High Yield Surgery MCQs for FMGE 2024: GIT & PYQs Part 1

[00:00:06]this is a shhot question it is being asked since the last 3 years it's been asked in all the exams and no one should make a mistake in this a 45-year-old male with a history of nid consumption comes to the emergency with severe abdominal pain he has tachicardia and hypertension and rebound tenderness now we know rebound tenderness is a feature of peritonitis right and why is there peritonitis because in the X-ray you can see gas under diaphragm so this is the X-ray of gas under diaphragm this nobody should make a mistake in every one should be able to diagnose this when there is gas under diaphragm we have to give IV fluids and take up the patient for an immediate lioy lomy means we have to open up the abdomen and explore a baby is playing un supervised complaints of difficulty in swallowing since the last few hours x-ray is done and a foreign body is seen so how do we differentiate whether this is in the trachea or it's in the esophagus you can very clearly see in the lateral film you can see this gas Shadow so we know that trachea is anterior trachea is anterior and esophagus is posterior and you can see that the coin is behind the trachea right so it's in the esophagus any which ways even in the question they've said the patient has difficulty in swallowing so patient will have difficulty in swallowing only when there is a foreign body in the esophagus you should know that there are three constrictions at 15 25 and 40 these values have also been asked and the narrowest portion is at 15 cm from the upper incisa this is the fareno esophagal junction or C6 the other two constrictions are when the arch of aota and when the Esopus pierces the diaphragm the gold standard investigation for GD is 24r pH monitoring this everyone should be aware of but there is a catch here they are asking gold standard so we will mask 24hour pH monitoring if they would have asked for gastroesophagal reflux disease what is the investigation of choice it is endoscopy so the investigation of choice is endoscopy the goal standard is 24hour pH monitoring this was another question which was asked in the recent fmg exam you have to identify the pathology they have shown an invertog It Was Written also this is an invertog invertog is done when there is an imperforate anus when there is an anoral malformation we turn the patient upside down we keep a metallic pointer at the proposed s of the anal opening and then we take an ex you can see that this is the gas Shadow and this is the marker if the distance is less than 2 cm we call it as a low anorectal malformation if the distance is more than 2 cm we call it as a high anorectal malformation right so this you should know this was a new topic which was asked in the fmg exam last time you should be aware of this a chronic alcoholic patient with liver disease presents with Molina and hematom misses what is the most likely cause so chronic alcoholic liver disease it is most likely due to esophagal viruses right hematomas and Molina it is due to esophagal viruses so varial bleeding can give rise to this malerie V steer is also seen in alcoholic patients but malerie V steer is self-limiting right it will start on the lower part of the esophagus and extends until the cardia but it is us usually self-limiting a patient who underwent this surgery few months back complaints of dizziness headache and sweating 40 minutes after consumption of food what is the most likely diagnosis so the patient has undergone some kind of gastric surgery which you can see and a gastrostomy has been done when a gastrostomy has been done these patients can present with dumping now the symptoms are occurring after 40 minutes so will it be early dumping or late dumping this is going to be late dumping also you can see that the features are of hypoglycemia dious headache sweating so which again tells us that these are features of late dumping now early dumping occurs due to Rapid influx of fluid inside the bubble patient will come with epigastric fullness nausea and vomiting and these features would start within 10 to 15 minutes of consumption of food and and early dumping if the patient takes in more food it will worsen late dumping on the other hand occurs due to rebound hypoglycemia which is occurring because of excessive insulin release so the features will be of hypoglycemia like in the question stem it will be improved by food and they will start 30 to 40 minutes after consumption of food now how do we prevent dumping that's another question which can be asked so small frequent meals avoid sugar Rich liquid avoid sugar Rich liquids avoid simple sugars and avoid liquids with meals these are the ways how we can prevent dumping syndrome what is the most common complication of the bariatric surgery it is iron deficiency vitamin B12 deficiency can also occur calcium or vitamin D3 deficiency can also occur but the most common is iron deficiency these three nutritional deficiencies you should be aware of this was also asked in the previous exam a patient is diagnosed with the pathology shown in the image which doctor should the patient be referred to you can see that this is Trico bzo Trico bzo is when there is a hair ball inside the stomach and why is this hair ball forming because the patient is eating his or her own hair so this is a psychiatric problem of tropy which is why the referal will go to a psychiatrist this I've already told you 25-year-old female with dysphasia barium is done gradual tapering this is acalasia cardia birds beak appearance again I'm reiterating this question because this will definitely definitely be asked it's a free one Mark which you should not lose out on a patient comes to the ER with acute abdominal pain since one day on examination there is guarding present again signs of peritonitis you can see gas under diaphragm and this gas under diaphragm suggests that there is a hollow viscous perforation another name for this massive gas under diaphragm is football sign which was asked in the recent neat exam this is known as football sign as well which was asked in the recent neat exam after binge drinking a young alcoholic male comes with hematomas which stops after some time what is the diagnosis so I showed you a previous question where they had given that the patient has chronic liver disease and hematosis and Molina there the answer was varises here the patient is alcoholic but it is self-limiting bleeding I told you it stops after some time so what was the other condition I told you malerie V tier this is a malerie V tier which is the tier in the lower half of the esophagus extends onto the cardia The Vessel which bleeds is the left gastric artery but it is self-limiting okay this question was asked last year in the fmg exam which of the following pairs of cancer staging have been marked correctly bladder cancer wh bladder cancer is going to be tnm staging testicular cancer is going to be again tnms where s stands for the value of the tumor marker oral cancer again we have the tnm staging gastric cancer you can have the Borman staging and the Japanese classification these are for gastric cancers for early gastric cancer you have the Japanese classification for advanced gastric cancer you have the Boran classification you don't need to know the details of both of them this question I've already told you this is regarding Nutcracker esophagus again questions regarding appendicitis are frequently asked I told you in the important topics what is the site of Maximum pain in acute appendicitis we know it is the murn point the surface marking of MC Bernie's Point has been asked many many many times in the exam you should not go wrong in the marking of MC Bernie's Point MC Bernie's point is the site of Maximum tenderness in appendicitis and and it is situated at the junction of lateral 1/3 and medial 2/3 again lateral 1/3 medial 2/3 along the line joining the interior Superior ALC spine with the umus right so that is where maximum tendonous is there soas sign can be seen this is when we do hyperextension of the hip or flexion against resistance and obturator sign can be seen when there's flexion and internal rotation which is done that can give rise to pain pain a female patient comes with a with right hypochondrial pain radiating to the back with vomiting on examination there is guarding in the right hypochondrium she has had similar episodes in the last one year so right hypochondrial pain which structure is there in the right hypochondrium gallbladder that is correct so whenever there is pain in the when there's colicy titis pain can be there in the right hypochondrium and guarding can can be there so the answer is going to be acute chitis don't get confused by pain radiating to the back right pain radiating to the back can happen in pancreitis but pancreatitis pain will be in the epigastrium it will radiate to the back and it is relieved when the patient bends forward another question which has been asked many times that the investigation of choice for kystis and gallstones is ultrasound and on ultrasound you see a post acoustic Shadow if there is a stone we will see a post acoustic shadow whereas if there is a polyp you will not see a post acoustic shadow no post acoustic shadowing will be seen here a 25-year-old patient now comes with right ilak fosa pain vomiting and is managed conservatively she was stable when the pain worsened and the fever increased okay she required extra peronal drainage under ultrasound so what has happened here there is right iliac fosa pain we know in the right ilc fosa the appendix can be there because the patient is being managed conservatively this would have been a case of an appendicular lump when there is an appendicular lump that is when we will manage the patient conservatively right now when conservative management was being done either the patient this can resolve and we can discharge the patient or the condition can worsen like in this case and the patient can start running fever so that means an appendicular absis was formed and that is what was drained using extra peronal drainage so this regime is called the asna Sharin regime where