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Iraqi Board General Surgery study materials
Iraqi Board General Surgery study resources

Iraqi Board General Surgery practice questions

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Question 1Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

During thyroidectomy, which nerve is most at risk of injury as it passes between the inferior thyroid artery and the tracheoesophageal groove, and what is the resulting deficit?

  1. Recurrent laryngeal nerve; ipsilateral vocal cord paresis with hoarseness Correct answer.
  2. Hypoglossal nerve; tongue deviation toward the lesion
  3. External branch of the superior laryngeal nerve; loss of high-pitch phonation
  4. Glossopharyngeal nerve; loss of gag reflex

Explanation

The recurrent laryngeal nerve ascends in the tracheoesophageal groove and has a close and variable relationship with the inferior thyroid artery, making it the structure most frequently injured during thyroid resection. Unilateral injury paralyzes the ipsilateral vocal cord in a paramedian position, producing hoarseness and a weak voice.

Question 2Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

A patient with a penetrating wound to the anterior triangle of the neck develops a hoarse voice and aspirates liquids. Which structure has most likely been injured?

  1. Sympathetic chain
  2. Phrenic nerve
  3. Vagus nerve Correct answer.
  4. Thoracic duct

Explanation

The vagus nerve descends in the carotid sheath and gives off the recurrent laryngeal branch, which supplies all intrinsic laryngeal muscles except cricothyroid. Injury causes vocal cord paralysis with hoarseness and loss of laryngeal protection, so liquids are aspirated.

Question 3Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which factor most increases the risk of venous thromboembolism after major abdominal surgery by promoting stasis and endothelial activation?

  1. Use of regional anesthesia
  2. Prolonged operative time and immobility Correct answer.
  3. Early ambulation on the first day
  4. Mild postoperative anemia

Explanation

Virchow's triad links thrombosis to stasis, endothelial injury, and hypercoagulability. Long operations and postoperative immobility produce venous stasis and endothelial activation, which are the dominant surgical risk factors for deep vein thrombosis.

Question 4Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

A 45-year-old man has a serum calcium of 2.9 mmol/L, a raised parathyroid hormone, and a history of recurrent renal stones. Which mechanism best explains the hypercalcemia?

  1. Increased calcitonin secretion
  2. Increased renal tubular phosphate reabsorption
  3. Excess parathyroid hormone-driven bone resorption and renal calcium reabsorption Correct answer.
  4. Deficient 1-alpha hydroxylation of vitamin D

Explanation

Primary hyperparathyroidism causes excess PTH, which increases osteoclastic bone resorption and renal tubular calcium reabsorption while promoting phosphate excretion. The net effect is hypercalcemia with hypophosphatemia, and the sustained calcium load predisposes to nephrolithiasis.

Question 5Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which pharmacokinetic change in the elderly most directly prolongs the effect of a single intravenous dose of a benzodiazepine?

  1. Increased volume of distribution for lipid-soluble drugs Correct answer.
  2. Reduced renal clearance of active metabolites
  3. Reduced hepatic blood flow
  4. Reduced gastric emptying

Explanation

Lipid-soluble benzodiazepines distribute widely into adipose tissue, and the increased proportion of body fat in older adults enlarges the volume of distribution. This prolongs the elimination half-life and the clinical effect even after a single intravenous dose.

Question 6Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

A patient on warfarin for a mechanical valve needs emergency surgery. Which agent most rapidly reverses the anticoagulant effect while also replacing vitamin K-dependent factors?

  1. Protamine sulfate
  2. Platelet transfusion
  3. Prothrombin complex concentrate plus intravenous vitamin K Correct answer.
  4. Fresh frozen plasma

Explanation

Prothrombin complex concentrate provides concentrated factors II, VII, IX, and X and corrects the INR within minutes, while intravenous vitamin K restores endogenous synthesis over hours. This combination is preferred for urgent reversal of warfarin in major bleeding or emergency surgery.

Question 7Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which organism is the most common cause of postoperative wound infection after clean elective surgery, and what is its typical Gram status?

  1. Staphylococcus aureus; Gram-positive cocci in clusters Correct answer.
  2. Pseudomonas aeruginosa; Gram-negative oxidase-positive rod
  3. Escherichia coli; Gram-negative bacilli
  4. Bacteroides fragilis; Gram-negative anaerobe

Explanation

Staphylococcus aureus, a Gram-positive coccus in clusters, colonizes skin and is the leading pathogen in clean surgical site infections. Its prevalence reflects the endogenous skin flora at the incision site.

