Surgery 6/2019: Spot Light On Surgery 2019 Mcqs Book DR Fadi Qutishat

Spot light on surgery 2019 MCQs Book Dr Fadi Qutishat 1
Surgery 6/2019
1)About acute mastitis ,one is true,
A.it is the underlying cause of the most nonnursing female breast abscess.
B.Primary skin infections of the breast (cellulitis or abscess) most commonly affect the
skin of the upper half of the breast
C.stop lactation can increase the risk of breast abscess
D.Staphylococcus epidermidis and streptococci are the most common causes
E.it is occur in women who are underweight and have small breasts.
Explanation
A.Acute mastitis is the underlying cause of the most nursing female breast abscess.
B.Primary skin infections of the breast (cellulitis or abscess) most commonly affect the
skin of the lower half of the breast
C.stop lactation can increase the risk of breast abscess due to milk stasis
D.Staphylococcus epidermidis and streptococci are not the most common causes.The
most common cause of acute mastitis is staphylococcus aureus.
E.it is less commonly occur in women who are underweight and have small
breasts.obesity is the risk factor of acute mastitis.
2)One is false about tatal Human body water and it's distribution,
A.it is more in males than in females
B.it increses with age
C.It is mainly occupied in the intracellular comprtment
D.The extracellular fluid (ECF) contains about one-third of total body water.
E.Total body fluid in 70 kg male adult is 42 L,ECF is 14 L and ICF is 28 L
Explanation
A.it is more in males than in females, it is true Male,By weight, the average human
adult male is approximately 60% water and the average adult female is approximately
55%.
B.TBW decreses with age,The TBW comprises approximately 70% of body weight in
infants, 65% in children, and 60% in adults. Infants' and children's higher body
water content, along with their higher metabolic rates and increased body surface area
to mass index, contribute to their higher turnover of fluids and solute.
C.It is mainly occupied in the intracellular comprtment,Total body water (TBW)
represents approximately 60% of body weight and traditionally has been divided into
the intracellular (40%) and extracellular spaces (20%). In the extracellular fluid,
the water is distributed in different parts: 75% in the interstitium, 20% in the plasma,
and 5% acting as transcellular fluid.
D.The extracellular fluid (ECF) contains about one-third of total body water,which
represent 20 % of TBW (60%).
E.Total body fluid in 70 kg male adult is 42 L,ECF is 14 L and ICF is 28 L
TBW =70×60%=42 L,ECF is one third of 42 = 14 L and ICF is two third of 42 =28 L.
3)The most important sign of traumatic rupture of urethra is,

A.Dysuria
B.Pain
C.Urine retintion
D.Bleeding per meatus
E.High ride prostate
Explanation
 The most important sign of traumatic rupture of urethra is bleeding per meatus.
 Symptoms of urethral rupture include pain with voiding or inability to void.
 Blood at the urethral meatus is the most important sign of a urethral injury.
 Additional signs include perineal, scrotal, penile, and labial ecchymosis, edema,
or both.
4)A 25 years old male patient,presented with sever stabbing flank pain for 6 hours
duration associated with nausea and vomiting.Urine analysis show 200 RBCs/hpf ,
serum cratinin 0,9 mg/dl .The best next in management at this stage is
A.KUB radiography
B.Renal ultrasonography
C.Intravenous Pyelography
D.non-contrast-enhanced computed tomography
E.Kidney MRI
Explanation
• Abdominal US is the most common and widely used first step physical tool in
urolithiasis diagnosis,it is non invasive and can Identify and follow-up stone without
radiation exposure ,also it Visualizes hydronephrosis.
• KUB radiography 90% of stones are radiopaque. This test is Good for follow-up of
urolithiasis.
• KUB and AXR will identify large radioopaque stones (calcium, struvite, and cystine
stones) but may miss smaller stones, uric acid stones, or stones overlying bony
structures; consider as an initial investigation in patients who have a history of
radioopaque stones and similar episodes of acute flank pain.
• The next step or defentive test for Dx is non-contrast-enhanced computed
tomography.
5)A 25 years old male patient presented to ER with nasal bone fracture and massive
bleeding.The most appropriate first step in management,
A.place ice on the nose for 15 minutes
B.Fixation by surgery
C.scuring the airway by Intubation
D.Imaging
E.IV fluid resuscitation then surgical repair
Explanation
Nasal Fractures
Etiology
 lateral force → more common, good prognosis anterior force → can produce
more serious injuries
 most common facial fracture
Clinical Features
• epistaxis/hemorrhage, deviation/flattening of nose, swelling, periorbital ecchymosis,

tenderness over nasal dorsum, crepitus, septal hematoma, respiratory obstruction,
subconjunctival hemorrhage
Treatment
• According to ATLS algorythim, First step in Tx is ABCDE approach.
• A:airway scuring.
• B:breathing
• C:circulation
• always inspect for and drain septal hematoma as this is a cause of septal necrosis and
perforation – completed in the ER with small incision in the septal mucosa followed by
packing
• closed reduction with Asch or Walsham forceps under anesthesia, pack nostrils with
petroleum or nonadhesive gauze packing, nasal splint for 7 d .
• best reduction immediately (<6 h) or when swelling subsides (5-7 d).

• rhinoplasty may be necessary later for residual deformity (30%).
managemant of nasal bleeding

• first-aid: ABCs, clear clots by blowing nose or suctioning, lean forward, pinch
cartilaginous portion of nose for 20 min twice
• assess blood loss: vitals, IV NS, cross match 2 units pRBC if significant
• if first aid measures fail twice, proceed to packing
• apply an anterior pack
■ clear nose of any clots
■ apply topical anesthesia/vasoconstrictors (lidocaine with epinephrine,
cocaine, or soaked pledgets)
• insert either a traditional Vaseline® gauze pack or a commercial nasal tampon
or balloon
• if bleeding stops, arrange follow-up in 48-72 h for reassessment and pack
removal
• if packing both nares, prophylactic anti-staphylococcal antibiotics to prevent
sinusitis or toxic shock syndrome
■ if bleeding is controlled with anterior pressure, cautery with silver nitrate can
be performed if the site of bleeding is identified (one side of septum only
because if both are cauterized this can lead to septal perforation)
• if suspect posterior bleed or anterior packing does not provide hemostasis,
consult ENT for posterior packing and further evaluation
■ posterior packing requires monitoring; can cause significant vagal response

and posterior bleeding source can lead to significant blood loss, therefore
usually requires admission.
6)Most serious early complication of electrical burn injury is

A.Myoglobinuria
B.Brain death
C.Cardiac Arrhythmia
D.compartment syndrome
E.infection
Explanation
ELECTRICAL BURNS
• depth of burn depends on voltage and resistance of the tissue (injury more
severe in tissues with high resistance)
 Tissue Resistance to Electrical Current

nerve < vessel/blood < muscle < skin < tendon < fat < bone.
 often presents as small punctate burns on skin, with extensive deep tissue
damage which requires debridement
 electrical burns require ongoing monitoring, as latent injuries can occur.
 watch for system-specific damages and abnormalities
■ abdominal: intraperitoneal damage
■ bone: fractures and dislocations especially of the spine and shoulder.
■ cardiopulmonary: anoxia, ventricular fibrillation, arrhythmias is the most
important and serious complication of electrical burn.
■ muscle: myoglobinuria indicates significant muscle damage →
compartment syndrome
■ neurological: seizures and spinal cord damage
■ ophthalmology: cataract formation (late complication)
■ renal: ATN resulting from toxic levels of myoglobin and hemoglobin
■ vascular: vessel thrombosis → tissue necrosis (increased Cr, K+, and
acidity), decrease in RBC (beware of hemorrhages/delayed vessel rupture)
 Treatment
• ABCs, primary and secondary survey, treat associated injuries
• beware of cardiac arrhythmias (continue cardiac monitoring)
• monitor: hemochromogenuria, compartment syndrome, urine output
• wound management: topical agent with good penetrating ability (silver
sulfadiazine or mafenide acetate)
• debride nonviable tissue early and repeat prn (every 48 h) to prevent
sepsis
• amputations frequently required.
7)Most important alarming sign of potential malignancy in chronic skin

ulcer is
A.increasing pain
B.No response to antibiotics for 2 weeks
C.Everted and raised edges
D.Granulation tissue
E.Mobile
Explanation
If a patient has chronic skin lesions associated with non-healing ulcers,
especially after sustaining burn injuries as a child, pathological examination
is indicated. This can allow a potential skin malignancy(SCC).
Signs of malignant skin cancer (SCC).

