Surgery multiple choice questions

Surgery
by Medical Educator Surgery

Surgery is a fundamental and intricate aspect of medical practice that involves the use of manual and instrumental techniques to investigate, diagnose, and treat various medical conditions or injuries. It is a field that demands precision, knowledge, and skill, as well as a deep understanding of anatomy, physiology, and patient care.

It is a discipline that spans a wide range of specialties, from general surgery to specialized fields like orthopedics, neurosurgery, and cardiovascular surgery. Surgeons play a crucial role in saving lives and improving the quality of life for patients.

Take the following multiple-choice questions to test your knowledge. Best of luck, and remember that the skills you acquire in surgery will be invaluable throughout your medical career.

Table of Contents

Acute Abdominal Pain

A 66 year old patient presents with a 1 hour of acute onset central abdominal pain to the A&E department. He has a history of diabetes, stroke, and ischaemic heart disease. He is bed bound in relation to the above co-morbidities. What could be the cause of the central abdominal pain?

  • Bowel Obstrudtion
  • Ruptured Abdominal Aortic Aneurysm
  • Appendicitis
  • Pancreattiis
  • Peptic Ulcer Disease

All of the above are common causes of central abdominal pain. Be wary of bracketing causes in exams. E.g. gallstones characteristically give RUQ pain which radiates to the tip of the right shoulder. However, this is not always the case and they can cause central pain.

Some early blood tests are available and show the following.

Hb  8.6 (13-18 g/dl)

MCV  88  (80-99 fL)

Plt  276  (150-300 x109/l)

WCC  6.2 (4-10 x109/l)

Na 134 (135-145mmol/l)

K 4.3 (3.5-5.1mmol/l)

U 4.3 (4-9mmol/l)

Creatinine  163 (60-100 micromols/l)

CRP 23 (<5mg/l)

Albumin  44 (35-45g/l)

Alk Phos 86 (<110iu/l)

ALT  24 (<40 iu/l)

Bilirubin  16 (<20 micromols/l)

GGT  23  (0-70)

INR   1.0

Glucose  4.5 (mmol/l)

Amylase  36 (<90)

CK  43 (iu/l)

Which one of the following diagnoses are made much less likely in light of these results?

  • Bowel Obstrudtion
  • Ruptured Abdominal Aortic Aneurysm
  • Appendicitis
  • Pancreattiis
  • Peptic Ulcer Disease

Appendicitis

A serum amylase has a sensitivity of >80% for detecting acute pancreatitis. IN a patient this unwell because of pancreatic inflammation you would expect a much higher amylase (e.g. 1000’s)

You wish to identify a diagnosis rapidly. Which is the best imaging modality of choice to arrive at a definitive diagnosis?

  • Departmental Ultrasound
  • Portable Ultrasound
  • CT abdomen
  • Abdominal Xray
  • Laparotomy

CT abdomen

An ultrasound would be helpful for diagnosing a ruptured AAA. It would also show some other organs (gallbladder) and identify free fluid (e.g. blood) in the peritoneum. However the imaging modality of choice would be a CT scan.

A laparotomy is needed in some urgent situations however if time allows the diagnostic images available from CT will provide you with more information about anatomy and structure.

Abdominal Pain 2

An 18 year old presents with abdominal pain, vomiting and anorexia for 12 hours. He is found to have generalised abdominal guarding. He has pain more in the right iliac fossa. Palpating in the left iliac fossa is painful but causes more pain in his right iliac fossa.

Blood tests show the following.

Hb 17.5(13-18 g/dl)

MCV 83(80-99 fL)

Plt 216 (150-300 x109/l)

WCC 12.3(4-10 x109/l)

Na132(135-145mmol/l)

K4.5(3.5-5.1mmol/l)

U6(4-9mmol/l)

Creatinine 102(60-100 micromoles/l)

CRP129(<5mg/l)

Albumin 40(35-45g/l)

Alk Phos83(<110iu/l)

ALT 41(<40 iu/l)

Bilirubin 5(<20 micromoles/l)

GGT21 (0-70)

INR 1.1

Glucose 28.1(mmol/l)

Amylase93(<90)

CK43(iu/l)

PSA 2.3(0-4ng/ml)

What is the diagnosis? Please choose as many of the below that apply.

  • He is highly likely to have type 1 diabetes
  • He is likely to have Munchausen’s
  • He is unlikely to have more than one pathology at the same time
  • He is likely to have gallstones
  • He is likely to have Pancreatitis
  • He is likely to have renal colic (Pathology on the left side)
  • He is likely to have renal colic (Pathology on the right side)
  • He is likely to have food poisoning
  • He is highly likely to have appendicitis

He is highly likely to have type 1 diabetes, and he is highly likely to have appendicitis.

The clinical signs suggest appendicitis. Don’t be fooled by small abnormalities in blood results in medical questions they may be a red herring (as in the amylase here).

The CRP is in keeping with any diagnosis

The raised blood sugar is highly suggestive of diabetes, even in the context of any acute insult. In an 18 year old this is likely to be type 1 diabetes. Check pH (acidosis) and urinary ketones (DKA).

ASA status

A 66 year old patient presents with a ruptured abdominal aortic aneurysm to the A&E department. He has a history of diabetes, stroke, and ischaemic heart disease. He is bed bound in relation to the above co-morbidities. He is found to have an AAA which has ruptured.

