Solved University SEQ (General Surgery) for MBBS and BDS

SEQ.1 A 25 years old poultry form worker is brought with inability to open his mouth for last three days. He had injury on his right foot ten days ago but kept working bare footed in farm without treatment. a) What is the diagnosis on high index of suspicion? b) Outline the management plan with prognosis? Key: 1 a) Tetanus

b) Management Plan: Isolation, quietness and comfort, drainage of pus and wound toilet will be needed. Human anti-tetanus globulin is given intramuscularly to limit the effects of free toxins and should be used in doses of 25500 units to give cover throughout the period of establishing active immunity by giving toxoid. A seriously ill patient, with dysphagia and reflex spasm, will need to have a nasogastric tube passed and seda-tion continued. The diet, the need for intravenous nutrition, the maintenance of balanced protein intake, and of renal function and cardiac function will be priorities. A tracheosto-my should be considered if the patient has any difficulty in breathing. The meticulous care of the tracheostomy tube includes suction and humidification Prognosis 30-40 % mortality in moderate to severe disease SEQ.2 A 15 years old school girl presents with 2x2 cm nodule on her left supraclavicular region for the last four months. She is having sweats at night and her sputum contains blood. She has lost about 10% of her body weight meanwhile. a) What is the likely disease causing swelling in her neck? b) How will you investigate her problem? Enumerate the necessary ones only. c) Name three components of management? Key: 2 a) Tuberculosis lymphadenitis (cold Abscess) b) Sputum for AFB and malignant cell, X-Ray chest, FNAC or Excision biopsy swelling, ESR, Base line Liver function test and ophthalmoscopy d) confirmation of diseases, Nutrition and hygiene, Antituberculosis Drugs , Follow up to see response and any side effects of drugs

SEQ. 3 A 40 years old garment factory worker reports with 1x1 cm ulcer on right side of her oral cavity since two months. She is a habitual of pan eater. She also notices a 0 .5xo.5 cm nodule on upper part of neck on same side. The surgeon examines and advises. a) What is his main suspicion b) Why has he come to this conclusion c) How should he proceed scientifically for the best results of treatment Key: 3 a) Carcinoma of oral cavity b) because the ulcer has enlarged neck node and she has risk factor of pan eating c) Incisional biopsy of the ulcer, FNAC of cervical nodule, CT scans Head and Neck, MRI, USG abdomen, SEQ.4 Six days after exploratory laparotomy for perforated appendix, 50 years old diabetic lady with moon face, looks toxic and has gangrene developing around her abdominal wound. As attending surgeon a) What is your main concern regarding the illness b) Your diagnosis is further strengthened by the presence of which specific features c) In few words outline the management Key 4 a) Synergistic gangrene with septicemia b) Diabetes mellitus, cushion syndrome, old age lady c) Broad spectrum antibiotics (Benzyl penicillin, Metronidazole, Gentamycin ) Debridement of wound, control of blood sugar, monitoring of vital sign and intake and Output charting, Blood transfusion, secondary wound closure or skin cover by grafting is Only attempted after infection has been completely eradicated and health granulation Tissue has formed. SEQ.5 A 77 years old house wife presents with 5x5 cm swelling on right side of neck which moves with deglutition .she has a normal voice and some difficulty in swallowing. Her pulse is 78 per minutes. She is not using any drugs. a) What investigations you will ask for in this patient

b) What diagnosis on one investigation can lead to suggestion of an operation c) Name three complications which can result from operation for this problem Key 5 a) Thyroid function test, FNAC, Indirect laryngoscopy, X-Rays thorax inlet b) If FNAC swelling shows malignancy C) Hypothyroidism, hypoparathyroidism, injury to recurrent laryngeal nerve, recurrence of Disease, hemorrhage (primary or reactionary) SEQ. 6 for reducing the infection rate in Operation Theater, the hospital infection control committee has given six point instructions for all to observe. Please reproduce them here Key 6 1) 2) 3) 4) 5) 6) 7) 8) proper scrubbing proper gowning and gloving reduce inappropriate movement in theater and reduce too many people in theater Reduce contaminations of instruments by unscrubbed persons. ventilatory system should be laminar air flow Proper skin preparation 7) proper draping 8) follow the universal precaution

SEQ. 7 A 35 years old school teacher comes to surgical outpatient department with a uniform swelling of 6x6 cm in front of neck. She has prominent eyes. Her pulse is 120/min. she is not using any medications. a) Enumerate the clinical tests to complete your evaluation b) Enlist the investigations in order of priority c) Give immediate management in maximum of six lines Key 7 a) Inspection of swelling, palpation of swelling, percussion and auscultation Eye signs, pulse, tremor, reflexes b) Thyroid function test, thyroid antibodies, Thyroid Scan c) Tab propranolol Tab Neomercazole

Lugols Iodine SEQ. 8 A 12 years old school boy comes with a bluish swelling 2x2 cm in size lifting his tongue upward and on left side. On examination it feels soft. a) What is your likely diagnosis with closet differential diagnosis with some points b) How will you treat this case Key 8 a) Ranula. Differential diagnosis is hemangioma, lymphangioma (undersurface of tongue) as Both are cystic and compressible, sublingual dermoid cyst, mucous retention cyst, tumor of sublingual gland is firm in consistency b) Excision of the sublingual gland or Marsupialization of the swelling SEQ.9 A 35 year old shopkeepers presents with discharging point on his right cheek a) What will be essential clinical examination in this case b) How will you proceed with the most appropriate treatment Key 9 a) The clinical examination consist of inspection (number, position, opening of sinus or fistula, discharge and surrounding skin) palpation (tenderness, wall of sinus, mobility and lump) examination with probe and examination of oral cavity and draining lymph nodes b) First confirm the diagnosis by relevant investigation, cytology and culture of discharge, sinogram or fistulogram, MRI Treatment according to the diagnosis, osteomyelitis, parotid fistula, actinomycosis, sebaceous cyst, and tuberculosis sinus SEQ.10 A 13 years old school boy brought after a highway traffic accident three hours ago. He bears an abrasion and bruise on right upper quadrant of abdomen. He has a pulse of 100/min and blood pressure of 100/60 mm Hg, complains of pain in abdomen. He narrates the whole story of accident a) What will you immediately do b) What will be your next step c) Outline the subsequent management plan

Key 10 a) Primary survey and resuscitation consists of assessment of airway with control of airway. Assessment of breathing and maintenance of circulation with crystalloid fluid,

appropriate analgesia, antibiotics and tetanus toxoid. Intake and output charting by indwelling follys catheter. Secondary survey and thorough examination of abdomen b) Next step is if patient vitally stable then request for relevant investigations, USG abdomen, Radiograph chest and abdomen, CT scan if needed, base line investigations, screened cross matched blood c) Management plan is according to the status of patient Monitoring of the vital sign pulse, temperature, respiratory rate, blood pressure Measurement of abdominal girth hourly, serial examinations of abdomen for Increasing tenderness or guarding or absence of bowel sounds and any signs of internal Bleeding, Keep nil per oral, Pass Nasogastric tube for aspiration and follys catheter for Urine output, intravenous fluids, analgesia and antibiotics. Local management of Abrasion if response to conservative treatment then continues the treatment. If Deterioration occurs then surgical intervention in the form of exploratory laparotomy i Needed. SEQ. 11 In May, A 20 year old student complains of pain in his right axilla for five days. On examination his axilla shows redness and is tender over 3x3cm area. a) What is your suspicion b) Give a sketch to manage his problem Key 11 a) Hydradenitis suppurativa b) A course of metronidazole, prolonged course of Erythromycin, avoid deodorant in axilla Keep axilla hygienically good, if the condition does not respond, then surgical excision is necessary. If a wide area of skin needs to be removed, the wound needs to be covered by a splitskin graft. SEQ. 12 A 24 years old newlywed woman comes with a firm swelling on her left supraclavicular fossa. She complains of numbness and weakness during washing of clothes. On examination this side pulse is weaker than on right side. On x-Rays chest, surgeon has discovered the cause of her problem and advised treatment. a) what the surgeon has discovered on x-rays b) What is the treatment advised and how should he proceed

Key 12 a) Cervical Rib on left side

b) Before surgery nerve conduction study, duplex scan subclavian artery or angiography is needed. The rib should be excised with periosteum otherwise it will regenerate Extraperiosteal excision of the cervical rib together with any bony prominence from the first rib.