• Immobile
• Everted and raised edges.
• Painless
• local extension, regional lymph node metastasis, and distant metastasis.
• High risk features for SCC include : depth >2 mm, facial lesions, poorly
defined borders, recurrent lesion, perineural invasion, poor differentiation,
and type of lesion (e.g. morpheoform)
8)Most important complication of circumferential burn in the upper limb is

A.infection
B.Rhabdomyolysis
C.Compartment Syndrome
D.Curling Ulcer
E.Hypovolemic Shock
Explanation
The most important complication of Circumferential burns is eschar formation
and development of compartment syndrome.
It can restrict respiratory
excursion and/or blood flow to extremities and
require escharotomy.
9)The gold standard investigation for diagnosis osteomyelitis is

A.Blood Culture
B.Bone Biopsy
C.Bone MRI
D.Technetium-99 Scan
E.Bone CT
Explanation
Osteomyelitis
• bone infection with progressive inflammatory destruction
Etiology
• most commonly caused by S. aureus
• mechanism of spread: hematogenous (most common) vs. direct-inoculation vs.
contiguous focus
• risk factors: recent trauma/surgery, immunocompromised patients, DM, IV
drug use, poor vascular supply, peripheral neuropathy
Clinical Features
• symptoms: pain and fever

• on exam: erythema, tenderness, edema common ± abscess/draining sinus
tract; impaired function/WB
Diagnosis
• workup includes: WBC and differential, ESR, CRP, blood culture,
• aspirate culture/bone biopsy is the gold standart for Dx.
Treatment of Osteomyelitis
• Acute Osteomyelitis
1. IV antibiotics 4-6 wk; started empirically and adjusted after obtaining blood
and aspirate cultures
2. ± surgery (I&D) for abscess or significant involvement
• Chronic Osteomyelitis
1. Antibiotics: both local (e.g. antibiotic beads) and systemic (IV)
2. Surgical debridement
10)Causes of bilateral lower limb edema include all of the following except,
A.Congestive heart failure
B.Nephrotic Syndrome
C.Retroperitoneal Sarcoma
D.Arterial Injury
E.Liver Cirrhosis
Explanation
 Leg swelling generally occurs because of an abnormal accumulation of

fluid in the tissues of the lower extremity. ...
 The acute condition Acute unilateral leg swelling may be caused by
arterial injury,deep vein thrombosis (DVT), ruptured popliteal cyst,
cellulitis, erythema nodosum, trauma, or gastrocnemius
musculotendinous rupture
 Causes of bilateral lower limb edema include salt retention, ,liver
cirrhosis,kidney failure, congestive heart failure, pregnancy, and
medication(CCB) side effects.
11)In pentrating wound of the heart ,The most common anatomical structure affected
is
A.Left Atrium
B.Left Ventricle
C.Right Atrium
D.Right Ventricle
E.Arche of Aorta
Explanation
Any organ within the chest is potentially susceptible to penetrating trauma, and each
should be considered in the evaluation of a patient with pentrating thoracic injury.
• Chest wall
• Lung and pleura
• Tracheobronchial system, including the esophagus, diaphragm, thoracic blood vessels,
and thoracic duct
• Heart and mediastinal structures, most common heart champer is RV.
12)A 45 years old femal patient presented with acute cholesystitis for elective
laporoscopic cholecystectomy.She was admitted to hospital and started on intravenous
fluid therapy,analgesia,antiemitics and antibiotics.After 2 hours of start this
management, patient developed shortness of breath and the vitals was BP 80/40
T=36,6 HR 125 RR 25 . On physical Exam ,there was marked Redness around peripheral
venous canulla,the most likely diagnosis
A.Hypovolemic Shock
B.Septic Shock
C.Cardiogenic Shock
D.Anaphylaxis
E.Pulmonary Embolism
Explanation
This is typical picture of anaphylactic reaction to medication that adminstered to
patient .
Anaphylaxis and Allergic Reactions
Etiology
• anaphylaxis is an exaggerated immune mediated hypersensitivity reaction that leads
to systemic histamine release, increased vascular permeability, and vasodilation;
regardless of the etiology, the presentation and management of anaphylactic reactions
are the same

• allergic (re-exposure to allergen)
• non-allergic (e.g. exercise induced)
Most Common Triggers for Anaphylaxis

• Foods (nuts, shellfish, etc.)
• Stings
• Drugs (penicillin, NSAIDs, ACEI)
• Radiographic contrast media
• Blood products
• Latex
Diagnostic Criteria
• anaphylaxis is highly likely with any of:
1. acute onset of an illness (min to hrs) with involvement of the skin, mucosal
tissue and at least one of
■ respiratory compromise (e.g. dyspnea, wheeze, stridor, hypoxemia)
■ hypotension/end-organ dysfunction (e.g. hypotonia, collapse, syncope,
incontinence)
2. two or more of the following after exposure to a LIKELY allergen for that
patient (min to hrs)
■ involvement of the skin-mucosal tissue
■ respiratory compromise
■ hypotension or associated symptoms
■ persistent gastrointestinal symptoms (e.g. crampy abdominal pain, vomiting)
3. hypotension after exposure to a KNOWN allergen for that patient (min to hrs)
■ management is also appropriate in cases which do not fulfill criteria, but who
have had previous episodes of anaphylaxis
■ life-threatening differentials for anaphylaxis include asthma and septic shock
■ angioedema may mimic anaphylaxis but tends not to improve with standard
anaphylaxis treatment
Management
• moderate reaction: generalized urticaria, angioedema, wheezing, tachycardia
■ epinephrine (1:1000) 0.3-0.5 mg (IM in lateral thigh)
■ antihistamines: diphenhydramine (Benadryl®) 25-50 mg IM
■ salbutamol (Ventolin®) 1 cc via MDI
• severe reaction/evolution: severe wheezing, laryngeal/pulmonary edema,
shock
■ ABCs, may need definitive airway (e.g. ETT) due to airway edema
■ epinephrine (1:1000) 0.1-0.3 mg IV (or via ETT if no IV access) to start, repeat
as needed
■ antihistamines: diphenhydramine (Benadryl®) 50 mg IV (~1 mg/kg)
■ steroids: hydrocortisone (Solucortef®) 100 mg IV (~1.5 mg/kg) or
methylprednisolone
(Solumedrol®) 1 mg/kg IV q6h x 24 h
■ large volumes of crystalloid may be required
13)Diarrhea is the characterstic feature of all of the following conditions except

A.Medullary thyroid cancer
B.Gastrinoma
C.Insulinoma
D.VIPoma
E.Carcinoid Tumor
Explanation
INSULINOMA
• tumour that secretes insulin
• most common pancreatic endocrine neoplasm; 10% associated with MEN1 syndrome
Clinical Features
• Whipple’s triad
• palpitations, trembling, diaphoresis, confusion, seizure, and personality changes
Investigations
• blood work: decreased serum glucose and increased serum insulin and C-peptide
• U/S, CT: insulinomas evenly distributed throughout head, body, tail of pancreas
Treatment
• only 10% are malignant

