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CSHK Part 2 EMQ study materials
CSHK Part 2 EMQ study resources

CSHK Part 2 EMQ practice questions

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Question 1Surgical sciences and principles of surgery (general surgery core knowledge)

A 24-year-old man has a 6-hour history of central abdominal pain that migrated to the right iliac fossa, with localised peritonism at McBurney's point. Which single finding best supports operative rather than conservative management?

  1. Low-grade pyrexia of 37.8 °C
  2. Mild anorexia with one episode of vomiting
  3. Localised guarding with rebound tenderness at McBurney's point Correct answer.
  4. A white cell count of 11.5 × 10⁹/L

Explanation

Localised peritonism indicates parietal peritoneal irritation, which in suspected appendicitis signals an inflammatory process likely to progress to perforation and justifies appendicectomy. Systemic markers such as mild leucocytosis, pyrexia and vomiting are common but nonspecific and do not by themselves mandate surgery.

Question 2Surgical sciences and principles of surgery (general surgery core knowledge)

During a laparoscopic cholecystectomy, dense adhesions obscure the triangle of Calot. Which step most reliably reduces the risk of common bile duct injury?

  1. Using diathermy to divide tissue close to the common bile duct
  2. Placing clips on any tubular structure before defining its origin
  3. Dissecting the hepatocystic triangle only after achieving the critical view of safety Correct answer.
  4. Converting to open surgery only after bleeding is encountered

Explanation

The critical view of safety requires clearance of the hepatocystic triangle and separation of the lower gallbladder from the cystic plate so that only two structures enter the gallbladder before clipping. Achieving this view before division is the single most effective preventive strategy against bile duct injury.

Question 3Surgical sciences and principles of surgery (general surgery core knowledge)

A 68-year-old woman presents with a painful, tender lump in the left groin below and lateral to the pubic tubercle. Which diagnosis is most consistent with this anatomical relationship?

  1. Femoral hernia Correct answer.
  2. Psoas abscess
  3. Inguinal hernia
  4. Saphena varix

Explanation

The pubic tubercle is the surface landmark dividing inguinal from femoral herniae: inguinal herniae emerge above and medial to it, while femoral herniae emerge below and lateral. A femoral hernia passes through the femoral canal and is more common in older women.

Question 4Surgical sciences and principles of surgery (general surgery core knowledge)

A 45-year-old man has a 3 cm gallstone in the gallbladder and recurrent biliary colic. Which complication is most specifically associated with a large stone impacted in the terminal ileum?

  1. Pancreatitis
  2. Gallstone ileus Correct answer.
  3. Mirizzi syndrome
  4. Cholangitis

Explanation

A large gallstone can fistulate into the duodenum and lodge at the narrow terminal ileum, producing small bowel obstruction known as gallstone ileus. Mirizzi syndrome instead results from extrinsic compression of the common hepatic duct by a stone in the gallbladder neck or cystic duct.

Question 5Surgical sciences and principles of surgery (general surgery core knowledge)

A 30-year-old man sustains a stab wound to the left anterior chest. He is hypotensive with distended neck veins, muffled heart sounds and a falling blood pressure on inspiration. Which immediate step is most appropriate?

  1. Insertion of a large-bore chest drain
  2. Focused assessment with ultrasound then discharge
  3. Pericardiocentesis as definitive management
  4. Emergency thoracotomy or sternotomy for cardiac tamponade Correct answer.

Explanation

Beck's triad of hypotension, distended neck veins and muffled heart sounds in penetrating chest trauma indicates cardiac tamponade, and the patient is unstable. The definitive treatment is surgical decompression by thoracotomy or sternotomy, with pericardiocentesis reserved only as a temporising measure.

Question 6Surgical sciences and principles of surgery (general surgery core knowledge)

A 55-year-old man has a 2 cm well-differentiated rectal adenocarcinoma 6 cm from the anal verge, staged T2 N0 M0. Which operation is most appropriate?

  1. Hartmann's procedure
  2. Local transanal excision
  3. Abdominoperineal excision of the rectum
  4. Anterior resection Correct answer.

Explanation

A T2 N0 tumour at 6 cm from the anal verge lies in the mid rectum and can usually be managed by anterior resection with total mesorectal excision and primary anastomosis. Abdominoperineal excision is reserved for tumours too close to the sphincter to permit a safe margin.

