CMS 2019 Paper II \u2013 Part A (Q1\u2013Q40)<\/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#cms19p2a*,#cms19p2a *::before,#cms19p2a *::after{box-sizing:border-box;margin:0;padding:0}\n#cms19p2a{--ter:#C0603A;--ter-pale:#fdf1ec;--teal:#2A7A6F;--teal-light:#3da394;--teal-pale:#eaf4f3;--ink:#1a1a1a;--ink-mid:#444;--ink-soft:#777;--line:#e0d8d4;--bg:#fdfaf8;--white:#fff;--cb:#43a047;--cb-bg:#eaf7ef;--wb:#e53935;--wb-bg:#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#cms19p2a .sen{height:1px}\n#cms19p2a .sb{position:fixed;top:0;left:0;right:0;z-index:99999;background:var(--white);border-bottom:2px solid var(--line);border-left:4px solid var(--ter);box-shadow:0 2px 12px 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0%,var(--line) 0%);display:flex;align-items:center;justify-content:center;margin:0 auto 20px;position:relative}\n#cms19p2a .ring::before{content:'';position:absolute;width:86px;height:86px;border-radius:50%;background:var(--white)}\n#cms19p2a .ri{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#cms19p2a .rp{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--teal)}\n#cms19p2a .rs{font-size:.6rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:.05em}\n#cms19p2a .sc h2{font-family:'Playfair Display',serif;font-size:1.2rem;color:var(--ink);margin-bottom:8px}\n#cms19p2a .nl{font-size:1rem;color:var(--teal);font-weight:600;margin-bottom:6px}\n#cms19p2a .vd{font-size:.85rem;color:var(--ink-soft);margin-bottom:20px}\n#cms19p2a .bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap;font-size:.8rem}\n#cms19p2a .band{padding:4px 12px;border-radius:16px;font-weight:600}\n#cms19p2a 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id=\"cms19p2a-sw\">0<\/strong><\/div>\n <div class=\"sb-it\">\u23f3 <strong id=\"cms19p2a-sr\">40<\/strong> left<\/div>\n <div class=\"sb-sep\"><\/div>\n <div class=\"sb-it\">Net <strong id=\"cms19p2a-sn\">0<\/strong> \/ <strong id=\"cms19p2a-sm\">160<\/strong><\/div>\n <\/div>\n <div class=\"sb-bar\"><div class=\"sb-fill\" id=\"cms19p2a-fill\"><\/div><\/div>\n<\/div>\n<div class=\"grace\" id=\"cms19p2a-grace\">\n <div class=\"gb\">\n <h3>Time's Up!<\/h3><p>Submitting in<\/p>\n <div class=\"gc\" id=\"cms19p2a-gc\">10<\/div>\n <button class=\"gnow\" id=\"cms19p2a-gnow\">Submit Now<\/button>\n <\/div>\n<\/div>\n<div class=\"hdr\">\n <h1>Combined Medical Services Examination 2019<br>Paper II \u00b7 Part A<\/h1>\n <p>General Surgery \u00b7 Orthopaedics \u00b7 Ophthalmology \u00b7 ENT \u00b7 Anaesthesia<\/p>\n <div class=\"meta\">\n <span class=\"bdg\">Questions 1 \u2013 40<\/span>\n <span class=\"bdg\">Options reshuffled<\/span>\n <button class=\"tbtn\" id=\"cms19p2a-tbtn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n<\/div>\n<div class=\"body\">\n <div id=\"cms19p2a-qs\"><\/div>\n <div class=\"sw\"><button class=\"btn\" id=\"cms19p2a-sub\">Submit Answers<\/button><\/div>\n <div class=\"sc\" id=\"cms19p2a-sc-box\">\n <div class=\"ring\" id=\"cms19p2a-ring\"><div class=\"ri\"><span class=\"rp\" id=\"cms19p2a-rp\">0%<\/span><span class=\"rs\">score<\/span><\/div><\/div>\n <h2>Your Result<\/h2>\n <div class=\"nl\" id=\"cms19p2a-nl\"><\/div>\n <div class=\"vd\" id=\"cms19p2a-vd\"><\/div>\n <div class=\"bands\">\n <span class=\"band bc\" id=\"cms19p2a-bc\"><\/span>\n <span class=\"band bw\" id=\"cms19p2a-bw\"><\/span>\n <span class=\"band bs\" id=\"cms19p2a-bs\"><\/span>\n <\/div>\n <button class=\"rbtn\" id=\"cms19p2a-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n<\/div>\n<\/div>\n<script>\n(function(){\n'use strict';\nvar NS='cms19p2a',TOTAL=40,MAX=160,TSECS=2400,GSECS=10;\nvar QS=[\n{id:1,stem:'What is the correct order of the normal phases of wound healing?',correct:'Haemostatic phase \u2192 Inflammatory phase \u2192 Proliferative phase \u2192 Remodelling phase',options:['Proliferative phase \u2192 Haemostatic phase \u2192 Inflammatory phase \u2192 Remodelling phase','Haemostatic phase \u2192 Inflammatory phase \u2192 Proliferative phase \u2192 Remodelling phase','Destructive phase \u2192 Proliferative phase \u2192 Remodelling phase \u2192 Inflammatory phase','Remodelling phase \u2192 Proliferative phase \u2192 Destructive phase \u2192 Inflammatory phase'],exp:'Wound healing follows a fixed sequence of four overlapping phases. HAEMOSTASIS (immediate): vasoconstriction, platelet plug, fibrin clot \u2014 stops bleeding and forms scaffold. INFLAMMATORY phase (0\u20133 days): neutrophils then macrophages debride and release growth factors. PROLIFERATIVE phase (3 days \u2013 3 weeks): fibroblasts deposit collagen, angiogenesis, epithelialisation, wound contraction. REMODELLING phase (3 weeks \u2013 2 years): collagen remodelled from type III to type I, scar matures and strengthens (up to 80% original tensile strength). Mnemonic: HIPR. Answer: Haemostatic \u2192 Inflammatory \u2192 Proliferative \u2192 Remodelling.'},\n{id:2,stem:'All of the following are risk factors for an increased risk of wound infection EXCEPT:',correct:'Hypertension',options:['Obesity','Hypertension','Jaundice','Cancer'],exp:'Wound infection risk factors: OBESITY \u2714 \u2014 poor tissue oxygenation, excess subcutaneous fat (poor vascularity), difficult closure. JAUNDICE \u2714 \u2014 bile acids impair neutrophil chemotaxis, coagulopathy, poor healing. CANCER \u2714 \u2014 malnutrition, immunosuppression, chemotherapy\/radiotherapy effects. HYPERTENSION \u2717 \u2014 per se does not directly increase wound infection risk; well-controlled hypertension is not a standard surgical wound infection risk factor. (Note: poorly controlled hypertension may affect perfusion, but is NOT classically listed as a wound infection risk factor in surgical texts.) Answer: Hypertension.'},\n{id:3,stem:'Systemic Inflammatory Response Syndrome (SIRS) is characterized by all of the following EXCEPT:',correct:'Platelet count (<1,00,000\/mm\u00b3)',options:['Hyperthermia (>38\u02daC)','Platelet count (<1,00,000\/mm\u00b3)','Tachypnoea (>20\/min)','Hypothermia (<36\u02daC)'],exp:'SIRS criteria (any 2 of 4): (1) Temperature >38\u00b0C (hyperthermia) or <36\u00b0C (hypothermia). (2) Heart rate >90\/min. (3) Respiratory rate >20\/min OR PaCO\u2082 <32 mmHg. (4) WBC >12,000\/mm\u00b3 or <4,000\/mm\u00b3 or >10% immature (band) forms. PLATELET COUNT is NOT a criterion for SIRS. Thrombocytopaenia (<1,00,000\/mm\u00b3) may be seen in sepsis or DIC but is not one of the four defining SIRS parameters. The question asks what is NOT a feature of SIRS. Answer: Platelet count <1,00,000\/mm\u00b3.'},\n{id:4,stem:'A 56-year-old gentleman underwent laparoscopic left hemicolectomy for left colonic carcinoma. Histopathology revealed the tumour invading submucosa and muscularis propria. Among 16 regional lymph nodes harvested, 2 were positive for malignant deposits. His AJCC staging will be:',correct:'T2, N1, M0',options:['T1, N1, M0','T2, N1, M0','T1, N0, M0','T2, N1, M1'],exp:'AJCC 8th edition colorectal staging: T stage \u2014 T1: invades submucosa only. T2: invades muscularis propria. T3: through muscularis propria into pericolorectal tissues. T4: invades visceral peritoneum or adjacent organs. This tumour invades BOTH submucosa AND muscularis propria \u2192 T2. N stage \u2014 N0: no nodes. N1: 1\u20133 regional nodes positive. N2: \u22654 nodes. Here 2 nodes positive \u2192 N1. M0: no distant metastasis (no mention of metastases). Final staging: T2, N1, M0 = Stage IIIA. Answer: T2, N1, M0.'},\n{id:5,stem:'All of the following are hormonal agents used in treatment of cancer EXCEPT:',correct:'Irinotecan',options:['Anastrazole','Irinotecan','Cabergoline','Leuprolide'],exp:'Hormonal\/endocrine agents used in cancer: ANASTRAZOLE \u2714 \u2014 aromatase inhibitor, blocks oestrogen synthesis; used in hormone receptor-positive breast cancer. CABERGOLINE \u2714 \u2014 dopamine agonist; suppresses prolactin; used in prolactinomas. LEUPROLIDE \u2714 \u2014 GnRH agonist; causes medical castration via downregulation; used in prostate cancer and hormone-sensitive breast cancer. IRINOTECAN \u2717 \u2014 a topoisomerase I inhibitor (cytotoxic chemotherapy); used in colorectal, lung, and ovarian cancers; completely unrelated to hormonal manipulation. Answer: Irinotecan.'},\n{id:6,stem:'Which of the following statements regarding lymphoedema are correct?\\n1. Patients experience constant dull ache and even severe pain sometimes\\n2. Manual lymphatic drainage has a role\\n3. Primary lymphoedema is caused by congenital lymphatic dysplasia\\n4. Nonne Milroy\\'s disease is a type of primary lymphoedema\\nSelect the correct answer:',correct:'1, 2, 3 and 4',options:['3 and 4 only','1 and 2 only','1, 2 and 3 only','1, 2, 3 and 4'],exp:'Evaluating each statement: (1) \u2714 Lymphoedema typically causes heaviness and a constant dull ache; severe pain can occur with acute inflammatory episodes or secondary infection. (2) \u2714 Manual lymphatic drainage (MLD) is a cornerstone of conservative management \u2014 part of complete decongestive therapy (CDT). (3) \u2714 Primary lymphoedema results from congenital aplasia, hypoplasia, or hyperplasia (dysplasia) of lymphatic vessels. (4) \u2714 Nonne-Milroy disease (Milroy disease) = hereditary, congenital onset primary lymphoedema due to FLT4\/VEGFR3 mutation \u2014 a classic type of primary lymphoedema. All four are correct. Answer: 1, 2, 3 and 4.'},\n{id:7,stem:'Indications for carotid endarterectomy in symptomatic patients are all of the following EXCEPT:',correct:'Persistent hypertension',options:['Hemianopia','Monocular blindness','Dysphasia','Persistent hypertension'],exp:'Carotid endarterectomy (CEA) is indicated in SYMPTOMATIC patients with significant carotid stenosis (>70%, and selected 50\u201369%). Symptoms must be ipsilateral neurological events: MONOCULAR BLINDNESS (amaurosis fugax \u2014 transient ischaemic attack of the ophthalmic artery) \u2714. DYSPHASIA (dominant hemisphere TIA\/minor stroke) \u2714. HEMIANOPIA (posterior circulation OR hemispheric ischaemia in relevant territory) \u2714. PERSISTENT HYPERTENSION \u2717 \u2014 hypertension is a risk factor for stroke but is NOT an indication for CEA; it is managed medically. CEA indication = neurological\/ocular ischaemic symptoms, not blood pressure control. Answer: Persistent hypertension.'},\n{id:8,stem:'A 45-year-old policeman presents with lipodermatosclerosis over the lower medial aspect of the left leg, along with a healed venous ulcer. As per CEAP classification his clinical classification will be:',correct:'C5',options:['C4a','C4b','C5','C6'],exp:'CEAP Clinical classification of chronic venous disease: C0: no visible or palpable signs. C1: telangiectasia\/reticular veins. C2: varicose veins. C3: oedema. C4a: pigmentation or eczema. C4b: LIPODERMATOSCLEROSIS or atrophie blanche. C5: healed venous ulcer. C6: active venous ulcer. This patient has BOTH lipodermatosclerosis (C4b) AND a HEALED ULCER. When both are present, the higher\/more advanced classification applies. A healed ulcer = C5 (subsumes C4b). Answer: C5.'