Surgery II - Topical Past Papers (2007-2019)

SURGERY II – PAST QUESTIONS
(2007-2019)
(Compiled by Shahroze Ahmed, N-66,
Nishtar Medical University)
CONTENTS
SR # Unit Page #
1 Orthopedic Surgery 2
2 Upper Gastrointestinal Tract 7
3 Lower Gastrointestinal Tract 18
4 Urology 27
5 Thyroid 36
6 Breast 38
7 Thorax 42
8 Cardiovascular 47
9 Neurosurgery 50
10 Head & Neck 54
11 Tracheostomy 61
1
ORTHOPEDIC SURGERY
▪ GENERAL PRINCIPLES
Types of Fractures & Principles of Management
1.
a) What is pathological fracture?
b) Give its two examples and outline principles of its treatment. [Annual 2019]
2. A 30-year-old pedestrian was hit by a bumper of a car leading to open fracture of

lower third of right tibia and fibula and brought to emergency of your hospital.
a) What do you understand by the term ‘open fracture’?
b) Name four complications of this type of fracture.
c) Briefly outline principles of treatment for this patient. [Supple 2010 held in 2011]
3. A 45-year-old motorcyclist meets a road traffic accident and develops simple

fracture of left radius and ulna. How would you treat this patient? [Annual 2008]
4. A 35-year-old gentleman fell while riding a horse. Luckily the only injury he sustained
was a compound fracture of his right tibia and fibula. He presents to you in the
accident emergency department with this injury. How will you treat it?
▪ FRACTURES OF UPPER LIMB

Humeral Fractures
1. An 8-year-old boy while riding bicycle fell landing on right outstretched hand. He
develops painful swelling around his right elbow joint. On examination, the radial
pulse is impalpable.
a) What is your diagnosis? How will you manage this case?
b) What possible complications can arise in this patient? [Supple 2011 held in 2012]
2.
a) What is supracondylar fracture of children?
b) Name two indications of open reduction for this fracture.
2
c) Write three complications which can occur after this fracture. [Supple 2008 held
in 2009]
Colles’ Fracture
1. A 70-year-old retired school teacher has a slip in the washroom and falls on her left
hand. She developed dinner fork deformity of her left wrist.
a) What is your diagnosis?
b) How would you treat her? [Supple 2007 held in 2008]
▪ FRACTURES OF LOWER LIMB

Femoral Fractures
1. A 65-year-old lady slips in the bathroom she is unable to stand and complains of pain
in the region of right hip joint.
a) What will be signs you will look to confirm fracture of neck of right femur?
b) What are the various types of fracture neck of femur and what is the significance
of various types?
c) How will you manage it?
d) What serious complications can occur in this patient due to this fracture?
[Supple 2019 held in 2020]
2. What is pathological fracture? Give two examples & treatment of such fracture of
left femur. [Annual 2019]
3. A 45-year-old female presented to accident & emergency department with right

sided shaft of femur fracture after trivial trauma. She was diagnosed as a case of
metastatic carcinoma breast 3 months ago. Diagnosis of pathological fracture was
made.
a) Name three other tumors that can lead to pathological fracture.
b) Outline treatment plan. [Annual 2017]
4. A 20-year-old motorcyclist meets a road traffic accident and presents to the accident
and emergency department with deformity of right lower limb along with swelling of
thigh but no skin wound. X-ray reveals transverse fracture of shaft of femur. How
would you treat this patient? [Annual 2007]
3
Tibial Fractures
1. A man 65 years sustained injury to his left lower leg. On examination, there was a
wound 5 cm above the ankle. X-ray showed comminuted fractures of tibia & fibula &
medial malleolus. Outline the treatment plan. [Supple 2013 held in 2014]
Pelvic Fractures
1. A 35-year-old male is presented to trauma center with pulse rate of 120/min and the
BP is 90/60 mm Hg. He is complaining of severe pain to his lower abdomen. His chest
is clear, abdomen is soft, non-tender and no fracture of the long bones of limbs is
identified. His pelvic examination reveals bony crepitus and pain.
a) What is the cause of shock in this patient?
b) What other injuries are suspected in association with it?
c) What is the initial management?
d) What is the definitive management? [Annual 2016]
Compartment Syndrome
1. A 30-year-old male presented in COD with simple undisplaced fracture of tibia.
Doctor on duty applied POP cast and discharged from hospital. Next morning,
patient presented with severe pain in leg, numbness and bluish discoloration of toes.
a) What is the likely complication?
b) What emergency measures should be carried out? [Annual 2018]
2. A 35-year-old male complains of severe pain in calf after road traffic accident. The
limb was trapped in the cabin of the vehicle. Radiography do not show any fractures.
a) What is the most probable cause of this presentation?
b) What investigations can help you reach the diagnosis?
c) Which sign signifies a late presentation? [Supple 2017 held in 2018]
▪ PEDIATRIC ORTHOPEDICS
Developmental Dysplasia of Hip (DDH)
1. Parents of newborn first baby girl bring their one-month-old baby to the outpatient
department after noticing shortening of her right lower extremity and increasing
difficulty in diaper change. There is history of breach delivery. Examination reveals
abnormal gluteal creases, 2 cm femoral shortening of right lower extremity and
decreased abduction of right hip joint.
a) What is the most likely clinical diagnosis?
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b) Briefly outline the treatment at this age. [Supple 2012 held in 2013]
▪ BONE TUMORS
1. A 12-year-old boy pretend with complaints of painful swelling of left lower femur.
Radiograph done at rural health center reveals sunburst bony lesion of femoral
metaphysis.
a) What is the most likely pathology?
b) Briefly outline the management plan. [Annual 2015]
2. A 25-year-old political worker presents with a painless swelling around right

mandibular angle. Examination reveals that it is a bone swelling. X-ray confirms it to
be a bone cyst. What are differential diagnoses in this case?
▪ BONE & JOINT INFECTIONS

Osteomyelitis
1. A 2-year-old boy has presented with pain around his hip. He is reluctant to move his
right lower limb. He has moderate grade intermittent fever. Plain radiograph
revealed widening of joint spaces.
a) What is the most likely diagnosis?
b) How will you treat this case? [Annual 2009]
Septic Arthritis
1. A 60-year-old man presents with acute onset of pain, swelling & erythema of the left
knee. On investigations, WBC is increased, CRP is increased & joint aspirated. WBC
count is greater than 50,000/ml.
b) How will you manage this patient? [Supple 2014 held in 2015]
Spinal Tuberculosis
1. A 30-year-old male from lower socio-economic background presented with
complains of backache for 3 months. He also gives history of malaise, weight loss and
low-grade fever. On examination, there is spinal tenderness and deformity (gibbus).
a) What is the most probable diagnosis and how would you confirm your
dialogisms?
b) How would you treat this patient?
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c) In advance cases of this disease, what findings may present on examination of
groin and femoral triangle and why? [Supple 2015 held in 2016]
▪ SPORTS INJURIES
Ankle Injury
1. Young girl twisted her ankle while dancing and presents with severe pain around
ankle. On examination, there is gross swelling of lateral side of ankle with tenderness
just below the lateral malleolus., pain increases on inversion of her ankle.
a) What is the clinical diagnosis?
b) What are different types of this condition?
c) What is the treatment for each type? [Annual 2010]
▪ PERIPHERAL NERVE INJURIES

Types
1. Describe various types of nerve injuries. [Supple 2010 held in 2011]
Specific Nerve Injuries

1. A patient had a cut on his wrist damaging the median nerve. What clinical findings
will be present in this patient? [Supple 2010 held in 2011]
2. A 20-year-old motorcyclist has a road traffic accident and develop left humeral shaft
fracture which is treated by extensor splintage. Later on, it is found that he is unable
to extend his left wrist and fingers. He also has loss of sensation over dorsum of
thumb. What is the cause of this dysfunction? How would you treat it?
▪ DEGNERATIVE DISEASES OF MUSCULOSKELETAL SYSTEM

Carpel Tunnel Syndrome
1. An obese lady of 45 years ago presents with complains of numbness, ‘pins and
needles’ sensation in medial three & half fingers, her complaints are worse at night
and get relieved by hands shaking. Examination reveals altered sensation on fingers
mentioned and some weakening of thenar muscle.
a) What is the diagnosis?
6
b) What is the cause and how you confirm diagnosis?
c) What is the management? [Supple 2011 held in 2012]
UPPER GASTROINTESTINAL TRACT

▪ ESOPHAGUS
Dysphagia
1. What are the causes of dysphagia how will you investigate a case of dysphagia?
[Annual 2013]
Gastroesophageal Reflux Disease (GERD)
1. A 55-year-old female presents with dysphagia along with history of heartburn and
minimal weight loss. Patent is more concerned about regurgitation of undigested
food especially at night. There is also a history of recurrent chest infections. On
examination, there is no positive findings except for mild pallor.
a) What is the most probable diagnosis?
b) If the patient gives history of significant weight loss, what alternative diagnosis
you will consider?
c) What investigations and treatment will you offer to this patient? [Annual 2014]
2. A 40-year-old doctor presents with epigastric pain and heartburn, provoked by food
intake. The symptoms aggravated when she lies flat. He also has episodes of acid
brash.
b) What are the complications of this condition? [Supple 2007 held in 2008]
Achalasia
1. A middle-aged woman presents with history of dysphagia for the last many years. It
becomes occasionally painful. The dysphagia is progressive. There is history of
nocturnal regurgitation.
a) What is the provisional diagnosis?
b) What is the differential diagnosis?
c) What investigations are needed to confirm the diagnosis?
d) How will you manage it? [Supple 2019 held in 2020]
7
2. A 24-year-old female presents with difficulty in swallowing for last three years, that
is more for liquids. There is history of recurrent chest infections and retrosternal
burning. The patient has severe bad breath with no significant weight loss.
b) What are the three most important investigations with possible findings?
c) Name three treatment options. [Annual 2016]
3. A 45-year-old male presented with dysphagia for liquids but not for solids. He also
complains of regurgitation and bouts of cough at night.
b) Justify the investigations to make the diagnosis.
c) What treatment options are available? [Annual 2015]
4. A 30-year-old carpenter presents to surgical outdoor department with dysphagia of 3

years duration. Now he has developed regurgitation of residual food. Barium
radiography shows bird beak at distal esophagus.
b) How would you treat this patient? [Annual 2007]
Esophageal Perforation
1. A 35-year-old male has esophagoscopy for removal of foreign body later in the ward,
he complains of pain in chest and difficulty in breathing. On examination, he has
tachycardia, tachypnea and hypotension. He also has surgical emphysema of neck
and chest wall.
a) What is your suspected diagnosis?
b) What immediate steps will you take?
c) What investigations will you carry out? [Supple 2008 held in 2009]
Corrosive/Caustic Injury
1. A 35-year-old female is admitted after drinking half glass of acid 12 weeks ago after
ra conflict with her husband. She has now absolute dysphagia.
a) Write down clinical diagnosis in this patient.
b) What investigations you will carry out to treat his case
c) Write down principles of management for this case. [Annual 2019]
8
Carcinoma Esophagus
1. A 40-year-old man gives history of regurgitation & dysphagia. Endoscopic

examination shows adenocarcinoma of lower end of esophagus.
a) What further assessment you will do?
b) Enumerate staging investigations that you will advise.
c) What treatment will you suggest? [Annual 2018]
2. A 36-year-old male presented with dysphagia since the last 5 months. Dysphagia is
progressive and now it is difficult to swallow even liquids.
a) Which radiological investigation can help in T (size) staging of the disease?
b) Name three operative approaches which can be performed in this patient.
c) Which is the recommended route of perioperative nutrition in these patients?
3. A 60-year-old male presented with progressive dysphagia for the last four months.
There is history of weight loss. On examination, patient has got pallor. Examination
of abdomen and chest is unremarkable. However, there is 3x3 cm hard lump
palpable in left supraclavicular fossa.
a) How would you proceed to diagnose cause of dysphagia and assess the extent of
this disease?
b) What is the significance of left supraclavicular mass?
c) What is the name given to the mass and the clinical sign? [Annual 2017]
4. A 50-year-old smoker, otherwise healthy, presents in the OPD for increasing

dysphagia in solids and liquids, anorexic and loss of weight for three months.
Endoscopic biopsy and relevant imaging reveal a T2N1M0 adenocarcinoma in lower
3rd of esophagus.
a) What other relevant history and physical examination may help you to rule out
advanced malignancy in esophageal cancer?
b) What do you understand by the term T2N1M0?
c) What treatment will you offer him? [Supple 2016 held in 2017]
5. A 70-year-old man presented with progressive dysphagia and weight loss for the last
4 months. Before developing dysphagia, he has been enjoying good health.
a) What are the two most important investigations you will do to clinch a definitive
diagnosis?
b) If the investigations show a large irregular ulcerated lesion, how would you stage
this disease?
9
c) What are the two common histopathological types of malignant lesions which
affect esophagus?
d) How would you treat this patient once malignancy is confirmed?
6. A 45-year-old female is under yearly surveillance endoscopy for Barrett’s change in

esophagus due to chronic GERD. The biopsy reveals a moderately differentiated
adenocarcinoma in Barrett’s esophagus. How will you manage this patient?
[Annual 2012]
▪ STOMACH & DUODENUM

