---

PAPER 1 - Ward Leaving Test, Surgery (MBBS 2022 D Batch)

---

Q1. Clinical Features and Examination Findings of a Reducible Hernia (5 marks)

Definition

Clinical Features (Symptoms)

• Swelling - appears on straining, coughing, or standing; disappears on lying down
• Dragging/aching discomfort - worsens with prolonged standing or exertion
• No constant pain - pain is present only transiently during straining
• History of increase in size with coughing or straining (cough impulse)
• No features of obstruction (no vomiting, no absolute constipation)

Examination Findings

• A swelling is visible in the groin/hernia site on standing or coughing
• Swelling disappears on lying down
• Overlying skin is normal
• In inguinal hernia: swelling may extend into the scrotum (indirect)

• Swelling is soft and reducible - can be pushed back into the abdomen with a gurgling sound
• Cough impulse is positive - a transmitted impulse is felt on the fingertip placed over the hernia ring when the patient coughs
• The hernia ring (defect in the abdominal wall) can be palpated once the hernia is reduced
• No tenderness (unlike irreducible or strangulated hernia)
• Sac can be felt as a smooth, rounded swelling

---

Q2. History of Present Illness (HOPI) Points in a Patient with Thyroid Swelling (5 marks)

HOPI for Thyroid Swelling

• When did the swelling first appear?
• Was onset sudden or gradual?
• Duration (weeks, months, years)

• Increasing, decreasing, or static in size?
• Rapid increase suggests malignancy or haemorrhage into a cyst

• Single nodule or multinodular?
• Midline (thyroglossal cyst) vs lateral (thyroid lobe)

• Dysphagia - difficulty swallowing (oesophageal compression)
• Dyspnoea / stridor - tracheal compression
• Hoarseness of voice - recurrent laryngeal nerve involvement (suggests malignancy)
• Distension of neck veins (superior mediastinal syndrome)

• Sudden pain in thyroid suggests haemorrhage into a cyst
• Dull aching pain - thyroiditis
• Radiation to ear (De Quervain's thyroiditis)

• Cervical lymphadenopathy - suggests malignancy

• Iodine deficiency (endemic area?)
• Previous radiation to neck
• Family history of thyroid disease or MEN syndrome
• Previous thyroid disease or surgery

• Fever, weight loss, malaise (suggests thyroiditis or malignancy)

---

Q3. Clinical Examination of Varicose Veins + Special Tests (5 marks)

Definition

Inspection (Patient Standing)

• Extent of varicosities - distribution along long saphenous (medial aspect) or short saphenous (posterior/lateral calf)
• Skin changes over medial malleolus: eczema, lipodermatosclerosis, pigmentation (haemosiderin), ulceration
• Ankle oedema
• Any obvious swelling at groin (sapheno-varix)
• Scars from previous surgery

Palpation

• Tenderness along the vein (phlebitis)
• Temperature (warmth in thrombophlebitis)
• Varicosity texture - soft and compressible
• Sapheno-varix at groin: soft, compressible, disappears on lying, positive fluid thrill on percussion below
• Feel for incompetent perforators (fascial defects along medial calf/thigh)

Special Clinical Tests

• Patient lies down; leg elevated to drain varices
• Finger/tourniquet applied at sapheno-femoral junction (upper thigh)
• Patient stands up
• Positive result: Varices remain empty while tourniquet is on - confirms SFJ incompetence
• On releasing tourniquet: veins fill rapidly from above - confirms SFJ as the source
• Negative result: Veins fill even with tourniquet on - incompetent perforators lower down

• Tourniquet applied at upper thigh (in standing patient)
• Patient asked to walk/exercise the leg for a few minutes
• Normal result: Varices empty (deep veins are patent, blood drains from superficial to deep)
• Positive (abnormal): Varices become more prominent, patient gets pain - indicates deep vein obstruction; surgery on varices is contraindicated

• With patient lying and veins collapsed, mark the sites of fascial gaps (perforators) along the medial leg
• These correlate with incompetent perforating veins

• Finger on sapheno-femoral junction; patient coughs
• Impulse felt - confirms SFJ incompetence

• Tap on one varicosity; impulse felt in another - confirms venous continuity

---

Q4. Causes of Right Iliac Fossa Lump + One Distinguishing Feature of Each (5 marks)

Classification and Causes

---

Q5. Clinical Examination of a Breast Lump (5 marks)