Question 8Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

A patient develops a wound infection 5 days after surgery. Which principle best explains why drainage alone often resolves an abscess without antibiotics?

  1. Antibiotics penetrate abscess cavities poorly, so mechanical drainage is the definitive therapy Correct answer.
  2. Host immunity is fully restored after drainage
  3. Abscess fluid is sterile
  4. Antibiotics are inactivated by pus

Explanation

An abscess has an acidic, hypoxic environment with poor blood supply, which limits antibiotic penetration and allows bacteria to persist. Drainage removes the bacterial load and restores tissue perfusion, so it is the definitive treatment and antibiotics are adjunctive.

Question 9Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which of the following best describes the hepatic blood supply and its oxygen contribution in a healthy adult?

  1. Portal vein supplies 70% of flow and 50% of oxygen Correct answer.
  2. Hepatic artery supplies 50% of flow and 70% of oxygen
  3. Portal vein supplies 30% of flow and 70% of oxygen
  4. Hepatic artery supplies 70% of flow and 50% of oxygen

Explanation

The portal vein delivers about 70% of hepatic blood flow but, because its blood is partly deoxygenated, contributes roughly half of the liver's oxygen. The hepatic artery supplies the remaining flow and oxygen, and this dual supply explains the liver's tolerance of portal vein occlusion.

Question 10Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

A patient with cirrhosis and portal hypertension has splenomegaly and thrombocytopenia. Which mechanism best explains the low platelet count?

  1. Reduced thrombopoietin production by the liver
  2. Disseminated intravascular coagulation
  3. Hypersplenism with splenic sequestration of platelets Correct answer.
  4. Autoimmune platelet destruction

Explanation

Portal hypertension causes splenic congestion and enlargement, and the enlarged spleen sequesters and destroys platelets, producing thrombocytopenia. This hypersplenism is a common cause of low platelets in cirrhotic patients.

Question 11Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which nerve is most likely injured during open inguinal hernia repair using a suture through the inguinal ligament just lateral to the pubic tubercle, causing numbness over the upper medial thigh?

  1. Lateral femoral cutaneous nerve
  2. Genitofemoral nerve (femoral branch) Correct answer.
  3. Iliohypogastric nerve
  4. Ilioinguinal nerve

Explanation

The femoral branch of the genitofemoral nerve passes beneath the inguinal ligament near the midpoint and supplies sensation to the upper medial thigh. A suture placed through the inguinal ligament lateral to the pubic tubercle can entrap it and cause numbness in that distribution.

Question 12Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which change in respiratory physiology occurs after upper abdominal surgery and contributes to postoperative atelectasis?

  1. Reduced tidal volume and vital capacity with shallow breathing Correct answer.
  2. Increased surfactant production
  3. Decreased closing volume
  4. Increased functional residual capacity

Explanation

Upper abdominal incisions and pain restrict diaphragmatic excursion and cause shallow breathing, reducing tidal volume and vital capacity. Functional residual capacity falls, small airways close, and atelectasis develops, which is why incentive spirometry and early mobilization are used.

Question 13Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which feature best distinguishes a benign follicular adenoma from follicular carcinoma of the thyroid on histology?

  1. Capsular invasion or vascular invasion Correct answer.
  2. Follicle formation
  3. Nuclear pleomorphism
  4. Presence of colloid

Explanation

Follicular adenoma and follicular carcinoma are both composed of follicles, so cytology alone cannot separate them. The diagnosis of carcinoma rests on capsular invasion or vascular invasion at the tumor capsule, which requires examining the interface between tumor and capsule.

Question 14Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

A patient with a long-standing burn scar develops a non-healing ulcer at the scar edge. Which malignant process should be suspected?

  1. Kaposi sarcoma
  2. Squamous cell carcinoma (Marjolin ulcer) Correct answer.
  3. Malignant melanoma
  4. Basal cell carcinoma

Explanation

Chronic burn scars, chronic ulcers, and sinus tracts can undergo malignant transformation to squamous cell carcinoma, historically termed a Marjolin ulcer. The tumor arises at the scar margin and tends to be aggressive, so biopsy of any non-healing scar ulcer is required.

Question 15Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which phase of wound healing is characterized by fibroblast proliferation, angiogenesis, and type III collagen deposition?