Upper Gastrointestinal Bleeding
1. A 30-year-old male presented with history of sever GIT bleeding for one day. There is
no previous episode of bleeding. On examination, patient is anxious, irritable with BP
90/60 mm Hg, pulse 110/min
a) How will you manage in order of priority?
b) What modern treatment modality you will suggest if patient is not improving on
endoscopic management and is unfit for surgery also? [Annual 2018]
Peptic Ulcer Disease
1. A 60-year-old male smoker develops sudden, severe abdominal pain after taking
medications for his osteoarthritis. The pain is generalized. It is associated with
vomiting.
a) What is provisional diagnosis?
b) What will be the abdominal finding?
c) What investigations you will order to know the diagnosis?
d) How will you manage him? [Supple 2019 held in 2020]
2. A 30-year-old male presents in emergency department with severe abdominal pain,

vomiting and absolute constipation. He is taking high doses of pain killers after
developing an abscess in right buttock for the past 5 days. Radiograph shows air
under both hemidiaphragms.
b) Which view of the radiograph should be done to identify hollow viscus
perforation?
c) What procedure is advised in this patient?
10
d) How would you manage the pain in this patient postoperatively?
3. A 50-year-old patient has been taking NSAIDs for knee arthritis. He presented in
surgical emergency with sudden onset of severe upper abdominal pain. On
examination pulse 120/min, BP 100/70, abdomen is tense & tender all over, bowel
sounds are absent.
a) What are the two radiological investigations which are most likely to give you the
diagnosis? Which one of the two is more accurate?
b) Describe his early management in emergency ward.
c) What is the significance of NSAID intake for arthritis in the patient?
d) Is measurement of serum amylase indicated in this patient? Give reason for your
answer. [Annual 2017]
4. A 50-year-old female has been taking NSAIDs for knee arthritis. She presented in
Emergency room with acute onset of severe epigastric pain spreading to whole of
abdomen. On examination, she looks dehydrated, pulse 100/min, BP 100/70 mm Hg.
Abdomen is tender and rigid all over with absent bowel sounds.
a) How would you explain her clinical outcome? Name one simple investigation to
confirm your clinical suspicion.
b) How would you resuscitate and treat this patient? [Supple 2016 held in 2017]
5. A 60-year-old smoker, known patient of Acid Peptic Disease, presents in the

Emergency Room with episodes of massive Upper Gastrointestinal Tract bleeding
one hour back. His pulse is 110/min and blood pressure of 90/60 mm Hg.
a) What do you understand by upper gastrointestinal bleeding?
b) How will you manage this patient in emergency?
c) Enlist indications of surgery in patients with bleeding peptic ulcer.
6.
a) Enumerate causes of upper GIT bleeding.
b) A 45-year-old smoker with history of Acid Peptic Disease presented in emergency
room with pulse 120/min, BP 100/60 mm Hg, had an episode of hematemesis.
How will you manage? [Supple 2014 held in 2015]
7. A 60-year-old female has been suffering from arthritis of both knees. She has been
taking diclofenac sodium for pain relief. There was no history of upper GI symptoms.
11
She was brought in surgical emergency with history of sudden onset of severe
epigastric pain since morning. Pain is continuous and getting worse. There is no
history of hematemesis. On examination, pulse is 110/min, BP is 100/70 mm Hg and
the whole abdomen is tender and tense.
a) How would you explain the patient’s condition?
b) How would you confirm your clinical diagnosis?
c) Briefly describe the management of this patient. [Annual 2014]
8. What are the complications of peptic ulcers? How will you treat a case of perforated
duodenal ulcer? [Supple 2013 held in 2014]
9. A 50-year-old male presented with severe pain in upper abdomen. He had a long
history of pain in epigastrium. On examination, his pulse rate was 120/min and
abdomen was distended.
b) How would you treat this case? [Annual 2013]
10. A 55-year-old general practitioner receiving NSAIs for OA for the last 5 years
presented with sudden severe pain in epigastrium. On examination, his pulse is
124/min and abdomen is tense and tender.
b) Discuss the management plan. [Supple 2011 held in 2012]
11. A 45-year-old patient presents with severe hematemesis. She gives history of chronic
back pain for which she takes analgesics regularly she also suffers from cirrhosis of
liver secondary to hepatitis.
a) Give two possible causes of hematemesis in this patient.
b) Name important three blood tests for this patient.
c) Give a plan of management. [Supple 2010 held in 2011]
12. A 60-year-old professor who is on NSAIDs for osteoarthritis for last 10 years presents
with sudden severe pain in epigastrium. On examination, his pulse rate is 120/min
and abdomen tense and tender.
12
▪ LIVER
Amebic Liver Abscess
1. A 15-year-old street beggar presents with discomfort in his right hypochondrium for
last one week. There are no constitutional symptoms. He had dysentery 2 weeks
ago. Examination reveals enlarged and tender liver but no jaundice.
b) What is the etiology and pathogenesis of this condition?
Hydatid Liver Disease

1. Write the name of causative organism, clinical features and management of Hydatid
liver disease. [Supple 2013 held in 2014]
Variceal Hemorrhage
1. A 45-year-old patient presents with severe hematemesis. She gives history of chronic
back pain for which she takes analgesics regularly. She also suffers from cirrhosis of
liver secondary to hepatitis.
a) Give two possible causes of hematemesis in this patient.
b) Name important three blood tests for this patient.
c) Give a plan of management. [Supple 2010 held in 2011]
▪ SPLEEN
Splenectomy
1.
a) Write down indications for splenectomy.
b) What are the complications of splenectomy? [Supple 2014 held in 2015]
▪ HEPATOBILIARY SYSTEM
Cholelithiasis (Gallstones)
1. A 40-year-old television artist is referred to you by a gynecologist. She had
abdominal ultrasonography done for some gynecological problem. The ultrasound
reports show gallstones. You advised her cholecystectomy, which she refuses as
these are silent stones. Tell her the effects and complications of the gallstones.
[Annual 2007]
13
Acute Cholecystitis
1. A 44-year-old diabetic woman presented to the Emergency Room with one day
history of constant abdominal pain and vomiting her bowels have opened normally
and have no urinary symptoms. She is febrile with a temperature of 38 C and pulse
rate of 116/min. She is not clinically jaundiced. On examination of the abdomen, she
is found to have severe tenderness in the right upper quadrant. The urine is clear
and rectal examination is normal.
b) What is your first line treatment?
c) What specific complication is this patient at risk of? [Annual 2015]
2. 40-year-old female presents with severe colicky pain in epigastrium radiating to right
hypochondrium present for last 2 hours. There is associated retching and vomiting.
She also gives history of similar episodic pain in past. On examination, abdomen is
soft and non-tender. Her pulse is 86/min, BP is 130/80 mm Hg, temperature is
normal.
b) How would you manage this case?
c) What investigations would you advise? [Supple 2010 held in 2011]
3. A 40-year-old lady has presented with pain in right hypochondrium with radiation to
right shoulder and jaundice with temperature. What is your appropriate
investigation plan? [Annual 2009]
Empyema of Gallbladder
1. A 40-year-old diabetic lady presents emergency with sudden severe pain in upper
abdomen. She looks toxic and has tenderness and guarding in RHC. USG reveals
distended gallbladder filled with pus.
a) What is this condition called?
b) Outline initial management plan for this patient.
c) Name two operations possible for this patient. [Annual 2010]
Cholecystectomy
1. A 45-year-old male is on warfarin after prosthetic mitral valve replacement. He is
planned for laparoscopic cholecystectomy on elective list. How will you manage him
in perioperative period? [Annual 2017]
14
2. Enlist the steps of open cholecystectomy in a 60-year-old female with a single 1 cm
stones in gallbladder on USG. [Supple 2014 held in 2015]
3. Enlist steps of laparoscopic cholecystectomy in 34-year-old female with multiple gall

stones. [Supple 2013 held in 2014]
Choledocholithiasis (CBD stone)

1. What are the treatment options for bile duct stones? [Annual 2009]
2. A 40-year-old receptionist presents with pain in right hypochondrium and

intermittent jaundice. She passes dark urine and pale stools. On abdominal
examination, gall bladder is impalpable.
Cholangitis
1. A 55-year-old female presents with three days history of high-grade fever, bouts of
upper abdominal pain and jaundice. There is history of laparoscopic cholecystectomy
for symptomatic gall stones two years ago. Examination reveals jaundice, pulse
130/min, BP 120/80 mm Hg and temperature 38.5 C. There is deep tenderness in
right upper abdomen with no palpable mass. Abdominal ultrasound shows dilated
common bile duct and a 1 cm echogenic shadow in its distal end.
a) What is most likely diagnosis?
b) Briefly describe your management plan, including various treatment.
2. A 45-year-old female housewife presented in OPD with history of right

hypochondrium pain, fever and intermittent jaundice for last month. She was
previously diagnosed as a case of cholelithiasis. On examination, there is jaundice
with impalpable gallbladder.
b) What investigations will you perform?
c) How will you manage the patient? [Annual 2011]
15
▪ PANCREAS
Acute Pancreatitis
1. A 55-year-old woman presented with sudden severe epigastric pain, which soon
became generalized. There is past history of repeated biliary colic. Her TLC is
1100/uL and amylase is 5000 U/L.
b) How will you manage her acute phase?
c) What is the long-term management? [Annual 2016]
2. A 35-year-old female is presented in emergency room with severe epigastric

localized pain, vomiting and abdominal distension. On examination, she is
dehydrated with pulse 112/min & BP 90/70 mm Hg. RR is 35/min along with severe
epigastric tenderness. Eight months back she was diagnosed to be suffering from
multiple tiny gallstones.
a) What is your most likely clinical diagnosis?
b) What investigations you will advise in this patient? [Annual 2013]
3. A 45-year-old male is admitted in emergency with diagnosis of acute biliary

pancreatitis.
a) How will you predict the severity of his disease employing Ranson scoring
system?
b) Enumerate the various local complications of acute pancreatitis you may
encounter in this patient. [Supple 2012 held in 2013]
4. A 60-year-old man presents in surgical emergency with short history of severe

epigastric pain. His vitals are pulse 110/minute, BP 90/60, temperature 102 F, TLC
20000/mm3, serum amylase 2000 IU.
b) How will you manage this? [Supple 2011 held in 2012]
5. A 35-year-old male presents with sudden severe pain in epigastrium associated with
vomiting, on examination, he is markedly tender in upper abdomen with some
rigidity of muscles of upper abdomen. X-ray abdomen is normal.
a) What is your clinical diagnosis?
b) How will you investigate this patient? [Supple 2008 held in 2009]
16
Pancreatic Cancer
1. A 70-year-old man with periampullary carcinoma is being prepared for palliative
surgery. He is deeply jaundiced with fever and have deranged bleeding profile.
a) How will you prepare this patient for surgery?
b) Write down names of minimally invasive procedure likely to be used to relieve
symptoms.
c) What palliative operation you will recommend in this case? [Annual 2019]
2. A 65-year-old male presented with three months history of progressively worsening

jaundice with dark colored urine and clay-colored stools. He has anorexia, weight
loss of 10 kg over one month. Examination reveals deep jaundice and palpable
gallbladder.
b) What is the underlying pathology?
c) How will you manage him? [Annual 2016]
▪ PERITONEUM, MESENTERY & RETROPERITONEAL SPACE

