CMS 2018 Paper II \u2013 Part C (Q81\u2013Q120)<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:wght@600;700&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#cms18p2c*,#cms18p2c *::before,#cms18p2c *::after{box-sizing:border-box;margin:0;padding:0}\n#cms18p2c{--ter:#C0603A;--tp:#fdf1ec;--teal:#2A7A6F;--tl:#3da394;--tlp:#eaf4f3;--ink:#1a1a1a;--im:#444;--is:#777;--ln:#e0d8d4;--bg:#fdfaf8;--wh:#fff;--cb:#43a047;--cbg:#eaf7ef;--wb:#e53935;--wbg:#fdf0f0;--r:10px;font-family:'Source Serif 4',Georgia,serif;font-size:16px;color:var(--ink);background:var(--bg);line-height:1.7;padding:0 0 48px}\n#cms18p2c .sn{height:1px}\n#cms18p2c .sb{position:fixed;top:0;left:0;right:0;z-index:99999;background:var(--wh);border-bottom:2px solid var(--ln);border-left:4px solid var(--ter);box-shadow:0 2px 12px rgba(0,0,0,.11);opacity:0;pointer-events:none;transform:translateY(-110%);transition:opacity .22s,transform 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var(--teal);color:var(--teal);border-radius:8px;padding:10px 28px;font-family:'Playfair Display',serif;font-size:.95rem;font-weight:700;cursor:pointer;transition:background .2s,color .2s}\n#cms18p2c .rb:hover{background:var(--teal);color:var(--wh)}\n@media(max-width:480px){#cms18p2c .hd h1{font-size:1.15rem}#cms18p2c .qt{font-size:.88rem}#cms18p2c .ox{font-size:.84rem}}\n<\/style>\n<\/head>\n<body>\n<div id=\"cms18p2c\">\n<div class=\"sn\" id=\"cms18p2c-sn\"><\/div>\n<div class=\"sb\" id=\"cms18p2c-sb\">\n <div class=\"sr\">\n <div class=\"ti\" id=\"cms18p2c-ti\">\u23f1 <strong id=\"cms18p2c-td\">40:00<\/strong><\/div>\n <div class=\"si\">\u2705 <strong id=\"cms18p2c-sc\">0<\/strong><\/div>\n <div class=\"si\">\u274c <strong id=\"cms18p2c-sw\">0<\/strong><\/div>\n <div class=\"si\">\u23f3 <strong id=\"cms18p2c-sr\">40<\/strong> left<\/div>\n <div class=\"ss\"><\/div>\n <div class=\"si\">Net <strong id=\"cms18p2c-sn\">0<\/strong> \/ <strong id=\"cms18p2c-sm\">160<\/strong><\/div>\n <\/div>\n <div class=\"sp\"><div class=\"sf\" id=\"cms18p2c-sf\"><\/div><\/div>\n<\/div>\n<div class=\"gr\" id=\"cms18p2c-gr\">\n <div class=\"gb\"><h3>Time's Up!<\/h3><p>Submitting in<\/p><div class=\"gc\" id=\"cms18p2c-gc\">10<\/div><button class=\"gn\" id=\"cms18p2c-gn\">Submit Now<\/button><\/div>\n<\/div>\n<div class=\"hd\">\n <h1>Combined Medical Services Examination 2018<br>Paper II \u00b7 Part C<\/h1>\n <p>General Surgery \u00b7 ENT \u00b7 Orthopaedics \u00b7 Critical Care \u00b7 Bariatric \u00b7 Vascular<\/p>\n <div class=\"mt\">\n <span class=\"bd\">Questions 81 \u2013 120<\/span>\n <span class=\"bd\">Options reshuffled<\/span>\n <button class=\"tb\" id=\"cms18p2c-tb\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n<\/div>\n<div class=\"bd2\">\n <div id=\"cms18p2c-qs\"><\/div>\n <div class=\"sw\"><button class=\"bt\" id=\"cms18p2c-sub\">Submit Answers<\/button><\/div>\n <div class=\"sc\" id=\"cms18p2c-sc-box\">\n <div class=\"rg\" id=\"cms18p2c-rg\"><div class=\"ri\"><span class=\"rp\" id=\"cms18p2c-rp\">0%<\/span><span class=\"rs\">score<\/span><\/div><\/div>\n <h2>Your Result<\/h2>\n <div class=\"nl\" id=\"cms18p2c-nl\"><\/div>\n <div class=\"vd\" id=\"cms18p2c-vd\"><\/div>\n <div class=\"bs\"><span class=\"bn bc\" id=\"cms18p2c-bc\"><\/span><span class=\"bn bw\" id=\"cms18p2c-bw\"><\/span><span class=\"bn bk\" id=\"cms18p2c-bk\"><\/span><\/div>\n <button class=\"rb\" id=\"cms18p2c-rb\">\u21ba Retry Quiz<\/button>\n <\/div>\n<\/div>\n<\/div>\n<script>\n(function(){\n'use strict';\nvar NS='cms18p2c',TOTAL=40,MAX=160,TSECS=2400,GSECS=10;\nvar QS=[\n{id:81,stem:'Cellulitis is:',correct:'A nonsuppurative invasive infection of tissues',options:['A suppurative invasive infection of skin and subcutaneous tissues','A nonsuppurative invasive infection of tissues','Infection caused by Gram negative bacilli','Infection caused by anaerobic Streptococci'],exp:'Cellulitis is a NONSUPPURATIVE (no pus formation) spreading infection of the skin and subcutaneous tissues. It is caused predominantly by Streptococcus pyogenes (Group A beta-haemolytic streptococcus) and Staphylococcus aureus. Features: diffuse spreading erythema, warmth, swelling, tenderness; no fluctuation (no abscess\/pus collection). This distinguishes cellulitis from an abscess (suppurative \u2014 pus-forming) or necrotising fasciitis (deeper). The organism spreads via lymphatics and tissue planes rather than forming a localised pus collection. \"Nonsuppurative\" is the key term. Gram-positive cocci are the usual organisms, not Gram-negative bacilli. Anaerobic Streptococci cause Meleney\\'s gangrene\/synergistic gangrene \u2014 not simple cellulitis.'},\n{id:82,stem:'Following are the factors for increased risk of wound infection EXCEPT:',correct:'Good blood supply',options:['Malnutrition','Good blood supply','Metabolic diseases (diabetes, uraemia)','Immunosuppression'],exp:'Risk factors for wound infection: Malnutrition \u2714 (impaired collagen synthesis, reduced immune function \u2192 poor healing, high infection risk). Metabolic diseases \u2714 \u2014 Diabetes mellitus (impaired neutrophil function, microangiopathy, neuropathy \u2192 impaired healing and high infection risk); uraemia (impaired platelet function and immune deficiency). Immunosuppression \u2714 (steroids, chemotherapy, HIV \u2192 reduced ability to fight infection). GOOD BLOOD SUPPLY: PROTECTIVE against infection \u2014 adequate blood supply delivers oxygen, nutrients, neutrophils, and antibodies to the wound; removes metabolic waste. Good vascularity = low infection risk. Poor blood supply (ischaemia, peripheral arterial disease) = HIGH infection risk. Answer: Good blood supply \u2014 EXCEPT (does NOT increase infection risk; it decreases it).'},\n{id:83,stem:'A 25-year-old lady post exploratory laparotomy (bowel injury during MTP, 2 days back). 24 hours post-op: pulse 106\/min, RR 26\/min, TLC 14,000\/cumm, blood urea 84 mg%, serum creatinine 2.0 mg\/dL. She is having:',correct:'Sepsis syndrome',options:['Wound infection','Systematic inflammatory response syndrome','Sepsis syndrome','Multisystem organ failure (MSOF)'],exp:'Criteria analysis: SIRS (Systemic Inflammatory Response Syndrome) requires \u22652 of: Temperature >38\u00b0C or <36\u00b0C, HR >90\/min \u2714 (106), RR >20\/min \u2714 (26), WBC >12,000 or <4,000 \u2714 (14,000). This patient meets SIRS criteria. SEPSIS = SIRS + confirmed or suspected INFECTION. She has a known infective source (bowel injury \u2192 peritoneal contamination \u2192 intra-abdominal sepsis) + SIRS criteria. SEPSIS SYNDROME (older terminology) = SIRS + infection + organ dysfunction \u2014 she has renal impairment (urea 84 mg%, creatinine 2.0 = acute kidney injury) indicating early organ dysfunction. MSOF\/MODS: multiple organ failure \u2014 would require more severe, established failure of multiple systems. Wound infection: localised, does not explain systemic parameters. Answer: Sepsis syndrome.'},\n{id:84,stem:'A 22-year-old man with occasional rectal bleeding. Colonoscopy shows numerous sessile polyps in descending and sigmoid colon. Family history: elder brother operated for thyroid malignancy. The young man should be advised:',correct:'Prophylactic panproctocolectomy',options:['Prophylactic panproctocolectomy','Prophylactic anterior resection','Surveillance colonoscopy every 6 months','Colonoscopic removal of all polyps'],exp:'Clinical picture: young male + multiple colonic polyps + family history of thyroid malignancy \u2192 GARDNER\\'S SYNDROME or FAMILIAL ADENOMATOUS POLYPOSIS (FAP). FAP: autosomal dominant APC gene mutation; >100 adenomatous polyps throughout colon\/rectum; 100% risk of colorectal carcinoma if untreated; associated extra-colonic features (Gardner\\'s: osteomas, desmoid tumours, thyroid cancer \u2014 explains family history). Management: PROPHYLACTIC PANPROCTOCOLECTOMY (total colectomy + proctectomy + ileostomy or ileo-anal pouch) is the definitive treatment \u2014 removes all at-risk colonic and rectal mucosa. Anterior resection leaves the rectum at risk. Colonoscopic polypectomy is insufficient (polyps are too numerous and recur). Surveillance alone is inadequate given 100% malignancy risk. Answer: Prophylactic panproctocolectomy.'},\n{id:85,stem:'A 47-year-old post-menopausal lady on adjuvant Tamoxifen for 3 years for carcinoma breast presents with blood clots per vagina. She is probably suffering from:',correct:'Carcinoma Endometrium',options:['Carcinoma Vulva','Carcinoma Vagina','Carcinoma Endometrium','Uterine fibroid'],exp:'TAMOXIFEN is a selective oestrogen receptor modulator (SERM): Anti-oestrogenic in breast tissue (used for ER-positive breast cancer). PRO-OESTROGENIC in the endometrium \u2014 stimulates endometrial proliferation. Long-term tamoxifen use (>2 years) significantly increases risk of ENDOMETRIAL CARCINOMA (2\u20133\u00d7 increased risk) and endometrial polyps. Post-menopausal bleeding in a tamoxifen user \u2192 ENDOMETRIAL CARCINOMA until proven otherwise. This is a well-recognised, important side effect of tamoxifen. Fibroids: typically regress post-menopause (oestrogen-dependent); possible with tamoxifen\\'s oestrogenic effect but less likely than carcinoma. Carcinoma vulva\/vagina: not related to tamoxifen. Answer: Carcinoma Endometrium.'},\n{id:86,stem:'Which of the following regarding blood supply of rectum is NOT true?',correct:'Middle rectal artery arises from external iliac artery and passes through the lateral ligaments into rectum',options:['Superior rectal artery is a direct continuation of Inferior mesenteric artery','Middle rectal artery arises from external iliac artery and passes through the lateral ligaments into rectum','Inferior rectal artery arises from internal pudendal artery','Inferior rectal artery traverses the Alcock\\'s canal into rectum'],exp:'Rectal blood supply: Superior rectal artery \u2714 TRUE \u2014 direct continuation of the inferior mesenteric artery (IMA); supplies upper rectum. Inferior rectal artery \u2714 TRUE \u2014 arises from internal pudendal artery; traverses Alcock\\'s canal (pudendal canal) in the ischioanal fossa to reach the lower rectum\/anal canal. MIDDLE RECTAL ARTERY: arises from the INTERNAL ILIAC ARTERY (anterior division) \u2014 NOT the external iliac artery. It passes through the lateral ligaments of the rectum to supply the middle rectum. \"Arises from external iliac\" is FALSE \u2014 it arises from internal iliac. Answer: Middle rectal artery arises from external iliac \u2014 NOT true.'},\n{id:87,stem:'Gastric conduit after oesophageal resection is based upon:',correct:'Right Gastroepiploic artery',options:['Right Gastroepiploic artery','Short gastric vessels and Vasa brevia','Left gastric artery','Right gastric artery'],exp:'Oesophagectomy with gastric conduit (gastric pull-up): The stomach is mobilised and fashioned into a tube (gastric conduit) to replace the oesophagus. The conduit is based on the RIGHT GASTROEPIPLOIC ARTERY \u2014 which runs along the greater curvature of the stomach in the gastroepiploic arcade and provides the primary blood supply to the gastric conduit after division of: Left gastric artery (divided), Short gastric vessels (divided), Left gastroepiploic artery (divided). The RIGHT gastroepiploic (branch of gastroduodenal artery from hepatic artery) and right gastric arteries are preserved. The conduit is perfused mainly by the right gastroepiploic arcade. This is critical knowledge for oesophageal surgery \u2014 ischaemia at the conduit tip (fundus) is the main complication. Answer: Right Gastroepiploic artery.'},\n{id:88,stem:'A 70-year-old male with comorbidities presents with a benign-appearing parotid tumour. The best option is:',correct:'Superficial Parotidectomy',options:['Tumour enucleation','Superficial Parotidectomy','Aspiration biopsy confirmation','Radio therapy'],exp:'Parotid tumour management: The most common benign parotid tumour is Pleomorphic Adenoma (benign mixed tumour). TUMOUR ENUCLEATION: CONTRAINDICATED \u2014 pseudocapsule of pleomorphic adenoma is thin and incomplete; enucleation leads to capsule rupture, tumour spillage, and high recurrence rate (up to 45%). SUPERFICIAL PAROTIDECTOMY \u2714 \u2014 the standard treatment for parotid tumours in the superficial lobe. Provides adequate margins, preserves the facial nerve, low recurrence. Suitable even in elderly with comorbidities (can be done under local\/regional anaesthesia if needed). FNAC (aspiration biopsy): useful for diagnosis confirmation but NOT definitive treatment; cannot distinguish pleomorphic from carcinoma reliably for follicular-type lesions. RADIOTHERAPY: no role for primary benign parotid tumour. Answer: Superficial Parotidectomy.'