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SURGERY MCQS AND EMQS

                         by
                   R. W. Parks
               MD, FRCSI, FRCS (Ed)
   Senior Lecturer/Honorary Consultant Surgeon
Department of Clinical and Surgical Sciences (Surgery)
              University of Edinburgh


                   T. Diamond
                BSc, MD, FRCS, FRCSI
                Consultant Surgeon
                  Mater Hospital
                      Belfast




              London o San Francisco
www.greenwich-medical.co.uk



                                           © 2003

                             Greenwich Medical Media Limited
                                 137 Euston Road, London
                                        NW1 2AA

                                 870 Market Street, Ste 720
                                  San Francisco, CA 94102

                                      ISBN 1841101869

                                    First Published 2003

While the advice and information in this book is believed to be true and accurate, neither
the authors nor the publisher can accept any legal responsibility or liability for any loss or
damage arising from actions or decisions based in this book. The ultimate responsibility for
the treatment of patients and the interpretation lies with the medical practitioner. The
opinions expressed are those of the authors and the inclusion in this book of information
relating to a particular product, method or technique does not amount to an endorsement
of its value or quality, or of the claims made by its manufacturer. Every effort has been
made to check drug dosages; however, it is still possible that errors have occurred.
Furthermore, dosage schedules are constantly being revised and new side-effects recognised.
For these reasons, the medical practitioner is strongly urged to consult the drug companies'
printed instructions before administering any of the drugs mentioned in this book.

Apart from any fair dealing for the purposes of research or private study, or criticism or
review, as permitted under the UK Copyright Designs and Patents Act 1988, this publication
may not be reproduced, stored, or transmitted, in any form or by any means, without the
prior permission in writing of the publishers, or in the case of reprographic reproduction
only in accordance with the terms of the licences issued by the appropriate Reproduction
Rights Organisations outside the UK. Enquiries concerning reproduction outside the terms
stated here should be sent to the publishers at the London address printed above.

The rights of R. W. Parks and T. Diamond to be identified as authors of this Work have been
asserted by them in accordance with the Copyright Designs and Patents Act 1988.

The publisher makes no representation, express or implied, with regard to the accuracy of
the information contained in this book and cannot accept any legal responsibility or
liability for any errors or omissions that may be made.

           A catalogue record for this book is available from the British Library.

                   Typeset by Mizpah Publishing Services, Chennai, India
                            Printed by Bell & Bain Ltd, Glasgow

                       Distributed by Plymbridge Distributors Ltd and
                              in the USA by JAMCO Distribution
Contents

Preface ........................................................................................................viii
List of Abbreviations ....................................................................................ix

Section 1 – Multiple Choice Questions (MCQs)
Preoperative Management – Questions ......................................................3
Principles of Anaesthesia – Questions ..........................................................6
Postoperative Management – Questions......................................................8
Nutritional Support – Questions ................................................................10
Surgical Sepsis: Prevention & Therapy – Questions....................................12
Surgical Techniques & Technology – Questions..........................................14
Trauma: General Principles of Management – Questions ........................16
Intensive Care – Questions ..........................................................................19
Principles of Cancer Management – Questions..........................................21
Ethics, Legal Aspects & Assessment of Effectiveness – Questions ............24
Haemopoietic & Lymphoreticular Systems – Questions ............................25
Alimentary System – Questions ..................................................................26
Vascular Surgery – Questions ......................................................................33
Endocrine Surgery – Questions....................................................................35
Breast – Questions........................................................................................39
Thoracic Surgery – Questions ......................................................................42
Genitourinary System – Questions ..............................................................44
Head & Neck – Questions ............................................................................46
Central Nervous System – Questions ..........................................................48
Musculoskeletal System – Questions ..........................................................50
Paediatric Surgery – Questions....................................................................52
Preoperative Management – Answers........................................................55
Principles of Anaesthesia – Answers ..........................................................58
Postoperative Management – Answers ......................................................60
Nutritional Support – Answers ....................................................................64
Surgical Sepsis: Prevention & Therapy – Answers ......................................66




                                                                                                                       v
Surgical Techniques & Technology – Answers ............................................70
     Trauma: General Principles of Management – Answers ............................74
     Intensive Care – Answers ............................................................................79
     Principles of Cancer Management – Answers ............................................82
     Ethics, Legal Aspects & Assessment of Effectiveness – Answers ................86
     Haemopoietic & Lymphoreticular Systems – Answers................................87
     Alimentary System – Answers......................................................................89
     Vascular Surgery – Answers ........................................................................99
     Endocrine Surgery – Answers ....................................................................101
     Breast – Answers ........................................................................................108
     Thoracic Surgery – Answers ......................................................................112
     Genitourinary System – Answers ..............................................................114
     Head & Neck – Answers ............................................................................118
     Central Nervous System – Answers ..........................................................121
     Musculoskeletal System – Answers ..........................................................123
     Paediatric Surgery – Answers ....................................................................125

     Section 2 – Extended Matching Questions (EMQs)
     Classification of Fitness for Surgery ..........................................................131
     Preoperative Prophylactic Measures ........................................................132
     Discontinuation of Drug Treatment Prior to Surgery ..............................133
     Appropriate Anaesthetic Techniques........................................................134
     Blood Transfusion ......................................................................................135
     Anaesthesia/Analgesia ..............................................................................136
     Classification of Surgical Wounds ............................................................138
     Wound Closure ..........................................................................................139
     Head Injury ................................................................................................140
     Sepsis ..........................................................................................................141
     Clinical Research ........................................................................................142
     Auto-immune Disease................................................................................143
     Intestinal Obstruction ................................................................................144
     Investigations ............................................................................................146
     Perianal Conditions ....................................................................................147
     Causes of Chronic Arterial Disease............................................................148
     Acute Arterial Disease................................................................................149
     Management of Vascular Disease ............................................................150
     Breast Disease ............................................................................................151
     Management of Chest Trauma..................................................................152
     Chest X-ray Findings ..................................................................................153
     Scrotal Swellings ........................................................................................154
     Treatment of Scrotal Swellings..................................................................155



vi
Presentation of Urological Pathology ......................................................156
Head & Neck Swellings ..............................................................................157
Depressed Level of Consciousness ............................................................158
Fracture Complications ..............................................................................160
Neonatal & Childhood Intestinal Obstruction..........................................161
Paediatric Emergencies ..............................................................................162




