UPSC-CMS 2014 - Surgery Practice Questions

Q: An electrical contact burn is considered to be:

Full thickness burn. ***Full thickness burn*** - Electrical contact burns are characterized by **high heat** generated at the point of contact, leading to **deep tissue destruction** that extends through the entire dermis and often into subcutaneous fat, muscle, or bone - The current pathway through the body causes additional damage internally, but the contact point itself typically reflects a **third-degree (full thickness) injury** due to intense localized heat - Entry and exit wounds from electrical burns characteristically show **charred, dry tissue** with central necrosis *Superficial partial thickness burn* - This type of burn involves only the **epidermis and superficial portion of the dermis**, typically presenting with blistering and redness - Electrical burns, especially contact burns, rarely result in such shallow injury due to the **intense and deep nature** of the energy transfer - The high voltage and current density at contact points cause damage far beyond superficial layers *Superficial scalding with blisters* - **Scald burns** are caused by hot liquids or steam and are typically **superficial or superficial partial thickness** - An electrical contact burn is distinct in its mechanism (electrical current) and the **severity of tissue damage** it causes, which extends far beyond the superficial layers - The mechanism of injury is fundamentally different from thermal scalding *Deep partial thickness burn* - Deep partial thickness burns extend into the **deeper dermis**, causing fluid-filled blisters and often mottled or waxy white areas - While electrical burns can involve deeper structures, the direct point of contact in an electrical contact burn usually causes damage that is **full thickness or beyond**, going past just the deep dermis - The concentrated heat and current flow at entry/exit sites result in complete destruction of all skin layers

Q: A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:

Colonoscopy. ***Colonoscopy*** - **Colonoscopy** is the gold standard for investigating symptoms like rectal bleeding, altered bowel habits, and tenesmus, as it allows for direct visualization of the entire colon and rectum. - It enables **biopsy of suspicious lesions** for histopathological diagnosis, which is crucial for confirming conditions like colorectal cancer or inflammatory bowel disease. *Contrast-enhanced CT scan* - A **contrast-enhanced CT scan** is primarily used for **staging known malignancies** and assessing for distant metastases, not as a primary diagnostic tool for initial symptoms. - While it can identify large masses, it might miss smaller lesions and does not allow for tissue biopsy. *Fecal occult blood test* - A **fecal occult blood test** screens for blood in the stool, which indicates gastrointestinal bleeding but does not pinpoint the source or cause. - It has **low sensitivity and specificity** for diagnosing underlying conditions like colorectal cancer or inflammatory bowel disease and is mainly a screening tool. *Ultrasonogram* - An **ultrasonogram** is generally not effective for evaluating the colon and rectum due to bowel gas interference. - It is more commonly used for investigating abdominal organs like the liver, gallbladder, and kidneys, or for pelvic pathology, but not the primary investigation for these colorectal symptoms.

Q: On second day following femoral embolectomy, the leg is found to be tender, tense and dusky with feeble dorsalis pedis pulse. The most appropriate management would be:

Fasciotomy. ***Fasciotomy*** - The symptoms (tender, tense, dusky leg with feeble dorsalis pedis pulse) occurring after revascularization strongly suggest developing **compartment syndrome**. - **Fasciotomy** is the most appropriate management to relieve pressure, restore blood flow, and prevent irreversible muscle and nerve damage. *Dye studies* - While imaging like angiography (dye studies) can assess vascular patency, they are not the immediate solution for suspected **compartment syndrome**. - Delaying definitive treatment for compartment syndrome for imaging can lead to **irreversible tissue damage**. *Doing re-embolectomy* - The problem is unlikely to be a persistent or recurrent embolus given the prior embolectomy and the presentation suggesting **compartment syndrome**, not ongoing arterial occlusion. - Repeating the procedure without addressing the underlying compartment pressure would be ineffective and potentially harmful. *Anticoagulant therapy* - Anticoagulation is crucial for preventing new clots or re-thrombosis but does not resolve the acute mechanical compression and ischemia of **compartment syndrome**. - It's part of the overall management but not the primary intervention for the immediate life-threatening limb condition described.

