General Surgery Principles Practice Questions

Q: A 30-year-old lady presents with fever and pain in the right hypochondrium, with a positive breath catch on palpation. What is the most likely clinical diagnosis?

Acute cholecystitis. ### Explanation **Correct Answer: B. Acute cholecystitis** The clinical presentation of fever, right hypochondriac pain, and a **"positive breath catch"** is the classic description of **Murphy’s Sign**, which is pathognomonic for acute cholecystitis. **Underlying Concept:** When a patient takes a deep breath, the diaphragm descends, pushing the inflamed gallbladder against the examiner’s stationary hand in the right hypochondrium. The contact between the inflamed parietal peritoneum and the gallbladder causes sharp pain, leading to a sudden arrest (catch) of inspiration. **Analysis of Incorrect Options:** * **A. Acute pancreatitis:** Typically presents with epigastric pain radiating to the back, often relieved by leaning forward. It does not typically elicit a positive Murphy’s sign. * **C. Acute appendicitis:** Usually presents with periumbilical pain migrating to the Right Iliac Fossa (McBurney’s point). While a high-lying (subhepatic) appendix can mimic gallbladder pain, Murphy’s sign is specific to the gallbladder. * **D. Acute mediastinitis:** Presents with retrosternal chest pain and systemic sepsis, usually following esophageal perforation or cardiac surgery; it has no association with abdominal palpation findings. **NEET-PG High-Yield Pearls:** * **Murphy’s Sign:** High sensitivity but lower specificity in the elderly. * **Boas’ Sign:** Hyperesthesia (increased sensitivity to touch) below the right scapula (distal distribution of the phrenic nerve), also seen in acute cholecystitis. * **Investigation of Choice:** Ultrasonography (USG) is the initial investigation; **HIDA scan** is the most sensitive (Gold Standard) for diagnosis. * **Saint’s Triad:** Cholelithiasis, Hiatus hernia, and Diverticulosis.

Q: Which of the following findings indicates hypoperfusion?

All of the above. **Explanation:** Hypoperfusion is defined as a state where the delivery of oxygenated blood is insufficient to meet the metabolic demands of tissues. It is the hallmark of shock. 1. **Systolic BP < 90 mm Hg:** While the body initially uses compensatory mechanisms (like tachycardia and vasoconstriction) to maintain blood pressure, a drop in systolic BP below 90 mm Hg (or a 40 mm Hg drop from baseline) is a classic clinical sign of **decompensated shock** and systemic hypoperfusion. 2. **Lactic Acidosis:** When tissues do not receive enough oxygen (hypoperfusion), cells shift from aerobic to **anaerobic metabolism**. This results in the production of lactate. A serum lactate level >2 mmol/L is a sensitive biochemical marker of occult tissue hypoxia. 3. **Oliguria:** The kidneys are highly sensitive to changes in perfusion. Hypoperfusion leads to decreased renal blood flow and a lower Glomerular Filtration Rate (GFR). Oliguria (urine output <0.5 mL/kg/hr in adults) is a key clinical indicator of end-organ dysfunction due to poor perfusion. **Why "All of the above" is correct:** Hypoperfusion is a multisystemic phenomenon. It manifests clinically through vital signs (hypotension), end-organ function (oliguria/altered mental status), and biochemical markers (lactic acidosis). Therefore, all three findings are valid indicators. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign of shock:** Tachycardia (except in neurogenic shock where bradycardia occurs). * **Best indicator of resuscitation adequacy:** Normalization of serum lactate levels and base deficit. * **Shock Index:** Heart Rate / Systolic BP (Normal: 0.5–0.7). An index >0.9 suggests significant hypoperfusion even if BP is "normal." * **Narrow Pulse Pressure:** Often precedes a drop in systolic BP in hemorrhagic shock.

Q: What is the best management for a contaminated wound with necrotic material?

Debridement. **Explanation:** The primary goal in managing a contaminated wound with necrotic material is to convert a "dirty" wound into a "clean" surgical wound. **Why Debridement is the Correct Answer:** Necrotic tissue acts as a culture medium for bacteria and prevents the formation of healthy granulation tissue. **Debridement** is the definitive surgical step that involves the removal of foreign bodies, devitalized tissue, and contaminants. By removing the nidus of infection and improving local blood supply, debridement reduces the bacterial load and creates an environment conducive to healing. In surgical principles, "source control" (debridement) always takes precedence over systemic therapy. **Analysis of Incorrect Options:** * **Tetanus Toxoid:** While essential for prophylaxis in contaminated wounds, it is an adjunct therapy. It prevents a specific complication (Tetanus) but does not address the existing infection or necrotic tissue. * **Gas Gangrene Serum:** This is largely of historical interest and is not used in modern standard management. Treatment for Clostridial infections is surgical debridement and high-dose Penicillin. * **Broad-spectrum Antibiotics:** Antibiotics are "adjuvants." They cannot penetrate necrotic, avascular tissue effectively. Without debridement, antibiotics alone will fail to clear the infection. **High-Yield Clinical Pearls for NEET-PG:** * **Golden Period:** Most traumatic wounds should be debrided and closed within 6 hours (the "Golden Period") to prevent established infection. * **Friedman’s Rule:** Debridement is the most important step in preventing gas gangrene. * **Wound Classification:** A wound with necrotic material is classified as a **Dirty/Infected wound** (Class IV), with an expected infection rate of >30% if not managed surgically.