we manage appendicular lumps via the conservative means if the patient recovers we discharge the patient and we call the patient after 6 weeks for an interval appendicectomy if the patient deteriorates we are dealing with an absis and we need to drain it moving on a newborn child comes with a scoid abdomen and respiratory distress x-ray shown so you can see that all the Babel is inside the thorax why is the bbel inside the thorax in a newborn child the causes congenital diaphrag fmatic hernia and congenital diaphragmatic hernia again a very important topic which has been asked in the exam two or three points which you should remember if you remember these two or three points you can answer questions regarding congenital diaphragmatic hernia the most common is BIC or left posterolateral and you can see this is also on the left side so this is most probably a bodic or left posterolateral hernia moag is right anteromedial you will get a scoid abdomen there's to be respiratory distress and the most common cause of death in these patients is pulmonary hypoplasia the lung does not develop and that is what causes death we've already discussed this now we have a 35-year-old patient who comes with sudden bout of chest pain after wretching and vomiting so alcoholic patient sudden chest pain after wretching and vomiting there is no hematom missis so this is not a malerie be steer or viruses right patient comes to the emergency there is Tachi cardia BP is all right osculation there is decreased air entry on the left side and a crunching sound is heard on osculating the heart this crunching sound is known as Hammond sign and he is diagnosed with Bor half syndrome which is not a part of maa's Triad so fever is not a part of maa's Triad maa's Triad is seen in spontaneous esophagal perforation or Bor half syndrome most common site is left posterolateral common in Alcoholics patient is going to come with ma striad which is wretching chest pain and subcutaneous MMA and I told you Hammond sign of crunching sound can be heard this is diagnosed using a contrast study this is Barett esophagus this image is has also been asked you know barats esophagus is is it dysplasia or metaplasia that is correct this is metaplasia this is metaplasia of squamous epithelium to colonar epithelium and this is also known as specialized intestinal metaplasia and if you do a biopsy of barats you're are going to see goblet cells that is the pathognomic thing which you will see you're going to see goblet cells this was asked in the exam kilan dein is a potential space between thyro farenas and cof farenas and what comes out through the kilan dein that's correct zener's diverticulum can come out through kilan dein it is a false diverticulum it starts in the midline posteriorly but final is left of the midline the earliest feature is regurgitation but the most common complication is aspiration pneumonitis another very important question a 40-year-old female comes with Progressive dysphasia to both solids and liquids now there is dysphasia to both solids and liquids since last month the body mass index is also low there are no systemic illnesses barium solow is shown so we can see there is gradual narrowing so what are we suspecting gradual tapering dysphasia to both solids and liquids acalasia right but it's a 40-year old patient weight loss also is there the differential is going to be carcinoma esophagus so which two investigations would you do to rule out both the conditions or to diagnose the condition so we need to do an we need to carry out upper GI endoscopy that will tell us about cancer and manometry that will tell us about the mortality disord so for mortality disorders we do manometry and to rule out cancer we going going to do an upper GI endoscopy so investigations for esophagal disorders match the following we have to do G I told you investigation of choice is endoscopy not 24hour pH monitoring cancer is endoscopic biopsy hial hernia is CT with oral contrast Zena's diverticulum is berium swallow and acalasia cardia morality disorders is manometry so please remember if you remember this table you can easily answer questions regarding the investigations regarding esophagal disorders a constant question which is definitely asked in the exam is hypertrophic pyloric stenosis infantile hypertrophic pyloric stenosis so we have a 3we male Child 3 week male child all these are very important usually manifests around third week male children are more frequently effective firstborn male child so the child has been diagnosed with idiopathic hypertrophic pyloric stenosis they've asked the metabolic abnormality this has been asked many many times it is hypochloric hypokalemic metabolic alkalosis so hypochloremic hypokalemic metabolic alkalosis so males are more commonly affected there is reduced levels of nitric oxide synthes in these patients you can get string sign double track sign or mushroom sign these are some of the signs which can be seen on a contrast study the metabolic abnormality I've already told you the fluid of choice has also been asked in the exam so you should know it is n by2 normal salign with dextrose and KCl we start potassium When urine output is adequate when do we start potassium When urine output is adequate then only we are going to start potassium replacement okay so just to reiterate what we've discussed in the previous question you have a five week male child five week old male child brought to the emergency with multiple episodes of non-bus vomiting why non-bus because the obstruction is in the stomach and bile will come in the deinum so the obstruction is before that so that's why it's non-bus so this is mushroom sign which I just showed you this is seen in hypertrophic pyloric stenosis the investigation of choice for hypertrophic pyloric cenosis is ultrasound and the best time to examine the child is during feeding a 45-year-old female had total gastrectomy 6 or 7 years back and now has anemia and neurological symptoms what type of anemia is most common in this patient I told you following gastrectomy I discussed one question earlier you can have iron deficiency this is most common vitamin D3 deficiency and vitamin B12 deficiency so iron deficiency is the most common but here there are saying that there is neurological symptoms also so neurological symptoms means it is going to be Megalo anemia which is due to B12 deficiency then only the patient will have neurological symptoms had they asked most common overall you would have marked iron deficiency which of the following deficiencies is seen where terminal Lum is removed due to Crohn so it's going to be B12 deficiency because absorption of B12 will occur in the terminal ilium patient is taking broadspectrum antibiotics for a long time and the patient now comes with diarrhea what is the most likely organism so broadspectrum antibiotics it can alter the gut flora and the patient can develop C cladium defil pseudomembranous oculitis or diarrhea and we can use oral vomisin in these patients a male patient presents to the opid with an abdominal lump in the perumal region which moves at right angles to the attachment of the mentry what is the most likely diagnosis so this question was asked two times 2 years back in both the fmg exams so this is a patient with a mric cyst and the most common type of mric cyst is a Kyo lymphatic cyst so entric cyst can be of two types Kyo lymphatic and entrogen and you should know that Kyo lymphatic cysts are the most common that's all you should know but very importantly what has been asked repeatedly is the TLO Triad so in mentri sis we are going to see the tilo Triad too Triad is a perumal lump which moves along perpendicular to the line of attachment of mentry and there is a transverse band of resonance so it moves perpendicular to the line of attachment of mentry there is a transverse band of resonance this is TLO Triad the in a 45-year-old female comes to the OPD with complaints of dysphasia and intermittent chest pain berium swallow is done and the image is shown what is the diagnosis like I told you the images of acalasia and [ __ ] screw esophagus are very important this barium image shows [ __ ] screw esophagus [ __ ] screw esophagus we will see in diffused esophagal spasm patient is going to come with chest pain and this chest pain can mimic myocardial infection so you should know diffuse esophagal spasm can present as [ __ ] screw esophagus these bariums are extremely important acalasia cardia you get the bird's beak appearance and in carcinoma you get rat tail appearance so this bird's beak appearance in acalasia which is a mortality disorder is extremely important you can see that there is gradual tapering whereas in cancer there is abrupt narrowing so you should not go wrong in these two berium images I've already discussed gas under diaphragm this we've discussed repeatedly another very common question is that patient is treated for gastric cancer and now develops a nodule over the UMAS what is the likely diagnosis so umal nodule in a patient with cancer this is known as Sister Mary Joseph's nodule and all these atypical presentations have been asked in the exam so Irish nodul is left axillary lymphadenopathy verow node has been asked many times verow node or left supraclavicular lymph node or trer sign is seen in advanced GI cancers tro so ters is left supraclavicular lymph node troo syndrome is migratory thrombol fitis which is seen with pancreatic cancer blumer shelf is metastasis into pouch of Douglas Sister Mary Joseph's nodule is perumal metastasis and krukenberg's tumor is bilateral ovarian metastasis which is seen in these patients so this is what Sister Mary Joseph's nodle looks like peral metastasis kooken bgs is bilateral ovarian metastasis which can be seen in gastric or breast cancer these are two more signs which can be seen in patients with Advanced cancers lesser trilat is multiple soric keratosis and tri Palms are hyper carotic Palms but most frequently in the ne in the fmg exam system AR Joseph nodule kenberg tumor and left supraclavicular lymph node has been asked what is the most commonly performed bariatric surgery procedure so the most commonly performed