},\n{id:9,stem:'What is true about the management of a corrosive injury of the oesophagus?',correct:'Early skilled endoscopy is must',options:['Early skilled endoscopy is must','Immediate surgery with oesophagectomy is advisable','Broad spectrum antibiotics should be started as soon as possible','Immediate NG tube insertion and gastric lavage should be performed'],exp:'Management of corrosive oesophageal injury: EARLY SKILLED ENDOSCOPY \u2714 \u2014 within 12\u201324 hours (not beyond 48h; not in first 2\u20133h due to risk): essential to assess depth and extent of injury; guides prognosis and management plan. IMMEDIATE OESOPHAGECTOMY \u2717 \u2014 only for Grade IIIb\/transmural necrosis with perforation; not routine. PROPHYLACTIC ANTIBIOTICS \u2717 \u2014 not routinely recommended without evidence of perforation\/infection. NG TUBE AND GASTRIC LAVAGE \u2717 \u2014 ABSOLUTELY CONTRAINDICATED in corrosive ingestion (risk of perforation, aspiration, further injury, re-exposure of oesophagus). Answer: Early skilled endoscopy is must.'},\n{id:10,stem:'Which of the statements regarding salivary gland neoplasms are correct?\\n1. 80\u201390% of parotid tumours are malignant\\n2. 90% of sublingual gland tumours are malignant\\n3. 60\u201370% of submandibular gland tumours are benign\\n4. Parotid gland is most common site for salivary gland tumours\\nSelect the correct answer:',correct:'2, 3 and 4',options:['1, 2 and 3','2, 3 and 4','1, 3 and 4','1, 2 and 4'],exp:'Salivary gland tumour facts: Parotid gland \u2714 = most common site (70\u201380% of all salivary gland tumours). Statement 1 \u2717: 80\u201390% of parotid tumours are BENIGN (not malignant); malignancy rate is only 15\u201325%. Statement 2 \u2714: sublingual gland tumours \u2014 70\u201390% are malignant (small glands \u2192 high malignancy ratio). Statement 3 \u2714: 60% of submandibular tumours are benign (40% malignant). Statement 4 \u2714: parotid is the most common site. Rule of thumb: the smaller the gland, the higher the malignancy rate. Correct statements: 2, 3 and 4. Answer: 2, 3 and 4.'},\n{id:11,stem:'A few days following viral fever, a 50-year-old female presented with pain in neck, fever, malaise and firm enlargement of both lobes of thyroid. Thyroid antibodies were normal and serum T4 was high normal. Probable diagnosis is:',correct:'Granulomatous thyroiditis',options:['Autoimmune thyroiditis','Lymphoma of thyroid','Granulomatous thyroiditis','Riedel\\'s thyroiditis'],exp:'GRANULOMATOUS (De Quervain\\'s \/ subacute) THYROIDITIS: post-viral inflammatory condition (often after URTI\/viral fever). Classical features: painful, tender, FIRM thyroid enlargement; fever; malaise; raised ESR; elevated T4 (leak from destroyed follicles = transient thyrotoxicosis). THYROID ANTIBODIES NORMAL \u2714 (distinguishes from Hashimoto\\'s\/autoimmune thyroiditis). Autoimmune (Hashimoto\\'s): positive TPO antibodies, rarely painful. Lymphoma: hard, rapidly growing, often in Hashimoto\\'s background. Riedel\\'s: woody hard, fixed, rare, painless, antibodies may be present. Post-viral + painful + raised T4 + normal antibodies = De Quervain\\'s. Answer: Granulomatous thyroiditis.'},\n{id:12,stem:'No increased relative risk of invasive breast carcinoma based on histopathological examination of benign breast tissue is for all of the following EXCEPT:',correct:'Solitary papilloma of lactiferous sinus',options:['Hyperplasia','Periductal mastitis','Squamous metaplasia','Solitary papilloma of lactiferous sinus'],exp:'Risk stratification of benign breast disease (Dupont & Page): NO increased risk (RR \u22481): adenosis, duct ectasia, mild hyperplasia, cysts, PERIDUCTAL MASTITIS, SQUAMOUS METAPLASIA (apocrine change), fibroadenoma without complex features. Slightly increased risk (RR 1.5\u20132\u00d7): moderate\/florid HYPERPLASIA, sclerosing adenosis, SOLITARY PAPILLOMA. Moderately increased risk (RR 4\u20135\u00d7): atypical ductal hyperplasia, atypical lobular hyperplasia. The question asks which is the EXCEPTION (i.e., which DOES carry increased risk). SOLITARY PAPILLOMA of lactiferous sinus \u2192 RR 1.5\u20132\u00d7 (slight increase). Answer: Solitary papilloma of lactiferous sinus.'},\n{id:13,stem:'Which of the following statements regarding Paget\\'s disease of nipple are correct?\\n1. It represents benign pathology of nipple areola complex\\n2. It is eczema-like condition of nipple and areola\\n3. Erosion of nipple is seen\\n4. Nipple biopsy is required for definitive diagnosis\\nSelect the correct answer:',correct:'2, 3 and 4',options:['1, 2 and 3','2, 3 and 4','1, 3 and 4','2 and 4 only'],exp:'Paget\\'s disease of the nipple: Statement 1 \u2717 \u2014 it is NOT benign; it is a MALIGNANT condition (intraepidermal adenocarcinoma of the nipple); virtually always associated with underlying DCIS or invasive carcinoma. Statement 2 \u2714 \u2014 clinically presents as an eczematous, erythematous, scaly, weeping rash of the nipple-areola complex mimicking eczema. Statement 3 \u2714 \u2014 as disease progresses, nipple erosion, ulceration, and destruction occur. Statement 4 \u2714 \u2014 definitive diagnosis requires NIPPLE BIOPSY showing Paget cells (large pale cells with prominent nucleoli within the epidermis). Correct: 2, 3 and 4. Answer: 2, 3 and 4.'},\n{id:14,stem:'A 36-year-old gentleman presents with long history of upper abdominal pain, periodic and often occurring early morning. For last 3 months, he has projectile vomiting which is non-bilious and unpleasant in nature with undigested food material. On examination he appears unwell, dehydrated and has lost weight. He is probably suffering from:',correct:'Gastric outlet obstruction',options:['Gastric outlet obstruction','Carcinoma stomach','Gastro-oesophageal reflux with oesophagitis','Superior mesenteric artery syndrome'],exp:'Gastric outlet obstruction (GOO): KEY FEATURES \u2014 long history of peptic ulcer disease (periodic early morning pain relieved by food\/antacids). PROJECTILE VOMITING \u2014 large volumes, non-bilious (obstruction is proximal to ampulla of Vater). UNDIGESTED FOOD in vomitus (food retained from previous meals). DEHYDRATION and WEIGHT LOSS from inability to absorb nutrition. SUCCESSION SPLASH may be present. Classic cause in this age group: pyloric stenosis from scarring of chronic duodenal ulcer. Succussion splash (+). Metabolic alkalosis (hypochloraemic, hypokalaemic). Answer: Gastric outlet obstruction.'},\n{id:15,stem:'A 40-year-old female presents with colicky abdominal pain, episodes of mild diarrhoea for 6 months, intermittent fever, weight loss, and multiple discharging sinuses on perineal examination. The most likely clinical diagnosis is:',correct:'Crohn disease',options:['Amoebic colitis','Crohn disease','Ulcerative colitis','Ileocaecal Tuberculosis'],exp:'Crohn\\'s disease: TRANSMURAL, SKIP LESION, ANY PART OF GI TRACT (mouth to anus). Key distinguishing feature here: PERIANAL DISEASE \u2014 multiple discharging sinuses\/fistulae are pathognomonic of Crohn\\'s disease (occur in ~30\u201340%; NOT seen in UC). Other features \u2714: colicky pain, diarrhoea, fever, weight loss, chronic course. Ulcerative colitis: confined to colon, mucosal only, NO perianal fistulae. Ileocaecal TB: similar to Crohn\\'s but perianal fistulae are rare and less typical. Amoebic colitis: dysentery, flask-shaped ulcers, no fistulae. PERIANAL SINUSES\/FISTULAE = hallmark of Crohn\\'s. Answer: Crohn disease.'},\n{id:16,stem:'A 48-year-old gentleman was being worked up for hepatocellular function. No history or signs of encephalopathy. Serum bilirubin 5 mg%, serum albumin 3.9 gm%, INR 1.6. Ultrasound showed no free fluid. As per Child-Turcotte-Pugh (CTP) classification, he was in:',correct:'CTP\u2013B',options:['CTP\u2013A','CTP\u2013B','CTP\u2013C','CTP\u2013D'],exp:'Child-Turcotte-Pugh scoring (each parameter scored 1\u20133): Bilirubin: <2 mg% = 1; 2\u20133 = 2; >3 = 3. This patient: 5 mg% \u2192 3 points. Albumin: >3.5 = 1; 2.8\u20133.5 = 2; <2.8 = 3. This patient: 3.9 g% \u2192 1 point. PT\/INR: <1.7 = 1; 1.7\u20132.3 = 2; >2.3 = 3. This patient: 1.6 \u2192 1 point. Ascites: None = 1. Encephalopathy: None = 1. TOTAL = 3+1+1+1+1 = 7 points. CTP-A = 5\u20136; CTP-B = 7\u20139; CTP-C = 10\u201315. Score 7 = CTP-B. Answer: CTP-B.'},\n{id:17,stem:'Which of the statements regarding Calot\\'s triangle are correct?\\n1. Common hepatic duct forms the medial boundary of the Calot\\'s triangle\\n2. Inferior surface of the right lobe of the liver forms the superior boundary of Calot\\'s triangle\\n3. Right hepatic artery is usually found as a content of the Calot\\'s triangle\\n4. Cystic duct and medial border of gall bladder forms the lateral border of Calot\\'s triangle\\nSelect the correct answer:',correct:'1, 2 and 3',options:['1, 2 and 3','2, 3 and 4','1, 3 and 4','1, 2 and 4'],exp:'Calot\\'s triangle (cystohepatic triangle) boundaries: MEDIAL: common hepatic duct \u2714 (statement 1 correct). SUPERIOR: inferior surface of the right lobe of the liver \u2714 (statement 2 correct). LATERAL: cystic duct + RIGHT border (not medial border) of gall bladder (statement 4 INCORRECT \u2014 says medial border). Contents: cystic artery, RIGHT HEPATIC ARTERY \u2714 (statement 3 correct \u2014 it passes through before giving cystic artery), lymph node of Calot (Lund\\'s node). Statement 4 says \"medial border\" of gall bladder \u2014 should be LATERAL border of cystic duct \/ right border of GB. Correct statements: 1, 2 and 3. Answer: 1, 2 and 3.'},\n{id:18,stem:'Consider the following statements regarding Opportunistic post-splenectomy infections (OPSI):\\n1. H. influenzae, N. meningitidis and S. pneumoniae are the most common causative agents\\n2. Risk is greatest in patients who have undergone splenectomy for trauma\\n3. Risk is greatest within the first 2\u20133 years following splenectomy\\n4. Prophylactic vaccination should be done 2 weeks prior to elective splenectomy\\nWhich are correct?',correct:'1, 3 and 4',options:['1, 2 and 3','2, 3 and 4','1, 3 and 4','1, 2 and 4'],exp:'OPSI (Overwhelming Post-Splenectomy Infection): Statement 1 \u2714 \u2014 Streptococcus pneumoniae (most common, ~50%), Haemophilus influenzae, Neisseria meningitidis are the \"encapsulated\" organisms \u2014 spleen is critical for opsonisation. Statement 2 \u2717 \u2014 Risk is NOT greatest in trauma splenectomy; it is greatest in splenectomy for HAEMATOLOGICAL diseases (thalassaemia, sickle cell, hereditary spherocytosis) \u2014 greatest immunological compromise. Trauma splenectomy has lower OPSI risk than haematological indications. Statement 3 \u2714 \u2014 Risk is highest in first 2\u20133 years post-splenectomy but persists lifelong. Statement 4 \u2714 \u2014 Vaccines (pneumococcal, meningococcal, Hib) should be given AT LEAST 2 weeks BEFORE elective splenectomy for optimal immune response. Correct: 1, 3 and 4. Answer: 1, 3 and 4.'