46. A woman comes with an ulcerated lesion 3 cm in the labia majorum.

What is the
lymphatic drainage of this area?
a. External iliac
b. Superficial inguinal LN
c. Para-aortic
d. Iliac
e. Aortic
Ans. Key is B. Superficial inguinal LN.

321. A 67yo female who had undergone a radical mastectomy now comes with the
complaint of
swelling and redness in her right upper limb. Involvement of which of the following
structures
explain these symptoms?
a. Epitrochlear LN
b. Cephalic vein
c. Subclavian artery
d. Axillary group of LN
e. Long thoracic nerve
Ans. The key is D. Axillary group of LN.
417. A 34yo man with a white patch on the margin of the mid-third of the tongue. Which is
the single most appropriate LN involved?
a. External iliac LN
b. Pre-aortic LN
c. Aortic LN
d. Inguinal LN
e. Iliac LN
f. Submental LN
g. Submandibular LN
h. Deep cervical LN

The key is G. Submandibular LN.

623. A 16yo boy following a RTA was brought to the ED with a swelling and deformity in his
right
thigh. Exam: airway is patent and is found to have a pulseless leg. Which structure is
involved in
this fx?
a. Femoral artery
b. Posterior tibial artery
c. Common peroneal nerve
d. Dorsalis pedis

a. Femoral artery

661. A 55yo man presents with an ulcer of the scrotum. Which of the following LN is
involved?
a. External iliac LN
b. Pre-aortic LN
c. Aortic LN
d. Inguinal LN
e. Iliac LN
f. Submental LN
g. Submandibular LN
h. Deep cervical LN

D. Inguinal LN

666. A 68yo woman is unable to extend the IP joint of her right thumb 7wks following a fx of
the right radius. Other finger and thumb movements are normal. What is the single most
likely tendon to be damaged?
a. Abductor pollicis longus
b. Extensor pollicis brevis
c. Extensor pollicis longus
d. Flexor digitorum profundus
e. Flexor pollicis longus

C. Extensor pollicis longus

Extensor pollicis brevis is inserted at the proximal phalanx of thumb meaning at MCP joint.
Its function is to extend MCP of thumb. However extensor pollicis longus is inserted at distal
phalanx of thumb so it causes extension at Interphalangeal joint and also at MCP joint of
thumb.

693. A 73yo woman with RA is unable to extend the fingers of her right hand at the MCP
joint and IP joints following a fall. What is the single most likely tendon to have been
damaged?
a. Extensor carpi radialis
b. Extensor carpi ulnaris
c. Extensor digitorum
d. Extensor indicis
e. Flexor digitorum profundum

c. Extensor digitorum
Extensor digitorum makes an extensor expansion and is inserted in lateral four fingers on
the dorsal aspect. It gives off 3 slips. Main attachment is at dorsal side of the base of
proximal phalanx. Middle slip is attached on the sides middle phalanx and lateral slips at the
sides of distal phalanx. Pt is unable to extend both the MCP and IP joints of all fingers

709. An alcoholic who has completely given up drinking hears voices. What is the most
appropriate tx?
a. Olanzapine
b. Diazepam
c. Acamprosate
d. Disulfiram
e. Haloperidol

This is psychosis. The patient has auditory hallucinations. Diazepam is used in acute alcohol
withdrawal. Acamprosate is to reduce cravings and maintain remission. Disulfiram is a
deterrent. Olanzapine is preferred over haloperidol as it is an atypical antipsychotic which
has fewer side effects.

1454.A 25yo male presents with fever and pain in the right lower thigh of 1m duration.
Exam: lower third of his thigh is red, hot and tender. The XR showed new bone formation.
What is the most probable dx?
a. Osteosarcomoa
b. Ewing’s sarcoma
c. Tuberculus arthritis
d. Exotosis
e. Fibrosarcoma
Answer= B. Ewing’s Sarcoma.

