5 .>U nri& a.

QUEST : A COMPREHENSIVE GUIDE TO UG ,

Surgery, Orthopedics
& Anesthesiology
MBBS Q. & A. from 2020 - 2008 includ in g regular, supplem entary & sem ester papers

Dr. Debanjan Kundu mbbs

M.D. Post Graduate Trainee at Dept, ot Radiation Oncology,
Ft. G. Kar Medical College and Hospital, Kolkata

Dr. Simantini Sircar mbbs

M.S., Obstetrics and Gynaecology, Kasturba Hospital, Delhi,
Senior Resident, Dept, of Obstetrics and Gynaecology,
CK Birla Hospital, Gurgaon.

ACADEMIC PUBLISHERS
5A Bhawani Dutta Lane, Kolkata-700073
E -m a il : contact@academlcpublisher$.in
Website : www.academicpublishers.in
| M B B S questions and answers o f regular & supplementary
QUEST : A COMPREHENSIVE GUIDE TO UG QUEST : A COMPREHENSIVE GUIDE TO UG
CONTENTS
ANATOMY PHYSIOLOGY
SECTIO N: 1 SURGERY

:
QUEST A COMPREHENSIVE GUIDE TO UG QUEST : A COMPREHENSIVE GUIDE TO UG 1. SEG M ENT-A
BIOCHEMISTRY FORENSIC MEDICINE & Solved Long Questions of Final MBBS 2008-2020 (Paper - 1) 1 -1 0 0
TOXICOLOGY Solved Long Questions of Final MBBS 2008-2020 (Paper —II) 101 -2 1 5

:
Q U E S T A KEY TO UG QUEST : A COMPREHENSIVE GUIDE TO UG
2. SEG M ENT-B
Solved Long Questions of Semesters (Paper - 1) 216 - 251
PHARMACOLOGY PATHOLOGY
Solved Long Questions of Semesters (Paper - II) 252 - 273

3. SEGM ENT-C
QUEST : A COMPREHENSIVE GUIDE TO UG .QUEST : A COMPREHENSIVE GUIDE TO UG
Solved Short Notes o f Final MBBS 2008-2020 (Paper-1) 2 7 4 -3 4 6

MICROBIOLOGY * OTORHINOLARYNGOLOGY Solved Short Notes o f Final MBBS 2008-2020 (Paper - II) 347 - 466
(ENT)
4. SEGMENT - D
Solved Short Notes o f Semesters 467 - 579
QUEST: A COMPREHENSIVE GUIDE TO UG QUEST : A COMPREHENSIVE GUIDE TO UG

COMMUNITY MEDICINE COMMUNITY MEDICINE 5. SEGMENT-E

(THEORY) (ORAL & PRACTICAL) Solved Shorts Notes o f Investigations 580 - 613

:
QUEST A COMPREHENSIVE GUIDE TO UG QUEST : A COMPREHENSIVE GUIDE TO UG
SECTION: 2 ORTHOPEDICS
OPHTHALMOLOGY (EYE) MEDICINE 1. G R O U P-I

Solved Short Notes o f Final MBBS 2008 - 2020 6 1 4 -6 9 3

QUEST: A COMPREHENSIVE GUIDE TO UG QUEST : A COMPREHENSIVE GUIDE TO UG 2. G R O U P-II

Solved Short Notes o f Semesters of Various Colleges 694 - 750
SURGERY, ORTHOPAEDICS OBSTETRICS & GYNAECOLOGY
& ANESTHESIOLOGY
SECTION: 3 ANESTHESIOLOGY

OUEST : A COMPREHENSIVE GUIDE TO UG ESSENTIAL MATHEMATICS Solved Short Notes 751 - 772

PAEDIATRICS FOR POSTGRADUATE MEDICAL

ENTRANCE EXAMINATIONS (PGMEE)

onlin e a va ila b le w ith w w w .fiipkart.com & w w w .acad em icpub lishers.in

 2011

Q.1 : A 45 yr old female patient presents with acute upper abdominal pain. Discuss the differential diagnosis and
management. - Ans. (See Page No. 33)
SECTION 1 - SURGERY Q1 : Enumerate causes of intestinal obstruction in Wants. Write clinical features, investigations and management of
intussusceptions in 7 yr old child. - Ans. (See Page No. 37)
SEGMENT A (P A P E R -I)
2011 Supplementary
2008
Q.1: Define shock. What are its different types? Outline the management of a patient presenting with features of
Q.1: Define and classify shock. How will you assess and treat a case of haemorrfiagic shock? Mention complications septicshock. - Ans. (See Page No. 38)
of blood transfusion. - Ans. (See Page No. 3) Q.2: Describe the clinical features, investigations and management of acute pancreatitis . - A n s (See Pane
Q.2: Enumerate the causes of bleeding per rectum. Mention how it is diagnosed. Outline the management for No. 38)
bleeding hemorrhoids. - Ans. (See Page No. 7) Q.3: What are the causes of lump in R.I.F in a male patient of 40 year old? How do you investigate and manage such
Q.3: What are the causes of obstructive jaundice? How do you establish the diagnosis? Discuss various options in a patient? - Ans. (See Page No. 38)
management of choledocholithiasis. - Ans. (See Page No. 10)
2012
2008 Supplementary
Q. 1: What are the types of haemorrhage? What are the methods of determining acute blood loss? How will you treat
Q. 1: Classify burn. How will you assess and manage a 35 year old woman weighing 60 kg admitted with 40% bum. haemorrhage? - Ans. (See Page No. 40)
- Ans. (See Page No. 13) Q.2: Middle aged patient presented with a big tense cystic lump in upper abdomen following an attack of acute
Q.2: Enumerate the causes of upper Gl bleeding. Discuss how a patient with this should be diagnosed and abdomen. How would you investigate and plan the management? - Ans. (See Page No. 42)
managed. - Ans. (See Page No. 13) Q.3: What are the causes of benign biliary strictures? Discuss the management of retained stones in common bile
Q.3: A 40 year old patient has come to emergency with acute pain in right hypochondrium. How will you make a duct. - Ans. (See Page No. 46)
clinical diagnosis? Outline the treatment strategy in such a patient. - Ans. (See Page No. 13)
2012 Supplementary
2009
Q.1: Define shock. Describe the pathophysiology of septic shock. How would you manage a patient sufferinq from
Q.1: Define and classify wounds. Discuss various factors influencing wound healing. Discuss management of septic shock? - Ans. (See Page No. 47)
diabetic foot. - Ans. (See Page No. 13) Q.2: How would you proceed to investigate and manage a 50 year old man who presented with lump in left iliac fossa
Q.2: A middle aged male patient presents with an epigastric lump. Discuss differential diagnosis. How would you and irregular bowel habit? - Ans. (See Page No. 47)
investigate? - Ans. (See Page No. 16) Q.3: A male patient presented with irreducible inguinal hernia on the right side of 6 hours duration. How will you
Q.3: What are the causes of weeping umbilicus? Discuss the problems related to VID and their remedies. - Ans. proceed to manage the patient? - Ans. (See Page No. 47)
(SeePageNo. 18)
2013
2009 Supplementary
Q.1: Discuss assessment of burn wound. Write in short pathophysiology of burn. How will you treat 30% burn in 50
Q. 1: Classify haemorrhage. How will you determine the amount of blood loss and treat it? - Ans. (See kg body weight female patient. - Ans. (See Page No. 49)
Page No. 20) .' Q.2: Classify colonic tumours. How will you manage a 60 yr old man presenting with fresh bleeding per rectum -
Q.2: Give an account of pathogenesis, clinical features and management of acute pancreatitis. - Ans.(SeePage Ans. (See Page No. 54)
No. 20) Q.3: Describe clinical features, diagnosis and management of choledocolithiasis. - Ans. (See Page No. 59)
Q.3: Define and classify intestinal obstruction. How will you diagnose and treat small intestinal obstruction. - Ans.
(See Page No. 20) 2013 Supplementary
2010
Q.1: What are the normal values of different body electrolytes? What are the electrolyte changes in a patient of long
Q.1: What are coagulation factors? Write in detail about mechanism of homeostasis. - Ans. (See Page No. 22) standing pyloric stenosis? How do they occur? How do you prepare such a patient before an elective operation?
Q.2 : What are the causes of upper Gl bleed? How will you manage acute variceal bleeding? - Ans. (See - Ans. (See Page No. 61)
Page No. 23) Q.2 : What are the causes of lump in right iliac fossa? Outline diagnosis and management of appendicular lu mo. -
Q.3: What are the causes of obstructive jaundice? Write the management of CA head of pancreas. - Ans. (See Ans. (See Page No. 63) •
Page No. 26) Q.3: A30yr old lady presented with severe abdominal pain and shock. Discuss differential diagnosisand management.
- Ans. (See Page No. 64)
2010 Supplementary
2014
Q. 1: Define claudication. What are the grades of claudication? How will you manage a case of Buergers disease with
-Q.1: Classify shock. Discuss the patho - physiology and management of septic shock. - Ans. (See Page No. 66)
dry gangrene of fool? - Ans. (See Page No. 29)
Q-2: Describe the clinical features, investigations and management of carcinoma of stomach. - An s. (See Page
Q.2: Enumerate the differential diagnosis of painless fresh bleeding per rectum. Plan the investigation and treatment No. 71)
of carcinoma of sigmoid colon. - Ans. (See Page No. 29)
Q.3 : A 50 years old patient presents with bleeding per rectum. How will you investigate and manaoe the patient?
Q.3: How will you evaluate, grade and manage a case of blunt splenic trauma? - Ans. (See Page No. 31)
- Ans. (See Page No. 73)

(10|
I" )
 2014 Supplementary Q.2: Mention the causes of nipple discharge. How will you investigate? How will you manage fibrocystic disease of
breast? - Ans. (See Page No. 93)
Q.1: What are the diseases of umbilicus? What are the presentation and treatment of Meckel's dhrerticulum? - Ans.
Q.2: Describe the clinical features of Gastric Outlet Obstruction. How will you investigate and (reat a 60 year old
(See Page No. 78) ' man presenting with Gastric Outlet Obstruction? - Ans. (See Page No. 93)
Q.2: How wifi you assess a breast lump in an elderly woman? Outline the treatment options of an early breast cancer
in a woman of 50 years. - Ans. (See Page No. 78)
2018
q ,3 ; vvhat are the indications of blood transfusion? What are its complications? What do you understand by massive
y blood transfusion? - Ans. (See Page No. 78) Q.1: A40 year old man presents with a non-healing ulcer over the lower part of his inleriot extremity. What are the
2015 causes? How will you investigate the case? What are the surgical considerations of diabetic foot ulcer? (No
operative details) - Ans. (See Page No. 93-94)
Q. 1: Describe the biological process of wound healing. What are the factors affecting wound heating? Treatment Q.2: A25 years old female, recently married, presents with sudden pain over ihe right lower abdomsn. How will you
options for presternal keloid.-Ans. (See Page No. 79) take up the case to come at a diagnosis? Outline the management of Acute Appendicitis. (No operative details).
Q.2: A 45 years old gentleman presents with intractable anemia and a painless lump in right iliac fossa of 3 months - Ans. (See Page No. 94)
duration. How would you investigate the case to confirm the diagnosis? Briefly outline a comprehensive Q.3: Wh^t are the causes of Intra abdominal lump in the region of epigastrium? Discuss the management of Hydatid
management of the problem.-Ans. (See Page No. 81) cyst of the liver. - Ans. (See Page No. 95)
q .3 : A 50 years old male comes to you with painless progressive jaundice and on clinical examination the gall
bladder is palpable. How will you investigate the patient to come to a diagnosis? Describe the preoperative 2018 Supplementary
preparations of jaundiced patients. - Ans. (See Page No. 84)
Q.1: Define Claudication. What are the grades of Claudication? How will you manage a case of Buerger's disease
2015 Supplementary with dry gangrene of the foot? - Ans. (See Page No. 95)
Q.2: What are Ihe common causes of Lower GIT bleeding? Describe in brief how will you investigate and manage
CM: Discuss the etiopathogenesis and management of acute pancreatitis. - Ans. (See Page No. 86) a patient with acute lower GIT bleeding. - Ans. (See Page No. 95)
Q.2: Define burns. Discuss the management of 40% burns in a 22 years female patient of 50 kg body weight, Q.3: Discuss the etiopathogenesis of Chronic Pancreatitis. What are the imaging characteristics of Chronic
carrying 12 weeks pregnancy. - Ans. (See Page No. 86) Pancreatitis? Mention the operation done for Chronic Pancreatitis.
Q.3: Classify ulcers. Discuss the pathology, clinical features, investigations and management of venous ulcer.
2019
- Ans. (See Page No. 86)
2016 CM: Define shock. Give the etiological classification of shock. Describe the pathogenesis and the management of
Ihe septic shock. - Ans. (See Page No. 95)
Q.1: Classify hemorrhage. Discuss briefly the management of hemorrhagic shock. Mention complications of blood
02: A 45 year old lady, known to be having USG evident cholelithiasis, admitted with the complaints of severe pain
transfusion. - Ans. (See Page No. 87) abdomen radiating to the back, out of proportion to any of the signs present and her laboratory values showed
Q.2 : A 50 year old man presents with alternate constipation and diarrhea. He has a lump in left iliac fossa.
a significant serum hyperamylasemia (3 times the normal value). How would you proceed to investigate
How would you investigate and diagnose the case. Outline the treatment of such case. - Ans. (See further, prognosticate and manage (principles only). - Ans. (See Page No. 95)
Page No. 87) . . . ..................................... Q.3: A 54 year ok) gentleman presents in the OPD with a history of dull, vague epigastric pain with persistently and
Q.3: A 45 year old man presented with a recently discovered lump in the epigastnum with rapidly developing
steadily progressive yellow discoloration of eyes and urine for last 4 months with intermittent rise of temperature
anorexia, asthenia, anemia and increasing vomiting. How would you investigate to arrive at the diagnosis?
with chills and rigor for last 15 days. He also gives a history of recently developed anorexia and gross weight
Outline the management of the case. - Ans. (See Page No. 87) ,•
loss. On examination, his gall bladder is palpable as soft cystic swelling. How would you proceed to have a
2016 Supplementary detailed work-141 of the patient prepare him for general anesthesia for a major operation and give the outline ol
his treatment (principles only including palliation). - Ans. (See Page No. 95)
Q.1: What is gangrene? What are the different types and causes of gangrene? Oiscuss briefly the management of
a young male of 32 years with dry gangrene on his left great toe? - Ans. (See Page No. 88) 2019 Supplementary
Q.2: Classify salivary tumours. Describe the pathology, clinical features and management of pleomorphic adenoma Q* How would you estimate the extent & depth ol burns in a flame burn victim? How would you calculate the
of parotid gland. - Ans. (See Page No. 89) quantity of fluid with the type of fluid & dose distribution of fluid necessary for resuscitation of a 40 Kg lady with
Q.3: What is triple assessment of breast lump? Discuss how will you manage a patient with early breast cancer. - 40% TBSA (Total Body Surface Area) burn, according to Purkland Formula? - Ans. (See Page No. 95).
Ans. (See Page No. 90) Q.2: A 50 year old gentleman, severely anemic, anorexic & cachectic, presents with the history of epigastric
2017 fullness & vomiting for last 4 months with the appearance of an irregular epigastric lump for last one month. How
would you proceed to diagnose, prognosticate & manage the patient? - Ans. (See Page No. 96)
Q.1: Describe the signs, symptoms, prevention and treatment of tetanus. - Ans. (See Page No. 91)
Q.3: A 25 year old young lady, married for last 3 months presents at the ER with severe right iliac fossa pain. How
Q.2: Discuss the investigations of a 50 year old male presenting with obstructive jaundice and palpable gall bladder. would arrive at a clinical diagnosis? What are the differentials diagnosis? What are the investigations you need
Give the outline of management of the patent, How will you prepare liver lor operation if needed? - Ans. (See to undertake to confirm your diagnosis? - Ans. (See Page No. 96)
Page No. 93) . . . »
Q.3: Discuss the pathophysiology oi acute intestinal obstruction. How will you manage a case of intussusception? December-January 2020
- Ans. (See Page No. 93)
Q.1: What are Hospital Acquired Infections (HAI) and Surgical site fnfeclions (SSI)? Define Bacteremia and Systemic
2017 Supplementary Inflammatory Response Syndrome (SIRS)? How would you prevent infections (broad outline only) - Ans.
(See Page No. 96)
Q,1: Describe tho clinical methods of assesumg surface area of bums wound. Describe the management of 40%
Q.2: A middle aged gentleman presents with profuse hematemesis following analgesic intake. How will investigate
burns injury in a 60 kg female patient. - Ans. (See Page No, 93) and manage this patient? What are the complications of chronic peptic ulcer? - Ans. (See Page No. 98)
(<J) (13)
 Q.3: A lactating women presents to emergency with painful lump in her right breast which is associated with lever. i Q.2: Classify renal neoplasms. How will you diagnose and manage a case of renal cell carcinoma? - Ans. (See
Write down the clinical examination, investigation and treatment of this patient. - Ans. (See Page No. 99) Page No. 139)
2011 Supplementary
June-July 2020
‘ Q.1: Describe the management of a lady ol 35 years presenting with toxic multinodular goitre. - Ans. (See Page
Q.1: Classify wounds. Write in details about wound healing and factors affecting wound healing. - Ans. (See Page No. 143)
No. 99) i Q.2: A 70 year old man presents with acute retention of uririe. l-!ow would you investigate the patient? Outline the
Q.2: A 60 year old man presenting with palpable lump in right hypochondrium with yellow discolouration of eye. What management in brief of benign hyperplasia of prostate. - Aris. (See Page No. 143)
is your diagnosis? Discuss the etiopathogenesis, investigation and treatment of this case. - Ans. (See Page
2012
No. 99)
Q.3: Classify burns. How will you manage a case of 30% burns with a short note on post burns sequelae. - Ans. Q.1: Classify thyroid neoplasms. Write clinical features, investigations and management of papillary carcinoma of
(See Page No. 100) the thyroid gland (A lady of 25 years old). - Ans. (See Page No. 143)
Q.2: A 40 years old gentleman presented with bilateral knobby renal lump in the abdomen. How do you investigate
SEGMENT A (P A P E R -II) and treat such a patient (operation details not required). •• Ans. (See Page No. 145)
2008
2012 Supplementary
Q.1: Enumerate the causes of haematuria. How will you confirm the diagnosis? What will you do for a patient
diagnosed to have carcinoma of urinary bladder? - Ans. (See Page No. 101) Q.1: What are the different types of nipple discharges with their clinical importance? How would you manage Stage-
Q.2: Discuss the pathogenesis of multinodular goiter. Mention the complications of such a goiter. How do you I carcinoma breast in a lady aged 40 years? - Ans. (See Page No. 147)
manage such a patient? - Ans. (See Page No. 108) jl. Q.2: 65 year old man presents to the emergency with acute retention of urine. How would you investigate & manage
the patient ? - Ans. (See Page No. 147)
2008 Supplementary 2013

Q.1: Enumerate the causes of acute retention of urine. What are the pathdogicaJ changes associated with prostratic Q.1: Deline hydronephrosis. Discuss the causes and management of unilateral hydronephrosis. - Ans. (See Page
hypertrophy? How will you manage such a patient ? - Ans. (See Page No. 113) No. 148)
Q.2: Discuss clinical features of pheochromocytoma. How do you diagnose this condition? What will you do to 3 Q.2; Describe lymphatic drainage of breast. Mention the risk (actors of breast carcinoma. How to manage a 52 year
manage it? - Ans. (See Page No. 114 old female patient with locally advanced breast carcinoma? - Ans. (See Page No. 150)
Q.3: A 50 year old gentleman presented with painless haematuria. What may be the possible causes? How would
. 2009 you investigate the case? Give an outline of the management. - Ans. (See Page No. 160)
Q.1: A 35 year old lady presents with a solitary thyroid nodule in right lobe. How would you come to a diagnosis and 2013 supplementary
manage such a patient? - Ans. (See Page No. 114)
Q.2: Classify kidney tumours. Mention different modes of presentation of Renal Adenocarcinoma. Outline the 1- Q.1: How do you classify goiter? Give an outline of investigations and management of a solitary nodular goiter.
management of such a patient. - Ans. (See Page No. 114) - Ans. (See Page No. 168)
i-Q.2: Classify renal neoplasms. Write clinical features, investigations and management of renal cell carcinoma in a
2009 Supplementary 40 years old male patient. - Ans. (See Page No. 173)
Q.3: Discuss thq clinical features of phaeochromocytoma. How will you diagnose this condition? Give an outline of
Q.1: Define hydronephrosis. What are the causes of unilateral hydronephrosis ? Discuss the managements a
management. - Ans. (See Page No. 174)
patient with stone in middle third of water. - Ans. (See Page No. 114)
Q.2: A 56 year old lady presents with a lump in upper and outer quadrant of right breast. Discuss briefly the 2014
management of such a patient. - Ans. (See Page No. 116)
Q.1: Discuss the clinical features, investigations and treatment of thyrotoxicosis. - Ans. (See Page No. 177)
2010 2 Q.2: Describe the pathophysiology of BHP. Mention the medical and surgical management of BHP. - Ans.(See
Page No. 183) .
Q. 1: What are the functions of thyroid and parathormone? Write in detail about clinical features, investigations and
0.3: Classify testicular tumours. Discuss investigations necessary to plan the treatment for a suspected testicular
treatment of hyperparathyroidism. - Ans. (See Page No. 116)
tumour. What are the treatment options available? - Ans. (See Page No. 188)
Q.2: Give differential diagnosis of scrotal swell ing. Write in detail about management of testicular tumour. - Ans.
(See Page No. 120) 2014 supplementary

2010 Supplementary Q.1: Discuss causes, investigation & management of haematuria. - Ans. (See Page No. 195)
Q.2: What are the different types of renal calculi ? Discuss the clinical features & management of renal calculi. -
Q.1: Classify thyroid malignancies. How will you manage a case of follicular carcinoma of thyroid? - Ans. (See Ans. (See Page No. 195)
Page No. 123) Q.3: What are the clinical features of primary hyper parathyroidism ? Discuss the investigation & managemt of
Q.2: A 40 year old patient presents with haematuria. Enumerate the differential diagnosis, plan the Investigations primary hyperparathyroidism. - Ans. (See Page No. 197)
and treatment. - Ans. (See Page No. 124)
2015
2011
Q.1: Classify goiter. How will you investigate and treat a 30 years old man with clinically discrete nodule of 3 cm
JQ. 1: Classify carcinoma of breast. How will you investigate and manage a case of early carcinoma of breast in a 40 diameter in right lobe of thyroid? - Ans. (See Page No. 197)
year old lady. - Ans. (See Page No. 125)

(14) (15)
 /

Q.2: Classify renal injury. Discuss clinical features and management of patient having injury to left kidney following
Q.2: Outline the etiopathogenesis of Mullinodular Goiter. Describe its management. - Ans. (See Page No. 211)
blunt trauma in left loin. - Ans. (See Page No. 197)
Q.3: Discuss the etiopathology of acute extradural hematoma. Mention the symptoms and the signs. Outline the
Q. 3 : Discuss the clinical features, complications and management of undescended testis. - Ans. (See Page
principle of its management. - Ans. (See Page No. 211)
No. 201)
2015 Supplementary 2019

Q.1: Describe the pathology, investigations and treatment of differentiated thyroid carcinoma. - Ans. (See Page Q.1: Enumerate the causes of anuria. How would you differentiate between prerenal and renal anuria. Give the
No. 202) management of calculus anuria, (principles only) - Ans. (See Page No. 211)
Q.2: Mention common causes of tump in left upper quadrant of abdomen. Describe the clinical features and manage­ Q.2: What are the anatomical and pathophysiological changes that lead to the development of the primary varicose
ment of renal cell carcinoma. - Ans. (See Page No. 203) veins of the lower limbs? How would you test clinically the competence of the valves of the sapheno-femoral,
Q.3: Mention the sites of narrowing of ureter. Describe the clinical features, complications and treatment of ureteric sapheno-popliteal junctions and the leg perforators? - Ans. (See Page No. 214)
stones. - Ans. (See Page No. 204) Give the management of a patient with primary varicose vein with sapheno-femoral incompetence.
Q.3: Define thyrotoxicosis. Enumerate the grade-wise presentation of the eye signs in thyrotoxicosis. Give the brief
2016
outline of the diagnosis and options of management of Graves Disease. - Ans. (See Page No. 214)
Q. 1: Enumerate the causes of painless hematuria. Discuss the investigation and treatment in a patient of 65 years
presented with painless hematuria. - Ans. (See Page No. 205) 2019 Supplementary
Q.2: Classify thyroid cancer. Discuss the management of FNAC proved follicular neoplasm of Right lobe of thyroid
Q.1: What are the different types of renal calculus? How does a patient of renal calculus present? How would you
in a lady of 45 years. - Ans. (See Page No. 205)
investigate to confirm diagnosis? - Ans. (See Page No. 214)
Q.3: What are the etiologies of pancreatitis? How will you investigate and treat a case of acute pancreatitis? - Ans.
Q.2: What are the principal symptoms of peripheral arterial occlusive disease? How would you proceed to investigate
(See Page No. 205)
such a case? What are the conservative management you advice in for a lower leg distal smaller vessel
2016 Supplementary disease? - Ans. (See Page No. 215)
Q.3: A 45 year old lady presents with rapidly developing lump in the upper outer quadrant of the right breast of the
Q.1: Discuss the clinical features and management of primary thyrotoxicosis. - Ans. (See Page No. 205)
size 4 cm x 5 cm with a palpable, mobile enlarged central group lymph node in the same axilla How would you
Q.2: Classify adrenal tumours. Describe the investigation and treatment of adrenal incidentaloma. - Ans. (See
confirm your diagnosis? How would you stage & prognosticate? How would you manage? - Ans. (See Page
Page No. 205)
No. 215)
Q.3: Enumerate the causes of relation of urine in different age groups. How will you investigate a case of relation of
urine ? How will you treat retention of urine ? - Ans. (See Page No. 206)
December-January 2020
' 2017
Q.1: Write down the effect of prostatic hypertrophy on urethra and urinary bladder. Mention the medical and surgical
Q.1: Disscuss the causes of haemoperitoneum and its management. - Ans. (See Page No. 207) treatment of benign prostatic hypertrophy. - Ans. (See Page No. 215)
Q.2: What are the clinical features of renal cell carcinoma ? How will you investigation and treat a case of renal cell Q.2: A 30 year old lady presents with 3 cm size solitary nodule on right thyroid lobe. Give the differential diagnosis.
carcinoma? - Ans. (See Page No. 210) How will you manage such patient? - Ans. (See Page No. 215)
Q.3: Discuss the clinical features, investigations and managem eni of pheochromocytoma. - Ans. (See Page Q.3: A middle-aged bus conductor presents with non healing ulcer and pigmentation in left lower leg near medial
No. 210) malleolus. How will you examine, investigate and manage this patient? - Ans. (See Page No. 215)
2017 Supplementary •
June-July 2020
Q. 1: Discuss the pathology of tumors of Salivary gland and management of Pleomorphic adenoma. - Ans. (See
Page No. 210) Q.1: Define gangrene. Discuss etiopathogenesis, clinical leatores, investigations and management of gas gangrene.
Q.2: 20 year old male presenting with right testicular mass - how will you proceed to investigate and manage this - Ans. (See Page No. 215) '
case? - Ans. (See Page No. 210) 02: Classify testicular tumours. How will you manage a 60 year old man presenting with seminoma testis. - Ans.
Q.3: 30 year young adult complaining of colicky pain from right loin to groin with vomiting - how will you investigate (See Page No. 215) .
and manage this case? - Ans. (See Page No. 210) Q.3: Describe the clinical features and management of Thyrotoxicosis. - Ans. (See Page No. 215)
i 2018
SEGMENT B (P A P E R -I)
Q.1: What are the different forms of Renal calculi? Discuss the clinical presentation and management of a stone in
the Renal pelvis. - Ans. (See Page No. 210) Q.1: Discuss briefly the D/D of right iliac fossa pain in a young adult male. How will you treat a case ol appendicular
Q.2: What is AND! to classify benign lesions of the breast? Discuss the management of discharge from the nipple. mass? - Ans. (See Page No. 216)
- Ans. (See Page No. 211) Q.2: Discuss briefly the different diagnostic blood fractions commonly used for surgical patients. Discuss the
Q.3: Classify thyroid neoplasms. Discuss the management of solitary thyroid nodule, 3 cm in size of a 30 years old complications of whole blood transfusions in brief. - Ans. (See Page No. 219)
female. - Ans.(SeePageNo.211) Q.3: Define ulcer. Describe the clinical exam. Ol an ulcer. Write down the treatment of venous ulcer. - Ans. (See
2018 Supplementary Page No. 222)
Q.4: Define and classify intermittent claudication. Describe the pathogenesis of Buerger's disease. How will you
Q.1: Discuss the presenting symptoms ol Benign Hyperplasia of Prostate. How will you manage a 65 year old male treat a case of Buerger's disease without gangrene? - Ans. (See Page No. 224)
patient with acute retention of urine in emergency and subsequently? - Ans. (See Page No. 211) Q.5: A 32 yrs old male patient attends the surgery OPD with chief complaints ol pain in the right calf, while walking,
for 2 months. He had been a chronic smoker for 10 yrs. On examination, he has reduction in peripheral pulses

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T3 (17)
 in the affected lower limb. What are the D/D? What investigations will you do in this case? What procedures can 2010
be done for improving the lower limb circulation? - Ans. (See Page No. 226)
Q.1: Hemangioma - Ans. (See Page No. 285)
Q.6 : Define and classify cysts. Discuss the management of a surgically relevant parasitic cystic disease. Write a
Q.2: Carotid body tumor - Ans. (See Pa ge No. 286)
brief account on pseudocyst of pancreas. - Ans.(SeePageNo.231)
Q.3: Branchial sinus - Ans. (See Page No. 287)
Q.7: A 60 yrs old lady has presented with jaundice, pruritus, pale stools and a palpable mass in the right upper
Q.4: Carcinoid tumor - An s. (See Page No. 288)
quadrant of abdomen, Enumerate the D/D. Which radiological Investigations will you recommend? Outline the
operative management of periampullary CA. - Ans. (See Page No. 236) 2010 Supplementary
Q.8 : Enumerate the endocrine tumors of pancreas. Oiscuss C/F, Investigations and treatment of any 2 of such
tumors. - Ans. (See Page No. 239) Q.1: Melanoma - Ans. (See Page No. 289)
Q.9 : A 45 yrs old man presented with rapidly developing anorexia, asthenia and fatigue with increasing Q.2: Blood substitutes - Ans. (See Page No. 289)
vomiting. How would you investigate to confirm the diagnosis? How would you stage and manage the Q.3: Trophic ulcer - Ans. (See Page No. 289)
patient? - Ans. (See Page No. 241) Q.4: Systemic inflammatory response syndrome - Ans. (See Page No. 289)
Q.10: A 55 yrs old male, chronic alcoholic, complains of severe, agonising, acute abdominal pain persisting for
2011
several hours, radiating to the back and a little relief on stooping. How would you investigate to confirm the
diagnosis, prognosticate and manage? - Ans. (See Page No. 247) Q.1: Pre operative preparation of a case of obstructive jaundice - Ans. (See Page No. 289)
Q.2: Epigastric hernia - Ans. (See Page No. 290)
SEGMENT B (P A P E R -II) Q.3: Deep vein thrombosis - Ans. (See Page No. 290)
Q.4: Active immunisation against tetanus - Ans. (See Page No. 291)
Q.1: A 20 yrs old actress has presented with a small goitre involving right lobe and ipsilateral lymphaden- 2011 Supplementary
opathy. How will you establish a diagnosis? Oiscuss the surgical management and complications. -
Ans. (See Page No. 252) Q.1: Marjolin’s ulcer - Ans. (See Page No. 292)
Q.2: A 70 yrs old male patient complains of inability to pass urine for past 8 hrs. How will you differentiate this from Q.2: Preoperative preparation of a patient of Pyloric stenosis - Ans. (See Page No. 292)
anuria? Outline the subsequent management of the case. - Ans. (See Page No. 256) Q.3: Blood fractions - Ans. (See Page No.292)
Q.3: What are the common surgical causes of haematuria? Discuss the diagnosis and management of haematuria Q.4: Hyponatremia - An s. (See Page No. 292)
due to carcinoma of urinary bladder. - Ans. (See Page No. 264) .
Q.4: A 48 yrs old female presented with a 4 cm lump in Right breast. Discuss the D/D and diagnostic approach to the 2012
condition. - Ans. (See Page No. 267) Q. 1: Post operative pain management - Ans. (See Page No. 294)
Q.2: Creating pneumoperitoneum in laparoscopic surgery - Ans. (See Page No. 294)
Q.3: Burst abdomen - Ans. (See Page No. 296)
SEGMENT C (P A P E R -I)
Q.4: Decubitus ulcer - Ans. (See Page No. 296)
2008 2012 Supplementary
Q.1: Methods of sterilisation - Ans. (See Page No. 274)
Q.1: Lipoma - Ans. (See Page No. 297)
Q.2: Biochemical abnormality in pyloric stenosis - Ans. (See Page No. 275) ..
Q.2: Metabolic acidosis - Ans.(See Page No. 297)
0.3: Universal precaution - Ans. (See Page No. 275) '
Q.3: TPN - Ans. (See Page No. 297)
0.4: Nipple discharge - Ans. (See Page No. 276)
Q.4: Prophylactic antibiotics - Ans. (See Page No. 299)
2008 Supplementary 2013
Q.1: Fibroadenoma of breast - Ans. (See Page No. 278)
Q. 1: Causes and treatment of metabolic acidosis - Ans. (See Page No. 300)
Q.2: Meckel’s diverticulum - Ans. (See Page No. 278)
Q.2: Venous ulcer - Ans. (See Page No. 301)
Q.3: Keloid - Ans. (See Page No. 278)
Q.3: Fournier's gangrene - Ans. (See Page No. 302)
Q.3: Anal Fissure - Ans. (See Page No. 278)
Q.4: Anorectal malformations - Ans. (See Page No. 303)
2009 Q.5: Torticollis - Ans. (See Page No. 304)
2013 Supplementary
Q.1: Arteriovenous fistula - Ans. (See Page No. 279)
Q.2: Basal cell carcinoma - Ans. (See Page No. 280)
Q.1: Complications of splenectomy - Ans. (See Page No. 305)
Q.3: Pre-operative preparation of a patient of pyloric stenosis - Ans. (See Page No. 282)
Q.2: Pilonidal sinus - Ans. (See Page No. 306)
Q.4: Autotransfusion ~ Ans. (See Page No. 282)
Q.3: Intercostal drain - Ans. (See Page No. 307)
Q.4: Core needle biopsy - Ans. (See Page No. 309)
2009 Supplementary
2014
Q.1: Intermittent claudication - Ans. (See Page No. 283)
Q.2: OPSI - Ans. (See Page No. 283) 0.1: Breast biopsy - Ans. (See Page No. 309)
Q.3: Oesophageal varices - Ans. (See Page No. 285) Q.2: Incarcerated hernia - Ans. (See Page No. 310)

(18) (19)
 2018

Q.3: Blood substitutes - Ans. (See Page No. 312) q.1 : Diagnostic peritoneal lavage - Ans. (See Page No. 334)
Q.4: Volvulus neonatorum - Ans. (See Page No. 313) q .2 : Colostomy = Ans. (See Page No. 334)
Q.5 : Amoebic liver abscess - Ans. (See Page No. 314) Q.3: Molecular subtypes of Breast carcinoma - Ans. (See Page No. 334)
q .4 : Intussusception - Ans. (See Page No. 334)
2014 Supplementary Q.5: Amebic liver abscess - Ans. (6ee Page No. 334)
Q.1: CTScan - Ans. (See Page No. 316) 2018 Supplementary
Q.2: Pleomorphic adenoma - Ans. (See Page No. 316)
Q.3: Pheochromocytoma - Ans. (See Page No. 316) Q.1: Sentinel Node Biopsy - Ans. (See Page No. 335)
Q.4 : Gallstone ileus - Ans. (See Page No. 316) Q.2: Surgical emphysema
Q.5: Femoralhernia - Ans.(SeePageNo.316) Q.3: Pleomorphic adenoma - Ans. (See Page No. 335)
Q.4: Low anterior resection of Carcinoma rectum - Ans. (See Page No. 335)
2015 Q.5: Malignant melanoma - Ans. (See Page No. 335)
Q.1: Ludwig's angina - Ans. (See Page No. 31B)
Q,2: Appendicular Lump - Ans. (See Page No. 318) 2019
Q.3: Types of anorectal abscess - Ans. (See Page No. 318) Q. 1: Subptvenic abscess - Ans. (See Page No. 336)
Q.4: MODS - Ans. (See Page No. 319) Q.2: Complications of splenectomy - Ans. (See Page No. 337)
Q.5: Estrogen & Progesterone Receptors - Ans. (See Page No. 321) 0.3: Femoral Hernia - Ans. (See Page No. 338)
Q.4: Adenomatous polyps of colon - Ans. (See Page No. 338)
2015 Supplementary Q.5: Tuberculous Cervical Lymphadenopathy - Ans. (See Page No. 338)
Q,1: Fibroadenoma - Ans. (See Page No. 322) 2019 Supplementary
Q.2: Branchial cyst - Ans. (See Page No. 322)
Q.3: Complications of splenectomy - Ans. (See Page No. 322) Q.1: Amoebic liver abscess - Ans. (See Page No. 338)
Q.4: Warthin's tumor - Ans. (See Page No. 322) Q.2: Rupture of the Spleen - Ans. (See Page No. 338)
Q.5: Colostomy - Ans. (See Page No. 323) Q.3: Pseudocyst of the pancreas - Ans. (See Page No. 338)
Q.4: Diagnosis of acute small bowel obstruction- Ans. (See Page No. 338)
2016
Q.5: Umbilical Hernia - Ans. (See Page No. 338)
0.1: Pancreatic pseudocyst - Ans. (See Page No. 324)
Q.2: Liver abscess - Ans. (See Page No. 324) December-January 2019-2020
Q.3: Marjolin's ulcer - Ans. (See Page No. 324)
Q.4: Femoral hernia - Ans. (See Page No. 324) Q.l: Parotid fistula. - Ans. (See Page No. 339)
Q.5: Hydatid cyst of liver - Ans. (See Page No. 324) 02. Cold abscess - Ans. (See Page No. 339)
0.3: Volvulus - Ans. (See Page No. 339)
0.4: Idiopathic Thrombocytopenic Purpura (ITP) - Ans. (See Page No. 339)
2016 Supplementary 0.5: Acute Necrotising Pancreatitis - Ans. (See Page No. 341)
Q.1: Thyroglossalcyst - Ans. (See Page No. 327)
June-July 2020
Q.2: Basal cell carcinoma - Ans. (See Page No.327)
Q.3: FNAC - Ans. (SeePage No. 327) 0.1: Ludwig's Angina - Ans. (See Page No. 343)
Q.4: Pelvic abscess - Ans. (See Page No. 327) Q.2: Fibroadenoma - Ans. (See Page No. 343)
Q.5: Closed loop obstruction - Ans. (See Page No. 328) Q.3: Liver abscess-Ans. (See Page No. 343) .
Q.4: Thyroglossalcyst- Ans. (See Page No. 344)
2017
Q.5: Keloid - Ans. (See Page No. 344)
Q.1: Alvarado Score - Ans. (See Page No. 332)
Q.2: Parotid abscess - Ans. (See Page No. 332)
Q.3: Gastrinoma - Ans. (See Page No.332) SEGMENT C (P A P E R - I I )
Q.4: Sentinel node biopsy - Ans. (See Page No. 333)
Q.5: Mesenteric cyst - A ns. (See Page No. 333) 2008
0.1: Venous ulcer - Ans. (See Page No. 347)
2017 Supplementary
Q.2: Epididymal cyst - Ans. (See Page No. 347)
Q.3: Tetany - Ans. (See Page No. 347)
Q.1: Sigmoid volvulus - Ans. (See Page No. 334)
0.2: Tuberculous cervical lymphadenopathy - Ans. (See Page No. 334) 0.4: Thyroglossat cyst - Ans. (See Page No. 348)
0.5: Dermoid cyst - Ans. (See Page No. 349)
Q.3: Keloid - Ans, (See Page No. 334)
Q.4: Ranula - Ans. (See Page No. 334)
0 5: Choledochal cyst - Ans. (See Page No. 334)
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 Q.6 : Exomphalos - Ans. (See Page No. 350) q .9: Mammography - Ans.(See Page No.373)
Q.7: Skin grafting - Ans. (See Page No. 351) q 10: Nerve injury - Ans. (See Page No. 373)
Q.8: Spinal anesthesia - Ans. (See Page No. 353) q 11: Management of Hirschsprung’s disease - Ans. (See Page No. 373)
Q.9: Double contrast enema - Ans. (See Page No. 353) q 12: Target FNAC - Ans. (See Page No. 373)
Q.10: Brachytherapy - Ans. (See Page No. 353) q ’13: Ultrasonic therapy - Ans. (See Page No. 373)
0.11: Dental cyst - Ans. (See Page No. 353) q .14 : Adamantinoma - Ans. (See Page No. 373)
Q.12: Flail chest - Ans. (See Page No. 354) Q.15: Solitary thyroid nodule - Ans. (See Page No. 373)
Q.13: Glasgow coma scale - Ans. (See Page No. 355)
Q.14: Therapeutic use of ultrasoundAns. (See Page No. 356) 2010
Q.15: Patent Ductus Arteriosus - Ans. (See Page No. 356)
Q.1 : Ecloplc yesicae - Ans. (See Page No. 373)
2008 Supplementary Q.2: Neurofibromatosis - Ans. (See Page No. 375)
Q.3: Paget's disease of nipple - Ans. (See Page No. 376)
Q.1: Carcinoid tumour - Ans. (See Page No. 358) q .4 : Fistula in ano - Ans. (See Page No. 376)
Q.2: Ranula - Ans. (See Page No. 358) Q.5: Varicocele - Ans. (See Page No. 377)
Q.3: Abdominal compartment syndrome - Ans. (See Page No. 358) Q.6: Subdural hematoma - Ans. (See Page No. 378)
Q.4: Desmoid tumour - Ans. (See Page No. 358) Q.7 : Muscle relaxants - Ans. (See Page No. 379)
Q.5: Clinical features of Hirschsprung’s disease - Ans. (See Page No. 358) Q.8: I13' scan - Ans. (See Page No. 379)
0.6: Cleft lip management in children - Ans. (See Page No. 358) Q.9: Congenital hypertrophic pyloric stenosis - Ans. (See Page No. 379)
Q.7: Tetanus prophylaxis - Ans. (See Page No. 359) Q.10: Lumbar puncture - Ans. (See Page No. 380)
Q.8 : Empyema thoracis - Ans. (See Page No. 359) Q.11: Ludwig's angina - Ans. (See Page No. 380)
Q.9: Epulis - Ans. (See Page No. 359) Q.12: Meningomyelocele - Ans. (See Page No. 381)
Q.10: Wax bath - Ans. (See Page No. 359) Q.13: Empyema thoracis - Ans. (See Page No. 381)
Q.11: Extradural haematoma - Ans. (See Page No. 359) Q.14: Patent Ductus Arteriosus - Ans. (See Page No. 381)
Q.12: Raynaud’s phenomenon - Ans. (See Page No. 359) Q.15: Referred pain - Ans. (See Page No. 383)
Q.13: Diagnostic use of ultrasound - Ans. (See Page No. 360)
Q.14: Axial flap - Ans. (See Page No. 360) 2010 Supplementary
Q.15: Careofaparaplegicpatient - Ans.(See Page No. 361)
Q.1: Mixed salivary tumour - Ans. (See Page No. 384)
2009 Q.2: Meconium ileus - Ans. (See Page No. 384)
Q.3: Post burn contracture - Ans. (See Page No. 384)
Q.1: Salivary calculi - Ans. (See Page No. 361) Q.4: FAST - Ans. (SeePage No. 384)
Q.2: Fournier's gangrene - Ans. (See Page No. 362)
Q.5: Tension pneumothorax - Ans. (See Pa ge No. 384)
Q.3: Breast abscess - Ans. (See Page No. 362)
Q.6: Epulis - Ans. (See Page No. 384)
Q.4: Complications of undoscended testis - Ans. (See Page No. 363)
Q.7: Glasgow coma scale - Ans. (See Page No. 384)
Q.5: MEN Syndrome - An?. (See Page No. 364)
Q,8: Gas gangrene - Ans. (See Page No. 384)
Q.6 : Anorectal malformations - Ans. (See Page No. 365) Q.9: Intravenous anaesthetics - Ans. (See Page No. 385)
Q.7: Extradural hematoma - Ans. (See Page No. 365) Q,10: Primary hyperparathyroidism - Ans. (See Page No. 385)
Q.8 : Cardiopulmonary Resuscitation - Ans. (See Page No. 367) Q.11: Hypersplenism - Ans. (See Page No. 386)
Q.9: MRI - Ans. (See Page No. 367) Q.12: Hydrocephalus - Ans. (SeePage No. 387)
Q.10: Complications of radiotherapy - Ans. (See Page No. 367) 0.13: Sentinel lymph node biopsy - Ans. (See Page No. 388)
Q.11: Fat embolism - Ans. (See Page No. 368) Q.14: Hospice - Ans.(See Page No.389) ■
Q.12: Odontomes - Ans. (See Page No.369) 0.15: Differential diagnosis of intracranial space occupying lesions - Ans. (See Page No. 389)
Q.13: Short wave diathermy - Ans. (See Page No. 370)
Q.14: Tension pneumothorax - Ans. (See Page No. 370) 2011
Q.15: Hypokalaemia - Ans. (SeePage No.371)
Q.1: Flail chest - Ans. (See Page No. 392)
2009 Supplementary Q.2: Post - operative pyrexia - Ans. (See Page No. 392)
Q.1: Hypospadius - Ans. (See Page No. 372) Q.3: Brain death - Ans. (See Page No. 394)
Q.2: Marjolin's ulcer - Ans. (See Page No. 372) Q.4: Split thickness skin graft - Ans. (See Page No. 394)
Q.3: Collar stud abscess - Ans. (See Page No. 372) Q.5: Spinal anesthesia - Ans. (See Page No. 394)
Q.4: Venous ulcer - Ans. (See Page No. 372) Q.6: Omphalocele - Ans. (See Page No. 394)
Q.5: Cleft palate - Ans. (See Page No. 372) Q.7: Retrosternal goitre - Ans. (See Page No. 394)
Q.6 : Complications of radiotherapy - An s. (See Page No. 372) Q.8 : Parotid abscess - Ans. (See Page No. 395)
Q.7: Regional anaesthesia - Ans. (See Page No. 372) Q.9: Alvarado score of acute pancreatitis - Ans. (See Page No. 396)
Q.8: Empyema thoracis - Ans. (See Page No. 372) Q.10: TURP - Ans. (See Page No. 397)

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 Q.11: Oxalate stone - Ans. (See Page No. 397) Q.13: Small bowel enema - Ans. (See Page No. 416)
Q.12: Wax bath - Ans. (See Page No. 398) Q.14: Tracheostomy - Ans. (See Page No. 416)
Q.13: Epulis - Ans. (See Page No. 399) Q.15: Frozen shoulder-physiotherapy - Ans. (See Page No. 416)
Q.14: MRI scan in surgery - Ans. (See Page No. 401)
Q.15: Radiation dermatitis - Ans. (See Page No. 401) 2013
Q.16: Spinal anesthesia - Ans. (See Page No. 401)
Q. 1 : Cleft lip - Ans. (See Page No. 417)
2011 Supplementary Q.2: Thyroglossal cyst - Ans. (See Page No. 419)
Q.3: Spinal anesthesia - Ans. (See Page No. 419)
Q.1: Paraphimosis - Ans. (See Page No. 401)
Q.2: Parotid fistula - Ans. (See Page No. 401) Q.4: Types of skin graft - Ans. (See Page No. 419)
Q.3: Hypospadius - Ans. (See Page No. 401) Q,5: Role of ERCP In obstructive jaundice - Ans. (See Page No. 419)
Q.4: Local anaesthesia - Ans. (See Page No. 402) Q.6: Oral submucous fibrosis - Ans. (See Page No. 419)
Q.5: Oschner-Sherren regimen - Ans. (See Page No. 402) Q.7: Wax bath - Ans. (See Page No. 420)
Q.6 : Stove-in-chest - Ans. (See Page No. 402) Q.8: Subdural hematoma - Ans. (See Page No. 420)
Q.7: Hydrocephalus - Ans. (See Page No. 402) Q.9: Intussusception - Ans. (See Page No. 420)
Q.8 : Ulnar nerve injury - Ans. (See Page No. 402) Q.10: Marjolin's ulcer - Ans. (See Page No. 421)
Q.9: Bedsore - Ans. (See Page No. 404)
Q.10: Bloody discharge per nipple - Ans. (See Page No. 404) 2013 Supplementary
Q.11 : Hydronephrosis - Ans. (See Page No. 405)
Q.1: Posterior urethral valve - Ans. (See Page No. 421)
Q.12: Adamantinoma - Ans. (See Page No. 405)
Q.2: Hutchinson's pupil - Ans. (See Page No. 422)
Q.13: Brachytherapy - Ans. (See Page No. 405)
Q.14: USG for hepatobiliary diseases - Ans. (See Page No. 405) Q.3: Empyema thoracis - Ans. (See Page No. 422)
Q.15: Cervical traction - Ans. (See Page No. 405) Q.4: PCNL - Ans. (See Page No. 422)
Q.5: Types of renal stone - Ans. (See Page No. 422)
2012 Q.6: Causes of scrotal swelling - Ans. (See Page No. 424)
Q.1: Breast biopsies - Ans. (See Page No. 406) Q.7: Pressure sore - A ns. (See Page No. 424)
Q.2: Causes of hematuria - Ans. (See Page No. 406) Q. 8: Hypospadius - Ans. (See Page No. 425)
Q.3: Antegrade pyelography - Ans. (See Page No. 406) Q.9: Keloid - Ans. (See Page No. 426)
Q.4: Stress gastritis - Ans. (See Page No. 406) Q.10: Tension pneumothorax - Ans. (See Page No. 427)
Q.5: P.SA - Ans. (See Page No. 406)
Q.6 : Paraphimosis - Ans. (See Page No. 408) 2014
Q.7: Lucid interval - Ans. (See Page No. 408)
Q.8 : Chest drain - Ans. (See Page No. 408) Q.1: Paget's disease of nipple - Ans. (See Page No. 427)
Q.9: Torsion of testis - Ans. (See Page No. 408) Q.2: Electric bums - Ans. (See Page No. 427)
Q.10: Tissue expansion - Ans. (See Page No. 409) Q.3: Dentigerous cyst - Ans. (See Page No. 428)
Q.11: Anesthetic monitoring devices - Ans. (See Page No. 410) Q.4: Lucid interval - Ans. (See Page No. 429)
Q.12: Radiotherapy in treatment of CA breast - Ans. (See Page No. 410) Q.5: Fistula in ano - Ans. (See Page No. 429)
Q.13: Ameloblastoma - Ans. (See Page No. 411) Q.6: Penile carcinoma - Ans. (See Page No. 429)
Q.14: Transluminal USG - Ans. (See Page No. 412) Q.7: Muscle relaxant - Ans. (See Page No. 430)
Q.15: Short wave diathermy - Ans. (See Page No. 412) Q.8: Flail chest - Ans. (See Page No. 430)
Q.9: Epidural anesthesia - Ans. (See Page No. 430)
2012 Supplementary
Q.10: Compartment syndrome - Ans. (See Page No. 430)
Q.1: Extradural haemorrhage - Ans. (See Page No. 412)
Q.2: DVT - Ans. (See Page No. 412) 2014 Supplementary
Q.3: Epididymal cyst - Ans. (See Page No. 412)
Q.4: ESWL - Ans. (See Page No. 412) Q.1: Parotid abscess - Ans. (See Page No. 431)
Q.5: Causes of haematuria - Ans. (See Page No.412) Q.2: Patient ductus arteriosus - Ans. (See Page No. 431)
Q.6 : Deniigerous cyst - Ans. (See Page No. 412) Q.3: Chordee - Ans. (See Page No. 431)
Q.7: Epidural anaesthesia - Ans. (See Page No. 413) Q.4: Chronic subdural haematoma - Ans. (See Page No. 431)
Q.8 : Brachytherapy - Ans. (See Page No.413) Q.5: Dentigerous cyst - Ans. (See Page No. 431)
Q.9: Nephroblastoma - Ans. (See Page No. 413) Q.6: Venous ulcer - Ans. (See Page No. 431)
Q.10: Bladder changes in BHP - Ans. (See Page No. 413) Q.7: Transluminal USG - Ans. (See Page No. 431)
Q.11 : Variants ol melanoma - Ans. (See Page No. 414) Q.8: Local anaesthesia in inguinal hernia surgery - Ans. (See Page No. 431)
Q.12: CABG - Ans. (See Page No. 415) Q.9: Radioactive iodine - Ans. (See Page No. 432)
Q.10: QUART - Ans. (See Page No. 433)

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2015 Q.6 : Autolransfusion - Ans. (See Page No. 446)

Q.7: Pulmonary embolism - Ans. (See Page No. 446)
Q.1: Breast abscess - Ans. (See Page No. 434) Q.8 : Myocutaneous flap - Ans. (See Page No. 448)
Q.2: Meconium ileus - Ans. (See Page No. 434) Q.9: ABPI - Ans. (See Page No. 449)
Q.3: Basal cell carcinoma - Ans. (See Page No. 434) Q.10: Tongue ulcers - Ans. (SeePage No. 450)
Q.4: Premalignant conditions ol penile carcinoma - Ans. (See Page No. 434)
Q.5: Acute pancreatitis - Ans. (See Page No. 436) 2017 Supplementary
Q.6 : Glasgow Coma Scale - Ans. (See Page No. 438)
Q.7: Radiofrequency ablation of tumors - Ans. (See Page No. 438) Q.1: Thyroglossal cyst - Ans. (See Page No. 450)
Q.8: Tension pneumothorax - Ans. (See Page No. 440) 0.2: MRCP - Ans. (See Page No. 451)
Q.9 : -Epulis - Ans. (See Page No. 440) Q.3: Complications of Radiotherapy - Ans. (See Page No. 451)
Q.10: Complications of spinal anesthesia - Ans. (See Page No. 440) Q.4: Imperforate anus - Ans. (See Page No. 451)
Q.5: Flail chest - Ans. (See Page No. 451)
2015 Supplementary Q.6: Glasgow coma scale - Ans. (See Page No. 451)
Q.7: IVU - Ans. (See Page No. 451)
Q1: Testicular torsion - Ans, (See Page No. 440) Q.8: Marjolin's ulcer - Ans. (See Page No. 451)
Q.2: Extradural hematoma - Ans. (See Page No. 440) Q.9: Hypospadias - Ans. (See Page No. 451)
Q.3: Flail chest - Ans. (See Page No. 440) Q.10: Ingrowing toe nail - Ans. (See Page No. 451)
Q.4: Ameloblastoma - Ans. (See Page No. 440)
Q.5: Submandibular sialolithiasis - Ans. (See Page No. 440) 2018
Q.6 : Pyloric stenosis in infant - Ans.(See PageNo.441)
Q.7: PDA - Ans.(See PageNo.441) Q.1: Lucid interval - Ans. (See Page No. 451)
Q.8: Wax bath-Ans. (See PageNo.441) Q.2: Thyroid storm - Ans. (See Page No. 451)
Q.9: Telecobalt therapy - Ans. (See Page No. 441) Q.3: Ranula - Ans. (See Page No. 452)
Q.4: ERCP - Ans. (See Page No. 452)
2016 Q.5: Testicular torsion - Ans. (See Page No. 452)
Q.6: PSA - Ans. (See Page No. 452)
Q.1: Epidural anesthesia - Ans. (See Page No. 441) Q.7: Brachytherapy - Ans. (See Page No. 452)
Q.2: Venous ulcer of lower leg - An s. (See Page No. 441) Q.8: Biomarkers
Q.3: Spina bifida - Ans. (See Page No. 441) Q.9: Triage
Q.4: MEN syndrome - Ans. (See Page No. 441) Q.10: Regional anesthesia - Ans. (See Page No. 452)
Q.5: Principle of skin grafting - Ans. (See Page No. 441)
Q.6 : Post burn contracture - Ans. (See Page No. 441) 2018 Supplementary
Q.7: Hydrocephalus - Ans. (See Page No. 441)
Q.8 : Hamartoma - Ans. (See Page No. 441) Q.1: Classilication of nerve injury - Ans. (See Page No. 452)
Q.9: Ionising radiation - Ans. (See Page No. 442) Q.2: Management of pneumothorax
Q.10: Bleeding from gum - Ans. (See Page No. 443) Q.3: Criteria of brain death - Ans. (See Page No. 452)
Q.4: Types of skin grafting - Ans. (See Page No. 452)
2016 Supplementary Q.5: Chemotherapy of testicular cancer - Ans. (See Page No. 452)
Q.6: Use ol LASERs in surgery
Q.1: PET Scan - Ans. (See Page No. 444) Q.7: Cleft lip - Ans. (See Page No. 452)
Q.2: Undescended lestis - Ans. (See Page No. 444) Q.8 : Glasgow coma scale - Ans. (See Page No. 452)
Q.3: Intermittent claudication - Ans. (See Page No. 444) Q.9: Preoperative assessment of pulmonary function
Q.4: Brachytherapy - Ans.(SeePage No. 444) Q.10: Dentigerouscyst - Ans.(See Page No. 452)
Q.5: Dental cyst - Ans. (See Page No. 444)
Q.6 : Fournier’s gangrene - Ans. (See Page No. 444) 2019
Q.7: Regional anaesthesia - Ans. (See Page No. 444)
Q.8 : Chest drain alter chest injury - Ans. (See Page No. 444) Q. 1 : Magnetic resonance cholangio-pancreatography (MRCP) - Ans. (See Page No. 453)
Q.9: Different types of nerve injuries - Ans. (See Page No. 444) Q.2: Epidural Anesthesia - Ans. (See Page No. 453)
Q.10: Pre-malignant condition of oral cavity - Ans. (See Page No. 444) Q.3: Split-thickness skin graft - Ans. (See Page No. 453)
Q.4: Choledochal Cyst - Ans. (See Page No. 453)
2017 Q.5: Complications of external beam radiation therapy - Ans. (See Page No. 453)
Q.6: Epulis - Ans. (See Page No. 455)
Q. 1: Subdural haemorrhage - An s. (See Page No. 446) Q.7: Ultrasound wave therapy- Ans. (See Page No. 455)
Q.2: P C N l - Ans. (See Page No. 446) Q.8: Flail chest with paradoxical respiration - Ans. (See Page No. 455)
Q.3: Complications of spinal anaesthesia - Ans. (See Page No. 446) Q.9: Secondary brain injury - Ans. (See Pa ge No. 455)
Q.4: DVT - Ans.(SeePage No. 446) Q.10: Diabetic foot - Ans. (See Page No. 457)
Q.5: Ludwig’s angina - Ans. (See Page No. 446)

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 2019 Supplementary
Q.16: Treatment of urinary bladder tumor - Ans. (See Page No. 478)
Q.1: Endoscopic Retrograde Cholangiopancreatography (ERCP)- Ans. (See Page No, 457)
Q.17: Carcinoma of tongue - Arts. (See Page No. 481)
Q.2: Spinal Anaesthesia - Ans. (See Page No. 457) Q.18: Massive blood transfusion - Ans. (See Page No. 483)
Q.3: Full thickness skin graft - Ans. (See Page No. 457) Q.19: Blood fractions * Ans. (See Page No. 484)
Q.4: Hypertrophic pyloric stenosis ol Infancy - A ns. (See Page No. 457) Q.20: Causes of buttock swelling - Ans. (See Page No. 484)
Q.5: Neo-adjuvant Radiotherapy - Ans. (See Page No. 457) Q.21: Frost-bite - Ans. (See Page No. 485)
Q.6 : Dental Cyst - Ans. (See Page No. 459) Q.22: Tendon transfer - Ans. (See Page No. 486)
Q.7: Post-traumatic pneumothorax- Ans. (See Page No. 459) Q.23: Ubiquitous tumor or Universal tumor or Lipoma - Ans. (See Page No. 486)
Q.8 : Intercostal chest tube drainage - Ans. (See Page No. 459) Q.24: Invertogram - Ans. (See Page No. 487)
Q.9: Extradural hemorrhage - Ans. (See Page No. 459) Q.25: Barrett's esophagus - Ans. (See Page No. 488)
Q.10: Venous ulcer - Ans. (See Page No. 459) Q.26: Tenesmus - Ans. (See Page No. 488)
QZ7\ ANDI - Ans. (See Page No. 489)
December-January 2019-2020 Q.28: Volume overload - Ans. (See Page No. 490)
Q.29: Osteogenesis imperfecta - Ans. (See Page No. 491)
Q.1: Branchial fistula - Ans. (See Page No. 459)
Q2: Regional Anesthesia-Ans. (See Page No. 460) Q30: 10 percent tumor - Ans. (See Page No. 492)
Q.31: Whipple's triad - Ans. (See Page No. 494)
Q.3: Endotracheal Intubation - Ans. (See Page No. 460)
Q.32: Post operative pulmonary complications - Ans. (See Page No. 495)
Q.4: Undescended Testis - Ans. (See Page No. 460)
Q.5: Complications of Chemotherapy - Ans. (See Page No. 460) Q.33: Complications of blood transfusion - Ans. (See Page No. 495)
Q.34: Mismatched blood transfusion-Managemenl - Ans. (See Page No. 496)
Q.6: IVU - Ans. (See Page No. 462)
Q.35: Myopectineal orifice - Ans. (See Page No. 497)
Q.7: Lucid interval - Ans. (See Page No. 462)
Q.36: Isometric exercise - Ans. (See Page No. 498)
Q.8: Cleft Palate - Ans. (See Page No. 463)
Q.9: Warthin's tumour - Ans. (See Page No. 463) Q.37: Saphena varix - Ans. (See Page No. 498)
Q.38: Blood component therapy - Ans. (See Page No. 499)
Q.10: Varicocele - Ans. (See Page No. 463)
Q.39: Treatment of hypercalcemic crisis in a patient ol hypothyroidism - Ans. (See Page No. 499)
Q.40 : Hirschprung'a disease - Ans. (See Page No. 499)
June-July 2020
Q.41: Neurogenic bladder - Ans. (See Page No. 501)
Q.1: Epidural Anaesthesia- Ans. (See Page No. 463) Q.42: Choledochal cyst - Ans. (See Page No. 501)
Q.2: Imperforate Anus - Ans. (See Page No. 463) Q.43: Mucocele of gall bladder - Ans. (See Page No. 502)
Q.3: Breast abscess - Ans. (See Page No. 463) Q.44: Choiesterosls - Ans. (See Page No. 503)
Q.4: Basal Cell Carcinoma - Ans. (See Page No. 463) Q.45: Meekers diverticulum - Ans. (See Page No. 503)
Q.5: Spina Bifida - Ans. (See Page No. 463) Q.46: Preparation for large bowel 6urgery - Ans. (See Page No. 505)
Q.6: Bleeding from gum- Ans. (See Page No. 463) Q.47: Familial adenomatous polyposis - Ans. (See Page No. 505)
Q.7: Hydrocephalus - Ans. (See Page No. 463) Q.48: Fibroadenoma - Ans. (See Page No. 506)
Q.8: Glasgow Coma Scale - Ans. (See Page No. 463) Q.49: Phyllode's lumor - Ans. (See Page No. 507)
Q.9: P.E.T. Scan - Ans. (See Page No. 463) 0.50: Stages of CA breast - Ans. (See Page No. 508)
Q.10: Cleft Lip-A n s. (See Page No. 463) CL61: Etiotogic factors In the development of breast carcinoma - Ans. (See Page No. 509)
Q.52: Adjuvant chemotherapy In breast carcinoma - Ans. (See Page No. 510)
SEGMENT D Q.53: Inflammatory carcinoma - Ans.(SeePageNo.SII)
Q.54: Gynecomastia - Ans. (See Page No. 512)
Q.1: Paradoxic aciduria/Metabolic changes following gastric outlet obstruction - Ans. (See Page No. 467) Q.55: Medullary carcinoma ol thyroid - Ans. (See Page No. 514)
Q.2: Euthanasia - Ans. (See Page No. 467) Q.56: Hashimoto's thyroiditis - Ans. (See Page No. 515)
Q.3: Bezoar - Ans. (See Page No. 467) Q.57: Prevention and treatment of simple goiler - Ans. (See PageNo.516)
Q.4: Wound debridement - Ans. (See Page No. 467) Q.58: Preoperative preparation in Grave's disease - Ans. (See Page No. 518)
Q.5: Virchow’s node - Ans. (See Page No. 468) Q 59: Complications of total thyroidectomy - Ans. (See Page No. 519)
Q.6 : Cystic hygroma - Ans. (See Page No. 468) Q.60: Metabolic and neuromuscular manifestations in Grave's disease - Ans. (See Page No. 520)
Q.7: Pharyngeal pouch - Ans. (See Page No. 469) Q.61: Gallstone ileus - Ans. (See Page No. 521)
Q.8: Catheterisation - Ans. (See Page No. 470) Q.62: Laparoscopic cholecystectomy - Ans. (See Page No. 521)
Q.9: Surgical drains - Ans. (See Page No. 471) Q.63: Hiatus hernia - Ans. (See Page No. 522)
0.10 : Preparation of jaundice patient for surgery - Ans. (See Page No. 472) Q.64: Cavernous hemangioma - Ans. (See Page No. 523)
Q.11: Laryngocole - Ans. (See Page No. 472) 0.65: Acute appendicular lump - Ans. (See Page No. 523)
Q.12: Chordee - Ans. (See Page No. 473) Q.66: Pseudocyst ol pancreas - Ans. (See Page No. 524)
Q.13: Thoracic outlet syndrome - Ans. (See Page No. 474) Q.67: Abdominal compartment syndrome - Ans. (See Page No. 525)
Q.14: Cervical rib - Ans. (See Page No, 475) Q.68: Ranula - Ans. (See Page No. 526)
Q.15. Cleft palate - Ans. (See Page No. 477) Q.69: Tourniquet - Ans. (See Page No. 527)
Q.70: Blood transfusion - Ans. (See Pa ge No. 528)

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 Q.71: Melanoma - Ans. (See Page No. 529) Q.6: Barium follow through XrRay - Ans. (See Page No. 583)
Q.72 ; Radiological features of various causes of intestinal obstruction Ans. (See Page No. 531) Q.7: Barium enema X-Ray - Ans. (See Page No. 584)
Q.73: Imperforate Anus - Ans. (See Page No. 532) Q.8: Double contrast barium enema - Ans. (See Page No. 585)
Q.74: Spread of carcinoma - Ans. (See Page No. 532) Q.9: MRCP - Ans. (See Page No. 586)
Q.75: Squamous cell carcinoma - Ans. (See Page No. 533) Q.10: ERCP - Ans. (See Page No. 586)
Q.76: Rhinophyma - Ans. (See Page No. 535) Q,11: MRI - Ans. (See Page No. 587)
Q.77: Web space infection - Ans. (See Page No. 535) Q.12: Therapeutic ultrasound - Ans. (See Page No. 589)
Q.78: Paronychia - Ans. (See Page No. 536) Q.13: CTScan - Ans. (See Page No. 590)
Q.79: SIRS - Ans. (See Page No. 536) Q.14: DRE - Ans. (See Page No. 591) '
Q.80: H.Pylori eradication regime - Ans. (See Page No. 537) Q.15: TURP - Ans. (See Page No. 591)
Q.81: Acute limb ischemia - Ans. (See Page No. 538) Q.16: Investigations of LUTS - Ans. (See Page No. 592)
Q.82: Collar stud abscess - Ans. (See Page No. 539) Q.17: Retrograde pyelography - Ans. (See Page No. 593)
Q.83: Critical limb ischemia - Ans. (See Page No. 540) Q.18: Antegrade pyelogram - Ans. (See Page No. 594)
Q.84: Intermittent claudication - Ans. (See Page No. 540) Q.19: Intravenous urethrogram - Ans. (See Page No. 595)
Q.85: Raspberry tumor - Ans. (See Page No. 541) Q.20: Cystoscopy - Ans. (See Page No. 595)
Q.86: Buerger's disease - Ans. (See Page No. 541) Q.21: Suprapubic cystostomy - Ans. (See Page No. 596)
Q.87: Complications of varicose veins - Ans. (See Page No. 544) 0.22: PCNL - Ans. (See Page No. 597)
Q.88: Horse-shoe kidney - Ans. (See Page No. 545) Q.23: ESWL - Ans. (See Page No. 598)
Q.89: Polycystic kidney - Ans. (See Page No. 547) Q.24: Bone scan - Ans. (See Page No. 598)
Q.90: Desmoid tumor - Ans. (See Page No. 548) 0.25: Thyroid scan - Ans. (See Page No. 599)
Q.91: Tracheoesophageal fistula - Ans. (See Page No. 549) Q.26: Mammography - Ans. (See Page No. 600)
Q.92: Matlory-Weiss syndrome - Ans. (See Page No. 550) 0,27: Lumbar puncture - Ans. (See Page No. 600)
Q.93: Sebaceous cyst - Ans. (See Page No. 550) Q.28: Duplex ultrasound - Ans. (See Page No. 602)
Q.94: Phimosis - Ans. (See Page No. 552) 0.29: Esophagoscopy - Ans. (See Page No. 602)
Q.95: Unilateral hydronephrosis or Causes of bilateral hydronephrosis Ans. (See Page No. 552) 0.30: Tracheostomy - Ans. (See Page No. 604)
Q,96: Staghorn calculus - Ans. (See Page No. 555) Q.31: Bronchoscopy - Ans. (See Page No. 606)
Q.97: Carcinoma of cheek - Ans. (See Page No. 556) Q.32: Colonoscopy - Ans. (See Page No. 607)
Q.98: Classification of nerve injury - Ans. (See Page No. 558) Q.33: Cholangiography - Ans. (See Page No. 608)
Q.99: Venesection - Ans. (See Page No. 559) Q.34: Pet scan- Ans. (See Page No. 611)
Q.100:Wilm'stumor - Ans. (See Page No. 560) Q.35: USG for Hepatobiliary diseases - Ans. (See Page No. 612)
Q.101: Cysts - Ans. (See Page No. 561)
Q.102: Testicular tumor markers - Ans. (See Page No. 562)
Q.103: Primary hydrocele - Ans. (See Page No. 563) SECTION - 2 (ORTHOPEDICS)
Q.104: Congenital hydrocele - Ans. (See Page No. 564)
Q.105: Encysted hydrocele of cord - Ans. (See Page No. 565) GROUP I
0.106: Secondary hydrocele - Ans. (See Page No. 565) 2008
Q.107: Post-burn contracture - Ans. (See Page No. 566)
Q.108: Volvulus - Ans. (See Page No. 567) Q.1: Frozen shoulder - Ans. (See Page No. 616)
0.109: Paralytic ileus - Ans. (See Page No. 568) Q.2: Complications of supracondylar fracture - Ans. (See Page No. 617)
Q.110: Meconium ileus - Ans. (See Page No. 569) Q.3: Sequestrum - Ans. (See Page No. 618)
0.111: Surgical site infection - Ans. (See Page No. 570) Q.4: Volkmann's ischaemic contracture - Ans. (See Page No. 620)
Q.112: Abscess - Ans. (See Page No. 571) Q.5: Talipes equines - Ans. (See Page No. 621)
Q.113: Pyogenic abscess - Ans. (See Page No. 571) Q.6: Bladder problem in spinal paraplegia - Ans. (See Page No. 624)
Q.114: Cold abscess - Ans. (See Page No. 573)
Q.115: Necrotising fasciitis - Ans. (See Page No. 573) 2008 Supplementary
Q.116: Parotid fistula - Ans. (See Page No. 574)
Q.117: Frey's syndrome - Ans. (See Page No. 575) Q.1: Fracture of patella - Ans. (See Page No. 625)
Q.118: Adenolymphoma - Ans. (See Page No. 576) Q.2: Colle's fracture - Ans. (See Page No. 625)
Q.3: Clinical features of spinal tuberculosis - Ans. (See Page No. 625)
SEGMENT E Q.4: Bone cyst - Ans. (See Page No. 626)
Q.5: Gibbus - Ans. (See Page No. 626)
Q.6 : Stress Fracture - Ans. (See Page No. 626)
Q.1: FA.S.T - Ans. (See Page No. 580)
Q.2: Diagnostic peritoneal lavage - Ans. (See Page No. 580) 2009
Q.3: SPECTScan - Ans. (See Page No.581) ‘
Q.4: Barium swallow X-Ray - Ans. (See Page No. 582) 0.1: Myositis ossificans - Ans. (See Page No. 627)
Q.5: Barium meal X-Ray - Ans. (See Page No. 582) Q.2: Pathological fracture - Ans. (See Page No. 628)

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 2012 Supplementary
Q.3: Carpal tunnel syndrome - Ans. (See Page No. 629)
Q.4: Fracture neck femur- types & complications - Ans. (See Page No. 630) 0.1 : Compartment syndrome - Ans. (See Page No. 656)
Q.5: Aetiopathogenesis of acute osteomyelitis - Ans. (See Page No. 631) 0.2 : Sequestrum - Ans. (See Page No. 656)
Q.6 : Spina bifida - Ans. (See Page No. 633) 0.3 : Radiological features of osteos arcoma - Ans. (See Page No. 656)
q 4: Indications of limb amputation - Ans. (See Page No. 656)
2009 Supplementary q .5 : Fracture decranon - Ans. (See Page No. 657)
Q5: Slipped disc - Ans. (See Page No. 658)
Q.1: Non-union of closed fracture - Ans. (See Page No. 634)
Q.2: Complications of supracondylar fracture of humerus - Ans. (See Page No. 635) 2013
Q.3: Paget's disease of bone - Ans. (See Page No. 635)
Q.4: Tension band wiring - Ans. (See Page No. 635) Q.1: Volkmann’s ischaemic contracture - Ans. (See Page No. 661)
Q.5: Indication for amputation - Ans. (See Page No. 635) Q.2: Ewing s tumor - Ans. (See Page No. 661)
Q.6 : Management of osteosarcoma - Ans. (See Page No. 635) Q.3 : Core needle biopsy - Ans. (See Page No. 661)
q .4 ; Colies' fracture - Ans. (See Page No. 662)
2010 Q.5 : Bone graft - Ans. (See Page No. 663)
Q.1: Exostosis - Ans. (See Page No. 637) 2013 Supplementary
Q.2: Brown's tumor - Ans. (See Page No. 638)
Q.3: Ewing's sarcoma - Ans. (See Page No. 639) Q.1 : CTEV- anatomical changes - Ans. (See Page No. 664)
Q.4: Spondylolisthesis - Ans. (See Page No. 640) Q.2: Monteggia fracture - Ans. (See Page No. 664)
Q.5: Bone scan - Ans. (See Page No. 641) Q.3: Carpal tunnol syndrome - Ans. (See Page No. 665)
Q.6 : TB spine - Ans. (See Page No. 642) Q.4: Non union of fracture - Ans. (See Page No. 665)
Q.5: External fixation - Ans. (See Page No. 667)
2010 Supplementary
Q.6: Recurrent dislocation of shoulder - Ans. (See Page No. 668)
Q.1: Tuberculosis of hip joint - Ans. (See Page No. 646) 2014
Q.2: Volkmann’s ischaemic contracture - Ans. (See Page No. 646)
Q.3: Club foot - Ans. (See Page No. 646) Q.1: Fractures occurring due to fall on outstretched hand - Ana. (See Page No. 669)
Q.4: Dupuytren’s contracture - Ans. (See Page No. 646) Q.2: Osteochondroma - Ans. (See Page No. 669)
Q.5: Giant cell tumour - Ans. (See Page No. 646) Q.3: Greenstick fracture - Ans. (See Page No. 669)
Q.6 : Avascular necrosis of femoral head - Ans. (See Page No. 646) Q.4: Fracture of patella - Ans. (See Page No. 670)
0.5: Spina bifida - Ans. (See Page No. 670)
2011
2014 Supplementary
Q. 1: Trigger finger - Ans. (See Page No. 646)
Q.2: Ewing's tumor - Ans. (See Page No. 647)
Q.1: Frozen shoulder - Ans. (See Page No. 670)
Q.3: Mechanism of fracture patella - Ans. (See Page No. 647)
Q.2: Brodies abscess - Ans. (See Page No.670)
Q.4: Brodie s absess - Ans. (See Page No. 646)
0 3 : Carpal tunnel syndrome - Ans. (See Page No.670)
Q.5: Carpal tunnel syndrome - Ans. (See Page No. 648)
0.4: Ewing's sarcoma - Ans. (See Page No. 670)
Q.6 : Shoulder dislocation - Ans. (See Page No. 648)
Q.5: Compound fracture - Ans. (See Page No. 670)
2011 Supplementary
20T5
Q.1: Sequestrum - Ans. (See Page No. 650)
Q.2: Frozen shoulder - Ans. (See Page No. 650) Q.1: Ring sequestrum - Ans. (See Page No. 671)
Q.3: DQdisease - Ans. (See Page No.650) Q.2: Exostosis of bone - Ans. (See Page No. 671) .
Q.4: Codman’s triangle - Ans. (See Page No. 650) Q.3: Volkmann's ischemic contracture - Ans.(SeePageNo.671)
Q.5: S-P Nail - Ans. (See Page No. 651) Q.4: Pathological fracture - Ans. (See Page No. 671)
Q.5: Ideal amputation stump - Ans. (See Page No. 673)
2012
Q.1: Fracture of clavicle - Ans. (See Page No. 651) 2015 Supplementary
Q.2: Tennis elbow - Ans. (See Page No. 652)
Q.3: Supracondylar fracture of humerus - Ans. (See Page No. 653) Q.1: Nonunion of fractures - Ans. (See Page No. 674)
Q.4: Dupuytren s contracture - Ans. (See Page No. 654) Q.2: Mallet finger - Ans. (See Page No. 674)
Q.5: Ruptured tendoachiltes - Ans. (See Page No. 655) Q.3: Baker's cyst - Ans. (See Page No. 674)
Q.6 : Mallet finger - Ans. (See Page No. 656) Q.4: Wrist drop
Q.7: Pyogenic osteomyelitis - Ans. (See Page No. 656) Q.5: Pott's fracture - Ans. (See Page No. 675)

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 2016
2019 Supplementary
Q.1: Carpal tunnel syndrome - Ans. (See Page No. 676)
Q.1: Complications of Colles fracture - Ans. (See Page No. 680)
0.2: Tardy ulnar nerve palsy - Ans. (See Page No. 675)
Q.2: Diagnosis of Vol kmann ischemia - Ans. (See Page No. 680)
Q.3: Supra condylar fracture ol humerus - Ans. (See Page No. 675) Q.3: Myositis ossificans - Ans. (See Page No. 680)
Q.4; Giant cell tumor - Ans. (See Page No. 675) Q.4: Cubitus varus - Ans. (See Page No. 681)
Q.5: Trendelenberg test for hip joint - Ans. (See Page No. 675) Q.5: Pathological fracture - Ans. (See Page No. 682)

2016 Supplementary
December-January 2019-2020
Q.1: Ewing's tumor - Ans. (See Page No. 676) 0.1: Sequestrum - Ans. (See Page No. 6B2)
Q.2: Genu varum - Ans. (See Page No. 676) Q.2: Pott’s paraplegia - Ans. (See Page No. 682)
0.3: Frozen shoulder - Ans. (See Page No. 676) Q.3: Tennis elbow - Ans. (See Page No. 687)
Q.4: Osteosarcoma - Ans. (See Page No. 676) Q.4: Avascular necrosis - Ans. (See Page No. 687)
Q.5: External fixation - Ans. (See Page No. 677) Q.5: Dupuytren'sContracture - Ans. (See Page No. 687)

2017
June-July 2020
Q. 1: Vdkmann's ischaemic contracture - Ans. (See Page No. 677) Q.1: Volkmann’s ischaemic contracture - Ans. (See Page No. 687)
0.2: Pathological fracture - Ans. (See Page No. 677) Q.2: Non union of fracture - Ans. (See Page No. 687)
Q.3: Congenital talipes equinovarus - Ans. (See Page No. 677) Q.3: Frozen shoulder - Ans. (See Page No. 687)
Q.4: Perthes disease - Ans. (See Page No. 677) Q.4: Ewing's Sarcoma - Ans. (See Page No. 687)
Q.5: Radial nerve injury due to fracture - Ans. (SeePage No. 677) Q.5: Fracture patella - Ans. (See Page No. 687)

GROUP- I I
2017 Supplementary
Q.1: Scaphoid fracture - Ans. (See Page No. 694)
Q.1: Injuries sustained by fall on outstretched hand - Ans. (See Page No. 678)
Q.2: Sudeck's osteodystrophy - Ans. (See Page No. 695)
Q.2: Complications of Supracondylar fracture - Ans. (See Page No. 678)
Q.3: Garre's sclerosing osteomyelitis - Ans. (See Page No. 695)
Q.3: Sequestrum - Ans. (See Page No. 678) Q.4: Blood supply of femoral head - Ans. (See Page No. 696)
Q.4: Non-union of fracture - Ans. (See Page No. 678) Q.5: Congenital dislocation of hip - Ans. (See Page No. 696)
Q.5: Ewing's sarcoma - Ans. (See Page No. 678) Q.6 : Physiotherapy in orthopedics - Ans. (See Page No. 698)
Q.7: Elbow dislocation - Ans. (See Page No. 699)
2018
Q.8: Plaster of Paris bandage (POP) - Ans. (See Page No. 700)
Q.9: Paget's disease - Ans. (See Page No. 701)
Q.1: Myositis ossificans - Ans. (See Page No. 678)
Q.10: Tardy ulnar nerve palsy - Ans. (See Page No. 701)
Q.2: Fracture patella - Ans. (See Page No. 678)
Q.11: Prolapsed intervertebral disc - Ans. (See Page No. 702)
Q.3: Complications of Colles' fracture - Ans. (See Page No. 678) Q.12: Osgood - Schlatter’s disease - Ans. (See Page No. 703)
Q.4: Pathological fracture - Ans. (See Page No. 678) 0.13: Gout - Ans. (See Page No. 704)
Q.5: Giant cell tumor - Ans. (See Page No. 678) Q.14: Tension Band Wiring (TBW) - Ans. (See Page No. 704)
Q.15: Genu valgum and Genu varum - Ans.(See Page No. 705)
2018 Supplementary 0.16: Fracture healing - Ans.(See Page No. 706)
Q.17: De-Quervan's disease - Ans. (See Page No. 706)
Q.1: Pathogenesis of Chronic Osteomyelitis - Ans. (See Page No. 678)
Q-18: Osteoarthritis - Ans. (See Page No. 707)
Q.2: Pott's Paraplegia - Ans. (See Page No. 678) Q.19: Septic arthritis - Ans. (See Page No. 709)
Q.3: Classification of fracture neck femur - Ans. (See Page No. 678) 0.20: Classification of fractures - Ans. (See Page No. 710)
Q.4: Spina bifida - Ans. (See Page No. 678) Q.21: Benett's dislocation - Ans. (See Page No. 710)
Q.5: Sequestrum - Ans. (See Page No. 678) Q.22: Traumatic paraplegia - Ans. (See Page No. 711)
Q 23: Intramedullary nail - Ans. (See Page No. 712)
2019 Q.24: Tom - Smith arthritis - Ans. (See Page No. 712)
Q-25: Fracture head of radius - Ans. (See Page No. 713)
Q.1: Cubitus valgus - Ans. (See Page No. 679) 0.26: Wrist drop - Ans. (See Page No. 714)
05: Fracture healing - Ans. (See Page No. 680) 0.27: Cock-up splint - Ans. (See Page No. 715)
Q.3: Osteosarcoma- Ans. (See Page No. 680) 0.28: Below knee amputation - Ans. (See Page No. 715)
Q.4: Club foot - Ans. (See Page No. 680) Q.29: Thomas test - Ans. (See Page No. 716)
Q.5: Supracondylar fracture of humerus- Ans. (See Page No. 680) Q.30: Perthes disease - Ans. (See Page No. 717)
Q.31: Calcaneum fracture - Ans. (Sec Page No. 720)
Q.32: Osteoid osteoma - Ans. (See Page No. 721)
Q.33: Simple bone cyst - Ans. (See Page No. 721)
Q.34 : Aneurysmal bone cyst - Ans. (See Page No. 722)
Q.3S: Fibrous dysplasia - Ans. (See Page No. 723)
Q.36: Osteoclastoma - Ans. (See Page No. 724)
Q,37: Osteosarcoma - Ans. (See Page No. 725)
Q.38: Crush syndrome - Ans. (See Page No. 727)
Q.39: ArthropJasty - Ans. (See Page No. 728)
Q.40: Arthroscopy - Ans. (See Page No. 728)
Q.4 1; Arthrodesis - Ans. (See Page No. 729)
Q.42: McMurray's osteotomy - Ans. (See Page No. 730)
Q.43: Galeazai fracture - Ans. (See Page No. 731)
Q.44: Foot drop - Ans. (See Page No. 731)
Q.45: Kyphosis - Ans. (See Page No. 732)
Q.46: Scoliosis - Ans. (See Page No. 733)
Q.47: Golfer's elbow - Ans. (See Page No. 734)
Q 48: Malunion - Ans. (See Page No. 735)
Q 49: Avascular necrosis - Ans. (See Page No. 736)
Q.50: Smith’s fracture - Ans. (See Page No. 737)
Q.511 TB hip - Ans. (See Page No. 737) Section - 1
0,52: Ingrowing toe-nail - Ans. (See Page No. 739)
0,53: Osteogenesis imperfecta - Ans. (See Page No. 740)
0.54: Madelung deformity - Ans. (See Page No. 741)
Q.55; Student's elbow - Ans. (See Page No. 741)
Q.56: Claw h'and - Ans. (See Page No. 742)

SECTION 3 - ANESTHESIOLOGY
SURGERY
q ,1 ; Spinal anesthesia - Ans. (See Page No. 753)
Q.2: Post spinal headache - Ans. (See Page No. 755)
Q.3: Muscle relaxants - Ans. (See Page No. 757)
Q.4: Monitoring in anaesthesia - Ans. (See Page No. 759)
Q.5: Pulse oxymetry - Ans. (See Page No. 761)
Q.6 : Preanesthetic check-up - Ans. (See Page No. 761)
0.7: Epidural anesthesia - Ans. (See Page No. 763)
Q.8: Regional anesthesia/Local anesthesia - Ans. (See Page No. 764)
Q.9: CPR - Ans. (See Page No. 766)
Q.10: Endotracheal intubation - Ans. (See Page No. 768)
Q.11: Intravenous anaesthetics - Ans. (See Page No. 770)
 SEGMENT - A
SOLVED LONG QUESTIONS OF FINAL MBBS
Paper - 1

2008

0.1 .-Define and classify shock. How will you assess and treat a case of hemorrhagic shock ? Mention
complications o f blood transfusion. [2 + 2 + 5 + 3 + 3 J

SHOCK
Section - 1 Definition : Shock may be defined as a state of depression of the vital functions of the body due to
inadequate tissue perfusion of the vital organs, resulting from insufficient microcirculation.
SURGERY
Classification -

SEG M ENT-A
SHOCK
Solved Long Questions of Final MBBS 2008-2015 (Paper - 1)
X H-
Solved Long Questions of Final MBBS 2008-2015 (Paper -11} Hypovolemic or Cardiogenlc
Oligaemic or Septic Vasogenic
Hematogenic Refer to next page for
SEGMENT - B Refer to next page tor details
X
details
Solved Long Questions o f Semesters of Various Colleges (Paper - 1) Hemorrhagic Non-
X Hemorrhagic
Solved Long Questions o f Semesters o f Various Colleges (Paper - II) Due to systemic
Bleeding Irom Bleeding into n z sepsis by
SEGMENT-C injury site injury site Loss of fluid and 1. E. Coli
plasma e.g. Bum 2. Klebsiella
Solved Short Notes of Final MBBS 2008-2015 (Paper - 1) Loss of ftuid 3. Pseudomonas
1. External 1. Into the Intestine e.g.
2. Internal 4. Staphylococcus
Solved Short Notes of Final MBBS 2008-2015 (Paper - II) 1. Fractured rib Vomiting, Diarrhea aureus <
2. Acute pancre­ 2. Into the peritoneum 5. Bacteroides
atitis e.g. Peritonitis
SEGMENT-D

Solved Short Notes o f Semesters of Various Colleges

SEGMENT - E ASSESSMENT OF HEMORRHAGIC SHOCK :

Solved Shorts Notes of Investigations 1. Symptoms -
Mild shock - (< 20% blood loss)
(a) Pale cold ctammy extremities
(b) Thirst
Moderate shock - (20-40% blood loss)
(a) Reduced urine output (< 0.5 ml/kg/hr)
Severe shock - (> 40% blood loss)
(b) Restlessness, anxiousness giving way to apathy, exhaustion
4 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 5

2. Signs -
Mild shock -
(a) Superficial veins collapse making insertion of infusion needle difficult
Moderate shock -
Due to loss (a) Oliguria
y of sympa­ (b) Hypotension
thetic tone (c) Tachycardia
Severe shock -
(a) Rapid pulse
(b) Low BP
(c) Anuria
(d) Unconsciousness

Signs of significant blood loss -

(a) Pulse > 100/min
(b) SBP<100m mHg
(c) DBP drop on sitting or standing >10 mm Hg
(d) Pallor/sweating
(e) Shock index (pulse rate : BP) > 1

3. Measurement o f blood lo s s :
(a) Clot size of a clenched fist = 500 ml
(b) Blood loss in closed tibial fracture = 500-1500 mi, in fracture femur = 500-2000 ml
(c) Weighing the swab before and after use
Rains factor:
Total amount of blood loss = Total difference in swab weightM.5 (for smaller wounds)
Total amount of blood loss = Total difference in swab weight*2 (for larger wounds)
(d) Hb% and PCV estimation
Intrinsic (e) Blood volume estimation using radioiodine technique or microhaematocrit method
1. Ml
(f) Measurement of CVP or PCWP
(Decreased myocardial 2. Arrhythmia
contractility) (g) Investigations specific for cause:
(i) USG abdomen
(ii) FAST
(iii) Diagnostic peritoneal lavage
(iv) Doppler and angiogram
r Cardiogenic (v) CT scan
Compressive r \
Shock 1. Cardiac tamponade TREATMENT of HEMORRHAGIC SHOCK :
(Compression of 2. Pneumothorax
(Defective pump
cardiac chambers) v 7 1. Resuscitation -
mechanism)
v------------------------ / This should begin immediately as soon as the patient is admitted.
(a) Establishment of clear airway
Pulmonary (b) Maintenance of adequate ventilation and oxygenation - lowering of head (increases cerebral
e.g. pulmonary circulation, provents stasis ol blood in leg musclos thereby preventing Edema), support of
Obstructive embolism jaw, moist oxygen administration
(Increased peripheral (c) Endotracheal intubation and mechanical ventilation may be needed in case of airway
vascular resistance) obstruction
Systemic
e.g. Obstruction of 2. Immediate arrest o f Hemorrhage:
aorta
(a) External bleeding - raising footend
- compression bandage
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 7
6 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Aneslhesiology

2. Transmission of Infections:
(b) Internal bleeding - surgical exploration (a) B acterial: Syphilis, Yersinia
(c) Bleeding from GIT - decompression of stomach and other specific measures (b) Viral: HIV, HBV, CMV, EBV
(c) Parasite: T. cruzi, Malaria
3. Extracellular fluid replacement:
□ 2 wide bore cannula inserted and intravenous infusion is started 3. Reactions caused by massive transfusion :
□ Ringer lactate is initially used (@ 1-2 It in 45 mins) till arrangement for whole blood is made. (a) Acid-Base Imbalance - Mainly metabolic acidosis because most of the citrate in the
It is better to withhold administration of blood until surgical control of bleeding is obtained or anticoagulant solution is present as sodium citrate, which becomes sodium bicarbonate as
atleast until just before induction of Anesthesia. Rapid replacement of fresh blood after control citrate is consumed.
of Hemorrhage will lead to fewest complications. At times when bleeding has been severe, - (b) Hyperkalaemla - Duo Jo shift of potassium out of R8C due to low temperature of storage
blood should be given before surgical control of Hemorrhage. (c) Citrate toxicity - Its main effect is to consume ionized calcium from the patient's body.
□ Non sugar crystalloid solution is used; sugar is avoided because it induces osmotic diuresis. (d) Hypothermia
□ Colloid solutions should not be used as in cases of severe shock, there is generalised (e) Failure o f coagulation - The causative factors are
damage of capillary endothelium and colloids may come out into interstitial tissues causing (i) DIC
pulmonary embolism. (ii) Dilution of clotting factors
(iii) Dilutional thrombocytopenia
4. Drugs:
4. Complications o f overtransfusion:
(a) Sedatives - used to alleviate pain
(a) Congestive cardiac failure - Mainly seen If whole blood transfusion is given to chronic anaemic
- Morphine for adults, barbiturates for children
patients and elderly individuals
(b) Chronotropic - used in patients having slow heart rate
(b) Circulatory overload causing heart failure
• agents - Atropine most widely used, followed by Isoprenaline
(c) lonotropic - used to improve myocardial contractility 5. Complications o f general i.v. fluid adm inistration:
agents - Dopamine, Dobutamine (a) Thrombophlebitis
(d) Vasodilators - used in septic, “traumatic cardiogenic" shock (b) Air embolism
(e) Vasoconstrictors - used in neurogenic shock
6. Due to transfusion components:
■ (f) Beta blockers - used in cardiogenic shock
- mainly used is Propranolol (a) Iron overload
(g) Diuretics - sometimes used in cardiogenic shock (b) Haemochromatosis
(h) Sodium bicarbonate - used if metabolic acidosis occurs
0 2 : Enumerate the causes o f bleeding per rectum. Mention how It is diagnosed. Outline the
management for bleeding hemorrhoids. [5+5+5]
COMPLICATIONS OF BLOOD TRANSFUSION
BLEEDING PER RECTUM
1. Transfusion reactions:
CAUSES :
(a) Incompatibility - There are 3 causes:
(i) Incompatible transfusion (A) Local causes:
(ii) Transfusion with blood which is already haemolysed by heating or freezing or over 1. In rectum and anal canal-
shaking (a) Hemorrhoids
(iii) Transfusion of blood after expiry date (b) Anal fissure
(b) Pyrexia! reactions - The causes are: (c) CA Rectum
(d) Rectal polyp
(i) Improperly sterilised transfusion sets
(ii) Presence of pyrogens in the donor apparatus (e) Ruptured perianal hematoma
(iii) Transfusion of infected blood (f) Others - ulceration, trauma, ruptured anorectal abscess, skin excoriation
(iv) Very rapid transfusion of blood 2. In colon-
(c) Allergic reactions - Due to allergic reaction to plasma products in the donor's blood (a) CA Colon
(d) Sensitisation to leucocytes and platelets - This occurs where many blood transfusions (b) Ulcerative colitis
have been given in the recent past. Antibodies are developed against WBC or platelets of (c) Crohn's disease
donated blood, which causes reactions. (d) Angiodysplasia of colon
(e) Immunological sensitisation
 8 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 9

(e) Amoebic ulcers (c) At times other than during defecation - Prolapsed piles, polyp, CA, ulcerative colitis, Crohn's
(f) Diverticular disease disease, angiodysplasia, etc.
(g) Bacillary dysentery
(h) Ischaemic colitis 6. Nature o f blood -

3. In small Intestine - (a) Blood alone - Polyps, Villous adenoma, Diverticulosis

(b) Blood mixed with mucus - Ulcerative colitis, Crohn's disease, Intussusception, Ischaemic
(a) Meckel’s diverticulum
colitis, CA colon
(b) Intussusception
(c) Blood streaked on stool - CA rectum, Anal fissure
(c) Mesenteric artery obstruction/ mesenteric ischaemia
(d) Fresh blood as splashes In pan - Hemorrhoids .
(d) Small bowel Tumor
(e) Maroon coloured stool - Meckel’s diverticulum
(B) General causes : (f) Red currant jelly in stool - Intussusception
(g) Bright red blood in stool - Rectal polyp
(a) Blood dyscrasia
(b) Liver failure 7. Associated pain -
(c) Renal failure (a) Present in - Anal fissure
(d) Drugs - NSAIDs, steroids (b) Absent in - CA, polyp
(All pathological conditions above Hilton's line are painless, below Hilton's line are painful
DIAGNOSIS: except CA)
[Lower G.l bleeding can be divided into three types - 8. Associated symptoms -
(a) Occult blood loss - Atleast 10 ml blood loss per day which is detected only by chemical tests. (a) Change in bowel habit (constipation followed by Diarrhea), constant colicky pain, distended
(b) Slow bleeding - Recognisable blood loss either altered or fresh per anum in a stable patient. abdomen, palpable lump - Left sided colonic CA
(c) Rapid/ severe bleeding - Rapid blood loss per anum reflected by hemodynamic instability.] (b) Paleness + dull pain in right lower abdomen + palpable mass - Right sided colonic CA
(c) Tenesmus, bladder symptoms, palpable mass - Sigmoid colon CA
(A) History :*
(d) Spurious Diarrhea, tenesmus, bloody slime - Rectal CA
1. A g e - (e) Something coming out per rectum - Hemorrhoids, polyp
(a) More common in children - Rectal polyp, Intussusception, Bacillary dysentery (f) Diarrhea - Ulcerative colitis, Crohn’s disease, dysentery
(b) More common in middle age - Hemorrhoids, Anal fissure
(c) More common in old age - CA Colon, CA Rectum (8) Clinical examination :

2. O n s e t- . 1. General survey -
Acute bleed occurs in Pallor in CA, ulcerative colitis, Crohn's disease, bleeding diathesis
(a) Mesenteric ischaemia 2. Abdominal examination -
(b) Angiodysplasia of colon (a) Lump in right or left iliac fossa - CA colon
(c) Ischaemic colitis
(b) Sausage shaped, smooth, firm, mobile, resonant mass with emptiness in right iliac fossa -
(d) Meckel's diverticulum
Intussusception
(e) Intussusception
(0 Acute episodes of ulcerative colitis (c) Distended abdomen - Ulcerative colitis
in rest conditions there is chronic bleed. • 3. Inspection o f anal opening - For Hemorrhoids, fissure
3. Amount o f blood lo s s - 4. Digital per rectal examination -
(a) Very small amount - Anal fissure (streak of fresh blood on stool) Not done in Anal fissure as painful
(b) Profuse - Hemorrhoids, acute bleeding conditions Hemorrhoids is not palpable unless thrombosed
4. Colour o f blood - CA rectum, polyp may be palpated
(a) Bright re d - from rectum or anal canal 5. Proctoscopic exam ination- .
(b) Dark red - from colon Visualisation of Hemorrhoids, Rectal polyp, Ca rectum
(c) Black - (melaena) from small intestine or higher up
(C) Investigations:
5. Relation o f bleeding to defaecation -
1. Colonoscopy
(a) At the time of passing hard stool - Anal fissure
2. Endorectal USG
(b) At the time o f passing stool, or just after defecation - Hemorrhoids

S
10 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS 0 Paper-I 11

3. Barium enema ( when not much scope for colonoscopy)

2. A g e -
4. Biopsy
5. For staging - X-ray chest, USG abdomen, CT abdomen (a) Young age - Biliary atresia, Choledochal cyst
6. Routine investigations for pre-anaesthetic check up - Hb, TLC, ESR, blood urea, serum creati (b) Middle age - Choledocholithiasis
(c) E lderly-C A
nine, blood sugar, Chest X-ray, ECG. (Management of Bleeding Hemorrhoids - See page 57).
3. S ex-
Q.3: What are the causes o f obstructive jaundice ? How do you establish the diagnosis 7 Discus (a) CA head pancreas, periampullary CA more common in males
various options in management o f choledocholithiasis. [ 5 + 5 + 5; (b) Choledocholithiasis, Cholangiocarcinoma, Choledochal cyst more common in females

OBSTRUCTIVE JAUNDICE 4. Assoc/atcd symptoms -

(a) Classical triad of recurrent attacks of right upper abdominal pain + slowly progressive jaundice
CAUSES: + palpable abdominal mass - Choledochal cyst
(b) Intermittent jaundice + weight loss + fever + pain - Sclerosing cholangitis
(c) Biliary colic + Charcot's triad ( Fluctuating jaundice + Intermittent pain In right upper abdomen
+ Fever with rig o r) [sometimes Reynaud’s pentad = Charcot’s triad + shock + mental
obtundation] - Choledocholithiasis
(d) Weight loss + asthenia + anorexia in all CA
Painless progressive jaundice in CA head of pancreas. Intermittent jaundice + Silvery stool
(due to mixing of undigested fat with metabolised blood derived) + Diarrhea with pale, foul
smelling stool in periampullary CA.

(B) Clinical Examination:

1. General survey -
(a) Pallor in CA
(b) Jaundice
(c) Enlarged Virchow's node in CA head of pancreas
2. Abdominal examination -
(a) Smooth, non tender, globular mass with well defined lower, medial and lateral margins,
moving with respiration palpable in right hypochondriac region i.e. Gall bladder - CA head of
pancreas, periampullary CA, Choledochal cyst (according to Courvoisier’s Law, in a patient
with jaundice, if there is palpable gall bladder, it is not due to stones)
(b) Hepatomegaly - in CA head of pancreas, periampullary CA, Cholangiocarcinoma, Klatskin
Tumor (if soft - due to hydrohepatosis, if hard, nodular - due to secondaries)
(c) Trousseau’s sign (migratory superficial thrombophlebitis) in CA pancreas
(C) Investigations:
(a) LF T - ‘
(i) Increased total bilirubin
(ii) Conjugated bilirubin raised
(iii) ALP, GGT highly raised
(iv) AST, ALT raised
(v) Albumin : globulin ratio normal or may be altered with reduced albumin
(b) Prolonged prothrombin time
DIAGNOSIS:
(c) USG abdomen
(A) History (d) ERCP - 'double duct' sign in CA head of pancreas
1. Chief complaint - (e) Barium meal - ‘Pad' sign in CA head of pancreas, 'Reverse 3' sign in periampullary CA
(a) Yellowish discolouration ol urine, eyes and skin (f) MRCP
(b) Intense pruritus (g) CT Scan
(c) Clay coloured stool (h) CA 19-9 in CA head of pancreas, periampullary CA
 12 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS D Paper-I 13

(i) PET
2008 Supplementary
(j) EUS
(k) Urine tests - (i) Fouchet’s test (for bile pigments)
(if) Hay's test (for bile salts) 0.1: Classify burn. How w ill you assess and manage a 35 year old woman weighing 60 kg admitted
(iii) Ehrlich's test (for urobilinogen) with 40% burn. ' [3 * 5 * 7 ]
A : See Section - 1 , Segment A, Paper - 1 , 2013, Qs. 1 (Page No. 49).
MANAGEMENT OF CHOLEDOCHOLITHIASIS 0.2: Enumerate the causes o f upper Gl bleeding. Discuss how a patient with this should be diagnosed
and managed. [5 + 5 * 5 ]
1. Preoperative preparation for obstructive jaundice A : See Section 1, segment A, Paper 1,2010, Qs. 2 (Page 23-24).
(a) Immediate hospitalisation
Q.3: A 40 year old patient has come to emergency with acute pain in right hypochondrium. How will
(b) Diet - high carbohydrate, low protein, no fat diet along with vitamin and calcium supplements you make a clinical diagnosis ? Outline the treatment strategy In such a patient. [5 * 10]
(c) Adequate hydration with oral and intravenous fluid
A: See section 1, Segment A, Paper I, 2011, Qs. 1 (Page 33) "ACUTE PAIN IN RIGHT
(d) i.v mannitol - 10% 200ml before, during or after surgery or Inj Furosemide 40mg i.v HYPOCHONDRIUM” .
(e) Inj Dopamine 2 ug/kg/min
(f) Inj Vitamin K 10mg for 3 days to correct prothrombin time if still no improvement, fresh frozen
2009
plasma is used
(g) Blood transfusion if severe anaemia
Q.1 . Define and classify wounds. Discuss various factors Influencing wound healing. Discuss
(h) Broad spectrum antibiotics management o f diabetic foot. [5+5 +5]
(i) If preoperative bilirubin >10mg%, ERCP stenting or PTBD done, else MRCP done

2. Ideal treatment - Endoscopic sphincterotomy by ERCP and bile duct stone removal by Dormia WOUNDS
basket catheter or Fogarty balloon catheter followed by laparoscopic cholecystectomy not within the
1st 24 hours of ERCP(as chance of ERCP pancreatitis) but in the same hospital admission. Definition : Break in the integrity of the skin or tissues, often associated with disruption of the structure
If laparoscopic facilities not available, then open cholecystectomy to be done. and function.

3. If ERCP not possible, laparoscopic choledocholithotomy followed by laparoscopic cholecystectomy Classification:

done. 1. Classification o f surgical wounds:
4. If laparoscopic facilities not available, then open cholecystectomy -* per operative cholangiogram -> (a) Clean - e.g. hemiorraphy, excision
choledocholithotomy - » T tube insertion -> within 7-10 days T tube is clamped, and patient observed (b) Clean contaminated - e.g. appendicectomy, bowel surgery
for development of pain, jaundice and fever -» free flow of dye is confirmed by T tube cholangiogram (c) Contaminated - e.g. acute abdominal condition, open fresh accidental wound
-» T tube removed by smart pull (d) Dirty infected - e.g. abscess drainage, empyema gall bladder
5. Management of retained CBD stones i.e. detected within 2 years of choledocholithotomy : / 2. Rank and Wakefield classification:
(a) Small stones may spontaneously pass down
(a) Tidy - e.g. surgical incision ‘
(b) Heparinised saline or biie acid flushing through T Tube( 250 ml normal saline with 25000 units
(b) Untidy - e.g. crushing, tearing, avulsion
i.v. Heparin)
(c) Contact dissolution with monooctanoin or methyl terbutyl ether f 3. On basis o f covering:
(d) Burrhene technique - After 6 weeks once T tube track gets matured, track if needed is dilated (a) Open - e.g. incised wound, lacerated wound
using graduated dilators. Then using Fogarty catheter or Dormia basket catheter or (b) Closed - e.g. abrasion, contusion
choledochoscope, stone is removed through T lube track under fluoroscopic guidance (C-
ARM) , 4. On basis o f seve rity:
(e) ERCP and stone removal in 3 weeks (a) Simple (only skin involved)
(f) Transduodenal sphincteroplasty or choledochojejunostomy (b) Complex (vessels, nerve, bones, tendons involved)
(g) ESWL with endoscopic sphincterotomy
/ 5. On basis o l involvement o f underlying viscera: '
(h) Through percutaneous transhepatic route, cholangioscope is passed and CBD visualised, stone
is identified and removed using Dormia basket catheter or Fogarty catheter (a) Penetrating - e.g stab wound, gun shot wound
(i) Laparoscopic choledocholithotomy (b) Non penetrating - e.g. abrasion, bruise
(j) Open choledocholithotomy often with open choledochojejunostomy 6. On basis o f velocity o f inflicting object:
(a) Low velocity
(b) High velocity
 T •

14 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - I 15

^ 7. On basis o f part o f body involved:

(a) Skin 3. Diseases -
(b) Mucosa (a) Anaemia
(c) Bone (b) Uraemia
(d) Brain (c) Jaundice
S. On basis o f clinical appearance: (d) Diabetes
(e) Blood dyscrasia
(a) Puncture ••
(f) Malignant disease
(b) Bruise *
(c) Abrasion \ 4. Steroids - Delay healing
(d) Incision . 5. Cytotoxic drugs - Delay healing
(e) Laceration
(f) Avulsion *
^M A N A G EM EN T OF DIABETIC FOOT
Factors influencing wound healing:

(A)LOCAL FACTORS: Main problems In diabetic fo o t:

1. Disposition - Skin wounds made in direction parallel to lines of Langer heal faster than those 1. Callosities •• . ,
made across these lines, because skin is less stretchable along these lines because of arrange­ 2. Trophic Ulcer
ment of collagen bundles in the dermis 3. Abscess 1 .
2. Vascularity - Wounds heal faster in areas with high vascularity like scalp, lace etc •4. Infection •*
3. Lymph and venous drainage - Edematous tissues heal slowly. Impaired lymphatic and venous 5. Gangrene - dry gangrene in old diabetics, wet gangrene in young diabetics
drainage delays healing 6. Osteomyelitis, arthritis
4. Necrosis - Delays healing ' Investigations:
5. Tension - Delays healing 1. B lo od -
6. Presence of foreign bodies - Delays healing as phase of granulation tissue formation cannot (a) Sugar
start unless tissue reaction induced by the foreign body ceases (b) Urea, creatinine
7. Infection - Delays healing as the granulation tissue formation cannot begin fill active inflamma­ (c) HbAie •
tion persists 2. Urine - Ketone bodies * •
8. Movements - Damage newly growing granulation tissue 3. Doppler study of lower limb to assess arterial patency
9. Anchorage - Delays healing by impairing wound contraction 4. Angiogram to look for proximal blockage
10. Radiation - Delays healing 5. Pus - for culture and sensitivity
11. W light - increases rate of healing 6. X-ray if osteomyelitis is suspected
12. Faulty technique of wound closure delays healing 7. USG abdomen - to see status of abdominal aorta
Treatment ;
(B) SYSTEMIC FACTORS: (A) Conservative treatm ent:
1. Age - Healing is faster in young age 1. Diabetes to be controlled by - (a) diet (b) drugs (c) insulin *
2. Nutrition - . 2. Control of obesity
(a) Protein - High level of protein is required as 3. Drugs -
(i) Afl proliferating cells demand protein ""''(a) Pentoxiphylline (improves blood circulation by reducing blood viscosity)
(ii) Collagen formation requires hydroxyproline and hydroxytysine (b) Cilostazole (Phosphodiesterase inhibitor which improves microcirculation)
(iii) Protein loss of catabolic phase has to be made for ,— (c) Low dose aspirin
(d) Dipyridamole
(b) Vitamins -
4. Care of foot -
(i) Vitamin C - For collagen synthesis
(a) Avoid injury .
(ii) Vitamin A - For epithelialisation
(b) Keep it clean and dry especially toe webs *
(iii) Vitamin D - For new bone formation (c) Regular dressing
(c) Minerals - (d) MCR (Micro Cellular Rubber) footwear to be used (farmers are advised to wrap fhe foot with
Zinc, calcium, manganese, magnesium and copper are required for wound healing polythene packet and then work in the fields)
5. Antibiotics used it infection
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 17
16 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics S Anesthesiology

2. Abdominal examination -
(B) Surgical treatm ent:
(i) Liver mass -
1. Infection- (a) Site - epigastric region
(a) Early cases - wide spread incision and drainage with debridement of wound removing all (b) Movement with respiration - present
necrotic tissue (c) Margins - upper border not felt, extends to left hypochondriac region
(b) Severe cases - amputation above knee or below knee (d) Consistency - hard, nodular
2. Trophic ulcer - (e) Percussion - dull
If superimposed infection, then local debridement with proper antibiotic administration (ii) Stomach mass-
3. Gangrene - (a) Site - epigastric region
(a) Localised dry gangrene - postpone operation and allow autoamputation to take place over (b) Movement with respiration - present
a period ol weeks (c) Margins - globular, ill defined
(b) Spreading gangrene - amputation (level to be determined based on investigations) (d) Consistency - hard, nodular
(e) Percussion - resonant/ impaired resonant
Q.2: A middle aged male patient presents with an epigastric lump. Discuss differential diagnosis. (I) Succusion splash - audible
How would you investigate ? [ 8 + 7] (g) Auscultopercussion
(iii) Pseudocyst -
EPIGASTRIC LUMP
(a) Site - epigastric region
Differential diagnosis: (b) Movement with respiration - absent/slight
(c) Mobility - restricted
1. Palpable left lobe of liver -
(d) Retroperitoneal mass
(a). Hepatoma
(e) Margins - lower border well palpable, upper border ill defined
(b) Liver secondaries
(f) Consistency-smooth, soft
(c) Amoebic liver abscess (g) Percussion - resonant
(d) Hydatid cyst of left lobe (h) Baid test positive
2. Stomach mass
(iv) Cystadenocarcinoma pancreas -
3. Pseudocyst of pancreas
4. Cystadenocarcinoma of pancreas (a) Site - epigastric region
5. Colonic mass - CA transverse colon (b) Movement with respiration - absent
6. Para-aortic lymph node enlargement - (c) Mobility - restricted
(a) Lymphoma (d) Retroperitoneal mass
(e) Margins - lower border well palpable, upper border ill denned
(b) Secondaries
(f) Consistency - soft
(c) Tuberculosis
(g) Percussion - resonant
7. Aortic aneurysm
(v) Para-aortic lymph node mass -
Diagnosis: (a) Site - deep in epigastrium
(A) History: (b) Movement with respiration - absent
1. Age - CA commonly in elderly (c) Mobility - restricted
(d) Percussion - resonanl
2. History of projectile vomit containing food taken 12 hours ago + feeling of something moving (ram
left to right - Stomach mass (vi) Aortic aneurysm -
3. History of constipation followed by Diarrhea (change in bowel habit) + abdominal pain + vomit - (a) Site - deep in epigastrium
Colonic mass (b) Movement with respiration - absent
4. History ol yellowish discolouration of urine and eyes, itching, palecolouredstool - CA pancreas (c) Mobility - restricted
5. History of acute attack of stabbing abdominal pain radiating to the flanks and back + profuse (d) Percussion - resonant
vomiting + retching, all occurring about 3 days before lump being palpable - Pancreatic pseudocyst (e) Consistency - soft, smooth
6. History of evening rise of temperature, cough, haemoptysis - TB (0 Pulsatile (expansile)
7. Ascites - Hepatic cause
(C) Investigations: 4
8. Loss of weight, anorexia, asthenia - in CA and TB
1. Routine - (i) Hb - reduced in CA, TB (ii) TLC raised in infection (iii) ESR increased in TB, infection
(B) Clinical examination: (iv) Blood urea, Serum creatinine (v) Blood sugar (vi) Chest X-ray (vii) ECG
1. General survey-Pallor in CA and TB
 18 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 19

2. Special - (i) Tuberculous peritonitis

(i) USG abdomen - (j) Acquired intestinal fistula in Crohn’s Disease
(a) Liver mass - hyperechogenic mass, mosaic pattern with thin halo and lateral shadows <k) Acquired intestinal fistula from secondary carcinoma
(b) Liver abscess - hypo/anechogontc mass, site, size, number, location PROBLEMS RELATED TO VID AND THEIR REMEDIES
(c) Hydatid cyst - rosettes of daughter cysts, double contoured cyst membrane, cyst wall
calcification Anatomy:
(d) Pseudocyst - size and thickness ' Between the head fold and the tail fold, the embryo becomes constricted by right and left lateral folds. The
(e) To see spread in ovary and other organs intervening dorsal portion of the yolk sac constitutes the midgut.At first the midgutcommunicates freely
(ii) CT abdomen - CECT useful in hepatic mass, pseudocyst pancreas. Cart wheel appearance with the rest of the yolk sac on its ventral aspect, but the continued growthof the folds results in narrowing
in hydatid cyst. Spiral CT shows portal vein Infiltration, retroperitoneal lymph node, size of of the connection, which becomes drawn out as the vitello - Intestinal duct.
Tumor
(iii) LFT, PT - altered In hepatic mass, pancreatic CA SI. NAMES ANOMALIES CLINICAL FEATURES INVESTIG­ TREATMENT
No ATIONS
(iv) Upper G! endoscopy - to detect stomach mass and take biopsy
(v) Barium meal - 1. Intestinal fistula VID completely 1) Faecal/urinary dis­ 1) Fistulogram 4 1) Fistulectomy
patent charge from umbili­ CT and resection
(a) CA Stomach - (1) Irregular filling defect; (2) Loss of rugosity; (3) Delayed emptying; (4) cus of bowel seg­
2) Discharge
Dilatation of stomach in CA pylorus; (5) Carmann’s meniscus sign i.e., margin of lesion 2) Recurrent infection study ment and patent
projects outward from ulcer VID followed by
3) Pain/tenderness and 3) USG abdomen
(b) Pancreatic CA - ‘pad1 sign . excoriation In and anastomosis of
(vi) Gastroscopy with biopsy - CA stomach bowel
around umbilicus
• (vii) Tumor markers - Umbilical sinus Small portion of Pain, swelling, discharge, 1) Discharge
2. 1) Treatment of
(a) CA 72-4: CA stomach VID near umbili­ tenderness around um­ study the cause
(b) CEA: CA stomach cus remains bilicus 2) Sinusogram 2) Antibiotics
(c) CA 19-9: CA pancreas patent. 3) USG, CT abdo­ 3) Umbilectomy
(d) CA 12-5: CA stomach men
(e) Alphafetoprotein : Liver mass Partially unobli­
3 Umbilical adenoma 1) Red swelling pro­
(viii) ERCP with pancreatic juice cytology or brush biopsy If pedunculated,
OH Enteroterato- terated VID near trudes out near um­
firm ligature tied
(ix) MRCP - to see biliary tree <‘ ma OR Umbilical umbilicus and bilicus around it, so that
polyp OR Rasp­ the mucosa pro­ 2) It is moist with mu­
(x) Coeliac and superior mesenteric angiogram Tumor falls of. If
berry Tumor lapses through cus
(xi) MRI abdomen reappears, umbi­
umbilicus 3) Tends to bleed on
lectomy done
touch

Q.3: What are the causes o f weeping umbilicus7 Discuss the problems related to VID and their 4. Intra abdominal VID closed on Assymptomatic USG abdomen Excision
remedies. [ 5 +5 +5] cyst OR Enterocy- either side but
stoma intervening por­
CAUSES OF WEEPING UMBILICUS tion remains
patent
1. Congenital; 5. Meckel's diverticu­ Assymptomatic, fea­ 1) Technitium 99
VID patent near Excision of Meckel's
(a) Intestinal fistula lum its attachment tures arise only due to (Tc99) radio diverticulum along
(b) Patent urachus to terminal ileum complications: isotope scan with its base and a
(c) Umbilical adenoma giving rise to 1) Bleeding 2) X-ray abdo­ short segment of
congenital diver­ 2) Uttre's hernia men ileum followed by
2. Acquired : ticulum 3) Barium meal end to end anasto­
3) Intestinal obstruction
(a) Umbilical dermatitis follow through mosis
4) Neoplasm 4) CT Scan
(b) Umbilical granuloma 5) Peptic ulcer
(c) Umbilical calculus or omphalith 6) Perforation
(d) Umbilical abscess
(e) Endometrioma 6. Vitellointestinal VID obliterated Volvulus, intestinal ob­ USG abdomen Excision
(f) Pilonidal sinus cord OR Intraab but a band per­ struction may occur
(g) Secondary carcinoma dominal band sists
(h) Sister Mary Joseph's nodule
 20 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 21

Anomalies: . A) Depending on site -

Sometimes the vitello - intestinal duct may persist completely or partially to give rise to the following 1) Proximal small bowel obstruction
conditions: 2) Distal small bowel obstruction
3) Large bowel obstruction
2009 Supplementary
B) Depending on aetiopathogenesis -

0 .1 : Classify haemorrhage. How w ill you determine the amount o f blood loss and treat It? Depending on aetiopathogenesis
[3 + 5 + 7]
A : See Section 1, Segment A, Paper 1,2012 (Page 40)

Q 3 : Give an account o f pathogenesis, clinical features and management o f acute pancreatitis. Dynamic
[5 + 5 + 5] Adynamic

A: ACUTE PANCREATITIS Postoperalive ^

Cessation of peristalsis —
In lumen In wall Outside wall
• Pathogenesis - Spinal injuries "
Pancreatic enzymes in the pancreatic acini remain as pro-enzymes (inactivated form). When the ,, *Round worm ♦ Tuberculous ♦ Adhesions Uraemia
proenzymes are activated, they produce series of changes which are characteristic of acute , •Gallstones stricture • Hernias Diabetes mallitus "
pancreatitis. The main causes of activation are - ^ • Meconeum • Malignancy • Volvulus Retroperitoneal haematoma/
(i) Epithelial break (ii) Mixing up of infected bile and the pancreatic proenzymes. ileus • Crohn's • Intussuscep­ surgery
‘ Inspissated disease tion Pseudo-obstruction
Following are the changes -
| faeces Mesenteric ischaemia
(1) The Klnins cause vasodilation and there is passage of fluid from the blood vessels into _ '
Electrolyte imbalance
pancreatic tissue causing oedema of pancreas and finally hypovalaemia with hypovolaemic
shock
(2) Collagenase and leclthinase act on collagen fibres of blood vessels and destroy them C) Depending on type -
causing Haemorrhage Blood collects in the pancreas, retropancreatic space and even the 1) Acute obstruction
peritoneal cavity. It may finally lead lo paralytic Ileus and collection of blood in toin (when 2) Subacute obstruction
patient lies down) and peri umbilical region (via falciform ligament) ■' 3) Chronic obstruction
(3) Lipase will act over the fat specially greater omentum. Fat is split into fatty acids and glycerol. 4) Closed loop obstruction
Fatty acids combine with calcium to form soap. These are white looking like pearl. These are
scattered over the omentum (fat necrosis) S M A LL INTESTINAL OBSTRUCTION
(4) Amylase absorbed through peritoneal surface into blood. So there is rise of serum amylase.
Clinical features:
(5) Destruction of p cells - » lack of insulin -» hyperglycaemia
A) Symptoms -
(6) As Ca2+ is mobilised to produce soap, there Is hypocalcaemia.
• Abdominal pain
(7) Finally, there is diminished excursion (movement) of diaphragm and lungs, particularly in left
side as tail of pancreas is in close contact with diaphragm. This leads to hypoventilation and Nature - Initially colicky, later continuous
finally partial pressure of O2 falls and partial pressure of CO2 rises. Severity - Intense
(8) Lastly, superadded infection on the necrotic pancreas leads to pancreatic abscess and Onset - Sudden
septicaemia, which finally may lead to renal failure, hepatic failure, respiratory failure and Site - Begins around umbilicus and then spreads to whole abdomen
even multiorgan failure.
Frequency - Recurring episodes occurring as short crescendo/decrescendo episodes
t R e s t- See Section 1, Segment B, Paper I, Qs. 10 (Page No. 247). (lasting about 30 seconds)
0.3 : Define and classify Intestinal obstruction. How will you diagnose and treat small intestinal • Abdominal distension -
obstruction. [5 + 5 + 5] * Minimal or absent in jejuna! obstruction
A: INTESTINAL OBSTRUCTION Associated with visible intestinal peristalsis and borborygmi sounds in ileal obstruction
(step ladder paralysis) *
• Definition - • Absolute constipation - No passage of flatus or faeces
Obstruction to (he peristaltic movements of intestine • Vomiting -
• Classification-
 22 QUEST : A Comprehensive Guic'e to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 23

* Early and persistent in jejunal obstruction Mechanism:

* Recurrent (initially bilious, later faeculent) in ileal obstruction
B) Signs - IflTffNSIC PATHWAY EXTRINSIC PATHWAY
• Tachycardia, tachypnoea
Inactive Factor XII Inactive Factor VII
• Fever
Collagen High mol. Wt. Kinlnogen,
• Bowel sounds increased initially, later absent if gangrene sets in I Tissue
• Dehydration -» Renal failure mromboptaslin
• Rebound tenderness if strangulation occurs, along with guarding and rigidity KaKikrein Factor Vila
P/R Exam -> Empty, dilated rectum often with tenderness.
□ Investigations:
• Blood investigations -
Activated Factor XII (Xlla) /
Factor Vila, TTh (tissue
* Complete haemogram (TLC may be increased) ■—► Factor Xla
Inactive Factor XI Tbrontoin
thromboplaatin) PP, Ca2*
* LFT
* KFT
* Serum electrolytes Inactive Factor IX - Factor IXa, PP
* Blood sugar
• Straight X-ray Abdomen - 1See Section 1, Segment C, Paper I, 2016 Inactive Factor VIII Factor Villa, Ca2'
Ttmmbin
• USG - J supplementary, Qs. 5 (Page No. 328)
□ Treatment:
Inactive Factor X
See Section 1, Segment C, Paper 1,2016 supplementary, Qs. 5 (Page No. 328) Factor Xa, Ca2*

Factor Va, PP
Inactive Factor V
Throm bin
2010
Q.1: What are coagulation factors? Write in detail about mechanism o f homeostasis. [5 + 10] Prothrombin ■ -► Thrombin

Fibrin monomer -4r - Fibrinogen

HOMEO STASIS
Polymerisation
Coagulation factors:
Blood coagulation is a complex process involving 13 coagulation factors in a specific cascading sequence Fibrin ftreads form loose, friable meshwork with blood corpuscles
resulting in formation of fibrin meshwork which entangles formed elements of blood and blood clot is
formed.
The factors are -
1. Factor I - Fibrinogen
Inactive Factor XIII ■
Throm bin

i
* - Factor Xllla, Ca2---------------►)

Stable clot

2. Factor II - Prothrombin
3. Factor III - Tissue thromboplastin .
4. Factor IV - Ca2+ Q. 2 : What are the causes o f upper Gl bleed ? How w ill you manage scute varlceal bleeding ?[8 + 7]
5. Factor V - Proaccelerin
6. Factor VI - does not exist UPPER Gl BLEED
7. Factor VII —Proconvertin
8. Factor VIII - Antihaemophilic globulin When the source of bleeding lies above the duodenojejunal flexure, it is referred to as upper G.l. tract
9. Factor IX - Christmas factor bleed
10. Factor X - Stuart - Prower factor
11. Factor XI - Plasma thromboplastin antecedent
12 Factor XII - Hageman factor
13. Factor XIII - Fibrin stabilising factor
24 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS O Paper-I 25

(d) Clinical examination to check for hepatosplenomegaly, ascites

(e) Cirrhotics to be graded on Child - Pugh score immediately
(f) Ryle's tube passed for aspiration of blood collected in G.l.T, also helps to know if there is any
fresh bleeding •
(g) i.v fluid started
(h) Moist 02 inhalation
(I) In-dwelling catheter to measure urine volume to maintain input-output chart
Ii) Till blood becomes available, plasma volume expanders used. Then blood transfusion when
btood is available ------ - * ------- "
(k) Inj Vit K 10 mg i.m twice daily for 2 days - » if no improvement in Prothrombin time -» FFP
(I) Platelet transfusion if possible
(m) Dopamine/ Dobutamine 2ug/kg/day may be used to restore BP
(n) H2 receptor antagonists to prevent stress ulcer
(0) In cirrhotics with hepatic encephalopathy - Lactulose 30 ml 8 hourly + Neomycin 1g 6 hourly
(p) If ascites - Spironolactone -> not improve - » Furosemide - » not improve - » combination -» not
improve -> Ameloride/ Bumetanide
If refractory ascites, careful paracentesis and salt-free albumin infusion
(q) Antibiotics to prevent spontaneous bacterial peritonitis ••••
(r) Monitoring of vital signs, fluid and electrolyte balance, input-output chart
(s) When patient becomes stable, upper Gl endoscopy is done to look for the cause - confirm the
oesophageal varices as the cause. - •

(B) Reduction of portal venous pressure :

Any one of the following is used -
4&) Vasopressin - 20 units in 100m! of 5% dextrose i.v over 10 mins, repeated if necessary 3-4 times
at hourly intervals
(b) Terlipressin - 2mg i.v 6 hourly till bleeding stops -> 1mg 6 hourly for further 24 hours
(c) Somatostatin and its synthetic analogue Octreotide - 50ug bolus dose -> 50ug in 24 hour

(C) Local measures:

(a) Balloon tamponade -
1. Using Sengstaken Blakemore tube - with 3 lumens
2. Using Minnesota tube - with 4 lumens
These tubes have 2 balloons, oesophageal and gastric. Tube introduced into tl\e Stomach
preferably through the mouth -» gastric balloon inflated and pulled back into cardia of stom­
ach -> still bleeding does not stop -» oesophageal balloon inflated

MANAGEMENT OF ACUTE VARICEAL BLEEDING (b) Endoscopic procedures -

1. Endoscopic sclerotherapy - 5cc Ethanolamine oleate injected into the varices
>} General measures : 2. Endoscopic variceal band ligation (EVBL)
(a) Immediate hospitalisation (D) Surgical m easures:
(b) Blood sample drawn for investigations _
J e) Transjugular intrahepatic portosystemic shunt (TIPSS)
(c) Quick history taken to assume the cause - (b) Portosystemic shunting and Oesophageal staple transection
1. H/O peptic ulcer symptoms, anti ulcer drug, endoscopy
2. Intake of alcohol, drugs causing bleeding (E) Prevention of recurrent bleeding (secondary prophylaxis):
3. H/O cirrhosis (a) Medical treatment - Beta-blockers + Nitrates

A
 26 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 27

(b) Endoscopic sclerotherapy - sclerosants like Ethanolamine oleate, Sodium morrhuate, Sodium
MANAGEMENT OF CA HEAD OF PANCREAS ,
tetradecyl sulphate 2 ml per varix every 2 weekly
(c) Endoscopic varicea! band ligation
Diagnosis:
(d) Transjugular intrahepatic portosystemic shunt - done if patient can afford liver transplantation as
it may result in hepatic encephalopathy (A) H istory:
(e) Porto-systemic shunt surgery - (a) Painless progressive yellowish discolouration of eyes and urine .
1. Non-seleclive shunts which decompress the entire portal venous system - (b) Intense pruritus
(i) End to end portocaval shunt (c) Clay coloured stool ,
(ii) Side to side portocaval shunt (d) Weight loss, anorexia, reduced appetite
(iii) Proximal splenorenal anastomosis (6) Clinical examination:
(iv) Mesocaval shunt (a) General survey -
2. Selective shunts which decompress only the varices 1. Pallor
Failure of above require liver transplantation which is the definitive treatment 2. Jaundice • _
3. Virchow's lymph node may be enlarged (Troissier's sign) .
0 . 3 : What are the causes o f obstructive Jaundice ? Write the management o f CA head o f pancreas. 4. Migratory superficial thrombophlebitis (Trousseau's sign).
. [5 + 10] (b) Abdominal examination -
1. Enlarged palpable liver (due to hydrohepatosis)
OBSTRUCTIVE JAUNDICE 2. A soft, non-tender,, smooth, globular, intraabdominal lump palpable in right hypochondriac
and right lumbar region, moving up and down with respiration, whose lateral, medial and
lower margins are well palpable.
Biliary atresia^
(C) Investigations: '
, □ Routine - (i) Hb - reduced in CA, TB (ii) TLC raised in infection (iii) ESR increased in TB, infection
(iv) Blood urea, Serum creatinine (v) Blood sugar (vi) Chest X-ray (vif) ECG
□ Special -
(a) LFT-
1. Increased total bilirubin
2. Conjugated bilirubin raised
3. ALP, GGT highly raised
4. AST, ALT raised
5. albumin : globulin ratio normal or may be altered with reduced albumin .
(b) Prolonged prothrombin time
(c) USG abdomen
f CAUSES OF ^ (d) ERCP - .
OBSTRUCTIVE
1. ‘Double duct' sign in CA head of pancreas
JAUNDICE
V J 2. Abrupt block of pancreatic duct with irregular stricture ;
3. Parenchymal flying . - *
4. Scrambled egg appearance
(e) Barium meal - 'Pad' sign in CA head of pancreas ;
(0 MRCP
(g) CT Scan
(h) CA 19-9 raised
(i) PET
(i) Endosonography and EUS guided biopsy
Klatskin Tumor J
(k) Urine tests - (i) Fouchet's test (for bile pigments)
(ii) Hay's test (for bile salts)
(iii) Ehrlich's test (for urobilinogen)
(I) Coeliac and superior mesenteric angiogram
 28 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 29

Pre-operative preparation: post-operative management:

Pre-operative preparation lor obstructive jaundice - • 1. Maintenance of proper fluid and electrolyte balance *
(a) Immediate hospitalisation - 2 Observation for bleeding; controlled by blood transfusion, FFP
(b) Diet - high carbohydrate, low protein, no fat diet alopg with vitamin and calcium supplements 3. Inj Vit K 10mg i.m for 5 days * *
(c) Adequate hydration with oral and intravenous fluid 4. Mannitol 200ml after surgery.
(d) i.v mannitol - 10% 200ml before, during or-after surgery or Inj Furosemide - 40mg i.v 5. inj Octreotide infusion for 5 days
(e) Inj Dopamine 2 ug/kg/miri- ' • • ' ■ • - 6. Antibiotics
(I) Inj Vitamin K 10mg for 3days to correct prothrombin time - » if still no improvement, fresh frozen 7. Nasogastric aspiration
plasma is used 8. Respiratory care
(g) Blood transfusion if severe anaemia 9. Monitoring of vitals
(h) Broad spectrum antibiotics / Pain control:
(i) If pre-operative bilirubin >10mg%, ERCP stenting or PTBD done, else MRCP done 1. CT guided 50% of 20 ml ethanol injection into celiac ganglion
Treatment: 2. Epidural Anesthesia
3. Opioids • .
(a) Operable cases- 4. Transthoracic splanchnicectomy
Whipple's operation 5. Palliative radiotherapy
(i) Following removed - (pain is caused due to retropancreatic nerve involvement and pancreatic duct obstruction caus­
1. Tumor ing stasis in the gland)
2. Head and neck of pancreas
3. C-loop of duodenum 2010 Supplementary
4. 40% of distal stomach
5. 10% of proximal jejunum O . l: Define claudication. What are the grades o f claudication? How w ill you manage a case o f
6. Lower end of CBD Buergers disease with dry gangrene o f foot? [2 + 4 * 9 ]
7. Gall bladder
A : See Section 1, Segment B, Paper-1, Qs. 4 (Page 224) and Qs. 5 (Page 226).
8. Lymph nodes -
• Peripancreatic Q ^B n u m e ra te the differential diagnosis o f painless fresh bleeding per rectum. Plan the Investigation
• Pericholedochal and treatment o f carcinoma o f sigmoid colon. [3 + 5 + 7 ]
• Paraduodenal
A : Differential diagnosis - See Section 1, Segment A, Paper I, Qs. 2. (Page 7) - All causes except
• Perihepatic
Anal Fissure.
(il) Continuity maintained by -
1. Choledochojejunoslomy CARCINOMA OF SIGMOID COLON
2. Pancreaticojejunostomy
3. Gastrojejunostomy, Q Clinical features:
(iii) Types - • More common in males
^ 1. Original Whipple's operation was 2-staged procedure - initial bypass and a 2nd stage resection
• Generalised features - Anorexia, Weight loss, Pallor, Cachectic look.
with closure of pancreatic slump
2. Trimble’s 1-staged procedure- ' • Colicky abdominal pain
3. Traverso - Longmire pylorus preserving pancreaticoduodenectomy • Altered bowel habits (alternating constipation and diarrhoea)
^ 4, Fortner’s regional pancreatectomy (extended Whipple’s) • Abdominal distension sometimes, due to obstruction
5. Total pancreatectomy
• Tenesmus
(b) Inoperable cases - . * *
• Passage of blood and mucus per rectum
(i) Roux-en-Y choledochojejunoslomy + gastrojejunostomy + cholecystectomy
• If metastasis occurs - liver enlarged, hard
(ii) ERCP + stent
- palpable left supraclavicular lymph nodes.
(iii) Chemotherapy - Gemcitabine
(iv) Immunotherapy □ Investigations:
(v) Radioactive iodine is on trial Routine blood investigations
(c) Other types of neoplasms in head of pancreas - - Complete hemogram with ESR
(i) Large neoplastic cyst in head of pancreas - Cystoduodenostomy - LFT
(ii) Cysladenocarcmoma of pancreas - Distal/ central/ total pancreatectomy - depending on extent
- KFT
and size of Tumor
30 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- I 31

- Blood sugar - Irinotecan

- Serum electrolytes
• Radiotherapy - No role
CEA (Carcino-Embiyogenic Antigen)
• Immunotherapy -
/ * - Level > 5 ng/ml is significant > Bevacizumab (VEGF)
- Preoperative level > 7.5 ng/ml indicates poor prognosis
> Cetuximab (EGFR)
Barium enema - “ Apple core lesion"
* • Secondary mets - Liver mets can be resected (There is role of metastatectomy in colorectal
Colonoscopy and biopsy - confirms diagnosis carcinoma)
Virtual colonoscopy is a recently developed useful investigation to visualise entire colon. • Follow-up-CEA levels are assessed.
USG Abdomen - to detect secondaries in liver, lymph node, etc
Q.3: How w ill you evaluate, grade and manage a case o f blunt splenic trauma ? [3 + 4 + 8]
CT Scan Abdomen - to see local spread, determine stage, nodal status and liver secondaries
FNAC of palpable left supraclavicular lymph nodes.
Ans : BLUNT SPLENIC TRAUMA
□ Treatment:
/ • preparation for large bowel surgery - See Section 1, Segment D, Qs. 46 (Page No. 505) ATLS guideline to be followed.
Antibiotic prophylaxis (Metronidaole + Cefoxitin / Ceftriazone / Profloxacin) - to be started 1• 'ABCDE' steps to be done, for evaluation and management
2 hours before incision. □ Grading:
/ • Pulmonary function tests and pulmonary exercise pre and post operatively ' “ Splenic Organ Injury Scale" -
Urinary catheterisation- Grade J: Non expanding subcapsular haemaloma < 10% surface area. Non-bleeding capsular
• Mesogastric tube placement laceration with < 1 cm depth
•- Surgery . G raded: Non expanding subcapsular haematoma 10-50% surface area. Non expanding
(a) Position - Supine or modified lithotomy position. intraparenchymal haematoma < 2 cm
(b) Incision - Midline s" Grade i l l : Expanding subcapsular or intraparenchymal haematoma. Bleeding subcapsular
(c) Procedure - haematoma or subcapsular haematoma > 50% area or intraparenchymal haematoma
> 2 cm or parenchymal laceration > 3 cm depth .
Abdomen explored systematically after peritoneal cavity is entered
Grade IV : Ruptured Intraparenchymal haematoma with active bleed; laceration involving
" 4.
segmental or hilar vessels with > 25% devascularisation
Special attention given to liver, peritoneum to evaluate distant metastasis
Grade V : Shattered or avulsed spleen; hilar disconnection with entire spleen devascularisation.
I ■ .
□ Evaluation:
Duke's staging followed
• Detailed history about injury - mode, time, place
(d) Resection - Rectosigmoid resection preferred.
• History about medical or surgical conditions of patients, any coagulation disorder or previous
Left radical hemicolectomy done (left Vi of transverse colon and descending trauma
colon removed along with lymph nodes) or sigmoidectomy done if localised
• Patient will be having following clinical features
tumour.
> Features of shock (pallor, tachycardia, hypotension)
(e) Safety margin - 5 cm
> Pain in upper abdomen
(f) Reconstruction/diversion - Bowel ends may be reanastomosed or proximal ends may
> Abdominal distension due to haemoperitoneum
be brought out as colostomy
> Dullness in left flank which does not shift due to clotting of the collected blood
(g) Drains - placement is optional
(Ballance’s sign)
• Chemotherapy -
> Referred pain in left shoulder due to irritation of phrenic nerve and left side of
> FOLFOX Regimen - diaphragm by the collected clot (Kefir's sign) .
- Folinto arid > Delayed presentation because of formation of subcapsular haematoma which later
- 5-Fluorouracil gives way. (The interval is called 'latent period of Bander)
- Oxiplatin > Muscle guard, rigidity if peritonitis occurs
> FOLFRI Regimen > Grey Turner’s sign (blackish discolouration over flanks)
- Folinic acid > Cullen’s sign (blackish discolouration over umbilicus)
- 5-Fluorouraci! > Saegesser's tender point between left sternocleidomastoid and scalenus medius,
32 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS O Paper-I 33

□ investigations: > Bag-mask ventilation may be given

• Blood Investigations r Moist oxygen inhalation
> Complete hemogram > Mechanical ventilation if endotracheal tube inserted.
> Grouping and cross matching D - Nervous system dysfunction to be assessed
V LFT E - Proper exposure and evaluation of other injuries along with eliciting history
> KFT B) Specific measures -
> BT,CT,CRT I) Non-operative measures - (done in Grade I, II, til injuries)
> PT.aPTT • Close observation clinically
> Blood sugar • Absolute bed rest
> Serum electrolytes • Sedation
• X-ray abdomen - • Serial CT Abdomen / USG Abdomen
> Obliteration of splenic outline
• Vitals and I/O charting
> Obliteration of psoas shadow
• Angiographic embolisation sometimes
> Indentation of fundic gas shadow
II) Operative measures - (done in Grade IV, V injuries)
> Elevation of left side of diaphragm
• Splenorraphy - done in clean incised wound, where spleen is spleen is salvaged by
> Fracture of left lower ribs suturing wound with placement of gel foam, absorbable mesh wrap over the wound,
> Free fluid in abdomen (done in Grade I, II, III injuries of haemodynamically unstable patient)
. USG Abdomen I FAST - investigation of choice in unstable patients • Partial splenectomy
-1 CT Scan Abdomen - investigation of choice In stable patient • Emergency splenectomy
• Diagnostic peritoneal lavage - significant if aspirated fluid contains [Post-splenectomy pneumococcal vaccine, meningococcal vaccine and influenza vaccine
> Gross blood > 10 ml are administered to prevent OPSI]
> RBC > 100,000/mm3
> WBC > 500/mm3
> Amylase >175 units/dl 2011
> Bile/bacteria/food fibres .' Q.1: A 45 year old female patient presents with acute upper abdominal pain. Discuss the differential
□ Management: diagnosis and management [7 + 8 ]

A) General measures -
ACUTE UPPER ABD O M IN AL PAIN
C - Circulation to be ascertained
> 2 16G cannula to be inserted Differential diagnosis -
> i.v. fluid to be administered (A) Surgical causes:
> blood to be drawn while inserting cannula 1. Biliary - (a) Acute cholecystitis (b) Acute cholangitis
> cenlral venous line if required 2. Stomach - (a) Acute peptic ulcer (b) Peptic ulcer perforation
> blood to be transfused when arranged 3. Pancreas - Acute pancreatitis
> urinary catheterisation 4. Liver - Liver abscess
5. Intestine - Acute intestinal obstruction
> input-output chart to be maintained
(B) Non - surgical causes:
A - Airway to be ascertained
> sucking of blood/secretions/foreign body by 'two finger’ sweep and suction under 1. Heart - Acute myocardial infarction
vision. 2. Lung - (a) Basal pneumonia (b) Empyema thoracis
3. Sickle cell disease
> Chin-lift and jaw-thrust manouvre to prevent tongue fall back
4. Acute intermittent porphyria
> Endotracheal intubation /Cricothyrotomy/Emergency tracheostomy may be required 5. Diabetes mellitus
sometimes. 6. Due to epilepsy
B - Breathing to be ascertained Management -
> Rate of respiration to be checked after proper exposure (a) History:
34 QUEST : A Comorehensive Guide to UG Surgery. Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 35
---- ■

• P ain- 6. USG abdomen -

(i) Sudden onset, colicky pain in the right upper abdomen, often radiating to the right shoulder (i) Presence of gallstone (acoustic shadow), thickened GB wall, pus in lumen, pericholecystic
- Acute cholecystitis . collection - Acute cholecystitis
(ii) Sudden onset pain almost in midline in upper abdomen - Acute peptic ulcer (ii) Edematous pancreas, peripancreatic fluid collection - Acute pancreatitis
(iii) Sudden onset severe pain in mid upper abdomen then moving towards right side of (iii) Dilated bowel and fluid - Acute intestinal obstruction
abdomen, then becoming generalised - Peptic ulcer perforation
7. CT Scan abdomen - if suspected Acute pancreatitis
(iv) Sudden onset, slabbing, upper abdominal pain, radiating to the flanks and back and
relieved on leaning forward (Mohameddan prayer position) - Acute pancreatitis 8. Peritoneal tap - if suspected Acute pancreatitis, Peptic perforation
(v) Sudden onset pain, initially severe colicky, later continuous severe pain - Acute intestinal 9. Upper Gl endoscopy(if not available then Barium meal X-ray - Acute peptic ulcer
obstruction
10. ECG - ST elevation, Pathological Q wave in Acute myocardial “ infarction”
(vi) Sudden onset retrosternal oppressive/ crushing pain - Acute myocardial infarction
• Associated features - Management:
(i) Nausea, vomit, fever - Acute cholecyslitip □ ACUTE CHOLECYSTITIS
(ii) Hematemesis, vomit - Acute peptic ulcer
Conservative treatment followed by elective cholecystectomy at interval of 8-10 weeks. Conservative
(iii)Fever, vomit, dehydration, oliguria, shock - Peptic ulcer perforation
treatment consists o f : *
(iv) Nausea, persistent vomit, retching - Acute pancreatitis
(v) Vomit, abdominal distension, absolute constipation, dehydration - Acute intestinal (a) Hospitalisation
obstruction (b) Nothing per mouth
(vi) Severe sweating, no relief by rest or aspirin - Acute myocardial infarction (c) Nasogastric aspiration for 3-5 days
• History of peptic ulcer disease (dyspepsia,belching, etc.), alcohol intake, similar attack (d) Intravenous fluid initially, later soft fat free diet
in past (e) Analgesic, antispasmodic
({) Broad spectrum antibiotic
' (b) Clinical examination :
(g) Observation and regular follow up using USG
• General survey:
Features of shock - Acute pancreatitis. Peptic ulcer perforation, Acute intestinal obstruction □ ACUTE PEPTIC ULCER
• Abdominal examination : (a) Control of hematemesis
(i) Tenderness, Murphy's sign positive, Boas' sign positive - Acute cholecystitis (b) H2 blockers or PPI
(ii) Tenderness - Acute peptic ulcer • □ PEPTIC PERFORATION
(ili) Tenderness, rebound tenderness (Blumberg's sign), card-board rigidity, later abdominal
distension, dullness over flanks, obliterated liver dullness, absent bowel sounds - Peptic (a) Hospitalisation •
ulcer perforation (b) Nothing per mouth
(iv) Tenderness, Grey Turner's sign positive, Cullen's sign positive, Fox sign positive - Acute (c) Nasogastric aspiration for 3-5 days , .
pancreatitis (d) Intravenous fluid initially, later soft fat free diet
(v) Tenderness, rebound tenderness, initially high pitched metallic sounds, later silent (e) Catherisation * * .
abdomen - Acute intestinal obstruction (0 Broad spectrum Antibiotic
(c) Investigations: (g) Emergency laparotomy followed by closure with omental patch

1. Complete Hemogram - Raised TLC in Acute cholecystitis, Acute pancreatitis * Manheim peritonitis index or APACHE II scoring system used to assess patient properly
2. Serum amylase, lipase, LOH raised in Acute pancreatitis □ ACUTE PANCREATITIS
3. LFT (a) Hospitalisation
4. Chest skiagram(PA view) - (b) Nothing per mouth
(i) To rule out basal pneumonia • (c) CVP line f
(ii) Free gas under right dome of diaphragm - Peptic perforation, or any hollow viscus (d) Total parenteral nutrition _
perforation (e) Intravenous fluid .
5. Skiagram abdomen (AP view) - (f) Fresh frozen plasrria '
(i) 10% gallstones are radioopaque - Acute cholecystitis * (g) Nasogastric aspiration
(ii) Sentinel loop, colon cut sign, obliteration of psoas shadow - Acute pancreatitis ' . (h) Catheterisation
(iii) Multiple air fluid levels (> 3) - Acute intestinal obstruction {>) Electrolyte management with monitor
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 37
36 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

n 2 • Enumerate causes o f intestinal obstruction in Infants. Write clinical features, Investigations

(j) Hemodialysis if required and management o f intussusceptions In 7years old child. [3 + 4 + 3 + 5 ]
_^(k) Pethidine to relieve pain
-^(1) Broad spectrum antibiotics
^ (m) Proton pump inhibitor to relieve stress ulcer
INTESTINAL OBSTRUCTION
(n) Calcium gluconate - 10% 10 ml/kg i.v 8 hourly
^ io ) Somatostatin/Octreotide to reduce pancreatic secretion Causes of intestinal obstruction in in fa nts:
(p) Protease inhibitor/ Acetylcholine/ Calcitonin 1. Hirschsprung's disease
(q) Steroids 2. Meconium ileus * . -
(r) Nebulisation, Bronchodilator 3. Meconium plug syndrome •
4. Intussusceptions (most common cause in children)
Q ACUTE INTESTINAL OBSTRUCTION
5 . Ileal/colonic atresia/stenosis (duodenal atresia is most common cause in neonates)
(a) Immediate hospitalisation 6. Neonatal small left colon syndrome
(b) Nasogastric aspiration - decompression of small bowel by Miller Abbott's tube or Cantor tube
(c) Intravenous fluid INTUSSUSCEPTION
(d) Broad spectrum antibiotics
Define:
(e) Fresh frozen plasma • '
Acute intestinal obstruction where telescoping or invagination of one segment of bowel into adjacent
<0 CVP
segment occurs (mostly occurring due to hypertrophy of Foyer's patches in ileum)
<g) PCWP
(h) Dopamine/ dobutamine if severe hypotension Clinical features:
(i) Emergency laparotomy ' (A) Symptoms -
History of child crying intermittently (during an episode of acute attack) and sleeps peacefully
once it gets reduced
Caecum identified
1. Sudden onset severe colicky abdominal pain
/ \ 2. Vomiting
Caecum collapsed Caecum distended 3. Abdominal distension
4. Absolute constipation
5. Passage of red currant jelly stool
Small intestinal obstruction Large intestinal obstruction (B) Signs -
1. Tenderness
\ / 2. Abdominal distension
A junction between the distended and collapsed part is reached 3. On palpation, a sausage shaped, smooth, firm, resonant lump palpable with concavity looking
towards umbilicus, which does not move with respiration, is mobile in all directions, contracts
I under palpating fingers, appears and disappears
This is the site of obstruction 4. Emptiness in right Iliac fossa (sign^fc-dance)
5. Step ladder peristalsis
I Investigations:
Obstruction relieved
1. Routine investigations - Hb, TLC, ESR, Chest X-ray, ECG
2. Straight X-ray abdomen -
I (a) Distended intestinal shadow
Viability ol gut checked
(b) Multiple air fluid levels
/ \ (c) Target sign - soft tissue mass with concentric area of luscency due to mesenteric fat
Viable Not viable (d) Meniscus sign - crescent of gas within colonic lumen that outlines apex of intussuscep­
tions
I I 3. Barium enema -
Gut kept inside, abdomen closed Resection and anastomosis
(a) Claw sign - rounded apex of intussusceptions protrudes into contrast column
I (b) Coiled spring sign (Pincer sign) - Edematous mucosal folds of returning limb outlined by
Abdomen closed after peritoneal wash contrast material
 38 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 39

4. USG abdomen - g History to be taken-

(a) Target sign • Details about lump - onset
(b) Pseudokidney sign - progress
(c) Buff's eye sign
- rapid increase in size
Treatment : • Details about associated features
1. Conservative - - pain abdomen -1
(a) Immediate hospitalisation jever I (appendicular abscess)
(b) Nasogastric aspiration - decompression of small bowel by Miller Abbott’s tube or Cantor - altered bowel habits ~i
tube - weightless J(carcinoma caecum)
(c) Intravenous fluid
(d) Broad spectrum antibiotics - dysentery (amoeboma)
(e) Fresh frozen plasma - paraspinal muscle spasm (psoas abscess)
(0 CVP □ Clinical examination - Nature of mass in right iliac fossa
(g) PCWP
• Smooth, lender, non-mobile mass, does not move with respiration, well-localised with distinct
(h) Dopamine/ dobutamine if severe hypotension
borders, resonant on percussion -> Appendicular mass
(i) Reduction by hydrostatic pressure by passing normal saline or barium enema
• Smooth, soft, tender, dull mass with indistinct borders -> Appendicular abscess
Surgical - ' ’ -
< Nodular, hard mass, mobile, resonant or impaired resonance -> .Carcinoma caecum
After laparotomy under GA, intussusception reduced by gently pushing it from apex (NEVER
• Smooth, hard, resonant, non-tender, does not move with respiration, restricted mobility -»
PULL). Then viability checked
lleocaecal TB
"Signs of nonliability : . • Smooth, soft, non-mobile, localised mass, with associated tenderness, gibbus in spine -»
(a) Blackish in colour -
Psoas abscess.
(b) Lustreless
(c) No peristaltic movement - □ Investigations -
(d) No bleeding on needle prick • Blood investigations
(e) No pulsation of mesenteric artery - Hb, Platelet
If viable -* gut kept inside and abdomen closed - TLC
If non-viable hot mop applied + 100% O2 -» still no improvement resection and - DLC *
anastomosis ~ *----------- " -------— 1 —
- ESR
- LFT
2011 Supplementary
- Serum electrolytes
0 .1: Define shock. What are Its different types ? Outline the management o f a patient presenting - Blood sugar
with features o f septic shock. [2 + 4 + 9] - Mantoux test
• USG Abdomen - to ascertain nature of lump
A; SHOCK
• CT Abdomen - to evaluate retroperitoneal mass
□ Definition - See Section 1, Segment A, Paper-1,2008, Qs. 1 , Page No. 3 • Colonoscopy - to rule out carcinoma caecum
□ Types - See Section 1, Segment A, Paper-1,2008, Qs. 1, Page No. 3 • IVU - to rule out renal lesions

□ Septic shock - See Section 1, Segment A, Paper-1,2014, Qs. 1, Page No. 68 □ Management -
• Appendicular lump - See Section 1, Segment A, 2013supplementary, Qs. 2, Page No. 64
Q.2: Describe the clinical features, investigations and management o f acute pancreatitis.
• Appendicular abscess - Incision and drainage of abscess cavity under general anaesthesia,
[S + S + S] followed by interval appendicectomy after 3 months.
A : See Section 1, Segment B, Paper-1, Qs. 10 (Page No. 247)
• Amebiasis - Medical management
0 .3 : What are the causes o f lump In R.I.Fin a male patient o f 40 year old? How do you investigate and • lleocaecal TB
manage such a patient? [S + S + S] - Antitubercular drug
- Surgery (limited ileocaecal resection / stricturopasty) if severe haemorrhage,
A: LUM P IN RIGHT ILIAC FOSSA IN M ALE
presentation of acute abdomen, intestinal obstruction
□ Causes - See Section 1 , Segment A, Paper-1, 2013 supplementary, Qs. 2, Page No- 63 (except • Psoas abscess - Incision and drainage under GA (only lateral approach advised)
Ovarian disease and Twisted ovarian cyst) • Carcinoma caecum - Right radical hemicolectomy after proper bowel preparation.
 40 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 41

2012 (B) SIGNS:

0. 1: W h a t a re the types o f Hemorrhage ? What are the methods o f determining acute blood loss ? (a) Mild shock -
How w ill you treat Hemorrhage? [3 + 6 + 6] (i) Superficial veins collapse making insertion of infusion needle difficult
(b) Moderate shock -
HEMORRHAGE
(i) Oliguria
Types of Hemorrhage:
(ii) Hypotension
(A) Based on visibility : (iii) Tachycardia
(a) External - bleeding that is revealed (c) Severe shock -
e.g. incised wound, lacerated wound (i) Rapid pulse
(b) Internal - bleeding that is concealed (ii) Low BP
e.g. liver injury, spleen injury (iii) Anuria
(c) Initially concealed, later revealed (iv) Unconsciousness
e.g. hematemesis, melaena
Signs of significant blood lo s s :
(B) Based on so u rce :
1. Pulse > 100/min
(a) Arterial - bright red, spurting like jet 2. SBP < 100 mm Hg
(b) Venous - dark red, steady and continuous 3. DBP drop on sitting or standing > 10 mm Hg
(c) Capillary - bright red, rapid
4. Pallor/ sweating
(C) Based on duration : - 5. Shock Index (pulse rate : BP) > 1
(a) Acute - sudden, severe
(C) MEASUREMENT OF BLOOD LOSS:
e.g. after trauma, surgery
(a) Clot size of a clenched fist = 500 ml
(b) Chronic - bleeding occurring for prolonged period
e.g. hemorrhoids, bleeding peptic ulcer (b) Blood loss in closed tibial fracture= 500 - 1500 ml, in fracture femur = 500 - 2000 ml
(c) Weighing the swab before and after use
(c) Acute on chronic - sudden onset severe bleeding occurring in people who are already anaemic
Rains factor: .
(0) Based on onset :
Total amount of blood loss = Total difference in swab weighf1.5(for smaller wounds)
(a) Primary - bleeding at time of surgery or injury Total amount of blood loss = Total difference In swab weighC2(for larger wounds)
(b) Secondary - bleeding occurring within 24 hours of surgery or injury (d) Hb% and PCV estimation - normal in acute blood loss
Cause is mostly slipping of ligature (e) Blood volume estimation using radioiodine technique or microhaematocrit method
(c) Tertiary - bleeding occurring in 7-14 days after surgery (f) Measurement of CVP or PCWP
Cause is mostly infection (g) investigations specific for cause:
(E) Based on possible Intervention: (i) USG abdomen
(ii) FAST
(a) Surgical - can be corrected by surgical intervention
(b) Non-surgical - cannot be corrected by surgical measures, mainly due to bleeding diathesis (iii) Diagnostic peritoneal lavage
(iv) Doppler and angiogram
Methods of determining acute blood lo s s ; (v) CT Scan
(A) SYMPTOMS:
Treatment of Hemorrhage:
(a) Mild shock- { < 20% blood loss)
(A) Stop blood lo ss:
(i) Pale cold clammy extremities
(ii) Thirst 1. Rest-
(b) Moderate shock - (20-40% blood loss) (i) Absolute rest
(i) Reduced urine output (< 0.5 ml/kg/hr) (ii) Pethidine may be used
(iii) Position of patient -
(c) Severe shock - (> 40% blood loss)
(i) Restlessness, anxiousness giving way to apathy, exhaustion (3> ! S r ha9e fr° m ,hyr0'deCt0my ~ head end of bed raised (reverse Trendelsnburg posi-

(b) Hemorrhage from varicose veins - loot end of bed raised (Trendelenburg position)
 42 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVEQ LONG QUESTIONS OF FINAL MBBS □ Paper-I 43

2. Pressure and packing from outside -

(c) Dermoid cyst
Sterile pieces of gauge and bandage are generally used for external compression
(d) Fibrocystic disease (mucoviscidosis)
f 3. Operative methods - (B) Acquired -
(i) Bleeding vessels during operation - (a) Retention cyst
C • Haemostatic forceps are applied to the bleeding vessels. Then the vessel is ligated. (b) Parasitic cyst -
• Smallest vessels can be coagulated using diathermy (i) Hydatid cyst
( • Larger vessels - transfixation suture used with silk (ii) Amoebic cyst
(ii) Hemorrhage in the form of oozing - (iii) Cysticercosis
• Oxycel or gelatine sponge (c) Neoplastic cyst -
• Gauge soaked in adrenaline solution (i) Cystadenoma - * Serous * Mucinous
f • Bone wax in case of oozing from bone (ii) Cystadenocarcinoma
(iii) Cystic teratoma
(iii) Bleeding vessel cannot be detected -
(iv) Secondary cavitation of solid Tumor
r Rolls of gauge used to pack the wound - * after 5 min, gauge pack removed - » slight bleeding- (v) Cystic islet cell Tumor
from spurting vessel identified -> vessel held by haemostat forceps - » vessel ligated
2. Simple cyst of liver
,- (iv) Profuse bleeding from rupture of solid viscus -
3. Hydatid cyst of liver
Whole or part of the viscus should be excised
4. Mesenteric cyst
(B) Restoration of blood volume:
5. Retroperitoneal cyst
(i) For chronic Hemorrhage - packed cells are used 6. Aortic aneurysm
(ii) For acute Hemorrhage- '
Blood sample sent for grouping and cross-matching -» by the time the report is received, History:
' infusion of crystalloid -» when blood becomes available, blood transfused
(a) Patient will give a history of sudden onset severe pain in central part of upper abdomen, radiating to
□ Haemostasis during laparoscopy- flanks and back, relieved slightly on attaining Mohameddan prayer position. Pain was associated
with severe nausea and vomiting. He was completely relieved after receiving i.v fluid and parenteral
1. Electrocoagulation
medication. After about weeks of the attack, patient noticed a small swelling in the central part of
2. Monopolar electrosurgery abdomen which was gradually increasing in size and often associated with dull aching pain - Pancreatic
3. Bipolar electrosurgery pseudocyst
4. Laser coagulation (b) Epigastric discomfort, weight loss, anorexia - Neoplastic cysts
v 5. LigaSure (c) History of painless progressive jaundice along with weight loss, anorexia - Pancreatic CA
6. Enseal vessel fusion Clinical examination:
7. Harmonic scalpel
(a) General survey - Pallor and jaundice in CA
8. Mechanical clips (b) Abdominal examination -
(i) Pseudocyst-
Q .2 : Middle aged patient presented with a big tense cystic lump in upper abdomen following an
attack o f acute abdomen. How would you Investigate and plan the management 7 [8 + 7] 1. Site - epigastric region
2. Movement with respiration • absent/slight
3. Mobility - restricted
BIG TENSE CYSTIC LUMP IN UPPER ABDOMEN
4. Retroperitoneal mass
Differential diagnosis: 5. Margins - lower border well palpable, upper border ill defined
6. Consistency - smooth, soft
Most probable diagnosis of big tense cystic lump in upper abdomen following an attack of acute abdomen
is PANCREATIC PSEUDOCYST. 7. Percussion - resonant
8. Baid test positive
Other differential diagnosis:
(if) Cystadenocarcinoma pancreas -
1. True cysts of pancreas:
1. Site - epigastric region
(A) Congenital-
2. Movement with respiration - absent
(a) Sequestration cyst
3. Mobility - restricted
(b) Enterogenous cyst
4. Retroperitoneal mass
44 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 45

5. Margins - lower border well palpable, upper border ill defined Management:
6. Consistency - soft
1. PSEUDOCYST OF PANCREAS :
7. Percussion - resonant
Indications o l surgery -
(iii) Liver m ass- .
(a) Size >6 cm
1. Site - epigastric region ■
(b) Cyst persisting for > 6 week
2. Movement with respiration - present
3. Margins - upper border not felt, extends to left hypochondriac region (c) Infected cyst
4. Consistency - cystic (d) Multiple
5. Percussion - resonant (e) Due to trauma
(iv) Mesenteric cy s t- (f) Thick wall

1. Site - umbilical region Options for surgery -

2. Movement with respiration - absent (a) Ideal operation if only pseudocyst in lesser sac - Cystogastrostomy (Anterior wall of stomach
3. Margins - well defined incised -> incision on posterior wall of stomach -> capsule of pseudocyst opened -> fluid sucked
4. Consistency - soft out fluid sent for cytology,culture sensitivity.cyst wall biopsy -> cyst cavity washed with normal
5. Fluctuant saline after breaking septae -> posterior wall of stomach sutured along with cyst wall so that
6. Painless contents of cyst wall will now drain into stomach -» anterior wall of stomach closed in layers)
7. Smooth (b) Laparoscopic cystogastrostomy
8. Percussion • band of resonance in front of cyst
(c) If pseudocyst + chronic pancreatitis - Cystogastrostomy + lateral pancreaticojejunostomy
9. Freely mobile in direction perpendicular to mesentery
(d) If pseudocyst in head of pancreas - Cystoduodenostomy
{(1-7)+(8)+(9)= Tillaux’s triad)
(e) If pseudocyst in tail or body of pancreas or pseudocyst extending beyond epigastrium -
(v)' Aortic aneurysm - Cystojejunostomy
1. Site - deep In epigastrium (f) USG guided aspiration in small pseudocysts
2. Movement with respiration - absent
(g) If gross infection/ rupture/ Hemorrhage - Cystogatrostomy + external drainage
3. Mobility - restricted
(h) If infection/ acutely progressing/ patient unfit for surgery or refuses surgery/ pseudocyst in unusual
4. Percussion - resonant
location not fit for internal drainage - Percutaneous drainage
5. Consistency - soft, smooth
6. Pulsatile (expansile) , 2. HYDATID CYST OF PANCREAS :
Investigations: (a) Ideal treatment is enucleation
1. Routine - (a) Hb - reduced in CA, TB (b) TLC raised in infection (c) ESR increased in TB, infection (d) (b) If cyst is large and involves body or tail of pancreas, distal pancreatectomy with splenectomy to be
Blood urea, Serum creatinine (e) Blood sugar (f) Chest X-ray (g) ECG done
2. Special - 3. NEOPLASTIC CYST OF PANCREAS : .
(a) USG abdomen - • (a) Large cyst in head of pancreas - Cystoduodenostomy
(i) Liver mass - hyperechogenic mass, mosaic pattern with thin halo and lateral shadows
(b) Large cyst in body of pancreas - Cystogastrostomy
(ii) Hydatid cyst - rosettes of daughter cysts, double contoured cyst membrane, cyst wall calcifi­
(c) Large cyst in tail of pancreas - Distal pancreatectomy
cation
(iii) Pseudocyst - size and thickness 4. CYSTADENOCARCINOMA OF PANCREAS :
(iv) Mesenteric cyst detected Distal/ central/ total pancreatectomy - depending on extent and size of Tumor
(v) To see spread in ovary and other organs
(b) CT abdomen - CECT useful in hepatic mass, pseudocyst pancreas. Cart wheel appearance in 5. HYDATID CYST OF UVEH :
hydatid cyst. Spiral CT shows portal vein infiltration, retroperitoneal lymph node, size of Tumor. (a) Medical - Albendazole/ Praziquantel/ Mebendazole
Mesenteric cyst detected (b) Surgical -
(c) LFT. P T -altered in hepatic mass, pancreatic CA
(performed after albendazole used for 21 days -» gap of 21 days - for 3 cycles)
(d) Tumor markers-
(i) Peritoneal cavity packed with mops soaked in scolicidal agents -> fluid from cyst aspirated
CA 19-9: CA pancreas -» scolicidal agents injected -» wait for 10 mins -> excision of hydatid cysl using natural
(e) ERCP with pancreatic juice cytology or brush biopsy cleavage plane between endocyst and pericyst
(f) MRCP - to see biliary tree (ii) Laparoscopic pericystectomy
(g) Coeliac and superior mesenteric angiogram (iii) PAIR (Puncture - Aspiration - Injection - Reaspiration)
(h) MRI abdomen
 46 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS O P a p e r-I 47

6. MESENTERIC CYST;
) Laparoscopic choledocholithotomy [ O r o t a L f y il u } o y r \ y
(a) Cholelymphatic cyst -» enucleation ' J f r . Open choledocholithotomy often with open choledochojejunostomy
(b) Enterogenous cyst -> removal of cyst with resection of adjacent segment of bowel

7. AORTIC ANEURYSM : 2012 S u p p le m e n ta ry

If aneurysm > 5.5 cm. then surgery is the treatment of choice -
(a) Open surgical aneurysm repair using PTFE or Dacron graft
(b) Endoluminal stent graft procedure using interventional radiology with Seldinger's technique [2 + 6 + 7 ]
(c) Massive blood transfusion and emergency surgery if ruptured aneurysm
A : Definition - See Section 1, Segment A, Paper-1,2008, Qs. 1, Page No. 3
0 .3 : What are the causes o f benign biliary strictures? Discuss the management o f retained stones Septic s h o c k - See Section 1, Segment A, Paper-1,2014, Qs. 1, Page No 68
In common bile duct. [5 + 10]

BILIARY STRICTURE
16 + 9]
Causes of benign biliary strictu re : A: LUMP IN LEFT fLIAC FOSSA
1. Traumatic - The probable causes ara -
During cholecystectomy or bile duct surgery, the following may lead to stricture :
» Carcinoma sigmoid or descending colon
When cystic artery bleeds, haemostat may be blindJy applied to the common hepatic duct causing • Psoas abscess
_injury and stricture • Ectopic kidney
(b) In fundus-first operation, excessive pull to the gall bladder may lead to clamping of both common • Undescended testis
hepatic and common bile duct • Lymph node mass
Ignorance of anomalies of bile duct and cystic duct
(d) Distal bile duct injury caused by dilators used for exploration of stones or to dilate sphincter of
• Oddi •
For details, See Section 1, Segment A, 2010 supplementary, Qs. 2, Page No 29
(e) Rarely after partial gastrectomy, liver surgery, duodenal and pancreatic surgery
2. Inflammatory -
Due to accumulation of bile around the common bile duct when cystic duct is not properly ligated 1*5]
during cholecystectomy
: IRREDUCIBLE INGUINAL HERNIA
(b) Ignored cholecystohepatic duct
ic) Sclerosing cholangitis
Recurrent CBD stones
S S E S & N" “ " ' v *” s“SMi0“ “ B* * "
Parasites - Ascaris lumbricoides, Clonorchis sinensis O Clinical features -
3. Fibrosis o f sphincter o f Oddi
• Swelling in groin which is better seen during straining, coughing and standing

MANAGEMENT OF RETAINED STONES IN COMMON BILE DUCT

.■ i s z ix s r p a i n o v e r p r e 'e x i s , i n g hernia’ which ,a,er becomes 9eneraiised
• Absolute constipation
Management of retained CBD stones i.e. detected within 2 years o f choledocholithotomy: • Distension of abdomen
/ (a) Small stones may spontaneously pass down • Features of toxicity - fever, dehydration
~ (b ) Heparinised saline or bite acid flushing through T Tube (250 ml normal saline with 25000 units • Reduced urine output
i.v. Heparin) Q On examination -
(c) Contact dissolution with monooctanoin or methyl terbutyl ether
^ (d) Burrhene technique - After 6 weeks once T tube track gets matured, track if needed is dilated • Swelling in inguinal region which is
using graduated dilators. Then using Fogarty catheter or Dormia basket catheter or - tense
choledochoscope, stone is removed through T tube track under fluoroscopic guidance (C-ARM) - tender
^-(e) ERCP and stone removal in 3 weeks ' - irreducible
(f) Transduodenal sphincteroplasty or choledochojejunostomy - has no impulse on coughing
_^<g) ESWL with endoscopic sphincterotomy • Hypotension
(h) Through percutaneous transhepatic route, cholangioscope is passed and CBD visualised, stone
• Tachycardia
Is identified and removed using Dormia basket catheter or Fogarty catheter
• Oliguria
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - 1 49
48 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

(iv) Pulsation of mesenteric artery

• Rebound tenderness (v) Bleeding from wall on needle prick
• Abdominal distension with guarding and rigidity
/ \
□ Investigations -
If viable If non-viable
• Routine blood investigations
I I
- Hb, Platelet Gut kept inside Resection and anastomosis done
- TLC (increased generally) abdomen with placement of drain
- DLC
- LFT \ /
- KFT Bassini's repair done by placing
- RBS interrupted non-absorbable sutures (NEVER USE MESH)
- Serum electrolytes □ post-operative care -
- Blood for grouping and crossmatching • Intravenous antibiotics to be continued
• Plain X-ray Abdomen - shows multiple air fluid levels • Maintenance intravenous fluid
• USG Abdomen . Oral diet started after bowel sounds become audible
• ECG | pre-anaesthetic evaluation • Drain removed after 4*5 days.
. CXR (PA view) J
□ Management - 2013
. High rish consent to be taken after admission
- i.v. cannula to be inserted and bloodsample to be taken simultaneously for investigations. Q. 1: Discuss assessment o f bum wound. Write in short pathophysiology o f bum. How will you treat
30% burn in 50 kg body weight female patient? [ 3 + 6 + 6]
• Intravenous fluids to be started
• Ryle’s tube to be inserted BURN WOUND
• Catheterisalion to be done
• Maintain I/O chart Assessment of burn w ound:

• Monitor vitals This can be done in three ways -

• Intravenous antibiotics (A) Depending on layers of skin involved:
• Emergency surgery -
Steps are as follows: Characteristics First degree Second degree Third degree Fourth degree
Groin incision made which extends into the most prominent area of swelling
Layers Involved Superficial lay­ a) Superficial type - Upto subcutaneous All layers involved
i ers of epidermis Deeper layers of epi­ along with muscles,
tissue
Sac exposed dermis bones
I b) Deep type-Epidermis
Constriction ring and superficial injuinal ring are cut and released and dermis
' I
Pain Present Present Absent Absent
Sac opened without allowing spillage of fluid
Appearance Hyperaemia of Vesicles/blisters are hall­ Charred, parchment Same as third de­
Fluid sucked by suction machine skin with slight mark; mottled, red ap­ like with eschar for­ gree with muscle
Edema of epi­ pearance mation with throm­ and bone involve­
i bosed superficial ment
dermis, no blis­
In the meanwhile bowel is held with fingers to prevent it from getting reduced ter veins
4
Healing Withoul scar­ a) Superficial type - by By epithelialisation Secondary healing
Viability of bowel is checked
ring pigmentation ■ from wound edge -
(i) Pinkish colour secondary healing
b) Deep type - by scar­
(ii) Normal lustre ring
(iii) Peristaltic movements present - _____