  1. Inflammation
  2. Proliferation Correct answer.
  3. Remodeling
  4. Hemostasis

Explanation

The proliferative phase, usually days 3 to 21, features fibroblast migration, granulation tissue formation, angiogenesis, and deposition of type III collagen. Remodeling later replaces type III with stronger type I collagen and reduces wound cellularity.

Question 16Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which mechanism best explains the hypotension seen in septic shock despite adequate fluid resuscitation?

  1. Primary bradycardia
  2. Reduced cardiac contractility alone
  3. Vasodilation with maldistribution of blood flow and capillary leak Correct answer.
  4. Increased systemic vascular resistance

Explanation

Septic shock is characterized by cytokine-mediated vasodilation, endothelial dysfunction, and capillary leak, producing a fall in systemic vascular resistance and maldistributed flow. Cardiac depression can contribute, but vasodilation and capillary leak are the central mechanisms, which is why norepinephrine is used.

Question 17Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which acid-base picture is most consistent with prolonged vomiting from gastric outlet obstruction?

  1. Metabolic acidosis with low bicarbonate
  2. Metabolic alkalosis with hypochloremia and hypokalemia Correct answer.
  3. Respiratory alkalosis with low carbon dioxide
  4. High anion gap metabolic acidosis

Explanation

Gastric fluid is rich in hydrogen and chloride, so prolonged vomiting causes loss of acid and chloride, producing a hypochloremic metabolic alkalosis. Volume depletion activates aldosterone, which promotes renal potassium loss and worsens the hypokalemia.

Question 18Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which statement about local anesthetics is correct regarding the effect of tissue pH on drug activity?

  1. Alkaline tissue traps the charged form inside the axon
  2. Local anesthetics act on sodium channels from the intracellular side after entering as cations
  3. Acidic infected tissue increases the proportion of uncharged base and speeds onset
  4. Acidic infected tissue reduces the uncharged base available to cross the membrane and slows onset Correct answer.

Explanation

Local anesthetics cross the nerve membrane in the uncharged base form and then block sodium channels from the intracellular side. In acidic infected tissue, more drug exists as the charged cation, less crosses the membrane, and anesthesia is slower and weaker, which is why infiltration into infected tissue often fails.

Question 19Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

Which feature best characterizes the blood supply of the stomach relevant to gastric surgery?

  1. The antrum is supplied by the short gastric arteries
  2. The greater curvature is supplied mainly by the left gastric artery
  3. The fundus is supplied by the gastroduodenal artery
  4. The lesser curvature is supplied by the left and right gastric arteries forming an arcade Correct answer.

Explanation

The lesser curvature receives the left gastric artery and the right gastric artery, which anastomose along the lesser curvature. The greater curvature is supplied by the left and right gastroepiploic arteries, and the fundus by the short gastric vessels.

Question 20Basic Sciences Applied to Surgery (anatomy, physiology, pathology, microbiology, pharmacology)

A patient with a suspected pheochromocytoma is scheduled for adrenalectomy. Which preoperative measure is most important to prevent intraoperative hypertensive crisis?

  1. Fluid restriction
  2. Alpha-adrenergic blockade before beta-blockade Correct answer.
  3. High-dose diuretic therapy
  4. Beta-blockade before alpha-blockade

Explanation

Pheochromocytoma secretes catecholamines, and unopposed alpha stimulation must be controlled first with alpha-blockade, followed by beta-blockade for reflex tachycardia. Reversing the order risks unopposed alpha vasoconstriction and severe hypertensive crisis.

Question 21General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A 28-year-old man sustains a stab wound to the right groin with active dark bleeding. Which of the following best describes the initial fluid resuscitation strategy according to current damage-control resuscitation principles?

  1. Immediate infusion of hypertonic saline to restore osmolality
  2. Aggressive crystalloid loading to maintain a systolic pressure above 120 mmHg
  3. Rapid infusion of 2 litres of crystalloid before any blood products
  4. Permissive hypotension with early balanced blood product transfusion Correct answer.

Explanation

Damage-control resuscitation emphasises early balanced blood products with permissive hypotension until surgical or endovascular haemorrhage control is achieved. Large-volume crystalloid dilutes clotting factors, worsens acidosis and coagulopathy, and increases mortality in haemorrhagic shock.

Question 22General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which phase of wound healing is characterised predominantly by fibroblast proliferation, angiogenesis, and deposition of type III collagen?

