Pre-NEET Surgery (Khandelwal & Arora) PDF
Pre-NEET Surgery (Khandelwal & Arora) PDF
Pre-NEET Surgery (Khandelwal & Arora) PDF
Surgery
Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: [email protected]
Overseas Of fices
J.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc.
83, Victoria Street, London City of Knowledge, Bld. 237, Clayton
SW1H 0HW (UK) Panama City, Panama
Phone: +44-2031708910 Phone: +507-301-0496
Fax: +02-03-0086180 Fax: +507-301-0499
Email: [email protected] Email: [email protected]
Jaypee Brothers Medical Publishers (P) Ltd Jaypee Brothers Medical Publishers (P) Ltd
17/1-B Babar Road, Block-B, Shaymali Shorakhute, Kathmandu
Mohammadpur, Dhaka-1207 Nepal
Bangladesh Phone: +00977-9841528578
Mobile: +08801912003485 Email: [email protected]
Email: [email protected]
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
2013, Jaypee Brothers Medical Publishers
All rights reserved. No part of t his book may be reproduced in any form or by any means
without the prior permission of the publisher.
This book has been published in good faith that the contents provided by the contributors
contained herein are original, and is intended for educational purposes only. While every
effort is made to ensure accuracy of information, the publisher and the author(s) specifically
disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application
of any of the contents of this work. If not specifically stated, all figures and tables are courtesy
of the author(s). Where appropriate, the readers should consult with a specialist or contact
the manufacturer of the drug or device.
[email protected]
so as to help us in further improvement of this book in
the subsequent edition.
Tips to tackle NEET
1. Questions ...................................................... 1 47
QUESTIONS
Fig. 1
Fig. 2
a. Atherosclerosis
b. Hypertension
c. Rheumatic heart disease
d. Trauma
6. A 33-Year-old woman presents to the emergency with diffuse,
cramping abdominal pain, nausea and vomiting that began this
morning. The abdominal pain is diffuse throughout and the patient
also describes her abdomen as looking slightly enlarged. She has a
history of chronic pancreatitis, as well as a cholecystectomy and two
cesarean sections. The patient states that she has had flatus but no
bowel movements since the pain began. On physical examination,
there is diffuse abdominal distention and high- pitched bowel sounds
without rebound tenderness of guarding present. Given the clinical
picture and upright x-ray of the abdomen shown in the image, which
of the following is the most likely diagnosis?
Fig. 3
4 Pre-NEET Surgery
a. Colon cancer
b. Mesenteric ischemia
c. Pancreatitis
d. Small bowel obstruction
7. A 36-year-old man with a history of abdominal tuberculosis
presents to the emergency with 2 days history of increasing abdominal
pain. The pain is diffuse, although most intense in the peri-umbilical
region. On questioning, he notes that he has not had a bowel
movement since the onset of the pain, nor has he vomited. On initial
physical examination, his abdomen is very distended and tender to
palpation. One hour later, his clinical condition has worsened. Which
of the following additional finding would most indicate the need for
emergent surgery?
a. Absence of bowel sounds
b. Absence of flatus
c. Bilious vomiting
d. Diffuse rebound tenderness
8. A 60-year-old man presents to the ED with severe headache and
diaphoresis that has been occurring intermittently for the previous 24
hours. He also notes occasional palpitations. The patients blood
pressure is 220/110mm Hg, and he has papilledema on funduscopic
examination. Intravenous phentolamine is effective at improving his
blood pressure. Subsequent measurement of 24-hour urinary
catecholamine metabolites yields increased values.
With which of the following neoplastic diseases is this patients cancer
often associated?
a. Insulinoma
b. Medullary thyroid cancer
c. Pancreatic adenocarcinoma
d. Pituitary adenoma
9. A breast cancer survivor presents to the clinic complaining of
swelling of the right upper limb with reddish blue maculo-pappular
lesions. She was treated for right sided carcinoma breast 10 years
back with MRM, chemotherapy and radiotherapy. What is the probable
cause of the patients symptoms?
a. Recurrence
Questions 5
b. Chronic lymphedema
c. Stuart- Treves syndrome
d. Axillary vein thrombosis
10. A 42-year-old lady with a prior history of intermittent right upper
quadrant (RUQ) abdominal pain following meals, presents to the doctor
with a more severe episode of a similar pain. She has also had nausea
and vomiting. On physical examination, she is febrile to 38.2oC
(100.8oF), obese, and has tenderness to palpation in the RUQ. An
abdominal ultrasound reveals some stones in her gallbladder.
Laboratory tests show:
WBC count 13,000/mm3
Total bilirubin 3.8mg/dL
Aspartate aminotransferase 130 U/L
Alanine aminotransferase 150 U/L
Alkaline aminotransferase 300 U/L
Amylase <30 U/L
Lipase 8 U/L
Which of the following is most likely responsible for her symptoms
and laboratory values?
a. A stone obstructing her common bile duct
b. A stone obstructing her cystic duct
c. A stone obstructing her pancreatic duct/ampulla of Vater
d. Stones in her gallbladder
11. A 17-year-old boy is brought to the emergency after a road traffic
accident. Upon presentation the patient is noted to have multiple
mandibular and maxillary fractures as well as an open right-sided fibular
fracture. The cervical spine was stabilized during transport to the
hospital. The patient remains unconscious with an oxygen saturation
of 78% on oxygen via face mask with a pulse of 146/min and a blood
pressure of 60/20 mm Hg. What is the next step in management for
this patient?
a. Administer fluids
b. Continue with face mask ventilation and proceed with the rest of
the primary trauma survey
c. Proceed with a cricothyroidotomy
d. Proceed with nasopharyngeal intubation
6 Pre-NEET Surgery
Fig. 4
b. Caecum
c. Sigmoid colon
d. Rectum
17. A 52-year-old woman undergoes a sigmoid resection with primary
anastomosis for recurrent diverticulitis. She returns to the emergency
room 10 days later with left flank pain and decreased urine output;
laboratory examination is significant for a white blood cell (WBC)
count of 20,000/mm3. She undergoes a CT scan that demonstrates
new left hydronephrosis, but no evidence of an intraabdominal abscess.