},\n{id:19,stem:'A 48-year-old male with history of chronic duodenal ulcer presented with sudden severe abdominal pain. Pulse 120\/min, BP 90\/60 mmHg. Abdomen: tenderness, rigidity, guarding. RR 20\/min. X-ray: gas under right dome of diaphragm. Probable diagnosis is:',correct:'Perforation Peritonitis',options:['Acute appendicitis','Acute Pancreatitis','Acute Myocardial infarction','Perforation Peritonitis'],exp:'GAS UNDER DIAPHRAGM (pneumoperitoneum) on erect chest X-ray is PATHOGNOMONIC of a hollow viscus perforation. In context of chronic duodenal ulcer history: PERFORATED DUODENAL ULCER \u2192 spilled gut contents \u2192 generalised peritonitis. Clinical features confirm peritonitis: peritoneal signs (tenderness + rigidity + guarding), haemodynamic compromise (shock: pulse 120, BP 90\/60). Acute pancreatitis: no pneumoperitoneum. Appendicitis: may perforate but gas under diaphragm less typical at this stage; no DU history. MI: no peritoneal signs. Gas under right hemidiaphragm + DU history + peritonitis = perforated DU \u2192 Perforation Peritonitis. Answer: Perforation Peritonitis.'},\n{id:20,stem:'A young sportsperson presented with severe pain in the groin extending into the scrotum and upper thigh. Pain is debilitating, he cannot exercise. On examination there is tenderness in the region of the inguinal canal and pubic tubercle. He is probably suffering from:',correct:'Sportsman hernia',options:['Varicocele','Inguinal hernia','Sportsman hernia','Femoral hernia'],exp:'SPORTSMAN\\'S HERNIA (Athletic pubalgia \/ Gilmore\\'s groin): a syndrome of posterior inguinal wall weakness WITHOUT a clinically detectable hernia. Affects young athletes (footballers, hockey players). Features \u2714: pain in groin radiating to scrotum\/inner thigh; aggravated by exercise (typically kicking, twisting); tenderness over INGUINAL CANAL and PUBIC TUBERCLE; no palpable hernia sac (distinguishes from inguinal hernia); pain at medial inguinal ring on cough impulse. Varicocele: scrotal swelling, \"bag of worms.\" Inguinal hernia: palpable reducible swelling. Femoral hernia: below and lateral to pubic tubercle. Answer: Sportsman hernia.'},\n{id:21,stem:'Ventral hernia includes all EXCEPT:',correct:'Inguinal hernia',options:['Epigastric hernia','Para-umbilical hernia','Lumbar hernia','Inguinal hernia'],exp:'VENTRAL hernias are those that protrude through the anterior ABDOMINAL WALL (ventral = front). Types: Epigastric \u2714 (midline between xiphoid and umbilicus), Umbilical\/Para-umbilical \u2714, Incisional \u2714, Spigelian \u2714, Lumbar \u2714 (posterior abdominal wall but grouped as ventral\/abdominal wall hernias in some classifications \u2014 Petit\\'s triangle, Grynfeltt\\'s triangle). INGUINAL HERNIA \u2717 \u2014 this is a GROIN\/INGUINAL hernia, passing through the inguinal canal in the groin. It is classified separately as an inguinoscrotal or groin hernia, NOT a ventral hernia. Answer: Inguinal hernia.'},\n{id:22,stem:'Diaphragmatic injury is suspected in a 50-year-old gentleman with history of blunt abdominal trauma, having a normal chest X-ray. He is best managed by:',correct:'Diagnostic laparoscopy',options:['Diagnostic peritoneal lavage and proceed','Upper GI contrast study','CECT abdomen','Diagnostic laparoscopy'],exp:'Diaphragmatic injury after blunt trauma with NORMAL CXR: CXR misses 30\u201350% of left-sided diaphragmatic injuries (bowel\/omentum may not have herniated yet). CECT abdomen is a good initial investigation but can still miss diaphragmatic tears (sensitivity ~71%). DIAGNOSTIC PERITONEAL LAVAGE: detects haemoperitoneum but cannot diagnose or repair diaphragmatic tears. UPPER GI CONTRAST: useful if hollow viscus herniation suspected but not first-line. DIAGNOSTIC LAPAROSCOPY \u2714: Gold standard for evaluating diaphragm when CXR is normal; directly visualises the diaphragm; can diagnose AND repair the defect; high sensitivity (~100%) for left-sided tears. Answer: Diagnostic laparoscopy.'},\n{id:23,stem:'A 20-year-old man had pain in the right side of abdomen. His X-ray abdomen AP view shows a radio-opaque shadow, which on lateral film falls behind the vertebral column. The probable diagnosis is:',correct:'Renal Calculus',options:['Gall stone disease','Renal Calculus','Calcified mesenteric lymph node','Phlebolith'],exp:'Localisation of radio-opaque shadows by lateral X-ray: ANTERIOR to spine (in front) = gallstones, calcified mesenteric lymph nodes, phleboliths (pelvic veins). BEHIND the vertebral column (POSTERIOR, overlapping spine on lateral) = RENAL CALCULI \u2014 the kidneys are retroperitoneal, positioned posteriorly adjacent to the vertebral column. Key discriminator: on lateral film, renal stones project OVER or BEHIND the vertebral bodies; gallstones project ANTERIOR. This patient: shadow behind vertebral column on lateral \u2192 RENAL CALCULUS. Answer: Renal Calculus.'},\n{id:24,stem:'Urinary bladder can be injured in all of the following operations EXCEPT:',correct:'Inguinal lymph node dissection',options:['Inguinal hernia repair','Hysterectomy','Surgery for rectum','Inguinal lymph node dissection'],exp:'Urinary bladder injury during surgery: INGUINAL HERNIA REPAIR \u2714 \u2014 bladder may be part of sliding hernia sac (medial to the sac, especially on left); injury possible during dissection. HYSTERECTOMY \u2714 \u2014 bladder closely related to the anterior uterus and cervix; most common organ injured during hysterectomy. SURGERY FOR RECTUM \u2714 \u2014 bladder lies anterior to rectum; vulnerable during total mesorectal excision (APR\/AR). INGUINAL LYMPH NODE DISSECTION \u2717 \u2014 nodes are in the femoral triangle, superficial and subcutaneous; the bladder is not in the surgical field. Answer: Inguinal lymph node dissection.'},\n{id:25,stem:'In diffuse axonal injury all are true EXCEPT:',correct:'CT scan shows pathognomonic finding',options:['Form of primary brain injury','Seen in high energy','Patient is comatose','CT scan shows pathognomonic finding'],exp:'Diffuse Axonal Injury (DAI): FORM OF PRIMARY BRAIN INJURY \u2714 \u2014 occurs at moment of impact; not secondary. HIGH ENERGY MECHANISM \u2714 \u2014 caused by acceleration-deceleration forces (rotational shear); road traffic accidents, falls from height. PATIENT IS COMATOSE \u2714 \u2014 immediate and prolonged loss of consciousness (immediate coma without lucid interval); often GCS 3\u20138. CT SCAN \u2717 \u2014 CT is typically NORMAL or shows only subtle findings (small haemorrhages in corpus callosum, grey-white interface, basal ganglia). CT does NOT show pathognomonic findings. MRI (especially DWI, GRE\/SWI sequences) is the investigation of choice for DAI. CT is insensitive. Answer: CT scan shows pathognomonic finding.'},\n{id:26,stem:'A 70-year-old man on anticoagulants for heart disease suffered a minor head injury. One month later he has severe headache with slowly developing neurological signs. The probable diagnosis is:',correct:'Chronic subdural haematoma',options:['Extradural haematoma','Acute subdural haematoma','Chronic subdural haematoma','Subarachnoid haemorrhage'],exp:'CHRONIC SUBDURAL HAEMATOMA (CSDH): key features perfectly matched \u2014 ELDERLY patient \u2714 (cerebral atrophy, stretched bridging veins). ANTICOAGULANTS \u2714 \u2014 major predisposing factor; even minor head trauma can cause bleeding. MINOR\/TRIVIAL head injury \u2714 (often forgotten). DELAYED PRESENTATION \u2014 symptoms appear WEEKS (>3 weeks) after injury \u2714 (1 month here). INSIDIOUS NEUROLOGICAL SIGNS \u2714 \u2014 slow accumulation and expansion of haematoma. Headache, cognitive decline, hemiparesis developing over days\/weeks. Extradural: arterial bleed, lucid interval then rapid deterioration, not weeks later. Acute SDH: within 72h. SAH: thunderclap headache, no delayed onset. Answer: Chronic subdural haematoma.'},\n{id:27,stem:'Regarding \"Quinsy\" all of the following are correct EXCEPT:',correct:'Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic',options:['It is an abscess in the peritonsillar region','Severe trismus is caused by spasm induced by pterygoid muscles','Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic','In early stage, intravenous broad spectrum antibiotics may resolve it'],exp:'Quinsy (peritonsillar abscess): Abscess in the peritonsillar region \u2714 \u2014 pus between the tonsillar capsule and the superior constrictor muscle. Trismus from pterygoid spasm \u2714 \u2014 the medial pterygoid muscle is adjacent; reflex spasm causes severe trismus (hallmark feature). IV antibiotics in early stage \u2714 \u2014 early cellulitis\/peritonsillar cellulitis may resolve with antibiotics; established abscess requires drainage. Pus pointing in ALL cases \u2717 \u2014 pointing of pus through thinned mucosa is seen in many cases but NOT in all; in early\/deep abscesses there may be no visible pointing. \"In all cases and is diagnostic\" is the false claim. Answer: Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic.'},\n{id:28,stem:'The most common organism causing Acute Otitis Media in children is:',correct:'Streptococcus pneumoniae',options:['Streptococcus pneumoniae','Staphylococcus epidermidis','Escherichia coli','Klebsiella pneumoniae'],exp:'Acute Otitis Media (AOM) \u2014 bacteriology: STREPTOCOCCUS PNEUMONIAE \u2714 = most common overall (30\u201340%), responsible for the most severe cases. Non-typeable Haemophilus influenzae (second most common, ~20\u201330%). Moraxella catarrhalis (~10\u201315%). Staphylococcus aureus and Group A streptococcus \u2014 less common. Staphylococcus epidermidis: a commensal, not a significant AOM pathogen. E. coli and Klebsiella: rarely cause AOM (neonates only). In children, S. pneumoniae = most common and most important cause. Answer: Streptococcus pneumoniae.'