                                                                                                           vii
Section 1
                    Multiple Choice
                   Questions (MCQs)
Preoperative Management – Questions ......................................................3
Principles of Anaesthesia – Questions ..........................................................6
Postoperative Management – Questions......................................................8
Nutritional Support – Questions ................................................................10
Surgical Sepsis: Prevention & Therapy – Questions....................................12
Surgical Techniques & Technology – Questions..........................................14
Trauma: General Principles of Management – Questions ........................16
Intensive Care – Questions ..........................................................................19
Principles of Cancer Management – Questions..........................................21
Ethics, Legal Aspects & Assessment of Effectiveness – Questions ............24
Haemopoietic & Lymphoreticular Systems – Questions ............................25
Alimentary System – Questions ..................................................................26
Vascular Surgery – Questions ......................................................................33
Endocrine Surgery – Questions....................................................................35
Breast – Questions........................................................................................39
Thoracic Surgery – Questions ......................................................................42
Genitourinary System – Questions ..............................................................44
Head & Neck – Questions ............................................................................46
Central Nervous System – Questions ..........................................................48
Musculoskeletal System – Questions ..........................................................50
Paediatric Surgery – Questions....................................................................52
Preoperative Management – Answers........................................................55
Principles of Anaesthesia – Answers ..........................................................58
Postoperative Management – Answers ......................................................60
Nutritional Support – Answers ....................................................................64
Surgical Sepsis: Prevention & Therapy – Answers ......................................66
Surgical Techniques & Technology – Answers ............................................70
Trauma: General Principles of Management – Answers ............................74
Intensive Care – Answers ............................................................................79
Principles of Cancer Management – Answers ............................................82
Ethics, Legal Aspects & Assessment of Effectiveness – Answers ................86
Haemopoietic & Lymphoreticular Systems – Answers................................87
Alimentary System – Answers......................................................................89
Vascular Surgery – Answers ........................................................................99
Endocrine Surgery – Answers ....................................................................101
Breast – Answers ........................................................................................108
Thoracic Surgery – Answers ......................................................................112
Genitourinary System – Answers ..............................................................114
Head & Neck – Answers ............................................................................118
Central Nervous System – Answers ..........................................................121
Musculoskeletal System – Answers ..........................................................123
Paediatric Surgery – Answers ....................................................................125
Preoperative
                                                   Questions
        Management

Q 1.   The American Society of Anesthesiologists (ASA)
       classification of fitness of patients for surgery includes
       the following

       A. ASA 1 where there is no organic, physiological, biochemical
          or psychiatric disturbance
       B. ASA 3 where there is mild to moderate systemic disturbance
          which does not limit normal activity
       C. ASA 4 where there are severe life-threatening systemic
          disorders
       D. ASA 5 where the patient is moribund with little chance of
          recovery
       E. ASA E where the letter E after a particular classification
          denotes an emergency operation


Q 2.   Concerning the risk of myocardial infarction during or
       following surgery

       A. Infarction 3 months prior to surgery increases the risk by 30%
       B. Infarction 6 months prior to surgery increases the risk by 6%
       C. The risk is 5–10% when there is no previous history of
          infarction
       D. Elective surgery should not be performed within 6 months of
          a myocardial infarction
       E. Gastrointestinal endoscopy should not be performed within
          6 months of a myocardial infarction


Q 3.   Hypertension

       A. Is defined by the World Health Organisation as a systolic
          blood pressure 160 mmHg and/or a diastolic blood pressure
             105 mmHg
       B. Is present in approximately 25% of adult patients
       C. Is a contraindication to elective surgery if the diastolic
          pressure exceeds 115 mmHg

MCQs    Surgery MCQs and EMQs                                              3
D. Should be treated with intravenous beta-blockers or glyceryl
                                    trinitrate if emergency surgery is necessary
                                 E. Treatment should be discontinued 2 weeks before elective
                                    surgery
Preoperative Management




                          Q 4.   The following drugs should be discontinued prior to
                                 surgery

                                 A.   Prednisolone
                                 B.   Progesterone-only oral contraceptive pill
                                 C.   Aspirin
                                 D.   Propranolol
                                 E.   Warfarin


                          Q 5.   The following investigations are appropriate prior to
                                 surgery

                                 A. An ECG in all patients 30 years
                                 B. A chest X-ray on all patients 40 years
Questions




                                 C. A biochemical screen (block) on all patients 30 years
                                    undergoing major surgery
                                 D. A haematocrit on all female patients
                                 E. A coagulation screen in all patients with obstructive
                                    jaundice


                          Q 6.   In a diabetic patient undergoing surgery

                                 A. The dose of depot insulin should be halved on the day prior to
                                    surgery and supplemented with soluble insulin later in the day
                                 B. Half the morning dose of insulin should be given on the day
                                    of surgery
                                 C. An intravenous infusion of 5% dextrose is erected on the
                                    morning of surgery
                                 D. Insulin requirements may increase after major surgery
                                 E. The majority of diabetic patients undergoing surgery have
                                    insulin-dependent (Type I) diabetes


                          Q 7.   The following statements concerning prophylaxis of
                                 thrombo-embolic disease are true
                                 A. An appropriate regimen involves enoxaparin 20 mg bd, given
                                    subcutaneously

4                         MCQs    Surgery MCQs and EMQs
B. Clinically significant thromboembolism occurs in
          approximately 1% of patients undergoing major surgery
       C. Mechanical measures contribute significantly to reduce the
          incidence of thromboembolism




                                                                          Preoperative Management
       D. Dextran 70 is widely used to reduce the incidence of
          postoperative deep vein thrombosis
       E. Age 35 years, obesity and malignancy are all significant risk
          factors for the development of deep vein thrombosis




                                                                           Questions




MCQs    Surgery MCQs and EMQs                                                                       5
Principles of
                                                      Questions
            Anaesthesia

    Q 1.   The following are intravenous induction anaesthetic
           agents

           A.   Propofol
           B.   Etomidate
           C.   Sevoflurane
           D.   Thiopentone
           E.   Halothane


    Q 2.   The following are depolarising neuromuscular blocking
           drugs

           A.   Suxamethonium
           B.   Atracurium
           C.   Vecuronium
           D.   Pancuronium
           E.   Atracurium


    Q 3.   The following statements concerning opioid analgesics
           are true

           A. Morphine is a synthetic alkaloid
           B. Morphine may be administered orally, intravenously,
              intramuscularly, subcutaneously and via the epidural
              (neuraxial) route
           C. Papavertum contains a mixture of morphine, pethidine and
              papaverine
           D. Fentanyl is a synthetic derivative of morphine
           E. Fentanyl causes significant cardiovascular instability


    Q 4.   The following are correct contents of common crystalloid
           solutions

           A. NaCl 0.9% contains 154 mmol of sodium per litre
           B. NaCl 0.9% contains 72 mmol of chloride per litre


6   MCQs    Surgery MCQs and EMQs
C. Glucose 5% contains 20 mmol of potassium per litre
       D. Hartmann’s contains 40 mmol of potassium per litre
       E. Hartmann’s contains 150 kCal per litre




                                                                          Principles of Anaesthesia
Q 5.   The following are significant advantages of regional
       anaesthesia

       A.   Avoidance of unconsciousness
       B.   Absence of respiratory depression
       C.   Sympathetic blockade
       D.   Blockade of motor function
       E.   Avoidance of Hypotension


Q 6.   Local anaesthesia

       A. Only affects sensory nerve fibres
       B. Is very effective for incision and drainage of cutaneous
          abscesses
       C. Must be injected into the tissues to become effective
       D. In high doses can cause convulsions and bradycardia




                                                                           Questions
       E. May not be used in the region of an end-artery


Q 7.   In general anaesthesia

       A. Pulse oximetry is used routinely to record the heart rate and
          oxygen saturation
       B. Patients require mechanical ventilation for the operative
          period
       C. Preoperative starvation ensures that the stomach is empty
       D. Bradycardia is treated with neostigmine
       E. Opioids do not cause direct myocardial depression