Patient Position

Inspection (Both Breasts Compared)

• Size, shape, symmetry of both breasts
• Skin changes: redness, oedema, peau d'orange (orange peel appearance - lymphoedema from blocked dermis = carcinoma), skin dimpling
• Nipple: retraction, inversion, discharge, Paget's disease (eczematous change of nipple)
• Prominent veins (Haller's sign - carcinoma)
• Any visible lump
• Arms raised above head - accentuates dimpling/tethering

Palpation

1. Site - which quadrant, distance from nipple (upper outer most common for carcinoma)
2. Size - in cm (two dimensions)
3. Shape - round, oval, irregular
4. Surface - smooth (fibroadenoma, cyst) vs irregular (carcinoma)
5. Consistency - soft (lipoma, abscess), firm (fibroadenoma), hard (carcinoma), fluctuant (cyst/abscess)
6. Tenderness - tender (abscess, fibroadenoma) vs painless (carcinoma)
7. Edge/Margins - well-defined (benign) vs ill-defined (malignant)
8. Mobility - mobile in two planes (fibroadenoma - "breast mouse") vs fixed (carcinoma)
9. Tethering/fixity:
   • Skin fixity: pinch skin over lump; dimpling = tethered to skin
   • Deep fixity: lump moves with muscle contraction (hand on hip/pushing in) = attached to pectoralis major
10. Nipple discharge - milky (galactorrhoea), bloody (papilloma/carcinoma), greenish (fibrocystic)

Lymph Node Examination (Axilla + Supraclavicular)

• Axillary nodes: Anterior (pectoral), posterior (subscapular), lateral (brachial), central, apical
• Supraclavicular nodes
• Note: size, consistency, fixity, number

• Level I: below lateral border of pectoralis minor
• Level II: behind pectoralis minor
• Level III: above/medial to pectoralis minor

Triple Assessment (Bailey & Love, 28th Ed.)

---

Q6. Steps of Examination of a Swelling in General (5 marks)

Step 1 - Inspection

1. Site and position - anatomical region
2. Size - approximate dimensions
3. Shape - spherical, oval, irregular
4. Surface - smooth vs bosselated/irregular
5. Skin over swelling - normal, red (inflamed), stretched, shiny, punctum, scars, sinuses, ulceration, colour changes
6. Visible pulsations - aneurysm
7. Visible peristalsis - hernia containing bowel
8. Relationship to surrounding structures - superficial vs deep

Step 2 - Palpation

1. Temperature - warm (inflamed/vascular), cold (lipoma, non-inflamed)
2. Tenderness - present (inflammatory/traumatic), absent
3. Consistency:
   • Soft (lipoma, abscess)
   • Firm (lymph node, fibroadenoma)
   • Hard (bone, calcified lesion, carcinoma)
   • Elastic (cyst, hydrocele)
4. Surface - smooth or nodular/irregular
5. Edge - well-defined or ill-defined
6. Fluctuation - indicates fluid content; test in two planes perpendicular to each other
7. Reducibility - if the swelling can be pushed back (hernia)
8. Pulsatility:
   • Transmitted pulsation - solid vascular tumour overlying an artery
   • Expansile pulsation - aneurysm (swells in all directions)
9. Compressibility - haemangioma (empties and refills)
10. Transillumination - shines light through fluid-filled cysts (hydrocele, cystic hygroma)
11. Plane of swelling - subcutaneous, deep fascia, muscle, bone
12. Mobility - in relation to skin and deep structures

Step 3 - Percussion

• Resonant - bowel/gas content
• Dull - solid or fluid-filled
• Hyperresonant - gas-filled distended viscus

Step 4 - Auscultation

• Bowel sounds (hernia containing gut)
• Bruit (aneurysm, AV malformation, vascular tumour)
• Venous hum

Step 5 - Special Tests

• Diaphanoscopy / transillumination
• Cough impulse (hernia)
• Cross-fluctuation (abscess tracking through tissue planes)

---

---

PAPER 2 - Sri Aurobindo University, Department of General Surgery

---

Q1. General Physical Examination of a Patient Presenting with Jaundice (5 marks)

General Inspection

• Cachexia/weight loss - suggests malignancy (carcinoma head of pancreas, cholangiocarcinoma)
• Well-nourished - suggests hepatitis or haemolytic jaundice

