INI-CET 2025 — Surgery
13 Previous Year Questions with Answers & Explanations
A 40-year-old male presents to the emergency department with severe respiratory distress, BP: 70/59 mmHg, tracheal deviation to the right, distended neck veins, and absent breath sounds on the left side. These findings are suggestive of a tension pneumothorax. What is the most appropriate immediate next step in management?
A 35-year-old patient presents with colicky pain and is diagnosed with a ureteric stone. Which of the following is the best diagnostic investigation in this case?
Which of the following statements regarding Vacuum-Assisted Closure (VAC) therapy is correct? 1. It promotes granulation tissue formation 2. It reduces interstitial and periwound edema 3. It drains excessive exudate 4. It increases local blood flow
What is a true statement about Z plasty?
Identify the procedure shown in the image.
Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?
Which of the following is not a contraindication for breast conservation surgery?
Which of the following is not included in T4b classification of breast cancer?
A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?
A 40-year-old male with head injury presents with respiratory distress and absent breath sounds on the right. GCS is 8/15. What is the most immediate next step in management?
INI-CET 2025 - Surgery INI-CET Practice Questions and MCQs
Question 1: A 40-year-old male presents to the emergency department with severe respiratory distress, BP: 70/59 mmHg, tracheal deviation to the right, distended neck veins, and absent breath sounds on the left side. These findings are suggestive of a tension pneumothorax. What is the most appropriate immediate next step in management?
- A. CT Chest
- B. Airway, breathing, and circulation (ABC) assessment
- C. Chest tube insertion
- D. Perform needle thoracostomy immediately (Correct Answer)
Explanation: ***Perform needle thoracostomy immediately*** * Tension pneumothorax is a **clinical diagnosis** and a life-threatening emergency requiring immediate intervention without waiting for imaging confirmation. * The classic triad of **hypotension (BP 70/59 mmHg), tracheal deviation, and distended neck veins** with absent breath sounds confirms the diagnosis. * **Immediate needle decompression** (2nd intercostal space, midclavicular line on affected side) is the correct first step to rapidly decompress the tension and restore venous return to the heart. * This is performed as part of the **primary survey** in ATLS protocol - tension pneumothorax is identified and treated during the "B" (breathing) assessment. * Delaying intervention to "complete an assessment" when the diagnosis is evident would be life-threatening. *Airway, breathing, and circulation (ABC) assessment* * While ABC assessment is fundamental in trauma management, the clinical findings described (tracheal deviation, absent breath sounds, hypotension) **are already the result of assessment**. * The patient requires **immediate intervention**, not further assessment. * In ATLS, tension pneumothorax is treated **during** the primary survey as soon as it is identified - you do not defer treatment to "complete" the assessment. *Chest tube insertion* * Tube thoracostomy (chest tube) is the **definitive management** for pneumothorax. * However, in a hemodynamically unstable patient with tension pneumothorax, **needle decompression must be performed first** for rapid relief. * Chest tube insertion follows after initial stabilization and is more time-consuming to perform. *CT Chest* * **CT imaging is contraindicated** in hemodynamically unstable patients (BP 70/59 mmHg). * Tension pneumothorax is a clinical diagnosis requiring immediate intervention - imaging would cause fatal delay. * CT chest may be considered only in **stable patients** with diagnostic uncertainty.
Question 2: A 35-year-old patient presents with colicky pain and is diagnosed with a ureteric stone. Which of the following is the best diagnostic investigation in this case?
- A. Ureteroscopy
- B. Non-contrast CT KUB (Correct Answer)
- C. Ultrasonography KUB
- D. Contrast-enhanced CT KUB
Explanation: ***Correct: Non-contrast CT KUB*** - It is currently the **gold standard** imaging modality for diagnosing acute **urolithiasis** (renal or ureteral stones) due to its superior sensitivity and specificity for detecting calculi. - NCCT KUB detects virtually all stone compositions (including radiolucent **uric acid stones**) and accurately determines their size, location, and secondary signs like **hydronephrosis**. *Incorrect: Ultrasonography KUB* - While useful for detecting **hydronephrosis** and large stones, USG has low sensitivity for smaller calculi, particularly those located in the **mid-ureter**. - It is often reserved for initial screening or cases where **radiation avoidance** is necessary, such as in pregnant patients or children. *Incorrect: Contrast-enhanced CT KUB* - The use of intravenous **contrast material** is unnecessary for diagnosing simple stones and can potentially obscure the visualization of small stone margins, making it less ideal than NCCT. - CECT is typically reserved for evaluating complex cases, such as suspected **pyelonephritis**, collecting system injury, or other non-calculous causes of obstruction. *Incorrect: Ureteroscopy* - Ureteroscopy is primarily a minimally invasive **therapeutic/surgical procedure** used for stone fragmentation and removal, not the default initial non-invasive diagnostic imaging tool. - Although it can confirm the presence of stones, it is invasive and should follow thorough non-invasive imaging like NCCT KUB to plan treatment effectively.