1
 SO QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-1 51

(B) Depending on thickness of skin Involved:

I
1. Partial thickness - Severe hypovolaemia
•
•
Involves superficial layers of skin
Reddish appearance with blisters
i
• Painful Reduced cardiac output -+ Decreased myocardial function
• Spontaneous regeneration of epithelium is expected, skin grafting is not necessary -> Decreased renal blood flow - * Oliguria
2. Full thickness - I
• Whole thickness of skin destroyed Altered pulmonary resistance
• Charred appearance i
• Insensitive Pulmonary Edema
• Spontaneous regeneration of epithelium cannot occur, skin grafting required
i
(C) Depending on severity o f b u m s:
Infection
Severity Full thickness Partial thickness I
Adults Children Systemic inflammatory Response Syndrome (SIRS)
I
MSd <2% <15% < 10%
Multi Organ Dysfunction Syndrome (MODS)
Moderate 2 - 10% 15-25% 10 - 20%
Severe > 10% >25% > 20% Changes In different system s:
1. CARDIOVASCULAR SYSTEM -
(D) Rule o f NINE (depending on % o f burns) : (a) Shock stage - reduced cardiac output, increased peripheral resistance, reduced ventricular end
The patient's palm is considered as 1% of TBSA (total body surface area) - diastolic volume
In adult patients, the surface areas of different body parts as a % of TBSA is as follows • Cause of shock -
1. Head + Face + Neck = 9%
Direct and chemical mediated vascular injury -> increased vascular
t Anterior chest wall = 9%
3. Posterior chest wall = 9% permeability
4. Anterior abdominal wall = 9%
Loss of fluid into the third space
5. Posterior abdominal wall = 9%
6. Each upper limb = 9%
7. Anterior part of each lower limb = 9% Redistribution of blood to the burnt areas
8. Posterior part of each lower limb = 9%
(b) Resuscitation stage - cardiac output increased, peripheral resistance decreased, plasma volume
9. Groin + Perineum = 1%
restored, perfusion of vital organs restored
• Fallacy - This rule is not applicable in children upto 14-15 years, electric burn, inhalation injurj
(c) Hypermetabolic stage - increased BMR due to physiological demand for tissue regeneration
for children, Lund and Browder Charts used.
(d) Hypercatabolic stage - due to infection/septicaemia/end stage organ failure, cardiac output
Pathophysiology: increased, BP falls, peripheral resistance reduced, generalised vasodilatation,liberation of toxic
chemical mediators
Heat Types of shock in bum -
i • Hypovolaemic shock
• Neurogenic shock
Coagulation necrosis of skin, subcutaneous tissue
• Septic shock
' I
! PULMONARY SYSTEM -
Release of vasoactive peptide (a) Increased ventilation, respiratory rate, pulmonary vascular resistance
I (b) Formation of circular eschar in chest - impairs respiration
Altered capillary permeability (c) Pulmonary Edema
(d) Hypoxia, atelectasis, lung abscess
i (e) ARDS
Loss of fluid (f) Inhalation injury
52 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- I 53

3. KIDNEYS - AGE AND WEIGHT ADJUSTED FLUID RATES

CATEGORY OF BURNS
(a) Renal blood flow and glomerular filtration rale both are reduced In Immediate post-burn period
(b) Renal failure and acute tubular necrosis Flame or scald Adults and older children (more 2 ml RL * body weight (in kg)*
(c) Electric bum may lead to myonecrosis, leading to renal failure than and equal to 14 years old) %TBSA

4. GASTROINTESTINAL TRACT AND LIVER - Flame or scald Children (less than 14 years old) 3 ml RL * body weight (in kg)*
%TBSA
(a) Hypomotility of GIT
(b) Paralytic ileus Electrical injury All ages 4 ml RL * body weight (in kg)‘
(c) Acute gastric dilatation %TBSA
(d) Increased hepatic enzymes and cholestatic jaundice
(b) PARKLAND REGIME - [This is most commonly used]
5. ENDOCRINE SYSTEM -
(a) Secretion of aldosterone and vasopressin - » Increased renal retentionof salt andwater Amount of fluid (in ml) = % of bum * body weight (in kg) * 4
Half amount given in 1st 8 hours, rest given in next 16 hours
(b) Secretion of epinephrine, cortisol, glucagon - » increased extracellular concentration of glucose,
mobilisation of fat (c) MUIR AND BURCLAY REGIME -
(c) Release of endorphins 1 Ration = {% of bums * body weight (in kg))/2
(d) RAAS activation - » vasoconstriction -» maintains renal blood flow 3 Rations given in 1st 12 hours
2 Rations given in 2nd 12 hours
6. IMMUNOLOGIC RESPONSE - 1 Ration given in 3rd 12 hours
Immunostimulation or Immunosuppression (varies) (d) GALVESTON REGIME - (For paediatric cases)
7. HAEMATOPOIETIC SYSTEM - 5000mt/m2 burned area + 1500ml/m2 total body surface area
(e) MODIFIED BROOKE REGIME -
(a)' Anaemia - due to blood loss, haemolysis
First 24 hours - 4ml/kg/ % of bums R.L (first half in 1st 8 hours), no colloid
(b) Serum erythropoietin level increased
Second 24 hours - Crystalloids to maintain urine output, Colloids (Albumin in R.L solution) -
Treatment o f 30% bum In 50kg body weight female patient : 0.3-0.5ml/kg/% of bums
(A) First aid: . (f) EVAN’S REGIME -
1. Stop the burning process and keep the patient away from the burning area First 24 hours - Normal saline 1ml/kg/% of bums, Colloids 1ml/kg/% of bums, 5% dextrose in
2. Cool the area with tap water by continuous irrigation for 20 mins. 200ml water
Second 24 hours - Half of the volume used in 1st 24 hours
(B) Indications for hospitalisation:
4. Fluids used -
1. Any moderate and severe bum
(a) Ringer Lactate (fluid of choice)
2, Airway burns of any type
(b) Normal Saline
3. Bums in extremes of age
(c) Hartmann fluid
4. All electrical/deep chemical bum
(d) Plasma
Initial care in emergency ward:
5. Route - Central vein by large bore intravenous cannula
1. Patient admitted 6. Monitor - Pulse, BP, urine output
2. Maintenance of airway, breathing, circulation
(E) General treatment: -
3, Clothing removed
1. O2 inhalation, endotracheal intubation may be needed sometimes
4. Cooling by running water for 20 mins
2. CVP line
5. Cleaning the parts to remove dust, mud, etc.
3. Total Parenleral Nutrition
6. Assessment of % of bum using Rule Of Nine
4. Catherisation
7. Sedatives, analgesics used 5. Antibiotics
8. Patient shifted to Bum Care Unit or a clean isolated room 6. Anti-ulcer drugs (H2 blocker) - Inj Ranitidine i.v 50ml 8 hourly
Fluid resuscitation: 7. Diuretics (Mannitol 1 ampoule) - used in following cases
1. When to start - As eariy as possible (a) high voltage electric bum
2. Indications - Bums involving 25% TBSA (b) with associated mechanical soft tissue injury
3. Quantity - (c) deep bums involving muscles
(d) extensive bums
(a) ATLS 10th edition updates
(e) oliguria persists in spite of large volume of fluid
 54 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics S Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 55

8. Tetanus prophylaxis -
(a) Patient immunised and last booster dose taken within last 5 years- Nothing required
(b) Patient immunised and last booster dose taken between last 5-10years - 1 booster dose ol
tetanus toxoid
(c) Patient not immunised or Immunisation status unknown or last booster taken >10 years ago
- 1 tetanus toxoid + Inj Human Tetanus Globulin 250 units
(F) Care of bum wound:
1. - First degree bum - no dressing or topical antibiotic required
2. Second degree burn - Topical antibiotic + Layered padded dressing
3. Third degree bum -
(a) Debridement - Escharotomy if eschar formation
(b) Dressing
(c) Topical antibiotics
(d) Wound excision and skin grafting after 3 weeks, MESH split skin graft for wider area
General rules of local management -
1.Dressing at regular intervals under general Anesthesia using
(a) paraffin gauze
(b) hydrocolfolds (b) Anal fissure
(c) plastic films (c) CA Rectum
(d) vaseline impregnated gauze (d) Rectal polyp
' (e) fenestrated silicone sheet
(e) Ruptured perianal hematoma
(f) biological dressing like amniotic membrane, synthetic biobrane
2. Open method - without dressing, only topical agent used; generally done for burns in head, face (0 Others - ulceration, trauma, ruptured anorectal abscess, skin excoriation
and neck 2. In colon -
3. Closed method - with dressing and topical agent (a) CA Colon
4. Topical agents are used after cleaning with povidone iodine solution (b) Ulcerative colitis
5. Topical agents used are - (c) Crohn's disease
(a) Silver sulfadiazine 1% (d) Angiodysplasia of colon
(b) Sulfamylon 5% (e) Amoebic ulcers
(c) Silver nitrate 0.5% (f) Diverticular disease
6. Tangential excision of bum wound with.skin grafting done after granulation tissue formation, but (g) Bacillary dysentery
may be done within 48 hours in patients with < 25% bums (h) Ischaemic colitis
(G) Post - resuscitation period: (B) General causes:
1. Prevention and treatment of infection (a) Blood dyscrasia
2. Proper nutrition (b) Liver failure
3. Fluid infusion - Glucose in water or R.L or colloid used i.v or orally (c) Renal failure
Amount of fluid (in ml) = 1500ml/m2 of body su rface area + evaporative fluid loss (i.e 25* % of burn (d) Drugs - NSAIDs, steroids
* m2 of body surface area)
4. Wound resurfacing + Splintage Diagnosis:
5. Physiotherapy (A) History:
Q. 2 : Classify colonic Tumors. How will you manage a 60 year old man presenting with fresh bleeding t. Onset-
per rectum. * « [ 5 ♦ 10] Acute bleed occurs in
(a) Angiodysplasia of colon
Classification of colonic Tum ors: See page 55.
(b) Ischaemic colitis
BLEEDING PER RECTUM IN 60 YEAR OLD (c) Acute episodes of ulcerative colitis
In rest conditions there is chronic bleed.
Causes o f fresh bleeding per rectum : 2. Amount of blood loss -
(A) Local causes:
(a) Very small amount - Anal fissure (streak ol fresh blood on stool)
1. In rectum and anal canal - (b) Profuse - Hemorrhoids, acute bleeding conditions
/a > H p m o r r h o id s
 56 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics 8 Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 57

3. Colour of blood - 3. Barium enema (when not much scope for colonoscopy)
(a) Bright red - from rectum or anal canal 4. Biopsy
(b) Dark red - from colon 5. For staging - X-ray chest, USG abdomen, CT abdomen
(c) Black - (melaena) from small intestine or higher up Routine investigations for pre-anaesthetic check up - Hb, TLC, ESR, blood urea, serum creatinine,
4. Relation of bleeding to defecation - blood sugar, Chest X-ray, ECG
(a) At the time of passing hard stool - Anal fissure Management:
(b) At the time of passing stool, or just after defecation - Hemorrhoids
(c) At times other than during defecation - Prolapsed piles, polyp, CA, uicerative colitis, Crohn's 1. Hemorrhoids -
disease, angiodysplasia, etc.
5. Nature of blood -
(a) Blood alone - Polyps, Villous adenoma, Oiverticulosis
(b) Blood mixed with mucus - Ulcerative colitis, Crohn’s disease, Ischaemic colitis, CA colon
(c) Blood streaked on stool - CA rectum, Anal fissure
(d) Fresh blood as splashes in pan - Hemorrhoids
(e) Bright red blood in stool - Rectal polyp
6. Associated pain -
(a) Present in - Anal fissure
(b) Absent in - CA, polyp
(All pathological conditions above Hilton’s line are painless, below Hilton’s line are painfii
except CA)
7 : Associated symptoms-
(a) Change in bowel habit (constipation followed by Diarrhea), constant colicky pain, distended
abdomen, palpable lump - Left sided colonic CA
(b) Paleness + dull pain in right lower abdomen + palpable mass - Right sided colonic CA
(c) Tenesmus, bladder symptoms, palpable mass - Sigmoid colon CA
(d) Spurious Diarrhea, tenesmus, bloody slime - Rectal CA
(e) Something coming out per rectum - Hemorrhoids, polyp
(f) Diarrhea - Ulcerative colitis, Crohn’s disease, dysentery

(B) Clinical examination:

1. General survey-
Pallor in CA, ulcerative colitis, Crohn’s disease, bleeding diathesis
2. Abdominal examination -
(a) Lump in right or left iliac fossa - CA colon
(b) Distended abdomen - Ulcerative colitis •
3. Inspection of anal opening - for Hemorrhoids, fissure
4. Digital per rectal examination -
Not done in Anal fissure as painful
Hemorrhoids is not palpable unless thrombosed
CA rectum, polyp may be palpated
5. Proctoscopic examination -
Visualisation of Hemorrhoids, Rectal polyp, Ca rectum

(C) Investigations:
1. Colonoscopy
2. Endorectal USG
58 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-1 59

2. Anal fissure - • Bowel wash using normal saline for 2-3 days before surgery
• Total gut irritation
• Antibiotics
(i) Abdomino - Perineal Resection (APR) - sigmoid, descending colon and upper rectum is
mobilised per abdominally; anal canal with perianal and perirectal tissues are dissected per
anally; retained colon is brought out as end colostomy in left iliac fossa.
(j) APR is the treatment of choice when
(i) Mesorectum is involved
(ii) Poorly differentiated Tumor
(iii) Nodes involved
(k) Criteria for anterior resection -
(i) Upper and middle third rectal growth
(ii) Above peritoneal reflection
(ii) Well-differentiated Tumor
(iv) < 4cm size Tumor
(v) T1N0/T2N0 Tumor
(vi) Tumor without lymphatic or venous spread
(I) Hartmann’s operation - excellent palliative procedure done in elderly people who are not fit
for major surgery, and in locally advanced Tumors.
(m) Preoperative and postoperative radiotherapy
(n) Chemotherapy -
• Neoadjuvant
• Adjuvant
• Palliative
4. Rectal polyps:
Transanal endoscopic microsurgery
5. CA coton:
(a) Right - sided: Right radical hemicolectomy with ileo-transverse anastomosis. In inoperable
3. Rectal carcinoma - cases, ileo-transverse anastomosis is done as a by-pass procedure.
(a) Surgery is the main method of treatment. (b) Left-sided: Left radical hemicolectomy
(b) Abdomino-Perineal Resection (APR) is the gold standard. 6. Crohn's disease. Ulcerative colitis : ■
(c) But if Tumor Is well differentiated and if there is adequate margin above the anal canal, a
(a) Steroids
sphincter saving Anterior Resection (AR) may be done.
(b) Azathioprine
(d) Total Mesorectal Excision (TME) should be the goal.
(c) 5-ASA
(e) Principles of surgery - (d) Antibiotics
• Distal margin - 2 cm away from the lesion (e) Metronidazole
• Proximal margin - 5 cm away from the lesion (I) Surgery if medical methods fail
. Radial margin - 3 cm ol mesorectum to be removed
7. Angiodysplasla:
(0 Laparoscopic APR/AR is becoming popular.
(q) For carcinoma rectum presenting with obstruction, an initial proximal colostomy is done. Bipolar coagulation along with angiography is the treatment: embolisation may be done.
Neoadjuvant chemoradiation is given. Patient is reassessed for operability. Then APR is
done with permanent colostomy.
0 .3 : Describe clinica l features, diagnosis and management o f choledocolithiasis. [4 + 4 + 7]
(h) Proper preoperative bowel preparation -
. Low residue diet for 48-72 hours before surgery, only clear liquid on day before surgery,
CHOLEDOCHOLITHIASIS
no feed on day of surgery
. Elemental diet lor 3-5 days before surgery Definition:
• Single dose of oral polyethylene glycol dissolved in 2lt of water on day before surgery Slones in common biliary duct and biliary tree
 60 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-/ 61

Clinical features:
the 1st 24 hours of ERCPfas chance of ERCP pancreatitis) but in the same hospital admission.
1 Assymptomatic If laparoscopic facilities not available, then open cholecystectomy to be done.
t. Biliary colic - right hypochondrial pain, radiating to the right shoulder, sudden onset, precipitated If ERCP not possible, laparoscopic choledocholithotomy followed by laparoscopic cholecystec­
by fatly heavy meal, peaks -> sustained for sometime -> gradually subsides spontaneously tomy done. ’
( not a true colic as little smooth muscle in wall of common bile duct) If laparoscopic facilities not available, then open cholecystectomy per operative cholanoio-
Charcot's triad of ascending cholangitis - gram choledocholithotomy T-Tube insertion -> within 7-10 days T tube is clamped and
(a) Fluctuating jaundice patient observed for development of pain, jaundice and fever ^ free flow of dye is confirmed bv
(b) Intermittent pain in right upper quadrant of abdomen T tube cholangiogram -> T tube removed by smart pull
(c) Fever with rigor 5. Management of retained CBD stones i.e. detected within 2 years of choledocholithotomy :
Raynaud's pentad of acute obstructive jaundice(suppurative cholangitis) -
(a) Small stones may spontaneously pass down
(a) Fluctuating jaundice
(b) Intermittent pain in right upper quadrant of abdomen (b) Heparinised saline or bile acid flushing through T Tube (250 ml normal saline with 25000
units i.v. Heparin)
(c) Fever with rigor
(d) Shock (0 Contact dissolution with monooctanoin or methyl terbutyl ether
(e) Mental obtundation (CO Burrtiene technique-After 6 weeks once T tube track gets matured, track if needed is dilated
5. Features of obstructive jaundice - S' Then usin9 F<>9arty catheter or Dormia basket catheter or
(a) Mustard coloured urine chotedochoscope, stone is removed through T tube track under fluoroscopic guidance (C-
(b) Pale clay coloured stool, steatorrtioea
(e) ERCP and stone removal in 3 weeks
(c) Intense pruritus
6. Pain and tenderness in epigastrium and right hypochondrium (f) Transduodenal sphincteroplasty or choledochojejunostomy
(g) ESWL with endoscopic sphincterotomy
Diagnosis: (h) Through ^rcutaneous transhepalic route, cholangioscope is passed and CBD visualised
1. Liver function test: stone is identified and removed using Dormia basket catheter or Fogarty catheter
(a) Total serum bilirubin - raised (i) Laparoscopic choledocholithotomy
(b) Conjugated bilirubin - raised (j) Open choledocholithotomy often with open choledochojejunostomy
(c) Serum protein - albumin, globulin normal
(d) AST, ALT - slightly raised •
(e) ALP, GGT - highly raised Supplementary 2013
(f) PT - prolonged
2. USG abdomen - CBD diameter > 1cm indicates biliary obstruction)
3. ERCP - gold standard as stones in retroduodenal part of CBD missed in USG ? Howdo they occur ? H o * do you prepare such
a patient before an elective operation ?
4. MRCP ' [5 + 5 + 5 ]
5. Routine investigations - Hb, TLC, ESR, Chesl X-ray, ECG Normal values o f different body electrolyte

Management: (a) Na+ : 130-150 mmol/lt

1. Preoperative preparation for obstructive jaundice (b) K+ : 3.5-5,5 mmol/lt
(a) Immediate hospitalisation (c) Cl- : 98-106 mmol/lt
(b) Diet - high carbohydrate, low protein, no fat diet along with vitamin and calcium supplements W) HCO5 : 24-28 mmol/lt
(c) Adequate hydration with oral and intravenous fluid (€) Ca2+ : 9-11 mg/dl
(d) i.v mannitol - 10% 200ml before, during or after surgery
ro P : 3-4.5 mg/dl
(e) Inj Dopamine 2 ug/kg/min
(9) Mg r 2-3 mg/dl
(f) Inj Vitamin K 10mg for 3days to correct prothrombin time -> if still no improvement, fresh
frozen plasma is used (h) pH : 7.3-7.4
(g) Blood transfusion if severe anaemia -
(h) Broad spectrum antibiotics
PYLORIC STENOSIS
(i) If preoperative bilirubin > 10mg%, ERCP stenting or PTBD done, else MRCP done
Electofyte changes:
2. Ideal treatment - Endoscopic sphincterotomy by ERCP and bile duct stone removal by Dormia
basket catheter or Fogarty balloon catheter followed by laparoscopic cholecystectomy not within Hypochloraemic hypocalaemic metabolic
alkalosis with hypocalcaemia and paradoxical aciduria
 62 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS D Parw - , „

Basis o f electrolyte changes:

Q .2: What are the causes o f lump In right iliac fossa ? Outline v
appendicular lump. 5 ° uWne d/a^ o s ls and management of
Projectile vomit - » loss of fluid and hydrochloric acid
[3 + 6 + 6 ]

1 '
LUMP IN RIGHT ILIAC FOSSA
Loss of H+, K+, Cl- Causes :

i
Hypochloraemic, hypokalaemic metabolic alkalosis
(A) Parietal swelling -
(a) Lipoma
(b) Desmoid Tumor
(B) Intraabdominal lump -
(a) Appendicular lump
Kidney tries to compensate by excreting Alkalosis leads to hypocalcaemia (b) Appendicular abscess
(c) lleocaecal tuberculosis
Low amounts of C l~, high amounts of HCOg (Gastric tetany) (d) Crohn’s disease
(e) CA caecum
I (f) Ovarian disease
While excreting HCO, , Na+ lost (g) Twisted ovarian cyst
(h) Actinomycosis
. I
Hyponatremia develops
. (i) Mesenteric lymphadenitis
(j) Lymphoma
I (C) Retroperitoneal lump -
R M S activated -> Aldosterone released - * Na+ retained in distal tubule in exchange of H+ (a) Hydronephrosis - right sided or bilateral
and K+ which are excreted in urine ‘ (b) Tumor in unaccended or dropped kidney
(c) Tumor in undescended right testis ,
I (d) Retroperitoneal sarcoma
Kidney passes acidic urine (H+) (e) Iliopsoas abscess

!■
Paradoxical aciduria (as in the background of melabolic acidosis, kidney should have excreted APPENDICULAR LUMP
alkaline urine) Definition:
Also called Periappendicular phlegmon.
Pre- operative preparation o f pa tien t:
t. Correction o l dehydration - i.v normal saline (not Ringer laclate) “ T infeC" ° n °0aJr# 3'5 an anack acu<* appendicitis.
2. Correction of electrolyte imbalance - i.v normal" saline. Once urine output becomes normal, (a) Inflamed appendix
potassium supplemented * - - * ‘ • (b) Greater omentum
3. Correction o l hypoproteinemia - (c) Edematous caecum
(a) Oral high protein diet.' Id) Dilated ileum
• (b) Amino add (e) Parietal peritoneum
(c) Fresh frozen plasma W Exudates which binds them all '
(d) Human albumin transfusion Diagnosis:
4. Correction ol anaemia - by blood transfusion •
(A) History:
5. Correction of hypocalcaemia - Calcium gluconate 10% 10 mi/kg i.v
6. Gastric lavage -
Done before each feed for 4-5 days prior to surgery 9,“ “aiv “ "»
Its advantages - (B) Clinical examination;
(a) Removes food residues in stomach
(b) Reduces mucosal Edema
* ' ,be — 6 —
fr.l Recovery of aastric tonicity
64 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 65

(b) Small gut perforation - typhoid ulcer, tubercular ulcer, Crohn’s disease
(C) Investigations:
(c) Large gut perforation - colonic ulcer
(a) TLC - raised
2. Inflammations -
(b) USG abdomen - confirms the mass, shows any pus if abscess
(a) Acute pancreatitis
Management: (b) Meckel's diverticulitis
If lump palpable, but not abscess (no fever, no rising TLC, increasing tenderness), then conservative 3. Obstetric causes -
management is done as nature has already localised the infection to prevent spread in pentoneum, which (a) Ruptured ectopic pregnancy
if disturbed, may lead to faecal fistula. (b) Uterine perforation/injury during abortion or termination of pregnancy
4 . Intestinal obstruction with strangulation
Ochsner-Shenen regimen:
5. Penetrating or blunt trauma abdomen
(a) Nothing per mouth
6. Perforation during surgery
(b) Intravenous fluid
(c) Analgesics 7. Septicaemia
(d) Antibiotics 8. Dissecling aortic aneurysm rupture
(e) Nasogastric aspiration for initial 2-3 days
(f) Monitoring everyday - (A) History:
(i) Temperature, BP, Pulse (a) Sudden onset, stabbing, upper abdominal pain, radiating to the flanks and back and relieved on
(il) TLC leaning forward (Mohameddan prayer position) - Acute pancreatitis
(iii) Palpation of lump to observe the size (b) Sudden onset severe pain in mid upper abdomen then moving towards right side of abdomen,
(A) If mass reduces in size, temperature and pulse becomes normal, TLC reduces, appetite improves then becoming generalised - Perforation
patient discharged and advised to come after 6 weeks for interval appendicectomy (c) Severe pain abdomen + amenorrhoea for 4-6 weeks + vomit or mild bleeding per vagina ->
(8) Criteria to discontinue the regimen - Ruptured ectopic pregnancy
(a) Patient becomes more toxic (tachycardia, temperature rises) (B) Clinical examination:
(b) Persistent vomit 1. Features of shock - tachycardia, tachypnoea, drowsiness, decreased urine, hypotension
(c) Increasing size of lump
2. Abdomen - tenderness in all quadrants, IPS may be sluggish or not audible if perforation occurs
(d) Pain becomes more intense
or in case of ruptured ectopic pregnancy, tense in consistency if perforation occurs
(e) Rising TLC
(f) Appendicular abscess formation 3. Grey Turner’s sign, Cullen's sign, Fox's sign in acute pancreatitis
In these cases, immediate surgery is done. Drainage if appendicular abscess. . 4. Severe pain abdomen + vomit + absolute constipation + abdominal distension -> Intestinal ob­
(C) Contraindications to Ihe regimen - struction
5. Chills, elevated temperature, pain abdomen -» Septicaemia
(a) Doubtful diagnosis
(b) Acute appendicitis in children and elderly 6. Features of perforation may also be present in blunt trauma
(c) Burst, gangrenous appendicitis (C) Management:
(d) Diffuse peritonitis ... .
Even before going for investigations, our prime concern should be the management of shock. 2 wide
(D) Patient of appendicitis taken for appendicectomy and palpation of right iliac fossa under general bore cannula should be inserted and i.v infusion started. Ringer’s lactate is used initially til I arrangement
Anesthesia revealed a mass - for whole blood is made. Non-sugar crystalloid solution may be used.
(a) If symptoms present for 3-5 days, appendicectomy performed as scheduled While canulla is inserted, blood is collected for following investigations -
(b) If symptoms present for longer duration (> 7 days) and a firm lump is palpable, surgery postponed
Hb%, TLC, DC, PCV, ESR, Platelets, ABO and rH grouping, Serum Amylase and Lipase.
and conservative management done followed by interval appendicectomy
Arrangement for whole blood orpacked cell is made in the meanwhile. Nasogastric aspiration is done.
Q .3 : A 30 year old lady presented with severe abdominal pain and shock. Discuss differential Patient's status reevaluated. When patient becomes stable than before, necessary radiological
diagnosis and management. [6 + 9 ] investigations may be done if emergency setup present - USG whole abdomen, FAST, CT scan
abdomen, MRI abdomen.
SEVERE ABDOMINAL PAIN AND SHOCK Prophylactic antibiotics started.
Morphine, Dob utamine, Dopamine, Noradrenaline are to be kept ready for use if the situation demands.
Differential diagnosis:
Blood transfusion is started when arranged.
This occurs in diffuse peritonitis which may be due to : In case of acute pancreatitis (as detected by raised Serum Amylase and Lipase, USG/CT findings
1. Perforation of GIT - showing Edematous pancreas with peripancreatic fluid) conservative management done, [for details
(a) Gastric cause - benign or malignant gastric ufcer refer to page 35]
 66 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ P aper-j 67

In other cases, following management done

(a) Ruptured ectopic pregnancy - Salpingectomy. If ovary is adhered or non-viable, then
salpingo-oophorectomy done
(b) Blunt trauma - Diagnostic Peritoneal Lavage (DPL) done. Emergency laparatomy done if
positive lavage signs present such as -
1. 10 ml or more gross amount of blood Due to loss
> of sympa­
2. Amylase level in fluid > 175IU/DL
thetic tone
3. WBC count > 500/mm A 3
4. RBC count > t lakh/mm A 3 --- - .
5. Presence of bile, bacteria, foreign body or food particle in fluid Vasogenic
Specific surgical procedures (which are carried out if conservative treatment is not enough) Shock
are as follows: (excessive pooling of
blood in peripheral circu­
• Duodenal injury - lacerations sutured surgically witha stenting or gastrojejunostomy
lation)
• Colonic injury - resection and anastomosis. Ileostomy/ hemicolectomy may be done if Due to pooling of
blood in limb muscle
required
and dilated splanch­
• Pancreatic Injury - Whipple's operation/ total pancreatectomy nic vessels
• Splenic injury - splenorrhapphy/ splenectomy
____ /
• Liver injury - small tear is sutured; for large tear Pringle’s manoeuvre is applied (by Peripheral vasodila^l
. compressing porta hepatis near Foramen of Winslow) tation due to release I
Anaphylactic^- of NO, histamine, I
Slow Release Ana-
2014 phyiactic Substance
A (SRS-A) I
0 . 1: Classify shock. Discuss the patho-physlology anti management o f septic shock. [3 + 6 + 6]

SHOCK

(Classification): >'

SHOCK

T IL
Hypovolemic or Cardiogenic
Oiigaemlc or Septic Vasogenic
Hematogenic R e fe r to n ext p a g e tor

~ : l i : : Refer to next page for details

details
Hemorrhagic Non-
Hemorrhagic
1--------1------------1 Due to systemic
Bleeding from Bleeding Into sepsis by
injury site injury site Loss of fluid and 1.E. Coli
plasma e.g. Bum X 2. Klebsiella
Loss of fluid 3. Pseudomonas
1. External 1. Into the intestine e.g. 4. Staphylococcus
2. Internal Vomiting, Diarrhea
1. Fractured rib aureus
2. Acute pancre­ 2. Into the peritoneum 5. Bacteroides
e.g. Peritonitis
atitis
 SOLVED LONG QUESTIONS OF FINAL MBBS 0 Paper-1 69
68 QUEST : A Compretxrelve Guide to UG SurQ*y. Orthopedics & Anesthesiology ___ __________^

Most blood pooled in cutaneous vascular bed -» skin red and hot
SEPTIC SHOCK
i
Diminished circulating blood volume
Pathogenesis:
I
Causative organisms -
Reduced blood supply to the vital organs and other areas
Both Gram positive and Gram negative organisms - mainly
(a) E-coli (B) Stage of. white/cold shock:
(b) Klebsiella Bacterial toxins cause an intravascular inflammatory process
(c) Proteus
(d) Pseudomonas I
Release of inflammatory factors
(6) f^ G r a m positive sepsis and shock - caused by dissemination of a potent I
from the organism, without evidence of bactena; artenal resistance falls but there is no Damage of lining wall of capillaries
reduction in cardiac output with normal urine output
J
• Gram negative sepsis and shock - caused by Exit of fluid from intravascular space into interstitial tissues
(i) operation or instrumentation in the genitourinary system
I
(ii) respiratory system infections Sharp fall in total blood volume
(iii) gastrointestinal tract infection
I
Toxins/ endotoxins from organisms Hypoperfusion of vital organs
i i
■inflammation, cellular activation of macrophages, neutrophils, monocytes Activation of cutaneous pressor mechanism
I I
Release of cytokinesis, free radicals Blood diverted from less essential skin to Important vital organs
i I
Chemotaxis of cells, endothelial injury, altered coagulation cascade - SIRS Skin becomes cold and pale
I This sequence of red and white shock, however, occurs only when the patient is normovolaemic prior
Reversible hyperdynamic warm stage to the onset of systemic sepsis. In contrast, if systemic sepsis develops in a subject who is already
I hypovolaemic, the patient passes straightaway to the stage ol cold shock. _
Severe circulatory failure with DIC - MODS Another important component of septic shock is marked oxygen desaturation of (issues, affected by - ■
i 1. Progressive pulmonary dysfunction -
Hypodynamlc, Irreversible cold stage (a) Primary cause is leakage of prolelnaceous fluid through the damaged capillary walls into the
interstitial tissues of the lungs and then into the alveolar spaces, causing gradual loss of
Stages o l septic sh o ck: alveolar function.
Septic shock is usually a combination of vasogenic and hypovolaemlc shock. (b) The condition is worsened by superimposed bacterial infection.
The vasogenic component - consists of pooling of a large volume of blood in the skin, reducing It* 2. Decreased oxygen utilisation by the tissues due to -
circulatory blood volume. • (a) Arteriovenous shunting
The hypovolaemic component - due to generalised leakage of intravascular fluid into the mtersMrf (b) Inability of the cells to utilise O2 as a direct effect of sepsis
tissue through the capillary walls, which suffer widespread damage due to bacterial toxins.
anagement:
(A) Stage o l red shock:
s~ ' (A) TREATMENT FOR SEPSIS -
Systemic sepsis
(a) Identification of the source - Bacterial blood culture, USG, CT, MRI may be helpful if source is not
I evident
Hypermetabolic state and heat production increases (b) Antibiotics - Combination of Cefazolin + Gentamicin/ Amikacin + Metronidazole started as generally
Diminution of arteriolar resistance
I the source is GIT. Later antibiotic therapy according lo culture sensitivity report '
(c) Surgery - Drainage of abscess, surgical debridement, removal of retained products of conception,
Heat loss accomplished by diversion of blood to skin by
etc. » . •
Opening of cutaneous arteriovenous shunt
 70 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-1 71

(B) GENERAL SUPPORTIVE MEASURE - 6. ECG

Resuscitation: 7. Chest X-ray
This should begin immediately as soon as the patient fs admitted. 8. Serum electrolytes
(a) Establishment of clear airway 9. Blood gas analysis at regular intervals
(b) Maintenance of adequate ventilation and oxygenation - lowering of head (increases cerebij
circulation, prevents stasis of blood in leg musctes thereby preventing Edema), support of )a* 0 .2 : Describe the clinical features, Investigations and management o f carcinoma o f stomach.
moist oxygen administration
(c) Endotracheal intubation and mechanical ventilation may be needed in case of airway obstruct)# [4 + 4 + 7 ]
CARCINOMA OF STOMACH
(C) TREATMENT FOR SHOCK - '
Clinical features:
(a) Extracellular fluid replacement :■' '
/ ''( A ) SYMPTOMS: _
(i) 2 wide bore cannula inserted and intravenous infusion is started '
(ii) Ringer lactate is initially used (@ 1-2 ft in 45 mins) till arrangement for whole blood is made New onset dyspepsia J
It is better to withhold administration of blood until surgical control of bleeding is obtained a Anorexia, nausea and loss of weight along with fatigue
atleast until just before induction of Anesthesia. Rapid replacement of fresh blood after coo Continuous upper abdominal pain or discomfort without periodicity, not relieved by food
trol of Hemorrhage will lead to fewest complications. At times when bleeding has beer If gastric outlet obstruction occurs -
severe, blood should be given before surgical control of Hemorrhage.
(a) Sensation of fullness after meals or early satietv
(iii) Non sugar crystalloid solution is used; sugar is avoided because it induces osmotic dierese (b) Belching { )
(iv) Colloid solutions should not be used as in cases of severe shock, there is generalise (c) Projectile vomiting - Vomitus is yellowish in colour (non-bilious). contains food material
- damage of capillary endothelium and colloids may come out into interstitial tissues causiri consumed more than 12 hours ago, leaving a sour taste in mouth
pulmonary embolism. (d) Feeling of a rolling mass moving from left to right in the abdomen (due to peristalsis)
Lump in abdomen
(b) Drugs:
Due to metastasis -
(i) Sedatives - used to alleviate pain
- Morphine for adults, baibiturates for children rw SW8'/!!9 (due t0 asciles from hepatic or Peri,onea| metastasis)
( ) Breathlessness (due to pleural effusion from pulmonary involvement)
(ii) Chronotropic agents - used in patients having slow heart rate
- Atropine most widely used, followed by Isoprenalme h e ta S d,SCO,0Urah'0n 0f eyes and un'" e (due 10 en,ar9ed lymph node obstructing porta
(iii) lonotroplc agents - used to improve myocardial contractility / (d) Backache (due to metastasis to vertebrae)
- Dopamine, Dobutamine ,r
(B) SIGNS
(iv) Vasoconstrictors - Norepinephrine is drug of choice
1, GeneraI survey -
(v) Steroids may be used if no response with adequate fluid replacement
(a) Cachectic look may be present
(vi) Sodium bicarbonate - used if metabolic acidosis occurs (b) Palfor
(c) Jaundice may be present
(D) MONITORING -
(d) Enlarged Virchow* lymph node (left supraclavicular) - Troissier's sign
1. Vital signs - (e) Enlarged Irish nodes in left axilla
(a) Pulse - Progressive tachycardia and irregular pulse indicate deterioration (0 Superficial migratory thrombophlebitis - Trousseau's sign
(b) BP - Better indication is MAP > PP > DBP or SBP (9) Due to paraneoplastic syndrome -
(c) Respiration - Persistent rapid and deep respiration and presence of cyanosis are unfavouraN • Dermatomyositis
signs • Acanthosis nigricans
(d) Temperature - Cold clammy skin is unfavourable, hyperpyrexia in septic shock is dangerou • Circinate erythema
2. Sensorium - Restlessness is unfavourable Systemic examination -
3. Urine output - MOST RELIABLE AND EASIEST GUIDE OF ADEQUATE PERFUSION. Urn (a) Abdominal examination -
output < 0.5 ml/kg/hr is insufficient (i)
nainahi ^ maSS' W''h i'T,paired res°nance, moves up and down with respiration i
4. CVP (Central Venous Pressure) - Best way is to raise Ihe rate of transfusion till CVP rises to II palpable
15cm of water (») In cases of gastric outlet obstruction —
5. PCWP (Pulmonary Capillary Wedge Pressure) - Indicates left ventricular function; Swangas • stomach is distended
Pulmonary Artery Floatation Catheter (SPAFC) is the best technique • succusion splash audible
• greater curvature ol stomach below umbilicus on ausculto-percusslon
 72 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF PINAL MBBS □ Paper-I 73

(iii) Sister Mary Joseph's nodule looked for(due to infiltration of umbilicus) (b) Adjuvant therapy: (chemotherapy after surgery)
(iv) Ascites is looked for Purpose - to increase survival rate
(b) Rectal examination - • Regimens which may be used -
To detect metastasis in pelvis and to exclude Krukenberg's Tumor j, 5-Fluorouracil + Leucovarin
(c) Skeletal system examination - 2- J>-FlMorouracii + Adriamycin + MitomvclnCfFAMregima^
3. Cisplatin, Epirubicin. Adriamycin, Oxafilatln, Capecitabine are other drugs used
To look for sternal tenderness and bony tenderness
(C) Radiotherapy -
Investigations :
/ No role
1. Routine blood examination - low Hb, high ESR
2. Routine stool examination - occult blood present in 80% cases (D) Lymph node dissection -
3. Gastric function tests - gross hypochlorhydria or achlorhydria and blood in basal secretion Group I (perigastric) nodes and Group II (along root of major vessels) nodes are removed generally
4. Upper Gl endoscopy (is the Gold Standard) and10 quadrant biopsy
(E) Palliative procedures -
5. Barium meal X-ray(if Endoscopy not possible) -
(a) irregular filling defect (a) Palliative partial gastrectomy - best method .
(b) loss of rugosity (b) Palliative anterior gastrojejunostomy
(c) delayed emptying (c) Devine's antral exclusion operation
(d) dilated stomach (d) SEMS (Self Expanding Metal Stents)
(e) margin of lesion projects outward from lesion into gastric lumen(Carmann's meniscus sign) (e) Laser recanalisation
6. For staging - (0 Palliative chemotherapy - FAM regime
' (a) Chest skiagram(P.A view) 1. Adherent to pancreas or colon or mesocolon
(b) CT Scan abdomen, chest, pelvis 2. Ascites
(c) MRI abdomen, chest, pelvis 3. Para-aortic lymph nodes
4. Secondaries in liver
(d) Endoscopic ultrasound
5. Blummershelf lymph nodes
7. Others - 6. Enlarged Virchow's node
(a) LFT 7. Sister Mary Joseph nodule
(b) PT 8. Irish node
(c) FNAC left supraclavicular lymph node
(d) Laparoscopy lor staging SOyear old patient presents with bleeding per rectum. How w ill you Investigate and manage
(e) Tetracycline fluorescence test the patient 7 [7 * 8 1
(f) Tumor markers - CA 72, CEA, CA 19-9, CA 12-5
(g) Combined PET
(h) Sentinel node biopsy BLEEDING PER RECTUM IN 50 YEAR OLD
Management: Causes of bleeding per rectum : '
■ (A) Surgery­ (A) Local causes:
’ (Treatment of choice) 1. In rectum and anal canal -
(a) If early growth involving pylorus region - Lower radical gastrectomy + Billroth II anastomosis (a) Hemorrhoids
(b) If growth in oesophago-gastric junction or upper part of stomach - Upper radical gastrectomy* (b) Anaf fissure
Oesophagogastric anastomosis (c) CA Rectum
(c) If growth in body of stomach - Total radical gastrectomy + Oesophagojejunal anastomosis (d) Rectal polyp ■
(d) EMR (Endoscopic Mucosal Resection) is done in Japan (e) Ruptured perianal hematoma
(B) Chemotherapy - (f) Others - ulceration, trauma, ruptured anorectal abscess, skin excoriation
2. In colon -
(a) Neoadjuvanl therapy : (chemotherapy before surgery)
(a) CA colon
Purpose -
1. to increase reducability (b) Ulcerative colitis
(c) Crohn's disease
2. to reduce recurrence
(d) Angiodysplasia of colon
3. to determine chemotherapy sensitivity
(e) Amoebic ulcers
74 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS O Paper-I 75

(f) Diverticular disease (B) Clinical examination:

(g) Bacillary dysentery 1. General survey-
(h) Ischaemic colitis Pallor in CA, ulcerative colitis, Crohn’s disease, bleeding diathesis
2. Abdominal examination -
(B) General causes:
(a) Lump in right or left iliac fossa - CA colon
(a) Blood dyscrasia (b) Distended abdomen - Ulcerative colitis
(b) Liver failure 3. Inspection of anal opening - for Hemorrhoids, fissure
(c) Renal failure 4. Digital per rectal examination -
(d) Drugs - NSAIDs, steroids Not done in Anal fissure as painful
Hemorrhoids is not palpable unless thrombosed
Diagnosis:
CA rectum, polyp may be palpated
(A) H istory: 5. Proctoscopic examination -
1. Onset - Visualisation of Hemorrhoids, Rectal polyp, Ca rectum
Acute bleed occurs in
(a) Angiodysplasia of colon (C) Investigations:
(b) Ischaemic colitis 1. Colonoscopy
(c) Acute episodes of ulcerative colitis 2. Endorectal USG
In rest conditions there is chronic bleed. 3. Barium enema ( when not much scope for colonoscopy)
2. Amount o l blood loss - 4. Biopsy
(a) Very small amount - Anal fissure (streak of fresh blood on stool) 5. For staging - X-ray chest, USG abdomen, CT abdomen
(b) Profuse - Hemorrhoids, acute bleeding conditions Routine investigations for pre-anaesthetic check up - Hb, TLC, ESR, blood urea, serum creatinine,
3. Colour of blood- blood sugar, serology, Chest X-ray, ECG
(a) Bright red - from rectum or anal canal Management:
(b) Dark red - from colon
(c) Black - (melaena) from small intestine or higher up 1. Hemorrhoids - (See chart on the next page no. 76)
4. Relation o l bleeding to defecation - 2. Analfissure- •
(a) At the time of passing hard stool - Anal fissure
(b) At the time of passing stool, or just after defecation - Hemorrhoids ,'
(c) At times other than during defecation - Prolapsed piles, polyp, CA. ulcerative colitis, Crohn’s
disease, angiodysplasia, etc.
5. Nature of blood-
(a) Blood alone - Polyps, Villous adenoma, Diverticulosis
(b) Blood mixed with mucus - Ulcerative colitis, Crohn’s disease. Ischaemic colitis, CA colon
(c) Blood streaked on stool - CA rectum, Analfissure .
(d) Fresh blood as splashes in pan - Hemorrhoids
(e) Bright red blood in stool - Rectal polyp
6. Associated pain -
(a) Present in - Anal fissure
(b) Absent in - CA, polyp
(All pathological conditions above Hilton's line are painless, below Hilton's line are painful
except CA)
7. Associated symptoms - .
(a) Change in bowel habit (constipation followed by Diarrhea), constant colicky pain, distended
abdomen, palpable lump - Left sided colonic CA
(b) Paleness + dull pain in right lower abdomen + palpable mass - Right sided colonic CA
(c) Tenesmus, bladder symptoms, palpable mass - Sigmoid colon CA
(d) Spurious Diarrhea, tenesmus, bloody slime - Rectal CA
(e) Something coming out per rectum - Hemorrhoids, polyp
(f) Diarrhea - Ulcerative colitis, Crohn’s disease, dysentery
76 QUEST : A Comprehensive Guide !o l/G Surgery, Orthopedies & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-1 77

(h) Proper preoperative bowel preparation -

• r jE r c & s ? hm s“ w
• Elemental diet for 3-5 days before surgery
. Single dose of oral polyethylene glycol dissolved in 211 of water on day before surgery
. Bowel wash using normal saline for 2-3 days before surgery
• Total gut irritation
• Antibiotics

W Ab“ ° - Pt T al R« ec,ion <ApR) - sigmoid, descending colon and upper rectum is

l^ il , P6rrf ?,n,na [y: 8nal ° anal With perianal and Pemectal tissues are dissecled per
anally, retained coton is brought out as end colostomy in left iliac fossa.
{j) APR is the treatment of choice when
• Mesorectum is involved
• Poorly differentiated Tumor
• Nodes involved
(k) Criteria for anterior resection -
« Upper and middle third rectal growth
• Above peritoneal reflection
• Well-differentiated Tumor
• < 4cm size Tumor
• T1N0/T2 NO Tumor
• Tumor without lymphatic or venous spread

<0 W m T ? °Pera,i0n“ eXCel,enl pal,ia,ive Procedure done in elderly people who are not fit
for major surgery, and in locally advanced Tumors.
(m) Preoperative and postoperative radiotherapy
(n) Chemotherapy -
• Neoadjuvant
• Adjuvant
• Palliative
Rectal polyps:
^•T ra n sa n a l endoscopic microsurgery
CA colon:
3. Rectal carcinoma -
(a) Surgery is the main method of treatment.
1-en-sWed. Led radical hemicolectomy
(c) But if Tumor is well differentiated and if there is adequate margin above the anal canal, a v- ^ 6 Crohn’s disease. Ulcerative colitis:
sphincter saving Anterior Resection (AR) may be done. (a) Steroids '
(d) Total Mesorectal Excision (TME) should be the goal. (b) Azathioprine
l^fe j^P rin c iples of surgery - (c) 5-ASA
• Distal margin - 2cm away from the lesion
(d) Antibiotics
* Proximal margin - 5cm away from the lesion
» Radial margin - 3cm of mesorectum to be removed («) Metronidazole
(f) Laparoscopic APR/AR is becoming popular. !>) Surgery if medical methods fail
(g) For carcinoma rectum presenting with obstruction, an initial proximal colostomy is done. '• Angiodysplasia :
Neoadjuvant chemoradialion is given. Patient is reassessed for operability. Then APR is
Bipolar coagulation along with angiography is the treatment: embolisalioro may be done.
done with permanent colostomy.
78 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Pap9f_ ( 7g

2014 Supplementary • Active blood loss > 100 ml/h

Q.1: What are the diseases o f umbilicus? What are the presentation and treatment o f Meckel's • Age > 70 year
diverticulum? [2 * 6 + 7 ] Hemoglobin > 7 g/dl with : .
Comorbid disease states or Hemodynamic instability
A: • Diseases of umbilicus - See Section 1, Segment A, Paper-1, 2009, Qs. 3 (Page No. 18)
[ BP = Blood pressure; HR = heart rate; SVn = mixed venous s a tu ra te h . ,.
• Meckel’s diverticulum - See Section 1, Segment D, Qs. 45, Page No. 503 BE = base excess.] 2 a n hemoglobin in oxygen;

Q 2 : How will you assess a breast lump In an elderly woman ? Outline the treatment options of an O Complications -
early breast cancer In a woman o f SOyears. [6 + 9] See Section 1, Segment D, Qs. 33 (Page No. 495)
□ Massive blood transfusion -
A : See Section 1, Segment A, Paper-ll,2011,Qs. 1, Page No. 128.
See Section 1, Segment D, Qs. 18, (Page No. 483)
Q.3: What are the Indications o f blood transfusion? What are Its complications? What do you
understand by massive blood transfusion ? [3 + 8 + 4]
2015
Ans: BLO O D TRANSFUSION

□ Indications - 15+5+5=15]
• Severe blood loss from trauma/bleeding ulcer/any pathological lesion '
• During major operative procedures WOUND HEALING
• Severe bums - • Wound:
' • Severe anaemia pre and post operatively
Wound occurs when integrity of any tissue is compromised (g.g skin breaks „
• Surgery of haemophilia patients or in thrombocytopenia
* Special indications - ~ M“ n g l - « * - “ >
• Whole Blood: ■
\ • Biological process o f wound healing:
- Acute blood loss -
The stages of wound healing are -
- Shock
I. Inflammation
- Exchange transfusion in neonate ,
• Packed red blood cells: II. Wound contraction
- Chronic severe anemia III- Epithelialisation
- Leukemia IV. Scar/granulation tissue formation
- Thalassemia V. Scar remodelling
• Platelets concentrate: I. Inflammation -
- Thrombocytopenia.
Platelets adhesion and aggregation
- Bleeding due to platelet dysfunction
- Malignancy i '
- Major surgery Form haemostatic plug along with clotting factors
* Transfusion Indications - ■ J*
Hemoglobin S 7 g/dl W i e n , vasoconstriction followed by vasodilatation ol blood vessels
Hemoglobin > 7 g/dl with one or more of the following :
• Systolic BP < 90 mm Hg . Increased permeability of blood vessels due to histamine and other chemical mediators
• HR > 100 beats/min
• Cardiac Index < 251. mftH n r 2 Stasis of blood flow
• SVn < 65%
2
• Arterial factate > 2 mm/l Margmation of the polymorphonuclear leucocytes
• Base excess £ 8 mEq/1 i'
• Oxygen delivery < 600 ml/min Rolling (mediated by selections) along vessel surface
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 81
80 QUEST : A Com prehensive Gude to UG Surgery, O rthopedy ^Anesthesiology

I
Fibrocytes secrete tropocollagen
Adhesion to vessel surface (mediated by integrins)
i
D iap edesis/ Transmigration of WBC through vessel wall (mediated by PECAM-1) Tropocollagen Condense f Reticufin fibres

-i J, Condense
Chemotoxls (main chemoattractant - C5a) Collagen
1
Opsonisation (main opsonin - C3b) • Collagen formation begins by Day 5
v ' • Maximum collagen formation on Day 20-21
Phagocytosis of bacteria I microbe by WBC B) Stage of devascularisation :
Clinically, inflammation represented as • Granulation tissue looks pale as some vessels undergo atrophy or their lumen get oblit­
• redness erated due to intimal proliferation.
• warm • Nerve fibre and lymphatics formed.
• tender • Mast cells appear and then disappear
• swelling • Finally scar tissue formed (Process called cicatrization)
. loss of function V. Scar remodelling -
• Central scar remodels itself after complete synthesis of scar tissue
After an initial lag period of 14 days, wound contraction occurs, when wound is reduced to almost • Collagen remodelling increases tensile strength of tissue, by effective cross-linking
80% of its size. It occurs due to -
. Collagen contraction
• Action of myofibroblasts

"■ ^ c e l r o n wound edges lose their attachment to underlying dermis, and migrate into the
wound
i
Fixed basal cells near wound edge proliferate
I
Entire wound re-eplthdialised within 36-48 hours.

Layering of epithelium begins and cells on surface become keratinised

IV. Scar/Granulation tissue formation - 0.1 0.3 1 3 10 30 100

Days
(A) Stage of vascularisalion:
After 72 hours, neutrophils are replaced by macrophages * Factors affecting wound healing -
.1 , See Section 1
They move towards centre ot wound * Treatment options for pre-stemal keloid -
See section 1; segment C; paper 2; 2013 supplementary; Question No 9 (Page 420).
Capillary loops and fibroblasts organise themselves into granulation tissue
i 2: A 45 year old gentleman presents with Intractable anaemia and a painless lump In right Iliac
fossa of 3 months duration. How would you in vestigate the case to confirm the diagnosis.
Capillary loops differentiate into arterioles and venules
Brielly outline a comprehensive management o f the problem. [8 + 7 = 15]
i
Fibroblasts fibrocytes
82 QUEST : A Comprehensive Guide lo U6 Surgery, Orthopedics & AnestheskXogy
SOLVED LONG QUESTIONS OF FINAL M8BS 0 Paper-I 83

ANAEMIA AND PAINLESS LUMP IN BIGHT IUAC FOSSA (C) Investigations:

. Blood investigations- •
• Age - 45 years • Complete blood count - Reduced hemoglobin
• Sex - Male , _ • CEA (Carcino Embryogenic Antigen) - Level > 5 ng/ml is significant
• rhief comDlaint - Anaemia + painless lump in nght iliac fossa • LFT (to check hepatic metastasis)
S f a ^ e hSory clearly indicates a probable Right sided coton ^ n c e r For c o n f * v* • Guaiac test - for occult blood in stool
need to take some other history, examine clinically and conclude with certain investigations,
• Radiological -
(A) H isto ry: • Colonoscopy and biopsy (to confirm)
« D ie t- Red meat intake _ • Virtual colonoscopy may be done
Saturated fat intake • Others to determine spread o f lesion -
Low fibre in diet
‘ FNAC of palpable lymph nodes
Vitamin A, C, E deficiency
• For staging and operability -» PET CT > CECT Abdomen
All these are dietary risk factors.
• For T stage/ depth -»USG
• Addiction -
« Treatment -
Smoking, alcohol - increase risk
• comorbld medical con ditions- Staging (Duke's Staging) Treatment
intestinal bowel disease (Ulcerative colitis > Crohn's disease) - Long standing diarrhea, Restaicted to Mucosa + Submucosa Surgery
A
abdominal discomfort and pain, severe malnutntion increase the risk
B-| - Invades muscle layer
• Family History o f -
B B2 - Beyond muscle layer Surgery + adjuvant chemo therapy
- FAP
- Gardner’s syndrome Hjgh risk
C, - B , + lymphadenopathy
- Turcot's syndrome
C
- HNPCC C2 - B 2 + lymphadenopalhy Neoadjuvant chemotherapy
- Pentz-Jeghers syndrome ^ ^ I
Surgery
- Junenile polyposis syndrome J
i
• Associated clinical features - Adjuvant chemotherapy
- Bleeding per tectum - Early feature 0 Distant metastasis Palliative treatment + Immunotherapy
- Anorexia
- Malaise • Surgery -
Abdominal discomfort 1 More in left
' Tumor in caecum -» Radical right hemicolectomy
Recent change in bowel habit J Sided colon CA
(Removal of terminal 10 cm ileum, caecum, ascending colon, right 1/3 transverse colon
(B) Clinical Examination: and ligating right branch of middle colic artery)
* Tumor in ascending colon / hepatic flexure -> Extended right hemicolectomy
• G e n eral- ' Severe pallor
(Radical right hemicolectomy with removal of right 2/3 transverse colon and ligation
* Cachectic look »
beyond left branch of middle colic artery)
. Abdominal - Mass in right iliac fossa with following features: These are followed by ileo-transverse anas tumor
Non-tender • Chemotherapy -
Mobile (1)Folinicacid
Hard
(2) 5-Fluoro uracil
Localised
Impaired resonant sound
Does not move with respiration

Systemic - * Any hepatomegaly

Oniplalin Ironetecan
* Lymphadenopathy
I 4.
* Ascites
* Rlartrior abnormality FOLFOX FOLFORI
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 85
84 QUEST ■ A C o m p re h e n s iv e Guide to UG Surgery. Orthopedics & Anes.hesidogy

(due to mixing of undigested fat with metabolised blood derived) + Diarrhea with pale, foul
. immunotherapy- smelling stool in periampullary CA.

* Bevacizumab (B) C linical Examination:

* Cetuximab
1. General survey ~
• Liver metastasis - (a) Pallor in CA
* Resection ol involved segment (b) Jaundice
(c) Enlarged Virchow’s node in CA head of pancreas
. Follow-up-
2 . Abdominal examination-
* CEA levels
* Colonoscopy every6 monthly (a) Smooth, non tender, globular mass with well defined lower, medial and lateral margins,
* USG - Abdomen moving with respiration palpable in right hypochondriac region i.e. Gall bladder - CA head of
pancreas, periampullary CA, Choledochal cyst (according to Courvoisler’s Law, in a patient
* LFT ■
with jaundice, if there is palpable gall bladder, it is not due to stones)
• pre-operative preparation - (b) Hepatomegaly - in CA head of pancreas, periampullary CA, Cholangiocarcinoma, Klalskin
* Bowel preparation (See Page No. 58-59) Tumor (if soft - due lo hydrohepatosis, if hard, nodular - due to secondaries)
* Blood transfusion (if HB < 10 g%) (c) Trousseau's sign (migratory superficial thrombophlebitis) in CA pancreas
* Antibiotic prophylaxis
(C) Investigations:
* Catheterisation
(a) LFT-
(i) Increased total bilirubin
Q .9 :
(ii) Conjugated bilirubin raised
Describe the preoperative preparation o f jaundiced patients. I (iii) ALP, GGT highly raised
(iv) AST, ALT raised
PAINLESS PROGRESSIVE JAUNDICE WtTH PALPABLE GALL BLADDER (v) Albumin : globulin ratio normal or may be altered with reduced albumin
(b) Prolonged prothrombin time
. Courvoisler's law - In a case of painless progressive Jaundice with palpable gall bladder, k
(c) USG abdomen
cause is unlikely to be gall stones. (d) ERCP - ‘double duct’ sign in CA head of pancreas
Rased on this, choledocolithiasis is ruled out.
. When gall bladder is palpable, the jaundice is likely to be obstructive type, wh.ch needs lok (e) Barium meal - ‘Pad’ sign in CA head of pancreas, 'Reverse 3’ sign in periampullary CA
<f) MRCP
confirmed from history and investigations. P an 6loi the conger*
. Now from the known causes of obstructive jaund.ce (See Quest,on No. 3. Page 10). the conger* (g)CT Scan
causes can be ruled out due !o the given age of the patient. (h) CA 19-9 in CA head of pancreas, periampullaiy CA
. Inflammatory causes may be ruled out due to absence of fever, pain abdomen. (i) PET
0) EUS
• So, the most likely D/D are -
(1) CA head of pancreas (k) Urine te s ts - (i) Fouchet’s test (for bile pigments)
(ii) Hay’s test (for bile salts)
(2) Periampullary CA
(iii) Ehrfich’s test (for urobilinogen)
(3) Cholangiocarcinoma
RE-OPERATIVE PREPARATION OF JAUNDICED PATIENT
(A) History
1. Chief complaint - (a) Immediate hospitalisation
(a) Yellowish discolouration of urine, eyes and skin . (b) Diet - high carbohydrate, low protein, no fat diet along with vitamin and calcium supplements
(b) Intense pruritus - • (c) Adequate hydration with oral and intravenous fluid
(c) Clay coloured stool (d) i.v mannitol -1 0 % 200ml before, during or alter surgery or Inj Furosemide 40mg i.v
(e) Inj Dopamine 2 ug/kg/min
2’ 7 c A !» ,< periampullary CA ™ „ m a te : C W a n s t o * - (I) Inj Vitamin K 10mg for 3 days to correct prothrombin lime - » if still no improvement, fresh frozen
common in females
plasma is used
<9) Blood transfusion if severe anaemia
3 Associated symptoms - (ri) Broad spectrum antibiotics
(0 If praoperative bilirubin > 10mg%, ERCP stenting or PT8D done, else MRCP done.
 86 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
-SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-
I 87

2015 Supplementary □ Wagner's grading o f ulcer -

Q. 1: Discuss the etiopathogenesis and management o f acute pancreatitis /7 + ij Grade 0 - preulcerative lesion / healed ulcer
Grade 1 - superficial ulcer
A : See Section 1, Segment B, Paper-I, Qs. 10. Page No. 247.
0 .2 ; Define burns. Discuss the management o f 40% burns in a 22 year female patient o f 50 kg boq
weight, carrying 12 weeks pregnancy. " - —- Grade 3 - abscess formation underneath/osteomyelitis
Grade 4 - gangrene ol part of the tissues / limb / foot
A; BURNS Grade 5 - gangrene of entire one area/foot
□ Types o f bums :
VENOUS ULCER
A) Thermal injury
- Scald See Section 1, Segment C. Paper-I. 2013. Qs. 2, Page No. 301.
- Flame bum
- Flash bum
- Contact bum 2016
B) Electrical injury
C) Chemical bums
- Acid [5 + 5 + 5]
- Alkali Ans : CLASSIFICATION OF HAEMORRHAGE
0) Sun bums
See Section 1. Segment A, Paper-I, 2012. Qs. i (page No. 40)
• E) Ionising radiation
F) Cold injury - Frost bite
management OF HAEMORRHAGIC s h o c k
Rest- See Section 1, Segment A, Paper-I. 2013, Qs. 1, Page No. 49.
See Section 1. Segment A. Paper-I, 2008, Qs. 1, (Page No. 3)
Q.3: Classify ulcers. Discuss the pathology, clinical features, investigations and managemente
venous ulcer.
------ -------— [5 + 2 + 2 + 2+q
COMPLICATIONS OF BLOOD TRANSFUSION
A; ULCERS
See Section 1, Segment A, Paper-I. 2008, Qs. 1, (Page No 6) »
CLASSIFICATION

r
Clinical Pathological A * : See Se<#on 1. Segment A. Paper-,. 2012 Supplementary. Q , 2. (Page No. 4 f c
Spreading
(Edge inflammed and oedematous)
T— ^ developing '" I? 6 epi9astriui” "fth rapidly
Healing sPecific Non-specific Malignant arrive at a diagnosis? Out,iM O i^nuuuffim M ^^he case! W Youlnvest'j^te to
(Sloping edge + Heallhy granu- + Serous • Syphilitic ■' • Traumatic Carcinomata
lation tissue discharge) • Tuberculous x • Venous • Melanotic AnS: LUMP IN EPIGASTRIUM
Callous • Meleney's ^ Arterial x * Rodent Q Symptoms -
(Indurated + Unhealthy granu- + Difficult ulcer • Trophic
edge lation tissue to heal) •Actinomycosis • Bazin's • Lump in epigastrium
Tropical
^ Infective ‘ A R|M h?SB^ l° P,in 9 aT Xia' aS’henia' anaemia' increasin9 vomiting.
s* Diabetic obstruction ' ^ ' h6 dia9" ° SiS " Gas,fic to gastriC outlet
• Cortisol
J e Section 1. Segment A. Paper-I, 2009, Qs. 2. Page No. 16
ulcer
See Section 1. Segment A. Paper-I, 2014, Qs. 2 Page No. 71
• Martorell's
hypertensive e Section 1. Segment C. Paper-I, 2009. Qs. 3 Page No. 282.
ulcer
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-I 89
88 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

□ investigations:
2016 Supplementary
. Blood - Complete hemogram
n 1 ■ What is aanarene’’ What are the different types and causes o f gangrene? Discuss briefly tbt - LFT
' ‘ management o f a young male o f 32 years with dry gangrene on his left great toe? [2 + 5 ,8 , - KFT
A; GANGRENE - Blood sugar
. Arterial Doppler
□ What Is I t: • USG Abdomen - to know about status of aorta
Macroscopic death of tissue in situ with or without putrefaction 0 Treatment:
□ Types: A) Limb saving methods -
• Dry
. Wet Limb saving methods
□ Causes :
^ Direct I 7
r» Traumatic
Treatment of Surgeries to improve
Indirect
underlying Care of feet DrUgS limb perfusion
__ Buerger's disease cause
Secondary to arterial occlusion To be kept d r y / Antibiotics \ / <aSperneed)
— Raynaud's disease Management V Lumbar sympa­
— Atherosclerosis of diabetes -> Injury to be avoided / -» Pentoxiphylline
thectomy \ /
— Diabetes Use of proper foot­ -> Vasodilators
Omentoplasty
__ Emboli wear (Microcellular
-» Low dose aspirin
rubber fo o tw e a r^ Profundoplasty
MCR) -» Dipyridamole
Venous gangrene -> Arterial graft by­
-> Limb not to be / pass
-» Ticlopidine
-» Infective — ■— Gas gangrene warmed
— Fournier’s gangrene *-> Praxilene Femoropopliteal
• Pressure areas to thrombectomy or
— Cancrum oris be protected • endarterectomy
— Boil
• Pus to be drained
_ Carbuncle
• Measures to relieve
-> Physical----- r - Burn pain .
— Scald Nutritional supple­
— Chemicals mentation
— Irradiation
— Electrical B) Life saving methods - Limited amputation is sufficient for dry gangrene.
— Frost-bite Different types are -
• Above knee amputation
MANAGEMENT OF DRY GANGRENE
• Below knee amputation
• Ray amputation
□ Diagnosis by examination:
• Gritti-Stokes tangenital amputation
• Colour changes - pale, greyish, brownish black
• Loss of pulsation 0.2: Classify salivary tumours. Describe the pathology, clinical features and mansyement of
• Loss of sensation pleomorphic adenoma of parotid gland. [5 1 3 + 3+ 4]
• Loss of function
Ans: SALIVARY TUMOURS
• Dry mummified
» Line of demarcation between viable and non-viable tissues
 SOLVED LONG QUESTIONS OF FINAL MBBS Q Paper-I 93
« «S T :A ^ ‘

Q 2: Discuss the Investigations o f a 50 year old male presenting with obstructive jaundice and
(ii) Emprosthotonus (forward)
palpable gallbladder. Give the outline o f management o f the patient. How w ill you prepare liver
(iii) Pleurosthotonus (lateral bend)
for operation if needed? [5 + 5 + 5 ]
. Hyperreflexia Ans: See Section 1, Segment A, Paper-1,2015, Qs. 3, (Page No. 84)
. Abdominal wall rigidity + haematoma
Q.3: Discuss the pathophysiology o f acute Intestinal obstruction. How w ill you manage a case of
• Urinary retention
Intussusception ? [5 + 10]
. Constipation
. Respiratory problems - Dyspnoea Ans: ACUTE INTESTINAL OBSTRUCTION
. Features of carditis
□ Symptoms:
• Fever
See Section 1, Segment C, Paper-1,2016 Supplementary, Qs. 5, (Page No. 328)
. Tachycardia
Q prevention: , 20 11,Q s .4 (PageNo.291) INTUSSUSCEPTION
See "ActiveProphylaxis"-Section 1, SegmentC, Paper I, i a

Q Treatment: See Section 1, Segment A, Paper-1,2011, Qs. 2, (Page No, 37)

* ’ T " E S T * * * - kapt in » <■** 2017 Supplementary

. ATG {Anti Tetanus ,mmun° ^ ° ^ " 1 Tetanus Serum) - attef tniliat Intravenous test
Q.1: Describe the clinica l methods o f assessing surface area o f burns wound. Describe the
management o f 40% burns injury in a 60 kg female patient. 110 + 5]
• Inj Tetanus toxoid - 0.5 ml intramuscular Ans : See Section 1, Segment A, Paper 1,2013, Q 1, (Page No. 49)
- 1 st dose initially
- 2 nd dose after month QS>: Mention the causes o f nipple discharge. How will you investigate? How w ill you manage
_ 3 rd dose after six months
fibrocystic disease o f breast? [3 + 5 + 7 ]

• Wound debridement ,• Ans: See Section 1, Segment C, Paper 1,2008, Q 4, (Page No. 276)
. Drainage of pus Q.3: Describe the clinical features o f Gastric Outlet Obstruction. How will you Investigate and treat
. Local instillation of ATG 250-5001U a 60 year old man presenting with Gastric Outlet Obstruction? [5 + 5 + 5]
• Oxygen inhalation
Ans: CA stomach - See Section 1, Segment A, Paper I, 2014, Q 2, (Page No. 71)
• Catheterisation
. Intravenous fluids + Electrolyte balancemaintenance
. Ryle’s tube insertion - f o r decompression initially and lateroreing
2018

Q.1: A 40 year old man presents with a non-healing ulcer over the lower part o f his Inferior extremity.
: — r.* o— •« • What are the causes ? How will you investigate the case? What are the surgical considerations
• Prevention of bed sore of diabetic foot ulcer? (No operative details) [3 + 7 + 5 ]
f Prevention of DVT
Ans: ULCER
• Proper back and bowel, bladder care
. Chest physiotherapy Q Definition:
Q Specific measures: It is a break in the continuity of the covering epithelium (skin or mucus membrane) due to cell
• Inj. Diazepam - 20 mg - 6 hourly death.
. Inj. Chlorpromazine - 25 mg - 6 hourly Q Classification o f ulcer :
. Inj. Phenobarbitone - 30 mg - 6 hourly
See Section 1,Segment A, Paper I, 2015 supplementary, Q 2, (Page No. 86)
• Bronehodilators
0 Clinical examination o f an ulcer :
. Steroids 1. Site
. Endotracheal intubation / Tracheostomy if required
> r # __ • Tuberculous ulcer - Neck (over cervical lymph nodes)
 94 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics S Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ P a p e r-, 95

• Syphilitic ulcer - Penis 0.3: What are the causes o f Intra abdominal iumo in th» ,
• Rodent ulcer - Forehead, face . . management o f Hydatid cyst o f the liver epigastrium? Discuss the
• Venous ulcer - Leg {above the medial malleolus) [5 + 1 0 ]
2. Number
• Single - Syphilitic ulcer, rodent ulcer, carcinomatous ulcer, venous ulcer m : i E S E Z r * sf ° " '• S w “ *■ 1 Q* **>■ ■»
HYDATIO CYST OF LIVER - See Section I.SegmenIC, P a p e , 2016, 0 5 . (Page No. 324)
• Multiple - Tuberculous ulcer
3. Size
2018 Supplementary
4. Shape
0.1: Define Claudication. What are the aradec n t n . „ rr, „ ~ ..
5. Margins - May be regular or irregular, oval or rounded
Buerger's disease with dry gangrene o f the foot? ^ ’ wll‘ Vou manage a case o f
• Tuberculous ulcer - Thin bluish margins
6. Edge o l the u lc e r- It is useful in diagnosis of ulcer as well as assessment of healing Ans: See section 1, Segment B, Paper I. Q 4, (Page No. 224),
• Tuberculous ulcer - Undermined edge
• Syphilitic ulcer - Punched out edge
• Rodent ulcer - Raised and beaded edge
M : BLEEDING PEB BECTUM . S„ S * ,, K & ^
• Carcinomatous ulcer - Rolled out and everted edge
‘ inflamed and edematous edge signifies spreading ulcer.
* Sloping edge is seen in a healing ulcer. 2019
' Indurated edge is a feature of non healing/ callous ulcer.
7. Floor o f the ulcer 0 1 :Z 7 e ^ t o ^
• Tuberculous ulcer - Pale granulation tissue
• Syphilitic ulcer - Wash leather slough
Paper 1, 2014, Q.1 (Page No. 66).’ *’ 2° ° 8' ° ' 1 (Pa9e N° ' 3)‘ & See Sec,i° n 1. Segment A,
• Rodent ulcer - scab (made of epithelial cells and dried serum)
• Carcinomatous ulcer - covered by necrotic tumor, blood and serum
• Venous ulcer - Healthy pink/ red granulation tissue o fs lv e r e ^ ^ ^ ^ th g With the
8. Base of the ulcer •'
• No induration - Venous ulcer
• Indurated - Syphilitic ulcer, rodent ulcer, carcinomatous ulcer, tuberculous ulcer
9. Any discharge from the ulcer
“ * ■ "■ « “ * s« s.
t Serous - healing ulcer
• Purulent - infected ulcer
• Bloody - Carcinomatous ulcer pusis^ l lyB0
n(IsleadlfyP
^og"Jss!l6^o°^scolMaUoy0l dU'''Va9Ue.epi9aStr'cpaln"',h
• Yellowish - Tuberculous ulcer
with Intermittent rise of temper&fure~wTlh skiv — — ^ - 1 ves and urine for last 4 months
10. Whether the ulcer extends to the normal tissue or not
history of recently de^lop^d anorexia and a ^ s ^ ln ^ i^ '°n ” * * * H* B,s° « * » '
Is palpable as soft cystic swelling How would v T tn A , ? examina,ion- his g a ll bladder
11. Examination of regional lymph nodes
W e n t, prepare ^ g Z R Z S ^ J S ^ * detailed " ° rk* P <>'the
• Rodent ulcer, venous ulcer - No involvement toatment(principles only Including palliation) J °Peration and give the outline o f his
• Tuberculous ulcer, syphilitic ulcer, carcinomatous ulcer - lymph node involved
12. Examination of distal pulses, sensations, joint movements, function of the limb ■ Ans. See Section 1, Segment A, Paper 1,2015. Q.3 (Page No. 84)

DIABETIC FOOT ULCER - See Section 1. Segment A, Paper 1,2009, Q 1, (Page No. 13).
Q' 2019 Supplementary
0 .2 : A 25 years old female, recently married, presents with sudden pain over the right lower abdomen
How w ill you take up the case to come at a diagnosis? Outline the management o f Acult
Appendicitis. (No operati ve details) [10 + 5] resuscitation o l a 40 Kg lady with 40’/ TBSA r r r f distribution o f fluid necessary for
A ns: See Section 1, Segment B, Paper I, Q 1, (Page No. 216) P o la n d Formula? SA < * * * Bod* Sur1ace Area) burn, according to

AnS: SeC,ion 1■Se9me"> ^ Paper I. 2013, Q. 1, (Page No. 49) fs * S * V

 95 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Q S: A 50 year old gentleman, severely anemic, anorexic A cachectic, presents with the history 0/
epigastric fullness A vomiting for last 4 months with the appearance o f an Irregular epigastric
□ Role o f hospital pharm acist:
SOLVED LONG QUESTIONS OF FINAL MBBS Cl .. , „
lump for last one month. How would you proceed to diagnose, prognosticate S manage the
patient? (5 + S + $ j

Ans: See Section 1, Segment B, Paper I, Q.9, (Page No. 241). b) Maintaining records of antibiotics distributed to medical department
□ Role o f nursing s ta ff:
Q.3: A 25 year old young lady, married fo r last 3 months presents at the EH with severe right ilijC
a) Participating in Infection Control Committee
fossa pain. How would arrive at a clinical diagnosis? What are the differentials diagnosis? Why
are the investigations you need to undertake to confirm your diagnosis? [5 + 5 + $] b) Promoting development and improvement ol nursing technique
c) Ongoing review of asepfic nursing policies
Ans: See Section 1, Segment B, Paper I, Q.1 (Page No. 216).
□ Central sterilisation service ;
a) Oversee use of different methods
December-January 2020 b) Ensure technical maintenance of the equipment
0 .1 : What are Hospital Acquired Infections (HAi) and Surgical site Infections (SSI)? Define Bacteremk 0 Role of food service: Maintain cleanliness and hygiene
and Systemic Inflammatory Response Syndrome (SIRS)? How would you prevent Infections □ Joint effort o f housekeeping and laundry services:
(broad outline only) [2 \ i + 2'A + 2J4 + 2Vt + 5]
Q Universal/standard precautions fo r infection control:
Ans: See Sect/on 1, Segment D, Short Notes Q. 79 (Page No. 536) Systemic Inflammatory Response
a) Hand hygiene - follow all steps at following points
Syndrome (SIRS).
i) before patient contact -
ii) before aseptic task
PREVENTION OF INFECTION (BRIEF OUTLINE) 5 marks
iii) after patient contact
Guidelines by National Center for Disease Control (NCDC) • iv) after body fluid exposure risk
□ Infection control committee to be established consisting o f : v) after contact with patient surroundings
• Chairperson b) Personal protective equipment
• Member secretary i) Gloves
• Members ii) Disposable plastic apron
• Relevant medical faculties iii) Mask
• Support services •v) Eye protection
• Infection control nurse e) Safe handling and disposal of sharps
• Infection control officer d) Follow needle stick injury protocol
□ Aim o f sterilisation: Asepsis 0 irrigate mucous membrane by washing under running water
It) never rub / squeeze the injury site
□ General guidelines for disinfection:
iii) wash with soap and water
a) Critical instruments -> undergo sterilisation before and after use
w) aPP'y antiseptic lotion to injury site
b) Semi-critical instruments -» high level disinfection before use and intermediate leve!
v) contact emergency room medical officer for management
disinfection after use
v0 complete incident report
c) Non critical instruments -» only intermediate or low level disinfection before and after use
e) Sa,e handling and disposal of waste
□ Role o f physician:
0 Managing blood and bodily fluids
a) Provide direct patient care practices which minimise infection
9) Disinfection of equipment
b) Follow appropriate hygiene practice
h> Dis'nfection of environment
c) Protecting own patients from other infected patients and infected hospital staff
0 Immunization
d) Comply with practices approved by Infection Control Committee
j) Isolation
e) Obtain appropriate microbiological specimen when infection present or suspected
f) Notifying cases of hospital acquired infection
 ________________SOLVED LONG QUESTIONS OF FINAL MBBS □ P ap e r-I 99
QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
98

> Progressive weight loss

> On examination
- epigastric fullness
- outlines of enlarged stomach
Ans : See Section 1. Segment A, Paper I, Q. 2 (Page No. 23-24) - succussion splash
- dehydration
C O M P LIC A TIO N S OF CH RO NIC PEPTIC U LCER
» Investigations -
□ Most common com plications: > CBC • ' •. •
a) Perforation - • > Serum electrolytes
b) Bleeding > Renal function test
c) Obstruction > Barium meal ’
d) Malignancy > Oesophago gastroduodenoscopy - dilated stomach with atrophic gastritis

□ Perforation ; • Treatment -
. Incidence - 4 -14 cases per 1 lakh individual a) Conservative - fluid and electrolyte .replacement ;•
. Clinical feature - Acute onset abdominal pain which begins in epigastrium, gradually becon* b) Medical - Gastric antisecretory agent .
generalised (when associated with diffuse peritonitis) . c) Surgical - Truncal vagotomy and gastrojejunostomy

• Diagnosis - □ Malignancy: Peptic ulcer can give rise to gastric carcinoma in 1% cases mostly adenocarcinoma.
> Chest X-ray (upright posture) - Pneumoperitoneum (Fordetails-See Page No. 71). ‘
> USG - decreased peristalsis and free fluid
0.3 : A lactating women presents to emergency with painful lump In her right breast which Is associated
> CECT - Identify site of perforation and presence of ongoing leakage with fever. Write down the clinical examination, Investigation and treatment o f this patient.
> Test for H. Pylori Infection [5 + 5 + 5]
• Management - Ans: See Section 1, Segment C, Paper II, Q. 3 (Page No. 362-363) Breast Abscess.
. > Nasogastric suction
• > Fluid resuscitation . •' ,
. > Antibiotics June-July 2020
> Surgery - If failure to imp rove within 24 hours
Q. I : Classify wounds. Write In details about wound healing and factors affecting wound healing.
- Omental patch closure
[5 + 5 + 5]
- Highly selective vagotomy
- Truncal vagotomy Ans: See Section 1, Segment A, Q. 1 (Page Nq. 13-14) and Page (79-81) “Wound Healing".
- Vagotomy with anlrectomy *-
Q.2: A BO year old man presenting with palpable lump In rig ht hypochondrium with yellow
□ Bleeding from peptic ulcer ; discolouration o f eye. What Is your diagnosis? Discuss the etiopathogenesis, investigation and
treatment o f this case. [3 + 4 + 4+ 4]
• Clinical features -
> Melaena Ans:
> Hematemesis .
> Features of shock - cold clammy extremit hypotension, tachycardia PALPABLE LUMP IN RIGHT HYPOCHONDRIUM
• Management - See page 24 □ Diagnosis:
□ Obstruction by peptic u lc e r: • Most common cause CARCINOMA HEAD OF PANCREAS
• Clinical features - • Other causes may be - ductal carcinoma
> Vomiting - projectile, yellow coloured (not bile stained), foul odour - Cholangiocarcinoma ol mid portion of common bHe duct
> Epigastric pain - gastric carcinoma with para aortic lymph node metastasis
 100 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

□ Etiopathogenesis: SEG M ENT-A

• Risk (actors
SOLVED LONG QUESTIONS OF FINAL MBBS
Paper - II
Demographic factors Environment / lifestyle Genetic factors & medical conditions

Age (peak Incidence Cigarette smoking Family history 2008

65-75 years i) Two first-degree relatives with
o.; ; Enumerate the causes o f hematuria. How w ill you confirm the diagnosis? What will you do fora
Male gender pancreas cancer; relative risk
patient diagnosed to have carcinoma o f urinary bladder? (5 + 5 + 5]
Black ethnicity Increases 1 8 -57-fold
ii) Germiline BRCA2 mutations in some CAUSES OF HEMATURIA
rare high-risk families
Hematuria is defined as abnormal presence of RBCs in urine.
Hereditary pancreatitis (50- to 70-fold
It is of 2 types: (1) gross (2) microscopic (> 5 RBC/hpf).
increased risk)
The causes of hematuria are as follows:
Chronic pancreatitis (5- to 15-fold A. Kidney cause:
Increased risk)
(a) Glomerular hematuria
Lynch syndrome (HNPCC) (i) Primary causes -
Ataxia telangiectasia 1. Acute post streptococcal glomerulonephritis (APSGN)
Peut2-Jeghers syndrome 2. IgA nephropathy
3. Membranous glomerulonephritis
Familial breast-ovarian cancer syndrome
4. Membrano-proliferative glomerulonephritis
Familial atypical multiple mole melanoma 5. Focal segmental glomerulosclerosis
Familial adenomatous polyposis - risk of 6. Alport syndrome
ampullary/duodenal carcinoma 7. Benign familial hematuria
Diabetes meliitus (ii) Secondary causes - . •
1. SUE
2. Subacute bacterial endocarditis (SABE)
□ Pathology; 3. Henoch Schonlein purpura (HSP)
• Tumors arising In head pancreas are mostly ductal adeno carcinoma 4. Hemolytic uraemic syndrome (HUS)
• Solid, scirrhous tumours characterised by neoplastic tubular glands within a market)! 5. Wegener's granulomatosis
desmoplastic fibrous stroma 6. Polyarteritis nodosa
• Infiltrate locally, typically along nerve sheaths, along lymphatics and Into blood vessels - 7. Exercise induced hematuria •
liver and peritoneal mats are common (b) Non-glometular hematuria
• Often preceded by pancreatic intraeplthelial neoplasia 1. Tumors -Wilm’s tumor, Renal cell carcinoma (RCC)
• Tumors arising from ampulla or distal CBD can present as a mass in head of pancreas 2. Trauma-Stab/Blunt injury
• Intraductal papillary mucinous neoplasms common in pancreatic head 3. Renal vascular disorders- Rena! vein thrombosis, Renal artery embolism, Renal aneurysm,
• Jaundice occurs due to obstruction of distal bile duct by the tumour Arterio-venous fistula
4. Infections- Pyelonephritis, Tubulo-interstitial nephritis
For Investigation and treatment See Section 1, Segment A, Paper I, Q. 3 (Page No. 27-2#
5. Anatomical abnormalities- Polycystic kidney disease, M ulticystic renal disease,
'Management of CA head of pancreas".
Hydronephrosis
0 .3 : Classify bums. How w ill you manage a case o f 30% bum s with a sho rt note on post bum 6. Kidney stone
sequelae. 7. Kidney TB
[5 + 5 + 5! 8. Idiopathic hypercalciuria
B Ureter cause :
Ans: See Section t, Segment A, Q. 1 (Page No. 49) 'Bum Wound” and See Section 1, Segment!)
’ • Ureteric stone
Q. 107 (Page No. 566) “Post-Burn Contracture".
Tumor

mi
 102 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 103

C. Bladder cause: 2 evaluation of gross hematuria -

1. Cystitis (a) colour of urine:
2. Tumor- Papilloma, Urothelial cell CA . Cola coloured- Hematuria of glomerular or upper urinary tract origin
3. Tuberculosis . Bright red coloured- Hematuria of bladder or lower urinary tract origin
4. Vesical calculus (b) Pattern of hematuria:
5. Urinary Bilharziasis • Hematuria throughout the stream- Hematuria can be of upper or lower urinary tract origin
D. Urethra cause : . Hematuria in the later part of voiding- Bladder pathology
1. Trauma •Hematuria in the initial part of voiding- Hematuria of lower urinary tract origin (Urethraf
2. Slone pathology)
3. Tumor (c) Recurrent hematuria- seen in IgA nephropathy, Alport syndrome, Benign familial hematuria,
£ Prostate ca u se : Idiopathic hypercalduria, Exercise induced hematuria, Urolithiasis

1. Benign prostatic hyperplasia (BPH) 3. Associated features -

2. Prostate CA (a) Pain;
• Colicky pain- kidney stone, ureteric stone
F. Miscellaneous causes:
• Dull aching pain- Vesical calculus, cystitis
1. Drugs - Analgesics (NSAIDs), Anticoagulant therapy
• Painless hematuria- RCC, Bladder CA, BPH, urinary bilharziasis, APSGN, leukemia,
2. Blood dyscrasias - Sickle cell anaemia, ITP, Leukemia
anticoagulant overdose, snake bite
3. Coagulation disorders - Hemophilia, DIC
(b) Fever- APSGN, pyelonephritis, cystitis, urinary bilharziasis, SABE
4. Snake bite
(c) Facial puffiness, hypertension- seen in APSGN
. DIAGNOSIS OF HEMATURIA (d) Symptoms suggestive of Lower urinary tract symptoms (LUTS) / bladder outlet obstruction
(Hesitancy, urgency, frequency, poor stream of urine, dribbling. Inadequate emptying) - BPH,
Prostalic CA, bladder/urethral pathologies
(e) Night fever, weight loss- Genitourinary TB
(f) H/O sore throat (2-3 weeks back) / pyoderma (3-6 weeks back) - seen in APSGN
(g) Deafness, visual problems- Alport syndrome
(h) Urticaria for a few days, fever after 4-8 weeks-Urinary bilharziasis
4. Occupational history:
• Aniline dye factory workers- Bladder carcinoma
• Long distance runners (>10 km) - Exercise induced hematuria
• Fresh water swimmers — Urinary bilharziasis
5. Family history- ■
• Hematuria with non-progressive renal disorder - Benign familial hematuria
• Hematuria, deafness, visual problems, progressive renal disorder - Alport syndrome
• Hematuria, renal stone- Idiopathic hypercalciuria
6. H/O drug Intake - Analgesics, Anticoagulants
7. H/O snake bite - Snake bite induced hematuria
□ General examination :
1. Pallor - seen in malignancy (RCC, Bladder CA), tuberculosis, HUS, leukemia
Confirmation o f hematuria:
2. Jaundice - seen in HUS, coagulopathy with hepatic failure
a H isto ry:
3. Edema - Pitting edema is seen in APSGN
1. A g e -
4. Lymph node - Cervical lymphadenopathy may be seen in Genitourinary TB
• Children - Vesical calculus 5. Pulse rate - Tachycardia is seen in rapid blood loss due to renal injury (kidney/ bladder)
• Young adults - Kidney stone, Kidney TB 6. Blood pressure - Hypertension is seen in APSGN, Polycystic kidney disease
• Adults - Polycystic kidney disease (Onset at 30-40 years of age) 7. Temperature - elevated in APSGN, pyelonephritis, cystitis, SABE, urinary bilharziasis
• Elderly - RCC, BPH, Prostate CA 8. Purpuric spots - seen in ITP, leukemia, anticoagulant therapy
 104 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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9. Osier’s nodes - seen in SABE (c) Culture and sensitivity:

10. Butterfly rash, arthritis - SLE
• Gram staining - useful in UTI
11. Lymphadenopathy, hepatosplenomegaly - Acute lymphoblastic leukemia
• AFB staining - AF8 may be observed in genitourinary TB
□ Systemic examination: (d) Special diagnostic investigations :
1. Abdominal lump -
•Va I 00' Urina,y Cal,CiUm' UnC aCid' 0Xa,ale excre,ion - ‘of urolithiasis, nephrolithiasis
• Kidney lump - seen in RCC, Wilm's tumor, polycystic kidney disease
•rhiiHron f >, 4 m9/k9’ Spot Urinary ^ 'c iu m : creatinine ratio > 0.2 (in
• Distended bladder - seen in prostatic CA, BPH children >1 year) - seen in idiopathic hypercalciuria
2. Abdominal tenderness - Blood profiles -
• Renal angle tenderness - kidney injury, polycystic kidney disease (PCKO), pyelonephritj • Complete hemogram
• Suprapubic tenderness - cystitis, vesical calculus • Serum urea, creatinine
3. P/R examination - • Serum total protein, albumin
• Enlarged smooth prostate, free overlying rectal mucosa - seen in BPH • Serum cholesterol
• Enlarged, hard, irregular prostate, fixed overlying rectai mucosa - seen in prostate CA • Serum electrolytes
4. Examination of genitalia - • Serum C3- Low serum C3 level seen in ;
• Varicocele - seen in RCC > APSGN
• Craggy epididymis, beaded vas deferens, hard and thickened seminal vesicles - seent > Membranoproliferative GN
Genitourinary TB > SLE nephropathy
• 5. Changing murmur in heart - seen In SABE > SABE nephropathy
□ Investigations : • Serum ASO titre- Increased ASO tifre is seen in APSG N
1. Urine examination - • Serum calcium, uric acid- for Urolithiasis, nephrolithiasis
(a) Routine examination :
T™ r d0,,i" !1“ W 8CT|- " ™ >2° ' " * " 5“ * • « •
• Specific gravity
• Protein
• Sugar (a) DTPA (Diethylene triamine pentaacetic add) scan,
• Blood (b) DMSA (Di mercapto succinic acid) scan,
• Ketone (c) MAG-3 (Mercapto Acetyl Glycine) scan
(b) Microscopic examination : Radiological investigations -
• Phase contrast microscopy - to detect dysmorphic RBC (a) Straight X-ray of KUB region :
• Radio-opaque shadows - kidney, ureteric and bladder stones
Glomerular Hematuria Non glomerular Hematuria • Enlarged kidneys - Polycystic kidney disease
(b) Intravenous urethrography (IVU):
• Clinical features- edema, hypertension more • Clinical features - edema, hypertension are
common uncommon • Filling defects in ureter or bladder - Tumor (if irregular), stone (if regular)
• Spider leg deformity of calyces - seen in PCKD
• Urine examination - (i)RBC casts - present • Urine examination - (i) RBC casts - absent
(ii) Albumin - 2+ or more (iii)Phase contrast (ii)Albumin - Trace or 1+ (iii) Phase contrast • Irregular calyces - seen in RCC
microscopy - Deformed/dysmorphic RBC microscopy - Dysmorphic RBC < 15%, • Missing calyces - seen in Kidney TB
> 15%. Acanthocytes > 5%, G-1 cells Acanthocytes < 5%, G-1 cells < 5% (c) USG of abdomen :
(Doughnut shaped ceils with blebs) > 5% • enlarged kidney - seen in RCC. Wilm's tumor, PCKD
(d) CT scan ;
' Exercise induced hematuria- Glomerular in origin, RBC casts are sometimes present in urine, doesm (e) Cystoscopy:
satisfy other criterias of glomerular hematuria
• Indications are -
• Worm like clots - seen in ureteric tumor
> H/O Lower urinary tract symptoms (LUTS)
• Flat disc like clots - seen in urethral pathology
> Hematuria with normal IVU
• Pieces of tumor - seen in papilloma of bladder
' Malignant cells found in cytology ol urine
• Ova of Schistosoma haematobium - seen in urinary bilharziasis
• may be followed by brush biopsy.
• Exfoliative cytology (by Papanicolau staining)
• bladder tumor, stone and tuberculosis can be diagnosed.
 106 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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• bilharzial pseudotubercles, bilharzial nodules, sandy patches, ulceration,

granuloma, papilloma (presence of any 1 or more) - suggestive of urinary MANAGEMENT OF CARCINOMA OF URINARY BLADDER
bilharziasis
A. For nonlnvasi ve bladder tumor
(f) Retrograde pyelography - to diagnose bladder and ureteric pathology
1. Endoscopic resection of bladder tumor
(g) Urethrography - to diagnose urethral pathology
2. Helmstein balloon degeneration and cystoscopic resection :
(h) Transrectal Ultrasound - to diagnose prostate CA, BPH
• Done for large papillary tumor
(i) Echocardiography - to diagnose SABE
Algorithm forevaluation o f hematuria:

IVU

JZ
Normal Abnormal
3. Intravesical chemotherapy:
• Used especially for carcinoma in situ
Cystoscopy Filling defect In
Renal stone Tumor • BCG is mostly used.
and biopsy

Bladder
I
Lateralising
the renal pelvis

Retrograde
• Dose-120 mg of BCG in 150 ml of normar saline weekly for six weeks

Normal I Renal CTAJSG • . ^ r 0^ 0" <f8Ver’ i0‘nt Pa,n’ 9ranuloma,ous Pros'a>i«is. disseminated
tumor ureteric pyelography/
bleeding *' Brush cytology • Contraindication- hematuria
• Mitomycin C, adriamycin, epirubicin, metrotrexate, thiotepa can also be used
Renal CT/USG 4. Systemic chemotherapy:
Solid lesion Cystic lesion
(probably (probably • Cisplatin, Adriamycin, 5-FU and mitomycin are used.
X m alignant) benign) J For Invasi ve bladder tumor
H , t. Radiotherapy :
Normal Tumor
Cystoscopy (a) Interstitial radiotherapy
and biopsy
• Often curative.
•
Implantation of radioactive gold grains (Au 198, half-life =2.5 days) / radioactive
tantalum wires (Ta 182, half-life = 4 months) is done.
(b) Radical deep external beam radiotherapy
• Dose- 45 Gy
• Cobalt 60 is used
• Advantage- Normal act of micturition can be maintained
• Complication- Thimble/Systolic bladder
2. Surgery ;
• Indications:
(a) Multiple tumors
(b) Recurrent tumors
(c) Sessile tumors
Id) Poorly differentiated tumors
(e) Adenocarcinoma
(f) Squamous cell carcinoma
(g) Carcinoma in situ
• Modalities:
(a) Partial cystectomy-
> Indication- single tumor, tumor confined to fundus of bladder
 108 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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> 2.5 cm margin of clearance is maintained □ Complications:

> Surgery is followed by external beam radiotherapy and chemotherapy. 1. Trachea) obstruction -
(b) Radical cystectomy - • by retroslernal extension of the goiter.
> Removal of urinary bladder, urethra, paravesical tissues, pelvic lymph nodes
• may follow hemorrhage into a nodule impacted in the thoracic inlet.
Is done. Hyterectomy with removal of part of vagina is done in females.
2. Secondary thyrotoxicosis - Transient episodes of mild hyperthyroidism (30%)
> Urinary diversion is done by ureterosigmoidostomy or continent ileal conduit
or rectal urinary pouch. 3. Carcinoma - Increased incidence of Follicular CA of thyroid reported from endemic areas.
. 3. Chemolherapy: Management:
(a) Intravesical chemotherapy . The term Multinodular goiter describes an enlarged, diffusely heterogeneous thyroid gland
• Done by BCG, mitomycin C, adriamycin, interferons. • Multinodular goiter is essentially of 2 types -
(b) Systemic chemotherapy - j. Simple (Non-toxic) Multinodular goiter
• Regimen for adjuvant therapy : (i) Cisplatin, adriamycin, mitomycin, vinblastin 2. Toxic Multinodular goiter
(ii) Methotrexate, vinblastin, adriamycin, cisplatin (MVAC) • Multinodular goiter may present a s :
• Neoadjuvant chemotherapy : Cisplatin is used (improves survival by 7%)

0 .2 : Discuss the pathogenesis o f multlnodular goiter. Mention the complications o f such a goiter, Non toxic Multinodular Goiter
Toxic Multinodular Goiter
How do you manage such o patient? [5 + S+i]
• More common in middle aged females (10:1) • Usually middle aged - 40 to 60 years of age
MULTINODULAR GOITER • Most patients are asymptomatic • F> M
• Swelling of neck, dysphagia, dyspnea • Secondary thyrotoxicosis
Pathogenesis: • Distension of cervical veins due to pressure
• Features of hyperthyroidism- Wt. loss, diarrhea,
effect
fatigue and muscle weakness, tremor, ofigo —
Persistent TSH stimulation • Dysphonia - Rare and suggests neoplastic le­ or amenorrhoea. excessive appetite, emo­
sion tional lability
Diffuse hyperplasia Active follicles 1 • Sudden pain with increase in size of gland- • Cardiovascular manifestaions - Palpitation,
due to large hemontiage within a cyst or a de­ Shortness of breath, Angina, Irregular heart
1 generative nodule or sometimes due to infec- rate
(on.
Fluctuating stimulation • Dysphagia, dyspnoea

Mixed pattern develops Areas of active and inactive tobules Wayne's Clinical Diagnostic Index -

Signs
I Palpable thyroid
Present Absent
Active lobules ♦3 -3
Exophthalmos +2
Become more vascular and Hemorrhage Central necrosis Lid retraction +2
hyperplastic Finger fremor +1
Bruit over thyroid +2 -2
Atrial fibrillation +4
Necrotic lobules coalesce to form nodules filled with either iodine-
Pulse Rate:
free colloid or a mass of new but inactive follicles.
90/mm +3
80/mln

Centre of the nodule is inactive. Only margin is active Hands:

i.e. Intemodular tissue is active. hot
+2
moist +f
typertdnetic movement 44
Continual repetition of this process - formations of many Lid lag
+1
nodules and hence Multinodular goiter.
110 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology
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Symptoms Present Absent

Non toxic goiter - Often shows patchy uptake with areas of hot and cold nodules
Palpitation +2 Toxic goiter- 'H o f areas
Excessive sweating +3 7. Indirect laryngoscopy -
Increased appetite +3
Reduced appetite -3 purpose)5 V0Cal° 0rdm° VementSPri° f f ° SUf9ery <mainlyf° rdoc™ e" 'a " ° " modicotegal
Increased weight -3 8. E C G - To detect cardiac abnormalities
Reduced weight +3 9. Baseline investigations -
Preference for cold +5 a) Complete hemogram: Hb%, TC, DC, ESR
Preference for heat -5 b) Blood lot sugar, urea and creatinine
> Index >19 = Toxic goiter c) Urine and stool routine examination
> Index 11 -1 9 a equivocal Treatment:
> Index <11 = Non toxic goiter (euthyroid) A Non toxic goiter

□ Investigations:
2) SuT'aryll0n,$ ^ ,nUl,in0dUlar 9° i,er are asymPfomat'C and do not require operation.
1. Thyroid function test -
a) TSH, Free T4- to detect hyperthyroidism. • II is preferred as MNG is an irreversible stage.
» Indications -
• Serum Thyroid-Stimulating Hormone (Normal 0.6-5 micro lU/mL)
a) Cosmetic reason
• Total T4 (Reference Range 55-150 nmol/L) and T3 (Reference Range 1.5-3.5 nmoU)
• Free T4 (Reference Range 12-28 pmol/l) and Free T3 (3-9 pmol/L) b) Retrosternal prolongation
Non-toxic go iter- Usually euthyroid with normal TSH and low-normal or normal free T4 levels. I c) Compressive symptoms
some nodules develop autonomy, suppressed TSH levels or hyperthyroidism d) MNG suspected to be neoplastic
Toxic goiter- Free T4 - very high, TSH- low or undetectable • Options -
b) Thyroid Antibodies assessment - to differentiate from autoimmune thyroiditis (TPO and a) Subtotal thyroidectomy­
Thyroglobulin antibodies) and Grave’s disease (LATS). > 2 x subtotal lobectomy + Isthmuseclomy
2. X-ray neck and chest - to detect tracheal deviation or compression or sometimes calcification
> 8 g thyroid tissue is retained in tracheo-oesophageal groove on both sides
3. Ultrasound ot neck - r burgery of choice
• To Identify impalpable nodules (<2-3 mm in diameter)
b) Total thyroidectomy - 2 x total lobectomy + isthmuseclomy
• Gives Information about size and multicentricity.
• Distinguishes solid from cystic lesion C) T ' * yZ U nm P'0cedure " Total lobectomy on the more affected side *
isthmuseclomy + Subtotal lobectomy on the less affected side
• To guide FNAC • Post operative complications - In 7-10 percent cases
4. CT/MRI-
• Postoperative levo-thyroxine (0.1 mg daily) - to prevent recurrence
• To evaluate Retrosternal extensions. • Recurrence - 10-20 percent within 10 years
• To detect Impalpable nodules Toxic goiter
5. FNAC-
(a) GENERAL MEASURES
• recommended in patients who have a dominant nodule or one that is painful a
enlarging 1. Rest
• Done as carcinomas have been reported in 5 to 10% of multinoduiar goiters. 2. Sedation
• Most experts have recommended 3-6 aspiration per nodule. Satisfactory specima (b) SPECIFIC MEASURES
contains atleast 5-6 groups ol cells, each group containing 10-15 well preserved
1- Anti - thyroid drugs
cells
6. Radioisotope study (Isotope used - 1123 [Half life -12-13 hrs] or Tc99[Half life-6 hrs]) • Initially given to make patient Euthyroid before surgery
• ‘ Hot ‘ nodule - Toxic • Carbimazole 10mg 6-8 hriy- Euthyroid state may be achieved by 6-8 wks
• 'Warm' nodule • Euthyroid; • Propranolol 20-40 mg BD/TDS- To ameliorate catfovascular symptoms
Warm nodule in Tc99 scan, but cold nodule in RAI scan- Discordant nodul* • Lugol s iodine 10-30 drops/day for 10 days prior to surgery - To reduce vascularity of
(Malignancy)
• ’ Cold' nodule - 20% malignant, 80% benign 2. Radioiodine Ihorapy
 112 QUEST: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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□ Indications ; • Failed radioiodine therapy

• Patient with cardiac complications • Those who require rapid resolution at thyrotoxic state
• Elderly ( initially 40yr age .however now more than 10 yr age eligible ) □ options:
□ Contraindication : Pregnane y • Total thyroidectomy (Surgery of choice)
□ Adjuvant: Pretreatment with lithium, rhTSH leads to increased effectiveness of uptake . Near total thyroidectomy - < 2 g of thyroid thyroid tissue is kept only to preserve parathyroi d
□ Isotope use d : 1131 (half life = 8 days) glands, near lower pole on one or both sides
□ Dose: 300-600 MBq or, 12-14 milicurie or, 160 microcurie/g of thyroid orally • Subtotal thyroidectomy
❖ Substantial improvement b/w 8-12 wks. □ Advantages:
> Rapid cure and High cure rate
□ Disadvantages:
Antithyroid therapy until • Recurrent thyrotoxicosis (5%)
eumetabolic state (2-8 wk) • Permanent hypothyroidism (20-45%)
• RLN injury
□ Pre operative:
Medication discontinued for 4
. CT scan, MRI .
days
• Restoration of euthyroidism
□ postoperative:
12-14 mCurie radioiodine is deposited into the Tab Carbimazole- 10mg, 6-8 hourly '
gland based on pretreatment RAIU test i
No clinical improvement for 7-14 days
i .
7 days thereafter, antithyroid drug is Euthyroid state achieved in 6-8 weeks
reinstituted for 3 months
I
Maintenance dose - 5mg, 8 hourly for 12-18 months

If size reduces No improvement j 2008 Supplementary

' ' 0. 1 : Enumerate the causes o f acute retention o f urfne. What are the pathological changes associated
Dose of Antithyroid
Second course of with prostratlc hypertrophy? How will you manage such a patient 7 [ s * 5 + 5]
drugs is tapered
therapy/Surgery
gradually : ACUTE RETENTION OF URINE

o Causes :
□ Adverse effects : A) Prostatic causes -
• Low level exposure to radiation (i) Benign hyperplasia of prostate
• Hypothyroidism (ii) Prostatitis
• Radiation induced thyroiditis (4% cases) (iii) Carcinoma of prostate
• Therapeutic dosing dilemma B) Bladder causes -
• Orbitopathy (i) Bladder calculus
3. Surgery (ii) Bladder neck muscular hypertrophy
□ Indications: («i) Bladder neck fibrosis
• Young patients (iv) Carcinoma of bladder
• Mid trimester pregnancy C) Urethra) causes -
• One or more large nodule with obstructive symptoms (i) Urethral calculus
 112 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ P ap e r-II 113

□ Indications: , Failed radioiodine therapy

• Patient with cardiac complications , Those who require rapid resolution at thyrotoxic state
• Elderly ( initially 40yr age .however now more than 10 yr age eligible) q Options:
□ Contraindication: Pregnancy . Total thyroidectomy (Surgery of choice)
□ A djuvant: Pretreatment with lithium, rtiTSH leads to increased effectiveness of uplake , Near total thyroidectomy - < 2 g of thyroid thyroid tissue is kept only to preserve parathyroid
□ Isotope used r i 131 (half life = 8 days) glands, near lower pole on one or both sides
□ Dose: 300-600 MBq or, 12-14 mllicurie or, 160 microcurie/g of thyroid orally , Subtotal thyroidectomy
<> Substantial Improvement b/w 8-12 wks. □ Advantages:
, Rapid cure and High cure rate
□ Disadvantages:
, Recurrent thyrotoxicosis (5%)
. Permanent hypothyroidism (20-45%)
. RLN injury
□ Pre operative:
• CT scan, MRI
• Restoration of euthyroidism
□ postoperative:
Tab Carbimazole - 10mg, 6-8 hourly
I
No clinical improvement for 7-14 days
I
Euthyroid state achieved in 6-8 weeks
i
Maintenance dose - 5mg, 8 hourly for 12-18 months

2008 Supplementary

Q. 1: Enumerate the causes o f acute retention o f urine. What are the pathological changes associated
with prostratlc hypertrophy? How will you manage such a patient ? [5 + 5 + 5]

Ans: ACUTE RETENTION OF URINE

______________________________________ □ Causes :
□ Adverse e ffe c ts : A) Prostatic causes -
• Low level exposure to radiation (i) Benign hyperplasia of prostate
• Hypothyroidism (ii) Prostatitis
• Radiation induced thyroiditis (4% cases) (iii) Carcinoma of prostate
« Therapeutic dosing dilemma B) Bladder causes -
• Orbitopalhy (I) Bladder calculus
3. Surgery (ii) Bladder neck muscular hypertrophy
□ Indications: (iii) Bladder neck fibrosis
• Young patients (iv) Carcinoma of bladder
• Mid trimester pregnancy C) Urethral causes -
• One or more large nodule with obstructive symptoms (i) Urethral calculus
 114 QUEST : A Comprehensive Guide to U6 Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-ll 115

(ii) Urethral stricture (Often patient found writhing in distress and pacing about trying to find a comfortable
(iii) Urethral tumour position, whereas patient with peritoneal irritation remains motionless to minimise
discomfort)
(iv) Urethritis
> Mimics - Appendicitis, cholecystitis, tubal or ovarian disease
0) Other causes -
, Nausea, vomiting, sweating (due to pain and reflex pylorospasm)
(i) Rupture urethra due to trauma
. increased frequency and urgency of micturition
<"> Phimosis 1 mainly in children » Strangury is frequently present
(iii) Meatal stenosis J
• Dysuria
(iv) Post-operative cases
• Haematuria
(v) Spinal injury
. Tenderness of costo-vertebral {renal) angle or, in iliac fossa may be found associated
(vi) Following spinal anaesthesia
sometimes.
(vii) Faecal impaction
□ investigations-
PROSTATIC HYPERTROPHY , Urine - Routine Examination
- Microscopic Examination
A : See Section 1, Segment A. Paper-ll 2014, Qs. 2, (Page No. 183)
- Culture and sensitivity (to be done before starting antibiotics and repeated after
Q.2 : Discuss clinical features o f pheochromocytoma. How do you diagnose this condition? Wht treatment)
will you do to manage It? t Plain radiograph of kidney, ureter and bladder (X-ray KUB)
A : See Section 1, segment A, Paper II, 2013 supplementary, Qs. 3 (Page No. 174) > detects radioopaque stones in 90% cases
> helps to assess size, shape and location of calculi
' 2009 > sensitivity 45-60%
> cannot visualise radioluscent stones (10% cases)
0.1: A 35 year old lady presents with a solitary thyroid nodule In right lobe. How would you come toi
diagnosis and manage such a patient? [8+7] • Ultrasonography abdomen -
> direct demonstration of stones
Ans: See Sec 1 Segment-A Paper-I; 2013 Supplementary Q.1, (Page No. 61)
> difficult to identify stones between PUJ and VUJ.
0.2: Classify kidney tumors. Mention different modes o f presentation o f Renal Adenocarcinomi • Intravenous urography -
Outline the management o f such a patient. ' [3+5+7] > traditional 'gold-standard'
Ans: See Sec 1 Segment-A Paper-1; 2011 Q.2, (Page No. 37) > structural and functional information
> only radioopaque stones detected
2009 Supplementary > contraindicated in contrast reaction, risk of nephrotoxicity
> Metformin to be discontinued at-time of IVU and to be withheld for subsequent 48
Q.1: Define hydronephrosis. What are the causes o f unilateral hydronephrosis ? Discuss ti* hours or when renal function normalises.
management o f a patient with stone In middle third o f water [2 *4 *9 ] • Non-contrast enhanced CT abdomen -
> high sensitivity (96%) and specificity (100%) than IVU
Ans: HYDRONEPHROSIS
> no use of contrast medium
See Section 1, Segment A, Paper-ll, 2013, Qs. 1 (Page No. 148) > the diagnostic test
• Blood investigations -
STONE IN MIDDLE THIRD OF URETER > Routine (Hb, Platelet, TLC, DLC)
> Blood urea
□ Diagnosis - A patient with stone in middle third of ureter will have following clinical presentation.
> Serum creatinine
• Ureteric colic - Pain with following features -
> Serum uric acid
> Nature - Colicky
> Serum electrolytes
> Intensity - Severe
0 Management -
> Radiation - From loin to groin may extend to genitalia
• Plenty of fluids/water orally
> Increases with - Exercise
• Medical expulsive therapy - mainly for stones less then 5 mm
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The combination therapy includes - ] Effect on general growth and development

1) NSAID - has ureteric relaxing effects
• Synthesis of somatomedins
2) Corticosteroid - to reduce locaJ edema through Its anti-inflammatory action
• Stimulate secretion of growth hormones
3) Antibiotics - to prevent/treat UTI
• Potentiate the action of GH
4) Calcium antagonists - suppresses fast component of ureteric contraction, leavi^
• Increased synthesis of structural proteins
peristaltic rhythm unchanged
2. Calorigenic action
5) a 1 adrenergic blockers - inhibit basal tone, peristaltic wave frequency and urate*
• Increase BMR
contraction in intramural parts
• Increase body temperature
• Acute pain to be relieved by pethidine (NOT Morphine)
• Increase O2 consumption in all tissues except brain, anterior pituitary, spleen, lymph
• Injection Furosemide along with I.v. fluids for fast relief
nodes and testes
• Surgical interventions -
3. Metabolic actions
* Indications - I) Size of stone more than 5 mm
(a) Carbohydrate metabolism:
ii) Impaction for 6-8 weeks
• Increased absorption of glucose from gut
iii) Pain comes and goes without further descent of stone
• Increased glycogenolysis
Iv) iVU shows hydronephrosis/hydroureter
• Increased gluconeogenesis
v) Infection supervenes with fever, chills, pyaemia • Inhibitory role on insulin action
* Surgeries done - • Increased peripheral utilisation of glucose
I) Uretero-Renoscoplc Stone Removal (URS) (b) Lipid metabolism
ii) Shock Wave Lithotripsy • Stimulates synthesis, mobilisation and degradation of lipids
• Iii) Open ureterolithotomy • Lower serum cholesterol level (increases no. of LDL receptors in liver)
Prevention of recurrence - (c) Protein metabolism
Advise adequate hydration (3-4 lit fluid/day) • Normal level of thyroid hormones leads to positive nitrogen balance
Avoid diets rich in calcium, vitamin C, oxalate sodium 1 • High level leads to protein catabolism
Advise dietary fibre and diet rich In magnesium J
- to reduce oxalate stones (d) Mineral metabolism
Allopurinol may be prescribed - to reduce urate stones • Lead to osteoporosis (negative balance of calcium and phosphate)
Penicillamine - to reduce cystine stones (e) Vitamin metabolism
Aluminium or ammonium hydrochloride - to reduce phosphate stones • Help In conversion of beta-carotene to vitamin A
Acetohydroxamic acid - to reduce bacterial originated stone • Absorption of vitamin B 12 from gut
4. Effects on nervous system
0 2 : A 56 year old lady presents with a lump In upper and outer quadrant o t right breast Discus
• Development and maturation of neurons
briefly the management o f such a patient K
• Help in myelinogenesis
Ans: LUMP OF RIGHT BREAST • Maintain a normal reaction time of the jerks
• Increase activity of RAS
See section I. segment B, Qs. 4, Page 267. , • High level produces fine tremor
5. Effects on CVS
□ Treatment -
• Positive inotropic, chronotropic, bathmotropic and dromotropic effects due to increased
• Early carcinoma - See section I, segment A, Paper-ll, 2011, Qs. 1, Page No. 125
number of beta adrenergic receptors and their increased sensitivity to catecholamines
• Locally advanced carcinoma - See section I. segment A, Paper-ll, 2013, Qs. 2, Page No. 150
« Increased contractility of the myocardium due lo increased alpha-Myosin heavy chain in
heart muscles
2010
• High level produces peripheral vasodilation and hyperdynamic circulation
0 .1: What are the functions o t thyroid and parathormone? Write In detail about clinical feature 6. Effects on musculoskeletal system
Investigations and treatment o f hyperparathyroidism. [3 + 4 + 4+<! • Growth and maintenance of skeletal muscle
Ans: • Maturation and differentiation of cartilages
Functions ol thyroid homnones - • Fusion of epiphyses and growth of bones both in length & girth
• High level leads to Thyrotoxic myopathy
 11$ QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS D Paper-II 119

7. Effects on digestive system 6. Kidney - Bilateral, multiple renal stones or nephrocalcinosis may occur
• Maintains the normal functions of the digestive system 7. Associations - Peptic ulcer, pancreatitis, MEN I syndrome
• Increased level causes increased appetite, Increased motility of gut and diarrhea - Band keratopathy, skin necrosis, myalgia, arthralgia, pseudogout, polyuria, glycosuria,
• Decreased level causes decreased appetite and constipation hypertension (33%)
8. Effects on skin 8. The combination of symptoms is known as ‘ Bones, stones, abdominal groans and psychic
moans’
• Normal metabolism of skin proteins like polysaccharides, hyaluronic acid, chondroj|
polysulphuric acid etc. 9. Acute hyperparathyroidism (crisis)
• rare but dangerous presentation
• Low level leads to retention of these substances along with retention of water in the si*
resulting in the edematous look (Myxedema) • Abdominal pain, vomiting, dehydration, oliguria, muscle weakness and death
9. Effects on other functions « Serum calcium is very high (>12% or > 3.5mmol/L)
• Stimulates erythropoiesis □ investigations:
• Increases milk production 1. Serum levels -
• Maintains normal reproductive function • High calcium (>10mg/dL)
• Has permissive action to some hormones e.g. catecholamines • Decreased phosphorus
• Increased Alkaline phosphatase
□ Functions o f parathormone:
« Increased PTH (> 0.5 mg/L) - Diagnostic
Primarily PTH increases the plasma calcium level for which it acts as follows :
2. Urinary levels -
1. Action on kidneys
• Increased calcium (> 250mg/24 hr)
• Increases calcium reabsorption in Distal convoluted tubules
■ Increased cAMP level in 90% cases
• Formation of cafcitriol from 25-hydroxycholecalciferol by direct stimulation of alpt#
3. X-ray features -
hydroxylase enzyme
• Inhibits reabsorption of phosphate in kidney • Salt-pepper appearance of skull
• High level maintains a high plasma calcium level and thus increases the filtered loadd • Sub-periosteal erosion of radial side of middle phalanx (specific)
calcium leading to calciuria • Calcification In bones
2. Action on gut 4. Thallium - Technetium scan shows hot spots which are diagnostic of parathyroid adenoma
• Helps absorption of calcium from the gut through formation of calcitriol in kidney 5. Technetium-99m labelled Sestamibi scan
3. Action on the bones • More sensitive than Thallium-Technetium scan (80%)
• Increases calcium permeability of the osteoclasts, osteoblasts and osteocytes • Very expensive
• Increases osteoclastic activity and bone destruction • used in parathyroid re-exploration
• Low concentration stimulates osteoblastic activity (bone remodelling) • Often combined with Single Photon Emission Computerised Tomography (SPECT)
■ Overall effect is mobilisation of calcium from bone 6. USG abdomen - to detect problems in pancreas, kidneys
4. Action on serum calcium 7. USG neck and CT/MRI scan of neck and mediastinum
• Increases flow of calcium into blood by­ 8. Other Investigations - Angiography, Venous sampling (Selective sampling for PTH)
> Mobilisation from bone □ Treatment:
> Increased reabsorption in kidney A Medical treatment
> Increased absorption in gut
• Usually ineffective for primary hyperparathyroidism
• Occasionally advocated for Acute hyperparathyroidism crisis
HYPERPARATHYROIDISM
> Forced diuresis - 3-5 L of normal saline with Frusemide
□ Clinical features: > Rehydration - Normal saline @300ml/hr
1. Common in middle aged women > To inhibit effects of vitamin D - Steroids 400mg i.v. for 5 days
2. Asymptomatic in > 50% cases > Pamidronate (90 mg i.v. slowly in 4 hrs)
3. Nonspecific and psychiatric symptoms (Neurotics) / Zoledronic acid (4 mg initially, 8 mg later)
4. Behavioural problems > To reduce serum calcium level - Mithramycin, calcitonin, bisphosphonates, Cinacalet
5. Bones - Osteitis fibrosa cystica (von Recklinghausen disease) in 5% cases, which shO«' (Calcium receptor agonist), Gallium nitrate (inhibits osteoclast resorption of calcium
single or multiples cysts or pseudotumour in jaw, skull or middle phalanges. The first boneS at the dose of 200mg/m2/day)
show these changes is the lamina dura of tooth. > estrogens, progesterons, raloxifene (Selective estrogen receptor modulator)
 120 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 121

B. Surgical treatment 10. Filariasis of scrotum

• Indication for parathyroldectomy- 11. Lipoma of the cord
> Severe symptoms 12. Lymphangioma of the cord
> Serum calcium > 11 mg%
Inguinal Hernia
> Urinary calcium > 400mg/24 hrs
> Young age group □ Definition : Hernia is abnormal protrusion of a pari or whole of a viscus through the wall of its
containing cavity.
> Markedly reduced bone density
O History:
> Urinary calculi
• The swelling reduces in size or disappears when the patient lies down.
> Neuromuscular presentations
. The swelling reappears when the patient stands and increases in size on coughing walkinq
• Subtotal parathyroidectomy is the treatment of choice - Surgical removal of the parathyroid
straining during defaecation.
glands and implantation of the gland tissue In forearm muscle mass (Brachioradialis) ornect
(Stemomastoid). At the transplantation site, marker stitch is placed. 100 mg of parathyroid □ On examination:
gland or one-third of one gland is auto transplanted. • Expansile impulse on coughing over the swelling observed during both inspection and
• Parathyroid carcinoma - Additional hemithyroidectomy with Lymph node dissection and palpation.
post operative radiotherapy may be required . On palpation, it is not possible to get above the swelling.
• Parathyroid adenoma of one gland with normal other glands - Removal of that gland with . Anatomically the swelling lies above and medial to the pubic tubercle.
adenoma only « Skin over the swelling is normal.
• Mediastinal parathyroid adenoma - After proper localisation, thoracoscopic removal may be
• There is visible peristalsis over the swelling. The swelling feels elastic and soft on palpation
• sufficient
is resonant on percussion and bowel sounds are audible over the swelling on auscultation!
• When all four glands are diseased - Total parathyroidectomy along with transcervicaj
• Test for reducibility. Invagination test, Deep ring occlusion test, Zieman's test etc are done to
thymectomy confirm the diagnosis.
• Familial and MEN syndromes - Total parathyroidectomy is done
Vaginal Hydrocele
• Complications of parathyroidectomy -
> Permanent hypoparathyroidism □ Definition: It is a condition characterised by accumulation of fluid in the tunica vaginalis sac of testis
> Persistent hyperparathyroidism (5%) □ History:
> Recurrent hyperparathyroidism (12 months after the first parathyroid surge/y, • No change in size of the swelling with lying down or during standing, walking, strenuous
hypercalcemia recurs) activities.
> Recurrent laryngeal nerve injury (1%) • No pain over the swelling.
> Hungry bone syndrome (Sudden drop in calcium level after surgery due to increased □ On examination:
absorption of calcium by bones) • No expansile impulse on coughing.
• It is possible to get above the swelling on palpation.
QJ2: Give differential diagnosis o f scrota! swelling. Write in detail about management o f testlculx
• The swelling is soft and cystic in feel.
tumor. [5 + 101 .
• The swelling Is fluctuant and initially transrlluminant.
SCR O TAL SW ELLING • Testis cant be palpated separately from the swelling.
□ Differential diagnosis: • The swelling is dull on percussion.

1. Inguinal hernia Encysted hydrocele o f the cord

2. Vaginal hydrocele
U S f S " , / . . ! * iS 9 condi,ion characterised by accumulation of fluid in the unobliterated intermediate
3. Encysted hydrocele of the cord segment of the processus vaginalis.
4. Testicular tumor Q History ;
5. Hematocele
• No change in size of the swelling with lying down or strenuous activities.
6. Chylocele
a On examination: .
7. Varicocele
8. Spermatocele • No expansile impulse on coughing.
• Swelling feels soft and cystic on palpation.
9. Epididymai cyst
• Fluctuation and Transillumination tests are positive.
 122 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS Q Paper-II 123

• Swelling is mobile from above downward and from side to side. front, the patient is asked to bow. Varicocele gets reduced in size (due to decreased blood
• Traction test - the swelling becomes less mobile on gentle traction to the testis (as it Is fixed flow through pampiniform plexus of veins).
to the spermatic cord).
Spermatocele
Testicular Tumor
□ Definition • It is an acquired unilocular retention cyst arising due to blockage of some portion of sperm
Q H istory: conducting mechanism of epididymis.
• The swelling was initially gradually increasing in size and lately rapidly increasing in size. □ On examination:
• No change in size of the swelling during daily activities. , Swelling is at the head of epididymis, above and behind theupper pole/body of the testis.
• Vague discomfort or a feeling of heaviness in the ipsilateral scrotum. • It looks like “third testis".
• There may be acute pain in the scrotum (due to hemorrhage or infarction), abdominal pain • The swelling feels soft and cystic on palpation.
(due to retroperitoneal metastasis), flank pain (due to ureteric obstruction), back pain (due to • It is fluctuant, but poorly transilluminant (due to barleywater like fluidwhich contains
involvement of psoas muscle and nerve roots). spermatozoa)
□ On examination :
Epldidymal Cyst
• It is possible to get above the swelling on palpation.
• Swelling feels firm on palpation. p Definition : It is a condition arising due to cystic degeneration of the epididymis (paradidymis/
appendix of the epididymis/ appendix of the testis/ the vas aberrans of Haller).
• Loss of testicular sensation.
□ History:
t There may be abdominal mass (bulky retroperitoneal metastasis), extremities edema (du«
to compression of Inferior Venacava). • Occurs in middle age.
• Swelling is often bilateral.
. Hematocele □ On examination:
□ D efinition: Bleeding into the tunica vaginalis sac due to rupture of one of the vessels in the tunica • Swelling feels tensely cystic on palpation.
following aspiration from a hydrocele or trauma to the testis. • Swelling feels like “ bunch of tiny grapes"(due toits lobulated surface)
□ History : • It is brilliantly transilluminant, appear as“ Chinese lantern pattern” (due to its clear fluid and
• After an history of trauma there is sudden onset of pain and swelling. finely tessellated numerous septae)
• Testis can be fell separately from the swelling.
□ On examination:
• Recent hematocele - Swelling is tender, fluctuant, nontransilluminant. ' Filariasls of Scrotum
• Old hematocele - Swelling Is nontender, nonfluctuant, nontransilluminant with loss of testicular □ History:
sensation.
• Gradually progressive thickening and swelling of the skin of scrotum and penis.
Chylocele • Watery discharge from the skin of scrotum occasionally.

□ Definition: It is a type of hydrocele characterised by lymphatic obstruction of the scrotal contents. II • Recurrent attacks of fever with chill and rigor. *
usually occurs following multiple attacks of filarial epididymoorchitis. The fluid contains fat which is • Recurrent episodes of pain in the groin and scrotum, i
rich in cholesterol and is derived from ruptured lymphatic varyx into the tunica. □ On examination:

Varicocele • Fissured, hyperkeratotic , rough skin overlying the scrotum and penis.
• Testis, epididymis, spermatic cord are not easily palpable.
□ Definiton : It is a condition characterised by dilatation and tortuosity of the pampiniform plexus ol
veins of the spermatic cord. MANAGEMENT OF TESTICULAR TUMOR
□ H isto ry:
Ans: See Sec 1, Segment-A, Paper-II; 2014 Q.3, (Page No. 188).
• Swelling usually disappears on lying dotfn and reappears on standing and walking.
• Dull aching/ dragging pain in the groin or scrotum.
2010 Supplementary
□ On examination :
• Swelling is at the root of the scrotum. 0-1: Classify thyroid malignancies. How w ill you manage a case o f follicular carcinoma of thyroid?
• No expansile impulse on coughing. [5 + 10]
• “Bag of worms" feeling (due to a mass of dilated vein) andthrill observed on palpation.
• Bow sign - After holding the swelling between index andmiddle fingerbehind and thumb in Ans: See Section 1, Segment A, Paper-ll, 2012, Qs. 1 Page No. 143.
 f

124 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVEO LONG QUESTIONS OF FINAL MB8 S O P aper-ll 125

FOLLICULAR CARCINOMA OF THYROID 2011

□ Clinical presentation - Q, 1; Classify carcinoma o f breast How w ill you Investigate and manage a case o f early carcinoma
e f breast In a 40 year old lady. 14 + 5 + ei
See Section 1, Segment A, Paper-ll, 2012, Qs. 1 Page No. 143
Associated features -
• Tracheal compression causing stridor CLASSIFICATION OF CARCINOMA OF BREAST
• Dyspnoea
• Chest pain
• Haemoptysis
• Hoarseness of voice due to Recurrent Laryngeal Nerve involvement
□ Investigations-
• FNAC IS INCONCLUSIVE - fails to diffe rentiate follicular adenoma and follicular carcinoma,
because main features of carcinoma like angioinvasion and capsular invasion cannot be
detected by FNAC
t Frozen section biopsy is useful
• Trucut biopsy may be done but risk of haemorrhage arid injury to vital structure reduces Its
use.
• R est-See Section 1, Segment A, Paper 11,2012, Qs. 1, Page No. 143.
□ Treatment -
• Current NCCN guidelines recommend Lobectomy along with IsthmusectOmy as initial surgery;
followed by frozen section biopsy. If histologic section confirms follicular carcinoma, total
thyroidectomy is advised.
• NCCN recommends total thyroidectomy as initial procedure only if invasivecancer or
metastatic disease is apparent at the time of surgery or if patient wishes to avoida second
surgery
• Therapeutic neck dissection of involved compartments to be done for clinically apparent/
biopsy proven disease.
• Maintenance dose ol Tab. L-thyroxine 0.1 mg once daily or T3 80 pg/day lifelong following
total thyroidectomy.
□ Follow-up - See Section 1, Segment-A, Paper-ll, 2012, Qs. 1, Page No. 144.
0 .2 : A 40 year old patient presents with haematuria. Enumerate the differential diagnosis, plan the
Investigations and treatment [4 + 7 * 4 ]

Ans: HAEM ATU R IA

□ Differential diagnosis - See Section 1, Segment-A, Paper-ll, 2008, Qs. 1, Page No. 94.
□ Investigations - See Section 1, Segment-A, Paper-ll, 2008, Qs. 1, Page No. 94.
□ Treatment -
A) Glomerular causes - Steroids (Details - refer to medicine books)
B) Tumor -
• Renal cell carcinoma - See Section-1, Segment-A, Paper-ll, 2011, Qs. 2 Page 139
• Wilm’s Tumour - See Section-1, Segment-D, Qs. 100, Page No. 560.
C) Ureteric stone - See Section 1, Segment-A, Paper-ll, 2009 supp, Qs. 1, Page No 114.
D) Bladder carcinoma - See Section 1, Segment-A, Paper-ll, 2008, Qs. 1, Page No. 107
E) Benign prostatic hyperplasia - See Section 1, Segment-A, Paper-ll, 2014, Qs- 2, Page 183
[Refer to Section 1, Segment-A, Paper-ll, 2013, Qs. 3. Page No. 163)
 126 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS O f FINAL MBBS □ Paper-ll 127

Q DCIS:
• Proliferation of malignant mammary ductal epithelial cells contained within intact basement
membrane without any access to lymphatics or vascular channel.
> Uniformly High grade tumor.
• Incidence - 5-20%
• 5 Histological types - > Tnple negative status - Negative ER. PR and HER-2/Neu receptors.
» Solid - High grade » Express molecular markers ol basal or myoepithelial cells.
> Comedo {with necrosis) - High grade (Most dangerous due to high chances of □ Tubular C A:
microinvasion)
> Cribriform - Low grade •* 1 has
It 2 best
2 prognosis
2 “ Sin9‘e CG" all
among l3yer 'ined
types of 'UbU,ar S,n,C' Ures and °Pen cen,ral space.
ductal CA.
> Papillary - Low grade □ Colloid C A:
> Micropapillary
. Microscopically - Malignant cells in a pool of abundant mucin.
« Rarely may present as swelling in breast or solitary duct discharge (nipple discharge)
□ Invasive Papillary CA ;
• On clinical examination, often there is no palpable abnormality
• On mammography, Clustered microcalcification (5-7 areas of polymorphic, linear or branching
clusters of calcification) is seen in 75% of cases, ■ " “ h p, p“ '“ - w o r n * ■ » ■ » *- «
• Ultrasound assisted FNAC may be needed for diagnosis. Q Adenoid cystic CA ;
• Treatment options - a) Breast Conservative Surgery (BCS) with Radiotherapy (RT) to the • Microscopically- Glandular spaces + dense mucoid material.
breast + Axillary dissection after Sentinel Lymph Node Biopsy (SLNB), if it is positive.
> Wide local excision or even Total mastectomy may be needed in some cases follows □ Paget's disease o f the n ipp le:
by adjuvant hormonal therapy.
• Prognostic indices for OCIS - ' 2 S CA * * a,on9 excfe,ofy duc,s
> Van Nuy's prognostic index (Size, Clearance. Grade and necrosis)
> Nottingham prognostic index (0.2*tumor size in cm + lymph node stage + tumor grade)
Q LCIS: ; T Tte t o d ™ « » » *» o i« * m m
• Arises in terminal duct lobular unit < *« £ s . — 1 » « *■ » « •> n
• Incidence - 3-5%. Common in perimenopausal while females. * • Treatment - Modified Radical Mastectomy (MRM)
« Poses high risk towards causing Invasive cancer.
□ Invasive lobular C A :
> 65% - invasive ductal CA (Ipsilateral or contralateral breast)
• Mullicentric, multifocal, bilateral tumor.
> 35% - invasive lobular CA (ipsilateral or contralateral breast)
• It Is Bilateral (50%), multifocal. • Microscopically - Lobule shows clustered tumor cells within the acini
• Clinically, no lump is palpable. • Shows Indian file pattern/single file pattern.
• On mammography, no calcification is seen. U Inflammatory breast CA :
• Immunohistochemisfry with e-Cadherin antibody - Positive • Known as Mastitis carcinomatosis/ Lactating carcinoma.
• Treatment - Hormonal therapy (Tamoxifen / Raloxifene) + Bilateral total mastectomy • Common in pregnant or lactating women
□ Invasive ductal CA NOS :
• Also known as Scirrhous CA.
• Macroscopically - hard, irregular, whitish yellow, non capsulated mass with cartilaginous
consistency. • It is a clinical diagnosis.
» Microscopically - small clusters of malignant cells between collagen bundles with an intensM • Mimics acute mastitis
stromal reaction (fibrous stroma).
• Atrophic scirrhous CA - Seen in elderly females, slow growing tumor, better prognosis, IOC ■' m™ ? , ; s s r r » - - -» » « - - 8een - —
FNAC, TOC- mastectomy or curative brachytherapy.

□ Medullary C A : •' E ?C S V
• Also known as Encephaloid type (duo to its brain like consistency macroscopically).
• Most BRCA1 associated ductal carcinoma • ' nd * “ *» •
 128 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 129

EARLY CARCINOMA OF BREAST IN A 40 YEAR OLD LADY

V Findings suggestive of malignant lesion -
1. Distorted architecture oi the breast parenchyma (irregular soft tissue shadow).
2. Micro calcifications (< 5 mm) with spiculations.
3. Focal dilatations of ducts.
4. Increased number and thickening of Cooper’s ligaments.
5. Heterogenous, polymorphic, high density opacity with irregular margin/
satellite lesion.
> American College of Surgeons (ACS) guidelines -
A Woman with average risk of breast CA should undergo regular screening
mammography, starting from 45 years age, annually to 54 yrs age, then biennially for
as long as the woman is in good health and has a life-expentancy of at leasl 10
years.
> Usual views taken -
1. Medio-lateral-oblique (MLO) view
2. Cranio caudal (CC) view
s ^ /d f^ C lin lc a l assessm ent:
> Amount of radiation exposure during mammography - 0.1-0.2 cGy (this amount of
• Hard lump In the breast which is most commonly painless. • radiation being not enough to cause malignant changes in breast itself)
• The second most common presentation is nipple discharge. • USG -
' • Ulceration and fungation of nipple areolar complex and /or surrouding skin.
> Done mainly in young females < 40 yrs of age in whom mammography is less
• Lymph node enlargement - axillary, supraclavicular.- sensitive due to dense breast tissue.
• Pain on the lesion (10% cases). V It is a preferred method for screening in pregnancy and early lactation.
• Chest pain, haemoptysis, bone pain and tenderness, pathological fracture, ascites, pleua > Purpose -
effusion
1. To know whether the lesion is solid or cystic.
• Symptoms due to secondaries in liver, secondary ovarian tumor.
2. To define size, extent and texture of the lesion.
□ Radiological Imaging: * > Findings suggestive of malignant lesion -
• First investigation to be done in a case of early breast CA is always a radiological imaging, as­ 1. Irregular internal echoes.
> These are non-invasive investigations. 2. Irregular posterior acoustic shadow.
> FNAC/ Open biopsy, if done first, may cause hematoma, which will alter the findina 3. Irregular margin.
on Imaging. 4. Non compressibility.
• MAMMOGRAPHY - 5. Ratio between anteroposterior to lateral/horizontal dimensions is >1.
> Done In females > 40 years of age. 6. Hypoechoic, more vertical mass.
> It is the only reliable means to detect non-palpable breast CA. 50% of breast CA mai 7. High frequency signals with continuous flow on doppler.
be seen on mammography before they are palpable. Further, it can identify breas > Disadvantage - Lesions < 1 cm may be missed.
CA at least 2 years before the mass becomes palpable. y Can guide FNAC, cheaper, easily available and has no risk of radiation.
> Indications - • MRI -
1. To evaluate suspicious breast lump, nipple discharge.
> Purpose -
2. To identify multicentricity, to know size and location of the masses.
1. To identify multifocal (> 1 foci in one quadrant) and multicentric breast tumor
3. To screen contralateral breast for additional masses in a patient undergo^ (MRI is even better than USG).
definitive surgery.
2. To image breasts with breast implants.
4. To screen both breasts before any cosmetic surgery.
3. To detect local recurrence or scar after mastectomy.
5. Screening before Breast Conservative Surgery (BCS).
4. To assess axillary metastasis.
6. Follow-up after BCS I Radiotherapy/ Neo-adjuvant chemotherapy.
5. To assess dermal extension.
130 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 131

> Indications - a Histopathologic Cytologlcal analysis -

1. Screening of young women and women In high risk group (History,
A) BREAST BIOPSY
therapeutic radiation In age < 30 yrs, Strong family history of breast q
BRCA 1/2 mutation, Personal history of DCIS/ Invasive breast CA, far*
0 Types:
history of beast and ovarian CA)
2. Suspected DCIS (MRi is the most sensitive investigation for DCIS)
> There is no risk of ionising radiation.
> IOC for imaging breasts In pregnant female.
> It is a bette r modality than other investigations for dense breasts.
> Findings suggestive of malignant lesion -
1. Mass with irregular intensity and spiculations
2. Thickened skin, changes in nipple.
3.. Lymphedema.
> Disadvantages -
1. Costly, not available easily.
2. Nol accurate, if done within 9 months of radiotherapy for breast CA.
3. Cannot be done in patients with incompatible metal prosthesis like cards
pacemaker.

BIRADS (Breast Imaging Reporting and Data based Scoring system):

> This Is a scoring system based on different investigations.
> Based on this, advice can be given regarding further investigations and diagnos

I FNAC:
• Fine needle aspiration cytology is the first, simplest and least invasive technique for obtaining
Grade 0 Grade 1 Grade 2 a cell diagnosis in breast cancer
• Mininum 6 aspirations are done using 21-30 G needle
• Inadequate/Incomplete ♦ Normal / Negative ♦ Benign • Giemsa, hematoxylin and eosin, papanicolaou stains used
assessment • Continue annual • Continue annual • It can be repeated 2 times
• As breast tissue Is dense, mammography mammography
mammogram cant Interprets • Advantages : (1) least painful (2) cheap (3) reliable (4) can be done on Out patient basis (5)
no evidence of malignant deposits along FNAC track
• Needs additional study
• Disadvantages: (1) Receptor study cant.be done (2) Invasivecancer cant be differentiated
from in situ disease (3) False negative results do occur, mainly due to sampling errors

Core needle b io p sy:

• It is the preferred method for diagnosis of palpable or non-palpable breast abnormalities
Grade 3 Grade 4 Grade 5 Grade 6
• Permits analysis of breast tissue architecture to give clear histological evidence and definitive
Possible/Probably Suspicious lump Highly suggestive of Biopsy proven preoperative diagnosis
benign Chance of CA * malignancy malignancy • Can confirm DCIS and invasive lesion
Chance of CA = 1-2% 25-50% Chance of CA = Known carcinoma • Can comment about grade and receptor status of tumor
Repeal imaging after Biopsy recommended 75-90%
3-6 months Biopsy required Frozen section biop sy:
• Nol usually practiced now-a-days
• Indication : when FNAC fails even after 2 trials or is negative
• Disadvantage: Shows 20% false negative results
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 133
132 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
-----------------------------------—----------- ------------------------------------------- - ■ — ‘ ^

» Sensitivity - Blue dye : 90%, Radioisotope : 98%

□ Exclslonal biopsy ;
, Best method is combined preoperative radioisotope injection into peritumour areat
» Also known as open biopsy peroperative patent blue dye Injection in the subareolar region.
» It Is the best and definitive Investigation for breast cancer , Positive SLNB - (a) Macrometastasis (> 2 mm) (b) Micrometastasis (< 2 mm)
• Incision is planned In such a way that It will be included In the eventual mastectomy incij, , Contraindicated in -
at a later date
J> Pregnancy
• Should give no (afse negative and no false positive results
> Inflammatory carcinoma of breast
□ Needle localised exclslonal biopsy (NLEB): > Patients allergic to vital blue dye or radio-colloid
• Procedure: (1) Through an incision under local anesthesia, a hook Is placed adjacent tot , Complications -
suspected lesion, using needle sheath over the tumor (2) Excision biopsy is done unj > Anaphylaxis
mammographic guidance >► Seroma formation
• Indication : When core needle biopsy fails to localise non-palpable tumor
> Blue tattooing of skin
> Passage of blue-green urine and stool for a small period
B) SENTINEL LYMPH NODE BIOPSY (SLNB)
C) AXILLARY SAMPLING
• The first lymph node draining the breast CA is referred to as Sentinel lymph node.
« It Is the first lymph node to be involved by tumor cells. • Not commonly used now.
• The Incidence of skip lesion (involvement of other lymph nodes skipping the sentinel node) ijj • Done by separate adequate curved incision, 6 cm below the apex of axilla, between the outer
low as 3%. border of pectoralis major and latissimus dorsi.
• It is done in all cases of early breast CA (stage T1 and T2) without clinically palpable lymph not • About 10-15 lymph nodes (Level I) are sampled.
before wide local excision of the primary tumor. • If Level I lymph nodes are not palpable, then only level II and level III lymph nodes are sampled.
• Markers used: • At least 4 largest lymph nodes are removed and sent separately for histological examination.
> Blue dye - Isosulphan vital blue dye (2.S-7.S mL) • Can detect skip metastasis in level II or level III lymph nodes.
Methylene blue dye ^
Other Investigations:
► Radioisotope - 99Tc radioisotope labelled albumin (1 mCi)
• Triple receptor assessment­
99Tc tagged sulphur coHoid ‘
> Estrogen Receptor (ER) study
□ Procedure :
* Estrogen sensitive cytosolic glycoprotein level >10 units per gram of tissue is
known as ER +ve status.
* ER +ve status indicates good response to hormone therapy and good
prognosis.
> Progesterone receptor (PR) study .
> HER 2/Neu receptor study
* Human epidermal growth receptor 2 Neu oncogene, also known as cErb B2,
is a tyrosine kinase receptor.
* Positivity indicates high grade tumor and poor prognosis.
• Cytological analysis of nipple discharge
> Sample is obtained through ductal lavage.
• Tumor markers
> CA 16/3 (Normal serum value <40 U/mL)
> CA 27
> CA 29
• Metastatic work up
> Chest X-ray / CT thorax
> USG/CT abdomen
134 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ P aper-ll 135

> X-ray/ MRI spine and pelvis

> LPT
> Complete hemogram
Ipsilateral, mobile,
” a-More than or
□ Staging: discrete Axillary a-Fixed/matted
axillary LN (4-9 LN
equal to 10 axillary
lymph node LN +ve/lpsllateral
involvement Involved)
TNM STAGING Infradavicular LN
clinically +ve
(1-3 In no.) b-lntemal mammary
LN +ve clinically in
Mpsilateral Internal
the absence ol
Tx - Primary tumor can’t be To - No evidence of primary mammary LN
axillary LN
assessed tumor involvement +
involvement
Axillary LN
involvement

c-lpsllateral
supraclavicular LN
Tj$-Carcinoma in situ (DCIS/ Tis — Paget's ds. of nipple with Involvement
LCIS) no tumor

T1 - Tumor size less than or Metastases

T1 mic - Microinvasion < 0.1 equal to 2 cm in greatest could not be Distant
assessed metastases
cm diameter (Tta - 0.1 -0.5 cm, Tib
- 0.5-1 cm, T ic -1 -2 cm)

. S ta g e l-^ N O
• Stagella-TpN, ,T i Nt ,T 2N0
T2 - Size > 2 cm but less than . Stage lib - T 2N, ,T 3N0
T3 - S iz e > 5 cm
or equal to 5 cm . Stage llla - T 0N2 , T,N2 , T2N2 . T3N ,, T3N2
. Stagelllb-T 4N0.T4N, ,T4N2
• Stage lllc - Any T ,N 3
• Stage IV - Any T, Any N .M ,
T4 - Tumor of any size fixed to
the chest wall or skin (T4a -
Fixed to chest wall*, T4b - 1. All other stages except Stage IV - M0
Fixed to skin**, T4c - T4a + T4t>, 2. Any N2 except T4 tumor - Stage Ilia
T4<j - Inflammatory breast (CA) 3. Any T4 except N3 node - Stage l!lb
4. AnyN3- Stage lllc
* Chest wall involvement - except pectoralis major muscle 5. Early breast Cancer - T, I T2 lesion + N0/N , node (Breast tumor less than or equal to5 cm in
** Skin involvement - Ulceration/edema/Satellite nodule size, without chest wall or skin involvement, with or without lymph node involvement < 4 in
no.)
6. Locally advanced breast cancer (LABC) - T3N0 , Stage Ilia, Slage lllb
7. Metastatic breast cancer - Slage IV
Treatment:
• Aims of treatment:
> To achieve likely cure
> Control of local disease in breast and axilla
 136 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 4 Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 137

>- Conservation of local formations and function of breast Ideal choice - Patey's modified radical mastectomy (Total / simple mastectomy may also be
> Prevention of recurrence done)
, Skin sparing mastectomy (SSM) - Through limited skin incision, excision of nipple areolar complex
> Prevention or delaying of distant metastases
with very limited skin removal is done here. It does not alter the recurrence rate and is cosmetically
• Modalities of treatment: superior.
> Control of disease in breast - Breast Conservation Surgery (BCS) OR Mastectom)
□ sentinel lymph nodes b io p sy:
> Treatment to axilla - Sentinel lymph node biopsy (SLNB) OR Axillary dissect**
. Done when axillary nodes are not clinically palpable.
clearance
> Post operative radiotherapy □ Axillary dissection/ clearance:
> Adjuvant chemotherapy • Done when clinically lymph nodes are palpable OR sentinel lymph node biopsy is positive
> Adjuvant hormonal therapy for carcinoma.
> Regular follow up - Tumor marker CEA, Radiosiotope bone scan • Removal of (at, fascia and nodes (level I and II) in the axilla is done.
• Dissection is done - (a) through a separate transverse incision in axilla, when advocated
BREAST CONSERVATION SURGERY (BCS):
with BCS and (b) by extension of breast incision, when advocated with MRM/ total mastectomy/
> Wide local excision of unicentric tumor with normal breast tissue clearance of 1 cm is idealj SSM
done. Curvilinear non radial incisions are used and skin flaps are not raised.Tumor clearances
confirmed by frozen section biopsy of the specimen(for adequacy, at least 1 mm clearance# □ postoperative radiotherapy(RT):
needed). Along with this, axillary dissection (level I and II nodes) is done through a separa « Indications -
incision and radiotherapy (4500 cGy) to breast and chest wall is given. . > Tumor size > 5 cm
- >• Quadrantectomy as a part of QUART therapy (Quadrantectomy + Axillary dissection of level! > High grade tumor
and II nodes through a separate incision + radiotherapy to breast [5000 cGy] and axilla (100; > Positive surgical margin
cGy] areas) may be used in some patients. Here removal of the entire quadrant of breast along > Pectoralis fascia involvement
with the ductal system, with normal breast tissue clearance of 2-3 cm, is done
> More than or equal to 4 axillary nodes are positive
• Indications: > Internal mammary LN +ve
> Breast lump < 4cm • External radiotherapy to chest wall is a must after BCS. Here adjuvant RT decreases the risk
> Clinically negative axillary nodes • • of recurrence after 10-15 yrs from 30% to 7%. Total dosage is 5000 cGy (200 cGy 5 days a
> Mammographically detected lesion week for 5 weeks).

> Well-differentiated lesion with low S phase • After total mastectomy, external RT to axilla can be give in patients if axillary dissection is not
done OR more than or equal to 4 axillary nodes are positive. Internal mammary and
> Breast of adequate size and volume to allow proper radiotherapy
supraclavicular lymph node areas may also be irradiated.
• High chance o f recurrence in cases o f: • Adverse effects of RT -
> Young female > Skin necrosis
> Inadequate surgery > Chest wall myositis
> High grade tumor > Interstitial pneumonitis
)> Lymphovascular invasion > Pleural effusion
> Pulmonary fibrosis
MASTECTOMY:
> Angiosarcoma (delayed complication)
• Indication:
> Tumor size > 4 cm 3 Adjuvant chemotherapy:

> Tumor margin is not free of tumor after BCS • Indications -

> Multicentric tumor > Any tumor > 1 cm in size
> Poorly-differentiated tumor V All LN +ve patients
> Central tumor beneath the nipple > High grade tumor - higher rate of proliferation, aneuploidy, microinvasi-v*
> Extensive intraductal carcinoma > Lymphovascular invasion
> History of earlier breast irradiation > Her2/Neu+ve ER-ve PR-ve tumor
138 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology
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• Assessment tor need of chemotherapy - . Letrozole -

> Oncotype Dx > 2.5 mg OD for 5 years (Latest data - 10 years dosage)
* Done in Stage I and II ER/ PR +ve patients
> A /E : vaginal dryness, night sweats, osteoporosis.
* 21 gene assay
* Calculates recurrence score q 2 : Classify renal neoplasms. How w ill you diagnose and manage a case o f renal cell carcinoma?
* Score < 18 : No chemotherapy required [4 + 5 + 6 ]
* Score 18-31: Role of chemotherapy is equivocal CLASSIFICATIO N O F R EN AL NEO PLASM S
* Score > 31 : Chemotherapy is required
A. Benign lesions
> Mammaprint
• Adenoma
* Done only for T, / T2 lesion with ER/P R +ve / -ve
• Oncocytoma
* 70 gene assay
• Angiomyolipoma (AML)
• Chemotherapy regimens -
B. Malignant lesions
>• First line drugs - CMF (cyclophosphamide, Methotrexate, 5-fluorouracll) in monthly • Wilm’s tumor/Nephroblastoma
/ 3 weekly cycles for 6 months - Most commonly used
• Renal cell carcinoma/Hypemephroma
OR, CAF (Cyclophosphamide, Adriyamycin /doxorubicin, 5-FU)
> Clear cell CA (70-80%)
OR, CEF (Cyclophosphamide, Epirubicin, 5-FU) - better regimen
* Most common Renal cell CA
> Second line drugs - Taxanes (Paclitaxel, docetaxel)
* Highly vascular
Cyclophosphamide with Anthracyclin (doxorubicin, epirubicin) for 4-8 cycles«
* Associations :
Paclitaxel thrice weekly
i) Loss of chr. 3p (associated with Von Hippel Lindau syndrome)
> Third line drugs - Gemcitabine
' ii) Loss of chr. 8p, 9p, 14q
• Adverse effects of chemotherapy -
iii) Gain of chr. 5p
> Bone marrow suppression
> Papillary CA (15-20%)
> Cardiotoxicity
* Mostly seen in acquired cystic renai disease
> Alopecia
* Hypovascular
> Gl side effects
* Associations:
Adjuvant hormonal therapy: . i) Loss of chromosome 14 and Y
• Indication - ER / PR +ve patients in all age groups ii) Trisomy of chr. 7 and 17
• Endocrine manipulations - V Chromophobe cell CA (3-5%)
> Ovarian ablation by surgery or radiation . * Associations:
> Pituitary ablationor adrenalectomy i) Birt Hogg Dube syndrome
> SERM ii) Loss of chr. 1,2,6,10,13
> Aromatase inhibitors iii) Gain of chr. 7,12,16,20
> LHRH agonists - Goserelin 3.6 mg every 28 days cycle for 2 years (Medical / > Collecting duct cell CA (< 1%)
oophorectomy) V Renal medullary CA
> Amincxjlutethimide (Medical adrenalectomy) * Seen in Sickle cell trait
• Protocol - * More in young (30-40 yrs)
> For premenopausal patients - Selective estrogen receptor modulator (SERM) like • Transitional cell CA of pelvis .
tamoxifen, raloxifene • Squamous cell CA of pelvis
> For post menopausal patients - Aromatase inhibitors like letrozole, anastrozole.
exemestane. DIAGNOSIS OF R EN AL C E LL CARCINO M A
• Tamoxifen - 3 Presentation:
> 10 mg BD or 20 mg BD for 5 years (Latest data - >10 yrs dosage is more beneficial! • Usually in the 6th-7th decade
> A/E : Hot flushes, Deep vein thrombosis, endometrial hyperplasia • M : F = 3 :2
• Usual presentation is hematuria
 140 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II

Dragging discomfort in loin > DTPA scan (Diethylene triamine pentaacelic acid)- for renal function
Palpable flank mass Chest X-ray - to rule out pulmonary metastasis
Few patients may present with Pelviureteric junction obstruction without evidence of infection Uver function te s t- to detect hepatic dysfunction
Sudden onset of Left sided varicocele in male patients Blood studies - elevated ESR, decreased Hb, Increased Calcium, decreased LDH
Typical triad (9%) - Gross hematuria + Flank pain + Palpable renal mass Bone scan - Done only when ALP is raised or bone pain is present
- indicates advanced disease.
• Features of advanced Renal cell CA (B) Treatment:
> Bilateral pedal edema due to compression of IVC by the mass
□ Staging: TNM staging
> Weight loss
> Night sweat
>
>
Fever
Palpable supraclavicular lymph node 12 T3 T4
> Cough and haemoptysis
> Paraneoplastic syndrome Invasion of
T ia - <4 cm, Gerota's
* 20% cases confined to fascia and
* Most commonly: Raised ESR (55%) kidney adrenal gland
* Other features:
T1B->4cm.
a) Hypertension - 36%
confined to
b) Anaemia - 35% kidney
• c) Cachexia - 34%
d) Hypercalcemia -1 3 %
e) Polycythaemia - 4%
0 Amyloidosis - 2%
g) Stauffer syndrome - (i) Hepatic dysfunction associated with RCC; (ii) 3­
20% cases; (iii) elevation of ALP (100%); (iv) Elevation of P Time (67%);
(v) Elevated bilirubin (20-30%) •

MANAGEMENT OF RENAL CELL CARCINOMA

(A) Investigations:
• Renal USG - Solid/cystic mass Single regional
• Plain X-ray abdomen - Calcified renal mass with irregular outline Lymph node
involvement
• CECT - Contrast enhanced lesion in the kidney (RCC until proven otherwise)
> May show muttilocuJar cyst with thickened septa and enhancement within the cyst
V Local staging ------ ------------
> Tumor extension into perinephric fat/lymph node/ renal vein/ IVC M0 Mt
• MRI - It is the best test lo recognise tumor thrombus in renal vein or IVC
• Distant metastasis
> It is also useful to evaluate a renal mass poorly defined inCT scan • No metastasis
> Can be done in contrast allergy, renal insuffiency, pregnancy
• MRA (Magnetic resonance angiography) - Done for blood vessel mapping in patients in
whom partial nephrectomy is to be done Stage III Stage IV
Stage 1 Stage II
• Nucleolide scan
* Ti • T4 any N
> DMSA scan (Dimercapto succinic acid) • T,N0M0 • T2 Ng Mg
* Ts any N Mg • Any T Any N M)
* for renal anatomy
* Increased uptake indicates Pseudotumour/Hypertrophic column of Bartini
* Decreased uptake indicates tumor or cyst
142 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 4 Anesthesiology
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□ Treatment:
• F o r T ^ j tumor 2011 Supplementary
Q.1 ■ Describe the management o f a lady o f 35 years presenting with toxic multlnodular goitre.

Ans: See Section 1, Segment A, Paper-ll, 2008, Qs. 2, Page 108. +^

0,2 ; A 70 year old man presents with acute retention o f urine. How would you Investigate the patient*
Outline the management in b rief o f benign hyperplasia o f prostate p T f? )

Ans: ACUTE RETENTION OF URINE

See Section 1. Segment-B, Paper-ll, Qs. 2, Page 256.

BENIGN HYPERPLASIA OF PROSTATE

See Section 1, Segment-A, Paper-ll, 2014, Qs. 2, Page 183.

2012

THYROID NEOPLASMS
Q Classification:

Thyroid
neoplasm

__ n z
Benign Malignant
I

Follicular Hurthle cell

4-10% cases - Tumor IVC thrombus below the level of IVC thrombus extending above Primary Secondary
adenoma type/Oncocytic
thrombus In venous system main hepatic vein the level of main hepatic vein- From
adenoma 1.CA colon
Raquires aggressive approach
• 45-75% cases - managed by Isolation of vessels followed I ' I 2. Renal cell CA
Nephrectomy + Thrombectomy by thrombectomy Venovenous bypass/ Foelal 3. Melanoma
Colloid
id 1 j Simple I
Embryonal
Cardiopulmonary bypass 4. CA breast
Hypothermic cardiac arrest

ForT4 tumor - Best option is En Bloc resection of all involved structures

For bulky lymphadenopathy - Surgical resection if feasible
For local recurrence of RCC (Adjuvant treatment for RCC)
> for local recurrence after radical nephrectomy (2-4%)
* localised - Re-resection (ii) Systemic - Ftadiotherapy
> for local recurrence after partial nephrectomy (1-10%)
* Completion nephrectomy / Repeal partial nephrectomy / thermal ablation
> for local recurrence after thermal ablation
.* Repeat thermal ablation / Salvage surgery (Partial or Radical nephrectomy)
 144 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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P A P ILLA R Y CA OF THYROID
c Prognosis:
□ Clinical features:
’ AMES scoring AGES scoring
• Symptoms
> Swelling in lower part of anterior aspect of neck which doesnot move with protmsjc, A ; Age - < 20 yrs has better prognosis A ; Age - < 20 yrs has better prognosis
of tongue M: Distant metastasis has worse prognosis G: Pathologic grade of the tumor
> Hoarseness of voice- may occur E: Extent of primary tumor • Well differentiated - better prognosis
• Signs m Invasion to capsule/blood vessels- • Poorly differentiated - worse prognosis
> Swelling is fixed to surrounding tissue worse prognosis
E : Extent of primary tumor
> Irregular surface with firm consistency . Non invasive - better prognosis
• Invasion to capsule/blood vessels-
> Rapid onset/ Recent rapid growth S: Size of the tumor-Size < 4 cm has better worse prognosis
> Palpable neck lymph nodes prognosis
• Non invasive - better prognosis
□ Investigations: S : Size of the tumor - Size < 4 cm has better
prognosis
• FNAC of thyroid nodule - Confirms diagnosis , ...
• USG neck - Hypoecholc lesion with poorly defined margin, with microcalcification, with 1%
vascularity, without any surrounding halo (Malignant lesion) OS :A to years old gentleman presented with bilateral knobby renal lump in the abdomen How do
you investigate and treat such a patient (operation details not required). [7 + e]
• Radioisotope study - shows “ Cold nodule”
• Thyroid function lest - Increased TSH level Ans: Bilateral knobby renal lump in the abdomen in a 40 years old gentleman Indicates towards the
diagnosis of Autosomal Dominant Polycystic Kidney Disease (ADPKD).
. • Metastatic work u p :
> CT scan of neck - ADPKD
* To detect impalpable nodules
□ Clinical features:
* To assess for tymphadenopathy
Typical presentation in a young adult -
> FNAC of lymph node
• Age of onset - 30-40 yrs
> X-ray/CT scan of chest - to assess lor lung metastasis
• Principal symptom - Hypertension (60% cases)
> USG/ CT abdomen
• Hematuria (40-50% cases) - gross or microscopic
> Liver Function Test
• Bilateral palpable renal lump - almost always
□ Management : • f^ PaL'n ” co,icky' (dus 10 clot/calculus)/acute (due to Infection /hemorrhage)/chronic (due
to stretching of the capsule)
A. Treatment:
• Gastrointestinal symptoms - Anorexia, nausea
Surgery. Extent of surgery depends on the size of thyroid swelling.
• Infection - Renal angle tenderness + Pyuria + Fever with chill and rigor
• < 1 cm - Hemithyroidectomy.
• Renal insufficiency
For extremes of ages- Near total thyroidectomy + Modified radical neck dissection type Ml q
Causes :
lymph nodes are involved)
• 1-2 cm - Controversial (Hemithyroidectomy/ Near total thyroidectomy/ Total thyroidectom • Compression of non-dilated nephron by cyst
• > 2 cm - Total thyroidectomy • Hypertension
Suppressive dose of levo-thyroxine 0.3 mg OD will be continued lifelong. • Prominence of renal epithelial apoptosis

B. Follow-up: a Associated abnorm alities:

« By measurement of Thyroglobulin level. Thyroglobulin >1-2 microgram/L after to*1 • Liver cyst (18%)
thyroidectomy indicates residual disease. > more in adult, more in female
• Recurrence - Completion thyroidectomy + LN dissection + radioiodine therapy (In eW® > usually asymptomatic
subjects only radioiodine therapy is advocated) may develop portal hypertension
• Berry's aneurysm (10-30% cases)
• Splenic cyst
 146 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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• Pancreatic cyst
• Arachnoid cyst ^ Hemodialysis ^

« Pineal gland cyst

_______ f ________
• Others - Colonic diverticula, Mitral vatve prolapse, Aortic aneurysm, Lung cyst
□ Diagnosis: ^ Bilateral nephrectomy^

3 generation involvement + Bilateral renal cyst on USG

I
OR,
The presumptive diagnosis of ADPKD without any family history requires : ^ Renal transplantation ^
. Bilateral renal cyst on USG + 2 or more of the following -
• Uver cyst more than or equal to 3
• Pancreatic cyst . 2012 Supplementary
i • Splenic cyst
• Solitary cyst of arachnoid or pineal gland 0. r ; What are the different types o f nipple discharges with their clinical Importance? How would you
• Aneurysm of cerebral artery manage Stage-! carcinoma breast In a lady aged 40 years ? [6 + 9]

□ Investigations: NIPPLE DISCHARGE

Ans:
• USG of whole abdomen - Bilateral renal cyst
• Intravenous urethrogram (IVU) - Types Clinical conditions
. i) Enlargement of kidney
Blood stained i) Duct papilloma (commonest)
fi) Distortion of calyceal system/ elongated compressed calyces —Spider leg appearance
ii) Ductal carcinoma
iii) Appearance of bubble in Nephrogram phase (due to stasis of dye within the cyst)
iii) Duct ectasia
• CT scan - ft is the ideal investigation to detect hemorrhage within the cyst (50-90 Hounsk
Serous i) Fibroadenosis
• MRI - indicated in patients with renal insufficiency, contrast allergy, pregnancy ii) Retention cyst
• Blood urea, Serum creatinine iii) Duct ectasia

• Decreased maximal osmolality of urine (Due to hampered concentrating capacity of kW»

• Urine RE/ME - Low specific gravity Types Clinical conditions
□ Treatment:
Milky i) Hyperprolactinaemia
• Presymptomatic stage- Wait and watch policy ii) Hypothyroidism
- Monitor BP and renal function iii) Pituitary tumour tike prolactinoma
• If infected cyst - Lipid soluble antibiotics are advocated Purulent i) Infection
> Quinolones ii) Malignancy (rare)
> Cefoperazone/Cefuroxime
Greenish i) Duct ectasia (commonest)
> Cotrimoxazole
ii) Fibrocystic disease (rare)
> Chloramphenicol
Serosanguinous i) Infection
• If there is pain, hemorrhage and infection due to overdistension of cysts, surgical intervene
is required - Rovsing's deroofing of the cyst with marsupiateation of the cut edge (par ii) Carcinoma
decreased in 90% of cases)
• USG guided percutaneous aspiration of cyst with/without instillation of sderosing agent! STAGE- I BREAST CARCINOMA
alcohol
• Laparoscopic/retroperitoneoscopic aspiration/ deroofing of renal cyst See Section-1, Segment-A, Paper-JI, 2011, Qs. 1. Page No. 128.
« When End Stage Renal Disease (ESRD) sets in (According to National Institute of DiaW 0.2: 65 year old man presents to the emergency with acute retention o f urine. How would you
and Kidney Disease guideline, GFR < lOmL/min and Serum creatinine > 8mg/<JL( investigate & manage the patient ? [7 + 8 ]
according to WHO criteria, GFR < 15 mL/min) - Renal Replacement Therapy (ROT
recommended Ans: See Section 1, Segment-B, Paper-ll, Qs. 2, Page 257.
 148 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 149
-------- — ----—------- ---- — — ■
, intravenous pyelography (IVP)
2013
> Dye (Sodium dialrizoate or Meglumine iothalamate) is Injected into the ante cubital vein
Q.1: Define hydronephrosis. Discuss the causes and management o f unilateral hydronephrosis > Films taken at 1 min (Nephrogram), 5 min, 15 min, 20 min
[2 + 5 +| > Shows i) dense nephrogram ii) enlarged kidney iii) flattened, club shaped, broadened
calyces iv) hydroureter
HYDRONEPHROSIS
>» Late films (4 hrs, 8 hrs, 24 hrs) can be taken to see bladder pathology as well as
0 Definition : It is the aseptic dilatation of pelvic calyceal system with or without obstruction olj. residual urine.
outflow tract. > Contraindication - Iodine sensitivity, toxic thyroid, multiple myeloma
□ Causes o f unilateral hydronephrosis: , CT scan
A Congenital - > Good anatomical and functional evaluation
• Pelvi-ureteric junction obstruction • Isotope renography/ Nucleotide scan C tfty Q
• Retrocaval ureter
> Individual kidney function is measured by Gamma camera
• Ureterocele
> Also includes anatomical evaluation and perfusion study
• Ureteric stricture
• Aberrant renal vessels (vein or arteryj-common on left side > Can be of 3 types - i) DTPA scan (using Diethyl Triamine Penta Acetic acid) ii) DMSA
scan (using Dimercapto Succmrc'Acid) iii) MAG 3 scan (using Mercapto Acetyl
B. Acquired -
Triglycerine)
• Intraluminal
> Shows - i) split renal function In vascular phase, secretory phase and excretory
> Stone in renal pelvis or ureter phase ii) site of obstruction
> Papillary necrosis (sloughed papilla) > Secretion less than 20% hails bad prognosis
• Intramural < Whitaker test
> Neoplasm of ureter > Fine needle is pushed into the renal pelvis through loin followed by saline perfusion
> Stricture of ureter following pelvis surgeries, removal of ureteric stone, TB ureter at 10 ml/min
> Infection e.g. UTI > Persistent increase in pressure suggests the diagnosis of hydronephrosis
• Extramural Treatment - It is done according to the cause of hydronephrosis.
> Compression by growth e.g. CA cervix, ovarian tumor • Congenital PUJ obstruction
> Retroperitoneal fibrosis
> Retroperitoneal CA •
□ Management o f unilateral hydronephrosis:
A patient with unilateral hydronephrosis usually presents with -
• Dull aching pain in loin with dragging sensation or heaviness
• Mass in the flank which is smooth, ballotable, mobile, moves with respiration with a band c
colonic resonance in front
• Dietl’s crisis - Following an attack of acute renal colic, swelling in the flank isseen. I
disappears after sometime following evacuation of large volume of urine
• Infected hydronephrosis - Fever + Chill and rigor + Renal angle tenderness
A. Investigations -
• Urine RE, ME and culture
> Done to detect UTI
• Blood biochemistry m
> Creatinine - to detect azotemia .
> Urea •
• USG of KUB (Kidney ureter bladder) with post void residual (PVR) urine
> Shows "loss of central echogenicity with dilatation of pelvic calycealsystem'
associated hydroureter, any stone disease
> False negative in about 35% cases
> False positive in - Parapelvic cyst, capacious extrarenal pelvis, vesico-ureteric reft*
> Disadvantage - It cant evaluate kidney function
 150 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-ll 151

• Retrocaval ureter - Anderson-Hyne’s operation

• Ureterocele - Cystoscopic ureteric meatotomy with removal of the cyst wall. Ureter* F:M=t50:1
reimplantation may be needed. < 0.5% cases are seen in males.
• Stricture urethra - Dilatation, Urethrotomy, urethroplasty q Race:
• Aberrant renal vessels - Hamilton-Stewart operation Seen in white > black
• Retroperitoneal fibrosis -
0 Diet:
> Drugs - Tamoxifen, Corticosteroids, Cyclophosphamide Alcoholism
> Omental wrapping of ureter following release of fibrous tissue High fatty diet
Obesity
O J : Describe lymphatic drainage o l breast. Mention the risk factors o f breast carcinoma. Howt,
manage a 52 year old female patient with locally advanced breast carcinoma? [4 + 3+|j High dose of esfrogen for prolonged therapy (HRT)
0 Menstrual histo ry:
LYMPHATIC DRAINAGE OF BREAST
• Early menarche (< 12 yrs) - 2 years delay nwers She risk of breast CA by 10%
A. Into the Axillary lymph nodes (75%) • Late menopause (> 50 yrs) - Doubles the risk of Dress; CA
□ Berg’s levels o f axillary lymph nodes: q Obstetric and Gynaecological history ;
• Level I (Below and lateral to pectoralis minor muscle) » Late first pregnancy (> 30 yrs) - 2 fold increased risk of breast CA
> Anterior/ pectoral/ external mammary group - This is the principal draining lymph node Q Family history :
- of the breast. The nodes in this group are situated along lateral thoracic vessels.
• H10 breast CA in 2 first degree relatives - 2-3 limes increased risk of breast CA
> Lateral group - Rarely involved in breast carcinoma. Nodes are situated along axilla
• H/O breast CA and ovarian CA
vein.
> Posterior/ subscapular group- Rarely involved in breast carcinoma. Q Personal histo ry:
• Level II (Behind pectoralis minor muscle) • H/O contralateral breast CA - Increased risk of 3-4 limes in cases of lobular CA
Central group - This is the 2nd most common lymph node group involved in breast carcinon* • H/O endometrial CA
This group is most easily palpable clinically.
• H/O fibrocystic disease of breast with atypical proliferation
• Level III (Above and medial to the pectoralis minor muscle) *
• H/O previous irradiation to breast
Apical/ subclavicular/ Halsted lymph node group - Not commonly involved in breast CA.
□ Genetic factors:
> Interpectoral/ Rotter's node - It lies between the pectoralis major and the pectorals
minor muscle. When involved, it indicates retrograde spread of the tumor, • BRCA 1 and BRCA 2 mutation - 50-70% risk lifelong
> Supraclavicular lymph nodes - Finally the lymphatics from axillary lymph node • p53 gene mutation
drain here. • pTEN gene mutation .
> Axillary Reverse Mapping (ARM - Injection of blue dye in upper part of the me<ft
• Ataxia telengiectasia
aspect of the arm) is done now-a-days to map the axillary lymph node drainage.
• Cowden’s syndrome
B. Into Ihe. Internal mammary lymph nodes (25%)
• These nodes are situated in intercostal spaces (2nd, 3rd and 4th) 1-2 cm lateral to the slemt
margin and placed vertically parallel to internal mammary vessels! 1 Mild to moderate risk Moderate to high risk Very high risk
t , Lymphatics from the medial half of the breast mainly drain here. Nulliparity Age > 60 yrs 1 Therapeutic radiation (Age
• The efferent lymphatics from here drain into subclavicular nodes. menarche, late LCIS > 30 yrs)
C. Into the contralateral axillary lymph nodes menopause
Atypical hyperplasia BRCA 1 / BRCA 2 mutation
• Negligible amount of lymphatics drain here. Obesity, alcohol, HRT Personal H/O DCIS/invasivs Family H/O breast CA and
breast CA (> 40 yrs) ovarian CA
[See Figure 1.2.1 (Page No. 202)]
Family H/O breast CA (first Personal H/O OCIS/invasive
degree relative, < 50 yrs) breast CA (< 40 yrs)
RISK FACTO R S OF BREAST C AR CINO M A Family H/O breast CA (2
□ Age: first degree relatives)
Increased incidence of breast carcinoma usually after 30 years.
I U «.,«l in -- On 1're
a r t r i » 90 VIS flOed.
 152 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 153

MANAGEMENT OF LOCALLY ADVANCED BREAST CARCINOMA IN A 52 YR 0 ^ V Findings suggestive of malignant lesion -

FEMALE 1. Distorted architecture of the breast pare nchyma (irregular soft tissue shadow).
2. Micro calcifications (< 5 mm) with speculations.
Diagnosis: 3. Focal dilatations of ducts.
4. Increased number and Ihickening of Cooper's ligaments.
5. Heterogenous, polymorphic, high density opacity with irregular margin/
satellite lesion.
y American College of Surgeons (ACS) guidelines -
A Woman with average risk of breast CA should undergo regular screening
mammography, starting from 45 years age. annually to 54 yrs age, then
biennially for as long as the woman is in good health and has a life-expentancy
of at least 10 years.
> Usual views taken -
1. Medio-lateral-oblique (MLO) view
2. Cranio caudal (CC) view
>• Amount of radiation exposure during mammography - 0.1-0.2 cGy (this amount of
radiation being not enough to cause malignant changes in breast itself)
□ Clinical assessm ent: . MRI­
• Hard lump in the breast which is most commonly painless. > Purpose -

. • The second most common presentation is nipple discharge. 1. To identify m ultifocal (> 1 foci in one quadrant) and multicentric breast tumor
(MRI is even better than USG).
• Ulceration and fungation of nipple areolar complex and /or surrouding skin.
2. To image breasts with breast implants.
• Lymph node enlargement - axillary, supraclavicular.
3. To detect local recurrence or scar after mastectomy.
• Pain on the lesion (10% cases).
4. To assess axillary metastasis.
• Chest pain, haemoptysis, bone pain and tenderness, pathological fracture, ascites, pleu 5. To assess dermal extension.
effusion
> Indications -
• Symptoms due to secondaries in liver, secondary ovarian tumor.
1. Screening of young women and women in high risk group (History of
□ Radiological Im aging: therapeutic radiation in age < 30 yrs, Strong family history of breast CA,
BRCA 1/2 mutation, Personal history of DCIS/ Invasive breast CA, family
• First investigation to be done in a case of early breast CA is always a radiological imaging, ss history of breast and ovarian CA)
> These are non-invasive investigations. 2. Suspected DCIS (MRI is trie most sensitive investigation for DCIS)
> FNAC/ Open biopsy. if done first, may cause hematoma, which will alter the findn; > There is no risk of ionising radiation.
on imaging.
> IOC for imaging breasts in pregnant female.
• MAMMOGRAPHY (bilateral) - > It is a better modality than other investigations for dense breasts.
> Done in females > 40 years of age. V Findings suggestive of malignant lesion -
> It is the only reliable means to detect non-palpable breast C A 50% of breast CA n* 1. Mass with irregular intensity and spiculations
be seen on mammography before they are palpable. Further, it can identify bre* 2. Thickened skin, changes in nipple.
CA at least 2 years before the mass becomes palpable.
3. Lymphedema.
> Indications -
> Disadvantages - .
1. To evaluate suspicious breast lump, nipple discharge.
1. Costly, not available easily.
2. To identify multicentricity, to know size and location of the masses.
2. Not accurate, if done within 9 months of radiotherapy for breast CA.
3. To screen contralateral breast for additional masses in a patient undergo*1
3. Cannot be done in patients with incompatible metal prosthesis like cardiac
definitive surgery.
pacemaker.
4. To screen both breasts before any cosmetic surgery.
BIRADS (Breast Imaging Reporting and Data based Scoring system) -
5. Screening before Breast Conservative Surgery (BCS).
> This is a scoring system based on different investigations.
6. Follow-up alter BCS / Radiotherapy/ Neo-adjuvant chemotherapy.
> Based on this, advice can be given regarding further investigations anti diagnosis.
 154 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 155

Grade 2 , Disadvantages : (1) Receptor study cant be done (2) Invasive cancer cant be differentiated
Grade 0 Grade 1
from in situ disease (3) False negative results do occur, mainly due to sampling errors.
• Inadequate/Incomplete • Normal 1 Negative • Benign
assessment (b) Core needle biop sy:
• Continue annual • Continue annual
mammography , It is the preferred method for diagnosis of palpable or non-palpable breast abnormalities
• As breast tissue is dense, mammography
mammogram cant interprets • Permits analysis of breast tissue architecture to give clear histological evidence and definitive
preoperative diagnosis
• Needs additional study
, Can confirm DCIS and invasive lesion
, Can comment about grade and receptor status of tumor
Grade 3 Grade 4 Grade 5 Grade 6 (c) Frozen section b io p sy:
, Not usually practiced now-a-days
• Possible/Probably • Suspicious lump • Highly suggestive of • Biopsy proven
. Indication: when FNAC fails even after 2 trials or is negative
benign • Chance of CA = ' malignancy malignancy
, Disadvantage: Shows 20% false negative results
• Chance of CA = 1-2% 25-50% • Chance of CA = • Known carcinoma
• Repeat imaging after • Biopsy recommended 75-90% (d) Exclslonal biopsy:
3-6 months • Biopsy required , Also known as open biopsy
• It is the best and definitive Investigation for breast cancer
□ Histopathological/ Cytologlcal analysis - • Incision is planned in such a way that it will be included in the eventual mastectomy incision
at a later date
BREAST BIOPSY • Should give no false negative and no false positive results
> Types: (e) Needle localised exclslonal biopsy (NLEB):
• Procedure: (1) Through an incision under local anesthesia, a hook is placed adjacent to the
suspected lesion, using needle sheath over the tumor (2) Excision biopsy is done under
mammographlc guidance
• Indication : When core needle biopsy fails to localise non-palpable tumor

Other investigations:
» Triple receptor assessment -
a) Estrogen Receptor (ER) study
> Estrogen sensitive cytosolic glycoprotein level > 10 units per gram of tissue
is known as ER -t-ve status.
> ER -t-ve status indicates good response to hormone therapy and good
prognosis. .
b) Progesterone receptor (PR) study
c) HER 2/Neu receptor study
> Human epidermal growth receptor 2 Neu oncogene, also known as cErb B2,
is a tyrosine kinase receptor.
> Positivity indicates high grade tumor and poor prognosis.
• Cytologlcal analysis of nipple discharge
a) Sample is obtained through ductal lavage.
(a) FNAC:
• Tumor markers
• Fine needle aspiration cytofogy is the first, simplest and least invasive technique for obtaining
a) CA 15/3 (Normal serum value <40 U/mL)
a cell diagnosis in breast cancer
b) CA 27
• Minimum 6 aspirations are done using 21-30 G needle
c) CA 29
• Giemsa, hematoxylin and eosin, papanicoiaou stains used
• Metastatic work up
• It can be repealed 2 times
> Chest X-ray / CT thorax - To look for pleural effusion, secondaries in lung (cannon
• Advantages : (1) least painful (2) cheap (3) reliable (4) can be done on Out patient basis (5) ball opacities on X-ray), mediastinal lymph nodes, secondaries in ribs.
no evidence of malignant deposits along FNAC track . > USG /CT abdomen - To look for secondaries in liver, ascites, Krukenberg tumor.
156 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS O Paper-II 157

> X-ray/ MRI spine and pelvis - To look tor osteolytic secondaries in bones. Plain X-rjL
will only detect the lesion when 60% ot bone is demineralised in metastatic bo^
disease.
> LFT
W Lymph nodes W sm W ~
> Complete hemogram
T cant be No nodes Node with
V Metabolic panel - Increased Alkaline phosphatase along with increased serurr. assessed micrometastasis
Calcium level and bone pain is an indication of bone scan.
> Radioisotope bone scan - To look for secondaries in bone in advanced cases. /\
positive bone scan will confirm the diagnosis of Metastatic carcinoma of breast, m
LABC.
> PET scan - To look for bone, soft tissue or visceral metastases.
Ipsilateral, mobile,
□ Staging: a-More than or
discrete Axillary a-Fixed/matted
lymph node axillary LN (4-9 LN equal to 10 axillary
involvement Involved) LN +ve/lpsilateral
TNM STAGING
clinically Infraclavicular LN
(1-3 in no.) b-lntemal mammary +ve
LN +ve clinically in b-lpsilateral Internal
Tx - Primary tumor can’t be To - No evidence of primary the absence of mammary LN
assessed tumor axillary LN involvement +
involvement Axillary LN
involvement
c-lpsilateral
supraclavicular LN
involvement
Tfe - Carcinoma in situ (DCIS/ Tis - Paget’s ds. of nipple with
LCIS) no tumor

s u m
v Metastases
T1 - Tumor size less than or could not be No Distant
T1 mic - Microinvasion < 0.1 equal to 2 cm in greatest assessed metastasis metastases
cm diameter (T i a - 0.1-0.5 cm, Tib
-0.5-1 cm, T ic - 1 -2 cm)
Stage I - T , NO
S tagella-T0N, .T jN , ,T2N0
Stage lib - T 2N, ,T3N0
T2 - Size > 2 cm but less than
T3 - S iz e > 5 cm Stage llla - T 0N2 , T,N2 , T2N2 , T3N , , T3N2
or equal to 5 cm
Stage lllb - T4N0 , T4N ,, T4N2
Stage lllc - Any T ,N 3
Stage IV -A n y T, A n yN .M ,
T4 - Tumor of any size fixed to
the chest wall or skin (T4a - I • All other stages except Stage IV - M0
Fixed to chest wall", T<b -
2- Any N2 except T4 tumor-Stage Ilia
Fixed to skin'*,T4c - T 4a + T4b,
Tid - Inflammatory breast (CA) Any T4 except N3 node - Stage lllb ,
Any N3 - Stage lllc

’ Chest wall involvement - except pectoralis major muscle Early breast Cancer - Tt / T2 lesion + N0/ N( node (Breast tumor less than or equal to 5 cm in size,
without chest wall or skin involvement, with or without lymph node involvement < 4 in no.)
** Skin involvement - Ulceration/edema/Satellite nodule
Locally advanced breast cancer (LABC) - T3N0 , Stage Ilia. Stage lllb
Metastatic breast cancer - Stage IV
158 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS O Paper-H 15 9

□ Treatment:
(b) For non-responders and patients with progressive disease
A For non-inflammatory breast CA
* Radiotherapy to breast, chest wall, axilla and supraclavicular region
• Objectives of management - >• Hormonal therapy
> To achieve local control of the disease > Surgery, if operable tumor
> To prevent or delay the distant metastasis 3. Approach to relapse after adjuvant chemotherapy
• Protocol of treatment -
> Initial neoadjuvant chemotherapy -
t Purpose:
> To achieve cytoreduction (downstaging of tumor)
> To convert inoperable tumor to operable one/ to convert a tumor needing mastectcm
to a tumor manageable by Breast Conservation Surgery (BCS)
> To target possible micrometastases
> To assess chemosensitivity
> Better cosmesis
• Given for 3-4 cycles
• Regimen - CMF (cyclophosphamide, Methotrexate, 5-fluorouracil) in monthly/3 weekly
OR, CAF (Cyclophosphamide, Adriyamycin /doxorubicin, 5-FU)
* OR, CEF (Cyclophosphamide, Epirubicin, 5-FU)
1. Assessment for response to chemotherapy
> The patients who underwent neoadjuvant chemotherapy are divided into 4 categaj
based on reponse - • Hormonal therapy -
* Complete responders without palpable tumor
> For ER/ PR +ve tumor - Tamoxifen 20 mg OD for 5 years
* Partial responders with > 50% decrease in tumor size
* Non-responders with < 50% decrease in tumor size ■
* Progressive disease with > 25% Increase in tumor size • Purpose of palliation is to control pain, to prevent bleeding or fungation
2. (a) For responders (complete and partial) • Usually there are no role of BCS and axillary dissection in LABC
• 5 year survival - 40-45%, 10 year survival - < 25%
I- For inflammatory breast CA
Palliative surgery - Total mastectomy / Modified Radical Mastectomy/ occasionally BCS
• Known as Mastitis carcinomatosis/ Lactating carcinoma.
• Common in pregnant or lactating women.
[ _________________
' K S S r M s < " * • 1 1'“ s“e' s° " M “ s •» » »
Remaining chemotherapy (3-4 cycles)
• Clinically -
> Painful, warm lesion with peau cf orange appearance

\
. ii „ ij z z s t ” M” ,o m * * '“™
Adjuvant radiotherapy • Mimics acute mastitis.

