Surgery Year 5, 5th Feb 2013

1) TRUE regarding reactionary haemorrhage A. It is delayed haemorrhage occurring within 24 hours after operation B. It is caused by dislodgement of clot C. It is associated with infection D. It requires re exploration E. It is usually venous Answer A. TRUE -Reactionary haemorrhage is delayed haemorrhage within 24 hours (Bailey n love pg 19) -Reactionary haemorrhage occurs within 24 hours after surgery or after injury,commonly 4-6 hours (SRBs manual of surgery, pg100) B. TRUE -Usually caused by dislodgement of clot by resuscitation, normalization of blood pressure n vasodilatation, or may result from technically failure such as slippage of ligature (Bailey n Love pg 19) Precipitating CommonCauses factors Coughing Thyroid surgery Vomiting Cholecystectomy Straining Major abdominal surgery Rise of blood Circumcision pressure Restlessness Hydrocele surgery Venous refilling Tonsillectomy during recovery fr anaesthesia Slipping of ligature Clot dislodgement (SRBs manual of surgery pg 100)

Surgery Year 5, 5th Feb 2013

C. TRUE Factors Infection Pressure by drain or bone malignancy (SRBs manual of surgery pg 100) D. TRUE

Common cause Erosion of carotid artery by cancer (secondaries in the neck) Haemorrhoidectomy Inguinal block dissection

-identify site of haemorrhage-ultrasound, endoscopy, CT scan, dpl(diagnostic peritoneal lavage), blood tools. -control of haemorrhage- surgery, endoscopic control, therapeutic embolization (SRB manual surgery pg 102)
http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x858.html

E. FALSE

-it is not always venous. The important thing is to know the sources of haemorrhage, whether originate from vein or artery and get it stopped. http://surgeryonline.wordpress.com/2008/09/20/haemorrhage/
http://www.meb.uni-bonn.de/dtc/primsurg/docbook/html/x858.html

2) A 34 year old man comes with painful swelling of left leg and foot. On examination there is local rise of temperature n tenderness. TRUE about the condition A. It is invasive infection of tissues B. It is poorly localized C. It is commonly caused by Clostridium perfringens D. Systemic signs are not present E. Blood culture is usually positive Answer Diagnosis is cellulitis (Bailey n Love pg 37) -it is the non suppurative invasive infection of tissues -poor localization in addition to cardinal signs of inflammation -typically caused by B-haemolytic strep, Staph, and Cl. Perfringens -systemic signs are common: chills, fever, rigors n SIRS(systemic inflammatory response syndrome: tachycardia, pyrexia, leucocytosis) E. FALSE -blood cultures are often negative 3) A young girl was admitted with dull pain in abdomen. In the evening she developed diffuse skin rash which responded to antihistamines. Ultrasound A. B. C. D. TRUE TRUE TRUE FALSE

Surgery Year 5, 5th Feb 2013

can revealed cystic lesion in the liver. Blood test reveals a high eosinophil count. In this scenario, which is/are TRUE A. This is a rupture of simple cyst of liver B. It is suggestive of ruptured hydatid cyst C. Treatment is masterly inactivity D. Treatment is exploratory laparotomy with albandazole cover E. Anaphylaxis can occur during laparotomy

Answer A. FALSE -dull pain in abdomen, skin rash, cystic lesion in liver, eosinophilia are suggestive of hydatid cyst of liver surgery (makhan lal saha) pg 136, (Bailey n love pg 58) -skin manifestation of intraperitoneal rupture of cyst: itching, urticaria bedside clinic in surgery (makhan lal saha pg 136) Watchful waiting/ watch and wait(WAW)/masterly inactivity is an approach to a medical problem in which time is allowed to pass before medical intervention or therapy is used. During this time, repeated testing may be performed. (wikipedia)/ A hands-off management philosophy in which certain conditions are closely monitored, but treatment withheld until symptoms either appear or some measurable parameter changes. Active management is begun once the patients become symptomatic. http://medical-dictionary.thefreedictionary.com/Masterly+inactivity This patient should be treated in a tertiary by a multidisciplinary team of hepatobiliary surgeon, physician, and interventional radiologist. Whether the patient is treated only medically or in combination with surgery will depend upon the clinical group (the cysts activity), number of cyst and their anatomical position. Leave asymptomatic and inactive cysts alone (monitor size by ultrasound). Active cyst should be first treated by a full course of albendazole. Then, do the surgery accordingly. (Bailey n Love pg 58)