• enucleation of solitary insulinomas may be done endoscopically
• tumours >2 cm located close to the pancreatic duct may require pancreatectomy or
pancreaticoduodenectomy
GASTRINOMA
• tumour secreting gastrin; cause of Zollinger-Ellison syndrome
Clinical Features
• abdominal pain, PUD, severe esophagitis
• multiple ulcers in atypical locations refractory of antacid therapy
Investigations
• blood work: serum gastrin levels (usually >1,000 pg/mL), secretin stimulation test
• U/S, CT: 70-90% found in Passaro’s triangle (head of pancreas medially, 2nd portion of
duodenum
inferiorly, and the confluence of the cystic and CBD superiorly)
• octreotide scintigraphy scan
Treatment
• 50% are malignant
• surgical resection of tumour dependent on location
• non-surgical treatment: chemotherapy, somatostatin analogues, interferon, and
chemoembolization
• if inoperable, vagotomy can be performed for symptomatic control
VASOACTIVE INTESTINAL PEPTIDE-SECRETING TUMOUR

• tumour secreting VIP; commonly located in the distal pancreas and
most are malignant when diagnosed
Clinical Features
• severe watery diarrhea causing dehydration, weakness, and electrolyte
imbalance
Investigations
• blood work: serum VIP levels
• U/S, CT
Treatment
• somatostatin analogues
• surgical resection/palliative debulkin
14)An 8 month old infant was brought by his mother for 3 cm strawberry hemangioma
on the neck, she stated that the lesion appeared 3 weeks after birth and increased in
size, the best management is:
A. Systemic steroid therapy.
B. LASER
C. Surgical excision
D. Ebmolization
E. Observation
Explanation
Hemangioma of Infancy
Clinical Presentation
• red or blue subcutaneous mass that is soft/compressible, blanches with pressure;
feels like a “bag of worms” when palpated
Pathophysiology
• benign vascular tumour,Benign vascular proliferation of endothelial
lining
Sign anf symptoms
Hot, firm red to blue plaques or tumours
Epidemiology
Appears shortly after birth; rarely may be congenital
Clinical course
Appears shortly after birth, increases in size over months, then regresses
50% of lesions resolve spontaneously by 5 yr
treatment
10% require treatment due to functional impairment (visual compromise,
airway obstruction, high output cardiac failure) or
cosmesis
Consider treatment if not gone by school age; topical timolol,
propranolol; systemic corticosteroids; laser treatment; surgery
15)A 19 years old patient presented to ER with gunshot in his umbilicus and
systolic BP 70 with tense abdominal distention,the best next step in
management is,
A.Exploration laparotomy
B.Keep on IV fluid till BP 90/70 then operate.
C.FAST
D.DPL
E.Abdomen CT scan.
Explanation
 This is typical picture of pentrating abdominal injury in unstable patient

 PENETRATING abdominal TRAUMA
• high risk of gastrointestinal perforation and sepsis
• history: size of blade, calibre/distance from gun, route of entry

• local wound exploration under direct vision may determine lack of peritoneal
penetration (not reliable in inexperienced hands) with the following exceptions:
• thoracoabdominal region (may cause pneumothorax)
• back or flanks (muscles too thick)
 Management
• general: ABCs, fluid resuscitation, and stabilization
• gunshot wounds always require laparotomy
16)A 45 years old female patient presented to endocrine clinic with Neck mass,On
physical exam, she found to have palpable thyroid nodule around 2×3 cm.She
underwent FNAC and found to have tumor cells with Psamomma body and lymphatic
metastasis, the most likely diagnosis
A.Follicular throid carcinoma
B.Medullary thyroid carcinoma
C.Papillay thyroid carcinoma
D.Anaplastic throid Cancer
E.Thyroid Lymphoma
Explanation
FNAC finding is tumor cells with Psamomma body and lymphatic metastasis that
represent key word for papillary thyroid cancer.
17)About Splenectomy,One of the following conditions is a major risk factor to develop

Overwhelming postsplenectomy sepsis syndrome(OPSS).
A.ITP
B.TTP
C.Trauma patient
D.Thalassemia
E.Heridatiry Spherosytosis
Explanation
• An overwhelming post-splenectomy infection (OPSI) is a rare but rapidly

fatal infection occurring in individuals following removal of the spleen. The infections
are typically characterized by either meningitis or sepsis, and are caused
by encapsulated organisms including Streptococcus pneumoniae
• a major risk factor to develop Overwhelming postsplenectomy sepsis syndrome(OPSS)
is Thalassemia major and sickle cell anemia
18)Common causes of splenomegally include all of the following except,

A. cyst*
B.portal HTN
C.Thalassemia Major
D.Lymphoma
E.Felty Syndrome
explanation
 cyst is a rare cause of splenomegaly.

 Felty syndrom (RA) ,portal HTN ,.Thalassemia Major are common causes of
splenomegaly.
19)A 25 year old male patient underwent a wheigt loss surgery ,roux en Y Gastric
Bypass surgery, 7th day post operatively HR 110 RR 22 BP 120/80 , 8th day
postoperatively HR 120 RR 25 Bp 120/80, and develop shortness of breath and
tachpnea. The most likely diagnosis is,
A.Internal Hemorrhage
B.Atelectasis
C.Pulmonary Embolism
D.DVT
E.Anastomosis Leak
Explanation
 This is picture of post gastrectomy anastomosis leak.

 The peak time of development anastomosis leak

Post GPB surgery is POD 5_8.
20)A 35 years old Women presented to ER with RUQ pain.On physical Exam
found to have Jaundice and fever .She underwent an abdomen US and the
finding was thickening of the gallbladder wall ,dilatation of CBD >12 mm With
cholelithiasis, the most appropriate next step in management is
A.Admission and Emergency Laparatomy.
B.Admission and Emergency opened cholesyctectomy.
C.Admission, iv fluid, antibiotics, recommend for urgent ERCP.
D.Admission and Emergency opened CBD exploration.
E.Admission and iv fluid, antibiotics, recommend for urgent MRCP.
Explanation
This is typical picture of acute ascending cholongitis.
Pathogenesis
• obstruction of CBD leading to biliary stasis, bacterial overgrowth, suppuration

and biliary sepsis – may
be life-threatening, especially in elderly
Etiology
• choledocholithiasis (60%), stricture, neoplasm (pancreatic or biliary), extrinsic
compression (pancreatic
pseudocyst or pancreatitis), instrumentation of bile ducts (PTC, ERCP), and
biliary stent
• organisms: E. coli, Klebsiella, Pseudomonas, Enterococcus, B. fragilis, and
Proteus
Clinical Features
• Charcot’s triad: fever, RUQ pain, and jaundice
• Reynold’s pentad: fever, RUQ pain, jaundice, shock, and confusion
• may have N/V, abdominal distention, ileus, acholic stools, and tea-coloured
urine (elevated direct
bilirubin)
Investigations
• CBC: elevated WBC + left shift
• may have positive blood cultures
• LFTs: obstructive picture (elevated ALP, GGT, and conjugated bilirubin, mild
increase in AST, ALT)
• amylase/lipase: rule out pancreatitis
• U/S: intra-/extra-hepatic duct dilatation