MCQs    Surgery MCQs and EMQs                                                                         7
Postoperative
                                                        Questions
           Management

    Q 1.   Complications of blood transfusion are

           A.   Urticaria
           B.   Hypokalaemia
           C.   Hepatitis C
           D.   ARDS
           E.   Jaundice


    Q 2.   Atelectasis

           A.   May impair gas exchange
           B.   May predispose to chest infection
           C.   Can be prevented by prophylactic treatment with antibiotics
           D.   Is a common cause of an early postoperative fever
           E.   May necessitate fibreoptic bronchoscopy to extract mucus
                plugs


    Q 3.   Postoperative fluid management of the surgical patient
           should

           A. Include administration of 40–60 mmol of potassium in the
              first 24 h
           B. Account for insensible losses of up to 1500 ml if the patient is
              septic
           C. Include packed red blood cells if the haematocrit falls below
              40%
           D. Aim to provide at least 1000 calories for the first three
              postoperative days
           E. Be increased if the central venous pressure falls below 8 cm
              H2O


    Q 4.   With regard to postoperative complications

           A. The most common site of intra-abdominal abscess formation
              is in the pelvis

8   MCQs    Surgery MCQs and EMQs
B. Secondary haemorrhage is often associated with diffuse
          bleeding from an infected operative site
       C. Hypotension is the earliest sign of hypovolaemia




                                                                         Postoperative Management
       D. The risk of deep venous thrombosis and pulmonary embolism
          is increased with malignancy
       E. Acute tubular necrosis due to inadequate renal perfusion is
          irreversible


Q 5.   Following major abdominal surgery

       A. Epidural anaesthesia often masks the clinical signs of post-
          operative secondary haemorrhage
       B. Insertion of a nasogastric tube prevents intestinal ileus
       C. Swinging pyrexia and diarrhoea are characteristic clinical
          features of a pelvic abscess
       D. Open drainage reduces the risk of septic complications
       E. Subcutaneous heparin administration reduces the incidence
          of deep venous thrombosis




                                                                          Questions
Q 6.   Postoperative pyrexia may occur secondary to

       A.   Subphrenic abscess
       B.   Deep venous thrombosis
       C.   Urinary tract infection
       D.   Atelectasis
       E.   Blood transfusion


Q 7.   The following are well-recognised specific postoperative
       complications
       A. Renal failure in jaundiced patients
       B. Deep venous thrombosis after varicose vein surgery
       C. Hyperglycaemia, high lactate levels and a prolonged
          prothrombin time following liver resection for colorectal
          metastases
       D. Positive Chvostek’s sign after thyroid lobectomy
       E. Urinary incontinence following inguinal hernia repair




MCQs    Surgery MCQs and EMQs                                                                       9
Nutritional
                                                        Questions
                  Support

     Q 1.   Parameters used to assess nutritional status include:

            A.   Serum albumin
            B.   Triceps skin-fold thickness
            C.   White cell count
            D.   Handgrip strength
            E.   Prothrombin time


     Q 2.   Severe malnutrition is indicated by

            A.     10% recent weight loss
            B.   Serum albumin 30 g/l
            C.   Peripheral oedema
            D.   Koilonychia
            E.   Gynaecomastia


     Q 3.   Enteral nutrition

            A. Increases the incidence of bacterial translocation
            B. Maintains the gut mucosal barrier function
            C. May be safely administered immediately after abdominal
               surgery
            D. Should be considered the first choice of feeding for severe
               head injury patients
            E. Is associated with increased risk of infective complications
               compared to TPN-fed patients


     Q 4.   Daily nutritional requirements for a 70 kg man are:
            A.   35–40 kCal/kg/day
            B.   1–2 g nitrogen/day
            C.   15 g protein/day
            D.   70 mmol K /day
            E.   2500 ml water/day



10   MCQs    Surgery MCQs and EMQs
Q 5.   TPN

       A. Most commonly is administered via large central veins
       B. Is indicated in approx 25% of patients in hospital requiring
          nutritional support
       C. Is indicated for all patients with paralytic ileus




                                                                         Nutritional Support
       D. Should be administered using an infusion pump
       E. May induce hepatocyte dysfunction




                                                                         Questions




MCQs    Surgery MCQs and EMQs                                                      11
Surgical Sepsis:
                                                     Questions
     Prevention & Therapy

     Q 1.   Features of the systemic inflammatory response
            syndrome (SIRS) include

            A.   Temp 38.4 C
            B.   Temp 35.6 C
            C.   WCC 4 cells/ml
            D.   Respiratory rate 20/min
            E.   PaCO2 32 mmHg


     Q 2.   Factors which prevent overgrowth of pathogenic bacteria
            in the gastrointestinal tract include

            A.   Small intestinal stasis
            B.   Secretion of IgE
            C.   Mucus production
            D.   Antibiotics
            E.   Blind loops


     Q 3.   Factors predisposing to nosocomial pneumonia include

            A. Oropharyngeal colonisation due to increased mouth
               breathing
            B. Routine use of H2 antagonists
            C. Use of a nasogastric tube
            D. Endotracheal intubation
            E. Impaired gag reflex


     Q 4.   Systemic endotoxin may trigger the release of
            A.   Pro-inflammatory cytokines
            B.   Anti-inflammatory cytokines
            C.   Complement
            D.   Platelet activating factor (PAF)
            E.   Endotoxin antibodies



12   MCQs    Surgery MCQs and EMQs
Q 5.   Factors predisposing to wound infection include




                                                                   Surgical Sepsis: Prevention & Therapy
       A.   Inadequate haemostasis
       B.   Prolonged operation
       C.   Diabetes
       D.   Obstructive jaundice
       E.   Malnutrition


Q 6.   Features of Adult Respiratory Distress Syndrome (ARDS)
       include

       A. Increased lung compliance
       B. Hypoxaemia associated with decreasing inspired oxygen
          concentration
       C. Pulmonary infiltrates on a chest X-ray
       D. Encephalopathy
       E. Dyspnoea or tachypnoea


Q 7.   Regarding antibiotics




                                                                    Questions
       A. Penicillins act by disrupting the peptidoglycan of the
          bacterial cell wall
       B. Ampicillin is effective against pseudomonas infections
       C. Cephalosporans are usually prescribed as a monotherapy
       D. Vancomycin is the treatment of choice for MRSA
       E. Aminoglycosides may cause nephrotoxicity


Q 8.   Indications to isolate patients infected with HIV, HBV or
       HCV include those with
       A.   Bleeding oesophageal varices
       B.   Profuse diarrhoea
       C.   Urinary tract infections
       D.   Diabetes
       E.   Surgical drains




MCQs    Surgery MCQs and EMQs                                                          13
Surgical Techniques
                                                         Questions
         & Technology

     Q 1.   Injection of 1% lignocaine with 1 in 200,000 adrenaline is
            a useful form of anaesthesia for

            A.   Reducing a Smith’s fracture
            B.   Performing a Zadek’s procedure
            C.   Repair of an indirect inguinal hernia
            D.   Central line insertion
            E.   Insertion of a Seton suture


