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DEPARTMENT OF SURGERY, HOSPITAL TAIPING

HOUSEMAN END OF POSTING EXAM
INSTRUCTIONS: 30 QUESTIONS, PLEASE CHOOSE THE BEST ANSWER FOR EACH QUESTION

1. You have a patient who is planned for emergency appendectomy. Her body weight is
50kg. She has been vomiting from the day before. Her BUSE results are:
Sodium 128 mmol/L
Potassium 2.7 mmol/L
Chloride 97mmol/L
Urea 9.1 mmol/L
The following fluid management is correct for her:
A. 2 litres of normal saline intravenous maintenance drip with 5g KCL added in
the drips per day
B. 2 litres of normal saline intravenous maintenance drip with 2g KCL added in the
drips per day
C. 1.5 litres of normal saline intravenous maintenance drip with 5g KCL added in the
drips per day
D. 1.5 litres of normal saline intravenous maintenance drip with 2g KCL added in the
drips per day
E. 1.5 litres of normal saline intravenous maintenance drip with 4g KCL added in the
drips per day

2. In 1 pint sodium chloride 0.9 %, there is

A. 0.9 g of sodium chloride
B. 9 g of sodium chloride
C. 0.45 g of sodium chloride
D. 4.5 g of sodium chloride
E. 9 mg of sodium chloride

3. Interpret the ABG

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pH 7.35
pCO2 50 mmHg
pO2 125 mmHg
SpO2 98%
HCO3 22 mmol/l
BE -5 mmol/l
A. Metabolic acidosis
B. Respiratory acidosis
C. Compensated metabolic acidosis with respiratory acidosis
D. Metabolic alkalosis
E. Respiratory alkalosis

4. A 28-year-old male was involved in a motor-vehicle accident in which he was the

motorcyclist, not wearing helmet. Upon arrival to Emergency & Trauma Department, he was
already in severe respiratory distress, cyanotic and hypotensive with blood pressure of 80/40
mmHg. He was bleeding profusely from the nose and had an obvious open femur fracture
with exposed bone. Breath sound were reduced on the right side of the chest. The initial
management priority should be:
A.Right chest tube insertion for pneumothorax
B. Control of haemorrhage with nasal packing.
C. Endotracheal intubation with in-line cervical traction.
D. Right lower limb traction to control haemorrhage

5. A patient presents post fall with a head injury. On arrival his eyes open to painful stimuli,
he is confused and withdraws to pain.
What is the GCS for the patient?
A. 7
B. 9
C. 10
D. 11

6. 42 year-old Malay male was brought to ED at 2AM, after he was involved in a house fire.
His wife and one child died during the incident. On examination, his GCS is E2V3M5 and
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noted to have 50% burns (mostly full thickness). Otherwise she is hemodynamically
unsupported. He weighs 80kg. How much fluid required to be given in the first 8 hours?
A. 8.4L
B. 8.0L
C. 1.6L
D. 16L
E. 800mL

7. A trauma victim comes with an open chest wound. What is your immediate course of
action?
A. Tracheostomy
B. Cricothyroidectomy
C. Orotracheal intubation
D. Close the wound with dressing
E. Perform CPR

8. A 35-year-old man is admitted after severing his arm on industrial machinery. His airway
is patent and there is no identifiable hindrance to breathing. His pulse is 110 beats/min, blood
pressure is 130/105 mmHg, and respiratory rate is 25 breaths/min. In which stage of shock
therefore is this patient?
A. Class I
B. Class II
C. Class III
D. Class IV
E. Impossible to say from given information

9. How much fluid should be given to an adult patient at the time of initial resuscitation
A. 500mL
B. 1000mL
C. 1500mL
D. 2000mL

10. Which of the following features suggest a complete large bowel obstruction?
I. Present of multiple loops of bowel with presence of valvulae conniventes
II. Dilated loops of bowel with haustra visible
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III. Distended abdomen with high pitch bowel sound

IV. Empty rectum on per rectal examination
V. Bilious vomitting
A. I only
B. II and III only
C. I,II and III only
D. I and IV only
E. All of above

