MULTIPLE CHOICE QUESTIONS

1. An otherwise healthy 65-year-old man is 16 hours postoperative from

laparoscopic left colectomy for colon adenocarcinoma. You are called by
the nurse because over the last 3 hours his urine output has been less
than 15 cc/hr. On evaluation, he reports feeling moderately anxious. His
heart rate is 102 bpm and his blood pressure is 120/80. His physical
examination is unremarkable.

The appropriate immediate next step in the management of the patient

include:

A. Give a 1-L fluid bolus

B. Measure hemoglobin

C. Return to the operating room for re-exploration

D. Send serum electrolytes

E. Wait and watch

ANSWER: A

2. A 75-year-old female is in the postoperative care unit after a left

hemicolectomy. You are called to evaluate her because she is suddenly
disoriented and agitated. What is your next step?

A. Arterial blood gas

B. Computed tomographic scan

C. Electrocardiogram
D. Naloxone administration

E. Vital signs and pulse oximetry

ANSWER: E

3. A 50-year-old male undergoes a elective right inguinal hernia repair

as an outpatient. Six hours later, he is unable to void despite multiple
attempts. What is the next step in his care?

A. Bladder scan, consider Foley placement

B. Discharge home
C. Fluid challenge with 1-L normal saline
D. Foley insertion for 14 days
E. Tamsulosin

ANSWER: A

4. A 68-year-old male status post a total abdominal colectomy with end

ileostomy is postoperative day 2 when his creatinine increases from 1.2
to 1.8. His urine output is low normal and you decide to check Fractional
excretion of Na, which comes back equal to 0.8%. What is his diagnosis?

A. Antibiotic nephrotoxicity

B. Intrinsic renal failure

C. Prerenal failure
D. Postrenal failure

E. Urinary tract infection

ANSWER: C

5. A 53-year-old male undergoes emergent exploratory laparotomy for

perforated sigmoid diverticulitis. He is not septic and makes urine
throughout the case, but the procedure lasts for 5 hours and the patient
receives over 4 L of intravenous crystalloid. When should this patient’s
Foley catheter be removed following surgery?

A. Immediately following the procedure

B. On postoperative day 1

C. On postoperative day 3 if no hematuria is present and ureteral injury ruled

out

D. On discharge

E. When patient is ambulatory

ANSWER: B

6. A 56-year-old female is admitted to the intensive care unit

(ICU) with a diffuse axonal injury after a motor vehicle

crash. The nursing staff notices coffee ground material

coming from her orogastric tube. What is the best intervention

to prevent this complication?

A. Enteral feeding.

B. Intravenous (IV) H2 blocker

C. IV PPI drip

D. Oral sucralfate

E. Oral proton pump inhibitor (PPI)

ANSWER : B

7. A 55-year-old emaciated alcoholic male presents with a 2-day history

of chest pain after forceful vomiting. He is taken to the OR for a
thoracotomy after he is found to have an esophageal rupture. A jejunal
feeding tube is placed and he is started on tube feeds on POD 1, when he
develops confusion, shallow breathing, and pulmonary edema. What
electrolyte abnormalities do you expect to see?

A. Hypophosphatemia, hypokalemia, hypomagnesemia

B. Hyperphosphatemia, hypokalemia, hypomagnesemia

C. Hypernatremia, hyperkalemia, hyperphosphatemia

D. Hypernatremia, hypokalemia, hypophosphatemia

E. Hyperkalemia, hypophosphatemia, hypomagnesemia

ANSWER: A

8. An obese patient with a body mass index (BMI) of 50

underwent a laparoscopic gastric bypass. Because of a

technical difficulty in the case, the procedure lasted for 8 h.

The patient was doing well postoperatively until 4 h, when

the nurse noted a change in the urine color from yellow to

dark brown. She also reported that the patient’s urine output

decreased and his creatinine increased from 1.0 to 1.5. Which

test would confirm the cause of these findings?

A. . Complete blood count

B. . Haptoglobin
C. . Renal ultrasound
D. . Serum creatinine kinase
E. . Urine electrolytes

ANSWER : D

9. A 52-year-old diabetic male presents to the emergency

department with chest pain, diaphoresis, and an elevated

troponin. He is taken to the cardiac catheterization lab.

Which of the following is contrast-induced AKI

(CIAKI)?

A. CIAKI is characterized by oliguria.

B. Evidence of CIAKI occurs within 6 to 24 h of contrast administration.
C. It is the most common form of iatrogenic AKI in hospitalized patients.
D. The creatinine returns to normal within 1 month of insult for most
patients.
E. The 1-year mortality associated with CIAKI is < 5%.

ANSWER : C

10. A 60-year-old TPN-dependent male with short-gut syndrome and

diarrhea presents with a non-healing leg wound. Which trace element
may he need supplementation with?

A. Copper
B. Fluorine
C. Manganese
D. Selenium
E. Zinc

ANSWER: E

11. In which group of patients is there a clinically proven reduction in

mortality following the resuscitation with hypertonic saline?
A. A 65-year-old female with mild-to-moderate dehydration

B. A 35-year-old male with moderate hyponatremia from psychogenic

polydipsia

C. A 40-year-old female with traumatic hemorrhagic shock following a motor

vehicle

accident and splenic laceration

D. A 5-year-old child with renal insufficiency

E. Hypertonic saline has not been shown to decrease mortality in any patient
population

ANSWER: E

12. A patient with severe sepsis secondary to cholangitis has received 4 L

of crystalloid resuscitation over the last 6 hours. His MAP remains below
65, but he is fluid responsive. Which of the following fluids should be
administered?