Peritonitis
1. A 40-year-old male underwent primary repair of typhoid perforation involving the
proximal ileum. On 4th post-operative day, he complains of abdominal pain and has
high grade fever. On examination, he looks toxic. His pulse is 120/min, BP 110/70
mm Hg, temperature 39.4 C. abdomen is distended and bowel sounds are not
audible. The abdominal drain reveals 1200 ml of greenish yellow fluid. There is
leakage of similar fluid from the wound.
a) What is the most likely diagnosis? And what could be the cause?
b) How will you manage this patient? [Annual 2012]
2. A 35-year-old male having history of fever for last 10 days now presents in
emergency with history of sudden onset of abdominal pain spreading to whole of the
abdomen. On examination, his pulse is 126/min and BP is 100/60 mm Hg. His
respiratory rate is 22/min. He has slight distension with rigidity of abdomen and
absent bowel sounds.
b) What investigations would you advise?
c) Briefly outline emergency management. [Supple 2010 held in 2011]
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LOWER GASTROINTESTINAL TRACT
▪ SMALL & LARGE INTESTINE
Intestinal Tuberculosis
1. A 35-year-old male presents with history of attack of abdominal pain and
intermittent diarrhea for the last 3 years. The patient has lost weight. He is anemic.
On examination, a mass is palpable in the right iliac fossa. The patient also gives
history of cough for the last 3 years.
a) What is provisional diagnosis?
b) What are the investigations needed to confirm the diagnosis?
2. A 35-year-old female presents with mass in right iliac fossa with history of distension
and abdominal colic of 5 months duration. She has history of cough and weight loss.
a) How would you investigate this patient?
b) What is your treatment plan for this patient? [Annual 2009]
Ulcerative Colitis
1. A 30-year-old female is known case of ulcerative colitis for 12 years presented in
emergency ward with complaints of severe abdominal pain, distension and loose
motions.
b) How will you manage?
c) Write two indications for surgical intervention. [Annual 2018]
2. A 25-year-old woman is admitted to the hospital because of fever, bloody diarrhea

and abdominal tenderness. She is on medical treatment including steroid for last on
year. On examination, she is toxic and dehydrated. Her abdominal X-ray shows
transverse colon of 12 cm diameter but no free intra-peritoneal air.
b) Discuss the treatment options of this patient. [Supple 2011 held in 2012]
3. A 40-year-old man has recently been diagnosed to be suffering from Ulcerative

Colitis. He is anxious about this diagnosis and wants to know:
a) What complications can occur due to this disease?
b) Name the investigations you will advise to confirm your suspicion.
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c) What are the treatment options? [Supple 2010 held in 2011]
Crohn’s Disease
1. A 45-year-old presented in OPD with history of multiple perianal fistulae associated
with altered bowel habits and abdominal pain. Tissue biopsy turned out to have
transmural inflammation with crypts. There was no evidence of any malignancy.
b) What serologic test would you do to confirm the report and to differentiate?
c) What inflammatory markers would you use to monitor the severity of disease?
d) Describe the radiological features of this disease on a SBFT.
e) Name surgical options to deal with the complications of this disease.
[Annual 2011]
Meckel’s Diverticulum
1. A 10-year-old child presents with abdominal pain around the umbilicus, which shifts
with movements and also there is history of melena. Barium meal shows there is
outpouching in lower of ileum.
b) What are other complications of this congenital abnormality? [Annual 2009]
Colorectal Carcinoma
1. A 56-year-old female has presented with bleeding per rectum for last 3 months. On
proctoscopy she has a mass 2 cm in size, 5 cm from the anal verge.
a) What is your suspected diagnosis?
b) What further investigations will you advise?
c) How will you stage the disease? [Annual 2019]
2. A 40-year-old gentleman presented with bleeding per rectum for the last 2 months.
Digital Rectal Examination (DRE) reveals an irregular mass 5 cm from the anal verge.
a) What will be the next step of management?
b) How will you investigate? [Annual 2018]
3. A 60-year-old male is diagnosed to have an adenocarcinoma of cecum. CT shows no

mesenteric lymph nodes or metastasis in the liver.
a) Name the operation you would like to perform.
b) Name the structures you would like to remove.
c) Name the structures you would like to prevent from injury of surgery.
19
4. A 60-year-old male presented with complains of fresh bleeding per rectum for the
last 6 months. There is no history of prolapse but he gives history of feeling of
incomplete defecation. On Digital Rectal Examination, a hard ulcerated lesion is felt
in the lower rectum.
a) How would you proceed with patient for confirming and staging the disease?
b) What are the treatment options?
c) What is the Duke’s staging and how it is related to the prognosis of disease?
5. A 65-year-old male presented with 6 months history of fresh per-rectal bleeding

along with constipation. For defecation, he has to strain with passage of blood along
with feces. There is no history of anything coming out of anal canal.
a) What is your clinical diagnosis and what clinical examination will you perform to
confirm your diagnosis?
b) Which investigation or examination should be done in this patient to rule out any
grave pathology considering his age?
c) Give the treatment according to the stages of this disease. [Annual 2014]
6. An elderly man with long standing history of constipation has presented in A&E with
history of discomfort in left iliac fossa & profuse fresh rectal bleed. Clinically, he is in
shock & abdominal examination revealed mild tenderness & fullness in left iliac
fossa.
a) Write down two probable clinical diagnoses.
b) List steps of management in emergency room. [Annual 2013]
7. A 56-year-old female presents with altered bowel habits, increasing constipation and
passage of blood and mucus per rectum. On examination, she is pale with normal
vital signs. Abdominal examination is unremarkable. Digital examination reveals an
ulcerated growth involving three fourths of the rectal wall just above the anal canal
with blood on the examining finger.
a) How will you establish the suspected diagnosis?
b) Briefly outline your management plan for this lady.
[Annual 2012]
8. A 60-year-old female presents with altered bowel habits, tenesmus and weight loss
for past one year. On per rectal examination, there is a rectal growth the lower limit
of which is 8 cm from the anal verge.
20
b) Discuss the management plan. [Supple 2011 held in 2012]
9. A 50-year-old woman presents with history of bleeding per rectum and increasing
constipation. Rectal examination reveals a mass in anorectum at 5 cm from the anal
verge raising the suspicion of carcinoma.
a) How will you confirm the diagnosis?
b) Write three imaging techniques used for staging.
c) What operation can be done to avoid permanent colostomy in this case?
[Annual 2010]
10. A 55-year-old policeman presents with bleeding per-rectum tenesmus and alteration
in bowel habits. Rectal examination reveals a mass in the lower third.
a) What is your provisional diagnosis?
b) How would you investigate him? [Supple 2007 held in 2008]
Ileostomy & Colostomy

1. A 36-year-old male underwent temporary loop sigmoid colostomy after repair of
rectal injury.
a) What complications will you look for in the post-operative period?
b) When will you advise reversal of colostomy and what relevant imaging
investigations will you obtain before reversal? [Supple 2012 held in 2013]
2. A 27-year-old man is suffering from familial polyposis coli. He is advised to have

surgery which will result in permanent stoma.
a) What is an intestinal stoma?
b) Give two examples of intestinal stoma.
c) Name two early and three late complications of intestinal stoma.
▪ INTESTINAL OBSTRUCTION
Adhesive Obstruction
1. A 25-year-old housemaid is diagnosed as a case of adhesive intestinal obstruction.
What symptoms and sings would be present in this case? [Annual 2008]
Sigmoid Volvulus
1. A 65-year-old man is admitted in emergency with lower abdominal pain, distension,
feculent vomiting and absolute constipation for the last 4 days. There is no history of
21
melena and weight loss. On examination, he is dehydrated and pulse 102/min and
BP 90/70 mm Hg. Abdomen is tense and tender in the lower part. DRE is non-
significant, abdominal X-ray revealed air distended loops in left iliac fossa.
b) Write down steps of treatment in emergency room. [Annual 2019]
2. A 60-year-old male presents in emergency with six hours history of sudden severe
abdominal pain, rapidly progressing abdominal distension, absolute constipation and
occasional vomiting. On examination, abdomen is hugely distended with no rebound
tenderness, absent shifting dullness and sluggish bowel sounds. X-ray plain abdomen
shows a dilated loop of large bowel running diagonally across the abdomen from
right to left with two fluid levels.
b) Briefly describe the management plan, including different options.
Intussusception
1. An infant was brought by his parents in surgical Emergency Room. Child has been
well previously but has been recently suffering from episodes of screaming and
drawing up his legs and appear pale. In between screaming attacks, he has been
lying listless. Vomiting is bilious and stool has blood with mucus. On examination of
abdomen, there is positive sign of Dance.
b) How would you confirm your diagnosis?
c) What is the sign of Dance?
d) How would you manage this patient? [Supple 2015 held in 2016]
2. A 9 months old male child was brought to emergency department with attacks of
sudden abdominal pain and vomiting for previous 24 hours, the mother told that he
passed blood and mucus in stools. Abdominal examination revealed a sausage
shaped lump in the umbilical area.
b) How would you treat this case? [Supple 2007 + Supple 2008]
▪ VERMIFORM APPENDIX
Appendectomy
22
1. A 15-year-old male presented with pain in right iliac fossa for one day associated
with nausea and anorexia. He has two episodes of vomiting. On examination, pulse is
90/min, BP is 120/80 mm Hg, temperature is 99 F and abdomen is tender. A
diagnosis of acute appendicitis is made. During surgery, his vermiform appendix
looked normal.
a) What would be the cause of his clinical picture?
b) How would you proceed in this patient on seeing a normal appendix?
c) Name two commonly performed incisions for appendectomy.
d) What complications can occur in the incision made for appendectomy?
[Annual 2014]
2. You are working as a house officer in the department of surgery at local public
hospital. Your professor has supervised a number of house officers through their first
appendectomy. You are to attempt an appendectomy under his supervision next
Saturday. Write down the steps of operation you would narrate to your supervisor
on that day during the pre-surgery meeting with him. [Supple 2008 held in 2009]
3. A 45-year-old senator presents in casualty outdoor department with a 12 hours

history of right lower abdominal pain. Physical examination reveals rebound
tenderness at McBurney’s point. He is diagnosed as suffering from acute appendicitis
and appendectomy is planned. Describe the steps of operation from skin to skin.
[Annual 2007]
Mass in Right Iliac Fossa