Which of the following is the most appropriate next step in
management?
a. Intravenous pyelogram after kidney function tests
b. Intravenous antibiotics and repeat CT in one week
c. No further management if urinalysis is negative for hematuria
d. Immediate reexploration
18. A 34-year-old man develops an enterocutaneous fistula originating
in the ileum secondary to abdominal tuberculosis. Which of the
following would be the most appropriate fluid for replacement of his
enteric losses?
a. D5W
b. 3% normal saline
c. Ringers lactate solution
d. 0.9% sodium chloride
19. A patient meets with a road traffic accident and is taken to the
emergency department. During the secondary survey of a trauma
patient, it becomes apparent that there is a depressed skull fracture.
You must decide if this changes the management plan for this patient.
Which of the following statements regarding skull fractures is true?
a. Depressed fractures are those in which the patients level of
consciousness is diminished or absent
b. Compound fractures are those in which the skull is fractured and
the underlying brain is lacerated
c. Any bone fragment displaced more than the thickness of the
adjacent skull
d. Drainage of cerebrospinal fluid via the ear or nose requires prompt
surgical treatment.
Questions 9
28. The following cases are scheduled to be operated in the OR. You
are the resident on duty and you are told to identify the clean-
contaminated case from the list.
a. Open cholecystectomy for cholelithiasis
b. Herniorrhaphy with mesh repair
c. Lumpectomy with axillary node dissection
d. Appendectomy with walled-off abscess
29. A 65-year-old woman presents with a 1-cm lesion with a pearly
border on her nose, and punch biopsy is consistent with a basal cell
carcinoma. She visits the doctor and he advises her Mohs micrographic
surgery. Which of the following statements is true regarding this
technique?
a. Mohs surgery results in a larger cosmetic defect because of the
emphasis on obtaining negative margins circumferentially
b. The major benefit of Mohs surgery is a shorter operating time
c. Mohs surgery is indicated for all basal and squamous cell
carcinomas
d. Frozen sections are not necessary if Mohs surgery is performed
e. There is no difference in cure rates between wide local excision
and Mohs surgery
30. A 25-year-old man is brought to the emergency room after
sustaining burns during a fire in his apartment. He has blistering and
erythema of his face, left upper extremity, and chest, with frank charring
of his right upper extremity. He is agitated, hypotensive, and
tachycardic. Which of the following statements concerning this patients
initial wound management is correct?
a. Topical antibiotics should not be used, as they will encourage
growth of resistant organisms
b. Escharotomy should be performed only if neurologic impairment
is imminent
c. The total body surface area burnt in this patient is 36%
d. Excision of areas of third-degree or deep second-degree burns
usually takes place three to seven days after injury.
31. A 54 year old patient presents with adhesive intestinal obstruction
for which he undergoes laparotomy and adhesiolysis. Which of the
following statements regarding nutrition in the post-operative period
for this patient is true?
Questions 13
Fig. 5
14 Pre-NEET Surgery
a. Aspirin
b. -blocker
c. Nissen fundoplication
d. Omeprazole
48. A 43-year-old woman presents to the ED with acute onset of severe
right upper quardrant abdominal pain that radiates to the infra-scapular
region. The patient complains of nausea and vomiting that
accompanies the pain. At presentation, her temperature is 101.2F,
blood pressure is 144/88 mm Hg, heart rate is 76/min, respiratory
rate is 14/min. Abdominal examination is significant for right upper
quadrant tenderness along with guarding and cessation of inspired
breath on deep palpation of the right upper quadrant. Which test should
be ordered first to work-up this patient?
a. Abdominal ultrasound
b. CT scan of the abdomen
c. Hepato-iminodiacetic acid scan
d. MRI of the abdomen
49. A child is brought to his pediatrician for evaluation of a rash, as
shown in the image. The child has had recurrent episodes with this
skin irritation, which appears to be non painful and non pruritic, and
has not spread to other regions of the body. The boys mother notes
that the lesions are weepy and ooze fluid that forms golden-colored
crusts over the affected skin. The patient has mild local
lymphadenopathy but no constitutional symptoms. Which is the most
appropriate treatment for this patient?
Fig. 6
Questions 19
a. Acyclovir
b. Hydrocortisone cream
c. Intravenous vancomycin
d. Topical murpirocin
50. A 22- year old man is stabbed in the right chest with a 5 cm long
knife blade. On arrival at the emergency department, he is wide awake
and alert. He is speaking with a normal tone of voice but complaining
of shortness of breath. The right hemithorax is hyperresonant to
percussion and has no breath sounds, the rest of the initial survey is
negative. His blood pressure is 110/75 mm Hg. pulse is 86/min. and
venours pressure is 3 cm H20. pulse oximetry shows a saturation of
85% which of the following is the most appropriate next step in patient
care?
a. Infusion of 2 L Ringers lactate
b. Securing an airway by orotracheal intubation
c. Immediate insertion of a needle into the right pleural space
d. Chest x-ray and insertion of a chest tube
51. A 35 year old man comes to the physician because of persistent
dull perineal pain and dysuria for 6 months the patient denies urinary
tract infections or urethral discharge. His temperature is 37 degrees.