B. TRUE

C. TRUE

D. TRUE

-preoperative albendazole therapy has some advantages:

Surgery Year 5, 5th Feb 2013

E. TRUE

1. Some of cyst may regress to some extend 2. The albendazole has scolicidal activity 3. In case of suddenly spillage of hydatid cyst fluid during operation, due to scolicidal effect, peritoneal seedling will be prevented- bedside clinics in surgery (makhan lal saha pg 136) complication of hydatid cyst is anaphylactic shock due to rupture of cyst- bedside clinics in surgery (makhan lal saha pg 136) During laparotomy, if the cyst is accidentally ruptured, it may cause anaphylaxis (logic thinking)

4) A 12 year old boy is brought with acute left scrotal pain. The differential diagnosis a. Torsion of testis b. Torsion of hydatid morgagni c. Acute epididymitis d. Incarcerated hernia e. Polyarteritis nodosa Answer The acute scrotum Bailey n Love pg 77 A. TRUE -most common in adolescent but may occur at any age. The pain is not always centred on scrotum but may be felt in groin or lower abdomen. -a hydatid of morgagni is an embryological remnant found on the upper pole of the testis.torsion of a testicular appendage characteristically affects boy just before puberty, possibly because of enlargement of the hydatid in response to gonadotrophins. The pain often increases over a day or two. -http://www.aafp.org/afp/1999/0215/p817.html -other conditions that rarely cause acute scrotal symptoms and signs include idiopathic scrotal oedema, an incarcerated inguinal hernia, vasculitis or scrotal haematoma -Polyarteritis nodosa is a disease that affects arteries, the blood vessels that carry oxygen-rich blood to organs and tissues. More adults than children get this disease. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002410/

B. TRUE

C. TRUE D. TRUE

E. FALSE

Surgery Year 5, 5th Feb 2013

5) A 40 year old woman has a BMI of 40kg/m2. Cancers associated with this condition include A. Breast B. Kidney C. Colon D. Oesophagus E. Endometrium Answer All are TRUE-- associated tumors in obesity/lack of physical exercise (Bailey n Love pg 97)

6) A 16 year old girl is admitted with severe abdominal pain. The following is/are TRUE A. Ultrasound as the first line of investigation B. CT is the best investigation for acute diverticulitis C. Plain x ray KUB is the best imaging modality for ureteric colic D. Plain x ray is the first investigation for suspected perforation E. Ultrasound is used to diagnose the causes of bowel obstruction

Answer A. TRUE -the use of imaging early in the assessment process is highly desirable. They are chest radiograpraph(erect), anterior radiograph (supine), IVU, ultrasound,CT scan, Focused CT scan, Focused high resolution ultrasound. (Bailey n love,The acute abdomen, pg 146) -CT scan is the best investigation for suspected diverticulitis and will allow staging of the disease to determine management (Bailey love pg 147) -CT is the most sensitive technique for detection of ureteric colic in renal colic and hematuria (Bailey n love pg 148) -erect chest and supine abdomen radiographs remain the investigations of choice when perforation of intestinal obstruction is suspected (Bailey n love pg 146) - both ultrasound and CT are useful in demonstrating the presence of fluid-filled dilated small bowel loops in high-grade obstruction Bailey n love pg 148

B. TRUE n C. FALSE D. TRUE

E. TRUE

Surgery Year 5, 5th Feb 2013

7. TRUE about immunohistochemistry A.It is a special staining method B.It relies on the use of specific antibody C.It helps to determine cell type and differentiation D.It has a role in determination of treatment and prognosis E.It has no role in infections Answer False; A special stain is a stain that is not routine.Immunohistochemistry chemical stains are conventionally excluded from this category .( Bailey and Loves Short Practise of Surgery,25th edition,page 176) True; This technology detects a specific antigen using an antobody.( Bailey and Loves Short Practise of Surgery,25th edition,page 177) True; Immunohistochemistry has numerous applications in tumour pathology ,including determination of cell type/direction of differentiation and elucidation of site of origin.( Bailey and Loves Short Practise of Surgery,25th edition,page 177) True; Immunohistochemistry may play a role in the selection of treatment and prognostic predictions. ( Bailey and Loves Short Practise of Surgery,25th edition,page 177) False; There are antibodies to many infective agents,including CMV,EBV,HSV,HHV8,Hep B.Some of these e.g EBV and HHV8 cannot be demonstrated by H&E and require immunohistochemistry . ( Bailey and Loves Short Practise of Surgery,25th edition,page 178)

