UPSC-CMS 2019 - Surgery Practice Questions

Q: A 70-year-old man on anticoagulants due to some heart disease suffered a minor head injury. One month later he has severe headache with slowly developing neurological signs. The probable diagnosis is:

Chronic subdural haematoma. ***Chronic subdural haematoma*** - This diagnosis fits the clinical picture of a **minor head injury** followed by a **delayed** presentation (one month later) of **slowly developing neurological signs** and headache, especially in an **elderly patient on anticoagulants**. - **Anticoagulation** increases the risk for bleeding, and the elderly are more susceptible due to brain atrophy, which stretches and makes bridging veins more vulnerable to tearing from minor trauma. *Acute subdural haematoma* - An acute subdural haematoma typically presents within **72 hours** of the initial trauma, with **rapidly progressive neurological deficits**, unlike the delayed and gradual onset described. - While anticoagulation increases risk, the **timeframe** of symptom onset is inconsistent with an acute presentation. *Extradural haematoma* - Extradural haematomas are usually associated with a **lucid interval** followed by rapid deterioration due to arterial bleeding, often from the **middle meningeal artery**, and rarely occur in the elderly or from minor trauma. - It would present much **sooner** after the injury, typically within hours, and is less common in this age group without significant impact. *Subarachnoid haemorrhage* - Subarachnoid haemorrhage typically presents with a **sudden onset**, **"thunderclap" headache**, often described as the "worst headache of my life," and is not typically associated with a minor head injury followed by a delayed, slowly progressive course. - While anticoagulants could worsen bleeding, the **temporal profile** and **gradual neurological decline** are not characteristic of a subarachnoid haemorrhage.

Q: Which of the following is NOT true about Dupuytren's Contracture?

Not familial. ***Not familial*** - This is the **CORRECT answer** because this statement is **FALSE** - Dupuytren's contracture **IS familial** and has a strong genetic predisposition. - The condition often runs in families, exhibiting an **autosomal dominant inheritance pattern**. - Its familial nature is a well-established risk factor, making "not familial" the incorrect statement about Dupuytren's contracture. *Autosomal dominant* - This statement is **TRUE** about Dupuytren's contracture, which is frequently inherited in an **autosomal dominant pattern**. - A single copy of an altered gene is sufficient to cause the condition. - This genetic link explains why it often runs in families and is more prevalent in certain populations (especially Northern Europeans). *Associated with alcoholism, smoking and hypothyroidism* - This statement is **TRUE**; Dupuytren's contracture has known associations with several risk factors including **alcoholism**, **smoking**, and **hypothyroidism**. - Other risk factors include diabetes mellitus and epilepsy. - These conditions are thought to influence cellular processes that contribute to the proliferation of fibroblasts and collagen deposition in the palmar fascia. *Occurs in elderly men* - This statement is **TRUE**; Dupuytren's contracture is more common in **males** and typically presents in **middle-aged to elderly individuals**. - While it can occur in women, it is more prevalent (male:female ratio ~7:1) and often more severe in men. - Peak incidence is in the 5th to 7th decades of life.

Q: In Split thickness graft, which part of the skin is/are included?

Epidermis and part of dermis. ***Epidermis and part of dermis*** - A **split-thickness skin graft** includes the entire **epidermis** and only a **portion of the dermis**. - This allows for easier engraftment and donor site healing due to less deep tissue removal. *Epidermis and dermis* - This describes a **full-thickness skin graft**, which includes the entire epidermis and the entire dermis. - While it provides better cosmetic results and less contraction, it requires a more complex donor site closure. *Epidermis only* - A graft consisting only of the epidermis would be too thin to be clinically useful and would likely not survive. - The dermis provides structural support and a blood supply critical for graft viability. *Epidermis, dermis and part of subcutaneous tissue* - This typically refers to a **composite graft** or a **flap**, not a split-thickness skin graft. - These grafts include deeper tissues, such as subcutaneous fat, to provide bulk and specialized structures.

Q: A young boy riding a motorcycle met with a road traffic accident. On examination he had maxillofacial trauma with paraesthesia of the lower lip. Most likely underlying fracture he has is:

Fracture of the mandibular body. ***Fracture of the mandibular body*** - **Paraesthesia of the lower lip** is a classic symptom of injury to the **inferior alveolar nerve**, which runs within the mandibular canal through the body of the mandible. - A fracture in the mandibular body can directly damage or compress this nerve, leading to altered sensation. *Fracture involving infraorbital foramen* - A fracture involving the **infraorbital foramen** would affect the **infraorbital nerve**, causing paraesthesia in the midface region, including the cheek, upper lip, and side of the nose, not the lower lip. - This nerve is a branch of the **trigeminal nerve (V2)**, whereas the nerve supplying the lower lip is a branch of **V3**. *Fracture of temporal bone* - A **temporal bone fracture** is more likely to cause symptoms related to the **facial nerve (cranial nerve VII)**, leading to facial paralysis, or hearing/balance issues due to damage to the inner ear structures. - It does not typically cause isolated paraesthesia of the lower lip. *Fracture involving floor of orbit* - A fracture of the floor of the orbit, often a **blowout fracture**, can entrap the **inferior rectus** or **inferior oblique muscles** and cause **diplopia** (double vision). - It may also involve the **infraorbital nerve**, leading to paraesthesia of the cheek, upper lip, and upper teeth, but not specifically the lower lip.

