General Surgery Principles Practice Questions

Q: Which of the following is NOT a complication of peritonitis?

Cardiac failure. **Explanation:** Peritonitis is a severe inflammatory process of the peritoneum, typically resulting from infection or chemical irritation. The systemic response to peritonitis is characterized by a massive release of inflammatory mediators and significant fluid shifts. **Why Cardiac Failure is the correct answer:** While peritonitis causes significant cardiovascular stress, **Cardiac Failure** is not a direct or typical complication of the disease process itself. Instead, peritonitis leads to **hypovolemia** (due to third-space fluid loss) and **septic shock**, which results in a high-output state or peripheral vasodilation rather than primary pump failure. Unless the patient has a pre-existing cardiac condition, the heart usually maintains its intrinsic function while struggling to compensate for low systemic vascular resistance. **Analysis of other options:** * **Residual Abscess:** This is a common local complication. Infected fluid can collect in dependent areas like the subphrenic space or the Pouch of Douglas, leading to localized abscess formation. * **Endotoxic Shock:** Gram-negative bacteria (common in gut perforation) release lipopolysaccharides (endotoxins), triggering a systemic inflammatory response syndrome (SIRS) and septic shock. * **Bone Marrow Suppression:** Severe, prolonged sepsis associated with peritonitis can lead to toxic suppression of the bone marrow, manifesting as leukopenia or thrombocytopenia. **NEET-PG High-Yield Pearls:** * **Most common cause of primary peritonitis:** *Streptococcus pneumoniae* (in children) or *E. coli* (in adults with cirrhosis). * **Most common cause of secondary peritonitis:** Perforation of a hollow viscus (e.g., Peptic ulcer or Appendix). * **Clinical Hallmark:** "Board-like" abdominal rigidity and rebound tenderness. * **Radiology:** Upright X-ray showing "pneumoperitoneum" (gas under the diaphragm) is the gold standard for diagnosing perforation.

Q: A 15-year-old girl, a regular swimmer, presents with sudden onset of abdominal pain, abdominal distension, and a fever of 39°C, along with obliteration of liver dullness. What is the most probable diagnosis?

Ruptured typhoid ulcer. ### Explanation **Correct Answer: A. Ruptured typhoid ulcer** The clinical presentation of sudden onset abdominal pain, distension, high-grade fever (39°C), and **obliteration of liver dullness** is a classic triad for **pneumoperitoneum** resulting from a hollow viscus perforation. In the context of a young patient in an endemic region, a ruptured typhoid ulcer is the most likely cause. Typhoid fever (caused by *Salmonella typhi*) leads to hyperplasia and subsequent necrosis of **Peyer’s patches** in the terminal ileum. Perforation typically occurs during the **third week** of the illness. The loss of liver dullness (Gas under the diaphragm) confirms the presence of free intraperitoneal air. **Why other options are incorrect:** * **B. Primary Bacterial Peritonitis (PBP):** Usually occurs in patients with pre-existing ascites (e.g., cirrhosis or nephrotic syndrome). It presents with diffuse pain but **does not** cause obliteration of liver dullness, as there is no hollow viscus perforation. * **C. Ruptured Ectopic Pregnancy:** While it causes sudden abdominal pain and shock, it typically presents with signs of internal hemorrhage (anemia, hypotension) rather than high-grade fever and pneumoperitoneum. * **D. UTI with PID:** These conditions cause pelvic pain and fever but do not result in free intraperitoneal air or the acute surgical abdomen seen here. **High-Yield Clinical Pearls for NEET-PG:** * **Site of Typhoid Perforation:** Usually within **45–60 cm** of the ileocaecal valve. * **Most Common Site of GI Perforation (Overall):** Duodenal ulcer (first part). * **Radiological Sign:** The most sensitive sign for perforation is **"Gas under the right dome of the diaphragm"** on an erect X-ray chest/abdomen. * **Management:** Typhoid perforation is a surgical emergency requiring resuscitation followed by primary closure or ileostomy.

