MPMSU MBBS Surgery 2024 Paper 1 questions with their answers

• Radiation Exposure: Childhood exposure to ionizing radiation (e.g., acne, thymic irradiation).
• Genetic Factors:
  • RET proto-oncogene – Medullary carcinoma
  • BRAF mutation – Papillary carcinoma
  • FNMTC, Cowden’s, Gardner’s, Carney complex
• Iodine Intake:
  • Deficiency → Follicular carcinoma
  • Excess → Papillary carcinoma
• Pre-existing Thyroid Disease:
  • MNG → Follicular carcinoma
  • Hashimoto’s → Papillary carcinoma
  • Graves’ → Rarely associated
• Environmental / Lifestyle: Carcinogen & goitrogen exposure

  1.Differentiated Thyroid CarcinomasPapillary: Most common, lymphatic spread

•   Follicular: Iodine-deficient areas, hematogenous spread
•   Hürthle Cell: Variant of follicular, more aggressive
•   Poorly Differentiated Carcinoma: Intermediate grade, worse prognosis

  2.Undifferentiated (Anaplastic) Carcinoma: Aggressive, poor survival
  3.Medullary Carcinoma: From C-cells, calcitonin secreting, RET mutation, MEN2
  4.Thyroid Lymphoma: Rare, linked to Hashimoto’s
  5.Metastatic Tumors: Commonly from RCC, metastasize to bone/lung

• Papillary Carcinoma: BRAF V600E / RET-PTC mutations → MAPK activation, lymphatic spread
• Follicular Carcinoma: RAS mutation, PAX8-PPARγ, capsular & vascular invasion, hematogenous spread
• Medullary Carcinoma: RET mutation, from C-cells, calcitonin-producing, part of MEN2
• Anaplastic Carcinoma: TP53/β-catenin/PI3K mutations, dedifferentiated, aggressive spread

1.  Treatment of Primary Tumor
   1. Total Thyroidectomy: Preferred for:
      1. Age > 45 yrs, Tumor > 1 cm
      2. Multifocal/Contralateral nodules
      3. Extra-thyroidal extension or metastasis
      4. History of radiation/MEN syndromes
      Pros: Facilitates I-131, Tg monitoring, lower recurrence
      Cons: Risk of RLN injury, hypoparathyroidism, lifelong thyroxine
   2. Lobectomy: Indicated in:
      1. Low-risk microcarcinoma (<1 cm="" li="">
      2. Unifocal, intrathyroidal, no nodal/distant spread
      Preserves thyroid function, fewer complications
2. Management of Lymph Node Metastasis
   1. Central Compartment Dissection (Level VI): Only if nodes are clinically suspicious
   2. Lateral Neck Dissection (Levels II–V): Therapeutic if nodes palpable or positive on imaging
   3. Note: “Berry-picking” obsolete; LN dissection not done prophylactically in adults
3. TSH Suppression Therapy
   1. Levothyroxine (T4): 0.2 mg/day to suppress TSH (<0 .1="" cases="" high-risk="" in="" li="" mu="">
   2. Triiodothyronine (T3): Used short-term during radioiodine prep (40–60 mcg/day)

1. Treatment of Primary
   • Situation 1: Thyroid swelling + scalp secondaries → Total thyroidectomy (essential for I-131 uptake)
   • Situation 2: Follicular Ca on HPE after MNG surgery → Completion thyroidectomy
     • Safe if done < 7 days or > 4 weeks
     • Avoid 7 days–4 weeks due to fibrosis risk
   • Situation 3: FNAC shows follicular cells in solitary nodule → Total thyroidectomy
2. Metastatic Disease
   • After Total Thyroidectomy: Bone scan
   • Single Metastasis: I-131 therapy ± radiotherapy
   • Multiple Metastases: I-131 therapy
3. Thyroxine Therapy
   • 0.2–0.3 mg/day to suppress TSH and replace hormone
4. Prognosis: 10-year mortality ≈ 15%

1. Surgery: Total thyroidectomy
2. MRND: If lymph nodes involved
3. Post-op: Thyroxine suppression & regular follow-up

Definition:

Shock due to loss of circulating volume, resulting in decreased tissue perfusion.