• Lemon-yellow (mild) - haemolytic jaundice
• Deep yellow/orange - obstructive jaundice (surgical significance)
• Yellow-green (greenish) - prolonged cholestasis/malignant obstruction
• Dark yellow + pale (anaemic) - haemolytic

Systematic Head-to-Toe Inspection

• Scleral icterus - earliest sign
• Xanthelasma (periorbital cholesterol deposits) - chronic cholestasis
• Kayser-Fleischer rings (Wilson's disease)
• Anaemia (pale conjunctiva) - haemolytic jaundice

• Jaundice distribution
• Scratch marks (excoriation) - obstructive jaundice (bile salts deposit in skin causing pruritus) - surgical significance
• Spider naevi (upper body) - hepatocellular disease, cirrhosis
• Palmar erythema - liver disease
• Purpura/bruising - coagulopathy (decreased clotting factor synthesis)
• Xanthomata (cholesterol deposits in skin folds) - prolonged obstruction

• Leuconychia (white nails) - hypoalbuminaemia (cirrhosis)
• Clubbing - liver disease, biliary cirrhosis
• Dupuytren's contracture - alcoholic liver disease
• Flapping tremor/asterixis - hepatic encephalopathy
• Palmar erythema

• Distension - ascites (chronic liver disease)
• Courvoisier's sign (Courvoisier's Law): Palpable, non-tender gallbladder in the presence of jaundice = malignant obstruction (carcinoma head of pancreas), NOT gallstones (stone disease causes fibrosed gallbladder) - surgically most important sign
• Hepatomegaly - smooth (hepatitis), nodular (metastases, cirrhosis)
• Splenomegaly - portal hypertension, haemolytic disease
• Caput medusae - dilated periumbilical veins in portal hypertension
• Ascites - shifting dullness, fluid thrill

• Virchow's node (left supraclavicular) - gastric/pancreatic malignancy
• Hepatic hilum lymphadenopathy

• Dark urine + pale stool - obstructive (surgical) jaundice (conjugated bilirubin in urine, no urobilinogen in stool)
• Dark urine + dark stool - hepatocellular
• Normal urine + dark stool - haemolytic

---

Q2. Clinical Examination of a Breast Lump (Same as Paper 1 Q5 above)

---

Q3. Method of Examination of a Swelling in the Neck (5 marks)

Inspection (Patient Seated, Good Lighting)

1. Site - midline vs lateral; which triangle (anterior/posterior)
2. Size and shape
3. Surface - smooth, lobulated
4. Skin - normal, red, sinus/fistula
5. Pulsation - carotid aneurysm
6. Movement with swallowing - ask patient to swallow water; thyroid swellings and thyroglossal cysts move upward with deglutition
7. Movement with tongue protrusion - thyroglossal cyst moves up on tongue protrusion (attached to hyoid via thyroglossal duct)

Palpation

1. Temperature and tenderness - warm and tender = inflammatory (thyroiditis, abscess)
2. Size, shape, surface, edge - as per general swelling exam
3. Consistency:
   • Soft (lipoma, abscess)
   • Firm (lymph node, thyroid goitre)
   • Hard (metastatic nodes, calcified)
   • Tense-cystic (branchial cyst, thyroglossal cyst)
4. Fluctuation - present in cystic swellings (abscess, branchial cyst)
5. Mobility - in all directions (lipoma, sebaceous cyst) vs restricted (deep cervical nodes)
6. Tracheal deviation - large goitre
7. Movement on swallowing - thyroid moves up
8. Movement on tongue protrusion - thyroglossal cyst moves up

Percussion

• Retrosternal extension of goitre: percuss over sternum - dull over retrosternal mass

Auscultation

• Bruit over thyroid - Graves' disease (increased vascularity)

---

Differentiating Cystic vs Solid Swellings

• Branchial cyst - upper anterior triangle, anterior to SCM, transilluminates (cholesterol crystals give "brilliant" transillumination)
• Thyroglossal cyst - midline, moves on swallowing AND tongue protrusion
• Cystic hygroma - multilocular, brilliantly transilluminates, posterior triangle, present at birth
• Cold abscess - fluctuant, non-tender, no warmth (TB)

---

Q4. Clinical Examination of an Inguinoscrotal Swelling (5 marks)

Inspection (Patient Standing)