On digital rectal examination the prostate is slightly tender and boggy
but not enlarged or indurated. Urinalysis is normal expressed prostatic
secretions show the following.
Leukocytes 30 cells/high power field
Becteria none
Cultures of prostatic secretion and urine are negative for bacteria.
Which of the following is the most likely diagnosis?
a. Acute cystitis
b. Acute prostatitis
c. Chronic bacterial prostatitis
d. Chronic non- bacterial prostatitis
52. An otherwise healthy 28 year old comes to his physician because
of painless enlargement of the right testis he began to feel a sensation
of heaviness in the right hemiscrotum approximately 6 months ago
physical examination reveals diffuse enlargement of the right testis,
but it is difficult to determine whether this is due to an intratesticular
20 Pre-NEET Surgery
53. 19 year old gang member is shot in the abdomen with 0.38 caliber
revolver. The entry would is in the epigastrium, to the left of the midine
the bullet is lodged in the psoas muscle on the right he is
hemodynamically stable and the abdomen is moderately tender. which
of the following is the most important step in diagnosis?
a. Close clinical observation
b. Emergency ultrasound
c. CT scan of the abdomen
d. Exploratory laparotomy
a. Myocardial contusion
b. Pulmonary contusion
c. Tension pneumothorax
d. Traumatic rupture of the aorta
56. Renal ultrasound and intravenous pyelography (IVP) in a 65-year-
old man evaluated for urinary incontinence reveals bilateral
hydronephrosis. Which of the following is the most likely condition
leading to (his complication)?
a. Age-associated detrusor overactivity
b. Alzheimer disease
c. Normal pressure hydrocephalus
d. Prostatic hyperplasia
57. A 57-year-old man is undergoing femoral popliteal bypass of his
right lower extremity because of severe peripheral vascular disease.
This patient has a long-standing history of claudication and shortness
of breath. He had a myocardial infarction 3 years ago and has had
progressive limitation of his exercise capacity because of his peripheral
vascular disease. Two weeks ago, he underwent lower extremity arterial
study that shoved severe diffuse disease of his right leg arterial system.
The patient is brought to the operating room, and during the procedure,
his right lower extremity is made blood-less by application of a thigh
tourniquet-for 1.5 hours. The surgeons complete their bypass and are
preparing to restore blood flow. Which of the following is an expected
consequence of this maneuver?
a. Decrease in blood pressure
b. Increase in cardiac output
c. Increase in preload
d. Increase in venous return
58. A 31 year old man is brought in the emergency department after
a motor vehicle accident. He has severe head injury and, on arrival
to the emergency department, has a Glassgow score of 8. His blood
pressure is stable and an urgent CT scan of the head reveals a large
subdural bleed with evidence of a middle shift. The patient is breathing
spontaneously without any respiratory assistance and is not intubated.
Which of the following is the most appropriate next step in
management?
22 Pre-NEET Surgery
a. Administer IV mannitol
b. Perform endotracheal intubation and hyperventilation
c. Induce a barbiturate coma
d. Initiate immediate surgical decompression
60. A 25 year old man is shot with a 0.22 caliber revolver. The entrance
wound is in the anterior lateral aspect of this thigh, and the bullet is
seen on x-ray films to be embedded in the muscles postero-lateral to
the femur. The emergency department physician cleans the wound
thoroughly which of the following is the most appropriate next step in
management?
a. Tetanus prophylaxis
b. Doppler studies
c. Arteriogram
d. Surgical exploration of the femoral vessels
61. A patient sustained third degree burns on both his arms when his
shirt caught on fire while he was lighting the backyard barbecue. The
burned areas are dry, white, leathery, anaesthetic and circumferential
around the arms and forearms which of the following parameters
should be very closely monitored?
a. Blood gases
b. Body weight
c. Carboxy hemoglobin levels
d. Peripheral pulses and capillary filling
Questions 23
65. A young man is shot in the upper part of the neck with a .22
caliber revolver. Inspection of the entrance and exit wounds indicates
that the trajectory of the bullet is above the level of the angle of the
mandible, but below the skull. He is fully conscious and neurologically
intact. A steady trickle of blood flows from both wounds, and it does
not seem to respond to local pressure. He is hemodynamically stable.
Which of the following is the most appropriate next step in diagnosis?
a. Continued clinical observation
b. Barium swallow
c. Arteriogram
d. Surgical exploration
66. A 61-year-old man with severe-three-vessel coronary disease and
diabetes is scheduled for abdominal surgery. The patient has a long
history of coronary disease and had a q-wave myocardial infarction 2
years ago. He has had type 1 diabetes mellitus for 12 years. His
medications include atenolol, insulin, and captopril. His last
hemoglobin A1c 3 months ago was 9,2%., Which of the following is
the most predictive of a peri-operative complication in this patient?
a. Poor exercise tolerance
b. Premature ventricular contractions (PVCs) on ECG
c. Recent myocardial infarction (Mi)
d. Recent shortness of breath
67. In the first postoperative day utter an open abdominal procedure,
a patient develops a temperature of 102 degrees F. He is encouraged
to ambulate, cough, and breathe deeply, but he is noncompliant. On
the second day, he is still febrile. Incentive spirometry and postural
drainage are instituted, but his participation is less than enthusiastic.
