + 5 + 5]
► ~ dissection : Done when LN status is NJ.:
A 55 years old chronic alcoholic maie complains of severe agonizing acute abdominal pain persisting
Removal of group I and group II LNs/ LN stations 1-11 with or without removal of spleen and
for several hours, radiating to the back with a little relief on stooping
tail of pancreas.
_ This clinical picture is suggestive of a diagnosis of Acute alcohol induced
► ..12~. dissection : Done when LN status is N2.
Removal of LN stations 1-16 with or without removal of spleen and tail of pancreas/ resection □ Clinical features :
of anterior lip of transverse mesocolon. A. Symptoms :
► D4 dissection: Not commonly done. Removal of LN stations 1-18. ► Sudden ~iJdill.lgr_c!.bdominal R?J!1..VJbic:_~J~ . .E:J<_<?I.U.C:~ali0JL~fl_~ is_r~!e,rr.9-.d_t9_ Lh_e back;
• f'.\ '"2 Patient gets some reiief by leaning_ QJ.stQ-Q.QiDQ.JQfr\Jl.CJ
3. Chemotherapy - -"'
► High fever, vomiting, tachypnea
a) Neoadjuvant therapy : (chemotherapy before surgery)
► Refractory hiccough
Purpose -
► Oliguria
i) to increase resectability (to downstage the tumor)
► Hematemesis, melena
ii) to reduce recurrence
B. Signs:
iii) to determine chemotherapy sensitivity
► Features of shock and hypovolemia, cyanosis, sornt?times rni!d jaundice
b) Regimens used -
► Abdomen - Distension, tenderness, rebound tenderness, guarding, rigidity, Grey Turner's
~ (Epirubicin, Cisplatin, 5-Fluorouracil)
sign, Cullen's sign. Fo:,: sign
* ~ (Epirubicin, Adriamycin, Cisplatin)
► Pleural effusion, Neurological derangements
* £QI (5-Fluorouracil, Doxorubicin, Triazinate)
c) Adjuvant therapy : (chemotherapy after surgery) INVESTIGATIONS
Purpose - to increase survival rate A. Laboratory investigations:
Regimens which may be used - 1. ~e;u~ ~m1~se -
i) 5-Fluorouracil + Leucovorin ►- It IS !he-first test to be advocated, although it is not sp~cific for acute_pancreatitis.
ii) 5-Fluorouracil + Adriamycin + Mitomycin C (FAM regime) ► Usually serum amylase is_increased upto 4 times its normal value or is> 1000.Somogyi units
iii) Cisplatin, Epirubicin, Adriamycin, Oxaliplatin, Capecitabine are other drugs used in acute pancreatitis, although value of serum amylase does not correiate with the severity of
attack of acute pancreatitis.
4. _R_ adiother~py -
.,;;::.ii..

i) No role. 2. Serum lipase -

~ '
ii) 45 Gray radiation + 5 Fluorouracil + Leucovorin- under trial ► More specific for acute pancreatitis.
.Q ► Its value does not correlate with the severity of attack of acute pancreatitis.
5. _Palliative_P.rocedures -
3. A~~ratio-(!} Vc,,;,A-e: ,~11.,,,.i'·,-., .1 :::::.:.'.::-·•··,
i) _Palliative partial g~strectomy - best method· ► (Urine amylase/serum amylase) *(serum creatinine/urinary creatinine) * 100 -:::. '"~,,;, 0,~1,,...,., , ). c
i i ) Pa II iati _vei_ ~.ri_tEl_rjqT_ .9 ast r(? j.9-ilJ.~-~-~.Q my ► A value > 6% indicate_~_~te pancreatitis (Normal value is 1-4%) ,Sri) O
iii) Devine's antral exclusion operation 4. Serum lactescence -
iv) SEMS (Self Expanding Metal Stents) ► MQs1..s.pacifi.c.JnJ1eredjJfilL~.idemia or alcohol induced pancreatitis.
v) -Lase! r9-can~!.i.~.1!li9.!1 5. Serum trypsin - Most accurate indicator of acute pancreatitis, yet rarely used.
vi) _Palliative chemotherapy (FAM regime) for : 6. Trypsinogen activator polypeptide (TAP) assay in serum and urine - It correlates with severity of
Adherent to pancreas or colon or mesocolon attack of acute pancreatitis.
Ascites 7. ,.9!3!: - It is increased (> -150 U/L). (t)
Para-aortic lymph nodes 8. LDH, Phospholipase A2 levels·
Secondaries in liver 9. Urinary lipase level
Blummershelf 10. LFT, Blood urea, .serum creatinine
Enlarged Virchow's node 11. Hematocrit, total leucocyte count, platelet count, coagulation profile
Sister Mary Joseph nodule 12. Blood glucose estimatio11 - Hyperglycemia is revealed.
Irish node 13. Serum calcium level - Hypocalcemia is seen.
 248 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - I 249

14. Arterial pO2 and pCO2 level estimation (to assess pulmonary insufficiency) Ranson 's prognostic criteria in alcohol induced pancreatitis (Non:ga/1 stone pancreatit/s)
2.
15. Peritoneal tap fluid examination - High amylase and protein levels. A. On admission :
8. Radiological investigations: a) Age > 55 years
1.
Plain X-ray abdomen - b) TLC > 16000 /cmm
► Distension of transverse colon with collapse of descending colon (Colon cut-off sign) c) Blood sugar > 200mg%
► 'Sentinel loop' of dilated proximal small bowel d) LOH> 7000 IU/L
► Renal halo sign e) AST > 250 IU/100 ml
► Air-fluid level in the duodenum B. Within first 48 hours :
► Obliteration of psoas shadow a) Serum calcium < 8 mg%
► Ground glass appearance b) Rise in BUN> 5 mg%
2. Spiral CT - c) Fall in hematocrit > 10%
► CECT is the investigation of choice for acute pancreatitis. d) PaO2 < 60 mmHg
► It is done after 72 hours to look for fluid collections, edema, necrosis (non-enhancement area e) Base deficit> 4 meq/L
> 30% or 3 cm), altered fat and fascial planes, bowel distension, mesenteric edema and f) Fluid sequestration > 6 L
hemorrhage. Ranson's score more than or equal to 3 indicates Severe pancreatitis.
► CT guided aspiration may be done and fluid sent for Gram staining and culture.
3. Glasgow Imrie prognostic criteria :
3. USG abdomen
A. On admission :
4. EUS (Endoscopic ultrasound) -
i) Age > 55 years
► To see necrosis, calcifications.
ii) TLC > 15000/cmm
► To assess CBD.
iii) PaO2 < 60mmHg
5. MRI, MRCP, ERCP - Usually not done in the acute phase.
iv) Blood urea > 16 mmol/L (with no response to Intravenous fluid administration)
6. Chest X-ray - To assess pleural effusion and ARDS.
v) Blood sugar > 200 mg% (without any history of diabetes mellltus)
PROGNOSTICATION 8. Within first 48 hours :
Scoring systems to assess the prognosis of a patient of acute pancreatitis are as follows : i) Serum calcium < 2 mmol/L
ii) Serum albumin < 3.2 g/dl
)(~lthazar CT scoring system :
iii) AST/ ALT> 600 U/L
/)(// • It is the best scoring system to prognosticate acute pancreatitis.
iv) LOH > 600 U/L
• 11 takes into account 2 things - (a) Pancreatic inflammation (b) Pancreatic necrosis
Score more than or equal to 3 indicates Severe pancreatltls,

• Normal pancreas - Score O 4. Acute Physiology and Chronic Health Evaluation (APACHE II) 1cor11 :
► In includes the following factors -
• Edematous pancreas OR Focal /diffus~~enlargement of pancreas - Score 1
Pancreatic Age
• Intrinsic changes I Mil~perifl~!!creatic inflammation - Score 2
inflammation • Heart rate
• Severe extrapancreatic changes with single fluid collection - Score 3 Mean arterial pressure
• Multiple exlr"!p~ncreatic collections OR gas bubbles in or adjacent to Rectal temperature
pancreas - ~ 4 PaO2
Arterial pH
• Normal pancreas - §core O Hematocrlt
Pancreatic • Necrosis ~ ~ o r equal t9.1Q~:'.'.'.o - ,$CQ!~g Total leucocyte count
necrosis Serum sodium
• Necrosis 30-50% - Score 4
• Serum potassium
• Necrosis > 50% - Score 6
• Serum creatinlne
• Glasgow coma scale score
• CT severity index -
► APACHE II - Modification (1996) : LFT has been added for gall stone induced pancreatitis
► 0-3 - Normal pancreas/ Mild pancreatitis
► APACHE-O - Obesity has been adclad
► 4-6 - Moderate pancreatitis ► Score more than or equal to 8 indicates severe pancreatitis with 11-18% mortality risk.
► 7-10 - Severe pancreatilis

32
 250 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- I 251

MANAGEMENT Options for surgical management of acute pancreatitis :

•
A. Conservative treatment : 1. Open surgery/ Laparotomy (Gold standard for infected pancreatic .necrosis)
1. Rehydration - i) Conventional clg_sed method ·
► @ 250-400 ml/hour. a) Laparntomy + Necrnsectomy (all necrotic tissue removed) + Wide debdridenient
, Done to compensate for 3rd space fluid loss. (pus,-(nfected fluid,toxins a·re also removed)+ Saline wash with 10-12 L of normal
, Done with NS, DNS, RL, Whole blood or concentrated RBC (packed cell) transfusion. saline + Adequate drainage + Q_bolecystectomy + Closure of abdomen in layers.
b) Re-laparoTomy is done late only on demand.
, In severe hemorrhagic pancreatitis, fresh frozen plasma and platelet concentrate may also
be required. ii) Open method
a) L'!.P_arotgrny + Necrosectomy + Wide debridement + Wash + Wide packing + Wound
► Urine output @ 30ml/hour to be maintained. Urinary catheterisation is to be done. left open. ·· --- -
2. Pain relief - by pethidine b) Repeated wash and packings are done until healthy granulation tissue develops.
3. Nasogastric aspiration iii) Sen:iJ::_o,pen method
4. ~-~st oxygen inhalation, Nebulisation with bronchodilators Laparotomy + Necrosectomy + Abdominal closurewith drainage + Re-laparotomy
later-on:- - -- ----- ~ - - - - - - - - ---------·-
5. Endotracheal intubation, ventilatory support, tracheostomy may have to be done on an emergency
basis when required. Hemodialysis is required in case of renal failure. iv) Bradley'~ rep_e, 9tf:ld laparotomies and wash
6. Central venous line is to be done and CVP to be monitored (with Swan-Ganz catheter) Zip technique is used to give repeated wash to remove necrotic tissues and toxins
until healthy granulation tissue develops on the pancreatic bed.
7. Proper electrolyte management with monitoring
2. Be_ger's _lav~
8. .Antibiotics -
Initial surgical debridement + Continuous closed peritoneal lavage of the pancreatic bed
, Third generation cephalosporins (Ceftazidime, cefotaxime), lmipenem, Meropenem are used. and lesser sac (with 10-12 L of normal saline OR hyperosmolar potassium free dialysate
► Indications : fluid @2Uhour)
Severe infected necrosis with proved culture Multiple tubes are used for lavage to remove the toxic material in the peritoneal cavity/
Pancreatic abscess formation retroperitoneal area until return fluid becomes clear.
3. Extra peritoneal lavage
Clinically rapidly progressive disease with deterioration
Done through bilateral flank incisions.
Prophylactically in severe pancreatitis
Blind procedure.
9. Total parenteral nutrition (TPN) using carbohydrate, amino acids, vitamins, minor elements Efficacy not established.
10. Intravenous Ranitidine (50mg) 6 hourly/ Pantoprazole (80mg) 12 hourly/ Omeprazole (40mg) 4. Laparoscopic surgery
12 hourly to prevent stress ulcers and erosive bleeding. Necrosectomy + .W.~2.~ + Drainage
11. Calcium gluconate (10%) 1O ml i.v. 8 hourly (to prevent hypocalcemia). 5. Endoscopfo- iiecrosectomy - - -
12. Octreotide (Intravenous : 50 microgram loading d.ose followed by 50 microgram in 5% dextrose 6. Jejunostomy
hourly) OR Somatostatin - to reduce pancreatic secretion. Can be done as an add-on procedure along with any of the above mentioned procedures.
13. Dopamine OR low molecular weight Dextran - to improve renal perfusion. Helps to achieve early enteral nutrition.
14. Steroid injection - 7. Further management to prevent recurrence (in a case of gall stone induced pancreatitis)
► Useful in the initial period of shock. i) Laparoscopic cholecystectomy
(a) To be done 2 weeks after the acute attack of pancreatitis.
:,. Given in pulmonary insufficiency and ARDS.
ii) Endoscopic sphincterotomy (ERCP) and stenting if needed
15. Protease inhibitors (Aprotinin, Antisnake venom, EACA), Anticholinergics (to reduce pressure of
sphincter of Oddi), Calcitonin C. Management of complications of acute pancreatitis :
16. Nasojejunal tube placement and feeding - a) Acute pse~docx:st - Percutaneous removal under Ultrasound or CT guidance or through an
:,. To be started as early as possible once ileus subsides. ena6scope .
► During recovery period, it reduces infection rate (by transmucosal migration of bacteria) and b) Pancreatic necrosis.-
improves nutritional status. ► Laparotomy + Debridement + Adequate drainage + Continuous lavage.
► Repeat laparotomies may have to be done once is 3 days.
B. Surgery (10-30% cases): c) Pancre~tj_g_§~. - Antibiotics + Percutaneous US or CT guided aspiration / Open drainage
• Indications for surgical intervention : d) Pancreatic fifil_lfill - If persists for > 6 months, then Spincterotomy + Resection of fistula with
a) Patient is non responsive to conservative treatment panEreaiic--~~secti~n + Pancreaticojejunostomy is done.
e) Respiratory complications (Pancreatic pleural effusion, ARDS) - Patient may neP.d ventilatory
b) Formation of pancreatic abscess or infected necrosis support · · ·
c) In severe necrotising pancreatitis, in a trial to save life of the patient
f) Systemic failure, MODS
 SOLVED LONG QUESTION$ OF SEMESTERS □ Paper- II 253

• SEGMENT-B In this particular clinical scenario, as the present has presented with ipsilateral lymphadenopathy, the
SOLVED LONG QUESTIONS OF SEMESTERS provisional diagnosis of thyroid neoplasm (Papillary CA/ Follicular CA/ Hurthle cell CA/ Medullary
CA) seems to be more relevant.
Paper - II
□ Investigations:
1. Thyroid function test- TSH, Free T 4 (to detect hyperthyroidism)
01. A 20 yrs old actress has presented with a small goiter involving right lobe and ipsilaternl
lymphadenopathy. How will you establish a diagnosis? Discuss the surgical managementlfnd ► Serum Thyroid-Stimulating Hormone (Normal 0.5-5 micro IU/ml)
complications. [3 + 6 + 6] ► Total T 4 (Reference Range 55-150 nmol/L) and T 3 (Reference Range 1.5-3.5 nmol/L)

02. A 70 yrs old male patient complains of inability to pass urine for past B hrs. How will you differentiate ► Free T 4 (Reference Range 12-28 pmol/L) and Free T 3 (3-9 pmol/L)
this from anuria? Outline the subsequent management of the case. [5 + 1OJ Non-toxic nodule - Usually euthyroid with normal TSH and low-normal or normal free T 4 levels. If
03. What are the common surgical causes of hematuria? Discuss the diagnosis and management of some nodules develop autonomy, suppressed TSH levels or hyperthyroidism
hematuria due to carcinoma of urinary bladder. [4 + 4 + 7] Toxic nodule - Free T4 - very high, TSH - low or undetectable
04, A 48 yrs old female presented with a 4 cm lump in Right breast. Discuss the DID and diagnostic 2. X-ray neck and chest- to detect tracheal deviation or compression or sometimes calcification.
approach to the condition. [7 + 8] 3. Ultrasound of neck -
► To Identify impalpable nodules(< 2-3 mm in diameter)
SOLUTIONS r Gives Information about size and multicentricity.
01. A 20 yrs old actress has presented with a small goiter involving right lobe and lp1llateral , Distinguishes solid from cystic lesion
lymphadenopathy. How will you establish a diagnosis? Discuss the surgical management and ,- To guide FNAC
c:ompfications. [~ + 6 + 6) -,. To assess for cervical lymphadenopathy.
, Colour Doppler USG helps in visualisation of small vessels within the gland
SMALL GOITER IN A 20 YEARS OLD FEMALE
4. CT/MRI-
□ Diagnosis: The 20 yrs old female has presented with a solitary thyroid nodule. It may be toxic (3·5%) ► To evaluate Retrosternal extensions.
or non-toxic.
► To assess for lymphadenopathy
• Causes/Differential diagnoses :
► To detect impalpable nodules
i) Toxic nodule (single/ one palpable nodule of a multinodul&r goiter) (most common]
5. FNAC~
ii) Thyroid adenomas (Follicular, Hurthle cell type) - 20%
► recommended in patients who have a dominant nodule or one that is painful or
iii) Papillary carcinoma of thyroid - 20%
enlarging
iv) Thyroid cyst - 10% ► Can detect colloid nodule, thyroiditis, thyroid cyst, thyroid carcinoma (papillary and
v) Medullary carcinoma of thyroid medullary)
• Solitary thyroid nodule may present with the following features , Cant differentiate between follicular adenoma and adenocarcinoma
i) Swelling in the anterior aspect of lower part of neck, which moves with deglutltlon ► Most experts have recommended 3-6 aspiration per nodule. Satisfactory specimen
and doesnot move with protrusion of tongue · contains atleast 5-6 groups of cells, each group containing 10-15 well preserved
ii) Tracheal deviation towards opposite side is common (Tr&il's sign, Two finger test) cells
► Grading - Thy1 (nondiagnostic),Thy2(noneoplastic),Thy3(follicular),Thy4(suspicious
iii) History and clinical features suggestive of malignancy -
of CA), Thy5(Malignant)
* Nodule in extremes of age group (child/> 60 yrs aged)
* Nodule in a male patient 6. True cut biopsy -
History of radiation on neck ► For diagnosis of carcinoma mainly- unresectable tumor, anaplastic CA, lymphoma
Family history of papillary/medullary CA of thyroid 7. Radioisotope study (Isotope used - I 123 [Half life - 12-13 hrs] or Tc99 [Half life-6 hrs])
Hoarseness of voice/stridor/dyspnea/dysphagia , "Hot" nodule - Toxic
* Irregular surface with firm consistency ► "Warm" nodule - Euthyroid (Non toxic) ;
Fixity to surrounding structure Warm nodule in Tc99 scan, but cold nodule in RAI scan - Discordant nodule
(Malignancy)
Rapid onset/ recent rapid growth in size
► "Cold" nodule - 20% malignant, 80% benign
Pain in the swelling
8. Power Doppler -
Palpable lymph node
► To know vascularity of the gland
► Resistive index> 0.7 (N = 0.65 - 0.7) indicates malignancy
252
254 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- II 255

9. Indirect laryngoscopy - To assess vocal cord movements prior to surgery {mainly for Toxic nodule -
documentation and medicolegal purpose).
•
1O. ECG - To detect cardiac abnormalities
11. Baseline investigations - Treatment of
► Complete hemogram : Hb%, TC, DC, ESR toxic nodule
,., Blood for sugar, urea and creatinine
, Urine and stool routine examination
□ Management: Indications for surgery in solitary nodule of thyroid Age < 45 years Age < 45 years
i) Malignant nodule/ Nodule suspicious of malignancy
ii) Follicular neoplasm
Antithyroid drugs**
iii) Nodule with obstructive symptoms until euthyroid status Radioiodine
iv) Toxic nodule in children is achieved therapy - 5
v) Complex cyst milicurie orally
vi) Cosmetically bothersome nodule
Surgery-
Treatment options : Hemithyroidectomy*
• Thyroid neoplasms -

• Thyroid cysts -
FNAC , Cyst > 4 cm in size ]
I
I ► Complex cyst {Cyst containing both solid and cystic areas) Surgery indicated
► Recurrent thyroid cyst
Hurthle cell Follicular Papillary CA Medullary CA
adenoma adenoma
• Colloid nodule -
I I I I
Oral levo-thyroxine
Hemithyroidec- Hemithyroidec- Near total Total J,
tomy tomy thyroidectomy thyroidectomy
followed by with lymph node Therapy failed- Progressive enlargement/ recurrent nodule
I I J,
levothyroxine dissection {upto
Histology-Hurthle Histology 0.3 mg OD level 6) Hemithyroidectomy
cell carcinoma Follicular ***
carcinoma • Hemithyroidectomy - Lobectomy (unilateral) + lsthmusectomy
I
~ •• Antithyroid drugs -
Total thyroidectomy
Completion • Initially given to make patient euthyroid before surgery
+ routine central
thyroidectomy
neck node removal • Carbimazole 10mg 6-8 hrly - Euthyroid state may be achieved by 6-8 wks
within 7 days or
+ modified radical after 3 weeks • Propranolol 20-40 mg BD/TDS - To ameliorate cadiovascular symptoms
neck dissection • Lugol's iodine 10-30 drops/day for 10 days prior to surgery - To reduce vascularity of gland
when lateral neck
nodes are palpable Total thyroidectomy {if ••• Near total thyroidectomy- < 2 g of thyroid thyroid tissue is kept only to preserve parathyroid
Frozen section biopsy glands, near lower pole on one or both sides.
proves carcinoma) CJ Complications of surgical management:
with lymph node
dissection a) Transient hypocalcemia -
.,., Seen in almost 50% cases.
}.- Occurs due to surgical injury to or inadvertent removal of parathyroid tissue.
► More likely in patients who have undergone thyroidectomy with central and lateral
• Non-toxic nodule - Hemithyroidectomy (Unilateral lobectomy+isthmusectomy)
neck dissection.
 256 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- II 257

► Rapid influx of serum calcium into bones in the immediate post operative period may Differentiation between anuria and retention of urine
cause severe hypocalcemia (known as Hungry Bone syndrome)- corrected by i.v.
calcium gluconate 10% 10 ml. □ History:
• Urge of micturition is present (strong) - Acute retention of urine
b) Permanent hypoparathyroidism -
• Urge of micturition is absent - Anuria
, Occurs in< 2% cases.
□ Clinical examination:
c) Injury to external branches of superior laryngeal nerve -
(a) Inspection -
► Approximately 20% patients are at risk for this injury.
.,_Distended hypogastrium (suggestive of full bladder) - Acute retention of urine
► Leads to alteration in pitch of voice due to weakness of cricothyroid muscle.
► Hypogastrium is not distended - Anuria
► Occurs when vessels at the superior pole of thyroid are ligated en masse.
(b) Palpation -
d) Injury to Reccurrent Laryngeal Nerve -
r Urinary bladder is palpable - Acute retention of urine
,- Occurs in < 1% of patients. :,... Urinary bladder is not palpable - Anuria
, Can occur by traction, ligation or severance.
(c) Percussion -
► Most commonly occurs in the last 2-3 cm of the course of RLN. ,. Dull note over hypogastrium - Acute retention of urine
► If recognised intraoperatively, primary re-approximation of perineurium using ► Normal/ tympanitic note over hypogastrium - Anuria
nonabsorbable sutures is often advocated.
□ Intervention :
► If uncorrected, patient presents with hoarseness of voice, aphonia.
► Usually recover in 3 weeks to 3 months. May require steroid supplement and speech On introduction of urinary catheter -
therapy. • Free flow of urine - Acute retention of urine
e) Injury to cervical sympathetic trunk- • No/ little flow of urine - Anuria
► May occur in invasive thyroid carcinomas and retropharyngeal goiters. ~~::::~--- MANAGEMENT OF ACUTE RETENTION OF URINE
► May lead to Homer's syndrome.
L Diagnosis of the cause of acute retention of urine
f) Injury to surrounding structures (carotid artery, jugular vein, esophagus) -
g) Bilateral vocal cord dysfunction - Causes of acute retention of urine :
► Laryngeal edema is there, may be due to hematoma. A. Bladder outlet obstruction due to -
► Benign prostatic hyperplasia (BPH)
► Airway is compromised.
► Requires immediate reintubation and often tracheostomy. ', Prostate CA
► Prostatic abscess or acute prostatitis
h) Postoperative hematoma or hemorrhage -
► May be due to slippage of ligatures of either superior thyroid artery or small veins or r Bladder CA
other pedicles. r Bladder neck fibrosis
► Severe strider and respiratory distress may be caused by tension hematoma under B. Urethral causes -
strap muscles. ► Stricture
► May sometimes require emergency reoperation for release of sutures and evacuation ► Calculus
of hematoma.
► Tumor
i) Seroma -
► Rupture of the urethra
► May need aspiration. r Phimosis
j) Wound cel/ulitis and infection - ,... Meatal stenosis
/ C. Drugs -
, ~ Oyrs old male patient complains of inability to pass urine for past 8 hrs. How will you differentiate ► Anticholinergics
V this from anuria? Outline the subsequent management of the case. [5 + 1O] ► Antihypertensives
► Tricyclic antidepressants (TCA)
INABILITY TO PASS URINE FOR PAST 8 HRS IN A 70 YRS OLD MALE
D. Miscellaneous -
This given clinical picture of a 70 yrs old male patient, unable to pass urine for the past 8 hrs, is ,,,, Neurogenic (Injury or disease of spinal cord)
suggestive of "Acute retention of urine". r Following spinal anesthesia

33
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - II 259
258 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

► Smooth muscle cell dysfunction associated with ageing Measures to relieve acute retention of urine :
► Fecal impaction ••1. conservative measures :
,.. Anal pain (following hemorrhoidectomy) • Reassurance
► Intensive postoperative analgesic therapy • Provision of privacy

□ @iiiiii) •
•
Sound of a running tap
Application of warmth and cold alternatively on the lower abdomen
1. Onset and duration of retention of urine - to confirm whether the retention is acute or acute on
chronic • Warm bath
2. History of Lower urinary tract symptoms (LUTS) - ~
Urinary catheterisation : .
Symptoms of voiding : J::l~ancy, ~ w (unimproved on straining), intermittent stream, • Done when conservative measures fail to relieve the retention.
dribbling, sense of incomplete bladder emptying • Done with proper aseptic precautions.
Sy~~s of storage : F~ocy, u__r~e~y. urge incontinence, nocturia, nocturnal enuresis Usually a fine Foley's catheter is introduced. If it fails, a Gibbon's catheter introduction may be
•
3. H/O fever with passage of turbid urine - seen in acute prostatitis attempted.
• Following catheterisation -
4. H/O fever with severe unremitting perinea! pain - seen in prostatic abscess
► Volume of urine drained is to be recorded.
5. H/O hematuria -: seen in BPH, prostate CA, bladder CA, urethral calculus, urethral tumor, ► Re-examination of abdomen to exclude other pathology (rupture of aortic aneurysm,
rupture of urethra
diverticulitis etc)
6. H/O trauma to pelvis, urethral instrumentation - seen in urethral stricture
7. Any H/O operatio[Lin perianal region 3. Suprapubic cystostomy: . .
• Done when catheterisation fails to relieve the retention or when cathetensat1on could not be
8. H/O weakness of limbs - seen in neurologic causes
done.
9. Any H/O spinal anesthesia
• It can be done by -
10. H/O drug intake - anticholinergics, antihypertensives, TCA a) Placement of commercially available Cystofix catheter using large bo~e needle
11. H/O systemic symptoms of underlying malignancy (recent significant weight loss, anorexia, b) Placement of Lawrence Add-a-Gath catheter using plastic suprapub1c trocar and
asthenia, bone pain etc) - seen in Prostate CA, bladder CA cannula
□ Clinical examination : c) Placement of Foley's catheter under direct vision through a small incision using local
anaesthetic
A. General survey - To look for:
• It is the procedure of choice in acute retention of u.rine due to traumatic rupture of urethra.
► Pallor - seen in malignancy (prostate CA, bladder CA)
► Temperature - elevated in acute prostatitis, prostate abscess 111. Special Investigations for Definitive Diagnosis of the cause :
► Dehydration A. For evaluation of prostate -
► Hypertension 1. Serum Prostate specific antigen (PSA) level (Normal = < 4ng/mL)
► Features of uraemia (e.g. hemorrhagic spots) 2. Serum acid phosphatase enzyme
► Perianal sensation - to exclude neurologic cause 3. International Prostate Symptom Score (IPSS)
B. Abdominal examination : 4. Uroflowmetry :
► Lump in abdomen - distended bladder ► Normal voided volume - > 150mL
► Tenderness at renal angle, hypogastrium ► Normal Maximum flow - > 10mUsec
C. Examination of external genitalia : ► Normal average flow - <10mUsec
► To exclude phimosis, meatal stenosis 5. USG of KUB region - Post Void Residual
► Palpation of urethra - to exclude urethral calculus, urethral tumor 6. Urodynamic study - voiding pressure, residual volume
D. PIR examination : 7. Transrectal USG - To assess the size of prostate
, Enlarged, smooth prostate with free overlying rectal mucosa - seen in BPH B. For evaluation of bladder and urethra -
►
" - seen in prostate CA
Hard, irregular prostate with fixed overlying rectal mucosa 1. Micturating cystourethrography (MCU) - to diagnose urethral stricture
► Tender prostate - seen in acute prostatitis, prostatic abscess 2. Cystoscopy - for direct visualisation of bladder wall (to diagnose bladder CA)
Investigations required for a definitive diagnosis of the cause of acute retention of urine are to be done 3. Cystography - a component of video-urodynamic assessment
only after relief of acute retention.
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- II 261
260 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Adverse effects -
IV. Definitive Treatment According to the cause :
•
a) Floppy iris syndrome
A. BPH- b) Postural hypo tension
0 /PSS: c) Retrograde/ dry ejaculation
• International Prostate Symptom Score I American Urologic Association Score d) Flushing
• 7 questions regarding symptoms in the past month
2_ 5 alpha reductase inhibitors - DHT
• (1) Incomplete emptying (2) Frquency (3) lntermittency (4) Urgency (5) Weak stream (6) • Act on static component - Inhibit conversion of testosterone to
Straining (7) Nocturia
• Maximum score - 7*5== 35
• Effective in palpable ePiarged prostate
• Drugs used -
• Mild symptoms - Score Less than or equal to 7 ,- Finasteride - 5mg daily for 6-8 months
• Moderate symptoms - Score 8- 19 ,- Dutasteride - 0.5 mg daily
• Severe symptoms - Score 20-35
3, Anticholinergics -
□ Medical treatment : , Drugs used :
',- Tolterodine - 2-4 mg
,- Solifenacin - 5-10 mg
IPSS•More than or equal to 8
► Darifenacin - 7.5-15 mg
Patient chooses non-invasive therapy
4. Phosphodiesterase 5 inhibitors -
• Drugs used :
Prostate < 30 g Prostate > 30 g ► Sildenafil
PSA < 15ng/mL PSA > 15ng/mL ,- Tadalafil
,- Vardenafil
Start Alpha blocker Alpha blocker + 5 alpha reductase
□ Surgical treatment :
inhibitor
• Indications of surgery -
- - - ; if No response - 1) Prostatism (frequency, dysuria, urgency)
For better responce-Add
Surgery 2) Acute retention of urine
Anticholinergic
3) Refractory/ chronic urinary retention with residual urine >200mL
4) Recurrent UT!
If erectile dysfunction - Add
5) Recurrent hematuria
Phosphodiesterase 5 inhibitor
6) Bladder stone
7) Bladder diverticula
If No response -
8) Hydroureter, Hydronephrosis
Surgery
• Minimal Invasive Therapy -
-,.. Transurethral resection of prostate (TURP)
1. Alpha 1 adrenergic blockers - * Most common and popular method as quicker recovery and early discharge are
• Act on dynamic component - Inhibit contraction of smooth muscle of prostate possible
• Reduce bladder neck resistance thereby improving urine flow * No suprapubic incision is needed
• Short acting drugs - Prazosin, lndoramin * Done using resectoscope with high frequency diathermy current
• Long acting drugs - Terazosin, Doxazosin * Continuous postoperative irrigation with glycine solution is needed for 72 hours
• Selective Alpha 1A receptor blocker - ► Holmium LASER enucleation of prostate (HOLEP)
► Tamsulosin - 0.4-0.8 mg daily for 12 weeks ,. Trans urethral needle ablation (TUNA) using high frequency radiowaves
, Alfuzosin - 10mg daily ',- Trans urethral vaporisation (TUVP)
► Silozosin - 4-8mg daily ► Trans urethral Microwave therapy (TUMT)
• Selective Alpha 1D receptor blocker - ► Trans urethral incision of prostate (TUIP)
Naftodipil improves nocturia (25-75 mg daily)
262 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- II 263

► Trans urethral balloon dilatation of prostate c. Urethral stricture -

, Prosthetic stents (lntraurethral / extraurethral) 1. Intermittent urethral dilatation
► High intensity ultrasound energy therapy 'r Gradual dilatation, initially with thin dilators, later with dilators of increasing thickness,
► Water induced thermotherapy in OT under proper aseptic precautions
2. Visual internal cystoscopic urethrotomy/ stricturotomy
• Surgery -
► Using cystoscope, stricture is visualised and fibrous tissue is completely cut at 12 o'
1) Millin's retropubic prostatectomy
clock position until it bleeds.
* Not commonly practiced
► Then Foley's carheter is passed and retained in position for 48 hrs.
* Done without opening of bladder
3. External urethrotomy
2) Young's perinea! open prostatectomy
4. Urethroplasty
3) Freyer's suprapubic transvesical open prostatectomy
► Stricture is excised.
* It was the procedure of choice for enlarged prostate,_before the advent of TURP
► Urethra is reconstructed using prepuceal or scrotal skin.
* Indication : Bladder pathology + Large median lobe
• Complications of surgical procedures - D. Bladder CA -
► Water intoxication with congestive cardiac failure - TURP syndrome □ For noninvasive bladder tumor:
-;,., Retrograde ejaculation - 65% 1. Endoscopic resection of bladder tumor
► Recurrent late UTI - 20% 2. Helmstein balloon degeneration and cystoscopic resection-
► Need for re-TURP/ Surgery in 10 years - 15% ► Done for large papillary tumor
',- Failure/ Recurrence of symptoms - 10%
',- Severe sepsis - 6%
Balloon is passed ~ pressure necrosis remaining part of the
► Erectile dysfunction - 5% balloon is inflated I-+ of the summit of the ~ tumor is resected
into urinary bladder
► Postoperative hematuria tumor through cystoscopy
;- Perforation of bladder or prostatic capsule

B. Prostate CA - 3. lntravesical chemotherapy :

► Used especially for carcinoma in situ
1. Wait and watch policy is ideally advocated in an elderly male (more than or equal to 70 yrs of
age) with early carcinoma. ► BCG is mostly used.
2. Radical prostatectomy (removal of prostate, seminal vesicle, distal sphincter with reconstruction ► Dose - 120 mg of BCG in 150 ml of normal saline weekly for six weeks
of urethra) : ► NE - BCG provocation (fever, joint pain, granulomatous prostatitis, disseminated
► Done in early disease (T1 a or T1 b) tuberculosis)
► Indications : (i) Life expectancy > 1O yrs (ii) PSA < 20 mmol/mL (iii) Bone scan negative ► Contraindication - hematuria
3. Bilateral subcapsular orchidectomy- can be done to reduce testosterone level :.- Mitomycin C, adriamycin, epirubicin, metrotrexate, thiotepa can also be used.
4. Transurethral resection of prostate (TURP) 4. Systemic chemotherapy :
5. Radical radiotherapy : ► Cisplatin, Adriamycin, 5-FU and mitomycin are used.
► Given for early carcinoma □ For invasive bladder tumor:
► Both interstitial and external radiation can be used 1. Radiotherapy
6. Pelvic lymph node dissection with 1125 radiation seeds implantation a) Interstitial radiotherapy
7. External radiotherapy/ Strontium 89 isotope radiotherapy- for bone secondaries ► Often curative.
8. Drugs: ► Implantation of radioactive gold grains (Au 198, half-life = 2.5 days) / radioactive
► Phosphorylated diethylstilbestrol (Honovan) tantalum wires (Ta 182, half-life= 4 months) is done.
► LHRH agonists (Leuprolide, Goserelin) b} Radical deep external beam radiotherapy
► Androgen receptor blocker (Flutamide, Bicalutamide) ► Dose-45 Gy
► Cyproterone acetate ► Cobalt 60 is used
9. TURP + Bilateral orchidectomy + External radiotherapy (for bone secondaries) + Flutamide/ ► Advantage - Normal act of micturition can be maintained
Honovan - commonly used method ► Complication - Thimble/Systolic bladder
 264 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- II 265

2. Surgery ureter cause :

•Indications - 1. Ureteric stone
► Multiple tumors 2. Tumor
,- Recurrent tumors c. Bladder cause :
, Sessile tumors 1. Cystitis
► Poorly differentiated tumors 2. Tumor - Papilloma, Urothelial cell CA
► Adenocarcinoma
3. Tuberculosis
► Squamous cell carcinoma
4. Vesical calculus
► Carcinoma in situ
5. Urinary Bilharziasis
• Modalities -
a) Partial cystectomy:
D. urethra cause :
* Indication - single tumor, tumor confined to fundus'of bladder 1. Trauma
* 2.5 cm margin of clearance is maintained 2. Stone
* Surgery is followed by external beam radiotherapy and chemotherapy. 3. Tumor
b) Radical cystectomy - E. Prostate cause :
* Removal of urinary bladder, urethra, paravesical tissues, pelvic lymph nodes is 1. Benign prostatic hyperplasia (BPH)
done. Hysterectomy with removal of part of vagina is done in females. 2. Prostate CA
* Urinary diversion is done by ureterosigmoidostomy or continent ilea! conduit or
rectal urinary pouch. HEMATURIA DUE TO CARCINOMA OF URINARY BLADDER
3. Chemotherapy
a) lntravesical chemotherapy - □ Diagnosis :
► Done by BCG, mitomycin C, adriamycin, interferons. A. History -
b) Systemic chemotherapy - 1. Evaluation of gross hematuria :
► Regimen for adjuvant therapy - (i) Cisplatin, adriamycin, mitomycin, vinblastin ► Colour of urine - bright red
(ii) Methotrexate, vinblastin, adriamycin, cisplatin (MVAC) ► Pattern of hematuria - Hematuria in the latter part of voiding
► Neoadjuvant chemotherapy - Cisplatin is used (improves survival by 7%) 2. Associated features :
► Hematuria is painless
03. What are the common surgical causes of hematuria? Discuss the diagnosis and management of ► Symptoms suggestive of Lower urinary tract symptoms (LUTS)/ bladder outlet
hematuria due to carcinoma of urinary bladder. [ 4 + 4 + 7) obstruction (Hesitancy, urgency, frequency, poor stream of urine, dribbling,
inadequate emptying)- present
COMMON SURGICAL CAUSES OF HEMATURIA
3. Occupational history :
Hematuria is defined as abnormal presence of RBCs in urine. ► Aniline dye factory workers
It is of 2 types : (1) gross (2) microscopic ( > 5 RBC/hpf). B. General examination -
The common surgical causes of hematuria are as follows - • Pallor-present
A. Kidney cause : C. Systemic examination
1. Tumors - Wilm's tumor, Renal cell carcinoma (RCC) D. Investigations -
2. Trauma - Stab/ Blunt injury 1. Urine examination -
3. Renal vascular disorders - Renal vein thrombosis, Renal artery embolism, Renal aneurysm, a) Routine examination :
Arterio-venous fistula * Specific gravity
4. Infections - Pyelonephritis, Tubulo-interstitial nephritis * Protein
5. Anatomical abnormalities - Polycystic kidney disease, Multicystic renal disease, * Sugar
Hydronephrosis
* Blood
6. Kidney stone
* Ketone
7. Kidney TB

34

.I
 266 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- II 267

b)Microscopic examination : * Implantation of radioactive gold grains (Au 198, half-life = 2.5 days)/ radioactive
* Phase contrast microscopy - to detect dysmorphic RBC tantalum wires (Ta 182, half-life= 4 months) is done.
* Exfoliative cytology (by Papanicolau staining) - for malignant cells b) Radical deep external beam radiotherapy
2. Blood profiles - * Dose - 45 Gy
a) Complete hemogram * Cobalt 60 is used
b) Serum urea, creatinine * Advantage - Normal act of micturition can be maintained
c) Serum electrolytes * Complication - Thimble/Systolic bladder
3. Radiological investigations - 2. Surgery
a) Intravenous urethrography (IVU) : Indications -
* Irregular Filling defects in bladder * Multiple tumors
* Hydronephrosis (often) •
Recurrent tumors
b) USG of abdomen: Sessile tumors
*
* To see bladder wall, pelvis, lymph nodes, liver Poorly differentiated tumors
*
c) CT scan - to evaluate the extension * Adenocarcinoma
d) MRI - to see invasion into pelvic wall * Squamous cell carcinoma
e) Cystoscopy: * Carcinoma in situ
* may be followed by brush biopsy. Modalities -
* bladder tumor is visualised. a) Partial cystectomy :
f) Retrograde pyelography ••• Indication - single tumor, tumor confined to fundus of bladder
4. Bimanual examination under General anesthesia - for staging of the tumor ❖ 2.5 cm margin of clearance is maintained

□ Management : ❖ Surgery is followed by external beam radiotherapy and chemotherapy.

A. For noninvasive bladder tumor b) Radical cystectomy:
❖ Removal of urinary bladder, urethra, paravesical tissues, pelvic lymph nodes
1. Endoscopic resection of bladder tumor
is done. Hysterectomy with removal of part of vagina is done in females.
2. Helmstein balloon degeneration and cystoscopic resection -
❖ Urinary diversion is done by ureterosigmoidostomy or continent ileal conduit
,- Done for large papillary tumor
or rectal urinary pouch.
3. Chemotherapy
pressure necrosis remaining part of the
Balloon is passed a)
lntravesical chemotherapy -
f-+ balloon is inflated ~ of the summit of the ~ tumor is resected
into urinary bladder * Done by BCG, mitomycin C, adriamycin, interferons.
tumor through cystoscopy
b) Systemic chemotherapy -
3. lntravesical chemotherapy - * Regimen for adjuvant therapy : (i) Cisplatin, adriamycin, mitomycin, vinblastin
► Used especially for carcinoma in situ (ii) Methotrexate, vinblastin, adriamycin, cisplatin (MVAC)
► BCG is mostly used. _ : ~- * Neoadjuvant chemotherapy : Cisplatin is used (improves survival by 7%)
,
►
Dose - 120 mg of BCG in 150 ml of normal saline weekly for six weeks
A/E - BCG provocation (fever, joint pain, granulomatous prostatitis, disseminated
LOCA 41f';rs old female presented with a 4 cm lump in Right breast. Discuss the DID and diagnostic
approach to the condition. [7 + 8]
tuberculosis)
► Contraindication - hematuria BREAST LUMP IN A 48 YEARS OLD FEMALE
)f}
',, Mitomycin C, adriamycin, epirubicin, metrotrexate, thiotepa can also be used. Causes:
4. Systemic chemotherapy - The probable causes of a breast lump (4 cm in size) in a female of this age group are :
,- Cisplatin, Adriamycin, 5-FU and mitomycin are used. 1. Ductal carcinoma
B. For invasive bladder tumor 2. Lobular carcinoma
1. Radiotherapy 3. Phyllodes tumor
a) Interstitial radiotherapy 4. Fibroadenoma
* Often curative. 5. Sclerosing adenosis / Aberration of normal development and involution (ANDI)
268 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - II 269

6. Traumatic fat necrosis

7. lntramammary mastitis/ Non-lactational abscess of breast EXAMINATION OF BREAST
8. Antibioma (a) Inspection :
9. Duct ectasia • Peau d' orange, dimpling of skin, retraction of nipple, ulceration, fungation, satellite nodules
1O. Tuberculosis of the breast - Breast carcinoma
11. Breast cyst • Stretched red breast skin with dilated veins and necrosis over the summit of the swelling
- Phyllodes tumor
Keeping the above mentioned differential diagnoses in mind, the case is to be approached through
proper history taking, clinical examination and relevant investigations. • Diffuse redness over breast - Non-lactational abscess of breast
Slit like retraction of nipple - Duct ectasia
History:
• Peau d' orange, sinus, discharge, bluish appearance of surrounding skin - Tuberculosis of
1. Onset, duration and progression of the lump : the breast
► Rapid growth to attain a large size - Phyllodes tumor
(b) Palpation :
► Non-progressive non-regressive lump - Traumatic fat necrosis
Smooth, firm, non-tender, well localised mass that moves freely within the breast -
2. Whether painful or painless : Fibroadenoma, Sclerosing adenosis
► Painful lump - Duct ectasia, Non-lactational abscess of breast Smooth, soft, non-tender, fluctuant mass - Phyllodes tumor, Breast cyst
► Mastalgia - may be present in Sclerosing adenosis Smooth, hard, non-tender mass adherent to breast tissue - Traumatic fat necrosis, Antibioma
3. Any swelling in the axil/a or opposite breast :
• Mass with diffuse tenderness, warmness, brawny induration - Non-lactational abscess of
► Axillary lymph node enlargement - Breast carcinoma (Ductal/lobular), Tuberculosis breast
of the breast • lndurated, tender mass under areola - Duct ectasia
► B/L breast lump - Lobular carcinoma, Duct ectasia, Breast cyst • Irregular ill-defined mass with ipsilateral lymph node enlargement - Breast carcinoma,
4. Any history of nipple discharge : Tuberculosis of the breast
► Bloody discharge - Breast carcinoma
C. SYSTEMIC EXAMINATION
► Purulent discharge - Non-lactational abscess of breast
(a) Abdominal examination :
).- Greenish/ creamy paste like discharge - Duct ectasia
•
To look for secondaries in liver, ascites, Krukenberg's tumor, deposits in rectouterine pouch-
5. Associated symptoms :
if present, suggestive of Breast carcinoma
► Weight loss, anorexia, bone pain, chest pain, cough, hemoptysis - Suggestive of
(b) Respiratory system examination :
underlying malignancy (Breast carcinoma)
• Pleural effusion - if present, suggestive of Breast carcinoma
► Abdominal pain, abdominal swelling - Suggestive of distant metastasis (Breast
carcinoma) (c) Musculoskeletal system examination :
► Recurrent cough, hemoptysis - Tuberculosis of the breast • Bony tenderness (in spine, long bones, skull) - if present, suggestive of Breast carcinoma
6. Past history: (d) Cardiovascular system examination
► H/O trauma - Traumatic fat necrosis (e) Nervous system examination
► H/O mastitis treated with antibiotics - Antibioma Investigations:
► H/O use of Hormone replacement therapy (HRT) - Breast carcinoma, Breast cyst I. RADIOLOGICAL IMAGING -
7. Family history:
• First investigation to be done is always a radiological imaging, as :
► H/O breast carcinoma or ovarian carcinoma in first degree relative - Breast carc.inoma
► These are non-invasive investigations.
8. Menstrual history :
► FNAC/ Open biopsy, if done first, may cause hematoma, which will alter the findings on
► Early menarche or late menopause - Breast carcinoma
imaging.
9. Obstetric history:
• Mammography :
► Nulliparity, late first child birth(> 35 years), no breastfeeding - Breast carcinoma
► Done in females > 40 years of age.
Examination : ► Indications -
A GENERALSURVERY 1. To evaluate suspicious breast lump, nipple discharge.
• Pallor - seen in Breast carcinoma 2. To identify multicentricity, to know size and location of the masses.
• Temperature - High grade fever is seen in Non-lactational abscess of breast 3. To screen contralateral breast for additional masses in a patient undergoing definitive
surgery.
270 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- II 271

4. To screen both breasts before any cosmetic surgery. ► Indications -

5. Screening before Breast Conservative Surgery (BCS). 1. Screening of young women and women in high risk group (History of therapeutic radiation
6. Follow-up after BCS / Radiotherapy/ Neo-adjuvant chemotherapy. in age< 30 yrs, Strong family history of breast CA, BRCA 1/2 mutation, Personal history
,... American College of Surgeons (ACS) guidelines - of DCIS/ Invasive breast CA, family history of breast and ovarian CA)
A Woman with average risk of breast CA should undergo regular screening mammography, 2. Suspected Ductal Carcinoma In Situ (MRI is the most sensitive investigation for DCIS)
starting from 45 years age, annually to 54 yrs age, then biennially for as long as the woman ► There is no risk of ionising radiation.
is in good health and has a life-expectancy of at least 1O years. ► IOC for imaging breasts In pregnant female.
► Usual views taken - ► It Is a better modality than other investigations for dense breasts.
1. Medio-lateral-oblique (MLO) view ,- Findings suggestive of malignant lesion -
2. Cranio caudal (CC) view 1. Mass with irregular intensity and spiculations
,- Amount of radiation exposure during mammography - 0.1-0.2 cGy'(this amount of radiation 2. Thickened skin, changes in nipple.
being not enough to cause malignant changes in breast itself)
3. Lymphedema.
:...- Findings suggestive of malignant lesion -
► Disadvantages -
1. Distorted architecture of the breast parenchyma (irregular soft tissue shadow).
1. Costly, not available easily.
2. Micro calcifications (< 5 mm) with spiculations.
2. Not accurate, If done within 9 months of radiotherapy for breast CA.
3. Focal dilatations of ducts. 3. Cannot be done in patients with incompatible metal prosthesis like cardiac pacemaker.
4. Increased number and thickening of Cooper's ligaments.
• BIRADS (Breast Imaging Reporting and Data based Scoring system) -
._.;;;ma
5. Heterogenous, polymorphic, high density opacity with irregular margin/ satellite lesion.
► This is a scoring system based on different investigations.
,- Well localised, smooth, regular shadow - Fibroadenoma, Sclerosing adenosis
► Based on this, advice can be given regarding further investigations and diagnosis.
• USG:
► Purpose - Grade 0 Grade 1 Grade 2
1. To know whether the lesion is solid or cystic.
2. To define size, extent and texture of the lesion. • Inadequate/Incomplete • Normal/Negative • Benign
assessment • Continue annual • Continue annual
, Cystic lesion - Phyllodes tumor, Breast cyst
• As breast tissue is mammography mammography
, Findings suggestive of malignant lesion - dense, mammogram cant
1. Irregular internal echoes. interprete
2. Irregular posterior acoustic shadow. • Needs additional study
3. Irregular margin.
4. Non compressibility.
5. Ratio between anteroposterior to lateral/horizontal dimensions is > 1 .
Grade 3 Grade 4 Grade 5 Grade 6
6. Hypoechoic, more vertical mass.
7. High frequency signals with continuous flow on doppler. . Possible/Probably • Suspicious lump . Highly suggestive
of malignancy
. Biopsy proven
malignancy
benign
, Disadvantage - Lesions < 1 cm may be missed.
• Chance of CA = 1-2%
• Chance of CA = 25-
50% . Chance of CA = • Known carcinoma
,- Can guide FNAC, cheaper, easily available and has no risk of radiation.
• Repeat imaging after . Biopsy recommended
. 75-90%
Biopsy required
• MRI: 3-6 months
► Purpose -
1. To identify multifocal ( >1 foci in one quadrant) and multicentric breast tumor.
II. HISTOPATHOLOGICAU CYTOLOGICAL ANALYSIS
2. To image breasts with breast implants.
3. To detect local recurrence or scar after mastectomy. BREAST BIOPSY
4. To assess axillary metastasis.
□ Types: (See chart on the next page)
5. To assess dermal extension.
272 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - II 273

Biopsy of breast
tissue
I Other relevant Investigations :
1. Triple receptor assessment -
I
a) Estrogen Receptor (ER) study
► Estrogen sensitive cytosolic glycoprotein level > 1O units per gram of tissue is known as
For palpable For non-palpable ER +ve status.
tumor tumor
► ER +ve status indicates good response to hormone therapy and good prognosis.
~
I
I J I I b) Progesterone receptor (PR) study
Core needle Frozen Excisional Minimally invasive c) HER 2/Neu receptor study
FNAC section
biopsy biopsy breast biopsy ► Human epidermal growth receptor 2 Neu oncogene, also known as cErb B2, is a tyrosine
biopsy
kinase receptor.
I. I I
► Positivity indicates high grade tumor and poor prognosis.
Stereotactic Ultrasound I Needle
Mammographic locaoised 2. Cytological and microbiological analysis of nipple discharge
MRI guided
excisional ► Sample is obtained through ductal lavage.
biopsy (NLEB)
►Can diagnose Breast carcinoma, Non-lactational abscess of breast, Duct ectasia.
3. Tumor markers
□ FNAC: a) CA 15/3 (Normal serum value < 40 U/mL)
• Fine needle aspiration cytology is the first, simplest and least inva.sive technique for obtaining a b) CA 27
cell diagnosis in breast carcinoma c) CA 29
• Mininum 6 aspirations are done using 21-30 G needle 4. Miscellaneous -
• Giemsa, hematoxylin and eosin, papanicolaou stains used a) Chest X-ray/ CT thorax :
• It can be repeated 2 times
► Pleural effusion - suggestive of Breast carcinoma
• Advantages : (1) least painful (2) cheap (3) reliable (4) can be done on Out patient basis (5) no
► Pulmonary cavitation - suggestive of pulmonary tuberculosis (seen in Tuberculosis of
evidence of malignant deposits along FNAC track
breast)
• Disadvantages : (1) Receptor study can not be done; (2) lnva.sive cancer can not be differentiated
b) USG/ CT abdomen
from in situ disease; (3) False negative results do occur, mainly due to sampling
errors ► Secondaries in liver, ascites, Krukenberg's tumor - seen in Breast carcinoma
• Chalky fluid with fat globules : seen in Traumatic fat necrosis c) X-ray / MRI spine and pelvis

I
► Osteolytic secondaries in bone - seen in Breast carcinoma
□ Core needle biopsy :
d) Metabolic panel - Increased Alkaline phosphatase along with increased serum Calcium
• It is the preferred method for diagnosis of palpable or non-palpable breast abnormalities level and bone pain is an indication of bone scan ..
• Permits analysis of breast tissue architecture to give clear histological evidence and definitive e) Radioisotope bone scan - To look for secondaries in bone in advanced cases. A positive

•
preoperative diagnosis
Can confirm DCIS and invasive lesion
bone scan will confirm the diagnosis of Metastatic carcinoma of breast, not Locally Advanced I
• Can comment about grade and receptor status of tumor
Breast Carcinoma.
I
f) PET scan- To look for bone, soft tissue or visceral metastases. i
□ Frozen section biopsy: g) LFT
• Nol usually practiced now-a-days h) Complete hemogram
• Indication : when FNAC fails even after 2 trials or is negative
• Disadvantage : Shows 20% false negative results
□ Excisional biopsy:
• Also known as open biopsy
• It is the best and definitive investigation for breast carcinoma
• Incision is planned in such a way that it will be included in the eventual mastectomy incision at a
later date
• Should give no false negative and no false positive results

35
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 275

SEGMENT- C
CHEMICAL -
SOLVED SHORT NOTES OF FINAL MBBS (a) Alcohols (ethyl alcohol, isopropyl alcohol)
Paper- I (b) Aldehydes (formaldehyde, glutaraldehyde)
(c) Phenols
FINAL MB PAPER - I SHORT QUESTIONS 2008 (d) Gases
(e) Halogens (bleaching powder, EUSOL)
Q.1 : Method of sterilisation
(f) Dyes
(g) Salts
METHOD OF STERILISATION (h) Surface active agents
□ ~hat is s~erilis~tion_ : Process by which an article, surface or medium is made free of Sterilisation of various surgical instruments :
microorganisms either in the vegetative or spore form all (a) Autoclave - all theatre appliances, syringes, clothes and bed sheets of burn patients
□ Types: (b) 2% Glutaraldehyde, Concentrated Lysol - sharp instruments, endoscopes
(c) Gamma radiation - syringes, disposable articles
(A) PHYSICAL -
(d) Ethylene oxide - heart-lung machine
(a) Sunlight
(b) Heat (e) UV radiation - OT
(f) Filtration - sera and biological materials
1) Dry heat -
i) Red heat (g) Formaldehyde - OT
ii) Flaming (h) Incineration - soiled dressing
iii) Incineration (i) Lysol - excreta, ward
iv) Hot air oven 0) EUSOL (Edinburgh University Solution) - to remove slough from wounds
2) Moist heat - (k) Spirit - before injection
i) < 100 degree Celcius - (I) lodophores - cleaning the skin before surgery
• Pasteurisation (Holder method, Flash method) (m) Savlon - hand wash
• lnspissation (n) Candy's lotion (0.1 % potassium permanganate solution) - bladder wash
• Vaccine bath
• Water bath
• Low temperature steam formaldehyde (LTSF) Q.2: Biochemical abnormality in pyloric stenosis
ii) At 100 degree Celcius -
• Boiling BIOCHEMICAL ABNORMALITY IN PYLORIC STENOSIS
• Tyndallisation
• Steam steriliser
□ What is pyloric stenosis : Chronic duodenal ulcer undergoes scarring and cicatrisation leading to
iii) > 100 degree Celcius -
• Autoclave - total obstruction of pylorus
121 degree Celcius □ Biochemical changes: Hypochloraemic hypokalaemic metabolic alkalosis with hypocalcaemia and
15 lb/metre square paradoxical aciduria (For details see Sec-1 Segment-A Paper-I 2013 Supp. 0.1, Page No. 62).
15 minutes for rubber drain, etc.
30 minutes for blunt metallic instruments
(c) Filtration 0.3 : Universal precaution
(1) Candle filter
(2) Asbestos filter UNIVERSAL PRECAUTION
(3) Sintered glass filter
(4) Membrane filter □ What is it: Precautionary measures taken by health care personnel while handling HIV patients
(5) Air filter
(6) Syringe filter
□ Why universal : As they are for everyone and to be followed everytime while handling such patients
(d) Radiation □ Why necessary :
(1) Ionizing (gamma ray, X-Ray) (a) To prevent cross infection
(2) Non-ionizing (UV ray) (b) To safeguard health care personnel who are at risk
(e) Ultrasonic and sonic vibrations (c) To avoid infection through hospital wastes

274
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 277
276 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

(d) lntraductal papilloma - Microdochectomy

□ Precautions :
(e) Hyperprolactinaemia -_Bromocriptine 2.5 !!!.9_at bedtime for 3 months
• He~lth care personnel must wear -
(f) Paget's disease - ~vlastectomy/iumpectomy + radiotherapy and and/or chemotherapy
1) double gloves
2) proper spectacles (g) Carcinoma - Mastectom 1/ + hormone therapy
3) head mask
4) theatre shoes Paget's
5) aprons Discharge /A disease
• Minimal parenteral injections frnm (:
Skin Fibrocystadenosis

I
• Walls and floor cleaned properly with soap and water surface i ·"'-
diseases
• Separate operation theatre for operations of such patients
• People inside operation theatre to wear disposable gown Serous Duct ectasia
• Operation theatre fumigated after surgery
• All equipments disinfected with glutaraldehyde
Carcinoma
• Contaminated gloves, clothing incinerated
• Spilled body fluids diluted with glutaraldehyde
Single
• Care in handling sharp objects duct
• Cuts, abrasions covered with waterproof dressing CAUSES
• Shaving to be avoided lntraductal

I
papi!loma
• Suction bottle half filled with glutaraldehyde
• No mouth pipetting to be done Blood lntraductal
• Resuscitation bag used, mouth-to-mouth breathing not preferred stained carcinoma
• Hands to be washed with soap before and after patient care
Duct ectasia

Discharge Duct ectasia

NIPPLE DISCHARGE
from duct
□ Causes : See Chart on next page Blood
Fibrocystadenosis
stained
□ lnvetigations:
(a) Discharge study lntraductal carcinoma
(b) FNAC
(c) USG (if< 40 years)
{d) Mammography (if> 40 years) Infection,
Purulent
abscess
□ Treatment :
{a) Duct ectasia - Cone excision of involved major ducts + antibiotics Duct
Multiple Greenish
(b) Infections -_Antibiotics+ drainage if abscess ectasia
ducts
(c) FibrocystadenosTs- -
1) Reassurance Serous
2) Oil of evening primrose capsules - 4 months (causes
3) Gamolenic acid same as in
single duct)
4) LHRH agonist
5) Tamoxifen
Lactation
6) Danazol
7) Vitamin E, B5
Milky Hypothyroidism
8) NSAIDs
9) Bromocriptine Hyperprolactinaemia
10) Diuretics
11) In severe - subc~taneous mastect?._my with prosthesis placement
 278 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 279

► Bleeding and discharge sometimes

2008 Supplementary
► On examination - i) Ulcer may be visible at anal margin
Q. 1 : Fibroadenoma of breast ii) Tag of skin (sentinel piles) visible in case of chronic fissure.
A : See Section - 1, Segment D, Os. 48 (Page No. 506). [Due to severe pain, proctoscopy and per-rectal examination is avoided]

Q.2: Meckel's diverticulum □ Treatment :

A) Conservative - ► Adequate fluid intake
A : See Section - 1, Segment D, Os. 45 (Page No. 503)
► Stool softeners, purgatives, bulk forming agents
Q.3: Keloid ► ~Hgt1 fibre diet
/ A: See Section - 1, Segment C, Paper II, 2013 Supp. Os. 9 (Page No. 426) ► Local anaesthetic agents, vasodilator ointments (Nifedipine ointment)
, //,.,Q;;{~ Anal Fissure ► Sitz bath
I// ► Oral calcium channel blockers
. ("// Ans :
ANAL FISSURE ► Regular anal dilatation
► Lord's dilatation done under GA in acute cases
□ Synonym : Fissure-in-ano
B) Surgical - ► Dorsal fissurectomy with sphincterotomy
□ What is it: Vertical tear or ulcer of the lower anal canal
► Lateral anal sphincterotomy
□ Site:
► Midline 2009
► Posteriorly (more in males) or anteriorly (more in females) Q.1 : Arteriovenous fistula
□ Extent : From anal verge till below the dentate line
ARTERIOVENOUS FISTULA
□ Depth : Superficial lesion
□ Types: □ What is it: Communication between arterial and venous systems other than the capillary bed
► Acute - recent onset; associated with severe sphincter spasm; without oedema or inflammatio □ Classification :
► Chronic - long duration; inflammed indurated margin with scar tissue; may be associate (a) Congenital
with sentinel pile. (b) Acquired -
□ Etiology: 1) Traumatic
► Constipation - hard stool stretches mucosa at posterior aspect of anal verge causing posterio 2) Surgical
tear 3) Following infection
► Anterior tear in female is due to poor support to pelvic floor 4) Following aneurysm formation
□ Causes: 5) Neoplasia
6) Therapeutic - for renal dialysis
► Hard stool
► Increased sphincter tone □ Pathophysiology:
► Diarrhoea • Rapid and turbulent local flow ➔ thrill, bruit, murmur
► Local ischaemia • High SBP, Venous return, Cardiac output, Pulse pressure
► Haemorrhoidectomy • Low DBP
► Sexually transmitted disease
► Ulcerative colitis, Crohn's disease □. Sites:
► Tuberculosis (a) Congenital -
1) limb
□ Clinical features :
2) lung
► H/0 constipation and straining at stool 3) Circle of Willis
► Pain in anal region - i) During defaecation 4) bowel, liver
ii) Severe in intensity (more in acute, less in chronic) (b) Acquired -
iii) Burning in nature 1) wrist
iv) Persists for a long time even after defaecation 2) brachia! region
(Pain is due to the fact that fissure is situated below dentate line which develops from 3) femoral region
ectodermal cloaca, and is supplied by pudenda! nerve)
280 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 281

□ Clinical features : IJ What is it: Low grade, locally invasive carcinoma, arising from basal layer of skin or adnexal basal
(a) Congenital - layer of hair follicle or musculocutaneous junction
1) limb - warm, lengthened, increased girth □ Speciality: Commonest _1J1alignant skin tum.sir
2) continuous thrill and machinery murmur all over lesion □ Predisposing factors :
3) dilated arterialised varicose veins seen (1) _UY.Jjgbt-
4) bone erosion (2) .MaJ.Qs » females
(b} Acquired - (3) .Y{Mas » blacks
At level of fistula -
1) □ Types:
Formation of aneurysmal sac between artery and vein at site of fistula - warm, pulsatile, (a) Clinicopathological -
smooth, soft, compressible swelling with continuous thrill and machinery murmur (1) Superficial type - small buds of tumor masses
2) Below level of fistula - (2) Morpheic type - dense stroma with basal cells and Type IV collagen
(i) Distal part ischaemic __J3} Fibroepithelioma type - elongated cords of basaloid cells with meshwork
(ii) Varicose veins 1b) Morphological -
3) Proximal to fistula - (1) E!9:§l§.guamous - behaves like sec, spreads into lymph nodes
Hyperdynamic circulation causes cardiac failure (2) g~/nodular
(c) Nicoladoni/Branham's sign - if feeding artery compressed, hyperdynamic flow diminishes (3) Multiple - often associated with Basal cell naevus syndrome (Gorlin syndrome), medullo-
immediately leading to fall of pulse rate, pulse vlume and size of lesion bfastorria and bifid ribs
(4) Nodular
□ Complications :
(5) . f'.!9.DJ.enied (mimics melanoma)
(a) Hemorrhage (6) Ulcerative
(b) Thrombosis (7) Geographical/Field fire or Forest fire BCC
(c) Cardiac failure
□ Clinical features :
□ Investigations: (a) Age - middle aged and elderly
(a) Angiography (b) Site - face (commonly above the line drawn between angle of mouth and ear lobule)
(b) USG (c) Ulcer with following features -
(c) Doppler 1) Non-tender
(d) CT scan 2) Dry
(e) MRI 3) Slowly growing
4) Non-mobile
□ Treatment :
5) Central scab
(a) Congenital - 6) Raised and beaded edge
1) Avoid injury
□ High risk BCC :
2) Feeding artery ligation
3) Sclerosant therapy (a) Size > 2 cm
4) Therapeutic embolisation (b) Near eye/nose/ear
5) Amputation when required (c) Ill defined margin
(d) Recurrent
(b) Acquired -
(e) lmmunosupressed
1) Complete excision if possible
2) Quadruple ligation - ligation of artery and venous components above and below the level of □ Investigations:
fistula (a) Edge biopsy
3) Feeding artery ligation (b) X-Ray of the part
(c) CT scan
□ Treatment :
(a) _Ra_diotherapy_:- all cases are radiosensitive
BASAL CELL CARCINOMA The contraindications are -
1) lesion in ear
□ Synonyms: 2) lesion close to lacrimal canaliculi
(a) Rodent's ulcer 3) if bone erosion has occurred
(b) Tear cancer

36
 282 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 283

(b) Surgery - (c) Functionally superior cells

'iTTridk:ations - contraindications of radiotherapy + recurrent ulcer (d) Lower risk of infectious diseases
2) Principle - wide excision with skin grafting (e) Normothermic
3) Methods -
(f) High levels of 2,3-DPG
(i) Laser surgery
(ii) Cryosurgery □ Disadvantages :
(iii) MOHS (Microscopically Oriented Histographic Surgery) (a) Depletion of plasma and platelets
(b) Coagulopathy
Q.3 : Pre-operative preparation of a patient of pyloric stenosis
□ Substances washed out:
PRE-OPERATIVE PREPARATION IN PYLORIC STENOSIS (a) Plasma
(b) Platelets
1) Correction of dehydration - i.v normal saline ( not Ringer lactate) (c) WBC
2) Correction of electrolyte imbalance - i.v normal saline. Once urine output becomes normal, (d) Anticoagulant solution
potassium supplemented □ Contraindications :
3) Correction of hypoproteinemia - (a) Bacterial comtamination
(a) Oral high protein diet (b) Malignancy
(b) Amino acid
(c) Fresh frozen plasma 2009 Supplementary
(d) Human albumin transfusion
4) Correction of anaemia - by blood transfusion Q.1 : Intermittent claudication
5) Correction of hypocalcaemia - Calcium gluconate 10% 10 ml/kg i.v A : See Section 1, Segment D, Os. 84 (Page No. 540)
6) Gastric lavage -
Q.2: OPS/
Done before each feed for 4-5 days prior to surgery.
Its advantages - ,Ans::~- OPSI
(a) Removes food residues in stomach
(b) Reduces mucosa! edema
(c) Recovery of gastric tonicity □ Full form : 0~~~..!!~Lr:!11!lfl Po~!_§~11_ectc:i1T1y l11Jection
□ Incidence: 4%
These measures are required because the following biochemical changes occur in a patient of
pyloric stenosis. (Refer MB 2008 Short note above) □ Timing: Anytim 7 aft~J_splenectomx bL:1!_'!12.~~-C?_om_1212.~in 1st t~9_years
□ Susceptibleiiit~ctive organisms: ► Streptococcus pneumoniae
!~t,ansfusfon ► Neisseria meningitidis
\ ► Haemophilus influenzae
// AUTOTRANSFUSION
► Babesia microti
□ What is it: Process where a patient receives his own blood for transfusion
□ Cause : Post-splenectomy there is reduced lgM, properdin, tuftin & other antibodies in body which
□ Collection time : Blood can be collected before surgery or during and after the surgery
disables phagocytosis of encapsulated bacteria.
□ Device used for collection : Cell Saver
□ Increased risk in : Those who have hemolytic diseases or are receiving radio/chemotherapy
□ Indications : Surgeries with significant blood loss -
□ Mortality rate : ~ ?
(a) Aneurysm
(b) Total joint replacement □ Clinical presentation :
(c) Spinal surgeries ► Prodromal phase begins with fever, chills, sore throat, rhinitis
(d) Cardiac surgeries Respiratory distress
►
□ Medical indications : Hypotension, shock
►
(a) Rare blood group DIC
►
(b) Restricted homologous blood supply Coma, death
(c) Risk of infectious disease transmission ►
□ Prevention :
□ Advantages :
► Lifel~nJJ_~~j~ction Benzathine Penicillin 12-24 lac units
(a) pH relatively normal
► Vaccine yrophylaxis
(b) Quickly available
284 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 285

□ Recommendations
',- Level 3: Supported by available data, but scientific evidence is lacking. Generally supported
, Level 1 by Class 111 data. Useful for educational purposes and in guiding future clinical research.
• None □ Treatment :
, Level 2 ,... Antibiotics - Ceftazidime, Cefoperazone, Amikacin
• Non-elective splenectomy patients should be vaccinated on or after postoperative ,... Blood transfusion
day 14.
',- Supportive management in ICU
• Asplenic patients should be revaccinated at the appropriate time interval for each
Y lmmunoglobulin transfusion
vaccine.
► Level 3 Q.3 : Oesophageal varices
• Elective splenectomy patients should be vaccinated at least 14 days prior to the Ans:
operation. OESOPHAGEAL VARICES
• Asplenic or immunocompromised patients (with an intact, but nonfunctional spleen) □ What is it: Dilated, tortuous sub-mucosa! veins situated in lower-third of oesophagu..§:
should be vaccinated as soon as the diagnosis is made.
□ Pathogenesis: ~uperficial veins lining lower third of oesophageal mucosa drain into left gastric vein,
• Pediatric vaccination should be performed according to the recommended pediatric
dosage and vaccine types with special consideration made for children less than 2 whic.h. finally drains into portal vein. In situations where venous pressure in portal system increases,
years of age. blood flow is redirected from liver to areas with lower portal pressure, leading to collateral circulation
in lower esophagus and certain other sites. The superficial veins of these areas become distended,
• When adult vaccination is indicated, the following vaccinations should be thin-walled; leading to formation of varices.
administered :
□ Causes : Portal hypertension due to any cause - mainly cirrhosis
( 1) STREPTOCOCCUS PNEUMONIAE
□ Factors causing variceal bleed:
Polyvalent pneumococcal vaccine (Pneumovax 23)
(2) HAEMOPHILUS INFLUENZAE TYPE B ', f:grt~-~~nous pressure
Haemophilus influenzae b vaccine (Hib TITTER) ,... Size ,- of
~c" ;
~-~"
the varix
• • ~•'•~-

(3) NEISSERIA MENINGITIDIS ,... Variceal wall tension

Age 16-55: Meningococcal (groups A, C, Y, W-135) polysaccharide ► Gastr():~~phageal reflux causing ulceratio.n
diphtheria toxoid conjugate vaccine (Menactra) 0 Clinical presentation :
Age > 55 : Meningococcal polysaccharide vaccine (Menomune- ,... Assymptomatic ~ ·
A/C/Y/W-135) Y Variceal rupture presents with~ haematemesis
- melaena
Vaccine Dose Route Revaccination - recurrent bleeding

Polyvalent pneumococcal 0.5mL SC* - shock

Every 6 years
□ Management: See Section 1, Segment A, Paper I, 2010, Qs. 2 (Page No. 24)
Quadravalent meningococcal / diphtheria conjugate 0.5mL IM upper deltoid Every 3-5 yearst
Quadravalent meningococcal polysaccharide 0.5mL SC* Every 3-5 years
Haemophilus b conjugate 0.5mL IM* None 2010
Q.1 : Haemangioma
Administered in the deltoid or lateral thign region.
*
t Contact the manufacturer for the latest recommendations prior to revaccination HAEMANGIOMA
□ What is it: Benign vascular endothelial tumor - developmental malformation of blood vessel
□ Level of Recommendation Definitions: □ Types:
► Level 1 : Convincingly justifiable based on available scientific information alohe. Usually (a) Capillary -
based on Class I data or strong Class II evidence if randomized testing is inappropriate. 1) Strawberry angioma
Conversely, low quality or contradictory Class I data may be insufficient to support a level I
recommendation. 2) Portwine stain
3) Salmon patch
► Level 2: Reasonably justifiable based on available scientific evidence and strongly supported
by expert opinion. Usually supported by Class II data or a preponderance of Class Ill evidence. (b) Venous/cavernous
(c) Arterial
286 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 287

Features Strawberry angioma Portwine stain Salmon patch Cavernous haemangioma Clinical features :
(a) swelling in carotid region of neck with following features -
Appears at 1-3 weeks after birth Since birth Since birth Birth 1) Unilateral
Progress Increase in size till 7-8 No change Disappears before Increase in size 2) Smooth
years, after which it re- 1 year of age 3) Firm
duces in size 4) With transmitted pulsation
5) Moves side-to-side
Site Anywhere, mainly face Face, shoulder, Forehead, occiput, Face, lips, mucous mem- (b) Features of TIA (transcient ischaemic attack) due to compression of carotid arter~
neck, buttock midline of body brane of cheeks (c) Thrill felt
Colour Bright/dark red Deep purple Bluish (d) Bruit audible
□ Site : At level of hyoid bone deep to anterior edge of sternocleidomastoid in anterior triangle
Shape Well-defined Diffuse swelling Raised from surface
□ Extension: Into cranial cavity along internal carotid artery (dumbbell tumor)
Features (a) Compressible (a) Compressible □ Shamblin classification :
(b) Soft
(c) Irregular surface {b) Not pulsatile Type I - Localised, easily resectable
(d) Not pulsatile Type II - Adherent, partially surrounding carotids
{e) Freely mobile Type Ill - Adherent, completely surrounding carotids
□ Investigations :
Refilling Quick (Emptying sign) Takes time
(a) Doppler
(b) Angiogram - widening/splaying of carotid artery with 'tumor blush' (Lyre sign)
□ Treatment : (c) CT scan
Wait and watch ➔ if exists even after 8 years of age, then following measures - (d) MRI
(a) Injection of sclerosing agent into the lesion □ Treatment :
(b) Cautery (a) If small ➔ excision
(c) Excision of the lesion after ligating feeding vessel (b) If large ➔ complete excision+ vascular graft

Q.2 : Carotid body tumor Q.3: Branchial sinus

CAROTID BODY TUMOR BRANCHIAL SINUS
□ Synonyms: □ What is it: Persistent second branchial cleft with a communication to the exterior
(a) Chemodectoma □ External orifice : At lower third of neck near anterior border of sternocleidomastoid
(b) Potato tumor
□ Internal orifice: In the anterior aspect of posterior pillar of tonsil present (then called a fistula), may be
(c) Non-chromaffin paraganglioma
absent with the tract ending blindly
□ Origin : Carotid body, located in adventitia of common carotid artery near its bifurcation
□ Tract:
□ Nature:
(a) Lined by ciliated columnar epithelium with few lymphoid tissue underneath
(a) Benign
(b) Lies between bifurcation of common carotid artery
(b) Locally malignant
(c) Spreads to regional lymph nodes and lung in 20% cases □ Aetiology : Branchial cyst incised mistaking it to be an abscess ! ,, .. ,

□
□
Blood supply: External carotid artery
Incidence :
□ Discharge: Mucoid or mucopurulent
□ Clinical features : Discharge from a small opening in the neck 10,_,-,1g,,\,..•~, i' ;)t"f-!~l'-''.o
,~'Y'-")0!/'1.t,
HJ\
o-i_(''·'F1 ·r,-,·.,;r.•
&J.,).; O \ ,. I' ~- "0' '-
'!'f
.'
1 1/'
,1,
/i~•('i
J~P1.J1 ,·>.i:>ii.~c..;
(a) Common in females □ Investigations :
(b) Common in high altitude (a) Discharge study / U9,G.✓ 1 ( • 1·
□ Pathology: (b) Sinusogram M.RJ '
(a) well-encapsulated □ Treatment :
(b) not hormonally active Surgical treatment
(c) hard Methylene blue injected into the tract ➔ Probe passed through the tract ➔ En.tire length of tract
(d) creamy yellowish colour dissected by an elliptical incision
(e) dense fibrous tissue present
□ Complications of surgery:
□ Age : Middle age Injury to -
288 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 289

(a) Carotids (c) Small bowel carcinoids - abdominal pain, features of intestinal obstruction
(b) Jugular vein (d) Hind gut carcinoids - bleeding per rectum, constipation, tenesmus
(c) Hypoglossal nerve
(e) Carcinoid syndrome - if secondaries in liver
(d) Glossopharyngeal nerve
(e) Spinal accessory nerve o investigations :
(a High levels of 5-HIAA (5-hydroxyindoleacetic acid) in urine
Q.4 : Carcinoid tumor (b) 1131 MIBG scan

CARCINOID TUMOR (c) CT scan

(d) 111 ln-octreotide scintigraphy
□ Occurs in: o Treatment :
(a) Appendix - 65% cases (a) If in tip of appendix ➔ appendicectomy
(b) Ileum - 25% cases
(c) Other parts of GIT (b) If in base of appendix or size > 2cm anywhere in appendix ➔ right hemicolectomy
(c) If in terminal ileum ➔ right hemicolectomy
(d) Ovary }
(e) Testis (rare) (d) If large sized small bowel carcinoid + spread to lymph nodes ➔ radical resection of small intestine
(f) Bronchus (e) If < 1 cm sized small bowel carcinoid without nodal spread ➔ segmental resection of small
□ Site: intestine
(a) Appendix - tip or distal 2/3 rd (f) If secondaries in liver ➔ surgical debulking hepatic resection+ embolisation or ligation of hepatic
(b) Ileum - terminal 2 feet artery
□ Number : Single in appendix, multiple in ileum
2010 Supplementary
□ Characteristics :
(a) Arise from enterochromaffin cells (Kulchitsky cells) found in crypts of Leiberkuhn
Q.1 : Melanoma
(b) Capable of APUD (Amine Precursor Uptake and Decarboxylation)
(c) Secrete vasoactive peptides A: See Section 1, Segment D, Os. 71 (Page No. 529)
□ Age : 50-60 years Q,2: Blood substitutes
□ Spread of small bowel carcinoids : A: See Section 1, Segment C, Paper I, 2014, 0. 3 (Page No. 312)
Size Nodal spread Liver spread Q.3 : Trophic ulcer
< 1 cm 20-30% 20-30% A : See "Pressure Sore" Section 1, Segment C, Paper 11, 2013 supplementary Os. 7 (Page No. 424)
1 -2 cm 60-80% 20% Q.4 : Systemic inflammatory response syndrome
> cm 80% 50% A : See Section 1, Segment D, Os. 79 (Page No. 536)

□ Types of small bowel carcinoids : 2011

Features Sites Secrete Nature Q, 1 : Pre operative preparation of a case of obstructive jaundice
Foregut carcinoids Bronchial, thymic, gas- Low levels of serotonin Argyrophilic
troduodenal, pancreatic PRE-OPERATIVE PREPARATION-OBSTRUCTIVE JAUNDICE
Midgut carclnoids Jejunal, ileal, appendiceal, High levels of serotonin Argenta/fin and argyrophilic (a) Immediate hospitalisation
right colic
(b) Diet - high carbohydrate, low protein, no fat diet along with vitamin and calcium supplements
Hindgut carcinoids Distal colon, rectal High levels of somatostatin Do not stain with silver (c) Adequate hydration with oral and intravenous fluid
and peptide YY
(d) i.v mannitol - 10% 200ml before, during or after surgery or lnj Furosemide 40mg i.v
(e) lnj Dopamine 2 ug/kg/min
□ Clinical features : (f) lnj Vitamin K 10mg for 3days to correct prothrombin time ➔ if still no improvement, fresh frozen
(a) Assymptomatic plasma is used
(b) If in appendix, features of appendicitis (g) Blood transfusion if severe anaemia

37
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 291
290 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

(c) Feeling of heaviness of lower limbs, accentuated by standing

(h) Broad spectrum antibiotics
(d) Leg is tense, tender, warm, pale, with stretched shiny skin
•' (i) ~operative bilirubin > 10mg%, ERCP stenting or PTBD done, else MRCP done
,,/·/ Signs:
'--/iL:1=k2: Epigastric hernia (a) Swelling
(b) Tenderness over thrombosed veins
EPIGASTRIC HERNIA
l----i6f Homan's sign positive (passive forceful dorsiflexion of foot with extended knee ➔ tenderness in
□ Synonym : Fatty hernia of linea alba calf)
L--(dt--Mosse's sign (gentle squeezing of lower part of calf from side to side is painful)
□ What is it: Protrusion of hernia in the midline through the interlaci~ibres of linea alba anywhere L-fef Neuhof's sign (thickening and deep tenderness elicited when calf muscles palpated deeply)
between umbilicus and xiphysternum .........
v(f/.-· Linton's test (tourniquet applied at sapheno-femoral junction ➔ patient made to walk ➔ limb kept
□ Reason behind naming : elevated ➔ persisting prominent superficial vein)
(a) Mostly occurs midway between xiphysternum and umbilicus
□ Investigations:
(b) Begins as a protrusion of extraperitoneal fat and as it grows bigger, it drags a pouch of peritoneum
(a) Venous Doppler
□ Incidence :
(b) DU~l(__§.9.ml.....
(a) 10% common (c) ·Pfethysmography
(b) M»F
~ (d) Phlebography
□ Speciality : (e) Venous pressure measurement
(a) Sacless hernia (f) Radioactive 112s fibrinogen study
(b) Content - omentum and/or small bowel □ Complications :
□ Clinical features : (a) Pulmonary embolism
(a) Assymptomatic (b) Infection, venous gangrene
(b) Swelling in epigastric region - tender (c) Recurrence
(c) Referred dyspepsia (d) Chronic venous insufficiency
(d) Cough impulse
□ Treatment :
(e) Irreducible
(a) Conservative -
□ Investigations : Gastroscopy
1) Bed rest
□ Treatment: Sac dealt with through a vertical incision, closed with non-absorbable interrupted sutures
2) Elevation of legs
3) Elastic stockinette
J 7 D e e p ve;n th,ombosls
4) Heparin
DEEP VEIN THROMBOSIS 5) Warfarin
6) Fibrinolytic drugs
□ Synonym : Phlebothrombosis (b) Surgical -
-~-------··
□ Aetiology: 1) Bypass procedure
(a) Following childbirth 2) Valvular repair
(b) Post-ope~ 3) Palma operation
(c) Muscletraum~ 4) May Husni operation
(d) Spontaneous in visceral neoplasm
(e) Immobility a \ , r ~ t i o n aga;nst tetanus
(f) Sitting before computers for long hours
□ Sites: . ACTIVE IMMUNISATION AGAINST TETANUS
(a) Calf is the most frequent site
(b) Pelvic veins □ Adults - 1st dose (
(c) Leg veins - femoral, popliteal
.J,,,-
1 month gap '- 0 1 J. b
1

(d) Upper limb vein - axillary 2 nd dose

□ Symptoms: -L 6 months gap
3rd dose
(a) Fever
(b) Pain and swelling in calf and thigh Each dose - 0.5 ml tetanus toxoid intramuscularly at insertion of deltoid muscle
292 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 293

► Euvolaemic hyponatremia - increase in total body water with normal body sodium
□ lnfants-
► Hypervolaemic hyponatremia increase in total body sodium with greater increase in
lAP schedule :
total body water
DPT1 at 6 weeks
□ Variants based on effective osmolality:
DPT2 at 10 weeks
► Hypotonic hyponatremia
DPT3 at 14 weeks
,, Isotonic hyponatremia
DPT 1st booster at 16-18 months
"i,- Hypertonic hyponatremia
DT (2 nd booster) at 5 years
□ Causes:
NIS schedule :
► Intestinal obstruction
DPT1 at 6 weeks } leading to severe vomiting
► Gastric outlet obstruction
DPT2 at 1O weeks
► Intestinal fistulas
DPT3 at 14 weeks
► Severe dehydration due to diarrhoea
DPT 1st booster at 16-24 months
► SIADH
DT (2 nd booster) at 5-6 years
► Stroke
□ Pregnancy -
► Immediately after trauma and surgery
2 doses of tetanus toxoid 1 month apart, but in India, given during registration and after 1 month
- - - - - - - - - -··---·····- ~•"·---·-··--·----·-"• .. --.,~~------- ------~--~------"- ► Following Ryle's tube aspiration
□ Additional booster dose given in major injuries
□ Clinical features :
□ Antitetanus globulin (ATG) 500-1000 unit~ intramuscularly given as prophylaxis in road accidents, A) Acute -
severe burns, crush in]urie~s-, war wounds.
► Sunken eyes
2011 Supplementary ► Dry tongue
► Dry wrinkled skin
Q.1 : Marjolin 's ulcer ► Irritable
A: See Section 1, Segment C, Paper II, 2013, Os. 10 (Page No. 421) ► Disoriented
Q.2: Preoperative preparation of a patient of Pyloric stenosis ► Hypotension
A: See Section 1, Segment C, Paper I, 2009, Os. 3 (Page No. 282) ► Dark, scanty urine
B) Chronic-
Q.3 : Blood fractions
A: See Section 1, Segment D, Os. 19 (Page No. 484) ► Hypothermia
► Behavioural changes
Q.4 : Hyponatremia
► Cranial nerve palsies
Ans:
HYPONATREMIA ► Progressive weakness
► Reduced tendon reflexes
□ What is it: Serum sodium level less than 135 mEg/L ► Pseudobulbar palsy
□ Classification: (Joint European Guideline) D Investigations:
► Mild 130 - 134 mEq/L Urine osmolality
►
► Moderate : 125 - 129 mEq/L Serum osmolality
►
► Profound : < 125 mEq/L Urinary sodium concentration
►
□ Types:
► Serum electrolytes
► Acute - presents with neurological symptoms □ Treatment:
► Chronic - causes pontine myelinosis ► Fluid administration - (i) Isotonic saline to hypovolaemic patients
□ Variants based on volume status : (ii) Salt and fluid restriction to hypervolaemic patients
► Hypovolaemic hyponatremia - decrease in total body water with greater decrease in (iii) Free water restriction in euvolaemic patients
total body sodium
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 295
294 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

0 Instruments - Verees or Tuohy needle

, Potassium repletion in hyponatremia secondary to diuretics
, Hypertonic (3%) saline in overtly symptomatic hyponatremia
o Purpose - To distend the abdominal wall and separate it from the abdominal contents

► Conivaptan (V1 A and V2 vasopressin receptor antagonist) for euvolaemic and hypervolaemic
o Establishment of pneumoperitoneum - lntraabdominal pressure is preset to 12-14 mm Hg in auto-
matic insufflator ➔ A 1 cm smiling incision is made just below umbilicus ➔ A Verees needle is
hyponatremia (contraindicated in hypovolaemic patients)
inserted into the abdomen at right angle such that underlying structures are not injured ➔ Position of
► Treatment of underlying cause. needle inside the abdominal cavity is confirmed by injecting about 5ml of saline and reaspirating it, or
by drop test ➔ Needle connected to an automatic insufflator by insufflation tube ➔ The gas flow is
2012 started @ 1-2 It/min and th,m ,na flow rate is gradually increased ➔ After adequate insufflations,
Verees needle is withdrawn and trochar is inserted
Q.1 : Post operative pain management
O Factors determining appropriate gas -
(a) type of anesthesia
POST-OPERATIVE PAIN MANAGEMENT (b) physiologic compatibility
□ Methods available : (c) toxicity
(d) ease of use
(a) Systemic - (e) safety
1) Opioids (f) delivery method
2) NSAIDs (g) cost
3) Paracetamol (h) non-combustibility
(b) Regional - □ Gases used -
1) Epidural (a) Carbon dioxide
2) Peripheral nerve block (b) Nitrous oxide
□ Order of effectiveness : (c) Argon
(d) Helium
Afferent neural blockade > High dose opioids > Epidural opioids > PCA > NSAIDs > Paracetamol
(e) Mixture of these gases
D Assessment : By using 1O point assessment scale
□ Why carbon dioxide preferred -
0 Safest method : PCA
(a)high diffusion coefficient
□ PCA: (b)normal metabolic end product rapidly cleared from body
(a) Full form - Patient controlled analgesia (c)highly soluble in blood and tissues
(b) What is it - Method of allowing a person in pain to administer their own pain relief (d)does not support combustion
(c) Routes of administration - (e)lowest risk of gas embolism
1) Oral
□ Gas delivery system -
2) Intravenous - via patient controlled analgesia infusion pump
3) Epidural (a)containment cylinder
4) Inhaled (b)insufflators
5) Nasal (c)tubing
6) Transcutaneous (d)filter
(d) Drugs used - (e)port
1) Opioids such as fentanyl
□ Rate of gas flow - 4-6 It/min
2) Local anaesthetics
3) Methoxy fluorine vapour □ Physiological effects -
4) Narcotics (a) CVS - reduced venous return, increased peripheral resistance, tachycardia
(b) Respiratory - reduced FRC
Q.2: Creating pneumoperitoneum in laparoscopic surgery (c) Renal - reduced renal functinn, reduced urine output
(d) GI - regurgitation of gastric contents, pulmonary aspiration
PNEUMOPERITONEUM IN LAPAROSCOPIC SURGERY
(e) Neurological - high intracranial tension, reduced cerebral perfusion
□ What is it - Introduction of gas into peritoneal cavity during laparoscopic surgery (f) Due to gas insufflation - arrhythmia, subcutaneous emphysema, pneumothorax, venous gas
embolism, injury to internal organs
□ Incision - Umbilical
 296 QUES~.: A C~ehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 297

(e) Comatose
(f) Tetanus
BURST ABDOMEN □ Predisposing factors :
(a) Anaemia
□ Synonym : Abdom~~j§__Q_EzD.Q..e (b) Pressure
□ What is it: _i:)is~~fltion of a lap-~~c,tgrr1y_~C>_~11d (c) Moisture
□ Time of occurrence : 5th-8th post operative day (d) Sensory loss
(e) Malnutrition
□ Aetiology: Sutures opposing deep layers i.e. peritoneum, rectus sheath tear-through
□ Investigations :
□ Factors related : (a) Study of discharge
(a) Choice of suture material (b) Blood sugar
(b) Upper midline vertical wounds more prone than transverse wounds (c) Edge biopsy
(c) Method closure - continuous more susceptible than interrupted (d) X-Ray of the part
(d) Wounds of major surgeries □ Treatment :
(e) Poor general health of patient (a) Treatment of the cause
(f) Post operative cough, vomit (b) Nutritional supplementation
□ Clinical features : (c) Frequent change of position
(a) Sudden give-away sensation generally after severe cough (d) Use of water bed
(b) Pinkish serosanguinous discharge (e) Avoidance of moisture
(c) Omentum/intestinal coils forced out (f) Proper cleaning of urine and excreta in bed ridden patients
□ Treatment : (g) Regular dressing
(a) Immediate hospitalisation (h) Antibiotics
(i) Excision of dead tissue followed by skin graft
(b) Intravenous fluid
(c) Sugery (wound opened ➔ coils replaced into abdominal cavity ➔ thorough wash ➔ wound
closed by all layer sutures, passing a non-absorbable suture material through plastic collar - 2012 Supplementary
"tension sutures", kept for 14 days)
(d) Antibiotics Q.1 :Lipoma
(e) Newer modalities of treatment - A : See Section 1, Segment D, Os. 23 (Page No. 486)
1) Biological dressing
Q.2: Metabolic acidosis
2) Wound vacuum system

ZDec
□ Complic ·on : lncisional hernia
;,us ulcer Y1' d ,\\
DECUBITUS ULCER
A: See Section 1, Segment C, Paper I, 2013, Os. 1 (Page No. 300)

Q.3: TPN
Ans:

·,·□
□
Synonym : Bed sore
Type of ulcer: Trophic ulcer with bone as base
D Fu// form : Total Parenteral Nutrition
TPN

□ What is it: Method of feeding given only through intravenous route, bypassing the gastrointestinal
□ Sites: tract
(a) Occiput
□ Site : Through subclavian / internal jugular vein by inserting a central catheter
(b) Scapular region
(c) Sacral region □ Contents:
(d) lschium ► Water ➔ 30-40 ml/kg/day
□ Commonin: ► Energy ➔ Medical patient 30 Kcal/kg/day
(a) Diabetic (Fat & carbo- Postoperative patient 30-45 Kcal/kg/day
(b) Bedridden
(c) Paraplegia hydrate) Hypercatabolic patient : 45 Kcal/kg/day
(d) Old age

38
298 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 299

,- Amino acids ➔ Medical patient 1g/kg/day □ Precaution : Weight gain must not be more than one kg/day otherwise it signifies fluid overload.
Postoperative patient 2g/kg/day □ Contraindications :
Hypercatabolic patient : 3g/kg/day ,- Blood dyscrasia
Acetate I gluconate 90 m Eq/kg/day ► Cardiac failure
► Minerals ➔

Chloride 130 m Eq/kg/day ► Altered fat metabolism

Chromium 15 mcg □ Complications :
Calcium 15 mEq
Copper 1.5 mg COMPLICATIONS
Iodine 120 mcg
Magnesium 20 mEq
Manganese
Sodium
2 mg
100 mEq
t
Biochemical
,..-
Technical
t
Others
Potassium 100 mEq
300 mg
• Electrolyte imbalance • Air embolism • Cholestatic jaundice
Phosphorus • Bleeding
Zinc 5 mg • Dehydration • Dermatitis
• Pneumothorax
• Hyperglycaemia
• Infection • Anaemia
,.. Vitamins ➔ Ascorbic acid 100 mg
• Azotemia • Thrombosis • Severe hepatic steatosis
Biotin 60 mcg
5 mcg • Hyperosmolarity • Catheter displacement • Metabolic acidosis
Cobalamin
• Sepsis • Candidiasis
Folate 400 mcg
• Catheter blockage
Pantothenic acid 15 mg
Riboflamin 3.6 mg
Q.4: Prophylactic antibiotics
Thiamine 3 mg
Ans:
Vil A 4000 IU
PROPHYLACTIC ANTIBIOTICS
Vil D 400IU
VitE 15 mg □ Purpose : Prevention of infection and complication by using antimicrobial therapy
VitK 200 mcg □ Used in:
► Post surgical cases
□ Indications :
► Medical conditions Spontaneous bacterial peritonitis
► High output abdominal fistula or duodenal/ pancreatic/ biliary fistula
- Rheumatic fever
,- Septicaemia
► Following major abdominal surgeries - Meningococcal disease
► Multiple trauma - Plague
),., Failure or contraindication for enteral nutrition - Recurrent UTI
► Short bowel syndrome - Recurrent cellulitis
□ Procedure : Subclavian vein catheter is passed below clavicle and fixed to skin and thus TPN is - Infective endocarditis
administered via a central vein like jugular or subclavian vein. □ Optimal prophylactic antibiotic: Must have following features
□ Monitoring patient: ► Bactericidal
► Fluid input-output chart ► Inexpensive
► Body weight ► Non-toxic
► Blood glucose ► Active against typical pathogens that can cause post operative surgical site infection
► Serum electrolytes □ Antibiotics commonly used:
► Blood urea, serum creatinine ► Cefazolin
► LFT ► Ciprofloxacin
 300 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 301

► Cefuroxime
► Vancomycin
► Doxycycline
VENOUS ULCER
► Metronidazole
► Penicillin □ Synonyms:
(a) Gravitational ulcer
2013 (b) Varicose ulcer

. r ✓,L:and treatment of metaboUc ac;dos;s □

□
What is it: .comelic~~~-~f_.va.~~os.e veins or deep vein thrombo.~Js
Pathogenesis :
X71.,0U.>C
1 METABOLIC ACIDOSIS Varicose veins or deep vein thrombosis
·-------~-.,--· . ~.-.. ---~~··-----·
l
□ What is it: A condition where either there is an excess of acids or there is a deficit of bases in the Valve cusps degenerate or remain impregnated in organised thrombus
body
□ Causes:
l
Chronic ambulatory venous hypertension
(a) Increase in amount of fixed acids - l . ······· -
1) Diabetic ketoacidosis
2) Lactic acidosis Defective microcirculation
3) Hypoxia
4) Starvation RSC diffuses into tissue_E!_ane
5) Shock or cardiac arrest ➔ anaerobic tissue metabolism ➔ rapid increase in lactic and
pyruvic acids Lysis of RSC
6) Renal insufficiency
7) Azotemia
8) Excessive exercise Release of haemosiderin
9) Rapid transfusion of blood stored in blood banks
10) Intestinal strangulation Fibrinogen escapes through large pores in venules
(b) Loss of bases - l
1) Diarrhea Accumulates to act as a barrier to diffusion of oxygen and other nutrients
2) Small bow!=)I fistula l
3) Ulcerative colitis Dermatitis with brawny edema, hyperpigmentation
4) Gastrocolic fistula .· · · · · •·. --------·······-· · · · · · · · · . . ···1 .............
5) Ureterosigmoidoscopy
6) Prolonged intestinal aspiration Anoxia
□ Clinical features : l
Tissue death and fat necrosis
--·--··---·--· J -.. . .....
(a) Rapid deep noisy respiration, often called 'air hunger'
(b) High BP, pulse rate
(c) Amidst fast breathing, patient stops breathing for a second and tries to moisten his dry lips with his Scratching due to itching because of dermatitis
dry tongue l
(d) Cold clammy skin Skin break
(e) Altered level of consciousness
l
□ Investigations:
~
□
(a) Strongly acidic urine ~\f\(\_Y Ulcer
(b) Low serum bicarbonate level
Sa/lent ;e,\,~ . ~ ··-- - -

□ Treatment :
(a) In cases with increased amount of fixed acid - Sodium bicarbonate to be infused, initial dose
being not more than 50 ml of 7.5% solution
(b) In cases of base deficit - Ringer lactate+ 4.2% solution of sodium bicarbonate infused
(a)_ Gaiter's zone - area where venous ulcer generally develops - around and above the medial
,maUeolibecause of the presence of large number of perforators whichtransitpressure changes
d}f-ecffy·mto superficial venous system - - - - - - - - - - - - - ... -· .. . . .. ··-· .
(b) biQodermatosclerosi~ - J:1yperpigmentation, !h_i~~~r1Jr::i.9, ~brorii~_i!:)fl_~!!lmation and induration of
the skin in the calf region and also around the ankle
 302 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS D Paper - I 303