Ewing’s Sarcoma
it is the malignant round cell tumor of long bones (typically diaphysis) and limb girdles,
usually presents in adolescents.
Radiographs show bony destruction, concentric layers of new bone formation (‘onion ring’
sign) and a soft tissue mass. MRI is helpful.
typically those with ewing sarcoma have a t 11:22 chromosomal translocation.

Treatment=
Chemotherapy, surgery and radiotherapy are required. The key adverse prognostic factor is
metastases at diagnosis

1571. A 70yo man presents with a fluctuant swelling of the scrotum which feels like worms
when he is standing but regresses when he lies down. What is the most probable dx?
a. Varicocele
b. Hematocele
c. Testicular CA
d. Epididymal cyst
e. Saphena varix
Key: Varicocele (A)
Reason: “BAG OF WORMS”. Hello.
Hematocele would be a collection of blood in the tunica vaginalis with h/o trauma. CA
would have history of painless lump with weight loss and hormonal effects. Epididymal cyst
usually develops in adulthood and contains clear or milky fluid, lies above and behind the
testes. Saphena Varix would lie below and lateral to the scrotum. A varicocele is a collection
of enlarged (dilated) veins (blood vessels) in the scrotum. It occurs next to and above one
testicle (testis) or both testes (testicles). Treatment is usually conservative with the best
option being to leave the varicocele alone if it isn’t symptomatic. If it is, consider surgery or
injection of a substance to block the veins. Both methods work well usually.

1572. A 52yo woman has had a swelling in the neck, hoarseness and stridor-both inspiratory
and expiratory for 2 months. What is the most probable dx?
a. CA larynx
b. CA thyroid
c. Vocal cord nodules
d. CA bronchus
e. Thyrotoxicosis
Key: CA thyroid (B)
Reason: Vocal cord nodules will not have swelling, CA Larynx will not have swelling either.
CA Bronchus would present with hemoptysis and dyspnoea. Thyrotoxicosis would have
other systemic signs. This is CA Thyroid unless proven otherwise.
Discussion:
1. Papillary (60%): Younger patients, spread to lymph nodes and lung. Treatment – total
thyroidectomy to remove non obvious tumour as well +/- node excision +/- radioiodine to
ablate residual cells. Give thyroxine to suppress TSH. Prognosis better if young and female.
2. Follicular (25%): Middle age, spreads early via blood to bone and lungs, well-
differentiated. Treatment – total thyroidectomy + T4 suppression + radioiodine ablation.
3. Medullary (5%): Sporadic or part of MEN syndrome, may produce calcitonin which can be
used as a tumour marker, they do not concentrate iodine. Perform a pheochromocytoma
screen post-op. Treatment is thyroidectomy + node excision. External beam radiotherapy to
prevent regional recurrence.
4. Lymphoma (5%): Female: male is 3:1. May present with stridor or dysphagia, do full
staging pre-treatment. Treatment – chemoradiotherapy. Assess histologically for MALT
origin.
5. Anaplastic (rare): Female to male ratio is 3:1. Elderly, poor response to treatment. In the
absence of unresectable disease, excise plus radiotherapy.

1574. A 23yo female presents with paraesthesia and loss of distal pulses in her arms. She is
noted to be hypertensive. She describes feeling unwell a month prior with fever and night
sweats. What is the most probable dx?
a. Kawasaki disease
b. Takayasu arteritis
c. Buerger’s disease
d. Embolism
e. Raynaud’s phenomenon
Key: Takayasu Arteritis (B)
Reason: Takayasu arteritis because it presents in age < 50 years and loss of distal pulses
(pulseless disease). It is a systemic vasculitis which often affects women 20-40 years.
Systemic features are common like fever, weight loss and night sweats. Hypertension is also
likely due to renal artery stenosis. Treatment is Prednisolone 1mg/kg/day.
Buerger’s would require a long smoking history. Kawasaki would present with
mucocutaneous symptoms. Raynaud’s would present with cyanosis of distal digits.
Discussion: Also called aortic-arch syndrome or pulseless disease. Rare outside of Japan,
systemic vasculitis. Affects the aorta and its major branches.
* Granulomatous inflammation, causes stenosis, thrombosis and aneurysms.
* Women aged 20-40 year.
* Symptoms depend on the artery involved with cerebral, eye and upper limb symptoms –
dizziness, visual changes, weak arm pulses.
* Systemic features – fever, weight loss, malaise, increased BP often due to renal artery
stenosis.
* Complications – aortic valve regurgitation, aortic aneurysm and dissection, ischemic stroke
(increased BP and thrombus) and IHD.
* Diagnosis – increased ESR and CRP, MRI & PET allow earlier diagnosis than angiography.
* Treatment – Initially prednisolone, methotrexate and cyclophosphamide in resistant
cases. BP control. Angioplasty, stenting, bypass for critical stenosis.

