Surgery-I Review NASIR HUSSAIN

1-SCQs:
1. Which one of the following is most likely to be a remote or paraneoplastic effect
of a primary adenocarcinoma of the lung ? (A)
A. Finger clubbing*
B. Dilation of the right pupil
C. Hoarseness
D. Impaired tandem walking
E. Seizures
2. A 69 year old man coughs up blood and comes to the Emergency Room.On
examination he is noted to have a ruddy, plethoric face. The retinal veins are
distended and he has dilated veins over the shoulders and upper chest. On
examination of the chest, he has no rales and no cardiac gallop. Which of the
following is least likely to be found on further evaluation of the patient ? (D)
A. A mediastinal mass on chest x-ray
B. Jugular venous distention
C. Swelling of his fingers and inability to take off his wedding band
D. Swelling of the ankles and distal legs*
E. A history of smoking 2 packages of cigarettes daily since age 18 years.
3. Which of the following is least likely to be found in flail chest? (A)
A. Hoarseness*
B. Tenderness
C. Deformity
D. Abnormal breathing exercises
E. Crepitus
4. Principles for the treatment of chronic pyothorax：(E)
A. Improve the general condition, eliminate symptoms and malnutrition
B. Improved drainage
C. Eliminate the causes and the pus cavity
D. Pulmonary function recovery
E. All of the above*
5. In acute pyothorax, methods of eliminating pus include the following except for:
(D)
A. Repeated pleural puncture to pump pus
B. Closed chest drainage
C. The rib bed chest closed drainage
D. Open drainage*
E. By thoracoscope to remove pus
6. in The pathological and physiological changes of tension pneumothorax, which
of the following is wrong：(B)
A. Large deep lung laceration, flapper fissure formation
B. Mediastinal swinging*
C. Severe respiratory and circulatory disorders
D. Severe subcutaneous emphysema formation
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E． The injured side and contralateral lung were severely squeezed
7. Thoracic trauma, can consider the application of respirator assisted positive
pressure breathing is: (A)
A. Multiple rib fracture*
B. Pressure pneumothorax
C. Progressive hemothorax
D. Cardiac tamponade
E. Closed pneumothorax
8. Correct statements regarding rectal carcinoid tumors include (D)
A. Endoscopic resection is sufficient for tumors smaller than 2 cm
B. Patients frequently present with the carcinoid syndrome
C. They are rapidly growing tumors
D. Local recurrence is rare with complete resection of the primary lesion*
E. They can develop the carcinoid syndrome even in the absence of liver metastases
9. A 35-year-old woman undergoes her first screening mammogram. Which of the
following mammographic findings would require a breast biopsy? (E)
A. Breast calcifications larger than 2 mm in diameter
B. Five or more clustered breast microcalcifications per square centimeter
C. A density that effaces with compression
D. Saucer-shaped microcalcifications
E. Multiple round well-circumscribed breast densities*
Q-10. When galactorrhea occurs in a high school student, a diagnostic associated
finding would be (B)
A. Gonadal atrophy
B. Bitemporal hemianopia*
C. Exophthalmos and lid lag
D. Episodic hypertension
E. “Buffalo hump”
11. Which of the following statements regarding split-skin grafts are true? (E)
A. Split-skin grafts can be cut at varying thicknesses using handheld or electrical
dermatomes
B. The best donor site for getting a split-skin graft in children or females is the
thigh
C. Other useful donor sites for split-skin grafts are the buttocks and the scalp
D. The size and number of bleeding points in the donor tissue for split-skin grafts
do not identify the thickness of the graft
E. The take of a split-skin graft is affected by a number of factors,including the presence
of group A beta-haemolytic Streptococcus*