: ~ y - DUC,al ° r ,0bU,8r 01 ma'i9nan' ce"s are in derma, lymphatics

1r • Mammography is inconclusive.
• FNAC confirms the diagnosis (shows undifferentiated cells).
Hormonal therapy • It is a Stage III B (T4d) locally advanced breast carcinoma.
• Treatment -
• ft has got worst prognosis. 5 year survival - 25-30%
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-ll 161
160 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Freshly passed
urine is collected in
a test tube

Naked eye/gross
examination of Microscopic
Centrifuged urine examination
on standing for
some time

X 2-
1. RBCs wittVwittiout
Bed or reddish RBC casts-Hematuria
llniformly pink
brown deposit of 2. No RBC + Anaemia
coloured urine
Intact RBCs with and reticulocytosis
with no deposit
clear supernatant present -
X Haemoglobinuria

c
3. No RBC + No
Q.3: A SOyear old gentleman presented with painless hematuria. What may be the possible causes! Indicates Indicates
anaemia or reticulocyto-
How would you investigate the c a s e ? Give an outline o f the management [5 + 5+^ Hematuria Haemoglobinuria
sis-Myoglobinuria

- PAINLESS HEMATURIA IN A 50 YEAR OLD MAN

> Hematuria in the initial part of voiding- Hematuria of lower urinary tract origin (Urethral
□ Possible cau ses: pathology)
Hematuria is defined as abnormal presence of RBCs in urine. 2. Associated features -
It is of 2 types - (1) gross (2) microscopic ( > 5 RBC/hpf). • Fever - APSGN, urinary bilharziasis
Causes of painless hematuria in a 50 year old gentleman are - • Facial puffiness, hypertension - seen in APSGN
• Dragging discomfort in loin - RCC
Renal cell carcinoma (RCC) .•
• Symptoms suggestive of Lower urinary tract symptoms(LUTS)/ bladder outlet obstruction
Bladder tumor - Papilloma, Urothelial cell CA
(Hesitancy, urgency, frequency, poor stream of urine, dribbling,inadequateemptying) -
'y f Benign prostatic hyperplasia (BPH) Bladder tumor, BPH
• Urinary bilharziasis • H/O sore throat (2-3 weeks back) / pyoderma (3-6 weeks back) - seen in APSGN
y * Acute post-streptococcal glomerulonephritis (APSGN)
• Urticaria for a few days, fever after 4-8 weeks-Urinary bilharziasis
/ Leukemia 3. Occupational history -
^ Anticoagulant overdose
• Aniline dye factory workers - Bladder carcinoma
/< Snake bite • Fresh water swimmers - Urinary bilharziasis
□ Diagnosis: 4. H'O drug intake - Anticoagulants
Confirmation of hematuria - (see the chart on next page) 5. H/O snake bite - Snake bite induced hematuria

□ H istory: □ General examination ;

1. Evaluation of gross hematuria - • Pallor - seen in malignancy (RCC, bladder CA), leukemia
• Colour of urine: • Edema - Pitting edema is seen in APSGN
> Cola coloured - Hematuria of glomerular or upper urinary tract origin • 8lood pressure - Hypertension is seen in APSGN
> Bright red coloured - Hematuria of bladder or lower urinary tract origin • Temperature - elevated in APSGN, urinary bilharziasis
• Pattern of hematuria: _ • Purpuric spots - seen in leukemia, anticoagulant overdose
> Hematuria throughout the stream - Hematuria can be of upper or lower urinary ^ Systemic examination:
origin I. Abdominal lump -
y Hematuria in the latter part of voiding - Bladder pathology • Kidney lump- seen in RCC

2'
162 QUEST : A Comprehensive Guide lo UG Surgery. Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 163

• Distended bladder - seen in BPH * Malignant cells found in cytology of urine

2. Examination of genitalia - >may bo followed by brush biopsy.
• Varicocele - seen in RCC rbladder tumor can be diagnosed.
3. P/R examination - >bilharzial pseudotubercles, bilharzlal nodules, sandy patches, ulceration,
• Enlarged smooth prostate, tree overtying rectal mucosa - seen in BPH granuioma, papilloma (presence of any 1 or more) - suggestive of urinary
bilharziasis
Investigations:
, Retrograde pyelography - to diagnose bladder tumor
1. Urine examination -
. Trans rectal Ultrasound - to diagnose BPH
• Routine examination:
> Specific gravity n M anagem ent:
V- Protein (I) MANAGEMENT OF RENAL CELL CARCINOMA
y Sugar
> Blood Staging: TNMstaging
» Ketone
• Microscopic examination :
> Phase contrast microscopy - lo detect dysmorphic RBC
V Pieces of tumor - seen in papilloma of bladder
> Ova of Schistosoma haematobium - seen in urinary bilharziasis TtA <4ctn, T2A- < 7 cm, T3A- Invasion Invasion of
> Exfoliative cytology (by Papanicoiau staining) confined to and < 10cm, into peri­ Gerota's
kidney confined to nephric fat fascia and
• Culture and sensitivity
kidney and renal vein adrenal gland
> Gram staining
T IB -<4 cm,
> APB staining
confined to T2B- < 10cm, Tumor
2. Blood profiles - kidney confined to thrombus in
• Complete hemogram kidney IVC below the
diaphragm
• Serum urea, creatinine
• Serum total protein, albumin
Tumor
• Serum cholesterol ,
thrombus in
• Serum electrolytes IVC above the
• Serum 0 3 - Low serum C3 level is seen in APSGN diaphragm
• Serum ASO litre - Increased ASO titre is seen in APSGN
• 20 minute whole blood clotting test (WBCT)- Clotting time > 20 mins Indicates snake ti
3. Renal biopsy - Immunofluorescent and electron microscopic study is done only when indie*
4. Renal function tests Single regional
1 Lymph node
• DTPA (Diethylene triamine penlaacetic acid) scan, Lymph node
involvement
involvement
• DMSA (Di mercapto succinic acid) scan,
• MAG-3 (Mercapto Acetyl Glycine) scan
5. Radiological investigations -
• Intravenous urethrography (tVU):
> Irregular Filling defects in bladder - Tumor
No metastasis Distant metastasis
> Irregular calyces - seen in RCC
• USG of abdomen :
> Enlarged kidney - seen in RCC Stage I Stage II Stage III Stage IV
• CT scan
• Cystoscopy: * T, N0 M0 • T 2 N0 M0 • T| _ jN i -2 Mg • T* any N
> Indications are - • Tj any N Mq * Any T Any N
* H/O Lower urinary tract symptoms (LUTS)
* Hematuria with normal IVU
164 QUEST : A Comprehensive Guide (o UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 165
: - |

O Treatment: (II) MANAGEMENT OF CARCINOMA OF URINARY BLADDER

A ForT1*2 tumor
Endoscopic resection of bladder tumor
, Helmstein balloon degeneration and cystoscopic resection -
> Done for large papillary tumor

pressure necrosis remaining part ot the

Balloon is passed balloon is Inflated —► of the summit of the tumor is resected
into urinary bladder through cystoscopy
tumor

. intravesical chemotherapy -
> Used especially for carcinoma in situ
> BCG is mostly used.
> Dose : 120 mg of BCG in 150 ml of normal saline weekly for six weeks
> A/E : BCG provocation (fever, joint pain, granulomatous prostatitis, disseminated
tuberculosis)
> Contraindication : hematuria
> Mitomycin C, adriamycin, epirubicin, metrotrexate, thiotepa can also be used,
t Systemic chemotherapy -
)c Cisplatin, Adriamycin, 5-FU and mitomycin are used.
For Invasive bladder tumor
• Radiotherapy
> Interstitial radiotherapy
* Oftei) curative.
* Impla ntation of radioactive gold grains (Au 198, half-life = 2.5 days) / radioactive
tantalum wires (Ta 182, half-life = 4 months) is done.
> Radical deep external beam radiotherapy
* Dose : 45 Gy
0. For bulky lymphadenopathy - Surgical resection if feasible
* Cobalt 60 is used
IVC thrombus below the level of IVC thrombus extending above * Advantage : Normal act of micturition can be maintained
4-10% cases - Tumor
thrombus In venous system main hepatic vein the level of main hepatic vein- * Complication : Thimble/Systolic bladder
Requires aggressive approadi • Surgery
45-75% cases - managed by Isolation of vessels followed > Indications:
Nephrectomy + Thrombectomy by thrombectomy Venovenous bypass/
Cardiopulmonary bypass * Multiple tumors
Hypothermic cardiac arrest * Recurrent tumors
8. For T3 tumor * Sessile tumours
C. For T4 tumor - Best option is En Bloc resection of all involved structures * Poorly differentiated tumors
D. For bulky lymphadenopathy - Surgical resection if feasible * Adenocarcinoma
E. For local recurrence of RCC (Adjuvant treatment for RCC) * Squamous cell carcinoma
• for local recurrence after radical nephrectomy (2-4%) * Carcinoma in situ
> localised - Re-resection (ii) Systemic - Radiotherapy > Modalities :
• for local recurrence after partial nephrectomy (1-10%) * Partial cystectomy -
> Completion nephrectomy / Repeat partial nephrectomy / thermal ablation ❖ Indication : single tumor, tumor confined to fundus of bladder
• for local recurrence after thermal ablation ❖ 2.5 cm margin of clearance is maintained
> Repeat thermal ablation / Salvage surgery (Partial or Radical nephrectomy! <• Surgery is followed by external beam radiotherapy and chemotherapy.
 166 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics S Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II

* Radical cystectomy - 1 Alpha 1 adrenergic blockers -

❖ Removal of urinary bladder, urethra, paravesical tissues, pelivic lymph • Act on dynamic component - Inhibit contraction of smooth muscle of prostate
is done. Hyterectomy with removal of part of vagina is done in females, . Reduce bladder neck resistance thereby improving urine flow
❖ Urinary diversion is done by ureterosigmoidostomy or continent ileal ccy^ • Short acting drugs: Prazosin, Indoramin
or rectal urinary pouch. • Long acting drugs : Terazosin, Doxazosin
• Chemotherapy • Selective Alpha 1A receptor blocker :
> Intravesical chemotherapy a) Tamsulosin - 0.4-0.8 mg daily for 12 weeks
* Done by BCG, mitomycin C, adriamycin, interferons. b) Alfuzosin-10mg daily
• Systemic chemotherapy - c) Silozosin - 4-8mg daily
> Regimen for adjuvant therapy : (i) Cisplatin, adriamycin, mitomycin, vinblastku . Selective Alpha 1D receptor blocker
Methotrexate, vinblastin, adriamycin, cisplatin (MVAC)
Naftodipil- imp roves nocturia (25-75 mg daily)
> Neoadjuvant chemotherapy: Cisplatin is used (improves survival by 7%) • Adverse effects -
a) Floppy iris syndrome
(iii) MANAGEMENT OF BPH
b) Postural hypotension
□ IPSS: c) Retrograde / dry ejaculation
• International Prostate Symptom Score / American Urologic Association Score d) Flushing
• 7 questions regarding symptoms in the past month 2. 5 alpha reductase inhibitors -
• 1. Incomplete emptying 2, Frquency 3.Intermittency 4. Urgency 5. Weak stream 6. Strarr . Act on static component: Inhibit conversion of testosterone to DHT
7. Nocturia • Effective in palpable enlarged prostate
• Maximum score - 7*5 = 35 • Drugs used:
• Mild symptoms - Score Less than or equal to 7 > Finasteride : 5mg daily for 6-8 months
• Moderate symptoms - Score 8-19 > Dutasteride: 0.5 mg daily
• Severe symptoms - Score 20-35 3. Anticholinergics -
A. Medical treatm ent: • Drugs used :
V Tolterodine - 2-4 mg
> Solifenacin - 5-10 mg
> Darifenacin - 7.5-15 mg
4. Phosphodiesterase 5 inhibitors -
• Drugs used:
> Sildenafil
> Tadalafil
> Vardenafil
Surgical treatment:
• Indications of surgery -
> Prostatism (frequency, dysuria, urgency)
> Acute retention of urine
> Refractory/ chronic urinary retention with residual urine > 200mL
> Recurrent UTI
> Recurrent hematuria
> Bladder stone
> Bladder diverticula
> Hydroureter, Hydronephrosis
• Min imal Invasive Therapy -
Transurethral resection of prostate (TURP)
Most common and popular method as quicker recovery and early discharge are
 168 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-ll 169

* No suprapubic incision is needed

* Done using resectoscope with high frequency diathermy current
* Continuous postoperative irrigation with glycine solution is needed for 72 ho^
> Holmium LASER enucleation of prostate (HOLEP)
> Trans urethral needle ablation (TUNA) using high frequency radiowaves
> Trans urethral vaporisation (TUVP)
> Trans urethral Microwave therapy (TUMT) ;
> Trans urethral incision of prostate (TUIP)
> Trans urethral balloon dilatation of prostate
> Prosthetic stents (Intraurethral / extraurethra!)
> High intensity ultrasound energy therapy
> Water induced thermotherapy
Surgery:
* Millin's retropubic prostatectomy
> Not commonly practiced
> Done without opening of bladder
* Young’s perineal open prostatectomy
* Freyer’s suprapubic transvesical open prostatectomy
> It was the procedure of choice for enlarged prostate before the advent of TURP
Hashimoto's
> Indication : Bladder pathology + Large median lobe Diffuse-Grave's autoimmune
disease thyroiditis
Complications o i surgical procedures:
Water intoxication with congestive cardiac failure - TURP syndrome
Retrograde ejaculation - 65% '
de-quervain's
Recurrent late LTTI - 20% Multinodular-
autoimmune
Plummer's disease
Need for re-TURP/ Surgery in 10 years -1 5 % thyroiditis
Failure/ Recurrence of symptoms -10 %
Severe sepsis - 6%
Erectile dysfunction - 5% ,
Toxic nodule Riedel's
Postoperative hematuria (solitary) ttiyrotdrtis
Perforation of bladder or prostatic capsule

(iii) MANAGEMENT OF URINARY BILHARZIASIS

1) Medical treatment - Long term Praziquantel or Metrilonate

2) Surgical treatment -
* For sequelae or complications of urinary bilharziasis
> for thimble bladder - ileocystoplasty/ cecocystoplasty
> for papilloma of bladder - cystoscopic diathermy fulgaration
> for squamous cell carcinoma ol bladder - radical cystectomy

2013 (supplementary)
Q.1: How do you classify goiter7 Give an outline o f Investigations and management o f a solitfi
nodular goiter. •[5+5+5]
GOITER

□ Classification - The term Goiter (Latin “guttef-throat) is used to describe generalised enlargem**
of the thyroid gland.
 170 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 171

□ ln^ ^ I v r o i d function test - TSH, Free T4 (to detect hyperthyroidism)

Diffuse hyperplastic goiter y 1- \ Serum Thyroid-Stimulating Hormone (Normal 0.5-5 U/mL)
‘ Tota, T4 (Reference Range 55-150 nmol/l) and T3 (Reference Range 1..5-3.5
nmol/L)
. Free T4 (Reference Range 12-28 pmol/L) and Free T3 (3-9 pjafll/L)
Physiological - Primary iodine Secondary iodine Vw ir nodule - Usually euthyroid with normal TSH and low-normal or normal free T4
1. Puberty deficiency - deficiency ||
■Y levels If some nodules develop autonomy, suppressed TSH levels or hyperthyroidism
2. Pregnancy endemic (dietary intake
< 100 microg/day) r-w;, nndule - Free T4 - very high, TSH - low or undetectable
2 - ; ay neck and chest - to detect tracheal deviation or compression or sometimes calcification.
. 3 ultrasound of neck -
Dyshormonogenetic ' / , To identify impalpable nodules (< 2-3 mm in diameter)
/ a
. Gives Information about size and multicentricity.
, Distinguishes solid from cystic lesions
Drugs-PAS thiocyanate,
lithium , To guide FNAC
. To assess for cervical lymphadenopathy.
Goitrogens-cabbage, . Colour Doppler USG helps in visualisation of small vessels within the gland
soyabean etc 4. CT/MRI-
. T o evaluate Retrosternal extensions.
. To assess for lymphadenopathy
. To detect impalpable nodules
SOLITARY THYROID NODULE

It is a single palpable nodule in an otherwise impalpable thyroid gland. It may be toxic (3-5%) or noMoi S 5. FNAC- ,
. Recommended in patients who have a dominant nodule or one that is painful or
□ Causes/Differential diagnoses: ,m
enlarging
(i) Toxic nodule (single / one palpable nodule of a multinodular goiter) [most common] . Can detect colloid nodule, thyroiditis, thyroid cyst, thyroid carcinoma (papillary and
(ii) Thyroid adenomas (Follicular, Hurthle cell type) - 20% medullary)
(iii) Papillary carcinoma of thyroid - 20% . Cant differentiate between follicular adenoma and adenocarcinoma
(iv) Thyroid cyst-1 0 % • Most experts have recommended 3-6 aspiration per nodule. Satisfactory specimen
(v) Medullary carcinoma of thyroid contains atleast 5-6 groups of cells, each group containing 10-15 well preserved
□ Solitary thyroid nodule may present with the following features : colls
• Grading - Thy1 (nondiagnostic),Thy2 (noneoplastic),Thy3 (follicular),Thy4
• Swelling in the anterior aspect of lower part of neck, which moves with deglutition and doesnJ
(suspicious of CA),Thy5 (Malignant)
move with protrusion of tongue
• Tracheal deviation towards opposite side is common (Trail's sign, Two finger test) 6. FNAB/ True cut biopsy -
. For diagnosis of carcinoma mainly- unresectable tumor, anaplastic CA, lymphoma
• History and clinical features suggestive of malignancy :
__ 7. Radioisotope study (Isotope used - 1123 [Half Sfe-12-13 hrs] or Tc99[Half life-6 hrs])
> Nodule in extremes of age group (child/ > 60 yr$ aged)
> Nodule in a male patient . • “ Hot" nodule - Toxic
> History of radiation on neck * * • “Warm" nodule - Euthyroid (Non toxic);
> Family history of papillary/medullary CA of thyroid Warm nodule in Tc99 scan, but cold nodule in RAI scan - Discordant nodule
> Hoarseness of volce/stridor/dyspnea/dysphagia (Malignancy)
> Irregular surface with firm consistency • "Cold” nodule - 20% malignant, 80% benign
>- Fixity to surrounding structure 8. Power Doppler -
V Rapid onset/ recent rapid growth in size • To know vascularity of the gland
V Pain in the swelling . Resistive index > 0.7 (N = 0.65-0.7) indicates malignancy
> Palpable lymph node .
 172 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS O Paper-II 173

9. Indirect laryngoscopy -
To assess vocal cord movements prior to surgery (mainly for documentation and medicole.
purpose). FNAC
10. ECG - To detect cardiac abnormalities
11. Baseline investigations -
( • Complete hemogram: Kb%, TC, DC, ESR Hurthfe cell Follicular .
• Blood for sugar, urea and creatinine | Papillary CA Medullary CA
adenoma adenoma
• Urine and stool routine examination
. 1
□ Treatment: ■ Harm
Near total thy­ '
thynoidectomy Hemithyroidectomy
Indications for surgery in solitary nodule of thyroid - roidectomy ••* Total thyroidec­
followed by levo- tomy with lymph
i) Malignant nodule/ Nodule suspicious of malignancy node dissection
[ Histology - Hurthle thyroxine 0.3 mg
ii) Follicular neoplasm OD . (upto level 6)
cell carcinoma
iii) Nodule with obstructive symptoms [ Histology Follicular
I ---------
iv) Toxic nodule in children carcinoma
Total thyroidectomy |
v) Complex cyst + routine central,
vi) Cosmetically bothersome nodule neck node removal, f Completion
+ modified radical thyroidectomy
y Treatment options - neck dissection within 7 days or
. • Non-toxic nodule • • Hemithyraidectomy (Unilateral lobectomy+isthmusectomy) when lateral neck. after 3 weeks
nodes are palpable Total thyroidec­
• Toxic nodule -
tomy (It Frozen
section biopsy
proves carcinoma)
with lymph node
dissection

• Colloid nodule -
Oral levo-thyroxine
i
Therapy failed- Progressive enlargement/ recurrent nodule
I ‘ .
y. Hemithyroidectomy
' Anti - thyroid drugs:
□ Initially given to make patient Euthyroid before surgery
Q Carbimazolo 10mg 6-8 hrly - Euthyroid state may be achieved by 6-8 wks
^ Propranolol 20-40 mg BD/TDS - To ameliorate cadiovascular symptoms
.. 3 Lu90,'s iodine 1°-30 drops/day for 10 days prior to surgery - To reduce vascularity of gland
... Hem,tt)yroidectomy - Lobectomy (unilateral) + Isthmuseclomy
• Thyroid cysts -
near ‘hyr° idectomy ~ < 2 9 of tissue is kept only to preserve parathyroid glands
> Cyst > 4 cm in size near lower pole on one or both sides.
> Complex cyst (Cyst containing both solid and cystic areas) Surgery indicated
> Recurrent thyroid cyst carcinoma in a A n . . . fc3tufcst Investigations and managemen t o l renal cell
w rcmoma in a 40 years old male patient. [3 + 5 + 3 + 4]
• Thyroid neoplasms - (see chart on next page)
Ans ‘ See Sec*l. Segment-A. Paper-IJ; 2011 Qs. 2 (Page 139-140).
174 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
r
r.
___________________ SOLVED LONG QUESTIONS OF FINAL MBBS □ P aper-ll 175

0 ,3 : Discuss the clinical features o f pheochromocytoma. How w ill you diagnose this condition? Ght • Polyuria
an outline o f management. (5 + 5+ j]
• Diarrhea (Due to elevated Basal Metabolic rale)
PHEOCHROMOCYTOMA . Weight loss (Due to elevated BMR)
• Constipation
Q Clinical Features :
• Raynaud's phenomenon
1. Age of onset - 4th-5th decade
• Cushingoid features
2. Typical features -
6. Rule of 10 for phaeochromocytoma -
a) • 10% familial
• 10% extra-adrenal
• 10% malignant
• 10% calcified
• 10% multiple
• 10% bilateral
• 10% hypotension
• 10% in children

b) Anxiety Q Investigations for diagnosis:

c) Sense of impending doom 1. Blood studies -
d) Facial pallor • elevated Total leucocyte count
e) Tremor • elevated ESR
f) Cyanosis • elevated Blood glucose
3. Cardiac manifestations - • decreased Renin
• Hypertension - Most common manifestation (90%) 2. Urinary metanephrine - Sensitivity > 97%(1.3mg/day)
- 60% sustained hypertension, 40% paroxysmal hypertension 3. Urinary Vanillyl mandeiic acid (VMA) - Sensitivity 89%
• Angina - More than7 mg/24hrs
• Myocardial infarction • 4. Plasma free metanephrine - Screening test of choice
• Supraventricular tachycardia 5. Serum chromogranin A - increased in 80% cases
• Ventricular premature beats 6. Imaging studies ~
• Cardiomyopathy • CT scan - Gives belter anatomical delineation
• Myocardial fibrosis • MRI - Investigation of choice (IOC)
• Congestive cardiac failure > More sensitive (>90%)
• Non-cardiogenic pulmonary edema (Pulmonary capillary wedge pressure/PCWP < > Light bulb appearance
18mmHg) • Metaiodo Benzyl Quinidine (MIBG) scan with Iodine 123 radioisotope
4. Crisis - t* To locate extra-adrenal phaeochromocytoma
• Sudden onset • Somatostatin Receptor Scintigraphy (SRS)
• Anorexia. Nausea, vomiting > By using Indium-111 Octreotide
• Chest pain, Abdominal pain > to locate occult phaeochromocytoma
• Hypertension, Tachycardia, Tremor • Positron Emission Tomography (PET) scan with 18-Fluorodeoxyglucose (FDG)
• Sense of impending doom > Best test
• Perspiration, Headache r Highly sensitive
5. Other features - Management:
• Confusion
Algorithm for management of Phaeochromocytoma :
• Psychosis
• Fever (elevated IL6)
176 QUEST : A Comprehensive Guide 10 UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MB8S Q P a p e r-ll 177

~~"-i ^ Treatment o f Operable phaeochromocytoma:

Hypertension, Headache, Perspiration, A preoperative Preparation -
Palpitation, Weight loss. Tremor
1 Alpha blocker - Given 4 weeks prior to the surgery

Plasma Iree metanephrine

_r
Negative Positive

Observe Confirmatory test-Urinary

metanephrine/catecholamlnes

Negative Positive Suppression is indicated by -

I • BP in supine posture <90/60 mmHg
Repeat urinary metanephrine CT/MRI” • BP in erect posture <160/90 mmHg
2. Beta blocker - Propranolol 40mg BD (Given 1 week prior to the surgery only after the patient is
fully alpha blocked)
■
3. Newer Calcium Channel Blocker like Felodipine
Negative Mildly elevated Positive
B. Intraoperative Treatment -
H t. Hypertensive crisis - Drug of choice (DOC) is Sodium Nitroprusside (0.5-10 Microgram/kg/min)
-------'------
Observe
r ~ --- - ■—— 1------------------- 1 ^
Clonidine suppression test* CT/MRI" i 2. Fatal arrhythmia - DOC is Esmolol (5 mg titrating dose, Half life is 10 mins)
' C. Adrenalectomy -
• Adrenal vein is ligated first
• To avoid breach in Ihe capsule of lumor during surgery
* Clonidine
• Rupture and spillage of the tumor should be prevented
suppression test
• In case of bilateral presentation of phaeochromocytoma, the opposite side can be operated
at a later date

Urinary Metanephrine
□ Treatment o t Inoperable pheochromocytoma:
Urinary Metanephrine
suppressed not suppressed Catecholamine Synthesis Inhibitor - Metyrosine 250 mg QDS
T 3 Treatment o f Metastatic pheochromocytoma:

GE Observe

•CT/MRI
CT/MRI" •
•
Chemotherapy - Cyclophosphamide, Vincristine, dacarbazine
High dose MIBG therapy with Iodine 123 and Iodine 131

2014
Age < 50 years, Age > 50 years, 0.1: Discuss the clinical features, investigations and treatment o f thyrotoxicosis. [5 + 5 + 5)
Multicentrlc Solitary lesion
THYRO TOXICOSIS
MI8 G Scan Preoperative prepara­
tion and Surgery Thyrotoxicosis refers to the symptom complex due to raised levels of thyroid hormones.
------'I-------- (Adrenalectomy) n occur in any age group.
Preoperative preparation and Se* predisposition - F : M = 8 . 1
Surgery (Adrenalectomy) S *wo Principal types - (i) Primary (ii) Secondary

<3
178 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS O f FINAL MBBS □ Paper-II 179

r Ectopic beats/ Extrasystoles

□ Clinical features:
V Pulsus paradoxus
A Symptoms
> Paroxysmal atrial tachycardia -
i) Cardiovascular system
V Paroxysmal alrial fibrillation .
> Palpitation
> Persistent atrial fibrillation not responding to digoxin
> Angina >
iii) Thyroid dermopathy
> Dyspnea .
> Pretibial myxedema - Skin around both ankles and feet become shiny, reddish,
ii) Gastrointestinal system
thickened with coarse hair. Occurs due to deposition of mucin like materials
r Diarrhea (Glycosaminoglycans) in skin and subcutaneous tissue.
> Weight loss (although appetite is increased)
*■ Pruritus _
iii) Genitourinary system > Palmar erythema
r Oligomenorrhea/amenorrhea *
> Dupuytren's contracture
y Urinary frequency (occasionally)
iv) Thyroid acropachy
iv) Skin > Clubbing of fingers and toes
V Hair loss > Hypertrophic pulmonary osteoarthropathy may occur
r Pruritus
> Gynecomastia PRIMARY THYROTOXICOSIS SECONDARY THYROTOXICOSIS
v) Musculoskeletal system
1. Symptoms are followed by thyroid swelling. 1. Symptoms follow thyroid swelling.
> Undue fatigue
2. Goiter is diffuse, smooth 2. Swelling is large, nodular
> Muscle weakness
3. Features are more severe 3. Features appear late , are less severe and
> Increase in linear growth (seen in children)
4. Eye signs are common * slowly progressive
vi) Neurological system
5. Cardiac manifestations are uncommon 4. Eye signs are not common
Tremor
6. Occurs in young 5. Cardiac features are common
Irritability
7. Entire thyroid gland is overactive 6. Occurs in adults and elderly
Nervousness
7. Internodular tissues are overactive
Insomnia
fl. Signs
Investigations:
i) Eye signs
> Stellwag's sign - Absence of normal blinking resulting into staring looks. It is Ihefe Thyroid function test
eye sign to appear. . (a) TSH, Free T4 - to detect hyperthyroidism. •
> Lid retraction (Dalrymple's sign) - Visible upper sclera due to higher upper eytf > Serum Thyroid-Stimulating Hormone (Normal .0.5-5 micro lU/mL)
with normal lower eyelid. 'r Total T4 (Reference Range 55-150 nmoi/L) and T3 (Reference Range 1.5-3.5 nmol/L)
> Lid lag (von Graefe’s sign) - Upper eyelid is unable to keep pace with the eyefe > Free T4 (Reference Range 12-28 pmot/L) and Free T3 (3-9 pmol/L)
when it looks downwards while following examiner’s finger. Non-toxic goiter - Usually euthyroid with normal TSH and low-normal or normal free T4 levels. If
> Jolfroy’s sign - Absence of wrinkling on forehead when patient looks upwards. some nodules develop autonomy, suppressed TSH levels or hyperthyroidism
r Moebius's sign - Lack of convergence of eyeball resulting in diplopia. Toxic goiter - Free T4 - very high, TSH - low or undetectable
> Exophthalmos - Visibility of lower sclera initially followed by visible upper scler# (b) Thyroid Antibodies assessment -
to spasm of upper eyelid and infiltration ol retrobulbar tissues with fluid). > to differentiate from autoimmune thyroiditis (TPO and Thyroglobulin antibodies)
> Grading of exopththalmos - > to detect Grave's disease (LATS).
* Mild- Stellwag's sign + Dalrymple’s sign + von Graefe’s sign > TSHRAb found in all Primary thyrotoxicosis
* Moderate - Joffroy's sign (c) TRH stimulation test - "No response" (No change is TSH level after 20 mins following
* Severe - Moebius's sign, diplopia, ophthalmoplegia inlravenous TRH 200 microg) suggests hyperthyroidism
* Malignant (misnomer)/Progressive - Chemosis. corneal ulceration, pap»e** X-ray neck and chest - to detect tracheal deviation or compression or sometimes calcification.
Cardiac manifestations Ultrasound of neck —
> Tachycardia and increased sleeping pulse rate (as per Crile’s grading) • To Identify impalpable nodules (<2-3 mm in diameter)
 180 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 181

• Gives Information about size and multicentricity. • Propranolol 20-40 mg BD/TDS - To ameliorate cadiovascular symptoms
• Distinguishes solid from cystic lesion * Lugol's iodine 10-30 drops/day for 10 days prior to surgery - To reduce vascularity
• To guide FNAC of gland
• To assess for cervical lymphadenopathy. > Disadvantages
• Colour Doppler USG helps in visualisation of small vessels within the gland • High recurrence rate •
4. CT/MRI - * Adverse effects - thrombocytopenia, agranulocytosis, hair loss, liver damage
• To evaluate Retrosternal extensions. . Radioiodine therapy .
• To assess for lymphadenopathy V Indications -
• To detect impalpable nodules i) Patient with cardiac complications
5. FNAC-
ii) Elderly (initially 40yr age, however now more than 10 yr age eligible)
• Recommended in patients who have a dominant nodule or one that is painful or enlarge
iii) Autonomous toxic nodule ‘
• Done as carcinomas have been reported in 5 to 10% of multinodular goiters.
> Contraindication - Pregnancy
•
Most experts have recommended 3-6 aspiration per nodule. Satisfactory specimen con^
atleast 5-6 groups of cells, each group containing 10-15 well preserved cells V Adjuvant - Pretreatment with lithium, rhTSH leads to increased effectiveness of uptake
6. Radioisotope study (Isotope used - 1123 [Half life -12 -13 hrs] or Tc99 [Half life-6 hrs]) r Isotope used - 1131 (half life = 8 days)
• “ Hot" nodule-Toxic V Dose —300-600 MBq OR 12-14 milicurie OR 160 microcurie/g of thyroid orally
' • "Warm” nodule- Euthyroid; > Substantial improvement b/w 8-12 wks.
Warm nodule in Tc99 scan, but cold nodule in RAI scan - Discordant nodule (Malignant
• "Cold" nodule - 20% malignant, 80% benign
Grave's diease (Primary thyrotoxicosis) - Diffuse uniform overactivity
Antithyroid therapy until
Secondary thyrotoxicosis - Heterogenous overactivity (only internodular areas show.increased up& eumetabolic
7. Indirect laryngoscopy state (2-8 wk)
To assess vocal cord movements prior to surgery (mainly for documentation and medicolegal puipos
8. ECG - To detect cardiac abnormalities
Medication discontinued
9. Baseline investigations - ,
for 4 days
• Complete hemogram : Hb%, TC, DC, ESR
• Blood for sugar, urea and creatinine
• Urine and stool routine examination 12-14 m Curie radioiodine is
deposited into the gland based on
□ Treatment:
pretreatment RAIU test
A GENERAL MEASURES
1) Rest
2) Sedation 7 days thereafter, antithyroid drug
is reinstituted for 3 months
B. SPECIFIC MEASURES '
1) Anti - thyroid drugs
y Indications -
r
i) Initially given to make patient Euthyroid before surgery . If size reduces No Improvement
ii) Soon after starting radioiodine therapy
iii) Thyrotoxicosis in children and in young adults
Dose of Antithyroid
iv) Thyrotoxicosis in pregnant women (preferred drug-Propylthiouracil) Second course of
drugs is tapered
therapy/Surgery
> Drugs - • gradually
* Carbimazole 10mg 6-8 hrly
OR Propylthiouracil 200 mg 8 hourly
- Euthyroid state may be achieved by 6-8 wks
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-ll 183
182 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

2 Describe the pathophysiology o f BHP. Mention the medical and surgical management o f BHP.
* Adverse effects -
i) Low level exposure to radiation
BENIGN PRO STATIC HYPERPLASIA
ii) Hypothyroidism
iii) Radiation induced thyroiditis (4% cases) 0 pathophysiology:
iv) Therapeutic dosing dilemma . Benign Prostatic Hyperplasia is involuntary hyperplasia of prostate due to disturbance of
v) Orbitopathy < normal ratio and quantity of circulating androgens and estrogens.
• Surgery < It is actually a benign neoplasm, also known as Fibromyoadenoma.
> Indications -
i) Young patients
ii) Mid trimester pregnancy
iii) Autonomous toxic nodule
iv) Toxic multinodular goiter :■
v) Grave’s ophthalmopathy
vi) One or more large nodule with obstructive symptoms
vii) Failed radioiodine therapy
viii) Failed / Prolonged treatment with antithyroid drugs (> 2 yrs)
ix) Those who require rapid resolution at thyrotoxic state
> Options -
a) Total thyroidectomy (Surgery of choice)
b) Near total thyroidectomy - < 2 g of thyroid thyroid tissue is kept only to preset
parathyroid glands, near lower pole on one or both sides
c) Subtotal thyroidectomy - 2 x subtotal lobectomy + isthmusectomy. 8 g thyra:
tissue is retained in tracheo-oesophageal groove on both sides
V Advantages -
* Rapid cure and High cure rate •
• DHT is five times more potent t han Testosterone. With i ncreasmg age, the level of testosterone
> Disadvantages - drops slowly. When the concurrent fall of the level of estrogen is not equal, prostate enlargement
a) Recurrent thyrotoxicosis (5%) occurs through Intermediate peptide growth factor. "
b) Permanent hypothyroidism (20-45%) t BPH usually arises from submucosal glands of periurethral transitional zone and enlarges
as lateral lobes narrowing the urethra. BPH may also arise from subcervlcal glands of central
c) RLN injury
zone and enlarges as middle (median) lobe projecting up into the bladder.
> Pre operative -
r-----------------------------------------------------------
* CT scan, MRI | Median lobe of prostate enlarges into the bladder
* Restoration of euthyroidism
> Post operative -
Tab Carbimazole - 10mg, 6-8 hourly 1 Detrusor muscle hypertrophy (lengthening of
I muscle fibres) occurs - Trabeculation
No clinical improvement for 7-14 days 2 Sacculations and diverticula formation in bladder
3. Compression of prostatic venous plexus leading
I to congestion - Vesfcal piles resulting in hema­
Euthyroid state achieved in 6-8 weeks turia

I “■Progressive increase in bladder pressure - In­

Maintenance dose - 5mg, 8 hourly for 12-18 months creased Post Void Residual (PVR) 5-12 mL
5. Backpressure causes hydroureter and hydro­
nephrosis
6 Secondary ascending infection- Pyelonephritis
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 185
184 QUEST : A Comprehensive Guide to UG Surgery, Orlhoped.cs & Anesthesiology

Management of BPH
IPSS-more than or equal to 8
Algorithm forevaluation:
IPSS-more than or equal to 7 |

A. Uroflowmetry
1. Normal voided volume > 150 mL
Watchful waiting
2. Normal Maximum flow > 10 mL/sec
I 3. Normal average flow <10 mL/sec
B. Post Void Residual

Discussion for patient opinion about

treatment modality

Patient chooses non-invasive Patient chooses invasive

therapy therapy

1. UsG
Watchful waiting 2. Urodynamic study

Minimal invasive
Medical treatment
therapy

Surgery

LI IPSS:
• International Prostate Symptom Score I American Urologic Association Score
• 7 questions regarding symptoms in the past month
• 1. Incomplete emptying 2. Frquency3. Intermittency 4. Urgency 5. Weak stream 6. Straining
7. Nocturia
• Maximum score - 7*5 = 35
• Mild symptoms - Score Less than or equal to 7
• Moderate symptoms - Score 8-19
• Severe symptoms - Score 20-35
 186 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 187

2 5 alpha reductase inhibitors - ■

• Act on static component- Inhibit conversion of testosterone to DHT
• Effective in palpable enlarged prostate
• Drugs used -
a) Finasteride - 5mg daily lor 6-8 months
b) Dutasteride - 0.5 mg daily
3. Anlicholinergics -

• Drugs used -
a) Tolterodine - 2-4 mg
b) Solifenacin - 5-10 mg
c) Darifenacin - 7.5-15 mg
4, phosphodiesterase 5 inhibitors-
• Drugs used -
a) Sildenafil
b) Tadalafil
c) Vardenafi!
Q Surgical treatment:
• Indications of surgery -
1) Prostatism (frequency, dysuria, urgency)
2) Acute retention of urine
3) Refractory/ chronic urinary retention with residual urine > 200mL
4) Recurrent UTI
5) Recurrent hematuria
6) Bladder stone
7) Bladder diverticula
Q M e d ia l treatm ent:
8) Hydroureter. Hydronephrosis
1. Alpha 1 adrenergic blockers - • Minimal Invasive Therapy -
• Act on dynamic component - Inhibit contraction ol smooth muscle of prostate > Transurethral resection of prostate (TURP)
• Reduce bladder neck resistance thereby improving urine flow * Most common and popular method as quicker recovery and earlydischarge are
• Short acting drugs ~ Prazosin, Indoramin possible
• Long acting drugs - Terazosin, Doxazosin * No suprapubic incision is needed
• Selective Alpha 1A receptor blocker - * Done using resectoscope with high frequency diathermy current
a) Tamsulosin - 0.4-0.8 mg daily for 12 weeks * Continuous postoperative irrigation with glycine solution is needed for 72 hours
b) Alfuzosin - 10mg daily > Hotmium LASER enucleation of prostate (HOLEP)
c) Silozostn - 4-8mg daily > Trans urethral needle ablation (TUNA) using high frequency radiowaves
• Selective Alpha 1D receptor blocker - > Trans urethral vaporisation (TUVP)
Naflodipil - improves nocturia (25-75 mg daily) > Trans urethral Microwave therapy (TUMT)
• Adverse effects - > Trans urethral incision of prostate (TUIP)
a) Floppy iris syndrome J* Trans urethral balloon dilatation of prostate
b) Postural hypotension > Prosthetic stents (Intraurethral / extraurethral)
c) Retrograde/ dry ejaculation > High intensity ultrasound energy therapy
d) Flushing > Water induced thermotherapy
 188 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
—
T ' SOLVED LONG QUESTIONS OF FINAL MBBS □ P aper-ll 189

# Surgery - j
5. Tumors of rete testis
> Millin's retropubic prostatectomy
• Adenoma
* Not commonly practiced
• Adenocarcinoma
* Done without opening of bladder
6. Adnexal and paratesticular tumors
> Young's perineal open prostatectomy
• Mesothelioma
> Prayer's suprapubic transvesical open prostatectomy
» Adenoma
* If was the procedure of choice for enlarged prostate before the advent of T(jf$1
• Sarcoma
* Indication : Bladder pathology + Large median lobe
7. Others -
• Complications of surgical procedures -
• Carcinoid
> Water intoxication with congestive cardiac failure - TURP syndrome j
• Secondaries
> Retrograde ejaculation - 65% r
• Soft tissue tumor
> Recurren t late UTf - 20%
• Unclassified
> Need for re- TURP/ Surgery in 10 years - 15%
> Failure/ Recurrence of symptoms - 10% i Q investigations:
> Severe sepsis - 6% <. Tumor markers
V Erectile dysfunction - 5% a) Beta HCG
^ > Postoperative hematuria • . • Half-life - 18-36 hrs
V Perforation of bladder or prostatic capsule • Secreted by syncyfiotropboblasts
• Elevated in -
Q.3 : Classify testicular tumors. Discuss investigations necessary to plan the treatment loti
i) Choriocarcinoma (100% cases)
suspected testicular tumor. What are the treatment options a variable ? [5+5 * Sj:
ii) Embryonal CA (65% cases)
TESTICULAR TUMORS iii) Advanced seminoma (15% cases)
• Also elevated in -
□ Classification: ,
E r f h^ lan9'° CA' Pancrea,ic CA- Re" * ' <*» CA, Breast CA,
1. Germ celf tumor (95%) Lung CA, Bladder CA, Gastnc CA
• Seminomatous (52-56%) - (i) Classic (ii) Spermatocytic (iii) Anaplastic b) Alpha fetoprotein (AFP)
• Non-seminomatous/ NSGCT (44-48%) • Half-life - 5-7 days
> Teratoma-Mature, Immature, Dermoid .- • Elevated in -
> Yolk sac tumor/ endodermal sinus tumor i) Yolk sac tumor
> Embryonal carcinoma ii) Embryonal CA
V Choriocarcinoma • Not elevated in seminoma and Chorio CA
2. Sex cord stromal tumors • Also elevated in -
• Leydig cell tumor i) Pancreatic CA, Gastric CA. Cholangio CA, Lung CA
• Sertoli cell tumor
») Alcoholic liver disease, Auto immune liver disease, Drug induced hepatitis
• Granulosa cell tumor Infectious liver disease ’
• Thecoma iii) Ataxia telecgiectasia, Tyrosinemia
• Fibroma c) LDH
3. Combined/ Mixed germ cell and sex cord stromal tumors - Gonadoblastoma • Half-life - 24 hrs
4. Lymphoid/ Hematopoietic tumors • Elevated in -
» Leukemia > Advanced seminoma (80% cases)
• Lymphoma * NSGCT (65% cases)
• Plasmacytoma • Also elevated in - Lymphoma
d) Placental Alkaline Phosphatase (PLAP)
• Elevated in - Seminoma
190 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 191

TNM classification
Serum tumor markers (S —Beta MCG, AFP, LDH)
■V

. Tx-T staging not • Tumor Confined • Tumor Confined • Tumor invading • Tumor invading
to testis/epididy­ to testis/epididy­ into spermatic into scrotum
Normal done
Marker mis mis cord • With or without
study Marker . To-No evidence
of tumor • No vascular/lym­ • With vascular/ • With or without vascular/lym ­
not done study phatic invasion lymphatic inva­ vascular/lym ­
, Tjs-Carcinoma in phatic Invasion
• Involvement of tu­ sion phatic Invasion
situ
nica albuginea, • Involvement of tu­
but not tunica nica vaginalis
vaginalis

Beta HCG - Beta HCG - 1*1 N2 V ■ Nj ■

Beta HCG - > 50000 mlU/ml
< 5000 mlU/mL 5000-50000 mlll/mL
• Nx-Lymph node • Single/Multiple LN • Single/Multiple LN * Regional node
study not done • Not more than • More than 2 cm >5 cm
AFP - 1000-10000 AFP­
AFP - < 1000 ng/ml > 10000 ng/mL . No-No lymph node 2 cm in greatest but less than or
ng/mL dimension equal to 5 cm
involvement

LDH - < 1.5* ULN LDH - > 10" ULN

(upper limit of normal LDH -1.5-10 'ULN

Distant spread to
nonregional lymph
2. USG of abdomen and scrotum
nodes
• 5-10 mega Hz Distant spread to
• Shows hypoechoic area within testis lungs
• Microlithiasis is testis may be present
• NSGCT may appear as heterogenous lesion / ----------------------------- T ~ \ • Any!
• Teratoma may show ectodermal tissue • N0
Stage 1 ; ■
3 OX abdomen . . . . . ssifg • M0
• To look lor retroperitoneal mass / secondaries, lymphadenopathy/ iliac and par. V________ ' J • So
aortic lymph nodes f - • Any T
• Correct staging can be done
Stage 2A * N1
4. Chest X-ray
• M0
• To rule out pulmonary secondaries • Sq/S j
\- y
5. MRI
• Superior to CECT • AnyT
6. Sperm cryopreservation • N?
• Done (or future fertility concern • M0
. Testicular tumor shows oligospermia (52% cases) and azoospermia (10% casMI • S0/S,

Scrotal FNAC/ Transcrotal incision biopsy is contraindicated because - • AnyT

It leaves inguinal part ol the spermatic cord & allers the lymphatic drainage of testis increasing rtf • Ni
Stage 2C
local recurrence, pelvic and inguinal metastasis. •
• Sq/S,
 192 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS D Paper

Any T 2C, 3 and 1s:

Any N
M,
S 1-3

' : y r . ... s a ® * AnyT

fe >* ■ ‘ • >1 • N0
• Mo
* St-3
m ■■

• Low grade tumor - Stage t , Stage 2A, Stage 2 B

• High grade tumor - Stage 2C, Stage 3, Stage Is

□ Treatment:
A. For seminoma (it is radiosensitive)
<1:

Tumor markers - at regular intervals for 5 Imaging studies - CT abdomen and chest once
years, then annually a year
j

B. For NSGCT (it is not radiosensitive, Teratoma is not even chemosensitive)

Slage 1:

Primary radiotherapy/Dog leg radiotherapy 20­ Primary chemotherapy - Cisplatin based (1-2 j
36 Gray to paraaortic + ipsilateral pelvis cycle)

Stage 2A and 2 B :
1. Dog leg radiotherapy
t if LN mass < 3 cm
• 20-35 Gray
2. Chemotherapy
• If bulky retroperitoneal LN (> 3 cm) or multiple LN metastasis
• BEP (Bleomycin + Etoposide + Cisplatin) for 3 cycles OR, EP (Etoposide + Cisplatin)k
4 cycles
 _ . , lft c urQGrv Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL IWBBS □ P aper-ll 195
194 QUEST : A Comprehensive Guide to UG Surgery, ■ '

2014 Supplementary
1. Primary chemotherapy - . . . '
• Criteria: j . Discuss causes, investigation & management o f haematurla. [4 + 3 + 8]
i) 8ulky retroperitoneal LN (> 3cm) Ans: See Section 1, Segment-A, Paper-ll, 2008, Qs. 1, Page 94 & 2013, Qs. 3, Page 165.
ii) Distant mets 0j . what are the different types o f renal calculi ? Discuss the clinical features & management o f
lit) Post orchldectomy tumor marker elevation r renal calculi. ■• [3 + 4 + 8]

. BEP for 2 cycles Ans: RENAL CALCULI

2. Primary Retro Peritoneal Lymph Node Dissection (RPLND)
0 Types-
« Criteria: ;•
Also Response to Predisposing
i) Small LN(< 3cm) _ Features X-Ray finding
Type called Lithotripsy factors
ii) Localised disease ■ . • • , . Mulberry • Brown Radioopaque Moderately J Hypercalciuria
Oxatate
. Nerve sparing RPLND is ideal, Modified RPLND is advocated to retain eiacutation stone • With sharp projections responsive •f Hyperoxaluria
stone
• Show envelope crystals in
! : >— !>«■ < * » » “ I” ’ urine
chylous ascites, lymphocele • Generally made of calcium
* ’ V oxalate
Stage 2A and 2 B : • Most common type
1. Chemotherapy • phosphate Staghom > Made of calcium magnesium or Radioopaque Moderately v Alkaline urine
• . Given to paUents suspected to have occult metastasis stone calculus ammonium phosphate responsive «r Excess alkali
• Smooth consumption
. Criteria - Elevated tumor marker/ Bulky retroperitoneal LN metastas.s • White / Urine infected
• BEP for 3 cycles OR, EP for 4 cycles • Coffin-lid shape with proteus sp.
• Usually solitary, takes up
2. RPLND shape of renal calyces
Cystine • Extremely hard Radioopaque Most resistant / Acidic urine
Stage 2C and 3 : _______________ ________ ' . stone • Hexagonal shape Inherited
cystinuria

Uric acid • Smooth Radio opaque Most •r Acidic urine

stone • Yellowish responsive •* Gout
• Multiple •f Hyperuricaemia
Xanthine • Smooth Radio opaque * Deficiency ot xan­
SI0.TO • Brick red thine oxidase
Indigo/ • Blue Radio opaque ^ Due to indinavir
tfidinavir use
stoiie
Triamterene / Due to
stone Triamterine use
as antihyperten­
sive

0 Clinical features -
• Pain:
* Site - j) Renal angle
ii) Hypochondrium
iii) Lumbar region
' Nature - i) Dull (due to stretching of capsule)
ii) Colicky (due to movement of small stone)
/ Intensity - Severe
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-ll 187
196 QUEST : A Comprehensive Guide lo UG Surgery. Orthopedics & Anesthesiology

b. For lower pole renal caluli ■

✓ Worsens on - Movement

«
✓ Associated with - Vomiting (due to pylorospasm - renogastric reflex)
Haematuria
i
< 1 cm
*
1-2 cm > 2 cm
«
•
Tenderness in renal angle
Fever with chills due to secondary bacterial infection
Investigation-
J
HU < 1000
f
HU > 1000
\
Is PCNL
SSD < 10 cm SSD > 10 cm Contraindicated
• Blood investigations -
i) Complete haemogram with ESR I I
ESWL Flexible
ii) Blood urea Retrograde- PCNL
iii) Serum creatinine Intrarenal Surgery
iv) Serum electrolytes - sodium, potassium, calcium, phosphate
v) Uric acid
3. if endouralogical surgery fail
vi) PTH level
Surgeries
• Urine investigation -
i) Pyelolithotomy - For stones in extrarenal pelvis
i) Routine & microscopy
ii) Extended Pyelolithotomy - Intrarenal pelvis
ii) Culture & sensitivity
• Plain X-Ray KUB iii) Nephrolithotomy - Incision at most convex surface (Brodel’s line)

• IVU iv) Nephrophyelo lithotomy - Incision both on kidney & pelvis (For staghom calculus]
• USG Abdomen [' v) Partial nephrectomy - Multiple stones occupy a pole
Treatment - vi) Others - (a) Bench surgery
1. For stones <0.5 cm (b) Anatrophic Pyelolithotomy
Conservative (c) Coagulum Pyelolithotomy
i) i.v. fluids
03: What are the clinical features o f primary hyper parathyroidism ? Discuss the In vestigation &
ii) Anlispasmodic & anti-inflammatory agents .
managemt o f primary hyperparathyroidism.[6 + 5 * 4 ]
iii) Ing. Furosemide 60-80mg i.v.
iv) Flush therapy Ans: See Section 1, Segment-A, Paper-ll, 2010, Qs. 1, Page No. 118.
v) Alkalinising agent, acidifying agent (for chronic cases)
vi) Relief of obstruction by double-J stent. 2015
2. Stones > 0.5 cm
0.1: Classify goiter. How w ill you Investigate and treat a 30 years old man with clinically discrete
Endourologlcal surgery
nodule o f 3 cm diameter in right lobe o f thyroid? (5 + 5 + 5]
a. For non-lower pole renal calculi --------
A. See Section 1 Segment A Paper I I 2013 (supplementary) Q.1, Page No. 168.

< 2 cm > 2 cm 0.2: Classify renal Injury. Discuss clinical features and management o f patient having injury to left
L kidney following blunt trauma In left loin. *[4+5+6]
{ ---------------‘--------------I
<1 cm >1 cm CLASSIFICATION OF RENAL INJURY

American Association for the Surgery of Trauma (AAST) grading for renal trauma is as follows -
1
ESWL 1
T
Uretero

; Renoscopic stone
Failure ► Lithotripsy

I
 198 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- I I 199

q Local examination of abdomen

• Contusion-Microscopic/Gross hematuria (Urologic study is normal)
Grade-1 a) inspection - Any abrasion, ecchymosis, fullness of flanks or abdominal swelling
• Hematofna-Subcapsular, non-expanding
b) palpation - Tenderness, muscle guard or rigidity, any palpable mass
v. c) Percussion - Any shifting dullness (suggestive of free fluid in abdomen), obliteration of
• Hematoma-Perirenal, non-expanding liver dullness (suggestive of free gas under diaphragm)
Grade - II /• • Laceration-Cortical, < 1 cm of parenchymal depth, without urinary d) Auscultation - IPS (absent bowel sounds in hemoperitoneum or peritonitis), any bruit
^ ■■ ■ :■ : j extravasation
e) Digital rectal examination- Any doughy feeling (suggestive of blood clot), any tenderness
Algorithm of renal trauma management •
• Laceration-Cortical, > 1 cm of parenchymal depth, no urinary
extravasation
RENALTRAUMA

Laceration-Extends through cortex, medulla and collecting system,

X
with extravasation of urine
Blunt Trauma Penetrating Trauma
Vascular-Main renal artery/vein injury, contained hemorrhage

X Microscopic or
Microscopic hematuria Gross hematuria with gross hematuria
Laceration-Shattered kidney , (> 5 RBC/hpf) without
.<
v iG rade;. ^ . ^ w features of shock
Vascular-Renal pedicle avulsion, devascularising kidney features of shock
----- ------T A
I Observation X
] Hemodynamlcally inyj
Hemodynamlcally
Unstable Stable
INJURY TO LEFT KIDNEY FOLLOWING BLUNT TRAUMA TO LEFT LOIN Selective renal
staging "— n
□ Clinical features: Exploratory CECT (IVP is
Clinical laparotomy optional)
1. Hematuria-mild, moderate or severe depending on the grade of the injury
follow-up I
2. Features of shock , Single shot IVP
Renal exposure
3. Sudden delayed severe hemorrhage- may occur between 3rd day to 3rd week after trauma inr on table
form of hematuria. I ~
Abnormal/ Done I f :
4. Clot colic
inconclusive 1. Grade V ,Injury
5. Pain and swelling in the loin v
2. Expanding /.pulsatile hematoma
6. Abdominal distension with paralytic ileus (due to implication of the splanchnic nerves! Selective renal 3. Patient becomes unstable with features of shock
retroperitoneal hematoma) exposure
4. Ureteropelvic junction obstruction
□ Management: ' ,
1. Primary survey and resuscitation
Investigations:
2. Secondary survey .
1. Intravenous pyelography (IVP)
A. History
• Investigation of choice
a) Time of injury, type of injury, site of injury
b) Hematuria-Microscopic/ gross, progression : decreasing / increasing • Single shot IVP- 2 mUkg BW radiocontrast injection into ante-cubital vein. After 10 mins,
single film is taken.
c) PairvSite, duration, character, radiation
• Purpose -
d) Any other symptoms •
(i) To observe contralateral kidney (functional or not)
B. General suntey •
(ii) To perform inlraoperative staging of the injury
a) Vitals-Pulse rale, BP. Rfl. temperature, urine output
2 CECT
b) Head to toe examinatiori-to exclude any other injury
• Gold standard test (highly sensitive and specific).
 200 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-ll 201

• Provides mosl definitive information about grading of renal trauma. HI if polar tear - Partial nephrectomy is done
• Absence of uptake of dye indicates injury to renal artery. IV II hilar injury, severe laceration - Total nephrectomy is dona, provided the contralateral
kidney is functioning normally
• Shows extent of injury, can evaluate other organ injuries.
3. USG abdomen /^ y D is c u s s the clinical features, complications and management o f undescended testis. [5 + 5 + S)
• Done to see amount of hematoma, type of injury and other associated injuries in the
Ans:
• Can be repeated at regular intervals (12-24 hourly) to assess progress. UNDESCENDED TESTIS
4. Urine RE/ME
g What is undescended te stis: Testis has failed to descend to scrotum
• Volume
□ incidence: Mostly in premature infants (30%)
• Cytology
3 Laterality: Right ( 5 0 % ) » left (30%) > bilateral (20%) [this is because right sided testis descends
• Albumin
later than the lelt sided one]
5. Blood examination
□ etiology:
• Blood urea, serum creatinine
(/a ) Familial
t Serum electrolytes
Gubernacular dysfunction
. Hb%
i^ c ) Short vas deferens
• Blood grouping and cross-matching
v ^ d f Lack of Calcitonin Gene Related Peptide (CGRP)
□ Treatment: e) LackofHCG
1. Conservative management I) Altered hypothalamo-pituitary gonadal axis

• Indications - Retroperitoneal adhesions

h) Prune-Belly syndrome
I. Patient is hemodynamically stable
□ Types/Clinical presentations:
II. Decreasing hematuria
1. Lumbar testis - complete failure of descent
III. Perinephric hematoma is not increasing
II. Iliac testis - testis remains just deep to deep ring
IV. No evidence of contrast extravasation on CECT
III. Inguinal testis - testis in inguinal canal
• Modalities -
IV. In superficial inguinal pouch - testis in space between external oblique and Scarpa's fascia
I. Bed rest
V. Scrotal testis - testis in upper part of scrotum
II. Calheterisatio.n
The condition with bilateral undescended testes which are clinically impalpable is known as
III. Intravenous fluid
Cryptorchidism.
IV. Blood transfusion (if needed)
In undescended testis, testis cannot brought down manually to lhe bottom of the scrotum.
V. Sedation, analgesics
O Complications: ’ TESTIS’ (PNEMONIC) f a 'X V\ \ ' '
VI. Antibiotics
Vli. Monitoring of patient ’ • Torsion V l
2. Epididymo-orchitis a
2. Surgery (Done only In 10-20% of patients)
3. Seminoma (Malignant transformation in undescended testis is 20 times more common than
• Indications - normal testis)
I. Persistent bleeding 4. Trauma
II. Expansile or pulsatile perirenal hematoma 5. Inguinal hernia (Indirect inguinal hernia - 70%)
III. Hilar injury 6. Sterility
IV. Urinary extravasation 7. Atrophy
V. Segmental arterial injury
Q Management:
• Modalities -
A. investigations:
I. Renorrhaphy (Transperitoneal approach)
1- USG abdomeh
II If kidney is friable - Cabot’s Nephrostomy is done
2- CT scan
 202 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper - II 203

3. Assessment of FSH, LH. HCG , papillo folicular carcinoma -> behaves like papillary carcinoma
4. Gonadal venogram » , Hurthle cell carcinoma -» behaves like Follicular carcinoma except with more bone spread.
5. Laparoscopy >
q Pathology-
B. Treatment: Papillary thyroid carcinoma -
1. Always surgery - done between 2-4 years of age, 6 months gap in case of bilateral involvemem i . Soft / firm / hard /cystic
2. Principles of surgery - ' « Solitary / multinodular
• Mobilisation of spermatic cord • Contains blackish brown fluid
• Repair of associated hernia ", • White cut surface
• Creation of scrotal pouch and fixation of testisinto the scrotum . On microscopy, shows -
• Orchidectomy done if testis is completely atrophied ” i) Cystic spaces
3. Hormone therapy used in following cases - ii) Papillary projections
• Doubtful retractile lestis iii) Subtle irregularities in nuclear contour with deep nuclear grooves & pseudoinclusions
• Bilateral cases + hypogenitalism + obesity (Orphan Annie eye nuclei)
4. Laparoscopic approach - orchidopexy is becoming popular iv) Psammoma bodies
• Slowly progressive
• No blood spread
• Spread via lymphatics
B. Follicular thyroid carcinoma -
• Capsular invasion
a - Lateral
• Angioinvassion
b - Central
• Spreads via blood / occassionally bones & lymph node
c - Pectoral
C. Hurthle cell carcinoma -
d-Apical
e - Supraclavicular • Subtype of follicular thyroid carcinoma
• Presence of oncocytes rich in mitochondria (Hurthle cell)
Pectoralis minor • Appear brown on cut surface
For Rest, See Sector 1, Segment-A, Papter-ll, 2012, Qs. 1, Page 144 &
Level I - Below lateral See Sector 1, Segment-A, Papter-ll, 2010 Supplementary, Qs. 1, Page 123.
Level II - Behind
OJ: Mention common causes o f lump in left upper quadrant o f abdomen. Describe the clinical
Level III - Above medial features & management o f renal cell carcinoma. [5 + 5 + 5]
Axillary vein
Ans: LUMP IN LEFT UPPER QUADRANT OF ABDOMEN
Fig. 1.2.1 ; Surgical levels of lymph nodes in the axilla draining the breast.
□ Causes -
• Splenic neoplasm
2015 Supplementary • Left sided renal causes -
i) Renal neoplasm
Q. 1: Describe the pathology, investigations & treatment o f differentiated thyroid carcinoma.
. ii) Polycystic kindney
[4 + 3 + 11
■ ’ iii) Hydronephrosis
Ans: DIFFERENTIATED THYROID CARCINOMA • Gastric outlet obstruction
• Carcinoma of pancreatic body & tail
□ Type-
• Retroperitoneal tumour -
• Papillary thyroid carcinoma ■ i) Lipoma
• Follicular thyroid carcinoma
ii) Neurofibroma
 204 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-ll 205

iii) Liposarcoma
ii) ESWL (for stones > 5 to < 2.5 cm)
iv) Biomyosarcoma
jjj) PCNL (for stones > 2.5 cm)
v) Lymphoma
iv) Uretero - Renoscopic Removal
vi) Secondaries
v) Open Ureterolithotomy
• Left sided adrenal tumour
• Left sided carcinoma colon B. Mid Ureter -
i) Flush
RENAL CELL CARCINOMA il) Uretero - Renoscopic Removal
See Section 1, Segment A, Paper-ll, 2011, Qs. 2, Page 139. Iii) Open Ureterolithotomy
C. Lower Ureter Flush
0 .3 : Mention the sites o f narrowing of ureter. Desctibe the clinical features, complication A treatment
o f ureteric stones [3 + 4 + 3 *$) i) Uretero - Renoscopic Removal
ii) Open Ureterolithotomy
Ans: SITES OF NARROWING OF URETER
iii) Ureteric meatotomy
1. Pelvi-ureteric junction for stones at ureteric orifice
iv) Dormia basket for single stone <10 mm
2. At brim of lesser pelvis i.e. as ureter enters pelvis & crosses over
3. Along passage through bladder wall i.e. at common vesicoureteric junction
2016
URETERIC STONES
0.1: Enumerate the causes o f painless haematuria. Discuss the investigation and treatment in a
See Section 1, Segment A, Paper-ll, 2009, Supplementary, Qs. 1, Page 114. patient o f 65 years presented with painless haematuria. [5 + 5 + 5 ]
□ Radiation o f pain Ans: See Section 1, Segment-A, Paper-ll, 2013, Qs. 3, Page 160.

Location Radiation site Nerve Involved Q2: Classify thyroid cancer. Discuss the management o f FNAC proved follicular neoplasm o f Right
lobe o f thyroid In a lady o f 45 years. [5 + 10]
Stone in upper ureter Testicles T,0, , 12through lesser & lower
splanchnic nerves Ans:
Stone in mid-ureter Right side Me Burney’s point llohypogastric or ilio inguinal □ Classification- See Section 1, Segment-A, Papter-ll, 2012,Qs. 1, Page 144.
(simulates appendicitis) nerve (T12, L,) P Follicular neoplasm - See Section 1, Segment-A, Papter-ll, 2010, Supplementary, Qs. 1, Page 124.
Left side Left lower quadrant
(simulates diverticulitis) 0.3: What are the etiologies o f pancreatitis 7 How w ill you investigate and treat a case o f acute
pancreatitis 7 [5 + 5 + 5 ]
Stone in lower portion of ureter Inner side of thigh or groin Genitofemoral nerve (L,, Lj)
(proximal to orifice) Ans: See Section 1, Segment-C, Papter-ll, 2015, Qs. 5, Page 436 &
.
See Section 1, Segment-B, Papter-I, Qs. 10, Page 247.
□ Complications-
s Obstruction
2016 Supplementary
s Infection
* Hydronephrosis, hydroureler 0.1: Discuss the clinical features and management o f primary thyrotoxicosis. [5 + 10]
s Ureteral stricture Ans: See Section 1, Segment-A, Paper-ll, 2014, Qs. 1, Page 177.
J Stone impaction
0 2 ■ Classify adrenal tumours. Describe the investigation and treatment o f adrenal Incidentaloma.
□ Treatment -
[5 + 1 0 ]
See Section 1. Segment-A, Paper-ll, 2009, Supplementary, Qs. 1 , Page 114.
Sugeries for different sites ADRENAL TUMOURS

A. Upper ureter -
i) Flush
 206 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 207

□ Classification- ✓ Imaging -
✓ Diagnostic algorithm

f T Rest See Section 1, Segment-A, Paper-ll, 2013, Supplementary, Qs. 3, Page 174.
Tumour of Cortex Tumour of Medulla Juxta Adrenal Masses
/ Adrenocortical ✓ Neuroblastoma ✓ Leiomyosarcoma of vena cova
adenoma •/ Phaechromocytoma s Retroperitoneal liposarcoma 2017
/ Adrenocortical / Ganglioneuroblastoma Retroperitoneal schwannoma
carcinoma 0 1 . Disscuss the causes o f haemoperitoneum and its management. [S + 10]
Neuroendocrine
carcinoma Ans: HAEMOPERITONEUM
r - ■ i
Miscellaneous n Causes -
/ Primary adrenal lymphoma / Penetrating and deep abdominal trauma
/ Massive macronodular adrenal ‘ / Stab wound , •
hyperplasia
/ Blunt trauma to abdominal organs
/ Hamartoma
/ Spleen rupture
■/ Teratoma
/ Bowel laceration - .
/ Angiomyolipoma
/ Pancreas laceration
/ Myelolipoma
/ Liver rupture •
f / Amyloidosis
/ Aorta or vascular rupture like abdominal aortic aneurysm ,
/ Plexiform neurofibroma / Uterine rupture
/ Rupture ectopic pregnancy >
DMA
ADRENAL INCIDENTALOMA !
/ Perforated gastric ulcer •
□ Differential diagnosis - « " J’ / Uterine rupture ■
•f Adenoma •/ Ovarian cyst rupture „
s Metastasis ✓ Rupture of malignant tumour in abdomen
/ Lymphoma Bleeding disorders
/ Phaeochromocytoma ' * □ Management -
/ Neuroblastoma ATLS protocol is to be followed -
✓ Adrenocortical carcinoma • A - Airway maintenance with cervical spine c a r e 1
/ Haematoma . - B - Maintenance of breathing ,
•f Myelolipoma C - Maintenance of circulation after proper assessment »
/ Adrenal hyperplasia (2 wide bore cannula 14G or 16G inserted, blooddrawn for investigations and cross­
/ Adrenal cyst matching and then intravenous fluids administered) '
/ Granulomatous disease D - Dysfunction of central nervous system excluded. .
E - Exposure of patient to look for external injuries.
Q.3; Enumerate the causes o f relation o f urine In different age groups. How w ill you investigate
case o f relation o f urine ? How will you treat retention o f urine ? [5 + 5+$ Then secondary survey done which includes following -
Q History- v
Ans: See Section 1, Segment-A, Paper-ll, 2008, Supplementary, Qs. I, Page 113 and
* Date and time of injury
See Section 1, Segment-B, Paper-ll, Qs. 1, Page 257.
' Mode of injury
□ Diagnosis -
J LMP & menstrual history in case of suspected ectopic pregnancy
J Most common presentation of adrenal masses ts incidental observation on cross-section imas1^
performed for other reason J Type of impact for vehicular accidents
 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-II 209
208

/ Type of weapon in case of penetrating injuries For blunt injury

/ Details about clinical features -
a) Pain - i) site I
Patient stable Patient unstable
ii) intensity
iii) character I
cECT Abdomen
1
ATLS protocol of initial
iv) radiation resuscitation
v) aggravating and relieving factors
I
b) Vomiting Evaluate
c) Haematemesis
d) Haematuria
Patient responsive Patient non-responsive
e) Abdominal swelling
Sther injuries at other parts of body I I
FAST/e-FAST Laparotomy
Past history (Founed Assessment by Sonagraphy for
Personal history about chronic disease - mainly bleeding disorder trauma/Extended-Fast)

t
Significant family history

Exam ination- }
No minimal collection Collection present Inconclusive

I ” I I I
Percussion Auscultation Conservative management Laparotomy Diagnostic peritoneal
Inspection palpation
Bowel sounds aspiration
/ Temperature / Obliteration of
/ Abdominal distension
✓ Tenderness liver dullness Per-rectal P
✓ Bruise around
umbilicus/flanks s Rebound Splenic dullness examination , i i *
> 10ml blood Inconclusive
tenderness Shifting dullness Per-vaginal :
/ Movement of examination in Presence of lood/bile/
/ Kefir's sign in I
abdomen with females ■ faecal matter
Diagnostic peritoneal lauage
respiration case of splenic
I (DPL - most sensitive investigation
/ Bleeding from any site injury
Laparotomy for haemoperitoneum
Q S p e c ific m a n a g e m e n t - _________ L
A. For penetrating injury If
> 103 RBC/ml No collection
> 500 WBC/ml
It > Food/bile/faecal matter
I
f Patient not stable Conservative
Patient stable
I management
I I Laparotomy
Check features of peritonitis Laparotomy

r Absent □ Conservative management -

Present

I I
CECT Abdomen
• Routine blood investigation - Hb
Laparotomy - TLC
- DLC
- LFT
 SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper-ll 211
210 OUFST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

2018
- KFT *
I
- Blood Sugar - . What are the different forms o f Renal calculi? Discuss the clinical presentation and management
- PT/aPTT : 0 ' ofa stone In the Renal pelvis. [5 + 10]
- BT/CT/CBT
f ins ■See Section 1, Segment A, Paper II, 2014 supplementary, Q 2, Page 195.
- ABO, Rh grouping
[ _ js a u d I to classify benign lesions of the breast? Discuss the management of discharge
Blood to be arranged for transfusion if required
■ ° ' from the nipple. [7 + 8]
I.v., cannulation
Ans: a NDI - See Section 1 , Segment D, Q 27, Page 489.
Catheterisation
MANAGEMENT OF NIPPLE DISCHARGE - See Section 1, Segment C, Paper I, 2008, Q 4,
Intravenous fluids
! Page 276.
i.v. antibiotics
0 3 • Classify thyroid neoplasms. Discuss the management o f solitary thyroid nodule, 3 cm in size o f
Bowel, bladder care a 30 years old female. [5 + 10]
Q.2: What are the clinics! features o f renal cell carcinoma 7 How w ill you Investigation andtre* Ans: CLASSIFICATION OF THYROID NEOPLASMS - See Section 1, Segment-A, Paper-ll, 2012,
case o f renal cell carcinoma ? * q f, Page 143.
Ans: See Section 1, Segment-A, Paper-ll, 2011, Qs. 2, Page 139. SOLITARY THYROID NODULE - See Section 1, Segment A, Paper II, 2013 supplementary, Q 1,
Page 168.
Q.3: Discuss the clinical features, Investigations and management of pheochromocytom^ ^

Ans : See Section 1, Segment-A, Paper-ll. 2013 supplementary. Qs. 3, Page 174. 2018 Supplementary

0.1: Discuss the presenting symptoms of Benign Hyperplasia o f Prostate. How will you manage a
2017 Supplementary 65 year old male patient with acute retention o f urine in emergency and subsequently? [5+5+5]

Q.1: Discuss the pathology o f tumors of Salivary gland and management o f Pleomorphic idem Ans: BHP - See Section 1, Segment A, Paper II, 2014, Q 2, Page 183.
[d i I
ACUTE RETENTION OF URINE - See Section 1, Segment 8, Paper II, Q 2, Page 257.
Ans : CLASSIFICATION OF SALIVARY TUMORS - See Section 1. Segment A, Paper l.» 02: Outline the etiopathogenesis o f Multinodular Goiter. Describe its management. [5 + 1 0 ]
supplementary, Q 2, Page 89.
Ans: See Section 1, Segment A, Paper II, 2008, Q 2, Page f . 0”5
PLEOMORPHIC SALIVARY ADENOMA - See Section 1. Segment C, Paper II, 2012, Q 5, Pagef
j. 0.3: Discuss the etiopathoiogy o f acute extradural hematoma. Mention the symptoms and the signs.
q j ; 2 0 year o l d m a l e p r e s e n t i n g with right testicular mass - how w ill you proceed to Inv Outline the principle o f its management. [5 + 5 + 5]

and manage this case? Ans: See Section 1, Segment C, Paper II, 2009, Q 7, Page 365.
Ans: See Section 1, Segment A, Paper II, 2010. Q 2, Page 120.
MANAGEMENT OF TESTICULAR TUMOR - See Sec 1, Segment-A, Paper-ll. 2014. Q 3. PaS»* 20"!9

0 .3 : 3 0 y e a r y o u n g a d u lt complaining o f colicky pain from right lo n g '0 .|;enumeratethe cause

you Investigate and manage this case. anuria. Give the management o f calculus anuria, (principles only) [5 + 5 + 5]
i young adult is suggestive of a diagnosis of "Sw* _
Ans : Colicky pain from right loin to groin in a )
Ureter".
See Section 1. Segment A, Paper II. 2009 supplementary. Q I. Page 114. ANURIA
See Section 1. Segment A, Paper II. 2015 supplementary. Q 3. Page 204.
J Anuria: Urine output less than 100 ml/24 hours
 212 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF FINAL MBBS Q Paper-II 213

□ Causes o f anuria; j Uanagement of calculus anuria :

■
r investigation-
---------s---------------------
f --------\ , Blood investigations -
Pre-renal Renal Postrenal i) Complete haemogram with ESR
(Sudden & severe drop in BP (Direct damage to kidneys by (Sudden obstruction of ^ ii) Blood urea
or interruption o! blood flow to inflammation, toxins, drugs, flow due to enlarged pro$i^ > iii) Serum creatinine
the kidneys from severe injury infection or reduced blood kidney stones, bladd^*
or illness) supply) fumour or injury) iv) Serum electrolytes - sodium, potassium, calcium, phosphate
v) Uric acid
Hypovolaemia Acute tubular necrosis Prostatic hypertrophy v
vi) PTH level
Dehydration • Ischaemia Blocked catheter
Hypotension • Toxins (antibiotics, 4 Urine investigation -
Malignancy
Impaired cardiac function contrast media) • Bladder cancer ; i) Routine & microscopy
Advanced liver disease Acute interstitial necrosis • Prostate cancer >' ii) Culture & sensitivity
Renal vascular disease • Inflammation . Plain X-Ray KUB
• Edema . IVU
• Drugs (Furosemide, • USG Abdomen
Penicillin)
r Treatment -
Glomerulonephritis
1. For stones <0.5 cm
• Post-infectious
Conservative
• SLE
i) I.v. fluids
• ANCA associated
• Anti-GBM disease ii) Antispasmodic & anti-inflammatory agents
• Henoch-Schonlein iii) Ing. Furosemide 60-80mg i.v.
purpura iv) Flush therapy
• Cryoglobulinaemia v) Alkalinising agent, acidifying agent (for chronic cases)
• Thrombotic microangio­ vi) Relief of obstruction by double-J stent.
pathy 2. Stones > 0.5 cm
> HP
Endourologlcal surgery
> HUS
a. For non-lower pole renal calculi_____

□ Differentiation between prerenal and renal anuria:

<2% TSm
Test Prerenal AKI Intrinsic AKI
f 1 I
* Urine specific gravity > 1.020 S 1.010 <Tf m >1 cm
f Urine sodium, mEq/L <20 >40 I I
Fractional excretion of sodium ESWL |
< 1% (neonates < 2%) > 2% (neonates > 2.5%)
^ Uretero
Fractional excretion of urea <35% >50%
Failure - _________ ^ Renoscopic stone
* Urine osmolality, mOsm/kg >500 <350 Lithotripsy
JJrea nitrogen-crealinine ratio >!>0 10 15 I
Filure------------------- - > PCNL
 214 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF FINAL MBBS □ Paper- I I
215

b. For lower pole renal caluli n i : 1Vhat are the principal symptoms o f peripheral arterial occlusive disease ?

r Ir [5 + 5 + 5]
< 1 cm 1-2 cm >2cm Ans: See Section 1, Segment B, Paper I, Q.5 (Page No. 226).

HU < 1000
I

HU > 1000
\
Is PCNL
SSD<10cm SSD>10cm Contraindicated
' ■ S S S S a a s a s w s s r
How would you manage? ,
\ I [5 + 5 + 5]
ESWL . Flexible
See Section J, Segment A, Paper II. 20t1, Q.1 (Page No. 125).
Retrograde'
_In^rarenaLSuagQLa
December-January 2019-2020
3. If endouralogical surgery fail
Surgeries '< a i : WrU* down the effecttof prostate hypertrophy on urethra and urinary bladder. Mention the
medical and surgical treatment o f benign prostatic hypertrophy. [ 5 + 5 + 5]
i) Pyelofithotomy - For stones in extrarenal pelvis
ii) Extended Pyelolithotomy - Intrarenal pelvis Ans: See Section 1, Segment A, Paper II. 2014,0.2 (Page No. 183-188).
iii) Nephrolithotomy - Incision at most convex surface (Brodel's line)
' ° 2 : * 30 year old lat/y presents with 3 cm size solitary nodule on rig h t thyroid lobe Giv„
iv) NepHrophyeIo7i!Kb tomy - Incision both on kidney & pelvis [For staghorn calcu)us| inferential diagnosis. How w ill you manage such patient? [s °
vT*Pa'rtial nepKrectomy^fvftlHiple stones occupy a pole Ans: See Section 1, Segment A, Paper If, (Page No. 170 & 172-173).
vi) Others - (a) Bench surgery
Q.3
(b)Anatrophic Pyelolithotomy
(c) Coagulum Pyelolithotomy

Q.2: What are the anatomical and pathophysiological changes that lead to the development d>
primary varicose veins o f the lower limbs? How would you test clinically the competence <*•
valves o f the sapheno-femoral, sapheno-popliteal junctions and the leg perforators?
Give the management o f a patient with prim ary varicose vein w ith sapheno-feits June-July 2020
Incompetence. [5 *Sk-
Ans: See Section 1, Segment D, Q. 37 (Page No. 498) Saphena ‘Varix’. - ofgas gangrene DiSCUSS el'°Palf,° 9enesis, clinical features, Investigations and management
[3 + 3 + 3 + 3 + 3 ]
0 .3 : Define thyrotoxicosis. Enumerate the grade-wise presentation o f the eye signs in thyrotom Ans: See Section 1, Segment C, Paper II Q.8 (Paqe No 3841
/ 7/i/a th/>
Give hrit*f outline
the brief ntttiinn n
o ff the
tht* diagnosis
Hiannncic un
and/1nntinnc n ff management
options o m anannmant n
o ff Graves H/e/iacA [5+5*
fZrauoc Disease. Kxfv ***/•

Ans : See Section t, Segment A, Paper II, 2014, Q.1 (Page No. 177); ^ s s lf y testicular tumours. How will you manage a 60 year old man presenting with seminoma
Sectin 1, Segment D, Q.58, (Page No. 518) & Section 1, Segment D, Q.60, (Page No. 520), [5 + 10]
Ans: See Section 1, Segment A, Paper II. Q.3 (Page No. 188).

0 3' De$cnbe the clinical features and management o f Thyrotoxicosis.

2019 Supplementary [8 + 7 ]
See Section 1. Segment A, Paper II, Q.1 (Page No. 177).
Q. 1 : What are the different types o f renal calculus? How does a patient o f renal calculus pr&
How would you investigate to confirm diagnosis? [S+S*

Ans : See Section 1. Segment A, Paper II, 2014 Supplementary, Q.2 (Page No 195).
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-i 217

SEGMENT- 8 l Crohn’s disease •

SOLVED LONG QUESTIONS OF SEMESTERS 4 Ileocecal tuberculosis (TB)
Paper - 1 5. Acute intestinal obstruction
6. Perforated peptic ulcer
7. Acute pancreatitis
0 . 1 : Discuss briefly the D/D o f right Iliac fossa pain in a young adult male. How will you treat j ^
B. Acute pyelonephritis
ofappendicularmass? [10 ^
j* 9. Ureteric stone
Q. 2 : Discuss briefly the different diagnostic blood fractions commonly used for surgical pg W Keeping the above differential diagnosis in mind thP
Discuss the complications of whole blood transfusions in brief. pJ
history taking, clinical examinations and relevant investigations. “ b®,hr0U£|h proper
Q.3: Define ulcer. Describe the clinical exam, of an ulcer. Write down the treatment of venous uk: □ History:
P+M . 1. Pain:
Q.4: Define and classify intermittent claudication. Describe the pathogenesis of Buerger's disgjj . Vague pain at right iliac fossa- Acute appendicits
How will you treat a case of Buerger's disease without gangrene? [2 -t-4+4^; . Cramping/colicky pain- Acute typhlitis, Ureteric stone
0 . 5 : A 32 yrs old male patient attends the surgery OPD with chief complaints o f pain in the right#
• s s s r ^ — -a . - m ,
while walking, fo r2 months. He had been a chronic smoker fo r 10 yrs. On examination,
reduction In peripheral pulses In the affected lower limb. What are the D/D? Whatlnvestigt^
will you do In this case? What procedures can be done for improving the lower limb c ir c u it
, [5+S.|
f
0 .6 : Define and classify cysts. Discuss the management o f a surgically relevant parasitic eft on l e a n i r X a ? lln c T a m " ^ '* * *
disease. Writea briefaccount on pseudocyst o f pancreas. 2. Associated features:
[1+4+4t|
• Nausea, vomiting, fever - Acute appendicitis
0 .7 : A 60 yrs old lady has presented with jaundice, pruritus, pale stools and a palpable masski
right upper quadrant o f abdomen. Enumerate the D/D. Which radiological investigations* • Watery diarrhea with mucus in stool with or without blood - Acute tvohlitis Crohn' h-
you recommend? Outline the operative management of periampullary CA. [3131! • * * r , ta . . I m i f e t a * t a p „ w a . foss, . ‘ <l“ “ “
{
0 .8 : Enumerate the endocrine tumors o f pancreas. Discuss OF, Investigations and treatmeiti abs” “ 9 « - * - « - Acule M ,
any 2 o f such tumors. • w t M , . dehydration, oNSWa. * d , . Pepr„
0 .9 : A 45 yrs old man presented with rapidly developing anorexia, asthenia and fatigue i usea, persistent vomiting, retching - Acute pancreatitis
increasing vomiting. How would you investigate to confirm the diagnosis? How wouldf
stage and manage the patient? [5+5*!
i J E T * * * W K>-
0 .1 0 : A 55 yrs old male, chronic alcoholic, complains o f severe, agonising, acute abdominal?
persisting tor several hours, radiating to the back and a little relief on stooping. Howwoukif
investigate to confirm the diagnosis, prognosticate and manage? [5+5<! Q Chnical examinaton :

1• General survey:
SOLUTIONS
* Pallor - Ileocecal TB, Crohn’s disease

Q. 1: Discuss briefly the D/D o f right iliac fossa pain in a young adult male. How will you treat ' 2 J S S 5 S * ‘ awMc f e “ * *■ « *- " , ,o *
o f appendicular mass?
perforation, acute p tm & s M s ™ 1 " Acut0 " " eslinat obstruction. Peptic oicer
DIFFERENTIAL DIAGNOSIS OF RIGHT ILIAC FOSSA PAIN f Abdominal examination :
i
Causes of right iliac (ossa pain in a young adult male: j
t Acute appendicitis '
2. Acule typhlitis / Neutropenic enterocolitis v
J
S
f
216 :
 218 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS O Paper-1 2 t9

» Tenderness, rebound tenderness (Blumberg's sign), card-board rigidity, later abdomi^; •

Ortsner- Shorten regimen:
distension, dullness over flanks, obliterated liver dullness, absent bowel sounds - pgp^
1) Nothing per mouth
ulcer perforation
2) Intravenous fluid
. Tenderness, Grey Turner’s sign positive, Cullen’s sign positive, Fox sign positive - Acuie
3) Analgesics
pancreatitis
Antibiotics
3. Per rectal examination: i
5) Nasogastric aspiration for initial 2-3 days
• Perianal fistula - suggests Crohn's disease
6) Monitoring everyday -
□ Investigations: a) Temperature, BP, Pulse
1. Complete homogram: b) TLC
• Raised TLC - Acute pancreatitis c) Palpation of lump to observe the size
• Raised E S R - Ileocecal TB A) II mass reduces in size, temperature and pulse becomes normal, TL<? reduces, appetite improves
2. Serum amylase, lipase, LDH- raised in acute pancreatitis -> patient discharged and advised to come after 6 weeks for interval appendicectomy
3. ADA (Adenosine deaminase activity): Serum value > 4 2 IU/L and/or ascitic fluid value > 33 lun * 8) Criteria to disconlinue the regimen -
is sensitive and specific for ileocecal TB. i) Patient becomes more toxic (tachycardia, temperature rises)
4. Urine for RE/ME/CS - Increased number of pus cells with bacterial growth seen in acuk: ii) Persistent vomit
pyelonephritis iii) Increasing size of lump
5. Stool for ova, parasite, cyst; stool for occult blood [ iv) Pain becomes more intense •
6. Chest skiagram (PA view): v) Rising TLC
• To look for primary focus of ileocecal TB * vi) Appendicular abscess formation •
« Free gas under right dome of diaphragm/Pneumoperitoneum (feature of hollow viscus ?
In these cases, immediate surgery is done. Drainage if appendicular abscess.
perforation) - Peptic ulcer perforation
C) Contraindications to the regimen -
7. Skiagram abdomen (AP view in erect pos lure):
i) Doubtful diagnosis
• Sentinel loop, colon cut sign, obliteration of psoas shadow - Acute pancreatitis
ii) Acute appendicitis in children and elderly
• Multiple air fluid levels (> 3) - Acute intestinal obstruction
iii) Burst, gangrenous appendicitis
8. USG abdomen: *
iv) Diffuse peritonitis
• Edematous pancreas, peripancreatic fluid collection - Acute pancreatitis
D) Patient of appendicitis taken for appendicectomy and palpation of right iliac fossa under general
• Dilated bowel and fluid - Acute intestinal obstruction
anesthesia revealed a mass -
9. Barium follow through X-ray: i) If symptoms present for 3-5 days, appendicectomy performed as scheduled
• Increased transit time, hypersegmeniation (chicken intestine). Ileal stricture (String sign), =
ii) If symptoms present for longer duration (> 7 days) and a firm lump is palpable, surgery
Pulled up cecum, conical cecum, Thickened ileocecal valve (Inverted umbrella sign/
postponed and conservative management done followed by interval appendicectomy
Fleischner sign), obtuse ileocecal angle (>150 degree), straightening of ileocecal juncticr
with goose neck deformity, ulcers in terminal ileum (napkin lesion) - Ileocecal TB Q. 2 : Discuss briefly the different diagnostic blood fractions commonly used for surgical patients.
. Cicatrisation of ileum (String sign of Kantor), rose thorn appearance of bowel wall, straighten^ Discuss the complications o f whole blood transfusions In brief. [7 + 8 ]
of valvulae connivenles - Crohn's disease
10. CECT abdomen - if suspected acute pancreatitis, intestinal obstruction ; DIFFERENT BLOOD FRACTIONS
11. Peritoneal tap - if suspected acute pancreatitis, peptic ulcer perforation
BLOOD SUBSTITUTES
12. Sigmoidoscopy, colonoscopy - to confirm Crohn’s disease

Q What are they - Substances which can be used instead ol blood to replenish the blood loss.
APPEN DICULAR MASS
Q Types-
□ Treatment: (A) Plasma and its derivatives *
If lump palpable, but not abscess (no fever, no rising TLC. increasing tenderness), then conservatM (8) Synthetically prepared solutions
management is done as nature has already localised the infection to prevent spread in peritoneum Q
Plasma an d Its derivatives -
which if disturbed, may lead to faecal fistula.
See “Blood Fractions" on the next page -
 220 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS O Paper-1 221
BLOOD FRACTIONS
(6) GELATINE-
Name Preparation Storage Indications "v . Mo/-wt 20000 - 40000
♦ Packed cell Centrifuging whole blood @2000-3000g 1-6°Cfor •
Chronic anaemia • Less effective than dextran as plasma volume expander
for 15 mins 35 days •
Old age
•
Children (C) FLUOROCARBONS -
• Platelet rich plasma — do— •
Bum *'■ . What is It - Hydrocarbons in which hydrogen atoms have been replaced by fluorine
•
Hypovolemia • Features — •
•
Severe protein loss * Colourless
• Human albumin (4.5%) Repeated fractionation of plasma 4°C Several .cirrhosis '' * odourless
months Edema /
* chemically inert
'nephrotic syndrt#*
* dense liquid
(Used as volume expander!
* poorly soluble
• Fresh frozen plasma Fresh plasma rapidly frozen (contains clot­ -40°C for • Severe liver disease
(FFP) ting factors) 2 years . DIC » Advantage -
[1 unit FFP = 3% rise in clotting factors] • Congenital clotting (acta
» « » , t a . p a ® * , tan s.
deficiency
• Following warfarin theratv • Precaution -
t Cryopredpitate Visible white supernatant fluid when FFP —■KJO— • Haemophilia A Patient has to be kept in hyperbaric environment during this transfusion
thawed at 4°C (factor VIII + Fibrinogen) • Von Willebrand’s disease
(D) HYDROXYETHYLSTARCH (HES) -
• Fibrinogen Orgonic liquid fractionation ol plasma Dried form • DIC "
• Afibrinogenaemia • Composition = Starch + Sodium hydroxide + Ethylene oxide
• Thrombocytopenia • Mol-wt: 60000 - 4,50,000
• Platelet concentrate Centrifugation of platelet rich plasma
• Drug induced hemorrtiags
• Prothrombin complex From pooled plasma which contains fac­ • Reversal of warfarin ova CO M PLICATIONS OF BLOOD TRANSFUSIO N
concentrate tors II, IX, X dose I. Transfusion reactions:
a) Acute hemolytic reactions -
Synthetically prepared solutions - • There are 3 causes:
(A) DEXTRAN - ' > Incompatible transfusion
• What is it - Polysaccharide polymer ' JhSkfngSi° " " i>h b'00d WfliCh iS a'ready haemolysed * Seating or freezing or over
t Production - Polysaccharide compound derived from bacterium Leuconostoc Mesentcrolfe
v Transfusion of blood after expiry date
lo which yeast extraction is added 1
• It is considered as criminal negligence in the court of law
• Disadvantages -
(i) induces rouleaux formation of R8C ■ — — <— «
(ii) interferes with platelet function
• ^ n a g e m e n ^ - ^ 63' 'aChyCardia' hyPolension. sweating, jaundice, smoky urine
(iii) interferes with blood grouping & cross matching
• Function - Restore plasma volume 0) Inj. Hydrocortisone/ dexamethasone i.v. stat
• Types - Oil Alkalization of blood (sodium bicarbonate, sodium lactate)
Ini) Fluid therapy
(i) Low molecular weight dexlran (mol. wt. 40000) - also known as rheomacrodex or dextran * (iv) Inf. mannitol
(ii) High molecular weight dexlran (mol. wt. 70000) - also known as dextran 70. (v) Inj. lurosemide i.v.
t Indications - • lt occasionally can be fatal.
(i) DIC yrexial reactions (most common complication) -
• The causes are :
(ii) Burn
(') Improperly sterilised transfusion sets
• Precautions -
Oi) Presence of pyrogens in the donor apparatus
(i) Not used > 1000 ml 0") Transfusion of infected blood
(ii) Blood sample for grouping & cross-matching to be drawn before introducing this solutW
c Air '/,V* Very fapid transfusion of blood
*9 ic reactions - Due to allergic reaction to plasma products in the donor's blood
 222 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-1

d) Sensitisation to leucocytes and platelets - This occurs where many blood transfusions haw ■'
Clinical examination o f an u lce r:
been given in the recent past. Antibodies are developed against WBC or platelets of dona^ ;
btood, which causes reactions. f. Site
• TRALI (Transfusion related acute lung injury): . Tuberculous ulcer - Neck (over cervical lymph nodes)
> Cause - It is mostly due to antibody against HLA and leucocyte specific antigens of | • Syphilitic ulcer - Penis
recipient in the donor plasma. It may also be due to antibody against donor’s leucocyte f • Rodent ulcer - Forehead, face
in recipient's plasma. . Venous ulcer - Leg (above the medial malleolus)
> Symptoms - Breathlessness, fever (approx. 4 hrs after transfusion) 2, Number
> Signs - Hypotension, Drop in oxygen saturation
• Single - Syphilitic ulcer, rodent ulcer, carcinomatous ulcer, venous ulcer
> May require ventilatory support. Recovery is usually complete.
« Multiple - Tuberculous ulcer
e) Immunological sensitisation
3. Size
• Transfusion related graft versus host disease (TGVH)- ;
4. Shape
» A rare and serious complication
5, Margins - May be regular or irregular, oval or rounded
> Cause - It is due to reaction againstrecipient’s tissues by donor lymphocytes.
Tuberculous ulcer - Thin bluish margins
> Commonly seen in immunocompromised, leukemia,lymphoma
> Features- Pancytopenia, toxic epidermal necrolysis (TEN), liver dysfunction
6, Edge of the ulcer - It is useful in diagnosis of ulcer as well as assessment of healing
• Tuberculous ulcer - Undermined edge
> Mortality is more than 90%.
» Syphilitic ulcer - Punched out edge
2. Transmission o f Infections : • Rodent ulcer - Raised and beaded edge
a) Bacterial: Syphilis, Yersinia • Carcinomatous ulcer - Rolled out and everted edge
•b) Viral: HIV, HBV, CMV, EBV r Inflamed and edematous edge signifies spreading ulcer.
c) Parasite: T.cruzi, Malaria > Sloping edge is seen in a healing ulcer.
3. Complications caused by massive transfusion: y Indurated edge is a feature of non healing/ callous ulcer.
a) Aci d-Base imbalance - main ly metabolic acidosis because most of the citrate in the anticoaguta, 7. Floor of the ulcer
solution is present as sodium citrate, which becomes sodium bicarbonate as citrate is consumed • Tuberculous ulcer - Pale granulation tissue
b) Hyperkalemia - due to shift of potassium out of RBC due to low temperature of storage • Syphilitic ulcer - Wash leather slough
c) Citrate toxicity - Us main effect is to consume ionized calcium from the patient's body resuKingit, • Rodent ulcer - scab (made of epithelial cells and dried serum)
hypocalcemia and bradycardia. * • Carcinomatous ulcer - covered by necrotic tumor, blood and serum
d) Hypothermia j • Venous ulcer - Healthy pink/ red granulation tissue
e) Failure of coagulation - The causative factors are : j 8. Base of the ulcer
• DIC • No induration - Venous ulcer
• Dilution of clotting factors • Indurated - Syphilitic ulcer, rodent ulcer, carcinomatous ulcer, tuberculous ulcer
« Dilutional thrombocytopenia 9. Any discharge from the ulcer
4. Complications o f general Intravenous fluid adm inistration: • Serous - healing ulcer
• Purulent - infected ulcer
a) Thrombophlebitis
• Bloody - Carcinomatous ulcer
b) Air embolism
• Yellowish - Tuberculous ulcer
S. Miscellaneous: 10. Whether the ulcer extends to the normal tissue or nol
a) Iron overload 11. Examination of regional lymph nodes
b) Hemochromatosis • Rodent ulcer, venous ulcer - No involvement
c) Congestive cardiac failure - mainly seen if whole blood transfusion in large quantities is given1-' • Tuberculous ulcer, syphilitic ulcer, carcinomatous ulcer - lymph node involved
chronic anemic patients, pregnant females, patients with cardiac problems and elderly individuals '2. Examination of distal pulses, sensations, joint movements, function of the limb

0 .3 : Define ulcer. Describe the clinical exam. Of an ulcer. Write down the treatment o f venous ul»
T R EATM EN T OF VENOUS ULCER
[2 + 8*5!
^ Conservative:
ULCER
b is g a rd REGIMEN
□ Definition :
• Elevation of the affected lower limb
It is a break in the continuity of the covering epithelium (skin or mucus membrane) due to cell
• Massage of the indurated area and the calf
 224 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-I 225

• Passive and active exercise

• Pressure bandage - applied spirally from base of toes upto knee joint overa piece of £ Ingestlon/inhalatlon of smoke
placed on the ulcer i i
• “ Four layer” bandage - developed by Charring Cross Hospital, London Carbon monoxide Nicotinic acid
t Regular cleaning of the ulcer using povidone iodine j
• Dressing with EUSOL (Edinburg University Solution of Lime - contains sodium hypochlorite, ?
calcium hydroxide and boric acid) ; i
• Antibiotics (depending on culture and sensitivity report of the discharge)
Carbon monoxide binds with tiemoglobin ;
» Topical steroids

□ Surgical: Formation of Carboxyhemoglobin

• Definite procedure for varicose vein (Trendelenburg operation etc) afterulcerheals by
conservative treatment
• Valve replacement
• Kistner’s valvuloplasty
. •*y ... ....
Results in
0 .4 : Define and classify Intermittent claudication. Describe the pathogenesis o f Buerger's disease,
How will you treat a case o f Buerger's disease without gangrene? [ 2 + 4 + 4 +5] j Vasopasm Hyperplasia of intima
f
, INTERMITTENT C LAU D IC ATIO N
I
u— JL
□ Definition: It can be defined as cramping pain in the muscle of limbs. j
• Arterial occlusion leads to accumulation of metabolites like lactic acid and substance P in the j Thrombosis and obliteration of vessels (usually medium sized vessels)
muscle, which causes the pain.
• Most common site - calf muscle (due to block in femoropoplitea! segment) Panarteritis Usually segmental involvement
• Other sites-foot (lower tibfal and plantar vessels), thigh (superficial femoral artery), buttock f
(common iliac or aortoiliac segment) J
« i1
□ Classification:
BOYD’S CLASSIFICATION OF CLAUDICATION ! Eventually involvement of artery, vein and nerve
• Grade I : Patient complains of pain after walking a distance
(The distance at which pain develops is known as ‘Claudication distance’. If patient continues ' Rest pain due to nerve involvement Features of ischemia in the affected limb
walking, increased perfusion in the muscle washes away the metabolites and pain is subsided)
• Grade I I : Pain still persists on continuing walk, but patient can walk with effort
• Grade I II: Patient has to take rest to relieve the pain. k

BUERGER'S DISEASE Following blockage, plenty of collaterals open up (around Joiee Joint/around buttoc k)

□ Pathogenesis: [Blood supply to the ischemic area is maintained Known as “Compensatory peripheral vascular disease"
Buerger's disease, also known as lhromboangitis obliterans, is almost exclusively seen in young
males who are smokers and/or tobacco users. (See chart on the next page)
□ Treatment:
J
1. Advise patient TO STOP SMOKING
| Continuation of smoking leads to blockage of collaterals resulting in servere ischemia
2. Care of the lim bs:
(a) Buerger’s position - To improve circulation head end of the bed is raised and foot end is
lowered. -■ ^ peripheral vascular disease a/k/a “ Critical limb ischemia" (Ulceration, rest pain,
(b) Buerger’s exercise - gangrene)
* Leg is elevated and lowered alternatively, each for 2 minutes for several minutes at a lime
* Regular graded exercises are to be done upto the point of claudication
 226 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- I 227

(c) Care of the foot (Chiropady) - 3 Diabetes mellitus

* To avoid trauma (even nail pairing) or pressure at pressure points in feet. 4 scleroderma
* To avoid exposure of feet lo more warm or cold temperature. 5 Autoimmune diseases - Rheumatoid arthritis, SLE
* To avoid dryness of feet and legs. j Atherosclerosis:
* Regular application of oil to feet and legs.
, Chronic inflammatory condition of elastic and muscular arteries.
* To wear socks with footwear. ]
, Risk factors - (1) Hypercholesterolemia/ Dyslipidemia ( Serum cholesterol > 200 mg%, Serum
* Heel raise by 2 cm.
LDL > 100 mg%, Serum HDL < 35 mg%) (2) Hypertension (3) Diabetes mellitus (4) Cigarette
3. Drugs: smoking (5) Hypertriglyceridemia (6) Elderly age group (7) Obesity / Sedentary lifestyle
S r Nifedipine - vasodilator (
3 Buerger's disease:
/> Low dose aspirin (75 mg once daily) - Anti-thrombin activity ;
, Inflammatory disorder involving distal medium sized vessels with cell mediated sensitivity to
Clopidogrel (75 mg)
type I and III collagen.
Atorvastatin (10 mg)
• Risk factors - ( 1 ) Young males (2) Cigarette/ tobacco use (3) Recurrent minor feet injuries
> Cilostazole (100 mg BO) - Phosphodiesterase inhibitor (improves circulation)
(4) Lower socioeconomic group (5) Poor hygiene
J y Pentoxiphylline - Increases oxygenation by increasing the flexibility ol RBCs *
> Graded injection of Xanthine nicotinate (3000 mg on day 1 to 9000 mg on day 5) - pron^ □ Diabetes mellitus :
ulcer healing • Diabetic neuropathy results in higher risk for injuries and subsequent infection of foot. Diabetic
4. Chemical sympathectomy - microangiopathy causes blockade in microcirculation resulting in hypoxia. Diabetic
> Injection of lignocaine 1% paravertebrally (L2, L3, L4) in front ol the lumbar fascia. atherosclerosis reduces the blood supply leading to gangrene.
> For long term efficacy, 5 mL phenol in water can be used. □ Scleroderma:
> Done under C-Arm guidance. • Progressive vasculitis causing fibrosis of skin, GIT, lungs, heart and kidneys.
> Advantage - Feet become warm immediately after injection • Common in females (M : F= 1 :4 ) in 4th-5th decade
> Disadvantage - Risk of Spinal cord Ischemia, risk of injury to IVC/aorta. • Association - CREST syndrome (Calcinosis cutis, Raynaud's phenomenon, Esophageal
5. Gene therapy - hypomotility, Sclerodactyly, Telengiectasia)
Intramuscular injection of VEGF (vascular endothelial growth factor) promotes angiogenesn
6 . Surgery - INVESTIGATIONS
> Omentoplasty - To revascularise the affected limb . >' \ s ( Blood investigations :
> Profun doplasty - To open more collaterals across the knee joint (in blockage of profit
• Hb%, Platelet count, ESR, Peripheral Blood Smear
femoris)
• Lipid profile
> Lumbar sympathectomy - To improve the cutaneous perfusion in the affected limb. 1
• Blood urea, serum creatinine
> llizarov method of bone lengthening - Causes neo-osteogenesis, improves overall Nr
• Blood sugar, Urine ketone bodies
supply, decreases rest pain and claudication. \
• IgG, Antinuclear and Anticentromere antibodies
> Amputations - Below-knee or Above-knee amputation based on site and severity ol vet-
occlusion. 2s Segmental Blood Pressure measurements :
• Measured at multiple levels - upper and lower thigh, upper calf, ankle.
y O . 5 : A 32 yrs old male patient attends the surgery OPD with chief complaints o f pain in the rigtiiu
• Normally blood pressure increases as we go further down the leg.
while walking, for 2 months. He had been a chronic smoker for 10 yrs. On examination, he*
reduction in peripheral pulses In the affected lower limb. What are the D/D7 What investigM • > 20 mm Hg gradient is abnormal. Pressure reductions between levels help to localise the
will you do In this case ? What procedures can be done for Improving the lo wer limb clrculib occlusion.
[ 5 +5*-; 3^ Arterial Doppler: Provides information about the following :
(a) arterial diameter (b) blood flow rate (c) velocity of flowing blood (d) assessment of slenosed
DIFFERENTIAL DIAGNOSIS segment

A case of 32 yrs old male presenting with pain in right calf, white walking, for 2 months and reducW. ^ plexscan.
peripheral pulses in the affected lower limb, on examination, indicates towards the pathology of If* Combination of Ultrasound (B mode) and Doppler study.
limb ischemia due to arterial occlusion.• Provides information about the following- (a) site, extent and severity of occlusion (b) collaterals
Differential diagnosis of this case is as follows - ^ (°) Pu|se wave tracing (d) blood pressure at various levels
1. Atherosclerosis USGabl/om en: to see block or aneurysm in abdominal aorta/ other vessels and other organs.-— ■
2. Thromboangitis obliterans (TAO) / Buerger's disease < 6' ECG/Echocardiography/Treadmill te s t: to assess the status of coronary circulation.
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-I 229
228 QUEST ' A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
----------------------------------------------------— ------------------------------------------------------------------------- - V
c) Care of the foot (Chiropady) -
!
• To avoid trauma (even nail pairing) or pressure at pressure points in feet.
'S I . Angiography:
• Retrograde transfemoral angiography by Seldinger technique is most commonly done. * To avoid exposure of feet to more warn or cold temperature.
done only when femoral pulsation can be felt. * To avoid dryness of feet and legs.
• Shows site, extent and severity of blockade j * Regular application of oil to feet and legs.
• Cork screw appearance of vessel (due to dilatation of vasa vasorum), Spider leg/ invert • • To wear socks with footwear.
tree collaterals, corrugated rippled artery (due to severe vasospasm) - suggestive ol • • Heel raise by 2 cm.
Buerger's disease 4 Care of the foot and toes in di-shelics:
• Distal run off through the collaterals is important to judge whether the ischemia is compensate S y To avoid any injury or pressure at pressure points.
ornot. [ y To keep the foot clean and dry.
8. Digital Subtraction Angiography (DSA) : y The limb should not be warmed.
• Here vessels and vascular anomalies are well delineated as other tissues are eliminate > To use Microcellular Rubber (MCR) footwear.
. from the image using computer softwares. | Drugs:
• Done to exclude arteriovenous malformations, hemangioma, vascular tumors. ^ , Nifedipine - vasodilator ■•
9. CT/MR angiogram : , Low dose aspirin (75 mg once daily) - Anti-thrombin activity -
Ankle Brachial Prtssure Index (ABPI}: Clopidogrel (75 mg) •
Atorvastatin (10 m g )'
• Normal value is 1
, Cilostazole (100 mg BD) - Phosphodiesterase type III inhibitor (improves circulation)
• Value less than 0.9-Ischemia is present
^ pentoxiphylline’- Increases oxygenation by increasing the flexibility of RBCs
• Value less than 0.3 - severe ischemia with gangrene ;
Graded injection of Xanthine nicotinate (3000 mg on day 1 to 9000 mg on day 5) - promotes ulcer
t f . Brown's vasomotor Index: healing
• (Rise in skin temperature - Rise in oral temperature) / Rise In oral temperature. • Vitamin B complex including Folic acid - reduces homocysteine level
« Specific nerve of the ischemic limb (like posterior tibial nerve for lower extremities)cl • Inositol, L-camitine, Magnesium, Vitamin E, Vitamin C - Used to improve walking distance
anesthetised. If ischemia is at vasospasm stage, the nerve block will relieve the vasospasr • Prostaglandins, VEGF (intramuscular injection promotes angiogenesis), E2F decoy (blocks intimal
and skin temperature will rise. and smooth muscle proliferation), Mesoglycan (breaks blood clot)
• Value more than 3.5 means the disease is due to vasospasm (can be relieved « Heparin - only used in embolism or acute phase
sympathectomy). , • Oral anticoagulants - only used if there is H/O embolism or atrial fibrillation
• Value less than 3.5 means sympathectomy would not be beneficial. • Drugs for scleroderma: D penicillamine, Para amino benzoic acid. Colchicine, Dimethyl sulfoxide.
12. Transcutaneous oxim etry: Surgery:
• Oxygen tension (tcP02) is measured by placing polarographic electrodes over skin at Ihigfc! 1. Percutaneous transluminal balloon angioplasty (PTA) -
leg and foot. tcP02 reflects underlying tissue perfusion. > Following Transfemoral retrograde angiography by Seldinger approach, PTA is done under
•
Normal value is 50-60 mmHg. fluoroscopic guidance. PTA with stenting,- using self-expandable or non-expandable stents,
Value less than 40 mmHg - Inadequate wound healing. may also be done.
Value less than 10 mmHg - Critical ischemia. V Types - (a) Conventional (b) Subintimal
13. Xenon 133 Isotope m ethod: Done to study muscle blood flow. * Indication - Done when the stenosis is less than 5 cm
> Advantages - (a) Stent, if needed, can be placed at a later date (b) Done under local anesthesia
PROCEDURES FOR IMPROVING LOWER LIMB C IR C U LATIO N *- Complications - Arterial dissection, thrombosis, embolism, pseudoaneurysm, retroperitoneal
hematoma, bleeding
A. General measures: Atherectomy - Removal of atheromatous plaque from the wall of the vessels by open surgery or
1. Stop smoking, Regular exercise .* through percutaneous route.
2. Control of diabetes, hypertension Thrombectomy - Removal of thrombus through an arteriotomy. Done in larger vessels (For
3. Care of the lim bs: aortoiliac, femoropopliteal blocks).
a) Buerger's position - To improve circulation head end of the bed is raised and foot cnd« 4 Endarterectomy -
lowered. r Removal of thrombus along with diseased intima of the vessel through an arteriotomy.
b) Buerger's exercise - *• Done in carotid, aortoiliac, aortofemoral blocks.
• Leg is elevated and lowered alternatively, each for 2 minutes for several mingles a'! *■ 3 methods - (a) Open method (b) Semi closed method (c) Wiley'seversion endartereclomy
time. ' Disadvantage - Reocclusion
• Regular graded exercises are to be done upto the point of claudication
 230 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-I 231

Profundoplasty: n line and classify cysts. Discuss the management o f a surgically relevant parasitic cystic
0.6 • 0 Se3Se. Write a brief account on pseudocyst o f pancreas. [ 1+4+4 +5]
> Done when there is a localised block in the opening of profunda femoris.
r Lateral angiogram view is used lo identify the orifice of profunda femoris. CYSTS
> Endarterectomy at the junction and closure with venous or synthetic (Dacron or PTFE) g(e. f
are done. ftnition: Cyst < KUSTIS (Greek word, which means 'Bladder')
> Advantage - Allows collaterals across knee joint to open through profunda femoris t w i J defined as a collection of fluid in a sac linedI by epitheliu
epithelium or endothelium.
providing good blood supply to below-knee level.
C:'Sl' ,r» usually hemispherical swellings which are smooth, well defined, fluctuant and sometimes
Bypass grafting procedures : , | fnese an* u •
|fiiisillu,n'nan
> Aortofemoral bypass graft is the gold standard procedure for Type I and type II aorto»~I
atherosclerotic occlusive disease with a long term patency rate of 70-80%. CLASSIFICATION OF CYSTS
> Grafts used can be arterial/ venous/ synthetic:
[A] Synthetic - Dacron woven graft, Dacron knitted graft, Polytetrafiuoroethylene (PTFE)
[B] Natural - Internal mammary artery, Long saphenous vein (reverse OR, in situ), Umb^J Thyroglossaij
vein graft (with minimum 3 mm diameter) cy* J
r Other bypass grafting procedures are : lleofemoral, Femorofemoral, Femoropop|j|e; f
Femorodistal, Axillofemoral. f
> Disadvantage: Leak, infection, reblock, thrombosis.
Lumbar sympathectomy:
•* I
>- Removal of Lg, L3, L4, L5 ganglia from the lumbar sympathetic chainwith retention of Lji-f
one side in bilateral cases. .
> Advantage: Increased cutaneous blood flow for 2-4 weeks (due to absence of constriction; i
arterioles and precapillary sphincters) resulting in improved nutritive distal perfusion, b® j
ulcer healing, reduced pain.
> Complications:
* Injury to IVC or aorta
* Injury fo bowel, ureter
* Bleeding lumbar veins
* Paraplegia due to Ischemiaof spinal cord .
* Dry ejaculation due todamage to B/L Lj ganglion
* Post- sympathetic neuralgia
* Wound infection
* Paradoxical gangrene of opposite lower extremity
^ 8. Chemical sympathectomy:
> Injection of lignocaine 1% paravertebrally (L2, L3, L4) in front of the lumbar fascia.
> For long term efficacy, 5 mL phenol in water can be used.
> Done under C-Arm guidance.
> Advantage - Feet become warm immediately after injection
> Disadvantage - Risk of Spinal cord ischemia, risk of injury to IVC/aorta.
9. Omentoplasty:
> Retaining one of the pedicles, omentum with its arcade of vessels can be mobilised in or*
to reach the lower limb to maintain the circulation.
Dermoid cyst o f) (
V Advantage : Control of ischemia, reduced pain, belter ulcer healing. ovary I
!r Complications : Abdominal sepsis, Incisional hernia, Intestinal obstruction.
10. For Buerger's disease : Cystadenomas)
llizarov method of bone lengthening- Causes neo-osteogenesis, improves overall blood supj*
decreases rest pain and claudication.
11. For diabetic foot: Surgical debridement ol the wound. . :
 232 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- I 233

MANAGEMENT OF A SURGICALLY RELEVANT PARASITIC CYSTIC D lS E ^ » Mebendazole

„ Dose - 600 mg daily
Hydatic cyst of liver is caused by dog tapeworm, Echinococcus granulosus, a parasite.
> Duration - 4 weeks
Its definitive host is dog, intermediate host is sheep and accidental host is man.
3 praziquantel
O Investigations for hydatid cyst o f liv e r: > Dose - 60 mg/kg (along with albendazole)
1. USG: Duration - 2 weeks
> It is diagnostic. PAIR (Puncture - Aspiration - Injection - Reaspiration):
*■ Findings - (a) Double contoured membrane of the cyst , indications -
(b) Rosettes of daughter cysts (cart wheel appearance) Inoperable patients
(c) Calcification of cyst wall > infected cysts
> Hassen Gharbi's USG based classification for hepatic hydatid cyst - > Relapsed cysts
Type 1 : Pure fluid collection > Gharbi type 1 and type 2 cysts
Type 2 : Fluid collection with split wall > Pregnant women
Type 3 : Fluid collection with septa y Children < 3 years of age
(t is done under ultrasound/ CT guidance.
Type 4 : Heterogeneous appearance
Procedure -
Type 5 : Reflecting thick walls
2. CT scan abdomen :
st is punctured with Cholangiography 22 gauge needle through Ihe thickest
a) It is Ihe radiological investigation of choice for hydatid cyst of liver.
r „ri of the cyst wall, under local anesthesia.
. b) More accurate than ultrasound in identifying cyst characteristics,
c) Old hydatid cysts show Serpent sign/ Crumpled membrane siqn
3. MRI;

3) ducts)'0 l0° k ,0r CySl0bil'a,y comrnunica,i°n. biliary hydatids (in common bile duct and heE 50% of cyst fluid is aspirated. Radio opaque dye is injected to look for any
communication.
4. Serological tests :
a) Immunoelectrophoresis - 80-95% sensitivity
b) ELISA Scolicidal agent (15-20% Hypertonic saline) is injected.
c) Indirect hemaglutination test
d) Latex agglutination test

5.
e) Immunofluorescence antibody test
Other laboratory tests: Reaspiration is done after 20 minutes.
$
a) PCR - useful in extrahepafic hydatid cyst and calcified hepatic hydatid.
b) Immunoblotling
c) Detection of precipitation line
8. Casoni’s test:
Alcohol (a sclerosant) is injected.
a) Intradermal test of historic importance.
b) Sensitivity is 75%.

0 Treatment o f hydatid cyst o f liv e r:

Contraindications of PAIR -
A. Drugs:
a) Dead/ calcified cyst
1. Albendazole b) Deep seated / Inaccessible cyst
V 4 week cycles. c) Muliloculated cyst/ honeycomb Cyst
' Started at least 2 weeks before any intervention. d) Cyst with cystobiliary communication
To be continued till 2 weeks after any intervention. e) Extra hepatic hydatid cyst
 234 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS O Paper-1 235

C. Surgery:
c) Contents
• It is the gold standard therapy for hepatic hydatid cyst d) Extent of necrosis in pancreas
• During open surgery, the peritoneal cavity is packed with mops soaked in povidone iodine (h e) Calcification and atrophy
in colour) to identify white scolices so as to prevent any spillage. Fluid from the cyst is aspirate? f) Regional vessels and their abnormalities
Scolicidal agent (hypertonic saline/ cetrimide/ chlorhexidine/ 10% povidone iodine/ Hydroo
3 mRCP - demonstrates ductal anatomy and its abnormality,
peroxide) is injected into the cyst cavity followed by reaspiration 20 minutes later.
cystopancreatic communication.
• Other surgical options - (a) Laparoscopic pericystectomy (b) Liver resection
4 ERCP - To look for communication/ fistula.
• Procedures to correct cystobiliary communications -
5 Barium meal (Lateral view) - Shows widened vertebra gastric angle with displaced stomach.
a) Pericystectomy and marsupialization
6 LPT, Serum amylase (Amylase level in cyst fluid is > 5000 units/ mL)
b) Suturing of the communication with Vicryl I PDS with T tube placement in the common hii» ^
duct ^ ' j Treatment -
, Majority of pancreatic pseudocysts are resolved spontaneously.
c) Capitonnage (spiral suturing of the bottom of the cyst cavity upward from the base of cavity ^
the edge of cyst wall); Introflexion (inverting the rim of the cyst edge without apposition' \ , Indications for intervention/ surgery -
omentoplasty a) Size > 6cm
d) Bipolar drainage b) Cyst with wall thickness > 6mm
e) Perdomo procedure c) Cyst persisting for > 6 weeks
f) Pericystojejunostomy d) Communicating cyst
e) Infected cyst
PSEUDOCYST OF PANCREAS J . Procedures -
• Most common complication of Pancreatic pseudocyst surgery - Hemorrhage
□ It is a localised collection of sequestrated pancreatic fluid, which occurs usually 3 weeks after an
‘ attack of acute pancreatitis. It may also occur after chronic pancreatitis.
□ It is called “pseudocyst" because it is an exudation cyst lined by granulation tissue, not epithelium
□ Sites - 1
• Lesser sac - Most common
• Duodenum i
• Jejunum
• Colon t
• Splenic hilum
0 D'Egidio classification -
Type I : After an attack of acute pancreatitis. Normal duct anatomy. No fistula / communication.
Type I I : After an attack of acute on chronic pancreatitis. Abnormal duct anatomy without stricture.
50% chance of fistula.
Type III: After an attack of chronic pancreatitis. Abnormal duct anatomy with stricture. Always
communicating.
Q C/F -
1, Epigastric swelling which is hemispherical, smooth, soft, non-mobile, not moving with respiration,
with well-defined lower margin and diffuse upper margin, with transmitted pulsation, confirmed
by knee-elbow positioning of the patient.
2. Baid’s lest - Ryle's tube passed can be felt per abdominally.
Complications of pseudocyst -
□ Investigations -
• Infection - Most common (20%)
1. USG abdomen : Shows size and thickness of (he cyst.
• Bleeding from splenic vessels (7%)
2. CT scan:
• Rupture (3%)
> CECT is the investigation of choice.
• Cholangitis
V It shows -
• Duodenal obstruction
a) Number, Size, shape, wall thickness
Pancreatic pseudocyst mimics cystic neoplasm of pancreas, although the former can be ... iierenliated
b) Pancreatic duct size
from the latter by CT findings and CEA level. .

(
 236 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-I 237

Q.7: A 60 yrs old lady has presented with jaundice, pruritus, pale stools and a palpable mass in«. i
right upper quadrant o f abdomen. Enumerate the D/D. Which radiological investigation f
6 ERCP with pancreatic juice cytology or brush biopsy
you recommend? Outline the operative management of periampullary CA. [3+3^ I
. Shows the site of obstruction in CBD with proximal dilatation
DIFFERENTIAL DIAGNOSIS • Any growth can be biopsied.
.Bile may be collected and exfoliative cytology can be done from the sample. This, along with
A clinical picture of jaundice, pruritus and pale stools in a 60 years old lady is suggestive of Obstruct f brush cytology, may be helpful in the diagnosis of cholangiocarcinoma of distal CBD.
surgical jaundice.
* If serum bilirubin is very high (>10mg%), stenl may be placed in the bile duct during ERCP to
A palpable mass in the right upper quadrant of abdomen in this patient is suggestive of gall b l ^ ‘ bring down the level of bilirubin.
enlargement, which necessitates consideration of Courvoisier's law.
. Findings suggestive of carcinoma of the head of pancreas :
Courvoisier's law states that - "In a patient with jaundice, if there is palpable gall bladder, then it is not<w|
i) Abrupt block in the pancreatic duct wilh irregular stricture
to stones*. The law has following exceptions:
II) Pancreatic duct encasement
(a) Double impaction of stone (one is CBD and another in cystic duct)
iii) Double duct sign- both pancreatic duct and CBD are cut off/ constricted
(b) Empyema gall bladder with primary CBD stone
iv) Scrambled egg appearance
(c) Distended gall bladder due to huge stone load
v) Parenchymal filling
Hence, the following differential diagnosis can be considered in this patient:
7. MRCP
Periampullary carcinoma j
• Carcinoma of the head of pancreas . It is preferred when serum bilirubin level is < 10mg% and preoperative stenlinq is not beino
contemplated. * a
• Ampullary carcinoma arising from ampulla of Vater ;
• It is a noninvasive diagnostic tool with 96% sensitivity and 99% specificity.
• Cholangiocarcinoma of distal common bile duct (CBD)
• II provides with delineation of the entire biliary tree and pancreatic duct along with any lesion.
• Duodenal adenocarcinoma
< 8. Percutaneous transhepatic cholangiography (PTC)
Carcinoma of gall bladder
Lymph node mass in the porta causing biliary obstruction (Due to metastasis/ lymphoma / tuberculosa • It is useful when ERCP (ails to detect and assess the site ol lesion and the patient is deeolv
jaundiced. v1
RELEVANT RADIOLOGICAL INVESTIGATIONS . Percutaneous transhepatic biliary drainage (PTBD) with a fine catheter left in situ to
decompress the biliary system, may be done in these cases.
1, USG abdomen
• Can delineate the anatomy ol gall bladder, liver, any growth, size of CBD (Normal diamefe; OPERATIVE MANAGEMENT OF PERIAMPULLARY CARCINOMA
is < 10 mm), lymph node status, portal vein, ascites.
• Can detect any stone in gall bladder and common bile duct. i lf lhe!f t y,mptoms or c,lnical signs of disseminated disease, and investigations don't reveal any
spread, Whipple s pancreaticoduodenectomy is the surgery of choice.
2. Endoscopic Ultrasound (EUS)/ Endosonography
Q Preoperative preparation:
• More accurate in assessment of pancreatic mass, staging of thedisease (T and N), loideiS^
involvement of portal venous system, CBD stones. ’ • ° ral and intravenous fluid for adequate hydration (Patients with obstructive jaundice usually
• Useful for EUS guided FNAC, Celiac axis neurolysis, EUS guided immunotherapy. ’ have dehydration and impaired renal function. Adequate rehydration is indicated by qood
unne output). ' 3
3. Barium meal X-ray
2. Intravenous manmtol 200 ml twice daily for 3 days prior to surgery (Patient is prone to develop
• Not routinely done now-a-days.
hepatorenal syndrome postoperatively which may result in renal failure due to blockage of
• Rose thorn appearance of medial border of duodenum, Reverse 3 sign (due to filling delect renal tubules by deposition of bile salts or due to gram negative septicemia).
- suggestive of periampullary carcinoma.
3. Adequate oral or intravenous glucose (Due to associated hepatocellular dysfunction the
• Pad sign (widened C loop of duodenum), gastric distension due to gastric outlet obstruct** glycogen reserve in liver is reduced in Ihese patients).
- suggestive of Carcinoma of the head of pancreas.
<• Inj .Vitamin K 10 mg IM for 5 days prior to surgery (Prothrombin Time may be prolonoed due
4. Spiral CT to decreased absorption of vitamin K).
• To assess operability, size and extent of growlh. 5. Broad spectrum antibiotics like 2nd generation cephalosporin and aminoglycoside
• To detect portal vein invasion, lymph node status. combination for 1-2 days prior to surgery (Patients have increased risk of infection and are
• CECT is the investigation of choice in periampullary carcinoma. prone to gram negative septicemia).
® Total parenteral nutrition [TPN] (If patient is malnourished).
5. CT/MR angiogram
• Evaluation of pulmonary function by Chest X-rsy and Pulmonary function test Pulmonary
• To assess vascularity, portal venous system.
physiotherapy is to be started
• Angiographic appearance of occlusion of celiac, superior mesenteric vessels or portal vs*
suggests nonresectability. 8- Preoperative biliary drainage by either ERCP stent,ny or PTBD in cases where preoperalive
serum bilirubin levels are >10mg%. Surgery is done alter 3 weeks once bilirubin level drops
oown adequately.
238 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 8 Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-1 239

□ Operative Procedures in operable cases: . ^numerate the endocrine tumors o f pancreas. Discuss CIF, Investigations and treatment o f
a n y 2 o f such tumors. [3 + 6 + 6 ]
1. Whipple's operation
> Removal of tumor + Head and neck of pancreas including uncinate process + c t00pl | ENDOCRINE TUMORS OF PANCREAS
duodenum + 10 cm proximal jejunum + Distal 40% stomach + Lower end of CBD +^ |
bladder + Pericholedochal, paraduodenal and perihepatic lymph nodes
r Continuity is maintained by choledochojejunostomy, pancreaticojejunostomy Insulinoma
gastrojejunostomy
V Mortality is 2-8%.
V Complications- Delayed gastric emptying, pancreatic fistula, bile leak, infection. i Gastrinoma
2. Traverso-Longmire pylorus preserving pancreaticoduodenectomy
V Here distal part of the stomach is not removed. Duodenum is cut 2 cm distal to 5;‘
pylorus. Glucagonoma
r It avoids the dumping syndrome, a complication of Whipple’s operation.
3. Fortner's regional pancreatectomy / Extended Whipple's operation
> Resection of a segment of superior mesenteric vessels and dissection of adjacent
VIPoma
nodes with maintenance of continuity of portal vein by a synthetic vascular graft. |
4. Total pancreatectomy j;
y It may be done in growth involving head and body of pancreas.
Somatostatinoma
* r It is preferred because -
a) Pancreatic growth may be multicentric.
b) There is higher chance of local recurrence after Whipple's operation.
INSULINOMA
c) Viable malignant cells may be present in the pancreatic duct.
d) Morbidity by postoperative pancreatic fistula or pancreatitis.is not seen here, j • Most common pancreatic endocrine tumor.
> Disadvantages - • Majority are benign (85%).
a) Mortality is higher than Whipple's operation 10-20%. ., • • Usually solitary.
b) Severe resistant diabetes mellilus is seen postoperatively which needs lifelong inair; • Arises from Beta cells of islets of Langerhans.
therapy. • Can be sporadic or associated with MEN syndrome type I.
c) Permanent pancreatic enzyme deficiency which needs pancreatic enzyn.|
□ Clinical features:
replacement therapy lifelong.
1. Abdominal discomfort, sweating, trembling, dizziness, diplopia, hallucinations. Convulsions and
Q Features o f unresectability: •;
unconsciousness may occur.
1. Multiple liver metastasis 2. The patients usually are overweight.
2. Peritoneal metastasis Whipple's triad is a feature of Insulinoma.
3. Malignant ascites
4. Extensive lymph node metastasis An attack of hypoglycemia in fasting state
5. Invasion of the growth into IVC Blood sugar level below 40 mg/dL during the attack
6. Invasion of the growth into superior mesenteric vessels, portal vein of celiac axis
Reversal of symptoms on administration of glucose.
□ Operative procedures in inoperable cases:
In these cases, palliative surgery is to be undertaken - >3 Investigations:
1. For relief of jaundice - Roux en Y choledochojejunostomy following cholecystectomy 1. Insulin radioimmunoassay following 72 hours fasting : j
2. If the patient has gastric outlel obstruction - gastrojejunostomy
3. For relief of pain-celiac plexus blockade with absolute alcohol Plasma insulin level > 7 microunit/mL
4. For steatorrhea - Enzymes Findings in Plasma insulin to glucose ratio > 0.3
5. Control of diabetes mellitus Insulinoma Proinsulin level > 24% of total insulin level
C peptide level > 1.2 pg/mL with glucose level < 40 mg/dL
 240 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUE'iftrjMS OH SEMESTERS D Papar -I >A'

> Proinsulin level > 40% of total insulin level is suggestive of malignant insulinoma. Hyofti’fjiislrinomis
2. Insulin provocation test using Calcium gluconate or tolbutamide.
3. MRI - to localise the tumor.
4. Celiac angiogram.
5. Infraoperative USG - It is the best modality to localise the tumor. ! .'ncrouidti iitiii uCtttMw:

□ Treatment:
• Benign insulinoma are treated by enucleation. Distal pancreatectomy (spleen; tail and the body
__________¥ ______ __
of pancreas are removed) may also be done. ] pH of duodenum becomm. <vad.t;
• To decrease insulin secretion - Octreotide.
• To control hypoglycemia - Diazoxide, Beta blockers, phenytoin, verapamil
• To treat metastatic insulinoma (when secondaries are present in liver or elsewhere) - Streptozoaa Pancreatic enzymes dor.'l get activated

•
GASTRINOMA

Second most common pancreatic endocrine tumor.

• i
Malabsoiptlon
• Most common pancreatic endocrine tumor seen in MEN syndrome type I.
• Common in males.
• It causes Zollinger Ellison syndrome type II. | Oiarmec j
• Majority of gastrinoma lie in Gastrinoma triangle/ Passaros triangle.
'• Most common location - 1st part of duodenum
• Majority are malignant (85%) 4 SccMrfe f.i jvr.-etian ins': -C n injection of s e c re t i.v., assessment of blood samples
before <;:kJ c* cry 5 after injection o13?.v?ii:'. h- ;0 minuses, will show a gastrin Isve!
mom tixiri or o ^u il to (SaseHn? gaatri.i vkIijg • > K> jx.
5. Basal auid output {> i i i mnq/hour)
6. PH or !>io ?;*?*;'» {•: **}
7. CT, MRI, Ir.traoncraiivs USG - lo localise the tumor.
8. Anciioyrj'ii
9 fttsftoecor-y
U T rsa kP iitl:
• As li.fijvr :-, :i g e s'ii.'iom r are iiialign&iu, fasJisal surgery W hipple's operation
(pa:icrei»Ncor.'iiile!;(wiomy) is usually dona'
* Cniiito^iiwi of tonjw >.•: Oisla! fjancrsaipctomj, rosy b<s sometimes.
♦ Vo iieal irMi-toiafe ya^lrinoma - High dose octreotide is used.

0 -9 : A <35 vis old m an p ie s e n ie d with rapidly developing anorexia, asthenia a n d fatigue with
merer,sing y tm ilin y How m>rM you itivostfaaUi to confirm tho diagnosis? How would you
Sfcri-r *i , J j p ' f‘ ;■ f4 t? .m tf [ 5+5+5 ]

□ Features : /,!S ft •?' •• - ,<i!y d i- 1.-;. ij., ■ anorexia, asihenia and fatigue with
isk".!-;vri..'i i . :;•> rlininsi :• ; ■>! (iic diagnosis ol Gasiric carcinoma.
1. Multiple, recurrent, refractory/resistant peptic ulcers in unusual sites (2nd/3rd/4th part of duodenum,
jejunum). ■ J
STOMACH
2. (See chart on the next page],
A $WPU--,'-A:
□ Investigations:
i) ?Aw.; is/vr.tit :i, ; U> •• wiiijihi
1. Gastrin assay (Normal level 100 150 pg/ml): Gastrin >1000 pg/ml
• . *\> • s*. O-j'W jnru Ufjpei sbdominai p«in or discomfort
2. Calcium provocation test j
3. Pentagastrin provocation test
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-I 243
242 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

iii) Anorexia, nausea, asthenia (weakness + fatigue) . ctnol examination - occult blood present in 80% cases
iv) If gastric outlet obstruction occurs - 4 R°U' c function tests - gross hypochlorhydria or achlorhydria and blood in basal secretion
> Sensation ol fullness after meals or early satiety * , Gl endoscopy (is the Gold Standard) and 10 quadrant biopsy
> Belching S n meal X-Ray (if Endoscopy not possible) -
V Projectile vomiting - vomitus is yellowish in colour (non-bilious), contains food mai 7' a irregular filling defect
consumed more than 12 hours ago, leaving a sour taste in mouth
jjj loss of rugosity
> Feeling of a rolling mass moving from left to right in the abdomen (due to peristalsis) iii) delayed emptying
v) Lump in abdomen
vi) Due to metastasis - J Margin projects outward from lesion into gastric lumen (Carmann's meniscus sign)
> Abdominal swelling (due to ascites from hepatic or peritoneal metastasis)
For staging-
> Breathlessness (due to pleural effusion from pulmonary involvement) n C hest skiagram (PA view)
> Yellowish discolouration of eyes and urine (due to enlarged lymph node obstructing | ii) CT Scan abdomen, chest, pelvis
hepatis) Hi) MRI abdomen, chest, pelvis
> Backache (due to metastasis to vertebrae) iv) Endoscopic ultrasound
Signs: t
9 Others-
a) General survey - \
i) UT
i) Cachectic look may be present
ii) PT
ii) Pallor Iii) FNAC from left supraclavicular lymph node
iii) Jaundice may be present iv) Laparoscopy for staging
iv) Enlarged Virchow's lymph node (left supraclavicular LN) - Troisier’s sign
v) Tetracycline fluorescence test
v) Enlarged Irish nodes in left axilla
vi) Tumor markers - CA 72. CEA, CA 19-9, CA 12-5
vi) Superficial migratory thrombophlebitis - Trousseau's sign
vii) Combined PET
vii) Due to paraneoplastic syndrome -
* Dermatomyositis viii) Sentinel node biopsy
* Acanthosis nigricans | TNM STAGING OF CARCINOMA STOMACH
* Circinate erythema
b) Systemic examination - Tslatus-
1) Abdominal examination :
> Nodular hard mass, with impaired resonance, moves up and down with respiration on
palpation
> In cases of gastric outlet obstruction - .
* stomach is distended
Carcinoma in situ
* succusion splash audible (intraepithelial tumor
* greater curvature of stomach below umbilicus on auscuito-percussion without invasion)
> Sister Mary Joseph's nodule looked for (due to infiltration of umbilicus)
> Ascites is looked for
2) Rectal examination -
To detect metastasis in pelvis and to exclude Krukenberg's tumor
3) Skeletal system examination -
To look for sternal tenderness and bony tenderness

RELEVANT INVESTIGATIONS Invasion of muscu-

Invasion of lamina Invasion of
laris propria
1. Routine blood examination - low Hb, high ESR propria or muscularis submucosa
2. Serum Electrolytes mucosa
3. Blood Sugar, blood urea, serum creatinine
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-1 245
244 QUEST : A Comprehensive Guide to UG Sutgery, Orthopedics & Anesthesiology

0de stations in Gastric Carcinoma (JEGC) -

tier (Perigastric LN)

r stall'"’ 1 : R|9hl Par£carQ'iac

] siaiion 2 : Left paracardiac
' S|ati0n 3 ' Along lessor curvature
' station 4 : Along greater curvature
' > 4a - Along short gastric vessels
N stains - ^ 4(j _ Along left gasSroepiploic vessels
> 4 c - Along right gastroepiploic vessels
, Station 5 : Supiapyloric
, Station 6 : Infrapyloric
fM W SKf W5? Group W N2 tier (LN along the intermediate arterial tnjnks)
M ia ii' ^ , station 7: Along left gastric artery
, Station 8 : Along common hepatic artery
Primary LN Mo evidence of , Station 9 : Along celiac trunk
status can no!!» lymph node 1-2 regional LNs 3-6 regional^ , station 10 : At splenic hilum
assess; spread involved involva) , station 11 : Along splenic artery
Group W ^ 3 Her (LN along the great vessels)
« Station 12 : At hepatoduodenal ligament
• Station 13 . Hetroduodenal/ relropancreatic LNs
• Station 14: At the root of mesentery
14a - Along superior mesenteric artery
> 14v - Along superior mesenteric vein
• Station 15 : Around middle colic artery
'• IS regional
i Station 16 : Para aortic LNs
lNs involvad
« Station 17 : Around lower esophagus
• Station 18 : Supradiaphragmatic
M status -
Group IV/ N 4 lier-Distant lymph nodes beyond these stations

MANAGEMENT
1. Surgery (Treatment of choice) -
Proximal resection margin is to be at least 6 cm to achieve mlcioso-vptofilly r.gativs margin.
Distant metastasis > If early growth involving pylorus region - Lower radica; yasifscior. y/ Ustal gastrectomy •;
Billroth II anastomosis
' If growth in esophago-gastric junction or upper part of slonwe!: • ' tooor radical gastrectomy/
j'lodui tprcac* j$ : , i: .j.sis ? Ci >. ’ i.'. o n ir ic Carcinoma (iJEGC) -
Esophagogaslrectomy + esophagogastric cen/ical/ thoracic ans-.vjv.os’i
** II growth in body of stomach - Total radical gash c-cbiiiy ♦«" anastomosis
r' EMR (Endoscopic Mucosal Resection) is done in Japan
R status (Tumor status after resection): . j
' Ho resection - No residual gross/macroscopic or m ia w w ^ k *•::■*« in tumor bsd •»
Negative resection margin
' FI i resection - No residual gross/macroscop'c tumor ir ' i:V" l;"d •; Positive resection
Nodes cant ixj •it.- rod't t}> s'afSWit 16 IN station* 4
margin
as^c >i*r(r •"•f'v'p I;
3 ; resection - Residua! grossAmacros:;opic -umor
246 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-I 247
-------------------------------------------------------------- — j
Jt o • 4 55 yrs male, chronic alcoholic, complains o f severe, agonising, acute abdominal pain
2. Lymph node dissection - °'1 persisting for several hours, radiating to the back and a little relief on stooping. How would you
> o , dissection : Done when LN status is No- Removal of Group I LNs/ LN stations t-«. | investigate to confitr. 1the diagnosis, prognosticate and manage? [5 + 5 + 5]
, D2 dissection : Done when LN status is N i.
A 55 yearsold chronic aicohclic msle complains of severe agonizing acute abdominal pain persisting
Removal of group I and group II LNs/ LN stations 1 -11 with or without removal of
lor several hours, radiating to the back with a little relief on stooping
tail of pancreas. j .This clinical picture is suggestive of a diagnosis of Acute alcohol induced pancreatitis.
> D3 dissection: Done when LN status is N2. <
Removal of LN stations 1-16 with or without removal of spleen and tail of pancreas/ a Clinici! features:
of anterior lip of transverse mesocolon. A Symptoms:
> D4 dissection : Not commonly done. Removal of LN stations 1-18. > sudden onset of upper abdominal pain which is excruciating and is referred to the back;
Patient gets some relief by leaning or stooping forward .
3. Chemotherapy - V High fever, vomiting, tachypnea »
a) Neoadjuvant therapy : (chemotherapy before surgery) V Refractory hiccough.,,, • "
* Purpose - V Oliguria .
i) to increase resectability (to downstage the tumor) > Hematemesis, melena .
ii) to reduce recurrence
S ig n s :
iii) to determine chemotherapy sensitivity
> Features of shock and hypovolemia, cyanosis, sometimes mild jaundice
b) Regimens used - > Abdomen - Distension, tenderness, rebound tenderness, 'guarding, rigidity, Grey Turner's
* ECF {Epirubicin, Cisplatin, 5-Fluorouracil) sign, Cullen’s sign, Fox sign
* EAP (Epirubicin, Adriamycin, Cisplatin) r Pleural effusion, Neurological derangements
* FDT (5-Fluorouracil, Doxorubicin, Triazinate)
INVESTIGATIONS
c) Adjuvant therapy: (chemotherapy after surgery)
* Purpose - to increase survival rate A Laboratory Investigations:
* Regimens which may be used - 5 ^ 1. Serum amylase - _
i) 5-Fluorouracil + Leucovorin > It is the first test to be advocated, although it is not specific for acute pancreatitis.
ii) 5-Fluorouracil + Adriamycin + Mitomycin C (FAM regime) V Usually serum amylase is increased upto 4 times its normal value oris > 1000 Somogyi units
iii) Cisplatin, Epirubicin, Adriamycin, Oxaliplatin, Capecitabine are other drugs us1
. in acute pancreatitis, although value of serum amylase does not correlate with the severity of
attack of acute pancreatitis.
4. Radiotherapy -
^ 2. Serum lipase - ,
i) No role.
r > More specific for acute pancreatitis.
ii) 45 Gray radiation + 5 Fluorouracil + Leucovorin- under trial
i > Its value does not correlate with the severity of attack of acute pancreatitis,
5. Palliative procedures - i 3. Amylase creatinine clearance ratio - .
i) Palliative partial gastrectomy - best method (Urine amylase/serum amylase) '(serum creatinine/urinary creatinine) * 100
ii) Palliative anterior gastrojejunostomy > A value > 6% indicates acute pancreatitis (Normal value is 1*4%)
iii) Devine's antral exclusion operation 4. Serum lactescence -
iv) SEMS (Self Expanding Metal Stents) > Most specific in hereditary hyperlipidemia or alcohol induced pancreatitis.
v) Laser recanalisation 5. Serum trypsin - Most accurate indicator of acute pancreatitis, yet rarely used.
vi) Palliative chemotherapy (FAM regime) for : 5- Tiypsinogen activator polypeptide (TAP) assay in serum and urine - It correlates with severity of
* Adherent to pancreas or colon or mesocolon attack of acute pancreatitis.
7. CRP - It is increased (> 150 U/L).
* Ascites
8. LDH, Phospholipase A2 levels
* Para-aortic lymph nodes
9- Urinary lipase level
* Secondaries in liver
^ 10- LFT, Blood urea, serum creatinine
* BJummershelf
^'11. Hematocrit, total leucocyte count, platelet count, coagulation profile
* Enlarged Virchow’s node
« *^2 . Blood glucose estimation - Hyperglycemia is revealed.
* Sister Maty Joseph nodule
•3 Serum calcium level - Hypocalcemia is seen.
* Irish node
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- I 249
QUFST : fl Comprehensi.'s 6 u & '«'> Surgery, OiihopecScs ti .'\tvw:fies;c*Kjy

, nroanoslic criteria in alcohol induced pancreatitis (N ongall stone pancreatitis)

14. Arterial p02 and pCOj levs! .••plinvuion (to assess pulmonary insch'ici'fncy)
flan5o r,s "
15. c a:i;r'neai tap fluid examiVm.inn High amylase and protein On admission'.
B. ,'lsc.fuloaksl i,iv 3s;lg r.iio n s: a) Age > 55 years
M TLC» 16000 /cmm
.
Plain X-ray abdomen -•
c) Blood sugar > 200mg%
> Distension of fransvers? c.rX- , rill: collapso cf (jesceiv.'^'i :$)■*• (Colon cui-off slum
ri lDH > 7000IUA.
r 'Sentinel loop' of dilated proximal small i:>owei
eJ AST > 250 IU/100 ml
t- viena! halo sign
> ^jr-fluid level in Ihs duoden'JiT , w hin lirst 48 hours :
а) sernm calcium < 8 mg%
!- Obliteration of psoas shadow^
> Ground glass appearance, . б) Rise in BUN > 5 mg%
2. Spiral C T ­ c) Fall in hematocrit > 10%
> CECT is the investigation of choice for acute pancreatitis. £ d) Pa02 < 60 mmHg
> (tis done after 72 hours iolook for fluid collections, edema, necrosis (non-enhancemenla^f e) Base deficit > 4 meq/L
> 30% or 3 cm), altered fat and faucial planes, bowel distension, rn&ssritanc edema n Fluid sequestration > 6 L
hemorrhage. Hanson's score more than or equal to 3 indicates Severe pancreatitis.
> CT guided aspiration may be done and fluid sent for Gram staining arid culture. t Glasgow Imrie prognostic criteria:
3. USG abdomen j A. On admission:
4. £US (Endoscopic ultrasound) - ' J j) Age > 55 years
^ . To soe necrosis, cateifiostionx ij) TLC > 15000/cmm
'<-■ To assess CBD. ’ \ iii) PaO? < 60mmHg ...........
5. MRI, W!HCP, fERCP - Usually not oo-u in Ihe acute phase. iv) Blood urea > 16 mmol/L (withno response lointravenous fluid administration)
S. Ciws! X-ray - To assess pleural effusion and ARDS. v) Blood sugar > 200 mg% (without anyhistory/ of diabetesmeMitus)
PROGNOSTICATION 3. Within first 48 hours:
j) Serum calcium < 2 mmol/L
Scoring systems to assess the prognosis; cf a patient of acute pancreaiii!;- &r<» trr. follows :
ii) Serum albumin < 3.2 g/dl
1. tialthzz&f C T scoring system :
iii) A ST/ALT>600U /L
o It is (he boat scoring system to prognosticate acute pancrealiiis. . iv) LDH > 600 U/L
(.• !i Mkss into account 2 things - (a) Pancreatic inflammation (b) Pwivjmalio necrosis S:ore more than or equal to 3 indicates Severe pancreatitis.
r - Norrnal pancreas - Score 0
Acufe Physiology and Chronic Health Evaluation (APACHE II) s c o re :
1 r In includes the following factors -
• Edomatcus pancreas OR Focal / diffuse enlanpriien! g? pa«ci«as •• Score I
* Age .
.u ancreauc j » Intrinsic changes i Miid peripancreatic inflammiV.'Oft • ctfore 2
inflsn;me!lon j * Heart rate
v Severe exlrapancreatic changes wilh single fiuio collection -• Score 3 * Mean arterial pressure
» Multiple o.trap-mc.'catic collections OR gas Cut.! . ii in ci adjacent lo * Rectal temperature
pancreas - Score -i * Pa02
■ Arterial pH
r « Normal pancreas - Score 0 * Hematocrit
I
* Total leucocyte count
Penereatic | ' Mecrosis Less than or eriua! to 30% - Scots 2
* Serum sodium
necrosis • Mecrosis 30-50% - t»-orc- 4
* Serum potassium
1 Necrosis > 50% • Score 6 * Serum creatinine
1 Glasgow coma scale score
C ? ; s v * n t y in c fe s - , APACHE II - Modification (1996): LFT has beenadded lo. gallstone induced p u v M
> 0-3 • Normal pancreas/ Mil. ;.-*-!cmaiitis «- APACHE-0 - Obesity has been added
>■ • Moderate pancreatic - Score more than or equal to 8 indicates severe pancreatitis with11-18% mortal.!/ risk
i- 7-10 - Sever? pancreatitis
 250 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS 0 Paper-I 251

MANAGEMENT

A. Conservative treatm ent: • 1. Open surgery/ Laparotomy (Gold standard for infected pancreatic necrosis)
1. Rehydration - ■ j) Conventional closed method
> @ 250-400 ml/hour. a) Laparotomy + Necrosectomy (all necrotic tissue removed) + Wide debdridement
(pus, infected fluid, toxins are also removed) + Saline wash with 10-12 L of normal
> Done to compensate for 3rd space fluid loss.
saline + Adequate drainage + Cholecystectomy + Closure of abdomen in layers.
> Done with NS, DNS, RL, Whole blood or concentrated RBC (packed cell) transfusion. |
b) Re-laparotomy is done late only on demand.
> In severe hemorrhagic pancreatitis, Iresh frozen plasma and platelet concentrate m ay^j
ii) Open method
be required.
a) Laparotomy + Necrosectomy + Wide debridement + Wash + Wide packing + Wound
> Urine output @ 30ml/hour to be maintained. Urinary calheterisation is to be done. left open.
2. Pain relief - by pethidine b) Repeated wash and packings are done until healthy granulation tissue develops.
3. Nasogastric aspiration iii) Semi-open method
4. Moist oxygen inhalation, Nebulisation with bronchodilators * Laparotomy + Necrosectomy + Abdominal closure with drainage + Re-laparotomy
5. Endotracheal intubation, ventilatory support, tracheostomy may have to be done on an emerge^ later on.
basis when required. Hemodialysis is required in case of renal failure. iv) Bradley's repeated laparotomies and wash
* Zip technique is used to give repeated wash to remove necrotic tissues and toxins
6. Central venous line is to be done and CVP lo be monitored (with Swan-Ganz catheter)
until healthy granulation tissue develops on the pancreatic bed.
7. Proper electrolyte management with monitoring
2. Beger’s lavage
8. Antibiotics - j * Initial surgical debridement + Continuous closed peritoneal lavage of the pancreatic bed
> Third generation cephalosporins (Ceftazidime, cefotaxime), Imipenem. Meropenem are usmj and lesser sac (with 10-12 L of normal saline OR hyperosmolar potassium free dialysate
> Indications: fluid ©2L/hour)
* Severe infected necrosis with proved culture * Multiple tubes are used for lavage to remove the toxic material in the peritoneal cavity/
retroperitoneal area until return fluid becomes clear.
* Pancreatic abscess formation
3. Extra peritoneal lavage
* Clinically rapidly progressive disease with deterioration
* Done through bilateral flank incisions.
* Prophylactically in severe pancreatitis * Blind procedure.
9. Total parenteral nutrition (TPN) using carbohydrate, amino acids, vitamins, minor elements * Efficacy not established.
10. Intravenous Ranitidine (50mg) 6 hourly / Pantoprazole (80mg) 12 hourly I Omeprazole (40irg| 4. Laparoscopic surgery
12 hourly to prevent stress ulcers and erosive bleeding. .' * Necrosectomy + Wash + Drainage
11. Calcium gluconate (10%) 10 ml i.v. 8 hourly (to prevent hypocalcemia). 5. Endoscopic necrosectomy
12. Octreotide (Intravenous : 50 microgram loading dose followed by 50 microgram in 5% dexttosf 6. Jejunostomy
hourly) OR Somatostatin - to reduce pancreatic secretion. * Can be done as an add-on procedure along with any of the above mentioned procedures.
13. Dopamine OR low molecular weight Dextran - to improve renal perfusion. * Helps to achieve early enteral nutrition.
7. Further management to prevent recurrence (in a case of gall stone induced pancreatitis)
14. Steroid injection -
i) Laparoscopic cholecystectomy
r Useful in the initial period of shock.
(a) To be done 2 weeks after the acute attack of pancreatitis.
V Given in pulmonary insufficiency and ARDS. ii) Endoscopic sphincterotomy (ERCP) and stenting if needed
15. Protease inhibitors (Aprotinin, Antisnake venom, EACA), Anticholinergics (to reduce pressured
Management o f complications o f acute pancreatitis :
sphincter of Oddi), Calcitonin
16. Nasojejunal tube placement and feeding - a) Acute pseudocyst - Percutaneous removal under Ultrasound or CT guidance or through an
endoscope
> To be started as early as possible once ileus subsides. ;
b) Pancreatic necrosis­
> During recovery period, it reduces infection rale (by transmucosal migration of bacteria) a*
> Laparotomy + Debridement + Adequate drainage + Continuous lavage.
improves nutritional status.
V Repeal laparotomies may have to be done once is 3 days.
B. Surgery (10-30% cases): c) Pancreatic abscess - Antibiotics + Percutaneous US or CT guided aspiration / Open drainage
• Indications lor surgical intervention:
d) Pancreatic fistula - If persists for > 6 months, then Spincterotomy + Reseclion of fistula with
pancreatic resection + Pancreaticojejunostomy is done.
a) Palienl is non responsive to conservative treatment
e) Respiratory complications (Pancreatic pleural effusion, ARDS) - Patient may neeo ventilatory
b) Formation of pancreatic abscess or infected necrosis support
c) In severe necrotising pancreatitis, in a trial to save life of the patient D Systemic failure, MODS
 SOLVI:.t) LONG QUESTIONS OF SEMESTERS D Paper-ll 253
, SEGMENT - B
SOLVED LONG QUESTIONS OF7 SEMESTERS in this particular dh ica l svznario, as the present has presented with ipsilateral lymphadenoDathv rho
provisional diagnosis of :hvro,d neoplasm (Papillary CA/ Follicular CA/ Hurthle cell CA/ M e d la r!
Paper - II CA) seems to ba mere relevant. weauiiary

] Investigations: .
Of. A 20 yrs old actress has presented with a small goiter Involving rig ht lobe and ipsilaterai
1. Thyroid function te .i - TSH. Free T4 (to detect hyperthyroWsm)
lymphadenopathy. How w ill you establish a diagnosis ? Discuss the surgical management and
complications. [3 + 6+6] >- Serum Thyroi'J-StimuSating Hormone (Normal 0.5-5 micro lU/mL)
02. A 70 yrs old male patient complains o f inability to pass urine for past 8 hrs. How w ill you differentiate > . otal T* (Reference Range 55-150 nmol/L) and T3 (Reference Range 1.5-3.5 nmoW.)
this from anuria? Outline the subsequent management o f the case. [5 + 1&] > Free T„ (Reference Range 12-28 pmol/L) and Free T3 (3-9 pmoI/L)
Q3. What are the common surgical causes o f hematuria? Discuss the diagnosis and management of OUt,lyroid With normal TSH an<*»°»-normal or normal free Ti levels If
hematuria due to carcinoma o f urinary bladder. [4 + 4 +7] some nodules dG-elop autonomy, suppressed TSH levels or hyperthyroidism
Toxic nodule - Free T4 - very high, TSH - low or undetectable
04, A 48 yrs old female presen ted with a 4 cm lump in Right breast. Discuss the D/D and diagnostic
approach to the condition. [7+sj

SOLUTIONS > To kfcmwy impalpable nodules (< 2-3 mm in diameter)

01. A 20 yrs old actress has presented with a small goiter involving rig h t lobe and Ipsllaterai > Gives Information about size and multicentricity,
lymphadenopathy. How w ill you establish a diagnosis ? Discuss the surgical management anti r Distinguishes solid from cystic lesion
complications. [3+6+6] > To guide FNAC
*■ To assess for cervical lymphadenopathy.
• SMALL GOITER IN A 20 YEARS OLD FEMALE
> Colour Doppler USG helps In visualisation of small vessels within the gland
□ Diagnosis: The 20 yrs old female has presented with a solitary thyroid nodule. II may be toxic (3-5%) | 4. CT/MRI­
or non-toxic.
> To evaluate Retrosternal extensions.
• Causes/Differential diagnoses : r To assess for lymphadenopathy
i) Toxic nodule (single I one palpable nodule of a multinoduiar goiter) [most common] f *• To detect impalpable nodules
ii) Thyroid adenomas (Follicular, Hurthle ceil type) - 20% 5. FNAC-
iii) Papillary carcinoma of thyroid - 20% ' f
iv) Thyroid cyst-1 0 % V ~ d6d ^ Patien'S Wh° haV6 3 d0m'nanl nodu,e or ° " e « « « Painful or
v) Medullary carcinoma of thyroid
• Solitary thyroid nodule may present with the following features : * m eduta'S C0" ° id n° dU'e' ,hyr° ldi'iS’ 'hyr° id CySt' ,hyroid cafc'n0ma ( W * *
\
>
i) Swelling In the anterior aspect of lower part of neck, which moves with deglutition I Cant differentiate between follicular adenoma and adenocarcinoma
and doesnot move with protrusion of tongue Most experts have recommended 3-6 aspiration per nodule. Satisfactory soecimen
ii) Tracheal deviation towards opposite side is common (Trail's sign. Two linger test) j cojitams atleasl 5-6 groups ot cells, each group*containingiS S S S H S
iii) History and clinical features suggestive of malignancy -
* Nodule in extremes of age group (child I > 60 yrs aged)
* Nodule in a male patient
True cut biopsy -
* History ol radiation on neck i
* Family history of papillary/medullary CA of thyroid r For diagnosis of carcinoma mainly- unresectable tumor, anaplastic CA lymphoma
* Hoarseness of voice/stridor/dyspnea/dysphagia r "nodule
' . ii“- Toxic
,ope used - 1,23 ina’ » • - ■
' ! -'3 m « » »
r Hot”
* Irregular surface with firm consistency
> "Warm" nodule - Euthyroid (Non toxic);
* Fixity to surrounding structure
* Rapid onset/ recent rapid growth in size ; (Malignancy)9 TC" bU' ^ M RAI sca" ' O'scordant nodule
* Pain in the swelling
- “ Cold” nodule - 20% malignant. 80% benign —'
* Palpable lymph node Power Doppler -
> To know vascularity of the gland
252
- Resistive index > 0.7 (N = 0.65 - 0.7) indicates malignancy
254 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-II 255

9. Indirect laryngoscopy - To assess vocal cord movements prior to surgery (mainly Toxic nodule -
documentation and medicolegal purpose).
10. E C G - To detect cardiac abnormalities
11. Baseline investigations -
> Complete hemogram : Hb%, TC, DC, ESR
> Blood for sugar, urea and creatinine
V Urine and stool routine examination
□ Management; Indications for surgery in solitary nodule of thyroid
i) Malignant nodule/ Nodule suspicious of malignancy
ii) Follicular neoplasm
iii) Nodule with obstructive symptoms
iv) Toxic nodule in children
v) Complex cyst
vi) Cosmetically bothersome nodule
Treatment options:
• Thyroid neoplasms - -

Thyroid cysts -
> Cyst > 4 cm in size
> Complex cyst (Cyst containing both solid and cystic areas) Surgery indicated
> Recurrent thyroid cyst .

• Colloid nodule -
Oral levo-thyroxine
i
Therapy failed- Progressive enlargement/ recurrent nodule
" I
Hemithyroidectomy
* Hemithyroidectomy - Lobectomy (unilateral) + Isthmusectomy
** Antithyroid drugs -
• initially given to make patient euthyroid before surgery
• Carbimazole lOmg 6-8 hrly - Euthyroid state may be achieved by 6-8 wks
• Propranolol 20-40 mg BD/TDS - To ameliorate cadiovascular symptoms
• Lugol’s iodine 10-30 drops/day for 10 days prior to surgery - To reduce vascularity of gland
**' Near total thyroidectomy-< 2 g of thyroid thyroid tissue is kept only to preserve parathyroid
glands, near lower pole on one or both sides.