SEQ. 13 A 55 years old farmer comes with history of swelling around left ear for the last ten years. It has recently increased in size up to 8x8 cm and he is unable to close his left eye a) What is your spot diagnosis b) What will you do to complete your clinical examination c) Outline the management plan in six lines

Key 13 a) Carcinoma left parotid gland with facial nerve involvement b) Examination of the whole parotid gland including inspection, bimanual palpation, Bidigital examination of duct, examination of facial nerve, temporomandibular joins And regional lymph nodes C) Confirmation of the diagnosis by FNAC of swelling, CT scans Head, Neck and face, MRI X-Ray chest, USG abdomen, after counselling the patient and taking consent the Radical parotidectomy with neck dissection is performed SEQ. 14 In September there is new epidemic of disease characterized by patients complaining of fever with rigors, headache and body aches. On examination, many patient show hemorrhagic small spots on their body. a) What is your most likely diagnosis b) Name two pathogenic elements in spread of this illness c) Suggest in few lines measures limit the spread of this disease Key 14

a) Dengue fever b) Aedes aegypti mosquitoes, ticks, infected blood products and organ transplantation, mother to child c) (1) Advocacy, social mobilization and legislation to ensure that public health bodies and communities are strengthened, (2) Collaboration between the health and other sectors (public and private), (3) An integrated approach to disease control to maximize use of resources, (4) evidence-based decision making to ensure any interventions is targeted appropriately (5) capacity-building to ensure an adequate response to the local situation

The primary method of controlling A. aegypti is by eliminating its habitats. This is done by emptying containers of water or by adding insecticides or biological control agents to these areas Reducing open collections of water through environmental modification is the preferred method of control; People can prevent mosquito bites by wearing clothing that fully covers the skin, using mosquito netting while resting, and/or the application of insect repellent

SEQ. 15 A 70 years old elder from tribal areas of Pakistan has a non-healing 1.5x1.5 cm ulcer on his right cheek for the last one year. On examination, the ulcer has rolled up margins with no evidence of any swelling in rest of his head and neck. a) Name two main suspicions keeping a high index b) Give management plan of diseases you favor with reference to any latest development in this field Key 15 a) b) Basal cell carcinoma, squamous cell carcinoma wide local excision of lesion or Radiotherapy

Latest development is Mohs Micrographic surgery SEQ.16 A 12 years old school boy is brought to emergency after a road traffic accident twenty minutes earlier. He has a laceration on his forehead, bleeding. He is fully conscience. a) What will be your first step b) In three lines give next plan c) Enlist definite management plan Key 16 a) Primary survey and resuscitation, airway, breathing and circulation. In this patient the first step is to stop the bleeding by pressure dressing. b) secondary survey , x-rays skull and neck to rule out skull fracture and cervical spine injury, Primary suturing of laceration c) appropriate analgesia and antibiotics , tetanus toxoid, primary suturing of lacerated wound with proline under aseptic measures , monitoring of the patient with Glasgow coma scale and follow up after 5 days for the examination of wound and stich removal SEQ. 17 A six years old girl is in outpatient department with discharging sinus of right side of neck just anterior to anterior border of sternocleidomastoid muscle since birth a) What is the most likely diagnosis b) Name most relevant investigation c) Suggest appropriate definite treatment

Key 17 a) Branchial sinus / fistula b) Sinogram / fistulogram, MRI c) Complete excision of sinus/ fistula tract by more than one transverse incision in neck under general anaesthesia SEQ.18 A 60 years old farmer complains of non-healing ulcer on his lower lip for the last four months. He has also observed 1x1 cm swelling on left side of neck. a) What is the most likely diagnosis with high index of suspicion b) Give two necessary investigation to reach diagnosis and design management c) Enumerate management options Key 18

a) Squamous cell carcinoma lower lip b) incision biopsy of lip ulcer, FNAC neck swelling, CT scan Head neck and chest c) Both surgery and radiotherapy are frequently employed and are highly effective methods of treatment, each giving cure rates of about 90 per cent. Small tumors: Up to one-third of the lower lip can be removed with a V or W-shaped excision with primary closure this method is suitable for tumor up to 2 cm in diameter. The residual defect is reconstructed by approximating and suturing the borders in three layers; mucosa, muscle and skin. Particular attention should be paid to the correct alignment of the vermilion junction. This simple procedure can readily be performed under local anaesthetic on an outpatient basis. Initially the lip will appear tight, but this improves after about 3 months. Intermediate Tumors: Larger tumors, which produce defects of between one-third and Two-thirds the size of the lower lip, require local aps for reconstruction. V or W excision will result in microstomia. Large central defects are best managed using the Johansen step technique This allows closure of the defect by symmetrical advancement of soft-tissue aps, utilizing the excess skin in the labio-mental grooves. Alternative techniques include the Bernard rotational ap. Total lip reconstruction Extensive tumors of the lower lip, which invade adjacent tissues (T4), have a high incidence of neck node metastasis. Patients with such advanced disease require surgery that may include Unilateral or bilateral selective neck dissection and total excision of the lower lip and chin. The lower lip defect is best reconstructed with a forearm ap SEQ. 19 Give a brief account of risk factors which make a wound more prone to infection. Key 19 Factors inuencing healing of a wound Site of the wound Structures involved Mechanism of wounding, Incision, Crush, Crush avulsion Contamination (foreign bodies/bacteria) Loss of tissue other local factors, Vascular insufciency (arterial or venous), Previous radiation, Pressure Systemic factors, Malnutrition or vitamin and mineral deciencies, Disease (e.g. diabetes mellitus), Medications (e.g. steroids), Immune deciencies [e.g. chemotherapy, acquired immunodeciency syndrome (AIDS), Smoking

SEQ. 20 A 18 years old club cricketer is disturbed by slowing increasing swelling under his tongue. On examination this looks blue and more prominent on right side and is fluctuant with little displacement of his tongue. This problem is observed for the last six months. a) What is the most likely diagnosis with one differential diagnosis b) Give four lines on management options Key 20 a) Ranula. Differential diagnosis is retention mucous cyst or tumor minor salivary gland b) Marsupialization of cyst Excision of cyst Excision of cyst and underlying sublingual gland Sometimes spontaneously disappear Never perform incision and drainage as recurrence is common SEQ. 21 A 25 years old house wife has noticed a 1x1.5 cm swelling on back of her neck for last one week. This is painful to touch. She also complains of discomfort during combing of her hair. a) What is the diagnosis b) How will you manage Key 21 a) sebaceous cyst b) excision of the cyst under local anaesthesia if abscess has formed in cyst then first incision and drainage is performed then later Excision of the cyst is performed. SEQ. 22 A 70 years old diabetic lady has presented with swelling of her right arm after an act of prolonged itching. Her arm is red and painful. She has fever with chills. a) What is the diagnosis b) What are the components of management? Key 22 a) cellulitis of right arm b) Appropriate Antibiotics

Enumerate

Proper analgesia Rest of arm Icing Elevation of right limb Compression with elastic bandage SEQ. 23 A 30 years old motor mechanic is worried by weight loss for last ten months. He has increased appetite, anxious and disturbed by hand tremors. On examination his pulse is 115/min. There is visible prominence in front of neck with staring gaze. a) What is the diagnosis b) Enlist necessary investigations c) Give three management options Key 23 a) Thyrotoxicosis b) Thyroid function test (T3, T4, TSH), thyroid antibodies, Thyroid scan c) Antithyroid drugs, Beta Blockers , Radioactive iodine , Thyroidectomy SEQ. 24 After getting a multivitamin injection on her left upper arm, this 40 year old house maid comes with painful swelling of left upper arm for last two weeks. She has fever with rigors. The swelling is 8x8 cm red hot, tender and fluctuant. a) What is the clinical diagnosis b) Outline the best option to manage c) Name important investigation which can bring complete resolution of problem Key 24 a) Injection Abscess left arm b) incision and drainage of abscess with secondary wound heeling c) pus for culture and sensitivity, biopsy of wall of abscess cavity, x-rays left arm to rule out osteomyelitis SEQ. 25 A 25 years old office clerk complains of pain and fatigue of his right hand after a prolonged desk work. On examination his right radial pulse is weaker than left. There is firm prominence on right supraclavicular fossa. a) What is the most likely clinical diagnosis b) Which simple routine investigation can give support to your diagnosis c) Outline the treatment