Q: All are included in the Child-Turcotte-Pugh classification except?

ALP. The **Child-Turcotte-Pugh (CTP) score** is a clinical tool used to assess the prognosis of chronic liver disease, primarily cirrhosis. It predicts mortality and the necessity for liver transplantation. ### Why ALP is the Correct Answer **Alkaline Phosphatase (ALP)** is a marker of cholestasis or bone turnover but is **not** a component of the CTP classification. While liver enzymes (ALT/AST/ALP) indicate liver injury, they do not accurately reflect the liver's functional reserve or synthetic capacity, which is what the CTP score aims to measure. ### Explanation of Other Options The CTP score consists of five parameters (mnemonic: **ABCDE**): * **A - Albumin:** Reflects the synthetic function of the liver. * **B - Bilirubin:** Indicates the liver's excretory function. * **C - Coagulation (INR/Prothrombin Time):** Reflects the synthesis of vitamin K-dependent clotting factors. * **D - Distension (Ascites):** Assessed via physical exam or ultrasound (None, Mild, Moderate/Severe). * **E - Encephalopathy:** Graded based on clinical severity (None, Grade 1-2, Grade 3-4). ### High-Yield Clinical Pearls for NEET-PG * **Scoring:** Each parameter is scored from 1 to 3. The total score ranges from **5 to 15**. * **Classification:** * **Class A (5–6 points):** Least severe, 100% 1-year survival. * **Class B (7–9 points):** Moderate severity. * **Class C (10–15 points):** Most severe, ~45% 1-year survival. * **CTP vs. MELD:** While CTP is bedside-friendly, the **MELD score** (Model for End-Stage Liver Disease) is now preferred for transplant allocation. MELD uses objective values: **Bilirubin, Creatinine, and INR** (and recently Sodium). * **Surgical Significance:** Patients with Child Class C are generally considered poor candidates for elective non-transplant surgery due to high perioperative mortality.

Q: Which of the following is not a sign of appendicitis?

Murphy's sign. **Explanation:** The correct answer is **B. Murphy's sign**. **Why Murphy's sign is the correct answer:** Murphy’s sign is the classic clinical indicator for **Acute Cholecystitis**, not appendicitis. It is elicited by asking the patient to take a deep breath while the clinician maintains pressure in the right upper quadrant (over the gallbladder). As the liver descends, the inflamed gallbladder strikes the examining fingers, causing the patient to catch their breath (inspiratory arrest). **Analysis of incorrect options (Signs of Appendicitis):** * **A. Rovsing's sign:** Indirect tenderness. Pressing in the Left Lower Quadrant (LLQ) causes pain in the Right Lower Quadrant (RLQ) due to the displacement of gas and peritoneal irritation. * **C. Obturator sign:** Pain on internal rotation of the flexed right hip. This indicates an inflamed **pelvic appendix** irritating the obturator internus muscle. * **D. Psoas sign:** Pain on passive extension of the right hip. This indicates a **retrocecal appendix** irritating the iliopsoas muscle. **High-Yield Clinical Pearls for NEET-PG:** * **McBurney’s Point:** The point of maximum tenderness, located 1/3rd of the distance from the ASIS to the umbilicus. * **Sherren’s Triangle:** Formed by the umbilicus, ASIS, and pubic symphysis; hyperesthesia in this area suggests appendicitis. * **Alvarado Score (MANTRELS):** A clinical scoring system where a score of ≥7 is highly suggestive of appendicitis. * **Gold Standard Imaging:** Contrast-enhanced CT (CECT) is the most accurate investigation, though Ultrasound is the initial choice in children and pregnant women.

Q: The composition of which of the following intravenous fluids most closely resembles that of plasma?