Complications o f surgical management:

a) Transient hypocalcemia -
> Seen in almost 50% cases.
*- Occurs due to surgical injury to or inadvertent removal of parathyroid tissue.
*• More likely in patients who have undergone thyroidectomy with central and lateral
• Non-toxic nodule - Hemithyroidectomy (Unilateral lobectomy+isthmusectomy) neck dissection.
 256 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper - II

> Rapid influx ol serum calcium into hcnes i:> the immediate post operative p e ^ , Differentiation between anuria and retention of urine
cause severe hypocalcemia (known as Hungry gone syndrome)- corrected r '
calcium gluconate 10% 10 ml.. ' 1 j History:
t Urge of micturition is present (strong) - Acute retention of urine
b) Permanent hypoparathyroidism - ,
• Urge of micturition is absent - Anuria
r Occurs in < 2% cases.
-j clinical examination:
c) Injury to oxlem al branches of superior laryngeal neivv -
(a) Inspection- .
> Approximately 20% patients are at risk for this injury.
r Leads to alteration in pitch of voice due to weakness of cricothyroid muscle. > Distended hypogastrium (suggestive of full bladder) - Acute retention of urine
> Hypogastrium is not distended - Anuria
r Occurs ivhen vessels at the superior pole ol thyroid are ligated en masse.
(b) Palpation-
d) Injury to Reccurrent Laryngeal Nerve - .
> Urinary bladder is palpable - Acute retention of urine
i- Occurs in < 1% of patients.
> Urinary bladder is not palpable - Anuria
*■ Can occur by traction, ligation or severance.
(c) Percussion -
*• Most commonly occurs in the Iasi 2-3 cm of the course of RLN.
> Dull note over hypogastrium - Acute retention of urine
^ If recognised intraoperatively, primary re-approximation of perineurium &
nonabsorbable sutures is often advocated. > Normal/ tympanitic note over hypogastrium - Anuria
<- If uricorrected, patient presents with hoarseness of voice, aphonia. 3 Intervention:
* Usually recovet in 3 weaks to 3 months. May require steroid supplement andsps On introduction of urinary catheter-
therapy. * Free flow of urine - Acute retention of urine
s) injury to cervical sympathetic trunk - • NoI little flow of urine - Anuria
r Way occur in invasive thyroid carcinomas and retropharyngeal goiters.
MANAGEMENT OF ACUTE RETENTION OF URINE
> May lead to Horner’s syndrome.
I) Injury to surrounding structures (carotid artery, jugular vein, esophagus) -
1 Diagnosis of the cause of acute retention of urine

a) Bilateral vocai cord dysfunction - Causes of acute retention of urine;

r Laryngeal edema is there, may be duo to ber.atoma. A. Bladder outlet obstruction due to -
» Airv/ay is compromised. r Benign prostatic hyperplasia (BPH)
r Requires immediate reintubaiion and olten tracheostomy. r Prostate CA
h) Postoperative hematoma or hemorrhage - *• Prostatic abscess or acute prostatitis *
<- May be due to slippage of ligatures of either stjperioi thyroid aitery or small m > Bladder CA
other pcdic'es. r Bladder neck fibrosis
.- Severe stridor and respiratory distress may be caused by tension hematomat. 8. Urethral causes -
strap muscles. i > Stricture
r May sometimes require emergency reoperaHon for release of sutures and ewes. S' Calculus
of hemaiorna. > Tumor
i) Seroma - *■ Rupture of the urethra
'r May need aspiration. *• Phimosis
j) Worutd OsPuUHS trid i,n/ecli<V' - y Meatal stenosis
C Drugs -
02. A 70yrs old male p i'tio ii! complains o f inability to pars ivinefoi psslShrs. How vjili you ifiite* y Anticholinergics
this from anuria? Outline the subsequent management o f the case. P'
' Antihypertensives
> Tricyclic antidepressants (TCA)
IN ABILITY TO PASS URINE FOR PAST P HRS IN A 70 Y n S O LD MALE j
D Miscellaneous -
This given cli'ical piclu-e a 70 yrs old male patten;, unatle to M r,; wins for the pasl8r‘| ' Neurogenic (Injury or disease of spinal cord)
suggestive of "Acute intention of urine” . " following spinal anesthesia
 258 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- II 259

> Smooth muscle cell dysfunction associated with ageing measures to relieve acute retention of urine:
> Fecal impaction ‘ dnservative m easures:
> Anal pain (following hemorrhoidectomy) , Reassurance
> Intensive postoperative analgesic therapy , provision of privacy
□ History : , Sound of a running tap
1. Onset and duration of retention of urine - to confirm whether the retention is acute or , Application of warmth and cold alternatively on the lower abdomen
chronic Ulet- . Warm bath
2. History of Lower urina ry tract symptoms (LUTS) - , urinary catheterisation:
Symptoms of voiding: Hestitancy, Poor flow (unimproved on straining), intermittent sir " , Done when conservative measures fail to relieve the retention.
dribbling, sense of incomplete bladder emptying , Done with proper aseptic precautions.
Symptoms of storage: Frequency, urgency, urge incontinence, nocturia, nocturnal enw* . Usually a fine Foley's catheter is introduced. If it fails, a Gibbon's catheter introduction may be
3. H/O fever with passage of turbid urine - seen In acute prostatitis attempted.
4. H/O fever with severe unremitting perineal pain - seen in prostatic abscess ( Following catheterisation -
5. H/O hematuria - seen in BPH, prostate CA, bladder CA, urethral calculus, urethral w > Volume of urine drained is to be recorded.
rupture of urethra > Re-examination of abdomen to exclude other pathology (rupture of aortic aneurysm,
6. H/O trauma to pelvis, urethral instrumentation - seen in urethral stricture diverticulitis etc)
7. Any H/O operation in perianal region 3 Suprapubic cystostomy:
8. H/O weakness of limbs - seen in neurologic causes » Done when catheterisation fails to relieve the retention or when catheterisation could not be
9. Any H/O spinal anesthesia done.
• It can be done by -
10. H/O drug intake - anticholinergics, antihypertensives, TCA
a) Placement of commercially available Cystofix catheter using large bore needle
11. H/O systemic symptoms of underlying malignancy (recent significant weight loss, anorea'
asthenia, bone pain etc) - seen in Prostate CA, bladder CA t» Placement of Lawrence Add-a-Cath catheter using plastic suprapubic trocar and
cannula
□ Clinical examination: Placement of Foley's catheter under direct vision through a small incision using local
c)
A. General surve y-T o look for: ? anaesthetic
> Pallor - seen in malignancy (prostate CA, bladder CA) * • It is the procedure of choice in acute retention of urine due to traumatic rupture of urethra.
> Temperature - elevated in acute prostatitis, prostate abscess II. Special Investigations for Definitive Diagnosis of the cause:
> Dehydration i A. For evaluation o f prostate -
> Hypertension 1. Serum Prostate specific antigen (PSA) level (Normal = < 4ng/mL)
> Features of uraemia (e.g. hemorrhagic spots) 2. Serum acid phosphatase enzyme *
> Perianal sensation - to exclude neurologic cause 3. International Prostate Symptom Score (IPSS) —'
B. Abdominal examination : i
^ 4. Uroflowmetry': £
> Lump in abdomen - distended bladder
> Normal voided volume - >150mL
> Tenderness at renal angle, hypogastrium
> Normal Maximum flow - >10mL/sec
C. Examination of external genitalia : i
> Normal average flow - <10mL/sec
> To exclude phimosis, meatal stenosis
5. USG of KUB region - Post Void Residual
> Palpation of urethra - to exclude urethral calculus, urethral tumor
6. Urodynamic study - voiding pressure, residual volume
D. P/R examination: :
7. Transrectal USG - To assess the size of prostate
> Enlarged, smooth prostate with free overlying rectal mucosa - seen in BPH
■ For evaluation o f bladder and urethra -
'*■ Hard, irregular prostate with fixed overlying rectal mucosa- seen inprostate CA j
I- Micturating cystourethrography (MCU) - to diagnose urethral stricture
> Tender prostate - seen in acute prostatitis, prostatic abscess
2. Cystoscopy - for direct visualisation of bladder wall (to diagnose bladder CA) -
Investigations required for a definitive diagnosis of the cause of acute retention of urine are to be dtfj
only after relief of acute retention. ; 3. Cystography - a component ol video-urodynamic assessment
 260 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-ll 261

, Adverse effects -
IV. Definitive Treatment According to the cause:
a) Floppy iris syndrome
A. BPH -
b) Postural hypotension
Q IPSS:
c) Retrograde/ dry ejaculation
• International Prostate Symptom Score / American Urologic Association Score
d) Flushing
• 7 questions regarding symptoms in the past month
2 5 alpha reductase inhibitors -
• (1) Incomplete emptying (2) Frquency (3) Intermittency (4) Urgency (5) Weak
, Act on static component - Inhibit conversion of testosterone to DHT
Straining (7) Nocturia
• Effective in palpable enlarged prostate
• Maximum score - 7*5= 35
, Drugs used -
• Mild symptoms - Score Less than or equal to 7
> Finasteride - 5mg daily for 6-8 months
• Moderate symptoms - Score 8-19
> Dutasteride - 0.5 mg daily
• Severe symptoms - Score 20-35
3 Anticholinergics -
□ Medical treatm ent:
• Drugs used:
V Tolterodine - 2-4 mg
> Solifenacin - 5-10 mg
I; > Darifenacin - 7.5-15 mg
i
!; 4 phosphodiesterase 5 inhibitors -
• Drugs used:

|
$
>
>
Sildenafil
Tadalafil
> Vardenafil

Surgical treatment:
• Indications of surgery - ’
1) Prostatism (frequency, dysuria, urgency)
2) Acute retention of urine
3) Refractory/ chronic urinary retention with residual urine >200ml
4) Recurrent UTI
5) Recurrent hematuria
6) Bladder stone
7) Bladder diverticula
8) Hydroureter, Hydronephrosis
Minimal Invasive Therapy -
Transurethral resection of prostate (TURP)
1. Alpha 1 adrenergic blockers -
• Act on dynamic component - Inhibit contraction of smooth muscle of prostate possible*1m° n 3nd P° PUlaf me,hod as quicker recovery and early discharge are
• Reduce bladder neck resistance thereby improving urine /low
* No suprapubic incision is needed
• Short acting drugs - Prazosin, Indoramin
• Long acting drugs - Terazosin, Doxazosin ,* Done usin9 resecloscope with high frequency diathermy current
• Selective Alpha 1A receptor blocker - * Continuous postoperative irrigation with glycine solution is needed for 72 hours
Holmium LASER enucleation of prostate (HOLEP)
> Tamsulosin - 0.4-0.8 mg daily for 12 weeks
Trans urethral needle ablation (TUNA) using high frequency radiowaves
> Affuzosin - 10mg daily
Trans urethral vaporisation (TUVP)
> Silozosin - 4-8mg daily
Trans urethral Microwave therapy (TUMT)
• Selective Alpha 1D receptor blocker -
Trans urethral incision of prostate (TUIP)
Naftodipil improves nocturia (25-75 mg daily)
 SOLVED LONG QUESTIONS OF SEMESTERS □ Paper- I I 263
262 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

, Urethral .trlcture -
> Trans urethral balloon dilatation of prostate
1 intermittent urethral dilatation —
> Prosthetic stents (Intraurethral / extraurethral)
---------? GraSuafdilatation, initially with thin dilators, later with dilators of increasing thickness,
> High intensity ultrasound energy therapy in OT under proper aseptic precautions
> Water induced thermotherapy 2 Visual internal cystoscopic urethrotomy/ stricturotomy
• Surgery - v Using cystoscope, stricture is visualised and fibrous tissue is completely cut at 12 o'
1) Millin's retropubic prostatectomy clock position until it bleeds.
* Not commonly practiced > Then Foley’s catheter is passed and retained in position for 48 hrs.
* Done without opening of bladder 3. External urethrotomy
2) Young's perineal open prostatectomy 4. U rethroplasty^
3) Freyer's suprapubic transvesical open prostatectomy “ V Stricture is excised.
* It was the procedure of choice for enlarged prostata before the advent ofTifc > Urethra is reconstructed using prepuceal or scrotal skin.
* Indication : Bladder pathology + Largemedian lobe
0 Bladder C A -
. Complications of surgical procedures -
□ for nonln vaslve bladder tum or:
> Water intoxication with congestive cardiac failure - TURP syndrome
> Retrograde ejaculation • 65% 1. Endoscopic resection of bladder tumor
> Recurrent late UTI - 20% 2." Helmstein balloon degeneration and cystoscopic resection­
> Need for re-TURP/ Surgery In 10 years -15% > Done for large papillary tumor
> Failure/ Recurrence of symptoms -10%
>• Severe sepsis • 6%
> Erectile dysfunction - 5%
> Postoperative hematuria
> Perforation of bladder or prostatic capsule [
I 3. Intravesical chemotherapy:
B. Prostate CA -
> Used especially for carcinoma in situ
1. Wait and watch policy is ideally advocated in an elderly male (more-than or equal to70jn|
> BCG is mostly used.
age) with early carcinoma.
> Dose -1 2 0 mg of BCG in 150 ml of normal saline weekly for six weeks
2. Radical prostatectomy (removal of prostate, seminal vesicle, distal sphincter with reconshudrj
> A/E - BCG provocation (fever, joint pain, granulomatous prostatitis, disseminated
of urethra) :
tuberculosis)
> Done in early disease (T1 a or T1 b)
> Contraindication - hematuria
> Indications: (I) Life expectancy >10 yrs (ii) PSA < 20 mmol/mL (iii) Bone scan ntjt
> Mitomycin C. adriamycin, epirubicin, metrotrexate, thiotepa can also be used.
3. Bilateral subcapsufar orchidectomy- can be done to reduce testosterone level
4. Systemic chemotherapy:
4. Transurethral resection of prostate (TURP)
> Cisplatin, Adriamycin, 5-FU and mitomycin are used.
5. Radical radiotherapy :
> Given for early carcinoma Q For Invasive bladder tum or:
> Both interstitial and external radiation can be used j 1- Radiotherapy
6. Pelvic lymph node dissection with 1125 radiation seeds implantation a) Interstitial radiotherapy
7. External radiotherapy/ Strontium 89 isotope radiotherapy- for bone secondaries V Often curative.
8. Drugs: > Implantation of radioactive gold grains (Au 198, half-life = 2.5 days) / radioactive
> Phosphorylated diethylstilbestrol (Honovan) = tantalum wires (Ta 182, half-life = 4 months) is done.
> LHRH agonists (Leuprolide, Goserelin) b) Radical deep external beam radiotherapy
> Androgen receptor blocker (Flutamide, Bicalutamide) > Dose - 45 Gy
> Cyproterone acetate .. > Cobalt 60 is used
9. TURP + Bilateral orchidectomy + External radiotherapy (for bone secondaries) + Fluia"1 > Advantage - Normal act of micturition can be maintained
Honovan - commonly used method > Complication - Thimble/Systolic bladder
 264 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ P apei-ll 265

2. Surgery Ureter cause:

• Indications - j Ureteric stone
> Multiple tumors 2, Tumor
. > Recurrent tumors
gladder cause :
> Sessile tumors
\ Cystitis
> Poorly differentiated tumors
2. Tumor - Papilloma, Urothelial cell CA
> Adenocarcinoma
3. Tuberculosis
> Squamous cell carcinoma
4. Vesical calculus
> Carcinoma in situ
5. Urinary Bilharziasis
• Modalities -
a) Partial cystectomy: Urethra cause :
* Indication - single tumor, tumor confined to fundus of bladder 1. Trauma
* 2.5 cm margin of clearance is maintained 2. Stone
* Surgery is followed by external beam radiotherapy and chemotherapy. 3. Tumor
b) Radical cystectomy - Prostate cause :
* Removal of urinary bladder, urethra, paravesical tissues, pelvic lymph nodejj t. Benign prostatic hyperplasia (BPH)
done. Hysterectomy with removal of part of vagina is done in females. 2. Prostate CA
* Urinary diversion is done by ureterosigmoidostomy or continent ileal condiAo
rectal urinary pouch. HEMATURIA DUE TO CARCINOMA OF URINARY BLADDER
3. Chemo^prapy-
a) Intravesical chemotherapy - Diagnosis:
> Done by BCG, mitomycin C, adriamycin, interferons. History -
b) Systemic chemotherapy - 1. Evaluation of gross hematuria :
> Regimen for adjuvant therapy - (i) Cisplatin, adriamycin, mitomycin, vinblash > Colour of urine - bright red
(ii) Methotrexate, vinblastin, adriamycin, cisplatin (MVAC) * > Pattern of hematuria - Hematuria in the latter part of voiding
> Neoadjuvant chemotherapy - Cisplatin is used (improves survival by 7%) 2. Associated features:
> Hematuria is painless
03. What are the common surgical causes o f hematuria ? Discuss the diagnosis and management
> Symptoms suggestive of Lower urinary tract symptoms (LUTS)/ bladder outlet
hematuria due to carcinoma o f urinary bladder. [4 + 4+7]
obstruction (Hesitancy, urgency, frequency, poor stream of urine, dribbling,
inadequate emptying)- present
COMMON SURGICAL CAUSES OF HEMATURIA
3. Occupational history: .
Hematuria is defined as abnormal presence of RBCs in urine. > Aniline dye factory workers
It is ol 2 types: (1) gross (2) microscopic (> 5 RBC/hpf) B. General examination -
The common surgical causes of hematuria are as follows - j • Pallor-present
I
A. Kidney cause: C. Systemic examination
1. Tumors - Wilm’s tumor, Renal cell carcinoma (RCC) 0. Investigations -
2. Trauma - Stab/ Blunt injury f 1. Urine examination -
3. Renal vascular disorders - Renal vein thrombosis, Renal artery embolism, Renal aneuiys>i a) Routine examination:
Arterio-venous fistula * Specific gravity
4. Infections - Pyelonephritis, Tubufo-interstitial nephritis
* Protein
5. Anatomical abnormalities - Polycystic kidney disease, Multicystic renal diseass
* Sugar
Hydronephrosis
* Blood
6. Kidney stone
* Ketone
7 Kidney TB

l 3(
 266 QUEST ; A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-ll 267

b) Microscopic examination:
* Implantation of radioactive gold grains (Au 193, half-life = 2.5 days) / radioactive
* Phase contrast microscopy - to detect dysmorphic RBC tantalum wires (Ta 182,half-life = 4 months) is done.
* Exfoliative cytology (by Papanicolau staining) - for malignant cells b) Radical deep external beam radiotherapy
2. Blood profiles - * Dose - 45 Gy
a) Complete hemogram * Cobalt 60 is used
b) Serum urea, creatinine * Advantage - Normal act of micturition can be maintained
c) Serum electrolytes * Complication - Thimble/Systolic bladder
3. Radiological investigations -
2. Surgery
a) Intravenous urethrography (IVU): y Indications -
* Irregular Filling defects in bladder * Multiple tumors
* Hydronephrosis (often) * Recurrent tumors
b) USG of abdomen: * Sessile tumors
* To see bladder wall, pelvis, lymph nodes, liver * Poorly differentiated tumors .
c) CT scan - to evaluate the extension ' . * Adenocarcinoma
d) MR! - to see invasion into pelvic wall * Squamous cell carcinoma
e) Cystoscopy: * Carcinoma in situ
* may be followed by brush biopsy. > Modalities -
* bladder tumor is visualised. a) Partial cystectomy:
0 Retrograde pyelography ❖ Indication - single tumor, tumor confined to fundus of bladder
4. Bimanual examination under General anesthesia - for staging of the tumor ❖ 2.5 cm margin of clearance is maintained
□ Management: •> Surgery is followed by external beam radiotherapy and chemolherapy.
A. For noninvasive bladder tumor b) Radical cystectomy:
1. Endoscopic resection of bladder tumor ❖ Removal of urinary bladder, urethra, paravesical tissues, pelvic lymph nodes
2. Helmstein balloon degeneration and cystoscopic resection - is done. Hysterectomy with removal of part of vagina is done in females.
❖ Urinary diversio n is done by ureterosigmoidostomy or continent ileal conduit
V- Done for large papillary tumor
or rectal urinary pouch.
3. Chemotherapy
a) Intravesical chemotherapy -
* Done by BCG, mitomycin C, adriamycin, interferons.
b) Systemic chemotherapy -
3. Intravesical chemotherapy - * Regimen for adjuvant therapy : (i) Cisplatin, adriamycin, mitomycin, vinblaslin
> Used especially for carcinoma in situ (ii) Methotrexate, vinblastin, adriamycin, cisplatin (MVAC)
> BCG is mostly used. * Neoadjuvant chemotherapy : Cisplatin is used (improves survival by 7%)
> Dose -1 2 0 mg of BCG in 150 ml of normal saline weekly for six weeks ;
04. A 48 yrs old female presented with a 4 cm lump In Right breast. Discuss the D/D and diagnostic
> A/E - BCG provocation (lever, joint pain, granulomatous prostatitis, disseminate approach to the condition. [7 + 8]
tuberculosis) j
> Contraindication - hematuria ,f BREAST LUMP IN A 48 YEARS OLD FEMALE
> Mitomycin C, adriamycin, epirubicin, metrotrexale, thiotepa can also be used. i. Causes : .
4. Systemic chemotherapy - ^t,e Probable causes of a breast lump (4 cm in size) in a female of this age group are :
> Cisplatin, Adriamycin, 5-FU and mitomycin are used.
1. Ductal carcinoma
B. For invasive bladder tumor 2. Lobular carcinoma
1. Radiotherapy 3 Phyllodes tumor
a) Interstitial radiotherapy 4. Fibroadenoma
* Oftencurative. 5 Sclerosing adenosis / Aberration of normal development and involution (AND!)
 266 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-II 269

6. Traumatic tat necrosis

EXAMINATION OF BREAST
7. Intramammary mastitis/ Non-lactational abscess of breast
8. Antibioma (a) Inspection:
9. Duct ectasia , peau d' orange, dimpling of skin, retraction of nipple, ulceration, fungation, satellite nodules
- Breast carcinoma
10. Tuberculosis of the breast
. Stretched red breast skin with dilated veins and necrosis over the summit of the swelling
11. Breast cyst
_ Phyllodes tumor
Keeping the above mentioned differential diagnoses in mind, the case is to be approached through
proper history taking, clinical examination and relevant investigations. . Diffuse redness over breast - Non-lactational abscess of breast
• Slit like retraction of nipple - Duct ectasia
H isto ry:
• Peau d’ orange, sinus, discharge, bluish appearance of surrounding skin - Tuberculosis of
1. Onset, duration and progression of the lum p: the breast
> Rapid growth to attain a large size - Phyl lodes tumor
(b) Palpation:
> Non-progressive non-regressive lump - Traumatic fat necrosis
, Smooth, firm, non-tender, well localised mass that moves freely within the breast -
2. Whether painful or painless : Fibroadenoma, Sclerosing adenosis
V Painful lump - Duct ectasia, Non-lactational abscess of breast • Smooth, soft, non-tender, fluctuant mass - Phyllodes tumor, Breast cyst
> Mastalgia - may be present in Sclerosing adenosis « Smooth, hard, non-tender mass adherent to breast tissue - Traumatic fat necrosis, Antibioma
3. Any swelling in the axilla or opposite breast: ■ • Mass with diffuse tenderness, warmness, brawny induration - Non-lactational abscess of
V Axillary lymph node enlargement - Breast carcinoma (Ductal/lobular). TuberculosB breast
of the breast • Indurated, tender mass under areola - Duct ectasia
* > B/L breast lump - Lobular carcinoma, Duct ectasia, Breast cyst
• Irregular ill-defined mass with ipsilateral lymph node enlargement - Breast carcinoma,
4. Any history o f nipple discharge: Tuberculosis of the breast
> Bloody discharge - Breast carcinoma
C. SYSTEMIC EXAMINATION
> Purulent discharge - Non-lactational abscess of breast
(a) Abdominal examination:
> Greenish/ creamy paste like discharge - Duct ectasia
• To look for secondaries in liver, ascites, Krukenberg’s tumor, deposits in rectouterine pouch-
5. Associated symptoms:
if present, suggestive of Breast carcinoma
> Weight loss, anorexia, bone pain, chest pain, cough, hemoptysis - Suggestive ol
(b) Respiratory system examination :
underlying malignancy (Breast carcinoma)
> Abdominal pain, abdominal swelling - Suggestive of distant metastasis (Breast • Pleural effusion - if present, suggestive of Breast carcinoma
carcinoma) (e) Musculoskeletal system examination:
> Recurrent cough, hemoptysis - Tuberculosis of the breast • Bony tenderness (in spine, long bones, skull) - if present, suggestive of Breast carcinoma
6. Past history: (d) Cardiovascular system examination .
> H/O trauma - Traumatic fat necrosis (e) Nervous system examination
> H/O mastitis treated with antibiotics - Antibioma Investigations:
> H/O use of Hormone replacement therapy (HRT) - Breast carcinoma, Breast cyst
I RADIOLOGICAL IMAGING -
7. Family history:
• First investigation to be done is always a radiological imaging, a s :
> H/O breast carcinoma or ovarian carcinoma in first degree relative - Breast carcinoma
y These are non-invasive investigations.
'8. Menstrual history:
> FNAC/ Open biopsy, if done first, may cause hematoma, which will alter thefindings on
V Early menarche or late menopause - Breast carcinoma
imaging.
9. Obstetric history:
• Mammography:
> Nulliparity, late first child birth (> 35 years), no breastfeeding - Breast carcinoma
*■ Done in females > 40 years of age.
Examination: indications -
A. GENERAL SURVERY 1. To evaluate suspicious breast tump, nipple discharge.
• Pallor - seen in Breast carcinoma 2- To identify multicentricity, to know size and location of the masses.
• Temperature - High grade fever is seen in Non-lactational abscess of breast 3. To screen contralateral breast for additional masses in a patient undergoingdefinitive
surgery.
270 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology___________ ^ SOLVED LONG QUESTIONS OF SEMESTERS O P aper-ll 271

4. To screen both breasts before any cosmetic surgery. > indications -

5. Screening before Breast Conservative Surgery (BCS). 1. Screening of young women and women in high risk group (History of therapeutic radiation
6. Follow-up after BCS / Radiotherapy/ Neo-adjuvant chemotherapy. in age < 30 yrs, Strong family history of breast CA, BRCA1/2 mutation, Personal history
of DCIS/ Invasive breast CA, family history of breast and ovarian CA)
> American College of Surgeons (ACS) guidelines -
A Woman with average risk of breast CA should undergo regular screening mammograpt, 2. Suspected Ductal Carcinoma In Situ (MRI is the most sensitive investigation for DCIS)
starting from 45 years age, annually to 54 yrs age, then biennially for as long as the wotnj, y There is no risk of ionising radiation.
is In good health and has a life-expectancy of at least 10 years. > IOC for imaging breasts in pregnant female.
> Usual views taken - y It is a better modality than other investigations for dense breasts.
1. Medio-lateral-oblique (MLO) view > Findings suggestive of malignant lesion -
2. Cranio caudal (CC) view 1. Mass with irregular intensity and spiculations
> Amount of radiation exposure during mammography - 0.1 -0.2 cGy (this amount of radiate 2. Thickened skin, changes in nipple.
being not enough to cause malignant changes in breast itself) 3. Lymphedema.
V Findings suggestive of malignant lesion - > Disadvantages -
1. Disto rted architecture of the breast parenchyma (irregular soft tissue shadow). 1. Costly, not available easily.
2. Micro calcifications (< 5 mm) with spiculations. 2. Not accurate, if done within 9 months of radiotherapy for breast CA.
3. Focal dilatations of ducts. 3. Cannot be done in patients with incompatible metal prosthesis like cardiac pacemaker.
4. Increased number and thickening of Cooper'sligaments. • BIRADS (Breast Imaging Reporting and Data based Scoring system) -
5’ Heterogenous, polymorphic, high density opacity with irregular margin/ satellite lews > This is a scoring system based on different investigations.
> Well localised, smooth, regular shadow - Fibroadenoma, Sclerosing adenosis V Based on this, advice can be given regarding further investigations and diagnosis.

• USG:
>> Purpose - Grade 0 Grade 1 Grade 2
1. To know whether the lesion is solid or cystic.
• Inadequate/Incomplete • Normal/Negative • Benign
2. To define size, extent and texture of the lesion. assessment • Continue annual • Continue annual
r
■ Cystic lesion - Phyltodes tumor, Breast cyst • As breast tissue Is mammography mammography
> Findings suggestive of malignant lesion - dense, mammogram cant
interprets
1. Irregular internal echoes.
• Needs additional study
2. Irregular posterior acoustic shadow.
3. Irregular margin.
4. Non compressibility.
5. Ratio between anteroposterior to lateral/horizontal dimensions is >1 .
Grade 3 Grade 4 Grade 5 Grade 6
6. Hypoechoic, more vertical mass.
7. High frequency signals with continuous flowon doppler. • Possible/Probably • Suspicious lump • Highly suggestive • Biopsy proven
benign • Chance of CA = 25­ of malignancy malignancy
> Disadvantage - Lesions < 1 cm may be missed.
• Chance Of CA = 1-2% 50% • Chance of CA = • Known carcinoma
> Can guide FNAC, cheaper, easily available and has no risk of radiation.j 75-90%
• Repeat imaging after • Biopsy recommended
I 3-6 months • Biopsy required
. MRI:
> Purpose -
1. To identify multifocal ( >1 loci in one quadrant) and multicentric breast tumor.
1 M'STOPATHOLOGICAL/ CVTOLOGICAL analysis
2. To Image breasts with breasl implants.
3. To detect local recurrence or scar after mastectomy. BREAST BIOPSV

4. To assess axillary metastasis. J rW>« •' (See chart on the next page)
5. To assess dermal extension.
i
272 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED LONG QUESTIONS OF SEMESTERS □ Paper-ll 273

Other relevant investigations:

* t Triple receptor assessment-
a) Estrogen Receptor (ER) study
y Estrogen sensitive cytosolic glycoprotein level >10 units per gram of tissue is known as
ER+ve status.
y ER +ve status indicates good response to hormone therapy and good prognosis.
b) progesterone receptor (PR) study
c) HER 2/Neu receptor study
> Human epidermal growth receptor 2 Neu oncogene, also known as cErb B2, is a tyrosine
kinase receptor.
> Positivity indicates high grade tumor and poor prognosis.
2 ecological and microbiological analysis of nipple discharge
y Sample is obtained through ductal lavage.
y Can diagnose Breast carcinoma, Non-lactational abscess of breast, Ouct ectasia.
3. Tumor markers
□ FNAC: a) CA 15/3 (Normal serum value < 40 U/mL)
• Fine needle aspiration cytology is the first, simplest and least invasive technique for obtain^ b) CA 27
cell diagnosis in breast carcinoma c) CA 29
* • Mininum 6 aspirations are done using 21-30 G needle 4. Miscellaneous -
• Giemsa, hematoxylin and eosin, papanicolaou stains used a) Chest X-ray / CT thorax:
• It can be repeated 2 times y Pleural effusion - suggestive of Breast carcinoma
• Advantages: (1) least painful (2) cheap (3) reliable (4) can be done on Out patient basis (5)ic > Pulmonary cavitation - suggestive of pulmonary tuberculosis (seen in Tuberculosis of
evidence of malignant deposits along FNAC track breast)
• Disadvantages : (1) Receptor study can not be done; (2) Invasive cancer can not be d iffe re d
b) USG / CT abdomen
from in situ disease; (3) False negative results do occur, rrjainfy due to samph
> Secondaries in liver, ascites, Krukenberg's tumor - seen In Breast carcinoma
errors
c) X-ray / MRI spine and pelvis
• Chalky fluid with (at globules : seen in Traumatic fat necrosis
> Osteolytic secondaries In bone - seen in Breast carcinoma
□ Core needle b io p s y : d) Metabolic panel - Increased Alkaline phosphatase along with Increased serum Calcium
• It is the preferred method for diagnosis of palpable or non-palpable breast abnormalities ! level and bone pain is an indication of bone scan..
• Permits analysis of breast tissue architecture to give clear histological evidence and d e » ! e) Radioisotope bone scan - To look for secondaries in bone in advanced cases. A positive
preoperative diagnosis bone scan will confirm the diagnosis of Metastatic carcinoma of breast, not Locally Advanced
• Can confirm DCIS and invasive lesion Breast Carcinoma.
• Can comment about grade and receptor status of tumor 0 PET scan - To look for bone, soft tissue or visceral metastases.
9) LFT
□ Frozen section b io p sy: j
h) Complete hemogram
• Not usually practiced now-a-days
• Indication: when FNAC fails even after 2 trials or is negative
• Disadvantage: Shows 20% false negative results

□ Bxclslonal b io p sy:
• Also known as open biopsy
• It is the best and definitive investigation for breast carcinoma
. Incision is planned in such a way that it will be included in the eventual mastectomy incision *
later date
• Should give no false negative and no false positive results
 SOLVEO SHORT NOTES OF FINAL MBBS □ Paper-I 275

SEGMENT - C
B) chem ical -
SOLVED SHORT NOTES OF FINAL MBBS la) Alcohols (ethyl alcohol, isopropyl alcohol)
Paper - 1 (b) Aldehydes (formaldehyde, glutaraldehyde)
(c) Phenols
FINAL MB PAPER - 1 SHORT QUESTIONS - 2008 jd) Gases
(e) Halogens (bleaching powder, EUSOL)
0 .1 : Method o f sterilisation
(f) Dyes
(g) Salts
M ETHO D OF ST E R ILIS A T IO N (h) Surface active agents

□ What Is sterilisatio n : Process by which an article, surface or medium is made free ot Sterilisation of various surgical instruments:
a
microorganisms either in the vegetative or spore form (a) Autoclave - all theatre appliances, syringes, clothes and bed sheets of bum patients
(b) 2% Glutaraldehyde, Concentrated Lysol - sharp instruments, endoscopes
□ Types:
(C) Gamma radiation - syringes, disposable articles
(A) PHYSICAL -
(d) Ethylene oxide - heart-lung machine
(a) Sunlight (e) UV radiation - OT
(b) Heat
(I) Filtration - sera and biological materials
1) Dry h e a t- s
(g) Formaldehyde - OT
i) Red heat
(h) Incineration - soiled dressing
ii) Flaming
iii) Incineration (i) Lysol - excreta, ward
. iv) Hot air oven (j) EUSOL (Edinburgh University Solution) - to remove slough from wounds
(k) Spirit - before injection
2) Moist heal -
I) < 100 degree Celcius - (I) lodophores - cleaning the skin before surgery
• Pasteurisation (Holder method, Flash method) (m) Savlon - hand wash
• Inspissation (n) Condy's lotion (0.1% potassium permanganate solution) - bladder wash
• Vaccine bath
• Water bath
« Low temperature steam formaldehyde (LTSF) 0.2 j Biochemical abnormality in pyloric stenosis
ii) At 100 degree Celcius -
• Boiling BIOCHEMICAL ABNORMALITY IN PYLORIC STENOSIS
• Tyndallisation
• Steam steriliser
Q Whit is pyloric stenosis: Chronic duodenal ulcer undergoes scarring and cicatrisation leading to
iii) > 100 degree Celcius -
total obstruction of pylorus
• Autoclave -
121 degree Celcius 3 Biochemical changes: Hypochloraemic hypokalaemic metabolic alkalosis with hypocalcaemla and
15 lb/metre square paradoxical aciduria (For details see Sec-1 Segment-A Paper-I 2013 Supp. 0.1, Page No. 62).
15 minutes lor rubber drain, etc.
30 minutes for blunt metallic instruments .
0.3: Universal precaution
(c) Filtration
(1) Candle filter
(2) Asbestos filter ' UNIVERSAL PRECAUTION
(3) Sintered glass filter
(4) Membrane filter J Wfiaf is i t : Precautionary measures taken by health care personnel while handling HtV patients
(5) Air filter
J Why universal: As they are for everyone and to be followed everytime while handling such patients
(6) Syringe Filter
J Why necessary:
(d) Radiation
(1) Ionizing (gamma ray, X-Ray) jjjj prevent cross infection
(2) Non-ionizing (UV ray) ( j To safeguard health care personnel who are at risk
(e) Ultrasonic and sonic vibrations (c) Tc avoid infection through hospital wastes

274
 276 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL M88S □ Paper-1 277

□ Precautions: Intraductal papilloma - Microdochectomy .

• Health care personnel must wear - Hyperprolactinaemia ' Bromocriptine 2.5 mg at bedtime for 3 months
1) double gloves paget's disease - Mastectomy/lumpectomy + radiotherapy and and/or chemotherapy
2) proper spectacles ^ Carcinoma - Mastectomy + hormone therapy .
3) head mask
4) theatre shoes
5) aprons
• Minimal parenteral injections
• Walls and floor cleaned properly with soap and water Fibrccystadenoslsj
• Separate operation theatre for operations of such patients
• People inside operation theatre to wear disposable gown
Serous 'If — Duel ectasia
• Operation theatre fumigated after surgery
• All equipments disinfected with glutaraldehyde
• Contaminated gloves, clothing incinerated Carcinoma
• Spilled body fluids diluted with glutaraldehyde
• Care in handling sharp objects
• Cuts, abrasions covered with waterproof dressing
• Shaving to be avoided Intraductal
• Suction bottle half filled with glutaraldehyde papilloma

•
•
•
No mouth pipetting to be done
Resuscitation bag used, mouth-to-mouth breathing not preferred
Blood
stained
/ Intraductal
carcinoma
• Hands to be washed with soap before and after patient care
Duct ectasia
Q.4: Nipple discharge

NIPPLE DISCHARGE Duct ectasia

□ Causes; See Chart on next page Blood

stained Fitirocystadenosis j
□ Invetlgatlons:
(a) Discharge study
(b) FNAC Intraductal carcinoma
(c) USG (if < 40 years)
(d) Mammography (if > 40 years)
Infection,
Purulent
Q Treatment:
(a) Duct ectasia - Cone excision of involved major ducts t antibiotics
(b) Infections - Antibiotics + drainage if abscess Greenish Duct
ectasia
(c) Fibrocystadenosis -
1) Reassurance Serous '
2) Oil of evening primrose capsules - 4 months (causes
3) Gamolenic acid same as in
4) LHRH agonist single duct)
5) Tamoxifen
6) Danazol
7} Vitamin E, Bg
8) NSAIDs
9) Bromocriptine
10) Diuretics
11) In severe cases - subcutaneous mastectomy with prosthesis placemen!
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 279
278 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Bleeding and discharge sometimes

2008 Supplementary nn examination - i) Ulcer may be visible at anal margin
> u ii) Tag of skin (sentinel piles) Visible in case of chronic fissure.
0 .1 : Fibroadenoma o f breast
[Due to severe pain, proctoscopy and per-rectal examination is avoided]
A : See Seclion - 1 , Segment D, Qs. 48 (Page No. 506).
TfpStlflGftt * . . .
Q.2: Meckel's diverticulum Ai Conservative — r Adequate fluid intake
A : See Section - 1 , Segment D, 0s. 45 (Page No. 503) '- stool softeners, purgatives, bulk forming agents
Q.3: Keloid High fibre diet
Local anaesthetic agents, vasodilator ointments (Nifedipine ointment)
A ; See Section - 1 , Segment C, Paper II, 2013 Supp. Qs. 9 (Page No. 426)
Sitz bath
Q .4: Anal Fissure
Oral calcium channel blockers
Ans: Regular anal dilatation
ANAL FISSURE Lord’s dilatation done under GA in acute cases
□ Synonym : Fissure-in-ano Dorsal fissurectomy with sphincterotomy
B) Surgical
□ What Is I t : Vertical tear or ulcer of the lower anal canal Lateral anal sphincterotomy
□ Site:
> Midline 2009
> Posteriorly (more in males) or anteriorly (more in females) Q j. Arteriovenous fistula
O E xtent: From anal verge till below the dentate line ARTERIOVENOUS FISTULA
□ Depth : Superficial lesion
0 what is I t : Communication between arterial and venous systems other than the capillary bed
□ Types :
> Acute - recent onset; associated with severe sphincter spasm; without oedema or inflanra: Q Classification:
> Chronic - long duration; inflammed indurated margin with scar tissue; may be assoc® (a) Congenital
with sentinel pile. (b) Acquired -
□ Etiology: . 1) Traumatic
> Constipation - hard stool stretches mucosa at posterior aspect of anal verge causing poste 2) Surgical
tear 3) Following infection
4) Following aneurysm formation
> Anterior tear in female is due to poor support to pelvic floor
5) Neoplasia
□ Causes :
6) Therapeutic - for renal dialysis
> Hard stool
> Increased sphincter tone 0 Pathophysiology:
> Diarrhoea • Rapid and turbulent local flow - » thrill, bruit, murmur
> Local ischaemia • High SBP, Venous return, Cardiac output, Pulse pressure
> Haemorrhoidectomy • Low DBP
> Sexually transmitted disease
Q Sites:
V Ulcerative colitis, Crohn's disease
> Tuberculosis (a) Congenital -
1) limb
□ Clinical features: • 2) lung
> H/O constipation and straining at stool 3) Circle of Willis
> Pain in anal region - i) During defaecation 4) bowel, liver
ii) Severe in intensity (more in acute, less in chronic) (b) Acquired -
iii) Burning in nature t) wrist
iv) Persists lor a long time even after defaecation 2) brachial region
3) femoral region
(Pain is due-to the fact that fissure is situated below dentate line which develops N
ectodermal cloaca, and is supplied by pudendal nerve)
 280 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics A Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - 1 281

Clinical features: . j f . low grade, locally invasive carcinoma, arising from basal layer of skin or adnexal basal
(a) Congenital - • 3 l^?r of hair follicle or musculocutaneous junction
1) limb - warm, lengthened, increased girth hUrfitlTT' Commonest malignant skin tumor
2) continuous thrill and machinery murmur all over lesion I predisposing fe to r s :
3) dilated arterialised varicose veins seen
ID UV light
4) bone erosion 2) Males » females
(b) Acquired - (3j Whiles » blacks
1) At level of fistula -
3 Types:
Formation of aneurysmal sac between artery and vein at site of fistula - warm, pg^, (a) Ciinicopathological -
smooth, soft, compressible swelling with continuous thrill and machinery murmur m ) Superficial type - small buds of tumor masses
2) Below level of fistula - (2) Morpheic type - dense stroma with basal cells and Type IV collagen
(i) Distal part ischaemic (3) Fibroepithefioma type - elongated cords of basaloid cells with meshwork
(ii) Varicose veins (b) Morphological -
3)
Proximal to fistula - (1) Basisquamous - behaves like SCC, spreads into lymph nodes
Hyperdynamic circulation causes cardiac failure (2) Cystic/nodular
(c) Nlcoladoni/8ranham’s sign - if feeding artery compressed, hyperdynamic flow diminish^ (3) Multiple - often associated with Basal cell naevus syndrome (Gorlin syndrome), medullo-
immediately leading to fall of pulse rate, pulse vlume and size of lesion blastoma and bifid ribs
Complications: (4) Nodular
(5) Pigmented (mimics melanoma)
(a) Hemorrhage (6) Ulcerative
(b) Thrombosis (7) Geographical/Field fire or Forest fire BCC
(c) Cardiac failure
Clinical features:
Investigations:
(a) Age - middle aged and elderly
(a) Angiography (b) Site - face (commonly above the line drawn between angle of mouth and ear lobule)
(b) USG (c) Ulcer with following features -
(c) Doppler t) Non-tender .
(d) CT scan 2) Dry
(e) MR! 3) Slowly growing
Treatment: 4) Non-mobile
5) Central scab
(a) Congenital -
6) Raised and beaded edge
1) Avoid injury
High risk BCC:
2) Feeding artery ligation
3) Sclerosant therapy (a) Size >2 cm
4) Therapeutic embolisation (b) Near eye/nose/ear
5) Amputation when required (c) III defined margin
(d) Recurrent
(b) Acquired -
(e) Immunosupressed
1) Complete excision if possible
2) Quadruple ligation - ligation of artery and venous components above and below the level t Investigations :
fistula (a) Edge biopsy
3) Feeding artery ligation (t>) X-Ray of the part
(c) CT scan
Q.2; Basal cell carcinoma Treatment:
(a) Radiotherapy - all cases are radiosensitive
BASAL CELL CARCINOMA
The contraindications are -
>) lesion in ear
□ Synonym s:
2) lesion close to lacrimal canaliculi
(a) Rodent’s ulcer 3; if bone erosion has occurred
(b) Tear cancer
 282 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 4 Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper- I 283

(b) Surgery -
,C) Functionally superior cells
1) Indications - contraindications of radiotherapy + recurrent ulcer
(d) Lower risk of infectious diseases
2) Principle - wide excision with skin grafting
3) Methods - /e) Normothermic
(i) Laser surgery (f) High levels of 2,3-DPG
(ii) Cryosurgery q p is a d v a n ta g e s :
(iii) MOHS (Microscopically Oriented Histographic Surgery) (a) Depletion of plasma and platelets
0 .3 : Pre-operative preparation o f a patient o f pyloric stenosis (b) Coagulopathy
j substances w a s h e d o u t :

PRE-OPERATIVE PREPARATION IN PYLORIC STENOSIS (a) Pfasma

(b) Platelets
1) Correction of dehydration - i.v normal saline ( not Ringer lactate) (c) WBC
2) Correction ot electrolyte imbalance - i.v normal saline. Once urine output becomes non*, (d) Anticoagulant solution
potassium supplemented 0 c o n t r a in d ic a tio n s :
3) Correction of hypoproteinemia -
(a) Bacterial contamination
(a) Oral high protein diet
(b) Malignancy
(b) Amino acid
(c) Fresh frozen plasma 2009 Supplementary
(d) Human albumin transfusion
4) Correction of anaemia - by blood transfusion
q.1 : intermittent claudication
5) Correction ot hypocalcaemia - Calcium gluconate 10% 10 ml/kg i.v
A : See Section 1, Segment D, Qs. 84 (Page No. 540)
' 6) Gastric lavage -
Done before each feed for 4-5 days prior to surgery. Q2: OPS!
Its advantages - Ans:
(a) Removes food residues in stomach OPSI
(b) Reduces mucosal edema
(c) Recovery of gastric tonicity □ Full form : Overwhelming Post Splenectomy Infection
These measures are required because the following biochemical changes occur in a patient d □ Incidence: 4%
pyforic stenosis. (Refer MB 2008 Short note above) □ Timing: Anytime after splenectomy but more common in 1st two years
□ Susceptible infective organism s: > Streptococcus pneumoniae
0 .4 : Autotransfusion
> Neisseria meningitidis
AUTOTRANSFUSION > Haemophilus influenzae
O What Is I t : Process where a patient receives his own blood for transfusion y Babesia microti

□ Collection tim e : Blood can be collected before surgery or during and after the surgery □ Cause: Post-splenectomy there is reduced IgM, properdin, tuftin & other antibodies in body which
□ Device used for collection: Cell Saver disables phagocytosis of encapsulated bacteria.
□ Indications: Surgeries with significant blood loss - Q Increased risk I n : Those who have hemolytic diseases or are receiving radio/chemotherapy
(a) Aneurysm 0 Mortality rate : 50-70%
(b) Total joinl replacement 0 Clinical presentation:
(c) Spinal surgeries > Prodromal phase begins with fever, chills, sore throat, rhinitis
(d) Cardiac surgeries '
> Respiratory distress
□ Medical Indications:
> Hypotension, shock
(a) Rare bfood group
> DIC
(b) Restricted homologous blood supply
(c) Risk of infectious disease transmission > Coma, death

□ Advantages : c Prevention:
> Lifelong Injection Benzathine Penicillin 12-24 lac units
(a) pH relatively normal
(b) Quickly available > Vaccine prophylaxis
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□ Recommendations
> Level 3 : Supported by available data, but scientific evidence is lacking. Generally supported
r Level 1 by Class III data. Useful for educational purposes and in guiding future clinical research.
• None q Treatment:
r Level 2 > Antibiotics - Ceftazidime, Cefoperazone, Amikacin
• Non-elective splenectomy patients should be vaccinated on or after postoperative > Blood transfusion
day 14.
> Supportive management in ICU
• Asplenio patients should be revaccinated at the appropriate time interval for each
> Immunoglobulin transfusion
vaccine. ..
> Level 3 0.3: Oesophageal varices
• Elective splenectomy patients should be vaccinated at least 14 days prior to ihe Ans:
operation. OESOPHAGEAL VARICES
• Asplenic or immunocompromised patients (with an intact, but nonfunctional spleen)
should be vaccinated as soon as the diagnosis is made. 0 What Is I t : Dilated, lortuous sub-mucosal veins situated in lower-third of oesophagus.
• Pediatric vaccination should be performed according to the recommended pediatric 0 pathogenesis: Superficial veins lining lower third of oesophageal mucosa drain into left gastric veiQ,
dosage and vaccine types with special consideration made for children less than 2 which finally drains in^portal_yein. In situations where venous pressure in portal system increases,
years of age. blood fl?w Is redirectealronTHyjj to.areas with lower portal pressure, leading to collateral circulation
• When adult vaccination is indicated, the following vaccinations should be in lower esophagus and certain other sites. H ie superficial veins of these areas become distended.
{KTi^walfecf“TeaBing to formation of varices. ‘ -------- ---------------------------------------
administered:
(1) STREPTOCOCCUS PNEUMONIAE 0 Causes: Portai hypertenslon'ffue to any cause - mainly cirrhosis
* Polyvalent pneumococcal vaccine (Pneumovax 23) □ Factors causing variceal bleed:
(2) HAEMOPHILUS INFLUENZAE TYPE B V Portal venous pressure
* Haemophilus influenzae b vaccine (Hib TITTER) 'r Size of the varix
(3) NEISSERIA MENINGITIDIS > Variceal wall tension
* Age 16-55 : Meningococcal (groups A, C, Y, W-135) polysaccharide > Gastro-esophageal reflux causing ulceration
diphtheria toxoid conjugate vaccine (Menactra) □ Clinical presentation:
* Age > 55: Meningococcal polysaccharide vaccine (Menomune- r Assymptomatic
A/CA7W-135) > Variceal rupture presents with - haematemesis
- melaena
Vaccine Dose Route Revaccination - recurrent bleeding
Polyvalent pneumococcal 0.5 mL s c- Every 8 years - shock ,
Quadravalent meningococcal / diphtheria conjugate 0.5 mL IM upper deltoid Every 3-5 years1 0 Management: See Section 1, Segment A, Paper I, 2010, Qs. 2 (Page No. 24)
Quadravalent meningococcal polysaccharide 0.5 mL s c- Every 3-5 years
Haemophilus b conjugate 0.5 mL IM- None 2010
0.1: Haemangioma
* Administered in the deltoid or lateral thign region,
t Contact the manufacturer for the latest recommendations prior to revaccination HAEMANGIOMA

3 What is i t : Benign vascular endothelial tumor - developmental malformation of blood vessel

□ Level of Recommendation Definitions: 2 Types:
> Level 1 : Convincingly justifiable based on available scientific information alone. Usually (a) Capillary -
based on Class I data or strong Class II evidence if randomized testing is inappropriate
1) Strawberry angioma
Conversely, low quality or contradictory Class I data may be insufficient to support a level I
recommendation. 2) Portwine stain
3) Salmon patch
> Level«?: Reasonably justifiable based on available scientific evidence and strongly supported
by expert opinion. Usually supported by Class II data or a preponderance of Class lit evidence. (b) Venous/cavernous
(c) Arterial
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Features Strawberry angioma Portwlne stain Salmon patch Cavernous haemanfliomj j clinical features:
Birth
|a) Swelling in carotid region of neck with following features -
Appears at 1-3 weeks after birth Since birth Since birth
1) Unilateral
Progress Increase In s)2e till 7-8 No change Disappears before Increase in size 2) Smooth
years, after which It re­ 1 year of age 3) Firm
duces in size 4) With transmitted pulsation
5) Moves side-to-side
Site Anywhere, mainly (ace Face, shoulder, Forehead, occiput, Face, lips, mucous mem
neck, buttock midline of body brane of cheeks (0) Features of TIA (transcient ischaemic attack) due to compression of carotid arter
(c) Thrill felt '
Colour Bright/dark red Deep purple Bluish (d) Bruit audible
Shape Well-defined Diffuse swelling Raised from surface q site: At level of hyoid bone deep to anterior edge of sternocleidomastoid in anterior triangle
q Extension: Into cranial cavity along internal carotid artery (dumbbell tumor)
Features (a) Compressible (a) Compressible
(b) Soft 3 S htm bllli classification:
(c) Irregular surface (b) Not pulsatile Type I - Localised, easily resectable
(d) Not pulsatile Type II - Adherent, partially surrounding carotids
(e) Freely mobile Type III - Adherent, completely surrounding carotids
Takes time U Investigations:
Refilling Quick (Emptying sign)
(a) Doppler
(b) Angiogram - widening/splaying of carotid artery with fumor blush’ (Lyre sign)
□ ' Treatment:
(c) CT scan
Wait and watch -» if exists even after 8 years of age, then following measures - (d) MRI
(a) Injection of sclerosing agent into the lesion Q Treatment:
(b) Cautery
(c) Excision of the lesion after ligating feeding vessel (a) If small -> excision
(b) II large - » complete excision + vascular graft
0 .2 : Carotid body tumor
0.3: Branchial sinus
CAROTID BODY TUMOR
BRANCHIAL SINUS
Synonyms:
Q What is i t : Persistent second branchial cleft with a communication to !he exterior
(a) Chemodectoma
□ External orifice: At lower third of neck near anterior border of sternocleidomastoid
(b) Potato tumor
(c) Non-chromaffin paraganglioma □ Internal orifice: In the ante rior aspect of posterior pillar of tonsil present (then called a fistula), may be
O rig in : Carotid body, located in adventitia of common carotid artery near its bifurcation absent with the tract ending blindly -
U Tract:
Nature:
(a) Benign (a) Lined by ciliated columnar epithelium with few lymphoid tissue underneath
(b) Locally malignant |b) Lies between bifurcation of common carotid artery
(c) Spreads to regional lymph nodes and lung in 20% cases b io lo g y ; Branchial cyst incised mistaking it to be an abscess
Blood sup ply: External carotid artery Q Discharge: Mucoid or mucopurulent
Incidence: 3 Clinical features: Discharge from a small opening in the neck
(a) Common in females Q Investigations:
(b) Common in high altitude (a) Discharge study
Pathology: , (•>) Sinusogram
(a) well-encapsulated - Treatment: '
(b) not hormonally active Surgicai treatment
(c) hard
Melhylene blue injected into the tract Probe passed through the tract -> Entire length of tract
(d) creamy yellowish colour seated by an elliptical incision
(e) dense fibrous tissue present
explications o f surgery:
A g e : Middle age fnjuryto_
 288 QUEST : A Comprehensive Guide 10 UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOT£S OF FINAL MBBS □ Paper-| 289

(a) Carotids (e) Small bowel carcinoids - abdominal pain, features of intestinal obstruction
(b) Jugular vein (d) Hind gut carcinoids - bleeding per rectum, constipation, tenesmus
(c) Hypoglossal nerve je) C a rcin o id syndrome - if secondaries in liver
(d) Glossopharyngeal nerve
(e) Spinal accessory nerve j investigations:
(a High levels of 5-HIAA (5-hydroxyindoleacetic acid) in urine
0 .4 : Carcinoid tum or ; (b) l13, MJ8G scan
(C) CT scan
CARCINOID TUMOR
0] 111in-octreotide scintigraphy
□ Occurs i n : j Treatment:
(a) Appendix - 65% cases (a) If in lip of appendix -» appendicectomy
(b) Ileum - 25% cases
(tf) II in base of appendix or size > 2cm anywhere in appendix -> right hemicolectomy
(c) Other parts of GIT
(C) If in terminal ileum -> right hemicolectomy
(d) Ovaiy "j
(e) Teslis ^ (rare) (d) If large sized small bowel carcinoid + spread to lymph nodes -» radical resection ol small intestine
(f) Bronchus J (e) If <1 cm sized small bowel carcinoid without nodal spread -> segmental resection of small
□ Site: intestine
(a) Appendix - tip or distal 2/3 rd (I) II secondaries in liver -> surgical debulking hepatic resection + embolisation or ligation of hepatic
(b) Ileum - terminal 2 feet arteiy
Q Num ber: Single in appendix, multiple in ileum
2010 Supplementary
□ Characteristics :
(a) Arise from enterochromaffin cells (Kulchitsky cells) found in crypts of Leiberkuhn 0.1 : Melanoma
(b) Capable of APUD (Amine Precursor Uptake and Decarboxylation)
(c) Secrete vasoactive peptides A : See Section 1, Segment D, Qs. 71 (Page No. 529)

□ A g e : 50-60 years 0.2: Blood substitutes

□ Spread o f small bowel carcinoids : A: See Section 1, Segment C, Paper 1,2014, Q. 3 (Page No. 312)
Size Nodal *pread Liver spread 0.3.-Trophic ulcer
< 1 cm 20-30% 20-30% A: See “Pressure Sore" Section 1, Segment C, Paper II, 2013 supplementary Qs. 7 (Page No. 424)
1 - 2 cm 60-80% 20% 0.4: Systemic inflammatory response syndrome

> cm 80% A: See Section 1, Segment D, Qs. 79 (Page No. 536)

50%

O Types o f small bowel carcinoids: 2011

.....
Features Sites Secrete Nature __ .1 1: Pre operative preparation o f a case o f obstructive / aundice
Foregut carcinoids Bronchial, thymic, gas­ Low levels of serotonin Argyrophillc
troduodenal, pancreatic PRE-OPERATIVE PREPARATION - OBSTRUCTIVE JAUNDICE
^ J
Midgut carcinoids Jejunal, ileal, appendiceal, High levels of serotonin Argentaffin and argyraf**j. (a) Immediate hospitalisation
right colic
(0) Diet - high carbohydrate, low protein, no fat diet along with vitamin and calcium supplements
Hindgut carcinoids Distal colon, rectal High levels ol somatostatin Do not stain nvifft \ Adequate hydration with oral and intravenous fluid
and peptide YY 1
---- 1 M) J.v mannitol - 10% 200ml before, during or after surgery or Inj Furosemide 40mg i v
I I lnl Dopamine 2 ug/kg/min
□ Clinical features:
III Plism aTruself^9 ^ ' ° C° :reC‘ pr0,hf0mbin time if stifl no improvement, fresh frozen
(a) Assymptomatic
(b) If in appendix, features of appendicitis (3) Blood transfusion if severe anaemia
290 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 8 Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS 0 Paper-1 291

Feeling of heaviness of lower limbs, accentuated by standing

(h) Broad spectrum antibiotics
(I) If preoperative bilirubin > 10mg%, ERCP stenting or PTBD done, else MRCP done [d) Leg's lense' tender' warm' Pale' wth stretched shiny skin

I g Signs :
Q.2: Epigastric hernia i.\ swefling
lb) Tenderness over thrombosed veins
EPIGASTRIC HERNIA
Homan's sign positive (passive forceful dorsiflexion of foot with extended knee - * tenderness in

□ Synonym : Fatty hernia of linea alba calf)

iri) Mosse's sign (gentle squeezing of lower part of calf from side to side is painful)
□ What Is I t : Protrusion of hernia in the midline through Ihe interlacing fibres of linea alba any*^
L i Neuhof's sign (thickening and deep tenderness elicited when calf muscles palpated deeply)
between umbilicus and xiphystemum ,n Linton’s test (tourniquet applied at sapheno-femoral junction - * patient made to walk -> limb kept
□ Reason behind naming: elevated -> persisting prominent superficial vein)
(a) Mostly occurs midway between xiphysternum and umbilicus
-j investigations:
(b) Begins as a protrusion of extraperitoneal fat and as It grows bigger, II drags a pouch of peritona-
(a) Venous Doppler '
□ Incidence:
<b) Duplex scan
(a) 10% common (c) plethysmography
(b) M » F |d) Phlebography
□ Speciality: (e) Venous pressure measurement
(a) Sacless hernia |l) Radioactive I125 fibrinogen study
(b) Content - omentum and/or small bowel j Complications:
0 Clinical features: (a) Pulmonary embolism
(a) Assymptomatic (b) Infection, venous gangrene
(b) Swelling in epigastric region - tender (c) Recurrence
(c) Referred dyspepsia (d) Chronic venous insufficiency
(d) Cough impulse f 3 Treatment:
(e) Irreducible
(a) Conservative -
□ Investigations: Gastroscopy .
1) Bedrest
□ Treatment; Sac dealt with through a vertical incision, closed with non-absortable interrupted skip.
2) Elevation of legs
3) Elastic stockinette
0 .3 : Deep vein thrombosis
4) Heparin
DEEP VEIN THROMBOSIS 5) Warfarin
6) Fibrinolytic drugs
□ Synonym : Phlebothrombosis (t>) Surgical -
□ Aetiology: 1) Bypass procedure
(a) Following childbirth 2) Valvular repair
(b) Post-operative 3) Palma operation
(c) Muscle trauma 4) May Husni operation
(d) Spontaneous in visceral neoplasm
(e) Immobility 0 i: Ac,ive immunisation against tetanus
(I) Sitting before computers for long hours
ACTfVE IMMUNISATION AGAINST TETANUS
□ S ite s :
(a) Calf is the most frequent site 3 Adults- lit dose
(b) Pelvic veins
1 month gap
(c) Leg veins - femoral, popliteaf
2™1dose
(d) Upper limb vein - axillary
6 monlhs gap
□ Symptoms:
3,d dose
■ (a) Fever
• h* . .. naK fKinh 1,036 - 0.5 ml letanus toxoid intramuscularly at insertion of deltoid muscle
 292 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-i 293

□ Infants - r Euvolaemic hyponatremia

■ - increase in total body water withnormal body sodium
\AP schedule: , Hypervolaemic hyponatremia - increase in total body sodium with greaterIncrease in
DPT1 at 6 weeks total body water

DPT2 at 10 weeks j ytriants based on effective osm olality:

DPT3 at 14 weeks ' r Hypotonic hyponatremia

DPT 1s1booster at 16-18 months isotonic hyponatremia

DT (2"° booster) at 5 years r Hypertonic hyponatremia

NIS schedule: ,j Causes:

OPT1 at 6 weeks r Intestinal obstruction ]
> Gastric outlet obstruction / ' ^ i n g to severe vomiting
DPT2 at 10 weeks
DPT3at 14 weeks r Intestinal fistulas
DPT 1“ booster at 16-24 months r Severe dehydration due to diarrhoea

DT (2"a booster) at 5-6 years >. SIADH

y Stroke
□ Pregnancy -
> Immediately after trauma and surgery
2 doses of tetanus toxoid 1 month apart, but In India, given during registration and after 1 month
y Following Ryle’s tube aspiration
□ Additional booster dose given in major injuries
j Clinical features:
. □ Antitetanus globulin (ATG) 500-1000 units intramuscularly given as prophylaxis in road accidet
severe bums, crush injuries, war wounds. A) Acute -

> Sunken eyes

2011 Supplementary > Dry tongue
> Dry wrinkled skin
Q.1: Marjolln's ulcer
> Irritable
A : See Section 1, Segment C, Paper II, 2013, Qs. 10 (Page No. 421)
'r Disoriented
Q.2: Preoperative preparation of a patient o f Pyloric stenosis > Hypotension
A : See Section 1, Segment C, Paper 1,2009, Qs. 3 (Page No. 282) *• Dark, scanty urine

Q.3: Blood fractions B) Chronic -

A : See Section 1, Segment D, Qs. 19 (Page No. 484) > Hypothermia
> 8chavioural changes •
Q .4: Hyponatremia
' Cranial nerve palsies
Ans:
HYPONATREMIA V Progressive weakness
' Reduced tendon reflexes
□ What Is i t : Serum sodium level less than 135 mEg/L
y Pseudobulbar palsy
□ Classification: (Joint European Guideline) if Investigations:
> Mild : 1 3 0 - 134mEq/L
' Urine osmolality
y Moderate: 1 2 5 - 129mEq/L
' Serum osmolality
V Profound : < 125 mEq/L
Urinary sodium concentration
□ Types ;
' Serum electrolytes
> Acute - presents with neurological symptoms Treatment:
> Chronic - causes pontine myalincsis
r Fluid administration - (i) Isotonic saline to hypovolaemic patients
□ Variants based on volume sta tu s:
(ii) Salt and fluid restriction to hypervolaemic patients
V Hypovolaemic hyponatremia - decrease in tolai body water with greater decieas*
icial body sodium (iii) Free water restriction in euvolaemic patients
 SOLVED SHORT NOTES OF FINAL MBBS D Paper-I 295
294 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

ptruments - Verees or Tuohy needle

> Potassium repletion in hyponatremia secondaiy to diuretics
_ To distend the abdominal wall and separate it from the abdominal contents
> Hypertonic (3%) saline in overtly symptomatic hyponatremia - purpose ■
rabllshment o f pneumoperitoneum - Intraabdominal pressure is preset to 12-14 mm Hg in auto-
V Conivaptan (V1A and V2 vasopressin receptor antagonist) for euvolaemic and hyp€(Vo|.
^ tic insufflator -» A 1 cm smiling incision is made just below umbilicus -> A Verees needle is
hyponatremia (contraindicated in hypovolaemic patients)
1113 rted into the abdomen at right angle such that underlying structures are not injured -» Position of
> Treatment of underlying cause. 'wjd/e inside the abdominal cavity is confirmed by injecting about 5ml of saline and reaspirating it, or
0 drop test -> Needle connected to an automatic insufflator by insufflation tube -> The gas flow is
2012 (arted ® it/min and then the flow rate is gradually increased -» After adequate insufflations,
Verses needle is withdrawn and trochar is inserted
Q. 1: Post operative pain management
j Factors determining appropriate gas -
(a) type of anesthesia
POST-OPERATIVE PAIN MANAGEMENT
(b) physiologic compatibility
□ Methods available: (c) toxicity
(<j) ease of use
(a) Systemic -
(e) safety
1) Opioids (I) delivery method
2) NSAIDs (gl cost
3) Paracetamol (h) non-combustibility
(b) Regional - j Gases used-
1) Epidural (a) Carbon dioxide
2) Peripheral nerve block (b) Nitrous oxide
□ Order o f effectiveness: (c) Argon
(d) Helium
Afferent neural blockade > High dose opioids > Epidural opioids > PCA > NSAIDs > Paraceiar
(e) Mixture ol these gases
□ Assessment: By using 10 point assessment scale
'J Why carbon dioxide preferred -
0 Safest m ethod: PCA
(a) high diffusion coefficient
U PCA: (b) normal metabolic end product rapidly cleared from body
(a) Full form - Patient controlled analgesia (c) highly soluble in blood and tissues
(b) What is it - Method of allowing a person in pain to administer their own pain relief (d) does not support combustion
(c) Routes of administration - (e) lowest risk of gas embolism
1) Oral
J Gas delivery system -
2) Intravenous - via patient controlled analgesia infusion pump
(a) containment cylinder
3) Epidural
(b) insufflators
4) Inhaled
(c) tubing
5) Nasal
6) Transcutaneous (d) filter
(d) Drugs used - (e) port
t) Opioids such as fentanyl Safe of gas flow - 4-6 It/min
2) Local anaesthetics
3) Methoxy fluorine vapour Physiological effects -
4) Narcotics (a) CVS - reduced venous return, increased peripheral resistance, tachycardia
(b) Respiratory - reduced FRC
Q.2: Creating pneumoperitoneum In laparoscopic surgery (c) Renal - reduced renal function, reduced urine output
W) Gl - regurgitation of gastric contents, pulmonary aspiration
PNEUMOPERITONEUM IN LAPAROSCOPIC SURGERY
(*) Neurological - high intracranial tension, reduced cerebral perfusion

0 What is It - Introduction of gas into peritoneal cavity during laparoscopic surgery ,f) Due to gas insufflation - arrhythmia, subcutaneous emphysema, pneumothorax, venous gas
embolism, injury to internal organs
□ Incision - Umbilical
 296 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 297

Q .3: Burst abdomen /e] Comatose

(0 Tetanus
BURST ABDOMEN
q predisposing factors:
(a) Anaemia
0 Synonym : Abdominal dehiscence
(b) pressure
O What Is I t : Disruption of a laparotomy wound (C) Moisture
□ Time o f occurrence: 5th-8th post operative day . m) Sensory loss
(fl) Malnutrition
□ A etio lo gy: Sutures opposing deep layers i.e. peritoneum, rectus sheath tear-through
q investigations:
□ Factors related:
(a) study of discharge
(a) Choice of suture material
(b) Blood sugar
(b) Upper midline vertical wounds more prone than transverse wounds (C) Edge biopsy
(c) Method closure - continuous more susceptible than interrupted (d) X-Ray of the part
(d) Wounds of major surgeries g Treatment:
(e) Poor general health of patient (a) Treatment of the cause
(f) Post operative cough, vomit (b) Nutritional supplementation
□ Clinical features: (c) Frequent change of position
(a) Sudden give-away sensation generally after severe cough (d) Use of water bed
(b) Pinkish serosangufnous discharge (e) Avoidance of moisture
(c) Omentum/intestinal coils forced out (f) Proper cleaning of urine and excreta in bed ridden patients
□ Treatment : (g) Regular dressing
(a) Immediate hospitalisation (h) Antibiotics
(b) Intravenous fluid (i) Excision of dead tissue followed by skin graft
(c) Sugery (wound opened -> coils replaced into abdominal cavity -» thorough wash -* wtv
closed by all layer sutures, passing a non-absorbable suture material through plastic cofo 2012 Supplementary
"tension sutures” , kept for 14 days)
(d) Antibiotics ' a i : Lipoma
(e) Newer modalities of treatment - A : See Section 1, Segment D, Qs. 23 (Page No. 486)
1) Biological dressing
2) Wound vacuum system 0.2: Metabolic acidosis
A:See Section 1, Segment C, Paper 1,2013, Qs. 1 (Page No. 300)
□ Com plication: Incisional hernia
0 .4 ; Decubitus ulcer 0.3: TPN
Ans:
DECUBITUS ULCER
TPN
Synonym : Bed sore
Full form : Total Parenteral Nutrition
Type o f ulcer .-Trophic ulcer with bone as base
What Is I t : Method of feeding given only through intravenous route, bypassing the gastrointestinal
Sites :
tract
(a) Occiput
(b) Scapular region Site: Through subclavian / internal jugular vein by Inserting a central catheter
(c) Sacral region Contents:
(d) Ischium
> Water-> 30-40 ml/kg/day
□ Common In :
* Energy-> Medical patient : 30 Kcal/kg/day
(a) Diabetic
(b) Bedridden (Fat & carbo- Postoperative patient : 30-45 Kcal/kg/day
(c) Paraplegia hydrate) Hypercatabolic patient: 45 Kcal/kg/day
(d) Old age
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Amino acids • Medical patient : 1g/kg/day

precaution: Weight gain must not be more than one kg/day otherwise it signifies fluid overload.
Postoperative patient : 2g/kg/day
Contraindications:
Hypercataboiic patient : 3g/kg/day
r■ Blood dyscrasia
Minerals Acetate / gluconate : 90 m Eq/kg/day > Cardiac failure
Chloride : 130 m Eq/kg/day > Altered fat metabolism
Chromium : 15 meg
CompHca,l° ns ■'
Calcium : 15mEq
Copper : 1.5 mg COMPLICATIONS
Iodine : 120 meg
Magnesium : 20 mEq
Manganese : 2 mg
1_
Sodium : 100 mEq
Biochemical Technical Others
Potassium : 100 mEq
. Electrolyte imbalance • Air embolism • Cholestatic jaundice
Phosphorus : 300 mg
• Bleeding • Dermatitis
Zinc : 5 mg » Dehydration
• Pneumothorax
. Hyperglycaemia • Anaemia
Vitamins Ascorbic acid : 100 mg • Infection
• Azotemia • Thrombosis • Severe hepatic steatosis
Biotin : 60 meg
• Hyperosmolarity • Catheter displacement • Metabolic acidosis
Cobalamin : 5 meg
• Sepsis • Candidiasis
Folate : 400 meg
• Catheter blockage
Pantothenic acid : 15 mg
Riboflamin : 3.6 mg
0.4: Prophylactic antibiotics
Thiamine : 3 mg
Ans:
VHA : 4000 IU
PROPHYLACTIC ANTIBIOTICS
VitD : 400 IU
VitE : 15 mg Q Purpose: Prevention of infection and complication by using antimicrobial therapy
VitK : 200 meg □ Used in :
Indications: > Post surgical cases
V High output abdominal fistula or duodenal / pancreatic / biliary fistula > Medical conditions - Spontaneous bacterial peritonitis
> Septicaemia - Rheumatic fever
> Following major abdominal surgeries - Meningococcal disease
> Multiple trauma - Plague
> Failure or Contraindication for enteral nutrition - Recurrent UTI
V Short bowel syndrome - Recurrent cellulitis
Procedure : Subclavian vein catheter is passed below clavicle and fixed to skin and thus TPNis - Infective endocarditis
administered via a central vein like jugular or subclavian vein. Q Optimal prophylactic an tibiotic; Must have following features
Monitoring patient: > Bactericidal
> Fluid input-output chart > Inexpensive
> Body weight > Non-toxic
> Blood glucose > Active against typical pathogens that can cause post operative surgical site infection
> Serum electrolytes D Antibiotics commonly used :
V Blood urea, serum creatinine > Cefazolin
> UN­ > Ciprofloxacin
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Cefuroxime
q 2 • Venous ulcer
Vancomycin
Doxycycline VENOUS ULCER
Metronidazole
Penicillin 2 synonyms:
(a) Gravitational ulcer
2013 (b) Varicose ulcer
j KViaf is i t : Complication of varicose veins or deep vein thrombosis

Q. 1 : Causes and treatment o f metabolic acidosis rj pathogenesis: .

Varicose veins or deep vein thrombosis
METABOLIC ACIDOSIS

□ What Is I t : A condition where either there is an excess of acids or there is a deficit of bases ini^ Valve cusps degenerate or remain impregnated in organised thrombus
body '1
□ Causes : Chronic ambulatory venous^hypertension
(a) Increase in amount of fixed acids -
1) Diabetic ketoacidosis Defective microcirculation
2) Lactic acidosis
I
3) Hypoxia
RBC diffuses into tissue plane
4) Starvation
5) Shock or cardiac arrest -> anaerobic tissue metabolism -» rapid increase in lactic s« i
pyruvic acids Lysis of RBC
6) Renal insufficiency i
7) Azotemia Release of haemosiderin
8) Excessive exercise i
9) Rapid transfusion of blood stored in blood banks
Fibrinogen escapes through large pores in venules
10) Intestinal strangulation
(b) Loss of bases- i
Accumulates to act as a barrier to diffusion of oxygen and other nutrients
1) Diarrhea
2) Small bowel fistula ■i’
3) Ulcerative colitis Dermatitis with brawny edema, hyperpigmentation
4) Gastrocolic fistula i
5) Ureterosigmoidoscopy Anoxia
6) Prolonged intestinal aspiration
i
O Clinical features: Tissue death and fat necrosis
(a) Rapid deep noisy respiration, often called 'air hunger' ' i
(b) High BP, puise rate
Scratching due to itching because of dermatitis
(c) Amidst fast breathing, patient stops breathing for a second and tries to moisten his dry lips withIs
]r
dry tongue
(d) Cold clammy skin Skin break
(e) Altered level of consciousness I
□ Investigations: Ulcer
(a) Strongly acidic urine
(b) Low serum bicaibonate level ^ Salient features:
□ Treatment: | (a) Gaiier's zone - area where venous ulcer generally develops - around and above Ihe medial
(a) In cases with increased amount of fixed acid - Sodium bicarbonate to be inlused, initial do* s malleoli because ol the presence of large number of perforators which transit pressure changes
being not more than 50 ml of 7.5% solution directly into superficial venous system
(b) In cases of base deficit - Ringer lactate + 4.2% solution of sodium bicarbonate infused (b) Lipodermatosclerosis - hypecpigmentation, thickening, chronic inflammation and induration of
the skin in ihe call region and afso around Ihe ankle
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□ Complications:
2 CiiisatiM organisms:
• Related to skin -
la) Staphyloccus aureus
1) Dermatitis
I, Hemolytic streptococci
2) Scarring
c) Microaerophilic streptococci
3) Eczema
4) Marjolin's ulcer mi E.coii
ei Clostridium welchn
5) Lipodermatosclerosis
(I) Bacteroides fragilis
• Others -
j Predisposing fa cto rs:
(a) Venous hemorrhage
(b) Talipes equino varus (8) Diabetes
(b) Malnourishment
(c) Calcification of vein
(d) Ankylosis of ankle joint (C) Old age
(d) immunosuppressed
(e) Periosteitis
(f) Infection 3 pathogenesis: Infection - » Fulminant inflammation of scrotal skin and subcutaneous tissue -> Oblit­
□ Investigations: erate arteritis in scrotal skin - » Cutaneous gangrene

(a) Doppler USG g Age: Elderly people

(b) Duplex scan 0 Clinical features:
(c) Complete blood count (a) Sudden onset severe pain in the scrotal region
(d) Ascending functional phlebography (b) Fast spreading cellulitis of scrotal skin
(e) Discharge study (c) Extends to groin
• (f) X-Ray of ankle (d) Extensive skin sloughing -» normal testis exposed
(g) Biopsy from edge of ulcer (e) Fever and other toxic features
□ Treatment: 0 Treatment:
(a) Conservative- , (a) Immediate hospitalisation
BISGARD REGIMEN (b) Intravenous fluid
1) Elevation of the affected lower limb (c) Catheterisation
2) Massage of the indurated area and the calf (d) Antibiotics
3) Passive and active exercise (e) Blood transfusion if required
4) Pressure bandage - applied spirally from base of toes upto knee joint over a piece ol lit (I) Excision of slough
placed on the ulcer - (g) Skin graft after lesion granulates
5) "Four layer" bandage - developed by Charring Cross Hospital, London □ Complication: Renal failure
6) Regular cleaning of the ulcer using povidone iodine
7) Dressing with EUSOL (Edinburg University Solution of Lime - contains sodium hypochlorte, QA : Anorectal malformations
calcium hydroxide and boric acid)
8) Antibiotics ANORECTAL MALFORMATIONS
9) Topical steroids
Q What Is i t : Abnormalities in development of rectum and anal canal
□ S urgical- •
1) Definite procedure for varicose vein (Trendelenburg operation, etc) after ulcer heals by cm1 2 Aetiology: Imperfect fusion of post-allantoic gut with the proctodeum
servative treatment 0 Incidence: 1 in 4500 new born
2) Valve replacement 0 Wingspread classification:
3) Kistner's valvuloplasty
1) High anomalies - (above puborectalis)
Q.3: Fournier’s gangrene (a) Clbacal deformity -
The urorectal septum fails to develop, hence the bladder and rectum become a single cavity
FOURNIER'S GANGRENE [See Fig. 1.5.1)
I
1 (b) Anorectal agenesis -
□ Synonym: Idiopathic gangrene of scrotum The urorectal septum develops partially
□ What Is i t : Vascular scrotal gangrene of infective origin [See Fig. 1.5.2]
2i Intermediate anomalies - (at level ol puborectalis)
 304 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS D Paper-I 305

3) Low anomalies - (below level of pelvic floor)

t Aetiology:
(a) Imperforate anus - „ Breech delivery
Intact anal membrane between endodermal and ectodermal cloaca ' Lymphadenitis
(SeeFig. 1.5.3] ( p ^ 3) stemomastoid tumor
(b) Covered anus - i, trauma
Anal opening covered by a triangular fold of skin 5) post burn contracture
[See Fig. 1.5.4] 6) Rheumatic
(c) Ectopic anus - 7) Due to scoliosis
gj to ocular causes
Anal opening situated in the vulva, vagina, vestibule or perineum
[See Fig. 1.5.5]
3 Types: .
(d) Microscopic anus -
a) Congenital
Very small anal opening b) Secondary
[See Fig. 1.5.6] j pathology • Sternocleidomastoid on one side is fibrosed - » cannot elongate -> shortened muscle -»
/ □ Clinical features: deformity
a) Newborn not able to pass meconium
q Clinical features:
b) Abdominal distension .
c) Absolute constipation, vomit, and other features of intestinal obstruction a) Chin points to opposite side
d) Finger gets obstructed in DRE in imperforate anus b) Restricted neck m ovem ents
c) Squint
□ Associated anom alies:
3 Treatment:
' a) Spinal anomalies
a) <1 year age -
b) Oesophageal fistula
* Daily manipulation
c) Cardiac anomalies
* Cervical collar
d) Renal abnormalities
e) VACTER anomalies b) > 1 year age -
* Unipolar release (release of only clavicular head of SCM)
'" O Investigations: ° Bipolar release (release of both clavicular and mastoid heads of SCM)
a) Wangenstein’s invertogram - •
1) High anomalies - rectal pouch proximal to Stephen's line 2013 Supplementary
2) Intermediate anomalies - rectal pouch at level of ischial spine (Kelly's point)
3) Low anomalies - rectal pouch distal to Stephen's line '
b) Murugassu's technique 0.1: Complications o f splenectomy
c) USG abdomen
COMPLICATIONS OF SPLENECTOMY
/ Q Treatment:
a) High anomalies - Colostomy - » posterior sagita^ anorectoplasty -> closure of colostomy a HEMORRHAGE -
b) Low anomalies - Single stage reconstruction like anopfesty, anovestibutoplasty, etc • Occurs mainly due to slipping of ligature at pedicle
• Bleeding from raw splenic bed is best controlled by hot mopsapplication
Q Complications:
• If severe bleeding, cut edges of gastrosplenic and lienorenal ligaments are approximated with
^ a) Faecal fistula continuous suture
b) Infection .
2 THROMBOSIS - Very rare
c) Stenosis
d) Faecal incontinence Q HEMATEMESIS - Occurs due to damage of stomach mucosa during ligation of short gastric vessels
^ GASTRIC FISTULA - Occurs due to compromise in vascular supply to the fundus and greater curvature
0 .5 : Torticollis
sf stomach, as the short gastric vessels are ligated during splenectomy
TORTICOLLIS ' a GASTRIC DILATATION - Occurs if nasogastric aspiration is not done properly
3 0PSI-
□ Synonym: Wry neck
□ What Is I t : Turning of neck to one side with chin pointing to opposite side • Full lorm : Overwhelming Post Splenectomy Infection
 306 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I

• Causative organisms:
a) Pneumococcus , 0<fi»rs ln :
* , Obese
b) Haemophilus influenza Lorry drivers
c) Neisseria meningitides people with excessive hairs in natal cleft region
d) Babesia microti jjj pe0pie who have to sit for long hours at a stretch
• When does it occur: About two years after splenectomy
• Clinical features: „ c0 <2 l le3,tjres; „
a) Multiple openings in natal cleft region covered by tuft of hair
a) Fever with chill
k) Abscess formation
b) Hypotension
J Discharging pus staining undergarments
c) Features of shock
e) Respiratory distress d) Pain
e) Coma 3 Trsa*menf •'
ai Initially - drainage of abscess + antibiotics
• Treatment:
5) Later - definitive treatment
a) Ventilatory support
1) Excision with multiple z-plasty
b) Total parenteral nutrition
2) Karydaki's excision
c) Antibiotics
d) Blood and immunoglobulin transfusion if required 3) Rhomboid Limberg buttock flap
4) Bascom technique of excision
• Prevention:
a) Pneumococcal vaccine - 3 weeks prior to splenectomy and repeated once in 6 years 3 Prevention:
b) Meningococcal and influenza vaccines prior to splenectomy a) Regular shaving of natal cleft
c) Life-fong Benzathine penicillin prophylaxis b) Proper perineal hygiene
' d) Antimalarial prophylaxis in malaria endemic areas
3 Complications:
Q.2: Pilonidal sinus a) Recurrence
t>) Sacral osteomyelitis
PILO NIDAL SINUS
c) Necrotising fasciitis
□ 'Pllo1= hair, ‘Nldu*’ = nest j Causes for high recurrence:
□ What Is I t : Multiple sinus tractscovered by tuft of hair located in the natal cleft а) Improper excision
□ S ite : Upper part of the natal cleft adjoining the sacrum б) Entry of new tuft of hair
c) Breakage of scar
O Pathogenesis:

Hair penetrates skin 0.3: Intercostal drain

A INTERCOSTAL DRAIN
Dermatitis
A 0 Synonym
Infection • Water seal drainage
A 3 m » tls lt
Pustule
• Closed drainage of pleural cavity
A 2 Indications-
Sinus tracts formed
A a) RTA with shortness of breath
b) Haemothorax, pneumothorax, haemopneumothorax
Hair gets sucked info the sinus tract by negative pressure
c) Rupture emphysematous bulla
I
<•) Empyema thoracis - stage 1,2.
Further irritation and granulation tissue formation
3 Position-
X
Pus formed ' Propped up with arm of affected side raised above head.
A 3 Anesthesia-
Multiple discharging sinuses • Local
 308 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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□ Antlsepting shaving A dressing -

• From level of clavicle till end of rib cage, including axilla. ^ . C * " » “ lle b ' op5y
CORE NEEDLE BIOPSY
Q Steps o f Insertion-
« If/I
■ Affected side confirmed by auscultation i the preferred method for the diagnosis of palpable or non-palpable breast abnormalities. It is
4 II» — j»v,*icinnflt hionsu for non-palpable breast tumors because a single surgical procedure
Triangle of safely demarcated can be planned based on the findings of core needle biopsy.
“ • Bounded by - anterior border of pectoralis major “
- mid axillary line n p e t:
- upper border of 5th rib * ■ „ Tiu-cut biopsy
Urge needle biopsy (using 6-14 gauge needle and single puncture)
• Includes 3rd & 4th rib
31 vacuum assisted core biopsy
L i J
4 image guided biopsies-
Incision line which is to be made inside the triangle of safety is infiltrated with 1% Ugnocaine (5^,
(a) Stereotactic mammographic core needle biopsy
with Adrenaline, 7 ml/kg it without Adrenaline) ™
(b) Ultrasound/MRI guided core needle biopsy
I
(c) Mammography guided wire localised excision biopsy
Transverse incision made over skin in triangle of safety
I 3 procedure (Tm cut biopsy):
, Done under local anesthesia
Fat & intercostal muscles dissected
, 14-18 gauge spring loaded needle is used
i
• Multiple punctures are done
When pleura is reached, patient winces in pain
I ■ 3 M in ta g e s ;
• Ugnocaine infiltrated in pleura a) Permits analysis of breast tissue architecture to give clear histological evidence and definitive
preoperative diagnosis
i
b) Can confirm DCIS and invasive lesion
Pleural fluid aspirated with syringe
c) Can comment about grade and receptor status of tumor
I
d) Low complication rate
Parietal pleura punctured, and fluid comes out
0) Avoidance of scarring
I 1) Low cost
Finger inserted to release adhesions ,
I 2014
After finger is taken out, chest tube inserted
0.1: Breast b io p s y
X
Chest tube connected to water seal bag. BREAST BIOPSY
[See Fig. 1.5.7J
□ Mechanism o f action - Biopsy of
Contents of pleural cavity collects in the water bag. This water seal drainage also prevents airto s* breast tissue
back into the pleura.
□ Proper functioning Indicated by -
For palpable For non-palpable]
Dancing water column (water column moves up with inspiration & moves down with expiration) tumor • tumor
□ Removal o f drainage tube -
a) No more collection in water bag
b) Drainage has diminished to less than 30 cc
c) X-Ray shows sulficient inflation of lung.
□ Complications-
a) Infection
Stereotactic Ultrasound/MRI Needle localised
b) Hemorrhage
Mammographic guided excisionat
c) Injury to intercostal nerves & vessels biopsy (NLEB)
 310 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 311

FNAC: Sac and contents are densely adherent to each other

• Fine needle aspiration cytology is the first, simplest and least invasive technique for ob;a d) scybalous content of the large bowel can be indented with the finger, like pulty.
cell diagnosis in breast cancer ^ « on examination:
• Mininum 6 aspirations are done a\ Colicky abdominal pain
• Giemsa, hematoxylin and eosin, papanicolaou stains used Tense tender irreducible swelling
• It can be rep eated 2 times c) Absence of expansile cough impulse
□ Advantages : (1) least painful (2) cheap (3) reliable (4) can be done on Out patient basis/t, d) If strangulated- Nausea, vomiting, Features of shock
evidence of malignant deposits along FNAC track e) spontaneous cessation of pain may be a sign of perforation

□ Disadvantages: j investigations:
(1) Receptor study cannot be done a) plain X-ray abdomen in erect posture
(2) Invasive cancer cannot be differentiated from in situ disease b) Serum electrolytes
(3) False negative results do occur, mainly due to sampling errors c) Blood urea, serum creatinine
d) Complete hemogram (TLC increased)
□ Core needle biop sy:
e) USG abdomen
' • It is the preferred method for diagnosis of palpable or non-palpable breast abnormalities
• Permits analysis of breast tissue architecture to give clear histological evidence and defat 2 Treatment:
preoperative diagnosis a) Nothing per mouth
• Can confirm DCIS and invasive lesion b) Nasogastric suction
• Can comment about grade and receptor status of tumor c) Broad spectrum antibiotic
□ Frozen section biop sy: d) Fluid and electrolytes maintenance
• Not usually practiced now-a-days e) Catheterisation to maintain adequate urine output
• Indication: when FNAC fails even after 2 trials or is negative f) Analgesia for pain
• Disadvantage: Shows 20% false negative results 0 S u rg e ry :
□ Exclslonal biop sy:
• Also known as open biopsy
• It is the best and definitive investigation for breast cancer
• Incision is planned in such a way that it will be included in the eventual mastectomy incisions!
later date
• Should give no false negative and no false positive results
□ Needle localised exclslonal biopsy (NLEB):
I
• Procedure:
(1) Through an incision under local anesthesia, a hook is placed adjacent to the suspee
lesion, using needle sheath over the tumor
(2) Excision biopsy is done under mammographic guidance
• Indication:
When core needle biopsy fails to localise non-palpable tumor

0 .2 : Incarcerated hernia
IN C AR C ER ATED H ER NIA

□ Contents o f hernial s a c :
• Colon occupies the hernial sac. The lumen of that portion of colon is blocked with faeces.

□ Features:
a) Always irreducible
b) Often obstructed, but may not be strangulated
 312 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics S Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper -1 313

0 .3 : Blood substitutes . Types-

m low molecular weight dextran (mol. wt. 40000) - also known as rheomacrodex or dextran 40
BLOOD SUBSTITUTES
(ii) High molecular weight dextran (mol. wt. 70000) - also known as dextran 70. .
□ What are they - Substances which can be used instead of blood to replenish the blood loss , Indications -
□ Types - i) DIC
(A) Plasma and its derivatives ii) Bums
(B) Synthetically prepared solutions , Precautions -

□ Plasma and its derivatl ves - (i) Not used > 1000 ml
(ii) Blood sample for grouping & cross-matching to be drawn before introducing this solution.

BLOOD FRACTIONS B g e l a t in e ­

Name Preparation Storage . Mol-wt 20000 - 40000

Indications '
. Less effective than dextran as plasma volume expander
• Packed cefl Centrifuging whole blood @2000-3000g 1-6°Cfor • Chronic anaemia
for 15 mi ns 35 days • Old age C. FLUOROCARBONS -
• Children
. What is it - Hydrocarbons in which hydrogen atoms have been replaced by fluorine
t Platelet rich plasma — do— • Burn
• Hypovolemia . Features -
• Severe protein loss a) Colourless
• Human albumin (4.5%) Repeated fractionation of plasma 4 X Several .cirrhosis ' b) odourless
months Edema / c) chemically inert
' nephrotic symhme d) dense liquid •
(Used as volume expander)
• Fresh frozen plasma Fresh plasma rapidly f rozen (contains clot­ -40°C for • Severe liver disease e) poorly soluble
(FFP) ting factors) 2 years . DIC • Advantage -
[1 unit FFP=3% rise in clotting factors) • Congenital clotting fact# Considered red cell substitute as it binds and releases oxygen rather than passively trans­
deficiency
porting dissolved oxygen.
• Following warfarin Iherapy
• Cryoprecipitate Visible white supernatant fluid when FFP —do— • Haemophilia A • Precaution -
thawed at 4°C (factor VIII t Fibrinogen) • Von Willebrancfs disease Patient has to be kept in hyperbaric environment during this transfusion.
• Fibrinogen Organic liquid fractionation of plasma Dried form • DfC
• Afibrinogenaemia (0) HYDROXYETHYLSTARCH (HES) -
• Platelet concentrate • Thrombocytopenia • Composition = Starch + Sodium hydroxide + Ethylene oxide
Centrifugation of platelet rich plasma
• Drug induced hemorrtiage . Mol-wt: 60000 - 4,50,000
• Prothrombin complex From pooled plasma which contains fac­ • Reversal of warfarin over­
concentrate tors II. IX. X dose
Q.4: Volvulus neonatorum

□ Synthetically prepared solutions - VOLVULUS NEONATORUM

(A) DEXTRAN - 0 What Is it -

• What is it - Polysaccharide polymer "Volvulus" is defined as a rotation in the axis of the loop of the bowel, either clockwise or anti­
• Production- Polysaccharide compound derived from bacterium Leuconostoc Mesenteroides, clockwise. "Volvulus neonatorum" is neonatal midgut volvulus secondary to midgut malrotation. It is
to which yeast extraction is added a life-threatening condition requiring treatment within 6 hours or less from onset.
• Disadvantages - 3 Development -
(i) induces rouleaux formation of RBC Normally by 12th week of gestation, the mid-gut returns to the fetal abdomen from the extra-embry­
onic coelom and begins rotating counterclockwise around the axis of superior mesenteric artery. In a
(ii) interferes with platelet function
classical case of intestinal malrotation, this doesnot occur as it should be. The caecum is at the central
(iii) interferes with blood grouping & cross matching and duodenojejunal flexure lies to the right of the midline, hence the base or atlachme.it of the small
• Function - Restore plasma volume bowel mesentery remains narrow, which predisposes to mid-gut volvulus.
 314 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 315

□ Clinical features - coecial feature: Amoebic abscess is usually sterile as trophozoites are found in wall of abscess and
1) Bile-stained vomiting (as the volvulus usually develops just below the ampulla of Vaterin. 0 not in the content
duodenum) 0 Stages:
2) Bloodstained stools may be passed by the baby- suggests strangulation Bj Amoebic hepatitis
□ Investigations - b) Amoebic abscess
Upper gastrointestinal contrast study - confirms the malrotation. q Site: Posterio-superior surface of right lobe
□ Treatment - (due to - larger size of right lobe
1) Resuscitation - streamline effect)
2) Urgent surgery- q pathology:
(a) Untwisting of the volvulus
Macroscopy -
(b) Widening the base of the small bowel mesentery
a) Enlarged liver
(c) Straightening the duodenum
b) Solitary, rarely multiple
(d) Positioning the bowel in a non-rotated position (Ladd's procedure).
t) Pus with following features -
(e) Occasionally removal of the appendix (as now, if retained, it lies in an abnormal sitewito
1) Chocolate coloured (anchovy sauce)
the abdomen)
2) Viscid
0 .5 : Amoebic liver abscess 3) Contains dead hepatocytes, RBC, necrotic material
AMOEBIC LIVER ABSCESS d) May be fixed to diaphragm due to peri-hepatitis

□ Synonym : Tropical abscess Uicdoscopy - (See Fig. 1.5.8)

□ IrWiaf is I t : Complication of amoebic dysentery • Clinical features:
□ Causative organism : Entamoeba histolytica (A) Systemic features in acute phase -
□ Common i n ; Alcohol ics, Cirrhotics 1) Weight loss
□ Pathogenesis: 2) Loss of appetite
3) Fever with chill and rigor
Amoebic typhylitis of caecum Infection from sigmoid 4) Jaundice
I i
Superior mesenteric vein ^ Inferior mesenteric vein Symptoms Signs
Portal vein (B) Abdominal features Upper abdominal pain (1) Tenderness
I (2) Guarding and rigidity
Liver (3) Splenomegaly
4- (4) Tender, soft, palpable liver in acute
Trophozoites release histiolysin phase; firm, smooth, non-tender
*1 liver in chronic cases
Destroy hepatocytes (5) Ascites
l
(C)Tiicracic features (1) Dry cough (1) Right sided pleural effusion
Amoebic hepatitis
I (2) Right shoulder pain (2) Intercostal tenderness
Liquefaction necrosis, blood vessel thrombosis, release and breaking of RBC (3) Chest pain-right side
— ■— .. ■ _ —— —. J
y
Multiple microabscess U Investigations:
I
a) TLC-raised
Coalesce
b) IFT - raised bilirubin, ALP. SGPT, SGOT, prolonged PT
I
c) USG Abdomen
Large abscess
 316 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics 4 Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS O Paper-I 317

d) Chest X-Ray fo-y . femoral hernia protrudes into femoral canal through femoral ring (medial to femoral
e) CT Scan abdomen \ descends upto saphenous opening and then escapes out into loose areloar tissue
f) Serological tests V la lity; Most prone for obstruction and strangulation among all hernias due to its narrow neck
f^irre g u la r pathway. 40% femoral hernia present as emergency hernia with obstruction or
□ Treatment:
strangula1ion-
a) Drugs -
Etiology:
1) Tab Metronidazole - 800 mg thrice daily - 10 days y Wide femoral canal
or
> Multiple pregnancies
Inj Metronidazole - 500 mg i.v. thrice daily - 1 0 days
Set predilection:
2) if patient continues to pass cyst even after full course of Metronidazole -
Tab Dihydroxyquinolone - 600 mg - 10 days F>>M
Laterality:
b) Aspiration -
> More common in right side
* Indications -
> 20% bilateral
1) Clinical features persist inspite of drug therapy
Clinicalpresentation
2) Clinical/radiographic evidence of hepatic abscess
* Procedure - . > Swelling with following features
- located below and lateral to public tubercle in the groin
Long, wide bore needle introduced in between 9th and 10th intercostal space, betwe«
anterior and posterior axillary lines - impulse on coughing
c) Percutaneous drainage - and aspirated fluid sent for culture and sensitivity - reducible with a gurgling sound
' d) Surgery - - dragging pain
Abscess opened -» pus evacuated -» Malecot’s catheter introduced and kept till stoppage ol V Obstrucion and strangulation presents with
drainage. - tender, painful swelling
- Irreducible
2014 Supplementary
- absent cough impulse
- abdominal distension
Q.1 :C T Scan • - vomiting
A : See Section 1, Segment E, Qs. 13 (Page No. 590) - fever, hypotension
0 2 : Pleomorphic adenoma > Gaur’s sign
A : See "P.S.A." Section 1, Segment C, Paper II, 2012, Qs. 5, (Page No. 406) - Pressure by the femoral hernial sac causes distension of superficial epigastric vein
and/or circumflex iliac vein
Q.3: Pheochromocytoma
Treatment:
A : .See Section 1, Segment A, Paper II, 2013 supplementary, Qs. 3 (Page No. 174)
r Lockwood low operation - approach from below inguinal ligament
0 .4 : Gallstone ileus V McEvedy high operation - done in cases of slrangulation
A : See Section 1, Segment D, Qs. 61 (Page No. 521) > Lotheissen’s operation - approach through Inguinal canal
Q S : Femoral hernia > A K Henry's approach - done in cases of bilateral femoral hernia
Ans : > Use of polypropylene mesh to close defect
FEMORAL HERNIA Differential diagnosis:

□ What Is I t : Abnormal protrusion of a viscous or part of a viscous through femoral canal Inguinal hernia
> Psoas abscess
□ Anatomy o f femoral canal:
> Femoral aneurysm
> Medial-most compartment of femoral shealh
' Haematoma
> Extent - From femoral ring to saphenous opening (where it is closed by cribriform fascia) >• Distenda! psoas bursa
> Contents - i) Lymph node of cloquet > Saphena varix •
ii) Fal > Lipoma
iii) Lymphatics > Enlarged cloquet node
 SIS QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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2015 . . , Sequalae-

Q.1: Ludwig's angina • Recurrence

See Section 1 Segment C Paper-ll, 2010, Question No. 11 (Page No. 380) • Fistula-in-ano (See Fig. 1.5.9)

Q.2: Appendicular lump

0,4 :AJOPS
See Section 1 Segment A Paper-1,2013 supplementary, Question No. 2 (Page No. 63 & 64)
MODS
Q.3: Types o l anorectal abscess
, Full form - Multi Organ Dysfunction Syndrome
ANORECTAL ABSCESS
, Definition - Development of potentially reversible physiologic derangemenl involving two or
• What is It - Abscesses around anal canal and lower rectum more organ systems not involved in the disorder, that resulted in ICU admission and arising in the
wake of a potentially life - threatening physiologic insult.
• Causative organisms -
. pathogenesis -
* E-Coli
* Bacteroides Toxins / endotoxins from organisms
* Staphylococcus i
* Streptococcus
Inflammation, cellular activation of macrophages, neutrophils, monocytes
* Proteus
• Commonly affected patients - I

. * Diabeties Release of cytokines, free radicals

* Immunocomp I
• Classification-
Chemotaxis of cells, endothelial injury, altered coagulation cascade - SIRS (Systemic Inflamma­
tory Response Syndrome)
Type Site Clinical feature Treatment I '
1) Perianal Superficial to perianal • Severe thrombing pain in • Incision and drainage offw Reversible hyperdynamic warm stage
abscess (60%) region I.e.. subcutane­ perianal region (cruciate incision preferaty
ous portion of external under general anesthesia i
t Increased on defaecation
sphincter. All loculi must be broket Severe circulatory failure
• Smooth, tender soft swell­ using sinus forceps andfin­
ing ger wound kept wide op® 4
and cavity is packed w#i
MODS
gauge T-bandage apple®
• Sitzbath I -

• Analgesics Hypodynamic, irreversible cold stage

• Antibiotics • SIRS-
• Laxatives Presence of 2 or more of the following -

2) Ischio-roctal Ischiorectal fossa Severe acute pain by side of • Same as described abo« ’ Temperature < 36°C or > 38°C
abscess (30%) anal canal, aggravated during * HR > 90/min
• Any presence of
defaecation
should be looked for J " RR > 20/min
3) Submucous Deep to mucous mem­ Perianal pain Small Incision and drainageft ’ TLC <4000/ p i or > 12000/ | il
abscess/ brane of anal canal stretching the anus or by
Intersphineterlc above dentate line a proctoscope • MOD Score
abscess i

4) Pelvi-rectal Above levator ani and Pelvic abscess which may be USG to find out cause »dj
abscess/Supra- below pelvic perito­ due to appendicitis, salpingi­ acordingly managed.
levator abscess neum tis, diverticulisls etc
 320 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS O Paper-I 321

Organ System ----- TargetTystem Convincing evidence Controversial or Investigational

Respiratory >300 226-300 151-225 76-150 DVT prophylaxis Anticoagulant therapies such as anti­
SIS
PO2 /F 1O2 thrombin III
R en a l Anti-cytokine and other mediator-tar­
£100 101-200 201-350 351-500 SDD (Selective Decontamination of the
Serum creatinine lwrw*ol°9ic geted therapies
Digestive Tract)
(Mmol/L)
Endocrine Corticosteroids in late sepsis
HepaVf
S e r u m b ilir u b in (n m o l / L ) S 20 21-60 61-120 121-240
>245
C a rd io v a s c u la r qj • Estrogen & Progesterone Receptors:
S10 10.1-15.0 15.1-20.0 21.1-30.0
R/P Ratio >30.0
ESTROGEN AND PROGESTERONE RECEPTOR
Haematoloalc
Platelet count (x 103/mm3)
>120 81-120 51-80 21-50 sso 0 Whit are they - Protein receptor molecules activated by hormones estrogen and progesterone
N e m o lo a lc
respectively
15 13-14 10-12 7-9 <6
Glasgow coma score A) ESTROGEN RECEPTORS
• Types (Based on location) -
HR x Right atrial pressure
R/P Ratio = a) Nuclear - ER a, ER p
MAP
b) Membrane - GPER30, Gq-mER, ER-X
■ Genetics -
• Effects of organ failure in MOOS -
Encoded by gene ESR1 (Chr. 6)
• Lung — ARDS and gene ESR 2 (Chr. 14)
• Liver — Acute liver insufficiency
• Location -
• Kidney - Acute kidney injury
' ERu — * Breast
• Cardiac — Cardiovascular failure * Endometrium
• Blood — Coagulopathy ' Ovary (stromal cells)
• Prevention of MODS in clinical set-up - * Hypothalamus
* ER p - * Kidney
Target system Convincing evidence Controversial or investigation! * Brain
‘ Ovary (Granulosa cells)
Lung Pressure or volume limited ventilation Liquid ventilation, non-physio^
to minimize barotrauma and volutrauma modes of ventilation (high freqM'W * Lungs
oscillation) * Heart
Cardiovascular Restrict transfusion of packed red cells * Prostate . '
Supranormal oxygen d®frvery, <**’
when hemoglobin is > 70 crystalloid fluids; SwanGanz cathett ‘ Endothelial cells
ization
B) PROGESTERONE RECEPTOR
Renal Avoidance of nephrotoxins Continuous veno-venous hemo®3® • Also known as - NR 3 C 3 (Nuclear Receptor Subfamily 3)
• Location - Intracytoplasmic
Gastrointestinal Stress ulcer prophylaxis with H2 Gastric tonometry
• Genetics - Encoded by PGR gene (Chr. t f)
blockers rather than sucralfate
• Location - ' Breast
Enteral nutrition * Endometrium

i
 322 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 323

C) SALIENT FEATURES Agt: Above 50 years

• ER upregulates PR "1 . . .. • More common in males
* Y in endometrium
• PR downregulates ER J 2 * '
incidence: 10%
Thus, progesterone acts only in Estrogen primed endometrium lite ra lly • Bilateral in 10% cases

j c ^ > lfM tu rt:

Breast CA types ER PR HER-2/neu > smooth
Luminal A + + - > Cystic
>■ Soft
Luminal B + + +
■
r Slow growing
Basal - - - r Fluctuant sometimes
y Non-tender
• Most common subtype - Luminal A j site: Lower pole of parotid gland
• Best prognosis - Luminal A j Chance o l m a lig n a n c y : Nil
• Worst prognosis - Basal 3 In v e s tig a tio n s : 1 “ Hot spot" on Tc" scan
2 FNAC
Selective Estrogen Receptor Modulator (SERM)
3 Treatment: Superficial parotidectomy
• Tamoxifen -i
. Raloxifen f used in treatment of Breast CA OS: Colostomy

Ans: •
Selective Progesterone Receptor Modulator (SPRM)
COLOSTOMY
• Mifepristone"j u s e d jn u te rj n e fibroids,
• Ulipristal acetate f contraception j Wh»t is i t : Artificial opening made in colon, extending to the skin, in order to divert the faeces and
flatus into a bag kept on the skin.

2015 Supplementary U Types:

(a) Temporary - Done in case where diversion of faeces is required to facilitate healing distally
0 .1 : Fibroadenoma in the colon and rectum. It is closed after the purpose is solved.
A : See Section 1, Segment D, Qs. 48 (Page No. 506) (b) Permanent - End colostomy, which remains open throughout rest of life

G .2: Branchial cyst (c) Transverse-Of two types

A : See Section 1, Segment C, Paper 1,2010, Qs. 3 (Page No. 287) (i) Loop -> 2 openings; one for stool and other for mucus. Loop of bowel is pulled out onto
abdomen and held in place with an external device
Q.3; Complications o l splenectomy
(ii) Double barrel -» Similar openings like loop colostomy but separated by a gap, in between
A : See Section 1, Segment C, Paper 1,2013 Supplementary, Qs. 1, (Page No. 305)
only proximal stoma is functioning.
Q.4: Warthin's tumour
U Indications :
Ans:
(a) Temporary colostomy
W ARTHIN’S TUMOUR
y Anorectal malformation *
□ Synonym : y Congenital megacolon
y Adenolymphoma y High anal fistula ^
y Papillary cystadenolymphomatosum y Left sided colonic growth or perforation
□ What Is i t : Benign tumour of parotid salivary gland
y Sigmoid volvulus «•>
□ Site : Lower pole of parotid gland; generally superficial lobe is only involved (b) Permanent colostomy
□ L in in g : Double layer of columnar epithelium, along with papillary projections into cystic spaces** y Carcinoma anal canal "
lymphoid tissue in stroma
. y AP Resection
□ O rigin: Due to trapping ol jugular lumph nodes in parotid gland during developmental period y After Hartmann's operation *''*
 324 QUEST ; A Comprehensive Guide to UG Surgery, Orthopedics S Anesthesiology
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□ S ites:
(a) Temporary -» V Right hypochondrium
> ^symptomatic
> Left iliac fossa
(b) Permanent -» Left iliac fossa,6 cm above andmedial to anterior superior iliac spin,
, Complications like jaundice and pain when it impinges onto biliary tree
y jrritation in right upper quadrant
(c) Transverse Upper abdomen, in middleor towards right side of body. . palpable mass in liver with classical thrill (hydatid thrill) elicited by three finger test
□ Complications: > Generalised symptoms - weight loss, dyspepsia, fatigue, vomiting
> Prolapse of mucosa • ''' y Features of anaphylaxis
> Necrosfs of stoma f sometimes, splenomegaly, pleural effusion may occur

V Parastomal hernia - camollotte sign - Following intrabiliary rupture, gas enters into cyst causing partial collapse
of the cyst wall
> Retraction and stenosis of stoma *■'
V Bleeding * * I complications:

> Enteritis and diarrhoea ' y infection

> Skin excoriation —- y Rupture into biliary tree and surrounding structures
> Obstructive jaundice
□ Colostomy ca re :
^ Calcification
> Skin care to prevent excoriation
> Anaphylaxis
> Close observation for complications
> Liver failure
> Training to manage colostomy
Invesligitions:
> Psychotherapy
r USG abdomen
> Dressing to be done.
> CT scan abdomen
2016 Classification based on CT find in gs:
y CL-unilocular anechoic cystic lesion without any internal echoes and septations
0 .1 : Pancreatic pseudocyst _ > C E1 - uniformly anechoic cyst with fine echoes settled in it representing hydatid sand
A : See Section 1, Segment B, Paper I, Qs. 6 (Page No. 231) > CE 2 - cyst with multiple septations giving it a multivesicular, rosette, or honeycomb
0 .2 : Liver abscess appearance, within a unilocular mother cyst. This stage is the active stage of the cyst
A : See Section 1, Segment C, Paper 1,2014, Qs. 5 (Page No. 314) ' CE 3 - unilocular cyst with daughter cysts having detached laminated membranes, giving
the appearance ol the water lily sign. This is the transitional stage of the cyst
0 .3 : M arjolln's ulcer
A : See Section 1, Segment C, Paper I I 2013, Qs. 10 (Page No. 421) * CE 4 - mixed hypo and hyperechoic contents with absent daughter cysts; these contents
give the appearance of a ball of wool (ball of wool sign) indicating th8 degenerative nature of
0 .4 : Femoral hernia the cyst
A : See Section 1, Segment C, Paper 1,2014 Supplementary, Qs. 5 (Page No. 316) * CE 5 - arch-shaped, thick, partially or completely calcified wall. This stage of cyst is inactive
Q.5: Hydatid cyst o f liver and infertile
Ans: > Serological tests
HYDATID CYST OF LIVER - ELISA
- Indirect haemagglutinalion test
□ What is i t : Infective cystic condition of liver - IFA test
□ Causative organism : Parasite Echinococcus granulosus (dog tapeworm) > LFT
□ Structure o f c y s t: From outside inwards- v Casoni’s test (now obsolete)
V Pericyst / Adventitia - fibrous tissue due to reaction of liver to parasite ' abdomen (to view biliary tree and its relation to hydatid cyst)
r Ectocyst - laminated membrane, whitish, elastic ' ERCP
>- Endocyst / Germinal epithelium - secretes hydatid fluid, brood capsules with scolWS ' PCR
* Detection of precipitation line - arc 5
' immunoblolting
326 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 327

□ Treatment: 2016 Supplementary

A) Drug therapy -
> Indications n i : nyroglossal cyst
(i) 4 days prior to intervention till 1 month or 3 month after intervention depei^ \ See Section 1, Segment C. Paper II, 2008, Qs. 4 (Page No. 348)
drug ^ Q j .Basal cell carcinoma
(ii) Multiple cysts
A. See Section 1, Segment C, Paper 1,2009, Qs. 2 (Page No. 280)
(iii) Inoperable cases
(iv) Surgically unfit patients 0.3: FNAC
(v) Cysts in lung, bone, brain Ans:
FNAC
> Drugs
(i) Albendazole - 3 cycles of 4 week drug therapy followed by 2 week drug free ink, q full form: Fine Needle Aspiration Cytology
(10 mg/kg/day)
g What is I t : Cytological study of tumour celts to find out the disease and confirm its benign or
(ii) Mebendazole - 600 mg daily for 4 weeks malignant nature
(iii) Praziquantel - 60 mg/kg along with Albendazole sometimes for 2 weeks. 3 Procedure:
B) PAIR (Puncture - Aspiration - Injection - Reaspiration) > 23-24 Gauge needle fixed to specialised syringes are used for aspiration
> Indications r Contents smeared on slides - both dry as wellas (hose fixed with100% methanol
(i) Infected cysts y Cytological study done after Papanicolaou, Geimsaor Romanowsky staining
(ii) Relapse 0 Indications: Lesions of
(iii) Inoperable cases > Parotid
(iv) Gharbi types 1 and 2 > Thyroid - not useful in follicular carcinoma
G hafwi classification : Type 1 - Pure fluid collection, Type - 2 Fluid colleclion *s>
V Lymph node
wall, Type 3 - Fluid collection + septa, Type 4 - Heterogenous appearance, Typ*;
> Breast
- Reflecting thick walls
> Liver *
> Procedure
Cyst punctured .
> Lung J USG guided
'■r Kidney
I
50% fluid aspirated along with multiple daughter cysts 0 Contraindication: Testicular tumour

I .
0 Advantages:

Scolicidal agents injected > Done in OPD

I r Least invasive
Reaspiration after 20 minutes > Cost effective
/• Very sensitive
C) Surgery-
r No need of anaesthesia
> Gold standard therapy
> No risk of tumour dissemination through the track
> Laparoscopic pericystectomy is becoming popular
Q Disadvantages:
> Procedures to correct cystobiliary communication
> Tissue study not possible
(i) Suturing of communication
(ii) Bipolar drainage > Negative result does not rule out malignancy

(iii) ERCP Sphincterotomy 0.4: PeMc abscess

(iv) Tube drainage of cavity - Ans:

(v) Internal drainage procedures like choledochojejunostomy, transduo#' PELViC ABSCESS

sphincteropoasty
What is it * Collection of pus in rectouterine or rectovesical pouch (pouch of Douglas)
Speciality: Most common intraperitoneal abscess
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□ Etiology: t Pattiogenesis:
V Pelvic Infections J Bowel loop is obstructed at its point of entry and exit creating closed loop
> Appendicitis I
> Sequelae of diffuse peritonitis Necrosis and gangrene at site of obstruction and over convex summit of bowel loop
> Postoperative cases of abdomen I
□ Clinical features: Perforation from these sites
> Mucus discharge per rectum i

> Diarrhoea Peritonitis

> Lower abdominal pain and distension
V Fever with chills and rigor INTESTINAL OBSTRUCTION
> Frequent burning micturition 3 pathophysiology o f mechanical obstruction:
□ Examination (t) The proximal portion of gut contracts vigorously to overcome the distal obstruction. This
P/R -» Soft, boggy, tender swelling In anterior wall of rectum leads to spasmodic pain and is known as abdominal colic.
(2) The proximal portion of gut gets distended due to collection of fluid and gas giving rise to
□ Investigations:
abdominal distension.
> Raised TLC
(a) Fluid is collected due to -
y USG abdomen - diagnostic
(i) Salivary secretion - 1500 cc in 24 hours
> CT abdomen
(ii) Gastric secretion - 2500 cc in 24 hours
□ Treatment:
(iii) Bile and pancreatic juice - 1000 cc in 24 hours
> Antibiotics started
(iv) Succus entericus (int, external secretion) - 3000 cc in 24 hours
> Abscess drained per-rectally under G/A after urinary catheterisation
(b) Air comes from-
> Laparotomy required sometimes
(i) Swallowed air during respiration
Q.5: Closed loop obstruction (ii) Diffusion of CO2 from the distended veins into lumen
Ans: (iii) Putrefaction of the intestinal contents
CLOSED LOOP OBSTRUCTION • (3) The stagnant material in the proximal gut is regurgitated into the stomach and finally comes
out as vomitus
□ What is I t : Type of intestinal obstruction in which two points along the course of a bowel art
(4) The distal portion of the gut is thrown into continuous spasm (no peristalsis) Hence, there is
obstructed at a single location thus forming a closed loop
no passage of faeces, or flatus. This is known as absolute constipation.
□ E tiology: Secondary to adhesions, twist of mesentery or herniation. The closed loop rotates aroun)
(5) During this process, there is loss of fluid and electrolytes leading to dehydration and exhaustion
its axis forming a volvulus.
(muscular weakness). It is due to - '
(i) Vomiting
Proximal bowel
(ii) Sequestration of fluid into intestinal lumen (fluid collected in the intestine does not get
absorbed. Hence, it is cut off from blood circulation. So, there is hypovolaemia which may
lead to shock)
(6) Due to enormous stretching of the wall, there is vascular jeopardy (loss of circulation in the
wall) which finally may lead to gangrene, perforation and peritonitis
1 Clinical features:
(1) Acute colicky abdominal pain
(2) Abdominal distension (distension more in upper abdomen in case of small intestinal
obstruction. In large gut obstruction, distension is more in lower abdomen and flanks)
(3) Vomiting - It is more characteristic of small gut obstruction. In large gut obstruct®. . vomiting
maybe absent.
(4) Absolute constipation (no flatus, no faecus)
Fig. : Closed loop obstruction
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(5) Features of dehydration - dried tongue, sunken eyes, features of electrolyte loss e . tnrnnna n f fluid chart and administration o l fluid based on calculation - The lossof the fluid is
fatigue, muscle weakness, lethargy, dried skin ' ^ ^^Jre cT b y : (I) amount of nasogastric aspiration
Q Investigations: (ii) urine output |
(1) Blood- (iii) invisible perspiration - 500 cc approx. j To,al ou,Put
(i) Routine examination - Hb, TC, DC, ESR, etc (iv) respiratory loss - 500 cc approx. }
(ii) Special examination - (a) Sugar, (b) urea, (c) creatinine, (d) electrolytes, (e) seruma*,. Intake should be according to output so that the loss is corrected but there will be no overloading
(2) X -R ay- ^ (If overload - Rx Lacix, Furosemide to induce diuresis)
(i) Straight X-Ray of abdomen - (It is known as Fluid Administration with Maintenance of Intake - Output Chart]
(a) Free gas under diaphragm indicates perforation (iii) Antibiotics - There is stagnation of intestinal contents leading to proliferation of the
(b) Distended intestinal shadows - The characteristic radiological features of each rvv, bacteria which are normally present in intestine (coliforms). There may be toxic effects
of gut are - which are combatted by antibiotics (specially Melronidazde)
* Ileum - featureless (wall is straight) (iv) In-dwelling catheter - To measure 24 hour urine output
* Jejunum - concertina effect (The valvulae connevantis of the jejunal n w Howto understand i f abdomen Is distended ?
are seen In a regular rythmic fashion) 1
Take a string - tie it around abdomen at level of umbilicus - now see (if any groove formed or not i.e.)
* Colon - presence of haustrations (colonic shadow) whether it becomes tightend -» distension progressing OR loosened -> distension degressing

0 Follow-up:
(a) Clinically - regarding distension, vomiting, etc
(b) Biochemically - about electrolytes
Results - (i) condition improving
frustrations not Opposite to (ii) condition deteriorating
opposite to each each other Effect - (i) If improves, continue conservative treatment
(ii) If deteriorates - operative intervention
°“ (Tr r r r r V
□ Surgical treatm ent:
A Indications -
Jejunum (1) conservative treatment fails
(2) rebound tenderness (suggests gangrene of gut)
abdomen needs to
(3) if rigidity appears - peritonitis be opened
Fig: Intestinal obstruction (4) if perforation cannot be differentiated
(5) if paralytic ileus develops
B. Steps of operation -
Presence of multiple fluid level with distended intestinal / gas shadows
Gas black - » shadow (1) Abdomen is opened by lower right paramedian incision -* (to see the caccum)
(2) Caecum is identified [See Chart on the next page]
Fluid -* white shadow
Procedure to check the viability -
Gas will exert equal vertical pressure on liquid. Hence horizontal level of fluid
(3) USG - doesnot help to diagnose intestinal obstruction but is important to differentiate to* Under normal condition, gut has the following characteristic features -
acute cholecystitis or acute pancreatitis (i) Pinkish in colour
(ii) Normal lustre
□ Treatment:
(iii) Peristaltic movements present
(A) Conservative treatment
(iv) On needle-prick, there is bleeding from the wall
(i) nasogastric suction - to decompress the distended intestine;
(v) Pulsation is present in the mesenteric artery
(ii) i.v. fluid - to compensate loss of fluid and electrolytes (glucose -*■ lor nutrition, electro^
-» to correct electrolyte imbalance) When the viability is doubted,

[ calculate the electrolyte loss and infuse specific fluid accordingly ] (i) the colour may change into black
(ii) lusture may be losl
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Q,:Sentinelnode biopsy
(2) Caecum is identified
A -See Section 1, Segment C, Paper II, 2010 supplementary, Qs. 13 (Page No. 388)
___ ____ L g 5 . Mesenteric cyst
Caecum collapsed Caecum distended
* I A" *: MESENTERIC CYST
Small intestinal obstruction Large intestinal obstruction What is I t : Cystic lesions in mesentery, can occur anywhere from duodenum lo rectum.
\ /
Reach a junction of distended and
collapsed part of the gut
Chylolymphalic | |
t m B S S ^ S l ' •
i
/ Origin Congenitally misplaced lymphatic Diverticulum or duplication from
This is the site of obstruction system adjacent bowel
\ Thin; with Hat endothelium Thick (contains all layers of bowel)
/ m
Obstruction relieved
Bloodsupply Independent From adjacent
✓ i \ •' Enucleation Done Not done
In lumen In wall Outside wall
Other features • Mainly in ileum
1 • Contain lymph/chyle
Viability of gut Is checked • Solitary
(i.e. if alive or not) • Unilocular

G Other causes / type s:

Viable Non-Viable. > Cysts of urogenital remnant
I > Hydatid cyst of mesentery
Keep it inside and Resection and > Teratomatous dermoid cysts
close the abdomen anastomosis t Cyst / haematoma formation following trauma
v Tuberculous cold abscess of mesentery
(iii) peristaltic movements absent / sluggish
□ Clinical features: -
(iv) needle-prick doesn't cause bleeding
Abdominal swelling - painless
(v) pulsation of mesenteric artery absent / feeble
- smooth
£ £ £ " • conditions, hot-mop Is applied. If the conditions improve. colour returns, lustra - fluctuant
th egut
me o u t!is viable.
I T T If not,
. °gut
T is non-viable.
’ 'hSM iS b'eedin9 ° n n° edle prick‘ fnesenteric arteries are pulsated, - freely mobile in direction
- not moving with respiration
2017 Q Tilhux's triad:
r Soft, smooth swelling in umbilical region
0 . 1 : Alvarado Score
> Freely mobile in a direction perpendicular to mesentery
A : See Section 1, Segment C, Paper II, 2011, Qs. 11 (Page No. 396) > Zone of resonance all around
Q.2; Parotid abscess 0 Age gro up; Childhood, more common in 2nd decade
A : See Section 1, Segment C, Paper II, 2011, Qs. 6 (Page No. 395)
Q investigations:
Q.3: Gastrinoma ' USG Abdomen
A : See Section 1, Segment B, Paper I, Qs. 8 (Page No. 240) CT Scan abdomen
 334 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 335

□ Treatment: 2018 Supplem entary

> Chylolymphatic cyst -> enucleation
y Enterogenous cyst - » removal ot cyst with resection ot adjacent bowel sentinel Node Biopsy
y □ Complications: \ See section 1, Segment C, Paper II, 2010 supplementary, Q 13, (Page No. 388).
y Torsion of cyst .. pleomorphic adenoma
> Rupture \ •See Section 1, Segment C, Paper II, 2012, Q 5 (Pleomorphic salivaiy adenoma), (Page No. 406).
y Infection
_i0(V enterlor resection o f Carcinoma rectum
y Haemorrhage
. . |n Rectal carcinoma-
S ’Q Differential diagnosis:
y Hydronephrosis I surgery is the main method of treatment. • - .
y Omental cysts (b) Abdomino-Perineal Resection (APR) is the gold standard.
y Tuberculosis . gu) jj Tumor is well differentiated and if there is adequate margin above the anal canal, a sphincter
saving Anterior Resection (AR) may be done.
2017 Supplementary (d) Total Mesorectal Excision (TME) should be the goal. •
(e) principles of surgery-
Q. J ; Sigmoid volvulus • Distal margin - 2cm away from the lesion
A : See Section t, Segment D, Q 108 (Volvulus), (Page No. 567). . Proximal margin - 5cm away from the lesion
. Radial margin - 3cm of mesorectum to be removed
0 .2 : Tuberculous cervical lymphadenopathy
(f) Laparoscopic AR is becoming popular.
A : See Section 1, Segment D, Q 82 (Collar Stud abscess), (Page No. 539).
|g) Proper preoperative bowel preparation - •
Q.3: Keloid • Low residue diet for 48-72 hour before surgery, only clear liquid on day before surgery, no
A : See Section 1, Segment C, Paper II, 2013 Suplementary, Q 9, (Page No. 426). feed on day of surgery
• Elemental diet for 3-5 days before surgery
0 .4 : Ranula
• Single dose of oral polyethylene glycol dissolved in 2lt of water on day before surgery
A : See Section 1, Segment 0, Q 68, (Page No. 526).
• Bowel wash using normal saline for 2-3 days before surgery
O.S: Choledochal cyst
• Total gut irritation
A : See Section 1, Segment 0, Q 42, (Page No. 501). • Antibiotics
(h) Criteria for anterior resection -
2018 • Upper and middle third rectal growth
• Above peritoneal reflection
Q. 1: Diagnostic peritoneal lavage
• Well-differentiated Tumor **
A : See Section 1, Segment E, Q 2, (Page No. 580).
• < 4cm size Tumor
0 .2 : Colostomy • T1N0/T2N0 Tumor
A : See Section 1, Segment C, Paper 1,2015 Supplementary, Q 5, (Page No. 323). • Tumor without lymphatic or venous spread.
(i) Preoperative and postoperative radiotherapy
0 .3 : Molecular subtypes o f Breast carcinoma (j) Chemotherapy *
A : See Section 1, Segment C, Paper 1,2015, Q 5 (Estrogen and Progesterone receptors), (Pag* • Neoadjuvant
No. 321). • Adjuvant
• Palliative
0 .4 ; Intussusception
A : See Section 1, Segment C, Paper II, 2013, Q 9, (Page No. 420). 0-5•' Malignant melanoma
A: See Section 1, Segment D, Q 71 (Melanoma), (Page No. 529).
Q.S: Amebic liver abscess
A : See Section 1, Segment C, Paper 1.2014, Q 5, (Page No. 314).
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2019 j Pathogenesis:

Q. 1: Subphrenlc Abscess .e!ia\ __ Hyperemia Ecudative 2-4 hr t Neutrophilic. Activation of mast cells,
Contamination fluid Macrophages exudate mesothelial lining cells
SUBPHRENIC ABSCESS

□ What Is I t : Localised collection of pus underneath right or left hemi-diaphragm Abscess <— Compartmentalization Fibrin Cytokines, Procoagulants
□ Speciality: Most common intra abdominal abscess of peritonitis
□ Anatom y:
a) Left subphrenic space : Boundaries as follows - 0 factors favouring abscess:

Above -» diaphragm
Behind -> Left triangular ligament, left lobe of liver, gastrohepatic omentum and ante*
J ___ L ] '

surface of stomach
f
Local factors Microbial factors
Right Falciform ligament
. Local fibrin deposition • Polymicrobial Flora
Left -> Spleen, gastrosplenic omentum, diaphragm
• Low pH • Bacteroides fragilis
b) Right subphrenic space : Boundaries as follows - • Particulate stool • Capsular polysaccharide
Above -> Diaphragm • Hypoxia
Below -> Right lobe of liver
Behind -> Anterior layer of coronary and right triangular ligaments 0 Clinical features:
Left -> Falciform ligament • Mostly non-specific (remember ‘pus somewhere, pus nowhere, pus under the diaphragm)
• Symptoms of toxaemia reappear after a few days ofdealing with some intra-abdominal
infective focus
• Condition steadily and often rapidly deteriorates
• Sweating
• Wasting and anorexia
• High spiking fever with chills
• Tachycardia
• Tachypnoea
• Epigastric fullness
• Pain in shoulder of affected side
• Persistent hiccough
0 Investigations:
• Chest X-ray - Collapse of lung, basal effusion, empyema, elevated diaphragm, air fluid level
• USG Abdomen
• CT Abdomen - Low alternation, lucent centre with rim enhancement
• Mftl
3 Management:
□ Causes o f abscess :
• i.v. fluids
a) Left side: Operation of stomach, tail of pancreas, spleen or splenic flexure of colon
• Antibiotics
b) Right s id e : ‘ Initial resuscitation is very crucial
• Perforating cholecystitis • CT guided drainage of abscess (Drain withdrawn over 10 days)
• Perforated duodenal ulcer
• Duodenal-cap 'blow-out' following gastrectomy and oppendicitis ; Complications o f splenectomy
A: See Section 1. Segment C. Paper 1,2013 Supplementary, Q.1, (Page No. 305)
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Q.3: Femoral Hernia HERNIA IN ADULTS (PARAUMBILICAL HERNIA)

A : See Section 1, Segment C, Paper 1,2014 Supplementary, Q.5, (Page No. 316) *»s • Conditions that cause stretching and thinning of linea alba -

Q.4: Adenomatous polyps o f colon , pregnancy

. Obesity
A : See Section 1, Segment D, Q.47, (Page No. 505) , Liver disease with cirrhosis
Q.5: Tuberculous CervicalLymphadenopathy Delect: Bounded with well defined fibrous margin
A : See Section 1, Segment D, Q.82 (Page No. 539) 'Collar Stud Abscess’. 3 location: Defect in median raphe is immediately adjacent to (most often above) the true umbilicus

"* * Small hernia -+ extraperitoneal fat or omenlum

2019 Supplementary Larger hernia - » small or large bowel
3 CompHc3,lons ; Umbilical hernia that includes bowel may become irreducible, obstructed and
Q.1: Amoebic liver abscess strangulated
A : See Section 1, Segment C, Paper 1,2014, Q.5 (Page No. 314) 3 Clinical features:
Q.2: Rupture o f the Spleen • Overweight (with thinned and attenuated midline raphe)
. Bulge typically slightly to one side of the umbilical depression -* crescent shaped umbilicus
A : See Section 1, Segment A, Paper 1,2010 Supplementary, Q.3 (Page No. 31)
• Abdominal pain due to tissue tension
Q.3: Pseudocyst o f the pancreas • Symptoms of bowel obstruction
A : See Section 1, Segment B. Paper I, Q.6 (Page No. 231) . Overtying skin - Stretched, thinned, develop dermatitis

. Q.4: Diagnosis o f acute small bowel obstruction 3 Sex affected: Females > Males
j Treatment:
A : See Section 1, Segment C, Paper 1.2016 Supplementary, Q.5, (Page No. 328) & See Sect*'
Segment D, Q.72 (Page No. 531) • Small hernia - Left alone if assymptomatic
• Large hernia - Mostly contain bowel, hence surgery advised
Q.5: Umbilical Hernia > Defects < 1 cm -> Closed with simple figure of 8 suture
UMBILICAL HERNIA OR
Repaired by Darn technique (non-absorbable, monofilament suture is criss crossed
□ What Is I t : A type of ventral hernia i.e., herniaon anterior abdominalwall across the defect and anchored firmly to the fascia)
□ Defect: Umbilical defect is present at birthbut closes as the stump of the umbilical cord ha *- Defects 1 • 2 cm -» Sutured with minimal tension (classic repair described by Mayo)
usually within a week ol birth. If this process is delayed, It leads to herniation. r Defects > 2 cm -♦ Mesh repair (Mesh may be placed in (a) within peritoneal cavity, (b) in
retromuscular space, (c) in extraperitoneal space, (d) in subcutaneous plane)
UMBILICAL HERNIA IN CHILDREN
□ Incidence : 10% of infants, higher incidence in premature babies
December-January 2019-2020
□ Timing: Appears within few weeks of birth
□ Sexes affected: Both male and female Of .Parotid fistula.
□ Symptoms : Often symptomless, but increases in size on crying and assumes a classic cart A: See Section 1, Segment D, Q.116 (Page No. 574-575)
shape OS: Cold abscess
□ Complication: Obstruction and strangulation rare below 3 years age
A: See Section 1, Segment D, Q. 114 (Page No. 573)
□ Treatment:
0.3: Volvulus
• Conservative management when asymptomatic below 2 years age
A: See Section 1, Segment D, Q.107 (Page No. 567)
• Parental reassurance (95% resolve spontaneously)
• Surgical repair if persists beyond 2 year age Idiopathic Thrombocytopenic Purpura (ITP)
(Small curvilinear incision below umbilicus -> neck of sac defined, opened and any
returned to peritoneal cavity -» sac closed -> redundant sac excised -> defect in linM*-
IDIOPATHIC THROMBOCYTOPENIC PURPURA
closed with interrupted sulures) ^ ^ al is i t ; The most common cause of acute onset thrombocytopenia in otherwise normal child
340 QUEST : A Comprehensive Guide to UG Surgery, Orthoped-cs & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-1 341

□ . Incidence: 1 in 20,000 children >• History suggestive of bone marrow syndrome or malignancy
□ Predisposing le c to r: Viral infection In recent past (most common Epstein Barr virus Infect)^ , Direct Coomb’s Test

□ Peak age g ro u p : 1 - 4 year old.

□ Pathophysiology:
Autoantibody develops directed against platelet surface , HIV infection
1 , Lymphoma
Antibody binds to platelet surface n fnatmant:
i , Counselling and education for mild, moderate symptoms
Circulating antibody coated platelets recognised by t intravenous immunoglobulin 0.8 - 1g/kg /day for 1-2 days
FC receptor on splenic macrophages -* ingested -» destroyed , intravenous Anti D therapy @ 50 - 75 pg/kg
, prednisolone 1 - 4 mg/kg/day - continued for 2 - 3 weeks
, splenectomy:
Indications are -
i) >4 year age with chronic ITP
ii) Not responding to medical management
)>
iii) Intracranial hemorrhage
j Prognosis:
J> • Spontaneous resolution in 70 • 80% cases
Antiplatelet antibody • <1% develop intracranial hemorrhage
Antibody coated platelet binds • 20% develop chronic ITP
to macrophage • ITP in younger children more likely to resolve

OS: Acute Necrotislng Pancreatitis

Clinical presentation:
• Sudden onset generalised petechiae and purpura ACUTE NECROTISING PANCREATITIS
• Age : 1 • 4 year
• Associated bleeding from gums and mucous membranes ] Revised Atlanta Classification 2019 - Morphological Types
• History of preceeding viral infection Necrotislng Pancreatitis
• No lymphadenopathy, joint pain, hepatosplenomegaly
Classification: Type of Collection Time (W/c) Necrosis Infection Location Appearance
Class 1 -♦ No symptoms
■Sterile ANC S4 Yes No In parenchyma Heterogenous, non­
Class 2 -> Mild symptoms
&/or extra liquified material,
Class 3 -> Moderate symptoms • Infected ANC Yes Yes
pancreatic variable loculated,
Class 4 Severe symptoms - menorrhagia, epistaxis, requires transfusion not encapsulate
Investigations:
• Severe thrombocytopenia (platelet count < 20 x 109/ll) • Slerfe WON In parenchyma Heterogenous, non­
Yes No
• PBS -> platelet size normal or increased >4 &/or extra liquified material,
• Wected WON Yes
• • Normal Hb, TLC, DLC Yes pancreatic variably loculated,
encapsulated
• Bone marrow study -> Norma! or increased megakaryocytes
Indications for bone marrow aspiration / biopsy -
> An abnormal WBC count
y Unexplained anaemia
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342 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

i CT guided needle aspiration done -♦ if purulent -> percutaneous drainage of

□ Pathophysiology:
Snfected fluid -» if sepsis worsens despite this -> pancreatic necrosectomy done
Mucosa! ischaemia/Reperfusion injury
I
I If further necrotic tissue forms - the
Impaired local immunity/bacterial overgrowth
options are (any 1 of the 4) -
I
Closed continuous lavage (Begems method)
Increased Intestinal permeability
closed drainage
I
Bacterial translocation iii) open packing
iv) closure & relaparotomy (Bradley’s method)
Blood-bone dissemination ^ Direct contamination (inierven.
(Distant infection) ------ ► Necrosis infection ------ tional procedure/surgery)
June-July 2020
□ Pathogenesis :
• Pancreatic necrosis refers to diffuse or focal area of non-viable parenchyma n t: Ludvig’s Angina
• Identified by absence of parenchymal enhancement on CECT ’ A • See Section 1, Segment C, Q.11 (Page No. 380)
• Associated with lysis of peripancreatic fat
02: Fibroadenoma
• Initially, leads to acute necrotic collection (ANC) - intra or extrapancreatic collect A: See Section 1. Segment D, Q.48 (Page No. 506)
containing fluid & necrotic material, with no definable wall .
• Gradually, over 4 wks, develops a well-delined inflammatory capsule -> walled off necros; Oj ■Uver abscess
* (WON) A: See Section 1, Segment C, Q. 5 “Amoebic Liver Abscess" (Page No. 314)
Initially sterile collection, later on infected due to translocation of gut bacterio. PYOGENIC LIVER ABSCESS
□ What Is I t : Local complication of acute pancreatitis.
0 £Oology: (Mostly unexplained)
Q CECT Criteria :
• Biliary stone disease
• Appendicitis
Acute necrotic collection (ANC) Walled off necrosis (WON) • Diverticular disease

• Occurs only in setting of acute • Requires 4 wks after onset of acute J Pathogenesis : 4 major ways in which pyogenic organisms invade the fiver
necrotising pancreatitis necrotising pancreatitis f) Travel through portal vein
• Heterogenous & non-liquid density of • Heterogenous with liquid & non-liquid 2) Blood borne infections
varying degrees in different location density varying degrees of loculations 3) Direct extension from a contiguous infection
4) Trauma
• No definable wall encapsulating the • Completely encapsulated
collection a Predisposing factors:

• Location - intra/extrapancreatic • Location - intra/extrapancreatic 1) Elderly

2) Diabetes
3) Immunocompromised
□ Management: 3 Clinical features:
• Early aggressive fluid resuscitation 1) Anorexia
• i.v. antibiotics - Metronidazole, 3rd generation cephalosporins, carbapenems 2) Fever
• Analgesics - NSAIDs, Opiates 3) Malaise
• Nasojejunal feeding 4) Right upper quadrant discomfort
St Nausea, vomit
• Respiratory support
6j Cough
• Sterile necrotic material should not be drained or interfered with. If patient shows signs«
7) Chest pain
 f
344 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper-I 345

□ Investigations:
1) USG ]
2) CT Scan (confirmatory) ] Mullilocu,a,ed c*s,ic mass <double ,af9et si3" on CT)
(Followed by aspiration for culture and sensitivity)
3) Blood culture
4) Culture of aspirated fluid
5) PCR - in culture negative pus
6) ChestX-ray- Right lower lobe atelectasis, right pleural effusion, elevated right hemkfopt^
□ Organisms :
1) Streptococcus milleri
2) Eschericia coli
3) Klebsiella sp.
4) Proteus sp.
□ Management : ------------------V ----------- "
1) Emperic broad spectrum parenteral antibiotic -> therapeutic regimen revised once culurt
__j Persistent anal W
and sensitivity report available
“ “H --------^ membrane V
• 1st line antibiotics - Penicillin, Aminoglycoside and Metronidazole OR Cephatospom

2)
& Metronidazole
USG Guided aspiration - Often repeated aspirations needed
v j A jy
. - If multiple abscess, only largest abscess may need to be aspirate,] Fig. 1.5.4 : Covered anus
Fig. 1.5.3: Imperforate anus
3) Surgical drainage needed if -
1) multiple abscess
2) loculated abscess
3) abscess with viscous content obstructing drainage catheter
4) underlying disease requiring primary surgical management
5) inadequate response to percutaneous drainage within 7 days * v y —
o
Q.4: Thyroglossalcyst
A : See Section 1, Segment C, Q.4 (Page No. 348) 0

Q.5; Keloid
A : See Section 1, Segment D, Q. 9 (Page No. 426) Fig. 1.5.6 : Microscopic anus
Fig. 1.5.5 : Ectopic anus
QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 8 Anesthesiology

SEG M ENT-C
Central necrotic zone
SOLVED SHORT NOTES OF FINAL MBBS
P a p e r-ll

2008
« j ; venous ulcer
section 1, Segment-C. Paper-1, 2013, Qs. 2. (Page No. 301-302)

o2: epididymal cyst

EPIDIDYMAL CYST

0 Origin: Congenital .
n Causes: Cystic degeneration of -
(1) paradidymis (organ ot Geralde)
(2) appendix of epididymis
(3) appendix of testis
(4) vas aberrans of Haller .
3 Age: Middle age
0 Clinical features:
a) Bilateral
b) Tensely cystic
c) Multiloculated
d) Contains clear fluid
e) Feel like 'bunch of tiny grapes'
f) Because of numerous septae, they are finely tessellated -» so brilliantly transilluminant,
appear like "Chinese lantern" pattern
3 Location: Behind body of testis
3 Treatment:
a) Avoid excision as much as possible as it results in infertility due to blockage
b) Excision in old age
0 Differential diagnosis:
a) Spermatocele
b) Encysted hydrocele of cord
0.3: Tetany
TETANY
3 What Is I t : Increased excitability of peripheral nerves due to hypocaicaemia or alkalosis or
Fig. t.5.9: Fistula-in-ano
hypomagnesaemia
“ Causes :
a) Due to hypocaicaemia -
1) Hypoparathyroidism
2) Malabsorption
3) Acute pancreatitis
4) Osteomalacia
 ¥
348 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 4 Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 349

5) Chronic renal failure c) Swelling moves up with protrusion of tongue

6) Wilson's disease d) pluctualion test positive
7) DiGeorge's syndrome e) Transillumination test negative

b) Due to alkalosis - 0 compl!cations;

1) Hyperventilation a) infection
2) Repeated vomiting of gastric juice b) Rupture
3) Excessive intake of alkalis c) Fistula

□ Clinical features: . rj investigations:

1) Circumoral paraesthesia a) Radioactive iodine scan
2) Carpopedal spasm - Twitching and weakness of foot and digits b) USG neck
3) Chvostek’s sign - Tapping above angle of jaw to stimulate branchesof facial nerve causes c) FNAC from the cyst
twitching of angle of mouth and eyelids g Treatment:
4) Trousseau's sign - Carpal spasm when sphygmomanometer applied to arm and pressure Excision of thyroglossal cyst along with throglossal duct, and part of hyoid bone (Sistrunk operation)
raised above systolic blood pressure
5) Stridor OS: Dermoid cyst
6) Mimicking convulsions
DERMOID CYST
□ Investigations :
1) ECG - Prolonged QT interval Thsre are 4 types of dermoids -
2) Low serum calcium 0 sEdUESTRATION DERMOID -
* 3) Low parathormone
• Wha t Is I t : Cyst arising from ectoderm
Q Treatment:
« Pathogenesis: Few of the ectodermal cells get sequestered into the deeper layers, form a
1) Calcium gluconate : 10% - 10 ml; 6-8 hourly cyst and get filled up with secretions from the lining epithelium
2) Oral calcium 1gm thrice daily + vitamin D supplementation daily
[See Fig. 1.6.1]
3) Magnesium sulphate supportive therapy
• Sites; •
4) Regular lollow-up
a) Post auricular dermoid
0 .4 : Thyroglossal cyst b) Root of nose (Internal angular dermoid)
c) External angular dermoid
THYROGLOSSAL CYST d) Sublingual dermoid
• Extension In to :
□ What Is i t : Cystic midline swelling of neck formed from unobliterated portion of thyroglossal duct
a) Dermoids in skull -> cranial cavity
□ A natom y:
b) External angular dermoid -> orbital cavity
e Thyroglossal duct or median thyroid diverticulum extends from foramen caecum to 2nd
tracheal ring, and usually gets obliterated • Contents:
• When it does not get obliterated completely, a cystic swelling may arise due to collection o! a) Desquamated material
secretions from the lining epithelium b) Hair follicle
c) Sweat glands
Sites :
d) Sebaceous glands
a) Beneath foramen caecum
• Age; 20-30 years
b) In floor of mouth
e) Suprahyoid • Clinical features:
d) Subhyoid Swelling with following features -
e) On the thyroid cartilage a) Soft
□ Pathology: Lined by pseudostratified ciliated columnar epithelium b) Smooth
Q Clinical features: c) Nontender
a) A swelling situated in front of neck d) Transillumination test negative
b) Swelling moves with deglutition e) Fluctuant (Paget’s test positive)
350 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 351

f) Overlying skin can be lifted up Features Exomphalos major Exomphalos minor

g) Resorption and indentation of bone underneath (bone guttering)
h) Impufse on cough if extension into intracranial cavity > 5 cm <5 cm
sac size
• Differential diagnosis: ■"jjJrtjiiicaTcord Inferior aspect of sac At the summit of sac
a) Sebaceous cyst attachment
b) Lipoma Content Small intestine, large intestine, liver Small intestine
. Complications: Not possible Possible
Primary closure
a) Infection
prognosis Poor Good
b) Hemorrhage
c) Calcification Treatment 1) Vitamin K Injection Sac twisted to reduce contents
d) Compression of structures 2) Antibiotics into peritoneal cavity -> abdomen
e) Ulceration 3) TPN strapped firmly -> removed after
• Investigations : 4) 0.5% mercurochrome + 65% 14 days
alcohol to promote granulation tissue
a) X-Ray of the part
formation
b) CT scan of the part
5) Wrap silastic silo around content
• Treatment: 6) Definitive surgical procedure if other
Enucleation of cyst along with proper haemostasis measures fall -

□ TUBULODERMOID -
Arises from embryonic tubular structures like thyroglossal cyst, postanal dermoid, ependymal cyst QJ: Skin grafting

□ IMPLANTATION DERMOID - SKIN GRAFTING

Painless, soft, smooth, tensely cystic, non-transilluminating swelling, often adhered to skin, founds
Q What Is I t : Transfer of skin from donor area to required (recipient) area
finger tips, as a result of minor pricks or trauma, due to which epidermis gets buried in deepe
subcutaneous tissue, and degenerates to form a cyst ■ G Types:
a) Partial thickness graft
□ TERATOMATOUS DERMOID -
b) Full thickness graft
Arises from germinal layers; found in ovary, testis, etc.
0 PARTIAL THICKNESS GRAFT
Q.6 : Exomphalos • Synonyms:
EXOMPHALOS a) Split thickness graft
b) Thiersch graft
□ Synonym : Omphalocele • What is i t : Transfer of full epidermis and part of dermis from donor to recipient area
□ Define : Developmental anomaly due to failure of whole or part of tho midgut to return intoit* • Types:
abdominal cavity during earty foetal life a) Thick
□ Sac covering: b) Intermediate
a) Outer layer - Amniotic membrane c) Thin
b) Middle layer - Wharton’s jelly • Indications:
c) Inner layer - Peritoneum a) Clean wound which cannot be apposed
0 Associated congenital anomalies: b) Well granulated ulcer
a) Beckwith Weidman Syndrome - exomphalos + macroglossia + gigantism c) After surgery to cover and close defect
b) Chromosomal trisomies - 13, 15.18, 21 • Contraindications : Not used over bone, tendon, cartilage, joint
c) Vitellointestinal duct anomaly + diaphragmatic hernia + malrotation of gut • Pre-requisites:
d) Bladder extrophy a) Healthy granulation tissue
e) Imperforate anus b) Beta hemolytic streptococci load < 105/gm of tissue
ft M p n in n n m v ftlo o filf!
 352 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 353

• Instruments used: , Advantages:

(a) Walson modification of Humby's knife (a) No contracture
(b) Down's blade (b) Good colour match
(c) Power dermatome (c) Sensation better retained than SSG
(d) Eschmann blade , Disadvantages:
(e) Sterilised razor blade (a) Cannot cover ulcers
• Donor area : Generally thigh (b) Used only for small areas
• Procedure: o t . spinal anesthesia
> Donor area - A : S e e Section- 3 , Qs.1 (Page No. 753)
(a) Graft taken using Humby's knife
(b) Punctate bleeding indicates proper graft removal oS: Double contrast enema .
(c) Dressing - Opened after 10 days £ see Section - 1, Segment - E, Qs. 8 (Page No. 585)
> Graft area -
Q10:Brachytherapy
(a) Scraped well
(b) Window cuts on graft BRACHYTHERAPY
(c) Graft placed and fixed
(d) Tie-over dressing j iWtaf is i t : Radiation given with the source placed very close to the tumor
(e) Mercurochrome applied
rj Radionuclides used:
(0 Dressing opened on 5th day
1) Iridium 192
_ • Stages: .
2) Caesium 137
(a) Stage of plasmatic imbibitions 3) Iodine 125
(b) Stage of inosculation 4) Gold 198
(c) Stage of neovascularisation
0 Types:
• Storage: 4 degree Centigrade for upto 21 days
1) Surface brachytherapy - Use moulds
• Advantages:
2) Intracavitary brachytherapy - Radiation material placed in cavity
(a) Wide area covered 3) Interstitial brachytherapy - Radiation material inserted into the tumor mass
(b) Easier to perform .
(c) Reduced chances of graft rejection 3 Advantages ;
• Disadvantages: a) Spares deeper and adjacent tissues
b) Surgery can be avoided
(a) Hematoma
c) Short time required
(b) Contractures
d) Small dose required
(c) Infection
(d) Graft failure e) Less side effects
<e) Loss of hair growth f) Curative and effective in early cancers
3 Disadvantages:
□ FULL THICKNESS GRAFT
a) Costly
• Synonym: Wolfe graft b) Technical difficulty
• What is i t : Skin graft including full dermis and epidermis c) Local complications
• Sites where used: d) Less available facilities
(a) Face
O f*: Dental cyst
(b) Eyelids
(c) Hands DENTAL CYST
(d) Fingers J Synonyms:
(e) Over joints • Periapical cyst
• Radicular cyst
t Donor areas:
What is i t : Epithelial odontome (cyst or tumor of the jaw)
(a) Supraclavicular area
(b) Post auricular area ~ Sl,e of occurrence: In relation to dental epithelium from under the root of chronically infected dead
(c) Groin crease area erupted t00th
 SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 355
354 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Q Lining : Squamous epithelium derived from epithelial debris of Mallassez

□ Clinical feature: Smooth tender swelling in jaw in relation to a caries tooth
□ Complications: 5
a) Infection
b) Osteomyelitis of jaw rre3Ment :
i t ) G e n e r a l-
0 Investigation : Orthopanto mogram 1) Patient in well-equipped ICU
[See Fig. 1.6.2] Intravenous fluid
2)
□ Treatment: 3) Ryle's tube
a) Antibiotics 4) Blood transfusion
b) Drainage or excision of cyst 5) Analgesic
c) Extraction of infected tooth 6) Sedative
7) Endotracheal intubation
Q.12 : Flail chest 8) Intercostal tube drainage
(B) Local -
FLAIL CHEST Musculoskeletal traction with towel clips
1)
Positive pressure respiration
□ What Is i t : Form of chest injury where there is fracture of two or more consecutive ribs, with each* 2)
having two or more fracture sites
0 )3; Glasgow coma scale
1ttS
□ Types:
a) Anterior N ^ S L A ! SGOW COMA SCALE
■ b) Lateral
j what is I t : Bedside scoring system for neurological assessment
c) Posterior
□ Aetiology: ' j Seale:
1) Road traffic accident . Eye response -
2) House collapse > Spontaneous : *
3) Bomb blast > Opens eyes to speech • 3
4) Stampede • V Opens eyes to pain • *
> No response '• 1
□ Pathology:
The fractured portion is called the flail segment, which loses anatomical and physiological conlinu, • Verbal response -
with the rest of the chest wall. > Oriented • ®
> Confused : 4
Leads to following derangements -
> Inappropriate words '• - 3
• Paradoxical respiration - During inspiration, air enters into the healthy fung fromfe >• Incomprehensible sound • 2
atmosphere, and this lung also draws air from the affected lung. Hence, when thoracic cap > No response : *
moves outwards, the flail segment is drawn inwards. During expiration, air from healthyiin;
• Motor response -
escapes partly into the atmosphere and partly into the affected lung, thereby moving outwit
V Obeys command 6
the flail segment, when the thoracic cage is actually moving inwards 5
> Localises pain
• Mediastinal flutter- Mediastinum moves during different phases of respiration -» kinkingc' 4
> Flexion to pain
great vessels and sudden cardiac arrest > Abnormal flexion 3
• Pendular movement of air - From on6 lung to other, causing respiratory failure duct V Abnormal extension 2
unavailability of atmospheric air > No response 1

□ Clinical features: interpretation:

a) History of trauma Total score - 15
b) Pain in chest Severe head injury - score < 8
c) Respiratory distress Moderate head injury - score 9-12
d) Paradoxical respiration Mild head injury - score 13-15
e) Features of shock Minimum score - .3
 356 QUEST : A Comprehensive Gutde to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 357

□ Component o f: Secondary survey in ATLS (Advanced Trauma Life Support) ^ o d y n w lc s :

□ Types o f head In ju ry:

Patent ductus arteriosus
(A) Injury to scalp -
a) Avulsion
i
Left to right shunt from aorta lo pulmonary artery
b) Laceration . ' .
(B) Injury to s k u ll- „ . i
a) Pond’s fracture w pressure gradient present throughout the cardiac cycle, this flow occurs both during systole and
b) Depressed fracture
c) Linear fracture f * •
(C) Injury to brain - Continuous murmur which starts in systole after S i, peaks at S2
a) Concusion - Temporary physiological changes leading lo transient lou i
consciousness with complete recovery Increased blood flow through pulmonary artery to lung (pulmonary plethora in X-Ray)
b) Contussion - Bruising occurs leading to cerebral edema
I
c) Laceration - Tearing of brain surface
Increased size of left atrium due to increased blood flow
d) Fracture of skull
□ Effects o f head In ju ry :
i .
Increased amount of blood passing through normal sized mitral valve
t) Brain edema ;
4
2) Brain ischemia .
Accentuated S i + delayed mitral diastolic murmur
3) Brain necrosis •
• 4) Extradural hematoma 4
5) Subdural hematoma Large amount of blood ultimately passes to lefl ventricle
6) Intracerebral hematoma i
7) Intraventricular hemorrhage Increase in size of left ventricle + prolongation of left ventricular systole
8) Coup and contercoup injury 4
9) Coning Delayed closure of aortic valve
10) Raised intracranial tension i
11) Fluid and electrolyte disturbance
Late A2 - paradoxical split of S2
12) Convulsions
13) CSF rhinorrhoea . ±
Large volume of blood passes through normal sized aortic valve and then causes dilatation of
Q.14: Therapeutic use o f ultrasound ascending aorta
A : See Section - 1 , Segment - E, Qs. 12. (Page No. 589) I
Aortic ejection systolic murmur ♦ aortic ejection click
0 . 15: Patent Ductus Arteriosus
3 Symptoms:
PATENT DUCTUS ARTERIOSUS
a) Dyspnoea •
□ What is i t : Persistence of patency of ductus arteriosus, which Is a vessel leading from bifurcaW b) Recurrent respiratory infections
pulmonary artery to aorta just distal to left subclavian artery c) Retarded growth and development
□ Prevalence: 3 Signs;
• 6th most common congenital heart disease (A) Inspection and palpation -
« F >M 1) Collapsing pulse
□ Types: 2) Wide pulse pressure
3) Apex beat shifted down and out
a) Silent
4) Hyperdynamic apex
b) Small
5) Continuous thrill at upper left sternum border
c) Moderate
6) Differential cyanosis if Eisenmenger's syndrome develops ( i.e , cyanosis only in
d) Large lower limbs and not in upper limbs)
 358 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 359

(B) Auscultation- retanus prophylaxis,

1) Loud Si c«e Section - 1 , Segmeni C. Paper - 1,2011, Qs. 4 (Page No. 291-292).
A* ^
2) S3 may be audible
..Empyema thoracis
3) Continuous machinery murmur at upper left sternum border A See Section - 1 , Segment C. Paper - II, 2010, Qs. 13 (Page No. 381-383).
4) Mid-diastolic flow murmur at apical region
5) Eddy sounds audible when large ductus
* See Section - 1, Segmeni C, Pnnei - II, 2011, Qs. 13 (Page No. 399-400).
□ Investigations:
a) ECG - Notched P wave, deep Q, tall R nib: Waxbath
b) Chest X-Ray - Prominent aortic knuckle, pulmonary plethora ft, See Section- 1 , Segment C, P aper-II, 2011, Qs. 12 (Page No. 398-399).
c) ECHO
0 ,1: Extradural haematoma
□ Treatment: A See Section - 1, Segment C. Paper - II, 2009, Qs. 7 (Page No. 365).
1) Medical -
q f2 : Raynaud’s phenomenon
(a) Indomethacin
(b) Prophylaxis for infective endocarditis RAYNAUD’S PHENOMENON
(c) Digoxin, diuretics for heart failure
.j yfat jS i t : Condition characterised by episodic attacks of vasospasm leading to closure of small
2) Transcatheter closure arteries and arterioles of distal parts or extremities.
3) Surgical - Ligation and division 3 Coifman criteria: “ Episodic attacks of well-demarcated reversible self-limiting colour changes for 1­
Complications: 20 minutes on exposure to coid/emotional stimuli and is symmetrical/bilateral lasting for atleast two
years.''
1) Eisenmenger's syndrome
■3 Phases in sequence:
2) Infective endocarditis
3) Heart failure 1) intense pallor

4) Paradoxical embolism 2) Cyanosis

3) Rubor upon warming
5) Pulmonary hypertension
0 Types:
6) Rupture of ductus arteriosus
1) Vasospastic
2) O bliterate
2008 Supplementary
3 Causes :
Q. 1: Carcinoid tumour A) Primary - Etiology not known
A : See Section - 1, Segment C, Paper - 1,2010, Qs. 4 (Page No. 288-289). B) Secondary -
> Obstructive arterial disease
Q.2: Ranula
* Buerger’s disease
A : See Section - 1, Segment 0, Qs. 68 (Page No. 526-527).
* Arteriosclerosis
0 .3 : Abdominal compartment syndrome * Thoracic outlet syndrome
A : See Section - 1 , Segment D, Qs. 67 (Page No. 525-526). > Immunologic
' Rheumatoid arthritis
Q.4: Desmoid tumour
* Scleroderma
A : See Section - 1 , Segment D, Qs. 90 (Page No. 548-549).
* SLE
Q.5: Clinical features o t Hirschsprung's disease > Drugs
A : See Section - 1 , Segment D, Qs. 40 (Page No. 499-500). * Beta blockers

0 .6 : Cleft lip management in children * OCP

* Ergot alkaloids
A : See Section - 1, SegmentC, P aper-ll, 2013,Qs. 1 (PageNo. 417-418).
> Environmental
 360 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 361

* Vibration 1) To cover over bone, cartilage, tendon

* Cold injury 2) To cover wide and deep defects
> Others 3j In cases of repeated graft failure
* Neoplasia j Advantages:
* Cryoglobulinemia 1) Better blood supply than graft
□ Physiology: 2) Good take up
3) Provides bulk, texture, colour to defect site
1) Increased sensitivity of o-2 receptors to norepinephrine
4) Cosmetically better
2) Increased serotonin and thromboxane
5) Allows required movements
3) Reduced nitric oxide and endothelin-1 in endothelial cells
0 Disadvantages:
□ Investigations:
1) Chances of infection
1) Digital plethysmography 2) Long duration of hospital stay
2) DSA / MR angiogram 3) Flap necrosis
3) Arterial Doppler / Duplex scan
,5 care of a paraplegic patient
4) Digital blood pressure gradient assessment
5) Laser Doppler flux CARE OF A PARAPLEGIC PATIENT
6) Nail fold capillary microscopy
Intensity of symptoms depends upon location and extent of damage to spinal cord. Special care
7) Cold recovery time (increased upto 30 minutes in Raynaud's) required to prevent infection. So following steps are to be followed -
• 8) Routine blood investigations - Lipid profile / blood sugar / coagulation studies 1) Immediate hospitalisation .
□ Treatment : 2) Immediate catheterisation
• Treatment of underlying cause 3) Proper bowel care
• Avoidance of precipitating factors 4) Air / Water bed to be arranged
• Drugs - Vasodilators, Pentoxiphylline, Nitrates, Prostacycline analogue 5) Proper care of bed sore
• Surgical - Cervical sympathectomy 6) Regular monitoring of catheter, to prevent UTI
Q.13 : Diagnostic use o t ultrasound 7) High quality wheelchair to be arranged
A : See "Investigations” Segment E. 8) Physical therapist and passive exercise

0 .1 4 : Axial flap
200 9
AXIAL FLAP
0.1: Salivary calculi
□ What Is fla p : A piece of viable tissue with a blood supply which can be used to reconstruct a tissue
SALIVARY CALCULI
defect.
□ Axial fla p : Superficial vascular pedicles pass along their long axes. 3 is i t : Stones in salivary gland
□ Parts : Q Types:
1) Base 1) Submandibular <80% cases)
2} Pedicle 2) Parotid (10% cases)
3) Tip ^ Reasons for higher Incidence o f submandibular calculi:
□ Areas where use d: a) Viscous gland secretion
1) Oral cavity b) Contains more calcium than parotid
2) Neck c) Drainage is non-dependent i.e. submandibular duct moves upward and opens by the side of
3) Breast frenulum lingue. Hence, due to antigravity, there is stagnation of secretions
4) Buttock “ Mnical features:
5) Limbs 1) Pain, swelling and tenderness in submandibular region and floor of mouth
□ Indications: 2) Duct Inflamed and swollen
 362 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS O Paper - II 363

3)Pain more during mastication (salivary colic) (mastication -» accumulation of secret;

, pathogenesis:
swelling - » irritation ot lingual nerve -> pain] -
4) Firm, tender swelling - Palpable bidigitally Bacteria reach breast via blood -» milk clots -* ducts blocked -> bacteria further multiply -»
finally duct blocked by epithelial debris -> abscess formation;'distended with pus t ' •.
5) Stone in duct palpable in floor of mouth
, Clinical features:
□ Investigations:
1) Affected breast becomes red, swollen, warm, tender
1) Intra-oral X-Ray - submandibular stones are radio-opaque, parotid stones are rarfi„i 2) Throbbing pain . .
2) ESR.TLC raised oluc^
3) Fever, malaise
3) FNAC of gland
4) Purulent nipple discharge
□ Treatment: .
, Complications:
a) If stone in duct -> incision in duct and stone removed intraorally, and then duct is left ooen 1) Antibloma
suturing may cause stricture ,3s
2) Sinus, fistula
b) If stone in gland - » excision of gland
3) Septicaemia
□ Operative procedure:
■ Treatment: /
Approach from submandibular region -> incision on skin in submandibular region, 5-8 cm lone
1) Drainage of abscess (radial(to prevent ductal disruption) or circumareolar (for cosmetic
parallel to and 2-4 cm below mandible -» incision deepened through deep fascia until gland vtsuafc,
reasons) incision in most fluctuant p a rt- another counter incision in most dependent
without raising flaps - * facial artery ligated twice -> lingual and hypoglossal nerves taken care of
part to place the drain, which is removed alter 2 days)
mylohyoid retracted to remove deep portion of gland drain placed after excision of gland, which,
removed after 2 days 2) Antibiotics ( i ^ V c r v ^ ^ 6 i^ f D ld U o > c ( M jL U w C f lo - tM
□ Complications o f surgery: • Differential diagnosis: Inflammatory carcinoma of breast
1) Hemorrhage Q NON-LACTATIONAL ABSCESS OF BREAST
2) Infection
• Aetiology:
3) Injury to lingual, hypoglossal, marginal mandibular nerves
4) Injury to nerve to mylohyoid 1) Periareolac infections
2) Duct ectasia
O Differential diagnosis:
• Causative organisms : Bacterioids, Gram negative organisms
1) Salivary neoplasm
• Clinical feature ; Tender swelling under areola
2) Submandibular lymphadenitis '
• Treatment : Drainage of abscess
0 .2 ; Fournier’s gangrene
0.4: Complications of undescended testis
A : See Section - 1, Segment C, Paper-1,2013, Qs. 3 (Page No. 302)

0 .3 : Breast abscess UNDESCENDED TESTIS - COMPLICATIONS

BREASTABSCESS 0 What is undescended Testis: Testis has failed lo descend to scrotum

□ Synonym: Intramammary mastitis 0 Incidence: Mostly in premature infants

0 Laterality: Right > left > bilateral (this is because right sided descends later than the left sided one)
□ Types:
a) Lactational 0 Aetiology:
b) Non-lactational 1) Familial
2) Gubemacular dysfunction
□ LACTATIONAL ABSCESS OF BREAST
3) Short vas deferens
• Found in : Laclating women 4) Lack of Calcitonin Gene Related Peptide (CGRP)
• Causative organism : Staphylococcus aureus • 5) Lack of HCG
• Predisposing factors: 6) Altered hypothalamo-pituitary gonadal axis
1) Baby not sucking properly 7) Retroperitoneal adhesions
2) Baby’s mouth infected 8) Prune-Belly syndrome
3) Retracted nipple 0 Types:
4) Cracks in nipple
5) Nipple not washed properly . a) Lumbar testis - Complete failure ol descent
b) Iliac testis - Testis remains just deep to deep ring
t
 W "

364 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 365

c) inguinal testis - Testis in inguinal canal

(B) Type II (Sippie's disease) defect in chromosome 10
d) In superficial inguinal pouch - Tsstis in space between external oblique and Scarpa's f ^
> Subtype lla -
e) Scrotal testis - Testis in upper part of scrotum
* Phaechromocytoma
□ Complications: * Parathyroid hyperplasia
1) Torsion * Medullary carcinoma of thyroid
2) Epididymo-orchitis * Megacolon
3) Seminoma > Subtype lib -
4) Trauma * Phaechromocytoma
5) Inguinal hernia * Medullary carcinoma of thyroid
6) Sterility * Mucosal neuroma in lips and eyelids
7) Atrophy * Marfanoid face
□ Investigations: 0 In v e s tig a tio n s :

1) USG abdomen a) For parathyroid hyperplasia -

2} CT scan > Serum calcium
3) Assessment of FSH, LH, HCG > Serum phosphate
4) Gonadal venogram > Serum PTH
5) Laparoscopy b) For pituitary tumor-
0 Treatment: V Prolactin level
>■ GH level
• Always surgery - Done between 2-4 years of age, 6 months gap in case of bilateral
involvement c) For pancreatic tumors-
• Principles of surgery - > Blood sugar
> Insulin level
a) Mobilisation of spermatic cord
b) Repair of associated hernia > Pancreatic polypeptide level
> Proinsulin level
c) Creation of scrotal pouch and fixation of testis into the scrotum
> Glucagon level
d) Orchidectomy done if testis is completely atrophied
> Gastrin level
• Hormone therapy used in following cases - d) Calcitonin level
1) Doubtful retractile testis e) Urinary catecholamine
2) Bilateral cases + hypogenitalism + obesity I) Thyroid function test
• Laparoscopic approach - Orchidopexy is becoming popular
3 Treatment: Surgical treatment of conditions
0 .5 : MEN Syndrome Qi ••Anorectal malformations
MEN SYNDRO M E A: See Section - 1, Segment C Paper - 1,2013, Qs. 4 (Page No. 303)
QJ: Extradural hematoma
□ Full fo rm : Multiple Endocrine Neoplasia
□ Synonym : MEA syndrome (Multiple Endocrine Adenomatosis) EXTRADURAL HEMATOMA
□ Inheritance : Autosomal dominant
3 Whif is I t : Collection of blood in extradural space i.e. between skull and dura
□ Features o f celts : APUD (Amine Precursor Uptake Decarboxytation) 8 Aetiology ;
□ Types: Trauma at temporo-parietal region leading to rupture of -
(A) Type I (Werner's syndrome) - defect in chromosome 11 a) Anterior branch of middle meningeal artery
> Pituitary tumor b) Posterior branch of middle meningeal artery
r Parathyroid adenoma/hyperplasia ^ c) Middle meningeal veins
> Pituitary endocrine tumors - insulinoma, gastrinoma, etc. ^ Jk •' temporo-parietal region
^terality: Unilateral or bilateral
 366 QUEST : A Comprehensive Guide (o UG Surgery, Orthopedics & Anesthesiology
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□ Pathogenesis: q j . cardiopulmonary Resuscitation

Trauma at temporo -parietal region A : See Section - 3. Qs. 9 (Page No. 766)
i
gJ:UHI
Fracture ol temporal bone
A; See Section - 1 , Segment E, Qs. 11 (Page No. 587)
I
Rupture of vessels 0 Complications o f radiotherapy
4
Bleeding towards scalp COMPLICATIONS OF RADIOTHERAPY
I *• 0 What is radiotherapy: Use of ionizing radiation as therapy mainly in malignant conditions
Hematoma , 0 Mode o f action:
4
a) Direct action on the target tissues
Stripping of dura from skull
b) Indirectly, release free radicals
•
c) Acts on different phases of cell cycle
Extradural hematoma
a Types:
1
1) Curative
Coning of uncus of temporal lobe through tentorial hiatus
2) Palliative
•t
Q Indications:
Pressure on pyramidal tract -4 ipsilateral hemiplegia
1) Seminoma testis
-i
2) Bladder tumors
CN III of affected side pressed between uncus and midbrain
3) Hodgkin's lymphoma
4' 4) Lung carcinoma
Constriction of unilateral pupil 5) Squamous cell carcinoma
I 6) Basal cell carcinoma
Midbrain of opposite side 7) Cervical carcinoma
X D Complications:
CN III of opposite side compressed between midbrain and uncus of opposite side (A) GIT­
X > Oral mucosa -
Constriction of pupil of opposite side (a) Ulcer
These series of papillary changes in pupil of affected and opposite side is called Hutchinson's pupl. (b) Oral thrush
and this total sequence is called Kernohan’s notch effect (c) Edema
{See Fig. 1.6.3J (d) Loss of taste
(e) Dysphagia
□ Clinical features: > Nausea, vomit, diarrhea
a) Lucid interval - Transient loss of consciousness immediately after trauma -» soon palie® (B) Infection - bacterial, fungal, viral
regains consciousness -» again starts deteriorating after 6-12 hours (C) Genitourinary -
b) Confusion, irritability 1) Oophoritis in females
c) Pupillary changes - Hutchinson's pupil 2) Oligozoospermia
d) Ipsilateral hemiplegia (0) Bone marrow suppression
e) Features of raised intracranial tension - Vomit, severe occipital headache, bradycardia, hip (E) Eyg-
1) Lens affected
BP ^
□ investigations: i Vii 2) Lacrimal gland affected
3) Eyelash affected
1) X-Ray skull
4) Dryness
2) CT scan of skull - Biconvex lesion [See Fig. 1.6.4] 5) Cataract
3) Electrolyte imbalance
(F) Radiation induced -
□ Treatment: Craniotomy - Burr-hole technique and raising ol osteoplastic flap to drain Ihe blood&
1) Malignancy
 SOLVED SHORT NOTES OF FINAL MBBS Q P a p e r-ll 369
368 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Aneslhesiology

2) Thimble bladder
3 Tie*)"M oist oxygen inhalation
3) Frozen pelvis
2) Albumin infusion
(G) Others -
3) low molecular weight heparin
1) Radiation dermatitis
4) Dextran
2) Radiation myelitis of spinal cord
3) Radiation nephritis ..I-Odontomes
4) Radiation osteomyelitis
0' ODONTOMES
5) Radiation pneumonitis
0 g iare the y: Cysts or tumors of the jaw arising from epithelial or mesothelial elements of the tooth
0 .1 1 : Fat embolism
germ
FAT EMBOLISM
~Dental cyst
□ What is i t : A fat embolism is a type of embolism that is often caused by physical trauma such
fracture of long bones, soft tissue trauma, and bums. *
Epithelial ( Dentigerous cyst]
□ Pathogenesis: Several mechanisms have been proposed to explain the pathogenesis of fat emboli*,
They may be acting together or singly - \ Adamantinoma )
1. Mechanical - Mobilisation of fluid fat following trauma to bone and soft tissue
Odontogenic myxoma,
2. Emulsion instability - Explains the pathogenesis of fat embolism in non-traumatic cases. ^ Based on
Connective fibroma
embolus formed by aggregation of plasma lipids (chylomicrons and fatty acids) due to distuiba«a origin
in emulsification of fat. Symptoms include fatty liver(hepatic steatosis) tissue
Cementoma,
3. Intravascuiar coagulation - May result from disseminated intravascular coagulation (DIC) dentinoma
4. Toxic injury - Blood vessels injured by high plasma levels of free fatty acid, results in increaiaj
vascular permeability and consequently pulmonary edema Malignant
ameloblastoma
□ Clinical features : Malignant
1) Drowsy, restlessness Fibrosarcoma
2) Constricted pupils
3) Cyanosis
4> Tachypnoea Ameloblastoma ]
5) Fat droplets in sputum
Classification Compound odontome
6) Froth in mouth and nostrils
7)
8)
Petechial hemorrhagic spots
Retinal artery emboli (earliest) - fluffy exudates, striae exudates
Cementoma
3
9) Fat droplets in urine Arise in Composite odontomaT)
from it
□ Complications:
Enameloma j
1) Pulmonary fat embolism
2) Systemic fat embolism.
' Radicular odontome J
□ Investigations:
Based on Dentinoma )
1) Serum lipase level increases in bone trauma - Often misleading
dental
2) Cytologic examination of urine, blood and sputum with Sudan or Oil Red 0 staining ffl epithelium
detect fat globules that are either free or in macrophages. This test is not sensitive, hows'* Odontogenic fibroma,
and does not rule out fat embolism myxoma
3) Blood lipid level is not helpful for diagnosis because circulating fat levels do not coirek"
with the severity of the syndrome "Arise i T ' U Dentatcyst )
4) Decreased hematocrit occurs within 24-48 hours and is attributed to intra-alveolar hemorrt13? relation to it
J ^ f Dentigerous cyst")
5) Alteration in coagulation
 370 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
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□ Dental c y s t: See Section - 1 , Segment C, Paper - II, 2008, Qs.11 (Page No. 353)
□ Dentigerous c y s t: See Section - 1 , Segment C, Paper - II, 2014, Qs. 3 (Page No. 42ej ^ K CollaPse ol ,un9 of affected side
□ Ameloblastoma : See Section - 1 , Segment C. Paper - II, 2012,Qs. 13 (Page No. 4n j 2) Displacement of mediastinum to opposite side -> compresses opposite lung

0 .1 3 : Short wave diathermy ptiology:

0 penetrating chest injury
SHORT WAVE DIATHERMY 2) Tuberculous focus rupture
3j Fracture of rib
□ What Is I t : Electrically induced heat using short wave radiotherapy
lnlerpleural pressure: More than atmospheric pressure
□ Current use d: High frequency alternating current
3 C om m unication with external a ir : Unidirectional
□ Operating voltage: 220 vo Its
□ Fuses: 6 Ampere 3 Clirlcal fe a tu re s :
1) Dyspnoea
□ Room temperature; 10-40 degree Celsius
2) Severe chest pain
□ M oisture: 10-80% 3) Shock
□ Wavelength: 11 metres 4) Cyanosis
□ Frequency: 27.33 MHz 1 5) Hyperresonance on percussion
6) Absence of breath sounds
□ Mechanism: Two condenser plates are placed on either side of the body part -> high frequency***
7) Shift of trachea and apex beat towards opposite side
travel between the two condenser plates - » as they pass through the body, they are converted into
.0 Indications: y Investigation:

1) Inflammation of shoulder joint, elbow joint 1) Chest X-ray

2) Heel pain 2) e-FAST: Barcode or Stratosphere sign in M mode
3) Cervical spondylosis 3 Complication: Respiratory failure
4) Osteoarthritis 3 Treatment: Needle decompression by thoracocentesis at 5th Intercostal Space, slightly anterior to
5) Bursitis Mid-Axillary line in adults (2nd Intercostal Space in children) [ATLS 10|h edition updates].
6) Sinusitis . 0.15: Hypokalemia
7) Low back ache HYPOKALEMIA
8) Ligament sprains in knee joints
j Whit Is I t : Se rum potassium level <3.5 mEq/L
□ Contraindications:
3 Types:
1) Coronary heart disease
a) Sudden - •
2) Hemorrhage
b) Gradual
3) Metal implants
J Aetiology:
4) Infections
a) Sudden - Diabetic coma patients treated with insulin
5) Malignancy
6) Pacemakers b) Gradual -
1) Following trauma, surgery (increased mobilisation of intracellular potassium to
. 7) Phlebitis
extracellular space + increased potassium excretion by kidneys)
8) Pregnancy
2) Starvation
9) Wet dressings 3) Gastric outlet obstruction
Q.14 : Tension pneumothorax 4) Loss of gastrointestinal secretions - ileostomy, duodenal fistula
5) Diarrhea in ulcerative colitis, villous tumor of rectum
TENSION PNEUMOTHORAX 6) Poisoning
7) After ureterosigmoidoscopy
□ What is I t : When the lacerated lung communicates with a branch of the bronchial tree through
8) Drugs like beta agonists
valvular rent, which allows entry of air during inspiration but prevents exit of air during expiration.|K
condition is called tension pneumothorax'. J finical features:
I) Gradual onset of drowsiness
 372 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology SOLVED S H O R T NOTES OF FINAL MBBS □ Paper - II 373

2) Slurred speech
3) Irritability ^ S e d lo o l.S e g m e m - - E, Qs. 26 (Page No. 600)
4) Weakness, muscular hypotonia
5} Absent deep reflexes * m■M/v* lnJurY
Section 1, Segment - D, Qs. 98 (Page No. 558)
6) Paralytic ileus -
Seeuintgement o f Hirschsprung's disease
7) Low B.P
* Section 1, Segment - D, Qs. 40 (Page No.. ■
499)
8} Bradycardia
9) Reddish flush in face a l2 : W ttFNAC _
10) Warm, dry skin See Section 1, Segment - E
11) Urinary incontinence B M o n lc th e n p y
12) Nocturia, polyuria ULTRASONIC THERAPY
Investigations:
utehanlsm of a ctio n : Ultrasonic waves of high frequency are produced by mechanical vibration in
1) Low serum potassium
3 ikTrrwlal treatment head of the ultrasound machine, which is then moved over the skin surface in the
2) ECG- region of injury, causing the energy lo be transmitted to the inflammed tissue.
> Prolonged QT interval T^mal effect: The ultrasound waves passing into the skin cause vibration of tissues surrounding
> Depressed ST segment theaffected area, especially those containing collagen. The vibration produces heat within the tissue,
> Inversion of T wave which increases the extensibility of tendons, joint capsules and ligaments, along with reducing pain
end muscle spasm.
> Prominent U wave
n Etiecls on healing process : Ultrasonic therapy accelerates the normal resolution time of the
Treatment: . irflammalory process by attracting more mast cells to the site of injury and also sometimes causes
1) Potassium chloride tablets orally - 2 gm 6 hourly increased blood flow in the site of injury. It also enhances collagen formation
2) In comatose patients or those with difficulty in swallowing - 40 mmol/litre of potassiumchk» 3 (/j* :The treatment metal head is moved over the site of injury for 3-5 mins, once or twice daily. The
in 5% dextrose or normal saline . Intensity and frequency may be varied as per requirement. This is of great use in sports medicine,
3) If alkalosis present - 20 ml of 10% solution of potassium chloride in 500 ml of 5% dexta lower frequency required for deeper structures and vice-versa.
3 Contradictions:
2009 Supplementary • Acute infection
• Malignancy
Q. 1 : Hypospadlus • Ischaemic tissue
A : See Section 1, Segment - C, Paper-ll, 2013 Supplemental, Qs. 8 (Page No. 425) • Exposed neural tissue
Q.2: Marjolin's ulcer • Pregnancy •
A : See Section 1, Segment-C, Paper II, 2013, Qs. 10 (Page No. 421) • Around ocular region or gonadal region
0 .3 : Collar stud abscess • Suspected bone fracture
A : See Section 1, Segment - D, Qs. 82 (Page No. 539) U. Adamantinoma
0 .4 : Venous ulcer *: See “Ameloblastoma" - Section 1, Segment-C, Paper-11,2012, Qs. 13 (Page No. 411)
A : See Section 1, Segment - C , Paper 1,2013, Qs. 2 (Page No. 301) M : Solitary thyroid nodule
Q.S: Cleft palate *: See Section 1, Segment - A, Paper II, 2013 supplementary, Qs. 1 (Page No. 170-171)
A : See Section 1, Segment - D, Qs. 15 (Page No. 477)
Q.6 : Complications o f radiotherapy 2010
A : See Section 1, Segment - C, Paper II, 2009, Qs. 10 (Page No. 367)
®l •' Ectopic veslcae
0 .7 : Regional anaesthesia
A : See Section 3, Qs. 8 (Page No. 764-765) ECTOPIC VESICAE
0 .8 : Empyema thoracis ■* tynonym; Extrophy ol bladder
A : See Section 1, Segment - C, Paper II, 2010, Qs. 13 (Page No. 381) ^ What Is I t : Congenital anomaly of urinary bladder
 374 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 37S

□ Incidence: Rare , correction of epispadius

' Excision of bladder and permanent ureterosigmold diversion done sometimes
□ Sex predilection: M > F
□ Types: Neurofibromatosis
a) Complete N E U R O FIB R O M A T O S IS
b) Incomplete
□ Defect: Ventral defect of the urogenital sinus and the overlying skeletal system imiflirT " •’ Von Recklinghausen's disease of nerve
□ E ffe ct: Anterior wall of urinary bladder and infraumbjlical pari of anterior abdominal wa!ifa) 3 L # It ■Condition in whichmultiple neurofibromas arise from cranial, peripheral and spinal
g ivnar n •
develop, along with the overlying muscles and bones ■■ nerves
□ Clinical features : 0 inheritance: Autosomal dominant
1) Oval/spherical defect in anterior abdominal wall
n TfP*s :
2) Inner surface of posterior wall of bladder protrudes through the defect - deep red in cofo* a) Type I - NF-1 gene located on chromosome17q11, commoner type
3) Everted mucous membrane becomes ulcerated and painful b) Type II - NF-2 gene located on chromosome22q12
4) Bleeds readily
a Gross pathology:
5} Dribbling of urine on anterior abdominal wall from ureteric orifices
, Spherical or cylindrical masses
□ Associated anom alies: • May or may not be encapsulated
a) In both sex- 0 Microscopy:
• Widely separated pubic bones . Proliferation of all elements in a peripheralnerve
• Absent symphysis pubis -* replaced by fibrous band -» pelvic ring less rigid -> fev . Elongated serpentine Schwann cells whichcan undergo malignant transformation
externally rotated -> waddling gait
0 Clinical features:
• Umbilicus absent
• Umbilical hernia 1) Multiple nodules - ..
• Laxity of anal sphincter • Distributed all over the body
• Spina bifida • Present since birth
b) In males - • Soft or hard
« Increase in number and size gradually
• Epispadius
• With distinct margin
• Penis broader, shorter, fixed to abdominal wall
2) Cafe - au - lait patches - Light brown macules with smooth borders (if 5 patches present over
• Scrotum not well-developed
1.5 cm, patient is likely to have neurofibromatosis)
• Prostate and seminal vesicles may be absent
3 Associated abnorm alities:
• Inguinal hernia
• Kyphosis, Scoliosis -
c) In females -
• Bilateral acoustic neuroma (NF2)
• Labia minora separated • Pigmented iris hamartoma - Lisch nodules
• Cleft clitoris • Intraosseous cystic lesions
□ Complications: • Pseudoarthrosis of tibia
1) Ulceration • Subperiosteal bone cysts
2) Pain • Meningioma
3) Repeated soakage • Phaeochromocytoma
4) Hydronephrosis • Orbital glioma (NFj)
5} Recurrent pyelonephritis • Medullary thyroid cancers
6) Metaplastic changes in mucosa -» adenocarcinoma 3 Complications:
7) Renal failure 1) Sarcomatous changes
2) Cystic degeneration
□ Treatment: Staged procedure
^ Treatment:
• Initial diversion of urine lo colon/rectum
• Iliac osteotomy Excision only in following conditions -
 376 QUEST : A Comprehensive Gukte to UG Surgery, Orthopedics & Anesthesiology
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1) Painful swelling
2) A very large swelling tundsrd classification:
^ a> submucous - in submucous plane
3) Swelling causing mechanical discomfort or pressure symptoms
^ subcutaneous - superficial to subcutaneous external sphincter
4) Suspicion of malignancy
c) Low anal - between subcutaneous and superficial part of external sphincter
0 .3 : Paget's disease o f nipple d) High anal - between superficial and deep part of external sphincter
e) pelvi-rectal - connects rectum to skin, passes through levator ani
PAG ET'S DISEASE O F NIPPLE [See Fig. 1.6.5]
SYWptoms: Severe throbbing pain in perianal region -> bursting of pus -> discharge of pus, soils
□ What Is I t : Malignant condition that outwardly may have the appearance of eczema •
changes Involving the nipple of fhe breast 8C2ema. wih ^ ^ gj^ienls -* relief of pain -> again throbbing pain after some days .
□ First described b y ; Sir James Paget j S igns:
□ Clinical features: Digital rectal examination is best
Goodsall's law -
1) Skin - The first symptom is usually an eczema-like rash. The skin of the nipple arrf =
imaginary line drawn between 2 ischial tuberosities
may be red, itchy and inflamed. After a period of time, the skin may become flaky or
ll externa! opening situated anterior to the line - tract is straight, internal opening lies directly opposite
2 Discharge - A discharge, which may be straw-colored or bloody, may ooze from the?
to external opening.
3) Sensation-Some women have a burning sensation * • “ •»»»»«■>*>, If external opening lies posterior to the line, or lies anterior to line and >1.5 inches away from anus -
4) Nipple changes —The nippfe may be inverted tract is curved, opens in midline posteriorly
5) ^ ® fnS' oban9e s - There may or may not be a lump in the breast, and there may be ,e<W [See Fig. 1.6.6]
_ • oozing and crusting, and a sore that does no! heal s
0 investigations:
The symptoms usually affect the nipple and then spread to the areola and then the .
is common for the symptoms to wax and wane. t) Fistulogram

□ Pathology : Paget’s disease of the breast is characterised by Paget cells. Paget cells are la™ 2) MRI

X Z3TT and«*en,nc’ hyperchromicnuc,ei ,ou"d StSSS& £

to the migratory theory, ductal carcinoma in situ cells migrate into the lactiferous sinuses
0 Treatment:
а) Low anal fistula -
S u r f t S ' ^ " cer. cells disruP ',he normal epithelial barrier and extracellular fluid accumulates! 1) Fistulectomy - Fistula opened - » fibrous tract excised
the surface of the skin, resulting in the crusting of the areola skin .
2) Fistulotomy - Probe inserted in fistula, tract incised and cut open - » allowed to granulate and
□ Investigations: heal from floor
t) Mammogram 3) STARR (Stappled Trans Anal Rectal Resection)
2) Biopsy 4) Hughe’s skin grafting
3) Immunohistochemistry б) High anal fistula -
O Treatment: Seton technique - Silk or linen ligature passed across fistula, and left in place with a lie, and
• Lumpectomy or mastectomy allowed to heal from above (cheese wiring effect of cutting setons)
Chemotherapy and/or radiotherapy may be necessary 0-5 ; Varicocele
Q.4: Fistula In ano
VARICOCELE

FISTULA IN ANO 0 What Is I t : Dilatation and tortuisity of pampiniform plexus of veins and testicular veins
0 4nafomy:
0 c&naf
canai fnd
ana anHeIi°em ^ ^ in penanal skin
an external opening 9ranula1ion ,issue whi<* has an internal opening in ani Pampiniform plexus of veins in scrotum - » join to form 4-8 veins in testis - > testicular vein -» right vein
drains into IVC, left vein drains into left renal vein, which drains into IVC
□ A etio lo gy : Perianal abscess
3 Common In : Tall young lean men
0 Park's classification:
3 types:
a) Trans-sphincferic
a) Primary
b) Intersphincteric
b) Secondary
c) Suprasphincteric -1 Laterality;
d) Extrasphincteric
More common in left side because -
t) Perpendicular entry of left testicular vein into left renal vein
 378 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 379

2) Lett renal vein compressed between aorta and superior mesenteric artery
3) Incompetent valve at junction of left testicular vein and left renal vein n 0 io to g y :
1) Laceration of cortex of brain
4) Left renal vein being longer may be compressed by loaded sigmoid colon
2) Rupture of superior cerebral veins - often by impact to the front or back of head
5) Left sided Renal Cell Carcinoma -> tumor thrombus in left renal vein -> obstr, ~
flow of left testicular artery ° ° slructs : Commoner in elderly (as brain atrophies with age, giving rise to more space for the brain to
6) Left suprarenal vein also drains into left renal vein and circulating adrenalin 3 within the skull)
constriction of testicular vein ne m% ca^
p Tyt#s :
□ E ffe ct: Infertility because - a) Acute
1) Varicocele leads to altered heat exchange mechanism -» hyperthermia b) Chronic
spermatogenesis 113 -* feduCe, a Clinical features:
2) Increased blood flow -* increased metabolic activity -> glycogen depletion j) Loss of consciousness, which worsens gradually, without any lucid interval
-» oligozoospermia J rV*olest, 2) Convulsions
3) Hypoxia of testis 3) Features of raised intracranial tension - hypertension, bradycardia
4) Leydig cell dysfunction due lo increased temperature 4) Focal neurological deficits
□ Grading:
q investigations:
I • Small t) CT scan - concavo-convex lesion
II - Moderate [See Fig. 1.6.7]
III - Large
2) Blood electrolytes
IV - Severely tortuous ,
0 Treatment:
□ Clinical features: 1) Craniotomy and evacuation of clot
1) Swelling in root of penis 2) Anticonvulsants
2) Bag of worms feeling 3) Antibiotics
3) Dragging pain sensation in groin and scrotal region
4) Impulse on coughing 0.7: Muscle relaxants
5) Swelling gets reduced on lying down A: See Section - 3, Qs. 3 (Page No. 757*758)
6) Bow sign - after holding varicocele between thumb and finger, if patient bows down varkxwi 0.8: f s’ scan
reduces in size (due to reduced blood flow)
A : See 'Investigations' - Thyroid scan (Section - 1 , Segment E, Qs. 25) [Page No. 599]
O Investigations:
0.9: Congenital hypertrophic pyloric stenosis
1) Venous Doppler of scrotum and groin
2) USG abdomen to detect RCC \ y C 6Co
bnlGgEe tn it a l h y p e r t r o p h ic p y l o r ic s t e n o s is
3) Semen analysis
□ Treatment: □ What is I t : Hypertrophy of the musculature of pyloric antrum of stomach especially circular muscle
fibres, causing primary failure of pylorus to relax ' ’ v
1) Palamo’s operation - suprainguinal extraperitoneal ligation of testicular vein
0 incidence: 4 in T000 births
2) Microscopic subinguinal varicocelectomy
□ Differential diagnosis: Q Common in : First born males
1) Lymph varix 0 Nature: Familial
2) Hydrocele Q Age: 3rd-6th week
3) Inguinal hernia 3 Clinical features:
4) Lipoma of spermatic cord 1) Vomiting -
• Projectile
Q.6 : Subdural hematoma
• Forcible
S U BD U R AL HEMATOMA • Non-bilious
2) Visible gastric peristalsis
□ What is i t : Collection of blood between duramater and brain
. 3) Palpable lump -
□ Incidence: Six times commoner than extradural hematoma • Mobile
• Firm
 380 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVEO SHORT NOTES OF FINAL MBBS □ Paper - II 381

QofiipUeutiont: (spreads very fast as infection lies deep to deep fascia)

• Smooth
® -I) Laryngeal edema
• Well defined margin
2) Septicaemia
« Moves with respiration
• Impaired resonance on percussion
4) Constipation 13 1) Intravenous fluid
2) Antibiotics
5) Dehydration
3) Decompression of submandibular region
6) Weight loss, anorexia
q 12: meningomyelocele
7) Electrolyte Imbalance - Hypokalaemic metabolic alkalosis
' a ; See Orthopedics - Spina bifida (Section - 2, Group - 1,2009, Qs. 6) [Page No. 633].
□ Investigations:
0 .1 $ : Empyema thoracis
1) USG abdomen -
• Pyloric muscle > 4 mm thick A: See next page
t Length of pyloric canal > 16 mm ft 14: Patient Ductus Arteriosus
• 'Doughnut' sign A : See Section - 1, Segment C, Paper - II, 2008, Qs. 15 (Page No. 356)
2) Barium meat -» obstruction
EMPYEMA THORACIS
□ Treatment: '
1) Correction of dehydration q What Is i t : Collection of pus in pleural cavity
2) Atropine methyl nitrate orally to relax pylorus a Aetiology: Always secondary
3) Ramsted's operation (after laparotomy, hypertrophied muscle Is cut along the length
• mucosa bulges out)
□ Differential diagnosis: EMPYEMA THORACIS
1) High intestinal obstruction
2) Duodenal atresia I ---------- — t
3) Intracranial hemorrhage Non-traumatic Traumatic
____J_____
0.10: Lumbar puncture r “ I -----------
Thoracic Extrathoraclc Iatrogenic Non-latrogenlc
A : See ‘Investigations’ Section (Section - 1 , Segment E, Qs. 27) (Page No. 600-602],
• Post-thoracotomy • Stab
0.11: Ludwig's angina • Lung resection • Gunshot wound
LUDW IG ’S A N G IN A • Paracentesis thoracis

-------------I
O What Is I t : Inflammatory edema of submandibular region and the floor of mouth
From From
□ Cause; Streptococcal infection Oesophagus below diaphragm
□ Precipitating factors: Carcinoma Subphrenic abscess
1) Oral or other malignancy Perforations Hepatic abscess
2) Salivary calculi Leaking anastomosis
3) Caries teeth
4) Chemotherapy ‘ -------- 1------------------------------ 1
□ Clinical features: Pulmonary Mediastinal From chest wall
1) Brawny swelling of submandibular region * Pneumonia • Osteomyelitis of sternum, ribs
2) Intraoral edema in the floor of mouth * Tuberculosis
* Bronchiectasis
3) Putrid halitosis
* Lung abscess
4) Fever, malaise
* Bronchogenic carcinoma
5) Dysphagia
6) Dyspnoea
 382 QUEST ; A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 383

Organisms Involved: 5j pus culture & sensitivity

• Streptococci 6) Bronchoscopy
• Staphylococci TREATMENT
• Pneumococci
• E-coli --------------X
• Klebsiella sp. Stage II Stage III
Stage I (Chronic empyema)
Stages: (Subacute empyema)
* 0 empyema)
• Open drainage • Decortication operation
1) Acute . Repealed aspirations
• Rib resection • Lobectomy (rare)
2) Subacute
I J j S S * closed drainage (Eloisers method)
3) Chronic - (a) closed type and (b) open type
• Respiratory physiotherapy
by intercostal tube
Pathogenesis: Serous fluid collects - » becomes purulent -» intrapleural clotting of pus thicket) • Antibiotics
of pleura -» fibrinous adhesions -» rigid contracted immobile chest with functionless lung underran . ATD(If reqd>
(frozen chest) -> pus perforates through intercostal space (empyema necessitans).