12. Which of the following statements regarding triage are true? (A)
A. Triage means treating the most seriously injured first*
B. Triage is carried out where the casualties are found
C. Triage is carried out at the same time as simple emergency life-saving procedures
D. Triage does not mean that a patient’s triage category cannot be reviewed
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E. Triage is best recorded with an appropriately coloured label attached to the
patient.
13. Which of the following statements regarding blast injuries are true? (A)
A. Casualties hidden behind walls or other obstructions are protected from blast
Injury*
B. Blasts mainly affect fluid-filled cavities in the body
C. Penetrating wounds from fragments are deep and their borders difficult to define
D. Contamination of a wound is not an issue as the heat sterilises any fragments
E. Patients are usually deaf so communication is a problem
14. Which of the following statements regarding tetanus are true? (C)
A. It is caused by the organism Clostridium perfringens
B. It causes damage by releasing an exotoxin
C. It thrives in anaerobic conditions*
D. The spores are found in soil
E. Heavily contaminated wounds require anti-tetanus globulin as well as tetanus toxoid
F. Penicillin V is ineffective against the organism
G. Patients developing tetanus can be managed using sedation and do not require
paralysing and ventilating
15. A 67 years old female is referred for consideration of total parenteral nutrition
(TPN) following a total colostomy. Which of the following biochemical and clinical
markers are suggestive of malnutrition? (B)
A. Albumin
B. Urea*
C. Transthyretin
D. Skin fold thickness
E. Weight loss
16. A 30-year-old man presents to the emergency department following a high
speed motor vehicle accident. His blood pressure is 70/50 mmHg with a strongly
positive FAST (focused abdominal sonography for trauma). His chest X-ray shows a
widened mediastinum. The most appropriate method to assess the widened
mediastinum in this patient is: (C)
A. aortogram
B. CT angiogram of the chest
C. repeat chest X-ray*
D. intraoperative TOE (transoesophageal echocardiography)
E. transthoracic echocardiography
17. Blunt liver trauma can be treated non surgically if (B)
A. No peritoneal signs
B. Low Grade injury on CT scan*
C. Severe COPD
D. Haemodynamically stable
E. US confirms <500mls peritoneal fluid collection
18. A multi-trauma patient opens his eyes and withdraws to painful stimuli, but
does not respond to voice. He is moaning but makes no comprehensible sounds.
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His Glasgow Coma Score is: (D)
A. 5
B. 6
C. 7
D. 8*
E. 9
19. All of the following are principles of antibiotic prophylaxis to prevent surgical
site infection EXCEPT (D)
A. Administer intravenous (IV) antibiotics within 1 hour of incision time
B. Select an antibiotic with a spectrum of activity against pathogens likely to be
encountered during surgery
C. Discontinue antibiotics 48 hours postoperatively
D. Intraoperatively re-dose cephalosporin prophylactic antibiotics every 2 half-lives
for long procedures*
20. Which of the following about blood transfusion are false? (D)
A. A haemoglobin level of 10 g/dL or less is now considered a typical indication
B. Fresh frozen plasma (FFP) is considered as the first-line therapy in
coagulopathic haemorrhage
C. Cryoprecipitate is useful in low fibrinogen states and in factor VIII deficiency
D. Platelets have a shelf life of 5 days*
E. Patients can pre-donate blood up to 3 weeks before surgery for autologous
transfusion.
21. Which of the following are true with regard to spread of gastric cancer? (B)
A. Tumour reaching the serosa usually indicates incurability
B. Blood-borne metastases commonly occur in the absence of lymph node spread*
C. Krukenberg’s tumours are always associated with other areas of transcoelomic spread
D. Sister Joseph’s nodule is diagnostic of gastric cancer
E. The lymphatic vessels related to the cardia have no relation to the oesophageal
lymphatics
22. What is the most common serious complication of an end colostomy? (C)
A. Bleeding
B. Skin breakdown
C. Parastomal hernia*
D. Colonic perforation during irrigation
E. Stomal prolapsed
23.Which of the following statements is true regarding the effects of colon
resection? (B)
A. Net absorption of water by the rectum has been demonstrated in humans
B. Patients who undergo major colon resections suffer little change in their bowel habits
following operation*
C. The left colon is better adapted for water absorption than the right colon
D. The right colon is better adapted for electrolyte absorption than the left colon
E. The role of the ileocecal valve in normal fluid homeostasis is well established