□ Complications: Causative organisms :

• Related to skin - (a) Staphy/occus aureus
1) Dermatitis (b) -Hemolyhc streptococc, ·
2) Scarring (c) Microaerophilic streptococci
3) Eczema (d) f=..J;Qli
4) Marjolin's ulcer (e) C/ostridium welchii
5) Lipodermatosclerosis (f) ·aacfeioides fragilis
• Others - □ Predisposing factors :
(a) Venous hemorrhage (a) Diabetes
(b) Talipes equino varus (b) Malnourishment
(c) Calcification of vein (c) Old age
(d) Ankylosis of ankle joint (d) lmmunosuppressed
(e) Periosteitis
□ Pathogenesis: Infection ➔ Fulminant inflammation of scrotal skin and subcutaneous tissue ➔ Oblit-
(f) Infection
erative arteritis in scrotal skin ➔ Cutaneous gangrene
□ Investigations :
□ Age : Elderly people
(a) Doppler USG
(b) i'Yuple.Xscan □ Clinical features :
(c) -Complete 61ood count (a) Sudden onset severe pain in the scrotal region
(d) Ascending functional phlebography (b) Fast spreading cellulitis of scrotal skin
(e) Discharge study (c) Extends to groin
(f) X-Ray of ankle (d) Extensive skin sloughing ➔ normal testis exposed
(g) Biopsy from edge of ulcer (e) Fever and other toxic features
□ Treatment : □ Treatment :
(a) Conservative - (a) Immediate hospitalisation
BISGARD REGIMEN (b) Intravenous fluid
(c) Catheterisation
1) Elevation of the affected lower limb
(d) Antibiotics
2) Massage of the indurated area and the calf
(e) Blood transfusion if required
3) Passive and active exercise
4) Pressure bandage - applied spirally from base of toes upto knee joint over a piece of felt (f) Excision of slough
(g) Skin graft after lesion granulates
placed on the ulcer
5) "Four layer" bandage - developed by Charring Cross Hospital, London □ Complication : Renal failure
6) Regular cleaning of the ulcer using povidone iodine
7) Dressing with EU SOL (Edinburg University Solution of Lime - contains sodium hypochlorite, Q.4 : Anorectal malformations
calcium hydroxide and boric acid)
8) Antibiotics ANORECTAL MALFORMATIONS
9) Topical steroids
□ What is it: Abnormalities in development of rectum and anal canal
□ Surgical-
1) Definite procedure for varicose vein (Trendelenburg operation, etc) after ulcer heals by con- □ Aetiology: Imperfect fusion of post-allantoic gut with the proctodeum
servative treatment □ Incidence : 1 in 4500 new born
2) Valve replacement □ Wingspread classification :
3) Kistner's valvuloplasty
1) High anomalies - (above puborectalis)
,;;t:3 : Fournier's gangrene (a) Cloaca! deformity -
/ The urorectal septum fails to develop, hence the bladder and rectum become a single cavity
FOURNIER'S GANGRENE [See Fig.1.5.1] tt,.,0/e ~ 3:}C.
{b) Ano rectal agenesis - J '-"
□ Synonym : Idiopathic ganw~neof scrotum . The urorectal septum develops partially
[See Fig. 1.5.2]
□ What is it: '-.'~-~_cuJar scrotal gangrene of infective o~ig_in_
2) Intermediate anomalies - (at level ofpu_~orectalis)
 304 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS D Paper- I 305

3) Low anomalies - (below level of pelvic floor)

□ Aetiology:
(a) lmperforate anus - 1) ~r,e~c: ~_gel ivery
Intact anal membrane between endodermal and ectodermal cloaca 2) Lymphadenitis
[See Fig. 1.5.3] 3) Sternomas!oid tumor
(b) Covered anus - 4) Trauma
Anal opening covered by a triangular fold of skin 5) Post burn contracture
[See Fig.1.5.4] 6) Rheumatic
(c) Ectopic anus - 7) Due to scoliosis
Anal opening situated in the vulva, vagina, vestibule or perineum 8) Due to ocular causes
[See Fig. 1.5.5]
(d) Microscopic anus - □ Types:
a) Congenital
Very small anal opening b) Secondary
[See Fig. 1.5.6]
□ Clinical features :
□ Pathology: Stern,ocleidomastC>Ld_gn QllJL.side is fibrosed ➔ cannot elon9ate ➔ shortened muscle ➔
._deforrr:iuy - ·
a) Newborn not able to pass meconium
□ Clinical features :
b) Abdominal distension . . .
c) Absolute constipation, vomit, and other features of intestinal obstruction a) . (;hin points,.,.,t~L<?B20~!t_e~.:'>ide
d) Finger gets obstructed in DRE in imperforate anus b) Restricted nEJck. movements
c) Squint
□ Associated anomalies :
□ Treatment :
a) Spinal anomalies
b) Oesophageal fistula a) < 1 year age -
c) Cardiac anomalies * Daily manipulation
d) Renal abnormalities * Cervical collar
e) VACTER anomalies b) > 1 year age -

□ Investigations : * Unipolar release (release of only clavicular head of SCM)

* Bipolar release (release of both clavicular and mastoid heads of SCM)
a) Wangenstein's invertogram -
1) High anomalies - rectal pouch proximal to Steph~n's _line . , .
2) Intermediate anomalies - rectal pouch at level of 1sch1al spine (Kelly s point) _,../,.,,,.--~-- 2013 Supplementary
_,,,-/__,./'
3) Low anomalies - rectal pouch distal to Stephen's line ' . _.,,,- /
b) Murugassu's technique Q~1-:-·t:oinplications of splenectomy
c) USG abdomen

□ Treatment : COMPLICATIONS OF SPLENECTOMY

a) High anomalies - Colostomy ➔ posterior sagital anorectoplasty ➔ c~osure of colostomy □ HEMORRHAGE - ..... ~ ......,.. ' W,Mi_. WWWl!!C

b) Low anomalies - Single stage reconstruction like anoplasty, anovestibuloplasty, etc

• Occurs mainly due to slipping of ligature at pedicle
□ Complications : • Bleeding from raw splenic bed is best controlled by hot mops application
a) Faecal fistula • If severe bleeding, cut edges of gastrosplenic and lienorenal ligaments are approximated with
continuous suture
b) Infection
c) Stenosis □ THRC?!".1_80~1S - Very rare

µ11.d). Faecal incontinence

TORTICOLLIS ~-:)
I. /
□
□
HEMATEME~IS - Occurs due to damage of stomach mucosa during ligation of short gastric vessels
G~ST~IC FISTULA- Occurs due to compromise in vascular supply to the fundus and greater curvature
of stomacli, as the short gastric vessels are ligated during splenectomy
Cl GA_~.!!~£ .91~~.!2':!. - Occurs if nasogastric aspiration is not done properly
\ ,,,•\

□ Synonym : Wry neck r--.:.. \ Cl OPSI-

□ What is it: Turning of neck to one side with chin pointing to opposite side • Full form : Overwhelming Post Splenectomy Infection
______________ ___ . -- .. ----
,, . . . -- . ·---·---- - -- ---·-'"· ~!~",t\illlt,I. - 1 ~ - \ ~ ~ , , _ •.,.,

39
306 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 307

• Causative organisms : Occurs in:

a) Pneumococcus a) Obese
b) Haemophilus influenza b) Lorry drivers
c) ·Neisseria menin i . c) People with excessive hairs in natal cleft region
d) a es1a microti d) People who have to sit for long hours at a stretch
• When does it occur: About two years after splenectomy
□ Clinical features :
• Clinical features : a) Multiple openings in natal cleft region covered by tuft of hair
a) Fever with chill ---- b) Abscess formation
b) Hypotension --- c) Discharging pus staining undergarments
c) Features of shock - ---··
d) Pain
e) Respiratory distress
e) Coma
· □ Treatment:
a) Initially - drainage of abscess + antibiotics
• Treatment: b) Later - definitive treatment
a) Ventilatory support 1) Excision with multiple z-plasty
b) Total parenteral nutrition 2) Karydaki's excision
c) Antibiotics
3) Rhomboid Limberg buttock flap
d) Blood and immunoglobulin transfusion if required
4) Bascom technique of excision
• Prevention :
a) Pneumococcal vaccine - 3 weeks prior to splenectomy and repeated once in 6 years □ Prevention:
b) Meningococcal and influenza vaccines prior to splenectomy a) Regular shaving of natal cleft
c) Life-long Benzathine penicillin prophylaxis b) Proper perinea! hygiene
d) Antimalarial prophylaxis in malaria endemic areas □ Complications :
Q.2 : Pilonidal sinus a) Recurrence
b) Sacral osteomyelitis
PILONIDAL SINUS c) Necrotising fasciitis

□ 'Pilo' = hair, 'Nidus' = nest □ Causes for high recurrence :

□ What is it: Multiple sinus tracts covered by tuft of hair located in the natal cleft a) Improper excision
b) Entry of new tuft of hair
□ Site : Upper part of the natal cleft adjoining the sacrum
c) Brea~ of_§car
□ Pathogenesis :
Hair penetrates skin Q.3\111(~rain
j, INTERCOSTAL DRAIN
Dermatitis
j, □ Synonym
Infection • Y~'-a!t:?r seal drainage __
j, □ What is it
Pustule • Closed dra,_L@fl~...9.LPlaucal cavity
j,
□ Indications -
Sinus tracts formed
j, a) RT A with shortness of breath
b) Haemothorax, pneumothorax, haemopneumothorax
Hair gets sucked into the sinus tract by negative pressure c) Rupture emph)"sematous bulla
j, d) Empyema thoracis - stage 1, 2.
Further irritation and granulation tissue formation
□ Position-
j,
Pus formed • P~e>p_R§!_cU,1JLW.i!b..1.i!I!L~~fe~~-~i9_e _raised above head.
j, □ Anesthesia -
Multiple discharging sinuses • Local
308 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 309

□ Antisepting shaving & dressing -

• From level of clavicle till end of rib cage, including axilla. CORE NEEDLE BIOPSY
□ Steps of insertion - What ls it:
Affected side confirmed by auscultation It is the preferred method for the diagnosis of palpable or non-palpable brea~Labnormaliti.es. It is
J, preferred over excisional biopsy for non-palpable breast tumors because a single surgical procedure
Triangle of safety demarcated can be planned based on the findings of core needle biopsy.
• Bounded by - anterior border of pectoralis major ] g Types:
[ - mid axillary line 1) Irl!•cut bio~
- upper border of 5th rib 2) l.arge needle biopsy (using 6-14 gauge needle and single puncture)
• Includes 3rd & 4th rib 3) Vacuum assisteacore biopsy
J, 4) Image guided biopsies -
Incision line which is to be made inside the triangle of safety is infiltrated with 1% Lignocaine (5 ml/kg If (a) Stereotactic mammographic core needle biopsy
with Adrenaline, 7 ml/kg it without Adrenaline) (b) Ultrasound/MRI guided core needle biopsy
J, (c) Mammography guided wire localised excision biopsy
Transverse incision made over skin in triangle of safety O Procedure {Tru cut biopsy):
J,
• Done under local anesthesia
Fat & intercostal muscles dissected • 14-18 gauge spring loaded needle is used
J,
• Multiple punctures are done
When pleura is reached, patient winces in pain
C Advantages :
J,
a) Permits analysis of breast tissue architecture to give clear histological evidence and definitive
Lignocaine infiltrated in pleura preoperative diagnosis
J, b) Can confirm DCIS and invasive lesion
Pleural fluid aspirated with syringe c) Can ~.c>r!lr:nenLabo!JJ,Jl!:?-9_~ and ~eceptor status oUumor
J, d) Low complication rate
Parietal pleura punctured, and fluid comes out e) Avoidance of scarring
J, f) Low cost
Finger inserted to release adhesions
J,
After finger is taken out, chest tube inserted
J,
Chest tube connected to water seal bag.
·~-----
a.ftBreast biopsy
2014

BREAST BIOPSY
[See Fig. 1.5.7]
~
~o/"J
._, -----.. /

□ Mechanism of action - [ Biopsy of J

Contents of pleural cavity collects in the water bag. This water seal drainage also prevents air to enter breast tissue
back into the pleura. I
I I

□ Proper functioning indicated by- [ For palpable

tumor
J For non-palpable
tumor
J
Dancing water column (water column moves up with inspiration & moves down with expiration)
I I
□ Removal of drainage tube - I I I I
Frozen Minimally
a) No more collection in water bag Core needle Excisional invasive
FNAC section
b) Drainage has diminished to less than 30 cc biopsy biopsy breast
biopsy
c) X-Ray shows sufficient inflation of lung. biopsy
□ Complications- I
I I I
a) Infection Stereotactic Needle localised
Ultrasound/MRI
b) Hemorrhage Mammographic guided excisional
c) Injury to intercostal nerves & vessels biopsy (NLEB)
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 311
310 QUEST: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

c) Sac and contents are densely adherent to each other

□ FNAC: d) Scybalous content of the large bowel can be indented with the finger, like putty.
• Fine needle aspiration cytology is the first, simplest and least invasive technique for obtaining a
□ On examination :
cell diagnosis in breast cancer a) Colicky abdominal pain
• Mininum 6 aspirations are done b) Tense tender irreducible swelling
• Giemsa, hematoxylin and eosin, papanicolaou stains used
c) Absence of expansile cough impulse
• It can be repeated 2 times d) If strangulated- Nausea, vomiting, Features of shock
\ / -A~vantages : (_1) least pain~ul (2) cheap (3) reliable (4) can be done on Out patient basis (5) no e) Spontaneous cessation of pain may be a sign of perforation
· evidence of malignant deposits along FNAC track
□ Investigations :
'-- _y~·o,sadvantages : a) Plain X-ray abdomen in erect posture
(1) Receptor studycannot be done

--
(2) ·lnvasive-can~~r ·cannot be differentiated from in situ disease
(3) False negative results do occur, mainly due to sampling errors
b) Serum electrolytes
c) Blood urea, serum creatinine
d) Complete hemogram {TLC increased)
e) USG abdomen
□ Core needle biopsy :
• It is the preferred method for diagnosis of palpable or non-palpable breast abnormalities
□ Treatment :
• Permits analysis of breast tissue architecture to give clear histological evidence and definitive
a) Nothing per mouth
preoperative diagnosis ---
b) Nasogastric suction
• Can confirm DCIS and invasive lesion
c) Broad spectrum antibiotic
• Can comment_ about _9~§1..<!e and receptor status of tumor
d) Fluid and electrolytes maintenance
□ Frozen section biopsy: e) Catheterisation to maintain adequate urine output
• Not u~ually practiced now-a-days f) Analgesia for pain
• Indication : when FNAC fails even after 2 trials or is negative
□ Surgery:
• Disadvantage : Shows 20% false negative results
□ Excisions/ biopsy:
Incision over hernial External oblique Hernial sac is exposed.
• Also known as open __biopsy _. Constriction ring (if any)
swelling extending upto _. muscle incised along
• It is th~ best and d!i!finitive investigation for breast cancer the scrotum the line of skin incision and superficial ring are
• Incision is planned in such a way that it will be included in the eventual mastectomy incision at a released
later date
• Should give no false negative and no false positive results
□ Needle localised excisions/ biopsy (NLEB):
,,,,. Procedure : If gut is non-viable/ The viability of the bowel Hernial sac is opened
necrosed/gangrenous is checked by Colour, Peri- along with suction of in-
(1) Through an incision under local anesthesia, a hook is placed adjacent to the suspected
• Resection and anas- stalsis, Pulsation and fected fluid (avoid spill-
lesion, using needle sheath over the tumor Bleeding. Cover the con-
tomosis done age of fluid)
(2) Excision biopsy is done under mammographic guidance • Placement of drain tents with warm mop along
with 100% oxygen inhala-
• Indication : tion for 20 mins ·
/ W~-c-ore needle biopsy fails to localise non-palpable tumor

\ Q7:!¢arcerated hernia If colour becomes pink/Peristalsis

\/ ,/ seen/Arterial pulsation visible or pal-
\._ _,,/<:_/ INCARCERATED HERNIA pable
□ Contents of hernial sac : • Reduce contents into abdominal
cavity
• Colon occupies the hernial sac. The lumen of that portion of colon is blocked with faeces. • Herniorrhaphy (Strengthening of
the posterior wall by Abrahamson-
□ Features: Darning method) done
a) Always irreducible
b) Often obstructed, but may not be strangulated
 312 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 313

Q.3 ,/£3~d substitutes • Types-

,/ ,/"'"'

,/~/c
BLOOD SUBSTITUTES (i) Low_ molecular weight dextran (mol. wt. 40000) - also known as rheomacrodex or dextran 40
_/'/
(ii) High molecular weight dextran (mol. wt. 70000) - also known as dextran 70.
□ What are they - Substances which can be used instead of blood to replenish the blood loss. • Indications -
□ Types - i) DIC
(A) Plasma and its derivatives ii) Burns
(B) Synthetically prepared solutions • Precautions -
□ Plasma and its derivatives - (i) Not used > 1000 ml
(ii) Blood sample for grouping & cross-matching to be drawn before introducing this solution.
BLOOD FRACTIONS
// B. GELATINE- rxpo,vd.(3
Name Preparation Storage Indications • Mol-wt 20000 - 40000 '
• Packed cell
/ " ~ · • .... -. CentrifuginQ whole blood
for 1'!°mTns·
@ 2000-3000g 1-6°C for
35 days
Old age
•
Chronic anaemia
• C.
• Less effective than dextran as plasma volume expander
F~~OROCARBONS - --:::;,;- · t ·" o,
• Children
r'pJ,, Jc,. , :, '!!J~-·
o.~ <tO' •
• Platelet rich plasma
,,,.~,, .---· ~ .--~---· 01,+
-
·cAv}
• Burn
• Hypovolemia •
What is it - Hydrocarbons in which hydrogen atoms have been replaced by fluorine
Features -
• Severe protein loss a) Colourless
• Human albumin (4.5%) Repeated f.':~ctionation of plasma 4°C Several cirrhosis b) odourless
months Edema
-
<:phr<;>J~c syndrome
(Used as volume expander)
c) chemically inert
d) dense liquid
• Fresh frozen plasma Fresh plasma rap}dly frozen (~ontains clot: -40°C for
•(FFPJ.
.
Severe liver disease
., e) poorly soluble
f
ting factors)
--·· -···

~llMt?rr ..
--
· · · 2 years • DIC
• Advantage -
[1 unit FFP = 3% rise in clotting factors] • Congenital clotting factor
deficiency Considered red cell substitute as it binds and releases oxygen rather than passively trans-
• Following warfarin therapy porting dissolved oxygen.
• Cryoprecjpitate Visible white supernatant fluid when FFP -do- • Haemophilia A • Precaution -
thawed at4°C _(1§.C::!Or \IHI_+ fibrinogen) • Von Willebrand's disease
• Fibrinogen Organic liquid fractionation of Qlasma Dried form DIC . Patient has to be kept in hyperbaric environment during this transfusion .

• Afibrinogenaemia (D) HYDROXYETHYLSTAR~H (HES) - ~

• Platelet concentrate Centrifugation of platelet rich plasma • Thrombocytopenia • Composition= Starch + Sodium hydroxide + Ethylene oxide
- • Drug induced hemorrhage • Mot-wt: 60000 - 4,50,000
• _Prothrombin complex From pooled plasma which contains lac- • Reversal of warfarin over-
concentrate tors 11, IX, X dose /'..-·· .. /

Q.4: V-ofvu/.U5rieonatorum
' __ ,/"'"·

□ Synthetically prepared solutions - VOLVULUS NEONATORUM

(A) DEXTRAN -
□ Whatisit-
• What is it - Polysaccharide polymer
"Volvulus" is defined as a rotation in the axis of the loop of the bowel, either clockwise or anti-
• Production _:::-P-olysaccharide compound derived from bacterium Leuconostoc Mesenteroides, clockwise. "Volvulus neonatorum" is neonatal midgut volvulus secondary to midgut malrotation. It is
to which yeast extraction is added a life-threatening condition requiring treatment within 6 hours or less from onset.
• Disadvantages - □ Development -
(i) induces ~ouleau_x form.;itig.!} o_f B._~C Normally by 12th week of gestation, the mid-gut returns to the fetal abdomen from the extra-embry-
(ii) i_~~~~er~s with 12_1§.telet function onic coelom and begins rotating counterclockwise around the axis of superior mesent€'rfc artery. In a
(iii) )nterferes with bloodgrouping & cross matching classical case of intestinal malrotation, this doesnot occur as it should be. The caecum ir, at the central
and duodenojejunal flexure lies to the right of the midline, hence the base or attachme.c·i of the small
• Function - Restore plasma volume
bowel mesentery remains narrow, which predisposes to mid-gut volvulus .

40
 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 315
314

□ Special feature : Amoebic abscess is usually sterile as trophozoites are found in wall of abscess and
□ Clinical features - ,
not in the content
1 ) Bile-stained vomi!iDg (as the volvulus usually develops just below the ampulla of Valer in the
□ Stages:
duodenum)
2) Bloodstained stools may be passed by the baby- sugges~ngulation a) Amoebic hepatitis
b} Amoebic abscess
□ Investigations -
Upper gastrointestinal contrast study - confirms the malrotation. □ Site : Posterio-superior surface of right lobe
(due to - larger size of right lobe '
□ Treatment -
- streamline effect )
1) Resuscitation
2) Urgent surgery- □ Pathology:
(a} Untwisting of the volvulus Macroscopy -
(b) Widening the base of the small bowel mesentery a) Enlarged liver _
(c} Straightening the duodenum b} Solitary, rarely multiple
(d) Positioning the bowel in a non-rotated position (Ladd'_s pro~e~ur~)- . . . c) P_LJ~_with following features -
(e} Occasionally removal of the appendix (as now, if retained, It lies in an abnormal site within 1) Chocolate coloured (anchovy sauce)
the abdomen) 2) Viscid
/ ~ e b i c liver abscess 3) Contains dead hepatocytes, RBC, necrotic material
AMOEBIC LIVER ABSCESS d)

Micdoscopy- (See Fi
□ Synonym : _Iropical absces~ -~~·-
□ What is it : Complication of amoebic dysentery • Clinical features :
~·· ·-,-- .. «·-··- ·-·"···- --·-·--·--•--··~·---- ... -----
□ Causative organism :_ Entamoeba histolytica (A) Systemic features in acute phase -

□ Common in: Alcoholics, Cirrhotics 1) Weight loss

2) Loss of appetite
□ Pathogenesis :
3) Fever with chill and rigor
Amoebic typhylitis of caecum Infection from sigmoid 4) Jaundice

t t
· vein
· ~,· .---~--~~'-'" ,/ Inferior mesenteric vein Symptoms Signs
Superior mesentenc
Portal vein f (B) Abdominal features Upper abdominal pain (1) Tenderness
(2) Guarding and rigidity
Liver
-i:---- (3) Splenomegaly
(4) Tender, soft, palpable liver in acute
Trophozoites release histiol)!sin phase; firm, smooth, non-tender
t - . liver in chronic cases

'Destroy
·· hepatocytes
t (5) Ascites

(C}Thoracic features (1) Dry cough (1) Right sided pleural effusion
Amoebic hepatitis
--------·•·t·•-· ------- (2) Right shoulder pain (2) lntercostal tenderness
Liquefaction necrosis blood vessel thrombosis, release and breaking of ABC (3) Chest pain-right side
. .' ·· 1
.. t ----·· ---·--
Multiple microabscess □ Investigations:
a) TLC - raised
Coalesce
b) LFT - raised bilirubin, ALP, SGPT, SGOT, prolonged PT
t c) USG Abdomen
~arge absce_s_s
316 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 317

d) Chest X-Ray □ Pathology : Femoral hernia protrudes into femoral canal through femoral ring (medial to femoral
e) CT Scan abdomen vein), descends upto saphenous opening and then escapes out into loose areloar tissue
f) Serological tests □ Speciality : Most prone for obstruction and strangulation among all hernias due to its narrow neck
and irregular pathway. 40% femoral hernia present as emergency hernia with obstruction or
□ Treatment : strangulation.
a) Drugs- □ Etiology:
1) Tab M~1rnDidazole - 800 mg thrice daily - 1O days
►
Wide femoral canal
or
lnj Metronidazole - 500 mg i.v. thrice daily- 10 days
►
Multiple pregnancies ~-,,+-Cf>:]·j ,,
□ Sex predilection : ' ,.___,. , I
2) If patient continues to pass cyst even after full course of Metronidazole - Fety'V'\-0.'hp..} ,i:]'r"L(),,-, 1" , r-1--1--.....--~

Tab Dihydroxyquin~lo12_e:i~·- 600 mg - 1O days

□
F_,?'_>_M___
ow•

Laterallty :
"/"l'\0
~-- v·e
., - l' /
..,,_..,_--~-____._
I /1,
/1,

b) Aspiration - 1

* Indications - ► More common in right side k.J-'\IV,IJ:}• oJ , ./'1

► 20% bilateral ~
1) Clinical features persist inspite of drug therapy
2) Clinical/radiographic eviaence of hepatic abscess □ Clln/cal presentation
* Procedure - ► Swelling with following features
Long, wide bore needle introduced in between 9th and 1Qth intercostal space, between - located below and lateral to public tubercle in the groi!:1
anterior and posterior axillary lines - - impulse on coughing
c) Percutaneous drainage - and aspirated fluid sent for culture and sensitivity - reducible with a gurgling sound
d) Surgery - - dragging pain
Abscess opened ➔ pus evacuated ➔ Malecot's catheter introduced and kept till stoppage of ► Obstrucion and strangulation presents with
drainage. - tender, painful swelling
- irreducible
2014 Supplementary
- absent cough imp~se
- abdominal distension
Q.1: CT Scan - vomiting
A: See Section 1, Segment E, Os. 13 (Page No. 590) - fever, hypotension
Q.2: Pleomorphic adenoma ► Gaur's sign
A: See "P.S.A." Section 1, Segment C, Paper 11, 2012, Os. 5, (Page No. 406) - Pressure by the femoral hernial sac causes distension of superficial epigastric vein
Q.3 : Pheochromocytoma and/or circumflex iliac vein
□ Treatment :
A: .See Section 1, Segment A, Paper II, 2013 supplementary, Qs. 3 (Page No. 174)
► Lockwood low operation - approach from below inguinal ligament
Q.4 : Gallstone ileus
► McEvedy high operation - done in cases of strangulation
A : See Section 1, Segment D, Qs. 61 (Page No. 521)
► Lotheissen's operation - approach through inguinal canal
Q.5: Femoral hernia ► A K Henry's approach - done in cases of bilateral femoral hernia
Ans· ► Use of polypropylene mesh to close defect
FEMORAL HERNIA □ Differential diagnosis :
□ What is it: Abnormal protrusion of ayiscous or part of a vi~_cous through femoral canal ► Inguinal hernia
► Psoas abscess
□ Anatomy of femoral canal:
► Femoral aneurysm
► Medial-most compartment of femoral sheath
► Haematoma
► Extent - From femoral ring to saphenous opening (where it is closed by cribriform fascia) ► Distendal psoas bursa
► Contents - i) Lymph node of cloquet ► Saphena varix
ii) Fat ► Lipoma
iii) Lymphatics ► Enlarged cloquet node
 318 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 319

2015
• Sequalae -
Q.1: Ludwig's angina Recurrence
See Section 1 Segment C Paper-II, 2010, Question No. 11 (Page No. 380} Fistula-in-ano (See Fig. 1.5.9)

Q.2: Appendicu/ar lump

See Section 1 Segment A Paper-I, 2013 supplementary, Question No. 2 (Page No. 63 & 64)

Q.3: ,.TYPe!f✓Of anorectal abscess MODS

' A ,,./.,,,/ ,/,,,,,_,••

\ y/ ,./' • Full form - Multi_?rgan Dysfunction Syndrome

\ ... / ... ·· ANORECTAL ABSCESS
• Definition - Developm~nt of po!entiall~ ~~~ible e.b~JQ_l~gi_c:__dEJ~an_gEJrn~,:it involving two or
• What is it - Abscesses around anal canal and lower rectum more_~!_!:l~~-~y~t~,,rn-~,:iot involved in the disorder, that resulted in ICU admission-and-arlsingin.the
wake of a pofent1ally life - threatening physiologic insult.
• Causative organisms -
E-Coli • Pathogenesis -
Bacteroides Toxins/ endotoxins from organisms
Staphylococcus j,
Streptococcus
Proteus Inflammation, cellular activation of macrophages, neutrophils, monocytes
j,
• ~o(Ditbr;e:ffected patients -
Release of cytokines, free radicals
• \~mmunocomp j,
~ Classification -
~~
(\ Chemotaxis of cells, endothelial injury, altered coagulation cascade - SIRS (Systemic Inflamma-

Type Site - Clinical feature Treatment

tory Response Syndrome)
j,
1) Perianal Superficial to perianal • Severe thrombing pain in • Incision and drainage of pus Reversible hyperdynamic warm stage
abscess (60%) region i.e., subcutane- perianal region (cruciate incision preferably
ous portion of external under general anesthesia. j,
sphincter. • Increased on defaecation
All loculi must be broken
• Smooth, tender soft swell- using sinus forceps and fin- Severe circulatory failure
ing ger wound kept wide open j,
and cavity is packed· with
gauge T-bandage applied) MODS
• Sitz bath j,
• Analgesics Hypodynamic, irreversible cold stage
• Antibiotics
• SIRS-
• Laxatives
Presence of 2 or more of the following -
2) lschio-rectal lschiorectal Iossa Severe acute pain by side of • Same as described above Temperature< 36°C or> 38°C
abscess (30%) anal canal, aggravated during
defaecation • Any presence of fistula HR> 90/min
should be looked for
RR> 20/min
3) Submucous Deep to mucous mem- Perianal pain Small incision and drainage by TLC< 4000 / µI or> 12000 / µI
abscess/ brane of anal canal stretching the anus or by using
lntersphineteric above dentate line a proctoscope • MOD Score
abscess

4) Pelvi-rectal Above levator ani and Pelvic abscess which may be USG to find out cause and
abscess/Supra- below pelvic perito- due to appendicitis, salpingi- acordingly mariaged.
levator abscess neum tis, diverticulisis etc
320 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 321

Organ System 0 1 2 3 4 Target system Convincing evidence Controversial or investlgational

Respiratory > 300 226-300 151-225 76-150 S 75 Hematologic DVT prophylaxis Anticoagulant therapies such as anti-
PO2 / FiO2 thrombin Ill
Renal
s 100 101-200 201-350 351-500 > 500 Jmmunologic SOD (Selective Decontamination of the Anti-cytokine and other mediator-tar-
Serum creatinine Digestive Tract) geted therapies
(µ mol/L)
Endocrine Corticosteroids in late sepsis
Hepatic
Serum bilirubin (µ mol/L) s 20 21-60 61-120 121-240 > 240 !

Cardiovascular .5: Estrogen & Progesterone Receptors: [MJe ~

S10 10.1-15.0 15.1-20.0 21.1-30.0 > 30.0
R/P Ratio
ESTROGEN AND PROGESTERONE RECEPTOR
Haematologic
> 120 81-120 51-80 21-50 S 20
Platelet count (x 10 3/mm 3 ) □ What are they - Protein receptor molecules activated by hormones estrogen and progestero:ie
respectively
Nemologic
15 13-14 10-12 7-9 S6
Glasgow coma score A) ESTROGEN RECEPTORS
• Types (Based on location)-
HR x Right atrial pressure
R/P Ratio= a) ,~c_!~ar - ER a, ER 0
MAP
b) Membrane - GPER30, Gq·mER, ER-X
• Genetics -
• Effects of organ failure in MODS - Encoded by gene ESR 1 (Chr. 6)
• Lung ARDS
------- and gene ESR 2 (Chr. 14)
• Liver Acute liver insufficien£_Y
~- ..... --~--~--~-· -----·----·~- • Location-
• Kidney Acute kid~E:Jy_in.LLJ,IY ER a * Breast
• Cardiac Cardiovascular failure * Endometrium
• Blood Coagulopathy * Qy_ary (stromal cells)
• Prevention of MODS in clinical set-up - * Hypothalamus
ER 13 * Kidney
Target system Convincing evidence Controversial or investigational * Brain
* Qvary (Granulosa cells)
Lung Pressure or volume limited ventilation Liquid ventilation, non-physiologic
to minimize barotrauma and volutrauma modes of ventilation (high frequency, * Lungs
oscillation) * Heart

Cardiovascular Restrict transfusion of packed red cells Supranormal oxygen delivery, non- * Prostate
when hemoglobin is > 7t crystalloid fluids; SwanGanz catheter- * Endothelial cells
ization
B) PROGESTERONE RECEPTOR
Renal Avoidance of nephrotoxins Continuous veno-venous hemofiltration • Also known as - NR 3 C 3 (Nuclear Receptor Subfamily 3)
• Location - lntracytoplasmic
Gastrointestinal Stress ulcer prophylaxis with H2 Gastric tonometry
blockers rather than sucralfate
• Genetics - Encoded by PGR gerie (Chr. _ 11)
• Location - * Breast
Enteral nutrition * Endometrium

41
 322 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL r,,:sss D Paper - I 323

C) SALIENT FEATURES □ Age : Above 50 years

• ER upregulates PR □ Sex : More common in males
} i!1 er_,c:lometrium
• PR downregulates ER □ Incidence : 10%
~ s , progesterone acts only in Estrogen primed endometrium □ Laterality : Bilateral in 10% cases
□ Clinical feature :
Breast CA types ER PR HER-2/neu ► Smooth
► Cystic
Luminal A + + -
► Soft
- ~ Luminal B + + + ',- Slow growing

··- Basal - - - ,..

►
Fluctuant sometimes
Non-tender
• Most comr:ion ~~gtype Luminal A □ Site : Lower pole of parotid gland
• B~,E prog~osis Luminal A □ Chance of malignancy: Nil
• Worsq~ro~nosis □ Investigations: 1 "Hot spot" on Tc 99 scan
2 FNAC
Selective Estrogen Receptor Modulator (SERM)
□ Treatment : Superficial parotidectomy
• Tamoxifen }
• R~i~xife; used in treatment of Breast CA Q.5: Colostomy
Ans:
Selective Progesterone Receptor Modulator (SPRM)
COLOSTOMY
• Mifepristone } used in uterine fibroids,
• Ulipr(stal acetate contraception □ What is it: Artificial opening rr_,9:c:j_~ iri colcm LE:lJ<tE:mdj11g to the s_ki11,i11.qrder to divert the faeces and
flatus
' into a "'bag
-- _ , ___kep_t on_tba.skil'.h
, _ --=--
□ Types:
2015 Supplementary
(a) Temporary - Done in case where diversion of faeces is required to facilitate healing distally
Q.1 : Fibroadenoma fr, the colon and rectum. It is closed after the purpose is solved.
A : See Section 1, Segment D, Os. 48 (Page No. 506) (b) Perma.nent - End colostomy, which remains open throughout rest of life
. Ai2 :,Bt'anchial cyst (c) Transverse - Of two types
A/:/~: See Section 1, Segment C, Paper I, 2010, Os. 3 (Page No. 287) (i) Loop ➔ 2 openings; one for stool and other for mucus. Loop of bowel is pulled out onto
abdomen and held in place with an external device
Q.3: Complications of splenectomy
(ii) Double barrel ➔ Similar openings like loop colostomy but separated by a gap, in between
,.. A ? e Section 1, Segment C, Paper I, 2013 Supplementary, Os. 1, (Page No. 305)
only proximal stoma is functioning.
, /parthin 's tumour
□ Indications :
~/l/ Ans:
(a) Temporary colostomy
WARTHIN'S TUMOUR
► Anorectal malformation
□ Synonym: ► Congenital megacolon
► Adenolymphoma ► High anal fistula
► ,Papillarycy~ta~~no~yr.1°1~~~r:11.~o~~f:1 ►
Left sided colonic growth or perforation
□ What is it: Benign tumour of parotid salivary gland
► Sigmoid volvulus
□ Site : Lowe; ;:i;~~.:roi</~,;~d:g;n~~ally·;~p;rficial lobe is only involved (b) Permanent colostomy
□ Lining: Double layer of columnar epithelium, along with papillary projections into cystic spaces and ► Carcinoma anal canal
lymphoid tissue in stroma
► AP Resection
□ Origin : Due to trapping of jugular lumph nodes in parotid gland during developmental period. ► After Hartmann's operation
324 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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□ Sites:
0 Clinical features :
(a) Temporary ➔ ► Right hypochondrium
---
► A~ymptomatic
► Left i!•ac fossa
► Complications like jaundice and P..ain when it impinges onto biliary tree
(b) Permanent ➔ Left iliac foss~: 6- cm above and medial to anterior superior iliac spine. ► l r r i t a ~ t upper quadrant
(c) Transverse ➔ Upper abdomen, in middle or towards right side of body.
► E~.'!1~~s in liver with classical thrill (hydatid thrill) elicited by three finger test
□ Complications: ► Generalised symptoms - WElig~Jl_oss,_dy~_p~psia,.fc;lti_gue, v9m]1Ln9
► Prolapse of mucosa ► Features of an§!_P~ylaxis
► Necrosis of stoma ► Sometimes, spl~..riomegaly, pleural effusion may occur
► Parastomal hernia ► Camollotte sign - Following intrabiliary rupture, gas enters into cyst causing partial collapse
of the cyst wall
► Retraction and stenosis of stoma
► Bleeding a Complications :
► Infection
► Enteritis and diarrhoea -----·-
► Rupture.. into biliary tree and surrounding structures
► Skin excoriation
► Obstructive jaundice
□ Colostomy care :
► Calcification
► Skin care to prevent excoriation
► Anaphylaxis
► Close observation for complications
► LJ~rJai11Jre
► Training to manage colostomy
□ Investigations :
► Psychotherapy
► USG abdomen
► Dressing to be done.
► QJ scanabdomen
2016 Classification based on CT findings :

► CL - unilocular anechoic cystic lesion without any internal echoes and septations
Q, 1 : Pancreatic pseudocyst
► CE 1 - uniformly anechoic cyst with fine echoes settled in it representing hydatid sand
A: See Section 1, Segment B, Paper I, Os. 6 (Page No. 231)
► CE 2 - cyst with multiple septations giving it a multivesicular, rosette, or honeycomb
Q.2 : Liver abscess appearance, within a unilocular mother cyst. This stage is the active stage of the cyst
A: See Section 1, Segment C, Paper I, 2014, Os. 5 (Page No. 314) ► CE 3 - unilocular cyst with daughter cysts having detached laminated membranes, giving
Q.3 : Marjolin 's ulcer the appearance of the water lily sign. This is the transitional stage of the cyst
A : See Section 1, Segment C, Paper II 2013, Qs. 10 (Page No. 421) ► CE 4 - mixed hypo and hyperechoic contents with absent daughter cysts; these contents
give the appearance of a ball of wool (ball of wool sign) indicating the degenerative nature of
Q.4 : Femoral hernia the cyst
.A:,/S,,se Section 1, Segment C, Paper I, 2014 Supplementary, Os. 5 (Page No. 316) ► CE 5 - arch-shaped, thick, partially or completely calcified wall. This stage of cyst is inactive
and infertile
'j':'Hydatid cyst of liver
Ans: ► Serological tests
HYDATID CYST OF LIVER ELISA
Indirect haemagglutination test
□ What is it: lnfElc:tive cystic condition __ of liver__
IFA .test
□ Causative organism : Parasite Echinococcus granulosus (dc:iil tapeworm) ► LFT
□ Structure of cyst : From outside inwards - ► Casoni's test (now obsolete)
► Perl£z'..~t / Adventitia - fibrous tissue due to reaction of liver to parasite ► _MRI abdomen (to view biliary tree and its relation to hydatid cyst)
► .Ectocyst - laminated membrane, whitish, elastic ► __
!;.BCP
► -~ndocy~sJ I Germinal epithelium - secretes hydatid fluid, brood capsules with scolices ► _p_QR
► Detection of precipitation line - arc 5
► lr:Dmunoblotting
326 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS D Paper- I 327

2016 Supplementary
□ Treatment :
A) Drug therapy -
Q.1 : Thyroglossal cyst
► Indications
A: See Section 1, Segment C, Paper II, 2008, Os. 4 (Page No. 348)
(i) 4 days prior to intervention till 1 month or 3 month after intervention depending on
drug Q.2: ~ e l l carcinoma
(ii) Multiple cysts 1,.. :"See Section 1, Segment C, Paper I, 2009, Os. 2 (Page No. 280)
(iii) Inoperable cases
Q.3 - " { ~ ~ - -
(iv) Surgically unfit patients
Ans:
(v) Cysts in lung, bone, brain FNAC
► Drugs
(i) Albendazole - 3 cycles of 4 week drug therapy followed by 2 week drug free interval □ Full form : Fine Needle Aspiration Cytology_
(10 rrig/kg!a'ay) □ What is it : Cyt()logb=il_ study of tumour cells to find out the disease and confirm its benign or
(ii) Mebendazole - ~-~ daily for 4 weeks malignant nature
(iii) Praziquantel - 60 mg/kg along with Albendazole sometimes for 2 weeks. □ Procedure :
► 23-24 Gau_g_~needle fixed to specialised syringes are used for aspiration
8) J'.f-JB (Puncture - A~irati~.r:1-~~lnlecti?n - J:leaspiration)
► Contents smeared on slides - both dry as well as those fixed with 100% methanol
► Indications
► Cytological study done after Papanicolaou, Geimsa or Romanowsky staining
(i) Infected cysts
(ii) Relapse □ Indications : Lesions of
(iii) Inoperable cases ► Parotid
(iv) Gharbi types 1 and 2 ► Thyroid - not useful in follicular carcinoma
GHARBI CLASSIFICATION : Type 1 - Pure fluid collection, Type - 2 Fluid collection+ Split ► Lymph node
wall, Type 3 - Fluid collection + septa, Type 4 - Heterogenous appearance, Type 5 ► Breast
- Reflecting thick walls ► Liver
>~/ Procedure ► Lung } USG guided
Cyst punctured ► Kidney
J,
□ Contraindication: Testicular tumour
50% fluid aspirated along with multiple daughter cysts -.......,,,-.~-~-
□ Advantages :
J,
► Done in OPD
Scolicidal agents injected
► Least invasive
J,
► Cost effective
Reaspiration after 20 minutes
► Very sensitive
C) Surgery - ► No need of anaesthesia
► <:3~_<:!_sJ_a_!)_~~PL ► No risk of tumour dissemination through the track
► Laparoscopic pericystectomy is becoming popular
□ Disadvantages :
► Procedures to correct cystobiliary communication
► Tissueytudyyot possible
(i) Suturing of communication
~~e result_~oes not rule ou_t malignancy.
(ii) Bipolar drainage
(iii) ERCP Sphincterotomy 0.4: ~scess
(iv) Tube drainage of cavity A
(v) Internal drainage procedures like choledochojejunostomy, transduodenal PELVIC ABSCESS
sphincteropoasty □ What is it: Collection of pus in rectouterine or rectovesical pouch (pouch of Douglas)
□ Speciality : Most common intraperitoneal abscess -- -
 328 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 329

□ Etiology: □ Pathogenesis :
';,, Pelvic infections Bowel loop is obstructed at its point of entry and exit creating closed loop
j,
► Appendicitis
► Sequalae of diffuse peritonitis Necrosis and gangrene at site of obstruction and over convex summit of bowel loop
j,
► Postoperative cases of abdomen
Perforation from these sites
□ Clinical features :
j,
► Mucus discharge per rectum
Peritonitis
► Diarrhoea
► Lower abdominal pain and distension
INTESTINAL OBSTRUCTION
► Fever with chills and rigor
► Frequent burning micturition □ Pathophysiology of mechanical obstruction:
□ Examination ( 1) The l)roximal portion of gut contracts vigorously to overcome the distal obstruction. This
leads to__ spasmodiQJ)ain and is known as abdominal colic.
P/R ➔ Soft, boggy, tender swelling in anterior wall of rectum
(2) The p_rQ_~i_r!l_al portion of gut gets distended due to collection of fluid and gas giving rise to
□ Investigations : abdominal distension.
► Raised TLC (a) Fluid is collected due to -
► USG abdomen - diagnostic (i) Salivary secretion - 1500 cc in 24 hours
► CT abdomen (ii) Gastric secretion - 2500 cc in 24 hours
□ Treatment : (iii) Bile and pancreatic juice - 1000 cc in 24 hours
► Antibiotics started (iv) Succus entericus (int, external secretion) - 3000 cc in 24 hours
► Abscess drained per-rectally under G/A after urinary catheterisation (b) Air comes from -

//
/,,,,,-----► Laparotomy required sometimes (i) Swallowed air during respiration
' : /1J,,8':Closed loop obstruction (ii) Diffusion of CO2 from the distended veins into lumen
\_,,--\' ,·· (iii) Putrefaction of the intestinal contents
· Ans:
CLOSED LOOP OBSTRUCTION (3) The stagnant material in the proximal gut is regurgitated into the stomach and finally comes
out as vomit,Y.S
□ What is it : Type of intestinal obstruction in which two points along the course of a bowel are (4) The distal portion of the gut is thrown into continuous spasm (no peristalsis) Hence, there is
obstructed at a single location thus forming a closed loop no passage of faeces, or flatus. This is known as ~e_~lu!~ constipation.
□ Etiology: Secondary to adhesions, twist of mesentery or herniation. The closed loop rotates around (5) During this process, there is loss of fluid and electrolytes leading to dehydration and exhaustion
its axis forming a volvulus. (muscular weakness). It is due to -
(i) Vomiting
Proximal bowel (ii) Sequestration of fluid into intestinal lumen (fluid collected in the intestine does not get
loop absorbed. Hence, it is cut off from blood circulation. So, there is hypovolaemia which may
lead to shock)
(6) Due to enormous stretching of the wall, there is vascular jeopardy (loss of circulation in the
wall) which finally may lead to gangrene, perforation and peritonitis

□ Clinical features :
Closed (dilated) loop (1) Acute colicky abdominal pain
(2) Abdominal distension (distension more in upper abdomen in case of small intestinal
Distal bowel loop obstruction. In large gut obstruction, distension is more in lower abdomen and flanks)
(3) Vomiting - It is more characteristic of small gut obstruction. In large gut obstructio'.;, vomiting
may be absent.
(4) Absolute constipation (no flatus, no faecus)
Fig. : Closed loop obstruction

42
330 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 331

(5) Features of dehydration - dried tongue, sunken eyes, features of electrolyte loss, extreme Maintenance of fluid chart and administration of fluid based on calculation - The loss of the fluid is
fatigue, muscle weakness, lethargy, dried skin measured by : (i) amount of nasogastric aspiration

l
(ii) urine output
□ Investigations: Total output
(iii) invisible perspiration - 500 cc approx.
(1) Blood-
(iv) respiratory loss - 500 cc approx.
(i) Routine examination - Hb, TC, DC, ESR, etc
(ii) Special examination -(a) Sugar, (b) urea, (c) creatinine, (d) electrolytes, (e) serum analyse Intake should be according to output so that the loss is corrected but there will be no overloading
(If overload - Rx Lacix, Furosemide to induce diuresis)
(2) X-Ray-
[It is known as Fluid Administration with Maintenance of Intake - Output Chart]
(i) Straight X-Ray of abdomen -
(a) Free gas under diaphragm indicates perforation (iii) Antibiotics - There is stagnation of intestinal contents leading to proliferation of the
bacteria which are normally present in intestine (coliforms). There may be toxic effects
(b) Distended intestinal shadows - The characteristic radiological features of each portion
which are combatted by antibiotics (specially Metronidazde)
of gut are -
(iv) In-dwelling catheter - To measure 24 hour urine output
Ileum - featureless (wall is straight)
Jejunum - concertina effect (The valvulae connevantis of the jejuna! mucosa How to understand if abdomen is distended ?
are seen in a regular rythmic fashion) Take a string - tie it around abdomen at level of umbilicus - now see (if any groove formed or not i.e.)
Colon - presence of haustrations (colonic shadow) whether it becomes tightend ➔ distension progressing OR loosened ➔ distension degressing
□ Follow-up :
(a) Clinically - regarding distension, vomiting, etc
(b) Biochemically - about electrolytes
Results - (i) condition improving
Ileum Opposite to (ii) condition deteriorating
Haustrations not each other
opposite
other to each_ _..,....,.___ Effect- (i) If improves, continue conservative treatment
(ii) If deteriorates - operative intervention

□ Surgical treatment :
A. Indications -
Jejunum (1) conservative treatment fails
(2) rebound tenderness (suggests gangrene of gut)
abdomen needs to
(3) if rigidity appears - peritonitis ] be opened
(4) if perforation cannot be differentiated
Fig : Intestinal obstruction
(5) if paralytic ileus develops
8. Steps of operation -
Presence of multiple fluid level with distended intestinal / gas shadows (1) Abdomen is opened by lower right paramedian incision ➔ (to see the caecum)
Gas black ➔ shadow (2) Caecum is identified [See Chart on the next page]
Fluid ➔ white shadow Procedure to check the viability -
Gas will exert equal vertical pressure on liquid. Hence horizontal level of fluid
Under normal condition, gut has the following characteristic features -
(3) USG - doesnot help to diagnose intestinal obstruction but is important to differentiate from
(i) Pinkish in colour
acute cholecystitis or acute pancreatitis
(ii) Normal lustre
D Treatment : (iii) Peristaltic movements present
(A) Conservative treatment (iv) On needle-prick, there is bleeding from the wall
(i) nasogastric suction - to decompress the distended intestine; (v) Pulsation is present in the mesenteric artery
(ii) i.v. fluid-to compensate loss of fluid and electrolytes (glucose ➔ for nutrition, electrolytes
When the viability is doubted,
➔ to correct electrolyte imbalance)
(i) the colour may change into black
[ calculate the electrolyte loss and infuse specific fluid accordingly ]
(ii) lusture may be lost
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 333
332 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Q.4 : Sentinel node biopsy

(2) Caecum is identified A: See Section 1, Segment C, Paper 11, 2010 supplementary, Os. 13 (Page No. 388)

I .J,,
.J,,
Caecum collapsed Caecum distended MESENTERIC CYST
J, J,
Large intestinal obstruction □ What is it: Cystic lesions in mesentery, can occur anywhere from(duodenum)to[fec1'lim)
Small intestinal obstruction
□ Major types :
~ /
Reach a junction of distended and
..Features
~------····· c· Enterogenous
collapsed part of the gut ~~~-~_i_:)
l Origin ~ongenitally misplaced lymph~tic .. Diverticulum or d_l/fl!l9?tionJrom
This is the site of obstruction .ststem_ c1~j_acent bowel

l Wall Thin; with flat endothelium Thick (contains all layers of bowel)

Obstruction relieved Blood supply Independent From adjacent

l Enucleation Done Not done

In lumen In wall Outside wall Other features • Mainly in ileum

• Contain lymph/ chyle
l • Solitary
Viability of gut is checked
• Unilocular
(i.e. if alive or not)

I .J,,
□ Other causes I types :
J ► Cysts of urogenital remnant
Viable Non-Viable
► Hydatid cyst of mesentery
J, J,
► T eratomatous dermoid cysts
Keep it inside and Resection and
anastomosis ► Cyst I haematoma formation following trauma
close the abdomen
► Tuberculous cold abscess of mesentery
□ Clinical features :
(iii) peristaltic movements absent I sluggish
Abdominal swelling - painless
(iv) needle-prick doesn't cause bleeding
- smooth
(v) pulsation of mesenteric artery absent/ feeble
- fluctuant
Under these conditions, hot-mop is applied. If the conditions improve, i.e., colour returns, lustre
peristaltic movements come back, there is bleeding on needle prick, mesenteric arteries are pulsated, - freely mobile in direction
the gut is viable. If not, gut is non-viable. - not moving with respiration
□ Tillaux's triad:
2017 ► Soft, smooth swelling in umbilical region
► Freely mobile in a direction perpendicular to mesentery
Q.1 : Alvarado Score ► Zone of resonance all around
/ A :~ Section 1, Segment C, Paper 11, 2011, Os. 11 (Page No. 396)
□ Age group : Childhood, more common in 2nd decade
J::_~arotid abscess ~';:,.~.....,..

□ Investigations:
· ···· A: See Section 1, Segment C, Paper 11, 2011, Os. 8 (Page No. 395)
► USG Abdomen
Q.3: Gastrinoma ► CT Scan abdomen
A: See Section 1, Segment B, Paper I, Os. 8 (Page No. 240)
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□ Treatment :
2018 Supplementary
► Chylolymphatic cyst ➔ enucleation
:,.- Enterogenous cyst ➔ removal of cysLwith resection of adjacent bowel Q.1 : Sentinel Node Biopsy
□ Complications: . A: See section 1, Segment C, Paper II, 2010 supplementary, Q 13, (Page No. 388).
:,.- Torsion of cyst Q.3: Pleomorphic adenoma
:,.- !1lJE!Ure
:,.-
,,
Infection
Haemorrhage
/-
A: See Section 1, Segment C, Paper II, 2012, Q 5 (Pleomorphic salivary adenoma), (Page No. 406).
~ w anterior resection of Carcinoma rectum
A: In Rectal carcinoma -
□ Differential diagnosis :
,, Hydronephrosis (a) Surgery is the main method of treatment.
► Omental cysts (b) ~domino-Perioeal Reseclioa .{Af:ill. is the gold standard.
,- Tuberculosis (c) But if Tumor is well differentiated and if there is adequate margin above the anal canal, a sphincter
Sc!\{]~nterior Resect[Qn..(AR) may be done. ·---
2017 Supplementary (d) Total Mesorectaj Excision (TME:) should be the goal.
(e) Principles of surgery -
Q. 1 : Sigmoid volvu/us • Distal margin - 2cm away from the lesion
A: See Section 1, Segment D, Q 108 (Volvulus), (Page No. 567). • Proximal margin - 5cm away from the lesion
Q.2: Tuberculous cervical lymphadenopathy • Radial margin - 3cm of mesorectum to be removed
(f) ~aparoscopic AR is becoming popular.
A; See Section 1, Segment D, Q 82 (Collar Stud abscess), (Page No. 539).
,/// (g) Proper preoperative bowel preparation -
1 ().3.;Keloid
• Low residue diet for 48-72 hour before surgery, only clear liquid on day before surgery, no
(/v/ A: See Section 1, Segment C, Paper II, 2013 Suplementary, Q 9, (Page No. 426). feed on day of surgery
Q.4: Ranula • Elemental diet for 3-5 days before surgery
A: See Section 1, Segment D, Q 68, (Page No. 526). • Single dose of oral polyethylene glycol dissolved in 2It of water on day before surgery
Q.5: Choledochal cyst • Bowel wash using normal saline for 2-3 days before surgery
• Total gut irritation
A: See Section 1, Segment D, Q 42, (Page No. 501 ).
• Antibiotics
(h) Criteria for anterior resection -
/'✓,-
2018
/'// • Upper and middle third rectal growth
/4~/(~iagnostic peritoneal lavage • Above peritoneal reflection
• Well-differentiated Tumor
// A: See Section 1, Segment E, Q 2, (Page No. 580).
• < 4cm size Tumor
Q.2: Colostomy • T1 N0/T2i~0 Tumor
A: See Section 1, Segment C, Paper I, 2015 Supplementary, Q 5, (Page No. 323). • Tumor without lymphatic or venous spread.
(i) Preoperative and postoperative radiotherapy
Q.3 : Molecular subtypes of Breast carcinoma ti) Chemotherapy -
A : See Section 1, Segment C, Paper I, 2015, Q 5 (Estrogen and Progesterone receptors), (Page -• Neoadjuvant
No. 321).
• Adjuvant
Q.4: lntussusception /~liative
A: See Section 1, Segment C, Paper 11, 2013, Q 9, (Page No. 420). ~-,;:~lignant melanoma

Q.5 : Amebic liver abscess A : See Section 1, Segment D, Q 71 (Melanoma), (Page No. 529).

A: See Section 1, Segment C, Paper I, 2014, Q 5, (Page No. 314).

336 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 337

//
7
:Subphrenic Abscess
2019 □ Pathogenesis :

Bacterial _,. Hyperemia Ecudative _2_-_4_h_r,. Neutrophilic _,. Activation of mast cells,
Contamination fluid Macrophages exudate mesothelial lining cells
SUBPHRENIC ABSCESS
□ What is it : Localised collection of pus underneath right or let~ hemi-diaphrag_m
Abscess - Compartmentalization - Fibrin - Cytokines, Procoagulants
!
□ Speciality : Most common intra abdominal abscess of peritonitis
□ Anatomy:
a) Left subphrenic space : Boundaries as follows - □ Factors favouring abscess :
Above ➔ diaphragm
Behind ➔ Left triangular ligament, left lobe of liver, gastrohepatic omentum and anterior
surface of stomach
Local factors Microbial factors
Right ➔ Falciform ligament
Left ➔ Spleen, gastrosplenic omentum, diaphragm • Local fibrin deposition • Polymicrobial Flora
• Low pH • Bacteroides fragilis
b) Right subphrenic space : Boundaries as follows -
• Particulate stool • Capsular polysaccharide
Above ➔ Diaphragm
• Hypoxia
Below ➔ Right lobe of liver
Behind ➔ Anterior layer of coronary and right triangular ligaments □ Clinical features :
Left ➔ Falciform ligament • Mostly non-specific (remember 'pus somewhere, pus nowhere, pus under the diaphragm)
• Symptoms of toxaemia reappear after a few days of dealing with some intra-abdominal
infective focus
'-..) • Condition steadily and often rapidly deteriorates
--- .... _ • Sweating
---....1 ,._....,',,__,
,._ \
•
•
Wasting and anorexia
High spiking fever with chills
• Tachycardia
• Tachypnoea
• Epigastric fullness
• Pain in shoulder of affected side
• Persistent hiccough
□ Investigations:
• Chest X-ray- Collapse of lung, basal effusion, empyema, elevated diaphragm, air fluid level
lntraperitoneal abscesses on sagittal section : (1) Left subphrenic; (3) Right • USG Abdomen
subphrenic. • CT Abdomen - Low alternation, lucent centre with rim enhancement
• MRI
□ Management :
□ Causes of abscess :
• i.v. fluids
a) Left side : Operation of stomach, tail of pancreas, spleen or splenic flexure of colon
• Antibiotics
b) Right side :
• Initial resuscitation is very crucial
• Perforating cholecystitis
• CT guided drainage of abscess (Drain withdrawn over 10 days)
• Perforated duodenal ulcer
• Duodenal-cap 'blow-out' following gastrectomy and appendicitis Q.2: Complications of splenectomy ~
A: See Section 1, Segment C, Paper I, 2013 Supplementary, 0.1, (Page N\305)_)
'-: '--., - - -:, i

43
 338 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 339

Q.3 : Femoral Hernia UMBILICAL HERNIA IN ADULTS GI;u~~~~;~~NIA))

A: See Section 1, Segment C, Paper I, 2014 Supplementary, Q.5, (Page No. 316) □ Causes : Conditions that cause stretching and thinning of linea alba -
• Pregnancy
Q.4 : Adenomatous polyps of co/0,1
• Obesity
A: See Section 1, Segment D, Q.47, (Page No. 505) • Liver disease with cirrhosis
Q.5: Tuberculous Cervical Lymphadenopathy □ Defect : Rounded with well defined fibrous margin
A: See Section 1, Segment D, Q.82 (Page No. 539) 'Collar Stud Abscess'. □ Location: Defect in median raphe is immediately adjacent to (most often above) the true umbilicus
□ Content : Small hernia ➔ extraperitoneal fat or omentum
2019 Supplementary Larger hernia ➔ small or large bowel
□ Complications : Umbilical hernia that includes bowel may become irreducible, obstructed and
a. 1 : Amoebic liver abscess strangulated
A: See Section 1, Segment C, Paper I, 2014, Q.5 (Page No. 314) □ Clinical features :
Q.2: Rupture of the Spleen • Overweight (with thinned and attenuated midline raphe)
• Bulge typically slightly to one side of the umbilical depression ➔ crescent shaped umbilicus
A: See Section 1, Segment A, Paper I, 2010 Supplementary, Q.3 (Page No. 31)
• Abdominal pain due to tissue tension
Q.3 : Pseudocyst of the pancreas • Symptoms of bowel obstruction
A: See Section 1, Segment B, Paper I, Q.6 (Page No. 231) • Overlying skin - Stretched, thinned, develop dermatitis
□ Sex affected : Females > Males
Q.4: Diagnosis of acute small bowel obstruction
□ Treatment :
A: See Section 1, Segment C, Paper I, 2016 Supplementary, Q.5, (Page No. 328) & See Section 1,
Segrrient D, Q.72 (Page No. 531) • Small hernia - Left alone if assymptomatic
• Large hernia - Mostly contain bowel, hence surgery advised
/ /O~p,:'llmbllica/ Hernia ► Defects < 1 cm ➔ Closed with simple figure of 8 suture
,/· ...,./
OR
UMBILICAL HERNIA
Repaired by Darn technique (non-absorbable, monofilament suture is criss crossed
□ What Is it: A type of ventral hernia i.e., hernia on anterior abdominal wall across the defect and anchored firmly to the fascia)
□ Defect : Umbilical defect is present at birth but closes as the stump of the umbilical cord heals, ► Defects 1 - 2 cm ➔ Sutured with minimal tension (classic repair described by Mayo)
usually within a week of birth. If this process is delayed, it leads to herniation. ► Defects> 2 cm ➔ Mesh repair (Mesh may be placed in (a) within peritoneal cavity, (b) in
retromuscular space, (c) in extraperitoneal space, (d) in subcutaneous plane)
UMBILICAL HERNIA IN CHILDREN
□ Incidence : 10% of infants, higher incidence in premature babies
December-January 2019-2020
□ Timing: Appears within few weeks of birth
□ Sexes affected : Both male and female Q.1 : Parotid fistula.
, I
□ Symptoms : Often symptomless, but increases in size on crying and assumes a classic conical A : See Sec· n 1, Segment D, Q.116 (Page No. 574-575)
shape
Q.2:
\ ',~,,/ ,, _,,,,.,
□ Complication : Obstruction and strangulation rare below 3 years age · ·· A: See Section 1, Segment D, Q.114 (Page No. 573)
□ Treatment:
Q.3: Vo/vu/us
• Conservative management when asymptomatic below 2 years age
A : See Section 1, Segment D, Q.107 (Page No. 567)
• Parental reassurance (95% resolve spontaneously)
• Surgical repair if persists beyond 2 year age Q.4: Idiopathic Thrombocytopenic Purpura {ITP)
(Small curvilinear incision below umbilicus ➔ neck of sac defined, opened and any contents
returned to peritoneal cavity ➔ sac closed ➔ redundant sac excised ➔ defect in linea alba
IDIOPATHIC THROMBOCYTOPENIC PURPURA
closed with interrupted sutures) □ What is it: The most common cause of acute onset thrombocytopenia in otherwise normal child
340 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - I 341

□ Incidence : 1 in 20,000 children ► History suggestive of bone marrow syndrome or malignancy

□ Predisposing factor: Viral infection in recent past (most common Epstein Barr virus infection) Direct Coomb's Test
•
□ Peak age group : 1 - 4 year old. Q 0/0:
□ Pathophysiology: • SLE
Autoantibody develops directed against platelet surface • HIV infection
J, • Lymphoma
Antibody binds to platelet surface □ Treatment :
J, • Counselling and education for mild, moderate symptoms
Circulating antibody coated platelets recognised by • Intravenous immunoglobulin 0.8 - 1g/kg /day for 1-2 days
FC receptor on splenic macrophages ➔ ingested ➔ destroyed • Intravenous Anti D therapy @ 50 - 75 µg/kg
• Prednisolone 1 - 4 mg/kg/day - continued for 2 - 3 weeks
• Splenectomy :
Indications are -
i) > 4 year age with chronic ITP
ii) Not responding to medical management
----➔- Iii) lntracranial hemorrhage
O Prognosis :
• Spontaneous resolution in 70 - 80% cases
Antiplatelet antibody Sensitized platelet • < 1% develop intracranial hemorrhage
Antibody coated platelet binds • 20% develop chronic ITP
to macrophage • ITP in younger children more likely to resolve

Q.5: Acute N~~'!t,;,J~creatitis

□ Clinical presentation :
•
•
Sudden onset generalised petechiae and purpura
Age : 1 - 4 year
:+:1/ ACUTE NECROTISING PANCREATITIS

• Associated bleeding from gums and mucous membranes □ Revised Atlanta Classification 2019 - Morphological Types
• History of preceeding viral infection Necrotising Pancreatitis
• No lymphadenopathy, joint pain, hepatosplenomegaly
□ Classification : Type of Collection Time (W/c) Necrosis Infection Location Appearance
Class 1 ➔ No symptoms
• Sterile ANC ~ 4 Yes No In parenchyma Heterogenous, non-
Class 2 ➔ Mild symptoms
&/or extra liquified material,
Class 3 ➔ Moderate symptoms • Infected ANC Yes Yes
pancreatic variable loculated,
Class 4 ➔ Severe symptoms - menorrhagia, epistaxis, requires transfusion not encapsulate
□ Investigations:
• Severe thrombocytopenia (platelet count < 20 x 10 9/lt) • Sterile WON In parenchyma Heterogenous, non-
Yes No
• PBS ➔ platelet size normal or increased >4 &/or extra liquified material,
• Infected WON Yes Yes pancreatic variably loculated,
• • Normal Hb, TLC, DLC
encapsulated
• Bone marrow study ➔ Normal or increased megakaryocytes
Indications for bone marrow aspiration / biopsy -
► An abnormal WBC count
► Unexplained anaemia
 342 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 343

□ Pathophysiology: sepsis, CT guided needle aspiration done ➔ if purulent ➔ percutaneous drainage of

infected fluid ➔ if sepsis worsens despite this ➔ pancreatic necrosectomy done
Mucosa! ischaemia/Reperfusion injury
t t
Impaired local immunity/bacterial overgrowth /---~- If further necrotic tissue forms - the

t
Increased intestinal permeability
t
,~

------
·---._ options are (any 1 of the 4) -
i) Closed continuous lavage (Beger's method)
ii) Closed drainage
iii) Open packing
Bacterial translocation
iv) Closure & relaparotomy (Bradley's method)
Blood-bone dissemination t Direct contamination (interven-
(Distant infection) __.. Necrosis infection ~ tional procedure/surgery)
June-July 2020
□ Pathogenesis :
Pancreatic necrosis refers to diffuse or focal area of non-viable parenchyma
------- ----- ----------'----~
Identified by absence of parenchymal e_nhancement on CECT A: See Section 1, Segment C, Q.11 (Page No. 380)
/"
Associated with lysis of peripancreatic fat 0.2: Fibroadenoma
Initially, leads to acut~ necrotic collection (ANC) - intra or extrapancreatic collection A: See Section 1, Segment D, Q.48 (Page No. 506)
containing fluid & necrotic material, wHh no definable wall
• Gradually, over 4 wks, develops a well-definedinflammatory capsule ➔ walled off necrosis /43 : Liver abscess
(WON) A: See Section 1, Segment C, Q. 5 "Amoebic Liver Abscess" (Page No. 314)
Initially sterile collection, later on infected due to translocation of gut bacteria.
PYOGENIC LIVER ABSCESS
□ What is it : Local complication of acute pancreatitis.
Etiology: (Mostly unexplained)
□ CECT Criteria :
• Biliary stone disease
,v"~-
c __
• Appendicitis
Acute necrotic collection (ANC) Walled off necrosis (WON) • Diverticular disease

• Occurs only in setting of acute
-
necrotising _p_13ncre~titis
• Heterogenous & non-liquid density of
varying degrees in different location
• No definable wall encapsulating the
collection
• Requires 4 wks after onset of acute Pathogenesis : 4 major ways in which pyogenic organisms invade the liver
necrotising pancreatitis I) Travel through portal vein
2) Blood borne infections
• Heterogenous with liquid & non-liquid
density varying degrees of loculations 3) Direct extension from a contiguous infection
4) Trauma
• Completely encapsulated
Predisposing factors :

• 1) Elderly
Location - intra/extrapancreatic • Location - intra/extrapancreatic
2) Diabetes
3) lmmunocompromised
□ Management : Clinical features :
• Early aggressive fluid resuscitation 1) Anorexia
• i.v. antibiotics - Metronidazole, 3rd generation cephalosporins, carbapenems 2) Fever
• Analgesics - NSAIDs, Opiates 3) Malaise
• Nasojejunal feeding 4) Right upper quadrant discomfort
• Respiratory support 5) Nausea, vomit
6) Cough
• Sterile necrotic material should not be drained or interfered with. If patient shows signs of
7) Chest pain
 344 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 345

□ Investigations:
Spine
1) USG }
Multiloculated cystic mass (double target sign on CT)
2) CT Scan (confirmatory)
(Followed by aspiration for culture and sensitivity)
3) Blood culture
4) Culture of aspirated fluid
5) PCR - in culture negative pus
6) Chest X-ray- Right lower lobe atelectasis, right pleural effusion, elevated right hemidiaphragm
0 Organisms:
Urorectal septum partially developed
1) Streptococcus milferi
Fig. 1.5.1 : Cloacal deformity Fig. 1.5.2 : Anorectal agenesis
2) Eschericia coli
3) Klebsiella sp.
4) Proteus sp.

□ Management : ----v------
1) Emperic broad spectrum parenteral antibiotic ➔ therapeutic regimen revised once culture
and sensitivity report available
• 1st line antibiotics - Penicillin, Aminoglycoside and Metronidazole OR Cephalosporin
Anal canal
Persistent anal
~~--~membrane v
2)
& Metronidazole
USG Guided aspiration - Often repeated aspirations needed
~
- If multiple abscess, only largest abscess may need to be aspirated Fig. 1 .5.3 : Imper/orate anus Fig. 1.5.4 : Covered anus
3) Surgical drainage needed if -
1) multiple abscess
2) loculated abscess
3) abscess with viscous content obstructing drainage catheter
4)
5)
underlying disease requiring primary surgical management
inadequate response to percutaneous drainage within 7 days --v------ ----v---- 0
0.4: Thyrog/ossal cyst
A: See Section 1, Segment C, 0.4 (Page No. 348) 0
~
,c/ .-

i ~.5/Keloid
\X// A : See Section 1, Segment D, Q. 9 (Page No. 426) Fig. 1.5.6 : Microscopic anus
Fig. 1.5.5 : Ectopic anus

Chest drain

Triangle of safety

Water seal bag

Fig. 1.5.7 : lntercostal drain

44
346 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

SEGMENT-C
Central necrotic zone
SOLVED SHORT NOTES OF FINAL MBBS
Paper- II

Destruction of
parenchymal 2008
cells Q.1 : Venous ulcer
A: See Section 1, Segment - C, Paper-I, 2013, Os. 2. (Page No. 301-302)
__,,___ Adjacent to
fibrous capsule Q.2: Epididymal cyst
(amoeba found)
EPIDIDYMAL CYST
□ Origin : Congenital
Fig. 1.5.8 : Microscopy (pathology) of amoebic liver abscess
□ Causes : Cystic degeneration of -
(1) paradidymis (organ of Geralde)
(2) appendix of epididymis
(3) appendix of testis
(4) vas aberrans of Haller
□ Age : Middle age
Internal
Supra- □ Clinical features :
sphincter
Levator
a) Bilateral
b) Tensely cystic
c) Multiloculated
d) Contains clear fluid
e) Feel like 'bunch of tiny grapes'
f) Because of numerous septae, they are 'finely tessellated ➔ so brilliantly transilluminant,
appear like "Chinese lantern" pattern
□ Location: Behind body of testis
□ Treatment :
Levator ani
a)· Avoid excision as much as possible as it results in infertility due to blockage
b) Excision in old age
lschiorectal □ Differential diagnosis :
a) Spermatocele
b} Encysted hydrocele of cord
Q.3: Tetany
TETANY
□ What is it : Increased excitability of peripheral nerves due to hypocalcaemia or alkalosis or
Fig. 1.5.9 : Fistula-in-ano
hypomagnesaemia
□ Causes:
a) Due to hypocalcaemia -
1) Hypoparathyroidism
2) Malabsorption
3) Acute pancreatitis
4) Osteomalacia

347
348 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS O Paper - 11 349
,,-~
I
~-
5) Chronic renal failure c) Swelling moves upwith protrusion of tongue
6) Wilson's disease d) Fluctuation test positive
7) DiGeorge's syndrome e) Transillumination test negative
b) Due to alkalosis -
1) Hyperventilation
2) Repeated vomiting of gastric juice
3) Excessive intake of alkalis
I □ Complications:
a)
b)
c)
Infection
Rupture
Fistula
□ Clinical features :
1) Circumoral paraesthesia
I
I
□ Investigations :
a) Radioactive iodine scan

I
2) Carpopedal spasm - Twitching and weakness of foot and digits b) USG neck
3) Chvostek's sign - Tapping above angle of jaw to stimulate branches of facial nerve causes c) FNAC from the cyst
twitching of angle of mouth and eyelids · □ Treatment :
4) Trousseau's sign - Carpal spasm when sphygmomanometer applied to arm and pressure E,ccision of thyroglossal cyst along with throglossal duct, and part of hyoid bone (Sistrunk operation)
raised above systolic blood pressure
5) Stridor Q.5 : Dermoid cyst
6) Mimicking convulsions
DERMOID CYST
□ Investigations:
1) ECG - Prolonged QT interval There are 4 types of dermoids -
2) Low serum calcium
□ SEQUESTRATION DERMOID-
3) Low parathormone
• What is It : Cyst arising from ectoderm
□ Treatment :
• Pathogenesis : Few of the ectodermal cells get sequestered into the deeper layers, form a
1) Calcium gluconate : 10% - 10 ml; 6-8 hourly
cyst and get filled up with secretions from the lining epithelium
2) Oral calcium 1gm thrice daily + vitamin D supplementation daily
[See Fig.1.6.1] ·
3) Magnesium sulphate supportive therapy
• Sites:
4) Re r follow-up
a) Post auricular dermoid
b) Root of nose (Internal angular dermoid)
c) External angular dermoid
THYROGLOSSAL CYST d) Sublingual dermoid
• · Extension into:
□ What is it : Cystic midline swelling of neck formed from unobliterated portion of thyroglossal duct
a) Dermoids in skull ➔ cranial cavity
□ Anatomy:
b) External angular dermoid ➔ orbital cavity
• Thyroglossal duct or median thyroid diverticulum extends from foramen caecum to 2nd
tracheal ring._ and usually gets obliterated • Contents:
• When it does not get obliterated completely, a cystic swelling may arise due to collection of a) Desquamated material
secretions fr.9m the lining ~ J : D b) Hair follicle
D Sites: c) Sweat glands
d) Sebaceous glands
a) Beneath foramen caecum
b) In floor of mouth • Age : 20-30 years
c) Suprahyoid • Clinical features :
d) Subhyoid Swelling with following features -
e) On the thyroid cartilage
a) Soft
□ Pathology : Lined by pseudostratified ciliated columnar epitheliu'!' b) Smooth
□ Clinical features : c) Nontender
a) A swelling_ situated in frg_o.LaLneck d) Transillumination test negative
b) Swellin_9._ moves ":'.i~~?.921utition . ~:~...... e) Fluctuant (Paget's test positive)
350 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS D Paper - 11 351

f) Overlying skin can be lifted up Features Exomphalos major __ Exomphalos minor

g) Resorption and indentation of bone underneath (bone guttering) /"'/"'-
-·'1 .) ;,- ··•;j
h) Impulse on cough if extension into intracranial cavity Sac size / > 5 cm
' ..----:-. ;'.
__
.,
.<5Cm

• Differential diagnosis : Umbilical cord Inferior aspect of sac At the summit of sac
a) Sebaceous cyst attachment
b) Lipoma Content Small intestine, large intestine, liver Small intestine
• Complications : Primary closure Not possible Possible
a) Infection Poor Good
Prognosis
b) Hemorrhage
c) Calcification Treatment 1) Vitamin K injection Sac twisted to reduce contents
d) Compression of structures 2) Antibiotics into peritoneal cavity ➔ abdomen
e) Ulceration 3) TPN strapped firmly ➔ removed after
4) 0.5% mercurochrome + 65% 14 days
• Investigations :
alcohol to promote granulation tissue
a) X-Ray of the part formation
b) CT scan of the part 5) Wrap silastic silo around content
• Treatment: 6) Definitive surgical procedure if other
Enucleation of cyst along with proper haemostasis measures fail

□ TUBULODERMOID -
Arises from embryonic tubular structures like thyroglossal cyst, postanal dermoid, ependymal cyst Q.7: Skin grafting r.~---/
□ IMPLANTATION DERMOID-
./ SKIN GRAFTING
Painless, soft, smooth, tensely cystic, non-transilluminating swelling, often adhered to skin, found in □ What Is It: Transfer of skin from donor area to required (recipient) area
finger tips, as a result of minor pricks or trauma, due to which epidermis gets buried in deeper
subcutaneous tissue, and degenerates to form a cyst □ Types:
a) _Partial thickness graft
□ TERATOMATOUS DERMOID - b) . Full thickness graft
Arises from germinal layers; found in ovary, testis, etc.
□ PARTIAL THICKNESS GRAFT
• Synonyms:
EXOMPHALOS a) Split thickneSS..Jl!.,~ft
b) Thiersch graft
Synonym:~~~- • What is it: Tr:.~.r:i.¥er _Qf full epidermis and_Q_aJtQ[ dermis_from donor to recipient area
□ Define : Developmental anomaly _9.ue JQJailur~_oL~b.QL~L.Q! part of~Jhe midgut to return in.toJ_he • Types:
. ~g_gominalcavity during early foetal life a) Thick
b) Intermediate
□ Sac covering :
c) Thin
a) Outer layer - Amniotic membrane
b) Middle layer - Wharton's jelly • Indications :
c) Inner layer - Peritoneum a) Clean wound which cannot be apposed
□ Associated congenital anomalies : b) Well granulated ulcer
a) Beckwith Weidman Syndrome - exomphalos + macroglossia + gigantism c) After surgery to cover and close defect
b) Chromosomal triso.mies - 13, 15, 18, 21 . • Contraindications : Not used over bone, tendon, cartilage, joint
c) \/jtello.irrt~stinal_duct anomaly + diaphragmatic hernia + malrotation of gut • Pre-requisites :
d) Bladder extrophy a) Healthy granulation tissue
e) _lmperforate anus b) Beta hemolytic streptococci load< 10 5 /gm of tissue
f) ~eningor11y~Qc::_~1.e_
352 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS O Paper - 11 353

• Instruments used : • Advantages :

(a) No contracture
(a) Watson modificationof Humb_y's,knife
(b) Good colour match
(b) Down's bl.ade.
(c) Sensation better retained than SSG
(c) .Power dermatome
(d) Eschmann blaae • Disadvantages :
(e) -Sterilised razorblade (a) Cannot cover ulcers
• Donor area (Cfene.rally-thight (b) Used only for small areas
• Procedure :
--------·····~-.- --~
Q.8 : Spinal anesthesia
► Donor area - A : See Section - 3, Qs.1 (Page No. 753)
(a) Graft taken using Humby's knife
Q.9: Double contrast enema
(b) Punctate bleeding indicates proper graft removal
(c) Dressing - Opened after 10 days A: See Section - 1, Segment - E, Os. 8 (Page No. 585)
► Graft area - Q.10 : Brachytherapy
(a) Scraped well
(b) Window cuts on graft BRACHYTHERAPY
(c) Graft placed and fixed
(d) Tie-over dressing □ What is it: Radiation given with the source placed very close to the tumor
(e) Mercurochrome applied □ Radionuclides used:
(f) Dressing opened on 5th day
1) Iridium 192
• Stages: 2) Caesium 137
(a) Stage of plasmatic imbibitions 3) Iodine 125
(b) Stage of inosculation 4) Gold 198
(c) Stage of neovascularisation
□ Types:
• Storage : 4 degree Centigrade for upto 21. days
1) Surface brachytherapy - Use moulds
• Advantages : 2) lntracavitary brachytherapy - Radiation material placed in cavity
(a) Wide area covered 3) Interstitial brachytherapy - Radiation material inserted into the tumor mass
(b) Easier to perform
□ Advantages :
(c) Reduced chances of graft rejection
a) Spares deeper and adjacent tissues
• Disadvantages :
b) Surgery can be avoided
(a) Hematoma c) Short time required
(b) Contractures
d) Small dose required
(c) Infection
e) Less side effects
(d) Graft failure
f) Curative and effective in early cancers
(e) Loss of hair growth
□ Disadvantages :
□ FULL THICKNESS GRAFT
a) Costly
• Synonym : Wolfe J!!:_i:lft b) Technical difficulty
• What is it : §~in__.9raft including full dermis and epidermis c) Local complications
Sites where used : · · ·~---· d) Less available facilities
•
(a) Face Q.11: Dental cyst \ ~ - -
(b) Eyelids ~ DENT AL CYST
(c) Hands
□ Synonyms:
(d) Fingers
(e) Over joints • _feriaEi~~l_g)(s.t
• f=l~~icular cyst
• Donor areas :
□ What is it: Epithelial odontome (cyst or tumor of the jaw)
(a) Supraclavicular .Jmia
(b) ·Post._auricuiji_ir~a □ Site of occurrence : In relation to dental epithelium from under the root of chronically infected dead
(c) Groin crease area erupted tooth

45
 354 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 355

□ Lining :_ Squamous epithelium derived from epithelial debris of Mallassez □ Investigations:

□ Clinical feature : Smooth tender swelling in jaw in relation to a caries tooth a) Chl;l_§_lXoBa.y.
b) Blood electrolytes
□ Complications:
c) . f\J1~rialf>aO2. PaCO2
a) Infection
□ Treatment :
b) Osteomyelitis of jaw
(A) General -
□ Investigation : Orthopantomogram
1) Patient in well-equipped ICU
[See Fig./,® 2) Intravenous fluid
□ Treatment : 3) Ryle's tube
a) Antibiotics 4) Blood transfusion
b) Drainage or excision of cyst 5) Analgesic
c) Extraction of infected tooth 6) Sedative
. _,,✓--- 7) Endotracheal intubation
! ,9,1_3;,Ffail chest 8) lntercostal tube drainage
// FLAIL CHEST (B) Local-
1) Musculoske_letal tra_ction with towel clips
□ What is it: Form of chest injury where there is fracture of two or more consecutive ribs, with each _rib 2) Positive· pressure respiration
having two or more fracture sites
Q.13:G~---
□ Types:
a) Anterior \_/ . / GLASGOW COMA SCALE
b) Lateral
c) Posterior □ What is it: Bedside scoring system for neurological assessment
□ Aetiology : □ Scale:
1) Road traffic accident • Eye response -
2) House collapse
3) Bomb blast ► Spontaneous 4
Opens eyes to speech
,,.► Opens eyes to pain
3
4) Stampede 2
□ Pathology: ► No response 1
The fractured portion is called the flail segment, which loses anatomical and physiological continuity
with the rest of the chest --- -------- -- - --- - - - - ---
• Verbal response -
► Oriented 5
Leads to following derangements - ► Confused 4
• faradoxical respiration - During inspiration, air enters into the healthy lung from the ► Inappropriate words 3
atmosphe-re, and this lung also draws air from the affected lung. Hence, when thoracic cage ► Incomprehensible sound 2
moves outwards, the flail segment is drawn inwards. During expiration, air from healthy lung ► No response 1
escapes partly into the atmosphere and partly into the affected lung, thereby moving outwards • Motor response -
the flail segment, when the thoracic cage is actually moving inwards ► Obeys command 6
• ~~tinal flutter- Mediastinum moves during different phases of respiration ➔ kinking of ► Localises pain 5
great vessels and sudden cardiac arrest ► Flexion to pain 4
• _F'en_cjuf9 r movement of air - From one lung to other, causing respiratory failure due to ► Abnormal flexion 3
unavailability of atmospheric air ► Abnormal extension 2
", No response 1
□ Clinical features :
0 Interpretation :
a) History of trauma
Total score - 15
b) Pain in chest
Severe head injury - score < 8
c) Respiratory distress
Moderate head injury - score 9-12
d) Paradoxical respiration
Mild head injury - score 13-15
e) Features of shock
Minimum score - 3
 356 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - 11 357

□ Component of: Secondary survey in ATLS (Advanced Trauma Life Support) t:l Haemodynamlcs :
□ Types of head injury:
Patent ductus arteriosus
(A) Injury to scalp -
a) Avulsion
J,
b) Laceration Left to ri9.~.!...s~.~.nt from aorta to pulmonary artery
.. J,
(B) Injury to skull -
a) Pond's fracture As pressure gradient present throughout the cardiac cycle, this flow occurs both during systole and
b) Depressed fracture diastole
c) Linear fracture J,
(C) Injury to brain - Continuous murmur which starts in systole after S1, peaks at S2
a) Concusion - Temporary physiological changes leading to transient loss of J,
consciousness with complete recovery Increased blood flow through pulmonary artery to lung (pulmonary plethora in X-Ray)
b) Contussion - Bruising occurs leading to cerebral edema
c) Laceration - Tearing of brain surface
J,
d) Fracture of skull Increased size of left atrium due to increased blood flow
J,
□ Effects of head injury:
Increased amount of blood passing through normal sized mitral valve
1) Brain edema
2) Brain ischemia
J,
3) Brain necrosis Accentuated S1 + delayed mitral diastolic murmur
4) Extradural hematoma J,
5) Subdural hematoma Large amount of blood ultimately passes to left ventricle
6) lntracerebral hematoma J,
7) lntraventricular hemorrhage Increase in size of left ventricle + prolongation of left ventricular systole
8) Coup and contercoup injury J,
9) Coning Delayed closure of aortic valve
10) Raised intracranial tension J,
11) Fluid and electrolyte disturbance
Late A2 - paradoxical split of S2
12) Convulsions
13) CSF rhinorrhoea
J,
Large volume of blood passes through normal sized aortic valve and then causes dilatation of
Q. 14 : Therapeutic use of ultrasound ascending aorta
A : See Section - 1, Segment - E, Qs. 12. (Page No. 589) J,
Aortic ejection systolic murmur + aortic ejection click
/
.,a.,1ft,f
. Patent Ductus Arteriosus
.. /"
\ )(/ PATENT DUCTUS ARTERIOSUS □ Symptoms:
a) Dyspnoea
□ What is it: Persistence of patency of ductus arteriosus, which is a vessel leading from bifurcation of b) Recurrent respiratory infections
P~j~~~~ry ~rt,:!X_t~--~~~~a just distaiTo·Ieffsubciavian arte_r.y . . .... . ···- c) Retarded growth and development
D Prevalence : Q Signs:
• 6th most common congenital heart disease (A) Inspection and palpation -
• F>M 1) Collapsing pulse
D Types: 2) Wide pulse pressure
a) Silent 3) Apex beat shifted down and out
b) Small 4) Hyperdynamic apex
5) Continuous thrill at upper left sternum border
c) Moderate
6) Differential cyanosis if Eisenmenger's syndrome develops (i.e., cyanosis only in
d) Large
lower limbs and not in upper limbs)
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - 11 359
358 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

(B) Auscultation - Q.7: Tetanus prophylaxis

A: See Section - 1, Segn;ent C, Paper - I, 2011, Os. 4 (Page No. 291-292).
1) Loud S1
2) S3 may be audible Q.8: Empyema thoracis
3) Continuous machinery murmur at upper left sternum border A: See Section - 1, Segment C, Paper - 11, 2010, Os. 13 (Page No. 381-383).
4) Mid-diastolic flow murmur at apical region
Q.9: Epulis
5) Eddy sounds audible when large ductus
A: See Section - 1, Segment G, Pnrer - 11, 2011, Os. 13 (Page No. 399-400).
□ Investigations:
a) ECG - Notched P wave, deep Q, tall R Q.10: Wax bath
A : See Section - 1, Segment C, Paper - 11, 2011, Os. 12 (Page No. 398-399).
b) '---Cl,~s_tX-Ray- Prominent aortic knuckle, pulmonary plethora
c) E:CHO Q.11 : Extradural haematoma
□ Treatment : A: See Section - 1, Segment C, Paper - 11, 2009, Os. 7 (Page No. 365).
1) Medical - Q.12: Raynaud's phenomenon
(a) lndomethac:in ...
RAYNAUD'S PHENOMENON
(b) Prophylaxis for infective endocarditis
(c) Digoxin, diuretics for heart failure □ What is it : Condition characterised by episodic attacks of vasospasm leading to closure of small
2) Transcatheter closure arteries and arterioles of distal parts or extremities.
3) Surgical - Ligation and division □ Coffman criteria : "Episoclic attacks of well-demarcated reversible self-limiting colour changes for 1-
20 minutes on exposure to cold/emotionai stimuli and is symmetrical/bilateral lasting for atleast two
□ Complications :
years."
1) Eisenmenger's syndrome
□ Phases in sequence :
2) Infective eri~ocarditis
1) Intense pallor
3) Heart failure
2) Cyanosis
4) Paradoxical embolism
3) Rubor upon warming
5) Pyl~onary hypertension
□ Types:
6) Rupture of ductus arteriosus
1) Vasospastic
2) Obliterative
2008 Supplementary
□ Causes:
A) Primary - Etiology not known
Q.1 : Carcinoid tumour
B) Secondary -
A: See Section - 1, Segment C, Paper - I, 2010, Qs. 4 (Page No. 288-289).
► Obstructive arterial disease
Q.2: Ranula Buerger's disease
A : See Section - 1, Segment D, Os. 68 (Page No. 526-527). Arteriosclerosis
Q.3: Abdominal compartment syndrome Thoracic outlet syndrome
A : See Section - 1, Segment D, Os. 67 (Page No. 525-526). ► Immunologic
Rheumatoid arthritis
Q.4 : Desmoid tumour
Scleroderma
A: See Section -1, Segment D, Os. 90 (Page No. 548-549). SLE
0.5: Clinical features of Hirschsprung's disease ► Drugs
A: See Section - 1, Segment D, Os. 40 (Page No. 499-500). Beta blockers
OCP
Q.6: Cleft lip management in children
Ergot alkaloids
A: See Section -1, Segment C, Paper- II, 2013, Os.1 (Page No. 417-418).
► Environmental
 360 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 361

Vibration 1) To cover over bone, cartilage, tendon

Cold injury 2) To cover wide and deep defects
►
Others 3) In cases of repeated graft failure
Neoplasia □ Advantages :
Cryoglobulinemia 1) Better blood supply than graft
□ Physiology: 2) Good take up
1) Increased sensitivity of o:-2 receptors to norepinephrine 3) Provides bulk, texture, colour to defect site
2) Increased serotonin and thromboxane 4) Cosmetically better
3) Reduced nitric oxide and endothelin-1 in endothelial cells 5) Allows required movements
□ Investigations: □ Disadvantages :
1) Digital plethysmography 1) Chances of infection
2) DSA / MR angiogram 2) Long duration of hospital stay
3) Flap necrosis
3) Arterial Doppler / Duplex scan
4) Digital blood pressure gradient assessment 15. Care of a paraplegic patient
5) Laser Doppler flux CARE OF A PARAPLEGIC PATIENT
6) Nail fold capillary microscopy
7) Cold recovery time (increased upto 30 minutes in Raynaud's) Intensity of symptoms depends upon location and extent of damage to spinal cord. Special care
required to prevent infection. So following steps are to be followed -
8) Routine blood investigations - Lipid profile / blood sugar / coagulation studies
1) Immediate hospitalisation
□ Treatment :
2) Immediate catheterisation
• Treatment of underlying cause
3) Proper bowel care
• Avoidance of precipitating factors
4) Air/ Water bed to be arranged
• Drugs - Vasodilators, Pentoxiphylline, Nitrates, Prostacycline analogue
5) Proper care of bed sore
• Surgical - Cervical sympathectomy
6) Regular monitoring of catheter, to prevent UTI
Q.13 : Diagnostic use of ultrasound 7) High quality wheelchair to be arranged
A : See "Investigations" Segment E. 8) Physical therapist and passive exercise
Q.14: Axial flap
2009
AXIAL FLAP
Q.1:Salivarycalc~li 1 ~
□ What is flap : A piece of viable tissue with a blood supply which can be used to reconstruct a tissue
defect. ~---------- SALIVARY CALCULI
□ Axial flap : Superficial vascular pedicles pass along their long axes.
□ What is it : Stones in saliv~!Y_fil!ilr:!.<ci _
□ Parts:
□ Types:
1) Base
1) Submandibular (80% cases)
2) Pedicle
2) farotid (10% cases)
3) Tip
□ Reasons for higher incidence of submandibular calculi:
□ Areas where used : a) Viscous gland secretion
1) Oral cavity
b) Contains more calcium than parotid .
2) Neck
c) D~aina9e is non-dependent i.e. submandibular duct moves ~pward and ~pens by the side of
3) Breast irenulum llngue. Hence, due to antigravity, there is stagnation of secretions
4) Buttock
5) Limbs □ Clinical features :
1) Pain, swelling and tenderness in submandibular region and floor of mouth
□ Indications : 2) Duct inflamed and swollen

,,
ill!.
46
 362 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 363

3) Pain more cJuring mastication (salivary colic) [mastication ➔ accumulation of secretions ➔ • Pat~?JL0_D$~1s :
swelling ➔ irritation of lingual nerve ➔ pain] Bacteria reach breast via blood ➔ milk clots ➔ ducts blocked ➔ bacteria further multiply ➔
4) Firm, tender swelling - Palpable bidigitally finally duct blocked by epithelial debris ➔ abscess formation, distended with pus
5) Stone in duct palpable in floor of mouth • Clinical featUff!S :
□ Investigations: 1) Affected breast becomes red, swollen, _warm, tender
1) Intra-oral X-Ray - submandibular stones are radio-opaque, parotid stones are radiolucent 2) Throbbing pc1Jo
2) ESR, TLC raised 3) Fever, malaise
3) FNAC of gland 4) Purulent nipple discharge
□ Treatment : • Comgl~cations :
a) If stone in duct ➔ incision in duct and stone removed intraorally, and then duct is left open, as 1) Antibioma
suturing may cause stricture 2) Sinus, fistula
b) If stone in gland ➔ excision of gland 3) Septicaemia
□ Operative procedure : • TreatmeQ! :
Approach from submandibular region ➔ incision on skin in submandibular region, 5-8 cm long, 1) Drainage of abscess (radial(to prevent ductal disruption) or circumareolar (for cosmetic
parallel to and 2-4 cm below mandible ➔ incision deepened through deep fascia until gland visualised reasons) incision in most fluctuant part - another counter incision in most dependent
without raising flaps ➔ facial artery ligated twice ➔ lingual and hypoglossal nerves taken care of ➔ part to place the drain, which is removed after 2 days)
mylohyoid retracted to remove deep portion of gland ➔ drain placed after excision of gland, which is 2) Antibiotics
removed after 2 days
• Q!~e!.~-~3.!'!JJ!}2~ : lnflammatory_!?arcinoma of breast
□ Complications of surgery:
1) Hemorrhage 0 NON-LACTATIONAL ABSCESS OF BREAST
2) Infection • Aetiology :
3) Injury to lingual, hypoglossal, marginal mandibular nerves 1) Periareolar infections
4) Injury to nerve to mylohyoid 2) Duct ectasia
□ Differential diagnosis: • Causative organisms : -~~!?!~r!<:JJ.9s, G_!~.!!.!nega\w...9rg~nism~
1) Salivary neoplasm • Clinical feature : Tender swelling under areola
2) Submandibular lymphadenitis • Treatment: Drainage of abscess

Q.2 : Fournier's gangrene 9-#•tlons of undescended testis

A: See Section - 1, Segment C, Paper-I, 2013, Os. 3 (P.age No. 302)
\. . UNDESCENDED TESTIS - COMPLICATIONS
Q.3 : Breast abscess
_/_____ BREAST ABSCESS □ What is undescended Testis: Testis has failed to descend to scrotum
□ Incidence : Mostly in premature infants
·Ef Synonym : lntramammary mastitis □ Laterality: Right > left > bilateral (this is because right sided descends later than the left sided one)
'.,A._/'•--"'··,,,.,""
□ Types: □ Aetiology :
a) Lactational
1) Familial
b) Non-lactational
2) Gubernacular dysfunction
□ LACTATIONAL ABSCESS OF BREAST 3) Short vas deferens
• Found in : Lactating women 4) Lack of Calcitonin Gene Related Peptide (CGRP)
•,/"'V-......,,.,..,.,A.,~

• Causative organism _ : Staphylococcus aureus 5) Lack of HCG

',r-,,,...,,..,.....-............. ....,,...........,,.,,..,.,,~_..,,,. _ _ , _ _ _ _ _ __
-~~

6) Altered hypothalamo-pituitary gonadal axis

• .f;_r(!_q,Lsp_g~!fl_f{ fa_~tg~~ :
7) Retroperitoneal adhesions
1) Baby not sucking properly
2) Baby's mouth infected 8) Prune-Belly syndrome
3) Retracted nipple □ Types:
4) Cracks in nipple a) Lumbar testis - Complete failure of descent
5) Nipple not washed properly b) 'Iliac testis - Testis remains just deep to deep ring
 364 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 365

c) ln9uinal testis - Testis in inguinal canal (B) Type II (Sipp/e's disease) defect in chromosome 10
d) In superficial inguinal pouch - Testis in space between external oblique and Scarpa's fascia ► Subtype Ila -
e) ~ I testis - Testis in upper part of scrotum * Phaechromocytoma
□ Complications : * Parathyroid hyperplasia
1) Torsion * Medullary carcinoma of thyroid
2) Epididymo-orchitis
* Megacolon
3) !5emi_noma_____ _ ► Subtype lib -
4) }rc;\tJnla * Phaechromocytoma
5) l_nQ.t,J_i~_~I hernia * Medullary carcinoma of thyroid
6) Sterility * Mucosal neuroma in lips and eyelids
7) !-J.r~ * Marfanold face

□ Investigations: O Investigations:
1) USG abdomen a) For parathyroid hyperplasia -
► Serum calcium
2)
3)
CT scan
Assessment of FSH, LH, HCG ► Serum phosphate ?
4) Gonadal venogram ► Serum PTH
5) Laparoscopy b) For pituitary tumor - 0

► Prolactin level C. O'/c,'·,· ·' ,.\

□ Treatment :
► GH level '..}VCP</'U(:,C,-.9.;j''r.t~h \j)\,.3cl,.. C •19"\.._
• Always sur:_gery - Done between 2-4 years of age, 6 months gap in case of bilateral
- "'Trivolveinent -
c) For pancreatic tumors - ~"f'l'"N_ y:::,J;c,,\d •i 0--.;-:fe:,1._ r>-C C ;~e-»'---\-
► \ .} V\ (._CY'Y1 C-•-t') •A'> V·
O'~,.. r-·\
• Principles of surgery -
►
Blood sugar
Insulin level
e_...,v~\ (', '. - }.c>ic'~ . _'_\. --,.__Ot"C
c ;'- -.:_; ~-
a) Mobilisation of spermatic cord ► Pancreatic polypeptide level {_,,
b) Repair of associated hernia ► Proinsulin level ~"(:.M,_ J"'" .,£>
c) Creation of scrotal pouch and fixation of testis into the scrotum ► Glucagon level V\ -P__}(V',CA:\o 'i'l'-J>--
d) Orchidectomy done if testis is completely atrophied ► Gastrin level
• Hormone therapy used in following cases - d) Calcitonin level \,
1) Doubtful retractile testis e} Urinary catecholamine
2) Bilateral cases + hypogenitalism + obesity f) Thyroid function test '~
• Laparoscopic approach - Orchidopexy is becoming popular □ Treatment : Surgical treatment of conditions \