Prior to his presentation to hospital what is his ASA classification? (American Society of Anaesthesiologists)

  • ASA 1
  • ASA 2
  • ASA 3
  • ASA 4
  • ASA 5

ASA 4

He has a number of comorbidities. The criteria are as follows:

1 Normally healthy

2 Mild disease

3 Severe systemic disease that limits activity

4 Incapacitating systemic disease that poses a threat to like

5 Moribund, unlikely to survive next 24 hours

The key word is “prior”.

C Diff

A 45 year old diabetic man is treated with broad spectrum antibiotics for 2 weeks for an infected foot ulcer.

He subsequently develops diarrhoea which is green, liquid and offensive. He is otherwise well in himself. Which is the diagnostic test of choice to rapidly identify the most likely cause?

  • Stool Culture (Microscopy Culture and Sensitivity)
  • Stool Culture (Ova Cyts and Parasites)
  • Blood Culture
  • Stool for Clostridium Difficele Toxin
  • Wound Swab
  • Stool for PCR
  • CT scan abdomen
  • MRI scan Abdomen

Stool for Clostridium Difficele Toxin

What is the antibiotic treatment of choice for this patient?

  • Metronidazole orally
  • Metronidazole IV
  • Amoxycillin orally
  • Amoxycillin IV
  • Tazocin IV
  • Cefuroxime IV
  • Cefuroxime and metronidazole IV

Metronidazole orally

C Diff can be treated in the first instance with either metronidazole or vancomycin (both orally in the first instance). Braod spectrum antibiotics like Tazocin and cefuroxime are more likely to put patients at risk of aquiring C diff as a result of destruction of the patients natural gut flora.

“Cef&met” are the traditional antibiotics for someone with an acute abdomen and possible systemic infection/perforation etc. Your local antibiotic policies may now be different to this.

Diagnostic image

An image taken form a diagnostic test further down the line of this patients care is shown. What is the image on view?

(source: public domain@wikimedia)
  • Lateral X-ray
  • MRI Abdomen
  • CT Abdomen Axial view
  • CT abdomen coronal view
  • CT abdomen sagittal view

CT abdomen sagittal view

45 year old diabetic

A 45 year old diabetic presents with a cold blue foot. He has lost sensation. He has no peripheral pulses. What is the most likely diagnosis?

  • Cellulitis
  • Reflex Sympathetic Dystrophy
  • Acute limb ischaemia
  • Chronic peripheral vascular disease and claudication
  • Spinal stenosis
  • Sciatica

Acute limb ischaemia

The diagnosis here is clear cut: acute symptoms makes a chronic problem less likely. No foot pulses=acute ischaemia until proven otherwise. Plan: urgent investigation i.e. angiography +/- plasty /stenting etc

Mortality AAA

For a ruptured AAA what is the estimated mortality in patients prior to presentation in the A&E department?

  • <5%
  • 10-20%
  • 20-30%
  • 30-50%
  • >50%

50%

About 65% of people who rupture their AAA will die before arriving in hospital.

Murphy’s test

If a new test has a 70% negative predictive value for cholecystitis, what is the chance a person could still have cholecystitis with a negative test?

  • 0%
  • 30%
  • 50%
  • 70%
  • 100%

30%

The test will correctly rule out cholecystitis in 70% of cases i.e. it has a 70% negative predictive value. Therefore it will miss 30% of cases

What will the effect of age be on the negative predictive value of Murphy’s sign? (e.g. in a 70 y.o. compared to a 25 y.o.)

  • No effect
  • Increase sensitivity
  • Reduce sensitivity
  • None of the above

Reduce sensitivity

Score -10 marks for answering none of the above! The older someone is the less clear cut the presentation.

E.g. an elderly woman with septicaemia may not be febrile. It would be highly unlikely for a fit and well young patient to develop sepsis with no fever.

34 year old female

A 34 year old obese female is known to have gallstones.
At her follow up clinic she complains of intermittent right upper quadrant pain. The pain is there for around 4-5 hours every day. She has a history of Irritable bowel syndrome but has been complaining of increased belching and flatulence.

On examination she has right upper quadrant tenderness but no guarding or rebound tenderness. She is not clinically jaundiced.
Temperature 373
Fingerprick blood glucose 6.2mmol/l
Urinalysis 1+blood 1+ protein


She has had symptoms for the past 12 weeks since a previous admission and feels she “cant take it any more”.

What is the most likely diagnosis here?

  • Acute Cholecystitis
  • Chronic Cholecystitis
  • Cholangitis
  • Biliary colic
  • None of the above

Chronic Cholecystitis

The history is of chronic symptoms. This makes biliary colic, acute cholecystitis and chronic cholecystitis all unlikely.

45 year old

A 45 year old used car salesman presents with a itching and is found to be jaundiced. His Examination is normal other than the finding of jaundice and a palpable gall bladder.

Regarding the following statement (true/false)

He is likely to have gallstones

  • True
  • False

False

He is more likely to have a disease other than gallstones…Theres a good reason for this.

Perforation

What proportion of patients with a perforated peptic ulcer will have free gas under the diaphragm on an erect CXR?

  • 10%
  • 25%
  • 50%
  • 75%
  • >90%

75%

Roughly 3/4 of perforations from perforations from peptic ulcer disease show up on an erect CXR.

Richters hernia

What is a Richter’s hernia?

  • A hernia that is strangulated
  • A hernia that involves the small bowel only
  • A hernia which is obstructed
  • A hernia that is irreducible
  • A hernia where only part of the bowel wall circumference herniates

A hernia where only part of the bowel wall circumference herniates