He lies in bed all day and hardly moves. By the third day, he is still
spiking fevers in the same range. Although efforts to improve his
ventilation continue, resolution of his problem will most likely require
which of the following?
a. Dopper studies of lower limb of deep kg and pelvic veins
b. Urinalysis, urinary cultures, and appropriate antibiotics
c. Chest x-ray, sputum cultures, and appropriate antibiotics
d. Cultures of his wound and wound opening if needed
Questions 25
68. 18-year-old man was traveling at a high speed when his car
slammed into a wall. He is brought into the emergency department by
ambulance. His blood pressure is 60/40 mm Hg, pulse is 95/min and
weak, RR is are 18/min, and central venous pressure is 2 cm H2O. He
is responsive only to painful stimuli. Breath sounds are equal bilaterally,
and cardiac auscultation reveals only tachycardia. The abdomen is
soft, non distended, and non tender with active bowel sounds. A chest
x-ray film shows a widened mediastinum. Which of the following is
the most likely diagnosis?
a. Cardiac tamponade
b. Flail chest
c. Ruptured thoracic aorta
d. Tension pneumothorax
72. The patient receives parental meperidine for pain and undergoes
appropriate diagnostic investigations. A. 0.5- cm stone is visualized in
the right ureter at the level of the vesicoureteral junction. The patent is
discharged with the advice to drink large amounts of fluids. The next
day, the patient returns to the emergency department with the same
symptomatology. He says that he did not pass the stone, and that the
pain recurred a few hours following the meperidine injection. Which
of the following is the most appropriate next step in management?
a. Conservative management with pain-medication
b. Aggressive diuretic treatment
c. Extracorporeal shock wave lithotripsy
d. Ureteroscopic stone extraction
Fig. 7
30 Pre-NEET Surgery
Fig. 8
Fig. 9
Questions 31
88. A 42 year old lady complains of left breast discomfort for several
months. The pain is aggravated before the menses and a week back
she noted a lump in the left breast. On examination there is diffuse
nodularity present in both the breasts and a small lump is palpable in
the left breast. An USG of the patient reveals diffuse nodularity of the
breast with a small cystic lesion. The cyst disappears after aspiration
and reveals greenish fluid. The follow up of the patient should include
a. MRI
b. Oral Contraceptives
c. observation with follow-up mammogram
d. Oral antibiotics
32 Pre-NEET Surgery
Fig. 10
34 Pre-NEET Surgery
Fig. 11
Questions 37
126. Which is the best way to get bile drainage in donor liver?
a. Donor bile duct with receipient bile duct
b. Donor bile duct with duodenum of recipient
c. Donor bile duct with jejunum of recipient
d. External drainage
127. Which of the following variable is not there in TRISS score
a. RTS
b. AGE
c. ISS
d. AIS
128. PCNL was done b/l at the site of 11th RIB. Most common
complication in this case would be
a. Pleural injury
b. Hematuria
c. Residual stone remnants
d. Damage to colon
129. A trauma patient with a closed head injury is admitted in the
neurosurgical ICU. His ICP measurement is seen to rise precipitously.
An acute increase in intracranial pressure is characterized by which of
the following clinical findings?
a. Respiratory irregularities
b. Decreased blood pressure
c. Tachycardia
d. Papilledema
130. A patient who has had angina as well as claudication reports
feeling light-headed on exertion, especially when lifting and working
with his arms. The subclavian steal syndrome is associated with which
of the following hemodynamic abnormalities?
a. Antegrade flow through a vertebral artery
b. Venous congestion of the upper extremities
c. Occlusion of the vertebral artery
d. Occlusion of the subclavian artery
42 Pre-NEET Surgery
146. A 32 year old man sustains a gunshot wound to the left buttock.
He is hemodynamically stable and there is no exit wound. An x-ray of
the abdomen shows the bullet to be located in the right lower quadrant.
Which of the following is most appropriate in the management of his
suspected rectal injury?
a. Barium studies of the colon and rectum
b. Endoscopy of the bullet track
c. Angiography
d. Sigmoidoscopy in the emergency room
147. A 24-year-old fire fighter sustains 30% TBSA burns to his torso,
face, and extremities. His wounds are treated topically with silver
nitrate. Which of the following complications is associated with use of
this agent?
a. Hypernatremia
b. Metabolic acidosis
c. Hyperchloremia
d. Methemoglobinemia
ANSWERS
Relative Contraindications
1. Collagen vascular disease is a relative contraindication to breast
conservation treatment because published reports indicate that
such patients tolerate irradiation poorly
2. Large tumor to breast ratio
3. The answer is b. (Bailey 25th edition) Buergers disease
(Thromboangiitis obliterans)
Age young men below 40 years of age, with history of smoking.
It characteristically involves small and medium sized arteries
(plantars, tibial, radial). Both upper and lower extremities are
affected. Lower extremity is more commonly involved
It is the inflammatory reaction in arterial wall with involvement of
neighboring vein and nerve.
Patient complains of claudication and presents with dry gangrene
Management involves smoking cessation and conservative
amputation. Sympathectomy provides temporary relief and is
contraindicated in intermittent claudication.
4. The answer is c. This is a classic description of nodular basal
cell carcinoma (BCC). BCC is usually described as a pearly,
telangiectatic nodular lesion with rolled borders.
Major risk factors are childhood sun exposure, fair skin, chronic
dermatitis, and xeroderma pigmentosum.
BCC is usually very slow-growing, but can result in extensive
destruction of local tissues and extension into the central nervous
system if untreated.
50 Pre-NEET Surgery
Penile urethra rupture occurs following a crush injury. Urine will flow
into the deep fascia of Buck within the penis.