},\n{id:29,stem:'A 50-year-old male presented with pain along the left arm and ptosis. His chest X-ray showed soft tissue opacity at the apex of the left lung along with erosion of the adjacent rib. The probable diagnosis is:',correct:'Pancoast lung',options:['Pancoast lung','Bronchial carcinoma','Lung abscess','Adenocarcinoma of lung'],exp:'PANCOAST TUMOUR (Superior Sulcus Tumour): APICAL LUNG TUMOUR at the superior sulcus. Classic Pancoast syndrome triad: (1) Shoulder\/arm pain (brachial plexus C8, T1, T2 involvement) \u2014 pain radiating down arm. (2) HORNER\\'S SYNDROME: ptosis + miosis + anhidrosis (involvement of sympathetic chain). (3) Rib\/vertebral erosion (T1, T2 ribs). CXR: apical opacity + rib erosion \u2714. Most commonly squamous cell or adenocarcinoma histologically. \"Bronchial carcinoma\" is a category but \"Pancoast\" is the SPECIFIC diagnosis here \u2014 the syndrome of apical tumour + Horner\\'s + arm pain + rib erosion is Pancoast. Answer: Pancoast lung (tumour).'},\n{id:30,stem:'Which of the following is NOT true about Dupuytren\\'s Contracture?',correct:'Not familial',options:['Autosomal dominant','Occurs in elderly men','Not familial','Associated with alcoholism, smoking and hypothyroidism'],exp:'Dupuytren\\'s contracture (palmar fibromatosis): Autosomal dominant \u2714 \u2014 hereditary basis, often positive family history (option c says \"not familial\" which CONTRADICTS this; hence option c is false). Occurs in elderly men \u2714 \u2014 predominantly men >50 years; male:female 6:1. Associated with: alcoholism \u2714, smoking \u2714, hypothyroidism \u2714, diabetes mellitus, epilepsy (phenytoin use), trauma, HIV. NOT FAMILIAL \u2717 \u2014 This is FALSE. Dupuytren\\'s HAS a clear autosomal dominant inheritance pattern and IS familial. This is the untrue statement. Answer: Not familial.'},\n{id:31,stem:'Which of the following statements regarding flat foot are true?\\n1. All children below 3 years have flat foot\\n2. 15% adults have flat foot\\n3. Painless flexible foot needs no treatment\\n4. Rigid flat foot is a result of tarsal coalition\\nSelect the correct answer:',correct:'1, 2, 3 and 4',options:['3 and 4 only','1 and 2 only','1, 2 and 3 only','1, 2, 3 and 4'],exp:'Flat foot (pes planus) facts: Statement 1 \u2714 \u2014 All children under 2\u20133 years have physiological flat feet (ligament laxity, fat pad in arch); longitudinal arch develops by 3 years. Statement 2 \u2714 \u2014 ~15\u201323% of adults have flat feet (flexible, asymptomatic). Statement 3 \u2714 \u2014 Painless, flexible (mobile) flat foot requires NO treatment; reassurance only; the arch appears when the child stands on tiptoe. Statement 4 \u2714 \u2014 Rigid flat foot (foot remains flat even non-weight bearing, no arch on tip-toe) is a hallmark of TARSAL COALITION (abnormal osseous\/fibrous\/cartilaginous fusion between tarsal bones, e.g., calcaneonavicular or talocalcaneal). All four statements are correct. Answer: 1, 2, 3 and 4.'},\n{id:32,stem:'All of the following are causes of acute red eye EXCEPT:',correct:'Acute macular oedema',options:['Conjunctivitis','Keratitis','Acute macular oedema','Acute glaucoma'],exp:'Causes of acute red eye (anterior segment involvement): CONJUNCTIVITIS \u2714 \u2014 diffuse conjunctival injection, discharge. KERATITIS \u2714 \u2014 circumcorneal (ciliary) injection, pain, photophobia. ACUTE ANGLE-CLOSURE GLAUCOMA \u2714 \u2014 red eye, severe pain, halos, nausea, vomiting, corneal oedema, raised IOP. Also: scleritis, episcleritis, uveitis, subconjunctival haemorrhage. ACUTE MACULAR OEDEMA \u2717 \u2014 the macula is in the POSTERIOR segment (central retina); macular pathology does NOT cause red eye. Macular oedema presents with central visual loss\/blurring, metamorphopsia \u2014 not redness. Answer: Acute macular oedema.'},\n{id:33,stem:'All are true about Vernal conjunctivitis EXCEPT:',correct:'Most signs are in lower lid',options:['Type of allergic conjunctivitis','Itchy eyes with other allergic problems','Cobblestone appearance','Most signs are in lower lid'],exp:'Vernal keratoconjunctivitis (VKC): Type of allergic conjunctivitis \u2714 \u2014 IgE-mediated (Type I hypersensitivity) + cellular (Type IV) reaction; seasonal exacerbations in warm\/dry climates. Intense itching \u2714, with other atopic features (asthma, eczema, rhinitis). Cobblestone (giant papillae) \u2714 \u2014 on UPPER tarsal conjunctiva (palpebral form); pathognomonic finding. MOST SIGNS IN LOWER LID \u2717 \u2014 FALSE. VKC predominantly affects the UPPER TARSAL conjunctiva and the limbus (limbal form: Trantas\\' dots at limbus). Lower lid involvement is NOT characteristic. Answer: Most signs are in lower lid.'},\n{id:34,stem:'Preoperative Samsoon and Young modified Mallampati test is used for assessing:',correct:'Difficulty in intubation',options:['Preoperative nutrition status of patient','Patient\\'s overall fitness for surgery','Difficulty in intubation','Blood requirement during surgery'],exp:'MALLAMPATI TEST (modified by Samsoon and Young, 1987): patient sits upright, mouth wide open, tongue protruded maximally, no phonation \u2014 examiner assesses visible oropharyngeal structures. CLASSES: I: soft palate, fauces, uvula, pillars visible. II: soft palate, fauces, uvula visible. III: soft palate and base of uvula visible. IV: only hard palate visible. PREDICTS DIFFICULT INTUBATION\/LARYNGOSCOPY: Class III\u2013IV correlates with difficult airway. Used as part of airway assessment before general anaesthesia. NOT for nutrition, overall fitness, or blood loss assessment. Answer: Difficulty in intubation.'},\n{id:35,stem:'In split-thickness graft, which part of the skin is included?',correct:'Epidermis and part of dermis',options:['Epidermis only','Epidermis and dermis','Epidermis and part of dermis','Epidermis, dermis and part of subcutaneous tissue'],exp:'Skin graft classification: SPLIT-THICKNESS SKIN GRAFT (STSG \/ Thiersch graft): contains EPIDERMIS + PART OF DERMIS (variable depth \u2014 thin, intermediate, or thick STSG). Harvested with dermatome. Donor site heals by re-epithelialisation from residual dermal appendages. FULL-THICKNESS GRAFT (Wolfe graft): entire epidermis + entire dermis (no subcutaneous fat). Donor site must be closed primarily. EPIDERMIS ONLY: not a practical graft. Epidermis + full dermis + subcutaneous tissue: would be a composite graft\/free flap. STSG = epidermis + PART of dermis. Answer: Epidermis and part of dermis.'},\n{id:36,stem:'A young motorcycle rider met with a road traffic accident with maxillofacial trauma and paraesthesia of the lower lip. Most likely underlying he has a:',correct:'Fracture of the mandibular body',options:['Fracture involving infraorbital foramen','Fracture involving floor of orbit','Fracture of the mandibular body','Fracture of temporal bone'],exp:'PARAESTHESIA OF LOWER LIP: innervation is the MENTAL NERVE (branch of inferior alveolar nerve \u2192 branch of V3\/mandibular division). The mental nerve exits via the MENTAL FORAMEN in the BODY OF THE MANDIBLE (between premolars). Fracture of mandibular body \u2192 injury to mental nerve \u2192 paraesthesia\/numbness of lower lip and chin. INFRAORBITAL nerve (exits infraorbital foramen): supplies infraorbital skin, upper lip, cheek \u2014 NOT lower lip. FLOOR OF ORBIT fracture: infraorbital nerve \u2192 upper lip\/cheek. TEMPORAL BONE: CN VII (facial) or CN VIII. Lower lip paraesthesia = mandibular body fracture. Answer: Fracture of the mandibular body.'},\n{id:37,stem:'A 20-year-old patient underwent open hernia surgery four days ago. He is running fever for the last one day and on local examination the operated site is wet with pus and surrounding redness and oedema. The appropriate management would be:',correct:'Opening sutures and cleaning of wound',options:['Change of antibiotics','Daily dressing','Opening sutures and cleaning of wound','Sending pus for C\/S'],exp:'POST-OPERATIVE WOUND INFECTION management: The patient has an ESTABLISHED WOUND ABSCESS (pus, cellulitis, local signs 4 days post-op). The fundamental surgical principle is: WHERE THERE IS PUS, LET IT OUT (Ubi pus, ibi evacua). The correct primary step is OPENING THE SUTURES AND CLEANING\/DRAINING the wound. This allows: drainage of pus, debridement of infected\/sloughy tissue, and secondary intention healing. Antibiotics alone (option a) are inadequate without drainage \u2014 pus is a closed-space infection. Daily dressing alone without drainage is insufficient. C\/S (culture\/sensitivity) should also be done BUT is secondary to the drainage step; it alone is not \"management.\" Answer: Opening sutures and cleaning of wound.'},\n{id:38,stem:'Good surgical practice and surgical ethics include all EXCEPT:',correct:'Experiment',options:['Respect autonomy','Informed consent','Confidentiality','Experiment'],exp:'Surgical ethics pillars: RESPECT AUTONOMY \u2714 \u2014 patient\\'s right to make informed decisions. INFORMED CONSENT \u2714 \u2014 mandatory before any surgical intervention; discloses risks, benefits, alternatives. CONFIDENTIALITY \u2714 \u2014 patient information must be protected. EXPERIMENT \u2717 \u2014 performing surgery as uncontrolled human experimentation without ethical approval, informed consent for research, or IRB oversight is NOT a principle of good surgical practice; it violates the Declaration of Helsinki. Experimental procedures require separate research ethics approval and full disclosure. \"Experiment\" per se is not a component of routine surgical ethics. Answer: Experiment.'},\n{id:39,stem:'Refeeding syndrome seen after enteral or parenteral nutrition is characterised by all EXCEPT:',correct:'Hyponatremia',options:['Hypophosphatemia','Hypocalcemia','Hypomagnesemia','Hyponatremia'],exp:'REFEEDING SYNDROME: occurs when malnourished patients receive rapid nutritional support after prolonged starvation. Pathophysiology: carbohydrate reintroduction \u2192 insulin surge \u2192 cellular uptake of electrolytes \u2192 characteristic electrolyte derangements. Classic electrolyte disturbances: HYPOPHOSPHATAEMIA \u2714 (hallmark; phosphate shifts into cells for phosphorylation; can cause respiratory failure, cardiac failure). HYPOMAGNESAEMIA \u2714 (magnesium shifts intracellularly). HYPOCALCAEMIA \u2714 (secondary to hypomagnesaemia affecting PTH). Also: hypokalaemia, thiamine deficiency, fluid shifts. HYPONATRAEMIA \u2717 \u2014 NOT a characteristic feature of refeeding syndrome; sodium handling is not directly implicated in this mechanism. Answer: Hyponatremia.'