A 46-year-old woman presents with a thyroid swelling. Ultrasound shows a solid hypoechoic nodule with microcalcifications, irregular margins, and taller-than-wide shape, measuring 1.2 cm. TI-RADS scoring classifies the lesion as TR5 (high suspicion). She has no compressive symptoms and TSH is normal. What is the most appropriate next step?
Answer: C
Explanation: The ultrasound features—solid, hypoechoic, microcalcifications, irregular margins, and taller-than-wide—indicate high malignancy risk, categorizing it as TI-RADS 5 (TR5). According to ACR TI-RADS criteria, FNAC is recommended for TR5 nodules measuring ? 1.0 cm. This patient’s 1.2 cm TR5 lesion crosses the FNAC threshold.
Teaching Points: - TR5 (high suspicion) ? FNAC ? 1.0 cm
- Ultrasound patterns are more important than size alone in TI
- RADS scoring
- TR5 nodules have the lowest cutoff for FNAC because of very high cancer risk
Before initiating nutritional support in a severely malnourished postoperative patient at risk of refeeding syndrome, what is the most appropriate management?
Answer: C
Explanation: (Surgery setting):
Severely malnourished surgical patients are metabolically unstable. If feeds are started without preparing the body, intracellular electrolyte shifts can trigger hypophosphatemia, hypokalemia, and hypomagnesemia. Supplementation of B-complex, thiamine, and daily multivitamins must precede feeding to prevent metabolic collapse.
Teaching Points: - Do not start feeds before correcting electrolytes in high
- risk patients.
- Thiamine and high
- potency B vitamins should be administered before enteral nutrition.
- Refeeding risk is high in cachexia, prolonged NPO, postoperative sepsis, bowel obstruction relief, and long ICU stay.
Which of the following surgeries is considered high-risk according to the Revised Cardiac Risk Index (RCRI)?
Answer: C
Explanation: RCRI defines high-risk surgery as:
Intraperitoneal
Intrathoracic
Supra-inguinal vascular surgery
Open abdominal aortic aneurysm repair = supra-inguinal vascular ? high-risk
Incorrect options:
A. Below-knee bypass ? infra-inguinal vascular = not high-risk for RCRI
B. Carotid endarterectomy ? not high-risk per RCRI
D. Total knee replacement ? orthopedic ? not high-risk
Teaching Points: Teaching Point:
Only intraperitoneal, intrathoracic, and supra-inguinal vascular procedures qualify as high-risk in RCRI — not all vascular surgeries.
All of the following are true regarding disclosure of risks during informed consent EXCEPT:
Answer: C
Explanation: Risk disclosure is based on materiality to the patient, not percentage incidence. Even rare risks must be discussed if they may significantly affect the patient’s decision.
Teaching Points: Teaching Point:
Consent follows the reasonable patient standard, not numerical incidence criteria.
Which of the following is NOT a recommended postoperative element of the ERAS protocol for colorectal surgery?
Answer: C
Explanation: ERAS promotes early postoperative oral intake, which improves gut motility and reduces postoperative ileus. Waiting for bowel sounds before feeding is outdated and delays recovery.
Other ERAS-supported components include early catheter and drain removal, mobilization, and multimodal analgesia without routine reliance on opioids.
Teaching Points: Teaching Point:
In ERAS colorectal pathways, gut stimulation begins early — feeding and ambulation start on the day of surgery or day 1; prolonged NPO is avoided.
Which feature makes NRS-2002 different from other nutritional screening tools?
Answer: B
Explanation: NRS-2002 is unique because it combines nutritional impairment score + disease severity score, improving prediction of clinical benefit from nutritional support.
Teaching Points: Teaching Point:
NRS-2002 = Nutritional Status (0–3) + Disease Severity (0–3) + Age ?70 (add +1).
Which imaging modality has the highest sensitivity for localizing an ectopic parathyroid adenoma in the mediastinum?
Answer: C
Explanation: 4D-CT (3D CT + perfusion phase) provides superior spatial resolution and vascularity-based contrast washout characteristics, especially for ectopic glands in mediastinum, retroesophageal space, and tracheoesophageal groove. Ultrasound has a limited role for ectopic glands and MRI has inferior localization.
Teaching Points: Teaching Point:
4D-CT is preferred for re-operative cases and ectopic adenoma localization, especially when USG/MIBI are inconclusive.
Which is the most accurate indicator of ongoing severe UGIB during resuscitation:
Answer: D
Explanation: Hemoglobin and BUN lag behind; lactate reflects tissue hypoperfusion and correlates with ongoing hemorrhagic shock and mortality risk.
Teaching Points: Teaching points:
Serial lactate is a strong prognostic marker in GI bleed
BUN/Cr rises in UGIB but is not a reliable indicator of severity
A 45-year-old woman presents with acute abdomen, tachycardia, BP 90/60. Ultrasound shows 12-cm left ovarian mass with ascites. CA-125 = 980. CT shows omental caking. Best surgical approach?
Answer: C
Explanation: Patient is hemodynamically unstable + peritoneal carcinomatosis ? cytoreductive laparotomy is indicated.
Diagnostic laparoscopy delays critical surgery; biopsy risks tumor rupture.
Teaching Points: Goal in advanced ovarian cancer surgery ? No gross residual disease
Surgery first if performance status allows; NACT if disease unresectable or medically unfit
Ascites + omental cake = high probability of HGSC