UPSC-CMS 2021 — Surgery
14 Previous Year Questions with Answers & Explanations
Which of the following are types of wound healing? 1. Primary Intention 2. Secondary Intention 3. Tertiary Intention 4. Quaternary Intention
A 60 year old lady underwent total abdominal hysterectomy. On the 3rd post operative day she suddenly became breathless while returning from washroom. Her blood pressure recorded was 80/50 mm of Hg. The most probable diagnosis is
A 52 year old female underwent MRM (Modified Radical Mastectomy). After few years, she developed lymphedema of the ipsilateral arm. Which of the following malignancies can develop in her arm?
A gentleman of 60 years presented with a brawny swelling of the submandibular region with inflammatory edema of mouth and putrid halitosis. Most likely he is suffering from
A 25 year old female patient with previous history of neck irradiation presents with thyroid swelling for last 6 months. The patient is clinically euthyroid. On examination, the right lobe of thyroid gland is enlarged with presence of ipsilateral cervical lymphadenopathy. The most probable clinical diagnosis in this patient is
An infant presented in the surgical OPD with complaints of a unilateral swelling in the neck. The swelling was soft, cystic, partially compressible and brilliantly transilluminant. The most probable diagnosis is
Which of the following is NOT a classical symptom of acute appendicitis ?
A 35 year old male patient with enteric fever presents to the emergency with sudden onset of generalised abdominal pain, abdominal distension, nausea, vomiting and constipation for last 48 hours. On examination, patient is dehydrated with PR = 110/min and BP = 100/60 mm Hg. There is generalised tenderness, rebound tenderness present and board like rigidity on per abdomen examination. The most likely complication of enteric fever in this patient is
A 45 year old female patient presents with a painless firm abdominal swelling of size 10 x 8 cm near the umbilicus. The swelling is reducible and shows no fixation to deeper structures. The most probable clinical diagnosis in this patient is
In Pringle Manoeuvre, clamping includes which of the following? 1. Common Bile Duct 2. Hepatic artery 3. Portal vein 4. Inferior Vena Cava
UPSC-CMS 2021 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: Which of the following are types of wound healing? 1. Primary Intention 2. Secondary Intention 3. Tertiary Intention 4. Quaternary Intention
- A. 1, 2 and 4
- B. 1, 2 and 3 (Correct Answer)
- C. 2, 3 and 4
- D. 1, 3 and 4
Explanation: ***1, 2 and 3*** - These options correctly identify the three recognized types of **wound healing** in surgical practice. - **Primary intention (healing by first intention)**: Clean wounds with approximated edges, minimal tissue loss, heals with minimal scarring (e.g., surgical incisions). - **Secondary intention (healing by second intention)**: Wounds with significant tissue loss that heal by granulation tissue formation, wound contraction, and epithelialization (e.g., pressure ulcers, large traumatic wounds). - **Tertiary intention (delayed primary closure)**: Contaminated wounds initially left open for 3-5 days, then closed after infection risk decreases. *1, 2 and 4* - This option incorrectly includes **"Quaternary Intention,"** which is **not a recognized classification** in wound healing. - Only primary, secondary, and tertiary intention are standard types described in surgical textbooks. *2, 3 and 4* - This option omits **"Primary Intention,"** the most common type of wound healing for clean surgical incisions. - It also incorrectly includes "Quaternary Intention," which does not exist in wound healing classification. *1, 3 and 4* - This option omits **"Secondary Intention,"** a crucial healing process for wounds with substantial tissue loss that cannot be primarily closed. - "Quaternary Intention" is not a valid wound healing type and represents a distractor in this question.
Question 2: A 60 year old lady underwent total abdominal hysterectomy. On the 3rd post operative day she suddenly became breathless while returning from washroom. Her blood pressure recorded was 80/50 mm of Hg. The most probable diagnosis is
- A. Postural hypotension
- B. Thromboembolism (Correct Answer)
- C. Transient ischaemic attack
- D. Secondary haemorrhage
Explanation: ***Thromboembolism*** - Sudden onset **breathlessness** and **hypotension** in a postoperative patient are classic signs of a **pulmonary embolism (PE)**, a severe form of thromboembolism. - Surgical procedures, especially pelvic surgeries like hysterectomy, are **risk factors** for deep vein thrombosis (DVT) which can lead to PE. *Postural hypotension* - While it can cause lightheadedness or dizziness upon standing, it typically doesn't present as sudden, severe **breathlessness** and sustained **hypotension**. - Its onset is directly related to a change in position, and the patient's symptoms are more severe than usually seen with postural changes. *Transient ischaemic attack* - A TIA involves **neurological deficits** such as weakness, speech disturbance, or visual changes, which are temporary. - It does not present with sudden **breathlessness** or profound **hypotension**. *Secondary haemorrhage* - This would typically manifest as signs of **blood loss**, such as fresh bleeding from the surgical site or distended abdomen, along with features of hypovolemic shock. - While hypotension would be present, the primary symptom would not be sudden **breathlessness**.