' r~Syndrome Q.6: Anorectal ma/formations :_)

\ A : See S · n- 1, Segment C Paper - 1, 2013, Os. 4 (Page No. 303)
/ / MEN SYNDROME
\Q.~ dural hematoma IL
□ Full form : M1:1lt!~ Endocrine Neoplasia
-•-""--••-••• - - - ~ - - , - • . , " ~ - • ~ • ~•"--r"~,••~••• '"'

□ Synonym : MEA syndrome (Multiple Endocrine Adenomatosis) EXTRADURAL HEMATOMA

□ Inheritance : Autosomal dominant
__ ..,, . --------~-"'""-··--- - □ What is it: Colle:!~?" of blood in extradural space i.~een skull and dura ")
□ Features of cells : ~ (Amine Precursor Uptake Decarboxylation) □ Aetiology:
□ Types: Trauma at temporo-parietal region leading to rupture of -
a) Anterior branch of middle meningeal artery
(A) Type I (Werner's syndrome)- defect in_chromosome 11
b) Posterior branch of middle meningeal artery
► Pituitary tumor
c) Middle meningeal veins
► Parathyroid adenoma/hyperplasia
► Pituitary endocrine tumors - insulinoma, gastrinoma, etc. □ Site: Temporo-parietal region
□ Laterality : Unilateral or bilateral
 366 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 367

□ Pathogenesis : a.B: Cardiopulmonary Resuscitation

A : See Section - 3, Os. 9 (Page No. 766)
Trauma at t~_m_p
1 o-Qarietal _r~ion
Q.9: MRI
Fracture of temporal bone A : See Section - 1, Segment E, Os. 11 (Page No. 587)
j,
Q.10: Complications of radiotherapy
Rupture of vessels
j,
COMPLICATIONS OF RADIOTHERAPY
Bleeding towards scalp
j, □ What is radiotherapy : Use of ionizing radiation as therapy mainly in malignant conditions
Hematoma □ Mode of action :
j, a) Direct action on the target tissues
Stripping of dura from skull b) Indirectly, release free radicals
j, c) Acts on different phases of cell cycle
Extradural hematoma □ Types:
j, - 1) Curative
Coning of uncus of temporal lobe through tentorial hiatus 2) Palliative
j, □ Indications :
Pressure on pyramidal tract ➔ ipsilateral hemiplegia
1) Seminoma testis
j, 2) Bladder tumors
CN Ill of affected side pressed between uncus and midbrain 3) Hodgkin's lymphoma
j, 4) Lung carcinoma
Constriction of unilateral pupil 5) Squamous cell carcinoma
j, 6) Basal cell carcinoma
Midbrain of opposite side 7) Cervical carcinoma
j, □ Complications :
CN Ill of opposite side compressed between midbrain and uncus of opposite side (A) GIT-
j, ,.
\,
Oral mucosa -
Constriction of pupil of opposite side (a) Ulcer
These series of papillary changes in pupil of affected and opposite side is called Hutchinson's pupil, (b) Oral thrush
and this total sequence is called Kernohan's notch effect (c) Edema
[See Fig@ (~;·,f] (d) Loss of taste
(e) Dysphagia
□ Clinical features : ► Nausea, vomit, diarrhea
,,,aY/Lucid interval - Transient loss of consciousness immediately after trauma ➔ soon patient (B) Infection - bacterial, fungal, viral
~ regains consciousness ➔ again starts deteriorating after 6-12 hours (C) Genitourinary -
b) Confusion, irritability 1) Oophoritis in females
c) Pupillary changes -::~Hutchinson's pu[?il 2) Oligozoospermia
d) lpsilateral hemiplegia · -· · ·· (D) Bone marrow suppression
e) Features of raised intracranial tension - Vomit, severe occipital headache, bradycardia, high (E) Eye-
BP 1) Lens affected
□ Investigations : 2) Lacrimal gland affected
3) Eyelash affected
1) X-Ray skull 4) Dryness
2) CT scan of skull - Biconvex lesion [See Fig. 1.6.4] 5) Cataract
3) Electrolyte imbalance (F) Radiation induced -
□ Treatment: Crani~!()n,y- Burr-hole techr1i9uE:iand raising of osteoplastic flap to drain the blood clot 1) Malignancy
368 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS O Paper - II 369

2) Thimble bladder □ Treatment :

3) Frozen pelvis 1) Moist oxygen inhalation
2) Albumin infusion
(G) Others-
3} Low molecular weight heparin
1) Radiation dermatitis
4) Dextran
2) Radiation myelitis of spinal cord
3) Radiation nephritis Q.12: Odontomes
4) Radiation osteomyelitis
ODONTOMES
5) Radiation pneumonitis
□ What are they: Cysts or tumors of the jaw arising from epithelial or mesothelial elements of the tooth
Q. 11 : Fat embolism
germ
FAT EMBOLISM
□ What is it: A fat embolism is a type of embolism that is often caused by physical trauma such as Dental cyst
fracture of long bones, soft tissue trauma, and burns.
Epithelial Dentigerous cyst
□ Pathogenesis: Several mechanisms have been proposed to explain the pathogenesis of fat embolism.
They may be acting together or singly - Adamantinoma
1. Mechanical - Mobilisation of fluid fat following trauma to bone and soft tissue
Odontogenic myxoma,
2. Emulsion instability - Explains the pathogenesis of fat embolism in non-traumatic cases. Fat Based on
Connective fibroma
embolus formed by aggregation of plasma lipids (chylomicrons and fatty acids} due to disturbances origin
in emulsification of fat. Symptoms include fatty liver(hepatic steatosis) tissue
Cementoma,
3. lntravascular coagulation - May result from disseminated intravascular coagulation (DIC} dentinoma
4. Toxic injury- Blood vessels injured by high plasma levels of free fatty acid, results in increased
vascular permeability and consequently pulmonary edema Malignant
ameloblastoma
□ Clinical features : Malignant
1) Drowsy, restlessness Fibrosarcoma
2) Constricted pupils
3) Cyanosis
4) Tachypnoea Ameloblastoma
5) Fat droplets in sputum
6) Froth in mouth and nostrils Classification Compound odontome
7) Petechial hemorrhagic spots
Cementoma
8) Retinal artery emboli (earliest) - fluffy exudates, striae exudates
9) Fat droplets in urine Arise in Composite odontome
from it
□ Complications:
1) Pulmonary fat embolism Enameloma
2) Systemic fat embolism.
Radicular odontome
□ Investigations :
Based on Dentinoma
1) Serum lipase level increases in bone trauma - Often misleading /
dental
2) Cytologic examination of urine, blood and sputum with Sudan or Oil Red O staining may epithelium
detect fat globules that are either free or in macrophages. This test is not sensitive, however, Odontogenic fibroma,
and does not rule out fat embolism myxoma
3) Blood lipid level is not helpful for diagnosis because circulating fat levels do not correlate
Dental cyst
with the severity of the syndrome Arise in
4) Decreased hematocrit occurs within 24-48 hours and is attributed to intra-alveolar hemorrhage relation to it
Dentigerous cyst
5) Alteration in coagulation

47
 370 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 371

□ Dental cyst: See Section - 1, Segment C, Paper - II, 2008, Os. 11 (Page No. 353) □ Effect:
1) Collapse of lung of affected side
□ Dentigerous cyst: See Section -1, Segment C, Paper- II, 2014, Os. 3 (Page No. 428)
2) [)!~placement of medi11stinum to opposUe side ~ compresses_ opposite lung
□ Ameloblastoma: See Section -1, Segment C, Paper- II, 2012, Os. 13 (Page No. 411)
□ Aetiology:
Q.13: Short wave diathermy 1) Penetrating chest injury
2) Tuberculous focus rupture
SHORT WAVE DIATHERMY
3) Fracture of rib
□ What is it : Electrically induced heat using short wave radiotherapy □ lnterpleural pressure : More than atmospheric pressure
□ Current used : High frequency alternating current □ Communication with external air: Unidirectional
□ Operating voltage : 220 volts □ Clinical features :
□ Fuses : 6 Ampere 1) Dyspnoea
□ Room temperature : 10-40 degree Celsius 2) Severe chest pain
3) Shock
0 Moisture : 10-80%
4) Cyanosis
□ Wavelength : 11 metres 5) Hyperresonance on percussion
□ Frequency: 27.33 MHz 6) Absence of breath sounds
□ Mechanism : Two condenser plates are placed on either side of the body part ➔ high frequency waves 7) Shift of trachea and apex beat towards opposite side
travel between the two condenser plates ➔ as they pass through the body, they are converted into heat □ Investigation :
□ Indications : 1) Chest X-ray
1) Inflammation of shoulder joint, elbow joint 2) e-FAST: Barcode or Stratosphere sign in M mode
2) Heel pain □ Complication : Respiratory failure
3) Cervical spondylosis □ Treatment: .Needle decompression by thoracocentesis at 5th lntercostal ~~ace, slightly anterior to
4) Osteoarthritis Mid-Axillary line in adults (2nd lntercostal Space in children) [ATLS 1Qth ed1t1on updates].
5) Bursitis ·---------
Q.15: Hypokalemia
6) Sinusitis
HYPOKALEMIA
7) Low back ache
8) Ligament sprains in knee joints □ What is it: Serum potassium level < 3.5 mEq/L
□ Contraindications : □ Types:
1) Coronary heart disease a) Sudden
2) Hemorrhage b} Gradual
3) Metal implants □ Aetiology:
4) Infections a) Sudden - Diabetic coma patients treatad with insulin
5) Malignancy b) Gradual -
6) Pacemakers 1) Following trauma, surgery (increased mobilisation of intracellular potassium to
7) Phlebitis extracellular space + increased potassium excretion by kidneys)
8) Pregnancy 2) Starvation
9} .. Wet dressings 3} Gastric outlet obstruction
,,. / /
4) Loss of gastrointestinal secretions - ileostomy, duodenal fistula
, <it1_f': Tension pneumothorax 5) Diarrhea in ulcerative colitis, villous tumor of rectum
', ' .. / / / TENSION PNEUMOTHORAX 6) Poisoning
7) After ureterosigmoidoscopy
□ What is it : When the lacerated lung communicates with a branch of the bronchial tree through a 8) Drugs like beta agonists
valvular rent, which allows entry ~f_ai~ dLJring.!n~pi~~!i~ll-~LJtJ>rev~nts exit of air durinJJ~xpiratio_n, this □ Clinical features :
conQlti.90 i.!; called 'tension_pneu!!lotho@J<'.
1) Gradual onset of drowsiness
 372 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 373

2) Slurred speech
3) Irritability Q.9: Mammography
4) Weakness, muscular hypotonia A: See Section 1, Segment - E, Os. 26 (Page No. 600)
5) Absent deep reflexes Q.10: Nerve injury
6) Paralytic ileus A: see Section 1, Segment - D, Os. 98 (Page No. 558)
7) Low B.P Q.11 : Management of Hirschsprung's disease
8) Bradycardia A: See Section 1, Segment - D, Os. 40 (Page No. 499)
9) Reddish flush in face Q.12: Target FNAC
10) Warm, dry skin
A : See Section 1 , Segment - E
11) Urinary incontinence
Q.13: Ultrasonic therapy
12) Nocturia, polyuria
ULTRASONIC THERAPY
□ Investigations:
1) Low serum potassium □ Mechanism of action : Ultrasonic waves of high frequency are produced by mechanical vibration in
2) ECG- the metal treatment head of the ultrasound machine, which is then moved over the skin surface in tile
region of injury, causing the energy to be transmitted to the inflammed tissue.
► Prolonged QT interval
□ Thermal effect: The ultrasound waves passing into the skin cause vibration of tissues surrounding
► Depressed ST segment
the affected area, especially those containing collagen. The vibration produces heat within the tissue,
► Inversion of T wave which increases the exten•;ibility of tendons, joint capsules and ligaments, along with reducing pain
;,- Prominent U wave and muscle spasm.
□ Treatment : □ Effects on healing process : Ultrasonic therapy accelerates the normal resolution time of the
inflammatory process by attracting more mast cells to the site of injury and also sometimes causes
1) Potassium chloride tablets orally - 2 gm 6 hourly
increased blood flow in the site of injury. It also enhances collagen formation
2) In comatose patients or those with difficulty in swallowing - 40 mmol/litre of potassium chloride □ Use: The treatment metal head is moved over the site of injury for 3-5 mins, once or twice daily. The
in 5% dextrose or normal saline
intensity and frequency may be varied as per requirement. This is of great use in sports medicine.
3) If alkalosis present - 20 ml of 10% solution of potassium chloride in 500 ml of 5% dextrose. Lower frequency required for deeper structures and vice-versa.
□ Contradictions :
2009 Supplementary • Acute infection
• Malignancy
Q.1 : Hypospadius
• lschaemic tissue
A: See Section 1, Segment - C, Paper-II, 2013 Supplementary, Qs. 8 (Page No. 425)
• Exposed neural tissue
Q.2: Marjolin 's ulcer
• Pregnancy
A: See Section Segment - C, Paper II, 2013, Os. 1O (Page No. 421)
1,
• Around ocular region or gonadal region
Q.3 : Collar stud abscess
• Suspected bone fracture
A : See Section 1, Segment - D, Qs. 82 (Page No. 539)
14. Adamantinoma
0.4 : Venous ulcer
A: See "Ameloblastoma" - Section 1, Segment - C, Paper-II, 2012, Os. 13 (Page No. 411)
A : See Section 1, Segment - C, Paper I, 2013, Os. 2 (Page No. 301)
0.2: Solitary thyroid nodule
0.5 : Cleft palate
A : See Section 1, Segment - A, Paper II, 2013 supplementary, Os. 1 (Page No. 170-171)
A: See Section 1, Segment - D, Qs. 15 (Page No. 477)
0.6: Complications of radiotherapy
2010
A: See Section 1, Segment - C, Paper II, 2009, Qs. 10 (Page No. 367)
0. 7: Regional anaesthesia Q. 1 : Ectopic vesicae
A: See Section 3, Os. 8 (Page No. 764-765) ECTOPIC VESICAE
0.8 : Empyema thoracis \
□ Synonym : Extrophy of bladder
A: See Section 1, Segment - C, Paper 11, 201 O, Os. 13 (Page No. 381)
□ What is it: Congenital anomaly of urinary bladder
 SOLVED SHORT NOTES OF FINAL MBBS O Paper - II 375
374 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

• Correction of epispadius
□ Incidence : Rare
• Excision of bladder and permanent ureterosigmoid diversion done sometimes
□ Sex predilection : M > F
□ Types: Q.2: Neurofibromatosis
a) Complete NEUROFIBROMATOSIS
b) Incomplete
□ Defect : Ventral defect of the urogenital sinus and the overlying skeletal system □ synonym : Von Recklinghausen's disease of nerve
□ What is it : Condition in which multiple neurofibromas arise from cranial, peripheral and spinal
□ Effect : Anterior wall of urinary bladder and infraumbilical part of anterior abdominal wall fail to
develop, along with the overlying muscles and bones nerves
□ Clinical features : □ Inheritance : Autosomal dominant
1) Oval/spherical defect in anterior abdominal wall □ Types:
2) Inner surface of posterior wall of bladder protrudes through the defect - deep red in colour a) Type I - NF-1 gene located on chromosome 17q11, commoner type
3) Everted mucous membrane becomes ulcerated and painful b) Type II - NF-2 gene located on chromosome 22q12
4) Bleeds readily □ Gross pathology:
5) Dribbling of urine on anterior abdominal wall from ureteric orifices • Spherical or cylindrical masses
□ Associated anomalies : • May or may not be encapsulated
a) In both sex - □ Microscopy:
• Widely separated pubic bones • Proliferation of all elements in a peripheral nerve
• Absent symphysis pubis ➔ replaced by fibrous band ➔ pelvic ring less rigid ➔ femurs • Elongated serpentine Schwann cells which can undergo malignant transformation
externally rotated ➔ waddling gait
□ Clinical features :
• Umbilicus absent
1) Multiple nodules -
• Umbilical hernia
• Distributed all over the body
• Laxity of anal sphincter
• Present since birth
• Spina bifida
• Soft or hard
b) In males - • Increase in number and size gradually
• Epispadius • With distinct margin
• Penis broader, shorter, fixed to abdominal wall 2) Cafe - au - lait patches - Light brown macules with smooth qorders (if 5 patches present over
• Scrotum not well-developed 1.5 cm, patient is likely to have neurofibromatosis)
• Prostate and seminal vesicles may be absent □ Associated abnormalities :
• Inguinal hernia
• Kyphosis, Scoliosis
c) In females - • Bilateral acoustic neuroma (NF2)
• Labia minora separated • Pigmented iris hamartoma - Lisch nodules
• Cleft clitoris • lntraosseous cystic lesions
□ Complications : • Pseudoarthrosis of tibia
• Subperiosteal bone cysts
1) Ulceration
• Meningioma
2) Pain
• Phaeochromocytoma
3) Repeated soakage
• Orbital glioma (NF 1)
4) Hydronephrosis
• Medullary thyroid cancers
5) Recurrent pyelonephritis
□ Complications:
6) Metaplastic changes in mucosa ➔ adenocarcinoma
7) Renal failure 1) Sarcomatous changes
2) Cystic degeneration
□ Treatment : Staged procedure
□ Treatment :
• Initial diversion of urine to colon/rectum
Excision only in following conditions -
• Iliac osteotomy
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 377
376 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

1) Painful swelling □ Standard classification :

2) A very large swelling a) Submucous - in submucous plane
3) Swelling causing mechanical discomfort or pressure symptoms b) Subcutaneous - superficial to subcutaneous external sphincter
c) Low anal - between subcutaneous and superficial part of external sphincter
4) Suspicion of malignancy
d) High anal - between superficial and deep part of external sphincter
~ g e t ' s disease of nipple e) Pelvi-rectal - connects rectum to skin, passes through levator ani
[See Fig. 1.6.5]
PAGET'S DISEASE OF NIPPLE
□ symptoms : Severe throbbing pain in perianal region ➔ bursting of pus ➔ discharge of pus, soils
□ What is it : .MalignanL~~-n-~(tj9_n that outwardly may have the appearance of eczema with skin garments -, relief of pain -, again throbbing pain after some days
changes involvlngtfienipple of the-breast·· - - --·-- '
. ·---· -~---~ □ Signs:
□ First described by: Sir James=-r<P"""ag""e:c:tt-- Digital rectal examination is best
D Clinical features : Goodsall's law -
1) Skin - The fi_rst sympt?m is usually an ~zema-like_E§lih. The skin of the nipple and areola Imaginary line drawn between 2 ischial tuberosities . . . .
may be red, itchy and inflamed. After a perlo'a" ofiirne, the skin may become flaky or scaly If external opening situated anterior to the line - tract is straight, internal opening lies directly opposite
2) Discharge - _A discharge, which may be straw-colored or bloody, may ooze from the area to external opening.
If external opening lies AOSterior to the line, or lies anterior to line and > 1.5 inches away from anus -
3) Sensation - Some women have a burning sensation
tract is curved, opens in 1midline posteriorly
4) Nipple changes - The nipple may be i~;~-~ted [See Fig. 1.6.6]
5) Breast changes - There may or may not be a ·lump in the breast, and there may be redness,
\
oozing and crusting, and a sore that does not heal □ Investigations:
The symptoms usually affect the nipple and then spread to the areola and then the breast. It 1) Fistulogram
is common for the symptoms to wax and wane. 2) MRI
□ Pathology: Paget's disease of the breast is characterised by Paget cells. Paget cells are large cells □ Treatment :
with clea_r cytoplasm and eccentric, hyperchromic nuclei foundthrougnout the epidermis. According
a) Low anal fistula -
to the migratory theory, ductal carcinoma in situ cells migrate into the lactiferous sinuses and the
1) Fistulectomy - Fistula opened ➔ fibrous tract excised
nipple skin. Cancer cells disrupt the normal epithelial barrier and extracellular fluid accumulates on
2) Fistulotomy - Probe inserted in fistula, tract incised and cut open ➔ allowed to granulate and
the surface of the skin, resulting in the crusting of the areola skin
heal from floor
□ Investigations : 3) STARR (Stappled Trans Anal Rectal Resection)
1) Mammogram 4) Hughe's skin grafting
2) Biopsy
b) High anal fistula - ,,,
3) lmmunohistochemistry Seton technique - Silk or linen ligature passed across fistula, and left in place with a tie, and
□Treatment : allowed to heal from above (cheese wiring effect of cutting setons)
• Lumpectomy or mastectomy
Chemotherapy and/or radiotherapy may be necessary Q.5: Va/fcocV
r\ . ./ VARICOCELE

\
; ~:~=--~nano
, ...✓ /
□ What is it: • Dilatation and tortuisity of-pampiniform
_:...________ ----------
plexus of veins and testicular
----~-~-
veins
---•-•~>'••-·-"··
'-,✓\._ •• / FISTULA IN ANO
□ /Anatomy:
Pampiniform plexus of veins in scrotum -, join to form 4-8 veins in testis ➔ testicular vein ➔ right vein
□ What is it: Hollow tract lined by unhealthy granulation tissue which has an internal opening in anal
drains into IVC, left vein drains into left renal vein, which drains into IVC
canal and an external opening in perianal skin
□ Aetiology : Perianal abscess D . Common in: Tall young lean men
□ Park's classification : □ Types:
a) Primary
a) Trans-sphincteric
b) Secondary
b) lntersphincteric
□ Laterality :
c) Suprasphincteric
d) Extrasphincteric More common in left side because -
1) P_erpE:1ndicular e~!~t~~!t!esticular vein intol~ft re.nal vein

48
 378 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 37~

2) Left renal vein compressed between aorta and superior mesenteric artery □ Aetiology:
3) Incompetent valve at junction of left testicular vein and left renal vein 1) Laceration of cortex of brain
4) Left renal vein being ~ e r may be compressed by loaded sigmoid colon 2) Rupture of superior cerebral veins - often by impact to the front or back of head
5) Left sided Renal Cell Carcinoma ➔ tumor thrombus in left renal vein ➔ obstructs venous □ Age : Commoner in elderly (as brain atrophies with age, giving rise to more space for the brain to
flow of left testicular artery move within the skull)
6) Left suprarenal vein also drains into left renal vein and circulating adrenaline may cause
□ Types:
constriction of testicular vein
a) Acute
□ Effect: Infertility because -
b) Chronic
1) Varicocele leads to altered heat exchange mechanism ➔ hyperthermia ➔ reduced
□ Clinical features :
spermatogenesis
1) Loss of consciousness, which worsens gradually, without any lucid interval
2) Increased blood flow ➔ increased metabolic activity ➔ glycogen depletion ➔ injury to testis
➔ottgozoospe rm ia --··· ... - 2) Convulsions
3) Features of raised intracranial tension - hypertension, bradycardia
3) !7ypoxia of testis
4) l,,~}'_dJJl cell dysfunctig11_gLJe to increased temperature 4) Focal neurological deficits

□ Grading: □ Investigations:
I - Small 1) CT scan - concavo-convex lesion
[See Fig. 1.6.7]
11 - Moderate
Ill - Large 2) Blood electrolytes
IV - Severely tortuous □ Treatment :
□ Clinical features : 1) Craniotomy and evacuation of clot
/
2) Anticonvulsants
1) ~(Q_g-~_.':9_~t_C>JJ:l~_riis
2) ~ag of W()rms_feeling 3) Antibiotics
3) _[?_r_a9.9.i__~.lLPil.i.'1. sensation in groin and scrotal region Q. 7 : Muscle relaxants
4) Impulse on coughirig A: See Section - 3, Os. 3 (Page No. 757-758)
5) §.'!'.V~!'lrl9Jlets reduced on l:}dmLQQ.Wn
6) _!;lQW..§ign - after holding varicocele between thumb and finger, if patient bows down, varicocele Q,8_~
reduces in size (due to reduced blood flow) A: See 'Investigations' - ~.~-=~L
Thyroid scan (Section - 1, Segment E, Os. 25) [Page No.:..
□ Investigations : Q.9: Congenital hypertrophic pyloric stenosis
1) VElnous Doppler of scrotum and groin ~--~~_,,,-··
. ;~----- CONGENITAL HYPERTROPHIC PYLORIC STENOSIS
2) .l:)_SG abdomen to detect RCC
3) §emen analysis □ What is it: Hypertrophy of the musculature of pyloric antrum of stomach especially circular muscle
□ Treatment : fibres, causing primary failure of pylorus to relax
1) Pala1119'iLC>2_era~ - suprainguinal extraperitoneaU~gatiori of testicular vein □ Incidence : 4 in 1000 births
2) Microscopic subinguinal varicocelectomy
□ Common in : First born males
□ Differential diagnosis :
□ Nature : Familial
1) Lymph varix
□ Age : 3rd-6th week
2) H~dro9.ele
□ Clinical features :
3) Inguinal hernia
4) Lipoma-ofspermatic cord 1) Vomiting -
/•::/· • Projectile
9,'!jSubdural hematoma • Forcible
./,' • Non-bilious
SUBDURAL HEMATOMA
2) Visible gastric peristalsis
□ What is it : Collection of blood between duramater and brain 3) Palpable lump -
□ Incidence : Six times commoner than extradural hematoma • Mobile
• Firm
 380 QUEST : A Comprehensive Guide to UG Surgery, Orthope.dics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS D Paper - II 381

• Smooth □ Complications: (spreads very fast as infection lies deep to deep fascia)
• Well defined margin 1) Laryngeal edema
• J\/oves with respiration 2) Septicaemia
• Impaired resonance on percussion □ Treatment :
4) Constipation 1) Intravenous fluid
5) Dehydration 2) Antibiotics
6) Weight loss, anorexia 3) Decompression of submandibular region
7) Electrolyte imbalance - Hypokalaemic metabolic alkalosis Q.12: Meningomyelocele
□ Investigations : A: See Orthopedics - Spina bifida (Section - 2, Group - I, 2009, Qs. 6) (Page No. 633].
1) USG abdomen - Q.13: Empyema thoracis
• Pyloric muscle > 4 mm thick A : See next page
• Length of pyloric canal > 16 mm Q.14: Patient Ductus Arteriosus
• 'Doughnut' sign
A: See Section - 1, Segment C, Paper - II, 2008, Qs. 15 (Page No. 356)
2) Barium meal ~ obstruction
□ Treatment : EMPYEMA THORACIS
1) Correction of dehydration
□ What is ft: Collection of pus in pleural cavity
2) Atropine methyl nitrate orally to relax pylorus
□ Aetiology : Always secondary
3) Ramsted's operation (after laparotomy, hypertrophied muscle is cut along the length until ·-,.'.~~~-_,

mucosa bulges out)

□ Differential diagnosis :
EMPYEMA THORACIS
1) High intestinal obstruction
2) Duodenal atresia
3) lntracranial hemorrhage Non-traumatic Traumatic
Q.1 O: Lumbar puncture
A : See 'Investigations' Section (Section - 1, Segment E, Qs. 27) [Page No. 600-602]. Thoracic Extra thoracic Iatrogenic Non-iatrogenic
. ~udwig's angina • Post-thoracotomy • Stab
. • Lung resection • Gunshot wound
// LUDWIG'S ANGINA • Paracentesis thoracis
I
□ What is it: ~fl~r:i:1'!1atory edema_~~ubmandibular region and the floor of mouth J l
□ Cause : Streptococcal infection - From From
□ Precipitating factors : Oesophagus below diaphragm
1) Oral or other malignancy • Carcinoma • Subphrenic abscess
• Perforations • Hepatic abscess
2) Salivary calculi
• Leaking anastomosis
3) Caries teeth
4) Chemotherapy
□ Clinical features :
Pulmonary Mediastinal From chest wall
1) Brawny swelling of submandibular region
• Pneumonia • Osteomyelitis of sternum, ribs
2) lntraoral edema in the floor of mouth • Tuberculosis
3) Putrid halitosis • Bronchiectasis
4) Fever, malaise • Lung abscess
5) Dysphagia • Bronchogenic carcinoma
6) Dyspnoea
 382 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 383

□ Organisms involved:
5) Pus culture & sensitivity
• Streptococci 6) Bronchoscopy
• Staphylococci
• Pneumococci TREATMENT
• E-coli
• Klebsiella sp.
Stage I Stage II Stage Ill
□ Stages:
(Acute empyema) (Subacute empyema) (Chronic empyema)
1) Acute
• Repeated aspirations • Open drainage • Decortication operation
2) Subacute
• Antibiotics • Rib resection • Lobectomy (rare)
3) Chronic - (a) closed type and (b) open type • Continuous closed drainage (Eloisers method)
D Pathogenes~s: Serous flui~ collect~ : becomes p~rulent ➔ intrapleural clotting of pus ➔ thickening by intercostal tube • Respiratory physiotherapy
of pleura ➔ f1bnnous adhesions ➔ rigid contracted immobile chest with functionless lung underneath • ATD (If reqd) • Antibiotics
(frozen chest) ➔ pus perforates through intercostal space (empyema necessitans).
Q.15: Referred pain
TYPES
REFERRED PAIN

t
Anatomical □ Pain: Sherrington defined pain as 'physical adjunct of an imperative protective reflex'.
Pathological Clinical

~
□ Referred pain : Visceral pain, felt at some distance on somatic structures, instead of being felt at the
Apical Exudative Acute
site of viscera.
lnterlobar Acute fulminant
' Fibrinopurulent toxic □ Synonym : Reflective pain.
Mediastinal
Lateral Subacute □ Examples:
Organising
Diaphragmatic Chronic • Pain in cholecystitis referred to tip of right shoulder, (as right shoulder is supplied by C4, C 5 ,
Latent Cs roots, while the diaphragm which is irritated by the inflammed gall bladder is supplied by
Persistent phrenic nerve (C3, C4, Cs)
Empyema
• Anginal chest pain referred to medial aspect of left arm
necessitans
Chronic empyema • Pain of appendicitis referred to skin around umbilicus.
with sinus □ Mechanism :
lnterlobar empyema
a) Convergence Theory :

□ Clinical features :
1) Pain in chest
2) Fever
3) Difficulty in breathing
4) Tenderness
Fibres carrying
pain from viscera

Fibres carrying pain

from dermatome
> Converge to form a
single pathway to
cortex
Pathway stimulated

inflammation
viscus)
of
Brain causes the
➔ by any means (e.g., ➔ pain to be projected
to the site of
receptors on skin
as somatic pain is
5) Rapid shallow respiration
more common
6) Stony dullness on percussion
7) Absence of breath sounds
8) Mediastinum displaced to opposite side b) Facilitation Theory:
□ Investigations:
1) Chest X-Ray (PA view) - Fluid in pleural cavity Visceral pain produces subliminal ➔ SGR cells are easily stimu- ➔ Pain felt on skin
2) Aspiration of pleural fluid fringe effect on the Substantia lated by minor stimuli on skin
3) ESR Gelatinosa of Rolando (SGR) cells,
4) Peripheral smear which receive somatic pain
 384 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS O Paper - II 385

□ Features:
• Size of referred pain related to -
0 Pathogenesis :
• Muscle gets involved from itr. origin to insertion
(a) intensity of pain
• Necrosis of muscle
(b) duration of pain
Production of gases - hydrogen sulphide, carbon dioxide etc.
• Temporal summation is a potent mechanism for generation of referred pain
• Extent of referred pain depends on central hyperexcitability □ Clinical features :
• Proximal spread of referred pain seen in people with chronic musculoskeletal pain • Foul smelling discharge from wound
• Modality-Specific somatosensory changes occur in referred areas. • Crepitus at site of wound
• Skin becomes brown coloured due to hemolysis
201 0 Supplementary • Renal failure features
• Jaundice
Q.1 : Mixed salivary tumour □ Types:
A: See "P.S.A." - Section 1, Segment - C, Paper-II, 2012, Os. 5 (Page No. 406-407) • Single muscle type
Q.2: Meconium ileus • Subcutaneous type
A : See Section 1, Segment - D, Os. 110 (Page No. 569-570) • Group type
Q.3: Post burn contracture • Massive type
A : See Section 1, Segment - D, Os. 107 (Page No. 566-567) • Fulminant type
Q.4:FAST □ Investigations:
• Routine blood tests
A : See Section 1, Segment -E, Os. 1 (Page No. 580)
• X-Ray of affected part shows gas shadow
Q.5: Tension pneumothorax
• LFT
A: See Section 1, Segment - C, Paper-II, 2009, Os. 14 (Page No. 370-371)
• Acid-base study
Q.6: Epulis
• Renal function test
A: See Section 1, Segment - C, Paper-II, 2011, Os. 13 (Page No. 399-400) • Pus culture and sensitivity
Q.7: Glasgow coma scale □ Treatment :
A : See Section 1, Segment - C, Paper-II, 2008, Os. 13 (Page No. 355-356) • lnj. Benzyl Penicillin
Q~~.:J3~agrene • lnj. Aminoglycosides

[__/t1/ GAS GANGRENE •

•
lnj. Metronidazole
Antiserum
□ What is gangrene : Death of a portion of body due to putrefaction, caused by infection with saprophytic • Hyperbaric oxygen
bacteria ---------- --···---..;.....
• Proper supportive measure - u/o chart, etc
□ Gas gangrene : Infective gangrene along with gas produced
• Proper debridement and amputation if reqd.
between the tissue ---- · ··
/,-~te
□ Other name ( M a l i g n ~
hydration

□ Causative agent : Q.'9:-~ous anaesthetics

• .91~~-~:_(~!..~'!! .. P..~J_(!.!'19.~-~ A :-See Page No. 770. _,/~-·

• C/ostridium histolyti!WfJ? Q.10: Primary hyperparathyroidis~-1/
• C/ostridium septicum PRIMARfHYPERPARATHYROIDISM
• Other coliforms
□ What is it : Unstimulated inappropriate high secretion of parathormone (PTH)
□ Toxins involved:
• Lecithinase □ Cause : . . . ) _ 85% cases
• Hyaluronidase • Solitary parathyroid adenoma (most common site - inferior parathyroid
• Haemolysin • Hyperplasia (14% cases)
• Proteinase • Carcinoma (1 % cases)

49
 386 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 387

□ Clinical feature.r; : 2) Splenomegaly

• Subtle presentation is assymptomatic hypercalcaemia 3) Compensatory bone marrow hyperplasia
• Cyclic moans (psychiatric changes) 4) Improvement following splenectomy
• Abdominal groans (acid peptic disorder) □ Types:
• Renal stones • Primary - with no underlying aetiology
• Bones affected - initially cortical, then cancellous • Secondary - with underlying aetiology
• Bradycardia □ causes:
• Muscle weakness
•
•
Constipation
Anorexia, weight loss
..
• _Portal_hypertension

•
~~.
Kala azar
-------~
• Polyuria and polydipsia • T.B.
□ Specific bone changes : • Schistosomiasis
• Tufting of terminal phalanx (radial aspect) • Myeloproliferative cU~?rder
• Sub periosteal resorption of middle phalanx □ Mainly affected sex : Females i
• Osteitis fibrosa cystica - cellular and marrow elements in long bones get replaced by fibr.:.ius □ Clinical features :
tissue [Von Recklinghausen disease]
• Osteoclastoma (Brown tumour)
• Fever
• Floating tooth (loss of lamina dura)
• Recurrent infections
• Salt-pepper appearance (pinhead stippling) in skull
• Bleeding from orifices
□ Investigations :
• Pallor
• Serum calcium i (> 12 mg%)
• Oral ulcerations
□ Treatment :
• Serum phosphorus j,
• Corticosteroids rarely are helpful
• Serum chloride i (> 112 mg%)
• Splenectomy is treatment of choice
• c1-/Poi- > 33
Q.12: Hy,~,/e~h✓-
• Serum PTH i (> 0.5 mg/L) ,/\ / .. HYDROCEPHALUS
• Urinary Calcium i (> 250 mg/24 hr)
□ What is it: Dilatation of ventricles of brain
• Serum ALP i
□ Pathology:
• X-ray skull - Salt pepper appearance
• Increased secretion of CSF
• To localise adenoma, Investigation of choice is Sestamibi scan
• Defective absorption of CSF
Best is Sestamibi scan
• Blockage in flow of CSF
Combined with PET scan
□ Treatment : □ Types:
a) Communicating - freely communicating with subarachnoid space
• Adenoma ➔ Gland in which adenoma present is removed
b) Non-communicating - obstructive type
• Hyperplasia ➔ 3½ out of 4 parathyroid glands removed
□ Etiology:
• MEN like familial case ➔ All 4 glands removed. 15 gland fragments created which are put
,Afito brachioradiatis muscle .
Communicating Non-communicating
. /9-o/li0,ersplenism
1) Cong8'1ital aqueductal stenosis 1) Subarachnoid haemorrhage
/ // / HYPERSPLENISM 2) Tubercular meningitis
/ 2) Vein of Galen malformation
□ What is it: Increased splenic function causing pancytopenia and hypercellular bone marrow 3) Posterior fossa tumour 3) Pneumococcal meningitis
□ Diagnostic features : ··
1) Anaemia an<::l/or leucopenia and/or thrombocytopenia
 388 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 389

□ Clinical features : Q.14 : Hospice

a) When sutures are open - HOSPICE
• Separation of sutures - earliest being coronal suture
• Increase in head size 0 What is it: Type of care that mainly focusses on palliation of chronically ill patients or patients in their
death bed.
•
Bulging of fontanelle
0 Goal: To attend to the emotional and spiritual needs of ailing patients
•
Sunset sign (reduced upward gaze)
[No papilloedema in infants]
0 Advantages :
• Provides support and care to terminally ill patients
b) When sutures are closed -
• Affirms life - neither hastens nor postpones death.
• Projectile vomitting
• Focusses on quality of life of patient and their attendents
• Early morning headache
• Teaches family members how to be the emotional support system of the patient
• Altered sensorium
• Main aim is caring, not curing
• Papilloedema
• Changes in sleep cycle
o How it works :
• Family member serves as primary caregiver. They are taught to take important decisions for
• Cushing reflex (hypertension, bradycardia, irregular respiration)
the patient
□ Investigations:
• Members of hospice - Staff make regular visits to assess the patient and provide other
a) When sutures open, IOC is Trans cranial USG services as required.
b) When sutures closed, IOC is - □ Hospice team consists of:
• In unstable patient ➔ Contrast CT
• In stable patient ➔ Contrast MRI
• Patient's personal physician
c) Others -
• Hospice physician
• Nurse
• Ventriculography
• Home attendants
• Air encephalography
• Social workers
□ Treatment :
• Counsellors
• Treat the underlying cause
• Trained volunteers
• Oral Acetozolamide
• Special therapists
• Tapping of lateral ventricles
□ Services provided :
• Ventriculo - cysternostomy (Torkildsen operation) • Manage patient's pain and symptoms
• Ventriculo peritoneal shunt • Provides necessary drugs and equipments
• Ventriculo atrial shunt • Trains family members
[ ~ n e l lymph node biopsy • Assists patient with psychological and spiritual aspects of death
• Makes short term in patient care available
SENTINEL LYMPH NODE BIOPSY
• Provides bereavement care to suffering family

□ What is sentinel node : Lymph node which is in a _9.irect drainage pathway from primary tumour Q.15: Differential diagnosis of intracranial space occupying lesions
□ Sentinel node biopsy: Histological stal 0f sentinel node is studied which also predicts the status
DIFFERENTIAL DIAGNOSIS - INTRACRANIAL SPACE OCCUPYING LESIONS
of distant lymph node
□ First introduced by: Cabana in 1977 introduced it as a staging procedure for penile carcinoma □ What are these : Lesions inside vault of skull (cranium)which may expand in volume to displace
□ Advantages : surrounding neural structures and lead to increase in intracranial pressure
• Minimally invasive □ Mechanism leading to symptoms :
• Low cost • Mass effect
} ➔ Increased ICP
• Gives idea about extent of lymph node resection • CSF obstruction
For rest details see page 128. • Irritation of cortex ➔ Seizures
 SOLVED SHORT NOTES OF FINAL MBBS D Paper - II 391
390 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

C. PARASITIC BRAIN CYSTS

• Compression
• Invasion } ➔ Focal neurological deficit
• Interruption with circulation Amoebic abscess
□ Differential diagnosis :
A. Brain tumours (non-neoplastic or metastatic)
B. Traumatic
C. Parasitic Ne:Jrocysticercosis
D. Inflammatory
E. Vascular • Presentation
F. Congenital Nausea, vomit
Headache
A. BRAIN TUMOURS
Epileptic seizure
Systemic toxicity (fever, malaise)
Glioma Symptoms of primary focus infection (Otitis media, sinusitis, etc)

Meningioma
D. INFLAMMATORY
Schwannoma
Primary Tuberculoma
PNET
• Types Syphilitic gumma
• Types Pituitary tumour
Fungal granuloma
Pinealoma

Metastasis from lung, kidney, breast

E. VASCULAR

□ Clinical presentation : AVM

• Headache
• Vomiting • Types Aneurysm
• Papilloedema
• Seizures CVA
• Focal deficits
• Altered sensorium
F. CONGENITAL
• Hearing problem (Schwannoma)
• Visual defects (Pituitary tumour)
Teratoma
• Perinaud's syndrome (Pinealoma)
B. TRAUMA
Extradural haematoma • Types Dermoid

• Types
Epidermoid
Subdural haematoma
□ Investigations :
For details see Page 350 and Page 363.
• CT I MRI Brain -
Glioblastoma - Irregular, expansile
 392 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 393

Meningioma - 'dural tail' sign b) 24-72 hours -

Acoustic schwannoma - "Ice-cream cone" sign • Chest infection
Pituitary adenoma .:. "Cottage loaf" or "Figure of 8" appearance • Pulmonary atelectasis
Mets - Irregular, scattered all over c) 3rd-7th post-operative day -
EDH - Biconvex, hyperdense • Chest infection
SDH - Biconcave, hyperdense • UTI
Neurocysticercosis - Ring enhancing lesions, discrete, with scolices • Wound infection
Tuberculoma - Conglomerate ring enhancing lesions, with huge oedema surrounding • lntraperitoneal sepsis
lesions Anastomotic leak
•
• MR Angiography Infective endocarditis
•
• Specific blood investigations for tuberculosis and cysticercosis Pelvic abscess
•
□ Treatment : • Subphrenic abscess
• Tumours - Surgical exision ± Radiotherapy • Transfusion reaction
- Gamma knife surgery • Thrombophlebitis
• SDH / EDH - Burr Hole surgery d) 7th-10th post-operative day -
- Craniotomy • Deep vein thrombosis
• Abscess - Drainage • Drug reaction
• Tuberculoma I Neurocysticercosis - Antimicrobial therapy • Pulmonary embolism
• Measures to reduce ICP • Nosocomial infections - pneumonia, UTI, sinusitis, otitis media
- Mannitol □ Assessment :
- Corticosteroids Full clinical examination
- Hyperventilation • Abdominal tenderness, distension
• Anti-epileptic therapy Respiratory rate, crepitations
•
- Phenytion Wound - erythema, discharge
•
- Carbamazepine Calf tenderness (Homan's sign, Mosse's sign)
•
• Any murmur
2011 □ Investigations:
1) Complete hemogram
Q.1 : Flail chest 2) Chest X-Ray
A: See Section - 1, Segment C, Paper - II, 2008, Qs. 12 (Page No. 354). 3) Sputum for Gram stain and culture
4) Urine - Routine examination and culture
Q.2 : Post - operative pyrexia 5) Arterial blood gas analysis
6) Wound swab for culture and sensitivity
POST- OPERATIVE PYREXIA
7) Blood culture
8) CT scan abdomen
□ What is it: Temperature > 38 degree Celsius or 100 degree Fahrenheit on 2 consecutive post-
9) USG abdomen
operative days, or > 39 degree Celcius on any 1 post-operative day
1O) Doppler scan of venous system
□ Aetiology:
□ Treatment :
a) In first 24 hours - 1) Atelectasis - Chest physiotherapy, bronchoscopic aspiration
• Pyrexial response to surgery
2) Pneumonia - Antibiotics
• Transfusion reactions 3) Pleural effusion - Pleural fluid tapping
• Pre-existing infection 4) Pulmonary embolism - Heparin
• Due to medications 5) Wound - Drainage of pus, proper dressing, antibiotics

50
 394 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 395

6) UTI - Antibiotics, alkalinising agent

7) DVT - Heparin
o Types:
a) Plunging - lntrathoracic goiter pushed into neck by increased intrathoracic pressure
8) Acetaminophen for comfort b) lntrathoracic
□ Prevention: c) Substernal - Part of nodule palpable in the lower part of neck
• Discontinue unnecessary medication
• Subclavian lines are preferred to femoral
o Symptoms:
1) Stridor
• Daily spontaneous breathing trials for intubated patients to reduce pneumonia 2) Cough
,., Use of enteral nutrition 3) Breathlessness
µ.;: lfrai~death 4) Dysphagia
I/

BRAIN DEATH
o Signs:
1) Neck veins engorged
□ What is it: Complete and irreversible loss of brain function 2) Lower border of thyroid gland not palpable
3) P~o'..Q_&lgo_Qositiv£:l (Patient raises arms above the level of should~r for few minutes ➔
□ Speciality : Used as an indicator of legal death
compression on SVC and trachea ➔ engorged dilated neck veins + stndor)
□ Declaration by : 2 independent physicians after thorough neurological examination twicE' at
4) Dull note audible on percussion over sternum
reasonable gap
□ Investigations :
□ Tests:
1) Radioactive iodine scan
1) Pupil fixed and dilated
2) CT scan
2) Pupillary reflex absent
3) Chest X-Ray
3) Corneal reflex absent
□ Treatment : Surgical removal
4) Conjunctional reflex absent
5) Oculo-cephalic reflex absent Q.B: Parotid abscess ~ ~ - - ,
6) Vestibulo-ocular reflex absent (__/___,--- PAROTID ABSCESS
7) Superficial and deep motor reflexes absent ➔ no response to pain, touch and temperature
8) Gap reflex, cough reflex absent □ Synonym : Suppurative parotitis
9) No respiratory movement, stoppage of ventilator □ What is it: _Abscess of parotid gland due to acute bacterial sialadenitis of p~rotid gland
10) Flat EEG
□ Causative organisms :
□ Importance : Time of brain death is important to be noted for the purpose of organ donation. 1) _S_tgpb_yJococcus aureus
Q.4 : Split thickness skin graft 2) StreptocoE._0:!2 viridians
A: See Section - 1, Segment C, Paper - 11, 2008, Os. 7 (Page No. 351-352) 3) Anaerobic organisms
Q.5: Spinal anesthesia 4) -~-negative organisms
A : See 'Anesthesiology' Section - 3, Qs. 1 (Page No. 753) □ Predisposing conditions :
Q.6: Omphalocele 1) After major surgery
A: Se.9Section - 1, Segment C, Paper -11, 2008, Os. 6 (Page No. 350). 2) Sepsis
/
3) Dehydration
/✓ p: Retrosternal goiter
4) Starvation
1x/ RETROSTERNAL GOITER 5) Poor oral hygiene
□ Symptoms:
□ What is it: > 50% of the goiter lies below suprasternal notch
1) Fever
□ Pathogenesis : In men whose necks are short and pretracheal muscles are strong, negative 2) Pain
intrathoracic pressure tends to draw goiter into thoracic cavity
3) Trismus
□ Classification :
□ Signs:
a) Primary - Arise from ectopic thyroid tissue
b) Secondary - Extension occurs from enlarged thyroid gland in neck 1) Swelling -
► warm
► red
396 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 397

► well-localised □ Diagnosis :
► tender 1) Tenderness at McBurney's point
2) Rebound tenderness at McBurney's point
► firm
3) Cutaneous hyperaesthesia over Sherren's triangle
► fluctuation is a late feature
4) Rovsing's sign - Pain occurs in right iliac fossa on pressing left iliac fossa
2) Pus from duct opening
5) Cape's psoas test - Pain in right iliac fossa on hyperextension of right hip
□ Investigations: 6) Obturator test - Pain in right iliac fossa on passive internal rotation of right hip
1) USG parotid region 7) Baldwing's test - Pain ever flanks when legs lifted· off bed with knee extended
2) Pus - Culture and sensitivity □ Treatment : Appendicectomy
3) Needle aspiration to confirm pus Q.10: TURP
[Sialogram not done in acute phase, which can cause infection]
A : See 'Investigations' Section (Section - 1, Segment E, Os. 15) [Page No. 591-592].
□ Treatment :
1) Drainage of pus Q.11 : Oxalate stone
2) Antibiotics OXALATE STONE
3) Proper hydration
4) Oral hygiene maintenance □ Synonym : Mul~.E:Jr!}'._?torrn
5) Proper nutrition □ Colour : Brown
□ Complications : □ Content: Calcium o~ate __
1) Fistula □ Surface : Sharp projections ~ hematuria
----~-•-="
=" -~~-" •"- A- > - S'

2) Septicaemia □ Shape:
3) Rupture into external auditory canal 1) Monohydrate stones - Dumbbell shaped
2) Dehydrate stones - Envelope shaped
Q.9 : Alvarado score of acute pancreatitis
□ Clinical features :
ALVARADO SCORE OF ACUTE PANCREATITIS 1) Pain -
► dull - Due to stretching of capsule
□ Also called: Mantrels scoring system ► colicky - Due to movement of small stone
□ Use : Bedside diagnosis of acute pancreatitis 2) Hematuria
□ Scoring system : MA\\ Rf '. 3) Fever
4) Pyuria
Symptoms Score 5) Renal angle tenderness
Migrating pain in right iliac fossa 1 □ Investigations :
Anorexia 1 1) Urine - Envelope crystals
Nausea and vomit 1 2) Serum calcium increased
Tenderness in right iliac fossa 2 3) ESR raised
4) Plain X-Ray KUB
Rebound tenderness 1
5) IVU
Elevated temperature 1
6) Urine analysis
Leucocytosis 2
□ Treatment :
Shift to left in neutrophilia in 1
a) For stones < 0.5 cm -
peripheral blood smear
1) Anti-inflammatory drugs, a~ti-spasmodic drugs
□ Interpretation: 2) Intravenous fluids
Score < 5 - Not sure 3) Injection Furosemide
Score 5-6 - Compatible 4) Flush therapy
Score 6-9 - Probable 5) Alkalinising agents, acidifying agents
Score > 9 - Confirmed 6) Relief of obstruction by double J-stent
Score > 7 indicates acute appendicitis, requires immediate operation
 398 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 399

b) For stones> 0.5 cm - □ Indications :

Endourological surgery 1) j\rth _r:i,t_i_~-
2) _Musclei~
/ For non-lower pole renal calculi ~ 3) .BJ1i1!l.ITL~
4) Inflammation
5) Fibromyalgia
>2cm
/<2cm~ 6) ~
7) Psoriasis
< 1 cm >1Cm 8) Tendonitis

t 9) Sudeck's osteodystrophy

l
ESWL 1O) Sport-related injuries
11) Moisturise and cleanse the skin
t 12) Open pores in skin
Mechanism : Slowly increasing temperature around affected area warms the subcutaneous layer
Failure ~ Uretero Renoscopic Stone Lithotripsy □ and triggers endorphin release to the affected site, thereby bringing relief
t
F a i l u r e - - - - - - - - - PCNL □
Contents of wax: Wax : paraffin ::: 7 : 1
Temperature of wax : 120 degree Celcius
□
Procedure : Specially formulated wax is heated in a container ➔ a regulator maintains a safe
□ temperature for the skin ➔ wax melts ➔ affected part submersed in the molten wax and removed ➔
-------- For lower por renal calculi
~ allowed to air-dry for 2 minutes ➔ procedure repeated for 5-1 O minutes ➔ after there are enough wax
layers, the affected part is wrapped in plastic and left to stand for 15 minutes ➔ when wax gets
~ 1-2cm >2cm
<1cm t hardened, it is peeled off

/ ~ Is PCNL contraindicated?
□ Contraindications :
1) Open wounds
HU< 1000 HU> 1000
SSD < 10 cm SSD > 10 cm
/
Yes
2) Skin rash
3) Cuts
No~
t t t PCNL
4) Burns
5) Varicose vein
ESWL Flexible retrograde intrarenal surgery
6) History of hypertension

c) If endourological surgery fails -

Q.13: Epulis >/;;:----_,
/
• Pyelolithotomy - For stones in extrarenal pelvis EPULIS
• Extended pyelolithotomy - For stones in intrarenal pelvis
□ Meaning : Upon a gum
• Nephrolithotomy - Incision at most convex surface (Brodel's line)
• Partial nephrectomy - If multiple stones occupy a pole □ What is it : S~lling arising fr~m mus~R~r~~~~-
• Others - □ Types:
► Bench surgery (A) _Congeni~l epulis
(B) Fibrous epulis
► Anatrophic pyelolithotomy
(C) Pregnancy epulis

,_?· .
a,~✓►

-xbath
Coagulum pyelolithotomy

WAX BATH
(DL MielomatOt,JS epulis
(E) Giant cell epulis
(F) Granulamatous epulis
(G) . Car~ino111~!<:>_tg3__epulis
□ What is it:_ Te~ue of adrr1i__ri,~stering surface heat therapy A. CONGENITAL EPULIS:
□ Principle: Involves immersion of the required body parts into molten paraffin wax to relieve pain, treat □ Features:
muscle injury and moisturize and deep cleanse the skin ►

··-------
Benign condition
 400 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 401

► Newborns f. GRANULOMATOUS EPULIS:

► Arises from gumpads • Mass of granulation tissue in gums around caries tooth
► Variant of granular cell myeloblastoma originating from gums • Localised, firm, fleshy mass in gum which bleeds on touch
► F>M G. CARCINOMATOUS EPULIS:
► Common ir. upper jaw • Sq~ous cell carcinoma of alveolus and gum
► Common in premolar/canine area • Localised, hard, indurated swelling with ulceration
□ Clinical features :
a. ~ n in surgery
Swelling with following features -
A: See Section - 1, Segment E, 'Investigations', Os. 11 (Page No:2.§I:-588).
• Well localised
• Firm Q~fnatitis
• Bleeds on touch
RADIATION DERMATITIS
□ Investigations :
1) X-Ray of jaw □ Synonym : Radiodermatitis
2) Orthopantomogram □ What is it : Skin disease associated with prolonged exposure to ionising radiation
3) Biopsy □ Types:
□ Treatment : Excision of epulis a) Acute - Caused by "erythema dose" of ionising radiation
b) Chronic - Caused by "sub-erythema dose" of ionising radiation
B. FIBROUS EPULIS :
c) Others
□ Features: □ Effects
• Benig_!l • Acute radiodermatitis
• Commonest 1) Erythema - Appears after 24 hours, at more than 2 Gy radiation
• Can occur at any age 2) Desquamation
• Arises from periodontal membrane 3) Blister
□ Clinical features : • Chronic radiodermatitis :
Swelling with following features - 1) Atrophic indurated plaques - (a) whitish and (b) yellowish
• Well-localised 2) Telangiectasia
• Hard 3) Hyperkeratosis
• Painless, non-tender • Others:
• Bleeds on touch 1) Eosinophilic, polymorphic and pruritic eruption - Occurs due to Cobalt therapy
□ Investigations: 2) Erythema multiforme - Due to phenytoin therapy
1) X-Ray of jaw □ Delayed non-specific effects :
2) Orthopantomogram 1) Radiation acne --, comedo-like papules
3) Biopsy 2) Radiation recall reactions --, occurs years after radiation treatment
□ Treatment : Excision of epulis with extraction of adjacent tooth Q.16: Spinal anesthesia
C. PREGNANCY EPULIS : A : See Section - 3, Qs. 1 (Page No. 753).
• Occur mostly in third month of pregnancy

------
• ~~!.~_'I~]l~is 2011 Supplementary
• Resembles fibrous epulis
- /P,ma,,himosis
\9~11
• Resolves after delivery
A: See Section 1, Segment - C, Paper-II, 2012, Os. 6 (Page No. 408)
D. MYELOMATOUS EPULIS:
0.2 : Parotid fistula
• Seen in leukaemic patients
A : See Section 1, Segment - D, Os. 116 (Page No. 57 4-575)
• Resolves when treated for leukemia
Q.3 : Hypospadius
E. GIANT CELL EPULIS : It is osteoclastoma causing ulceration and hemorrhage of gums
A: See Section 1, Segment - C, Paper-II, 2013 supplementary, Os. 8 (Page No. 425-426)

51
402 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 403

Q.4 : Local anaesthesia

A: See Section 3, Os. 8 (Page No. 764-765)
Q.5 : Oschner - Sherren regimen
A : See "Appendicular lump" Sec 1, Segment - A, Paper-I, 201'3 supplementary, Os. 2 (Page No. 63-64)
Q.6 : Stove-in-chest
STOVE-IN-CHEST
Medial intermuscular septum
□ What is it: Localised indentation over chest wall following blunt trauma
□ Pathological anatomy:
• Fracture of contiguous 2-3 ribs at .all east two places
• Area of bone between the two fracture sites is driven in
□ Clinical features :
• H/O blunt trauma
• Localised indentation on chest wall leading to pain, tenderness Dorsal branch to skin
M
• Respiratory distress
• Features of neurogenic shock
□ Difference with flail-chest: The affected part of chest wall does not lose its structural and physiological
continuity with rest of chest wall. The entire chest moves symmetrically. Hence there is NO
PARADOXICAL RESPIRATION.
Fig. Injury to Ulnar nerve
□ Investigations:
• X-ray chest (PA view)
• 7 cm above the wrist it gives a dorsal branch which supplies the skin over the medial 1½
• Blood gas analysis
fingers on the dorsal aspect
• Other routine investigations
• It enters into the palm superficial to flexor retinaculum .
• CT Thorax may be required
• In the palm it supplies
□ Treatment :
A. Motor -
• Analgesics and antibiotics (i) Hypothenar muscles
• Depressed segment may be lifted with towel clip (ii) 3rd and 4th lumbricales
• Nowadays, positive pressure ventilation is the new mode of treatment (iii) All interossei
Q.7: Hydrocephalus (iv) Adductor pollicis
A: See Section 1, Segment - C, Paper-II, 2010 supplementary, Os. 12 (Page No. 387). B. Sensory - Medial 1½ fingers and adjoining palm

Q.8: Ulnar nerve injury INJURY. OF ULNAR NERVE -

□ Sites:
ULNAR NERVE INJURY
1) At the elbow
□ Surgical anatomy 2) At the wrist
• Continuation of medial cord of brachia! plexus (Ca, T 1) □ Causes:
• No branch in arm I. At the wrist -
( 1) Sharp cut injury over front and medial aspect of wrist. Even a superficial cut can
• Pierces medial intermuscular septum and goes into posterior compartment
cause injury (since nerve lies superficial to flexor retinaculum)
• Runs close and behind medial epicondyle
II. At the elbow-
• Enters into forearm (1) Supracondylar
• In the forearm it supplies flexor carpi ulnaris and medial half of flexor digitorum profundus (2) Medial epicondyle
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 405
404 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

• No destruction of nipple areola complex as lesion is superficial

(3) Tardy ulnar palsy- Due to stretching of the nerve in a case of cubitus valgus. (elbow)
resulting from malunited supracondylar fracture • Treatment is - Hadfield operation (Cone excision of multiple ducts)
(4) Ulnar Tunnel syndrome For Rest, See Section 1, Segment - C, Paper-I, 2008, Qs. 4 (Page No. 276)
□ Effects: --a.11: Hydronephrosis
I. At the wrist- A: see Section 1, Segment - A, Paper-II, 2013, Qs. 1 (Page No. 148)
• Sensory - Sensory loss to medial 1 ½ finger and adjacent palm Q.12: Adamantlnoma
A: See "Ameloblastoma" Section 1, Segment - C, Paper-II, 2012, Os. 13 (Page No. 411)
• Motor - (i) Atrophy of hypothenar muscles
Q.13 : Brachytherapy
(ii) Card Test the +ve (test for interossei - Patient is asked to hold a card
A: See Section 1, Segment - C, Paper-II, 2008, Qs.10 (Page No. 353)
between the fingers. The card is pulled. Patient cannot hold)
(iii) Book Test +ve (Test for integrity of adductor pollicis. The patient is Q.14: USG for hepatobiliary diseases
asked to hold a book by adducting the 1humbs. When the book is A: See Page No. 612-613.
pulled out, the tip of the thumb is flexed on the affected the side. Flexor Q.15: Cervical traction
pollicis longus contracts to keep the book)
II. At thee/bow-
CERVICAL TRACTION
(1) Same as injury at wrist □ Objective of traction :
(2) Additional - • To reduce fracture, dislocation and maintain them
• Motor - Radial deviation of the wrist on flexion of wrist against • Prevention of deformity
resistance (because of unopposed action of flexor carpi ulnaris)
• Correction of soft tissue contracture
• Sensory - Loss of sensation on dorsal aspect of medial 1½ fingers
• Immobilising painful inflammed joint
• Deformity - Claw Hand
O Types of traction :
Q.9 : Bedsore
A) Fixed - Counter traction is provided by part of body
A: See Section 1, Segment - C, Paper-I, 2012, Os. 4, "Decubitus ulcer" (Page No. 296)
B) Sliding - Counter traction provided by weight of body
~ ~ o d y discharge per nipple _
□ Role of cervical traction : Helps to create space between cervical vertebra to keep them healthy,
I // BLOODY DISCHARGE PER NIPPLE and prevent further compression
□ Parts:
□ Sources of bloody discharge per nipple : • Retracting table/couch
a) From single duct - Duct.12.~[[lQ_ma_ • Cervical traction collar (spongy in nature)
b) From multiple ducts - Ductal carcinoma • Metal hook to catch the collar
--·-------
- P!JCt~_g_gsja • Retracting wire/cable
A. DUCT PAPILLOMA · □ Crutchfield traction :
• Most common cause of bloody discharge • Reduction of cervical spine injury achieved by skull traction applied through skull callipers
• Young age called Crutchfield tongs.
• Blood oozes from same site repeatedly • Weight of upto 1O ~g applied and X-ray checked every 12 hours
• No lump • After adequate reduction, light traction is continued for 6 wks, followed by immobilisation of
• No pain / tenderness neck in a moulded PoP cast or plastic collar.
• Not detected on any radiological investigation however subareolar lump may be detected on □ Head Halter traction :
USG • It is a type of skin traction equivalent to spinal traction used for cervical spine injuries
• Treatment is microdochectomy • Types - a) Canvas type
B. DUCT ECTASIA b) Cryle type
• Above 40 years age • Complications - a) pressure on chin
• Common in smokers b) pressure on occiput
• Bloody discharge accompanied with greenish discharge c) pressure at TM joint
• Bilateral
 406 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS D Paper - II 407

2012 Histopathology:
, Epithelial cells - Columnar/squamous/basal
Q.1 : Breast biopsies , Myoepithelial cells
A: See Section - 1, Segment C, Paper - I, 2014, Os. 1 (Page No. 309-310). , Mucoid material with myxomatous change
-~~uses of hematuria , Cartilage/pseudocartilage
,--<__ ,, A: See Section - 1, Segment A, Paper -11, 2008,' Os. 1 (Page No. 94) o Salient features :
Q.3 · Antegrade pyelography , Though capsulated, it nny come out as pseudopods and may extend beyond the main limit
of the tumor tissue
i ~ / y . s e e 'Investigations' segment (Section - 1, Segment E, Os. 18) [Page No. 594]
'"Q.4
_... : Stress gastritis , Sometimes only the deep lobe is involved
□ Clinical features :
STRESS GASTRITIS 1) Features of parotid tumor -
► Curtain sign - the mass cannot be moved above zygomatic bone as deep parotid fascia
□ What is it:, Inflammation of gastric mucosa occuring ,in stressful conditions is attached above the zygomalic bone
□ Symptoms: ► Raised ear lobule
1) Epigastric discomfort ► Deviation of uvula and pharyngeal wall towards midline
2) Nausea 2) Swelling with following features -
3) Vomit ► Solitary
► Unilateral
□ Complications :
► Firm
1) Peptic ulcer disea~e
► Lobulated or smooth
2) Gastric polyps
► Mobile
3) Benign and malignant gastric tumors 3) Obliteration of retromandibular groove
□ Investigations: □ Features on impending malignancy:
1) Upper GI endoscopy 1) Pain
2) Routine CBC 2) Rapid increase in size
3) Stool test 3) Nodularity
□ Treatment : 4) Involvement of -
► Skin (ulceration)
1) i.v. Ranitidine 50 mg 8 hourly
► CNVII
2) i.v. Omeprazole I Pantoprazole
► Masseter
,,,-· 3) Sucralfate orally •
► Neck lymph nodes
. ,/p:5: P.S.A ( \?.•.,.\Cl'.J'M()'.)·~.\,0 □ Complications :
,)~'.,/ "--··· I
P.S.A 1) Malignancy
2) Recurrence
□ Full form : Pleomorphic salivary adenoma
□ Investigations :
□ Synonym : Mixed salivary tumor
1) FNAC
□ Speciality : 9ommonest salivary gland tumor
2) 99 mrech scan to differentiate from adenolymphom~
□ Most common gland involved: _P.arotid gland 3) CT scan
□ Least common gland involved : Submandibular gland 4) MRI
□ Gross pathology: □ Treatment :
Contains - Surgery
, Cartilages , If superficial lobe involved ➔ superficial parotidectomy (part of the parotid gland superficial
• Solid tissues to CN VI I removed) · ·,. ·-·
• Cystic spaces , If both lobes involved ➔ total conservative parotidectomy
 408 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 409

2) Nausea and vomit

PARAPHIMOSIS Signs:
1) Scrotum swollen and tender
□ What is it : Condition. where_J_here is inability to place back the retracted prepucial skin over the
giE.lli!s. [See Fig. t~.:W ?; r,:, ~ ·-·---·--·· - .._ · 2) Red, oedematous scrotum
3) Deming's sign - Affected testis lies at a higher level due to twisting of spermatic cord and
□ Effect : Ring like constrictio·n formed proximal to corona and prepucial skin spasm of cremaster
□ Pathogenesis : Constricting band ➔ obstruction to venous outflow ➔ edema and congestion of 4) Angeli's sign - Opposite testis lies horizontally due to mesorchium
glans ➔ necrosis
Investigations :
□ Etiology:
1) Leucocytosis._
1) After urethral catheterisation 2) Doppler study of scrotum
2) After sexual intercourse 3) USG abdomen
□ Treatment : 4) MRI abdomen
1) 1 ml isotonic saline+ 150 units hyaluronidase ➔ injected into each lateral aspect of constriction □ Differential diagnosis :
ring, following which manual reduction tried after swelling gets reduced 1) Acute epididymo-orchitis - Pain relieved on elevation of testis for few seconds (Prehn's sign),
2) Multiple needle punctures may be made to reduce edema, before manual reduction of worsened in torsion of testis
prepucial skin 2) Strangulated inguinal hernia - In case of torsion of incompletely descended testis
3) If manual reduction is unsuccessful, initial dorsal slit to reduce edema + antibiotic and 3) Torsion of appendage of testis
analgesic ➔ circumcision after 3 weeks 4) Mumps orchitis
Q.7: Lucid interval 5) Jra_u_r_n_?
A: See Section - 1, Segment C, Paper - II, 2009, Os. 7 (Page No. 365-366) □ Treatment :
Q.8 : Chest drain • Immediate hospitalisation ➔ exploration of scrotum ➔ untwisting of torsion of testis ➔ viability
of testis checked ➔ if viable, testis fixed to scrotal sac
/ A : S~Section - 1, Segment C, Paper - I, 2013 Supplementary, Os. 3 (Page No. 307-308)
• If testis becomes non-viable ➔ orchidectomy after taking informed consent
Q.9 ;,-Torsion of testis
/'
• If doubt ➔ orchidectomy postponed
. TORSION OF TESTIS
~ ~ e n it is a bilateral condition, other side fixed should also be fixed
□ What is it: Testis twists in its own axis thereby hampering the blood supply of testis
ah . ~ expansion
□ Direction of rotation: Right testis ➔ clockwise, left testis ➔ anticlockwise ./
TISSUE EXPANSION
□ Age : Peripubertal males
□ Predisposing factors : □ What is it: J3ec_c:>J:1_~t_r:_':l_ctive surgical technigue.!_hich allows the body to gr_<:>~-~2<traskin, bone or other
1) Inversion of testis tissues_ where there has been tis§Ue loss due_to any cause · ·
2) ~ndesce~_E:_d or ectopic testis □ Mechanism : A balloon - like expander with silicon shell inserted under the skin near the required
3) _Long m~~orchium area ➔ shell is gradually filled with saline water through a self-sealing port attached to a filling tube
4) High investment of tunica vaginalis that enters the balloon ➔ skin gets stretched and accommodates to the changed vascular pressure ➔
5) Voluminous tunica vaginalis new skin placed over the defect and sutured
6) Gap between epididymis and body of testis □ Indications :
7) Heavy straining 1) Breast reconstruction
□ Initiating factor: Spasm of cremaster which inserts onto the cord obliquely 2) Hair transplantation
3) After removal of major congenital skin naevi
□ Pathology: Torsion from within outwards ➔ vascular occlusion ➔ edema of testis and spermatic cord
4) llizarov's technique of external fixation
upto point of occlusion ➔ gangrene of testis and epididymis
□ Complications:
□ Symptoms:
1) Hematoma
1) Pain -
2) Infection
► Sudden onset
► Severe 3) Scarring
► In groin and testicles 4) Discolouration
► Referred to lower abdomen 5) Skin or fat necrosis

52
 41 O QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS D Paper - II 411

□ Advantages : (b) More than 4 nodes positive

1) Less noticeable scars than with skin grafts or flaps (c) Extranodal spread
2) Almost same skin colour, texture and sensation as normal skin □ Dose:
3) Less risk of tissue loss as the blood supply and nerve supply remains connected • 200 cGy units daily 5 days/week x 6 weeks.
□ Disadvantages :
1) Cosmetic value is poor because of unwanted bulge created by expander Q.13.. :·.·. AAmm~e'3P'6~
2) Costly -~ AMELOBLASTOMA
3) Repeated saline injections required
□ Synonyms:
4) Time consuming
• Adamantinoma
□ Ideal candidate:
• Eve's disease
1) Those with thin skin
• Multilocular cystic disease of jaw
2) Non-smokers
□ Arises from : [)-~~~L.fillli_hfil.Ly_m
3) Unscarred skin
□ Site:
, ~ ; ; t h e t i c monitoring devices . .
1) Mandible
· A: See 'Anaesthesiology' Section - 3, Os. 4 (Page No. 759). 2) Maxilla
;'~diotherapy in treatment of CA breast - 3) Tibia (rare)
1
4) Base of skull in relation to Rathke's pouch(rare)
,__/L/ RADIOTHERAPY IN TREATMENT OF CA BREAST
□ Nature : Locally malignant
□ Indications : Used for all stages of breast cancer □ Histopathology: Variant of ba_~al cell carcinoma with cords of odontogenic epithelium, stellate reticulum
1) After conservative breast surgery like cells and columnar ameloblast like cells
2) Preoperative - to reduce size of lesion □ Prognosis: Curable
3) Bone secondaries □ Locularity: Multilocular
4) Inflammatory carcinoma of breast □ Laterality : Unilateral
5) Women with limited DCIS (Stage 0), in whom negative margins are achieved by lumpectomy □ Age : 40-50 years
or by re-excision
□ Clinical features :
6) Women with stage I, Ila, or lib breast cancer, in whom negative margins are achieved by
1) Swelling in jaw
lumpectomy or by re-excision
2) Large size, gradually increases in size
7) Higher risk of relapse after surgery -
3) Painless
(a) Patients < 35 year age
4) Hard
(b) Invasive carcinoma
5) Smooth
(c) With multifocal disease
6) No lymph node enlargement
8) More than 4 positive lymph nodes in axilla
7) Outer table expansion, inner table intact
9) Premenopausal women with metastatic disease involving 1-3 lymph nodes
10) Atrophic scirrhous carcinoma of breast □ Sex predilection : M > F
11) Advanced locoregional breast carcinoma (Stage Illa or lllb) □ Investigations :
□ Site: 1) Orthopantomogram - Honey-comb appearance
(A) To chest wall (breast area, internal mammary and supraclavicular area) 2) Biopsy from the swelling
(a) High risk group □ Treatment: Segmental resection of mandible or hemimandibulectomy with reconstruction of mandible
(b) After conservative surgery (curettage and bone graft not done)
(c) T3 tumor> 5 cm □ Differential diagnosis :
(d) Inflammatory carcinoma 1) Dentigerous cyst
(e) Close surgical margin of < 2 cm 2) Osteoclastoma of mandible
(8) To axilla 3) Dental abscess
4) Jaffe's tumor
(a) Axillary dissection not done
 412 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II

Q.7: Epidural anaesthesia

TRANSLUMINAL USG A: see Section 3, Os. 7, (Page No. 763-764)
□ What is it: Transluminal USG is actually the incorporation of an ultrasonic transducer in the tip of a Q.8 : Brachytherapy
flexible endoscope or the use of stand-alone ultrasound probes. It is also known as "Endoscopic A: see Section 1, Segment - C, Paper-II, 2008, Os. 10, (Page No. 353)
Ultrasonography (EUS)".
Q.9: N f ] ~ ~ ! ~
□ Uses:
NEPHROBLASTOMA
A. Diagnostic
(a) To obtain images of gastrointestinal lesions that are not apparent on superficial views, □ Other Name : Wilm's tumour
including lesions within the wall of the gut as well as those that lie beyond like pancreatic or □ Speciality: 2nd most common abdominal tumour in children
lymph node lesions.
□ Age group : 3 - 6 years
(b) To complement more conventional radiologic tests to help determine the resectability and
□ Histological feature : Metanephric blastema
curative potential of surgery in oesophageal and pancreatic CA.
(c) To guide fine-needle aspiration, which often provides pathologic confirmation of suspicious □ Presentation: Triad of • J',bgpminal lump
lesion. • Fever
B. Therapeutic
EUS-directed celiac plexus neurolysis (a technique that appears to be effective for the treatment □
•
-----
Haematuria
Prognostic indicator: Best is histology
of pain in patients with pancreatic CA) □ Metastasis to : Lungs
□ Accuracy:
□ Salient features :
• More accurate than conventional radiologic techniques like abdominal ultrasonography and • Presence of nephrogenic rests (nephroblastomatosis) in resected specimen indicates
CT scan increased risk of developing Wilm's tumour in contralateral kidney
• It is probably the single best test for diagnosis of pancreatic endocrine tumors (sensitivity • Rarely crosses midline unlike neuroblastoma
approximately 95%)
• Vascular invasion occurs but not intraspinal invasion unlike neuroblastoma
• It is also the procedure of choice for imaging of wall lesions of the gastrointestinal tract,
□ Investigation of choice : CT Scan Abdomen (does not show any intratumoral calcification unlike
mostly submucosal lesions (accuracy= 65 to 70%)
neuroblastoma)
• For preoperative staging of a variety of gastrointestinal tumors, it has overall accuracy of
> 90%. □ Staging system :
• National Wilm's Tumour Staging Group Classification (Pre chemotherapy)
Q.15: Short wave diathermy
• International Society of Paediatric Oncology (Post chemotherapy)
A : See Section - 1, Segment C, Paper - 11, 2009, Os. 13 (Page No. 370).
□ Treatment :
2012 Supplementary Stage I - IV ➔ Radical nephrectomy + / - chemoradiation
Stage V ➔ Chemoradiation with Adriamycin, Vincristine, Actinomycin - D
Q.1 : Extradural haemorrhage
□ Syndromes associated :
A: See Section 1, Segment - C, Paper-II, 2009, Os.7, (Page No. 365-366)
• Beckwith Weidmann syndrome
Q.2:DVT
• Deny's Drash syndrome
A: See Section 1, Segment - C, Paper-I, 2011, Os.3, (Page No. 290-291)
• WAGR (Wilm's tumour+ Aniridia + Genitourinary abnormalities+ Mental retardation)
0.3 : Epididymal cyst

~rSWL
A: See-Section 1, Segment - C, Paper-II, 2008, Os.2, (Page No. 347)

,,, A : See Section 1, Segment - E, Os. 23, (Page No. 598)

0.10 :JM{~nges in BHP

□
.· .
BLADDER CHANGES IN BHP

BHP : Benign enlargement of prostate which occurs generally after 50 years

Q.5 : Causes of haematuria
□ Pathogenesis :
A: See Section 1, Segment - A, Paper-II, 2008, Os. 1, (Page No. 94) • Involuntary hyperplasia due to disturbance of the ratio of circulating androgens and estrogen
Q.6 : Dentigerous cyst • Pulsatile release of LHRH from hypothalamus ·
A: See Section 1, Segment - C, Paper-II, 2014, Os. 3, (Page No. 428-429) j,
414 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - 11 415

LH releases from anterior pituitary • Speciality - Most aggressive variant

J, c. Lentigo maligna melanoma -
Stimulates Leydig cells of testes • Location - f&ce (Hutchinson's melanotic freckle), hands, neck
J,
• Age - Old age, more in women
Testosterone released
• Growth - Slow
J,
• Appearance - Lentigo I B,own macule
Acts on prostate
• Arise from - Not known
J,
• Prognosis - Very good
5 a reductase type II released
J, • Speciality - Least malignant and less common variety

Converts testosterone to dihydrotestostone D. Acral lentiginous melanoma -

• .As a QerSO!U!9§~Ull13__testosterone decreases, estrogen level remains same. Due to this • Location - Palms, soles, subungal region
imbalance, Intermediate Pepfide Growt11··ractor·acisTo caiis~-pfosfaticJ:lyperplasia--- • Age - Middle age in Japan, Africa, Asia
0 Structural changes : • Growth - Vertical
• Appearance - Large size, Nodular; often a flat irregular macule
• Median and lateral lobe mainly get enlarged
• Mimics - Fungal infection / pyogenic granuloma
• Median lo_be enlarges and presse~ onto the bladder
• Prognosis - Poor
• Bladder develops trabeculations anj sacculations and later it leads to formation of diverticula
• Speciality - Least common variant
□ Functional changes :
E. Amelanotic melanoma -
• Due to introversion of sensitive urethral mucosa into bladder, the frequency of micturition
increases • Location - Anywhere
• Overflow and terminal dribbling • Age - Middle or old age
• Hesitancy and urgency • Growth - Rapidly progressive
• Appearance - Pink fleshy mass (Tumour cells lose capacity to synthesize melanin)
• Impaired bladder emptying leads to cystitis, urethritis and bladder calculi
• Mimics - Soft tissue sarcoma
• Chronic retention leads to bladder enlargement which makes the bladder palpable, with
suprapubic tenderness on abdominal examination • Markers for diagnosis - S100, HMB45
• Prognosis - Worst
Q.11 :Va,riants of melanoma
F. Desmoplastic melanoma -
VARIANTS OF MELANOMA
• Location - Head, neck
A. Superficial spreading type - • Speciality - High affinity for perineural invasion
• Location - anywhere in body High recurrence rate
• Age - Mainly middle age For Rest, see Section 1, Segment - D, Os. 71 (Page No. 529-530)
• Growth - Radial Q.12: CABG
• Appearance - Irregular, variegated
• Arises from - Pre-existing naevus
\ CABG
• Prognosis - Good □ Full form : _?oronary Artery Bypass Grafting
• Speciality - Commonest variant of melanoma □ What is it: Most common type of open heart surgery
B. Nodular melanoma - □ Goals of CABG :
• Location - anywhere in body (mainly mucosa! and mucocutaneous region) of head, • Improve quality of life of patients with CHO
neck, trunk
• Reduce angina
• Age - Young age, more in men • Lower risk of AMI
• Growth - Vertical • Improve ejection fraction (pumping function) of heart
• Appearance - Nodular, uniform □ Function : Improve blood flow to heart
• Arise from - De-novo □ Indications :
• Prognosis - Poor • Triple vessel disease
 416 QUEST: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
// SOLVED SHORT NOTES OF FINAL MBBS □ Paper - 11 417

• Left main artery disease o Phyt·otherapy:

• Abnormal left ventricular function ) Pendulum stretch - With relaxed shoulders, the patient should stand and lean over slightly,
• To help perfusion of viable myocardium immediately after AMI , allowing the affected arm to hang down, followed by swirling the arm in small circle, and
• Failed PTCA gradually increasing the diameter of swirl
□ Types: B) Finger walk - Patient should touch the wall at waist level with fingertips of affected arm with
• On pump CABG elbow slightly bent, the patient must walk his fingers up the wall, till he has raised his arm
• Off pump CABG comfortably as far as he can, and then slowly lower the arm and repeat this.
□ Types of Grafts : C) Towel stretch - Patient must hold one end of a three foot long towel behind his back and grab
A) Venous graft - Great saphenous vein used usually. In case of varicosities in GSV, short opposite end with other hand. Initially towel must be horizontal. Gradually better arm should
saphenous vein isus·ea·~ . be used to pull the affected arm upward to stretch it. This is to be repeated 10-20 times a day
8) Arterial graft - D) Armpit stretch - Patient must use his better arm to lift the affected arm onto a shelf as high as
• ,Left internal ttlo_r_acic art~_ry diverted to left anterior descending branch of left coronary his chest level. Then he must gently bend his knees opening up the armpit and then straighten.
artery To be repeated 10-20 times everyday.
• Ri.9ht internal thoracic artery reaches right coronary artery, left anterior descending E) Cross-body reach - Patient must use better arm to lift the affected arm at the elbow level and
artery and some branches of circumflex artery bring it up and across his body, exerting pressure very gently to stretch his shoulder. To be
• _f3adial }:lrt§JY may also be used done for 15-20 sec, 10-20 times each day.
• Gastroepiploic artery rarely used F) Outward and Inward rotation - Patient must hold a rubber exercise band between hands with
C) Synthetic graft - Made of dacron elbows at 90° degree angle kept closed to his sides. The lower part of affected arm is to be
□ Complications : rotated outward and inward two or three inches and to be held for 5 seconds and repeated.
• AMI
2013
• CVA
• Ankle swelling
• Arrythmia CLEFT LIP
• Graft rejection
• Renal failure □ Aetiology: ..A cle~-1- J; f.
~\.-t~ <11'\'\ opeMJ~ ; "' ~e__
1) Familial
•.., Vein graft occlusion
2) Radiation v.p~ JJ'p ~ ~ ex'leM.cl. iv-dt, e "Y\.OS,.e..'
\ . ~ m a l l bowel enema
A : §ee Section 1, Segment - E, Os. 35
3) Rubella infection 'Tue- o~'~ ~ e. O'YI O"Yle ~1de, -bo~ side
, J.<Y.f~--a111;heostomy
4) Maternal epilepsy o~ "in ~'.e. "fflodle.
5) Protein, vitamin deficiency
~ -- '·A·; See Section 1, Segment - E, Qs. 30 (Page No. 604-605)
6) Chromosomal abnormality
Q.15: Frozen shoulder- physiotherapy
□ Classification :
FROZEN SHOULDER- PHYSIOTHERAPY A. (a) Complete (extends to nasal floor)
□ What is Frozen shoulder: Disease of unknown aetiology where the gleno-humeral joint becomes (b) Incomplete (does not extend to nasal floor)
stiff and painful due to loss of resilience of joint capsule, along with adhesions between its folds. B. (a) Simple (not associated with cleft palate)
□ Other name : Periarthritis shoulder (b) Compound (associated with cleft palate)
□ Clinical features : C. (a) Median/Central (Hare-lip : between the two median nasal processes)
• Pain in shoulder, initially at night and gradually throughout the day (b) Lateral (between maxillary process and median nasal process) -
• Stiffness of shoulder, initially limited to abduction and internal rotation only ► Unilateral
□ Treatment : ► Bilateral
• Physiotherapy forms mainstay treatment □ Associated syndromes :
• Hot fomentation • Pierre-Robin syndrome
• Analgesies • Stickler's syndrome
• Intra-articular hydrocortisone injection • Treacher-Collin's syndrome

53
418 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 419

• Apert's syndrome
3) Post-operative antibiotic spray
• Down syndrome
4) Stitches removed on 6th-7th post operative day
• Klippel - Feil syndrome
5) Speech therapy
□ Complications :
6) Training for sucking, swallowing
1) Difficulty in sucking and swallowing
Q.2: Thyroglossal cyst
2) Defect in uttering labial and palatal consonants
A: See Section - 1, Segment C, Paper - II, 2008, Qs. 4 (Page No. 309)
3) Nasal regurgitation
Q.3: Spinal anesthesia
4) Nasal intonation
A : See Section - 3, Qs. 1 (Page No. 753)
5) Recurrent upper respiratory tract infections
6) Respiratory obstructions Q.4 : Types of skin graft
A: See Section - 1, Segment C, Paper - 11, 2008, Qs. 7 (Page No. 351-352)
7) Chronic suppurative otitis media
8) Atrophic rhinitis a.5: Role of ERCP in obstructive jaundice
9) Hypoplasia of maxilla A : See 'ERCP' - 'Investigations' Segment (Section - 1, Segment E, Qs. 10) [Page No. 586-587)
10) Cosmetic problems Q.6: O r a ~ ~ fibrosis
11) Problems due to associated syndromes
· \,;/ ORAL SUBMUCOUS FIBROSIS
□ Treatment :
► Millard criter(c}_ - □ What is it: Progressive fibrosis deep to the mucosa of oral~
• Haemoglobin 1O gm/di □ Etiology:
• Age - 10 weeks old 1) Chillies
• Weight - 10 lb --- , 5 ·:;, •~2- 2) Tobacco
► Age - Before 6 months (before dentition) 3) Racial - Common among Indians/Asians
► Pre-requisites - 4) Localised collagen disorder
1) Cupid's bow must be intact 5) Dietary causes - Vit A, B deficiency
2) Vermillion notching should not be present □ Age - Middle age
3) Continuity of white line to be maintained □ Sex predilection : M = F
4) Proper markings made prior to surgery □ Site:
5) Infection must not be present 1) Buccal mucosa
► Operation done - 2) Soft palate
Millard's operation 3) Faucial pillars
• Incision made in gingivolabial fold and upper lip mobilised □ Clinical features :
• Local nasolabial flaps are rotated 1) Vesicular eruptions
• If bilateral cleft lip repair - 2) Soreness, burning sensation in mouth, aggravated during meals
(a) Single stage operation (Veau/Black method) 3) Ankyloglossia
(b) 2 stage operation (6 months gap in between) 4) Trismus
• Injection adrenaline to achieve haemostasis 5) Reddish area ➔ superficial ulcers ➔ stiff fibrotic bonds + scarring
• Management of associated primary and secondary cleft palate deformity □ Treatment :
• Tennison's z-plasty (Tennison-Randall triangular flap) 1) Avoid predisposing factors
• Suturing in three layers - Mucosa to mucosa, muscle to muscle, skin to skin 2) Local injection of -
► Post-operative measures - Dexamethasone + Hyalase ➔ biweekly for 10 weeks
(4 mg) (1500 units)
1) Hands of patient should be tied or mother should be careful that the baby does not soil the
dressing 3) Vitamin supplements
2) Use of Logan's bow 4) Correction of anaemia
5) Wide excision, followed by skin grafting
420 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 421

Q.7: Wax bath • Nasogastric aspiration - Decompression of small bowel by Miller Abott's tube or Cantor
A: See Section - 1, Segment C, Paper - II, 2011, Os. 12 (Page No. 398) tube
Q.8 : Subdural hematoma • Intravenous fluid
A: See Section - 1, Segment C, Paper -11, 2010, Os. 6 (Page No. 378) • Broad spectrum antibiotics
• Fresh frozen plasma
Q.9: lntussusception
• CVP
~~ INTUSSUSCEPTION
• PCWP
□ What is it : Acute intestinal obstruction where telescoping or invagination of one segment of bowel • Dopamine/ dobutarnine if severe hypotension
into adjacent segment occurs (mostly occurring due to hypertrophy of Peyer's patches in ileum) • Reduction by hydrostatic pressure by passing normal saline or barium enema
□ Symptoms : History of child crying intermittently (during an episode of acute attack) and sleeps 2) Surgical -
peacefully once it gets reduced After laparotomy under GA, intussusception reduced by gently pushing it from apex (NEVER
1) Sudden onset severe colicky abdominal pain PULL). Then viability checked.
2) Vomiting 3) Signs of non-viability :
3) Abdominal distension • Blackish in colour
4) Absolute constipation • Lustreless
5) Passage of red currant jelly stool • No peristaltic movement
□ Signs: • No bleeding on needle prick
1) Tenderness • No pulsation of mesenteric artery
2) Abdominal distension If viable ➔ gut kept inside and abdomen closed
3) On palpation, a sausage shaped, smooth, firm, resonant lump palpable with concavity looking If non-viable ➔ hot mop applied + 100% 0 2 ➔ still no improvement ➔ resection and
towards umbilicus, which does not move with respiration, is mobile in all directions, contracts ~ ,anastomosis
under palpating fingers, appears and disappears r ,,/,,--.,,,/~
4) Emptiness in right iliac fossa (sign de dance) <i.1<1: Marjolin's ulcer
5) Step ladder peristalsis MARJOLIN'S ULCER
□ Investigations :
□ What is it: Well differentiated squamous cell carcinoma arisin!L~~~r:11-~~?~!~l~-:~~ue t~~~p_eat~j
1) Routine investigations - Hb, TLC, ESR, Chest X-Ray, ECG bre!~O~-·-- . .... -
2) Straight X-Ray abdomen -
□ Features:
(a) Distended intestinal shadow 1) No lymphatics in scar, hence cannot spread to lymph node
(b) Multiple air fluid levels
2) Locally maligni:rnt
(c) Target sign - Soft tissue mass with concentric area of luscency due to mesenteric fat
3) Painless as no_~!':~r1-~e>.lved
(d) Meniscus sign - Crescent of gas within colonic lumen that outlines apex of intussusceptions
4) Raised everted edge with induration but not always
3) Barium enema -
5) Siow growing,--due to less vascularity
(a) Claw sign - Rounded apex of intussusceptions protrudes into contrast column
□ Investigation :
(b) Coiled spring sign (Pincer sign) - Oedematous mucosa! folds of returning limb outlined
by contrast material • Edge biopsy
4) USG Abdomen - □ Treatment :
(a) Target sign • No use of radiotherapy as it is radio resistant
(b) Pseudokidney sign Wide excision of lesion alongwith a margin of at least 1 cm is excised
•
(c) Bull's eye sign Amputation if - recurrence after wide excision in proximal part of limb
•
□ Treatment: - big ulcer in distal part of limb
1) Conservative -
Q.1 : P..osterior urethral valve
• Immediate hospitalisation
 422 QUE2-: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiolcgy SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 423

___,//
/1/ POSTERIOR URETHRAL VALVE TYPES OF RENAL STONE

□ What is it : Congenital symmetrical valves in posterior part of urethra, situated just below ..

fstone
Colour Content Shape, surface Aetiology Special feature
verumontanum, which prevents outflow of urine
Brown Calcium oxalate Sharp projections ➔ _ l:iigb_oxal!!.te Shows envelope
□ Pathology:
berry crystals more prone to· cause intake crystals in urine
• Bladder wall hypertrophied and thickened ) ---·-·~· hematuria (monohy-
• Proximal part of urethra very dilated
-.. --;-::.------· drate crystals are
.. dumbbell shaped,
□ Clinial features : di hydrate crystals are
1) Poor urinary stream envelope shaped)
2) Features of infection and hydronephrosis "1<>5Phate White .CalQilJ_rT) Qhosehate Smooth (triple stones Infected alkaline Radioopaque
3) Vesico - ureteral reflux crystals or Calcium, are coffin lid shaped) urine - from stag:
4) Difficulty in passing urine t'°e. L;,;~;::-,--"· Magnesium and
Ammonium phos-
hor·n-· calculus,

5) Bladder palpable as a firm swelling ('Cricket-ball' bladder) ! phatecrystals (Triple

which take the
shape of renal
□ Complication : stone) calyces
• Renal failure
'
Jjricacid -Yellowish Uric acid crystals Smooth, hard Gout, uricosuria Multiple, radiolu-
□ Investigations: ~one
-~---~--···~· ------- scent (detected
c'·"

1) Micturating cystaurethrography (MCU) by USG)

2) USG Abdomen
Urata sto_!'le Yellowish _Urata cry~.!_~~~ Smooth, hard Gout (Same as uric
3) IVU ---- acid stones)
4) Blood urea, serum creatinine
□ Treatment :
• Suprapubic cystostomy initially ➔ Cystoscopic resection of posterior urethral valve later
Cystine
stone
-- Yellow ➔
greenish hue
on exposure
Cyst!~El_9~ Hexagonal, s_C>fL Cystinuria,
acidic urine
~·-·--
Radioopaque
as contains
sulphur
□ Differential diagnosis:
Xanthine Brick red Xanthine crystals Smooth Due to xanthine
. _ _,..,,,,,,.~.......-,-~..-•-·.,~--
1)
2)
Neurogenic bladder
Marion's disease
stone ,.- _,,,,,

-•·
oxidase
deficiency
, , ~:3;,ffutchinson 's pupil Indigo stone Blue Smooth
l_X.,,.-/ A_,; See ~.~ction - 1, Segment C, Paper- 11, 2009, Qs. 7 (Page No. 365)
Struvlte stone Whitish Magnesium, Smooth Ammonia and None
\ ,,fl§~mp;~ma thoracis yellow Aluminium, urea splitting
, _ _,, A: See Section - 1, Segment C, Paper - 11, 2010, Os. 13 (Page No. 381) Carbonate, organisms like
Phosphate Klebsiella sp.,
Q.4: PCNL
Proteussp.
A : See 'Investigations' Segment (Section - 1, Segment E, Qs. 22) [Page No. 597)
Q.5: Types of renal stone Rest - Refer to MB 2011 [See Section -1, Segment C, Paper - 11, 2011, Os. 11 (Page No. 397-398))
(Clinical features, Investigations, Treatment of Oxalate stone)
A : See Chart on the next page
 424 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 425

/
x7auses of scrotal swelling □ Staging:
a) Early superficial - Non blanching erythema
b) Late superficial - Partial thickness skin loss
CAUSES OF SC ROT AL SWELLING c) Early deep - Full thickness skin loss excluding fascia
d) Late deep - Full thickness skin loss involving deeper tissues

Acute causes Chronic causes □ Predisposing factors :

• Nutritional deficiency------
• Hydrocele • Diabetic neuropathy____,.,-
lschaemia • Spermatocele • Peripheral neuritis
• Torsion of testis • Varicocele • Tabes dorsalis
• Testicular infarction testis
• Epididymal cyst • Paraplegia
• Appendiceal torsion(
T epididymis • Spinal injury
,rauma • Leprosy
• Testicular rupture • Spina bifida
• Haematocele
□ Clinical features : Painless punched-out ulcer, immobile, with bone as base
• lntratesticular hematoma
□ Investigations:
Hernia 1) Blood sugar
Inflammatory conditions 2) Discharge study
• HSP (Vasculitis of scrotal wall) 3) X-Ray of the part
• Fat necrosis of scrotal wall □ Treatment :
Infections conditions 1) Treatment of the underlying cause
• Acute orchitis 2) Nutritional supplementation
• Acute epididymitis 3) Antibiotics
• Acute epididymoorchitis 4) Vacuum assisted closure (perforated drain kept over foam dressing covering the pressure
• F urnier's gangrene sore ➔ dressing is sealed with transparent adhesive sheet ➔ drain connected to vacuum

\Y' Pressure sore

PRESSURE SORE
apparatus)
5) Slough excision
6) Regular dressing
7) Skin graft after sore granulates
8) Proper care -
□ Synonyms: ► Lifting the limb for 10 seconds once in every 10 minutes
• Neurogenjc. u!G€r ► Change in position once in 2 hours
• Trophtc ulcer ► Use of water bed
□ What is it: Condition where tissue necrosis and ulceration occurs du~.!_o prolongec:lJ)_r:essyre ► Urinary and faecal care
□ Sites: ► Absorbent porous clothing
1) Occi!)ut ► Psychological counselling
2) _Shoulder
3) .sacr.um
HYPOSPADIUS
r:;,:,
.
4) 9"'.§l.Lis~hial tL11Jerosity
5) Buttocks
□ What is it: Condition where external meatus of urethra is situated proximal than the normal, and on
6) J-irutls
the undersurface (ventral aspect) of the penis.
□ Pathogenesis : Blood flow to skin stops when external pressure becomes > 30 mm Hg ➔ tissue
□ Speciality: Commonest congenital malformation of urethra
hypoxia ➔ necrosis ➔ ulceration
□ Incidence: 1 in 350 males.
□ Pathology : Callosity ➔ suppuration ➔ gives way through a central hole which extends into the
□ Types: (Based on situation of external meatus)
deeper plane upto the underlying bone as perforating ulcer
a) Glandular - undersurface of glans penis