TYPES REFERRED PAIN

I j Plln; Sherrington defined pain as ‘physical adjunct of an imperative protective reflex .

Anatomical Pathological Clinical 2 Referred pain: Visceral pain, felt at some distance on somatic structures, instead of being felt at the
Acute
Apical Exudative site of visoera.
Interlobar Acute fulminant
U Synonym: Reflective pain.
Mediastinal Fibrin opuruleni toxic
Subacute Q Examples:
Lateral U Organising . Pain in cholecystitis referred to tip of right shoulder, (as right shoulder is supplied by C4. Cs,
Diaphragmatic Chronic
Latent C« roots, while the diaphragm which is irritated by the inflammed gall bladder is supplied by
Persistent phrenic nerve (C3, C4, C5)
■Empyema • Anginal chest pain referred to medial aspect of left arm
necessitans
• Pain of appendicitis referred to skin around umbilicus.
— Chronic empyema
with sinus Q Mechanism:
Interlobar empyera a) Convergence Theory:

Fibres carrying
□ Clinical features: pain from viscera Pathway stimulated Brain causes the
Converge to form a
1) Pain in chest single pathway to by any means (e.g., pain to be projected
2) Fever inflam m ation of to the site of
Fibrescarrying pain cortex
3} Difficulty in breathing viscus) receptors on skin
tom dermatome
as somatic pain is
4) Tenderness
more common
5) Rapid shallow respiration
6) Stony dullness on percussion
7) Absence of breath sounds b) Facilitation Theory:
8) Mediastinum displaced to opposite side
□ Investigations : —> Pain felt on skin
Visceral pain produces subliminal SGR cells are easily stimu­
1) Chest X-Ray (PA view) - Fluid in pleural cavity lated by minor stimuli on skin
Mnge effect on the Substantia
2) Aspiration of pleural fluid Gelatinosa of Rolando (SGR) cells,
3) ESR which receive somatic pain
4) Peripheral smear
 384 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper -11 385

□ Features: pethogenesis ’’ . . .
• Size ol referred pain related to - , Muscle gets involved from its ongm to insertion
(a) intensity of pain , Necrosis of muscle
(b) duration of pain , production of gases - hydrogen sulphide, carbon dioxide etc.
• Temporal symmation is a potent mechanism for generation of referred pain i OinicBimatures: ,
• Extent of referred pain depends on central hyperexcitability , Foul smelling discharge from wound
• Proximal spread of referred pain seen in people with chronic musculoskeletal pain . Crepitus at site of wound
• Modality-Specific somatosensory changes occur in referred areas.
, Skin becomes brown coloured due to hemolysis
. Renal failure features
2 0 1 0 S u p p le m e n ta ry
, jaundice

Q.1: Mixed salivary tumour 3 Types: .

, Single muscle type
A : See "P.S.A.” - Section 1, Segment - C, Paper-ll, 2012, Qs. 5 (Page No. 406-407)
. Subcutaneous type
Q 2 : Meconium Ileus
. Group lype
A : See Section 1, Segment - D, Qs. 110 (Page No. 569-570)
• Massive type
Q.3: Post bum contracture
. Fulminant type
A : See Section 1, Segment-D, Qs. 107 (Page No. 566-567)
3 Investigations: .
Q.4: FAST • Routine blood tests
' A : See Section 1, Segment-E, Qs. 1 (Page No. 580) • X-Ray of affected part shows gas shadow
Q.S: Tension pneumothorax . LFT
A : See Section 1, Segm ent-C, Paper-ll,2009,Qs. 14(Page No.370-371) • Acid-base study
Q.6: Epulis • Renal function test
A : See Section 1, Segment - C , Paper-ll, 2011, Qs. 13 (Page No. 399-400) • Pus culture and sensitivity
Q.7: Glasgow coma scale . □ Treatment:
A : See Section 1, Segment - C, Paper-ll, 2008, Qs. 13 (Page No. 355-356) • Inj. Benzyl Penicillin
Q.8: Gas gangrene • Inj. Aminoglycosides
• Inj. Metronidazole
GAS GANGRENE
• Antiserum ' .
□ What Is gangrene : Death of a portion ol body due to putrefaction, caused by inlection with saprophyte • Hyperbaric oxygen -
bacteria • Proper supportive measure - u/o chart, etc
□ Gas gangrene : Infective gangrene along with gas produced by bacteria, which gets trapped t • Proper debridement and amputation if re<)d.
between the tissue • Adequate hydration
□ Other na m e: Malignant oedema
03: Intravenous anaesthetics
□ Causative agent :
A: See Page No. 770.
• Clostridium perfringes
°-10: Primary hyperparathyroidism
• Clostridium histolyticum
• Clostridium septicum PRIMARY HYPERPARATHYROIDISM
• Other coliforms
2 What Is it : Unstimulated inappropriate high secretion of parathormone (PTH)
□ Toxins involved:
Cause:
• Lecithinase
• Solitary parathyroid adenoma (most common site - inferior parathyroid) - 85% cases
• Hyaluronidase
• Hyperplasia (14% cases)
• Haemolysin
• Carcinoma (1% cases)
• Proteinase
 386 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-II 387

□ Clinics! features: 2) splenomegaly

t
• Subtle presentation is assymptomatic hypercalcaemia 3) Compensatory bone marrow hyperplasia
• Cyclic moans {psychiatric changes) improvement following splenectomy
• Abdominal groans {acid peptic disorder)
• Renal stones , primary - with no underlying aetiology
• Bones affected - initially cortical, then cancellous , Secondary - with underlying aetiology
• Bradycardia
• Muscle weakness . Portal hypertension
• Constipation , Malaria
• Anorexia, weight loss , Kala azar
• Polyuria and polydipsia
. T.B.
□ Specific bone changes: i Schistosomiasis
• Tufting of terminal phalanx (radial aspect) a Myeloproliferative disorder
• Sub periosteal resorption of middle phalanx •) Mainly effected s e x : Females
• Osteitis fibrosa cystica - cellular and marrow elements in long bones qet reolaced h»rk. •j Clinical fe a tu re s :
tissue (Von Recklinghausen disease] ■*
• Fever »
• Osteoclastoma (Brown tumour)
• Recurrent infections
« Floating tooth (loss of lamina dura)
t Bleeding from orifices
. • Salt-pepper appearance (pinhead stippling) in skull
• Pallor
□ Investigations:
• Oral ulcerations .
• Serum calcium T (> 12 mg%)
3 Treatm ent:
• Serum phosphorus I
• Corticosteroids rarely are helpful
• Serum chloride T (> 112 mg%)
t Splenectomy is treatment of choice
• c r/p o |-> 3 3 0.12: Hydrocephalus ^
• Serum PTH t (> 0.5 mg/L) ^''H Y D R O C E P H A L U S
• Urinary Calcium T (> 250 mg/24 hr)
• Serum ALP T 3 What is I t : Dilatation of ventricles of brain
0 Pathology:
• X-ray skull - Salt pepper appearance
• Increased secretion of CSF
• To localise adenoma, Investigation of choice Is Sestamibl scan
• Defective absorption of CSF
Best is Sestamibl scan
• Blockage in flow of CSF
Combined with PET scan
□ Treatment: 3 Types:
a) Communicating - freely communicating with subarachnoid space
• Adenoma -> Gland in which adenoma present is removed
b) Non-communicating - obstructive type
• Hyperplasia -»354 out of 4 parathyroid glands removed
3 Etiology:
• MEN like familial case -» All 4 glands removed. 15 gland fragments created which are pul
into brachioradiatis muscle ' .
___ Communicating Non-communicating
0 .1 1 ; Hypersplenism
Congenital aqueductal stenosis - 1) Subarachnoid haemorrhage .*
HYPERSPLENISM 2) Vein of Galen malformation ->• 2) Tubercular meningitis r •
□ What is i t : Increased splenic function causing pancytopenia and hypercellular bone mano* 3) Posterior fossa tumour 3) Pneumococcal meningitis
□ Diagnostic features;
1) Anaemia and/or leucopenia and/or thrombocytopenia
 388 QUEST : A Comprehensive Guide to UG Sweety, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS D P a p e r-ll 389

□ Clinical features :
a) When sutures are open - * _ . . nosplce

• Separation of sutures - earliest being coronal suture ' HOSPICE

• Increase in head size * y/tittis It • Type of care that mainly focusses on palliation of chronically ill patients or patients in their
• Bulging of fontanelle '
2 death bed.
• Sunset sign (reduced upward gaze) . Coil' To attend to the emotional and spiritual needs of ailing patients
[No papilloedema In infants]
, Advantage* :
b) When sutures are closed - , Provides support and care to terminally ill patients
• Projectile vomitting ' y - , Affirms life - neither hastens nor postpones death.
• Early morning headache-: , Focusses on quality of life of patient and their attendents
• Altered sensorium , Teaches family members how to be the emotional support system of the patient
• Papilloedema , Main aim Is caring, not curing
• Changes in sleep cycle : Howit works: •
• Cushing reflex (hypertension, bradycardia, Irregular respiration) ( Family member serves as primary caregiver. They are taught to take important decisions for
□ Investigations: . the patient
a) When sutures open, IOC is Trans cranial USG' . • Members of hospice - Staff make regular visits to assess the patient and provide other
to When sutures closed, IOC Is - . services as required.
• In unstable patient -> Contrast CT. ~. 2 Hospice team consists o f :
• In stable patient -> Contrast MRI • Patient’s personal physician
c) Others - < Hospice physician
.• Ventriculography • Nurse
• Air encephalography • Home attendants
□ Treatment : , • Social workers
• Treat the underlying causS-''''’ • Counsellors
• Oral Acetozolamide ^ • • Trained volunteers
• Tapping of lateral ventricles • Special therapists
• Ventriculo • cystemostomy (Torkildsen operation) } Services provided:
• Ventriculo peritoneal shbnt ^ • Manage patient’s pain and symptoms
• Ventriculo atrial shunt / • Provides necessary drugs and equipments
0 .13: Sentinel lymph node biopsy • Trains family members
• Assists patient with psychological and spiritual aspects of death
SENTINEL LYMPH NODE BIOPSY • Makes short term in patient care available
• Provides bereavement care to suffering family
□ What is sentinel no de: Lymph node which is in a direct drainage pathway from primary tunw
G15.-Differential diagnosis o f intracranial space occupying lesions
□ Sentinel node biop sy: Histological stal of sentinel node is studied which also predicts thes®1
of distant lymph node DIFFERENTIAL DIAGNOSIS - INTRACRANIAL SPACE OCCUPYING LESIONS
□ First Introduced b y : Cabana in 1977 introduced it as a staging procedure for penile carcinoca
□ Advantages: J Wlutare these ; Lesions inside vault of skull (cranium)which may expand in volume to displace
surrounding neural structures and lead to increase in intracranial pressure *
• Minimally invasive ,
Mechanism leading to sym ptom s:
• Low cost
• Mass effect 1 .
• Gives idea about extent of lymph node resection
• CSF obstruction J ** Increased ICP
For rest details see page 128.
’ Irritation of cortex —> Seizures
 390 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 4 Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS 0 P a p e r-ll 391

• Compression 1 ' PARASITIC BRAIN CYSTS

• Invasion | - Focal neurological deficit
• Interruption with circulation
Differential diagnosis:
A. Brain tumours (non-neoplastic or metastatic)
B. Traumatic
C. Parasitic
D. Inflammatory
E. Vascular
, Presentation
F. Congenital
.♦ Nausea, vomit
A. BRAIN TUMOURS * Headache
* Epileptic seizure
* Systemic toxicity (fever, malaise)
Glioma ]
* Symptoms of primary focus infection (Otitis media, sinusitis, etc)
Meningioma ]
0 INFLAMMATORY
Schwannoma ) .
Primary
PNET
J

Types Pituitary tumour ]

Pinealoma )

------ ( Metastasis from lung, kidney, breast ] >

□ Clinical presentation:
• Headache
• Vomiting
• Papilloedema
• Seizures
• Focal deficits
• Altered sensorium
• Hearing problem (Schwannoma)
• Visual defects (Pituitary tumour)
• Perinaud's syndrome (Pinealoma)

3 Investigations:
For details see Page 350 and Page 363.
• CT/MRI Brain -
* Glioblastoma - Irregular, expansile
 392 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 393

* Meningioma - ‘dural tail’ sign b) 24-72 hours-

* Acoustic schwannoma - “ Ice-cream cone" sign , Chest infection
* Pituitary adenoma - ‘'Cottage loaf’ or “ Figure ol 8" appearance , Pulmonary atelectasis
* Mets - Irregular, scattered all over c) 3id-7lh post-operative day -
* EOH - Biconvex, hyperdense , Chest infection
* SDH - Biconcave, hyperdense . UTI
* Neurocysticercosls - Ring enhancing lesions, discrete, with scolices . Wound infection
' * Tuberculoma-Conglomerate ring enhancing lesions, with huge oedema surroui^ , intraperitoneal sepsis
lesions ^
. Anastomotic leak
• MR Angiography
. Infective endocarditis
• Specific blood investigations for tuberculosis and cysticercosis
, Pelvic abscess
□ Treatment : . Subphrenic abscess
• Tumours- Surgical exlsion ± Radiotherapy . Transfusion reaction
- Gamma knife surgery > Thrombophlebitis
• SDH/EDH - Burr Hole surgery ij) 7th-10th post-operative day -
- Craniotomy « Deep vein thrombosis
• Abscess - Drainage • Drug reaction
. • Tuberculoma / Neurocysticercosis - Antimicrobial therapy • Pulmonary embolism
• Measures to reduce ICP • Nosocomial infections - pneumonia, UTI, sinusitis, otitis media
- Mannitol
Q Assessment:
- Corticosteroids
Full clinical examination
- Hyperventilation
• Abdominal tenderness, distension
• Anti-epileptic therapy
• Respiratory rate, crepitations
- Phenytion ,
« Wound - erythema, discharge
- Carbamazepine
• Calf tenderness (Homan’s sign, Mosse’s sign)
• Any murmur
2011 Q Investigations:
1) Complete hemogram
0 .1 : Flail chest 2) Chest X-Ray
A : See Section - 1, Segment C, P a p e r-ll, 2008, Qs. 12 (Page No. 354). 3) Sputum for Gram stain and culture
4) Urine - Routine examination and culture
0 .2 : Post - operative pyrexia
5) Arterial blood gas analysis
6) Wound swab for culture and sensitivity
PO ST - O PERATIVE PYREXIA
7) Blood culture
□ What Is I t : Temperature > 38 degree Celsius or 100 degree Fahrenheit on 2 consecutive post­ 8) CT scan abdomen
operative days, or > 39 degree Celcius on any 1 post-operative day 9) USG abdomen
10) Doppler scan of venous system
□ A etiology:
^ Treatment:
a) In first 24 hours -
• Pyrexial response to surgery ') Atelectasis - Chest physiotherapy, bronchoscopic aspiration
2) Pneumonia - Antibiotics
• Transfusion reactions
3) Pleural effusion - Pleural fluid lapping
• Pre-existing infection
4) Pulmonary embolism - Heparin
• Due to medications
5) Wound - Drainage ot pus, proper dressing, antibiotics
 394 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 395

6) UTI - Antibiotics, alkalinising agent

7) DVT-Heparin 0 plunging - Intrathoracic goiter pushed into neck by increased intrathoracic pressure
8) Acetaminophen for comfort b) Intrathoracic
□ Prevention: c) Substemal - Part of nodule palpable in the lower part of neck
• Discontinue unnecessary medication
n symptoms: .
• Subclavian lines are preferred to femoral 1) Stridor
• Daily spontaneous breathing trials for intubated patients to reduce pneumonia
2) Cough
■ Use of enteral nutrition 3) Breathlessness .
Q.3: Brain death 4) Dysphagia
g Signs:
V ^ R A I N DEATH 1) Neck veins engorged
2) Lower border of thyroid gland not palpable
□ What Is I t : Complete and irreversible loss of brain function
3) Pemberton's sign positive (Patient raises arms above the level of shoulder for few minutes -»
□ Speciality: Used as an indicator of legal death compression on SVC and trachea -» engorged dilated neck veins + stridor)
□ Declaration b y : 2 independent physicians after thorough neurological examination twiw a<
4) Dull note audible on percussion over sternum
reasonable gap
□ In v e s tig a tio n s :
0 Tests:
1) Radioactive iodine scan
1) Pupil fixed and dilated
2) CT scan
2) Pupillary reflex absent;
3) Chest X-Ray
3) Corneal reflex absent ■ . .
0 Treatment: Surgical removal
4) Conjunctional reflex absent
5) Oculo-cephalic reflex absent 0 J : Parotid abscess
6) Vestibulo-ocular reflex absent PARO TID ABSCESS
7) Superficial and deep motor reflexes absent - » no response to pain, touch and temperate
8) Gap reflex, cough reflex absent Q Synonym: Suppurative parotitis
9) No respiratory movement, stoppage of ventilator , Q IWiaf Is I t ; Abscess of parotid gland due to acute bacterial sialadenitis of parotid gland
10) Rat EEG
0 Causative organism s:
□ Importance: Time of brain death is important to be noted for the purpose of organ donation. 1) Staphylococcus aureus
Q.4: Split thickness skin graft ' 2) Streptococcus viridians
A : See Section - 1, Segment C, Paper - II, 2008, Qs. 7 (Page No. 351-352) 3) Anaerobic organisms
0 .5 ; Spinal anesthesia 4) Gram negative organisms

A : See 'Anesthesiology' Section - 3, Qs. 1 (Page No. 753) 0 Predisposing conditions:

Q.6: Omphalocele 1) After major surgery
A : See Section - 1. Segment C, Paper - II. 2008, Qs. 6 (Page No. 350). 2) Sepsis
3) Dehydration
0 .7 : Retrosternal goiter
4) Starvation
RETROSTERNAL GOITER 5) Poor oral hygiene
0 Symptoms :
□ What Is I t : > 50% of the goiter lies below suprasternal notch
1) Fever
□ Pathogenesis : In men whose necks are short and pretracheal muscles are strong, negate 2) Pain
intrathoracic pressure tends to draw goiter into thoracic cavity
3) Trismus
□ Classification:
2 Signs:
a) Primary - Arise from ectopic thyroid tissue
I ) Swelling -
b) Secondary - Extension occurs from enlarged thyroid gland in neck
> warm
> red
 SOLVED SHORT NOTES OF FINAL MBBS Q Paper - II 397
396 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

> well-localised 3 Tenderness at McBumey's point

> tender 2 Rebound tenderness at McBumey's point
> firm 3) Cutaneous hyperaesthesia over Sherren’s triangle
» fluctuation is a late feature 4 Rovsing’s sign - Pafn occurs in right iliac fossa on pressing left Iliac fossa
2) Pus from duct opening 5 Cope's psoas test - Pain in right iliac fossa on hyperextension of right hip
6 Obturator test - Pain in right iliac fossa on passive Internal rotation of right hip
□ Investigations:
7) Baldwing’s test - Pain over flanks when legs lifted off bed with knee extended
1} USG parotid region
g T re a tm e n t: Appendicectomy
2) Pus - Culture and sensitivity
3) Needle aspiration to confirm pus q.io -.t v m

[Sialogram not done in acute phase, which can cause infection] A. ^'investigations' Section (Section - 1 , Segment E, Qs. 15) [Page No. 591-592].

□ Treatment: g f f ; Oxalate stone

1) Drainage of pus
OXALATE STONE
2) Antibiotics
3) Proper hydration * 0 synonym: Mulberry stone
4) Oral hygiene maintenance
0 Colour: Brown
5) Proper nutrition • 0 Content: Calcium oxalate
□ Complications: 0 Surface: Sharp projections -> hematuria
. 1) Fistula D Shape:
2) Septicaemia 1) Monohydrate stones - Dumbbell shaped
3) Rupture into external auditory canal 2) Dehydrate stones - Envelope shaped
0 3 : Alvarado score o f acute pancreatitis 0 Clinical features ;
1) Pain­
A LV A R A D O SCORE OF ACUTE PANC REATITIS s' dull - Due to stretching of capsule
» colicky - Due to movement of small stone
□ Also called: Mantrels scoring system
2) Hematuria
□ U se: Bedside diagnosis of acute pancreatitis 3) Fever
□ Scoring system : 4) Pyuria
5) Renal angle tenderness
Symptoms Score
0 Investigations: t .
Migrating pain in right iliac fossa 1 1) Urine - Envelope crystals
Anorexia 1 2) Serum calcium increased
Nausea and vomit 1 3) ESR raised
Tenderness in right iliac fossa 2 4) Plain X-Ray KUB
Rebound tenderness 1 5) IVU
Elevated temperature 1 6) Urine analysis
Leucocytosis 2 3 Treatment:
Shift to left in neutrophilia in 1 a) Forstones< 0.5 c m -
peripheral blood smear 1) Anti-inflammatory drugs, anti-spasmodic drugs
...
2) Intravenous fluids
□ Interpretation: 3) Injection Furosemide
Score < 5 - Not sure 4) Flush therapy
Score 5-6 - Compatible 5) Alkalinising agents, acidifying agents
Score 6-9 - Probable
6) Relief of obstruction by double J-stent
Score > 9 - Confirmed
Score > 7 indicates acute appendicitis, requires immediate operation
 398 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL M8BS □ Paper - II 399

b) For stones >0.5 cm -

1 indic^ons:
Endourological surgery J j) Arthritis
2) Muscle injury
For non-lower pole renal calculi 3) Rheumatism
4) inflammation
> 2 cm 5) Fibromyalgia
.<2 cm
6) Eczema
7) psoriasis _
< 1 cm 8) Tendonitis
I 9) sudeck's osteodystrophy
ESWL 10) Sport-related injuries
1 j) Moisturise and cleanse the skin
I 12) Open pores in skin
Mechanism : Slowly increasing temperature around affected area warms the subcutaneous layer
and trigger's endorphin release to the affected site, thereby bringing relief
j contents of wax: W ax: paraffin = 7 :1
0 Temperature o f w a x: 120 degree Celcius
2 procedure : Specially formulated wax is heated in a container -» a regulator maintains a safe
For lower pole renal calculi . temperature for the skin -* wax melts -> affected part submersed In the molten wax and removed ->
J X allowed to air-dry for 2 minutes -> procedure repeated for 5-10 minutes -> after there are enough wax
layers, the affected part is wrapped in plastic and left to stand for 15 minutes -> when wax gets
1-2cm >2cm
< 1 cm hardened, it is peeled off
/ \ ▼ 3 Contraindications:
jer > Is PCNL contraindicated?
1) Open wounds
HU < 1000 HU > 1000 N.
2) Skin rash
SSD < 10 cm SSD > 10 cm yes No 3) Cuts
4) Burns
1 I j PCNL 5) Varicose vein
ESWL Flexible retrograde intrarenal surgery
6) History of hypertension

c) If endourological surgery fails - 0,13: Epulis

• Pyelolithotomy - For stones in extrarenal pelvis EPULIS
• Extended pyelolithotomy - For stones in intrarenal pelvis
• Nephrolithotomy - Incision at most convex surface (Brodel's line) i) Meaning: Upon a gum
• Partial nephrectomy - If multiple stones occupy a pole 3 What is i t : Swelling arising from mucoperiosteum of gums
• Others - 2 Types:
> Bench surgery (A) Congenital epulis
> Anatrophlc pyelolithotomy (B) Fibrous epulis
(C) Pregnancy epulis
V Coagulum pyelolithotomy
(D) Myelomatous epulis
Q.12: Wax bath (E) Giant cell epulis
W AX BATH (F) Granulomatous epulis
(G) Carcinomatous epulis
□ What Is I t : Technique of administering surface heat therapy A- CONGENITAL EPULIS :
□ Principle: Involves immersion of the required body parts into molten paraffin wax to relieve pain. K 81 Q Features :
muscle injury and moisturize and deep cleanse the skin y Benign condition
 490 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS Q Paper - II 401

> Newborns GOANULOMATOUS EPUUS:

> Arises from gumpads • . ^ j / ass of granulation tissue in gums around caries tooth
> Variant of granular cell myeloblastoma originating from gums , Localised, firm, fleshy mass in gum which bleeds on touch
> F>M
CARCINOMATOUS EPUUS:
> Common ir. upper jaw
. Squamous cell carcinoma of alveolus and gum
> Common in premolar/canine area
, Localised, hard, indurated swelling with ulceration
□ Clinical features:
g U :URI scan in surgery
Swelling with following features -
• Well localised A ■See Section - 1 , Segment E, ‘Investigations', Qs. 11 (Page No. 587-588).
• Firm q 1$: Radiation dermatitis
• Bleeds on touch
RADIATION DERMATITIS
□ Investigations:
1) X-Ray of jaw 3 Synonym: Radiodermatitis
2) Orthopantomogram 3 What is i t : Skin disease associated with prolonged exposure to ionising radiation
3) Biopsy
3 Typ*s 1
□ Treatment: Excision of epulis a) Acute - Caused by "erythema dose" of ionising radiation
B. FIBROUS EPULIS: b) Chronic - Caused by “sub-erythema dose” of ionising radiation
c) Others
' □ Features: •
3 Effects
• Benign
• Acute radiodermatitis
• Commonest
1) Erythema - Appears after 24 hours, at more than 2 Gy radiation
• Can occur at any age
2) Desquamation
• Arises from periodontal membrane 3) Blister
□ Clinical features : • Chronic radioderm atitis:
Swelling with following features - •. 1) Atrophic indurated plaques - (a) whitish and (b) yellowish
• Well-localised 2) Telangiectasia
• Hard 3) Hyperkeratosis
• Painless, non-tender • O thers: ' .
• Bleeds on touch 1) Eosinophilic, polymorphic and pruritic eruption - Occurs due to Cobait therapy
□ Investigations: 2) Erythema mulliforme - Due to phenytoin therapy
1) X-Ray of jaw Q Delayed non-specific effects:
2) Orthopantomogram
1) Radiation acne -> comedo-like papules
3) Biopsy
2) Radiation recall reactions - » occurs years after radiation treatment
□ Treatment: Excision of epulis with extraction of adjacent tooth
0-16: Spinal anesthesia
C. PREGNANCY EPULIS : A: See Section - 3, Qs. 1 (Page No. 753).
• Occur mostly in third month of pregnancy
• Due to inflammatory gingivitis 4 2011 Supplementary
• Resembles fibrous epulis
• Resolves after delivery ■'Paraphimosis
D. MYELOMATOUS EPULIS: *•' See Section 1. Segment - C , Paper-ll, 2012, Qs. 6 (Page No. 408)
• Seen in leukaemic patients 03 --Parotid fistula
• Resolves when treated for leukemia A;SeeSection 1, Segment - D, Qs. 116 (PageNo. 574-575)
E. GIANT CELL EPULIS : It is osteoclastoma causing ulceration and hemorrhage of gums Q-3;Hypospadius
• See Section 1, Segment - C, Paper-ll, 2013 supplementary, Qs. 8 (Page No. 425-426)
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0 .4 : Local anaesthesia
A : See Section 3, Qs. 8 (Page No. 764-765)
0 .5 ; Osclwer - Sherren regimen
A : See “Appendicular lump" Sec 1, Segment - A, Paper-1,20T3 supplementary, Qs. 2 (Page No, ^
Q.6: Stove-ln-chest

STOVE-IN-CHEST

□ What Is I t : Localised indentation over chest wall following blunt trauma

□ Pathological anatomy:
• Fracture of contiguous 2-3 ribs at atleast two places
• Area of bone between the two fracture sites is driven in
□ Clinical features;
• H/O blunt trauma
< Localised Indentation on chest wall leading to pain, tenderness
• Respiratory distress
• Features of neurogenic shock
□ ' Difference with flall-chest: The affected part of chest wall does not lose its structural and physiokiga
continuity with rest of chest wall. The entire chest moves symmetrically. Hence there is NO
PARADOXICAL RESPIRATION.
□ Investigations:
• X-ray chest (PA view)
» Blood gas analysis • 7 cm above the wrist it gives a dorsal branch which supplies the skin over the medial 156
fingers on the dorsal aspect
• Other routine investigations .
•It enters into the palm superficial to flexor retinaculum.
• CT Thorax may be required
• In (he palm it supplies
□ Treatment :
A. Motor-
. • Analgesics and antibiotics
(i) Hypothenar muscles
• Depressed segment may be lifted with towel clip (ii) 3rd and 4th lumbricales
• Nowadays, positive pressure ventilation Is the new mode of treatment (iii) All interossei
0 .7 : Hydrocephalus (iv) Adductor pollicis
A : See Section 1, Segment - C, Paper-ll, 2010 supplementary, Qs. 12 (Page No. 387). B Sensory - Medial 1Vi fingersand adjoining palm
Q.S : Ulnar nerve Injury tow* of U lnar N erve -

3 Sites:
U LN AR NERVE INJURY
1) At the elbow
Q Surgical anatomy 2) At the wrist
• Continuation of medial cord of brachial plexus (Ca, T 1) Causes:
• No branch in arm I A t the wrist -
• Pierces medial intermuscular septum and goes into posterior compartment (1) Sharp cut injury over front and medial aspect of wrist. Even a superficial cut can
cause injury (since nerve lies superficial to flexor retinaculum)
• Runs close and behind medial epicondyle
At the elbow -
• Enters into forearm
(1) Supracondylar
• In the forearm it supplies flexor carpi ulnaris and medial half of flexor digitorum profunoW (2) Medial epicondyle
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(3) Tardy ulnar palsy - Due to stretching of the nerve in a case of cubitus , Mo destruction of nipple areola complex as lesion is superficial
resulting from malunlted supracondylar fracture , Treatment is - Hadfield operation (Cone excision of multiple ducts)
(4) Ulnar Tunnel syndrome For Best, See Section 1, Segment - C, Paper-1,2008, Qs. 4 (Page No. 276)
□ E ffe cts: Hydronephrosis
1. A tth ew rist- See Section 1, Segment-A, Paper-ll, 2013, Qs. 1 (Page No. 148)
• Sensory - Sensory loss to medial 1 Yi finger and adjacent palm
g l! : adamantinoma
gje ••Ameloblastoma" Section 1, Segment-C, Paper-ll, 2012, Qs. 13 (Page No. 411)
• M otor- (i) Atrophy of hypothenar muscles <
Braehytherapy
(ii) Card Test the +ve (test for interossei - Patient is asked to hold an
between the fingers. The card is pulled. Patient cannot hold) g jj section 1, Segment - C, Paper-ll, 2008, Qs. 10 (Page No. 353)
(iif) Book Test +ve (Test for integrity of adductor pollicis. The pati™, A« •USG tor hepatobiliary diseases
asked to hold a book by adducting the thumbs. When ihe see Page No. 612-613.
pulled out, the tip of the thumb is flexed on the affected the side, fw 0f5: Cervical traction
pollicis longus contracts to keep the book)
II. At the elbow - CERVICAL TRACTION
(1) Same as injury at wrist
g Objective o f traction:
(2) Additional -
• To reduce fracture, dislocation and maintain them
• Motor - Radial deviation of the wrist on flexion of wrist again;
• Prevention of deformity
resistance (because of unopposed action of flexor caipi uin*,.
• Correction of soft tissue contracture
• • Sensory - Loss of sensation on dorsal aspect of medial 1Vi fingers
t Immobilising painful inflammed joint
• Deformity - Claw Hand
3 Types of traction:
0 .9 : Bedsore
A) Fixed - Counter traction is provided by part of body
A : Sea Section 1, Segm ent-C, Paper-1,2012, Q s.4. "Decubitus ulcer'1(Page No. 296)
B) Sliding - Counter traction provided by weight of body
'(5.10: Bloody discharge per nipple
3 Role of cervical tra ctio n : Helps to create space between cervical vertebra to keep them healthy,
BLO O D Y DISCHARGE PER NIPPLE . and prevent further compression
Q Parts:
□ Sources o f bloody discharge per nipp le:
• Retracting table/couch
a) From single duct - Duct papilloma
• Cervical traction collar (spongy in nature)
b) From multiple ducts - Ductal carcinoma • Metal hook to catch the collar
- Duct ectasia • Retracting wire/cable
A. DUCT PAPILLOMA 3 Crutchfield traction :
• Most common cause of bloody discharge • Reduction of cervical spine injury achieved by skull traction applied through skull callipers
• Young age called Crutchfield tongs.
• Blood oozes from same site repeatedly • Weight of upto 10 Kg applied and X-ray checked every 12 hours
• No lump • After adequate reduction, light traction is continued for 6 wks, followed by immobilisation of
• No pain /tenderness neck in a moulded PoP cast or plastic collar.
• Not detected on any radiological investigation however subareolar lump may be detected 3 Head Halter tra ctio n :
USG • It is a type of skin traction equivalent to spinal traction used for cervical spine injuries
• Treatment is microdochectomy • Types - a) Canvas type
B. DUCT ECTASIA b) Cryle type
» Above 40 years age, • Complications - a) pressure on chin
« Common in smokers % b) pressure on occiput
• Bloody discharge accompanied with greenish discharge c) pressure at TM joint
• Bilateral
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2012 „ tfislop3thology:
, Epithelial cells - Columnar/squamous/basal .
Q.1: Breast biopsies
, Myoepithelial cells
A : See Section - 1, Segment C, Paper - 1,2014, Qs. 1 (Page No. 309-310).
» Mucoid material with myxomatous change
Q 2 ; Causes o t hematuria , cartilage/pseudocartilage
A : See Section - 1, Segment A, Paper - II, 2008, Qs. 1 (Page No. 94) n features:
Q.3: Antegrade pyelography • Though capsulated, it may come out as pseudopods and may extend beyond the main limit
A : See ‘Investigations’ segment (Section - 1 , Segment E, Qs. 18) [Page No. 594] of the tumor tissue
, Sometimes only the deep lobe is involved
Q.4: Stress gastritis
q ClMctl features:
^ \ ^ 8 f R E S S GASTRITIS 1) Features of parotid tumor -
y Curtain sign - the mass cannot be moved above zygomatic bone as deep parotid fascia
□ What Is I t : Inflammation of gastric mucosa occuring in stressful conditions
Is attached above the zygomatic bone
□ Symptoms:
> Raised ear lobule
1) Epigastric discomfort > Deviation of uvula and pharyngeal wall towards midline
2) Nausea 2) Swelling with following features -
3) Vomit > Solitary
□ Complications: - > Unilateral
1) Peptic ulcer disease > Firm
2) Gastric polyps > Lobulated or smooth ' .
> Mobile
3) Benign and malignant gastric tumors
3) Obliteration of retromandibular groove
□ investigations:
Q Features on Impending malignancy:
1) Upper Gl endoscopy '
1) Pain
2) Routine CBC
2) Rapid increase in size
3) Stool lest . 3) Nodularity
□ Treatment: ■ 4) Involvement of -
1) i.v. Ranitidine 50 mg 8 hourly > Skin (ulceration)
2) i.v. Omeprazole / Pantoprazole > CN VII
3) Sucralfate orally > Masseter
> Neck lymph nodes
Q.5:P.S.A
0 Complications:
P.S.A 1) Malignancy
□ Full fo rm ; Pleomorphic salivary adenoma 2) Recurrence
0 Investigations:
□ Synonym : Mixed salivary tumor
1) FNAC
□ Speciality : Commonest salivary gland tumor
2) ""Tech scan to differentiate from adenolymphoma
□ Most common gland involved : Parotid gland
3) CT scan
O Least common gland involved: Submandibular gland 4) MRI
□ Gross pathology: 9 Treatment:
Contains - Surgery
• Cartilages
• If superficial lobe involved - » superficial parotidectomy (part of the parotid gland superficial
• Solid tissues to CN VII removed)
• Cystic spaces .
• II both lobes involved -* total conservative parotidectomy
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Q.$: Paraphimosis
2) Nausea and vomit
PARAPHIMOSIS
$igns:
j) Scrotum swollen and tender
□ What Is I t : Condition where there is inability to place back the retracted
glands. [See Fig. 1.6.8] ' r prepucial 2) Red, oedematous scrotum
Effect; Ring like constriction formed proximal to corona and prepucial skin Deming's sign - Affected testis lies at a higher level due to twisting of spermatic cord and
a)
spasm of cremaster
Pathogenesis : Constricting band -» obstruction to venous outflow -> edema and
glans -> necrosis Angell’s sign - Opposite testis lies horizontally due to mesorchlum
If
Etiology: .
1) After urethral cathelerfsation 1) Leucocytosis
2) After sexual intercourse 2) Doppler study of scrotum
Treatment: 3) USG abdomen
4) MRI abdomen
1) 1 ml isotonic saline +1 SO units hyaluronidase
liia,, { j Differential diagnosis:
ring, following which manual reduction tried after's ^ i^ T s '^ d
1) Acute epididymo-orchitis - Pain relieved on elevation of testis for few seconds (Prehn's sign),
2)
pt S i " r PUnC'UreS may ^ made ,0 redUC0 Sd9ma' be,ore ma" ua' reduclii aionji worsened in torsion of testis
2) Strangulated inguinal hernia - In case of torsion of incompletely descended testis
3) If manual reduction is unsuccessful, initial dorsal slit to reduce edema +
analgesic . circumcision after 3 weeks
anai/iMiA ■antibioiic aim 3) Torsion of appendage of testis
4) Mumps orchitis
0 .7 : Lucid Interval
5) Trauma
A : See Section - 1 , Segment C, P aper-II, 2009. Qs. 7 (Page No. 365-366)
Treatment:
Q.8: Chest drain
• Immediate hospitalisation -* exploration of scrotum -» untwisting of torsion of testis -» viability
A : See Section - I, Segment C, Paper - 1, 2013 Supplementary, Os. 3 (Page No. 307-308) of testis checked -> if viable, testis fixed to scrotal sac
Q.9: Torsion o f testis • If testis becomes non-viable - » orchldectomy after taking informed consent
TORSION OF TESTIS • If doubt -> orchidectomy postponed
□ What Is I t : Testis twists in its own axis thereby hampering the bfood supply of testis
• As often it Is a bilateral condition, other side fixed should also be fixed
□ Direction o f rotatio n; Right teslis -* clockwise, left testis -> anticlockwise 0.10: Tissue expansion
□ A g e : Peripuberta! males TISSUE EXPANSION
□ Predisposing factors :
0 What is i t : Reconstructive surgical technique which allows the body to grow extra skin, bone or other
1) Inversion of testis • . .
tissues where there has been tissue loss due to any cause
2) Undescended or ectopic testis
3 Mechanism : A balloon - like expander with silicon shell insertedunder the skinnear the required
3) Long mesorchium
area -» shell is gradually filled with saline water through a salf-sealing portattached to a Tilling tube
4) High Investment ol tunica vaginalis
(hat enters the balloon -> skin gets stretched and accommodates to the changed vascular pressure -*
5) Voluminous tunica vaginalis new skin placed over the defect and sutured
6) Gap between epididymis and body of teslis 3 Indications:
7) Heavy straining
1) Breast reconstruction
Initiating fa cto r: Spasm ol cremaster which inserts onto the cord obliquely 2) Hair transplantation
! ° rf ° n ,r° m Wi'hin oulwards -» oscular occlusion -> edema of testis and spermaticerf 3) After removal of major congenital skin naevi
upto point of occlusion -> gangrene of testis and epididymis 4) ilizarov's technique of external fixation
Symptoms: “ Cotriplications: ’ ,
I) Pain­ 1) Hematoma
> Sudden onset 2) Infection
> Severe 3) Scairing
> In groin and testicles 4) Discolouration
> Referred to lower abdomen 5) Skin or fat necrosis
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□ Advantages:
(b) More than 4 nodes positive
1) Less noticeable scars than with skin grafts or flaps (c) Extranodal spread
2) Almost same skin colour, texture and sensation as normal skin
3) Less risk of tissue loss as the blood supply and nerve supply remains connected n 0o& :
, 200 cGy units daily 5 days/week x 6 weeks.
□ Disadvantages:
a iJ : Ameloblastoma
1) Cosmetic value is poor because of unwanted bulge created by expander
2) Costly AMELOBLASTOMA
3) Repeated saline injections required
4) Time consuming 0 synonyms:
□ Ideal candidate: , Adamantinoma
1) Those with thin skin » Eve's disease
2) Non-smokers • Multiiocular cystic disease of jaw
3) Unscarred skin q prises from : Dental epithelium
0 .1 1 : Anaesthetic monitoring devices 0 Site:
A : See ‘Anaesthesiology’ Section - 3 , Qs. 4 (Page No. 759). 1) Mandible
2) Maxilla
Q. 12: Radiotherapy In treatment o f CA breast
3) Tibia (rare)
RADIOTHERAPY IN TREATMENT OF CA BREAST 4) Base of skull in relation to Rathke's pouch(rare)
G Nature: Locally malignant
□ Indications: Used for all stages of breast cancer
Q Histopathology: Variant of basal cell carcinoma with cords of odontogenic epithelium, stellate reticulum
1) After conservative breast surgery like cells and columnar ameloblast like cells
2) Preoperative - lo reduce size of lesion
0 Prognosis: Curable
3) Bone secondaries
0 Locularity: Multiiocular
4) Inflammatory carcinoma of breast
□ Laterality: Unilateral
5) Women with limited DCfS (Stage 0), in whom negative margins are achieved by lumpectm,
or by re-excision , 0 Age: 40-50 years
6) Women with stage I, lla, or lib breast cancer, in whom negative margins are achievedtn □ Clinical features:
lumpectomy or by re-excision 1) Swelling in jaw
7) Higher risk of relapse after surgery - 2) Large size, gradually increases in size
(a) Patients < 35 year age 3) Painless
(b) Invasive carcinoma 4) Hard
(c) With multifocal disease 5) Smooth
8) More than 4 positive lymph nodes in axilla • 6) No lymph node enlargement
9) Premenopausal women with metastatic disease involving 1-3 lymph nodes 7) Outer table expansion, inner table intact
10) Atrophic scirrhous carcinoma of breast Q Sex predilection; M > F
11) Advanced locoregional breast carcinoma (Stage Ilia or lllb) 0 Investigations:
□ Site: 1) Orthopantomogram - Honey-comb appearance
(A) To chest wall (breast area, internal mammary and supraclavicular area) 2) Biopsy from the swelling
(a) High risk group Q Treatment: Segmental resection of mandible or hemimandibulectomy with reconstruction of mandible
(b) After conservative surgery (curettage and bone graft not done)
(c) T3 tumor >5 cm 2 Differential diagnosis: .
(d) Inflammatory carcinoma 1) Dentigerous cyst
(e) Close surgical margin of < 2 cm 2) Osteoclastoma of mandible
(B) To axilla 3) Dental abscess
(a) Axillary dissection not done 4) Jaffe's tumor
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Q .U : Transluminal USG
„ 7. Epidural anaesthesia
TRANSLUMINAL USG y see Section 3. Qs. 7, (Page No. 763-764)
a l : Brachytherapy
□ What Is I t : Transluminal USG is actually the incorporation of an ultrasonic transducer in the tip .
flexible endoscope or the use of stand-alone ultrasound probes. It Is also known as ‘Ei y See Section 1, Segment - C, Paper-ll, 2008, Qs. 10, (Page No. 353)
Ultrasonography (EUS)". q J : Nephroblastoma
□ Uses:
NEPHROBLASTOMA
A Diagnostic
(a) To obtain images of gastrointestinal lesions that are not apparent on superficial vie^ j other Name: Wilm's tumour
including lesions within the wall of the gut as well as those that lie beyond like pancrealic p Speciality: 2nd most common abdominal tumour in children
lymph node lesions.
3 AjeBr0UP : 3 ~ 6 years
(b) To complement more conventional radiologic tests to help determine the resectability ax
curative potential of surgery in Oesophageal and pancreatic CA. 0 Histological feature: Metanephric blastema
(c) To guide fine-needle aspiration, which often provides pathologic confirmation of suspkaous 3 presentation: Triad of • Abdominal lump
lesion. • Fever
B. Therapeutic • Haematuria
EUS-directed celiac plexus neurolysis (a technique that appears to be effective for the treatmenr 0 Prognostic indicator: Best Is histology .
of pain in patients with pancrealic CA) ■ q Metastasis to : Lungs
□ A ccura cy:
0 Ssllent features:
• More accurate than conventional radiologic techniques like abdominal ultrasonography at
• Presence of nephrogenic rests (nephroblastomatosis) in resected specimen indicates
CT scan
Increased risk of developing Wilm's tumour in contralateral kidney
• It is probably the single best test for diagnosis of pancreatic endocrine tumors (sensHivi)>
• Rarely crosses midfine unlike neuroblastoma
approximately 95%)
< Vascular invasion occurs but not intraspinal invasion unlike neuroblastoma
• It is also the procedure ol choice for imaging of wall lesions of the gastrointestinal trad,
mostly submucosal lesions (accuracy - 65 to 70%) > D Investigation o f c h o ic e : CT Scan Abdomen (does not show any intratumoral calcification unlike
neuroblastoma)
• For preoperative staging of a variety of gastrointestinal tumors, it has overall accuracy ol
> 90%. a Staging system:
• National Wilm's Tumour Staging Group Classification (Pre chemotherapy)
0 . 15: Short wave diathermy
• International Society of Paediatric Oncology (Post chemotherapy)
A : See Section - 1, Segment C, Paper - II, 2009, Qs. 13 (Page No. 370).
Q Treatment: .
2012 Supplementary Stage I —IV —* Radical nephrectomy + / - chemoradiation
Stage V -» Chemoradiation with Adriamycin, Vincristine, Actinomycin - D
Q. 1 : Extradural haemorrhage
3 Syndromes associated:
A : See Section 1, Segment - C, Paper-ll, 2009, Qs.7, (Page No. 365-366)
• Beckwith Weidmann syndrome
C M : DVT
• Deny’s Drash syndrome
A : See Section 1, Segment - C, Paper-1,2011, Qs.3, (Page No. 290-291)
• WAGR (Wilm's tumour + Aniridia + Genitourinary abnormalities + Mental retardation)
0 .3 : Epldldymal cyst
0-10: Bladder changes In BHP
A : See Section 1, Segment - C , Paper-ll, 2008. Qs.2, (Page No. 347)
0 .4 : ESWL BLADDER CHANGES IN BHP
A : See Section 1, Segment - E, Qs. 23, (Page No. 598)
^ fiWP: Benign enlargement of prostate which occurs generally after 50 years
0 .5 : Causes o f haematuria
3 Pathogenesis:
A : See Section 1, Segment - A, Paper-ll, 2008, Qs. 1, (Page No. 94)
• Involuntary hyperplasia due to disturbance of the ratio of circulating androgens and estrogen
Q.6: Dentigerous cyst • Pulsatile release ot LHRH from hypothalamus
& : See Section 1. Seament-C. Paper-ll, 2014, Qs. 3, (Page No. 428-429) i
 414 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 415

LH releases from anterior pituitary , Speciality - Most aggressive variant

4- c Lentigo maligna melanoma -
Stimulates Leydig cells of testes , Location - face (Hutchinson's melanotic freckle), hands, neck
I « Age - Old age, more in women
Testosterone released , Growth - Slow
I , Appearance - Lentigo / Brown macule
Acts on prostate
. Arise from - Not known
£
• Prognosis - Very good
5 a reductase type II released
. Speciality - Least malignant and less common variety
I
0 Acral lentiginous melanoma -
Converts testosterone to dihydrotestostone
, Location - Palms, soles, subungal region
• As a person ages, the testosterone decreases, estrogen level remains same. Due to
imbalance, Intermediate Peptide Growth Factor acts to cause prostatic hyperplasia • Age - Middle age in Japan, Africa, Asia
• Growth - Vertical
□ Structural changes:
» Appearance - Large size, Nodular; often a flat irregular macule
• Median and lateral lobe mainly get enlarged
• Mimics - Fungal infection / pyogenic granuloma
■ Median lobe enlarges and presses onto the bladder
• Prognosis - Poor
• Bladder develops trabeculations and sacculations and later it leads to formation of diverticula
• Speciality - Least common variant
□ Functional changes:
E. Amelanotic melanoma -
• Due to introversion of sensitive urethral mucosa into bladder, the frequency of micturition
• Location - Anywhere
Increases
• Age - Middle or old age
t Overflow and terminal dribbling
• Growth - Rapidly progressive
• Hesitancy and urgency
« Appearance - Pink fleshy mass (Tumour cells lose capacity to synthesize melanin)
• Impaired bladder emptying leads to cystitis, urethritis andbladder calculi
• Mimics - Soft tissue sarcoma
• Chronic retention leads to bladder enlargement whichmakes the bladder palpable, with
suprapubic tenderness on abdominal examination • • Markers for diagnosis - S100, HMB45
• Prognosis - Worst
0 .1 1 : Variants o f melanoma
F. Desmoplastic melanoma —
VARIANTS O F M ELANOM A
• Location - Head, neck
A Superficial spreading type - • Speciality - High affinity for perineural invasion
• Location - anywhere in body High recurrence rate
• Age - Mainly middle age For Rest, see Section 1, Segment - D. Qs. 71 (Page No. 529-530)
• Growth - Radial 0.U: CABG
• Appearance - Irregular, variegated
CABG
• Arises from - Pre-existing naevus
• Prognosis - Good 3 Full form: Coronary Artery Bypass Grafting
« Speciality - Commonest variant of melanoma 3 W hitish: Most common type of open heart surgery
8- Nodular melanoma - 3 CotlsofCABG:
• Location - anywhere in body (mainly mucosal and mucocutaneous region) of head, • Improve quality of life of patients with CHD
neck, trunk • Reduce angina
• Age - Young age, more in men • Lower risk of AMI
• Growth - Vertical • Improve ejection fraction (pumping function) of heart
» Appearance - Nodular, uniform Unction: Improve blood flow to heart
• Arise from - De-novo ^ ia tlo n s :
• Prognosis - Poor • Triple vessel disease
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- • Left main artery disease

• Abnormal left ventricular function pendulum stretch - With relaxed shoulders, the patient should stand and lean over slightly,
• To help perfusion of viable myocardium immediately after AMI allowing the affected arm to hang down, followed by swirling the arm in small circle, and
• Failed PTCA gradually increasing the diameter of swirl
□ Types: Finger w a lk- Patient should touch the wall at waist level with fingertips of affected arm with
• On pump CABG elbow slightly bent, the patient must walk his fingers up the wall, till he has raised his arm
• Off pump CABG comfortably as far as he can, and then slowly lower the arm and repeat this.
□ Types o f Grafts : Cj Towel stretch - Patient must hold one end of a three foot long towel behind his back and grab
A) Venous graft - Great saphenous vein used usually. In case of varicosities in g opposite end with other hand. Initially towel must be horizontal. Gradually better arm should
saphenous vein is used * be used to pull the affected arm upwa rd to stretch it. This is to be repeated 10-20 times a day
B) Arterial graft- qj A r m p it stretch - Patient must use his better arm to lift the affected arm onto a shelf as high as

• Left internal thoracic artery diverted to left anterior descending branch of left corftiJ. his chest level. Then he must gently bend his knees opening up the armpit and then straighte n.
To be repeated 10-20 times everyday.
• Right internal thoracic artery reaches right coronary artery, left anterior descem E) Cross-body reach - Patient must use better arm.to lift the affected arm at the elbow level and
artery and some branches of circumflex artery ' bring it up and across his body, exerting pressure very gently to stretch his shoulder. To be
• Radial artery may also be used done for 15-20 sec, 10-20 times each day.
• Gastroepiploic artery rarely used F) Outward and Inward rotation - Patient must hold a rubber exercise band between hands with
C) Synthetic graft - Made of dacron elbows at 90° degree angle kept closed to his sides. The lower part of affected arm is to be
□ Complications; rotated outward and inward two or three inches and to be held for 5 seconds and repeated.
« AMI
• CVA 2013
• Ankle swelling •
0.1:Clettlip
• Ariythmia
CLEFT LIP
• Graft rejection
• Renal failure 3 Aetiology:
• Vein graft occlusion • 1) Familial
0 .13: Small bowel enema 2) Radiation
A : See Section 1, Segment - E, Qs. 35 3) Rubella Infection
4) Maternal epilepsy
Q.14: Tracheostomy
5) Protein, vitamin deficiency
A : See Section 1, Segment - E, Qs. 30 (Page No. 604-605)
Q. 15: Frozen shoulder - physiotherapy 6) Chromosomal abnormality
J Classification:
FROZEN SHOULDER - P HYSIO TH ERAPY A. (a) Complete (extends to nasal floor)
(fa) Incomplete (does not extend to nasal floor)
0 What Is Frozen s h o ulder: Disease of unknown aetiology where the gleno-humeral joint becomes
stiff and painful due to loss of resilience of joint capsule, along with adhesions between its folds. B. (a) Simple (not associated with cleft palate)
0 Other nam e; Periarthritis shoulder (b) Compound (associated with cleft palate)
□ Clinical features: C- (a) Median/Central (Hare-lip : between the two median nasal processes)
• Pain in shoulder, initially at night and gradually throughout the day (b) Lateral (between maxillary process and median nasal process) -
• Stiffness of shoulder, initially limited to abduction and intemaf rotation only > Unilateral
□ Treatment: > Bilateral
• Physiotherapy forms mainstay treatment Associated syndrom es:
• Hot fomentation • Pierre-Robin syndrome
• Analgesies • Stickler's syndrome
• Intra-articular hydrocortisone injection • Treacher-Collin’s syndrome
418 QUEST *. A Comprehensive Guide to UG Surgery, OrthopetScs & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 419

• Apert's syndrome 3) post-operative antibiotic spray -

• Down syndrome Stitches removed on 61h-71h post operative day
• Klippel - Feil syndrome 5) speech therapy
□ Complications: Training for sucking, swallowing
1) Difficulty in sucking and swallowing
2) Defect in uttering labial and palatal consonants ^S fre S e c tio n - 7 , Segment C, Paper - II, 2008, Qs. 4 (Page No. 309)
3) Nasal regurgitation
...SpinsI anesthesia
4) Nasal Intonation
\ See Section - 3, Qs. 1 (Page No. 753)
5) Recurrent upper respiratory tract infections
„„n o e s o f skin graft
6) Respiratory obstructions
\ See Section - 1 , Segment C, Paper - II, 2008, Qs. 7 (Page No. 351-352)
7) Chronic suppurative otitis media
„ r . note o i ERCP in obstructive jaundice
8) Atrophic rhinitis
A-See 'ERCP’ - 'Investigations’ Segment (Section - 1 , Segment E, Qs. 10) (Page No. 586-587]
9) Hypoplasia of maxilla
US:Oriisubmucous fibrosis
10) Cosmetic problems
11) Problems due to associated syndromes ORAL SUBMUCOUS FIBROSIS
□ Treatment:
> Millard criteria - j tWwf is •' Progressive fibrosis deep to the mucosa of oral cavity
« Haemoglobin 10 gm/dl 3 Etiology:
• Age - 10 weeks old t) Chillies
• Weight - 1 0 lb 2) Tobacco
> Ago - Before 6 months (before dentition) 3) Racial - Common among Indians/Asians
> Pre-requisites - 4) Localised collagen disorder
1) Cupid's bow must be intact • 5) Dietary causes - Vtt A, B deficiency
2) Vermillion notching should not be present 3 Age - Middle age
3) Continuity of white line to be maintained 3 Sex predilection : M = F
4) Proper markings made prior to surgery 3 Site:
5) Infection must not be present 1) Buccal mucosa
> Operation done - 2) Soft palate
Millard's operation 3) Faucial pillars
• Incision made in gingivolabial fold and upper lip mobilised 3 Clinical features:
1) Vesicular eruptions
• Local nasolabial flaps are rotated
2) Soreness, burning sensation in mouth, aggravated during meals
• If bilateral cleft lip repair -
3) Ankyloglossia
(a) Single stage operation (Veau/Black method)
4) Trismus
(b) 2 stage operation (6 months gap in between)
5) Reddish area -* superficial ulcers -* stiff fibrotic bonds + scarring
• Injection adrenaline to achieve haemostasis
3 'Treatment:
• Management of associated primary and secondary cleft palate deformity
1) Avoid predisposing factors
• Tennison's z-plasty (Tennison-Randali triangular flap)
2) Local injection of -
• Suturing in three layers - Mucosa to mucosa, muscle to muscle, skin to skin
Dexamethasone + Hyalase -» biweekly for 10 weeks
> Post-operative measures - .
(4 mg) (1500 units)
1) Hands of patient should be tied or mother should be careful that the baby does not so3^
3) Vitamin supplements
dressing
4) Correction of anaemia
2) Use of Logan's bow
5) Wide cxcision, followed by skin grafting
 ji
420 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 421

Nasogastric aspiration - Decompression of small bowel by Miller Abolt's tube or Cantor

Q.7: Wax bath
A : See Section- 1 , Segment C, Paper-II, 2011, Qs. 12 (Page No. 398) tube
Q.3: Subdural hematoma Intravenous fluid

A : See Section - 1, Segment C, Paper - II, 2010, Qs. 6 (Page No. 378) Broad spectrum antibiotics

Q.9: Intussusception Fresh frozen plasma

CVP
INTUSSUSCEPTION
PCWP
□ What Is i t : Acute intestinal obstruction where telescoping or invagination of one segment ol bo, Dopamine/ dobutamine if severe hypotension
into adjacent segment occurs (mostly occurring due to hypertrophy of Peyer's patches in ileum) * Reduction by hydrostatic pressure by passing normal saline or barium enema

2> After laparotomy under GA, intussusception reduced by gently pushing it from apex (NEVER
1) Sudden onset severe colicky abdominal pain PULL). Then viability checked.
2) Vomiting 3) Signs ol non-viability:
3) Abdominal distension , Blackish in colour
4) Absolute constipation
• Lustreless
5) Passage of red currant jelly stool • No peristaltic movement
□ Signs: . No bleeding on needle prick
1) Tenderness
. No pulsation of mesenteric artery
2) Abdominal distension
If viable -> gut kept inside and abdomen closed
3) On palpation, a sa usage shaped, smooth, firm, resonant lump palpable with concavity lookksj If non-viable -> hot mop applied + 100% 02 -> still no improvement -> resection and
towards umbilicus, which does not move with respiration, is mobile in all directions, conta»
anastomosis
under palpating fingers, appears and disappears
4) Emptiness in right iliac fossa (sign de dance) q 10:Marjolln's ulcer
5) Step ladder peristalsis MARJOLIN'S ULCER
□ Investigations: .
3 What Is I t : Well differentiated squamous cell carcinoma arising from a scar ulcer due to repeated
1) Routine investigations - Hb, TLC, ESR, Chest X-Ray, ECG
breakdown.
2) Straight X-Ray abdomen -
3 Features:
(a) Distended intestinal shadow
1) No lymphatics in scar, hence cannot spread to lymph node
(b) Multiple air fluid levels
2) Locally malignant
(c) Target sign - Soft tissue mass with concentric area of luscency due to mesenteric )al
3) Painless as no nerves involved
(d) Meniscus sign - Crescent of gas within colonic lumen that outlines apex of intussuseeptas
4) Raised everted edge with induration but not always
3) Barium enema -
5) Slow growing, due to less vascularity
(a) Claw sign - Rounded apex of intussusceptions protrudes into contrast column
(b) Coiled spring sign (Pincer sign) - Oedematous mucosal folds of returning limb outtned 0 Investigation:
by contrast material • Edge biopsy
4) USG Abdomen - 3 Treatment:
(a) Target sign • No use of radiotherapy as it is radio resistant
(b) Pseudokidney sign • Wide excision of lesion alongwith a margin of at least 1 cm isexcised
(c) Bull’s eye sign • Amputation if - recurrence after wide excision in proximal part of limb
□ Treatment: - big ulcer in distal part of limb
1) Conservative -
•' Posterior urethral valve
• Immediate hospitalisation
 422 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 423

POSTERIOR URETHRAL VALVE

TYPES OF RENAL STONE
a What is i t : Congenital symmetrical valves in posterior part of urethra, situated
verumontanum, which prevents outflow of urine ' |Usl befc, Colour Content Shape, surface Aetiology Special feature
□ Pathology: Brown Calcium oxalate Sharp projections -* High oxalate Shows envelope
crystals more prone tocause intake crystals in urine
• Bladder wall hypertrophied and thickened hematuria (monohy­
• Proximal part of urethra very dilated •» drate crystals are
1
□ Clinial features: i dumbbell shaped,
[ dihydrate crystals are
1) Poor urinary stream
envelope shaped)
2) Features of infection and hydronephrosis
White Calcium phosphate Smooth (triple stones Infected alkaline Radioopaque
3) Vesico - ureteral reflux (M S p M *0 crystals or Calcium. are coffin lid shaped) urine-from stag-
4) Difficulty In passing urine !sw»
Magnesium and horn calculus,
i
} Ammonium phos­ which take the
5) Bladder palpable as a firm swelling ('Cricket-ball' bladder) 3
phate crystals (Triple shape of renal
□ Complication:
stone) calyces
• Renal failure 1

0 Investigations: Yellowish Uric acid crystals Smooth, hard Gout, uricosuria Multiple, radiolu-
jitm scent (detected
1) Micturating cystaurelhrography (MCU) by USG)
% 2) USG Abdomen L
M » stone Yellowish Urate crystals Smooth, hard Gout (Same as uric
3) IVU
acid stones)
4) Blood urea, serum creatinine
f - ■
O Treatment: iCysfoe Yellow-* Cystine crystals Hexagonal, soft Cystinuria, Racfoopaque
Isom greenish hue acidic urine • as contains
• Suprapubic cystostomy initially -» Cystoscopic resection of posterior urethral valve laler on exposure sulphur
0 Differential diagnosis: 1

1) Neurogenic bladder 'Xarrtne Brick red Xanthine crystals Smooth Due to xanthine
[d m oxidase
2) Marion's disease deficiency
Q.2: Hutchinson's pupil
Mgostone Blue Smooth
A : See Section - 1, Segment C, Paper - II, 2009, Qs. 7 (Page No. 365)
Sruvitestone Whitish Magnesium, Smooth Ammonia and None
Q.3: Empyema thoracis
yellow Aluminium, urea splitting
A : See Section - 1, Segment C, Paper - If. 2010, Qs. 13 (Page No. 381) Carbonate, organisms like
Q.4: PCNL Phosphate Klebsiella sp.,
Proteus sp.
A : See ‘Investigations’ Segment (Section - 1, Segment E, Qs. 22) (Page No. 597]
Q.5: Types o f renal stone fltsl - Refer lo MB 2011 (See Section - 1 , Segment C, Paper - II. 2011, Qs. 11 (Page No. 397-398)]
C|-n«al features. Investigations, Treatment of Oxalate stone)
A : See Chart on the next page
 S O L V E D SHORT NOTES OF FINAL M30S □ P a p e r-ll 425
424 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

0 .6 : Causes o f scrotal swelling

0 51,5 . garly superficial - Non blanching erythema
h Late superficial - Partial thickness skin loss
CAUSES OF SCROTAL SWELUNG ' Ear,y ^ e p - Full thickness skin loss excluding fascia
d) Late deep - Full thickness skin loss involving deeper tissues

Acute causes n predisposin9 factors:

Chronic causes
0 , Nutritional deficiency •
• Hydrocele . Diabetic neuropathy
Ischaemia
• Spermatocele , peripheral neuritis
• Torsion of testis
• Varicocele , Tabes dorsalis
• Testicular infarction
• Epididyma) cyst , paraplegia
• Appendiceal torsion:
\ epididymis , Spinal injury ’
Trauma
. Leprosy
• Testicular rupture , Spina bifida
• Haematocele 3 Clinical features: Painless punched-out ulcer, immobile, with bone as base
• Intratesticular hematoma
g investigations:
Hernia
1 ) Blood sugar
Inflammatory conditions 2) Discharge study
• HSP (Vasculitis of scrotal wall) 3) X-Ray of the part
• Fat necrosis of scrotal wall 0 Treatment:
Infections conditions 1) Treatment of the underlying cause
• Acute orchitis 2) Nutritional supplementation
• Acute epididymitis 3) Antibiotics .
• Acute epididymoorchitis 4) Vacuum assisted closure (perforated drain kept over foam dressing covenng the pressure
• Fournier’s gangrene sore -» dressing is sealed with transparent adhesive sheet -> drain connected to vacuum
apparatus)
5) Slough excision
0 .7 : Pressure sore 6) Regular dressing

PRESSURESORE 7) Skin graft after sore granulates

8) Proper c a r e - . ,
□ Synonyms: > Lifting the limb for 10 seconds once in every 10 minutes
• Neurogenic ulcer > Change in position once in 2hours
• Trophic ulcer > Use of water bed
□ What is i t : Condition where tissue necrosis and ulceration occurs due to prolonged pressure > Urinary and faecal care
S ite s: > Absorbent porous cfothing
1) Occiput > Psychological counselling
2) Shoulder
OS:Hypospadius
3) Sacrum
HYPOSPADIUS
4) Over ischial tuberosity
S) Buttocks 3 What Is I t : Condition where external meatus of urethra is situated proximal than the normal, and on
6) Heels tha undersurfaca (ventral aspect) of the penis.
□ Pathogenesis : Blood flow to skin stops when external pressure becomes > 30 mm Hg -» *iss*
2 Speciality: Commonest congenital malformation of urethra
hypoxia -» necrosis -» ulceration
3 Incidence: 1 in 350 males.
□ Pathology : Callosity -* suppuration -> gives way through a central hole which extends in10'"*
° Types : (Based on situation of external meatus)
deeper plane upto the underlying bone as perforating ulcer
a) Glandular - undersurface of glans penis
 SOLVED SHORT NOTES OF FINAL MBBS D P a p e r-ll 427
426 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

b) Coronal - at corona glandis

c) Penile - body of penis ■* j. History o1 injury
d) Peno-scrotal - at junction of penis and scrotum Swelling with following features -
e) Perineal - scrotum is sptit and urethra opens in between its two halves. > Flattened and raised from the surface
[See Fig. 1.6.9] >> Pinkish black in colour
□ Clinical features : > Painful
1) Urine soakage over scrotum with dermatitis > Accompanied wtth itching, oozing
2) Urethral opening situated on undersurface of penis y Blanches on pressure
□ Associated abnorm alities: V Spreads to surrounding tissue
• Chordee y Margin irregular with claw-like processes
• Narrow ectopic meatus j complications:
• Small penis
1) Infection
• Absence of urethra and corpus spongiosum distal to abnormal urethral orifice
2) Marjolin’s ulcer
• ‘Hooded’ prepuce
3) Recurrence
• Bilateral underscended testis
□ Complications: g Treatment:
1) Erection difficult and painful due to chordee a) Conservative-
2) Obstruction to urinary outflow 1 ) | ntrakeloidal injection of - .
3) Infertility * Steroids
□ ' Treatment: * Methotrexate
a) Glandular hypospadius -> no treatment required; meatotomy required if too small meatus * Vitamin A
b) Other varieties -» staged procedure * Hyaluronidase
Stage I - Straightening of penis (performed between 1.5 - 2 yrs) 2) Ultrasonic therapy
Stage II - Reconstruction of urethra (performed between 5 - 7 yrs) 3) Silicone gel sheeting
4) Deep X-Ray therapy
Q. 9 .Keloid
b) Surgical -
KELOID
I ntrakeloidal excision (Major portion of keloid removed after incision made just inside the
□ Naming: 'Like a daw' margin -* margins stitched -+ left over part treated by intrakeloidal steroid injection)
□ What is I t : Flattened swelling of skin, due to proliferation of fibroblasts and immature blood vessels
on top of a scar, produced by any skin injury, and characterised by oozing, blanching and itching Q Differential diagnosis: Hypertrophied scar

□ Pathology: 0.10: Tension pneumothorax

• Primitive mesenchymal cells stimulated by skin injury, which heap up to form a swelling A: See Section - 1. Segment - C, Paper-ll, 2009, Qs.14 (Page No. 370-371)
• No capsule
2014
□ Types:
a) Spontaneous (occurs without scar formation)
0.1: Paget's disease o f nipple
b) General - Following injury
□ Aetiology: A: See Section - 1 , Segment C, Paper - II, 2010, Qs. 3 (Page No. 376)
1) Local factors - Incision crosses Langer's line 02: Electric burns
2) Familial ELECTRIC BURNS
3) Coloured races - Negros
4) Tuberculosis ^ Aetiology:

5) Dislocation of hair follicle a) High voltage current

□ S ites : b) Low voltage currenl
1) Chest wall -1 Type ol injury:
2) Sternum a) Low voltage current - Direct injury ai the point of conlacf
3) Upper arm
 SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 429
428 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

b) High voltage current - Direct injury at the point of contact + damage of tissues that emu. Mstigatlon: Orthopantomogram
electricity 3 m [See Fig. 1.6.10]
0 Mechanism o f In ju ry : Tissue damage occurs when electrical energy is converted into th n Trestment •'
energy, so the resulting injury is a thermal bum ^ u aj if small -» excision
□ Changes In s k in : b) If large -> marsupialisation -» excision of cyst - t extraction of unerupted tooth
• Involved at 2 sites -
, j . Lucid interval
> Point of contact with electrical source A • See Section - 1, Segment C, Paper - II, 2009, Qs, 7 (Page No. 365-366)
> Site of exit at which patient is grounded
ns . fistula in ano
• Undergoes coagulation necrosis H• See Section - 1 , Segment C, Paper - II, 2010, Qs. 4 (Page No. 376-377)
• Minimal destruction occurs, compared to deep tissue destruction
s . peniie carcinoma
□ Maximum tissue damage occurs In : Muscle, nerve and blood vessels (which offer least resislancej
u PENILE CARCINOMA
□ Factors specifying amount o f damage:
1) Resistance of tissues 0 Aetilogy ••
2) Amount of electric current passing through 1) premalignant conditions -
> Phimosis
□ Salient clinical features:
> Chronic balanoposthitis
1) Ulcers more common in axilla, antecubital fossa (as eleclrical resistance is much reducedby
> Leukoplakia
moisture)
> Erythroplasia of Querat (Paget's disease of penis)
2) ‘Port-wine* coloured urine (due to release of haemochromogens from musculature into bbo)
> Cutaneous hom
circulation, which are excreted via urine)
V Verrucuous carcinoma
□ Treatment :
r Balanitis xerotica obliterans
1) Electric current should be stopped
> Genital wart
2) Cardiopulmonary resuscitation to be started
2) Sexually transmitted diseases
3) Adequate fluid replacement
3) HIV infection
4) Ringer Lactate, mannitol should be considered
4) HPV infection
5) Operative management may be required in case of hemodynamic ihstability
Q Origin: From inner surface of prepucial skin which has squamous epithelial lining
6) Cutaneous electrical injuries to be debrided meticulously, cleared and topical antimicrobial
bum creams to be applied 3 Types:
a) Squamous cell carcinoma (most common)
7) Mafenide acetate preferred
b) Adenocarcinoma (arising from Tyson's gland)
8) Immediate exploration of stony hard muscle edema
c) Basal cell carcinoma (arising from coronal sulcus)
9) Arteriography may be required
d) Melanoma
10) Complete neurologic examination
Q Pathology:
0 .3 ; Dentlgerous cyst
• Papilliferrous
DENTIGEROUS CYST • Infiltrating
• Ulcerative
□ Synonym : Follicular odontome
0 Site: Gians penis (commonest)
□ What Is I t : Epithelial odontome (cyst or tumor of the jaw)
3 Spread:
□ Site o f occurrence: In relation to dental epithelium from an unerupted tooth, over ils crown
a) Directly to -
□ Special features:
> Body of penis
• Unilocular
V Urethral meatus
• Common in lower jaw
> External iliac lymph nodes
• Common in premolars/molars
b) Lymphatic spread to -
• Causes expulsion of outer table of mandible
> Horizontal group of inguinal lymph nodes
□ Clinical features : Painless swelling in jaw, which is smooth and hard
V External iliac lymph nodes
□ Complications: Adamantinoma
> Cloquet lymph nodes
□ Infection: Rare i
430 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS D P a p e r-ll 431

□ Clinical features: a c f « ^ l,e a tu re s :

1) Pain
1) Painless ulcerative lesion
2) Diffuse swelling
2) Recent onset phimosis should raise suspicion
3) Cold limbs
3) Foul smelling, purulent discharge
4) Paraesthesia
4) Lesion has everted edge, fungation and induration
5) Pulselessness
5) Hard nodular enlarged lymph nodes palpable
6) Pallor
□ Investigations:
q Uost reliable clinical s ig n : Affected muscle if passively stretched produces severe pain
1) Edge biopsy q C o m p lic a tio n s :
2) FNAC of lymph nodes 1) Infection
3) USG abdomen 2) Gangrene of limb
4) Sentinel lymph node biopsy (Cabana sentinel node located above and medial t; 3) Chronic ischaemic contracture
saphenofemoral junction) 4) Renal failure
□ Treatment: 5) Disabled limb
a) Small non-invasive lesion - • jj Treatment:
> Nd :YAG laser 1) If compartment pressure > 30 mm (Hg - * Fasciotomy) [adequate lengthy incision involving
> 5-Fluorouracil cream skin, subcutaneous fat, deep fascia till muscle is (visible -» multiple) incisions if needed,
> Radiotherapy separate incisions in each compartment]
2) Catherisation
b) Invasive lesion -
3) Blood transfusion
> Lesion involving prepuce Circumcision
4) Antibiotics
> Lesion involving glans penis or distal part of shaft -» Partial amputation ol pe«j
5) Diuretics/mannitol
leaving behind a 2,5 cm stump
6) Hyperbaric oxygen
> Lesion Involving proximal shaft -> Total amputation of penis + Total scrotectomyanj
orchidectomy + Perineal urethrostomy 2014 Supplementary
c) Inguinal lymph node involvement -
> Antibiotics treatment for 6 weeks to eliminate infection M : Parotid abscess
> If adenopathy persists, bilateral inguinal nodal dissection is done over Dresslefs A:See Section 1, Segment - C, Paper-ll, 2011, Qs.8, (Page No. 395-396)
quadrangle [See Fig. 1.6.11] 01: Patient ductus arteriosus
> Post-operative radiotherapy »:See Section 1, Segment - C, Paper-ll, 2008, Qs.15, (Page No. 356-357)
0 .7 : Muscle relaxant U :Chordee
A : See 'Anaesthesiology' Section - 3, Qs. 3 (Page No. 757-758) A:SeeSection 1, Segmenl-D, Qs,12, (Page No. 473-474)
Q.8: Flail chest M : Chronic subdural haematoma
A : See Section - 1 , Segment C, Paper - II, 2008, Qs. 12 (Page No. 354-355) *:See Section 1, Segment - C , Paper-ll, 2010, Qs.6, (Page No. 378-379)
Q.9: Epidural anes thesla i i : Dentigerous cyst
A : See ‘Anaesthesiology' Section - 3, Qs. 7 (Page No. 763) *:5ee Section 1, Segment - C, Paper-ll, 2014, Qs.3, (Page No. 428-429)
Q.10: Compartment syndrome M; Venous ulcer
COMPARTMENT SYNDROME *;See Section 1 , Segment - C, Paper-1,2013, Qs.2, (Page No. 301-302)
Transluminal USG
□ Common s ite s :
Section 1, Segment-C, Paper-ll, 2012, Qs.14, (Page No. 412)
t) Calf
**•' Local anaesthesia In Inguinal hernia surgery
2) Forearm
□ Cause: LOCAL ANAESTHESIA IN INGUINAL HERNIA SURGERY
1) Fracture of underlying bone compressing major vessels
2) Closed injuries causing hematoma J Drug used: Xylocaine 0.5% with or without Adrenaline
 432 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 433

□ Dosage : , Following total thyroidectomy

• Xylocaine 0.5% only -> 2mg/kg . Toxic thyroid nodule cases after hemithyroidectomy
• Xylocaine 0.5% + Adrenaline -> 7mg/kg
0 Mves:
□ Methods used:
J , |«3 -» 13 hour
A. Field block (Shouldice method)- Skin (about 4 cm length) between ASIS and pubic sympk
is infiltrated , |124 -* 4 days
i ■ , i'25 -» 60 days
Skin, subcutaneous tissue and the two layers of superficial fasia (Camper and Scarpa) a, , |« i -» 8 days
incised 6
n szlisnt features:
I . Patient should not take L-thyroxine for 6 weeks prior to radio-iodine therapy
Area deep to external oblique aponeurosis (EOA) is infiltrated and EOA incised . Injection TRH if given, radio-iodine scan can be done after 24 hours
I , i * 3behaves similar to inorganic I127 in our body, and gets released as protein bound
Inguinal canal and hemial sac are exposed, whichare also infiltrated
iodine (PB1)
B. Point/Nerve block - Xylocaine infiltrated 2 cm above and medial to ASIS to bloci . i’23can be safely used in children and pregnant lady
iliohypogastric nerve
, High dose of retinoic acid makes I131 to accumulate in tumour cells
‘ I
■ Conception to be avoided for 1 year after radio-iodine therapy
Mid-inguinal point (i.e., midpoint between ASIS and pubic symphysis) is infiltrated
. MRI is ideal when radio iodine therapy is planned:
I .
Skin over pubic tubercle also infiltrated 0.10: QUART
i QUART
Xylocaine infiltrated just below inguinal ligament lateral to femoral artery to block the genital 0 full form ; Quadrantectomy, axillary dissection and radiotherapy
branch of genitofemoral nerve. 3 What Is I t : Type of conservative breast surgery done in certain cases of breast carcinoma
0 .9 : Radioactive Iodine 3 Clearance: Removal of entire quadrant with ductal system with 2-3 cm normal breast tissue

RAD IOACTIVE IODINE a Axillary dissection: Done through separate incision. Level I and II nodes are removed
Q Radiotherapy: Post-operative radiotherapy given to breast (5000 cGy) and axilla (1000 cGy)
□ Isotopes:
Q First started b y ; Umberto Veronesi from Milan
. I '23
U Indications:
. |« 4
• Breast lump less than 4 cm
. I125 • Clinically negative axillary nodes
. I13’ • Well differentiated tumour with low S phase
□ Uses : Both therapeutic and diagnostic • Mammographically detected lesion
• I’23 -* Functional studies of thyroidgland • Breast of adequate si2e and volume
• I124 -> PET scan • Feasibility of axillary dissection and radiotherapy to intact breast
• l l2S -> Brachytherapy and RIA (Radio Immuno Assay) 3 Contraindications:
• I13’ -> Radioactive iodine therapy • Tumour size > 4 cm
□ Diagnostic use Indications (0-rays used): • Positive axillary lymph nodes > N,
• Ectopic thyroid • Poorly differentiated tumour
• Suspected toxicity • Mullicentric tumour
• After total thyroidectomy to look for secondaries • High tumour I breast size ratio
• Earlier breast irradiation
• Retrosternal thyroid
• Pregnancy
• Toxic thyroid nodule
? Advantages :
□ Therapeutic u se s:
• Good cosmetic appearance
• Primary thyrotoxicosis cases after 40 years
• Preservation of vascular supply and innervation of nipple-areola complex in most cases.
 434 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 435

2015 , Treatment -
I. Surgical excision (Total glans resurfacing with STSG/ circumcision/ Moh's micrographic
Q .1: Breast abscess surgery)
A ns: See Section - 1, Segment C, Paper II, 2009, Q.3 (Page No. 362-363) II. 5%-fluorouracil (topically on alternate days for 4-6 weeks)
Q.2: Meconium Ileus III. CO2 Laser (1 mm depth; 3-4 weeks to heal) or Neodymium : VAG Laser (6 mm depth; 2­
A ns: See Section - 1 , Segment D, Q.110, (Page No. 569-570) 3 months to heal)

Q.3: Basal cell carcinoma IV. Cryotherapy (Liquid nitrogen)

A ns: See Section - 1, segment C, Paper 1,2009, Q. 2 (Page No. 300-301) 2 B uschke-Low ensteln tumor (Giant condyloma accumlnatum)

Q.4: Premallgnant conditions o f penile carcinoma , Low grade variant of Squamous cell CA of penis.
Ans: • Morphology - Large, exophytic, slow growing and locally aggressive lesion with warty
appearance.
PREMALIGNANT CONDITIONS OF PENILE CARCINOMA
. Site - Usually occurs on uncircumcised glans or prepuce (can be on urethra, vulva, vagina,
The premalignant penile lesions are as follows cervix, anus, oral/nasal cavities, plantar surfaces of feet)
, Associated with HPV 6,11 (NOT 16,18)
A. HPV RELATED A. NON-HPV RELATED
« Treatment - Local excision
Erythroplasia of Queyrat (Non-keratlnlsing CIS) Lichen sclerosus et atrophlcus/Balanitis xerotica ottSe:*, 3. Bowenoid papulosis
Bowen's disease (Keratinlsing CIS) Cutaneous penile hom
• Mostly occurs in young sexually active/ promiscuous men in the second or third decade of
Buschke-Lowensteln tumor (Giant condyloma Leukoplakia of penis life, usually uncircumcised. It can affect females as well.
accuminatum)
« Morphology - Multiple red velvety maculopapular areas which often coalesce to form plaques.
Bowenoid papulosis pseudoepitheliomatous, keratotic and micaceous bala.-^
(PEKMB) • Site - On the glans or shaft of penis.
• Histology - Abnormal keratinocytes are spread discontinuously (Unlike the continuous spread
A HPV related lesions in Bowen's disease) throughout the epidermia.

1. Carcinoma In situ (CIS) • • Association - With HPV 16

• Sexually transmitted; female partners are at increased risk for cervical neoplasia.
• Full thickness intraepidermal carcinoma of penis.
• Often acts as benign lesion unless the person is immunosuppressed; may regress
• Originally described by Querat (1911).
spontaneously.
• Based on location of lesions, divided into two entities which are histologically similar-
• Treatment-(1 ) Conservative surveillance
(a) Erythroplasia of Queyrat
(2) 5-FU
(b) Bowen's disease
(3) Ablation (Laser, cryotherapy or electric ablation)
• Erythroplasia of Queyrat - Smooth, velvety, bright red, sharply defined plaques on muccu
surfaces of penis such as inner prepuce and glans. The lesions are usually painless, butc* Non-HPV related lesions
have areas of erosion. Risk of malignant transformation is upto 30%. I. Uchen sclerosus et atrophicus
• Bowen's disease - Solitary, scaly, red, well-defined plaques on follicle bearing are* -
• Also known as 8alanitis xerotica obliterans (BXO)
penile shaft and scrotum, often with crusting ulceration. Mostly occurs at the age of $■<’■
years. Risk of malignant transformation is 5%. • Most common premalignant lesion of penis,
• Risk factors of penis CIS - ' It is an idiopathic chronic progressive inflammatory process.
(i) HPV 16,18,31,33 • Presents most commonly in uncircumcised males in third or fourth decade; sometimes females
are affected too.
(ii) Immunosuppression
(iii) Poor genital hygiene • Morphology - Flat white patches with atrophic plaques which may coalesce or sclerose

(iv) Phimosis . • Site - On glans or prepuce

(v) Use of tobacco products • Histology - Thinning of rete pegs, hyperkeratosis, chronic inflammatory infiltrate comprising
of lymphocytes and plasma cells
(vi) Number of sexual partners
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 437
436 QUEST : A Comprehensive Guido lo UG Surgery, Orthopedics & Anesthesiology

, Duodenal ulcer/ Crohn's disease

• Complications - (1) Pruritus, Pathological phimosis, meatal stenosis, urethral strict^
, periampullary tumor/diverliculum
males (2) Burning sensation, dyspareunia in females
, Pancreatic duct stricture
• 2.3% ot those diagnosed with BXO have SCC penis; 10 - 33% progress to invasive scr
15-17 years; Synchronous BXO is found in 28-50% of those treated for penile CA. ’ , Pancreatic divisum
, Ascariasis, Clonorchis sinensis
• Treatment - (a) If asymptomatic - no therapy
, Trauma
(b) Symptomatic -
I. Topical steroids (Betamethasone or 0.1% Triamcinolone twice dally) 2 Alcohol induced

II. Circumcision can be done, although excision is avoided due to high recurrence. 3 clinical features:
I sudden onset, stabbing, upper abdominal pain, radiating to the flanks and back and relieved on
2. Cutaneous penile horn
leaning forward (Mohameddan prayer position)
• Rare; usually develops over pre-existing lesion (nevus, wart, malignant neoplasm);^., 1 Nausea, Persistent vomiting, Retching
overgrowth and comification of epithelium.
3 High fever
Morphology - Conical and exophytic lesion associated with areas of chronic inflammafa
Histology - extreme hyperkeratosis, dyskeratosis and acanthosis (abnormal thickening 3 Clinical examination:
the prickle cell layer of the skin) X General survey - Features of shock (dehydration, oliguria)
High risk of malignant transformation (around 30%) to low grade SCC. B. Abdominal examination -
Association-With HPV 16 1. Tenderness, rebound tenderness, guarding, rigidity
Treatment - Surgical excision with a margin with dose follow-up 2. Grey Turner’s sign positive (Hemorrhagic spots and ecchymosis in the flanks)
3. Leukoplakia of penis 3. Cullen's sign positive (Discolouration around the umbilicus)
Rare 4. Fox sign positive (Discolouration below inguinal ligament)
Morphology - White verrucous plaques on mucosal surfaces. 0 Investigations:
Site - Gians or prepuce. 1. Complete hemogram (Raised TLC), CRP
Association - Occurs more commonly in patients with DM; related probably lo chronci 2. Serum amylase, lipase, LDH - raised
recurrent infection 3. Serum Trypsin, Trypsinogen activation polypeptide (TAP)
Dysplastic changes are seen in 10-20% of cases. 4. Serum lactescence - Most specific for alcohol induced pancreatitis
4. Pseudoeplthellomatous, keratotic and micaceous balanitis (PEKMB) 5. Albumin creatinine clearance ratio - increased (> 6%)
Rare idiopathic condition 6. Skiagram abdomen (AP view) - Sentinel loop, colon cut off sign, obliteration of psoas shadow,
renal halo sign
Morphology - Solitary, well-circumscribed, thick, Inelastic, hyperkeratotic plaque
laminated appearance. 7. USG abdomen - Edematous pancreas, peripancreatic fluid collection

Site - Gians of penis 8. CT scan abdomen - Spiral CT is the Gold standard investigation.

Histology - Hyperplastic epidermia with ridges extending deep Into dermis. 9. Peritoneal tap - Fluid shows high amylase and protein levels.

Occurs usually in elderly, uncircumcised males. 3 Treatment:

Association - May have concurrent verrucous carcinoma. 1. Hospitalisation
Treatment - Surgical excision or ablation with dose follow-up 2. Nothing per mouth
Q.S: Acute pancreatitis 3. CVP line
4. Total parenteral nutrition
Ans: ACUTE PANCREATITIS 5. Intravenous fluid
6. Fresh frozen plasma
□ Definition : Acute pancreatitis refers to acute inflammation of normally existing pancreas. 7. Nasogastric aspiration
□ Etiology: 8- Catheterisation
1. Pancreatic duct obstruction due to : 9- Electrolyte management with monitoring

• Biliary tract stones (Most common)

 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 439
438 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

(a) For RFA of liver tumors, an antibiotic course is administered to patients with severe cirrhosis,
10. Hemodialysis if required
immunosuppression, Iarge tumors, central tumors, ascites, prior hepatic artery therapy (pump/
11. Pethidine to relieve pain chemoembolization/ embolization) or biliary pathology (dilated ducts, biliary-enteric
12. Broad spectrum antibiotics (Ceftazidime, Cefoperazone, Cefotaxime, Imipenem) anastomoses, or prior sphincterotomy).
13. Proton pump inhibitor to relieve stress ulcer (Pantoprazole 80 mg BD) (b) For RFA of renal tumors, the antibiotics are continued for 1 week after the ablation, if the
14. Calcium gluconate - 10% 10 ml/kg i.v. Shrly thermal lesion touches the collecting system or there is a history of reflux or recurrent urinary
15. Somatostatin/Octreotide to reduce pancreatic secretion infections.
16. Protease inhibitor/ Acetylcholine/ Calcitonin g Use: .
17. Steroids ^ Hepatic tumors
18. Nebulisation, bronchodilator ip the treatment of HCC, the range of indications for percutaneous RFA includes the following main
categories.
Q.6: Glasgow Coma Scale
• HCC at an early stage
A n s : See Section - 1 , Segment C, Paper II, 2008, Q.13 (Page No. 355-356)
• Primary treatment for small tumors (<3 tumors, each measuring <3 cm)
Q.7: Radiofrequency ablation o f tumors • Inoperable primary liver tumor
• Treatment of patients who cannot undergo general anesthesia or are not operative candidates
A ns: .
because of comorbidity or advanced age
RADIOFREQUENCY ABLATION OF TUMORS
• Liver metastasis, most commonly colorectal, especially if the patient is not an operative
Q What is It - Radiofrequency ablation (RFA) is a modified electrocautery technique that is use#, candidate
local, minimally invasive tissue ablation. • Breast, thyroid and neuroendocrine metastasis

□ Mechanism o f action - In RFA, a needle is inserted into the organ, usually under US orCT guidanct • A hepatoma or multiple small lesions in patients who are waitingfor liver transplantation
Once the needle (unipolar or bipolar) is placed within the tumor, a generator is used to detve:) < Recurrent and progressive lesions
rapidly alternating-current (RF energy). Radiofrequency electric fields drive ionic currents in bsw Contraindications for percutaneous RFA of liver tumors include the following :
and cause resistive heating through frictional heat produced by rapid agitation of adjacent cells.,!'
50-52°C, cells undergo coagulative necrosis in 4-6 minutes; at temperatures greater than 60*c. • Bile duct or major vessel invasion
coagulative necrosis is instantaneous. With single needle nonperfused electrodes, coagulate • Significant extrahepatic disease
diameters are limited to approx. 1.6 cm. Recent advances in RFA technique have resulted in large • Child-pugh class C cirrhosis or active infection
volumes of tissue ablation (7 cm diameter in a 30 min session) with relatively tow complication rate
• Decompensated liver disease
and minimal collateral damage. There are a variety of methods for increasing coagulation vote
with RFA, among which the most successful ones are - (a) Slow or pulsed heating (b) Mullipretf • Lesions that are difficult to reach with electrodes or when electrodeplacement is impaired
array electrodes (c) Internal electrode cooling (d) Saline infusion • Tumors that occupy more than 40% of the volume of the liver

% □ Clinical technique- • Patients with metastatic lesions larger than 3 cm (as the risk of recurrence with RFA is high)

• Pre-procedural evaluation may include triphasic CT, MRI, ultrasound (US), PT/APTT/INR, C8C • Large or numerous tumors
IFT, CEA, AFP, hepatitis panel, EKG. • Proximity to vital structures like vessels and adjacent organs(relative contraindication)
• RFA can be performed in 3 approaches- (a) percutaneous (b) laparoscopic (c) openI surgical • Lesions larger than 5 cm (relative contraindication)
• The choice of approach depends on- (i) the condition of the patient (ii) tumor size (iii) number (* B. Extrahepatic tumors
location (v) growth pattern of tumor (vi) operator and local practice patterns.
I. Kidney -
• One to four grounding pads are placed on the thighs or back in order to complete an electnc
• RFA Is especially appealing for patients with a genetic predisposition to multiple bilateral
circuit. A more uniform thermal lesion is created when the rectangular pads are placed Will'S*
metachronous renal cancers, such as von-Hippel Lindau (VHL) or hereditary papillary
long side transverse with respect to the needle, resulting in less risk of pad burns.
renal cancer (HPRC).
• US and/or CT (followed by MR) are most commonly used for guidance. CT alternating «iH'us
• Renal RFA has been found to be most effective in tumors less than 3 cm in diameter.
can be used to provide maximum visualization during different stages of the procedure. IX*>
ablation, ‘hyperechogenicity from microbubbles' can be seen to be expanding from the new- H Bone -
electrode on Ultrasound. Miniboluses of 50 cc iodinated contrast are often administered to V>S’JJ For over 10 years, it has been used to treat osteoid osteoma, a benign, slow-growing painful
a tumor or thermal lesion in CT during the procedure and to choose the next target area. lesion
• Pre-procedural prophylactic antibiotics are used routinely while a prophylactic course is 9,'*n/ III- Lung
certain high-risk situations:
 440 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiofogy SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 441

IV. Breast caloric Stenosis in infant

SeC|ion 1. Segment - C, Paper-ll. 2010, Qs.9, (Page No. 379-380)
V. Adrenal gland
H: S®®
□ Complications:
°r ' P o rtio n 1 Segment - C. Paper-ll. 2008, Qs.15, (Page No. 356-357)
1. Pain (Large, subcapsular, porta hepatis, or peri-diaphragmatic lesions tend to be more pai^,
. \ijai bdth
2. Low-grade fever e section 1, Segment - C. Paper-ll. 2011, Qs.12, (Page No. 398)
3. Tumor seeding and back bleeding
^Telecobalt therapy
4. Pneumothorax (with a transthoracic approach to hepatic or lung lesions)
TELECOBALT THERAPY
5. Pleural effusion (in cases where treatment is adjacent to pleura, as in liver dome lesions)
6. Shoulder pain (related to diaphragmatic bum) what is I t : Medical use of gamma rays emitted from radioisotope cobalt - 60
7. Skin burns (Due to improperly placed grounding pads) 3 2 tooe: Stable dichromatic beams of 1.17 and 1.33 MeV are produced, which results in average
8. In RFA of hepatic tumors - peritoneal bleeding, needle-track seeding, hepatic abscess, perforatro- 3 beam energy of 1-25 MeV
of a gastrointestinal wall, hemothorax, hepatic decompensation, asymptomatic arterioportal shw,
and biliary portal shunt with hemobilia. n Hilf-life •' 5-3 years
procedure : Patient sits or lies on a couch and an external source of radiation Is pointed at a
9. In renal ablations - Transient hematuria, urinoma, ureteral stricture, and renal Insufficiency 2 particular body part
□ Follow u p : g Indications:
• Post-procedure contrast-enhanced CT or MR is used to determine the extent of coagulation , T, and T2 lesions of laryngeal carcinoma
• Lack of enhancement has been shown lo correlate with coagulation necrosis (A thin rim ol • Esophageal carcinomas
enhancement corresponding to a hyperemic inflammatory reaction or hemorrhagic granulate# < Early vocal cord carcinomas
tissue is normal, which usually resolves in about one month) « Bronchial carcinoma.
• Foflow-up imaging is to be done at 2- to 6 weeks, then every 3 months for more than 1 year.
2016
• Residual enhancement, Increase in size of ablation region, or increase in irregularity or nodulafy
of ablation region suggests recurrent tumor. q.1 ; Epidural anaesthesia

Q. 8 : Tension pneumothorax A: See Section 3, Qs.7 (Page No. 763-764)

02: Venous ulcer lower leg
A n s : See Section - 1, Segment C, Paper II. 2009, Q.14 (Page No. 370-371)
A: See Section 1, Segment-C, Paper-I, 2013, Qs.2 (Page No. 301-302)
Q.9: Epulis Q.3: Spina bifida
A n s : See Section - 1 , Segment C, Paper II, 2011, Q.13 (Page No. 399-400) A: See Section 2, Group - 1, 2009, Qs.6 (Page No. 633-634)
Q.4: MEN Syndrome
Q.10: Complications o f spinal anesthesia
A: See Section 1, Segment - C, Paper-ll, 2009, Qs.5 (Page No. 364-365)
Ans: See Section - 3 (Anesthesiology), Q.1 (Page No. 753-754).
OS: Principle o f skin grafting
A: See Section 1, Segment - C. Paper-ll. 2008, Qs.7 (Page No. 351-352)
2015 Supplementary
OS: Post burn contracture
Q. 1: Testicular torsion A: See Section 1, Segment - D, Qs. 107, (Page No. 566-567)
A : See Section 1, Segment - C, Paper-ll, 2012, Qs.9, (Page No. 408-409) 0.7: Hydrocephalus
Q .2: Extradural haematoma A: See Section 1, Segment - C, Paper-ll, 2010 Supplementary, Qs.12 (Page No. 387)
A : See Section 1, Segment - C, Paper-ll, 2009, Qs.7, (Page No. 355-366) 0.1: Hamartoma
Q.3: Flail chest HAMARTOMA
A : See Section 1, Segment - C, Paper-ll, 2008, Qs.12, (Page No. 354-355)
Q.4: Ameloblastoma first coined b y : Albrecht in 1904
J Derivation: From Greek word meaning 'fault' or ‘missfire’
A : See Section 1. Segment - C, Paper-ll, 2012, Qs.13, (Page No. 411)
-1 Definition : Developmental malformation consisting of a benign lesion with aberrant differentiation
Q.5: Submandibular sialolithiasis mwhich tissues of a particular body part are arranged haphazardly , producing a mass of disorganised
A : See Section 1, Segment - C, Paper-ll, 2009, Qs.1, (Page No. 361-362) but mature specialised cells or tissue indigenous to the specific site
 442 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 443

O Types:
• Single forms o f particles:
• Multiple « Alpha particles .
□ Features: , Beta particles
, Positrons
• Mostly present at birth or appear in early childhood
, Photons
• May regress as in strawberry haemangioma
, Neutron (indirect radiation)
• Growth occurs at par with surrounding tissue
• Non capsulated 0 physical e ffe cts:
• Benign, rarely malignant , Nuclear effects - Nuclear transmutation and induced radioactivity
This occurs by - a) Photodisintegration
• May be associated with chromosomal abnormality
□ Examples: b) Alpha absorption

• Vascular hamartoma (haemangioma) c) Neutron activation

• Angiomatous syndrome t Electrical effects - Increase conductivity and thereby allowing transmission of damaging
current levels. This phenomenon is used in Geiger Muller counter.
• Benign naevus
« Chemical effects - Formation of free radicals by radiolysis that lead to ozone crack, disruption
• Skeletal hamartoma
of crystal lattices in metals.
• Neurofibroma
0 Effects on Health :
• Adenoma sebaceum
• Determi nistic effects - Occurs du e to high doses of radiation
• Glomus tumour
• Stochastic effects - Heritable conditions occurring due to mutation of somatic cells due to
• Lymphangioma
radiation.
□ Complications:
q Ways to lim it radiation exposure:
• Bleeding
• Good to have radiation detector
• Infection
• Time distance and shielding should be used
• Gigantism
< Respirator or Face Mask to be used
• Pressure symptoms
• To be well-informed about various radiation sources
• Cosmetic problem
0 Treatment: Q.10: Bleeding from gum
• Cryotherapy BLEEDING FROM GUM
• Ligation of feeding vessel
Q Causes : .
• Sclerotherapy
• Gingivitis .
• Laser / excision therapy
• Brushing teeth roughly
0 .9 : Ionising radiation • Traumatic
• Thrombocytopenia
IONISING RADIATION
• Leukaemia
° 2 f t ! ’’ ,Ra,dia,ti0n " f 1en0U9h energy 80 ,hat durin9 an interaction with an atom, it can removed • Bleeding disorders
lightly bound electrons from the orbit of an atom, causing the atom to become charged or ionised.
Q Risk factors:
0 Types: a
• Smoking
• Waves
• Tobacco chewing
• Particles
• Diabetes
0 Forms of waves:
• Pregnancy
• Gamma rays • Broken fillings / dentures
• X-rays • HIV /AIDS
• Higher UV rays • Genetic
 444 QUEST . A Comprehensive Guido to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 445

□ Investigations:
• Routine blood investigations w l e u k o p l a k ia -

. BT.CT Qettnlti°n : White patch in oral mucosa which cannot be characterised clinically or pathologically to
• PT.aPTT 3 any other disease
• Inspection ot oral cavity rj ca u se s: “7S”
□ Treatment: , Smoking
• Maintain proper oral hygiene , Sepsis
• Brush teeth carefully , Syphilis
• Treat underlying condition. . Spices
. Sharp tooth
2016 Supplementary
. Spirit
0 .1 : PET Scan • Superficial glossitis
A : See Page No. 611. • Chewing of betel leaves
Q-2 : Undescended testis • Chronic hypertrophic candidiasis
A : See Section 1, Segment - C, Paper-ll, 2009, Qs. 4 (Page No. 363-364)
0 Histology:
Q.3: Intermittent claudication
• Parakeratosis
A : See Section 1, Segment-O, Qs. 84 (Page No. 540-541)
• Dyskeratosis
0 .4 : Brachytherapy
• Acanthosis - Elongation of rete ridges
A : See Section 1, Segment - C, Paper-ll, 2008, Qs. 10 (Page No. 353)
Q Types:
Q.S: Dental cyst
• Homogenous
A : See Section 1, Segment - C, Paper-ll, 2008, Qs. 11 (Page No. 353-354)
• Speckled
Q.6: Fournier's gangrene
• Nodular
A : See Section 1, Segment - C, Paper-1,2013, Q$. 3 (Page No. 302-303)
Q.7: Regional anaesthesia 0 Site:

A : See Section 3, Qs. 8 (Page No. 764-765) • Buccal mucosa

Q.8: Chest drain after chest injury • Oral commissure
□ Investigation: Biopsy
A: I T 003' 3' Drain" Sec,ion 1' Segment" C, Paper-I, 2013 supplementary, Qs. 3 (Page No.
307*308) ' 0 Treatm ent:
0 .9 : Different types o f nerve injuries • Stop all etiological factors
A : See Section 1, Segment - D, Qs. 98 (Page No. 558-559) • Excision may be required followed by skin graft
0.1 0: Pre-maiignant condition o f oral cavity • C02 laser excision
• Iso retinoin
PRE-MALIGNANT CONDITIONS OF ORAL CAVITY
B) ERYTHROPLAKIA
They are -
Q Definition: Red velvety appearance of mucosa which cannot be attributed to any other disease
a) Leukoplakia
b) Erythroplakia Q Histology:
High risk lesions
c) Chronic hyperplastic candidiasis • Parakeratosis
d) Oral submucosal fibrosis • Severe epithelial dysplasia
e) Syphilitic glossitis Medium risk lesions • Decreased keratin causing red colour
f) Sideropenic dysphagia Q Site; .
g) Oral lichen planus • Ginginobuccaf sulcus
h) Discoid lupus erythematosis Low risk lesions • Floor of mouth
i) Dyskeratosis congenita • Lower alveolar mucosa
 446 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 447

□ Investigation: Biopsy
8) Suggesting small emboli located distally ' .
□ Treatment: Surgical excision
• Pleuritic chest pain
C) ORAL SUBMUCOSAL FIBROSIS • Cough
See Section 1, Segment - C, Paper-ll, 2013 Qs. 6 (Page No. 419) • Haemoptysis
D) CHRONIC HYPERPLASTIC CANDIDIASIS Hast fre que nt sym ptom : Dyspnoea

□ S ite :
f/est fre q u e n t s i g n : Tachypnoea
n predisposing factor:
• Commissures of mouth
. Surgery
• Tongue
, immobilisation
□ Treatment:
3 SCOchanges:
• Topical / Systemic antifungal drugs
, Sinus tachycardia (most common)
• Excision / Laser therapy
t Right ventricular strain pattern (T-wave inversion in leads V| to V4 )
E) SIDEROPENIC DYSPHAGIA . S|Qh T|,| pattern -
• Other name - Plummer Vinson Syndrome a) Deep S waves in lead I
• Causes - Atrophy of epithelium b) Q wave in lead III
• Treatmenl - Proper iron therapy. c) Inverted T-wave in lead III
• New onset atrial fibrillation / flutter
2017 • Right axis deviation / RBBB .‘ .
Q.1: Subdural haemorrhage
A : See Section 1, Segment - C, Paper-ll, 2010, Qs. 6 (Page No 378-379)
Q.2: PCNL
A : See Section 1, Segment - E, Qs. 22 (Page No. 597)
0 .3 : Complications o f spinal anaesthesia
A : See Section 3, Qs. 1 (Page No. 753-754)
Q.4: DVT
A : See Section 1, Segment - C, Paper-1,2011, Qs. 3 (Page No. 290-291)
Q.5: Ludwig’s angina
A : See Section 1. Segment - C, Paper-ll. 2010, Qs. 11 (Page No. 380)
Q.6; Autotransfusion
A : See Section 1, Segment-C, Paper-1,2009, Qs. 4 (Page No. 282)
Q.7: Pulmonary embolism

PULMONARY EMBOLISM

□ What Is I t : Sudden blockage of an artery in lung, usual by a blood clot originating froma different site.
□ Most common cause: DVT in large veins of leg
□ Symptoms :
A) Suggesting large emboli causing marine PE
• Sudden onset dyspnoea
• Pleuritic chest pain
• Hypotension .
• Syncope
• Cyanosis
 446 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 449

□ Investigations
, com pl^tlons:
• MDCT (Investigation of choice) , Donor site haematoma, uncontrolled bleeding, infection
• D-dimer assay (most sensitive) , Recipient site flap necrosis, infections, seroma .
• Pulmonary angiography (most specific) „ LATISSIMUS DORSI FLAP
• Lung V-Q scan (in case of renal insufficiency) , Anatomy - Back muscle, just below shoulder and behind armpit
□ Management: » Dominant pedicle - Thoracodorsal artery
0 .8 : Myocutaneous flap , Secondary pedicle - Perforating branches of intercostal and lumbar arteries
, Pedicle length - Upto 15 cm
MYOCUTANEOUS FLAP , Nerve supply - Thoracodorsal nerve
, Uses - Breast reconstruction
□ What is fla p : Transfer of donor tissue along with its blood supply to recipient area
□ Indications: 0.9: ABPI
• Cover wider and deeper areas ABPI
• Repeated skin graft failure
j Pull form: Ankle Brachial Pressure Index
• Cover bone, tendon or cartilage
j IWiaf is i t : Index which gives us an idea about presence of peripheral arterial disease
□ Parts :
Q Method:
• Base
• Patient placed supine
« Pedicle
• Cuff of sphygmomanometer is inflated proximal to the arteries of arm and ankle till pulse
• Tip ceases as seen in Doppler ultrasound.
□ What is Myocutaneous fla p : Composite soft tissue flap in which skin provides wound closure • Cuff is then slowly deflated
muscle mass serves as a carrier for the blood supply . The point at which arterial pulse is redetected via Doppler probe is the systolic pressure of
□ Exam ples: the artery

• Pertoralis major flap 0 Arteries used :

• Ann - Brachial artery
• Latissimus dorsi flap
• Ankle -
(Both fall in Type V of Mathes and Nahai Classification)
* Posterior tibial artery
A) PMMC (PECTOHALIS MAJOR MYOCUTANEOUS FLAP)
* Arteria dorsalis pedis
• Anatomy - Fan shaped muscle of anterior chest Wall 3 Calculation:
• Dominant pedicle - Pectoral branch of thoraco acromial artery ABP, = SBPjnanWe
• Secondary pedicle - Perforator branches of internal mammary artery SBP in arm
• Nerve supply - Lateral and Medial Pectoral Nerves 0 Interpretation:
□ Types :
>1.2 - Calcification of arterial wall indicating peripheral vascular disease
• Muscle paddle
0.9 - 1.2 - Normal
• Full paddle
0.8 - 0.9 - Some arterial disease + / - venous ulcer
• Island
• Free CLASSIFICATION
• Osteomyocutaneous
I : •
□ U ses:
• Flap of choice in cancer patients requiring secondaryreconstruction 1 1
• Reconstruction of mandible, floor ol mouth, upper neck, lower third of face Painful Painless
Q Contraindication : • Dental ulcers • Syphilitic ulcers
• Prior H/O radical axillary node dissection • Aphthous ulcers • Malignant ulcers
• Prior flap reconstruction of breast • Tuberculous ulcers • Lichen planus ulcers
 450 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 451

0.5- 0.8- Moderate arterial disease + / - mixed ulcer

<0.5 - Severe arterial disease ..ffRCP
Section 1, Segment E, Q 9, (Page No. 586).
□ S ensitivity: 90%
y ^ p lic a tio n s o f Radiotherapy •
□ Specificity: 98%
□ Disadvantages: °3 Section 1. Segment C, Paper II, 2009, Q 10. (Page No. 367)

• Unreliable results in case of arterial calcification

\ i -MP'<i0,ateanUS'
• Resting ABPI is insensitive to mild PAD See Section 1. Segment C, Paper 1,2013, Q 4 (Anorectal malformations), (Page No. 303)
• Lack of protocol standardisation
chest
0.10: Tongue ulcers
Section 1. Segment C, Paper II, 2008, Q 12, (Page No. 354-355)
TONGUE ULCERS
9S:GI#gow coma scale

A) DENTAL ULCERS ‘ - ^ SeC|ion 1, Segment C, Paper II, 2008, Q 13, (Page No. 355)
• Common cause is rubbing of tongue on sharp edges of teeth, dentures or accidental bit™
t/:W
B) APHTHOUS ULCER
4 . See Section 1, Segment E, Q 19 (Intravenous Urethrogram), (Page No. 595)
• Repeated formation of benign ulcers in otherwise healthy Individual
• Cause is idiopathic though nutritional deficiency is commonly associated 0j:U3rjolin‘s ulcer
• Occur periodically and heal completely in between attack. k See Section 1, Segment C, Paper II. 2013, Q 10, (Page No. 421)
• Site is mainly non-keratinising epithelial surfaces
Oi: Hypospadias
C) TUBERCULOUS ULCER
»: See Section 1. Segment C, Paper II. 2013 Supplementary, Q 8, (Page No. 425)
• Typical stellate ulcer mostly on dorsum of tongue
• Undermined edges and granulating floor 0.10-.Ingrowing toe nail
D) SYPHILITIC ULCER l: SeeSection 2, Group II, Q. 52, (Page No. 739)
• Mucous patches - Slightly elevated plaques, may be covered by grey pseudomembrane
• Multiple lesions coalesce to form serpiginous lesions described as snail-track ulcers 2018
E) MALIGNANT ULCER
SI: Lucidinterval
• Initially painless, later becomes painful due to infection or involvement of lingual nerve
»:See Section 1, Segment C, Paper II, 2009, Q 7 (Extradural hematoma), (Page No. 365)
• Mostly in lateral margin of tongue
F) UCHEN PLANUS ULCER . ' 01: Thyroidstorm .
• White lacy lesions
<: ACUTE HYPERPARATHYROIDISM (CRISIS)
□ Investigation:
• Biopsy • rare but dangerous presentation
• Routine investigations for TB, Syphilis • Abdominal pain, vomiting, dehydration, oliguria, muscle weakness and death
□ Treatment: • Serum calcium is very high (> 12% or > 3.5mmol/L)

• Maintain oral hygiene Advocated for Acute hyperparathyroidism c ris is :

• Topical corticosteroids for aphthous ulcer *■ Forced diuresis - 3-5 L of normal saline with Fmsemide
« Specific treatment for TB and Syphilis.
> Rehydration - Normal saline @300mL/hr

2017 Supplementary * To inhibit effects of vitamin D - Steroids 400mg i.v. for 5 days
' Pamidronate (90 mg i.v slowly in 4 hre)
0 .1 : Thyroglossal cyst
I Zoledronic acid (4 mg initially, 8 mg later)
A : See Section 1. Segment C. Paper II. 2008, Q 4, (Page No. 348),
 452 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 453

> To reduce serum calcium level - Mithramycin, calcitonin, bisphosphonates. r 2019

(Calcium receptor agonist), Gallium nitrate (inhibits osteoclast resorption of na'i:>
dose of 200mg/m2/day) cafclu^ » ^
ygnetlc resonance cholanglo-pancreatography (MRCP)
> estrogens, progesterons, raloxifene (Selective estrogen receptor modulator)
** Section 1, Segment E. 0.9 (Page No. 586)
Q.3: Ranula
^ tp ld u ra l Anesthesia
A : See Section 1, Segment D, Q 68, (Page No. 526).
.^Section 3 ,Q.7 (Page No. 763)
Q.4: ERCP
y.Split-thlckness skin graft
A ; See Section 1, Segment E, Q 10. (Page No. 586).
t gee Section 1, Segment C, Paper II, 2008, Q.7, (Page No. 351)
Q.S: Testicular torsion
ft, ; Choledochal Cyst
A : See Section 1, Segment C, Paper II, 2012, Q 9, (Page No. 408).
( .See Section 1. Segment D, Q.42 (Page No. 501)
Q.6: PSA Complications o f External beam radiation therapy
A : See Section 1, Segment C, Paper II, 2012, Q 5, (Page No. 406).

Q.7: Brachytherapy COMPLICATIONS OF EXTERNAL BEAM RADIOTHERAPY

A : See Section 1, Segment C, Paper II, 2008, Q 10, (Page No. 353).
Com plications arising due to radiotherapy stems from effects of Ionizing radiation on normal human

Q.10: Regional anesthesia wws. They can be enumerated as follows -

A : See Section 3. Q 8. (Page No. 764). l Infections in cancer p a tie n ts :

Radiation therapy (RT) impairs mucosal immunity as several levels and suppresses bone marrow
2018 Supplementary function resulting in local and systemic bacterial infections, mucosal candidiasis, HSV infection.
i Anemia, Neutropenia & Thrombocytopenia:
Q.1: Classification o f nerve injury Hemi Body Irradiation, Pelvic external beam radiotherapy can often lead to these complications due
A : See Section 1, Segment D, Q 98, (Page No. 558). . to gross myelosuppression.
According to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0, neutropenia
Q.3: Criteria o f brain death
isdefined by a granulocyte count s1,500/pL When ANC (Absolute neutrophil count) is < 500/nL, risk
A : See Section 1, Segment C, Paper II, 2011, Q 3, (Page No. 394). and severity of infection becomes Inversely related to the neutrophil count.

Q.4: Types o f skin grafting CTCAE defines thrombocytopenia as a platelet count <100,000/(iL. The risk of hemorrhage increases
\ when platelet count is < 50,000/nL.
A : See Section 1, Segment C, Paper II, 2008, Q 7, (Page No. 351).
i Nausea & v o m itin g :
Q.S: Chemotherapy o f testicular cancer
Risk of Radiation Induced Nausea and Vomiting (RINV) is defined principally by anatomic area
A : See Section 1, Segment A Paper II. 2014, Q 3 (Treatment of Testicular tumors), (Page No. 188). receiving treatment as well as type of treatment.

Q.7: Cleft lip

Risk Category Radiotherapy Modality
A : See Section 1, Segment C, Paper II, 2013, Q 1, (Page No. 417).
High Total Body Irradiation
Q.8: Glasgow coma scale
Moderate RT to Upper Abdomen, Craniospinal irradiation
A : See Section 1, Segment C, Paper II, 2008, Q 13, (Page No. 355). Low RT to lower thoracic region, pelvis, head and neck, brain
Q.10: Dentigerous cyst Minimal RT to extremities and breast

A : See Section 1, Segment C, Paper II, 2014, Q 3, (Page No. 428).

*• Diarrhea :
®arrhea is defined as passage of more than 3 unformed stools in 24 hours. Treatment induced
®arrhea can be associated with life threatening dehydration, renal failure and electrolyte abnormalities.
 SOLVED SHORT NOTES OF FINAL MBBS □ Paper - II 4S5
454 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology

Radiation injury to the lower intestine is usually seen after treatment of cancers of the anu
cervix, uterus, prostate, urinary bladder, and testes and as part of total-body irradiation R ' Related Fatigue (CRF) may be defined as a distressing persistent, subjective s e n s e ^
of the abdomen or pelvis damages intestinal mucosa, causing prostaglandin release a ^ ^ i fmotional and/or cognitive tiredness or exhaustion related to cancer or cancer reatmen
malabsorption. These lead to increased intestinal peristalsis, causing diarrhea. ( 1 ^ ’ , proportional to recent activity and that Interferes with usual functioning. Dlr<*, ®ffect °<
^ th e ra p y has been implicated as a contributor to the intensity of fatigue In cancer patients.
Acute radiation enteritis or proctitis occurs within 6 weeks of therapy. Symptoms inclucf
cramping pain, tenesmus, bleeding. These symptoms usually resolve without specific the* <tar*H
2 to 6 months. * ^ P n m a T c a n c e r s (SPC) are one of the most serious complications of anti-cancer treatment^
Late radiation enteritis or proctitis generally occurs 8 to 12 months after therapy. |t may ^ S o U a t e d cancer has been shown to increase with increasing dose for cancero fth e
malabsorption and/or diarrhea, with more rapid transit times occurring in the affected bowe! esophagus, lungs, stomach, meningioma, sarcoma and pancreatic cancer In addtton to

5. Oral com plications: brea L dose, radiotherapy fields, which directly reflect the volume of normal exposed Issue, can

These complications include oral mucositis and associated oropharyngeal pain, xerostomia a ffe ct SPC risk.
infection. Oral mucositis is a dose- and rate-limiting toxicity for RT in the head and neck cancer0' ^
Atrophic changes in the oral epithelium occur usually at total doses of 16 to 20 Gy, administers^ * I l ^ i n R T ’ s ^ l a t e d with high risk of cognitive decline. In long term survivors, worse cognitive
rate of 2 Gy per day. Teeth in the irradiated field may become desensitized, placing the patient S o n has been reported at 1 year following adjuvant WBRT.
for asymptomatic early caries. a
, uadiatJon lethality: It refers to death occurring within a few weeks due to specific high intensity
Late effects of External Beam Radiotherapy delivered to the head and neck include soft tissue ft
15' S i o n exposure to the whole body. The mode of death depends on the magnitude of the radiation
trismus, nonhealing or slow healing mucosal ulcerations, and slow-healing dental extraction*!
RT-lnduced fibrotic changes may occur in the masticatory muscles or the temporal mandibular
up to 1 year after RT. Osteoradionecrosis is reported following tooth extractions not timed lo ^ j) Radiation dose> 100 Gy- Cerebrovascular syndrome (death within 24-48 hours)
extraction site healing for 10 to 14 days before the start of RT. It is usually related to trauma andhints, ii) Radiation dose 5-12 Gy- Gastrointestinal syndrome (death in 9-10 days)
incidences are reported with total doses to the bone exceeding 65 Gy. iii) Radiation dose 2.5-5 Gy- Hematopoietic syndrome (death in several weeks to 2 months)
6. Pulmonary to x ic ity :
Radiation pneumonitis develops in 5-15% of patients receiving high-dose external beam radiations* qs; Epulis
treatment of lung cancer. Symptoms of acute radiation pneumonitis usually become evident 2loj A :S e e Section 1, Segment C, Paper 11,2011, Q.13, (Page No. 399)
months after the completion of therapy. However, when the injury is severe, a chronic phase (>i
months after radiation) ensues which may persist for months or years. Factors like female so*, QJ: Ultrasound wave therapy

lower lobe site of primary lung cancer, concurrent chemotherapy, previous irradiation, and withdra»ai A : See Section 1. Segment C, Paper II. 2009 supplementary, Q.13, (Page No. 373)
of steroids may potentiate classic radiation pneumonitis.
01: Flail chest with paradoxical respiration ..
7. Cardiac to x ic ity :
A :S e e Section 1, SegmentC, Paper II. 2008, Q.12, (PageNo. 354)
Pericarditis and pericardial effusion are regarded as the most common side effects of cardiac irradiata
However, as per recent evidence Radiation-induced coronary heart disease (CHD) is the ms OS: Secondary brain Injury
concerning long-term risk of cardiac irradiation, particularly in patients at high risk for ischemic disease
A;
A highly referenced population-based, case-control study of major coronary events by Darby eta'
(1958-2001) showed that for breast EBRT, an increase in Mean Heart Dose of 1 Gy was associate: SECONDARY BRAIN INJURY
with a 7% increase in cardiac events.
D Brain in ju ry : An insult to brain, not of degenerative or congenital nature, caused by an external
8. Hair lo s s :
physical force that may produce a diminished or altered state of 7 * " * ^
Cranial irradiation can cause hair loss. Palliative whole-brain radiation (WBRT) or Prophylactic Crafi^ impairment of cognitive abilities or physical functioning, often resulting in disturbance of behavtou a
Irradiation (PCI) causes temporary hair loss that starts approximately 2 to 3 weeks after initiasins
or emotional functioning.
radiation and resolves 2 to 3 months after cessation of RT. However, higher doses of curative treats
to the brain can cause permanent hair loss as great as 50%. 2 Types ot brain In ju ry:
a) Primary -* Irreversible cellular injury as a direct result of injury
9. Gonadal dysfunction:
b) Secondary -» Damage to cells that are not initially injured
Radiation can cause germ cell depletion, loss of gonadal hormones, mutagenic changes ii'98lS
cells. In the conventionally fractionated regimens, doses to the testes above 0.15 Gy are requiredi- Q Timing ot secondary brain In ju ry : H o u rs to weeks after injury
produce any reduction in sperm count. The duration of azoospermia is dose dependent. CumuW®
doses of fractionated radiotherapy of more than 2.5 Gy generally result in likely permanent azoospe^
 456 QUEST : A Comprehensive Guide to UG Surpery. Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 457

□ Mechanism o f Inju ry:

- Intracranial pressure monitoring indicated in comatosed patients with r
a) 6CS 3 - 8 with abnormal CT scan
b) Normal CT with > 2 features at admission -
Blunt,"iury Penetrating Injury i) Age >40 years
ii) Unilateral or bilateral motor posturing
* Assau" . Slab
iii) SBP < 90 mm Hg
' Motor vehicle collision . Gunshot wound
< induced hyperventilation
* Fal1 • Explosion
, Hyperosmolar therapy
□ Classification o f brain In ju ry: . Corticosteroid - inconclusive role
a) Open brain injury - Skull penetration ■ Barbiturate coma
b) Closed brain injury - no skull penetration • Surgical interventions for refractory ICP e.g. external ventricular damage.

□ Pathogenesis : Rotations / translational acceleration -► diffuse shearing / stretch of l1l: Diabetic foot
vascular cell membranes -> Increased permeability -* intracellular calcium influx - triqoers *“ j. SeeSection 1, Segment A, Paper 1,2009, Q.1, (Page No. 15)
breakdown of cytoskeleton interruption of axonal transport -> accumulation of B-?mvloirf n

m *m’ " w “ - 2019 Supplementary

□ Secondary injury consists o f:
• Hypoxia / ischaemia jt ; Endoscopic Retrograde Cholangiopancreatography (ERCP)
. *Increased intracranial pressure C See Section 1, Segment E, Q.10, (Page No. 586)
• Infection, meningitis
• Hydrocephalus Ol: Spinal Anaesthesia
• Brain abscess I. SeeSection 3, Q.1 (Page No. 753)
• Hypercapnia
M: Fvll thickness skin graft
• Acidosis
»: See Section 1, Segment C, Paper II, 2008, Q.7, (Page No. 351)
3 Z H H f . lmpaCt sy" drom e; Extreme,y rare outcome where death or severe neurologic injury occurs
n a person sustains a second concussion before symptoms from an earlier one have subsided HI: Hypertrophic pyloric stenosis o f infancy
3 Management:
»:SeeSection 1, Segment C, Paper II, 2010, Q.9, (Page No. 378)
Maintenance of airway, breathing, circulation
H : Neo-adjuvant Radiotherapy
Adequate sedation
Avoidance of hypo/hyperglycaemia »: .
Instituting normothermia NEO-ADJUVANT RADIOTHERAPY
Prevention of seizures
Correction of anaemia and coagulopathy tecer palienls often undergo treatment for a prolonged duration and most sites require multimodality
Deep vein thrombosis prophylaxis •raiment that is executed in multiple steps. In oncological perspective, the term "Neo-Adjuvant" refers to
Early nutritional therapies to part of treatment that happens prior to the "Definitive" treatment. Mostly Neo-adjuvant therapy is
Stress ulcer prophylaxis ssociaied with tumor downstaging so as lo improve the effectiveness and ease of definitive treatment.

Hygiene maintenance to prevent infections 3 Carcinoma Rectum :

Specific monitoring InCA Rectum, Neo-adjuvant radiotherapy has emerged as the slandard of care along with or without
- Pulse oximetry concurrent chemotherapy. It is associated with improved tumor resectability and tolerance (both
- ECG acute and chronic), in addition to downstaging of tumor. It increases potential for expanded sphincter
- BP preservation options in carcinoma of distal rectum Appropriate neo-adjuvant preoperative radiation
•• End tidal carbon dioxide has been shown to increase Local Control (LC) and Overall Survival (OS) of patients.
- Core body temperature The Swedish Rectal Cancer Trial which evaluated 1,168 patients (accrued from 1987 to 1990) with
'Kectable, Dukes A to C rectal cancer. The 5-year Local Recurrence (LR) rates ( 11% vs. 27%) were
 458 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MB8S □ Paper - II 459

numerically and statistically superior with preoperative radiation treatment (25Gy in 5 fractions , Therefore there stili is no dear evidence that preoperalive radiotherapy improves survival of patients
week) followed by definitive surgery compared to surgery alone. At follow-up of 13 years os* 1 with potentially resectable esophageal cancer,
38% versus 30% in favour of neoadjuvant preoperalive radiotherapy with all stages benefiting Bil
oS: Dental Cyst
The ideal time interval between neoadjuvant RT and definitive surgery was sludied in the Freiw,
Lyon 90-01, which delivered 39 Gy in 13 fractions (no preoperative chemotherapy). After a m j . See Section 1, Segment C, Paper II, 2008, Q.11, (Page No. 353)
follow-up of 33 months, the pCR (pathological complete response) rate was numerically f, qj ■post-traumatfc pneumothorax
(although not statistically significant) and the pathologic downstaging rate was statistically beii^
favour of longer interval before surgery (6-8 weeks compared to 2 weeks interval). ef'1 A ■see Section 1, Segment C, Paper II, 2009, Q.14, (Page No. 370) Tension Pneumothorax’*
A Dutch multicenter, phase III study, CKVO 95-04, of 1,861 patients was undertaken to evaluate qj) . intercostal chest tube drainage
role of short-course preoperative radiation with TME (Total Mesorectal Excision) as the defo^
surgery. The study again highlighted the value of radiation treatment in reducing local recurrent A■see Section 1, Segment C, Paper 1,2013 supplementary, Q.3, (Page No. 307)
long follow-up. However, the perineal complication rate was slightly higher in the preoperative radial 0 9: Extradural hemorrhage
arm of 26% versus 18% In the TME alone arm. Updated toxicity analysis indicates a higher intifcJ
of sexual dysfunction and slower recovery of bowel function, more fecal incontinence, and genera#, A: See Section 1, Segment C, Paper II, 2009, Q.7, (Page No. 365)
poorer quality of life with short-course preoperative radiation. 0.10: Venous ulcer
Two meta-analyses were carried out to explore the benefit of neoadjuvant preoperative radiafe,
see Section 1, Segment C, Paper 1,2013, Q.2 (Page No. 301)
treatment. One analysis reported that neoadjuvant radiation treatment was associated with s ig n ify
fewer LRs, improved specific survival, and an OS benefit. The second meta-analysis provided byth,
Colorectal Cancer Collaborative Group, also noted a significant reduction in the risk of LR and dean December-January 2019-2020
• from rectal cancer with preoperative radiotherapy.

□ CA Pancreas: 0.1: Branchial fistula

The use of neoadjuvant R7 here with or without concurrent chemotherapy is not supported by tni A :
Phase ill Randomised Controlled Trials (RCT), as none has been conducted yet. A review of the BRANCHIAL FISTULA
Surveillance, Epidemiology, and End Results (SEER) database supports the use ol neoadjmti
treatment in (potentially) resectable pancreatic cancer. Median OS was 23 months in patients receiving □ What is it :
neoadjuvanl EBRT and 12 months in the surgery-alone cohort. Wilh respect to chemoradiation. II* • Branchial tract anomaly, which results from improper development of branchial apparatus
first RCT phase II study comparing immediate surgery (arm A) with surgery after neoadjuvanl (Branchial apparatus consists of - branchial arches
chemoradiotherapy (arm B) for (potentially) resectable tumors was reported. Conventional!/ - pharyngeal pouches
fractionated, the conformal RT included an elective nodal volume dose of 50.4 Gy and 55.8 Gy tothe - branchial grooves
tumor. The trial under-recruited (73/254 planned patients) with considerable impact on statistical - branchial membranes)
power. However, an Important finding is that neoadjuvant therapy was well tolerated with few*
• Fistula represents persistence of both deft and corresponding pouch forming a communication
hematological toxicities.
that is epithelial lined (generally persistent 2nd branchial cleft)
□ CA Esophagus: 0 Location: Lies caudal to the structures derived from that particular arch and connects the skin to the
The use of preoperative radiation therapy has potential biologic and physical advantages, in addition foregut
lo the ones elucidated above- Increased tumor radioresponsiveness secondary to improved turn* 0 Lining: Stratified squamous, columnar or ciliated epithelium
oxygenation, a theoretical decreased likelihood of dissemination at the time of surgery and avoid**1
Q Laterality: Unilateral or bilateral
of surgery in patients with rapidly progressive disease.
However, none of the RCTs conducted by Launois et at, European Organisation (or Research ^ 3 External o rific e : In tower third of neck near anterior border of sternocleidomastoid
Treatment of Cancer (EORTC), Amottetal, Wang etal show any significant survival advantage to®* 3 Internal o rifice : On anterior aspect of posterior faucial pillar just behind the tonsil
patients receiving neoadjuvant preoperative RT in esophageal cancer.
Q Clinical features:
A meta-analysis from the Oesophageal Cancer Collaborative Group evaluated data from 5 RCTs*'
• Opening in neck (lower part)
> 1,100 patients comparing preoperative radiotherapy plus surgery versus surgery atone. At a flieW1
• Slight mucopurulent discharge from opening
follow-up of 9 years there was an overall reduction in the risk of death of 11 % and absolute sum®
benefit of 4% at 5 years with the use of preoperative radiotherapy. However, this numerical be"6* ^ Investigations:
was not statistically significant. • Upper airway endoscopy
• FNAC - to clarify diagnosis and rule out metastatic cancer
 460 QUEST : A Comprehensive Guide to LTQ Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 461

• CT Scan - Investigation of choice CTCAE defines thrombocytopenia as a platelet count < 100,000/pL. The risk of hemorrhage increases
• MRI when platelet count is < 50,000/ mL.
• CT fistulography P Nausea & vom iting :
□ Treatment: Chemotherapy-induced nausea and vomiting (CINV) remains one of the most dreaded side effects
• Complete surgical excision indeed. Before the era of newer antiemetic drugs, approx. 80% patients would experience at least an

• In case of acute infection, first treat with antibiotics and then surgical excision after con»|sl. episode of nausea or vomiting after chemotherapy of moderate to high emetogenic potential.
resolution Classification of emetic risk of intravenous antineoplastic agents is as follows:

0 .2 : Regional Anesthesia
High (> 90%) Anthracycline-Cyclophosphamide
A : See Section 3, Q.8, (Page No. 764) combination
Cisplatin
0 .3 : Endotracheal Intubation Cyclophosphamide (>1500 mg/m2)
A : See Section 3, Q.10, (Page No. 768) Moderate (30-90%) Carboplatin
0 .4 : Undescended Testis Cyclophosphamide (<1500mg/m2)
Anthracyclines
A : See Section 1, Segment C, Paper Ii, Q.4, (Page No. 363)
~Low (10-30%) Docetaxel
0 .5 : Complications o f Chemotherapy 5-Fluorouracil
Gemcitabine
A: Methotrexate
COMPLICATIONS OF CHEMOTHERAPY Minimal (<10%) Bleomycin
Vincristine
□ Infections In cancer patients: Vinblastine
■ Cancer patients are at increased risk for various infections because of chemotherapeutic drugs and
other antineoplastic agents.
0 Diarrhea & constipation:
Diarrhea is defined as passage of more than 3 unformed stools in 24 hours. Treatment induced
Treatment related factors Infection diarrhea can be associated with life threatening dehydration, renal failure and electrolyte abnormalities.
Corticosteroids The chemotherapeutic agents most commonly causing diarrhea are : 5-Fluorouracil, capecitabine,
Bacteria, P. jirovecii, C. neoformans, Herpes
Irinotecan.
viruses
Chronic Constipation according to ROME II criteria entails the presence of any 2 of the following
Nucleoside analogues (e.g. Fludarabine) Bacteria, P. jirovecii, C. neoformans, Herpes symptoms for at least 12 weeks- straining during bowel movements, lumpy or hard stool, sensation of
viruses Incomplete evacuation, sensation of anorectal blockage, manual maneuvers to remove stool, < 3
Alemtuzumab CMV, VZV, P. Jirovecii bowel movements per week. Among chemotherapeutic agents, vinca alkaloids have the propensity
Rituxlmab VZV, P.jiroveci to cause constipation due to their neuropathic effects.

Bruton TKI (e.g. Ibrutinib) Aspergillosis, P. jirovecii Q Oral complications:

PIK-3CA inhibitors P. jirovecii These complications include oral mucositis, oral chronic graft versus host disease and associated
oropharyngeal pain, xerostomia, oral infection.
Q Pulmonary to xicity:
□ Neutropenia & Thrombocytopenia:
These are most frequent manifestations of cytotoxic chemotherapy induced myelosuppression. Tte
may adversely impact antineoplastic treatment including more frequent hospitalizations, increased Chemotherapeutic agents Mechanism of pulmonary toxicity
treatment cost, reduction in dose intensity of chemotherapy, treatment discontinuation and increased
Bleomycin Direct endothelial toxicity via oxygen free radicals
mortality.
According to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0, neutro^2 Susulphan Direct alveolar epithelial toxicity
is defined by a granulocyte count S 1,500/jjiL. When ANC (Absolute neutrophil count) is < 500/m>-. ^
Mitomycin C Endothelial injury, alveolar macrophage activation
and severity of infection becomes inversely related to the neutrophil count.
Nitrosoureas Direct injury through oxidative stress
 462 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 463

Cardie to x ic ity :
0 (: C M P*’ate
gge section 1, Segment D, Q.15, (Page No. 477)
Chemotherapeutic agents Cardiovascular toxlcitles
oS. 0 rthln's tumour
Anthracyclines Irreversible dilated cardiomyopathy ~~
See section 1, Segment C, Paper I, Q.4, (Page No. 322)
Mitomycin CHF
Varicocele
Busulfan CHF , See Section 1, Segment C, Paper II, Q.5, (Page No. 377)
Vinca alkaloids Hypotension

June-July, 2020
Hair lo s s :
Alopecia has been ranked as the third most common adverse event of cancer treatment. H i: Epidural Anaesthesia

H: see Section 3. Q.7, (Page No. 763)

High Risk Chemotherapeutic agents likely to cause complete alopecia
0.2: Imperforate Anus
Cyclophosphamide, Ifosfamide
A : See Section 1, Segment C, Paper I, Q.4, (Page No. 303)
Doxorubicin, Actinomycin-D
03: Breast abscess
Paclitaxel, Docetaxel
»:See Section 1, Segment C, Paper II, Q.3, (Page No. 362)
Etoposide, Irinotecan
0.4: Basal Cell Carcinoma
i: See Section 1, Segment C, Paper I, Q.2, (Page No. 280)
□ ' Gonadal dysfunction:
Chemotherapy can have varying effects on the sperm quality and quantity. Cyclophosphamide, OJ: Spina Bifida
Chlorambucil, Procarbazine, Cisplatin, Busulfan, Ifosfamide, Actinomycin-D may cause azoospermia. k. See Section 2, Group I, Q.6, (Page No. 633)
□ Fatigue: 0.5; Bleeding from gum
Cancer Related Fatigue (CRF) may be defined as a distressing, persistent, subjective sensed
Jt: See Section 1, Segment C, Paper II, Q.10, (Page No. 443)
physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment
that is not proportional to recent activity and that interferes with usual functioning. Direct elfeel d 0.7: Hydrocephalus
chemotherapy has been implicated as a contributor to the intensity of fatigue in cancer patients.
A: See Section 1, Segment C, Paper II, Q.12, (Page No. 387)
□ Second cancers:
CIS: Glasgow Coma Scale
Second Primary Cancers (SPC) are one of the most serious complications of anti-cancer treatmert
Alkylating agents has long been recognized to be associated with t-MDS/AMl. Moreover, »: See Section 1, Segment C, Paper II, Q.13. (Page No. 355)
epipodophyllotoxins, anthracyclines are associated with a clinically and cytogenetically distinct AMI 03: P ET. Scan
type having shorter incubation period.
See Section 1, Segment E, (Page No. 611)
□ Neurocognltive effects:
0-W: Cleft Up
Post-treatment cognitive decline has been demonstrated in many oncologic conditions such as sold
tumor cancers (Breast, lung, colorectal, testicular, ovarian and prostate) and lymphoma; and *: See Section 1, Segment C, Paper II, Q.1, (Page No. 417)
antimetabolties, DNA cross-linking agents, mitotic inhibitors are associated with it.

Q.6: IVU

A : See Section 1, Segment E, Q.19, (Page No. 595)

Q.7: Lucid Interval

A : See Section 1, Segment C, Paper II, Q.7, (Page No. 408)
 SOLVED SHORT NOTES OF FINAL MBBS □ P a p e r-ll 465
464 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

White lesion
with oonveny
inward

M id lin e
shift

Fig. 1.6.4: CT Scan finding of

extradural hematoma

Ipsilateral pupil Contralateral pupil

Initially Normal 0 Normal #

CN III of ipsilateral side Pinpoint constriction • Normal Q

compressed i
—"1
CN III of opposite side Widely dilated 0 Pinpoint constriction •
compressed ;

Finally Widely dilated 0 Widely dilated 0 !