bariatric surgery proced procedure is laparoscopic sleeve gastrectomy right is laparoscopic sleeve gastrectomy you should know Ru Andy gastric bypass is the most acceptable bariatric surgery procedure now no longer the most commonly performed most commonly is sleeve gastrectomy and gastric bending is also a procedure the advantage of bending is that this is a reversible bariatric surgery procedure so banding is a reversible bariatric surgery procedure which of the following IV agents is not used to manage aperi Hemorrhage so propanolol IV propanolol is not use because if there is upper GI Hemorrhage blood pressure is already low and in a low blood pressure If you give IV propanolol that can bring down the pressure further that can be detrimental oral propanolol is used as prophylaxis not IV propanolol these are certain tubes which are used to control AP Hemorrhage temporarily you have ssten blore Minnesota and linton's tube in the fmg exam details of these tubes have not been asked you should know the pressure the hepatic Venus pressure gradient 6 to 10 you will have preclinical sinusoidal portal hypertension more than 10 we call it clinically significant portal hypertension and more than 12 is when the viruses start to rupture so these three values have been asked in the exam you should remember them B obstruction I told you is a very important topic many many times Babble obstruction investigations are asked elderly lady comes with non-passage of feis and beus vomiting x-ray is shown what is the diagnosis so is this small bubble or large bubble this is small bble I will just explain to you why this is small bbel obstruction similar question question was asked next year they had shown the image and they had asked which Loops are dileted so these are Jal Loops which are arranged in a step ladder pattern I will just explain this to you so that it becomes easier for you to answer so whenever we get a patient with Babel obstruction now what are the clinical features of bble obstruction you can have vomiting obstipation distension and pain okay anyone who comes with this the first investigation which we do is x-ray abdomen erect and suine we are going to do x-ray abdomen erect and suine that is what we are going to carry out in these patients so once we've done an x-ray abdomin erect and suine erect x-ray you will see air fluid levels if there are more than three air fluid levels that is suggestive of obstruction the supine film tells us about the sight Jud will have a feathery appearance you can see that there are complete Vol these are known as complete Vol which are extending from one wall to the other and you will get a feathery appearance that is why in this question you can see we had marked jum because of the feathery appearance similarly you can see complete volv here as well that is why we are calling it small bowel obstruction large bavel is seen in the periphery of the X-ray film and in complete H strations you can compare them with these Vol Vol were going from one wall to the other whereas H strations do not Traverse the entire wall so which of the following statements is not true regarding Babel obstruction so if we are going to operate a patient with Babel obstruction please remember I've told you initial investigation investigation of choice initial management of bble obstruction is we make the patient nil peroral NPO we are going to use IV fluids IV antibiotics painkillers put in a nasogastric tube now when we do surgery the first structure which we need to analyze is the seeum if the seeum is collapsed we call it small intestinal obstruction if the seeum is distended we call it large bble obstruction so the first structure we are going to see is the seeum this was also asked in the fmg exam patient comes with low grade fever anorexia weight loss barium meal follow through this investigation is seen this is classical of ilocal tuberculosis many names for this swan neck deformity right you can see there is a pulled up icj there is a pulled up ilocal Junction in these patients this is seen in ilocal tuberculosis x-ray of the patient after abdominal surgery is shown you can see distended bbel so the patient is in a state of IAS now patient is in a state of IAS the most common cause of IAS is hypokalemia hypokalemia can give rise to prolonged IAS very important very very important you should know for the exam performing an appendicectomy surgeon Encounters this Legion 2 ft proximal to the alocal junction what is the diagnosis this is meels diverticulum asked almost every year in the fmg exam mecal diverticulum it is a remnant of the vtil intestinal duct it is a true diverticulum because all the layers are there and you get rule of two 2% population you see it in 2 in long and it is situated 2 ft from The iole Junction so meal's the most common presentation in children is bleeding and this bleeding occurs due to ectopic gastric mucosa this this was also asked in last to last year's fmg exam we diagnosed this using a technum 99 per technate scan and it is a self-limiting condition the most common presentation in adults is obstruction due to interception that is the most common presentation in adults interception is when one bubble Loop goes into the other and in interception you should know the radiological signs you can get claw sign and you can get Target sign as well so interception claw sign and Target sign you can see Target sign on ultrasound this is coffee bean appearance this is coffee bean appearance which is seen in sigmoid volvulus this has also been asked many times this can also give rise to obstruction and you get this coffee bean sign or bent inner tube sign in sigmoid volvulus you can also Al get birds beak sign if you do a contrast study a newborn comes with beus vomiting remember we did hypertrophic pyloric stenosis there it was non-bus vomiting here the child is coming with beus vomiting so the obstruction is distal to the second part of deinum and you can see double bubble sign you can see two bubbles on an X-ray this is deodal atreia and we need to carry out diodo diosy in these patients this is Jal atreia where you will get Triple bubble sign so Jal atreia we are going to see Triple bubble sign in jinal atreia this question was asked last year in the fmg exam they had asked you to identify the sto in the right ilak fosa so in the right elak fosa we can only bring out the alium right left elak fosa we can bring out the colon as well but right elak fosa we can only bring out the iium so it is either a loop alosi or an OSI and because we can see two openings one and two this is a loop alosi in an end alosi only one opening we would have seen so you can see here end sto single opening Loop or double barrel sto you will see two openings complications of stoa the most common complication is skinic scoriation but the most common long-term complication of colosi is parastomal herniation so you can see here this image is Loop ostomy I just showed you why is it Loop ostomy here you can see a single opening so this is an end colostomy because one more reason of iosi versus colosi is that iosi is raised above the surface iosi is raised above the surface whereas a colostomy is always flush with the skin it is at the same level as the skin 45y old male comes with pain abdomen vomiting and diarrhea serum serotonin value is raised in the second test and discussion or second potential question video I had told you about endocrine surgery and I told you every year they're either asking carcinoid or or they are asking about foch chromosoma here serotonin is raised so this will go in favor of carcinoid tumor okay so you should know about carcinoid and foch chromosoma another very important question 19-year-old male came to the ER with the recurrent episodes of interception on surgery we can see a polyp the histopathology of the polyp is shown below you can see it as an arborizing pattern pattern it is like a tree Arbor Rising pattern is there okay like a tree so this is a hamatom matus polyp and this Syndrome has been asked many times PUD jger syndrome many many times this has been asked in the fmg exam this is because of lkb1 stk1 gene on chromosome 19 jum is the most common site and you will see peroral melanosis in these patients you're going to see perioral melanosis in these patients a 36y old male comes with passage of blood and mucus in the feces sigmoidoscopy you can see rectal inflammation on biopsy Crypt abscesses are seen so crypsis you should know that we are dealing with ulcerative colitis in ulcerative colius rectal involvement is more common in Crohn's disease in Al involvement is more common ulcerative colitis is continuous spread whereas Crohn's disease you will get skip lesions in Crohn's disease both are inflammatory bubble diseases patient is suffering from inflammatory bubble disease patient comes with peritonitis and perforation of the ilium how should this patient be managed so because the patient has come with peritonitis and perforation and there is inflammatory bubble disease the best would be to carry out an iosi and to carry out definitive surgery later 70-year-old male comes with bleeding per rectum there is a mass suspicious for cancer what will you suspect what will you suggest so if you have a suspicious growth in the rectum and we want to confirm the diagnosis what will we do sigmoidoscopy or colonoscopy so in these patients we should carry out a colonoscopy because we should see the entire colon sometimes there can be multiple tumors so it's worthwhile seeing the entire colon 3day old child comes with greenish yellow discharge from the umus what is the most likely cause so greenish yellow discharge from the amas this persistent Amal end of vitillo intestinal duct so what is this vtil intestinal duct this vtil intestinal duct joins the small bbel with the umus this is the vitellointestinal duct now normally this vtil intestinal duct closes if it is persistent if it is persistent then there will be feal matter through the umus right if the intestinal end is persistent then this we've discussed will become meal diverticulum and if the umal end is persistent then the patient can come with greenish yellow discharge