  1. Proliferative phase Correct answer.
  2. Haemostasis phase
  3. Remodelling phase
  4. Inflammatory phase

Explanation

The proliferative phase (roughly days 4 to 21) is dominated by fibroblasts laying down type III collagen, new capillary formation, and granulation tissue. Remodelling later replaces type III with stronger type I collagen.

Question 23General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A surgical trainee is donning sterile gloves using the closed technique. Which action maintains sterility during the procedure?

  1. Adjusting the mask with a gloved hand after gowning
  2. Touching the outer surface of the glove with the bare opposite hand
  3. Allowing the glove cuff to roll over the gown cuff
  4. Keeping the gloved hands above the waist and within the sterile field Correct answer.

Explanation

Sterile fields are defined as the area above waist level and within the operator's direct view; gloved hands must remain there to avoid contamination. Touching the outer glove surface with bare skin or the mask with a gloved hand breaks sterility.

Question 24General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A 70-year-old man with a strangulated inguinal hernia has cool peripheries, a heart rate of 128/min, and a blood pressure of 84/50 mmHg. Which type of shock best fits this presentation?

  1. Neurogenic shock
  2. Distributive (septic) shock Correct answer.
  3. Hypovolaemic shock
  4. Cardiogenic shock

Explanation

Strangulated bowel releases toxins and causes systemic vasodilation with warm or cool peripheries, tachycardia, and hypotension, consistent with distributive septic shock. Pure hypovolaemic shock would typically follow significant blood or fluid loss rather than bowel ischaemia alone.

Question 25General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which intravenous fluid is most appropriate for initial resuscitation of an adult with hypovolaemia from vomiting and diarrhoea who has no cardiac or renal comorbidity?

  1. 10% dextrose
  2. 5% dextrose
  3. 0.9% sodium chloride Correct answer.
  4. 0.18% sodium chloride with 4% dextrose

Explanation

Balanced isotonic crystalloid such as 0.9% sodium chloride or Ringer's lactate is the standard for initial volume resuscitation because it stays in the extracellular compartment. Dextrose-containing fluids distribute into total body water and provide negligible intravascular volume.

Question 26General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A patient is scheduled for elective colorectal surgery. Which preoperative measure has the strongest evidence for reducing surgical site infection?

  1. Routine postoperative wound irrigation with hydrogen peroxide
  2. Preoperative shaving of the operative site the night before
  3. Routine prolonged antibiotic prophylaxis for 5 days
  4. Intravenous antibiotic prophylaxis within 60 minutes of incision Correct answer.

Explanation

Timing prophylaxis so that tissue concentrations peak at incision, usually within 60 minutes, is the single most effective antimicrobial measure. Prolonged prophylaxis, razor shaving, and peroxide irrigation do not reduce and may increase infection risk.

Question 27General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A 35-year-old woman is 24 hours after laparotomy. Her wound edges are apposed with sutures and there is minimal collagen deposition. Which statement best describes healing in this wound at this stage?

  1. Healing is by tertiary intention after delayed closure
  2. Healing is delayed until sutures are removed
  3. Healing is by primary intention with minimal granulation tissue Correct answer.
  4. Healing is by secondary intention with abundant granulation

Explanation

A clean surgical wound with apposed edges heals by primary intention, with minimal granulation tissue and a fine scar. Secondary intention applies to open wounds left to granulate, and tertiary intention to deliberately delayed closure.

Question 28General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which of the following patients has the highest risk of impaired wound healing?

  1. A 65-year-old receiving long-term corticosteroids for rheumatoid arthritis Correct answer.
  2. A 25-year-old with a body mass index of 24
  3. A 30-year-old with a clean laceration and normal glucose
  4. A 40-year-old taking iron supplements for mild anaemia

Explanation

Corticosteroids suppress the inflammatory phase and fibroblast activity, and advanced age further impairs healing, making this the highest-risk patient. The other patients have no major impediments to healing.

Question 29General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A trauma patient arrives with a systolic pressure of 80 mmHg, a distended abdomen, and no external bleeding. Which is the most appropriate immediate next step?

  1. Observation with serial haemoglobin measurements
  2. Immediate CT scan with contrast of the abdomen
  3. Administration of 3 litres of crystalloid before imaging
  4. Focused assessment with sonography for trauma and activation of massive transfusion protocol Correct answer.

