UPSC-CMS 2016 - Surgery Practice Questions

Q: Bisgaard treatment refers to that of:

Venous ulcer. ***Venous ulcer*** - **Bisgaard treatment** is a historical surgical technique specifically developed for the management of **chronic venous ulcers**. - This treatment aims to improve venous return and reduce venous hypertension by surgically addressing incompetent perforator veins and superficial venous reflux. *An ischaemic ulcer* - **Ischaemic ulcers** are caused by arterial insufficiency and require interventions to improve arterial blood flow, such as revascularization. - Bisgaard treatment is not appropriate for ischaemic ulcers as it does not address the underlying **arterial occlusive disease**. *An in-growing toe nail* - An **ingrown toenail** is a common podiatric condition typically treated with local procedures like nail avulsion or matrixectomy. - Bisgaard treatment is a complex vascular surgical procedure and bears no relevance to the treatment of an ingrown toenail. *Ruptured tendo achillis* - A **ruptured Achilles tendon** is an orthopaedic injury that requires surgical repair or conservative management involving immobilization. - Bisgaard treatment is exclusively for venous ulcer disease and has no role in the management of tendon injuries.

Q: Glasgow coma scale (GCS) score ranges between:

3 and 15. **3 and 15** * The **Glasgow Coma Scale (GCS)** is a neurological scale that aims to give a reliable and objective way of recording the conscious state of a person [2]. * A score of **3 represents the lowest possible level of consciousness**, indicating a severe injury [1], while **15 represents full consciousness** [1]. * *1 and 15* * The GCS assesses three components: **eye opening, verbal response, and motor response** [2]. Each component has a minimum score of 1. * Therefore, a total score of 1 is not possible as the minimum score for any individual component is 1, and there are three components. * *2 and 15* * The lowest possible score for any single component in the GCS is 1 (e.g., no eye opening, no verbal response, no motor response). * With three components, the sum of the minimum scores (1+1+1) is 3, making a total score of 2 impossible. * *0 and 15* * The GCS is designed with a minimum score of 1 for each of its three categories. * A score of 0 is not used in the GCS scoring system; the lowest possible score for any component is 1, even in an unresponsive state.

Q: The most common cause of intestinal obstruction is:

Bands and adhesions. ***Bands and adhesions*** - **Post-surgical adhesions** are the most common cause of small bowel obstruction, often forming after abdominal surgeries due to tissue healing. - These fibrous bands can **constrict or kink** the bowel, leading to a mechanical blockage. *Inflammatory abdominal conditions* - Conditions like **Crohn's disease** or **diverticulitis** can cause obstruction, but they are less frequent than adhesions as a primary cause. - Obstruction due to inflammation often involves **strictures** or inflammation-induced narrowing of the lumen. *Obstructed hernia* - **Hernias** (inguinal, femoral, umbilical, incisional) can become obstructed or strangulated, causing acute obstruction. - While a significant cause, the overall incidence is lower than that of adhesions, especially looking at all cases of intestinal obstruction. *Gastrointestinal malignancy* - **Colorectal cancer** is a common cause of large bowel obstruction, and other GI malignancies can cause small bowel obstruction. - Malignancy-related obstructions typically involve **tumor growth** causing luminal narrowing, but adhesions remain the leading cause overall.

Q: A 30 year old lady sustained chest injury in an accident and presented with massive haemothorax on right side. Tube thoracostomy drained 1800 ml of blood. What is the most appropriate treatment?