A. 0.9% NS, 1 L over 1 hour

B. 0.45% NS, 2 L over 1 hour

C. 5% albumin, 500 cc over 1 hour

D. Dextran 40, 500 cc over 2 hours

E. Hetastarch, 6% solution, 1 L over 1 hour

ANSWER: C
13. A patient with a known history of coronary artery disease presents
to the emergency room with shortness of breath and extensive lower
extremity edema. Initial laboratory studies reveal a sodium of 124
mmol/L. Initial therapy includes which of the following:

A. Administration of 1 L of 0.9 NS. Fluid restriction to 1 L of free water per day

B. Administration of 500 cc 3% NaCl

C. Administration of 500 cc lactated Ringer solution

D. Fluid restriction to 2 L of free water per day

E. 500 cc bolus Dextrose saline

ANSWER: B

14. A 57-year-old male who developed atrial fibrillation is noticed to

have a drop in his platelets to 60,000/μL 7 days after initiation of a
heparin drip. He goes on to develop lower extremity swelling, and the
presence of a new DVT is confirmed with ultrasound. What if any
changes should be made to address his anticoagulation regimen and
thrombocytopenia?

A. Continue heparin drip

B. Discontinue all anticoagulation and place an IVC filter

C. Obtain a hematology consult

D. Start the patient on a bivalirudin drip

E. Start platelet transfusion

ANSWER: D

15. A 45-year-old male is septic and found to have DIC with

hypofibrinogenemia. Which of the following products would be
appropriate to administer?

A. Cryoprecipitate
B. DDAVP
C. FFP
D. PRBCs
E. Whole blood

ANSWER: A

16. A 72-year-old male has been admitted to the surgical ICU for 16 days
after surgical repair of a spontaneous duodenal perforation due to
steroids for his SLE. He developed pneumonia and has required
mechanical ventilation since his Operation. He underwent tracheostomy
placement on POD 6. Yesterday he had a small amount of blood from his
tracheostomy which stopped spontaneously. He now develops
significantly more hemoptysis through his tracheostomy and his
respiratory status is rapidly decompensating. Your next step should be
to:

A. Remove the tracheostomy, place your finger through the tracheostomy site,
and apply pressure to the innominate artery.
B. Tube thoracostomy placement.

C. Transfuse 2 units of PRBCs followed by FFP and platelets as with a massive

transfusion protocol.

D. Urgent CT to evaluate for potential PE followed by systemic

anticoagulation.

E. Urgent ENT consult for bleeding.

ANSWER: A

17. A 47-year-old male with Crohn’s colitis maintained on 40 mg

prednisone daily for the past year presents for elective colectomy. The
procedure was uncomplicated, and he was adequately resuscitated. In
the postanesthesia care unit (PACU) the patient is noted to be febrile and
hypotensive with MAPs in the 50s. What is your next step in
management?

A. Antibiotics

B. Epinephrine

C. Hydrocortisone

D. IV dobutamine

E. 1 unit of packed red blood cells

ANSWER :C
18. An obese 21-year-old male suffers multiple fractures and a liver
injury; 21 days later, he develops acute dyspnea, diaphoresis, and
desaturates to 86% at room air. A computed tomography (CT) of the
chest is positive for pulmonary embolus. Which factor is least likely to
cause venous thromboembolic event:

A. BMI
B. Hypertriglyceridemia
C. Pelvic fractures
D. Severity of injury
E. Smoking

ANSWER : B

19. A 34-year-old man sustained a gunshot wound to his abdomen that

necessitated exploratory laparotomy and small bowel resection. Two
weeks after the initial operation, he was reexplored for a large
intraabdominal abscess. Which of the following will result in the most
rapid gain in strength of the new incision?

A. A separate transverse incision is made.

B. The midline scar is excised with a 1-cm margin.

C. The midline incision is reopened without excision of the scar.

D. The midline incision is left to heal by secondary intention.

E. The rate of gain in strength is not affected by the incision

technique.
ANSWER : C.

20. A 29-year-old black woman is scheduled for incision and drainage of

a breast abscess that has recurred three times despite ultrasound-
guided needle drainage. The patient has a history of keloid formation
and is concerned about an unsightly scar on her breast. How will you
best manage this patient?

A. An incision placed perpendicular to the lines of natural skin tension will

result in the least obvious scar.

B. By applying pressure dressing.

C. Hypertrophic scars excision and resuturing.

D. Keloid excision followed by intralesional steroid injection.

E. Reassurance.

ANSWER : D

21. A 30-year-old man is scheduled for definitive management of his

open wounds after undergoing embolectomy and fasciotomies on his left
lower extremity. He underwent skin grafting ,so what you will see in
patient?

A. A split-thickness skin graft undergoes approximately 40% shrinkage

immediately after harvesting.

B. A full-thickness skin graft undergoes approximately 10% shrinkage

immediately after harvesting.
C. Secondary contraction is more likely to occur in full-thickness skin graft.

D. Sensation usually returns to areas that have undergone skin grafting.

E. Skin grafts may be exposed to moderate amounts of

sunlight without changing pigmentation.

ANSWER : D

22. A 21-year-old graduate student has a large hypertrophic scar on the

lower part of her face. The patient had sustained a laceration on her face
2 years previously after hitting her face on the side of a swimming pool.
What you will advise him regarding scar revision surgery?

A. It corrects undesirable pigmentation.

B. Revision should be performed earlier in children than in adults.

C. Surgery should be done before scar maturation.

D. Scar revision should performed in the first 3 months to minimize fibrosis.

E. Scar revision should be delayed for approximately 1 year to allow

maturation.

ANSWER : E

23. A 68-year-old diabetic man undergoes a below-knee amputation. The

patient’s postoperative course is complicated by severe depression and
anorexia. Before discharge, the patient is started on a multivitamin
regimen. What are the roles of vitamin in wound healing?
A. High doses of vitamin C improve wound healing.