Explanation

Haemodynamically unstable blunt abdominal trauma with suspected haemoperitoneum requires rapid bedside FAST and immediate blood product resuscitation, often proceeding directly to laparotomy. CT is reserved for stable patients and large crystalloid volumes worsen coagulopathy.

Question 30General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which statement about the use of alcohol-based hand rub for surgical hand antisepsis is correct?

  1. It is applied to wet hands to improve coverage
  2. It is less effective than plain soap and water for reducing transient flora
  3. It requires a shorter contact time than social hand hygiene
  4. It should be applied to dry hands and rubbed until completely dry Correct answer.

Explanation

Alcohol-based hand rubs are applied to dry hands and rubbed until dry to achieve maximal antimicrobial effect and adequate contact time. Wet hands dilute the preparation and reduce efficacy.

Question 31General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A patient with a strangulated hernia has a lactate of 5 mmol/L, a heart rate of 130/min, and warm peripheries. Which pathophysiological mechanism best explains the hypotension?

  1. Acute loss of circulating blood volume
  2. Obstruction of venous return by pericardial effusion
  3. Reduced myocardial contractility
  4. Systemic vasodilation with maldistribution of blood flow Correct answer.

Explanation

Septic mediators cause vasodilation and capillary leak, producing distributive shock with warm peripheries and raised lactate from impaired tissue perfusion. This differs from haemorrhagic shock, where vasoconstriction produces cool peripheries.

Question 32General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which of the following is the most reliable clinical indicator of adequate resuscitation in a previously healthy adult with haemorrhagic shock?

  1. A haemoglobin level above 100 g/L
  2. Normalisation of blood pressure alone
  3. A central venous pressure of 15 cmH2O
  4. Urine output of at least 0.5 mL/kg/hour with improving lactate Correct answer.

Explanation

Urine output and lactate clearance reflect end-organ perfusion and are more reliable than blood pressure alone, which can be maintained by vasoconstriction despite ongoing hypoperfusion. Haemoglobin and single central venous pressure readings are poor resuscitation endpoints.

Question 33General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A patient with short bowel syndrome after massive resection requires long-term nutritional support. Which statement about nutritional access is most appropriate?

  1. Peripheral parenteral nutrition is preferred for long-term support
  2. Total parenteral nutrition is contraindicated after bowel resection
  3. Enteral feeding should be used whenever the remaining gut is functional Correct answer.
  4. Oral intake should be withheld indefinitely to reduce output

Explanation

Enteral nutrition preserves gut mucosal integrity, reduces bacterial translocation, and is preferred whenever the remaining intestine can absorb nutrients. Parenteral nutrition is reserved for intestinal failure when enteral feeding is insufficient.

Question 34General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A patient is 5 days after emergency laparotomy and develops a wound with spreading erythema, warmth, and purulent discharge. Which is the most appropriate initial management?

  1. Start oral antibiotics without opening the wound
  2. Apply a topical antibiotic ointment and observe
  3. Open the wound, drain the pus, and send a culture Correct answer.
  4. Re-suture the wound tightly to prevent further contamination

Explanation

A surgical site infection with purulent collection requires opening and draining the wound, which is the definitive treatment, along with culture-directed antibiotics if systemic signs are present. Antibiotics alone cannot penetrate an undrained collection.

Question 35General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which of the following best describes the mechanism by which a closed suction drain reduces surgical site infection in contaminated wounds?

  1. It delivers local antibiotics to the wound bed
  2. It removes accumulated fluid and reduces dead space Correct answer.
  3. It sterilises the wound by continuous irrigation
  4. It increases local oxygen tension directly

Explanation

Closed suction drains evacuate serosanguineous collections and obliterate dead space, removing a medium for bacterial proliferation. They do not deliver antibiotics, sterilise the wound, or directly raise tissue oxygen tension.

Question 36General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A patient with major burns is being resuscitated. Which formula is commonly used to estimate the initial 24-hour crystalloid requirement?

  1. Brooke formula using 1 mL/kg per percent burn
  2. Parkland formula using 4 mL/kg per percent total body surface area Correct answer.
  3. Evans formula using colloid only
  4. Holliday-Segar formula using 100 mL/kg for the first 10 kg

Explanation

The Parkland formula estimates 4 mL/kg per percent total body surface area of Ringer's lactate in the first 24 hours, with half given in the first 8 hours from the time of injury. The Holliday-Segar formula estimates maintenance fluids in children.

