INI-CET 2024 — Surgery
10 Previous Year Questions with Answers & Explanations
A 40-year-old male with a head injury presents with a GCS of 8, BP of 90/60, and HR of 120. A CT scan shows an epidural hematoma. What are the immediate management priorities?
During thyroidectomy, which nerve, if damaged, can cause a hoarse voice?
A 55-year-old man has a history of difficulty swallowing and frequent choking while eating. A barium swallow shows a posterior pharyngeal diverticulum. What is the most likely diagnosis?
Patients requiring immediate life-threatening care are categorized under which of the following triage?
Which of the following is not done in the primary survey of trauma?
Case of trauma in a patient with an unknown blood group. Patient is unstable and requires urgent blood transfusion. Which type of blood should be transfused?
A 55-year-old male patient presents to the clinic with left lower lip weakness following a recent parotid gland surgery. Considering the surgical history and current symptoms, what is the most likely site of the lesion causing this patient's condition?
Lower lip paralysis after a parotidectomy is most likely due to injury to which structure?
A 25-year-old male college student presents to emergency after road traffic accident. Patient is in state of shock and breath sounds are decreased on the side of chest trauma (left side). Normal heart sounds, no elevated JVP and dull note on percussion. What is the diagnosis?
Arrange the following according to good outcome a - zone of stasis b - zone of coagulation c - zone of hyperemia
INI-CET 2024 - Surgery INI-CET Practice Questions and MCQs
Question 1: A 40-year-old male with a head injury presents with a GCS of 8, BP of 90/60, and HR of 120. A CT scan shows an epidural hematoma. What are the immediate management priorities?
- A. Intubation and ventilation (Correct Answer)
- B. Administer mannitol for intracranial pressure management
- C. Perform immediate craniotomy
- D. Administer intravenous fluids and monitor vital signs
Explanation: ***Intubation and ventilation*** - A GCS of 8 or less mandates **immediate intubation** to protect the airway and prevent aspiration in a patient who cannot maintain their airway. - In the **ATLS primary survey sequence**, airway management is the first priority, though in practice this is done **simultaneously** with fluid resuscitation. - Maintaining **adequate oxygenation and normocapnia** is crucial for preventing secondary brain injury and managing intracranial pressure. - **Critical point**: While this patient requires both airway management AND fluid resuscitation urgently, securing the airway takes immediate precedence as the patient cannot protect their airway at GCS 8. *Administer mannitol for intracranial pressure management* - While mannitol can reduce ICP, it is **not an immediate priority** before securing airway, breathing, and circulation. - Mannitol is **contraindicated in hypovolemic/hypotensive patients** as it acts as an osmotic diuretic and can worsen hypotension. - ICP management with mannitol should only be considered after hemodynamic stabilization and in the context of signs of herniation. *Perform immediate craniotomy* - Although epidural hematomas typically require **urgent surgical evacuation**, the patient must first be physiologically stabilized. - **No patient should go to the operating room in hemorrhagic shock** without ABC stabilization. - Airway protection, ventilation, and circulatory resuscitation must precede definitive neurosurgical intervention to ensure the patient can safely tolerate anesthesia and surgery. *Administer intravenous fluids and monitor vital signs* - This is a **critical and equally urgent priority** - the patient is in shock (BP 90/60, HR 120), likely from associated injuries or blood loss. - **Hypotension (SBP <90 mmHg) is the most detrimental secondary insult** in head-injured patients and doubles mortality (per Brain Trauma Foundation guidelines). - Fluid resuscitation should begin **simultaneously** with airway management to restore cerebral perfusion pressure. - However, in the ATLS sequence, airway (A) precedes circulation (C), making intubation the first listed priority, though both must be addressed concurrently in practice.
Question 2: During thyroidectomy, which nerve, if damaged, can cause a hoarse voice?