11. How long does serum amylase remains elevated in acute pancreatitis?
A. Less than 24 hours
B. 1 to 3 days
C. 5 to 14 days
D. 2 to 4 weeks

12. The diagnosis of acute pancreatitis is based on :

A. Laboratory investigations (serum amylase > 3x upper limit of normal)
B. Imaging (USG or CT)
C. Clinical (typical epigastric pain, radiating to the back, relieved by leaning forward)
D. 2 out of 3 of the above options (A to C)
E. Only if all criteria (A to C) mentioned are met

13. A 47-year-old woman has 12h of progressive onset epigastric and upper abdominal pain
and rigors with temperatures up to 39.2°C. Her pulse is 102bpm, blood pressure is
110/70mmHg, and there is mild jaundice present. Which is the single most likely diagnosis?
A. Ascending cholangitis
B. Biliary colic
C. Acute cholecystitis
D. Empyema of the gallbladder
E. Hepatic failure

14. In obstructive jaundice, LFTs usually show

A. Elevated indirect bilirubin and ALP
B. Elevated indirect bilirubin and GGT
C. Elevated direct bilirubin and ALP
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D. Elevated direct bilirubin and ALT

E. Elevated direct bilirubin and AST

15. A 57 year old gentleman underwent an abdomino-perineal resection (APR) for a low
rectal cancer. On examination he has a stoma in his left iliac fossa (LIF), which is flushed
with the skin and there is no spout. The content in the stoma bag are well formed stools.
What type of stoma has this patient got?
A. Loop colostomy
B. End colostomy
C. Ileostomy
D. Urostomy
E. Mucous fistula

16. A 68-year-old man presents with a rectal tumour palpable at approximately at 10cm from
the anal verge. CT confirms this and the biopsy shows it to be a rectal adenocarcinoma. The
BEST surgical option would be:
A- Sigmoid colectomy
B- Abdominoperineal resection
C- Anterior resection
D- Left hemicolectomy

17. Which of the following most commonly associated with metastasis to contralateral
breast?
A. Paget disease
B. Invasive ductal carcinoma
C. Invasive lobular carcinoma
D. Phylloides tumour
E. Atypical ductal hyperplasia

18. A 55-year old lady underwent left sided modified radical mastectomy and level 2 axillary
clearance for breast cancer (without reconstruction). After the operation she was found to
have a winging of scapula. She is otherwise well. What is the most likely cause of this?
Please select one of the following:
A. Patient has suffered a TIA
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B. Damage to the thoracodorsal nerve during surgery

C. Damage to the long thoracic nerve during surgery
D. Damage to the serratus anterior muscle during surgery
E. Dislocated scapula

19. Which statement accurately corresponds to the Forrest classification

A. Forrest 1a: oozing ulcer
B. Forrest 1b: visible vessel
C. Forrest 2a: hematin base
D. Forrest 2b: Adherent clot

20. A 32-year-old man has a reducible, indirect inguinal hernia. The hernia can be held in
reduction by maintaining pressure over one particular location. Which single term most likely
describes this location?
A. Arcuate line
B. Deep inguinal ring
C. McBurney’s point
D. Mid-inguinal point
E. Superficial inguinal ring

21. The preferred surgical incision in simple open cholecystectomy for symptomatic
cholelithiasis is
A. Lanz
B. Gridiron
C. Kocher
D. Rutherford-morrisosn
E. Midline incision

22. A man is moving into a new house and during the process lifts a large chest of drawers.
As he lifts he feels a severe pain in the lower right quadrant of his abdomen. He finds that he
can no longer lift without pain and the next day goes to see his physician. Surgery is
indicated and during the surgery the surgeon opens the inguinal region and finds a hernial sac
with a small knuckle of intestine projecting through the abdominal wall just above the
inguinal ligament and lateral to the inferior epigastric vessels. The hernia was diagnosed as:
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A. A direct inguinal hernia