1575. A 35yo woman presents with mass in the groin. Exam: mass found just below and
lateral to the pubic tubercle. There is no cough impulse and it is irreducible. What is the
most probable dx?
a. Direct inguinal hernia
b. Strangulated hernia
c. Femoral hernia
d. Saphena varix
e. Femoral aneurysm
Key: Femoral Hernia (C)
Reason: Femoral Hernias are common in women and they present below and lateral to the
pubic tubercle. They are likely to be irreducible and have no cough impulse. It isn’t
strangulated because strangulation presents with systemic signs like vomiting, fever, pain
and patient becomes toxic and requires surgery. Inguinal hernias would be above and
medial to the pubic tubercle. Saphena Varix is a dilatation of the termination of the great
saphenous vein into the sapheno-femoral junction but it has a positive cough impulse and
would also reduce spontaneously on lying down. The aneurysm would be pulsatile and have
a bruit as well.

1577. A lady presents with a swelling below the groin crease that can be reduced. There is
no med hx of note. What is the most probable dx?
a. Inguinal hernia
b. Strangulated hernia
c. Testicular tumor
d. Epididymal cyst
e. Femoral hernia
Key: Femoral Hernia (E)
Reason: Obvious. Only option that fits. None of the other swellings are below the groin
crease, rather they are located in the scrotum.

1579. A 45yo mechanic presents with a reducible swelling in the groin, impulse on coughing
is present. He has mild dragging pain in the abdomen, otherwise he’s normal. What is the
management strategy?
a. Truss
b. Elective herniorrhaphy
c. Urgent herniorrhaphy
d. Elective herniotomy
e. Reassure
Key: Elective Herniorrhaphy (B)
Reason: Herniotomy is done in children, Truss not suitable here, Urgent herniorrhaphy is
done only in strangulated cases. Reassurance isn’t suitable here.