B. Iron deficiency has been linked to defects in long-term wound remodeling.

C. Vitamin A is for hydroxylation of lysine in collagen synthesis.

D.Vitamin E is involved in the stimulation of fibroplasia, collagen cross-

linking, and epithelialization.

E. Zinc deficiency results in delayed early wound healing.

ANSWER: E

24. An 85-year-old nursing home patient is found to have a worsening

stage III sacral pressure ulcer. The ulcer is debrided and tissue for
culture obtained. Tissue cultures reveal 10*8 organisms per gram of
tissue after operative debridement. What is the next most appropriate
step in the management of the patient’s wound?

A. Debridement with immediate application of a split-thickness skin graft

B. Intravenous antibiotics

C. Muscle flap coverage

D. Repeat debridement

E. Wound vacuum-assisted closure (VAC)

ANSWER : D
25. A 46-year-old man is evaluated shortly after undergoing radiation
therapy and chemotherapy for primary laryngeal cancer. He also gives a
history of long-term steroid use for rheumatoid arthritis. The patient
complains of a chronic, nonhealing wound on his neck, just over his right
clavicular head. Which statement regarding the treatment of this wound
is true?

A. The wound should be treated with compression dressings.

B. The wound should be treated with injected steroids.

C. The patient should start taking vitamin A, and the wound should be covered
with antimicrobial dressings.

D. The patient should start taking vitamin C, and the wound should be kept
open to air.

E. The wound should be excised and a skin graft applied.

ANSWER : C

26. A 35-year-old woman is concerned regarding her risk of developing

breast cancer. Her sister was diagnosed with breast cancer at the age of
37. The cancer was thought to be familial, as she was found to be
carrying the BRCA1 gene. In a woman carrying the BRCA1 gene, what is
the lifetime risk of developing breast cancer?

A. 10-30%
B. 20-50%
C. 50-80%
D. 70-90%
E. 80-100%
ANSWER: C

27. An otherwise fit 85-year-old man presents with an eight hour history
of an acutely ischaemic right arm with severe pain in the hand and
fingers. He is right handed. There was no history of pain or restricted
movement prior to this current episode. He has a history of atrial
fibrillation for which he has been prescribed digoxin and takes
appropriate medications for hypertension. On examination the hand is
very cold and pale but some movement and sensation are preserved.
There is a good axillary artery pulse but distal pulses are impalpable.
How will you manage?

A. Arrange a duplex scan

B. Book an outpatient appointment for vascular surgery
C. Commence heparin
D. Embolectomy
E. Thrombolysis

ANSWER: D

28. A 37-year-old male presents with a six hour history of profuse

vomiting and over the last two hours had developed left sided chest pain
and dyspnoea. On examination he had a pulse of 111 beats per minute
regular and a blood pressure of 167/91 mmHg. On palpation, he had
crepitus over the left supraclavicular region and neck, reduced heart
sounds and left basal sided crackles, plus some dullness to percussion
over the right base of the chest. What is the most appropriate initial
investigation?
A. CT with oral contrast
B. Echocardiogram
C. Gastrografin swallow
D. Rigid oesophagoscopy
E. Upper GI endoscopy

ANSWER: C

29. A 65-year-old woman presents to the surgical outpatient clinic with

ulceration over the tips of the toes in her left foot and a large ulcer over
her right heel. She also complains of paraesthesia in both feet.The ankle-
brachial pressure indices are 1.05 on the right and 1.2 on the left. On
neurological assessment, proprioception and vibration sense are
reduced. Choose the single most appropriate diagnosis.

A. Hypertensive ulcer (Martorell's ulcer)

B. Neuropathic ulcer
C. Pyoderma gangrenosum
D. Squamous cell carcinoma
E. Vasculitic ulcer

ANSWER: B

30. A 23-year-old female is involved in a high speed road traffic accident

and after extraction from her car is brought to the Emergency
department. On initial primary survey, she is immobilised. She is
making slightly confused conversation. Initial observations reveal a
tachycardia of 120 bpm, and a systolic blood pressure of 90 mmHg. She
has a respiratory rate of 30 and her chest is dull to air entry on the right
hand side. She is tender over his right upper quadrant on abdominal
examination. How much of her circulating blood volume is she likely to
have lost?

A. Nil
B. Up to 15%
C. 15% to 30%
D. 30% to 40%
E. Greater than 40%

ANSWER:D

31. A 69-year-old woman presents with abdominal pain, distention and

vomiting. Clinical examination showed no scars of previous surgery but
there was a tender swelling in her groin.
In theatre, low approach was used to repair her femoral hernia. Black
small bowel was seen inside the sac but when the neck was opened, the
small bowel slipped back inside the abdomen.
Which of the following is the most appropriate course of action in this
case?

A. Cut the inguinal ligament and enter the abdomen

B. Perform a laparotomy
C. Repair the hernia and do a laparoscopy
D. Repair the hernia and observe on the ward
E. Use a Babcock's to try to get the slipped bowel loop

ANSWER: B
 32. A 46-year-old male school teacher is admitted to the intensive care
unit with an episode of severe acute pancreatitis. His family wants to
speak to you regarding his prognosis.
What is the most common cause of death in severe acute pancreatitis
after the first week?

A. Ascending cholangitis
B. Infected pancreatic necrosis
C. Myocardial infarction
D. Pneumonia
E. Retroperitoneal haemorrhage

ANSWER: B

33. A 52-year-old man is admitted with obstructive jaundice. Ultrasound

shows a dilated common bile duct and therefore he requires MRCP to
identify the etiology of the biliary obstruction.
Which of the following is an absolute contraindication to MRCP?

A. Cardiac pacemaker
B. Claustrophobia
C. Gadolinium anaphylaxis
D. Previous biliary bypass
E. Recent laparoscopic cholecystectomy

ANSWER: A

34. A 79-year-old man has been admitted with abdominal pain and
distention. CT has confirmed sigmoid volvulus which was untorted using
flexible sigmoidoscopy. The next morning the abdomen is less distended
and generally soft but the patient has been getting increasingly
tachycardic and tachypnoeic overnight. Bloods show a raised TLC and
metabolic acidosis.
Which of the following would be the most appropriate next step in
management?