Fig 1.6.3 : Hutchinson's pupil

59
466 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 8 Anesthesiology

S EG M ENT-D

SOLVED SHORT NOTES OF SEMESTERS

^ j . paradoxic aciduria/Metabolic changes following gastric outlet obstruction

A; See Section - 1 , Segment - A, Paper-1, 2013 Supplementary, Q. 1 (Page No. 61-62)
02: Euthanasia

EUTHANASIA

3 What is I t : Practice of intentionally ending a life in order lo relieve pain and suffering, often called
"painless inducement of quick death"

3 Types:
, Voluntary - With patient’s consent
, involuntary - Against patient's will
, Non-voluntary - Where patient’s consent is not available
t Active-U s e of lethal subslances
• Passive - Withhold common treatment

0.3: Bezoar
BEZOAR

0 Definition: Mass found trapped in gastrointestinal tract

3 Types:
• By content-
> Food bezoar
> Lacto-bezoar (inspissated milk)
A S IS
'*■ Pharmacobezoar
> Phytobezoar (indigestible plant)
> Diospyrobezoar (unripe persimmons)
r Trichobezoar (hairball)
• By location -
> Oesophagus
> Large intestine (faecolilh)
Trachea (tracheobezoar)
3 Pseudobezoar: Indigestable object introduced intentionally into GIT

Wound debridement

WOUND DEBRIDEMENT

^ ^U nltion; Medical management of dead, damaged or infected tissue lo improve healing potential
F i g . 1 .6 .1 1 : P e n ile C a r c in o m a
01 remaining healthy tissue
J Types:
,' Burn debridement

467
 468 QUEST : A Comprehensive Guide lo UQ Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS <69

• Wound debridement
Mediastinum
• Infection debridement
Groin ,
□ Methods o f nemo v a l:
- Ptfotogy:
« Surgical - Done under general anesthesia, fastest method, done to remove large amo Aggregation of cysts looking like soap-bubble
necrotic and infected tissue ™*
Larger cysts near surface, smaller cysts located in deeper planes
• Mechanical - Done if moderate amount of necrotic tissue is to be removed, allows dre: Each cyst has a mosaic appearance
proceed from moist to dry region and then remove manually
Content - Clear lymph, does not clot
• Chemical/Enzymatic - Done if large amount of necrotic tissue is to be removed, generally ea. Lining of cyst - endothelial lining
is removed this way ^
Clinical features:
• Autolytic - Occlusive or seml-occlusive dressing, hydrocollold gel used
welling with following features -
• Maggot therapy - Maggots consume only necrotic tissue in 2-3 days time by extracorr» j
digestion. Smooth
Soft
Q.5: Virchow's node Fluctuation test positive
Brilliantly transilluminant
VIRCHOW’S NODE Compressible
Complications:
Q D efinition; It is the cervical lymph node in left supraclavicular fossa
Respiratory distress
□ Supply fro m : Lymph vessels in abdominal cavity
Hemorrhage
□ Trolssler's s ig n : Enlarged hard node occurring In malignant conditions Infection -» abscess - * septicaemia
□ Named a fte r: Rudolf Virchow m tm ent:
O U se: To detect carcinoma in stomach, pancreas, etc.
preoperative injection of sclerosants -> aspiration of contents -» when capsule gets thickened
□ Differential diagnosis; by fibrous tissue, entire aggregation of cysts is excised
• Lymphoma If respiratory obstruction -> aspiration of cysts + tracheostomy
• Breast carcinoma Antibiotics
• Arm Infection .
□ Pathogenesis: Lymph drainage from most of body (thoracic duct) enters venous circulation viaW 07: Pharyngeal pouch
supraclavicular vein -> metastatic deposits block the thoracic duct -» regurgitates into Virchows
PHARYNGEAL POUCH
node -> Node enlarged.
3 Synonym: Zenker's diverticulum
0 .6 : Cystic hygroma
3 tWwf is I t : Protrusion of pharyngeal mucosa through Killian's dehiscence, which is a weak area of
CYSTIC HYGROMA posterior pharyngeal wall between oblique fibres of thyropharyngeus and transverse upper fibres of
cricopharyngeus of the inferior constrictor of pharynx
□ Synonym s:
3 Nerve supply: Thyropharyngeus - » cranial accessory nerve, cricopharyngeus - » external laryngeal
• Cavernous lymphangioma nerve
• Hydrocele of neck J Aetiology: Imperfect relaxation of cricopharyngeus -» raised pharyngeal pressure -» protrusion of
□ What is I t : Cystic swelling due to sequestration of a portion of jugular lymph sac from lympte*1 mucosa
system, during in-utero development 3 Position; Pulsion diverticulum -> starts in midline -» expands and reaches vertebrae -> deviates
Q A g e : Generally present since birth, sometimes presents in early infancy towards left side of the neck
□ S ite s: 0 Stages: '

• Posterior triangle of neck (commonest) ’ Small diverticulum points towards vertebrae

• Tongue Large globular diverticulum with a vertical opening causing regurgitation
« Cheek 3 Large pouch visible in the neck as globular swelling having a horizontal opening
• Axilla [See Fig. 1.7.1]
 470 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 471

□ Clinical features: 2 frdl&tlons '

> Dysphagia Acute/chronic urinary retention
» Sensation of food sticking at the back of mouth After orthopaedic procedures that limit movement
> Swelling in neck - Soft, smooth, tender Input - output monitoring
> Regurgitation, cough at night , Benign hyperplasia of prostate
> Gurgling noise while swallowing , incontinence
> Recurrent respiratory infections , Surgical interventions involving bladder and prostate

□ Investigations: 0 compilations:
> Barium swallow X-Ray lateral view , Bleeding
> Chest X-Ray , False passage
> CT Neck , Infection
, paraphimosis
□ Treatment:
, Urethral striclures
> Pharyngeal pouch excision + cricopharyngomyotomy
q procedure: Patient in supine position - * consent taken, procedure explained -> sterile gloves worn
> Dohlmann's endoscopic procedure of excision
external genitalia cleaned with 2% povidone iodine (ideally applied from mid-chest to mid-thigh)
> Antibiolics
sterile drape used to isolate the area -4 with help of gauge, prepucial skin is retracted beyond
□ Differential diagnosis: level of corona glandis -> once again genitalia is cleansed with povidone iodine -> 10 -2 0 m l syringe
_ > Lymph cyst loaded with 2% lignocaine - » penis held vertically and llgnocaine is inserted through external urinary
meatus into urethra -> external urinary meatus closed with thumb to avoid coming out of jelly -»
> Branchial cyst
gentle urethral massage at undersurface of penis for 5 mins to allow easy dissipation of anaesthetic
> Cold abscess in neck
jelly -» assistant gives sterile catheter -> penis with retracted prepuce held vertically to straighten the
□ Complications o f surgery: penile urethra -» gradually catheter is inserted into urethra through meatus - * urine comes out
> Pharyngeal fistula immediately in case of retention -»10-15ml distilled water used to inflate the balloon of the Folley's
> Abscess in neck catheter -» catheter is withdrawn till balloon snugly fits -» prepucial skin is retracted to prevent
paraphimosis -» catheter connected to urobag -> colour and amount of urine is noted
> Oesophageal stenosis .
> Infection (pneumonia, mediastinitis) QS: Surgical drains

Q.8: Catheterisation SURGICAL DRAINS

CATHETERISATION Q (Wat Is I t : A tube is used to remove pus, blood, or other fluids from a wound, which otherwise may
become a focus of infection
□ What is I t : A latex, polyurethane or silicon tube known as urinary catheter is inserted into a patients
bladder via the urethra, which allows urine to drain freely from bladder for collection in an uroban Q Purpose:

□ F orm s: • Prevent accumulation of fluid

• Prevent accumulation of air
• Indwelling - Permanent
• To characterise fluid
• Intermittent - Removed after each catheterisation
3 Indications:
□ Types:
• Plastic surgery including myocutaneous flap surgery
• Simple rubber catheter
• Breast surgery •
• Folley's balloon catheter -
• Orthopaedic surgery
a. 2-way
• Chest drainage after pneumothorax
b. 3-way
• Chest surgery
• Maleeot's catheter
• Infected cysts
• De - Pezzer's catheter
• Pancreatic surgery
• Gibbon’s catheter
• Biliary surgery
 472 QUEST : A Comprehensive Guide (o UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 473

Thyroid surgery external - Herniates through thyrohyoid membrane, situated in anterior third of laryngeal ventricle,
Neurosurgery ' between false cords and thyroid cartilage

Types: , Combined
Cli„lcal features:
Open - Drain fluid onto a gauze pad or into a stoma bag e.g. corrugated rubber drain (ha* k
risk of infection) ^ Swelling with following features -
Closed - Tubes draining fluid into a bag/bottle e.g. chest drain (has low risk of infection) ' , Situated in neck in relation to larynx, adjacent to thyrohyoid membrane
Active - Maintained under suction 2. Unilateral
Passive - No suction, working according to differential pressure between body cavities 3. Smooth
exterior a"d
4. Soft
Silastic - Relatively inert, induce minimal tissue reaction 5. Ovoid
Red rubber - Induce intense tissue reaction 6. Resonant/tympanic
Complications: 7 Becomes prominent while blowing, coughing, performing valsalva manouvre

High risk of infection 8. Moves up with larynx on swallowing

Damage may induce anastomotic leak 9. Boggy in feel
, pus discharged into pharynx if laryngocele gets infected
□ Special varieties:
t Hoarseness of voice
Jackson - Pratt drain
, Cough
Penrose drain
Negative pressure wound therapy 0 investigations:
Redivac drain > X-Ray neck
Pigtail drain > CTScan
Davol v Laryngoscopy
Chest tube 3 Treatment:
eneral measures : A. Internal laryngocele - Marsupial isation
To ensure drain is secure B. External laryngocele - Excision through transverse cervical incision (neck ligated, divided and
Accurately measure and record drainage output and nature, colour, etc. whole sac excised)
Monitor changes in character, volume [See Fig. 1.7.2]
Use measurements of fluid loss to assist intravenous replacement of fluids
Q.12:Chordee
□ Removal: Removed once drainage has stopped or becomes < 25 ml/day
CHORDEE
Q.10: Preparation o f Jaundice patient for surgery
0 What is I t : Bending of glans penis, which is more prominent during erection
A : See Section - 1, Segment-A, Paper-1,2010, Q.3 (Page No. 26)
Q.11: Laryngocele 0 Aetiology:
• Hypospadius
LARYNGOCELE • Epispadius
• After circumcision, if more skin cut over ventral aspect
□ What Is I t : Narrow necked, air - containing diverticulum, arising due to herniation of laryngeal
mucosa 3 Types:
□ Common In : • Dorsal
• Glass blowers • Ventral
• Professional trumpet players 3 Pathogenesis: In hypospadius, the urethra is situated proximally than normal in the undersurface ol
• People with chronic cough penis, while in epispadius it is situated proximally and upper surface of penis. A fibrous band is
formed proximal lo these openings, which contracts during erection giving rise to chordee.
□ Types:
[See Fig. 1.7.3]
• Internal - Confined within larynx, may displace and enlarge the false vocal cord
 474 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 475

□ Treatment:
Bony mass above clavicle
• Chordee due to hypospadius -► correction during the staged operation for hypospa(li Poor capillary refilling
• Chordee due to circumcision => Stilbestrol IUs Absent or feeble pulse
6mg daily Adson's test positive (Hand raised above head, after feeling radial pulse -» patient asked to take
’i ' deep breath and turn head to same side -> change in pulse noted)
Fibrous tissue excised Roos test positive (patient not able to raise arm above shoulder, for longer time in affected side
i and drops the hand down)
Skin graft Elevated arm stress test
Q.13: Thoracic outlet syndrome Hyperabduction manouvre

THORACIC OUTLET SYNDROME Investigation:

X-Ray neck, cervical spine
□ What Is i t : Syndrome complex occurring due to n eurovascular bundle compression in thoracic
Subclavian angiogram
0 Spaces o l thoracic o u tle t: ****
CT angiogram _
Space Bounded by Contents CT neck
1. Scalene triangle y Scalenus anterior >
Subclavian artery Nerve conduction studies
> Scalenus medius y Brachial plexus EMG
#■ 1st rib
q Treatment:
2. Costoclavicular space > Scalenus medius > Subclavian artery
> Clavicle y Subclavian vein J .
> 1st rib y Brachial plexus Conservative Surgical
Costoclavicular space
> Avoid weight lifting y Transaxillary (ROOS)
0 Etiology:
y Exercise - (1st rib and cervical rib excision)
Fracture clavicle or 1st rib
1. Neck stretching > Supraclavicular approach for cervical rib,
Long transverse process of C7 vertebra 2. Breathing soft tissue excision, scalenectomy
Cervical rib 3. Postural
Exostosis y Drugs -
Scalene muscle hypertrophy 1. analgesics
Anomalous insertion of scalene muscle 2. antidepressents
□ Symptoms: 3. muscle relaxants
> Physiotherapy

f 0.14: Cervical rib

CERVICAL RIB
Neurological Vascular
y Paraesthesia 3 What is i t : Extension of costal element (anterior part) of transverse process of C7vertebra more than
Claudication
> Pain - shoulder, arm 2.5 cm
Gangrene
forearm, finger Ischaemic ulcer 3 Sex predilection : F » M
Weakness - forearm, hand 2 Laterality: Right sided
> Occipital headache ^ Types:
Signs : * Complete bony
• Pulsatile swelling in supraclavicular region + thrill and bruit • Complete fibrous
• Scalene muscle tenderness • Partial bony
* Combined
 SOLVED SHORT NOTES OF SEMESTERS 477
476 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Subclavian angiogram
□ Pathology:
“ Olh0fs - Blood sugar, lipid profile
Cervical rib narrows scalene triangle
2 Treatment:
I
Conservative -
Compression of subclavicular artery, C8 and T, nerve
' (Same as thoracic outlet syndrome)
I
Angulation of subclavian artery * ^Sym ptom atic without arterial compression -> Scalenectomy + extraperitosteal resection of
I cervical rib ± resection of 1st rib
Constriction of artery at sile where artery crosses cervical rib > Symptomatic with arterial compression scalenectomy + extraperitosteal resection of cervical
i rib ± resection of 1 st rib + subclavian artery reconstruction ± graft
Eddie's current created in blood flow y Gangrenous toe -» amputation
I 0 pim ential diagnosis
Sudden release of pressure distal to narrowing
. Cervical spondylosis
I
, Syringomyelia
Post-stenotic dilatation => Venturi phenomenon
, carpal tunnel syndrome
I
, pan coast tumor
Stasis of blood
I
0. 1$: Cleft Palate
• Thrombosis -> Embolus -> May extend into subclavian artery CLEFT PALATE
I
Ischaemia in hand and forearm q Cause:
Failure of fusion of two palatine processes
Digital gangrene _ Defect in fusion of lines between premaxilla (developed from medial nasal process) and palatine
□ Clinical features: processes of maxilla

A. Features In neck - 3 Types:

• Hard fixed bony mass in supraclavicular region Type I — Complete
• Palpable thrill, audible bruit above clavicle Type I I — Incomplete
B. Neurological features (most common presentation) - Tingling and numbness in little finger, Typella— Bifid uvula
medial side of hand and forearm. Type lib — Bifid soft palate
C. Vascular manifestations (most problematic manifestation) - Type lie — Bifid soft palate + posterior part of hard palate
• Wasting of thenar, hypothenar and forearm
Q Classification:
• Pain - More during work, exercise and relieved by rest
• Digital gangrene
f ” Cleft o l secondary palate Others
• Adson's test positive (Hand raised above after feeling radial pulse -> patient asked to lake Cleft of primary palate
deep breath and turn head to same side -* any change in pulse noted) (In front of incisive foramen) (In front of incisive foramen)
• Roos test positive (patient not able to raise arm above shoulder, for longer lime, in #*
affected side and drops the hand down) r * Complete Incomplete Submucous
Complete Incomplete
• Elevated Arm Stress Test ( Modified Roos Test ] (Arm elevated above shoulder, with elbow I " I
(absence ol (rudimentary
fully stretched - » rapid movement of finger - » fatigue on the side where cervical rib present) Cleft of both Cleft lip and
premaxilla) premaxilla)
□ Investigations: primary and cleft palate
secondary together
• Chest X-Ray r " i' palates
» X-Ray of neck Unilateral Median Bilateral
• Arterial Doppler of subclavian artery, upper limb
 478 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 479

□ Aetiology: | • j Types of urinary bladder tu m o r:

□ Associated syndrom es: See Section-1, Segment-C, Paper II, 2013 supp., Q.i _ c.
I [Page No. 417] ^
□ Problems faced:
□ Clinical examination :
I. Non-invasive tumor without involving lamina propria
Torch focussed inside oral cavity.
When free margin of septum visible, it is bilateral
□ Treatment:
A Millard’s criteria -
• 10 pound weight
• 10 gm % Haemoglobin
• 10 weeks old
B. Timing -
II. Non-invasive tumor involving lamina propria
Between 1 0 - 1 8 months
• Early repair -> retarded maxillary growth due to trauma to growlh centre and periostea
of maxilla
• Late repair -» speech defect
C. Pre-operative preparation -
• Nutrition maintained
• Infection controlled
• Spoon feeding practised
0. Operation -
Wardill - Kilner push-back operation
• Abnormal insertion of tensor palati released
• Mucoperiosteal flaps raised in palate which is sewed together
• If maxillary hypoplasia -» osteotomy of maxilla
• With orthodontic help, teelh extraction and alignment of dentition done
• Hook of pterygoid hamulus is fractured to relax tensor palate muscle to relieve tension on
suture line IV. Carcinoma-in-situ
• Palatal defect closed using 3 layers
E. Post-operative management -
• Regular examination of ear, nose, throat during follow - up period
• Hearing aids * These are the different types of transitional cell carcinoma (which Is the commonest)
• Control of otitis media * Other types - Adenocarcinoma
• Speech therapy/pharyngoplasty/veloplasty - Squamous cell carcinoma
• Dental problems corrected
3 TNM Staging:
0.16 : Treatment of urinary bladder tumor Carcinoma-in-situ
\ -
T. ~ Non-invasive papillary tumor
TREATM ENT O F URINARY B LA D D ER TUM O R T, - Invades only lamina propria
T, - Invades muscularis propria
Treatment depends on the type of tumor
T, - Invades perivesical tissues
\ ~ Invades surrounding organs, abdominal wall
480 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiotogy
SOLVED SHORT NOTES OF SEMESTERS 481

N„ - No nodes
N, - Single regional nodal-spread < 2cm size Ctrcinoma o f tongue
N2 - Single regional nodal-spread 2-5cm size
or Multiple regional nodal-spread < 5cm size CARCINOMA OF TONGUE
M0 - No distant spread
l i e n e e : Accounts for more than hall of all intra oral carcinomas
M, - Distant spread present
j Sexpredilection :M = F
Treatment:
j predisposing factors:
• T „,N 0,M0-
, Smoking
Repeated cystoscopy + Excision biopsy of unstable areas
, Spices
• t , . n 0, m 0- , Betel nut chewing
> Cystodiatbermy and endoscopic transurethral resection of tumor , Chronic superficial glossitis
> If large tumor - » tumor removed Iransvesicaily , Sepsis
> Care taken to saucerize deeply into the wall of bladder to remove completely the base . Sharp tooth
tumor , Syphilis
> Follow up - Regular cystoscopies until bladder has been clear for 5 years , Chronic hypertrophic candidiasis
> Alternative approach for large papillary tumor -> Helmstein balloon degeneration fnm^ < Leukoplakia
pressure necrosis of summit of tumor) < Erythroplakia
> Intravesical chemotherapy - . Oral submucosal fibrosis
Uses - BCG (120 mg in 150 ml N.S - weekly x 6 weeks)
a Types:
- Mitomycin C
- Adriamycin Gross -» 1. Ulcerative
2. Warty growth or papillary
> Systemic chemotherapy -
3. Indurated plaque
Uses - Cisplatin, Adriamycin, 5-FU, Mitomycin
4. Fissure
. T2,N 0/N 1.M#-
Histologically -» 1. Squamous cell carcinoma (commonest)
>If solitary tumor with base < 4-5 cm
2. Adenocarcinoma
-Transvesical excision + Curative interstitial radiotherapy (using implantation of goldgw
3. Melanoma
( Au 198 ] or radioactive tantanium wires [ Ta 182 ]
> If solitary tumor, situated at fundus of bladder with margin of clearance 2.5 cm - ] Sites:
- Partial cystectomy + Intravesical / systemic chemotherapy + Radical deep external bean
• Anterior 2I3rd at or near edges (50%)
radiotherapy (45 Gy - using cobait (>0) • Posterior V3 rd (20%)
. T,, N0/N ,,M 0- • Tip (10%)
> If age < 65 yr -» Preoperative radiotherapy (2000 - 4000 rads) + Radical cystectomy+prt« • Ventral surface (9%)
node dissection • Dorsum (7%)
> If age > 65 yr -> Radical radiotherapy (6000 rads over period of 6 weeks or more) 3 Spread:

A- Local spread -» CA tongue

Viable tumor demonstrable Viable lumor not demons®*

i I Anterior 2/} rd Posterior’ /3 rd
Salvage cystectomy Nothing more done I I
Genioglossus muscle • Tonsil
CT Scan is a must Floor of mouth • Pharynx | Corresponding side
* In radical cystectomy In females, extended hysterectomy done Mandible S 1
• Epiglottis
tits —J
• Soft palate
After surgery, urinary diversion done
• Larynx
• Cervical spine
482 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 483

B Treatment for primary growth -

B. Lymphatic spread -»
• Tip ol tongue -> Lymphatics through floor of month -» Submental nodes , Growth < 2 cm size -» wide excision alongwith a wide margin of mucosa atleast 1 cm
wide (Brachy therapy may be given)
•I ^ , Growth > 2 cm size in -» Preoperative radiotherapy (Interstitialradiotherapy)
Juguloomohyold gland Jugulodigastric group of UpWf
anterior s/3rd of tongue 4 Fails
. Anterior % rd of tongue - * Submandibular nodes Deep cervical nodes Hemiglossectomy •
r Jugulodigastric group of upper deep cervical nodes , Growth < 2 cm in -> Teletherapy (with cobalt BO)
posterior V3rd of tongue I Fails
• Pos,erlor V d °* ,on9ue 1 j ugu|oomohyoid gland
Total glossectomy
t Central lymphatics from , Growth > 2 cm in External beam irradiation
either side of median raphe - * Pass vertically downwards in midline of tongue b e l w ^
posterior '/3rd of tongue 1 Fails
genioglosus
Total glossectomy
Jugulodigastric group of lymph nodes
. Growth in tip of tongue -> Wide excision + Radiotherapy (according to size as mentioned
above)
□ Clinical features: ■ If mandible involved -» Hemimandibulectomy
• Age - More than 50 years • Reconstruction of tongue and other area by flap surgery or skin graft
• Painless lump/ulcer in tongue g Treatment for secondary growth -
• Pain develops later due to infection • Same side palpable, mobile lymph nodes -> radical neck block dissection
> Pain referred to ear If lingual nerve involved • Bilateral mobile lymph nodes - » one side radical block; other side functional block dissection
► Pain on swallowing in case of CA posterior third of tongue or supraomohyoid block dissection
. Excessive salivation - Often blood stained • Fixed lymph nodes - » deep X-Ray therapy
• Foetor oris ‘[Wide excision or hemiglossectomy + hemimandibulectomy + radical neck dissection = Commando
• Dysphagia operation)
• Ankyloglossus 0. Chemotherapy -
• Inability to articulate • For-palliation
• Hoarseness ol voice • Also given in post-operative period
• Lump in neck - due to enlarged cervical nodes • Price-Hill regimen used
• Ulcer with following features E. Palliative Treatment -
- >arge amount of induration
• Large fixed lymph nodes deep X-Ray
- bleeds on touch • Failure of radiotherapy and surgery -» Cryo surgery
- everted • Extreme pain due to advanced growth -» blocking of trigeminal nerve with 5% phenol
- may cross midline
lit; Massive blood transfusion
Q Investigations :
• Edge biopsy SSIVE BLOOD TRANSFUSION
• Indirect and direct laryngoscopy
What Is I t : Replacement / transfusion of blood equivalent to patient's blood volume in 24 hour
• CT Scan
• FNAC of lymph nodes • M u tto n s : .
• Chest X-Ray ' Severe trauma
• Orthopantomogram ' Primary hemorrhage

Q Treatment: Volume transfused:

*Mt* -» 5 - 6 litres %
A Ancillary treatment -
« Mouth kept clean by antiseptic moulh wash Wldren -» 85 ml/kg
. Antibiotic started after culture and sensitivity tests Averse effects :
. Treatment of caries tooth, gingivitis ’ Coagulopathy
• Syphilis should be excluded ' Citrate toxicity

I
 SOLVED SHORT NOTES OF SEMESTERS 4S5
494 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

• ARDS
•* FROST-BITE
• Infection
• Poor oxygen delivery ll s ll: Medical condition where localised damage Is caused lo skin & other tissues due to freezing
• Hypothermia
• Hypocalcaemia j ^ s t a g e s called : F M p
• Hyperkalaemia
3
• Acidosis Farthest from heart
Q.19 : Blood fractions | Those with large exposed areas

BLOOD FRACTIONS j ClF:

First Degree > Called frost nip
Name Preparation Storage Indications""'' ' > Affects surface of skin
• Packed cell Centrifuging whole blood @2000-3000g 1-6"C for •
Chronic anaemia " > Initially itching and pain
for 15 mins 35 days •
Old age y Then skin develops white, red, yellow patche and become numb.
•
Children
> Long term insensitivity to both-heat & cold.
• Platelet rich plasma — do— •
Bum
•
Hypovolemia , Second Degree > Skin may freeze and harder.
•
Severe protein loss > Deep tissues not affected
• Human albumin (4.5%) Repeated fractionation of plasma 4°C Several , cirrhosis ' > Blisters 1-2 days after becoming frozen
months Edema/
> Heal in 1 month
nephroticsynd:®* > Area become insensitive lo both hot and cold.
(Used as volume expand,
• Fresh frozen plasma Freshplasma rapidy frozen (conlainsdot­ -40°Cfor • Severe liver tisease ' , Third and foruth Degree
(FFP) ting factors) 2 years • DIC > Musde, tendons, blood vessels, nerves all freeze
[1 unit FFP=3% rise in clotting factors] • Congenital clotting (act*
y Skin hard, waxy
deficiency
> Use of area temporarily lost
. Following warfarin Iherap,
• Cryopredpttate Visible white supernatant fluid when FFP • Haemophilia A > Loss of sensation due to nerve damage
—do—
thawed at4°C (factor VIII + Fibrinogen) • Von Willetxarxfs cfceas« > Fingers and toes may be ampuled if area becomes gangrenous
• Fibrinogen Orgonic liquid fractionation of plasma Dried form « DIC > May fall off if untreated.
• Afibrinogenaemia
# 0 buses:
• Platelet concentrate Centrifugation of platelet rich plasma • Thrombocytopenia
• Drug Induced hemorrhags • Wet clothes
• Prothrombin complex From pooled plasma which contains fac­ • Reversal of warfarin . Atmosphere temperature below freezing point
concentrate tors II, IX, X dose • Inadequate clothing
i Cramped positions
Q20 : Causes o f Buttock swelling
• Extreme cold
CAUSES OF BUTTOCK SWELLING • Medication
• Exposure to liquid nitrogen and other cryogenic liquids
□ Buttock Injury • Tight cfothing or boots
a Fracture
Q Risk factors:
a Hematoma
□ • DM
Abscess (See Short Note •*- Ischiorectal Abscess)
□ Scar tissue • Peripheral neuropathy
a • Use of beta blockers .
Malignancy
□ Sebaceous cyst (See Short Note — Sebaceous cyst) 3 Treatment: •
□ Lipoma (See Short Note — Lipoma) .* Patient shifted to warm environment
u Insect bite • Passive warming
a Arteriovenous fistula involving lower limb
 SOLVED SHORT NOTES OF SEMESTERS
486 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

• Active warming - » immersing injured tissue in water bath

• Warm clothing
• Splinting and / or wrapping frostbitten extremities ) Diffuse (Pseudolipoma)
• Debridement and / or amputation of necrotic tissue is usually delayed \ Multip'e
“Frozen in January, amputate in July” , ciiSlf!c*<lonbased° n :
0 2 2 : Tendon transfer ,S«e •
y Subcutaneous
TENDON TRANSFER > Submucosal
Subserosal
0 What is I t : Transfer of one tendon from its existing site to another site where its function is reni
> subsynovial
the newer site rtl1®
y Subperiosteal
□ Indications: > Subfascial
• Ulnar, median, radial nerve, spinal cord injury causing muscle paralysis > intraarlicular
• CNS disorders — CP, CVA, Spinal muscle atrophy y Intramuscular
• Hypoplastic thumb i, intermuscular
• Birth brachial plexopathy j. Extradural
0 Procedure : , Content
V Neurolipoma (painful lipoma contains nerve tissue)
Origin of muscle, nerve supply, blood supply left in place
j, Naevolipoma (lipoma contains excessive vascularity)
i > Fibrolipoma (lipoma contains fibrous tissue)
Tendon insertion detached and re-inserted into the required site
BClinical features:
□ Requisites :
. A g e -A n y age
• Tendon should be able to acquire the function at newer site . Swelling with following features —
• Function of transferred tendon should be maintained by other tendons y Lobulated, smooth
□ Complications: > Painless
• Infection ' > Non-tender
• Hemorrhage > Overlying skin free
> No increased temperature
• Surgical scar
> Edge soft, compressible (“slip" sign)
< Splint / cast immobilisation
V Semifluctuant (as fat In body temperature remains In semiliquid condition)
□ Example: > Trans illumination test may be positive (even though it is not a cyst)
UJnar claw hand > Freely mobile over deeper structures
(Tendon of Flexor digitorum superficialis lumbrical canal of digits) 0 Complications:
Q.23 : Ublqultus tumor or Universal tumor or Lipoma • Myxomatous changes
• Liposarcoma
UBIQUITOUS TUMOR • Calcification
OR • Saponification
UNIVERSAL TUMOR OR LIPOMA 3 Treatment:
Excision (Enucleation)
□ What Is i t : Benign tumor arising from yellow fat cells
024: Invertogram
□ S ite : Can occur anywhere except brain (hence the name) but commonly subcutaneous tissue o!-
INVERTOGRAM
• trunk
• nape of neck See Section - 1 , Segment - C, Paper-1,2013, Q.4 “ARM" (Page 303]
• limbs
^ Purpose: Used to investigate extent ol defect in anal or rectal atresia.
□ Speciality: Commonest benign tumor
 488 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 4 Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 489

□ Procedure: Anus is marked with a radioopaque marker -» baby inverted - » lateral

, OR®'1 Pain,ul1
□ Inference: Air In rectum rises to highest point, indicating extent of atresia * Accompanied by involuntary straining

0.25 : Barrett's esophagus , 'ptferential diagnosis:

, Crohn’s disease
BAR R ETT’S ESOPHAGUS , ulcerative colitis
□ Synonym : Columnar epithelium lined lower oesophagus (CELLO) , Rectal abscess
, Colon cancer
□ What Is I t : Metaplasia in mucosa of lower part of oesophagus due to GERD
, Colonic infection
□ P athology: Normal stratified squamous epithelium lining replaced by simple columnar en.k , Irritable bowel syndrome
with goblet cells. “ ""eSwr,
, Coeliac disease
□ Site : Lower part of oesophagus , pelvic floor dysfunction
□ Speciality: Prone to malignant transformation a Infection — Shigellosis, amoebiasis
□ Types:
•
•
Long segment -> > 3 cm
Short segment -» < 3 cm
,
n Treatment :

,
Treatment of causes
Methadone
□ Histological classification:
O f f : AUDI
• Intestinal - » contains goblet cells
ANDI
• Junctional -> contains mucus glands
• Gastric -» contains parietal cells, chief cells q Full from: Aberrations of Normal Development and Involutions of the breast
Q Clinical features: 3 What Is i t : Includes varierty of b enign breast disorders occurring at different periods of reproductive
• Heartburn periods in females.
• Fatty dyspepsia 3 Aetiology:
• Epigastric pain • Relative hyperoestrogenism
• Regurgitation — due to (I) increased oestrogen secretion
• Nocturnal reflux (ii) deficient progesterone production
• Dysphagia • Abnormal prolactin secretion
• Hematemesis • Inadequate essential fatty acid intake
□ Complications: • Excessive caffeine ingestion
• Dysphagia • Psychonecrosis
• Hemorrhage Aberration Diseased status
Age
• Ulceration
| Early reproductive 1. Fibroadenoma Giant fibroadenoma (> 5 cm)
• Stricture age (15-25 yrs.)
• Adenocarcinoma of O-G junction 2. Juvenile hypertrophy of stroma Multiple fibro-adenosis
□ Treatment: Mature reproductive Generalised enlargement due to raised Fibrocystadenosis
age (25-40 yrs.) hormonal effect
• Endoscopic mucosal resection and biopsy
• PPI ^ Involution age A Lobular involution Cystic disease of breast
(40-55 yrs.) Macrocysts
• Antireflux surgery for GERD
• Argon beam coagulation G. Ductal involution • Periductal mastitis
• Ductal dilatation • Non-lactational abscess
• Laser ablation
• Nipple discharge • Mammary duct fistula
0.26 : Tenesmus • Bacterial infection
C. Epithelial involution
TENESMUS
Epithelial hyperplasia and atypia
□ What Is i t : Feeling of incomplete defaecation
^ Pathology;
O Clinical features:
* Gross -s > Rubbery consistency
• Inability / difficulty to empty bowel even if bowel contents have already been evacuated
> While or yellow areas on section
 490 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 491

Q Histopathology: f corticosteroid therapy

• Fibrosis Hyperaldosteronism
• Cysts , Low protein intake
• Hyperplasia , Administration of hypertonic fluids-mannitol
• Papillomatosis Cause; Compromised regulatory mechanisms for sodium handling resulting in high total body sodium
Q Variant - Sclerosing adenosis and a consequent increase in extracellular body weight

□ Clinical features: Q Clink*1features :

, Gain in weight
• Mastalgia - Cyclical
, Ascites
- Non-cyclical
, Dyspnoea
• Breast lump with following features -
, pedal edema
> Multiple
, Bounding pulse
> Nodular
, Audible S3
> Inseparable among themselves
, Hypertension
> Easily movable within breast
, CVP raised
> More obvious when examined between thumb and fingers
• Distended JVP
>» Not adherent to pectoral fascia or skin
t Oliguria, azotemia
□ Complication:
P Treatment:
• Epithelial hyperplasia may lead to carcinoma , Diuretics
□ ■Treatment: • Vasodilators
A) Cyclical mastalgia - • Ultrafiltration
• Assurance • Oral vasopressin antagonists
• Breast support • Adenosine A-1 receptor antagonists
• Tab Danazol 200 - 400 mg daily • Monitor fluid input-output
• Dialysis for acute cases
• Bromocriptine for 3 months
• Tamoxifen 029: Osteogenesis imperfecta
• Medroxyprogesterone
B) Non-cyclical mastalgia - OSTEOGENESIS IMPERFECTA
• Non-steroidal analgesics !J Synonym:
• Local anaesthetic injection • Brittle bone disease
C) Surgery if (Excision biopsy) -> a) Failure of conservative management • Lobstein syndrome
b) Intolerable pain 0 What is i t : Congenital bone disorder characterised by brittle bones that are prone to fracture
c) Swelling persists inspite of conservative treatment 0 Delect: Deficiency of Type-1 collagen resulting in defective connective tissue
Q28 : Volume overload Q Genetic m utation: COL 1A1 and COL 1A2 genes
0 Types: 8
VOLUME OVERLOAD
Q Clinical features:
O Synonym : Hypervolaemia • Bones fracture easily
□ What Is I t : Excess fluid in blood • Loose joints
• Poor muscle tone
□ Conditions:
• Slight spinal curvature
• Congestive cardiac failure
• Slight protrusion of eyes
• Liver failure
• Blue grey sclera
• Kidney failure
• Early loss of hearing
• Excessive intake of sodium
• Dentinogenesis imperfecta (present in IB)
 492 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 493

□ Complications: features o f m alignancy:

• Respiratory failure
Hemorrhage
• Intracerebral hemorrhage High Ki-67 positive cell
□ Diagnosis: Necrosis
• Skin biopsy Nuclear DNA ploidy v
• DNA testing High PASS (Phaeochromocytoma of Adrenal gland Scale Score)
• Prenatal diagnosis by amniocentesis (raised inorganic pyrophosphate) Capsular and vascular Invasion
□ Treatment: (Nocure) High neuron specific enolase (NSE)
• Bisphosphonate Clinical features:
• Surgical correction of bones
Severe headache
• Antibiotics
Dyspnoea
• Physiotherapy
Weakness
□ Differential diagnosis:
Pallor
• Rickets Persistent or paroxysmal hypertension
• Child abuse
Blurred vision
• Osteomalacia
Abdominal mass -
0.30 : 10 percent tumor (a) Smooth
(b) Cross midline
10 PERCENT TUMOR
(c) Not move with respiration
□ Synonym : Phaeochromocytoma • (d) Non-mobile
(e) Palpitation may cause fluctuation in blood pressure
□ What Is i t : Tumor arising from chromaffin cells
□ Pathology: Associated w ith :
• Adrenal medulla (commonest) . MEN lla or MEN lib
• Extradural chromaffin tissue (organ of zuckerkandl) i Renal cell carcinoma
• Bladder . Von-Recklinghausen disease
□ Nature : . Von-Hippel Lindau disease
« CNS and retinal haemangioblastoma
• Soft brownish-grey-pink tumor
• Secretes the following : Investigations:
(a) Norepinephrine or other catecholamines . IVU
. u rinary 24 hour VMA excretion greater than 7 mg%
(b) VIP
(c) Calcitonin • USG Abdomen
(d) ACTH • MRI
(e) PTH related polypeptide « CT Scan
□ Types: • Arteriography •
• Benign (90%) • MIBG
• Malignant (10%) Treatment:
□ Why c a lle d ' 10 percent' tumor : BP controlled by o-blocker
• 10% familial I
• 10% childhood (i-b looker
• 10% multiple 1
• 10% bilateral • Adrenalectomy (with sodium nitroprusside i.v. infusion)
• 10% malignant I
• 10% extradural Specimen sent for dichromate staining which stains the specimen brown
• 10% calcified
• 10% not associated with hypertension
494 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 495

Q.31 : Whipple's Triad > Proinsutin level > 24% of total insulin
•p. c-peptide level raised (> 1.2 ng/ml) + glucose level <40 mg%
WHIPPLE’S TRIAD yRI _ To localise tumor
□ What Is I t : Characteristic of insulinoma , coeliac angiogram
, insulin provocation test
□ Triad:
, Endosonography

Attack of hyperglycaemia with Attacks consist Attacks promptly relieved 2 Treatm ent :
serum blood sugar below principally of by feeding or parenteral , Enucleation
50mg/dl / | \ administration of glucos:e , Control hypoglycaemia - Diazoxide, betablockers, phenytoin
Stupor Confusion loss of , Octreotide - To reduce insulin secretion
consciousness , Calcium channel blockers
and are related to , Streptozotocin
fasting and exercise
nj2 : Post operative pulmonary complications

What Is Insulinoma : POST OPERATIVE PULMONARY COMPLICATIONS

• Insulin producing adenoma of fl cell
g Risk factors:
Speciality: . Age - Extremes
• Commonest Islet cell tumor . Sex - Male
A ge : • Lifestyle - Smokers, obesity
i Chronic diseases - Asthma, TB, COPD, chronic bronchitis
• >45 years • Type of surgery - thoracic and upper abdominal surgeries
Site : < Operative complications - Anaesthetic complications, aspiralion, etc
• Post-operative problems - Septicaemia, DVT, pulmonary embolism
• Equal distribution in head, tail and body of pancreas
0 Pulmonary com plications:
Pathology:
• Bronchitis
• Encapsulated, firm, yellow-brown nodules • Bronchopneumonia
• 70% solitary, 10% multiple • Lung abscess
Clinical features : • Lung collapse
• Abdominal discomfort • Alkalosis
• Sweating • Pleural effusion/empyema
• Weakness . ARDS
due to release of epinephrine • Respiratory failure
• Hunger
caused by hypoglycaemia
• Trembling 0 Investigations:
• Tachycardia • Chest X-Ray
« Weight gain (due to over eating) • Arterial blood gas analysis
• Permanent neurologic deficit 3 Treatment:
• Cerebral symptoms - (due to slower decrease in blood sugar) • Suction-aspiration of tracheobronchial secretions
- Headache 4 Ventilator support with endotracheal intubation
- Convulsion • Tracheostomy
- Coma • Respiratory physiotherapy
- Visual disturbance • Antibiotics
- Mental confusion : Complications o l Blood Transfusion
Investigations:
COMPLICATIONS OF BLOOD TRANSFUSION
• Insulin radioimmunoassay
> Increase in plasma insulin level (> 7p U/ml) •**) Transfusion reactions:
> Insulin-glucose ratio > 0.3 ' Incompatibility- (most important)
 496 QUEST : A Comprehensive Guide io UG Surgery, Orthopedics 8 Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 497

> Causes are -» (a) Incompatible transfusion Haemoglobinurea on urine analysis

(b) Transfusion of blood after expiry date , indirect Coomb's test positive
Prolonged prothrombin time
(c) Transfusion of blood already haemolysed by shaking, over-free,;,
heating ^ , Reduced fibrinogen level
, Raised serum lactate dehydrogenase
> This occurs mainly due to -
, Raised blood urea nitrogen
(a) Negligence in looking at label of blood bottle and matching j; v
, Raised serum creatinine
requisition paper
(b) imperfect grouping and cross - matching p Clinical findings:

• Pyrexia! reaction - , Fever + rigor

, Headache
> Causes are - (a) Improperly sterilized transfusion sets
, Nausea, vomit
(b) Transfusion of infected blood
, Pain in loin
(c) Presence of ‘pyrogens' in donor apparatus
• Tingling sensation in extremities
(d) Very rapid transfusion of blood •
, Dyspnoea
• Allergic reaction -
, Diminished urine output
Occurs due to allergic reaction to plasma product in donor's blood
• Jaundice
• Immunological sensitisation - • Renal failure features
This occurs in patients who have received blood transfusion in recent past,, occurring due b
Q Treatment:
development of antibodies against white blood cells and platelets.
• Immediate halt of transfusion
(B) Transmission of diseases:
• Bed rest
• • Bacterial- (1) Syphilis; (2) Yersinia
• Fresh specimen of blood and urine to be sent to laboratory along with rejected bottle of blood
• V ira l- (1) Serum hepatitis; (2) HBV, HCV; (3) HIV; (4) CMV; (5) EBV
. Transfer to ICCU
• Parasite - (1) T-cruzi; (2) Malaria
• Moist oxygen inhalation @ 4 It/min
(C) Reactions due to massive transfusion : « CVP line done
• Due to transfusion components - • i-v fluid infusion
> Acid-base imbalance (metabolic alkalosis, as most of the citrate present as sodium cHraie, • 10 ml of isotonic solution of sodium lactate + 10 ml of saturated solution of sodium bicarbonate
becomes sodium bicarbonate when citrate is consumed) injected intravenously
> Iron overload • Diuretics - » furosemide i.v.
> Haemochromatosis • Mannitol injected i.v.
> Hyperkalaemia (due to shift of potassium out of RBC because of low temperature of storage] • Antipyretics and analgesics
> Citrate intoxication • Corticosteroids (Hydrocortisone 100 mg i.v.)
• Hypothermia - « Epinephrine (for anaphylaxis)
(as in emergency conditions, blood is rushed directly from refrigerator to patient) • Diphenhydramine (to treat urticaria)
• Vasopressors (to maintain SBP)
• Coagulation failure -
• Dialysis in extreme cases
Caused by - (a) DIC; (b) Dilutional thrombocytopenia; (c) Dilution of clotting factors
0J5: Myopectineal orifice
(D) Complications of over-transfusion :
Congestive cardiac failure (mainly occurs in whole blood transfusion given to chronic anaemic patienty
MYOPECTINEAL ORIFICE
(E) Complications of intravenous fluid administration:
Importance: Site of indirect, direct inguinal, femoral and some interstitial hernias
(a) Air embolism; (b) Thrombophlebitis
3 Function:
Q.34 : Mismatched blood transfusion - management
• Passageway for testicle to reach scrotum
M ISM ATC HED BLO O D TRANSFUSION - M AN A G E M E N T • Passageway for the great vessels to lower exremity
□ Investigatory findings: Boundary;

• Reduced haemoglobin • Medially -> Lateral border of rectus muscle

• Raised serum bilirubin, indirect bilirubin • Laterally - t iliopsoas
 498 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 499

• Superiorly -> Arching fibres of transversus abdominis and internal oblique

Cough impulse present (Morrissey's cough impulse)
• Inferiorty -> Cooper ligament
" venous hum audible on auscultation
□ Protected b y : Associated w ith :
Combined lamina of the aponeurosis of transversus abdominis and the fascia transversalis Varicose veins
□ Divided b y : 3 'investigations:
Anteriorly -> Inguinal ligament
Posteriorly -» Iliopubic tract
,
,
USG
Duplex scan
□ Perforated by : j Treatment:
Superior part -» Spermatic cord , juxtafemoral flush ligation of saphenous vein + below knee stripping of the vein
Inferior part -» Femoral vessels 3 Differential diagnosis:
0.36 : Isometric exercise , Groin lump causes like femoral hernia
Blood component therapy
ISOMETRIC EXERCISE
□ Synonym; Isometrics BLOOD COMPONENT THERAPY
□ What Is I t : Type of strength training in which the joint angle and muscle length do not change during ^Section - 1 , Segment - D, Qs. 19 “ Blood Fractions" (Page No. 484)
contraction
□ Position during exercise: Static 0J5 ; Treatment o f hypercalcemic crisis In a patient o f hypothyroidism.

□ Types : . TREATMENT OF HYPERCALCEMIC CRISIS IN A PATIENT OF HYPOTHYROIDISM

. • Overcoming Isometric - Joint and muscle work against an immovable object
■ Admission in ICCU
• Yielding isometric - Joint and muscle are held in a static position while opposed by resistance
• Immediate sedation using Morphine/Pethidine
□ Resistance In Isometric exercise : . Moist oxygen inhalation
• Body's own structure and ground < i.v. fluid administration
• Free weights, weight machine • Control of hyperpyrexia - Tepid sponging/ice pack
• Structural items • Tab propylthiouracil
• Pressure-plate type equipment . 600 mg stat -* 200 mg 8 hourly daily
□ Medical u se s: OR
• To detect heart murmurs - Murmur of MR gets louder as compared to murmur of AS Tab Carbimazole
• To prevent disuse syndrome 60 mg stat -> 20 mg 8 hourly daily
• Prevent muscle atrophy experienced by astronauts living in zero gravity • Potassium Iodide - 5 drops 6 hourly
• Tab Dexamethasone - 2 mg 6 hourly i.v. .
□ Comparison with dynamic exercise:
• Tab Propranolol - 2 mg i.v. 4 hourly (to control tachycardia)
• Isometric exercise increases strength at specific joint angles of the exercises performed and
• Tab Diazepam - 1 0 mg/lab - 1 tab twice daily
additional joint angles to a lesser extent
• Tab Digitalis (to control atrial fibrillation)
• Dynamic exercise Increases strength throughout the full range of motion
• Antibiotics
Q .3 7: Saphena varix 5<0: Hirschprung’s disease
SAPHENA VARIX
HIRSCHPRUNG'S DISEASE
□ Synonym: Saphenous varix J Synonym: Primary megacolon
□ What Is I t : Dilation of saphenous vein at the saphenofemoral junction in the groin ^ What is I t : Congenital condition occuring in newborn, mostly leading to intestinal obstruction
□ Cause : Valvular incompetence J O o g e n e s is : Gene mutation in Chromosome 10, rarely 13
□ Clinical features :
• Bluish tinge ailure of migration of neuroblasts from the vagal nerve trunks
• Soft, compressible Aetiology; Absence of ganglionic cells ol pelvic para-sympathetic system in Auerbach's plexus and
• Disappears on lying down ^issner’s plexus
 SOLVED SHORT NOTES OF SEMESTERS 501
500 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

/$er patient attains 10 kg weight, definite procedure done -

□ Sites Involved:
’ excision of agangfionic segment
• Anus
(b) coloanal anastomosis
• Rectum (C) closure of colostomy
• Internal sphincter [procedures used -
□ Zones: [See Fig. 1.7.4] > Soave's mucosectomy
□ Types: > Modified Swenson’s operation
• Ultrashort segment -» Anal canal + terminal rectum > Modified Duhanimel operation]
• Short segment (most common) -» Anat canal + rectum j K ; Neurogenic bladder
• Long segment -» Anal canal + rectum + part of colon
• Total colonic -» Anal canal + rectum + full length of colon NEUROGENIC BLADDER >
• Segmental -> Skip areas involved ^S ec-2 , Group - 1,2008, Q.6, "Bladder problems in Spinal Paraplegia". (Page No. 624-625)
□ Clinical features:
Choledochal cyst
• Common in males
• More in infants CHOLEDOCHAL CYST
• Constipation - j Whit Is I t : Congenital cystic enlargement of CBD
a) Newborn fails to pass meconium even after 3 days
3 Todanl Classification:
b) Goat-peilet like stool in children
Type I (60%) - Dilatation of extrahepatic CBD
c) On introducing finger into rectum to pass meconium, child passes toothpaste like stool k*
straining Subtype a -» cystic dilatation
• Abdominal distension - Subtype b - » focal dilatation
a) Becomes obvious by 3rd day Subtype c - » fusiform dilatation
b) Visible peristalsis Type II (5%) - Lateral saccular diverticulum of CBD
• Malnutrition Type III (5%) - Dilatation of intraduodenal segment of CBD (choledochocele)
. DRE- Type IV (30%)-
a) Tight sphincter .
Subtype a -> Dilatation of CBD and intrahepatic biliary dilatation
b) Empty rectum
Subtype b -> Multiple extraheptaic cysts
c) Child passes lot of gas and meconium
Type V - Multiple intrahepatic cysts (Caroli's disease)
□ Investigations:
J Aetiology:
• Barium enema - Shows extent and the three zones
• Localised perforation in bile duct
• Rectal biopsy - Absence of ganglionic cells
• Distal obstruction and destruction of proximal duct epithelium by pancreatic juice when both bile
• Anorectal manometry
duct and pancreatic duct open commonly at Ampulla of Vater
• Acetylcholine esterase staining
- Sexpredilection:
□ Complications:
• F:M = 4 :1
• Enterocolitis
3 Clinical features:
• Intestinal obstruction
• Classical triad -
• Constipation
> Recurrent attacks of right upper quadrant abdominal pain
• Perforation
* Slowly progressing jaundice
• Septicaemia
’*• Palpable abdominal mass which is soft, smooth, resonant, not mobile
• Peritonitis
' Fever
□ Treatment:
J Complications:
t Colostomy
• Complete biliary obstruction
• Nutritional supplementation
• Type III pancreatitis
 502 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 503

• Biliary cirrhosis
3 con>pl‘< *tlo n s : ‘
• Cholangio carcinoma
, Empyema 9a" bladder
• CBD stone, GB stone Pseudomyxoma peritonei
□ Investigations:
a # ; choiesterosls
• Intravenous cholangiography
. USG CHOLESTEROSIS
• Hepatobiliary nuclide scanning q Synonym: Strawberry gall bladder
• CT Scan - To see intrahepatic biliary system q what is It-' A type of cholecystoses I.e., a chronic inflammatory condition of gall bladder with cholesterol
. ERCP deposits
• MRCP g pathology: Red mucosa of gall bladder studded with minute yellow flecks giving a typical picture of
. LFT ripe strawberry
□ Treatment: g Pathogenesis: Distension of mucosal folds with aggregation of round and polyhedral histiocytes
Cholecystectomy in all types - (foamy cells phagocytose cholesterol)

Type I -> Excision of cyst + Roux-en-y hepaticojejunostomy

Deposits become more massive
Type II -> Excision of diverticulum + suturing of CBD I
Type III -> Endoscopic sphincterotomy Celis die with release of lipids
Type IVa -» Liver transplantation I
Precipitation of cholesterol crystals in sub-epithelial region
Type IVb -> Liver segmental resection
Type V -> Liver transplantation 0 Aetiology:
• Excessive absorption of cholesterol from bile by epithelial cells of gall bladder
0.43; Mucocele o f Gall bladder
• Lymphatic & venous stasis predispose to accumulation of cholesterol absorbed from bile contents
MUCOCELE OF GALL BLADDER • Failure of mucosa to secrete cholesterol results in abnormal deposition of cholesterol within
mucosa and submucosa
□ What Is I t : Gall bladder distended with mucus Q Clinical features:
□ Pathogenesis : Obstruction of cystic duct by stone in Hartmann's pouch, without infection in • Assymptomatic
bladder *
Q Investigations:
■ i
• USG Abdomen
Absorption of bile and secretion of mucus into gall bladder by its wall
• Isotope study
□ Content: Sterile mucus
Q Treatment:
□ Clinical features:
• Cholecystectomy
• Swelling in right hypochondrium with following features -
0 Complications:
> Painless
• Infection
> Smooth
> Soft • Precipitate stone formation
5» Non-tender • Premalignant condition
> Globular Meckel's diverticulum
> Palpable lateral and lower borders of gall bladder, upper border not well-defined
• Dyspepsia M EC KEL’S DIVERTICULUM

□ investigations: ^ What Is i t : Congenital diverticulum arising from terminal ileum due to unobliterated proximal portion
• LFT of vitellointestinal duct •
• USG abdomen 3 Occurence:
□ Treatment: • M>F

• Cholecystectomy • Primarily in children

 504 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 505

Q Features : q . preparation for large bowel surgery

• Present in 2% population
PREPARATION FOR LARGE BOWEL SURGERY l
• Possesses mesentry like mesoappendix
• Contains heterotopic epithelium like gastric, colonic and rarely pancreatic tissue in 20% Case 3 indications:
• Contains all 3 layers of bowel, hence it is a true diverticulum Carcinoma colon
Q Length: Carcinoma rectum
Anorectal malformations
• 2 inch
Megacolon
□ S ite:
Familial adenomatous polyposis
• 2 feet from ileocaecal valve, on antimesenteric border of ileum Diverticulitis
□ Blood supply: Before colonoscopy
• Independent blood supply from a bloodvessel arising from terminal branch of superior mesenleric Before colostomy closure *
artery 2 preparation:
□ Clinical features: • Diet:
• Assymptomatic unless complications occur Low residue diet for 2-3 days before surgery/procedure
□ Complications; (BLIND + P2) ' I
1) Bleeding - maroon coloured blood along with dark red clots via rectum, due to peptic ulceration Clear liquid diet on day before surgery/procedure
produced by secretion of acid-pepsin by ectopic gastric mucosa I
2) Littre's hernia - Meckel's diverticulum present as a content in hernial sac Empty stomach on day of surgery
3) Intestinal obstruction: ^ • Bowol wash:
a) Obstruction occurs around a band running from tip of diverticulum to umbilicus For 2-3 days before surgery using 1-2 lit of normal saline -
b) Intussusception due to swollen, inflammed heterotopic epithelium at mouth of diverticulum . Osmotic catharsis:
4) Neoplasm - GIST/Carclnoid ' 200 ml oral mannitol for 2-3 days prior to surgery
5) Diverticulitis - Inflammation of Meckel's diverticulum due to lodgement of food residues withinii OR
6) Peptic ulceration - Due to ectopic gastric mucosa
Single dose of oral Polyethylene Glycol dissolved in 2 lit of water and drunk on day before
7) Perforation surgery - 11
□ Investigation: ^ • Total gut irritation:
• Technetium (T99m) radioisotope scan Ryle’s tube passed beyond D-J flexure
• X-Ray abdomen
1 f
• Barium meal follow through
Patient sits on comode/couch
• CT Scan
i '
□ Treatment:
N.S. passed through tube @ 2-3 lit/hour
• If assymptomatic, left alone
' I ~
• If found during laparotomy Once clear fluid passes rectum, wash should be continued for further 1 hour
I
(Total 8-9 tit N.S reqd.)
If narrow mouthed with thickened wall
Elemental diet:
1 /
Surgery Pre-digested food which gets absorbed by terminal ileum and leaves no residue, thereby rendering
I f- a ) Base narrow an empty colon - taken for 3-5 days before surgery

b) Adhesions present Familial adenomatous polyposis

c) < 2 years age
d) Complications present, FAMILIAL ADENOMATOUS POLYPOSIS
- Excision of Meckel's diverticulum along with its base and a short segment of ileum followedbi'
What Is I t : Neoplastic polyp of colon
end to end anastomosis
Speciality: Pre-malignantcondition
 506 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 507

□ A g e : Adolescents Bj Microscopy -
□ Sex predilection: M = F
Intracanalicular variety Pericanalicular variety
□ Genetics: Inherited as autosomal dominant neoplastic chromosome (Chromosome no 5)
• Glandular proliferation • Fibrous tissue proliferation
□ Number: Multiple
• Large • Small
□ S ite : Mainly large intestine, rarely small intestine and stomach
• Soft • Hard
Q Associated conditions:
• Duct distorted • Normal duct
• Gardner’s syndrome (Desmoid tumor, osteoma, epidermoid cyst)
• Turcot’s syndrome (FAP + brain tumor) 0 Age:
• Duodenal or ampullary carcinoma , 15-25 years (pericanalicular variety - common)
, 30-50 years (intracanalicular variety)
□ Pathology:
q clinical features:
• Conglomeration of multiple polyps
, Lump in breast with following features :
• Tubular adenoma
> Painless
□ Clinical features:
> Smooth
• Assymptomatic > Solitary
• Loose stool with blood and mucus > Slowly growing
• Intermittent lower abdominal pain > More often in lower part of breast
• Anorexia, weight loss > Freely mobile ("breast mouse”)
• Anaemia > round margin - well circumscribed
□ Investigations: > Firm in consistency
• • Double contrast barium enema • No nipple discharge
• Sigmoidoscopy/colonoscopy followed by biopsy • No axillary lymph node involvement
□ Screening : 0 Investigation:
For all family members: • USG (< 30 years) or Mammography (if > 30 years)
• DNA tests for FAP . FNAC
• Pigment spots in retina (CHIRPES) 0 Treatment:
□ Treatment: • Pericanaficular variety - Enucleation
• Intracanalicular variety - Enucleation not possible, hence excision
Protocolectomy + Ileoanal anastomosis with ileal pouch
(Periareolar or submammary incision given)
OR
0.49: Phyllode's tumor
Conservative total colectomy + lleorectal anastomosis + Regular follow-up (if present on follow up,
snaring of polyps) + Sulindac 300 mg twice daily or Aspirin 325 mg once daily PHYLLODE’S TUMOR
0.48: Fibroadenoma Q Synonyms:
• Phyllode’s sarcoma
FIBROADENO M A
• Cystosarcoma phyllodes
□ What Is I t : Benign encapsulated breast tumor containing both glandular and fibrous tissue • Benign cystosarcoma
□ O rigin: ANDI of a single lobule • Serocystic disease of Brodie
□ Speciality: Commonest benign tumor of female breast 0 Naming: Phyllodes is a Greek word which means "leaf-like” - name given due to leaf-iike projections
of the tumor
□ A etiology: Increased sensitivity of a focal area of breast to oestrogen
0 What is i t : Benign breast tumor which can be locally aggressive and sometimes metastatic
□ Pathology:
2 Pathology:
A) Gross-
A) Grass - ■
• Soft
• Capsulated
* Hard
• Very enlarged
« Giant (> 5 cm)
• With cystic spaces
 508 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 509

B) Microscopy -
j. _ No nodal involvement
• Cystic spaces with leaf-like projections
_ Axillary node involved - ipsilateral, mobile, discrete
• Hypercellularity and pleomorphism
□ A ge: N2"
Nfc " Axillary node involved - ipsilateral, fixed to one another and other structures
• Premenopausal women around 40 years of age
Na, - ipsilateral inframammary node involved without ipsilateral axillary
□ Spread:
• Via blood to lung and bone
Nr .
Njj - Ipsilateral infraclavicular node involved with/without ipsilateral axillary
□ Clinical features: - Ipsilateral Inframammary node involved with ipsilateral axillary
• Swelling in breast with following features : - Ipsilateral supraclavicular node involved with/without ipsilateral axillary
y Highly enlarged - No metastasis
> Smooth |t)i _ Distant metastasis
> Firm and soft at places
g Stages:
* Non-tender
> Fluctuant Early invasive f~ 1 Ti NoMo
> Overlying skin tense, with venous prominence carcinoma lla - T o ^ M o .T ^ tM o .T ^ o M o
Not fixed to skin or deeper structures L l l b - T 2N,M0,T 3N0,M 0
• No axillary lymph node involvement
• No retraction of nipple or nipple discharge Locally advan- f "la “
ced carcinoma Wb - Tj ^ M o.T jNj Mo
□ Investigations:
L lllc - T4N0M0,T4N,M0,T4N2M0
» Mammography
• FNAC Oistant spread Q IV - Any T, Any N, M,
• Chest X-Ray (to look for secondaries)
0.51: Etlologlc factors In development o f breast carcinoma
□ Treatment:
• Smaller ones -> simple enucleation ETIOLOGIC FACTORS IN DEVELOPMENT OF BREAST CARCINOMA
• Older patients -» wider excision with 1 cm margin of normal breast tissue
• If malignant - » total mastectomy □ Age:
• Increased risk with increasing age
Q.SO: Stages o f CA breast
Q Gender:
STAGES OF CA BREAST • F>M (150:1)
TNM Staging of Breast Carcinoma Q Country o f b irth :

T0 - No evidence of primary • West» Far East

Tjj - Carcinoma-in-situ • Migrants assume risk of host community with 2 generations
T* pagets “ Pagst's disease of nipple with no lumor • Less industrialised nations have low rates
Ti - Tumor si2e < 2 cm Q Family H istory:
T1a - 0.1-0.5 cm • 2-3 fold increased risk in 1st degree relatives of patient with breast carcinoma (mother, sister,
Tji, - 0.5-1 cm daughter)
T)c - 1-2 cm • Risk gets reduced with distant relative
T2 - Tumor size 2-5 cm • Risk increased if 1st degree relative had bilateral carcinoma
T3 — Tumor size > 5 cm • Risk increased if history of ovarian cancer
' T4 - Fixed to chest wall/skin ^ Genetic Factors:
T<a “ Fixed to chest wall • BRCA 1 -> Breast CA
T ^ - Fixed lo skin Ovarian CA
T*c " ^ 4 3 + Tjj) • BRCA 2 -> Breast CA in both sex
T4d - Inflammatory carcinoma Pancreas CA
 510 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 511

Ovarian CA
Proslate CA 1 -
Laryngeal CA All node positive carcinoma
• Other associated hereditary syndromes: Node negative carcinoma if > 1 cm size
> U Fraumeni syndrome - p53 defect Node negative CA > 0.5 cm with adverse prognostic factors :
> Cowden’s syndrome - PTEN defect j, High nuclear grade
y HNPCC —MSH2, MLH1 defect j, High histologic grade
> Peutz Jegher's syndrome - LKBt defect > Blood vessel or lymph vessel invasion
□ Personal h isto ry: > HER2/neu overexpression
• CA of contralate ra I breast > Negative hormone receptor status
• Ovarian CA 2 Adjutant hormone therapy (Tamoxifen) given t o :
• Endometrial CA , ER positive patients (ER - oestrogen receptor)
□ Hormonal fa cto rs: j postmenopausal women:
(Increased risk with increased exposure to endogenous oestrogen) , Use Is controversial
• Early menarche (< 12 years) , Tamoxifen/Aromatase inhibitor is ideal
• Late menopause (> 55 years)
g indications:
• Nulliparity
• Obesity , Inflammatory carcinoma
i Advanced carcinoma breast as a palliative procedure
Q Late full term 1s t pregnancy:
• Stage IV carcinoma with secondaries in bone, liver
(Reduced risk with early child bearing and breast feeding)
• Post-operative after simple mastectomy
> 30 years age increases risk
□ D iet: • pre-menopausal women with poorly differentiated tumor

• Alcohol 0 chemotherapy regimen :

• High fat diet CAF (Cyclophosphamide, Adriamycin, 5-Fluorouracil)
□ Previous benign breast disease: OR
• Ductal involvement by cells of atypical ductal hyperplasia • CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil) — monthly/3 weekly cycles for 6 months
• Moderate/Florid epitheliosis Q Newer d ru g s:
• Atypical ductal/lobular hyperplasia • Taxanes (Paclitaxel, Docataxel)
□ SES:
0 Neoadjuvant chemotherapy:
• High
• Administration of adjuvant therapy before primary therapy (surgery or radiotherapy)
□ Irradiation:
• Down-stages the tumor
• Increases risk • Makes large operable primary lumor amenable for conservative breast surgery
□ HRT:
0S3: Inflammatory carcinoma
Concomitant oestrogen and progesterone administration

Q.S2: Adjuvant chemotherapy In breast carcinoma INFLAMMATORY CARCINOMA

0 Synonyms:
A D JU V A N T CHEMOTHERAPY IN BR E A S T CAR C IN O M A
• Lactating carcinoma
□ What is I t :
• Mastitis carcinomatosis
have received local 3 Speciality: Most malignant type of CA breast
0 Objective : j Pathogenesis : Cancer cells block lymph vessels in the skin ol breast
3 Naming: As breast often looks swollen and red
2 3 L t S T S f "* ■» « *» » ■ * - ® Stage; T ^ Nany Many
 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics S Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 513
512

□ A ge : 50 - 6 0 years
□ Additional features:
» Hormone receptor negative Aetiology
• Common in obese women
• Rapidly spreading
r ~ ^f
□ Spread: Chest wall, bone, lungs physiological Pathological
□ Clinical features:
In newborn
• Swelling 1 affecting > l/3rd of breast (due to maternal/placental oestrogen)
• Redness >
» Skin - (i) Pink In adolescent
(ii) Peau-de-orange (due to plasma oestradiol reaching adult
• Rapid increase in breast size range before testosterone)

. Sensation of heavyness Ol aging

• Burning sensation (decreasing testicular function, increasing
• Inverted nipple fatty tissue)
• Swollen lymph nodes
□ Investigation
r
• FNAC Idiopathic
• • Mammogram (commonest) T
Drugs Absolute Oestrogen Excess
• PET scan
• Bone scan Estrogens Increased substrate lor
□ Treatment E.g.: Diethylstibestrol . peripheral aromatisation
E.g.: • Thyrotoxicosis
Systemic chemotherapy + Radiotherapy Drugs inhibiting • Cirrhosis
(Neoadjuvant - Anthracycline, Taxanes testosterone synthesis
HRT-Tamoxifen, Letrozole) E.g: ♦ Cimetidine
Increased testicular
• Ketoconazole
oestrogen secretion
0.54: Gynaecomastla
Drugs enhancing E.g.: • Testicular tumor
oestrogen production • Bronchogenic
G YNAECO M ASTIA
E .g : • Clomiphen carcinoma
□ What Is I t : Hypertrophy of male breast more than usual due to increase in ductal and connectot • Gonadotrophins
tissue elements often attaining features of female breast Increased extraglandular
Drugs acting by unknown aromatisation
□ Basle mechanism : Excess of oestrogen
mechanism
E .g : • Busulfan
• CCB
Relative Oestrogen Excess

Congenital delects Other defects

E.g:< Anorchia E.g :* Viral orchitis
Klinfelter's Trauma
syndrome

ss
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514 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

□ Clinical features: Clinical features:

• Diffuse enlargement of breast J , Age-Any

• Well-localised
' Single or multiple nodules in thyroid
• Small
, Diarrhea
• Firm or hard nodule under areola

□
• Pain, tenderness may be present
Investigations: ■
t
, Flushing
Hypertension
T ra ch e a l compression, dysphagia, hoarseness
• Relevant to cause Cervical lymphadenopathy
E.g.: LFT, Hormone assay, etc , Kidney stones .
□ Treatment: investigations:
• Treatment of underlying cause , FNAC - Amyloid deposition with dispersed malignant cells and C-celJ hyperplasia
• Drugs - Tamoxifen, Aromatase inhibitor , Tumor marker - Raised calcitonin .
• Surgery - Mastectomy, Reduction mammoplasty , USG abdomen
• Suction - Assisted lipectomy , USG neck
, Urinary VMA, catecholamines, metanephrine
0.55: Medullary carcinoma o f thyroid
, "'Indium octreotide screening
M EDULLARY CARCINOMA O F THYRO ID 3 Treatment:
. Total thyroidectomywith central node dissection
□ Speciality: Uncommon type of thyroid malignancy
, Neck lymph nodeblock dissection if lymph node Involved
□ Arises fro m : Parafollicular C-cells • No role of hormone therapy/radioactive iodine
□ Inheritance: Autosomal dominant . External beam radiotherapy for residual tumor
□ Characteristic features: • Somatostatin/octreotide for diarrhea
• Non-follicular histological appearance « Associated phaeochromocytoma -> adrenalectomy
• Origin from parafollicular C-cells . I
• Secretion of calcitonin total thyroidectomy
□ Pathology: . If MCT + Parathyroid hyperplasia in MEN IIA,
• Variable size - Total thyroidectomy
• Composed of solid mass of cells, hence 'medullary' - Central node dissection
• 'Amyloid stroma' wherein malignant cells are dispersed - Total parathyroidectomy
• Presence of thyrocalcitonin granules - Autotransplantation
□ Secretes: 0.56: Hashimoto s thyroiditis
• Calcitonin HASHIMOTO’S THYROIDITIS
• Serotonin
• Prostaglandin Q Synonyms:
. VIP • Struma lymphomatosa
• ACTH • Diffuse non-goitrous thyroiditis
□ Spread: • Lymphadenoid goiter
Initially lymph nodes of neck and superior mediastinum • Chronic lymphocytic thyroiditis
7 i 2 Speciality: Most common form of thyroiditis
Then lung, liver, adrenals, bone ^ Aetiology:
I Autoimmune disease - Thyroid gland becomes sensitive to its own cell constituents
Advanced cases to trachea and oesophagus 4 autoantigens exist - a) Thyroid cell microsomes
□ Associated conditions: b) Thyroid cell nuclear component
• MEN II syndrome c) Thyroglobulin
• Phaeochromocytoma d) Non-thyroglobulin colloid
 SOLVED SHORT NOTES OF SEMESTERS 517
616 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

prtventlon o f simple goiter :

□ Associated features:
3 Endemic areas -> all table salts must contain iodide
• Papillary carcinoma of thyroid
' Drug induced -> discontinuation of drug
• Pernicious anaemia and autoimmune gastritis in family members
prevention of consumption of goitrogens
□ Pathology:
, iodine rich diet - e.g, eggs, milk, seafood
• Hyperplasia -> fibrosis -» infiltration with plasma cells and lymphocytic cells
, Treitment o f simple goiter:
• Askanazy cells are typical (large epithelial cells with oxyphilic changes)
Aj Diffuse hyperplastic goiter:
□ Clinical features:
y L-thyroxine 0.3 mg/day for few months
• Age - Perimenopausal women, around 50 years
’ I
• Sex - Mostly females
0.1 mg/day for few years
• Onset - Insidious
> Subtotal thyroidectomy - if
• Diffuse enlargement of both lobes with following features - firm, rubbery, painful, tender (a) failure to respond to medicine
• Initially toxic features present, but later features of hypothyroidism develop ' ’^ (b) intraglandufar hemorrhage -» rapid increase in size
• Hepatosplenomegaly may be present
(c) intrathoracic goiter -> respiratory obstruction
□ Investigations:
(d) pressure symptom, pain present
• T j, T4 - Reduced
B) Multinodular goiter:
• TSH - Raised
> Subtotal or total thyroidectomy if many nodules/both lobes involved
• FNAC
> Lobectomy if one lobe involved
• Thyroid antibodies - Antimicrosomal, antithyroglobulin
C) Colloid goiter-
• ESR raised
Subtolal thyroidectomy
. □ Treatment:
Post-operative L-thyroxine given in all cases
• If small size + patient euthyroid -> no treatment required
• If goiter + hypothyroid -> L-thyroxine therapy CLASSIFICATION OF GOITER
• If I) pressure symptoms .
GOITER
Ii) cosmetic purposeI Subtotal thyroidectomy
iii) extremely enlarged goiter 1
• Steroid therapy may be helpful +
SIMPLE TOXIC NEOPLASTIC THYROIDITIS RARE CAUSES
Q.S7: Prevention and treatment o f simple goiter NONTOXIC (See below) (See below) • Bacterial
Hashimotos' • Amyloid
PREVENTION AN D TREATM ENT OF S IM PLE GOITER autoimmune
thyroiditis
□ G oiter: Enlargement of thyroid gland
De-Quervan's
0 Aetiology o f simple g o ite r:
thyroiditis
Stimulation of increased TSH secretion due to tow circulating thyroid hormones
• Familial goiter Reidel’s thyroiditis

• Physiological- Due to high metabolic demands Dtae Multinodular Colloid Solitary

hyperplastic goiter goiter non-toxic
• Endemic goiter — Due to low iodide content in food 9oiler nodule
• Goitrogens - E .g .: Vegetables of brassica family like cabbage, turnip, etc drugs like PAS.
antithyroid drugs
• Dyshormonogenesis - Enzyme deficiency -> low thyroxin discharge -+ T TSH
• Sporadic goiter - No definite cause
fysiologica] Primary Iodine deficiency Secondary Mine deficiency
□ Types : ' Pregnancy Endemic goiter • Goitrogens
• Diffuse hyperplastic goiter * Puberty • Drugs - PAS, lithium
• Nodular goiter • Excess dietary fluoride
• Colloid goiter • Dyshormonogenesis
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518 QUEST : A Comprehensive Guide lo UG Surgery. Orthopedics & Anesthesiology

^ p lic a tio n s o f total Thyroidectomy

TOXIC GOITER
COMPLICATIONS OF TOTAL THYROIO ECTOMY
I

With hyperthyroidism Without hyperthyroidism

___ i_______ • Jod Basedow's th y,*! Immediate Late
— }
• Excess L-thyroxineimak Thyroid insufficiency
Hemorrhage
High TSH Low TSH • After recent thyroid surg Hypertrophic scar/keloid
Infection
Ectopic TSH Grave's disease • Struma ovary Recurrent thyrotoxicosis
Respiratory obstruction
secreting tumor Toxic multinodular goiter • Neonatal h y p e rth y ,^ Progressive exophthalmos
Recurrent laryngeal nerve palsy
TSH secreting Toxic solitary nodule • Subacute thyroiditis
Tetany
pituitary adenoma
Thyroid storm

NEOPLASTIC GOITER
^ T V E N T OF COMPLICATIONS
1
r ~ 1 j Hemorrhage (Primary or Reactionary):
Benign Malignant [C/F - Tachycardia, hypotension, breathlessness, severe stridor)
• Follicular adenoma , if small hematoma -* Aspiration
• Papillary adenoma , || large hematoma - » Immediate release ol sutures, pressure over trachea released
• Hurthle cell adenoma I
Hematoma evacuated
1 I
Follicular Cell Origin Parafollicular C-ceil origin Non-thyroidceUonp Bleeding vessels ligated
Medullary carcinoma of • Malignant lymphoma q infection:
thyroid • Sarcoma
. U sed suction drainage 1 For Prevention
• Metastatic deposits
TX" “1T
•
•
Proper hemostasis
Antibiotics
J

Differentiated Undifferentiated
\ • Antipyretics
• Papillary carcinoma Anaplastic carcinoma
i Q Recurrent laryngeal nerve p a ls y :
• Follicular carcinoma !
• Hurthle cell carcinoma • Prevention -»
1
3 > nerve identified before ligating thyroid artery
0.5 8: Preoperative preparation in Grave’s disease > artery Iigated far away from thyroid
> posterior lamina of pre-tracheal fascia kept intact
PREOPERATIVE PREPARATION IN GRAVE’S DISEASE • Permanent palsy - Rare
□ Antithyroid drug to bring patient to euthyroid state • If bilateral palsy -» Immediate tracheostomy
Tab Propylthiouracil - 100 mg thrice daily, till patient becomes euthyroid • If temporary palsy -»
(Operation done about 2 months after patient becomes euthyroid) > recovers in 3 weeks • 3 months
□ Iodide o r Iodine to reduce size and vascularity of thyroid gland > steroid supplement
lugol's iodinle solution - 10 drops 3 times daily for 10 days prior to operation > speech therapy
OR 0 Respiratory obstruction:
Tab Potassium iodide - 60 mg 3 times daily for 10 days prior to operation Release of tension hematoma -
□ Beta adrenergic blockers to reduce pulse rate, tremor, anxiety -I if no improvement
Tab Propranolol - 40 mg thrice daily
Endotracheal intubation
Given 7 days prior to operation
Continued for 7 days post-operatively
 520 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 521

□ Tetany:
(C/F: Weakness, Carpopedal spasm, convulsions, stridor, Chvostek’s sign) GALLSTONE ILEUS
Serum calcium estimation
. u . jype of acute intestinal obstruction due to blockage by gall stone, which has gained entry
i
3 l^ e mtostine through cholecystoduodenal or cholecystogastric or cholecyslointestinal fistula
Inj Calcium gluconate (10%) - 10 ml i.v. 8 hourly
I n pathogenesis:
J Calculous cholecystitis
When tolerate oral medication,
4.
Tab. Calcium gluconate - 500 mg 8 hourly
Suppuration and adhesion over duodenal wall
□ Thyroid sto rm :
Acute exaceitation of thyrotoxicosis in patients who have not been made auequately entWu Cholecystoduodenal fistula
to the surgery ^
I
Treatment - See Short Note (Page No. 499) - Treatment of Hypercatcaemic Crisis in a car Gallstones pass into duodenum, form a mass
Hypothyroidism'
4
□ Thyroid Insufficiency: Blocks terminal ileum
Lifelong L-thyroxine I
Gallstone ileus
0.60: Metabolic and neuromuscular manifestations In Grave's disease
3 Clinical features:
METABOLIC AND NEUROMUSCULAR MANIFESTATIONS IN GRAVE’S DISEASE , Pain abdomen
. Features of intestinal obstruction - Abdominal distension, vomit, absolute constipation, shock
Manifestations in Grave's disease are due to -
• Sympathetic overactivity g investigations:
• Increased catabolism , Plain X-Ray abdomen -
□ Neuromuscular m anifestations: a) multiple air fluid levels
b) branching gas pattern (air in biliary tract)
• Undue fatigue
• USG abdomen
• Wasting
< CT scan
• Muscle weakness (most evident in proximal limb muscles)
3 Treatment:
• Myopathy in extreme cases
Laparotomy -> Enterotomy -» Removal of gallstones
• Tremor of extended and abducted fingers
1
• Hyperactive tendon reflexes
Closure of enterotomy
• Insomnia
i
• Irritability
Cholecystectomy after 6 -12 weeks
• Excitable and restless
□ Metabolic manifestations: 0.62: Laparoscopic cholecystectomy

• G.I. system -» > Increased appetite but weight loss LAPAROSCOPIC CHOLECYSTECTOMY
> Diarrhea
• Integument -> > Hair loss Q What Is I t : Most popular method to remove gall bladder
> Warm, moist skin -> gradually heat intolerance Q Speciality: Gold standard treatment for gallstone
> Facial flushing Q Anesthesia: General
V Increased sweating A Position: Supine, head end up and right side up
> Pruritus
0 Ports used:
> Palmar erythema
• 10 mm - » umbilicus - to pass telescope
*• Soft, fragile nails
• 10 mm -4 epigastric - to pass working instruments, take out stones
• Genitourinary -* V Oligo or amenorrhoea
• 5 mm midctavicular line close to costal margin - to pass grasper for graspingHartmann's pouch
System > Urinary frequency
• 5 mm -> anterior axillary line at level of umbilicus - to pass grasper for grasping fundus of GB
 522 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 523

□ Procedure ;
Pneumoperitoneum created (For details Refer to Short Note ‘Creating Pneumoperitoneum in ( ^ ^ e X F e a tu r e s Sliding Hernia Rolling Hernia
I ' • Axial hiatus hemia • Para-oesophageal hiatus hernia
, synonyms
Ports inserted
* Type I hiatus hemia ♦ Type II hiatus hemia
I
Graspers inserted through respective ports . incidence Commonest Rare
I • Not a true hernia • True hemia
. Anatomy
Calot’s triangle dissected via dissector introduced through epigastric port • Phreno-oesophageal • Phreno-oesophageal membrane
membrane intact ruptured
Cystic duct and artery identified
T ^ c a l features • May be assymptomatic • Fullness after meals
• Associated with GERD • Early satiety
Posterior adhesions released first
• Post prandial vomit
• Dysphagia
Cystic duct and artery clipped
• Hiccough
I
• Abdominal pain
Gall bladder dissected off liver bed using cautery and removed through epigastric port
• Chest pain
• Regurgitation
Bleeding points coagulated
• Arrythmia
i
Tube drain placed through 5 mm port . investigations ♦ Barium meal X-Ray • Plain X-Ray (retrocardiac air-fluid
level)
. *
All ports removed • Oesophagoscopy • Barium meal X-Ray
1 • ECG
Ports sutured • 3D CT Scan
• Flexible fibreoptic gastro-
□ Complications: oesophagoscopy before operation
Bleeding
• Treatment Same as for GERD • Excision of sac and repair of defect
Infection
Bile leak • General - * control of obesity • Gastrectomy if gangrenous
Bile duct injury * stop smoking • Mesh reinforcement to hiatus to
• Drugs - PPI, H2 blockers close defect
Subphrenic abscess
prokinetics
Injury to colon, duodenum
• Endoluminal therapies
0.63: Hiatus hernia • Antireflux surgery

HIATUS HERNIA
0.64: Cavernous hemangioma
□ What Is it : Herniation of stomach into thorax through oesophageal hiatus in diaphragm
□ Speciality: Most common type of diaphragmatic hernia
CAVERNOUS HEMANGIOMA
□ Classification: See Section - 1, Segment - C, Paper I, 2010, Q.1 'Hemangioma' (Page No. 285)
Type I [Sliding hernia] -> Cephalad displacement of gastro-oesophageal junction through hiatus*
Q65.‘ Acute appendicular lump
mediastinum
Type II [Rolling hemia) - t Superior migration of fundus of stomach along side the GE junction and
ACUTE APPENDICULAR LUMP
oesophagus Into the mediastinum with GE junction in normal intraabdominal location
Type III -> Type I + type II Q Synonym - Periappendicular phlegmon
Type IV -» Hernia which has other abdominal viscera as content a What Is It - Localisation of infection occuring 3-5 days after an attack of acute apps-vlicitis
For rest, Refer to "Appendicular Lump" - Sec - 1 , Paper-1, Supplementary 2013, Q.2 fPage No. 63)
 524 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 4 Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 525

0 .6 6 : Pseudocyst o f pancreas
j Com pletions:
PSEUDOCYST OF PANCREAS
, infection - » abscess
, Hemorrhage
□ W h a tis it- Collection of amylase rich fluid enclosed in a wall of fibrous or granulation tissue jni
sac of peritoneum or peripancreatic cellular tissue , Rupture
, GIT obstruction
□ Naming - Called 'Pseudocyst' as not lined by endothelium
, Cholangitis
□ Etiology -
, Cholestasis
• After 3 weeks following attack of acute pancreatitis
3 Differential diagnosis :
• Following trauma
, Aortic aneurysm
• Recurrent chronic pancreatitis
, Cysladeno carcinoma of pancreas
□ Sites -
, Retroperitoneal tumor
• Lesser sac (commonest) • Uvercyst
• Duodenum , Mesenteric cysi
• Jejunum <rare) , Hydatid cyst
• Splenic hilum 0 Investigations : .
• Colon , USG Abdomen
□ Types - i CT Scan-abdomen
• Acute . MRCP
• Chronic . LFT
- • Communicating (with pancreatic duct) » Barium meal (lateral view) - Widened vertebrogastric angle with displaced stomach
• Non-communicating 3 Treatment :
□ Fluid content - See Sec-1, Segment-A, 2012 Paper-I, Q . 2 - ‘Big Tense Cystic Lump In Upper Abdomen' [Pg. 42]
• Contains: „
OM: Abdominal compartment syndrome
> Albumin
> Mucin ABDOMINAL COMPARTMENT SYNDROME
> Cholesterin
3 What Is I t : Intra abdominal pressure raised to more than 12 mm Hg.
> Blood cells
V Necrotic tissue 0 Etiology:
• Very high level of amylase • Intestinal obstruction
• Colour - Clear • Multiple trauma
• Specific gravity - Low • Laparoscopic procedures
• pH - Alkaline • Post operative Ileus
• Acute gastric dilation
□ Clinical features -
• Acute abdomen
• Swelling in epigastrium with following features :
3 Busch pressure gra d in g: (based on intra abdominal pressure)
> Size - Variable
I - 10-15 cm H20
> Shape - Hemispherical
I I - 15-25 cm H20
> Surface - Smooth
1“ - 25-35 cm H20
> Consistency - Soft
lv -> 3 5 c m H 20
> Margin - Upper diffuse
3 Clinical features:
Lower welt-defined
• Hypoxia, hypercarbia
i- Movement with respiration - Absent
• Reduced urine output
V Mobility - Absent
• Reduced venous return
'* Percussion - Resonant
' Distended abdomen
v Tenderness - May be present
' High pulse
• Baid test - Ryfe's tube passed felt per abdominally • Low blood pressure
' Cardiac arrest
526 QUEST : A Comprehensive Guide to UG Surgeiy, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 527

Q Treatment - , Transillumination - Brilliantly transilluminant

• Resuscitation; patient shifted to ICU , Fluctuation - Fluctuant and cross-fluctuant (in case of plunging ranula)
• Bladder pressure assessment
j Coinplioat' o n s :
• Ryle’s tube aspiration , Bupture
• Surgical decompression beyond Grade III , infection
Q.68: Ranula , Repeated trauma
, interfere with speech and swallowing
RANULA
, Damage Wharton’s duct
□ What is it - Transparent cyst on floor of mouth g Treatment:
□ Naming - Derived from "Rana” meaning frog, as ranula looks like belly of frog , Marsupialisation initially -> Excision when wall of ranula is thickened
□ Origin - Extravasation cyst arising from sublingual gland or mucus glands of Blandyn and Nutvior,
floor of mouth OS,; TOURNIQUET
□ Pathogenesis - g fu nction : Cut off blood supply to a limb temporarily (to create a bloodless fietd)
Blockage of duct of the glands g P rerequisite : Limb exsanguination using Rhys-Davis exsanguinator
' I
Retention cyst 0 Site:

I Lower limb -* Mild thigh above knee joint

Increased pressure Upper limb -* Mid biceps above elbow joint
• 4. Q Applied: Over layers of gauze/cotton, not on bare skin
Rupture of acini
■i 0 Pressure:
Extravasation cyst
Adults Children
□ Pathology- Upper limb 250 mm Hg 150 mm Hg
• Lined by columnar epithelium or cuboidal epithelium, which in turn is covered by delicate capsule Lower limb 300 mm Hg 250 mm Hg
of fibrous tissue
• Content - Clear ropy or jelly-like fluid 0 Types :
□ Types - • Rubber tourniquet
• Simple ranula - When ranula is situated only on floor of mouth • Martius tourniquet
• Plunging ranula - Intrabuccal ranula having a cervical prolongation which comes down alongthe • Com pneumatic tourniquet
posterior border of mylohyoid, and appears in submandibular region • Pneumatic tourniquet
□ Age- • Esmarch rubber elastic bandage tourniquet
• Children and young adults • Specialised sophisticated tourniquet
3 Uses:
□ Sex predilection -
• Create - bloodless field for limb surgery
• M=F
• To access vein - for i.v. inj, iv sampling
Q Clinical features -
• Diagnostic test - ITP, varicose vein
Swelling with following features : • First aid in bleeding condition of limbs
• Site - Floor of mouth, below tongue and on side of frenulum
2 Time: Upper limb - 1 min, Lower limb - 2 min
• Size - Variable (1-5 cm diameter)
^ Contraindications:
• Surface - Smooth
• Colour - Bluish • Peripheral vascular disease
• Atherosclerosis
• Laterality - Unilateral
• Tenderness - Absent • Infection
• DVT
• Temperature - Not warm
• Consistency - Soft or hard • Crush syndrome
• Sickle cell disease
 528 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics &. Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 529

O Complications: Tested for infection:

• Crush syndrome * > HIV - 1 . 2
y H T L V -1 ,2
• Ischemia and gangrene
• Skin blister and necrosis y Hep - B, C
• Infection > CMV
• Increase bleeding if improperly placed > Malaria
« Neuropraxia > Syphilis
> West Nile virus
Q. 70: Blood trans fusion
> Chagas disease

BLO O D TRANSFUSION IB) Before transfusion:

, Patient’s blood group properly checked and documented correctly in requisition form
□ Indications :
, Product details and details on requisition form are matched properly
• Acute blood loss following trauma
. Slow infusion started
• Major surgery
• Bums-Plasma (G) Alter transfusion:
• Septicaemia , Constant monitoring of vitals every 15 mins
• Chronic anaemia . Check for fever, chills, urticaria
• ITP, Hemophilia . Urine volume
• Prophylactic measure prior to surgery
j / j : Melanoma
□ Donor criteria:
' • Weight 45 kg MELANOMA
• Fit without serious disease - HlV, Hep B
g Define - Most aggressive malignant ■cuteneous tumor arising from epidermal melanocytes
□ Collection:
3 Sites-
• Sac containing 75 ml CPD (Citrate, Phosphate, Dextrose) solution
• Head, Neck
□ Storage:
• Eyes
• 4'C in speciaf refrigerator - 3 weeks. • Mucocutaneous junction
3 Blood fractions: • Trunk
A : See Section - 1 , Segment - D, Q.19 "Blood Fractions" (Page No. 484) • Lower, upper limb
3 What Is transfused:
3 Predisposing factor-
• Every 4 unit SAGM blood -> 1 unit whoie blood given • Sunlight
• Every 2 unit SAGM blood -» 1 unit (400 ml) 4.5% human albumin given • SES
’ «A» er ?r?Up'r’9 and c,oss'ma,chin9. 540ml blood transfused in 4 hours (40 drops/min) using • Family H/o
filtered dnp set
• H/o earlier skin CA
S - Sodium chloride
• Immunosuppressive drugs
A - Adenosine a) allows good viability of cells
• Xeroderma pigmentosa
G - Glucose anhydrate b) devoid of protein
« Familial dysplastic naevus
M - Mannltol c) useful in anaemies
9 Sporadic dysplastic neavus
Complications o f blood transfusion:
• Junctional naevus
A : See Section - 1, Segment - D, Q.33 "Complications of blood transfusion" (Page No. 495-4961 • Large congenital naevus
Precautions:
3 Classification
(A) Processing of blood before transfusion : (A) Braslow’s (based on thickness of invasion)
• Component separation I - < 0.75 mm
• ABO, Rh grouping II - 0 .7 5 - < 1.5mm
• Pathogen Reduction Treatment - Addition of riboflavin with subsequent exposure to UV V III - 1.5 - < 4 mm
• Leukoreduction / Leukodepletion IV - a 4 mm
 530 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 531

(B) AJCC Tumor thickness Nodal spread

fivestlgriO"3 -
Thin < 1 mm <10% No incision biopsy only excision biopsy
Intermediate 1 -4 mm 20•25% Tumor marker:
Thick >4 mm 60% ' > mela- a
> sioo
(C) Clarck’s
> LDH
1 -* Epidermis
HMB45
2 -» Extends into papillary dermis
3 -* Completely fills ■ Lymph node; FNAC, SLMB
4 -» Reticular dermis , USG, CT, Chest X-Ray
5 -> S.C. tissue ^ Treatment -

□ Types - (1) For Primary :

• Cutaneous , Wide excision
• Extra cutaneous , Amputation 1 joint above (if wider area)
• Occult . Eyes - Enucleation of eye
□ Clinical types- . Anal canal -> APR
• Superficial spreading - Most common (2) Lymph node:
• Nodular - More aggressive . SLNB
• Lentigo maligna - Less common, least malignant » Regional Block dissection •
• Acral lentiginous - Least common, worst type i CT if fixed node
• Amelanotic (3) Recurrent:
• Desmoplastlc • Isolated limb perfusion using melphalm
□ Phases o f growth - • Laser ablation
• Radial growth phase - Horizontal spread (4) Chemotherapy:
• Vertical growth phase - Invasion f After surgery
□ Clinical features - (5) RT:
(A) Arises denovo or from pre-existing naevus • Secondary in bone
(B) Unknown before puberty, spreads from mother to foetus • Brain
> A - Asymmetry (6) Endolymphatic therapy;
> B - Border irregular • Control of disease in nodes
> C - Colour change (7) Immunological therapy:
> 0 - Diameter > 6 cm • BCG, Levimasole
> E - Elevated
Off: Radiological features o f various causes o f Intestinal obstruction
> Ulceration, bleeding, itching
> Rapid growth RADIOLOGICAL FEATURES OF VARIOUS CAUSES OF INTESTINAL OBSTRUCTION .
(C) Satellite nodules -> 2 nodules within 2 cm of primary
Radtotogical examination is the most important diagnostic tool to confirm the clinical diagnosis and locate
In-transit nodules -> 2 nodules > 2 cm from primary
ft* site of obstruction accurately
(D) Spread to -
(1) Brain; (2) Bone; (3) Liver; (4) Lung; (5) Skin 3 Straight X-Ray Abdomen -

□ Spread - • Positions:

« Lymphatics - Regional lymph node > Supine

• Retrograde spread to dermal lymphatics - secondary nodules > Upright (both AP and lateral view)
• Blood > Left lateral decubitus
 532 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 533

• Characteristic feature : Gas shadows and multiple air-fluid levels > Bone
• Number: More than 3 air fluid levels (as normally 3 air fluid levels present in duode j, Brain
fundus of stomach and caecum) ^ j. Adrenals
• Cause: Gut gets distended with air and fluid proximal to obstruction due to - Retrograde venous spread through vertebral venous plexus in carcinoma prostate, causing
" osteoblastic secondaries in pelvic bones and vertebra
Fluid Air
Mdphatic spread:
(a) Salivary secretion (1500 cc/day) (a) Swallowed during respiration " - , By embolisation: Malignant cells get dislodged from lymphatic vessels and spread to other lymph
(b) Gastric secretion (2500 cc/day) (b) Diffusion of CO2 from distended veins into |urTl '
nodes freely
(c) Bile, pancreatic juice (1000 cc/day) (c) Putrefaction of intestinal contents 8,1 E.g.: In breast carcinoma, spread from axillary lymph node to supra-clavicular lymph node
(d) Succus entericus (3000 cc/day) , By permeation: Malignant cells proliferate through lymphatic vessels upto lymph node
E.g.: In breast carcinoma, spread of cells to axillary lymph nodes
• Radiological feature - .
, Retrograde lymphatic spread: When lymphatic vessels get blocked by malignant cells
> Gas exerts vertical pressure on fluid -> horizontal fluid level
E.g.: In breast carcinoma, spread to opposite breast, opposite axilla, mediastinum
> Shadows are formed where loops are formed
Transcoelomic spread: Spillage of malignant cells from primary site and spread occurring along
> In each loop, gas floats up on top of fluid, gas in black and fluid white
serous cavities
E.g.: Krukenberg tumor
• Site — -j along natural passages or epithelial lined space:

Jejunum -> Concertina effect due to Valvulae Conniventes (white lines occupying entire transvev Eg: papilloma of renal pelvis
diameter of bowel) 3 Seedling: '
Ileum -» Straight pipe, characterless , From lower lip to upper lip (kiss cancer)
Large bowel -> Haustrations (discontinuous white lines placed irregularly) > Recurrence in scar after surgery for malignancy
Small bowel -» Occupies central portion of abdomen > Seedling in peritoneal cavity from malignancy in abdominal organ
□ Barium Enema - Indicated when clinical features and straight X-Ray abdomen suggest cotai 3 Inoculation:
obstruction
During clumpsy surgical procedure
□ USG abdomen - ■,
______ } Show dilated bowel loops 0.75: Squamous cell carcinoma
□ C T S ca n - J
Features of 'Intussusception' - See Section - 1, Segment - A, Paper-1,2011, Q. 2 (Page No. 37) SQUAMOUS CELL CARCINOMA
Features of 'Volvulus' - Short Note (Semesters) (Page No. 567).
0 Synonym:
0 .7 3 : Imperforate Anus • Kangri cancer
• Chimney cancer
See Section - 1 , Segment - C, Paper-1,2013, Q.4 'Anorectal Malformation’ (Page No. 303)
• Epithelioma
Q.74: Spread o f carcinoma
3 What is I t:
Carcinoma arising from squamous layer of skin
SPREAD OF CARCINOMA
0 Examples:
□ Direct spread - Into adjacent organs, soft tissues, vessels, bone
• Chimney scrotal cancer (due to irritation by tar)
□ Blood spre ad - • Kang cancer of Tibetans (due to sleeping over hot bed to control cold)
• Occurs through veins (as thin walled, so infiltration easier) • Kangri cancer in Kashmir (due to constant placing of hot charcoal pot over abdominal wall to
• Arteries impermeable as wall as elastic control cold)
• Processes involved: 3 Pre-malignantconditions:
> Permeation (e.g. renal cell carcinoma) • Leukoplakia
> Embolisation (other malignancies) • Paget’s disease
• Blood spread occurs to following organs: • Bowen's disease
> Lungs ' Chemically induced chronic irritation
> Liver • Senile keratosis
 534 QUEST ; A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 535

• Radiodermatitis
^ . flhlnophyma
• Viral - HPV 5 , HPV 16
• Solar keratosis RHINOPHYMA
• Tobacco use
Sfnonyms:
• Xeroderma pigmentosa
, potato Nose
Q Speciality ;
, Bottle Nose
Second most common skin cancer tfhstls I t : Glandular form of acne rosacea which causes immense thickening of distal part of skin of
□ Genetics; pose with visible openings of sebaceous follicles
Expresses cytokeratins 1 and 10 0 otogy: Hypertrophy + adenomatous changes in sebaceous glands
□ Pathology: j clinical features: Bluish red nose with dilated capillaries
• Proliferative g treatment: Excision of excess tissue and reconstruction
• Red plaque like
• Ulcerative ftff; WEB SPACE INFECTION
□ Variants : 3 Surgical anatom y:
• Verrucuous carcinoma , Number - 3
• Marjolin’s ulcer , Shape - Triangular
• Self-healing squamous cell carcinoma , Boundary -
□ Histology: > Proximally - Transverse metacarpal ligament
» Distally - Web of fingers
• Spindle cells
> Sides - Head of metacarpal and proximal phalanx
• Malignant whorls of squamous cells with epithelial or keratin pearls
• Contents -
• Deep and peripheral marginal clearance
> Loose areolar tissue
□ Broder's classification:
> Lumbrical canal through which tendon of lumbrical posses
I - Well differentiated (a 75% Keratin pearls)
3 Etiology:
II - Moderately differentiated (50 - 75% Keratin pearls)
i Abrasion
III - Poorly differentiated (25 - 50% Keratin pearls)
• Pin-prtek
IV - Very poorly differentiated (< 25% Keratin pearls) • Callosities
□ Clinical features: • Infection of proximal volar spaces
• Ulceroproliferative lesion 2 Causative organism s:
• Indurated base and edge • Staphylococcus
• Raised, everted edge • Streptococcus
• Blood discharge from lesion • Gram negative organisms
• Regional lymphadenopathy - Hard, fixed, nodular J Clinical features:
□ Investigations : • Fever
• Edge biopsy • Pain and tenderness - Maximum on volar aspect
• FNAC from lymph node • Pus points out dorsally
□ Treatment : • V sign - Separation of Fingers
• Radiotherapy -1 Complication:
• Wide excision followed by skin graft • Spreads into other web and hand spaces
• Block dissection of lymph node 3 Treatment:
• Chemotherapy (Vincristine, Bleomycin, Methotrexate) • Elevate hand -
• Palliative external radiotherapy • Antibiotic, analgesic
• Drainage under LA -4 separate incision for each web space - transverse incision on volar
aspect of web, deepened to reach the space by dividing fibres of palmar
fascia
 536 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 537

Q.78: Paronychia
Trauma
PARONYCHIA Shock
Acute Paronychia pathogenesis:

□ What Is i t : Commonest hand infection Failure of inflammatory localisation

Vasodilatation
□ S ite: Pus collects in subcuticular area under eponychium
Thrombosis
□ Cause : Minor injury
Increased endothelial permeability
□ Organisms:
Leucocyte migration and activation
• Staphylococcus Neutrophil sequestration
• Streptococcus Release of free radicals, cytokines, arachidonic acid
□ Clinical features Abnormal nitric oxide synthesis
• Throbbing pain and tenderness Complement activation
• Floating nail - Due lo collection of pus under nail root DIC
□ Treatment: q part o t : Severely decompensated reversible shock
• Pus drainage by incision over eponychium 0 Leads to : MODS (Multi Organ Dysfunction Syndrome)
• Pus sent for culture and sensitivity 0 prognosis: Poor
• Antibiotic, analgesic
QgO: H.Pylorl eradication regime
• If floating nail, it is removed
Chronic Paronychia H. PYLORI ERADICATION REGIME
O Cause : Fungal infection
0 What Is H. pylori : Spiral shaped flagellated gram negative organism
□ Clinical features :
• Itching Q Present in :
• Recurrent pain • Deep mucosal layer of antrum
• Discharge • Duodenum (rare)
□ Investigations: 0 Features :
• Scrapings sent for culture • Urease activity -> protects it from H+ ions in gastric acid, and by producing ammonia provides a
□ Treatment : source of nitrogen
• Antifungal • Ammonia thereby produced has 2 actions -
• Antibiotic (a) Stimulate G-cells to release gastrin
• Nail removal in severe cases 4
0.7 9: SIRS gastric acid hypersecretion
(b) Alters gastric epithelial permeability
SIRS ' i
□ Full fo rm : Systemic Inflammatory Response Syndrome mucosal injury
□ What is I t : Body's systemic response to an infection • Flagellae - » permits it to penetrate mucosa and migrate to regions of lower acidity
0 Clinical param eters: • Bacteria secrete cytokines and enzymes which disrupt mucosal barrier

• Hypothermia (< 36°C) or hyperthermia {> 38°C) 0 Causative agent o f :

• Tachypnoea (> 20/min) • Type B gastritis
• Tachycardia (Pulse > 90/min) • Gastric ulcer
□ Laboratory param eter: • Duodenal ulcer
• Gastric carcinoma
• Total leucocyte count > 12000/mm3
0 Tests : .
□ Etiology:
•■ Sepsis • Rapid urease test
• Burn 3 C j 3/C ^^ breath test
• Serology to identify IgG antibody
 638 QUEST .■A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 539

□ Eradication regim en:

2a - Well-compensated
TRIPLE THERAPY (Used in areas where clarithromycin resistance is low) 2b - Poorly-compensated
(First line therapy]
Stage 3 - R9St Pain
Lansoprazole [30 mg BD] ^ 4- Gangrene, ischaemic ulcer
OR fittrmlttent claudication:
Omeprazole [20 mg BD) , Crampy muscle pain occurring due to arterial occlusion
Amoxycillin
OR [1mg BD] g festuras o f Ischaemla:
Pantoprazole [40 mg BD] Clarithromycin , Pallor
4 “ OR
OR
+ [500 mg BD]
for 7-•Hdays . Pain
Metronidazole , paraesthesia
Rabeprazole [20 mg BD]
[400 mg BD] , pulselessness
OR
, paralysis
Esomeprazole [40 mg BD] , Diminished hair
, Thinning of skin
[Combination with Metronidazole and Clarithromycin may induce resistance] , Loss of subcutaneous fat
[Metronidazole & Clarithromycin combination should be used in patients with penicillin h y p e r s * ^ , Muscle wasting
• Ulceration in digits
• Cold skin
Triple therapy + Bismuth 0 Investigations:
0 .8 1 : Acute limb Ischaemla • Blood tests - Blood sugar, lipid profile, peripheral smear platelet count
• Doppler
ACUTE LIMB ISCHAEMIA • Duplex scan
□ Causes : • Plethysmography
• Retrograde transfemoral seldinger angiography
• Acute arterial occlusion due to embolism
• Trauma 0 Treitment:
• Tourniquet application • Control of hypertension, diabetes
• Radiation injury • Percutaneous transluminal balloon angioplasty
• Diabetes • Bypass graft surgery
• Scleroderma
942: Collar stud abscess
• Atherosclerosis
• Artertopathics - Buerger's disease, Raynand’s disease COLLAR STUD ABSCESS
□ Types o f em bollsation:
• Cardioarterial 3 What is it :
• Arterioarterial Bilocular abscess with one locule deep to deep fascia and another locule in superficial fascia, both
□ Sites o f embolisation In limb ischaemla: locules intercommunicating with each other through a small perforation in deep fascia
• Bifurcation of common femoral artery Q Types: .
• Bifurcation of popliteal artery • Pyogenic
• Bifurcation of common iliac artery • Tuberculous
• Bifurcation of aorta
Q Stages o f tuberculous lym phadenitis: [See Fig. 1.7.5]
O Fontaine classification:
Stage 1 : Lymphadenitis (discrete nodes, non-tender, firm)
Stage 1 - Assymptomatic
Stage 2 : Matting (firm, non-tender, move together en-masse)
Stage 2 - Intermittent claudication
 T
540 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 541

Stage 3 : Cold abscess (deep to deep fascia)

rj goyd’s classification o f critical limb Ischaemia
Stage 4 : Collar stud abscess (cold abscess rupturing through deep fascia) grade I : Pain affer walking for some distance, but pain reduces if walking is continued (as collaterals
Stage 5 : Sinus formed open up which wash off the metabolites)
□ Pathogenesis: Grade II • persists on continuing walk, but patient can walk with effort
Rupture of cold abscess through deep fascia gives rise to collar stud abscess which is adher Grade III •’ PBtient needs to take rest to relieve pain
overlying skin j u f f t ; See Short Note ‘Acute Limb Ischaemia’ (Page No. 538)
□ Clinical features:
0jS : Raspberry tum or
• Swelling in neck
• Non-tender RASPBERRY TUMOR
• Smooth
• Cross fluctuation present q Synonyms:
• Tonsils may be studded with tubercles , Umbilical polyp
• Features of pulmonary tuberculosis • Umbilical adenoma
□ Investigations: • Enteroteratoma
• Haematocrit 0 Aetiology : Vitellointestinal duct partially unobliterated near umbilicus, and its mucosa prolapses
• ESR through umbilicus, giving rise to a tumor
« Chest X-Ray □ Age: Common in infants
* • FNAC of lymph node for AFB smear and culture q Histology: Columnar epithelium rich in goblet cells
' • PCFt □ Clinical features:
□ Treatment: Swelling protruding out near umbilicus with following features :
• Antitubereular drug • Reddish in colour
• Aspiration • Moist with mucus
• Incision and drainage • Tends to bleed on touch
• Surgical removal if failure of medical treatment Q Complications:
Q.83: Critical lim b Ischaemia « Infection
« Intestinal obstruction
CR ITIC AL LIMB ISCHAEM IA
0 Differential d iag nosis: Umbilical granuloma
O What is I t : Recurring ischaemic rest pain persisting for more than 14 days or ulceration and gangrene
□ Treatment:
of foot or toes with ankle systolic pressure less than 50 mm Hg or toe systolic pressure less than35
mmHg. • If pedunculated - firm ligature tied around its base, so that tumor falls off in few days
• Actual treatment - umbilectomy with excision of vitellointestinal duct and exploration of abdomen
(Rest - Refer to Section - 1 , Segment - D, Q.811Acute Limb Ischaemia’ (Page No. 538)]
(If associated Meckel’s diverticulum found, it is to be excised along with umbilectomy)
Q.64: Intermittent claudication
Q-8ff: Buerger's disease
INTERMITTENT CLAU D IC ATIO N
BUERGER’S DISEASE
□ What is i t : Crampy muscle pain due to arterial occlusion
□ N am ing: "Claudio" - Latin word meaning "I limp” ^ Synonyms:

□ Pathogenesis: Arterial occlusion -> accumulation of substance P and lactic acid in muscle -> Pain • Thromboangiitis obliterans
• Presenile gangrene
□ Claudication distance: The distance after walking which pain is experienced
□ Fontaine classification of limb ischaemia * What is i t : Non-atherosclerotic inflammatory disorder, involving medium sized and distal arterial
wa,J, with involvement of adjacent nerves and veins, terminating in thrombosis of artery, with cell
A : See Short Note ’Acute Limb Ischaemia’ mediated sensitivity to Type I and Type III collagen
 542 QUEST : A Comprehensive Guide to UG Surge»y, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 543

□ Etiology: (Compensatory peripheral disease)

• Smoking (> 20 cigarettes/day) i
• Chronic fungal infection Patient continues to smoke
• HIA B5/A9 inheritance I
• Autonomic overactivity Disease progresses, collaterals get blocked
• familial predisposition I
• Low socio-economic status Decompensated peripheral vascular disease OR Critical limb ischaemia
□ Shlanoya's crite ria : I
• Tobacco use Rest pain, ulcer, gangrene
• Disease starts before 45 years of age 3 S ym pto m s:
• Absence of hyperiipidaemia or diabetes meflitus , Intermittent claudication initially, progressing to rest pain
• DJstal extremity involved first without embolic or athero-sclerotic features , pain due to ischaemic neuritis and recurrent migratory superficial thrombophlebitis
• With or without thrombophlebitis • Postural colour change - » trophic changes -> ulceration and gangrene
. Classical triad o f :
□ Pathogenesis:
> Claudication
Carbon monoxide, nicotinic add in smoke > Superficial migratory thrombophlebitis
I > Raynaud's phenomenon
Trigger immune response .
3 Signs:
, I
Walls of small and medium sized vessels invaded by polymorphonuclear leucocytes • Features of ischaemia:
i > Pallor
Vasospasm + Hyperplasia of Inlima > Pulselessness (posterior tibial, artera dorsalis pedis)
I
> Pain
Thrombosis In vessels
> Paraesthesia
I
Obliteration of vessels > Paralysis
I > Hair loss
Panarteritis > Skin atrophy
I > Brittle nails
Artery and vein bound together by fibrous adhesions • Buerger’s test (angle at which pallor appears indicates severity)
1
> 90“ - normal
Adjacent Nerve also gets involved
< 20° - critical
i
Agonising pain • Fuschig's cross leg test (if popliteal pulsation present, oscillatory movement of leg perceived)
I Q In ve stig a tio n s:
Thrombus shows fibroblastic activity and endothelial proliferation
• Arterial Doppler and Duplex B-Scan
I
• Transbrachial angiogram
Thrombus organised into fibrous tissue
I • Transfemora! retrograde angiogram
Elastic lamina of artery thickened • USG abdomen (to look for abdominal aorta aneurysm)
I • Haemoglobin, blood sugar
Ischaemic features in limb
I
Collaterals open up to maintain blood supply to ischaemic area
 544 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 545

□ Treatment:
CcmP^ lions:_______________________________
Treatment Complications

CONSERVATIVE
T
SURGICAL OTHERS
r
SKIN
I
OTHERS

I Venous ulcer • Thrombophlebitis

VEGF - i.m injection Dermatitis • Hemorrhage
(endothelial ceil milo^ Eczema • Deep vein thrombosis
which promotes Maijolin’s ulcer • Periostitis, ankylosis of ankle
angiogenesis) Lipodermatosclerosis joint
• Calcification of vein
r
Pigmentation
• Talipes equino varus
Lumbar Arterial Omentoplasty Amputation
sympathectomy reconstruction (to revascularise rj venous u lc e r: Varicose veins -» chronic venous hypertension around ankle ->haemosiderin
(if gangrene
(in case of segmental affected limb) deposition in subcutaneous plane from lysed RBC -> eczema -» dermatitis- » fibrosis -> anoxia ->
(relieve pain, occurs)
promote ulcer proximal occlusion) ulcer, generally around and above medial malleoli
healing) Treated using Bisgard regime
9 Dermatitis and eczema: (Pathogenesis - see above)
Treated by application of ointment containing zinc oxide and coal tar twice daily or betamethazone
ointment
” 1 Q Marjolin’s u lce r: Wide excision is done
GENERAL MEDICAL
0 Lipodermatosclerosis : Refers to fibrin deposition + tissue death + scarring

Stop
r I
Care of
Vasodilators - e.g. Nifedipine

Low dose aspirin - 75 mg/day (due to

3 Pigmentation: Generally seen in lower part of leg
D Thrombophlebitis:
It is the inflammation of superficial veins
antithrombin activity
smoking limbs
Treatment:
Buerger's Pentoxiphylline (increases flexibility of RBC
and help them to reach micro-circulation in > Antibiotics ,
position
a better way to increase oxygenation) > Foam rubber with elastic bandage placed on inflammed vein
Buerger’s > Sleep with legs elevated
exercise Prostaglandin therapy (PGA - 1)
0 Hemorrhage: Profuse due to rupture of veins
Heel raise Treatment:
Phosphodiesterase inhibitor (clopldogrel,
cilostazole) > Application of firm pad and bandage
Care of feet > Elevation of leg
Analgesics Dextran 3 Periostitis: Occurs in long standing cases especially when venous ulcer is formed over medial
surface of tibia
Proper footwear Steroid
3 Calcification : Seen in walls of varicose veins, after many years
Phenylbutazone 0 Talipes equlno varus : Occurs due to practice of patients to walk on toes for relief of pain due to
varicosity, leading to shortening of Achilles tendon *
Treated by physiotherapy and remedial exercise
0.87: Complications o f varicose veins
°M : Horse shoe kidney
COMPLICATIONS OF VARICOSE VEINS HORSE SHOE KIDNEY
□ Varicose veins : Dilated tortuous veins due to reversal of blood flow through its faulty valves -* What is i t : Developmental anomaly of kidney where there is failure of complete ascent of kidneys
with fusion of lower poles commonly and upper poles rarely
 546 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 547

□ Aetiology: Tivatment:
N eed ed if complications arise (treated according to complications)
Fusion of subdivisions of mesonephric duct, at 30th - 40th day of intrauterine life
i g f i: polycystic kidney

Kidneys cannot ascend above origin of inferior mesenteric artery POLYCYSTIC KIDNEY
I
Ittfat is i t : Hereditary disease of kidney
Bridge of tissue joins the lower poles
j ^ of manifestation: After 40 years
□ Site o f fu s io n : Part of tissue joining the lower poles, in front of vertebra lies in front of l 4
■j mheritanee: Autosomal dominant (chromosome 16)
□ Pathology:
• Pelvis lies on anterior surface of kidney as normal rotation of kidney cannot occur ■j Laterallty: Bilateral
• Ureter rides over isthmus to traverse anterior surface of fused portion 3 Associated w ith : Cysts of pancreas, spleen liver
• Ureteral obstruction • 3 Aetiology:
• Aberrant renal vessels Defect in mechanism of joining between uriniferous tubules and collecting tubules
• Hydronephrosis i
• Infection Blind secretory tubules which are connected to functioning glomeruli become cystic
• Tuberculosis I
• Calculus formation Cysts enlarge
□ Sex predilection : 4.
• M >F Compress adjacent tissues
□ Symptoms: 1
• Assymptomatic Gradually occlude normal tubules
• Ureteral obstruction 3 pathogenesis:
• Complaints due to hydronephrosis, infection, calculus Mutation in genes PKD1 and PKD 2, which produce polycysteine proteins that inhibit overgrowth of
• Due to renodigestive reflex, gastrointestinal symptoms mimicking peptic ulcer, append* epithelium
cholelithiasis i
□ Signs: . Epithelial proliferation
i '
• Fixed
Blockage
• Non-mobile midline mass at L4 level
;
• Firm
Retention .
• Resonant
i
□ Investigations:
Cystic
• Intravenous urogram -
3 Pathology:
> Renal pelvis lies on anterior surface of its respective kidney
• Bilateral condition
> Medialisation of lower calyces
• Kidney enlarged 3-4 times
> Curving of ureter like flower-vase'
« Yellowish-red thin walled cysts, which do not communicate with renal pelvis
• USG abdomen
• Content - Thin/thick/viscid; yellowish/darkbrown/amber coloured
• CT, MRl abdomen
• Lined by single layer of cells - Flattened or cubical or columnar
» Tomograms
3 Symptoms :
• Renal scanning
• Appear after 40 years of age
□ Complications:
• Abdominal swelling
• Infection • Pain - Dull aching in loin (due to tension on renal capsule by enlarging cyst)
• Hydronephrosis - Acute abdominal (due to rupture of cyst)
« Ureteral obstruction - Colicky (due to stone)
• Calculus formation • Hematuria
 548 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 549

• Hypertension
• Infection
• Uraemia - Headache, nausea, vomit, anorexia, weakness, drowsiness Fibroma

□ S ig ns: Bilateral knobby lump Non-encapsulated

□ Investigations : really invasive
Haemoglobin Microscopically - Contains multinucteated plasmodial giant cells
Blood urea, serum creatinine
Urine examination Firm to hard mass with irregular surface
Straight X-Ray (enlarged renal shadows) j Spelling - Parietal (confirmed with leg raising test)
IVU - 'Splder-leg’ pattern with elongated compressed renal pelvis, narrowed and stretched rm
Hvestlgstlon :
USG - Confirms j- ^
DTPA renogram , USG abdomen
C om plications: , X-Ray
1 , Biopsy
Pyelonephritis
i Trtitment:
Hematuria
, Wide excision with 2.5 cm margin
Infection
i
Renal insufficiency
Mesh placement to abdominal defect
Uraemia • Drugs used - sundilac, tamoxifen
□ Treatment: . Moderately radiosensitive
A) Conservative: 3 Recurrence:
' > High fluid intake ■ High
> Low protein diet
ISl: Trscheo-oesophageal fistula
> Stop strenous activities
> Iron therapy T R A C H E O -OESOPHAGEAL FISTULA
> Antibiotics
3 What Is I t : A tract lined by unhealthy granulation tissue between trachea and oesophagus
> Control of hypertension
B) Surgical: J Associated w ith :
> Rovsing's operation (done for large cyst causing pressure over ureier) VACTER anomalies
(cyst opened -> fluid evacuated - » cut edge marsupialised] [V - Vertebral defects
> Hemodialysis followed by bilateral nephrectomy if renal failure sets in A - Anal atresia
C -Cardiacdefect (VSD/PDA)
Q.90: Desmoid tumor TE - Tracheo-oesophageal fistula
DESMOID TUMOR R - Radial hypoplasia, renal agenesis]
3 Types :
□ What Is I t : Benign fibrous tumor arising from musculo-aponeurotic layer of abdominal wall, espec*
below level of umbilicus • A-Total atresia
• B - Upper fistula + lower atresia
□ Synonym: Recurrent fibroid of Paget
• C - Lower fistula + upper atresia (commonest type)
□ Aetiology: • D- Upper & lower fistula
• Stretching ot abdominal muscles during pregnancy in multiparae women • E - ‘H’ type
• Trauma -1 Wnlcal features :
• Hematoma • Cough |
• Old abdominal operation scars • Cyanosis [ with 24 hours of birth of newborn
□ Associated with : • Regurgitation of feeds !
Gardner's syndrome 1. Familial adenomatous polyposis ‘ Constant pouring of saliva from mouth j
2. Odontomes '’instigations :
3. Osteomas Contrast study
4 Epidermal cysl • Passage of nasogastric tube
 SOLVED SHORT NOTES OF SEMESTERS 551
550 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

0 atls H '• Retention cyst occurring due to blockage of duct of sebaceous gland
• Chest X-Ray
• Echocardiography j Common s it e s :
□ T re a tm e n t : , Scalp
• Feeding gastrostomy done , Face
• Fistula identified and resected -» lower segment anastomosed to blind upper segment , Scrotum
(never seen in palms and soles)
0 . 9 2 : M a llo ry -W e is s s y n d ro m e
g p /th o g e n e sis:
MALLORY-WEISS SYNDROME Sebaceous glands situated In dermis, secretes sebum through sebaceous duct

□ W hat Is I t : Condition characterised by superficial linear mucosal laceration at oesophago-g^, 4.

If duct gets blocked
□ P a th o g e n e s is : Sudden increase in intra-abdominal pressure during vomiting is transmiii , 4-
oesophagus against closed glottis ' Gland becomes distended with Its own secretions
Q S it e : One O’ clock position at oesophago-gastric junction (commonest) I
Q A e tio lo g y : Severe vomiting (due to migraine/vertigo/alcohol intake) followed by severe hemaiem^, Sebaceous cyst

0 pathology:
O C lin ic a l fe a tu re s :
i Lining - Squamous epithelium (epidermal layer only)
• Severe vomit
• Content - Yellowish pultaceous material with unpleasant smell, containing sebum, fat
• Hematemesis
• WaH has a parasite - Demodex folliculorum
• Features of shock
0 Clinical fe a tu re s :
□ In v e s tig a tio n s :
• Oesophagoscopy (best) Swelling with following features :
• Gastroscopy with inflated stomach • Soft, cystic
. PCV • Smooth
• Haemoglobin % • Smooth
• Cotliac angiography • Painless
□ D iffe re n tia l d ia g n o s is : • Non-tender
• Oesophageal varices • Freely mobile
• Erosive gastritis
• Adherent to skin
□ T r e a tm e n t:
• Fluctuation positive .
• Nasogastric aspiration
• Transiflumination negative
• Intravenous fluid administration
• Bluish punctum present (indicates blocked duct) over summit
• NPM (nothing per mouth)
3 C om plications:
• Haemostatic agents like vasopressin
• Endoscopic injection therapy may be required « Abscess formation
• If continuous bleed - » long proximal gastrotomy • Infections
I • Sebaceous horn (due to hardening of slowly discharged sebum)
blood clots evacuated • Ulceration - Cock's peculiar tumor
I • Calcification •
mucosal tear oversewn • Malignancy
Treatment:
0 .9 3 : SEBACEOUS CYST
• Total excision of cyst
0 S ynonym s ; • If abscess -» drainage followed by excision
• Epidermoid cyst
• WEN
 SOLVED SHORT NOTES OF SEMESTERS 553
552 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

• If scrotal sebaceous cyst - (a) Extramural cau se s:

> Solitary -» excision • Aberrant renal vessels
> Multiple , Pressure on ureter by loaded sigmoid colon
y/ \ • Compression by carcinoma cervix, rectum, etc
affecting part affecting entire , Idiopathic retroperitoneal fibrosis
of scrotal skin scrotal skin , Retrocaval ureter
I I • Movable kidney causing kinking of ureter
that part of scrotal entire skin + cysts excised (b) intramural causes:
skin including i . Congenital pelvi-ureteric junction obstruction
cysts excised testis placed in pockets made in ■ Ureterocele
subcutaneous tissue at medial . Congenital atretic ureteric orifice
aspect of respective thigh • Inflammatory stricture of urethra following TB, removal of stone, etc
Q .9 4 : PHIMOSIS • Narrow ureteric orifice
. Neoplasm of ureter (mostly papilloma)
□ W hat is I t - Inability to retract the prepucial skin over glans penis, beyond corona glandis, due to ver,
small orifice of prepuce (c) Intraluminal causes :
• Stone in renal pelvis or ureter
□ A e tio lo g y -
t Congenital folds at upper end of ureter
A) Congenital: Pinhofe meatus, ballooning of prepuce during micturition
• Sloughed papilla in papillary necrosis •
B) Acquired:
B) Bilateral hydronephrosis -
> Traumatic
(a) Causes in urethra:
> Inflammatory - balanitis, balanoposthitis, posthitis
• Congenital -
' > Neoplastic - carcinoma penis
> Pin hole meatus
□ A ge- ■ > Congenital stricture of external urethral meatus
• Congenital - Detected within first few years of life > Congenital posterior urethral valve
• Acquired - Present later in life • Acquired -
□ C lin ic a l fe a tu re s - > BPH
• Difficulty in micturition • > Carcinoma prostate
• Recurrent pain and purulent discharge in cases of inflammation >• Inflammatory stricture of urethra
• Occassionaly paraphimosis > Carcinoma cervix, rectum, uterus
• Very small prepucial opening, such that prepuce cannot be retracted beyond glans penis > Phimosis
□ C o m p lic a tio n s - (b) Causes in bladder:
• Paraphimosis • • Calculus in bladder
• Prepuceal calculi • Neuromuscular dysfunction of bladder sphincter
• Retention of urine » Bladder neoplasm
• Balanoposthitis • • Neoplasm of organs adjacent to bladder
□ T re a tm e n t - Q Pathology-

• Circumcision Initially pressure burden is taken up by pelvis

0 .9 5 : UNILATERAL HYDRONEPHROSIS Burden taken up by calyces

OR i
Burden taken up by renal parenchyma
CAUSES OF BILATERAL HYDRONEPHROSIS
1
0 What Is h y d ro n e p h ro s is - Aseptic dilatation of renal pelvicalyceat system with accompanying Renal parenchyma thins out
destruction of kidney parenchyma, caused due to partial or intermittent obstruction to outflow of urine X
Dilatation of renal pelvis and calyces
□ A e tio lo g y -
(Average capacity of 7 - 10 cc changes lo 300 - 500 cc)
A) U nilate ral hydronephrosis - (obstruction above level of urinary bladder)
 554 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 555

□ S tage s - (based on communication of hydronephrotic sac with urinary tract)

• Open Com pll««lo n s ~
• Intermittent perinephric abscess
• Closed , pyonephrosis

□ C la s s ific a tio n - , Renal failure

I. Hydronephrosis only p in v e s tig a tio n s -

Hydronephrosis wilh hydroureter , Blood urea, serum creatinine
II. Pelvic , Hb%
Renal , USG abdomen
Pelvirenal , Straight X-Ray of abdomen - Enlarged renal shadow
, IVU - Flattened and club shaped calyces
ill. Extrarenal pelvic
, Whitaker Test
Intrarenal pelvic
, CT Scan
IV. Intermittent
, Isotope renography - DTPA scan
Persistent
g T reatm ent -
V. Unilateral
, if cause is aberrant renal vessel -> Hamilton Stewart operation (kidney mobilised and upper and
Bilateral without renal failure
lower poles approximated together so that artery is made to slip away from site of compression)
Bilateral with renal failure
• Other causes treated
□ F a te o f o th e r k id n e y in u n ila te ra l h y d ro n e p h ro s is -
> Posterior urethral valve -> cystoscopic figuration of valve
• Starts hypertrophying in 3 weeks > Phimosis - » circumcision
' • Assumes additional function to compensate failure of affected kidney > BHP - » TURP
□ C lin ic a l fe a tu re s - > Stricture urethra -> dilatation, urethrotomy, urethroplasty
A) Unilateral cases : • Anderson - Hyne's dismembered pyeloplasty (Spasmodic segment and redundant pelvis excised
• Dull aching loin pain + dragging sensation in congenital PUJ obstruction -> new pelvis created -> c u t end of pelvis anastomosed to the
• Right side more commonly affected ureter in dependent position)
• Non-dismembered pyeloplasty (PUJ not transected here)
• Acute renal colicky pain intermittently
• Bilateral cases
• Loin swelling with following features:
v! \
> Smooth
without with renal
*■ Ballotable renal failure failure
> Mobile
i 4-
> Moves with respiration
kidney functioning Bilateral nephrostomy
> Band of colonic resonance in front better operated and hemodialysis •
• Dietl’s crisis i.e., renal colic followed by passage of large volume of urine, thereafter loin first, other kidney
swelling disappears dealt after 3 months
• Renal angle tenderness • Laparoscopic or retroperitoneoscopic pyeloplasty
• Dysuria
0.96: S tagh orn c a lc u lu s
• Hematuria
• Hypertension in some cases STAGHORN CALCULUS
B) Bilateral c a s e s :
Q What is i t - Stone occupying renal pelvis and calyces
• Features of bladder outlet obstruction - frequency, urgency, hesitancy
Q Synonym - Triple phosphate stone
• Loin pain
• Altacks of renal colic 3 Content - Calcium phosphate + Aluminium phosphate + Magnesium phosphate

• Loin swelling Q L a te ra lity - Bilateral

• Severe cases - oliguria, edema, hiccough Q C o lo u r- White
9 C o n s is te n c y - Soft
^ S u rfa c e - Smooth
 556 QUEST : A Comprehensive Guide .o UG Surgery, Orthopedcs & Anesthes,ofogy SOLVED SHORT NOTES OF SEMESTERS 557

□ S hape - Coffin lid shaped

, Sepsis
□ A e tio lo g y - Pre-existing infection (commonly E. Coli) pre-malignant conditions (leukoplakia, erythroplakia, hyperplastic candidiasis, oral submucosal
□ C lin ic a l fe a tu re s - fibrosis)
» Pain over renal angle, lumbar, hypochondriac region 0 pathology-
, Macroscopy:
Dull Colicky
> Proliferative
(due to stretching (due to movement
> Ulcerative
of capsule) of small stones) •
y Verrucuous
• Vomit (due to renogastric reflex)
• Pyuria . Microscopy:
• Fever > Squamous cell carcinoma (commonest)
• H em aturia
> Adenocarcinoma
• Renal angle tenderness 0 SHe­
□ C o m p lic a tio n s - , Posterior half of cheek commonly
• Pyonephrosis 0 Spread-
• Pyelonephritis , Direct- outwards to skin (fungation, ulceration, fistula formation)
• Perinephric abscess - deeper to buccinator, pterygoids, base of skull, mandible
• RenaJ failure
• Lymphatic - submental, submandibular, deep cervical, lateral pharyngeal
□ In v e s tig a tio n s -
• Plain X-Ray KUB a Clinical features-
• USG abdomen • Ulcer with induration and everted edge - initially painless, gradually increases in size
• IVU • P a in -if Involves skin, bone
• Blood urea, serum creatinine • Referred pain to ear (due to involvement of lingual nerves)
• Urine microscopy and culture and sensitivity • Trismus 1 due t0 jnv0|vement of pterygoids or posterior extension
• Isotope renogram - DTPA • Dysphagia >
□ T reatm ent - • Involvement of relromolar trigone
• Antibiotic • Submandibular and upper deep cervical lymph nodes - enlarged, hard, nodulas, fixed

• PCNL (if size > 2.5 cm) • Infiltration of nerves-

> CN XI - defective shrugging of shoulder
• Unilateral cases -> nephropyelolithotomy
> CN XII - deviation of tongue to same side
f f i l a S CaSGS “ *Dkidney beH8r ,unctionin9 trealed firs». «her kidney after 3 months > Cervical sympathetic chain - H om er's syndrome
Bilateral cases + Pyonephrosis - » initially bilateral nephrostomy
• Fungation and bleeding from major vessels (carotid blow out)
i • Absence of superficial temporal artery pulsation (due to compression of external carotid artery)
nephropyelolithotomy after
□ TNM s ta g in g :
. proper IVU
• Nephrectomy In some cases T|~Size < 2 cm N( - Lymph node < 3 cm, same side N3 - Lymph node > 6 err
0 .9 7 : C a rc in o m a o f c h e e k
T j-S iz e 2 - 4 c m N2 - Lymph node 3 - 6 cm Mg - no invasion

CARCINOMA O F C H E E K T3 -S ize > 4 cm a -» Single M^ - distant spread

0 P re c ip ita tin g fa c to rs - T< - Any size involving bone, b -» Multiple, same side
soft tissue, muscle c -» Multiple, bilateral or
• Betal nut chewing
opposite side
• Smoking
• Spirit
^ In v e s tig a tio n s -
• Sharp tooth
• Spices • Edge biopsy - from 2 sites (Keratin pearls seen)
• Syphilis • FNAC from lymph node
 558 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF SEMESTERS 559

• Orthopantomogram
« CT Scan Sunderland’s Classification

□ Treatm ent - L Conduction block

II Axonotmesis with preservation of endoneurium
1. Early growth, no bone involved -» Curative radiotherapy OR Wide excision
II, Disruption of endoneurium
2. Growth + Mandible involved -> Wide excision + Hemi mandibulectomy
IV Disruption of endoneurium and perineurium
3. Operable growth + Mobile lymph node on same side -» Wide excision + Radical
node dissection (RLND) * iyrnph y Disruption ol endo, peri and epineurium - Neurotmesis

4. Operable growth + Mobile lymph node on opposite side -» Wide excision + RLND on c o J9: Venesection
4 Functional block dissection on opposite side an>eside
VENESECTION
5. Fixed primary tumor -» Palliative external radiotherapy
OR g synonym - Venous cut down
Advanced neck lymph node secondaries n what is I t - Procedure in which vein is exposed, venotomy done and a wide bore cannula introduced
6. If extend to upper alveolus -» Partial/Total maxillectomy inside vein under direct vision
7. Others - (a) Post-operative radiotherapy in Ta, T4 □ indica tions-
(b) Prophylactic block dissection in No , In patients requiring profonged intravenous fluid therapy
(c) Pre-operative radiotherapy if fixed lymph node , in patients requiring rapid fluid infusion - e.g., burn, shock
8. Chemotherapy before and after surgery . For measurement of CVP
9. Post-operative reconstruction by flap surgery , For parenteral nutrition
0 .9 8 : Classification o f nerve Injury 0 veins s e le c te d -
. Basilic vein
■ CLASSIFICATION OF NERVE INJURY • Cephalic vein
A. Seddon’s Classification - • Great saphenous vein [advantage is that it Is superficially placed] (sometimes contraindicated as
vein used for CABG)
• NEUROPRAXIA :
0 Steps -
> Temporary physiological paralysis of nerve conduction
Area cleaned with povidone iodine and draped
> No organic damage to nerve fibre or sheath 4'
> Produced by minor stretching . 1% lignocaine injected transversely across the vein
> No reaction of degeneration 4
> Recovery complete, taking hours to weeks Transverse incision made across the vein and deepened upto subcutaneous tissue
<1
• AXONOTMESIS: Vein dissected from surrounding tissue
> Rupture of nerve fibres or axons within intact nerve sheath i
> Wallerian degeneration occurs in distal portion of broken axons leaving nerve sheaths Ligatures passed proximal and distal to the incision site around the vein, but only the distal one is tied
empty tightly, held by hemostatic forceps
4r
r Time required for recovery varies - occurs first in muscle nearest to lesion and lastly in
peripheral skin Curved needle passed through middle of vein (to facilitate venotomy)
4>
> Produced by compression by tourniquets, stress due to fractures, dislocations, etc Vein wall in front of needle incised
^ ^ *oss sensation, diminished tone and power, anesthesia and paralysis of muscles i
pestricted to area supplied by damaged nerves 6F size infant feeding tube or scalp vein catheter introduced
> Treated by proper nutrition, passive movement of joints, exercise of paralysed m u s c le s I
• NEUROTMESIS: Proximal ligature tied to fix cannula with in vein

> Partial or complete division of nerve fibres and their sheaths End of cannula tied to intravenous fluid channel
y Partial lesion produces lateral neuroma, complete lesion produces terminal neuroma ■ i
> Retrograde degeneration occurs upto first noda of Ranvier Cannula fixed to skin by a suture passed around it and skin incision closed with interrupted skin sutures
> C/F - complete loss of motor and sensory function and loss of reflexes 3 C o m p lic a tio n s -
> Recovery incomplete
• Hemorrhage
> Treated by nerve suturing
• Infection
 SOLVED SHORT NOTES OF SEMESTERS 563
562 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

or markers - Substances found in blood, urine or body tissues that are elevated in specific
□ C lin ic a l fe a tu re s -
Smooth 3 cancers
Detected by - Immunohistochemistry
Cystic in consistency
Hemispherical shape 1 m arkers r a is e d In d iffe re n t te s tic u la r tu m o rs -

Non-tender ^ /Uphafetoprotein (AFP) - Raised in teratoma

Well-localised ' _ Raised in a) chorio carcinoma
Fluctuant b) teratoma
May be transllluminant Non seminomatous
c) embryonal carcinoma
germ cell tumor
E ffe c ts - d) 10% advanced cases of seminoma
Compression of adjacent structures placental alkaline phosphatase - Raised in seminoma
Infection LDH " Raised in 80% advanced seminoma,
Hemorrhage 60% non-seminomatous germ cell tumor
Rupture Importance o f tumor markers - Helps in delecting seminoma and teratoma as mode of treatment
Calcification isdifferent for the two varieties
Torsion Seminoma -» a) High orchidectomy + radiotherapy
B r illia n tly tra n s lllu m in a n t c y s ts - b) Cisplatin (chemotherapy)
Ranula Teratoma -» a) High orchidectomy + Retroperitoneal Radical Lymph Node Dissection (RPLND)
Lymph cyst b) Cisplatin (chemotherapy)
Epididymal cyst
2)03; Primary hydrocele
O- Fa lse c y s ts -
PRIMARY HYDROCELE
Pancreatic pseudocyst
Cystic degeneration of tumor 0 Hydrocele - Abnormal collection of serous fluid in between the two layers of tunica vaginalis or
Post-hemorrhage in a hematoma within some part of processus vaginalis
Apoplectic cyst in brain 3 primary hydrocele - Hydrocele whose cause is unknown
3 Types of primary hydrocele -
Q .1 0 2 : TESTICU LAR TUMOR M ARKERS
• Vaginal hydrocele (commonest)
Q H is to lo g ic a l c la s s ific a tio n o f te s tic u la r tu m o rs • Congenital hydrocele (whole processus vaginalis remains patent)
• Funicular hydrocele (processus vaginalis patent upto top of testis)
• Infantile hydrocele (tunica vaginalis and processu s vaginalis distended upto internal ring, but sac
If has no connection with peritoneal cavity)
Germ cell tumors Sex cord stromal Combined germ cell Others • Encysted hydrocele of cord
tumor and sex cord • Hydrocele of canal of Nuck (in relation to round ligament)
►Lymphoma
stromal tumor • Hydrocele of hernial sac (due to adhesions in hernial sac)
►Sertoli cell
Seminoma tumor • Bilocular hydrocele/hydrocele-en-bisac (two intercommunicating sacs)
►Carcinoid
Leydig cell Gonadoblastoma 3 Composition o l h y d ro c e le flu id -
Non-seminomatous
tumor • Colour - Amber
►Choriocarcinoma • Spedfic gravity - 1.022-1.024
• Granulosa cell
►Teratoma tumor • Content - > water
Seconds"*
►Embryonal > inorganic salts
Adnexal and > 6% albumin
carcinoma
para testicular > fibrinogen
►Yolk sac tumor tumor
> cholesterol and tyrosine crystals
►Sarcoma Aetiology -
• Defective absorption of hydrocele fluid
■Mesothelioma ■“ Excessive production of hydrocele fluid
 564 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 565

• Interference with lymphatic drainage of the fluid Disappears in suPine posture as fluid in tunica vaginalis drains into abdominal cavity
• Connection with peritoneal cavity ' easily reducible
□ C lin ic a l fe a tu re s - ' Csiriotbe emP,ied by d'9',al pressure as it causes “inverted ink bottle" effect
• Age - Congenital variety since birth, rest in middle aged people jreitment -
• Scrotal swelling (inguinal swelling in funicular type, inguinosorotal swelling in infantile h Harmiotomy
With following features:
> Unilateral/bilateral
0
j ; Encysted hydrocele of cord

> Possible to get above swelling in vaginal type ENCYSTED HYDROCELE OF CORD
> Fluctuation test positive
Hydrocele - Abnormal collection of serous fluid in between the two layers of tunica vaginalis or
> Transillumination test positive
*aiin some part of processus vaginalis
> Dull on percussion
facysted hydrocele o f cord - Central portion of processus vaginalis remains patent, (upper and
> Irreducible
lower parts become obliterated) around which fluid accumulates
> Testis cannot be felt separately (in vaginal type)
Hamlng - Named so, as it presents as a swelling in relation to spermatic cord
> Congenital hydrocele disappears when patient lies supine
3 Futures of hydrocele fluid - See'Primary Hydrocele’
> Traction test pathognomonic in encysted hydrocele of cord
> Cross fluctuation test pathognomonic in bilocular hydrocele 3 ctottcal fea ture s -
, Cystic swelling in inguinal, inguino - scrotal or scrotal region depending on the site of patent
□ C o m p lic a tio n s -
processus vaginalis
• Infection
« Oval cysting swelling in relation to spermatic cord
• Rupture
■ Fluctuation test positive
• Calcification of sac
• Transillumlnation test positive
• Haematocele
■ Testis can be felt separate from the swelling
• Atrophy of testis
• Irreducible
□ T reatm ent - • Cough impulse absent
• Vaginal hydrocele : . « Traction test pathognomonic (on gentle traction, swelling moves downwards and becomes less
> Small - Jaboulay's method of aversion of sac mobile)
> Big - Lord's plication 3 Complications - See Section - 1 . Segment - 1 , Q.103, ‘Primary Hydrocele’ (Page No. 563)
• E ncysted hydrocele o f cord - Excision 3 Treatment- Excision
• C ongenital hydrocele - Herniotomy HIM: Secondary h y d ro c e le
Q.104 : C o n g e n ita l h y d ro c e le
SECONDARY HYDROCELE
C O NG ENITAL HYDROCELE
2 Hfdrocele - Abnormal collection of serous fluid in between the two layers of tunica vaginalis or
□ Abnormal collection of serous fluid in between the two layers of tunica vagii
H y d ro c e le - *ith*n some part of processus vaginalis
within some part of processus vaginalis ^ Secondary h y d ro c e le - Hydrocele is secondary to a disease in testis and/or epididymis
□ Processus vaginalis remains patent, hence tunica vaginalis dire# 3 Aetiology-
C o n g e n ita l h y d ro c e le -
communicates with peritoneal cavity A) Infection - • Acute epididymoorchitis
[Hernia does not occur as the communicating orifice at deep inguinal ring is too small for protrusjon • Filarlasis Due to excess production of
of abdominal contents] • Tuberculosis hydrocele fluid
□ A e t io lo g y - (a) Tuberculous peritonitis in children (b) Ascites • Syphilis
□ A ge - Present since birth Malignancy
□ F e atures o f flu id - See ‘Primary Hydrocele’ (Page No. 563). C) Trauma - Posthemiorraphy hydrocele
□ C lin ic a l fe a tu re s - Inguinoscrotal swelling with following fealures : ^ futures o f h y d ro c e le f lu id - See ‘Primary Hydrocele' (Page No. 539).
• Appears in erect posture
 SOLVED SHORT NOTES OF SEMESTERS 567
566 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology

pressure garments
□ C lin ic a l fe a tu re s - • Management of itching at scar regions using antihistaminics, moisturising creams, aloe vera
• Small swelling (except in filariasis) silicone gel treatment
• Lax
a 0 ; VolVUlUS
• Testis palpable
• Fluctuation positive VOLVULUS
• Transillumination positive
g What Is I t - Rotation of gut in its own axis in clockwise or anticlockwise direction
□ T reatm ent -
• Rest P Sites­

• Aspiration , Sigmon colon (commonest)

• Antibiolics , Caecum
, Small intestine (volvulus neonatorum) - See Sec-1, Sec • C, MB Paper 1,2014, Q. 4 [Pg. 313]
Q .1 0 7 : P o s t-b u rn c o n tra c tu re
, stomach
POST-BURN CO NTRACTURE sigmold volvulus - Sigmoid colon rotates in its own axis in clockwise or anticlockwise direction to

cause acute intestinal obstruction

□ W hat Is i t - Tightening of skin after a second or third degree bum
g predispo sing fa c to rs -
□ A e tio lo g y - When a skin gets burnt, the surrounding skin begins to pull together, resulting inconlractufe
, Overloaded colon
□ E ffe c ts -
« Long pelvic mesocolon
• Face - Disfigurement
, Adhesions
• Eye - > Ectropion
. Short/narrow attachment of sigmoid mesocolon
> Entropion
. Peridiverticulitis
> Corneal ulcer
> Corneal sclerosis Q Pathophysiology-

• Mouth - Microstomia , <154 turn -» venous obstruction -> congestion -* CO2 diffuses into lumen -» huge colonic
• Neck - Restricted neck movement distension
• > 114 turn -> arterial obstruction -» gangrene -> perforation -> peritonitis
• Finger - > Swan neck deformity
(DIP hyperflexion, PIP hyperextension) • Q Clinical features -

> Boutennaire deformity • Age - Elderly

(PIP hyperflexion, DIP hyperextension) • Sex predilection - M > F
• Limbs - Contracture and restricled movements at wrist, elbow, knee, ankle, toes . Sudden colicky lower abdominal pain starting from left side and then spreading throughout abdomen
• Marjolin's ulcer (See Short Note ‘Marjolin’s ulcer1, Page No. 421) • Huge abdominal distension
• Others - > Hypertrophic scar and keloid • Absolute constipation
> Growth retardation in children • Vomiting (very late feature)
> Repeated breaking of scar, infection • Features of shock
> Pain, tenderness in scar contracture • Tyre-like feel of abdomen
□ P re v e n tio n - 0 Inve stigatio ns -
In case of burnt hand -» splinting of hand and wrapping of each finger individually • Routine blood investigations
In case of burnt neck -> hyperextension of neck during healing process • Straight X-ray abdomen
Joint exercise in full range during recovery (a) Dahl-From ent's sign or Coffese bean sign or Bent inner lube sign :
Topical silicon sheeting > Hugely dilated large gut loop extending from pelvis to upper abdomen
Saline expanders for scar > Two loops distinctly seen with outer borders
Pressure garments for long period > Intervening wall formed by inner walls
T reatm ent - > Distended gut walls seem to be converging towards pelvis
• Release of contracture surgically -» use of skin grail or 'Z-plasty’
 568 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 569

(b) f l (omega) sign : Single grossly dilated loop of colon arising out of pelvis and ext Qinlcal fea ture s -
towards diaphragm
Marked abdominal distension
• Contrast enema - Bird’s beak sign
' Absenl bowel sounds
• CT abdomen ' No passage of flatus - Absolute constipation
T reatm ent - , Vomiting (effortless)
• Hospitalisation Absence of pain/dull abdominal pain
• Resuscitation with i.v. fluids \ Tachycardia
• Catheterisation , Respiratory distress
• Antibiotics Features of electrolyte imbalance
• Flatus tube/Sigmoidoscope passed j investigations -
- - _ _ —
X-ray abdomen - Multiple fluid levels and gas shadow
If derotation occurs Derotation does not occur
, USG abdomen
; i
Patient passes flatus Laparatomy through midline incision . ECG
, Serum electrolytes estimation
and faeces, distension
reduces ! 3 Treatment -
Dilated sigmoid colon derotated manually , Nasogastric aspiration
X , j.v. fluid administration
Checked for viability , Intestinal decompression using flatus tube
✓
If viable Not viable ( Electrolyte management
I I • Primary cause treated
SigmoidopexyResection and anastomosis ■ Urine output measurement by catheterisation
✓ ^
Distal end brought out as Distal end closed
CAUSES OF INTEST INAL OBSTRUCTION
mucus fistula from rectum (Hartmann’s operation)
(Paul - Miculicz operation)

1 'r ^
0 .1 0 9 : PARALYTIC ILEUS Duodenum Heum Large Intestine

□ S y n o n y m - Adynamic intestinal obstruction 1 and . xb« trictures * TB stricture

Jejunum . Gall stone ileus • Malignancy
□ W hat Is It - State of failure of transmission of peristaltic waves due to neuromuscular failure in
« Congenital • Mai gnancy • ARM
Auerbach’s and Meissner’s plexus
! • Leiomyoma • Her lias * Volvulus
□ P atho gen es is - • Lipoma • Rou ndworm • Congenital
Failure of transmission of peristaltic waves • Malignancy • Con genital megacolon
i • Bands and adhesions • Crolin’s disease • Bands and adhesions
Accumulation of intestinal fluid and gas in lumen
X
Abdominal distension 0.IW; MECONIUM ILEUS
□ Types - 3 What Is It - Neonatal manifestation of fibrocystic disease of pancreas, where intestinal obstruction is
caused by impaction of meconium in distal ileum
Types Causes
3 Associated w ith - Cystic fibrosis, respiratory dysfunction, exocrine pancreatic insufficiency
• Postoperative paralytic ileus • Infective - pus, blood, bile, toxins
^ Clinical fe a tu re s -
• Peritonitis • Uraemia, Hypokalemia __ _
4 Occurs in neonates i
• Metabolic paralytic ileus • Retroperitoneal hemorrhage 1 Distended abdomen
* Ascites (due to meconium spillage from perforation or inflammatory response to the ischaemic,
• Reflex paralytic • Spinal injury, Plaster jacket
over distended small intestine)

n
 570 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 571

Failure ol passage of meconium , . Levels ol SSI Clinical features

Bilious vomit 3) Organ or space infection • Abscess formation
Respiratory dysfunction (Affects part of the body which
Small and empty rectum has not been manipulated
In v e s tig a tio n s - during surgery)
Plain X-ray abdomen: Calcified meconium pellets with multiple air fluid levels a p p e a iin n .
a fliskfactors-
bubbles (Neuhouser sign) ----------------— 1
. Factors that increase risk of endogenous contamination . ae
Vomitus (containing trypsin) does not digest gelatin of X-ray film when poured on it _ e.g., procedures that involve body parts with high concentration of normal flora, such as the
Sweat analysed for sodium and chloride (> 90 m mol/lit)
bowel
Contrast enema - Microcolon 4 terminal ileum filled with pellets of meconium , Factors that diminish efficacy of general immune response
Elevated albumin level in meconium _ e.g., steroids, immunosuppressive therapy
C o m p lic a tio n s - , Factors that increase the risk of exogenous contamination
Intestinal bolus obstruction - - e.g., Prolonged operations
Volvulus
Gangrene 0 A ge­
, Age more than 40 years is a risk factor
Perforation
Peritonitis 1X112: A b s c e s s
□ T re a tm e n t - (i) Non-operative (ii) Operative ABSCESS
• N o n -o p e ra tiv e :
a What Is it - Localised collection of pus in a tissue space, organ or cavity
> Gastrograffin contrast enema
> Acetylcholine wash a Types-
> Treatment for cystic fibrosis • Pyogenic abscess
• O p e ra tiv e : • Pyaemic abscess
t Metastatic abscess Rest: See Next Qs. (Q.113 &Q .114)
> Bishop Koop operation
• Cold abscess
0 .1 1 1 : S u rg ic a l s ite in fe c tio n aJJJ; Pyogenic Abscess
SUR G ICAL SITE INFECTION Q Define - Localised collection ol pus in a cavity, lined by granulation tissue, covered by pyogenic
membrane
□ S u rg ic a l s ite - Incision or cut in skin made by a surgeon lo carry put a surgical procedure andd*
tissue handled or manipulated during the procedure Q Causative o r g a n is m s -
□ S u rg ic a l s ite In fe c tio n - This occurs when microorganisms gain entry into the part of the body that • Staphylococcus aureus
has been operated on, and multiply in the tissues • Streptococcus pyogenes
□ W hen d o e s it b e c o m e a p p a re n t - • Anaerobes
• Gram negative bacteria
• Most often between 5th - 10th post-operative day
3 Mode o f In fe c tio n -
• SSI affecting deeper tissues occurs after several months of theoperation
• Direct
• L e v e ls o f S SI C lin ic a l fe a tu re s • Haematogenous
1) Superficial incisional • Swelling • Lymphatics
(Affects skin and • Pain • Extension from adjacent tissues
subcutaneous tissue) • Redness Q Risk fa c t o r s -
• Heat at site of SSI • Malnutrition
2) Deep incisional • Fever • Anaemia
(Affects fascial and • Presence of pus • Extremes of age
muscle layers) • Tenderness • DM
• Throbbing pain • HIV
• Separation of edges of incision exposing
, • RTA
deeper tissues • Type and virulence of organisms
 S72 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 573

□ P a th o g e n e s is - [See Fig. 1.7.6] Mode o f tre atm e nt:

• Macrophages and polymorphs release lysosomal enzymes which cause liquefaction y Drainage of abscess
- » pus formation > Antibiotics
• Protein exudation - » fibrin deposition + pyogenic membrane formation g114 : C old Abscess
□ C lin ic a l fe a tu re s -
COLD ABSCESS
• Localised swelling -> smooth, soft, fluctuant •
• Fever with chill and rigor a No signs of Inflammation
• Visible (pointing) pus , caused by M ycobacterium tuberculosis
• Throbbing pain , Non-dependent incision given

• Pointing tenderness , No drain placed

• Redness, local warmth at site of abscess fl.ffJ.‘ Necrotislng fasciitis
0 S ite s - .
NECROTISING FASCIITIS
A) E xternal B) Internal
• Neck • Retroperitoneal 0 What Is i t - Spreading Inflammation of skin, deep fascia and soft tissues with extensive destruction
• Axilla • Lung and toxaemia
• Breast • Brain q fa u sa tlve o rg a n is m s -
• Dental • Retropharyngeal , . Streptococcus pyogenes
• Abdominal wall • Anaerobes
□ In v e s tig a tio n s - t Gram negative bacteria
. • TLC -R aised 0 Sites -
• Blood sugar t Lower limb
• USG • Groin
• Gallium isotope scan < Porineum
• Blood culture i Lower part of abdomen
□ C o m p lic a tio n s - 0 Risk factors - -
• Septicaemia • • Old age
• Antibioma • Immunocompromised individuals
• Sinus, fistula • Smoking
• Brain abscess - » RICT, epifepsy • DM
• Lung abscess ->Bronchopleural fistula, AROS
• HIV
• Liver abscess -* Hepatic failure
Q Types -
□ Treatm ent -
• I - due to mixed infection
• P rin c ip le :
• II - due to streptococcus pyogenes
> Abscess should be formed during draining
• E x c e p tio n s :
Q Pathology -
Acute inflammation
V Axillary I ■
> Breast Edema
> Parotid i
> Thigh Necrosis
> Ischiorectal I
Cutaneous microvasculature thrombosis
• Features o f form ed a b s c e s s :
V Visible pus Q Clinical fe a tu re s -
'r Pointing tenderness • Rapid spread of infection
> Fluctuation • Sudden swelling and pain in affected part
> Excruciating pain
 574 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTERS 575

• Edema f Discharge study

• Discolouration
• Foul smelling discharge j MB'
• Oliguria Q Treatment -

• Features of toxaemia - low BP, high fever with chill and rigor , Radiotherapy
□ M anagem ent - Exploration of fistula
) Anticholinergics
• i.v. fluid
, Newman Sebrock’s operation
• Fresh blood transfusion
If still features persist -> secretomotor supply of parotid (CN VIII) is cut
• Antibiotics
If stenosis at orifice of Stenson’s duct - » papillotomy at orifice
• Catheterisation
Failed cases -> Total conservative parotidectomy
• Control of DM
• Pus-culture and sensitivity (IfIT: Frey’s syndrome
• Blood culture
» Electrolyte management and monitoring FREY’S SYNDROME
• Radical wound excision of gangrenous skin and necrosed tissue at repeated intervals
• Oxygen inhalation 0 Synonyms -

• Vacuum assisted dressing , Auriculotemporal Syndrome

• Split skin graft when healthy granulation tissue appears , Gustatory sweating
. Baillarger's syndrome
0 .1 1 6 : P a ro tid fis tu la .
• Dupuy’s syndrome

. PAROTID FISTULA 5 tim e d a fte r -

» Lucie Frey (Polish surgeon)
□ W hat Is i t - Fistulous tract connecting parotid duct/gland to external skin
0 What is I t - A condition where there is sweating of the face during chewing of food
□ O rig in - From parotid duct/gland/ductules
□ O p e n in g - Q P ilh o lo g y -
Intercommunication between post-ganglionic parasympathetic fibres from otic ganglion and
• Inside mouth (internal fistula)
sympathetic nerves from superior cervical ganglion
• Outside mouth (external fistula)
I
□ Types -
Occurs in auriculotemporal nerve
• Major (when tract connects parotid duel) i
• Minor (when tract communicates with minor ductules or acini) Auriculotemporal nerve has 2 branches
□ A e tio lo g y - Auricular branch Temporal branch
• After drainage of parotid abscess I i

• After superficial parotidectomy Supplies external acoustic meatus, skin of auricle Supplies hairy skin of temple
• Trauma above external acoustic meatus, surface of
• After biopsy tympanic membrane

O D is c h a rg e -
4.
Injury to auriculotemporal nerve
• Profuse amount from duel
I
• Minimal from gland Sweating and hyperaesthesia occurs in the area of skin supplied by its branches
□ C lin ic a l fe a tu re s -
0 Aetiology - Surgery/accidental injury to parotid gland or temporomandibular nerve
• Passage of saliva through external opening - 'Aggravated during taking food
2 Clinical fe a tu re s - Flushing + sweating + pain + hyperaesthesia - in skin over face during mastication
• Tenderness
3 Investigation - Starch-iodine Test
• Trismus
Involved skin painted with iodine
□ In v e s tig a tio n s -
• Sialography . i
* Dried
• Fistulogram
 SOLVED SHORT NOTES OF SEMESTERS 577
576 QUEST : A Comprehensive Guide (o UG Surgery, Orthopedics & Anesthesiology

A
Dry starch applied over it
I
Blue colour in affected area
(due to increased sweat in affected area)
□ T reatm ent -

• Jacobsen neurectomy
• Inj. Botulinum toxin to affected skin
• Antiperspirants
pouch
• Stemomastoid flaps placed over parotid bed

0 .1 1 8 : A d e n o ly m p h o m a ol

ADEN O LYM PHO M A

□ S ynonym s - Fig. 1.7.1 : Pharyngeal Pouch

• Warthin’s tumor
• Papillary cystadeno lymphomatosum
□ W hat Is I t - Monomorphic adenoma arising from parotid epithelium
□ O rig in - During embryonal life, jugular lymph sacs get trapped
□ S ite - Usually lower pole of parotid gland
□ C o m p o s itio n -
(i) Double layer of columnar epithelium
(ii) Lymphoid tissue in stroma
(iii) Papillary projections into cystic spaces
□ A g e - 60 years and above
□ S e x p re d ile c tio n - M » F
□ C lin ic a l fe a tu re s -
Swelling with following features :
• Smooth
• Soft
• Cystic
• Often bilateral
• Non-tender
• Fluctuation positive
• Transillumination negative
• In lower pole of parotid gland
□ In v e s tig a tio n s -
. FNAC
• Tech99m scan -> "hot spot" (diagnostic)
□ T reatm ent -
• Superficial parotidectomy
578 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology SOLVED SHORT NOTES OF SEMESTFpo

Lvmph
node
Matting

• .V o -

S tage 1 Stage 2

Fibrous band
(C hordee)

Fig. 1.7.3 : Chordee

Stage 5

Fig. 1.7.5 : Collar stud abscess

Hypertrophied zone (most proximal pari with normal ganglion

cells, dilated with hypertrophied circular muscle fibres)

Pyogenic membrane

Granulation tissue
Transition zone (proximal to aganglionic zone, contains few
ganglion cells forming a cone)
Loculi

Pus

Aganglionic zone (distal immobile spastic segment)

Fig. 1.7.4 : Hirschsprung's disease

Fig. 1.7.6: Pyogenk> Abscess

 SOLVEO SHORT NOTES OF INVESTIGATIONS 581

SEGMENT - E
fo r p o s itiv e lavag e In d ic a tin g tra um a
SOLVED SHORT NOTES OF INVESTIGATIONS \ > = 10ml blood
, RBC count > 1lakh/mm3
Q .1 :F .A .S .T , WBC count > 500/mm3
Amylase level in fluid >175 lU/dl
F.A.S.T
presence of bile, bacteria, food particles or foreign body
□ F u ll f o r m : Focussed Abdominal Sonar Trauma - c o n tra in d ic a tio n s :
□ W hat Is I t : Rapid bedside USG , When laparotomy is definitely indicated
0 P u rp o s e : Screening test for blood collected around heart or abdominal organs after trauma , previous laparotomy
□ A rea s e x a m in e d : ”4P" , pregnancy
• Pouch of Morrison/Hepatorenal recess , Obesity
• Perisplenic space g disadvantages:
• Pericardium . Invasive
• Pelvis < Not portable i.e. not a bedside method
□ E x te n d e d F .A .S .T : Also allows lo r the examination of both lungs by adding bilateral anterior thora* « No quicker assessment
sonography to the F.A.S.T examination -» allows detection of pneumothorax 0 No* re placed b y :
□ A d v a n ta g e s :
FAS.T
• Less invasive than Diagnostic Peritoneal Lavage
. • Involves no exposure to radiation HJ-.SPECT Scan

• Cheaper than CT scan, but similar accuracy SPE C TS C A N

• Quicker evaluation of trauma patients
• Portable bedside method fl Full fo r m : Single Photon Emission Computed Tomography
3 What is I t : Nuclear medicine tomographic imaging technique using gamma rays, showing how blood
□ D is a d v a n ta g e s :
flows to tissues and organs
• Cannot detect blood < 100ml in cavities
• Not reliable for bowel or penetrating injuries 3 Working p r in c ip le :
• Often needs to be repeated Integrates 2 technologies to view the body - (a) CT scan (b) Radioactive material
□ In te rp re ta tio n : Positive F.A.S.T result -> appearance of a dark (anechoic) strip in dependent areas Patient injected with a radiolabelled chemical
FJfght upper quadrant - Morrison's pouch
Emits gamma rays detected by scanner
Left upper quadrant - Perisplenic space
Pelvis - Behind bladder (Pouch of douglas)
Computer collects this information
□ W hat is d o n e n e x t :
I
_ Stable patient -» CT scan
Translates it into 2-D cross-sections
Positive result CT
i
^ Unstable patient -> Laparotomy
These cross-sections added together to form a 3-D image
Negative result - * Search for extra - abdominal sources of bleeding
3 Radioisotopes u s e d :
Q. 2 : D ia g n o s tic p e rito n e a l la va g e • Io d in e -123
DIAG NO STIC PERITONEAL LAV AG E (DPL) • Technetium - 99m
• Xenon-1 3 3
□ F ir s t d e s c rib e d b y : Ha user Root in 1965 • F lu o rin e -18
□ I n d ic a tio n : Blunt injury abdomen making the patient unstable • Thallium - 201
□ P ro c e d u re : Through a subumbilical lavage catheter, 11t N.S/R.Lis infusedinto theperitoneal cawf
^ Advantages o ve r PET s c a n :
-> patient changed to different positions - » fluid content is aspirated from abdomen for assess'11®'-1
1 • Tracer stays in blood stream rather than being absorbed by surrounding tissues, thereby
limiting images to areas where blood flows
580
 SOLVED SHORT NOTES OF INVESTIGATIONS 583
582 QUEST : A Comprehensive Guide lo UG Surgery. Orthopedics & Anesthesiology

Brnced u r e : Patient ingests gas pellets + citric acid to expand stomach -> 3 cups(709 ml) of barium
• Cheaper 3 ingested -► patient rolls over to coat the oesophagus, stomach, duodenum -» X-ray films
• More readily available yKan in different positions
□ U ses:
fypCS •
Helps (o detect the following - , Single contrast (using only barium sulphate)
• Reduced blood flow to myocardium or injured sites in brain . Double contrast (barium sulphate + radioluscent contrast e.g. air, C02, N2)
• Presurgical evaluation of medically uncontrolled seizures
• Blood deprived (ischaemic) areas of brain following stroke n Us*s :
Used to detect:
• Brain tumors
. CA stomach -
• Fracture in spine > irregular filling defect
□ C o n tra in d ic a tio n s :
> loss of rugosity
Pregnant and lactating mothers V> delayed emptying
> dilated stomach
Q. 4 : B a riu m s w a llo w X -ra y
> margin of lesion projects outward from lesion into gastric lumen(Carmann s menis­
BARIUM SWALLOW X-RAY cus sign)
• Gastric ulcers -
O S y n o n y m : Oesophagography
> niche on lesser curve, notch on greater curve
□ W hat is i t : Medical imaging procedure used to examine and diagnose pathological conditions oj
> ulcer crater projects beyond the lumen of ulcer
upper GIT (Oesophagus and some part of stomach)
> regular margin of ulcer crater - 'stomach spoke-wheel pattern’
□ P r in c ip le : X-ray pictures are taken while barium sulphate coats oesophagus and stomach as patcen)
> overhanging mucosa at margins of a benign ulcer projects inwards towards ulcer -
swallows the contrast material
Hampton's line
□ P ro c e d u re : Patient drinks barium sulphate suspension -> as he swallows, fluoroscopy images taken
> converging mucosal folds towards base of ulcer
in different positions @ 2-3 frames/sec
• Duodenal ulcers -
□ U s e s : Helps to detect following conditions
a) absence of duodenal cap
• Achalasia cardia - ‘rat tail' deformity or 'bird's beak’ appearance b) ‘trifoliate’ duodenum due to secondary duodenal diverticula which occurs as a resu
• CA oesophagus - irregular filling defect
of scarring of ulcer
• Tracheo - oesophageal fistula
c) ulcer crater
• GERD
• Diverticula
• Zenker's diverticulum
1 Polyp
• Hiatus hernia
• Motility abnormalities
• Oesophageal stricture
0 D ia d va n ta g e s:
□ D is a d v a n ta g e s :
• Gas production in stomach
« Gas production in oesophagus • Irradiation
• Irradiation Q C o n tra in d ic a tio n :
0 C o n tra in d ic a tio n : • Children
• Children • Pregnancy
• Pregnancy
0.5; Barium fo llo w th ro u g h X -ra y
Q. 5 : B a riu m m e a l X -ra y BARIUM FOLLOW THROUGH X-RAY
BARIUM MEAL X-RAY Q What Is i t : Medical imaging procedure used to examine and diagnose pathological conditions of
U S y n o n y m : Upper Gl series small intestine .
0 P rin c ip le : X-ray pictures are taken while barium sulphate coats small intestine after patient ingests
□ W hat Is i t : Medical imaging procedure used to examine anddiagnosepathological conditions ol
the contrast material .
lower part of oesophagus, stomach and duodenum
0 P ro c e d u re : Patient ingests gas pellets ♦ citric acid to expand s,omHaf^ r^ . bnaQ
ns^ ® ^ P ho 20 40 and
□ P rin c ip le : X-ray pictures are taken while bariumsulphate coatsoesophagus,stomachand duode­
-* patient rolls over to coat the small intestine -> X-ray films taken in different positio . .
num after patient ingests the contrast material
90 mins
 584 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 585

□ In d ic a tio n o f c o m p le te d t e s t : When contrast material has reached terminal ileum and caecu . Qouble c o n tra s t b a riu m enem a
Q U ses: 11 ' DO UBLE CO NTRAST BARIUM ENEMA
U sed to d e te c t:
t is I t : A procedure in which X-rays of colon and rectum are taken after a liquid containing barium
• Crohn's disease - intermittent sections of strictured bowel 0 into rectum. Then air inflates colon to give a better contrast to visualise mucosa of colon
• Ulcerative colitis
n syn o n ym s:
• Small intestinal tumors
. Lower gastrointestinal series
□ D is a d v a n ta g e s :
, Air contrast barium enema
• Gas production in small intestine
q pro ce d u re :
• Irradiation
□ C o n tra in d ic a tio n ; Laxative ingested previous night
-1
• Children
Via enema tube 1 litre barium sulphate solution infused into colorectum per anally
• Pregnancy
!
Q. 7 : B a riu m enem a X -ra y
X-ray taken
BARIUM ENEMA X-RAY !
patient asked to evacuate bowel
□ S y n o n y m : Lower gastrointestinal series
I
□ W hat Is i t : Medical imaging procedure used to examine and diagnose pathological conditions «i Post-barium evacuation X-ray taken
colon
I
□ P r in c ip le : X-ray pictures are taken while barium sulphate fills the colon via rectum
Colon inflated with air
Q P ro c e d u re :
4
Patient lies on X-ray table -* control X-ray taken - » patient asked to lie on the side -> a well-lubricated
X-ray taken
enema tube is inserted into rectum -> barium sulphate, a radioopaque contrast medium is allowedIt
flow into the colon -> flow is monitored on X-ray fluoroscope screen -» patient assumes drffereni 0 Ind ications:
positions and the picture in different positions are taken
□ P re p a ra tio n o f p a tie n t: INDICATIONS
• Liquid diet •
• Drinking Magnesium citrate and warm water enemas to clear out any stool particle
• Check history of allergy to barium
Therapeutic D ia g n o s tic
□ Types:
Intussusception in . CA colon (irregular filling defect)
• Single contrast (using only barium sulphate)
children , . ulcerative colitis (lead pipe appearance)
• Double contrast (barium sulphate + radioluscent contrast e.g. air, COj, N2)
« lleocaecal TB (obtuse ileocaecal angle)
□ P u rp o s e :
• Congenital megacolon (narrow zone, then
« Identify inflammation of intestinal wall - e.g. IBD zone of cone, followed by dilated proximal
• Monitor progress of IBO segment)
• Detect strictures, diverticula, Hirchsprung's disease • Diaphragmatic hernia (colonic shadow in left
• Help correct intussusceptions thoracic cavity)
• Evaluate abdominal symptoms such as pain, blood instool, altered bowel habit • Colonic polyp (smooth, regular filling defect)
• Evaluate anorexia, anaemia, weight loss
• Functional cause considered (irritable bowel syndrome)if picture normal
3 C ontraind ication:
□ V a ria n t:
Any acute condition of colon
If perforation detected, water used instead of barium
0 C om p lications:
□ R is k s :
• Constipation
• Exposure to X-ray
.* * Cramping
• Bowel perforation
• Colon puncture

71
 586 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 587

Q. 9 : MRCP Therapeutic -
MRCP > Endoscopic sphincterotomy (both of the biliary and the pancreatic sphincters)
> Removal of stones
□ F u ll f o r m : Magnetic Resonance Cholangio Pancreaticography
> Insertion of stents
□ W hat is I t : A form of cholangiography that uses magnetic resonance imaging to visualise biliarv V Dilation of striclures (e.g. primary sclerosing cholangitis, anastomotic strictures after
pancreatic ducts in a non-invasive manner liver transplantation)
Q In tro d u c e d i n : 1991
3 Contraindications:
□ P u rp o s e : Produces detailed images of liver, gall bladder, bile duct, pancreas and pancreatic du i
. Acute pancreatitis (unless persistently raised or worsening bilirubin suggests ongoing ob­
Q U ses: struction)
• Checking liver, bile duct, gall bladder and pancreas for gallstones, tumors, infection or m • Previous pancreatoduodenectomy
flammation
• Coagulation disorder if sphincterotomy planned
• Investigating pancreatitis
• Recent myocardial infarction
• Investigating abdominal pain
• Inadequate surgical back-up
• Best used when serum bilirubin <10mg/dl and no pre-operative stenting is contemplated
• History of contrast dye anaphylaxis
□ C h e c k lis t b e fo re M R C P :
• Poor health condition for surgery
• Internal pacemaker/defibrillator
• Severe cardiopulmonary disease
• Cochlear implant
0 Technique:
• Surgical clip
• Prosthetic heart valve Patient is sedated -» endoscope is inserted through the mouth, down the oesophagus, into the
stomach, through the pylorus into the duodenum where the ampulla of Vater is visualised -> a cannula
. • Artificial limb
is inserted through the ampulla -> a radiocontrast dye (60% urograffin) is Injected into the bile ducts
• Implanted electronic device and/or pancreatic duct -» fluoroscopy is used to look for blockages, or other lesions such as stones
□ S ld e -e ffe c ts : [When needed, the opening of the ampulla can be enlarged (sphincterotomy) with an electrified wire
Reaction to contrast dye when used (sphincterotome) and access into the bile duel obtained so that gallstones may be removed or other
□ C o n tra in d ic a tio n : Pregnancy therapy performed]
□ A d v a n ta g e s o v e r E R C P : 0 C o m p lica tio n s:
• Non - invasive , • Pancreatitis
• Delineate full biliary treeand not just the part proximal to the obstruction • Gut perforation
• No dye required • Oversedation can result in dangerously low blood pressure, respiratory depression, nausea,
• Can be used in acute pancreatitis, duodenal injury, cholangitis and vomiting
□ D isadva ntag e : No therapeutic procedure like stenting, basketing, biopsy can be earned out • Bleeding after sphincterotomy
• Cholangitis
Q. 1 0 : ERCP
ERCP 0.11: MRI

Q F u ll fo rm : Endoscopic Retrograde Cholangio pancreatography MRI

□ W hat is I t : Technique that combines the use of endoscopy and fluoroscopy to diagnose and Ireai
Q Full fo rm : Magnetic Resonance Imaging
certain pathologies of the biliary or pancreatic ductal systems
0 S ynon ym s:
□ In d ic a tio n s :
• Nuclear magnetic resonance imaging
• Diagnostic -
• Magnetic resonance tomography
> Obstructive jaundice
Q What is i t : Medical imaging technique used in radiology to visualise internal structures of body in
> Chronic pancreatitis
details
> Gallstones with dilated bile ducts on ultrasonography
D Typ es:
> Bile duct tumors
• Plain MRI
y Suspected injury to bile ducts either as a result ot trauma or iatrogenic
« Contrast MRI
> Sphincter of Oddi dysfunction
^ Contrast m a te ria l u s e d : Gadolinium intravenously
r Pancreatic tumors

S ’
 SOLVED SHORT NOTES OF INVESTIGATIONS 589
5B8 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

q 12: T h e ra p e u tic u lt r a s o u n d
□ p r in c ip le :
THERAPEUTIC ULTRASOUND
Patient placed In external high magnetic fields -* protons of hydrogen atoms rotate In phase with
each other and gradually return to their original position releasing small amounts of energy which is
Generally if refers to any kind of procedure that uses ultrasound for the rapeutic benefit. Its uses are as
detected by sensitive coils -> proton density and relaxation time are assessed by radiofrequency
follows:
pulse - » computer generates a Gray scale image from this data
• To guide aspiration of amoebic liver abscess
□ In te rp re ta tio n :
• T, relaxation time - • To guide pericardial tap
> Time taken to return to original axis • Focused high-energy ultrasound pulses can be used to break calculi such as kidney stones
> T, images used to find out normal anatomical details into fragments small enough to be passed from the body without undue difficulty, a procedure
known as lithotripsy
> It has got high soft tissue discrimination
> Here fluid looks black « Intraoperative ultrasound lo assess the operability of tumor (extent of tumor, lymph node
status)
• T2 relaxation time -
> Time taken by proton to diphase « To treat benign and malignant tumors by a procedure known as "High Intensity Focused
Ultrasound (HIFU)” , also called “ Focused Ultrasound Surgery (FUS)". In this procedure,
> Used to assess pathological process
generally lower frequencies than medical diagnostic ultrasound is used (250-2000 kHz), but
V Here fluid looks white
at significantly higher time-averaged intensities. The treatment is often guided by Magnetic
• Proton density images - fluid looks in between white and black Resonance Imaging (MRI)-this is called “ Magnetic Resonance-guided Focused Ultrasound
□ U ses : Surgery (MRgFUS)"
To detect the following - • To deliver chemotherapy to brain cancer cells and various drugs to oth er tissues is called
. • Joint pathology detection ■Acoustic Targeted Drug Delivery (ATDD)*. These procedures generally use high frequency
• Intracranial lesions ultrasound (1-10 MHz) and a range of Intensities (0-20 watts/cm2). The acoustic energy is
• Spinal lesions focused on the tissue of interest to agitate its matrix and make it more permeable for thera­
• Musculoskeletal lesions peutic drugs

□ S p e c ia l v a r ie tie s :
» Focused ultrasound sources can be used for cataract treatment by phacoemulsification
• MR Angiogram • Low-intensity ultrasound can be used to stimulate bone-growth and to disrupt the blood-
• Cardiac MRI brain barrier for drug delivery
• Breast MRI • Ultrasound is essential to the procedures of ultrasound-guided sclerotherapy and
"Endovenous Laser Ablation (EVLA)' of varicose veins
• MRCP
• MR Spectroscopy • Ultrasound-assisted lipectomy can be done. Liposuction can also be assisted by ultrasound
□ A d v a n ta g e s : • Doppler ultrasound may be used in aiding tissue plasminogen activator treatment in stroke
• Artefacts not common sufferers in the procedure called 'Ultrasound-enhanced systemic thrombolysis', but the pro­
• More specific and sensitive than CT scan cedure is still under trial .
• Gives direct anatomical sections of area with lesions at a higher resolution • Low Intensity pulsed ultrasound is used for therapeutic tooth and bone regeneration

□ Disadvantages : • Ultrasound can also be used for "Elastography". This can be useful in medical diagnosis, as
elasticity can discern healthy tissue from unhealthy tissue for specific organs or growths.
• Not easily available
Ultrasonic elastography is different from conventional ultrasound, as a transceiver (pair) and
• High cost a transmitter are used instead of only a transceiver. One transducer acts as both the transmit- *
• Poor patient compliance ter and receiver to image the region of interest over time. The extra transmitter is a very low
« Difficult in claustrophobic patients frequency transmitter, and perturbs the system so the unhealthy tissue oscillates at a low
• Not ideal in emergencies and critically ill patients frequency and the healthy tissue does not. The transceiver, which operates at a high fre­
. Not useful in lung pathology and subarachnoid hemorrhage quency (typically MHz) lhen measures the displacement of the unhealthy tissue (oscillating
□ C o n tra in d ic a tio n s :
at a much lower frequency). The movement of the slowly oscillating tissue is used to deter­
mine the elasticity of the material, which can then be used to distinguish healthy tissue from
» Patients with prosthesis in body
the unhealthy tissue
• Those with pacemakers
• Ultrasound has been shown to act synergislically with antibiotics in killing of bacteria
• Patients with cochlear implant .
□ P re c a u tio n : . ..
Remove all metallic foreign bodies and other magnetically attractive matenals before ms v
1,.1'
 S90 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 591

Q. 1 3 :C T s c a n „ a d vanta ges:
CT SCAN . g 1-2 mm sized sections are possible
□ F u ll f o r m : Computerised tomography ,; , Amount of exposure to radiation is less
□ In v e n te d b y : Godfrey Hounsefield in 1963 , More accurate, sensitive and specific
□ P rin c ip le : Narrow X-ray beams are passed from rotating X-ray generator through the gantrv u* , Small lesions are also detected
patient is placed -» X-rays pass through tissues -» some rays get absorbed, some pass th , CT guided biopsies
depending on tissue density -> different grades ol absorption in different tissues are detected th p D isadvantages:
sensitive detectors which are translated to a Gray scale image by a computer rou^
i • « interpretation by experienced radiologist required
□ D e n s ity o f tis s u e s :
. Artefacts can be present
Numbered as Hounsefield Units (HU)
• High cost
W ater-zero HU
• Not easily available
Air - minus 1000 HU
Bone - plus 1000 HU 0,14: DRE
Density of other tissues comes in between air and bone DRE
□ Types:
• Plain g Full fo r m : Digital Rectal Examination
• Contrast g What Is I t : internal examination of rectum by a physician or health care personnel
□ N e w e r v a r ia n t:
g procedure: Exposure from midchest -> patient lies in Simp's position (left leg straight, right leg flexed
at knee and hip and is drawn towards abdomen) -» patient asked to relax buttock and take deep
• Spiral CT
breaths -> physician spreads buttocks apart and examines external area for any abnormality -> then
A d v a n ta g e s :
he slips his gloved index finger lubricated with lignocaine into the rectum through the anus and
> Reduced scan time palpates the interior for about 1 minute
y Imaging in both arterial and venous phases possible 0 U ses:
> Impaired lesion detection • Diagnosis of rectal neoplasms
> Multiplanar and 3-D analysis like CT Angiography • Diagnosis of prostatic disease - tumor, BPH
• HRCT (High Resolution CT) • Estimation of tonicity of anal sphincter - faecalincontinence, neurological disease
V Used in chest scan, where thin sections are taken to have better quality images • Examination in females for gynaecological palpation ofinternal organs
□ C o n tra s t a g e n ts :
• Examination of hardness and colour of faeces
• Ionic - . • Prior to colonoscopy or proctoscopy
> Sodium diatrizoate • To evaluate hemorrhoids
V
Meglumine iothalamate - e.g. Urograffin, Conroy • To exclude imperforate anus
- Cheaper, bul toxic and anaphylactic • Combined with Faecal Occult Blood Test to diagnose aetiology of anaemia
• Non-ionic -
> lohexol Q.15:TURP

'r lopamiro TURP

- Expensive, but safer
Q What is I t : Transurethral resection of prostate is an urological procedure
□ In d ic a tio n s :
Q Ind ications:
• Trauma - Head injury, chest injury, abdominal trauma, etc.
• Benign prostatic hyperplasia
• Neoplasm - Exact location, size, vascularity, extent, operability
• Late stages of prostatic carcinoma
o Inflammatory conditions - Psoas abscess, pseuodocyst
0 Types:
□ F in d in g s :
• C onventional (m onopolar) TURP - utilizes a wire loop with electrical current flowing in one
• Extradural hematoma - Biconvex lesion
direction (thus monopolar) through the resectoscope to cut the tissue
• Subdural hematoma - Concavoconvex lesion
• B ipolar TURP - newer technique that uses bipolar current to remove the tissue; allows
• Smooth margin in benign condition saline irrigation and eliminates the need for an ESU grounding pad thus preventing post-
• irregular margin in malignant condition < TURP hyponatremia
 592 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 593

La ser p rostale TURP - utilizes laser energy to remove tissue (With laser prostate sur , Bacteriological -
fiber optic cable pushed through the urethra is used to transmit lasers such as holmi > Clean catch midstream urine specimen
:YAG high powered Ved" or potassium titanyl phosphate (KTP) “green' to vaponze .js* > > 105/ml -> significant bacteruria
enoma. More recently the KTP laser has been supplanted by a higher power laser so. ^
, Biochemical -
based on a lithium triboratecrystal, though it is still commonly referred to as a "Greenl^hi-1*
KTP procedure) " » Electrolytes
Plasm akinetic resection - uses ionized vapour that heats up by low voltage electricity
> Glucose
semi-spherical button to vaporize the prostate tissue from inside and only leave a 2.3 > Bilirubin
shell. This procedure is considered to be the least intrusive of all techniques currently a > Haemoglobin
a U Ia n itiJ
able and has lless
n » i< n n o l « \n A r n t ii/A lA n f iA n r a n / 4 n f k n r t A A m i a l n e / u i n n n
post-operative complications and a short convalescence > Myoglobin
□ P ro c e d u re : Strips of tissue are cut from bladder neck down lo level of verumontanum usinq n urodynam lc s tu d ie s :
frequency diathermy current, which is applied across a loop mounted on the hahd-held trigger o' . W hat is i t : Study that assesses how bladder and urethra are function Ing
resectoscope -> proper coagulation of bleeding points -> ‘chips’ of prostate removed from bladde « U s e : Help explain symptoms -
using Ellik evacuator -» Hyponatremia prevented by continuous irrigation with 1.5% isotonic glycine
> incontinence
and recent introduction of continuous-flow resectoscope -> a triple lumen catheter is inserted throw*
> frequent urination
the urethra to irrigate and drain the bladder after the surgical procedure is complete
> sudden strong urge, but no micturition
□ C o m p lic a tio n s :
> painful urination
• Bleeding (most common)
> recurrent UTI
• Clot retention and clot colic
• C onducted b y : urologists, urogynaecologists
• Bladder wall injury such as perforation (rare) .
P spe cific te s t s :
• TURP S y n d ro m e : Hyponatremia and water intoxication (symptoms resembling brain stroke
• P ost-void residual volume -
in an elderly presenting patient) caused by an overload of fluid absorption (e.g. 3 to 4 Litres)
> Urinary catheter inserted following complete bladder emptying
from the open prostatic slnusiods during the procedure. This complication can lead k>
confusion, changes in mental status, vomiting, nausea, and even coma > If urine volume > 180ml - » UTI
[To prevent TURP syndrome 1) The length of the procedure is limited to less than one hourjj > If increased urine volume -> overflow incontinence
the height of the container of irrigating solution above the surgical table determining the • M icroscopy a n d culture
hydrostatic pressure driving fluid into the prostatic veins and sinuses is kept to a minimum! • UroHowmetry -
• Bladder neck stenosis . > Measures how fast patient can empty bladder
• Urinary incontinence - due to injury of external sphincter system which may be preventedby > Pressure uroflowmetry -> measures rale of voiding + bladder and rectal pressure
taking the Verumontanum of the prostate as a distal limiting boundary during TURP > Helps demonstrate - i) bladder muscle weakness ii) obstruction to bladder outflow
• Retrograde ejaculation and impotence • M ultichannel cystom etry -
• Stricture urethra > Measures pressure in rectum and bladder using 2 pressure catheters, to deduce
• Recurrence contractions of bladder wall during bladder filling or other provocative maneuvres
> Strength ol urethra can be tested during this phase using a cough or Valsalva
Q. 1 6 : In v e s tig a tio n s o f LU TS
maneuvre - to confirm genuine stress incontinence
INVESTIGATIONS O F LUTS • U rethral pressure profiiom etry - Measures strength of sphincter contraction
• E lectrom yography - Measurement of electrical activity in bladder neck
□ U r in e :
• Dipstick test - Chance of infection if colour change due to protein, nitrite • A ssessm ent o f tightness along length o f urethra
• Fluoroscopy —Moving video X-Rays of bladder and bladder neck during voiding
• Microscopy -
> RBC 0. 17: R etrogra de p y e lo g ra p h y
> WBC RETROGRADE PYELOGRAPHY
r Bacteria
> Casts ^ What Is I t : Invasive radiographic examination of kidneys from a distal direction via ureters
• Cytological - Q In d ica tio n s:
> Urinary sediment examination • Failure to show any dye in IVU in 72 hours film
> Bladder tumor antigen detection '■ • Urinary tuberculosis
 SOLVED SHORT NOTES OF INVESTIGATIONS 595
594 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

• Urothelial tumors from renal pelvis ^ in d ic a tio n s :

•
• Asessmenl of displacement, drainage, enlargement or fixation of structures of renal coUeo
system
Detection of complete or partial obstruction due to blood clot, calculus, perinephric absr»
*
■ ,
, , Pregnancy f i e gnain/y
Bleeding diathesis

etc. 3 * ! ’ Visualise ureters when other procedures like IVP and Retrograde pyelogram have not pro­
• Assessment for integrity of renal pelvisandureters after blunt trauma vided definite information
• Hypersensitivity to iodine based contrastmaterial , Detect obstruction of urinary tract due to stricture, stones, clot, tumor
□ P ro c e d u re : „
. intravenous u re th ro g ra m
Under general anesthesia, cystoscope passed and ureteric orifice visualised -» ureteric calh i
passed - » sodium diatrizoate dye is injected -> patient put in 15 degrees head down position to a**
6 ’ INTRAVENOUS URETHROGRAM
dye to reach upper urinary system - » X-Ray taken
; A radiological procedure used to visualize abnormalities of the urinary system, including
□ A d v a n ta g e s :
3 the kidneys, ureters and bladder,
• Prior to dye injection, selective urine sample can be taken for investigative purpose
p p re q u islte : Renal function is to be normal
• Getter delineation of anatomy
i indications:
• Brush biopsy may be taken from suspectedurothelial tumors of upper urinary tract
, Congenital anomalies -
□ D is a d v a n ta g e s :
> Horse-shoe kidney - Flower-vase appearance
• Anesthesia required
> Polycystic kidney - Spider-leg appearance
• Laborious
> Ureterocele - Adder(cobra) head appearance
□ R is k s :
. Hydronephrosis - Clubbing of cup-shaped calyces
- • Hemorrhage
• Renal cell carcinoma - Irregular filling delect
• Bladder perforation
• Obstructive uropathy
• Nausea, vomit
• Bilateral stones in urinary tract
. UTI
• Renal injury
• Vasovagal response
, Post-surgery follow-up
□ C o n tra in d ic a tio n s :
• Pregnancy 3 Overnight fasting for 8 hours + laxatives used to dear bowel - » Control plain X-Ray W B taken1->> 11ml
• Severe dehydration test dose of sodium diatriazoate injected i.v -> waited for 10 mms -» if no adverse reaction, g y
0 . 1 8 : A n te g ra d e p y e lo g ra m injected i.v -* X-Ray taken at 5 mins (No. 1). 15 mms (No. 2), 30 mins (No. 3)
ll N on-visualisation o f k id n e y s : No contrast dye seen in X-Ray film even after 12 hours
ANTEG RADE PYELOGRAM
3 C ontraind ications:
□ W hat Is I t : Type of X-Ray used to diagnose an obstruction of upper urinary tract
. Multiple myeloma
□ P ro c e d u re : Kidneys examined with USG or CT scan -» after Ihey are located, overlying skin
• Iodine sensitivity
anaesthetised -> needle passed directly into kidney, via which dye is injected to outline the renal
• Hypergammaglobulinaemia
collecting system - » X-Ray taken
• Toxic thyroid conditions
Q C o m p lic a tio n s :
• Reaction to iodine-based dye 220: C ystosco py
• Hot flush CYSTOSCOPY
• Nausea, vomit
a M at Is i t ; Endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.
• Breathing difficulty
• Low B.P 3 Types:
• Cardiac arrest • Flexible
• Bleeding
• Sepsis 3 ProcedurePatient in lithotomy position -> Spinal or general anesthesi* -*
%ough urethra along with continuous glycine irrigation -* urethra, bladder and th
• Urinoma
aie visualised
• Blood clots in nephrostomy lube
 596 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES OF INVESTIGATIONS 597