Resuscitation and prepare for urgent thoracotomy. ***Resuscitation and prepare for urgent thoracotomy*** - A **massive hemothorax**, defined as draining >1500 ml of blood initially or >200 ml/hour for 2-4 hours, indicates significant ongoing bleeding requiring surgical intervention. - Urgent **thoracotomy** is necessary to identify and control the source of hemorrhage in such cases. *Clamp the chest tube to cause the tamponade* - Clamping the chest tube in a massive hemothorax can lead to **cardiac tamponade** or worsening **respiratory distress** by trapping blood in the pleural space. - This action would dangerously increase **intrathoracic pressure** and is contraindicated as it prevents proper drainage and exacerbates hypovolemic shock. *Put one more chest tube* - While additional chest tubes might be considered for inadequate drainage in certain situations, a massive hemothorax (1800 ml) signifies a major vascular injury, making multiple tubes insufficient to control the bleeding. - The priority is to stop the bleeding surgically, not just to drain more blood, which would only accelerate **exsanguination**. *Correction of hypovolemic shock* - **Resuscitation** is a critical initial step, but it is not the definitive treatment for a massive hemothorax with ongoing bleeding. - Without addressing the source of the bleeding via **thoracotomy**, simply managing the **hypovolemic shock** would be futile as the patient would continue to bleed out.

Q: In a case of obstructed hernia, strangulation is suggested by which of the following? 1. Presence of shock 2. Pain is never completely absent 3. Localised tenderness is associated with rebound tenderness 4. Pain persists despite conservative management 5. An external hernia becomes tense, tender, irreducible, with recent increase in size Select the correct answer using the code given below:

1, 2, 3, 4 and 5. ***1, 2, 3, 4 and 5*** - All listed options (presence of **shock**, persistent pain, **localized and rebound tenderness**, failure of conservative management, and a **tense, tender, irreducible hernia** with recent size increase) are classic indicators of **hernia strangulation**. - **Strangulation** is a surgical emergency where the blood supply to the herniated tissue is compromised, leading to **ischemia** and potential **necrosis**, requiring immediate intervention. *1, 2, 4 and 5 only* - This option incorrectly omits **localized tenderness associated with rebound tenderness**, which is a crucial sign of peritoneal irritation and impending or established strangulation. - While other signs are accurate, the absence of this specific finding makes the option incomplete for a comprehensive understanding of strangulation. *1, 2, 3, 4 only* - This option misses the critical clinical sign of an **external hernia becoming tense, tender, irreducible, with a recent increase in size**, which is a direct and often visible sign of strangulation. - The physical examination findings of the hernia itself are paramount in diagnosing strangulation. *1, 3 and 5 only* - This option omits two significant indicators: **pain is never completely absent** (implying continuous, severe pain) and **pain persists despite conservative management**. - Continuous pain and refractoriness to treatment highlight the progressive and severe nature of strangulation.

Q: Regarding haemorrhagic shock, which one of the following statements is correct?

Loss of 40% of circulating volume is life threatening. ***Loss of 40% of circulating volume is life threatening*** - A loss of **40% or more** of circulating blood volume corresponds to **Class IV haemorrhagic shock**, which is a severe, life-threatening condition requiring immediate and aggressive resuscitation. - At this stage, the body's compensatory mechanisms are overwhelmed, leading to profound systemic hypoperfusion, **organ dysfunction**, and a high risk of mortality. *Tachycardia presents in 100% of hypovolemic patients* - While **tachycardia** is a common compensatory mechanism in hypovolemia, it is not present in 100% of patients due to factors such as **beta-blocker use** or **pacemaker rhythm**. - In some early stages of blood loss, especially in young, healthy individuals, sufficient compensatory mechanisms may delay the onset of significant tachycardia. *Clinically manifested when > 10% of loss of total blood volume occurs* - Haemorrhagic shock is typically **clinically manifest** when there is a blood loss greater than **15%** (Class I shock), which represents approximately 750 mL in an average adult. - A loss of **less than 10%** often does not produce overt clinical signs as the body's compensatory mechanisms can effectively maintain vital signs within normal ranges. *In acute stage of shock, systemic vasodilation becomes evident* - In the acute stage of hemorrhagic shock, the body's primary compensatory mechanism is **systemic vasoconstriction**, not vasodilation, to maintain central blood pressure and perfuse vital organs. - **Vasodilation** can occur in the later, decompensated stages of shock, particularly in instances of **septic or neurogenic shock**, leading to a further drop in blood pressure.

Q: Which one of the following structures is not removed during a classical radical neck dissection?