B. A femoral hernia
C. An incisional hernia
D. An indirect inguinal hernia

23. A 14 year-old male presents to the casualty with an acutely tender right scrotum. He was
playing football 2 hours ago, and was hit in the groin with the football. On examination, the
skin overlying the right scrotum appears grossly normal. The testis is palpable, in a transverse
lie, and is exquisitely painful. There is an absence of the cremasteric reflex. He is otherwise
well. What is the most appropriate management plan for him?
A. Doppler ultrasound of the testicular artery
B. Antibiotics and discharge
C. Antibiotics and observation in the ward
D. Immediate surgical exploration
E. Macroscopic and microscopic urinalysis

24. A 39-year-old woman was a pedestrian hit by a car while crossing the road. She
complains of chest and abdominal pains. On examination, her GCS score is 14/15 (E4, V4,
M6). Her vital observations are as follows: BP 86/32 mmHg; pulse 145/min. She has bruising
and tenderness over her lower left 9th and 10th ribs. She has rebound tenderness and
guarding over the left upper quadrant of her abdomen. Her chest X-ray demonstrates left rib
fractures affecting ribs 8–10.
A. Tension pneumothorax
B. Cardiac tamponade
C. Flail segments
D. Rupture spleen
E. Haemothorax
25. A 66 year old diabetic man sustained an unstable pelvic fracture after a fall from height.
He was initially treated with several weeks of bed rest. Upon transfer to a tertiary care centre,
examination of the sacral region revealed a 10x12cm area of full thickness skin loss with
exposed sacral bone. Which of the following stages of pressure bed sore best describes the
above ulcerated wound?
A. Stage 1
B. Stage 2
C. Stage 3
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D. Stage 4
E. Stage 5

26. A 9 year old girl was scalded by hot soup and is brought to ED by her parents. During
examination of the burn wound the girl remains calm and complains of no pain over the burn
site. The skin appears pale and does not blanch to pressure. The likely severity of her burn is

A. Superficial Burn
B. Partial Thickness Burn
C. Full Thickness Burn
D. Mixed Thickness Burn
E. Neuropathic Burn

27. A 27-year-old woman, 2 days post-thyroidectomy has numbness around her mouth and
pins and needles sensation in her fingers
A. Bilateral incomplete recurrent laryngeal nerve paralysis
B. Hypocalcemia
C. Tracheomalacia
D. Superior laryngeal nerve palsy
E. Unilateral complete recurrent laryngeal nerve palsy

28. Virchow’s node is described for the below lymph node:

A. Left axillary lymph node
B. Upper deep cervical lymph node
C. Left supraclavicular lymph node
D. Right inguinal lymph node
E. Mediastinal lymph node

29. 24 year old woman presented to district emergency department. Presented with lower
abdominal pain, distension, dysuria, vomiting or 3 days. Past surgical history of laparoscopic
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appendicectomy 10 years ago. Multiple admission for lower abdominal pain before. AXR
shows dilated small bowel of 3.5cm and urine FEME shows leucocyte 2+. What would you
do?
A. Admit, insert NG & observe at district hospital
B. Take urine C&S and Treat as UTI
C. Refer to tertiary hospital for intestinal obstruction
D. Get USG abdomen as outpatient
E. Discharge with reassurance and TCA cm with AXR

30. Helicobacter pylori is an organism which is a cause of peptic ulcer disease. Which of the
following oral regimen effectively eradicate H. pylori infection?
A. Ampicillin 1g BD, Clarithromycin 1g BD, Pantoprazole 80mg BD
B. Amoxycillin 500mg BD, Clarithromycin 1g BD, Pantoprazole 40mg BD
C. Augmentin 1g BD, Clarithromycin 500mg BD, Pantoprazole 40mg BD
D. Amoxycillin 1g BD, Clarithromycin 500mg BD, Pantoprazole 40mg BD
E. Ampicillin 1g BD, Clarithromycin 500mg BD, Pantoprazole 20mg BD

1. A
2. D
3. B
4. C
5. C
6. B
7. D
8. B
9. B
10. B
11. B
12. D
13. A
14. C
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15. B
16. C
17. C
18. C
19. D
20. B
21. C
22. D
23. D
24. D
25. D
26. C
27. B
28. C
29. C
30. D