Surgery Year 5, 5th Feb 2013

8. A patient with Body Mass Index (BMI) of 38kg/m2 is admitted for cholecystectomy.The possible problems associated with surgery in this patient are: A.Myocardial Infarction B.Aspiration C.Deep Vein Thrombosis D.Pressure sore E.Pain control

Answer TRUE; Abdominal surgical wounds may compromise respiratory fuction by splinting the diaphragm.Sudden onset of shortness of breath and tachypnoea may be caused by pulmonary emboism,myocardial infarction,chest infection,pneumothorax,acute bronchospasm or bronchopneumonia. (Bailey and Loves Short Practise of Surgery,25th edition,page 260). TRUE; Aspiration, or breathing food or fluid into the lungs, can be a problem, during surgery. Some patients also experience an increased heart rate or elevated blood pressure during the process .(http://surgery.about.com/od/beforesurgery/a/RisksSurgery.htm) TRUE; Specific post operative complications.Cardiovascular complications,Deep Vein Thrombosis.Risk factors for DVT age >60yrs,Recent surgery,Immobilisation,Trauma,OCP,Obesity,Heart failure,Cancer,Arteriopathy. . (Bailey and Loves Short Practise of Surgery,25th edition,page 262,summary box 20.5). TRUE; General complications,Pressure sores occur as result of friction or persisting pressure on soft tissue.They particularly affect the pressure points on recumbent patient,including the sacrum,greater trochanter and heels.Risk factors are poor nutritional status,dehydration,and lack of mobility. (Bailey and Loves Short Practise of Surgery,25th edition,page 266). TRUE;General Management of immediate postoperative period :Ensure ABC,Monitor pain,watch for complications,monitor bp,pulse and oxygen saturation. (Bailey and Loves Short Practise of Surgery,25th edition,page 258,summary box 20.1). (summary box 13.8,page 189).

Surgery Year 5, 5th Feb 2013

9. A 20year old with with yellowish dislocoration of skin,sclera,and bilirubin of 10mg is taken up for emergency surgery.What are the preoperative preparations? A.Injection of vitamin k B.Injection Vitamin D C.Hydration of patient D.Dextrose containing Intravenous Fluid E.Antibiotics

Answers TRUE; Jaundiced patients are also at risk of significant secondary complications.Impaired clotting occurs because of Vit k deficiency and should be corrected. (Bailey and Loves Short Practise of Surgery,25th edition,page 189). False; Vitamin D is used for conditions of the heart and blood vessels, including high blood pressure and high cholesterol. It is also used for diabetes, obesity, muscle weakness, multiple sclerosis, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), asthma, bronchitis, premenstrual syndrome (PMS), and tooth and gum disease. (http://www.webmd.com/vitamins-supplements/ingredientmono-929vitamin%20d.aspx?activeIngredientId=929&activeIngredientName=vitamin%20d) True; There is also an increased risk of renal failure(hepatorenal syndrome) so patients must be kept well hydrated.( (Bailey and Loves Short Practise of Surgery,25th edition,page 189). True; pre-operative fluid expansion. ? (http://www.surgical-tutor.org.uk/default-home.htm?system/abdomen/jaundice.htm~right) True: There is also an increased risk of renal failure(hepatorenal syndrome) so patients must be kept well hydrated,as well as risk of other infections,so that prophylactic antibiotics will also be needed.( (Bailey and Loves Short Practise of Surgery,25th edition,page 189).