Lactated Ringer's solution. **Explanation:** The goal of fluid resuscitation is to maintain physiological homeostasis. **Lactated Ringer’s (LR) solution**, also known as Hartmann's solution, is considered the most "physiological" crystalloid because its electrolyte composition and osmolarity closely mimic human plasma. **Why Lactated Ringer's is Correct:** * **Electrolytes:** Unlike normal saline, LR contains potassium (4 mEq/L) and calcium (3 mEq/L) in concentrations similar to plasma. * **Buffer:** It contains **Sodium Lactate**, which is metabolized by the liver into bicarbonate, helping to maintain acid-base balance and preventing the hyperchloremic metabolic acidosis often seen with large volumes of saline. * **Osmolarity:** Its osmolarity (approx. 273 mOsm/L) is closer to plasma (285–295 mOsm/L) than other common crystalloids. **Why Other Options are Incorrect:** * **Isotonic Saline (0.9% NaCl):** Contains supra-physiological levels of Chloride (154 mEq/L vs. plasma 100 mEq/L). Large volumes lead to hyperchloremic metabolic acidosis. * **1/5th Isotonic Saline:** This is a hypotonic solution used primarily in pediatric maintenance fluids; it does not resemble plasma and can cause cellular swelling. * **4.3% Dextrose:** This is essentially free water once the glucose is metabolized. It is used to treat dehydration but does not provide the electrolyte support required for plasma volume expansion. **High-Yield NEET-PG Pearls:** * **Fluid of Choice:** LR is the fluid of choice for **burns (Parkland Formula)** and **hemorrhagic shock**. * **Contraindication:** Avoid LR in patients receiving blood transfusions in the same line (Calcium in LR can bind to Citrate anticoagulant, causing **clotting**). * **Metabolism:** Avoid LR in severe liver failure as the liver cannot convert lactate to bicarbonate, potentially worsening lactic acidosis.

Q: If the caecum is involved as a part of the wall of a hernial sac and is not its content, then it will be known as:

Sliding hernia. ### Explanation **Correct Answer: C. Sliding Hernia (Hernie en Glissade)** A **Sliding Hernia** occurs when a retroperitoneal organ (most commonly the **caecum** on the right or the **sigmoid colon** on the left) drags its overlying peritoneum with it as it descends through the hernial orifice. Consequently, the organ itself forms a portion of the **posterior wall of the sac**, rather than being free content within the sac. This is a crucial surgical distinction because an inadvertent incision into the "sac" on its posterior aspect can result in accidental injury to the bowel. **Analysis of Incorrect Options:** * **A. Richter’s Hernia:** This involves the protrusion of only a **portion of the bowel wall circumference** through the defect. It can lead to strangulation without causing complete intestinal obstruction. * **B. Spigelian Hernia:** This is a ventral hernia occurring through the **linea semilunaris** (at the level of the arcuate line), lateral to the rectus abdominis muscle. * **D. Interstitial Hernia:** Here, the hernial sac lies **between the layers of the abdominal wall** (e.g., between the external and internal oblique muscles) rather than protruding into the subcutaneous tissue. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organs involved:** Bladder (often in direct inguinal hernias), Caecum (right side), and Sigmoid colon (left side). * **Surgical Caution:** Never open a hernial sac from the posterior side; always open it anteriorly to avoid injuring the sliding component. * **Demographics:** Sliding hernias are more common in elderly males and are almost always associated with **indirect inguinal hernias**. * **Diagnosis:** Often suspected clinically when a large, long-standing hernia cannot be completely reduced.

Q: Neurogenic shock is characterized by what?