□ In d ic a tio n s : ; mrfdwith swab holding forceps -> Bladder confirmed by - i) urine coming out on needle aspiration ii)
• Therapeutic - ^tended veins on anterior surface of bladder iii) change in nature of fat -> 2 stay sutures taken
> TURP trough full thickness of anterior wall of urinary bladder - » incision through the midline of anterior wall
> Urethrotomy of bladder using f 1-no. surgicaf blade - » finger inserted to remove stones and look for any pathology
,, Malecot’s catheter inserted and stay sutures removed -> fixed with purse-string suture -> linea
> Bladder tumor resection
8fta, skin sutured
> Figuration of posterior urethral valve
j C ontraind ications:
Cystolithotripsy
> Cystolitholapaxy « Bladder cancer in cases of clot retention
• Diagnostic - . Lower abdominal incisions with likelihood of adhesions
> To visualise pathology in urethra, bladder and ureteric orifice t Pelvic fracture
> To viualise bladder fistulas ] C om plications:

□ C o n tra in d ic a tio n s : . UTI

• Prostatitis . Blockage
• Acute cystitis • Bladder stones
□ C o m p lic a tio n s : • Bladder cancer
• Water intoxication • Bypass track b y urine
• Bleeding ttt:PCNL
• Infection
PCNL
. □ B lu e lig h t c y s to s c o p y :
The Blue light (Hexaminolevulinate fluorescence) cystoscopy involves instilling a photosensifcng g fu ll fo r m : Percutaneous Nephrolithotomy
agent, such as Cysview, into the bladder. The Blue light cystoscopy contains a light source andtyj
0 llh a t fe I t : Surgical procedure to remove stones from the kidney by a small puncture wound (up to
is transmitted through a fluid light cable connected to an endoscope to light up the area to be observed about 1 cm) through the skin
The photosensitizing agent preferentially accumulates porphyrins in malignant cells as opposed to
3 Indications:
nonmalignant cells of urothelial origin. Under subsequent blue-light illumination, neoplastic lesions
fluorescence red, enabling visualization of tumors. The Blue light cystoscopy is used to detect m Slones with following features -
muscle invasive papillary cancer of the bladder • Stones > 2.5 cm
t • Present near the pelvic region
Q. 2 1 : S u p ra p u b ic c y s to s to m y
• Multiple in number
SUPRAPUBIC CYSTOSTOMY • Not responding to ESWL
Q S ynonym s: 3 Procedure :
• Vesicostomy With a small 1 centimeter incision in the loin, the Percutaneous nephrolithotomy (PCN) needle Is
• Epicystostomy passed into the pelvis of the kidney -* The position of the needle is confirmed by fluoroscopy - » A
guidewire is passed through the needle into the pelvis -> The needle is then withdrawn with the guide
□ W hat is I t : Surgically created connection between the urinary bladder and the skin which is usedis
wire still inside the pelvis -» Over the guide wire the dilators are passed and a working sheath is
drain urine from the bladder in individuals with obstruction of normal urinary flow
introduced -» A nephroscope is then passed inside and small stones faken out
□ P re re q u is ite : Bladder must be full - adequate distension almost half-way between symphysis pul*
(hcase the stone is big it may first have to be crushed using ultrasound probes and then the stone
and umbilicus may be done by ragmeots removed)
• oral fluids
■ Complications:
• intravenous fluids administration
• Injury to the colon
• diuretics
• Injury to the renal blood vessels
□ In d ic a tio n s :
• Urinary leak may persist for a few days
• Failed urethral catheter
• fnfection
• Long term usage
• Hydrothorax if PCNL is done through 11th intercostal space
O P ro c e d u re :
• Bleeding
Local anaesthetic infiltration - » Incision 4-5 cm long from 2cm above symphysis -» skin,su^ -
fascia, linea alba cut -» extraperitoneSI fatty tissue and peritoneum sweeped upwards by 8 v3 ,
 598 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS $99

Q. 2 3 : ESW L ^ v a n ta g e s : Measures aspect of bone metabolism or bone remodelling which other imaging
techniques cannot do
ESWL
Q u se s:
□ F u ll fo rm : Extracorporeal shock wave lithotripsy • Fractures
□ W hat Is I t : Non-invasive treatment of kidney stones using an acoustic pulse (a type of endourni • Infections
surgery) “9** • Tumors
□ S h o c k w aves p ro d u c e d b y : p Contraindications:
• Electromagnet t Osteoporosis
• Electrohydraulic • Multiple myeloma
• Piezo-electric 0 procedure : Radioactive material (Tech99m) injected in peripheral vein -» scanned with gamma
□ P ro c e d u re : Electromagnetic shock waves passed to stone through water bath @ 2/sec -* ^ r a - » SPECT used for imaging
fragmented using Domier lithotripter which are later flushed out ^ 0 S p e c ific ity in c re a s e d b y : Indium1" labelled WBC Test + Tech®91" injection
□ In d ic a tio n s : Ureteric, kidney or bladder stones < 2.5 cm
q p r e c a u tio n s : Empty bladder first
□ A d v a n ta g e s :
g f lin e p h a s e s c a n :
• OPD procedure
• 1st phase - shows perfusion fo a lesion
• Hard oxalate stones better treated by this melhod
• 2nd phase - shows vascularity to an area (after 5 mins)
• No anesthesia required
. • 3rd phase - shows amount of bone turnover (after 3 hours)
• Non invasive
• No pain ft 25: Th yroid s c a n
• No blood loss THYROID SCAN
□ D is a d v a n ta g e s :
0 What Is I t : A. thyroid scan uses a radioactive tracer and a special camera to measure how much tracer
• Cannot be used for larger stones > 2.5 cm the thyroid gland absorbs from the blood
• Relies on normal urine flow for clearance 0 R adioisotope u s e d :
• Not easily available • I123 gamma rays(not I 131) - most common
0 C o m p lic a tio n s : , 99mjc
• Hematuria , 0 P u rp o se : To distinguish between functioning and non-functioning thyroid
« Injury to adjacent structures Q Time re q u ire d :
• Renal hematoma • I123 scan-2 4 hours
• Fragments of stone retained in ureter • • 99mjc scan _ 3Q minutes
□ C o n tra in d ic a tio n s : Q Instrum ent u s e d : Gieger Muller’s gamma ray counter
• Pregnancy Q Ind ications:
• Bleeding diathesis • Doubtful toxicity
• Abdominal aneurysms « Autonomous toxic nodule
• Sepsis • After total thyroidectomy
• Renal failure • Retrosternal thyroid
• Renal artery calcification • Ectopic thyroid
□ P re c a u tio n s : Q P re re q u isite s:
« Kidney function has to be normal • No L-Throxine intake for 6 weeks prior to the scan
• Stent may have to be used for largestones • T3 60 microgram/day (medication to be stopped 10 days prior to scan)
Q P roce dure:
• Diclofenac may be needed to relieve ureteric colic
The radioisotope is given orally in empty stomach on the previous day or injected into the vein
Q. 2 4 : B o n e s c a n
0 In te rp re ta tio n s :
BONE SCAN • ‘Hof area - » increased uptake -» toxic condition
Q S y n o n y m : Bone scintigraphy • 'Warm' area -> normal uptake - » euthyroid
Q D e fin itio n : Nuclear scanning tesl to find certain abnormalities in bone
• 'Cold' area -* no uptake -> non-functional, may be carcinoma
 600 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 601

Q .2 6 : M a m m o g ra p h y , Encephalitis
, Subarachnoid hemorrhage
MAM M O GRAPHY
, intracranial hemorrhage due to trauma
□ W hat Is I t : X-Ray of soft tissue of breast using low ampere and high voltage , intracranial SOL
□ F ilm s : , To look for lymphoblast to evaluate relapse of ALL in meninges
• Craniocaudal
T l» W e u lic ~ , .
• Mediolateral w , Relief from raised intracranial tension
□ D o s e : 0.1 Gy radiation , Introduction of antimeningococcal serum
□ In fe re n c e : , Introduction of drugs
• Microcalcification -> malignancy , Spinal anesthesia
• Soft tissue shadow -» if regular then benign, if irregular then malignant q Contraindications:
• Size , Brain tumor at cerebellopontineangle
• Location • , Spinal cord tumor
• Spicutation • Septicaemia
• Duct distortion , Brain abscess
• Density -» if fow then benign, if high then malignant , intracranial hemorrhage
• Architectural distortion -> malignancy • Patient in convulsion
• Skin thickened -> malignancy • Advanced CVS disease
. Vertebral deformties
□ G ra d in g :
• Abnormal respiratory pattern
I - Negative
0 Complications:
II - Benign
• Post spinal headache
III - Probably benign
• Nausea
IV - Suspicious of malignancy
» Paraesthesia
V - Suggestive of malignancy
• Spinal/epidural bleeding
VI - Known malignancy
• Introduction of infection
□ In d ic a tio n s : - •
• Adhesive arachnoiditis
• Screening if age > 40 years « Trauma to spinal cord
• Obese • Paraplegia
• Follow up after conservative surgery Q Site ol collection :
• Follow up if benign lesion has malignant potential
• L3-L4 vertebrae .
• Mammography guided biopsy • Cisternal puncture
• Mastalgia •Ventricular puncture
« To detect spread to opposite breast •Combined spinal - cisternal puncture
□ X e n o m a m m o g ra p h y ; Useful for dense breast where mammography is done on selenium paper Q Procedure : Patient in left - lateral position/sitting on stool stooping forward with maximum flexion -»
overlying skin prepared with antiseptics - infiltration of skin and fascia with small amount of 1%
0 . 2 7 : L u m b a r p u n c tu re
lignocaine -> imagiaary line drawn joining highest points of two iliac crests passes through L3; - U
LUMBAR PUNCTURE vertebrae -> lumbar puncture needle stitette in-situ is pushed forward and slightly upward in midline
between L3 - U vertebrae till a peculiar give-away sensation is felt -> stilette removed -> pressure
□ S y n o n y m : Spinal tap measured by fitting manometer to needle or drop count method -> CSF collected in 3 stenlo tubes
□ W hat is I t : Diagnostic and therapeutic procedure performed to collect cerebrospinal fluid sample fof 5ml each
microbiological, biochemical and cytological analysis Q CSFe x a m in a tio n :
□ In d ic a tio n s : • P hysical -
A) D iagnostic ~ > Appearance - normal
• Meningitis ,i > Colour - clear
• Meningoencephalitis > Coagulum - absent
 602 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 603

• C ytologicaI - > Injection of oesophageal varices

> TC > Endoscopic removal of benign lesions
> OLC > Dilatation in case of oesophageal strictures, cardiac achalasia
• B iochem ical - > Insertion of Soutlar’s or Mousseau - Barbin tube in palliative treatment of oesoph­
> Protein : 20-40 mg% ageal carcinoma
r Glucose : 40-80 mg% « D iagnostic -
> Chloride : 720-760 mg% To investigate cause for retrosternal burning, dysphagia,
• B acteriological - 0 contraindications:
> Gram stain • Trismus
> Acid fast slain « Aneurym of aorta
V India ink preparation • Disease of cervical spine
Q. 2 8 : D u p le x u ltra s o u n d
• Receeding mandible
0 Anesthesia:
DUPLEX ULTRASOUND
• General anesthesia + Orotracheal intubation
□ D e fin itio n : Test lo see how blood moves through arteries and vein
0 position:
Q P r in c ip le :
• Barking dog position (see Oesophagoscopy)
• Traditional ultrasound - uses sound waves that bounce off vessels to create picture
0 B asic s te p s w h ile In s e rtio n o f in s tru m e n t :
• Doppler - records reflecting sound waves to measure their speed and other aspects of t e
flow • Identification of aryetenoids
Q Types :
• Passing cricopharyngeal sphincter without applying force
• Arterial • Crossing aortic arch and left bronchus
> Passing cardia, identified by velvety mucosa
• Carotid
• Renal Q p o st-o p e ra tive c a r e :
• Arms and leg » Sips of plain water

□ P ro c e d u re : Patient lies down -» gel smeared -> transducer used -> computer measures reflected • Regular diet _____ pain in interscapular region
waves • Signs of oesophageal perforation --------abrupt rise of temperature
□ Accessory u s e d : Blood pressure cuff for measuring ABPI(Ankle Brachial Pressure Index) Q C o m p lic a tio n s : sur9ical ™Physema of neck
□ U ses: • Injury to oral cavity, teeth, lips
To diagnose the following - • Oesophageal perforation
• Abdominal aneurysm • Tracheal compression
• Arterial occlusion • Injury to pharynx, aryetenoids
• Blood Clot
□ A dvantages o f fib r e o p tic o e s o p h a g o s c o p y :
• Carotid occlusive disease
• Bedside procedure
• Renal vascular disease
• General anesthesia not required
• Varicose vein
• Used In cases of jaw or spine abnormalities
Q. 2 9 : O e s o p h a g o s c o p y t Accurate diagnosis due to good illumination & magnification
OESOPHAGOSCOPY • Removal of small foreign bodies
• Precision biopsies can be taken
□ Types:
• Dilatation of structures
• Rigid
• Oesophageal stenting
• Flexible fibre optic
Q Transnasal o e s o p h a g o s c o p y :
• T ransnasal
□ In d ic a tio n s : • Performed through nose
• Therapeutic - • Air can be inflated to distend walls of oesophagus for better viewing
> Foreign body removal • Oesophagus can be examined upto gastric fundus.
 604 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 605

O .3 0 : T ra c h e o s to m y Q Steps:
TRACHEOSTO M Y Vertical incision made from cricoid cartilage to just above sternal notch
OR
□ W hat Is I t : Making an opening in anterior wall of trachea & converting it into stoma on skin surface
Transverse incision made 5cm above sternal notch between anterior border of sternocleidomastolds of
□ In d ic a tio n s :
both sides
(A) Respiratory insufficiency - I
Chronic lung disorders - COPD, bronchitis Strap muscles separated & retracted laterally
(B) Respiratory obstm ction - I
• Trauma - Isthmus retracted upwards
> due to endoscopy i
> external injury to larynx, trachea Lignocaine Injected in trachea
> fracture of mandible I
Pretracheal fascia incised
• Infections -
i
> acute epiglottitis
Trachea incised & converted into circular opening
> diphtheria
I
> Ludwig's angina Trachoestomy tube inserted & secured by adhesive tapes
> retropharyngeal abscess I
> peritonsillar abscess Gauge dressing placed
• Neoplasma Q po st-o p e ra tive c a s e :
_ • Congenital anomalies
• Constant supervision
• Foreign body in larynx
• Care of tracheostomy tube
• Bilateral abductor paralysis
• Proper humidification
(C) R etained secretions -
• Periodic deflation of cuffed tube
• Painful cough
• Aspiration of pharyngeal secretions
COMPLICATIONS
• Neuromuscular disorders
□ Types:

. Emergency .Therapeutic Im m e d ia te In te rm e d ia te R em o te
• Elective I Routine / Orderly I Tranquil < T
^ Prophylactic • Primary Hemorrhage Displacement of tube Secondary hemorrhage
• Permanent (in bilateral abductor paralysis) • Blood aspiration Blocking of tube Tracheal stenosis
• Mini (cricothy roldotomy) • Apnoea Subcutaneous emphysema T racheo-oesophageal
• Percutaneous dilational tracheostomy • Injury to oesophagus Atelectasis, lung abscess fistula
□ L e v e ls : Secondary hemorrhage Tracheo-cutaneous fistula
• High (above level of thyroid isthmus) . Local wound infection Problems of decannulation
• Mild (through 2nd & 3rd tracheal ring)
• Low (below level of isthmus)
O P o s itio n :
• Supine + Extended neck
□ A n e s th e s ia :

• Local infiltration of lignocaine

606 QUEST : A Comprehensive Guido to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 607

Q. 3 1 : B ro n c h o s c o p y -^ f^ a W e s Rigid bronchoscopy Flexible bronchoscopy

BRONCHOSCOPY
, Anesthesia General Topical
There are 2 types of bronchoscopy - (a) Rigid (b) Flexible High Low
.Cost
□ In d ic a tio n s : , Bedside exam Not possible Possible
, advantages • Foreign body removal is • Nasal cavity, supraglottic &
INDICATIONS easier glottic areas, segmental &
• Better control of haemo­ subsegmental bronchi visible
_ } rrhage • Useful in jaw & neck abnor­
RIGID FLEXIBLE malities or injuries
• Large piece can be taken
for biopsy
I
----------- *
Diagnostic Therapeutic 132: C olonoscopy
Collection of bronchial secretions for micro­ Removal of retained
COLONOSCOPY
biological tests secretions or mucus
Determine cause of wheezing, hemoptysis, plugs
o Synonym : Coloscopy
persistent unexplained caugh Removal of foreign
0 What Is I t : Endoscopic examination of large gul & distal part of small bowel with a CCD camera or a
Vocal cord palsy body
fibre optic camera on a flexible tube passed through anus upto caecum
X-Ray chest finding being hilar/mediastinal
0 Length o f lu b e : 160 cm
shadows, obstructive emphysema, atelectasis,
etc. 0 Procedure:
• Done under GA with laryngeal mask airway
□ C o m p lic a tio n s : • Techniques used -
> Elongation
• Injury to oral cavity, teeth, lips
> Dither-torquing
• Hypoxia
• Hemorrhage J- Looping with a maneuver
• Cardiac arrest • Continuous air inflation to visualise lumen
• Laryngeal edema • Technique differs in patients after hemicolectomy

□ P o s itio n : (barking dog position) 3 Indications:

• Supine
• Head elevated by 10-15 cm INDICATIONS
• Neck flexed on thorax, head extended on atlanto - occipital joint
□ In tro d u c tio n o f b ro n c h o s c o p e : T
Therapeutic Diagnostic
v/ \
Direct introduction of bron- Through 1Polypectomy Bleeding per rectum
choscope through glottis laryngoscope To take biopsies from colon Unexplained changes in bowel habit
Dilatation of stricture colon CA colon
Q P re c a u tio n s : Fulgalion IBD
• Proper size of bronchoscope to be chosen
Older patients with severe anaemia
• Should not be forced through glottis
When barium enema shows irregularity
• Should not be prolonged procedure
• Removal £. introduction of instrument repeatedly must be avoided
 608 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 609

□ C o n tra in d ic a tio n : 4. Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after
• Acute ulcerative colitis liver transplantation)
□ C o m p lic a tio n s : , Contraindications:
• Bowel perforation 1. Acute pancreatitis (unless persistently raised or worsening bilirubin suggests ongoing
• Sepsis obstruction)
• Hemorrhage 2. Previous pancreatoduodenectomy
□ D is a d v a n ta g e :
3. Coagulation disorder if sphincterotomy planned
4. Recent myocardial infarction
• Takes longer time
□ A d v a n ta g e :
5. Inadequate surgical back-up .
6. History of contrast dye anaphylaxis
• Helps to visualise full colon
7. Poor health condition for surgery
Q. 3 3 : C h o la n g io g ra p h y
8. Severe cardiopulmonary disease
CHOLANG IO G RAPHY « T e ch n iq u e :
Patient is sedated -» Endoscope is inserted through the mouth, down the oesophagus, into
□ W hat Is i t : Cholangiography is procedure to visualise the hepatobiliary tree to identify any pathology
the stomach, through the pylorus into the duodenum where the ampulla of Vater is visualised
□ Typ es : -» A cannula is inserted through the ampulla -» A radiocontrast dye (60% urograffin) is
(a) Intravenous cholangiography injected into the bile ducts and/or pancreatic duct -» Fluoroscopy is used to look for block­
(b) Endoscopic retrograde cholangiopancreatography (ERCP) ages, or other lesions such as stones [When needed, the opening of the ampulla can be
(c) Magnetic resonance cholangiopancreatography (MRCP) enlarged (sphincterotomy) with an electrified wire (sphincterotome) and access into the bile
duct obtained so that gallstones may be removed or other therapy performed]
(d) Percutaneous transhepatic cholangiography (PTC)
« C o m p lica tio n s:
(e) Peroperative cholangiography
(0 Post operative T-tube cholangiography 1. Pancreatitis
□ In tra v e n o u s c h o la n g io g ra p h y : 2. Gut perforation
• W hat is i t : A dye (Meglumine ioglycamate/ Biligram) is injected i.v. and multiple skiagramsd
3. Oversedation can result in dangerously low blood pressure, respiratory depression,
abdomen are taken. nausea, and vomiting
• A d v a n ta g e : It can be combined with Oral cholecystogram (OCG) to study the function ot gall 4. Bleeding after sphincterotomy
bladder. ■ 5. Cholangitis
• Disadvantage : (i) drug reaction (ii) poor visualisation (iii) the procedure is not useful when * MRCP:
serum bilirubin is > 3 mg% • What is it - A form of cholangiog raphy that uses magnetic resonance imaging to visualise
Q ERCP: biliary and pancreatic ducts in a non-invasive manner
• What is i t : Technique that combines the use of endoscopy and fluoroscopy to diagnose and • Introduced in - 1991
treat certain pathologies of the biliary or pancreatic ductal systems • Purpose - Produces detailed images of liver, gall bladder, bile duct, pancreas and pan­
• In d ic a tio n s : creatic duct
> Diagnostic - • Uses -
1. Obstructive jaundice 1. Checking liver, bile duct, gall bladder and pancreas for gallstones, tumors, infection
or inflammation
2. Chronic pancreatitis
3. Gallstones with dilated bile ducts on ultrasonography 2. Investigating pancreatitis
4. Bile duct tumors 3. Investigating abdominal pain
5. Suspected injury to bile ducts either as a result of trauma or iatrogenic 4. Best used when serum bilirubin <10mg/dl and no pre-operative stenting is
contemplated
6. Sphincter of Oddi dysfunction
‘ Checklist before MRCP :
7. Pancreatic tumors
1. Internal pacemaker/defibrillator
» Therapeutic -
1. Endoscopic sphincterotomy (both of the biliary and the pancreatic sphincters) 2. Cochlear implant
3. Surgical clip
2. Removal of stones
4. Prosthetic heart vatve
3. Insertion of stents
5. Artificial limb
QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES OF INVESTIGATIONS 611

6. Implanted electronic device PET SCAN

• Side-effects -
Reaction to contrast dye when used Full fo r m : Positron Emission Tomography

• Contraindication - Pregnancy ° u m i is If i Nuclear imaging technique that creates detailed, computerised pictures of organs and
• Advantages over ERCP - 0 issues inside the body, to assess the biochemical and physiological status of a tissue.
1. Non- invasive prin ciple u s e d : Electronic collination
2. Delineate full biliary tree and not just the part proximal to the obstruction 0 R etgents u s e d :
3. No dye required , Two protons - positive electrons (positrons)
4. Can be used in acute panceatitis, duodenal injury,cholangitis , Most clinically used positron emitting radionucleotides -
• Disadvantage: No therapeutic procedure like stenting, basketing, biopsy can be carried
i) Fluoro - deoxyglucose (FDG)
. PTC:
ii) Rb82
> Whaf is it - It is done in case of severe obstructive jaundice under cover of antfciofics
after control of any type of bleeding tendency. iii) N13
> Indications - iv) O15
1. Cases of ERCP failure g Delectors u s e d :
2. Klatskln tumor • Bismuth germanate (BGO) crystals
3. High biliary strictures • Sodium iodide crystals
4. High blocks in biliary tree whenexternal catheter drainage is required (this is 0 p ro c e d u re :
known as Percutaneous transhepatic biliary drainage/ PTBD) . Patient injected with glucose solution that contains a small amount of radio active matenal,
> Technique - which is absorbed by particular tissues
Fluoroscopy (C-ARM) /CT/ US guided Introduction of Chiba or Okuda needle {15cm • Patient rests on table and then is slidedinto a PET Scanner.
long, 0.7 mm in diameter, flexible, blunt without a bevelled end) into liver in midaxfflaiy
■ Today, almost all PET scans are performed on Instruments that are combined PET and CT
line through right 8th intercostal space -» Needle in dilated biliary radicle -* Bile
aspirated (and sent for cytology, biochemical analysis and culture) -> water soluble Scanners,
dye is injected -» visualisation of dilated biliary radicles, site and extent of obstruction; t Time taken - 20-30 minutes.
therapeutic stenting through the site of obstruction in the biliary tree can also be d o n e
0 U ses:
> Complications - ■ • Detect carcinoma
1. Bleeding
• Detect metastasis
2. Biliary leak and peritonitis
• Assess effectiveness of treatment plan •
3. Septicemia . Reassess post-chemotherapy / post-treatment recurrence of carcinoma or spread of mats.
• Peroperative cholangiography :
• Determine blood flow to heart muscle .
> What is it - ft is done following cholecystectomy before exploration of CBD onthe opera­
• Identify areas of heart that would benefit from procedure like angioplasty, CABG.
tion table to assess for residual CBD stones, stricture, atresia. Itis also known as On
Table Cholangiography (OTC). • Evaluate abnormalities in brain, like tumours.
> Technique - Through cystic duct a fine polythene catheter is passed into the CBD -»a • Locate temporal lobe epilepsy.
radio-opaque dye is injected -» C-ARM image intensifier is used -» If dye freely and
Q A d v a n ta g e s :
completely goes into duodenum, fhe OTC Is normal. Any block or stricture in the CBDcan
• Very specific - provides details on both function and anatom structure of body
be identified by this procedure.
> Precaution - The syringe should be made air-free carefully. • High accuracy
> Complications- ( 1 ) Infection (2) Bile leak • Detect early onset of disease
• Postoperative T-tube cholangiography : Q D is a d v a n ta g e s :
> Technique - • Expensive
Choledocholomy done - » Kefir's T-tube is placed into the CBD -> After 10-14 days, wale; < Radiation exposure to patient
soluble dye is injected into the tube -> X- ray is taken - » If the dye freely and complele!/
t Allergic reaction to radio tracer.
goes to the duodenum, there is no blockage. T-tube can be removed then. Blockage
, . Results adversely affected il patient is diabetic I has taken meal few hours prior to procedure.
indicates residual CBD stones.
612 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT MOTES OF INVESTIGATIONS 613

USG FOR HEPATO BILIARY DISEASES > Vascular diseases Thrombosis of hepatic vein and membranous obstruction of IVC can be
diagnosed.
□ Use o f USG In h e p a to b ilia ry d is e a s e :
g B e n e fits o f fo c u s s e d b e d s id e b ilia r y s o n o g ra p h y :
Provides structural information but not functional details
> Decreases time to diagnose cholelithiasis and cholecystitis
□ A d v a n ta g e s :
> Assess degree of obstruction in choledocholithlasis
• Safest
> Can provide bedside radiographic corroboration of physical examination findings.
• Least expensive
> Safe in pregnant and children, hence very useful for emergency obstetric and neonatal
' . • Most sensitive for imaging biliary system cases.
□ In d ic a tio n s o f u s e :
• Screening of biliary tract abnormalities
• Detection of liver masses
t Evaluation of hepatobiliary tract in patients with right upper quadrant abdominal pain.
• Differentiation of Intra - and extra-hepatic causes of jaundice.
• Evaluation of spleen size to help diagnose splenomegaly - suggesting portal hypertension
□ P a th o lo g ie s :
> Gallstones -
• Cast intense echoes with distal acoustic shadows
. • Transabdominal ultrasound can detect stones > 2 mm, size (sensitivity > 95%)
• Endoscopic ultrasound can delect stones as small as 0.5 mm.
> Biliary sludge -
• Low level echoes that lie as a layer in the dependent portion of gall bladder without
acoustic shadow.
> Cholecystitis -
• Thickened gall bladder wall (> 3 mm)
• Impacted stone in gall bladder neck
• Pericholecystic fluid
• Ultrasonographic Murphy's sign (tenderness when gall bladder is palpated)
> Extrahepatic obstruction -
• Dilated bile ducts (> 10 mm)
• Retroduodenal dilatation may not be visible
• Trans abdominal ultrasonography may not reveal the cause or level of biliary obstruction,
endoscopic ultrasound is better
> Liver lesions -
• Focal lesions > 1 cm size canbe detected
• Cysts - echo free
• Solid lesions - echogenic
• Carcinoma - irregular solid mass
« Guides aspiration and biopsy
• Fatty liver “I
, . Can be detected
» Cirrhosis J
• Ultrasound dastography to measure liver stiffness as index of hepatic fibrosis.
 Section - 2

ORTHOPEDICS

G R O U P-I

Solved Short Notes of Final MBBS 2008-2015

G R O U P -II .

Solved Short Notes of Semesters of Various Colleges

 GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 617

GROUP- I
3 Manipulation under anesthesia - External rotation - * abduction - » flexion
SOLVED SHORT NOTES OF FINAL MBBS 4. Triamcinolone injection , .
»,) operative - rarely required .
2008 I. Open release • .
1.1 : Frozen s h o u ld e r
2 Arthroscopic capsular release .
FROZEN SHOULDER
0 2 ■Complications o f s u p ra c o n d y la r fra c tu re
□ S ynonym s :
. • Periarthritis shoulder COMPLICATIONS OF SUPRACONDYLAR FRACTURE
• Perieapsulitis
• Adhesive capsulitis
• Adhesive bursitis COMPLICATIONS OF
SUPRACONDYLAR
^ " — nohU-g eralj0'nt b^coni&s Dainfut and stiff due to loss ol resilience of H* iik.. FRACTURE
✓ J>robably due to inflammation and adhesions^ ---------------------------- sI!Pfousrap;i^ ^ .
3 E t i o l o g y ^Idiopathic; may be due to microtranma "
/Q A s s o c ia te d w ith .■ 1 .1
• Trauma 1 Immediate Early Late
• Diabetes. (at the time of fracture)
|(atth (within 1st 2-3 days) (in weeks to months)
• Thyroid disease
□ L u n d b e rg c la s s ific a tio n : Injury to Malunion
( 1 ) Prim ary-No triggering event present brachial aftery Volkmann’s
ischaemia
Volkmann's
Injury to nerve
C lin ic a l fe a tu r e s : ischaemic
(median
contracture
neive » radial
nerve)
Myossitis
' •'nrafh^ f 7 ln'lially lBSS 'n S6Vefi,y ,han pain and ,imi,ec, t0 in,ernal rotation, then abduction , ossificans
gradually increasing in severity and all movements are limited -> gradual ly diminish in intend
-> some residual stiffness persists, especially restricted external rotation
K .
• WastingQf shoulder miK^loc
Q INJURY TO BRACHIAL ARTERY -
„ l n ^ s tiJ a e
t^ nQSS ° ye ^ i£gESjgndon and anterior part of greater tuberosity

Causes absence of radial pulse

* . X-ray
* M2 L " . I
• Arthrography Closed reduction
w/ Q T re a tm e n t:
I
(Self limiting disease which resolves by 6-9 months)
(a) Conservative- - *
1. Physical therapy - - Pulse returns within 1 hour (Plan A) Pulse does not return
, • Interferential therapy-: I s ' ^
• Ultrasonic therapy ••' ' Capillary circulation good Capillary circulation poor (Plan 8 )
• TENS Maintain in slab tor 46 hours I
2. Exercise - J, Keep in slab under closed observation Vessel explored
• Reciprocal pulley exercise /
Proper reduction of fracture 'I'
. • Free-swinging exercise • / Improves Does notimprove |ntema| reduction
• Capsular stretching exercise .
f I
Plan A Pfan B
616
 S13 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS SI 9

□ VOLKMANN'S ISCHAEMIA- g Types o f s e q u e s tr u m :

> D e fin e : Ischaemic injury to muscles of flexor compartment of forearm
> C ause : Injury to brachial artery in supracondylar fracture
> M u s c le s a ffe c te d : Deep muscles supplied by anterior interosseous artery - Flexor digito^ f TYPES OF SEQUESTRUM
profundus and Flexor pollicis longus V-------------------- ---------------------
> C lin ic a l fe a tu r e s :
r ................. 1 i
• Severe ischaemic pain
• Stretch pain ( According to colour J f According to shape J
• Tenderness
• Swelling of fingers —^ Feathery ^ —( Ring ^
'y C o m p lic a tio n s : Compartment syndrome
> T re a tm e n t:
— ^ Coralliform — ^ Pencil-like ^
• Remove any splint/bandage causing compression
• Elevation of forearm and advised to move fingers
4- —^ Ivory ^ — ^ Cylindrical ^
No improvement in 2 hours
I —^ Conical ^
—( Black ^
Fasciotomy
□ MALUNION -
— ^ Green ^
* > S p e c ia lity : Commonest complication of supracondylar fracture
> P a th o a n a to m y : Fracture unites with distal fragment tilted medially and internally rotated .....

> R e s u lt: Cubitus varus/gu nstock deformity

Q A e tio lo g y:
> A e tio lo g y :
• Delay in treatment
1. Inadequate reduction
• Inadequate treatment
2. Displacement of fracture segment within the plasler
• Highly virulent organisms
> T re a tm e n t: If severe cosmetic abnormality -> French osteotomy
• Reduced host resistance
□ VOLKMANN’S ISCHAEMIC CONTRACTURE -
Q P atho logy:
A r See Short note - Volkmann’s ischaemic contracture (Page No. 620)
□ MYOSSITIS OSSIFICANS - Following acute osteomyelitis
A: See Short note - Myossitis ossificans (Page No. 627-628)
X
0 . 3 : S e q u e s tru m
Disturbed periosteal blood flow New subperiosteal bone formation
SEQUESTRUM
1 I
Y
□ IVTiaf Is c h r o n ic o s te o m y e litis : Infection of bone, persisting for >3 weeks, along with absence of any Dead bone surrounded by granulation tissue This sclerotic bone is involucrum
systemic symptoms and characterised by a discharging sinus
1 1
□ Types: 1 Y
• Secondary to acute osteomyelitis Sequestrum formed It overlies the sequestrum
• Garre's osteomyelitis 1 1
• Brodie's abscess r Y
Inner surface smooth, outer surface Irregular Cloacae (holes) formed to drain out pus
□ W hat Is s e q u e s tru m : Piece of dead bone, within a living bone affected by chronic osteomyelitis,
surrounded by infected granulation tissue, having a smooth inner surface and irregular outer surface
Site : Lower end of femur
[See Fig. 2.9.1] 3 Clinical fe a tu re s :
• Past history of open fracture/trivial trauma/fever and pain in affected part
S20 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 621

• Discharging sinus • Volkmann's sign positive - Can extend fingers only when wrist is flexed
• History of bone pieces coming out • Bunnell deformity - Wrist flexed, forearm pronated, thumb adducted
• Waxing - Waning pattern of symptoms 0 Treatm ent:
• Reduced range of movements
• Mild case - Volkmann’s splint
• Puckered scars around sinus
t Moderate case - Maxpage soft tissue sliding operation
• Increased bone girth
t Severe ca se - (a) Forearm shortening operation •' ,
• Tenderness
(b) Carpal bone excision
In v e s tig a tio n s :
(c) Arthrodesis of wrist '
• X-ray -
Talipes e q u in e s
> Irregular and thickened corlex
> Sequestrum (increased bone density, surrounded by radiolu scent zone) TALIPES EQUINUS
>• Involucrum + cloacae
g What is I t : Orthopaedic deformity where foot is plantar-flexed (actually this is found i n acquired CTEV
> Patchy scferosis
where equinus component is more prominent than varus component. In Talipes equinovarus, foot is
. CT, MRI plantar-flexed, adducted and inverted) [See Fig. 2.9.2]
• Sinogram 0 S ynonym : Club foot
• Pus - Culture and sensitivity 0 Basic d e fo rm itie s :
T re a tm e n t: • Cavus - exaggerated longitudinal arch of foot
• Surgical - • Adduction of forefoot - at midtarsal joint
> C-Cauterisation • Varus of hindfoot - inversion at midtarsal joint
> A-Amputation • Equinus - foot fixed in plantar-flexion
> S-Sequestrectomy
Q A e tio lo g y: ..
> E-Excision of infected bone
> S-Saucerisation
• Antibiotics
TALIPES UINOVARUS
• Rest ises
. • Continuous suction-irrigation after wound closure
C o m p lic a tio n s :
• Acute exacerbation Congenital Acquired
• Growth abnormality (lengthen, shorten, deformity)
• Pathological fracture _ Genetic (autosomal Post burn
• Joint stiffness dominant) contracture
• Sinus tract malignancy
_ Raised intrauterine ]
Amyloidosis Cerebral palsy j
pressure J
y 'A : V olk m a n n 's Is c h a e m ic c o n tra c tu re
_ Ischaemia of calf Volkmann’s ischaemic
VOLKMANN’S ISCHAEMIC CONTRACTURE muscles contracture

□ W hat is I t : Late complication of supracondylar fracture and sequalae of Volkmann's ischaemia _ Fibrosis of soft - Leprosy
□ P a th o a n a to m y : Ischaemia replaced by fibrous tissue -> Contracts -» Draws fingers and wris! in tissues
flexion Post polio residual
□ C lin ic a l fe a tu re s : - [Breech presentation]
paralysis
• Flexion deformity of wrist and fingers
j Arthrogryposis
• Atrophy of forearm
multiplex congenita
• Skin dry
• Nails atrophied - f Myelomeningocele j
• Sensory loss may occur if median nerve injury

i
622 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 623

P a th o a n a to m y : (6) Secondary changes -

(1) Bones - (a) Weight bearing exaggerates deformity
(a) All bones of foot - small (b) Callosity and bursae on lateral side
(b) Neck of talus - angulated, faces downwards and medially g C linical fe a tu re s :
(c) Calcaneum — short, concave medially Foot plantar-flexed, adducted and inverted
(2) Joints-
g in v e s tig a tio n s :

P o s itio n s J o in t m a lp o s ltlo n e d X-ray - Angle between long axis of talus and calcaneum i.e. Kite's angle < 35 degrees
g T re a tm e n t:
Equinus Ankle joint
Inversion Subtalar joint
Forefoot adduction Mid-tarsal joint Talipes equino varus
Forefoot cavus Mid-tarsal joint
I
(3) Muscles and tendons - Secondary causes excluded
Muscles of calf underdeveloped -> Following tendons contracted
^ X
Presents early/at birth Presents late
X
Posteriorly Medially
i
I i Manipulation alone
Achilles tendon (a) Flexor hallucis longus
(Mother advised to manipulate foot
(b) Flexor digitorum longus after each feed
(c) Tibialis posterior Pressure for 5 seconds - » release
pressure - » pressure
(4) Capsules and ligaments -
This is continued for 5 minutes)
All ligaments on postero-medial side are shortened

Side Involved Ligaments affected OR

i-
Posterior 1) Capsule of ankle joint
Manipulation and POP
2) Capsule of subtalar joint (a) 6-18 months - Postero-medial
3) Posterior talofibular ligament ( 1) Kite's technique (started at 1 soft tissue release
4) Posterior calcaneofibular ligament month of age, using below - knee (b) 18 months - 4 years -
piaster casts, changed fortnightly, Complete subtalar release
Medial 1) Talonavicular ligament deformities corrected sequentially
2) Spring ligament adduction -> inversion - » equinus) (c) 4-7 years -
3) Deltoid ligament (2) Ponsetti's technique (started at (1) Dilwyn Ewan’s operation
Plantar 1) Plantar fascia 1st week of age, done for 2-3 (2) Dwyer's calcaneal osteotomy
2) Plantar ligament weeks; by putting thumb pressure
(3) Joshi's External Stabilisation
over talus head, calcaneo-cuboid-
Others Interosseous ligament between talus and System
navicular complex is externally
calcaneum _| rotated under talar head) (4) lllizarov's technique of external
reduction
(5) Skin- (3) Bansahel/Dimeglio modified French
Shortening technique (5) 8-12years-Wedgetarsectomy
(a) Medial side:

Deep creases
(b) Lateral side - Dimples
 624 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 825

[b] Parasympathetic (S2.S3.S4) - Nerve of voiding (Contraction of detrusor and relaxation of

internal sphincter,also carries Bladder filling sensation)
(4) Motor nucleus - Pudendal nerve (S2.S3.S4) [Controls external sphincter]
0 o f b la d d e r p ro b le m s In s p in a l p a ra p le g ia :

(1) Shock bladder - Stage of neural shock soon after spinal injury, which results in no sense of
fullness of bladder and evacuation. There is Overflow incontinence.
(2) Incomplete lesions of spinal cord above S2.S3.S4 - Frequency, urgency of micturition
(3) Complete transection of spinal cord at the level of Dj-D 9 vertebrae - Cortical control is lost.
There is retention of urine with overflow incontinence. Later ’ Reflex bladder/Automatic bladder"
develops when there is reflex evacuation on collection of some urine. There is incomplete
evacuation and residual urine remains inviting infections.
(4) Sympathectomy (complete transection of spinal cord at lumbar region) - Tone of internal
sphincter decreases resulting in frequency of micturition. Constant dribbling of urine (True
incontinence) may occur. Bladder is never full.
(5) Parasympathectomy (complete transection of spinal cord at sacral region) - There is complete
loss of voluntary control of micturition resulting in “Autonomous bladder” . Retention with overflow
incontinence is there. But incomplete evacuation occurs and high amount of residual urine
remains. Patients are taught to stimulate perineum in order to micturate.
0 in v e s tig a tio n s :
• X-ray of spine
• Micturating cystourethrogram
• Post micturition USG - To assess residual urine
• Urine - Microscopic examination and culture
• Urodynamic studies
G Treatm ent:
• Treatment of the cause is to be done
• Intermittent catheterization to relieve retention - In case of overflow incontinence, for a male
Q. 6 : B la d d e r p ro b le m in s p in a l p a ra p le g ia
patient urinary pot or condom catheter can be used; for a female patient catheterization is the
only choice. Before discharge, to teach patient the sensation of fullness of bladder clamp the
BLADDER PROBLEM IN SPINAL PARAPLEGIA
catheter at 2-3 hours interval for 2 days. Then patient is observed for 1 day for any progress.
Bladder dysfunction due to neurological disorders is termed as “ Neurogenic Bladder'’. • Physiotherapy, Pelvic exercises, Electrical stimulation of perineal muscles
□ F o r n o rm a l u r in a ry c o n tin e n c e fth e a b ility to e x e rc is e v o lu n ta ry c o n tro l) a n d v o id in g , a balance • Drugs- Alpha adrenergic blockers, Carbachol, Distigmine
n e e d s to b e th e re a m o n g th e fo llo w in g f o r c e s : • Antibiotics-To treat infection
(1) Detrusor muscle contraction
(2) Abdominal muscle contraction 2008 S u p p le m e n ta ry
(3) Activity of bladder neck (internal sphincter)
(4) Activity of urethral sphincters (external sphincter) 0.1: F racture o f p a te lla

□ The n e rv e s u p p ly o f th is s y s te m Is a s fo llo w s : A : See Section 2, Group 1,2011, Qs. 3 (Page No. 64?)

(1) Cortical centre - In Frontal lobe 0-2: Co lie 's fra c tu re

(2) Higher centres - Facilitator/ centres at pons and posterior hypothalamus. Inhibitory centre u! A : See Section 2, Group 1,2013, Qs. 4 (Page No. 662)
midbrain
0 J : C lin ica l fe a tu re s o f s p in a l tu b e rc u lo s is
(3) Lower centres -
A : See Section 2, Group 1,2010, Qs. 6 (Page No. 642)
(a] Sympathetic (Ti • L2) - Nerve of filling (Relaxation of detrusor and contraction of interna'
sphincter) 1

i
 626 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 627

0 .4 : B one c yst j Cause :

A : See Section 2, Group II, Os. 32 and Qs. 33 (Page No. 721-722) y Increasing amount or intensity of activity
y Improper equipment
Q .S : G lbb us
A ns: v y Increased physical stress
GIBBUS y Unfamiliar surface
g Clinical fe a tu re : Pain at the site of fracture, which increases with activity and subsides with rest,
□ W hat is i t : Type of hyphotic structural deformity where there is prominence of two or three spinous
processes and these vertebrae become wedged r) in ve stig a tio n s:
□ D e riv a tio n ; Gibbus Is Latin for "hump” or •‘hunch" y X-Ray
> CT
□ C auses:
(A) Congenital — > Apart syndrome V MRI

> Cofftn-Lowng syndrome P T re a tm e n t:

> Cretinism (hypothyroidism) - sail vertebrae > Rest
> Achondroplasia > Pain-free activity for 6-8 weeks
. > Mucopolysaccharidoses- (i) Hurler syndrome > Shoe inserts/braces to be used
(Ii) Hunter syndrome 0 p reventio n:
(iii) Morateaux-Lary syndrome > Healthy diet rich in Vitamin-D and calcium
(B) Acquired— > Pott's disease (Spinal TB) V Use of proper equipment
> Spinal osteomyelitis > Cross-training
> Compression fractu re with collapse of vertebral bodies (vertebra plana) > Set incremental goals when indulging in any new sports activity.
as in -
(i) Metastasis
2009
(ii) Osteoporosis
(iii) Histiocytosis 1 1: Myositis ossificans

» Sch euer mann disease MYOSITIS OSSIFICANS

□ C lin ic a l e x a m in a tio n fin d in g : When viewed from behind, deformity looks sharply angled. The
D S ynonym : Post-traumatic ossification (traumatic myositis ossificans)
hunchback deformity becomes more prominent when patient bends forward. (Adam's forward bending
Test) Q What Is I t : Ossification of hematoma around joint - t formation of bone mass - » restricts joint movements

□ In v e s tig a tio n s : 3 A e tio lo g y: Severe trauma where capsule and periosteum stripped off from bones

> X-Ray 0 Commonest s i t e : Elbow joint

> MRI - Measure Cobb’s angle Q A ge: Children > adults

□ T re a tm e n t: Early treatment of the underlying cause is required. 0 Occurs i n :

• Neuronal damage from head injury
0 . 6 : S tre s s F ra c tu re
• Paraplegia
Ans:
• Massage after trauma
STRESS FRACTURE
9 Clinical fe a tu r e s :
□ W h a t is I t : Oversue injury which occurs when muscles become fatigued and are unable to absorb the • Stiffness
added shock, and then transfer the stress to bone causing tiny fracture • Loss of joint movement
□ S ite : Weight-bea ring bones of lower leg and foot J X-ray fe a tu re s :
□ S e x p r e d ile c tio n : F > > M • Active myositis - fluffy margins of bone mass
• Mature myositis - trabeculated mass and well-defined margins
 626 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 629

□ T re a tm e n t: .
• Rest n in ttm e n t:

• Physiotherapy later , Detection of underlyi ng cause of fracture

• Surgical excision , Assessment of capacity of fracture to unite, based on nature of underlying disease -
□ P re c a u tio n : No massage after trauma > Generalised disorder (Paget's disease, osteoporosis) - unite with conventional methods
□ Other t y p e s : > Bone cyst, benign tumor - delayed union
• Myositis ossificans progressive > Fractures in osteomyelitic bones - long time to unite
• Myositis ossificans hypertrophica > Fractures through metastatic bone lesions - do not unite, repair using bone graft
Q .2 : P a th o lo g ic a l fra c tu re 5 3; Carpal tunnel syndrome
PATHOLOGICAL FRACTURE CARPAL TUNNEL SYNDROME
□ W hat Is I t : Fracture in a bone made weak by some underlying disease
g in tro d u ctio n : Syndrome due to compression of median nerve as it passes beneath flexor retinaculum
□ B one s a ffe c te d m o s t c o m m o n ly : Thoracic and lumbar vertebral bodies
q Aetiology:
□ C auses:
« Colies' fracture
• Amyloid disease
< Raynaud's phenomenon
CAUSES OF PATHOLOGICAL
• Pregnancy
FRACTURES
t Aberrant forearm muscles

X • Lipoma
• Idiopathic synovitis
LOCALISED DISEASES GENERALISED DISEASES
• Diabetes
X I n_ • Rheumatoid arthritis
INFLAMMATORY ('neoplastic MISCELLANEOUS HEREDITARY • Obesity
(Pyogenic (Simple bone cyst, (Osteogenesis • Myxedema
osteomyelitis, ------ Aneurysmal, imperfecta,
Tubercular Benign Malignant ] Q Age: Post menopausal females
bone cyst, Osteopetrosis)
osteomyelitis) (Giant cell Eosinophilic 0 Clinical features:
turrior, Primary granuloma, etc) ACQUIRED • Tingling numbness in lateral 3'/, fingers and that portion of hand
Enchondroma) (Osteosarcoma,
Ewing's tumor) (Osteoporosis, • Clumsiness In carrying out fine movement
Rickets)
• Thenar muscle
Secondary • Atrophy and wrist weakness in chronic cases
(lung, prostate,
kidney, etc) • Tinel's sign - Tapping median nerve along its course in the wrist over flexor retinaculum'
numbness or paraesthesia at median nerve distribution
• Phalen's manoeuvre positive - Flexion of wrist for 30-60 seconds -> numbness or paraesthesia
at median nerve distribution
□ A g e -w is e c o m m o n e s t ca u s e s :
• Birth - 5 years - Osteogenesis irnpe rfecta {See Fig. 2.9.3]
• Durkan’s carpal compression test positive - Compress median nerve at wrist for 30 seconds
• S-20 years - Osteomyelitis, Simple bone cyst
-* numbness or paraesthesia at median nerve distribution
• 20-50 years - Cystic lesions of bone. Osteomalacia, Malignancy
' Blood pressure cuff test - Shows signs of nerve compression
• > 50 years - Osteoporosis, Multiple myeloma
3 Investigations:
□ C lin ic a l fe a tu r e s :
' Nerve conduction velocity reduced
• History of discomfort in region of affected bone before fracture
• MRI
• Fracture sustained with trivial trauma
^ Treatm ent: Dividing the flexor retinaculum decompresses the nerve
 630 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 631

O. 4 : F ra c tu re n e c k fe m u r■ ty p e s a n d c o m p lic a tio n s p tre a tm e n t:

FRACTURE NECK FEMUR Fracture neck femur

□ Types: X
Undisplaced Displaced
• Intraarticular (True fracture neck femur)-discussed below
• Extraarticular (Intertrochanteric fracture)
□ A ge : Elderly
J ^ ^
Age < 60 years Age > 60 years
Hip spica in children
□ S ex p r e d ile c tio n : F > M
Thomas splint in adults
□ C a u s e : Trivial fall or sometimes
□ C la s s ific a tio n : Multiple screw fixation
• ANATOMICAL CLASSIFICATION-
Closed reduction Prosthetic replacement
> Subcapital (just below head) reqd
> Transcervical (middle of neck)
> Basal (at base of neck)
[See Fig. 2.9.4]
Reduced Not reduced
/
Normal hip
\
Pre-existing arthritis
• PAUWEL’S CLASSIFICATION - J I
(based on angle of inclination of displaced fragment from horizontal plane)
Multiple screw fixation Open reduction I
Hemiarthroplasty
i
Total hip
I • 30 degrees
replacement
II - 50 degrees
III - 70 degrees
• GARDEN’S CLASSIFICATION - Q C o m p lic a tio n s :
(based on degree of displacement) • AVASCULAR NECROSIS-
Stage 1 - Incomplete fracture > Cause - Insufficient blood flow through ligamentum teres
Stage 2 - Complete fracture + not displaced > Effects - (i) Non-union
Stage 3 - Complete fracture + partially displaced (fi) Deformed head
Stage 4 - Complete fracture + completely displaced > Evident after - 2 years in X-ray
□ C lin ic a l fe a tu r e s ; > Investigation of choice - MRI
• Pain in groin > Treatment - (i) In young - Total hip replacement, Arthrodesis, Meyer’s procedure
• Unable to move limb (ii) In elderly - Hemireplacement arthroplasty, Total hip replacement
• Affected limb externally rotated . NON-UNION -
• Limb shortened > Pseudoarthrosis + Trendelenburg test positive
> Treatment: (i) Neck reconstruction
• Tenderness in anterior hip point and on bitrochanteric compression
(ii) Pauwel's osteotomy
• Attempted hip movements painful
• OSTEOARTHRITIS -
• Active straight leg raising nol possible
> Due to - (i) Avascular deformation of head
□ X -ra y fe a tu r e s :
(ii) Union in faulty alignment
Medial cortex of neck > Troatment - (i) In children - Intertrochanteric osteotomy
« Break in , . ..
Shenton s line (ii) In elderly - Total hip replacement
Trabecular stream 5 : A e tio p a th o g e n e s is o f a c u te o s te o m y e litis
• Femur externally rotated
• Overriding of greater trochanter ACUTE PYOGENIC OSTEOMYELITIS

^ What Is p y o g e n ic o s te o m y e litis : Infection of bone by pyogenic organisms

932 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology G R O U P - I D SOLVED SHORT NOTES OF FINAL MBBS 633

□ Types: q S ite- Metaphysis of

• Acute- • Upper femur (commonest)
> Primary (haematogenous spread) - commonest » Lower femur
> Secondary (due to open fracture or surgery) » Upper tibia
• Chronic 0 A g e : Childhood
□ A e tlo p a th o g e n e s ls : q sm p re d ile c tio n :M > F

• Normal anatomy - Metaphysis i.e. the part between diaphysis and epiphysis, is highly vascular P C linical fe a tu r e s :
- arteries end in capillaries and veins begin, forming hair-pin loop. Any stasis of blood fin • Pain, swelling at metaphyseal end
makes it highly vulnerable to microbial infection. • Later abscess in muscle plane
• Causative organ isms - • Toxic features
> Staphylococcus aureus 0 In v e s tig a tio n s :
> Group B Streptococcus • Raised ESR
> Staphylococcus epidermidis • Raised TLC
> Haemophilus influenzae • X-ray - Earliest sign is subperiosteal new bone deposition
> Salmonella typhi • Bone scan
> Pseudomonas 0 Treatm ent:
• Spread of infection - via blood • Presents In < 48 hours -
• Pathogenesis - > Rest
> Antibiotics
Bacteria reach bone via blood
> Intravenous fluid
I • Presents after > 48 hours -
Get lodged in metaphysis
Surgical exploration and drainage followed by rest, i.v. fluid and antibiotics
4 □ C o m p lica tio n s:
Inflammatory reaction • General - *
4
Bone destruction, pus formation
> Septicaemia
> Pyaemia
•

4
Pus travels in different directions
• Local -
> Chronic osteomyelitis
> Acute pyogenic arthritis
^ 1 X > Pathological fracture ■
Along medullary cavity Out of cortex To the joint □ D ifferential d ia g n o s is :
• Acute rheumatic arthritis
1 I • Acute septic arthritis
Thrombosis of medullary vessels ^
• Acute poliomyelitis
Lies subperiosteally
0 .6 : Spina b ifid a
^ X
Subperiosteal new bone formation Periosteum lifted SPINA BIFIDA

^ N , Q What Is I t : Failure of enfolding of nerve elements within spinal canal during developmental period
Damage of periosteal blood supply Perforates periosteum
0 S ite s:
4 i • Lumbosacral
Segment of bone rendered avascular '
| Abscess in muscle • Thoracolumbar
Q Types :
Sequestrum formed *),ane
• Spina bifida occulta
[See Fig. 2 . 9 . 5 ] __________________ t • Spina bifida aperta
634 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - i □ SOLVED SHORT NOTES OF FINAL MBBS 635

SPINA BIFIDA OCCULTA; q j ; Complications o f supracondylar fracture o f humerus

□ W hat Is i t - Vertebral arches fail lo fuse bifid spinous processes of vertebrae A : See Section 2, Group 1,2008, Qs. 2 (Page No. 617)
□ C o m m o n e s t s ite - Lumbosacral region (Si commonest) 0.3 '■Psget’s disease o f bone
□ C lin ic a l fe a tu re s - A : See Section 2, Group II. Qs. 9 (Page No. 701)
• Dimpling of skin
q.4 ; Te nsion b a n d w irin g
• Lipoma
A : See Section 2, Group II, Qs. 14 (Page No. 704)
• Dermal sinus
Q £ : Indication tor amputation
• Tuft of hair ••
□ N e u ro lo g ic a l m a n ife s ta tio n s : A : See Section 2, Group 1,2012 Supplementary, Qs. 4 (Page No. 656)
• Cause : 0 .6 : M a nage m en t o f o ste o sa rco m a
> Tethering of spinal cord to filum terminate
Ans:
> Defeclive neural development (myelodysplasia) MANAGEMENT OF OSTEOSARCOMA
> Tethering of spinal cord to undersurface of skin by fibrous membrane (membrane
reunions) (For introduction See Section 2, Group II, Qs. 36, (Page No. 724))
> Diastematomyelia(bifid cord, transfixed with antero-posterio r bone bar) □ Investigations:
• F e a tu re s : . > X-R ay- (i) Sunray appearance-Tumour grows into the overlying soft tissues. New bone
> Muscle imbalance in lower limbs is laid down centrifugally, along the blood vessels within the tumour.
> Muscle wasting (ii) Periosteal reaction
• > Foot deformities (iii) Codman's Triangle - See Section 2, Group I, 2011 Supplementary, Qs. 4
(Page No. 642)
SPINA BIFIDA APPERTA:
> Serum alkaline phosphatase -
□ W hat Is I t - Involves vertebral arches, overtying soft tissues, skin, meninges and often the neural lube
Tumour -> T Serum ALP - » Tumour removal -> I S. ALP -> Recurrence or metastasis
□ C o m m o n e s t s ite - Dorso-lumbar spine
□ Types -
• Meningocele - Meninges protrudes out through a defect in neural arch, contains only CSF T S. ALP
> Biopsy - to confirm diagnosis
. Menin gomyelocele - Neural elemenls along with meninges protrude out
• Syringomyelocele - Dilated central canal of spinal cord, cord protrudes out along with the > Chest X-ray - to detect lung metastasis

meninges and neural elements > CT. MRI - to know extent of involvement of affected bone which is necessary for amputation
and limb saving surgery
• Myelocele - Due to arrest in closure of neural groove, CSF may leak out through the upper
end of an elliptical raw surface (2nd commonest type) □ T reatm ent :
[See Fig. 2.9.6] A) Amputation - It can be of 2 types
□ In v e s tig a tio n s : > Palliative - » For pain relief and better life
• Plain X-ray spine > Definitive -> Complete removal of tumour
• CT/MRI of spine and head
□ T re a tm e n t: Site of tumour Level of amputation
• Deformity correction
• Upper end of humerus -» Forequarter amputation
• Development of limb function
• Upper end of tibia -» Mid-thigh amputation
• Urological treatment for bladder incontinence
• Upper end of femur -» Hindquarter amputation
. Ventriculo-peritoneal shunt for hydrocephalus
Hip disarticulation for early lesions
2009 S up plem en tary • Lower end of femur -» Hip disarticulation
Mid-thigh amputation for early lesiom
0 . 1 : N o n -u n io n o f c lo s e d fra c tu re
A : See Section 2, Group I, 2003 supplementary, Qs. 4 (Page No. 665)
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636 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

2010
B) Chemotherapy -
> Given pre or post-operative 0, 1; e x o s to s is
> Drugs use d - (i) Methotrexate EXOSTOSIS
(ii) Citrovorum (actor
g What Is I t : Commonest benign tumor of bone
(iii) Cisplatin
0 S ynonym s:
(iv) Endoxan
• Osteochondroma
C) Radiotherapy -
• Diaphyseal aclasis
Indications are - (i) Local control of tumours occurirtg at surgically inaccessible sites
• Cartilage capped exostosis
(ii) Patients no) ready for surgery
0 Define : Exophytic outgrowth on the surface of bone, as a resull of detachment of a part of bone
0) Immunotherapy -
growth plate, capped by hyaline cartilage
A portion of tumour is implanted into a sarcoma survivor and is removed after 14 days
The sensitized lymphocytes from the donor are infused into the patient, which finally Kill [See Flfl. 2.9.7]
the cancer cells selectively. 0 P a ih o a n a to m y :
E) Follow-up - » It is a result of aberration of growth plate
For next 6-8 weeks to evaluate any recurrence or metastasis • Some cells at the margin of the growth plate, instead of growing longitudinally, start growing
F) Treatment plan - centrifugally
• Longitudinal growth of rest of growth plate continues, exostosis comes to lie at the metaphysis,
pointing towards the draphysis
Clinical Features • When longitudinal growth stops, exostosis also stops growing
• Tip gets covered with hyaline cartilage, rest made of mature bone
I □ A g e : Adolescents
Initial evaluations (X-ray, Chest X-ray)
□ C linical fe a tu re s :
Swelling with following features -
Biopsy to confirm diagnosis • Bony
• Non-tender
. Hard

f
Normal Chest X-ray
Y
Chest X-ray showing secondaries •
» Sessile/pedunculated
Surface smooth

______ I______ • Margins well-defined

I • Arising from underlying bone
f CT Scan • Not attached to skin or superficial structures
Local control Control ol spread
0 R isk fa c to rs fo r m a lig n a n t c h a n g e :
Neo-adjuvant
chemotherapy f
Single Single
•
•
Sessile
Situated in proximal part
Adjuvant
lesion lesion • Multiple in number
chemotherapy
0 S ite : Metaphysis
I I 0 C o m p lic a tio n s :
Resection of Palliative ablation
secondary lesion of tumour and • Compression of neurovascular bundle

f
Limb ablation
If
Limb saving
chemotherapy •
•
Limitation of joint movement
Pain and tenderness if -
surgery surgery 1. Direct compression of nerves
2. Fracture of base of growth
 638 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 639

3. Malignant transformation to chondrosarcoma in 1% cases q T r e a tm e n t:

4. Bursitis of overlying bursa • Surgical excision of hormone secreting tissue

□ X -ra y fin d in g s : < Orthopaedic treatment
• Exophytic bony growth extending laterally from the bone, arising from metaphyseal region « Calculi removal from kidney
• Actual size more than radiological size as cartilage cap not visible s s a rc o m a
□ T re a tm e n t:
EWING’S SARCOMA
• No treatment required if asymptomatic
• Excision including overlying bursa and periosteum over exostosis if - rj w hat is i t : Highly aggressive malignant bone tumor
1. for cosmetic reasons fl toe .-10-20 years
2. suspected malignancy 0 Bones a ffe c te d :
3. single exostosis • Long bones - Mainly femur and tibia
4. jeopardising daily activities • Flat bones - Mainly pelvis, calcaneum •
Q. 2 : B ro w n ’s tu m o r 0 s it e : Diaphysis,
BR O W N ’S TUMOR 0 P a th o lo g y: '
• May involve entire medullary cavity
O A s s o c ia te d w ith : Hyperparathyroidism • Tumor tissue - Greyish wftite
□ W hat Is I t : Expansile lytic bone lesion • Consistency - Soft, thin, almost like pus
□ P a th o lo g y : Collection of osteoclasts • Bone expanded, periosteum elevated with subperiosteal new bone formation
□ Site : Mainly maxilla, mandible • Tumor ruptures through cortex early and extends into soft tissue
□ A g e : 30-40 years (F > M) 0 H is to p a th o lo g y :
0 A c tio n o f P T H : • Sheets of small uniform cells resembling lymphocytes
Activates adenylyl cyclase in bone - » increased cAMP - * increased release of lysosomal enzymes • Tumor cells surround a central clear area forming a pseudorossete
from osteoclasts -> breakdown of organic matrix of bone - » Caz+ released into ECF Q P a th o g e n e sis:
□ C lin ic a l fe a tu re s : Begins In bone marrow, probably from endothelial cells
• Bone pain ----------- --------- 1 ---------------------------
• Anorexia, fatigue, nausea, vomit, abdominal cramp Spreads in Haversian system to bone surface
• Pathological fracture I --------
• Renal colic Subperiosteal new bone formation
□ X -ra y fe a tu re s : *-------------- I --------------------
• Expansile lytic lesion appearing like bone tumor in maxilla or mandible Repeated layer after layer
» Others - 0 S pre ad: Metastasis via blood to lungs and bones
> Subperiosteal bone erosion - ol radial border of digital bones
Q C linical fe a tu re s :
> Resorption ol terminal phalanges
• Intermittent throbbing pain
> Demineralisation
• Pain followed by swelling
> Soft tissue calcification
• Low grade fever and malaise
> Nephrocalcinosis
Q In v e s tig a tio n s :
> Chondrocalcinosis
o Blood - Raised ESR, leucocytosis
> Pepper-pot appearance of skull
X-rays -
> Ragger jersey appearance of vertebrae (due to osteoporosis and osteosclerosis)
> Diaphyseal moth-eaten lesion
□ O th e r in v e s tig a tio n s : > Lytic lesion with permeative margins
• Blood - high Ca, PTH, ALP; low phosphate > Lesion in medullary zone of midshaft with cortical destruction and new bone formation
• Urine - low Ca, high phosphate in layers - onion-peel appearance
• CT scan neck . y* Open biopsy
640 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 641

□ T re a tm e n t: q X-ray fe a tu re s :
. Chemotherapy - Vincristine, Adriamycin and Cyclophosphamide (VAC) monthly for IMScydes • Lateral view - displacement
• Radiotherapy - Highly radiosensitive but high recurrence t Oblique view - abnormal pars interarticularis (‘Scottish dog* sign)
• Surgery - Local amputation, bone resection g T re a tm e n t:
□ D iffe re n tia l d ia g n o s is : • Mild cases -
• Chronic osteomyelitis > Rest
• Osteosarcoma > Braces
• Osteoclastoma > Spinal exercise

• Chondrosarcoma • Severe cases - Decompression of nerve + Fusion of affected spinal segments

• Metastatic neuroblastoma q , 5 .-Bone sc a n
[See Fig. 2.9.8]
BONESCAN
Q .4 : S p o n d y lo lis th e s is q What is i t : A bone scan is a diagnostic procedure (nuclear scanning test )used to evaluate abnormalities
involving bones and joints. A radioactive substance is injected intravenously, and the image of its
SPONDYLOLISTHESIS
distribution in the skeletal system is analyzed to detect certain diseases or conditions
□ In tro d u c tio n : Forward displacement of a vertebrae over lower one 0 p rin c ip le : A nuclear bone scan is a functional test: it measures an aspect of bone metabolism or bone
remodeling, which most other imaging techniques cannot. The nuclear medicine scan technique is
□ S fte :L 4- L 5 orL4 - S ,
sensitive to areas of unusual bone-rebuilding activity because the radiopharmaceutical is taken up by
□ Types: osteoblast cells that build bone. The technique therefore is sensitive to fractures and bone reaction to
• • Isthmic - Defect in pars intercularis, of the following types - Infections and bone tumors, including tumor metastases to bones, because all these pathologies trigger
> Fatigue fracture osteoblast activity.
> Acute fracture Q P re p a ra tio n :
> Intact but elongated • Some specialized blood studies should be drawn before this study is begun.
Effect - Anterior part of vertebrae + spinal column above it is displaced forwards, posterior part « Jewellery or metallic objects need to be removed.
remains with lower vertebrae 0 T e ch n iq u e :
• Dysplastic - Congenital abnormality in development of vertebral column • In the nuclear medicine technique, the patient is injected (usually into a vein in the arm or
• Traumatic hand, occasionally the foot) with a small amount of radioactive material such as 740 MBq of
technetium-99m-MDP and then scanned with a gamma camera
t Degenerative
• In evaluating for tumors, the patient is injected with the radioisotope and returns in 2-3 hours
• Pathological - Bone disease weakening the articulation
for imaging. Image acquisition takes from 30 to 70 minutes, depending if SPECT images are
□ M e yerdin g s y s te m g r a d in g : required
Percentage of displacement • If the physician wants to evaluate for osteomyelitis (bone infection) or fractures, then a Three
Grade
Phase/Triphasic Bone Scan is performed where 20-30 minutes of images (1st and 2nd phases)
1 <25% are taken during the initial injection. The patient then returns in 2-3 hours for additional images
25-50% (3rd Phase). Sometimes late images are taken at 24 hours after injection
II
Q P hases: The three phase bone scan detects different types of pathology in the bone.
III 50-75%
75-100% fWST PHASE
IV
> 100% • Also known as the nuclear angiogram or the flow phase.
V
« During this phase, serial scans are taken during the first 2 to 5 seconds after injection of the
□ S y m p to m s : Backache and nerve abnormalities in lower limb technetium-99m-MDP
□ A g e : Isthmic type In young, degenerative type in elderly
• This phase typically shows perfusion to a lesion.
• Detects moderate to severe pathology
O C lin ic a l e x a m in a tio n :
• 'Step' palpable above sacral crest in vertebral column SECOND PHASE
• Increased lumbar lordosis • Image of this phase is also known as the blood pool image
• Sciatic nerve stretching on Straight Leg Raising Test • Obtained 5 minutes after injection

it
 642 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS

• This shows the relative vascularity to the area. p a th o g e n e sis:

• Areas with moderate to severe inflammation have dilated capillaries, which is where u* . BONE-
blood flow is stagnant and the radioisotope can 'pool'.
Inflammation
• This phase shows areas of intense or acute inflammation more definitively comparer m i , I
the third phase
Local trabecular necrosis and caseation
THIRD PHASE I

• Delayed phase Intense local hyperaemia

• Obtained 3 hours after the injection, when the majority of the radioisotope has been I
metabolized Demineralisation of bone
• This phase best shows the amount of bone turnover associated with a lesion i
Cortices of bone get eroded in absence of adequate body resistance
*1
□ S p e c ific ity In c re a s e d b y : By performing an Indium 111 -labeled white blood cell test combined wUh
a technetium-99m-MDP injection. Infected granulation tissue and pus find their way to sub-periosteal and soft-tissue planes
I
□ A fte r c a r e : Fluids are encouraged after the scan to aid in the excretion of the radioisotope.
Cold abscess
□ R a d ia tio n d o s e o b ta in e d : A typical radiation dosage obtained during a bone scan is 6.3 mSv
i
□ In te rp r e ta tio n s :
May burst out to form sinuses
• Normal - The normal appearance of the scan will vary according to the patient’s age. in I
general, a uniform concentration of radionuclide uptake is present in all bones in a normal scan
Affected bone may undergo pathological fracture
• Abnormal -
. JOINT -
• > A high concentration of radionuclide occurs in areas of increased bone activity. These
regions appear brighter and may be referred to as ‘hot spots.’ They may indicate Low grade synovitis + thickening of synovial membrane
healing fractures, tumors, infections, or other processes that trigger new bone
formation. Tubercular infection causes slow destruction of articular cartilage
V Lower concentrations of radionuclide may be called 'cold spots." Poor blood flowto
an area of bone, or bone destruction from a tumor may produce a cold spot. Synovium inflamed (this inflammatory synovium at periphery of cartilage is called Pannus)

□ P u rp o s e : Starts destroying cartilage from periphery

To detect the following - i
• Cancer-primary or secondary Ultimately, cartilage completely destroyed
1
• Infection In the bone
Joint gets distended with pus
• Fractures that are difficult to detect on X-ray
i •
• Unexplained pain may be evaluated
Joint capsule, ligament become lax, joint subluxated
• Eariy arthritic changes
1-
• Moniioring both the progression of the disease and the effectiveness of treatment
Pus and tubercular debris burst out of joint capsule
• Suspected child abuse I
□ P re c a u tio n s : A patient who is unable to remain still for an extended period of time may require Cold abscess
sedation for a bone scan I
□ C o n tra in d ic a tio n s : Pregnant and lactating mothers Chronic discharging sinus
□ D is a d v a n ta g e : The bone scan is not sensitive lo osteoporosis or multiple myeloma in bones • HEALING -
Q . 6 : T b s p in e Healing occurs by fibrosis
TUBERCULO SIS OF SPINE . i
Considerable destruction of articular cartilage, joint space completely lost
□ S y n o n y m : Caries spine
□ A e tio lo g y : Mycobacterium tuberculosis Traversed by bony trabeculae between bones forming the joint (bony ankylosis)
□ P a th o lo g y : Chronic granulomatous inflammation with caseation necrosis
 644 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 645

□ S p re a d : S ym pto m s:
• Skeletal TB is always secondary • Pain -
• Spreads through Batson's paravertebral venous plexuses, which communicates free! - > Back pain commonest
visceral plexus of abdomen wilh > nitially diffused, later localised
□ Types: > May be radicular pain
• Paradiscal - ’ Embryological segment' affected • Stiffness -
• Central - Body of single vertebra affected - » earty collapseof weakened vertebra -> we(j(1 > Early symptom
collapse (common) or Concertina collapse , > Protective mechanism wherein paravertebral muscles go into spasm
• Anterior - Anterior part of vertebral body affected -»spreads up and down under ante** • Cold abscess - Swelling or problems due to its compression of neural structures
longitudinal ligament
• Paraplegia -
• Posterior - Posterior complex of vertebra affected i.e. pedicle, lamina, spinous process
transverse process ["""grades of Pott's paraplegia
□ S ta g e s :
I 1 Patient unaware + Babinski's sign positive
• Stage of destruction -
’ II Clumpsiness, spasticity while walking but can walk without support
Bacteria lodge in contiguous areas of 2 adjacent vertebrae
I III Not able to walk + Paraplegia in extension + partial loss of sensation
Granulomatous inflammation IV Unable to walk + Paraplegia in flexion+■Severe muscle spasm + Near complete
I loss of sensation 4 Sphincter disturbance
Erosion of vertebral margins
J' • Deformity - Gradually increasing prominence of spine ('gibbus')
Compromised nutrition of intervening discs, which is derived from end-plates of adjacent vertebrae • Constitutional symptoms -
1 > Evening rise of temperature
Disc degeneration > Weight loss, anorexia, fatigue
I
Q C linical e x a m in a tio n :
Complete destruction • G a it-
• Collapse of vertebrae -
> Short steps to avoid jerking
Weakening of trabeculae of vertebral body > Twists whole body to look sideways
I • Attitude and deformity -
Collapse of vertebrae
> Prominence of 2-3 spinous processes (gibbus)
• Cold abscess formation -
> Loss of lumbar lordosis
Collection of pus and tubercular debris from a diseased vertebra > Stiff, straight neck
I • Para-vertebral swelling -
Pus tracks in any direction > Due to cold abscess
> Fluctuating in nature
Travels backwards Travels anteriorly or by side ol vertebrae • Tenderness - Elicited by pressing on side of spinous processes in an attempt to rotate vertebrae
i
• Movement - Limited spinal movement
Compresses neural structures in spinal cord
• Neurological examination
3 In v e s tig a tio n s :
Travels along musculo-fascial plane to appear superficially at places far away from site of leswn
• X-ray -
• Stage of healing - > Reduction of disc space (earliest sign)
Lytic areas replaced by new bones > Destruction of vertebral body
I
> Rarefaction above and below lesion
Adjacent vertebrae undergo fusion by bony bridges
V Cold abscess visible
i
> Erosion of posterior elements seen on Oblique X-ray
Permanent changes in shape of vertebral body
> Density of affected bone increases during healing
 646 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS S47

• CT Scan - Is I t : Constriction of fibrous digital sheath prevents free gliding of the contained flexor tendon

r Detects very small paravertebral abscess Cause: Generally due lo repeated microtrauma
> Extent ol destruction of posterior segment of vertebral body Q associated d is o r d e r s :
In cases presenting as 'spinal tumor syndrome' where X-ray is not helpful
r , Diabetes mellitus
• MRI - Investigation of choice to evaluate cord compression • Gout
• Myelography • Rheumatoid arthritis
• Biopsy j Commonly a ffe c te d : Middle and ring finger
• ELISA, PCR, Mantoux lest 3 p tto o a n a to m y :
□ T re a tm e n t: ■ Tendon swollen proximal to the sheath -> on trying to straighten finger, swollen tendon cannot enter
• Control of infection - into the sheath -> locking of finger - » overcome by forcibly extending finger when finger extends with
snap-like trigger of pistol
> Antitubercular drugs (2HRZE + 4HR)
[See Fig. 2.9.9]
> Rest
> Nutritious diet j Age ■4th and 5th decade
] c lin ica l fe a tu re s :
• Care of spine - Initially bed rest, as healing starts, slow immobilisation with spine sudom
In brace or collar wwim • A sharp ‘click’ felt on flexion/extension of affected finger
• Treatment of cold abscess - • Pain at the base of affected fi nger on trying to passively extend that finger
> Aspiration • Gradually difficulty in extending the fingers increases
> Evacuation • Swollen tendon felt proximal to the sheath
□ C o m p lic a tio n s : 0 Treatm ent:
• • Cold abscess » Mild cases-Local ultrasonic therapy
• Neurological compression • Long standing cases - Intralesional Triamcinolone
• Severe cases - Operative release of flexor tendon sheath
2010 Supplementary Q D ifferential d ia g n o s is : Bowler's thumb

0.2: Ewfng’s tu m o r
0 . 1 : T u b e rc u lo s is o l h ip fo in t
A : See Section 2, Group II, Qs. 51 (Page No. 737) A : See Section - 2. Group - 1,2010, Q.3 (Page No. 639)

0 . 2 ; V o lk m a n n ’s is c h a e m ic c o n tra c tu re / p t f : M echanism o f fra c tu re p a te lla

A : See Section 2, Group 1,2008, Qs. 4 (Page No. 620) FRACTURE OF PATELLA
Q .3 : C lu b F o o t Q .Causes :
A : See “Talipes Equinus" Section 2, Group 1,2008 (Page No. 621) • Direct force (blow on anterior aspect of knee in flexed position)
0 . 4 : D u p u y tre n 's c o n tra c tu re • Indirect force
A : See Section 2, Group 1,2012, Qs. 4 (Page No. 654) 0. Types :
Q .5 : G ia n t c e ll tu m o u r
• Two-part fracture - Fracture line passes transversely across patella, dividing it into 2 parts,
occurring due to sudden severe contraction o l quadriceps
A : See "Osteoclastoma" Section 2, Group II, Qs. 36 (Page No. 724)
• Stellate fracture - Comminuted fracture
0 . 6 : A v a s c u la r n e c ro s is o f fe m o ra l h e a d [See Fig. 2.9.10)
A : See Section 2, Group II, 2008, Qs. 49 (Page No. 736)

2011 Patellar fracture held in position i.e. undisplaced by

Q. 1 : T rig g e r fin g e r N
Patellar retinaculae on the sides Intact pre-patellar expansion of quadriceps in front
TRIGGER FINGER If force of quadriceps tendon is stronger
□ S ynonym s: X
• Snapping finger Pulls fragments apart
• Digital tenovaginitis 1
• Digital stenosing tenovaginitis Rupture of patellar retinaculae
 648 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 649

□ C lin ic a l fe a tu re s :
• Pain and swelling over knee 0 Typ es:
• Unable to lift leg with knee in full extension (extensor lag)
• Crepitus felt in comminuted fracture
• Gap palpable between fragments in displaced fracture
• Knee swollen due to haemarthrosis
□ Jf-ra y fin d in g s :
• A-P view
» Lateral view
• Skyline view
D T re a tm e n t:

• for 3 w e e k ,raClUre ~ Plas,er casl ,rorn 9roin ,0 iusl above malleoli, with fully extended knee

• Segment)^30'11'6 " TenSi° n band (f° f de,ai'S V'de Semes,er Orthopaedics Short Notes
• S tellate fracture - Patellectomy
Q. 4 : B ro d ie 's a b s c e s s

BRO DIE’S ABSCESS

□ W hat Is I t : Type of chronic osteomyelitis where defence mechanism of body has been able to limit h .
infection, thereby creating a bone abscess
□ Ape .‘ 11-20 years
□ Site:
• Upper end of tibia
• Lower end of femur
□ C lin ic a l fe a tu re s :

• Deep boring pain - Worsens at night and with activity, and relieved with rest
• Tenderness
• Increased girth [See Fig. 2.9.12]

□ X -ra y : Circular luscent zone surrounded by sclerotic tissue 0 P a th o lo g ica l c h a n g e s :

□ T re a tm e n t: Surgical evacuation and curettage along with antibiotics • Bankart's lesion (stripping of glenoidaf labrum along with periosteum from anterior surface of
[See Fig. 2.9.11] glenoid and scapular neck)
• Hill-Sach's lesion (depression in postero-lateral quadrant of head of humerus, caused by
Q. 5 .• C a rp a l tu n n e l s y n d ro m e
impingement by anterior edge of glenoid on the head as it dislocates)
A : See Section - 2, Group - 1,2009, Q.3 (Page No. 629)
• Rounding off of anterior glenoid rim
0. 6 : S h o u ld e r d is lo c a tio n
Q S y m p to m s :
SHOULDER DISLO CATION • Shoulder abducted and externally rotated, and patient supports the injured arm at the elbow
□ S p e c ia lity : Shoulder joint is the commonest joint in human body to dislocate because -
• History of fall on outstretched hand followed by pain and inability to move shoulder
• Shallow glenoid fossa 0 C lin ic a l e x a m in a tio n :
• Laxity of ligaments
• Normal round contour of shoulder joint is lost, it looks flattened
• Enormous range of movements permissible in shoulder joint • Fullness below clavicle due to displaced head
0 C auses :
« Adduction and internal rotation restricted
• Fall on outstretched hand with shoulder abducted and externally rotated
• Axillary nerve sensation over lateral part of deltoid is examined
• Direct blow on front of shoulder
• Dugas' test - Inability to touch opposite shoulder
• Electric shock or epileptiform convulsion
 650 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I D SOLVED SHORT NOTES OF FINAL MBBS 651

• Hamilton’s ru le r test - A ruler can be placed on the lateral side of ami touching the acromi p Found in :
and lateral condyle of humerus due to flattening of the shoulder, which otherwise is not possihi1'
> Osteosarcoma
normally *
V Ewing’s sarcoma
» Callaway’s test - Circumference of affected shoulder is more than the unaffected shouw6r
□ In v e s tig a tio n s : 'r Aneurysmal bone cyst
• X-ray - r Osteomyelitis
> AP view - Overlapping of head of humerus and glenoid > Metastasis
> True lateral scapular view - To differentiate anterior and posterior dislocation > Giant cell tumour
> Stryker - Notch view
> Juxtachortical chondrosarcoma
> Hill - Sach view
> Malignant fibrous, histiocytoma
> West - Point view
• MRI - to detect Sankart’s lesion 0.5 :S -P N a ll

• CT Scan - to detect bony Bankarl’s lesion Ans:

□ T re a tm e n t: S-P NAIL
Reduction under general anesthesia - » immobilisation of the shoulder in a chest-arm bandage for 3 0 F u ll f o r m : Smith Peterson nail
weeks
□ What is I t : Cannufated triflanged nail used for internal fixation of fracture neck of femur
Techniques of reduction -
p Named a f t e r : Marius Smith-Peterson in 1953
• Kocher’s manoeuvre - Traction -> external rotation -> adduction -» internal rotation
• Hippocrates manoeuvre - Done when assistant not available □ O ther u s e : Along with a McLaughlin’s plate to fix. Inter-trochanteric fractures
• • Stimson’s (gravity) method Q Role o f c a n n u la tlo n : It can be threaded over guide-wire, introduced at the correct site by visualising
• Saha’s method in X-ray,
□ C o m p lic a tio n s : Q A d v a n ta g e s :
• Injury to axillary nerve }> Provides good stability as it cuts only a little part of bone
• Recurrent dislocation of shoulder r Prevents axial rotation of fragments
• Failure to reduce the dislocation
• Shoulder stiffness 2012
0 . 1 : F ra ctu re o f c la v ic le
2011 S u p plem en tary
FRACTURE OF CLAVICLE
0 . 1 : S e q u e s tru m
Q A g e : Children
A : See Section 2, Group 1,2008, Qs. 3 (Page No. 618)
□ C auses:
0 . 2 : F ro ze n s h o u ld e r
• Fall on shoulder
A : See Section 2, Group f, 2008, Qs. 1 (Page No. 616)
• Fall on outstretched hand
Q .3 : D Q d is e a s e Q P a th o a n a to m y : Commonest site of fracture is middle 1/3rd and outer 1/3rd junction. After fracture,
A : See Section 2, Group II, Qs. 17 (Page No. 706) part of clavicle medial to fracture is displaced upwards due to pull by sternocleidomastoid, part lateral
0 .4 : C o d m a n 's tria n g le to fracture is displaced downwards due to pull by pectoralis major.
Ans: □ Types:

CO DM AN’S TRIANG LE • Middle 1/3rd - 80% cases

« Distal 1/3rd -1 5 % cases
□ W hat Is I t : Triangular area of subperiosteal new bone seen at tumour - host cortex junction at the
> Type I - minimally displaced between ligaments, no displacement
ends of the tumour
> Type II - displaced fracture medial tocoracoclavtcular (CC)ligament
□ 1s t d e s c rib e d b y : Ribbert in 1914
> Type III - fracture through acromioclavicular joint, no displacement
□ N am e d a f t e r : Ernest Amory Codman
□ P a th o g e n e s is : With aggressive lesions, the periosteum does not have time to ossify with stwl’s o*
• Proximal 1/3rd - 5% cases
new bone. So, only edge of raised periosteum will ossify
 652 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 653

□ D ia g n o s is : • Chair test
• History of trauma • Bowden test
» Pain, swelling in the clavicular region, cannot raise arm • Mill test
• Confirmation by X-ray • Motion stress test
• Neurological deficit may occur in upper arm 0 T re a tm e n t:
□ T re a tm e n t : • Activity modification
• Closed treatment - For middle 1/3rd, proximal 1/3rd, distal 1/3rd Types I and ||| • Physical therapy - Ice application, ultrasonic therapy
> Triangular sling • Intralesional Triamcinolone Injection
r Figure of '8' bandage . • Bracing or strapping
> Active exercise after relief of pain • NSAIDs, Corticosteroids
• Open reduction and internal fixation - • Surgery - After 6-12 months of failed conservative treatment
> ForType II distal 1/3rd fracture > Percutaneous release of tendons
> If severe neurodeficit > Open debridement
> For open fracture > Arthroscopic debridement
> If vascular injury □ D iffe re n tia l d ia g n o s is :
G C o m p lic a tio n s : • Radial tunnel syndrome
• Early - • Osteochondral intraarticular lateral elbow lesion
V Injury to brachial plexus
0. 3 : S u p ra c o n d y la r fra c tu re o f h u m e ru s
>- Injury to subclavian artery
» Later - SUPRACONDYLAR FRACTURE OF HUMERUS
> Shoulder stiffness
Q What Is I t : Fractu re of humerus where fracture line passes transversely through distal metaphysis of
> Mal-union/Non-union humerus just above the condyles
Q. 2 : T e nnis e lb o w D A g e : 5-8 years because -
TENNIS ELBOW • Laxity of ligaments increases chances of hyperextension
• Flattened cross-section of humerus
□ S y n o n y m : Lateral epicondylitis • Presence of nu merous fossas (radial, olecranon, coronoid) reduces the strength ol humerus
□ D e fin itio n : Pain and tenderness in lateral epicondyle of humerus due to non-specific inflammation al • Due to thick anterior capsule acting as a fulcrum, olecranon process may strike the thin
the origin of extensor muscles of forearm (tendinosis) supracondylar region during hyperextension, because the capsule causes the olecranon to
0 S p e c ia lity ; Angiofibroblastic inflammation (as fibroblast hyperplasia -» vascular hyperplasia -* firmly engage in the olecranon fossa
abnormal collagen production 0 C a u se : Fall on outstretched hand with elbow being forced into hyperextension as the hand strikes
□ S ide a ffe c te d : Dominant arm the elbow -
0 Mos t c o m m o n ly a ffe c te d : Degeneration of extensor carpi radialis brevis 0 T yp e s :
□ A ge : 30-60 years Gartland classification -
□ C auses :
• Tennis players EXTENSION TYPE (98%) i.e. distal fragment FLEXION TYPE(2%) I.e. distal fragment
• While carrying suitcase extended (tilted backwards) in relation to flexed (tilted forwards) in relation to proximal
• Squeezing clothes proximal fragment fragment
□ S y m p to m s : Insidious onset pain in the lateral epicondylar region which is aggravated by putting a Type I - Non-displaced Type I - Non-displaced
stretch on the extensor muscles Type II - Displaced but intact posterior cortex Type II - Displaced but intact anterior cortex
□ C lin ic a l e x a m in a tio n :
Type III - Completely displaced Type III - Completely displaced
• Thompson’s test - Shoulder flexed to 60 degrees -> elbow extended - » forearm pronated -»
wrist extended -4 pressure applied on 2nd/3rd metacarpals and patient tries to flex and uhar
deviate the wrist -» severe pain occurs [See Fig. 2.9.13]
• Cozen’s test - Elbow flexed, forearm pronated -> wrist extended against resistance -> seve,e
pain
 654 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology
GROUP - I Q SOLVED SHORT NOTES OF FINAL MBBS 655

□ S y m p to m s :
n A e tio lo g y :
• Pain
3 Hereditary (autosomal dominant)
• Swelling
, Alcoholic cirrhosis
• Unable to move elbow • Epileptics receiving sodium hydantoin
Q C lin ic a l e x a m in a tio n :
. Diabetes
• 3 bony point relationship not changed
. AIDS
• Unusual prominence of olecranon tip
• Tuberculosis
□ D is p la c e m e n ts :
q p s th o a n a to m y :
• Posterior tilt
• Posterior shift Palmar aponeurosis is a thin, lough membrane beneath palmar skin
• Proximal shift I I
• Medial tilt Proximally Distally
• Medial shift I I
• Lateral shift Continues as Palmaris longus Oivides into slips lor each finger
• Internal rotation • 4*
Slips fuse with fibrous flexor sheath
□ X -ra y fe a tu r e s :
A
• A-P view -
Extend till middle phalanx
> Proximal shift
> Medial tilt Here, pathology begins as a nodule -> palmar aponeurosis thickens and contracts -* flexion deformity
olfingere
• > Medial shift
0 C linical fe a tu r e s :
> Lateral shift
• Mostly ring finger affected, 2nd most affected is little finger (generally limited to medial three
> Internal rotation
fingers)
• Lateral view -
• Thickening of palmar aponeurosis felt at bases of affected fingers
r Posterior tilt
• Flexion at metacarpophalangeal and proximal interphalangeal joint
> Posterior shift
G D iffe re n tia l d ia g n o s is :
> Proximal shift.
• Flexor tendon contracture (flexion also at distal interphalangeal joint)
□ T re a tm e n t:
• Claw hand (metacarpophalangeal joint extended, proximal interphalangeal joint flexed)
Type I - Cast for 3 weeks
Q T re a tm e n t:
Type II - Manipulation under anesthesia ♦ cast
• Early cases - Radiotherapy
Type III - Open/closed reduction + Percutaneous K-wire fixation
• Severe cases -
(Cast In supracondylar fracture -
V Fasciectomy with post-operative splint
> wHh elbow kept in maximum flexion that does not jeopardise Ihe radial pulse
r Resection + arthrodesis
> forearm pronated
> starting from deltoid muscle insertion 0.5 : R u p tu re d te n d o a c h ille s
> extends till proximal palmar crease
RUPTURED TENDOACHILLES
> just short of knuckles
> excluding base of thumb) 0 S p e c ia lity : Commonest tendon to rupture
□ C o m p lic a tio n s : Q P athogenesis : Avascular degeneration
A : See Section - 2, Group - 1, 2008, Q. 2 (Page No. 617) 0 A g e : > 40 years

0 . 4 : D u p u y tre n 's c o n tra c tu re 3 S y m p to m s : History of sudden feeling of being struck above heel while running or jumping and inability
to stand on toes thereafter
DUPUYTREN’S CONTRACTURE 0 C linical e x a m in a tio n :

□ W hat Is I t : Proliferative fibroplasia of palmar aponeurosis

• Gap seen and fell 3-5cm above insertion of tendon, which increases with dorsiflexion ol ankle
.< • Weak plantar flexion
• Simmond's test - Patient in prone position -> calf squeezed -» no plantar flexion
 656 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 657

□ T re a tm e n t: (0 Plastic repair
• Early cases - Tendon sutured with foot in passively plantar llexion position -> plaster (ii) Secondary closure of skin flap
foot in equinus position for 8 weeks -> shoe with raised heel for 6 weeks *• (iii) Revision of stump
• Late cases - Tendon lengthening and suturing (iv) Reamputation at a higher level
0 . 6 : M a lle t fin g e r Closed amputation - skin is closed primarily
(B) End/dose bearing
M ALLET FINGER
Non-end/side bearing
□ S y n o n y m : Baseball finger (C) Weight bearing
□ W hat Is i t : Avulsion fracture of distal phalanx at the insertion of extensor tendon slip at the base ol Non-weight bearing
distal phalanx 0 L e ve ls:
□ C auses: y Above elbow
• Direct injury to the finger tip > Below elbow
• Finger tip forcibly extended > Above knee
□ C lin ic a l fe a tu re s : Distal interphalangeal joint in slight flexion - active extension not possible, passive > Below knee
extension possible
> Shoulder disarticulation
□ D ia g n o s is :
V Elbow disarticulation
• Clinical examination
> Hip disarticulation
• Lateral view X-ray
y Knee disarticulation
□ T re a tm e n t:
> In d ic a tio n s :
• Constant DIP hyperextension splint - for 8 weeks
y Injury - to save life in crush injuries
• Open repair if large bony avulsion fracture
y Dead, dying devitalised tissue
[See Fig. 2.9.14] y Infections -
Q. 7 : P y o g e n ic o s te o m y e litis • Chronic osteomyelitis
A : See Section - 2, Group - 1, 2009, Q. 5 (Page No. 631-632) « Necrotising fascitis
> Gangrene due to
• Atherosclerosis
2012 S upplem en tary
• Diabetes
0 .1 : C o m p a rtm e n t s y n d ro m e • Ergots, maggots
A ; See Section 1, Segment C, Paper Ii, 2014, Qs. 10 (Page No. 430) • Embolism •

Q-2 : S e q u e s tru m • Buerger’s disease

• Diabetic foot
A : See Section 2, Group I, 2008, Qs. 3 (Page No. 618)
• Gas gangrene
Q .3 : R a d io lo g ic a l fe a tu re s o f o s te o s a rc o m a
• Peripheral vascular disease
A : See Section 2, Group II, Qs. 36 (Page No. 617)
• Malignancies
Q .4 : In d ic a tio n s o f lim b a m p u ta tio n
- Osteosarcoma
Ans:
- Marjolin’s ulcer
INDICATIONS OF LIMB AM PUTATIO N
- Rhabdomyosarcoma
□ W hat is a m p u ta tio n : Part of limb is removed through bone - Malignant fibrous histiocytoma
□ Types: - Severe congenital or acquired deformity
(A) • Guillotine or open amputation - skin not closed over amputation stump, when would is F racture d e c ra n o n
unhealthy. •’ Ans:
After certain inteval, following may be done -
 S58 QUEST : A Comprehensive Guide to UG Surgery. Orthopedics & Anesthesiology GROUP - 1 □ SOLVED SHORT NOTES OF FINAL MBBS S59

FRACTURE OLECRANON „ ptthoiogy:

•" Degenerative changes in vertebral disc like
O A g o g r o u p : Adults
(i) Weakening and disintegration of posterior part of annulus fibrosus
O C a u s e : Direct injury like a fall onto the point of elbow
(ii) Softening and fragmentation of nucleus pulposus
□ P a th o a n a to m y : Triceps muscle attached to the proximal fragment pulls it, thereby creating a ru*
the fracture site. '
_ II
□ Types: .
I -> Fracture (no displacement of fragments) Due to injury or spontaneous disintegration, annulus fibrosis becomes weak and nucleus
pulposus tends to bulge through the defect
II -» Fracture + Displacement of fragments
Itl - » Comminuted fracture
; • ^
Nucleus pulposus comes out of annulus fibrosus and lies under posterior longitudinal ligament
siwaw (contact with parent disc is still not lost)

' Ii •

The posterior longitudinal ligament ruptures and the extruded nucleus pulposus looses its
contact with parent disc

' a
Extruded nucleus pulposus becomes flattened, fibrosed and calcifies.

metof
*oss a
Residual nucleus pulposus becomes fibrosed
□ S y m p to m s : Pain and swelling at fracture
□ S ig n s : II
> Tenderness
HGEW
New bone formation begins at points where posterior longitudinal ligament has been separated
> Crepitations from the vertebral body leading to spur formation.
> Gap between fragments - active extension of elbow is not possible
— Posterior
□ In v e s tig a tio n s : X-ray elbow jt-AP and Lateral view Nucleus
longitudinal Nucleus pulposus
□ T re a tm e n t: ligament pulposus lies under
> Type I -» Immobilisationin an above - elbow plaster slab in30° flexion for 3 weeks Degenerated
bulges (7 posterior
through

T
> Type II -» Tension-band wiring (TBW) annulus longitudinal
defect in ligament
fibrosus
> Type III -» If not separated, treated like Type I. If separatedfragments, TBW or excision ol annulus
fragments done. Fragmented
I nucleus
□ C o m p lic a tio n s : A)STAGE OF pulpOS US B) DISC PROTRUSION C) DISC EXTRUSION
NUCLEUS
> Non-union
degeneration
> Osteoarthritis
> Stiffness of elbow
Ff p *___ . Extended disc loses
0 . 6 : S lip p e d d is c
I O \_ Z ) contact with parent
Ans: disc
SLIPPED DISC

□ W hat Is I t : "Slipped disc” is a term used for both vertebral disc prolapse and disc herniation
D) DISC SEOUESTflATtON
660 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 661

□ C lin ic a l fe a tu r e s : > Muscle relaxant

> Age - 20-40 year > Hot fomentation
> Low backache - dull or acute; made worse by exertion, sitting, standing or forward bendi > Exercises, physiotherapy
relieved by rest. In®'
> TENS
> Sciatic pain - radiates to gluteal region, back of thigh and leg, and to postero-lateral calf dm
heel ^ > Fenestration
Root compression Pain radiation > Hemilaminectomy
> Laminotomy
L 2 -L 3 => Front of thigh
> Laminectomy
L5 => Anterolat aspect of leg andanlde
SI => Posterolateral calf and heel 2013
H i : V olkm ann’s Is c h a e m ic c o n tra c tu re
> Associated pamesthesia, urinary and bowel incontinence.
A : See Section - 2. G roup - 1,2008, Q. 4 (Page No. 620)
□ E x a m in a tio n :
j 2 : E w in g's tu m o r
> Movement - Patient not able to bend forward; any such attempt leads to spasm of paraspinal A : See Section - 2, Group - 1.2010, Q. 3 (Page No. 639)
muscles
d j : Core ne edle b io p s y
> Posture - Patient stands with rigid Iumbar spine, trunk seems shifted forward and fitted to or*
side • CORE NEEDLE BIOPSY
> Tenderness in lumbosacral region.
0 What Is I t : A procedure that removes small but solid samples of tissue using a hollow 'core' needle.
> Straight leg raising test (SLRT) - Positive SLRT at 40° or less suggests root compression For palpable ('able to be felt') lesions, the physician fixes the lesion with one hand and performs a
□ La segue te s t - Hip lifted to 90° with knee bent, and then when examiner tries to extend the knee freehand needle biopsy with the other.
gradually. Patient experiences severe pain in back of leg or thigh. 3 In d ic a tio n s : Mainly for breast carcinoma and musculoskeletal tumors
□ N e u ro lo g ic a l d e f ic it : a A ddition al m e a s u re s : In case of non-palpable lesions, stereotactic mammography, or ultrasound, or
PET guidance is used.
m m m m • With stereotactic mammography - possible to pinpoint the exact location of a mass based on
L3 - L 4 knee extensors are weak In great toe and medial Sluggish on images taken from two different angles of the X-ray machine
L4
side ol leg absent kneejerk • With ultrasound - possible to watch the needle on the ultrasound monitor to help guide it to
the area of concern
L4 - L 5 l-s Extensor hallucis longus Over dorsum of foot and Ankle jerk is
• With PET (positron emission tomography) - the lesion is targeted in 3D based on a positron
and foot dorsiflexore lateral side of leg normal
emission tomography (PET) image of the breast
weakness
0 A d va n ta g e :
L5 - S 1 St Plantar flexors of foot are Over lateral side of foot Absent or sluggish • Has a special cutting edge allowing removal of a bigger sample of tissue; a relatively large
weak ankle jerk sample can be removed through a small single incision in the skin
• Takes few minutes to be performed
In v e s tig a tio n s : • Almost painless
> X-ray of spine - Disc space narrowed in chronic disc prolapse 0 Needle s iz e ; The needle used during core needle biopsy is larger than the needle used with FNAC
> CT scan 0 D isadva ntag e: May cause some bruising
> MR! - investigation of choice ^ T echnique:
• Core needle biopsy for palpable masses -
> EMG - to assess denemation and other neurological deficit
> Done in a health care provider's office
T re a tm e n t:
> Before the procedure, local anaesthetic used to numb the skin and tissue around the
(a) > Rest suspicious area
> Analgesics ' > Then needle is inserted and a small amount of tissue is removed
 6«2 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology GROUP-I □ SOLVED SHORT NOTES OF FINAL MBBS 563

• Core needle biopsy for nonpalpable masses - p x * a y fe a tu re s :

> likely to be done in a clinic or imaging centre » Cortical break at corticocancellous junction
> Abnormal area located with the help of ultrasound and then needle insert * « Displacements - Mainly dorsal tilt
• Core needle biopsy with stereotactic mammography -
• Axis of radius and 2nd metacarpal does not lie in same line
> Patient lies on her stomach on a special table and her breast fits through a h0|e jn,
q T re a tm e n t:
» Undisplaced fracture - Codes’ cast
> Before the procedure, the health care provider will use a local anaeslhstir 1
the area c 10 numb • Displaced - Manipulative reduction-> immobilisation in Colies' cast
> Breast will be compressed like it is for a mammogram, and several imaor* , (Colles' cast - From just below elbow to the proximal palmar crease, and just short of knuckles,
taken. These images help the provider guide the biopsy device to the s u s o L ^ excluding the thumb, witti the wrisl kept In slight palmar flexion and ulnar deviation, and the
in the breast H 0Usarea forearm pronated)
> A needle in the device removes tissue samples. j C o m p lic a tio n s :
□ C o m p a ris o n w ith F N A C : FNAC is a less reliable and less informative diagnostic method ih«„ • Malunion
needle biopsy. Although a negative or indeterminate FNAC resull requires follow-uo or a ra? °°fe • Stiffness of fingers (commonest)
w coro necdl0. « is still a cost-effective procedure. Stereotactic guidance considerably in c rp n ..^ • Complex regional pain syndrome
costs of core needle biopsy, and therefore USG guidance should be used whenever possible
• Carpal Tunnel syndrome
0 . 4 : C o lie s ' fra c tu re
• Extensor pollici^ longus tendon rupture
CO LLES’ FRACTURE • Distal radio-ulnar joint instability

□ W hat Is I t : Transverse fracture at distal end of radius, at Its corticocancellous junction about q. 5 : Bone g r a ft
from the distal articular surface, with typical deformities
BONE GRAFT
[See Fig. 2.9.1 SJ
0 What Is I t : Pieces of bone taken from some part of patient's body or some other person's body and
□ A g e ; Elderly women (due to postmenopausal osteoporosis)
placed at another site
□ C a u s e : Fall on outstretched hand
0 p u rp o s e : Stimulating bone formation and filing bone defects
□ A s s o c ia te d d e fo r m itie s :
0 Types:
• Lateral displacement .
(a) AUTOGRAFT -
• Dorsal displacement
• Derived from the patient's bod/
• Lateral shift
• Generally these are free grafts’ (i.e. without blood supply) which provide just a scaffold
• Dorsal shift upon which new bone is laid; a bone stimulating protein called 'bone morphogenic
• impaction of fragments protein' is liberated, which helps In osteogenesis
• Supination • Preserving blood supply by following techniques -
□ A s s o c ia te d I n ju r ie s : V Muscle-pedicle bone graft
• Fracture of styloid process of ulna »• Free vascula/ised bone graft
• Rupture of triangular cartilage o l ulna (b) ALLOGRAFT-
• Rupture of ulnar collateral ligament • Derived from another human being - living or dead(cadaveric graft)
• Rupture of interosseous radio-ulnar ligament • Stored In bone banks
□ C lin ic a l fe a tu r e s : • Used when enough bone not available from host
• Pain + swelling + deformity of wrist (c) XENOGRAFT-
• Tenderness and irregularity of fower end of radius • Derived from other species like bovine bone graft
• Dinner-fork deformity - Radial styloid process lies at same level or higher than ulnar styloid (d) ARTIFICIAL BONE-
process
• Made of hydroxyapatite
• Wrist broadened
• Derived from corals
• Ulnar head prominent • Used in developed countries
• Shortened forearm
• Has osteo-conduclive potential

I
 6S4 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 665

□ S it e s : • Type II - Flexion type (15%) - ulna shaft angulates posteriorly (flexes) and radial head
• Anterior and posterior Iliac crest dislocates posteriorly.
• Fibula (except distal 7-8 cm) • Type III - Lateral type (20%) - ulna shaft angulates laterally (bent to outside) and radial head
• Olecranon dislocates to the side.
• Proximal tibia • Type IV - Combined type (5%) - ulna shaft and radial shaft are both fractured and radial head
• Radial/femoral head is dislocated, typically anteriorly.
□ in d ic a tio n s : q C lin ic a l fe a tu re s ;
• Non-union, delayed union • Pain and swelling in upper part of forearm
• To fill bony cavities • Movements of elbow and forearm restricted
• Arthrodesis of joints
• Tenderness
• Establish continuity between bony defects
g In v e s tig a tio n s : X-ray both A-P and lateral view
□ In s tru m e n ts u s e d ;
0 T re a tm e n t: External reduction to relocate radial head -» cast lor 2-3 weeks - » re-evaluatlon under
• Osteotome
X-ray -> not reduced - » Open reduction and internal fixation
• Chisel
0 C o m p lic a tio n ; Malunion
• Gouge with mallet
• Bone cutting forceps [See Fig. 2.9.16]
□ Types o f a u to g r a fts :
ft 3 : C arpal tu n n e l s y n d ro m e
• Cortical (used where structural support needed) - e.g. fibula
A : See Section - 2, Group - 1,2009, Q. 3 (Page No. 629)
• Cancellous (for osteogenesis) - e.g. iliac crest
• Corticocancellous - e.g. rib ft 4 ; N o n-unio n o f fra c tu re
□ S u b s titu te s fo r b o n e g r a f t :
NON-UNION O F FRACTURE
• Bone marrow
• Trfcalcium phosphate 0 What Is I t :HealinQo( the fracture fragments tias not progressed sufficiently for the stipulated time for
• Collagraft that site, type of fracture and for that age of the patient “ •
• Calcium phosphate 0 7/me: 9 months for all fractures, except 3 months for -
• Unsolved fracture - fracture neck of femur .
2013 - Supplementary
• Essential fracture - fracture lateral condyle of humerus
0 . 1 : C TEV- a n a to m ic a l c h a n g e s □ Types: '
A : See Section - 2, Group - 1,2008, Q. 5 (Page No. 621) • Atrophic - No callus formation ' •
0 . 2 : M o n te g g la fra c tu re « Hypertrophic - Callus formed, but fails to bridge the gap
Q C a u se s:
MONTEGGIA FRACTURE

□ W hat Is I t : Fracture ol upper third of ulna along with dislocation of head of radius
□ N am e d a f t e r ; Giovanni Battista Monteggla.
□ A e tio lo g y :
• Fall on an outstretched hand with the forearm in excessive pronation
• Direct blow on back of upper forearm rarely
• Hyperextension
□ B a d o c la s s ific a tio n :
There are four types (depending upon displacement of the radial head):
• Type I - Extension type (60%) - ulna shaft angulates anteriorly (extends) and radial
dislocates anteriorly.
 666 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 667

g T re a tm e n t:
• No treatment if mild cases
• lllizarov’s technique
• Open reduction and internal fixation
• Fragment excision
0 , 5 : E xte rn a l fix a tio n

EXTERNAL FIXATION

p W hat Is I t : External fixation is a surgical treatment used to stabilize bone and soft tissues at a distance
from the operative or injury focus
□ p u rp o s e ; They provide un obstructed access to the relevant skeletal and soft tissue structures for their
initial assessment and also for secondary interventions needed to restore bony continuity and a functional
soft tissue cover.
□ Parts:
• Schanz pin
• Connecting rods
• Clamps
Distraction osteogenesis
□ B asle p r in c ip le : Osteogenesis requires dynamic state i.e OR
Compression osteogenesis
□ In d ic a tio n s :
• Limb-lengthening
• Stabilization of infected non-unions
• Stabilization of severe open fractures
• Deformity correction
□ C om m on s ite s :
» Initial stabilization of soft tissue and bony disruption in poly trauma patients (damage control
• Lateral condyle of humerus
orthopaedics)
• Lower third of ulna
• Arthrodesis
« Scaphoid
• Ligamentotaxis
• Neck of femur
• Osteotomies
• Lower third of tibia
• Pelvic ring disruptions
□ C lin ic a l fe a tu r e s :
• Certain pediatric fractures
• Painless • Temporary transarticular stabilization of severe soft tissue and ligamentous injuries
• Mobility at fracture site
□ C o n tra in d ic a tio n s :
• Increasing deformity
• Patient with compromised immune system
□ X -ra y fe a tu re s :
• Non compliant patient who would not be able to ensure proper wire and pin care
• Fracture ends smooth and rounded
t Pre-existing internal fixation that prohibits proper wire or pin placement
« Little callus
• Bone pathology precluding pin fixation
• Fracture fine visible
Q ILLIZAROVS TECHNIQUE OF EXTERNAL FIXATION
• Sclerosis
• Commonest externa! fixator
• Osteopenia
 668 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GHOUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 669

• A d v a n ta g e s - • M RI - t o d e t e c t B a n k a r t's le s io n

> I m m e d ia t e lo a d b e a r in g • C T S c a n - t o d e t e c t b o n y B a n k a r t 's le s io n

V M o r e t h a n 1 p r o b le m c o r r e c t e d a t a tim e • A r th r o g r a m

> H e a lt h y v ia b le b o n e g Treatment:
• D isa d v a n ta g e s - », A tr a u m a tic c a s e s -

> I n c o n v e n ie n t > R e h a b ilit a t io n

> P in t r a c t in fe c tio n > In fe rio r c a p s u l a r s h ift o p e r a t io n

> N e rv e p a ls y • Traumatic cases -

> J o in t s t if f n e s s S u r g e r y r e q u ir e d if > 2 e p i s o d e s

> In ju ry t o u n d e r ly in g s t r u c t u r e s > P u tti-P la tt o p e r a t io n - D o u b le b r e a s t in g o f s u b s c a p u l a r i s t e n d o n t o p r e v e n t e x t e r n a l

> L o n g d u ra tio n t r e a tm e n t r o ta tio n a n d a b d u c tio n

• T e c h n iq u e - ' > B a n k a r t ’s o p e r a tio n - G le n o id la b r u m a n d to m c a p s u l e a r e r e a t t a c h e d in fro n t o f

g le n o id rim , d o n e e a s i l y w ith 'a n c h o r s ’
> S t a b ilis a t io n b y R in g F ix a to r
> B r is t o w 's o p e r a tio n - C o r a c o id p r o c e s s a n d m u s c le s a t t a c h e d t o it, a r e o s le o t o m iz e d
[ S t a i n le s s s t e e l w ir e s p u t th r o u g h b o n e - » w ir e s p u t u n d e r t e n s io n -> w ires then
a t its b a s e a n d fix e d t o lo w e r - h a lf o f a n t e r io r m a r g in o f g le n o id
a t t a c h e d t o s t e e l rin g s w ith h e lp o f b o lt s - » r in g s i n t e r c o n n e c t e d b y th r e a d e d rods
w ith n u t s o n e it h e r s i d e s -> n u ts h e lp t o m o v e t h e r in g s u p a n d d o w n ] > B o y t c h e v 's o p e r a t io n - S u b s c a p u la r is m a d e ta u t b y p u ttin g c o r a c o b r a c h ia lis a n d s h o rt
h e a d o f b i c e p s b e lo w s u b s c a p u l a r i s
> D is tr a c tio n o r c o m p r e s s i o n b y tw is tin g n u t s a t r e q u ir e d s it e @ 1 m m /d a y ( 1/4 mn, 4
tim e s a d a y ) > M a g n u s o n - S t a c k o p e r a tio n - S u b s c a p u la r is a n d c a p s u l e d e t a c h e d a n d th e n r e a t ta c h e d
m o r e la te r a lly
0 . 6 : Recurrent dislocation ot shoulder
» A r t h r o s c o p ic B a n k a r t r e p a ir

RECURRENT DISLOCATION OF SHOULDER

2014
□ What Is I t : S h o u l d e r jo in t g e t s d is lo c a t e d v e r y o fte n
Q A g e: Young age
0 . 1 : Fractures occurring due to tall on outstretched hand
□ Causes:
• A n a t o m ic a lly u n s t a b le jo in t - e . g . M a r ia n ’s s y n d r o m e F R A C T U R E S O C C U R R IN G D U E T O FA LL ON O U TSTR ETCH ED HAND
• E p ile p tic p a tie n t

• I n a d e q u a t e h e a lin g o f p r e v io u s d is lo c a t io n
Q In children-

□ Subtypes: • F r a c t u r e c l a v i c l e ( S e e S e c t io n - 2 , G r o u p - 1 , 2 0 1 2 , Q . 1 [ P a g e N o . 6 5 1 ] )

• T r a u m a tic • S u p r a c o n d y la r f r a c t u r e o f h u m e r u s ( S e e S e c t io n - 2 , G r o u p - 1 , 2 0 1 2 , Q . 3 [ P a g e N o . 6 5 3 ])

• A tr a u m a tic □ In young adults - F r a c t u r e s c a p h o id ( S e e S e c t i o n - 2 , G r o u p — 1 1 , 0 . 1 [ P a g e N o . 6 9 4 ])

□ Essential lesions: □ In elderly-

• B a n k a r t 's le s io n 1 (fo r d e t a ils v id e " S h o u ld e r D i s lo c a t i o n ” - M B O r th o • C o ll e s ' f r a c t u r e ( S e e S e c t io n - 2 , G r o u p - 1 , 2 0 1 3 , Q . 4 [P a g e N o. 6 6 2 -6 6 3 ])

• H ill-S a c h ’s le s io n J S h o r t N o te 2 0 1 1 , P a g e N o . 6 4 8 ) • F r a c t u r e s h a f t h u m e r u s ( S e e O r t h o p e d ic s h o r t n o t e s fro m S e m e s t e r s s e g m e n t )

• D e l e c t o f a n t e r io r rim o f g le n o id • F r a c t u r e r a d ia l h e a d ( S e e S e c t io n - 2 , G r o u p - II, Q . 2 5 [ P a g e N o . 7 1 3 ] )
0 Clinical features: • F r a c t u r e c a p it u lu m

• P o w e r o f d e lt o id m u s c le t e s t e d • F r a c t u r e t r a p e z iu m

• A x illa r y n e r v e fu n c tio n t e s t e d • B e n n e t t ’s f r a c t u r e ( S e e S e c t io n - 2 , G r o u p - II, Q . 2 1 [ P a g e N o . 7 1 0 ] )

• A p p r e h e n s i o n t e s t - P a tie n t t r ie s t o r e s is t w h e n s h o u l d e r is g r a d u a l ly a b d u c t e d 0 . 2 : Osteochondroma
□ Investigations:
A : S e e S e c t io n - 2 , G r o u p - 1, 2 0 1 0 , Q . 1 [ P a g e N o . 6 3 7 ]
• X-ray -
0- 3 : Greenstick fracture
> A P v ie w - o v e r la p p in g o f h e a d o f h u m e r u s a n d g le n o id

> T r u e la t e r a l s c a p u l a r v ie w - t o d iffe r e n tia te a n t e r io r a n d p o s t e r io r d is lo c a tio n G R E E N S T IC K F R A C T U R E

> S t r y k e r - N o tc h v ie w
Q What Is I t : F r a c t u r e in y o u n g , s o f t b o n e w h ic h b e n d s a n d p a r tia lly b r e a k s
> Hill - S a c h v ie w
[ S e e F ig . 2 . 9 . 1 7 ]
> W e s t - P o in t v ie w
 GROUP - I 0 SOLVED SHORT NOTES OF FINAL MBBS 671
670 QUEST : A Comprehensive Guide lo UG Surety, Orthopedics & Anesthesiology

q In v e s tig a t io n s ;
□ A g e : I n f a n c y , c h ild h o o d > B lo o d c o u n ts
□ A e tio lo g y : H ig h r is k (a ilin g a c t iv it ie s
> X -R a y
□ Types : > C u lt u r e a n d s e n s it iv ity o f p u s
■ T r a n s v e r s e fra c tu r e

> T o r u s fra c tu r e
0 Treatment i
• B o w fr a c t u r e > A n t& io tlc s - A ll o p e n fr a c tu r e s to b e tr e a te d w ith C e f a z o lin o r e q u iv a le n t G r a m -p o s itiv e c o v e r a g e
T y p e II a n d III in ju r ie s w ill r e c e i v e G r a m n e g a t i v e c o v e r a g e in a d d it io n t o t h is lik e a n y
□ C lin ic a l f e a t u r e s :
A m in o g l y c o s id e in ju r ie s a t ris k o f a n a e r o b ic in f e c tio n s m u s t r e c e i v e P e n ic illin o r C lin d a m y c in
• B a b y c r i e s in c o n s o l a b ly d u e t o p a in
• S w o l le n , r e d d is h a r e a s a t s it e o f Ira c tu re > T e t a n u s to x o id a n d T e t a n u s im m u n o g lo b u lin

> S u r g ic a l m e a s u r e -
□ T re a tm e n t: S p lin t s
(i) P r o p e r p r e - o p e r a t iv e d e t a ils to b e e v a l u a t e d r e g a r d in g n e u r o lo g ic a n d v a s c u la r s t a t u s
Q. 4 : Fracture o f patella
(ii) irrig a tio n o f w o u n d
A : S e e S e c tio n - 2 , G ro u p - 1 , 2 0 1 1 , Q . 3 [P a g e N o. 6 4 7 ]
(iii) D e b r id e m e n t o f u n h e a lth y t is s u e
Q. S : Spina bifida (iv) F r a c t u r e s ta b ilis a tio n
A : S e e S e c t i o n - 2 , G r o u p - I, 2 0 0 9 , Q . 6 [ P a g e N o . 6 3 3 -6 3 4 ]
(v) L o c a l a d ju n c t s - P M M A c e m e n t , h e a t s t a b le a n tib io tic p o w d e r

(vi) V a c u u m a s s i s t e d c lo s u r e (V A C )
2014 Supplementary
(vii) N e g a t i v e p r e s s u r e w o u ld th e r a p y

Q Complications:
Q. 1 : Frozen shoulder ,
> In fe c tio n ( G r a d e I -> 0 - 2 % )
A : S e e 'S e c t i o n 2 , G r o u p 1 , 2 0 0 8 , Q s . 1 ( P a g e N o . 6 1 6 )
> N o n -u n io n ( G r a d e II —> 2 — 1 0 % )
Q J2 ; Brodle's abscess (G r a d e III- * 1 0 - 5 0 % )
A : S e e S e c tio n 2 , G r o u p 1, 2011 . Q s . 4 (P a g e N o. 648)

O j ; Carpal tunnel syndrome 2015

A : S e e S e c tio n 2 . G r o u p 1 , 2 0 0 9 . Q s . 3 ( P a g e N o. 6 2 9)
0 . 1: Exostosis o f bone
Q .4: Ewing's sarcoma
A : S e e S e c t io n 2 G r o u p - 1 2 0 1 0 , Q s . 1 ( P a g e N o . 6 3 7 )
A : S e e S e c tio n 2 , G r o u p 1 ,2 0 1 0 , Q s . 3 ( P a g e N o . 6 39 )
0.2: Volkmamis Ischaemic contracture.
Q . 5 : Compound fracture
A : S e e S e c t io n 2 G ro u p -I 2 0 0 8 Q s . 4 ( P a g e N o . 6 2 0 )
Ans *
COM POU ND FRACTU RE a 3 : Pathological fracture
A : S e e S e c t io n 2 G r o u p - 1 2 0 0 9 Q s . 2 (P a g e N o. 628
O Synonym : O p e n fra c tu re
0.4: Ring sequestrum
□ W hat Is I t : F r a c t u r e in w h ic h t h e r e is a n o p e n w o u ld o r b r e a k in t h e s k in n e a r t h e s i t e o l b r o k e n bone
SEQUESTRUM
□ Grades : " G u s t il o O p e n F r a c t u r e C la s s if ic a t io n "

) -» S k in w o u n d < 1 c m c o m m u n ic a t in g w ith fr a c t u r e , c l e a n w o u n d 3 What Is chronic osteom yelitis : In fe c tio n o f b o n e , p e r s is tin g fo r > 3 w e e k s , a l o n g w ith a b s e n c e o f a n y
II -» S k in w o u n d > 1 c m c o m m u n ic a t in g w ith f r a c t u r e , b u t < 1 0 c m w ith o u t e x t e n s i v e s o ft tissue s y s t e m ic s y m p t o m s a n d c h a r a c t e r is e d b y a d is c h a r g in g s in u s

dam age Q Types:

III E x t e n s i v e s o f t t i s s u e la c e r a tio n > 1 0 c m • S e c o n d a r y t o a c u t e o s t e o m y e lit is

I n c lu d e s f r a c t u r e s th a t h a v e b e e n o p e n f o r 8 h ou rs p rio r t o tr e a t m e n t • G a r r e ’s o s t e o m y e l it is
• B r o d i e 's a b s c e s s
III A - * T y p e III f r a c t u r e w ith a d e q u a t e p e r io s t e a l c o v e r a g e o f f r a c t u r e b o n e

III B -> T y p e III f r a c t u r e w ith e x t e n s i v e s o f t t i s s u e l o s s a n d p e r io s t e a l s trip p in g a n d bone ^ What Is sequestrum : P i e c e o f d e a d b o n e , w ith in a liv in g b o n e a f f e c t e d b y c h r o n i c o s t e o m y e litis ,
s u rro u n d e d b y in f e c t e d g r a n u la tio n t i s s u e , h a v in g a s m o o t h in n e r s u r f a c e a n d ir r e g u la r o u te r s u r f a c e .
d a m a g e . A s s o c i a t e d w ith m a s s i v e c o n ta m in a tio n
[ S e e F ig . 2 . 9 . 1 ]
III C -» T y p e 111 fr a c t u r e w ith a r te r ia l in ju ry re q u ir in g r e p a ir
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GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 673

□ Types of sequestrum: g S ite ; W h e r e p in is in s e r t e d a t fr a c tu r e s it e .

c
C lin ic a l f e a t u r e s :

T Y P E S OF SEQ U ESTRU M • P a s t h is to r y o f o p e n fractu re/trivia l tr a u m a / fe v e r a n d p a in in a f f e c t e d p a rt f o llo w e d b y t re a tm e n t

w ith fix a t io n b y u s in g p in s . ™
• D i s c h a r g in g s in u s

• H is to r y o f b o n e p i e c e s c o m in g o u t
A c c o r d i h g t o c o lo u r " ^ ) ^ A c c o r d in g lo s h a p e J
• W a x i n g - W a n i n g p a tte r n o f s y m p t o m s
• R e d u c e d r a n g e o f m o v e m e n ts
F e a th e ry ^ • P u c k e r e d s c a r s a r o u n d s in u s

• I n c r e a s e d b o n e girth
• T en d ern ess
C o r a llilo r m J
0 investigations:
• X -ra y -
Iv o r y )
> I r r e g u la r a n d th ic k e n e d c o r t e x

> S e q u e s t r u m ( in c r e a s e d b o n e d e n s it y , s u r r o u n d e d b y r a d io lu s c e n t z o n e )
B la c k
D > In v o lu cr u m + c l o a c a e
y P a t c h y s c l e r o s is
• C T , M RI
• S in o g r a m
« P u s - C u lt u r e a n d s e n s it iv ity
□ Treatment:
□ What Is R ing sequestrum :
• S u r g ic a l - »
• C h a r a c t e r is t ic r a d io g r a p h ic fin d in g fo llo w in g c h r o n ic o s te o m y e litis d u e to m a jo r p in -tract infections
> C - C a u t e r i s a ti o n
• T h e r m a l n e c r o s i s w it h o u t in fe c t io n p r e s e n t s a s a z o n e o f s c l e r o s i s a r o u n d t h e tra c t. > A -A m p u ta tio n
• A n a rr o w rad to iu ce n t h a lo m a y su rro u n d t h e d e n s e re g io n o f s c le r o s is in d icatin g a s s o c ia t e d infection, y S -S e q u e stre cto m y
a A etio lo g y: > E - E x c i s io n o f in f e c t e d b o n e

• D e la y in tr e a t m e n t > S - S a u c e r i s a t io n
• A n t ib io t ic s
• I n a d e q u a t e tr e a t m e n t
• R est
• H ig h ly v ir u le n t o r g a n is m s
• C o n t in u o u s s u c tio n -ir r ig a tio n a f t e r w o u n d c lo s u r e
• R e d u c e d h o s t r e s is ta n c e
Q Complications:
□ P a th o lo g y : • A c u te e x a c e rb a tio n
• G r o w t h a b n o r m a lit y ( le n g th e n , s h o r te n , d e fo rm ity )
• P a t h o lo g ic a l f r a c tu r e
F o llo w in g a c u t e o s t e o m y e lit is • J o in t s t i f f n e s s
• S in u s t r a c t m a lig n a n c y
^ X • A m y lo id o s is
D is t u r b e d p e r io s t e a l b lo o d flo w N e w s u b p e r i o s t e a l b o n e fo rm a tio n
0- S: Ideal amputation stump

I I ID E A L A M P U T A T IO N S T U M P -
D e a d b o n e s u r r o u n d e d b y g r a n u la t io n t i s s u e T h is s c l e r o t i c b o n e is in v o lu c r u m

0 Wiat Is amputation s tu m p :

T h e p a rt t h a t is le ft b e y o n d a h e a lt h y jo in t fo llo w in g a m p u t a t io n is c a l le d a n I d e a l a m p u t a t io n s tu m p .
S e q u e s tr u m fo rm e d 11 o v e r l ie s th e se q u e stru m
& Ideal stump should have following features:
A) Healing -
. i i • M ust b e a d e q u a te
In n er s u r f a c e s m o o t h , o u t e r s u r f a c e irre g u la r C l o a c a e ( h o le s ) f o r m e d t o d ra in o u t p u s
• F r e e fr o m in fe c tio n
874 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I O SOLVED SHORT NOTES OF FINAL MBBS 675

g l : Pott’s fracture
B) Shape -
• R o u n d e d , g e n tle co n to u r A n s:

• A d e q u a t e m u s c l e p a d d in g
POTT’S FRACTURE
• E n d b e a rin g g Synonym:
• B o n e e n d w e ll c o v e r e d w ith m u s c le > D u p u y tr e n f r a c t u r e
» D is a r t ic u la t io n > P o t t 's s y n d r o m e I
. S i d e p a d o r a d e q u a t e b o n y s u r f a c e t o b e a r w e ig h t fo r v a r y in g p e n o d
q What Is I t : B im a lle o la r a n k le f r a c tu r e
• T h ic k s k in a n d m u s c le fla p
g Symptoms : In s ta n t s e v e r e p a in a n d u n a b le to p u t w e ig h t o n le g + S w e ll in g + B r u is in g
• N o re d u n d a n t s o ft tis s u e
g Signs : S e v e r e t e n d e r n e s s o n t h e m a lle o li •
C) Length-
g Mechanism of In ju r y : C o m b in e d a b d u c t io n a n d e x te r n a l ro ta tio n fro m a n e v e r s i o n f o r c e c a u s in g
• S u f f ic ie n t t o b e a r p r o s t h e s i s
strain o n d e lto id lig a m e n t
• For A
g Associated In ju rie s : S h e a r i n g o ff o f -

2015 Supplementary > P o s t e r io r m a r g in o f d is ta l e n d o f tib ia

V F ib u la s u p e r io r to tib io fib u la r s y n d e s m o s i s

Q .1 : N on-union o f fracture
Q Investigations : X - r a y o f f o o t A P a n d la te r a l v ie w

A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 3 s u p p le m e n t a r y , Q s . 4 ( P a g e N o . 6 6 5 ) g Treatment:
> M o b iliz a tio n e x e r c i s e
Q 3 : Mallet finger ■
V P la s te r c a s t
A : S e e S e c tio n 2 , G ro u p 1 ,2 0 1 2 , Q s . 6 (P a g e N o. 656)
> A n k le b r a c e / w a lk in g b o o t
Q . 3 : B aker’s cyst
> S u r g e r y t o f ix in te rn a l b o n e s

A" * : BAKER’S CYST

2016
□ N am ed a f te r : M o r a n l B a k e r
□ W hat Is I t : C y s t i c s w e llin g fo u n d in p o s t e r o - la t e r a l a s p e c t o f k n e e _ 0.1: Carpal tunnel syndrome
□ O rig in : S y n o v ia l m e m b r a n e o f k n e e p r o je c t s o u t th r o u g h a g a p in t h e c a p s u l e , w h ic h g e t s distended A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 9 , Q s . 3 ( P a g e N o . 6 2 9 )

b y s y n o v ia l flu id t o fo rm a c y s t i c s w e llin g 02: Tardy ulnar nerve p a lsy

□ A ssociated w it h : A rth ritis o f k n e e A : S e e S e c t io n 2 , G r o u p II, Q s . 1 0 ( P a g e N o . 7 0 1 )

□ A g e: O ld e r a g e U : Supracondylar fracture o f humerus

□ Symptoms: A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 2 , Q s . 3 ( P a g e N o . 6 5 3 ) "
> P a in in k n e e jo in t
W : Giant cell tumor
> S i z e o f s w e llin g i n c r e a s e s w ith fle x io n o f k n e e a n d r e d u c e s w ith e x t e n s i o n o f k n e e
A : S e e " O s t e o c l a s t o m a " S e c t io n 2 , G r o u p II, Q s . 3 6 ( P a g e N o . 7 2 4 )
□ S ig n s :
IS : Trendelenburg test for hip joint .
> T r a n s illu m in a tio n t e s t p o s it iv e / n e g a t iv e
An s:
> F lu c t u a t io n t e s t p o s it iv e
TRENDELENBURG TEST FOR HIP JOINT
□ Investigations:
Q What Is i t : T e s t u s e f u l in d e te r m in in g t h e in te g r ity o f h ip a b d u c t o r m u s c le fu n c t io n a n d h ip s ta b ility
> X - R a y k n e e jt.

> M RI k n e e jt. ® Described b y : F r ie d r ic h T r e n d e le n b u r g in 1 9 8 7

^ Principle: B o d y w e i g h t is d is trib u te d e q u a l ly o n b o th lim b s w h e n a p e r s o n s t a n d s o n b o th le g s . But

□ T re a tm e n t:
•rtien h e s t a n d s o n o n e l e g , t h e b ra in tr ie s lo a llig n t h e w h o l e b o d y w e i g h t o f t h e tru n k o v e r th e w e ig h t­
> A n a lg e s ic s
bearing le g . T h is is a c h i e v e d b y c o n t r a c t io n o f h ip a b d u c t o r s o f th a t s id e , w h ic h , b y c o n tr a c tin g from
> A k n t ib io t ic s telow , p u lls th e ip s ila te r a f ilia c c r e s t d o w n t o w a r d s th a t s id e , c a u s in g ( h e p e lv is t o till. T h is is c o m p e n s a t e d
> S u r g ic a l r e m o v a l o f c y s t t y the b e n d in g o f v e r t e b r a l c o lu m n to o p p o s i t e s i d e . H e r e ,
676 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - f □ SOLVED SHORT NOTES OF FINAL MBBS 677

F u lc r u m = C e n t r e o f h ip jo in t 05; External fixation

F a ilu re o t l e v e r a r m = N e c k o f f e m u r A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 3 s u p p le m e n ta r y , Q s . 5 ( P a g e N o . 6 6 7 )
A n y c o m p o n e n t o f t h is s y s t e m l e a d s lo t h e t e s t b e in g p o s it iv e
2017
Q Pre-requisites:
y n o f ix e d a b d u c t io n I a d d u c t io n d e fo rm ity 0 f ; Volkmann’s Ischaem ic contracture
> A b le to s ta n d o n o n e le g , u n s u p p o rte d fo r 3 0 s e c o n d s A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 6 , Q s . 4 ( P a g e N o . 6 2 0 )

> ip s ila t e r a t k n e e , a n k le a n d o p p o s it e h ip s h o u ld b e n o rm a l Q2: Pathological fracture

A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 9 , Q s . 2 (Page N o . 6 2 8 )
□ Procedure:
OJ: Congenital talipes equlnovams
> E x a m in e r s t a n d s b e h in d t h e p a tie n t
> P a tie n t Is a s k e d t o r a is e t h e f o o t o f t h e n o rm a l s i d e fro m t h e g r o u n d , h o ld in g t h e h ip a t between A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 8 , Q s . 5 ( P a g e N o . 6 2 1 )

n e u t r a l 3 0 d e g r e e o l f le x io n . K n e e s h o u l d b e f le x e d e r io u g h to a llo w t h e f o o t t o b e d e a r ol the q_4; Perthes disease

g r o u n d in o r d e r l o n u llify t h e e f f e c t o f r e c t u s f e m o n s . A : S e e S e c t io n 2 , G r o u p II, Q s . 3 0 ( P a g e N o . 7 1 7 )

> P o s it io n o f p e lv i s Is n o t e d 05; Radial nerve Injury due to fracture

> T h e n p a t ie n t Is a s k e d t o r a i s e t h e f o o t o f a f f e c t e d s id e A n s:

> P o s it io n o f p e lv i s is a g a i n n o te d . RADIAL NERVE INJURY DUE TO FRACTURE

g Anatomy o f radial nerve :

0 t e s t i .e ., N o rm a l r e s p o n s e - P e l v i s o f n o n - s t a n c e s i d e is e l e v a t e d a n d th is posture
> C o n t in u a t io n o f p o s t e r io r c o r d o f b r a c h ia l p le x u s
is m a in t a in e d fo r 3 0 s e c o n d s
> S u p p lie s lo n g h e a d o f t r ic e p s in a x illa
P o s it iv e t e s t I e A b n o r m a l r e s p o n s e -♦ P e l v i s o f n o n - s t a n c e s i d e Is e it h e r n o t e l e c t e d alaU
o ° n o t m a ^ m a H y 'e le v a t e d a b o v e t h e s t a n c e s id e , o r c a n n o t m a in ta in th is p o s t u r e fo r 30 seconds > S u p p lie s m e d ia l a n d la t e r a l h e a d o f tr ic e p s in s p ir a l g r o o v e

> S u p p lie s b r a c h io r a d ia li s , e x t e n s o r c a r p i r a d ia lis lo n g u s a n d e x t e n s o r c a r p i ra d ia lis b r e v i s

□ Causes of positive te s t: b e y o n d s p ir a l g r o o v e
> P a in fu l h ip c o n d it io n s - (i) R h e u m a to id arth ritis
> B e lo w e l b o w , it g i v e s p o s t e r io r i n t e r o s s e o u s n e r v e w h ic h p i e r c e s s u p in o t o r a n d s u p p l ie s a ll
(ii) Ankylosing spondylitis
m u s c le s o f e x t e n s o r s i d e o f f o r e a r m
> F u lc r u m f a ilu r e - (I) H ip d is lo c a t io n > T h e r e a f t e r n e r v e b e c o m e s p u r e ly s e n s o r y
(ii) D e v e lo p m e n t a l d y s p la s i a o f hip
(iii) F e m o r a l h e a d d e s t r u c t io n d u e t o s e p t i c arth ritis

> L e v e r a r m f a ilu r e - (i) Neck f e m u r f r a c tu r e

1) In s p ira l g r o o v e F r a c tu r e s h a f t o f h u m e r u s • S e n s o r y -> s e n s o r y l o s s o f la t­
(ii) P e r t h e s d i s e a s e
(iii) Trochanteric fracture e r a l 3 .5 fin g e r s

> A b d u c to r f a ilu r e - (i) P o lio m y e litis • M o to r - »

(if) M N D > W ris td ro p *

(iii) M u s c le d y s t r o p h y
> O n ly little e x e n s i o n o f e lb o w
p o s s i b l e a s fu n c tio n o f lo n g
2016 Supplementary h e a d o f tr ic e p s is p e r s is t e n t

2) B e y o n d s p ir a l g r o o v e S u p r a c o n d y la r f r a c tu r e • S e n s o r y s e n s o r y l o s s o f la t­
Q .1 : Ewing's tumor e r a l 3 .5 fin g e r s
A : S e e S e c t io n 2 , G r o u p 1 . 2 0 1 0 , Q s . 3 ( P a g e N o . 6 3 9 ) F r a c t u r e d is lo c a tio n o f h e a d
o f ra d iu s ♦ M o to r -»
O . J ; Genu varum
V W r is t d r o p *
A : S e e S e c t i o n 2 , G r o u p II, Q s . 1 5 ( P a g e N o . 7 0 5 )
> F u ll e x t e n s i o n o f e l b o w p o s ­
Q .3 : Frozen shoulder s ib le a s e n tir e tr ic e p s is f u n c ­

A : S e e S e c tio n 2 , G ro u p 1 ,20 0 8 , Q s . 1 ( P a g e N o . 6 1 6 ) tio n in g

Q .4 : Osteosarcom a ' W rist d r o p -4 W r is t r e m a in s in p la m a r fle x io n d u e to w e a k n e s s o f d o r s if l e x o n s (F o r d e t a ils see

A : S e e S e c t i o n 2 , G r o u p II, Q s . 3 7 ( P a g e N o . 7 2 5 ) S e c t io n 2 , G r o u p II, Q s . 2 6 ( P a g e N o . 6 8 2 ))
678 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
G R O U P -I □ SOLVED SHORT MOTES OF FINAL MBBS 8>9

2019
2017 Supplementary
q .1 : Cubitus valgus
Q .1 : Injuries sustained by fall on outstretched hand
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 4 , Q 1 , ( P a g e N o . 6 6 9 ) C U B IT U S VALGU S

Q 2 : Com plications o f S upracondylar fracture. □ What Is I t : D e fo r m ity in w h ic h c a r r y in g a n g l e is i n c r e a s e d s o th a t t h e f o r e a r m Is a b d u c t e d e x c e s s i v e l y

A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 8 , Q 2 , ( P a g e N o . 6 1 7 ) in re la tio n t o t h e upper end

Q .3 : Sequestrum 0 C au ses:
A : S e e S e c t io n 2 . G r o u p 1 , 2 0 0 8 , Q 3 , ( P a g e N o . 6 1 8 ) a) C o n g e n it a l- T u r n e r ’s s y n d r o m e

Q . 4 : N on-union o f fracture - N o on an syn d ro m e

A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 3 S u p p le m e n t a r y , Q 4 , ( P a g e N o . 6 6 5 ) b) P r e v i o u s f r a c t u r e o f lo w e r e n d o f h u m e r u s o r c a p itu lu m w ith m a lu n lo n

c) I n t e r f e r e n c e w ith e p ip h y s e a l g r o w th o n la te r a l s i d e fro m In ju ry o r In fe ctio n

Q .S : Ewing's sarcom a
A : S e e S e c t io n 2 , G r o u p 1 ,2 0 1 0 , Q 3 , ( P a g e N o . 6 3 9 ) □ Clinical fe a tu re : I n c r e a s e d c a r r y in g a n g l e a t e lb o w - f o r e a r m s t ic k s o u t

□ Com plications:
2018
• U ln a r n e u r o p a t h y - M o s t c o m m o n -> T a r d y u ln a r n e r v e p a l s y

Q Treatm ent:
Q .1 : M yositis ossificans
• M ild d e fo r m ity - » N o t r e a t m e n t
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 9 , Q 1 , ( P a g e N o . 6 2 7 )
• M o d e r a t e to s e v e r e d e fo r m ity -> M e d ia l d o s e d w e d g e o s t e o t o m y
Q 2 : Fracture patella
• T a r d y u ln a r n e r v e p a l s y -> A n te r io r tr a n s p o s it io n o f u ln a r n e r v e
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 1 , Q 3 , ( P a g e N o . 6 4 7 )
TARDY U LN A R N E R V E P A L S Y
Q .3 : C om plications o f C olies' fracture
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 3 , Q 4 , ( P a g e N o . 6 6 2 )
□ What Is I t : L a t e o n s e t u In a r n e r v e p a l s y

□ Causes :
Q .4 : Pathological fracture
A : S e e S e c t io n 2 , G r o u p I, 2 0 0 9 . Q 2 , ( P a g e N o . 6 2 8 ) • D i s p la c e d m e d ia l e p ic o n d y le h u m e r u s

• M a lu n ite d la t e r a l c o n d y le h u m e r u s
Q .S : G iant cell tum or
A : S e e S e c t io n 2 , G r o u p tl, Q 3 6 , ( P a g e N o . 7 2 4 ) • E lb o w d is lo c a t io n

• S h a l lo w u ln a r g r o o v e *
2018 Supplementary
• C o n t u s io n s o f u ln a r n e r v e •

• H y p o p la s ia o f h u m e r a l t r o c h le a
Q .1 : Pathogenesis o f Chronic Osteom yelitis
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 9 , Q 5 , ( P a g e N o . 6 3 1 ) □ Clinical fe a tu re s :

• W e a k n e s s o f g rip
QJ2: Pott's Paraplegia
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 0 . Q 6 (T B S p in e ). ( P a g e N o. 6 4 2 ) • T in g lin g n u m b n e s s o f little f in g e r

0 . 3 : Classification o f fracture neck fem ur • C a r d t e s t p o s it iv e (u ln a r n e r v e p a l s y -y w e a k n e s s o f p a l m a r in t e r o s s e i - » w e a k a d d u c tio n o f

little fin g e r )
A : S e e S e c t io n 2 . G r o u p 1 . 2 0 0 9 , Q 4 , ( P a g e N o . 6 3 0 )
• F r o m e n t 's s i g n p o s it iv e (u ln a r n e r v e p a l s y -» w e a k n e s s o f a d d u c t o r p o llic is - * fle x io n o f
0 . 4 : Spina bifida
in t e r p h a la n g e a l jo in t w h ile g r a s p in g a p a p e r b e t w e e n th u m b a n d r a d ia l b o r d e r o f h a n d )
A : S e e S e c t io n 2 , G r o u p I, 2 0 0 9 , Q 6, (P a g e N o. 633)
• F le x io n t e s t p o s it iv e
Q .5 : Sequestrum
^ Investigation: N e r v e c o n d u c t io n t e s t
A : S e e S e c t io n 2 , G r o u p I, 2 0 0 8 , Q 3 , ( P a g e N o . 6 1 8 ) .
680 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I □ SOLVED SHORT NOTES OF FINAL MBBS 681

0.4: Cubitus Varus

□ Trea tm e n t;
• C o n s e r v a t iv e - E lb o w e x t e n s i o n s p lin t s a t n ig h t C U B IT U S VARU S

• O p e ra tiv e - R e m o v a l o f u ln a r n e r v e fr o m g r o o v e -» n e u r o ly s i s if n e c e s s a r y -» anterior
q Synonym : G u n s t o c k d e fo r m it y
tr a n s p o s it io n to f le x o r s u r f a c e o f e lb o w
0 W hat Is I t : M o s t c o m m o n c o m p li c a t io n o f d i s p l a c e d s u p r a c o n d y l a r f r a c t u r e ; tr ip la n a r d e f o r m it y
w ith c o m p o n e n t s o f v a r u s , h y p e r e x t e n s i o n a n d in te r n a l r o ta tio n ( F o r e a r m d e v i a t e d in w a r d s w ith
r e s p e c t to a rm a t e l b o w w ith la t e r a l a n g u la t io n in fu ll e x t e n s i o n )

0 Incidence : 3 - 5 7 %

Q Causes :
• M ost com m on - m a lu n ite d s u p r a c o n d y l a r h u m e r u s

• I n f e c t iv e - m e d ia l g r o w t h p la t e d a m a g e

• T r a u m a tic - la t e r a l c o n d y le f r a c t u r e

• C o n g e n ita l - e p ip h y s e a l d y s p la s ia

• V a s c u la r - o s te o n e c r o s is o f tr o c h le a

• N e o p la s tic - s e c o n d a r y t o e x o s t o s i s in d is t a l h u m e r u s

Q E x a m in a tio n :
A) In s p e c tio n :

H y p e r e x t e n s i o n d e fo r m ity

L im ite d f le x io n

M e d ia l tilt a n d la t e r a l a n g u la t io n a t e l b o w

P r o m i n e n c e o f la te r a l c o n d y l e h u m e r u s

W a s tin g o f m u s c le s
0 . 2 : Fracture heeling
G u n - s t o c k d e f o r m it y - l o o k s lik e a lo a d i n g s t o c k o f o ld lo n g b a r r e l g u n s
A : S e e S e c t io n 2 , G r o u p II, Q . 1 6 , ( P a g e N o . 7 0 6 )
B) P a lp a t io n :
O J : Osteosarcoma
T h i c k e n i n g a n d ir r e g u la r ity o f s u p r a c o n d y l a r r id g e s
A : S e e S e c t io n 2 , G r o u p II, Q . 3 7 , ( P a g e N o . 7 2 5 ) P r o m i n e n t la te r a l c o n d y le - d u e t o r o t a t io n o f d is t a l f r a g m e n t

0 .4 .-C lubfoot T h r e e p o in t r e la t io n s h ip d o e s n o t m a k e a n e q u il a t e r a l t r ia n g le

A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 8 , Q . 5 ( P a g e N o . 2 9 8 ) T a l i p e s e q u in u s ’ . D ecrease In c a r r y in g a n g l e •

I n c r e a s e d in t e r n a l r o ta tio n ( Y a m a m o t o T e s t )
O .S : Supracondylar fracture o f humerus
Q Grading o f se v e rity :
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 2 , Q . 3 ( P a g e N o . 6 5 3 )
• G ra d e I -» L o s s o f p h y s io lo g ic a l v a lg u s a n g le

• G r a d e II —» 0 — 1 0 ° v a r u s

2019 Supplementary • G r a d e III —» 1 1 — 2 0 ° v a r u s

• G r a d e IV - > > 20* v a ru s

0 . 1 : Com plications o f Colies fracture
Q Com plications : U ln a r n e r v e p a l s y
A : S e e S e c t i o n 2 , G r o u p 1 , 2 0 1 3 . Q .4 ( P a g e N o . 6 6 2 )
Q X-ray findings :
0 . 2 : Diagnosis o f Volkmann Ischem ia
1) D ecrease in n o r m a l p h y s i o l o g i c a l v a l g u s
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 8 , Q .4 ( P a g e N o . 6 2 0 ) AP 2) I n c r e a s e in B a u m a n n ’s a n g le
*iew
0 . 3 : Myositis ossificans 3) M e ta p h y s e o - d ia p h y s e a l a n g le ( K le b b - S h e r m a n ) > 9 0 °

_ 4) H u m e r o - u ln o a n g l e ( O p p e n h e im ) - d e c r e a s e d ( m o s t a c c u r a t e fin d in g )
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 9 , Q . 1 , ( P a g e N o . 6 2 7 )
 682 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - 1 □ SOLVED SHORT NOTES OF FINAL MBBS 683

Lateral f 5) N o r m a lly n o o v e r l a p b e tw e e n la t e r a l c o n d y la r e p i p h y s i s and o le c ra n o n e p ip h y s is - i Q G rades:

v ie w j s ig n if ic a n t tilt o f d is t a l f r a g m e n t o c c u r s , t h e r e i s o v e r l a p b e t w e e n t h e t w o - "C re s c e n t
s ig n ' m G r a d e s o f P o t t 's p a r a p le g i a

□ T r e a tm e n t: I P a tie n t u n a w a r e + B a b in s k i's s ig n p o s it iv e

1) O b s e r v a tio n - G e n e r a l l y n o t a p p r o p r i a t e a s little r e m o d e ll in g o c c u r s in o l d e r ch ild II C lu m p s in e s s , s p a s t i c i t y w h ile w a lk in g b u t c a n w a lk w ith o u t s u p p o r t

2 ) H e m i - e p i p h y s i o d e s i s a n d g r o w t h a lt e r a t io n - d o e s n o t h e l p t o c o r r e c t d e fo r m ity , only III N o t a b l e to w a lk + P a r a p le g ia in e x t e n s i o n + p a r tia l l o s s o f s e n s a t io n

h e l p s in p r e v e n t i n g it fr o m i n c r e a s i n g ’ ^
IV U n a b le to w a lk + P a r a p le g ia in f le x io n + S e v e r e m u s c l e s p a s m + N e a r c o m p le te
3) C o r r e c tiv e o s te o to m y
l o s s o f s e n s a t io n + S p h in c t e r d is t u r b a n c e
a) L a te r a l c lo s in g w e d g e o s te o to m y

b) M e d ia l o p e n w e d g e o s t e o t o m y w ith b o n e g r a ft □ C lassificatio n:
c) O b l iq u e o s t e o t o m y w ith d e r o t a t io n
a) P a r a p le g ia o f a c t i v e d i s e a s e - e a r ly o n s e t
4) M ost c o m m o n - F r e n c h o s t e o t o m y ( P o s t e r i o r lo n g it u d in a l a p p r o a c h ) b) P a r a p le g i a o f h e a l e d d i s e a s e - la te o n s e t
- M o d ifie d F r e n c h O s t e o t o m y ( P o s t e r o l a t e r a l a p p r o a c h )
□ P ro g n o sis: D e p e n d s o n -

• S e v e r it y

• D u ra tio n

• L e v e l o f d e fic it

• A c tiv ity o f d i s e a s e

• G e n e r a l c o n d itio n o f p a tie n t

• P r e s e n c e o f a s s o c ia te d d is e a s e

T U B E R C U L O S I S O F S P IN E

□ S yn o n y m ; C a r i e s s p i n e

□ A e tio lo g y : M y c o b a c t e r iu m t u b e r c u lo s is

□ P ath o lo g y: C h r o n ic g r a n u lo m a t o u s in fla m m a tio n w ith c a s e a t i o n n e c r o s i s

□ Pathogenesis:

• BONE-

In fla m m a tio n
I ’

L o c a l tra b e c u la r n e c r o s is a n d c a s e a tio n
0 .5 : P athological fracture I

A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 9 , 0 . 2 , ( P a g e N o . 6 2 8 ) I n t e n s e lo c a l h y p e r a e m ia
i
D e m in e r a lis a tio n o f b o n e
December-January 2019-2020 4

C o r t i c e s o f b o n e g e t e r o d e d in a b s e n c e o f a d e q u a t e b o d y r e s i s t a n c e
0 . 1 : Sequestrum 4

A : S e e S e c t i o n 2 , G r o u p I, 2 0 0 8 , Q .3 ( P a g e N o . 6 1 8 ) I n fe c te d g r a n u la t io n t i s s u e a n d p u s fin d th e ir w a y to s u b - p e r io s t e a l a n d s o f t - t is s u e p la n e s
I
0 .2 : Pott's paraplegia
C o ld a b s c e s s

POTTS PARAPLEGIA 4
M a y b u r s t o u t to fo rm s i n u s e s
□ W hat Is I t : M o s t s e r i o u s c o m p lic a t io n o f t u b e r c u lo s is o f s p i n e I

□ Highest risk I n : C e r v i c o - d o r s a l r e g io n A f f e c t e d b o n e m a y u n d e r g o p a t h o lo g i c a l Ira c tu re

 GROUP-ID SOLVED SHORT NOTES OF FINAL MBBS 685
684 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

0 Stages :
• JO IN T -
• S t a g e o f d e s t r u c t io n -
L o w g r a d e s y n o v it is + th ic k e n in g o l s y n o v ia l m e m b r a n e
B a c t e r ia lo d g e in c o n t ig u o u s a r e a s o f 2 a d j a c e n t v e r t e b r a e
i
T u b e r c u l a r in fe c t io n c a u s e s s lo w d e s t r u c t io n o f a r t ic u la r c a r t i la g e
G r a n u lo m a t o u s in fla m m a tio n
i
I
S y n o v iu m in fla m e d (th is in fla m m a to r y s y n o v iu m a t p e r ip h e r y o f c a r t i la g e i s c a l le d P a n n u s )
E r o s io n o f v e r te b r a l m a r g in s
' i
i
S t a r t s d e s t r o y in g c a r t i la g e fro m p e r ip h e r y
C o m p r o m is e d n u tritio n o f in te r v e n in g d i s c s , w h ic h is d e r i v e d fro m e n d - p l a t e s o f a d ja c e n t v e r t e b r a e
; I
U ltim a te ly , c a r t ila g e c o m p le t e ly d e s t r o y e d D i s c d e g e n e r a t io n

I I
C o m p le t e d e s tr u c tio n
J o in t g e t s d is t e n d e d w ith p u s
• C o lla p s e o f v e r te b r a e -
I
W e a k e n in g o f t r a b e c u l a e o f v e r t e b r a l b o d y
J o in t c a p s u l e , lig a m e n t b e c o m e la x , jo in t s u b l u x a t e d
I
I
C o lla p s e o f v e r te b r a e
P u s a n d tu b e r c u la r d e b r is b u r s t o u t o f jo in t c a p s u l e
• C o ld a b s c e s s fo r m a tio n -
I .
C o ll e c t io n o f p u s a n d t u b e r c u la r d e b r is fr o m a d i s e a s e d v e r t e b r a
. C o ld a b s c e s s
I
I P u s t r a c k s in a n y d ir e c t io n •
C h r o n ic d is c h a r g in g s in u s

. H E A L IN G - T ra v e ls b a c k w a r d s T r a v e l s a n te r io r ly o r b y s i d e o f v e r t e b r a e
I
H e a lin g o c c u r s b y fib r o s is
C o m p r e s s e s n e u r a l s t r u c t u r e s in s p in a l c o r d
4
C o n s i d e r a b l e d e s t r u c t io n o f a r tic u la r c a r t i la g e , jo in t s p a c e c o m p le t e ly lo s t
T r a v e l s a l o n g m u s c u lo - f a s c ia l p la n e to a p p e a r s u p e r f ic ia lly a t p l a c e s f a r a w a y fr o m s it e o f le s io n
i
• S t a g e o f h e a lin g -
T r a v e r s e d b y b o n y t r a b e c u l a e b e t w e e n b o n e s fo r m in g t h e jo in t ( b o n y a n k y l o s is )
L y tic a r e a s r e p l a c e d b y n e w b o n e s

□ S p re a d : I
• S k e le t a l T B i s a l w a y s s e c o n d a r y A d ja c e n t v e r t e b r a e u n d e r g o f u s io n b y b o n y b r id g e s

• S p r e a d s t h r o u g h B a t s o n 's p a r a v e r t e b r a l v e n o u s p l e x u s e s , w h ic h c o m m u n i c a t e s f r e e ly with I

v i s c e r a l p le x u s o f a b d o m e n P e r m a n e n t c h a n g e s in s h a p e o f v e r t e b r a l b o d y

□ S ym p to m s:
□ T y p es :
• P a r a d is c a ! - " E m b r y o lo g ic a l s e g m e n t " a f f e c t e d • P a in -

• C e n t r a l - B o d y o f s in g le v e r t e b r a a f f e c t e d -♦ e a r ly c o l l a p s e o f w e a k e n e d v e r t e b r a -+ w ed g in g > B a c k p a in c o m m o n e s t

c o l l a p s e ( c o m m o n ) o r C o n c e r t in a c o l la p s e > In itially d if f u s e d , la t e r lo c a l is e d

> M a y b e r a d ic u la r p a in
. A n te r io r - A n te r io r p a r t o l v e r t e b r a l b o d y a l f e c t e d -> s p r e a d s u p a n d d o w n u n d e r anterior
• S tiffn e s s -
lo n g itu d in a l li g a m e n t
> E a r ly s y m p t o m
. P o s t e r io r - P o s t e r io r c o m p le x o f v e r t e b r a a f f e c t e d i. e . p e d i c l e , la m in a , s p i n o u s p r o c e s s ,
> P r o t e c t iv e m e c h a n i s m w h e r e in p a r a v e r t e b r a l m u s c l e s g o in to s p a s m
tran sv erse p ro c e s s
• C o ld a b s c e s s - S w e llin g o r p r o b le m s d u e t o its c o m p r e s s i o n o f n e u r a l s t r u c tu r e s

• D e fo r m ity - G r a d u a lly i n c r e a s i n g p r o m in e n c e o f s p i n e (" g ib b u s " )

 686 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP-I □ SOLVED SHORT NOTES OF FINAL MBBS 687

• C o n s t it u t io n a l s y m p t o m s - • T re a tm e n t o f c o ld a b s c e s s -

> Evening r is e o f te m p e r a t u r e > A s p ir a t io n

V W e i g h t l o s s , a n o r e x i a , f a t ig u e > Evacuation

□ C linical ex am in atio n : 0 Com plications:

• G a it— • C o ld a b s c e s s
> S h o r t s t e p s t o a v o i d je r k in g • N e u r o l o g ic a l c o m p r e s s i o n
> T w is t s w h o l e b o d y t o lo o k s i d e w a y s
0 . 3 ; Tennis elbow
• A ttitu d e a n d d e f o r m it y -
A : S e e S e c t io n 2 , G r o u p 1 , 2 0 1 2 , Q . 2 ( P a g e N o . 6 5 2 )
> P r o m i n e n c e o f 2 - 3 s p i n o u s p r o c e s s e s ( g ib b u s )

> L o s s o f lu m b a r lo r d o s is 0 .4 : A vascular necrosis

> S tiff, s t r a ig h t n e c k
A : S e e S e c t io n 2 , G r o u p II, Q .4 9 ( P a g e N o . 7 3 6 )
• P a r a - v e r t e b r a l s w e ll in g -
O S : Dupuytren's C ontracture
V D u e to c o ld a b s c e s s

> F lu c t u a t in g in n a t u r e A : S e e S e c t i o n 2 , G r o u p 1 , 2 0 1 2 , Q .4 ( P a g e N o . 6 5 4 )

• T en d ern ess - E lic it e d b y p r e s s in g o n s i d e o f s p i n o u s p r o c e s s e s in a n a t t e m p t t o rotate

v e rte b ra e
J u n e - J u ly , 2 0 2 0
» M o v e m e n t - L im ite d s p i n a l m o v e m e n t

• N e u r o l o g ic a l e x a m in a t io n
0 .1 : Volkmann’s Ischaem ic contracture
□ Investigations: A : S e e S e c tio n 2 , G ro u p 1 , 20 0 8 , Q .4 ( P a g e N o . 620)

• X -r a y -
O J : Non union o f fracture
> R e d u c t io n o f d i s c s p a c e ( e a r li e s t s ig n )
A : S e e S e c tio n 2 , G ro u p 1 ,2 0 1 3 s u p p le , Q .4 ( P a g e N o . 6 6 5 )
> D e stru c tio n o f v e rte b ra l b o d y

> R a r e f a c li o n a b o v e a n d b e lo w le s io n O J : Frozen shoulder

> Cold a b s c e s s v is ib le A : S e e S e c t io n 2 , G r o u p 1 , 2 0 0 8 , Q . t ( P a g e N o . 6 1 6 )
> E r o s io n o f p o s t e r io r e l e m e n t s s e e n o n O b liq u e X - r a y
0 .4 : Ewing's Sarcom a
> D e n s it y o f a f f e c t e d b o n e i n c r e a s e s d u rin g h e a lin g
A : S e e S e c tio n 2 , G ro u p 1 ,2 0 1 0 , Q .3 ( P a g e N o. 6 3 9 )
• C T Scan -

> D e t e c t s v e r y s m a ll p a r a v e r t e b r a l a b s c e s s CLS: Fracture patella

> E x t e n t o f d e s t r u c t io n o f p o s t e r io r s e g m e n t o f v e r t e b r a l b o d y A : S e e S e c tio n 2 , G ro u p 1 ,2 0 1 1 , Q .3 ( P a g e N o. 6 4 7 )
> In c a s e s p r e s e n t in g a s ‘s p in a l t u m o r s y n d r o m e ' w h e r e X - r a y is n o t h e lp fu l

• M R I - I n v e s t ig a t io n o f c h o i c e t o e v a l u a t e c o r d c o m p r e s s i o n

• M y e lo g r a p h y

• B io p s y

• E U S A , P C R , M a n to u x te st

□ T re a tm e n t:

• C o n t r o l o f in f e c t io n -

> A n t it u b e r c u la r d r u g s (2 H R Z E + 4 H R )

> R est

> N u tritio u s d ie t

» C a r e of s p i n e - In itia lly b e d r e s t , a s h e a lin g s t a r t s , s l o w im m o b ilis a t io n w ith s p i n e s u p p o rte d

in b r a c e o r c o l la r
 GROUP - 1 □ SOLVED SHORT NOTES OF FINAL MBBS 689
668 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Smooth inner surface ol

Fig. 2.9.1 : Sequestrum

_______________________________ _

a - Along medullary cavity

Fig. 2.9.2 : Clubfoot In baby b - Out of cortex

c - To the join!
d - Pus in muscular plane

Fig. 2 .9 .5 '. Spread ot pus from metaphysls

(Acute osteomyelitis)
690 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - I 0 SOLVED SHORT NOTES OF FINAL MBBS 691

Inflammatory thickening ol librous

sheath of Hexor tendons

Fig. 2.9.9 : Trigger Finger

Fig. 2.9 .6 : S p in a BHida

Onion pee!
appearance

Extension type Flexion type

Fig. 2.9.11 : Brodie's abscess Fig. 2.9.13 : Supracondylar fracture of humerus

(Left arm and forearm - lateral view)

Fig. 2.9.8 : Ewing's sarcoma

692 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology GROUP - | □ SOLVED SHORT NOTES OF FINAL MBBS 693

S u b c o ra c o id
(m ost com m on )
Subglenoid

S u b c la v ic u la r
Fig. 2 .9 .1 5 : C o lle s ' fracture
N = Normal
0 = Dislocated
F ig. 2 .9 . 1 2 : T y p e s o l shoulder dislo catio n

ulna
Fig. 2 .9 .1 6 : Monteggia fracture
 GROUP - II 0 SOLVED SHORT NOTES OF SEMESTERS 69S

GROUP - II
Q. 2 : Sudeck's osteodystrophy
SOLVED SHORT NOTES OF SEMESTERS
SUDECK’S OSTEODYSTROPHY
O. 1 : S cap ho id fracture □ Syno nym s:

SCAPHOID FRACTURE • C a u s a lg ia

• R e f l e x s y m p a t h e t ic d y s t r o p h y
□ A g e : A d o l e s c e n t s a n d y o u n g a d u lt s • C o m p le x r e g io n a l p a in s y n d r o m e
□ Site : W a is t o f s c a p h o i d is m o r e c o m m o n t h a n t u b e r o s it y , l e a s t c o m m o n b e in g p r o x im a l p o le • R e f l e x N e u r o v a s c u la r D y s tr o p h y (R N D )
[F ig . 2. 10. 1] • A m p lifie d M u s c u l o s k e l e t a l P a in S y n d r o m e ( A M P S )
□ Sym ptom s : F a ll o n o u t s t r e t c h e d h a n d -» p a in a n d s w e llin g o v e r r a d ia l a s p e c t o f w r is t □ What Is i t ; P o s t - t r a u m a t ic o s t e o d y s t r o p h y
□ S ig n s : □ Associated with : C o m p lic a tio n o f C o d e ’s fr a c tu r e
• F u l ln e s s a n d t e n d e r n e s s in a n a t o m ic a l s n u ff-b o x □ When n o tic e d : A fte r p la s t e r r e m o v e d
• W a t s o n t e s t p o s it iv e ( p a t i e n t 's p r o n a t e d fo r e a r m w ith w r is t in s lig h t u ln a r d e v ia tio n and □ Causes :
e x t e n s i o n -> d o r s a lly d ir e c t e d f o r c e a p p lie d o v e r v o la r a s p e c t o f w ris t j u s t d is t a l to radius j.«
• A b n o r m a l a n d p r o l o n g e d s y m p a t h e t ic n e r v o u s r e s p o n s e
s c a p h o i d -» w r is t i s m o v e d fr o m u ln a r t o r a d ia l d e v ia t io n w h ile p r e s s u r e o n s c a p h o id is
• L ib e r a tio n o f h is t a m in e fro m in ju r e d t is s u e
m a in t a in e d -> p a in + s c a p h o i d s u b l u x a t e s b e y o n d d o r s a l rim o f r a d iu s )
□ S ta g e s :
□ Investigations:
• S t a g e I - C h a r a c t e r i z e d b y s e v e r e , b u rn in g p a in a t t h e s i t e o f t h e in ju ry, m u s c le s p a s m s , jo in t
• S k ia g r a m o f w rist - R a d ia l o b liq u e v ie w , u ln a r o b liq u e v ie w , la te ra l v ie w , p o s te ro -a n te rio rv ie tt
s t if f n e s s , r e s t r ic t e d m o b ility , r a p id h a ir a n d n a il g r o w th , a n d v a s o s p a s m .
• C T S can
• S t a g e II - C h a r a c t e r i z e d b y m o r e I n te n s e p a in . S w e llin g s p r e a d s , h a ir g ro w th d im in is h e s , n a ils
t M RI
b e c o m e c r a c k e d , b rittle, g r o o v e d , a n d s p o tt y , o s t e o p o r o s i s b e c o m e s s e v e r e a n d d iffu s e , jo in ts
• B one Scan t h ic k e n , a n d m u s c l e s a tr o p h y .
□ T re a tm e n t: • S t a g e III - C h a r a c t e r iz e d b y ir r e v e r s ib le c h a n g e s In t h e s k in a n d b o n e s , w h ile t h e p a in b e c o m e s
u n y ie ld in g a n d m a y in v o l v e t h e e n tir e lim b . T h e r e Is m a r k e d m u s c l e a tr o p h y , s e v e r e l y lim ited
H is to r y o f fa ll + c lin ic a l f e a t u r e s , b u t n o f e a t u r e s o n s k i a g r a m m o b ility o f t h e a f f e c t e d a r e a , a n d f le x o r t e n d o n c o n t r a c t io n s

i □ Clinical fe a tu re s :
▼
T h u m b S p ic a S c a p h o i d C a s t a n d im m o b ilis a tio n fo r 2 w e e k s • D is c o lo u r a tio n
1 • S t if fn e s s

X -r a y r e p e a t e d • R ed n ess

• P a in fu l s w e llin g

• H y p e r t iy d r o s is
N o fr a c t u r e F ra ctu re • A ilo d y n ia •

N o a c t i v e tr e a tm e n t *
U n d i s p la c e d
\U n d is p la c e d > 1 m m
□
«

•
A t r o p h y o f h a ir a n d s k in

In vestigation s:
X - r a y - P e r ia r t ic u la r o s t e o p o r o s i s
OR S c a p h o lu n a te a n g le > 60 d e g re e s • T o t e s t h y p e r h y d r o s i s - N in h y d rin s w e a t t e s t
D i s p la c e d < 1 m m R a d io l u n a t e a n g l e > 1 5 d e g r e e s
□ Treatm ent: P h y s io t h e r a p y + N S A ID
1T 1
0 . 3 ; C arre’s sclerosing osteom yelitis
C a s t fo r 1 2 w e e k s O p e n r e d u c t io n + I n te r n a l fixation
GARRE’S SCLEROSING OSTEOMYELITIS
□ C om plications: □ D e fin e : S c l e r o s i n g n o n - s u p p u r a t iv e c h r o n ic o s t e o m y e lit is
• A v a s c u l a r n e c r o s is □ A g e .- A d o l e s c e n t s
• N o n - u n io n Q Pathogenesis: S y m m e t r ic a l th ic k e n in g o f c o r t i c o - c a n c e l lo u s b o n e w ith p a r tia l o b s t r u c t io n o f m a rro w
• O s t e o a r t h r it is o f w rist space
__ 4
u Site : S h a f t s o f f e m u r a n d tib ia
694

li
 696 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I I D SOLVED SHORT NOTES OF SEMESTERS 697

□ C linical fe a tu re s : □ P ath o lo g y:
• P r o l o n g e d lo w g r a d e p a in • F e m u r h e a d d is lo c a t e d u p w a r d s a n d la te r a lly
• M ild s w e llin g a n d t e n d e r n e s s • F em u r n e c k e x c e s s iv e ly a n te v e rte d

( F e v e r a n d p a in w h ic h b e g a n a c u t e ly s u b s i d e b u t fu s ifo r m o s s e o u s e n l a r g e m e n t p e r s is t s ) • A c e ta b u lu m - s h a llo w

□ T re a tm e n t: • L ig a m e n t u m t e r e s - h y p e rtro p h ie d

• A c u t e s y m p t o m s s u b s i d e w ith r e s t a n d a n tib io tic s • i n v e r t e d lim b u s

• P a in c a n b e r e l ie v e d b y m a k in g a h o le / g u tte r in b o n e • C a p s u l e o f h ip j o i n t - s t r e t c h e d

□ D ifferential d iag n o sis: * • S u r r o u n d in g m u s c le - a d a p t iv e s h o r te n in g

« O s t e o id o s t e o m a □ Clinical fe a tu re s :
• E w in g ’s s a r c o m a • 0-6 m o n t h s -
O r to la n i - B a r to w t e s t p o s it iv e ( m a y b e n e g a t i v e if a c e t a b u l a r d y s p la s ia )
Q. 4 : B lood su pp ly o f fem oral head
• 6 - 1 8 m o n th s -
BLO O D SU PPLY O F FEM ORAL H EAD > R e d u c e d a b d u c t io n

> T r e n d e le n b u r g t e s t p o s itiv e
□ Sources :
> W a d d lin g g a it
• M e d u lla r y / m e t a p h y s e a l v e s s e l s
> G a l e a z i s ig n p o s it iv e
• R e tin a c u la r v e s s e l s fr o m la te r a l s i d e o f n e c k o f f e m u r -
> T e l e s c o p i c t e s t p o s it iv e
> L a t e r a l e p ip h y s e a l v e s s e l s
• 18 -3 6 m o n th s -
> B r a n c h o f m e d ia l c ir c u m fle x fe m o r a l a r te r y
> W i d e p e r in e u m
• F o v e a l v e s s e l s fro m lig a m e n t u m t e r e s
> I n c r e a s e d lu m b a r lo r d o s is
□ Age-wise s u p p ly :
> S h o r t e n e d lim b
(a ) T ill 4 y e a r s - F r o m a ll 3 s o u r c e s
> A s s y m e t r ic th ig h f o ld s
(b ) B e t w e e n 4 - 7 y e a r s - R e l in a c u la r v e s s e l s a s o s s ific a t io n o f p h y s e a l c a r t i la g e l e a d s t o c u t-o ff
o f m e t a p h y s e a l s u p p ly a n d s u p p ly fr o m lig a m e n tu m t e r e s d e v e l o p s fu lly a f t e r 7 y e a r s □ In vestigation s:
(c) A f t e r 7 y e a r s - B o th r e t in a c u la r a n d f o v e a l v e s s e l s • 0 -6 m o n t h s - U S G

□ S alient fe a tu re s : • 6 - 1 2 m o n t h s - U S G o r X - r a y (V o n R o s e n 's v ie w )

• N u trie n t a r t e r y s u p p l i e s b o n e m a rro w a n d in n e r 2/3 rd c o m p a c t b o n e • > 1 2 m o n t h s - X -r a y

• T e r m in a l b r a n c h e s o f n u trie n t a r t e r y m a k e h a ir-p in lo o p a t e p i p h y s e o - d i a p h y s e a l rea ctio n X-ray findings:

a n d a n a s t o m o s e w ith e p ip h y s e a l a n d m e t a p h y s e a l a r t e r ie s (1 ) H ea d o f fe m u r-

• In a g r o w in g b o n e , m e t a p h y s is r e c e i v e s s u p p ly fro m m e t a p h y s e a l v e s s e l s a n d n u trie n t artery, > D e la y e d a p p e a r a n c e o f o s s ific a t io n c e n t r e o f h e a d o f f e m u r

w h ile e p ip h y s is r e c e i v e s s u p p ly fro m e p ip h y s e a l v e s s e l s > R e t a r d e d d e v e l o p m e n t o f o s s i fi c a t io n c e n t r e o f h e a d o f f e m u r

[ F ig . 2 .1 0 .2 ] > L a t e r a l + u p w a r d d is p la c e m e n t o f h e a d o f fe m u r

(2 ) A c e t a b u l u m -
0 . 5 ; Congenital dislocation o f hip
> S lo p in g
C O N G E N I T A L D I S L O C A T I O N O F H IP (3 ) O th e rs -