Surgery Year 5, 5th Feb 2013

10. Which of the following is/are part of anesthetic triad used during surgery? A.Unconciousness B.Pain relief C.Amnesia D.Muscle Relaxation E.Sleep Answer True True False True False *The general anaesthetic triad,unconciousness,pain relief,muscle relaxation. (Bailey and Loves Short Practise of Surgery,25th edition,page 195,summary box 14.2)

Surgery Year 5, 5th Feb 2013

11. Following gases are used to create pneumoperitoneum include: A.Methane B.CO2 C.Helium D.Nitrous Oxide E.Argon Answer False True True True True Gases used for pneumoperitoneum include carbon dioxide (CO2), air, oxygen, nitrous oxide (N2O), argon, helium and mixtures of these gases. (http://laparoscopy.blogs.com/prevention_management/chapter_01_pneumoperitoneum /)

Surgery Year 5, 5th Feb 2013

12. A 68year old male patient underwent anterior resection for carcinoma rectum.He developed hypotension.15hours after surgery.The possible causes are: A.Post operative bleeding B. Myocardial Infarction C.Epidural Anesthesia D.Inadequate fluid replacement E.Leakage of bowel anastomosis Answers True True True True True *The commonest cause of low blood pressure post operatively is hypovolemia,as a result of bleeding or insuffient fluid replacement;however a myocardial infarction may also present with hypotension,as an overdose of analgesics,especially opiods. Specifically epidural anesthesia may be complicated by hypotension because of vasodilatation of veins.Septic shock may also be present in this way. Summary box 20.4 Low Blood Pressure Postoperatively *Is the patient dehydrated? *Has the patient had an epidural aneasthesia? *Is the pateint losing blood? *Is the patient on too much morphine? *Has the patient had a myocardial infarction? (Bailey and Loves Short Practise of Surgery,25th edition,page 262)

Surgery Year 5, 5th Feb 2013

13. An elderly woman presents with sweating and confusion. The thyroid function test reveals low TSH and elevated T3 and T4. The differential diagnosis are: A. Graves disease B. Toxic nodule C. Sick euthyroid disease D. Thyroiditis E. Myxoedema Answer: A. True. It is primary thyrotoxicosis. (ms 288, manipal manual surgery) TSH levels are low and T3 and T4 are high. (ms 292, manipal manual surgery) B. True. This the other form of thyrotoxicosis. (ms 283, manipal manual surgery) C. False. Euthyroid sick syndrome, sick euthyroid syndrome, non-thyroidal illness syndrome or low T3 low T4 syndrome. (http://en.wikipedia.org/wiki/Euthyroid_sick_syndrome) D. False. In hashimotos thyroiditis, T4 is normal and TSH normal/raised. 9ms 757, bailey and love) E. False. Hypothyroidism is diagnosed in individuals with elevated TSH levels and low levels of free T4 and T3. (http://www.medscape.org/viewarticle/567307_2)

14. Which of the following is/are true regarding multiple endocrine tumour (MEN)? A. they are always benign in nature B. they are mostly inherited C. the mode of inheritance is autosomal dominant D. MEN-1 is caused by mutations in menin gene E. MEN-2 is caused by mutation in RET proto oncogene Answer: A. False. MEN mostly inherited sundromes by a different pattern of benign and malignant tumours in different endocrine glands. (ms 823, Bailey and Love 25th edition) B. True. MEN mostly inherited sundromes by a different pattern of benign and malignant tumours in different endocrine glands. (ms 823, Bailey and Love 25 th edition)

Surgery Year 5, 5th Feb 2013

C. True. Mode of inheritance is autosomal dominant in MEN-1 and MEN-2 . (ms 823, Bailey and Love 25th edition) D. True. Identification of MEN-1 (menin) gene (ms 825, Bailey and Love 25th edition) E. True. MEN-2a, disease is caused by RET proto-oncogene in codon 634. (ms 825, Bailey and Love 25th edition)

15. Which of the following statements are true regarding abscesses? A. Staph aureus is one of the most causative organisms B. the abscess wall is composed of epithelium C. most wound site abscesses occur before the patient is discharged from hospital D. antibiotics are indicated if there is evidence of cellulitis E. Actinomyces causes acute abscess Answer: A. True. Pyogenic abscess is commonest form of an abscess and usually produced by Staphylococcal infections. (ms11, manipal manual surgery) B. False. The area around the abscess is encircled by fibrin products and it is infiltrated with leukocytes and bacteria. (ms 11, manipal manual surgery) C. False. Abscess most present within the first week but can be seen as late as the third postoperative week, even after leaving hospital. (http://www.patient.co.uk/doctor/common-postoperative-complications) D. True. Antibiotics used to treat cellulitis associated with abscess or purulent drainage should target CA-MRSA until proven otherwise with culture data. (http://emedicine.medscape.com/article/214222-treatment) E. False. Actinomycosis abscesses grow larger as the disease progresses, often over months. (http://en.wikipedia.org/wiki/Actinomycosis)