1. A 60-year-old man has pain over the right iliac fossa along with non-tender mass
since four months. He has also lost 15 kg body weight. There has been episode of
melena. Clinical examination reveals a pale looking weak patient with firm irregular
mobile lump in RIF.
a) Enlist four differential diagnoses in above patient.
b) How will you investigate this case? [Supple 2013 held in 2014]
2. A 26-year-old female presented in emergency with her husband with history of pain
in right iliac fossa, fever and vomiting for last five days. On examination, there is
palpable mass.
a) What will be your differential diagnoses?
b) What further important questions you will ask in the history?
c) What investigations will you perform?
d) How will you manage the patient? [Annual 2011]
23
3. A 45-year-old female presents with severe anemia. On examination, a mass is
palpable in right iliac fossa which is intraabdominal ad relatively mobile.
a) Give two most probable diagnoses.
b) How will you investigate this patient? [Supple 2008 held in 2009]
▪ ANAL CANAL
Anal Fissure
1. A 25-year-old male presents with severe excruciating pain during defecation with
bleeding. On physical examination of anal canal, a fissure is noticed at the 6 o’clock
position.
a) Define fissure.
b) What are the other painful conditions of anorectal region?
c) What is the management of this patient? [Supple 2019 held in 2020]
2. A 40-year-old female who has chronic constipation has been diagnosed to have a
posterior midline chronic anal fissure.
a) Define anal fissure. When will you label it as chronic?
b) Enlist various causes of atypical presentation and location of fissure.
c) What is the treatment plan for this patient? [Supple 2016 held in 2017]
3. A young male of 30 years has presented with painful defecation and streak of blood
along the feces. There is no history of injury.
a) What is the probable diagnosis?
b) What is the management of this condition? [Annual 2009]
4. A 35-year-old housemaid presents to hospital with sharp agonizing pain starting

during defecation and lasting for 1 hour or so, after which it ceases suddenly. She
also notices bright red blood streaks on stool.
Hemorrhoids
1. A 45-year-old male presents with history of mucus and blood discharge per rectally
for the past 5 months on and off associated with something coming out of the
rectum and reduces spontaneously.
b) How would you classify different severity/degrees of this condition?
24
c) Enumerate two complications of stapled hemorrhoidectomy?
2. A 65-year-old male presents with complains of fresh per rectal bleeding for 3
months. It is not mixed with stools. He also complains for something coming out of
anus during defecation but goes back on its own after defecation.
b) What examination is indicated in this patient to diagnose his disease considering
his age?
c) Describe the treatment options in this patient if your clinical diagnosis is correct.
[Annual 2017]
3. A 62-year-old female presented with complaints of something coming out of rectum

as shown in the picture:

b) What are the two differential diagnoses?
c) Name two operations of this condition.
d) How will you clinically make the final diagnosis? [Annual 2016]
4. A 45-year-old female complains of painless bleeding at defecation with appearance

of lumps at anus on defecation, which could be reduced manually. She now
presented in Emergency room with sudden onset of severe pain on defecation and
inability to reduce lumps.
25
b) What are the steps of open hemorrhoidectomy? [Annual 2015]
5. A 40-year-old female presents with history of repeated episodes of painless bleeding

at defecation and feels soft masses coming out at defecation. Suspected diagnosis is
hemorrhoids.
a) Name two investigations you will carry out to confirm the diagnosis.
b) What complications can occur in hemorrhoids? [Supple 2008 held in 2009]
Fistula-in-Ano
1. A 39-year-old male presented with complains of a pit near his rectum which bursts
after every few months. The opening is secondary to an old history of an abscess in
the perineum.
a) Give a classification based on relations of the pathology to Anal Sphincter (Park’s
classification)?
b) What is Goodsall’s rule?
c) Enlist two latest investigations which help in identification of primary and
secondary tracts accurately. [Supple 2009 held in 2010]
▪ HERNIA, UMBILICUS & ABDOMINAL WALL

Inguinal Hernia
1. A 60-year-old male presented with an irreducible swelling in the right groin. Patient
gives history of reducibility in the same swelling. There is history of worsening pain in
the swelling and vomiting.
b) What critical step in the operation is different from an elective case of hernia
repair? [Supple 2017 held in 2018]
2. A 45-year-old male presented to Emergency Room with a complaint of recurrent

bilious vomiting, abdominal pain and absolute constipation for the last two days
associated with tachycardia and fever. On examination, abdomen is distended with
absent bowel sounds and a tender swelling is present in left groin.
b) Write down the most appropriate investigation with expected findings.
c) How will you manage the patient? [Annual 2016]
26
Herniotomy & Herniorrhaphy
1. Enumerate four commonest complications of open hernia repair.
2.
Enlist steps of operation mesh repair of right inguinal hernia in 47 years old male.
[Annual 2013]
3. A 40-year-old man on operation list is to have mesh repair for inguinal hernia.
Enumerate the steps of this operation. [Annual 2010]
4. A 20-year-old university student has to undergo left inguinal herniorrhaphy by

Lichtenstein method. Write the steps of this operation from skin to skin.
[Annual 2008]
UROLOGY
▪ KIDNEY & URETER

Renal Trauma
1. A young male was involved in a fight and received a severe blow in his right loin. On
examination, his pulse is 100/min, BP is 100/70 mm Hg and pallor is positive. On
palpation, abdomen has mild tenderness in right lumbar region only. Bowel sounds
are sluggish. His abdominal ultrasound shows normal liver along with a hematoma in
right paracolic gutter.
b) What is the most common symptom of this organ injury, which is not mentioned
in the history of patient?
c) How would you manage this patient?
d) What specific urological complications can occur in this patient (both early and
late)? [Annual 2014]
Hydronephrosis
1. A 23-year-old female presents with two-year history of pain and dull aching
sensation in the right loin with sensation of dragging heaviness made worse by
intake of excessive fluid. Examination reveals a bimanually palpable mass in right
27
lumbar region. Abdominal ultrasound reveals a large right kidney with marked
dilation of pelvic calyceal system and some loss of cortical thickness.
a) Enlist atleast two other imaging investigations which help you to make a
management plan.
b) Enlist atleast four indications of surgery in this condition.
c) What operative treatment options are available for this patient?
Renal Stones
1. A 24-year-old male presented with right flank pain. He had similar complaints 4
months ago and diagnosed to have renal stones.
a) Name four different types of renal stones.
b) Write down their six complications. [Annual 2017]
2. A 45-year-old male has been diagnosed to have a staghorn stone in the right kidney.
a) Enumerate various types of renal calculi. What type of stone staghorn calculus is?
b) Enlist various treatment options for renal stones.
c) How will you prevent recurrent stone formation? [Supple 2016 held in 2017]
3. A 25-year-old male presented with pain in right lumbar region radiating to groin. He
also has hematuria and pyuria. On X-ray KUB opacity in renal area is found.
b) What is the different diagnosis?
c) Suggest investigations to rule out other conditions.
4. A 45-year-old lady is undergoing right pyelonephrolithotomy. What are the salient

features of this operation? [Supple 2011 held in 2012]
Ureteric Stones
1. A 35-year-old male presents with acute colicky pain in the right loin which radiated
to the ipsilateral iliac fossa and genitalia. The patient is in agony. There is history of
burning micturition.
b) What investigations will you order in this patient to confirm the diagnosis?
c) How will you manage it? [Supple 2019 held in 2020]
28
2. A young male presented with acute onset of severe pain in right loin radiating
anteriorly to right groin. Patient is in severe pain and rolling in the bed.
a) What is the initial management of this patient?
b) What investigation will you do to reach a diagnosis? What could be the expected
finding in contrast study?
c) What are the various treatment options available for treatment of ureteric
stone? [Supple 2015 held in 2016]
3. A 35-year-old female presents with severe colicky pain radiating from left loin to
groin. There is history of recurrent attack of such pain in past associated with
burning micturition and blood-stained urine. There is no history of fever. An
abdominal x-ray reveals a 1 cm long radio-opaque shadow near the left ischial spine.
b) Outline your management plan including various treatment options available for
this patient. [Annual 2012]
4. A 30-year-old male presented in emergency department with severe pain in left

lumbar region, pain radiated from loin to groin. What radiological investigations will
you ask, and explain what you have to see in these? [Annual 2011]
5. A laborer working in bathas comes to ER with pain in right abdomen radiating to

genitalia, with dysuria and hematuria.
a) How would you investigate this patient?
b) What is management plan for stone in lower third of ureter? [Annual 2009]
Renal Tumors
1. A 60-year-old man presented to OPD with history of weight loss, hematuria and dull
pain in right lumbar area. On examination, he has mobile mass and is anemic. A
clinical diagnosis of renal cell carcinoma is made.
a) What paraneoplastic syndromes are associated with this?
b) What other investigations will you advise in this case
c) What operation will you advise in this case? [Annual 2019]
2. A 45-year-old female presents with history of painless hematuria for last one year.
Now she complains of a lump in her left loin which is painless.
b) How will you investigate this patient?
c) Name three common malignant tumors of the kidney. [Supple 2008 held in 2009]
29
3. A 70-year-old male complains of pain in right lumbar region for three months and
frequent hematuria. On abdominal examination, his right kidney is enlarged and
palpable on bimanual examination.
b) Enlist the radiological investigations. [Annual 2008]
4. A 1-year-old boy is brought to hospital for rapidly growing abdominal mass,

hematuria and general ill health. Examination reveals hugely enlarged left kidney.
b) How would you investigate this case? [Annual 2007]
5. A 60-year-old man presented with hematuria and dragging discomfort in his left loin.
Examination showed a palpable mass in left lumbar region.
b) How would you treat this case?
▪ URINARY BLADDER
Urinary Retention
1. A 60-year-old male presented in emergency with inability to pass urine for the last
12 hours. He is in pain. On examination of abdomen, there is a smooth well-defined
mass palpable in supra-pubic region which is dull on percussion.
b) What is the nature of dull mass palpable?
c) What is the commonest cause of his problem?
d) How would you treat him? [Annual 2017]
Bladder Injuries
1. A 55-year-old male is brought to emergency after crush injury to the lower part of
the abdomen, he is conscious and complains of pain in the pelvic region and inability
to pass urine. The abdomino-pelvic examination reveals extensive bruising and
ecchymosis in pelvic region. There is tender swelling in the hypogastric region with
blood at the external meatus.
a) What is the most likely injury?
b) How will you confirm your diagnosis?
c) How will you treat this condition in emergency? [Annual 2010]
30
Bladder Stones
1. A 35-year-old male presents with two-year history of increased frequency of urine,
sensation of incomplete bladder emptying and occasional hematuria. He also gives
history of painful micturition especially at the end of micturition and pain referred to
the tip of penis. Physical examination is normal.
b) Briefly outline your management plan including various treatment options
available for this patient. [Supple 2012 held in 2013]
Urinary Bladder Fistulae

1. A 24-year-old female after delivery presented with urinary soiling through vagina.
a) What can be possible causes?
b) How will you manage her? [Supple 2014 held in 2015]
Neuropathic Bladder
1. A 60-year-old woman presented in OPD with complaints of difficulty in passing urine
and dribbling. Examination reveals a non-tender distended bladder.
b) Name three possible causes of this condition in female.
c) Name tow specific investigations you will advise for her. [Annual 2010]
▪ PROSTATE
Benign Prostatic Hyperplasia
1. A 50-year-old male presented in OPD with complains of increased frequency of
micturition, thinning of stream and sense of incomplete evacuation of urinary
bladder.
a) What is differential diagnosis of this problem?
b) What complications can arise if the problem is not treated? [Annual 2018]
2. A 60-year-old male presents in the OPD with symptoms of frequency, nocturia

urgency and poor urine stream. A provisional diagnosis of Benign Prostatic
Hyperplasia is made.
a) Enlist urodynamic criteria used to select best treatment options for symptomatic
patients.
b) Name various drugs and operative treatment options available for the disease.
c) What is TUR (Transurethral Resection) syndrome? [Supple 2016 held in 2017]
31
3. A 60-year-old retired civil officer has been diagnosed as suffering from benign
prostatic hyperplasia. What symptoms and signs may be present in this case?
Prostatic Carcinoma
1. A 50-year-old male presented in OPD with complains of increased frequency of
micturition, thinning of stream and sense of incomplete evacuation of urinary
bladder.
a) What is differential diagnosis of this problem?
b) What complications can arise if the problem is not treated? [Annual 2018]
2. A 65-year-old male presented with lumbar spine, pain and pelvic bone pain. He also
gave history of difficulty in passing urine and hematuria. X-ray lumbar spine and
pelvis showed the bone to be dense and coarse. Digital Rectal Examination revealed
large hard irregular prostate.
a) How would you explain the appearance in x-ray of lumbar spine?
c) How would you manage this particular patient?
d) What are the tumor markers of this disease? [Supple 2015 held in 2016]
3. A 55-year-old patient attends outpatient clinic with complaint of low backache of