A. Chest x ray
B. Flexible sigmoidoscopy
C. Laparotomy
D. Repeat CT
E. Rigid sigmoidoscopy on the ward

ANSWER: C

35. A 25-year-old man has sustained a shotgun wound to the abdomen.

At laparotomy there are multiple injuries to the small and large bowel
and he is haemodynamically unstable.
Which of the following is the most appropriate management?

A. Closure of all injuries and laparostomy

B. Closure of all injuries and second look at 24 hours
C. Staples across injured sections, washout, multiple drains and laparostomy.
D. Washout, multiple drains, abdominal closure and second look at 24 hours
E. Washout, multiple drains and laparostomy

ANSWER: C

36. A firm 2-3 cm mass is palpable in the upper outer quadrant of the left
breast of a 51-year-old woman. There are no palpable axillary lymph
nodes. A wide local excision with axillary node dissection is performed
and the breast lesion is found to have positive immunohistochemical
staining for HER2/neu (c-erb B2). Staining for oestrogen and
progesterone receptors is negative.
Which of the following additional treatment options is most appropriate,
based upon these findings?

A. Radical mastectomy
B. St John's wort
C. Tamoxifen
D. Trastuzumab
E. Vancomycin

ANSWER:D

37. A 17-year-old female with profound learning difficulties is admitted

from a nursing home with suspected appendicitis. She is accompanied by
a staff nurse who has been caring for her for a number of years. The
nurse tells you his family cannot be contacted and will not get involved
with the decision whether to operate.

What is the most appropriate course of action?

A. Ask the nurse to sign the consent form, as she has known him for sometime
B. Ask the patient to sign the consent
C. Get the trust lawyer to contact the court and get a decision
D. Perform capacity- assessment, proceed with treatment if patient cannot
give consent
E. Proceed with the operation without family consent

ANSWER: D
38. A 45-year-old male presents with a six hour history of profuse
vomiting and over the last two hours had developed left sided chest pain
and dyspnoea. On examination he had a pulse of 111 beats per minute
regular and a blood pressure of 167/91 mmHg. On palpation, he had
crepitus over the left supraclavicular region and neck, reduced heart
sounds and left basal sided crackles, plus some dullness to percussion
over the right base of the chest. What is the most appropriate initial
investigation ?
A. CT with oral contrast
B. Echocardiogram
C. Gastrografin swallow
D. Rigid oesophagoscopy
E. Upper GI endoscopy

ANSWER: C

39. A 27-year-old woman with Crohn's disease. She presents with

cutaneous manifestations. Which of the following is not associated with
crohn’s disease?

A. Amyloidosis
B. Cholelithiasis
C. Dermatitis herpetiformis
D. Pyoderma gangrenosum
E. Urinary oxalate stones

ANSWER: C

40. A 63 year old woman presented with a malabsorption syndrome. She

had a past history of radiotherapy for cervical cancer. Small intestine
biopsy reveals villous atrophy, crypt hypertrophy, and chronic
inflammatory cell infiltrate of the lamina propria together with an
increase in intraepithelial lymphocytes.
What is the most likely diagnosis?
A. Bacterial overgrowth
B. Coeliac disease
C. Crohn's disease
D. Mesenteric ischaemia
E. Radiation enteropathy

ANSWER: B

41. An 83-year-old man presents with a lump adjacent to his left nipple.
Triple assessment reveals a 2 cm estrogen receptor positive
adenocarcinoma. The tumor should be treated definitively with which of
the following?

A. Mastectomy with Sentinel Lymph Node Biopsy

B. Radiotherapy
C. Simple mastectomy
D. Subcutaneous mastectomy
E. Wide local excision

ANSWER: A

42. A 79-year-old man presented with six year history of vomiting after
eating. Gastroscopy showed no abnormality and barium swallow showed
hold up of the contrast in the stomach for six hours.
Which of the following would be the most appropriate management in
this case?

A. Do nothing
B. Gastrojejunostomy
C. Partial gastrectomy
D. Prokinetic agent
E. Total gastrectomy

ANSWER: D

43. A 65-year-old man presented with epigastric discomfort and weight

loss of 21 kg over six months. Plain abdominal x-ray showed
calcifications in the upper abdomen.
Which of the following is the most likely diagnosis?

A. Chronic pancreatitis
B. Gastric cancer
C. Gastritis
D. Nephrocalcinosis
E. Pancreatic carcinoma

ANSWER: A

44. A 61 year old man underwent an upper GI endoscopy for a T2N0M0

esophageal tumor. The gastroenterologist perforates the esophagus.
Following the procedure the patient is stable.
What is the correct course of action?

A. Immediate esophagectomy
B. Oesophageal stent
C. Refer to upper GI team
D. Treat conservatively
E. Watch and wait strategy

ANSWER: D
45. A 53-year-old man presents with a 14 days history of severe right
upper quadrant pain. He has recently returned from a two-week holiday
in the Caribbean. He reports multiple episodes of vomiting and
diarrhoea. He has completed a course of antibiotics. On examination he
is focally tender in the right upper quadrant. An ultrasound of the gall
bladder shows a distended gall bladder with no stones.

What is the most likely diagnosis?

A. Acute pancreatitis
B. Clostridium difficile colitis
C. Duodenal ulceration
D. Helicobacter gastritis
E. Salmonella cholecystitis

ANSWER: E

46. A 32-year-old hairdresser presents to her general practitioner with a

four month history of fever and chills, abdominal discomfort and
diarrhoea. She also states that she passes air occasionally when she
attempts to pass urine. On examination, she is tender over the right iliac
fossa. Per rectal examination is unremarkable but a few small ulcers are
noticed around the perianal region. Colonoscopy reveals skip lesions of
linear ulcers and transverse fissures giving cobblestone appearance of
the mucosa.