Key 25 a) symptomatic right cervical rib b) X-Rays cervical spine and chest c) Extraperiosteal excision of the cervical rib together with any bony prominence from the first rib SEQ. 26 A 60 years old shopkeeper comes to outpatient department with 10x10 cm swelling of left side of face below and in front of left ear for last 15 years. There has been recent increase in size. a) What is the clinical diagnosis b) Which clinical examination is mandatory in this case c) Give few line on management Key 26 a) Pleomorphic adenoma left parotid gland probably malignant change has occurred b) Facial Nerve examination, bimanual examination of parotid gland and examination of neck lymph nodes c) After the confirmation of diagnosis with FNAC and CT or MRI scan superficial left parotidectomy with preservation of facial nerve if it is benign otherwise in case of malignancy radical parotidectomy with resection of nerve trunk and radical neck dissection accordingly SEQ.27 A 65 years old bus accident victim is brought to emergency one week after the accident. His initial care was done by family at home. He is toxic looking with temperature 101F. His injured right leg is swollen, tender and discolored. On examination a crepitus is discovered. a) What is your clinical diagnosis b) Which simple investigation will clinch the diagnosis c) Enlist the treatment options in three lines Key 27 a) gas gangrene right leg b) X-Rays right leg will show subcutaneus gas c) Treatment, to be effective, requires immediate action: Maximum doses of penicillin (up to 2.4 g 4-hourly) or clindamycin and metronidazole, blood transfusion. Either exposure of all the affected muscle groups by long incisions or, in the subcutaneous infections, multiple subcutaneous drainage and slough extraction by incisions into the subcutaneous tissue. Hyperbaric oxygen where this is available. It is said to be helpful in the postoperative period.

The use of antiserum used to be recommended, but clinical experience was variable SEQ. 28 Grandfather of 75 years is losing weight over the past four months due to increasing difficulty to swallow solid food. He has noticed a small 1x1cm firm swelling in his left supraclavicular fossa. a) What is your suspicion on priory and its basis b) Which investigation specific to problem will be your choice? name three only c) How will you counsel the patient and family about management options Key 28 a) carcinoma esophagus as he has dysphagia, weight loss and supraclavicular lymph node b) barium swallows, endoscopy , CT scan Neck chest and upper abdomen c) the patient and the family will be counselled about the management according to the stage of disease and operability, resectability of tumor and site of tumor. Surgery and Radiotherapy is curative if tumor is in the upper or middle part of esophagus and it is not metastasized distally. Palliation can be done by intubation of esophagus by different tubes or stents, surgical resection of esophagus and transposition of defect with stomach or colon or small intestine SEQ. 29 A 14 years old swimmer attends clinic with headache, fever and nose block. Headache is dull and changes with different postures a) What is the likely diagnosis b) Which imaging technique will be useful to support your diagnosis c) Outline the management Key 29 a) Maxillary sinusitis b) X-Rays paranasal sinus, CT scan face, MRI face c) Decongestant nasal spray, analgesia, antibiotics, Antral lavage under local or general anaesthesia, Intranasal endoscopic operations permit the precise removal of diseased mucosa with minimal trauma to adjacent tissues. CaldwellLuc radical antrostomy. SEQ. 30 Three days after tooth extraction this 50 years old teacher comes to emergency with a swelling of floor of mouth displacing her tongue upward. She looks toxic and finding difficulty in teaching due to voice limitation. Her breathing is also uncomfortable while she lies in bed a) What is your most likely suspicion b) Which serious problem can occur if untreated c) Give steps of management

Key 30 a) Ludwig angina b) airway obstruction due to glottic edema c) Broad-spectrum antibiotics such as amoxacillin or cefuroxime combined with metronidazole to combat the anaerobes. In advanced cases where the swelling does not subside rapidly with such treatment, a curved submental incision may be used to drain both submandibular triangles. The mylohyoid muscle may be incised to decompress the floor of the mouth. Simple but generous corrugated drains may be placed in the wound which is then lightly sutured. This operation may be conducted under local anaesthesia and on rare occasions an additional tracheostomy may be necessary. SEQ. 31 A young female patients from low socioeconomic class presents with a pus discharging sinus in the lower part of the posterior triangle of the neck. Chest X-Rays reported tubercular lesion at the apex of right lung. a) What other investigation are required to confirm the diagnosis b) What is your plan of treatment in this case Key 31 a) pus for culture sensitivity and AFB, sinus wall for histopathology, PCR, growth of bacteria takes 6 weeks. b) Good nutrition and hygienic living. Treatment with triple therapy consisting of rifampicin 600 mg, isoniazid 300 mg and pyrazinamide 15002000 mg per day given orally for at least 23 months is the standard chemotherapy at present, followed by 6 months of double therapy (rifampicin plus isoniazid). Sensitivity testing is usually available at the end of the first period of triple therapy and, if the source of the infection is with an organism that is resistant to one of these drugs, appropriate changes can then be made. Ethambutol may be of use in resistant cases. In cases of pulmonary tuberculosis, the sputum should be examined to assess progress every month until the smears are negative, but should the number of acid-fast bacilli increase or the cultures remain positive, the development of resistance or noncom-pliance of the patient with treatment should be considered. SEQ. 32 A 5 years old male child presents with soft cystic swelling about 12 cm in diameter in the lower part of anterior triangle of neck. It has been present since birth and increasing in size. on transillumination it is brilliantly translucent.

a) What is the differential diagnosis b) What complication may arise if not treated now c) What advise will you give to parents regarding treatment of this patient Key 32 a) cystic hygroma, branchial cyst, b) Respiratory difficulty, infections c) complete excision of the cyst at an early stage. Injection of a sclerosing agent, for example picibanil (OK-432), may reduce the size of the cyst; however, they are commonly multicystic and if the injection is extracystic subsequent surgery may be more difcult. SEQ. 33 while eating food a young male gets severe colicky pain in the right submandibular salivary gland which becomes enlarged and painful. Patient also gets fever a) How will you investigate this problem b) What is the treatment of this condition c) What are the complications of stone in submandibular salivary gland duct Key33 a) Lower occlusal X-Rays, Sialogram, ultrasound and CT scan b) If the stone is lying within the submandibular duct in the oor of the mouth anterior to the point at which the duct crosses the lin-gual nerve (second molar region), the stone can be removed by incising longitudinally over the duct. Once the stone has been delivered, the wall of the duct should be left open to promote free drainage of saliva. Where the stone is proximal to the lingual nerve, i.e. at the hilum of the gland, stone retrieval via an intraoral approach should be avoided as there is a high risk of damage to the lingual nerve during exploration in the posterior lingual gutter. Treatment is by simultaneous submandibular gland excision and removal of the stone and ligation of the submandibular duct under direct vision. C) infection, pain, stricture formations, recurrence of stone

SEQ. 34 A 50 years old lady who been eating betel (pan) for the last 15 years, develops a painless ulcer in the middle of the right lateral border of her tongue. It is gradually increasing in size and has everted margins and its base is hard to touch

a) Clinically what is your diagnosis b) How will you investigate this case c) What methods of treatment are available for this condition Key 34 a) Carcinoma tongue b) incisional biopsy to confirm the diagnosis , CT scan head neck and chest, MRI face , USG abdomen c) Radiotherapy , chemotherapy and surgery ( hemiglossectomy with radical neck dissection SEQ. 35 a young boy of eighteen years met with an accident, while driving a motor cycle. He sustained blunt injury to his abdomen. in the emergency room his blood pressure was 80mm Hg, and pulse rate was 120/minute, he was pale a) Which is the most common solid intra-abdominal organ to rupture in blunt abdominal trauma b) What investigations are required to confirm the diagnosis c) How will you resuscitate and prepare this patient for operation Key 35 a) liver b) Four quadrant aspiration , Diagnostic peritoneal lavage ( for hemoperitoneum ) USG Abdomen , CT scan Abdomen ( for hemoperitoneum and rupture of solid organs ) c) Emergency resuscitation always starts with assessment of airway, breathing and circulation. In this patient two wide bore intravenous cannulas are inserted and ringer lactate fluid is given till blood is available, nasogastric tube is passed for aspiration. Follys catheter for urin output measurement. Antibiotics and analgesia, arrangement of cross matched blood. Informed consent of the patient SEQ. 36 seven years old diabetic female patient developed right ischiorectal abscess. It was rapidly enlarging in size and patient was very septic. At places the skin was gangrenous. The wound was foul smelling. It was clinically diagnosed as synergistic gangrene (necrotizing fascitis) a) Which micro bacteria are involved in this infection b) What other investigations are to be carried out in this case c) What is the treatment of this condition Key 36