     Q 2.   Diathermy

            A. Produces coagulation by oscillation of tissue ions
            B. In bipolar form is useful at circumcision
            C. In monopolar form is useful to obtain haemostasis in grade
               IV liver injuries
            D. May cause burns at sites distant from the point of contact
            E. In NdYAG form is used to destroy lesions in the
               gastrointestinal tract


     Q 3.   Wound healing

            A. Is characterised by increased vascular permeability
            B. Is associated with release of growth factors and cytokines by
               leukocytes and macrophages
            C. Is characterised by wound contracture due to shortening of
               myofibrils
            D. Is retarded by vitamin A deficiency
            E. Is improved by nutrients


     Q 4.   The following factors may adversely affect the healing of
            wounds

            A. Exposure to ultraviolet light
            B. Obstructive jaundice
            C. Advanced neoplasia

14   MCQs    Surgery MCQs and EMQs
D. Exposure to ionising radiation
       E. Infection




                                                                           Surgical Techniques & Technology
Q 5.   Wound infection rates

       A. Are approximately 10% in clean wounds
       B. Can be reduced by shaving the operative site 24 h prior to
          surgery
       C. Can be reduced by minimizing the prehospital stay
       D. Can be reduced by application of chlorhexidine or iodine
          preparations in theatre to the operative site
       E. Are increased in patients with zinc deficiency

Q 6.   Burn injuries
       A. Involving 20% of body surface area can be managed by daily
          dressings by a district nurse
       B. Involving the thorax may require escarotomy
       C. Of partial thickness are often painless, but needle pricks can
          usually be felt




                                                                            Questions
       D. Requires fluid replacement of 2–4 ml/kg per percent body
          surface burn within the first 24 h
       E. To the head and neck have the lowest mortality rates

Q 7.   The general effects of burn injury are

       A.   Increased metabolic rate
       B.   Impaired immune function
       C.   Hypernatraemia
       D.   Hypoalbuminaemia
       E.   Impairment of gut barrier function

Q 8.   Contemporary management of burn injuries includes

       A. Early enteral feeding
       B. Administration of broad-spectrum antibiotics to prevent
          colonisation of the burn site prior to skin grafting
       C. Meshing of split-skin grafts to allow up to six times the
          potential coverage of the graft
       D. Application of occlusive, nonabsorptive dressings which
          should be changed on a daily basis
       E. Early release of contractures to allow early mobilisation and
          to obtain the best functional and aesthetic result

MCQs    Surgery MCQs and EMQs                                                               15
Trauma: General
              Principles of                             Questions
              Management

     Q 1.   When a casualty has severe facial injuries

            A. An immediate danger to life is blood loss
            B. Transport to the casualty department should be in the supine
               position
            C. Airway obstruction can occur due to inhaled blood
            D. Surgical cricothyroidotomy may be required due to
               oedema
            E. Cervical spine injury should be considered after securing a
               definitive airway

     Q 2.   In the early assessment and resuscitation of a trauma
            patient

            A. Application of a tourniquet to control obvious external
               blood loss from a limb is essential to minimise hypovolaemic
               shock
            B. Airway patency ensures adequate ventilation
            C. A urinary catheter should be inserted if the patient is
               unconscious
            D. A normal lateral cervical spine X-ray excludes a cervical spine
               injury
            E. Nasotracheal intubation should be undertaken in the apnoeic
               patient

     Q 3.   In compensated hypovolaemia due to haemorrhage
            A. There is no significant reduction of systemic blood
               pressure
            B. The vital organs are inadequately perfused
            C. There will be associated bradycardia
            D. The patient may feel thirsty
            E. 1000 ml of blood may have been lost from the intravascular
               compartment

16   MCQs    Surgery MCQs and EMQs
Q 4.   Severe head injury may be associated with




                                                                         Trauma: General Principles of Management
       A.   Raised systemic arterial blood pressure
       B.   No evidence of damage on CT scan
       C.   Secondary injury due to tissue hypoxia
       D.   Retention of carbon dioxide
       E.   A Glasgow Coma Score of 10


Q 5.   Indications for emergency thoracotomy include

       A. Patients with penetrating precordial injuries who are
          in EMD
       B. Immediate evacuation of 750 ml blood on insertion of a
          chest drain
       C. Continued blood loss from a chest drain of 200 ml/h
          for 3 h
       D. A haemodynamically stable patient with a wide mediastinum
          on chest X-ray
       E. A patient with hypoxia and a flail chest segment


Q 6.   Definite indications for emergency laparotomy are




                                                                          Questions
       A. Stab wounds to the back with evidence of injury to the renal
          parenchyma
       B. Gunshot wound to the abdomen
       C. Stab wound to periumbilical region with protrusion of
          bowel
       D. Haemodynamically stable patient with a liver laceration
          and free intra-abdominal fluid on CT scan
       E. Injured diaphragm


Q 7.   Diagnostic peritoneal lavage (DPL)

       A. Is less sensitive than a CT scan for intraperitoneal
          bleeding
       B. Is positive if the red cell count is 10,000 RBCs/mm3
       C. Is positive if the white cell count is 1000 WBCs/mm3
       D. Should be performed in a haemodynamically unstable
          patient with peritonism
       E. Is positive if the aspirate contains bowel contents




MCQs    Surgery MCQs and EMQs                                                                 17
Q 8.   Liver injuries
Trauma: General Principles of Management




                                                  A. Are predominantly due to blunt trauma in the UK
                                                  B. Due to deceleration forces, as in road traffic accidents,
                                                     commonly cause lacerations between the anterior and
                                                     posterior sectors of the right lobe of the liver
                                                  C. May result in hyperpyrexia
                                                  D. Frequently necessitate anatomical resection of the involved
                                                     liver lobe
                                                  E. Can be managed by packing gauzes into hepatic lacerations
                                                     and transferring the patient to a specialist liver unit for
                                                     definitive surgical treatment


                                           Q 9.   In the management of burn injuries

                                                  A. Patients should receive 35% oxygen via a face mask if
                                                     inhalation injury is suspected
                                                  B. 2–4 ml crystalloid per kilogram body weight per percent body
                                                     surface burn is required in the first 24 h to maintain an
                                                     adequate circulating blood volume
                                                  C. One half of the estimated fluid requirement for the first 24 h
                                                     should be administered over the first 4 h
 Questions




                                                  D. Prophylactic antibiotics are indicated in the early postburn
                                                     period
                                                  E. Acid burns are generally more serious than alkali burns


                                           Q 10. The metabolic response to injury includes

                                                  A.   Increased ADH secretion
                                                  B.   Elevation of serum growth hormone
                                                  C.   Increased ACTH secretion from the hypothalamus
                                                  D.   Transient hypoglycaemia in the early stage after injury
                                                  E.   Increased urinary resorption of potassium




18                                         MCQs    Surgery MCQs and EMQs
Intensive Care                               Questions


Q 1.   Cardiac output

       A.   Is a function of stroke volume and mean arterial pressure
       B.   Is regulated by the autonomic nervous system
       C.   Is regulated by chemoreceptors
       D.   Can be measured by a thermodilutional technique
       E.   Can increase to 40 L/min with exercise

Q 2.   Cardiac tamponade

       A.   Is exacerbated by restrictive pulmonary disease
       B.   May result from penetrating cardiac wounds
       C.   Results in a low CVP
       D.   Is associated with pulsus paradoxus
       E.   Requires open surgical evacuation of blood and clot