54
 426 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 427

b)Coronal - at corona glandis clinical features :

c)Penile - body of penis 1) History of i0jU!,Y
d)Peno-scrotal - at junction of penis and scrotum 2) Swelling with following features -
e)Perinea! - scrotum is split and urethra o.oens in between its two halves.
-~
[See Fi$(: 1.6.9] l .
►
►
Flattened and raised from the surface
Pinkish black in colour
□ Clinical features : •.--.....,/
► Painful
1) Urine soakage over scrotum with dermatitis ► Accompanied with itching, oozing
2) Urethral opening situated on undersurface of penis ► Blanches on pressure
□ Associated abnormalities : ► Spreads to surrounding tissue
• Chordee ► Margin irregular with claw-like processes·
• Narrow ectopic meatus
□ Complications :
• Small penis
• Absence of urethra and corpus spongiosum distal to abnormal urethral orifice 1) 10!~~~i~~---
• 'Hooded' prepuce 2) Marjolin'sulcer
• Bilateral underscended testis 3) Recurrence
□ Complications : □ Treatment :
1) Erection difficult and painful due to chordee a) Conservative -
2) Obstruction to urinary outflow 1) lntrakeloidal injection of -
3) Infertility Steroids
□ Treatment : Methotrexate _
a) Glandular hypospadius ➔ no treatment required; meatotomy required if too small meatus Vitamin A.
b) Other varieties ➔ staged procedure Hyaluronidc1se _
Stage I - Straightening of penis (performed between 1.5 - 2 yrs) 2) Ultrasonic therapy
Stage II - Reconstruction of urethra (performed between 5 - 7 yrs)
3) Silicone gel sheeting
4) Deep X-Ray therapy
KELOID b) Surgical -
□ Naming : 'Like a claw' lntrakeloidal excision (Major portion of keloid removed after incision made just inside the
· margin ➔ margins stitched ➔ left over part treated by intrakeloidal steroid injection)
□ What is it: Flattened ~welling of skin, d~!<:>,eroliferation of fibrobla~ls and imm~~l!!~.~lo_<:>_9._y_9-ss~~
o~ top of a scar, produced btc1.':Y_skin injury, and g~c1r~c::_t~r!~~-d by oozing, bla!l_~~i-~~ c1~ i!?hin_g_ □ Differential diagnosis : Hypertrophied scar
□ Pathology:
Q.10: Tension pneumothorax
• Primitive mesenchymal cells stimulated by skin injury, which heap up to form a swelling
A: See Section - 1, Segment - C, Paper-II, 2009, Qs.14 (Page No. 370-371)
• No capsule
□ Types: 2014
a). Spontaneous (occurs without scar formation)
b) General - Following injury 0.1 : Paget's disease of nipple
□ Aetiology: A ;7See cii~n - 1, Segment C, Paper -11, 2010, Os. 3 (Page No. 376)
1) Local factors - Incision crosses Langer's line
2) Familial
~ ctric burns
3) Coloured races - Negros ELECTRIC BURNS
4) Tuberculosis □ Aetiology:
5) Dislocation of hair follicle a) High voltage current
□ Sites: b) Low voltage current
1) Chest wall
□ Type of injury:
2) Sternum
a) Low voltage current - Direct injury at the point of contact
3) Upper arm
 428 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - 11 429

b) High voltage current - Direct injury at the point of contact+ damage of tissues that conduct Investigation : Orthopantomogram
electricity [See Fig. 1.6.1 O]
□ Mechanism of injury : Tis~~c:lamage occurs when e.lectrical energy is converted into thermal o Treatment :
energy, so the resulting injury is a thermal}Jurn . .. .. a) If small ➔ excision
□ Changes in skin : b) If la,:ge ➔ marsupialisation ➔ excision of cyst ➔ extraction of unerupted tooth
• Involved at 2 sites -
~val
► Point of contact with electrical source
"A: See Section - 1, Segment C, Paper - II, 2009, Qs. 7 (Page No. 365-366)
► Site of exit at which patient is grounded
Q.5: Fistula in ano
• Undergoes coagulation necrosis
A: See Section - 1, Segment C, Paper - 11, 2010, Qs. 4 (Page No. 376-377)
• Minimal destruction occurs, compared to deep tissue destruction
□ Maximum tissue damage occurs in: Muscle, nerve and blood vessels (w.t,ich offer least resistance) 4~~inoma
□ Factors specifying amount of damage:
PENILE CARCINOMA
1) Resistance of tissues □ Aetilogy:
2) Amount of electric current passing through 1) Premalignant conditions -
□ Salient clinical features : ► Phimosis
► Chronic balanoposthitis
1) Ulcers more common in axilla, antecubital fossa (as ele6trical resistance is much reduced by
moisture) 1 ► Leukoplakia
► Erythroplasia of Querat (Paget's disease of penis)
2) 'Port-wine' coloured urine (due to release of haemochromogens from musculature into blood
circulation, which are excreted via urine) ► Cutaneous horn
► Verrucuous carcinoma
□ Treatment:
► Balanitis xerotica obliterans
1) Electric current should be stopped
► Genital wart
2) Cardiopulmonary resuscitation to be started
2) Sexually transmitted diseases
3) Adequate fluid replacement
3) HIV infection
4) Ringer Lactate, mannitol should be considered
5) Operative management may be required in case of hemodynamic instability 4) HPV infection
6) Cutaneous electrical injuries to be debrided meticulously, cleared and topical antimicrobial □ Origin : From i~er surface of ~repucial skin which has squamous epithelial lining
burn creams to be applied □ Types:
7) Mafenide acetate preferred a) §quamous cell carcinom~ (most common)
8) Immediate exploration of stony hard muscle edema b) Adenocarcin9n.i~. (arising from Tyson's gland) .
9) Arteriography may be required c) Basal cell carcinoma (arising from coronal sulcus}
/.<' 1~piete neurologic examination d) . Meili"noma
□
1
Pathology:·
'\.e(~tigerous cyst
1____/'-~:.: DENTIGEROUS CYST •
•
Papilliferrous
Infiltrating
□ Synonym : Follicular odontome • Ulcerative
□ What is it: Epithelial odontome (cyst or tumor of the jaw) □ Site: Glans penis (commonest)
□ Site of occurrence: In relation to dental epithelium from an unerupted tooth, over its crown □ Spread:
□ Special features : a) Directly to -
• Unilocular ► Body of penis
► Urethral meatus
• Common in lower jaw
► External iliac lymph nodes
• Common in premolars/molars
• Causes expulsion of outer table o_f mandible b) Lymphatic spread to -
► Horizontal group of inguinal lymph nodes
□ Clinical features : Painless swelling in jaw, which is smooth and hard
► External iliac lymph nodes
□ Complications : Adamantinoma
► Cloquet lymph nodes
□ Infection : Rare
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 431
430 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

□ Clinical features : 0 Clinical features :

1) P_c1inless ujcerative _lesion 1) Pain
2) 11ecent ons~t phimosis should raise suspicion 2) Diffuse swelling
3) Foul smelling, purulent discharge 3) Cold limbs
4) Lesion has everted edge, fungation and induration 4) Paraesthesia
5) Hard nodular ~nlarged_ lymph nodes palpable · 5) Pulselessness
6) Pallor
□ Investigations:
O Most reliable clinical sign : Affected muscle if passively stretched produces severe pain
1) Edge biopsy
O Complications:
2) FNAC of lymph nodes
1) Infection
3) USG abdomen
2) Gangrene of limb
4) Sentinel lymph node biopsy (Cabana sentinel node located above and medial to 3) Chronic ischaemic contracture
saphenofemoral junction)
4) Renal failure
□ Treatment : 5) Disabled limb
a) Small non-invasive lesion - □ Treatment :
► Nd :YAG laser 1) If compartment pressure > 30 mm (Hg ➔ FasciotOl]lY) [adequate lengthy incision involving
► 5-Fluorouracil cream skin, subcutaneous fat, deep fascia till muscle is (visible ➔ multiple) incisions if needed,
► Radiotherapy separate incisions in each compartment]
b) Invasive lesion - 2) Catherisation
► Lesion involving prepuce ➔ Circumcision 3) Blood transfusion
4) Antibiotics
► Lesion involving glans penis or distal part of shaft ➔ Partial amputation of penis
leaving behind a 2.5 cm stump 5) Diuretics/mannitol
6) Hyperbaric oxygen
► Lesi?n involving proximal shaft ➔ Total amputation of penis+ Total scrotectomy and
orchtdectomy + Perinea! urethrostomy · 2014 Supplementary
c) Inguinal lymph node involvement -
► Antibiotics treatment for 6 weeks to eliminate infection Q, 1 : Parotld abscess
► If adenopathy persists, bilateral inguinal nodal dissection is done over Dressler's A: See Section 1, Segment - C, Paper-II, 2011, Os.8, (Page No. 395-396)
quadrangle [See Fig. 1.6.11]
Q.2 : Patient ductus arteriosus
. / ..,...---· ► Post-operative radiotherapy A: See Section 1, Segment - C, Paper-II, 2008, Os.15, (Page No. 356-357)
~Muscle relaxant
A : See 'Anaesthesiology' Section - 3, Os. 3 (Page No. 757-758)
(J,,·Jf·~!)«lee .
A: Se~~l, Segment - D, Os.12, (Page No. 473-474) .
Q.8: Flail chest -
0.4J~~~ subdural haematoma
A: See Section - 1, Segment C, Paper - II, 2008, Os. 12 (Page No. 354-355)
A : See Section 1, Segment - C, Paper-II, 2010, Os.6, (Page No. 378-379)
Q.9: Epidural anesthesia
Q.5 : Dentlgerous cyst
A,: Se;,'.fo.rraesthesiology' Section - 3, Os. 7 (Page No. 763)
A: See Section_,,.1, Segment - C, Paper-II, 2014, Os.3, (Page No. 428-429)
f' ,.X:~~mpartment syndrome Q.6: V!J)O~lcer
' ·. COMPARTMENT SYNDROME A =.~action 1, Segment - C, Paper-I, 2013, Os.2, (Page No. 301-302)
□ Common sites : Q.7: Transluminal USG
1) Calf..--- A=_ Se-~
e ecr ·1, Segment - C, Paper-II, 2012, Os.14, (Page No. 412)
2) Forearm ····- · Q.B/!-?' anaesthesia in inguinal hernia surgery ----------
□ Cause: LOCAL ANAESTHESIA IN INGUINAL HERNIA SURGERY
1) Fracture of underlying bone compressing major vessels
2) Clpsed injuries causing hematoma □ Drug used : Xylocaine 0.5% with or without Adrenaline
 432 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS O Paper - II 433

□ Dosage:
• Following total thyroidectomy
• Xylocaine 0.5% only ➔ 2mg/kg
• To;ic thyroid nodule cases after hemithyroidectomy
• Xylocaine 0.5% + Adrenaline ➔ ?mg/kg
□ Methods used: Half-lives :
,123 ➔ 13 hour
A. Field block (Shouldice method)- Skin (about 4 cm length) between ASIS and pubic symphysi •
is infiltrated s 1124 ➔ 4 days
•
j, ,125 ➔
• 60 days
~ki_n, subcutaneous tissue and the two layers of superficial fasia (Camper and Scarpa) are • 1131 ➔ 8 days
incised
j, 0 Salient features :
• Patient should not take L-thyroxine for 6 weeks prior to _radio-iodine_t!]~ll!PY
Area deep to external oblique aponeurosis (EOA) is infiltrated and EOA incised
j, • Injection TRH if given, radio-iodine scan can be done after 24 hours
• 1123 behaves similar to inorganic 1127 in our body, and gets released as protein bound
Inguinal canal and hernial sac are exposed, which are also infiltrated
iodine (PBI)
B. Point I Nerve block - Xylocaine infiltrated 2 cm above and medial to ASIS to block· • 1123 can be safely used in children and pregnant lady
iliohypogastric nerve
j, • Hi;hd;s~--~-f retinoic acid makes 1131 to accumulate in tumour cells
Mid-inguinal point (i.e., midpoint between ASIS and pubic symphysis) is infiltrated • Conception to be avoided for 1 year after radio-iodine therapy
j, • MRI is ideal when radio iodine therapy is planned,
Skin over pubic tubercle also infiltrated 'ajfr~
j, QUART
Xylocaine infiltrated just below inguinal ligament lateral to femoral artery to block the genital
----
branch of genitofemoral nerve. 'O Full form : Quadrantectomy, axillary dissection and radiotherapy
□ What is it: Type of conservative breast surgery done in certain cases of breast carcinoma
~:fl-: Radioactive iodine
□ Clearance : Removal of entire quadrant with ductal syst~m with 2-3 cm normal breast tissue
\.¥/ RADIOACTIVE IODINE □ Axillary dissection: Do-~e through separate incision. ~ and II nodes are removed
□ Isotopes: □ Radiotherapy: Post-operative radiotherapy given to breast (5000 cGy) and axilla (1000 cGy)
• I12_3... □ First started by: Umberto Veronesi from Milan
• 11~4- □ Indications :
• i.!2_5 • Breast lump -~ess_ than 4__ cm
• ,1_31 • Clinically negative axillary nodes
□ Uses : Both therapeutic and diagnostic
• Well differentiated tumour with low S phase
• Mammograf?hically detected lesion
• 1
123
➔ _Fu~9~iori~L;,tudies of thyroid gland • Breast of adequate size and volu'!le
• 1124 ➔ PET scan
• F;~;lbility of axillary dissection and radiotherapy to intact breast
• 1125
➔ Brachytherapy and ~(Radio lmmuno Assay) D Contraindications: ( r}~'-"f'°'}-·c
• R 1131
_ ad'Io~c_t·Ive 10
. d'me t herapy
➔
• Tumour size > 4 cm
□ DiagnostiE._ use indications (P-rays used) : • Positive axillary lymph nodes > N1
• Ectopic .t~yroid • Poorly differentiated tumour
• _Suspected toxicity • Multicentric tumour
• After total thyroidectomy to look for secondaries • High tumour/ breast size ratio
• Retrosternal thyroid • Earlier breast irradiation
• Toxic thyroid nodule • Pregnancy
□ ItJ~rae,eutiq_yses : D Advantages :
• P~imary thyro!Q~i9C>,l>~!3_cases after 40 years • Good cosmetic appearance
• Preservation of vascular supply and innervation of nipple-areola complex in most cases .
55
 434 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 435

2015 • Treatment -
I. Surgical excision (Total glans resurfacing with STSG/ circumcision/ Moh's micrographic
Q.1 : Breast abscess surgery) --
Ans: See Section -1, Segment C, Paper II, 2009, Q.3 (Page No. 362-363) 11. 5%-fluorouracil (topically on alternate days for 4-6 weeks)
Q.2 : Meconium ileus
--·------------
111. CO 2 Laser (1 mm depth; 3-4 weeks to heal) or Neodymium: YAG Laser (6 mm depth; 2-
Ans : See Section - 1, Segment D, 0.110, (PaeJ0 No. 569-570) 3 months to heal)
Q.3 : Basal cell carcinoma IV. Cryotherapy (Liquid nitrogen)
Ans: See Section - 1, segment C, Paper I, 2C09, Q. 2 (Page No. 300-301) 2. Buschke-Lowenstein tumor (Giant condyloma accuminatum)
, ~emalignant conditions of penile carcinoma • Low grade variant of Squamous cell CA of penis.
\~,;:,;;: ■ Morphology - Large, exophytic, slow growing and locally aggressive lesion with warty
PREMALIGNANT CONDITIONS OF PENILE CARCINOMA appearance.
• Site - U~LJall~-~..£1,l!.§..9.n uncir£:umc(~~--.£ll<'.l_Q~_grJ?repuce (can be on urethra, vulva, vagina,
The premalignant penile lesions are as follows - cervix, anus, oral/nasal cavities, plantar surfaces of feet)
• 8ssociated with HPV 6, 11 (NOT 16, 18)
A. HPV RELATED A. NON-HPV RELATED
• Treatment - Local excision
Erythroplasia of Queyrat (Non-keratinising CIS) Lichen sclerosus et atrophicus/Balanitis xerotica obliterans
3. Bowenoid papu/osis
Bowen's disease (Keratinising CIS) Cutaneous penile horn
• Mostly occurs in young sexually ac_!ivefprgrniscuous meo in the second or third decade of
Buschke-Lowenstein tumor (Giant condyloma Leukoplakia of penis life, usually undrcumcised. It can affect females as well.
accuminatum)
• Morphology - Multiple red velvety maculopapular areas which often coalesce to form plaques.
Bowenoid papulosis Pseudoepitheliomatous, keratotic and micaceous balanitis
(PEKMB) • Site - On th~.£ll?ns or shaft.Qt_penis.
• Histology - Abnormal keratinocytes are spread discontinuously (Unlike the continuous spread
A. HPV related lesions in Bowen's disease) throughout the epidermia.
1. Carcinoma in situ (C/S) • Association - With HPV 16
• Sexually transmitted; female partners are at increaseg,Ji~~ {QL9.E,;lryi9.?I nE:!Of?l~sia.
• --~~JU~J9kness intraepidermal 9~9_ir:ioma of p~nis ..
•
'"••-•--...:...-----------
Often acts as benign lesion unless the person is immunosuppressed; may regress
• Originally described by Querat (1911 ).
spontaneously.
• Based on location of lesions, divided into two entities which are histologically similar-
• Treatment -(1) (?9nservative surveillance
(a) f:~~;t,~pJ,~~'.~~,~~~X!,~t
(2)~
(b) -~P"Y.~D'.5.--~i~~~
(3) ~~ (Laser, cryotherapy or electric ablation)
• Erythroplasia of Queyrat --~1!1.'?.?.th, yelv~!Y, _bright r~d, sha.rnl~ defined elagues on m1,1_QQ_~_?I
surfaces of penis such as inner prepuce and glans. The lesions are usually painless, but can B. Non-HPV related lesions
have areas of erosion. Risk of malignant transformation is upto 30%.
1. Lichen sclerosus et atrophicus
• Bowen's disease - ~olitary, §!g_a,Iy, red, Vlell-def,i~~9..J2!~gy_!1S...on {ollicle beari □g__~r~~-s of
penile shaft and scrotum, often with crusting ulceration. Mostly occurs at the age of 50-60 • Also known as Balanitis xerotica obliterans (BXO)
years. Risk of malignant transformation is 5%. • M~~!-~?-~-~~-~-~~malignant lesion of penis. __
• Risk factors of penis CIS - • It is an idiopathic chronic progressive inflammatory process.
(i) . ·HPV 16, 18,31,33 • Presents most commonly in uncircumcised males in third or fourth decade; sometimes females
(ii) lmmunosuppression are affected too.
(iii) Poor genital hygiene • Morphology - F~~YJ-~tij.§!Q.ha.s..wit.b....at.r.9p_bitLPI~.9..Y.~.~-~hich may coalesce or sclerose
(iv) Phimosis • Site - Ong_lans_oJ_prepuce
(v) Use of tobacco products • Histology - Thinning of rete pegs, hyperkeratosis, chronic inflammatory infiltrate comprising
.(vi) Number of sexual partners of lymphocytes and plasma cells
 SOLVED SHORT NOTES OF FINAL MBBS D Paper - II 437
436 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Duodenal ulcer/ Crohn's disease

•
• Complications - (1) Pruritus, Pathological phimosis, meatal stenosis, urethral stricture .
• Periampullary tumor/diverticulum
males (2) Burning sensation, dyspareunia in females
Pancreatic duct stricture
• 2.3% of those diagnosed with BXO have sec penis; 10 - 33% progress to invasive sec . •
Pancreatic divisum
15-17 years; Synchronous BXO is found in 28-50% of I-hose treated for penile CA. 111 •
Ascariasis, Clonorchis sinensis
• Treatment - (a) If asymptomatic - no therapy •
• Trauma
(b) Symptomatic -
Alcohol induced
I. Top_!9_c1!~tE:i_roids (Betamethasone or 0.1 % Triamcinolone twice daily)
II. ,Circumcision can_b_13_cfone, although excision is avoided due to high recurrence. Clinical features : .
Sudden onset, stabbing, upper abdominal pain, radiating to the flanks and back and relieved on
2. Cutaneous penile horn 1· leaning forward (Mohameddan prayer position)

• ~'...-usually develops over pre-existing lesion (nevus, wart, malignant neoplasm); due to 2. Nausea, Persistent vomiting, Retching
overgrowth and cornification of epithelium.
3. High fever
• Morphology - Conical and exophytic lesion associated with areas of chronic inflammation.
Clinical examination :
• Histology - extreme hyperkeratosis, dyskeratosis and acanthosis (abnormal thickening of
the prickle cell layer of the skin) A. General survey - Features of shock (dehydration, oliguria)
• High risk of malignant transformation (around 30%) to low grade sec . B. Abdominal examination -
• Association - With HPV 16 1. Tenderness, rebound tenderness, guarding, rigidity
• Treatment - Surgical excision with a margin with close follow-up 2. Grey Turner's sign positive (Hemorrhagic spots and ecchymosis in the flanks)
3. Leukoplakia of penis 3. Cullen's sign positive (Discolouration around the umbilicus)
4. Fox sign positive (Discolouration below inguinal ligament)
• ..B.arli
• Morphology - White verrucous plaques on mucosa! surfaces. O Investigations :
• Site - _§lans or prepuce. 1. Complete hemogram (Raised TLC), CRP
• Association ~ Occurs more commonly in patients with DM; related probably to chronic 2. Serum amylase, lipase, LOH - raiseg_
recurrent infection 3. Serum ·Trypsin, Trypsinogen activation polypeptide (TA~_)_ .
• Dysplastic changes are seen in 10-20% of cases. 4. $~rum lactescence - Most specific for alcohol indl:!Eed pancreatit1s

4. Pseudoepitheliomatous, keratotic and micaceous balanitis (PEKMB) 5. Albumin creatinine clearance ratio - increased (> 6%) _ h d
6. Ski~gramabdomen (AP view) - Sentinel loop, colon cut off sign, obliteration of psoas S a ow}
• Rare idiopathic condition.
renal halo si9_!1 .
• Morphology - Solitary, well-circumscribed, t.b.l2~iJ.!1elastic, hyper.~~~Eltotic plaque with 7. USG abdomen - Edematous pancreas, perip_a._ncreatic fl!J.[d collection
laminated appearance. ·
8. CT scan abdomen - Spiral CT is the Gold standard investigation.
• Site - Glans ~eni~
9. · Peritoneal tap - Fluid shows high amylase and protein levels.
• Histology - Hyperplastic epidermia with ridges extending deep into dermis .
• Occurs usually in elderly, uncircumcised males . □ Treatment :
• Association - May have concurrent verrucous carcinoma. 1. Hospitalisation
• ,Treatment - _Surgical excision or ablation with close follow-up 2. Nothing per mouth
,/ ·-···-----
°'5 :
,.,.-/'" ,,/,,,.,'
,.,-/'

j,Cute pancreatitis
.
3.
4.
CVP line
Total parenteral nutrition
/ i~s: ACUTE PANCREATITIS
5. Intravenous fluid
6. Fresh frozen plasma
□ Definition : Acute pancreatitis refers to acute inflammation of normally existing pancreas. 7. Nasogastric aspiration
□ Etiology: 8. Catheterisation
9. Electrolyte management with monitoring
1. Pancreatic duct obstruction due to :
• , Biliary tract stones (Most common)
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 439
438 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

(a) For RFA of liver tumors, an antibiotic course is administered to patients with severe cirrhosis,
10. Hemodialysis if required immunosuppression, large tumors, central tumors, ascites, prior _hepatic artery th_~rapy (pump/
11. Pethidine to relieve pain chemoemboHzetioni embolization) or biliary pathology (dilated ducts, b1hary-entenc
12. Broad spectrum antibiotics (Ceftazidime, Cefoperazone, Cefotaxime, lmipenem) anastomoses, or prior sphincterotomy).
13. Proton pump inhibitor to relieve stress ulcer (Pantoprazole 80 mg BD) (b) For RFA of renal tumors, the antibiotics are continued for 1 week after the ablation, i~ the
14. Calcium gluconate - 10% 10 ml/kg i.v. 8hrly thermal lesion touches the collecting system or there is a history of reflux or recurrent urinary
15. Somatostatin/Octreotide to reduce pancreatic secretion infections.
16. Protease inhibitor/ Acetylcholine/ Calcitonin □ Use:
17. Steroids A. Hepatic tumors
18. Nebulisation, bronchodilator In the treatment of HCC, the range of indications for percutaneous RFA includes the following main
0.6 : Glasgow Coma Scale categories.
• HCC at an early stage
Ans: See Section - 1, Segment C, Paper 11, 2008, O.13 (Page No. 355-356) • Primary treatment for small tumors (<3 tumors, each measuring <3 cm)
. O:J :Jh{diorrequency ablation of tumors
• Inoperable primary liver tumor ·
Treatment of patients who cannot undergo general anesthesia or are not operative candidates
~: • because of comorbidity or advanced age
RADIOFREQUENCY ABLATION OF TUMORS Liver metastasis, most commonly colorectal, especially if the p'atient is not an operative
•
□ What is it - Radiofrequency ablation (RFA) is a modified electrocautery technique that is used for candidate
local, minimally invasive tissue ablation. • Breast, thyroid and neuroendocrine metastasis .
A hepatoma or multiple small lesions in patients who are waiting for liver transplantation
□ Mechanism of action-In RFA, a needle is inserted into the organ, usually under US or CT guidance. •
Once the needle (unipolar or bipolar) is placed within the tumor, a generator is used to deliver a • Recurrent and progressive lesions
rapidly alternating current (RF energy). Radiofrequency electric fields drive ionic currents in tissue Contraindications for percutaneous RFA of liver tumors include the following :
and cause resistive heating through frictional heat produced by rapid agitation of adjacent cells. At
50-52°C, cells undergo coagulative necrosis in 4-6 minutes; at temperatures greater than 60° C, • Bile duct or major vessel invasion
coagulative necrosis is instantaneous. With single needle nonperfused electrodes, coagulation • Significant extrahepatic disease
diameters are limited to approx. 1.6 cm. Recent advances in RFA technique have resulted in larger Child-pugh class C cirrhosis or active infection
volumes of tissue ablation (7 cm diameter in a 30 min session) with relatively low complication rates •
• Decompensated liver disease
and minimal collateral damage. There are a variety of methods for increasing coagulation volume
Lesions that are difficult to reach with electrodes or when electrode placement is impaired
with RFA, among which the most successful ones are - (a) Slow or pulsed heating (b) Multiprobe •
array electrodes (c) Internal electrode cooling (d) Saline infusion Tumors that occupy more than 40% of the volume of the liver
•
Patients with metastatic lesions larger than 3 cm (as the risk of recurrence with RFA is high)
□ Clinical technique - •
• Large or numerous tumors . _ . .
• Pre-procedural evaluation may include triphasic CT, MRI, ultrasound (US), PT/APTT/INR, CBC,
Proximity to vital structures like vessels and adjacent organs (relative contramd1cat1on)
LFT, CEA, AFP, hepatitis panel, EKG. •
• RFA can be performed in 3 approaches- (a) percutaneous (b) laparoscopic (c) open/ surgical. • Lesions larger than 5 cm (relative contraindication)
• The choice of approach depends on- (i) the condition of the patient (ii) tumor size (iii) number (iv) B. Extrahepatic tumors
location (v) growth pattern of tumor (vi) operator and local practice patterns.
I. Kidney -
• One to four grounding pads are placed on the thighs or back in order to complete an electrical • RFA is especially appealing for patients with a genetic predisposition to mu_ltiple bila_teral
circuit. A more uniform thermal lesion is created when the rectangular pads are placed with the metachronous renal cancers, such as von-Hippel Lindau (VHL) or hereditary papillary
long side transverse with respect to the needle, resulting in less risk of pad burns.
renal cancer (HPRC).
• US and/or CT (followed by MR) are most commonly used for guidance. CT alternating with US • Renal RFA has been found to be most effective in tumors less than 3 cm in diameter.
can be used to provide maximum visualization during different stages of the procedure. During
ablation, "hyperechogenicity from microbubbles" can be seen to be expanding from the needle II. Bone-
electrode on Ultrasound. Miniboluses of 50 cc iodinated contrast are often administered to visualize For over 10 years, it has been used to treat osteoid osteoma, a benign, slow-growing painful
a tumor or thermal lesion in CT during the procedure and to choose the next target area.
lesion
• Pre-procedural prophylactic antibiotics are used routinely while a prophylactic course is given in
Ill. Lung
certain high-risk situations :
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 441
440 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

IV. Breast Q.6: Pyloric stenosis in infant

A: See §ection 1, Segment - C, Paper-II, 2010, Os.9, (Page No. 379-380)
V. Adrenal gland
. ·'7/Pf)-A_____
□ Complications :
a. .
,A_: ~ction 1, Segment - C, Paper-II, 2008, Qs.15, (Page No. 356-357)
1. Pain (Large, subcapsular, porta hepatis, or peri-diaphragmatic lesions tend to be more painful)
a,B:W~
2. Low-grade fever A: See Section 1, Segment - C, Paper-II, 2011, Qs.12, (Page No. 398)
3. Tumor seeding and back bleeding
0\g~rapy
4. Pneumothorax (with a transthoracic approach to hepatic or lung lesions)
5. Pleural effusion (in cases where treatment is adjacent to pleura, as in liver dome lesions)
TELECOBALT THERAPY
6. Shoulder pain (related to diaphragmatic burn) □ What is it: Medical use of gamma rays emitted from radioisotope cobalt - 60
7. Skin burns (Due to improperly placed grounding pads) □ Isotope : Stable dichromatic beams of 1.17 and 1.33 MeV are produced, which results in average
8. In RFA of hepatic tumors-peritoneal bleeding, needle-track seeding, hepatic abscess, perforation beam energy of 1.25 MeV
of a gastrointestinal wall, hemothorax, hepatic decompensation, asymptomatic arterioportal shunt □ Half-life : 5.3 years
and biliary portal shunt with hemobilia. □ Procedure : Patient sits or lies on a couch and an external source of radiation is pointed at a
9. In renal ablations - Transient hematuria, urinoma, ureteral stricture, and renal insufficiency. particular body part
□ Followup: □ Indications :
• Post-procedure contrast-enhanced CT or MR is use.ct to determine the extent of coagulation. • T 1 and T 2 lesions of laryngeal carcinoma

• Lack of enhancement has been shown to correlate with coagulation necrosis (A thin rim of • Esophageal carcinomas
enhancement corresponding to a hyperemic inflammatory reaction or hemorrhagic granulation • Early vocal cord carcinomas
tissue is normal, which usually resolves in about one month) • Bronchial carcinoma.
• Follow-up imaging is to be done at 2- to 6 weeks, then every 3 months for more than 1 year. 2016
• Residual enhancement, increase in size of ablation region, or increase in irregularity or nodularity
of ablation region suggests recurrent tumor. Q.1 : Epidural anaesthesia

Y ? f o n pneumothorax
A: See ~c!!9D 3, Qs.7 (Page No. 763-764)
Q . 2 ~ s ulcer lower leg
: Ans : See Section - 1, Segment C, Paper 11, 2009, 0.14 (Page No. 370-371) A =·S;e Section 1, Segment - C, Paper-I, 2013, Qs.2 (Page No. 301-302)
Q.9: Epulis Q.3 : Spina bifida
Ans: See Section - 1, Segment C, Paper 11, 2011, 0.13 (Page No. 399-400) A: See Section 2, Group -1, 2009, Qs.6 (Page No. 633-634)
Q.4 : MEN SyndrOl[l~----------
Q.10 : Complications of spinal anesthesia
A: Se.§J3e~ 1, Segment - C, Paper-II, 2009, Qs.5 (Page No. 364-365)
Ans: See Section - 3 (Anesthesiology), 0.1 (Page No. 753-754). Q.5 :1',rit'iciple of skin grafting
A: See Section 1, Segment - C, Paper-II, 2008, Os.7 (Page No. 351-352)
2015 Supplementary
Q.6: Frmiit;;rn contracture
Q.1 : Testicular torsion A: See Section 1, Segment - D, Os. 107, (Page No. 566-567)
A: See Section 1, Segment - C, Paper-II, 2012, Qs.9, (Page No. 408-409) Q.7: Hydrocephalus
A : See Section 1, Segment - C, Paper-II, 2010 Supplementary, Os.12 (Page No. 38n
)/:;f-r'E;trad~ral haematoma
· -- A: See Section 1, Segment - C, Paper-II, 2009, Os.7, (Page No. 365-366) Q.8 : Haf1]jJFl6iiia \r"\ I' ;~;,.":./•·;-no sort
Q.3 : Flail chest ' HAMARTOMA) ,-,v,'v"v'H' ·1 i'\ ·\
'1':h.O"✓/ d~- c• c/i,('O- '"' · '-;,. i
A : ,See Section 1, Segment - C, Paper-II, 2008, Os.12, (Page No. 354-355)
□ First coined by: Albrecht in 1904
~y.'Ameloblastoma
□
1
Derivation : From Greek word meaning 'fault' or 'missfire' . .
'- ~; ~ Section 1, Segment - C, Paper-II, 2012, Qs.13, (Page No. 411)
□ Definition: Developmental malformation consisting of a benign lesion with aberrant dif~erentia!ion,
yJr.s: Submandibular sialolithiasis in which tissues of a particular body part are arranged haphaz~~dly: producing a mass of disorganised
A: See Section 1, Segment - C, Paper-II, 2009, Qs.1, (Page No. 361-362) but mature specialised cells or tissue indigenous to the spec1f1c site

56
 442 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 443

□ Types:
□ Forms of particles :
• Single
• Alpha particles
• Multiple • Beta particles
□ Features: • Positrons
• Mostly present at birth or appear in early childhood • Photons
• May regress as in strawberry haemangioma • Neutron (indirect radiation)
• Growth occurs at par with surrounding tissue □ Physical effects :
• Non capsulated • Nuclear effects - Nuclear transmutation and induced radioactivity
• Benia~, !arely malignant This occurs by - a) Photodisintegration
• May be associated with chromosomal abnormality b) Alpha absorption
□ Examples: c) Neutron activation
• '{,!g:ular hamartoma (haemangioma) • Electrical effects - Increase conductivity and thereby allowing transmission of damaging
• Angt()111atous syndrome current levels. This phenomenon is used in Geiger Muller counter.
• Benign naevus • Chemical effects - Formation of free radicals by radiolysis that lead to ozone crack, disruption
• Skeletal hamartoma of crystal lattices in metals.
• t-J~urofjbroma □ Effects on Health :
• Manama sebaceum • Deterministic effects - Occurs due to high doses of radiation
• Glomus tumour • Stochastic effects - Heritable conditions occurring due to mutation of somatic cells due to
• Lymphangioma radiation.
□ Complications : □ Ways to limit radiation exposure :
• Bleeding • Good to have radiation detector
• Infection • Time distance and shielding should be used
• Gigantism • Respirator or Face Mask to be used
• Pressure symptoms • To be well-informed about various radiation sources
• Cosmetic problem
Q.10: Bleeding from g y m ~
□ Treatment :
• Cryotherapy
· _,,,k:/"" BLEEDING FROM GUM
• Ligation of feeding vessel
□ Causes:
· • Sclerotherapy • Gingivitis
• /Laser I excision therapy • Brushing teeth roughly
/
. )~~sing radiation • Traumatic
• Thrombocytopenic1
\_ IONISING RADIATION
• Leukaemia
□ What is it: Radiation with enough energy so that during an interaction with an atom, it can remove the • Bleeding disorders
tightly bound electrons from the orbit of an atom, causing the atom to become charged or ionised. □ Risk factors :
□ Types:
• Smokin9
• Waves • Tobacco chewing
• Particles • Diabetes
□ Forms of waves : • Pregnancy
• Gamma rays • Broken fillings/ dentures
• X-rays • HIV/ AIDS
• Higher UV rays • Genetic

.'
 444 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 445

□ Investigations :
A) LEUKOPLAKIA -
• Routine blood investigations
□ Definition: 'Nhite patch in oral mucosa which cannot be characterised clinically or pathologically to
• BT,CT
any other disease
• PT, aPTT
• Inspection of oral cavity □ Causes: "7S"
□ Treatment: • Smoking
• Maintain proper oral hygiene • Sepsis
• Brush teeth carefully • Syphilis
• Treat underlying condition. • Spices
• Sharp tooth
2016 Supplementary
• Spirit
Q.1 : PET Scan • Superficial glossitis
A: See Page No. 611. • Chewing of betel leaves
Q.2 : Undescended testis • Chronic hypertrophic candidiasis
A: See .Section 1, Segment - C, Paper-II, 2009, Os. 4 (Page No. 363-364) □ Histology:
~termittent claudication • Parakeratosis
✓ -A : See Section 1, Segment - D, Os. 84 (Page No. 540-541) • Dyskeratosis
Q.4 : Brachytherapy • Acanthosis - Elongation of rete ridges
A: See Section 1, Segment - C, Paper-II, 2008, Os. 10 (Page No. 353) □ Types:
Q.5 : Dental cyst
• Homogenous
A: See Section 1, Segment - C, Paper-II, 2008, Os. 11 (Page No. 353-354)
• Speckled
'~"Fournier's gangrene ' '
• Nodular
A: See Section 1, Segment - C, Paper-I, 2013, Os. 3 (Page No. 302-303)
□ Site:
Q. 7: Regional anaesthesia
A S Section 3, Os. 8 (Page No. 764-765)
• Buccal mucosa
• Oral commissure
, ~ e s t drain after chest injury
□ Investigation : Biopsy
,\ A . See "lntercostal Drain" Section 1, Segment - C, Paper-I, 2013 supplementary, Os. 3 (Page No.
307-308) □ Treatment :
( Jc::~fferent types of nerve injuries • Stop all etiological factors
A : See Section 1, Segment - D, Os. 98 (Page No. 558-559) • Excision may be required followed by skin graft
';)6 ~alignant condition of oral cavity • CO 2 laser excision
• lso retinoin
~_,,/ PRE-MALIGNANT CONDITIONS OF ORAL CAVITY
B) ERYTHROPLAKIA
They are - □ Definition : _Red velvety appearance of mucosa which cannot be attributed to any other disease
a) Leukoplakia
b)
c)
Erythroplakia
Chronic hyperplastic candidiasis
} High risk lesions
□ Histology:
• Parakeratosis
Severe epithelial dysplasia
d) Oral submucosal fibrosis •
e)
f)
Syphilitic glossitis
Sideropenic dysphagia
} Medium risk lesions
□
•
Site:
Decreased keratin causing red colour

g) Oral lichen planus • Ginginobuccal sulcus

h)
i)
Discoid lupus erythematosis
Dy_skeratosis congenita
} Low risk lesions •
•
Floor of mouth
Lower alveolar mucosa
 446 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 447

□ Investigation : Biopsy
B) Suggesting small emboli located distally
□ Treatment: Surgical excision • Pleuritic chest pain
C) ORAL SUBMUCOSAL FIBROSIS • Cough
• Haemoptysis
See Section 1, Segment - C, Paper-II, 2013 Os. 6 (Page N $ ~
□ Most frequent symptom : Dyspn()ea_
D) CHRONIC HYPERPLASTIC CANDIDIASIS
□ Most frequent sign: .!.1:l~~_ypr1oea
□ Site: □ Pre-disposing factor:
• Commissures of mouth • Surgery
• Tongue • Immobilisation
□ Treatment : □ ECG changes :
• Topical/ Systemic antifungal drugs • §i_r:i~s tachycardi,9_(most common)
• Excision / Laser therapy • Right ventricular strain pattern (T-wave invetsion in leads V 1 to V 4)
E) SIDEROPENIC DYSPHAGIA • S1 0 11 T 111 pattern -
a) Deep S waves in lead I
• Other name - Plum.mer_\lir1~onSyndrome
b) Q wave in lead Ill
• Causes - Atrophy of epithelium
c) Inverted T-wave in lead Ill
• Treatment - Proper iron therapy.
• New onset atrial fibrillation / flutter
2017 • Right axis deviation / RBBB

, 1 9,1%bdural haemorrhage
'·-~~ See Section 1, Segment - C, Paper-II, 2010, Os. 6 (Page No. 378-379) PULMONARY EMBOLISM
._/;[..Y.' PCNL
\ --~-1,.. yee~tion 1, Segment - E, Os. 22 (Page No. 597)
~omplications of spinal anaesthesia
A: See _9-0ction 3, Os. 1 (Page No. 753-754) Low Risk Intermediate Risk High Risk
yA'1.~--tfvT • Normal right ventricular • Right ventricular dys- • Right ventricular dys-
function function function
\. ·-1(' See Section 1, Segment - C, Paper-I, 2011, Os. 3 (Page No. 290-291)
Q.5: Ludwig's angina + + +
• Normotension • Normotension • Hypotension
A: See Section 1, Segment - C, Paper-II, 2010, Os. 11 (Page No. 380)
✓~,..Autotransfusion
< A: See Section 1, Segment - C, Paper-I, 2009, Qs. 4 (Page No. 282)
Anticoagulation done Thro~bolysis __
Q.7_,;-Pµlfnonary embolism with IVG filters
,."',,. OR
.// PULMONARY EMBOLISM Embolectoml'.'. __

□ What is it:_ Sud<:l~n_l)lCJ_c:kc1__g~ of an artery i~ lung, ~i,~~t>y a blood clot originating.fr.Q1JLc!.s!~!~rent site.
□ Most common cause: D_\IT in large veifllLQU!;l__g____
□ Symptoms: • Elderly patient
• Young patient
A) Suggesting large emboli causing marine PE • Significant
• No comorbidities
comorbidities
• Sudden onset dyspnoea
• Pleuritic chest pain
• Hypotension
Thrombolysis
• Syncope or
-• Cyanosis ~n:!t>olectomy
 448 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - 11 449

□ Investigations □ complications :
• !-'1f>Q}"Jlnvestigation of choice) • Donor site haematoma, uncontrolled bleeding, infection
• D-dimer assay (most sensitive) • Recipient site flap necrosis, infections, seroma
• Pulmon,uy an~iOJE~fl_hy (most specific)
B) LATISSIMUS DORSI FLAP
• Lung V-Q scan (in case of renal insufficiency)

\#
• Anatomy - Back muscle, just below shoulder and behind armpit
~~ment: • Dominant pedicle - Thoracodorsal artery
···,--utaneous flap • Secondary pedicle - Perforating branches of intercostal and lumbar arteries
MYOCUTANEOUSFLAP • Pedicle length - Upto 15 cm
\ ..
• Nerve supply - Thoracodorsal nerve
□ What is flap : _:!:~~~~~! of cloner tissu~ al':)n~ 1Nit_h its. blood supply to recipient area • Uses - _B~east reconstruction
□ Indications : Q.9:ABPI<~
• Cover wider and deeper areas ABPI
• Repeated skin graft failure
□ Full form: Ankle Brachia! Pressure Index
• Cover bone, tendon or cartilage
□ What is it: Index which gives us an idea about presence of peripheral arterial disease
□ Parts:
□ Method:
• Base
• Pedicle
• Patient placed supine
• Tip
• Cuff of sphygmomanometer is inflated proximal to the arteries of arm and ankle till pulse
ceases as seen in Doppler ultrasound.
□ What is Myocutaneous flap: Composite soft tissue flap in which skin provides wound closure, and • Cuff is then slowly deflated
muscle mass serves as a carrier for the blood supply • The point at which arterial pulse is redetected via Doppler probe is the systolic pressure of
□ Examples : fedn9'.t:Jj~ the artery
• ~teHalis major_!)f!Q. □ Arteries used :
• ~issimus dorsi flap • Arm - Brachia! artery
(Both fall in Type V of Mathes and Nahai Classification) • Ankle -
Posterior tibial artery
A) PMMC (PECTORALIS MAJOR MYOCUTANEOUS FLAP)
Arteria dorsalis pedis
• Anatomy - Fan shaped muscle of anterior chest w·a11 □ Calculation :
• Dominant pedicle - Pectoral branch of thoraco acromial artery SBP in ankle
• Secondary pedicle - Perforator branches of internal mammary artery ABPI = SBP in arm
• Nerve supply - Lateral and Medial Pectoral Nerves
□ Interpretation:
□ Types:
• Muscle paddle
__> 1.2 (j) - _Qalcification of arterial wall indicating peripheral vascular disease
0.9 - 1.2 Normal
• Full paddle
0.8 - 0.9 Some arteMJ disease + I - venous ulcer
• Island
• Free
CLASSIFICATION
• Osteomyocutaneous
□ Uses: I
• Flap of choice in cancer patients requiring secondary reconstruction
• .Fl~£c>nstruction of mandibI~, floor of mouth, upper neck, le>_INer third of f~ce Painful Painless
□ Contraindication : • Syphilitic ulcers
• Dental ulcers
• Prior H/0 radical axillary node dissection • Aphthous ulcers • Malignant ulcers
• Prior flap reconstruction of breast • Tuberculous ulcers • Lichen planus ulcers

57
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 451
450 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesioiogy

0.5 - 0.8 4:L Moderate arterial disease + / - mixed ulcer

< 0.5 - Severe arterial disease : see Section 1, Segment E, Q 9, (Page No. 586).
□ Sensitivity : '90%
--- - ~ ~ s of Radiotherapy _
□
□
Specificity ~98%
Disadvantages :
~<j: see Section 1, Segment C, Paper II, 2009, Q 1O, (Page No. 367)
• Unreliable results in case of arterial calcification ·~g.4: /mperforate anus*
• Resting ABPI is insensitive to mild PAD
iJ:See ~qt~~-1, Segment C, Paper I, 2013, Q 4 (Anorectal malformations), (Page No. 303)

_/ ~ k of protocol standardisation "~11c11est

$ o n g u e ulcers •~: see Section 1, Segment C, Paper II, 2008, Q 12, (Page No. 354-355)

TONGUE ULCERS Q.6: Glasgow coma scale

A: see Section 1, Segment C, Paper II, 2008, Q 13, (Page No. 355)
A) DENTAL ULCERS
• Common cause is rubbing_ of tongue on sharp eqg_es of teeth, dentures or accidental biting Q.7: /VU
B) APHTHOUS ULCER /4: See §ection 1, Segment E, Q 19 (Intravenous Urethrogram), (Page No. 595)
• Repeated formation of benign ulcers in otherwise healthy individual
~•sulcer
• Cause is_!_?~~hic though n_LJ!_!i!LoDal deficie119y is commonly associated
• Occur periodically and heal completely in between attabk.
A: See ction 1, Segment C, Paper II, 2013, Q 10, (Page N o ~ .

• Sfte is mainly non-keratinising epithelial surfaces ospadias

C) TUBERCULOUS ULCER A: See S~ion 1, Segment C, Paper II, 2013 Supplementary, Q 8, (Page No. 425)
• Typical stellate ulcer mostly on dorsum of tong_ye
e,;,lt(rfng toe nail
• Undermined egg_~s and granulating floor
----··-·-- -•-"~"··-·· - - - - - - -
A: s.e{section 2, Group 11, Q. 52, (Page No. 739}
0) SYPHILITIC ULCER
• Mucous patches - Slightly elevated plaques, may be covered by grey pseudomembrane
2018
• Multiple lesions coalesce to form serpiginous lesions described as snail-track ulcers
E) MALIGNANT ULCER
Q/U~~I
• Initially painless, later becomes painful due to infection or involvement of lingual nerve A: See Section 1, Segment C, Paper 11, 2009, Q 7 (Extradural hematoma), (Page No. 365)

F)
• Mostly in lateral margin of tongue
LICHEN PLANUS ULCER
Q.2: T,W~¥- 01 .._,

• White lacy lesions A: / / ACUTE HYPERPARATHVROIDISM (CRISIS)

□ Investigation :
• Biopsy • rare but dangerous presentation
Abdominal pain, vomiting, dehydration, oliguria, muscle weakness and death
• Routine investigations for TB, Syphilis •
• Serum calcium is very high(> 12% or> 3.5mmol/L}
□ Treatment :
Advocated for Acute hyperparathyroidism crisis :
• Maintain oral hygiene
► Forced diuresis - ~_:-5 _b~,:ior[!19 1saline Y{ith Frusemide
•
•
Topical corticosteroids for aphthous ulcer
Specific treatment for TB and Syphilis.

2017 Supplementary
►
►
--
Rehydration - Normal saline _@39QmL/hL
___. --
To inhibit effects of vitamin D - Steroids 400!!1.9 i.v. for 5 days
► Pamidronate (90 mg i.v. slowly in 4 hrs)
0.1 : Thyroglossal cyst / Zoledronic acid (4 mg initially, 8 mg later)

A: See Section 1, Segment C, Paper 11, 2008, Q 4, (Page No. 348).

 . 452 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 453

► To reduce serum calcium level - Mithramycin, calcitonin, bisphosphonates, Cinacalet 2019

(Calcium receptor agonist), Gallium nitrate (inhibits osteoclast resorption of calcium at the
dose of 200mg/m2/day) Q . ~ c e cholangio-pancreatography (MRCP)
. / / estrogens, progesterons, raloxifene (Selective estrogen receptor modulator)
A: See Section 1, Segment E, Q.9 (Page No. 586)
~:Ranula
Q.2: Epidural Anesthesia
~S~ction 1, Segment D, Q 68, (Page No. 526).
1 A: see Section 3, 0.7 (Page No. 763)
,_/-)¥,f: ERCP Q.3: Sp/it-thickness skin graft
t A : S~ection 1, Segment E, Q 10, (Page No. 586).
A: See Section 1, Segment C, Paper II, 2008, 0.7, (Page No. 351)
/ ~ Testicular torsion .. Q.4 : Choledochal Cyst
A: See Section 1, Segment C, Paper II, 2012, Q 9, (Page No. 408). A: ~ee ~on 1, Segment D, Q.42 (Page No. 501)
~PSA . Q . 5 , - ~ S of External beam radiation therapy
;:,/
A: See Section 1, Segment C, Paper 11, 2012, Q 5, (Page No. 406). A:
. / ..
~~chytherapy COMPLICATIONS OF EXTERNAL BEAM RADIOTHERAPY
· · · - A: See Section 1, Segment C, Paper II, 2008, Q 10, (Page No. 353). Complications arising due to radiotherapy stems from effects of Ionizing radiation on normal human
Q.10: Regional anesthesia tissues. They can be enumerated as follows -

A : See Section 3, Q 8, (Page No. 764). 1. Infections in cancer patients :

Radiation therapy (RT) impairs mucosa! immunity as several levels and suppresses bone marrow
function resulting in local and systemic bacterial infections, mucosa! candidiasis, HSV infection.
2018 Supplementary
2. Anemia, Neutropenia & Thrombocytopenia : .
0P-ssiflcation of nerve injury Hemi Body Irradiation, Pelvic external beam radiotherapy can often lead to these complications due
to gross myelosuppression. ·
. A_: See Section 1, Segment D, Q 98, (Page No. 558).
,,.~..,,,.,.... .
_.,,,,.,,.,,,.., , ~,,,
According to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0, neutropenia
.,r/~jJ:~: Criteria of brain death
, ,,,,.
•,.,,
is defined by a granulocyte counts; 1,500/µL. When ANC (Absolute neutrophil count) is< 500/µL, risk
· A :)3e~ction 1, Segment C, Paper 11, 2011, Q 3, (Page No. 394). and severity of infection becomes inversely related to the neutrophil count.
CTCAE defines thrombocytopenia as a platelet count <100,000/µL. The risk of hemorrhage increases
. J4/:Types of skin grafting
\. .. • -·· when platelet count is < 50,000/µL.
A: See Section 1, Segment C, Paper 11, 2008, Q 7, (Page No. 351 ).
.,,,.,, ,,,,,........ a. Nausea & vomiting :
•· /Oy'themotherapy of testicular cancer Risk of Radiation Induced Nausea and Vomiting (RINV) is defined principally by anatomic area
. ,Y ,.,.,.,
L-· · '· · A : See Section 1, Segment A, Paper 11, 2014, Q 3 (Treatment of Testicular tumors), (Page No. 188). receiving treatment as well as type of treatment.

Q.7: Cleft lip

Risk Category Radiotherapy Modality
A: See Section 1, Segment C, Paper 11, 2013, Q 1, (Page No. 417).
High Total Body Irradiation
Q.8 : Glasgow coma scale
Moderate RT to Upper Abdomen, Craniospinal irradiation
A : See Section 1, Segment C, Paper 11, 2008, Q 13, (Page No. 355).
L)(?' Dentigerous cyst
Low
Minimal
RT to lower thoracic r~gion, pelvis, head and neck, brain
RT to extremities and breast

- A: See Section 1, Segment C, Paper 11, 2014, Q 3, (Page No. 428).

4, Diarrhea :
Diarrh.ea is defined as passage of more than 3 unformed stools in 24 hours. Treatment induced
diarrhea can be associated with life threater,ing dehydration, renal failure and electrolyte abnormalities.
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 455
454 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Radiation injury to the lower intestine is usually seen after treatment of cancers of the anus, rect fatigue: . . . .
ncer Related Fatigue (CRF) may be defined as a di~tressing, persistent, sub1ect1ve sense of
cervix, uterus, prostate, urinary bladder, and testes and as part of total-body irradiation. Radiothe Ca i I emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment
of the abdomen or pelvis damages intestinal mucosa, causing prostaglandin release and bile phys_ca' t proportional to recent activity and that interferes with usual functioning. Direct effect of
malabsorption. These lead to increased intestinal peristalsis, causing diarrhea. that 18 no · of fa1·1gue ·m cancer pat·1en t s.
radiotherapy has been implicated as a contributor to the intensity
Acute radiation enteritis or proctitis occurs within 6 weeks of therapy. Symptoms include diarrh
cramping pain, tenesmus, bleeding. These symptoms usually resolve without specific therapy wi second cancers : . . .
2 to 6 months. ond Priml!ry cancers (SPC) are one of the most serious c~m~hcat1o~s of anti-cancer treatment.
Late radiation enteritis or proctitis generally occurs 8 to 12 months after therapy. It may manifest S::k of radiation-rl:)lated cancer has been shown to increase with mcreasm~ dose for cancer~ _of the
malabsorption and/or diarrhea, with more rapid transit times occurring in the affected bowel. Rreast, esophagus, lungs, stomach, meningioma, sarcoma and pancreatic cancer. In ~dd1t1on to
~adiation dose, ra<;iiotherapy fields, which directly reflect the volume of normal exposed tissue, can
5. Oral complications :
affect SPC risk. ·
These complications include oral mucositis and associated oropharyngeal pain, xerostomia, 0
infection. Oral mucositis is a dose- and rate-limiting toxicity for RT in the head and neqk cancer setti Neurocognitlve effects : ..
Atrophic changes in the oral epithelium occur usually at total doses of 16 to 20 Gy, aqministered • Whole brain RT is associated with high risk of cognitive decline. In long term survivors, worse cognitive
rate of 2 Gy per day. Teeth in the irradiated field may become desensitized, placing the patient at function has been reported at 1 year following adjuvant WBRT.
for asymptomatic early caries. Earl Radiation lethality: It refers to death occurring within a few weeks due to specific high int~n~ity
Late effects of External Beam Radiotherapy delivered to the head and neck include soft tissue fibro • radi!ion exposure to the whole body. The mode of death depends on the magnitude of the radiation
trismus, nonhealing or slow healing mucosa! ulcerations, and slow-healing dental extraction sit
dose.
RT-induced fibrotic changes may occur in the masticatory muscles or the temporal mandibular j i) Radiation dose>100 Gy- Cerebrovascular syndrome (death within 24-48 hours)
up to 1 year after RT. Osteoradionecrosis is reported following tooth extractions not timed to all
extraction site healing for 10 to 14 days before the start of RT. It is usually related to trauma and hig ii) Radiation dose 5-12 Gy- Gastrointestinal syndrortle (death in 9-10 days)
incidences are reported with total doses to the bone exceeding 65 Gy. iii) Radiation dose 2.5-5 Gy- Hematopoietic syndrome (death in several weeks to 2 months)

6. Pulmonary toxicity :
:Epulis - ~
Radiation pneumonitis develops in 5-15% of patients receiving high-dose external beam radiation f
treatment of lung cancer. Symptoms of acute radiation pneumonitis usually become evident 2 to :SeeSection 1, Segment C, Paper 11, 2011, Q.13, (Page No. 399)
months after the completion of therapy. However, when the injury is severe, a chronic phase(~ ~
7: Ultrasound wave therapy
months after radiation) ensues which may persist for months or years. Factors like female sex,
: See section 1, Segment C, Paper 11, 2009 supplementary, Q.13, (Page No. 373)
lower lobe site of primary lung cancer, concurrent chemotherapy, previous irradiation, and withdraw
of steroids may potentiate classic radiation pneumonitis. (l~~]FhJi~fwith paradoxical respiration
7. Cardiac toxicity : :,., : See.Section 1, Segment C, Paper II, 2008, Q.12, (Page No. 354)
Pericarditis and pericardia! effusion are regarded as the most common side effects of cardiac irradiatio
· ~ } ~ ~ i n injury
However, as per recent evidence Radiation-induced coronary heart disease (CHO) is the m
concerning long-term risk of cardiac irradiation, particularly in patients at high risk for ischemic dise A: ,
A highly referenced population-based, case-control study of major coronary events by Darby et
(1958-2001) showed that for breast EBRT, an increase in Mean Heart Dose of 1 Gy was associat SECONDARY BRAIN INJURY
with a 7% increase in cardiac events.
Brain injury : An insult to brain, not of degenerative or congenital n~ture, cause~ by an ext~rnal
8. Hair loss : physical force that may produce a diminished or altered state of co~sc~ous_ness, which results. in an
Cranial irradiation can cause hair loss. Palliative whole-brain radiation (WBRT) or Prophylactic Cran' impairment of cognitive abilities or physical functioning, often resulting m disturbance of behavioural
Irradiation (PCI) causes temporary hair loss that starts approximately 2 to 3 weeks after initial" or emotional functioning.
radiation and resolves 2 to 3 months after cessation of RT. However, higher doses of curative treatm
Types of brain injury:
to the brain can cause permanent hair loss as great a$ 50%.
a) Primary ➔ Irreversible cellular injury as a direct result of injury
9. Gonadal dysfunction : b) Secondary ➔ Damage to cells that are not initially injured
Radiation can cause germ cell depletion, loss of gonadal hormones, mutagenic cha ges in ge
Cl Timing of secondary brain injury: Hours to weeks after injury
cells. In the conventionally fractionated regimens, doses to the testes above 0.15 Gy re required t
produce any reduction in sperm count. The duration of azoospermia is dos ent. Cumulativ
doses of fractionated radiotherapy of more than 2 .5 Gy generally result in likely permanent azoospermia.
 456 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - 11 457

□ Mechanism of injury:
lntracranial pressure monitoring indicated in comatosed patients with :
a) GCS 3 - 8 with abnormal CT scan
b) Normal CT with 2 2 features at admission -
Blunt injury Penetrating injury i) Age > 40 years
• Assault ii) Unilateral or bilateral motor posturing
• Stab
• Motor vehicle collision iii) SBP < 90 mm Hg
• Gunshot wound
• Fall Induced hyperventilation
• Explosion
• Hyperosmolar therapy
□ Classification of brain injury: • Corticosteroid - inconclusive role
a) Open brain injury - Skull penetration Barl:ljturate coma
b) Closed brain injury - no skull penetration urgical interventions for refractory ICP e.g. external ventricular damage.

□ Pathogenesis : Rotational I translational acceleration ➔ diffuse shearing / stretch of axonal d . : Diabetic foot
vascular cell membranes ➔ Increased permeability ➔ intracellular calcium influx- triggers proteoly~~ : See Section 1, Segment A, Paper I, 2009, Q.1, (Page No. 15)
brea~down of ~ytoskeleton interruption of axonal transport ➔ accumulation of ~-amyloid precurs'i;
protein, formation of axonal bulbs, secondary axotomy and inflammatory response ➔ declin •
cerebral blood flow ➔ secondary injury. e rn
2019 Supplementary
□ Secondary injury consists of:
.:----
ndoscopic Retrograde Cholangiopancreatography (ERCP)
Hypoxia I ischaemia
Increased intracranial pressure ee Sect"on 1, Segment E, Q.10, (Page No. 586)
Infection, meningitis
· . · naesthesia
Hydrocephalus
Brain abscess ee Se,.etion 3, Q.1 (Page No. 753)
Hypercapnia
/ /

· thickness skin graft

Acidosis
A: See Section 1, Segment C, Paper II, 2008, Q.7, (Page No. 351)
□ Second impact syn~rome: Extremely rare outcome where death or severe neurologic injury occurs
when a person sustains a second concussion before symptoms from an earlier one have subsided. Q.4: Hypertrophic pyloric stenosis of infancy
□ Management : A: See Section 1, Segment C, Paper II, 2010, 0.9, (Page No. 378)
Maintenance of airway, breathing, circulation
Q . ~ ~Radiotherapy
Adequate sedation
Avoidance of hypo/hyperglycaemia A:
Instituting normothermia NEO-ADJUVANT RADIOTHERAPY
Prevention of seizures
Correction of anaemia and coagulopathy Cancer patients often undergo treatment for a prolonged duration and most sites require multimodality
Deep vein thrombosis prophylaxis treatment that is executed in multiple steps. In oncological perspective, the term "Neo-Adjuvant" refers to
Early nutritional therapies the part of treatment that happens prior to the "Definitive" treatment. Mostly Neo-adjuvant therapy is
associated with tumor downstaging so as to improve the effectiveness and ease of definitive treatment.
Stress ulcer prophylaxis
Hygiene maintenance to prevent infections Carcinoma Rectum :
Specific monitoring In CA Rectum, Neo-adjuvant radiotherapy has emerged as the standard of care along with or without
Pulse oximetry concurrent chemotherapy. It is associated with improved tumor resectability and tolerance (both
ECG acute and chronic), in addition to downstaging of tumor. It increases potential for expanded sphincter
BP preservation options in carcinoma of distal rectum. Appropriate neo-adjuvant preoperative radiation
End tidal carbon dioxide has been shown to increase Local Control (LC) and Overall Survival (OS) of patients.
Core body temperature The Swedish Rectal Cancer Trial which evaluated 1,168 patients (accrued from 1987 to 1990) with
resectable, Dukes A to C rectal cancer. The 5-year Local Recurrence (LR) rates (11 % vs. 27%) were

58
458 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS O Paper - II 459

numerically and statistically superior with preoperative radiation treatment (25Gy in 5 fractions over 1 Ther~fore there still is no clear evidence that preoperative radiotherapy improves survival of patients
week) followed by definitive surgery compared to surgery alone. At follow-up of 13 years, OS was with potentially resectable esophageal cancer.
38% versus 30% in favour of neoadjuvant preoperative radiotherapy with all stages benefiting.
Q.6: Dental Cyst ~ -
The ideal time interval between neoadjuvant RT and definitive surgery was studied in the French trial
Lyon 90-01, which delivered 39 Gy in 13 fractions (no preoperative chemotherapy). After a median A: See Section 1, Segment C, Paper II, 2008, O.11, (Page No. 353)
follow-up of 33 months, the pCR (pathological complete response) rate was numerically better
(although not statistically significant) and the pathologic downstaging rate was statistically better in a . ~ i c pneumothorax
favour of longer interval before surgery (6-8 weeks compared to 2 weeks interval). A: See Se~ion 1, Segment C, Paper 11, 2009, Q.14, (Page No. 370) 'Tension Pneumothorax'*
A Dutch multicenter, phase Ill study, CKVO 95-04, of 1,861 patients was undertaken to evaluate the
i,.-s·:i~I chest tube drainage
role of short-course preoperative radiation with TME (Total Mesorectal Excision) as the definitive
surgery. The study again highlighted the value of radiation treatment in reducing local r~currence at A: See Section 1, Segment C, Paper I, 2013 supplementary, Q.3, (Page No. 307)
long follow-up. However, the perinea! complication rate was slightly higher in the preoperative radiation
Q.9 : Extradural hemorrhage
arm of 26% versus 18% in the TME alone arm. Updated toxicity analysis indicates a higher incidence
of sexual dysfunction and slower recovery of bowel function, more fecal incontinence, and generally A: s~~ Segment C, Paper 11, 2009, 0.7, (Page No. 365)
poorer quality of life with short-course preoperative radiation.
~~ousulcer
Two meta-analyses were carried out to explore the benefit of neoadjuvant preoperative radiation
treatment. One analysis reported that neoadjuvant radiation treatment was associated with significantly A: See Section 1, Segment C, Paper I, 2013, 0.2 (Page No. 301)
fewer LRs, improved specific survival, and an OS benefit. The second meta-analysis provided by the
Colorecta/ Cancer Collaborative Group, also noted a significant reduction in the risk of LR and deat,h
from rectal cancer with preoperative radiotherapy.
December-January 2019-2020

□ CA Pancreas : a. 1 : Branchial fistula

The use of neoadjuvant RT here with or without concurrent chemotherapy Is not supported by any A:
Phase Ill Randomised Controlled Trials (RCT), as none has been conducted yet. A review of the BRANCHIAL FISTULA
Surveillance, Epidemiology, and End Results (SEER) database supports the use of neoadjuvant
treatment in (potentially) resectable pancreatic cancer. Median OS was 23 months in patients receiving □ What is it:
neoadjuvant EBRT and 12 months in the surgery-alone cohort. With respect to chemoradiation, the • Branchial tract anomaly, which results from improper development of branchial apparatus
first ACT phase II study comparing immediate surgery (arm A) with surgery after neoadjuvant (Branchial apparatus consists of - branchial arches
chemoradiotherapy (arm B) for (potentially) resectable tumors was reported. Conventionally - pharyngeal pouches
. fractionated, the conformal RT included an elective nodal volume dose of 50.4 Gy and 55.8 Gy to the branchial grooves
tumor. The trial under-recruited (73/254 planned patients) with considerable impact on statistical - branchial membranes)
power. However, an important finding is that neoadjuvant therapy was well tolerated wifh fewer
hematological toxicities. • Fistula represents persistence of both cleft and corresponding pouch forming a communication
that is epithelial lined (generally persistent 2nd branchial cleft)
□ CA Esophagus : □ Location : Lies caudal to the structures derived from that particular arch and connects the skin to the
The use of preoperative radiation therapy has potential biologic and physical advantages, in addition foregut
to the ones elucidated above- Increased tumor radioresponsiveness secondary to improved tumor □ Lining: Stratified squamous, columnar or ciliated epithelium
oxygenation, a theoretical decreased likelihood of dissemination at the time of surgery and avoidance
of surgery in patients with rapidly progressive disease. □ Laterality : Unilateral or bilateral
However, none of the RCTs conducted by Launois et al, European Organisation for Research and □ External orifice : ~_lower third of neck near anterior border ~~ sternocleidom~st?id
Treatment of Cancer (EORTC), Arnott et al, Wang et al show any significant survival advantage for the □ Internal orifice : On anterior aspect of posterior faucial pillar just behind ,the t?nsil
patients receiving neoadjuvant preoperative RT in esophageal cancer ..
□ Clinical features :
A meta-analysis from the Oesophageal Cancer Collaborative Group evaluated data from 5 RCTs of
> 1,100 patients comparing preoperative radiotherapy plus surgery versus surgery alone. At a median • Opening in neck ......
--'---"'--·---·· (lower part)
.... __ ,.____ _
,

follow-up of 9 years there was an overall reduction in the risk of death of 11 % and absolute survival • $li_9t}!_m.YQ_<;>purulent discharge f~Q,~?£~~~~-~
benefit of 4% at 5 years with the use of preoperative radiotherapy. However, this numeric71 neflt □ Investigations :
was not statistically significant.
• Upper airway endoscopy
• FNAC - to clarify diagnosis and rule out metastatic cancer
 460 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 461

• CT Scan - Investigation of choice

• MRI CTCAE defines thrombocytopenia as a platelet count< 100,000/µL. The risk of hemorrhage increases
when platelet count is < 50,000/ µL.
• CT fistulography
Nausea & vomiting :
□ Treatment :
Chemotherapy-induced nausea and vomiting (CINV) remains one of the most dreaded side effects
Complete surgical excision
indeed. Before the era of newer antiemetic drugs, approx. 80% pati~-~~ould experience at least an
In case of acute infection, first treat with antibiotics and then surgical excision after complete episode of nausea or vomiting after chemotherapy of moderate to high emetogenic potential.
resolution
Classification of emetic risk of intravenous antineoplastic agents is as follows :
~ i o n a / Anesthesia
High(> 90%) Anthracyc!ine-Cyclophosphamide
. A: See Section 3, 0.8, (Page No. 764)
combination
, ,/(ij_;,Er(clotracheal Intubation Cisplatin
_,,/(.:::.;;:.
Cyclophosphamide (> 1500 mg/m2)
· A : See Section 3, 0.10, (Page No. 768)
' Moderate (30-90%) Carboplatin
,,.-
//9,-4(
,,,~
Undescended Testis Cyclophosphamide (<1500mg/m2)
A: See Section 1, Segment C, Paper II, 0.4, (Page No. 363) Anthracyclines

. ~ .,4/complications of Chemotherapy
Low (10-30%) Docetaxel
5-Fluorouracil
~: Gemcitabine
Methotrexate
COMPLICATIONS OF CHEMOTHERAPY
Minimal (<10%) Bleomycin
□ Infections in cancer patients : Vincristine
Vinblastine
Cancer patients are at increased risk for various infections because of chemotherapeutic drugs and
other antineoplastic agents.
□ Diarrhea & constipation :
Treatment related factors Diarrhea is defined as assa e of more than 3 unforme~--s~ogl8-JE)__ 24 hours. Treatment ind~?ed
Infection
diarrhea can be associated with life threatening e ydration, renal failure and electrolyte abnormalities.
Corticosteroids Bacteria, P. jirovecii, C. neoformans, Herpes The chemotherapeutic agents most commonly causing dia.rrhea are : 5-Fluorouracil, capecitabine,
viruses lrinotecan.
Nucleoside analogues (e.g. Fludarabine) Bacteria, P. jirovecii, C. neoformans, Herpes Chronic Constipation according to ROME II criteria entails the presence of any 2 of the foll~wing
viruses symptoms for at least 12 weeks- ~training during q~I movements, lumpy or hard stool, sensation of
incomplete evacuation, sensation of anorE:if.LqLQJQckage, r:nanua_l rrianEJU\/El~S. ..~()_rEl~()ve stool, ~.
Alemtuzumab CMV, VZV, P. jirovecii bowel movemeots 12er week. Among chemotherapeutic agents, vmca alkaloids have the propensity
Rituximab VZV, P.jiroveci to cause constipation-cfueTo their neuropathic effects.
Bruton TKI (e.g. lbrutinib) Aspergillosis, P. jirovecii □ Oral complications : .
PIK-3CA inhibitors P. jirovecii T ~ s include oral mucositis, oral chronic graft versus host disease and associated
oropharyngeal. pain, xerostomia, oral infection.
□ Neutropenia & f!!!ombocytoeenia : □ Pulmonary toxicity :
These are !!lOSt frequent manifestations of cytotoxic chemotherapy induced myelosuppression. This
may adversely impact antineoplastic treatment incluciing more frequent hospitalizations, increased Chemotherapeutic agents Mechanism of pulmonary toxicity
treatment cost, reduction in dose intensity of chemotherapy, treatment discontinuation and increased
mortality. Bleomycin Direct end_othelial toxicity via oxygen free radicals
According to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0, neutropenia Busulphan Direct alveolar epithelial toxicity
....• ··-·-·"· ··-··· .. ·-·
is defined by a granulocyte counts 1,500/µL. When ANG (Absolute neutrophil count) is< 500/µL, risk ,

and severity of infection becomes inversely related to the neutrophil count. Mitomycin C _E:nd()ttlelic:1I. iniury, alveolar macrophage activation
Nitrosoureas Direct injury through oxidative stress
"l"""""r

lv1BBS D Paper - II 465

462 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MB -..

□ Gardie toxicity :

Chemotherapeutic agents Cardiovascular toxicities

te
on 1, Segment D, 0.15, (Page No. 477)

'stumour
I
Anthracyclines Irreversible dilated cardiomyopathy 1, Segment C, Paper I, Q.4, (Page No. 322)
Mitomycin CHF
ele
Busulfan .CHF
tion 1, Segment C, Paper 11, Q.5, (Page No. 377)
Vinca alkaloids

June-July, 2020
□ Hair loss:
- ~
Alopecia has been ranked as the third most common adverse event of cancer treatment. . : Epidural Anaesthesia
: See Section 3, Q.7, (Page No. 763)
High Risk Chemotherapeutic agents likely to cause complete alopecia
: lmperforate Anus
Cyclophosphamide, lfosfamide
: See Section 1, Segment C, Paper I, 0.4, (Page No. 303)
Doxorubicin, Actinomycin-D
, .3 : Breast abscess
Paclitaxel, Docetaxel
Etoposide, lrinotecan
lA: See Section 1, Segment C, Paper II, Q.3, (Page No. 362)
~c;;~inoma
' ,/
-~: Se~~tion 1, Segment C, Paper I, 0.2, (Page No. 280)
D ' Gonadal dysfunction :
Chemotherapy can have varying effects on the sperm quality and quantity. Cyclophosphamide, [;,spins Blfida
Chlorambucil, Procarbazine, Cisplatin, Busulfan, lfosfamide, Actinomycin-D may cause azoospermia. A: See Section 2, Group I, Q.6, (Page No. 633)
□ Fatigue:
Q.6: Bleeding from gum
Cancer Related Fatigue (CRF) may be defined as a distressing, persistent, subjective sense of
physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment
A: Se;/~ 1, Segment C, Paper 11, Q.10, (Page No. 443)
that is not proportional to recent activity and that interferes with usual functioning. Direct effect of tg;,:{µydrocephalus
chemotherapy has been implicated as a contributor to the intensity of fatigue in cancer patients.
A: See Section 1, Segment C, Paper II, Q.12, (Pa~e No. 387)
□ Second cancers :
Q.8 : Glasgow Coma Scale
Second Primary Cancers (SPC) are one of the most serious complications of anti-cancer treatment.
Alkylating agents has long been recognized to be associated with t-MDS/AML. Moreover, A: S e ~ n 1, Segment C, Paper 11, 0.13, (Page No. 355)
epipodophyllotoxins, anthracyclines are associated with a clinically and cytogenetically distinct AML
type having shorter incubation period. 05:U T. Scan
A: See Section 1, Segment E, (Page No. 611)
□ /:Jeurocpgnitive effects :
Post-treatment cognitive decline has been demonstrated in many oncologic conditions such as solid ~:~~p
tumor cancers (Breast, lung, colorectal, testicular, ovarian and prostate) and lymphoma; and A: See Section 1, Segment C, Paper 11, 0.1, (Page No. 417)
/ antimetabolties, DNA cross-linking agents, mitotic inhibitors are associated with it.
' /,,~ /.,"/
----··(:~:IVU
~__/ Section 1, Segment E, Q.19, (Page No. 595)

/ ~ Lucid interval
\ A: See Section 1, Segment C, Paper 11, Q.7, (Page No. 408)
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 465
464 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

1 = Submucous fistula
- - - - - - - - - - - - ~ Endoderm
2 = Subcutaneus fistula
- - Mesoderm Deep external sphincter 3 = Low anal fistula
- - - - - - - - , - - - - : : : - - - . _ _ Ectoderm 4 = High anal fistula
5 = Pelvi-rectal fistula
\v Ectoderm invaginates Superficial external
/ inner layers Cyst from sphincter
under root of
infected dead
erupted tooth
------'~'---- Subcutaneous
external sphincter

__.,_
Filled up with

t / secretions from lining

epithelium
Fig. 1.6.2 : Dental Cyst (Finding in
~-orthopantomogram)

Fig. 1.6,5 : Types of anal fistula

Imaginary
line
External opening lies anterior
➔ straight tract
White lesion
with convexity

Fig. 1.6.1 : Dermoid Cyst Midline

inward
-(
shift lschial
tuberosity

Fig. 1.6.4 : CT Scan finding of External opening lies posterior

extradural hematoma ➔ curved tract

Fig. 1.6.6 : Fistula In Ano (Goodsall's law)

lpsilateral pupil Contralateral pupil

White inability to place back
Initially Normal
• Normal
• Lesion
with
retracted prepucial

•
concavity
CN Ill of ipsilateral side
compressed
Pinpoint constriction
• Normal inward

CN 111 of opposite side

compressed
Widely dilated

• Pinpoint constriction
•
Finally Widely dilated
//'

' - y / e i g . 1.6.3 , H"tohiesoo's P"P"

• Widely dilated
• Fig. 1.6.7 : Subdural hematoma
CT finding
Fig. 1.6.8 : Paraphimosis

59
466 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

SEGMENT-D
SOLVED SHORT NOTES OF SEMESTERS

Q.1 : Paradoxic aciduria I Metab.olic changes following gastric outlet obstruction

A: See Section -1, Segment-A, Paper-I, 2013 Supplementary, a. 1 (Page No. 61-62)

Q.2 : Euthanasia
0+---- Penile
EUTHANASIA
O What is it: Practice of intentionally ending a life in order to relieve pain and suffering, often called
"Painless inducement of quick death"
O Types:
• Voluntary - With patient's consent
Cyst over crown of
unerupted tooth • Involuntary - Against patient's will
• Non-voluntary - Where patient's consent is not available
• Active - Use of lethal substances
- - - - Perinea! Fig. 1.6.10 : Dentigerous cyst • Passive - Withhold common treatment
(Finding in orthopantomogram)
Q.3: Bezoar
BEZOAR

□ Definition : Mass found trapped in gastrointestinal tract

,. /Fi;: 1.6.9 : Types of hypospadius
/
□ Types:
• By content-
► Food bezoar
► Lacto-bezoar (inspissated milk)
ASIS ► Pharmacobezoar
► Phytobezoar (indigestible plant)
Pubic ► Diospyrobezoar (unripe persimmons)
tubercle ► Trichobezoar (hairball)
• By location -
20 cm Oesophagus
►
15cm ► Large intestine (faecolith)
► Trachea (tracheobezoar)
□ Pseudobezoar : lndigestable object introduced intentionally into GIT

Q.4 : Wound debridement

WOUND DEBRIDEMENT
Dressler's quadrangle
□ Definition: Medical management of dead, damaged or infected tissue to improve healing potential
Fig. 1.6.11 : Penile Carcinoma of remaining healthy tissue
□ Types:
• Burn debridement

467
468 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 469

• Wound debridement
• Infection debridement • Mediastinum
• Groin
□ Methods of removal:
Pathology:
• Surgical - Done under general anesthesia, fastest method, done to remove large amount of
• Aggregation of cysts looking iike soap-bubble
necrotic and infected tissue
• Larger cysts near surface, smaller cysts located in deeper planes
• Mechanical - Done if moderate amount of necrotic tissue is to be removed, allows dressing to
• Each cyst has a mosaic nppearance
proceed from moist to dry region and then remove manually
• Content - Clear lymph, does not clot
• Chemical/Enzymatic - Done if large amount of necrotic tissue is to be removed, generally eschar
• Lining of cyst - enrJothelial lining
is removed this way
O Clinical features :
• Autolytic - Occlusive or semi-occlusive dressing, hydrocolloid gel used
Swelling with following features -
• Maggot therapy - Maggots consume only necrotic tissue in 2-3 days time by extracorporeal
digestion. • Smooth
• Soft
Q.5: Vlrchow's node • Fluctuation test positive
• Brilliantly transilluminant
VIRCHOW'S NODE • Compressible

□ Definition : It is the cervical lymph node in left supraclavicular fossa

O Complications :
• Respiratory distress
□ Supply from : Lymph vessels in abdominal cavity
• Hemorrhage
□ Troissier's sign : Enlarged hard node occurring in malignant conditions
• Infection ➔ abscess -> septicaemia
□ Named after : Rudolf Virchow O Treatment :
□ Use: To detect carcinoma in stomach, pancreas, etc.
• Preoperative injection of sclerosants ➔ aspiration of contents ➔ when capsule gets thickened
□ Differential diagnosis : by fibrous tissue, entire aggregation of cysts is excised
• Lymphoma • If respiratory obstruction ➔ aspiration of cysts + tracheostomy
• Breast carcinoma • Antibiotics
• Arm infection
□ Pathogenesis: Lymph drainage from most of body (thoracic duct) enters venous circulation via left 0.7: Pharyngeal pouch
supraclavicular vein ➔ metastatic deposits block the thoracic duct ➔ regurgitates into Virchow's
node ➔ Node enlarged. PHARYNGEAL POUCH
□ Synonym : Zenker's diverticulum
Q.6 : Cystic hygroma
□ What is it: Protrusion of pharyngeal mucosa through Killian's dehiscence, which is a weak area of
CYSTIC HYGROMA posterior pharyngeal wall between oblique fibres of thyropharyngeus and transverse upper fibres of
cricopharyngeus of the inferior constrictor of pharynx
□ Synonyms:
□ Nerve supply: Thyropharyngeus ➔ cranial accessory nerve, cricopharyngeus ➔ external laryngeal
• Cavernous lymphangioma nerve
• Hydrocele of neck
□ Aetiology: Imperfect relaxation of cricopharyngeus ➔ raised pharyngeal pressure ➔ protrusion of
□ What Is it : Cystic swelling due to sequestration of a portion of jugular lymph sac from lymphatic mucosa
system, during in-utero development
□ Position : Pulsion diverticulum ➔ starts in midline ➔ expands and reaches vertebrae ➔ deviates
□ Age : Generally present since birth, sometimes presents in early infancy towards left side of the neck
□ Sites: □ Stages:

• Posterior triangle of neck (commonest) 1. Small diverticulum points towards vertebrae

• Tongue 2. Large globular diverticulum with a vertical opening causing regurgitation
• Cheek 3. Large pouch visible in the neck as globular swelling having a horizontal opening
• Axilla [See Fig.1.7.1]
470 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 471

□ Clinical features : Indications :

► Dysphagia • Acute/chronic urina.ry rete,ntion
► Sensation of food sticking at the back of mouth • After orthopaedic procedures that limit movement
► Swelling in neck - Soft, smooth, tender • Input - output monitoring
► Regurgitation, cough at night • Benign hyperplasia of prostate
► Gurgling noise while swallowing • Incontinence
► Recurrent respiratory infections • Surgical interventions involv,ng bladder and prostate

□ Investigations: □ Complications :

► Barium swallow X-Ray lateral view • Bleeding

► Chest X-Ray • False passage
• Infection
► CT Neck
• Paraphimosis
□ Treatment :
• Urethral strictures
► Pharyngeal pouch excision + cricopharyngomyotomy
□ Procedure : Patient in supine position ➔ consent taken, procedure explained ➔ sterile gloves worn
► Dohlmann's endoscopic procedure of excision ➔ external genitalia cleaned with 2% povidone iodine (ideally applied from mid-chest to mid-thigh)
► Antibiotics ➔ sterile drape used to isolate the area ➔ with help of gauge, prepucial skin is retracted beyond
□ Differential diagnosis : level of corona glandis ➔ once again genitalia is cleansed with povidone iodine ➔ 10-20ml syringe
loaded with 2% lignocaine ➔ penis held vertically and lignocaine is inserted through external urinary
► Lymph cyst
meatus into urethra ➔ external urinary meatus closed with thumb to avoid coming out of jelly ➔
► Branchial cyst gentle urethral massage at undersurface of penis for 5 mins to allow easy dissipation of anaesthetic
► Cold abscess in neck jelly ➔ assistant gives sterile catheter ➔ penis with retracted prepuce held vertically to straighten the
□ Complications of surgery: penile urethra ➔ gradually catheter is inserted into urethra through meatus ➔ urine comes out
immediately in case of retention ➔ 10-1 Sml distilled water used to inflate the balloon of the Folley's
► Pharyngeal fistula
catheter ➔ catheter is withdrawn till balloon snugly fits ➔ prepucial skin is retracted to prevent
► Abscess in neck
paraphimosis ➔ catheter connected to urobag ➔ colour and amount of urine is noted
► Oesophageal stenosis
► Infection (pneumonia, mediastinitis) Q.9 : Surgical drains

Q.B: Catheterisation SURGICAL DRAINS

CATHETERISATION □ What is it: A tube is used to remove pus, blood, or other fluids from a wound, which otherwise may
become a focus of infection
□ What is it : A latex, polyurethane or silicon tube known as urinary catheter is inserted into a patient's
□ Purpose:
bladder via the urethra, which allows urine to drain freely from bladder for collection in an urobag
• Prevent accumulation of fluid
□ Forms:
• Prevent accumulation of air
• Indwelling - Permanent
• To characterise fluid
• Intermittent - Removed after each catheterisation
□ Indications :
□ Types:
• Plastic surgery including myocutaneous flap surgery
• Simple rubber catheter
• Breast surgery
• Folley's balloon catheter -
• Orthopaedic surgery
a. 2-way
• Chest drainage after pneumothorax
b. 3-way
• Chest surgery
• Malecot's catheter
• Infected cysts
• De - Pezzer's catheter
• Pancreatic surgery
• Gibbon's catheter
• Biliary surgery
472 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 473

• Thyroid surgery External - Herniates through thyrohyoid membrane, situated in anterior third of laryngeal ventricle,
• between false cords and thyroid cartilage
• Neurosurgery
• Combined
□ Types:
Clinical features :
• Open - Drain fluid onto a gauze pad or into a stoma bag e.g. corrugated rubber drain {has high
risk of infection) Swelling with following features -
•
• Closed - Tubes draining fluid into a bag/bottle e.g. chest drain (has low risk of infection) 1. Situated in neck in relation to larynx, adjacent to thyrohyoid membrane
• Active - Maintained under suction 2. Unilateral
• Passive - No suction, working according to differential pressure between body cavities and 3. Smooth
exterior 4. Soft
• Silastic - Relatively inert, induce minimal tissue reaction 5. Ovoid
• Red rubber - Induce intense tissue reaction 6. ResonanVtympanic
□ Complications: 7. Becomes prominent while blowing, coughing, performing valsalva manouvre
8. Moves up with larynx on swallowing
• High risk of infection
9. Boggy in feel
• Damage may induce anastomotic leak
• Pus discharged into pharynx if laryngocele gets infected
□ Special varieties :
• Hoarseness of voice
• Jackson - Pratt drain
• Cough
• Penrose drain
Investigations :
• Negative pressure wound therapy
• Redivac drain ► X-Ray neck
• Pigtail drain ► CT Scan
• Davol ► Laryngoscopy
• Chest tube □ Treatment :
□ General measures : A. Internal laryngocele - Marsupialisation
• To ensure drain is secure B. External laryngocele - Excision through transverse cervical incision (neck ligated, divided and
• Accurately measure and record drainage output and nature, colour, etc. whole sac excised)
• Monitor changes in character, volume ,.. --· [See Fig.1.7.2]
• Use measurements of fluid loss to assist intravenous replacement of fluids
Q.12~_
□ Removal : Removed once drainage has stopped or becomes < 25 ml/day
CHORDEE
Q.10: Preparation of jaundice patient for surgery
□ What is it : Bending of glans penis, which is more prominent during erection
A: See Section - 1, Segment -A, Paper-1, 2010, 0.3 (Page No. 26)
Q.11 : Laryngocele □ Aetiology :
• .t!J.POSpadiu~_
LARYNGOCELE • .E:pispadius
• After circu_rnci§_iQn, if more skin cut over ventral aspect
□ What is it : Narrow necked, air - containing diverticulum, arising due to herniation of laryngeal
mucosa □ Types:
□ Commonin: • Dorsal
• Glass blowers • Ventral
• Professional trumpet players □ Pathogenesis : In hypospadius, the urethra is situated proximally than normal in the ~ndersurface ~f
• People with chronic cough penis, while in epispadius it is situated proximally and upper surface of penis. A fibrous band 1s
formed proximal to these openings, which contracts during E:rection giving rise to chordee.
□ Types:
• Internal - Confined within larynx, may displace and enlarge the false vocal cord
[See F i ~ ; ·
~'.~~v~
A fl\

60
474 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMtSTERS 475

□ Treatment : Bony mass above clavicle

•
• Chordee due to hypospadius ➔ correction during the staged operation for hypospadius Poor capillary refilling
•
• Chordee due to circumcision ⇒ Stilbestrol • Absent or feeble pulse
6mg daily Adson's test positive (Hand raised above head, after feeling radial pulse ➔ patient asked to take
•
j, deep breath and turn head to same side ➔ change in pulse noted)
Fibrous tissue excised Roos test positive (patient not able to raise arm above shoulder, for longer time in affected side
•
j, and drops the hand down)
Skin graft • Elevated arm stress test
Q. 13 : Thoracic outlet syndrome • Hyperabduction manouvre

THORACIC OUTLET SYNDROME □ Investigation :

• X-Ray neck, cervical spine
□ What is it: Syndrome complex occurring due to neurovascular bundle compression in thoracic outlet.
• Subclavian angiogram
□ Spaces of thoracic outlet : • CT angiogram
Space Bounded by Contents • CT neck
1. Scalene triangle ► Scalenus anterior ► Subclavian artery • Nerve conduction studies
► Scalenus medius ► Brachia! plexus • EMG
► 1st rib Treatment:
□
2. Costoclavicular space ► Scalenus medius ► Subclavian artery
► Clavicle ► Subclavian vein
► 1st rib ► Brachia! plexus Conservative Surgical
► Costoclavicular space ► Avoid weight lifting ► Transaxillary (ROOS)
□ Etiology: ► Exercise - [ 1st rib and cervical rib excision ]
• Fracture clavicle or 1st rib 1. Neck stretching ► Supraclavicular approach for cervical rib,
• Long transverse process of C 7 vertebra 2. Breathing soft tissue excision, scalenectomy
• Cervical rib 3. Postural
• Exostosis ► Drugs -
1. analgesics
• Scalene muscle hypertrophy
2. antidepressents
• Anomalous insertion of scalene muscle
3. muscle relaxants
□ Symptoms: ► Physiotherapy
I Q.14 : Cervical rib
CERVICAL RIB
Neurological Vascular
□ What is it: Extension of costal element (anterior part) of transverse process of C 7 vertebra more than
► Paraesthesia ► Claudication
2.5cm
► Pain - shoulder, arm ► Gangrene
□ Sex predilection : F » M
forearm, finger ► lschaemic ulcer
► Weakness - forearm, hand □ Laterality : Right sided
► Occipital headache □ Types:
□ Signs: • Complete bony
• Pulsatile swelling in supraclavicular region + thrill and bruit • Complete fibrous
• Scalene muscle tenderness • Partial bony
• Combined
476 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 477

• Subclavian angiogram
□ Pathology:
• Others - Blood sugar, lipid profile
Cervical rib narrows scalene triangle
□ Treatment:
j,
Compression of subclavicular artery, C 8 and T 1 nerve • Conservative -
j, (Same as thoracic outlet syndrome)
Angulation of subclavian artery • Surgical -
► Symptomatic without arterial compression ➔ Scalenectomy + extraperitosteal resection of
j,
cervical rib ± resection of 1st rib
Constriction of artery at site where artery crosses cervical rib
► Symptomatic with arterial compression scalenectomy + extraperitosteal resection of cervical
j, rib ± 1·esection of 1st rib + subclavian artery reconstruction ± graft
Eddie's current created in blood flow ► Gangrenous toe ➔ amputation
j,
□ Differential diagnosis
Sudden release of pressure distal to narrowing
j, • Cervical spondylosis
• Syringomyelia
Post-stenotic dilatation ⇒ Venturi phenomenon
• Carpal tunnel syndrome
j,
• Pan coast tumor

Thrombosis ➔ Embolus
Stasis of blood

➔
j,
May extend into subclavian artery
0-r~-
CLEFT PALATE
j,
lschaemia in hand and forearm □ Cause:
j, f='anure Of fusion Of_tWQj)cl_iatine )2!:_?Cesses
Digital gangrene - Defect in fusion of lines between premaxilla (developed from medial nasal process) and palatine
□ Clinical features : processes of maxilla
A. Features in neck - □ Types:
• Hard fixed bony mass in supraclavicular region Type I - Complete
• Palpable thrill, audible bruit above clavicle Type II- Incomplete
B. Neurological features (most common presentation) - Tingling and numbness in little finger, Type Ila- Bifid uvula
medial side of hand and forearm. Type lib- Bifid soft palate
C. Vascular manifestations (most problematic manifestation) - Type lie- Bifid soft palate + posterior part of hard palate
• Wasting of thenar, hypothenar and forearm
□ Classification :
• Pain - More during work, exercise and relieved by rest
• Digital gangrene
• Adson's test positive (Hand raised above after feeling radial pulse ➔ patient asked to take Cleft of primary palate Cleft of secondary palate Others
deep breath and turn head to same side ➔ any change in pulse noted) (In front of incisive foramen) (In front of incisive foramen)
• Roos test positive (patient not able to raise arm above shoulder, for longer time, in the
affected side and drops the hand down) t
!
t
Complete
t
Incomplete
t
Submucous
• Elevated Arm Stress Test [ Modified Roos Test] (Arm elevated above shoulder, with elbow Complete Incomplete
fully stretched ➔ rapid movement of finger ➔ fatigue on the side where cervical rib present) (absence of (rudimentary
premaxilla) premaxilla) Cleft of both Cleft lip and
□ Investigations : I primary and cleft palate
• Chest X-Ray t
Unilateral Median Bilateral
secondary
palates
together
• X-Ray of neck
• Arterial Doppler of subclavian artery, upper limb
478 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 479

□ Aetiology: O Types of urinary bladder tumor:

□ Associated syndromes : See Section_.- 1, Segment - C, Paper II, 2013 supp., Q.1 - Cleft Lip
[Page N @ ' )
□ Problems faced :
□ Clinical examination :
Torch focussed inside oral cavity. I. Non-invasive tumor without involving lamina propria
When free margin of septum visible, it is bilateral
D Treatment :
A. Millard's criter/a - ( Z
• 10 pound weight
• 10 gm % Haemoglobin
• 10 weeks old
B. Timing -
Between 10 - 18 months 11. Non-invasive tumor involving lamina propria
• Early repair ➔ retarded maxillary growth due to trauma to growth centre and periosteum
of maxilla
• Late repair ➔ speech defect
C. Pre-operative preparation -
• Nutrition maintained
• Infection controlled
• Spoon feeding practised
D. Operation -
Wardill - Kilner push-back operation Ill. Invasive tumor
• Abnormal insertion of tensor palati released
• Mucoperiosteal flaps raised in palate which is sewed together
• If maxillary hypoplasia ➔ osteotomy of maxilla
• With orthodontic help, teeth extraction and alignment of dentition done
• Hook of pterygoid hamulus is fractured to relax tensor palate muscle to relieve tension on
suture line
IV. Carcinoma-in-situ
o Palatal defect closed using 3 layers
E. Post-operative management -
• Regular examination of ear, nose, throat during follow - up period
• Hearing aids
• Control of otitis media • These are the different types of transitional cell carcinoma (which is the commonest)

• Speech therapy/pharyngoplasty/veloplasty • Other types - Adenocarcinoma

- Squamous cell carcinoma
• Dental problems corrected
□ TNM Staging :
Q.16 : Treatment of urinary bladder tumor
Tis - Carcinoma-in-situ
Ta - Non-invasive papillary tumor
TREATMENT OF URINARY BLADDER TUMOR
T1 - Invades only lamina propria
Treatment depends on the type of tumor T2 - Invades muscularis propria
T3 - Invades perivesical tissues
T4 - Invades surrounding organs, abdominal wall
480 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

SOLVED SHORT NOTES OF SEMESTERS 481

No nodes
Single regional nodal-spread < 2cm size a. 17: Carcinoma of tongue
Single regional nodal-spread 2-5cm size
or Multiple regional nodal-spread < 5cm size CARCINOMA OF TONGUE
M0 - No distant spread
M1 Distant spread present O Incidence : Accounts for more than half of all intra oral carcinomas
O Sex predilection : M = F
□ Treatment:
O Predisposing factors :
• Tis' No, Mo -
Repeated cystoscopy + Excision biopsy of unstable areas • Smoking
• Spices
• T1> N0 , M0 -
• Betel nut chewing
► Cystodiathermy and endoscopic transurethral resection of tumor
• Chronic superficial glossitis
► If large tumor ➔ tumor removed transvesically • Sepsis
► Care taken to saucerize deeply into the wall of bladder to remove completely the base of • Sharp tooth
tumor ·
• Syphilis
► Follow up - Regular cystoscopies until bladder has been clear for 5 years
• Chronic hypertrophic candidiasis
► Alternative approach for large papillary tumor ➔ Helmstein balloon degeneration (causes • Leukoplakia
pressure necrosis of summit of tumor)
• Erythroplakia
► lntravesical chemotherapy - • Oral submucosal fibrosis
Uses - BCG (120 mg in 150 ml N.S - weekly x 6 weeks)
□ Types:
- Mitomycin C
- Adriamycin Gross ➔ 1. Ulcerative
► Systemic chemotherapy - 2. Warty growth or papillary
Uses - Cisplatin, Adriamycin, 5-FU, Mitomycin 3. lndurated plaque
4. Fissure
• T2, No/N1, Mo-
► If solitary tumor with base < 4-5 cm Histologically ➔ 1. Squamous cell carcinoma (commonest)
- Transvesical excision + Curative interstitial radiotherapy (using implantation of gold grains 2. Adenocarcinoma
[ Au 198] or radioactive tantanium wires [ Ta 182] 3. Melanoma
► If solitary tumor, situated at fundus of bladder with margin of clearance 2.5 cm - □ Sites:
- Partial cystectomy + lntravesical / systemic chemotherapy+ Radical deep external beam
• Anterior 2/ 3 rd at or near edges (50%)
radiotherapy (45 Gy - using cobalt 90)
• Posterior 1/ 3 rd (20%)
• T3, No/N1, Mo- • Tip (10%)
► If age< 65 yr➔ Preoperative radiotherapy (2000 - 4000 rads)+ Radical cystectomy + pelvic • Ventral surface (9%)
node dissection • Dorsum (7%)
► If age > 65 yr ➔ Radical radiotherapy (6000 rads over period of 6 weeks or more) □ Spread:
A. Local spread ➔ CA tongue

Viable tumor demonstrable

j,
Viable tumor not demonstrable
j,
~
Anterior 2 / 3 rd Posterior 1/ 3 rd
Salvage cystectomy Nothing more done t t

* In radical cystectomy ~
CT Scan is a must
In females, extended hysterectomy done
•
•
•
Genioglossus muscle
Floor of mouth
Mandible
•
•
•
Tonsil
Pharynx
Epiglottis
J
Corresponding side

After surgery, urinary diversion done • Soft palate

Larynx
• Cervical spine

61
482 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 483

B. Lymphatic spread ➔ B. Treatment for primary growth -

• Tip of tongue ➔ Lymphatics thro.ugh floor of month ➔ Submental nodes • Growth < 2 cm size ➔ wide excision alongwith a wide margin of mucosa atleast 1 cm
1 1 wide (Brachy therapy may be given)
Juguloomohyoid gland Jugulodigastric group of Upper • Growth > 2 cm size in ➔ Preoperative radiotherapy (Interstitial radiotherapy)
• Anterior 213rd of tongue ➔ Submandibular nodes Deep cervical nodes anterior 2//d of tongue 1 Fails
Hemiglossectomy
Jugulodigastric group of upper deep cervical nodes • Growth < 2 cm in ➔ Teletherapy (with cobalt 60)
[
• Posterior 1/3rd of tongue - J h .d
ugu Ioomo yo, g Ian
d posterior / 3 rd of tongue
1 1 Fails
• Central lymphatics from Total glossectomy
either side of median raphe ➔ Pass vertically downwards in midline of tongue between two • Growth > 2 cm in ➔ External beam irradiation
genioglosus posterior 113rd of tongue 1 Fails
Total glossectomy
Jugulodigastric group of lymph nodes • Growth in tip of tongue ➔ Wide excision + Radiotherapy (according to size as mentioned
above)
□ Clinical features :
• If mandible involved ➔ Hemimandibulectomy
• Age - More than 50 years • Reconstruction of tongue and other area by flap surgery or skin graft
• Painless lump/ulcer in tongue
C. Treatment for secondary growth -
• Pain develops later due to infection
• Same side palpable, mobile lymph nodes ➔ radical neck block dissection
► Pain referred to ear if lingual nerve involved
• Bilateral mobile lymph nodes ➔ one side radical block; other side functional block dissection
► Pain on swallowing in case of CA posterior third of tongue
or supraomohyoid block dissection
• Excessive salivation - Often blood stained
• Fixed lymph nodes ➔ deep X-Ray therapy
• Foetor oris
*[Wide excision or hemiglossectomy + hemimandibulectomy + radical neck dissection= Commando
• Dysphagia
operation]
• Ankyloglossus
• Inability to articulate D. Chemotherapy -
• Hoarseness of voice • For palliation
• lump in neck - due to enlarged cervical nodes • Also given in post-operative period
• Price-Hill regimen used
• Ulcer with following features
- large amount of induration E. Palliative Treatment -
- bleeds on touch • Large fixed lymph nodes ➔ deep X-Ray
- everted • Failure of radiotherapy and surgery ➔ Cryo surgery
- may cross midline • ,.-Extreme pain due to advanced growth ➔ blocking of trigeminal nerve with 5% phenol
□ Investigations : 0.1,,:;/;;;assive blood transfusion
//
• Edge biopsy [,/· . MASSIVE BLOOD TRANSFUSION
• Indirect and direct laryngoscopy
• CT Scan □ What is it: Replacement/ transfusion of blood equivalent to patient's blood volume in 24 hour
·-------. -------·· . ---- " -·---~.,--. ---~·-··
··••'" '"'" ... ' .·-~ ,. ... ,_,,,__ ___ __ ... ......... .. ...., .. ,,.,,--~~"~" ..
,_ ,~,. , ,, , ,, , '" ., , ,; .. ..,_....,..........--.~~·-·-,.~---
,

• FNAC of lymph nodes □ Indications :

• Chest X-Ray • Severe trauma
• Orthopantomogram
• Primary hemorrhage
□ Treatment: □ Volume transfused:
A. Ancillary treatment - Adults ➔ 5 - 6 litres
• Mouth kept clean by antiseptic mouth wash Child~_~...Q.. ---~---85_[1~
• Antibiotic started after culture and sensitivity tests
□ Adverse effects :
• Treatment of caries tooth, gingivitis
• Coagulopathy
• Syphilis should be excluded
• Citrate toxicity
 SOLVED SHORT NOTES OF SEMESTERS 485
484 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
Frost-Bite
• ARDS FROST-BITE
• Infection
• Poor oxygen delivery What is it : Medical condition where localised damage is caused to skin & other tissues due to freezing
• Hypothermia Initial stages called: Frost nip
• Hypocalcaemia_
Sites:
• Hyperkalaemi."1
Farthest from heart
• Acidosis •
• Those with large exposed areas
Q.19: Blood fractions
C/F:
BLOOD FRACTIONS • First Degree ► Called frost nip
Name Preparation Storage Indications ► Affects surface of skin
► Initially itching and pain
• Packedcell Centrifuging whole blood @ 2000-3000g 1-6°C for • Chronic anaemia
for 15 mins 35 days • Oldage ► Then skin develops white, red, yellow patche and become numb.
• Children ► Long term insensitivity to both-heat & cold.