},\n{id:89,stem:'FNAC is NOT conclusive in which one of the following thyroid swellings?',correct:'Follicular carcinoma thyroid',options:['Papillary carcinoma thyroid','Follicular carcinoma thyroid','Medullary carcinoma thyroid','Thyroiditis'],exp:'FNAC of thyroid \u2014 reliability: Papillary carcinoma \u2714 \u2014 FNAC is highly diagnostic; classic nuclear features (Orphan Annie eye nuclei, nuclear grooves, intranuclear inclusions, psammoma bodies) are easily identified on cytology. Medullary carcinoma \u2714 \u2014 FNAC shows characteristic features (amyloid stroma, plasmacytoid cells); calcitonin immunostaining confirms. Thyroiditis (Hashimoto\\'s) \u2714 \u2014 FNAC shows lymphocytes, H\u00fcrthle cells, follicular cells. FOLLICULAR CARCINOMA: FNAC CANNOT distinguish between follicular adenoma (benign) and follicular carcinoma (malignant). The diagnosis of follicular carcinoma requires HISTOLOGICAL evidence of capsular invasion and\/or vascular invasion \u2014 which cannot be assessed on cytology (aspirate does not preserve tissue architecture). FNAC of a follicular lesion = \"follicular neoplasm\" (indeterminate) \u2192 requires hemi\/total thyroidectomy for diagnosis. Answer: Follicular carcinoma.'},\n{id:90,stem:'Patients with phlebographically confirmed deep vein thrombosis of the calf:',correct:'Are at risk for significant pulmonary embolism',options:['Can expect asymptomatic recovery if treated promptly with anticoagulant','May be effectively treated with low-dose heparin','May be effectively treated with pneumatic compression stockings','Are at risk for significant pulmonary embolism'],exp:'Calf (distal) DVT: Untreated calf DVT propagates proximally (to popliteal, femoral veins) in ~20\u201330% of cases. Proximal DVT carries significant risk of PULMONARY EMBOLISM (PE) \u2014 the proximal thrombus can embolise to the pulmonary circulation. Even isolated calf DVT carries a real (though smaller) risk of PE. Current guidelines recommend anticoagulation for confirmed symptomatic calf DVT (or surveillance with proximal extension monitoring). \"Asymptomatic recovery with anticoagulation\" understates the treatment need. \"Low-dose heparin\" is prophylactic dosing \u2014 treatment requires THERAPEUTIC anticoagulation. \"Pneumatic compression\" is prophylaxis \u2014 not treatment of confirmed DVT. The key message: calf DVT IS at risk for significant PE due to proximal propagation. Answer: Are at risk for significant pulmonary embolism.'},\n{id:91,stem:'Herceptin (Trastuzumab) is an immunotherapeutic agent used for:',correct:'Carcinoma breast',options:['Carcinoma prostate','Carcinoma breast','Carcinoma rectum','Ovarian malignancy'],exp:'TRASTUZUMAB (Herceptin): a humanised monoclonal antibody targeting HER2 (Human Epidermal Growth Factor Receptor 2 \/ ErbB2). PRIMARY USE: HER2-positive CARCINOMA BREAST \u2014 approximately 20\u201325% of breast cancers overexpress HER2 (gene amplification); these tumours are aggressive but respond dramatically to trastuzumab. Used in: HER2+ early breast cancer (adjuvant), HER2+ metastatic breast cancer (palliative). Also used in: HER2-positive gastric\/gastro-oesophageal junction adenocarcinoma (Trastuzumab in combination with chemotherapy \u2014 ToGA trial). NOT used for: prostate cancer, colorectal cancer, ovarian cancer (different targets and mechanisms). Herceptin = HER2-targeted therapy = breast cancer (and HER2+ gastric cancer). Answer: Carcinoma breast.'},\n{id:92,stem:'Mainstay of accurate diagnosis of pancreatic injury following blunt abdominal trauma is:',correct:'Computed Tomogram',options:['Computed Tomogram','Diagnostic peritoneal lavage','USG abdomen','MRI abdomen'],exp:'Pancreatic injury diagnosis after blunt trauma: USG abdomen: limited for pancreas \u2014 retroperitoneal organ, obscured by bowel gas; insensitive for ductal injury. Diagnostic peritoneal lavage (DPL): non-specific for retroperitoneal injuries; does not assess pancreatic duct integrity. MRI\/MRCP: excellent for ductal anatomy but takes longer, less available in acute trauma, less accessible in haemodynamically unstable patients. CT ABDOMEN (with IV contrast) \u2714 \u2014 MAINSTAY: demonstrates pancreatic lacerations, haematoma, peripancreatic fluid, ductal disruption (indirectly), and associated injuries. CT grading (AAST) guides management. ERCP\/MRCP used for suspected main pancreatic duct injury when CT is equivocal. In haemodynamically stable trauma patients, contrast-enhanced CT is the gold standard for pancreatic injury assessment. Answer: Computed Tomogram.'},\n{id:93,stem:'Pancreatic pseudocysts developing complications are best managed by:',correct:'Surgery',options:['Conservative treatment','Radiologically guided interventions','External drainage','Surgery'],exp:'Pancreatic pseudocyst management: Uncomplicated pseudocysts: many resolve spontaneously (conservative management; wait 6 weeks for maturation). Complications of pseudocysts (haemorrhage, infection, rupture, gastric\/biliary obstruction, enlarging): SURGERY \u2714 \u2014 internal drainage (cystogastrostomy, cystojejunostomy, cystduodenostomy) is the gold standard for COMPLICATED pancreatic pseudocysts. Internal drainage into bowel provides definitive treatment. Radiologically guided aspiration\/drainage: for infected pseudocysts (pancreatic abscess) as a bridge or definitive treatment in poor surgical candidates \u2014 but surgery remains gold standard for complicated pseudocysts with structural complications. External drainage (pigtail catheter): for infected\/contaminated pseudocysts \u2014 not definitive for structural complications. Conservative: for uncomplicated\/asymptomatic. Complicated pseudocysts = Surgery (internal drainage). Answer: Surgery.'},\n{id:94,stem:'Which one of the following regarding absorbable meshes is NOT true?',correct:'They show very good results as collagen deposition is maximum',options:['They are made of polyglycolic acid fibre','They are used in temporary abdominal wall closure','They are used to buttress sutured repair','They show very good results as collagen deposition is maximum'],exp:'Absorbable meshes (e.g., Vicryl\/polyglactin, Dexon\/polyglycolic acid): Made of polyglycolic acid (PGA) fibre \u2714 \u2014 or polyglactin 910 (Vicryl). Used in temporary abdominal wall closure \u2714 \u2014 \"damage control\" laparotomy; bridge the fascial defect temporarily before definitive closure. Used to buttress sutured repair \u2714 \u2014 reinforces primary suture lines in contaminated\/infected fields where non-absorbable mesh is contraindicated. NOT IDEAL FOR PERMANENT REPAIR: absorbable meshes are absorbed over 60\u201390 days; they are replaced by fibrous tissue but collagen deposition is INSUFFICIENT for durable repair \u2014 they do NOT show \"very good results\" as permanent hernia repair (high recurrence rates). Non-absorbable meshes (polypropylene, polyester) provide permanent support with good collagen ingrowth. \"Collagen deposition is maximum\" and \"very good results\" are NOT true for absorbable meshes. Answer: Very good results\/maximum collagen deposition \u2014 NOT true.'},\n{id:95,stem:'Which one of the following is NOT a surgical modality for management of femoral hernia?',correct:'The canal ring narrowing operation (Lytle\\'s)',options:['Lotheissen\\'s (Inguinal) operation','The high approach (McEvedy)','The low approach (Lockwood)','The canal ring narrowing operation (Lytle\\'s)'],exp:'Femoral hernia repair approaches: Lotheissen\\'s (inguinal\/transinguinal) approach \u2714 \u2014 repair from above through the inguinal canal; allows concurrent inguinal hernia repair. McEvedy\\'s (high\/extraperitoneal) approach \u2714 \u2014 vertical incision above inguinal ligament; excellent access for strangulated femoral hernias; allows bowel resection if needed. Lockwood\\'s (low\/crural) approach \u2714 \u2014 directly below inguinal ligament over the hernial sac; simple for elective cases. LYTLE\\'S OPERATION (canal ring narrowing): used for INGUINAL HERNIA (narrows the internal inguinal ring) \u2014 NOT a standard approach for femoral hernia repair. Lytle\\'s is not among the three classical femoral hernia repairs. Answer: Lytle\\'s canal ring narrowing operation \u2014 NOT a femoral hernia surgical modality.'},\n{id:96,stem:'\"Triangle of Doom\" dissected and seen during Laparoscopic inguinal hernia repair is bounded by all EXCEPT:',correct:'Inferior epigastric artery',options:['Vas deference','Cord structures','Peritoneal fold','Inferior epigastric artery'],exp:'Triangle of Doom (in TAPP\/TEP laparoscopic inguinal hernia repair): A peritoneal triangle containing the EXTERNAL ILIAC VESSELS (artery and vein). Boundaries: Medial: VAS DEFERENS \u2714. Lateral: GONADAL\/CORD VESSELS (testicular vessels) \u2714. Superior: PERITONEAL FOLD \u2714 (peritoneal reflection). Contents: External iliac artery and vein \u2014 structures at risk of catastrophic haemorrhage if violated. The triangle is called \"doom\" because dissection or stapling here can injure the external iliac vessels. INFERIOR EPIGASTRIC ARTERY: not a boundary of the Triangle of Doom; it defines the \"Triangle of Pain\" (lateral to gonadal vessels \u2014 contains genitofemoral and lateral femoral cutaneous nerves). Answer: Inferior epigastric artery \u2014 NOT a boundary.'},\n{id:97,stem:'Antro-choanal polyp always arises from:',correct:'Maxillary sinus',options:['Maxillary sinus','Posterior ethmoidal cells','Posterior end of the septum','Nasopharynx'],exp:'ANTROCHOANAL POLYP (Killian\\'s polyp): a benign polyp that arises EXCLUSIVELY from the MAXILLARY SINUS (antrum) \u2014 specifically from the mucosa of the posterior\/inferior wall of the maxillary sinus. It grows through the maxillary ostium into the middle meatus, then extends posteriorly through the choana into the nasopharynx. Clinical features: unilateral nasal obstruction, predominantly in children and young adults. Treatment: endoscopic surgical removal including the stalk (otherwise recurs). Distinguished from simple nasal polyps (bilateral, ethmoidal origin, associated with allergy\/asthma). \"Always arises from the maxillary sinus\" is the classic, definitive statement. Answer: Maxillary sinus.'},\n{id:98,stem:'Paralytic ileus is a type of:',correct:'Adynamic obstruction',options:['Dynamic obstruction','Adynamic obstruction','Inflammatory obstruction','Drug induced obstruction'],exp:'Classification of intestinal obstruction: MECHANICAL (DYNAMIC) obstruction: physical blockage of bowel lumen; bowel peristalsis initially increased (borborygmi, colic), then may fail. Types: simple, strangulated, closed loop. FUNCTIONAL (ADYNAMIC) obstruction: bowel lumen is PATENT but peristalsis is absent or ineffective. PARALYTIC ILEUS \u2714 is the classic adynamic obstruction \u2014 failure of peristalsis due to: peritonitis, post-operative ileus, hypokalaemia, retroperitoneal haematoma, drugs (opioids, anticholinergics). Features: abdominal distension, absent bowel sounds, no colic, no mechanical cause. Pseudo-obstruction (Ogilvie\\'s syndrome) is also adynamic. \"Inflammatory obstruction\" and \"drug-induced obstruction\" are not standard classifications. Paralytic ileus = adynamic\/functional obstruction. Answer: Adynamic obstruction.'},\n{id:99,stem:'Indication of Coronary Artery Bypass Grafting (CABG) is:',correct:'Triple vessel disease',options:['More than 25% stenosis of critical left main stem','More than 25% stenosis of proximal left anterior interventricular artery','Triple vessel disease','Deranged Stress Echocardiography report'],exp:'CABG indications (ACC\/AHA guidelines): LEFT MAIN STEM stenosis \u226550% (not 25%) \u2014 significant reduction in calibre requiring intervention. Proximal LAD stenosis \u226570% (not 25%) \u2014 significant proximal LAD disease is a strong CABG indication. TRIPLE VESSEL DISEASE \u2714 \u2014 three-vessel coronary artery disease (LAD + circumflex + RCA stenosis \u226570%) is a Class I indication for CABG, especially with reduced LV function (EF <35%) or diabetes. Also: Left main equivalent (LAD + circumflex proximal disease). Failed PCI, LV dysfunction + viable myocardium. 25% stenosis is SUBCRITICAL \u2014 no intervention indicated at 25% stenosis in any vessel. Deranged stress echo alone (without defining anatomy) is not an indication \u2014 coronary angiography is needed first. Answer: Triple vessel disease.'},\n{id:100,stem:'Normal anatomical narrowing of ureter are present in all EXCEPT:',correct:'Crossing the abdominal aorta',options:['Ureteropelvic junction','Crossing the abdominal aorta','Entering bladder wall','Ureteric orifice'],exp:'Three normal anatomical NARROWINGS of the ureter (sites where calculi most commonly obstruct): (1) PELVIURETERIC JUNCTION (PUJ\/UPJ) \u2714 \u2014 where the renal pelvis joins the ureter. (2) CROSSING OF THE PELVIC BRIM \/ ILIAC VESSELS \u2714 \u2014 where the ureter crosses the common iliac artery bifurcation (not the abdominal aorta). (3) VESICOURETERIC JUNCTION (VUJ) \u2014 where the ureter enters the bladder wall (ureterovesical junction) \u2714 \/ ureteric orifice \u2714. CROSSING THE ABDOMINAL AORTA: the ureter does NOT normally cross the abdominal aorta; it runs lateral to the aorta. The pelvic brim narrowing is at the common iliac vessels, not the aorta. \"Crossing the abdominal aorta\" is NOT a standard anatomical narrowing of the ureter. Answer: Crossing the abdominal aorta.'