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24. Correct statements regarding rectal carcinoid tumors include (D)
A. Endoscopic resection is sufficient for tumors smaller than 2 cm
B. Patients frequently present with the carcinoid syndrome
C. They are rapidly growing tumors
D. Local recurrence is rare with complete resection of the primary lesion*
E. They can develop the carcinoid syndrome even in the absence of liver metastases

25. A 35 years old woman undergoes her first screening mammogram. Which of
the following mammographic findings would require a breast biopsy? (E)
A. Breast calcifications larger than 2 mm in diameter
B. Five or more clustered breast microcalcifications per square centimeter
C. A density that effaces with compression
D. Saucer-shaped microcalcifications
E. Multiple round well-circumscribed breast densities*
26.When galactorrhea occurs in a high school student, a diagnostic associated
finding would be (B)
A. Gonadal atrophy
B. Bitemporal hemianopia*
C. Exophthalmos and lid lag
D. Episodic hypertension
E. “Buffalo hump”
27.Incisional biopsy of a breast mass in a 35-year-old woman demonstrates a
hypercellular fibroadenoma (cystosarcoma phylloides) at the time of frozen
section.Appropriate management of this lesion could include (A)
A. Wide local excision with a rim of normal tissue*
B. Lumpectomy and axillary lymphadenectomy
C. Modified radical mastectomy
D. Excision and postoperative radiotherapy
E. Excision, postoperative radiotherapy, and systemic chemotherapy
28. A man who smokes cigarettes has an increased incidence of all of the following
cancers in comparison to a man who never smoked except which one ? (D)
A. Small cell carcinoma of the lung
B. Squamous cell cancer of the larynx
C. Transitional cell cancer of the bladder
D. Adenocarcinoma of the prostate*
E. Squamous cell cancer of the lung
Q-29. Which one of the following statements is wrong ? (E)
A. Cigar smoking is associated with health risks*
B. Industrial exposure to some chemicals is associated with an increased risk of lung
cancer*
C. Asbestos exposure and cigarette smoking act synergistically to increase the risk of
lung cancer*
D. Inhaled radiation is associated with an increased risk of lung cancer*
E. Passive exposure to cigarette smoke has no health risks*
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30.Which one of the following statements about small cell carcinoma of the lung is
correct ? (A)
A. The etiological factors differ from those of non-small cell lung cancer*
B. Surgical resection is an important component of therapy
C. Impairment in tandem walking and finger to nose touching may indicate a
paraneoplastic (remote) effect of cancer
D. Chemotherapy is not a component of therapy of patients with small cell lung cancer
E. Most patients die of complications due to growth of tumor at the primary site in the
lung
31.You are asked to see a 65 years old unconscious patient in A&E. He was brought
in by ambulance. He looks pale and his peripheries are cold and clammy. On
examination his pulse rate is 60 bpm, BP 70/45 and saturations are 96% on 4 L of
oxygen. His Central Venous Pressure (CVP) is raised ( 14 cm of H2O). The most