Question 7Surgical sciences and principles of surgery (general surgery core knowledge)

A 72-year-old woman has a firm, painless, irregular mass in the upper outer quadrant of the breast with skin tethering. Which feature most strongly suggests malignancy rather than a benign lesion?

  1. Skin tethering over the mass Correct answer.
  2. Cyclical tenderness before menses
  3. Smooth, mobile, well-defined margins
  4. Rapid fluctuation in size with the menstrual cycle

Explanation

Skin tethering reflects tumour infiltration of Cooper's suspensory ligaments and is a hallmark of invasive breast carcinoma. Benign lesions such as fibroadenomas or cysts are typically smooth, mobile and may vary with the menstrual cycle.

Question 8Surgical sciences and principles of surgery (general surgery core knowledge)

A 60-year-old man has a 4 cm abdominal aortic aneurysm. Which surveillance interval is recommended for an asymptomatic aneurysm of this size?

  1. No further surveillance
  2. Three-monthly ultrasound surveillance
  3. Annual ultrasound surveillance Correct answer.
  4. Immediate elective repair

Explanation

Asymptomatic infrarenal aortic aneurysms of 3.0–4.4 cm are managed with annual ultrasound surveillance, because the risk of rupture at this size is very low. Intervention is generally reserved for aneurysms of 5.5 cm or more, rapid growth, or symptoms.

Question 9Surgical sciences and principles of surgery (general surgery core knowledge)

A 35-year-old man presents with a 6-hour history of severe epigastric pain radiating to the back, with epigastric tenderness and a serum lipase three times the upper limit of normal. Which initial management step is most appropriate?

  1. Urgent laparotomy
  2. Immediate CT scan before any resuscitation
  3. Aggressive intravenous fluid resuscitation with analgesia Correct answer.
  4. Immediate ERCP regardless of duct dilatation

Explanation

Acute pancreatitis is managed initially with goal-directed intravenous fluids, analgesia, antiemetics and monitoring, since most cases are self-limiting. CT imaging and ERCP are reserved for diagnostic uncertainty, severity assessment after 72 hours, or evidence of biliary obstruction.

Question 10Surgical sciences and principles of surgery (general surgery core knowledge)

A 50-year-old man has a 1.5 cm papillary thyroid carcinoma confined to one lobe with no nodal disease. Which operation is most appropriate?

  1. Simple enucleation of the nodule
  2. Hemithyroidectomy alone without discussion of completion
  3. Total thyroidectomy Correct answer.
  4. Radioactive iodine ablation as sole treatment

Explanation

For papillary thyroid carcinoma larger than 1 cm, total thyroidectomy allows radioiodine ablation, thyroglobulin surveillance and reduces contralateral recurrence. Hemithyroidectomy may be considered for small low-risk tumours but limits adjuvant options and follow-up.

Question 11Surgical sciences and principles of surgery (general surgery core knowledge)

A 40-year-old woman has a 3 cm proximal ureteric stone with severe colic and an obstructed infected system. Which intervention is most appropriate?

  1. Observation with analgesia alone
  2. Elective ureteroscopy in six weeks
  3. Oral tamsulosin and outpatient review in two weeks
  4. Urgent decompression with a ureteric stent or percutaneous nephrostomy Correct answer.

Explanation

An obstructed infected urinary tract is a urological emergency requiring urgent decompression by stent or nephrostomy, followed by antibiotics and later definitive stone treatment. Delaying drainage risks urosepsis and renal loss.

Question 12Surgical sciences and principles of surgery (general surgery core knowledge)

A 28-year-old man sustains blunt abdominal trauma with a splenic laceration and is haemodynamically stable with no peritonism. Which management is most appropriate?

  1. Immediate splenectomy
  2. Discharge with outpatient review
  3. Diagnostic peritoneal lavage followed by laparotomy
  4. Non-operative management with close monitoring in a facility with surgical backup Correct answer.

Explanation

Haemodynamically stable blunt splenic injury without peritonism can be managed non-operatively with monitoring, serial examination and access to immediate surgery. Splenectomy is reserved for haemodynamic instability or failure of non-operative management.

Question 13Surgical sciences and principles of surgery (general surgery core knowledge)

A 65-year-old man has a 3 cm renal mass with a tumour thrombus extending into the inferior vena cava below the hepatic veins. Which statement about management is most accurate?