Q 3.   The Adult Respiratory Distress Syndrome (ARDS)

       A. May occur following massive blood transfusion
       B. Is characterised by the development of radiological signs
          prior to clinical deterioration
       C. Is associated with the systemic inflammatory response
          syndrome (SIRS)
       D. Is associated with increased lung compliance
       E. Often requires respiratory support using artificial ventilation
          with positive end-expiratory pressure (PEEP)

Q 4.   Artificial ventilation

       A. Is indicated for type III respiratory failure
       B. Is best achieved with relatively low tidal volumes at a
          relatively fast rate
       C. For a short duration will be easier to be weaned from than
          that continued for a more prolonged period
       D. Necessitates paralysis of the patient
       E. May reduce venous return if PEEP is used

MCQs    Surgery MCQs and EMQs                                               19
Q 5.   The Systemic Inflammatory Response Syndrome (SIRS)

                        A.   Implies a focus of sepsis which must be localised and treated
                        B.   Rarely leads to end organ failure
                        C.   Stimulates fixed tissue macrophages to secrete cytokines
                        D.   May be associated with gut barrier dysfunction
                        E.   May be associated with a compensatory anti-inflammatory
Intensive Care




                             response


                 Q 6.   Acute renal failure

                        A. May cause a metabolic acidosis
                        B. Is diagnosed when the urinary output falls below 800 ml in
                           24 h
                        C. In critically ill patients should be treated by haemodialysis
                        D. Is associated with hypokalaemia
                        E. May be minimised by treating with a Dopamine infusion at
                           0.5–3 mg/kg/h


                 Q 7.
Questions




                        Acute liver failure may be associated with

                        A.   Reduced systolic blood pressure
                        B.   Hyperglycaemia
                        C.   Hypernatraemia
                        D.   An increased prothrombin time
                        E.   Encephalopathy