Question 3: A 52 year old female underwent MRM (Modified Radical Mastectomy). After few years, she developed lymphedema of the ipsilateral arm. Which of the following malignancies can develop in her arm?
- A. Malignant Melanoma
- B. Lymphangiosarcoma (Correct Answer)
- C. Lymphoma
- D. Malignant fibrous histiocytoma
Explanation: ***Lymphangiosarcoma*** - This is a rare, aggressive **vascular tumor** that can develop in chronically lymphedematous limbs, particularly after **mastectomy** for breast cancer. - The chronic lymphatic obstruction and inflammation are thought to be predisposing factors, leading to the condition known as **Stewart-Treves syndrome**. *Malignant Melanoma* - This cancer arises from **melanocytes** in the skin and is primarily associated with UV radiation exposure or existing nevi, not chronic lymphedema. - While it can occur anywhere on the body, there is no direct causal link between modified radical mastectomy and the development of melanoma in the arm. *Lymphoma* - Lymphoma is a cancer of the **lymphocytes** within the lymphatic system, typically presenting as swollen lymph nodes or B-symptoms. - Although lymphedema involves the lymphatic system, it generally predisposes to angiosarcoma rather than lymphoma in this specific clinical context. *Malignant fibrous histiocytoma* - This is a type of **soft tissue sarcoma** that can occur in various locations, but it is not specifically linked to chronic lymphedema following mastectomy. - While its etiology can be complex, it does not have the well-established association with chronic lymphedema that lymphangiosarcoma does.
Question 4: A gentleman of 60 years presented with a brawny swelling of the submandibular region with inflammatory edema of mouth and putrid halitosis. Most likely he is suffering from
- A. Ludwig's angina (Correct Answer)
- B. Acute lymphadenitis
- C. Tubercular adenitis
- D. Chronic lymphadenitis
Explanation: ***Ludwig's angina*** - This is a **rapidly progressive cellulitis** of the submandibular, sublingual, and submental spaces, commonly originating from **odontogenic infections**. - The classic presentation includes **brawny edema** (firm, woody induration) of the submandibular region, inflammatory edema of the mouth, and **putrid halitosis** indicative of an anaerobic infection. *Acute lymphadenitis* - This involves inflammation of the lymph nodes, typically characterized by **tender, enlarged nodes**. - While it can be associated with infection, it usually does not present with the diffuse, *brawny* swelling of the floor of the mouth and submandibular area as described, nor the severe systemic symptoms often linked to Ludwig's angina. *Tubercular adenitis* - This is a **chronic granulomatous inflammation** of lymph nodes, typically presenting as slowly enlarging, **non-tender masses**. - It does not cause acute, rapidly spreading cellulitis or *brawny* edema with severe halitosis, which are hallmark features of Ludwig's angina. *Chronic lymphadenitis* - This refers to persistent or recurrent inflammation of lymph nodes, often due to protracted infection or inflammatory processes. - It usually manifests as **enlarged, firm, sometimes mobile lymph nodes**, but does not involve the acute, diffuse, and rapidly spreading *brawny* edema characteristic of a severe fascial space infection like Ludwig's angina.