  1. Radical nephrectomy with caval thrombectomy can be performed, often with cardiothoracic support Correct answer.
  2. Systemic therapy alone is standard for level II thrombus
  3. Caval thrombus precludes any surgical treatment
  4. Tumour thrombus below the hepatic veins is unresectable

Explanation

Renal cell carcinoma with level II caval thrombus (below the hepatic veins) is potentially curable by radical nephrectomy with thrombectomy, often requiring vascular or cardiothoracic assistance. Surgery offers the best survival in the absence of metastatic disease.

Question 14Surgical sciences and principles of surgery (general surgery core knowledge)

A 70-year-old man has a large, irreducible inguinoscrotal hernia with erythema and systemic sepsis. Which management is most appropriate?

  1. Manual reduction and discharge with analgesia
  2. Ultrasound-guided aspiration of the sac
  3. Elective repair after a course of antibiotics
  4. Resuscitation and emergency operative repair with resection of non-viable bowel Correct answer.

Explanation

A strangulated hernia is a surgical emergency requiring resuscitation and prompt operative exploration, with resection of ischaemic bowel and repair of the defect. Delay increases mortality from perforation and sepsis.

Question 15Surgical sciences and principles of surgery (general surgery core knowledge)

A 58-year-old woman has a 2 cm pancreatic head adenocarcinoma with no vascular involvement and no metastases. She is fit for surgery. Which operation is most appropriate?

  1. Pancreaticoduodenectomy (Whipple procedure) Correct answer.
  2. Total pancreatectomy with routine portal vein resection
  3. Distal pancreatectomy with splenectomy
  4. Palliative biliary stenting alone

Explanation

Resectable adenocarcinoma of the pancreatic head is treated by pancreaticoduodenectomy, which removes the head, duodenum, distal bile duct and regional nodes. Distal pancreatectomy is used for body or tail tumours, and stenting is palliative.

Question 16Surgical sciences and principles of surgery (general surgery core knowledge)

A 45-year-old man has a 4 cm duodenal ulcer with a visible non-bleeding vessel and signs of recent haemorrhage. Which endoscopic therapy is most appropriate?

  1. Endoscopic dual therapy with clips plus adrenaline injection Correct answer.
  2. Adrenaline injection alone
  3. Immediate surgical oversewing without endoscopy
  4. Proton pump inhibitor infusion alone

Explanation

High-risk stigmata such as a non-bleeding visible vessel warrant endoscopic dual therapy, combining a mechanical method such as clips with adrenaline injection to reduce rebleeding. Adrenaline alone is inferior, and surgery is reserved for failure of endoscopic control.

Question 17Surgical sciences and principles of surgery (general surgery core knowledge)

A 62-year-old woman has a 3 cm anal squamous cell carcinoma confined to the anal canal with no nodal disease. Which initial treatment is most appropriate?

  1. Chemoradiotherapy with mitomycin and fluorouracil Correct answer.
  2. Observation with repeat biopsy in six months
  3. Abdominoperineal excision as first-line
  4. Local excision alone

Explanation

Anal squamous cell carcinoma is primarily treated with chemoradiotherapy combining mitomycin and fluorouracil, which achieves sphincter preservation and good cure rates. Surgery is reserved for salvage of residual or recurrent disease.

Question 18Surgical sciences and principles of surgery (general surgery core knowledge)

A 55-year-old man has a 5 cm solitary liver metastasis from colorectal cancer with no extrahepatic disease and adequate future liver remnant. Which management offers the best chance of long-term survival?

  1. Liver resection of the metastasis Correct answer.
  2. Palliative care only
  3. Radiofrequency ablation as first-line
  4. Systemic chemotherapy alone

Explanation

Resectable colorectal liver metastases with no extrahepatic disease offer the best long-term survival with hepatic resection, often combined with perioperative chemotherapy. Ablation and systemic therapy are alternatives when resection is not feasible.

Question 19Surgical sciences and principles of surgery (general surgery core knowledge)

A 70-year-old man has a 3 cm bladder tumour invading the muscularis propria with no metastases. Which treatment is most appropriate for a fit patient?

  1. Intravesical BCG alone
  2. Radical cystectomy with urinary diversion Correct answer.
  3. Partial cystectomy with observation
  4. Transurethral resection alone

Explanation

Muscle-invasive bladder cancer in a fit patient is treated by radical cystectomy with urinary diversion, often after neoadjuvant chemotherapy. Transurethral resection and intravesical BCG are inadequate for muscle invasion.

Question 20Surgical sciences and principles of surgery (general surgery core knowledge)

A 25-year-old man has a 1 cm pigmented lesion on the back with irregular borders and recent enlargement. Excisional biopsy confirms melanoma with a Breslow thickness of 1.2 mm and no ulceration. Which additional step is most appropriate?