Question 37General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A patient with a temporary ileostomy has high-output losses of 3 litres per day. Which electrolyte disturbance is most likely?

  1. Hyperkalaemia and metabolic alkalosis
  2. Hypernatraemia and metabolic acidosis
  3. Hypokalaemia and metabolic acidosis Correct answer.
  4. Hypocalcaemia and respiratory alkalosis

Explanation

High-output ileostomy losses are rich in sodium, potassium, and bicarbonate, producing hypokalaemia and a non-anion-gap metabolic acidosis. Volume depletion and hyponatraemia are also common.

Question 38General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which statement about the surgical safety checklist is most accurate?

  1. It is required only for emergency procedures
  2. It replaces the need for surgical site marking
  3. It includes sign-in, time-out, and sign-out phases to reduce preventable harm Correct answer.
  4. It is completed only after the patient leaves the operating theatre

Explanation

The WHO-style checklist has three phases: sign-in before induction, time-out before incision, and sign-out before the patient leaves theatre, reducing communication errors and retained items. It supplements but does not replace site marking.

Question 39General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A patient with a clean-contaminated operation develops a fever of 39°C on the second postoperative day with tachycardia and hypotension. Which is the most appropriate first action?

  1. Remove all intravenous lines immediately without cultures
  2. Obtain blood cultures and start broad-spectrum antibiotics after cultures Correct answer.
  3. Start antifungal therapy empirically
  4. Wait 48 hours for culture results before antibiotics

Explanation

Early postoperative sepsis requires cultures followed promptly by empirical broad-spectrum antibiotics, along with source assessment and fluid resuscitation. Delaying antibiotics for culture results increases mortality.

Question 40General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which of the following best explains why a colonic anastomosis is more prone to leak than a small bowel anastomosis?

  1. The colon has more rapid epithelial turnover
  2. The colon has a higher bacterial load and thinner wall with segmental blood supply Correct answer.
  3. The colon lacks collagen synthesis capacity
  4. The colon has a richer blood supply than the small bowel

Explanation

The colon has a high luminal bacterial load, a thin wall, and segmental blood supply from marginal arteries, all of which impair anastomotic healing. Small bowel has a richer vascular arcade and lower bacterial load.

Question 41General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A patient is receiving total parenteral nutrition. Which monitoring parameter is most important to detect a serious complication of this therapy?

  1. Weekly skin prick allergy testing
  2. Daily chest X-ray
  3. Serum amylase every 6 hours
  4. Blood glucose and electrolytes with triglyceride levels Correct answer.

Explanation

Total parenteral nutrition requires monitoring of glucose, electrolytes, and triglycerides to detect hyperglycaemia, refeeding disturbances, and hypertriglyceridaemia. Overfeeding and rapid refeeding can cause serious metabolic complications.

Question 42General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which of the following is the most appropriate method for confirming correct placement of a central venous catheter before use?

  1. Palpation of the neck for a thrill
  2. Auscultation of the chest alone
  3. Chest radiograph or ultrasound to confirm tip position and exclude pneumothorax Correct answer.
  4. Blood gas analysis from the distal port only

Explanation

Radiographic or ultrasound confirmation ensures the tip lies in the lower superior vena cava and excludes pneumothorax before the line is used. Auscultation and blood gas analysis alone are insufficient.

Question 43General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

A trauma patient has been resuscitated with 6 units of packed red cells and remains coagulopathic with ongoing oozing. Which adjunct is most appropriate?

  1. Fresh frozen plasma and platelets guided by point-of-care coagulation testing Correct answer.
  2. Withholding all blood products until laboratory results return
  3. Intravenous vitamin K alone
  4. Additional crystalloid boluses

Explanation

After massive transfusion, balanced replacement of plasma and platelets guided by viscoelastic testing corrects dilutional and consumptive coagulopathy. Further crystalloid worsens dilution, and vitamin K alone does not correct acute coagulopathy of trauma.

Question 44General Surgical Principles and Perioperative Care (asepsis, wound healing, trauma resuscitation, shock, fluids and nutrition, surgical infection)

Which of the following best describes the purpose of the surgical time-out immediately before incision?

  1. To administer prophylactic antibiotics
  2. To confirm patient identity, procedure, site, and relevant allergies with the whole team Correct answer.
  3. To document the surgeon's operative findings
  4. To obtain informed consent from the patient

Explanation

The time-out is a team pause before incision to confirm patient identity, correct procedure and site, allergies, and anticipated critical events. Consent is obtained before transfer to theatre and antibiotics are given earlier.

