INI-CET May 2024|| Surgery Recall ||Dr.Saurabh Dixit ||Important add on concepts for NEET PG 2024

a easy standard paper we are not expecting the in set paper to be so easy so today I will start with this uh in set you can say recall because again when we talk about the upcoming exam we get to know the mood so it's very important for us to understand the Ina set related questions and what could be the probable questions that could be asked in the upcoming exams so if you have given in head it's already passed so you don't panic about if you have done it good it's good otherwise just take it as a practice test so this time we had questions from git also uh from thyroid also from breast also from Urology also general surgery yeah trauma was there but not too many questions unlike the standard you know I said already we have seen that we don't get a lot of questions last to last it was 10 then it was seven questions and this year we have got got gone a decent got a questions have been asked so let us start from them and let us start the discussion we I've already mentioned what is the topic what is the subtopic so PDF will be available to you after the class and uh I will be discussing what could we okay so what is not a marker of gist this is a straightforward question so you know the gist they are associated with CIT mutation and when they are associated with CIT mutation this is a standard you can say marker for them then one more very important marker that we have is the platelet derived growth factor Alpha this is again very very simple straightforward marker platelet derived growth factor Alpha whenever I you can say start this topic I always start with the markers of the gist and I tell that the gist which arises with them they are the traditional gist if the CIT mutation is not there remember if CIT is not there or plat derived growth factor Alpha mutation is not there then that will be known as a wild gist and when we talk about wild gist what are the markers for wild gist you all know that we have the brph then we have the Galatin 3 Galatin 3 Wilms tumor 1 WT one gene so these are the standard you can say markers for the V then what about this sual dehydrogenase now when we talk about sual dehydrogenase this is something associated with a familial gist and when we talk about familial gist plus paragangliomas plus parag ganglioma now this condition this is known as Carnes staticus syndrome so when we talk about cares staticus syndrome this is the variety which is positive there so this is what is very very very important that car static syndrome May sdh sual dehydrogenase type B is present so this is also a marker apart from that we have Dodge so you question need PG it can be again asked but remember this is nrg1 is not a marker for just let us go to the next question now this is again a ritual earlier you used to get a question in every exam about GC recent we have seen one question on EDH sdh will be there so first of all even if you don't read the question let us read the question 25y old patient uh you can say presents two trauma post RTA in unconscious state with the following CT presentation the moment you see the CT presentation what are you getting this you are getting this by convex Shadow and this is a case of EDH so EDH with loss of consciousness now this patient is unconscious right now now so probably the GCS is going to be low remember if the GCS is not more than 8 and if the clot thickness is more than 1.5 and along with that we have we have certain other important things like the volume if the volume is more than 30 cc you will have to go for surgery sdh in comparison to EDH is managed in a different way like EDH is considered as a surgical emergency so whenever we have a patient of EDH yes you will have to go for surgery and what is the surgery we have to go for cromy or option that's the same thing that is craniotomy so AB we were discussing like what could be a potential one more question coming from this so we need to understand that every year we have a mood so this year again we may get a question on this and if you get a question on EDH versus sdh what is the next thing that we get to see so students when we talk about EDH there could be a question yes the first line management the first line management is surgery everyone knows that it is the kency but what are the indications for conservative management so if this question is asked again in the you can say exam taking the coming upcoming neat PG so if this question is asked what are the indications for conservative management yes you can do a conservative management if three conditions are fulfilled what is that if the GCS of the patient is more than eight along with that the clot thickness the clot thickness is less than 1.5 cm and along with that the clot volume is less than 30 cc if all these three things are satisfied yes you can go for conservative management so EDS question so this is a very popular question question yeah so here one question said about unequal pupil to you can understand if the pupil response is look this is these are the recall questions so I have not given the exam Nara if you uh if you can help me with the more proper refined options yes it would be great I've just collected this from you people only even though if the pupil is you can say having an altered uh condition like hinson's pupil is there so these are the signs of developing neurological deficit so EDH in a patient with neurological deficit the management is not going to change it is going to be the surgery surgery surgery next is you got a question this was a straightforward question I I hope most of you must have marked it right so patient complains of dysphasia regurgitation and weight loss so when we talk about any problem like lot of people start yelling this is a classical triod of eaia this and that it's a useless thing esophagal disorders are diagnosed on manometry upper G endoscopy and combination of other investigation that includes the berium as well as the 24 pH monitoring so any problem even if you have a cancer in the you can say esophagus again you will have the same problem of dysphasia regurgitation regurgitation along with that weight loss but need PG just see try to understand