},\n{id:101,stem:'Which one of the following is NOT correct regarding Adenocarcinoma of the kidney (Renal Cell Carcinoma)?',correct:'It always presents with haematuria',options:['It is also called Grawitz tumour','It always presents with haematuria','It may be associated with Pyrexia of unknown origin','Renal vein extension may embolize to lungs'],exp:'Renal Cell Carcinoma (RCC \/ Adenocarcinoma kidney \/ Hypernephroma): Grawitz tumour \u2714 TRUE \u2014 named after Paul Grawitz who described it (also called hypernephroma as it was thought to arise from adrenal rests). PUO (Pyrexia of Unknown Origin) \u2714 TRUE \u2014 RCC is a classic cause of PUO; paraneoplastic pyrexia from cytokine production (IL-6). Renal vein extension \u2714 TRUE \u2014 RCC characteristically invades the renal vein \u2192 IVC \u2192 can embolise to pulmonary arteries (cannon ball metastases); also direct IVC thrombus. ALWAYS PRESENTS WITH HAEMATURIA: NOT CORRECT. Classic triad (haematuria + loin pain + palpable mass) occurs in only ~10% of cases. Most RCC are now discovered INCIDENTALLY on imaging. Haematuria is common (~60%) but NOT universal \u2014 \"always\" is false. Answer: Always presents with haematuria \u2014 NOT correct.'},\n{id:102,stem:'Which one of the following regarding abdominal paediatric surgery is correct?',correct:'Incision can be closed with absorbable suture',options:['Transverse abdominal incision is always used','Incision can be closed with absorbable suture','Bowel must be always anastomosed in double layer','Skin over abdomen can never be closed with subcuticular sutures'],exp:'Paediatric abdominal surgery principles: Transverse incision \"always\": FALSE \u2014 both transverse and vertical incisions are used depending on the procedure; no absolute rule. Bowel anastomosis \"always double layer\": FALSE \u2014 single-layer anastomosis is equally effective and widely used in paediatric surgery (and adult surgery). Skin \"never\" with subcuticular sutures: FALSE \u2014 subcuticular sutures are commonly used in paediatric surgery to provide a cosmetically superior, suture-removal-free closure that is ideal for children. ABSORBABLE SUTURES for incision closure \u2714 TRUE \u2014 in paediatric surgery, absorbable sutures (polyglactin\/Vicryl, poliglecaprone\/Monocryl) are routinely used for fascial and skin closure, avoiding the need for suture removal in children. Answer: Incision can be closed with absorbable suture.'},\n{id:103,stem:'Genetic disorder predisposing patients to develop Berry aneurysm includes all EXCEPT:',correct:'Neurofibromatosis Type II',options:['Adult polycystic kidney','Fibromuscular dysplasia','Neurofibromatosis Type II','Marfan\\'s syndrome'],exp:'Conditions associated with intracranial Berry (saccular) aneurysms: Adult polycystic kidney disease (ADPKD) \u2714 \u2014 up to 10\u201312% of ADPKD patients have intracranial aneurysms; PKD1\/PKD2 mutations affect vascular connective tissue. Fibromuscular dysplasia \u2714 \u2014 non-inflammatory, non-atherosclerotic arterial disease; affects renal and carotid\/intracranial arteries; associated with intracranial aneurysms. Marfan\\'s syndrome \u2714 \u2014 connective tissue disorder (FBN1 mutation); weakened arterial walls predispose to aneurysms (aortic > intracranial). Also: Ehlers-Danlos syndrome (Type IV), coarctation of aorta, AVM. NEUROFIBROMATOSIS TYPE II (NF2): characterised by bilateral vestibular schwannomas, meningiomas, ependymomas \u2014 NOT classically associated with Berry aneurysms. NF1 has some vascular associations but NF2 is primarily a tumour predisposition syndrome. Answer: Neurofibromatosis Type II.'},\n{id:104,stem:'Which one of the following regarding Nasal polyps is NOT true?',correct:'Nasal polyps are very painful to touch',options:['Nasal polyps are very painful to touch','Simple polyps are bilateral','Bleeding polyp may indicate malignancy','Meningocele must be excluded in children with polyps'],exp:'Nasal polyps \u2014 facts: Simple (ethmoidal) polyps: BILATERAL \u2714 TRUE \u2014 associated with chronic sinusitis, allergy, aspirin sensitivity, asthma. Bleeding polyp \u2714 TRUE \u2014 a polyp that bleeds easily may indicate malignancy (angiofibroma in adolescent males, inverted papilloma, carcinoma) \u2014 needs biopsy. Meningocele in children \u2714 TRUE \u2014 nasal polyps in children (especially unilateral) should prompt exclusion of meningocele or encephalocele (nasal glioma\/heterotopic brain tissue) before any intervention \u2014 blind biopsy\/removal can cause CSF leak and meningitis. PAINFUL: nasal polyps are characteristically INSENSITIVE\/PAINLESS to touch \u2014 they can be probed or manipulated without pain (in contrast to turbinate hypertrophy which is sensitive). \"Very painful to touch\" is FALSE \u2014 a key clinical distinguishing feature of polyps. Answer: Nasal polyps are very painful \u2014 NOT true.'},\n{id:105,stem:'Allen\\'s test is used in Cardiac surgery:',correct:'When radial artery harvest is planned',options:['To select finger prick for blood glucose estimation','When radial artery harvest is planned','For evaluation of AV fistula','To check warmth of hands'],exp:'ALLEN\\'S TEST: assesses the adequacy of the ULNAR collateral circulation to the hand when the radial artery is occluded. Performed by: simultaneously compressing both radial and ulnar arteries \u2192 patient clenches fist (hand blanches) \u2192 release ulnar artery \u2192 hand should flush pink within 7 seconds (normal = adequate ulnar collateral). A NORMAL Allen\\'s test confirms safe RADIAL ARTERY HARVEST \u2014 the hand will be adequately perfused by the ulnar artery alone post-harvest. CARDIAC SURGERY \u2714 \u2014 radial artery is commonly used as a conduit for coronary artery bypass grafting (CABG); Allen\\'s test is mandatory before harvesting. Also used before radial artery cannulation for arterial line placement in ICU. AV fistula evaluation: different tests (thrill, bruit, duplex). Blood glucose: not relevant. Answer: When radial artery harvest is planned.'},\n{id:106,stem:'In a lateral facial wound, if facial nerve injury is suspected, it should be:',correct:'Primary repair should be attempted',options:['Left alone','Skin and subcutaneous flaps to be raised to cover the cut ends','Primary repair should be attempted','Secondary repair using microscope gives best result'],exp:'Facial nerve injury management: If the nerve is CUT in a LATERAL facial wound (proximal to a line from tragus to lateral canthus \u2014 where branches are identifiable): PRIMARY REPAIR \u2714 \u2014 immediate microsurgical neurorrhaphy (end-to-end) in a clean\/fresh wound gives the BEST functional results. Timing is critical: the distal nerve stumps can still be stimulated electrically for up to 72 hours post-injury, aiding identification. Primary repair within hours is superior to secondary repair. \"Left alone\": unacceptable for complete nerve transaction \u2014 spontaneous regeneration alone is inadequate. \"Cover the cut ends\": temporary measure only. \"Secondary repair using microscope gives best results\": the microscope IS used for primary repair \u2014 secondary repair (delayed) has inferior outcomes due to scarring, fibrosis, and muscle atrophy. PRIMARY repair with microscope = best results. Answer: Primary repair should be attempted.'},\n{id:107,stem:'Radiologic views used for fracture Mandible (body and Ramus) are all EXCEPT:',correct:'Submentovertex',options:['Orthopantomogram','Lateral obliques','Lower occlusal','Submentovertex'],exp:'Radiological views for mandibular fracture (body and ramus): Orthopantomogram (OPG\/Panorex) \u2714 \u2014 best single view; shows the entire mandible in one image; ideal for body, angle, ramus, condylar fractures. Lateral oblique views \u2714 \u2014 show body, angle, and ramus; useful when OPG not available. Lower occlusal view \u2714 \u2014 shows symphyseal, parasymphyseal, and body fractures en face (cross-sectional view of mandibular arch). Posteroanterior (PA) mandible \u2014 shows ramus and condyles. SUBMENTOVERTEX (SMV \/ jug-handle view): used to assess the ZYGOMATIC ARCHES (to detect zygomatic arch fractures \u2014 \"handle of jug\" sign) and base of skull, NOT for mandibular body\/ramus fractures. Answer: Submentovertex \u2014 NOT used for mandibular body\/ramus fractures.'},\n{id:108,stem:'Mallory-Weiss tear causing haematemesis is seen over:',correct:'Gastroesophageal junction',options:['Oesophagus','Gastroesophageal junction','Anterior wall of stomach','Fundus of stomach'],exp:'MALLORY-WEISS SYNDROME: longitudinal mucosal tears at the GASTROESOPHAGEAL JUNCTION (GEJ) \u2014 the junction of the oesophagus and stomach, typically on the gastric side of the GEJ. Mechanism: sudden increase in intragastric\/intra-abdominal pressure (forceful vomiting, retching, coughing, straining) \u2192 shearing stress at the GEJ \u2192 mucosal laceration \u2192 arterial bleeding \u2192 haematemesis. Classic history: alcoholic patient + repeated vomiting \u2192 then haematemesis. 75\u201390% stop bleeding spontaneously. Management: endoscopic haemostasis (adrenaline injection, clipping, banding). NOT in the mid-oesophagus, anterior stomach wall, or fundus. Answer: Gastroesophageal junction.'},\n{id:109,stem:'Which one of the following factors is NOT involved in the pathogenesis of Systemic Inflammatory Response Syndrome (SIRS)?',correct:'Microvascular occlusion',options:['Increased cytokine production','Abnormal nitric oxide synthesis','Free radical production','Microvascular occlusion'],exp:'SIRS pathogenesis involves: Increased cytokine production \u2714 \u2014 TNF-\u03b1, IL-1, IL-6, IL-8 released from activated macrophages\/monocytes; mediators of systemic inflammation. Abnormal nitric oxide synthesis \u2714 \u2014 inducible NOS (iNOS) produces excess NO \u2192 profound vasodilation \u2192 hypotension (key mechanism in septic shock). Free radical production \u2714 \u2014 reactive oxygen species (ROS) from activated neutrophils \u2192 oxidative stress \u2192 endothelial damage, organ dysfunction. MICROVASCULAR OCCLUSION: this is a feature of DISSEMINATED INTRAVASCULAR COAGULATION (DIC) \u2014 microthrombi occluding microcirculation. While SIRS can LEAD TO DIC, microvascular occlusion per se is not a primary pathogenic mechanism of SIRS itself. SIRS pathogenesis is primarily pro-inflammatory (cytokines, mediators, NO, free radicals) rather than thrombotic. Answer: Microvascular occlusion.'},\n{id:110,stem:'Sleeve Gastrectomy done for Morbid obesity is a:',correct:'Restrictive procedure',options:['Restrictive procedure','Reversible procedure','Mildly restrictive and mainly malabsorptive','Malabsorptive procedure only'],exp:'Bariatric surgery classification: RESTRICTIVE procedures: reduce stomach capacity \u2192 reduce food intake. Examples: Sleeve gastrectomy \u2714, Adjustable gastric band, Vertical banded gastroplasty. MALABSORPTIVE procedures: bypass absorptive intestinal surface. Examples: Biliopancreatic diversion (BPD), Jejunoileal bypass. COMBINED restrictive + malabsorptive: Roux-en-Y Gastric Bypass (RYGB) \u2014 most commonly performed combined procedure. SLEEVE GASTRECTOMY: removes ~75\u201380% of the stomach (greater curvature) leaving a narrow gastric tube (\"sleeve\"); PURELY RESTRICTIVE \u2014 reduces volume, reduces ghrelin (hunger hormone from gastric fundus), no intestinal bypass. NOT reversible (permanent gastrectomy). NOT malabsorptive. Answer: Restrictive procedure.'},\n{id:111,stem:'Pre-operative Nutrition Screening in a patient with morbid obesity planned for Gastric Bypass includes all EXCEPT:',correct:'Serum Insulin',options:['Serum Magnesium','Serum Calcium','Serum Vitamin B12','Serum Insulin'],exp:'Pre-operative nutritional screening before Roux-en-Y Gastric Bypass (RYGB): Morbidly obese patients frequently have pre-existing nutritional deficiencies. Mandatory screening: Serum Calcium \u2714 \u2014 calcium absorption impaired post-bypass (bypasses duodenum = main Ca absorption site); hypocalcaemia\/metabolic bone disease risk. Serum Magnesium \u2714 \u2014 hypomagnesaemia common in morbidly obese; critical for cardiac and neuromuscular function. Serum Vitamin B12 \u2714 \u2014 B12 absorption requires intrinsic factor from gastric parietal cells + ileal receptor; bypass reduces intrinsic factor \u2192 B12 deficiency. Also: Iron, Folate, Vitamin D, Thiamine, Zinc, Vitamin A. SERUM INSULIN: this measures pancreatic function\/insulin resistance \u2014 it is NOT a nutritional screening parameter. It may be checked for diabetes assessment but is not part of standard pre-operative NUTRITIONAL screening panels. Answer: Serum Insulin.'