CT scan reveals an enterovesical fistula.

Which of the following is the correct diagnosis?

A. Carcinoma of the caecum

B. Carcinoma of the sigmoid colon
C. Chron’s disease
D. Typhoid gastroenteritis
E. Ulcerative colitis
ANSWER: C

47. A 73-year-old lady presents on the ER with severe left iliac fossa pain.
Examination reveals a pyrexia and localised tenderness in the left iliac
fossa. She is treated conservatively with broad spectrum antibiotics and
settles over the next one week. On review in the out patient department
four weeks later she reports that she has had recurrent urinary tract
infections and has pneumaturia.

What is the most appropriate investigation?

A. Abdominal x-Ray
B. Colonoscopy
C. CT scan
D. MRI scan
E. US scan

ANSWER: B

48. A 77-year-old man presents to the acute surgical intake with left iliac
fossa pain.
He has no significant co-morbidity. He is investigated with a CT scan that
demonstrates uncomplicated diverticulitis of the sigmoid colon. His
condition improves with conservative treatment with antibiotics and he
is ready for hospital discharge. What is the most appropriate next step in
his management?

A. Elective laparoscopic sigmoid colectomy

B. Elective open sigmoid colectomy
C. Flexible sigmoidoscopy at six weeks
D. Flexible sigmoidoscopy on the next available list
E. Repeat CT scan
ANSWER:C

49. A 26-year-old lady, who is 34 weeks pregnant, is referred by the on-

call obstetric team with a 72 hour history of severe thrombosed external
haemorrhoids.

Which of the following is the preferred management of this lady?

A. Botox injection
B. Conservative treatment
C. Ferguson haemorrhoidectomy
D. Incision and evacuation of the haematoma
E. Injection sclerotherapy

ANSWER : B

50. A patient has previously undergone a small bowel resection.

Histopathology at the time showed a gastrointestinal stromal tumour
with 2 mitoses per high powered field.
Which of the following would be the most appropriate management for a
pelvic recurrence?

A. Chemotherapy and radiotherapy

B. Chemotherapy and surgery
C. Chemotherapy only
D. Conservative
E. Surgery only

ANSWER: C
51. On the eighth day after an exploratory laparotomy and bowel
resection complicated by intraabdominal hypertension, a 65-year-old
female who remains intubated in the intensive care unit (ICU) develops a
fever of 102°F. An infectious workup reveals a new right lower lobe
consolidation. When initiating antibiotic therapy for presumed
ventilator-associated pneumonia (VAP), which of the following does not
treat Pseudomonas aeruginosa?

A. Cefepime
B. Aampicillin/sulbactam
C. Ticarcillin
D. Aztreonam
E. Ciprofloxacin

ANSWER : B

52. A 78-year-old man with a history of urinary retention and a chronic

indwelling urinary catheter is admitted to the hospital from his nursing
home with a new-onset altered mental status, and a catheter-associated
urinary tract infection (CAUTI) is suspected. Which of the following is
true regarding CAUTIs?

A. A 7-day antibiotic treatment is adequate for patients whose symptoms

respond promptly to treatment.

B. A CAUTI can be diagnosed by the presence of greater than 10*5 cfu/mL of

bacteria in a urine specimen.

C. Pyuria is a specific indicator for urinary tract infections..

D. Proteus mirabilis is the most common organism cultured in CAUTIs.

E. Urine specimens being sent for culture can be obtained from the catheter
bag.
ANSWER : A

53. A newborn presented with bloated abdomen shortly after birth with
passing of less meconium.A full thickness rectal biopsy was carried out.
Which one of the following rectal biopsy finding is most likely to be
present?

A. Atropic changes
B. Fibrosis of submucosa
C. Hyalinization of muscular coat
D. Lack of ganglion cell
E. Thickened muscularis propria

Answer: D

54. A 40 years old female with history of C section 03 weeks back

presented in opd with pain and swelling lt leg since 03 days. On
examination she is vitally stable but tender and swollen lt leg.What will
be the investigation of choice to confirm the diagnosis
A. Coagulation profile
B. Duplex Imaging
C. Doppler usg
D. D- Dimers
E. FDP

Answer: B

55. A 40 years old female with history of C section 03 weeks back

presented in opd with pain and swelling lt leg since 03 days.On
examination she is vitally stable but tender and swollen lt leg.She
developed hepatin induced thrombocytopenia on starting treatment
with heparin. The most appropriate management in this case is:

A. Fondaparinux
B. IVC filter
C. LMWH
D. Rivaroxaban
E. Warfarin

Answer: A

56. A 23 years old man presented in ER with history of falland blunt

trauma lt hypochondrium 04 hours back.He was complaining of severe
abdominal pain.on examination he has pulse rate of 115b/min, BP
90/60 mmhg, Abdomen tense and generalized tender. The most
appropriate investigation to confirm the diagnosis?
A. CECT abdomen
B. Diagnostic laparoscopy
C. DPL
D. FAST
E. X-ray abdomen erect

Answer: D

57. A 47 years old lady presented with a lesion in Rt lower quadrant of rt

breast on routine mammography.A core biopsy of lesion shows atypical
ductal hyperplasia.The most appropriate management in this case is?