Question 3: Which of the following statements regarding Vacuum-Assisted Closure (VAC) therapy is correct? 1. It promotes granulation tissue formation 2. It reduces interstitial and periwound edema 3. It drains excessive exudate 4. It increases local blood flow
- A. All correct (Correct Answer)
- B. 1 and 3 correct
- C. 2 and 4 correct
- D. 1, 2, 3 correct
Explanation: ***All correct*** - Vacuum-Assisted Closure (VAC) therapy, or Negative Pressure Wound Therapy (**NPWT**), provides several mechanical and biological benefits that collectively promote complex wound healing and preparing the wound bed for definitive closure. - The therapeutic effects of NPWT include promoting **granulation tissue formation**, reducing **interstitial and periwound edema**, draining excessive **exudate** (which lowers bacterial load), and significantly increasing **local blood flow** (perfusion) in the wound bed. ***1 and 3 correct*** - This option is incomplete because the reduction of **edema** (statement 2) and the increase in **local blood flow** (statement 4) are well-established, crucial mechanisms of NPWT. - Excluding statements 2 and 4 falsely limits the physiological effects of VAC, which relies on managing tissue pressure and perfusion for optimal results. ***2 and 4 correct*** - This option is incomplete because the primary visible clinical goals of NPWT, namely the promotion of **granulation tissue** (statement 1) and the active removal of **exudate/infectious material** (statement 3), are ignored. - NPWT's ability to stimulate cellular activity for **granulation** is one of its most critical roles in preparing the wound for closure. ***1, 2, 3 correct*** - While statements 1, 2, and 3 are correct, this option excludes the crucial benefit of statement 4: increasing **local blood flow**. - Increased blood flow ensures adequate delivery of **oxygen and nutrients** to support cellular repair and proliferation, which is fundamental to successful vacuum-assisted wound healing.
Question 4: What is a true statement about Z plasty?
- A. To increase length (Correct Answer)
- B. It is a type of split-thickness skin graft
- C. Zigzag suturing
- D. Flap turning
Explanation: ***To increase length*** - The primary purpose of **Z-plasty** is to lengthen a contracted scar or structure, typically achieving a 50% to 75% increase in length. - It also helps to change the direction of a scar, making it align better with **Langer's lines** (lines of tension), thus improving cosmetic outcomes. - The **central limb** of the Z increases in length when the two triangular flaps are transposed. *It is a type of split-thickness skin graft* - Z-plasty is **not a graft** but rather a **local tissue rearrangement technique** using transposition flaps. - A **split-thickness skin graft (STSG)** is a separate reconstructive technique used to cover large wounds or burns and is harvested superficially. - Z-plasty utilizes adjacent tissue without the need for harvesting skin from another site. *Zigzag suturing* - This term is sometimes inaccurately used to describe the final appearance of a Z-plasty closure, but the fundamental goal of Z-plasty is **length increase and scar reorientation**, not creating a zigzag pattern. - A **W-plasty**, which creates a pattern of small triangles in a zigzag fashion, is used primarily to break up long linear scars and prevent scar contracture, not for significant lengthening. *Flap turning* - Although Z-plasty involves transposing two triangular flaps, the purpose is not merely flap turning but specifically **increasing length and changing the direction** of the tissue. - The flaps are designed at specific angles (usually 30°, 45°, or 60°) to optimize the redistribution of tissue and relieve **tissue tension**.
Question 5: Identify the procedure shown in the image.