},\n{id:40,stem:'The capillary refill time is prolonged in all types of shock EXCEPT:',correct:'Septic shock',options:['Hypovolaemic shock','Cardiogenic shock','Septic shock','Obstructive shock'],exp:'Capillary refill time (CRT): normal <2 seconds. Mechanism of prolongation: peripheral vasoconstriction reduces cutaneous blood flow \u2192 slower refill. HYPOVOLAEMIC SHOCK \u2714 \u2014 decreased preload \u2192 reflex vasoconstriction \u2192 prolonged CRT. CARDIOGENIC SHOCK \u2714 \u2014 low cardiac output \u2192 compensatory vasoconstriction \u2192 prolonged CRT. OBSTRUCTIVE SHOCK \u2714 (e.g., tension pneumothorax, cardiac tamponade) \u2014 reduced output \u2192 vasoconstriction \u2192 prolonged CRT. SEPTIC SHOCK (EARLY\/WARM PHASE) \u2717 \u2014 characterised by VASODILATION (cytokine-mediated), warm peripheries, bounding pulse, NORMAL or even SHORTENED CRT (hyperdynamic phase). CRT may NOT be prolonged in warm septic shock. 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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#cms19p2a .rbtn:hover{background:var(--teal);color:var(--white)}\n@media(max-width:480px){#cms19p2a .hdr h1{font-size:1.15rem}#cms19p2a .qt{font-size:.88rem}#cms19p2a .ot{font-size:.84rem}}\n<\/style>\n<\/head>\n<body>\n<div id=\"cms19p2a\">\n<div class=\"sen\" id=\"cms19p2a-sen\"><\/div>\n<div class=\"sb\" id=\"cms19p2a-sb\">\n <div class=\"sb-row\">\n <div class=\"ti\" id=\"cms19p2a-ti\">\u23f1 <strong id=\"cms19p2a-td\">40:00<\/strong><\/div>\n <div class=\"sb-it\">\u2705 <strong id=\"cms19p2a-sc\">0<\/strong><\/div>\n <div class=\"sb-it\">\u274c <strong id=\"cms19p2a-sw\">0<\/strong><\/div>\n <div class=\"sb-it\">\u23f3 <strong id=\"cms19p2a-sr\">40<\/strong> left<\/div>\n <div class=\"sb-sep\"><\/div>\n <div class=\"sb-it\">Net <strong id=\"cms19p2a-sn\">0<\/strong> \/ <strong id=\"cms19p2a-sm\">160<\/strong><\/div>\n <\/div>\n <div class=\"sb-bar\"><div class=\"sb-fill\" id=\"cms19p2a-fill\"><\/div><\/div>\n<\/div>\n<div class=\"grace\" id=\"cms19p2a-grace\">\n <div class=\"gb\">\n <h3>Time's Up!<\/h3><p>Submitting in<\/p>\n <div class=\"gc\" id=\"cms19p2a-gc\">10<\/div>\n <button class=\"gnow\" id=\"cms19p2a-gnow\">Submit Now<\/button>\n <\/div>\n<\/div>\n<div class=\"hdr\">\n <h1>Combined Medical Services Examination 2019<br>Paper II \u00b7 Part A<\/h1>\n <p>General Surgery \u00b7 Orthopaedics \u00b7 Ophthalmology \u00b7 ENT \u00b7 Anaesthesia<\/p>\n <div class=\"meta\">\n <span class=\"bdg\">Questions 1 \u2013 40<\/span>\n <span class=\"bdg\">Options reshuffled<\/span>\n <button class=\"tbtn\" id=\"cms19p2a-tbtn\">\u23f1 Start Timed Mode<\/button>\n <\/div>\n<\/div>\n<div class=\"body\">\n <div id=\"cms19p2a-qs\"><\/div>\n <div class=\"sw\"><button class=\"btn\" id=\"cms19p2a-sub\">Submit Answers<\/button><\/div>\n <div class=\"sc\" id=\"cms19p2a-sc-box\">\n <div class=\"ring\" id=\"cms19p2a-ring\"><div class=\"ri\"><span class=\"rp\" id=\"cms19p2a-rp\">0%<\/span><span class=\"rs\">score<\/span><\/div><\/div>\n <h2>Your Result<\/h2>\n <div class=\"nl\" id=\"cms19p2a-nl\"><\/div>\n <div class=\"vd\" id=\"cms19p2a-vd\"><\/div>\n <div class=\"bands\">\n <span class=\"band bc\" id=\"cms19p2a-bc\"><\/span>\n <span class=\"band bw\" id=\"cms19p2a-bw\"><\/span>\n <span class=\"band bs\" id=\"cms19p2a-bs\"><\/span>\n <\/div>\n <button class=\"rbtn\" id=\"cms19p2a-retry\">\u21ba Retry Quiz<\/button>\n <\/div>\n<\/div>\n<\/div>\n<script>\n(function(){\n'use strict';\nvar NS='cms19p2a',TOTAL=40,MAX=160,TSECS=2400,GSECS=10;\nvar QS=[\n{id:1,stem:'What is the correct order of the normal phases of wound healing?',correct:'Haemostatic phase \u2192 Inflammatory phase \u2192 Proliferative phase \u2192 Remodelling phase',options:['Proliferative phase \u2192 Haemostatic phase \u2192 Inflammatory phase \u2192 Remodelling phase','Haemostatic phase \u2192 Inflammatory phase \u2192 Proliferative phase \u2192 Remodelling phase','Destructive phase \u2192 Proliferative phase \u2192 Remodelling phase \u2192 Inflammatory phase','Remodelling phase \u2192 Proliferative phase \u2192 Destructive phase \u2192 Inflammatory phase'],exp:'Wound healing follows a fixed sequence of four overlapping phases. HAEMOSTASIS (immediate): vasoconstriction, platelet plug, fibrin clot \u2014 stops bleeding and forms scaffold. INFLAMMATORY phase (0\u20133 days): neutrophils then macrophages debride and release growth factors. PROLIFERATIVE phase (3 days \u2013 3 weeks): fibroblasts deposit collagen, angiogenesis, epithelialisation, wound contraction. REMODELLING phase (3 weeks \u2013 2 years): collagen remodelled from type III to type I, scar matures and strengthens (up to 80% original tensile strength). Mnemonic: HIPR. Answer: Haemostatic \u2192 Inflammatory \u2192 Proliferative \u2192 Remodelling.'},\n{id:2,stem:'All of the following are risk factors for an increased risk of wound infection EXCEPT:',correct:'Hypertension',options:['Obesity','Hypertension','Jaundice','Cancer'],exp:'Wound infection risk factors: OBESITY \u2714 \u2014 poor tissue oxygenation, excess subcutaneous fat (poor vascularity), difficult closure. JAUNDICE \u2714 \u2014 bile acids impair neutrophil chemotaxis, coagulopathy, poor healing. CANCER \u2714 \u2014 malnutrition, immunosuppression, chemotherapy\/radiotherapy effects. HYPERTENSION \u2717 \u2014 per se does not directly increase wound infection risk; well-controlled hypertension is not a standard surgical wound infection risk factor. (Note: poorly controlled hypertension may affect perfusion, but is NOT classically listed as a wound infection risk factor in surgical texts.) Answer: Hypertension.'},\n{id:3,stem:'Systemic Inflammatory Response Syndrome (SIRS) is characterized by all of the following EXCEPT:',correct:'Platelet count (<1,00,000\/mm\u00b3)',options:['Hyperthermia (>38\u02daC)','Platelet count (<1,00,000\/mm\u00b3)','Tachypnoea (>20\/min)','Hypothermia (<36\u02daC)'],exp:'SIRS criteria (any 2 of 4): (1) Temperature >38\u00b0C (hyperthermia) or <36\u00b0C (hypothermia). (2) Heart rate >90\/min. (3) Respiratory rate >20\/min OR PaCO\u2082 <32 mmHg. (4) WBC >12,000\/mm\u00b3 or <4,000\/mm\u00b3 or >10% immature (band) forms. PLATELET COUNT is NOT a criterion for SIRS. Thrombocytopaenia (<1,00,000\/mm\u00b3) may be seen in sepsis or DIC but is not one of the four defining SIRS parameters. The question asks what is NOT a feature of SIRS. Answer: Platelet count <1,00,000\/mm\u00b3.'},\n{id:4,stem:'A 56-year-old gentleman underwent laparoscopic left hemicolectomy for left colonic carcinoma. Histopathology revealed the tumour invading submucosa and muscularis propria. Among 16 regional lymph nodes harvested, 2 were positive for malignant deposits. His AJCC staging will be:',correct:'T2, N1, M0',options:['T1, N1, M0','T2, N1, M0','T1, N0, M0','T2, N1, M1'],exp:'AJCC 8th edition colorectal staging: T stage \u2014 T1: invades submucosa only. T2: invades muscularis propria. T3: through muscularis propria into pericolorectal tissues. T4: invades visceral peritoneum or adjacent organs. This tumour invades BOTH submucosa AND muscularis propria \u2192 T2. N stage \u2014 N0: no nodes. N1: 1\u20133 regional nodes positive. N2: \u22654 nodes. Here 2 nodes positive \u2192 N1. M0: no distant metastasis (no mention of metastases). Final staging: T2, N1, M0 = Stage IIIA. Answer: T2, N1, M0.'},\n{id:5,stem:'All of the following are hormonal agents used in treatment of cancer EXCEPT:',correct:'Irinotecan',options:['Anastrazole','Irinotecan','Cabergoline','Leuprolide'],exp:'Hormonal\/endocrine agents used in cancer: ANASTRAZOLE \u2714 \u2014 aromatase inhibitor, blocks oestrogen synthesis; used in hormone receptor-positive breast cancer. CABERGOLINE \u2714 \u2014 dopamine agonist; suppresses prolactin; used in prolactinomas. LEUPROLIDE \u2714 \u2014 GnRH agonist; causes medical castration via downregulation; used in prostate cancer and hormone-sensitive breast cancer. IRINOTECAN \u2717 \u2014 a topoisomerase I inhibitor (cytotoxic chemotherapy); used in colorectal, lung, and ovarian cancers; completely unrelated to hormonal manipulation. Answer: Irinotecan.'},\n{id:6,stem:'Which of the following statements regarding lymphoedema are correct?\\n1. Patients experience constant dull ache and even severe pain sometimes\\n2. Manual lymphatic drainage has a role\\n3. Primary lymphoedema is caused by congenital lymphatic dysplasia\\n4. Nonne Milroy\\'s disease is a type of primary lymphoedema\\nSelect the correct answer:',correct:'1, 2, 3 and 4',options:['3 and 4 only','1 and 2 only','1, 2 and 3 only','1, 2, 3 and 4'],exp:'Evaluating each statement: (1) \u2714 Lymphoedema typically causes heaviness and a constant dull ache; severe pain can occur with acute inflammatory episodes or secondary infection. (2) \u2714 Manual lymphatic drainage (MLD) is a cornerstone of conservative management \u2014 part of complete decongestive therapy (CDT). (3) \u2714 Primary lymphoedema results from congenital aplasia, hypoplasia, or hyperplasia (dysplasia) of lymphatic vessels. (4) \u2714 Nonne-Milroy disease (Milroy disease) = hereditary, congenital onset primary lymphoedema due to FLT4\/VEGFR3 mutation \u2014 a classic type of primary lymphoedema. All four are correct. Answer: 1, 2, 3 and 4.'},\n{id:7,stem:'Indications for carotid endarterectomy in symptomatic patients are all of the following EXCEPT:',correct:'Persistent hypertension',options:['Hemianopia','Monocular blindness','Dysphasia','Persistent hypertension'],exp:'Carotid endarterectomy (CEA) is indicated in SYMPTOMATIC patients with significant carotid stenosis (>70%, and selected 50\u201369%). Symptoms must be ipsilateral neurological events: MONOCULAR BLINDNESS (amaurosis fugax \u2014 transient ischaemic attack of the ophthalmic artery) \u2714. DYSPHASIA (dominant hemisphere TIA\/minor stroke) \u2714. HEMIANOPIA (posterior circulation OR hemispheric ischaemia in relevant territory) \u2714. PERSISTENT HYPERTENSION \u2717 \u2014 hypertension is a risk factor for stroke but is NOT an indication for CEA; it is managed medically. CEA indication = neurological\/ocular ischaemic symptoms, not blood pressure control. Answer: Persistent hypertension.'},\n{id:8,stem:'A 45-year-old policeman presents with lipodermatosclerosis over the lower medial aspect of the left leg, along with a healed venous ulcer. As per CEAP classification his clinical classification will be:',correct:'C5',options:['C4a','C4b','C5','C6'],exp:'CEAP Clinical classification of chronic venous disease: C0: no visible or palpable signs. C1: telangiectasia\/reticular veins. C2: varicose veins. C3: oedema. C4a: pigmentation or eczema. C4b: LIPODERMATOSCLEROSIS or atrophie blanche. C5: healed venous ulcer. C6: active venous ulcer. This patient has BOTH lipodermatosclerosis (C4b) AND a HEALED ULCER. When both are present, the higher\/more advanced classification applies. A healed ulcer = C5 (subsumes C4b). Answer: C5.'