the mood last year Chicago 2 was last to last year Chicago 2 was as in I set then last year also so there was a question on eaia again there's a question on eaia so there's always a mood of examiner or the trend Trend like B and you know L Lota that singer trend is going on so same way this is the trend so whenever you have such kind of presentation you need to understand am I provided with something other in the am I provided with some other significant information in the question yes if you see the barium image now you can see a classical smooth tapering so don't say that CA esophagus can also present with this eaia can also present with this and even rare cases of early cases of diffuse esophagal spasm can also present with this but even the zeners diverticulum could also present with this that it is intermittent dysphasia with helosis however if only this much of information is given you cannot comment on the diagnosis but if you see berium there is smooth tapering this is what is very important since there is smooth tapering the C esophagus has been ruled out there is no pouches so no pouching so if there is no pouching zeners is ruled out and in case of diffuse esophagal spasm you know it is a condition and if it is a condition you would get something like this what is this this is a screw esophagus and here you get a classical bird beak appearance so this classical bird beak appearance this is helping you diagnose a condition of ealia this is what is very very very important go to my lectures find them every time I discuss this topic in great depth and detail so B eaia is very very very important topic for your exams and let us have a just one you can say hint okay sir question eia so what could be the question in eaia students eaia is a manometric diagnosis it is very very very very important faculties eaia is a what is a diagnosed by the class they don't practice teaching and when you keep on teaching and you don't see the patients you will lose the clinical touch and the importance of the clinical scenario around you remember eaia is a very important topic for your exams try to understand what happens in eaia and if you remember this you'll not even have to mug up anything so whenever we talk about eaia you need to understand there is Progressive loss of misers and mric plexes so when we talk about Progressive loss of inhibitory ganglions but inhibitory ganglions are lost therefore therefore the relaxation part of the of the esophagus will be be lost are you getting this point or no and then you have dysfunctional NOS when we talk about NOS that is nitrous oxide syntheis so definitely the GE Junction will be at a higher tone and the first thing that you get on manometry this is what is really very important so on manometry the first thing that you get to see that is there is increase tone of alas there is increased tone of alas but then since there is loss of inhibitory ganglions there is no one to oppose the atile choline important and therefore there is Progressive spasm of the esophagus which starts from the lower end so increase tone the second thing is failure to relax the third thing is the third thing is there is a peristalsis why there is a peristalsis because B the peristalsis is generated because of a combination of inhibitory and excitatory ganglions a peristalsis is there then there is low amplitude waves the amplitude of the waves is low and the last is in the late stage the esophagus is completely collapse but ATI choline is causing the collapse and this is going to cause pressurization of esofagus and remember remember uh you can just try to refresh you can try to refresh I don't think that there is any problem at my end maybe uh the internet is lagging at your site because I'm myself using this I've logged on on one of a set so you can just try to refresh it so pressurization of the esophagus AP peristalsis low amplitude loss of you can say uh failure to relax and increase tone and this is the criteria for diagnosis of you can say eaia so what is the criteria for diagnosis it is very important that eaia is a manometric diagnosis so increase Stone failure to relax AP peristalsis low amplitude wave and pressurization of the esophagus so those who are I've seen lot of faculties giving lot of solutions but this is a classical Tri ofis then you are not a surgeon you are a homopathic doctor so may we have a good radiological support a good evidence of Investigation tools which will help us so you know this now we get a question that a patient presenting to you with penetrating thoracic trauma with the following image so whenever we talk about penetrating thoracic trauma you know that there could be plural injury there could be pericardial injury and there could be diaphragmatic injury majority of the patients of diaphragmatic injury are you can say asymptomatic however let us try to understand what could be the classical presentation had it been a pericardial injury had it been a pericardial injury you would got a clear lung Shadow but you can see this is air and here this is air rest what is there so there is haziness it is not absolutely you can say fibrotic something like a tumor but after trauma if you're having this much of haziness with the air fluid level this is the most common diagnosis of hemothorax but this is what is very important Again by this question we need to understand what is the mood of the 2024 exams hemo thoric P question traumatic thoracic injury P question yes you can expect more important questions what is that so if you can if you get a question if I were to make a question someone said sir this is a trend now moo is a trend make a real on moo and so what I would have asked in case of this heoric remember I would have asked what is the criteria for massive hemo thoric this is again important let us revise it for upcoming neat PG exams so when we talk about massive hemorex what is concept of massive heoric more than 1,500 ml blood so more than 1500 ml blood into the thorx in case of adults this is what however in kids in kids this is not the scenario more than 25 to 30% of blood volume more than 25 to 30% of blood volume in case of kids this is what is massive hemo thoric but if I were to make a question