a) A mixed pattern of organisms is responsible: coliforms, staphylococci, Bacteroides spp., anaerobic streptococci and Pepto streptococci have all been implicated, acting in synergy. b) Pus for culture and sensitivity , MRI ischiorectal area, CT scan abdomen , Endoluminal USG c) broad spectrum antibiotics, inotropic sport , blood sugar control, serial extensive debridements , later graft on defects SEQ. 37 Fifty five years old patient had a soft, compressible swelling on the left side of neck for the last 8 years, it was gradually increasing in size and would further enlarge with taking food and reduce in size after regurgitation of food, he also complained of difficulty in swallowing a) Describe the investigations to confirm the diagnosis b) What plan would you suggest for treatment Key 37 a) video fluoroscopic swallowing study. Barium swallow , b) Preoperative physiotherapy and attention to the respiratory, cardiovascular and nutritional aspects of the patient are important. Preoperative chest physiotherapy and perioperative antibiotics are recommended. Surgical excision of the pouch through neck approach. SEQ. 38 twenty five years old male patient sustained open wound to his right thigh in a factory. The wound was heavily contaminated with dirt. on third day of injury he developed full-blown tetanus a) How will you manage this case b) What is the prognosis Key 38 a) Isolation, quietness and comfort, drainage of pus and wound toilet will be needed. Human anti-tetanus globulin is given intramuscularly to limit the effects of free toxins and should be used in doses of 25500 units to give cover throughout the period of establishing active immunity by giving toxoid (tetanus vaccine, adsorbed) im. Antibiotics, including penicillin and metronidazole, are indicated along with measures to protect the lungs. In dangerously ill patients, a major cyanotic convulsion will require curarization. Intermittent positive-pressure respiration should be provided, and intensive nursing care with increasing sedation would be needed b) the death rate can be reduced to approximately 15 per cent. 30 % mortality in severe cases

SEQ. 39 A 60 years old man presents with progressive dysphagia for solids. He gives history of weight loss. He has been smoking for the last 30 years .on examination he looks wasted. Barium swallow study showed stricture at the mid esophagus. a) b) c) Key 39 a) Body weight ,Anthropometry (skin fold thickness, mid arm circumference), Lymphocyte count, Serum albumin b) Esophagoscopy and taking biopsy c) Confirmation of the diagnosis by endoscopy Assessing and improving the nutrition CT chest and abdomen to assess the extent of tumor Staging the diseases Preparation of the patient for surgery including fitness for general anesthesia Assessment of pulmonary function Surgical management (curative or palliative) according the stage of disease Follow up of the patient for complications and recurrence of diseases SEQ. 40 A 25 years old female presented with multiple swellings in front of neck. She gives history of palpation, weight loss and disturbance of menses. On examination, the swellings are firm in consistency and move with swallowing. Radiograph neck shows deviation of trachea. a) b) c) Key 40 a) Toxic Multinodular goiter b) Thyroid Function Test (T3 ,T4 & TSH ), Ultrasound Thyroid Gland , Thyroid Scan c) Confirmation of the diseases Anti-thyroid drugs and beta-blocker to control the hyperthyroid status before What is the most likely diagnosis? How will you confirm the diagnosis? How will you manage this case? How will you assess the nutrition status of this patient? What is the next step to confirm the diagnosis? How will you treat this patient?

definitive surgery When patient becomes Euthyroid, plan for total thyroidectomy Preparation of patient includes informed consent and counseling regarding total thyroidectomy especially explain the nature of disease, complications of procedure and use of thyroxin for whole life indirect laryngoscopy, stop antithyroid drug at night and give beta blocker in the morning with sips of water SEQ.41 A 60 years old male smoker presented with non-healing ulcer on the left lateral side of tongue. On examination, 2x2 cm ulcer present over the posterior third part of the left lateral side of tongue. Submandibular lymph node hard in consistency is also palpable.

a) b) c)

What are differential diagnoses How will confirm your diagnosis What are the principles of management

Key 41 a) Tuberculous ulcer Dental ulcer Syphilitic ulcer Malignant ulcer (squamous cell carcinoma) b) Incisional biopsy. c) Confirmation of the disease Staging of the diseases with MRI or CT Head, Neck & Chest Radiotherapy or Surgical treatment according to the stage of disease Up to 30% of patients with a T1 (<2cm diameter) tumor have occult metastasis at presentation and should undergo simultaneous treatment of the neck by either selective neck dissection or radiotherapy. When performing surgical excision of the primary tumor, a 2-cm margin in all planes should be achieved to ensure a wide, complete excision.

In Advanced tumors (T3 andT4), a major resection of the tongue and oor of the mouth and mandible is required. T4 tumors of the oral tongue often cross the midline, for which total glossectomy is the only option to achieve adequate tumor clearance. SEQ. 42 A 20 years old male got trauma to face in road traffic accident. He complains of pain neck. On examination the left cheek is depressed and there is parasthesia over the cheek a) How will you assess the patient in emergency room? b) What is le Fort classification? c) What is the possibly of neck pain in the patient?

Key 42

a) Primary survey and resuscitation Airway with care of neck spine Breathing Circulation Deformity Exposure Secondary survey head to toe examination Radiograph Head, Neck and Chest OPG (Orthopantomograph) CT scans Head and Neck. b) Le Fort classified the Fracture of Maxilla in to three groups Le Fort I Separates the alveolus and palate from the facial skeleton above. Fracture line runs from the nasal pyriform aperture to lateral &medial walls of maxillary antrum posteriorly to include the lower part of the pterygoid plates

Le Fort II Pyramidal in shape .Runs through the bridge of the nose & ethmoid to medial part of the infraorbital rim & infraorbital foramen to posteriorly through the lateral wall of the maxillary antrum at a higher level than Le Fort. I to the pterygoid plates at the back cribriform plate may be fractured. CSF rhinorrhea Le Fort III effectively separates facial skeleton from the base of the skull to nasal bridge, septum & ethmoid. Irregularly through the bones of orbit to frontozygomatic suture to lateral wall of the maxillary sinus at a higher level & the pterygoid plates .Cribriform plate fracture leading to CSF rhinorrhea c) Neck pain may be due to cervical spine injury SEQ. 43 A 35 years old male presented with submandibular swelling which increase in size after meal. He also complains of pain in the swelling after taking lemon drinks. On examination, the swelling is bimanually palpable. a) b) c) Key 43 What is the most likely diagnosis? How will you investigate this case? How will you treat this patient?

a) Calculus in submandibular gland b) Radiograph floor of mouth as majority stones are radiopaque Sialogram to see the level of obstruction in submandibular duct. c) If the stone is lying within the submandibular duct in the oor of the mouth anterior to the point at which the duct crosses the lingual nerve (second molar region), the stone can be removed by incising longitudinally over the duct. Once the stone has been delivered, the wall of the duct should be left open to promote free drainage of saliva. Suturing the duct will lead to stricture formation and the recurrence of obstructive symptoms. Where the stone is proximal to the lingual nerve, i.e. at the hilum of the gland, stone retrieval via an intraoral approach should be avoided, as there is a high risk of damage to the lingual nerve during exploration in the posterior lingual gutter. Treatment is by simultaneous submandibular gland excision and removal of the stone and ligation of the submandibular duct under direct vision.

SEQ. 44 A 20 years old female presented with swelling in the right side of neck. She also gives history of low-grade fever and weight loss. On examination, the swelling is soft, nontender and fluctuant. Her ESR is 90 mm/HG.

a) b) c) Key 44

Give three differential diagnoses. How will you investigate this patient? How will you treat this patient?

a)

cold abscess Branchial cyst Cystic hygroma

b)

Thorough history and examination of neck along with swelling Fine Needle Aspiration Cytology Culture and sensitivity of aspirate Excision biopsy

c)

If it is cold abscess repeated aspirations and give anti- tuberculosis drugs for 9 months. Follow the patient for response and see the side effects of drugs. If it is Branchial cyst then it is excised If it is cystic hygroma then it is also excised

SEQ. 45 A 30 years old man got blunt trauma abdomen in road traffic accident. In the emergency room, he is received in semiconscious stat. His pulse is 120/min and blood pressure is 90/60 mm/Hg. His abdomen is gradually distending. a) b) c) Key 45 a) internal bleeding my due to liver laceration, splenic laceration and injury to mesentery What is the possible cause of hypotension What is this type of shock? How will you manage this patient

b) Hypovolemic shock c) Primary Survey and resuscitation Pass nasogastric tube Pass Foleys catheter for urine output measurements Give antibiotics Arrange cross-matched blood Take informed consent for exploratory laparotomy and Shift the patient to Operation Theater for exploratory laparotomy If liver trauma then manage it according to the grade of injury If spleen is injured then then splenectomy If mesentery is lacerated then repair it. SEQ. 46. A 25-year-old female presented with swelling in front of neck, palpitation and tremor of hands. On examination the swelling is diffuse, non-tender and moves with swallowing .USG neck shows no nodularity.

a)

Justify your diagnosis.

b) c)

Write three appropriate investigations, which are helpful in making diagnosis. Write three options to treat this patient

Key 46

a. b) c)

Diffuse toxic goiter as swelling is diffuse in consistency and there are more CNS signs Thyroid function test, Thyroid scan and thyroid antibodies Antithyroid drugs

Radioactive iodine Thyroidectomy SEQ. 47. A 60-year-old farmer presented with non- healing ulcer on the right cheek. On examination, it has pearly rolled edge and telangiectatic vessels. No cervical lymph node palpable.