},\n{id:112,stem:'In postoperative care the long term risks after Bariatric Surgery include all EXCEPT:',correct:'Deep Vein Thrombosis',options:['Protein Calorie Malnutrition','Deep Vein Thrombosis','Vitamin and Micronutrient depletion syndromes','Weight regain'],exp:'Long-term risks after bariatric surgery: Protein Calorie Malnutrition \u2714 \u2014 inadequate dietary intake + malabsorption; risk of kwashiorkor-like states especially post-BPD\/DS. Vitamin and Micronutrient depletion \u2714 \u2014 B12, iron, calcium, vitamin D, thiamine deficiency syndromes; require lifelong supplementation. Weight regain \u2714 \u2014 common long-term issue (~20\u201330% of patients regain significant weight by 5 years); due to dietary non-compliance, pouch dilation, psychological factors. DEEP VEIN THROMBOSIS: DVT is an EARLY\/PERI-OPERATIVE complication (within days to weeks of surgery) \u2014 morbidly obese patients are high VTE risk in the post-operative period. It is NOT a LONG-TERM risk specific to bariatric surgery. Long-term thrombosis risk actually DECREASES after bariatric surgery (weight loss improves VTE risk factors). Answer: Deep Vein Thrombosis \u2014 NOT a long-term risk.'},\n{id:113,stem:'Hilton\\'s method of Incision and Drainage of abscess has the advantage of:',correct:'Avoids injury to underlying vessels and nerves',options:['Complete drainage of pus','Avoids injury to underlying vessels and nerves','Provides irrigation','Heals without scar'],exp:'HILTON\\'S METHOD of I&D: a technique of abscess drainage using BLUNT DISSECTION with sinus forceps\/artery forceps rather than incision with a knife. Technique: small skin incision \u2192 sinus forceps introduced closed \u2192 opened (spreading) to gently enlarge the tract through subcutaneous tissue. PRIMARY ADVANTAGE \u2714: AVOIDS INJURY TO UNDERLYING VESSELS AND NERVES \u2014 the blunt spreading action separates tissue along tissue planes without cutting; vessels and nerves are displaced rather than severed. Particularly useful in areas with important underlying structures (axilla, groin, perineum). NOT advantages of Hilton\\'s method: Complete drainage \u2014 not better than incisional drainage. Irrigation \u2014 not a feature. Heals without scar \u2014 any incision scars. Answer: Avoids injury to underlying vessels and nerves.'},\n{id:114,stem:'Indications of computed tomography after head injury include all EXCEPT:',correct:'Mild head injury in a 50-year-old man',options:['Glasgow Coma Scale < 13 at any point','Open depressed fracture','Mild head injury in a 50 year old man','Amnesia > 30 minutes'],exp:'CT head indications after head injury (NICE guidelines \/ ATLS): GCS <13 at any point \u2714 \u2014 moderate\/severe head injury = immediate CT. Open\/depressed skull fracture \u2714 \u2014 risk of underlying brain injury\/intracranial haematoma. Amnesia >30 minutes post-injury \u2714 \u2014 significant mechanism indicator for intracranial injury. Also: focal neurological deficit, vomiting >1 episode, age >65 with LOC\/amnesia, dangerous mechanism, on anticoagulants, GCS <15 after 2 hours. MILD HEAD INJURY IN A 50-YEAR-OLD MAN (no other risk factors): mild head injury alone (GCS 14\u201315, brief LOC, no amnesia, no focal deficit) in an otherwise healthy adult is NOT a standalone indication for CT. Age >65 is a risk factor, but 50 years without other criteria does not mandate CT. Mild head injury without additional risk factors = clinical observation, not mandatory CT. Answer: Mild head injury in a 50-year-old man.'},\n{id:115,stem:'Mondor\\'s disease is:',correct:'Thrombophlebitis of superficial veins of the breast and anterior chest wall',options:['Thrombophlebitis of superficial veins of the breast and anterior chest wall','Other name for tuberculosis of breast','Rare type of chronic intramammary abscess','Named after the scientist who first coined the term \"Actinomycosis of Breast\"'],exp:'MONDOR\\'S DISEASE: thrombophlebitis of the SUPERFICIAL VEINS of the breast and anterior chest wall (typically the thoracoepigastric and lateral thoracic veins). Clinical features: painful, cord-like subcutaneous induration running along the breast or chest wall; skin dimpling\/retraction may be present (can mimic carcinoma). Causes: trauma, bra straps, surgery, after breast augmentation. Usually self-limiting (resolves in 6\u20138 weeks). Clinical importance: must be distinguished from carcinoma (which can also cause skin tethering). Named after Henri Mondor (French surgeon, 1939). NOT tuberculosis, NOT abscess, NOT actinomycosis-related. Answer: Thrombophlebitis of superficial veins of breast and anterior chest wall.'},\n{id:116,stem:'Sengstaken-Blakemore tube is used to control bleeding in:',correct:'Bleeding varices',options:['Renal trauma','Bleeding varices','Splenic injury in portal hypertension','Duodenal ulcer bleed'],exp:'SENGSTAKEN-BLAKEMORE (SB) TUBE: a triple-lumen tube used for TAMPONADE of BLEEDING OESOPHAGEAL AND GASTRIC VARICES. Components: Oesophageal balloon (inflated to tamponade oesophageal varices), Gastric balloon (inflated in stomach to anchor the tube and tamponade gastric varices\/gastroesophageal junction), Gastric aspiration lumen. Indication: acute variceal haemorrhage uncontrolled by endoscopic therapy (banding, sclerotherapy) or pharmacotherapy (terlipressin, octreotide) \u2014 used as a BRIDGE to definitive therapy (TIPS, surgery). Complications: aspiration pneumonia, oesophageal rupture, pressure necrosis. NOT for: renal trauma (surgical\/interventional radiology), splenic injury (surgery\/embolisation), peptic ulcer (endoscopy\/surgery). Answer: Bleeding varices.'},\n{id:117,stem:'Which one of the following regarding Pancreatic effusion is correct?',correct:'Free fluid collection in Pleural cavity',options:['Free fluid collection in Pleural cavity','Never associated with abdominal collection','Pancreatic stenting is to be done','Percutaneous drainage under image guidance is necessary'],exp:'PANCREATIC PLEURAL EFFUSION (Pancreatic pseudopleura): occurs when a disrupted pancreatic duct or pancreatic pseudocyst communicates with the pleural space via a pancreatico-pleural fistula \u2192 enzyme-rich fluid accumulates in the PLEURAL CAVITY \u2714 (free fluid in pleural space = exudate with very high amylase). Features: large recurrent pleural effusion (often left-sided) in a patient with chronic pancreatitis or pancreatic ductal disruption; pleural fluid amylase > 1000 U\/L. NOT \"never associated with abdominal collection\" \u2014 can coexist with ascites\/pseudocyst. Pancreatic stenting (via ERCP) is one management option for the ductal disruption \u2014 but not universally required; surgery (Roux-en-Y internal drainage, distal pancreatectomy) may be needed. Percutaneous drainage alone is often insufficient (the fistula persists). The correct statement: it is free fluid collection in the pleural cavity. Answer: Free fluid collection in pleural cavity.'},\n{id:118,stem:'Which one of the following bone is affected in Kienb\u00f6ck\\'s disease?',correct:'Lunate bone',options:['Lunate bone','Capitellum of the humerus','Metatarsal','Navicular bone'],exp:'KIENB\u00d6CK\\'S DISEASE: avascular necrosis (osteonecrosis) of the LUNATE bone of the wrist. Cause: interruption of lunate blood supply (single or dual vessel supply) \u2192 ischaemic necrosis \u2192 collapse of lunate \u2192 progressive wrist arthritis. Clinical: wrist pain, limited range of motion, tenderness over lunate (dorsal wrist). Radiography: sclerosis \u2192 fragmentation \u2192 collapse of lunate (Lichtman staging I\u2013IV). Associated with ulnar minus variant (negative ulnar variance). Treatment: unloading procedures (joint levelling), immobilisation, or salvage (proximal row carpectomy, wrist fusion). Other avascular necroses: Perthes disease = femoral head, Freiberg\\'s = 2nd metatarsal head, K\u00f6hler\\'s = navicular (foot), Panner\\'s = capitellum of humerus. Kienb\u00f6ck\\'s = LUNATE. Answer: Lunate bone.'},\n{id:119,stem:'Which one of the following regarding management of acute wounds is NOT true?',correct:'Clamps should be used to stop all bleeding vessels',options:['The whole patient should be examined according to ATLS principles','Wounds should be examined taking into consideration site and structures damaged','Bleeding wounds should be elevated and a pressure pad applied','Clamps should be used to stop all bleeding vessels'],exp:'Acute wound management principles: ATLS assessment \u2714 TRUE \u2014 systematic evaluation (ABCDE) of the whole patient; life-threatening injuries take priority over wound management. Site and structures assessment \u2714 TRUE \u2014 identify which structures are involved (nerves, vessels, tendons, bones) before deciding management. Elevation + pressure pad \u2714 TRUE \u2014 elevation reduces venous pressure; direct pressure is the most effective first measure for wound bleeding (applies pressure to the bleeding point). CLAMPS: \"Clamps should be used to stop ALL bleeding vessels\" is NOT TRUE and is DANGEROUS. Blind clamping of vessels in wounds risks: injury to adjacent nerves (especially in face, hand), catching the wrong structure, incomplete haemostasis. Only clearly visible, accessible bleeding points should be ligated\/clipped \u2014 and in wounds near important structures, pressure alone is safer until proper exploration in theatre. Answer: Clamps to stop all bleeding vessels \u2014 NOT true.'},\n{id:120,stem:'Risk Scoring System which can be used post-operatively is:',correct:'POSSUM \u2192 Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity',options:['ASA \u2192 American Society of Anaesthesiologist','MET \u2192 Metabolic Equivalent Task','RCRI \u2192 Revised Cardiac Risk Index','POSSUM \u2192 Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity'],exp:'Risk scoring systems: ASA (American Society of Anaesthesiologists) score: PRE-OPERATIVE \u2014 classifies physical status (I\u2013VI) before surgery; used for pre-operative risk assessment. MET (Metabolic Equivalent Task): PRE-OPERATIVE \u2014 functional capacity assessment for cardiac risk evaluation before surgery. RCRI (Revised Cardiac Risk Index \/ Lee index): PRE-OPERATIVE \u2014 predicts major adverse cardiac events in non-cardiac surgery (uses 6 clinical predictors). POSSUM (Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity) \u2714 POST-OPERATIVE \u2014 uses 12 physiological variables + 6 operative variables; calculated AFTER the operation is completed to predict post-operative morbidity and mortality; used for audit and quality benchmarking. P-POSSUM (Portsmouth modification) is also commonly used. POSSUM is the only score listed that can be applied POST-OPERATIVELY. Answer: POSSUM.'}\n];\n\nfunction shuffle(a){var b=a.slice();for(var i=b.length-1;i>0;i--){var j=Math.floor(Math.random()*(i+1));var t=b[i];b[i]=b[j];b[j]=t;}return b;}\nvar L=['A','B','C','D'];\nvar ua={},ans=0,so={},sub=false,tr=false,rem=TSECS,ti=null,gi=null;\n\nfunction fmt(s){var m=Math.floor(s\/60),x=s%60;return(''+m).padStart(2,'0')+':'+(''+x).padStart(2,'0');}\nfunction $(id){return document.getElementById(NS+'-'+id);}\n\nfunction startTimer(){\n if(tr||sub)return;tr=true;\n var b=$('tb');b.textContent='\u23f1 '+fmt(rem);b.classList.add('rn');\n $('ti').classList.add('on');\n ti=setInterval(function(){\n rem--;var d=fmt(rem);$('td').textContent=d;b.textContent='\u23f1 '+d;\n if(rem<=300)$('ti').classList.add('wn');\n if(rem<=0){clearInterval(ti);ti=null;grace();}\n },1000);\n}\nfunction stopTimer(){if(ti){clearInterval(ti);ti=null;}tr=false;}\nfunction grace(){\n if(sub)return;var g=GSECS;$('gc').textContent=g;$('gr').classList.add('sh');\n 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consolidate the weaker areas.':pct>=40?'Fair \u2014 systematic revision recommended.':'Needs significant revision across these topics.';\n $('vd').textContent=v;\n $('bc').textContent='\u2705 '+c+' Correct';$('bw').textContent='\u274c '+w+' Wrong';$('bk').textContent='\u23ed '+sk+' Skipped';\n var s=$('sc-box');s.style.display='block';s.scrollIntoView({behavior:'smooth',block:'center'});\n}\n\nfunction init(){\n $('gn').addEventListener('click',function(){hideGrace();showScore();});\n $('tb').addEventListener('click',function(){if(!tr&&!sub)startTimer();});\n $('sub').addEventListener('click',showScore);\n $('rb').addEventListener('click',function(){build();window.scrollTo({top:0,behavior:'smooth'});});\n new IntersectionObserver(function(e){$('sb').classList.toggle('vs',!e[0].isIntersecting);},{threshold:0}).observe($('sn'));\n build();stats();\n}\nif(document.readyState==='loading'){document.addEventListener('DOMContentLoaded',init);}else{init();}\n})();\n<\/script>\n<\/body>\n<\/html>\n","protected":false},"excerpt":{"rendered":"<p>CMS 2018 Paper II \u2013 Part C (Q81\u2013Q120) \u23f1 40:00 \u2705 0 \u274c 0 \u23f3 40 left Net 0 \/ 160 Time's Up! Submitting in 10 Submit Now Combined Medical Services Examination 2018Paper II \u00b7 Part C General Surgery \u00b7 ENT \u00b7 Orthopaedics \u00b7 Critical Care \u00b7 Bariatric \u00b7 Vascular Questions 81 \u2013 120 Options reshuffled \u23f1 Start Timed Mode Submit Answers 0%score… <\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[18,56],"tags":[],"class_list":["post-36814","post","type-post","status-publish","format-standard","hentry","category-cms","category-surgery"],"yoast_head":"\n<title>CMS 2018 P2 Part-C - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/2026\/05\/11\/cms-2018-p2-part-c\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"CMS 2018 P2 Part-C - atsixty\" \/>\n<meta property=\"og:description\" content=\"CMS 2018 Paper II \u2013 Part C (Q81\u2013Q120) \u23f1 40:00 \u2705 0 \u274c 0 \u23f3 40 left Net 0 \/ 160 Time's Up! 