- A. Dog ear excision (Correct Answer)
- B. Keloid excision
- C. Z plasty
- D. Transposition flap
Explanation: ***Dog ear excision*** - The image illustrates the surgical correction of a **"dog ear" deformity**, which is a pucker of redundant skin and fat that can form at the end of a linear wound closure. - The technique shown involves excising a triangle of excess skin and subcuticular tissue to flatten the closure and improve the cosmetic outcome, which is characteristic of this procedure. *Keloid excision* - A **keloid** is a type of raised scar that grows beyond the boundaries of the original wound. Excision of a keloid involves removing pathologic scar tissue, not correcting a pucker of normal skin. - Keloid management often requires adjuvant therapies like **intralesional steroids** or **radiation** to prevent recurrence, which is not part of the simple excision shown. *Z plasty* - A **Z-plasty** is a scar revision technique used to lengthen a contracted scar or reorient it along natural skin lines. It involves creating and transposing two triangular flaps in a 'Z' shape. - The procedure in the image does not involve the characteristic **'Z'-shaped incisions** or the transposition of flaps seen in a Z-plasty. *Transposition flap* - A **transposition flap** is a surgical technique where a segment of skin and underlying tissue is moved from a donor site to cover an adjacent defect, while remaining attached to its original blood supply. - The image shows removal of excess tissue at the site of a primary closure, not the transfer of tissue to cover a separate wound.
Question 6: Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?
- A. 0.3 (Correct Answer)
- B. 0.9
- C. 0.7
- D. 0.5
Explanation: ***Correct: 0.3*** - An ABPI value of ≤ **0.4** is indicative of **severe peripheral artery disease (PAD)**, which is associated with critical limb ischemia (CLI). - **Critical Limb Ischemia (CLI)** is defined as ABI < **0.4** or toe pressure < 30 mmHg, which corresponds to severe compromise in blood flow, often leading to **imminent gangrene** or rest pain. *Incorrect: 0.5* - An ABPI of **0.5** to **0.9** indicates **moderate PAD**. At this stage, patients typically experience **intermittent claudication** during exertion, but not imminent rest pain or tissue loss. - While significant, it does not represent the severe flow reduction required for *imminent* tissue necrosis like gangrene. *Incorrect: 0.7* - An ABPI of **0.7** falls within the range of **mild to moderate PAD** (0.5–0.9), where symptoms are usually limited to claudication. - This value indicates only moderate compromise in blood supply, far above the threshold for **critical limb ischemia**. *Incorrect: 0.9* - An ABPI of **0.9** to **1.3** is considered **normal** or almost normal. Values below 0.9 signify the presence of PAD. - This level of blood flow provides adequate perfusion and certainly poses **no risk of gangrene**.
Question 7: Which of the following is not a contraindication for breast conservation surgery?
- A. Scleroderma
- B. History of radiation
- C. Multiple cancer in one quadrant (Correct Answer)
- D. Persistent positive margin
Explanation: ***Multiple cancer in one quadrant*** - This presentation is defined as **multifocal carcinoma**, where multiple tumor foci are located within the same quadrant of the breast. - Unlike true multicentric disease (carcinoma in two or more quadrants), multifocal disease is **not an absolute contraindication** for breast conservation surgery (BCS), provided all lesions can be excised with clear margins and the planned cosmetic result is acceptable. ***Scleroderma*** - Active connective tissue disorders like **scleroderma** or active **Systemic Lupus Erythematosus (SLE)** are absolute contraindications for BCS due to a high risk of adverse reactions to post-operative radiotherapy. - Radiation in these patients can lead to severe complications, including high rates of **fibrosis**, edema, and poor cosmetic outcomes. ***History of radiation*** - A **previous history of therapeutic radiation** to the breast or chest wall (e.g., for Hodgkin's lymphoma or previous breast cancer) is an absolute contraindication. - Re-irradiating the same tissue increases the risk of severe cumulative dose toxicity, local complications, and potentially **radiation-induced malignancy**. ***Persistent positive margin*** - The inability to achieve tumor-free margins of excision, even after **multiple re-excisions** (usually 2-3 attempts), remains an absolute contraindication to BCS. - Performing BCS despite persistently positive margins results in an unacceptably high risk of local recurrence, necessitating a complete **mastectomy**.
Question 8: Which of the following is not included in T4b classification of breast cancer?
- A. Satellite nodule
- B. Ulceration
- C. Peau d'orange
- D. Cellulitis/erythema over one-third of the breast (inflammatory breast cancer) (Correct Answer)
Explanation: ***Cellulitis/erythema over one-third of the breast (inflammatory breast cancer)*** - This description corresponds to a **T4d** tumor, which is classified as **Inflammatory Breast Cancer (IBC)**. - IBC is a separate classification from T4b and is characterized by erythema, edema, and peau d'orange involving at least one-third of the breast, often with rapid onset. - T4d is **not included in T4b classification**; it is a distinct category within T4 tumors. *Incorrect: Satellite nodule* - **Satellite skin nodules** are a feature that can be included in **T4b** classification according to AJCC staging. - T4b includes ulceration and/or ipsilateral satellite nodules and/or edema of the skin (including peau d'orange). *Incorrect: Ulceration* - **Skin ulceration** is a specific defining feature of **T4b** tumors. - It represents direct tumor extension causing breakdown of the overlying skin. *Incorrect: Peau d'orange* - **Peau d'orange** (skin edema due to lymphatic obstruction) is a characteristic feature of **T4b** classification. - It gives the skin an orange-peel appearance and indicates locally advanced disease.