A) B) C) Key 47

What is the most probable diagnosis? How will you confirm your diagnosis? Enlist the treatment options in this patient

a) Basal cell carcinoma b) Wide local excision and histopathology c) Mohs micrographic surgery Radiotherapy Surgical excision and closure of wound SEQ. 48. A 50-year-old male presented with non-healing ulcer on the right lateral side of tongue. On examination, the edge of ulcer is everted and base is indurated. A 3cm hard lymph node is palpable in right side of neck. a) How will you confirm the diagnosis? b) How will you treat this patient? c) Name the different types of neck dissections Key 48 a) incisional biopsy b) After confirmation of diseases stage the diseases Up to 30% of patients with a T1 (<2cm diameter) tumor have occult metastasis at presentation and should undergo simultaneous treatment .Advanced tumors (T3 andT4) often encroach upon the oor of the mouth and, occasionally, the mandible. In these circumstances, a major resection of the tongue and oor of the mouth and mandible is required of the neck by either selective neck dissection or radiotherapy. T4 tumors of the oral tongue often cross the midline, for which total glossectomy is the only option to achieve adequate tumor clearance. c) Classical radical neck dissection involves resection of the cervical lymphatics, the lymph nodes and those structures closely associated such as the internal jugular vein, the accessory nerve, the submandibular gland and the sternomastoid muscle. These structures are all removed en bloc and in continuity with the primary disease if possible. The main

disability that follows the operation is the drooping of the shoulder due to paralysis of the trapezius muscle as a consequence of excision of the accessory nerve. Modified radical neck dissection in selected cases one or more of the three following structures are preserved, the accessory nerve, the sternocleidomastoid muscle or

the internal jugular vein, but otherwise all major lymph node groups and lymphatics are excised. Selective neck dissection in this type of dissection one or more of the major lymph node groups is preserved along with sternomastoid muscle, accessory nerve and internal jugular vein. Under these circumstances, the exact groups of nodes excised must be documented. SEQ. 49 Bomb Blast occurred near your hospital and you are expected to receive 20 casualties. a) What is the common scheme of assessment for these patients? b) What are the commonest steps of ATLS (Advanced Trauma Life Support)? Key 49 a) A common scheme of assessment is presented below. Triage sieve a quick survey is made to separate the dead and the walking from the injured. Triage sort remaining casualties are now assessed and allocated to three or four groups according to local protocols:

category 1 critical and cannot wait. Airway obstruction and catastrophic Hemorrhage are examples; category 2 urgent. Serious injury but can wait a short time, 30 minutes in most systems; category 3 less serious injuries. Not endangered by delay category 4 expectant. Severe multisystem injury. Survival not likely; (optional) heavy manpower demands.

b)

ATLS component steps Primary survey identify what is killing the patient Resuscitation treat what is killing the patient Secondary survey proceed to identify all other injuries Definitive care develop a definitive management plan Primary survey and resuscitation must be concurrent.

SEQ. 50 An elderly man had a hard lymph node palpable in the upper part of the right side of the neck, anterior to the sternomastoid muscle. FNAC confirmed metastatic carcinoma, probably from a primary in the oropharynx. a) Where would you look for the primary focus b) What other investigations would you do for management of the case Key 50 a) tongue , lip, pharynx, larynx, buccal cavity b) CT scan, MRI, USG Abdomen, Laryngoscopy, if primary found then incisional biopsy of lesion. SEQ. 51 A 45 years old female patient from Gilgit had multinodular goiter for the last 15 years. One year ago she developed tachycardia, weight loss, tremors in hands and sweating of palms a) What is the diagnosis b) What investigations are required to confirm the diagnosis

Key 51 a) b) Toxic multinodular goiter Thyroid Function Test ( T3, T4, THS ) Thyroid Scan

SEQ. 52 A thirty five years old female patient had history of recurrent stone in both kidneys for which she lithotripsy done in Past. Now she had developed another stone in the right kidney. She also suffers from peptic ulcer diseases and radiological examination reveals multiple cysts in the limb bones. a) Clinically what is your diagnosis b) What investigations are required for confirmation

c) How will you manage this case Key 53 a) primary hyperparathyroidism b) raised level of S/Ca, low level of phosphate , raised level of parathyroid hormone( PTH ) USG Neck, MIBG scan c) after taking the detail history of patient, performing relevant physical and systemic examination, confirmation of the diagnosis by specific investigation and localisation of the parathyroid adenoma before definite surgical management. if it is parathyroid adenoma or malignancy then parathyroidectomy of respective gland is performed by carefully preserving the recurrent laryngeal nerve. if it is hyperplasia of glands then all the four glands are removed and small pieces of gland are implanted in the sternocleidomastoid muscle or brachioradialis muscle in the arm.

SEQ. 53 A 45 years old patient developed an ulcerating lesion 1cm in diameter on the neck just below her right eye. The biopsy of the ulcer revealed basal cell carcinoma. a) Clinically how does basal cell carcinoma present b) What are the different types of treatment available? In your opinion what is the best treatment Key 53 a) Clinically it is slowly growing locally malignant carcinoma skin. Its margins are pearly white and rolled up. No lymph node enlargement occurs. b) wide local excision with reconstruction of defect, Mohs micrographic surgery. Local application of 5-uorouracil, imiquimod, cryosurgery , radiotherapy In my opinion in this patient Mohs micrographic surgery is best as lesion is around the eye SEQ. 54 A dentist notices a shaggy white mass in gingivobuccal recess of a 68 years old man. It has been increasing in size and bleeds occasionally. a) What investigations for the confirmation of diagnosis and plan of treatment are required b) What treatment would you suggest if it turns out to be cancerous Key 54 a) incisional biopsy of the mass , CT scan Head , Face , Neck and Chest, MRI face , USG abdomen b) if the tumor is small size (T1, T2) the wide local excision including the underlying muscle or bone. if node positive then supraomohyoid neck dissection. if the tumor large

in size (T3, T4) then approach is lip-splitting technique, wide excision of the tumor with segment resection of involved bone. Reconstruction of the defect by radial artery forearm flap or temporalis muscle flap SEQ. 55 Mother of five years old child brought her son to you with complaint of that her son has a midline painless, cystic swelling in front of neck just below the hyoid bone. It has recently become red, painful and child has fever. a) What is the differential diagnosis b) How will you confirm the diagnosis c) What is the treatment of this condition Key 55 a) infected thyroglossal cyst , acute infection in previously cold abscess, infected sebaceous cyst b) Aspiration of cyst and culture of material , USG of Cyst c) The treatment depends on the diagnosis. if infected thyroglossal cyst give antibiotics to settle the acute infection followed by complete excision of cyst with central core of hyoid bone (Sistrunk operation). If the diagnosis is cold abscess then give specific treatment (antituberculosis drugs). if infected sebaceous cyst then first do incision and drainage and later when infection is settled total excision of cyst wall. SEQ. 56 A diabetic patients developed multiple discharging sinus on the right side of the neck near the right angle of mandible with fever. Pus was sent for culture and it reported as actinomycosis a) What is the differential diagnosis b) What are the complications of this infection if not treated in time c) What is the best treatment for this condition Key 56 a) carbuncle , Actinomycosis , osteomyelitis of mandible , cold abscess b) it will burst out and spread in to tissue planes , gums can become indurate and bony swelling occur , sinus formation can occur , in chronic wounds malignancy can occur c) benzyl penicillin , lincomycin , tetracycline SEQ. 57 A 26 years old psychiatric patient presents with brawny swelling in the right submandibular region and odynophagia. Examination reveals trismus, edema of the tongue and floor of mouth along with putrid halitosis. a) What is the most likely diagnosis b) What are various complications of the untreated condition