• Platelet rich plasma -do- • Burn , Second Degree ► Skin may freeze and harder.
• Hypovolemia
► Deep tissues not affected
• Severe protein loss
► Blisters 1-2 days after becoming frozen
• Human albumin (4.5%) Repeated fractionation of plasma 4°C Several cirrhosis
Edema( ► Heal in 1 month
months
nephrotic syndrome ► Area become insensitive to both hot and cold.
(Used as volume expander)
• Third and foruth Degree
• Fresh frozen plasma Fresh plasma rapidly frozen (contains clot- -40°C for • Severe liver disease
► Muscle, tendons, blood vessels, nerves all freeze
(FFP) ting factors) 2 years • DIC
• Congenital clotting factor ► Skin hard, waxy
[1 unit FFP = 3% rise in clotting factors]
deficiency ► Use of area temporarily lost
• Following warfarin therapy ► Loss of sensation due to nerve damage
• Cryoprecipitate Visible white supernatant fluid when FFP --do- • Haemophilia A ► Fingers and toes may be amputed if area becomes gangrenous
thawed at 4°C (factor VIII+ Fibrinogen) • Von Willebrand's disease ► May fall ('lff if untreated.
• Fibrinogen Organic liquid fractionation of plasma Dried form • DIC
• Afibrinogenaemia □ Causes:
• Platelet concentrate • Thrombocytopenia • Wet clothes
Centrifugation of platelet rich plasma
• Drug induced hemorrhage • Atmosphere temperature below freezing point
• Prothrombin complex From pooled plasma which contains fac- • Reversal of warfarin over• • Inadequate clothing
concentrate tors II, IX, X dose
• Cramped positions
Q.20 : Causes of Buttock swelling • Extreme cold
• Medication
CAUSES OF BUTTOCK SWELLING • Exposure to liquid nitrogen and other cryogenic liquids
• Tight clothing or boots
□ Buttock injury
□ Fracture □ Risk factors :
□ Hematoma • DM
□ Abscess (See Short Note --.- lschiorectal Abscess) • Peripheral neuropathy
□ Scar tissue • Use of beta blockers
□ Malignancy □ Treatment :
□ Sebaceous cyst (See Short Note - Sebaceous cyst)
• Patient shifted to warm environment
□ Lipoma (See Short Note - Lipoma)
• Passive warming
□ Insect bite
□ Arteriovenous fistula involving lower limb
486 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 487

• Active warming ➔ immersing injured tissue in water bath Varieties:

• Warm clothing • Encapsulated
• Splinting and / or wrapping frostbitten extremities • Diffuse (Pseudolipoma)
• Debridement and / or amputation of necrotic tissue is usually delayed • Multiple
"Frozen in January, amputate in July" □ Clasification based on :
Q.22 : Tendon transfer • Site
► Subcutaneous
TENDON TRANSFER ► Submucosal
□ What is it: Transfer of one tendon from its existing site to another site where its function is required at ► Subserosal
the newer site ► Subsynovial
► Subperiosteal
□ Indications :
► Subfascial
• Ulnar, median, radial nerve, spinal cord injury causing muscle paralysis ► Intraarticular
• CNS disorders - CP, CVA, Spinal muscle atrophy ► Intramuscular
• Hypoplastic thumb ► lntermuscular
• Birth brachia! plexopathy ► Extradural
□ Procedure : • Content
Origin of muscle, nerve supply, blood supply left in place ► Neurolipoma (painful lipoma contains nerve tissue)
► Naevolipoma (lipoma contains excessive vascularity)
t ► Fibrolipoma (lipoma contains fibrous tissue)
Tendon insertion detached and re-inserted into the required site
□ Clinical features :
□ Requisites :
• Age - Any age
• Tendon should be able to acquire the function at newer site • Swelling with following features -
• Function of transferred tendon should be maintained by other tendons ► Lobulated, smooth
□ Complications : ► Painless
• Infection ► Non-tender
• Hemorrhage ► Overlying skin free
► No increased temperature
• Surgical scar
► Edge soft, compressible ("slip" sign)
• Splint / cast immobilisation
► Semifluctuant (as fat in body temperature remains in serniliquid condition)
□ Example:
► Trans illumination test may be positive (even though it is not a cyst)
Ulnar claw hand ► Freely mobile over deeper structures
(Tendon of Flexor digitorum superficialis ➔ lumbrical canal of digits) □ Complications :
Q.23 : Ubiquitus tumor or Universal tumor or Lipoma • Myxomatous changes
• Liposarcoma
UBIQUITOUS TUMOR • Calcification
OR • Saponification
UNIVERSAL TUMOR OR LIPOMA □ Treatment:
Excision (Enucleation)
□ What is it: Benign tumor arising from yellow fat cells
Q.24 : lnvertogram
□ Site : Can occur anywhere except brain (hence the name) but commonly subcutaneous tissue of-
• trunk INVERTOGRAM
• nape of neck
See Section - 1, Segment - C, Paper-I, 2013, 0.4 "ARM" - [Page 303]
• limbs
□ Purpose : Used to investigate extent of defect in anal or rectal atresia.
□ Speciality : Commonest benign tumor
488 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 489

□ Procedure : Anus is marked with a radioopaque marker ➔ baby inverted ➔ lateral radiograph taken • Often painful!
□ Inference : Air in rectum rises to highest point, indicating extent of atresia • Accompanied by involuntary straining
□ Differential diagnosis:
Q.25 : Barrett's esophagus
• Crohn's disease
BARRETT'S ESOPHAGUS • Ulcerative colitis
□ Synonym : Columnar epithelium lined lower oesophagus (CELLO) • Rectal abscess
□ What is it: Metaplasia in mucosa of lower part of oesophagus due to GERD
• Colon cancer
• Colonic infection
□ Pathology : Normal stratified squamous epithelium lining replaced by simple columnar epithelium
with goblet cells.
• Irritable bowel syndrome
• Coeliac disease
□ Site : Lower part of oesophagus • Pelvic floor dysfunction
□ Speciality : Prone to malignant transformation • Infection - Shigellosis, amoebiasis
□ Types: □ Treatment :
• Long segment ➔ > 3 cm • Treatment of causes
• Short segment ➔ < 3 cm • Methadone
□ Histological classification :
• Intestinal ➔ contains goblet cells
ANDI
• Junctional ➔ contains mucus glands
• Gastric ➔ contains parietal cells, chief cells □ Full from : Aberrations of Normal Development and Involutions of the breast
□ Clinical features : □ What is it: Includes varierty of benign breast disorders occur.r:i!}g__atdifferent periods of reproductive
p_~!iods in females. -
• Heartburn
□ Aetiology:
• Fatty dyspepsia
• Epigastric pain • Relative hyperoestrogenism
• Regurgitation - due to (i) in~r~_ased oestrogen secretion gs)
(ii) deficient progesterone production (S)
• Nocturnal reflux
• Dysphagia • Abnormal prolactin secretion ·---
• Hematemesis • Inadequate essential fatty acid intake

□ Complications : • Excessive caffeine ingestion

• Oysphagia • Psychonecrosis 7 ?
• Hemorrhage Age Aberration Diseased status
• Ulceration Early reproductive 1. Fibroadenoma Giant fibroadenoma (> 5 cm)
• Stricture age (15-25 yrs.) 2. Juvenile hypertrophy of stroma Multiple fibro-adenosis
• Adenocarcinoma of O-G junction
Mature reproductive Generalised enlargement due to raised Fibrocystadenosis
□ Treatment : age (25-40 yrs.) hormonal effect
• Endoscopic mucosa! resection and biopsy
Involution age A. Lobular involution Cystic disease of breast
• PPI (40-55 yrs.) Macrocysts
• Antireflux surgery for GERO
B. Ductal involution • Periductal mastitis
• Argon beam coagulation • Ductal dilatation • Non-lactational abscess
• Laser ablation • Nipple discharge • Mammary duct fistula
Q.26 : Tenesmus • Bacterial infection
C. Epithelial involution
TENESMUS Epithelial hyperplasia and atypia
□ What is it: Feeling of incomplete defaecation □ Pathology:
□ Clinical features : • Gross ➔ ► Rubbery consistency
• Inability/ difficulty to empty bowel even if bowel contents have already been evacuated ► While or yellow areas on section

62
490 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 491

□ Histopathology: • Corticosteroid therapy

• Hyperaldosteronism
• Fibrosis ·----
• Low protein intake
• Cysts
• Administration of hypertonic fluids-mannitol
• Hyperplasia -
• Papillomatosis Cause: Compromised regulatory mechanisms for sodium handling resulting in high total body sodium
and a consequent increase in extracellular body weight
□ Variant - Sclerosing adenosis
□ Clinical features : □ Clinical features :
• Mastalgia - Cyclical
• Gain in weight

- Non-cyclical
• Ascites

• Breast lump with following features -

• Dyspnoea

► Multiple ___,/
• Pedal edema
• Bounding pulse
► Nodular./
• Audible 83
► Inseparable among themselves,_____,.,.-
• Hypertension
► Easily movable within breast ,_.,.,,.
• CVP raised
► More obvious when examined between thumb and fingers _,/-
• Distended JVP
► Not adherent to pectoral fascia or skin _.-
• Oliguria, azotemia
□ Complication :
□ Treatment:
• Epithelial hyperplasia may lead to carcinoma • Diuretics
□ Treatment : • Vasodilators

A) Cyclical mastalgia - • Ultrafiltration

• Assurance • Oral vasopressin antagonists

• Breast support • Adenosine A-1 receptor antagonists

• Tab Danazol 200 - 400 mg daily
• Bromocriptine
• Tamoxifen
• Medroxyprogesterone
B) Non-cyclical mastalgia -
• Non-steroidal analgesics
• Local anaesthetic injection
C) Surgery if (Excision biopsy)
Q.28 : Volume overload
□ Synonym : Hypervolaemia
□ What is it: Excess fluid in blood
□ Conditions :
• Congestive cardiac failure
• Liver failure
• Kidney failure
• Excessive intake of sodium
• Monitor fluid input-output
]
• Dialysis for acute cases
for 3 months
Q.29 : Osteogenesis imperfecta
OSTEOGENESIS IMPERFECTA
□ Synonym:
• Brittle bone disease
➔ a) Failure of conservative management • Lobstein syndrome
b) Intolerable pain □ What is it: Congenital bone disorder characterised by brittle bones that are prone to fracture
c) Swelling persists inspite of conservative treatment □ Defect: Deficiency of Type-I collagen resulting in defective connective tissue
□ Genetic mutation : COL 1A 1 and COL 1A2 genes
□ Types: 8
VOLUME OVERLOAD □ Clinical features :
• Bones fracture easily
• Loose joints
• Poor muscle tone
• Slight spinal curvature
• Slight protrusion of eyes
• Blue grey sclera
• Early loss of hearing
• Dentinogenesis imperfecta (present in IB)
492 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

SOLVED SHORT NOTES OF SEMESTERS 493

□ Complications :
• Respiratory failure Features of malignancy:
• lntracerebral hemorrhage • Hemorrhage
□ Diagnosis : • High Ki-67 positive cell
• Skin biopsy • Necrosis
• DNA testing • Nuclear DNA ploidy
• Prenatal diagnosis by amniocentesis (raised inorganic pyrophosphate) • High PASS (Phaeochromocytoma of Adrenal gland Scale Score)
□ Treatment: (No cure) • Capsular and vascular invasion
• Bisphosphonate • High neuron specific enolase (NSE)
• Surgical correction of bones
□ Clinical features :
• Antibiotics
• Physiotherapy
• Severe headache
• Dyspnoea
□ Differential diagnosis : • Weakness
• Rickets • Pallor
• Child abuse • Persistent or paroxysmal hypertension
• Osteomalacia • Blurred vision
Q.30 : 10 percent tumor • Abdominal mass -
(a) Smooth
10 PERCENT TUMOR (b) Cross midline
□ Synonym : Phaeochromocytoma (c) Not move with respiration
• (d) Non-mobile
□ What is it: Tumor arising from chromaffin cells
(e) Palpitation may cause fluctuation in blood pressure
□ Pathology:
□ Associated with :
• Adrenal medulla (commonest)
• MEN Ila or MEN lib
• Extradural chromaffin tissue (organ of zuckerkandl)
• Renal cell carcinoma
• Bladder
• Von-Recklinghausen disease
□ Nature:
• Von-Hippe! Lindau disease
• Soft brownish-grey-pink tumor
• CNS and retinal haemangioblastoma
• Secretes the following :
□ Investigations :
(a) Norepinephrine or other catecholamines
• IVU
(b) VIP
• Urinary 24 hour VMA excretion greater than 7 mg%
(c) Calcitonin
• USG Abdomen
(d) ACTH
(e) PTH related polypeptide • MRI
• CT Scan
□ Types:
• Benign (90%) • Arteriography
• Malignant (10%) • MIBG
□ Why called '1 Opercent' tumor: □ Treatment :
• 10% familial BP controlled by a-blocker
• 10% childhood J,
• 10% multiple ~-blocker
• 10% bilateral J,
• 10% malignant Adrenalectomy (with sodium nitroprusside i.v. infusion)
• 10% extradural J,
• 10% calcified Specimen sent for dichromate staining which stains the specimen brown
• 10% not associated with hypertension
494 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 495

Q.31 Whipple's Triad ► Proinsulin level > 24% of total insulin

□ What is it: Characteristic of insulinoma
□ Triad:
Attack of hyperglycaemia with
serum blood sugar below
50 mg/di
► C-peptide level raised (> 1.2 µg/ml) + glucose level <AO mg%
WHIPPLE'S TRIAD MRI - To localise tumor
•
• Coeliac angiogram
• Insulin provocation test
• Endosonography
Attacks consist Attacks promptly relieved Treatment:
+ + by feeding or parenteral
principally of • Enucleation
~ J, \,i administration of glucose • Control hypoglycaemia - Diazoxide, betablockers, phenytoin
Stupor Confusion loss of • Octreotide - To reduce insulin secretion
and are related to
consciousness • Calcium channel blockers
fasting and exercise • Streptozotocin
Q.32 : Post operative pulmonary complications

□ What is insulinoma : POST OPERATIVE PULMONARY COMPLICATIONS

• Insulin producing adenoma of ~ cell
O Risk factors:
□ Speciality: • Age - Extremes
• Commonest Islet cell tumor • Sex - Male
• Lifestyle ~ Smokers, obesity
□ Age:
• Chronic diseases - Asthma, TB, COPD, chronic bronchitis
• > 45 years • Type of surgery - thoracic and upper abdominal surgeries
□ Site : • Operative complications - Anaesthetic complications, aspiration, etc
• Post-operative problems - Septicaemia, DVT, pulmonary embolism
• Equal distribution in head, tail and body of pancreas
□ Pulmonary complications :
□ Pathology:
• Bronchitis
• Encapsulated, firm, yellow-brown nodules
• 70% solitary, 10% multiple
• Bronchopneumonia
• Lung abscess
□ Clinical features : • Lung collapse
• Abdominal discomfort • Alkalosis
•
•
•
•
!:::~:~s ]
Hunger
. .
due to release of epinephrine
caused by hypoglycaemia
•
•
Pleural effusion/empyema
ARDS
Respiratory failure
□ Investigations :
• Trembling
• Tachycardia • Chest X-Ray
• Weight gain (due to over eating) • Arterial blood gas analysis
• Permanent neurologic deficit □ Treatment :
• Cerebral symptoms - (due to slower decrease in blood sugar) • Suction-aspiration of tracheobronchial secretions
- Headache • Ventilator support with endotracheal intubation
- Convulsion • Tracheostomy
- Coma • Res iratory physiotherapy
- Visual disturbance t ·otics
- Mental confusion omplications of Blood Transfusion
□ Investigations :
COMPLICATIONS OF BLOOD TRANSFUSION
• Insulin radioimmunoassay
► Increase in plasma insulin level (> 7µ U/ml) (A) Transfusion reactions :
► Insulin-glucose ratio > 0.3 • Incompatibility- (most important)
496 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 497

► Causes are ➔ (a) Incompatible transfusion • Haemoglobinurea on urine analysis

• Indirect Coomb's test positive
(b) Transfusion of blood after expiry date
• Prolonged prothrombin time
(c) Transfusion of blood already ·haemolysed by shaking, over-freezing or
• Reduced fibrinogen level
heating
• Raised serum lactate dehydrogenase
► This occurs mainly due to -
• Raised blood urea nitrogen
(a) Negligence in looking at label of blood bottle and matching it with • Raised serum creatinine
requisition paper
Clinical findings :
(b) imperfect grouping and cross - matching
• Pyrexial reaction - • Fever + rigor

► Causes are - (a) Improperly sterilized transfusion sets

• Headache

(b) Transfusion of infected blood

• Nausea, vomit

(c) Presence of 'pyrogens' in donor apparatus

• Pain in loin

(d) Very rapid transfusion of blood

• Tingling sensation in extremities

• Allergic reaction -
• Dyspnoea
• Diminished urine output
Occurs due to allergic reaction to plasma product in donor's blood
• Jaundice
• Immunological sensitisation - • Renal failure features
This occurs in patients who have received blood transfusion in recent past,. occurring due to □ Treatment :
development of antibodies against white blood cells and platelets.
• Immediate halt of transfusion
(B) Transmission of diseases : • Bed rest
• Bacterial - (1) Syphilis; (2) Yersinia • Fresh specimen of blood and urine to be sent to laboratory along with rejected bottle of blood
• Viral - (1) Serum hepatitis; (2) HBV, HCV; (3) HIV; (4) CMV; (5) EBV • Transfer to ICCU
• Parasite - (1) T-cruzi; (2) Malaria • Moist oxygen inhalation @ 4 IVmin
(C) Reactions due to massive transfusion : • CVP line done
• Due to transfusion components - • i-v fluid infusion
► Acid-base imbalance (metabolic alkalosis, as most of the citrate present as sodium citrate, • 10 ml of isotonic solution of sodium lactate + 1O ml of saturated solution of sodium bicarbonate
becomes sodium bicarbonate when citrate is consumed) injected intravenously
► Iron overload • Diuretics ➔ furosemide i.v.

► Haemochromatosis • Mannitol injected i.v.

► Hyperkalaemia (due to shift of potassium out of RBC because of low temperature of storage) • Antipyretics and analgesics
► Citrate intoxication • Corticosteroids (Hydrocortisone 100 mg i. v.)
• Epinephrine (for anaphylaxis)
• Hypothermia -
• Diphenhydramine (to treat urticaria)
(as in emergency conditions, blood is rushed directly from refrigerator to patient)
• Vasopressors (to maintain SBP)
• Coagulation failure - • Dialysis in extreme cases
Caused by - (a) DIC; (b) Dilutional thrombocytopenia; (c) Dilution of clotting factors
0.35 : Myopectineal orifice
(D) Complications of over-transfusion :
Congestive cardiac failure (mainly occurs in whole blood translusion given to chronic anaemic patients) MYOPECTINEAL ORIFICE
(E) Complications of intravenous fluid administration:
□ Importance : Site of indirect, direct inguinal, femoral and some interstitial hernias
(a) Air embolism; (b) Thrombophlebitis
□ Function:
Q.34 : Mismatched blood transfusion - management
• Passageway for testicle to reach scrotum
MISMATCHED BLOOD TRANSFUSION - MANAGEMENT • Passageway for the great vessels to lower exremity
□ Boundary:
□ Investigatory findings :
• Medially ➔ Lateral border of rectus muscle
• Reduced haemoglobin
• Laterally ➔ iliopsoas
• Raised serum bilirubin, indirect bilirubin

63
 498 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 499

• Superiorly ➔ Arching fibres of transversus abdominis and internal oblique • Cough impulse present (Morrissey's cough impulse)
• Inferiorly ➔ Cooper ligament • Venous hum audible on auscultation
□ Protected by : Associated with :
Combined lamina of the aponeurosis of transversus abdominis and the fascia transversalis • Varicose veins
□ Divided by: Investigations :
Anteriorly ➔ Inguinal ligament • USG
Posteriorly ➔ lllopubic tract • Duplex scan
□ Perforated by : Treatment:
Superior part ➔ Spermatic cord • Juxtafemoral flush ligation of saphenous vein + below knee stripping of the vein
Inferior part ➔ Femoral vessels O Differential diagnosis:
Q.36 : Isometric exercise • Groin lump causes like femoral hernia
Q.38: Blood component therapy
ISOMETRIC EXERCISE
□ Synonym : Isometrics BLOOD COMPONENT THERAPY
□ What is it: Type of strength training in which the joint angle and muscle length do not change during See Section - 1, Segment - D, Os. 19 "Blood Fractions" (Page No. 484)
contraction
□ Position during exercise : Static
Q.39 : Treatment of hypercalcemic crisis in a patient of hypothyroidism.
□ Types: TREATMENT OF HYPERCALCEMIC CRISIS IN A PATIENT OF HYPOTHYROIDISM
• Overcoming isometric - Joint and muscle work against an immovable object • Admission in ICCU
• Yielding isometric - Joint and muscle are held in a static position while opposed by resistance
• Immediate sedation using Morphine/Pethidine
□ Resistance in isometric exercise : • Moist oxygen inhalation
• Body's own structure and ground • i.v. fluid administration
• Free weights, weight machine • Control of hyperpyrexia - Tepid sponging/ice pack
• Structural items • Tab propylthiouracil
• Pressure-plate type equipment 600 mg stat ➔ 200 mg 8 hourly daily
□ Medical uses : OR
Tab Carbimazole
• To detect heart murmurs - Murmur of MR gets louder as compared to murmur of AS
60 mg stat ➔ 20 mg 8 hourly daily
• To prevent disuse syndrome
• Prevent muscle atrophy experienced by astronauts living in zero gravity • Potassium iodide - 5 drops 6 hourly
□ Comparison with dynamic exercise :
• Tab Dexamethasone - 2 mg 6 hourly i.v .
• Tab Propranolol - 2 mg i.v. 4 hourly (to control tachycardia)
• Isometric exercise increases strength at specific joint angles of the exercises performed and
additional joint angles to a lesser extent
• Tab Diazepam - 10 mg/tab - 1 tab twice daily
Tab Digitalis (to control atrial fibrillation)
• Dyn;amic exercise increases strength throughout the full range of motion
• Antibiotics
r7·;,,,.ia~hena varix
'./' · ,",,, SAPHENA VARIX Q.t. ~ii~-~lsease HIRSCHPRUNG'S DISEASE

□ Synonym : Saphenous varix □ Synonym : Primary megacolon

□ What is it : Dilation of saphenous vein at the saphenofemoral junction in the groin
□ What is it : Congenital condition occuring in newborn, mostly leading to intestinal obstruction
□ Cause: Valvular incompetence □ Pathogenesis : Gene mutation in Chromosome 1O, rarely 13
□ Clinical features : j,
• Bluish tinge Failurnof_n:,Jgration of neuroblasts from the vagal nerve trunks
• Soft, compressible □ Aetiology: Absence of ganglionic cells of pel~ic para-sympathetic system in Auerbach's plexus and
• Disappears on lying down Meissner's plexus
500 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 501

□ Sites Involved: After patient attains 1O kg weight, definite procedure done -

• (a) excision of aganglionic segment
• Anus
• Rectum (b) coloanal anastomosis
• Internal sphincter (c) closure of colostomy
[Procedures used -
□ Zones: [See Fig. 1.7.4]
► Soave's mucosectomy
□ Types:
► Modified Swenson's operation
• Ultrashort segment ➔ Anal canal + terminal rectum ► Modified Duhammel operation]
• Short segment (most common) ➔ Anal canal+ rectum
• Long segment ➔ Anal canal + rectum + part of colon 0.41: Neurogenic bladder
• Total colonic ➔ Anal canal +rectum+ full length of colon NEUROGENIC BLADDER
• Segmental ➔ Skip areas involved
See Sec- 2, Group -1, 2008, 0.6, "Bladder problems in Spinal Paraplegia". (Page No. 624-625)
□ Clinical features : _,,,,,,-.. ,_,--···-
• Common in males a ~ cyst
• More in infants
CHOLEDOCHAL CYST
• Constipation -
a) Newborn fails to pass meconium even after 3 days O What is it: Cong_enital ~tic enlargement of CBD
.....--- - "--···-" - - - - - ,_ ___:;c._ _ " " - - --~--·-··--·~-

b) Goat-pellet like stool in children 0 Todani Classification :

"·
(,.,..---.._ ...
c) On introducing finger into rectum to pass meconium, child passes toothpaste like stool with Type I (60%) - Dilatation of extrahepatic CBD ,~____--.
straining Subtype a ➔ cystic dilatation
• Abdominal distension - Subtype b ➔ focal dilatation
a) Becomes obvious by 3rd day
Subtype c ➔ fusiform dilatation
b} Visible peristalsis
Type II (5%) - Lateral saccular diverticulum of CBD
• Malnutrition
Type Ill (5%) - Dilatation of intraduodenal segment of CBD (choledochocele)
• DRE-
a) Tight sphincter Type IV (30%) -
b) Empty rectum Subtype a ➔ Dilatation of CBD and intrahepatic biliary dilatation
c) Child passes lot of gas and meconium Subtype b ➔ Multiple extraheptaic cysts
□ Investigations : Type V - Multiple intrahepatic cysts (Caroli's disease)
• Barium enema - Shows extent and the three zones □ Aetiology:
• Rectal biopsy - Absence of ganglionic cells • Localised perforation in bile duct
• Anorectal manometry • Distal obstruction and destruction of proximal duct epithelium by pancreatic juice when both bile
• Acetylcholine esterase staining duct and pancreatic duct open commonly at Ampulla of Valer
□ Complications : □ Sex predilection :
• Enterocolitis • F:M=4:1
• Intestinal obstruction □ Clinical features :
• Constipation • Classical triad -
• Perforation ► Recurrent attacks of right upper quadrant abdominal pain
• Septicaemia ► Slo-wTy progressingjaundice -
• Peritonitis ► Palpable abdominal mass which is soft, smooth, resonant, not mobile
□ Treatment : • Fever
• Colostomy □ Complications :
• Nutritional supplementation • Complete biliary obstruction
• Type Ill pancreatitis
502 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 503

• Biliary cirrhosis Complications :

• Cholangio carcinoma • Empyema gall bladder
• CBD stone, GB stone • Pseudomyxoma peritonei
□ Investigations: Q.44 : Cholesterosis
• Intravenous cholangiography
• USG
CHOLESTEROSIS
• Hepatobiliary nuclide scanning □ Synonym·: Strawberry gall bladder
• CT Scan - To see intrahepatic biliary system □ What is it: A type of cholecystoses i.e., a chronic inflammatory condition of gall bladder with cholesterol
• ERCP deposits
• MRCP □ Pathology: Red mucosa of gall bladder studded with minute yellow flecks giving a typical picture of
• LFT ripe strawberry
□ Treatment: □ Pathogenesis : Distension of mucosal folds with aggregation of round and polyhedral histiocytes
(foamy cells phagocytose cholesterol)
~olecystectomy in all types -
Type I ➔ Excision of cyst + Roux-en-y hepaticojejunostomy Deposits become more massive
Type II ➔ Excision of diverticulum + suturing of CBD 1,
Type Ill ➔ Endoscopic sphincterotomy Cells die with release of lipids
1,
Type !Va ➔ Liver transplantation
Precipitation of cholesterol crystals in sub-epithelial region
Type IVb ➔ Liver segmental resection
□ Aetiology:
Type V ➔ Liver transplantation
• Excessive absorption of cholesterol from bile by epithelial cells of gall bladder
Q.43 : Mucocele of Gall bladder • Lymphatic & venous stasis predispose to accumulation of cholesterol absorbed from bile contents
• Failure of mucosa to secrete cholesterol results in abnormal deposition of cholesterol within
MUCOCELE OF GALL BLADDER
mucosa and submucosa
□ What is it: Gall bladder distended with mucus □ Clinical features :
□ Pathogenesis : Obstruction of cystic duct by stone in Hartmann's pouch, without infection in gall • Assymptomatic
bladder □ Investigations :
1, • USG Abdomen
Absorption of bile and secretion of mucus into gall bladder by its wall
• Isotope study
□ Content: Sterile mucus
□ Treatment :
□ Clinical features : • Cholecystectomy
• Swelling in right hypochondrium with following features -
□ Complications :
► Painless
• Infection
► Smooth
• Precipitate stone formation
► Soft
• Premalignant condition
► Non-tender
►
►
Globular
Palpable lateral and lower borders of gall bladder, upper border not well-defined
~-1~:~verticulum c::-:::!:
MECKEL'S DIVERTIC~LUM)
• Dyspepsia
□ Investigations : □ What is it: Congenital diverticulum arising from terminal ileum 9ue to unobliterated proximal p(')rt_~_n
of vitellointestinal duct ----
• LFT
• USG abdomen □ Occurence :

□ Treatment : • M> F
• Cholecystectomy • Primarily in children
Ii
i

504 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 505
\Z~:~:,/
□ Features: Q.46: Preparation for large bowel surgery
• Present in ?._!~c,J?.1!!.a,.!iQn
• Po~sesses mesentry like mesoappendix PREPARATION FOR LARGE BOWEL SURGERY
• Contains heterotopic ee ithelium like gastric, colonic and rarely pancreatic tissue in 20% cases Indications :
• Contains all 3_Jayers of bowel, hence it is a true dl~um
• Carcinoma colon
□

□
. Length:

Site:
~-
• Carcinoma rectum
• Anorectal malformations
• Megacolon
• 2 feet from ileocaecal valve, on antimesenteric bo_r~_!:!r of_ileum • Familial adenomatous polyposis
□ Blood supply:
• Dive rticu Iitis
• Before colonoscopy
• lndeQ.._ende!l!_~lood supply from a blood vessel arising from terminal branch of superior mesent~ric • Before colostomy closure
~ □ Preparation :
□ Clinical features : • Diet:
• Ass~r:nptomatic unless complications oc~ur Low residue diet for 2-3 days before surgery/procedure
□ Complications: (BLIND+ P 2 ) j,
~ -
1) Bleeding - maroon coloured blood along with dark red clots via rectum, due to peptic ulceration, Clear liquid diet on day before surgery/procedure
produced by secretion of acid-pepsin by ectopic gastric mucosa j,
2) Littre's hernia - Meckel's diverticulum present as a content in hernial sac Empty stomach on day of surgery
3) Intestinal obstruction : • Bowel wash :
a) Obstruction occurs around a band running from tip of diverticulum to umbilicus For 2-3 days before surgery using 1-2 lit of normal saline
b) lntussusception due to swollen, inflammed heterotopic epithelium at mouth of diverticulum • Osmotic catharsis :
4) Neoplasm - GIST/Carcinoid 200 ml oral mannitol for 2-3 days prior to surgery
5) Diverticulitis - Inflammation of Meckel's diverticulum due to lodgement of food residues within it OR
6) Peptic ulceration - Due to ectopic gastric mucosa
Single dose of oral Polyethylene Glycol dissolved in 2 lit of water and drunk on day before
7) Perforation surgery
□ Investigation : • Total gut irritation :
• Technetium (T99m) radioisotope scan
Ryle's tube passed beyond D-J flexure
• X-Ray abdomen ------ -- . --.i:-··
• Barium meal follow through
Patient sits on comode/couch
• CT Scan
j,
□ Treatment :
N.S. passed through tube @ 2-3 lit/hour
• If assymptomatic, left alone
j,
• If found during laparotomy
Once clear fluid passes rectum, wash should be continued for further 1 hour
j,
If narrow mouthed with thickened wall (Total 8-9 lit N.S reqd.)
j, • Elemental diet :
Surgery Pre-digested food which gets absorbed by termina+ileum and leaves no residue, thereby rendering
If - a) Base narrow an empty colon - taken for 3-5 days before surgery
b) Adhesions present 0,47: fatnllial adenomatous polyposis
c) < 2 years age
d) Complications present, FAMILIAL ADENOMATOUS POLYPOSIS
Excision of Meckel's diverticulum along with its base and a short segment of ileum followed by
end to end anastomosis
.□ What is it: Neoplastic polyp of colon
□ Speciality: Pre-malignant condition

64
 506 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 507

□ Age : Adolescents B) Microscopy -

□ Sex predilection : M = F lntracanalicular variety Pericanalicular variety
□ Genetics : Inherited as autosomal dominant neoplastic chromosome (Chromosome no. 5)
• Glandular proliferation • Fibrous tissue proliferation
□ Number : Multiple
• Large • Small
□ Site : Mainly large intestine, rarely small intestine and stomach • Soft • Hard
□ Associated conditions : • Duct distorted • Normal duct
• Gardner's syndrome (Desmoid tumor, osteoma, epidermoid cyst)
□ Age:
• Turcot's syndrome (FAP + brain tumor)
• 15-25 years (pericanalicular variety - common) ~
• Duodenal or ampullary carcinoma
• 30-50 years (intracanalicular vari~ty) - - -
□ Pathology:
□ Clinical features :
• Conglomeration of multiple polyps
• Lump in breast with following features :
• Tubular adenoma
► Painless•----
□ Clinical features : ► Smooth
• Assymptomatic ► Solitary
• Loose stool with blood and mucus ► Slowly growing
• "Trilefmmenl lower abdominai-p~in ► More often in lower part of breast
• Anorexia, weight loss ► Freely mobile ("breast mouse")
• Anaemia ► round margin - well circumscribed
□ Investigations : ► Firm in consistency
• Double contrast barium en~l'J'la • No nipple discharge
• Sigmoidoscopy/colonos9.gpy followed by biopsy • No axillary lymph node involvement
/-~-~-----------· □ Investigation :
□ Screening :
• USG(< 30 years) or Mammography (if> 30 years)
For all family members :
• FNAC
• DNA tests for FAP
□ Treatment :
• Pigment spots in retina (CHIRPES)
• Pericanalicular variety - Enucleation
□ Treatment :
• lntracanalicular variety - Enucleation not possible, hence excision
Protocolectomy
vv~"-. . . . ___._._/'.,., ,. .+__ lleoanal
.,. ,. , ,_, . ,.,.,. ., , .anastomosis
., ,~.,., ,.. . ..,.....,_,,,,.~. . . . with ileal pouch
~
(Periareolar or submammary incision given)
OR
Q.49: Phy/lode's tumor
Cons_erva~-~--t_gtaj._9-9.l~y + lleorectal anastomosis+ Regular follow-up (if present on follow up,
· · snaring of polyps) + S u ~ d a i l y or Aspirin 325 mg once daily I
PHYLLODE'S TUMOR

~oadenoma □ Synonyms : \.____../

• Phyllode's sarcoma
FIBROADENOMA • Cystosarcoma phyllodes
□ What is it: _I?enign encapsulated breast tumor containing both glandular and fibrous tissue • Benign cystosarcoma
□ Origin : ANDI of a single lobule • Serocystic disease of Brodie
□ Naming: Phyllodes is a Greek word which means "leaf-like" - name given due to leaf-like projections
□ Speciality: Common~§.UJ~!Ji_gn tumor of female breast
of the tumor
□ Aetiology : Increased sensitivity of a focal area of breast to oestrogen
□ What is it: Benign breast tumor which can be locally aggressive and sometimes metastatic
□ Pathology: □ Pathology:
A) Gross- A) Gross-
• Soft • Capsulated
• Hard • Very enlarged
• Giant (> 5 cm) • With cystic spaces
508 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 509

B) Microscopy - No - No nodal involvement

• Cystic spaces with leaf-like projections N1 - Axillary node involved - ipsilateral, mobile, discrete
• Hypercellularity and pleomorphism N2-
□ Age: N2a - Axillary node involved - ipsilateral, fixed to one another and other structures
• Premenopausal women around 40 years of age N2b - lpsilateral inframammary node involved without ipsilateral axillary
□ Spread: N3-
• Via blood to lung and bone N3a - lpsilateral infraclavicular node involved with/without ipsilateral axillary
□ Clinical features : N3b - lpsilateral inframammary node involved with ipsilateral axillary
N3c - lpsilateral supraclavicular node involved with/without ipsilateral axillary
• Swelling in breast with following features :
► Highly enlarged Mo - No metastasis
► Smooth M1 - Distant metastasis
► Firm and soft at places □ Stages:
► Non-tender I - T1N0Mo
►
►
►
Fluctuant
Overlying skin tense, with venous prominence
Not fixed to skin or deeper structures
Early invasive
carcinoma [ Ila -T 0N1Mo,T1N1Mo,T2N0Mo
llb - T 2N1Mo, T 3No, Mo

[
• No axillary lymph node involvement Illa - T 0N2Mo, T1N2Mo, T2N2Mo
Locally advan-
• No retraction of nipple or nipple discharge ced carcinoma lllb ~ T3N1Mo, T3N2Mo
□ Investigations : Ille - T4N 0 Mo, T4N1 Mo, T4N2Mo
• Mammography Distant spread [ IV - Any T, Any N, M1
• FNAC
• Chest X-Ray (to look for secondaries) Q.51 : Etiologic factors In development of b r ~ o m a
□ Treatment :
ETIOLOGIC FACTORS IN DEViLOPMENT OF BREAST CARCINOMA
• Smaller ones ➔ simple enucleation
• Older patients ➔ wider excision with 1 cm margin of normal breast tissue □ AgtJ:
• If malignant ➔ total mastectomy
• Increased risk with increasing age
Q.50: Stages of CA breast □ Gender:
ST AGES OF CA BREAST • F > M (150 : 1)
□ Country of birth :
TNM Staging of Breast Carcinoma
• West>> Far East
T O - No evidence of primary • Migrants assume risk of host community with 2 generations
Tis - Carcinoma-in-situ • Less industrialised nations have low rates
Tis pagets - Paget's disease of nipple with no tumor
□ Family History :
T 1 - Tumor size< 2 cm • 2-3 fold increased risk in 1st degree relatives of patient with breast carcinoma (mother, sister,
T1a - 0.1-0.5cm daughter)
T 1b - 0.5-1 cm • Risk gets reduced with distant relative
T 1c - 1-2 cm • Risk increased if 1st degree relative had bilateral carcinoma
T 2 - Tumor size 2-5 cm • Risk increased if history of ovarian cancer
T 3 - Tumor size > 5 cm
□ Genetic Factors :
T 4 - Fixed to chest wall/skin
• BRCA 1 ➔ Breast CA
T4a - Fixed to chest wall
Ovarian CA
T 4b - Fixed to skin
• BACA 2 ➔ Breast CA in both sex
T4c - T 4a + T 4b
T4d - Inflammatory carcinoma Pancreas CA
51 o QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 511

Ovarian CA Adjuvant chemotherapy given to :

Prostate CA • All node positive carcinoma
Laryngeal CA • Node negative carcinoma if > 1 cm size
• Other associated hereditary syndromes : • Node negative CA > 0.5 cm with adverse prognostic factors :
► Li Fraumeni syndrome - p53 defect ► High nuclear grade
► Cowden's syndrome - PTEN defect
► High histologic grade
► HNPCC - MSH2, MLH1 defect
► Blood vessel or lymph vessel invasion
► Peutz Jegher's syndrome - LKB1 defect
► HER2/neu overexpression
□ Personal history : ► Negative hormone receptor status
• CA of contralateral breast □ Adjuvant hormone therapy (Tamoxifen) given to:
• Ovarian CA
• ER positive patients (ER - oestrogen receptor)
• Endometrial CA
□ Post-menopausal women:
□ Hormonal factors :
• Use is controversial
(Increased risk with increased exposure to endogenous oestrogen)
• Tamoxifen/Aromatase inhibitor is ideal
• Early menarche (< 12 years)
• Late menopause (> 55 years) □ Indications :
• Nulliparity • Inflammatory carcinoma
• Obesity • Advanced carcinoma breast as a palliative procedure
□ Late full term 1st pregnancy: • Stage IV carcinoma with secondaries in bone, liver
(Reduced risk with early child bearing and breast feeding) • Post-operative after simple mastectomy
> 30 years age increases risk • Pre-menopausal women with poorly differentiated tumor
□ Diet: Q Chemotherapy regimen :
• Alcohol GAF (Cyclophosphamide, Adriamycin, 5-Fluorouracil)
• High fat diet OR
□ Previous benign breast disease : CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil) - monthly/3 weekly cycles for 6 months
• Ductal involvement by cells of atypical ductal hyperplasia
□ Newer drugs :
• Moderate/Florid epitheliosis
• Taxanes (Paclitaxel, Docataxel)
• Atypical ductal/lobular hyperplasia
□ Neoadjuvant chemotherapy:
□ SES:
• Administration of adjuvant therapy before primary therapy (surgery or radiotherapy)
• High
• Down-stages the tumor
□ Irradiation :
• Makes large operable primary tumor amenable for conservative breast surgery
• Increases risk
□ HRT: Q.53 : Inflammatory carcinoma
Concomitant oestrogen and progesterone administration
INFLAMMATORY CARCINOMA
Q.52 : Adjuvant chemotherapy in breast carcinoma
□ Synonyms:
ADJUVANT CHEMOTHERAPY IN BREAST CARCINOMA • Lactating carcinoma
□ What is it: • Mastitis carcinomatosis
Use of systemic therapy {chemotherapy and/or hormone therapy) in patients who have received local □ Speciality: Most malignant type of CA breast
therapy but are al risk of relapse □ Pathogenesis : Cancer cells block lymph vessels in the skin of breast
□ Objective : □ Naming : As breast often looks swollen and red
Eliminate the occult metastasis responsible for late recurrences while they are microscopic and
D Stage : T 4d Nany Many
vulnerable to anticancer agents
512 QUEST: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 513

CJ Aetiology:
□ Age : 50 - 60 years
□ Additional features :
• Hormone receptor negative Aetiology
• Common in obese women
• Rapidly spreading
□ Spread: Chest wall, bone, lungs Physiological Pathological
□ Clinical features :
In newborn
• Swelling } affecting > 1/3rd of breast (due to maternal/placental oestrogen)
• Redness
• Skin - (i) Pink In adolescent
(due to plasma oestradiol reaching adult
(ii) Peau-de-orange
range before testosterone)
• Rapid increase in breast size
• Sensation of heavyness Of aging
• Burning sensation (decreasing testicular function, increasing
fatty tissue)
• Inverted nipple
• Swollen lymph nodes
□ Investigation
• FNAC Idiopathic
• Mammogram (commonest)
Drugs Absolute Oestrogen Excess
• PET scan
• Bone scan Estrogens Increased substrate for
E.g. : Diethylstibestrol peripheral aromatisation
□ Treatment
E.g. : • Thyrotoxicosis
Systemic chemotherapy + Radiotherapy Drugs inhibiting • Cirrhosis
(Neoadjuvant - Anthracycline, Taxanes testosterone synthesis
HRT - Tamoxifen, Letrozole) E.g : • Cimetidine
Increased testicular
• Ketoconazole
oestrogen secretion
Q.54 : Gynaecomastia Drugs enhancing E.g. : • Testicular tumor
oestrogen production • Bronchogenic
GYNAECOMASTIA E.g : • Clomiphen carcinoma
• Gonadotrophins
□ What is it : Hypertrophy of male breast more than usual due to increase in ductal and connective
Increased extraglandular
tissue elements often attaining features of female breast
Drugs acting by unknown aromatisation
□ Basic mechanism : Excess of oestrogen mechanism
E.g : • Busulfan
• CCB
Relative Oestrogen Excess

I
t
Congenital defects Other defects
E.g : • Anorchia E.g : • Viral orchitis
• Klinfelter's • Trauma
syndrome

6.5
 SOLVED SHORT NOTES OF SEMESTERS 515
514 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Clinical features :
□ Clinical features : • Age - Any
• Diffuse enlargement of breast • M= F
• Well-localised • Single or multiple nodules in thyroid
• Small • Diarrhea
• Firm or hard nodule under areola • Flushing
• Pain, tenderness may be present • Hypertension
□ Investigations : • Tracheal compression, dysphagia, hoarseness
• Cervical lymphadenopathy
• Relevant to cause
E.g.: LFT, Hormone assay, etc • Kidney stones
□ Investigations :
□ Treatment :
• FNAC - Amyloid deposition with dispersed malignant cells and C-cell hyperplasia
• Treatment of underlying cause
• Tumor marker - Raised calcitonin
• Drugs - Tamoxifen, Aromatase inhibitor
• USG abdomen
• Surgery - Mastectomy, Reduction mammoplasty
• USG neck
• Suction - Assisted lipectomy
• Urinary VMA, catecholamines, metanephrine
Q.55: Medullary carcinoma of thyroid • 111 Indium octreotide screening

□ Treatment :
MEDULLARY CARCINOMA OF THYROID
• Total thyroidectomy with central node dissection
□ Speciality: Uncommon type of thyroid malignancy • Neck lymph node block dissection if lymph node involved
□ Arises from : Parafollicular C-cells • No role of hormone therapy/radioactive iodine
□ Inheritance : Autosomal dominant • External beam radiotherapy for residual tumor
• Somatostatin/octreotide for diarrhea
□ Characteristic features :
• Associated phaeochromocytoma ➔ adrenalectomy
• Non-follicular histological appearance
t
• Origin from parafollicular C-cells
total thyroidectomy
• Secretion of calcitonin
• If MCT + Parathyroid hyperplasia in MEN IIA,
□ Pathology:
Total thyroidectomy
• Variable size - Central node dissection
• Composed of solid mass of cells, hence 'medullary'
- Total parathyroidectomy
• 'Amyloid stroma' wherein malignant cells are dispersed - Autotransplantation
• Presence of thyrocalcitonin granules
Q.56: Hashimoto's thyroiditis
□ Secretes:
• Calcitonin HASHIMOTO'S THYROIDITIS
• Serotonin □ Synonyms:
• Prostaglandin • Struma lymphomatosa
• VIP • Diffuse non-goitrous thyroiditis
• ACTH • Lymphadenoid goiter
□ Spread:
• Chronic lymphocytic thyroiditis
Initially lymph nodes of neck and superior mediastinum
~ t □ Speciality: Most common form of thyroiditis
Then lung, liver, adrenals, bone □ Aetiology:
t Autoimmune disease - Thyroid gland becomes sensitive to its own cell constituents
Advanced cases to trachea and oesophagus 4 autoantigens exist - a) Thyroid cell microsomes
□ Associated conditions : b) Thyroid cell nuclear component
c) Thyroglobulin
• MEN II syndrome
d) Non-thyroglobulin colloid
• Phaeochromocytoma
 516 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 517

□ Associated features : Prevention of simple goiter:

• Papillary carcinoma of thyroid • Endemic areas ➔ all table salts must contain iodide
• Pernicious ahaemia and autoimmune gastritis in family members
, Drug induced --, discontinuation of drug
□ Pathology: • Prevention of consumption of goitrogens
• Hyperplasia ➔ fibrosis ➔ infiltration with plasma cells and lymphocytic cells
• Iodine rich diet - e.g, eggs, milk, seafood
• Askanazy cells are typical (large epithelial cells with oxyphilic changes)
Treatment of simple goiter :
□ Clinical features : A) Diffuse hyperplastic goiter :
• Age - Perimenopausal women, around 50 years ► L-thyroxine 0.3 mg/day for few months
• Sex - Mostly females
• Onset - Insidious 0.1 mg/oay for few years
• Diffuse enlargement of both lobes with following features - firm, rubbery, painful, tender, smooth
► ~_ubtotal thyroidectomy - if
• Initially toxic features present, but later features of hypothyroidism develop
(a) failure to respond to medicine
• Hepatosplenomegaly may be present (b) intraglandular hemorrhage ➔ rapid increase in size
□ Investigations : (c) intrathoracic goiter ➔ respiratory obstruction
• Ta, T4 - Reduced (d) pressure symptom, pain present
• TSH - Raised B) Multinodular goiter :
• FNAC ► Subtotal or.total thyroidec.~omy if many nodules/both lobes involved
• Thyroid antibodies - Antimicrosomal, antithyroglobulin ► ~obectomy if one lobe involved
• ESR raised C) Colloid goiter -
□ Treatment : Subtotal thyroidectomy
• If small size + patient euthyroid ➔ no treatment required Post-operntive ythyi:.oxine given in all cases
• If goiter+ hypothyroid ➔ L-thyroxine therapy
• If i) pressure symptoms CLASSIFICATION OF GOITER
~~? cosmetic purpose } Subtotal thyroidectomy
GOITER
111) extremely enlarged goiter
I

. /
Q.57:

~-
• Steroid therapy may be helpful

Prevention and treatment of simple goiter

PREVENTION AND TREATMENT OF SIMPLE GOITER

•
SIMPLE
NON-TOXIC
t
TOXIC
(See below)
NEOPLASTIC
(See below)
t
THYROIDITIS

Hashimotos'
't
RARE CAUSES
• Bacterial
• Amyloid

~
autoimmune
Goiter: Enlargement of thyroid gland thyroiditis
□ Aetiology of simple goiter: De-Quervan's
Stimulation of increased TSH secretion due to low circulating thyroid hormones thyroiditis
• Familial goiter .
Reidel's thyroiditis
• Physiological - Due to high metabolic demands
Diffuse Multinodular Colloid Solitary
• Endemic goiter - Due to low iodide content in food
hyperplastic goiter goiter non-toxic
• Goitrogens - E.g. : Vegetables of brassica family like cabbage, turnip, etc. drugs like PAS, goiter nodule
antithyroid drugs
• Dyshormonogenesis - Enzyme deficiency ➔ low thyroxin discharge ➔ i TSH

□
•
Types:
•
Sporadic goiter - No definite cause

Diffuse hyperplastic goiter

•
Physiological
• Pregnancy
• Puberty
Primary iodine deficiency
Endemic goiter
Secondary iodine deficiency
•
•
Goitrogens
Drugs - PAS, lithium
• Nodular goiter
• Excess dietary fluoride
• Colloid goiter
• Dyshormonogenesis
 SOLVED SHORT NOTES OF SEMESTERS 519
518 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Q.59: Complications of total Thyroidectomy

TOXIC GOITER
COMPLICATIONS OF TOTAL THYROIDECTOMY

~ Complications~
With hyperthyroidism Without hyperthyroidism
I • Jod Basedow's thyroiditis Immediate Late
t •
•
Excess L-thyroxine intake
After recent thyroid surgery
• Hemorrhage • Thyroid insufficiency
HighTSH LowTSH
Infection Hypertrophic scar/keloid
• Ectopic TSH • Grave's disease • Struma ovary
secreting tumor • Toxic multinodular goiter • Neonatal hyperthyroidsm • Respiratory obstruction Recurrent thyrotoxicosis
• Toxic solitary nodule • Subacute thyroiditis • Recurrent laryngeal nerve palsy • Progressive exophthalmos
• TSH secreting
Tetany
pituitary adenoma
• Thyroid storm

NEOPLASTIC GOITER TREATMENT OF COMPLICATIONS

□ Hemorrhage (Primary or Reactionary):

Benign Mallgna( [C/F - Tachycardia, hypotension, breathlessness, severe stridor]
• Follicular adenoma • If small hematoma --+ Aspiration
• Papillary adenoma • If large hematoma ➔ Immediate release of sutures, pressure over trachea released
• Hurthle cell adenoma ,J,
Hematoma evacuated
,J,
Follicular Cell Origin Parafollicular C-cell origin Non-thyroid cell origin Bleeding vessels ligated
Medullary carcinoma of • Malignant lymphoma □ Infection:
thyroid • Sarcoma
•
I • Metastatic deposits
•
Use of suction drainage
Proper hemostasis } For Prevention

Differentiated
i
Undifferentiated
• Antibiotics
• Antipyretics
• Papillary carcinoma Anaplastic carcinoma
• Follicular carcinoma
□ Recurrent laryngeal nerve palsy :
• Prevention ➔
• Hurthle cell carcinoma
► nerve identified before ligating thyroid artery
Q.58: Preoperative preparation in Grave's disease ► artery ligated far away from thyroid
► posterior lamina of pre-tracheal fascia kept intact
PREOPERATIVE PREPARATION IN GRAVE'S DISEASE • Permanent palsy - Rare
□ Antithyroid drug to bring patient to euthyroid state • If bilateral palsy ➔ Immediate tracheostomy //~
Tab Propylthiouracil - 100 mg thrice daily, till patient becomes euthyroid • If temporary palsy ➔
(Operation done about 2 months after patient becomes euthyroid) ► recovers in 3 weeks - 3 months
□ Iodide or iodine to reduce size and vascularity of thyroid gland ► steroid supplement
lugol's iodinle solution - 10 drops 3 times daily for 10 days prior to operation ► speech therapy
OR □ Respiratory obstruction :
Tab Potassium iodide - 60 mg 3 times daily for 1O days prior to operation Release of tension hematoma
□ Beta adrenergic blockers to reduce pulse rate, tremor, anxiety t if no improvement
Tab Propranolol - 40 mg thrice daily Endotracheal intubation
Given 7 days prior to operation
Continued for 7 days post-operatively
520 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 521

□ Tetany:
(C/F : Weakness, Carpopedal spasm, convulsions, strider, Chvostek's sign)
GALLSTONE ILEUS
Serum calcium estimation
J, □ What is it: Type of acute .intestinal obstru~!io~cl.lJ~.tg.blockage~y gall stone, which has_g_!l..ined ~otr:y
lnj Calcium gluconate (10%) - 10 ml i.v. 8 hourly iri!<:?_ the intestine thr<?ugh ch~l~~X~todu~denal 9r cholecystogastric or cholecysto.intestinal fi!Stula
J, □ Pathogenesis :
When tolerate oral medication, Calculous cholecystilis
Tab. Calcium gluconate - 500 mg 8 hourly j,

□ Thyroid storm : Suppuration and adhesion over duodenal wall

j,
Acute exacerbation of thyrotoxicosis in patients who have not been made auequately enthyroid prior
Cholecystoduodenal fistula
to the surgery . j, .
Treatment - See Short Note (Page No. 499) - 'Treatment of Hypercalcaemic Crisis in a patient of
Gallstones pass into duodenum, form a mass
Hypothyroidism'
j,
□ Thyroid insufficiency:
Blocks terminal ileum
Lifelong L-thyroxine j,
Q.60: Metabolic and neuromuscular manifestations in Grave's disease Gallstone ileus
□ Clinical features :
METABOLIC AND NEUROMUSCULAR MANIFESTATIONS IN GRAVE'S DISEASE • Pain abdomen
Manifestations in Grave's disease are due to - • Features of intestinal obstruction - Abdominal distension, vomit, absolute constipation, shock
• Sympathetic overactivity □ Investigations :
• Increased catabolism • Plain X-Ray abdomen -
□ Neuromuscular manifestations : a) multiple air fluid levels
b) branching gas pattern (air in biliary tract)
• Undue fatigue
• USG abdomen
• Wasting
• CT scan
• Muscle weakness (most evident in proximal limb muscles)
□ Treatment :
• Myopathy in extreme ca.ses
• Tremor of extended and abducted fingers Laparotomy ➔ Enterotomy ➔ Removal of gallstones
j,
• Hyperactive tendon reflexes
Closure of enterotomy
• Insomnia
j,
• Irritability
Cholecystectomy after 6 - 12 weeks
• Excitable and restless
□ Metabolic manifestations : Q.62: Laparoscopic cholecystectomy
• G.I. system ➔ ► Increased appetite but weight loss LAPAROSCOPIC CHOLECYSTECTOMY
► Diarrhea
□ What is it: Most popular method to remove gall bladder
• Integument ➔ ► Hair loss
► Warm, moist skin ➔ gradually heat intolerance □ Speciality : Gold standard treatment for gallstone
► Facial flushing □ Anesthesia : General
► Increased sweating □ Position : Supine, head end up and right side up
► Pruritus
□ Ports used :
► Palmar erythema
• 10 mm ➔ umbilicus - to pass telescope
► Soft, fragile nails
• 1O mm ➔ epigastric - to pass working instruments, take out stones
• Genitourinary ➔ ► Oligo or amenorrhoea
• 5 mm ➔ midclavicular line close to costal margin - to pass grasper for grasping Hartmann's pouch
System ► Urinary frequency
• 5 mm ➔ anterior axillary line at level of umbilicus - to pass grasper for grasping fundus of GB

66
 (
522 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 523

□ Procedure :
Pneumoperitoneum created (For details Refer to Short Note 'Creating Pneumoperitoneum in Lap-Surgery') Type & Features Sliding Hernia Rolling Hernia
J,
Ports inserted • Synonyms • Axial hiatus hernia • Para-oesophageal hiatus hernia
J, • Type I hiatus hernia • Type II hiatus hernia
Graspers inserted through respective ports • Incidence Commonest Rare
J,
Calot's triangle dissected via dissector introduced through epigastric port
• Anatomy • Not a true hernia . True hernia
J,
• Ph reno-oesophageal • Phreno-oesophageal membrane
membrane intact ruptured
Cystic duct and artery identified
J, • Clinical features • May be assymptomatic • Fullness after meals
Posterior adhesions released first • Associated with GERO • Early satiety
J, • Postprandial vomit
• Dysphagia
Cystic duct and artery clipped
J,
. Hiccough
Gall bladder dissected off liver bed using cautery and removed through epigastric port • Abdominal pain
J, • Chest pain
Bleeding points coagulated
J,
.• Regurgitation
Arrythmia
Tube drain placed through 5 mm port • Investigations • Barium meal X-Ray • Plain X-Ray (retrocardiac air-fluid
J, level)
All ports removed • Oesophagoscopy • Barium meal X-Ray
J, • ECG
Ports sutured • 3D CT Scan

□ Complications :
• Flexible fibreoptic gastro-
oesophagoscopy before operation
• Bleeding
• Infection • Treatment Same as for GERO • Excision of sac and repair of defect
-----

• Bile leak • General - * control of obesity • Gastrectomy if gangrenous ,-----------

• Bile duct injury * stop smoking • Mesh reinforcement to hiatus to
• Subphrenic abscess • Drugs - PPI, H2 blockers close defect
pro kinetics
• Injury to colon, duodenum
. Endoluminal therapies
0.63: Hiatus hernia • Antireflux surgery

HIATUS HERNIA
Q.64 : Cavernous hemangioma
□ What is it : Herniation of stomach into thorax through oesophageal hiatus in diaphragm
□ Speciality: Most common type of diaphragmatic hernia CAVERNOUS HEMANGIOMA
□ Classification : See Section - 1, Segment - C, Paper I, 2010, 0.1 'Hemangioma' (Page No. 285)
Type I [Sliding hernia] ➔ Cephalad displacement of gastro-oesophageal junction through hiatus into
mediastinum Q.65: Acute appendicular lump
Type II [Rolling hernia] ➔ Superior migration of fundus of stomach along side the GE junction and
oesophagus into the mediastinum with GE junction in normal intraabdominal location ACUTE APPENDICULAR LUMP
Type Ill ➔ Type I + type II D Synonym - Periappendicular phlegmon
Type IV ➔ Hernia which has other abdominal viscera as content □ What is it - Localisation of infection occuring 3-5 days after an attack of acute appendicitis
For rest, Refer to "Appendicular Lump" - Sec - 1, Paper-I, Supplementary 2013, Q.2 (Page No. 63)
524 QUEST : A Comprehens:ve Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 525

0 Complications :
Q.66 : Pseudocyst of pancreas
Infection ➔ abscess
•
PSEUDOCYSTOFPANCREAS •
Hemorrhage
• Rupture
□ What is it- Collection of amylase rich fluid enclosed in a wall of fibrous or granulation tissue, in lesser • GIT obstruction
sac of peritoneum or peripancreatic cellular tissue • Cholangitis
□ Naming - Called 'Pseudocyst' as not lined by endothelium • Cholestasis
□ Etiology - 0 Differential diagnosis :
• After 3 weeks following attack of acute pancreatitis • Aortic aneurysm
• Following trauma • Cystadeno carcinoma of pancreas
• Recurrent chronic pancreatitis • Retroperitoneal tumor
□ Sites - • Liver cyst
• Lesser sac (commonest) • Mesenteric cyst
• Hydatid cyst
• Duodenum 0 Investigations :
• Jejunum ] (cam)
• Splenic hilum • USG Abdomen
• CT Scan-abdomen
• Colon • MRCP
D Types -
• LFT
• Acute • Barium meal (lateral view) - Widened vertebrogastric angle with displaced stomach
• Chronic □ Treatment :
• Communicating (with pancreatic duct)
• Non-communicating See Sec-1, Segment - A, 2012 Paper-I, Q.2 - 'Big Tense Cystic Lump In Upper Abdomen' [Pg. 42)

□ Fluid content - 0.67: Abdominal compartment syndrome

• Contains: ABDOMINAL COMPARTMENT SYNDROME
► Albumin
► Mucin □ What is it : Intra abdominal pressure raised to more than 12 mm Hg.
► Cholesterin □ Etiology:
► Blood cells • Intestinal obstruction
► Necrotic tissue • Multiple trauma
• Very high level of amylase • Laparoscopic procedures
• Colour - Clear • Post operative ileus
• Specific gravity - Low • Acute gastric dilation
• pH - Alkaline • Acute abdomen
□ Clinical features - Cl Busch pressure grading: (based on intra abdominal pressure)
• Swelling in epigastrium with following features : I - 10-15 cm H20
► Size - Variable II - 15-25 cm H2 0
► Shape - Hemispherical Ill - 25-35 cm H20
► Surface - Smooth IV - > 35 cm H20
► Consistency - Soft □ Clinical features :
► Margin - Upper diffuse • Hypoxia, hypercarbia
Lower well-defined • Reduced urine output
► Movement with respiration - Absent • Reduced venous return
► Mobility - Absent • Distended abdomen
► Percussion - Resonant • High pulse
► Tenderness - May be present • Low blood pressure
• Baid test - Ryle's tube passed felt per abdominally • Cardiac arrest
526 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 527

□ Treatment - • Transillumination - Brilliantly transilluminant

• Resuscitation; patient shifted to ICU • Fluctuation - Fluctuant and cross-fluctuant (in case of plunging ranula)
• Bladder pressure assessment
□ Comp_lications :
• Ryle's tube aspiration
• Rupture
• Sur · Cdecompression beyond Grade Ill
• Infection
anula • Repeated trauma
RANULA • Interfere with speech and swallowing
• Damage Wharton's duct
□ What is it - _Transriarent cyst on floor of mouth • □ Treatment :
□ Naming - Derived from "Rana" meaning frog, as ranula looks like belly of frog • Marsupialisation initially ➔ Excision when wall of ranula is thickened
□ Origin - Extravasation cyst arising from sublingual gland.or mucus glands of Blandyn and Nuhn on
floor of mouth Q.69: TOURNIQUET
□ Pathogenesis - □ Function : Cut off blood supply to a limb temporarily (to create a bloodless field)
j~-j~~i;;~f duct of the g_lan_c:l_s
□ Pre-requisite : Limb exsanguination using Rhys-Davis exsanguinator
··-· j,
Retention cyst □ Site:
j, Lower limb ➔ Mild thigh above knee joint
Increased pressure Upper limb ➔ Mid biceps above elbow joint
j,
□ Applied: Over layers of gauze/cotton, not on bare skin
Rupture of acini
j, □ Pressure:
Extravasation cyst
Adults Children
□ Pathology- Upper limb 250 mm Hg 150 mm Hg
• Lined by columnar epithelium or cuboidal epithelium, which in turn is covered by delicate capsule 250 mm Hg
Lower limb 300 mm Hg
of fibrousffssue
• Content - Clear ropy or jelly-like fluid □ Types :
□ Types- • Rubber tourniquet
• Simple ranula - When ranula is situated only on floor of mouth • Martius tourniquet
• Plunging ranula - lntrabuccal ranula having a cervical prolongation which comes down along the • Com pneumatic tourniquet
posterior border of mylohyoid, and appears in submandibular region • Pneumatic tourniquet
□ Age- • Esmarch rubber elastic bandage tourniquet
• Children and young adults • Specialised sophisticated tourniquet
□ Sex predilection - □ Uses:
• M= F • Create - bloodless field for limb surgery
□ Clinical features - • To access vein - for i.v. inj, iv sampling
• Diagnostic test - ITP, varicose vein
Swelling with following features :
• First aid in bleeding condition of limbs
• Site - E!oor of mouth, below tongue and on side of frenulum
□ Time : Upper limb - 1 min, Lower limb - 2 min
• Size - Variable (1-5 cm diameter)
• Surface - Smooth □ Contraindications :
• Colour - Bluish • Peripheral vascular disease
• Laterality - Unilateral • Atherosclerosis
• Tenderness - Absent • Infection
• Temperature - Not warm • DVT
• Consistency - Soft or hard • Crush syndrome
• Sickle cell disease
528 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOtVED SHORT NOTES OF SEMESTERS 529

□ Complications : • Tested for infection :

• Crush syndrome ► HIV-1, 2
• lschemia and gangrene ► HTLV-1, 2
• Skin blister and necrosis ► Hep- B, C
• Infection ► CMV
• Increase bleeding if improperly placed ► Malaria
• Neuropraxia ► Syphilis
► West Nile virus
Q. 70 : Blood transfusion
► Chagas disease
BLOOD TRANSFUSION (B) Before transfusion :
□ Indications : • Patient's blood group properly checked and documented correctly in requisition form
• Acute blood loss following trauma • Product details and details on requisition form are matched properly
• Major surgery • Slow infusion started
• Burns-Plasma (C) After transfusion :
• Septicaemia • Constant monitoring of vitals every 15 mins
• Chronic anaemia • Check for fever, chills, urticaria
• ITP, Hemophilia • Urine volume
• Prophylactic measure prior to surgery Q.71,~--
□ Donor criteria :
• Weight 45 kg MELANOMA
• Fit without serious disease - Hit', Hep B
□ Define - !:'.lost aggressive malignant ~ cuteneous tumor arising from epidermal melanocytes
□ Collection :
□ Sites -
• Sac containing 75 ml CPD (Citrate, Phosphate, Dextrose) solution
• Head, Neck
□ Storage: • Eyes ____
• 4 °C in special refrigerator - 3 weeks.
• Mucocutaneous junction
□ Blood fractions :
• Trunk
A: See Section - 1, Segment - D, 0.19 "Blood Fractions" (Page No. 484)
• Lower, upper limb
□ What is transfused :
□ Predisposing factor -
• Every 4 unit SAGM blood --, 1 unit whole blood given • _Su~jigl}!
• Every 2 unit SAGM blood --, 1 unit (400 ml) 4.5% human albumin given • SES
• After grouping and cross-matching, 540 ml blood transfused in 4 hours (40 drops/min) using
filtered drip set • Family H/o
• H/o eariier skin CA

]
S - Sodium chloride
A - Adenosine a) allows good viability of cells • lmmunoSLJ()E_ressive drugs
G - Glucose anhydrate b) devoid of protein • Xeroderma pigmentosa
M - Mannitol c) useful in anaemies • Familial dysplastic naevus

□ Complications of blood transfusion: • Sporadic dysplastic neavus

A : See Section - 1, Segment - D, 0.33 "Complications of blood transfusion" (Page No. 495-496)
• Junctional naevus
• Large congenital naevus
□ Precautions :
□ Classification
(A) Processing of blood before transfusion :
(A) Braslow's (based on thickness of invasion)
• Component separation I - < 0.75 mm
• ABO, Rh grouping II - 0.75- < 1.5 mm
• Pathogen Reduction Treatment - Addition of riboflavin with subsequent exposure to UV ray
lll-1.5-<4mm
• Leukoreduction / Leukodepletion
IV - :e:: 4 mm

67
530 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 531

(8) AJCC Tumor thickness Nodal spread Investigations -

Thin
Intermediate
<1mm
1 -4 mm
< 10%
20 - 25%
•
•
, ______
No incision biopsy only excision b~psy
Tumor marker:
Thick >4mm 60% ► MELA-A
► S 100
(C) Clarck's
► LDH
1 ➔ Epidermis
► HMB 45
2 ➔ Extends into papillary dermis
• Lymph node : FNAC, SLNB
3 ➔ Completely fills
4 ➔ Reticular dermis • US!:3, c,:_!(?11est X-Ray
5 ➔ S.C. tissue 0 Treatment -
□ Types- (1) For Primary:
• _Cutane'?_l:!_~_ • Wide excision
• _f:xtr~cutaneous • Amputation 1 joint above (if wider area)
• Occult • Eyes - Enucleation of eye
□ Clinical types - • Anal canal ➔ APR
• Superficial spreading - Most common (2) Lymph node :
• .~g9ular - More aggressive • SLNB
• Len~lE maligna - Less common, least malignant • Regional Block dissection
• Acral lentiginous - Least common, worst type • CT if fixed node
• Amelanotic (3) Recurrent :
• Desmoplastic • Isolated limb perfusion using melphalm
□ Phases of growth - • Laser ablation
• _Rfigi_a.J growth.Qb_<!§le - Horizontal spread (4) Chemotherapy:
• yertical growth phase - Invasion • After surgery
□ Clinical features - (5) RT:
(A) Arises denovo or from pre-existing naevus • Secondary in bone
(8) Unknown before puberty, spreads from mother to foetus • Brain
► A - Asymmetry (6) Endolymphatic therapy :
► B - Border irregular • Control of disease in nodes
► C - Colour change (7) Immunological therapy :
► D - Diameter > 6 cm • BCG, Levimasole
► E - Elevated
Q. 72: Radiological features of various causes of intestinal obstruction
► Ulceration, bleeding, itching
► Rapid growth RADIOLOGICAL FEATURES OF VARIOUS CAUSES OF INTESTINAL OBSTRUCTION ,
(C) Satellite nodules ➔ 2 nodules within 2 cm of primary
Radiological examination is the most important diagnostic tool to confirm the clinical diagnosis and locate
In-transit nodules ➔ 2 nodules > 2 cm from primary
the site of obstruction accurately
(D) Spread to -
(1) Brain; (2) Bone; (3) Liver; (4) Lung; (5) Skin □ Straight X-Ray Abdomen -
□ Spread- • Positions :
• Lymphatics - Regional lymph node ► Supine
• Retrograde spread to dermal lymphatics - secondary nodules ► Upright (both AP and lateral view)
• Blood ► Left lateral decubitus
532 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 533

► Bone
• Characteristic feature : Gas shadows and multiple air-fluid levels
► Brain
• Number : More than 3 air fluid levels (as normally 3 air fluid levels present in duodenal cap,
fundus of stomach and caecum) ► Adrenals
• Cause : Gut gets distended with air and fluid proximal to obstruction due to - • Retrograde venous spread through vertebral venous plexus in carcinoma prostate, causing
osteoblastic secondaries in pelvic bones and vertebra
Fluid Air
Lymphatic spread :
(a) Salivary secretion (1500 cc/day) (a) Swallowed during respiration • By embo/isation : Malignant cells get dislodged from lymphatic vessels and spread to other lymph
(b) Gastric secretion (2500 cc/day) (b) Diffusion of CO2 from distended veins into lumen nodes freely
(c) Bile, pancreatic juice (1000 cc/day) (c) Putrefaction of intestinal contents E.g. : In breast carcinoma, spread from axillary lymph node to supra-clavicular lymph node
(d) Succus entericus (3000 cc/day) • By permeation : Malignant cells proliferate through lymphatic vessels upto lymph node
E.g. : In breast carcinoma, spread of cells to axillary lymph nodes
• Radiological feature -
• Retrograde lymphatic spread : When lymphatic vessels get blocked by malignant cells
► Gas exerts vertical pressure on fluid ➔ horizontal fluid level E.g. : In breast carcinoma, spread to opposite breast, opposite axilla, mediastinum
► Shadows are formed where loops are formed
□ Transcoelomic spread : Spillage of malignant cells from primary site and spread occurring along
► In each loop, gas floats up on top of fluid, gas in black and fluid white serous cavities
E.g. : Krukenberg tumor
□ Spread along natural passages or epithelial lined space :
• Site -
E.g : Papilloma of renal pelvis
Jejunum ➔ Concertina effect due to Valvulae Conniventes (white lines occupying entire transverse
diameter of bowel) □ Seedling:
Ileum ➔ Straight pipe, characterless • From lower lip to upper lip (kiss cancer)
Large bowel ➔ Haustrations (discontinuous white lines placed irregularly) • Recurrence in scar after surgery for malignancy
Small bowel ➔ Occupies central portion of abdomen • Seedling in peritoneal cavity from malignancy in abdominal organ
□ Barium Enema - Indicated when clinical features and straight X-Ray abdomen suggest colonic □ Inoculation :
obstruction During clumpsy surgical procedure
□ USG abdomen - } Q.75: Squamous cell carcinoma
□ Show dilated bowel loops
CTScan-
Features of 'lntussusception' - See Section - 1, Segment - A, Paper-I, 2011, Q. 2 (Page No. 37) SQUAMOUS CELL CARCINOMA
Features of 'Volvulus' - Short Note (Semesters) (Page No. 567). □ Synonym:
Q.73: lmperforate Anus • Kangri cancer
• Chimney cancer
See Section - 1, Segment - C, Paper-I, 2013, Q.4 'Anorectal Malformation' (Page No. 303)
• Epithelioma
Q.74: Spread of carcinoma □ What is it:
Carcinoma arising from squamous layer of skin
SPREAD OF CARCINOMA
□ Examples:
□ Direct spread - Into adjacent organs, soft tissues, vessels, bone • Chimney scrotal cancer (due to irritation by tar)
□ Blood spread - • Kang cancer of Tibetans (due to sleeping over hot bed to control cold)
• Occurs through veins (as thin walled, so infiltration easier) • Kangri cancer in Kashmir {due to constant placing of hot charcoal pot over abdominal wall to
• Arteries impermeable as wall as elastic control cold)
• Processes involved : □ Pre-malignant conditions :
► Permeation (e.g. renal cell carcinoma) • Leukoplakia
► Embolisation (other malignancies) • Paget's disease
• Blood spread occurs to following organs : • Bowen's disease
► Lungs • Chemically induced chronic irritation
► Liver • Senile keratosis
534 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 535

• Radiodermatitis i?Q.76: Rhinophyma

• Viral - HPV .5, HPV 16
• Solar keratosis RHINOPHYMA
• Tobacco use
• Xeroderma pigmentosa
o Synonyms:

□ Speciality :
• Potato Nose
• Bottle Nose
Second most common skin cancer 0 What is it: Glandular form of acne rosacea which causes immense thickening of distal part of skin of
□ Genetics: nose with visible openings of sebaceous follicles
Expresses cytokeratins 1 and 1O o Etiology : Hypertrophy + adenomatous changes in sebaceous glands
□ Pathology: o Clinical features : Bluish red nose with dilated capillaries
• Proliferative o Treatment : Excision of excess tissue and reconstruction
• Red plaque like
• Ulcerative Q.77: WEB SPACE INFECTION
□ Variants: □ Surgical anatomy :
• Verrucuous carcinoma • Number - 3
• Marjolin's ulcer • Shape - Triangular
• Self-healing squamous cell carcinoma • Boundary -
► Proximally - Transverse metacarpal ligament
□ Histology:
► Distally - Web of fingers
• Spindle cells
► Sides - Head of metacarpal and proximal phalanx
• Malignant whorls of squamous cells with epithelial or keratin pearls
• Contents -
• Deep and peripheral marginal clearance
► Loose areolar tissue
□ Broder's classification : ► Lumbrical canal through which tendon of lumbrical posses
I - Well differentiated (~ 75% Keratin pearls) □ Etiology:
II - Moderately differentiated (50 - 75% Keratin pearls) • Abrasion
Ill - Poorly differentiated (25 - 50% Keratin pearls) • Pin-prick
IV - Very poorly differentiated(< 25% Keratin pearls) • Callosities
□ Clinical features : • Infection of proximal volar spaces
• Ulceroproliferative lesion □ Causative organisms :
• lndurated base and edge • Staphylococcus
• Raised, everted edge • Streptococcus
• Blood discharge from lesion • Gram negative organisms
• Regional lymphadenopathy - Hard, fixed, nodular □ Clinical features :
□ Investigations : • Fever
• Edge biopsy • Pain and tenderness - Maximum on volar aspect
• FNAC from lymph node • Pus points out dorsally
□ Treatment : • V sign - Separation of fingers
• Radiotherapy □ Complication :
• Wide excision followed by skin graft • Spreads into other web and hand spaces
• Block dissection of lymph node □ Treatment :
• Chemotherapy (Vincristine, Bleomycin, Methotrexate) • Elevate hand
• Palliative external radiotherapy • Antibiotic, analgesic
• Drainage under LA ➔ separate incision for each web space - transverse incision on volar
aspect of web, deepened to reach the space by dividing fibres of palmar
fascia
 536 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 537

Q.78: Paronychia • Trauma

PARONYCHIA • Shock
□ Pathogenesis :
Acute Paronychia
• Failure of inflammatory localisation
□ What is it : Commonest hand infection • Vasodilatation
□ Site : Pus collects in subcuticular area under eponychium • Thrombosis
□ Cause : Minor injury • Increased endothelial permeability
□ Organisms : • Leucocyte migration and activation
• Staphylococcus • Neutrophil sequestration
• Streptococcus • Release of free radicals, cytokines, arachidonic acid
□ Clinical features : • Abnormal nitric oxide synthesis
• Complement activation
• Throbbing pain and tenderness
• DIC
• Floating nail - Due to collection of pus under nail root
□ Part of: Severely decompensated reversible shock
□ Treatment:
□ Leads to: MODS (Multi Organ Dysfunction Syndrome)
• Pus drainage by incision over eponychium
• Pus sent for culture and sensitivity □ Prognosis: Poor
• Antibiotic, analgesic Q.80: H.Pylori eradication regime
• If floating nail, it is removed
H. PYLORI ERADICATION REGIME
Chronic Paronychia
□ Cause : Fungal infection □ What is H. pylori : Spiral shaped flagellated gram negative organism
□ Clinical features : □ Present in :
• Itching • Deep mucosa! layer of antrum
• Recurrent pain
• Duodenum (rare)
• Discharge
□ Features:
□ Investigations :
• Urease activity ➔ protects it from H+ ions in gastric acid, and by producing ammonia provides a
• Scrapings sent for culture
source of nitrogen
□ Treatment :
• Ammonia thereby produced has 2 actions -
• Antifungal
(a} Stimulate G-cells to release gastrin
• Antibiotic -1,
• Nail removal in severe cases gastric acid hypersecretion
Q.79: SIRS
(b) Alters gastric epithelial permeability
SIRS -1,
mucosa! injury
□ Full form : Systemic Inflammatory Response Syndrome
• Flagellae ➔ permits it to penetrate mucosa and migrate to regions of lower acidity
□ What ls it: Body's systemic response to an infection • Bacteria secrete cytokines and enzymes which disrupt mucosa! barrier
□ Clinical parameters :
□ Causative agent of:
• Hypothermia(< 36°C) or hyperthermia (> 38°C)
• Type B gastritis
• Tachypnoea (> 20/min)
• Gastric ulcer
• Tachycardia (Pulse > 90/min)
• Duodenal ulcer
□ Laboratory parameter : • Gastric carcinoma
• Total leucocyte count> 12000/mm3 □ Tests:
□ Etiology: • Rapid urease test
• Sepsis • C13/C 14 breath test
• Burn • Serology to identify lgG antibody

68
538 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 539

□ Eradication regimen : 2a - Well-compensated

TRIPLE THERAPY (Used in areas where clarithromycin resistance is low) 2b - Poorly-compensated
Stage 3 - Rest pain
[First line therapy]
Stage 4 - Gangrene, ischaemic ulcer
Lansoprazole [30 mg BD]
□ Intermittent claudication :
OR • Crampy muscle pain occurring due to arterial occlusion
Omeprazole [20 mg BD] Amoxycillin
□ Features of ischaemia :
OR [1mg BO]
• Pallor
Pantoprazole [40 mg BD]
OR
+ OR
Metronidazole
+ Clarithromycin
[500 mg BO]
for 7-14 days •
•
•
Pain
Paraesthesia
Pulselessness
Rabeprazole [20 mg BD] [400 mg BO]
OR • Paralysis

Esomeprazole [40 mg BO]

• Diminished hair
• Thinning of skin
[Combination with Metronidazole and Clarithromycin may induce resistance] • Loss of subcutaneous fat

[Metronidazole & Clarithromycin combination should be used in patients with penicillin hypersensitivity] • Muscle wasting

QUADRUPLE THERAPY [Second line therapy] (Used in 1st line treatment failure and highly resistant
• Ulceration in digits

cases of clarithromycin) • Cold skin

□ Investigations :
Triple therapy + Bismuth
• Blood tests - Blood sugar, lipid profile, peripheral smear platelet count
Q.81 : Acute limb ischaemia • Doppler.
• Dupl~.J5 scan
ACUTE LIMB ISCHAEMIA
• Plethysmography
□ Causes: • Retrograde transfemoral seldinger angiography
• Acute arterial occlusion due to embolism □ Treatment :
• Trauma • Control of hypertension, diabetes
• Tourniquet application • Percutaneous transluminal balloon angioplasty
• Radiation injury • Bypass graft surgery
• Diabetes
• Scleroderma Q.82 : Collar stud abscess
• Atherosclerosis
• Arteriopathics - Buerger's disease, Raynand's disease
COLLAR STUD ABSCESS
□ Types of embolisation : □ What is it:
• Cardioarterial
Bilocular abscess with one locule deep to deep fascia and another locule in superficial fascia, both
• Arterioarterial
locules intercommunicating with each other through a small perforation in deep fascia
□ Sites of embolisation in limb ischaemia :
□ Types:
• Bifurcation of common femoral artery
• Pyogenic
• Bifurcation of popliteal artery
• Tuberculous
• Bifurcation of common iliac artery
• Bifurcation of aorta □ Stages of tuberculous lymphadenitis : (See Fig. 1.7 .5]
□ Fontaine classification : Stage 1 Lymphadenitis (discrete nodes, non-tender, firm)
Stage 1 - Assymptomatic Stage 2 : Matting (firm, non-tender, move together en-masse)
Stage 2 - Intermittent claudication
 540 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 541

Stage 3 Cold abscess (deep to deep fascia)

J!_oyd's classification of critical limb ischaemia
Stage 4 Collar stud abscess (cold abscess rupturing through deep fascia)
Grade I Pain after walking for some distance, but pain reduces if walking is continued (as collaterals
Stage 5 Sinus formed open up which wash off the metabolites)
□ Pathogenesis : Grade II Pain persists on continuing walk, but patient can walk with effort
Rupture of cold abscess through deep fascia gives rise to collar stud abscess which is adherent to Grade Ill Patient needs to take rest to relieve pain
overlying skin □ Rest: See Short Note 'Acute Limb lschaemia' (Page No. 538)
□ Clinical features :
Q.85 : Raspberry tumor
• Swelling in neck
• Non-tender RASPBERRY TUMOR
• Smooth
• Cross fluctuation present □ Synonyms:
• Tonsils may be studded with tubercles • Umbilical polyp
• Features of pulmonary tuberculosis • Umbilical adenoma
□ Investigations : • • Enteroteratoma

• Haematocrit □ Aetiology : Vitellointestinal duct partially unobliterated near umbilicus, and its mucosa prolapses
through umbilicus, giving rise to a tumor
• ESR
• Chest X-Ray □ Age : Common in infants
• FNAC of lymph node for AFB smear and culture □ Histology: Columnar epithelium rich in goblet cells
• PCR □ Clinical features :
□ Treatment : Swelling protruding out near umbilicus with following features :
• Antitubereular drug • Reddish in colour
• Aspiration • Moist with mucus
• Incision and drainage • Tends to bleed on touch
• Surgical removal if failure of medical treatment □ Complications :
Q.83: Critical limb ischaemia • Infection
• Intestinal obstruction
CRITICAL LIMB ISCHAEMIA
□ Differential diagnosis : Umbilical granuloma
□ What is it: Recurring ischaemic rest pain persisting for more than 14 days or ulceration and gangrene
□ Treatment :
of foot or toes with ankle systolic pressure less than 50 mm Hg or toe systolic pressure less than 30
• If pedunculated - firm ligature tied around its base, so that tumor falls off in few days
mm Hg.
• Actual treatment - umbilectomy with excision of vitellointestinal duct and exploration of abdomen
[Rest - Refer to Section - 1, Segment - D, Q.81 ' Acute Limb lschaemia' (Page No. 538)]
(If associated Meckel's diverticulum found, it is to be excised along with umbilectomy)
/~;,-64,(lntermittent claudication
Q.86 : Buerger's disease
-~// INTERMITTENT CLAUDICATION
BUERGER'$ DISEASE
□ What is it: Crampy mu~cle pair, due to arterial occlusion
□ Naming : "Claudio" - Latin word meaning "I limp" □ Synonyms:

□ Pathogenesis : Arterial occlusion ➔ <!-ccu111ulation of substance P-~~~-la_c_tic ac.id in muscle ➔~ • Thromboangiitis obliterans
• Presenile gangrene
□ Claudication distance : The distance after walking which pain is experienced
□ What is it : Non-atherosclerotic inflammatory disorder, involving medium sized and distal arterial
□ Fontaine classification of limb ischaemia
wall, with involvement of adjacent nerves and veins, terminating in thrombosis of artery, with cell
A: See Short Note 'Acute Limb lschaemia' mediated sensitivity to Type I and Type Ill collagen
542 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 543

□ Etiology: (Compensatory peripheral disease)

J,
• Smoking (> 20 cigarettes/day)
• Chronic fungal infection Patient continues to smoke
• HLA B5/A9 inheritance J,
• Autonomic overactivity Disease progresses, collaterals get blocked
• Familial predisposition J,
• Low socio-economic status Decompensated peripheral vascular disease OR Critical limb ischaemia
Shianoya 's criteria : J,
□
• Tobacco use Rest pain, ulcer, gangrene
• Disease starts before 45 years of age □ Symptoms:
• Absence of hyperlipidaemia or diabetes mellitus • Intermittent claudication initially, progressing to rest pain
• Distal extremity involved first without embolic or athero-sclerotic features • Pain due to ischaemic neuritis and recurrent migratory superficial thrombophlebitis
• With or without thrombophlebitis • Postural colour change ➔ trophic changes ➔ ulceration and gangrene
• Classical triad of :
□ Pathogenesis :
► Claudication
Carbon monoxide, nicotinic acid in smoke ► Superficial migratory thrombophlebitis
J, ► Raynaud's phenomenon
Trigger immune response
J, □ Signs:
Walls of small and medium sized vessels invaded by polymorphonuclear leucocytes • Features of ischaemia :
J, ► Pallor
Vasospasm + Hyperplasia of intima ► Pulselessness (posterior tibial, artera dorsalis pedis)
J,
► Pain
Thrombosis in vessels
► Paraesthesia
J,
► Paralysis
Obliteration of vessels
J, ► Hair loss
Panarteritis ► Skin atrophy
J, ► Brittle nails
Artery and vein bound together by fibrous adhesions • Buerger's test (angle at which pallor appears indicates severity)
J,
> 90° - normal
Adjacent Nerve also gets involved
< 20° - critical
J,
Agonising pain • Fuschig's cross leg test (if popliteal pulsation present, oscillatory movement of leg perceived}
J, □ Investigations :
Thrombus shows fibroblastic activity and endothelial proliferation
• Arterial Doppler and Duplex B-Scan
J,
• Transbrachial angiogram
Thrombus organised into fibrous tissue
J, • Transfemoral retrograde angiogram
Elastic lamina of artery thickened • USG abdomen (to look for abdominal aorta aneurysm)
J, • Haemoglobin, blood sugar
lschaemic features in limb
J,
Collaterals open up to maintain blood supply to ischaemic area
544 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

□ Treatment :

Treatment

CONSERVATIVE SURGICAL OTHERS

t
VEGF - i.m injection
(endothelial cell mitogen
which promotes
angiogenesis)

Lumbar Arterial Omentop/asty Amputation

sympathectomy reconstruction (to revascularise (if gangrene
(relieve pain, (in case of segmental affected limb) occurs)
promote ulcer proximal occlusion)
healing)

GENERAL MEDICAL
I Vasodilators - e.g. Nifedipine
~ t Low dose aspirin - 75 mg/day (due to
Stop Care of
antithrombin activity
smoking limbs
Buerge r's Pentoxiphylline (increases flexibility of RBC
position and help them to reach micro-circulation in
a better way to increase oxygenation)
Buerge r's
exercise Prostaglandin therapy (PGA - 1)

Heel raise Phosphodiesterase inhibitor (clopidogrel,

cilostazole)
Care of fee·t

Analgesics Dextran

Proper footwear Steroid

Phenylbutazone

Q.87: Complications of varicose veins

COMPLICATIONS OF VARICOSE VEINS

□ Varicose veins: Dilated tortuous veins due to reversal of blood flow through its faulty valves
r 546 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 547

CJ Treatment:
□ Aetiology:
Fusion of subdivisions of mesonephric duct, at 30th - 40th day of intrauterine life • Needed if complications arise (treated according to complications)
J, Q.89 : Polycystic kidney
Kidneys cannot ascend above origin of inferior mesenteric artery
POL YCYSTIC KIDNEY
J,
Bridge of tissue joins the lower poles What is it: Hereditary disease of kidney
□ Site of fusion : Part of tissue joining the lower poles, in front of vertebra lies in front of L4 Age of manifestation : After 40 years
□ Inheritance: Autosomal dominant (chromosome 16)
□ Pathology :
• Pelvis lies on anterior surface of kidney as normal rotation of kidney cannot occur □ Laterality: Bilateral
• Ureter rides over isthmus to traverse anterior surface of fused portion □ Associated with: Cysts of pancreas, spleen liver
• Ureteral obstruction □ Aetiology :
• Aberrant renal vessels Defect in mechanism of joining between uriniferous tubules and collecting tubules
• Hydronephrosis j,
• Infection Blind secretory tubules which are connected to functioning glomeruli become cystic
• Tuberculosis J,
• Calculus formation Cysts enlarge
□ Sex predilection : J,
• M>F Compress adjacent tissues
J,
□ Symptoms:
Gradually occlude normal tubules
• Assymptomatic
• Ureteral obstruction □ Pathogenesis :
• Complaints due to hydronephrosis, infection, calculus Mutation in genes PKO 1 and PKO 2, which produce polycysteine proteins that inhibit overgrowth of
• Due to renodigestive reflex, gastrointestinal symptoms mimicking peptic ulcer, appendicitis, epithelium
cholelithiasis J,
□ Signs: Epithelial proliferation
J,
• Fixed ] Blockage
• Non-mobile midline mass at L4 level
J,
• Firm
• Resonant Retention
J,
□ Investigations :
Cystic
• Intravenous urogram -
□ Pathology :
► Renal pelvis lies on anterior surface of its respective kidney
• Bilateral condition
► Medialisation of lower calyces
• Kidney enlarged 3-4 times
► Curving of ureter like 'flower-vase'
• Yellowish-red thin walled cysts, which do not communicate with renal pelvis
• USG abdomen
• Content - Thin/thick/viscid; yellowish/darkbrown/amber coloured
• CT, MRI abdomen
• Lined by single layer of cells - Flattened or cubical or columnar
• Tomograms
□ Symptoms :
• Renal scanning
□ Complications :
• Appear after 40 years of age
• Abdominal swelling
• Infection
• Pain - Dull aching in loin (due to tension on renal capsule by enlarging cyst)
• Hydronephrosis - Acute abdominal (due to rupture of cyst)
• Ureteral obstruction - Colicky (due to stone)
• Calculus formation
• Hematuria
 SOLVED SHORT NOTES OF SEMESTERS 551
550 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

What is it : Retention cyst occurring due to blockage of duct of sebaceous gland

• Chest X-Ray
• Echocardiography Common sites :
□ Treatment : • Scalp
• Feeding gastrostomy done • Face
• Scrotum
• Fistula identified and resected ➔ lower segment anastomosed to blind upper segment
(never seen in palms and soles)
Q.92: Mallory-Weiss syndrome
Pathogenesis :
MALLORY - WEISS SYNDROME Sebaceous glands situated in dermis, secretes sebum through sebaceous duct
j,
□ What is it : Condition characterised by superficial linear mucosa! laceration at oesophago-gastric
If duct gets blocked
junction
□ Pathogenesis : Sudden increase in intra-abdominal pressure during vomiting is transmitted t j,
0 Gland becomes distended with its own secretions
oesophagus against closed glottis
□ Site : One O' clock position at oesophago-gastric junction (commonest) j,
□ Aetiology: Severe vomiting (due to migraine/vertigo/alcohol intake) followed by severe hematemesis Sebaceous cyst
or melaena
□ Pathology:
□ Clinical features :
• Lining - Squamous epithelium (epidermal layer only)
• Severe vomit • Content - Yellowish pultaceous material with unpleasant smell, containing sebum, fat
• Hematemesis
• Wall has a parasite - Demodex folliculorum
• Features of shock
□ Clinical features :
□ Investigations :
Swelling with following features :
• Oesophagoscopy (best)
• Gastroscopy with iriflated stomach • Soft, cystic
• PCV • Smooth
• Haemoglobin % • Smooth
• Colliac angiography • Painless
□ Differential diagnosis : • Non-tender
• Oesophageal varices • Freely mobile
• Erosive gastritis
• Adherent to skin
□ Treatment :
• Fluctuation positive
• Nasogastric aspiration
• Transillumination negative
• Intravenous fluid administration • Bluish punctum present (indicates blocked duct) over summit
• NPM (nothing per mouth)
□ Complications :
• Haemostatic agents like vasopressin
• Endoscopic injection therapy may be required • Abscess formation
• If continuous bleed ➔ long proximal gastrotomy • Infections
j, • Sebaceous horn (due to hardening of slowly discharged sebum)
blood clots evacuated • Ulceration - Cock's peculiar tumor
j, • Calcification
mucosa! tear oversewn • Malignancy
□ Treatment :
Q.93: SEBACEOUS CYST
• Total excision of cyst
□ Synonyms: • If abscess ➔ drainage followed by excision
• Epidermoid cyst
• WEN
554 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 555

□ Stages - (based on communication of hydronephrotic sac with urinary tract)

□ Complications -
• Open
• Perinephric abscess
• Intermittent
• Pyonephrosis
• Closed
• Renal failure
□ Classification -
I. Hydronephrosis only
□ Investigations -
Hydronephrosis with hydroureter
• Blood urea, serum creatinine
• Hb%
II. Pelvic
• USG abdomen
Renal
Pelvirenal
• Straight X-Ray of abdomen - Enlarged renal shadow
• IVU - Flattened and club shaped calyces
Ill. Extrarenal pelvic
• Whitaker Test
lntrarenal pelvic
• CT Scan
IV. Intermittent • Isotope renography - DTPA scan
Persistent Treatment -
□
V. Unilateral • If cause is aberrant renal vessel ➔ Hamilton Stewart operation (kidney mobilised and upper and
Bilateral without renal failure lower poles approximated together so that artery is made to slip away from site of compression)
Bilateral with renal failure • Other causes treated
D Fate of other kidney in unilateral hydronephrosis - ► Posterior urethral valve ➔ cystoscopic fulguration of valve
• Starts hypertrophying in 3 weeks ► Phimosis ➔ circumcision
• Assumes additional function to compensate failure of affected kidney ► BHP ➔ TURP
► Stricture urethra ➔ dilatation, urethrotomy, urethroplasty
□ Clinical features -
• Anderson - Hyne's dismembered pyeloplasty (Spasmodic segment and redundant pelvis excised
A) Unilateral cases :
in congenital PUJ obstruction ➔ new pelvis created ➔ cut end of pelvis anastomosed to the
•Dull aching loin pain + dragging sensation ureter in dependent position)
•Right side more commonly affected • Non-dismembered pyeloplasty (PUJ not transected here)
•Acute renal colicky pain intermittently • Bilateral cases
•Loin swelling with following features : ,.( ';
► Smooth without with renal
► Ballotable renal failure failure
► Mobile J, J,
► Moves with respiration kidney functioning Bilateral nephrostomy
► Band of colonic resonance in front better operated and hemodialysis
• Dietl's crisis i.e., renal colic followed by passage of large volume of urine, thereafter loin first, other kidney
swelling disappears dealt after 3 months
• Renal angle tenderness • Laparoscopic or retroperitoneoscopic pyeloplasty
• Dysuria Q.96: Staghorn calculus
• Hematuria
• Hypertension in some cases STAGHORN CALCULUS
B) Bilateral cases : □ What is it - Stone occupying renal pelvis and calyces
• Features of bladder outlet obstruction - frequency, urgency, hesitancy
□ Synonym - Triple phosphate stone
• Loin pain
□ Content - Calcium phosphate + Aluminium phosphate + Magnesium phosphate
• Attacks of renal colic
□ Laterality - Bilateral
• Loin swelling
• Severe cases - oliguria, edema, hiccough □ Colour - White
□ Consistency- Soft
□ Surface - Smooth
558 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 559