recent origin. He also gives history of urinary frequency and poor interrupted stream
present for last six months. On examination, he is looking pale and weak. He has
palpable distended urinary bladder. Digital Rectal Examination revealed a hard,
irregular prostate.
a) What is the clinical suspicion?
b) Name the investigation you will advise to confirm your suspicion.
c) What are treatment options? [Supple 2010 held in 2011]
4. A man of 65 year has presented with nocturnal frequency and poor stream. Rectal
examination reveals a nodular in right lateral lobe of prostate which is firm to hard in
consistency.
a) What is the investigation plan for this patient?
b) What are the complications of TRUP? [Annual 2009]
32
▪ URETHRA & PENIS
Urethral Injuries
1. A 28-year-old male laborer presents in emergency with inability to pass urine after
falling astride a scaffolding bar. Examination reveals a tender globular swelling in
suprapubic region, bruising in perineum and evidence of blood on the tip of external
urinary meatus.
b) How will you manage this patient? [Annual 2012]
2. A 31-year-old male presented in surgical emergency when he had fallen astride a

loose manhole cover with bleeding from urethral meatus, perineal hematoma and
has developed acute urinary retention.
c) How will you manage this patient? [Annual 2011]
3. A young man of 35 years presented in emergency with history of astride injury

leading to pain in perineum, perineal hematoma and bleeding from external urinary
meatus.
b) How will you treat this case? [Annual 2008]
4. A 70-year-old boy pedestrian falls astride a loose manhole cover and presented to
emergency ward 1 hour later with retention of urine, painful perineal swelling and
bleeding from external urinary meatus.
b) How would you treat him? [Annual 2007]
Urethral Strictures
1. A 30-year-old man presents with difficulty passing urine for last 4 months. He passes
urine with thin stream and has to strain on urination.
b) How will you confirm your diagnosis?
c) Write down options of treatment for your diagnosis. [Annual 2019]
2. What are causes of stricture urethra in a male patient? How will you confirm and
treat it? [Supple 2013 held in 2014]
33
3. A 20-year-old male presents to you with complaints of thin stream of micturition for
last 6 months. He gives history of urethral discharge for last 8 months as well.
a) What is your diagnosis? What is its cause?
b) How will you investigate?
c) How will you treat this patient? [Supple 2008 held in 2009
Circumcision
1. A 1-week-old infant is brought to hospital for circumcision. Open method
circumcision is planned for him. What are the steps of this operation?
▪ TESTES & SCROTUM

Cryptorchidism
1. A 4-year-old child has bilateral undescended testes.
a) Enlist four possible complications.
b) What is surgical treatment? [Annual 2018]
Testicular Torsion
1. A 15-year-old boy complains of sudden agonizing pain in the right groin while playing
a match of hockey. He is feeling nausea. On examination of inguinoscrotal region,
skin of scrotum is inflamed.
b) What is differential diagnosis?
c) What is the management? [Supple 2019 held in 2020]
2. A teenage present with an acute scrotum after being hit by a cricket ball.
a) What are the other three differentials of this condition?
b) Which investigations can best identify viability of testis in the swelling?
c) What is initial management of this condition? [Supple 2017 held in 2018]
3. A 12-year-old boy presented to emergency room complaining of sudden onset of

testicular pain. The pain wakes him from his sleep and has persisted for the last 3
hours. His smother says that he has vomited once. He had a similar attack of pain a
year ago, but that subsided quickly. On examination, left hemi-scrotum feels normal,
but the right side is swollen and tender. On palpation, the right testis is elevated. The
cremasteric reflex is absent.
a) What is the most likely diagnosis? Also give differential diagnosis.
34
b) How will you manage this child? [Annual 2015]
4. A 15-year-old boy presents with sudden severe agonizing pain in his right groin and
lower abdomen for last 2 hours. He feels nauseated. Patient is afebrile. Abdominal
examination does not reveal any tenderness. There is no history of shifting pain, but
history of self-limiting pain a few days ago is present. However, this time the pain is
persistent.
a) What further clinical examination should be done to reach a diagnosis?
b) Give most probable diagnosis and one alternative diagnosis.
c) What single investigation you will order before definitive treatment?
d) What is the definitive treatment? [Annual 2014]
5. A young school boy has presented with sudden severe pain & swelling of the right
hemi-scrotum. He also vomited but is stable hemodynamically. Examination revealed
very tender, swollen scrotum with effusion.
b) What investigations will you advise to confirm the diagnosis? [Annual 2013]
6. A 12-year-old boy while cycling suddenly develops severe pain and swelling in right
groin. On examination, his pulse is 120.minute, temperature is 99 F, and a tense
tender swelling presents at superficial inguinal ring.
a) What are differential diagnoses?
b) Discuss operative management of this patient. [Supple 2011 held in 2012]
Varicocele
1. A 40-year-old male had radical left nephrectomy secondary to renal cell carcinoma.
Six months later, he felt dragging sensation in left testis. He said that when he
palpates his scrotum, he has a feeling as if it contains a bunch of worms.
a) What is the likely diagnosis?
b) How renal CA can spread?
c) How does it affect the fertility of this patient? [Annual 2016]
Hydrocele
1. A 35-year-old male presented with a right sided painless inguinal scrotal swelling. It
is relatively firm on palpation; upper limit is reachable and transillumination test is
positive.
a) What is probable diagnosis?
b) Name different anatomical types of this condition.
35
c) Outline the treatment option. [Supple 2010 held in 2011]
Testicular Tumors
1. Give classification of testicular tumors. How will you manage a case of testicular
seminoma? [Supple 2013 held in 2014]
Hematuria
1. A 50-year-old man had hematuria for last 4 years. He also complains of severe
backache.
a) Enlist the causes of his symptoms.
b) What investigations will you carry out to reach a final diagnosis?
[Annual 2015]
THYROID
Surgical Anatomy
1. Name the arteries supplying the thyroid gland. From which artery these arise?
[Annual 2011]
Thyroglossal Duct, Cyst & Fistula

1. A 12-year-old boy developed a swelling in the midline in front of his neck. It
developed infection and ruptured onto the skin causing persistent pus discharge. On
examination the swelling moves with swallowing and protrusion of the tongue.
b) What is the surgical management of the case? [Annual 2016]
2.
c) Name the ectopic sites of thyroid gland and anomalies of thyroglossal tract.
d) What is struma ovarii? [Annual 2011]
Goiter
1.
a) Define and classify goiter.
b) How will you investigate a case of multinodular goiter?
[Annual 2013]
36
Hyperthyroidism
1. A 30-year-old female presented with large multinodular goiter and prominent eyes.
She looked agitated and gives history of weight loss despite good appetite.
a) What is your diagnosis and how will you confirm your diagnosis?
b) What are the different treatment options available for this patient?
c) What options you will choose for this patient and why?
[Annual 2017]
2. A 25-year-old female presented with multiple swellings in front of her neck. She gave
history of palpitations, weight loss and disturbance of menstrual cycle. Her pulse is
110/min. on examination, the swellings are firm in consistency and move with
swallowing. Neck radiograph showed deviation of trachea.
a) Enlist the investigations to work up this patient.
b) How will you manage this case? [Annual 2015]
3. A 30-year-old female presents in surgical OPD with complaints of palpitation for past
six months. On examination, there is a 2 cm swelling in front of neck.
b) Give the management plan for this patient.
Thyroid Cancer
1. A 26-year-old female presents with two years history of gradually enlarging painless
swelling in front of neck on left side. On examination, pulse 74/min, BP 120/80 mm
Hg and temperature 37 C. there is 2x3 cm hard non-tender swelling in right lobe of
thyroid gland. On ipsilateral cervical lymph node is enlarged and hard in consistency.
FNAC reveals a papillary carcinoma. Briefly outline management plan for this patient.
2. A patient has undergone total thyroidectomy for differentiated papillary carcinoma.

a) What is the role of radio-iodine in the follow-up of this patient?
b) Name the drug and its dose to prevent the recurrence of disease.
Thyroidectomy
1.
a) Write down steps of total thyroidectomy for multinodular goiter.
b) Write down two complications of this operation. [Annual 2019]
37
2. A young lady with multinodular goiter has been advised surgery for cosmetic
reasons. Give the steps of operation for subtotal thyroidectomy. [Annual 2009]
BREAST
Investigating Breast Disease
1. What is meant by triple assessment? [Supple 2017 held in 2018]
2. A 25-year-old lady presented with pain and discomfort in both breasts since two
years. How will you manage this patient? [Annual 2012]
3. A school going girl has felt a lump in her left breast. on examination, there is non-
tender, freely mobile mass of 2 cm.
a) How will you evaluate this lump?
b) What is the treatment plan for this patient? [Annual 2009]
4. What is the role of MRI in lump breast? [Supple 2014 held in 2015]
Nipple Discharge
1. Write down differential diagnosis of unilateral nipple discharge in a female 35 years
of age. [Annual 2019]
2. Write down causes of unilateral nipple discharge in female 35 years of age. How will
you investigate this case? [Annual 2013]
Fibroadenoma
1. A 35-year-old midwife presents with a 2 cm diameter painless lump in her left breast
for last 3 months. On examination, lump is discrete and freely mobile.
b) How you would treat this case? [Annual 2008]
Phyllodes Tumor
1. What is Phyllodes tumor of the breast? Describe its presentation and treatment.
38
Fat Necrosis
1. A 28-year-old ice skater presents several weeks after having sustained an injury to
her left breast. she has painful mass in the upper outer quadrant. Skin retraction is
noticed & 3-4 cm mass in diameter can easily be palpated. What is the most likely
diagnosis? [Supple 2014 held in 2015]
Breast Abscess
1. A 25-year-old woman who is breast feeding her three months old baby develops pain
in the left breast. She is running fever and feeling difficulty in lactation. On
examination, breast is tender and overlying skin is red and inflamed.
b) What is the pathogenesis of this disease?
c) What is the treatment? [Supple 2019 held in 2020]
2. A lactating mother who is 24 years of age developed a painful lump in her left breast.
On examination, the skin overlying the lump looks red, the lump was tender and the
skin temperature was raised. Patient also complains of fever of 102 F for last 24
hours.
b) Name the causative organism causing this condition.
c) How will you manage early and late stages of this disease? [Annual 2016]
3. A 26-year-old breastfeeding mother presented with fever and pain in right breast.
she has a temperature of 37.9 C and a pulse rate of 92/min. on examination, there is
a localized, tender area adjacent to areola of the right breast. There is surrounding
erythema and tender lymphadenopathy in the right axilla.
b) What other investigations would you order?
c) What are the treatment options? [Annual 2015]
4. A 25-year-old lactating mother presents with pain in her left breast. On examination,
there is tender 4x4 cm lump in upper quadrant of breast with inflamed overlying
skin.
b) Outline the treatment plan for this patient.
c) What advice will you give to this patient regarding lactation?
39
5. A 30-year-old lactating housemaid presents with painful swelling of her left breast
for last two weeks. Examination reveals tense, tender, swollen, fluctuant left breast.
A diagnosis of acute breast abscess is made and incision and drainage is planned.
What are the steps of this operation? [Supple 2007 held in 2008]
Gynecomastia
1. A 35-year-old male presents with two years history of gradual painless enlargement
of both breasts.
b) What relevant history and examination will you perform to find out the cause of
this condition?
c) What treatment will you suggest to this patient? [Supple 2012 held in 2013]
2. A 25-year-old male presents with bilateral generalized enlargement of his breasts.