},\n{id:9,stem:'What is true about the management of a corrosive injury of the oesophagus?',correct:'Early skilled endoscopy is must',options:['Early skilled endoscopy is must','Immediate surgery with oesophagectomy is advisable','Broad spectrum antibiotics should be started as soon as possible','Immediate NG tube insertion and gastric lavage should be performed'],exp:'Management of corrosive oesophageal injury: EARLY SKILLED ENDOSCOPY \u2714 \u2014 within 12\u201324 hours (not beyond 48h; not in first 2\u20133h due to risk): essential to assess depth and extent of injury; guides prognosis and management plan. IMMEDIATE OESOPHAGECTOMY \u2717 \u2014 only for Grade IIIb\/transmural necrosis with perforation; not routine. PROPHYLACTIC ANTIBIOTICS \u2717 \u2014 not routinely recommended without evidence of perforation\/infection. NG TUBE AND GASTRIC LAVAGE \u2717 \u2014 ABSOLUTELY CONTRAINDICATED in corrosive ingestion (risk of perforation, aspiration, further injury, re-exposure of oesophagus). Answer: Early skilled endoscopy is must.'},\n{id:10,stem:'Which of the statements regarding salivary gland neoplasms are correct?\\n1. 80\u201390% of parotid tumours are malignant\\n2. 90% of sublingual gland tumours are malignant\\n3. 60\u201370% of submandibular gland tumours are benign\\n4. Parotid gland is most common site for salivary gland tumours\\nSelect the correct answer:',correct:'2, 3 and 4',options:['1, 2 and 3','2, 3 and 4','1, 3 and 4','1, 2 and 4'],exp:'Salivary gland tumour facts: Parotid gland \u2714 = most common site (70\u201380% of all salivary gland tumours). Statement 1 \u2717: 80\u201390% of parotid tumours are BENIGN (not malignant); malignancy rate is only 15\u201325%. Statement 2 \u2714: sublingual gland tumours \u2014 70\u201390% are malignant (small glands \u2192 high malignancy ratio). Statement 3 \u2714: 60% of submandibular tumours are benign (40% malignant). Statement 4 \u2714: parotid is the most common site. Rule of thumb: the smaller the gland, the higher the malignancy rate. Correct statements: 2, 3 and 4. Answer: 2, 3 and 4.'},\n{id:11,stem:'A few days following viral fever, a 50-year-old female presented with pain in neck, fever, malaise and firm enlargement of both lobes of thyroid. Thyroid antibodies were normal and serum T4 was high normal. Probable diagnosis is:',correct:'Granulomatous thyroiditis',options:['Autoimmune thyroiditis','Lymphoma of thyroid','Granulomatous thyroiditis','Riedel\\'s thyroiditis'],exp:'GRANULOMATOUS (De Quervain\\'s \/ subacute) THYROIDITIS: post-viral inflammatory condition (often after URTI\/viral fever). Classical features: painful, tender, FIRM thyroid enlargement; fever; malaise; raised ESR; elevated T4 (leak from destroyed follicles = transient thyrotoxicosis). THYROID ANTIBODIES NORMAL \u2714 (distinguishes from Hashimoto\\'s\/autoimmune thyroiditis). Autoimmune (Hashimoto\\'s): positive TPO antibodies, rarely painful. Lymphoma: hard, rapidly growing, often in Hashimoto\\'s background. Riedel\\'s: woody hard, fixed, rare, painless, antibodies may be present. Post-viral + painful + raised T4 + normal antibodies = De Quervain\\'s. Answer: Granulomatous thyroiditis.'},\n{id:12,stem:'No increased relative risk of invasive breast carcinoma based on histopathological examination of benign breast tissue is for all of the following EXCEPT:',correct:'Solitary papilloma of lactiferous sinus',options:['Hyperplasia','Periductal mastitis','Squamous metaplasia','Solitary papilloma of lactiferous sinus'],exp:'Risk stratification of benign breast disease (Dupont & Page): NO increased risk (RR \u22481): adenosis, duct ectasia, mild hyperplasia, cysts, PERIDUCTAL MASTITIS, SQUAMOUS METAPLASIA (apocrine change), fibroadenoma without complex features. Slightly increased risk (RR 1.5\u20132\u00d7): moderate\/florid HYPERPLASIA, sclerosing adenosis, SOLITARY PAPILLOMA. Moderately increased risk (RR 4\u20135\u00d7): atypical ductal hyperplasia, atypical lobular hyperplasia. The question asks which is the EXCEPTION (i.e., which DOES carry increased risk). SOLITARY PAPILLOMA of lactiferous sinus \u2192 RR 1.5\u20132\u00d7 (slight increase). Answer: Solitary papilloma of lactiferous sinus.'},\n{id:13,stem:'Which of the following statements regarding Paget\\'s disease of nipple are correct?\\n1. It represents benign pathology of nipple areola complex\\n2. It is eczema-like condition of nipple and areola\\n3. Erosion of nipple is seen\\n4. Nipple biopsy is required for definitive diagnosis\\nSelect the correct answer:',correct:'2, 3 and 4',options:['1, 2 and 3','2, 3 and 4','1, 3 and 4','2 and 4 only'],exp:'Paget\\'s disease of the nipple: Statement 1 \u2717 \u2014 it is NOT benign; it is a MALIGNANT condition (intraepidermal adenocarcinoma of the nipple); virtually always associated with underlying DCIS or invasive carcinoma. Statement 2 \u2714 \u2014 clinically presents as an eczematous, erythematous, scaly, weeping rash of the nipple-areola complex mimicking eczema. Statement 3 \u2714 \u2014 as disease progresses, nipple erosion, ulceration, and destruction occur. Statement 4 \u2714 \u2014 definitive diagnosis requires NIPPLE BIOPSY showing Paget cells (large pale cells with prominent nucleoli within the epidermis). Correct: 2, 3 and 4. Answer: 2, 3 and 4.'},\n{id:14,stem:'A 36-year-old gentleman presents with long history of upper abdominal pain, periodic and often occurring early morning. For last 3 months, he has projectile vomiting which is non-bilious and unpleasant in nature with undigested food material. On examination he appears unwell, dehydrated and has lost weight. He is probably suffering from:',correct:'Gastric outlet obstruction',options:['Gastric outlet obstruction','Carcinoma stomach','Gastro-oesophageal reflux with oesophagitis','Superior mesenteric artery syndrome'],exp:'Gastric outlet obstruction (GOO): KEY FEATURES \u2014 long history of peptic ulcer disease (periodic early morning pain relieved by food\/antacids). PROJECTILE VOMITING \u2014 large volumes, non-bilious (obstruction is proximal to ampulla of Vater). UNDIGESTED FOOD in vomitus (food retained from previous meals). DEHYDRATION and WEIGHT LOSS from inability to absorb nutrition. SUCCESSION SPLASH may be present. Classic cause in this age group: pyloric stenosis from scarring of chronic duodenal ulcer. Succussion splash (+). Metabolic alkalosis (hypochloraemic, hypokalaemic). Answer: Gastric outlet obstruction.'},\n{id:15,stem:'A 40-year-old female presents with colicky abdominal pain, episodes of mild diarrhoea for 6 months, intermittent fever, weight loss, and multiple discharging sinuses on perineal examination. The most likely clinical diagnosis is:',correct:'Crohn disease',options:['Amoebic colitis','Crohn disease','Ulcerative colitis','Ileocaecal Tuberculosis'],exp:'Crohn\\'s disease: TRANSMURAL, SKIP LESION, ANY PART OF GI TRACT (mouth to anus). Key distinguishing feature here: PERIANAL DISEASE \u2014 multiple discharging sinuses\/fistulae are pathognomonic of Crohn\\'s disease (occur in ~30\u201340%; NOT seen in UC). Other features \u2714: colicky pain, diarrhoea, fever, weight loss, chronic course. Ulcerative colitis: confined to colon, mucosal only, NO perianal fistulae. Ileocaecal TB: similar to Crohn\\'s but perianal fistulae are rare and less typical. Amoebic colitis: dysentery, flask-shaped ulcers, no fistulae. PERIANAL SINUSES\/FISTULAE = hallmark of Crohn\\'s. Answer: Crohn disease.'},\n{id:16,stem:'A 48-year-old gentleman was being worked up for hepatocellular function. No history or signs of encephalopathy. Serum bilirubin 5 mg%, serum albumin 3.9 gm%, INR 1.6. Ultrasound showed no free fluid. As per Child-Turcotte-Pugh (CTP) classification, he was in:',correct:'CTP\u2013B',options:['CTP\u2013A','CTP\u2013B','CTP\u2013C','CTP\u2013D'],exp:'Child-Turcotte-Pugh scoring (each parameter scored 1\u20133): Bilirubin: <2 mg% = 1; 2\u20133 = 2; >3 = 3. This patient: 5 mg% \u2192 3 points. Albumin: >3.5 = 1; 2.8\u20133.5 = 2; <2.8 = 3. This patient: 3.9 g% \u2192 1 point. PT\/INR: <1.7 = 1; 1.7\u20132.3 = 2; >2.3 = 3. This patient: 1.6 \u2192 1 point. Ascites: None = 1. Encephalopathy: None = 1. TOTAL = 3+1+1+1+1 = 7 points. CTP-A = 5\u20136; CTP-B = 7\u20139; CTP-C = 10\u201315. Score 7 = CTP-B. Answer: CTP-B.'},\n{id:17,stem:'Which of the statements regarding Calot\\'s triangle are correct?\\n1. Common hepatic duct forms the medial boundary of the Calot\\'s triangle\\n2. Inferior surface of the right lobe of the liver forms the superior boundary of Calot\\'s triangle\\n3. Right hepatic artery is usually found as a content of the Calot\\'s triangle\\n4. Cystic duct and medial border of gall bladder forms the lateral border of Calot\\'s triangle\\nSelect the correct answer:',correct:'1, 2 and 3',options:['1, 2 and 3','2, 3 and 4','1, 3 and 4','1, 2 and 4'],exp:'Calot\\'s triangle (cystohepatic triangle) boundaries: MEDIAL: common hepatic duct \u2714 (statement 1 correct). SUPERIOR: inferior surface of the right lobe of the liver \u2714 (statement 2 correct). LATERAL: cystic duct + RIGHT border (not medial border) of gall bladder (statement 4 INCORRECT \u2014 says medial border). Contents: cystic artery, RIGHT HEPATIC ARTERY \u2714 (statement 3 correct \u2014 it passes through before giving cystic artery), lymph node of Calot (Lund\\'s node). Statement 4 says \"medial border\" of gall bladder \u2014 should be LATERAL border of cystic duct \/ right border of GB. Correct statements: 1, 2 and 3. Answer: 1, 2 and 3.'},\n{id:18,stem:'Consider the following statements regarding Opportunistic post-splenectomy infections (OPSI):\\n1. H. influenzae, N. meningitidis and S. pneumoniae are the most common causative agents\\n2. Risk is greatest in patients who have undergone splenectomy for trauma\\n3. Risk is greatest within the first 2\u20133 years following splenectomy\\n4. Prophylactic vaccination should be done 2 weeks prior to elective splenectomy\\nWhich are correct?',correct:'1, 3 and 4',options:['1, 2 and 3','2, 3 and 4','1, 3 and 4','1, 2 and 4'],exp:'OPSI (Overwhelming Post-Splenectomy Infection): Statement 1 \u2714 \u2014 Streptococcus pneumoniae (most common, ~50%), Haemophilus influenzae, Neisseria meningitidis are the \"encapsulated\" organisms \u2014 spleen is critical for opsonisation. Statement 2 \u2717 \u2014 Risk is NOT greatest in trauma splenectomy; it is greatest in splenectomy for HAEMATOLOGICAL diseases (thalassaemia, sickle cell, hereditary spherocytosis) \u2014 greatest immunological compromise. Trauma splenectomy has lower OPSI risk than haematological indications. Statement 3 \u2714 \u2014 Risk is highest in first 2\u20133 years post-splenectomy but persists lifelong. Statement 4 \u2714 \u2014 Vaccines (pneumococcal, meningococcal, Hib) should be given AT LEAST 2 weeks BEFORE elective splenectomy for optimal immune response. Correct: 1, 3 and 4. Answer: 1, 3 and 4.'