Question 9: A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?
- A. 6
- B. 4
- C. 5
- D. 7 (Correct Answer)
Explanation: ***7*** - The Alvarado score (MANTRELS) is a clinical scoring system used to diagnose **acute appendicitis** based on symptoms, signs, and laboratory findings. - **Components present in this patient:** - **M**igration of pain (umbilicus → RIF): **1 point** - **A**norexia/Nausea (nausea present): **1 point** - **T**enderness in right iliac fossa: **2 points** - **R**ebound tenderness: **0 points** (not mentioned) - **E**levated temperature (fever): **1 point** - **L**eukocytosis (WBC 14,000 > 10,000/cmm): **2 points** - **S**hift to left (neutrophilia): **0 points** (not provided) - **Total score: 1 + 1 + 2 + 1 + 2 = 7 points** - A score of **7-8 indicates probable appendicitis** and typically warrants surgical intervention or further imaging based on clinical judgment. *4* - A score of 4 suggests **low probability of appendicitis**. - This score indicates that appendicitis is unlikely, warranting observation or alternative diagnosis consideration. *5* - A score of 5 indicates **intermediate/equivocal probability** of appendicitis. - Patients typically require **active observation, serial examinations**, or imaging (ultrasound/CT) for confirmation. *6* - A score of 6 also falls into the **intermediate risk category** with higher suspicion than score 5. - Usually warrants **imaging or close observation** but is lower than the calculated score for this patient.
Question 10: A 40-year-old male with head injury presents with respiratory distress and absent breath sounds on the right. GCS is 8/15. What is the most immediate next step in management?
- A. Secure airway (Correct Answer)
- B. Contrast-enhanced CT (CECT)
- C. Oxygen by nasal prongs
- D. Intercostal chest drain (ICD)
Explanation: ***Secure airway*** - In a patient with **head injury** (GCS 8/15) and **respiratory distress**, establishing a definitive, protected airway is the **absolute priority** following **ABC** principles of trauma management. - A GCS of **≤8** is a clear indication for **endotracheal intubation** to prevent aspiration, ensure adequate ventilation, and protect the airway. - While absent breath sounds suggest **pneumothorax**, the absence of hemodynamic instability (hypotension, tachycardia) or other signs of **tension pneumothorax** (JVD, tracheal deviation) suggests this is likely a **simple pneumothorax** rather than tension. - In simple pneumothorax with severe head injury, **airway securement takes precedence** per ATLS guidelines, followed immediately by chest decompression. - **Note:** If clinical signs of **tension pneumothorax** were present (cardiovascular collapse, severe hypotension), immediate needle decompression would take priority even before intubation, as positive pressure ventilation in untreated tension pneumothorax can be fatal. *Incorrect: Intercostal chest drain (ICD)* - While the patient shows signs of **pneumothorax** or **hemothorax** (absent breath sounds on right), and ICD placement is definitely required, it comes *after* securing the airway in this scenario. - The **critical GCS of 8** makes airway protection the immediate priority to prevent aspiration and respiratory arrest. - ICD placement should follow immediately after intubation, as the patient needs both interventions urgently. *Incorrect: Contrast-enhanced CT (CECT)* - Imaging studies are necessary for definitive diagnosis but are **secondary to resuscitation** and addressing immediate life threats. - Transporting an unstable patient with GCS 8 and an unprotected airway to CT scanner is dangerous and violates **ATLS principles**. - **"Treat first, scan later"** is the rule in unstable trauma patients. - CT is performed after airway is secured, breathing is stabilized, and patient is hemodynamically stable. *Incorrect: Oxygen by nasal prongs* - While oxygen supplementation is important, **nasal prongs** provide inadequate oxygenation for a patient in severe respiratory distress with GCS 8. - This passive method does not address the **unprotected airway** or provide adequate ventilation support. - With GCS 8, the patient cannot protect their airway and requires **definitive airway management** (endotracheal intubation), not just supplemental oxygen.