so these are the three things which can go wrong with the vitellointestinal duct what if they say that the child is coming with urine from the amus then it is because of Urus persistent Urus 5-year-old child is brought with chronic constipation patient is taking stool softeners and patient is able to pass stools there was delayed meconium what should be done to confirm the diagnosis so chronic constipation delayed passage of meconium we should suspect hrung disease and hpr's disease we should do barium enema and manometry that is what should be done this is congenital megacolon and in these patients the definitive diagnosis will be made using definitive diagnosis is made using rectal biopsy so the next question is identify the condition based on the image like I said this one question from perianal disorders is definitely asked and you can see that there is an absis here and there is p discharge so if a perianal absis forms and then it starts discharging that becomes a perianal fistula so an if you don't drain an absis properly it becomes a perianal Fula I'll just show you the images of other perianal disorders which you should know about this is rectal prolapse this is pylon nidal sinus also known as Jeep driver disease where you can get multiple multiple abscesses and sinuses but they are in the natal Clift not around the anus but slightly above that that is how you differentiate between a perianal Fula and pilonidal sinus these are thrombos piles this is a Fisher with a skin tag and only in chronic anal fissures chronic Chic anal fissures will you see a skin tag this is going to be painful whereas usually bleeding in hemorrhoids is painless a male patient comes with itching in the perianal region and soakage of his undergarment with purin discharge you have to diagnose the condition this is a perianal again I told you perianal fisha you can see multiple openings here this is perianal fish the classification of perianal fish has been asked this was asked last year only it is the parks classification you should know the parks classification is for peral fish and the most common is inter sphincteric type inter sphincteric type is the most common recently questions from rectal prolapse surgery are being frequently asked and they had shown an image and they had asked which surgery is being carried out this is the wiring where we are doing a purse strings where we are taking a purse string suture so you should be aware of this image per string suture is being taken you don't need to know a lot of details just know that this is the wiring where we take a Pur string suture this is a perenial procedure for rectal prolapse this is known as dilom procedure and this is rectopexy rectopexy is an abdominal procedure this was asked in non fmg exam so just knowing these three procedures and the image is enough it has not been asked in the fmg exam as yet very important are gallstones invariably gallstone questions are asked like I said ultrasound is the investigation of choice and you can see a shadow here post acoustic shadow so we know we are dealing with we know we are dealing with G Stones porcelain gallbladder is when there is calcific of the wall of the gallbladder and this can increase the risk of cancer in these patients a patient has findings of gallstone abutting the cystic duct with dilation of the common hepatic duct what is the most likely diagnosis this you need to understand this has been asked a couple of times this is Miry syndrome this has been asked this is Miry syndrome so in Mir syndrome what happens is that the gallbladder becomes adherent with the common bile duct so gallbladder is adherent with the common bile duck and because it is adherent the stone pushes against the common bile duck when the stone pushes against the common bile duct the common hepatic duct becomes dilated and finally a fistula will form between the gallbladder and the common bile duct this is known as mirizzi syndrome you should also know about regas Triad regas Triad is seen in gallstone ilas gallstone ilas is when a gall stone causes Bop obstruction this is secondary to a Kyo deodal fistula so the gallstone comes down from the gallbladder into the deum through a fisha and the most common side of obstruction is the terminal ilium or the last 60 cm of ilium you get regas triad regular Triad you will get num numilia that means air in the Beary tree you will get small intestinal obstruction which you can see here and you are going to see a radio opaque Shadow we see a radioopaque shadow in right ilc fosa so these are the three things which we see in reg's Triad a patient underwent a lap colist ectomy and in the post-operative period he develops fever and tachicardia counts are raised and ultrasound shows a collection in the right hypochondrium so the surgery was done gallbladder was removed from the right hypochondrium now there is a collection there means there is a leak and if there is a leak the first thing which we are going to do is we are going to put a pigtail catheter to drain the collection now this is a very important slide this slide will fetch you at least two questions in your exam so it's very important that you memorize this Slide the investigation of choice for gallstones is ultrasound gall stones is ultrasound we I told you post acoustic shadowing for CBD s it is MRCP what is MRCP MRCP is magnetic resonance cango pancreatic graphy so it is a type of an MRI which is being done for bilary disorders right MRCP for CBD microlites this you don't need to remember for fmg is e endoscopic ultrasound the gold standard to detect CBD stones and to treat them is ercp this is er ercp now in the fmg exam they had also given an image of ercp and they had asked you whether this is ercp or MRCP so how do we differentiate the two in ercp you will always see this endoscope in the image you will always see the endoscope MRCP you are not seeing the endoscope ercp you will always see the endoscope and ercp is both d agnostic and therapeutic whereas MRCP is just diagnostic so small B leakage after kcty patient is stable we'll just monitor symptomatic patients with B leak after kcty within 3 days we re-explore after 3 days we are going to put in a pigtail a patient comes with multiple Gall Stones Under goes an ultrasound CBD diameter is 12 mm CBD is dilated serum B Rubin is raised Alp is raised what is the next step next step in this patient is going to be MRCP I told you to pick up CBD Stones we will do MRCP in these patients which of the following is not a feature of pumo Peroni so pneumo Peroni we create when we are doing laparoscopy and laproscopy you will get raised intracranial pressure and not reduced Ed intracranial pressure so whenever we do laparoscopy 10 to 14 mm of mercury is the pressure when pumo Peroni is created you should know that sinus bradicardia initially there is bradicardia that is the most common arhythmia please remember that initially there is Brad Guardia due to vagal stimulation there can also be hypotention in these patients the diaphragm is pushed up so the thoracic volumes are reduced but the intracranial pressure is going to be increased in these patients very important which instrument is used for creating pumo Peroni this has been asked TIN number of times this is the varies needle all of you should know how to identify the varies needle you have a stop valve here and you can see it has a belled edge so this is a various needle used for creating pumo Peroni this is again a various needle for pumo Peroni this is a sharp trokar which is used during laparoscopy these are the laparoscopic instruments this is robotic surgery which is the latest thing which is being done and this is Sills that is single incision laparoscopic surgery but from laparoscopic surgery the most important question is varies needle which you people should be able to identify last year's exam they asked an alcoholic patient comes with severe abdominal pain pancreatitis is suspected and you have collection around the pancreas which enzyme is most likely to be elevated so we know initially lipase and amas are going to be elevated so whenever we are suspecting pancreatitis we will send out lipas and Ames identify the operation shown very very important last 2 years this question is definitely being asked that is vipp surgery so vipp surgery is pancreatico diod denomy and Whipples is done for per ulary cancers rooftop or Chevron incision is done and three anastomosis are there look carefully three anastomosis gastrostomy kid Doo josi means bile duck and jum and pancreatic oosi three anastomosis are done in bipples procedure the most common complication is anastomotic leak most commonly which leaks is the pancreatico jomy now please again this image you should be able to identify for the exam 25-year-old alcoholic male comes with pain in the epigastrium radiating to the back on examination there is a lump palpable in the EP gastri so I told you pain in the epigastrium radiating to the back pancreatitis and you see a lump as well on CT this is a pancreatic pseudois the most common site for pancreatic pseudois is the Lesser sack so you should be able to identify this clinical stem and the CT this was also asked in the fmg exam you have to identify the condition you can see that the pancreas is wrapping around the deod this is anular pancreas anular pancreas forms when the vental pancreatic butd fails to rotate right when vental pancreatic but fails to rotate anular pancrea is going to form there's going to be circular tissue around the second part of deinum patient is going to come with projectile vomiting again double bubble sign will be seen we've already discussed conal diaphragmatic hernia I've told you bokic is more common this was also asked in the fmg exam review the image and identify the condition you can see this is a paramal hernia right this is an incisional hernia this is epigastric hernia because it is coming out through the epigastrium how do we differentiate umal from paramal hernia umal hernia the amus is inverted right here you can see in this question the amus is not inverted here the amus is inverted okay amus has come out this is paral hernia where just one amus is