16. Which of the following statements are true regarding clostridial wound infections? A. clostridial are gram positive aerobic spore bearing cocci B. thin, brown and sweet smelling exudate is seen in gas gangrene C. Necrotic and foreign materials in wounds increase the risk of infection D. the spores are widely spread in soil and manure

Surgery Year 5, 5th Feb 2013

E. the sign and symptoms are due to the endotoxins Answer: A. False. Clostridium consists of anaerobic, spore forming, Gram positive bacilli. (ms 226, microbiology Bhaveja) B. True. A thin, sero-sanguinolent exudate with a sickly, sweet odor is present. Swelling and edema of the infected area is pronounced. The muscles appear dark red to black or greenish. (http://membership.uhms.org/?page=cmm) C. True. Infection can occur through contamination of wounds (fractures, bullet wounds) with dirt or any foreign material contaminated with C. perfringens. (http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/clostridium-perfringenseng.php) D. True. Most species are saprophytes found in soil, water and decomposing plant and animal matter. E. False. Clostridium enterotoxins are toxins produced by Clostridium species. http://en.wikipedia.org/wiki/Clostridium_enterotoxin

17. Which of the following require more than one dose of prophylactic antibiotic? A. prolonged operation B. excessive blood loss C. Gastrointestinal surgery D. Insertion of prosthesis E. Unexpected contamination Answer: A. True. In prolonged surgery of greater than four hours, further antibiotic doses may be required to maintain the concentration, particularly if the antibiotic has a short half-life (http://www.australianprescriber.com/magazine/28/2/38/40#.UZ5rVLVmiSo) B. False. Not related to any infection due to excessive blood loss. The antibiotic should be active against the bacteria most likely to cause an infection. http://www.australianprescriber.com/magazine/28/2/38/40#.UZ5rVLVmiSo C. False. For intraluminal prophylaxis erythromycin base or metronidazole and neomycin or kanamycin (3 times 1g per dose per day) are given the day before the operation. (http://www.ncbi.nlm.nih.gov/books/NBK6917/)

Surgery Year 5, 5th Feb 2013

D. False. Indeed, various investigations have demonstrated that a single dose of teicoplanin is equally protective as multiple doses of other antibiotics usually used. (http://www.ncbi.nlm.nih.gov/pubmed/11428097) E. False. Prophylaxis does not need to cover all bacterial species found in the patient's flora, as some species are either not particularly pathogenic or are low in numbers or both. http://www.australianprescriber.com/magazine/28/2/38/40#.UZ5rVLVmiSo

18. Which of the following is/are true for undescended testis? A. Orchidopexy in a subdartos pouch is the treatment of choice B. the operation is recommended at the age of 2 years C. laparotomy is indicated when a testis is impalpable (intra-abdominal) D. undescended testes are associated with increased risk of testicular germ cell tumors E. orchidopexy reduces the chance of malignancy Answer: A. True. Testis is placed in a pouch constructed between the dartos muscle and skin. (ms 1378, bailey and love 25th edition) B. True. 2 years is the ideal age to operate in bilateral case, and 4 years for unilateral case. (ms 807, manipal manual surgery) C. True. It can be done by open or laparoscopic. (ms 807, manipal manual sugery) D. True. Seminoma of testis and other testicular malignancies are reported in greater frequency in undescended testis than in normal testis. (ms 807, manipal manual surgery) E. False. Increased liability to malignant disease is not necessarily corrected by orchidopexy but early diagnosis of a tumour is easier. (ms 1378, bailey and love, 25th edition)

Surgery Year 5, 5th Feb 2013

19. Which of the following statements are TRUE about the causation of cancer? A. Environmental factors have been implicated in more than 80 percent of cancers B. HPV infection is associated with cancer of the penis C. Familial breast cancer involving BRCA1 and BRCA2 has an autosomal recessive inheritance D. Wood dust is associated with paranasal sinus cancers E. Pituitary tumours are part of MEN type 2A syndrome