A. Excision only
B. Excisional biopsy with wire localization
C. Follow up mammography in 06 months
D. Modified radical mastectomy
E. Partial mastectomy with SNLB

Answer: B

58. A 74 years old man admitted with abdominal pain distension and
fullness for 04 days.He is a known case of gallstone .No history of
previous surgery.Having history of rt hypochondrial pain after taking
fatty meals.On examination he is afebrile, pulse 95 b /min, BP 120/80
mmhg, Abdominal examination shows generalized abdominal distension
and resonant on percussion.Most likely diagnosis is?
A. Acute cholecystitis
B. Choledocholithiasis
C. Ca gallbladder
D. Empyema Gallbladder
E. Gallstone ileus

Answer: E

59. A 74 years old man admitted with abdominal pain distension and
fullness for 04 days. He is a known case of gallstone .No history of
previous surgery. Having history of rt hypochondrial pain after taking
fatty meals.On examination he is afebrile, pulse 95 b /min, BP 120/80
mmHg, Abdominal examination shows generalized abdominal
distension and resonant on percussion. What is the most appropriate
investigation in this case ?

A. Abdominal x-ray Erect & supine

B. Contrast enhanced CT
C. ERCP
D. MRCP
E. Ultrasound Abdomen

ANSWER: B

60. A 74 years old man admitted with abdominal pain distension and
fullness for 04 days. He is a known case of gallstone .No history of
previous surgery. Having history of Rt hypochondrial pain after taking
fatty meals. On examination he is afebrile, pulse 95 b /min, BP 120/80
mmHg, Abdominal examination shows generalized abdominal
distension and resonant on percussion. The most appropriate
management in this case is:

A. Emergent laparoscopic decompression

B. Endoscopic decompression
C. Observation
D. Promotility agents
E. Surgical exploration

ANSWER: E

61. A 02 years old child presented with swelling at umblicus since birth.
On examination the swelling is reducible with positive cough impulse
with no skin changes. What is the indication of surgery in this patient..?

A. Asymptomatic also need surgery

B. Defect size more than 1cm
C. Persistent swelling after one year
D. Persistent swelling after 02 years of age
E. Progressive enlarging swelling after the age of 1-2 years

ANSWER: E
62. A 06 years old child presented with swelling at umbilicus since birth.
On examination the swelling is reducible with positive cough impulse
with 2x2 cm defect. The most appropriate management in this case is.

A. Conservative treatment as child is asymptomatic

B. Counseling of attendant for wait and watch
C. Primary closure
D. Mesh repair
E. Mayo’s Repair

ANSWER: C

63. A 50 years old man presented with hematemesis and upper

abdominal pain since 02 weeks. Endoscopy revealed a growth at pyloric
antrum of stomach. On CT scan abdomen the growth involving the
pyloric antrum without infiltration or invasion to surrounding
structures and no evidence of distant metastasis. At laparotomy the
neoplastic growth was observed to involve the posterior wall of the
stomach And pancreas upto 06cm of pancreatic tail. The evidence of
incurability in ca stomach is

A. Involvement of Pancreatic tail

B. Nodal involvement of N4 and beyond
C. Splenic involvement
D. Solitary metastatic nodule in liver
E. Transverse colon involvement

ANSWER: B

64. A 20 years old female with history of psychiatric illness presented in

ER with the complain of pain in Abdomen, abdominal distension and
vomiting. On examination she was found to have alopecia and crepitus
in epigastrium. The most likely diagnosis is.
A. Ca pyloric antrum
B. Intestinal TB
C. Pyloric stenosis
D. Rectus sheath hematoma
E. Trichobezoar

ANSWER: E

65. A 48 years old male has been worked up for a rectal carcinoma.
Staging found the tumour to be a T3N1 mid-rectal tumour, 6 cm from
anal verge.

What is the most appropriate management for this patient?

A. Neoadjuvant-chemoradiotherapy followed by TME anterior resection

B. Neoadjuvant chemoradiotherapy followed by TME anterior resection with
loop ileostomy
C. Perform a total mesorectal excision(TME) anterior resection
D. Perform a TME anterior resection with defunctioning loop ileostomy
E. TME anterior resection followed by adjuvant chemotherapy

ANSWER: B
66. 36-year old male football player presents with sudden onset of
severe abdominal pain. He was previously fit and well other than taking
ibuprofen for a long term knee injury. On examination he is in severe
pain, pulse 113 bpm, blood pressure of 109/69 mmHg and has a rigid
abdomen.
The most appropriate diagnosis for the following case history.

A. Appendicitis
B. Ischaemic colon
C. Pancreatic necrosis
D. Perforated diverticular abscess
E. Perforated peptic ulcer

ANSWER : E

67. A 38-year-old woman presents to the Emergency department with a

one week history of right upper quadrant pain, vomiting, fever, loss of
appetite and generalised itch. Her temperature is 37.9°C. On
examination, she is jaundiced and is very tender over the right
hypochondrium. She is known to have had ulcerative colitis for the past
20 years.

The most appropriate diagnosis

A. Autoimmune hepatitis
B. Acute liver failure
C. Chronic persistent hepatitis
D. Primary haemochromatosis
E. Sclerosing cholangitis

ANSWER: E
68. A 43-year-old female presents to the surgical outpatient clinic with
painful ulcers and abscess formation in her perineal region. On
examination, there are few small abscesses and multiple skin tags in the
region. The skin over the area is tender, red and indurated. She also
reports similar problems in her inguinal regions and axilla.
The most likely diagnosis

A. Carcinoma of the anal canal

B. Hidradenitis suppurativa
C. Pelvirectal abscess
D. Pilonidal abscess
E. Proctalgia fugax

ANSWER : B

69. A 33-years old man presents to his general practitioner with sharp,
agonising pain during defecation. The pain is worse during the initial
stages of defecation which can last up to 30-60 minutes following
defecation. Although there is no overt per rectal bleeding, he has noticed
streaks of blood on the tissue paper. His appetite is normal and weight
stable.
the most likely diagnosis