someone said that this is an old outdated question but if you see the last neat PG question there was a question on this so in case of you can say hemothorax neorx what is the management intercostal chest drain insertion yeah you know so that is what is known as tube thoracostomy now my question is is there any indication to do a thoracotomy so what are the indications for thoracotomy so question a so question Isa indication of thoracotomy for hemothorax we all know that we do thoracostomy this is what is very important very very very important so what are the indication first is Sir if it is a patient of massive hemox thoracotomy has to be done because it is bleeding in a huge volume and patient can collapse the second is Sir you have done a thorax you can say you have inserted a drain into the Torx and the volume which comes out it's of Paramount importance so volume that is what is known as initial chest drain output so remember initial initial drain output drain output more than more than 1,000 ml in case of penetrating injury definitely if it is penetrating injury it is more neat and clean and more than 1,000 ml means something vital is bleeding or or or more than 15 100 ml in case of what trauma students blun trauma this is obviously qualifying for massive hemorex so suppose you miscalculated or you are not knowing you inserted a chest drain and 1600 ml came out you have to do the third is suppose you did a chest in uh you can say intercoastal drain insertion the volume which came out was 300 what to do again monitor for next one hour again subsequent 1 hour so drain output this is what is very very very important so to drain output more than 200 mL this the last year's question was based on this point so drain output more than 200 mL per hour for at least for at least three consecutive Arts but this is significant and it means something vital is bleeding and this is an indication for toac toy so say if we see the mood and we see question this is a very close question concept which can be asked the fourth is a case of caged hemo thoric so when we talk about caged hemo thoric what do you mean by CED heoric clotted heoric if someone has to ask a very good question what is clotted heoric and when will you say that the blood has been clotted imagine this is a torax and this is the blood so when you insert the first drain if nothing comes out you may think that I have not placed the drain properly and you insert one more if two drains fail to evacuate the thorx this is what is considered to be a cake demo thorx students I'm not boasting about my strike rate because genius people keep on commenting that okay this is my strike rate this is my strike rate these are the questions Legends don't talk about this if you are a surgery D you can say the pattern if you are a serg or a student you yourself know that all the questions were covered in my notes word to word all the question so I don't have to boast about this thing I just keep on explaining you the basics and Basics are the one which will be asked in surgery surgery Haka syndrome so again let us go to the next question a question that what is this kit so it's a very simple there was a question on what is this kit and it was a Peg Peg how to understand that this is a peg not a central C centrer line catheter remember a peg what is Peg per cutaneous endoscopic gastrostomy percutaneous percutaneous endoscopic endoscopic gastro gastro stoy but first of all if you see this instrument if you see this instrument this is an introducer with a you can say with a uh with a Inlet for two fingers and you can pull the structures in so B we need to pull the tube in so we have an introduced ucer which will pass through the stomach go through the abdominal wall go outside and then you will pull the tube in and this is what is a peg po per cutaneous endoscopic gastrostomy catheter but it is not a pigtail catheter you can I've already discussed each and everything in my classes I've even shared a lot of videos how a pigtail catheter looks likees this is how the pig tail is the moment you pull out the stilet it curves into a pig tail this is not a center line so let us and of course it's not Oro uh you can say gastric tube what is the indication yes it is indicated when you have to start with supplemental nutrition this is what is the simplest thing that you can understand in context with this and let us understand that okay the mood says there could be a question on supplemental nutrition so let us understand those M Master Concepts all these PDFs will be attached to your class post class you can say video will be attached with this uh PDF so from the app you can always download it and save it remember whenever you want to start supplemental nutrition this is what is very important let us quickly revise this important and if the question is asked in context with this question already covered this in Rapid revision so supplemental nutrition if you have to start you have to ask yourself okay should I start it and if I want to start the supplemental nutrition you again have to ask one more question duration of duration of lack of feed B important question duration of lack of feed if it is more if it is less than 7 Days in that case no need to start with the supplemental nutrition if it is more than 7 days or more than equal to 7 days then start supplemental nutrition now when we talk about about supplemental nutrition you know that we have to start with parentral or entral so this is decided like entral should be given until unless contraindicated so very next thing is that is entral nutrition contraindicated you all know that it is contraindicated in five six conditions what what are they in case of perforation in case of peritonitis sever diarhea sever vomiting several Mal absorption and relatively contraindicated in case of the sepsis also it is contraindicated in obstruction so if it is contraindicated yes in that case you go for Parental nutrition if no then you will have to go for the classical entral nutrition when you want to start with parental nutrition so either you can give it by peripheral roote or you can give it by the central root the very next thing that you have to ask is how long do you want so if you want a