},\n{id:19,stem:'A 48-year-old male with history of chronic duodenal ulcer presented with sudden severe abdominal pain. Pulse 120\/min, BP 90\/60 mmHg. Abdomen: tenderness, rigidity, guarding. RR 20\/min. X-ray: gas under right dome of diaphragm. Probable diagnosis is:',correct:'Perforation Peritonitis',options:['Acute appendicitis','Acute Pancreatitis','Acute Myocardial infarction','Perforation Peritonitis'],exp:'GAS UNDER DIAPHRAGM (pneumoperitoneum) on erect chest X-ray is PATHOGNOMONIC of a hollow viscus perforation. In context of chronic duodenal ulcer history: PERFORATED DUODENAL ULCER \u2192 spilled gut contents \u2192 generalised peritonitis. Clinical features confirm peritonitis: peritoneal signs (tenderness + rigidity + guarding), haemodynamic compromise (shock: pulse 120, BP 90\/60). Acute pancreatitis: no pneumoperitoneum. Appendicitis: may perforate but gas under diaphragm less typical at this stage; no DU history. MI: no peritoneal signs. Gas under right hemidiaphragm + DU history + peritonitis = perforated DU \u2192 Perforation Peritonitis. Answer: Perforation Peritonitis.'},\n{id:20,stem:'A young sportsperson presented with severe pain in the groin extending into the scrotum and upper thigh. Pain is debilitating, he cannot exercise. On examination there is tenderness in the region of the inguinal canal and pubic tubercle. He is probably suffering from:',correct:'Sportsman hernia',options:['Varicocele','Inguinal hernia','Sportsman hernia','Femoral hernia'],exp:'SPORTSMAN\\'S HERNIA (Athletic pubalgia \/ Gilmore\\'s groin): a syndrome of posterior inguinal wall weakness WITHOUT a clinically detectable hernia. Affects young athletes (footballers, hockey players). Features \u2714: pain in groin radiating to scrotum\/inner thigh; aggravated by exercise (typically kicking, twisting); tenderness over INGUINAL CANAL and PUBIC TUBERCLE; no palpable hernia sac (distinguishes from inguinal hernia); pain at medial inguinal ring on cough impulse. Varicocele: scrotal swelling, \"bag of worms.\" Inguinal hernia: palpable reducible swelling. Femoral hernia: below and lateral to pubic tubercle. Answer: Sportsman hernia.'},\n{id:21,stem:'Ventral hernia includes all EXCEPT:',correct:'Inguinal hernia',options:['Epigastric hernia','Para-umbilical hernia','Lumbar hernia','Inguinal hernia'],exp:'VENTRAL hernias are those that protrude through the anterior ABDOMINAL WALL (ventral = front). Types: Epigastric \u2714 (midline between xiphoid and umbilicus), Umbilical\/Para-umbilical \u2714, Incisional \u2714, Spigelian \u2714, Lumbar \u2714 (posterior abdominal wall but grouped as ventral\/abdominal wall hernias in some classifications \u2014 Petit\\'s triangle, Grynfeltt\\'s triangle). INGUINAL HERNIA \u2717 \u2014 this is a GROIN\/INGUINAL hernia, passing through the inguinal canal in the groin. It is classified separately as an inguinoscrotal or groin hernia, NOT a ventral hernia. Answer: Inguinal hernia.'},\n{id:22,stem:'Diaphragmatic injury is suspected in a 50-year-old gentleman with history of blunt abdominal trauma, having a normal chest X-ray. He is best managed by:',correct:'Diagnostic laparoscopy',options:['Diagnostic peritoneal lavage and proceed','Upper GI contrast study','CECT abdomen','Diagnostic laparoscopy'],exp:'Diaphragmatic injury after blunt trauma with NORMAL CXR: CXR misses 30\u201350% of left-sided diaphragmatic injuries (bowel\/omentum may not have herniated yet). CECT abdomen is a good initial investigation but can still miss diaphragmatic tears (sensitivity ~71%). DIAGNOSTIC PERITONEAL LAVAGE: detects haemoperitoneum but cannot diagnose or repair diaphragmatic tears. UPPER GI CONTRAST: useful if hollow viscus herniation suspected but not first-line. DIAGNOSTIC LAPAROSCOPY \u2714: Gold standard for evaluating diaphragm when CXR is normal; directly visualises the diaphragm; can diagnose AND repair the defect; high sensitivity (~100%) for left-sided tears. Answer: Diagnostic laparoscopy.'},\n{id:23,stem:'A 20-year-old man had pain in the right side of abdomen. His X-ray abdomen AP view shows a radio-opaque shadow, which on lateral film falls behind the vertebral column. The probable diagnosis is:',correct:'Renal Calculus',options:['Gall stone disease','Renal Calculus','Calcified mesenteric lymph node','Phlebolith'],exp:'Localisation of radio-opaque shadows by lateral X-ray: ANTERIOR to spine (in front) = gallstones, calcified mesenteric lymph nodes, phleboliths (pelvic veins). BEHIND the vertebral column (POSTERIOR, overlapping spine on lateral) = RENAL CALCULI \u2014 the kidneys are retroperitoneal, positioned posteriorly adjacent to the vertebral column. Key discriminator: on lateral film, renal stones project OVER or BEHIND the vertebral bodies; gallstones project ANTERIOR. This patient: shadow behind vertebral column on lateral \u2192 RENAL CALCULUS. Answer: Renal Calculus.'},\n{id:24,stem:'Urinary bladder can be injured in all of the following operations EXCEPT:',correct:'Inguinal lymph node dissection',options:['Inguinal hernia repair','Hysterectomy','Surgery for rectum','Inguinal lymph node dissection'],exp:'Urinary bladder injury during surgery: INGUINAL HERNIA REPAIR \u2714 \u2014 bladder may be part of sliding hernia sac (medial to the sac, especially on left); injury possible during dissection. HYSTERECTOMY \u2714 \u2014 bladder closely related to the anterior uterus and cervix; most common organ injured during hysterectomy. SURGERY FOR RECTUM \u2714 \u2014 bladder lies anterior to rectum; vulnerable during total mesorectal excision (APR\/AR). INGUINAL LYMPH NODE DISSECTION \u2717 \u2014 nodes are in the femoral triangle, superficial and subcutaneous; the bladder is not in the surgical field. Answer: Inguinal lymph node dissection.'},\n{id:25,stem:'In diffuse axonal injury all are true EXCEPT:',correct:'CT scan shows pathognomonic finding',options:['Form of primary brain injury','Seen in high energy','Patient is comatose','CT scan shows pathognomonic finding'],exp:'Diffuse Axonal Injury (DAI): FORM OF PRIMARY BRAIN INJURY \u2714 \u2014 occurs at moment of impact; not secondary. HIGH ENERGY MECHANISM \u2714 \u2014 caused by acceleration-deceleration forces (rotational shear); road traffic accidents, falls from height. PATIENT IS COMATOSE \u2714 \u2014 immediate and prolonged loss of consciousness (immediate coma without lucid interval); often GCS 3\u20138. CT SCAN \u2717 \u2014 CT is typically NORMAL or shows only subtle findings (small haemorrhages in corpus callosum, grey-white interface, basal ganglia). CT does NOT show pathognomonic findings. MRI (especially DWI, GRE\/SWI sequences) is the investigation of choice for DAI. CT is insensitive. Answer: CT scan shows pathognomonic finding.'},\n{id:26,stem:'A 70-year-old man on anticoagulants for heart disease suffered a minor head injury. One month later he has severe headache with slowly developing neurological signs. The probable diagnosis is:',correct:'Chronic subdural haematoma',options:['Extradural haematoma','Acute subdural haematoma','Chronic subdural haematoma','Subarachnoid haemorrhage'],exp:'CHRONIC SUBDURAL HAEMATOMA (CSDH): key features perfectly matched \u2014 ELDERLY patient \u2714 (cerebral atrophy, stretched bridging veins). ANTICOAGULANTS \u2714 \u2014 major predisposing factor; even minor head trauma can cause bleeding. MINOR\/TRIVIAL head injury \u2714 (often forgotten). DELAYED PRESENTATION \u2014 symptoms appear WEEKS (>3 weeks) after injury \u2714 (1 month here). INSIDIOUS NEUROLOGICAL SIGNS \u2714 \u2014 slow accumulation and expansion of haematoma. Headache, cognitive decline, hemiparesis developing over days\/weeks. Extradural: arterial bleed, lucid interval then rapid deterioration, not weeks later. Acute SDH: within 72h. SAH: thunderclap headache, no delayed onset. Answer: Chronic subdural haematoma.'},\n{id:27,stem:'Regarding \"Quinsy\" all of the following are correct EXCEPT:',correct:'Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic',options:['It is an abscess in the peritonsillar region','Severe trismus is caused by spasm induced by pterygoid muscles','Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic','In early stage, intravenous broad spectrum antibiotics may resolve it'],exp:'Quinsy (peritonsillar abscess): Abscess in the peritonsillar region \u2714 \u2014 pus between the tonsillar capsule and the superior constrictor muscle. Trismus from pterygoid spasm \u2714 \u2014 the medial pterygoid muscle is adjacent; reflex spasm causes severe trismus (hallmark feature). IV antibiotics in early stage \u2714 \u2014 early cellulitis\/peritonsillar cellulitis may resolve with antibiotics; established abscess requires drainage. Pus pointing in ALL cases \u2717 \u2014 pointing of pus through thinned mucosa is seen in many cases but NOT in all; in early\/deep abscesses there may be no visible pointing. \"In all cases and is diagnostic\" is the false claim. Answer: Pus may be seen pointing underneath the thin mucosa in all cases and is diagnostic.'},\n{id:28,stem:'The most common organism causing Acute Otitis Media in children is:',correct:'Streptococcus pneumoniae',options:['Streptococcus pneumoniae','Staphylococcus epidermidis','Escherichia coli','Klebsiella pneumoniae'],exp:'Acute Otitis Media (AOM) \u2014 bacteriology: STREPTOCOCCUS PNEUMONIAE \u2714 = most common overall (30\u201340%), responsible for the most severe cases. Non-typeable Haemophilus influenzae (second most common, ~20\u201330%). Moraxella catarrhalis (~10\u201315%). Staphylococcus aureus and Group A streptococcus \u2014 less common. Staphylococcus epidermidis: a commensal, not a significant AOM pathogen. E. coli and Klebsiella: rarely cause AOM (neonates only). In children, S. pneumoniae = most common and most important cause. Answer: Streptococcus pneumoniae.'},\n{id:29,stem:'A 50-year-old male presented with pain along the left arm and ptosis. His chest X-ray showed soft tissue opacity at the apex of the left lung along with erosion of the adjacent rib. The probable diagnosis is:',correct:'Pancoast lung',options:['Pancoast lung','Bronchial carcinoma','Lung abscess','Adenocarcinoma of lung'],exp:'PANCOAST TUMOUR (Superior Sulcus Tumour): APICAL LUNG TUMOUR at the superior sulcus. Classic Pancoast syndrome triad: (1) Shoulder\/arm pain (brachial plexus C8, T1, T2 involvement) \u2014 pain radiating down arm. (2) HORNER\\'S SYNDROME: ptosis + miosis + anhidrosis (involvement of sympathetic chain). (3) Rib\/vertebral erosion (T1, T2 ribs). CXR: apical opacity + rib erosion \u2714. Most commonly squamous cell or adenocarcinoma histologically. \"Bronchial carcinoma\" is a category but \"Pancoast\" is the SPECIFIC diagnosis here \u2014 the syndrome of apical tumour + Horner\\'s + arm pain + rib erosion is Pancoast. Answer: Pancoast lung (tumour).'