forming one of the boundaries of the hernia right so you look at this this image and this image are similar but that is why it is paramal hernia and not Amal hernia and paramal hernia small opening so it can undergo strangulation a newborn is found to have herniation of Babel and liver through the amas which is covered with a membrane so what is the diagnosis so there are two conditions in a newborn omalos seal and gastrochisis omalos is through the umus covered by a membrane and liver can also herni it so you can see the child is born all this defect is come out through the umus liver also you can see but it is covered by a membrane so the answer here is going to be omalos gastrosis is not covered by a membrane it is adjacent to the umus that is gastrochisis so these are the abdominal wall defects which you should be aware of so the first question is that which cancer can develop in long-standing Venus ulcers you know that Venus ulcers can be seen in patients with varicose veins and the options are basil cell carcinoma malignant melanoma Squam cell carcinoma and angos saroma so the correct answer here is quam cell carcinoma and you know such an ulcer which develops in long-standing Venus ulcers is known as a marolin ulcer so long-standing Venus ulcers and burn scars can undergo malignant change and the name marelin alcer has been asked multiple times in the exam so please remember this this margul Lin ala is usually a Squam cell carcinoma and how do we identify a SCA cell carcinoma it is going to have raised inverted margins the the image of marelin ulcer was asked in the last year's fmg exam so you should know the image as well it will be in the region of a scar there are usually one to two questions from skin cancer so I'll just briefly tell you about skin cancers as well the other one which has been asked in your exam is basil cell carcinoma this is also known as a rodent ulcer very important known as a rodent ulcer and it has pearly white margin right it has rolled out pearly white margin so squas had raised diverted cauliflower like margin basal cell carcinoma has rolled out pearly white edges and the important thing is why do we call it a rodent tuler because it buries it Burrows locally it invades locally right but lymphatic and distant spread is uncommon so this point has also been asked in the exam another point which has been asked the most common side for basal cell carcinoma is the face above the line joining the angle of the mouth to the ear lobule that above this line is the most common side where basil cell carcinoma can occur malignant melanoma there are certain on liners which have been asked you should remember these four on liners which have been asked in the exam the most common type is superficial spreading type the best prognosis is of lentigo malna Leno malna is type of an nc2 melanoma it does not invade verse prognosis is of nodular melanoma and the most common melanoma in dark skinned patients this has also been asked in your exam is acryl melanoma so remember these four points in a melanoma another point which has been asked what are the changes which can be seen in a pre-existing mole which will tell me that that mole is getting converted into a malignant lesion so you can remember this as AB B CDE e this has been asked a is for asymmetry B is for irregular borders C is for change in color D is an increase in diameter of the lesion if it becomes more than 6 mm and E is if it is evolving change in size shape color so if you not noce ABCDE changes in any pre-existing mole then that can be a pointer that it is getting converted into a malignancy so this was regarding the first question the next question which we have to discuss is which one of the following is not an indication for leomy you know leomy is opening up the abdomen in a patient with penetrating abdominal trauma now the key word which we have to remember but here is penetrating you know there can be two types of abdominal traumas commonly blunt and penetrating they are talking about penetrating trauma so the options are presence of rebound tenderness by leakage wound superficial to Peroni and tag of momentum hanging out correct answer here is wound superficial to the Peroni we don't do a lioy immediately in these patients look presence of rebound tenderness you know rebound tenderness is a sign of peritonitis so if there is peritonitis we definitely have to operate the patient B leakage means that either the babble has been injured or there's been some other bilary tree injury you have to explore the patient and Mum hanging out means the Peroni has been breached only if the Peroni has been breached reach then only the momentum is going to come out so if that happens you have to explore the patient so please remember if you have a penetrating abdominal wound just remember any wound superficial to the Peroni above the Peroni you can just suture the wound and send the patient for a CT for further evaluation you know cctt is contrast and CD scan but if there is a peronal breach that means the Peroni has been breached okay in that case we have to do a leomy especially if there's peritonitis if the umum is hanging out or if there is bile staining of the dressing the next question is a straightforward question asked multiple times the most common organ injured in penetrating abdominal trauma so the correct answer here is liver and you should remember these on liners these onliners have been frequently Asked in the exam so another question is which is the most common organ injured in seat Bel syndrome this is also been asked in seat Bel syndrome the answer is mentry of the bubble so please remember these on liners they've been asked quite frequently in the exam the most common organ injured in Blunt abdominal trauma is spleen penetrate has changed and please remember this penetrating liver is more common than small intestine GSW is gunshot wound gunshot wound to the abdomen the most common organ injured is the small intestine seed Bel Syndrome has also been asked seat Bel syndrome can occur if you're wearing a seat belt and suddenly the there you apply the brakes so you will move forward the seat belt will will push you back so the organs get compressed between the seat belt and the vertebra that is seat belt syndrome it is again the mentry of the bbel deceleration injury is the DJ flexure that is deodo jenal flexure and overall the most common organ injured is spleen another question which has been ask what is the most appropriate time to give antibiotics before surgery this has been asked multiple times and options are at the time of induction of anesthesia 30 minutes to 1 hour before surgery 4 hours before surgery after skin incision the correct answer here is 30 minutes to 1 hour before surgery earlier the answer was induction of anesthesia but the latest guidelines say that 30 minutes to 1 hour before surgery is when the profy actic antibiotics should be given so please remember these important points prevention of Mo infection is commonly asked and it usually you have one question from this topic so you need to know that prophylactic antibiotics the best time is 30 minutes to 1 hour before surgery the repeat dose in case of prolonged surgery can be given after 4 hours this has not been asked in the fmg exam as yet but can be asked in the future the other methods to reduce wound infections the best method you know is hand hygiene is washing of hands and another question which has been asked in your exam when you have to remove hair from an operative site please remember no shaving shaving increases the wound infection rate these days we do clipping of hair using a hair clipper so no shaving clipping of hair should be done using a hair clipper another common question in your exam is regarding granula so they've asked the best treatment for a ranula options given were incision and drainage aspiration of the swelling excision of the submandibular gland and excision of the swelling plus the sublingual gland so the correct answer here is excision of the sublingual gland and the swelling so ranila you know is it is a mucus extravasation sis please remember extravasation involving the subl salivary gland the image has also been asked in the exam so you should remember the image you can see that it presents as a cystic swelling in the floor of the mouth and this cystic swelling is brilliantly trans luminant they've also asked in your exam what are the other brilliantly trans luminant swellings you know of so the other brilliantly trans luminant swellings can be a lymphoma or a cystic hygroma right you can also have epidermal cyst and sometimes hydril can also be brilliantly trans luminant hydril are trans luminant but brilliantly transilluminate are usually lymphangioma or cystic hygroma ranila and epidermal Cy the management of a ranilla is excision of the sublingual salivary gland and the swelling another treatment option for vanilla which has also been asked in the exam is marsupialization so this is another treatment option for ranas marsupialization can also be done please remember no incision and drainage for ranilla otherwise there is a high recurrence rate this question has also been asked previously the most common type of renal Stone so the most common type of renal stone is calcium oxalate Stone just briefly about renal Stones calcium oxalate is the most common type of renal stone and you know it is formed in acidic urine it is radioopaque you know that 90% renal stones are radioopaque and calcium oxalate stones will have speculated margins it has sharp margins which is why it presents early another stone is stuite or stagon Stone it is also known as triple phosphate Stone this has also been asked and the question which has been asked that this triple phosphate or stuite or stagon stone is seen in infected or alkaline urine and the organism responsible is proteus this has been asked in your exam other types of stones sine stones are also radioopaque and the question which has been asked there the hardest stones and you cannot break them by eswl the full form of eswl has also been asked in your exam it is a method to deal with renal Stones it is known as extra corporeal