• Orthopantomogram B, Sunderland's Classification

• CT Scan
I. Conduction block
□ Treatment - II. Axonotmesis with preservation of endoneurium
1. Early growth, no bone involved ➔ Curative radiotherapy OR Wide excision Ill. Disruption of endoneurium
2. Growth + Mandible involved ➔ Wide excision + Hemi mandibulectomy IV. Disruption of endoneurium and perineurium
3. Operable growth + Mobile lymph node on same side ➔ Wide excision + Radical neck lymph V. Disruption of endo, peri and epineurium - Neurotrnesis
node dissection (RLND) Q.99 : Venesection
4. Operable growth + Mobile lymph node on opposite side ➔ Wide excision + RLND on same side
+ Functional block dissection on opposite side VENESECTION
5. Fixed primary tumor ➔ Palliative external radiotherapy O Synonym - Venous cut down
OR
O What is it- Procedure in which vein is exposed, venotomy done and a wide bore cannula introduced
Advanced neck lymph node secondaries inside vein under direct vision
6. If extend to upper alveolus ➔ Partial/Total maxillectomy
[J Indications -
7. Others - (a) Post-operative radiotherapy in T3, T 4
• In patients requiring prolonged intravenous fluid therapy
(b) Prophylactic block dissection in No
• In patients requiring rapid fluid infusion - e.g., burn, shock
(c) Pre-operative radiotherapy if fixed lymph node
• For measurement of CVP
8. Chemotherapy before and after surgery
• For parenteral nutrition
9. Post-operative reconstruction by flap surgery
□ Veins selected -
~-9B~~ion of nerve injury • Basilic vein
• Cephalic vein
~~ CLASSIFICATION OF NERVE INJURY
• Great saphenous vein [advantage is that it is superficially placed] (sometimes contraindicated as
A. Seddon's Classification - vein used for CABG)
• NEUROPRAXIA: □ Steps -
► Temporary yhysiqlog_ical paralysisof nerve conduction Area cleaned with povidone iodine and draped
j,
► No organic damage to nerve fibre or sheath
1% lignocaine injected transversely across the vein
► Produced by minor stretching j,
► No reaction of degeneration Transverse incision made across the vein and deepened upto subcutaneous tissue
► Recovery complete, taking hours to weeks j,
Vein dissected from surrounding tissue
• AXONOTMESIS:
j,
► .Bu2ture of nerve fibres or_~xons within intact nerve sheath Ligatures passed proximal and distal to the incision site around the vein, but only the distal one is tied
► Wallerian degeneration occurs in distal portion of broken axons leaving nerve sheaths tightly, held by hemostatic forceps
empty j,
► Time required for recovery varies - occurs first in muscle nearest to lesion and lastly in Curved needle passed through middle of vein (to facilitate venotomy)
peripheral skin j,
► Produced by compression by tourniquets, stress due to fractures, dislocations, etc Vein wall in front of needle incised
j,
► C/F ➔ loss of sensation, diminished tone and power, anesthesia and paralysis of muscles
6F size infant feeding tube or scalp vein catheter introduced
pestricted to area supplied by damaged nerves j,
► Treated by proper nutrition, passive movement of joints, exercise of paralysed muscles Proximal ligature tied to fix cannula with in vein
• NEUROTMESIS : j,
► Partial or complete division of nerve fibres _?ncl_th~~heaths End of cannula tied to intravenous fluid channel
j,
► Partial lesion produces lateral neuroma, complete lesion produces terminal neuroma
Cannula fixed to skin by a suture passed around it and skin incision closed with interrupted skin sutures
► Retrograde degeneration occurs upto first node of Ranvier
► C/F - complete loss of motor and sensory function and loss of reflexes □ Complications -
► Recovery incomplete • Hemorrhage
► Treated by nerve suturing • Infection
 $0LVED SHORT NOTES OF SEMESTERS 561

□ Signs -
• Abdominal lump with following features -
► firm/hard
► smooth
,.\·. lobular
► mobile
► bimanually palpable
► moves with respiration
,,
\•
dullness in renal angle
► resonant band in front
► located in loin
► does not cross midline
• Hypertension
□ Investigations -
• Complete blood count - polycythemia,
• USG abdomen
• CT Scan abdomen
• Straight X-ray - enlarged renal shadow, eggshell peripheral calcification
• Renal angiography
• Radioisotope scan
□ Treatment -
• Unilateral ➔ Nephrectomy + postoperative radiotherapy
• Bilateral ➔ Bilateral partial nephrectomy
OR
Nephrectomy on one side (Nephron sparing surgery) + partial nephrectomy on other side
• Chemotherapy - Actinomycin D, Vincristin, Doxorubicin (may be given pre-operatively)

0.101 : CYSTS
□ What is it - Collection of fluid in a sac lined by endothelium or epithelium
□ Classification -

CYSTS

Congenital Acquired Cystic tumor Traumetic

• Cysts of embryonic • Exudation Eg: Dermoid cyst of cyst
remnant Eg: Bursa, ovary,
Eg : Urachus cyst hydrocele Cystadernoma
• Dermoid cyst • Distension Parasitic cyst
Eg: Sequestration Eg: Ovarian cyst, Eg: Hydatid
dermoid Lymph cyst cyst
. Tubu/odermoid . Retention
Degenerative
cyst
Eg: Thyroglossal Eg : Epididymal cyst,
Necrosis of
cyst Sebaceous cyst
tumor

71
 SOLVED SHORT NOTES OF SEMESTERS 563
562 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

rumor markers - Substances found in blood, urine or body tissues that are elevated in specific
□ Clinical features -
cancers
• Smooth
Detected by - lmmunohistochemistry
• Cystic in consistency
• Hemispherical shape rumor markers raised in different testicular tumors -
• Non-tender • Alphafetoprotein (AFP) - Raised in teratoma
• Well-localised • ~-HCG - Raised in a) chorio carcinoma
• Fluctuant b) teratoma
Non seminomatous
• May be transilluminant c) embryonal carcinoma ] germ cell tumor
□ Effects - d) 10% advanced cases of seminoma
• Compression of adjacent structures • Placental alkaline phosphatase - Raised in seminoma
• Infection • LOH - Raised in 80% advanced seminoma,
• Hemorrhage 60% non-seminomatous germ cell tumor
• Rupture □ Importance of tumor markers - Helps in detecting seminoma and teratoma as mode of treatment
• Calcification is different for the two varieties
• Torsion Seminoma ➔ a) High orchidectomy + radiotherapy
□ Brilliantly transilluminant cysts - b) Cisplatin (chemotherapy)
• Ranula Teratoma ➔ a) High orchidectomy + Retroperitoneal Radical Lymph Node Dissection (RPLND)
• Lymph cyst b) Cisplatin (chemotherapy)
• Epididymal cyst
Q.103: Primary hydroce/e
□ False cysts -
PRIMARY HYDROCELE
• Pancreatic pseudocyst
• Cystic degeneration of tumor □ Hydrocele - Abnormal collection of serous fluid in between the two layers of tunica vaginalis or
• Post-hemorrhage in a hematoma within some part of processus vaginalis
• Apoplectic cyst in brain □ Primary hydrocele - Hydrocele whose cause is unknown
□ Types of primary hydrocele -
Q.102: TESTICULAR TUMOR MARKERS
• Vaginal hydrocele (commonest)
□ Histological classification of testicular tumors • Congenital hydrocele (whole processus vaginalis remains patent)
• Funicular hydrocele (processus vaginalis patent upto top of testis)
• Infantile hydrocele (tunica vaginalis and processus vaginalis distended upto internal ring, but sac
has no connection with peritoneal cavity)

~c-i
Germ cell tumors Sex cord stromal
tumor
Sertolicell
tumor
Combined germ cell
and sex cord
stromal tumor

t
t
Others

Lymphoma

Carcinoid
•
•
•
•
Encysted hydrocele of cord
Hydrocele of canal of Nuck (in relation to round ligament)
Hydrocele of hernial sac (due to adhesions in hernial sac)
Bilocular hydrocele/hydrocele-en-bisac (two intercommunicating sacs)

Non-seminomatous
Leydig cell Gonadoblastoma □ Composition of hydrocele fluid -
tumor • Colour - Amber
Choriocarcinoma • Specific gravity - 1.022 - 1.024
Granulosa cell
Teratoma tumor • Content - ► water
Secondaries
► inorganic salts
Embryonal
Adnexal and ► 6% albumin
carcinoma
para testicular ► fibrinogen

t
Yolk sac tumor tumor ► cholesterol and tyrosine crystals
Sarcoma Cl Aetiology -
• Defective absorption of hydrocele fluid
Mesothelioma • Excessive production of hydrocele fluid
564 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 565

• Interference with lymphatic drainage of the fluid • Disappears in supine posture as fluid in tunica vaginalis drains into abdominal cavity
• Connection with peritoneal cavity • Not easily reducible
□ Clinical features - , Cannot be emptied by digital pressure as it causes "inverted ink bottle" effect
• Age - Congenital variety since birth, rest in middle aged people rreatment-
• Scrotal swelling (inguinal swelling in funicular type, inguinoscrotal swelling in infantile type) Hermiotomy
With following features : 05 : Encysted hydrocele of cord
► Unilateral/bilateral
► Possible to gel above swelling in vaginal type ENCYSTED HYDROCELE OF CORD
► Fluctuation test positive
Hydrocele - Abnormal collection of serous fluid in between the two layers of tunica vaginalis or
► Transillumination test positive within some part of processus vaginalis
► Dull on percussion
Encysted hydrocele of cord - Central portion of processus vaginalis remains patent, (upper and
► Irreducible lower parts become obliterated) around which fluid accumulates
► Testis cannot be felt separately (in vaginal type) Naming - Named so, as it presents as a swelling in relation to spermatic cord
► Congenital hydrocele disappears when patient lies supine
Features of hydrocele fluid - See 'Primary Hydrocele'
► Traction test pathognomonic in encysted hydrocele of cord
Clinical features -
► Cross fluctuation test pathognomonic in bilocular hydrocele
• Cystic swelling in inguinal, inguino - scrotal or scrotal region depending on the site of patent
□ Complications -
processus vaginalis
• Infection • Oval cysting swelling in relation to spermatic cord
• Rupture Fluctuation test positive
• Calcification of sac • Transillumination test positive
• Haematocele • Testis can be felt separate from the swelling
• Atrophy of testis
·z
• Irreducible
□ Treatment - ~11 , Cough impulse absent
• Vaginal hydrocele : 'if , Traction test pathognomonic (on gentle traction, swelling moves downwards and becomes less
► Small - Jaboulay's method of eversion of sac mobile)
► Big - Lord's plication Complications - See Section - 1, Segment - 1, 0.103, 'Primary Hydrocele' (Page No. 563)
• Encysted hydrocele of cord - Excision Treatment - Excision
• Congenital hydrocele - Herniotomy l,Q,106: Secondary hydrocele
Q.104: Congenital hydroce/e
SECONDARYHYDROCELE
CONGENITAL HYDROCELE i □ Hydrocele - Abnormal collection of serous fluid in between the two layers of tunica vaginalis or
□ Hydrocele - Abnormal collection of serous fluid in between the two layers of tunica vaginalis or"i within some part of processus vaginalis
within some part of processus vaginalis □ Secondary hydrocele - Hydrocele is secondary to a disease in testis and/or epididymis
□ Congenital hydrocele - Processus vagihalis remains patent, hence tunica vaginalis directly,: □ Aetiology-
communicates with peritoneal cavity A) Infection - • Acute epididymoorchilis
[Hernia does not occur as the communicating orifice at deep inguinal ring is too small for protrusion i • Filarlasis Due to excess production of

□
□
of abdominal contents]
Aetiology- (a) Tuberculous peritonitis in children (b) Ascites
Age - Present since birth B) Malignancy
•
•
Tuberculosis
Syphilis J hydrocele fluid

□ Features of fluid - See 'Primary Hydrocele' (Page No. 563). C) Trauma - Postherniorraphy hydrocele
□ Clinical features - lnguinoscrotal swelling with following features : Cl Features of hydrocele fluid - See 'Primary Hydrocele' (Page No. 539).
• Appears in erect posture
 566 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 567

• Pressure garments
□ Clinical features -
• Management of :tchinti at scar regions using antihistaminics, moisturising creams, aloe vera
• Small swelling (except in filariasis)
• Silicone gel treatment
• Lax
• Testis palpable i·:·;·}.Q
Q. 11.0088~:
\l ~ -
• Fluctuation positive ;2,t)~~.// VOLVULUS
• Transillumination positive ~"/'.,\-

□ Treatment - o What is it - Rotation of gut in its own axis in clockwise or anticlockwise direction
• Rest O Sites -
• Aspiration • Sigmoid colon (commonest)
./~ ~·· ..Antibiotics Caecum
Small intestine (volvulus neonatorum) - See Sec-1, Sec - C, MB Paper I, 2014, Q. 4 [Pg. 313]
"'/a:fo1: Post-burn contracture
Stomach
POST-BURN CONTRACTURE o Sigmoid volvulus - Sigmoid colon rotates in its own axis in clockwise or anticlockwise direction to
□ What is it - Tightening of skin after a second or third degree burn cause acute intestinal obstruction
·-----·-- --- __. _____.._____ - .. ·-----·-------------~--
•..
O Predisposing factors -
□ Aetiology- When a skin gets burnt, the surrounding skin begins to pull together, resulting in contracture
□ Effects - • Overloaded colon
• Face Disfigurement • Long pelvic mesocolon
• Eye ,- Ectropion • Adhesions
Y Entropion • Short/narrow attachment of sigmoid mesocolon
► Corneal ulcer • Peridiverticulitis
► Corneal sclerosis □ Pathophysiology -
• Mouth - Microstomia • < 1½ turn ➔ venous obstruction ➔ congestion ➔ CO2 diffuses into lumen ➔ huge colonic
• Neck Restricted neck movement distension
• Finger - ► Swan neck deformity • > 1½ turn ➔ arterial obstruction ➔ gangrene ➔ perforation ➔ peritonitis
(DIP hyperflexion, PIP hyperextension) □ Clinical features -
► Boutennaire deformity • Age - Elderly
(PIP hyperflexion, DIP hyperextension) • Sex predilection - M > F
• Limbs - Contracture and restricted movements at wrist, elbow, knee, ankle, toes • Sudden colicky lower abdominal pain starting from left side and then spreading throughout abdomen
• Marjolin's ulcer (See Short Note 'Marjolin's ulcer', Page No. 421) • Huge abdominal distension
• Others - ► Hypertrophic scar and keloid • Absolute constipation
>- Growth retardation in children • Vomiting (very late feature)
► Repeated breaking of scar, infection • Features of shock
► Pain, tenderness in scar contracture • Tyre-like feel of abdomen
□ Prevention - □ Investigations -
• In case of burnt hand ➔ splinting of hand and wrapping of each finger individually • Routine blood investigations
• In case of burnt neck ➔ hyperextension of neck during healing process • Straight X-ray abdomen
• Joint exercise in full range during recovery (a) Dah/-Froment's sign or Coffese bean sigr:l. or Bent inner tube sign :
• Topical silicon sheeting ► Hugely dilated large gut loop extending from pelvis to upper abdomen
• Saline expanders for scar ► Two loops distinctly seen with outer borders
• Pressure garments for long period ► Intervening wall formed by inner walls
□ Treatment - ► Distended gut walls seem to be converging towards pelvis
• Release of contracture surgically ➔ use of skin graft or 'Z-plasty'
568 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 569

(b)n (omega) sign : Single grossly dilated loop of colon arising out of pelvis and extending Clinical features -
towards diaphragm Marked abdominal distension
• Contrast enema - Bird's beak sig!}_ Absent bowel sounds
• CT abdomen
• No passage of flatus - Absolute constipation
□ Treatment - Vomiting (effortless)
• Hospitalisation • Absence of pain/dull abdominal pain
• Resuscitation with i.v. fluids • Tachycardia
• Catheterisation • Respiratory distress
• Antibiotics • Features of electrolyte imbalance
• Flatus tube/Sigmoidoscope passed □ Investigations -
• X-ray abdomen - Multiple fluid levels and gas shadow
If derotation occurs Derotation does not occur
J, • USG abdomen
J,
• ECG
Patient passes flatus Laparatomy through midline incision
• Serum electrolytes estimation
and faeces, distension
reduces J, □ Treatment -
Dilated sigmoid colon derotated manually • Nasogastric aspiration
J,
Checked for viability
• i.v. fluid administration

.! \; • Intestinal decompression using flatus tube

If viable Not viable Electrolyte management
J, J, Primary cause treated
Sigmoidopexy Resection and anastomosis • Urine output measurement by catheterisation
ii' \;
Distal end brouqht out as Distal end closed
CAUSES OF INTESTINAL OBSTRUCTION
mucus fistula from rectum (Hartmann's operation)

Q.109:
(Paul - Miculicz operation)

PARALYTIC ILEUS Duodenum

and
l
Ileum Large intestine
□ Synonym - Adynamic intestinal obstruction • TB strictures • TB stricture
Jejunum • Gall stone ileus • Malignancy
□ What is it - State of failure of transmission of peristaltic waves due to neuromuscular failure in
• Congenital • Malignancy • ARM
Auerbach's and Meissner's plexus
• Leiomyoma • Hernias • Volvulus
□ Pathogenes is - • Lipoma • Roundworm • Congenital
Failure of transmission of peristaltic waves • Malignancy • Congenital megacolon
J, • Bands and adhesions • Crohn's disease • Bands and adhesions
Accumulation of intestinal fluid and gas in lumen
J,
Abdominal distension Q.110 MECONIUM ILEUS
□ Types - □ What is it - Neonatal manifestation of fibrocystic disease of pancreas, where intestinal obstruction is
Types Causes ~~~used by impaction of meconium in distal ileum ·~
□ Associated with - Cystic fibrosis, respiratory dysfunction, exocrine pancreatic insufficiency
• Postoperative paralytic ileus • Infective - pus, blood, bile, toxins
• Peritonitis . Uraemia, Hypokalemia
□ Clinical features -

• Metabolic paralytic ileus . Retroperitoneal hemorrhage

•
•
Occurs in neonates
Distended abdomen
. Reflex paralytic • Spinal injury, Plaster jacket • Ascites (due to meconium spillage from perforation or inflammatory response to the ischaemic,
over distended small intestine)

72
570 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 571

• Failure of passage of meconium Levels of SSI Clinical features

• Bilious vomit
3) Organ or space infection • Abscess formation
• Respiratory dysfunction (Affects part of the body which
• Small and empty rectum has not been manipulated
□ Investigations - during surgery)
• Plain X-ray abdomen : Calcified meconium pellets with multiple air fluid levels appearing as soap
□ Risk factors -
bubbles (Neuhouser sign)
• Vomitus (containing trypsin) does not digest gelatin of X-ray film when poured on it • Factors that increase risk of endogenous contamination
- e.g., procedures that involve body parts with high concentration of normal flora, such as the
• Sweat analysed for sodium and chloride (> 90 m mol/lit)
bowel
• Contrast enema - Microcolon + terminal ileum filled with pellets of meconium
• Elevated albumin level in meconium • Factors that diminish efficacy of general immune response
- e.g., steroids, immunosuppressive therapy
□ Complications -
• Factors that increase the risk of exogenous contamination
• Intestinal bolus obstruction - e.g., Prolonged operations
• Volvulus
□ Age-
• Gangrene
• Perforation • Age more than 40 years is a risk factor
• Peritonitis Q.112: Abscess
□ Treatment - (i) Non-operative (ii) Operative ABSCESS
• Non-operative :
□ What is it - Localised collection of pus in a tissue space, organ or cavity
,, Gastrograffin contrast enema
► Acetylcholine wash □ Types -
,, Treatment for cystic fibrosis • Pyogenic abscess
• Operative : • Pyaemic abscess
• Metastatic abscess Rest: See Next Os. (Q.113 & O.114)
► Bishop Koop operation
• Cold abscess
Q.111 : Surgical site infection
0.113: Pyogenic Abscess
SURGICAL SITE INFECTION □ Define - Localised collection of pus in a cavity, lined by granulation tissue, covered by pyogenic
membrane
□ Surgical site - Incision or cut in skin made by a surgeon to carry 9ut a surgical procedure and the
tissue handled or manipulated during the procedure· □ Causative organisms -
□ Surgical site infection - This occurs when microorganisms gain entry into the part of the body that • Staphylococcus aureus
has been operated on, and multiply in the tissues • Streptococcus pyogenes
□ When does it become apparent - • Anaerobes
• Gram negative bacteria
• Most often between 5th - 10th post-operative day
□ Mode of infection -
• SSI affecting deeper tissues occurs after several months of the operation
• Direct
• Levels of SSI Clinical features • Haematogenous
1) Superficial incisional • Swelling • Lymphatics
(Affects skin and • Pain • Extension from adjacent tissues
subcutaneous tissue) • Redness □ Risk factors -
• Heat at site of SSI • Malnutrition
2) Deep incisional • Fever • Anaemia
(Affects fascia! and • Presence of pus • Extremes of age
muscle layers) • Tenderness • DM
• Throbbing pain • HIV
• Separation of edges of incision exposing
• RTA
deeper tissues
• Type and virulence of . •nisms
572 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

□ Pathogenesis - [See Fig. 1.7.6] • Mode of treatment :

• Macrophages and polymorphs release lysosomal enzymes which cause liquefaction of tissues ► Drainage of abscess
➔ pus formation ► Antibiotics
• Protein exudation ➔ fibrin deposition + pyogenic membrane formation Q.114 : Cold Abscess
□ Clinical features -
• Localised swelling ➔ smooth, soft, fluctuant COLD ABSCESS
• Fever with chill and rigor • No signs of inflammation
• Visible (pointing) pus • Caused by Mycobacterium tuberculosis
• Throbbing pain • Non-dependent incision given
• Pointing tenderness • No drain placed
• Redness, local warmth at site of abscess
Q.115 : Necrotising fasciitis
D Sites -
A) External B) Internal NECROTISING FASCIITIS
• Neck • Retroperitoneal □ What is it - Spreading inflammation of skin, deep fascia and soft tissues with extensive destruction
• Axilla • Lung and toxaemia
• Breast • Brain □ Causative organisms -
• Dental • Retropharyngeal
. Abdominal wall
• . Streptococcus pyogenes
• Anaerobes
D Investigations - • Gram negative bacteria
• TLC - Raised □ Sites -
• Blood sugar • Lower limb
• USG
• Groin
• Gallium isotope scan
• Perineum
• Blood culture
• Lower part of abdomen
D Complications -
□ Risk factors -
• Septicaemia
• Old age
• Antibioma
• lmmunocompromised individuals
• Sinus, fistula
• Smoking
• Brain abscess ➔ RICT, epilepsy
• OM
• Lung abscess ➔ Bronchopleural fistula, ARDS
• HIV
• Liver abscess ➔ Hepatic failure
□ Types -
□ Treatment -
• Principle : • I - due to mixed infection
► Abscess should be formed during draining • II - due to streptococcus pyogenes
• Exceptions : □ Pathology -
► Axillary Acute inflammation
► Breast -1,
► Parotid Edema
-1,
► Thigh
Necrosis
► lschiorectal j,
• Features of formed abscess : Cutaneous microvasculature thrombosis
► Visible pus □ Clinical features -
► Pointing tenderness
• Rapid spread of infection
► Fluctuation
• Sudden swelling and pain in affected part
► Excruciating pain
 574 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 575

• Edema • Discharge study

• Discolouration
• MRI
• Foul smelling discharge
• Oliguria O Treatment -
• Features of toxaemia - low BP, high fever with chill and rigor • Radiotherapy
□ Management - • Exploration of fistula
• Anticholinergics
• i.v. fluid • Newman Sebrock's operation
• Fresh blood transfusion • If still features persist-) secretomotor supply of parotid (CN VIII) is cut
• Antibiotics • If stenosis at orifice of Stenson's duct -) papillotomy at orifice
• Catheterisation • Failed cases ~ Total conservative parotidectomy
• Control of DM
• Pus-culture and sensitivity Q.117: Frey's syndrome
• Blood culture
• Electrolyte management and monitoring FREY'S SYNDROME
• Radical wound excision of gangrenous skin and necrosed tissue at repeated intervals
□ Synonyms -
• Oxygen inhalation
• Vacuum assisted dressing • Auriculotemporal syndrome
• Split skin graft when healthy granulation tissue appears • Gustatory sweating
• Baillarger's syndrome
/9,1y/4rotid fistula • Dupuy's syndrome
\// □ Named after -
/<: ·· PAROTID FISTULA
• Lucie Frey (Polish surgeon)
□ What is it - Fistulous tract connecting parotid duct/gland to external skin
·-···-----·-·· -- ·--··-···-···--··-----.....::.c.;:.;.;.._ □ What is it - A condition where there is sweating of the face during chewing of food
□ Origin - From parotid duct/gland/ductules
□ Pathology -
□ Opening -
Intercommunication between post-ganglionic parasympathetic fibres from otic ganglion and
• Inside mouth (internal fistula)
sympathetic nerves from superior cervical ganglion
• Outside mouth (external fistula) j,
□ Types - Occurs in auriculotemporal nerve
• Major (when tract connects parotid duct) j,
• Minor (when tract communicates with minor ductules or acini) Auriculotemporal nerve has 2 branches
IC
□ Aetiology - Auricular branch Temporal branch
• After drainage of parotid abscess j, t
Supplies external acoustic meatus, skin of auricle Supplies hairy skin of temple
• After superficial parotidectomy
• Trauma above external acoustic meatus, surface of
tympanic membrane
• After biopsy
t
□ Discharge - Injury to auriculotemporal nerve
• Profuse amount from duct j,
• Minimal from gland Sweating and hyperaesthesia occurs in the area of skin supplied by its branches
□ Clinical features - □ Aetiology - Surgery/accidental injury to parotid gland or temporomandibular nerve
• Passage of saliva through external opening - 'Agwavated dur!r:ill...@king food □ Clinical features - Flushing+ sweating+ pain+ hyperaesthesia - in skin over face during mastication
Tenderness ······----··· ----
• □ Investigation - Starch-iodine Test
• Trismus
Involved skin painted with iodine
□ Investigations - j,
• Sialography
Dried
• Fistulogram
 SOLVED SHORT NOTES OF SEMESTERS 577
576 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

j,
Dry starch applied over it
j,
Blue cotour in affected area Oblique fibres of
thyropharyngeus
(due to increased sweat in affected area)
□ Treatment -
• Jacobsen neurectomy Killian's dehiscence
• lnj. Botulinum toxin to affected skin
• Antiperspirants
Pharyngeal pouch
• Sternomastoid flaps placed over parotid bed

Q.118 : Adenolymphoma 1---------~~ cricopharyngeus

Transverse fibres of

ADENOLYMPHOMA
□ Synonyms - Fig. 1.7.1 : Pharyngeal Pouch

• Warthin's tumor
• Papillary cystadeno lymphomatosum
□ What is it - Monomorphic adenoma arising from parotid epithelium
□ Origin - During embryonal life, jugular lymph sacs get trapped
□ Site - Usually lower pole of parotid gland
□ Composition -
(i) Double layer of columnar epithelium
External laryngocele
{ii) Lymphoid tissue in stroma
(iii) Papillary projections into cystic spaces
□ Age - 60 years and above
□ Sex predilection - M » F
□ Clinical features -
Swelling with following features :
Thyrohyoid membrane
• Smooth
• Soft
• Cystic
• Often bilateral
• Non-tender
• Fluctuation positive
• Transillumination negative
• In lower pole of parotid gland Fig. 1.7.2 : Laryngocele
□ Investigations -
• FNAC
• Tech 99 m scan ➔ "hot spot" {diagnostic)
□ Treatment -
• Superficial parotidectomy

73
578 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 579

Matting

Penis

·I. . . . . . Stage 3
Stage 1 Stage 2
Superficial
fascia

Fibrous band
(Chordee) Deep fascia

Fig. 1.7.3 : Chordee

Stage 4 Stage 5

Fig. 1.7.5 : Collar stud abscess

~ Hypertrophied zone (most proximal part with normal ganglion

cells, dilated with hypertrophied circular muscle fibres)

Pyogenic membrane

Transition zone (proximal to aganglionic zone, contains few

ganglion cells forming a cone)

Aganglionic zone (distal immobile spastic segment)

Fig. 1.7.4 : Hirschsprung's disease

Fig. 1.7.6 : Pyogenic Abscess

 SOLVED SHORT NOTES OF INVESTIGATIONS 581
SEGMENT-E

SOLVED SHORT NOTES OF INVESTIGATIONS Criteria for positive lavage indicating trauma :
• > = 10ml blood
• ABC count > 1lakh/mm3
• WBC count > 500/mm3
F.A.S.T • Amylase level in fluid > 175 IU/dl
□ Full form : Focussed Abdominal Sonar Trauma • Presence of bile, bacteria, food particles or foreign body
□ What is it: Rapid bedside USG contraindications :
·□ Purpose : Screening test for blood collected around heart or abdominal organs after trauma • When laparotomy is definitely indicated
-□ Areas examined : "4P" • Previous laparotomy
• Pouch of Morrison/Hepatorenal recess • Pregnancy
• Perisplenic space • Obesity

.
• Pericardium Disadvantages :
----- • Invasive
~
□ Extended F.A.S. T: Also allows for the examination of both lungs by adding bilateral anterior thoracic • Not portable i.e. not a bedside method
sonography to the F.A.S.T examination ➔ allows detection of pneumothorax ·· • No quicker assessment
-~---"·" ~~-· " . ·- ,.., .,,~................,,. ,.,.,,,,~... " • " -
.. ' ' "

□ Advantages : □ Now replaced by :

• Less invasive than Diagnostic Peritoneal Lavage F.A.S.T
• Involves no exposure to radiation
Q. 3 : SPECT Scan
• Cheaper than CT scan, but similar accuracy
• Quicker evaluation of trauma patients SPECTSCAN
• Portable bedside method Q Full form : Single Photon Emission Computed Tomography
□ Disadvantages : Q What is it: Nuclear medicine tomographic imaging technique using gamma rays, showing how blood
• Cannot detect blood < 100ml in cavities flows to tissues and organs
• Not reliable for bowel or penetrating injuries □ Working principle :
• Often needs to be repeated
Integrates 2 technologies to view the body - (a) CT scan (b) Radioactive material
□ Interpretation: Positive F.A.S.T result ➔ appearance of a dark (anechoic) strip in dependent areas
Patient injected with a radiolabelled chemical
Right upper quadrant - Morrison's pouch !
Left upper quadrant - Perisplenic space Emits gamma rays detected by scanner
Pelvis - Behind bladder (Pouch of douglas) ! .
□ What is done next: Computer collects this information
/ Stable patient ➔ CT scan !
Positive result Translates it into 2-D cross-sections
~ Unstable patient ➔ Laparotomy !
Negativ;,resuU_7 Search for extra - abdominal sources of bleeding These cross-sections added together to form a 3-D image
-- /
Q/:Di!Jldostic peritoneal lavage □ Radioisotopes used:
• Iodine - 123
__.,,-/~-- _,,/ DIAGNOSTIC PERITONEAL LAVAGE (DPL)
• Technetium - 99m
□ First described by : Hauser Root in 1965 • Xenon - 133
□ Indication : Blunt injury abdomen making the patient unstable • Fluorine - 18
□ Procedure : Through a subumbilical lavage catheter, 1It N.S/R.L is infused into the peritoneal cavity • Thallium - 201
➔ patient changed to different positions ➔ fluid content is aspirated from abdomen for assessment □ Advantages over PET scan :
• Tracer stays in blood stream rather than being absorbed by surrounding tissues, thereby
580 limiting images to areas where blood flows
 582 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 583

• Cheaper Procedure : Patient ingests gas pellets + citric acid to expand stomach ➔ 3 cups(709 ml) of barium
• More readily available sulphate ingested ➔ patient rolls over to coat the oesophagus, stomach, duodenum ➔ X-ray films
□ Uses: taken in different positions
Helps to detect the following - Types:
• Reduced blood flow to myocardium or injured sites in brain • Single contrast (using only barium sulphate)
• Presurgical evaluation of medically uncontrolled seizures • Double contrast (barium sulphate+ radioluscent contrast e.g. air, Co2, N2)
• Blood deprived (ischaemic) areas of brain following stroke Uses:
• Brain tumors Used to detect :
• Fracture in spine • CA stomach -
□ Contraindications : ► irregular filling defect
Pregnant and lactating mothers ► loss of rugosity
► delayed emptying
0. 4: Barium swallow X-ray ► dilated stomach
► margin of lesion projects outward from lesion into gastric lumen(Carmann's menis-
BARIUM SWALLOW X-RAY
cus sign)
□ Synonym : Oesophagography • Gastric ulcers -
□ What is it : Medical imaging procedure used to examine and diagnose pathological conditions of ► niche on lesser curve, notch on greater curve
upper GIT (Oesophagus and some part of stomach) ► ulcer crater projects beyond the lumen of ulcer
□ Principle: X-ray pictures are taken while barium sulphate coats oesophagus and stomach as patient ► regular margin of ulcer crater - 'stomach spoke-wheel pattern'
swallows the contrast material ► overhanging mucosa at margins of a benign ulcer projects inwards towards ulcer -
□ Pro_cedure: Patient drinks barium sulphate suspension ➔ as he swallows, fluoroscopy images taken Hampton's line
m different positions @ 2-3 frames/sec ► converging mucosal folds towards base of ulcer
□ Uses : Helps lo detect following conditions • Duodenal ulcers -
• Achalasia cardia - 'rat tail' deformity or 'bird's beak' appearance a) absence of duodenal cap
• CA oesophagus - irregular filling defect b) 'trifoliate' duodenum due to secondary duodenal diverticula which occurs as a result
• Tracheo - oesophageal fistula of scarring of ulcer
• GERD c) ulcer crater
• Zenker's diverticulum • Diverticula
• Hiatus hernia • Polyp
• Oesophageal stricture • Motility abnormalities
□ Disadvantages : □ Diadvantages :
• Gas production in stomach
• Gas production in oesophagus
• Irradiation
• Irradiation
□ Contraindication :
□ Contraindication :
• Children
• Children
• Pregnancy
• Pregnancy
Q, 6: Barium follow through X-ray
Q. 5: Barium meal X-ray
BARIUM FOLLOW THROUGH X-RAY
BARIUM MEAL X-RAY
□ What Is it : Medical imaging procedure used to examine and diagnose pathological conditions of
□ Synonym: Upper GI series small intestine
□ What is it : Medical imaging procedure used to examine and diagnose pathological conditions of □ Principle : X-ray pictures are taken while barium sulphate coats small intestine after patient ingests
lower part of oesophagus, stomach and duodenum the contrast material
□ Principle : X-ray pictures are taken while barium sulphate coats oesophagus, stomach and duode• □ Procedure : Patient ingests gas pellets + citric acid to expand stomach ➔ barium sulphate ingested
num after patient ingests the contrast material ➔ patient rolls over to coat the small intestine ➔ X-ray films taken in different positions at 0, 20, 40 and
90 mins
 584 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 585

□ Indication of completed test: When contrast material has reached terminal ileum and caecum Q. 8: Double contrast barium enema
□ Uses:
Used to detect :
DOUBLE CONTRAST BARIUM ENEMA
• Crohn's disease - intermittent sections of strictured bowel □ What is it: A procedure in which X-rays of colon and rectum are taken after a liquid containing barium
• Ulcerative colitis is put into rectum. Then air inflates colon to give a better contrast to visualise mucosa of colon
• Small intestinal tumors □ Synonyms:
□ Disadvantages : • Lower gastrointestinal series
• Gas production in small intestine • Air contrast barium enema
• Irradiation □ Procedure :
□ Contraindication : Laxative ingested previous night
• Children J,
• Pregnancy Via enema tube 1 litre barium sulphate solution infused into colorectum per anally
J,
Q. 7: Barium enema X-ray
X-ray taken
BARIUM ENEMA X-RAY J,
□ Synonym : Lower gastrointestinal series Patient asked to evacuate bowel
J,
□ What is it : Medical imaging procedure used to examine and diagnose pathological conditions of
colon Post-barium evacuation X-ray taken
J,
□ Principle : X-ray pictures are taken while barium sulphate fills the colon via rectum
□ Procedure : Colon inflated with air
J,
Patient lies on X-ray table ➔ control X-ray taken ➔ patient asked to lie on the side ➔ a well-lubricated
enema tube is inserted into rectum ➔ barium sulphate, a radioopaque contrast medium is allowed to X-ray taken
flow into the colon ➔ flow is monitored on X-ray fluoroscope screen ➔ patient assumes different
□ Indications :
positions and the picture in different positions are taken
□ Preparation of patient:
INDICATIONS
• Liquid diet
• Drinking Magnesium citrate and warm water enemas to clear out any stool particle I
• Check history of allergy to barium ~
□ Types: Therapeutic Diagnostic
• Single contrast (using only barium sulphate) lntussusception in • CA colon (irregular filling defect)
children
• Double contrast (barium sulphate + radioluscent contrast e.g. air, CO 2 , N2 ) • Ulcerative colitis (lead pipe appearance)
□ Purpose: • lleocaecal TB (obtuse ileocaecal angle)
• Identify inflammation of intestinal wall - e.g. IBD • Congenital megacolon (narrow zone, then
• Monitor progress of IBD zone of cone, followed by dilated proximal
• Detect strictures, diverticula, Hirchsprung's disease segment)
• Help correct intussusceptions • Diaphragmatic hernia (colonic shadow in left
thoracic cavity)
• Evaluate abdominal symptoms such as pain, blood in stool, altered bowel habit
• Evaluate anorexia, anaemia, weight loss • Colonic polyp (smooth, regular filling defect)
• Functional cause considered (irritable bowel syndrome) if picture normal
□ Variant: □ Contraindication :
If perforation detected, water used instead of barium Any acute condition of colon
□ Risks: □ Complications :
• Exposure to X-ray • Constipation
• Bowel perforation • Cramping
• Colon puncture

74
 586 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 587

• Therapeutic -
► Endoscopic sphincterotomy (both of the biliary and the pancreatic sphincters)
► Removal of stones
□ Full form : Magnetic Resonance Cholangio Pancreaticography ► Insertion of stents
□ What is it: A form of cholangiography that uses magnetic resonance imaging to visualise biliary and ► Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after
pancreatic ducts in a non-invasive manner liver transplantation)
□ Introduced in: 1991 □ Contraindications :
□ Purpose : Produces detailed images -9.tJ)_ver, _gallbladder, bile duct, ~~~~c!!ld ~-~~~~-~uct • Acute pancreatitis (unless persistently raised or worsening bilirubin suggests ongoing ob-
D Uses: struction)
• Checking liver, bile duct, gall bladder and pancreas for gallstones, tumors, infection or in- • Previous pancreatoduodenectomy
flammation • Coagulation disorder if sphincterotomy planned
• Investigating pancreatitis • Recent myocardial infarction
• Investigating abdominal pain • Inadequate surgical back-up
• Best used when serum bilirubin <1 0mg/dl and no pre-operative stenting is contemplated • History of contrast dye anaphylaxis
□ Checklist before MRCP : • Poor health condition for surgery
• Internal pacemaker/defibrillator • Severe cardiopulmonary disease
• Cochlear implant □ Technique :
• Surgical clip
Patient is sedated ➔ endoscope is inserted through the mouth, down the oesophagus, into the
• Prosthetic heart valve stomach, through the pylorus into the duodenum where the ampulla of Valer is visualised ➔ a cannula
• Artificial :,mb is inserted through the ampulla ➔ a radiocontrast dye (60% urograffin) is injected into the bile ducts
• Implanted electronic device and/or pancreatic duct ➔ fluoroscopy is used to look for blockages, or other lesions such as stones
□ Side-effects : [When needed, the opening of the ampulla can be enlarged (sphincterotomy) with an electrified wire
Reaction to contrast dye when used (sphincterotome) and access into the bile duct obtained so that gallstones may be removed or other
therapy performed]
□ Contraindication : Pregnancy
□ Complications :
□ Advantages over ERCP :
• .N~!L=--..illvasiv.a • Pancreatitis
• Delineate full biliary tree and not just the part proximal to the obstruction • Gut perforation
• No_clye _reqLJired • Oversedation can result in dangerously low blood pressure, respiratory depression, nausea,
• Can be used in acute pancreatitis, duodenal injury, cholangitis and vomiting
□ Disadvantage : ~therapeutic_p_Igcedure like stenting, basketing, biopsy can be carried out • Bleeding after sphincterotomy
• Cholangitis
-~~-- ERCP
0. 77: MRI

□ Full form : Endoscopic Retrograde Cholangio pancreatography

MRI
□ What is it ;f~~hnique that combines the use of endoscopy and fluoroscopy to diagnose and treat □ Full form : Magnetic Resonance Imaging
certain pathologies of the biliary or pancreatic ductal systems □ Synonyms:
□ Indications : • Nuclear magnetic resonance imaging
• Diagnostic - • Magnetic resonance tomography
► Obstructive jaundice □ What is it : Medical imaging technique used in radiology to visualise internal structures of body in
► Chronic pancreatitis details
► Gallstones with dilated bile ducts on ultrasonography □ Types:
► Bile duct tumors • Plain MRI
► Suspected injury to bile ducts either as a result of trauma or iatrogenic • Contrast MRI
► Sphincter of Oddi dysfunction □ Contrast material used : Gadolinium intravenously
► Pancreatic tumors
 SOLVED SHORT NOTES OF INVESTIGATIONS 589
588 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

a. 12: Therapeutic ultrasound

□ Principle : THERAPEUTIC ULTRASOUND
Patient placed in external high magnetic fields ➔ protons of hydrogen atoms rotate in phase with
each other and gradually return to their original position releasing small amounts of energy, which is □ Generally it refers to any kind of procedure that uses ultrasound for therapeutic benefit. Its uses are as
detected by sensitive coils ➔ proton density and relaxation time are assessed by radiofrequency follows:
pulse ➔ computer generates a Gray scale image from this data
• To guide aspiration of amoebic liver abscess
□ Interpretation :
• To guide pericardia! tap
• T 1 relaxation time -·
• Focused high-energy ultrasound pulses can be used to break calculi such as kidney stones
► Time taken to return to original axis
into fragments small enough to be passed from the body without undue difficulty, a procedure
► T 1 images used to find out normal anatomical details
known as lithotripsy
► It has got high soft tissue discrimination
• lntraoperative ultrasound to assess the operability of tumor (extent of tumor, lymph node
► Here fluid looks black
status)
• T 2 relaxation time -
• To treat benign and malignant tumors by a procedure known as "High Intensity Focused
► Time taken by proton to diphase
Ultrasound (HIFU)", also called "Focused Ultrasound Surgery (FUS)". In this procedure,
► Used to assess pathological process generally lower frequencies than medical diagnostic ultrasound is used (250-2000 kHz), but
► Here fluid looks white at significantly higher time-averaged intensities. The treatment is often guided by Magnetic
• Proton density images - fluid looks in between white and black Resonance Imaging (MRl)-this is called "Magnetic Resonance-guided Focused Ultrasound
D Uses: Surgery (MRgFUS)"
To detect the following - • To deliver chemotherapy to brain cancer cells and various drugs to other tissues is called
• Joint pathology detection "Acoustic Targeted Drug Delivery (ATDD)". These procedures generally use high frequency
ultrasound (1-1 O MHz) and a range of intensities (0-20 watts/cm2). The acoustic energy is
• lntracranial lesions focused on the tissue of interest to agitate its matrix and make it more permeable for thera-
• Spinal lesions peutic drugs
• Musculoskeletal lesions
D Special varieties : • Focused ultrasound sources can be used for cataract treatment by phacoemulsification

• MR Angiogram • Low-intensity ultrasound can be used to stimulate bone-growth and to disrupt the blood-
brain barrier for drug delivery
• Cardiac MRI Ultrasound is essential to the procedures of ultrasound-guided sclerotherapy and
• Breast MRI •
"Endovenous Laser Ablation (EVLA)" of varicose veins
• MRCP
• MR Spectroscopy • Ultrasound-assisted lipectomy can be done. Liposuction can also be assisted by ultrasound

D Advantages : • Doppler ultrasound may be used in aiding tissue plasminogen activator treatment in stroke
sufferers in the procedure called "Ultrasound-enhanced systemic thrombolysis", but the pro-
• Artefacts not common cedure is still under trial
• More specific and sensitive than CT scan • Low intensity pulsed ultrasound is used for therapeutic tooth and bone regeneration
• Gives direct anatomical sections of area with lesions at a higher resolution
• Ultrasound can also be used for "Elastography". This can be useful in medical diagnosis, as
□ Disadvantages :
elasticity can discern healthy tissue from unhealthy tissue for specific organs or growths.
• Not easily available Ultrasonic elastography is different from conventional ultrasound, as a transceiver (pair) and
• High cost a transmitter are used instead of only a transceiver. One transducer acts as both the transmit-
• Poor patient compliance ter and receiver to image the region of interest over time. The extra transmitter is a very low
• Difficult in claustrophobic patients frequency transmitter, and perturbs the system so the unhealthy tissue oscillates at a low
• Not ideal in emergencies and critically ill patients frequency and the healthy tissue does not. The transceiver, which operates at a high fre-
• Not useful in lung pathology and subarachnoid hemorrhage quency (typically MHz) then measures the displacement of the unhealthy tissue (oscillating
at a much lower frequency). The movement of the slowly oscillating tissue is used to deter-
□ Contraindications :
mine the elasticity of the material, which can then be used to distinguish healthy tissue from
• Patients with prosthesis in body
the unhealthy tissue
• Those with pacemakers • Ultrasound has been shown to act synergistically with antibiotics in killing of bacteria
• Patients with cochlear implant
□ Precaution :
Remove all metallic foreign bodies and other magnetically attractive materials before this procedure
590 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 591

a. 13: CT scan Advantages :

CT SCAN • 1-2 mm sized sections are possible
□ Full form : Computerised tomography • Amount of exposure to radiation is less
□ Invented by : Godfrey Hounsefield in 1963 • More accurate, sensitive and specific
□ Principle : Narrow X-ray beams are passed from rotating X-ray generator through the gantry where • Small lesions are also detected
patient is placed ➔ X-rays pass through tissues ➔ some rays get absorbed, some pass through, • CT guided biopsies
depending on tissue density ➔ different grades of absorption in different tissues are detected through Disadvantages :
sensitive detectors which are translated to a Gray scale image by a computer • Interpretation by experienced radiologist required
□ Density of tissues : • Artefacts can be present
Numbered as Hounsefield Units (HU) • High cost
Water - zero HU • Not easily available
Air - minus 1000 HU
Bone - plus 1000 HU Q, 14: DRE

Density of other tissues comes in between air and bone DRE

□ Types:
□ Full form : Digital Rectal Examination
• Plain
□ What Is It: Internal examination of rectum by a physician or health care personnel
• Contrast
□ Procedure : Exposure from midchest ➔ patient lies in Simp's position (left leg straight, right leg flexed
□ Newer variant :
at knee and hip and is drawn towards abdomen) ➔ patient asked to relax buttock and take deep
• Spiral CT breaths ➔ physician spreads buttocks apart and examines external area for any abnormality ➔ then
Advantages : he slips his gloved index finger lubricated with lignocaine into the rectum through the anus and
-,,, Reduced scan time palpates the interior for about 1 minute
)., Imaging in both arterial and venous phases possible □ Uses:
Y Impaired lesion detection • Diagnosis of rectal neoplasms
)., Multiplanar and 3-D analysis like CT Angiography • Diagnosis of prostatic disease - tumor, BPH
• HRCT (High Resolution CT) • Estimation of tonicity of anal sphincter - faecal incontinence, neurological disease
,- Used in chest scan, where thin sections are taken to have better quality images • Examination in females for gynaecological palpation of internal organs
□ Contrast agents: • Examination of hardness and colour of faeces
• Ionic - • Prior to colonoscopy or proctoscopy
,- Sodium diatrizoate • To evaluate hemorrhoids
-,,, Meglumine iothalamate - e.g. Urograffin, Conroy • To exclude imperforate anus
- Cheaper, but toxic and anaphylactic • Combined with Faecal Occult Bloodiest to diagnose aetiology of anaemia
• Non-ionic -
-,,, lohexol 0.15(~/
► lopamiro TURP
- Expensive, but safer
□ What is it : _lransurethral resection of prostate is an urological procedure
□ Indications :
□ Indications :
• Trauma - Head injury, chest injury, abdominal trauma, etc.
• Benign prostatic hyperplasia
• Neoplasm - Exact location, size, vascularity, extent, operability
• Late stages of prostatic carcinoma
• Inflammatory conditions - Psoas abscess, pseuodocyst
□ Types:
□ Findings:
• Conventional (monopo/ar) TURP - utilizes a wire loop with electrical current flowing in one
• Extradural hematoma - Biconvex lesion d1reciion (thus monopoTarfffirough the resectoscope to cut the tissue
• Subdural hematoma - Concavoconvex lesion • ,BipQLfl[IURP - newer technique that uses bipolar current !o remove the tissue: allows
• Smooth margin in benign condition saline irrigation and eliminates the need for an ESU grounding pad thus preventing post-
• Irregular margin in malignant condition TURP hyponatremia
592 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF INVESTIGATIONS 593

• Las_e!_pJQ_§Jgte_Ii.!BP- utilizes laser energy to remove tissue (With laser prostate surgery a
fiber optic cable pushed through the urethra is used to transmit lasers such as holmium-Nd • Bacteriological -
:YAG high powered "red" or potassium titanyl phosphate (KTP) "green" to vaporize the ad. ► Clean catch midstream urine specimen
enoma. More recently the KTP laser has been supplanted by a higher power laser source ► > 10 5/ml ➔ significant bacteruria
based on a lithium triboratecrystal, though it is still commonly referred to as a "Greenlight" or • Biochemical -
KTP procedure) ► Electrolytes
• Plasmakinetic resection - uses ionized vapour that heats up by low voltage electricity and
semi-spherical button to vaporize the prostate tissue from inside and only leave a 2-3 mm ► Glucose
► Bilirubin
shell. This procedure is considered to be the least intrusive of all techniques currently avail-
able and has less post-operative complications and a short convalescence
,..
Haemoglobin

□ Procedure : Strips of tissue are cut from bladder neck down to level of verumontanum using high. ► Myoglobin
frequency diathermy current, which is applied across a loop mounted on the hand-held trigger of Urodynamic studies :
resectoscope ➔ proper coagulation of bleeding points ➔ 'chips' of prostate removed from bladder • What is it: Study that assesses how bladder and urethra are functioning
using Ellik evacuator ➔ Hyponatremia prevented by continuous irrigation with 1.5% isotonic glycine • Use : Help explain symptoms -
and recent introduction of continuous-flow resectoscope ➔ a triple lumen catheter is inserted through ► incontinence
the urethra to irrigate and drain the bladder after the surgical procedure is complete ,- frequent urination
□ Complications : ► sudden strong urge, but no micturition
• Bleeding (most common) ► painful urination
• Clot retention and clot colic ► recurrent UTI
• BladdEirwall injury' such as perforation (rare) • Conducted by : urologists, urogynaecologists
• TURP Syndrome : Hyponatremia and wat~llntoxication (symptoms resembling brain stroke □ Specific tests :
in an elderly presenting patient) caused by an overload of fluid absorption (e.g. 3 to 4 Litres) • Post-void residual volume -
from the open prostatic sinusiods during the procedure. This complication can lead to ► Urinary catheter inserted following complete bladder emptying
confusion, changes in mental status, vomiting, nausea, and even coma
► If urine volume >180ml ➔ UTI
[To prevent TURP syndrome 1) The length of the procedure is limited to less than one hour 2)
► If increased urine volume ➔ overflow incontinence
the height of the container of irrigating solution above the surgical table determining the
hydrostatic pressure driving fluid into the prostatic veins and sinuses is kept to a minimum] • Microscopy and culture
• Bladder neck_stenosis • Uroflowmetry -
► Measures how fast patient can empty bladder
• Urinary inc.011.ti.r:t~i!ce - due to injury of external sphincter system which may be prevented by
taking the Verumontanum of the prostate as a distal limiting boundary during TURP ► Pressure uroflowmetry ➔ measures rate of voiding + bladder and rectal pressure
• Fl~t_r2grade ejaculation and impotence , Helps demonstrate - i) bladder muscle weakness ii) obstruction to bladder outflow
• Strictur-~ -u~eth..r? --- --- • Multichannel cystometry -
• Recurrence ► Measures pressure in rectum and bladder using 2 pressure catheters, to deduce
contractions of bladder wall during bladder filling or other provocative maneuvres
a. 16: Investigations of LUTS ► Strength of urethra can be tested during this phase using a cough or Valsalva
INVESTIGATIONS OF LUTS maneuvre - to confirm genuine stress incontinence
• Urethral pressure profilometry - Measures strength of sphincter contraction
□ Urine: • Electromyography - Measurement of electrical activity in bladder neck
• Dipstick test - Chance of infection if colour change due to protein, nitrite
• Assessment of tightness along length of urethra
• Microscopy - • Fluoroscopy- Moving video X-Rays of bladder and bladder neck during voiding
► RBC
► WBC Q. 17: Retrograde pyelography

► Bacteria RETROGRADEPYELOGRAPHY
► Casts
□ What is it: Invasive radiographic examination of kidneys from a distal direction via ureters
• Cytological -
□ Indications :
► Urinary sediment examination
► Bladder tumor antigen detection • Failure to show any dye in IVU in 72 hours film
• Urinary tuberculosis

75
 594 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 595

• Urothelial tumors from renal pelvis Contraindications:

• Asessment of displacement, drainage, enlargement or fixation of structures of renal collecting • Pregnancy
system • Bleeding diathesis
• Detection of complete or partial obstruction due to blood clot, calculus, perinephric abscess uses:
~- ' Visualise ureters when other procedures like IVP and Retrograde pyelogram have not pro-
• Assessment for integrity of renal pelvis and ureters after blunt trauma
•
vided definite information
• Hypersensitivity to iodine based contrast material lion of urinary tract due to stricture, stones, clot, tumor
□ Procedure :
Under general anesthesia, cystoscope passed and ureteric orifice visualised ➔ ureteric catheter
passed ➔ sodium diatrizoate dye is injected ➔ patient put in 15 degrees head down position to allow INTRAVENOUS URETHROGRAM
dye to reach upper urinary system ➔ X-Ray taken
What is it: A radiological procedure used to visualize abnormalities of the urinary system, including
□ Advantages :
the kidneys, ureters and bladder.
• Prior to dye injection, selective urine sample can be taken for investigative purpose
□ Prerequisite: Renal function is_to be normal
• Better delineation of anatomy
• Brush biopsy may be taken from suspected urothelial tumors of upper urinary tract □ Indications :
• Congenital anomalies -
□ Disadvantages :
► Horse-shoe kidney - Flower-vaseappearance
• Anesthesia required
► ~y~tkfciney - Spider-leg appearance
• Laborious
□ Risks:
_
► Ure_terocele - Adder(<?~brc:) head appearance
• Hydron~hJ09-!S - C:~bb~_~L9l:-J.P_-shap_ed calyces
• Hemorrhage
• Re~al___ceJL 9_ar9i~Qma - lrregu.!9..r.JillJriJLdef9.9t
• Bladder perforation
• Nausea, vomit • Obstruc!i_\/eY!.9~
• Bilateral stones in urinary tract
• UTI .,,,....~'------
........

• Vasovagal response • Renal ,!_nJ~ry

□ Contraindications : • Post:~U!ft~P
□ Procedure :
• Pregnancy
Overnight fasting for 8 hours+ laxatives used to clear bowel ➔ Control plain X-Ray KUB taken ➔ 1 ml
• Severe dehydration test dose of sodium diatriazoate injected i.v ➔ waited for 1O mins ➔ if no adverse reaction, 1ml/kg dye
, 1/fitegrade pyelogram injected i.v ➔ X-Ray taken at 5 mins (No. 1), 15 mins (No. 2), 30 mins (No. 3)
\_~ ANTEGRADE PYELOGRAM □ Non-visualisation of kidneys: No contrast dye seen in X-Ray film even after 12 hours
□ Contraindications :
□ What is it: Type of_ X-Ray used to diagnose an obstructiol'I of upper urinary tract
• Multiple myeloma
□ Procedure : Kidne~amined with USG. or CT scan ➔ after they are located, overlying skin
• Iodine sensitivity
anaesthetised ➔ needle passed directly into kidney, via which dye is injected to outline the renal
collecting system ➔ X-Ray taken • Hypergammaglobulinaemia
• Toxic thyroid conditions
□ Complications :
• Reaction to iodine-based dye Q. 20 : Cystoscopy
• Hot flush CYSTOSCOPY
• Nausea, vomit □ What is it: Endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.
• Breathing difficulty
• Low B.P 0 Types:
• Cardiac arrest • Flexible
• Bleeding • Rigid
• Sepsis □ Procedure : Patient in lithotomy position ➔ Spinal or general anesthesia ➔ cystoscope inserted
through urethra along with continuous glycine irrigation ➔ urethra, bladder and then ureteric orifices
• Urinoma
are visualised
• Blood clots in nephrostomy tube
596 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 597

□ Indications : h~ld with swab holding forceps -➔ Bladder confirmed by - i) urine coming out on needle aspiration ii)
distended veins on anteri0r surface of bladder iii) change in nature of fat ➔ 2 stay sutures taken
• Therapeutic -
through full thickness of anterior wall of urinary bladder ➔ incision through the midline of anterior wall
, TURP of bladder using 11-no. surgical biade ➔ finger inserted to remove stones and look for any pathology
► Urethrotomy ➔ Malecot's catheter inserted and stay sutures removed ➔ fixed with purse-string suture ➔ linea
► Bladder tumor resection alba, skin sutured
► Fulguration of posterior urethral valve □ Contraindications :
► Cystolithotripsy • Bladder cancer in cases of clot retention
► Cystolitholapaxy • Lower abdominal incisions with likelihood of adhesions
• Diagnostic - • Pelvic fracture
► To visualise pathology in urethra, bladder and ureteric orifice
□ Complications :
► To viualise bladder fistulas
• UTI
□ Contraindications :
• Blockage
• Prostatitis
• Bladder stones
• Acute cystitis
• Bladder cancer
□ Complications :
• Bypass track by urine
• Water intoxication
• Bleeding Q. 22: PCNJ..
• Infection PCNL
□ Blue light cystoscopy :
□ Full form : Percutaneous Nephrolithotomy
The Blue light (Hexaminolevulinate fluorescence) cystoscopy involves instilling a photosensitizing
agent, such as Cysview, into the bladder. The Blue light cystoscopy contains a light source and light □ What is it: Surgical pr~edure to remove stones from the kidney by a small puncture wound (up to
about 1 cm) through the skin •······ · - · -···-·
is transmitted through a fluid light cable connected to an endoscope to light up the area to be observed.
The photosensitizing agent preferentially accumulates porphyrins in malignant cells as opposed to □ Indications :
nonmalignant cells of urothelial origin. Under subsequent blue-light illumination, neoplastic lesions Stones with following features -
fluorescence red, enabling visualization of tumors. The Blue light cystoscopy is used to detect non- • Stones > 2.5 cm
muscle invasive papillary cancer of the bladder
• Present near the pelvic region
"~~~"•"•--~----•-•-•-----•••-~-~•-•~s
Q. 21 : Suprapubic cystostomy • Multiple in number
SUPRAPUBIC CYSTOSTOMY • Not_r~-~e:'nding to ES~!:,
□ Procedure :
□ Synonyms: With a small 1 centimeter incision in the loin, the Percutaneous nephrolithotomy (PCN) needle is
• Vesicostomy passed into the pelvis of the kidney ➔ The position of the needle is confirmed by fluoroscopy ➔ A
• Epicystostomy guide wire is passed through the needle into the pelvis ➔ The needle is then withdrawn with the guide
□ What is it: Surgically created connection between the urinary bladder and the skin which is used to wire still inside the pelvis ➔ Over the guide wire the dilators are passed and a working sheath is
drain urine from the bladder in individuals with obstruction of normal urinary flow introduced ➔ A nephroscope is then passed inside and small stones taken out
□ Prerequisite: Bladder must be full - adequate distension almost half-way between symphysis pubis (In case the stone is big it may first have to be crushed using ultrasound probes and then the stone
and umbilicus may be done by fragments removed)
• oral fluids □ Complications :
• intravenous fluids administration • Injury to the colon
• diuretics • Injury to the renal blood vessels
□ Indications : • Urinary leak may persist for a few days
• Failed urethral catheter • Infection
• Long term usage • Hydrothorax if PCNL is done through 11th intercostal space
□ Procedure : • Bleeding
Local anaesthetic infiltration ➔ Incision 4-5 cm long from 2cm above symphysis ➔ skin, superficial
fascia, linea alba cut ➔ extraperitoneal fatty tissue and peritoneum sweeped upwards by a gauge
598 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 599

□ Advantages : Measures aspect of bone metabolism or bone remodelling which other imaging
ESWL techniques cannot do
□ Uses:
□ Full form : _Ex_t!ac:_grgq~~-?I ~hock wave lithotripsy • Fractures
□ What is it: Non-invasive treatment of kidney stones using an acoustic pulse (a type of endourologica1 • Infections
surgery)
• Tumors
□ Shock waves produced by:
□ Contraindications :
• Electrom8:£!~-~! • Osteoporosis
• Electrohydraulic
• Multiple myeloma
• Piezo-electric
□ Procedure : Radioactive material (Tech99m) injected in peripheral vein ➔ scanned with gamma
□ Procedure : Electromagnetic shock waves passed to stone through water bath @ 2/sec ➔ stones camera ➔ SPECT used for imaging
fragmented using Dornier lithotripter which are later flushed out
□ Specificity increased by: lndium111 labelled WBC Test+ Tech99m injection
□ Indications : Ureteric, kidney or bladder stones < 2.5 cm _
□ Precautions : Empty bladder first
□ Advantages :
□ Three phase scan :
• OPD procedure
• 1st phase - shows perfusion to a lesion
• Hard oxalate stones better treated by this method
• 2nd phase - shows vascularity to an area (after 5 mins)
• No anesthesia required
• 3rd phase - shows amount of bone turnover (after 3 hours)
• Non invasive
• No pain Q. 25 : Thyroid scan
• No blood loss THYROID SCAN
□ Disadvantages : □ What is it: A thyroid scan uses a radioactive tracer and a special camera to measure how much tracer
• Cannot be used for larger stones > 2.5 cm the thyroid gland absorbs from the blood
• Relies on normal urine flow for clearance □ Radioisotope used:
• Not easily available • 1123 gamma rays(not 1131 )- most common
□ Complications : • 99mTc
• Hematuria □ Purpose: To distinguish between functioning and non-functioning thyroid
• Injury to adjacent structures □ Time required :
• Renal hematoma • 11 23 scan - 24 hours
• Fragments of stone retained in ureter • 99mTc scan - 30 minutes
□ Contraindications : □ Instrument used: Gieger Muller's gamma ray counter
• Pregnancy □ Indications :
• Bleeding diathesis • Doubtful toxicity
• Abdominal aneurysms • Autonomous toxic nodule
• Sepsis • After total thyroidectomy
• Renal failure • Retrosternal thyroid
• Renal artery calcification • Ectopic thyroid
□ Prerequisites :
□ Precautions :
• Kidney function has to be normal • No L-Throxine intake for 6 weeks prior to the scan
• Stent may have to be used for large stones • T3 60 microgram/day (medication to be stopped 10 days prior to scan)
• Diclofenac may be needed to relieve ureteric colic □ Procedure :
The radioisotope is given orally in empty stomach on the previous day or injected into the vein
Q. 24 : Bone scan
□ Interpretations :
BONESCAN • 'Hot' area ➔ increased uptake ➔ toxic condition
□ Synonym : Bone scintigraphy • 'Warm' area ➔ normal uptake ➔ euthyroid
□ Definition : Nuclear scanning test to find certain abnormalities in bone • 'Cold' area ➔ no uptake ➔ non-functional, may be carcinoma
 600 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 601

• Encephalitis
MAMMOGRAPHY • Subarachnoid hemorrhage
• lntracranial hemorrhage due to trauma
□ What is it: X-Ray of soft tissue of breast using low ampere and high voltage
• lntracranial SOL
□ Films:
• To look for lymphoblast to evaluate relapse of ALL in meninges
• Craniocaudal
B) Therapeutic -
• Mediolateral
• Relief from raised intracranial tension
□ Dose : 0.1 Gy radiation
• Introduction of antimeningococcal serum
□ Inference : • Introduction of drugs
• Microcalcification ➔ malignancy • Spinal anesthesia
• Soft tissue shadow ➔ if regular then benign, if irregular then malignant
• Size
□ Contraindications :
• Location
• Brain tumor at cerebellopontine angle
• Spinal cord tumor
• Spiculation
• Septicaemia
• Duct distortion
• Brain abscess
• Density ➔ if low then benign, if high then malignant • lntracranial hemorrhage
• Architectural distortion ➔ malignancy • Patient in convulsion
• Skin thickened ➔ malignancy • Advanced CVS disease
□ Grading: • Vertebral deformties
I - Negative • Abnormal respiratory pattern
II - Benign □ Complications:
Ill - Probably benign • Post spinal headache
IV - Suspicious of malignancy • Nausea
V - Suggestive of malignancy • Paraesthesia
VI - Known malignancy • Spinal/epidural bleeding
□ Indications : • Introduction of infection
• Screening if :1ge > 40 years • Adhesive arachnoiditis
• Obese • Trauma to spinal cord
• Follow up after conservative surgery • Paraplegia
• Follow up if benign lesion has malignant potential □ Site of collection :
• Mammography guided biopsy • L3-L4 vertebrae
• Mastalgia • Cisternal puncture
• To detect spread to opposite breast • Ventricular puncture
• Combined spinal - cisternal puncture
□ Xenomammography: Useful for dense breast where mammography is done on selenium paper
□ Procedure : Patient in left - lateral position/sitting on stool stooping forward with maximum flexion ➔
Q. 27: Lumbar puncture overlying skin prepared with antiseptics - infiltration of skin and fascia with small amount of 1 %
lignocaine ➔ imaginary line drawn joining highest points of two iliac crests ~asses throug_h L3_ -. L4
LUMBAR PUNCTURE
vertebrae ➔ lumbar puncture needle stilette in-situ is pushed forward and slightly upward 111 m1dhne
□ Synonym : Spinal tap between L 3 - L 4 vertebrae till a peculiar give-away sensation is felt ➔ stilette rem~ved ➔ ~ressure
measured by fitting manometer to needle or drop count method ➔ CSF collected tn 3 sterile tubes
□ What is it: Diagnostic and therapeutic procedure performed to collect cerebrospinal fluid sample for
5ml each
microbiological, biochemical and cytological analysis
□ CSF examination :
□ Indications :
A) Diagnostic - • Physical -
► Appearance - normal
• Meningitis
► Colour - clear
• Meningoencephalitis
► Coagulum - absent

76
602 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 603

• Cytological - ► Injection of oesophageal varices

► TC ► Endoscopic removal of benign lesions
► DLC ► Dilatation in case of oesophageal strictures, cardiac achalasia
• Biochemical - ► Insertion of Soutlar's or Mousseau - Barbin tube in palliative treatment of oesoph-
► Protein : 20-40 mg% ageal carcinoma
► Glucose : 40-80 mg% • Diagnostic -
► Chloride : 720-760 mg% To investigate cause for retrosternal burning, dysphagia,
• Bacteriological - □ Contraindications:
► Gram stain • Trismus
► Acid fast stain • Aneurym of aorta
► India ink preparation • Disease of cervical spine
• Receeding mandible
Q. 28: Duplex ultrasound
□ Anesthesia :
DUPLEX ULTRASOUND
• General anesthesia + Orotracheal intubation
□ Definition : Test to see how blood moves through arteries and vein □ Position:
□ Principle: • Barking dog position (see Oesophagoscopy)
• Traditional ultrasound - uses sound waves that bounce off vessels to create picture □ Basic steps while insertion of instrument:
• Doppler - records reflecting sound waves to measure their speed and other aspects of their
• Identification of aryetenoids
flow
• Passing cricopharyngeal sphincter without applying force
□ Types:
• Crossing aortic arch and left bronchus
• Arterial
• Passing cardia, identified by velvety mucosa
• Carotid
□ Post-operative care :
• Renal
• Arms and leg • Sips of plain water
• Regular diet - - - - - - - pain in interscapular region
□ Procedure : Patient lies down ➔ gel smeared ➔ transducer used ➔ computer measures reflected
waves • Signs of oesophageal perforation - - - - abrupt rise of temperature
□ Accessory used: Blood pressure cuff for measuring ABPl(Ankle Brachia! Pressure Index) -------- surgical emphysema of neck
□ Complications :
□ Uses: • Injury to oral cavity, teeth, lips
To diagnose the following - • Oesophageal perforation
• Abdominal aneurysm • Tracheal compression
• Arterial occlusion • Injury to pharynx, aryetenoids
• Blood clot □ Advantages of fibreoptic oesophagoscopy:
• Carotid occlusive disease • Bedside procedure
• Renal vascular disease • General anesthesia not required
• Varicose vein • Used in cases of jaw or spine abnormalities
Q.29:0esophagoscopy • Accurate diagnosis due to good illumination & magnification
• Removal of small foreign bodies
OESOPHAGOSCOPY
• Precision biopsies can be taken
□ Types:
• Dilatation of structures
• Rigid
• Oesophageal stenting
• Flexible fibre optic
□ Transnasaloesophagoscopy:
• Transnasal
• Performed through nose
□ Indications :
• Air can be inflated to distend walls of oesophagus for better viewing
• Therapeutic -
► Foreign body removal • Oesophagus can be examined upto gastric fundus.
604 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF INVESTIGATIONS 605

Q. 30 : Tracheostomy
0 Steps:
TRACHEOSTOMY '£.ertical incision made from cricoid cartilage to just above sternal notch
- -·---~-· --- - "'""-·---~·=•-~-~-· - . ~..
□ What is it: Making an opening in anterior wall of trachea & converting it into stoma on skin surface.
□ Indications : Transverse incision made 5cm above sternal notch between anterior border of slernocleidomastoids of
(A) Respiratory insufficiency - both side.s
Chronic lung disorders - COPD, bronchitis 1-
(8) Respiratory obstruction - Strap muscles separated & retracted laterally
• Trauma - 1-
lsthmus retracted upwards
► due to endoscopy
1-
, external injury to larynx, trachea
Lignocaine injected in trachea
► fracture of mandible 1-
• Infections - Pretracheal fascia incised
► acute epiglottitis 1-
► diphtheria Trachea incised & converted into circular opening
► Ludwig's angina 1-
► retropharyngeal abscess Trachoestomy tube inserted & secured by adhesive tapes
>' peritonsillar abscess 1-
• Neoplasma Gauge dressing placed
• Congenital anomalies 0 Post-operative case :
• Foreign body in larynx • Constant supervision
• Bilateral abductor paralysis • Care of tracheostomy tube
(C) Retained secretions - • Proper humidification
• Painful cough • Periodic deflation of cuffed tube
• Aspiration of pharyngeal secretions
• Neuromuscular disorders COMPLICATIONS
□ Types:
I
•
•
•
Emergency
Elective I Routine I Orderly I Tranquil
Permanent (in bilateral abductor paralysis)
< Therapeutic

Prophylactic
•
~
Immediate
Primary Hemorrhage •
Intermediate
Displacement of tube
t
Remote
• Secondary hemorrhage
• Mini (cricothy roidotomy) • Blood aspiration • Blocking of tube • Tracheal stenosis
• Percutaneous dilational tracheostomy • Apnoea • Subcutaneous emphysema • Trachea-oesophageal
• Injury to oesophagus • Atelectasis, lung abscess fistula
□ Levels:
• Secondary hemorrhage • Trachea-cutaneous fistula
• High (above level of thyroid isthmus)
• Local wound infection • Problems of decannulation
• Mild {through 2nd & 3rd tracheal ring)
• Low (below level of isthmus)
□ Position:
• Supine + Extended neck
□ Anesthesia :
• Local infiltration of lignocaine
606 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 607

Q. 31 : Bronchoscopy
Features Rigid bronchoscopy Flexible bronchoscopy
BRONCHOSCOPY
• Anesthesia General Topical
There are 2 types of bronchoscopy - (a) Rigid (b) Flexible
• Cost High Low
□ Indications : • Bedside exam Not possible Possible
• Advantages • Foreign body removal is • Nasal cavity, supraglottic &
INDICATIONS
easier glottic areas, segmental &
• Better control of haemo- subsegmental bronchi visible
rrhage • Useful in jaw & neck abnor-
RIGID FLEXIBLE malities or injuries
• Large piece can be taken
i for biopsy

Diagnostic Therapeutic a. 32: Colonoscopy

• Collection of bronchial secretions for micro- • Removal of retained
biological tests secretions or mucus
COLONOSCOPY
• Determine cause of wheezing, hemoptysis, plugs □ Synonym : Coloscopy
persistent unexplained caugh • Removal of foreign
□ What is it: Endoscopic examination of large gut & distal part of small bowel with a CCD camera or a
• Vocal cord palsy body
fibre optic camera on a flexible tube passed through anus upto caecum
• X-Ray chest finding being hilar/mediastinal
□ Length of tube: 160 cm
shadows, obstructive emphysema, atelectasis,
etc. □ Procedure :
• Done under GA with laryngeal mask airway
□ Complications : • Techniques used -
• Injury to oral cavity, teeth, lips ► Elongation

• Hypoxia ► Dither-torquing
• Hemorrhage ► Looping with a maneuver
• Cardiac arrest • Continuous air inflation to visualise lumen
• Laryngeal edema • Technique differs in patients after hemicolectomy
□ Position: (barking dog position) □ Indications :
• Supine
• Head elevated by 10-15 cm INDICATIONS
• Neck flexed on thorax, head extended on atlanto - occipital joint
□ Introduction of bronchoscope :
IL' '::.i Therapeutic Diagnostic
Direct introduction of bron- Through • Polypectomy • Bleeding per rectum
choscope through glottis laryngoscope • To take biopsies from colon • Unexplained changes in bowel habit
• Dilatation of stricture colon • CA colon
□ Precautions :
• Fulgation • IBD
• Proper size of bronchoscope to be chosen
• Older patients with severe anaemia
• Should not be forced through glottis
• When barium enema shows irregularity
• Should not be prolonged procedure
• Removal & introduction of instrument repeatedly must be avoided
608 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 609

□ Contraindication : 4. Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after
• Acute ulcerative colitis liver transplantation)
□ Complications : • Contraindications :
• Bowel perforation 1. Acute pancreatitis (unless persistently raised or worsening bilirubin suggests ongoing
obstruction)
• Sepsis
2. Previous pancreatoduodenectomy
• Hemorrhage
3. Coagulation disorder if sphincterotomy planned
□ Disadvantage :
4. Recent myocardial infarction
• Takes longer time
5. Inadequate surgical back-up
□ Advantage :
6. History of contrast dye anaphylaxis
• Helps to visualise full colon
7. Poor health condition for surgery
a. 33: Cho/angiography 8. Severe cardiopulmonary disease
CHOLANGIOGRAPHY • Technique:
Patient is sedated ➔ Endoscope is inserted through the mouth, down the oesophagus, into
D What is it: Cholangiography is procedure to visualise the hepatobiliary tree to identify any pathology. the stomach, through the pylorus into the duodenum where the ampulla of Vater is visualised
D Types: ➔ A cannula is inserted through the ampulla ➔ A radiocontrast dye (60% urograffin) is
(a) Intravenous cholangiography injected into the bile ducts and/or pancreatic duct ➔ Fluoroscopy is used to look for block-
(b) Endoscopic retrograde cholangiopancreatography (ERCP) ages, or other lesions such as stones [When needed, the opening of the ampulla can be
enlarged (sphincterotomy) with an electrified wire (sphincterotome) and access into the bile
(c) Magnetic resonance cholangiopancreatography (MRCP)
duct obtained so that gallstones may be removed or other therapy performed]
(d) Percutaneous transhepatic cholangiography (PTC)
(e) Peroperative cholangiography
• Complications :
1. Pancreatitis
(f) Post operative T-tube cholangiography
2. Gut perforation
□ Intravenous cha/angiography :
3. Oversedation can result in dangerously low blood pressure, respiratory depression,
• What is it: A dye (Meglumine ioglycamate/ Biligram) is injected i.v. and. multiple skiagrams of
nausea, and vomiting
abdomen are taken.
4. Bleeding after sphincterotomy
• Advantage: It can be combined with Oral cholecystogram (OCG) to study the function of gall
bladder. 5. Cholangitis
• Disadvantage : (i) drug reaction (ii) poor visualisation (iii) the procedure is not useful when MRCP:
serum bilirubin is > 3 mg% • What is it -A form of cholangiography that uses magnetic resonance imaging to visualise
□ ERCP: biliary and pancreatic ducts in a non-invasive manner
• Introduced in - 1991
• What is it: Technique that combines the use of endoscopy and fluoroscopy to diagnose and
treat certain pathologies of the biliary or pancreatic ductal systems • Purpose - Produces detailed images of liver, gall bladder, bile duct, pancreas and pan-
creatic duct
• Indications :
• Uses -
► Diagnostic -
1. Checking liver, bile duct, gall bladder and pancreas for gallstones, tumors, infection
1. Obstructive jaundice
or inflammation
2. Chronic pancreatitis
2. Investigating pancreatitis
3. Gallstones with dilated bile ducts on ultrasonography
3. Investigating abdominal pain
4. Bile duct tumors
4. Best used when serum bilirubin <1 0mg/dl and no pre-operative stenting is
5. Suspected injury to bile ducts either as a result of trauma or iatrogenic
contemplated
6. Sphincter of Oddi dysfunction
Checklist before MRCP :
7. Pancreatic tumors
1. Internal pacemaker/defibrillator
, Therapeutic -
2. Cochlear implant
1. Endoscopic sphincterotomy (both of the biliary and the pancreatic sphincters)
3. Surgical clip
2. Removal of stones
4. Prosthetic heart valve
3. Insertion of stents
5. Artificial limb

77
610 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 611

6. Implanted electronic device PET SCAN

• Side-effects -
Reaction to contrast dye when used □ Full form: Positron Emission Tomography
• Contraindication - Pregnancy □ What is it: Nuclear imaging technique that creates detailed, computerised pictures of organs and
• Advantages over ERCP - tissues inside the body, to assess the biochemical and physiological status of a tissue.
1. Non - invasive □ Principle used: Electronic collination
2. Delineate full biliary tree and not just the part proximal to the obstruction
□ Reagents used :
3. No dye required
• Two protons - positive electrons (positrons)
4. Can be used in acute panceatitis, duodenal injury, cholangitis
• Most clinically used positron emitting radionucleotides -
Disadvantag~ : No therapeutic procedure like stenting, basketing, biopsy can be carried out
i) Fluoro - deoxyglucose (FOG)
• PTC:
► What is it - It is done in case of severe obstructive jaundice under cover of antibiotics ii) Rb 82
after control of any type of bleeding tendency. iii) N13
► Indications - iv) 0 15
1. Cases of ERCP failure □ Detectors used :
2. Klatskin tumor • Bismuth germanate (BGO) crystals
3. High biliary strictures • Sodium iodide crystals
4. High blocks in biliary tree when external catheter drainage is required (this is'
□ Procedure :
known as Percutaneous transhepatic biliary drainage/ PTBD)
► Technique - • Patient injected with glucose solution that contains a small amount of radio active material,
which is absorbed by particular tissues
Fluoroscopy (C-ARM) /CT/ US guided introduction of Chiba or Okuda needle (15 cm
l?ng, 0.7 mm i~ diamet~r, flexible, blunt without a bevelled end) into liver in midaxillary • Patient rests on table and then is slided into a PET Scanner.
Today, almost all PET scans are performed on instruments that are combined PET and CT
hne through nght 8th mtercostal space ➔ Needle in dilated biliary radicle ➔ Bile •
aspirated (and sent for cytology, biochemical analysis and culture) ➔ water soluble Scanners.
dye is injected ➔ visualisation of dilated biliary radicles, site and extent of obstruction; • Time taken - 20-30 minutes .
therapeutic stenting through the site of obstruction in the biliary tree can also be done
► Complications - □ Uses:

1. Bleeding • Detect carcinoma

• Detect metastasis
2. Biliary leak and peritonitis
• Assess effectiveness of treatment plan
3. Septicemia
Reassess post-chemotherapy/ post-treatment recurrence of carcinoma or spread of mets.
• Peroperative cholangiography : •
► What is it - It is done following cholecystectomy before exploration of CBD on the opera- • Determine blood flow to heart muscle
Identify areas of heart that would benefit from procedure like angioplasty, CABG .
tion table to assess for residual CBD stones, stricture, atresia. It is also known as On •
Table Cholangiography (OTC). Evaluate abnormalities in brain, like tumours .
•
► Technique - Through cystic duct a fine polythene catheter is passed into the CBD ➔ a Locate temporal lobe epilepsy .
radio-opaque dye is injected ➔ C-ARM image intensifier is used ➔ If dye freely and •
completely goes into duodenum, the OTC is normal. Any block or stricture in the CBD can □ Advantages :
be identified by this procedure. • Very specific - provides details on both function and anatom structure of body
► Precaution - The syringe should be made air-free carefully. • High accuracy
► Complications - (1) Infection (2) Bile leak • Detect early onset of disease
• Postoperative T-tube cholangiography : □ Disadvantages :
► Technique -
Choledochotomy done ➔ Kehr's T-tube is placed into the CBD ➔ After 10-14 days, water
• Expensive
• Radiation exposure to patient
soluble dye is injected into the tube ➔ X- ray is taken ➔ If the dye freely and completely
goes to the duodenum, there is no blockage. T-tube can be removed then. Blockage • Allergic reaction to radio tracer .
Results adversely affected if patient is diabetic / has taken meal few hours prior to procedure .
indicates residual CBD stones. •
612 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 613

USG FOR HEPATOBILIARY DISEASES ► Vascular diseases - Thrombosis of hepatic vein and membranous obstruction of IVG can be
diagnosed.
□ Use of USG in hepatoblllary disease : Benefits of focussed bedside biliary sonography:
Provides structural information but not functional details ► Decreases time to diagnose cholelithiasis and cholecystitis
□ Advantages : ► Assess degree of obstruction in choledocholithiasis
• Safest ► Can provide bedside radiographic corroboration of physical examination findings.
• Least expensive ► Safe in pregnant and children, hence very useful for emergency obstetric and neonatal
• Most sensitive for imaging biliary system cases.
□ Indications of use :
• Screening _of biliary tract abnormalities
• petection of liver masses
• Evaluation of hepatobiliary tract in patients with right upper quadrant abdominal pain.
• Differentiation of intra - and extra-hepatic causes of jaundice.
• Evaluation of spleen size to help diagnose splenomegaly - suggesting portal hypertension.
□ Pathologies :
► Gallstones -
• Cast intense echoes with distal acoustic shadows
• Transabdominal ultrasound can detect stones> 2 mm, size (sensitivity> 95%)
• Endoscopic ultrasound can detect stones as small as 0.5 mm.
► Biliary slu~~
• Low level echoes that lie as a layer in the dependent portion of gall bladder without
acoustic shadow. ·
► _E_t,olecystitis_-:-
• Thickened gall bladder wall (> 3 mm)
• Impacted stone in gall bladder neck
• Pericholecystic fluid
• Ultrasonographic Murphy's sign (tenderness when gall bladder is palpated)
► E,xtrahepatic obsti:Y..@QD..::-
• Dilated bile ducts {> 1O mm)
• Retroduodenal dilatation may not be visible
• Trans abdominal ultrasonography may not reveal the cause or level of biliary obstruction;
endoscopic ultrasound is better
► Liver lesions -
• Focailesions > 1 cm size can be detected
• Cysts - echo free
• Solid lesions - echogenic
• Carcinoma - irregular solid mass
• Guides aspiration and biopsy
• Fatty liver ]
Can be detected
• Cirrhosis
• Ultrasound clastography to measure liver stiffness as index of hepatic fibrosis .
 Section 2

ORTHOPEDICS

1. GROUP-I

Solved Short Notes of Final MBBS 2008-2015

2. GROUP- II
Solved Short Notes of Semesters of Various Colleges
 GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 617

GROUP-I
3. Manipulation under anesthesia - External rotation ➔ abduction ➔ flexion
SOLVED SHORT NOTES OF FINAL MBBS 4. Triamcinolone injection
(b) Operative - rarely required
2008 1. Open release
2. Arthroscopic capsular release
FROZEN SHOULDER a._/2-."Cgmpffcations of supracondylar fracture
□ Synonyms:
J, _./'

• P..eriar!britis shoulder ~ COMPLICATIONS OF SUPRACONDYLAR FRACTURE

• _PericapsulJtis
• _Adhesive capsulitis COMPLICATIONS OF
• Adhesive bursitis SUPRACONDYLAR
□ What is it: GlenohumeraljQint becomes painful and stiff due to loss of resilience of its fibrous capsule FRACTURE
probably due to inflammation and adhesions
□ Aetiology : Idiopathic; may be due to microtrauma
□ Associated with : Immediate Early Late
• Trauma (at the time of fracture) (within 1st 2-3 days) (in weeks to months)
• Diabetes
• Thyroid disease
Injury to Malunion
□ Lundberg classification :
brachia! artery Volkmann's
(1) Primary - No triggering event present
- -- ischaemia
(2) Secondary - Triggering factor causes chronic inflammation and subsequent changes Volkmann's
□ Age : 40-70 years old women Injury to nerve ischaemic
□ Clinical features : (median contracture
nerve~ial
• Pain - Initially worse at night ➔ later dull aching pain throughout the day ➔ gradually diminishes --nerve)
in severity ➔ disappears by 18 months Myossitis
• Stiffriess _- Initially less in severity than pain and limited to internal rotation, then abduction ➔ ossificans
-gradually increasing in severity and all movements are limited ➔ gradually diminish in intensity
➔ some residual stiffness persists, especially restricted external rotation
• _Wa~!Ln_g_Qf shoulder muscles 0 INJURY TO BRACHIAL ARTERY -
• Tenderness over biceps tendon and anterior part of greater tuberosity
□ Investigations : Causes absence of radial pulse
•
•
X-ray
MRI
t
Closed reduction
• Arthrography
□ Treatment :
(Self limiting disease which resolves by 6-9 months)
(a) Conservative - Pulse returns within 1 hour (Plan A) Pulse does not return
1. Physical therapy -
• lnterferential therapy
~ ~
Capillary circulation good Capillary circulation poor (Plan B)
• Ultrasonic therapy
• TENS
Maintain in slab for 48 hours
t t
2. Exercise -
• Reciprocal pulley exercise
i
Proper reduction of fracture
Keep in slab under closed observation
✓ ~
Vessel explored

t
Improves Does not improve Internal reduction
• Free-swinging exercise
• Capsular stretching exercise t t
Plan A Plan B
616
78
618 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 619

□ VOLKMANN'S ISCHAEMIA - □ Types of sequestrum :

► Define : lschaemic injury to muscles of flexor compartment of forearm
► Cause : Injury to brachia! artery in supracondylar fracture
► Muscles affected: Deep muscles supplied by anterior interosseous artery - Flexer digitorum TYPES OF SEQUESTRUM
profundus and Flexer pollicis longus
► Clinical features :
• Severe ischaemic pain
According to colour According to shape
• Stretch pain
• Tenderness
• Swelling of fingers Feathery Ring
, Complications : Compartment syndrome
► Treatment : Coralliform Pencil-like
• Remove any splint/bandage causing compression
• Elevation of forearm and advised to move fingers
Ivory Cylindrical
.J,
No improvement in 2 hours
.J, Black Conical
Fasciotomy
□ MALUNION- Green
► Speciality: Commonest complication of supracondylar fracture
► Pathoanatomy : Fracture unites with distal fragment tilted medially and internally rotated
► Result: Cubitus varus/gunstock deformity
□ Aetiology:
► Aetiology: ····· · _..,,..
• Delay in treatment
1. Inadequate reduction
• Inadequate treatment
2. Displacement of fracture segment within the plaster
• Highly virulent organisms
► Treatment: If severe cosmetic abnormality ~ French osteotomy
• Reduced host resistance
□ VOLKMANN'S ISCHAEMIC CONTRACTURE - □ Pathology:
A: See Short note - Volkmann's ischaemic contracture (Page No. 620)
□ MYOSSITIS OSSIFICANS - Following acute osteomyelitis
A: See Short note - Myossitis ossificans (Page No. 627-628)
/ ~
Q. 3 : Sequestrum Disturbed periosteal blood flow New subperiosteal bone formation
SEQUESTRUM
t
Dead bone surrounded by granulation tissue
t
This sclerotic bone is involucrum
□ What is chronic osteomyelitis: Infection of bone, persisting for >3 weeks, along with absence of any

□
systemic symptoms and characterised by a discharging sinus
Types:
t It overlies the sequestrum
Sequestrum formed
• Secondary to acute osteomyelitis
•
•
Garre's osteomyelitis
Brodie's abscess
t
Inner surface smooth, outer surface irregular Cloacae (holes) formed to drain out pus
□ What is sequestrum : Piece of dead bone, within a living bone affected by chronic osteomyelitis,
surrounded by infected granulation tissue, having a smooth inner surface and irregular outer surface.
□ Site: Lower end of femur
□ Clinical features :
[See Fig. 2.9.1]
• Past history of open fracture/trivial trauma/fever and pain in affected part
620 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 621

• Discharging sinus • Volkmann's sign positive - Can extend fingers only when wrist is flexed
• History of bone pieces coming out • Bunnell deformity - Wrist flexed, forearm pronated, thumb adducted
• Waxing - Waning pattern of symptoms Treatment:
• Reduced range of movements
• Mild case - Volkmann's splint
• Puckered scars around sinus
• Moderate case - Maxpage ~.Qf_t tiss_ue sliding operation
• Increased bone girth
• Tenderness • Severe case - (a) Forearm shortening operation
□ Investigations:
( Sr-) (b) Carpal bone excision
(c) Arthrodesis of wrist
• X-ray -
► Irregular and thickened cortex '
if'' .--l \
► Sequestrum (increased bone density, surrounded by radioluscent zone) TAUPES EQUINUS CJvb t:7-,!)
► lnvolucrum + cloacae
□ What is it: Orthopaedic deformity where foot is plantar-flexed (actually this i~ found in_ acquired CTE~
► Patchy sclerosis
where equinus component is more prominent than varus component. In Tallpes equmovarus, foot rs
• CT, MRI .---- ,,,- ..,,,---,,----v--,~
plantar-flexed, adducted and inverted) [See F i g ® ~·-.~)
Sinogram
□ Synonym: Club-foot - t. _,,
',' :'--••-,_,,.,_,._.
• Pus - Culture and sensitivity ' _,_w..,~•"-
□ Basic deformities :
□ Treatment :
~ " • Cavus - exaggerated longitudinal arch of foot
• Surgical - 0r1,:,,~·"..s. 0 ·\ fl
• Adduction of forefoot - at midtarsal joint
►
C-Cauterisation ) _,, 1·1· (' J ·,) -''.\ !,· , . 1, '/'>1 :.' 1 •: ·.l • Varus of hindfoot - inversion at midtarsal joint
► A-Amputation ( '::-C:r//' p:t:') ·r,r- (?,,; ~ r:/S- ::rlv"e__ • Equinus - foot fixed in plantar-flexion
► S-Sequestrectomy · .'Ertr r;,0:) Y/-- -:,:::::::.""l ; : ~ ) - • ~ :;}[\_
□ Aetiology :
► E-Excision of infected bone/ r, ~ ,~_f· ~;; .. :J ~_{)l'j1') •. / ~\ ' I 7' C.. 9;;.
► S-Saucerisation ( f
1
1('' C ::-,-t
• Antibiotics o,r..J ' f:c;--~-~r.- Q. "~'P~ .- r
, '---..;- -, •· I TALIPES EQUINOVARUS
• Rest ,.., "l · , , -Sr c'\ ?) ' I, f
Causes
• Continuous suction-irrigation after wound closure -.. ,.A

□ Complications :
• Acute exacerbation Congenital Acquired
• Growth abnormality (lengthen, shorten, deformity)
• Pathological fracture Genetic (autosomal Post burn
• Joint stiffness dominant) contracture
• Sinus tract malignancy
Raised intrauterine Cerebral palsy
• Amyloidosis
pressure
Q. 4 : Volkmann's ischaemic contracture
lschaemia of calf Volkmann's ischaemic
VOLKMANN'S ISCHAEMIC CONTRACTURE ) muscles contracture

□ What is it : Late complication of supracondylar fracture and sequalae of Volkmann's ischaemia Fibrosis of soft Leprosy
□ Pathoanatomy : lschaemia replaced by fibrous tissue ➔ Contracts ➔ Draws fingers and wrist in tissues
flexion Post polio residual
□ Clinical features : Breech presentation paralysis
• Flexion deformity of wrist and fingers
Arthrogryposis
• Atrophy of forearm
multiplex congenita
• Skin dry
• Nails atrophied Myelomeningocele
• Sensory loss may occur if median nerve injury
622 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I O SOLVED SHORT NOTES OF FINAL MBBS 623

□ Pathoanatomy: (6) Secondary changes -

(1) Bones - (a) Weight bearing exaggerates deformity
(a) All bones of foot - small (b) Callosity and bursae on lateral side
(b) Neck of talus - angulated, faces downwards and medially □ Clinical features :
(c) Calcaneum -- short, concave medially Foot plantar-flexed, adducted and inverted
(2) Joints - □ Investigations :
X-ray - Angle between long axis of talus and calcaneum i.e. Kite's angle < 35 degrees
Positions Joint ma/positioned
□ Treatment :
Equinus Ankle joint
Inversion Subtalar joint
Talipes equino varus
Forefoot adduction Mid-tarsal joint
Forefoot cavus Mid-tarsal joint
Secondary causes excluded
(3) Muscles and tendons -
Muscles of calf underdeveloped ➔ Following tendons contracted / ~
Presents late
~
Presents early/at birth

Posteriorly Medially ~
~ ~ Manipulation alone
Achilles tendon (a) Flexor hallucis longus (Mother advised to manipulate foot
(b) Flexor digitorum longus after each feed
(c) Tibialis posterior Pressure for 5 seconds ➔ release
pressure ➔ pressure
(4) Capsules and ligaments -
This is continued for 5 minutes)
All ligaments on postero-medial side are shortened
OR
Side involved Ligaments affected
Posterior 1) Capsule of ankle joint Manipulation and POP (a) 6-18 months - Postero-medial
2) Capsule of subtalar joint soft tissue release
(1) Kite's technique (started at
3) Posterior talofibular ligament month of age, using below - knee (b) 18 months - 4 years -
4) Posterior calcaneofibular ligament plaster casts, changed fortnightly, Complete subtalar release
Medial 1) Talonavicular ligament deformities corrected sequentially (c) 4-7 years -
2) Spring ligament adduction ➔ inversion ➔ equinus)
(1) Dilwyn Ewan's operation
3) Deltoid ligament (2) Ponsetti's technique (started at
1st week of age, done for 2-3 (2) Dwyer's calcaneal osteotomy
Plantar 1) Plantar fascia
weeks; by putting thumb pressure (3) Joshi's External Stabilisation
2) Plantar ligament over talus head, calcaneo-cuboid- System
Others lnterosseous ligament between talus and navicular complex is externally
(4) lllizarov's technique of external
calcaneum rotated under talar head)
reduction
(3) Bansahel/Dimeglio modified French
(5) Skin - . (5) 8-12 years -Wedge tarsectomy
~ Shortening technique
(a) Medial side~
Deep creases
(b) Lateral side - Dimples
624 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 625

[b) Parasympathetic (S2,S3,S4) - Nerve of voiding (Contraction of detrusor and relaxation of

internal sphincter.also carries Bladder filling sensation)
(4) Motor nucleus - Pudenda! nerve (S2,S3,S4) [Controls external sphincter]
O Types of bladder problems in spinal paraplegia :
(1) Shock bladder - Stage of neural shock soon after spinal injury, which results in no sense of
fullness of bladder and evacuation. There is Overflow incontinence.
Corrected Not corrected (2) Incomplete lesions of spinal cord above S2,S3,S4 - Frequency, urgency of micturition
(3) Complete transection of spinal cord at the level of D1-D9 vertebrae - Cortical control is lost.
Maintenance in Dennis Brown There is retention of urine with overflow incontinence. Later "Reflex bladder/Automatic bladder"
splint till 1.5 year age develops when there is reflex evacuation on collection of some urine. There is incomplete
evacuation and residual urine remains inviting infections.
(4) Sympathectomy (complete transection of spinal cord at lumbar region) - Tone of internal
After 1.5 year, CTEV shoe in day, sphincter decreases resulting in frequency of micturition. Constant dribbling of urine (True
DB Splint at night incontinence) may occur. Bladder is never full.
(5) Parasympathectomy (complete transection of spinal cord at sacral region)- There is complete
loss of voluntary control of micturition resulting in "Autonomous bladder". Retention with overflow
Follow-up till 10-12 year age incontinence is there. But incomplete evacuation occurs and high amount of residual urine
remains. Patients are taught to stimulate perineum in order to micturate.
i □ Investigations :
• X-ray of spine
(If recur, treat as late presentation)
• Micturating cystourethrogram
All deformities left Equinus left Varus left • Post micturition USG - To assess residual urine

i
Posteromedial soft tissue release
i
Posterior soft tissue release
i
Dwyer's
•
•
Urine - Microscopic examination and culture
Urodynamic studies
osteotomy □ Treatment:
• Treatment of the cause is to be done
• Intermittent catheterization to relieve retention - In case of overflow incontinence, for a male
Q. 6: Bladder problem in spinal paraplegia
patient urinary pot or condom catheter can be used; for a female patient catheterization is the
BLADDER PROBLEM IN SPINAL PARAPLEGIA only choice. Before discharge, to teach patient the sensation of fullness of bladder clamp the
catheter at 2-3 hours interval for 2 days. Then patient is observed for 1 day for any progress.
Bladder dysfunction due to neurological disorders is termed as "Neurogenic Bladder". • Physiotherapy, Pelvic exercises, Electrical stimulation of perinea! muscles
□ For normal urinary continence(the ability to exercise voluntary control) and voiding, a balance • Drugs- Alpha adrenergic blockers, Carbachol, Distigmine
needs to be there among the following forces : • Antibiotics - To treat infection
(1) Detrusor muscle contraction
(2) Abdominal muscle contraction 2008 Supplementary
(3) Activity of bladder neck (internal sphincter)
(4) Activity of urethral sphincters (external sphincter) Q.1 : Fracture of patella
□ The nerve supply of this system is as follows : A: See Section 2, Group I, 2011, Os. 3 (Page No. 647)
(1) Cortical centre - In Frontal lobe Q.2: Col/e's fracture
(2) Higher centres - Facilitatory centres at pons and posterior hypothalamus, Inhibitory centre at A : See Section 2, Group I, 2013, Os. 4 (Page No. 662)
midbrain
Q.3 : Clinical features of spinal tuberculosis
(3) Lower centres -
A : See Section 2, Group I, 2010, Os. 6 (Page No. 642)
[a] Sympathetic (T 1 - L2) - Nerve of filling (Relaxation of detrusor and contraction of internal
sphincter)

79
626 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 627

Q.4 : Bone cyst ·o Cause:

A: See Section 2, Group II, Qs. 32 and Qs. 33 (Page No. 721-722) ► Increasing amount or intensity of activity
Q.5: Gibbus ► Improper equipment
Ans: ► Increased physical stress
GIBBUS ► Unfamiliar surface

□ What is it: Type of hyphotic structural deformity where there is prominence of two or three spinous O Clinical feature : Pain at the site of fracture, which increases with activity and subsides with rest.
processes and these vertebrae become wedged O Investigations:
□ Derivation : Gibbus is Latin for "hump" or "hunch" ► X-Ray
□ Causes: ► CT
(A) Congenital - ► Apert syndrome ► MRI
► Coffin-Lowng syndrome O Treatment :
► Cretinism (hypothyroidism) - sail vertebrae ► Rest
► Achondroplasia ► Pain-free activity for 6-8 weeks
► Mucopolysaccharidoses - (i) Hurler syndrome ► Shoe inserts/braces to be used
(ii) Hunter syndrome □ Prevention :
(iii) Morateaux-Lary syndrome ► Healthy diet rich in Vitamin-D and calcium
(8) Acquired - ► Pott's disease (Spinal TB) ► Use of proper equipment
► Spinal osteomyelitis ► Cross-training
► Compression fracture with collapse of vertebral bodies (vertebra plana) ► Set incremental goals when indulging in any new sports activity.
as in-
(i) Metastasis
2009
(ii) Osteoporosis
,1~
(iii) Histiocytosis Q. 1 :My,jsltis oss1,1cans