A. Anal fissure
B. Carcinoma of the anal canal
C. Fistula in ano
D. Perianal haematoma
E. Proctalgia fugax

ANSWER : A
70. A 33 years old man of Indian origin presents to his general
practitioner with a five day history of sharp pains over the right upper
quadrant of his abdomen, fever, chills and rigors. On examination, he is
jaundiced and appears dehydrated. His temperature is 38.2ºC. He had
been to India recently and he says that he was suffering from dysentery
for a few days during his stay there.
the most likely diagnosis

A. Acute cholecystitis
B. Acute viral hepatitis
C. Amoebic liver abscess
D. Hydatid cyst of the liver
E. Sub-phrenic abscess

ANSWER: C

71. A 63 years old sheep farmer presents to his general practitioner with
a three week history of dull aching pain over the right upper quadrant of
his abdomen and loss of appetite. On examination, he is jaundiced and a
mass can be felt over his right hypochondrium. His routine bloods reveal
a very high eosinophil count. Plain abdominal x ray shows a calcified
mass over the right hypochondrium.
the most likely diagnosis

A. Amoebic liver abscess

B. Ascaris lumbricoides cyst
C. Acute viral hepatitis
D. Hydatid cyst of the liver
E. Sub-phrenic abscess

ANSWER: D
72. A 26 years old teacher presents to the surgical outpatient clinic with
a 08 week history of right-sided lower abdominal pain, loss of appetite
and diarrhoea. She opens her bowels 10-12 times/day and the stools are
mixed with mucus. She has recently noticed some abscesses in her
perianal region. Her blood tests reveal a microcytic, hypochromic
anaemia and raised inflammatory markers
the most probable diagnosis

A. Appendicitis
B. Carcinoma of the ileo-caecal region
C. Crohn's disease
D. Ischaemic colitis
E. Pelvic inflammatory disease

ANSWER: C

73. A 23 years old woman is brought to the Emergency department with

severe, right-sided lower abdominal pain and mild vaginal bleed. She is
pale, and her pulse rate is 114/min and blood pressure is 93/65 mmHg.
Her last menstrual period was 06 weeks ago.
The most probable diagnosis

A.Appendicitis
B. Mittelschmerz
C. Pelvic inflammatory disease
D. Ruptured ectopic pregnancy
E. Torsion of Rt. ovary

ANSWER :D
74. An 83 years old woman, who is in known atrial fibrillation, is brought
to the Emergency department with an 08 hour history of severe, colicky
pain in the peri-umbilical region, vomiting and per rectal bleeding. Her
blood pressure is 103/71 mmHg and her pulse rate is 96/min. Her bowel
sounds are absent. Arterial blood gas analysis reveals elevated lactate
levels and metabolic acidosis.
The most probable diagnosis

A. Carcinoma of the ileo-caecal region

B. Ischaemic colitis
C. Pelvic inflammatory disease
D. Torsion of the ovary
E. Ulcerative colitis

ANSWER: B

75. A 73 years old male presented with 19 hours of acute abdominal

pain. He was noted to have generalised peritonitis and free intra-
peritoneal air on an erect chest x ray. At laparotomy, he was found to
have widespread faecal peritonitis due to perforated sigmoid
diverticular disease.
The most appropriate operation for the patient

A. Anterior resection
B. Hartmann's procedure
C. Panproctocolectomy
D. Sigmoid colectomy and primary anastomosis
E. Subtotal colectomy with ileostomy

ANSWER: B
76. A severely traumatized woman is seen in the Emergency room with
decreased mental status .Prior to intubation, she doesn’t open her eyes,
withdraws with all of her extremities and makes incomprehensible
sounds .what is her Glasgow coma scale ?

A. 3
B. 5
C .4
D. 7
E. 12

Answer: D

77. An 18yr old man is admitted to the ER following a motorcycle

accident. He is alert and fully oriented, but witness to the accident report
an interval of unresponsiveness following the injury. Skull films shows
fracture of left temporal bone. Following scans, the patient suddenly
loses consciousness and dilatation of the left pupil occurs. Which of the
following the most likely diagnosis?

A. A ruptured berry aneurysm

B. Acute subdural hematoma
C. Chronic subdural hematoma
D. Epidural hematoma
E. Intracerebral hemorrhage

Answer: D
78. 30 yrs old male had wound on his Rt knee due to trauma. With
regard to wound healing process, which of the following cell types are
the first infiltrating cells to enter the wound and peaking at 24 to 48 hrs?

A. Fibroblats
B. Macrophages
C. Monocytes
D. Neutrophils
E. Platelets

Answer: B

79. A 35 yr old woman undergoes an elective laparoscopic

cholecystectomy for cholelithiasis. During surgery there is no spillage of
bile. Which of the following wound classes best describe her procedure?

A. Aseptic.
B. Clean
C. Clean Contaminated
D. Contaminated
E. Dirty

Answer: C
80. A 25 yr old woman arrives in the ER following an automobile
accident. she is acutely dyspneic with respiratory rate of 50/min. Breath
sounds are markedly diminished on the right side. Which of the
following is the best first step in the management of the patient?

A. Chest tube in Rt pleural space

B. Draw blood for ABGs
C. Needle thoracostomy
D. Perform pericardiocentesis
E. Take x-ray chest

Answer: A

81. A patient was kicked in his left flank. His vitals, B.P. 110/70mmHg,
pulse 90 b/min, abdomen soft, non-tender patient has H/O frank
hematuria, most appropriate next step would be,

A. CT scan with contrast

B. CT abdomen plain
C. Exploratory laparotomy
D. Renal Function Tests
E. X ray abdomen
Answer: A

82. A patient was hit in his left flank. His vitals, B.P. 90/50mmHg, pulse
120 b/min, abdomen was tender and patient has H/O frank hematuria,
most appropriate next step would be ?