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id=\"cms18p2c-ti\">\u23f1 <strong id=\"cms18p2c-td\">40:00<\/strong><\/div>\n <div class=\"si\">\u2705 <strong id=\"cms18p2c-sc\">0<\/strong><\/div>\n <div class=\"si\">\u274c <strong id=\"cms18p2c-sw\">0<\/strong><\/div>\n <div class=\"si\">\u23f3 <strong id=\"cms18p2c-sr\">40<\/strong> left<\/div>\n <div class=\"ss\"><\/div>\n <div class=\"si\">Net <strong id=\"cms18p2c-sn\">0<\/strong> \/ <strong id=\"cms18p2c-sm\">160<\/strong><\/div>\n <\/div>\n <div class=\"sp\"><div class=\"sf\" id=\"cms18p2c-sf\"><\/div><\/div>\n<\/div>\n<div class=\"gr\" id=\"cms18p2c-gr\">\n <div class=\"gb\"><h3>Time's Up!<\/h3><p>Submitting in<\/p><div class=\"gc\" id=\"cms18p2c-gc\">10<\/div><button class=\"gn\" id=\"cms18p2c-gn\">Submit Now<\/button><\/div>\n<\/div>\n<div class=\"hd\">\n <h1>Combined Medical Services Examination 2018<br>Paper II \u00b7 Part C<\/h1>\n <p>General Surgery \u00b7 ENT \u00b7 Orthopaedics \u00b7 Critical Care \u00b7 Bariatric \u00b7 Vascular<\/p>\n <div class=\"mt\">\n <span class=\"bd\">Questions 81 \u2013 120<\/span>\n <span class=\"bd\">Options reshuffled<\/span>\n <button class=\"tb\" id=\"cms18p2c-tb\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n<\/div>\n<div class=\"bd2\">\n <div id=\"cms18p2c-qs\"><\/div>\n <div class=\"sw\"><button class=\"bt\" id=\"cms18p2c-sub\">Submit Answers<\/button><\/div>\n <div class=\"sc\" id=\"cms18p2c-sc-box\">\n <div class=\"rg\" id=\"cms18p2c-rg\"><div class=\"ri\"><span class=\"rp\" id=\"cms18p2c-rp\">0%<\/span><span class=\"rs\">score<\/span><\/div><\/div>\n <h2>Your Result<\/h2>\n <div class=\"nl\" id=\"cms18p2c-nl\"><\/div>\n <div class=\"vd\" id=\"cms18p2c-vd\"><\/div>\n <div class=\"bs\"><span class=\"bn bc\" id=\"cms18p2c-bc\"><\/span><span class=\"bn bw\" id=\"cms18p2c-bw\"><\/span><span class=\"bn bk\" id=\"cms18p2c-bk\"><\/span><\/div>\n <button class=\"rb\" id=\"cms18p2c-rb\">\u21ba Retry Quiz<\/button>\n <\/div>\n<\/div>\n<\/div>\n<script>\n(function(){\n'use strict';\nvar NS='cms18p2c',TOTAL=40,MAX=160,TSECS=2400,GSECS=10;\nvar QS=[\n{id:81,stem:'Cellulitis is:',correct:'A nonsuppurative invasive infection of tissues',options:['A suppurative invasive infection of skin and subcutaneous tissues','A nonsuppurative invasive infection of tissues','Infection caused by Gram negative bacilli','Infection caused by anaerobic Streptococci'],exp:'Cellulitis is a NONSUPPURATIVE (no pus formation) spreading infection of the skin and subcutaneous tissues. It is caused predominantly by Streptococcus pyogenes (Group A beta-haemolytic streptococcus) and Staphylococcus aureus. Features: diffuse spreading erythema, warmth, swelling, tenderness; no fluctuation (no abscess\/pus collection). This distinguishes cellulitis from an abscess (suppurative \u2014 pus-forming) or necrotising fasciitis (deeper). The organism spreads via lymphatics and tissue planes rather than forming a localised pus collection. \"Nonsuppurative\" is the key term. Gram-positive cocci are the usual organisms, not Gram-negative bacilli. Anaerobic Streptococci cause Meleney\\'s gangrene\/synergistic gangrene \u2014 not simple cellulitis.'},\n{id:82,stem:'Following are the factors for increased risk of wound infection EXCEPT:',correct:'Good blood supply',options:['Malnutrition','Good blood supply','Metabolic diseases (diabetes, uraemia)','Immunosuppression'],exp:'Risk factors for wound infection: Malnutrition \u2714 (impaired collagen synthesis, reduced immune function \u2192 poor healing, high infection risk). Metabolic diseases \u2714 \u2014 Diabetes mellitus (impaired neutrophil function, microangiopathy, neuropathy \u2192 impaired healing and high infection risk); uraemia (impaired platelet function and immune deficiency). Immunosuppression \u2714 (steroids, chemotherapy, HIV \u2192 reduced ability to fight infection). GOOD BLOOD SUPPLY: PROTECTIVE against infection \u2014 adequate blood supply delivers oxygen, nutrients, neutrophils, and antibodies to the wound; removes metabolic waste. Good vascularity = low infection risk. Poor blood supply (ischaemia, peripheral arterial disease) = HIGH infection risk. Answer: Good blood supply \u2014 EXCEPT (does NOT increase infection risk; it decreases it).'},\n{id:83,stem:'A 25-year-old lady post exploratory laparotomy (bowel injury during MTP, 2 days back). 24 hours post-op: pulse 106\/min, RR 26\/min, TLC 14,000\/cumm, blood urea 84 mg%, serum creatinine 2.0 mg\/dL. She is having:',correct:'Sepsis syndrome',options:['Wound infection','Systematic inflammatory response syndrome','Sepsis syndrome','Multisystem organ failure (MSOF)'],exp:'Criteria analysis: SIRS (Systemic Inflammatory Response Syndrome) requires \u22652 of: Temperature >38\u00b0C or <36\u00b0C, HR >90\/min \u2714 (106), RR >20\/min \u2714 (26), WBC >12,000 or <4,000 \u2714 (14,000). This patient meets SIRS criteria. SEPSIS = SIRS + confirmed or suspected INFECTION. She has a known infective source (bowel injury \u2192 peritoneal contamination \u2192 intra-abdominal sepsis) + SIRS criteria. SEPSIS SYNDROME (older terminology) = SIRS + infection + organ dysfunction \u2014 she has renal impairment (urea 84 mg%, creatinine 2.0 = acute kidney injury) indicating early organ dysfunction. MSOF\/MODS: multiple organ failure \u2014 would require more severe, established failure of multiple systems. Wound infection: localised, does not explain systemic parameters. Answer: Sepsis syndrome.'},\n{id:84,stem:'A 22-year-old man with occasional rectal bleeding. Colonoscopy shows numerous sessile polyps in descending and sigmoid colon. Family history: elder brother operated for thyroid malignancy. The young man should be advised:',correct:'Prophylactic panproctocolectomy',options:['Prophylactic panproctocolectomy','Prophylactic anterior resection','Surveillance colonoscopy every 6 months','Colonoscopic removal of all polyps'],exp:'Clinical picture: young male + multiple colonic polyps + family history of thyroid malignancy \u2192 GARDNER\\'S SYNDROME or FAMILIAL ADENOMATOUS POLYPOSIS (FAP). FAP: autosomal dominant APC gene mutation; >100 adenomatous polyps throughout colon\/rectum; 100% risk of colorectal carcinoma if untreated; associated extra-colonic features (Gardner\\'s: osteomas, desmoid tumours, thyroid cancer \u2014 explains family history). Management: PROPHYLACTIC PANPROCTOCOLECTOMY (total colectomy + proctectomy + ileostomy or ileo-anal pouch) is the definitive treatment \u2014 removes all at-risk colonic and rectal mucosa. Anterior resection leaves the rectum at risk. Colonoscopic polypectomy is insufficient (polyps are too numerous and recur). Surveillance alone is inadequate given 100% malignancy risk. Answer: Prophylactic panproctocolectomy.'},\n{id:85,stem:'A 47-year-old post-menopausal lady on adjuvant Tamoxifen for 3 years for carcinoma breast presents with blood clots per vagina. She is probably suffering from:',correct:'Carcinoma Endometrium',options:['Carcinoma Vulva','Carcinoma Vagina','Carcinoma Endometrium','Uterine fibroid'],exp:'TAMOXIFEN is a selective oestrogen receptor modulator (SERM): Anti-oestrogenic in breast tissue (used for ER-positive breast cancer). PRO-OESTROGENIC in the endometrium \u2014 stimulates endometrial proliferation. Long-term tamoxifen use (>2 years) significantly increases risk of ENDOMETRIAL CARCINOMA (2\u20133\u00d7 increased risk) and endometrial polyps. Post-menopausal bleeding in a tamoxifen user \u2192 ENDOMETRIAL CARCINOMA until proven otherwise. This is a well-recognised, important side effect of tamoxifen. Fibroids: typically regress post-menopause (oestrogen-dependent); possible with tamoxifen\\'s oestrogenic effect but less likely than carcinoma. Carcinoma vulva\/vagina: not related to tamoxifen. Answer: Carcinoma Endometrium.'},\n{id:86,stem:'Which of the following regarding blood supply of rectum is NOT true?',correct:'Middle rectal artery arises from external iliac artery and passes through the lateral ligaments into rectum',options:['Superior rectal artery is a direct continuation of Inferior mesenteric artery','Middle rectal artery arises from external iliac artery and passes through the lateral ligaments into rectum','Inferior rectal artery arises from internal pudendal artery','Inferior rectal artery traverses the Alcock\\'s canal into rectum'],exp:'Rectal blood supply: Superior rectal artery \u2714 TRUE \u2014 direct continuation of the inferior mesenteric artery (IMA); supplies upper rectum. Inferior rectal artery \u2714 TRUE \u2014 arises from internal pudendal artery; traverses Alcock\\'s canal (pudendal canal) in the ischioanal fossa to reach the lower rectum\/anal canal. MIDDLE RECTAL ARTERY: arises from the INTERNAL ILIAC ARTERY (anterior division) \u2014 NOT the external iliac artery. It passes through the lateral ligaments of the rectum to supply the middle rectum. \"Arises from external iliac\" is FALSE \u2014 it arises from internal iliac. Answer: Middle rectal artery arises from external iliac \u2014 NOT true.'},\n{id:87,stem:'Gastric conduit after oesophageal resection is based upon:',correct:'Right Gastroepiploic artery',options:['Right Gastroepiploic artery','Short gastric vessels and Vasa brevia','Left gastric artery','Right gastric artery'],exp:'Oesophagectomy with gastric conduit (gastric pull-up): The stomach is mobilised and fashioned into a tube (gastric conduit) to replace the oesophagus. The conduit is based on the RIGHT GASTROEPIPLOIC ARTERY \u2014 which runs along the greater curvature of the stomach in the gastroepiploic arcade and provides the primary blood supply to the gastric conduit after division of: Left gastric artery (divided), Short gastric vessels (divided), Left gastroepiploic artery (divided). The RIGHT gastroepiploic (branch of gastroduodenal artery from hepatic artery) and right gastric arteries are preserved. The conduit is perfused mainly by the right gastroepiploic arcade. This is critical knowledge for oesophageal surgery \u2014 ischaemia at the conduit tip (fundus) is the main complication. Answer: Right Gastroepiploic artery.'},\n{id:88,stem:'A 70-year-old male with comorbidities presents with a benign-appearing parotid tumour. The best option is:',correct:'Superficial Parotidectomy',options:['Tumour enucleation','Superficial Parotidectomy','Aspiration biopsy confirmation','Radio therapy'],exp:'Parotid tumour management: The most common benign parotid tumour is Pleomorphic Adenoma (benign mixed tumour). TUMOUR ENUCLEATION: CONTRAINDICATED \u2014 pseudocapsule of pleomorphic adenoma is thin and incomplete; enucleation leads to capsule rupture, tumour spillage, and high recurrence rate (up to 45%). SUPERFICIAL PAROTIDECTOMY \u2714 \u2014 the standard treatment for parotid tumours in the superficial lobe. Provides adequate margins, preserves the facial nerve, low recurrence. Suitable even in elderly with comorbidities (can be done under local\/regional anaesthesia if needed). FNAC (aspiration biopsy): useful for diagnosis confirmation but NOT definitive treatment; cannot distinguish pleomorphic from carcinoma reliably for follicular-type lesions. RADIOTHERAPY: no role for primary benign parotid tumour. Answer: Superficial Parotidectomy.'