likely diagnosis is: (B)
Please select one of the following:
A. Septic shock
B. Cardiogenic shock*
C. Anaphylactic shock
D. Hypovolemic shock
32.Regarding penetrating neck trauma, which one of the following is NOT a soft
sign? (A)
Please select one of the following:
A. Expansile hematoma*
B. Dysphonia
C. Dysphagia
D. Minimal hemoptysis or hematemesis
E. Dyspnoea
33.Which of the following is the best guide to fluid replacement in a burns
patient? (B)
A. Haemoglobin and haematocrit
B. Urine output*
C. Urine osmolality
D. Plasma volume
E. Specific gravity
34.Please use the Parkland formula to calculate the appropriate fluid
requirements for a patient who is 50 kg with a 40% full thickness BSA burn, which
occurred 4 hours ago. (A)
A. Ringer’s Lactate 500cc/hr x 8 hours then 250cc/hr x 16 hours*
B. Ringer’s Lactate 250cc/hr x 4 hours then 125cc/hr x 16 hours
C. Ringer’s Lactate 1000cc/hr x 4 hours then 250cc/hr x 16 hours
D. Ringer’s Lactate 250cc/hr x 16 hours then 125cc/hr x 8 hours
35. A 67 years old female is referred for consideration of total parenteral nutrition
(TPN) following a total colostomy. Which of the following biochemical and clinical
markers are suggestive of malnutrition? (B)
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A. Albumin
B. Urea*
C. Transthyretin
D. Skin fold thickness
E. Weight loss
36. A 30 years old man presents to the emergency department following a high
speed motor vehicle accident. His blood pressure is 70/50 mmHg with a strongly
positive FAST (focused abdominal sonography for trauma). His chest X-ray shows a
widened mediastinum. The most appropriate method to assess the widened
mediastinum in this patientis (C)
A. Aortogram
B. CT angiogram of the chest
C. Repeat chest X-ray*
D. Intraoperative TOE (transoesophageal echocardiography)
E. Transthoracic echocardiography
37. Blunt liver trauma can be treated non surgically if: (B)
A. No peritoneal signs
B. Low Grade injury on CT scan*
C. Severe COPD
D. Haemodynamically stable
E. US confirms <500mls peritoneal fluid collection
38. A multi-trauma patient opens his eyes and withdraws to painful stimuli, but
does not respond to voice. He is moaning but makes no comprehensible sounds.
His Glasgow Coma Score is: (D)
A. 5
B. 6
C. 7
D. 8*
E. 9
39. All of the following are principles of antibiotic prophylaxis to prevent surgical
site infection EXCEPT: (D)
A. Administer intravenous (IV) antibiotics within 1 hour of incision time
B. Select an antibiotic with a spectrum of activity against pathogens likely to be
encountered during surgery
C. Discontinue antibiotics 48 hours postoperatively
D. Intraoperatively re-dose cephalosporin prophylactic antibiotics every 2 half-lives for
long procedures*
40. Which of the following about blood transfusion are false? (D)
A. A haemoglobin level of 10 g/dL or less is now considered a typical indication
B. Fresh frozen plasma (FFP) is considered as the first-line therapy in coagulopathic
haemorrhage
C. Cryoprecipitate is useful in low fibrinogen states and in factor VIII
deficiency
D. Platelets have a shelf life of 5 days*
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(E) Patients can pre-donate blood up to 3 weeks before surgery for autologous