Q: A 20-year-old patient underwent open hernia surgery four days ago. He has had fever for the last day and on local examination the operated site was wet with pus and surrounding redness and edema. The appropriate management would be:

Opening sutures and cleaning of wound. ***Opening sutures and cleaning of wound*** - The presence of **fever**, **pus**, **redness**, and **edema** indicates a **surgical site infection (SSI)** with abscess formation, necessitating immediate **wound exploration** and **drainage**. - **Opening the sutures** allows for complete removal of pus, debridement of necrotic tissue, and proper irrigation, which are critical steps in managing a deep-seated infection. *Sending pus for C/S* - While **culture and sensitivity (C/S)** is important for guiding antibiotic therapy, it does not address the immediate mechanical problem of pus accumulation. - Delaying drainage for C/S results would allow the infection to spread, causing further tissue damage. *Daily dressing* - **Daily dressing** alone is insufficient for a wound with active infection and pus accumulation; it cannot effectively drain the infection. - Though necessary as part of wound care, it needs to be preceded by effective drainage. *Change of antibiotics* - Changing **antibiotics** without addressing the underlying source of infection (the pus collection) will likely be ineffective as antibiotics cannot penetrate well into an abscess. - Antibiotics are a crucial adjunct to surgical drainage, not a replacement.

Q: Good surgical practice and surgical ethics include all EXCEPT:

Experiment without consent. ***Experiment without consent*** - Performing an experiment or research procedure on a patient **without proper informed consent** is a direct violation of medical ethics and good surgical practice. - Even well-designed clinical research requires **explicit patient consent**, **ethics committee approval**, and adherence to principles of *non-maleficence* and *beneficence*. - Conducting any experimental procedure without consent violates patient autonomy and the fundamental ethical principle of **informed consent**. *Confidentiality* - **Confidentiality** is a cornerstone of patient care, ensuring that patient information is protected and disclosed only with proper consent or legal requirement. - Maintaining confidentiality is an essential component of good surgical practice and medical ethics. *Informed consent* - **Informed consent** is a fundamental ethical and legal requirement before any medical procedure, ensuring the patient understands the *risks, benefits, alternatives*, and prognosis. - It upholds the principle of *patient autonomy*, allowing individuals to make decisions about their own healthcare. *Respect autonomy* - **Respect for autonomy** means acknowledging and upholding a patient's right to *make their own decisions* about their medical care, free from coercion. - This principle guides processes like obtaining informed consent and respecting a patient's choices, even if they differ from the medical professional's recommendation, as long as the patient is competent.

Question 1

A 70-year-old man on anticoagulants due to some heart disease suffered a minor head injury. One month later he has severe headache with slowly developing neurological signs. The probable diagnosis is:

Accepted Answer

Chronic subdural haematoma

Answer

Acute subdural haematoma

Answer

Extradural haematoma

Answer

Subarachnoid haemorrhage

Question 2

Which of the following is NOT true about Dupuytren's Contracture?

Accepted Answer

Not familial

Answer

Autosomal dominant

Answer

Associated with alcoholism, smoking and hypothyroidism

Answer

Occurs in elderly men

Question 3

In Split thickness graft, which part of the skin is/are included?

Accepted Answer

Epidermis and part of dermis

Answer

Epidermis and dermis

Answer

Epidermis only

Answer

Epidermis, dermis and part of subcutaneous tissue

Question 4

A young boy riding a motorcycle met with a road traffic accident. On examination he had maxillofacial trauma with paraesthesia of the lower lip. Most likely underlying fracture he has is:

Accepted Answer

Fracture of the mandibular body

Answer

Fracture involving infraorbital foramen

Answer

Fracture of temporal bone

Answer

Fracture involving floor of orbit

Question 5

A 20-year-old patient underwent open hernia surgery four days ago. He has had fever for the last day and on local examination the operated site was wet with pus and surrounding redness and edema. The appropriate management would be:

Accepted Answer

Opening sutures and cleaning of wound

Answer

Sending pus for C/S

Answer

Daily dressing

Answer

Change of antibiotics

Question 6

Good surgical practice and surgical ethics include all EXCEPT:

Accepted Answer

Experiment without consent

Answer

Confidentiality

Answer

Informed consent

Answer

Respect autonomy

UPSC-CMS 2019 — Surgery