support for a longer time then it's better to insert a center line and go for tpn so duration of support if less than equal to one week in that case PPN that is peripheral parental nutrition more than one week then you will have to start with tpn Total parentral Nutrition when we talk about entral nutrition what to do again you have to ask yourself duration of support but if you want a support for less than 4 weeks versus more than 4 weeks if you want it for more than 4 weeks you need a permanent you can say or a longlasting catheter and that is where you will have feeding gastrostomy or feeding josty this depends whether you are having a good gastric empting or no less than 4 weeks yes you can go for RT feed R stew feed or NJ feed so this is the mood related topic mood related question related topic this is what is really very very very very important very important next is let us go to the next question but you got a question this is a very simple question so this was a patient uh 52y old female presents with invasive ductal cancer with skin ulceration and inflammation so ulceration of the skin you know it qualifies for t4b and inflammatory sign will be always present at the ulcerative end so don't think that it's a t4d also because merely inflammatory signs are not a diagnostic of inflammatory carcinoma inflammatory carcinoma is actually the signs and symptoms of mesitis along with that there's a criteria there's a the the standard criteria is that more than 2/3 of the breast surface involved extensive involvement of the breast in a short span of time not responding to the conventional antibiotics taken for the you can say uh for the patients of mesitis so this is a patient with classical t4b cancer if you see this this was something image was looking like this but stage remember the stage three includes andc compasses all things 3 a 3B 3 we have 3 a 3B 3 C stage four is metastat metastatic so this cannot be answered remember what is the best answer here either you can say stage three since we cannot comment on stage only by knowing the T because we don't know the lymph node status we don't know the you can say the metastasis status so I would say that option C is far better than option A this is what is the simplest way of understanding this let us go and you can say quickly revise but let us quickly revise this concept of let us quickly revise the concept of uh this classification of CBR when you talk about CA breast within 2 minutes we'll revise but CA breast is divided into early into locally Advan locally Advan and into advance so when we talk about Advance this this is any T this is any n but M should be one when we talk about early size should be less than equal to 5 so T1 to T2 n should be n0 to N1 and it should be n0 when we talk about the locally advaned all of us know that t0 n T4 n0 m0 T3 N1 m0 any T but n 2 to N3 and m0 but last last exam last NE PG question the question was Sir who will take care of this T3 n0 m0 you have to understand you need PG question now you can understand the mood the trend matters Trend matters last year question question so this is known as large large inoperable large inoperable CA breast now why this is large inoperable because of tasis no because of the surgical inoperability now when we talk about surgical inoperability what is the reason for this you know that whenever we talk about C breast so if this is the tumor we need to spare the space above also below also and then we need to remove the specimen and do a closure but if the tumor is Big that is more than 5 cm the the skin flaps will not be possible you will remove the tumor but you will not be able to close this wound and that is why the problem will arise let us move forward so this is looking like a gemstone anyways this is a image on x-ray crystallography try to understand this this is what is simple now 42y old male presents with recurrent UTI on urine analysis it reveals alkaline pH following is the X-ray crystallography image students have shared me this image only so B the things which you can say resemble this it could be resembling something like an envelope also or it could be looking like a coffin lid also so coffin lid versus envelope this if this was the image because it looks more close to that when we talk about the coffin lid versus envelop Stones where are we you can say uh where do we see them then if you see the history the history is suggestive of what infection so infection Associated and this is more of alkaline infection Associated so first thing is it cannot be a cine Stone it cannot be uric acid Stone because both are seen at a pH of five to then we have triple phosphate and oxalate Stone hria can be seen with them any of them but hematuria is more common with the oxalate Stone remember we have uh you can say calcium o uh sorry so we have calcium oxalate monohydrate and calcium oxalate dihydrate dihydrate is envelope shape but this is not associated with infection but triple phosphate is associated with alkaline form of infection so yes this is the best answer of this is this clear to everyone so you have to correlate the things anyways there was a question again from the esophagus esophagus this time we saw the maximum questions in git which of the following is or are atypical complications of gerer D so GD motility disorder both have been covered GD complication atypical complication what do you mean by this let us understand now when we talk about the typical complication we know because it is because of the reflux now sometimes the reflux might enter into the trachea also and when it enters into the trachea it will cause nagging cuff this is what is now it will cause inflammation and inflammation related laringitis asthma and in late stages it may cause interstial lung disease or pulmonary fibrosis so all four of them are you can say associated with this I hope all of you know that this is the mood and if it is a mood what could be the mood related questions let us understand this let us understand this is what is very important for you to understand okay so when we talk about any question which which can be related if I have to ask someone says okay sir ask one question from G related to its complication something related to its