Decreased peripheral vascular resistance. **Explanation:** Neurogenic shock occurs due to the loss of sympathetic vasomotor tone, typically following a high spinal cord injury (above T6). This leads to massive **vasodilation** in the peripheral vasculature. **Why Option C is Correct:** The hallmark of neurogenic shock is a sudden **decrease in peripheral vascular resistance (SVR)**. The loss of sympathetic outflow results in the relaxation of vascular smooth muscle, leading to arterial and venous dilation. This increases the venous capacitance, reduces venous return to the heart, and results in hypotension. **Analysis of Incorrect Options:** * **Option A:** In neurogenic shock, the skin is typically **warm and dry** due to vasodilation and the loss of sympathetic sweat gland innervation. "Cool and moist" skin is characteristic of hypovolemic or cardiogenic shock. * **Option B:** Cardiac output is usually **decreased** or normal, never increased. The reduction in preload (due to venous pooling) and the loss of sympathetic drive to the heart prevent an increase in output. * **Option D:** While both bradycardia and hypotension are clinical features of neurogenic shock, the **primary hemodynamic mechanism** that defines the shock state is the massive drop in systemic vascular resistance. (Note: In many exams, if "all of the above" isn't an option, the physiological driver—decreased SVR—is the preferred answer). **High-Yield Clinical Pearls for NEET-PG:** 1. **The Classic Triad:** Hypotension, Bradycardia, and Hypothermia (due to poikilothermia). 2. **Distinguishing Feature:** It is the only type of shock where **bradycardia** occurs instead of compensatory tachycardia (due to disruption of T1-T4 cardioaccelerator fibers). 3. **Management:** Initial treatment involves aggressive fluid resuscitation followed by vasopressors (e.g., Norepinephrine or Phenylephrine) to restore vascular tone. Atropine is used to manage symptomatic bradycardia.

Question 1

Which of the following is NOT a complication of peritonitis?

Accepted Answer

Cardiac failure

Answer

Residual abscess

Answer

Endotoxic shock

Answer

Bone marrow suppression

Question 2

A 15-year-old girl, a regular swimmer, presents with sudden onset of abdominal pain, abdominal distension, and a fever of 39°C, along with obliteration of liver dullness. What is the most probable diagnosis?

Accepted Answer

Ruptured typhoid ulcer

Answer

Primary bacterial peritonitis

Answer

Ruptured ectopic pregnancy

Answer

Urinary tract infection with pelvic inflammatory disease

Question 3

All are included in the Child-Turcotte-Pugh classification except?

Accepted Answer

ALP

Answer

Bilirubin

Answer

Ascites

Answer

INR

Question 4

Which of the following is not a sign of appendicitis?

Accepted Answer

Murphy's sign

Answer

Rovsing's sign

Answer

Obturator sign

Answer

Psoas sign

Question 5

The composition of which of the following intravenous fluids most closely resembles that of plasma?

Accepted Answer

Lactated Ringer's solution

Answer

Isotonic saline

Answer

1/5th isotonic saline

Answer

4.3% dextrose

Question 6

A 26-year-old man is resuscitated with packed red blood cells following a motor vehicle collision complicated by a fractured pelvis and resultant hemorrhage. A few hours later the patient becomes hypotensive with a normal central venous pressure (CVP), oliguric, and febrile. Upon examination, the patient is noted to have profuse oozing of blood from his intravenous (IV) sites. Which of the following is the most likely diagnosis?

Accepted Answer

Transfusion reaction

Answer

Hypovolemic shock

Answer

Acute adrenal insufficiency

Answer

Gram-negative bacteremia

Question 7

Which of the following is true about abdominal compartment syndrome?

Accepted Answer

Decreased urine output

Answer

Intra-abdominal pressure > 15 cm H2O

Answer

Increased renal blood flow

Answer

Decreased venous return

Question 8

If the caecum is involved as a part of the wall of a hernial sac and is not its content, then it will be known as:

Accepted Answer

Sliding hernia

Answer

Richter's hernia

Answer

Spigelian hernia

Answer

Interstitial hernia

Question 9

Neurogenic shock is characterized by what?

Accepted Answer

Decreased peripheral vascular resistance

Answer

Cool and moist skin

Answer

Increased cardiac output

Answer

Bradycardia and hypotension

Question 10

A 50-year-old man presents with complaints of a painful tender mass situated one-third of the way between the xiphisternum and umbilicus. What is the likely diagnosis?

Accepted Answer

Epigastric hernia

Answer

Omphalocele

Answer

Spigelian hernia

Answer

Fibrosarcoma of the abdominal wall

General Surgery Principles — MCQs

General Surgery Principles — MCQs

On this page

Practice by Chapter

Want unlimited practice?