- A. Recurrent laryngeal; loops under aorta/subclavian (Correct Answer)
- B. Superior laryngeal; with superior thyroid artery
- C. Glossopharyngeal; along posterior thyroid
- D. Hypoglossal; inferior to thyroid
Explanation: ***Recurrent laryngeal; loops under aorta/subclavian*** - The **recurrent laryngeal nerve (RLN)** innervates most of the intrinsic muscles of the larynx, including the **posterior crico-arytenoid muscle**, which is responsible for abducting the vocal cords. - Damage to the RLN during thyroidectomy can lead to **vocal cord paralysis**, resulting in a hoarse voice, stridor, or aspiration. *Superior laryngeal; with superior thyroid artery* - The **superior laryngeal nerve (SLN)** branches into external and internal laryngeal nerves. The **external laryngeal nerve** runs with the **superior thyroid artery** and innervates the **cricothyroid muscle**, which is responsible for tensioning the vocal cords. - Damage to the SLN can cause subtle changes in voice pitch and reduced vocal range but typically does not cause hoarseness or vocal cord paralysis, which is more characteristic of RLN injury. *Glossopharyngeal; along posterior thyroid* - The **glossopharyngeal nerve (CN IX)** provides sensory innervation to the posterior third of the tongue, tonsils, pharynx, and middle ear, and motor innervation to the stylopharyngeus muscle. - It is not directly related to vocal cord function or hoarseness as a result of thyroid surgery. *Hypoglossal; inferior to thyroid* - The **hypoglossal nerve (CN XII)** innervates all extrinsic and intrinsic muscles of the tongue, controlling tongue movement. - Damage to the hypoglossal nerve would affect speech articulation and swallowing but not directly cause hoarseness or vocal cord paralysis.
Question 3: A 55-year-old man has a history of difficulty swallowing and frequent choking while eating. A barium swallow shows a posterior pharyngeal diverticulum. What is the most likely diagnosis?
- A. Zenker's diverticulum (Correct Answer)
- B. Esophageal stricture
- C. GERD
- D. Achalasia
Explanation: ***Zenker's diverticulum*** - A **Zenker's diverticulum** is a **pseudodiverticulum** that occurs due to herniation of the pharyngeal mucosa at Killian's triangle, often causing dysphagia and regurgitation in older adults. - The **barium swallow** revealing a **posterior pharyngeal diverticulum** is a classic finding for Zenker's, and the symptoms of difficulty swallowing and choking are consistent with food lodging in the pouch. *Esophageal stricture* - An **esophageal stricture** is a narrowing of the esophagus, which would cause difficulty swallowing (dysphagia), but typically wouldn't lead to a **posterior pharyngeal diverticulum** on barium swallow. - While strictures can cause choking, the primary finding described in the barium swallow points away from a simple stricture. *GERD* - **Gastroesophageal reflux disease (GERD)** can cause dysphagia due to **esophagitis** or stricture formation, but it is not typically associated with a **posterior pharyngeal diverticulum**. - The main symptoms of GERD include **heartburn** and acid regurgitation, though atypical symptoms exist, the diverticulum is not characteristic. *Achalasia* - **Achalasia** is a motility disorder characterized by impaired relaxation of the **lower esophageal sphincter** and loss of peristalsis in the esophageal body, leading to dysphagia and regurgitation. - A barium swallow in achalasia typically shows a **dilated esophagus** with a "bird's beak" appearance at the LES, not a posterior pharyngeal diverticulum.
Question 4: Patients requiring immediate life-threatening care are categorized under which of the following triage?
- A. Black
- B. Yellow
- C. Red (Correct Answer)
- D. Green
Explanation: ***Red*** - The **red tag** is assigned to patients with immediate, life-threatening injuries or illnesses who have a high probability of survival with prompt medical intervention. - This category signifies that the patient needs **critical care** and immediate transport to a medical facility to stabilize their condition. *Black* - The **black tag** is reserved for patients who are deceased or whose injuries are so severe that survival is unlikely, even with extensive medical care. - This category indicates that resources should be allocated to those with a higher chance of survival. *Yellow* - The **yellow tag** is for patients with significant injuries that require medical attention but are not immediately life-threatening. - These patients can usually wait for a few hours before receiving definitive treatment. *Green* - The **green tag** is for patients with minor injuries or illnesses that are not life-threatening and who can often care for themselves or wait for medical attention for several hours. - They are considered the "walking wounded" and usually require minimal medical intervention.
Question 5: Which of the following is not done in the primary survey of trauma?