Answers : A. True; Genetic contribution to the 80% of tumours to whose occurrence environmental factors contribute. Environmental factors have been implicated in more than 80% of cases of cancer. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 94) B. True; HPV infection is associated with carcinoma of penis and cervix. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 96) C. False; Familial breast cancer involving BRCA1 and BRCA2 has an autosomal dominant inheritance pattern. (http://www.cancer.net/all-aboutcancer/genetics/genetics-breast-cancer -American Society of Clinical Oncology) D. True; Wood dust is associated with paranasal sinus cancers. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 96) E. False; MEN type 2A syndrome includes parathyroid tumours, islet cell tumours, and pituitary tumours. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 94)

Surgery Year 5, 5th Feb 2013

20. The following cancers are associated with obesity A. Breast B. Kidney C. Colon D. Oesophagus E. Endometrium

Answers : A. True; Obesity/lack of physical exercise is associated with cancers of breast, kidney, colon, oesophagus, and endometrium. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 97) B. True; as above. C. True; as above. D. True; as above. E. True; as above.

21. Surgical risks of a diabetic patient include : A. Infection B. Myocardial infarction C. Pressure sore D. Poor wound healing E. Pain control

Answers : A. True; Increased risk of local and general sepsis. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 190). Metabolic syndrome including diabetes, uraemia and jaundice are risk factors for increased risk of wound infection. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 34)

Surgery Year 5, 5th Feb 2013

B. True; Surgery may also precipitate myocardial ischaemia in diabetic patients. The presence of significant coronary artery disease may not always result in typical symptoms of ischaemic heart disease. Silent myocardial ischaemia may be present in up to 20% of patients with diabetes, especially those with macrovascular disease elsewhere, with microalbuminuria or with 2 or more additional cardiovascular risk factors. Such patients should undergo cardiac evaluation prior to major surgery. (https://www.diabetessociety.com.au/documents/PerioperativeDiabetesMana gementGuidelinesFINALCleanJuly2012.pdf) C. True; Neuropathic complications requiring pressure care. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 190). Pressure sore is general complication of surgery applies to all immobilized patient after surgery. (Bailey&Loves Short Practice of Surgery, 25 th edition, Page 266). Neuropathy affects between 30-50% of people with diabetes and places them at increased risk of heel ulceration, particularly if peripheral vascular disease is also present. (Gordois A, Scuffham P, Shearer A, Oglesby A, Tobian JA. The health care costs of diabetic peripheral neuropathy in the US Diabetes Care 2003;26:1790-5.) D. True; Metabolic diseases such as diabetes mellitus, uraemia, jaundice, disseminated malignancy and AIDS are contributors to infection and poor wound healing response. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 34) E. False; Regional and local anaesthesia techniques have the potential to reduce post-operative pain and nausea. (http://www.diabetes.org.uk/Documents/Professionals/Reports%20and%20st atistics/Management%20of%20adults%20with%20diabetes%20undergoing% 20surgery%20and%20elective%20procedures%20%20improving%20standards.pdf) Some students tend to think that pain control may be difficult to be achieved peri-operatively due to diabetic neuropathy. Micro and macroangiopathy in

Surgery Year 5, 5th Feb 2013

diabetic made us doubt whether the anaesthesia is delivered through circulation and whether pain felt during operation may or may not be resolved. From what Ive read, the answer is pain control through anaesthesia is adequately achieved and therefore does not pose as surgical risk in diabetic. Students opinion Diabetic neuropathy only poses problem peri-operatively through autonomic neuropathy. Patients with autonomic neuropathy may also have impaired cardiovascular reflexes resulting in hypotension at the induction of anaesthesia, as well as an impaired respiratory drive post-operatively, and the anaesthetist should be therefore be informed if autonomic neuropathy is present. (https://www.diabetessociety.com.au/documents/PerioperativeDiabetesMana gementGuidelinesFINALCleanJuly2012.pdf)

Surgery Year 5, 5th Feb 2013

22. Risk factor for thrombosis include : A. Young age B. Pregnancy C. Smoking D. Trauma E. Malignancy

Answers : A. False; Risk factors for thrombosis includes increasing age, malignancy, trauma or surgery especially in abdomen, pelvis and lower limbs, pregnancy/puerperium, immobility, obesity, family/personal history of thrombosis and drugs like oestrogen, smoking. (Bailey&Loves Short Practice of Surgery, 25th edition, Page 190) B. True; as above. C. True; as above. D. True; as above. E. True; as above.