},\n{id:89,stem:'FNAC is NOT conclusive in which one of the following thyroid swellings?',correct:'Follicular carcinoma thyroid',options:['Papillary carcinoma thyroid','Follicular carcinoma thyroid','Medullary carcinoma thyroid','Thyroiditis'],exp:'FNAC of thyroid \u2014 reliability: Papillary carcinoma \u2714 \u2014 FNAC is highly diagnostic; classic nuclear features (Orphan Annie eye nuclei, nuclear grooves, intranuclear inclusions, psammoma bodies) are easily identified on cytology. Medullary carcinoma \u2714 \u2014 FNAC shows characteristic features (amyloid stroma, plasmacytoid cells); calcitonin immunostaining confirms. Thyroiditis (Hashimoto\\'s) \u2714 \u2014 FNAC shows lymphocytes, H\u00fcrthle cells, follicular cells. FOLLICULAR CARCINOMA: FNAC CANNOT distinguish between follicular adenoma (benign) and follicular carcinoma (malignant). The diagnosis of follicular carcinoma requires HISTOLOGICAL evidence of capsular invasion and\/or vascular invasion \u2014 which cannot be assessed on cytology (aspirate does not preserve tissue architecture). FNAC of a follicular lesion = \"follicular neoplasm\" (indeterminate) \u2192 requires hemi\/total thyroidectomy for diagnosis. Answer: Follicular carcinoma.'},\n{id:90,stem:'Patients with phlebographically confirmed deep vein thrombosis of the calf:',correct:'Are at risk for significant pulmonary embolism',options:['Can expect asymptomatic recovery if treated promptly with anticoagulant','May be effectively treated with low-dose heparin','May be effectively treated with pneumatic compression stockings','Are at risk for significant pulmonary embolism'],exp:'Calf (distal) DVT: Untreated calf DVT propagates proximally (to popliteal, femoral veins) in ~20\u201330% of cases. Proximal DVT carries significant risk of PULMONARY EMBOLISM (PE) \u2014 the proximal thrombus can embolise to the pulmonary circulation. Even isolated calf DVT carries a real (though smaller) risk of PE. Current guidelines recommend anticoagulation for confirmed symptomatic calf DVT (or surveillance with proximal extension monitoring). \"Asymptomatic recovery with anticoagulation\" understates the treatment need. \"Low-dose heparin\" is prophylactic dosing \u2014 treatment requires THERAPEUTIC anticoagulation. \"Pneumatic compression\" is prophylaxis \u2014 not treatment of confirmed DVT. The key message: calf DVT IS at risk for significant PE due to proximal propagation. Answer: Are at risk for significant pulmonary embolism.'},\n{id:91,stem:'Herceptin (Trastuzumab) is an immunotherapeutic agent used for:',correct:'Carcinoma breast',options:['Carcinoma prostate','Carcinoma breast','Carcinoma rectum','Ovarian malignancy'],exp:'TRASTUZUMAB (Herceptin): a humanised monoclonal antibody targeting HER2 (Human Epidermal Growth Factor Receptor 2 \/ ErbB2). PRIMARY USE: HER2-positive CARCINOMA BREAST \u2014 approximately 20\u201325% of breast cancers overexpress HER2 (gene amplification); these tumours are aggressive but respond dramatically to trastuzumab. Used in: HER2+ early breast cancer (adjuvant), HER2+ metastatic breast cancer (palliative). Also used in: HER2-positive gastric\/gastro-oesophageal junction adenocarcinoma (Trastuzumab in combination with chemotherapy \u2014 ToGA trial). NOT used for: prostate cancer, colorectal cancer, ovarian cancer (different targets and mechanisms). Herceptin = HER2-targeted therapy = breast cancer (and HER2+ gastric cancer). Answer: Carcinoma breast.'},\n{id:92,stem:'Mainstay of accurate diagnosis of pancreatic injury following blunt abdominal trauma is:',correct:'Computed Tomogram',options:['Computed Tomogram','Diagnostic peritoneal lavage','USG abdomen','MRI abdomen'],exp:'Pancreatic injury diagnosis after blunt trauma: USG abdomen: limited for pancreas \u2014 retroperitoneal organ, obscured by bowel gas; insensitive for ductal injury. Diagnostic peritoneal lavage (DPL): non-specific for retroperitoneal injuries; does not assess pancreatic duct integrity. MRI\/MRCP: excellent for ductal anatomy but takes longer, less available in acute trauma, less accessible in haemodynamically unstable patients. CT ABDOMEN (with IV contrast) \u2714 \u2014 MAINSTAY: demonstrates pancreatic lacerations, haematoma, peripancreatic fluid, ductal disruption (indirectly), and associated injuries. CT grading (AAST) guides management. ERCP\/MRCP used for suspected main pancreatic duct injury when CT is equivocal. In haemodynamically stable trauma patients, contrast-enhanced CT is the gold standard for pancreatic injury assessment. Answer: Computed Tomogram.'},\n{id:93,stem:'Pancreatic pseudocysts developing complications are best managed by:',correct:'Surgery',options:['Conservative treatment','Radiologically guided interventions','External drainage','Surgery'],exp:'Pancreatic pseudocyst management: Uncomplicated pseudocysts: many resolve spontaneously (conservative management; wait 6 weeks for maturation). Complications of pseudocysts (haemorrhage, infection, rupture, gastric\/biliary obstruction, enlarging): SURGERY \u2714 \u2014 internal drainage (cystogastrostomy, cystojejunostomy, cystduodenostomy) is the gold standard for COMPLICATED pancreatic pseudocysts. Internal drainage into bowel provides definitive treatment. Radiologically guided aspiration\/drainage: for infected pseudocysts (pancreatic abscess) as a bridge or definitive treatment in poor surgical candidates \u2014 but surgery remains gold standard for complicated pseudocysts with structural complications. External drainage (pigtail catheter): for infected\/contaminated pseudocysts \u2014 not definitive for structural complications. Conservative: for uncomplicated\/asymptomatic. Complicated pseudocysts = Surgery (internal drainage). Answer: Surgery.'},\n{id:94,stem:'Which one of the following regarding absorbable meshes is NOT true?',correct:'They show very good results as collagen deposition is maximum',options:['They are made of polyglycolic acid fibre','They are used in temporary abdominal wall closure','They are used to buttress sutured repair','They show very good results as collagen deposition is maximum'],exp:'Absorbable meshes (e.g., Vicryl\/polyglactin, Dexon\/polyglycolic acid): Made of polyglycolic acid (PGA) fibre \u2714 \u2014 or polyglactin 910 (Vicryl). Used in temporary abdominal wall closure \u2714 \u2014 \"damage control\" laparotomy; bridge the fascial defect temporarily before definitive closure. Used to buttress sutured repair \u2714 \u2014 reinforces primary suture lines in contaminated\/infected fields where non-absorbable mesh is contraindicated. NOT IDEAL FOR PERMANENT REPAIR: absorbable meshes are absorbed over 60\u201390 days; they are replaced by fibrous tissue but collagen deposition is INSUFFICIENT for durable repair \u2014 they do NOT show \"very good results\" as permanent hernia repair (high recurrence rates). Non-absorbable meshes (polypropylene, polyester) provide permanent support with good collagen ingrowth. \"Collagen deposition is maximum\" and \"very good results\" are NOT true for absorbable meshes. Answer: Very good results\/maximum collagen deposition \u2014 NOT true.'},\n{id:95,stem:'Which one of the following is NOT a surgical modality for management of femoral hernia?',correct:'The canal ring narrowing operation (Lytle\\'s)',options:['Lotheissen\\'s (Inguinal) operation','The high approach (McEvedy)','The low approach (Lockwood)','The canal ring narrowing operation (Lytle\\'s)'],exp:'Femoral hernia repair approaches: Lotheissen\\'s (inguinal\/transinguinal) approach \u2714 \u2014 repair from above through the inguinal canal; allows concurrent inguinal hernia repair. McEvedy\\'s (high\/extraperitoneal) approach \u2714 \u2014 vertical incision above inguinal ligament; excellent access for strangulated femoral hernias; allows bowel resection if needed. Lockwood\\'s (low\/crural) approach \u2714 \u2014 directly below inguinal ligament over the hernial sac; simple for elective cases. LYTLE\\'S OPERATION (canal ring narrowing): used for INGUINAL HERNIA (narrows the internal inguinal ring) \u2014 NOT a standard approach for femoral hernia repair. Lytle\\'s is not among the three classical femoral hernia repairs. Answer: Lytle\\'s canal ring narrowing operation \u2014 NOT a femoral hernia surgical modality.'},\n{id:96,stem:'\"Triangle of Doom\" dissected and seen during Laparoscopic inguinal hernia repair is bounded by all EXCEPT:',correct:'Inferior epigastric artery',options:['Vas deference','Cord structures','Peritoneal fold','Inferior epigastric artery'],exp:'Triangle of Doom (in TAPP\/TEP laparoscopic inguinal hernia repair): A peritoneal triangle containing the EXTERNAL ILIAC VESSELS (artery and vein). Boundaries: Medial: VAS DEFERENS \u2714. Lateral: GONADAL\/CORD VESSELS (testicular vessels) \u2714. Superior: PERITONEAL FOLD \u2714 (peritoneal reflection). Contents: External iliac artery and vein \u2014 structures at risk of catastrophic haemorrhage if violated. The triangle is called \"doom\" because dissection or stapling here can injure the external iliac vessels. INFERIOR EPIGASTRIC ARTERY: not a boundary of the Triangle of Doom; it defines the \"Triangle of Pain\" (lateral to gonadal vessels \u2014 contains genitofemoral and lateral femoral cutaneous nerves). Answer: Inferior epigastric artery \u2014 NOT a boundary.'},\n{id:97,stem:'Antro-choanal polyp always arises from:',correct:'Maxillary sinus',options:['Maxillary sinus','Posterior ethmoidal cells','Posterior end of the septum','Nasopharynx'],exp:'ANTROCHOANAL POLYP (Killian\\'s polyp): a benign polyp that arises EXCLUSIVELY from the MAXILLARY SINUS (antrum) \u2014 specifically from the mucosa of the posterior\/inferior wall of the maxillary sinus. It grows through the maxillary ostium into the middle meatus, then extends posteriorly through the choana into the nasopharynx. Clinical features: unilateral nasal obstruction, predominantly in children and young adults. Treatment: endoscopic surgical removal including the stalk (otherwise recurs). Distinguished from simple nasal polyps (bilateral, ethmoidal origin, associated with allergy\/asthma). \"Always arises from the maxillary sinus\" is the classic, definitive statement. Answer: Maxillary sinus.'},\n{id:98,stem:'Paralytic ileus is a type of:',correct:'Adynamic obstruction',options:['Dynamic obstruction','Adynamic obstruction','Inflammatory obstruction','Drug induced obstruction'],exp:'Classification of intestinal obstruction: MECHANICAL (DYNAMIC) obstruction: physical blockage of bowel lumen; bowel peristalsis initially increased (borborygmi, colic), then may fail. Types: simple, strangulated, closed loop. FUNCTIONAL (ADYNAMIC) obstruction: bowel lumen is PATENT but peristalsis is absent or ineffective. PARALYTIC ILEUS \u2714 is the classic adynamic obstruction \u2014 failure of peristalsis due to: peritonitis, post-operative ileus, hypokalaemia, retroperitoneal haematoma, drugs (opioids, anticholinergics). Features: abdominal distension, absent bowel sounds, no colic, no mechanical cause. Pseudo-obstruction (Ogilvie\\'s syndrome) is also adynamic. \"Inflammatory obstruction\" and \"drug-induced obstruction\" are not standard classifications. Paralytic ileus = adynamic\/functional obstruction. Answer: Adynamic obstruction.'},\n{id:99,stem:'Indication of Coronary Artery Bypass Grafting (CABG) is:',correct:'Triple vessel disease',options:['More than 25% stenosis of critical left main stem','More than 25% stenosis of proximal left anterior interventricular artery','Triple vessel disease','Deranged Stress Echocardiography report'],exp:'CABG indications (ACC\/AHA guidelines): LEFT MAIN STEM stenosis \u226550% (not 25%) \u2014 significant reduction in calibre requiring intervention. Proximal LAD stenosis \u226570% (not 25%) \u2014 significant proximal LAD disease is a strong CABG indication. TRIPLE VESSEL DISEASE \u2714 \u2014 three-vessel coronary artery disease (LAD + circumflex + RCA stenosis \u226570%) is a Class I indication for CABG, especially with reduced LV function (EF <35%) or diabetes. Also: Left main equivalent (LAD + circumflex proximal disease). Failed PCI, LV dysfunction + viable myocardium. 25% stenosis is SUBCRITICAL \u2014 no intervention indicated at 25% stenosis in any vessel. Deranged stress echo alone (without defining anatomy) is not an indication \u2014 coronary angiography is needed first. Answer: Triple vessel disease.'},\n{id:100,stem:'Normal anatomical narrowing of ureter are present in all EXCEPT:',correct:'Crossing the abdominal aorta',options:['Ureteropelvic junction','Crossing the abdominal aorta','Entering bladder wall','Ureteric orifice'],exp:'Three normal anatomical NARROWINGS of the ureter (sites where calculi most commonly obstruct): (1) PELVIURETERIC JUNCTION (PUJ\/UPJ) \u2714 \u2014 where the renal pelvis joins the ureter. (2) CROSSING OF THE PELVIC BRIM \/ ILIAC VESSELS \u2714 \u2014 where the ureter crosses the common iliac artery bifurcation (not the abdominal aorta). (3) VESICOURETERIC JUNCTION (VUJ) \u2014 where the ureter enters the bladder wall (ureterovesical junction) \u2714 \/ ureteric orifice \u2714. CROSSING THE ABDOMINAL AORTA: the ureter does NOT normally cross the abdominal aorta; it runs lateral to the aorta. The pelvic brim narrowing is at the common iliac vessels, not the aorta. \"Crossing the abdominal aorta\" is NOT a standard anatomical narrowing of the ureter. Answer: Crossing the abdominal aorta.'