  1. Wide local excision alone without nodal staging
  2. Immediate completion lymphadenectomy of all basins
  3. Sentinel lymph node biopsy Correct answer.
  4. Systemic immunotherapy without staging

Explanation

Sentinel lymph node biopsy is offered for melanomas thicker than 1.0 mm to provide accurate nodal staging and guide further management. Completion lymphadenectomy is performed only when the sentinel node is positive, and immunotherapy is reserved for higher-stage disease.

Question 21Surgical sciences and principles of surgery (general surgery core knowledge)

A 60-year-old woman has a 3 cm pancreatic neuroendocrine tumour in the tail of the pancreas with no metastases. Which operation is most appropriate?

  1. Enucleation of the tumour
  2. Pancreaticoduodenectomy
  3. Total pancreatectomy
  4. Distal pancreatectomy with splenectomy Correct answer.

Explanation

Tumours of the pancreatic body and tail are managed by distal pancreatectomy, usually with splenectomy for oncological clearance. Pancreaticoduodenectomy is reserved for head lesions, and enucleation is suitable only for small, superficial, benign-behaving lesions.

Question 22Surgical sciences and principles of surgery (general surgery core knowledge)

A 65-year-old man has a 6 cm abdominal aortic aneurysm with a contained rupture and is haemodynamically unstable. Which management is most appropriate?

  1. Emergency endovascular or open repair with permissive hypotension Correct answer.
  2. Observation with serial haemoglobin
  3. Aggressive fluid loading to normalise blood pressure before imaging
  4. Elective repair after optimisation in one week

Explanation

A ruptured abdominal aortic aneurysm requires emergency repair, with endovascular repair preferred where anatomy allows, and permissive hypotension to avoid dislodging clot. Aggressive fluid resuscitation before control can worsen bleeding by raising pressure.

Question 23Surgical sciences and principles of surgery (general surgery core knowledge)

A 55-year-old woman has a 4 cm adrenocortical tumour with clinical features of cortisol excess and no metastases. Which management is most appropriate?

  1. Adrenalectomy with perioperative glucocorticoid cover Correct answer.
  2. Bilateral adrenalectomy
  3. Observation with annual imaging
  4. Chemotherapy as first-line

Explanation

A functioning adrenocortical tumour causing Cushing's syndrome is treated by adrenalectomy, with perioperative glucocorticoid cover because the contralateral gland is suppressed. Observation risks progression and uncontrolled hypercortisolism.

Question 24Surgical sciences and principles of surgery (general surgery core knowledge)

A 45-year-old man has a 2 cm insulinoma in the pancreatic head with no metastases. Which management is most appropriate?

  1. Distal pancreatectomy
  2. Observation with diazoxide alone
  3. Pancreaticoduodenectomy
  4. Enucleation of the tumour Correct answer.

Explanation

Small, benign-behaving insulinomas in the pancreatic head can often be enucleated if they are sufficiently distant from the main pancreatic duct. Pancreaticoduodenectomy is reserved for larger or malignant tumours, and medical therapy is only for poor surgical candidates.

Question 25Surgical sciences and principles of surgery (general surgery core knowledge)

A 70-year-old man has a 3 cm oesophageal adenocarcinoma at 30 cm from the incisors with no nodal or distant metastases. Which operation is most appropriate?

  1. Oesophagectomy with colonic interposition as first choice
  2. Endoscopic mucosal resection alone
  3. Definitive chemoradiotherapy without surgery
  4. Subtotal oesophagectomy with gastric conduit reconstruction Correct answer.

Explanation

Localised oesophageal adenocarcinoma is treated by subtotal oesophagectomy with gastric pull-up and lymphadenectomy, often after neoadjuvant therapy. Endoscopic resection is limited to superficial lesions, and colonic interposition is reserved for when the stomach is unusable.

Question 26Surgical sciences and principles of surgery (general surgery core knowledge)

A 30-year-old man sustains a penetrating stab wound to the left chest and presents with hypotension, distended neck veins and absent breath sounds on the left. Which initial manoeuvre is most appropriate before definitive drainage?

  1. Urgent CT scan of the chest with contrast
  2. Endotracheal intubation with positive pressure ventilation
  3. Pericardiocentesis via a subxiphoid approach
  4. Immediate needle decompression in the second intercostal space Correct answer.