Causes:

• Loss of blood – Haemorrhagic shock
• Loss of plasma – Burns shock
• Loss of fluid – Dehydration (e.g. gastroenteritis)

Pathophysiology:

↓ Preload → ↓ Stroke Volume → ↓ Cardiac Output → Hypotension & Hypoperfusion

• Cold peripheries
• Tachycardia
• Low blood pressure
• ↓ Urine output
• Altered mental status (confused or moribund in severe shock)

Classification (based on severity):

• Class I–IV depending on percentage of volume loss
• Class III & IV are considered severe, with marked hypotension and oliguria

Clinical Features:

• Tachycardia
• Hypotension
• Cold, clammy skin
• Delayed capillary refill
• Oliguria
• Altered sensorium

Treatment

Goal:

Restore circulating volume and tissue oxygenation as early as possible.

1. Crystalloids (First-line)

• Preferred in initial resuscitation
• Use Ringer Lactate
• Volume required: 2–3x the volume lost
• Saline: Risk of hyperchloraemic metabolic acidosis if used in large amounts
• 5% Dextrose: Not used—hypotonic after metabolism

2. Colloids

• Can be used in equal volume to loss
• Not preferred in initial resuscitation

3. Blood Transfusion

• Required if large blood loss
• Replace with blood products to restore oxygen-carrying capacity

Wound healing is influenced by both general and local factors.

• Age: Children heal faster; elderly heal slower due to decreased collagen.
• Debilitation & Malnutrition: Vitamin C and zinc deficiencies delay healing.
• Diabetes Mellitus: Microangiopathy, atherosclerosis, ↓ phagocytosis, ↑ infection risk.
• Jaundice & Uraemia: Poor fibroblast function delays repair.
• Cytotoxic Drugs & Malignancy: Inhibit cell proliferation (e.g., Doxorubicin).
• Generalised Infection: Systemic inflammation delays healing.
• Corticosteroids: Delay early healing due to anti-inflammatory action.
• Severe Malnutrition: Risk of wound dehiscence, leaks (albumin < 2 g/dL).

• Poor Blood Supply: Slower healing over poorly vascularised areas (e.g., tibia).
• Local Infection: Destroys granulation tissue; halts healing if bacterial load high.
• Haematoma: Medium for infection.
• Faulty Wound Closure: Excess tension or bad technique delays healing.
• Hypoxia: Seen in anaemia, smoking; ↓ angiogenesis and collagen production.
• Smoking: Vasoconstriction and ↑ CO impair oxygen delivery.
• Ionising Radiation: Causes fibrosis and poor healing via endarteritis.
• Foreign Bodies: Cause chronic inflammation and infection.

Derived from French word trier meaning "to sort." Used during mass casualty events to sort patients by severity of injury.

First action: Call for expert help (fire services, trauma centers, etc.)

Conducted by a trauma team, led by the senior-most doctor/surgeon. Patients are tagged with colored flags based on urgency.

• Red – Immediate: Needs treatment immediately to survive (e.g., obstructed airway, tension pneumothorax)
• Yellow – Urgent: May die within 1–2 hours without treatment (e.g., massive bleeding, hypovolemia)
• Green – Delayed: Stable, can wait (e.g., minor fractures)
• Blue – Expectant: Unsavable injuries (e.g., extensive burns, brainstem injury)
• Black/White – Dead: No signs of life

1. Can the patient walk?
   • Yes → Green (Delayed)
   • No → Check breathing
2. Is the patient breathing?
   • No → Open airway
     • If still not breathing → Black (Dead)
     • If resumes → Red (Immediate)
   • If already breathing → Count respiratory rate:
     • <10 or >30 → Red (Immediate)
     • 10–30 → Check circulation
3. Circulation Check:
   • Cap refill >2 sec or Pulse >120 → Red (Immediate)
   • Cap refill <2 sec or Pulse <120 → Yellow (Urgent)

• If trauma center is nearby: Scoop and run
• If far: Stay and play (stabilize on-site)
• Always ensure rescuer safety in unstable environments