2-Matching Questions:
(A) Haemolytic transfusion reaction due to incompatibility.....4
(B) Fluid overload............................................................................……..3
(C) Disseminated intravascular coagulation (DIC)..................…..2
(D) Hypocalcaemia........................................................................………..1
(E) Infection.....................................................................................………..5

Choose and match the correct diagnosis with each of the scenarios given below:
1. A 38-year-old man requires several units of blood transfusion due to multiple injuries
sustained as a result of a fall. He develops tetany and complains of cicumoral tingling.

2. A 34-year-old motorcyclist sustains multiple injuries after an RTA. He is brought to the

hospital in severe shock and requires multiple blood transfusions. It is observed that the
bleeding is still uncontrolled and the blood fails to clot.

3. A 86-year-old woman is admitted with a haemoglobin (Hb) of 5.6 g/dL. The HO

prescribes 4 units of blood. These 4 units are transfused over a period of 6 h. Four hours
later the patient is found to be having difficulty in breathing. Chest examination reveals
fine creps bilaterally. Chest X-ray confirms pulmonary oedema.

4. The ward is very busy and quite a few staff have phoned in sick. There are two
patients (with the same surnames) needing blood transfusions. The staff nurse points to
the blood units on the table and asks the HCA to start them as she is just going off for her
break. The blood transfusion is started. Within a few minutes the patient is unwell and
his urine is haemorrhagic. He collapses and becomes anuric. He is also found to be
jaundiced.

5. A 28 years old male is taken to a nearby hospital after sustaining injuries while on a
safari in Africa. He has lost a lot of blood and is hence given 2 units of blood transfusion.
He develops fever and chills with rigors the next day. Peripheral blood smear
demonstrates malarial parasite.

3-Definitions:
1.Acepsis:
Absence of microorganisms that cause disease; freedom of infection,is called acepsis.

2.Glasgow coma scale:

The Glasgow Coma Scale (GCS) is used to describe the general level of consciousness
in patients with traumatic brain injury (TBI) and to define broad categories of
headinjury.The GCS is divided into 3 categories, eye opening (E), motor response (M),
and verbal response (V). → GCS score = E + M + V.
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3.SIRS:
SIRS (Systemic Inflammatory Response Syndrome) is the body's response to an
infectious or noninfectious insult. Although the definition of SIRS refers to it as an
"inflammatory" response, it actually has pro- and anti-inflammatory components.

4.Surgucal infection:
Surgical infection: Is infection that occurs to the surgical wound/site within 30 days of
the surgical operation. Typical signs include: delayed healing, discoloration of tissues,
abnormal smell, bleeding,lymphangitis.

5.Perioperative treatment:
Perioperative generally refers to the 3 phases of surgery: preoperative,intraoperative,
and postoperative. The goal of perioperative care is to provide bett care for patients at
this 3 phase.

6.Metabolic acidosis
Metabolic acidosis occurs when the body produces too much acid and the pH becomes
less than 7.5 i.e;(pH<7.5).

7.Parkland formula:
The Parkland formula is a burn formula used to estimate the amount of replacement
fluid required for the first 24 hours in a burn patient so as to ensure they remain
hemodynamically stable.The Parkland formula is mathematically expressed as:
→ V = 4 x m x (A x 100).

8.Shock:
A syndrome that results from inadequate perfusion of tissues.
-Insufficient to meet metabolic demand.
-Lead to cellular dysfunction, elaboration of inflammatory mediators, and celluar injury
which may be limited, or widespread.

9.Epidural hematoma:
Epidural hematoma or epidural bleeding, is a type of traumatic brain injury (TBI) in
which a buildup of blood occurs between the dura mater (the tough outer membrane of
the CNS) and the skull. Around 15–20% of epidural hematoma are fatal.

10.Hyperkalemia:
When excessive potassium (>5.5mmol/L) enters into blood circulation,the condition is
called hyperkalemia.
11.Tumor:
A tumor is as a neoplasm lead to an abnormal mass of tissue which may be solid or
fluid-filled that possesses no physiological function and arises from uncontrolled usually
rapid cellular proliferation.
 There are to types of tumor; benign and malignant.
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4-Short Questions:
1.What is SIRS?
It is the body's response to an infectious or noninfectious insult. Although the definition of
SIRS refers to it as an "inflammatory" response, it actually has pro- and anti-inflammatory
components.
-Clinically, the Systemic Inflammatory Response Syndrome (SIRS) is the occurrence of at
least two of the following criteria: fever >38.0°C or hypothermia <36.0°C, tachycardia >90
beats/minute, tachypnea >20 breaths/minute, leucocytosis >12x109/L or leucopoenia
<4x109/L.

2.What is hypovolemic shock? How to treat it?

Hypovolemic shock is a life-threatening condition that results when you lose more than 20
percent (one-fifth) of your body's blood or fluid supply. This severe fluid loss makes it
impossible for the heart to pump a sufficient amount of blood to your body.
Treatment:
-Elevate lower extremities 8-12 inches.
-Maintain body temperature.
-Provide rapid supportll.
-Start IV therapy.
-Apply Military anti-shock trousers (MAST) if needed.