Q: A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:

T2 N1 M1. ***T2 N1 M1*** **(Correct Answer)** - **T2** indicates the tumor invades the **muscularis propria** in the TNM classification for colorectal cancer. - **N1** signifies involvement of **one to three regional lymph nodes**, which corresponds to "one or two nodes involved" in the question. - **M1** denotes the presence of **distant metastasis**, specifically a "solitary metastasis in the liver" as described. *T1 N2 M1* - **T1** describes a tumor that invades the **submucosa** but not the muscularis propria, which is less advanced than the scenario described. - **N2** would imply involvement of **four or more regional lymph nodes**, contradicting the "one or two nodes involved" stated in the question. *T1 N1 M1* - **T1** indicates invasion into the **submucosa**, not reaching the muscularis propria as specified in the case description. - The **N1** and **M1** components are consistent with the nodal involvement and distant metastasis, but the **T stage** is incorrect. *T2 N2 M1* - While **T2** is correct for invasion into the muscularis propria, **N2** incorrectly implies involvement of **four or more regional lymph nodes**. - The question states "one or two nodes involved," making **N1** the appropriate nodal classification.

Q: After undergoing surgery, for carcinoma of colon, a patient developed single liver metastasis of 2 cm. What would be the next treatment?

Resection. ***Resection*** - For a **single, resectable liver metastasis** from colorectal carcinoma, surgical **resection offers the best chance of cure** and is the gold standard of treatment. - The size of the metastasis (2 cm) is well within the criteria for surgical removal, and the absence of multiple lesions or widespread disease makes it a prime candidate for curative surgery. *Radio frequency ablation* - **RFA** is typically considered for patients with **unresectable liver metastases** or those who are not surgical candidates. - While it can be effective for small lesions, it is generally preferred when resection is not possible due to factors like lesion location (e.g. adjacent to major vessels), patient comorbidities, or multiple lesions. *Chemo-radiation* - **Chemoradiation** is more commonly used in the treatment of the **primary colorectal cancer** itself, especially in locally advanced rectal cancer, or for palliative purposes in metastatic disease. - It is **not the primary curative treatment** for an isolated, resectable liver metastasis. *Acetic acid injection* - **Acetic acid injection** is a form of **chemical ablation** and is sometimes used for small liver tumors, particularly hepatocellular carcinoma. - It is generally considered **less effective and less predictable** than RFA or surgical resection for colorectal liver metastases and is not the preferred treatment for a resectable lesion.

Q: Which one of the following parts of intussusception is most susceptible to ischaemia and perforation?

Apex. ***Apex*** - The **apex** is the **leading edge** (distal tip) of the intussusceptum that protrudes furthest into the intussuscipiens. - It is the **most distal point** from its blood supply and experiences the **greatest degree of vascular compromise**. - The apex suffers from **pressure necrosis** due to compression against the intussuscipiens and maximal venous congestion. - This makes it the **most susceptible site for ischemia, necrosis, and perforation** in intussusception. - Clinically, when perforation occurs, it is **most commonly at the apex**. *Neck* - The **neck** is the constricted point where the intussusceptum enters the intussuscipiens. - While the neck does compress the **mesentery and blood vessels**, causing venous outflow obstruction that affects the entire intussusceptum, it is not itself the most susceptible site for perforation. - The neck causes the ischemia, but the apex suffers the most from it. *Intussuscipiens* - The **intussuscipiens** is the **outer receiving segment** that engulfs the intussusceptum. - Its blood supply remains relatively intact as it is not invaginated. - It is **not susceptible** to ischemia in the same way as the invaginated segment. *Intussusceptum* - The **intussusceptum** refers to the **entire invaginated inner segment**. - While the whole intussusceptum can become ischemic, the question asks for the **specific part** most susceptible. - Within the intussusceptum, the **apex is the most vulnerable point** for ischemia and perforation.

Q: A 30 year old lady comes with history of bloody discharge from her right nipple while taking bath. On examination, there is a cystic swelling in the subareolar region. The clinical diagnosis would be:

Intraductal papilloma. ***Intraductal papilloma*** - **Bloody nipple discharge**, especially unilateral and spontaneous, is the hallmark symptom of an **intraductal papilloma**. - The presence of a **subareolar cystic swelling** further supports this diagnosis, as papillomas are benign growths arising within the breast ducts. *Duct ectasia* - This condition typically presents with a **thick, sticky, multi-colored nipple discharge**, not usually bloody. - It is more common in **perimenopausal** or postmenopausal women and is often associated with inflammation and nipple retraction. *Fibrocystic disease* - Characterized by **cyclic breast pain**, tenderness, and multiple palpable masses, often bilateral. - Nipple discharge, if present, is usually **clear, green, or brown**, but rarely bloody. *Intraductal carcinoma* - While it can cause bloody nipple discharge, it is less common in this age group (30-year-old). - More likely to present with a **firm or hard palpable mass** rather than a cystic swelling, and often accompanied by skin changes or nipple retraction. - The benign cystic nature of the swelling makes intraductal papilloma more likely in this clinical scenario.