1580. A 25yo man present with a mass in the groin after heavy lifting. Exam: mass is found
just above and medial to the pubic tubercle. It is reducible. On applying pressure on the
internal ring,
cough impulse is still present. What is the most likely dx?
a. Direct inguinal hernia
b. Indirect inguinal hernia
c. Femoral hernia
d. Strangulated hernia
e. Femoral aneurysm
Key: Direct inguinal hernia (A)
Reason: Above and medial to the pubic tubercle, reducible inguinoscrotal swelling, ring
occlusion test –ve indicates a direct inguinal hernia rather than an indirect inguinal hernia.
Discussion: Hernias always contain a portion of peritoneal sac and may contain viscera,
usually small bowel and omentum.
Presentation:
* Swelling in the groin that may appear with lifting and be accompanied by sudden pain.
* Indirect hernias are more prone to cause pain in the scrotum and cause a 'dragging
sensation'.
* An impulse (increase in swelling) may be palpable on coughing.
* It may not be possible to see the hernia if it is reduced.
* If a lump is present, it may be reducible
There are two types of inguinal hernia:
* Indirect: a protrusion through the internal inguinal ring passes along the inguinal canal
through the abdominal wall, running laterally to the inferior epigastric vessels. This is the
more common form accounting for 80% of inguinal hernias, especially in children. It is
associated with failure of the inguinal canal to close properly after passage of the testis in
utero or during the neonatal period.
* Direct: the hernia protrudes directly through a weakness in the posterior wall of the
inguinal canal, running medially to the inferior epigastric vessels. It is more common in the
elderly and rare in children.
Differential diagnosis: * Femoral hernia: this is seen in various forms, at simplest as a small
swelling in the top of the inside of the thigh. Alternatively, it may be deflected to appear
higher as an inguinal hernia. It is either irreducible or reduces only slowly with pressure. *
Hydrocele (when differentiating from an inguinoscrotal hernia, note that it is possible to get
above a hydrocele on examination).
* Spermatic cord hydrocele.
* Lymph node swelling. * Abscess.
* Saphena varix.
* Varicocele.
* Bleeding. * Undescended testis.
Management:
* Conventional surgery was based on Bassini's operation; this consisted of apposition of the
transversus abdominis and transversalis fascia and the lateral rectus sheath to the inguinal
ligament. The Shouldice technique uses two layers of running suture in a similar fashion.
* However, the Lichtenstein technique is widely used, where a piece of open-weave
polypropylene mesh is used to repair and reinforce the abdominal wall. This operation is
easier to learn, gives earlier mobility and has a very low recurrence rate. The standard repair
now uses prostheses, usually polypropylene mesh. It is, however, associated with a slightly
increased risk of infection.
* Some of the traditional meshes are heavy and associated with postoperative stiffness and
pain. This has led to the development of lighter meshes. A systematic review has failed to
find any differences in long-term and short-term complications between the two.
* Laparoscopic repair is usually reserved for recurrences and bilateral hernias. There is less
postoperative pain, full recovery is better, and return to work is faster. However, the price is
increased compared with the conventional approach, and there appears to be a higher
number of serious complications of visceral (especially bladder) and vascular injuries.
* There are two approaches: either the transabdominal preperitoneal (TAPP) or the totally
extraperitoneal (TEP) procedure. In TAPP, the surgeon goes into the peritoneal cavity and
places a mesh through a peritoneal incision over possible hernia sites. TEP is different, as
the peritoneal cavity is not entered and mesh is used to seal the hernia from outside the
peritoneum. The mesh, where used, becomes incorporated by fibrous tissue.
* Surgery can be performed on a day-case basis, and for seven days afterwards the patient
should avoid driving and lifting. The patient should be able to resume normal activities over
the subsequent 2-3 weeks, but, with a heavy job, it can take up to six weeks to return to
work.
* A truss may be required where surgery is inadvisable or refused; however, it can be
difficult for patients to manage and cannot be recommended as a definitive form of
treatment.
Complications:
These include:
* Recurrence: 1.0% - most happening within five years of operation. Recurrence rate
increases:
o In children aged younger than 1 year
o In elderly patients
o After incarcerations
o In those with ongoing increased intra-abdominal pressure
o Where there is growth failure
o With prematurity
o Where there are chronic respiratory problems
o In girls with sliding hernias
* Infarcted testis or ovary with atrophy.
* Wound infection. * Bladder injury.
* Intestinal injury.
* A hydrocele from fluid accumulation in the distal sac usually resolves spontaneously but
sometimes requires aspiration.

1637. A 60yo man has had increasing pain in both buttocks, thighs and calves on walking for
three
months. He has also recently developed impotence. Femoral and distal pulses are absent in
both
limbs. What is the SINGLE most likely site of arterial obstruction?
a. Aorto iliac
b. External iliac
c. Femoropopliteal
d. Internal iliac
e. Tibial
Key is A: Aorto iliac
Page 718 OHCM 8th edition.
Patient is suufering from leriche’s syndrome.
Classic triad of:
· Pain and claudication of buttock and thighs
· Erectile dysfunction from aorto iliac occlusive disease
· Absent femoral and distal pulse.