On examination there is tender discoid enlargement of both breasts.
b) What are the causes of this condition?
c) What options are available for treatment? [Annual 2010]
Breast Carcinoma
1. A 50-year-old female presented with a 4 cm mass at upper and outer quadrant of
right breast. There are no axillary lymph nodes palpable. True-cut biopsy reveals
invasive ductal cancer grade I. there is no evidence of metastasis.
a) What is the stage of cancer?
b) How will you manage?
c) What are the recent advances in the management of this cancer?
[Annual 2018]
2. A 40-year-old premenopausal female comes to the OPD with a lump 1.8x2 cm

beneath nipple and areola of her right breast with mobile ipsilateral axillary nodes.
Systemic examination is unremarkable. Tru-cut biopsy reveals Ductal Carcinoma. She
is positive for Estrogen, Progesterone and Her-2/Neu receptors.
a) How would you categorize her cancer?
b) What relevant imaging and blood test will help to stage her disease?
c) Outline your treatment pan along with reasons.
3. How will you diagnose CA breast? [Supple 2014 held in 2015]
40
4. A 65-year-old female presents with dry and cracked nipples of her right breast. Her
left breast is normal. She has been treated by dermatologist who gave her treatment
for eczema but there was no improvement. Clinical examination shows partial
erosion of the nipple of right breast.
c) What further examination and investigation you will perform before definite
treatment of this patient?
d) Enumerate the different treatment modalities in this disease.
[Annual 2014]
5. A 40-year-old peri-menopausal patient presents in outpatient clinic. On examination,

she has a 3 cm mobile mass in right upper quadrant of left breast with tethering of
overlying skin. There are palpable mobile lymph nodes in left axilla.
b) What is the stage of the disease?
c) How will you investigate the patient? [Supple 2010 held in 2011]
6. A 35-year-old female nulliparous presents in surgical OPD suffering from a 3 cm

hard, fixed mass in upper quadrant of the right breast.
a) How will you establish the diagnosis?
b) What is the treatment plan? [Supple 2011 held in 2012]
7. A 35-year-old female presented in OPD with a slow growing lump in upper outer
quadrant of left breast for last 11 months. On examination, there is 3 cm lump in left
breast which is mobile and not involving the skin and underlying muscles. Left
axillary lymph nodes are also palpable and freely mobile with no clinical evidence of
spread of the disease to distant organs.
a) What is the stage of the tumor?
c) How will you manage this patient? [Annual 2011]
8. A 50-year-old nulliparous peri-menopausal college principal presents with a 3 cm

diameter lump in upper outer quadrant of her left breast. The lump is stony hard,
and not fix to underlying muscles or overlying skin. Palpable mobile axillary lymph
nodes are also present. FNAC confirms the diagnosis of infiltrating ductal carcinoma.
Further investigations reveal no distant metastases.
a) What is the stage of the disease according to TNM staging system?
41
b) How would you treat her? [Annual 2007]
Mastectomy
1. A 23-year-old female presents with a slowly growing lump in her breast.
a) Name the nerves which need to be preserved in cases of modified radical
mastectomy, along with their major innervations.
b) What are the three levels of axillary clearance in modified radical mastectomy?
2. A 55-year-old female underwent Patey’s mastectomy for ductal carcinoma of right

breast.
a) The excised mass in her surgery should include which structures dissected en
block?
b) How axilla is accessed in Patey’s mastectomy?
c) During axillary dissection, which structures should be preserved?
d) How would you avoid shoulder joint stiffness post-operatively?
[Annual 2017]
3. A 60-year-old lady from a village presented with 3x4 cm hard lump in upper inner
quadrant of left breast. on examination, lump is tethered to skin but not attached to
deeper structures. There are five mobile lymph nodes easily palpable in left axilla.
FNAC was done and reported back as positive for malignant cells. Rest of clinical
examination is normal except for mild conjunctival pallor.
a) What is the preferable treatment option considering her social background?
b) What structures surgeon should excise in the surgical treatment of this patient?
c) Enumerate complications of this surgery. [Supple 2015 held in 2016]
THORAX
▪ LUNGS
Hemoptysis
1.
a) Give differential diagnoses of hemoptysis in a 20-year-old and 60-year-old
patient.
b) What other associated chest symptoms may be present in a patient with
hemoptysis?
42
c) How would you investigate the patient to reach a diagnosis? [Annual 2014]
Bronchogenic Carcinoma
1. How would you diagnose and stage a patient with carcinoma of lung?
▪ CHEST TRAUMA
1. A 35-year-old motorcyclist was involved in road traffic accident. He suffered from
chest trauma.
a) Enumerate the six injuries which are immediately life-threatening.
b) Enumerate the six injuries which are potentially life-threatening.
c) What is sucking chest wound? What is its initial management? [Annual 2017]
Pneumothorax
1. A 35-year-old male suffering from pulmonary TB suddenly develops dyspnea. It is
associated with sharp pain in the right chest. The patient is breathless and in
respiratory distress. On auscultation, breath sounds are absent on right side. Neck
veins are engorged and trachea is shifted to opposite side.
b) What is the emergency treatment?
c) What is the definite treatment? [Supple 2019 held in 2020]
2. A 45-year-old patient with history of pulmonary tuberculosis is admitted with

sudden shortness of breath and left sided chest pain. He is tachycardiac, tachypneic
with oxygen saturation 89% at room air with absent breath sounds on left side and
hyper-resonant percussion.
a) What is your clinical diagnosis in this case?
b) How will you treat this case in emergency?
c) Write down principles of further management of this case. [Annual 2019]
3. A victim of a suicide bomb blast presents with multiple small shrapnel injuries over
the chest and abdomen. He complains of severe shortness of breath and absent air
entry in right hemithorax and distended neck veins.
a) Enlist boundaries of triangle of safety.
b) How would you differentiate this condition from cardiac tamponade?
c) What is most appropriate management plan in this patient?
43
4. A 35-year-old male presents with severe dyspnea one hour after Road Traffic
Accident. His pulse is 110/min & R/R is 30/min. there is decreased movement of
chest on right side with diminished breath sounds and hyper-resonant percussion
note.
b) How will you manage the patient? [Annual 2016]
5.
a) What is pneumothorax?
b) Classify pneumothorax.
c) From what lung conditions pneumothorax has to be differentiated?
d) What type of pneumothorax is life-threatening and how should it be managed?
6. A young man presented with severe dyspnea after Road Traffic Accident (RTA) half
an hour ago. His pulse rate is 110/min, BP 100/70 mm Hg & respiratory rate 24/min.
on examination, right-sided chest movements are decreased, there are diminished
breath sounds on right side. What is your probable diagnosis & how will you manage
it? [Supple 2014 held in 2015]
7. A 24-year-old man presented to A&E after a road traffic accident. He is severely

dyspneic. Breath sounds on right side of the chest are diminished & percussion note
is resonant.
b) How will you treat him in emergency department? [Annual 2013]
8. 75-year-old imam masjid presents with injury to right chest following road traffic
accident. He is severely dyspneic, with a respiratory rate of 55/min, breath sounds
are absent on right side.
b) How would you treat this case? [Supple 2008 held in 2009]
Hemothorax/Hemopneumothorax
1. A 25-year-old male is brought to the Emergency Room with a history of Road Traffic
Accident. His pulse is 110/minute and blood pressure of 95/70 mm Hg. On
examination, trachea is central and breath sounds are absent on the right side with
dullness on percussion. The abdomen, pelvis and long bones are normal.
44
b) How will you manage him in Emergency Room?
c) What are the indications of Thoracotomy in this patient?
2. A 30-year-old male presented to the Emergency Room with stab wound of the chest
just below the nipple. On examination, he has tachycardia and a very feeble pulse
with engorged neck veins.
a) What is the diagnosis of this patient?
b) How would you manage this patient? [Annual 2015]
3. A 20-year-old boy is brought to the emergency in a state of hypovolemic shock. On

examination, there is left-sided chest crepitus and tenderness. How will you manage
this case? [Supple 2011 held in 2012]
4. A motorcyclist bumped into a car and sustained injury on right side. Examination
reveals tachypnea, limited respiratory movements on right side and diminished
breath sounds in lower part of the chest with dullness on percussion.
a) What is your investigation plan?
b) How will you manage such a patient? [Annual 2009]
Cardiac Tamponade
1. A young male suffered a stab wound in the front of left side of chest. He is brought
to Emergency Room in a state of shock. On examination, his neck veins are
engorged. His heart sounds are muffled but his breath sounds are present.
a) What is the cause of shock in this patient?
b) What is the main differential diagnosis of this condition?
c) How would you confirm your diagnosis?
d) What is the treatment of this condition? [Supple 2015 held in 2016]
2. A 20-year-old boy got stab injury to left side of chest in a fight. On examination the
external wound is about 2 cm from the left sternal border in the 4th intercostal
space. He has blood pressure of 80/60 mm Hg with engorged jugular veins. His pulse
is paradoxical.
b) What is the emergency treatment of this patient? [Annual 2015]
3. A patient has presented with history of chest injury and has blood pressure of 80/50
mm Hg.
45
b) What is the emergency management of this patient? [Annual 2009]
Flail Chest
1. A 20-year-old man is brought to emergency after a road traffic accident. He is
hypotensive and in respiratory distress. Examination of chest reveals a flail segment.
a) What is the flail chest?
b) Why he is in respiratory distress?
c) What is the treatment? [Annual 2010]
2. A 45-year-old shopkeeper is struck by vehicle and presents in emergency ward with

dyspnea. On examination, there is blunt injury to the chest and a segment of right
chest wall moves inward during inspiration and outward during expiration.
Chest Intubation
1. A 38-year-old male is stabbed with a kitchen knife in right upper chest. He complains
of pain and difficulty in breathing. A diagnosis of right sided hemopneumothorax is
made and insertion of an intercostal chest drain is planned. Write essential steps of
insertion of an intercostal chest drain in this patient. [Annual 2012]
2. A patient is brought to emergency with hemopneumothorax. Chest intubation is

indicated to relieve his symptoms. Enumerate the steps of chest intubation.
3. A 55-year-old bank officer meets road traffic accident and sustain blunt injury to
chest. He presents to emergency ward with dyspnea. Examination reveals absent
breath sounds on right side. Chest x-ray shows right hemopneumothorax. You
decided to do chest intubation. What are the steps of this operation? [Annual 2007]
Thoracotomy
1. A 35-year-old female is placed on operation table for left posterolateral thoracotomy
under GA. Your consultant asks you to make the appropriate position of the patient
for operation. Describe in detail the position you will like to place the patient.
2. What are the indications of urgent thoracotomy? [Supple 2011 held in 2012]
46
CARDIOVASCULAR
▪ HEART
Coronary Artery Disease
1. A 70-year-old person complains of chest pain, breathless and fatigue. It is affecting
his daily routine.
a) Suspecting ischemic disease, what are the various investigations you will order to
assess his cardiac condition?
b) Based on the investigations, what are the indications of coronary bypass surgery?
2. A 70-year-old female is scheduled for coronary artery bypass graft (CABG) combined
with aortic valve surgery employing CP bypass. Enlist atleast 10 potentially serious
complications which this patient may experience after being operated using
cardiopulmonary bypass technique. [Supple 2012 held in 2013]
3. A 60-year-old female presents in emergency suffering from chest pain,

breathlessness and syncope. She is suspected to be suffering from IHD.
a) How will you investigate her?
b) What are the indications of CABG? [Supple 2011 held in 2012]
4. A 55-year-old business executive with triple vessel disease has to undergo coronary
artery bypass grafting under CP bypass. Briefly describe cardiopulmonary bypass.
[Annual 2008]
5. A 50-year-old corporate executive has triple vessel coronary disease. Medical

treatment is unsatisfactory in this patient. What are different surgical treatment
options available for him? [Supple 2007 held in 2008]
Congenital Heart Disease

1. A tired and lethargic child, with history of cyanotic attacks that relieves on squatting
was diagnosed as a case of Cyanotic Congenital Heart disease.
a) Name the most common type of congenital heart disease.
b) Enumerate four intra-cardiac lesions.
c) Enlist two investigations to confirm the diagnosis. [Annual 2016]
47
▪ BLOOD VESSELS
Acute Limb Ischemia
1. A diabetic female patient 60 years of age is referred to surgical department after an
acute attack of Myocardial Infarction along with atrial fibrillation. Four hours later,
she complains of severe pain in her right calf along with numbness.
b) What other clinical examination you will perform to make this diagnosis?
c) When and what will be your treatment in this patient? [Annual 2019]
2. A 40-year-old obese male admitted to Cardiac Care Unit after a myocardial infarction
develops acute pain in the right lower limb and is unable to move it actively.
a) What are the clinical features suggestive of an embolus travelling into limb from
heart?
b) What are the emergency treatment options for such patients?
c) What is the type of gangrene presenting with acute limb ischemia?
3. A female patient 60 years of age suffered an acute attack of MI along with atrial
fibrillation. Four hours later, she complains severe pain in right calf along with
numbness.
Chronic Limb Ischemia