Question 45Gastrointestinal and Hepatobiliary Surgery (esophagus, stomach, small and large bowel, liver, biliary tree, pancreas, spleen)

A 55-year-old man presents with painless obstructive jaundice and a palpable, non-tender gallbladder. Which finding on imaging most strongly suggests a malignant cause rather than a stone?

  1. A distended gallbladder with a thickened wall and pericholecystic fluid
  2. Multiple small calculi within the gallbladder lumen with acoustic shadowing
  3. Dilated intrahepatic ducts with a normal-calibre common bile duct
  4. A stricture of the distal common bile duct with upstream ductal dilatation and pancreatic head mass Correct answer.

Explanation

Courvoisier's law states that a palpable, non-tender gallbladder in a jaundiced patient is unlikely to be due to stones and raises suspicion of malignant distal biliary obstruction, typically pancreatic head or periampullary carcinoma. The key imaging finding is a distal stricture with a mass and upstream dilatation.

Question 46Gastrointestinal and Hepatobiliary Surgery (esophagus, stomach, small and large bowel, liver, biliary tree, pancreas, spleen)

Which of the following is the most appropriate initial management for a haemodynamically stable patient with a grade III splenic injury and no other injuries?

  1. Immediate splenectomy
  2. Diagnostic peritoneal lavage followed by laparotomy
  3. Splenic artery embolisation as first-line for all grades
  4. Non-operative management with close monitoring Correct answer.

Explanation

Haemodynamically stable patients with blunt splenic injury, including grade III, are managed non-operatively with monitoring and serial examination. Splenectomy is reserved for haemodynamic instability or failure of non-operative management.

Question 47Gastrointestinal and Hepatobiliary Surgery (esophagus, stomach, small and large bowel, liver, biliary tree, pancreas, spleen)

A 30-year-old man has a 2 cm duodenal ulcer with a visible vessel on endoscopy. Which endoscopic therapy is most appropriate?

  1. Nasogastric lavage with cold saline
  2. Observation alone with repeat endoscopy in 48 hours
  3. Immediate surgical oversewing of the ulcer
  4. Endoscopic clipping or thermal therapy with epinephrine injection Correct answer.

Explanation

Forrest IIa lesions (visible vessel) carry a high rebleeding risk and require endoscopic haemostasis, usually with a combination of epinephrine injection and a mechanical or thermal method. Dual therapy reduces rebleeding and need for surgery.

Question 48Gastrointestinal and Hepatobiliary Surgery (esophagus, stomach, small and large bowel, liver, biliary tree, pancreas, spleen)

Which of the following is the most common cause of acute pancreatitis in adults worldwide?

  1. Post-ERCP instrumentation
  2. Hypertriglyceridaemia
  3. Gallstones Correct answer.
  4. Alcohol

Explanation

Gallstones and alcohol are the two leading causes of acute pancreatitis, with gallstones being the most common overall. Hypertriglyceridaemia and post-ERCP pancreatitis are less frequent causes.

Question 49Gastrointestinal and Hepatobiliary Surgery (esophagus, stomach, small and large bowel, liver, biliary tree, pancreas, spleen)

A 60-year-old woman has a 1 cm sessile rectal polyp. Which feature on histology most strongly predicts the need for surgical resection?

  1. Sessile serrated lesion without dysplasia
  2. Hyperplastic polyp
  3. Villous adenoma with high-grade dysplasia Correct answer.
  4. Tubular adenoma with low-grade dysplasia

Explanation

Villous architecture and high-grade dysplasia are associated with a higher risk of harbouring or progressing to carcinoma. Such lesions, particularly if incompletely excised or large, warrant consideration of surgical resection.

Question 50Gastrointestinal and Hepatobiliary Surgery (esophagus, stomach, small and large bowel, liver, biliary tree, pancreas, spleen)

Which of the following is the definitive treatment for achalasia cardia?

  1. Long-term calcium channel blockers
  2. Endoscopic botulinum toxin injection for all patients
  3. H2 receptor antagonists
  4. Heller myotomy or pneumatic dilatation Correct answer.

Explanation

Achalasia is treated definitively by disrupting the lower oesophageal sphincter, either surgically with Heller myotomy or by pneumatic dilatation. Medical therapy and botulinum toxin provide temporary relief and are used in patients unfit for definitive treatment.