Superior bladder wall rupture, also called dome rupture, is caused by
forceful compression of a full bladder. This form of bladder rupture
causes urine to flow into the peritoneal cavity.
Urethral rupture above the urogenital diaphragm (at the junction of
the prostatic and membranous urethra) due to a fractured pelvis or
improper catheter insertion causes urine to flow into the retropubic
space. On examination, there is blood at the tip of the meatus and
DRE reveals a high-riding prostate.
16. The answer is a. This patient presents with chronic diarrhea,
intermittent facial flushing, and a murmur consistent with tricuspid
stenosis, a triad of findings classic for carcinoid tumor. Carcinoid tumor
in the GIT most commonly occurs in the distal part of ileum followed
by the appendix. Carcinoid tumor secretes setetonin which causes
vasoactive responses such as those mentioned. Electron microscopy
reveals salt and pepper granlutation of cells, consistent with their
neuroendoctrine origin. Elevated urinary 5-HIAA is diagnostic.
Carcinooid tumors can also be found in the rectum but not as frequently
as the distal ileum and appendix. Rectal carcinoids have a propensity
to metastatize early.
[Maingots Abdominal Operations]
17. The answer is a. (Bailey 25th edition, Smiths Urology) The
patient should undergo an intravenous pyelogram after kidney function
tests for a suspected ureteral injury. Iatrogenic ureteral injuries are
common after gynaecological and colo-rectal procedures.
Intraoperatively, intravenous administration of methylene blue or
indigocyanine green may facilitate identification of an injury. However,
delay in diagnosis is common, and patients may present with flank
pain, fevers, and signs of sepsis, ileus, or decreased urine output.
CT scan may demonstrate hydronephrosis or a fluid collection
(urinoma). Initial diagnosis and management should include urinalysis,
although hematuria may not always be present. Surgical manage-
ment should be delayed if diagnosis is late (10 to 14 days), and
operative strategy is dependent on the location of the injury. Diagnostic
imaging such as a pyelogram or nuclear medicine scan may be helpful
to identify the site of the injury.
Answers 57
18. The answer is c. (Bailey 25th edition) Bile and the fluids found
in the duodenum, jejunum, and ileum all have an electrolyte content
simi-lar to that of Ringers lactate. Saliva, gastric juice, and right colon
fluids have high K+ and low Na+ content. Pancreatic secretions are
high in bicarbonate. It is important to consider these variations in
electrolyte patterns when cal-culating replacement requirements
following gastrointestinal losses.
21. The answer is b. (Bailey 25th edition) The femoral canal contains
the deep inguinal lymph nodes and is enclosed inside the femoral
sheath with the femoral artery and vein. In a femoral hernia, this is the
potential space into which abdominal contents herniate. A mnemonic
for the contents of the femoral triangle is N(AVEL) (laterally to
medially) for Nerve, Artery, Vein, Empty space, Lymphatics.
58 Pre-NEET Surgery
early excision, including decreased hospital stay and lower cost. This
is especially true of burns encompassing within 20% of the total body
surface area. In conjunction with early excision, topical antimicrobials
such as silver sulfadiazine are extremely important in delaying
colonization of the newly excised or fresh burn wounds. The body
surface area burnt in this patient is 45%.
Meticulous attention to deep circumferential burns is racial in the
management of burn patients. Progressive tissue edema may lead to
progressive vascular and neurologic compromise. Because the blood
supply is the initial system affected, frequent assessment of flow is
vital, with longitudinal escharotomy performed at the first sign of
vascular compromise. A low threshold should be maintained in
performing an escharotomy in the setting of severely burned limbs.
31. The answer is b. (Bailey 25th edition) Patients who undergo
uncomplicated abdominal surgeries can be given enteral feeds once
bowel sounds appear. There is no need to wait for the patient to pass
feces. Parenteral nutrition should only be considered if a patient cannot
be given enteral feeds for more than 5 days.
The advantages of enteral feeding over parenteral feeding are:
a. It is physiological
b. Cheap
c. No special preparation required; no sterilisation required
d. It prevents villous atrophy, which can lead to translocation of
bacteria from the gut
e. Maintains the entero-hepatic circulation and prevents biliary stasis,
which occurs with parenteral nutrition.
32. Answer is c. (Maingots Abdominal Operations) Osteitis cystica
fibrosa is is a finding in patients with primary hyperparathyroidism and
represents sub- periosteal resorption, characteristically on the radial
aspect of the middle phalanx. This is not a reported complication after
partial gastrectomy. Patients who have undergone partial gastrectomy
may, however, have osteoporosis secondary to impaired calcium
absorption due to the Billroth II reconstruction (since calcium is normally
absorbed in the proximal intestineduodenum and jejunum). Fatty
acids may also be malabsorbed due in inadequate mixing of bile salts
and lipase with ingested fat, and therefore steatorrhea may result. Either
megaloblastic anemia due to vitamin B12 deficiency (due to lack of
intrinsic factor, which is necessary for B12 absorption and is normally
62 Pre-NEET Surgery
Contd...
Answers 63
Contd...
Selective Algorithm
Treat endoscopically
Segmented Resection
EBL
TIPS
Balloon Tamponade
Assess Patients
Candidacy for transplant
also lead to pathology that may not show up until later, such as
pulmonary contusion or myocardial contusion. The former produces
the classic white-out of the lung (contused lung is exquisitely sensitive
to fluid overload, and the fluid leaks easily) along with respiratory
distress.Myocardial contusion shows up like an infraction, both clinically
(arrhythmias) and on ECG. You would expect it in association with
sternal fractures rather than with rib fractures.