► Sch euer mann disease MYOSITIS OSSIFICANS

□ Clinical examination finding : When viewed from behind, deformity looks sharply angled. The
hunchback deformity becomes more prominent when patient bends forward. (Adam's forward bending
Test)
□ Investigations :
□ Synonym: Post-traumatic ossification (traumatic myositis ossificans)
□ What is it: Ossifica~~matoma _around joint ➔ formation of bone mass ➔ restricts joint movements
□ Aetiology: Severe trauma where capsule and periosteum stripped off from bones

► X-Ray □ Commonest site : Elbow joint

► MRI - Measure Cobb's angle □ Age : Children > adults .
□ Treatment: Early treatment of the underlying cause is required. □ Occurs in:
• Neuronal damage from head injury
Q.6 : Stress Fracture
• Paraplegia
Ans:
• Massage after trauma
STRESS FRACTURE
□ Clinical features :
□ What is it: Oversue injury which occurs when muscles become fatigued and are unable to absorb the • Stiffness
added shock, and then transfer the stress to bone causing tiny fracture • Loss of joint movement
□ Site : Weight-bearing bones of lower leg and foot □ X-ray features :
□ Sex predilection : F > > M • Active myositis - fluffy margins of bone mass
• Mature myositis - trabeculated mass and well-defined margins
 628 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 629

□ Treatment :
• Rest
o Treatment :
• Detection of underlying cause of fracture
• Physiotherapy later • Assessment of capacity of fracture to unite, based on nature of underlying disease -
• Surgical excision
► Generalised disorder (Paget's disease, osteoporosis) - unite with conventional methods
□ Precaution : No massage after trauma
► Bone cyst, benign tumor - delayed union
□ Other types :
► Fractures in osteomyelitic bones - long lime to unite
• Myositis ossificans progressive
► Fractures through metastatic bone lesions - do not unite, repair using bone graft
• Myositis ossificans hypertrophica
fl,/
_ / 2 : Pathological fracture Q. 3 : Carpal_!!!,~yndrome

PATHOLOGICAL FRACTURE ~--- CARPAL TUNNEL SYNDROME

□ What is it: Fracture in a bone made weak by some underlying disease □ Introduction: Syndrome due to compression of median nerve ~s it passes beneath flexor retinaculum
□ Bones affected most commonly: Thoracic and lumbar vertebral bodi~s □ Aetiology:
□ Causes: • Colles' fracture
[
• Amyloid disease I

• Raynaud's phenomenon
CAUSES OF PATHOLOGICAL • Pregnancy
FRACTURES r
• Aberrant forearm muscles f

I • Lipoma
I I
• Idiopathic synovitis
[ LOCALISED DISEASES 1 GENERALISED DISEASES]
• Diabetes
I
"I • Rheumatoid arthritis

lT
I I

INFLAMMATORY [ NEOPLASTIC J MISCELLANEOUS HEREDITARY

• Obesity
(Pyogenic
I
I
7 (Simple bone cyst, ► (Osteogenesis • Myxedema
osteomyelitis, Age : Post menopausal females
Aneurysmal, imperfecta, □
Tubercular
osteomyelitis)
Benign
(Giant cell
( Malignant l bone cyst, I Osteopetrosis) □ Clinical features :
~
Eosinophilic
tunior, Primary • Tingling numbness in lateral 3 1/ 2 fingers and that portion of hand
granuloma, etc)
Enchondroma) ,- (Osteosarcoma, 'C ► ACQUIRED • Clumsiness in carrying out fine movement
Ewing's tumor) (Osteoporosis,
Rickets) • Thenar muscle
Secondary • Atrophy and wrist weakness in chronic cases
- (lung, prostate,
kidney, etc)
• Tinel's sign - Tapping median nerve along its course in the wrist over flexor retinaculum '
-
numbness or paraesthesia at median nerve distribution
• Phalen's manoeuvre positive - Flexion of wrist for 30-60 seconds ➔ numbness or paraesthesia
at median nerve distribution , , -···---.
□ Age-wise commonest causes : i [See Fig. 2.9.;U.)
• Birth - 5 years - Osteogenesis imperfecta Durkan's carpal compression t~fposTtive·=·compress median nerve at wrist for 30 seconds
• 5-20 years - Osteomyelitis, Simple bone cyst
• ➔ numbness or paraesthesia at median nerve distribution
• 20-50 years - Cystic lesions of bone, Osteomalacia, Malignancy Blood pressure cuff test - Shows signs of nerve compression
•
• > 50 years - Osteoporosis, Multiple myeloma □ Investigations :
□ Clinical features : • Nerve conduction velocity reduced
• History of discomfort in region of affected bone before fracture
• MRI
• Fracture sustained with trivial trauma □ Treatment: Dividing the flexor retinaculum decompresses the nerve
 630 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 631

Q. 4 : Fracture neck femur- types and complications

FRACTURE NECK FEMUR Fracture neck femur~

□ Types: /
Undisplaced Displaced
• lntraarticular (True fracture neck femur)-discussed below

□
• Extraarticular (lntertrochanteric fracture)
Age : Elderly i / ~
Hip spica in children Age < 60 years Age > 60 years
□ Sex predilection : F > M
Thomas splint in adults
□
□
Cause : Trivial fall
Classification :
• ANATOMICAL CLASSIFICATION -
► Subcapital (just below head)
or sometimes
Multiple screw fixation
l
Closed reduction
l
Prosthetic replacement
reqd
► Transcervical (middle of neck) //' ~
► Basal (at base of neck) Reduced Not reduced I
Normal hip
\
[See Fig. 2.9.4]
i i Pre-existing arthritis
• PAUWEL'S CLASSIFICATION -
(based on angle of inclination of displaced fragment from horizontal plane)
I - 30 degrees
Multiple screw fixation Open reduction i
Hemiarthroplasty
i
Total hip
replacement
II - 50 degrees
Ill - 70 degrees
• GARDEN'S CLASSIFICATION - □ Complications :
(based on degree of displacement) • AVASCULAR NECROSIS -
Stage 1 - Incomplete fracture ► Cause - Insufficient blood flow through ligamentum teres
Stage 2 - Complete fracture + not displaced ► Effects - (i) Non-union
Stage 3 - Complete fracture + partially displaced (ii) Deformed head
Stage 4 - Complete fracture + completely displaced ► Evident after - 2 years in X-ray
□ Clinical features : ► Investigation of choice - MRI
• Pain in groin ► Treatment - (i) In young - Total hip replacement, Arthrodesis, Meyer's procedure
• Unable to move limb (ii) In elderly - Hemireplacement arthroplasty, Total hip replacement
• Affected limb externally rotated • NON-UNION -
• Limb shortened ► Pseudoarthrosis + Trendelenburg test positive
► Treatment : (i) Neck reconstruction
• Tenderness in anterior hip point and on bitrochanteric compression
(ii) Pauwel's osteotomy
• Attempted hip movements painful
• OSTEOARTHRITIS-
• Active straight leg raising not possible
► Due to - (i) Avascular deformation of head
□ X-ray features :
(ii) Union in faulty alignment
~ Medial cortex of neck ► Treatment - (i) In children - lntertrochanteric osteotomy
• Break in
~ ► Shenton's line (ii) In elderly - Total hip replacement
Trabecular stream Q. 5 : Aetiopathogenesis of acute osteomyelitis
• Femur externally rotated
• Overriding of greater trochanter ACUTE PYOGENIC OSTEOMYELITIS
□ What is pyogenic osteomyelitis : Infection of bone by pyogenic organisms
632 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 633

□ Types: □ Site : Metaphysis of

• Acute- • Upper femur (commonest)
► Primary (haematogenous spread) - commonest • Lower femur
► Secondary (due to open fracture or surgery) • Upper tibia
• Chronic □ Age : Childhood
□ Aetiopathogenesis : □ Sex predilection : M > F
• Normal anatomy- Metaphysis i.e. the part between diaphysis and epiphysis, is highly vascular □ Clinical features :
- arteries end in capillaries and veins begin, forming hair-pin loop. Any stasis of blood flow • Pain, swelling at metaphyseal end
makes it highly vulnerable to microbial infection. • Later abscess in muscle plane
• Causative organisms - • Toxic features
► Staphylococcus aureus □ Investigations :
► Group B Streptococcus • Raised ESR
► Staphylococcus epidermidis • Raised TLC
► Haemophilus influenzae • X-ray - Earliest sign is subperiosteal new bone deposition
► Salmonella typhi • Bone scan
► Pseudomonas □ Treatment :
• Spread of infection - via blood • Presents in< 48 hours -
• Pathogenesis - ► Rest
► Antibiotics
Bacteria reach bone via blood
► Intravenous fluid
t • Presents after> 48 hours -
Get lodged in metaphysis Surgical exploration and drainage followed by rest, i.v. fluid and antibiotics
t □ Complications :
Inflammatory reaction • General -
t ►
►
Septicaemia
Pyaemia
Bone destruction, pus formation
t • Local -
► Chronic osteomyelitis
Pus travels in different directions
► Acute pyogenic arthritis
/ ~ ► Pathological fracture
Along medullary cavity Out of cortex To the joint □ Differential diagnosis :
• Acute rheumatic arthritis
-i
Thrombosis of medullary vessels l
Lies subperiosteally
•
•
Acute septic arthritis
A poliomyelitis

~
a.-!,#a bifida
/
Subperiosteal new bone formation Periosteum lifted
SPINA BIFIDA

/ ~ □ What is it : Failure of enfolding of nerve elements within spinal canal during developmental period
Damage of periosteal blood supply Perforates periosteum
□ Sites:

Segment of bone tendered avascular t • Lumbosacral C

-}- Abscess in muscle • Thoracolumbar (
plane □ Types:
Sequestrum formed
• Spina bifida occulta
[See Fig. 2.9.5] • Spina bifida aperta

80
634 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 635

SPINA BIFIDA OCCULTA: LI Q.2 : Complications of supracondylar fracture of humerus

□ What is it- Vertebral arches fail to fuse ➔ bifid spinous processes of vertebrae A: See Section 2, Group I, 2008, Os. 2 (Page No. 617)
□ Commonest site - Lumbosacral region (S1 commonest)
Q.3 : Paget's disease of bone
□ Clinical features -
A: See Section 2, Group II, Os. 9 (Page No. 701)
• Dimpling of skin
Q.4 : Tension band wiring
• Lipoma
• Dermal sinus A: See Section 2, Group II, Os. 14 (Page No. 704)
• Tuft of hair Q.5 : Indication for amputation
□ Neurological manifestations : A: See Section 2, Group I, 2012 Supplementary, Os. 4 (Page No. 656)
• Cause:
Q.6 : Management of osteosarcoma
► Tethering of spinal cord to filum terminale
Ans:
► Defective neural development (myelodysplasia)
MANAGEMENTOFOSTEOSARCOMA
► Tethering of spinal cord to undersurface of skin by fibrous membrane (membrane
reuniens) [For introduction See Section 2, Group II, Os. 36, (Page No. 724)]
► Diastematomyelia(bifid cord, transfixed with antero-posterior bone bar) □ Investigations :
• Features: ► X-Ray- (i) Sunray appearance - Tumour grows into the overlying soft tissues. New bone
► Muscle imbalance in lower limbs is laid down centrifugally, along the blood vessels within the tumour.
► Muscle wasting (ii) Periosteal reaction
► Foot deformities (iii) Codman's Triangle - See Section 2, Group I, 2011 Supplementary, Os. 4
(Page No. 642)
SPINA BIFIDA APPERT A :
► Serum alkaline phosphatase -
□ What is it- Involves vertebral arches, overlying soft tissues, skin, meninges and often the neural tube
□ Commonest site - Dorso-lumbar spine Tumour ➔ i Serum ALP ➔ Tumour removal ➔ J, S. ALP ➔ Recurrence or metastasis
□ Types- J,
• Meningocele - Meninges protrudes out through a defect in neural arch, contains only CSF i S. ALP
• Meningomyelocele - Neural elements along with meninges protrude out ► Biopsy - to confirm diagnosis
• Syringomyelocele - Dilated central canal of spinal cord, cord protrudes out along with the ► Chest X-ray - to detect lung metastasis
meninges and neural elements ► CT, MRI - to know extent of involvement of affected bone which is necessary for amputation
• Myelocele - Due to arrest in closure of neural groove, CSF may leak out through the upper and limb saving surgery
end of an elliptical raw surface (2nd commonest type) □ Treatment:
[See Fig. 2.9.6] A) Amputation - It can be of 2 types
□ Investigations : ► Palliative ➔ For pain relief and better life
• Plain X-ray spine ► Definitive ➔ Complete removal of tumour
• CT/MRI of spine and head
□ Treatment : Site of tumour Level of amputation
• Deformity correction
• Development of limb function • Upper end of humerus ➔ Forequarter amputation
• Urological treatment for bladder incontinence • Upper end of tibia ➔ Mid-thigh amputation
• Ventriculo-peritoneal shunt for hydrocephalus • Upper end of femur ➔ Hindquarter amputation
Hip disarticulation for early lesions
2009 Supplementary • Lower end of femur ➔ Hip disarticulation
Mid-thigh amputation for early lesionr
Q. 1 : Non-union of closed fracture .~. ~,~-
A: See Section 2, Group I, 2003 supplementary, Os. 4 (Page No. 665)
636 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I D SOLVED SHORT NOTES OF FINAL MBBS 637

B) Chemotherapy - 2010
► Given pre or post-operative
► Drugs used - (i) Methotrexate
EXOSTOSIS
(ii) Citrovorum factor
(iii) Cisplatin □ What is it: Commonest benign tumor of bone
(iv) Endoxan □ Synonyms:
C) Radiotherapy - • Osteochondroma
Indications are - (i) Local control of tumours occuring at surgically inaccessible sites • Diaphyseal aclasis
(ii) Patients not ready for surgery • Cartilage capped exostosis
D) lmmunotherapy - □ Define : Exophytic outgrowth on the surface of bone, as a result of detachment of a part of bone
A portion of tumour is implanted into a sarcoma survivor and is removed after 14 days. growth plate, capped by hyaline cartilage
The sensitized lymphocytes from the donor are infused into the patient, which finally kill [See Fig. 2.9.7)
the cancer cells selectively. □ Pathoanatomy:
E) Follow-up - • It is a result of aberration of growth plate
For next 6-8 weeks to evaluate any recurrence or metastasis • Some cells at the margin of the growth plate, instead of growing longitudinally, start growing
F) Treatment plan - centrifu~ ..
• Longitudinal growth of rest of growth plate continues, exostosis comes to lie at the metaphysis,
pointing towards the diaphysis
Clinical Features
• When longitudinal growth stops, exostosis also stops growing

t
Initial evaluations (X-ray, Chest X-ray) □
• Tip gets covered with hyaline cartilage, rest made of mature bone
Age : Adolescents
□ Clinical features :
t
Biopsy to confirm diagnosis
Swelling with following features -
• Bony

I • Non-tender

+
Normal Chest X-ray
t
Chest X-ray showing secondaries
•
•
•
Hard
Sessile/pedunculated
Surface smooth

t
CT Scan
•
•
•
Margins well-defined
Arising from underlying bone
Not attached to skin or superficial structures
Control of spread
I □ Risk factors for malignant change :
• Neo-adjuvant
chemotherapy t
Single
t
Single
•
•
Sessile
Situated in proximal part
• Adjuvant
lesion lesion • Multiple in number
chemotherapy
t
Resection of
t
Palliative ablation
□
□
Site : Metaphysis
Complications :
secondary lesion of tumour and • Compression of neurovascular bundle
chemotherapy • Limitation of joint movement
Limb ablation Limb saving • Pain and tenderness if -
surgery surgery 1. Direct compression of nerves
2. Fracture of base of growth
638 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 639

3. Malignant transformation to chondrosarcoma in 1% cases □ Treatment :

4. Bursitis of overlying bursa • Surgical excision of hormone secreting tissue
□ X-ray findings : • Orthopaedic treatment
• Exophytic bony growth extending laterally from the bone, arising from metaphyseal region • Calculi removal from kidney
• Actual size more than radiological size as cartilage cap not visible
---~~ •••"''"----------------••••~,--~~--~-~.a~•••----•••-'•• a_.3:Ew~~a
□ Treatment:
• No treatment required if asymptomatic : /1/ EWING'S SARCOMA
• Excision including overlying bursa and periosteum over exostosis if - □ What is it : Highly aggressive malignant bone tumor
1. for cosmetic reasons
□ Age: 10-20 years l'-/0,1·/'t;)
2. suspected malignancy
□ Bones affected :
3. single exostosis
• Long bones - Mainly femur and tibia
4. jeopardising daily activities
• Flat bones - Mainly pelvis, calcaneum
Q. 2: Brown's tumor □ Site ~ _rngghysis
BROWN'S TUMOR □ Pathology:
• May involve entire medullary cavity
□ Associated with : Hyperparathyroidism • Tumor tissue - Greyish white
□ What is it: Expansile lytic bone lesion • Consistency - Soft, thin, almost like pus
□ Pathology : Collection of osteoclasts • Bone expanded, periosteum elevated with subperiosteal new bone formation
□ Site : Mainly maxilla, mandible • Tumor ruptures through cortex early and extends into soft tissue
□ Age : 30-40 years (F > M) □ Histopathology:
□ Action of PTH: • Sheets of small uniform cells resembling lymphocytes
Activates adenylyl cyclase in bone ➔ increased cAMP ➔ increased release of lysosomal enzymes • Tumor cells surround a central clear area forming a pseudorossete
from osteoclasts ➔ breakdown of organic matrix of bone ➔ Ca 2+ released into ECF □ Pathogenesis :
□ Clinical features : Begins in bone marrow, probably from endothelial cells
• Bone pain J,
• Anorexia, fatigue, nausea, vomit, abdominal cramp Spreads in Haversian system to bone surface
• Pathological fracture J,
• Renal colic Subperiosteal new bone formation
□ X-ray features: J,
• Expansile lytic lesion appearing like bone tumor in maxilla or mandible Repeated layer after layer
• Others-
□ Spread : Metastasis via blood to lungs and bones
► Subperiosteal bone erosion - of radial border of digital bones
□ Clinical features :
► Resorption of terminal phalanges
• Intermittent throbbing pain
► Demineralisation
• Pain followed by swe~~~~- (_ L; k-e ~~ ccvvv-g.J
► Soft tissue calcification
• Low grade fever and malaise
► Nephrocalcinosis
□ Investigations: · ----
► Chondrocalcinosis
• Blood - Raised ESR, leucocytosis
► Pepper-pot appearance of skull
• X-rays-
► Ragger jersey appearance of vertebrae (due to osteoporosis and osteosclerosis)
► Diaphyseal moth-eaten lesion
□ Other investigations : ► Lytic lesion with permeative margins
• Blood - high Ca, PTH, ALP; low phosphate ► Lesion in medullary zone of midshaft with cortical destruction and new bone formation
• Urine - low Ca, high phosphate in layers - onion-peel appearance
• CT scan neck • Open biopsy
640 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 641

□ Treatment : □ X-ray features :

• 9!}~n:,Qt~~py - Vincristine, Adriarl]J'_~iri and C::yglophosphamide (VAC) monthly for 12-18 cycles • Lateral view - displacement
• Radiotherapy - Highly radiosensitive but high recurrence • Oblique view - abnormal pars interarticularis ("Scottish dog" sign)
• S~rgery'--:::-Cocal amputation, bone resection □ Treatment :
=,~-~----- ,'
□ Differential diagnosis : • Mild cases -
• Chronic osteomyelitis ► Rest
• Osteosarcoma ► Braces
• Osteoclastoma ► Spinal exercise
• Chondrosarcoma • Severe cases - Decompression of nerve + Fusion of affected spinal segments
• Metastatic neuroblastoma Q. 5 : Bone scan

BONESCAN
Q. 4 : Spondylolisthesis □ What is it: A bone scan is a diagnostic procedure (nuclear scanning test )used to evaluate abnormalities
involving bones and joints. A radioactive substance is injected intravenously, and the image of its
SPONDYLOLISTHESIS
distribution in the skeletal system is analyzed to detect certain diseases or conditions
□ Introduction : Forward displacement of a vertebrae over lower one □ Principle: A nuclear bone scan is a functional test: it measures an aspect of bone metabolism or bone
remodeling, which most other imaging techniques cannot. The nuclear medicine scan technique is
□ Site: L4 - L5 or L4 - S 1
sensitive to areas of unusual bone-rebuilding activity because the radiopharmaceutical is taken up by
□ Types: osteoblast cells that build bone. The technique therefore is sensitive to fractures and bone reaction to
• lsthmic - Defect in pars intercularis, of the following types - infections and bone tumors, including tumor metastases to bones, because all these pathologies trigger
►
Fatigue fracture osteoblast activity.
►
Acute fracture □ Preparation :
► Intact but elongated • Some specialized blood studies should be drawn before this study is begun.
Effect - Anterior part of vertebrae + spinal column above it is displaced forwards, posterior part • Jewellery or metallic objects need to be removed.
remains with lower vertebrae □ Technique :
• Dysplastic - Congenital abnormality in development of vertebral column • In the nuclear medicine technique, the patient is injected (usually into a vein in the arm or
• Traumatic hand, occasionally the foot) with a small amount of radioactive material such as 740 MBq of
• Degenerative technetium-99m-MDP and then scanned with a gamma camera
• Pathological - Bone disease weakening the articulation • In evaluating for tumors, the patient is injected with the radioisotope and returns in 2-3 hours
for imaging. Image acquisition takes from 30 to 70 minutes, depending if SPECT images are
□ Meyerding system grading : required
Grade Percentage of displacement • If the physician wants to evaluate for osteomyelitis (bone infection) or fractures, then a Three
Phase!Triphasic Bone Scan is performed where 20-30 minutes of images (1st and 2nd phases)
I <25% are taken during the initial injection. The patient then returns in 2-3 hours for additional images
II 25-50% (3rd Phase). Sometimes late images are taken at 24 hours after injection
□ Phases : The three phase bone scan detects different types of pathology in the bone.
Ill 50-75%
IV 75-100% FIRST PHASE

V > 100% • Also known as the nuclear angiogram or the flow phase.
• During this phase, serial scans are taken during the first 2 to 5 seconds after injection of the
□ Symptoms : Backache and nerve abnormalities in lower limb technetium-99m-MDP
□ Age : lsthmic type in young, degenerative type in elderly • This phase typically shows perfusion to a lesion.
□ Clinical examination : • Detects moderate to severe pathology
• 'Step' palpable above sacral crest in vertebral column SECOND PHASE
• Increased lumbar lordosis • Image of this phase is also known as the blood pool image
• Sciatic nerve stretching on Straight Leg Raising Test • Obtained 5 minutes after injection

81
642 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 643

• This shows the relative vascularity to the area. O Pathogenesis :

• Areas with moderate to severe inflammation have dilated capillaries, which is where the • BONE-
blood flow is stagnant and the radioisotope can "pool". Inflammation
• This phase shows areas of intense or acute inflammation more definitively compared with J,
the third phase Local trabecular necrosis and caseation
THIRD PHASE J,
• Delayed phase Intense local hyperaemia
J,
• Obtained 3 hours after the injection, when the majority of the radioisotope has been
metabolized Demineralisation of bone
J,
• This phase best shows the amount of bone turnover associated with a lesion
Cortices of bone get eroded in absence of adequate body resistance
J,
□ Specificity increased by: By performing an indium 111-labeled white blood cell test combined with
Infected granulation tissue and pus find their way to sub-periosteal and soft-tissue planes
a technetium-99m-MDP injection. J,
□ Aftercare : Fluids are encouraged after the scan to aid in the excretion of the radioisotope.
Cold abscess
□ Radiation dose obtained : A typical radiation dosage obtained during a bone scan is 6.3 mSv J,
□ Interpretations : May burst out to form sinuses
• Normal - The normal appearance of the scan will vary according to the patient's age. In J,
general, a uniform concentration of radionuclide uptake is present in all bones in a normal scan Affected bone may undergo pathological fracture
• Abnormal-
• JOINT-
,. A high concentration of radionuclide occurs in areas of increased bone activity. These
regions appear brighter and may be referred to as "hot spots." They may indicate Low grade synovitis + thickening of synovial membrane
J,
healing fractures, tumors, infections, or other processes that trigger new bone
formation. Tubercular infection causes slow destruction of articular cartilage
J,
► Lower concentrations of radionuclide may be called "cold spots." Poor blood flow to
an area of bone, or bone destruction from a tumor may produce a cold spot. Synovium inflamed (this inflammatory synovium at periphery of cartilage is called Pannus)
J,
□ Purpose: Starts destroying cartilage from periphery
J,
To detect the following -
Ultimately, cartilage completely destroyed
• Cancer - primary or secondary J,
• Infection in the bone
Joint gets distended with pus
• Fractures that are difficult to detect on X-ray J,
• Unexplained pain may be evaluated Joint capsule, ligament become lax, joint subluxated
• Early arthritic changes J,
• Monitoring both the progression of the disease and the effectiveness of treatment Pus and tubercular debris burst out of joint capsule
• Suspected child abuse J,
□ Precautions : A patient who is unable to remain still for an extended period of time may require Cold abscess
sedation for a bone scan J,
□ Contraindications : Pregnant and lactating mothers Chronic discharging sinus
□ Disadvantage : The bone scan is not sensitive to osieoporosis or multiple myeloma in bones • HEALING -
Q. 6 : Tb spine Healing occurs by fibrosis
J,
TUBERCULOSIS OF SPINE
Considerable destruction of articular cartilage, joint space completely lost
□ Synonym : Caries spine J,
□ Aetiology: Mycobacterium tuberculosis Traversed by bony trabeculae between bones forming the joint (bony ankylosis)
□ Pathology: Chronic granulomatous inflammation with caseation necrosis
 644 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - I O SOLVED SHORT NOTES OF FINAL MBBS 645

□ Spread:
Symptoms:
• Skeletal TB is always secondary
• Pain -
• Spreads through Batson's paravertebral venous plexuses, which communicates freely With
visceral plexus of abdomen ► Back pain commonest
□ Types: ► Initially diffused, later localised
► May be radicular pain
• Paradiscal - "Embryological segment" affected
• Central - Body of single vertebra affected ➔ early collapse of weakened vertebra ➔ wedglhg • Stiffness -
collapse (common) or Concertina collapse ► Early symptom
► Protective mechanism wherein paravertebral muscles go into spasm
• Anterior - Anterior part of vertebral body affected ➔ spreads up and down under anterior
longitudinal ligament • Cold abscess -· Swelling or problems due to its compression of neural structures
•
Posterior - Posterior complex of vertebra affected i.e. pedicle, lamina, spinous process, • Paraplegia -
transverse process
□ Stages: Grades of Pott's paraplegia
• Stage of destruction - Patient unaware + Babinski's sign positive
Bacteria lodge in contiguous areas of 2 adjacent vertebrae II Clumpsiness, spasticity while walking but can walk without support
j, Ill Not able to walk + Paraplegia in extension + partial loss of sensation
Granulomatous inflammation IV Unable to walk+ Paraplegia inflexion+ Severe muscle spasm+ Near complete
j,
loss of sensation + Sphincter disturbance
Erosion of vertebral margins
j,
Compromised nutrition of intervening discs, which is derived from end-plates of adjacent vertebrae
• Deformity - Gradually increasing prominence of spine ("gibbus")
j, • Constitutional symptoms -
► Evening rise of temperature
Disc degeneration
j, ► Weight loss, anorexia, fatigue
Complete destruction □ Clinical examination :
• Collapse of vertebrae - • Gait-
► Short steps to avoid jerking
Weakening of trabeculae of vertebral body
j, ► Twists whole body to look sideways
Collapse of vertebrae • Attitude and deformity -
• Cold abscess formation - ► Prominence of 2-3 spinous processes (gibbus)
► Loss of lumbar lordosis
Collection of pus and tubercular debris from a diseased vertebra
j, ► Stiff, straight neck
• Para-vertebral swelling -
~ Pus tracks in any direction ~
► Due to cold abscess
► Fluctuating in nature
Travels backwards Travels anteriorly or by side of vertebrae

Compresses j,neural structures in spinal cord
Travels along musculo-fascial plane to appear superficially at places far away from site of lesion
• Stage of healing -
Lytic areas replaced by new bones
j,
Adjacent vertebrae undergo fusion by bony bridges
j,
Permanent changes in shape of vertebral body
l • Tenderness - Elicited by pressing on side of spinous processes in an attempt to rotate vertebrae
• Movement - Limited spinal movement
• Neurological examination
□ Investigations :
• X-ray-
► Reduction of disc space (earliest sign)
► Destruction of vertebral body
► Rarefaction above and below lesion
► Cold abscess visible
► Erosion of posterior elements seen on Oblique X-ray
► Density of affected bone increases during healing
 GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 647
646 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

What is it : Constriction of fibrous digital sheath prevents free gliding of the contained flexor tendon
• CT Scan -
Cause : Generally due to repeated microtrauma
, Detects very small paravertebral abscess
Associated disorders :
, Extent of destruction of posterior segment of vertebral body
• Diabetes mellitus
r In cases presenting as 'spinal tumor syndrome' where X-ray is not helpful
• Gout
• MRI - Investigation of choice to evaluate cord compression
• Rheumatoid arthritis
• Myelography
Commonly affected : Middle and ring finger
• Biopsy
Pathoanatomy:
• ELISA, PCR, Mantoux test
Tendon swollen proximal to the sheath -, on trying to straighten finger, swollen tendon cannot enter
□ Treatment : into the sheath -, locking of finger -, overcome by forcibly extending finger when finger extends with
• Control of infection - snap-like trigger of pistol
, Antitubercular drugs (2HRZE + 4HR) [See Fig. 2.9.9]
, Rest
□ Age : 4th and 5th decade
► Nutritious diet
□ Clinical features :
• ~are of spine - Initially bed rest, as healing starts, slow immobilisation with spine supported • A sharp 'click' felt on flexion/extension of affected finger
in brace or collar
• Pain at the base of affected finger on trying to passively extend that finger
• Treatment of cold abscess - • Gradually difficulty in extending the fingers increases
► Aspiration
• Swollen tendon felt proximal to the sheath
-, Evacuation
□ Treatment :
□ Complications :
• Mild cases - Local ultrasonic therapy
• Cold abscess
• Long standing cases - lntralesional Triamcinolone
• Neurological compression • Severe cases - Operative release of flexor tendon sheath
□ Differential diagnosis : Bowler's thumb
2010 Supplementary
0. 2: Ewing's tumor
Q.1 : Tuberculosis of hip joint A : See Section - 2, Group - I, 2010, 0.3 (Page No. 639)
A: See Section 2, Group II, Os. 51 (Page No. 737)
Q.3 : Mechanism of fracture patella
Q.2 : Volkmann 's ischaemic contracture
A: See Section 2, Group I, 2008, Os. 4 (Page No. 620)
FRACTURE OF PATELLA
Q.3 : Club Foot □ Causes:
• Direct force (blow on anterior aspect of knee in flexed position)
A : See "Talipes Equinus" Section 2, Group I, 2008 (Page No. 621)
• Indirect force
Q.4: Dupuytren's contracture
□ Types:
A: See Section 2, Group I, 2012, Os. 4 (Page No. 654) • Two-part fracture - Fracture line passes transversely across patella, dividing it into 2 parts,
Q.5: Giant cell tumour occurring due to sudden severe contraction of quadriceps
A: See "Osteoclastoma" Section 2, Group 11, Os. 36 (Page No. 724) • Stellate fracture - Comminuted fracture ......----
Q.6 : A vascular necrosis of femoral head . ('.[Se~t=1g.2.9.~~J (~1
A: See Section 2, Group II, 2008, Os. 49 (Page No. 736) □ Mechanism :
Patellar fracture held in position i.e. undisplaced by
2011
le""' ">I
Q. 1 : Trigger finger Patellar retinaculae on the sides Intact pre-patellar expansion of quadriceps in front
TRIGGER FINGER If force of quadriceps tendon is stronger
J,
□ Synonyms:
• Snapping finger Pulls fragments apart
J,
• Digital tenovaginitis
Rupture of patellar retinaculae
• Digital stenosing tenovaginitis
 648 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 649

□ Clinical features : □ Types:

• Pain and swelling over knee
• Unable to lift leg with knee in full extension (extensor lag)
• Crepitus felt in comminuted fracture
• Gap palpable between fragments in displaced fracture [ TYPES OF SHOULDER DISLOCATION
]
• Knee swollen due to haemarthrosis I
□ X-ray findings: I I I
• A-P view ANTERIOR DISLOCATION POSTERIOR LUXATIO ERECTA
• Lateral view (Head of humerus comes DISLOCATION (Head of humerus
• Skyline view out of glenoid cavity and (Head of humerus comes to lie in sub-
□ Treatment : lies anteriorly) comes out of glenoid position)
• Undisplaced fracture - Plaster cast from groin to just above malleoli, with fully extended knee glenoid cavity and
for 3 weeks lies posteriorly,
Subglenoid behind glenoid)
• Two-part fracture - Tension band wiring (for details vide Semester Orthopaedics Short Notes

•
Segment)
Stellate fracture - Patellectomy
---- (Head lies in front of
glenoid)
/fJ>4: Brodie's abscess
,, ~,,,...,,,·

//~/ BRODIE'S ABSCESS Subcoracoid

□ What is it: Type of chronic osteomyelitis where defence mechanism of body has been able to limit the
infection, thereby creating a bone abscess
---- (Head lies below
coracoid process)
□ Age : 11-20 years
□ Site:
Subclavicular
• Upper end of tibia ~
(Head lies below
• Lower end of femur
clavicle)
□ Clinical features :
• Deep boring pain - Worsens at night and with activity, and relieved with rest
• Tenderness [See Fig. 2.9.12]
• Increased girth
□ Pathological changes :
□ X-ray: Circular luscent zone surrounded by sclerotic tissue
□ Treatment: Surgical evacuation and curettage along with antibiotics • Bankart's lesion (stripping of glenoidal labrum along with periosteum from anterior surface of
glenoid and scapular neck)
[SeeFig.~~
• Hill-Sach's lesion (depression in postero-lateral quadrant of head of humerus, caused by
Q. 5 : Carpal tunnel syndrome impingement by anterior edge of glenoid on the head as it dislocates)
A: See Section - 2, Group -1, 2009, Q.3 (Page No. 629) • Rounding off of anterior glenoid rim
Q. 6: Shoulder dislocation □ Symptoms:
SHOULDER DISLOCATION • Shoulder abducted and externally rotated, and patient supports the injured arm at the elbow
• History of fall on outstretched hand followed by pain and inability to move shoulder
□ Speciality: Shoulder joint is the commonest joint in human body to dislocate because -
• Shallow glenoid fossa □ Clinical examination :
• Laxity of ligaments • Normal round contour of shoulder joint is lost, it looks flattened
• Enormous range of movements permissible in shoulder joint • Fullness below clavicle due to displaced head
□ Causes: • Adduction and internal rotation restricted
• Fall on outstretched hand with shoulder abducted and externally rotated • Axillary nerve sensation over lateral part of deltoid is examined
• Direct blow on front of shoulder • Dugas' test - Inability to touch opposite shoulder
• Electric shock or epileptiform convulsion

82
650 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 651

• Hamilton's ruler test - A ruler can be placed on the lateral side of arm touching the acromion □ Foundin:
and lateral condyle of humerus due to flattening of the shoulder, which otherwise is not possible
► Osteosarcoma
normally
► Ewing's sarcoma
• Callaway's test - Circumference of affected shoulder is more than the unaffected shoulder
□ Investigations : ► Aneurysmal bone cyst
• X-ray - ► Osteomyelitis
,- AP view - Overlapping of head of humerus and glenoid ► Metastasis
, True lateral scapular view - To differentiate anterior and posterior dislocation ► Giant cell tumour
► Stryker - Notch view ► Juxtachortical chondrosarcoma
► Hill - Sach view
► Malignant fibrous, histiocytoma
► West - Point view
• MRI - to detect Bankart's lesion 0.5 : S-P Nail
• CT Scan - to detect bony Bankart's lesion Ans:
□ Treatment : S-P NAIL
Reduction under general anesthesia --, immobilisation of the shoulder in a chest-arm bandage for 3 □ Full form : Smith Peterson nail
weeks
□ What is it: Cannulated triflanged nail used for internal fixation of fracture neck of femur
Techniques of reduction -
□ Named after: Marius Smith-Peterson in 1953
• Kocher's manoeuvre - Traction --, external rotation --, adduction --, internal rotation
□ Other use : Along with a McLaughlin's plate to fix. lnter-trochanteric fractures
• Hippocrates manoeuvre - Done when assistant not available
• Stimson's (gravity) method □ Role of cannulation: It can be threaded over guide-wire, introduced at the correct site by visualising
• Saha's method in X-ray.
□ Complications : □ Advantages :
• Injury to axillary nerve ► Provides good stability as it cuts only a little part of bone
• Recurrent dislocation of shoulder , Prevents axial rotation of fragments
• Failure to reduce the dislocation
• Shoulder stiffness 2012
Q. 1 : Fracture of clavicle
2011 Supplementary
FRACTURE OF CLAVICLE
0.1 : Sequestrum
□ Age : Children
A: See Section 2, Group I, 2008, Os. 3 (Page No. 618)
□ Causes:
0.2 : Frozen shoulder
• Fall on shoulder
A: See Section 2, Group I, 2008, Os. 1 (Page No. 616) • Fall on outstretched hand
0.3 : DO disease □ Pathoanatomy: Commonest site of fracture is middle 113rd and outer 113rd junction. After fracture,
A: See Section 2, Group II, Os. 17 (Page No. 706) part of clavicle medial to fracture is displaced upwards due to pull by sternocleidomastoid, part lateral
to fracture is displaced downwards due to pull by pectoralis major.
0.4: Codman's triangle
□ Types:
Ans:
• Middle 113rd - 80% cases
CODMAN'S TRIANGLE
• Distal 1/3rd - 15% cases
□ What is it: Triangular area of subperiosteal new bone seen at tumour - host cortex junction at the ► Type I - minimally displaced between ligaments, no displacement
ends of the tumour
► Type II - displaced fracture medial to coracoclavicular (CC)ligament
□ 1st described by: Ribbert in 1914
► Type Ill - fracture through acromioclavicular joint, no displacement
□ Named after: Ernest Amory Codman
• Proximal 113rd - 5% cases
□ Pathogenesis : With aggressive lesions, the periosteum does not have time to ossify with shells of
new bone. So, only edge of raised periosteum will ossify
 652 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 653

□ Diagnosis : • Chair test

• History of trauma • Bowden test
• Pain, swelling in the clavicular region, cannot raise arm • Mill test
• Confirmation by X-ray • Motion stress test
• Neurological deficit may occur in upper arm □ Treatment :
□ Treatment : • Activity modification
•
Closed treatment - For middle 113rd, proximal 113rd, distal 113rd Types I and Ill • Physical therapy- Ice application, ultrasonic therapy
► Triangular sling • lntralesional Triamcinolone injection
► Figure of '8' bandage • Bracing or strapping
► Active exercise after relief of pain • NSAIDs, Corticosteroids
• Open reduction and internal fixation - • Surgery-After 6·12 months of failed conservative treatment
► For Type II distal 113rd fracture ► Percutaneous release of tendons
► If severe neurodeficit ► Open debridement
► For open fracture ► Arthroscopic debridement
► If vascular injury □ Differential diagnosis :
□ Complications: • Radial tunnel syndrome
• Early - . / ~Osteochondral intraarticular lateral elbow lesion
► Injury to brachia! plexus ~pracondylar fracture of humerus
► Injury to subclavian artery
• Later - SUPRACONDYLARFRACTUREOFHUMERUS
► Shoulder stiffness □ What Is It: Fracture of humerus where fracture line passes transversely through distal metaphysis of
► Mal-union/Non-union humerus just above the condyles
. Jr.~Tennis elbow □ Age : 5·8 years because -

, J/
// TENNIS ELBOW • Laxity of ligaments increases chances of hyperextension
• Flattened cross-section of humerus
□ Synonym : Lateral epicondylitis • Presence of numerous fossas (radial, olecranon, coronoid) reduces the strength of humerus
□ .Definition : .F'.~l.r!. and tenderness in lateral Eill_icondyle of humerus due to non-specific inflammation at • Due to thick anterior capsule acting as a fulcrum, olecranon process may strike the thin
the origin of extensor muscles of forearm (tendinosis) supracondylar region during hyperextension, because the capsule causes the olecranon to
□ Speciality : Angiofibroblastic inflammation (as fibroblast hyperplasia ➔ vascular hyperplasia ➔ firmly engage in the olecranon fossa
abnormal collagen production □ Cause : Fall on outstretched hand with elbow being forced into hyperextension as the hand strikes
□ Side affected: Dominant arm the elbow
□
·----
Most commonly affected: Degeneration of extensor carpi radialis brevis □ Types:
□ Age : 30-60 years Gartland classification -
□ Causes:
• Tennis players EXTENSION TYPE (98%) i.e. distal fragment FLEXION TYPE(2%) i.e. distal fragment
• While carrying suitcase extended (tilted backwards) in relation to flexed (tilted forwards) in relation to proximal
• Squeezing clothes proximal fragment fragment
□ Symptoms : Insidious onset pain in the lateral epicondylar region which is aggravated by putting a Type I - Non-displaced Type I - Non-displaced
stretch on the extensor muscles Type II - Displaced but intact posterior cortex Type II - Displaced but intact anterior cortex
□ Clinical examination :
Type Ill - Completely displaced Type Ill - Completely displaced
• Jhompsoo'.s test - Shoulder flexed to 60 degrees ➔ elbow extended ➔ forearm pronated ➔ ~~~· ~

wrist extended ➔ pressure applied on 2nd/3rd metacarpals and patient tries to flex and ulnar
deviate the wrist --, severe pain occurs
• .Cozen's test - Elbow flexed, forearm pronated--, wrist extended against resistance--, severe
pain
 654 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 655

□ Symptoms: □ Aetiology:
• Pain • Hereditary (autosomal dominant)
• Swelling • Alcoholic cirrhosis
• Unable to move elbow • Epileptics receiving sodium hydantoin
□ Clinical examination : • Diabetes
• 3 bony point relationship not changed • AIDS
• Unus~rnminencJ of olecrruion'iip- __ • Tuberculosis
□ Displacements :
□ Pathoanatomy:
• Posterior tilt
Palmar aponeurosis is a thin, tough membrane beneath palmar skin
• Posterior shift
j, j,
• Proximal shift
• Medial tilt Proximally Distally
j, j,
• Medial shift
Continues as Palmaris longus Divides into slips for each finger
• Lateral shift
j,
• Internal rotation
Slips fuse with fibrous flexor sheath
□ X-ray features : j,
• A-P view- Extend till middle phalanx
► Proximal shift
Here, pathology begins as a nodule ➔ p~~mar aponeurosis thickens and contracts ➔ flexion deformity
► Medial lilt
of tinge:~
► Medial shift
□ Clinical features :
► Lateral shift
• Mostly ring finger affected, most affected is little finger (generally limited to medial three
► Internal rotation fingers) ·-
• Lateral view - • Thickening of palmar aponeurosis felt at bases of affected fingers
► Posterior tilt • Flexion at metacarpophalangeal and proximal interphalangeal joint
► Posterior shift
□ Differential diagnosis :
► Proximal shift
• Flexor tendon contracture (flexion also at distal interphalangeal joint)
□ Treatment : • Claw hand (metacarpophalangeal joint extended, proximal interphalangeal joint flexed)
Type I - Cast for 3 weeks
□ Treatment :
Type II - Manipulation under anesthesia + cast
• Early cases - Radiotherapy
Type Ill - Open/closed reduction + Percutaneous K-wire fixation
• Severe cases -
(Cast in supracondylar fracture -
► Fasciectomy with post-operative splint
► with elbow kept in maximum flexion that does not jeopardise the radial pulse
,- Resection + arthrodesis
► forearm pronated
► starting from deltoid muscle insertion Q. 5: Ruptured tendoachilles

► extends till proximal palmar crease RUPTURED TENDOACHILLES

► just short of knuckles
► excluding base of thumb) 0 Speciality : Commonest tendon to rupture
□ Pathogenesis : Avascular degeneration
□ Complications :
A: See Section - 2, Group - I, 2008, Q. 2 (Page No. 617) □ Age : > 40 years
□ Symptoms : History of sudden feeling of being struck above heel while running or jumping and inability
)#~;:rtren's contracture to stand on toes thereafter
\_/ DUPUYTREN'S CONTRACTURE □ Clinical examination :
• Gap seen and felt 3-5cm above insertion of tendon, which increases with dorsiflexion of ankle
□ What is it: Proliferative fibroplasia of palmar aponeurosis
• Weak plantar flexion
• Simmond's test - Patient in prone position ➔ calf squeezed ➔ no plantar flexion
656 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 657

□ Treatment : (i) Plastic repair

• Early cases - Tendon sutured with foot in passively plantar flexion position ➔ plaster with (ii) Secondary closure of skin flap
foot in equinus position for 8 weeks ➔ shoe with raised heel for 6 weeks (iii) Revision of stump
• Late cases - Tendon lengthening and suturing (iv) Reamputation at a higher level
Q. 6 : Mallet finger • Closed amputation - skin is closed primarily
(B) • End/close bearing
MALLET FINGER
• Non-end/side bearing
□ Synonym : Baseball finger (C) • Weight bearing
□ What is it: Avulsion fracture of distal phalanx at the insertion of extensor tendon slip at the base of • Non-weight bearing
distal phalanx □ Levels:
□ Causes: ► Above elbow
• Direct injury to the finger tip
► Below elbow
• Finger tip forcibly extended
► Above knee
□ Clinical features: Distal interphalangeal joint in slight flexion - active extension not possible, passive
► Below knee
extension possible
► Shoulder disarticulation
□ Diagnosis :
► Elbow disarticulation
• Clinical examination
► Hip disarticulation
• Lateral view X-ray
► Knee disarticulation
□ Treatment :
► Indications :
• Constant DIP hyperextension splint - for 8 weeks
► Injury - to save life in crush injuries
• Open repair if large bony avulsion fracture
► Dead, dying devitalised tissue
[See Fig. 2.9.14]
► Infections -
Q. 7: Pyogenic osteomye/itis • Chronic osteomyelitis
A: See Section - 2, Group -1, 2009, 0. 5 (Page No. 631-632) • Necrotising fascitis
► Gangrene due to
2012 Supplementary • Atherosclerosis
• Diabetes
Q. 1 : Compartment syndrome • Ergots, maggots
A: See Section 1, Segment C, Paper II, 2014, Os. 10 (Page No. 430) • Embolism

Q.2 : Sequestrum • Buerger's disease

A: See Section 2, Group I, 2008, Os. 3 (Page No. 618) • Diabetic foot
• Gas gangrene
Q.3 : Radiological features of osteosarcoma
• Peripheral vascular disease
A : See Section 2, Group 11, Os. 36 (Page No. 617)
• Malignancies
Q.4 : Indications of limb amputation
Osteosarcoma
Ans:
Marjolin's ulcer
INDICATIONS OF LIMB AMPUTATION
Rhabdomyosarcoma
□ What is amputation : Part of limb is removed through bone Malignant fibrous histiocytoma
□ Types: Severe congenital or acquired deformity
(A) • Guillotine or open amputation - skin not closed over amputation stump, when would is
Q.5 : Fracture decranon
unhealthy.
Ans:
After certain inteval, following may be done -

83
658 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 659

FRACTURE OLECRANON lo Pathology:

~•· [ Degenerative changes in vertebral disc like
□ Age group: Adults i.'' ~~~ii ('.! Weak~ning and disintegration of posterior part of annulus fibrosus
□ Cause : Direct injury like a fall onto the point of elbow ·. IJEGENERATION (11) Softening and fragmentation of nucleus pulposus
□ Pathoanatomy: Triceps muscle attached to the proximal fragment pulls it, thereby creating a gap at
the fracture site. jJ,
□ Types: DISC [ Due to injury or spontaneous disintegration, annulus fibrosis becomes weak and nucleus
I ➔ Fracture (no displacement of fragments) PROTRUSION pulposus tends to bulge through the defect
II ➔ Fracture + Displacement of fragments
Ill ➔ Comminuted fracture jJ,
Nucleus pulposus comes out of annuius fibrosus and lies under posterior longitudinal ligament
DISC
EXTRUSION
[ (contact with parent disc is still not lost)
Triceps
jJ,
DISC [ The posterior longitudinal ligament ruptures and the extruded nucleus pulposus looses its
SEOUESTRA- contact with parent disc
TION
jJ,
Extruded nucleus pulposus becomes fl~tened, fibrosed and calcifies.

STAGE OF [
FIBROSIS
Type I Type II Type Ill
Residual nucleus pulposus becomes fibrosed
□ Symptoms : Pain and swelling at fracture jJ,
□ Signs:
► Tenderness STAGE OF
New bone formation begins at points where posterior longitudinal ligament has been separated
[
FIBROSIS from the vertebral body leading to spur formation.
►. Crepitations
► Gap between fragments - active extension of elbow is not possible Posterior Nucleus
□ Investigations : X-ray elbow jt-AP and Lateral view longitudinal Nucleus pulposus
ligament pulposus .__,/ lies under
□ Treatment : bulges
Degenerated ~ posterior
► Type I ➔ Immobilisation in an above- elbow plaster slab in 30° flexion for 3 weeks through longitudinal
annulus defect in
► Type II ➔ Tension-band wiring (TBW) fibrosus ligament
annulus
► Type Ill ➔ If not separated, treated like Type I. If separated fragments, TBW or excision of Fragmented
fragments done. nucleus
A)STAGE OF pulposus B) DISC PROTRUSION C) DISC EXTRUSION
□ Complications : NUCLEUS
► Non-union DEGENERATION

► Osteoarthritis
► Stiffness of elbow Extended disc loses
Q.6 : Slipped disc contact with parent
disc
Ans:
SLIPPED DISC
□ What is it: "Slipped disc" is a term used for both vertebral disc prolapse and disc herniation. D) DISC SEQUESTRATION
 660 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 661

□ Clinical features :
► Age - 20-40 year
,.► Muscle relaxant
Hot fomentation
► Low backache - dull or acute; made worse by exertion, sitting, standing or forward bending; ► Exercises, physiotherapy
relieved by rest.
► TENS
► Sciatic pain - radiates to gluteal region, back of thigh and leg, and to postero-lateral calf and
(b) ► Fenestration
heel
Root compression Pain radiation ► Hemilaminectomy

⇒ Front of thigh ► Laminotomy

L2-L3
Anterolat aspect of leg and ankle ► Laminectomy
LS ⇒

S1 ⇒ Posterolateral calf and heel 2013

Q. 1: Volkmann's ischaemic contracture
► Associated paraesthesia, urinary and bowel incontinence.
A: See Section - 2, Group - I, 2008, Q. 4 (Page No. 620)
□ Examination : Q. 2: Ewing's tumor
► Movement - Patient not able to bend forward; any such attempt leads to spasm of paraspinal A: See Section - 2, Group - I, 2010, Q. 3 (Page No. 639)
muscles
Q. 3 : Core needle biopsy
► Posture - Patient stands with rigid lumbar spine, trunk seems shifted forward and titted to one
side CORE NEEDLE BIOPSY
► Tenderness in lumbosacral region. □ What is it: A procedure that removes small but solid samples of tissue using a hollow "core" needle.
► Straight leg raising test (SLRT) - Positive SLRT at 40° or less suggests root compression For palpable ("able to be felt") lesions, the physician fixes the lesion with one hand and performs a
□ Lasegue test - Hip lifted to 90° with knee bent, and then when examiner tries to extend the knee freehand needle biopsy with the other.
gradually. Patient experiences severe pain in back of leg or thigh. □ Indications : Mainly for breast carcinoma and musculoskeletal tumors
□ Neurological deficit : □ Additional measures: In case of non-palpable lesions, stereotactic mammography, or ultrasound, or
PET guidance is used .
.•,,;{eve1'·.' Root •tfeoted Motor weakness ~ensory wea~n.ess ·R,~tlexes • With stereotactic mammography - possible to pinpoint the exact location of a mass based on
In great toe and medial Sluggish on images taken from two different angles of the X-ray machine
L3-L4 L4 knee extensors are weak
side of leg absent knee jerk • With ultrasound - possible to watch the needle on the ultrasound monitor to help guide it to
the area of concern
L5 Extensor hallucis longus Over dorsum of foot and Ankle jerk is
L4-L5 • With PET (positron emission tomography) - the lesion is targeted in 3D based on a positron
lateral side of leg normal
Iii!I and foot dorsiflexors
weakness
emission tomography (PET) image of the breast
ii □ Advantage:
L5-S1 S1 Plantar flexors of foot are Over lateral side of foot Absent or sluggish • Has a special cutting edge allowing removal of a bigger sample of tissue; a relatively large
Ir weak ankle jerk sample can be removed through a small single incision in the skin
• Takes few minutes to be performed
□ Investigations : • Almost painless
► X-ray of spine - Disc space narrowed in chronic disc prolapse □ Needle size : The needle used during core needle biopsy is larger than the needle used with FNAC
□ Disadvantage : May cause some bruising
► CTscan
□ Technique :
► MRI - investigation of choice
• Core needle biopsy for palpable masses -
► EMG - to assess denernation and other neurological deficit
► Done in a health care provider's office
□ Treatment: ► Before the procedure, local anaesthetic used to numb the skin and tissue around the
(a) ► Rest suspicious area
► Then needle is inserted and a small amount of tissue is removed
► Analgesics
662 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I D SOLVED SHORT NOTES OF FINAL MBBS 663

□ X-ray features:
• Core needle biopsy for nonpalpable masses -
► likely to be done in a clinic or imaging centre • Cortical break at corticocancellous junction
► Abnormal area located with the help of ultrasound and then needle inserted • Displacements - Mainly dorsal tilt
• Core needle biopsy with stereotactic mammography - • Axis of radius and 2nd metacarpal does not lie in same line
► Patient lies on her stomach on a special table and her breast fits through a hole in the □ Treatment :
table • Undisplaced fracture - Colles' cast
► Before the procedure, the health care provider will use a local anaesthetic to numb • Displaced - Manipulative reduction ➔ immobilisation in Colles' cast
the area (Colles' cast- From just below elbow to the proximal palmar crease, and just short of knuckles,
► Breast will be compressed like it is for a mammogram, and several images will be excluding the thumb, with the wrist kept in slight palmar flexion and ulnar deviation, and the
taken. These images help the provider guide the biopsy device to the suspicious area forearm pronated)
in the breast
□ Complications :
► A needle in the device removes tissue samples.
• Malunion
□ Comparison with FNAC: FNAC is a less reliable and less informative diagnostic method than core
• Stiffness of fingers (commonest)
n~edle biopsy. Al_t~ou~h a negative ?r indeterminate FNAC result requires follow-up or a re-biopsy
with core needle, 111s still a cost-effective procedure. Stereotactic guidance considerably increases the • Complex regional pain syndrome
costs of core needle biopsy, and therefore USG guidance should be used whenever possible • Carpal Tunnel syndrome
• Extensor pollicis longus tendon rupture
Q~.4 : Col/es' fracture
~istal radio-ulnar joint instability
COLLES' FRACTURE
□ What is it: Transverse fracture at distal end of raJ:jiJ.l§, at its corticocancellous junction, about 2cm Q:~
from the distal articular surface, with typical deformities BONE GRAFT
[See Fig. 2.9.15] □ What is it : Pieces of bone taken from some part of patient's body or some other person's body and
□ Age: Elderly women (due to postmenopausal osteoporosis) placed at another site
□ Purpose : Stimulating bone formation and filing bone defects
□ Cause: Fall on outstretched hand
□ Associated deformities : □ Types:
(a) AUTOGRAFT -
• Lateral displacement ~ 1 _;;;}.0\+
t,)t • Derived from the patient's body
• Dorsal displacement
• Generally these are 'free grafts' (i.e. without blood supply) which provide just a scaffold
• Lateral shift
upon which new bone is laid; a bone stimulating protein called 'bone morphogenic
• Dorsal shift J\!:\-
protein' is liberated, which helps in osteogenesis.
• Impaction of fragments SL,v'(\~ ()>' CY''/\. • Preserving blood supply by following techniques -
(' '
• Supination ::;,
► Muscle-pedicle bone graft
□ Associated injuries :
► Free vascularised bone graft
• Fracture of styloid process of ulna
(b) ALLOGRAFT-
• Rupture of triangular cartilage of ulna
• Derived from another human being - living or dead(cadaveric graft)
• Rupture of ulnar collateral ligament
• Stored in bone banks
• Rupture of interosseous radio-ulnar ligament
• Used when enough bone not available from host
□ Clinical features :
(c) XENOGRAFT -
• Pain + swelling + deformity of wrist • Derived from other species like bovine bone graft
• Tenderness and irregularity of lower end of radius (d) ARTIFICIAL BONE -
• Dinner-fork deformity - Radial styloid process lies at same level or higher than ulnar styloid • Made of hydroxyapatite
process
• Derived from corals
• Wrist broadened
• Used in developed countries
• Ulnar head prominent
• Has osteo-conductive potential
• Shortened forearm
664 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I D SOLVED SHORT NOTES OF FINAL MBBS 665

□ Sites: • Type II - Flexion type (15%) - ulna shaft angulates posteriorly (flexes) and radial head
• Anterior and posterior iliac crest dislocates posteriorly.
• Fibula (except distal 7-8 cm) • Type Ill.,. Lateral type (20%) - ulna shaft angulates laterally (bent to outside) and radial head
• Olecranon dislocates to the side.
• Proximal tibia • Type IV - Combined type (5%) - ulna shaft and radial shaft are both fractured and radial head
• Radial/femoral is dislocated, typically anteriorly.
~·-·---- _,_... .. -----head
" ...-~

□ Indications : □ Clinical features :

• Non-union, delayed union • Pain and swelling in upper part of forearm
• To fill bony cavities • Movements of elbow and forearm restricted
• Arthrodesis of joints
• Tenderness
• Establish continuity between bony defects
□ Investigations : X-ray both A-P and lateral view
□ Instruments used :
□ Treatment: External reduction to relocate radial head ➔ cast for 2-3 weeks ➔ re-evaluation under
• Osteotome
X-ray ➔ not reduced ➔ Open reduction and internal fixation
• Chisel
□ Complication : Malunion
• Gouge with mallet
• Bone cutting forceps [See Fig. 2.9.16]
□ Types of autografts :
Q. 3 : Carpal tunnel syndrome
• Cortical (used where structural support needed) - e.g. fibula
A: See Section - 2, Group - I, 2009, Q. 3 (Page No. 629)
• Cancellous (for osteogenesis) - e.g. iliac crest
• Corticocancellous - e.g. rib Q. 4 : Non-union of fracture

□ Substitutes for bone graft:

NON-UNION OF FRACTURE
• Bone marrow
• Tricalcium phosphate □ What is it: Healing of the fracture fragments has not progressed sufficiently for the s~ipulated time for
• Collagraft that site, type of fracture and for that age of the patient
• Calcium phosphate □ Time : 9 months for all fractures, except 3 months for -
• Unsolved fracture - fracture neck of femur
2013 - Supplementary
• Essential fracture - fracture lateral condyle of humerus
Q. 1 : CTEV- anatomical changes □ Types:
A : See Section - 2, Group - I, 2008, 0. 5 (Page No. 621) • Atrophic - No callus formation
Q. 2 : Monteggia fracture • Hypertrophic - Callus formed, but fails to bridge the gap
□ Causes:
MONTEGGIA FRACTURE
□ What is it: Fracture of upper third of ulna along with dislocation of head of radius
□ Named after : Giovanni Battista Monteggia.
□ Aetiology:
• Fall on an outstretched hand with the forearm in excessive pronation
• Direct blow on back of upper forearm rarely
• Hyperextension
□ Bado classification :
There are four types (depending upon displacement of the radial head) :
• Type I - Extension type (60%) - ulna shaft angulates anteriorly (extends) and radial head
dislocates anteriorly.

84
666 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 667

□ Treatment:
CAUSES OF • No treatment if mild cases
NON-UNION
• lllizarov's technique
• Open reduction and internal fixation
Related to Related to Related to • Fragment excision
patients fracture treatment Q. 5 : External fixation

EXTERNAL FIXATION
Old age Distraction Inadequate
at fracture reduction □ What is it: External fixation is a surgical treatment used to stabilize bone and soft tissues at a distance
site from the operative or injury focus
Systemic
□ Purpose : They provide unobstructed access to the relevant skeletal and soft tissue structures for their
diseases- Distraction
Soft tissue initial assessment and also for secondary interventions needed to restore bony continuity and a functional
diabetes,
interposition soft tissue cover.
malignancy
□ Parts:
Bone loss • Schanz pin
• Connecting rods

Pathological • Clamps
fracture _,::,, Distraction osteogenesis
·□ Basic principle : Osteogenesis requires dynamic state i.e OR
Infection ~c ompress1on
. osteogenes1s.
□ Indications :
Damage to • Limb-lengthening
blood supply • Stabilization of infected non-unions
• Stabilization of severe open fractures
• Deformity correction
□ Common sites :
• Initial stabilization of soft tissue and bony disruption in poly trauma patients (damage control
• Lateral condyle of humerus orthopaedics)
• Lower third of ulna
• Arthrodesis
• Scaphoid
• Ligamentotaxis
• Neck of femur
• Osteotomies
• Lower third of tibia
• Pelvic ring disruptions
□ Clinical features :
• Certain pediatric fractures
• Painless
• Temporary transarticular stabilization of severe soft tissue and ligamentous injuries
• Mobility at fracture site
□ Contraindications :
• Increasing deformity
• Patient with compromised immune system
□ X-ray features :
• Non compliant patient who would not be able to ensure proper wire and pin care
• Fracture ends smooth and rounded
• Pre-existing internal fixation that prohibits proper wire or pin placement
• Little callus
• Bone pathology precluding pin fixation
• Fracture line visible
• Sclerosis D ILLIZAROV'S TECHNIQUE OF EXTERNAL FIXATION
• Osteopenia • Commonest external fixator
668 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 669

• Advantages - • MRI - to detect Bankart's lesion

► Immediate load bearing • CT Scan - to detect bony Bankart's lesion
► More than 1 problem corrected at a time • Arthrogram
► Healthy viable bone □ Treatment :
• Disadvantages - • Atraumatic cases -
► Inconvenient ► Rehabilitation
► Pin tract infection ► Inferior capsular shift operation
► Nerve palsy • Traumatic cases -
► Joint stiffness Surgery required if > 2 episodes
► Injury to underlying structures ► Putti-Platt operation - Double breasting of subscapularis tendon to prevent external
rotation and abduction
► Long duration treatment
► Bankart's operation - Glenoid labrum and torn capsule are reattached in front of
• Technique -
glenoid rim, done easily with 'anchors'
► Stabilisation by Ring Fixator
► Bristow's operation - Coracoid process and muscles attached to it, are osteotomized
[Stainless steel wires put through bone ➔ wires put under tension ➔ wires then
at its base and fixed to lower-Mlf of anterior margin of glenoid
attached to steel rings with help of bolts ➔ rings interconnected by threaded rods,
► Boytchev's operation - Subscapularis made taut by putting coracobrachialis and short
with nuts on either sides ➔ nuts help to move the rings up and down]
head of biceps below subscapularis
► Distraction or compression by twisting nuts at required site @ 1mm/day (1/4 mm 4
► Magnuson-Stack operation - Subscapularis and capsule detached and then reattached
times a day)
more laterally
Q. 6 : Recurrent dislocation of shoulder ► Arthroscopic Bankart repair
RECURRENT DISLOCATION OF SHOULDER
//;,,,-/· 2014
□ What is it: Shoulder joint gets dislocated very often / /
□ Age: Young age Q. ,·; F,;ctures occurring due to fall on outstretched hand
D Causes:
• Anatomically unstable joint - e.g. Marfan's syndrome FRACTURES OCCURRING DUE TO FALL ON OUTSTRETCHED HAND
• Epileptic patient
□ In children -
• lnadeqllate healing of previous dislocation
• Fracture clavicle (See Section - 2, Group -1, 2012, Q. 1 [Page No. 651])
D ·Subtypes :
• Supracondylar fracture of humerus (See Section - 2, Group - I, 2012, Q. 3 [Page No. 653])
• Traumatic
□ In young adults - Fracture scaphoid (See Section - 2, Group - II, Q. 1 [Page No. 694])
• Atraumatic
□ Essential lesions : □ In elderly-
• Calles' fracture (See Section - 2, Group -1, 2013, Q. 4 [Page No. 662-663])
• Bankart's lesion } (for details vide "Shoulder Dislocation" - MB Ortho
Short Note 2011, Page No. 648) • Fracture shaft humerus (See Orthopedic short notes from Semesters segment)
• Hill-Sach's lesion
• Defect of anterior rim of glenoid • Fracture radial head (See Section - 2, Group -11, Q. 25 [Page No. 713])
□ Clinical features : • Fracture capitulum
• Power of deltoid muscle tested • Fracture trapezium
• Axillary nerve function tested • Bennett's fracture (See Section - 2, Group - II, Q. 21 [Page No. 71 O])
• Apprehension test - Patient tries to resist when shoulder is gradually abducted Q. 2: Osteochondroma
□ Investigations : A: See Section - 2, Group - I, 201 O, Q. 1 [Page No. 637]
• X-ray -
·, o/eenstick fracture
► AP view - overlapping of head of humerus and glenoid
► True lateral scapular view - to differentiate anterior and posterior dislocation , GREENSTICK FRACTURE
► Stryker - Notch view □ What is it: Fracture in young, soft bone which bends and partially breaks
► Hill - Sach view
► West - Point view [See Fig~~!?]) ~
'----~
 670 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 671

□ Age: Infancy, childhood □ Investigations :

□ Aetiology: High risk falling activities ► Blood counts
□ Types: ► X-Ray
• Transverse fracture ► Culture and sensitivity of pus
• Torus fracture
□ Treatment:
• Bow fracture
► Antibiotics -All open fractures to be treated with Cefazolin or equivalent Gram-positive coverage
□ Clinical features : Type II and Ill injuries will receive Gram negative coverage in addition to this like any
• Baby cries inconsolably due to pain Aminoglycoside injuries at risk of anaerobic infections must receive Penicillin or Clindamycin
• Swollen, reddish areas at site of fracture
► Tetanus toxoid and Tetanus immunoglobulin
□ Treatment : Splints
► Surgical measure -
Q. 4 : Fracture of patella (i) Proper pre-operative details to be evaluated regarding neurologic and vascular status
A: See Section - 2, Group - I, 2011, 0. 3 [Page No. 647] (ii) Irrigation of wound
a. 5 : Spina bifida (iii) Debridement of unhealthy tissue
A: See Section - 2, Group -1, 2009, 0. 6 [Page No. 633-634] (iv) Fracture stabilisation
(v) Local adjuncts - PMMA cement, heat stable antibiotic powder
2014 Supplementary (vi) Vacuum assisted closure (VAC)
(vii) Negative pressure would therapy
Q.1 : Frozen shoulder □ Complications :
A: See Section 2, Group I, 2008, Os. 1 (Page No. 616) ► Infection (Grade I ➔ 0 - 2%)
Q.2: Brodie's abscess ► Non-union (Grade II ➔ 2-10%)
A: See Section 2, Group I, 2011, Os. 4 (Page No. 648) (Grade Ill ➔ 10 - 50%)

Q.3 : Carpal tunnel syndrome

2015
A : See Section 2, Group I, 2009, Os. 3 (Page No. 629)
Q.4 : Ewing's sarcoma a. 1 : Exostosis of bone
A : See Section 2, Group I, 2010, Os. 3 (Page No. 639) A : See Section 2 Group-I 2010, Os. 1 (Page No. 637)
_,)'~-Compound fracture Q. 2 : Volkmamis /schaemic contracture.
/
Ans: A : See Section 2 Group-I 2008 Os. 4 (Page No. 620)
COMPOUND FRACTURE Q. 3 : Pathological fracture

□ Synonym : ~ fr~ct~:fi) . . .
A : See Section 2 Group-I 2009 Os.2 (Page No. 628
□ What is it: Fracture in which there is an open would or break in the skin near the site of broken bone 07?'1"estrum
□ Grades: "Gustilo Open Fracture Classification" SEQUESTRUM
➔ Skin wound < 1 cm communicating with fracture, clean wound
□ What is chronic osteomyelitis: Infection of bone, persisting for >3 weeks, along with absence of any
II ➔ Skin wound> 1 cm communicating with fracture, but< 10 cm without extensive soft tissue
systemic symptoms and characterised by a discharging sinus
damage
0 Types:
Ill ➔ Extensive soft tissue laceration> 10 cm
• Secondary to acute osteomyelitis
Includes fractures that have been open for 8 hours prior to treatment • Garre's osteomyelitis
Ill A ➔ Type Ill fracture with adequate periosteal coverage of fracture bone • Brodie's abscess
Ill B ➔ Type Ill fracture with extensive soft tissue loss and periosteal stripping and bone □ What is sequestrum : Piece of dead bon~e, _within a _livin\L~Qne affected by chronic osteomyelitis,
damage. Associated with massive contamination surrounded by infected granulation tissue, having a smooth inner surface and irregular outer surface.
Ill C ➔ Type Ill fracture with arterial injury requiring repair [See F i g ( ~
672 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I D SOLVED SHORT NOTES OF FINAL MBBS 673

□ Types of sequestrum : □ Site: Where pin is inserted at fracture site.

□ Clinical features :
TYPES OF SEQUESTRUM • Past history of open fracture/trivial trauma/fever and pain in affected part followed by treatment
with fixation by using pins.
• Discharging sinus
• History of bone pieces corning out
According to colour According to shape
• Waxing - Waning pattern of symptoms
• Reduced range of movements
Feathery Ring • Puckered scars around sinus
• Increased bone girth
Pencil-like • Tenderness
Coralliform
□ Investigations :
• X-ray-
Ivory Cylindrical
► Irregular and thickened cortex
► Sequestrum (increased bone density, surrounded by radioluscent zone)
Black Conical ► lnvolucrum + cloacae
► Patchy sclerosis
Green • CT, MRI
• Sinogram
• Pus - Culture and sensitivity
□ Treatment:
□ What is Ring sequestrum :
• Surgical -
• Characteristic radiographic finding following chronic osteomyelitis due to major pin-tract infections ► C-Cauterisation
• Thermal necrosis without infection presents as a zone of sclerosis around the tract. ► A-Amputation
• A narrow radiolucent halo may surround the dense region of sclerosis indicating associated infection. ► S-Sequestrectomy
□ Aetiology: ► E-Excision of infected bone
► S-Saucerisation
• Delay in treatment
• Antibiotics
• Inadequate treatment
• Rest
• Highly virulent organisms
• Continuous suction-irrigation after wound closure
• Reduced host resistance
□ Complications :
□ Pathology : • Acute exacerbation
• Growth abnormality (lengthen, shorten, deformity)
• Pathological fracture
Following acute osteomyelitis • Joint stiffness

/ ~
Disturbed periosteal blood flow
i
Dead bone surrounded by granulation tissue
• Sinus tract malignancy
• Amyloidosis
New subperiosteal bone formation
c~d~amputation stump
i
This sclerotic bone is involucrum
/ IDEAL AMPUTATION STUMP

i i
It overlies the sequestrum
□ What is amputation stump :
The part that is left beyond a healthy joint following amputation is called an ideal amputation stump.
Sequestrum formed
□ Ideal stump should have following features :

'
i
Inner surface smooth, ~)er surface irregular Cloacae (holes) formed to drain out pus
A) Healing-
• Must be adequate
• Free from infection

85
674 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 675

8) Shape -
• Rounded, gentle contour
• Adequate muscle padding POTT'$ FRACTURE
• End bearing
• Bone end well covered with muscle
Synonym:
► Dupuytren fracture
• Disarticulation
► Pott's syndrome I
• Side pad or adequate bony surface to bear weight for varying period
• Thick skin and muscle flap What is it: Bimalleolar ankle fracture
• No redundant soft tissue Symptoms : Instant severe pain and unable to put weight on leg + Swelling + Bruising
C) Length - Signs : Severe tenderness on the malleoli
• Sufficient to bear prosthesis Mechanism of injury : Combined abduction and external rotation from an eversion force causing
• For A strain on deltoid ligament
□ Associated injuries : Shearing off of -
2015 Supplementary ► Posterior margin of distal end of tibia
► Fibula superior to tibiofibular syndesmosis
Q.1 : Non-union of fracture □ Investigations : X-ray of foot AP and lateral view
A: See Section 2, Group I, 2013 supplementary, Qs. 4 (Page No. 665) □ Treatment :
Q.2 : Mallet finger ► Mobilization exercise
A : See Section 2, Group I, 2012, Os. 6 (Page No. 656) ► Plaster cast
Q.3 : Baker's cyst ► Ankle brace/ walking boot
Ans: ► Surgery to fix internal bones
BAKER'S CYST
2016
□ Named after: Morant Baker
□ What is it: Cystic swelling found in postero-lateral aspect of knee Q.1 : Carpal tunnel syndrome
□ Origin : Synovial membrane of knee projects out through a gap in the capsule, which gets distended A: See Section 2, Group I, 2009, Qs. 3 (Page No. 629)
by synovial fluid to form a cystic swelling
Q.2: Tardy ulnar nerve palsy
□ Associated with: Arthritis of knee
A : See Section 2, Group II, Qs.10 (Page No. 701)
□ Age : Older age
Q.3 : Supracondylar fracture of humerus
□ Symptoms:
A: See Section 2, Group I, 2012, Os. 3 (Page No. 653)
► Pain in knee joint
► Size of swelling increases with flexion of knee and reduces with extension of knee Q.4 : Giant cell tumor
A: See "Osteoclastoma" Section 2, Group II, Qs. 36 (Page No. 724)
□ Signs:
► Transillumination test positive / negative a.¥(;r,ctelenburg test for hip joint
► Fluctuation test positive ' Ans:
□ Investigations :
TRENDELENBURG TEST FOR HIP JOINT
► X-Ray knee jt. □ What is it: Test useful in determining the integrity of hip abductor muscle function and hip stability
► MRI knee jt. □ Described by: Friedrich Trendelenburg in 1987
□ Treatment : □ Principle : Body weight is distributed equally on both limbs when a person stands on both legs. But
► Analgesics when he stands on one leg, the brain tries to allign the whole body weight of the trunk over the weight-
► Akntibiotics bearing leg. This is achieved by contraction of hip abductors of that side, which, by contracting from
below, pulls the ipsilateral iliac crest down towards that side, causing the pelvis to tilt. This is compensated
► Surgical removal of cyst
by the bending of vertebral column to opposite side. Here,
676 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 677

Fulcrum = Centre of hip joint : Q.5 : External fixation

Failure of lever arm = Neck of femur
A: See Section 2, Group I, 2013 supplementary, Os. 5 (Page No. 667)
Any component of this system leads to the test being positive
□ Pre-requisites : 2017
► No fixed abduction / adduction deformity Q.1: Volkmann's lschaemic contracture
► Able to stand on one leg, unsupported for 30 seconds A: See Section 2, Group I, 2008, Os. 4 (Page No. 620)
► lpsilateral knee, ankle and opposite hip should be normal Q.2: Pathological fracture
□ Procedure : A: See Section 2, Group I, 2009, Os. 2 (Page No. 628)
► Examiner stands behind the patient Q.3: Congenital tallpes equinovarus
► Patient is asked to raise the foot of the normal side from the ground, holding the hip at between A : See Section 2, Group I, 2008, Os. 5 (Page No. 621)
neutral 30 degree of flexion. Knee should be flexed enough to allow the foot to be clear of the Q.4 : Perthes disease
ground in order to nullify the effect of rectus femoris. A: See Section 2, Group 11, Os. 30 (Page No. 717)
► Position of pelvis is noted Q.~~erve Injury due to fracture
► Theh patient is asked to raise the foot of affected side Ans:
► Position of pelvis is again noted. RADIAL NERVE INJURY DUE TO FRACTURE
□ Interpretation :
□ Anatomy of rad/al nerve :
► Negative test i.e., Normal response ➔ Pelvis of non-stance side is elevated and this posture
► Continuation of posterior cord of brachia! plexus
is maintained for 30 seconds
► Supplies long head of triceps in axilla
► Positive test i.e., Abnormal response ➔ Pelvis of non-stance side is either not elevated at all
or not maximally elevated above the stance side, or cannot maintain this posture for 30 seconds ► Supplies medial and lateral head of triceps in spiral groove
► Supplies brachioradialis, extensor carpi radialis longus and extensor carpi radialis brevis
□ Causes of positive test :
beyond spiral groove
► Painful hip conditions - (i) Rheumatoid arthritis
► Below elbow, it gives posterior interosseous nerve which pierces supinotor and supplies all
(ii) Ankylosing spondylitis
muscles of extensor side of forearm
► Fulcrum failure - (i) Hip dislocation ► Thereafter nerve becomes purely sensory
(ii) Developmental dysplasia of hip
(iii) Femoral head destruction due to septic arthritis '\$Jtes oft~Jury due to fracture Type of fracture
► Lever arm failure - (i) Neck femur fracture
(ii) Perthes disease 1) In spiral groove Fracture shaft of humerus • Sensory ➔ sensory loss of lat-
(iii) Trochanteric fracture eral 3.5 fingers
► Abductor failure - (i) Poliomyelitis • Motor ➔
(ii) MND ► Wrist drop*
(iii) Muscle dystrophy
► Only little exension of elbow
possible as function of long
2016 Supplementary head of triceps is persistent

Q.1 : Ewing's tumor 2) Beyond spiral groove Supracondylar fracture • Sensory ➔ sensory loss of lat-
eral 3.5 fingers
A: See Section 2, Group I, 2010, Os. 3 (Page No. 639) Fracture dislocation of head
Q.2 : Genu varum of radius • Motor ➔
► Wrist drop*
A: See Section 2, Group 11, Os. 15 (Page No. 705)
► Full extension of elbow pos-
Q.3 : Frozen shoulder sible as entire triceps is func-
A: See Section 2, Group I, 2008, Os. 1 (Page No. 616) tioning
Q.4 : Osteosarcoma
* Wrist drop ➔ Wrist remains in plamar flexion due to weakness of dorsiflexons [For details see
A: See Section 2, Group II, Os. 37 (Page No. 725) Section 2, Group 11, Os. 26 (Page No. 682)]
678 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I D SOLVED SHORT NOTES OF FINAL MBBS 679

2017 Supplementary 2019

Q. 1 : Injuries sustained by fall on outstretched hand Q.~us

A: See Section 2, Group I, 2014, 0 1, (Page No. 669) CUBITUS VALGUS
Q.2: Complications of Supracondylar fracture.
□ What Is it: Deformity in which carrying angle is increased so that the forearm is abducted excessively
A: See Section 2, Group I, 2008, 0 2, (Page No. 617)
in relation to the upper end
Q.3 : Sequestrum
□ Causes:
A: See Section 2, Group I, 2008, 0 3, (Page No. 618)
a) Congenital - Turner's syndrome
Q.4 : Non-union of fracture - Noonan syndrome
A: See Section 2, Group I, 2013 Supplementary, 0 4, (Page No. 665)
b) Previ~~ frncture of lower end of humerus or capitulum with malunion
Q.5: Ewing's sarcoma c) Interference with epiphyseal growth on lateral side from injury or infection
A: See Section 2, Group I, 2010, 0 3, (Page No. 639)
□ Clinical feature: Increased carrying angle at elbow - forearm sticks out
□ Complications :
2018
• Uln~_!!E3_ll~opathy - Most common ➔ Tardy ulnar nerve palsy
Q.1 : Myositis ossificans □ Treatment :
A: See Section 2, Group I, 2009, 0 1, (Page No. 627) • Mild deformity ➔ No treatment
Q.2 : Fracture patella • Moderate to severe deformity ➔ Medial closed wedge osteotomy
A: See Section 2, Group I, 2011, Q 3, (Page No. 647) • Tardy ulnar nerve palsy ➔ Anterior transposition of ulnar nerve
Q.3: Complications of Col/es' fracture TARDY ULNAR NERVE PALSY
A: See Section 2, Group I, 2013, Q 4, (Page No. 662) □ What is it : Late onset ulnar nerve palsy
Q.4 : Pathological fracture □ Causes:
A: See Section 2, Group I, 2009, 0 2, (Page No. 628) • Displaced medial epicondyle humerus
Q.5: Giant cell tumor • Malunited lateral condyle humerus
A: See Section 2, Group II, 0 36, (Page No. 724)
• Elbow dislocation
• Shallow ulnar groove
2018 Supplementary
• Contusions of ulnar nerve
Q.1 : Pathogenesis of Chronic Osteomyelitis • Hypoplasia of humeral trochlea
A: See Section 2, Group I, 2009, 0 5, (Page No. 631) □ Clinical features :
Q.2: Pott's Paraplegia • Weakness of grip
A: See Section 2, Group I, 2010, 0 6 (TB Spine), (Page No. 642) • Tingling numbness of little finger
Q.3 : Classification of fracture neck femur • Card test positive (ulnar nerve palsy ➔ weakness of palmar interossei ➔ weak adduction of
A: See Section 2, Group I, 2009, 0 4, (Page No. 630) little finger)
Q.4 : Spina bifida • Froment's sign positive (ulnar nerve palsy ➔ weakness of adductor pollicis ➔ flexion of
A: See Section 2, Group I, 2009, Q 6, (Page No. 633) interphalangeal joint while grasping a paper between thumb and radial border of hand)

0.5: Sequestrum • Flexion test positive

A: See Section 2, Group I, 2008, 0 3, (Page No. 618). □ Investigation: Nerve conduction test
680 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 681

□ Treatment :
• Conservative - Elbow extension splints at night CUBITUS VARUS
• Operative - Removal of ulnar nerve from groove ➔ neurolysis if necessary ➔ anterior
transposition to flexor surface of elbow □ Synonym : Gunstock deformity
□ What is it : Most common complication of displaced supracondJl!ar fracture; triplanar deformity
with components of varus, hyper extension and internal rotation (Forearm deviated inwards with
respect to arm at elbow with lateral angulation in full extension)
□ Incidence : 3 - 57%
□ Causes:
• Most common - malunited supracondylar humerus
• Infective - medial growth plate damage
• Traumatic - lateral condyle fracture
• Congenital - epiphyseal dysplasia
• Vascular - osteonecrosis of trochlea
• Neoplastic - secondary to exostosis in distal humerus
□ Examination :
A) Inspection :
• ~!lsi~~E~to-~
NORMAL CUBITUS VALGUS • Limited flexion
• Medial tilt and lateral angulation at elbow
• Prominence of lateral condyle humerus
Q.2 : Fracture healing • Wasting of muscles
A : See Section 2, Group II, 0.16, (Page No. 706) • Gun-stock deformity - looks like a loading stock of old long barrel guns

Q.3 : Osteosarcoma B) Palpation :

• Thickening and irregularity of supracondylar ridges
A: See Section 2, Group 11, Q.37, (Page No. 725)
• Prominent lateral condyle - due to rotation of distal fragment
Q.4 : Club foot • Th.ree poin(!~1:1tionship .does not make an equilateral triangle
A: See Section 2, Group I, 2008, 0.5 (Page No. 298) 'Talipes equinus'. • Decrease in carrying angle
Q.5 : Supracondylar fracture of humerus • Increased internal rotation (Yamamoto Test)

A : See Section 2, Group I, 2012, 0.3 (Page No. 653) □ Grading of severity :
• Grade I ➔ Loss of physiological valgus angle
• Grade II ➔ O - 10° varus
2019 Supplementary • Grade Ill ➔ 11 - 20° varus
• Grade IV ➔ > 20° varus
Q.1 : Complications of Col/es fracture
A : See Section 2, Group I, 2013, 0.4 (Page No. 662) □ Complications : Ulnar nerve palsy
□ X-ray findings :
Q.2: Diagnosis of Volkmann ischemia
1) Decrease in normal physiological valgus
A: See Section 2, Group I, 2008, 0.4 (Page No. 620)
AP [ 2) Increase in Baumann's angle
Q.3: Myositis ossificans view 3) Meta physeo - diaphyseal angle (Klebb-Sherman) > 90°
A: See Section 2, Group I, 2009, 0.1, (Page No. 627) 4) Humero-!,Jlno angle (Oppenheim) - decreased (most accurate finding)

86
682 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 683

Lateral { 5) Normally no overlap between lateral condylar epiphysis and olecranon epiphysis; if □ Grades:
view significant tilt of distal fragment occurs, there is overlap between the two - "Crescent
Grades of Pott's paraplegia
sign" 0 \ -
□ Treatment : I Patient unaware + Babinski's sign positive
1) Observation - Generally not appropiiate as little remodelling occurs in older child II Clumpsiness, spasticity while walking but can walk without support
2) Hemi-epiphysiodesis and growth alteration - does not help to correct deformity, only Ill Not able to walk + Paraplegia in extension + partial loss of sensation
helps in preventing it from increasing IV Unable to walk+ Paraplegia inflexion+ Severe muscle spasm+ Near complete
3) Corrective osteotomy loss of sensation + Sphincter disturbance
a) Lateral closing wedge osteotomy
b) Medial open wedge osteotomy with bone graft □ Classification :
c) Oblique osteotomy with derotation a) Paraplegia of active disease - early onset
4) Most common - __F~Qb_osteotomy (Posterior longitudinal approach) b) Paraplegia of healed disease - late onset
- Modified French Osteotomy (Posterolateral approach) □ Prognosis : Depends on -
• Severity
• Duration
• Level of deficit
• Activity of disease
• General condition of patient
• Presence of associated disease

TUBERCULOSIS OF SPINE
□ Synonym : Caries spine
□ Aetiology: Mycobacterium tuberculosis
□ Pathology: Chronic granulomatous inflammation with caseation necrosis
□ Pathogenesis :
• BONE-
Inflammation
NORMAL CUBITUS VARUS J,
Local trabecular necrosis and caseation
l
Q.5 : Pathological fracture
Intense local hyperaemia
A: See Section 2, Group I, 2009, 0.2, (Page No. 628) J,
Demineralisation of bone
December-January 2019-2020 J,
Cortices of bone get eroded in absence of adequate body resistance
J,
Q.1 : Sequestrum
Infected granulation tissue and pus find their way to sub-periosteal and soft-tissue planes
A: See Section 2, Group I, 2008, 0.3 (Page No. 618) J,
Q~2 : Pott's paraplegia Cold abscess
J,
POTTS PARAPLEGIA
May burst out to form sinuses
□ What is it : Most serious complication of tuberculosis of spine
J,
Affected bone may undergo pathological fracture
□ Highest risk in : Cervico-dorsal region
684 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 685
~==
• JOINT- □ Stages:
Low grade synovitis + thickening of synovial membrane • Stage of destruction -
-1,
Bacteria lodge in contiguous areas of 2 adjacent vertebrae
Tubercular infection causes slow destruction of articular cartilage -1,
-1, Granulomatous inflammation
Synovium inflamed (this inflammatory synovium at periphery of cartilage is called Pannus) -1,
-1, Erosion of vertebral margins
Starts destroying cartilage from periphery -1,
-1, Compromised nutrition of intervening discs, which is derived from end-plates of adjacent vertebrae
Ultimately, cartilage completely destroyed -1,
-1, Disc degeneration
-1,
Joint gets distended with pus
Complete destruction
-1,
• Collapse of vertebrae -
Joint capsule, ligament become lax, joint subluxated
Weakening of trabeculae of vertebral body
-1, -1,
Pus and tubercular debris burst out of joint capsule Collapse of vertebrae
-1, • Cold abscess formation -
Cold abscess Collection of pus and tubercular debris from a diseased vertebra
-1, -1,
Chronic discharging sinus ~ Pus tracks in any direction ~
• HEALING -
Travels ~ackwards Travels anteriorlylor by side of vertebrae
Healing occurs by fibrosis
-1, Compresses neural structures in spinal cord
Considerable destruction of articular cartilage, joint space completely lost
-1, Travels along musculo-fascial plane to appear superficially at places far away from site of lesion
Traversed by bony trabeculae between bones forming the joint (bony ankylosis) • Stage of healing -
□ Spread: Lytic areas replaced by new bones
-1,
• Skeletal TB is always secondary
Adjacent vertebrae undergo fusion by bony bridges
• Spreads through Batson's paravertebral venous plexuses, which communicates freely with
J,
visceral plexus of abdomen
Permanent changes in shape of vertebral body
□ Types:
□ Symptoms:
• Paradiscal - "Embryological segment" affected
• Central - Body of single vertebra affected ➔ early collapse of weakened vertebra ➔ wedging • Pain-
collapse (common) or Concertina collapse ► Back pain commonest

• Anterior - Anterior part of vertebral body affected ➔ spreads up and down under anterior ► Initially diffused, later localised
► May be radicular pain
longitudinal ligament
• Stiffness-
• Posterior - Posterior complex of vertebra affected i.e. pedicle, lamina, spinous process, --►-- Early symptom
transverse process
► Protective mechanism wherein paravertebral muscles go into spasm
• Cold abscess - Swelling or problems due to its compression of neural structures
• Deformit~ - Gradually increasing prominence of spine ("gibbus")
686 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 687

• Constitutional symptoms - • Treatment of cold abscess -

► Evening rise of te111pE:1rnture ► Aspiration
► Weight loss, anorexia, fatigue ► Evacuation
□ Clinical examination: □ Complications :
• Gait-
~---·,-·- • Cold abscess
► Short steps to avoid jerking • Neurological compression
► Twists whole body to look sideways
Q.3 : Tennis elbow
• Attitude and deformity -
► Prominence of 2-3 spinous processes (gibbus) A: See Section 2, Group I, 2012, 0.2 (Page No. 652)
► . ___
Loss of lumbar lordosis
,___,,,__,......... -.,-,-~"- Q.4 : A vascular necrosis
► Stiff, straight neck A: See Section 2, Group 11, 0.49 (Page No. 736)
• Para-vertebral swelling -
► Due to cold abscess Q.5 : Dupuytren 's Contracture
► Fluctuating in nature A: See Section 2, Group I, 2012, 0.4 (Page No. 654)
• Tenderness - Elicited by pressing on side of spinous processes in an attempt to' rotate
vertebrae
June-July, 2020
• Movement - Limited spinal movement
• Neurological exc1n:iin~!~srn Q.1 : Volkmann's ischaemic contracture
□ Investigations: A: See Section 2, Group I, 2008, 0.4 (Page No. 620)
• X-ray -
Q.2: Non union of fracture
► Reduction of disc space (earliest sign)
A: See Section 2, Group I, 2013 supple, 0.4 (Page No. 665)
► Destruction of vertebral body
► Rarefaction above and below lesion Q.3 : Frozen shoulder
► Cold abscess visible A: See Section 2, Group I, 2008, 0.1 (Page No. 616)
,- Erosion of posterior elements seen on Oblique X-ray
Q.4: Ewing's Sarcoma
► Density of affected bone increases during healing
A : See Section 2, Group I, 2010, 0.3 (Page No. 639)
• CT Scan -
► Detects very small paravertebral abscess Q.5 : Fracture patella
► Extent of destruction of posterior segment of vertebral body A: See Section 2, Group I, 2011, 0.3 (Page No. 647)
► In cases presenting as 'spinal tumor syndrome' where X-ray is not helpful
• MRI - Investigation of choice to evaluate cord compression
• Myelography
• Biopsy
• ELISA, PCR, Mantoux test
□ Treatment :
• Control of infection -
► Antitubercular drugs (2HRZE + 4HR)
► Rest
► Nutritious diet
• Care of spine - Initially bed rest, as healing starts, slow immobilisation with spine supported
in brace or collar
 GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 689
688 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Smooth inner surface of

sequestrum

Phalen's manoeuvre

lmegular outer surface

of sequestrum

Fig. 2.9.1 : Sequestrum

Fig. 2.9.3 : Manoeuvre reproduces Carpal tunnel syndrome

a - Sub-capital
b - Trans-cervical
c - Basal

a - Along medullary cavity

b - Out of cortex
Fig. 2.9.2 : Clubfoot in baby
c - To the joint
d - Pus in muscular plane

Fig. 2.9.4 : Fracture neck femur Fig. 2.9.5 : Spread of pus from metaphysis
(Acute osteomyelitis)

87
690 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 691

0cculta Meningocele Meningomyclocele

Inflammatory thickening of fibrous

Two-part fracture Stellate fracture
sheath of flexor tendons
Syringomyelocele Myelocele
Fig. 2.9.9 : Trigger Finger

Fig. 2.9.6 : Spina Bifida

Growth
plate

Pus

Onion peel Sclerotic

Exophytic growth
appearance margin

Extension type Flexion type

Hyaline cartilage Fig. 2.9.11 : Brodie's abscess Fig. 2.9.13 : Supracondylar fracture of humerus
(Left arm and forearm - lateral view)
.~, . "-

,, '

Fig. 2.9.7 : Exostosis "~.Pfi(;.9.8 : Ewing's sarcoma

692 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 693

Inner cortex
bends

Break in cortico-
Subcoracoid cancellous junction of
(most common) radius
Subglenoid

Subclavicular Fig. 2.9.17 : Greenstick fracture

N = Normal
Fig. 2.9.15 : Calles' fracture
D = Dislocated \
Fig. 2.9.12: Types of shoulder dislocation

Radial head dislocated

Fracture upper third of

ulna

Fig. 2.9.16 : Monteggia fracture

Fig. 2. 9.14 : Mallet finger

 GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 695

GROUP - II Q. 2 : Sudeck's osteodystrophy

SOLVEDSHORTNOTESOFSEMESTERS SUDECK'S OSTEODVSTROPHV

Q. 1 : Scaphoid fracture □ Synonyms:

• Causalgia
SCAPHOID FRACTURE
• Reflex sympathetic dystrophy
□ Age : Adolescents and young adults • Complex regional pain $yndrome
□ Site: Waist of scaphoid is more common than tuberosity, least common being proximal pole • Reflex Neurovascu!ar Dystrophy (RND)
[Fig. 2.10.1] • Amplified Musculoske!etal Pain Syndrome (AMPS)
□ Symptoms : Fall on outstretched hand ➔ pain and swelling over radial aspect of wrist □ What is it: Post-traumatic osteodystrophy
□ Signs: □ Associated with : Complication of Celle's fracture
• Fullness and tenderness in anatomical snuff-box □ When noticed: After plaster removed
• Watson test positive (patient's pronated forearm with wrist in slight ulnar deviation and □ Causes:
extension ➔ dorsally directed force applied over volar aspect of wrist just distal to radius i.e. • Abnormal and prolonged sympathetic nervous response
scaphoid ➔ wrist is moved from ulnar to radial deviation while pressure on scaphoid is • Liberation of histamine from injured tissue
maintained ➔ pain + scaphoid subluxates beyond dorsal rim of radius) □ Stages:
□ Investigations : • Stage I - Characterized by severe, burning pain at the site of the injury, muscle spasms, joint
• Skiagram of wrist - Radial oblique view, ulnar oblique view, lateral view, postero-anterior view stiffness, restricted mobility, rarid hair and nail growth, and vasospasm.
• CT Scan • Stage II - Cha:·acterized 'Qy more intense pain. Swelling spreads, hair growth diminishes, nails
• MRI become cracked, brittle, grooved, and spotty, osteoporosis becomes severe and diffuse, joints
• Bone Scan thicken, ana muscles atrophy.
□ Treatment : • Stage 111- Characterized by irreversible changes in the skin and bones, while the pain becomes
unyielding and may involve the entire limb. There is marked muscle atrophy, severely limited
mobility of the affected area, and flexor tendon contractions
History of fall + clinical features, but no features on skiagram
□ Clinical features :
t
Thumb Spica Scaphoid Cast and immobilisation for 2 weeks
• Discolouration

t
X-ray repeated
•
•
Stiffness
Redness
• Painful swelling
• Hyperhydrosis
No fracture acture • Allodynia

t ~
• Atrophy of hair and skin
□ Investigations :
No active treatment
Undisplaced Undisplaced > 1 mm • X-ray - Periarticular osteoporosis
OR Scapholunate angle > 60 degrees • To test hyperhydrosis - Ninhydrin sweat test
Displaced < 1 mm Radiolunate angle > 15 degrees □ Treatment: Physiotherapy+ NSAID

t t Q. 3: Garre's sclerosing osteomyelitis

Cast for 12 weeks Open reduction + Internal fixation
GARRE'$ SCLEROSING OSTEOMYELITIS
□ Define: Sclerosing non-suppurative chronic osteomyelitis
□ Complications :
• Avascular necrosis □ Age : Adolescents
• Non-union □ Pathogenesis: Symmetrical thickening of cortico-cancellous bone with partial obstruction of marrow
• Osteoarthritis of wrist space
□ Site : Shafts of femur and tibia
694
696 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 697

□ Clinical features : □ Pathology :

• Prolonged low grade pain • Femur head dislocated upwards and laterally
• Mild swelling and tenderness • Femur neck excessively anteverted
(Fever and pain which began acutely subside but fusiform osseous enlargement persists) • Acetabulum - shallow
□ Treatment : • Ligamentum teres - hypertrophied
• Acute symptoms subside with rest and antibiotics • Inverted limbus
• Pain can be relieved by making a hole/gutter in bone • Capsule of hip joint - stretched
□ Differential diagnosis: • Surrounding muscle - adaptive shortening
• Osteoid osteoma □ Clinical features :
• Ewing's sarcoma • 0-6 months -
Q. 4 : Blood supply of femoral head
Ortolani - Barlow test positive (may be negative if acetabular dysplasia)
• 6-18 months -
BLOOD SUPPLY OF FEMORAL HEAD ► Reduced abduction
□ Sources: ► Trendelenburg test positive
• Medullary/metaphyseal vessels ► Waddling gait
• Retinacular vessels from lateral side of neck of femur - ► Galeazi sign positive
► Telescopic test positive
► Lateral epiphyseal vessels
► Branch of medial circumflex femoral artery • 18-36 months -
• Foveal vessels from ligamentum teres ► Wide perineum
► Increased lumbar lordosis
□ Age-wise supply :
(a) Till 4 years - From all 3 sources ► Shortened limb
► Assymetric thigh folds
(b) Between 4-7 years - Retinacular vessels as ossification of phys ea I cartilage leads to cut-off
of metaphyseal supply and supply from ligamentum teres develops fully after 7 years □ Investigations :
(c) After 7 years - Both retinacular and foveal vessels • 0-6 months - USG
□ Salient features : • 6-12 months - USG or X-ray (Von Rosen's view)
• Nutrient artery supplies bone marrow and inner 213rd compact bone • > 12 months - X-ray
• Terminal branches of nutrient artery make hair-pin loop at epiphyseo-diaphyseal reaction X-ray findings :
and anastomose with epiphyseal and metaphyseal arteries (1) Head of femur -
• In a growing bone, metaphysis receives supply from metaphyseal vessels and nutrient artery, ► Delayed appearance of ossification centre of head of femur
while epiphysis receives supply from epiphyseal vessels ► Retarded development of ossification centre of head of femur
[Fig. 2.10.2) ► Lateral + upward displacement of head of femur
(2) Acetabulum -
Q. 5: Congenital dislocation of hip
► Sloping
CONGENITAL DISLOCATION OF HIP (3) Others -
► Shenton's line broken
□ Newer term/synonym : Developmental dysplasia of hip (DDH) ► Need help of -
□ Aetiology : Acetabular index
• Heredity related lax joints Perkin's line
• Hormone induced lax joints Hil-gen-reiner's line
• Breech presentation Wiberg's centre angle
□ Types: [Fig. 2.10.3]
• Dislocated at birth
□ Treatment:
• Dislocated after birth • 0-6 months -
• 6-18 months -