complication so when we talk about gerer and when we talk about complication so we have typical complications and we have atypical complications atypical we have discussed and the typical complication that we have we have something which is known as barretts esophagus this is important and then we have CA esophagus and you know that adino CA is what is seen now when we see the mood why I'm telling you I'm talking about mood because last year PG paper so you had a question on Barett esophagus I think it was NE or said barretts question so again the trend is continued so when we talk about this barretts esophagus and if you ask me sir make one question on Barett esophagus I hope you know that what is defined as bar esophagus The squamocolumnar Junction this migrates up so there is upward migration of migration of Squam colar Junction and along with that we have intestinal metaplasia students even this is also not important the most important thing is on HP you get to see what cells goblet cells this is what is important very very very important important and you know that yeah I think is the question a no the question was on atypical this is this is what I have gathered from the you can say from the recalls so they have asked about the atypical complications of the ger now when we talk about the barretts what is the short segment Barett when we talk about short segment this is less than three segment CM when we talk about long segment barretts this is more than 3 cm when we talk about ra short bar esophagus this is defined as less than 1 cm this is what is a Barett esophagus now bar esophagus types and based on the types we can quickly revise their management also it is unknown for atpa there is Barett esophagus Barett esophagus without atpa Point number one point number one is without atpa the second is Barett esophagus unknown for atpa unknown for ATP then we have the displasia it could be the low grade displasia and it could be highr displasia but I've already told you that the Barett esophagus with ATP uh bar es esophagus without ATP written with ATP sorry without atpa and Barett esophagus unnown for AIA you will have to go for conservative management with anti-reflux medication this is very important anti-reflux medication and along with that annual upper GI endoscopy followup this is what is very important if you get a question on low grade displasia what is the management same anti-reflux anti-reflux therapy has to be given and when we talk about anti-reflux therapy along with that six monthly upper GI endoscopy followup can you see the difference now when we talk about high grid dysplasia you have to start with anti-reflux antireflux therapy so moral of the story is we will start with anti-reflux therapy and along with that reassess reassess after 3 months now this is what is very important why because AG barretts stays as barretts for a long time so this is what is known as persistent persistent High grid displasia now this this is a candidate for intervention now when we talk about intervention you can go for radio frequency ablation or you can go for endoscopic mucosal reection EMR is that clear so mood related F question and that is why my kids have anticipated okay so they know that this would be the questions but a very easy straightforward question again you will say mood but last neat I said there was a question it was there in fmg question so which is the most common hernia in females or in males in both of them this is indirect inguinal hernia so indirect inguinal hernas this is the answer but if the question is asked because last year they have asked the question on EHS EHS classification question and when you talk about EHS classification you know European hernia Society has been the oldest in hernia management and they are the one who have actually decided a lot of protocols so you know e stands for iology what could be iology it is primary that is not associated since birth so you can write P it could be congenital that is by birth or students it could be recurrent this is what is R so this is the simple R then we have hernia defect when we talk about hernia defect what are the things that we have up to 1.5 CM up to 1.5 CM you will say 1 F more than 1.5 up to 3 cm you will write 2f and More Than 3 cm you will write 3F this is what is very important up exam last exam there was a question and then when we talk about the site you know that if it is medial then that is actually for the direct hernas direct inguinal hernia then if it is lateral Lateral with respect to the infer gastric so that is indirect hernas and it could be femoral so if it is so it could be M it could be L if it could be F so this is how we decide what is what so question yes this would be the most probable question that would be asked okay student let us move forward and discuss one more question now what is the significance of er positive with context to C breast but try to understand that whenever we talk about C breast we need to study the molecular resemblance of the tumor and that is why we have four standard molecules ER PR herun new er PR herun new and ki67 so they tell about the tumor and its significance now here but they don't have any diagnostic they don't have any therapeutic so there are surrogate molecular marker this is absolutely true and since there are molecular marker their positivity their negativity will give you a chance to add or you can say refrain from using a hormone therapy so remember if you see the option C is better than option b why yes it could be a prognostic factor but not in a normal C breast in case of metastatic C breast where all the other factors have been nullified then it is a significant prognostic factor so yes option C is also right option b is also right if I have to choose I will choose option C it's a surrogate molecular marker and it is an indirect prognostic marker remember but exams may you always have questions where two options can be right and you have to choose the best so this is the answer that I would have chosen because yes it's a surrogate molecular mark for next is again my favorite topic kangos here you get a lot of questions but you have to understand that primary sclerosing colangitis is the most important