Explanation

The picture is a tension pneumothorax, which is a clinical diagnosis requiring immediate decompression without waiting for imaging. Needle decompression converts the tension physiology to a simple pneumothorax before a chest drain is placed. Positive pressure ventilation before decompression can worsen the tension.

Question 27Surgical sciences and principles of surgery (general surgery core knowledge)

A 45-year-old man has a 2 cm biopsy-proven squamous cell carcinoma of the mid-oesophagus with no nodal or distant metastases. He is fit for surgery. Which single treatment offers the best chance of long-term cure?

  1. Oesophagectomy with lymphadenectomy Correct answer.
  2. Endoscopic mucosal resection
  3. Palliative stenting
  4. Definitive chemoradiotherapy alone

Explanation

Localised oesophageal squamous carcinoma in a fit patient is best treated with radical oesophagectomy and lymphadenectomy, often with perioperative therapy. Surgery offers the most reliable locoregional control and cure for resectable disease. Endoscopic resection is reserved for very early superficial lesions.

Question 28Surgical sciences and principles of surgery (general surgery core knowledge)

A 55-year-old woman has a 3 cm papillary thyroid carcinoma confined to one lobe with no lymph node involvement. Which operation is most appropriate?

  1. Total thyroidectomy with central neck dissection Correct answer.
  2. Lobectomy alone
  3. Hemithyroidectomy with ipsilateral modified radical neck dissection
  4. Radioactive iodine ablation without surgery

Explanation

For papillary thyroid carcinoma larger than 1 cm, total thyroidectomy with central compartment clearance is the standard oncological operation. It facilitates radioiodine ablation and surveillance with thyroglobulin. Lobectomy alone risks leaving occult contralateral disease.

Question 29Surgical sciences and principles of surgery (general surgery core knowledge)

A 60-year-old man has a 5 cm infrarenal abdominal aortic aneurysm with a contained rupture and is haemodynamically unstable. Which management is most appropriate?

  1. Elective endovascular repair in one week
  2. Beta-blocker therapy and blood pressure control
  3. Urgent open repair after fluid resuscitation Correct answer.
  4. Serial ultrasound surveillance every six months

Explanation

A contained rupture with haemodynamic instability is a surgical emergency requiring urgent repair, usually open in this setting. Permissive hypotension and rapid transfer to theatre improve survival. Surveillance or medical therapy would be fatal.

Question 30Surgical sciences and principles of surgery (general surgery core knowledge)

A 35-year-old woman has a 4 cm firm, mobile mass in the left breast with no skin changes. Core biopsy shows a fibroadenoma. Which management is most appropriate?

  1. Whole-breast radiotherapy
  2. Neoadjuvant chemotherapy
  3. Mastectomy with sentinel node biopsy
  4. Reassurance and routine follow-up Correct answer.

Explanation

A biopsy-proven fibroadenoma in a young woman is benign and can be managed with reassurance and follow-up. Excision is reserved for large, symptomatic or uncertain lesions. Malignant treatments are not indicated for benign histology.

Question 31Surgical sciences and principles of surgery (general surgery core knowledge)

A 25-year-old man has a 1 cm pigmented lesion on the back with irregular borders and recent enlargement. Excisional biopsy confirms a 0.6 mm Breslow thickness melanoma with no ulceration. Which management is most appropriate?

  1. Wide local excision with a 3 cm margin and sentinel node biopsy
  2. Observation alone
  3. Isolated limb perfusion
  4. Wide local excision with a 1 cm margin Correct answer.

Explanation

For melanomas up to 1 mm thick, a 1 cm excision margin is adequate and sentinel node biopsy is not routinely indicated. Thicker lesions require wider margins and nodal staging. Observation alone risks incomplete clearance.

Question 32Surgical sciences and principles of surgery (general surgery core knowledge)

A 50-year-old man has a 4 cm solitary liver metastasis from colorectal cancer with no extrahepatic disease and adequate future liver remnant. Which treatment offers the best chance of long-term survival?

  1. Liver transplantation
  2. Palliative chemotherapy alone
  3. Hepatic resection Correct answer.
  4. Radiofrequency ablation as sole therapy

Explanation

Resection of solitary colorectal liver metastasis offers the best chance of long-term survival and potential cure. Chemotherapy alone is palliative. Ablation is generally reserved for lesions unsuitable for resection.

Question 33Surgical sciences and principles of surgery (general surgery core knowledge)

A 65-year-old woman has a 3 cm anal squamous cell carcinoma confined to the anal canal with no nodal disease. Which initial treatment is most appropriate?