Treatment
• initial: NPO, fluid and electrolyte resuscitation, ± NGT, IV antibiotics (treats
80%)
• biliary decompression
■ ERCP + sphincterotomy: diagnostic and therapeutic
■ PTC with catheter drainage: if ERCP not available or unsuccessful
■ laparotomy with CBD exploration and T-tube placement if above fails
• all patients should also have a cholecystectomy, unless contraindicated
Prognosis
• suppurative cholangitis mortality rate: 50%
21)A 65 years old male patient presented to emergancy room complaining of

sever colicky abdominal pain and vomiting associated with abdominal distention
for 2 days duration.On plain abdominal X-ray Found to have inverted U sign in
left lower Quadrant and a lot of peripheral air fluid levels.The most likely
diagnosis
A.Colon Cancer.
B.Adhesional Intestinal obstruction
C.Strangulated Inguinal Hernia
D.Sigmoid Volvolus
E.Ileus
Explanation
Volvulus
Definition
• rotation of segment of bowel about its mesenteric axis
• sigmoid (65%), cecum (30%), transverse colon (3%), and splenic flexure (2%)
• 5-10% of large bowel obstruction; 25% of intestinal obstruction during
pregnancy
Risk Factors
• age (50% of patients >70 yr: stretching/elongation of bowel with age is a
predisposing factor)
• high fibre diet (can cause elongated/redundant colon), chronic constipation,
laxative
abuse, pregnancy, bedridden, and institutionalization (less frequent evacuation
of bowels)
Clinical Features
• symptoms due to bowel obstruction or intestinal ischemia
• colicky abdominal pain, persistence of pain between spasms, abdominal

distention, and vomiting
Investigations
• AXR (classic findings): “omega”, “bent inner-tube”, “coffee-bean” signs,
inverted U shape
• barium/Gastrografin® enema: “ace of spades” (or “bird’s beak”) appearance
due to funnel-like luminal
tapering of lower segment towards volvulus
• sigmoidoscopy or colonoscopy as appropriate
• CT: “whirl pattern” of mesenteric vessels twisting about the volvulus axis
Treatment
• initial supportive management (same as initial management for bowel
obstruction (see Large Bowel
Obstruction, GS29)
• cecum
■ nonsurgical
◆may attempt colonoscopic detorsion and decompression; successful 15-20%
of cases
■ surgical
◆right colectomy + ileotransverse colonic anastomosis
• sigmoid
■ nonsurgical
◆decompression by flexible sigmoidoscopy and insertion of rectal tube past
obstruction
◆subsequent elective surgery recommended (50-70% recurrence)
■ surgical
◆surgical resection with or without primary anastomosis
◆indications: strangulation, perforation, or unsuccessful endoscopic
decompression
22)A 65 years old male patient presented to clinic with Abdominal Aortic
Aneurysm 6 cm diameter.He underwent opened surgical repair and Just after
the end of surgery Patient started to complain of sudden sever pain in the
abdomen. His vital signs as the following Bp 80/40 mmhg RR 25 HR 42 beat per
minute, CVP 8 cm H2o, Tempreture 36,5
The most likely diagnosis
A.Pulmonary Embolism
B.Cardiac Tamponade
C.Cardiogenic Shock
D.Neurogenic Shock
E.Hemorrhagic Shock
Explanation
Neurogenic shock is a distributive type ofshock resulting in low blood pressure,
occasionally with a slowed heart rate, that is attributed to the disruption of the
autonomic pathways within the spinal cord. It can occur after damage to the
central nervous system, such as spinal cord injury and traumatic brain injury.
Neurogenic shock is generalized low perfusion state due to sever CNS(brain or

spinal cord) injury characterised by hypotension and bradycardia.
23)Regarding acute pancreatitis .Most common Cause of late death is one of the
following
A.Acute respiratory distress syndrome(ARDS)
B.Biliary Sepsis
C.Bleeding
D.infection and DIC.
E.Psudocyst
Explanation
Most common cause of early death in acute pancreatitis is ARDS and Most
common cause of late death in acute pancreatitis is infection and DIC.
24) A 70 kg male presented to ER with a 40% total body surface area second
degree burn and inhalation injury . The fluid resuscitation that should be
initiated is :
A. Lactated Ringer’s solution at 350 mI/hr.
B.D5 lactated Ringer’s solution at 700 ml/hr.
C.Lactated Ringer’s solution at 100 mI/hr.
D.Normal saline solution at 700 mI/hr.
E.Lactated Ringer’s solution at 250 mI/hr
Explanation
Barkland formula
4 ml R/L × TBS of 2ed and 3ed degree burned area× body weight
4 ×70×40=11,200
11,200÷2=5600
5600÷8=700 ml.
25)A 23 years old male patient presented to ER with facial burn and respiratory
distress.On physical Exam He found to have partial thickness burn involving the
nose,lips,brows,mouth and anterior neck area, as well as RR 30 per minutes and
there was a mild horseness of voice and tachpnea.The most aproppriate next
step in management is
A.Admission and start IV fluid therapy
B.Observation in the ER for 24 hours.
C.Admission and consider Tracheal intubation
D.Admission and consider crycothyroidotomy
E.Admission and consult plastic surgery team
Explanation
Burn
Clinical Presentation/Physical Exam Findings
• burn size
■ rule of nines; does not include 1st degree burns
• burn depth
■ superficial (1st degree): epidermis only (e.g. sunburn), painful and tender to
palpation
■ superficial partial thickness (2nd degree): extends to epidermis and superficial
dermis, blister formation occurs, very painful
■ deep partial thickness (2nd degree): involves hair follicles, sebaceous glands;
skin is blistered,
exposed dermis is white to yellow, absent sensation
■ full thickness (3rd degree): epidermis and all dermal layers; skin is pale,
insensate, and charred or leathery
■ deep (4th degree): involvement of fat, muscle, even bone
Management
• remove noxious agent/stop burning process
• establish airway if needed (indicated with burns >40% BSA or smoke inhalation
injury)
• resuscitation for 2nd and 3rd degree burns (after initiation of 2 large bore IVs)
• fluid boluses if unstable
■ Parkland Formula: Ringer’s lactate 4 cc/kg/%BSA burned >2ed degree; give

half in first 8 h, half in next 16 h; maintenance fluids are also required if patient
cannot tolerate PO hydration
■ urine output is best measure of resuscitation, should be 40-50 cc/h or 0.5

cc/kg/h; avoid diuretics
• pain relief: continuous morphine infusion with breakthrough bolus

• investigations: CBC, electrolytes, U/A, CXR, ECG, ABG, carboxyhemoglobin
• burn wound care: prevent infection, clean/debride with mild soap and water,
sterile dressings
• escharotomy or fasciotomy for circumferential burns (chest, extremities)
• topical antibiotics, systemic antibiotics infrequently indicated
• tetanus prophylaxis if burn is deeper than superficial dermis
Disposition
• admit
■ 2nd degree burns >10% BSA, or any significant 3rd degree burns
■ 2nd degree burns on face, hands, feet, perineum, or across major joints
■ electrical, chemical burns, and inhalation injury
■ burn victims with underlying medical problems or immunosuppressed
patients.
26)Regarding breast cancer screening.The most true statement of the following

is
A.Start after 40 years old in all females.
B.Breast ultrasound is the best in females age more than 30 years old
C.screening depends on patient clinical risk factors
D.Dense breasts increase the sensitivity of mammography and are associated
with an decresed risk for breast cancer.
E.Breast MRI is currently the best available population-based method to detect
breast cancer at an early stage.
Explanation
A.Start after 45 years old in females with average risk of breast cancer.
Women ages 40 to 44 should have the choice to start annual breast cancer
screening with mammograms (x-rays of the breast) if they wish to do so.
Women age 45 to 54 should get mammograms every year.
• average-risk women: women age 40-74 with no personal history of breast

cancer, history of breast cancer in 1st degree relatives, known mutations of the
BRCA1/BRCA2 genes or previous exposures of the chest wall to radiation
B.Breast MRI is the best in females age more than 30 years old.
C.screening depends on patient average risk factors.
D.Dense breasts decrease the sensitivity of mammography and are associated
with an incresed risk for breast cancer.
E.mamography is currently the best available population-based method to
detect breast cancer at an early stage.
Mammography
• age 40-49: routine screening with mammography not recommended (weak
recommendation - moderate quality evidence)
• age 50-74: routine screening q2-3yr
27)Most common warning sign of advance acute arterial injury is