Tension pneumothorax produces shock and high central venous
pressure (CVP), along with respiratory distress, and air is seen in the
x-ray. The ultimate hidden injury in blunt, chest trauma is traumatic
rupture of the aorta . X-ray films would show widening of the
mediastinum, and the eventual clinical manifestation would be
exsanguinating hemorrhage.
56. The answer is d. (Bailey 25th edition) Prostatic hyperplasia
results in partial obstruction of the proximal urethra, causing hesitancy
and decreased force of stream. With increasing degrees of prostatic
enlargement, the volume of urine remaining in the bladder after voiding
increase progressively until complete urinary retention manifests with
occasional overflow incontinence. Urinary retention leads to dilatation
of the ureters and renal pelvis.
Age-associated detrusor overactivity is the most common cause of
urinary incontinence in the elderly. It manifests with an uncontrollable
urge to urinate not triggered by Stress maneuvers. It seems to be related
to a deficiency in the descending pathways that inhibit the voiding
reflex triggered by bladder distension. This condition does not lead to
urinary retention. Urinary incontinence associated with Alzheimer
disease and normal pressure hydrocephalus is similar to detrusor over
actvity and results from failure to inhibit the contractions of the vesical
detrusor muscle.
57. The answer is a. (Bailey 25th edition) The During vascular
procedures, the use of cross clamping and tourniquets produces
localized or regional ischemia. The consequences of ischemia include
the accumulation of metabolic waste products and acid load , which
are freely available the systemic circulation once they gain access to
it. The primary consequence of this is profound and dramatic systemic
hypotension that can be prolonged for hours after a procedure. Such
a phenomenon has obvious con sequences for management of patients
such as this man with coexisting cardiac disease.
74 Pre-NEET Surgery
Barium studies are essential when one suspects esophageal injury that
is not demonstrated by gasirografin swallow. As pointed out above,
however, that area of injury here is well above where the esophagus
begins. Surgical exploratory might be unavoidable in hemodynamically
unstable patients whose vascular injuries cannot be controlled by
arteriographic embolizalition Surgery can be performed in this area if
needed, but for technical reasons it is not our first choice of
management.
66. The answer is c. (Bailey 25th edition) There are a host of
important factors in the assessment of preoperative risk for patients
undergoing non cardiac surgical procedures criteria have been
published that aid in this stratification. One needs a very basic
understanding or important preoperative risk factors that portray a
very poor surgical outcome. any evidence of recent exacerbation of a
patients underlying coronary disease (angina, worsened or poor
baseline exercise tolerance recent infarction are major red flags that
should make the physician call into question the need for a non-
emergent procedure. Of these the one with the highest incidence of
perioperative death or cardiac event is a recent myocardial infarction.
Poor exercise tolerance certainly suggests underlying coronary disease
in this patient; but that diagnosis is already known. The critical issue is
assessing his risk of an event given his underlying condition.
Premature ventricular contractions (PVCs) on ECG are common
findings in patients with coronary disease. ECG indications of poor
risk mostly reflect an exacerbation of underlying heart disease heart
disease (ST segment depressions, new bundle branch blocks. PVCs.
However, are common even in healthy patients, and numerous clinical
trials have demonstrated that they are quite benign. Suppressing them
with medications is associated with increased mortality. Unless
tachtcardia sustained runs (ventricular tachycardia), they are not a
predictor of adverse events.
67. The answer is c. (Bailey 25th edition) Fever on first postoperative
day is almost invariably from atelectasis, the treatment of which requires
active participation and cooperation from the patient. If atelectasis
does not resolve, it leads lo he development of pneumonia, which can
be identified in chest x-ray films and confirmed with sputum cultures.
AT that time the process is no longer purely mechanical but is also
infectious, thus requiring antibiotics. Deep venous thrombosis ) occurs
78 Pre-NEET Surgery
about 5-7 days after surgery and is a hidden source of fever, i.e.
nothing else seems be wrong. This patient is clearly a candidate for
thrombosis (he lies in bed doing nothing all day) but right now his
problem is probably in the lung. The urine is a good possibility when
the fever starts on day 3, but the persistence of fever since day
1 points to the lung. Three days is too soon for a wound infection to
be the cause of the fever. Five to seven days is a more likely time
frame.
68. The answer is d. (ATLS guidelines 8th edition) This patient
experienced a severe de-acceleration injury. He is hypotensive,
tachycardic, and minimally responsive. He is in hemorrhagic shock.
The chest X-ray reveals a widening mediastinum suggesting rupture
of the thoracic aorta, which is a common catastrophic injury in
deceleration accidents. This patient is in grave danger. The treatment
is immediate surgical repair of the injury with fluid and blood
resuscitation.
Cardiac tamponade is associated with hypotension and tachycardia.
However, pulsus para- doxus (systolic blood pressure drops 10 mm
Hg on respiration) and distant heart sounds might be discovered on
physical examination, and his central venous pressure would be high.
Chest x-ray films would show an enlarged cardiac silhouette. The ECG
would exhibit low lead voltage and variable amplitude. However,
pericardtocentesis is both the diagnostic and therapeutic procedure of
choice.
69. The answer is c. (Bailey 25th edition) This man With a central
lesion, would require a pneumonectomy rather than a lobectomy.
After resectional pulmonary surgery is done, however, a patient must
be left with a least 800 ml in the FEV to live a decent life. Anything
less than that would make him a pulmonary cripple, or outright kill
him. Because of his COPD, this patient is already severely limited,
with a total FEV of 1100 ml. Were the bad lung to be removed, he
would be left with only 40% of 1100 ml 440 ml The only option left is
radiation and chemotherapy.