1. A 45-year-old male, diabetic, hypertensive and smoker, complains of pain in the calf
on walking which is relieved on resting. He presents with gradual blackening of 4th
and 5th toes of his right foot.
a) What is your diagnosis? Give brief justification.
b) How will you confirm the diagnosis?
c) Based on his clinical presentation, what is the most likely site of his disease?
d) Outline the management plan for him. [Supple 2016 held in 2017]
2. A 55-year-old salesman complains that he gets pain in his right calf after walking a
distance of one kilometer. The pain settles after resting but recurs walking the same
distance. He is smoker and hypertensive. On examination, his femoral pulses are
normal on palpation but his right popliteal, tibial and dorsalis pedis pulses are
absent.
48
a) Name the symptom he is describing,
b) What is the probable cause?
c) How will you investigate this patient? [Supple 2008 held in 2009]
Gangrene
1. A 45-year-old man who is immunocompromised presented with a gangrene.
a) What are different types of gangrene?
b) How will you investigate?
c) Give different treatment options. [Annual 2018]
Abdominal Aortic Aneurysm

1. A middle-aged male found to have small pulsating mass at the level of umbilicus
during the routine abdominal examination.
b) What is classification of this lesion?
c) What are indications of surgery? [Supple 2014 held in 2015]
2. A 65-year-old man who was diagnosed to have pulsatile mass of 6 cm diameter in his
abdomen a few months ago, now presents in emergency after he collapsed at home
with sudden severe pain in abdomen. On examination, he is in shock and has tender
rigid abdomen.
b) Outline the management plan for this patient. [Annual 2010]
3. A 60-year-old hypertensive male presents in emergency with 2 hours history of

sudden onset of severe abdominal pain and headache. His pulse is 120/min and BP is
80/60 mm Hg. Abdominal examination reveals a tender pulsatile mass in the upper
abdomen.
b) Briefly outline your management plan. [Annual 2012]
Aortic Dissection
1. A 60-year-old male smoker who is hypertensive without any history of diabetes
presented in ER with severe tearing intrascapular pain. Suspecting acute Myocardial
infarction, his ECG was done which did not show acute change of MI. His cardiac
enzymes and troponins were also normal. He said he did not take his routine anti-
hypertensive medication for the last few days. His BP on admission was 200/120 mm
Hg.
49
b) What are the latest advanced investigations to confirm the diagnosis?
c) Enumerate complications of this pathology. [Annual 2014]
Thoracic Outlet Syndrome

1. A 25-year-old female presents in outpatient department with complaints of pain and
numbness in left hand and forearm. She also develops cyanosis of left-hand fingers.
On examination, radial pulse disappears when the patient takes deep breath and
turns her face to right side. There is fullness in left supraclavicular space.
b) What are the different types of this disease?
c) How will you investigate and treat this condition? [Annual 2011]
Venous Ulcers
1. A 65-year-old male presents with an ulcer of long duration on his right ankle. On
examination, he has an irregular 3x3 cm, shallow pale looking ulcer on medial aspect
of the ankle.
a) What is the probable cause of this ulcer?
b) Name the investigations you will advise for this patient.
c) Outline briefly the management for this patient. [Supple 2010 held in 2011]
Deep Vein Thrombosis

1. A 60-year-old male who was bedridden develops fever of 100 F followed by pain and
swelling in his right calf. Right calf is tender with raised temperature as compared to
left side.
b) How will you manage this patient in emergency?
c) What measures can be taken to prevent this condition in future? [Annual 2011]
NEUROSURGERY
▪ HEAD INJURIES
Skull Injury
1. A 20-year-old male is brought to emergency after road traffic accident. Examination
revealed that patient is unconscious. GCS is 6. Blood-mixed CSF from nose and ear is
draining and there is bruise behind ear.
50
a) What type of head injury is this patient suffering from?
b) What other important physical sings will you elicit? [Annual 2018]
Brain Injuries
1. A young boy suffered a head injury in a motor cycle accident and arrived in the
emergency with bleeding from his head and a GCS of 8.
a) Write down Glasgow Coma Scale to assess head injury.
b) How will you prevent secondary brain injury in this patient?
[Annual 2009]
2. A 40-year-old male presented in accident and emergency department after road

traffic accident.
a) How would you do primary survey?
b) He opens his eyes to command, localized pain and is confused. Calculate his
Glasgow Coma Scale (GCS) score.
c) What is significance of GCS? [Annual 2017]
3. A 25-year-old male is brought to the Emergency Room with history of Road Traffic
Accident and isolated head injury. His pulse is 90/minute and his Blood Pressure is
115/80 mm Hg. He opens eyes to pain, withdraws to pain and utters
incomprehensible sounds.
a) What is his Glasgow Coma Score (GCS)? Justify.
b) How would you manage him in the Emergency Room?
c) Enlist three important management measures to prevent ‘secondary brain injury’
4. A 40-year-old male presented in A&E department after road traffic accident. How
would you do primary survey? He opens his eyes to command, localized pain & is
confused. Calculate his Glasgow coma score & what is its significance? [Annual 2013]
5. A 35-year-old male driver sustains head injury following a high-speed motor vehicle
crash. On examination, he is drowsy with pulse rate of 90/min and BP of 118/80 mm
Hg. Examination of chest, abdomen and musculoskeletal system is normal.
a) What neurological examination will you perform to assess the severity of head
injury in this patient?
b) How will you prevent secondary brain injury in this patient? [Annual 2012]
51
6. A 27-year-old male car driver had a head crash with a side wall barrier. He was found
unresponsive at the site of crash with GCS of 6, low volume thready pulse and rapid
shallow breathing. And his right leg at thigh is bent at an angle. You are the 1 st
responder at the site of the crash.
a) What are your priorities in the management of this patient?
b) How would you ensure a safe transfer of this patient to the hospital?
[Annual 2011]
Extradural Hematoma
1. A young man receives a severe blow in his right temple during a fight. When he was
brought to Emergency Room, he was drowsy and irritable, pulse 56/min and BP
160/90 mm Hg. There is left hemiparesis and right pupillary dilation.
a) What is the significance of pulse and BP reading in this patient? What initial
measures will you take on the basis of his vital signs?
b) What is your clinical diagnosis and which is investigation of choice in this patient?
c) What is the significance of pyrexia in such patient? [Supple 2015 held in 2016]
2. Enumerate different types of intracranial hematomas. What are the indications of CT

scan after head injury? [Supple 2013 held in 2014]
3. A 28-year-old motorcyclist is brought to emergency of tertiary care hospital

following a high-speed crash when his head struck to the side of an electric pole. He
is confused and has a large ulcerated wound on left temporal region which is not
actively bleeding. There is history of brief period of unconsciousness following injury.
He has been resuscitated with ATLS protocol.
a) What are the guidelines to obtain a CT scan of head after injury?
b) Briefly outline the management of an acute extradural hematoma.
4. A 60-year-old gentleman falls in the washroom while taking a shower. He is also

found unconscious by the housemaid but by the time help arrives he has regained
consciousness. Later that day he is brought to you in the Accident and Emergency
department in a coma and x-ray of skull reveals fracture of the right temporal bone.
How would you manage this case? [Supple 2008 held in 2009]
5. 60-year-old recently retired public servant slipped in bathroom in the morning and
becomes unconscious, but gains consciousness within minutes. He becomes well and
does not feel the need to go to hospital. In the same afternoon, he is brought to
52
emergency ward in coma. X-ray reveals fracture of right temporal bone. How would
you manage this case? [Annual 2007]
Subdural Hematoma
1. A 30-year-old motorcyclist is injured in Road Traffic Accident. He is brought to
Emergency Room. On examination, he is semiconscious with noisy breathing. There
is no facial bleeding. His pulse is 90/min and blood pressure is 120/70 mm Hg.
Examination of chest, abdomen and extremities is unremarkable.
b) What are the indications of CT scan?
c) What is the basic principle of management in this patient?
[Annual 2015]
2. Enumerate different types of intracranial hematomas. What are the indications of CT

scan after head injury? [Supple 2013 held in 2014]
Brain Death
1.
a) Define brainstem death.
b) What are stages of diagnosis?
c) What are brainstem reflexes? [Supple 2014 held in 2015]
2. A patient suffering from severe head injury had been on ventilator support in the
ICU. After 2 weeks he developed brain stem death. How would you think the
diagnosis of the brain stem death is made? [Supple 2011 held in 2012
Brain Tumors
1.
a) Classify primary brain tumors on the basis of cell of origin and histologic grade.
b) What are the cardinal features of brain tumors? [Supple 2019 held in 2020]
Hydrocephalus
1. A 6-year-old child has presented with irritability, headache, projectile vomiting and
blurring of vision progressively worsening over the past few weeks. A local doctor
has commented on presence of ‘Sun Setting’ sign.
a) What is the patient most probably suffering from and what are its common
etiologies?
53
c) How Monro-Kellie doctrine can explain this condition?
2. A child with ‘sun-setting’ eye sign presents with vomiting, blurred vision and
drowsiness. CSF pressure is raised in this child.
b) Enlist two main types of this problem.
c) Enlist two main drainage procedures to treat it. [Annual 2016]
▪ DISEASES OF THE VERTEBRA & SPINAL CORD

Prolapsed Intervertebral Disc
1. A 50-year-old male, lifetime smoker, developed low back pain radiating down the
right lower limb. He was lifting a heavy box from floor when he suddenly developed
severe back pain and was unable to stand up straight. He has been running a fruit
shop for the last 25 years.
a) What is the most probable diagnosis based on the history of the patient?
b) What is the pathophysiology of his symptoms?
c) What are the risk factors mentioned in the history of patient?
d) How would you manage this patient? [Annual 2014]
2. A young laborer developed onset of severe back pain on lifting while bending. He
also had numbness in legs along with difficulty passing urine.
a) What is your most likely diagnosis?
b) What positive finding will you expect on clinical examination?
c) How would you investigate this patient?
d) What is the treatment? [Annual 2008]
HEAD & NECK

▪ SALIVARY GLANDS
Disorders of Minor Salivary Glands
1. A young girl of 17 years of age presents with a painless cystic swelling of 1 cm in size
presents on inner surface of lower lip. It is trans-illuminant.
54
b) What is the usual cause of this lesion?
c) Give the management options for this girl. [Supple 2010 held in 2011]
Disorders of Sublingual Glands

1. A teenage girl presented with soft fluctuant swelling in submental region. On
intraoral examination, a bulge is also seen in the floor of mouth.
b) What is the pathology of this lesion?
c) What will be the result of transillumination test of this swelling?
d) Mention two investigations for diagnosis confirmation.
e) What is the treatment? [Supple 2015 held in 2016]
Disorders of Submandibular Glands

1. A 32-year-old female attends surgical outpatient clinic with recurrent right
submandibular swelling and low-grade fever. Swelling becomes bigger in size during
eating. On clinical examination, she had redness and tenderness in the right
submandibular area with poor orodental hygiene. OPG X-ray indicated 0.5x0.5 cm
opacity in sublingual area.
b) Write down three differential diagnoses. [Annual 2019]
2. A 60-year-old male has been suffering from painless swelling at the angle of right
lower jaw for 10 years. Initially, it was small with not much change in its size but for
the last one month it has started growing. On examination, the swelling is 5x6 cm,
firm consistency with restricted mobility over deep structures. Skin over it is normal
and not adherent to it.
a) What type of the swelling patient is suffering from and what change might have
occurred in it?
b) Clinical examination of which structure should be done in this patient?
c) Give brief description of its examination.
d) Give brief management of this patient. [Annual 2014]
Disorders of Parotid Gland

1. A 25-year-old female presented with a right sided swelling near the angle of the jaw
postero-inferior to ear lobe for the past 4 months. There is no change in the size with
swallowing and is non-tender.
a) Enlist three most common differential diagnoses of such swellings.
b) What are the common signs of malignancy in such swellings?
55
c) Enlist three complications of the procedure due to injuries to surrounding nerves.
2. A 35-year-old male presented in OPD with 3x2 cm swelling at angle of mandible on

right side for last one month. On examination and investigations, he was found to
have a tumor of the right parotid gland.
a) What is the most common tumor of the parotid gland?
b) How will you investigate the patient?
c) What structure will you like to preserve during surgery of superficial
parotidectomy and name the common complications of parotid surgery?
[Annual 2011]
3. A 35-year-old retired soldier presents with a slow growing painless swelling below
the lobule of left ear. Examination reveals a tumor arising from parotid gland. How
would you classify parotid tumor? [Supple 2007 held in 2008]
▪ TUMORS OF THE ORAL CAVITY

Premalignant Conditions of Oral Cavity
1. What are conditions associated with malignant transformation of oral cavity and
oropharynx? [Supple 2014 held in 2015]
Oral Cancer
1. A 60-year-old male presents with an ulcer on right lateral border of tongue. He is
feeling difficulty in swallowing. He gives history of pan chewing for the last 40 years.
On physical examination, a lump is palpable in neck.
b) Briefly discuss the various investigations you will order in this patient.
2. A 60-year-old female presented with a non-healing ulcer at buccal mucosa posterior.