20               MCQs    Surgery MCQs and EMQs

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Surgery Questions

  • 1. SURGERY MCQS AND EMQS by R. W. Parks MD, FRCSI, FRCS (Ed) Senior Lecturer/Honorary Consultant Surgeon Department of Clinical and Surgical Sciences (Surgery) University of Edinburgh T. Diamond BSc, MD, FRCS, FRCSI Consultant Surgeon Mater Hospital Belfast London o San Francisco
  • 2. www.greenwich-medical.co.uk © 2003 Greenwich Medical Media Limited 137 Euston Road, London NW1 2AA 870 Market Street, Ste 720 San Francisco, CA 94102 ISBN 1841101869 First Published 2003 While the advice and information in this book is believed to be true and accurate, neither the authors nor the publisher can accept any legal responsibility or liability for any loss or damage arising from actions or decisions based in this book. The ultimate responsibility for the treatment of patients and the interpretation lies with the medical practitioner. The opinions expressed are those of the authors and the inclusion in this book of information relating to a particular product, method or technique does not amount to an endorsement of its value or quality, or of the claims made by its manufacturer. Every effort has been made to check drug dosages; however, it is still possible that errors have occurred. Furthermore, dosage schedules are constantly being revised and new side-effects recognised. For these reasons, the medical practitioner is strongly urged to consult the drug companies' printed instructions before administering any of the drugs mentioned in this book. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the UK Copyright Designs and Patents Act 1988, this publication may not be reproduced, stored, or transmitted, in any form or by any means, without the prior permission in writing of the publishers, or in the case of reprographic reproduction only in accordance with the terms of the licences issued by the appropriate Reproduction Rights Organisations outside the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publishers at the London address printed above. The rights of R. W. Parks and T. Diamond to be identified as authors of this Work have been asserted by them in accordance with the Copyright Designs and Patents Act 1988. The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made. A catalogue record for this book is available from the British Library. Typeset by Mizpah Publishing Services, Chennai, India Printed by Bell & Bain Ltd, Glasgow Distributed by Plymbridge Distributors Ltd and in the USA by JAMCO Distribution
  • 3. Contents Preface ........................................................................................................viii List of Abbreviations ....................................................................................ix Section 1 – Multiple Choice Questions (MCQs) Preoperative Management – Questions ......................................................3 Principles of Anaesthesia – Questions ..........................................................6 Postoperative Management – Questions......................................................8 Nutritional Support – Questions ................................................................10 Surgical Sepsis: Prevention & Therapy – Questions....................................12 Surgical Techniques & Technology – Questions..........................................14 Trauma: General Principles of Management – Questions ........................16 Intensive Care – Questions ..........................................................................19 Principles of Cancer Management – Questions..........................................21 Ethics, Legal Aspects & Assessment of Effectiveness – Questions ............24 Haemopoietic & Lymphoreticular Systems – Questions ............................25 Alimentary System – Questions ..................................................................26 Vascular Surgery – Questions ......................................................................33 Endocrine Surgery – Questions....................................................................35 Breast – Questions........................................................................................39 Thoracic Surgery – Questions ......................................................................42 Genitourinary System – Questions ..............................................................44 Head & Neck – Questions ............................................................................46 Central Nervous System – Questions ..........................................................48 Musculoskeletal System – Questions ..........................................................50 Paediatric Surgery – Questions....................................................................52 Preoperative Management – Answers........................................................55 Principles of Anaesthesia – Answers ..........................................................58 Postoperative Management – Answers ......................................................60 Nutritional Support – Answers ....................................................................64 Surgical Sepsis: Prevention & Therapy – Answers ......................................66 v
  • 4. Surgical Techniques & Technology – Answers ............................................70 Trauma: General Principles of Management – Answers ............................74 Intensive Care – Answers ............................................................................79 Principles of Cancer Management – Answers ............................................82 Ethics, Legal Aspects & Assessment of Effectiveness – Answers ................86 Haemopoietic & Lymphoreticular Systems – Answers................................87 Alimentary System – Answers......................................................................89 Vascular Surgery – Answers ........................................................................99 Endocrine Surgery – Answers ....................................................................101 Breast – Answers ........................................................................................108 Thoracic Surgery – Answers ......................................................................112 Genitourinary System – Answers ..............................................................114 Head & Neck – Answers ............................................................................118 Central Nervous System – Answers ..........................................................121 Musculoskeletal System – Answers ..........................................................123 Paediatric Surgery – Answers ....................................................................125 Section 2 – Extended Matching Questions (EMQs) Classification of Fitness for Surgery ..........................................................131 Preoperative Prophylactic Measures ........................................................132 Discontinuation of Drug Treatment Prior to Surgery ..............................133 Appropriate Anaesthetic Techniques........................................................134 Blood Transfusion ......................................................................................135 Anaesthesia/Analgesia ..............................................................................136 Classification of Surgical Wounds ............................................................138 Wound Closure ..........................................................................................139 Head Injury ................................................................................................140 Sepsis ..........................................................................................................141 Clinical Research ........................................................................................142 Auto-immune Disease................................................................................143 Intestinal Obstruction ................................................................................144 Investigations ............................................................................................146 Perianal Conditions ....................................................................................147 Causes of Chronic Arterial Disease............................................................148 Acute Arterial Disease................................................................................149 Management of Vascular Disease ............................................................150 Breast Disease ............................................................................................151 Management of Chest Trauma..................................................................152 Chest X-ray Findings ..................................................................................153 Scrotal Swellings ........................................................................................154 Treatment of Scrotal Swellings..................................................................155 vi
  • 5. Presentation of Urological Pathology ......................................................156 Head & Neck Swellings ..............................................................................157 Depressed Level of Consciousness ............................................................158 Fracture Complications ..............................................................................160 Neonatal & Childhood Intestinal Obstruction..........................................161 Paediatric Emergencies ..............................................................................162 vii
  • 6. Section 1 Multiple Choice Questions (MCQs) Preoperative Management – Questions ......................................................3 Principles of Anaesthesia – Questions ..........................................................6 Postoperative Management – Questions......................................................8 Nutritional Support – Questions ................................................................10 Surgical Sepsis: Prevention & Therapy – Questions....................................12 Surgical Techniques & Technology – Questions..........................................14 Trauma: General Principles of Management – Questions ........................16 Intensive Care – Questions ..........................................................................19 Principles of Cancer Management – Questions..........................................21 Ethics, Legal Aspects & Assessment of Effectiveness – Questions ............24 Haemopoietic & Lymphoreticular Systems – Questions ............................25 Alimentary System – Questions ..................................................................26 Vascular Surgery – Questions ......................................................................33 Endocrine Surgery – Questions....................................................................35 Breast – Questions........................................................................................39 Thoracic Surgery – Questions ......................................................................42 Genitourinary System – Questions ..............................................................44 Head & Neck – Questions ............................................................................46 Central Nervous System – Questions ..........................................................48 Musculoskeletal System – Questions ..........................................................50 Paediatric Surgery – Questions....................................................................52