1. Location - inguinal vs scrotal vs inguino-scrotal
2. Side - right/left/bilateral
3. Size and shape
4. Skin - normal, erythematous (strangulated hernia), dilated veins (varicocele)
5. Cough impulse - visible expansion on coughing
6. Whether it extends above inguinal ligament (hernia extends into groin; hydrocele is primarily scrotal)

Palpation

• Cannot get above swelling = Inguinoscrotal hernia (extends through inguinal canal)
• Can get above swelling = Intrascrotal swelling (hydrocele, epididymal cyst, orchitis, tumour)

• Cough impulse: positive (expansile impulse over external ring)
• Reducibility: contents pushed back with gurgling
• On reduction: feel the inguinal canal and deep ring
• Distinguish indirect from direct:
  • Indirect: originates above and lateral to pubic tubercle; goes down to scrotum; controlled by pressing over deep ring
  • Direct: above and medial to pubic tubercle (Hesselbach's triangle); rarely descends to scrotum; NOT controlled at deep ring

---

Differentiating Hernia from Hydrocele

---

Q5. Clinical Examination of a Patient with Varicose Veins (Same as Paper 1 Q3)

---

Q6. Examination of a Case of Chronic Ulcer in the Leg (5 marks)

Systemic Examination First

• Diabetes mellitus (neuropathic ulcer): check for peripheral neuropathy (loss of sensation - Semmes-Weinstein monofilament test, vibration, proprioception), Charcot joints
• Hypertension / Atherosclerosis (ischaemic ulcer): cardiac examination, BP in both arms
• Anaemia, nutritional status: poor healing
• Rheumatoid arthritis (vasculitic ulcer): joint deformities
• Blood pressure and peripheral pulses

---

Local Examination

Inspection of the Ulcer

1. Site:
   • Medial malleolus / gaiter area = venous ulcer
   • Foot/toes/heel = arterial (ischaemic) ulcer
   • Over bony prominences = pressure ulcer
   • Painless plantar surface = neuropathic ulcer
2. Size (length x width in cm)
3. Shape - round, oval, irregular
4. Number - single vs multiple
5. Edge:
   • Sloping/shelving edge = healing or venous ulcer
   • Punched-out edge = ischaemic or syphilitic
   • Undermined edge = tuberculosis / decubitus
   • Rolled/everted edge = carcinoma
   • Raised and pearly edge = rodent ulcer (BCC)
6. Floor:
   • Pink granulation = healing
   • Pale/grey granulation = infected / ischaemic
   • Slough/necrotic tissue = poor healing
   • Exposed tendon or bone = deep/ischaemic
7. Surrounding skin:
   • Varicose eczema, lipodermatosclerosis, haemosiderin pigmentation = venous
   • Pale, hairless, shiny, cold = arterial
   • Callosity around ulcer = neuropathic (Marjolin's ulcer from chronic scar)

Palpation

• Temperature of surrounding skin (warm = venous; cold = arterial)
• Tenderness (venous ulcers are painful; neuropathic are painless)
• Edge consistency (hard edge = malignant transformation - Marjolin's ulcer)
• Depth of ulcer
• Floor - granulation, slough, bone

Regional Lymph Nodes

• Inguinal lymph nodes - enlarged if infected

---

Assessment of Vascularity (Critical for Surgical Planning)

1. Peripheral pulses:
   • Femoral, popliteal, posterior tibial, dorsalis pedis
   • Absent/weak pulses = arterial disease (ABPI needed)
2. Capillary Refill Time (CRT):
   • Normal < 2 seconds; > 2 sec = poor perfusion
3. Buerger's test:
   • Elevate leg to 45° - if pallor develops = arterial insufficiency
   • Then hang leg down - reactive hyperaemia (Buerger's angle < 30° = severe ischaemia)
4. Venous guttering: Superficial veins empty on elevation = arterial disease
5. Skin color changes - dependent rubor, elevation pallor = critical ischaemia

• ABPI (Ankle Brachial Pressure Index): < 0.9 = PAD; < 0.5 = critical ischaemia; if < 0.6, compression bandaging is contraindicated
• Duplex Doppler ultrasound - maps venous/arterial flow
• Toe pressures / Transcutaneous oxygen (TcPO₂) - for diabetics (calcified vessels give falsely high ABPI)
• MR/CT Angiography - for surgical planning

---

Ulcer Type Summary

---