A. CT scan
B. DPL
C. Fast scan
D. Laparotomy
E. wait and watch

Answer: D

83. After completion of laparotomy for gastric perforation, patient

develops oozing from wound, 5 blood pints were transfused during
surgery. Patient is on injectable, anti-coagulant, best management would
be

A. Cryo precipitate
B. FFP
C. Protamine sulphate
D. Vitamin K
E. Whole blood transfusion
Answer: C

84. A person having Papillary thyroid cancer which is 3cm in size and
in one lobe, lymph node negative. What will be the definitive
management?

A. Lobectomy and isthumsectomy

B. Near total thyroidectomy
C. Sub Total thyroidectomy
E. Total thyroidectomy
D. Thyroid Function Test

Answer: E

85. A 6 yr old boy with undescended testes. What will be the best
investigation for localization of undescended testis:

A. CT
B. Clinical examination
C. Laproscopy
D. MRI
E. USG

Answer: C
86. 50 yr old male slept overnight hanging his right arm, in morning he is
feeling numbness of his ring and little finger, what type of nerve injury is
this?

A. Axontemesis
B. Ganglion injury
C. Neuropraxia
D. Neurontemesis
E. Nerve palsy

Answer: C

87. After a prolonged laparotomy for intestinal obstruction, consultant

asked the resident to close the abdomen. Which suture is considered
best to close Abdominal rectus sheath ?

A. PDS
B. Prolene
C. Silk
D. Synthetic
E. Vicryl

Answer: B

88. 23 years old lady comes in emergency with injury at her left arm,
there is superficial epidermal injury that dose go beyond epidermis,
most likely it is
A. Abrasion
B. Bruise
C. Contusion
D. Incision
E. Laceration

Answer: A

89. 15 years old patient comes with complain of alternative history of

diarrhea and constipation, pain in abdomen o/E. He has multiple
perianal fistula and rectal structure, on investigation patient has chronic
pain and swelling inflammatory disease with non caseating granuloma,
most likely the diagnosis is

A. Ca colon
B. Crohn’s disease
C. IBS
D. T.B intestine
E. Ulcerative colitis

Answer: B

90. 52 year old obese female present to you with a pain in the right
Hypochondrium, fever and jaundice. What is the most likely diagnosis?

A. Acute cholecystitis
 B. Acute pancreatitis
C. Ascending cholangitis
D. Choledochoholithiasis
E. Obstructive jaundice

Answer: C

91. A 35-year-old woman is concerned regarding her risk of developing

breast cancer. Her sister was diagnosed with breast cancer at the age of
37. The cancer was thought to be familial, as she was found to be
carrying the BRCA1 gene. In a woman carrying the BRCA1 gene, what is
the lifetime risk of developing breast cancer?

A. 10-30%
B. 20-50%
C. 50-80%
D. 70-90%
E. 80-100%

Answer: D

92. An 85 year old man undergoes open surgical repair of a symptomatic

hernia. During the operation the hernia sac is found to contain an
inflamed appendix. What is the name of such type of hernia?

A. Amyand’s hernia
B. Incisional hernia
C. Littre’s hernia
 D. Maydle’s hernia
E. Pantaloon hernia

Answer: A

93. A 22-year-old-boy college student notice a bulge in his right groin.

It is accentuated with coughing, but is easily reducible. Which of the
following hernais follows the path of the spermatic cord within the
cremaster muscle?

A. Direct inguinal hernia

B. Femoral hernia
C. Indirect inguial hernia
D. Spigelian hernia
E. Sliding hernia

Answer: C

94. 65 yrs old male presented in surgical opd with complains of 6 months
history of on and off blood in urine along with weight loss. What is the most
common cause of gross hematuria in a patient older than 60 years of age?

A. Benign prostatic hyperplasia

B. Bladder cancer
C. Infection
D. Renal calculi
E. Trauma
Answer: B

95. A 21-year-old woman presents with an asymptomatic breast mass. No

risk factor of Ca breast. How will you manage in outpatient?

A. Mammography will play an important role in diagnosing the lesion.

B. Should go for chemotherapy first.
C. The mass should always be excised.
D. The lesion should be considered pre-malignant.
E. Ultrasonography is often useful in the differential diagnosis of this lesion.

Answer: E

96. A 27 year old woman undergoes an emergency spleenectomy following

a fall from the roof wall. Which of the following best describes her
perioperative care?

A. Give broad spectrum Antibiotics.

B. She requires platelets.
C. There is higher chance of malignancy
D. Vaccination must be administered after two weeks of surgery
E. Vaccination should include polyvalent pneumococcus, H.influenza B and
Meningococcus.
Answer: E

97. A 2 yr old boy is seen by the paediatric surgeon. His mother is

concerned that his scrotum appears intermittently swollen on the left,
apparently worsened by some recent viral illness. The testicle remains
palpable. What is the diagnosis?

A. Femoral hernia
B. Hydrocele
C. Inguinal hernia
E. Varicocele
D. Testicular tumor

Answer: B

98. A 28 year old women is diagnosed with a 2.5cm fibroadenoma after

attending the breast clinic.
What is the most appropriate management?

A. Mastectomy and axillary node sampling

B. Neoadjuvant chemoradiotherapy
C. Reassurance
D. Simple excision
E. Tamoxifen

Answer: C

99. A 17 year old presents with highly mobile, discrete lump in the
outer aspect of her left breast.
What is the most likely diagnosis?
 A. Breast carcinoma
B. Ductal ectasia
C. Duct papilloma
D. Fibroadenoma
E. Phyllodes tumor

Answer: D

100. A 28 year old women with documented gallstones presents with

acute pancreatitis, amylase 900 U/L, and cotemporary MRCP confirms
normal ductal anatomy. Her liver function has normalized by day 2.
She is clinically stable now. What best treatment modality you want to
choose for her?

A. Continue antibiotics
B. ERCP
C.Lap Cholecystectomy
D MRCP
E. Ultrasound

Answer: C