  • 7. Preoperative Management – Answers........................................................55 Principles of Anaesthesia – Answers ..........................................................58 Postoperative Management – Answers ......................................................60 Nutritional Support – Answers ....................................................................64 Surgical Sepsis: Prevention & Therapy – Answers ......................................66 Surgical Techniques & Technology – Answers ............................................70 Trauma: General Principles of Management – Answers ............................74 Intensive Care – Answers ............................................................................79 Principles of Cancer Management – Answers ............................................82 Ethics, Legal Aspects & Assessment of Effectiveness – Answers ................86 Haemopoietic & Lymphoreticular Systems – Answers................................87 Alimentary System – Answers......................................................................89 Vascular Surgery – Answers ........................................................................99 Endocrine Surgery – Answers ....................................................................101 Breast – Answers ........................................................................................108 Thoracic Surgery – Answers ......................................................................112 Genitourinary System – Answers ..............................................................114 Head & Neck – Answers ............................................................................118 Central Nervous System – Answers ..........................................................121 Musculoskeletal System – Answers ..........................................................123 Paediatric Surgery – Answers ....................................................................125
  • 8. Preoperative Questions Management Q 1. The American Society of Anesthesiologists (ASA) classification of fitness of patients for surgery includes the following A. ASA 1 where there is no organic, physiological, biochemical or psychiatric disturbance B. ASA 3 where there is mild to moderate systemic disturbance which does not limit normal activity C. ASA 4 where there are severe life-threatening systemic disorders D. ASA 5 where the patient is moribund with little chance of recovery E. ASA E where the letter E after a particular classification denotes an emergency operation Q 2. Concerning the risk of myocardial infarction during or following surgery A. Infarction 3 months prior to surgery increases the risk by 30% B. Infarction 6 months prior to surgery increases the risk by 6% C. The risk is 5–10% when there is no previous history of infarction D. Elective surgery should not be performed within 6 months of a myocardial infarction E. Gastrointestinal endoscopy should not be performed within 6 months of a myocardial infarction Q 3. Hypertension A. Is defined by the World Health Organisation as a systolic blood pressure 160 mmHg and/or a diastolic blood pressure 105 mmHg B. Is present in approximately 25% of adult patients C. Is a contraindication to elective surgery if the diastolic pressure exceeds 115 mmHg MCQs Surgery MCQs and EMQs 3
  • 9. D. Should be treated with intravenous beta-blockers or glyceryl trinitrate if emergency surgery is necessary E. Treatment should be discontinued 2 weeks before elective surgery Preoperative Management Q 4. The following drugs should be discontinued prior to surgery A. Prednisolone B. Progesterone-only oral contraceptive pill C. Aspirin D. Propranolol E. Warfarin Q 5. The following investigations are appropriate prior to surgery A. An ECG in all patients 30 years B. A chest X-ray on all patients 40 years Questions C. A biochemical screen (block) on all patients 30 years undergoing major surgery D. A haematocrit on all female patients E. A coagulation screen in all patients with obstructive jaundice Q 6. In a diabetic patient undergoing surgery A. The dose of depot insulin should be halved on the day prior to surgery and supplemented with soluble insulin later in the day B. Half the morning dose of insulin should be given on the day of surgery C. An intravenous infusion of 5% dextrose is erected on the morning of surgery D. Insulin requirements may increase after major surgery E. The majority of diabetic patients undergoing surgery have insulin-dependent (Type I) diabetes Q 7. The following statements concerning prophylaxis of thrombo-embolic disease are true A. An appropriate regimen involves enoxaparin 20 mg bd, given subcutaneously 4 MCQs Surgery MCQs and EMQs
  • 10. B. Clinically significant thromboembolism occurs in approximately 1% of patients undergoing major surgery C. Mechanical measures contribute significantly to reduce the incidence of thromboembolism Preoperative Management D. Dextran 70 is widely used to reduce the incidence of postoperative deep vein thrombosis E. Age 35 years, obesity and malignancy are all significant risk factors for the development of deep vein thrombosis Questions MCQs Surgery MCQs and EMQs 5
  • 11. Principles of Questions Anaesthesia Q 1. The following are intravenous induction anaesthetic agents A. Propofol B. Etomidate C. Sevoflurane D. Thiopentone E. Halothane Q 2. The following are depolarising neuromuscular blocking drugs A. Suxamethonium B. Atracurium C. Vecuronium D. Pancuronium E. Atracurium Q 3. The following statements concerning opioid analgesics are true A. Morphine is a synthetic alkaloid B. Morphine may be administered orally, intravenously, intramuscularly, subcutaneously and via the epidural (neuraxial) route C. Papavertum contains a mixture of morphine, pethidine and papaverine D. Fentanyl is a synthetic derivative of morphine E. Fentanyl causes significant cardiovascular instability Q 4. The following are correct contents of common crystalloid solutions A. NaCl 0.9% contains 154 mmol of sodium per litre B. NaCl 0.9% contains 72 mmol of chloride per litre 6 MCQs Surgery MCQs and EMQs
  • 12. C. Glucose 5% contains 20 mmol of potassium per litre D. Hartmann’s contains 40 mmol of potassium per litre E. Hartmann’s contains 150 kCal per litre Principles of Anaesthesia Q 5. The following are significant advantages of regional anaesthesia A. Avoidance of unconsciousness B. Absence of respiratory depression C. Sympathetic blockade D. Blockade of motor function E. Avoidance of Hypotension Q 6. Local anaesthesia A. Only affects sensory nerve fibres B. Is very effective for incision and drainage of cutaneous abscesses C. Must be injected into the tissues to become effective D. In high doses can cause convulsions and bradycardia Questions E. May not be used in the region of an end-artery Q 7. In general anaesthesia A. Pulse oximetry is used routinely to record the heart rate and oxygen saturation B. Patients require mechanical ventilation for the operative period C. Preoperative starvation ensures that the stomach is empty D. Bradycardia is treated with neostigmine E. Opioids do not cause direct myocardial depression MCQs Surgery MCQs and EMQs 7
  • 13. Postoperative Questions Management Q 1. Complications of blood transfusion are A. Urticaria B. Hypokalaemia C. Hepatitis C D. ARDS E. Jaundice Q 2. Atelectasis A. May impair gas exchange B. May predispose to chest infection C. Can be prevented by prophylactic treatment with antibiotics D. Is a common cause of an early postoperative fever E. May necessitate fibreoptic bronchoscopy to extract mucus plugs Q 3. Postoperative fluid management of the surgical patient should A. Include administration of 40–60 mmol of potassium in the first 24 h B. Account for insensible losses of up to 1500 ml if the patient is septic C. Include packed red blood cells if the haematocrit falls below 40% D. Aim to provide at least 1000 calories for the first three postoperative days E. Be increased if the central venous pressure falls below 8 cm H2O Q 4. With regard to postoperative complications A. The most common site of intra-abdominal abscess formation is in the pelvis 8 MCQs Surgery MCQs and EMQs
  • 14. B. Secondary haemorrhage is often associated with diffuse bleeding from an infected operative site C. Hypotension is the earliest sign of hypovolaemia Postoperative Management D. The risk of deep venous thrombosis and pulmonary embolism is increased with malignancy E. Acute tubular necrosis due to inadequate renal perfusion is irreversible Q 5. Following major abdominal surgery A. Epidural anaesthesia often masks the clinical signs of post- operative secondary haemorrhage B. Insertion of a nasogastric tube prevents intestinal ileus C. Swinging pyrexia and diarrhoea are characteristic clinical features of a pelvic abscess D. Open drainage reduces the risk of septic complications E. Subcutaneous heparin administration reduces the incidence of deep venous thrombosis Questions Q 6. Postoperative pyrexia may occur secondary to A. Subphrenic abscess B. Deep venous thrombosis C. Urinary tract infection D. Atelectasis E. Blood transfusion Q 7. The following are well-recognised specific postoperative complications A. Renal failure in jaundiced patients B. Deep venous thrombosis after varicose vein surgery C. Hyperglycaemia, high lactate levels and a prolonged prothrombin time following liver resection for colorectal metastases D. Positive Chvostek’s sign after thyroid lobectomy E. Urinary incontinence following inguinal hernia repair MCQs Surgery MCQs and EMQs 9
  • 15. Nutritional Questions Support Q 1. Parameters used to assess nutritional status include: A. Serum albumin B. Triceps skin-fold thickness C. White cell count D. Handgrip strength E. Prothrombin time Q 2. Severe malnutrition is indicated by A. 10% recent weight loss B. Serum albumin 30 g/l C. Peripheral oedema D. Koilonychia E. Gynaecomastia Q 3. Enteral nutrition A. Increases the incidence of bacterial translocation B. Maintains the gut mucosal barrier function C. May be safely administered immediately after abdominal surgery D. Should be considered the first choice of feeding for severe head injury patients E. Is associated with increased risk of infective complications compared to TPN-fed patients Q 4. Daily nutritional requirements for a 70 kg man are: A. 35–40 kCal/kg/day B. 1–2 g nitrogen/day C. 15 g protein/day D. 70 mmol K /day E. 2500 ml water/day 10 MCQs Surgery MCQs and EMQs