CT scan of the upper abdomen to rule out liver metastasis and
mediastinoscopy to biopsy carinal nodes are necessary steps to establish
curability. There is no point in doing a pneumonectomy if there are
liver or carinal node metastases.
Answers 79
Zone I
Inferior aspect of cricoid cartilage to
the thoracic outlet
Zone II
Cricoid to angle of mandible
zone III
Angle of mandible to the base of the
skull
Answers 87
91. The answer is a. (Sabiston 18th edition) (Mostly arise from 2nd
branchial arch)
The mature structures of the head and neck are embryologically
derived from six pairs of branchial arches, their intervening clefts
externally, and pouches internally. Congenital cysts, sinuses or
fistulas result from failure of these structures to regress, persisting
in an aberrant location.
By definitions, all branchial remnants are present at the time of
birth, although they may not become clinically evident until later
in life.
In children, fistulas are more common than external sinuses, which
are more common than cysts.
In adults, cysts predominate.
First branchial remnants are typically located in the front of back
of the ear, or in the upper neck in the region of the mandible.
Fistulas typically course through the parotid gland, deep, or
through branches of the faicla nerve, and end in the external
auditory canal.
Remnants from the second branchial cleft are the most common.
The external ostium of these remnants is located along the anterior
border of the SCM, usually in the upper half to lower third of the
muscle. The fistula ascends along the carotid sheath till the hyoid
bone and then traverses medially to extend between the carotid
artery bifurcation. It then courses behin the posterior belly of
digastrics and ends in the tonsillar fossa.
Third branchial cleft remnants usually do not have associated
sinuses or fistulas and are located in the suprasternal notch or
clavicular region.
All branchial anomalies should be excised early in life since
repeated infections are common and make the resection difficult
at a later stage.
92. The answer is c. (ATLS guidelines 8th edition)
There are three components of GCS:
Eye openinig
Motor response
Verbal response
Answers 89
Response Score
Eye opening
Opens eyes spontaneously 4
Opens eyes in response to speech 3
Open eyes in response to painful stimulation
(e.g. endotracheal suctioning) 2
Does not open eyes in response to any stimulation 1
Motor response
Follows commands 6
Makes localized movement in response to painful stimulation 5
Makes nonpurposeful movement in response to noxious stimulation 4
Flexes upper extremities/extends lower extremities in response to pain 3
Extends all extremities in response to pain 2
Makes no response to noxious stimuli 1
Verbal response
Is oriented to person, place, and time 5
Converses, may be confused 4
Replies with inappropriate words 3
Makes incomprehensible sounds 2
Makes no response 1
Contd...
OR
Metastases in ipsilateral supraclavicular lymph node(s) with or without
axillary or internal mammary lymph node involvement.
N3a Metastases in ipsilateral infraclavicular lymph node(s).
N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary
lymph node(s).
N3c Metastases in ipsilateral supraclavicular lymph node(s).
Treatment of DCIS
Mastectomy, Excision and radiotherapy and excision alone have all
been proposed as management strategies for DCIS. The appropriate
therapy for women with DCIS depends on the extent of the lesion,
risk of local recurrence with each form of treatment and patients
attitude towards the risk and benefits of a particular therapy.
RENAL TRAUMA
Of all the injuries to the genitourinary systems injuries to the kidney
from external trauma are the most common.
Hematoma is the best indicator of traumatic running system injury.
However, the degree of hematoma and severity of the renal injury do
not correlate consistently.
Answers 99
Trauma
Blunt Penetrating
Selective
imaging Unstable Stable
Abdominal Abdominal CT
Exploration
Following on table
Abnormal or
inconclusive
Relative Indications
Urinary extravasation
Non-Viable tissue >20%
Delayed diagnosis of arterial injury
Segmental arterial injury
Incomplete staging
112. The answer is a. (Campbell 9th edition)
Cryptorchism
Normal testicular descent is defined as testis that remains stationery
within the dependent portion of scrotum. Therefore cryptorchism is a
developmental defect in which the testis fails to descent completely in
to scrotum.
Key point
Testicular decent is normally complete between the 30th and 32nd
week of question.
Normal HPG axis is usually necessary for testicular descent.
102 Pre-NEET Surgery
Consequences
a. Infertility: Paternity significantly compromised in men with previous
B/ but not unilateral cryptorchidsm.
b. Neoplasia: The most common tumor that develops from crypt
orchid testis is seminoma.
Hernia: Patent processes vaginitis is found in more that 90% of
patients with on undescended testis.
c. Testicular torsion
HIV
Alcoholic liver disease.
Hepatolithiasis.
Diabetes Mellitus.
Cholelithiasis has minimal impact as a risk factor for cholongio-
carcinoma.
124. The answer is a. (Devita 9th edition)
Most common site of chlogiocarcinoma
Hilum 67%
Distal 2.7%
Intrahepatic 6%
Most common presentation painless jaundice 70-90%), followed by
pruritus (66%), abdominal pain, weight loss (30-50%) and fever (20%).
125. The answer is c. (SAGES manual) Classification of surgical
procedures
Predominantly malabsorptive procedures
Biliopancreatic diversion
Jejunoileal bypass
Endoluminal sleeve
Predominantly restrictive procedures
Vertical Band Gastroplasty
Adjustable gastric band
Sleeve gastrectomy
Intragastric balloon
Mixed procedures
Gastric Bypass Surgery
Sleeve gastrectomy with duodenal switch
Implantable Gastric Stimulation
126. The answer is a. (Blumgart)
may be stented with a Ttube brought out through the distal recipient
duct. The T-tube is removed 3 months later, after a normal
cholangiogram has been obtained. Many surgeons no longer use
T-tubes routinely. Less commonly,If there is a major size discrepancy
between the donor and recipient ducts, or if the recipient bile duct is
diseased (as in PSC) or too small (as in pediatric cases), a choledochoje-
junostomy is performed. The duct is anastomosed to a Roux-en-Y
limb of jejunum using a stented end-to-side technique.