thing then we have the chemicals and in chemicals you have thorotrast you can say aromatic hydrocarbons so aromatic hydrocarbons we have thoras this is important then students there is something which is known as hipat liasis so hepatolithiasis means Stone in the hepatic duct yes they cause Kango but carolis yes kocal cyst kocal cyst is an important risk factor then there is something which is known as V mayberg disease so when we talk about V mayberg disease or you can say multiple bilary homas multiple bilary hamartomas they are also a risk factor for this remember yes liver fluke off his torus sinensis or ascariasis they are all risk factor for this but hepatitis is a risk factor for HCC not a risk factor for Kanga but easy a question next is let us understand one more question 54 year old presents with lower leap weakness post recent pared gland surgery you know that pared gland through the pared gland we have a facio venous plane of Patty what is this facio venous plane of Patty I hope all of you should be knowing this so when we talk about this is the Deep lobe this is The Superficial lobe and through this we have the retromandibular vein and just above this we have the facial nerve and its branches so you know the trunks upper lower and then we have the external koted artery below this so lot of complications can arise but the most important is maybe because of the facial nerve injury now the patient is having lower lip weakness which is due to the mandibular division of the facial nerve so let us see what are the answers in this case injury to grer oracular nerve but this will cause loss of n you can say sensation over the skin of Partin you must have seen that movie so here the patient will also not feel that Tupper this is why because of the injury to Greater oracular nerve then cervical branch of facial nerve no temporal branch no it is the mandibular branch which is going to cause this so injury to main facial trunk will involve the denervation of all of them and that is what go and check my YouTube video on facial nerve injury and all the things that we have I've demonstrated it many of times so the answer for this is a it is due to the if this is the option and if they have asked about mandibular Branch it should be the answer in that case now L letion with midline swelling in the neck with a nodule containing amyot stroma what is the possible origin of this relation but a thyroid swelling and when we talk about thyroid swelling which contains amloid containing amloid What is the most important thing what is the most important tumor now we are talking about MTC what is MTC we all know medular thyroid cancer again you see the mood recently there was a question in set also there was a question last year MTC question blood so these are the tumors of what these are the tumors of par folicular cells let us quickly understand this and question imtc so let us have two three important Concepts about that also so when we talk about MTC medular thyroid cancer two three things we need to understand that it is associated with red protooncogene mutation it's a tumor where you have caly tonin to be increased and why because it's a tumor of par folicular cells this is what is very very very important then you know there is increase in CA because it's a carcinoma and Paran neoplastic syndromes are also there because of which you have increase in histamine so you know that we have pittis all those vasomotor symptoms you have increase in serotonin so you have diarrhea and then you have increase in acts so you have the Cushing SL syndrome remember on HP you get to see am myoid stroma question along with that there is also one inclusion body which people call as cell ball inclusion bodies so cell ball inclusion bodies can be a part of this remember I'm not here to discuss this question so I will always ask about the management but MTC is an aggressive tumor which has an extensive spread extensive and aggressive spread by the lymphatic Roots so whenever we are managing any carcinoma the rule is that throw that tumor outside the body if you think it's a cancer the place should be outside the body so when we talk about the management of MTC remember what is the rule total thyroidectomy has to be done and along on with that prophylactic profilacticos now when we talk about prophylactic neck dissection what do you mean by this the rule is the rule is always always screen always screen the next Landing Zone sub importante many of you mug this up with the concept of remain one step ahead this is what is very very very important why not option as am no amod dois is not seen in thyroid very often okay so I don't think that what option would have been amod dois but the students have discussed that so why a thyroid swelling will present to you with am myoid stroma remember a nodule I think the question also described about the nodule the tumor so a tumor with Amo stroma this is of MTC modu you can say thyroid will never have a nodular rizing because of Amo dosis Amo is is possible AMU but a nodule which on FNA or which on biopsy revealed amod dois this is seldom due to amiloidosis it is due to amiloidosis associated with MTC so it is because of the tumor that the amiloidosis has started not you can say isolated event of amiloidosis anyways let us let us understand so case number one what is the case number one when you have the tumor in the you can say gland so at least you would have done what total thyroidectomy and along with that if you have to do something yes you will screen the next Landing Zone and therefore you will go for prophylactic Central neck dissection this is what is very important so what is the management total thyro plus prophylactic Central neck dissection case number two when we talk about case number two what is that imagine there is a tumor with few Central neck lymph nod also so be tumor remove every evidence so you would have gone for total in this case and along with that you would also have gone for Central neck dissection if the tumor has to move from this side it would move in this place so therefore profilactico actic Ipsy lateral Mr RND D would be done in this so what would be the answer total tectomy plus Central neck dissection plus prophylactic