- A. Intubation
- B. NCCT head (Correct Answer)
- C. ICD drainage
- D. CXR
Explanation: ***NCCT head*** - A **Non-Contrast CT (NCCT) head** is typically performed during the **secondary survey** once the patient is hemodynamically stable and life-threatening conditions have been addressed. - The primary survey focuses on immediate **life-saving interventions** for airway, breathing, circulation, disability, and exposure. *Intubation* - **Intubation** is a critical intervention during the primary survey, specifically under the **'A' (Airway)** component, to establish and secure a patent airway in a compromised patient. - Failure to establish an airway can rapidly lead to **hypoxia** and death. *ICD drainage* - **Intercostal drain (ICD) drainage** is an urgent intervention in the primary survey, falling under **'B' (Breathing)**, to manage conditions like **tension pneumothorax** or massive hemothorax. - These conditions can severely compromise ventilation and circulation, requiring immediate relief. *CXR* - A **Chest X-ray (CXR)** is a rapid and essential diagnostic tool in the primary survey, also under **'B' (Breathing)**, to identify life-threatening thoracic injuries such as pneumothorax, hemothorax, or mediastinal shift. - It provides quick information crucial for immediate management decisions.
Question 6: Case of trauma in a patient with an unknown blood group. Patient is unstable and requires urgent blood transfusion. Which type of blood should be transfused?
- A. O- (Correct Answer)
- B. AB+
- C. O+
- D. A+
Explanation: ***O-*** - **O-negative blood** is considered the **universal donor** because it lacks A, B, and Rh (D) antigens, making it safe for transfusion to patients of any blood type in an emergency. - In a critically unstable patient with an unknown blood group requiring urgent transfusion, using **O-negative blood minimizes the risk of a severe acute hemolytic transfusion reaction**. *AB+* - **AB-positive blood** is the **universal recipient** blood type, meaning individuals with AB+ blood can receive blood from any donor. - However, transfusing AB+ blood to a patient with an unknown blood type could lead to a **severe hemolytic reaction** if the patient is not AB+. *O+* - While **O-positive blood** is common and can be given to individuals who are Rh-positive, it contains the **Rh antigen**. - Transfusing O-positive blood to an Rh-negative patient (whose Rh status is unknown in this emergency) could cause **alloimmunization** and a hemolytic reaction. *A+* - **A-positive blood** contains A antigens and Rh antigens. - Giving A-positive blood to a patient with an unknown blood type is risky, as it would cause a **hemolytic reaction** if the patient is B, AB, or O, or if they are Rh-negative.
Question 7: A 55-year-old male patient presents to the clinic with left lower lip weakness following a recent parotid gland surgery. Considering the surgical history and current symptoms, what is the most likely site of the lesion causing this patient's condition?
- A. Main trunk of facial nerve
- B. Temporal branch of facial nerve
- C. Parotid duct
- D. Marginal mandibular branch of the facial nerve (Correct Answer)
Explanation: ***Marginal mandibular branch of the facial nerve*** - This branch supplies the muscles around the lower lip, including the **depressor anguli oris** and **depressor labii inferioris**, which are responsible for lower lip movement. - Damage to this specific branch during **parotid gland surgery** is a common cause of isolated **lower lip weakness**, as it runs superficial to the submandibular gland and is vulnerable during dissections in this area. *Main trunk of facial nerve* - Injury to the main trunk would result in **widespread paralysis** of all facial muscles on the affected side, not just isolated lower lip weakness. - The main trunk emerges from the stylomastoid foramen and then enters the parotid gland before branching, so damage here would affect all subsequent branches. *Temporal branch of facial nerve* - This branch innervates muscles responsible for eyebrow movement and forehead wrinkling (e.g., **frontalis muscle**). - Damage to the temporal branch would cause inability to raise the eyebrow and smooth out the forehead, not lower lip weakness. *Parotid duct* - The parotid duct (Stensen's duct) is responsible for transporting saliva from the parotid gland to the oral cavity. - Injury to the parotid duct would lead to complications like **salivary fistula** or **sialocele**, but it does not carry motor innervation to facial muscles and would not cause weakness.
Question 8: Lower lip paralysis after a parotidectomy is most likely due to injury to which structure?
