UPSC CMSE Surgery Syllabus

Triple assessment of a breast lump consists of what three components?

1) Clinical examination, 2) Imaging (mammography in older women, ultrasound in young women), 3) Pathology (FNAC or core-needle biopsy).

What is Paget's disease of the nipple and what does it indicate?

An eczematous, eroding lesion of the nipple-areola caused by intraepithelial spread of malignant ductal cells; it indicates an underlying breast carcinoma (often DCIS or invasive ductal) until proven otherwise.

Name the most common type of invasive breast cancer and the key receptors assessed for prognosis/therapy.

Invasive ductal carcinoma (NST) is most common. Receptors assessed: estrogen receptor (ER), progesterone receptor (PR), and HER2/neu - guiding hormonal and targeted (trastuzumab) therapy.

What is the difference between hyperthyroidism, hypothyroidism, and a euthyroid goitre clinically?

Hyperthyroidism: excess thyroid hormone - weight loss, heat intolerance, tachycardia, tremor. Hypothyroidism: deficiency - weight gain, cold intolerance, bradycardia, lethargy. Euthyroid goitre: thyroid enlargement with normal hormone levels.

What is Graves' disease and its triad of distinctive features?

Graves' is autoimmune hyperthyroidism due to TSH-receptor stimulating antibodies. Distinctive triad: diffuse goitre, exophthalmos (ophthalmopathy), and pretibial myxoedema; also thyroid acropachy.

What is the most common thyroid malignancy and how does it differ in spread from follicular carcinoma?

Papillary carcinoma is most common - spreads via LYMPHATICS (cervical nodes), excellent prognosis. Follicular carcinoma spreads HAEMATOGENOUSLY (lung, bone) and cannot be diagnosed by FNAC (needs capsular/vascular invasion on histology).

Which thyroid cancer arises from parafollicular C cells, what does it secrete, and which syndrome is it linked to?

Medullary thyroid carcinoma - arises from parafollicular C cells, secretes CALCITONIN (a tumour marker), and is associated with MEN 2A and MEN 2B syndromes (RET proto-oncogene).

Define a fracture and contrast a simple (closed) fracture with a compound (open) fracture.

A fracture is a break in the continuity of bone. Simple/closed: overlying skin intact. Compound/open: fracture communicates with the exterior through a skin/mucosal wound - high infection risk, surgical emergency.

What is a greenstick fracture and in whom does it occur?

An incomplete fracture where one cortex breaks and the other bends (bone bows), occurring in CHILDREN because of their soft, pliable bones.

List the principles of fracture management (the 4 R's).

Resuscitation (in polytrauma), Reduction (restore alignment - closed or open), Retention/immobilization (cast, traction, internal/external fixation), and Rehabilitation (restore function).

Name the stages of fracture healing.

1) Haematoma formation, 2) Inflammation, 3) Soft callus (fibrocartilage), 4) Hard callus (woven bone), 5) Remodelling (lamellar bone). Primary healing occurs with rigid fixation (no callus); secondary healing forms callus.

What classification is used for open fractures, and what defines its most severe grade?

Gustilo-Anderson classification. Type IIIC is the most severe: open fracture with arterial injury requiring repair, regardless of wound size.

Define a dislocation and distinguish it from a subluxation.

Dislocation: complete loss of contact between the articular surfaces of a joint. Subluxation: partial loss of contact (the surfaces remain partly apposed).

Which is the most commonly dislocated major joint and the most common direction?

The shoulder (glenohumeral joint) is the most commonly dislocated; ANTERIOR dislocation is by far the most common type, risking axillary nerve injury.

In posterior hip dislocation, how does the limb characteristically lie and which nerve is at risk?

The limb is flexed, adducted, and internally rotated (and shortened). The SCIATIC nerve is at risk of injury.

Differentiate osteoarthritis from rheumatoid arthritis in pathology and joint involvement.

Osteoarthritis: degenerative cartilage loss, affects weight-bearing joints (knee, hip), Heberden's/Bouchard's nodes, stiffness worse with use. Rheumatoid: autoimmune symmetric inflammatory synovitis of small joints (MCP, PIP), morning stiffness >1h, pannus, RF/anti-CCP positive.

Name the classic radiographic features of osteoarthritis.

LOSS: Loss of joint space (asymmetric), Osteophytes, Subchondral sclerosis, Subchondral cysts.

What crystal causes gout, what is its appearance under polarized light, and the joint most affected?

Monosodium urate crystals - needle-shaped with NEGATIVE birefringence under polarized light. The first metatarsophalangeal joint (podagra) is classically affected.

What is the most common primary malignant bone tumour, its age group, and classic X-ray sign?

Osteosarcoma - most common in adolescents/young adults, typically around the knee (distal femur/proximal tibia). Classic signs: 'sunburst' appearance and Codman's triangle (periosteal elevation).

Describe Ewing's sarcoma: cell origin, age, X-ray appearance, and genetics.

A small round blue cell tumour of children/adolescents, often in the diaphysis of long bones/pelvis, with an 'onion-skin' periosteal reaction on X-ray; associated with the t(11;22) translocation (EWS-FLI1).