Shockwave lithotripsy so extra corporeal Shockwave lithotripsy is eswl that is eswl you should know the full form extra corporeal shock wave lithotripsy uric acid stones are the most common radiolucent stones and they can be seen in gout and talisis syndrome another question is which is the investigation of choice to diagnose renal Stones options are cect X-ray KU ncct that is non-contrast CT and ultrasound so what do you think is the correct answer the correct answer is non-contrast CT scan ncct and you should know three areas where ncct is the investigation of choice so non-contrast CT scan is the investigation of choice for renal Stones salivary gland stones and head trauma renal stones and head trauma both have been asked in the exam the investigation of choice please remember it is not contrasting and CT scan it is noncontrast CT scan ncct the next question which you should know about hydral in a child is best managed by so congenital hydril the treatment is herniotomy please remember this the treatment for congenital hydril is herniotomy this has been asked multiple times so the most common type of hydrosil is known as vaginal hydrosil right and primary vaginal hydril is the most common type primary vaginal and the treatment for primary vaginal hydral there are two procedures you can either do Lord pation or you can do iversion of Sac or jabas procedure so this is for vaginal hydril and I've told you normal vaginal hydril primary vaginal hydril is trans luminant congenital hydrosil on the other hand congenital hydril is when the sac when the sac is going to communicate with the peronal cavity so there is this is congenital hydrosil in this you have a patent processus vaginalis that means it is communicating with the peronal cavity and there is invariable a hernial sack present as well so in these patients we are going to carry out in these patients we will carry out a herniotomy as treatment this has been asked multiple times in the exam please remember this herniotomy is the treatment in these patients the next question is that you have a 25y old lady who complaining of discharge from the breast but it is from a single duck and it is bloody discharge so they've asked the most appropriate treatment options are radical excision microdochectomy mastectomy or a biopsy to rule out cancer right so which condition are we talking about you know the most common cause of bloody nipple discharge from a single duct is a duct papilloma is a duct papilloma that is the most common cause of bloody nipple discharge from a single duct so the treatment when you have a single duct involvement is micro ectomy micro ectomy you know is removal of a single duct and the lump that is microdochectomy so greenish nipple discharge can be from multiple ducts it is seen in duct Tasia and because multiple ducts are involved we will carry out had Fields procedure or cone exision of all the duct right so when multiple ducts are involved that is usually in duct Tasia all the ducts are removed that is known as head Fields procedure but if a single duct is involved single duct bloody nipple discharge you will get induct papiloma that is the most common cause and because 10% duct papilomas can be associated with dcis you know what DCI is dcis is ductal carcinoma in C2 right noninvasive cancer so in this case we will do a micro dctom that means removal of a single duct and the lump okay so that is what we carry out to De to diagnose a ductal papilloma we do an ultrasound if an ultrasound is inconclusive we will do an MRI this was a question in last year's exam the most common vein used for Central vein catheterization the answer here is internal jugular vein very important question can be asked again you know Central Venus lines the most common vein is internal jugular vein subclavian vein is commonly used when you have to give tpn for a long duration tpn you know is total parental nutrition when you are giving nutrition through the IV line you would you can use the subclavian vein commonly there is increased risk of pumo thorax when you're inserting a subclavian line right and great saus vein is not used for Central Venus catheterization but it is used for Venus cutdown Venus cutdown or Venus section is done in trauma patients if you're unable to insert an ivy line there you can do a Venus cut down and the great saus vein is the most common vein used there so invariably there is one question from sutures in your exam and the question here is which one of the following is not an absorbable suture right options are polyglactin polypropylene polyone and catgut so the answer Here Is polypropylene polypropylene you know is Proline and Proline is a nonabsorbable suture the others are all absorbable sutures polyglactin you know is known as vcil and this vcil it dissolves in 60 to 90 days this has also been asked in your exam polyone is PDS it is also an OB absorbable suture but this has double the absorption time as Vil 180 days and Cat gut and chromic Cat gut are also absorbable sutures another question which has been asked cat gut is deriv from not the gut of cat but it is arise from sheep gut right so not cat gut it is actually from sheep gut so sutures can be absorbable or non-absorbable absorbable sutures can be further divided into natural and synthetic I've just told you cat gut is derived from sheep gut from the sub mucosa synthetic absorbable sutures are monoc best for subcuticular suturing Vil I just told you is polyglactin dissolves in 60 to 90 days this is also been asked nonabsorbable sutures can also be natural and synthetic natural non-absorbable sutures all of you are familiar with silk synthetic non-absorbable sutures Proline Proline Is polypropylene very important Proline you should know the uses it is used as the hernia mesh the hernia mesh is made out of Proline sutures also it is used for vascular repair to repair V vessels you use Proline sutures and it is used to close the Rector sheath this is also been asked in the exam right so these are the uses of Proline sutures ethylone or nylon is also a non-absorbable suture used for skin suturing now invariably you have one or two instruments the images are given and they ask you to identify them this was asked last year they had asked you to identify this instrument and if you've ever been to the theater you can easily ident identify this as a curved artery forceps so you can see it is curved right so you can have curved or straight artery forceps this one is curved and you can see that these are there are these serration which are present there so serration are present you can either have a curved artery or a straight artery forceps the name suggests that you can hold a bleeding vessel with this right the other option this one was an Ali tissue forceps this is also been asked how do you identify Ali tissue forceps you will see these teeth at the tip right and because there are teeth there it can cause trauma so you will not use it in delicate structures you will use it at you you will use it to hold tough structures like the sheath or the fascia you will not hold delicate structures with alleys forceps this one is a backcock forceps you can see the difference from alleys there are no teeth here it is the there is some space between the two handles so you can hold a tubular structure using Babcock forceps right like the appendix or the fallopian tube can be used can be held using a bapc forceps this is a sponge holder so see the difference between Bap coocks you know you there is some space it is slightly curved this is a sponge holder and you hold a sponge using a sponge holder and then you clean the area so you must have seen the surgeon before starting any case they clean the area they hold the sponge using this sponge holder so all these instruments have been asked you should remember these another question which has been asked frequently in your exam what is the utility of the instrument shown in the image so this instrument you have to identify the utility options are to make an incision no we use a blade to make an incision right split thickness skin grafting is the correct answer here it is used for split thickness skin grafting and this instrument is known as a Humes knife asked many times in the exam right you know the difference between a graft and a flap a graft is one which does not have its own blood supply flap has its own blood supply right so you know that skin grafts can be of two types you can either have split thickness skin grafts or full thickness skin grafts split thickness skin graft as the name suggests it is thin it is also known as The graft full thickness is thick it is known as Wolf's graft split thickness skin graft has epidermis and part of dermis very slight area of dermis can also be there and the most common donor site is the thigh for a split thickness skin graft full thickness skin graft has epidermis and dermis and please remember we can use the post oric skin but we never use the axilla for full thickness skin grafting and and to raise a split thickness skin graft we use a Humes knife so the last question which I want to discuss in this module is regarding GCS it is very very important invariably there is one question from glasgo Coma score in your exam so the question here is that a 25-year-old male meets with a road traffic accident and the ambulance brings the patient to the emergency room his vitals are stable and he opens his eyes to painful stimulus he's abusing the doctors and his limbs go into abnormal flexion on painful stimulus so you need to memorize the GCS score you know it has three components eye opening verbal response and motor response and if you add them up here the score turns out to be eight how so you can see that eye opening is to painful stimul simus that is E2 right he's abusing the doctors or abusing the nurses means in appropriate words so common in head injury patients common in patients who are under the influence of alcohol so V3 inappropriate words and abnormal flexion that is another three this is abnormal flexion or decorticate rigidity so the score here is eight you know the minimum GCS score is three and the maximum GCS score is 15 so please remember