},\n{id:101,stem:'Which one of the following is NOT correct regarding Adenocarcinoma of the kidney (Renal Cell Carcinoma)?',correct:'It always presents with haematuria',options:['It is also called Grawitz tumour','It always presents with haematuria','It may be associated with Pyrexia of unknown origin','Renal vein extension may embolize to lungs'],exp:'Renal Cell Carcinoma (RCC \/ Adenocarcinoma kidney \/ Hypernephroma): Grawitz tumour \u2714 TRUE \u2014 named after Paul Grawitz who described it (also called hypernephroma as it was thought to arise from adrenal rests). PUO (Pyrexia of Unknown Origin) \u2714 TRUE \u2014 RCC is a classic cause of PUO; paraneoplastic pyrexia from cytokine production (IL-6). Renal vein extension \u2714 TRUE \u2014 RCC characteristically invades the renal vein \u2192 IVC \u2192 can embolise to pulmonary arteries (cannon ball metastases); also direct IVC thrombus. ALWAYS PRESENTS WITH HAEMATURIA: NOT CORRECT. Classic triad (haematuria + loin pain + palpable mass) occurs in only ~10% of cases. Most RCC are now discovered INCIDENTALLY on imaging. Haematuria is common (~60%) but NOT universal \u2014 \"always\" is false. Answer: Always presents with haematuria \u2014 NOT correct.'},\n{id:102,stem:'Which one of the following regarding abdominal paediatric surgery is correct?',correct:'Incision can be closed with absorbable suture',options:['Transverse abdominal incision is always used','Incision can be closed with absorbable suture','Bowel must be always anastomosed in double layer','Skin over abdomen can never be closed with subcuticular sutures'],exp:'Paediatric abdominal surgery principles: Transverse incision \"always\": FALSE \u2014 both transverse and vertical incisions are used depending on the procedure; no absolute rule. Bowel anastomosis \"always double layer\": FALSE \u2014 single-layer anastomosis is equally effective and widely used in paediatric surgery (and adult surgery). Skin \"never\" with subcuticular sutures: FALSE \u2014 subcuticular sutures are commonly used in paediatric surgery to provide a cosmetically superior, suture-removal-free closure that is ideal for children. ABSORBABLE SUTURES for incision closure \u2714 TRUE \u2014 in paediatric surgery, absorbable sutures (polyglactin\/Vicryl, poliglecaprone\/Monocryl) are routinely used for fascial and skin closure, avoiding the need for suture removal in children. Answer: Incision can be closed with absorbable suture.'},\n{id:103,stem:'Genetic disorder predisposing patients to develop Berry aneurysm includes all EXCEPT:',correct:'Neurofibromatosis Type II',options:['Adult polycystic kidney','Fibromuscular dysplasia','Neurofibromatosis Type II','Marfan\\'s syndrome'],exp:'Conditions associated with intracranial Berry (saccular) aneurysms: Adult polycystic kidney disease (ADPKD) \u2714 \u2014 up to 10\u201312% of ADPKD patients have intracranial aneurysms; PKD1\/PKD2 mutations affect vascular connective tissue. Fibromuscular dysplasia \u2714 \u2014 non-inflammatory, non-atherosclerotic arterial disease; affects renal and carotid\/intracranial arteries; associated with intracranial aneurysms. Marfan\\'s syndrome \u2714 \u2014 connective tissue disorder (FBN1 mutation); weakened arterial walls predispose to aneurysms (aortic > intracranial). Also: Ehlers-Danlos syndrome (Type IV), coarctation of aorta, AVM. NEUROFIBROMATOSIS TYPE II (NF2): characterised by bilateral vestibular schwannomas, meningiomas, ependymomas \u2014 NOT classically associated with Berry aneurysms. NF1 has some vascular associations but NF2 is primarily a tumour predisposition syndrome. Answer: Neurofibromatosis Type II.'},\n{id:104,stem:'Which one of the following regarding Nasal polyps is NOT true?',correct:'Nasal polyps are very painful to touch',options:['Nasal polyps are very painful to touch','Simple polyps are bilateral','Bleeding polyp may indicate malignancy','Meningocele must be excluded in children with polyps'],exp:'Nasal polyps \u2014 facts: Simple (ethmoidal) polyps: BILATERAL \u2714 TRUE \u2014 associated with chronic sinusitis, allergy, aspirin sensitivity, asthma. Bleeding polyp \u2714 TRUE \u2014 a polyp that bleeds easily may indicate malignancy (angiofibroma in adolescent males, inverted papilloma, carcinoma) \u2014 needs biopsy. Meningocele in children \u2714 TRUE \u2014 nasal polyps in children (especially unilateral) should prompt exclusion of meningocele or encephalocele (nasal glioma\/heterotopic brain tissue) before any intervention \u2014 blind biopsy\/removal can cause CSF leak and meningitis. PAINFUL: nasal polyps are characteristically INSENSITIVE\/PAINLESS to touch \u2014 they can be probed or manipulated without pain (in contrast to turbinate hypertrophy which is sensitive). \"Very painful to touch\" is FALSE \u2014 a key clinical distinguishing feature of polyps. Answer: Nasal polyps are very painful \u2014 NOT true.'},\n{id:105,stem:'Allen\\'s test is used in Cardiac surgery:',correct:'When radial artery harvest is planned',options:['To select finger prick for blood glucose estimation','When radial artery harvest is planned','For evaluation of AV fistula','To check warmth of hands'],exp:'ALLEN\\'S TEST: assesses the adequacy of the ULNAR collateral circulation to the hand when the radial artery is occluded. Performed by: simultaneously compressing both radial and ulnar arteries \u2192 patient clenches fist (hand blanches) \u2192 release ulnar artery \u2192 hand should flush pink within 7 seconds (normal = adequate ulnar collateral). A NORMAL Allen\\'s test confirms safe RADIAL ARTERY HARVEST \u2014 the hand will be adequately perfused by the ulnar artery alone post-harvest. CARDIAC SURGERY \u2714 \u2014 radial artery is commonly used as a conduit for coronary artery bypass grafting (CABG); Allen\\'s test is mandatory before harvesting. Also used before radial artery cannulation for arterial line placement in ICU. AV fistula evaluation: different tests (thrill, bruit, duplex). Blood glucose: not relevant. Answer: When radial artery harvest is planned.'},\n{id:106,stem:'In a lateral facial wound, if facial nerve injury is suspected, it should be:',correct:'Primary repair should be attempted',options:['Left alone','Skin and subcutaneous flaps to be raised to cover the cut ends','Primary repair should be attempted','Secondary repair using microscope gives best result'],exp:'Facial nerve injury management: If the nerve is CUT in a LATERAL facial wound (proximal to a line from tragus to lateral canthus \u2014 where branches are identifiable): PRIMARY REPAIR \u2714 \u2014 immediate microsurgical neurorrhaphy (end-to-end) in a clean\/fresh wound gives the BEST functional results. Timing is critical: the distal nerve stumps can still be stimulated electrically for up to 72 hours post-injury, aiding identification. Primary repair within hours is superior to secondary repair. \"Left alone\": unacceptable for complete nerve transaction \u2014 spontaneous regeneration alone is inadequate. \"Cover the cut ends\": temporary measure only. \"Secondary repair using microscope gives best results\": the microscope IS used for primary repair \u2014 secondary repair (delayed) has inferior outcomes due to scarring, fibrosis, and muscle atrophy. PRIMARY repair with microscope = best results. Answer: Primary repair should be attempted.'},\n{id:107,stem:'Radiologic views used for fracture Mandible (body and Ramus) are all EXCEPT:',correct:'Submentovertex',options:['Orthopantomogram','Lateral obliques','Lower occlusal','Submentovertex'],exp:'Radiological views for mandibular fracture (body and ramus): Orthopantomogram (OPG\/Panorex) \u2714 \u2014 best single view; shows the entire mandible in one image; ideal for body, angle, ramus, condylar fractures. Lateral oblique views \u2714 \u2014 show body, angle, and ramus; useful when OPG not available. Lower occlusal view \u2714 \u2014 shows symphyseal, parasymphyseal, and body fractures en face (cross-sectional view of mandibular arch). Posteroanterior (PA) mandible \u2014 shows ramus and condyles. SUBMENTOVERTEX (SMV \/ jug-handle view): used to assess the ZYGOMATIC ARCHES (to detect zygomatic arch fractures \u2014 \"handle of jug\" sign) and base of skull, NOT for mandibular body\/ramus fractures. Answer: Submentovertex \u2014 NOT used for mandibular body\/ramus fractures.'},\n{id:108,stem:'Mallory-Weiss tear causing haematemesis is seen over:',correct:'Gastroesophageal junction',options:['Oesophagus','Gastroesophageal junction','Anterior wall of stomach','Fundus of stomach'],exp:'MALLORY-WEISS SYNDROME: longitudinal mucosal tears at the GASTROESOPHAGEAL JUNCTION (GEJ) \u2014 the junction of the oesophagus and stomach, typically on the gastric side of the GEJ. Mechanism: sudden increase in intragastric\/intra-abdominal pressure (forceful vomiting, retching, coughing, straining) \u2192 shearing stress at the GEJ \u2192 mucosal laceration \u2192 arterial bleeding \u2192 haematemesis. Classic history: alcoholic patient + repeated vomiting \u2192 then haematemesis. 75\u201390% stop bleeding spontaneously. Management: endoscopic haemostasis (adrenaline injection, clipping, banding). NOT in the mid-oesophagus, anterior stomach wall, or fundus. Answer: Gastroesophageal junction.'},\n{id:109,stem:'Which one of the following factors is NOT involved in the pathogenesis of Systemic Inflammatory Response Syndrome (SIRS)?',correct:'Microvascular occlusion',options:['Increased cytokine production','Abnormal nitric oxide synthesis','Free radical production','Microvascular occlusion'],exp:'SIRS pathogenesis involves: Increased cytokine production \u2714 \u2014 TNF-\u03b1, IL-1, IL-6, IL-8 released from activated macrophages\/monocytes; mediators of systemic inflammation. Abnormal nitric oxide synthesis \u2714 \u2014 inducible NOS (iNOS) produces excess NO \u2192 profound vasodilation \u2192 hypotension (key mechanism in septic shock). Free radical production \u2714 \u2014 reactive oxygen species (ROS) from activated neutrophils \u2192 oxidative stress \u2192 endothelial damage, organ dysfunction. MICROVASCULAR OCCLUSION: this is a feature of DISSEMINATED INTRAVASCULAR COAGULATION (DIC) \u2014 microthrombi occluding microcirculation. While SIRS can LEAD TO DIC, microvascular occlusion per se is not a primary pathogenic mechanism of SIRS itself. SIRS pathogenesis is primarily pro-inflammatory (cytokines, mediators, NO, free radicals) rather than thrombotic. Answer: Microvascular occlusion.'},\n{id:110,stem:'Sleeve Gastrectomy done for Morbid obesity is a:',correct:'Restrictive procedure',options:['Restrictive procedure','Reversible procedure','Mildly restrictive and mainly malabsorptive','Malabsorptive procedure only'],exp:'Bariatric surgery classification: RESTRICTIVE procedures: reduce stomach capacity \u2192 reduce food intake. Examples: Sleeve gastrectomy \u2714, Adjustable gastric band, Vertical banded gastroplasty. MALABSORPTIVE procedures: bypass absorptive intestinal surface. Examples: Biliopancreatic diversion (BPD), Jejunoileal bypass. COMBINED restrictive + malabsorptive: Roux-en-Y Gastric Bypass (RYGB) \u2014 most commonly performed combined procedure. SLEEVE GASTRECTOMY: removes ~75\u201380% of the stomach (greater curvature) leaving a narrow gastric tube (\"sleeve\"); PURELY RESTRICTIVE \u2014 reduces volume, reduces ghrelin (hunger hormone from gastric fundus), no intestinal bypass. NOT reversible (permanent gastrectomy). NOT malabsorptive. Answer: Restrictive procedure.'},\n{id:111,stem:'Pre-operative Nutrition Screening in a patient with morbid obesity planned for Gastric Bypass includes all EXCEPT:',correct:'Serum Insulin',options:['Serum Magnesium','Serum Calcium','Serum Vitamin B12','Serum Insulin'],exp:'Pre-operative nutritional screening before Roux-en-Y Gastric Bypass (RYGB): Morbidly obese patients frequently have pre-existing nutritional deficiencies. Mandatory screening: Serum Calcium \u2714 \u2014 calcium absorption impaired post-bypass (bypasses duodenum = main Ca absorption site); hypocalcaemia\/metabolic bone disease risk. Serum Magnesium \u2714 \u2014 hypomagnesaemia common in morbidly obese; critical for cardiac and neuromuscular function. Serum Vitamin B12 \u2714 \u2014 B12 absorption requires intrinsic factor from gastric parietal cells + ileal receptor; bypass reduces intrinsic factor \u2192 B12 deficiency. Also: Iron, Folate, Vitamin D, Thiamine, Zinc, Vitamin A. SERUM INSULIN: this measures pancreatic function\/insulin resistance \u2014 it is NOT a nutritional screening parameter. It may be checked for diabetes assessment but is not part of standard pre-operative NUTRITIONAL screening panels. Answer: Serum Insulin.'