23. TRUE regarding water homeostasis : A. The Total Body Water (TBW) content in an adult male is 70% of body weight B. Two-third of TBW is intracellular C. An average adult has approximately 3L of plasma D. TBW is highest in elderly women E. Water move freely across cell membranes

Answers : A. False; Total body water content in average 70kg adult male is 60% of body weight, or about 42 liters. (Textbook of Medical Physiology, by Guyton&Hall, Page 293 and S.Das Textbook of Surgery, 6th edition, Page 24) B. False; 28 liters of TBW equivalent to 40%, are intracellular.

Surgery Year 5, 5th Feb 2013

C. True; Extracellular fluid consists of 20% of TBW or 14 liters of water in which three-fourth of ECF is interstitial fluid, and the remaining one-fourth is plasma equivalent to 3 liters. (Textbook of Medical Physiology, by Guyton&Hall, Page 293) D. False; TBW is highest in infants which is 77%. (S.Das Textbook of Surgery, 6 th edition, Page 24) E. False; Cell membrane consists of lipid bilayer. Water is highly lipid insoluble. However, water freely moves through channel protein. (Textbook of Medical Physiology, by Guyton&Hall, Page 45)

24. TRUE regarding vomiting due to small bowel obstruction : A. The creatinine level is elevated B. There is a rise in urine osmolality C. There is increase in urinary sodium (Na) excretion D. Hyperchloraemia is a common feature E. Antidiuretic Hormone(ADH) rises

Answers : A. True; Sustained vomiting causing hypovolaemia and dehydration which manifests as oliguria, haemoconcentration and azotemia. (S.Das Textbook of Surgery, 6th edition, Page 881). Hypovolaemia can cause reduced renal perfusion which will further cause prerenal acute renal failure characterized by increased creatinine level. (Davidsons Principles&Practice of Medicine, 21st edition, Page 484) B. True; Urine osmolality is used to measure the number of dissolved particles per unit of water in the urine. Dehydration due to vomiting will cause an increase in urine osmolality. (http://emedicine.medscape.com/article/2088250overview#aw2aab6b2)

Surgery Year 5, 5th Feb 2013

C. False; Vomiting causes loss of fluid and sodium. As compensatory mechanism, urine output and sodium excretion will be reduced. Urinary sodium concentration <30mmol/L. (Davidsons Principles&Practice of Medicine, 21st edition, Page 435 and 445) D. False; Vomiting causes expulsion of hydrochloric acid from stomach. With contribution from dehydration, hypochloraemia is a feature of vomiting in intestinal obstruction. (S.Das Textbook of Surgery, 6th edition, Page 881) E. True; ADH is activated in both hypovolaemic and chronic hypervolaemic states. ADH is secreted by posterior pituitary.

Surgery Year 5, 5th Feb 2013

25. Advantages of minimal access surgery include : A. Decrease in wound size B. Decreased postoperative pain C. Shorter operating time D. Improved vision E. Reduced operating theatre cost

Answer A. True (Bailey and Loves 25th edition, page 248, summary box 19.1) B. True (Bailey and Loves 25th edition, page 248, summary box 19.1) C. False (Bailey and Loves 25th edition, page 248, not mention in summary box 19.1) D. True (Bailey and Loves 25th edition, page 248, summary box 19.1) E. False (Bailey and Loves 25th edition, page 248, not mention in summary box 19.1)

26. A. B. C. D. E.

TRUE regarding deep vein thrombosis (DVT) : Obese patients are more prone to DVT Clinical diagnosis is very obvious Hip and knee replacement surgery are high risk Confirmation is by venography and / or duplex Doppler Ultrasound (US) Optimum hydration is essential to prevent DVT

Answer A. True ; patient factors - obesity (Bailey and Loves 25th edition, page 936, Table 54.1 Risk factors for venous thromboembolism) B. False ; The diagnosis of deep vein thrombosis and pulmonary embolism should be established by special investigations as the symptoms and signs are non-specific and may be entirely lacking. (Bailey and Loves 25th edition, page 937) C. True ; disease or surgical procedure trauma or surgery especially of pelvis, hip and lower limb. (Bailey and Loves 25th edition, page 936, Table 54.1 Risk factors for venous thromboembolism)

Surgery Year 5, 5th Feb 2013

D. True ; if D-dimer is raised, a duplex ultrasound examination of deep veins should be performed. (Bailey and Loves 25th edition, page 937) E. True ; prophylaxis of DVT early mobilization, walking, adequate hydration ( Manipal Manual of Surgery 3rd edition, page 116)