so when we talk about the case three but is question this may you have the lymph nodes in the lateral part of the neck so at least by rule be evidence of tumor you will have to remove so yes you will have to go for total thyroidectomy along with that Central neck dissection and when we talk about this scenario you will go for bilateral Mr R ND this is the simplest way of management let us move and go to the next question a patient a 22-year-old alcoholic patient presents with severe hematemesis so patient with upper GI bleed due to portal hypertension the USD shows distended portal vein with per you can say with uh uh with Co eot texture hyper eoic and Co Eco texture in the liver what is the next appropriate management but you are dealing with upper GI bleed this is what is really important and this is associated with portal hypertension what is the protocol of this this is what is really important the first is you need to secure ABC this is the first thing that you will do you will go for secure ABC and after this the next thing is you need to control you need to control the blood pressure control the blood pressure along with that you need to stabilize the patient so control the blood pressure and resuscitation of the patient is really very very important now when you talk about the controlling of the blood pressure resuscitation and along with that you will start with injection octreotide injection octreotide or somatostatin analogs or you can go for turly pressing all those things huh but remember if the bleeding stops if the bleeding stops then only so post 12 to 24 hours within 12 to 24 hours now you will go for upper GI endoscopy immediate upper GI endoscopy early intervention is important so within 12 to 24 hours but before that you need to stabilize now there could be two options it could be now this depends what is the cause answer deci broad spectrum antibiotics but that is not the first line priority yes it is given broad spectrum antibiotics are given perform liver biopsy not at all urgent endoscopy with very ation not at all I will tell you start with fluids and electrolyte replacement This Is The Answer let me tell you how do we manage this important this is very very very important so let us let us see this okay now whenever we have a patient of whenever we have a patient of upper GI bleed and the patient with portal hypertension with portal hypertension the next is you will try to control bleed now once you control the bleed or you can say you have done this all those things like secure ABC and then start octreotide start otide and once you have done this the next thing is the next thing is okay plan upper GI endoscopy plan upper GI endoscopy but when you plan upper G endoscopy the very next thing is where is the location so question we will do a band liation Yes or no so question told severe vomiting not hematom okay a severe vomiting was there I don't know the question you can text me the question or if you have you can type it here only so if it is a question associated with the this is what is I'm telling since I've not given the exam it is all recall based Nara you can type this question in the comment section I'll just uh tell you the answer based on that also next is location but the location could be the G Junction it could be the G Junction it could be the lower esophagus lower esophagus or it could be the gas isolated isolated gastric varis type one important G Junction lower esophagus or isolated gastric varices here then it is different management if it is isolated gastric type two or if it is others the management shall be different so if the ig2 or others are there the next thing is you have to plan for tips I hope you know trans jugular intrahepatic poo systemic shunt or brto retrograde balloon trans Venus you can say occlusion this is what is the management if the patient is having isolated gastric vysis but if it is a g Junction if it is a Veris or if it's a lower esophagal you can say bleeders you have to understand is it bleeding is it bleeding so so bleeding persists you have to understand this or bleeding stops if the bleeding stops you have gone for Endoscopy if the bleeding stops in that case continue continue ooti continue ooti for 3 to 4 days and along with that antibiotics for antibiotics for 10 to 14 days at least and the conventional yeah so yes sir patient was alcoholic binge of alcohol last 5 days remember being alcoholic doesn't mean it's a portal hypertension if it is a portal hypertension that scenario will be different alcoholic patients can have gastritis also should could be a gastric ulcer so can you just elaborate the options whether the options were related to portal hypertension or no so one option was glow clor di di no please you can you can give me the entire question I'll just comment on that scenario also so Chlor daop oxide is not the ideal management here now next is if the bleeding continues B if the bleeding continues you have options what are they the first is evl endoscopic veral liation or the sclerotherapy or the balloon tonate if this persist if this persists Beyond this so you have done sclerotherapy if it persists in that case in that case Cas you can plan the you can say balloon temponaut I hope you know and you know about that balloon Tempo knut is one option if balloon Tempo knut fails AA balloon Tempo knuts or you can plan for tips or you can plan for shunt these are the options that we have or you can plan for devascularization surgeries so these are the options that we have when you talk about devascularization surgery go and check my notes I have described about the concept of the sugiura surgeries and the one more is that is the splenopexy also recently that has also been added anyways so n you can just text me the question along with the options I'll revert back to that again there was a question on wilm's tumor not true about wilm's tumor when we talk about not true about wi's tumor it presents with an abdominal Mass yes it presents it is seen in both male and female yes you know the classical presentation is a mother noticing an abdominal bulge while bathing the baby or changing the clothes lung metastasis is a late and rare presentation but 80% survival after chemo and radio