  1. Wide local excision with flap reconstruction
  2. Abdominoperineal resection
  3. Chemoradiotherapy (mitomycin and fluorouracil) Correct answer.
  4. Local excision alone

Explanation

The standard first-line treatment for anal squamous cell carcinoma is chemoradiotherapy with mitomycin and fluorouracil. Surgery is reserved for salvage after failed chemoradiotherapy or for very small superficial lesions. This preserves sphincter function.

Question 34Surgical sciences and principles of surgery (general surgery core knowledge)

A 55-year-old man has a 1.5 cm duodenal ulcer with a visible non-bleeding vessel and signs of recent haemorrhage. Which endoscopic therapy is most appropriate?

  1. Epinephrine injection alone
  2. Combination therapy with epinephrine injection plus a mechanical clip Correct answer.
  3. Argon plasma coagulation alone
  4. No endoscopic therapy; start high-dose proton pump inhibitor alone

Explanation

A visible vessel with recent haemorrhage is a high-risk stigma requiring endoscopic haemostasis. Combination therapy with epinephrine plus a mechanical or thermal method reduces rebleeding compared with monotherapy. Proton pump inhibitor alone is inadequate for high-risk lesions.

Question 35Surgical sciences and principles of surgery (general surgery core knowledge)

A 28-year-old man sustains blunt abdominal trauma with a grade III splenic laceration and is haemodynamically stable with no peritonism. Which management is most appropriate?

  1. Diagnostic laparotomy
  2. Immediate splenectomy
  3. Non-operative management with monitoring and serial assessment Correct answer.
  4. Splenic artery embolisation in all cases

Explanation

Haemodynamically stable patients with blunt splenic injury and no peritonism can be managed non-operatively with monitoring. Embolisation is reserved for active contrast extravasation or high-grade injury. Laparotomy is reserved for instability or peritonism.

Question 36Surgical sciences and principles of surgery (general surgery core knowledge)

A 62-year-old man has a 3 cm renal mass with a tumour thrombus extending into the inferior vena cava below the hepatic veins. Which management is most appropriate?

  1. Partial nephrectomy alone
  2. Active surveillance
  3. Systemic targeted therapy alone
  4. Radical nephrectomy with thrombectomy Correct answer.

Explanation

Renal cell carcinoma with IVC tumour thrombus below the hepatic veins is best treated with radical nephrectomy and thrombectomy. Partial nephrectomy is inadequate for a large mass with venous extension. Systemic therapy alone is reserved for metastatic disease.

Question 37Surgical sciences and principles of surgery (general surgery core knowledge)

A 70-year-old man has a 3 cm oesophageal adenocarcinoma at 30 cm from the incisors with no nodal or distant metastases. Which management is most appropriate?

  1. Oesophagectomy with lymphadenectomy Correct answer.
  2. Endoscopic mucosal resection
  3. Definitive chemoradiotherapy alone
  4. Palliative stenting

Explanation

A resectable oesophageal adenocarcinoma in a fit patient is treated with oesophagectomy and lymphadenectomy, often with perioperative therapy. Endoscopic resection is for very early superficial lesions. Palliative stenting is for advanced disease.

Question 38Surgical sciences and principles of surgery (general surgery core knowledge)

A 35-year-old man presents with a 6-hour history of severe epigastric pain radiating to the back, with epigastric tenderness and raised serum amylase. Which initial management is most appropriate?

  1. Aggressive intravenous fluid resuscitation and analgesia Correct answer.
  2. Urgent laparotomy
  3. Immediate ERCP
  4. Oral intake and observation

Explanation

Acute pancreatitis is managed initially with aggressive fluid resuscitation, analgesia and supportive care. ERCP is indicated only for concurrent cholangitis or persistent biliary obstruction. Laparotomy is not indicated without complications.

Question 39Surgical sciences and principles of surgery (general surgery core knowledge)

A 72-year-old woman has a firm, painless, irregular mass in the upper outer quadrant of the breast with skin tethering. Core biopsy confirms invasive ductal carcinoma. Which management is most appropriate?

  1. Multidisciplinary planning with surgery and adjuvant therapy Correct answer.
  2. Observation with serial mammography
  3. Excision alone without further treatment
  4. Primary endocrine therapy alone

Explanation

Invasive breast carcinoma requires multidisciplinary planning including surgery and adjuvant therapy based on receptor status and stage. Excision alone risks recurrence and undertreatment. Observation is inappropriate for confirmed malignancy.