},\n{id:30,stem:'Which of the following is NOT true about Dupuytren\\'s Contracture?',correct:'Not familial',options:['Autosomal dominant','Occurs in elderly men','Not familial','Associated with alcoholism, smoking and hypothyroidism'],exp:'Dupuytren\\'s contracture (palmar fibromatosis): Autosomal dominant \u2714 \u2014 hereditary basis, often positive family history (option c says \"not familial\" which CONTRADICTS this; hence option c is false). Occurs in elderly men \u2714 \u2014 predominantly men >50 years; male:female 6:1. Associated with: alcoholism \u2714, smoking \u2714, hypothyroidism \u2714, diabetes mellitus, epilepsy (phenytoin use), trauma, HIV. NOT FAMILIAL \u2717 \u2014 This is FALSE. Dupuytren\\'s HAS a clear autosomal dominant inheritance pattern and IS familial. This is the untrue statement. Answer: Not familial.'},\n{id:31,stem:'Which of the following statements regarding flat foot are true?\\n1. All children below 3 years have flat foot\\n2. 15% adults have flat foot\\n3. Painless flexible foot needs no treatment\\n4. Rigid flat foot is a result of tarsal coalition\\nSelect the correct answer:',correct:'1, 2, 3 and 4',options:['3 and 4 only','1 and 2 only','1, 2 and 3 only','1, 2, 3 and 4'],exp:'Flat foot (pes planus) facts: Statement 1 \u2714 \u2014 All children under 2\u20133 years have physiological flat feet (ligament laxity, fat pad in arch); longitudinal arch develops by 3 years. Statement 2 \u2714 \u2014 ~15\u201323% of adults have flat feet (flexible, asymptomatic). Statement 3 \u2714 \u2014 Painless, flexible (mobile) flat foot requires NO treatment; reassurance only; the arch appears when the child stands on tiptoe. Statement 4 \u2714 \u2014 Rigid flat foot (foot remains flat even non-weight bearing, no arch on tip-toe) is a hallmark of TARSAL COALITION (abnormal osseous\/fibrous\/cartilaginous fusion between tarsal bones, e.g., calcaneonavicular or talocalcaneal). All four statements are correct. Answer: 1, 2, 3 and 4.'},\n{id:32,stem:'All of the following are causes of acute red eye EXCEPT:',correct:'Acute macular oedema',options:['Conjunctivitis','Keratitis','Acute macular oedema','Acute glaucoma'],exp:'Causes of acute red eye (anterior segment involvement): CONJUNCTIVITIS \u2714 \u2014 diffuse conjunctival injection, discharge. KERATITIS \u2714 \u2014 circumcorneal (ciliary) injection, pain, photophobia. ACUTE ANGLE-CLOSURE GLAUCOMA \u2714 \u2014 red eye, severe pain, halos, nausea, vomiting, corneal oedema, raised IOP. Also: scleritis, episcleritis, uveitis, subconjunctival haemorrhage. ACUTE MACULAR OEDEMA \u2717 \u2014 the macula is in the POSTERIOR segment (central retina); macular pathology does NOT cause red eye. Macular oedema presents with central visual loss\/blurring, metamorphopsia \u2014 not redness. Answer: Acute macular oedema.'},\n{id:33,stem:'All are true about Vernal conjunctivitis EXCEPT:',correct:'Most signs are in lower lid',options:['Type of allergic conjunctivitis','Itchy eyes with other allergic problems','Cobblestone appearance','Most signs are in lower lid'],exp:'Vernal keratoconjunctivitis (VKC): Type of allergic conjunctivitis \u2714 \u2014 IgE-mediated (Type I hypersensitivity) + cellular (Type IV) reaction; seasonal exacerbations in warm\/dry climates. Intense itching \u2714, with other atopic features (asthma, eczema, rhinitis). Cobblestone (giant papillae) \u2714 \u2014 on UPPER tarsal conjunctiva (palpebral form); pathognomonic finding. MOST SIGNS IN LOWER LID \u2717 \u2014 FALSE. VKC predominantly affects the UPPER TARSAL conjunctiva and the limbus (limbal form: Trantas\\' dots at limbus). Lower lid involvement is NOT characteristic. Answer: Most signs are in lower lid.'},\n{id:34,stem:'Preoperative Samsoon and Young modified Mallampati test is used for assessing:',correct:'Difficulty in intubation',options:['Preoperative nutrition status of patient','Patient\\'s overall fitness for surgery','Difficulty in intubation','Blood requirement during surgery'],exp:'MALLAMPATI TEST (modified by Samsoon and Young, 1987): patient sits upright, mouth wide open, tongue protruded maximally, no phonation \u2014 examiner assesses visible oropharyngeal structures. CLASSES: I: soft palate, fauces, uvula, pillars visible. II: soft palate, fauces, uvula visible. III: soft palate and base of uvula visible. IV: only hard palate visible. PREDICTS DIFFICULT INTUBATION\/LARYNGOSCOPY: Class III\u2013IV correlates with difficult airway. Used as part of airway assessment before general anaesthesia. NOT for nutrition, overall fitness, or blood loss assessment. Answer: Difficulty in intubation.'},\n{id:35,stem:'In split-thickness graft, which part of the skin is included?',correct:'Epidermis and part of dermis',options:['Epidermis only','Epidermis and dermis','Epidermis and part of dermis','Epidermis, dermis and part of subcutaneous tissue'],exp:'Skin graft classification: SPLIT-THICKNESS SKIN GRAFT (STSG \/ Thiersch graft): contains EPIDERMIS + PART OF DERMIS (variable depth \u2014 thin, intermediate, or thick STSG). Harvested with dermatome. Donor site heals by re-epithelialisation from residual dermal appendages. FULL-THICKNESS GRAFT (Wolfe graft): entire epidermis + entire dermis (no subcutaneous fat). Donor site must be closed primarily. EPIDERMIS ONLY: not a practical graft. Epidermis + full dermis + subcutaneous tissue: would be a composite graft\/free flap. STSG = epidermis + PART of dermis. Answer: Epidermis and part of dermis.'},\n{id:36,stem:'A young motorcycle rider met with a road traffic accident with maxillofacial trauma and paraesthesia of the lower lip. Most likely underlying he has a:',correct:'Fracture of the mandibular body',options:['Fracture involving infraorbital foramen','Fracture involving floor of orbit','Fracture of the mandibular body','Fracture of temporal bone'],exp:'PARAESTHESIA OF LOWER LIP: innervation is the MENTAL NERVE (branch of inferior alveolar nerve \u2192 branch of V3\/mandibular division). The mental nerve exits via the MENTAL FORAMEN in the BODY OF THE MANDIBLE (between premolars). Fracture of mandibular body \u2192 injury to mental nerve \u2192 paraesthesia\/numbness of lower lip and chin. INFRAORBITAL nerve (exits infraorbital foramen): supplies infraorbital skin, upper lip, cheek \u2014 NOT lower lip. FLOOR OF ORBIT fracture: infraorbital nerve \u2192 upper lip\/cheek. TEMPORAL BONE: CN VII (facial) or CN VIII. Lower lip paraesthesia = mandibular body fracture. Answer: Fracture of the mandibular body.'},\n{id:37,stem:'A 20-year-old patient underwent open hernia surgery four days ago. He is running fever for the last one day and on local examination the operated site is wet with pus and surrounding redness and oedema. The appropriate management would be:',correct:'Opening sutures and cleaning of wound',options:['Change of antibiotics','Daily dressing','Opening sutures and cleaning of wound','Sending pus for C\/S'],exp:'POST-OPERATIVE WOUND INFECTION management: The patient has an ESTABLISHED WOUND ABSCESS (pus, cellulitis, local signs 4 days post-op). The fundamental surgical principle is: WHERE THERE IS PUS, LET IT OUT (Ubi pus, ibi evacua). The correct primary step is OPENING THE SUTURES AND CLEANING\/DRAINING the wound. This allows: drainage of pus, debridement of infected\/sloughy tissue, and secondary intention healing. Antibiotics alone (option a) are inadequate without drainage \u2014 pus is a closed-space infection. Daily dressing alone without drainage is insufficient. C\/S (culture\/sensitivity) should also be done BUT is secondary to the drainage step; it alone is not \"management.\" Answer: Opening sutures and cleaning of wound.'},\n{id:38,stem:'Good surgical practice and surgical ethics include all EXCEPT:',correct:'Experiment',options:['Respect autonomy','Informed consent','Confidentiality','Experiment'],exp:'Surgical ethics pillars: RESPECT AUTONOMY \u2714 \u2014 patient\\'s right to make informed decisions. INFORMED CONSENT \u2714 \u2014 mandatory before any surgical intervention; discloses risks, benefits, alternatives. CONFIDENTIALITY \u2714 \u2014 patient information must be protected. EXPERIMENT \u2717 \u2014 performing surgery as uncontrolled human experimentation without ethical approval, informed consent for research, or IRB oversight is NOT a principle of good surgical practice; it violates the Declaration of Helsinki. Experimental procedures require separate research ethics approval and full disclosure. \"Experiment\" per se is not a component of routine surgical ethics. Answer: Experiment.'},\n{id:39,stem:'Refeeding syndrome seen after enteral or parenteral nutrition is characterised by all EXCEPT:',correct:'Hyponatremia',options:['Hypophosphatemia','Hypocalcemia','Hypomagnesemia','Hyponatremia'],exp:'REFEEDING SYNDROME: occurs when malnourished patients receive rapid nutritional support after prolonged starvation. Pathophysiology: carbohydrate reintroduction \u2192 insulin surge \u2192 cellular uptake of electrolytes \u2192 characteristic electrolyte derangements. Classic electrolyte disturbances: HYPOPHOSPHATAEMIA \u2714 (hallmark; phosphate shifts into cells for phosphorylation; can cause respiratory failure, cardiac failure). HYPOMAGNESAEMIA \u2714 (magnesium shifts intracellularly). HYPOCALCAEMIA \u2714 (secondary to hypomagnesaemia affecting PTH). Also: hypokalaemia, thiamine deficiency, fluid shifts. HYPONATRAEMIA \u2717 \u2014 NOT a characteristic feature of refeeding syndrome; sodium handling is not directly implicated in this mechanism. Answer: Hyponatremia.'},\n{id:40,stem:'The capillary refill time is prolonged in all types of shock EXCEPT:',correct:'Septic shock',options:['Hypovolaemic shock','Cardiogenic shock','Septic shock','Obstructive shock'],exp:'Capillary refill time (CRT): normal <2 seconds. Mechanism of prolongation: peripheral vasoconstriction reduces cutaneous blood flow \u2192 slower refill. HYPOVOLAEMIC SHOCK \u2714 \u2014 decreased preload \u2192 reflex vasoconstriction \u2192 prolonged CRT. CARDIOGENIC SHOCK \u2714 \u2014 low cardiac output \u2192 compensatory vasoconstriction \u2192 prolonged CRT. OBSTRUCTIVE SHOCK \u2714 (e.g., tension pneumothorax, cardiac tamponade) \u2014 reduced output \u2192 vasoconstriction \u2192 prolonged CRT. SEPTIC SHOCK (EARLY\/WARM PHASE) \u2717 \u2014 characterised by VASODILATION (cytokine-mediated), warm peripheries, bounding pulse, NORMAL or even SHORTENED CRT (hyperdynamic phase). CRT may NOT be prolonged in warm septic shock. 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