the GCS score so by discussing these 15 questions I've told you a lot of points other than the questions itself so please make a note of these points for your upcoming fmg exam best Imaging reporting and Data Systems right I'll repeat again breast Imaging reporting and Data Systems this is a method to document any breast radiological scan which is done okay so we have to find out the false statement not true means we have to find out the false statement here it is applicable to mamogram ultrasound and MRI this is true all birads for lumps need to undergo true cut biopsy I'll just show you that bats four are suspicious lumps and all suspicious lumps require a true cut bips a to rule out cancer this is also true bat's three lumps should be followed up with repeat Imaging tests after 3 months right so byat 3 is probably benign and we keep the patient under shortterm followup but the shortterm followup is after 6 months and not 3 months so this is a false statement and bat zero is incomplete test where you can't make out what is the actual problem there and then there you need further Imaging so the correct answer here is c for bats 3 six monthly followup is required this byat table has been asked many many times in the exam so you should know about this byat zero is incomplete I just told you so supposing somebody's had a mamogram and it comes out as byat zero then you need to do additional tests like ultrasound or MRI in these patients so that is what we do in birad zero byad 1 is negative and there's nothing wrong there you call the patient after 1 year bads 2 is benign again you call the patient after one year no biopsy birads 3 has been asked many times probably benign short-term followup after 6 months is recommended all birads four lesions which are suspicious require a true cut bypc please remember not an fnac the investigation of choice for a breast lump is true cut or core needle biopsy it is not fnac please remember this byat 5 is highly suspicious of malignancy again a true cut biy is required the next question is which does not classify as a locally Advanced Breast Cancer so one question regarding staging is asked in almost every exam and breast cancer and oral cancer stagings have been asked the most number of times so you should know them by heart these two staging should be very clear right so the correct answer here is tumor more than 4 cm locally Advanced Breast carcinoma by definition is any tumor which is T3 N1 m0 right any T4 NE N2 that is fixed or matted nodes or any N3 that means infraclavicular or supraclavicular lymph nodes so these comprise locally Advanced Breast Cancer you know that inflammatory breast cancer is T4 D so this is locally Advanced chest wall involvement is T4 a this is also locally Advanced and skin involvement is T 4 B right so you need to know this that these are locally Advanced tumor more than 4 cm is not locally Advanced so this is the tnm staging the important things you should know that T1 is a tumor less than equal to 2 cm T2 is more than 2 but less than equal to 5 cm T3 is more than five T4 a is to the chest wall but what is the important thing which has been asked in the exam that involvement of the pectoralis muscle is not chest wall involvement please don't make this mistake a lot of students mark this wrongly in the exam involvement of the pectoralis muscles is not chest wall involvement doesn't make it T4 please remember this t4b is involvement of the the skin and only three things classify skin involvement orange peel appearance of body orangan ulceration and satellite nodules so three things orange peel appearance of aun satellite nodules or ulceration retraction and dimpling are not signs of skin involvement please remember this retraction and dimpling not signs of skin involvement and t4d is inflammatory breast cancer so this is the T staging you should know this by heart the next question is that a patient under goes pared surgery and after a few months the patient starts complaining of sweating over the pared region while eating food right so they're sweating over the pared region while eating food which of the following statements is not true regarding this condition so first of all you need to know what is the condition which we are talking about this is known as phrase syndrome asked many times in the exam phrase syndrome or gustatory sweating right that means when the patient eats food there will be sweating over the region of the pared and we have to find out the false statement here so oracular temporal nerve is implicated this is true mostly involved are the parasympathetic fibers this is also true it can be prevented by proper dissection during surgery to avoid injury to the oricle temporal nerve this is false it is not because of injury to the oracular temporal nerve that this condition develops in fact if the oracular temporal nerve is injured then this condition will not develop so this develops because when we remove the superficial lobe these nerve endings which are left they grow up till the skin they grow and they start supplying the skin so whenever the patient eats food these nerve endings will now stimulate the sweat glands over the skin and there'll be sweating there right so the prevention of freay syndrome if you want to prevent freay syndrome we want to put something between the skin and these nerve endings so if you put a muscle flap like a digastric or a stocor muscle flap to cover this right if I cover this bed with a digastric or a stocl asteroid flap then phase syndrome will not occur Botox can be used in the management of this condition this is true so the correct answer here is C this is important for the exam another question in last year's exam and this was a very good question how do we know about deep lobe involvement on clinical examination so in for rotted you know there is a superficial lobe and there is a deep lobe if the Deep lobe is enlarged the tonsillar fosa on that side if you ask the patient to open the mouth the tonsillar fosa will be pushed medially if the Deep lobe is involved of course the confirmation is by Radiology the next question is a few days following viral fever a 50-year-old female presented with pain in the neck fever malaise and a firm enlargement of both the thyroid lobes thyroid antibodies were normal and serum T4 was high normal most probable diagnosis so here the clinch the Clincher here is the thing which we can with which you can clinch the diagnosis here is the viral fever right so V after viral fever swelling in the neck that is a Telltale sign of that is a Telltale sign of granulatus thyroiditis okay Telltale sign of granulatus thyroiditis also known as Subacute or viral thyroiditis so Subacute Deans or viral thyroiditis this is also known as granatus thyroiditis can occur after upper respiratory tract infection four to 6 weeks later there can be a lymphocytic infiltrate and that lymphocytic infiltrate can destroy the follicles and the stored hormone is released that is why T4 can be T T3 T4 can be raised initially after that because the follicles are destroyed there is hypothyroidism but gradually over 2 to 3 months the follicles regenerate on their own so this is a self-limiting condition it starts after a viral infection but after 2 to 3 months the patient is fine patient is going to have a painful neck swelling that is the key and upper respiratory tract infection these are the two key words which you should look for and the management is mainly symptomatic and you can put the patient on steroids if the symptoms are severe you know that the most common thyroiditis is Hashimoto also known as lymphocytic thyroiditis in aimoto or lymphocytic thyroiditis it is autoimmune Auto antibodies are there and here there is prolonged hypothyroidism okay in viral or dear ones it was self-limiting recovery was happening on its own here there is prolonged hypothyroidism in hashimotos okay and you can find raised Auto antibody levels Auto antibody levels will be raised in hashimotos so the next question is that a 45y old female de presents to the opid with a thyroid swelling for of 3 months duration there is rapid increase in size of this thyroid swelling and patient gives a history of a similar thyroid swelling in a father fnac reveals aoid Rich troma this question has been asked many many times diagnosis so am myoid R stroma you know is a classical sign of medary thyroid cancer so this is the slide which has also been asked and you know this pinkish material is amloid so if you get amloid on a thyroid epiny specimen it is medary carcinoma thyroid and you know medary carcinoma thyroids sporadic tumors are more common than familial and familial tumors this is also been asked familiar tumors are seen in men 2A syndrome what is men men is multiple endocrine neoplasia syndrome so Men 2 syndrome is where you can see medular thyroid cancer and the most aggressive medary thyroid cancer is seen in men Tob this question has also been asked and medary thyroid cancer can show both lymphatic and hematogenous spread this slide of papillary thyroid cancer has also been asked many many times in the exam and these bluish bodies somoma bodies at least 10 to 15 times this question has been asked these are folky of distopic calcification you know there are two types of calcifications dropic and metastatic these are distopic calcification bodies somoma bodies and they can be seen in papillary carcinoma thyroid you should also know the other tumors where they can be seen that is also been asked Mena cus cadino carcinoma of the ovary so I'm repeating menoma prolactinoma cus cadino carcinoma of the ovary cus tumors of the pancreas and papillary thyroid cancer also papillary variant of renal cell carcinoma so these are the various places that somoma bodies can be seen also you can see orphan anid nuclei papillary thyroid cancer is the most most common thyroid cancer also has the best prognosis most common and the best prognosis which of the following statements regarding Venus ulcers are true except so we want to know the false statement regarding Venus ulcers longstanding Venus ulcers can develop into marolin ulcer true this was asked last year marolin ulcers are