Question 40Surgical sciences and principles of surgery (general surgery core knowledge)

A 50-year-old man has a 1.5 cm papillary thyroid carcinoma confined to one lobe with no nodal disease. Which factor most strongly influences the choice of total thyroidectomy over lobectomy?

  1. Normal preoperative calcium
  2. Patient preference alone
  3. Absence of lymph node involvement
  4. Tumour size greater than 1 cm Correct answer.

Explanation

Tumour size greater than 1 cm is a key factor favouring total thyroidectomy because it permits radioiodine ablation and thyroglobulin surveillance. Patient preference alone is insufficient. Nodal status and calcium do not determine extent of thyroidectomy.

Question 41Surgical sciences and principles of surgery (general surgery core knowledge)

A 65-year-old man has a 3 cm bladder tumour invading the muscularis propria with no metastases. Which treatment is most appropriate?

  1. Radical cystectomy with urinary diversion Correct answer.
  2. Intravesical BCG alone
  3. Partial cystectomy alone
  4. Transurethral resection alone

Explanation

Muscle-invasive bladder cancer is best treated with radical cystectomy and urinary diversion, often with neoadjuvant chemotherapy. Transurethral resection alone is inadequate for muscle invasion. Intravesical BCG is for non-muscle-invasive disease.

Question 42Surgical sciences and principles of surgery (general surgery core knowledge)

A 40-year-old woman has a 3 cm proximal ureteric stone with severe colic and an obstructed infected system. Which complication most strongly dictates the need for emergency decompression rather than lithotripsy?

  1. Stone size greater than 2 cm
  2. Obstruction with infection Correct answer.
  3. Proximal stone location
  4. Severe colic alone

Explanation

Obstruction with infection is the key factor requiring emergency decompression because of the risk of urosepsis. Stone size, location and colic alone do not mandate emergency decompression. Lithotripsy can be performed once infection is controlled.

Question 43Surgical sciences and principles of surgery (general surgery core knowledge)

A 68-year-old man develops fever, tachycardia, wound erythema and crepitus over the abdominal wall on the third day after laparotomy for perforated sigmoid diverticulitis. Which single most appropriate initial step in surgical management is indicated alongside broad-spectrum antibiotics and fluid resuscitation?

  1. Emergency surgical re-exploration with wide debridement of all necrotic tissue Correct answer.
  2. Percutaneous image-guided drainage of a presumed intra-abdominal abscess alone
  3. Bedside needle aspiration of the wound for culture and observation for 24 hours
  4. Application of topical antiseptic dressing with delayed closure of the wound

Explanation

Crepitus, systemic sepsis and rapid progression after laparotomy indicate necrotising soft tissue infection of the abdominal wall, a surgical emergency. The controlling step is urgent re-exploration with radical debridement of all non-viable tissue, repeated as needed, together with broad-spectrum antibiotics and resuscitation. Delay while awaiting cultures or imaging worsens mortality.

Question 44Surgical sciences and principles of surgery (general surgery core knowledge)

A 58-year-old woman has a 2.5 cm unilocular anechoic thyroid cyst. Aspiration yields 8 mL of clear fluid and the cyst completely resolves. Cytology of the fluid is reported as benign. Which is the most appropriate next step in management?

  1. Radioactive iodine ablation of the thyroid remnant
  2. Repeat fine-needle aspiration only if the cyst recurs or symptoms return Correct answer.
  3. Urgent open biopsy of the thyroid isthmus
  4. Total thyroidectomy with central neck dissection

Explanation

A simple cyst that fully collapses after aspiration and has benign fluid cytology carries a very low risk of malignancy. Current practice is clinical follow-up with repeat aspiration or ultrasound only if the cyst recurs or becomes symptomatic. Surgery is reserved for recurrence, suspicious ultrasound features or compressive symptoms.

Question 45Surgical sciences and principles of surgery (general surgery core knowledge)

A 62-year-old man has a 4 cm mid-rectal adenocarcinoma staged T3N0 by MRI with a clear circumferential resection margin. He has no distant metastases. Which management plan offers the best oncological outcome?