127. The answer is d. (Trauma care) RTS, ISS, AGE are included
in TRISS
TRISS The international golden standard for severity scoring and
probability of survival (Ps) calculation is the TRAUMA AND INJURY
SEVERITY SCORE/ TRISS. TRISS is a composite calculator based
on anatomical and physiological severity indicators. For TRISS
operation , the RTS parameters(RR, BP, GCS) are vected, vectors
being deducted by logistic regression analysis on large US trauma
databases
RTS(vected) = 0.9386(GCS CODE) + 0.7326(BP code)+ 0.2908(RR
code).RTS can thus take on values from 0 to 7.848
TRISS is based on a probability distribution: Ps=1/(1+e)^ (-b)
The value b is set by the regression equation b= b0 +b1(RTS)+b2(
ISS) + b3(AGE). AGE is defined as a dichotomy vaiable: (AGE
<55yrs)= 0: ( AGE > 55yrears)= 1. THE value b is set separately
for blunt and penetrating injury.
128. The answer is a. (Smith's Urology) Compliation of PCNL
The most common complication of PCNL is bleeding. Others are
extavasation, inadvertent perforation of collecting system, incomplete
stone removal and sepsis. But in few cases to approach upper calyceal
stones 11th rib approach is employed in thoses cases pleural injury in
the form hydrothorax or pneumothorax is more common.
1. Bleeding venous bleeding is most common, it can be managed
by clamping the nephrostomy tube for 30 to45 min. arterial
bleeding is more serious prolem, can occur either preoperative or
in postoperative period.
2. Extravasation- normal saline should be used as the irrigation fluid
to minimize adverse effect if extravasation occurs..
108 Pre-NEET Surgery
133. The answer is d. (ATLS guidelines) At one time all full thickness
burns were allowed to heal by granulation over a period of 2-3 weeks,
before skin grafting was done. The area was kept free of bacteria by
the use of topical agents . the current preference is to do early excision
and grafting of burned areas that appear to be full thickness, if they
are not extensive. Best time of this is within 3-5 days and it should not
be delayed beyond 10 days. Debridement is often indicated in the
long term preparation of the area to be grafted but wet to dry dressing
would be less effective than antibacterial agents. Mafenide is used in
areas where deep penetration is needed, otherwise its not a first choice
as its application is painful and can produce acidosis.
134. The answer is c. (Devita) The most common procedure today
for treatment of localized renal carcinoma greater than 4 cm is radical
nephrectomy . Radical nephrectomy includes complete removal of
Gerotas fascia and its contents, including the kidney and the adrenal
gland, and provides a better surgical margin than simple removal of
the kidney. Many clinicians believe that in view of the rarity of ipsilateral
adrenal metastasis and the potential morbidity associated with
adrenalectomy, a macroscopically normal ipsilateral adrenal gland
should not be removed with the kidney when the tumor is in the lower
pole of the kidney The treatment of patients with either bilateral renal
110 Pre-NEET Surgery
hrs after an elective operation has been completed and this practice
should be avoided to prevent increasing microbial drug resistance.
Broad-spectrum antibiotic coverage, including against anaerobic
organisms, is required only in cases where such flora are anticipated,
such as during colon resections; otherwise cefazolin is the antibiotic of
choice for cases requiring antibiotic prophylaxis.
144. The answer is c. (Schwartz)
Heparin induced thrombocytopenia (HIT), which is a complication
of heparin therapy, at both prophylactic and therapeutic doses of
heparin, is mediated by antibodies to the complexes formed by binding
of heparin to platelet factor 4 in a pre-viously unexposed patient. HIT
typically manifests after five days as a decrease in platelet counts by
50% of the highest preceding value or to a level less than 100.000/
mm3. Complications of HIT are related to venous and/or arterial
thromboembolic phenomena. Treatment of HIT consists of cessation
of heparin (including low-molecular weight heparins) and institution
of a non- heparin anticoagulant such Lepirudin and conversion to
oral warfarin when appropriate. Cessation of heparin alone is
inadequate to prevent thromboembolic complications, and warfarin
should not be .started until the platelet count is above 100,000/cumm.
Platelet transfusion is not indicated, as HIT results in thrombotic rather
than hemorrhagic complication.
145. The answer is a. (Sabiston 19th edition, Robbins)
Glioblastoma multiforme is the most common form of primary
intracranial neuro-epithelial tumor. It is a heterogeneous glial cell tumor
derived from the malignant degeneration of an astrocytoma or
anaplastic astrocytoma. These tumors are most com-monly found in
the cerebral hemispheres during the fifth decade of life. CT and MRI
scans typically reveal an irregular lesion with hypodense central
necrosis, peripheral ring enhancement of the highly cellular tumor
tissue, and surrounding edema and mass effect. Curative resections
are rare. Therapy consists of surgical resection followed by external
beam radiation. The course of the disease progresses rapidly after
presentation, with median survival being one year.
146. The answer is d. (Sabiston 19th edition)
Penetrating injury to the intra-peritoneal or extra-peritoneal rectum
should be diagnosed by immediate sigmoidoscopy. Contrast studies
114 Pre-NEET Surgery