88
698 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II D SOLVED SHORT NOTES OF SEMESTERS 699

• EXERCISE THERAPY -
Pre-operative surface tension
t
Percutaneous adductor tenotomy
PURPOSE TYPES

t
Operative closed reduction
t
Arthrogram
/ ~
Medial dye pool < 5-7 mm Hourglass constriction
( 1) Joint mobilisation (a) Passive joint movement
(b) Active joint movement
(c) Continuous passive mobilisation
(2) Muscle strengthening (a) Static/Isometric (muscle contracts, length
remains same)
(b) Dynamic/Isotonic (muscle contracts,
produces movement)

t
Hip spica plaster
t
Open reduction
(1) active
(2) active assisted (with physiotherapist's
help)
(3) active resisted (against resistance)
• 18-36 months - (3) To improve coordination {This is used in special situations like
Open reduction + Pelvic osteotomy cerebral palsy, polio patients)
• > 36 months -
Open reduction (no pre-operative traction needed}
• TRACTIONS -
a. 6: Physiotherapy in orthopaedics ► To separate joint surface while giving passive movement to joint
► To relax muscle in spasm
PHYSIOTHERAPY IN ORTHOPAEDICS
► To correct deformities
□ What is it : Non-operative orthopaedic treatment • MASSAGE-
□ Aim: Systemic and scientific manipulation of skin and underlying soft tissues to relieve pain and
• Alleviate pain relax muscles
• Restoration of function • HYDROTHERAPY -
□ Used as: By principle of buoyancy, pain is relieved and muscles relax
• Primary treatment • OCCUPATIONAL THERAPY-
• In conjugation with other treatment ► Activities of daily living
► Work related activities
□ Methods:
► Leisure time activities
• ICE THERAPY -
► used during 1st 24-72 hours of injury a. 7: Elbow dis,ocation
► reduces pain, hematoma, inflammation
ELBOW DISLOCATION
• HEAT THERAPY -
► increases blood flow, thereby causing relief of pain □ Types:
► used for 15-20 mins, 2-3 times/day • Posterior (commonest)
► Types: • Postero-medial
(1) Surface heat - • Postero-lateral
(a) hot water bottle • Divergent (ulna - medially, radius - laterally)
(b) warm bath □ Associated fractures :
(c) wax bath • Fracture medial epicondyle
(2) Deep heat - • Fracture head of radius
(a) short wave diathermy • Fracture coronoid process of ulna
{b) ultrasonic therapy □ Symptoms : Fall on outstretched hand with slightly flexed elbow ➔ severe pain at elt.<Jw
(c) microwave
 GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 701
700 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

► Immobilisation after repair blood vessels, nerves, tendons

□ Clinical examination : ► To make moulds used for making braces
• 3 bony point relationship reversed d Complications :
• Reduced length of forearm, normal length of arm • Distal neurovascular compromise due to tight plastering
• Triceps tendon prominent (bowstringing of triceps) • Pressure sores on skin
• Median nerve palsy □ Advice after plaster :
□ Diagnosis: By X-ray • Constant finger toe movement to be done
D Treatment: Open reduction and internal fixation -----, above elbow slab for weeks • There should be no contact with water
D Complications : • If fingers /toes appear swollen/blackish/numb, it should be reported immediately
• Myositis ossificans • Range of movement exercises of all other joints in that limb, which are not within the plaster
• Elbow stiffness atleast 2-3 times daily
[Fig. 2.10.4] a. 9 : Paget's disease
Q. B : Plaster of Paris bandage (POP) PAGET'S DISEASE
PLASTER OF PARIS BANDAGE (POP) D Synonym : Osteitis deformans
□ What is it: Commercially available machine-made plaster of paris impregnated bandage □ Characterised by: Progressive tendency of bones to bend, get thickened, become spongy
□ Width: 3/4/6 inch D Commonly affected : Tibia
□ Chemica/formula: CaSO 4 .1/2H 2 O (hemihydrated salt of CaSO 4 ) D Cause : Osteoclast function abnormality
□ Chemical reaction : Exothermic reaction (becomes hard in contact with water) □ Age : > 40 years
□ Pathology : Initially soft, vascular bone -----, later hard, dense
□ Used as:
□ Clinical features: Dull pain, bowing and thickening of bone
FORMS ADVANTAGES DISADVANTAGES □ Investigations :
Cast Maintains reduction Edema • X-Ray - Multiple confluent lytic areas, interspersed with new bone formation
• Bone scan - Increased uptake
Slab (6-8 layers in upper limb, Does not cause edema Does not maintain reduction
□ Complications :
10-12 layers in lower limb)
• Pathological fracture
• Malignant changes
D Factors affecting critical setting : □ Treatment :
• Temperature of water • Calcitonin
• Manufacturer
• Impurities a. 10: Tardy ulnar nerve palsy
• Humidity
D Uses: TARDY ULNAR NERVE PALSY
• Orthopaedic uses - □ What is it: Late onset ulnar nerve palsy
► Temporary immobilisation D Causes:
► Definitive treatment of fracture shaft humerus, Celle's fracture, Greenstick fracture, • Displaced medial epicondyle humerus
Type I, II supracondylar fracture
• Malunited lateral condyle humerus
► Post-operative as a slab
• Elbow dislocation
► Deformity correction - CTEV
• Shallow ulnar groove
>- Broomstick plaster - For containment in Perthes disease • Contusions of ulnar nerve
► Hip-spica
• Hypoplasia of humeral trochlea
► As external fixator - Pin plaster technique in calcaneum fracture, etc.
□ Clinical features :
► Functional cast bracing
• Non-orthopaedic uses - • Weakness of grip
► Immobilisation after skin graft • Tingling numbness of little finger
702 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 703

• Card test positive (ulnar nerve palsy ➔ weakness of palmar interossei ➔ weak adduction of □ Clinical examination :
little finger) • Posture -
• Froment's sign positive (ulnar nerve palsy ➔ weakness of adductor pollicis ➔ flexion of ► Patient stands with rigid flattened lumbar spine
interphalangeal joint while grasping a paper between thumb and radial border of hand) ► Whole trunk shifted forward on hip
• Flexion test positive ► Trunk lilted to one side
□ Investigation : Nerve conduction test • Movement - Patient cannot bend forward
□ Treatment : • Tenderness in lumbosacral region
• Conservative - Elbow extension splints at night • Straight Leg Raising Test - Positive at 40 degrees
• Operative - Removal of ulnar nerve from groove ➔ neurolysis if necessary ➔ anterior • Lasegue test positive
transposition to flexor surface of elbow • Neurological examination
Q. 11 : Prolapsed intervertebral disc □ Investigations :
• X-ray - To rule out infection
PROLAPSED INTERVERTEBRAL DISC
• Myelograpliy -
□ Define : Protrusion/extrusion of nucleus pulposus through a rent in annulus pulposus .,_, Root cut off sign
[Fig. 2.10.5] :.- Block to flow of dye at that level
□ Sequence: • CT
• MRI
• Nucleus degeneration
• EMG
• Nucleus displacement
□ Treatment :
• Stage of fibrosis/healing
• Conservative -
Nucleus pulposus bulges through defect in annulus pulposus ► Rest
J, ► Analgesic, muscle relaxant
Nucleus pulposus comes out of annulus pulposus ► Physiotherapy
J, ► Lumbar traction
Nucleus pulposus lies under posterior longitudinal ligament ► TENS (Transcutaneous electrical nerve stimulation)
(though contact with parent disc is not lost) • Operative -
J, ► Fenestration
Disc extrusion ► Laminotomy
J, ► Hemi-laminectomy
Contact lost with parent disc ► Laminectomy
J, • Chemonucleosis
Sequestered disc • Percutaneous discectomy
[Fig. 2.10.6] Q. 12: Osgood- Schlatter's disease
□ Site of exit of nucleus pulposus : Posterolaterally OSGOOD-SCHLATTER'$ DISEASE
□ Level: L4 - Ls, C5 - Ca
□ Synonym : Osteochondritis
□ Associated changes :
□ Define : Epiphysitis/apophysitis of tibial tubercle
• Spinal roots compressed
• Reduced height of disc ➔ affects articulation of posterior facet joints [Fig. 2.10.7]
□ Symptoms: □ Etiology : Traction injury of apophysis of tibial tubercle into which patellar tendon is inserted
• Age - 20-40 years with sedentary lifestyle □ Symptoms:
• Low back ache • Age - Adolescents
• Sciatic pain • Pain after running, jumping, cycling, climbing stairs
• Pins and needle sensation corresponding to dermatome and LMN palsy of affected nerve □ Clinical examination :
root • Tender lump over tibial tubercle
• _Active knee extension against resistance - Painful

-\
704 QUEST : A comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 705

□ Treatment : • Medial and lateral malleoli of ankle

• Rest • Greater tuberosity of humerus
• Ice pack • Greater trochanter of femur
• NSAID • Lateral end of clavicle
• Activity modification □ Pre-requisite :
□ Differential diagnosis : Johansson - Larsen disease • Strong bony surface on compression side (else fixation failure)
• Strong wire (else implant failure)
Q. 13: Gout
• Pre-stressing
GOUT
□ Advantages :
□ What is it: . • Dynamic compression of fracture site
• Inherited disorder where disturbed purine metabolism leads to excessive accumulation of • Minimum implant material required
uric acid in blood • Minimum post-operative immobilisation
• Impaired excretion of uric acid by kidneys due to drugs like thiazide, furosemide, etc. • Low cost
In accumulation of sodium biurate crystals in soft tissues like cartilage, tendons, and bursa □ Complications :
□ Age : > 40 years • Skin irritation
□ Clinical features : . . . • Wire may break
• Arthritis_ Sudden onset pain generally occurring first in metatarso-phalangeal J01nt of big • 2nd operation required for implant removal
toe Q ~ valgum and genu varum
• Bursitis - Mainly affects olecranon bursa /

Tophi formation in soft tissue GENU VALGUM AND GENU VARUM

•
□ Investigations :
FEATURES
•
•
Raised serum uric acid
Urate crystals in aspirate from joint/bursa Synonym
GENU VALGUM
Knock knee
- Bow legs
GENU VA~

□ Treatment : What is it Knees abnormally approximated, Ankles abnormally approximated,

• Acute cases - knees abnormally divergent
ankles abnormally divergent
► NSAID
► Colchicine Causes 1) Post-traumatic 1) Post-traumatic
► Steroid injection 2) Post-inflammatory 2) Post-inflammatory
3) Neoplastic 3) Neoplastic
• Chronic cases -
► Uricosuric drugs - Probenacid, Sulphinpyrazone 4) Bone softening - rickets, 4) Bone softening - rickets,
osteomalacia, etc. osteomalacia, etc.
► Synthesis inhibitor - Allopurinol
5) Joint stretching 5) Joint stretching
Q. 14 : Tension Band Wiring (TBW)
Pathogenesis Unequal growth from 2 sides of Unequal growth from medial side of
TENSION BAND WIRING (TBW) growth plate growth plate
□ Define : Wire used for internal fracture and wire applied on tension surface of bone Clinical features 1) Age - appears at 2-3 years 1) Age - appears at 2-3 years
□ Principle : 2) Abnormal approximation of 2) Abnormal approximation of
• Centrally loaded fractured bone ➔ uniform compression at fracture site knees and divergence of ankles ankles and divergence of knees
• Eccentrically loaded fractured bone ➔ distraction on tensile surface . 3) Degree of deformity estimated 3) Degree of deformity estimated by
• If tensile surface kept fixed ➔ eccentric force cannot open up fracture ➔ distracting tensile by measuring intermalleolar measuring distance between two
force changed to compressive force distance with knees in contact knees, ankles held together
in supine position (> 8 cm)
□ Uses:
4) Flat foot may be present
In fixing following fractures -
5) Associated features of
• Patella underlying disease
• Olecranon

89
706 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 707

FEATURES GENU VALGUM GENU VARUM • Overuse syndrome (sustained ulnar deviation of wrist ➔ microtrauma ➔ painful thickening of
tendon sheath)
Treatment 1) Spontaneous recovery in most 1) Spontaneous recovery in most • Subclinical collagen disease
idiopathic cases idiopathic cases □ Age : 30-50 years, F > M
2) Medial shoe raise 2) Medial shoe raise with outer raise □ Symptoms:
3) If > 10 cm intermalleolar 3) If deformity persists beyond
• Pain in anatomical snuff box, which increases while wringing clothes, lifting glass of water
distance by 4 years of age ➔ childhood, surgical correction • Pinch grip is very painful
Supracondylar Closed Wedge required □ Clinical examination :
Osteotomy • Tender and thickened tendon sheath over radial styloid process
• With thumb flexed and adducted, attempted extension and abduction against resistance is
[Fig. 2.10.8] painful
• Finkelstein test [Fig. 2.10.1 O]
'\ □ Investigations :
• USG
FRACTURE HEALING
• MRI

Stage of □ Treatment :
Duration Features
• Physical therapy
1) Hematoma formation Upto 7 days Bone fracture ➔ blood ooze out ➔ hematoma ➔ • Triamcinolone injection
periosteum stripped off ➔ fracture end necrosis ➔
• Operative release of tendon sheath
sensitization of precursor cells

2) Granulation tissue 2-3 weeks Precursor cells proliferate and differentiate to form Q. 18 : Osteoarthritis
formation fibroblasts, osteoblasts, vessels ➔ clot gives rise
OSTEOARTHRITIS
to loose fibrous mesh, which is ultimately removed
by macrophage, giant cells ➔ soft granulation □ Define: Degenerative joint disease primarily affecting articular cartilage
tissue formed in between fragments
□ Aetiology :
3) Callus formation 4-12 weeks Granulation tissue creates osteoblasts ➔ osteo- • Primary (idiopathic)
blasts lay down intercellular matrix, which gets im- • Secondary
pregnated with calcium ➔ callus (woven bone) for- ► Avascular necrosis
mation
► DOH
4) Remodelling 1-2 years Woven bone replaced by mature bone i.e., lamel- ► Malunited fracture
lar bone formation by multicellular unit based re- ► Coxa vara
modelling of callus
□ Pathology :
5) Modelling Many years Bone gradually strengthened and sharpening of High water content+ Proteoglycan depletion - from cartilage matrix
cortices occur at el]Qosteal and periosteal sui.faces
-- -·- :;; ··-.,,__ J,
Repeated weight bearing ➔ fibrillation of articular cartilage

Q. 17: De-Quervan's disease

~=~_) ~-4S) ~-/ r
J,
Cartilage abraded
J,
DE-QUERVAN'S DISEASE
Bone exposed
□ Synonym: De-Quervan's tenosynovitis J,
□ What is it : Stenosing tenovaginitis of Abductor pollicis longus and Extensor pollicis brevis Subchondral bone becomes eburnated + Bone at margins form osteophytes
J,
□ Pathoanatomy:
Loose flakes of cartilage incite inflammation
• Stenosis at a point where tendon's direction changes because fibrous sheath acts as a pulley
causing maximum
7.08 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 7.09

,j, Q. 19: Septic arthritis

Capsule thickened SEPTIC ARTHRITIS
,j,
Stiffness, deformity of joint □ Define : Arthritis caused by pyogenic organisms
□ Synonyms:
□ Age : Elderly
□ Commonly affected : Hip joint, knee joint • Pyogenic arthritis
□ Symptoms: • Infective arthritis
• Pain - initially intermittent on starting activity, later severe crampy after activity) • Suppurative arthritis
• Swelling □ Age : Children, M > F
• Stiffness
□ Causative agents: Staphylococcus, Streptococcus, Pneumococcus, Gonococcus
• Feeling of instability and locking
□ Spread:
□ Clinical examination :
• Haematogenous (commonest)
• Joint line tenderness
• Crepitus • Secondary to nearby osteomyelitis
• Irregular, enlarged looking joint - Due to formation of peripheral osteophytes • Penetrating wounds
• Deformities - genu varus; flexion, adduction and external rotation of hip • Umbilical cord sepsis
• Effusion • Latrogenic
• Subluxation □ Pathogenesis :
• Wasting of quadriceps femoris Infection ➔ inflammation in synovium ➔ fluid exudation in joint and joint cartilage destruction
□ Investigations : □ Joint involved: Commonly knee joint
• X-ray- □ Clinical features :
► Narrow joint space
• High grade fever, malaise, etc.
► Subchondral sclerosis
• Severe throbbing pain in affected joint which becomes swollen, reddened
► Subchondral cysts • Painful limp
► Osteophyte
► Joint deformity □ Investigations :
• ESR, Serology to rule out Rheumatoid arthritis • X-ray - Increased joint space
• Serum uric acid level to rule out gout • USG - Collection in joint
□ Treatment : • Blood - Raised TLC, ESR
• Analgesics • Blood culture
• Chondroprotective agents • Joint aspirate culture
• Viscosupplementation □ Treatment :
• Supportive measures - • Broad spectrum antibiotics
► Reduction of weight
• Joint put to rest in splint/traction
► No stress
• Pus aspirated ➔ joint washed ➔ suction drain put
► Local heat application
• Late cases ➔ arthrotomy
► Exercise
► Application of counter-irritants □ Complications :
• Operative measures - • Deformity
► Osteotomy • Stiffness
► Joint replacement • Pathological dislocation
► Joint debridement • Osteoarthritis
► Arthroscopic procedures
710 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS. 711

□ Treatment :
Q. 20 : Classification of fractures
Closed reduction and percutaneous K-wire fixation ➔ if not possible, open reduction and internal
fixation (plaster cast not advist'ld as may lead to incongruity)
□ Complication :
CLASSIFICATION OF FRACTURES
Mal-union ➔ painful osteoarthritis ➔ persistent pain and loss of grip

Q. 22 : Traumatic paraplegia
Based on Based on Based on Based on Based on Based on
aetiology displacement relationship complexity quantum of pattern TRAUMATIC PARAPLEGIA
with external force causing
environment fracture □ Cause: Spinal injury, commone::,t being fracture-dislocation of dorso-lumbar spine
Simple Transverse
Traumatic Undisplaced (# in 2 □ Pathology :
Closed pieces) High • Cord compression
(does not velocity Oblique
communi- • Cord
Pathological Disr; aced Complex
cate with • Root
(# through a (# in multi-
bone made overlying Low Spiral • Incomplete lesion -
pie pieces)
weak by skin) velocity
► Central cord lesion
some Com minuted ► Anterior cord lesion
underlying Open
disease) (break in ► Posterior cord lesion
overlying ► Cord hemisection
skin) Segmental
□ Neurological deficit at different levels :
• Cervical spine ➔
[Fig.2.10.11] ► Above Cs - paralysis of respiratory muscles
Q. 21 : Benett's dislocation ► At Cs - paralysis of muscles of upper limb, lower limb, thorax, abdomen + sensory
loss + visceral function loss
BENETT'$ DISLOCATION
► Below Cs - deformities depending upon level
□ What is it: Oblique intra-articular fracture of base of first metacarpal with subluxation/dislocation of • Thoracic spine ➔
metacarpal ► T 1 - T g - trunk and lower limb muscles paralysis
□ Speciality: This intra-articular fracture is the most common type of fracture of the thumb ► T 10 - lower limb muscle paralysis
□ Named after: Edward Hallaran Bennett • Dorso-lumbar spine (D11 - L 1) ➔ UMN/LMN palsy of limbs

□ Biomechanics : • Below L1 ➔ flaccid paralysis and sensory loss autonomic loss in distribution of affected areas
Metacarpal shaft ➔ pulled by abductor pollicis longus ➔ pulled proximally and laterally □ Investigations :
Distal metacarpal ➔ pulled by adductor pollicis ➔ adducted and supinated • Neurological examination
□ Complicating factors : • CT
• Tension from the Abductor Pollicis Longus muscle (APL) subluxates the fragment in a dorsal, • MRI
radial, and proximal direction • X-ray
• Tension from the APL rotates the fragment into supination □ Treatment :
• Tension from the Adductor Pollicis muscle (ADP) displaces the metacarpal head into the palm Phase I - Emergency care
□ Clinical features : Phase II - Definitive care -
• Instability of the CMC joint of the thumb • Clinical assessment
• Pain and weakness of the pinch grasp • Investigations
• Pain, swelling, and ecchymosis around the base of the thumb and thenar eminence, and • Ward care -
especially over the CMC joint of the thumb ► Kept with pillow on hard bed with mattress
• A weakened ability to grasp objects or perform such tasks as tying shoes and tearing a piece ► Care of back - prevent pressure sores
of paper.
712 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II D SOLVED SHORT NOTES OF SEMESTERS 713

► Personal hygiene □ Risk:

► Bladder and bowel care • Prematurity
• Treatment of fraciure • Umbilical vein catheterisation
Phase Ill - Rehabilitation - physical psychological, social • Femoral vein puncture
Q. 23 : lntramedullary nail
D Symptoms:
• Painless limp
INTRAMEDULLARY NAIL
• Acute onset with rapid abscess formation
□ Made by : Kuntscher D Signs:
□ Parts: • Unstable gait
• 2 blunt ends - Reduces chances of cortical break while insertion • Affected limb shorter
• Clover leaf cross-section - Prevents rotation within intramedullary cavity • Hip movements increased in all directions
• Slot/gaps - • Telescopy test positive
► Allow bending on tensile surface □ Investigations :
► Reduce the diameter
• X-ray - Complete absence of head and neck of femur and increased joint space
► Beam effect (increase the strength) D Treatment :
• 2 eyes/fenestrations at ends - helps in easy extraction of nail • Joint aspiration
It is hollow which -
• Urgent decompression arthrotomy and antibiotics
• Allows bone marrow continuity
• Preserves bone nutrition Q. 25 : Fracture head of radius
• Allows guide wire passage FRACTURE HEAD OF RADIUS
D Use : Fixation of transverse diaphyseal fracture of shaft of femur
□ Cause:
□ Principle: Three point fixation
□ Determination of length of nail : • Fall on outstretched hand
With knee extended, • Associated with Monteggia fracture
□ Age: Adults
Distance between tip of greater trochanter to lateral joint line in cm - 2cm
□ Types:
OR
Distance between tip of greater trochanter to upper border of patella + 2cm • Undisplaced
D Methods of insertion : • Fragment< 1/3rd
• Antegrade nailing • Fragment> 113rd
• Retrograde nailing • Comminuted
□ Disadvantage : No rotational stability [Fig. 2.10.12]
□ Complications: □ Symptoms: Mild pain, swelling over lateral aspect of elbow
• Stuck nail □ Signs:
• Splintering of cortex • Localised tenderness over head of radius
• Migration of nail • Painful forearm rotation
□ Position of nail post-operatively: Slot faces antero-laterally (tensile surface), eye faces postero- □ Investigations : X-ray
medially (compressive surface) □ Complications :
• Joint stiffness
Q. 24 : Tom - Smith arthritis
• DRUJ (Distal Radio-Ulnar Joint) instability
TOM - SMITH ARTHRITIS • Osteoarthritis
□ What is it: Acute septic arthritis of hip seen in infants □ Treatment:
D Aetiology : • Undisplaced fracture ➔ Collar and cuff sling + analgesic
• Umbilical/skin sepsis • Marginal _fracture with displa~ement ➔ intra-articular lidocaine injection ➔ range of movement
• Osteomyelitis of metaphysis/epiphysis noted ➔ tf full, treated as und1splaced fracture and if reduced then open reduction with internal
fixation '

90
714 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 715

• Comminuted fracture ➔ Excision of radial head followed by metal prosthesis • Operative -

• If associated elbow dislocation, then it is first reduced and then fracture treated ► Nerve suturing/nerve graft
► Tendon transfer
Q. 26 : Wrist drop
WRIST DROP Q. 27: Cock-up splint

□ What is it: Deformity of hand characterised by palmar flexion of wrist along with flexion of fingers at
COCK-UP SPLINT
metacarpophalangeal joint □ Types:
D Causes: • Short - Holds wrist in extension, distal margin ends below fingers
• Radial nerve injury at any level • Long - Holds wrist and fingers in extension, distal margin till tip of fingers
• Lead poisoning (involves radial nerve except nerve to brachioradialis) • Dynamic - Used in cases where fingers can be actively flexed, prevents stiffness
□ Pathological anatomy : □ Indications :
Radial nerve supplies the extensors of the wrist - Extensor carpi radialis longus, Extensor carpi ra~ialis • Wrist drop
brevis, Extensor carpi ulnaris. When radial nerve injury occurs, the wrist cannot ?e ext~nded actively
• After extensor tendon surgery of upper limb
and gets flexed by the unopposed action of Flexor carpi radialis and Flexor carpi ulnans.
• Volkmann's ischaemic contracture
Radial nerve (posterior interosseous branch) also supplies the extensors of the fingers_ - Extensor
indicis, Extensor digitorum, Extensor digiti minimi, Extensor pollicis longus. When the n_erve 1s damaged, Q. 28 : Below knee amputation
active extension of fingers at metacarpophalangeal joints is not possible, and the fingers are flexed
BELOW KNEE AMPUTATION
due to unopposed action of the long flexor tendons.
□ Effects of radial nerve injury at various levels : □ Synonym : Burgess amputation
• At elbow {low lesion) - □ Amputation : Removal of part of limb in between 2 joints
Cannot actively extend thumb, fingers at metacarpophalangeal joint and wrist □ Below knee amputation : Amputation from below the level of knee
• At arm (high lesion) - □ Speciality : Commonest amputation done
In addition to features of low lesion
□ Type : Amputation using flap
► Brachioradialis and supinator power lost
□ Varieties :
► Autonomous zone sensation lost (i.e. over anatomical snuff box)
• Closed
• At axilla (very high lesion) -
• Open (Guillotine)
► In addition to features of high lesion
□ Level:
► Triceps paralysed
• Non-ischaemic limb - Musculo-cutaneous junction of gastrocnemius
□ Causes of radial nerve palsy at various levels : • lschaemic limb - Transcutaneous oxygen measurement to assess the vascularity
• In the elbow - □ Ideal stump :
Dislocation or fracture neck of radius • 14-17 cm from knee joint
• In the radial groove - • Heals adequately
► Saturday night palsy • Adequate length (8 cm minimum) to bear prosthesis
► Prolonged tourniquet application • Rounded gentle contour with adequate muscle padding
► Fracture shaft of humerus □ Flap:
• In the axilla - • lschaemic limb ➔ long posterior, short anterior, equal medial and lateral flaps
► Crutch palsy • Non-ischaemic limb ➔ equal anterior and posterior flaps
► Fracture upper end of humerus □ Technique :
□ Investigations : Nerve conduction velocity • Tourniquet used for haemostasis in non-ischaemic limbs
□ Treatment : • Osteotomy at proposed site
• Conservative - • Fibula divided higher than proposed site of cut of tibia or often removed
► Cock-up splint • Tibial stump bevelled anteriorly
► Physical therapy • Nerves dissected out ➔ pulled distally ➔ sharply cut ➔ retracts proximally
If no improvement by 9 months, operative measures used • Muscles sutured across bone end to periosteum by tendon myodesis or myo~1!2,i,ty

I\
 716 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 717

• Large vessels doubly ligated for haemostasis

□ Procedure :
• Suction drainage - Drain removed after 2 days
Patient lies supine with legs straight
□ Post-operative care : J,
• Regular dressing Exposure from below xiphysternum to knees, keeping genitalia covered
• Rehabilitation J,
• Physiotherapy Examiner stands on the affected side of the patient
• Crutch for 3 months, then suction socket prosthesis placed J,
□ Indications : Lumbar lordosis is confirmed visually by seeing light passing through a gap between the bed and the
• Peripheral vascular disease - gangrene in Diabetes, TAO, etc. lumbar region
J,
• Trauma - Crush injury
• Neoplasm - Osteosarcoma Hand insuniated between bed and the lumbar region such that examiner's dorsum of hand rests on the
bed
• Severe elephantiasis, Madura foot J,
• Frostbite
Examiner grasps the non-pathological lower limb just below the knee and gradually helps in flexing
• Burn the hip of the non-pathological side of the patient, till the patient's lumbar region touches the
• Gas gangrene examiner's palm of the hand resting on the bed
• Congenital anomalies J,
□ Advantages : Examiner brings out the hand resting on the bed and the patient's hip of the other side is flexed to
• Better prosthesis placement some more degrees to completely obliterate the lumbar lordosis, till the patient's back touches the
bed (excess flexion will cause anterior tilting of pelvis)
• Greater range of movement without limp and without support J,
□ Complications: As this happens, the affected hip will automatically come to lie in the deformed i.e. flexed position
• EARLY - J,
► Infection Gentle downward pressure is applied on the thigh of the non-pathological side to prevent any extra hip
► Hemorrhage flexion due to spasm
► Hematoma □ Interpretation : Angle formed between longitudinal axis of hip and bed is the fixed flexion deformity
► Necrosis of hip
• LATE- [Fig. 2.10.13]
► Pain □ Fallacies :
► Painful scar Difficult to be performed in following conditions -
► Flap necrosis • Obese patients as lordosis cannot be appreciated properly
► Stump ulceration • Both hips affected
► Ring sequestration formation • lpsilateral knee stiffness/ankylosis
► Phantom limb pain • Female elderly patient as exposure required
► Residual limb pain □ Alternative test :
► Joint contractures Patient prone on bed with legs hanging ➔ initially lumbar spine is straight i.e. no lordosis, with obvious
Q. 29 : Thomas test flexion deformity (if any) ➔ lumbar spine stabilised by examiner's palm ➔ hip gently extended till
lordosis c- es visible ➔ angle between thigh and body denotes the fixed flexion deformity
THOMAS TEST
□ Purpose : Evaluate degree of flexion deformity of hip
PERTHES DISEASE
□ Aim: To remove compensatory lumbar lordosis in order to make the flexion deformity prominent
□ Prerequisites : □ Synonyms:
• Attendant of same gender as patient • Legg-Calve-Perthes disease
• Verbal consent from patient after being explained the procedure • Osteochondritis deformans
• Hard, flat table • Pseudo-coxalgia
• Coxa-juvenilis
718 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 719

□ What is it: Avascular necrosis of femoral ~,ead in a child □ Treatment :

□ Age: 4-10 years • Acute cases - Surface traction for 3 weeks+ analgesics, antibiotics
□ Aetiology: • Long standing cases -
Disrupted blood supply from retinacular vessels due to - 1. Supervised neglect in -
• Synovitis ► Caterall Type I
• Septic arthritis of hip joint ► Caterall Type II in age< 6 years
• Haemarthrosis ► Caterall Type Ill in age< 6 years
• Hypofibrinolysis 2. Containment in -
• Antithrombotic factor deficiency ► Caterall Type II in age > 6 years
• Gaucher's disease ► Caterall Type Ill in age> 6 years
• Cretinism ► Caterall Type IV
• Rickettsial infection
• Caisson's disease CATERALL CLASSIFICATION (Based on X-ray)
□ Pathoanatomy:
Type Antero-posterior view Lateral view
• Stage of ischaemia -
Blood supply blocked ➔ ischaemia Type I Joint space increased Slight anterior epiphyseal involvement
But articular cartilage gets nutrition from synovial fluid ➔ remains viable Type II Density of head increased < 50% involvement of epiphysis from
• Stage of necrosis - anterior to middle
Bone death of capital femoral epiphyses Type Ill > 50% epiphysis involved, > 50% involvement with small posterior
• Stage of revascularisation and repair - head-within-head sign viable part
New bone deposition on avascular trabeculae
Type IV Collapsed flattened head Almost complete involvement of epiphysis
Calcification over necrosed marrow
• Stage of remodelling -
Containment-
Slow repair leads to following changes -
• Conservative :
► Change in shape of femoral head - oval/coxa magna/mushroom shaped/flattened
► Broomstick plaster
► Neck - broad, short
► Scottish Rite abduction splint
► Femoral neck-shaft angle - angle becomes< 120 degrees (normal 135 degrees) i.e.
• Surgical:
coxa vara
► Femoral osteotomy (Varus subtrochanteric derotation osteotomy)
□ Symptoms:
► Pelvic osteotomy
• Painless limping
• Pain occurs with activity, is of sudden onset and relieved by rest Treatment based on age -
□ Clinical examination : Based on age :
• Short stature < 5 years : Observation and NSAIDs
• Trendelenburg gait 5-8 years : Concentric containment : abduction brace or osteotomy
• Wasting of muscles 9+ years : Operative treatment often fails (many need THA as adult)
• Tenderness at anterior hip point □ Head at risk signs :
• Spasm of adductor • Clinical -
• Fixed flexion deformity of hip ► Obesity
• Reduced abduction-in-flexion and internal rotation-in-flexion of hip ► Elderly (age > 10 years)
• Trendelenburg test positive ► Fixed flexion + adduction deformity of hip
□ Investigations : ► Progressive decrease of hip movements
• X-ray (both AP and Lateral view) • X-Ray features -
• MRI
► Gage sign in A-P view (V-shaped porotic area in lateral physis)
• USG
► Lateral subluxation of head
• Bone scan
► Horizontal growth plate
720 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 721

► Calcification lateral to epiphysis (All these along with no weight bearing for 12 weeks)
► Changes in metaphysic-cysts, short and broad neck of femur ► Recent trend - surgical reconstruction of the fractures
[Fig. 2.10.14] □ Complications :
□ Sign of healed Perthes disease: Sagging rope sign in X-ray • Osteoarthritis
• Stiffness of subtalar joint ➔ no inversion or eversion
a. 31: Ca/caneum fracture
Q. 32 : Osteoid osteoma
CALCANEUMFRACTURE
OSTEOID OSTEOMA
□ Relevant anatomy :
• Calcaneum - Forms bone of the heel □ What is it: Commonest true benign tumor
• Articulation - upper surface with talus, front with cuboid □ Pathology : Consists of nidus of entangled arrays of partially mineralised osteoid trabeculae
• Inferior surface prolonged backwards as 'tuber calcanei' surrounded by dense sclerotic bone
• Angle of Bohler ➔ Angle between anterior and posterior aspects of superior surface of □ Age : 5-25 years
calcaneum. Decreases in calcaneum (becomes< 25°) □ Site : Diaphyses of lower extremity bones
• Angle of Gissane ➔ Angle between downward and upward slopes of calcaneum superior
□ Clinical features :
surface. Increases in calcaneum fracture (becomes> 100°)
• Nagging pain, which is worse at night, and relieved by salicylates
[Fig. 2.10.15]
• Mild tenderness at site of lesion
□ Cause: Fall from height on heel • Palpable swelling sometimes
□ Types of fracture : □ Investigations:
• Isolated crack • X-ray - Visible zone of sclerosis with a radioluscent nidus in centre, usually <1 cm in size
• Compression fracture - Bone shattered like egg shell
• CT scan
□ Classification :
□ Treatment : Complete excision of the nidus along with sclerotic bone
• Undisplaced
□ Prognosis : Good
• Extra-articular
• Intra-articular (commonest) - articular surface of calcaneum fails to withstand stress ➔ driven [Fig. 2.10.16]
downwards into bone ➔ crushing delicate trabeculae of bone into powder
Q. 33 : Simple bone cyst
□ Symptoms:
• Swelling and pain in region of heel SIMPLE BONE CYST
• Not able to bear weight on affected foot □ Synonym: Unicameral bone cyst
□ Clinical examination : □ What is it: Only true cyst of bone
• Swelling and broadening of heel □ Aetiology: Unknown
• Ecchymosis around heel after 2-3 days □ Pathology :
• Movement of ankle not much impaired • Cavity in bone lined by thin membrane
□ Other associated injuries : • Contains serous or serosanguinous yellow fluid
• Fracture of spine (mainly atlanto-axial joint) □ Age: Children and adolescents
• Fracture of pelvis (pubic rami) • 4-8 years ➔ active stage with lesion nearer to epiphysis
□ X-ray features : Reduced tuberjoint angle on lateral view • 9-13 years ➔ latent stage with lesion nearer to diaphysis
□ Treatment : □ Sites : Ends of long bones, commonest being upper end of humerus
• Undisplaced fracture - Below knee plaster cast for 4 weeks ➔ mobilisation exercise
□ Clinical features :
• Compression fracture - • Asymptomatic
► Foot kept elevated + below knee plaster slab for 2-3 weeks • Pathological fracture
Pain and swelling subside • Deformities
_J,
• Growth disturbance
Slab removed + ankle and feet mobilised □ X-ray features :
_J,
Lesion with following features -
Leg elevation continued + compression bandage for 4-6 weeks

91
722 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 723

• Radioluscent □ Stages:
• Well-defined • Stage I - Osteolysis
• Lobulated • Stage II -
• Central ► Rapid increase in size of osseous erosion
• Site - Diaphysis (latent stage), metaphysis(active stage) ► Enlargement of involved bone
• Maximum width less than width of epiphyseal plate ► Formation of shell around central part of the lesion
□ Treatment : • Stage Ill - Fully developed radiological pattern
• Spontaneous healing after fracture □ Age : 10-40 years
• 1-2 injections of methylprednisolone into cyst □ Site : Ends of long bones
• Curettage and graft □ Clinical features :
□ Differential diagnosis : • Gradually increasing swelling
• Aneurysmal bone cyst • Pathological fractures
• Osteoclastoma • Local rise of temperature
• Fibrous dysplasia • Quadriplegia if spinal lesions
[Fig. 2.10.17] • Headache if skull lesions
Q. 34 : Aneurysmal bone cyst □ X-ray features :
• Eccentric well-defined radioluscent lesion
ANEURYSMALBONECYST
• Trabeculation present
□ What is it: Benign osteolytic metaphyseal vasocystic bone neoplasm characterised by several sponge- • Overlying cortex expanded
like blood or serum filled, generally non-endothelialised spaces of various diameters, enclosed in a • UNLIKE OSTEOCLASTOMA, LESION DOES NOT EXTEND UPTO ARTICULAR MARGIN
shell, ballooning up the overlying cortex
□ Treatment : Curettage + bone cementing/bone grafting
□ Misnomer: As neither an aneurysm nor a cyst
□ Differential diagnosis :
□ First described by : Jaffe and Lichtenstein in 1962
• Osteoclastoma
□ Pathogenesis :
• Telangiectatic osteosarcoma
• Consequence of increased venous pressure and resultant dilatation and rupture of local vascular
network [Fig. 2.10.18]
• Arterio-venous fistula within bone Q. 35 : Fibrous dysplasia
□ Aetiology : FIBROUS DYSPLASIA
Arise from pre-existing -
• Chondroblastoma □ What is it: Developmental disorder in which a normal trabecular bone is replaced by fibrous tissue
• Chondromyxoid fibroma □ Pathogenesis :
• Osteoblastoma • Mass of fibrous tissue formed grows inside the bone ➔ erodes the cortices of bone from within
• Chondrosarcoma • A thin layer of sub-periosteal bone forms around the mass, so that bone appears expanded
• Fibrous dysplasia □ Types:
• Osteoclastoma • Monostotic(affects single bone)
• Oteosarcoma • Polyostotic(affects multiple bones) •
• Haemangioendothelioma • Monomelic(affects one limb)
□ Pathology : □ Age : Children and adolescents
• Classic/Standard form (95%) - □ Clinical features :
► Blood filled clefts among bony trabeculae • Asymptomatic
► Osteoid tissue in stromal matrix • Polyostotic -
• Solid form (5%) - ► Pain
► Fibroblastic proliferation ► Limp
► Osteoid production ► Swelling
► Degenerated calcifying fibromyxoid elements ► Deformity
► Pathological
 724 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II D SOLVED SHORT NOTES OF SEMESTERS 725

□ Associated features : □ Clinical examination :

• Precocious puberty • Bony swelling with following features -
► Eccentrically located at end of bone
• Cafe-au-lait skin spots
► Smooth surface
This is called Mcune Albright syndrome
► Firm/hard
□ Investigations:
► Tender on firm palpation
• X-ray -
► Warm
► Lesion in metaphysis or diaphysis
► Skin over swelling is free
► Well-defined margins
• Adjacent joint effusion - More common than in osteosarcoma
► Central or eccentric
• Restricted joint movement
► Reactive sclerosis
• Limb deformity if associated pathological fracture
► Endosteal scalloping ➔ thinning of cortex
• Skin appears shiny with venous prominence
► Pathological tracture (typical Shepherd's Crook deformity in proximal femoral lesions)
• Distal neurovascular deficit
► Translucent patches with a 'ground-glass' appearance, trabeculated, expanding the
overlying cortex □ Investigations :
• Serum alkaline phosphatase - Raised • X-ray -
• Biopsy - For confirmation ► Solitary lesion
□ Treatment : ► Eccentric
• Only observation if monostotic ► 'Soap-bubble' appearance (tumor homogenously lytic - trabeculae of remnants of
• Other cases - bone traverse it - give rise to a loculated appearance)
► Cortex thinned out
► Deformities ➔ osteotomy + internal fixation
·"' / ► Pathological fracture ➔ curettage + bone graft + internal fixation
►
►
No calcification within tumor
LESION EXTENDS TO ARTICULAR SURFACE UNLIKE ANEURYSMAL BONE CYST
~ /Q. 36 : Ostea,clastoma (f~w.1v . -
' · (C,;ovd otl :.,v,,10.,:PSTEOCLASTOMA • Biopsy - Open or FNAC ...-
□ Synonym : Giant Cell Tumor (GCT) • CT scan
□ What is it: Commonest benign neoplasm of bone with variable growth potential • MRI
• Serum acid phosphatase - Raised
□ Age : 20-40 years ·
□ Treatment :
□ Sex predilection : F > M
• If benign + cortex intact ➔ adequate meticulous curettage + 70% alcohol and 5% phenol
□ Site : ~piphyseo-metaphyseal region (common in distal radius, distal femur and proximal tibia) application + bone cementing
□ Campanacci grading : · • If suspected malignancy + cortex broken ➔ wide local excision followed by reconstruction -
Type I - Osteolytic lesion inside bone ► Arthrodesis by Turn-o-plasty
Type 11 - Cortical expansion ~- Arthrodesis by bridging gap with fibular graft
.,..,,,,,.,.-~ ,,,..,,.,..,,,..
Type 111 - Break in overlying cortex, extends into soft tissues
Q.37rcoma
□ Enneking's grading:
• Latent OSTEOSARCOMA
• Active □ Synonym : Osteogenic sarcoma
• Aggressive □ What is it : Second most common and highly malignant primary bone tumor
□ Pathology: □ Incidence : 1 in 75000
• Cell of origin is uncertain □ Age : Bimodality - 15-25 years and > 45 years
• Highly vascular stroma
□ Sex predilection : M > F
• Tumor has undifferentiated, spindle cells, which are profusely interspersed with multinucleate
□ Site : Metaphysis (lower end of femur, upper end of tibia, upper end of humerus)

□
giant cells
Symptoms : Swelling slowly increasing in size followed by pain ·¥ □ Pathology: Tumor of mesenchymal cells, characterised by formation of osteoid matter by tumor cells
726 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 727

□ Classification : ► Overlying cortex eroded

► Codmann's triangle - triangular area of sub-periosteal new bone seen at tumor-host
cortex Junctfon -"--'
►
I CLASSIFICATION
I
►
New bone formation in matrix of tumor
Sunray appearance - tumor grows into overlyin,9 soft tissue
--------·--·-··~ ! / .,.~----~-~----~- ,,
I ! __ [Fig. 2.10.20)_)
j Based on clinical setting / / Based on dominant histomorphologyj • Serum alkaline phosphatase - Raised
• Biopsy
Primary Fibroblastic • Bone scan
- (15-25 years, - (fish-flesh sarcomatous • CT scan
unknown cause) appearance)
• Chest X-ray
□ Treatment: Neoadjuvant chemotherapy ➔ high amputation ➔ adjuvant chemotherapy
Secondary Osteoblastic □ Differential diagnosis :
(> 45 years, due - (greyish-white, hard,
- to underlying gritty feeling when cut)
•
•
Ewing's tumor
Chronic osteomyelitis
bone disease)
• Aggressive GCT
Chondroid
Q. 38 : Crush syndrome
- (opalescent, blue-grey)
CRUSH SYNDROME

Telangiectatic or osteolytic □ What is it: Symptom complex in which a portion of the body is crushed due to a heavy weight fallen on
(large areas of tumor that part thereby crushing the underlying tissues
- necrosis and blood filled □ Aetiology :
spaces, most malignant) • Building collapse
• Mine injuries
• Tourniquet used for a long time
□ Spread: Through blood, first to the lungs • Air raids
□ Symptoms: • Earthquakes
• Constant boring pain, worse as swelling increases in size □ Pathogenesis : Muscle crushed ➔ myohaemoglobin enters into circulation ➔ precipitates in renal
• Pain followed by swelling, which is fast growing ¥ tubules ➔ renal tubular necrosis
• Significant weight loss, anorexia, fatigue □ Clinical features :
□ Clinical examination: • Crushed muscles become swollen
• Severe pallor (more anaemic than cachectic) • Limb becomes pulseless, red, blistered
• Swelling with following feature_s - • Reduced urine output
► At metaphysis • Patient gradually starts showing restlessness, apathy, delirium
► Tender □ Treatment :
► Warm
• Tourniquet applied proximal to crushed muscles which is gradually released so that toxic
► Overlying skin shiny with venous prominence substances gradually enter circulation
► Ill-defined margins • Parallel incisions to relieve tension
• Neurovascular structures compressed • Intravenous fluid - 500 ml + urinary output
• Restricted adjacent joint movement • Mannitol 20% -1 gm/kg i.v in 12 hours
• Enlarged regional lymph nodes • Catheterisation
□ Investigations : • Hemodialysis in severe conditions
• X-ray -
► Lesion with irregular margin in metaphysis
728 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 729

Q. 39 : Arthroplasty • Expensive
ARTHROPLASTY • Requires expertise and skill
□ Indications :
□ What is it : Orthopaedic surgery where the articular surface of a r1usculoskeletal joint is replaced,
remodelled, or realigned by osteotomy or some other procedure • Hip -
► Femoroacetabular impingement (FAI)
□ Indications :
► Labral tears
• Osteoarthritis
► Loose I foreign body removal
• Rheumatoid arthritis
► Chondral (cartilage) lesions
• Avascular necrosis
► Osteochondritis dessicans
• Congenital dislocation of the hip joint
• Acetabular dysplasia (shallow hip socket) ► Ligamentum teres injuries (and reconstruction)

• Frozen shoulder ► lliopsoas tendinopathy (or 'snapping psoas')

► Trochanteric pain syndrome
• Traumatized and malaligned joint
► Snapping iliotibial band
• Joint stiffness
► Osteoarthritis (controversial)
□ Types:
► Sciatic nerve compression (piriformis syndrome)
Names Details Indications ► lschiofemoral impingement
► Direct assessment of hip replacement.
Excision arthroplasty Articular surface excised to create a Hip and elbow lesions • Shoulder -
gap between the articular ends,
► Subacromial impingement
which is filled by fibrous tissue
► Acromioclavicular osteoarthritis
Hemiarthroplasty One articular surface excised and Fracture neck femur e.g., Austin- ► Frozen shoulder (adhesive capsulitis)
replaced by metal, silicon or rubber Moore hemiarthroplasty ► Chronic tendonitis
prosthesis of similar type ► Removal of loose bodies
Total replacement Both articular surfaces excised and Hip osteoarthritis e.g., Total hip ► Shoulder instability
arthroplasty replaced by prosthetic components replacement ► Subacromial decompression
► Bankarts lesion repair
[Fig. 2.10.21] ► Rotator cuff repair
Q. 40 : Arthroscopy
• Wrist -
► Repetitive strain injury
ARTHROSCOPY ► Fractures of the wrist and torn or damaged ligaments

□ What is it: Minimally invasive surgical procedure in which an examination and sometimes treatment ► Wrist osteoarthritis
of damage of the interior of a joint is performed using an arthroscope • Spine -
□ Advantages : ► Spinal disc herniation and degenerative discs
• Minimally invasive ► Spinal deformity
• Joint does not have to be opened up fully, small incisions are made ► Tumors
• Reduced recovery time Q. 41 : Arthrodesis
• Less trauma to the connective tissue
• Less scarring because of the smaller incisions ARTHRODESIS
• Little immobilisation required □ Synonym:
• Dynamic assessment of joint • Artificial ankylosis
□ Disadvantages : • Artificial syndesis
• Irrigation fluid is used to distend the joint and make a surgical space. Sometimes this fluid □ What is it: Artificial induction of joint ossification between two bones via surgery, to ei;minate any
leaks (extravasates) into the surrounding soft tissue, causing edema motion at joint
• Not suitable for every joint pathology

92
730 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 731

□ Indication : This is done to relieve intractable pain in a joint which cannot be managed by pain Q. 43 : Galeazzi fracture
medication, splints, or other normally-indicated treatments
• Painful stiff joints GALEAZZI FRACTURE
• Grossly unstable joints □ What is ~t: Fracture ~f the radial diaphysis at the middle and distal third junction, along with dislocation/
□ Types: sublux~t1on of the d1st_al radioulnar joint. It has been called the "fracture of necessity," because it
• Extra-articular - Extracapsular bridge of bone created between articulating bones necessitates open surgical treatment in the adult. Nonsurgical treatment results in persistent or recurrent
• Intra-articular - Articular surfaces made raw and joint immobilised in position of optimum dislocations of the distal ulna
function until bony union occurs □ Named after: Ricardo Galeazzi
• Combined □ Aetiology :
[Fig. 2.10.22] • Fall on outstretched hand with pronated forearm
□ Position of arthrodesis : • Direct trauma on wrist (dorsolateral aspect)
□ Clinical features :
JOINT INVOLVED POSITION
• Pain and soft-tissue swelling at the fracture site and at the wrist joint
Ankle Males - Neutral position • Compartment syndrome
Females - Plantar flexion •Paralysis of the flexor pollicis longus and flexor digitorum profundus muscles to the index
finger, resulting in loss of the pinch mechanism between the thumb and index finger
Knee 5-10 degrees flexion
• Wrist drop due to injury to radial nerve, extensor tendons or muscles
Hip 15 degrees flexion, no abduction/adduction, neutral rotation □ X-ray features :
Wrist 20 degrees dorsiflexion • Radius angulated dorsally
Elbow Unilateral - 75 degrees flexion • Widened DRUJ
Bilateral - 70 degrees flexion in one, 130 degree flexion in other • Fracture ulnar styloid
□ Treatment :
Shoulder 25 degrees flexion, 30 degrees abduction, 45 degrees internal rotation
Open reduction and internal fixation

Q. 42 : McMurray's osteotomy
D Complication : Mal-union

McMURRAY'S OSTEOTOMY 0. 44 : Foot drop

FOOT DROP
□ Synonyms:
• Abduction osteotomy □ What is it: Gait abnormality in which the dropping of the forefoot
• Linear osteotomy D Pathoanatomy :
□ Indication : • Damage to the common fibular nerve
Fracture neck femur - • Paralysis of the muscles in the anterior portion of the lower leg.
• Non-union of intrascapular fracture □ Clinical features :
• Avascular necrosis • Inability or impaired ability to raise the toes or raise the foot from the ankle (dorsiflexion)
□ Principle : The entire weight of the body passes through head and neck, and then directly transmitted • In walking, the raised leg is slightly bent at the knee to prevent the foot from dragging along
through shaft of femur the ground
□ Technique : Femur cut through and through in between greater trochanter and lesser trochanter ➔ • Steppage gait
lower end hinged to ischial tuberosity ➔ both the portions fixed with a plate • Pe~ple suf!ering from the condition drag their toes along the ground or bend their knees to lift
□ Advantages : their foot higher than usual to avoid the dragging
• Low cost □ Diseases associated :
• Easy technique • Amyotrophic lateral sclerosis
□ Disadvantages : • Muscular dystrophy
• Inability to squat • Charcot Marie Tooth disease
• Slight shortening of limb • Multiple sclerosis
• Difficulty in walking • Hereditary spastic paraplegia
• Friedreich's ataxia
732 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 733

□ Investigations:
□ Clinical features :
• MRI • Visible deformity
• MRN • Backache
• EMG • Compensatory lumbar lordosis exaggerated
□ Aetiology:
• Straight leg raising test limited to 60 degrees
• Neuromuscular disease
□ X-ray features :
• Peroneal nerve (common, i.e., frequent) - chemical, mechanical, disease
• Wedging of vertebral bodies
• Sciatic nerve-direct trauma, iatrogenic;
• Dense fragmented epiphyseal plates
• Lumbosacral plexus
• Small translucent areas near disc spaces known as Schmorl's nodes
• L5 nerve root (common, especially in association with pain in back radiating down leg)
□ Treatment :
• Cauda equina syndrome, which is caused by impingement of the nerve roots within the
spinal canal distal to the end of the spinal cord • Little deformity + no pain - No treatment required
• Spinal cord (rarely causes isolated foot drop) - poliomyelitis, tumor • Little deformity + little pain - Exercises
• Brain (uncommon, but often overlooked) - stroke, TIA, tumor • Severe deformity+ severe pain - Posterior plaster shell at night, plaster jacket during the day
• Genetic (as in Charcot-Marie-Tooth Disease and hereditary neuropathy with liability to pressure palsies) Q. 46 : Scoliosis
• Nonorganic causes
SCOLIOSIS
□ Treatment :
• The underlying disorder must be treated □ What is it: Sideways curvature of spine
• Spinal stenosis - Non-surgical treatments for spinal stenosis include a suitable exercise □ Classification :
program developed by a physical therapist, activity modification (avoiding activities that
cause advanced symptoms of spinal stenosis), epidural injections, and anti-inflammatory
medications like ibuprofen or aspirin. If necessary, a decompression surgery that is minimally ( CLASSIFICATION l
destructive of normal structures may be used to treat spinal stenosis. I
• Ankles can be stabilized by lightweight orthoses, available in molded plastics as well as
softer materials that use elastic properties to prevent foot drop. Additionally, shoes can be [ Structural ] ( Non-structural
J
fitted with traditional spring-loaded braces to prevent foot drop while walking. Regular exercise
is usually prescribed
• Functional Eectrical Stimulation (FES)

Q. 45: Kyphosis
H Idiopathic -
Compensatory
(occurs to compensate for
tilt of pelvis)
Congenital
KYPHOSIS
(associated with
□ What is it: Excessive backward convexity of the spine - hemivertebrae, Postural (curve
block vertebrae,
t- straighten on bending
□ Types:
unsegmented bar) towards)
( CLASSIFICATION }
I

[ Structural ) l Non-structural i Paralytic

-
Sciatic
(due to unilateral painful
spasm of paraspinal
Round Postural muscles)
1- (Gentle backward curvature - (In tall people because of their - Other causes like
neurofibromatosis
of spinal column) tendency to stoop forwards)

Angular Compensatory
- (Sharp backward prominence ,_ (Occurs to compensate other □ Pathoanatomy :
of spinal column) deformities) • Primary curve - Lateral curvature of a part of spine
::===---------
1 r Mobile
• Secondary curves - Compensatory curvatures in direction opposite to primary curvature,
above or below the primary curve
~ (Seen in muscle weakness disorders)
• Lateral curvature - Associated with rotation of vertebrae
734 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS
735
• Lateral curvature of thoracic spine ➔ associated with rotation of vertebrae ➔ prominence of □ Common tendons involved:
rib cage on convex side ➔ rib hump
• Pronator teres
• Types of scoliosis in thoraco-lumbar spine - Dorsal scoliosis, dorso-lumbar scoliosis, lumbar
• Flexor carpi radialis
scoliosis
[Fig. 2.10.23] □ S~ml:'toms _: .'.enderness over medial epicondyle which is worsened by wrist flexion a d ,
I
gnppmg act1v1ties n s,rong
□ Clinical features :
CJ Cl~iclbal examlna_tion : ~olfer's ~lbow sign (elbow semiflexed ➔ forearm supinated ➔ isometric wrist
• Pain an e ow extension against resistance --, pain)
• Visible deformity mainly □ Treatment :
• Neurological deficit rarely • Non-steroidal anti-inflammatory drugs (NSAIDs) : Ibuprofen, naproxen or aspirin
□ X-ray features : A-P view in erect and supine posture + lateral view • Heat or ice
• Cobb's angle - Angle between line passing through the margins of the vertebrae at the ends • A count~r-force brace or "elbow strap" to reduce strain at the elbow epicondyle to limit pain
of the curve provocation '
• Reisser's sign - To assess progress of curve (iliac apophysis fuses with iliac bone at maturity • lntralesional Triamcinolone injection
and indicates completion of growth which means no further curving will occur) □ Differential diagnosis :
• Rotation of vertebrae -Assessed by position of spinous processes and pedicles on A-P view • Baseball Pitcher's Elbow
• Congenital scoliosis - Wedging, hemivertebrae, fused ribs, etc. • Climber's Elbow
□ Treatment : • Little Leagure's Elbow
(A) Conservative - • Cubital tunnel syndrome
• Exercises Q. 48 : Ma/union
• Supports -
► Boston brace MALUNION
► Milkauwee brace t:I What Is It: Fracture fails to unite in proper position, resulting in disability of clinical significance
► Reisser's turn-buckle cast 0 Aetiology :
► Localiser cast • Improper treatment
[Indications - • Unchecked muscle pull
► Postural curve • Excessive comminution
► Well-balanced double curves □ Sites : Fractures occurring at end of bones like -
► Structural curves of less than 30 degrees] • Fracture clavicle
(B) Operative - • Colles' fracture
• Congenital scoliosis - Simple fusion • Supracondylar fracture of humerus
• Idiopathic scoliosis - Fusion after stretching spine by following methods - □ Consequences :
► Cotrel traction • Limitation of movements
► Localiser cast • Deformities
► Halo-pelvic distraction system • Limb shortening
► Harrington's distraction system □ Treatment :
► Dwyer's compression assembly
► Luque-Hartshill systems
[Indications - TREATMENT
► Congenital scoliosis
► Curves showing deterioration radiologically Not required - can get
► If associated backache] corrected by remodelling
Corrective osteotomy
Q. 47: Golfer's elbow
Fracture site opened and
GOLFER'S ELBOW malunion corrected
□ Synonym : Medial epicondylitis Osteoclasis
□ What is it: An inflammatory condition of the medial epicondyle of humerus Exc~sion of protruding bone
 GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 737
736 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

_,,/~,//' ► Excision of avascular segment

fl)P.1: A vascular necrosis ► Hip resurfacing or metal on metal (MOM) resurfacing
l/// AVASCULAR NECROSIS ► Core decompression
► Free Vascular Fibular Graft (FVFG)

-·---
□ Synonym:
► Transplantation of nucleated cells from bone marrow into avascular necrosis lesions
• Osteonecrosis
after core decompression
• ~fars:;tion
• Ase_ptic necfo_§iS
Q. 50: Smith's fracture
• lschemic bone necrosis
□ What isir-Dise~se where there is ceHular de_a,t~Jrie.c::m~isJ.g,! bone C?,rT1P()!1~n~~- d_~e_-~nte~ruption SMITH'S FRACTURE
of the blood,,supply -·-···- ,, -- .
□ Synonym : Reverse Calles' fracture
D Cause:
• Chemotherapy □ What is it: Fracture of the distal radius with distal fracture fragment being displaced volarly (ventrally)
□ Named after: Orthopaedic surgeon, Robert William Smith
• Alcoholism
• Excessive steroid use □ Aetiology :
• Post trauma • Direct blow to the dorsal forearm
• Caisson disease (decompression sickness) • Fall onto flexed wrists with supinated forearm
• Vascular compression □ Deformity present: Garden-spade deformity
• Vasculitis □ Age: Adults
• Arterial embolism □ Comparison with Col/e's fracture:
• Damage from radiation • In Calles' fracture, distal fragment is displaced dorsally
• Bisphosphonates (particularly the mandible) • Less common than Calles' fracture
□ Clinical features : □ Treatment:
• Primarily affects the joints at the shoulder, knee, and hip
• An undisplaced fracture may be treated with a cast alone for 6 weeks
• The classical sites are - Head of femur, neck of talus and waist of scaphoid
• A fracture with mild angulation and displacement may require closed reduction
□ Site : Epiphysis • Significant angulation and deformity may require an open reduction and internal fixation
□ Age : 30-50 years • An open fracture will always require surgical intervention
□ Consequences: Deformation of bone ➔ secondary osteoarthritis ➔ painful limitation of joint
□ Complications :
□ Investigations :
• Stiffness of joints
• In the early stages -
• Malunion
► Bone scintigraphy
[~ "_Smith Fracture" is a named vertebral fracture occurring most commonly in the lumbar spine, is
► MRI
s1m1lar to that of a Chance fracture and is associated with seat-belt injuries. This fracture represents a
• In the later stages -
fracture through the posterior elements including the superior articular processes but not the spinous
X-ray : process, as well as an avulsion fracture of the vertebral body]
Relatively more radio-opaque due to the nearby living bone becoming resorbed
►
secondary to reactive hyperaemia
► The necrotic bone itself does not show increased radiographic opacity, as dead bone Q. 51: TB hip
cannot undergo bone resorption which is carried out by living osteoclasts TUBERCULOSIS OF HIP
A radioluscent area following the collapse of subchondral bone (crescent sign) and
► ringed regions of radiodensity resulting from saponification and calcification of marrow □ Causative agent : Mycobacterium tuberculosis
fat following medullary infarcts □ Speciality : 2nd most commonly affected secondary site after spine
□ Treatment: □ Age : Children and adolescents
• Conservative - □ Spread: By blood (always secondary)
► Delay weight bearing □ Initial focus :
► Bisphosphonates (e.g. alendronate) • Epiphyseal region
• Operative - • Metaphyseal region
► Total hip replacement

93
738 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 739

• Roof of acetabulum □ Clinical examination:

• Greater trochanter •
Initial stages - stiff-hip gait (forward and backward movement at lumbar spine used for
• Synovial membrane propulsion of lower limbs), later stages - antalgic gait (reduced stance phase)
□ Pathogenesis : • Thigh and gluteal muscles wasted
• Swelling around hip due to cold abscess
Infected granulation tissue harbouring the bacilli from initial bony focus • Attitude - (as described in stages above)
J, • Anterior hip point tender, bitrochanteric compression test positive
Erodes overlying cartilage ➔ reaches joint • Trendelenburg test positive
J, • Limitation of both active and passive movements
Synovial hypertrophy (pannus) + effusion □ Investigations :
J, • X-ray pelvis -
Pannus extends over and under cartilage ➔ erodes it ► Haziness of bones around hip

Joint becomes full of pus, gran:i:::n tissue 1 Bone ~ecome raw

►
►
►
Reduced joint space
Irregular outline of articular ends
'Pestle and mortar' appearance of acetabulum
Synovium becomes thickened, edematous
► Sclerosis around hip if healing starts
J,
• X-ray chest
Multiple cavities formed in head and acetabulum
J, • Blood - ESR raised, ELISA, PCR
• Mantoux test
Head partially absorbed
J, • Sputum for acid-fast bacilli
□ Treatment :
Constant pull of muscles
J, • Conservative -
Remaining head dislocates from acetabulum ➔ wandering acetabulum ► Antitubercular drugs
J, ► Immobilisation using below-knee skin traction
Pus bursts through capsule • Operative -
✓ ~ ► Joint debridement
Perforates acetabulum Cold abscess in groin or greater trochanter region ► Arthrodesis
J, ► Corrective osteotomy
Pelvic abscess ► __
Girdlestone arthroplasty
J, , / " / ' ~ - Total hip replacement
Healing by fibrous ankylosis
a~owing toe-nail
INGROWING TOE-NAIL
□ Stages:
• Stage I (Stage of synovitis) - Effusion into joint ➔ hip in a position of maximum capacity i.e. □ Pathology: One side of nail of toe curls inwards deep into the side of the nail bed, thereby forming a
lateral spike ------------------- -- ---- -------
flexion, abduction, external rotation (FABER). Apparent limb lengthening occurs
• Stage II (Stage of arthritis)-Articular cartilage destroyed ➔ spasm of powerful muscles around □ Site : Great toe
hip ➔ flexion, adduction, internal rotation (FADIR). Apparent limb shortening occurs □ Aetiology :
• Stage Ill (Stage of erosion) - Acetabular head eroded ➔ dislocation/subluxation of hip ➔ • Idiopathic
FADIR. True shortening occurs • Wearing tight shoes
□ Symptoms: • Excessive sweat
• Limp • Clipping the nails too short
• Pain around groin radiating to knee and often associated with night cries (caused by rubbing □ Clinical features :
of 2 diseased surfaces, when movement occurs due to muscle relaxation during sleep) • Side of the nail curls deep inwards
• Evening rise of temperature, night sweats • Skin lateral to it overhangs it, becomes painful and infected
• Apathetic, pale and loss of appetite • • Granulation tissue can be seen at the edge of digging nail
740 QUEST: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 741

□ Treatment : Q. 54 : Madelung deformity

• Conservative -
► Tight shoes avoided MADELUNG DEFORMITY
► Feet and hand kept clean and dry □ What is it : Characterized by malformed wrists, wrist bones and short stature
► Dressing with povidone iodine if infected □ Nature : Congenital
► Soframycin ointment □ Age : After 1O years
• Surgical - Radical removal of affected side of nail along with the corner of the germinal □ Aetiology :
envelope to prevent recurrence • Idiopathic
a. 53 : Osteogenesis imperfecta • Congenital
• Post-traumatic
OSTEOGENES~IMPERFECTA
• Diaphyseal aclasis
□ Synonyms: □ Pathology :
• Fragilitis ossium Defective medial 113rd radial epiphysis ➔ more growth of lateral 2/3rd of radius distally ➔ ulnar and
• Brittle bone disease volar angl.llation of distal radius ➔ prominence of distal ulna and volar subluxation of carpal bones
• Lobstein syndrome □ Clinical features :
□ What is it : Condition characterised by tendency for frequent fractures because of weak and brittle • Broadened wrist
bones • Ulnar and volar angulation of distal radius
□ Pathogenesis : Defective collagen synthesis ➔ deficiency of mainly Type 1 collagen • Dorsal prominence of ulnar head
□ Genetic mutation : COL 1A 1 and COL 1A2 gene • Forearm shortened
□ Types :8 • Restricted pronation, supination of forearm and dorsiflexion of wrist
□ Inheritance : Autosomal dominant disorder, a severe variant is autosomal recessive □ Investigations : X-ray
□ Associated features : □ Treatment :
• Blue sclera • Conservative - In paediatric cases
• Otosclerosis • Surgical - If pain and disability persists
• Joint laxity ► Milch recession osteotomy for skeletally immature bones
□ Clinical features : ► Darrach's operation for skeletally mature bones
• Frequent fractures with minimal trauma • Repeated minor injuries, such as repeated leaning on the point of the elbow on a hard surface
• Slight spinal curvature
• Poor muscle tone a. 55: Student's elbow
• Loose joints STUDENT'S ELBOW
• Slight protrusion of eyes
□ Synonym:
• Early loss of hearing
• Olecranon bursitis
□ Complications :
• Elbow bump
• Respiratory failure
• Baker's elbow
• lntracerebral hemorrhage
□ Investigations :
□ What is it: Inflammation of bursa between olecranon and triceps tendon
□ Aetiology :
• Prenatal diagnosis by amniocentesis
• DNA testing • Single injury to the elbow (e.g., a hard blow to the tip of the elbOW)
• Skin biopsy • Repeated minor injuries, such as repeated leaning on the point of the elbow on a hard surface
□ Age : 20-50 years
□ Treatment :
□ Clinical features :
No cure still following used -
• Bisphosphonates • Swelling in the elbow, which can sometimes be large enough to restrict motion
• Pain originating in the elbow joint from mild to severe which can spread to the rest of the arm
• Antibiotics to treat bone infection
• If the bursa is infected ➔ redness + skin warm + spontaneously and draining pus
• Physiotherapy
□ Treatment :
• Surgical correction of bones
• Activity modificati<;>n
742 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVE
.~TES OF SEMESTERS 745
C
(!)
.c
(!)
• Physical therapy - Ice application, ultrasonic therapy a..
E
• lntralesional Triamcinolone injection Foveal 0
Proximal vessels......, 0
• Bracing or strapping <(
• NSAIDs, Corticosteroids
f-
(/)
• Surgery - After 6-12 months of failed conservative treatment UI
:)
► Percutaneous release of tendons 0
► Open debridement
► Arthroscopic debridement

a. 56 : Claw hand Fig. 2.10.1 : Locations of Scaphoid fracture

CLAW HAND
□ What is it: Deformity in which hand assumes posture identical to cat's paw
□ Aetiology : Fig. 2.10.2 : Blood supply of femur
• Klumpke's paralysis
• Ulnar nerve injury at wrist
• Volkmann's ischaemic contracture
• Combined ulnar and median nerve injury
□ Mechanism :
Ulnar nerve cut at wrist ➔ interossei paralysed ➔ inability to flex MCP joint ➔ hyperextension at MCP
joint by unopposed action of long extensor tendons Shallow acetabulum
□ Treatment Small displaced
• Conservative - head
► Hand placed in proper splint
► Physiotherapy '<--+--+-- Break in
• Surgical - Nerve suturing Shenton's line

Fig. 2.10.3 : Congenital dislocation of hip

II Annulus
f fibrosus
I
l

I Medial
epicondyle
Lateral
epicondyle
Nucleus
pulposus

I.
;
'a' is hearly equal to 'b'
i.e., nearly isosceles triangle
- 3 bony point relationship
This is reversed in elbow dislocation Fig. 2.10.5 : Prolapsed intervertebral disc
t
! Fig. 2.10.4 : Dislocation of elbow

i
744 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 745

Degenerated
Prolapsed disc
annulus

Fragmented
nucleus
pulposus

Stage of degeneration Stage of protrusion

(I) (II)

\\ Sequestered
Extruded
"--p-c:C:)-'•.:,· ~ disc lntermalleolar
disc distance knees
a .., U approximated Ankles approximated

f Fig. 2.10.8: Genu Valgum, Genu Varum

Stage of extrusion Stage of sequestration

(Ill) (IV)

Stage of hematoma ➔
Fig. 2.10.6 : Pathology of disc prolapse

Stage of granulation
tissue formation ➔

I
I
I
Callus formation ➔

j
i
t
'
!i
'I Remodelling ➔

Fibula
l
I

I., Modelling➔

Il
Fig. 2.10.7: Osgood - Schlatter's disease
lI Fig. 2.10.9 : Fracture healing

'
I
94
746 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 747

Lumbar lordosis

Fig. 2.10.10 : Finkelstein Test (De-Quervan's disease)

(1) Transverse

8 ~- """'""'''
Fixed flexion deformity

Fig. 2.10.13: Thomas Test

(2) Oblique

0 v\)-
M
Fragmeot < 'I,
(3) Spiral

--t
V-
Calcification Lateral subluxation of head

(4) Comminuted

00
~
Fragm,ot > 'I, Horizontal physis

(5) Segmental

~ LP - Comminuted
Fig. 2. 10.14 : Perthes disease

□
Fig. 2.10.11 : Classification of fracture based on pattern Fig. 2.10.12 : Fracture head of radius
748 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 749

Expansion of
overlying contex

Blood filled Soap bubble

radioluscent appearance
Falling leaf sign lesion

Calcaneum
Fig. 2.10.18: Aneurysmal bone cyst ,-·-
Fig. 2.1 o. 15(A) : Calcaneum fracture Fig. 2.10.17 : Simple bone cyst Fig. 2.10.19 : Osteoclastoma

Selerotic bone

Radioluscent Codmann's
nidus triangle

Sun-ray
appearance

Less than 1 cm

Calcaneum Fig. 2.10.16: Osteoid osteoma

Fig. 2.10.1 S(B) : Calcaneum fracture Lesion in

metaphysis

Fig. 2.10.20 : Osteosarcoma

750 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

d Heals by fibrosis

One articular surface

{a) Normal
ti
{b) Excision arthroplasty

Both articular
replaced by prosthesis surfaces
replaced by
prosthesis

Section 3

(c) Hemi-replacement arthroplasty

(d) Total replacement arthroplasty
ANESTHESIOLOGY
Fig. 2.10.21 Osteosarcoma

Secondary
curves

Primary
curve

Extra-articular Intra-articular Combined

Fig. 2.10.22 : Types of Arthrodesis

Fig. 2.10.23: Curves in Scoliosis

 SECTION-3
SOLVED SHORT NOTES
Q.1 : Spinal anesthesia

SPINAL ANESTHESIA
□ What is it: Form of regional anesthesia
□ Synonym:
• Subarachnoid block
• lntrathecal block
□ Indications :
• Orthopaedic surgery - of lower limbs and pelvis
• General surgery -
', pelvic surgery
Section-3 ',
,.. perinea! surgery
hernia
ANESTHESIOLOGY ► hydrocele
', testicular
', appendix
• Gynaecological- all uterine surgeries like myomectomy, Caesarean section, cervical surgeries
1. Solved Short Notes • Urology -
,... bladder stone
► ureteric stone
► prostate surgery
□ Contraindications :

CONTRAINDICATIONS

Absolute Relative

Uncontrolled HTN

Hypovolaemic shock IHD

Bleeding disorder
Patient on
aspirin
Patient on
anticoagulant
Spinal
deformity
Septicaemia

Infected at Previous spinal

local site surgery

95 753
754 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES 755

0 Types: fo~ P1~J:r %t:-1 't

• Caudal (upto L5) fi)g,,. (Dp'M '2 COMPLICATIONS

• Low spinal (upto L 1)

L2
• Mid-spinal (upto T10) Intra- Post-
operative operative
• High spinal (upto T6)
• Unilateral spinal
Hypotension Urinary retention
0 Procedure:
• Position- lateral OR sitting OR prone
Bradycardia Post spinal headache
• Approach-midline OR lateral OR lumbosacral(Taylor)
• Site- L3-L4 OR L4-L5 Cranial nerve paralysis
Respiratory paralysis
• 24-26 G needle passed through interspin_~~-~-~P-~~~ and ligamentum flavum ~o reach (except CN I, IX, X)
subarachnoid space to get clear CSF ➔ r,eedle rotated 360 degrees and drug Is slowly
_injected ➔ ~li-~~~t_!hen kept in supine position Nausea and vomit Meningitis
□ Site of action : Spinal nerves+ Dorsal ganglia
□ Drugs used : Difficulty in phonation Cauda equina
syndrome
• Local anaesthetics
► Lignocaine-5% in 7.5% Dextrose Restlessness, anxiety Chronic adhesive
arachnoidtis
► Bupivacaine-0.5% in 8% Dextrose
► Tetracaine-1% in 5% Dextrose L.A. toxicity Paraplegia
► Procaine-10% in 5% Dextrose
• Opioids. Cardiac arrest Spinal cord ischaemia
• Others-ketamine
□ Advantages : Bloody tap Anterior spinal artery
syndrome
• Low cost
• Reduced bleeding due to hypotension Broken needle Backache
• Adequate relaxation achieved
• Less respiratory complications
□ Contraindications : □ Factors affecting duration of block:
• Allergy • Dose
• Increasing conctretation
• Sepsis
• Pharmacological profile of drug
• Cardiac patients
• Type of drog
• Spinal tumors
• Added vasoconstrictors
• Kyphosis. scoliosis
Q.2: Post spinal headache
□ Complications :
POST SPINAL HEADACHE
□ What is it : Cause of headache after spinal anesthesia
□ Cause: Low Pressure Headache due to seepage of cerebrospinal fluid from dural rent created by
spinal needle.
□ Amount of Cerebrospinal fuid loss: 1O ml/hr
75 5 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHOAT NOTES 757

□ Pathogenesis : CSF lekage ➔ Changes in hydrodynamics ➔ Traction on pain sensitive structures □ Other cauH of headache after spinal anesthesia :
➔ Pain Meningeal irritation - due to bacterial or chemical meningitis (It is high pressure headache, having no
relation with posture)
□ Etiology:
• Needle size : 16G needle ➔ 75% cases Q.3 : Muscle r11laxants
25G needle ➔ 1.3 % cases
MUSCLE RELAXANTS
• Type of needle: Increasing incidence with dural cutting needle
Decreasing incidence with dural separating needle □ What are they : Drugs that act peripherally at neuromuscular junction/muscle fibre itself or centrally
in cerebrospinal axis to reduce tone and/or cause paralysis
• High altitude
□ Classification :
• History of headache
• Inadequate hydration
•
•
Pregnancy
Female, young age I MUSCLE RELAXANTS I
□ Clinical features : I
I I
Pain with following features - Centrally acting Peripherally
• Presents after - 12 to 24 hrs (when patient starts sitting) e.g. Baclofen acting
• Site - occipital, (rarely frontal)
I
• Assosiated - pain and stiffness in neck I I
• Nature - throbbing Directly acting
e.g. Dantrolene, Neuromuscular
• Relived by - lying down blocking
sodium
• Aggravated by - sitting, strong light,noise I
• Lasts for-7 to10 days. I I
Depolarisisng Non-depolarising
□ Treatment : blockers e.g. (Competitive)
Succinylcholine blockers
TREATMENT (SCh)

Long acting
'"-
e.g. Doxacurium,
Preventive Curative Pancurium

Small bore needle Lie supine in slight Intermediate acting

Trendelenburg position - e.g. Vecuronium,
Atracurium
Adequate hydration Analgesic
Short acting
i.v. fluid
- e.g. Mivacurium
Avoid pillow for next
24 hours
Abdominal binders
□ Mechanism of action :
Prone position after • Non-depolarising agent -
surgery Desmopressin
NDMR are competitive antagonists with acetylcholine at acetylcholine receptors and NDMR
5-6% CO 2 in 0 2 inhalation bind at the alpha subunit at which acetylcholine binds. They also block prejunctional nicotinic
Avoid sitting in receptors on motor nerve endings (exhibit 'fade' phenomenon)
post-operative period • Depolarising agent -
Oral/i.v. caffeine
SCh attaches to the same site as acetylcholine, producing same action as acetylcholine. But,
unlike acetylcholine which is easily metabolized, SCh metabolism depends on the
Epidermal blood patch
concentration gradient of succinylcholine between plasma and neuromuscular junction. So
 758 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES 759

excessive excitability of SCh at neuromuscular junction produces repeated depolarisations Q.4 : Monitoring in anesthesia
and contractions (fasciculations). At this stage, both voltage and time dependent gates of
receptor are open but after sometime time-dependent gate closes producing relaxation inspite MONITORING IN ANESTHESIA
of SCh molecules attached to receptors. Secondly continuous presence of SCh leads to □ BASIC MONITORING -
-~
accommodation (inexcitability) of perijunctional membrane making it irresponsive. This is • Pulse rate
how SCh produces relaxation preceeded by continuous contraction i.e. Phase I block
• Colour of skin - detect cyanosis
•· A' Actions : • Blood pressure
/ • Skeletal muscles - NDMR rapidly produce muscle weakness followed by flaccid paralysis. • Inflation of chest
Depolarising75Tockers produce fasciculations lasting for few seconds before inducing flaccid • Precordial and t~r,,sr;;p,hageal stethoscopy
paralysis
• Signs of sympathetic overactivity - lacrimation, perspiration
• CVS- • Urine output
ganglionic blockade
► NDMR ➔
* Reduce BP due to ~ histamine release
□ ADVANCED (INSTRUMENTAL) MONITORING-

~ reduced venous return

• Cardiovascular monitoring :
1. Non invasive methods -
* Increase heart rate due to ganglionic blockade ► ECG - Lead II to detect arrhythmia, V1-V6 to detect ischaemia
► Depolarisisng agents ➔ ► Non-invasive BP(NIBP) - measures BP at set intervals automatically by
* Bradycardia (due to activation of vagal ganglia) automated oscillometry
* Tachycardia+ reduced BP (due to stimulation of sympathetic ganglia) ► Transoesophageal echocardiography -
• .!:1-i§tiailline release - by NDMR * detect LV wall motion abnormality
► hypotension * detect valvular dysfunction
► flushing * detect intracardiac air
► bronchospasm 2. Invasive methods -
► increased respiratory secretions ► Invasive BP (IBP)-
• ~~ - Depolarising agents cause hyperkalaemia * Radial artery commonly chosen
• _9JJ - Depolarising agents cause the following : * Allen's test done before radial artery cannulation to assess patency of ulnar
► increased intragastric pressure artery
► increased salivation ► Central venous pressure monitoring (CVP) -
► increased gastric secretions * Ideal - right internal jugular vein as it is valveless
► increased peristalsis * Indications -
• ..§Y.~ - Depolarising agent raise intraocular tension ❖ Major surgeries where large fluctuations in hemodynamics expected
❖ Open heart surgeries
□ Uses:
❖ Fluid management in shock
• Adjuvants to general anaesthetics
❖ Parenteral nutrition
• Assissted ventilation
* Complications -
• Avoid convulsions and trauma from electroconvulsive therapy
❖ Air embolism
• Severe cases of tetanus and status epilepticus
❖ Thromboembolism
• Succinylcholine in malignant hyperthermia ❖ Cardiac arrhythmia
□ Other salient points : ❖ Pneumo/haemo/chylo-thorax
• First muscle to be blocked - central muscles of body ► Pulmonary artery catheterisation -
• Prolonged apnoea after SCh administration due to - * Catheter used - Swan-Ganz catheter
► low pseudocholinesterase * Uses -
► atypical pseudocholinesterase ❖ Measure cardiac chambers pressure
► phase II block ❖ Calculate cardiac output
• Gallamine is the only NDMR to cross BBB and placenta ❖ Measure pulmonary artery occlusion pressure
• Reversal of block by anticholinesterase ❖ Best guide to assess tissue perfusion ·
❖ Titration of fluid infusion
760 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES 761

□ Respiratory monitoring: □ Neuromuscular monitoring:

• Pulse oxymetry - • Commonly used muscle is adductor pollicis supplied by ulnar nerve
, Aim - To measure oxygen saturation in blood (SpO2) • Neuromuscular monitor delivers a number of stimuli among which 'train of fou( is the most
► Application of probes - useful method
* Finger-nail bed □ Monitoring depth of anesthesia : done clinically
* Toe-nail bed □ Monitoring blood loss :
* Ear lobule This is done by -
* Tip of nose • Gravimetric method
► Normal SpO2 - 97-98% • Volumetric method
;,- Principle - A source of light is emitted at two wavelengths (660 nm and 940 nm) from • Colorimetric method
a probe which when passes through tissue containing blood is absorbed by pulsatile □ Expired gas analysis :
artery and capillary blood and non-pulsatile venous blood and tissue. The ratio of
Mass spectrometers, Raman gas analysers used to measure concentration of anaesthetic vapours
two is calculated by pulse oxymeter which converts it into oxygen saturation
□ Evoked responses :
► Use - For detection of hypoxia in intraoperative and postoperative period
• SSEP (Somatosensory)
► Abnormalities -
• AEP (Auditory)
* Carboxy haemoglobin - SpO2 95%
• VEP (Visual)
* Methaemoglobin - SpO2 85%
• Capnography - Q.5 : Pulse oxymetry
► It is the continuous measurement of end tidal volume carbon dioxide and its waveform A : See the previous answer
► Normal : 32-42 mm Hg
► Uses: Q.6 : Preanaesthetic check-up
* surest confirmatory sign of correct intubation
PREANAESTHETIC CHECK~UP
diagnose malignant hyperthermia
□ HISTORY-
* ETCO 2 is zero in cardiac arrest
• Blood gas analysis - • Alcohol intake
► Blood gas values of mixed venous blood • Drug intake
► pO2 = 40 mm Hg • Smoking
► pCO2 = 46 mm Hg • Any allergy
► 02 saturation 75 % • Chronic ~ough
► Mixed venous oxygen ➔ best indicator of cardiac output • Chronic diseases - HTN, Diabetes, TB, Bronchial asthma, etc
► Arterial oxygen ➔ better indicator of pulmonary function • Regular medication if any (antihypertensives, antiepileptics, etc.)

• Lung volumes - by spirometer □ CLINICAL EXAMINATION -

• Oxygen analysers - to monitor actual value of 02 delivered • General survey :
• Airway pressure monitoring - it should be < 20-25 cm H2O ;, Posture
□ Temperature monitoring : ► Neck movements
• Indications - ► Mouth opening, jaws
► cardiac surgery ► Teeth
► infant, small children ► Tremor
► febrile patient ► Veinous prominence
► patient prone to develop malignant hyperthermia ► Pallor
':--.
,-
• Core temperature monitoring sites - Jaundice
► oesophagus ► Clubbing
► pulmonary artery ► Edema
► nasopharynx ► B.P
► Pulse

96
762 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES 763

Q.7: Epidural anesthesia

• Airway:( t-J\o'.'l'b
► Mouth opening EPIDURAL ANESTHESIA
► Thyromental distance
□ Anatomy : Epidural space is the potential space between dura anteriorly and ligamentum flavum
► Temporomandibular joint assessment posteriorly, with negative pressure inside, extending from foramen magnum to sacral hiatus · -
► Mallampati scoring - 0 Needle used: Touhy needle
Class I - Soft palate + Faucial pillar + Uvula visible
Class II - Soft palate+ Faucial pillar visible
} IEasy intubation I □ Procedure: After needle inserted, epidural catheter placed in the space and fixed ➔ 2% xylocaine or
5% bupivacaine injected into the space
Class Ill - Soft palate visible }
□ Difference with spinal anesthesia :
[Samsons Young modification - Difficult intubation
• To achieve epidural analgesia or anesthesia, a larger dose o f ~ is typically necessary
Class IV - Only hard palate seen]
than with spinal analgesia or anesthesia
• Respiratory system : ( • The onset of analgesia is ~ r with epidural analgesia or anesthesia than with spinal
Signs of asthma, COPD, TB, etc. analgesia or anesthesia
• Cardiovascular system :: ',~ · • An epidural injection may be performed anywhere along the vertebral CQ.ill!!ln (cervical,
Following conditions excluded - thoracic, lumbar, or sacral), wfole spinal injections are typically performed below the second
► HTN lumbar vertebral body to avoid piercing and consequently damaging the spinal cord
► IHD • It is !iasier to achieve segmental analgesia or anesthesia using the epidural route than using
► Arrythmia the spinal route
► Cardiac failure • An indwelling cath~r is more commonly placeg_in the setting of epidural analgesia or
► Valvular heart disease
anesthesia than with spinal analgesia or anesthesia.

• Abdomen : Liver diseases, etc. excluded CD ;:;::;:,_;,>c':- □ Indications :

• Spine: • For analgesia alone, where surgery is not contemplated

► Overlying skin for any infection • As an adjunct to general anesthesia.This may reduce the patient's requirement for opioid
► Spinal curvature analgesics. This is suitable for a wide variety of surgery, for example gynaecological surgery
► lntervertebral space (e.g. hysterectomy), orthopaedic surgery (e.g. hip replacement), general surgery (e.g.
laparotomy) and vascular surgery (e.g. open aortic aneurysm repair)
□ INVESTIGATIONS - • As a sole technique for surgical anesthesia. Some operations, most frequently Caesarean
section, may be performed using an epidural anaesthetic as the sole technique
• Complete blood count
• For post-operative analgesia, after an operation where the epidural technique was used as
• Blood grouping either the sole anaesthetic, or was used in combination with general anesthesia
• Haematocrit • For the treatmentof back pain
• Blood sugar • For the treatment of chronic pain or palliation of symptoms in terminal care, usually in the
• Blood urea short- or medium-term
• Serum creatinine , q,.1fi:tvantages :
• Serum electrolytes
• Used for continuous_repeatec:l prolo~d anesthesia
• Chest X-Ray
• ECG • Can be used for several d~ys
• Blcod gas analysis □ Contraindications :
• Other cardiac monitoring if required • Anatomical abnormalities, such as spiri? bifida or scoliosis
□ TREATMENT- • Previous spinal surgery
• Correction of anaemia • Certain problems of the central nervous system, including l!JUltiple sclerosis or syringomyelia
• Preoperative antibiotics • Certain hfillrt-valve problems (such as aortic stenosis, where the vasodilation induced by the
anaesthetic may impair blood supply to the thickened heart muscle)
• Control of respiratory and cardiac diseases • E31~~g_L11g cliso_rcjer (coagulopathy) or anticoagulant medication (e.g. warfarin) • ~isk of spinal
□ PRECAUTIONS - cord-compressing hematoma
• p~starvatio~h_C>ur~!!?! !(quids and_.6 hours for soll~s • !nfeQtion near the point of intended insertion
• Dentures, contactlerises, jewellery removed • c\~_§Jgy to the anaesthetic
764 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES 765

□ Choice of agents : (,.,..~◊"I\(

')
I/,
• Local anaesthetics - lidocaine, mepivacaine, ~Llp}vacaine
• Opioids - morphine, fentanyl, sufentanil, and pethidine I CLASSIFICATION
I
----- I
□ Epidural anesthesia during childbirth :

ADVANTAGES DISADVANTAGES
I Injectable I I Surface
I
Low potency Short duration Soluble
• Decreased maternal hyperventilation and • Increased need for oxytocin to stimulate
- - e.g. Cocaine
i11gr~§l~El<:L9J<Y.!le115-~ppl~!? baby uterine contractions e.g. Procaine, Chloroprocaine

• _Better pain relief than other pain medication • Increased risk of muscular weakness for a
periodof time.after the.birth . -·
• Decreased_ circulatinJL adreng.corticotropic Intermediate potency and
-
Insoluble
hormone and decreased fetal distress • Increased risk of Caesarean section for fstal ,- duration e.g. Benzocaine
distress e.g. Lidocaine, Prilocaine

• ~~_9_El'lY..EHY (second stage of labour)

High potency
• Increased risk of very 19.,.,. blood pressure
- Long duration
• Increased risk of fluid retention
. ...
e.g. Tetracaine, Bupivacaine

□ Complications : □ Mechanism of action : Drug in undissociated form penetrates axonal membrane a n d ~ - gets
• ~Jil!l!iL is m a r k e ~ if inadvertently given intravenously, causing excitation, ionized ➔ Ionized form binds to receptor situated insodium channel in inactivated state from inner
nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision, or seizures, side ➔ !:JJQQ.!s.s_channel ➔ _prJven_t~.cf ~p9l_11!Jsation
followed by depression, drowsiness, loss of consciousness, respiratory depression and apnea
□ Types: .
• Very~.do.fill.S of epidural anaesthetic can cause paralysis of the intercostal muscles and • central techniques - Neuraxial blockade (epidural anesthesia, spinal anesthesia)
thoracic diaphragm (which are responsible for breathing), and loss of sympathetic nerve
input to the heart, which may cause a significant decrease in heart rate and blood pressure • Peripheral techniques -
► topical (surface) anesthesia
• The ~nsatjon ~rl_<!~_?~!f!!:lific~':!fu'._gimiQt~
• Large doses of epidurally administered opioids may cause troublesome Itching, and respiratory ► Infiltration block
depression - -------· ► plexus blocks such as brachia! plexus blocks
• Accide~ ~ural puncture with headache ► single nerve blocks
• ~loo~y J~p ► intravenous regional anesthesia (Bier's block)
• C_<;ll~El!~.': f!li~J~.£Eld into the subarachnoid space □ Onset of action depends on :
• NeurologicalJniLJJY • dose and concentration
• Epidural al)scess • pKa ( p
• ~f)idural hem~!oma • type of nerve fibre
• frequency of nerve stimulation
Q.8 : Regional anesthesia/Local anesthesia
□ Duration of action depends on :
• dose
REGIONAL/LOCAL ANESTHESIA
• pharmaceutical profile of drug
□ What are they : Drugs which upon topical applicatiop or local injection cause reversible loss of • plasma protein binding
sensory perception in a restricted area of body, along with muscular paralysis and loss of autonomic • metabolism
:~~if aQQ]ied over.a mixed _r:,erve ---•··-·······-··-...--- -
• addition of vasoconstrictor
[Local anesthesia is used for a small part of the body, regional anesthesia is used for a larger part of
□ Adverse effects :
the body) • CNS_ dizziness, auditory and visual disturbance, mental confusion
□ Classification : • CVS - bradycardia, hypotension, cardiac arrhythmia
• Hypersensitivity reaction
 766 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES 767

Q.9: CPR
(Patient in supine position ➔ rescuer stands on side ➔ one hand locked over other hand ➔
CPR compression over lower third of sternum ➔ sternum depressed by 1 .5-2 inches, relaxation should be
□ Full form : r---,~.~----,.,,.--.....,.__..._
Cardiopulmonary resuscitation equal to compression)
□ Components: □ Def/br/1/ator :
• §asic life support (BLS) BLS ➔ Automatic external defibrillator
• Advanced life support (ALS) ALS ➔ Manual defibrillator
• }>os1~or:t ( ) Indications -
□ What is it: Symptomatic therapy to resuscitate a patient with cardiac arrest • Ventricular tachycardia
□ Basic parameters :
1 • Ventricular fibrillation
• Airway A 0
• Breathing 6 I Drugs In ALB :
• Circulation C • Adrenaline
• Defibrillator !) t • Atropine
• Drugs :.1:) • Amiodarone
□ Airway management :
• BLS-
'
I □
• Llgnocaine
Monitoring of CPR:
► ,_Qpen mouth, suction of airways (finger sweep method in unconscious patients) f • Capnography
• Carotid pulsation
► Tilt head backwards - use pillow/sandbag to slightly extend neck

• ALS-
► Chin lift
► Jaw thrust manoeuvre i.e. mandible pulled forward

Equipments ➔ Guidel's airway tube, oropharyngeal tube

'It □
•

•
•
Coronary perfusion pressure
Compl/catlons :
Pneumothorax
Lung injury
► I,

► Endotracheal intubation_ (most definitive method) • Rib fracture

❖ To remove foreign bodies - • Pneumomediastinum
*
*
*
Manual compression over lower sternum
Infant chest thrust
Heimlich manoeuvre (compress abdomen 6-10 times, rescuer standing
I •
•
Injury to abdominal organs
Pneumopericardium

behind patient) ALGORITHM FOR BASIC LIFE SUPPORT

* 4 blows on middle of back
* Cricothyrotomy Assessment of consciousness by shaking
□ Breathing management : j,
• BLS- No response
j,
► !:'.louth to mouthjopen airway ➔ pinch nose ➔ create an airtight seal ➔ give breath Open airway and check breathing
over 1 second with sufficient force to move chest) j,
► Mouth to airway (Safar or Brook airway) If breathing absent or patient gasping ➔ 2 rescue breaths by any of the above mentioned methods
► Bag and mask ventilation each over 1 second
• ALS - j,
►
Ventilation by advanced methods - ~ Carotid pulsation checked - - - - . _
❖ Endotracheal intubation
❖ Laryngeal mask airw,ay (LMA) Absent Present
❖ Combitube i j,
Chest compressions started Breaths given @ 10-12 breaths/min
❖ Tr~heostomy_tube
► Ventilation by automatic ventilators
i
Continued till defibrillator arranged
□ Maintenance of circulation :
Cardiac massage
i
Defibrillation done, while rhythm monitored
 SOLVED SHORT NOTES 769
768 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

□ Instruments used :
ALGORITHM FOR ADVANCED LIFE SUPPORT • Laryngoscope
• Endotracheal tube
Assessment of consciousness by shaking □ Features of the cuff:
j, • Pressure ➔ < 30 cm of H2O
Airway and breathing management • Volume ➔ 4-8 ml of air
j, □ Required size of tube : (internal diameter)
. . . - - - - Circulation assessed • Premature babies ➔ 2.5 mm
• 0-6 months ➔ 3-3.5 mm
Absent Present • 6 months-1 year ➔ 3.5-4 mm
j, j, • 1-6 years ➔ [(Age in years)/3] + 3.5 mm
Chest compressions started @ 100/min Breaths given @ 10-12 breaths/min • > 6 years ➔ [(Age in years)/4] + 4.5 mm
j, j, • Adult males ➔ 9 mm
Rhythm assessed .--------~~ Non-shockable • Adult females ➔ 8 mm
j, □
Shockable
t Required length of tube to be inserted :
• Children ➔ [(Age in years)/2] + 12 cm
I
,
j, • CPR continued
• Adult males ➔ 23 cm
• Adrenaline 1 mg i.v., repeated
One shock given
j, at 3-5 mins interval
t • Adult females ➔ 21 cm
CPR for 2 minutes • Vasopressin after 2nd dose of □ Technique :
j, Patient lies supine with pillow under occiput
adrenaline j,
~ .-----•:. Rhythm reassessed ----- • Atropine, at 3-5 mins interval Extension at atlanto-axial joint, flexion at cervical spine
/ j, -----. j,
Recovered Still shockable Non-shockable Laryngoscope blade inserted from right side of mouth
j, j, j,
CPR stopped CPR continued, Adrenaline injected Laryngoscope is slowly advanced displacinl tongue to the left until epiglottis visualised
j,
Another shock given Lifted anteriorly to visualise glottis
j, j,
.___C_y_c_le_r_e-pe_a_te_d_o_n_c_e_ _ _ CPR for 2 minutes Endotracheal tube passed between vocal cords
j, j,
Amiodarone/lignocaine injected Cuff inflated
j, j,
' - - - - - - - - - - - - - - A n o t h e r shock given Position of tube verified by capnography and chest auscultation
j,
Tube secured at mouth with adhesive tapes
Q.10: Endotracheal intubation

ENDOTRACHEAL INTUBATION □ Complications :

• Laryngospasm
□ What is it: Placement of a flexible plastic tube into the trachea to maintain an open airway in critically • Dental injury
injured, ill or anaesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, • Hemodynamic alterations
and to prevent the possibility of asphyxiation or airway obstruction • Perforation of the trachea or oesophagus . .
□ Indications : • Pulmonary aspiration of gastric contents or other foreign b_od1es. . . ila es
• Fracture or dislocation of the cervical spine, temporomand1bular Joint or arytenoid cart g
• Hypoxia
• Unconscious patients • Decreased oxygen content
• Manipulation of airway • Elevated arterial carbon dioxide
• Vocal cord weakness
• Airway obstruction
□ Prerequisites : □ Other methods of intubation :
• General anesthesia • Cricothyrotomy
• Neuromuscular blocking agent • Tracheostomy

97
 r

770 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

BIBLIOGRAPHY 771

INTRAVENOUS ANAESTHETICS

□ Drug details :
A) !ti,i()penton~.~()dium
B) Methohexitone sodium
C) Propofol
D) Etomidate
E) Slower acting drugs
F) Ketamine
. ., -M~~--•M-•-
G) Fentanyl BIBLIOGRAPHY
H) Dexmedetomidine
□ Classification :
,- Inducing agents - • Bailey and Love's Short Practice of Surgery, 25th Edition
• Thiopentone sodium, • Schwartz's Principles of Surgery, 10th Edition
• Methohexitone sodium, • Sabiston textbook of Surgery, 19th edition
• Propofol, • SRB's Manual of Surgery, 4th Edition
• Etomidate.
• Bedside Clinics in Surgery by Dr. Makhan Lal Saha
► Slower acting drugs -
• Benzodiazepines-Diazepam, Lorazepam, Midazolam • Current Medical diagnosis and Treatment, 50th Anniversary Edition (2011 )
• Dissociative anesthesia-Ketamine • Harrison's Principles of Internal Medicine, 19th Edition
• Opioid analgesia-Fentanyl. • A Concise Textbook of Surgery, 7th Edition by Dr. Somen Das
□ Mechanism :
► Major targets are_GABAh_!_eceptor gated -
• Cl-channel. (Many inhalation anesthetics, barbiturates, benzodiazepines and propofol)
► NMDA receptors are type of glutamate receptor. (N 20, Ketamine)

.,