Recently she developed complaint of difficulty in opening of mouth.
b) How will you investigate the problem? [Annual 2018]
3. A 58-year-old woman who has been chewing ‘betel nut’ for the last twenty years,
has a 3 cm painless ulcer on the right side of her tongue for the last 10 months.
There are palpable ipsilateral submandibular lymph nodes in the neck.
56
a) How would you investigate the patient?
b) What is the most common operative plan if there is no distant metastasis?
c) What is the most common histologic variety of tumor on the tongue?
4. A 50-year-old smoker comes to the OPD with a 1 cm x 1 cm ulcer on the lower lip for
the last 2 months. The ulcer is not healing despite using antibiotics, steroids and
fungal creams.
c) What modalities are available to treat him? [Supple 2016 held in 2017]
5. A 70-year-old tobacco chewing female presents with fungating growth on the right
side of her tongue. Biopsy revealed malignant growth.
a) Which is the most common tumor of the tongue?
b) Name the five principal lymph node levels of the neck.
c) Enlist five investigations which help to confirm the diagnosis and staging the
disease. [Annual 2016]
6. An old lady with long history of chewing Areca nut (pan masala) presented with a
lesion on the vermillion border of lower lip. Biopsy was taken which confirmed
malignancy.
a) Histopathological which type of malignancy commonly occur in the lip/oral
cavity?
b) Biopsy should be taken from which part of ulcer in case of suspected malignancy?
c) What are two main modalities of treatment for oropharyngeal malignancy?
d) What are the general principles of managing oropharyngeal CA?
e) How does this lesion on lip tend to spread? [Supple 2015 held in 2016]
7. A 62-year-old smoker presented with non-healing ulcer on the left lateral side of
tongue. On examination, the ulcer is present over the posterior side of the tongue.
Submandibular lymph nodes hard in consistency are also palpable.
a) What are the differential diagnoses?
b) What are the principles of management? [Annual 2015]
8. A 62-year-old alcoholic presents with an indurated ulcer 1.5 cm in length in the right
lateral aspect of his tongue.
57
b) What are the predisposing factors?
c) What are different cervical lymph node levels? [Supple 2014 held in 2015]
9. A 60-year-old male presented with a 1.5x2 cm ulcer on the left lateral border of
posterior 1/3 of tongue for last 3 months. It has failed to heal despite treatment
from a local doctor. On examination, ulcer edges are indurated and examination of
neck reveals a non-tender lump 2x2 cm in left submandibular region.
b) What investigations will you do in this patient?
c) What are treatment options in this patient?
d) What are the risk factors for this disease? [Annual 2014]
10. A 55-year-old woman who has been chewing ‘betel nut’ for the last twenty years,
has a painful ulcer on the side of her tongue for the last six months. Examination
revealed a 3 cm ulcer on right lateral margin of anterior two-thirds of tongue with
hard base & raised edges. There were no palpable lymph nodes in the neck. X-ray
chest is normal.
b) What investigations will you do to confirm your diagnosis? [Annual 2013]
11. A 65-year-old smoker presents with an ulcerated mass on internal border of the
tongue. On examination he has deviation of the tongue with loss of sensation over
the tongue.
b) What is the cause and deviation and loss of sensation of tongue?
c) What will be your management plan? [Annual 2010]
12. A 35-year-old patient presents with hyperkeratotic patches on his tongue.

b) Give various causes of this condition. [Supple 2009 held in 2010]
13. A patient has ulcer in the anterior third of the tongue with a lymph node in the
submental region.
a) What is your investigation plan?
58
14. A 65-year-old politician, who is betel chewer for last 50 years, presents with 1.5 cm
diameter ulcerated swelling on lateral border of the tongue. On examination,
swelling is hard.
15. A 50-year-old male presented with 3.5 cm ulcer on margin of his tongue for previous
6 months. He gave history of betel chewing for previous 30 years. Examination
revealed that the ulcer had indurated base and everted margins.
b) How would you treat this case?
Management of Neck Dissection in Oral Cancer

1. A 30-year-old male presents in the OPD with gradual enlargement of neck nodes for
the last four months. There is a history of weight loss as well.
a) Enumerate three relevant common differential diagnoses.
b) For your differential diagnoses, write the characteristics of lymph nodes for each.
c) Lymph node biopsy reveals Metastatic Papillary Carcinoma of Thyroid. Total
Thyroidectomy with a Modified Radical Neck Dissection is planned. Define
Modified Radical Neck Dissection and name the structures at risk during the
dissection. [Supple 2016 held in 2017]
Metastatic Cervical Lymph Nodes

1. A 55-year-old female presents with four months history of gradually enlarging
painless swelling on upper left neck. On examination, the swelling is firm to hard,
relatively fix with well-defined margins. FNAC reveals cervical lymph node with
squamous cell carcinoma.
a) How will you look for primary lesion?
b) Briefly describe the management plan for this patient.
▪ NECK SWELLINGS
1. A mother brings her 5-year-old son with a history of swelling on the right side of
neck. It is soft, fluctuant and non-tender. Transillumination test is positive.
b) Describe two other swelling in the neck with differentiating features.
c) What are the complications of this swelling? [Supple 2019 held in 2020]
59
2. A 20-year-old male presented with a discharging sinus in the posterior triangle of
neck. Examination revealed multiple lymph nodes matted together in posterior
triangle of neck at the site of sinus.
a) What is pathophysiology of this clinical condition?
3.
a) What are the common causes of lymph node enlargement in the posterior
triangle of neck?
b) How will you confirm the diagnosis?
c) And what precautions you undertake while excising this lymph node?
4. A 15-year-old sanitary worker presents to you with a slow growing lump on the right
side of the neck for last 6 months. Examination reveals enlarged matted together
upper deep cervical lymph nodes.
b) How would you investigate her? [Annual 2007]
▪ CLEFT LIP & PALATE

1. A neonate suffering from unilateral cleft lip and palate is brought to a pediatric
surgeon.
a) What is the ideal time for primary repair procedures of cleft lip & palate?
b) What are the long-term complications that these children are likely to develop?
2. Parents brought their newborn male baby for a splitting defect in the left side of his
upper lip, difficulty in sucking the breast milk & leakage of any feed milk from the
nose.
b) What are the principles of management of this condition? [Annual 2012]
▪ MAXILLOFACIAL INJURIES
Mandibular Fractures
1. A 25-year-old motorcyclist meets a road traffic accident and presents to accident and
emergency department with injury to face. Examination reveals no external wound
60
but there is mild bleeding from lower labial sulcus. X-ray shows fracture of mandible
through to the right canine fossa. How would you treat this case? [Annual 2007]
▪ DENTAL SURGERY
Ameloblastoma
1. Write clinical features and treatment of ameloblastoma of mandible.
TRACHEOSTOMY
1.
a) Enlist indications of tracheostomy.
b) Write down the complications of tracheostomy. [Annual 2017]
2. Enlist indications & complications of tracheostomy. [Supple 2013 held in 2014]
3. A young adult is brought to emergency. Tracheostomy is needed. Describe the steps

of emergency tracheostomy. [Supple 2008 held in 2009]
61

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SURGERY II – PAST QUESTIONS

2. A 30-year-old pedestrian was hit by a bumper of a car leading to open fracture of

3. A 45-year-old motorcyclist meets a road traffic accident and develops simple

▪ FRACTURES OF UPPER LIMB

▪ FRACTURES OF LOWER LIMB

3. A 45-year-old female presented to accident & emergency department with right

2. A 25-year-old political worker presents with a painless swelling around right

▪ BONE & JOINT INFECTIONS

▪ PERIPHERAL NERVE INJURIES

Specific Nerve Injuries

▪ DEGNERATIVE DISEASES OF MUSCULOSKELETAL SYSTEM

UPPER GASTROINTESTINAL TRACT

Gastroesophageal Reflux Disease (GERD)

4. A 30-year-old carpenter presents to surgical outdoor department with dysphagia of 3

1. A 40-year-old man gives history of regurgitation & dysphagia. Endoscopic

4. A 50-year-old smoker, otherwise healthy, presents in the OPD for increasing

6. A 45-year-old female is under yearly surveillance endoscopy for Barrett’s change in

▪ STOMACH & DUODENUM

Peptic Ulcer Disease

2. A 30-year-old male presents in emergency department with severe abdominal pain,

5. A 60-year-old smoker, known patient of Acid Peptic Disease, presents in the

Hydatid Liver Disease

3. Enlist steps of laparoscopic cholecystectomy in 34-year-old female with multiple gall

Choledocholithiasis (CBD stone)

2. A 40-year-old receptionist presents with pain in right hypochondrium and

2. A 45-year-old female housewife presented in OPD with history of right

2. A 35-year-old female is presented in emergency room with severe epigastric

3. A 45-year-old male is admitted in emergency with diagnosis of acute biliary

4. A 60-year-old man presents in surgical emergency with short history of severe

2. A 65-year-old male presented with three months history of progressively worsening

▪ PERITONEUM, MESENTERY & RETROPERITONEAL SPACE

2. A 25-year-old woman is admitted to the hospital because of fever, bloody diarrhea

3. A 40-year-old man has recently been diagnosed to be suffering from Ulcerative

3. A 60-year-old male is diagnosed to have an adenocarcinoma of cecum. CT shows no

5. A 65-year-old male presented with 6 months history of fresh per-rectal bleeding

Ileostomy & Colostomy

2. A 27-year-old man is suffering from familial polyposis coli. He is advised to have

3. A 45-year-old senator presents in casualty outdoor department with a 12 hours

Mass in Right Iliac Fossa

4. A 35-year-old housemaid presents to hospital with sharp agonizing pain starting

3. A 62-year-old female presented with complaints of something coming out of rectum

a) What is your diagnosis?

4. A 45-year-old female complains of painless bleeding at defecation with appearance

5. A 40-year-old female presents with history of repeated episodes of painless bleeding

▪ HERNIA, UMBILICUS & ABDOMINAL WALL

2. A 45-year-old male presented to Emergency Room with a complaint of recurrent

4. A 20-year-old university student has to undergo left inguinal herniorrhaphy by

▪ KIDNEY & URETER

4. A 45-year-old lady is undergoing right pyelonephrolithotomy. What are the salient

4. A 30-year-old male presented in emergency department with severe pain in left

5. A laborer working in bathas comes to ER with pain in right abdomen radiating to

4. A 1-year-old boy is brought to hospital for rapidly growing abdominal mass,

Urinary Bladder Fistulae

2. A 60-year-old male presents in the OPD with symptoms of frequency, nocturia

3. A 55-year-old patient attends outpatient clinic with complaint of low backache of

2. A 31-year-old male presented in surgical emergency when he had fallen astride a

3. A young man of 35 years presented in emergency with history of astride injury

▪ TESTES & SCROTUM

3. A 12-year-old boy presented to emergency room complaining of sudden onset of

Thyroglossal Duct, Cyst & Fistula