A.Pain
B.Palor
C.Loss of distal pulse
D.parasthesia
E.paralysis
Explanation
Acute Arterial Ischemia
Definition
• acute occlusion of a peripheral artery, usually without a history of claudication
• urgent management required
■ skeletal muscle can tolerate 6 h of ischemia before irreversible damage and
myonecrosis; exception is
in acute-on-chronic occlusion, where previously developed collaterals allow
more time
• tends to be lower extremity > upper extremity; femoropopliteal > aortoiliac
• paralysis and neuromuscular compromise are signs of late ischemia
Etiology and Risk Factors
• embolism vs. thrombosis
■ examples of conditions that predispose to embolism are: arrhythmias,
endocarditis, and arterial aneurysms
■ existing atherosclerotic plaques (i.e. chronic PAD) can rupture causing
thrombosis
■ previous vascular grafts/reconstructions can fail and thrombose leading to
acute presentation
■ hypercoagulable states can contribute to arterial thrombosis
Symptoms of Acute Limb Ischemia

6 Ps – all may not be present
Pain: absent in 20% of cases
Pallor: within a few hours becomes mottled
cyanosis
Paresthesia: light touch lost first then sensory
modalities
Paralysis/Power loss: most important, heralds
impending gangrene
Polar/Poikilothermia/’Perishing cold’
Pulselessness: not reliable.
28)A 35 year old woman presented to ER with swelling of right leg and redness
for 3 days duration prior to ER visit . She underwent dopplar ultrasound and she
was diagnosed to have Deep vien Thromposis and she was prescribed long term
warfarin therapy .Best test to follow up the patient on long term Warfarin
therapy is
A.Bleeding time
B.Partial Thromboplastin Time
C.Cloting Time
D.Prothrombin Time
E.platelets Count
Explanation
• Best for follow up test for warfarin therapy is pt or INR
• Best for follow up test for heparin therapy is ptt.
29)Most common cause of Late deaths in burn patient is

A.Sepsis
B.Hypovolemia
C.Contractures
D.Neurogenic shock
E.Hypothermia
30)A 35 year old male patient has superficial partial-thickness burns to the back of the
right arm, posterior trunk, left leg, anterior head and neck.Using the Rule of Nines,
calculate the total body surface area percentage that is burned?
A. 45%
B. 37%
C. 36%
D. 27%
E.50%
Explanation
Burned BSA
 Back of the right arm 4,5%

 Posterior trunk 18%
 Left leg 18%
 Anterior head and neck 4,5%
Total burned BSA=45%
31)Most common site of Lymphoma in the Gastrointestinal tract is

A.Esophagus.
B.Stomach.
C.Small bowel.
D.Pancreas.
E.Large bowel.
32)A patient states they have been vomiting for the last 4 days. The patient is irritable,
weak, and reporting muscle cramping and weakness. On assessment, the patient is
experiencing bradypnea with a respiratory rate of 10. The patient has the following
ABGs result: HCO3 40, pH 7.55, PaCO2 50. Which condition below is presenting?
A. Metabolic alkalosis partially compensated
B. Metabolic alkalosis fully compensated
C. Metabolic acidosis partially compensated
D. Metabolic acidosis not compensated
E.Respiratory alkalosis not compensated
Explanation
Ph 7,55 is base
Hco3 40 is base (metabolic)
Co2 50 is acid (respiratory).
The final Dx is metabolic alkalosis partially compensated.
33) Which of the following statements about

hemorrhoids is not true?A. Hemorrhoids are specialized “cushions”
present in everyone.
B.External hemorrhoids are covered by skin whereas internal hemorrhoids are covered
by mucosa.
C.Pain is often associated with uncomplicated hemorrhoids.
D. Hemorrhoidectomy is reserved for third and fourth degree hemorrhoids
E.Hemorrhoid is most common cause of lower GI bleeding in middle age adults.
Explanation
C.Pain is often associated with complicated hemorrhoids.
34)Which statement is true about hidradenitis suppurativa
A.It is a disease of the apocrine sweat glands.

B. It causes multiple perianal and perineal sinuses that drain watery pus.
C.The sinuses do not communicate with the dentate line.
D.The treatment is surgical
E.All of the above.
35)A third degree cirumferential burn in the arm and forearm region, which of the
following is most important for monitoring,
A.Blood gases
B.Carboxy-oxygen level
C.Macroglobiunria cryoglobinuria
D.Peripheral pulse and circulation
E.Body Tempruture
Explanation
Most important complication of cirumferential burn is compartment syndrome., so you
have to check Peripheral pulse and circulation in such patient.
36)A 25 year old female patient has a long history of constipation and passage of hard
stools ,She presented with recurrant rectal pain described as burning, cutting, or tearing
that occurs with bowel movements associated with bright-red blood appears on the
surface of stools.On physical examination She Found to have tear in lower half of the
anal canal, Deep anal ulcer,Sentinel pile,Enlarged anal papillae at dentate line.The best
next step in management is
A.Hemorrhoidectomy.
B.Topical anesthetic.
B.Increase fluid intake and Diet modification.
C.Lateral Internal Sphincterotomy
D.Fistulectomy.
Explanation
This is typical picture of chronic anal fistula.
The best managemant in such case is surgical treatment(C.Lateral Internal
Sphincterotomy).
Anal Fissures
Definition
• tear of anal canal below dentate line (very sensitive squamous epithelium)
• 90% posterior midline, 10% anterior midline
• if off midline: consider other possible causes such as IBD, STIs, TB, leukemia, or anal
carcinoma
• repetitive injury cycle after first tear
■ sphincter spasm occurs preventing edges from healing and leads to further tearing
■ ischemia may ensue and contribute to chronicity
Etiology
• forceful dilation of anal canal: large, hard stools and irritant diarrheal stools
• tightening of anal canal secondary to nervousness/pain leads to further tearing
• others: habitual use of stool bulking agents, and childbirth
Clinical Features
• acute fissure
■ very painful bright red bleeding especially after bowel movement, sphincter spasm on
limited DRE
■ treatment is conservative: stool softeners, bulking agents, and sitz baths (heals 90%)
• chronic fissure (anal ulcer)
■ triad: fissure, sentinel skin tags, and hypertrophied papillae
treatment
◆stool softeners, increased fibre intake, and sitz baths
◆topical nitroglycerin or calcium channel blocker (nifedipine): increases local blood