27. Which of the following clinical signs are evidence of a base of skull fracture? A. Cerebrospinal fluid (CSF) rhinorrhoea B. Cerebrospinal fluid (CSF) otorrhoea C. Battles sign D. Periorbital bruising E. Haemotympanum

Answer A. True ; CSF otorrhoea or rhinorrhoea often resolves spontaneously. (Bailey and Loves 25th edition, page 308) B. True ; CSF otorrhoea or rhinorrhoea aften resolves spontaneously. (Bailey and Loves 25th edition, page 308) C. True ; In fracture of the posterior fossa behind the foramen magnum, a patch of ecchymosis appears within 3 or 4 days near the tip of the mastoid process, Battles sign. (Clinical Surgery by S. Das 7th edition, page 198) D. True ; periorbital bruising has been described in association with basal skull fracture, orbital cellulitis and cavernous sinus thrombosis. (http://jnnp.bmj.com/content/69/6/812.full.pdf) E. True ; the most common causes of hemotympanum are therapeutic nasal packing, epistaxis, clotting disorders, blunt trauma to the head and skull base fracture. (http://www.ent-surgery.com.au/ent-blog/about-the-ear/hemotympanum2/)

Surgery Year 5, 5th Feb 2013

28. A. B. C. D.

Direct inguinal hernia : Is usually congenital Contains bowel, omentum and bladder Occurs with an indirect hernia Protrudes through the posterior wall of inguinal canal, lateral to the inferior epigastric vessels. E Has a high risk of strangulation

Answer A. False ; a direct inguinal hernia is always acquired. (Bailey and Loves 25 th edition, page 974) B. True ; Inguinal hernia can be classified according to the contents of hernia either enterocele, omentocele or cystocele. C. True : In case of pantaloon or saddle bag hernia, both a direct and indirect inguinal hernia sac lying on either side of inferior epigastric vessels. Also called as dual hernia. (Bedside Clinics in Surgery by Makhan Lal Saha, page 37) D. False ; A direct hernia comes out directly forwards through the posterior wall of the inguinal canal. Whereas the neck of the indirect hernia is lateral to the inferior epigastric vessels, the direct hernia usually emerges medial to this except in pantaloon type. (Bailey and Loves 25th edition, page 971) E. False ; As the neck of the sac is wide, direct inguinal hernias do not often strangulate. (Bailey and Loves 25th edition, page 974)

29. A. B. C. D. E.

Complications of total thyroidectomy include : Hoarseness of voice Airway obstruction Haemorrhage Hypercalcaemia Hyperglycemia

Answer A. True ; Recurrent laryngeal nerve paralysis and voice change. (Bailey and Loves 25th edition, page 791) B. True ; Respiratory obstruction. (Bailey and Loves 25th edition, page 790)

Surgery Year 5, 5th Feb 2013

C. True : Haemorrhage ( Bailey and Loves 25th edition, page 790) D. False ; hypocalcaemia is due to parathyroid insufficiency. (Bailey and Loves 25th edition, page 791) E. False ; (Bailey and Loves 25th edition, page 790)

30. A. B. C. D. E.

A femoral hernia : Is commoner in women than in men Emerges below and lateral to the pubic tubercle Is related on its medial side to the lacunar ligament and laterally to the femoral vein Has a significantly higher rate of complications than an inguinal hernia Is cured by Bassinis operation

Answer A. True ; (Bailey and Loves 25th edition, page 977, Summary box 57.11) B. True ; The hernia actually comes out superficially through the saphenous opening situated 1 inches below and lateral to the pubic tubercle. (Clinical Surgery by S. Das, 7th edition, page 445) C. True ; The femoral canal is bounded superoanteriorly by the inguinal ligament, inferoposteriorly by the pubic ramus and pectineus muscle, medially by the lacunar ligament and laterally by the femoral vein. (Clinical Surgery by S. Das, 7th edition, page 445) D. True ; As the femoral ring and the neck of the sac are narrow, obstruction and strangulation are very common. (Manipal Manual of Surgery, 3rd edition, page 692) E. False ; Surgical treatment of femoral hernia includes the low operation of Lockwood, high operation of McEvedy and the inguinal operation of Lotheissen. Bassinis operation is used in surgical treatment og inguinal hernia.

END.