Question 5: A 25 year old female patient with previous history of neck irradiation presents with thyroid swelling for last 6 months. The patient is clinically euthyroid. On examination, the right lobe of thyroid gland is enlarged with presence of ipsilateral cervical lymphadenopathy. The most probable clinical diagnosis in this patient is
- A. Papillary carcinoma thyroid (Correct Answer)
- B. Lymphoma
- C. Medullary carcinoma thyroid
- D. Follicular carcinoma thyroid
Explanation: ***Papillary carcinoma thyroid*** - A history of **neck irradiation** is a significant risk factor for **papillary thyroid carcinoma**. - **Cervical lymphadenopathy** is a common presentation, as papillary carcinoma frequently metastasizes to regional lymph nodes, and the patient is **euthyroid**. *Lymphoma* - While neck mass and lymphadenopathy can occur with lymphoma, a history of **previous neck irradiation** is a stronger predisposing factor for thyroid carcinoma, and **thyroid lymphoma** often presents with a rapidly enlarging goiter or compressive symptoms. - Though irradiation can increase the risk of some lymphomas, it's a more direct and strong risk factor for thyroid cancer in the setting of thyroid swelling. *Medullary carcinoma thyroid* - **Medullary thyroid carcinoma** typically arises from **parafollicular C cells** and is often associated with elevated **calcitonin levels** and may be familial (e.g., MEN 2 syndromes), which are not mentioned. - While it can present with lymphadenopathy, the history of irradiation points more strongly towards papillary carcinoma. *Follicular carcinoma thyroid* - **Follicular carcinoma** is less commonly associated with a history of **neck irradiation** compared to papillary carcinoma and tends to metastasize hematogenously rather than primarily to regional lymph nodes. - It often presents as a solitary nodule, and while lymph node involvement can occur, it's less characteristic than in papillary carcinoma.
Question 6: An infant presented in the surgical OPD with complaints of a unilateral swelling in the neck. The swelling was soft, cystic, partially compressible and brilliantly transilluminant. The most probable diagnosis is
- A. Branchial fistula
- B. Branchial cyst
- C. Thyroglossal cyst
- D. Cystic Hygroma (Correct Answer)
Explanation: ***Cystic Hygroma*** - A **cystic hygroma (lymphangioma)** is a congenital malformation of the lymphatic system, typically presenting in infants as a soft, compressible, and **brilliantly transilluminant** neck mass. - The hallmark feature is **brilliant transillumination** due to the clear lymphatic fluid within the multiloculated cystic spaces. - Commonly located in the **posterior triangle of the neck** (75%) or submandibular region, though can occur anywhere in the neck. - The presentation of a soft, cystic, partially compressible, and brilliantly transilluminant unilateral neck swelling in an infant is classic for cystic hygroma. *Branchial cyst* - A **branchial cyst** arises from incomplete obliteration of the branchial apparatus during embryonic development. - Typically presents in **older children or young adults** (late childhood to third decade), not commonly in infancy. - Located in the **lateral neck** along the anterior border of the sternocleidomastoid muscle. - While it can be soft and cystic, **brilliant transillumination is not a hallmark feature** of branchial cysts, making this less likely in an infant with this classic presentation. *Branchial fistula* - A **branchial fistula** is an abnormal tract connecting the skin to the pharynx, presenting with a small external opening that may discharge mucus or saliva. - It is **not a cystic swelling** and does not present with transillumination, as it is a communicating tract rather than a closed cystic mass. *Thyroglossal cyst* - A **thyroglossal cyst** is a **midline neck swelling** that moves with protrusion of the tongue and swallowing, reflecting its embryonic origin from the thyroglossal duct. - The question specifically mentions a **unilateral swelling**, which rules out thyroglossal cyst as it characteristically occurs in the midline.
Question 7: Which of the following is NOT a classical symptom of acute appendicitis ?
- A. Periumbilical colic
- B. Anorexia
- C. Constipation (Correct Answer)
- D. Nausea
Explanation: ***Constipation*** - While patients with appendicitis may experience altered bowel habits, **constipation is not a classic or defining symptom**; **diarrhea** can even be present. - The primary symptoms relate to inflammation and irritation of the appendix, not typically leading to significant constipation. *Periumbilical colic* - This is a very common early symptom, often described as a **vague, dull pain around the umbilicus** as the appendix initially becomes inflamed. - The pain later **migrates to the right lower quadrant** as the inflammation localizes to the parietal peritoneum. *Anorexia* - **Loss of appetite** is a highly characteristic and almost universal symptom in patients with acute appendicitis. - It often precedes the onset of abdominal pain and is considered a significant diagnostic indicator. *Nausea* - **Nausea and vomiting** are very common symptoms, often following the onset of abdominal pain. - These gastrointestinal symptoms are due to the visceral irritation caused by the inflamed appendix.