flow,
promotes healing, and relieves sphincter spasm
◆lateral internal anal sphincterotomy (most effective): objective is to relieve sphincter
spasm →
increases blood flow and promotes healing; but 5% chance of fecal incontinence
therefore not
commonly done
◆alternative treatment: botulinum toxin: inhibits release of acetylcholine (ACh),
reducing
sphincter spasm
37)A 70 year old male patient Known to have HTN,DM and CKD,presented to ER with
massive bright red per rectum.The most likely diagnosis is,
A.Ascending colon Talaengectasia.
B.Sigmoid Volvolus.
C.Sigmoid Diverticulosis
D.Internal Hemorroids
E.Puptic Ulcer Disease.
Explanation
Most common cause of massive painless LGIB in elderly is diverticular disease.
Diverticulosis
Epidemiology
• 5-50% of Western population, lower incidence in non-Western countries, M=F
• prevalence is age dependent: <5% by age 40, 30% by age 60, 65% by age 85
• 95% involve sigmoid colon (site of highest pressure)
Pathogenesis
• risk factors
■ lifestyle: low-fibre diet (predispose to motility abnormalities and higher intraluminal
pressure),
inactivity, and obesity
■ muscle wall weakness from aging and illness (e.g. Ehler-Danlos, Marfan’s)
• high intraluminal pressures cause outpouching to occur at point of greatest weakness,
most commonly
where vasa recta penetrate the circular muscle layer, therefore increased risk of
hemorrhage
Clinical Features
• uncomplicated diverticulosis: asymptomatic (70-80%)
• episodic abdominal pain (often LLQ), bloating, flatulence, constipation, diarrhea
• absence of fever/leukocytosis
• no physical exam findings or poorly localized LLQ tenderness
complications
■ diverticulitis (15-25%): 25% of which are complicated (i.e. abscess, obstruction,
perforation, fistula)
■ bleeding (5-15%): PAINLESS rectal bleeding, 30-50% of massive LGIB
■ diverticular colitis (rare): diarrhea, hematochezia, tenesmus, and abdominal pain
Treatment
• uncomplicated diverticulosis: high fibre, education
• diverticular bleed
■ initially workup and treat as any LGIB
■ if hemorrhage does not stop, resect involved region
38)Regarding Mammary intraductal papiloma,All of the following are false except,

A.It is a malignant lesions with an incidence of approximately 2-3%.
B.It is the most common cause of unilateral bloody nipple discharge in women age 20-
40.
C.Mammography is the most definitive test for diagnosis.
D.Mastectomy is the treatment of choice
E.it is mostly undetectable on ultrasound
Explanation
A.It is a benign lesions with an incidence of approximately 2-3%.
B.It is the most common cause of unilateral bloody nipple discharge in women age 20-
40.
C.Breast Ultrasound is the most definitive test for diagnosis.
D.lobeectomy with duct excision is the treatment of choice
E.it is mostly visible on ultrasound
39) A 25 year old male patient presented to ER with pentrating gun shot chest wall
injury. What is the immediate management of traumatic open pneumothorax in the
emergancy room,
A.Chest tube placement in 4th intercostal space
B.Place a three-sided occlusive dressing over injury site.
C.Needle thoracentesis in 2nd intercostal space
D.Emergancy thoracotomy
E.VATS (video-assisted thoracoscopic surgery)
Explanation
This case is a typical case of chest injury with development open pneumothorax.
Open Pneumothorax
Air entering chest from wound rather than trachea
Physical exam
Gunshot or other wound (hole >2/3 tracheal diameter) ± exit wound
Unequal breath sounds
Investigation
ABG: decreased pO2
Management
• Air-tight dressing sealed on 3 sides
• Chest tube
• Surgery
40)About acute appendicitis ,All of the following are true except,

A. Anorexia is present in the most of the cases.
B.periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting.
C.Diarrhea is a feature of acute appendicitis.
D.Most of the appendix location is pelvic
E.Vomiting is Nearly always follows the onset of pain.
Explanation
A. Anorexia is present in the most of the cases of acute appendicitis.
B.periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting.
C.Diarrhea is a feature of acute appendicitis, especially pelvic appandicitis
D.Most of the appendix location is retrocecal

The appendix is usually located in the lower right quadrant of the abdomen, near the
right hip bone. The base of the appendix is located 2 cm beneath the ileocecal valve
that separates the large intestine from the small intestine.
E.Vomiting is Nearly always follows the onset of pain.
Acute Appendicitis
Epidemiology
• 6% of population, M>F
• 80% between 5-35 yr of age
Pathogenesis
• luminal obstruction → bacterial overgrowth → inflammation/swelling → increased
pressure →
localized ischemia → gangrene/perforation → localized abscess (walled off by
omentum) or peritonitis
etiology
■ children or young adult: hyperplasia of lymphoid follicles, initiated by infection

■ adult: fibrosis/stricture, fecolith, or obstructing neoplasm
■ other causes: parasites, or foreign body
Clinical Features
• most reliable feature is progression of signs and symptoms
• low grade fever (38ºC), rises if perforation
• abdominal pain then anorexia, N/V
• classic pattern: pain initially periumbilical; constant, dull, poorly localized, then well
localized pain over McBurney’s point
■ due to progression of disease from visceral irritation (causing referred pain from
structures of the embryonic midgut, including the appendix) to irritation of parietal
structures
■ McBurney’s sign • signs
■ inferior appendix: McBurney’s sign (see sidebar), Rovsing’s sign (palpation pressure to
left abdomen causes McBurney’s point tenderness). McBurney’s sign is present
whenever the opening of the appendix at the cecum is directly under McBurney’s point;
therefore McBurney’s sign is present even when the appendix is in different locations
■ retrocecal appendix: psoas sign (pain on flexion of hip against resistance or passive
hyperextension of hip)
■ pelvic appendix: obturator sign (flexion then external or internal rotation about right
hip causes pain)
complications
■ perforation (especially if >24 h duration)
■ abscess, phlegmon
■ sepsis
Investigations
• laboratory
■ mild leukocytosis with left shift (may have normal WBC counts)
■ higher leukocyte count with perforation
■ β-hCG to rule out ectopic pregnancy
■ urinalysis
• imaging
■ U/S: may visualize appendix, but also helps rule out gynecological causes – overall
accuracy 90-94%, can rule in but CANNOT rule out appendicitis
■ CT scan: thick wall, enlarged(>6 mm), wall enhancement, appendicolith, and
inflammatory changes – overall accuracy 94-100%, optimal investigation
Treatment
• hydrate, correct electrolyte abnormalities
• appendectomy (gold standard)
■ laparoscopic vs. open
■ complications: intra-abdominal abscess, appendiceal stump leak
■ perioperative antibiotics:
◆cefazolin + metronidazole if uncomplicated peri-operative dose is adequate
◆consider treatment with post-operative antibiotics for perforated appendicitis
• for patients who present with an abscess (palpable mass or phlegmon on imaging and
often delayed diagnosis with symptoms for >4-5 d), consider radiologic drainage +
antibiotics x 14 d ± interval appendectomy once inflammation has resolved =
(controversial)
• recent research supports antibiotic only treatment as reasonable for uncomplicated
appendicitis, with 10-20% recurrence rates
• colonoscopy in the elderly to rule out other etiology (neoplasm)
Prognosis
• mortality rate: 0.08% (non-perforated), 0.5% (perforated appendicitis)
41)A 40 year old female patient presented to clinic complaining of recurrant bloody
diarrhea and colicky abdominal pain for more than 3 months duration.On physical
exam,there are multiple aphthus ulcers in the mouth,angular stomatitis ,cheilitis
and abdominal mass.Colonoscopy showed colonic skip lesions with epitheloid
granuloma.The most likely diagnosis is
A.Colon Cancer
B.Rectal Cancer
C.Crohn's Disease
D.Ulcerative Colitis
E.Diverticular Disease
Explanation
 This clinical and colonoscopy picture is characterstic for C.Crohn's Disease.
Crohn’s Disease
Definition
• chronic transmural inflammatory disorder potentially affecting the entire
gut from mouth to perianal region (“gum to bum”)
Epidemiology
• incidence 1-6/100,000; prevalence 10-100/100,000

• bimodal: onset before 30 yr, second smaller peak age 60; M=F
• incidence of Crohn’s increasing (relative to UC) especially in young females
• more common in smokers ,Caucasians, Ashkenazi Jews
■ risk in Asians increases with move to Western countries