Q: Which of the following is not true regarding ‘no scalpel’ vasectomy?

Scrotal skin is cut with LASER to expose the vas.. ***Scrotal skin is cut with LASER to expose the vas.*** - The "no-scalpel" technique specifically avoids cutting the scrotal skin with a **scalpel** or **LASER**. - Instead, a **small puncture** is made using a specialized instrument to access the vas deferens. *The failure rate is same as that of conventional vasectomy.* - The failure rate for no-scalpel vasectomy is generally very low and comparable to, or even slightly lower than, conventional vasectomy. - This is due to the precise identification and handling of the **vas deferens** through the small puncture. *Special instruments are used to deliver the vas instead of cutting the skin.* - This statement is true; the no-scalpel technique utilizes **specialized forceps** to puncture and stretch the scrotal skin. - This creates a small opening to access the vas deferens without needing a traditional incision. *It is a very popular method in China.* - The no-scalpel vasectomy technique was developed in China in 1974 by Dr. Li Shunqiang, where it gained widespread adoption. - Its popularity in China significantly contributed to its global recognition as a minimally invasive and effective method for male contraception.

Question 1

Match List-I with List-II and select the correct answer using the code given below the Lists:

**List-I (Procedure)**
A. Highly selective vagotomy
B. Vagotomy with gastrojejunostomy
C. Subtotal gastrectomy
D. Nissen's fundoplication

**List-II (Complication)**
1. Metabolic bone disease
2. Post-prandial gas bloat
3. Lesser curve necrosis
4. Diarrhea

**Code:**

Accepted Answer

A→2  B→4  C→1  D→3

Answer

A→2  B→1  C→4  D→3

Answer

A→3  B→1  C→4  D→2

Answer

A→3  B→4  C→1  D→2

Question 2

An electrical contact burn is considered to be:

Accepted Answer

Full thickness burn

Answer

Superficial partial thickness burn

Answer

Superficial scalding with blisters

Answer

Deep partial thickness burn

Question 3

A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:

Accepted Answer

Colonoscopy

Answer

Contrast-enhanced CT scan

Answer

Fecal occult blood test

Answer

Ultrasonogram

Question 4

What is the treatment of choice in a patient with Crohn’s disease, where inflamed appendix was found on exploration?

Accepted Answer

Ileo–colic resection and anastomosis

Answer

Appendectomy

Answer

Closing the abdomen and starting medical treatment

Answer

Right hemicolectomy

Question 5

On second day following femoral embolectomy, the leg is found to be tender, tense and dusky with feeble dorsalis pedis pulse. The most appropriate management would be:

Accepted Answer

Fasciotomy

Answer

Dye studies

Answer

Doing re-embolectomy

Answer

Anticoagulant therapy

Question 6

A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:

Accepted Answer

T2 N1 M1

Answer

T1 N2 M1

Answer

T1 N1 M1

Answer

T2 N2 M1

Question 7

After undergoing surgery, for carcinoma of colon, a patient developed single liver metastasis of 2 cm. What would be the next treatment?

Accepted Answer

Resection

Answer

Radio frequency ablation

Answer

Chemo-radiation

Answer

Acetic acid injection

Question 8

Which one of the following parts of intussusception is most susceptible to ischaemia and perforation?

Accepted Answer

Apex

Answer

Neck

Answer

Intussuscipiens

Answer

Intussusceptum

Question 9

A 30 year old lady comes with history of bloody discharge from her right nipple while taking bath. On examination, there is a cystic swelling in the subareolar region. The clinical diagnosis would be:

Accepted Answer

Intraductal papilloma

Answer

Duct ectasia

Answer

Fibrocystic disease

Answer

Intraductal carcinoma

Question 10

Which of the following is not true regarding ‘no scalpel’ vasectomy?

Accepted Answer

Scrotal skin is cut with LASER to expose the vas.

Answer

The failure rate is same as that of conventional vasectomy.

Answer

Special instruments are used to deliver the vas instead of cutting the skin.

Answer

It is a very popular method in China.

UPSC-CMS 2014 — Surgery