Question 8: A 35 year old male patient with enteric fever presents to the emergency with sudden onset of generalised abdominal pain, abdominal distension, nausea, vomiting and constipation for last 48 hours. On examination, patient is dehydrated with PR = 110/min and BP = 100/60 mm Hg. There is generalised tenderness, rebound tenderness present and board like rigidity on per abdomen examination. The most likely complication of enteric fever in this patient is
- A. Small bowel perforation (Correct Answer)
- B. Cholecystitis
- C. Small bowel enteritis
- D. Small bowel obstruction
Explanation: ***Small bowel perforation*** - The sudden onset of **generalised abdominal pain**, **distension**, **rebound tenderness**, and **board-like rigidity** in a patient with enteric fever strongly indicate **peritoneal irritation** due to perforation. - **Enteric fever** (typhoid) commonly causes **Peyer's patch hyperplasia and necrosis**, leading to full-thickness bowel wall damage and perforation, typically in the **ileum**. *Cholecystitis* - While cholecystitis can occur with enteric fever, it usually presents with **right upper quadrant pain**, **fever**, and **leukocytosis**, not generalized abdominal pain or peritoneal signs. - It does not typically cause **board-like rigidity** or signs of **perforation**. *Small bowel enteritis* - Small bowel enteritis causes **crampy abdominal pain**, **diarrhea**, and **vomiting**, but usually without the severe peritoneal signs like generalized tenderness and board-like rigidity. - It does not typically lead to systemic signs of shock and severe peritonitis as seen in this patient. *Small bowel obstruction* - Small bowel obstruction presents with **abdominal pain**, **distension**, **vomiting**, and **constipation**, but usually with **hyperactive bowel sounds** initially, progressing to absent. - The presence of **rebound tenderness** and **board-like rigidity** points more towards peritonitis from perforation rather than uncomplicated obstruction.
Question 9: A 45 year old female patient presents with a painless firm abdominal swelling of size 10 x 8 cm near the umbilicus. The swelling is reducible and shows no fixation to deeper structures. The most probable clinical diagnosis in this patient is
- A. Incisional hernia
- B. Umbilical hernia (Correct Answer)
- C. Inguinal hernia
- D. Femoral hernia
Explanation: ***Umbilical hernia*** - An **umbilical hernia** presents as a swelling near the umbilicus, is often **painless**, and tends to be **reducible**, especially in adults where it can be acquired. - The patient's age and the location and characteristics of the swelling (painless, firm, reducible, unfixed near the umbilicus) are highly consistent with an umbilical hernia, which commonly affects middle-aged women. *Incisional hernia* - An **incisional hernia** develops at the site of a previous surgical incision, which is not mentioned in the patient's history. - While it can be reducible, its location near the umbilicus without a history of abdominal surgery makes it less likely than an umbilical hernia. *Inguinal hernia* - An **inguinal hernia** occurs in the **groin region**, above the inguinal ligament, and not typically near the umbilicus. - While also often **reducible**, its anatomical location differentiates it from the described swelling. *Femoral hernia* - A **femoral hernia** presents as a swelling in the **upper thigh**, inferior to the inguinal ligament, and is more common in women. - The described swelling's location near the umbilicus rules out a femoral hernia.
Question 10: In Pringle Manoeuvre, clamping includes which of the following? 1. Common Bile Duct 2. Hepatic artery 3. Portal vein 4. Inferior Vena Cava
- A. 2, 3 and 4
- B. 1, 2 and 3 (Correct Answer)
- C. 1, 3 and 4
- D. 1, 2 and 4
Explanation: ***1, 2 and 3*** - The **Pringle maneuver** involves clamping structures within the **hepatoduodenal ligament** to temporarily control bleeding from the liver. - The three main structures within the hepatoduodenal ligament that are clamped are the **hepatic artery**, the **portal vein**, and the **common bile duct**. *2, 3 and 4* - This option incorrectly includes the **inferior vena cava (IVC)**, which is not part of the hepatoduodenal ligament and therefore not clamped during a standard Pringle maneuver. - Clamping the IVC would lead to severe hemodynamic instability and is not a part of this routine surgical maneuver. *1, 3 and 4* - This option incorrectly includes the **inferior vena cava (IVC)**, which is not clamped during the Pringle maneuver. - It also omits the **hepatic artery**, a major blood supply to the liver, which must be clamped along with the portal vein to effectively reduce hepatic blood flow. *1, 2 and 4* - This option incorrectly includes the **inferior vena cava (IVC)**, which is located posterior to the liver and not within the hepatoduodenal ligament. - It also omits the **portal vein**, which contributes to the majority of the liver's blood supply and is crucial to occlude during the Pringle maneuver to control bleeding effectively.