NEET-PG 2021 - Surgery Practice Questions

Q: In which condition is gas under the diaphragm most commonly seen on imaging?

Secondary. ***Correct: Secondary*** - **Gas under the diaphragm** is a classic sign of a **perforated viscus**, which is a severe form of **secondary peritonitis**. - Secondary peritonitis typically arises from the **rupture or perforation of an abdominal organ**, allowing gas and contents to leak into the peritoneal cavity. *Incorrect: Tertiary* - **Tertiary peritonitis** refers to persistent or recurrent peritonitis after seemingly adequate surgical and antibiotic treatment for primary or secondary peritonitis. - It is associated with **immunocompromised states** or **low-virulence organisms** and does not typically present with free gas under the diaphragm. *Incorrect: Retained stone* - A **retained stone** (e.g., gallstone, renal stone) can cause obstruction or inflammation but does not directly lead to **gas under the diaphragm**. - While it might indirectly lead to perforation if neglected, it's not the most common direct cause of **free peritoneal gas**. *Incorrect: Primary* - **Primary peritonitis** (also known as spontaneous bacterial peritonitis) occurs without an apparent source of contamination within the abdominal cavity, often in patients with ascites and **liver cirrhosis**. - It is characterized by bacterial infection of the ascitic fluid but does not involve a perforated viscus or **free gas under the diaphragm**.

Q: Mr. Ramu, a 35-year-old male, sustained a straddle injury in a motor vehicle accident and presents to the emergency department with blood at the urethral meatus. What is the next appropriate step in his management?

Retrograde urethrogram. ***Retrograde urethrogram*** - **Blood at the urethral meatus** after a straddle injury is highly suggestive of **urethral injury**, and a retrograde urethrogram is the diagnostic test of choice to assess the integrity of the urethra. - This procedure involves injecting contrast into the urethra to visualize any extravasation, strictures, or complete disruptions before attempting catheterization. *CECT Abdomen* - A CECT abdomen is primarily used to assess **solid organ injuries** or **intra-abdominal bleeding**, which is not the primary concern suggested by blood at the urethral meatus. - While broad abdominal trauma may warrant a CECT, it does not directly evaluate urethral integrity. *FAST* - **FAST (Focused Assessment with Sonography for Trauma)** is a rapid ultrasound examination to detect **free fluid (blood)** in the peritoneal or pericardial cavities. - It is used to identify **intra-abdominal or pericardial hemorrhage** and guide resuscitation, but it does not visualize the urethra. *Abdomen X-ray* - An abdomen X-ray can detect **fractures of the pelvis** or foreign bodies, but it does not provide detailed imaging of soft tissues like the urethra. - It would not show urethral extravasation or disruption, making it insufficient for diagnosing urethral injury.

Q: A **hemodynamically stable** patient involved in a Road Traffic Accident (RTA) presents with: - Absent air entry on the left side of the chest. - Tenderness in the left lower chest wall. What is the next step in the Emergency Medicine Room (EMR) management?

Chest X-ray. ***X-ray*** - In a **hemodynamically stable** patient with absent air entry and chest wall tenderness post-RTA, a **chest X-ray** is the most appropriate initial imaging in the EMR. - It quickly diagnoses conditions like **pneumothorax**, **hemothorax**, or **rib fractures** and guides management decisions. - **Important**: Clinical assessment for **tension pneumothorax** (hypotension, tracheal deviation, distended neck veins) must be done first. If tension pneumothorax is suspected, **immediate needle decompression** is required without waiting for imaging. - X-ray is **rapidly available** and provides crucial information for trauma management in stable patients. *FAST* - **Focused Assessment with Sonography for Trauma (FAST)** is primarily used to detect **intra-abdominal free fluid** (hemoperitoneum) or pericardial effusion in trauma. - While valuable in RTA evaluation, it is not the primary diagnostic tool for absent air entry in the chest. - FAST has limited sensitivity for **pneumothorax** and does not visualize **rib fractures** in detail. *DPL* - **Diagnostic Peritoneal Lavage (DPL)** is an invasive procedure used to detect **intra-abdominal injury** and hemorrhage. - It has largely been replaced by FAST and CT scans due to its invasive nature and lower specificity. - DPL provides **no information about chest injuries** and is irrelevant for evaluating absent air entry. *CT* - A **CT scan** (chest CT) provides highly detailed imaging and is excellent for diagnosing specific chest injuries. - However, it is **time-consuming**, requires patient transport, and is typically reserved for **stable patients** after initial X-ray assessment. - In the immediate EMR setting, X-ray is preferred for rapid decision-making, with CT used for further evaluation if needed.

Question 1

A patient is found to have an asymptomatic common bile duct (CBD) stone two years after cholecystectomy on routine imaging. What is the most appropriate initial management?

Accepted Answer

ERCP with sphincterotomy and stone extraction

Answer

Keep on active surveillance

Answer

Medical dissolution therapy with ursodeoxycholic acid

Answer

Surgical exploration and choledochotomy

Question 2

In which condition is gas under the diaphragm most commonly seen on imaging?

Accepted Answer

Secondary

Answer

Tertiary

Answer

Retained stone

Answer

Primary

Question 3

A patient with a left hypochondrium contusion presents with systolic blood pressure of 70 mm Hg and pulse rate of 110 bpm. What is the best step in management?

Accepted Answer

Emergency surgical exploration

Answer

Conservative management with observation

Answer

Chest tube insertion

Answer

Antibiotic therapy

Question 4

Mr. Ramu, a 35-year-old male, sustained a straddle injury in a motor vehicle accident and presents to the emergency department with blood at the urethral meatus. What is the next appropriate step in his management?

Accepted Answer

Retrograde urethrogram

Answer

CECT Abdomen

Answer

FAST

Answer

Abdomen X-ray

Question 5

A **hemodynamically stable** patient involved in a Road Traffic Accident (RTA) presents with:

- Absent air entry on the left side of the chest.
- Tenderness in the left lower chest wall.

What is the next step in the Emergency Medicine Room (EMR) management?

Accepted Answer

Chest X-ray

Answer

FAST (Focused Assessment with Sonography for Trauma)

Answer

DPL (Diagnostic Peritoneal Lavage)

Answer

CT scan (Computed Tomography)

NEET-PG 2021 — Surgery