Trapezius. ***Trapezius*** - The **trapezius muscle** is consistently spared (not removed) in a classical radical neck dissection, although it becomes non-functional due to sacrifice of its motor nerve supply. - While the muscle remains anatomically in place, removal of the **accessory nerve** leads to denervation of the trapezius, causing severe shoulder dysfunction including **shoulder drop** and inability to abduct the arm past 90 degrees. *Accessory nerve* - The **accessory nerve (cranial nerve XI)** is sacrificed in a classical radical neck dissection to ensure complete removal of lymphatic tissue and metastatic disease. - Its removal results in **denervation and paralysis of the trapezius muscle**, leading to shoulder weakness, shoulder drop, and limited shoulder abduction. - The accessory nerve also innervates the sternocleidomastoid, though this muscle is removed in the procedure. *Sternocleidomastoid* - The **sternocleidomastoid muscle** is removed in a classical radical neck dissection for oncological clearance, as lymph nodes closely associated with it can harbor metastatic disease. - Its removal contributes to cosmetic defect and can affect neck contour and mobility. *Internal jugular vein* - The **internal jugular vein** is resected during a classical radical neck dissection to achieve en bloc removal of lymphatic tissue in levels II, III, and IV, which often contain metastatic disease. - Its removal can lead to **venous congestion** in the head and neck initially, although collateral circulation through the external jugular and vertebral venous systems usually develops over time.

Q: Mousseau-Barbin Tube (M.B.Tube) is used for:

Advanced cancer oesophagus. ***Advanced cancer oesophagus*** - The **Mousseau-Barbin tube** is a type of **endoscopic stent** used for palliative management of **dysphagia** caused by advanced **oesophageal cancer**. - It provides a lumen through obstructed oesophageal segments, allowing patients to swallow food and liquids more easily. *Advanced cancer oropharynx* - While dysphagia can be a symptom of oropharyngeal cancer, the Mousseau-Barbin tube is specifically designed for placement within the **oesophagus**. - Management for advanced oropharyngeal cancer often involves other interventions like **radiotherapy**, **chemotherapy**, or **surgical resection**. *All of these* - This option is incorrect because the Mousseau-Barbin tube has a specific application for the **oesophagus**. - It is not routinely used for cancers of the oropharynx or stomach due to differences in anatomical location and disease progression. *Advanced cancer stomach* - Advanced stomach cancer, particularly in the distal stomach, would not typically benefit from an oesophageal stent. - Gastric outlet obstruction can occur, but specific **gastric stents** or **surgical bypasses** are used for this.

Q: Which one of the following is the investigation of choice in a patient with haematemesis?

Flexible upper gastrointestinal endoscopy. ***Flexible upper gastrointestinal endoscopy*** - This is the **investigation of choice** for haematemesis as it allows for direct visualization of the upper gastrointestinal tract to identify the source of bleeding [1]. - It also enables **therapeutic intervention**, such as injection sclerotherapy, banding, or clip application, to stop the bleeding [1]. *Contrast enhanced CT scan* - A CT scan is generally **not the primary investigation** for acute haematemesis because it offers less diagnostic accuracy for mucosal lesions and cannot provide therapeutic intervention [1]. - While it can identify large bleeds or structural abnormalities, it is **less sensitive for smaller bleeds** or subtle mucosal abnormalities compared to endoscopy. *Barium meal for stomach and duodenum* - A barium meal is **contraindicated in acute gastrointestinal bleeding** as the barium can obscure endoscopic views and interfere with subsequent attempts at endoscopy or angiography [1]. - It provides **limited diagnostic information** about the active bleeding site and offers no therapeutic capabilities. *Selective left gastric angiography* - Angiography is typically reserved for cases of **severe, persistent bleeding** where endoscopy has failed to locate or control the bleed. - It is an **invasive procedure** with potential complications and is not indicated as the initial diagnostic investigation.

Q: Consider the following statements: 1. Carbon dioxide is the safest gas for creating pneumoperitoneum in operative laparoscopy. 2. Laparoscopic sterilization is not recommended during the period of immediate postpartum. Which of the statements given above is/are correct?