students it is the surgery and the chemo this is what is very important so chemo plus surgery it is important it is not surgery alone it is not chemo alone so chemo with surgery yes you can have different options of of Na and what is the surgery that we have radical radical nephro urri toy nephro Ur rectomy this is what but what is the difference between radical nephrectomy and nephro ureterectomy understand in radical nephrectomy you will remove the uror up to the pelvis so at the level of where the pelvis is starting you will remove when you talk about nephro urri toy right up to the insertion at the level of bladder you will remove the urer so this is what is the ideal management it is radical is the best book for Pediatric radic is radical be accepted this is what is now not a part of primary survey primary survey is the survey done bedside so this is very important it is done bedside and it is done with an intention and aim to rule out immediate lifethreatening Sur you can say injury and save the life of the patient so will you do x-ray chest yes bedside x-ray has to be done to see whether it's a numo or whether there are fractures Etc intercostal drain insertion tube thoracostomy has to be inserted in certain cases of neoo thoric intubation if the patient is going or showing you Progressive Progressive desaturation but say ncct CT cannot be done bed site so you'll not consider about this so ncct is not a part of this this is what is very very very important understanding the mood so when we talk about the mood we have primary survey everyone knows about that primary survey and then once the patient is hemodynamically stable we do what survey students we do secondary survey and when you have done secondary survey 24 hours 48 hours and 72 hours you will also do a survey which is known as tertiary survey so tertiary survey is a modified version of secondary survey it's a replica but yes done at 24 48 72 hours to modify the outcome of your interventions so you have done some intervention you need to uh you can say have a look on these patients for certain delayed complications which might be arised so survey yes it is there is that clear or no next is horseness of voice seen post surgery but thyroid surgery Hess of void is due to recurrent lenal nerve injury this is what is important so strap muscle dissection whenever we talk about strap muscle dissection V triangle dissection Tule of zuker candle and Superior thyroid vessel liation now this is what is very important now when we talk about the strap muscles they are important landmark and at the point when they are entering so there's a ccoy you can say CCO uh sorry there's a uh there there are lot of triangles so this is the koted when we talk about this is the koted this is koted and this is the inferior thyroid pedicle which is running so the classical recurrent lenal nerve along with this you can say uh the inferior thyroid pedicle forms a lot of you can say triangular relations one of them is a be triangle we have lot of triangles so we have if you go through my lectures I have discussed around 78 triangles I'm not going to discuss here but yes the BR triangle is a is is is a triangle where if you dissect the recurrent lenal nerve injury can be seen tuberal of the zuker candle is the most posterior lateral part where if you don't locate the recurrent lenal nerve means it is not there or you have already injured so but Superior thyroid pedicle is associated with the extrinsic you can say lenal nerve and it is not associated with this current lenal nerve injury so it will not be seen in this case yes or no let us move forward again false with respect to crons but cron versus ulcerative coli it is very simple ulcerative colitis remember oer so ulcerative colitis involves the mucosa cronn is a complete involvement one very important thing where do you see so if you talk about the the you can say the leion so leion is complete transm versus in ulcerative colitis it is the mucosal granulomas the granulomas will be seen in the cron this is then when we talk about the location where are they found remember remember it is found in the large intestine only it can be seen anywhere this is important even in the large in the small crons but what about the rectum rectum is always involved always invol involved remember it may be it may not be involved what about perenium now this is what is important perenium is spared here but it is a very common relation so rectum but perenial Rel are very important which variey is associated with fistula it is seen here not here strictures it is very common here it may be it may not be perforations perforations yes it is seen here so B A malignancy now again if we compare about malignancy a very high risk here here you have a low risk so with comparison to ulcerative colitis what is true about what is what is true about this cron no perianal letion this is false contiguous Les no they are associated with Cobble Stone or snake skin appearance so that is we have discontinuous skip relations so skip relations are there so this point is also false less risk of colog cancer yes of hemat Casia now you must be thinking hemat Casia is nothing but stool with blood but instead of this if we see what do we get to see in cronn we get to see diarrhea this is what is very very very important plus rectal bleeding so diarrhea plus rectal bleeding you can say it could be hemat Casia but not uh sorry it could be rectoria this term is rectoria independent bleeding so recto Ria not hemat Casia hemat Casia means streaks of Blood on the wellform stool so I would say option b is far better than option A in this case so this was about this I set I hope you enjoyed this paper and uh you developed some Concepts why I discuss a lot of things because I wanted to tell you that the topics the concepts are repeated the questions are not repeated the topics are repeated so uh keep on on learning with surgery dada and don't panic about the exam the exam is gone Jo so let us now concentrate on the upcoming neat PG exam so till then bye-bye

Channel: SURGERY DADA Dr Saurabh Dixit

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Id: cmJYRKQDvlo

Length: 61min 10sec (3670 seconds)

Published: Mon May 20 2024