},\n{id:112,stem:'In postoperative care the long term risks after Bariatric Surgery include all EXCEPT:',correct:'Deep Vein Thrombosis',options:['Protein Calorie Malnutrition','Deep Vein Thrombosis','Vitamin and Micronutrient depletion syndromes','Weight regain'],exp:'Long-term risks after bariatric surgery: Protein Calorie Malnutrition \u2714 \u2014 inadequate dietary intake + malabsorption; risk of kwashiorkor-like states especially post-BPD\/DS. Vitamin and Micronutrient depletion \u2714 \u2014 B12, iron, calcium, vitamin D, thiamine deficiency syndromes; require lifelong supplementation. Weight regain \u2714 \u2014 common long-term issue (~20\u201330% of patients regain significant weight by 5 years); due to dietary non-compliance, pouch dilation, psychological factors. DEEP VEIN THROMBOSIS: DVT is an EARLY\/PERI-OPERATIVE complication (within days to weeks of surgery) \u2014 morbidly obese patients are high VTE risk in the post-operative period. It is NOT a LONG-TERM risk specific to bariatric surgery. Long-term thrombosis risk actually DECREASES after bariatric surgery (weight loss improves VTE risk factors). Answer: Deep Vein Thrombosis \u2014 NOT a long-term risk.'},\n{id:113,stem:'Hilton\\'s method of Incision and Drainage of abscess has the advantage of:',correct:'Avoids injury to underlying vessels and nerves',options:['Complete drainage of pus','Avoids injury to underlying vessels and nerves','Provides irrigation','Heals without scar'],exp:'HILTON\\'S METHOD of I&D: a technique of abscess drainage using BLUNT DISSECTION with sinus forceps\/artery forceps rather than incision with a knife. Technique: small skin incision \u2192 sinus forceps introduced closed \u2192 opened (spreading) to gently enlarge the tract through subcutaneous tissue. PRIMARY ADVANTAGE \u2714: AVOIDS INJURY TO UNDERLYING VESSELS AND NERVES \u2014 the blunt spreading action separates tissue along tissue planes without cutting; vessels and nerves are displaced rather than severed. Particularly useful in areas with important underlying structures (axilla, groin, perineum). NOT advantages of Hilton\\'s method: Complete drainage \u2014 not better than incisional drainage. Irrigation \u2014 not a feature. Heals without scar \u2014 any incision scars. Answer: Avoids injury to underlying vessels and nerves.'},\n{id:114,stem:'Indications of computed tomography after head injury include all EXCEPT:',correct:'Mild head injury in a 50-year-old man',options:['Glasgow Coma Scale < 13 at any point','Open depressed fracture','Mild head injury in a 50 year old man','Amnesia > 30 minutes'],exp:'CT head indications after head injury (NICE guidelines \/ ATLS): GCS <13 at any point \u2714 \u2014 moderate\/severe head injury = immediate CT. Open\/depressed skull fracture \u2714 \u2014 risk of underlying brain injury\/intracranial haematoma. Amnesia >30 minutes post-injury \u2714 \u2014 significant mechanism indicator for intracranial injury. Also: focal neurological deficit, vomiting >1 episode, age >65 with LOC\/amnesia, dangerous mechanism, on anticoagulants, GCS <15 after 2 hours. MILD HEAD INJURY IN A 50-YEAR-OLD MAN (no other risk factors): mild head injury alone (GCS 14\u201315, brief LOC, no amnesia, no focal deficit) in an otherwise healthy adult is NOT a standalone indication for CT. Age >65 is a risk factor, but 50 years without other criteria does not mandate CT. Mild head injury without additional risk factors = clinical observation, not mandatory CT. Answer: Mild head injury in a 50-year-old man.'},\n{id:115,stem:'Mondor\\'s disease is:',correct:'Thrombophlebitis of superficial veins of the breast and anterior chest wall',options:['Thrombophlebitis of superficial veins of the breast and anterior chest wall','Other name for tuberculosis of breast','Rare type of chronic intramammary abscess','Named after the scientist who first coined the term \"Actinomycosis of Breast\"'],exp:'MONDOR\\'S DISEASE: thrombophlebitis of the SUPERFICIAL VEINS of the breast and anterior chest wall (typically the thoracoepigastric and lateral thoracic veins). Clinical features: painful, cord-like subcutaneous induration running along the breast or chest wall; skin dimpling\/retraction may be present (can mimic carcinoma). Causes: trauma, bra straps, surgery, after breast augmentation. Usually self-limiting (resolves in 6\u20138 weeks). Clinical importance: must be distinguished from carcinoma (which can also cause skin tethering). Named after Henri Mondor (French surgeon, 1939). NOT tuberculosis, NOT abscess, NOT actinomycosis-related. Answer: Thrombophlebitis of superficial veins of breast and anterior chest wall.'},\n{id:116,stem:'Sengstaken-Blakemore tube is used to control bleeding in:',correct:'Bleeding varices',options:['Renal trauma','Bleeding varices','Splenic injury in portal hypertension','Duodenal ulcer bleed'],exp:'SENGSTAKEN-BLAKEMORE (SB) TUBE: a triple-lumen tube used for TAMPONADE of BLEEDING OESOPHAGEAL AND GASTRIC VARICES. Components: Oesophageal balloon (inflated to tamponade oesophageal varices), Gastric balloon (inflated in stomach to anchor the tube and tamponade gastric varices\/gastroesophageal junction), Gastric aspiration lumen. Indication: acute variceal haemorrhage uncontrolled by endoscopic therapy (banding, sclerotherapy) or pharmacotherapy (terlipressin, octreotide) \u2014 used as a BRIDGE to definitive therapy (TIPS, surgery). Complications: aspiration pneumonia, oesophageal rupture, pressure necrosis. NOT for: renal trauma (surgical\/interventional radiology), splenic injury (surgery\/embolisation), peptic ulcer (endoscopy\/surgery). Answer: Bleeding varices.'},\n{id:117,stem:'Which one of the following regarding Pancreatic effusion is correct?',correct:'Free fluid collection in Pleural cavity',options:['Free fluid collection in Pleural cavity','Never associated with abdominal collection','Pancreatic stenting is to be done','Percutaneous drainage under image guidance is necessary'],exp:'PANCREATIC PLEURAL EFFUSION (Pancreatic pseudopleura): occurs when a disrupted pancreatic duct or pancreatic pseudocyst communicates with the pleural space via a pancreatico-pleural fistula \u2192 enzyme-rich fluid accumulates in the PLEURAL CAVITY \u2714 (free fluid in pleural space = exudate with very high amylase). Features: large recurrent pleural effusion (often left-sided) in a patient with chronic pancreatitis or pancreatic ductal disruption; pleural fluid amylase > 1000 U\/L. NOT \"never associated with abdominal collection\" \u2014 can coexist with ascites\/pseudocyst. Pancreatic stenting (via ERCP) is one management option for the ductal disruption \u2014 but not universally required; surgery (Roux-en-Y internal drainage, distal pancreatectomy) may be needed. Percutaneous drainage alone is often insufficient (the fistula persists). The correct statement: it is free fluid collection in the pleural cavity. Answer: Free fluid collection in pleural cavity.'},\n{id:118,stem:'Which one of the following bone is affected in Kienb\u00f6ck\\'s disease?',correct:'Lunate bone',options:['Lunate bone','Capitellum of the humerus','Metatarsal','Navicular bone'],exp:'KIENB\u00d6CK\\'S DISEASE: avascular necrosis (osteonecrosis) of the LUNATE bone of the wrist. Cause: interruption of lunate blood supply (single or dual vessel supply) \u2192 ischaemic necrosis \u2192 collapse of lunate \u2192 progressive wrist arthritis. Clinical: wrist pain, limited range of motion, tenderness over lunate (dorsal wrist). Radiography: sclerosis \u2192 fragmentation \u2192 collapse of lunate (Lichtman staging I\u2013IV). Associated with ulnar minus variant (negative ulnar variance). Treatment: unloading procedures (joint levelling), immobilisation, or salvage (proximal row carpectomy, wrist fusion). Other avascular necroses: Perthes disease = femoral head, Freiberg\\'s = 2nd metatarsal head, K\u00f6hler\\'s = navicular (foot), Panner\\'s = capitellum of humerus. Kienb\u00f6ck\\'s = LUNATE. Answer: Lunate bone.'},\n{id:119,stem:'Which one of the following regarding management of acute wounds is NOT true?',correct:'Clamps should be used to stop all bleeding vessels',options:['The whole patient should be examined according to ATLS principles','Wounds should be examined taking into consideration site and structures damaged','Bleeding wounds should be elevated and a pressure pad applied','Clamps should be used to stop all bleeding vessels'],exp:'Acute wound management principles: ATLS assessment \u2714 TRUE \u2014 systematic evaluation (ABCDE) of the whole patient; life-threatening injuries take priority over wound management. Site and structures assessment \u2714 TRUE \u2014 identify which structures are involved (nerves, vessels, tendons, bones) before deciding management. Elevation + pressure pad \u2714 TRUE \u2014 elevation reduces venous pressure; direct pressure is the most effective first measure for wound bleeding (applies pressure to the bleeding point). CLAMPS: \"Clamps should be used to stop ALL bleeding vessels\" is NOT TRUE and is DANGEROUS. Blind clamping of vessels in wounds risks: injury to adjacent nerves (especially in face, hand), catching the wrong structure, incomplete haemostasis. Only clearly visible, accessible bleeding points should be ligated\/clipped \u2014 and in wounds near important structures, pressure alone is safer until proper exploration in theatre. Answer: Clamps to stop all bleeding vessels \u2014 NOT true.'},\n{id:120,stem:'Risk Scoring System which can be used post-operatively is:',correct:'POSSUM \u2192 Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity',options:['ASA \u2192 American Society of Anaesthesiologist','MET \u2192 Metabolic Equivalent Task','RCRI \u2192 Revised Cardiac Risk Index','POSSUM \u2192 Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity'],exp:'Risk scoring systems: ASA (American Society of Anaesthesiologists) score: PRE-OPERATIVE \u2014 classifies physical status (I\u2013VI) before surgery; used for pre-operative risk assessment. MET (Metabolic Equivalent Task): PRE-OPERATIVE \u2014 functional capacity assessment for cardiac risk evaluation before surgery. RCRI (Revised Cardiac Risk Index \/ Lee index): PRE-OPERATIVE \u2014 predicts major adverse cardiac events in non-cardiac surgery (uses 6 clinical predictors). POSSUM (Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity) \u2714 POST-OPERATIVE \u2014 uses 12 physiological variables + 6 operative variables; calculated AFTER the operation is completed to predict post-operative morbidity and mortality; used for audit and quality benchmarking. P-POSSUM (Portsmouth modification) is also commonly used. POSSUM is the only score listed that can be applied POST-OPERATIVELY. 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consolidate the weaker areas.':pct>=40?'Fair \u2014 systematic revision recommended.':'Needs significant revision across these topics.';\n $('vd').textContent=v;\n $('bc').textContent='\u2705 '+c+' Correct';$('bw').textContent='\u274c '+w+' Wrong';$('bk').textContent='\u23ed '+sk+' Skipped';\n var s=$('sc-box');s.style.display='block';s.scrollIntoView({behavior:'smooth',block:'center'});\n}\n\nfunction init(){\n $('gn').addEventListener('click',function(){hideGrace();showScore();});\n $('tb').addEventListener('click',function(){if(!tr&&!sub)startTimer();});\n $('sub').addEventListener('click',showScore);\n $('rb').addEventListener('click',function(){build();window.scrollTo({top:0,behavior:'smooth'});});\n new IntersectionObserver(function(e){$('sb').classList.toggle('vs',!e[0].isIntersecting);},{threshold:0}).observe($('sn'));\n build();stats();\n}\nif(document.readyState==='loading'){document.addEventListener('DOMContentLoaded',init);}else{init();}\n})();\n<\/script>\n<\/body>\n<\/html>\n","protected":false},"excerpt":{"rendered":"<p>CMS 2018 Paper II \u2013 Part C (Q81\u2013Q120) \u23f1 40:00 \u2705 0 \u274c 0 \u23f3 40 left Net 0 \/ 160 Time's Up! Submitting in 10 Submit Now Combined Medical Services Examination 2018Paper II \u00b7 Part C General Surgery \u00b7 ENT \u00b7 Orthopaedics \u00b7 Critical Care \u00b7 Bariatric \u00b7 Vascular Questions 81 \u2013 120 Options reshuffled \u23f1 Start Timed Mode Submit Answers 0%score… <\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[18,56],"tags":[],"class_list":["post-36814","post","type-post","status-publish","format-standard","hentry","category-cms","category-surgery"],"yoast_head":"\n<title>CMS 2018 P2 Part-C - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/2026\/05\/11\/cms-2018-p2-part-c\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"CMS 2018 P2 Part-C - atsixty\" \/>\n<meta property=\"og:description\" content=\"CMS 2018 Paper II \u2013 Part C (Q81\u2013Q120) \u23f1 40:00 \u2705 0 \u274c 0 \u23f3 40 left Net 0 \/ 160 Time's Up! 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