3.What signs suggest continued bleeding within the pleural cavity after chest trauma?
-Progressive high pulse rate & low BP rate.
-BP can't maintain the normal level after infusion or transfusion
-Hemoglobin, RBC count & hematocrit to reduce
-No blood found by pleurocentesis because of blood clotting but chest X ray examination
shows increased pleural cavity shadow.
-Drainage volume exceed 200ml/h continuously for 3 hours after closing plural cavity
drainage.

4.The four common pathology types of lung cancer？

According to the arising position of tumor:
(1) Central type: Arise from main bronchus, lobar and segmented bronchus.
(2) Peripheral type: Arise from beyond segmental bronchus.
According to management principles:
(1) Small cell lung carcinoma (SCLC).
(2) Non small cell lung carcinoma (NSCLC).

5.Write short notes on aseptic technique.

Aseptic technique means using practices and procedures to prevent contamination from
pathogens.It involves applying the strictest rules to minimize the risk of infections.There
are 2 types of asepsis;medical asepsis and clinical asepsis.
Medical asepsis:
-Clean technique used.
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-Controls microorganisms.
-Basic hand hygiene used.
-Clean equipments and supplies.
-Clean field.
Surgical asepsis:
-Sterile technique used
-Absence of microorganisms
-Surgical scrub performed
-Sterile equipments and supplies
-Sterile field

6.What is hypovolemic shock? How to treat it?

Hypovolemic shock is a life-threatening condition that results when you lose more than 20
percent (one-fifth) of your body's blood or fluid supply. This severe fluid loss makes it
impossible for the heart to pump a sufficient amount of blood to your body.
Treatment:
-Elevate lower extremities 8-12 inches.
-Maintain body temperature.
-Provide rapid support.
-Start IV therapy.
-Apply Military anti-shock trousers (MAST) if needed.

7.Please list the Glasgow Coma Scale (GCS) with clinical parameter and scale.
Definition: The Glasgow Coma Scale (GCS) is used to describe the general level of
consciousness in patients with traumatic brain injury (TBI) and to define broad categories
of headinjury.
Clinical parameter and scale: The GCS is divided into 3 categories, eye opening (E), motor
response (M), and verbal response (V).The three values separately as well as their sum are
considered. The lowest possible GCS (graded 1 in each element) is 3 (deep coma or death),
while the highest is 15 (fully awake person).Mathematically:
→ GCS score = E + M + V.

8.Would you please briefly talk about the treatment of cancer?

Treatment of cancer:
(i) Surgery. (ii) Radiotherapy. (iii) Chemotherapy. (iv) Other treatment methods.

9.Please state the tumor TNM staging system?

The TNM system is the most widely used cancer staging system.The “N” refers to the the
number of nearby lymph nodes that have cancer. The “M” refers to whether the cancer has
metastasized. This means that the cancer has spread from the primary tumor to other
parts of the body

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5-Case:
A 52 years old woman presents with headaches and blurred vision ongoing for about 4
years.Recently, her headaches were getting worse and she want to see a neurologist.
What is yourdiagnoses and differential diagnoses ( at least 3 kinds of diseases) for the
woman? What examinations should you ordered to her? What therapy should you used?

Diagnosis: Pituitary adenoma.

Differential diagnosis: Meningeoma, Aneurysm , Craniopharyngioma, Angioreticuloma,
Dysembryoma,Germ cell tumor or Germinal tumor, Chordoblastoma, Chordocarcinoma
or chordoepithelioma.
Examinations: MRI or / and CT.
Therapy: Operation to remove the tumor, take some medicine , or radiotherapy.

2. Explain Surgrical trauma.

-Primary survey/resuscitation:Airway, Breathing,Circulation,Disability,Exposure and
Environment.
-Secondary survey:Complete physical exam, including all orifices: ears, nose, mouth,
vagina,rectum.
-Definitive care.

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