Both 1 and 2. ***Both 1 and 2*** - **Carbon dioxide (CO2)** is the safest gas for creating pneumoperitoneum due to its **rapid absorption** and **excretion** by the body, minimizing the risk of gas embolism and tissue toxicity. - Laparoscopic sterilization is generally **not recommended during the immediate postpartum period** (first 6-8 weeks) due to the **enlarged uterus**, increased vascularity, and altered anatomy, which elevate the risk of complications such as hemorrhage and organ perforation. *1 only* - While carbon dioxide is indeed the safest gas for pneumoperitoneum, this option is incorrect because the second statement regarding postpartum sterilization is also accurate. - Selecting this option would imply that statement 2 is false, which is not the case. *Neither 1 nor 2* - This option is incorrect because both statements are clinically accurate and accepted practices in operative laparoscopy and postpartum care. - Both statements reflect standard surgical and obstetric guidelines. *2 only* - This option is incorrect because, in addition to the second statement being true, the first statement (regarding the safety of CO2 for pneumoperitoneum) is also correct. - Choosing this option would suggest that CO2 is not the safest gas, which contradicts established medical practice.

Question 1

Bisgaard treatment refers to that of:

Accepted Answer

Venous ulcer

Answer

An ischaemic ulcer

Answer

An in-growing toe nail

Answer

Ruptured tendo achillis

Question 2

Glasgow coma scale (GCS) score ranges between:

Accepted Answer

3 and 15

Answer

1 and 15

Answer

2 and 15

Answer

0 and 15

Question 3

The most common cause of intestinal obstruction is:

Accepted Answer

Bands and adhesions

Answer

Inflammatory abdominal conditions

Answer

Obstructed hernia

Answer

Gastrointestinal malignancy

Question 4

A 30 year old lady sustained chest injury in an accident and presented with massive haemothorax on right side. Tube thoracostomy drained 1800 ml of blood. What is the most appropriate treatment?

Accepted Answer

Resuscitation and prepare for urgent thoracotomy

Answer

Clamp the chest tube to cause the tamponade

Answer

Put one more chest tube

Answer

Correction of hypovolemic shock

Question 5

In a case of obstructed hernia, strangulation is suggested by which of the following?

1. Presence of shock
2. Pain is never completely absent
3. Localised tenderness is associated with rebound tenderness
4. Pain persists despite conservative management
5. An external hernia becomes tense, tender, irreducible, with recent increase in size

Select the correct answer using the code given below:

Accepted Answer

1, 2, 3, 4 and 5

Answer

1, 2, 4 and 5 only

Answer

1, 2, 3, 4 only

Answer

1, 3 and 5 only

Question 6

Regarding haemorrhagic shock, which one of the following statements is correct?

Accepted Answer

Loss of 40% of circulating volume is life threatening

Answer

Tachycardia presents in 100% of hypovolemic patients

Answer

Clinically manifested when > 10% of loss of total blood volume occurs

Answer

In acute stage of shock, systemic vasodilation becomes evident

Question 7

Which one of the following structures is not removed during a classical radical neck dissection?

Accepted Answer

Trapezius

Answer

Accessory nerve

Answer

Sternocleidomastoid

Answer

Internal jugular vein

Question 8

Mousseau-Barbin Tube (M.B.Tube) is used for:

Accepted Answer

Advanced cancer oesophagus

Answer

Advanced cancer oropharynx

Answer

All of these

Answer

Advanced cancer stomach

Question 9

Which one of the following is the investigation of choice in a patient with haematemesis?

Accepted Answer

Flexible upper gastrointestinal endoscopy

Answer

Contrast enhanced CT scan

Answer

Barium meal for stomach and duodenum

Answer

Selective left gastric angiography

Question 10

Consider the following statements:

1. Carbon dioxide is the safest gas for creating pneumoperitoneum in operative laparoscopy.
2. Laparoscopic sterilization is not recommended during the period of immediate postpartum. Which of the statements given above is/are correct?

Accepted Answer

Both 1 and 2

Answer

1 only

Answer

Neither 1 nor 2

Answer

2 only

UPSC-CMS 2016 — Surgery