> S h e n t o n ’s lin e b r o k e n .
□ N ewer te rm /syn o n ym : D e v e lo p m e n t a l d y s p la s ia o f hip (D D H ) > N e e d h e lp o f -
□ A e tio lo g y : * A c e t a b u l a r in d e x
• H e r e d ity r e la t e d l a x jo in ts * P e r k in ’s lin e
• H o r m o n e in d u c e d la x jo in ts * H il-g e n -r e in e r ’ s lin e
• B r e e c h p r e s e n t a t io n *. W i b e r g ’s c e n t r e a n g le
□ Types: [ F ig . 2 . 1 0 . 3 ]
• D i s l o c a t e d a t birth □ Treatm ent:
• D i s l o c a t e d a f t e r birth 0-6 m o n t h s -

• 6 -18 m o n th s -
698 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 699

. E X E R C IS E T H E R A P Y -
P r e - o p e r a l iv e s u r f a c e t e n s io n

PU RPOSE TYPES
4
P e r c u ta n e o u s a d d u c to r te n o to m y
( 1 ) J o in t m o b ilis a t io n (a) P a s s i v e jo in t m o v e m e n t
I (b ) A c t iv e jo in t m o v e m e n t
O p e r a t i v e c l o s e d r e d u c tio n (c) C o n t in u o u s p a s s i v e m o b ilis a tio n

I (2) M u s c le s t r e n g t h e n in g (a ) S ta t ic / I s o m e t r ic ( m u s c le c o n t r a c t s , le n g th
A r th r o g r a m r e m a in s s a m e )
(b) D y n a m i c / I s o t o n i c (m u s c le c o n tra c ts,
^ X p r o d u c e s m o v e m e n t)
M e d ia l d y e p o o l < 5 - 7 m m H o u r g la s s c o n s t r ic t io n
( 1 ) a c t iv e

I i (2) a c t i v e a s s i s t e d (w ith p h y s io t h e r a p is t 's

H ip s p i c a p la s t e r O p e n re d u c tio n h e lp )
(3 ) a c t i v e r e s i s t e d ( a g a in s t r e s is t a n c e )

(3 ) T o im p r o v e c o o r d in a t io n ( T h i s is u s e d in s p e c i a l s i t u a t i o n s lik e
• 1 8 - 3 6 m o n th s -
c e r e b r a l p a l s y , p o lio p a t ie n t s )
O p e n r e d u c t io n + P e l v i c o s t e o t o m y

» > 3 6 m o n th s -
O p e n r e d u c t io n ( n o p r e - o p e r a t iv e t r a c t io n n e e d e d ) • T R A C T IO N S -

> T o s e p a r a t e jo in t s u r f a c e w h ile g iv in g p a s s i v e m o v e m e n t to jo in t
Q. 6 : P hysiotherapy In orthopaedics
> T o r e la x m u s c l e in s p a s m
PHYSIOTHERAPY IN ORTHOPAEDICS > T o c o r r e c t d e fo r m it ie s
» M ASSAG E -
□ W hat is I t : N o n - o p e r a t iv e o r t h o p a e d ic tr e a t m e n t
* S y s t e m i c a n d s c i e n t if ic m a n ip u la tio n o f s k in a n d u n d e r ly in g s o f t t i s s u e s t o r e l i e v e p a in a n d
□ A im :
r e la x m u s c le s
• A ll e v ia t e p a in
• H YDROTH ERAPY-
• R e s t o r a t io n o f fu n c tio n
B y p r in c ip le o f b u o y a n c y , p a in is r e lie v e d a n d m u s c l e s r e la x
□ U sed a s :
t O C C U P A T IO N A L T H E R A P Y -
• P r im a r y t r e a t m e n t
> A c t iv it ie s o f d a ily liv in g
• In c o n ju g a t io n w ith o t h e r t r e a t m e n t
> W o r k r e l a t e d a c t iv it ie s
0 M e th o d s :
> L e is u r e tim e a c t iv it ie s
. IC E T H E R A P Y -
r u s e d d u r in g 1 s t 2 4 - 7 2 h o u r s o ( in ju ry
0. 7 : Elbow dislocation

V r e d u c e s p a in , h e m a t o m a , in fla m m a tio n ELBOW DISLOCATION

. HEAT T H E R A P Y -
□ Types :
> i n c r e a s e s b lo o d f lo w , t h e r e b y c a u s i n g r e lie f o f p a in
• P o s t e r io r ( c o m m o n e s t )
» u s e d fo r 1 5 - 2 0 m in s , 2 - 3 t im e s / d a y
• P o s t e r o - m e d ia l
> T yp es:
• P o s t e r o - la t e r a l
(1 ) S u rfa c e h e a t -
• D i v e r g e n t ( u ln a - m e d ia lly , r a d iu s - la te ra lly )
( a ) h o t w a t e r b o t t le
□ Associated fra c tu re s :
(b ) w a r m b a th
• F r a c t u r e m e d ia l e p ic o n d y le
(c ) w a x b a th
• F r a c t u r e h e a d o f r a d iu s
(2 ) D eep heat -
(a ) s h o r t w a v e d ia t h e r m y • F r a c t u r e c o r o n o id p r o c e s s o f u ln a

(b ) u lt r a s o n ic t h e r a p y 0 Symptoms ; F a ll o n o u t s t r e t c h e d h a n d w ith s lig h tly f le x e d e l b o w - > s e v e r e p a in a t e lb o w

(c ) m ic r o w a v e
 700 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 701

Q Clinical ex am in atio n : > Im m o b ilis a tio n a f t e r r e p a ir b lo o d v e s s e l s , n e r v e s , t e n d o n s

• 3 b o n y p o in t r e la t io n s h ip r e v e r s e d > T o m a k e m o u ld s u s e d fo r m a k in g b r a c e s
• R e d u c e d le n g t h o f fo r e a r m , n o rm a l le n g t h o f a rm
□ C om plications:
• T r i c e p s t e n d o n p r o m in e n t ( b o w s t r in g in g o f t r ic e p s )
• D is ta l n e u r o v a s c u la r c o m p r o m is e d u e t o tig h t p la s te r in g
• M e d ia n n e r v e p a l s y
• P r e s s u r e s o r e s o n s k in
□ D iag no sis: B y X - r a y □ Advice a fte r p la s te r :
□ Treatm ent: O p e n r e d u c t io n a n d in te rn a l fix a tio n -> a b o v e e l b o w s l a b fo r w e e k s • C o n s t a n t f in g e r t o e m o v e m e n t t o b e d o n e
□ C om plications: • T h e r e s h o u l d b e n o c o n t a c t w ith w a t e r
• M y o s itis o s s i f i c a n s • If f in g e r s / t o e s a p p e a r s w o lle n / b la c k is h / n u m b , it s h o u ld b e r e p o r t e d im m e d ia te ly
• E lb o w s t if f n e s s • R a n g e o f m o v e m e n t e x e r c i s e s o f a ll o t h e r jo in ts in th a t lim b , w h ic h a r e n o t w ith in t h e p la s t e r
[ F ig . 2 . 1 0 .4 ] a t l e a s t 2 - 3 t im e s d a ily

0. 8 : Plaster o f Paris bandage (POP) Q. 9 : P aget’s disease

P A G E T ’S D IS E A S E
PLASTER OF PARIS BANDAGE (POP)
□ What Is I t : C o m m e r c ia lly a v a i la b l e m a c h i n e - m a d e p la s t e r o f p a r i s im p r e g n a t e d b a n d a g e □ S y n o n y m : O s t e it is d e f o r m a n s

□ W idth: 3/4/6 in c h □ C haracterised b y : P r o g r e s s i v e t e n d e n c y o f b o n e s to b e n d , g e t t h ic k e n e d , b e c o m e s p o n g y

□ Chem ical fo rm u la ; C a S 0 4.1/2 H 20 ( h e m ih y d r a t e d s a l t o f C a S 0 4) □ C om m only a ffe c te d : T ib ia

□ Chem ical re a c tio n : E x o t h e r m ic r e a c t io n ( b e c o m e s h a r d in c o n t a c t w ith w a t e r ) □ C a u s e ; O s t e o c l a s t f u n c t io n a b n o r m a lity

□ Used a s : ' □ A g e: > 40 yea rs

□ P ath o lo g y: In itia lly s o f t , v a s c u l a r b o n e - » la t e r h a r d , d e n s e -
FORM S ADVANTAGES D IS A D V A N T A G E S
□ Clinical fe a tu re s : D u ll p a in , b o w in g a n d t h ic k e n in g o f b o n e
C ast M a in ta in s r e d u c t io n E dem a □ In vestig a tio n s:
• X - R a y - M u ltip le c o n f lu e n t ly tic a r e a s , i n t e r s p e r s e d w ith n e w b o n e f o r m a tio n
S la b (6-8 la y e r s in u p p e r lim b , D o es not c a u s e ed em a D o e s n o t m a in ta in re d u c tio n
• B o n e s c a n - I n c r e a s e d u p ta k e
10-12 la y e r s in lo w e r lim b)
□ C o m p lications:
• P a t h o lo g ic a l f r a c t u r e
□ Factors affecting critical setting :
• M a lig n a n t c h a n g e s
• T e m p e ra tu re o f w a te r
□ T reatm ent:
• M a n u fa c t u r e r
• C a lc it o n in
• Im p u ritie s

• H u m id ity 0 . 1 0 : Tardy u lnar nerve p a lsy

□ Uses :
TAR D Y ULNAR NERVE P A LSY .
• O r t h o p a e d ic u s e s -
> T e m p o r a r y im m o b ilisa tio n
□ What Is I t : L a t e o n s e t u ln a r n e r v e p a l s y
> D e fin itiv e tr e a t m e n t o f f r a c t u r e s h a f t h u m e r u s , C o d e 's fr a c t u r e , G r e e n s t i c k fractu re,
□ C auses:
T y p e I, II s u p r a c o n d y la r f r a c t u r e
• D i s p la c e d m e d ia l e p ic o n d y le h u m e r u s
> P o s t - o p e r a t iv e a s a s la b
• M a lu n it e d la te r a l c o n d y le h u m e r u s
V D e fo r m ity c o r r e c tio n - C T E V
< E lb o w d is lo c a t io n
> B r o o m s t ic k p la s t e r - F o r c o n t a in m e n t in P e r t h e s d i s e a s e
• S h a l lo w u ln a r g r o o v e
> H ip - s p lc a
• C o n t u s io n s o f u ln a r n e r v e
> A s e x t e r n a l fix a to r - P in p la s t e r t e c h n iq u e in c a l c a n e u m f r a c t u r e , e t c .
• H y p o p la s ia o f h u m e r a l tr o c h le a
> F u n c t io n a l c a s t b r a c in g
□ Clinical fe a tu re s :
• N o n - o r t h o p a e d ic u s e s -

> Im m o b ilis a tio n a f t e r s k in g ra ft ■' • W e a k n e s s o f g rip

• T in g lin g n u m b n e s s o f little fin g e r

 GROUP - II D SOLVEO SHORT NOTES OF SEMESTERS
702 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology

p Clinical exam ination :

• C a r d l e s t p o s it iv e ( u ln a r n e r v e p a l s y w e a k n e s s o l p a lm a r in t e r o s s e i - » w e a k a d d u c tio n of
• P o s tu re -
little fin g e r)
■ > P a tie n t s t a n d s w ith rigid fla tte n e d lu m b a r s p i n e
• F r o m e n t 's s i g n p o s it iv e (u ln a r n e r v e p a l s y - » w e a k n e s s o f a d d u c t o r p o llic is -> fle x io n o f
> W h o le tru n k s h ill e d fo rw a rd o n hip
in t e r p h a la n g e a l jo in t w h ile g r a s p i n g a p a p e r b e t w e e n th u m b a n d r a d ia l b o r d e r o f hand)
> T r u n k tilte d t o o n e s id e
• F le x io n t e s t p o s it iv e
. M o v e m e n t - P a tie n t c a n n o t b e n d fo r w a r d
□ In v e s tig a tio n : N e r v e c o n d u c t io n t e s t
• T e n d e r n e s s in lu m b o s a c r a l r e g io n
□ T re a tm e n t:
i • S t r a ig h t L e g R a is i n g T e s t - P o s i t i v e a t 40 d e g r e e s
• C o n s e r v a t i v e - E lb o w e x t e n s i o n s p lin t s a t n ig h t
• L a s e g u e t e s t p o s it iv e
• O p e ra tiv e - R e m o v a l o f u ln a r n e r v e fr o m g r o o v e - » n e u r o ly s i s if n e c e s s a r y - » a n te rio r
• N e u r o l o g ic a l e x a m in a t io n
t r a n s p o s it io n t o f le x o r s u r f a c e o f e lb o w
0 Investigations:
Q. 1 1 : P rolapsed intervertebral disc
• X -r a y - T o ru le o u t in le c tio n

PROLAPSED INTERVERTEBRAL DISC . M y e lo g r a p h y -

> R o o t c u t o ff s ig n
□ D e fin e : P r o t r u s io n / e x t r u s io n o f n u c l e u s p u l p o s u s th r o u g h a re n t in a n n u lu s p u l p o s u s > B lo c k to f lo w o f d y e a t th a t le v e l ,
[ F ig . 2 .1 0 .5 ]
• CT
□ Sequence: « M RI
• N u c le u s d e g e n e r a t i o n « EM G
• N u c le u s d is p la c e m e n t 0 Trea tm e n t:
• S t a g e o f fib r o s is / h e a lin g ■ • C o n s e r v a tiv e -

* N u c le u s p u l p o s u s b u l g e s th r o u g h d e f e c t in a n n u lu s p u l p o s u s > R est
y A n a l g e s i c , m u s c le r e la x a n t
I
> P h y s io th e r a p y
N u c le u s p u l p o s u s c o m e s o u t o f a n n u lu s p u l p o s u s
> L u m b a r tr a c tio n
i .
; > T E N S ( T r a n s c u t a n e o u s e le c t r ic a l n e r v e s tim u la tio n )
N u c le u s p u l p o s u s li e s u n d e r p o s t e r io r lo n g itu d in a l lig a m e n t
• O p e ra tiv e -
( t h o u g h c o n t a c t w ith p a r e n t d i s c is n o t lo st)
> F e n e s t r a t io n
1
> L a m in o t o m y
D is c e x t r u s io n
> H e m i- la m in e c t o m y
I
> L a m in e c t o m y
C o n t a c t lo s t w ith p a r e n t d is c
• C h e m o n u c le o s is
i
• P e r c u t a n e o u s d is c e c t o m y
S e q u e s t e r e d d is c
i 0.1 2 : O s g o o d - S c h la t te r 's d is e a s e
[ F ig . 2 .1 0 .6 ]
OSGOOD - SCHLATTER’S DISEASE
□ S ite o f ex it o f nucleus p u lp o s u s : P o s t e r o la t e r a lly
□ L e v e l: I 4 - L 5 , C 5 - C g □ S yn o n y m : O s t e o c h o n d r it is
□ A sso ciated c h a n g e s : D D e fin e : E p ip h y s it is / a p o p h y s itis o f tib ial tu b e r c le
• S p in a l r o o t s c o m p r e s s e d [ F ig . 2.10.7]
• R e d u c e d h e ig h t o f d i s c - » a f f e c t s a r tic u la tio n o f p o s t e r io r f a c e t jo in t s D E tio lo g y : T r a c t io n in ju ry o f a p o p h y s i s o f tib ial t u b e r c l e in to w h ic h p a t e lla r t e n d o n is in s e r t e d
□ S y m p to m s :
□ S ym p to m s:
• A g e - 2 0 -4 0 y e a r s w ith s e d e n t a r y life s t y le
• A g e - A d o le s c e n ts
• Low back ach e
• P a in a f t e r ru n n in g , ju m p in g , c y c lin g , c lim b in g s t a ir s
• S c i a t i c p a in
D Clinical ex am in atio n :
• P in s a n d n e e d l e s e n s a t i o n c o r r e s p o n d i n g t o d e r m a t o m e a n d L M N p a l s y o f a f f e c t e d n e r v e
• T e n d e r lu m p o v e r tib ia l t u b e r c le
ro o t
• ' Active knee extension against resistance - Painful
 704 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I I D SOLVED SHORT NOTES OF SEMESTERS 70S

Q T re a tm e n t: • M e d ia l a n d la t e r a l m a lle o li o f a n k le
• R est • G r e a t e r t u b e r o s it y o f h u m e r u s
• Ice p a c k • G r e a t e r t r o c h a n t e r o f fe m u r

. N S A ID « L a t e r a l e n d o f c la v i c le
• A c tiv ity m o d ific a tio n □ P re -re q u isite:
□ Differential d ia g n o s is : J o h a n s s o n - L a r s e n d i s e a s e • S t r o n g b o n y s u r f a c e o n c o m p r e s s i o n s i d e ( e l s e fix a tio n fa ilu r e )
■ S t r o n g w ir e ( e l s e im p la n t fa ilu re )
Q. 1 3 : G out
• P re -s tre s s in g
GOUT , □ A d v an tag e s:
• D y n a m ic c o m p r e s s i o n o f f r a c tu r e s it e
□ What Is I t :
• M in im u m im p la n t m a te r ia l r e q u ire d
• I n h e r ite d d is o r d e r w h e r e d is t u r b e d p u r in e m e t a b o lis m l e a d s to e x c e s s i v e a c c u m u la tio n ol
u r ic a c i d in b lo o d • M in im u m p o s t - o p e r a t iv e im m o b ilisa tio n

• Im p a ir e d e x c r e t io n o f u r ic a c i d b y k id n e y s d u e t o d r u g s lik e t h ia z i d e , f u r o s e m id e , e t c . • Low cost

In a c c u m u la t io n o f s o d iu m b iu r a t e c r y s t a l s In s o f t t i s s u e s lik e c a r t i l a g e , t e n d o n s , a n d bursa □ C o m p licatio n s:

□ A g e : > 40 y e a r s 1 • S k in irritation

• W ir e m a y b r e a k
□ Clinical fe a tu re s :
• A r th r itis - S u d d e n o n s e t p a in g e n e r a l l y o c c u r r in g fir s t in m e t a t a r s o - p h a l a n g e a l jo in t o f big • 2n d o p e r a t io n r e q u ir e d fo r im p la n t r e m o v a l

to e
j Q. 1 5 : Genu valgum an d genu varum
• B u r s it is - M a in ly a f f e c t s o l e c r a n o n b u r s a
• T o p h i fo r m a tio n in s o f t t is s u e GENU VALGUM AND GENU VARUM
□ In vestig a tio n s:
FEATURES GENU VALGUM GENU VARUM
• R a i s e d s e r u m u r ic a c i d
• U r a te c r y s t a l s in a s p ir a t e fr o m jo in t/ b u rs a Synonym K nock k n e e B o w le g s
□ Trea tm e n t:
W hatisit K n e e s a b n o r m a lly a p p r o x im a t e d , A n k l e s a b n o r m a ll y a p p r o x im a t e d ,
• A cu te c a s e s -
a n k l e s a b n o r m a lly d iv e r g e n t k n e e s a b n o r m a lly d iv e r g e n t
> N S A ID
Causes 1) P o s t-tr a u m a tic 1) P o s t- t r a u m a tic
> C o lc h i c in e
2) P o s t-in fla m m a to r y 2) P o s t- in fla m m a t o r y
> S t e r o id in je c tio n
3) N e o p la s tic 3) N e o p la s t ic
• C h r o n ic c a s e s -
4) B o n e s o f t e n in g - r ic k e ts , 4) B o n e s o f t e n in g - r ic k e ts ,
y U r ic o s u r ic d r u g s - P r o b e n a c id , S u lp h in p y r a 2o n e
o s t e o m a la c i a , e t c . o s t e o m a la c i a , e t c .
> S y n t h e s i s in h ib ito r - A llo p u rin o l
5 ) J o in t s tr e tc h in g 5 ) J o in t s t r e t c h in g
Q . 1 4 : Tension B and W iring (T B W ) .
Pathogenesis U n e q u a l g r o w t h fr o m 2 s i d e s o f U n e q u a l g r o w t h fr o m m e d ia l s id e o f
TENSION BAND WIRING (TBW) g r o w th p la te g r o w t h p la t e

□ D e fin e : W ir e u s e d f o r in te r n a l f r a c t u r e a n d w ir e a p p lie d o n t e n s io n s u r f a c e o f b o n e Clinical features 1) A g e - a p p e a rs at 2 -3 yea rs 1) A g e - a p p e a r s a t 2 -3 y e a r s

□ P rin c ip le : 2) A b n o r m a l a p p r o x im a tio n o f 2) A b n o rm a l a p p r o x im a tio n of

• C e n t r a l ly l o a d e d f r a c t u r e d b o n e - » u n ifo rm c o m p r e s s i o n a t f r a c t u r e s it e k n e e s a n d d iv e r g e n c e o f a n k le s a n k le s a n d d iv e r g e n c e o f k n e e s

• E c c e n t r ic a ll y l o a d e d f r a c t u r e d b o n e - » d is tr a c tio n o n t e n s ile s u r f a c e 3) D e g r e e o f d e fo r m ity e s t im a t e d 3) D e g r e e o f d e fo rm ity e s t im a t e d b y

b y m e a s u r in g in t e r m a lle o la r m e a s u r in g d is t a n c e b e t w e e n tw o
• If t e n s ile s u r f a c e k e p t f ix e d -> e c c e n t r i c f o r c e c a n n o t o p e n u p f r a c t u r e d is tr a c tin g tensile
d is t a n c e w ith k n e e s in c o n t a c t k n e e s , a n k le s h e ld to g e th e r
f o r c e c h a n g e d t o c o m p r e s s i v e fo r c e
in s u p in e p o s itio n (> 8 cm )
□ U ses:
4) F ia t f o o t m a y b e p r e s e n t
In fix in g fo llo w in g f r a c t u r e s -
5) A s s o c ia te d fe a tu r e s of
• P a te ll a
u n d e r ly in g d i s e a s e
• O le c r a n o n

S3
 GROUP - I I D SOLVEO SHORT NOTES OF SEMESTERS 707
706 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

• O v e r u s e s y n d r o m e ( s u s t a in e d u ln a r d e v ia tio n o l w ris t m ic r o lr a u m a -> p a in fu l th ic k e n in g o f

FEATURES GENU VALGUM GENU VARUM te n d o n sh e a th )

• S u b c lin ic a l c o l l a g e n d i s e a s e
Treatment 1) S p o n t a n e o u s r e c o v e r y In m o s t 1) S p o n t a n e o u s r e c o v e r y in m ost
id io p a th ic c a s e s I d io p a th ic c a s e s q A g e : 3 0 -5 0 y e a r s , F > M

2) M e d ia l s h o e r a i s e
0 Sym ptom s:
2) M e d ia l s h o e r a i s e w ith o u te r raise
• P a in in a n a t o m ic a l s n u f f b o x , w h ic h i n c r e a s e s w h ile w r in g in g c lo t h e s , liftin g g l a s s o f w a te r
3) If > 10 cm in te r m a lle o la r 3) If d e f o r m i t y p e r s i s t s b e y o n d • P in c h g r ip is v e r y p a in fu l
d i s t a n c e b y 4 y e a r s o f a g e -» c h i l d h o o d , s u r g i c a l c o r r e c tio n
S u p r a c o n d y la r C l o s e d W e d g e 0 Clinical ex a m in a tio n :
r e q u ir e d
O ste o to m y • T e n d e r a n d t h ic k e n e d te n d o n s h e a t h o v e r ra d ia l s ty lo id p r o c e s s
• W ith th u m b f le x e d a n d a d d u c t e d , a t t e m p t e d e x t e n s i o n a n d a b d u c tio n a g a i n s t r e s is t a n c e is

p ain fu l
[ F ig . 2 .1 0 .8 ]
• F in k e ls te in t e s t [ F ig . 2 . 1 0 . 1 0 ]

Q Investigations:
Q. 1 6 : Fracture healing
. USG
FRACTURE HEALING • MRI

□ Treatm ent:
S ta g e of D u r a tio n F e a tu r e s
• P h y s ic a l t h e r a p y

1) H e m a t o m a fo r m a tio n B o n e f r a c tu r e - » b lo o d o o z e o u t - » h e m a to m a -» • T r ia m c in o lo n e in je c tio n
U p to 7 d a y s
p e r io s t e u m s t r ip p e d o ff -> f r a c t u r e e n d n e c r o s is -> • O p e ra tiv e r e le a s e o f te n d o n s h e a th
s e n s it i z a t io n o f p r e c u r s o r c e l l s

2) G r a n u la tio n t i s s u e 2 -3 w e e k s P r e c u r s o r c e l l s p r o life r a t e a n d d if f e r e n t ia t e t o form

Q .1 8 : Osteoarthritis
fo rm a tio n f ib r o b la s t s , o s t e o b l a s t s , v e s s e l s - » d o t g i v e s rise O S T E O A R T H R IT IS

t o l o o s e f ib r o u s m e s h , w h ic h is u ltim a te ly re m o v e d
by m a c r o p h a g e , g i a n t c e l l s - » s o f t g ra n u la tio n □ D e fin e : D e g e n e r a t i v e jo in t d i s e a s e p rim a rily a f f e c t in g a r t ic u la r c a r t i la g e
t i s s u e f o r m e d in b e t w e e n f r a g m e n t s □ A etiolo gy:

3) C a l lu s fo rm a tio n • P r im a r y (id io p a th ic )
4 -12 w eek s G r a n u la t io n t i s s u e c r e a t e s o s t e o b l a s t s - * o s t e o ­
b la s t s la y d o w n I n te r c e llu la r m a trix , w h ic h g e t s im­ • S eco n d ary .

p r e g n a t e d w ith c a lc iu m - * c a l l u s ( w o v e n b o n e ) for­ > A v a s c u l a r n e c r o s is

m a tio n > DDH

> M a lu n ite d fr a c tu r e
4) R e m o d e llin g 1-2 yea rs W o v e n b o n e r e p l a c e d b y m a t u r e b o n e i .e ., la m el­
> C o x a vara
la r b o n e fo r m a tio n b y m u ltic e llu la r u n it b a s e d re­
m o d e llin g o f c a l lu s □ P ath olo gy:
5) M o d e llin g H ig h w a t e r c o n t e n t + P r o t e o g ly c a n d e p le t io n - fro m c a r t i la g e m atrix
M any yea rs B o n e g r a d u a l ly s t r e n g t h e n e d a n d s h a r p e n in g of
c o r t i c e s o c c u r a t e n d o s t e a l a n d p e r io s t e a l s u r fa c e s I
R e p e a t e d w e ig h t b e a r i n g -> fib rillatio n o f a r tic u la r c a r t i la g e
[ F i g . 2 .1 0 .9 ]

Q. 1 7 : D e-Q uervan’s disease C a r t il a g e a b r a d e d

I
DE-QUERVAN’S DISEASE B o n e exp o sed
I
□ S y n o n y m : D e - Q u a r v a n ’s t e n o s y n o v it is
S u b c h o n d r a l b o n e b e c o m e s e b u r n a t e d + B o n e a t m a r g in s fo rm o s t e o p h y t e s
□ W hat Is I t : S t e n o s i n g t e n o v a g in it is o f A b d u c t o r p o llic is lo n g u s a n d E x t e n s o r p o llic is b r e v i s
i
□ P ath oan ato m y: L o o s e f la k e s o f c a r t i la g e in c it e in fla m m a tio n
• S t e n o s i s a l a p o in t w h e r e t e n d o n 's d ir e c tio n c h a n g e s b e c a u s e f ib r o u s s h e a t h a c t s a s a p ulley
c a u s i n g m a x im u m
 708 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 709

I
C a p s u l e t h ic k e n e d j 0. 1 9 : Septic arthritis
I
S E P T IC A R T H R IT IS
S t if f n e s s , d e fo rm ity o f jo in t j

□ A g e : E ld e rly i 0 D e fin e : A rth ritis c a u s e d b y p y o g e n i c o r g a n is m s

□ Com monly a ffe c te d : H ip jo in t, k n e e join t 0 S yn o n y m s:
□ Sym pto m s: • P y o g e n i c arth ritis
• P a in - in itially in te rm itte n t o n s ta rtin g a c tiv ity , la t e r s e v e r e c r a m p y a f t e r a c tiv ity )
• I n fe c tiv e a rth ritis
• S w e ll in g
• S u p p u r a t i v e arth ritis
• S t if fn e s s
□ A g e : C h ild r e n , M > F
• F e e l in g o f in s ta b ility a n d lo c k in g
□ Causative a g e n ts : S t a p h y l o c o c c u s , S t r e p t o c o c c u s , P n e u m o c o c c u s , G o n o c o c c u s
□ Clinical exam ination :
□ S p re a d :
• J o in t lin e t e n d e r n e s s

• C r e p it u s • H a e m a to g e n o u s (c o m m o n e st)

• Irre g u la r, e n l a r g e d lo o k in g jo in t - D u e t o fo rm a tio n o f p e r ip h e r a l o s t e o p h y t e s • S e c o n d a r y t o n e a r b y o s t e o m y e lit is

• D e fo r m itie s - g e n u v a r u s ; fle x io n , a d d u c t io n a n d e x t e r n a l r o ta tio n o f h ip • P e n e t r a t in g w o u n d s

• E ffu s io n • U m b ilic a l c o r d s e p s i s
• S u b lu x a t io n • L a tr o g e n lc
• W a s t in g o f q u a d r i c e p s fe m o r is
0 P ath og enesis:
□ Investigations:
In fe c tio n -+ in fla m m a tio n in s y n o v iu m - » flu id e x u d a t io n in jo in t a n d jo in t c a r t i la g e d e s t r u c t io n
• X -ra y -
□ Joint In v o lv e d : C o m m o n ly k n e e jo in t
> N a r r o w jo in t s p a c e
j □ C linical fe a tu re s :
> S u b c h o n d ra l s c le r o s is
« H ig h g r a d e f e v e r , m a l a is e , e t c .
> S u b ch o n d ra l c y s ts

> O ste o p h y te • S e v e r e t h r o b b in g p a in in a f f e c t e d jo in t w h ic h b e c o m e s s w o ll e n , r e d d e n e d

> J o in t d e fo r m ity • P a in fu l lim p

« E S R , S e r o l o g y t o r u le o u t R h e u m a t o id arth ritis i □ Investigations:

• S e r u m u ric a c i d le v e l t o r u le o u t g o u t • X -r a y - I n c r e a s e d jo in t s p a c e
□ Trea tm e n t: • U S G - C o ll e c t io n in jo in t
• A n a lg e s ic s • B lo o d - R a i s e d T L C , E S R
• C h o n d r o p r o t e c t iv e a g e n t s
> • B lo o d c u lt u r e
• V i s c o s u p p le m e n t a t io n
• J o in t a s p ir a t e c u lt u r e
• S u p p o r t iv e m e a s u r e s -
Q Trea tm e n t:
> R e d u c t io n o f w e ig h t
« B r o a d s p e c t r u m a n tib io tic s
> N o s tre ss
• J o in t p u t t o r e s t in sp lin t/ tractio n
> L o c a l h e a t a p p lic a t io n
• P u s a s p ir a t e d - » jo in t w a s h e d - » s u c t io n d r a in p u t
> E x e r c is e

> A p p lic a t io n o f c o u n te r-irrita n ts • L a t e c a s e s - » a rth r o to m y

• O p e ra tiv e m e a s u r e s — Q C om plications:

> O ste o to m y • D e fo rm ity

> J o in t r e p l a c e m e n t • S t if fn e s s

> J o in t d e b r id e m e n t • P a t h o lo g ic a l d is lo c a t io n
> A r t h r o s c o p ic p r o c e d u r e s • ,i O s t e o a r t h r it is ..
 GROUP - I I D SOLVED SHORT NOTES OF SEMESTERS. 711
710 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology

□ T reatm ent:
0 . 2 0 : Classification o f fractures
C l o s e d r e d u c tio n a n d p e r c u t a n e o u s K -w ire fix a tio n - » If n o t p o s s i b l e , o p e n r e d u c t io n a n d in tern a l
fix a tio n ( p la s t e r c a s t n o t a d v i s e d a s m a y le a d to in c o n g r u ity )

□ C om plication:
C L A S S IF IC A T IO N O F F R A C T U R E S
M al-u n io n - » p a in fu l o s t e o a r t h r it is - » p e r s is t e n t p a in a n d l o s s o f g rip

X 0 . 2 2 : Traumatic paraplegia

E
X
B a s e d on B a s e d on B a s e d on B a s e d on B a s e d on B a s e d on
T R A U M A T IC P A R A P L E G IA
a e tio lo g y d is p la c e m e n t relation ship c o m p le x ity q uan tum o f p attern
with extern al fo r c e c a u s in g
en v iro n m en t f ra c tu r e
□ C a u s e : S p in a l Injury, c o m m o n e s t b e in g fr a c t u r e - d is lo c a tio n o f d o r s o - lu m b a r s p i n e
Sim ple
-T ra n sv e rse □ Pathology :
- T ra u m a tic - U n d isp la ced (# in 2
C lo s e d p ie c e s ) H igh • C o rd c o m p re s s io n
(d o e s not v e lo c ity - O bliq ue • C ord
- D isp a c e d co m m u n i­
P a th o lo gical C o m p le x • Root
c a t e with
(# th rou gh a (# in m ulti­
o v erlyin g Low - Spiral • I n c o m p le t e le s io n -
b one m ade p le p ie c e s )
skin ) v e lo c ity > C e n t r a l c o r d le s io n
w eak by
som e > A n te r io r c o r d le s io n
- Comminuted
un derlying O pen
(b reak in
> P o s t e r io r c o r d le s io n
d is e a s e )
o v erlyin g > C o r d h e m is e c t io n
Segmentai
skin )
□ Neurological d eficit a t different levels ;

• Cervical spine ->

( F ig . 2 . 1 0 . 1 1 ] > A b o v e C s - p a r a ly s is o f re s p ir a to r y m u s c le s

0 . 2 1 : Benett's dislocation » At C 5- p a r a l y s i s o f m u s c le s o f u p p e r lim b , lo w e r lim b , t h o r a x , a b d o m e n + s e n s o r y

lo s s + v i s c e r a l fu n c tio n lo s s
BENETT’S DISLOCATION > B e lo w C 5- d e f o r m itie s d e p e n d in g u p o n le v e l

□ W hat Is I t : O b l iq u e in t r a - a r lic u la r fr a c t u r e o f b a s e o f first m e t a c a r p a l w ith s u b lu x a tio n / d is lo c a tio n of • Thoracic spine ->

m e ta ca rp a l > T1- T 9- tru n k a n d lo w e r lim b m u s c le s p a r a ly s is

□ S p ec iality: T h is in t r a - a r t ic u la r f r a c t u r e is t h e m o s t c o m m o n t y p e o f f r a c t u r e o f t h e th u m b > T 10 - lo w e r lim b m u s c le p a r a ly s is

• D o r s o - lu m b a r s p i n e ( D u - L i) -> U M N /LM N p a l s y o f lim b s

□ N am ed a f te r : E d w a r d H a ila r a n B e n n e t t
« B e lo w L i - » fla c c id p a r a ly s i s a n d s e n s o r y lo s s a u t o n o m ic l o s s in d is trib u tio n o f a f f e c t e d a r e a s
□ B lo m ec h an lcs:
□ In vestig a tio n s:
M e t a c a r p a l s h a f t -> p u lle d b y a b d u c t o r p o llic is lo n g u s -> p u lle d p r o x im a lly a n d la t e r a lly

D is ta l m e t a c a r p a l -> p u lle d b y a d d u c t o r p o llic is -> a d d u c t e d a n d s u p in a t e d • N e u r o lo g ic a l e x a m in a t io n

• CT
□ Com plicating fa c to rs :
. MRI
• T e n s i o n fr o m t h e A b d u c t o r P o llic is L o n g u s m u s c le ( A P L ) s u b l u x a t e s t h e f r a g m e n t in a d o rsal,
• X -ra y
r a d ia l, a n d p r o x im a l d ir e c tio n

• T e n s i o n fr o m t h e A P L r o t a t e s t h e fr a g m e n t in to s u p in a t io n □ Trea tm e n t:

• T e n s i o n fr o m t h e A d d u c t o r P o llic is m u s c le ( A D P ) d i s p l a c e s t h e m e t a c a r p a l h e a d in to t h e palm P h a se I - E m ergen cy c a re •

P h a s e II - D e fin itiv e c a r e -
□ C linical fe a tu re s :
• C lin ic a l a s s e s s m e n t
• I n s ta b ility o f t h e C M C jo in t o f t h e th u m b
« I n v e s t ig a t io n s
• P a in a n d w e a k n e s s o f t h e p in c h g r a s p
• W ard c a r e -
• P a in , s w e ll in g , a n d e c c h y m o s i s a r o u n d t h e b a s e o f t h e th u m b a n d th e n a r e m in e n c e , and
> K e p i w ith p illo w o n h a r d b e d w ith m a ttr e s s
e s p e c i a l l y o v e r t h e C M C jo in t o f t h e th u m b
> C a r e o f b a ck - p reven t p re ssu re so res
• A w e a k e n e d a b ility t o g r a s p o b je c t s o r p e rfo rm s u c h t a s k s a s ly in g s h o e s a n d te a r in g a p ie c e
of p ap er.
 712 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 4 Anesthesiology GROUP - I I D SOLVED SHORT NOTES OF SEMESTERS 713

> P e r s o n a l h y g ie n e j □ R is k : ,

> B la d d e r a n d b o w e l c a r e • P re m a tu rity

• T r e a t m e n t o f f r a c iu r e • U m b ilic a l v e in c a t h e t e r is a t io n

P h a s e III - R e h a b ilit a t io n - p h y s ic a l p s y c h o lo g ic a l , s o c i a l • F e m o r a l v e in p u n c tu r e

Q S ym pto m s: -
Q. 2 3 : Intram edullary nail
• P a in le s s lim p
IN T R A M E D U L L A R Y N A IL
• A c u t e o n s e t w ith r a p id a b s c e s s fo rm a tio n

□ Made b y : K u n ts c h e r .□ S ig n s:
□ P a r ts : • U n s t a b le g a it

• 2 b lu n t e n d s - R e d u c e s c h a n c e s o f c o r t ic a l b r e a k w h ile in s e r tio n • A f fe c t e d lim b s h o r t e r

• C l o v e r l e a f c r o s s - s e c t i o n - P r e v e n t s ro ta tio n w ith in in tr a m e d u lla r y c a v it y • H ip m o v e m e n t s i n c r e a s e d in a ll d ir e c tio n s

• S lo t / g a p s - • T e l e s c o p y t e s t p o s it iv e

V A llo w b e n d in g o n t e n s ile s u r f a c e □ In vestigation s:

V R e d u c e t h e d ia m e t e r • X -r a y - C o m p le t e a b s e n c e o f h e a d a n d n e c k o f f e m u r a n d i n c r e a s e d jo in t s p a c e

> B e a m e f f e c t ( i n c r e a s e t h e s tre n g th ) □ Treatm ent:

• 2 e y e s / f e n e s t r a t io n s a t e n d s - h e lp s in e a s y e x t r a c t io n o f n a il • J o in t a s p ir a tio n
It is h o llo w w h ic h - . • U r g e n t d e c o m p r e s s i o n a rth r o to m y a n d a n tib io tic s
• A llo w s b o n e m a r r o w c o n tin u ity .
Q. 2 5 : Fracture head o f radius
• P r e s e r v e s b o n e n utrition

• A llo w s g u i d e w ir e p a s s a g e F R A C T U R E H E A D O F R A D IU S
!
□ U s e : F ix a tio n o f t r a n s v e r s e d i a p h y s e a l fr a c tu r e o f s h a f t o f fe m u r
i □ C au se:
□ P rin c ip le : T h r e e p o in t fix a tio n
• F a ll o n o u t s t r e t c h e d h a n d
□ Determ ination o l len gth o f n a il:
j • A s s o c i a t e d w ith M o n t e g g i a fr a c t u r e
W ith k n e e e x t e n d e d ,
: Q A g e : A d u lts
D i s t a n c e b e t w e e n tip o f g r e a t e r t r o c h a n t e r t o la te ra l jo in t lin e in c m - 2 c m
□ Types :
OR
• U n d is p la c e d
D i s t a n c e b e t w e e n tip o f g r e a t e r tr o c h a n t e r to u p p e r b o r d e r o f p a t e lla + 2 c m
• F r a g m e n t < 1 /3rd
□ Methods o f In s e rtio n : .
• F r a g m e n t > 1/ 3 rd
• A n t e g r a d e n a ilin g
• C o m m in u t e d
• R e t r o g r a d e n a ilin g
( F ig . 2 . 1 0 . 1 2 ] ­
□ D isadvantage: N o r o ta tio n a l s ta b ility
' □ S ym pto m s: M ild p a in , s w e llin g o v e r la te r a l a s p e c t o f e lb o w
□ Com plications:
• S t u c k n a il □ S ig n s :
I• L o c a l is e d t e n d e r n e s s o v e r h e a d o f ra d iu s
• S p lin te r in g o f c o r t e x
• P a in fu l fo r e a r m ro ta tio n
• M ig ra tio n o f n ail

□ Position o f n a il p o st-op eratively : S lo t f a c e s a n t e r o - la t e r a lly ( t e n s ile s u r f a c e ) , e y e f a c e s p o s t e r o ­ I □ In vestigation s ; X -r a y

m e d ia lly ( c o m p r e s s i v e s u r f a c e ) □ C om plications:
• J o in t s t if f n e s s
0 . 2 4 : Tom - Smith arthritis • D R U J (D is ta l R a d io - U ln a r J o in t) in s ta b ility
T O M - S M IT H A R T H R IT IS • O s t e o a r t h r it is

□ Treatm ent:
□ W hat Is I t ; A c u t e s e p t i c a rth r itis o f h ip s e e n in in fa n ts
• U n d i s p la c e d f r a c t u r e -> C o lla r a n d c u f f s lin g + a n a l g e s i c
O A e tio lo g y :
• M a r g in a l f r a c t u r e w ith d is p la c e m e n t -> in lra -a rtic u la r lid o c a in e in je c t io n -> ran g e of m ovem ent
• U m b ilic a l/ s k in s e p s i s
•’ n o t e d - » if fu ll, t r e a t e d a s u n d is p la c e d fr a c tu r e a n d if r e d u c e d , t h e n o p e n r e d u c tio n w ith in tern a l
• O s t e o m y e l it is o f m e t a p h y s is / e p ip h y s is
fix a tio n
 714 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II 0 SOLVED SHORT NOTES OF SEMESTERS 715

• C o m m in u t e d f r a c t u r e -» E x c is io n o f r a d ia l h e a d fo llo w e d b y m e t a l p r o s t h e s i s
• Operative -
• If a s s o c i a t e d e l b o w d is lo c a t io n , th e n it is first r e d u c e d a n d t h e n f r a c t u r e t r e a t e d
> N e r v e s u tu r in g / n e r v e g ra ft
0 . 2 6 : W rist drop > T e n d o n tra n s fe r

W R IS T D R O P 0 . 2 7 : Cock-up s p lin t

U W hat Is I t : D e fo rm ity o f h a n d c h a r a c t e r is e d b y p a lm a r fle x io n o f w r is t a l o n g w ith fle x io n o f fin g e r s at C O C K -U P S P L IN T

m e t a c a r p o p h a l a n g e a l jo in t
□ T y p es:
□ C auses:
• S h o r t - H o ld s w r is t in e x t e n s i o n , d is t a l m a r g in e n d s b e lo w f in g e r s
• R a d ia l n e r v e in ju ry a t a n y le v e l
« L o n g - H o ld s w r is t a n d fin g e r s in e x t e n s i o n , d is t a l m a r g in till tip o f f in g e r s
• L e a d p o is o n in g ( in v o l v e s ra d ia l n e r v e e x c e p t n e r v e t o b r a c h io r a d ia lis )
• D y n a m ic - U s e d in c a s e s w h e r e f in g e r s c a n b e a c t i v e l y f le x e d , p r e v e n t s s t if fn e s s
□ P athological a n a to m y :
□ Indications:
R a d ia l n e r v e s u p p l ie s t h e e x t e n s o r s o f t h e w ris t - E x t e n s o r c a r p i r a d ia lis lo n g u s , E x t e n s o r c a r p i rad ialis
b r e v i s , E x t e n s o r c a r p i u ln a r is . W h e n r a d ia l n e r v e in ju ry o c c u r s , t h e w r is t c a n n o t b e e x t e n d e d a c t iv e ly • W rist d r o p

a n d g e t s f l e x e d b y t h e u n o p p o s e d a c t io n o f F le x o r c a r p i r a d ia lis a n d F le x o r c a r p i u ln a r is . • A ft e r e x t e n s o r t e n d o n s u r g e r y o f u p p e r lim b

R a d ia l n e r v e ( p o s t e r io r in t e r o s s e o u s b r a n c h ) a l s o s u p p l ie s t h e e x t e n s o r s o f t h e f in g e r s - E x te n s o r • V o lk m a n n ’ s i s c h a e m i c c o n t r a c t u r e
in d ic is , E x t e n s o r d ig ito ru m , E x t e n s o r d igiti m in im i, E x t e n s o r pollicJs lo n g u s . W h e n t h e n e r v e is d a m a g e d ,
Q . 2 8 : Below knee am putation
a c t i v e e x t e n s i o n o f f in g e r s a t m e t a c a r p o p h a l a n g e a l jo in ts is n o t p o s s i b l e , a n d t h e f in g e r s a r e fle x e d
d u e to u n o p p o s e d a c t i o n o f t h e lo n g f le x o r t e n d o n s . BELOW K N E E A M P U T A T IO N
□ Effects o f radial nerve In ju ry a t various le v e ls :
□ S y n o n y m : B u r g e s s a m p u t a t io n ■ •
• A t e l b o w (lo w l e s i o n ) -
□ A m p utatio n : R e m o v a l o f p a r t o f lim b in b e t w e e n 2 jo in ts
C a n n o t a c t i v e l y e x t e n d th u m b , f in g e r s a t m e t a c a r p o p h a l a n g e a l jo in t a n d w ris t
• A t a r m (h ig h le s io n ) - □ Below knee a m p u ta tio n : A m p u ta tio n fro m b e lo w th e le v e l o f k n e e

In a d d itio n t o f e a t u r e s o f lo w le s io n O S p eciality ; C o m m o n e s t a m p u ta tio n d o n e

> B r a c h io r a d ia lis a n d s u p in a t o r p o w e r lo s t O T y p e : A m p u ta tio n u s i n g fla p

> A u t o n o m o u s z o n e s e n s a t io n lo s t ( i.e . o v e r a n a t o m ic a l s n u f f b o x ) □ V arieties:
» A t a x illa ( v e r y h ig h le s io n ) - • C lo s e d

> In a d d it io n t o f e a t u r e s o f h ig h le s io n ' • O p e n (G u illo tin e )

> T r ic e p s p a r a ly s e d □ L e v e l:

□ Causes o f rad ia l nerve p a ls y a t various le v e ls : • N o n - is c h a e m ic lim b - M u s c u lo - c u t a n e o u s ju n c lio n o f g a s t r o c n e m i u s

• In t h e e l b o w - • I s c h a e m ic lim b - T r a n s c u t a n e o u s o x y g e n m e a s u r e m e n t to a s s e s s t h e v a s c u la r it y

D is lo c a t io n o r f r a c t u r e n e c k o f ra d iu s
□ Ideal s tu m p :

• In t h e r a d ia l g r o o v e - • 1 4 - 1 7 c m fr o m k n e e jo in t

> S a t u r d a y n ig h t p a l s y • H e a ls a d e q u a t e l y

• > P r o l o n g e d to u r n iq u e t a p p lic a t io n « A d e q u a t e le n g t h (8 c m m in im u m ) to b e a r p r o s t h e s i s

> F ra ctu re s h a ft o f h u m e ru s • R o u n d e d g e n t l e c o n t o u r w ith a d e q u a t e m u s c le p a d d in g

• In t h e a x illa - □ Flap:

> C ru tch p a ls y • I s c h a e m ic lim b -> lo n g p o s te r io r , s h o r t a n te r io r , e q u a l m e d ia l a n d la t e r a l f la p s

> F ra c tu re u p p e r e n d o f h u m eru s • N o n - is c h a e m ic lim b - » e q u a l a n te r io r a n d p o s t e r io r fla p s

□ Technique:
□ In vestig atio ns ; N e r v e c o n d u c t io n v e lo c it y
• T o u r n iq u e t u s e d fo r h a e m o s t a s i s in n o n - i s c h a e m ic lim b s
□ T re a tm e n t:
• O s t e o t o m y a t p r o p o s e d s it e
• Conservative -
• F ib u la d iv id e d h ig h e r th a n p r o p o s e d s it e o f c u t o f tib ia o r o f t e n r e m o v e d
> C o c k - u p s p lin t
• T ib ia l s t u m p b e v e l l e d a n te rio rly
v P h y s ic a l I h e r a p y
• N e r v e s d i s s e c t e d o u t - » p u lle d d is t a lly - * s h a r p ly c u t - » r e t r a c t s p r o x im a lly
If n o im p r o v e m e n t b y 9 m o n th s , o p e r a t iv e m e a s u r e s u s e d
■
’ • M u s c le s s u t u r e d a c r o s s b o n e e n d to p e r io s t e u m b y t e n d o n m y o d e s i s o r m y o p :u c.ty
 GROUP - II O SOLVED SHORT NOTES OF SEMESTERS 717
716 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

' □ P ro ced u re:

• L a r g e v e s s e l s d o u b ly lig a t e d fo r h a e m o s t a s i s
I . P a ti e n t lie s s u p in e w ith l e g s s tr a ig h t
• S u c t io n d r a i n a g e - D r a in r e m o v e d a ft e r 2 d a y s
;
□ Post-operative c a r e :
E x p o s u r e fro m b e lo w x ip h y s t e m u m t o k n e e s , k e e p in g g e n it a li a c o v e r e d
• R e g u la r d r e s s i n g
j I
• R e h a b ilit a t io n E x a m in e r s t a n d s o n t h e a f f e c t e d s i d e o f t h e p a tie n t
• P h y s io th e r a p y i
• C r u t c h f o r 3 m o n t h s , th e n s u c t io n s o c k e t p r o s t h e s i s p la c e d L u m b a r lo r d o s is is c o n f ir m e d v is u a lly b y s e e i n g lig h t p a s s i n g th r o u g h a g a p b e t w e e n t h e b e d a n d t h e
□ In dication s: - lu m b a r r e g io n

• P e r ip h e r a l v a s c u l a r d i s e a s e - g a n g r e n e in D i a b e t e s , T A O , e t c . I

• T r a u m a - C r u s h in ju ry H an d in s u n ia t e d b e t w e e n b e d a n d t h e lu m b a r r e g io n s u c h th a t e x a m in e r 's d o r s u m o f h a n d r e s t s o n t h e
bed
• N e o p la s m - O s t e o s a r c o m a
I I
• S e v e r e e l e p h a n t ia s is , M a d u r a fo o t
E x a m in e r g r a s p s t h e n o n - p a t h o lo g ic a l lo w e r lim b just b e lo w t h e k n e e and gradually h e l p s in Hexing
• F r o s t b ite
t h e h ip o f t h e n o n - p a t h o lo g ic a l s i d e o f th e p a t ie n t , till t h e p a t ie n t 's lu m b a r r e g io n t o u c h e s t h e
• Bum
e x a m in e r 's p a lm o f t h e h a n d r e s tin g o n t h e b e d
• G a s gan gren e
? A
• C o n g e n ita l a n o m a lie s E x a m in e r b r in g s o u t t h e h a n d r e s tin g o n t h e b e d a n d t h e p a t ie n t ’s h ip o f t h e o t h e r s id e is f le x e d to
□ A d v a n ta g e s : ; s o m e m o r e d e g r e e s t o c o m p le t e ly o b lit e r a t e t h e lu m b a r lo r d o s is , till t h e p a t ie n t 's b a c k t o u c h e s th e
b e d ( e x c e s s fle x io n w ill c a u s e a n te r io r tilting o f p e lv is )
• B e t t e r p r o s t h e s i s p la c e m e n t
-I '
• G r e a T e r r a n g e o f m o v e m e n t w ith o u t lim p a n d w ith o u t s u p p o r t
A s th is h a p p e n s , t h e a f f e c t e d hip w ill a u t o m a t ic a lly c o m e t o lie in t h e d e f o r m e d i.e . f le x e d p o s itio n
□ C om plications :
I
« EARLY - G e n t le d o w n w a r d p r e s s u r e is a p p l ie d o n t h e th ig h o f (h e n o n - p a t h o lo g ic a l s i d e t o p r e v e n t a n y e x t r a hip
> In fe c tio n fle x io n due to spasm
» H em o rrh a ge
‘ 0 In terpretation: A n g le f o r m e d b e t w e e n lo n g itu d in a l a x i s o f h ip a n d b e d is ( h e f ix e d fle x io n d e fo rm ity
> H e m a to m a o f h ip
> N e c r o sis [ F ig . 2 . 1 0 . 1 3 }
• LATE­
□ Fallacies :
> P a in
D ifficu lt t o b e p e r f o r m e d in fo llo w in g c o n d i t io n s -
> P a in fu l s c a r
• O b e s e p a t ie n t s a s lo r d o s is c a n n o t b e a p p r e c i a t e d p r o p e r ly
> F la p n e c r o s i s *
• B o t h h ip s a f f e c t e d
> S tu m p u lc e r a t io n
• I p s ila te r a l k n e e s t if fn e s s / a n k y lo s is
> R in g s e q u e s t r a t io n fo rm a tio n
• F e m a l e e ld e r l y p a tie n t a s e x p o s u r e r e q u ir e d
> P h a n t o m lim b pain
Q Alternative t e s t :
> R e s i d u a l lim b p a in
P a tie n t p r o n e o n b e d w ith l e g s h a n g i n g - » in itially lu m b a r s p i n e is s tr a ig h t i.e . n o lo r d o s is , w ith o b v io u s
> J o in t c o n t r a c t u r e s
fle x io n d e fo r m ity (if a n y ) - » lu m b a r s p i n e s t a b ilis e d b y e x a m in e r 's p a lm - » h ip g e n t l y e x t e n d e d till
0 . 2 9 : Thomas test lo r d o s is b e c o m e s v is i b le - » a n g l e b e l w e e n th ig h a n d b o d y d e n o t e s t h e f ix e d fle x io n d e fo rm ity

TH OM AS TEST 0 . 3 0 : P erthes disease

O P u rp o s e : E v a lu a t e d e g r e e o f fle x io n d e fo r m ity o f hip

PERTHES DISEASE
□ A im : T o r e m o v e c o m p e n s a t o r y lu m b a r lo r d o s is in o r d e r to m a k e t h e fle x io n d e f o r m it y p r o m in e n ! □ S yno nym s:
□ P re req u is ites: • L e g g - C a lv e - P e r t h e s d is e a s e

• A tt e n d a n t o f s a m e g e n d e r a s p a tie n t • O s t e o c h o n d r i t is d e f o r m a n s

• V e r b a ! c o n s e n t fro m p a t ie n t a fte r b e in g e x p la i n e d t h e p r o c e d u r e , • P s e u d o - c o x a lg i a

• H a rd , fla t t a b le • C o x a - ju v e n ilis
718 QUEST : A Comprehensive Guide lo UG Surgery. Orthopedics & Anesthesiology GROUP - I I D SOLVED SHORT NOTES OF SEMESTERS 719

□ W hat Is I t : A v a s c u la r n e c r o s i s o f fe m o r a l h e a d in a ch ild □ T reatm ent:

□ A g e : 4 -10 y e a rs • A c u t e c a s e s - S u r f a c e tra c tio n fo r 3 w e e k s + a n a l g e s i c s , a n tib io tic s

□ A etio lo g y: • L o n g s t a n d in g c a s e s -

D is r u p te d b lo o d s u p p l y fr o m r e t in a c u la r v e s s e l s d u e t o - 1. S u p e r v i s e d n e g l e c t in -

• S y n o v it is > C a te r a llT y p e I

• S e p t ic a rth r itis o f h ip jo in t > C a t e r a ll T y p e II in a g e < 6 years

• H a e m a r t h r o s is > C a t e r a ll T y p e III in a g e <6 yea rs

• H y p o f ib r ln o ly s is 2. C o n t a i n m e n t in -

• A n tith r o m b o tic f a c t o r d e f ic i e n c y > C a t e r a ll T y p e II in a g e > 6 years

• G a u c h e r’ s d is e a s e > C a t e r a ll T y p e III in a g e >6 yea rs

• C r e t in is m > C a t e r a ll T y p e IV

• R ic k e t t s ia l in fe c tio n
C A T E R A L L C L A S S IF IC A T IO N ( B a s e d o n X -ra y )
• C a i s s o n 's d i s e a s e

□ P ath oan ato m y: Type A ntero-posterlor view Lateral view

• S t a g e o f is c h a e m ia - .
B lo o d s u p p l y b lo c k e d - > is c h a e m ia Type I J o in t s p a c e in c r e a s e d S lig h t a n t e r io r e p i p h y s e a l in v o lv e m e n t

B u t a r t ic u la r c a r t i la g e g e t s n u tritio n fro m s y n o v ia l flu id -> r e m a in s v ia b le T y p e II D e n s it y o f h e a d in c r e a s e d < 50% in v o lv e m e n t o f e p i p h y s i s fro m

• S t a g e o f n e c r o s is - a n t e r io r t o m id d le

B o n e d e a t h o f c a p it a l fe m o r a l e p i p h y s e s T y p e III > 50% e p ip h y s is in v o lv e d , > 5 0 % in v o l v e m e n t w ith s m a ll p o s t e r io r

• S t a g e o f r e v a s c u l a r is a t io n a n d r e p a ir - h e a d - w it h in - h e a d s ig n v ia b le p a rt
N e w b o n e d e p o s it io n o n a v a s c u l a r t r a b e c u l a e
T y p e IV C o l l a p s e d f la tt e n e d h e a d A lm o s t c o m p le t e in v o lv e m e n t o f e p ip h y s is
C a lc i fi c a t io n o v e r n e c r o s e d m a rro w

• S t a g e o f r e m o d e llin g - C ontainm ent-

S l o w r e p a ir l e a d s to fo llo w in g c h a n g e s -
• C onservative:
> C h a n g e in s h a p e o f f e m o r a l h e a d - o v a l/ c o x a m a g n a / m u s h r o o m s h a p e d / fla t t e n e d
> B r o o m s t ic k p la s t e r
> N e c k - b ro a d , sh ort > S c o t t i s h R ite a b d u c t io n sp lin t
> F e m o r a l n e c k - s h a f t a n g l e - a n g l e b e c o m e s < 1 2 0 d e g r e e s (n o r m a l 1 3 5 d e g r e e s ) i.e.
• Surgical :
co x a vara
> F e m o r a l o s t e o t o m y (V a r u s s u b t r o c h a n t e r i c d e r o t a tio n o s t e o t o m y )
□ S ym p to m s:
> P e lv ic o ste o to m y
• P a i n l e s s lim p in g
Treatment based on ag e -
• P a in o c c u r s w ith a c t iv it y , is o f s u d d e n o n s e t a n d r e l ie v e d b y r e s t
Based on a g e :
□ Clinical e x a m in a tio n :
< 5 y e a r s : O b s e r v a t io n a n d N S A I D s
■ S h o rt sta tu re
5 -8 y e a r s : C o n c e n t r i c c o n t a i n m e n t : a b d u c t io n b r a c e o r o s t e o t o m y
• T r e n d e le n b u r g g a it
9 + y e a r s : O p e r a t i v e t r e a tm e n t o fte n fa ils ( m a n y n e e d T H A a s a d u lt)
• W a s t in g o f m u s c l e s
• T e n d e r n e s s a t a n t e r io r h ip p o in t □ Head a t risk signs :
• S p a s m o f a d d u cto r • Clinical -
• F ix e d fle x io n d e fo r m it y o f h ip > O b e s ity
. R e d u c e d a b d u c t io n - in - fle x io n a n d in te rn a l ro ta tio n -in -lle x io n o f h ip > E ld e r ly ( a g e > 1 0 y e a r s )
• T r e n d e le n b u r g t e s t p o s it iv e > F ix e d f le x io n + a d d u c t io n d e fo r m ity o f hip
□ In vestig a tio n s: ■ > P r o g r e s s i v e d e c r e a s e o f hip m o v e m e n t s

• X -r a y ( b o th A P a n d l a t e r a l v ie w ) • X-Ray features -
. M RI > G a g e s ig n in A - P v ie w ( V - s h a p e d p o r o tic a r e a in la t e r a l p h y s is )
. USG V L a t e r a l s u b lu x a tio r , o f h e a d
• B one scan > H o r iz o n ta l g r o w th p la te
 720 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 721

> C a lc ific a t io n la t e r a l t o e p ip h y s is
(A ll t h e s e a l o n g w ith n o w e ig h t b e a r i n g fo r 1 2 w e e k s )
> C h a n g e s in m e t a p h y s i c - c y s t s , s h o r t a n d b r o a d n e c k o f f e m u r
> R e c e n t t r e n d - s u r g ic a l r e c o n s tr u c tio n o f t h e f r a c t u r e s
[ F ig . 2 . 1 0 . 1 4 ] □ C om plications:
□ Sign o f h ealed Perthes d is e a s e : S a g g i n g r o p e s ig n rn X -r a y • O s t e o a r t h r itis

• S t i f f n e s s o f s u b t a la r jo in t - » n o in v e r s io n o r a v e r s io n
Q , 3 1 : Calcaneum fracture

CALCAN EU M FRACTURE Q. 3 2 : O steoid osteom a

□ R elevant a n a to m y : O S T E O ID O STEO M A

• C a lc a n e u m - F o rm s b o n e o f th e h e e l
□ What Is i t : C o m m o n e s t tr u e b e n ig n tu m o r
• A r tic u la tio n - u p p e r s u r f a c e w ith t a l u s , fro n t w ith c u b o id
□ P ath o lo g y : C o n s i s t s o f n id u s o f e n t a n g l e d a r r a y s o f p a r t i a lly m i n e r a li s e d o s t e o i d t r a b e c u l a e
« In fe rio r s u r f a c e p r o l o n g e d b a c k w a r d s a s ‘t u b e r c a l c a n e i ' su rro u n d e d b y d e n s e s c le r o tic b o n e
• A n g le o f B o h l e r -> A n g l e b e t w e e n a n t e r io r a n d p o s t e r io r a s p e c t s o f s u p e r io r s u r f a c e ol
□ A g e : 5 -2 5 y e a r s
c a l c a n e u m . D e c r e a s e s in c a l c a n e u m ( b e c o m e s < 2 5 ° )
O S ite : D i a p h y s e s o f lo w e r e x t r e m ity b o n e s
• A n g le o f G i s s a n e - » A n g l e b e t w e e n d o w n w a r d a n d u p w a r d s l o p e s o f c a l c a n e u m s u p e rio r
s u r f a c e . I n c r e a s e s in c a l c a n e u m f r a c t u r e ( b e c o m e s > 10 0 °)
□ Clinical fe a tu re s :

[ F ig . 2 . 1 0 . 1 5 ] • N a g g i n g p a in , w h ic h is w o r s e a t n ig h t, a n d r e l ie v e d b y s a li c y la t e s
• M ild t e n d e r n e s s a t s it e o f le s io n
□ C a u s e : F a ll from h e ig h t on h e e l
• P a l p a b l e s w e llin g s o m e t im e s
□ Types o f fracture :
□ Investigations:
• I s o la te d c r a c k

• C o m p r e s s io n f r a c t u r e - B o n e s h a t t e r e d lik e e g g s h e ll
• X - r a y - V is ib le z o n e o f s c l e r o s i s w ith a r a d io lu s c e n t n id u s in c e n t r e , u s u a lly < 1 c m in s i z e
• C T scan
Q C lassificatio n:
• U n d is p la c e d □ T rea tm e n t: C o m p le t e e x c is i o n o f t h e n id u s a l o n g w ith s c l e r o t i c b o n e

• E x tr a -a r tic u la r □ P ro g n o sis: G o o d

• In tra -a rtic u la r ( c o m m o n e s t ) - a r t ic u la r s u r f a c e o f c a l c a n e u m f a ils t o w it h s t a n d s t r e s s - » driven [F Jg. 2 . 1 0 . 1 6 ]

d o w n w a r d s in to b o n e - » c r u s h in g d e l i c a t e t r a b e c u l a e o f b o n e in to p o w d e r
0 . 3 3 : Sim ple b o n e cy st
□ S ym pto m s:
• S w e llin g a n d p a in in r e g io n o f h e e l S IM P L E B O N E C Y S T
• N o t a b l e to bear w e i g h t o n a f f e c t e d fo o t
□ S yn o n y m : U n ic a m e r a l b o n e c y s t
□ Clinical ex am in atio n :
O What Is I t : O n ly t r u e c y s t o f b o n e
• S w e llin g a n d b r o a d e n in g o f h e e l
□ A e tio lo g y : U n k n o w n
• E c s c h y m o s is a r o u n d h e e l a f t e r 2 - 3 d a y s
□ P a th o lo g y : •
• M o v e m e n t o f a n k l e n o t m u c h im p a ire d
• C a v i t y in bone lin e d b y thin m e m b r a n e
□ Other associated in ju r ie s :
• C o n t a i n s s e r o u s o r s e r o s a n g u i n o u s y e llo w flu id
• F r a c t u r e o f s p i n e (m a in ly a t la n t o - a x ia l jo in t)
□ A g e : C h ild r e n a n d a d o l e s c e n t s
• F r a c t u r e o f p e lv is ( p u b ic ram i)
• 4 -6 y e a r s -> a c t i v e s t a g e w ith le s io n n e a r e r t o e p ip h y s is
□ X -ray fe a tu re s : R e d u c e d tu b e r jo in t a n g l e o n la t e r a l v ie w
• 9 - 1 3 y e a r s -> la t e n t s t a g e w ith le s io n n e a r e r t o d ia p h y s i s
O Treatm ent:
□ S ite s : E n d s o f lo n g b o n e s , c o m m o n e s t b e in g u p p e r e n d o f h u m e r u s
• U n d i s p la c e d f r a c t u r e - B e lo w k n e e p la s t e r c a s t fo r 4 w e e k s -> m o b ilis a t io n e x e r c i s e
□ Clinical fe a tu re s :
• C o m p r e s s io n f r a c t u r e -
• A s y m p t o m a t ic
> F oot kep t e le v a te d 4 b e l o w k n e e p la s t e r s la b fo r 2 - 3 w e e k s
• P a t h o lo g ic a l f r a c t u r e
P a in a n d s w e llin g s u b s id e
• D e fo r m it ie s
I
• G r o w t h d is t u r b a n c e
S l a b r e m o v e d + a n k l e a n d f e e t m o b ilis e d
□ X -ray fe a tu re s :
1
L e s io n w ith fo llo w in g f e a t u r e s -
L e g e l e v a t io n c o n t in u e d 4 c o m p r e s s i o n b a n d a g e fo r 4 - 6 w e e k s
 722 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology » GROUP - I I D SOLVED SHORT NOTES OF SEMESTERS 723
1

• R a d io lu s c e n t > Q S ta g e s :
• W e l l- d e f in e d | • S t a g e I - O s t e o ly s is

• L o b u la t e d • S t a g e II -

• C e n tra ! > R a p id in c r e a s e in s i z e o f o s s e o u s e r o s io n

• S it e - D i a p h y s is (la t e n t s t a g e ) , m e t a p h y s is ( a c t r v e s t a g e ) > E n la r g e m e n t o f in v o lv e d b o n e

• M a x im u m w id th l e s s th a n w id th o f e p ip h y s e a l p la t e > F o rm a tio n o f s h e ll a r o u n d c e n t r a l p a r t o f t h e le s io n

□ Treatm ent : • S t a g e III - F u lly d e v e l o p e d r a d io lo g ic a l p a tte r n

• S p o n t a n e o u s h e a lin g a f t e r fr a c t u r e ; □ Age : 1 0 - 4 0 y e a r s
• 1-2 in je c t i o n s o f m e t h y lp r e d n ls o lo n e in to c y s t □ S ite : E n d s o f lo n g b o n e s
• C u r e t t a g e a n d g r a ft □ Clinical fe a tu re s :
□ Differential d ia g n o s is : • G r a d u a l ly i n c r e a s i n g s w e llin g
• A n eu rysm al b o n e cy st • P a t h o lo g ic a l fr a c t u r e s
• O s te o c la s to m a • L o c a l r is e o f t e m p e r a tu r e
• F ib r o u s d y s p l a s i a • Q u a d r ip le g ia if s p in a l le s io n s
[ F ig . 2 . 1 0 . 1 7 ] • H e a d a c h e if s k u ll le s io n s

Q. 3 4 : A neurysm al bone eyst □ X-ray fe a tu re s :

• E c c e n t r ic w e ll- d e fin e d r a d io lu s c e n t le s io n
ANEURYSMAL BONE CYST
| • T i a b e c u la t i o n p r e s e n t
□ W hat Is It : B e n ig n o s t e o ly t ic m e t a p h y s e a l v a s o c y s t i c b o n e n e o p la s m c h a r a c t e r is e d b y s e v e r a l s p o n g e ­ • O v e r ly i n g c o r t e x e x p a n d e d
lik e b lo o d o r s e r u m fille d , g e n e r a ll y n o n - e n d o t h e lia lis e d s p a c e s o f v a r io u s d i a m e t e r s , e n c l o s e d in a
. U N L IK E O S T E O C L A S T O M A , L E S I O N D O E S N O T E X T E N D U P T O A R T I C U L A R M A R G IN
s h e ir, b a llo o n in g u p t h e o v e r ly in g c o r t e x
I
j □ T re a tm e n t: C u r e t t a g e + b o n e c e m e n tin g / b o n e g r a ftin g
□ M is n o m e r: A s n e it h e r a n a n e u r y s m n o r a c y s t
□ D ifferential d ia g n o s is :
□ First described b y : J a f f e a n d L ic h t e n s t e in in 1 9 6 2
• O s te o c la s to m a
□ P ath o g en e sis:
• T e la n g ie c ta tic o s te o s a r c o m a
• C o n s e q u e n c e o f i n c r e a s e d v e n o u s p r e s s u r e a n d r e s u lta n t d ila ta tio n a n d r u p tu re o f lo c a l v a s c u la r
n e tw o rk [ F ig . 2 . 1 0 . 1 8 ]

• A r t e r io - v e n o u s f is t u la w ith in b o n e , 0 . 3 5 : Fibrous dysplasia

□ A e tio lo g y :
F IB R O U S D Y S P L A S IA
A r is e fr o m p r e - e x is t in g -
• C h o n d r o b la s to m a □ What Is I t : D e v e l o p m e n t a l d is o r d e r in w h ic h a n o r m a l t r a b e c u l a r b o n e is r e p l a c e d b y f ib r o u s t is s u e
• C h o n d r o m y x o ld fib r o m a □ P ath o g en e sis:
• O s te o b la s to m a • M a s s o f f ib r o u s t i s s u e fo rm e d g r o w s in s id e t h e b o n e -> e r o d e s t h e c o r t i c e s o f b o n e fr o m within
• C h o n d ro sarco m a • A th in la y e r o f s u b - p e r io s t e a l b o n e f o r m s a r o u n d t h e m a s s , s o t h a t b o n e a p p e a r s e x p a n d e d
• F ib r o u s d y s p la s i a □ Types:
• O s t e o c la s t o m a • M o n o s t o t ic ( a f f e c t s s in g le b o n e )

• O te o sa rco m a • P o l y o s t o t ic ( a f f e c t s m u ltip le b o n e s )

• H a e m a n g lo e n d o t h e lio m a • M o n o m e lic ( a f f e c t s o n e lim b)

□ P a th o lo g y : □ A g e : C h ild r e n a n d a d o l e s c e n t s
• C la s s i c / S t a n d a r d fo r m ( 9 5 % ) - □ Clinical features :
> B lo o d fille d c l e f t s a m o n g b o n y t r a b e c u l a e • A s y m p t o m a t ic •
> O s t e o id t i s s u e in s t r o m a l m atrix • P o ly o s to tic -
• S o li d fo rm ( 5 % ) - ► P a in
> F ib r o b la s t ic p ro life r a tio n > Lim p
> O s t e o i d p r o d u c tio n » S w e llin g
» D e g e n e r a t e d c a lc if y in g fib ro m y x o id e l e m e n t s , > D e fo rm ity

V P a th o lo g ic a l
 724 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 725

□ Associated fe a tu re s : 0 C linical ex am in atio n :

• P r e c o c io u s p u b e rty • B o n y s w e llin g w ith fo llo w in g f e a t u r e s -

• C a W - a u - la lt s k in s p o t s > E c c e n t r ic a lly lo c a t e d a t e n d o f b o n e

T h is Is c a l l e d M c u n e A lb r ig h t s y n d r o m e > S m o o th s u r fa c e

Q Investigations: » F irm /h ard

• X -ra y - > T e n d e r o n firm p a lp a tio n

> L e s io n In m e t a p h y s ls o r d ia p h y s is ’ » W a rm

> W e l l- d e f in e d m a r g in s > S k in o v e r s w e llin g is f r e e

> C e n tr a l o r e c c e n tric -I • A d ja c e n t jo in t e f f u s io n - M o r e c o m m o n th a n In o s t e o s a r c o m a

> R e a c tiv e s c le r o s is • R e s t r ic t e d jo in t m o v e m e n t

> E n d o s t e a l s c a llo p in g - » th in n in g o f c o r t e x • L im b d e fo r m ity if a s s o c i a t e d p a t h o lo g ic a l f r a c t u r e

> P a t h o lo g ic a l f r a c t u r e (ty p ic a l S h e p h e r d 's C r o o k d e fo r m it y in p r o x im a l f e m o r a l le sio n s) • • S k in a p p e a r s s h in y w ith v e n o u s p r o m in e n c e

> T r a n s l u c e n t p a t c h e s w ith a 'g r o u n d - g la s s ' a p p e a r a n c e , t r a b e c u l a t e d , e x p a n d in g the • D is ta l n e u r o v a s c u la r d e fic it

o v e r ly in g c o r t e x □ Investigations:
• S e r u m a lk a lin e p h o s p h a t a s e - R a is e d • X -ra y -
• B io p s y - F o r c o n fir m a tio n
> S o lit a r y le s io n
□ T reatm ent: > E c c e n t r ic
• O n ly o b s e r v a t io n If m o n o s t o t ic > ‘ S o a p - b u b b le ’ a p p e a r a n c e (tu m o r h o m o g e n o u s ly ly tic - t r a b e c u l a e o f r e m n a n t s o f
• O th e r c a s e s - • b o n e t r a v e r s e it - g i v e r is e t o a lo c u la t e d a p p e a r a n c e )

• > D e fo r m it ie s - » o s t e o t o m y + in te rn a l fix a tio n y C o r t e x th in n e d o u t

> P a t h o lo g ic a l f r a c t u r e -> c u r e t t a g e + b o n e g r a ft + in t e r n a l fix a tio n > N o c a lc if ic a t i o n w ith in tu m o r

y L E S I O N E X T E N D S T O A R T I C U L A R S U R F A C E U N L IK E A N E U R Y S M A L B O N E C Y S T
0 . 3 6 : O steoclastom a
[ F ig . 2 . 1 0 . 1 9 ]
O STEO CLASTO M A
• B io p s y - O p e n o r F N A C

□ S y n o n y m : G ia n t C e l l T u m o r ( G C T ) • C T scan

□ What Is I t : C o m m o n e s t b e n ig n n e o p l a s m o f b o n e w ith v a r ia b le g r o w t h p o t e n t ia l • MRI

□ A g e : 2 0 -4 0 y e a n s • S e r u m a c i d p h o s p h a t a s e - R a is e d

□ Sex predilection ; F > M □ Treatm ent:

• If b e n ig n + c o r t e x in ta c t -» a d e q u a t e m e t ic u lo u s c u r e t t a g e + 7 0 % a l c o h o l a n d 5 % p h e n o l
O S ite ; E p i p h y s e o - m e t a p h y s e a l r e g io n ( c o m m o n in d is ta l r a d iu s , d is t a l f e m u r a n d p r o x im a l tib ia)
a p p lic a t io n + b o n e c e m e n t in g
□ Cam panaccl g r a d in g :
• If s u s p e c t e d m a l ig n a n c y + c o r t e x b r o k e n - » w id e lo c a l e x c i s i o n f o l lo w e d b y r e c o n s tr u c tio n -
T y p e I - O s t e o ly t i c le s io n I n s id e b o n e
> A r t h r o d e s is b y T u m - o - p la s t y
T y p e II - C o r t ic a l e x p a n s io n
> A r t h r o d e s is b y b r id g in g g a p w ith fib u la r g ra ft
T y p e III - B r e a k in o v e r ly in g c o r t e x , e x t e n d s in to s o f t t i s s u e s

□ Enneklng's grading ; Q. 3 7 : Osteosarcoma

• L a te n t O STEO SAR CO M A

• A c t iv e
□ S yno nym : O s t e o g e n i c s a r c o m a
• A g g r e s s iv e
□ What Is I t : S e c o n d m o s t c o m m o n a n d h ig h ly m a lig n a n t p r im a r y b o n e t u m o r
□ P athology:
□ Incidence : 1 in 7 5 0 0 0
• C e ll o f o rig in is u n c e r t a in
D A g e : B im o d a lity - 1 5 - 2 5 y e a r s a n d > 4 5 y e a r s
• H ig h ly v a s c u l a r s t r o m a
□ Sex pred ilec tio n : M > F
• T u m o r h a s u n d iff e r e n t ia t e d , s p i n d le c e l l s , w h ic h a r e p r o f u s e ly in t e r s p e r s e d w ith m u ltin u c le a le
g ia n t c e l ls 0 S ite : M e t a p h y s is ( lo w e r e n d o f fe m u r , u p p e r e n d ot tib ia , u p p e r e n d o f h u m e r u s )

□ S ym p to m s: S w e llin g s lo w ly i n c r e a s i n g in s i z e fo llo w e d b y p a in □ P ath o lo g y: T u m o r o f m e s e n c h y m a l c e l ls , c h a r a c t e r i s e d b y fo r m a tio n o f o s t e o i d m a t te r b y tu m o r c e lls

 726 QUEST ; A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 727

□ Classification : > O v e r ly in g c o r t e x e r o d e d

> C o d m a n n ’s t r ia n g le - tr ia n g u la r a r e a o f s u b - p e r io s t e a l n e w b o n e s e e n a t t u m o r -h o s t
c o r t e x ju n c tio n

> N e w b o n e fo rm a tio n in m a trix o f tu m o r

> S u n r a y a p p e a r a n c e - tu m o r g r o w s Into o v e r ly in g s o f t t i s s u e

[ F ig . 2 .1 0 .2 0 ]

• S e r u m a l k a l in e p h o s p h a t a s e - R a i s e d
• B io p s y

• B one scan t

• C T scan

• C h e s t X -r a y

□ Treatm ent: N e o a d j u v a n t c h e m o t h e r a p y - » h ig h a m p u ta tio n -> a d ju v a n t c h e m o t h e r a p y

□ Differential d ia g n o s is :
• E w in g ’s tu m o r

• C h r o n ic o s t e o m y e l it is

• A g g r e s s iv e G C T

Q. 3 8 : Crush syndrom e

CRU SH SYN DRO M E

O W hat Is I t : S y m p t o m c o m p le x in w h ic h a p o rtio n o f th e b o d y Is c r u s h e d d u e t o a h e a v y w e i g h t fa lle n o n

th a t p a rt t h e r e b y c r u s h in g t h e u n d e r ly in g t i s s u e s

□ A e tio lo g y :
• B u ild in g c o l l a p s e

• M in e in ju r ie s

• T o u r n iq u e t u s e d f o r a lo n g tim e
□ S p re a d : T h r o u g h b lo o d , firs t t o t h e lu n g s • A ir r a id s
□ S y m p to m s : • E a rth q u a k e s
• C o n s t a n t b o r in g p a in , w o r s e a s s w e llin g i n c r e a s e s in s i z e □ Pathogenesis : M u s c le c r u s h e d -> m y o h a e m o g lo b ln e n t e r s Into c ir c u la t io n -» p r e c ip it a t e s in re n a l
• P a in f o l lo w e d b y s w e llin g , w h ic h is f a s t g r o w in g t u b u le s - » r e n a l t u b u la r n e c r o s is
• S ig n if ic a n t w e i g h t l o s s , a n o r e x i a , f a t ig u e □ C linical fe a tu re s :
□ C linical ex am in atio n :
• C r u s h e d m u s c l e s b e c o m e s w o lle n
• S e v e r e p a llo r ( m o r e a n a e m i c th a n c a c h e c t i c )
• L i n * b e c o m e s p u l s e l e s s , re d , b lis t e r e d
• S w e llin g w ith fo llo w in g f e a t u r e s -
• R e d u c e d u r in e o u tp u t
> A t m e t a p h y s is
• P a t i e n t g r a d u a l ly s t a r t s s h o w in g r e s t l e s s n e s s , a p a t h y , d e liriu m
> T ender
□ T reatm ent:
> W a rm
• T o u r n iq u e t a p p l ie d p r o x im a l to c r u s h e d m u s c le s w h ic h is g r a d u a l ly r e l e a s e d s o th a t to x ic
> O v e r ly i n g s k in s h in y w ith v e n o u s p r o m in e n c e
s u b s t a n c e s g r a d u a l ly e n t e r c ir c u la tio n
> I ll- d e fin e d m a r g in s
• P a r a lle l in c is io n s to r e lie v e t e n s io n
• N e u r o v a s c u la r s t r u c t u r e s c o m p r e s s e d
• I n t r a v e n o u s flu id - 5 0 0 m l + u r in a r y o u tp u t
• R e s t r ic t e d a d j a c e n t jo in t m o v e m e n t
• M a n n ito l 20% - 1 g m / k g i.v in 1 2 h o u rs
• E n la r g e d r e g io n a l ly m p h n o d e s
• C a t h e t e r i s a t io n
□ In vestigation s:
« H e m o d ia ly s is in s e v e r e c o n d itio n s
• X -ra y -

> L e s i o n w ith ir r e g u la r m a r g in in m e t a p h y s is
 728 QUEST: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II 0 SOLVED SHORT NOTES OF SEMESTERS 729

0 . 3 9 : A rthroplasty • E x p e n s iv e
• R e q u ir e s e x p e r t i s e a n d skill
ARTHROPLASTY
□ Indications:
□ What Is I t : O r t h o p a e d ic s u r g e r y w h e r e t h e a r t ic u la r s u r f a c e o f a m u s c u lo s k e l e t a l jo in t is re p la c e d ,
• Hip -
r e m o d e lle d , o r r e a lig n e d b y o s t e o t o m y o r s o m e o t h e r p r o c e d u r e
i > F e m o r o a c e t a b u l a r im p in g e m e n t (F A I)
0 In d ica tio n s:
*; > L ab ral te a rs
• O s t e o a r th r it is
> L o o s e / f o r e ig n b o d y r e m o v a l
• R h e u m a t o id a rth ritis
\ > C h o n d r a l ( c a r t ila g e ) le s io n s
• A v a s c u la r n e c r o s is
> O s t e o c h o n d r i t is d e s s i c a n s
• C o n g e n it a l d is lo c a t io n o f t h e h ip join t
> L ig a m e n tu m t e r e s in ju rie s (a n d r e c o n s tr u c tio n )
• A c e t a b u l a r d y s p l a s i a ( s h a llo w h ip s o c k e t ) •J
4
> I li o p s o a s t e n d in o p a t h y (o r ‘s n a p p in g p s o a s ’ )
• F r o z e n s h o u ld e r
1
i T r o c h a n t e r ic p a in s y n d r o m e
• T r a u m a t iz e d a n d m a la lig n e d jo in t
1 > S n a p p in g iliotib ia l b a n d
• J o in t s t if f n e s s
> O s t e o a r t h r it is ( c o n tr o v e r s ia l)
□ Types: > S c i a t i c n e r v e c o m p r e s s i o n (p irifo rm is s y n d r o m e )

> I s c h io f e m o r a l im p in g e m e n t
N am es Details Indications
y D ir e c t a s s e s s m e n t o f h ip r e p la c e m e n t .
E x c is io n a r th r o p la s t y A r tic u la r s u r f a c e e x c i s e d to c r e a t e a H ip a n d e l b o w le s io n s • S h o u ld e r -
g a p b e t w e e n th e a r tic u la r e n d s ,
y S u b a c r o m ia l im p in g e m e n t
w h ic h is fille d b y f ib r o u s t i s s u e
y A c r o m io c l a v ic u l a r o s te o a r t h r it is

H e m ia rth ro p la s ty O n e a r t ic u la r s u r f a c e e x c i s e d a n d F r a c t u r e n e c k f e m u r e . g . , A u s tin - > F r o z e n s h o u l d e r ( a d h e s i v e c a p s u litis )

r e p l a c e d b y m e ta l, s ilic o n o r ru b b e r M o o r e h e m ia r t h r o p la s t y > C h r o n ic te n d o n itis

p r o s t h e s i s o f s im ila r t y p e i > R e m o v a l o f l o o s e b o d ie s

T o ta l r e p la c e m e n t B o th a r t ic u la r s u r f a c e s e x c i s e d a n d H ip o s t e o a r t h r i t i s e . g . , T o t a l hip > S h o u l d e r in s ta b ility

a rth r o p la s ty r e p l a c e d b y p r o s t h e t ic c o m p o n e n t s re p la c e m e n t y S u b a c r o m ia l d e c o m p r e s s i o n

> B a n k a r t s le s io n r e p a ir

[F ig . 2 . 1 0 . 2 1 ]
1 > R o t a t o r c u f f r e p a ir

• W r is t-
0 . 4 0 : A rthroscopy
> R e p e t i t iv e s tra in in ju ry
ARTHROSCOPY F r a c t u r e s o f t h e w r is t a n d t o m o r d a m a g e d lig a m e n t s

> W r is t o s te o a r th r itis
□ What Is I t : M in im a lly in v a s iv e s u r g ic a l p r o c e d u r e in w h ic h a n e x a m in a t io n a n d s o m e t im e s trea tm en t
• S p in e -
o f d a m a g e o f t h e in te rio r o f a jo in t is p e r fo r m e d u s in g a n a r t h r o s c o p e
y S p in a l d i s c h e r n ia tio n a n d d e g e n e r a t iv e d i s c s
□ Advantages :
> S p in a l d e fo r m ity
• M in im a lly in v a s iv e
> T u m o rs
• J o in t d o e s n o t h a v e t o b e o p e n e d u p fu lly , s m a ll in c is io n s a r e m a d e

• R e d u c e d r e c o v e r y tim e Q. 4 1 : Arthrodesis
• L e s s tr a u m a t o t h e c o n n e c t i v e t is s u e
ARTHRODESIS
• L e s s s c a r r in g b e c a u s e o f t h e s m a lle r in c is io n s

• L ittle Im m o b ilis a tio n r e q u ire d □ S yn o n y m :

• D y n a m ic a s s e s s m e n t o f join t • A rtific ia l a n k y l o s is

□ D isadvantages: • A rtificia l s y n d e s i s

• Irrig a tio n flu id is u s e d to d is t e n d t h e jo in t a n d m a k e a s u r g ic a l s p a c e . S o m e t im e s th is fluid □ What is i t : A rtific ia l in d u c tio n o f jo in t o s s ific a t io n b e t w e e n tw o b o n e s v ia s u r g e r y , to e lim in a te a n y

l e a k s ( e x t r a v a s a t e s ) in to t h e s u r r o u n d in g s o f t t is s u e , c a u s i n g e d e m a m o tio n a t jo in t

• N o t s u it a b l e fo r e v e r y jo in t p a t h o lo g y

I.
 730 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 731

□ Indication : T h is i s d o n e t o r e l ie v e in t r a c t a b le p a in in a jo in t w h ic h c a n n o t b e m a n a g e d b y pain 0 . 4 3 : Gaieazzi fracture

m e d ic a tio n , s p lin t s , o r o t h e r n o r m a lly - in d ic a t e d t r e a t m e n t s
GALEAZZI FRACTU RE
• P a in fu l stiff jo in ts

• G r o s s l y u n s t a b le jo in ts □ What Is I t : F r a c t u r e o f t h e ra d ia l d ia p h y s i s a t t h e m id d le a n d d is ta l th ird ju n c tio n , a l o n g w ith d is lo c a tio n /

□ Types: s u b lu x a t io n o f t h e d is ta l ra d io u ln a r jo in t. It h a s b e e n c a l le d t h e " fr a c tu r e o f n e c e s s i t y , ■b e c a u s e it
n e c e s s i t a t e s o p e n s u r g ic a l tr e a tm e n t in th e a d u lt. N o n s u r g ic a l tr e a tm e n t r e s u lts in p e r s is te n t o r r e c u rre n t
• E x t r a - a r tic u la r - E x t r a c a p s u la r b r id g e o f b o n e c r e a t e d b e t w e e n a r t ic u la t in g b o n e s
d is lo c a t io n s o f t h e d is t a l u ln a
• In tra -a rtic u la r - A r tic u la r s u r f a c e s m a d e r a w a n d jo in t im m o b ilis e d in p o s it io n o f optim um
fu n c tio n un til b o n y u n io n o c c u r s □ Nam ed a f te r : R ic a r d o G a i e a z z i

• C o m b in e d □ A etio lo g y:
[ F ig . 2 .1 0 .2 2 ] • F a ll o n o u t s t r e t c h e d h a n d w ith p r o n a t e d fo r e a r m

□ Position o f a rth ro d e s is : • D ir e c t t r a u m a o n w ris t ( d o r s o la te r a l a s p e c t )

□ Clinical fe a tu re s :
JO IN T IN V O L V E D P O S I T IO N
• P a in a n d s o f t - t is s u e s w e llin g a t t h e fr a c t u r e s it e a n d a t t h e w r is t jo in t

A n k le M a le s - N e u tr a l p o s itio n • C o m p a rtm e n t sy n d ro m e

F e m a l e s - P la n t a r fle x io n • P a r a l y s i s o f t h e f le x o r p o llic is lo n g u s a n d f le x o r d ig ito ru m p r o fu n d u s m u s c l e s to t h e in d e x

fin g e r , r e s u ltin g in l o s s o f t h e p in c h m e c h a n i s m b e t w e e n t h e th u m b a n d in d e x fin g e r
K nee 5 - 1 0 d e g r e e s fle x io n • W rist d r o p d u e t o in ju ry to r a d ia l n e r v e , e x t e n s o r t e n d o n s o r m u s c le s

Hip 1 5 d e g r e e s fle x io n , n o a b d u c t io n / a d d u c t io n , n e u t r a l ro ta tio n □ X -ray fe a tu re s :

W rist 20 d e g r e e s d o r s ifle x io n • R a d iu s a n g u la t e d d o r s a liy

. W id e n e d D R U J
E lb o w U n ila te r a l - 7 5 d e g r e e s fle x io n
• F r a c t u r e u ln a r s ty lo id
B ila te ra l - 7 0 d e g r e e s fle x io n in o n e , 1 3 0 d e g r e e f le x io n in o t h e r
□ T reatm ent:
S h o u ld e r 2 5 d e g r e e s fle x io n , 3 0 d e g r e e s a b d u c t io n , 4 5 d e g r e e s in te rn a l rota tion
O p e n r e d u c t io n a n d In tern a l fix a tio n

□ C om plication: M a l-u n io n
Q. 4 2 : McMurray's osteotom y
0 . 4 4 : Foot drop
McMURRAY’S OSTEOTOMY
FOOT DROP
□ S yn o n y m s:
□ What Is i t : G a it a b n o r m a lity in w h ic h t h e d r o p p in g o f t h e fo r e fo o t
« A b d u c t io n o s t e o t o m y
□ P ath oan ato m y:
• L in e a r o s t e o t o m y
• D a m a g e to t h e c o m m o n fib u la r n e r v e
□ In d ica tio n :
• P a r a ly s i s o f t h e m u s c l e s in t h e a n te r io r p o rtio n o f t h e lo w e r le g .
F ra ctu re n e c k fe m u r -
□ C linical f e a t u r e s :
• N o n -u n io n o f in t r a s c a p u la r f r a c t u r e
• In ab ility o r im p a ir e d a b ility to r a i s e t h e t o e s o r r a i s e t h e fo o t fro m t h e a n k l e (d o rs ifle x io n )
• A v a s c u la r n e c r o s is
• In w a lk in g , t h e r a i s e d le g is s lig h t ly b e n t a t t h e k n e e to p r e v e n t t h e f o o t fro m d r a g g in g a lo n g
□ P rin c ip le : T h e e n t ir e w e ig h t o f t h e b o d y p a s s e s th r o u g h h e a d a n d n e c k , a n d t h e n d ir e c t ly tra n s m itte d
th e g rou n d
th ro u g h s h a ft o f fe m u r
• S t e p p a g e g a it
□ T e chn iqu e: F e m u r c u t th r o u g h a n d th r o u g h in b e t w e e n g r e a t e r t r o c h a n t e r a n d l e s s e r t r o c h a n t e r - *
lo w e r e n d h in g e d t o is c h ia l t u b e r o s it y -» b o th t h e p o r tio n s f ix e d w ith a p la t e • P e o p l e s u f fe r in g fro m t h e c o n d it io n d r a g th e ir t o e s a l o n g t h e g r o u n d o r b e n d th e ir k n e e s to lift
t h e ir f o o t h ig h e r th a n u s u a l t o a v o i d t h e d r a g g in g
□ A d v an tag e s ;
□ D iseases a s s o c ia te d :
• Low cost
• A m y o tr o p h ic la te r a l s c l e r o s i s
• E a s y t e c h n iq u e
• M u s c u la r d y s t r o p h y
□ D isa d va n ta g es:
• C h a r c o t M a r ie T o o t h d i s e a s e
• In ab ility to s q u a t
• M u ltip le s c l e r o s i s
« S lig h t s h o r t e n in g o< lim b
i » H e r e d ita r y s p a s t i c p a r a p le g i a
• D iffic u lty in w a lk in g
• F r ie d r e ic h ’s a t a x i a
 732 QUEST : A Comprehensive Guide (o UG Surgery, Orthopedics & Anesthesiology
GROUP - II D SOLVED SHORT NOTES OF SEMESTERS • 733

□ Investigations:
□ Clinical fe a tu re s :
• MRI
• V is ib le d e fo rm ity
• URN
• B ackache
• EM G
• C o m p e n s a t o r y lu m b a r lo r d o s is e x a g g e r a t e d
□ A etio lo g y:
• S t r a ig h t le g ra is in g t e s t lim ite d t o 6 0 d e g r e e s
• N e u ro m u s c u la r d is e a s e
□ X -ray fe a tu re s :
• P e r o n e a l n e r v e ( c o m m o n , i . e ., fr e q u e n t) - c h e m ic a l, m e c h a n i c a l , d i s e a s e
• W e d g in g o f v e r t e b r a l b o d ie s
• S c ia t i c n e r v e - d ir e c t tr a u m a , ia tr o g e n ic ;
• D e n s e f r a g m e n t e d e p i p h y s e a l p la t e s
• L u m b o s a c r a l p le x u s
• S m a ll t r a n s lu c e n t a r e a s n e a r d i s c s p a c e s k n o w n a s S c h m o r l's nodes
• L 5 n e r v e r o o t ( c o m m o n , e s p e c i a l l y in a s s o c ia t i o n w ith p a in in b a c k r a d ia t in g d o w n le g )
□ T rea tm e n t:
• C a u d a e q u in a s y n d r o m e , w h ic h is c a u s e d b y im p in g e m e n t o f t h e n e r v e r o o t s w ith in th e
• L ittle d e fo r m ity 4 n o p a in - N o t r e a t m e n t r e q u ir e d
s p in a l canal d is t a l t o t h e e n d ol the s p in a l cord
• L ittle d e fo r m ity + little p a in - E x e r c i s e s
• S p in a l c o r d ( r a r e ly c a u s e s is o l a t e d f o o t d ro p ) - p o lio m y e litis , t u m o r
• S e v e r e d e fo r m ity + s e v e r e p a in - P o s t e r io r p la s t e r s h e ll a t n ig h t, p la s t e r ja c k e t d u rin g t h e d a y
• B ra in (u n c o m m o n , b u t o f t e n o v e r lo o k e d ) - s t r o k e , T IA , tu m o r

• G e n e tic (a s in C h arcot-M arie-T ootfi D is e a s e a n d hered itary n e u ro p a th y w ith liability to p r e s s u r e p alsies) Q. 4 6 : Scoliosis
• N o n o r g a n ic c a u s e s
SCOLIOSIS
□ T re a tm e n t:
• T h e u n d e r ly in g d is o r d e r m u s t b e t r e a t e d □ W hat Is I t : S i d e w a y s c u r v a tu r e o f s p i n e
• S p in a l s t e n o s i s - N o n - s u r g ic a l t r e a t m e n t s fo r s p in a l s t e n o s i s in c lu d e a s u it a b l e e x e r c i s e □ C lassificatio n:
p r o g r a m d e v e l o p e d b y a p h y s i c a l t h e r a p is t , a c t iv it y m o d ific a t io n ( a v o id in g a c t i v it i e s th a t
cause a d v a n c e d s y m p t o m s o f s p i n a l s t e n o s is ) , e p id u r a l in je c t io n s , a n d a n ti-in fla m m a to r y
m e d ic a t io n s lik e ib u p r o f e n o r a s p irin . If necessary, a d e c o m p r e s s io n s u r g e r y t h a t i s m in im a lly C L A S S IF IC A T IO N )

d e s t r u c t iv e o f n o r m a l s t r u c t u r e s m a y b e u s e d t o t r e a t s p in a l s t e n o s i s .

• A n k le s c a n b e s t a b iliz e d b y lig h tw e ig h t o r t h o s e s , a v a i la b l e in m o l d e d p l a s t i c s a s w e ll a s
S tru c tu ra l N o n -stru c tu ra l
s o f t e r m a t e r ia ls t h a t u s e e l a s t i c p r o p e r t ie s t o p r e v e n t f o o t d r o p . A d d it io n a lly , s h o e s c a n b e
fitte d w ith tra d itio n a l s p r i n g - lo a d e d b r a c e s t o p r e v e n t f o o t d r o p w h ile w a lk in g . R e g u la r e x e r c i s e
i s u s u a lly p r e s c r ib e d , C o m p e n sa to ry
I d io p a t h ic
• F u n c tio n a l E e c t r ic a ! S t im u la t io n ( F E S ) ( o c c u r s t o c o m p e n s a t e fo r
tilt o f p e lv is )
Q. 4 5 : Kyphosis
C o n g e n ita l
KYPHOSIS ( a s s o c i a t e d w ith
P o s tu ra l (cu rv e
□ W hat Is I t : E x c e s s i v e b a c k w a r d c o n v e x it y o f t h e s p in e - h e m iv e r te b r a e ,
s t r a i g h t e n o n b e n d in g
□ Types: b lo c k v e r t e b r a e ,
to w a rd s )
u n s e g m e n te d b ar)

G C L A S S IF IC A T IO N

S c ia tic
P a r a ly t ic
( d u e to u n ila t e r a l p a in fu l
Structural N o n -stru c tu ra l
s p a s m o f p a r a s p in a l
m u s c le s )
R ou n d P o stu ra l O t h e r c a u s e s lik e
(G e n tle b a c k w a r d c u r v a t u r e (In tall p e o p le b e c a u s e o f th eir n e u r o fib r o m a to s is
o f s p in a l co lu m n ) te n d e n c y t o s t o o p fo rw a rd s)

A n gu lar C o m p e n sa to ry
(O c c u rs to c o m p e n s a te o th e r □ P a th o a n a to m y :
( S h a r p b a c k w a r d prominence
d efo rm ities) • P r im a r y c u r v e - L a te r a l c u r v a t u r e o f a p a r t o f s p i n e
o f s p in a l co lu m n )
. S e c o n d a r y c u r v e s - C o m p e n s a t o r y c u r v a t u r e s in d ir e c tio n o p p o s i t e to p rim a r y c u r v a t u r e ,
M obile
.' a b o v e o r b e lo w th e p rim a r y c u r v e
( S e e n in m u s c le w e a k n e s s d is o rd e rs )
• L a t e r a l c u r v a t u r e - A s s o c i a t e d w ith ro ta tio n o f v e r t e b r a e
 734 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - I I D SOLVED SHORT NOTES OF SEMESTERS 735

« L a t e r a l c u r v a t u r e o f t h o r a c ic s p i n e - » a s s o c i a t e d w ith r o ta tio n o f v e r t e b r a e -> p r o m in e n c e o f □ Common tendons In v o lv e d :

rib c a g e o n c o n v e x s i d e -> rib h u m p • P ro n a to r te r e s
• T y p e s o f s c o l i o s i s in t h o r a c o - lu m b a r s p i n e - D o r s a l s c o li o s i s , d o r s o - lu m b a r s c o l i o s i s , lu m b a r • F le x o r c a r p ! ra d ia lis
s c o lio s i s Q Sym ptoms : T e n d e r n e s s o v e r m e d ia l e p ic o n d y le w h ic h is w o r s e n e d b y w r is t fle x io n a n d s t r o n g
[ F ig . 2 .1 0 .2 3 ] g rip p in g a c t iv it ie s

□ Clinical fe a tu re s : □ Clinical ex a m in a tio n : G o lfe r 's e lb o w s ig n ( e lb o w s e m if le x e d - » fo r e a r m s u p in a t e d - » is o m e tr ic w ris t

a n d e lb o w e x t e n s i o n a g a i n s t r e s is t a n c e - » p a in )
• P a in
□ Treatm ent:
• V i s ib le d e f o r m it y m a in ly
» N o n - s te r o id a l a n ti-in fla m m a to r y d r u g s ( N S A I D s ) : Ib u p r o fe n , n a p r o x e n o r a s p irin
• N e u r o l o g ic a l d e f ic it r a r e ly
• H e a t o r ic e
□ X -ray fe a tu re s : A - P v i e w in e r e c t a n d s u p in e p o s t u r e + la t e r a l v ie w
• A c o u n t e r - f o r c e b r a c e o r " e lb o w s tra p " to r e d u c e s tr a in a t t h e e l b o w e p ic o n d y le , to lim it p a in
• C o b b ’ s a n g l e - A n g l e b e t w e e n lin e p a s s i n g th r o u g h t h e m a r g in s o f t h e v e r t e b r a e a t t h e e n d s
p r o v o c a tio n
o f th e cu rv e
• I n tr a le s io n a l T r ia m c in o lo n e In jectio n
• R e i s s e r ’s s i g n - T o a s s e s s p r o g r e s s o f c u r v e ( ilia c a p o p h y s i s f u s e s w ith ilia c b o n e a t m a tu rity
□ Differential d ia g n o s is :
a n d in d i c a t e s c o m p le t io n o f g r o w th w h ic h m e a n s n o f u r th e r c u r v in g w ill o c c u r )
• B a s e b a l l P it c h e r ’s E lb o w
• R o t a t io n o f v e r t e b r a e - A s s e s s e d b y p o s it io n o f s p i n o u s p r o c e s s e s a n d p e d i c l e s o n A - P v ie w
t C lim b e r ’s E lb o w
• C o n g e n it a l s c o l i o s i s - W e d g in g , h e m iv e r t e b r a e , f u s e d rib s , e t c .
• U ttle L e a g u r e ’ s E lb o w
□ Treatm ent:
• C u b it a l tu n n e l s y n d r o m e
(A ) C o n s e r v a t i v e -

• E x e r c is e s Q. 4 8 : M ai union
• S u p p o rts • M A L U N IO N
> B o s to n b r a c e
□ W hat Is I t : F r a c t u r e fa ils t o u n it e in p r o p e r p o s itio n , r e s u ltin g in d is a b ilit y o f c lin ic a l s ig n if ic a n c e
> M ilk a u w e e b r a c e
□ A etio lo g y:
> R e i s s e r 's tu r n - b u c k le c a s t
• Im p r o p e r tr e a tm e n t
> L o c a lis e r c a s t
• U n c h e c k e d m u s c le p u ll
[I n d ic a tio n s -
• E x c e s s i v e c o m m in u tio n
> P o s tu ra l c u rv e ,
□ S ite s : F r a c t u r e s o c c u r r in g a t e n d o f b o n e s lik e -
> W e l l- b a la n c e d d o u b l e c u r v e s
• F r a c t u r e c la v i c le
> S tru c tu ra l c u r v e s o f le s s th a n 3 0 d e g r e e s ]
• C o l i e s ’ fr a c tu r e
(B ) O p e r a t i v e -
• S u p r a c o n d y la r f r a c tu r e o f h u m e r u s
• C o n g e n it a l s c o l i o s i s - S im p le fu s io n
□ C onsequences:
• I d io p a th ic s c o l i o s i s - F u s io n a ft e r s t r e t c h in g s p i n e b y fo llo w in g m e t h o d s -
• L im ita tio n o f m o v e m e n t s
> C o t r e l t r a c t io n
• D e fo r m itie s
> L o c a lis e r c a s t
> H a l o - p e lv ic d is t r a c t io n s y s t e m • L im b s h o r te n in g

> H a r r in g to n ’ s d is tr a c tio n s y s t e m 0 T rea tm e n t:

> D w y e r 's c o m p r e s s i o n a s s e m b l y
> L u q u e - H a r t s h ifl s y s t e m s
[I n d ic a tio n s -

> C o n g e n i t a l s c o li o s i s
> C u r v e s s h o w in g d e t e r io r a t io n r a d io lo g ic a lly

> If a s s o c i a t e d b a c k a c h e ]

0 . 4 7 : Golfer's elbow

G O L F E R ’S ELBOW
- ( Osteoclasis )
□ Synonym : M e d ia l e p ic o n d y lit is
-( E x c is io n o f p rotru d in g b o n e )
□ W hat Is I t : A n in f la m m a t o r y c o n d itio n o f t h e m e d ia l e p ic o n d y le o f h u m e r u s
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GROUP - M O SOLVED SHORT NOTES OF SEMESTERS 737

0 . 4 9 : A vascular necrosis '*■ E x c i s io n o f a v a s c u l a r s e g m e n t

A V A S C U L A R N E C R O S IS r H ip r e s u r f a c in g o r m e t a l o n m e ta l (M O M ) r e s u r f a c in g

□ S yno nym : > C o r e d e c o m p r e s s io n

V F r e e V a s c u la r F ib u la r G r a ft (F V F G )
• O s te o n e c r o s is

• B o n e in fa rc tio n > T r a n s p la n ta tio n o f n u c l e a t e d c e l l s fro m b o n e m a r r o w in to a v a s c u l a r n e c r o s i s le s io n s

a f t e r c o r e d e c o m p r e s s io n
• A s e p t i c n e c r o s is

• I s c h e m ic b o n e n e c r o s i s
Q. 5 0 : S m ith ’s fracture
□ W hat Is I t : D i s e a s e w h e r e t h e r e is c e llu la r d e a t h ( n e c r o s is ) o f b o n e c o m p o n e n t s d u e t o in terru p tion
o f t h e b lo o d s u p p ly S M IT H ’S F R A C T U R E
□ Cause:
□ S yn o n y m : R e v e r s e C o l l e s ' fr a c tu r e
• C h e m o th e ra p y
□ W hat Is i t : F r a c t u r e o f t h e d is ta l r a d iu s w ith d is t a l f r a c t u r e f r a g m e n t b e i n g d i s p la c e d v o la r ly (v e n tra lly )
• A lc o h o li s m
□ N am ed a f te r : O r t h o p a e d ic s u r g e o n , R o b e r t W illia m S m ith
• E x c e s s i v e s t e r o id u s e
□ A e tio lo g y :
• P o s t tra u m a
• C a i s s o n d i s e a s e ( d e c o m p r e s s io n s i c k n e s s ) • D ir e c t b lo w t o t h e d o r s a l fo re a rm

• V a s c u la r c o m p re s s io n • F a ll o n t o f l e x e d w r is ts w ith s u p in a t e d f o r e a r m

• V a s c u lit is □ Deform ity p r e s e n t: G a r d e n - s p a d e d e fo rm ity

• A r te r ia l e m b o li s m □ A g e : A d u lts
• D a m a g e fr o m ra d ia tio n □ Com parison with Colie's fractu re:
• B i s p h o s p h o n a t e s (p a r tic u la r ly t h e m a n d ib le ) • In C o l i e s ' f r a c t u r e , d is t a l f r a g m e n t i s d i s p la c e d d o r s a lly
□ C linical fe a tu re s : • L e s s c o m m o n th a n C o l l e s ' fr a c tu r e
• P rim a rily a f f e c t s t h e jo in t s a t t h e s h o u l d e r, k n e e , a n d h ip □ T reatm ent:
• T h e c l a s s i c a l s i t e s a r e - H e a d o f fe m u r , n e c k o f t a lu s a n d w a i s t o f s c a p h o id
• A n u n d i s p l a c e d f r a c t u r e m a y b e t r e a t e d w ith a c a s t a l o n e fo r 6 w eeks
□ S ite : E p ip h y s is
• A f r a c t u r e w ith m ild a n g u la tio n a n d d is p la c e m e n t m a y r e q u ir e c l o s e d r e d u c tio n
□ Age : 3 0 -5 0 y e a r s
• S ig n if ic a n t a n g u la t io n a n d d e fo rm ity m a y r e q u ir e a n o p e n r e d u c tio n a n d in te r n a l fix a tio n
□ C onsequences: D e fo r m a tio n o f b o n e - * s e c o n d a r y o s te o a rth ritis -> p a in fu l lim itatio n o f join t m o v e m e n t
• A n o p e n f r a c t u r e w ill a l w a y s r e q u ir e s u r g ic a l in te rv e n tio n
□ In vestigation s:
□ C o m p licatio n s:
• In t h e e a d y s t a g e s -
• S t i f f n e s s o f jo in ts
> B o n e s c in t ig r a p h y
• M a lu n io n
» M RI
(A 'S m i t h F r a c t u r e " is a n a m e d v e r te b r a l f r a c tu r e o c c u r r in g m o s t c o m m o n ly in t h e lu m b a r s p i n e , is
• In t h e la t e r s t a g e s -
s im ila r t o th a t o f a C h a n c e fr a c tu r e a n d is a s s o c i a t e d w ith s e a t - b e l t in ju r ie s . T h is f r a c t u r e r e p r e s e n t s a
X -r a y :
f r a c t u r e t h r o u g h t h e p o s t e r io r e l e m e n t s in c lu d in g t h e s u p e r io r a r t ic u la r p r o c e s s e s b u t n o t th e s p in o u s
> R e l a t i v e l y m o r e r a d io - o p a q u e d u e t o t h e n e a r b y liv in g b o n e b e c o m i n g r e s o r t e d
p r o c e s s , a s w e ll a s a n a v u ls i o n fr a c tu r e o f t h e v e r t e b r a l b o d y }
s e c o n d a r y t o r e a c t i v e h y p e r a e m ia

> T h e n e c r o t i c b o n e it s e lf d o e s n o t s h o w i n c r e a s e d r a d io g r a p h ic o p a c it y , a s d e a d b o n e
Q .5 1 :T B h lp
c a n n o t u n d e r g o b o n e r e s o r p t io n w h ic h is c a r r ie d o u t b y liv in g o s t e o c l a s t s

> A r a d io lu s c e n t a r e a fo llo w in g t h e c o l l a p s e o f s u b c h o n d r a l b o n e ( c r e s c e n t s ig n ) an d T U B E R C U L O S I S O F H IP
r in g e d r e g io n s o f r a d io d e n s it y re s u ltin g fro m s a p o n if ic a t io n a n d c a lc if ic a t io n o f m arro w
Q Causative a g e n t: M y c o b a c t e r iu m t u b e r c u lo s is
f a t fo llo w in g m e d u lla r y in fa r c ts

□ Tre a tm e n t: □ S p e c ia lity : 2 n d m o s t c o m m o n ly a f f e c t e d s e c o n d a r y s i t e a f t e r s p i n e

• C o n s e r v a tiv e - □ A g e : C h ild r e n a n d a d o l e s c e n t s

> D e l a y w e ig h t b e a r in g □ S p re a d : B y b lo o d ( a lw a y s s e c o n d a r y )
> B is p h o s p h o n a t e s ( e .g . a le n d r o n a t e ) □ Initial focus :
• O p e ra tiv e - « E p i p h y s e a l r e g io n

> T o t a l h ip r e p la c e m e n t • M e t a p h y s e a l r e g io n

S.V
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GROUP - II □ SOLVED SHORT NOTES OF SEMESTERS 733

• R o o f o f a c e t a b u lu m
□ Clinical ex am in atio n : •
• G r e a te r tro c h a n te r
• Initial s t a g e s - s tiff-h ip g a l l ( fo r w a r d a n d b a c k w a r d m o v e m e n t a t lu m b a r s p i n e u s e d fo r
• S y n o v ia l m e m b r a n e
p r o p u ls io n ol lower limbs), la t e r s t a g e s - a n t a lg i c g a i t ( r e d u c e d s t a n c e p h a s e )
□ P ath og enesis: • T h ig h a n d g lu t e a l m u s c l e s w a s t e d

• S w e llin g a r o u n d h ip d u e to c o ld a b s c e s s
I n f e c t e d g r a n u la t io n t i s s u e h a r b o u r in g t h e b a c illi fro m in itia l b o n y f o c u s
• A ttitu d e - ( a s d e s c r i b e d in s t a g e s a b o v e )
ir • A n t e r io r h ip p o in t t e n d e r , b it r o c h a n t e r ic c o m p r e s s i o n t e s t p o s it iv e
E r o d e s o v e r ly in g c a r t i la g e -> r e a c h e s jo in t
• T r e n d e le n b u r g t e s t p o s it iv e
I
• L im ita tio n o f b o t h a c t i v e a n d p a s s i v e m o v e m e n t s
S y n o v i a l h y p e r t r o p h y (p a n n u s ) + e f f u s io n
□ Investigations ;
't
• X -r a y p e lv is -
P a n n u s e x t e n d s o v e r a n d u n d e r c a r t i la g e -> e r o d e s if
> H a z i n e s s o f b o n e s a r o u n d hip
> R e d u c e d jo in t s p a c e
J o in t b e c o m e s full o f p u s , g r a n u la t io n t i s s u e B o n e e n d s b e c o m e raw
> I r r e g u la r o u tlin e o f a r t ic u la r e n d s

S y n o v iu m b e c o m e s t h ic k e n e d , e d e m a t o u s > ‘P e s t l e a n d m ortar* a p p e a r a n c e o f a c e t a b u lu m

i > S c l e r o s i s a r o u n d h ip if h e a lin g s ta r t s

M u ltip le c a v i t i e s fo r m e d in h e a d a n d a c e t a b u lu m • X -ra y c h e s t

- i • B lo o d - E S R r a i s e d , E L I S A , P C R

H e a d p a r tia lly a b s o r b e d • M a n to u x te s t
i • S p u t u m f o r a c i d - f a s t b a c illi

C o n s t a n t p u ll o f m u s c le s □ T rea tm e n t:
i • C o n s e r v a tiv e -
R e m a in in g h e a d d i s l o c a t e s fro m a c e t a b u lu m - » w a n d e r in g a c e t a b u lu m > A n t itu b e r c u la r d r u g s
I > Im m o b ilis a tio n u s in g b e lo w - k n e e s k in tra c tio n
P u s b u r s ts th ro u g h c a p s u le » O p e ra tiv e -

> J o in t d e b r id e m e n t
P e r f o r a t e s a c e t a b u lu m C o ld a b s c e s s in g r o in o r g r e a t e r t r o c h a n t e r r e g io n > A r t h r o d e s is
*1 > C o r r e c tiv e o s te o to m y
P e lv ic a b s c e s s
> G ir d l e s t o n e a r th r o p la s ty
4
> T o t a l h ip r e p l a c e m e n t
H e a lin g b y f ib r o u s a n k y l o s is
0 . 5 2 : Ingrowing toe-nail

□ S ta g e s : IN G R O W IN G T O E -N A IL

• S t a g e I ( S t a g e o f s y n o v it is ) - E ffu s io n in to jo in t - > h ip in a p o s it io n o f m a x im u m c a p a c i t y i.e .

□ P a th o lo g y : O n e s i d e o l n a il o f t o e c u r l s in w a r d s d e e p in to t h e s i d e o f t h e n a il b e d , t h e r e b y fo rm in q a
fle x io n , a b d u c t i o n , e x t e r n a l ro ta tio n ( F A B E R ) . A p p a r e n t lim b l e n g t h e n in g o c c u r s la t e r a l s p i k e 3
• S t a g e II ( S t a g e o f arth ritis) - A rtic u la r c a r t i la g e d e s t r o y e d -> s p a s m o f p o w e r fu l m u s c le s a ro u n d 0 S ite : G r e a t t o e
h ip - » f le x io n , a d d u c t io n , in te r n a l ro ta tio n (F A D I R ) . A p p a r e n t lim b s h o r t e n in g o c c u r s
0 A etio lo g y:
• S t a g e III ( S t a g e o f e r o s io n ) - A c e t a b u l a r h e a d e r o d e d -> d is lo c a t io n / s u b fu x a t io n o f hip ~»
• I d io p a th ic
F A O I R . T r u e s h o r t e n in g o c c u r s
• W e a r in g tig h t s h o e s
□ S ym p to m s:
• E x c e s s iv e s w e a t
• L im p
• C lip p in g t h e n a ils t o o s h o rt
• P a in a r o u n d g r o in r a d ia t in g t o k n e e a n d o f t e n a s s o c i a t e d w ith n ig h t c r i e s ( c a u s e d b y ru b b in g
□ Clinical fe a tu re s ;
of 2 d i s e a s e d s u r f a c e s , w h e n m o v e m e n t o c c u r s d u e t o m u s c l e r e la x a t io n d u r in g s le e p )
• S i d e o f t h e n a il c u r l s d e e p in w a r d s
• E v e n in g r is e o f t e m p e r a t u r e , n ig h t s w e a t s
• S k in la t e r a l to it o v e r h a n g s it, b e c o m e s p a in fu l a n d in f e c t e d
• A p a t h e t ic , p a l e a n d l o s s o l a p p e t it e
• 'G r a n u l a t io n t i s s u e c a n b e s e e n a l th e e d g e o f d ig g i n g n a il
 GROUP - I 1 D SOLVED SHORT NOTES OF SEMESTERS 741
740 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology

Q. 5 4 : Madelung deform ity •

□ T rea tm e n t:
M ADELU NG D E F O R M IT Y
• C o n s e r v a tiv e -

> T ig h t s h o e s a v o i d e d □ W hat Is I t : C h a r a c t e r i z e d b y m a lf o r m e d w r is t s , w ris t b o n e s a n d s h o r t s t a t u r e

> F e e t a n d h a n d k e p t c l e a n a n d d ry □ N a tu re : C o n g e n it a l
> D r e s s i n g w ith p o v id o n e io d in e If in fe c t e d □ A g e : Alter 1 0 y e a r s

> S o f r a m y c in o in tm e n t □ A etio lo g y:
. S u r g ic a l - R a d ic a l r e m o v a l o f a f f e c t e d s id e o f n a il a l o n g w ith t h e c o m e r o f t h e g e rm in a l • Id io p a th ic
e n v e lo p e to p re v e n t re c u r re n c e • C o n g e n it a l

• P o s t - t r a u m a t ic
Q. S 3 : Osteogenesis Im perfecta
• D ia p h y s e a l a c la s is
O S T E O G E N E S IS IM P E R F E C T A
□ P ath o lo g y:
□ S yno nym s ; D e fe c t i v e m e d ia l 1/ 3 rd r a d ia l e p ip h y s is - > m o r e g r o w th o f la t e r a l 2/3 rd o f r a d iu s d is ta lly - » u ln a r a n d
• F ra g ilitis o s s l u m v o la r a n g u la t io n o f d is t a l r a d iu s -> p r o m in e n c e o f d is t a l u ln a a n d v o la r s u b lu x a t io n o f c a r p a l b o n e s

• B rittle b o n e d i s e a s e a Clinical fe a tu re s :
• L o b s t e in s y n d r o m e • B r o a d e n e d w ris t

0 W hat Is I t : C o n d it io n c h a r a c t e r i s e d b y t e n d e n c y fo r fr e q u e n t f r a c t u r e s b e c a u s e o f w e a k a n d brittle • U ln a r a n d v o la r a n g u la t io n o f d is t a l ra d iu s

bones • D o r s a l p r o m in e n c e o f u ln a r h e a d
Q P ath og enesis: D e f e c t i v e c o l l a g e n s y n t h e s i s -4 d e f ic i e n c y o f m a in ly T y p e 1 c o l l a g e n • F orearm s h o rte n e d
□ G enetic m u ta tio n : C O L 1 A 1 a n d C O L 1 A 2 g e n e • R e s t r ic t e d p r o n a t io n , s u p in a t io n o f f o r e a r m a n d d o r s ifle x io n o f w r is t
□ Types: 8 . □ In vestigation s: X - r a y
□ In heritance: A u t o s o m a l d o m in a n t d is o r d e r , a s e v e r e v a r ia n t is a u t o s o m a l r e c e s s i v e □ Treatm ent:
□ A ssociated fe a tu re s : • C o n s e r v a t iv e - In p a e d ia t r ic c a s e s
• B lu e s c l e r a ■ S u r g ic a l - If p a in a n d d is a b ility p e r s is t s
• O t o s c le r o s is > M ilc h r e c e s s i o n o s t e o t o m y fo r s k e le t a ll y Im m a tu re b o n e s
• J o in t la x ity > D a r r a c h ’s o p e r a t io n f o r s k e le t a lt y m a tu r e b o n e s
□ C linical fe a tu re s : • R e p e a t e d m in o r in ju r ie s , s u c h a s r e p e a t e d le a n in g o n t h e p o in t o f t h e e l b o w o n a h a r d s u r f a c e
• F r e q u e n t f r a c t u r e s w ith m in im a l t r a u m a
0 . 5 5 : Student's elbow
• S lig h t s p i n a l c u r v a t u r e

• P o o r m u s c le to n e STU D E N TS ELBOW

• L o o s e jo in ts
□ S yno nym : •
• S lig h t p r o f u s i o n o f e y e s
• O le c r a n o n b u r s it is
• E a r ly l o s s o f h e a r in g
• E lb o w b u m p
□ Com plications :
• B a k e r 's e l b o w
• R e s p ir a t o r y f a il u r e
□ What Is I t : In fla m m a tio n o f b u r s a b e t w e e n o l e c r a n o n a n d t r ic e p s t e n d o n
• I n tr a c e r e b r a l h e m o r r h a g e
0 A etio lo g y:
□ In vestigation s:
• S i n g le in ju ry t o t h e e l b o w ( e . g . , a h a r d b lo w to t h e tip o f t h e e lb o w )
• P r e n a t a l d i a g n o s i s b y a m n i o c e n t e s is
• R e p e a t e d m in o r in ju r ie s , s u c h a s r e p e a t e d le a n in g o n t h e p o in t o f t h e e l b o w o n a h a r d s u r f a c e
• D N A t e s t in g
□ A g e : 2 0 -5 0 y e a r s
• S k in b io p s y
0 Clinical fe a tu re s :
Q T re a tm e n t:
• S w e llin g in t h e e l b o w , w h ic h c a n s o m e t im e s b e la r g e e n o u g h t o r e s tr ic t m o tio n
N o c u r e still fo llo w in g u s e d -
• P a in o r ig in a tin g in t h e e l b o w jo in t fro m m ild t o s e v e r e w h ic h c a n s p r e a d t o t h e r e s t o f t h e a rm
• B is p h o s p h o n a t e s
» If t h e b u r s a i s i n f e c t e d - * r e d n e s s + s k in w a r m + s p o n t a n e o u s l y a n d d r a in in g p u s
• A n tib io tic s t o t r e a t b o n e in fe c tio n
0 Treatm ent:
• P h y s io t h e r a p y
• A c tiv ity m o d ific a tio n
• S u r g ic a l c o r r e c t i o n of b o n e s
742 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics S Anesthesiology GROUP - II D SOLVED SHORT NOTES OF SEMESTERS 743

• P h y s ic a l t h e r a p y - I c e a p p lic a t io n , u lt r a s o n ic t h e r a p y

• I n t r a le s io n a l T r ia m c in o lo n e in je c tio n

• B r a c in g o r s t r a p p in g
• N S A I D s , C o r t ic o s t e r o i d s
• S u r g e r y - A fte r 6 - 1 2 m o n t h s o f f a ile d c o n s e r v a t i v e t r e a tm e n t

> P e r c u ta n e o u s r e le a s e o f te n d o n s

> O p e n d e b r id e m e n t
> A r t h r o s c o p ic d e b r id e m e n t

0 . 5 6 : C law hand
C LA W HAND

□ V W iaf Is I t : D e fo rm ity in w h ic h h a n d a s s u m e s p o s t u r e id e n t ic a l to c a t 's p a w

□ A e tio lo g y :
• K lu m p k e 's p a r a ly s is

• U ln a r n e r v e in ju ry a t w r is t

• V o lk m a n n ’s is c h a e m i c c o n t r a c t u r e
• C o m b i n e d u ln a r a n d m e d ia n n e r v e in ju ry

□ M e c h a n is m ;
U ln a r n e r v e c u t a t w r is t - » i n t e r o s s e i p a r a l y s e d -> in a b ility t o f le x M C P jo in t - » h y p e r e x t e n s io n a t M C P
jo in t b y u n o p p o s e d a c t io n o f lo n g e x t e n s o r t e n d o n s

□ Treatm ent
» C o n s e r v a tiv e -
> H a n d p l a c e d in p r o p e r s p lin t

> P h y s io t h e r a p y

• S u r g ic a l - N e r v e s u tu r in g

Annulus
tibrosus

Nucleus
pulposus

10.5 : Prolapsed Intervertebral disc

744 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology GROUP - I I O SOLVEO SHORT NOTES OF SEMESTERS 745

Degenerated
annuljs Prolapsed disc

Fragmented
nucleus
pulposus

Stage of degeneration Stage of protrusion

(I)

Sequestered
' disc

(IV)

Fig. 2.10.6 : Pathology of disc prolapse

Fig. 2.10.7 : Osgood - Schlatter’s disease

Fig. 2 .1 0 .9 : Fracture healing
746 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology GROUP - II D SOLVED SHORT NOTES OF SEMESTERS 747

Fig. 2.10.10 : Flnketstein Test (De-Quervan’s disease)

(.1) Transverse

Undisplaced
Fig. 2.10.13: Thomas Test

(2) Oblique

Fragment < V,

(3) Spiral

— Fragment > '/,

(4) Comminuted

/ w j C O P Fig. 2.10.14 : Perthes disease

(5) Segmental
r l — Comminuted

y
Fig. 2.10.11 : Classification of traclure based on pattern Fig. 2-10.12 : Fracture head of radius
748 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology
GROUP - II □ SOLVEO SHORT NOTES OF SEMESTERS 749

Expansion ol
overlying conlex

Blood filled
radioluscert
lesion

F ig. 2 .1 0 .1 8 : A n eu rysm al b o n e c y s t

Fig. 2.10.15(D) : Calcaneum fracture

Fig. 2.10.20 : Osteosarcoma

750 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics 8 Anesthesiology

Section - 3

ANESTHESIOLOGY
F ig. 2 .10 .2 1 : O ste o sa rc o m a

Fig. 2.10.23 : Curves in Scoliosis

 SECTION- 3
SOLVED SHORT NOTES

Q .1 : Spinal anesthesia

SPINAL ANESTHESIA
0 What Is I t : F o r m o f r e g io n a l a n e s t h e s i a

□ S yno nym :
• S u b a r a c h n o i d b lo c k

• I n tr a th e c a l b lo c k

□ Indications:
• O r t h o p a e d ic s u r g e r y - o f lo w e r lim b s a n d p e lv is

• G en eral su rgery -

> p e lv ic s u r g e r y
Section - 3 > p e r in e a l s u r g e r y

> h e r n ia
ANESTHESIOLOGY > h y d r o c e le

> t e s t ic u l a r

> a p p e n d ix

• G y n a e c o lo g i c a l - a ll u te r in e s u r g e r i e s Ii k e m y o m e c t o m y , C a e s a r e a n s e c t i o n , c e r v ic a l s u r g e ries
1. Solved Short Notes
• U r o lo g y -
> b la d d e r s t o n e

> u r e te r ic s t o n e

> p ro s ta te su rg ery

□ C ontraindications:

C O N T R A IN D IC A T IO N S

X
Absolute Relative

- HICT - Uncontrolled HTN

Hypovoiaemic shock IHD

- Bleeding disorder
Patient on
aspirin
Patient on
anticoagulant
Spinal
deformity
Septicaemia

u Infected
local site n ___ I
5_
Previous spinal
surgery

95 7 5 3
 764 QUEST : A Comprehensive Gutde io UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES 7SS

□ Types:
« C a u d a l ( u p to L 5 )

• L o w s p in a l (u p to L I )

• M id - s p in a l ( u p t o T 1 0 )

• H ig h s p i n a l ( u p t o T 6)

• U n ila t e r a l s p i n a l

□ P ro c e d u re : .

• P o s it io n - la t e r a l O R s ittin g O R p r o n e

• A p p r o a c h - m id lin e O R la t e r a l O R lu m b o s a c r a l( T a y lo r )

• S it e - L 3 -L 4 O R L 4 -L 5

• 2 4 - 2 6 G n e e d l e p a s s e d t h r o u g h I n t e r s p i n o u s s p a c e a n d ll g a m e n t u m f la v u m t o r e a c h
s u b a r a c h n o id s p a c e to g e t d e a r C S F n e e d l e r o t a t e d 3 6 0 d e g r e e s a n d d r u g is s lo w ly
in je c t e d - * p a t ie n t t h e n k e p t in s u p in e p o s itio n

□ Site o f a c tio n : S p in a l n e r v e s f D o r s a l g a n g lia

□ Drugs u s e d : .

• L o c a l a n a e s th e tic s

. > L i g n o c a i n e - 5 % in 7 . 5 % D e x t r o s e

> B u p iv a c a in e - 0 .5 % in 8% D e x tro s e

> T e t r a c a i n e -1 % in 5 % D e x t r o s e

> P r o c a i n e - 1 0% in 5 % D e x t r o s e

• O p io id s

• O t h e r s - k e t a m in e

□ A d v a n ta g e s : ,

• Low cost

« R e d u c e d b le e d i n g d u e t o h y p o t e n s io n

• A d e q u a t e r e la x a t io n a c h i e v e d

• L e s s r e s p ir a t o r y c o m p li c a t io n s

□ C ontraindications:
. □ Factors affecting duration o f b lo c k :
• A ll e r g y
• D o se
• S e p s is • I n c r e a s in g c o n c tr e t a t io n
• C a r d i a c p a t ie n t s • P h a r m a c o l o g ic a l p ro file o f d ru g

• S p in a l tumors • T y p e o fd r o g

• A d d e d v a s o c o n s t r ic t o r s
• K y p h o s is , s c o l i o s i s

Q . 2 ; Post spinal headache

□ C om plications:

POST SPINAL HEADACHE

□ W hat is i t : C a u s e o f h e a d a c h e a l t e r s p in a l a n e s t h e s i a
□ Cause : L o w P r e s s u r e H e a d a c h e d u e t o s e e p a g e o f c e r e b r o s p in a l flu id fro m d u r a l re n t c r e a t e d b y
s p in a l n e e d le .

*Q A m ount o f Cerebrospinal fuid lo s s : 1 0 ml/hr

 SOLVED SHORT NOTES 757
756 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology

□ Other cause o f headache a fte r spinal a n e s th e s ia :

□ P ath og enesis: C S F l e k a g e - » C h a n g e s in h y d r o d y n a m ic s - » T r a c t io n o n p a in s e n s i t i v e s t r u c t u r e s
M e n in g e a l irritation - d u e t o b a c t e r ia l o r c h e m ic a l m e n in g itis (It is h ig h p r e s s u r e h e a d a c h e , h a v in g n o
- » P a ln re la tio n w ith p o s lu r o )
□ Etiology:
0 . 3 : M uscle relaxants
• N e e d le s i z e : 1 6 G n e e d l e -> 7 5 % c a s e s

2 5 G n e e d le —» 1 . 3 % c a s e s MUSCLE RELAXANTS
• T y p e o f n e e d le : I n c r e a s in g i n c id e n c e w ith d u r a l c u ttin g n e e d le
□ W hat are th e y : D r u g s th a t a c t p e r ip h e r a lly a t n e u r o m u s c u la r ju n c tio n / m u s c le fib r e its e lf o r c e n t r a lly
D e c r e a s i n g in c id e n c e w ith d u ra l s e p a r a t i n g n e e d le
in c e r e b r o s p in a l a x i s to recbico tone a n d / o r c a u s e p a r a ly s is
• H ig h a ltitu d e
Q Classification :
• H is to r y o f h e a d a c h e

• I n a d e q u a t e h y d r a t io n

» P regn an cy

• F e m a le , y o u n g a g e

□ Clinical fe a tu re s :
P a in w ith fo llo w in g f e a t u r e s -
» P r e s e n t s a f t e r - 1 2 t o 2 4 h r s ( w h e n p a t ie n t s t a r t s sittin g )

» S i t e - o c c ip it a l, ( r a r e ly fro n ta l)
• A s s o s i a t e d - p a in a n d s t if f n e s s in n e c k

• N a t u r e - th r o b b in g

• R e liv e d b y - ly in g d o w n
• A g g r a v a t e d b y - s ilt in g , s t r o n g lig h t ,n o is e

• L a s t s fo r - 7 ( o l 0 d a y s .

O Treatm ent:

□ Mechanism o f a c tio n :
• N o n - d e p o la r is in g a g e n t -
N D M R a r e c o m p e t it iv e a n t a g o n is t s w ith a c e t y lc h o l in e a t a c e t y lc h o l in e r e c e p t o r s a n d N D M R
b in d a t t h e a l p h a s u b u n it a t w h ic h a c e t y lc h o l in e b in d s . T h e y a l s o b lo c k p r e ju n c t io n a l n ic o tin ic
r e c e p t o r s o n m o to r n e r v e e n d i n g s (e x h ib it 'f a d e ' p h e n o m e n o n )

• D e p o la r is in g a g e n t -
S C h a t t a c h e s t o t h e s a m e s it e a s a c e t y lc h o lin e , p r o d u c in g s a m e a c tio n a s a c e t y lc h o l in e . B u t,
u n lik e a c e t y lc h o l in e w h ic h is e a s i l y m e t a b o l iz e d , S C h m e ta b o lis m d e p e n d s o n th e
c o n c e n t r a t io n g r a d ie n t o f s u c c in y lc h o li n e b e t w e e n p l a s m a a n d n e u r o m u s c u la r fu n c tio n . S o
 75# QUEST: A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES 759

e x c e s s i v e e x c it a b ilit y o f S C h a t n e u r o m u s c u la r ju n c tio n p r o d u c e s r e p e a t e d d e p o la r i s a t io n s 0 . 4 : M onitoring In tn e s th e s la

a n d c o n t r a c t io n s ( f a s c lc u la t io n s ) . A t th is s t a g e , b o th v o l t a g e a n d t im e d e p e n d e n t g a t e s o f
M O N I T O R I N G IN A N E S T H E S I A
r e c e p t o r a r e o p e n b u t a f t e r s o m e t im e t im e - d e p e n d e n t g a t e c l o s e s p r o d u c in g r e la x a t io n In sp ite
o f S C h m o l e c u l e s a t t a c h e d t o r e c e p t o r s . S e c o n d l y c o n t in u o u s p r e s e n c e o f S C h l e a d s lo □ B A S I C M O N IT O R IN G -
a c c o m m o d a t i o n (in e x c ita b ility ) o f p e r iju n c tio n a l m e m b r a n e m a k in g it ir r e s p o n s iv e . T h is is • P u l s e ra te
h o w S C h p r o d u c e s r e la x a t io n p r e c e e d e d b y c o n t in u o u s c o n t r a c t io n i.e . P h a s e I b lo c k • C o lo u r o f s k i n - d e t e c t c y a n o s i s
A c tio n s : « B lo o d p r e s s u r e
• Skeletal muscles - N D M R r a p id ly p r o d u c e m u s c le w e a k n e s s f o llo w e d b y f la c c id p a r a ly s is . • In fla tio n o f c h e s t
D e p o la r is in g b lo c k e r s p r o d u c e f a s c ic u l a t r o n s la s t in g fo r f e w s e c o n d s b e f o r e I n d u c in g fla c c id • P r e c o r d ia l a n d o e s o p h a g e a l s t e t h o s c o p y •
p a r a ly s is • S i g n s o f s y m p a t h e t ic o v e r a c t iv it y - la c rim a tio n , p e r s p ir a tio n
CVS­ • U r in e o u tp u t
> NDMR _> » g a n g lio n ic b lo c k a d e
□ A D V A N C E D (IN S T R U M E N T A L ) M O N IT O R IN G -
R e d u c e B P d u e to — ► h is t a m in e r e l e a s e
• Cardiovascular m onitoring:
r e d u c e d v e n o u s retu rn 1. N o n In v a siv e m e th o d s -

* I n c r e a s e h e a r t r a t e d u e t o g a n g lio n i c b l o c k a d e > E C G - L e a d II t o d e t e c t a r r h y th m ia , V I - V 6 t o d e t e c t I s c h a e m ia

> D e p o la r ls js n g a g e n t s - * > N o n -in v a s iv e B P (N IB P ) - m e a s u r e s B P a t s e t in t e r v a ls a u t o m a t ic a lly b y

a u t o m a t e d o s c illo m e t r y
* B r a d y c a r d i a ( d u e t o a c t iv a t io n o f v a g a l g a n g lia )

* T a c h y c a r d i a + r e d u c e d B P ( d u e l o s tim u la tio n o f s y m p a t h e t ic g a n g lia )

> T r a n s o e s o p h a g e a l e c h o c a r d io g r a p h y -

* d e t e c t L V w a ll m o tio n a b n o r m a lity
• H is t a m in e r e l e a s e - b y N D M R

• > h y p o te n s io n * d e t e c t v a lv u la r d y s fu n c t io n
* d e t e c t in t r a c a r d ia c a ir
> f lu s h in g
2. In v a siv e m e th o d s - .
> b ron ch osp asm
> i n c r e a s e d r e s p ir a t o r y s e c r e t io n s > I n v a s i v e B P (I B P ) -

* R a d ia l a r te r y c o m m o n ly c h o s e n
» M e t a b o lic - D e p o la r is i n g a g e n t s c a u s e h y p e r k a la e m ia
• G I T - D e p o la r is i n g a g e n t s c a u s e t h e f o l lo w i n g : * A ll e n 's t e s t d o n e b e f o r e r a d ia l a r te r y c a n n u la t io n t o a s s e s s p a t e n c y o f u ln a r
a r te r y
> I n c r e a s e d in t r a g a s t r ic p r e s s u r e
> C e n t r a l v e n o u s p r e s s u r e m o n ito rin g ( C V P ) -
> i n c r e a s e d s a li v a t io n
* I d e a l - righ t in te rn a l ju g u la r v e in a s It Is v a l v e l e s s
> i n c r e a s e d g a s t r ic s e c r e t io n s
* I n d ic a t io n s -
> i n c r e a s e d p e r is t a l s is
<• M a jo r s u r g e r ie s w h e r e la r g e flu c t u a tio n s in h e m o d y n a m ic s e x p e c t e d
• E y e - D e p o la r is i n g a g e n t r a i s e in t r a o c u la r t e n s io n
<• O p e n h e a rt s u r g e r ie s
□ Uses :
<• FluJd m a n a g e m e n t in s h o c k
• A d ju v a n t s t o g e n e r a l a n a e s t h e t i c s
❖ P a r e n t e r a l nutrition
• A s s i s s t e d v e n tila tio n
* C o m p lic a t io n s -
• A v o id c o n v u l s i o n s a n d t r a u m a fro m e l e c t r o c o n v u l s iv e th e ra p y
❖ A ir e m b o lis m
• S e v e r e c a s e s o f t e t a n u s a n d s t a t u s e p if e p t ic u s
❖ T h r o m b o e m b o lis m
« S u c c in y l c h o li n e in m a lig n a n t h y p e r t h e r m ia ❖ C a r d i a c a r r h y th m ia
□ O ther salien t p o in ts : ❖ P n e u m o / h a e m o / c h y lo - t h o r a x

« F irs t m u s c le t o b e b lo c k e d - c e n t r a l m u s c l e s o f b o d y > P u lm o n a r y a r t e r y c a t h e t e r is a t io n -

« P r o l o n g e d a p n o e a a f t e r S C h a d m in is tr a tio n d u e to - * C a th e te r u s e d - S w a n -G a n z c a th e te r

> lo w p s e u d o c h o l i n e s t e r a s e * U ses - '

> a ty p ic a l p s e u d o c h o lin e s t e r a s e <• M e a s u r e c a r d ia c c h a m b e r s p r e s s u r e

> p h a s e II b lo c k <• C a l c u la t e c a r d i a c o u tp u t

• G a lla m i n e is t h e o n ly N D M R t o c r o s s B B B a n d p la c e n t a ❖ M e a s u r e p u lm o n a r y a r te r y o c c l u s i o n p r e s s u r e
❖ B e s t g u i d e to a s s e s s t is s u e p e r f u s io n
• R e v e r s a l o f b lo c k b y a n t i c h o li n e s t e r a s e
<• T itra tio n ol flu id in fu s io n
 760 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES 761

□ Respiratory m o n ito rin g : | □ Neurom uscular m o n ito rin g :

• Pulse oxym etry- • C o m m o n ly u s e d m u s c le is a d d u c t o r p o llic is s u p p l ie d b y u ln a r n e r v e
> A im - T o m e a s u r e o x y g e n s a t u r a t io n in b lo o d ( S p 02) • N e u r o m u s c u l a r m o n ito r d e l iv e r s a n u m b e r o f s tim u li a m o n g w h ic h t r a i n o f four* is t h e m o s t
V A p p lic a t io n o f p r o b e s - u s e fu l m e th o d

* F in g e r - n a il b e d □ Monitoring depth o f a n e s th e s ia : d o n e c lin ic a lly

* T o e - n a il b e d G M onitoring blood lo s s :
* E a r lo b u le T h is is d o n e b y -

* T ip o f n o s e » • G r a v im e t r ic m e th o d

> N o rm a l S p 0 2- 9 7 -9 8 % » V o lu m e tr ic m e t h o d
> P r in c ip le - A s o u r c e o f lig h t is e m itte d a t t w o w a v e l e n g t h s ( 6 6 0 n m a n d 9 4 0 n m ) fro m • C o lo r im e tr ic m e t h o d
a p r o b e w h ic h w h e n p a s s e s th r o u g h t i s s u e c o n t a in in g b lo o d Is a b s o r b e d b y p u ls a tile | □ E xpired gas a n a ly s is :
a r t e r y a n d c a p illa r y b lo o d a n d n o n - p u ls a t ile v e n o u s b lo o d a n d t i s s u e . T h e ra tio o f
M a s s s p e c t r o m e t e r s , R a m a n g a s a n a l y s e r s u s e d to m e a s u r e c o n c e n t r a t io n o f a n a e s t h e t ic v a p o u r s
t w o i s c a l c u l a t e d b y p u l s e o x y m e t e r w h ic h c o n v e r t s it in t o o x y g e n s a t u r a t io n
□ E voked re s p o n s e s :
> U s e - F o r d e t e c t io n o f h y p o x ia in in t r a o p e r a t iv e a n d p o s t o p e r a t i v e p e r io d
1 • S S E P (S o m a to se n so ry )
> A b n o r m a lit ie s -
• A E P (A u d ito ry )
* C a r b o x y h a e m o g lo b in - S p 02 9 5 %
• V E P (V is u a l)
* M e t h a e m o g lo b in - SpOz 8 5 %

• Capnography - Q . 5 : Pulse oxym etry

> It i s t h e c o n t in u o u s m e a s u r e m e n t o f e n d tid a l v o lu m e c a r b o n d io x id e a n d its w a v e f o r m A : S e e t h e p r e v io u s a n s w e r

> N o r m a l: 3 2 -4 2 m m H g

* > U ses: Q.6 : Preanaesthetic check-up

* s u r e s t c o n fir m a t o r y s ig n o f c o r r e c t in tu b a tio n
PREANAESTHETIC CHECK-UP
* d i a g n o s e m a lig n a n t h y p e r t h e r m ia
□ H IS T O R Y -
* E T C O 2 is z e r o in c a r d i a c a r r e s t
• A lc o h p l in ta k e
• B lo o d g a s a n a l y s i s -
• D r u g in ta k e
> B lo o d g a s v a l u e s o f m ix e d v e n o u s b lo o d
• S m o k in g
> p O j = 40 mm Hg •
' • A n y a l le r g y
> pC0 2= 46 mm Hg
• C h r o n ic c o u g h
> O 2 s a t u r a t io n 7 5 %
• C h r o n ic d i s e a s e s - H T N , D i a b e t e s , T B , B r o n c h ia l a s t h m a , e t c
> M ix e d v e n o u s o x y g e n -> b e s t in d ic a to r o f c a r d i a c o u tp u t

> A r te r ia l o x y g e n -> b e t t e r in d ic a to r o f p u lm o n a r y fu n c tio n • R e g u la r m e d ic a t io n if a n y ( a n t ih y p e r t e n s iv e s , a n t ie p ile p t ic s , e tc .)

• L u n g v o lu m e s - b y s p ir o m e t e r □ C L IN IC A L E X A M IN A T IO N -

• O x y g e n a n a l y s e r s - t o m o n ito r a c t u a l v a l u e o f O 2 d e liv e r e d • General su rvey :

• A ir w a y p r e s s u r e m o n ito rin g - it s h o u ld b e < 2 0 - 2 5 c m H 2O r P o s tu re

□ Temperature m o n ito rin g : > N e c k m o v e m e n ts

• I n d ic a tio n s - > M o u th o p e n in g , ja w s

> c a r d ia c s u rg e ry > T e e th

> in fa n t, s m a ll c h ild re n 5* T rem or

> f e b r ile p a tie n t > V e i n o u s p r o m in e n c e

> p a t ie n t p r o n e t o d e v e l o p m a lig n a n t h y p e r t h e r m ia > P a llo r

> J a u n d ic e
• C o r e t e m p e r a t u r e m o n ito r in g s it e s -
> C lu b b in g
> oesophagus

> p u lm o n a r y a rte ry > E dem a

> n asop h aryn x > B .P

> P u ls e

96
 762 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES 763

• A ir w a y : 0 .7 : E pidural anesthesia
>• M o u th o p e n i n g
EPIDURAL ANESTHESIA
> T h y r o m e n t a l d is t a n c e
‘ > T e m p o r o m a n d ib u la r jo in t a s s e s s m e n t □ A n a to m y : E p id u r a l s p a c e is t h e p o t e n tia l s p a c e b e t w e e n d u r a a n te r io r ly a n d lig a m e n tu m fla v u m
p o s te r io r ly , w ith n e g a t i v e p r e s s u r e I n s id e , e x t e n d in g fro m f o r a m e n m a g n u m t o s a c r a l h ia tu s
> M a lla m p a ti s c o r in g -
C l a s s I - S o f t p a l a t e + F a u c ia l p illa r + U v u la v is ib le □ N e e d l e u s e d : T o u h y n e e d le
| E a s y in tu b a tio n
C l a s s II - S o f t p a l a t e + F a u c ia l p illa r v is ib le □ P ro ced ure : A ft e r n e e d le in s e r t e d , e p id u r a l c a t h e t e r p la c e d in t h e s p a c e a n d f ix e d - » 2 % x y lo c a in e o r
5 % b u p iv a c a i n e in je c t e d in to t h e s p a c e
C l a s s III - S o f t p a l a t e v is ib le

[ S a m s o n s Y o u n g m o d ific a tio n - G Difference with sp inal a n esth es ia:

| D iffic u lt in tu b a tio n
C l a s s I V - O n ly h a r d p a l a t e s e e n ] • T o a c h i e v e e p id u r a l a n a l g e s i a o r a n e s t h e s i a , a la r g e r d o s e o f d r u g Is ty p ic a lly n e c e s s a r y

• Respiratory system: th a n w ith s p i n a l a n a l g e s i a o r a n e s t h e s i a

S ig n s o f a s th m a , C O P D , T B , e tc . • T h e o n s e t o f a n a l g e s i a is s l o w e r w ith e p id u r a l a n a l g e s i a o r a n e s t h e s i a t h a n w ith s p in a l
a n a lg e s ia o r a n e s t h e s ia
• Cardiovascular system :
• A n e p id u r a l in je c tio n m a y b e p e r f o r m e d a n y w h e r e a l o n g t h e v e r t e b r a l c o lu m n (c e r v ic a l,
F o llo w in g c o n d it io n s e x c lu d e d -
th o r a c ic , lu m b a r , o r s a c r a l ) , w h ile s p i n a l in je c tio n s a r e t y p ic a lly p e r f o r m e d b e lo w t h e s e c o n d
> H TN
lu m b a r v e r t e b r a l b o d y t o a v o i d p ie r c in g a n d c o n s e q u e n t ly d a m a g in g t h e s p in a l c o r d
> IH O
• It is e a s i e r to a c h i e v e s e g m e n t a l a n a l g e s i a o r a n e s t h e s i a u s in g th e e p id u r a l ro u te th a n u s in g
> A r r y th m ia
t h e s p i n a l r o u te
> C a r d i a c fa ilu r e
• A n in d w e llin g c a t h e t e r i s m o r e c o m m o n ly p l a c e d in t h e s e t t in g o f e p id u r a l a n a l g e s i a o r
> V a lv u l a r h e a r t d i s e a s e a n e s t h e s i a t h a n w ith s p in a l a n a l g e s i a o r a n e s t h e s i a .
• A bdom en : L iv e r d i s e a s e s , e t c . e x c lu d e d
□ In dications:
• S p in e :
• F o r a n a l g e s i a a l o n e , w h e r e s u r g e r y is n o t c o n t e m p la t e d
> O v e r ly i n g s k in fo r a n y in fe c tio n
• A s a n a d ju n c t t o g e n e r a l a n e s t h e s i a . T h i s m a y r e d u c e th e p a t ie n t 's r e q u ir e m e n t fo r o p io id
> S p in a l c u r v a t u r e
a n a l g e s i c s . T h is is s u it a b l e fo r a w id e v a r ie t y o f s u r g e r y , fo r e x a m p le g y n a e c o l o g i c a l s u r g e r y
> I n te r v e r te b r a l s p a c e ( e . g . h y s t e r e c t o m y ) , o r t h o p a e d i c s u r g e r y ( e . g . h ip r e p l a c e m e n t ) , g e n e r a l s u r g e r y ( e .g .
la p a r o t o m y ) a n d v a s c u l a r s u r g e r y ( e .g . o p e n a o r tic a n e u r y s m re p a ir)
O IN V E S T IG A T IO N S -
• A s a s o l e t e c h n iq u e f o r s u r g i c a l a n e s t h e s i a . S o m e o p e r a t io n s , m o s t fr e q u e n t ly C a e s a r e a n
• C o m p le t e b lo o d c o u n t
s e c t io n , m a y b e p e r f o r m e d u s in g a n e p id u r a l a n a e s t h e t i c a s t h e s o l e t e c h n iq u e
• B lo o d g r o u p in g
• F o r p o s t - o p e r a t iv e a n a l g e s i a , a f t e r a n o p e r a t io n w h e r e t h e e p id u r a l t e c h n iq u e w a s u s e d a s
• H a e m a t o c r it
e i t h e r t h e s o l e a n a e s t h e t i c , o r w a s u s e d in c o m b in a tio n w ith g e n e r a l a n e s t h e s i a
• B lo o d s u g a r
• F o r th e tr e a tm e n t o f b a c k p a in
• B lo o d u r e a
• F o r t h e t r e a t m e n t o f c h r o n ic p a in o r p a llia tio n o f s y m p t o m s in te rm in a l c a r e , u s u a lly in t h e
• S e r u m c r e a t in in e s h o r t- o r m e d iu m -te r m
• S e ru m e le c tr o ly te s
□ Advantages :
• C h e s t X -R a y
• U s e d fo r c o n t in u o u s r e p e a t e d p r o l o n g e d a n e s t h e s i a
. ECG
• C a n b e u s e d tor s e v e r a l d a y s
• B lo o d g a s a n a ly s i s
□ C ontraindications:
• O t h e r c a r d i a c m o n ito rin g if r e q u ir e d
• A n a t o m ic a l a b n o r m a lit ie s , s u c h a s s p i n a b ifid a o r s c o li o s i s
□ TREATM ENT-
• P r e v io u s s p in a l s u r g e r y
• C o r r e c t io n o f a n a e m i a
• C e r t a in p r o b le m s o f t h e c e n t r a l n e r v o u s s y s t e m , in c lu d in g m u ltip le s c l e r o s i s o r s y r in g o m y e lia
• P r e o p e r a t i v e a n t ib io t ic s
• C e r t a in h e a r t - v a lv e p r o b le m s ( s u c h a s a o r t ic s t e n o s i s , w h e re t h e v a s o d il a t io n in d u c e d b y th e
« C o n t r o l o f r e s p ir a t o r y a n d c a r d i a c d i s e a s e s
a n a e s t h e t i c m a y im p a ir b lo o d s u p p l y to th e t h ic k e n e d h e a r t m u s c le )

□ P R E C A U T IO N S - • B le e d in g d is o r d e r ( c o a g u l o p a t h y ) o r a n t i c o a g u la n t m e d ic a t io n ( e .g . w a r fa r in ) • ris k o f s p in a l

• P r e o p e r a t iv e s t a r v a t io n fo r 4 h o u r s fo r liq u id s a n d 6 h o u r s fo r s o li d s c o r d - c o m p r e s s in g h e m a to m a
• I n fe c lio n n e a r t h e p o in l o f in t e n d e d in s e rtio n
• D e n t u r e s , c o n t a c t l e n s e s , je w e ll e r y r e m o v e d
• A lle r g y to t h e a n a e s t h e t ic
 764 QUEST : A Comprehensive Guide lo UG Surgery, Orthopedics & Anesthesiology
SOLVED SHORT NOTES 765

Q Choice o f a g e n ts :
• L o c a l a n a e s t h e t i c s - lid o c a in e , m e p iv a c a in e , b u p iv a c a i n e
C LA S S IFIC A TIO N
• O p io id s - m o r p h in e , fe n t a n y l, s u fe n t a n il, a n d p e th id in e
I
j :
□ Epidural anesthesia during ch ild b irth :
Injectable S u r fa c e

ADVANTAGES D IS A D V A N T A G E S

• D e c r e a s e d m a t e r n a l h y p e r v e n t ila t io n a n d • I n c r e a s e d n e e d f o r o x y t o c in t o s t im u la t e L o w p o ten cy S h ort duration S olu b le

in c r e a s e d o x y g e n s u p p ly to b a b y u te r in e c o n t r a c t io n s e .g . P ro ca in e, C h loro p rocaln e e .g . C o c a in e

• B e t t e r p a in r e lie f th a n o t h e r p a in m e d ic a t io n • I n c r e a s e d ris k o f m u s c u la r w e a k n e s s fo r a
p e r io d o f tim e a f t e r t h e birth
• D e c r e a s e d c ir c u la t in g a d r e n o c o r t ic o t r o p ic Interm ediate p o te n c y and
Insoluble
h o r m o n e a n d d e c r e a s e d fe t a l d is t r e s s • I n c r e a s e d ris k o f C a e s a r e a n s e c t io n f o r fe ta l duration
e .g . B e n z o ca in e
d is t r e s s e .g . Lidocaine, Prilocaine

• L o n g e r d e liv e r y ( s e c o n d s t a g e o f la b o u r)
High p o ten cy
• I n c r e a s e d r is k o f v e r y lo w b lo o d p r e s s u r e
Long duration
• I n c r e a s e d risk o f flu id r e te n tio n e .g . T etra cain e, B u p iv aca in e

□ C om plications:
□ Mechanism o f a c tio n : D ru g in u n d i s s o c i a t e d fo rm p e n e t r a t e s a x o n a l m e m b r a n e a n d in s id e It g e t s
• B u p i v a c a i n e is m a r k e d ly t o x i c II i n a d v e r t e n t ly g i v e n i n t r a v e n o u s l y , c a u s i n g e x c it a t io n ,
io n iz e d - > I o n iz e d fo rm b in d s t o r e c e p t o r s it u a t e d in s o d iu m c h a n n e l in in a c t iv a t e d s t a t e fro m in n e r
n e r v o u s n e s s , t in g lin g a r o u n d t h e m o u th , tin n itu s, tre m o r, d i z z i n e s s , b lu r r e d v is io n , o r s e i z u r e s , s i d e -> b lo c k s c h a n n e l -*■ p r e v e n t s d e p o la r is a t io n
f o llo w e d b y d e p r e s s i o n , d r o w s l n e s s , l o s s o f c o n s c i o u s n e s s , r e s p ir a t o r y d e p r e s s i o n a n d a p n e a
□ Types:
• V e r y la r g e d o s e s o f e p id u r a l a n a e s t h e t ic c a n c a u s e p a r a ly s is o f t h e in t e r c o s t a l m u s c l e s a n d
• C e n t r a l t e c h n iq u e s - N e u r a x ia l b lo c k a d e ( e p id u r a l a n e s t h e s i a , s p i n a l a n e s t h e s i a )
t h o r a c ic d ia p h r a g m (w h ic h a r e r e s p o n s i b l e fo r b r e a t h in g ) , a n d l o s s o f s y m p a t h e t ic n e r v e
in p u t t o t h e h e a r t , w h ic h m a y c a u s e a s ig n ific a n t d e c r e a s e in h e a r t r a t e a n d b lo o d p r e s s u r e • P e r ip h e r a l t e c h n iq u e s -

• T h e s e n s a t i o n o f n e e d in g t o u r in a te is o ft e n s ig n ific a n t ly d im in is h e d > t o p ic a l ( s u r f a c e ) a n e s t h e s i a

« L a r g e d o s e s o f e p id u r a lly a d m in is t e r e d o p io id s m a y c a u s e t r o u b l e s o m e itc h in g , a n d re s p ir a to r y > Infiltration b lo c k

d e p re s s io n > p le x u s b lo c k s s u c h a s b r a c h ia l p le x u s b lo c k s

• A c c id e n t a l d u r a l p u n c t u r e w ith h e a d a c h e > s in g le n e r v e b lo c k s

• B lo o d y ta p > in t r a v e n o u s r e g io n a l a n e s t h e s i a ( B ie r 's b lo c k )

• C a t h e t e r m is p l a c e d in to t h e s u b a r a c h n o id s p a c e □ Onset o f action depends o n :

• N e u r o l o g ic a l in ju ry • d o s e a n d c o n c e n t r a t io n -

• E p id u r a l a b s c e s s • pKa

• E p id u r a l h e m a t o m a • t y p e o f n e r v e fib re

• f r e q u e n c y o f n e r v e s tim u la tio n
Q .8 : R egional anestheslaJLocal anesthesia
□ Duration o f action depends o n :
• d ose
REGIONAL/LOCAL ANESTHESIA
• p h a r m a c e u t ic a l p ro file o f d r u g

□ What are they : D r u g s w h ic h u p o n t o p ic a l a p p lic a t io n o r lo c a l in je c t io n c a u s e r e v e r s ib l e l o s s o f • p la s m a p ro te in b in d in g

s e n s o r y p e r c e p t io n in a r e s t r ic t e d a r e a o f b o d y , a lo n g w ith m u s c u la r p a r a l y s i s a n d l o s s o f a u t o n o m ic . • m e t a b o lis m
c o n t r o l if a p p l ie d o v e r a m ix e d n e r v e
» a d d itio n o f v a s o c o n s t r ic t o r
( L o c a l a n e s t h e s i a is u s e d f o r a s m a ll p a rt o f t h e b o d y , r e g io n a l a n e s t h e s i a is u s e d fo r a l a r g e r p a r t o f
□ Adverse effects :
th e b o d y ]
• C N S - d i z z i n e s s , a u d ito r y a n d v is u a l d is t u r b a n c e , m e n ta l c o n f u s io n
□ C lassificatio n: • C V S - b r a d y c a r d ia , h y p o t e n s io n , c a r d ia c a r r h y th m ia

• H y p e r s e n s it iv ity r e a c t io n
 766 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES 767

0 . 9 : CPR ( P a t ie n t In s u p i n e p o s it io n -» r e s c u e r s t a n d s o n s i d e o n e h a n d l o c k e d o v e r o t h e r h a n d ->
c o m p r e s s i o n o v e r lo w e r th ird o f s te r n u m - » s te r n u m d e p r e s s e d b y 1 . 5 - 2 in c h e s , r e la x a tio n s h o u ld b e
CPR
e q u a l to c o m p re s sio n )
□ Fu ll fo r m : C a r d i o p u lm o n a r y r e s u s c it a t io n
□ D efibrillator:
□ C om po nen ts:
BLS -4 A u to m a tic e x t e r n a l d e fib rilla to r
• B a s i c life s u p p o r t ( B L S )
A L S - * M a n u a l d e fib rilla to r
• A d v a n c e d life s u p p o r t (A L S )
Indications -
• P o s t r e s u s c it a t io n life s u p p o r t
• V e n tr ic u la r t a c h y c a r d ia .
□ W hat is I t : S y m p t o m a t ic t h e r a p y t o r e s u s c it a t e a p a t ie n t w ith c a r d i a c a r r e s t
• V e n t r ic u la r fib rillatio n
□ Basic p a ra m e te rs :
• A ir w a y □ Drugs In A L S :
• B r e a t h in g • A d r e n a li n e
• C ir c u la t io n • A t r o p in e
• D e fib r illa to r • A m lo d a r o n e
• D ru gs • L ig n o c a ln e
□ A irw ay m a n a g e m e n t: □ Monitoring o f C P R :
• B LS-
• C ap n ograp h y
> O p e n m o u t h , s u c t io n o f a i r w a y s ( fin g e r s w e e p m e t h o d in u n c o n s c i o u s p a t ie n t s )
• C a r o t i d p u ls a tio n
> T ilt h e a d b a c k w a r d s - u s e p ilJ o w / s a n d b a g to s lig h t ly e x t e n d n e c k
« C o r o n a r y p e r f u s io n p r e s s u r e
. > C h in lift
□ C om plications:
> • J a w th r u s t m a n o e u v r e i.e . m a n d ib le p u lle d fo r w a r d
• P n e u m o th o ra x
• A LS-
• L u n g in ju ry
> E q u ip m e n t s - » G u id e l's a ir w a y t u b e , o r o p h a r y n g e a l t u b e
• R ib fr a c tu r e
> E n d o t r a c h e a l in tu b a tio n ( m o s t d e fin it iv e m e th o d )
• P n e u m o m e d ia s t in u m
<• T o r e m o v e fo r e ig n b o d ie s -
• Injury t o a b d o m in a l o r g a n s
* M a n u a l c o m p r e s s i o n o v e r lo w e r s t e r n u m
• P n e u m o p e r ic a r d iu m
* I n fa n t c h e s t th ru s t ,

* H e im lic h m a n o e u v r e ( c o m p r e s s a b d o m e n 6 - 1 0 t im e s , r e s c u e r s t a n d in g
b e h in d p a tie n t)
ALGORITHMFPB BASIC L I F E SUPPORT
* 4 b lo w s o n m id d le o f b a c k
A s s e s s m e n t o f c o n s c i o u s n e s s b y s h a k in g
* C r ic o t h y r o t o m y
i
□ B reathing m a n a g e m e n t: N o resp o n se
• B LS- V
> M o u th t o m o u t h ( o p e n a ir w a y - * p in c h n o s e - » c r e a t e a n a irtig h t s e a l - » g iv e b r e a t h O p e n a i r w a y a n d c h e c k b r e a t h in g
over 1 s e c o n d w ith s u ffic ie n t f o r c e t o m o v e c h e s t ) i
> M o u th t o a i r w a y ( S a f a r o r B r o o k a ir w a y ) If b r e a t h in g a b s e n t o r p a t ie n t g a s p i n g -> 2 r e s c u e b r e a t h s b y a n y o f t h e a b o v e m e n t io n e d m e t h o d s

> B a g a n d m a s k v e n tila tio n each over 1 secon d

• ALS - i
_____ - C a r o t id p u ls a tio n c h e c k e d
> V e n t ila t io n b y a d v a n c e d m e t h o d s -

E n d o t r a c h e a l in tu b a tio n
A bsen t P resen t
<• L a r y n g e a l m a s k a i r w a y (L M A )
I I
❖ C o m b i tu b e
C h e s t c o m p r e s sio n s s ta rte d B r e a t h s g i v e n @ 1 0 - 1 2 b re a th s / m in
❖ T r a c h e o s to m y tu b e
... I '

> V e n t ila t io n b y a u t o m a t ic v e n tila to r s C o n t in u e d till d e fib r illa to r a r r a n g e d

□ M aintenance o f c irc u la tio n : i
C a rd ia c m a s s a g e D e fib rilla tio n d o n e , w h ile rh y th m m o n ito re d
 768 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology SOLVED SHORT NOTES 769

□ Instrum ents u s e d :
ALGORITHM FOR ADVANCED LIFE SUPPORT • L a ryn go sco p e
• E n d o tra c h e a l tu b e
A s s e s s m e n t o f c o n s c i o u s n e s s b y s h a k in g
□ Features o f the c u ff:
-I
• P r e s s u r e - » < 3 0 c m o f H 2O
A ir w a y a n d b r e a t h in g m a n a g e m e n t
• V o lu m e - » 4 -8 m l o f a ir
I
□ R equired size o f tu b e : (in te rn a l d ia m e te r )
_ C ir c u la tio n a s s e s s e d ___
• P r e m a t u r e b a b i e s -> 2 . 5 m m
• 0 -6 m o n t h s - * 3 - 3 .5 m m
A bsent P resen t
• 6 m o n th s-1 y e a r -> 3 .5 - 4 m m
I I
• 1 -6 y e a r s - » [ ( A g e in y e a r s ) / 3 ] + 3 .5 m m
C h e s t c o m p r e s s i o n s s t a r t e d @ 100/m in B r e a t h s g i v e n @ 1 0 - 1 2 b re a th s / m in
• >6 y e a r s -> [ ( A g e in y e a r s ) / 4 ] + 4 . 5 m m
I i • A d u lt m a l e s - » 9 m m
R h y th m a s s e s s e d ---------------- ► N o n - s h o c k a b le • A d u lt f e m a l e s -> 8 mm
I
A □ Required len gth o f tube to b e In s e rte d :
S h o c k a b le
C P R c o n t in u e d • C h ild r e n - » [ ( A g e in y e a rs ) / 2 ] + 1 2 c m
-I
A d r e n a lin e 1 m g i.v ., r e p e a t e d • A d u lt m a l e s - » 2 3 c m
O n e s h o c k g iv e n
a t 3 - 5 m in s in te rv a l • A d u lt f e m a l e s -> 2 1 c m

C P R f o r 2 m in u t e s V a s o p r e s s in a fte r 2 n d d o s e o f □ Technique:
I a d r e n a lin e
P a tie n t li e s s u p in e w ith p illo w u n d e r o c c ip u t
R h y th m r e a s s e s s e d ___ A t r o p in e , a t 3 - 5 m in s in te r v a l

E x t e n s io n a t a tla n to - a x ia l jo in t, fle x io n a t c e r v i c a l s p i n e
R eco vered S till s h o c k a b l e N o n - s h o c k a b le X
I I L a r y n g o s c o p e b la d e in s e r t e d fro m rig h t s id e o f m o u th

C P R s to p p e d C P R c o n t in u e d , A d r e n a lin e in je c t e d J*
■
I L a r y n g o s c o p e is s lo w l y a d v a n c e d d is p la c in g t o n g u e to t h e le ft u n til e p ig lo t t is v i s u a l is e d
A n o t h e r s h o c k g iv e n
L ifte d a n te r io r ly to v i s u a l i s e g lo t tis

“ C P R fo r 2 m in u te s 1
Cycle repeated once
i E n d o tra c h e a l tu b e p a s s e d b e tw e e n v o c a l c o r d s
4
A m io d a r o n e / lig n o c a in e in je c t e d
C u f f in fla te d
1
------------ A n o t h e r s h o c k g iv e n
I
P o s it io n of t u b e v e r if ie d b y c a p n o g r a p h y a n d c h e s t a u s c u lt a t i o n
>1
Q. 10: Endotracheal Intubation T u b e s e c u r e d a t m o u th w ith a d h e s i v e t a p e s

ENDOTRACHEAL INTUBATION Q C om plications:

• L aryn gosp asm
□ W hat Is I t : P l a c e m e n t o f a fle x ib le p la s t ic lu b e in to t h e t r a c h e a t o m a in ta in a n o p e n a i r w a y in c ritica lly
• D e n t a l in ju ry
in ju re d , ill o r a n a e s t h e t i z e d p a t ie n t s t o fa c ilita te v e n tila tio n o f t h e lu n g s , in c lu d in g m e c h a n i c a l v en tila tio n ,
• H e m o d y n a m ic a lt e r a t io n s
a n d t o p r e v e n t t h e p o s s ib il it y o f a s p h y x ia t io n o r a ir w a y o b s t r u c t io n
• P e r f o r a t io n o f t h e t r a c h e a o r o e s o p h a g u s
□ Indications:
• P u l m o n a r y a s p ir a tio n o f g a s t r ic c o n t e n t s o r o t h e r f o r e ig n b o d i e s
• H y p o x ia • F r a c t u r e o r d is lo c a t io n o f t h e c e r v ic a l s p i n e , te m p o r o m a n d ib u la r jo in t o r a r y t e n o id c a r t i la g e s
• U n c o n s c io u s p a t ie n t s • D e c r e a s e d o x y g e n co n te n t
• M a n ip u la tio n o f a i r w a y • E l e v a t e d a r te r ia l c a r b o n d io x id e
• A ir w a y o b s t r u c t io n • V o ca l cord w e a k n e ss

□ P re req u is ites: □ Other m ethods o f In tu b atio n :

• G e n e ra l a n e s th e s ia • C r ic o t h y r o t o m y

• N e u r o m u s c u l a r b lo c k in g a g e n t • T r a c h e o s to m y

97
 770 QUEST : A Comprehensive Guide to UG Surgery, Orthopedics & Anesthesiology BIBLIOGRAPHY

INTRAVENOUS ANAESTHETICS

□ Drug d e ta ils :
A) T h io p e n t o n e s o d iu m

B) M e t h o h e x it o n e s o d iu m

C) P r o p o fo l

D) E lo m id a t e

E) S lo w e r a c tin g d ru g s

F) K e t a m in e
BIBLIOGRAPHY
G) F e n ta n y l

H) D e x m e d e t o m id in e

□ C lassificatio n: • B a R e y a n d L o v e 's S h o r t P r a c t ic e o f S u r g e r y , 2 5 th E d itio n

> I n d u c in g a g e n t s -
• S c h w a r t z ’s P r in c ip le s o f S u r g e r y , 1 0 th E ditio n
• T h io p e n t o n e s o d iu m ,
• S a b is t o n te x t b o o k o f S u r g e r y , 1 9 th ed itio n
• M e t h o h e x it o n e s o d iu m ,
• S R B ’s M a n u a l o f S u r g e r y , 4 th E d itio n
• P r o p o fo l,

• E lo m id a t e . • B e d s i d e C lin ic s In S u r g e r y b y D r. M a k h a n L a l S a h a

> S lo w e r a c tin g d r u g s - • C u r r e n t M e d ic a l d i a g n o s i s a n d T r e a t m e n t, 50 th A n n iv e r s a r y E d itio n ( 2 0 1 1 )

• 'B e n z o d i a z e p i n e s - D i a z e p a m , L o r a z e p a m , M id a z o la m
• H a r r is o n 's P r in c ip le s o f In tern al M e d ic in e , 1 9 th E d itio n
• D is s o c ia tiv e a n e s th e s ia - K e ta m in e
• A C o n c i s e T e x t b o o k o f S u r g e r y , 7 th E d itio n b y D r. S o m e n D a s
• O p io id a n a l g e s i a - F e n t a n y l .

□ M e ch a n ism :
> M a jo r t a r g e t s a r e G A B A a r e c e p t o r g a t e d -

• C l- c h a n n e l. ( M a n y in h a la t io n a n e s t h e t i c s , b a r b it u r a t e s , b e n z o d i a z e p i n e s a n d p ro p o fo l)

> N M D A r e c e p t o r s a r e t y p e o f g lu t a m a t e r e c e p t o r . (N 20 , K e t a m in e )
 QUEST: A KEY TO UG

OBSTETRICS &
GYNAECOLOGY
Solved WBUHS papers (2009-2020)

SounakDutta m b bs (w b u h s ), p g t

Shaurya Basak m b bs (w b u h s ), p g t

QUEST: A COMPREHENSIVE GUIDE TO UG

MEDICINE
Solved WBUHS papers (2010-2020)

AnupamMandal mbbs, pgt

QUEST: A COMPREHENSIVE GUIDE TO UG

PAEDIATRICS
Solved WBUHS papers (2008-2020)

Shatanik Sarkar m bbs, mo

DebasreeGuha m b bs . m d