  • 16. Q 5. TPN A. Most commonly is administered via large central veins B. Is indicated in approx 25% of patients in hospital requiring nutritional support C. Is indicated for all patients with paralytic ileus Nutritional Support D. Should be administered using an infusion pump E. May induce hepatocyte dysfunction Questions MCQs Surgery MCQs and EMQs 11
  • 17. Surgical Sepsis: Questions Prevention & Therapy Q 1. Features of the systemic inflammatory response syndrome (SIRS) include A. Temp 38.4 C B. Temp 35.6 C C. WCC 4 cells/ml D. Respiratory rate 20/min E. PaCO2 32 mmHg Q 2. Factors which prevent overgrowth of pathogenic bacteria in the gastrointestinal tract include A. Small intestinal stasis B. Secretion of IgE C. Mucus production D. Antibiotics E. Blind loops Q 3. Factors predisposing to nosocomial pneumonia include A. Oropharyngeal colonisation due to increased mouth breathing B. Routine use of H2 antagonists C. Use of a nasogastric tube D. Endotracheal intubation E. Impaired gag reflex Q 4. Systemic endotoxin may trigger the release of A. Pro-inflammatory cytokines B. Anti-inflammatory cytokines C. Complement D. Platelet activating factor (PAF) E. Endotoxin antibodies 12 MCQs Surgery MCQs and EMQs
  • 18. Q 5. Factors predisposing to wound infection include Surgical Sepsis: Prevention & Therapy A. Inadequate haemostasis B. Prolonged operation C. Diabetes D. Obstructive jaundice E. Malnutrition Q 6. Features of Adult Respiratory Distress Syndrome (ARDS) include A. Increased lung compliance B. Hypoxaemia associated with decreasing inspired oxygen concentration C. Pulmonary infiltrates on a chest X-ray D. Encephalopathy E. Dyspnoea or tachypnoea Q 7. Regarding antibiotics Questions A. Penicillins act by disrupting the peptidoglycan of the bacterial cell wall B. Ampicillin is effective against pseudomonas infections C. Cephalosporans are usually prescribed as a monotherapy D. Vancomycin is the treatment of choice for MRSA E. Aminoglycosides may cause nephrotoxicity Q 8. Indications to isolate patients infected with HIV, HBV or HCV include those with A. Bleeding oesophageal varices B. Profuse diarrhoea C. Urinary tract infections D. Diabetes E. Surgical drains MCQs Surgery MCQs and EMQs 13
  • 19. Surgical Techniques Questions & Technology Q 1. Injection of 1% lignocaine with 1 in 200,000 adrenaline is a useful form of anaesthesia for A. Reducing a Smith’s fracture B. Performing a Zadek’s procedure C. Repair of an indirect inguinal hernia D. Central line insertion E. Insertion of a Seton suture Q 2. Diathermy A. Produces coagulation by oscillation of tissue ions B. In bipolar form is useful at circumcision C. In monopolar form is useful to obtain haemostasis in grade IV liver injuries D. May cause burns at sites distant from the point of contact E. In NdYAG form is used to destroy lesions in the gastrointestinal tract Q 3. Wound healing A. Is characterised by increased vascular permeability B. Is associated with release of growth factors and cytokines by leukocytes and macrophages C. Is characterised by wound contracture due to shortening of myofibrils D. Is retarded by vitamin A deficiency E. Is improved by nutrients Q 4. The following factors may adversely affect the healing of wounds A. Exposure to ultraviolet light B. Obstructive jaundice C. Advanced neoplasia 14 MCQs Surgery MCQs and EMQs
  • 20. D. Exposure to ionising radiation E. Infection Surgical Techniques & Technology Q 5. Wound infection rates A. Are approximately 10% in clean wounds B. Can be reduced by shaving the operative site 24 h prior to surgery C. Can be reduced by minimizing the prehospital stay D. Can be reduced by application of chlorhexidine or iodine preparations in theatre to the operative site E. Are increased in patients with zinc deficiency Q 6. Burn injuries A. Involving 20% of body surface area can be managed by daily dressings by a district nurse B. Involving the thorax may require escarotomy C. Of partial thickness are often painless, but needle pricks can usually be felt Questions D. Requires fluid replacement of 2–4 ml/kg per percent body surface burn within the first 24 h E. To the head and neck have the lowest mortality rates Q 7. The general effects of burn injury are A. Increased metabolic rate B. Impaired immune function C. Hypernatraemia D. Hypoalbuminaemia E. Impairment of gut barrier function Q 8. Contemporary management of burn injuries includes A. Early enteral feeding B. Administration of broad-spectrum antibiotics to prevent colonisation of the burn site prior to skin grafting C. Meshing of split-skin grafts to allow up to six times the potential coverage of the graft D. Application of occlusive, nonabsorptive dressings which should be changed on a daily basis E. Early release of contractures to allow early mobilisation and to obtain the best functional and aesthetic result MCQs Surgery MCQs and EMQs 15
  • 21. Trauma: General Principles of Questions Management Q 1. When a casualty has severe facial injuries A. An immediate danger to life is blood loss B. Transport to the casualty department should be in the supine position C. Airway obstruction can occur due to inhaled blood D. Surgical cricothyroidotomy may be required due to oedema E. Cervical spine injury should be considered after securing a definitive airway Q 2. In the early assessment and resuscitation of a trauma patient A. Application of a tourniquet to control obvious external blood loss from a limb is essential to minimise hypovolaemic shock B. Airway patency ensures adequate ventilation C. A urinary catheter should be inserted if the patient is unconscious D. A normal lateral cervical spine X-ray excludes a cervical spine injury E. Nasotracheal intubation should be undertaken in the apnoeic patient Q 3. In compensated hypovolaemia due to haemorrhage A. There is no significant reduction of systemic blood pressure B. The vital organs are inadequately perfused C. There will be associated bradycardia D. The patient may feel thirsty E. 1000 ml of blood may have been lost from the intravascular compartment 16 MCQs Surgery MCQs and EMQs
  • 22. Q 4. Severe head injury may be associated with Trauma: General Principles of Management A. Raised systemic arterial blood pressure B. No evidence of damage on CT scan C. Secondary injury due to tissue hypoxia D. Retention of carbon dioxide E. A Glasgow Coma Score of 10 Q 5. Indications for emergency thoracotomy include A. Patients with penetrating precordial injuries who are in EMD B. Immediate evacuation of 750 ml blood on insertion of a chest drain C. Continued blood loss from a chest drain of 200 ml/h for 3 h D. A haemodynamically stable patient with a wide mediastinum on chest X-ray E. A patient with hypoxia and a flail chest segment Q 6. Definite indications for emergency laparotomy are Questions A. Stab wounds to the back with evidence of injury to the renal parenchyma B. Gunshot wound to the abdomen C. Stab wound to periumbilical region with protrusion of bowel D. Haemodynamically stable patient with a liver laceration and free intra-abdominal fluid on CT scan E. Injured diaphragm Q 7. Diagnostic peritoneal lavage (DPL) A. Is less sensitive than a CT scan for intraperitoneal bleeding B. Is positive if the red cell count is 10,000 RBCs/mm3 C. Is positive if the white cell count is 1000 WBCs/mm3 D. Should be performed in a haemodynamically unstable patient with peritonism E. Is positive if the aspirate contains bowel contents MCQs Surgery MCQs and EMQs 17
  • 23. Q 8. Liver injuries Trauma: General Principles of Management A. Are predominantly due to blunt trauma in the UK B. Due to deceleration forces, as in road traffic accidents, commonly cause lacerations between the anterior and posterior sectors of the right lobe of the liver C. May result in hyperpyrexia D. Frequently necessitate anatomical resection of the involved liver lobe E. Can be managed by packing gauzes into hepatic lacerations and transferring the patient to a specialist liver unit for definitive surgical treatment Q 9. In the management of burn injuries A. Patients should receive 35% oxygen via a face mask if inhalation injury is suspected B. 2–4 ml crystalloid per kilogram body weight per percent body surface burn is required in the first 24 h to maintain an adequate circulating blood volume C. One half of the estimated fluid requirement for the first 24 h should be administered over the first 4 h Questions D. Prophylactic antibiotics are indicated in the early postburn period E. Acid burns are generally more serious than alkali burns Q 10. The metabolic response to injury includes A. Increased ADH secretion B. Elevation of serum growth hormone C. Increased ACTH secretion from the hypothalamus D. Transient hypoglycaemia in the early stage after injury E. Increased urinary resorption of potassium 18 MCQs Surgery MCQs and EMQs
  • 24. Intensive Care Questions Q 1. Cardiac output A. Is a function of stroke volume and mean arterial pressure B. Is regulated by the autonomic nervous system C. Is regulated by chemoreceptors D. Can be measured by a thermodilutional technique E. Can increase to 40 L/min with exercise Q 2. Cardiac tamponade A. Is exacerbated by restrictive pulmonary disease B. May result from penetrating cardiac wounds C. Results in a low CVP D. Is associated with pulsus paradoxus E. Requires open surgical evacuation of blood and clot Q 3. The Adult Respiratory Distress Syndrome (ARDS) A. May occur following massive blood transfusion B. Is characterised by the development of radiological signs prior to clinical deterioration C. Is associated with the systemic inflammatory response syndrome (SIRS) D. Is associated with increased lung compliance E. Often requires respiratory support using artificial ventilation with positive end-expiratory pressure (PEEP) Q 4. Artificial ventilation A. Is indicated for type III respiratory failure B. Is best achieved with relatively low tidal volumes at a relatively fast rate C. For a short duration will be easier to be weaned from than that continued for a more prolonged period D. Necessitates paralysis of the patient E. May reduce venous return if PEEP is used MCQs Surgery MCQs and EMQs 19
  • 25. Q 5. The Systemic Inflammatory Response Syndrome (SIRS) A. Implies a focus of sepsis which must be localised and treated B. Rarely leads to end organ failure C. Stimulates fixed tissue macrophages to secrete cytokines D. May be associated with gut barrier dysfunction E. May be associated with a compensatory anti-inflammatory Intensive Care response Q 6. Acute renal failure A. May cause a metabolic acidosis B. Is diagnosed when the urinary output falls below 800 ml in 24 h C. In critically ill patients should be treated by haemodialysis D. Is associated with hypokalaemia E. May be minimised by treating with a Dopamine infusion at 0.5–3 mg/kg/h Q 7. Questions Acute liver failure may be associated with A. Reduced systolic blood pressure B. Hyperglycaemia C. Hypernatraemia D. An increased prothrombin time E. Encephalopathy 20 MCQs Surgery MCQs and EMQs