  1. Neoadjuvant chemoradiotherapy followed by total mesorectal excision Correct answer.
  2. Anterior resection with no mesorectal excision and no adjuvant therapy
  3. Defunctioning colostomy alone as palliative symptom control
  4. Local transanal excision of the tumour with close follow-up

Explanation

Locally advanced mid-rectal cancer (T3) with an intact margin is best treated with neoadjuvant chemoradiotherapy to downstage the tumour, followed by total mesorectal excision, which removes the mesorectum intact and reduces local recurrence. Adjuvant chemotherapy is then considered based on final pathology.

Question 46Surgical sciences and principles of surgery (general surgery core knowledge)

A 24-year-old man is brought to the emergency department after a motorcycle crash. He is hypotensive and tachycardic, and focused assessment with sonography shows free fluid in the right upper quadrant. Which is the most appropriate immediate management?

  1. Diagnostic peritoneal lavage to quantify the haemoperitoneum
  2. Emergency laparotomy after rapid resuscitation with blood products Correct answer.
  3. CT abdomen with intravenous contrast before any intervention
  4. Serial abdominal examination with observation for 12 hours

Explanation

Blunt abdominal trauma with haemodynamic instability and free intraperitoneal fluid indicates ongoing haemorrhage that cannot be controlled non-operatively. The patient needs activation of massive transfusion and immediate laparotomy for haemostasis. Imaging and lavage only delay control of bleeding in an unstable patient.

Question 47Surgical sciences and principles of surgery (general surgery core knowledge)

A 70-year-old man is assessed before elective open repair of an incisional hernia. His body mass index is 38, he has type 2 diabetes and he smokes 20 cigarettes daily. Which single preoperative measure most reduces his risk of surgical site infection?

  1. Tight intraoperative glycaemic control only
  2. Prophylactic antibiotics continued for five postoperative days
  3. Smoking cessation at least four weeks before surgery Correct answer.
  4. Routine preoperative bowel preparation

Explanation

Smoking impairs wound healing through tissue hypoxia and is an independent, modifiable risk factor for surgical site infection. Stopping at least four weeks before surgery substantially reduces wound complications. Prolonged antibiotics, prolonged operating time and poor glycaemic control all increase rather than decrease infective risk.

Question 48Surgical sciences and principles of surgery (general surgery core knowledge)

A 45-year-old woman has a 3 cm duodenal ulcer with a visible vessel and active bleeding on endoscopy. Endoscopic therapy with adrenaline injection and a clip achieves haemostasis. Which is the most appropriate next step?

  1. Repeat endoscopy in 24 hours regardless of clinical status
  2. Immediate surgical oversewing of the ulcer
  3. Oral proton pump inhibitor and early discharge
  4. High-dose intravenous proton pump inhibitor infusion for 72 hours Correct answer.

Explanation

After successful endoscopic haemostasis of a high-risk bleeding ulcer, high-dose intravenous proton pump inhibitor therapy stabilises the clot and reduces rebleeding. Endoscopic therapy plus acid suppression is the standard of care; surgery is reserved for failure of endoscopic control or rebleeding.

Question 49Surgical sciences and principles of surgery (general surgery core knowledge)

A 38-year-old man is admitted with a 12-hour history of generalised peritonitis. At laparotomy, a perforated prepyloric ulcer is found with generalised contamination of the peritoneal cavity. Which single operative step is most important in reducing postoperative morbidity?

  1. Placement of a feeding jejunostomy
  2. Routine gastrectomy with lymphadenectomy
  3. Thorough peritoneal lavage with copious warm saline Correct answer.
  4. Routine drainage of the subphrenic spaces

Explanation

In perforated peptic ulcer with established peritonitis, the key manoeuvre after closing the perforation is thorough peritoneal lavage to reduce bacterial load and prevent continuing sepsis. Omental patch repair is standard; more extensive gastric surgery is not indicated in the emergency setting.

Question 50Surgical sciences and principles of surgery (general surgery core knowledge)

A 55-year-old man has a large, irreducible inguinoscrotal hernia. During surgery for strangulation, a loop of small bowel is dusky and does not improve after 15 minutes of warm packs and intravenous fluids. Which is the most appropriate action?

  1. Returning the bowel to the abdomen and closing without resection
  2. Exteriorising the bowel as a stoma without resection
  3. Resection of the non-viable bowel with primary anastomosis Correct answer.
  4. Reduction of the bowel and placement of a mesh plug

Explanation

Bowel that remains dusky and fails to recover after warming and resuscitation is non-viable and must be resected to prevent perforation and ongoing sepsis. Primary anastomosis is usually safe in a stable patient, and the hernia defect can be repaired without mesh in a contaminated field.