1. Airway with Cervical Spine Protection
   • Assess: Foreign body, tongue fall, jaw fracture
   • Interventions:
     • Lift jaw
     • Intubation
     • Suction airway
     • Tracheostomy/cricothyrotomy if needed
     • Apply cervical collar in all trauma cases
   • Mnemonic: LIFTJAW
2. Breathing & Oxygen
   • Check: Tension pneumothorax, rib fractures, hemothorax, surgical emphysema
   • Give high-flow oxygen
   • Tension pneumothorax is clinical — do not delay for X-ray
3. Circulation & Bleeding Control
   • Assess: Feeble pulse, low BP, visible/internal bleeding
   • Investigations: USG, CT, ECHO
   • Management: 2 large IV lines, 2L crystalloids, control bleeding
4. Disability (Neuro Assessment)
   • AVPU: Awake, Voice response, Pain response, Unresponsive
   • Use GCS and check pupil reaction
5. Exposure & Environment Control
   • Fully expose patient
   • Prevent hypothermia
6. Fingers & Tubes (Key Box)
   • Check orifices: Ear, nose, mouth, rectum, vagina, urethra
   • Insert: NG tube, ETT, Foley catheter, IV/central line

• ABCDE – Airway, Breathing, Circulation, Disability, Exposure
• LIFTJAW – For airway management
• AVPU – Consciousness level
• AMPLE – Allergies, Medications, Past history, Last meal, Events
• FAST – Focused Assessment with Sonography in Trauma

Flail chest results from severe chest trauma involving multiple rib fractures.

Definition: Fracture of three or more ribs at two places—anteriorly and posteriorly—leading to a free-floating segment of the chest wall.

The flail segment loses its attachment to the chest wall and moves paradoxically:

• Inspiration: Segment drawn inward (negative pressure)
• Expiration: Segment bulges outward

This paradoxical respiration leads to:

• Hypoventilation
• CO₂ retention
• Respiratory failure

1. Anterior Flail: Fractures at costochondral junction on both sides of sternum
2. Posterior Flail: Fractures of posterior chest wall ribs
3. Lateral Flail: Fractures of the shaft of the ribs

I. Commonly Done Procedures

• Anterior Flail: Stabilize with metal plates and screws (costal cartilage to sternum)
• Posterior Flail: Usually no treatment needed (scapula provides natural support)
• Lateral Flail:
  • Chest wall stabilization
  • Positive pressure ventilation
  • Velcro rib belt
  • Intercostal chest tube (removal of air/blood)
  • Reduce respiratory dead space
  • Treat pulmonary contusion
  • Pain control: Epidural analgesia (preferred), Intercostal nerve blocks

II. Other Methods

• Surgical Stabilization:
  • Rarely required
  • Open reduction, osteofixation with metal plates and screws
• Internal Pneumatic Fixation: Stabilization with positive pressure ventilation
  • Requires intubation for ≥1 week
• IPPV (Intermittent Positive Pressure Ventilation):
  • Start early (before hypoxia)
  • Benefits:
    • Proper rib union in inspiratory position
    • Reduces chest wall deformity
    • Improves pulmonary function

Ranula is a cystic swelling that arises from the sublingual salivary gland and the accessory salivary glands (glands of Blandin and Nuhn) located in the floor of the mouth.

The term "ranula" is derived from its resemblance to the belly of a frog (Rana hexadactyla).

A well-differentiated squamous cell carcinoma that arises in chronic scars—commonly burn scars or venous ulcers.

• Slow-growing and painless
• Locally malignant due to avascular, aneural scar tissue
• Spreads to lymph nodes only after invading healthy skin

• Wide local excision is the treatment of choice
• Amputation may be required for extensive or deeply invasive ulcers

Total fluid for first 24 hours = 4 ml × Body Weight (kg) × % TBSA (Total Body Surface Area burned)

• ½ of the calculated fluid is given in the first 8 hours (from time of burn)
• Remaining ½ is given over the next 16 hours

Maintain urine output of 0.5–1 ml/kg/hour

Pectoralis Major Muscle is spared in Patey’s Modified Radical Mastectomy.

• Maintains chest wall contour
• Improves cosmetic appearance
• Allows better shoulder function
• Supports stronger arm use

Collection of blood between the dura mater and the inner table of the skull.

• Injury to the middle meningeal artery or vein, especially in the middle cranial fossa.

• Frontal
• Parietal
• Vertex
• Posterior fossa

Skull fracture is seen in 60–80% of cases.

• Initial unconsciousness
• Lucid interval (temporary recovery)
• Subsequent deterioration

Confirmed by CT scan.