• smoking incidence in Crohn’s patients is higher than general population
Pathology
• most common location: ileum + ascending colon
• linear ulcers leading to mucosal islands and “cobblestone” appearance
• granulomas are found in 50% of surgical specimens, 15% of mucosal
biopsies
Clinical Features
• natural history unpredictable; young age, perianal disease, and need for
corticosteroids have been
associated with poor prognosis, but associations are not strong enough to
guide clinical decisions
• most often presents as recurrent episodes of abdominal cramps, non-
bloody diarrhea, and weight loss
• ileitis may present with post-prandial pain, vomiting, RLQ mass; mimics
acute appendicitis
• extra-intestinal manifestations are more common with colonic
involvement
• fistulae, fissures, abscesses are common
• deep fissures with risk of perforation into contiguous viscera (leads to
fistulae and abscesses)
• enteric fistulae may communicate with skin, bladder, vagina, and other
parts of bowel
Investigations
• colonoscopy with biopsy to visualize (less often gastroscopy)
• CT/MR enterography to visualize small bowel
• CRP elevated in most new cases, useful to monitor treatment response
(especially acutely in UC)
• bacterial cultures, O&P, C. difficile toxin to exclude other causes of
inflammatory diarrhea
Management
Lifestyle/Diet Smoking cessation

• Fluids only during acute exacerbation
• Enteral diets may aid in remission only for Crohn’s ileitis, not colitis
• No evidence for any non-enteral diet changing the natural history of
Crohn’s disease, but may affect symptomsThose with extensive small bowel
involvement or extensive resection require electrolyte, mineral, and vitamin
supplements (vit D, Ca2+, Mg2+, zinc, Fe, B12)
Antidiarrheal Agents*
• Loperamide (Imodium®) > diphenoxylate (Lomotil®) > codeine (cheap but
addictive)All work by decreasing small bowel motility, used only for
symptom relief
• CAUTION if colitis is severe (risk of precipitating toxic megacolon),
therefore avoid during flare-ups
5-ASA**
• Efficacy controversial: Is currently used for mild ileitis
• Sulfasalazine (Salazopyrin®): 5-ASA bound to sulfapyridine ~Hydrolysis by
intestinal bacteria releases 5-ASA (active component)Dose-dependent
efficacy
• Mesalamine (Pentasa®): coated 5-ASA releases 5-ASA in the ileum and
colon when inflammation is mild
Antibiotics
• e.g. metronidazole (20 mg/kg/d, bid or tid dosing) or ciprofloxacin
• Best described for perianal Crohn’s, although characteristically relapse
when discontinued
Corticosteroids
• Prednisone: starting dose 40 mg OD for acute exacerbations; IV
methylprednisolone if severe
• No proven role for steroids in maintaining remissions;
Immunosuppressives
• 6-mercaptopurine (6-MP), azathioprine (Imuran®); methotrexate (used less
often)
• More often used to maintain remission than to treat active inflammation
• Most commonly used as steroid-sparing agents. i.e. to lower risk of relapse
as corticosteroids are withdrawn
• May require >3 mo to have beneficial effect; usually continued for several
years
• May help to heal fistulae, decrease disease activity
• Side effects: vomiting, pancreatitis, bone marrow suppression, increased
risk of malignancy (i.e. lymphoma)
Biologics
• Infliximab IV (Remicade®) or adalimumab SC (Humira®): both = antibody to
TNF-α
• Proven effective for treatment of fistulae and patients with medically
refractory CD
• First-line immunosuppressive therapy with inflixmab + azathioprine more
effective than using either alone.
Surgical
• Surgery generally reserved for complications such as fistulae, obstruction,
abscess, perforation, bleeding, and for medically refractory disease
• If <50% or <200 cm of functional small intestine, risk of short bowel
syndrome
complications
■ intestinal obstruction/perforation
■ fistula formation
■ malignancy (lower risk compared to UC)
• surveillance colonoscopy same as ulcerative colitis if more than 1/3 of
colon involved.
42)All are true about Body Mass Index (BMI) except,

A.BMI 15 represents underweight.
B.BMI 20 represents optimal weight
C.It is equal Height in meter quadrant over the weight in kilograms.
D.BMI 26 represents overweight
E.BMI 36 is indication for weight loss surgery.
Explanation
BMI =wt in kg/ht in meter quadrant.
Normal BMI is 18,5 -24,9.
BMI < 18,5 is underweight
BMI 25-29,9 is overweight
BMI > 30 is obesity grade I
BMI > 35 is obesity grade II
BMI > 40 is obesity grade III (morbid obesity)
BMI >50 is obesity grade IV(supermorbid obesity)
Indication for bariatric (weight loss)

surgery is Obesity grade III,IV and grade II if obesity grade II assiociated with
metabolic syndrome.
A.BMI 15 represents underweight.

B.BMI 20 represents optimal weight
C.It is equal weight in kilograms over the
Height in meter quadrant.
D.BMI 26 represents overweight

E.BMI 36 is indication for weight loss surgery.
43)Regarding breast fibroadenoma,one is true

A.It is a premalignant condition.
B.It is Bipolar tumor composed of stromal and epithelial elements.
C.It is common in females > 30 years old.
D.In general, ultrasonography (US) is not useful in diagnosis of
fibroadenoma.
E.Mastectomy is only recommended if the fibroadenoma gets larger or
causes increased symptoms.
Explanation
A.It is a benign condition.
B.It is Bipolar tumor composed of stromal and epithelial elements.
C.It is common in females < 30 years old.
D.In general, ultrasonography (US) is useful in diagnosis of fibroadenoma.
E.Lobectomy is only recommended if the fibroadenoma gets larger or causes
increased symptoms.
Fibroadenoma
Most common breast tumour in women
<30 yr
Clinical features
Nodules: firm, rubbery, discrete, well-circumscribed, non-tender, mobile,
hormone-dependent (unlike cysts), needle aspiration yields no fluid
Investigation
• Core or excisional biopsy some times required ifconcerned about
malignancy
• U/S and FNA alone cannot differentiate fibroadenoma from Phyllodes
tumour
Management
• Generally conservative: serial observation
• Consider excision of fibroadenoma (lobectomy) if size 2-3 cm and growing
on serial U/S (q6mo x 2 yr is usual follow-up), if symptomatic, formed after
age 35, or patient preference or features on core biopsy suggestive of a
Phyllodes tumour
44)Enterocutanous Fistula which take the longest time to heal is

A.Esophagus
B.Pancreas
C.Colon
D.Small Bowel
E.Stomach
Explanation
Fistula
Definition
• abnormal communication between two epithelialized surfaces (e.g.
enterocutaneous, colovesical, aortoenteric, and entero-enteric)
Etiology
• foreign object erosion (e.g. gallstone, graft)
• inflammatory states (e.g. infection, IBD [Crohn’s > UC], and diverticular
disease)
• iatrogenic/surgery (e.g. post-operative anastomotic leak, and radiation)
• congenital, trauma
• neoplastic
Investigations
• U/S, CT scan, fistulogram
• measure amount of drainage from fistula
Treatment
• decrease secretion: octreotide/somatostatin/omeprazole
• surgical intervention: dependent upon etiology (for non-closing fistulas);
uncertainty of diagnosis
45)Regarding diabetic foot infection ,one is true