Squam cell carcinomas in long-standing Venus ERS ambulatory Venus hypertension theory is the most acceptable Theory correct all varicose ulcer should be treated with antibiotics this is false this is the wrong statement only infected Venus ulcers need to be treated with antibiotics otherwise you don't give antibiotics neither oral nor topical and Vac dressing you know vac dressing is negative pressure or vacuum or suction dressing can be used in nonhealing Venus ulcers after de Brightman this is also true so the correct answer here is C this is a Venus uler the most common site has been asked it is the gator area Gator area or the medial malus the region of the medial malus is the most common side for a Venus salsa and the treatment is regarding the bisard's regime where we educate the patient we advise limb elevation elastic compression stockings dressings have to be done I'm again repeating only infected patients require antibiotics otherwise you don't need to give antibiotics and surgery long-standing Venus ulcers this image was asked last year in the exam margerin ulcer can develop it is a Sarma cell carcinoma in long-standing Venus ulcers or burn scars another very common question asked in the exam is most common mediastinal tumor and the correct answer here is Thoma this has been asked many times this is the most common mediastinal Mass it is in the anterior mediastinum the most common mediastinal mass and children are neurogenic tumors which are seen in the posterior mediastinum right this has also been asked so you should know these two points regarding mediastinal tumors very very important question for the exam is regarding IV lines so you have a 32ye old trauma patient after road traffic accident and the patient has a blood pressure of 0 systolic and pulse rate of 110 so of course there is hypotension and tachicardia we need to give this patient fluids quickly so which IV line are we going to use so it is called common sense that if I want to give fluids quickly I need a wide bore I need a thick IV line so that fluids can go quickly not a narrow one so which is the thickest one out of all of them all of these options gray so you need to remember the color coding orange is 14 that is the thickest or widest bore gray is 16 green is 18 pink is 20 blue is 22 yellow is 24 so the widest bore is 14 and the narrowest is 24 which is why 24 gauge canas are used in children where they're thin veins narrow veins but the flow rate is also less whereas with an orange or a gray canala because they are wide bore the flow rate is very quick right so when the patient is dehydrated or you want to give Fast fluids use a wide bone or canala invariably in every exam there is a question from shock so you have a 70 kg male who's come to the emergency following a stab injury to the abdomen his pulse rate is 110 and his BP is 90 by 60 so again tachicardia and hypotension is there what percentage of blood volume has he lost so you know that hypotension will develop in class three shock class three hypo shock is when you will have hypotension systolic BP will fall and I've told you that you can remember the the percentage of blood volume lost like the scoring of a tennis game so class one is going to be 0 to 15% Class 2 is 15 to 30% class 3 is 30 to 40% right and class 4 is more than 40% and I've just told you that hypotension is seen in class three shock so the correct answer here will be 30 to 40 so this is the table I've just told you this is the table so class 1 is less than 15 Class 2 is 15 to 30 class 3 is 30 to 40 and class 4 is more than 40 remember it like the scoring of a tennis game hypotension systolic BP is going to fall for the first time in class three shock and the other thing which you should know tachicardia is the earliest feature of hypovolemia tachicardia is the earliest feature of hypovolemia but systolic BP falls for the first time in class class three shop and in class three the patient will have hypotension the patient will also be confused and these patients you need to give crystalloids and colloids both you need to give fluids and you might also need blood products in class three which is the most common vessel used for intraarterial BP monitoring so if you go to the ICU intraarterial BP monitoring is done in patients who are very critical and the radial artery is used most commonly but before using the radial artery there is one test which you need to do that test is known as the Allen test only after the Allen test will you use the radial artery for intraarterial BP monitoring what does the alen SS tell us alen B test tells us the patency of the radio alar communication whether the radial and the alar arteries are communicating with each other or not if they are not then we don't use the radial artery otherwise there can be compromised blood supply to a certain segment of the hand which is the most common vessel used for Central catheterization this was asked last year in the exam a very important question the correct answer is internal jugular vein so internal jugular vein is the most common vein used for Central Venus catheterization right subclavian vein has the highest risk of pneumothorax when we use for Central Venus catheterization femoral vein has the highest rate of infection or thrombosis and great saphenous vein is not used for Central Venus catheterization it is for Venus cut down so internal jugular vein is the most common veins subclavian highest rate of pneumothorax femoral highest rate of infection or thrombosis and great saus vein is used for Venus cutdowns the next question is the most common cause of mortality following trauma so the most common cause of mortality following trauma is head injury this has been asked many times in the exam you can see here that there is a trimodal distribution of mortality following trauma the first spike is at the time of impact and mostly deaths are due to severe head injury unfortunately these patients are going to die at the sight of injury you cannot save them but the next group the cause of death is within 1 hour right and the common causes are Airway obstruction tracho bronchial injury open and tension pumo thorax circulatory arrest and cardiac tamponade and hemothorax so these injuries if the patient receives proper care within the first hour these injuries can be prevented which is why the first hour following trauma is is known as the golden hour following trauma so proper attention during the golden hour can save lives and trauma patients this question has also been asked in the exam another very very important topic is glasgo Coma score all of you should memorize the glasgo Coma score for your upcoming exams so you have a 32ye old male who brought to the emergency following a road traffic accident he's opening his eyes to painful stimulus and uttering inappropriate words on painful stimulus he's able to localize pain from the left side but his right hand goes into abnormal flexion what is his GCS score right so please remember here here we know that e painful simulus is to okay inappropriate words in appropriate words is going to be V3 and the patient is able to localize pain and the other hand is going into abnormal flexion so the concept here which I want you to remember which has been asked that the highest motor response is to be considered so the correct answer is going to be E2 V3 M5 highest motor response is always considered okay so this is the GCS scoree you need to memorize this motor response M6 is obeying commands M5 is localizing M4 is withdrawal M3 is abnormal flexion abnormal flexion is also known as decorticate rigidity M2 is abnormal extension or decerebrate rigidity and M1 is no movement verbal response V5 is oriented normal speech V4 is confused V3 is inappropriate words when say the patient is abusing V2 is incomprehensible sounds the patient only mumbles no words come out and V1 is no response eye opening spontaneous is E4 to speech it is E3 to pressure or pain E2 and no eye opening is E1 you know the maximum GCS score is 15 and if the patient is incubated if you have an incubated patient then we write it as VT and VT is equal to 1 it is given a score of one although the new GCS score will write it as V NT non testable right this is the latest one the latest update if the patient is intubated you will write it as VNT non- testable but if VNT is not there in the options you can Mark VT also and VT is given a score of one this is also a very important question you have a 20-year-old boy following a road traffic accident pulse rate is 100 per minute BP is 90 systolic right so Tachi cardia and hypotension his saturation is low and respiratory rate is high there is decreased breath sound on the right side and a hyper resonant note on percussion so hyperresonant node what does that mean does that mean that there is air or liquid inside yes air because in liquid you are going to get a dull note on percussion so this is the classical description of tension neumotorax because there is altered hemodynamic status that means there's tachicardia hypotension and there is hyperresonant note on that site so tension neumotorax is the correct answer you can see in this x-ray you can see tension neumotorax this is the site where pneumothorax is there and there is a mediastinal shift to the other side so you will get a hyper resonant percussion note here the Emergency Management is needle thoracocentesis asked many times in adults it is done in the fifth intercostal space in the mid axillary line so this is an update it is done in the fifth intercostal space in the mid auxiliary line in adults now in children it is done in the second intercostal space in the midclavicular line right children second intercostal space mid cicular line the old one only and the definitive management is we have to put in a tube a chest tube tube thoracocentesis and this is done in the Triangle of safety right so Emergency Management needle decompression followed by chest tube is the management of tension numo thorax you should know the new place in adults where it is inserted the needle it is the fifth intercostal space mid auxiliary line so these were some important questions for your upcoming exams