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II Answers of Surgery Question Papers for MBBS Students WBUHS (2008-2020) rd 3 Prof. M.B.B.S, Part - II Paper I I – Answers of Surgery Question Papers for M.B.B.S Students Dr. Arkaprovo Roy ASSOCIATE PROFESSOR DEPARTMENT OF GENERAL SURGERY MEDICAL COLLEGE, KOLKATA The West Bengal University of Health Sciences M.B.B.S. 3rd Professional Part – II Examination, Paper – II, Examination, 2020 Subject: Surgery Time: 21/2 hrs. Paper: II Marks: 60 Attempt all questions Group -A 1. Write down the effect of prostatic hypertrophy on urethra and urinary bladder. Mention the medical and surgical treatment of benign prostatic hypertrophy. 5+5+5 Group - B 2. Answer any one of the following: a) A 30 year old lady presents with 3cm solitary nodule on right thyroid lobe. Give the differential diagnosis. How will you manage such patient? 5+10 b) A middle aged bus conductor presents with non healing ulcer and pigmentation in left lower leg near medial malleolus. How will you examine, investigate and manage this patient? 5+5+5 Group - C 3. Write short notes on any three of the following: 3x5 a) Branchial fistula. b) Regional anaesthesia. c) Endotracheal intubation. d) Undescended testis. e) Complications of chemotherapy. Group - D 4. Write short notes on any three of the following: 3x5 a) I.V.U b) Lucid interval. c) Cleft palate. d) Warthin’s tumour. e) Varicocele. Answers. 1. Effect of prostatic hypertrophy on urethra and urinary bladder: BPH is the most common cause of lower urinary tract symptoms (LUTS), which are divided into storage, voiding, and symptoms which occur after urination. Storage symptoms include the need to urinate frequently, waking at night to urinate, urgency (compelling need to void that cannot be deferred), involuntary urination, including involuntary urination at night, or urge incontinence (urine leak following a strong sudden need to urinate). Voiding symptoms include urinary hesitancy (a delay between trying to urinate and the flow actually beginning), intermittency (not continuous), involuntary interruption of voiding, weak urinary stream, straining to void, a sensation of incomplete emptying, and terminal dribbling (uncontrollable leaking after the end of urination, also called post-micturition dribbling).These symptoms may be accompanied by bladder pain or pain while urinating, called dysuria. Bladder outlet obstruction (BOO) can be caused by BPH. Symptoms are abdominal pain, a continuous feeling of a full bladder, frequent urination, acute urinary retention (inability to urinate), pain during urination (dysuria), problems starting urination (urinary hesitancy), slow urine flow, starting and stopping (urinary intermittency), and nocturia. BPH can be a progressive disease, especially if left untreated. Incomplete voiding results in residual urine or urinary stasis, which can lead to an increased risk of urinary tract infection. BPH most often occurs during this second growth phase. As the prostate enlarges, it presses against the urethra. The bladder wall becomes thicker. One day, the bladder may weaken and lose the ability to empty fully, leaving some urine in the bladder. Treatment: Medical therapy: as follows Alpha-blockers 5-alpha-reductase inhibitors Other drugs These medications relax the smooth These medications block the Phosphodiesterase 5 muscles of the prostate and bladder production of DHT, which inhibitors neck to improve urine flow and reduce accumulates in the prostate and bladder blockage. may cause prostate growth Nonselective Finasteride 5 mg daily Tadalafil Phenoxybenzamine 10 mg Dutasteride 0.5 mg daily twice a day Subcutaneous implant Yearly Alpha-1, short-acting Triptorelin pamoate 3.75 mg Prazosin 2 mg twice a day every month Alpha-1, long-acting Terazosin 5 or 10 mg daily Doxazosin 4 or 8 mg daily Alpha-1a selective Tamsulosin 0.4 or 0.8 mg daily Alfuzosin 10 mg daily Silodosin 4 or 8 mg daily Surgical indications include: Refractory urinary retention (failing at least one attempt at catheter removal), Recurrent urinary tract infection from BPH, Recurrent gross hematuria from BPH, Bladder stones from BPH, renal insufficiency from BPH, or Large bladder diverticula. Conventional Surgical treatment: Transurethral resection of the prostate: best option. Risks of TURP: include retrograde ejaculation (75%), impotence (5–10%), and incontinence (<1%). Complications include bleeding, urethral stricture or bladder neck contracture, perforation of the prostate capsule with extravasation, and if severe, TUR syndrome resulting from a hypervolemic,hyponatremic state due to absorption of the hypotonic irrigating solution. Clinical manifestations of the TUR syndrome include nausea, vomiting, confusion, hypertension, bradycardia, and visual disturbances. The risk of the TUR syndrome increases with resectiontimes >90 minutes. Treatment includes diuresis and, in severe cases, hypertonic saline administration. Transurethral incision of the prostate—Men with moderate to severe symptoms and a small prostate often have posterior commissure hyperplasia (elevated bladder neck). These patients will often benefit from an incision of the prostate. This procedure is more rapid and less morbid than TURP. Open simple prostatectomy—When the prostate is too large to be removed endoscopically, an open enucleation is necessary.Glands >100 g are usually considered for open enucleation. o A simple suprapubic prostatectomy is performed transvesically and is the operation of choice in dealing with concomitant bladder pathology. o In a simple retropubic prostatectomy, the bladder is not entered. Minimally Invasive Therapy: Laser therapy—Many different techniques of laser surgery for the prostate have been described. Two main energy sources of lasers have been utilized—Nd:YAG and holmium:YAG. 2. a) Differential diagnosis of apparent solitary thyroid nodules: 1) Benign thyroid neoplasms 2) Malignant thyroid 3) Other thyroid 4) Nonthyroid lesions neoplasms abnormalities a) Follicular b) Papillary a) Papillary carcinoma a) Thyroiditis a) Lymphadenopathy adenoma adenoma b) Follicular Carcinoma b) Thyroid cyst b) Thyroglossal duct i) Colloid c) Medullary carcinoma c) Infections cyst ii) Simple c) Teratoma d) Anaplastic carcinoma d) Granulomatous c) Parathyroid adenoma iii) Foetal e) Metastatic cancer disease (e.g., d) Laryngocele iv) Embryonal d) Lipoma f) Sarcoma sarcoidosis) v) Hurthle cell g) Lymphoma e) Dermoid cyst Diagnostic Tools of Solitary Thyroid Nodule: Clinical examination Radiological studies: Histopathological studies: Neck ultrasonography Fine needle aspiration cytology Isotope scanning of the thyroid Frozen section . Laboratory studies: CT scan Final histopathological T3,T4,TSH examination. Treatment of the Solitary Cold Thyroid Nodule: Non-Surgical: Surgical: -No treatment, just follow-up by FNAC -Isthmo-lobectomy -Hormone suppressive therapy -Near total thyroidectomy -Aspiration of a cyst -Total thyroidectomy -Ethanol injection -Recently, Laser photocoagulation Workup of a solitary thyroid nodule: 2. b) Diagnosis of this case is venous ulcer. Examination of the leg should for this patient: Palpation of pulses Signs of venous disease o Brawny skin o Haemosiderin pigmentation o Varicose eczema o Atrophie blanche (patchy areas of ischemia) o Lipodermatosclerosis. Signs of arterial disease o Shiny, hairless, pale and cool skin Ulcer examination - describe where possible for every ulcer: o Position o Colour o Tenderness o Temperature o Shape o Size o Specific to the ulcer: . Base . Edge . Depth . Discharge . Relationship to other structures . Lymph nodes o State of local tissues, including pulses - if cannot feel pulses then use Doppler Surrounding region o For pain, oedema, erythema, warmth, induration, discoloration, maceration, dryness, scarring from previous wounds, hair pattern, gangrenous digits, clubbing, cyanosis, capillary refill, and varicose veins. Investigations: The evaluation of patients with venous ulceration primarily includes noninvasive methods to elucidate the distribution and extent of pathology. Duplex ultrasound is the first line of investigation, as it provides assessment of both reflux and obstruction conditions. In patients with iliofemoral pathology, axial imaging with computed tomography scan or magnetic resonance imaging should be performed. If the treatment of iliofemoral vein obstruction is warranted, then invasive assessment using venography and/or intravascular ultrasound should be used to guide the interventional procedure. Venous valve reflux can be identified and accurately characterized by duplex ultrasound, whereas the ultrasound assessment of functional abnormality associated with obstruction is less reliable. In patients with ulceration, the evaluation for and treatment of proximal venous obstruction has resulted in improved ulcer healing. A venous leg ulcer can be susceptible to bacterial infection. Symptoms of an infected leg ulcer can include: Worsening pain A green or unpleasant discharge coming from the ulcer Redness and swelling of the skin around the ulcer A high temperature (fever) Nonsurgical Treatment Infected ulcers Necessitate treatment of the infection first. Staphylococcus aureus, Streptococcus pyogenes, and Pseudomonas species are responsible for most infections. Usually treated with local wound care, wet-to-dry dressings, and oral antibiotics. Topical antiseptics should be avoided. Severe infections require intravenous antibiotics. Leg elevation Leg elevation can temporarily decrease edema and should be instituted when swelling occurs. This should be done before a patient is fitted
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