A.Severe, chronic, or previously treated infections are usually caused by
aerobic bacteria.
B.Compromise of the blood supply from macrovascular disease is the
underlying cause.
C. Foul Wound discharge is usually present in Deep-skin and soft-tissue
diabetic infections.
D.In Deep skin and soft-tissue infections, Surgical debridement is usually
indicated.
E.The WBC and ESR are markedly elevated in diabetic Cellulitis.
Explanation
A.Severe, chronic, or previously treated infections are usually caused by

mixed bacteria.
B.Compromise of the blood supply from microvascular disease is the
underlying cause.
C. Foul Wound discharge is rarely present in Deep-skin and soft-tissue
diabetic infections.
And it common assiociated with acute osteomylitis.
D.In Deep skin and soft-tissue infections, Surgical debridement is usually
indicated.
E.The WBC and ESR are minimalky elevated in diabetic foot Cellulitis.
46)Risk factors of Hepatcellular Carcinoma include all of the following

except,
A.Hepatitis A infection
B.Hepatitis B infection
C.Wilson disease
D.Fatty liver
E.Hepatitis C infection
Explanation
• Risk factors of Hepatcellular Carcinoma is HBV and HCV,Fatty liver
disease(NAFLD),
• Wilson disease has a minimal risk of HCC.
• HAV is not a risk factor of HCC.
47)About femoral hernia one is true,

A.It is located lateral to femoral vien.
B.Femoral artery is located lateral to it.
C.It is most common hernia in females.
D.Treatment only for symptomatic patient.
E.It rarely become incarcerated or strangulated.
Explanation
A.It is located medial to femoral vien.

B.Femoral artery is located lateral to it.
C.indirct inguinal hernia is the most common hernia in females.
D.surgical Treatment for all patient, despit of the patient is symptomatic or
asymptomatic.
E.It commonly become incarcerated or strangulated.
48)About Fluid therapy ,one of the following is false

A.It is classified into crystaloid and colloid types.
B.Normal Saline contents are Na 154 meq/L and Cl 154 meq/L and osmolarity
is 308 mOsm/L.
C.Ringer lactate contents are Na 130 meq/L,K 4 meq/L,Ca 3 meq/L,Cl
109meq/L,lactate 28meq/L and Osmolarity is 274 mOsm/L
D.Dextrose 5 water contents are glucose 5 gram/L and Osmolarity is 152
mOsm/L.
E.Normal Saline and Ringer lactate are isotonic solutions.
Explanation
Dextrose 5 water contents are glucose 50 gram/L and Osmolarity is 152
mOsm/L.
49)Most common cause of delayed wound healing is

A.Diabetus mellitus
B.Smoking
C.Infection
D.Stress
E.Radiation
Explanation
Factors Influencing Wound Healing
• Local (reversible/controllable)
1. Mechanical (local trauma, significant crush, avulsion, tension)
2. Blood supply (ischemia/circulation)
3. Temperature
4. Technique and suture materials
5. Retained foreign body
6. Infection
7. Venous HTN
8. Peripheral vascular disease
9. Hematoma/seroma (h infection rate)
• General (often irreversible)

1. Age (affects healing rate)
2. Nutrition (protein, vitamin C, O2)
3. Tobacco smoking
4. Alcohol abuse
5. Chronic illness (e.g. DM, cancer, CVD, renal failure)
6. Immunosuppression (steroids, chemo)
7. Tissue irradiation
8. Genetic predisposition to abnormal healing (e.g. hypertrophic or keloid
scarring, collagen vascular disease)
9. Skin type
50)One is not true about pancreatitis,
A.Pancreatic necrosis is often seen on CT and might result in pancreatic

Failure.
B.Most of the mortality due to systemic effect.
C.Choledocholithiasis does not cause chronic pancreatitis.
D.Abdominal pain associated with chronic pancreatitis improve with
progression of the disease
E.Serum amylase and lipase are usually normal during acute stage of chronic
pancreatitis.
Explanation
 Abdominal pain associated with chronic pancreatitis get worse with

progression of the disease.
Answer 6/2019
1 C 16 C 31 B 47 B
2 B 17 D 32 A 48 D
3 D 18 A 33 C 49 C
4 B 19 E 34 E 50 D
5 C 20 C 35 D
6 C 21 D 36 C
7 C 22 D 37 C
8 C 23 D 38 B
9 B 24 B 39 B
10 D 25 C 40 D
11 D 26 C 41 C
12 D 27 E 42 C
13 C 28 D 43 B
14 E 29 A 44 B
15 A 30 A 45 D
46 A

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Spot light on surgery 2019 MCQs Book Dr Fadi Qutishat 1

3)The most important sign of traumatic rupture of urethra is,

• epistaxis/hemorrhage, deviation/flattening of nose, swelling, periorbital ecchymosis,

• best reduction immediately (<6 h) or when swelling subsides (5-7 d).

managemant of nasal bleeding

■ posterior packing requires monitoring; can cause significant vagal response

6)Most serious early complication of electrical burn injury is

 Tissue Resistance to Electrical Current

7)Most important alarming sign of potential malignancy in chronic skin

Signs of malignant skin cancer (SCC).

8)Most important complication of circumferential burn in the upper limb is

9)The gold standard investigation for diagnosis osteomyelitis is

• symptoms: pain and fever

 Leg swelling generally occurs because of an abnormal accumulation of

are the same

Most Common Triggers for Anaphylaxis

13)Diarrhea is the characterstic feature of all of the following conditions except

• only 10% are malignant

VASOACTIVE INTESTINAL PEPTIDE-SECRETING TUMOUR

feels like a “bag of worms” when palpated

 This is typical picture of pentrating abdominal injury in unstable patient

• history: size of blade, calibre/distance from gun, route of entry

17)About Splenectomy,One of the following conditions is a major risk factor to develop

• An overwhelming post-splenectomy infection (OPSI) is a rare but rapidly

18)Common causes of splenomegally include all of the following except,

 cyst is a rare cause of splenomegaly.

 This is picture of post gastrectomy anastomosis leak.

 The peak time of development anastomosis leak

• obstruction of CBD leading to biliary stasis, bacterial overgrowth, suppuration

• U/S: intra-/extra-hepatic duct dilatation

21)A 65 years old male patient presented to emergancy room complaining of

• colicky abdominal pain, persistence of pain between spasms, abdominal

Neurogenic shock is generalized low perfusion state due to sever CNS(brain or

■ Parkland Formula: Ringer’s lactate 4 cc/kg/%BSA burned >2ed degree; give

cannot tolerate PO hydration

■ urine output is best measure of resuscitation, should be 40-50 cc/h or 0.5

• pain relief: continuous morphine infusion with breakthrough bolus

26)Regarding breast cancer screening.The most true statement of the following

• average-risk women: women age 40-74 with no personal history of breast

27)Most common warning sign of advance acute arterial injury is

■ hypercoagulable states can contribute to arterial thrombosis

Symptoms of Acute Limb Ischemia

29)Most common cause of Late deaths in burn patient is

 Back of the right arm 4,5%

Total burned BSA=45%

31)Most common site of Lymphoma in the Gastrointestinal tract is

The final Dx is metabolic alkalosis partially compensated.

33) Which of the following statements about

34)Which statement is true about hidradenitis suppurativa

A.It is a disease of the apocrine sweat glands.

◆topical nitroglycerin or calcium channel blocker (nifedipine): increases local blood

38)Regarding Mammary intraductal papiloma,All of the following are false except,

Air entering chest from wound rather than trachea

40)About acute appendicitis ,All of the following are true except,

D.Most of the appendix location is retrocecal

■ children or young adult: hyperplasia of lymphoid follicles, initiated by infection

 This clinical and colonoscopy picture is characterstic for C.Crohn's Disease.

• incidence 1-6/100,000; prevalence 10-100/100,000

■ risk in Asians increases with move to Western countries

Lifestyle/Diet Smoking cessation

42)All are true about Body Mass Index (BMI) except,

Indication for bariatric (weight loss)

A.BMI 15 represents underweight.