What is a giant cell tumour (osteoclastoma) of bone - location and X-ray pattern?

A locally aggressive (usually benign) tumour arising at the EPIPHYSIS/metaphysis of long bones (commonly distal femur/proximal tibia) after epiphyseal closure (20-40 yrs); shows a 'soap-bubble' lytic appearance.

Define osteomyelitis and name the most common causative organism.

Osteomyelitis is infection/inflammation of bone and marrow. Staphylococcus aureus is the most common causative organism overall (Salmonella is classic in sickle-cell disease).

Define sequestrum and involucrum in chronic osteomyelitis.

Sequestrum: a piece of dead, avascular bone separated from living bone (acts as a nidus for persistent infection). Involucrum: new living bone formed by the periosteum surrounding the sequestrum.

What is Pott's disease and which spinal region is most commonly affected?

Pott's disease is tuberculous osteomyelitis (spondylitis) of the spine; it most commonly affects the lower THORACIC and thoracolumbar vertebrae, classically causing gibbus deformity and cold (paravertebral) abscess.

What is the most common cause of acute low back pain with sciatica, and the commonest level?

Lumbar intervertebral disc prolapse (herniated nucleus pulposus) compressing a nerve root; the L4-L5 and L5-S1 levels are most commonly affected.

What is cauda equina syndrome and why is it a surgical emergency?

Compression of the lumbosacral nerve roots causing saddle anaesthesia, bilateral sciatica, bladder/bowel dysfunction (urinary retention/incontinence) and lower-limb weakness. It is a surgical emergency requiring urgent decompression to avoid permanent deficits.

What is the most common organism causing uncomplicated urinary tract infection, and the typical urinalysis findings?

Escherichia coli (uropathogenic). Urinalysis: pyuria (leucocytes), positive nitrites and leucocyte esterase, bacteriuria; significant culture ≥10^5 CFU/mL.

Differentiate cystitis from pyelonephritis clinically.

Cystitis (lower UTI): dysuria, frequency, urgency, suprapubic pain, usually no fever. Pyelonephritis (upper UTI): high fever with rigors, flank pain, costovertebral angle tenderness, nausea/vomiting, systemic illness.

What is the most common type of urinary tract stone and the conditions favouring its formation?

Calcium oxalate stones are most common (~70-80%). Favoured by hypercalciuria, hyperoxaluria, dehydration, and low urinary citrate; they are radio-opaque on X-ray.

Which urinary stone is associated with infection by urease-producing organisms, and what shape does it form?

Struvite (magnesium ammonium phosphate, 'triple-phosphate') stones - associated with urease-producing bacteria (Proteus) and alkaline urine; they form large 'staghorn' calculi.

What is the classic clinical presentation of ureteric colic and the investigation of choice?

Sudden severe colicky loin-to-groin pain, restlessness, with haematuria, nausea and vomiting. Non-contrast CT KUB is the investigation of choice (most sensitive); ultrasound is preferred in pregnancy.

Contrast benign prostatic hyperplasia (BPH) and prostate carcinoma in terms of zone of origin.

BPH arises from the TRANSITIONAL (periurethral) zone, causing bladder outflow obstruction. Prostate carcinoma usually arises from the PERIPHERAL zone, allowing palpation as a hard nodule on digital rectal exam.

What tumour marker is used for prostate cancer, and which grading system describes its histology?

Prostate-specific antigen (PSA) is the tumour marker. The Gleason score (grading group) describes histological differentiation; prostate adenocarcinoma classically metastasizes to bone (osteoblastic/sclerotic lesions).

What is the most common type of bladder cancer, its key risk factors, and cardinal symptom?

Transitional cell (urothelial) carcinoma. Risk factors: smoking, aromatic amines (aniline dye/rubber industry), cyclophosphamide; schistosomiasis causes squamous cell carcinoma. Cardinal symptom: painless gross haematuria.

What is the most common malignant renal tumour in adults, the triad, and classic associated finding?

Renal cell carcinoma (clear cell type, from proximal tubule). Classic triad: haematuria, flank pain, palpable mass (late). May cause left-sided varicocele (renal vein invasion) and paraneoplastic syndromes (polycythaemia, hypercalcaemia).

What is the most common renal malignancy in children and its typical age/presentation?

Wilms' tumour (nephroblastoma) - typically in children under 5 years, presenting as a painless abdominal mass; associated with WT1 gene mutation and WAGR/Beckwith-Wiedemann syndromes.

Define azoospermia and distinguish obstructive from non-obstructive causes in male infertility.

Azoospermia = complete absence of sperm in the ejaculate. Obstructive: normal spermatogenesis but blocked outflow (e.g., vasal/epididymal obstruction, absent vas deferens) - normal testes/FSH. Non-obstructive: testicular failure of spermatogenesis - small testes, raised FSH.

Why is varicocele a correctable cause of male infertility and which side is most commonly affected?

Varicocele raises scrotal/testicular temperature and impairs spermatogenesis (low count and motility); it is surgically correctable. It is far more common on the LEFT (left testicular vein drains at a right angle into the renal vein).