c) Outline a treatment plan for this patient Key 57 a) Ludwig angina b) dysphagia , painful obstruction of the airway, glottic edema c) Antibiotics , curved submental incisions to drain out both submandibular triangles under local anaesthesia , Rarely tracheostomy may be needed SEQ. 58 A 28 years old male presented with enlarged cervical lymph nodes. Enumerates various causes of cervical lymphadenopathy Key 58 Causes of cervical lymphadenopathy Inammatory, Reactive hyperplasia Infective, Viral (infectious mononucleosis, HIV) Bacterial (Streptococcus, Staphylococcus, Actinomycosis, Tuberculosis, Brucellosis Protozoan, Toxoplasmosis Neoplastic, Malignant Primary, e.g. lymphoma Secondary, e.g. squamous cell carcinoma Known primary Occult primary SEQ. 59 A 35 years old female presents with non-healing ulcerative lesion in the right submandibular region following the extraction of a carious tooth. On examination there is brawny edema and purulent discharge from the lesion which contains yellowish granules a) b) c) d) Key 59 a) b) actinomycosis actinomycosis Israelii What is the most likely diagnosis What is the causative organism of this condition How will you confirm the diagnosis What is the treatment of this condition

c)

d)

Diagnosis depends on finding the organism in pus or in tissue section. Pus should be collected in a sterile tube (a swab is usually insufficient) and inspected in a good light for the presence of pinhead-sized sulphur granules. On microscopy, the granules are seen to consist of Gram-posi-tive branching bacilli. The peripheral filaments radiate4 from the central part of the granule and may be surrounded by Gram-negative tissue clubs benzyl penicillin, tetracycline , lincomycin

SEQ. 60 A 38 years laborer presents with a painless swelling in the left cervical region. There is history of evening rise of fever and generalized malaise. the swelling is 3x4 cm, soft, nontender and fluctuant with normal local temperature. there are matted cervical lymph nodes on the same side. a) What is the most likely diagnosis b) What investigations will you suggest to reach the diagnosis c) Briefly outline the treatment of this condition Key 60 a) cold abscess ( tuberculosis lymphadenitis ) b) ESR, Pus for Culture and AFB, FNAC from matted lymphonods , excision biopsy lymph node , Mycodott c) Multiple Aspirations of cold abscess, good nutrition and hygiene condition, Anti tuberculosis therapy for 9 months (rifampicin, ethambutol, isoniazid, pyrazinamide) according to the weight of patient. Now DOTT ( directly observed treatment therapy ) method adopted to insure the compliance of patient SEQ. 61 a) Define the terms cellulitis and Lymphangitis b) What are the common organisms responsible for these lesions c) What is the clinical presentation of these conditions Key 61 a) cellulitis is the nonsuppurative invasive infection of tissues. In addition to the cardinal signs of inflammation, there is poor localisation .lymphangitis is inflammation of the lymphatics b) Beta-hemolytics streptococci, staphylococci and C. perfringens. c) Lymphangitis is caused by similar processes but presents as painful red streaks in affected lymphatics. Cellulitis is usually located at the point of injury and subsequent tissue infection. Lymphangitis is often accompanied by painful lymph node groups in the rebated drainage area.

SEQ. 62 A 47 years old intravenous drug abuser who is suspected to have HIV infection presented with right sided parotid abscess requiring incision and drainage. as a surgeon, what precautions will you take to protect yourself during parotid surgery Key 62 wear goggles for eye protection Wear double gloves and long shows carry out the procedure in an orderly manner. Surgical assistants should be kept to a minimum should be instructed not to move while the operation is proceeding. If the assistants position is to be adjusted then the operating surgeon should stop operating while changes are being made. This should avoid the risk of the operating surgeon injuring an assistants hand while it is being moved across the operative field. The operation should proceed in a slow and methodical manner with meticulous attention to hemostasis, taking care to avoid unexpected rapid bleeding which changes the tempo of the procedure and increases the risk of inadvertent injury to the operators. No sharp instruments or scalpels should be passed across the operative field from hand to hand. All instruments are passed from the scrub nurse to the surgeon and back to the scrub nurse in a dish, thereby reducing the risk of injury while passing instruments.

SEQ. 63 A 46 years old man presents with an irregular bright red lesion on the mucosal aspect of right cheek, diagnosed as Erythroplakia a) Define Erythroplakia b) Enumerate the pathological features of this lesion c) Outline the treatment of this lesion

Key 63 a) Erythroplakia is dened as any lesion of the oral mucosa that presents as a bright red plaque which cannot be characterized clinically or pathologically as any other recognizable condition. b) The lesions are irregular in outline and separated from adjacent normal mucosa. The surfaces may be nodular. These lesions occasionally coexist with leukoplakia. c) As the incidence of malignant change in Erythroplakia is 17-fold higher than in leukoplakia. In every case of Erythroplakia there are areas of epithelial dysplasia, carcinoma in situ or invasive carcinoma. Clearly, all Erythroplakia areas must be completely excised either surgically or with a carbon dioxide laser, and the specimens submitted for careful pathological examination.

SEQ. 64 enumerates various lesions and conditions of oral mucosa associated with increased risk of malignancy Key 64 Conditions associated with malignant transformation High-risk lesions Erythroplakia Speckled Erythroplakia Chronic hyperplastic candidiasis Medium-risk lesions Oral submucous brosis Syphilitic glossitis Sideropenic dysphagia (PatersonKelly syndrome) Low-risk/equivocal-risk lesions Oral lichen planus Discoid lupus erythematosus Discoid keratosis congenita

SEQ. 65 An eight year old child has presented with delayed eruption of primary teeth. a) Enumerate the local factors related to delayed eruption b) Enumerate the systemic factors related to delayed eruption Key 65 a) Local factors loss of space/overcrowding additional teeth dentigerous cysts retention of deciduous tooth. b) Systemic factors metabolic diseases cretinism and rickets; osteodystrophies cleidocranial dysostosis and brous dysplasia; hereditary gingival bromatosis.

SEQ. 66 A 45 years old female has been diagnosed as a case of Sjogren Syndrome a) What is Sjogren Syndrome b) How will you diagnose this condition c) How will you treat this patient Key 66 a) b) Sjgrens syndrome is an autoimmune condition causing progressive destruction of salivary and lacrimal glands. The characteristic pathological feature of Sjgrens syndrome is the progressive lymphocytic inltration, acinar cell destruction and proliferation of duct epithelium in all salivary and lacrimal gland tissue. The diagnosis is based on the history as no single laboratory investigation is pathognomonic of either primary or secondary Sjgrens syndrome Management of Sjgrens syndrome remains symptomatic. No known treatment modies or improves the xerostomia or keratoconjunctivitis sicca. An ophthalmological assessment is important, and articial tears are essential to preserve corneal function. For dry mouth, various articial salivary substitutes are available, but

c)

patients often consume large volumes of water, carrying a bottle of water with them at all times. In the dentate patient, the use of salivary substitutes with uoride is important to counter the risk of accelerating dental caries. Other oral complications include oral candidosis and accelerated periodontal disease.