- A. Buccal branch of the facial nerve
- B. Cervical branch of the facial nerve
- C. Temporal branch of the facial nerve
- D. Marginal mandibular branch of the facial nerve (Correct Answer)
Explanation: ***Marginal mandibular branch of the facial nerve*** - The **marginal mandibular branch** innervates the muscles of the lower lip and chin, including the **depressor anguli oris**, **depressor labii inferioris**, and **mentalis**. - Injury to this nerve during a **parotidectomy**, where it can be inadvertently cut or damaged due to its superficial course over the mandible, results in ipsilateral **lower lip paralysis** and an asymmetric smile. *Buccal branch of the facial nerve* - The **buccal branch** primarily innervates the muscles around the mouth, such as the buccinator and orbicularis oris, affecting **upper lip movement** and cheek function. - Damage to this branch would typically affect functions like chewing and smiling, but not specifically the lower lip. *Cervical branch of the facial nerve* - The **cervical branch** innervates the **platysma muscle**, which is involved in neck skin tension and depressing the mandible. - Injury to this branch would cause weakness or paralysis of the platysma, not lower lip paralysis. *Temporal branch of the facial nerve* - The **temporal branch** innervates the muscles of the forehead and around the eye, including the **frontalis** and **orbicularis oculi**. - Damage to this branch would result in the inability to wrinkle the forehead and close the eye, but not lower lip paralysis.
Question 9: A 25-year-old male college student presents to emergency after road traffic accident. Patient is in state of shock and breath sounds are decreased on the side of chest trauma (left side). Normal heart sounds, no elevated JVP and dull note on percussion. What is the diagnosis?
- A. Massive Hemothorax (Correct Answer)
- B. Cardiac tamponade
- C. Flail chest
- D. Tension pneumothorax
Explanation: ***Massive Hemothorax*** - The combination of **shock**, **decreased breath sounds**, and **dullness to percussion** on the injured side is highly indicative of massive hemothorax. - A massive hemothorax involves rapid accumulation of a large volume of blood (typically >1500 mL) in the pleural space, leading to significant **hypovolemic shock** and **respiratory compromise**. *Cardiac tamponade* - Characterized by **Beck's triad**: **hypotension**, **muffled heart sounds**, and **elevated JVP**, none of which are fully present here (heart sounds are normal, JVP is not elevated). - While it can cause shock, the lung findings (decreased breath sounds, dullness) point away from a primary cardiac issue. *Flail chest* - Defined by **paradoxical chest wall movement** due to fractures of multiple adjacent ribs in two or more places, which is not mentioned in the presentation. - Although it can lead to respiratory distress, it typically presents with crepitus and localized pain, not necessarily with dullness to percussion or profound shock from blood loss. *Tension pneumothorax* - Presents with **absent or decreased breath sounds** and **hyperresonance to percussion** on the affected side, along with **tracheal deviation** away from the affected side and distended neck veins. - The key differentiating factor here is the **dullness to percussion**, which is inconsistent with the air accumulation seen in tension pneumothorax.
Question 10: Arrange the following according to good outcome a - zone of stasis b - zone of coagulation c - zone of hyperemia
- A. a > b > c
- B. a > c > b
- C. c > a > b (Correct Answer)
- D. a = c > b
Explanation: **Context:** This question refers to Jackson's burn wound model, which describes three concentric zones in a burn injury. ***c > a > b*** (Correct Answer) - The **zone of hyperemia (c)** has the **best prognosis** for recovery because tissue damage is minimal, involving primarily vasodilation and increased blood flow. This zone typically recovers completely within 7-10 days. - The **zone of stasis (a)** has an **intermediate prognosis**; tissue here is potentially salvageable but at risk of progression to necrosis within 24-48 hours if not properly managed (adequate fluid resuscitation, prevention of infection, avoiding vasoconstrictors). - The **zone of coagulation (b)** has the **worst prognosis**, as cellular damage is irreversible with immediate coagulative necrosis. This tissue will eventually slough off and requires debridement. *a > b > c* - Incorrectly suggests the **zone of stasis** has better outcome than **zone of hyperemia**, which contradicts the pathophysiology of burn injuries. - The **zone of coagulation** cannot have better outcome than **zone of hyperemia** as it represents dead tissue. *a > c > b* - Incorrectly places **zone of stasis** as having the best outcome when it has only intermediate prognosis. - The **zone of hyperemia** should be first as it has the highest probability of complete recovery without intervention. *a = c > b* - Incorrectly equates the prognosis of **zone of stasis** and **zone of hyperemia**, despite clear differences in severity and reversibility of tissue damage. - The **zone of hyperemia** has unequivocally better prognosis than the **zone of stasis**.