SEQ. 67 A 35 years old female presents with an enlarged thyroid gland. while considering the appropriate management of this patient, how are various thyroid swelling classified Key 67 Simple goitre (euthyroid) Diffuse hyperplastic (Physiological, Pubertal, and Pregnancy) Multinodular goitre Toxic: Diffuse, Graves disease Multinodular, Toxic adenoma Neoplastic, Benign, Malignant Inammatory Autoimmune Chronic lymphocytic thyroiditis Hashimotos disease Granulomatous De Quervains thyroiditis Fibrosing Riedels thyroiditis Infective Acute (bacterial thyroiditis, viral thyroiditis, subacute thyroiditis)

Chronic (tuberculous, syphilitic) Other, Amyloid SEQ. 68 A 40 years old male presents with history of upper abdominal pain aches and pain various bones, frequent passage of gravels in the urine and variable mode changes during the past 2 years. Clinical examination is unremarkable. His serum calcium is 3 mmol/L and BUN and creatinine are within normal range. a) b) c) d) Key 68 a) Hyperthyroidism b) Raised level of serum calcium and parathyroid hormone , low level of phosphate in serum , high level of urinary calcium c) USG Neck , MIBG scan , MRI Neck, CT scan Neck , selective angiography and selective venous sampling d) Parathyroidectomy where adenoma present. if there is hyperplasia then all the four glands are removed with transplantation of small pieces in the sternocleidomastoid muscle or brachioradialis muscle SEQ. 69 A mother brings her 3 months old son with complains of gradually enlarging swelling on the right upper neck which increases in size when the child cries. on examination the swelling is 6x8 cm in size, non-tender, soft to cystic and brilliantly trans illuminant. The temperature overlying skin is normal and fluctuation test is positive a) b) c) d) Key 69 a) cystic hygroma neck b) The cysts are lled with clear lymph and lined by single layer of epithelium with a mosaic appearance. c) respiratory problem , rupture , infection , obstruct the labor d) Denitive treatment is complete excision of the cyst at an early stage. Injection of a sclerosing agent, for example picibanil (OK-432), may reduce the size of the cyst; What is the most likely diagnosis What is the pathology of this lesion What are the various complications if the condition is left untreated What is the treatment What is the most likely diagnosis Enumerate various investigations to confirm the diagnosis Enumerate various investigations to localize the causative lesion What is the treatment of this condition

however, they are commonly multicystic and if the injection is extracystic subsequent surgery may be more difcult. SEQ. 70 What do you understand by the term Radical Neck Dissection enumerate various types of radical neck dissections mentioning the various structures removed in every type Key 70 this means removal of all the cervical lymph enbloc with other surrounding tissue along the primary tumor Types of neck dissections Classical radical neck dissection (Crile) the classic operation involves resection of the cervical lymphatics, the lymph nodes and those structures closely associated such as the internal jugular vein, the accessory nerve, the submandibular gland and the sternomastoid muscle. These structures are all removed en bloc and in continuity with the primary disease if possible. The main disability that follows the operation is the drooping of the shoulder due to paralysis of the trapezius muscle as a consequence of excision of the accessory nerve.

Modified radical neck dissection in selected cases one or more of the three following structures are preserved, the accessory nerve, the sternocleidomastoid muscle or the internal jugular vein, but otherwise all major lymph node groups and lymphatics are excised.

Selective neck dissection in this type of dissection one or more of the major lymph node groups is preserved along with sternomastoid muscle, accessory nerve and internal jugular vein. Under these circumstances the exact groups of nodes excised must be documented.

SEQ. 71 A 35 years old motorcyclist met a road traffic accident and sustained abrasions and lacerations of the face. A deep lacerations on the right side causes complete transection of ipsilateral facial nerve and parotid duct a) b) c) d) Key 71 Enumerate the basic steps while examine a patient for faciomaxillary trauma Outline the principles of management of facial soft tissue injuries What is the treatment of transected facial nerve What is the treatment of transected parotid duct

a) Commence with lacerations and soft-tissue injuries Systematically examine bones including the occiput and cranial vault Check dental occlusion and palpate the mouth Check cranial nerves Photographs are useful b) Facial soft tissues have an excellent blood supply and heal well. They should be sutured as soon as possible following the injury after careful exploration, debridement and cleaning, particularly where foreign bodies may be embedded. Many lacerations may be closed using local anaesthesia, injecting into the edges of the wound. If the patient is due to have a general anaesthetic and there is a delay, the wounds should be temporarily closed in advance, using local anaesthesia. Tissue sufciently traumatized to have lost its blood supply should be removed with a sharp scalpel, and the edge to which it is to be apposed trimmed to t as appropriate. Great care should be taken to replace tissues accurately, particularly in cosmetically important landmarks such as the vermilion border of the lips, the eyelids and nasal contours. Hemostasis is important. Muscle and underlying tissues should be brought together with absorbable sutures so that the edges of the wound lie passively within 2 mm of their nal position. Then ne monolament sutures (5/0 or 6/0) are used to bring the wound edges together Sutures should be placed so as to avoid compromising the blood supply of the apices of small aps. Vacuum drains are used where there is concern over dead space beneath the wounds. The lacerations should be covered with antibiotic ointment two or three times per day, and broad-spectrum antibiotics should be prescribed. Ideally, alternate sutures should be removed from the third day with the remaining sutures removed on the fth day. Intraoral lacerations require careful debridement, and closure in layers with resorbable suture materials. Lacerations to mobile structures such as the tongue and soft palate can often be under estimated in terms of their depth. Failure to close the deeper layers of intraoral lacerations may predispose to later dehiscence, c) Primary repair is the most appropriate treatment d) Cannulate from the mouth and anastomose over the stent

SEQ. 72 35 years old lady presents with solitary nodule in front of neck which moves on deglutition with recent change in voice A) What is the diagnosis B) What important relevant investigations are required C) What are the treatment options in papillary carcinoma Key 72

a) Thyroid Carcinoma b) thyroid scan , FNAC solitary nodule , Thyroid function test( T3,T4, THS), CT Neck and chest , USG neck and abdomen c) Total thyroidectomy with neck dissection, radioactive iodine therapy and thyroxin in suppressive doses.

SEQ. 73 Painful red looking swelling in right submandibular region in 20 years old boy with following findings and complaints, difficulty on swallowing, throbbing pain, tender and fluctuant swelling a) What are the possible diagnosis b) What is the treatment Key 73 a) Ludwig angina , sialadenitis , abscess b) if Ludwig angina then first try antibiotics if do not respond then make incision over the swelling and decompress the submandibular triangle. if submandibular abscess then incision and drainage done along with appropriate antibiotics SEQ. 74 a) define bacteremia and septicemia b) what precaution would you take in extraction of tooth in a patient who has mitral valve replacement Key 74 a) Bacteremia means just presence of bacteria in the blood and septicemia mean when these organism multiplying and producing toxins in the blood b) the patient should get prophylactic antibiotics before extraction of tooth

SEQ. 75 what do you know by term a) healing by first intention b) healing by second intention give two examples of each Key 75

a) Where wound edges are apposed healing proceeds rapidly to closure; this is known as healing by first intention or primary healing; eg surgical wounds closed primarily , thyroidectomy , parotidectomy or traumatic laceration on face sutured primarily heal by first intention b) Where the wound edges are apart, such as when there has been tissue loss, the same biological processes occur, but rapid closure is not possible. Angiogenesis and fibroblast proliferation result in the formation of granulation tissue. These contracts to reduce wound area and allow epithelialization across its surface to achieve wound closure. This is known as healing by second intention. all wound after debridement kept open for healing by second intention or wound after incision and drainage also heal by second intention SEQ. 76 A patients has undergone subtotal thyroidectomy for toxic goitre a) enumerate various post-operative complications b) how will you manage postoperative hemorrhage in such case Key 77 a) hypoparathyroidism , primary and reactionary hemorrhage, injury to recurrent laryngeal nerve , injury to superior laryngeal nerve , thyrotoxicosis crises , keloid scar, seroma formation b) if postoperative hemorrhage occurs within 24 hours it is called reactionary hemorrhage if airway is compromised in the ward open the stiches to relieve the pressure of hematoma and pack the wound. Inform the theater staff anesthetics and surgeon about the shift of patient. in theater control bleeding points under anesthesia and put suction drains in the wound. Replace blood loss and monitor the vital signs SEQ. 77 A 60 years old man presents with I cm ulcer on lateral side of tongue with rolled margins and a lymph node in submandibular region a) what is the diagnosis b) what investigations are required to confirm the diagnosis c) what are the treatment options Key 77 a) carcinoma tongue b) incisional biopsy , FNAC submandibular lymph node , CT scan Neck and oral cavity, MRI oral cavity , USG abdomen c) surgery and radical neck dissection followed by radiotherapy or chemotherapy if required, only radiotherapy. carbon dioxide laser may be used for the partial glossectomy SEQ. 78 A young patients has been brought to emergency room with facial trauma and difficulty in breathing:

a) what steps you will take to restore breathing b) what is the cricothyroidotomy Key 78 a) remove the blood or any other material in the oral cavity and immediately cricothyroidotomy b) it is the emergency procedure to maintain the airway patent by making incision in the cricothyroid membrane and putting mini tube in the trachea to restore airway SEQ. 79 a) what is the classification of maxillofacial injury b) What is management of LeFort 1 type of fracture Key 79 a) soft tissue injury , facial skeletal injuries (upper third ,middle third and lower third ) Injury to facial nerve, injury to parotid duct, blow out fracture of orbit, nasal bone fractures b) The lower part of the maxilla is approached through a gingival sulcus incision above the maxillary teeth as far back as the second molar. Fractures may be identied with ease through this route and xed with plates or wires. The dental arch is restored to its original shape as far as possible so that it matches the pre-morbid occlusion with the mandibular arch. To achieve accurate location, dental arch bars or eyelet wires may need to be applied. Where this is anticipated, the necessary wiring is undertaken before the main part of the operation is commenced.

SEQ. 80 A patients with hepatitis C infection has come to you for dental treatment a) What precautions you will take to avoid transmission to other patients and yourself b) How will you sterilize, used instruments c) What is the rout of infection in hepatitis C Key 80 a) there should be careful protocols for the handling of blood and body fluids in order to reduce the risk of auto-infection and cross-infection, for hepatitis B and C viruses such precautions are of particular importance in patients who have pre-existing infection or who are immunosuppressed.

General measures include: education of staff so that they are fully aware that there is a full vaccination Programme for hepatitis B; the availability of advice for staff in the event of injury. practical measures include: identifying high-risk patients reduction of the number of staff in the theatres to cover essential roles only removal of all extraneous equipment from the theatre; Staff should avoid contact with contaminated body fluids, especially blood, and in this respect abrasions should be covered. If the member suffers from eczema, he or she should be excluded from the theatres and if contamination does occur rapid washing should be undertaken. When handling potentially contaminated blood or body fluids, scrub staff should use non permeable gowns and masks with eye protection and should double glove. Circulating personnel should use plastic aprons and wear gloves. Spills should be dealt with by staff wearing gloves and using absorbent disposable clothes; hypochlorite 1 per cent solution may be applied to blood spilt on the floor. Particular care should be taken with the handling of sharps, which should always be kept in receivers. Swabs should be counted but not left exposed, as for routine operations on a spike rack; they should be placed in deep swab pockets on plastic racks. Disposable equipment should be placed in yellow bags at the earliest possible time, then sealed and double bagged with a hazard label attached. Soiled linen should be placed in special alginate bags and sent to the laundry clearly m arked. At the end of the case all surfaces should be cleaned with detergents and the Domestic Officer informed. b) high level of disinfection and cleaning of instrument then sterilization of instrument c) This may follow blood transfusion, plasma infusion and, rarely, the administration of sera, infection resembling infective hepatitis except that the incubation period is about 12 weeks. Transmission by plasma has been reduced by avoiding the pooling of plasma from a large number of donors. Trans-mission by syringes is prevented if all syringes are disposable. It occurs

amongst those who are drug addicts and possibly after tattooing or ear piercing. There is an extremely high rate among certain homosexual communities. In certain centers more than 50 per cent of male homosexual patients have antibody indicating exposure and about 5 per cent have active disease. In Athens, a group of prostitutes was found to have a rate 20 times that of married pregnant women, possibly due to more frequent coitus near the period or to other sexually transmitted diseases, producing bleeding that transmits the infection.

SEQ. 81 A 60 KG patient with 30% burn and coughing has been admitted in the ward a) What are the important steps in treatment b) What is his fluid requirement c) How would you assess percentage of burn and depth of burn Key 81 a) admit the patient , primary survey and resuscitation of patient ( airway, breathing and circulation ) proper analgesia , b) The simplest formula (for adults) is: 34 ml/kg body weight/% burn/in the first 24 hours. Half of this volume is given in the first 8 hours and the rest in the next 16 hours. Total fluid requirement will be 7200ml in 24 hours c) rule of nine , Burn depth depends, in thermal injury, upon: the temperature of the burning agent; the mode of transmission of heat; the duration of the contact. SEQ. 82 A fifty years old man presents with gradual dysphagia to solid a) What are the relevant investigations b) What is the most probable diagnosis Key 82 a) Barium swallow , Endoscopy , Endoluminal USG, CT scan Neck, chest and upper abdomen b) carcinoma esophagus SEQ. 83 A patients presents with painless swelling in lateral side of neck, firm consistency, six month duration a) What are the important points in history that you will ask

b) What investigations are required to make diagnosis c) What is FNAC Key 83 a) progression of swelling , associated symptoms , any history of ear discharge or nose problem , any lesion on the scalp and oral cavity , any history of contact with tuberculosis patient b) FNAC swelling, Excision biopsy , USG neck, CT scan , MRI , X-Ray Chest , ESR, c) It is fine needle aspiration cytology SEQ. 84 a) what are the various varieties of shock b) Enumerate the clinical features of hypovolemic shock c) Attendant of patient, while witnessing a dental procedure collapse with following finding Pulse 50/ minute, thready Blood pressure 70/40 mmHg Beads of sweat on forehead (what type of shock she has suffered) Key 84 a) Hypovolemic , cardiogenic , septic , vasovagal , anaphylactic, burn shock, neurogenic shock b) c) low volume pulse, tachy cardia , low blood pressure, clod clammy extremities , sweating , decreased urin output, low CVP psychogenic or vasovagal shock

SEQ. 85 A child five months old has presented with unilateral cleft lip and palate a) b) c) d) Key 85 a) classication is the LAHSHAL system, which is able to describe site, size and extent, as well as type of cleft How would you classify his deformity? what is your management plan Pre-operative preparation Timing of surgery Objectives of good repair

b) consent and counselling of parents , base line investigation , arrangement of blood and other item necessary for surgery c) Cleft lip repair is commonly performed between 3 and 6 months of age, whereas cleft palate repair is frequently performed between 6 and 18 months. d) The ultimate goal in cleft lip and palate management is a patient with a normal appearance of lip, nose and face, whose speech is normal, and whose dentition and facial growth fall within the range of normal development. Surgical techniques are aimed at restoring normal anatomy. With the exception of rare conditions such as holoprosencephaly, there is no true hypoplasia of the tissues involved on either side of the cleft. There is, however, displacement, deformation and underdevelopment of the muscles and facial skeleton. Emphasis is placed on muscular reconstruction of the lip, nose and face as well as muscles of the soft palate. Normal or near-normal

SEQ. 86 A 20 years old female underwent appendectomy for perforated acute appendicitis. On 5th post-operative day she complains of diarrhoea and passage of mucous discharge per rectum. Rectal examination revealed bulging of the anterior rectal wall. a) b) c) Key 86 a) Pelvic abscess b) USG abdomen and CT scan abdomen c) Drainage of abscess through rectum USG or CT guided aspiration of abscess SEQ. 87 A 30 years old married female presented with pain abdomen and vomiting. Pain is worsened by movement or breathing. She also gives history of vaginal discharge. On examination, her pulse is 100/min and temperature is 102F. There is tenderness and guarding in the abdomen. On vaginal examination she has tenderness on the movement of cervix. What is the most likely diagnosis? How will you confirm the diagnosis? What are the treatment options?

A) What is the differential diagnosis? B) How will you investigate this patient? C) How will you treat this patient?

Key 87 a) Pelvic inflammatory diseases Perforated appendix Ruptured ectopic pregnancy b) Thorough history is taken regarding the pain and vomiting ,last menstrual period Detailed general physical and abdominal examination including rectal and vaginal examination. pregnancy test, BHCG, USG abdomen, Full Blood Count, urin complete examination c) Admit the patient, Keep Nil per oral, pass follys catheter, appropriate antibiotic, prepare for exploratory laparotomy if perforated appendix or pelvic peritonitis or ruptured ectopic pregnancy. during exploration manage according to the diagnosis

SEQ. 88 A 40-year-old bankers is suffering from duodenal ulcer for last 10 years. He is not properly taking medication for this problem. He presented with projectile non-bilious vomiting. On examination, he looks dehydrate and peristalsis is visible in the upper abdomen.

A) What is the most likely diagnosis? B) How will you confirm your diagnosis? C) How will you manage this patient? Key 88 a) Gastric outlet obstruction due to complication of long standing ulcer b) Barium meal study , Endoscopy to assess the ulcer and take biopsy from suspicious area c) After confirming the diagnosis and ruling out the malignancy gastrojejunostomy and vagotomy is performed

SEQ. 89 A 60 years old man presented with mass in the upper abdomen. There is history of anorexia, dyspepsia and weight loss. He is chain smoker for last 30 years. On examination, he is wasted and looks pale .A hard mass palpable in the epigastrium. Hematology investigation shows iron deficiency anaemia a) what investigations are required to make diagnosis?

b) What are the principles of treatment in this patient? Key 89 a) CT Scan abdomen with oral and I/V contrast , USG abdomen , Endoscopy and Punch biopsy,