Q: Which of the following is a cause of secondary hemorrhage?

Sloughing of the blood vessel wall. In surgery, hemorrhage is classified based on the timing of the bleed relative to the procedure. Understanding these distinctions is high-yield for NEET-PG. ### **Explanation of the Correct Answer** **Secondary Hemorrhage** occurs typically **7 to 14 days** after surgery. The underlying cause is almost always **infection**. Bacteria cause inflammation and suppuration, leading to the **sloughing of the blood vessel wall** or the breakdown of a suture line. Because it involves tissue necrosis, it is often a surgical emergency requiring antibiotics and proximal vessel ligation. ### **Analysis of Incorrect Options** * **A & B. Dislodgement of clot and Normalization of blood pressure:** These are the classic causes of **Reactionary Hemorrhage**. This occurs within **24 hours** (usually within 4–6 hours) of surgery. As the patient recovers from anesthesia and their blood pressure returns to normal (or "rebounds"), the increased pressure can dislodge a weak clot or "blow off" a ligature that was sufficient during the hypotensive state of surgery. * **D. All of the above:** This is incorrect because the mechanisms for reactionary and secondary hemorrhage are pathologically distinct. ### **High-Yield NEET-PG Pearls** * **Primary Hemorrhage:** Occurs at the time of injury or operation (e.g., inadequate ligation). * **Reactionary Hemorrhage:** Occurs within 24 hours. *Key trigger:* Rise in BP/Restlessness. * **Secondary Hemorrhage:** Occurs 7–14 days later. *Key trigger:* Infection/Sepsis. * **Management Tip:** For secondary hemorrhage in a limb, the treatment of choice is often ligation of the artery proximal to the infected site, as suturing the friable, infected vessel wall usually fails.

Q: Which of the following is NOT used in the treatment of Marjolin's ulcer?

Radiotherapy. **Explanation:** **Marjolin’s ulcer** is a highly aggressive **Squamous Cell Carcinoma (SCC)** that arises in areas of chronic inflammation, most commonly in old burn scars (cicatrix), chronic osteomyelitis sinuses, or long-standing venous ulcers. **Why Radiotherapy is the Correct Answer:** Radiotherapy is generally **avoided** and considered ineffective for Marjolin’s ulcer for two primary reasons: 1. **Radio-resistance:** The dense, avascular fibrous tissue (scar tissue) surrounding the ulcer is poorly oxygenated. Since radiation requires oxygen to generate free radicals for DNA damage, these ulcers are notoriously resistant to radiotherapy. 2. **Risk of recurrence/Malignancy:** Radiation can further compromise the blood supply to the already scarred area, leading to poor healing and potentially inducing further malignant transformation in the surrounding unstable skin. **Analysis of Incorrect Options:** * **A & D. Wide Excision/Resection:** This is the **treatment of choice**. A margin of at least 2 cm is required due to the high risk of local recurrence and the aggressive nature of the lesion. * **C. Amputation:** This is indicated if the ulcer is deep, involves the underlying bone (osteomyelitis), involves major neurovascular bundles, or if wide local excision would result in a non-functional limb. **Clinical Pearls for NEET-PG:** * **Latency Period:** The average time for malignant transformation is 30–35 years. * **Lymphatic Spread:** Unlike typical SCC, Marjolin’s ulcer has a higher rate of regional lymph node metastasis because the scar tissue lack normal lymphatics; once the tumor breaches the scar, it spreads rapidly. * **Biopsy:** Always perform an edge biopsy to confirm the diagnosis. * **Prognosis:** It is much more aggressive than primary SCC of the skin.

Q: Which classification is commonly used for diabetic foot gangrene?

Texas classification. The classification of diabetic foot ulcers and gangrene is a high-yield topic in surgery, focusing on assessing the severity and predicting the risk of amputation. **Explanation of the Correct Answer:** **A. Texas Classification:** This is currently the preferred system because it is more comprehensive than older models. It uses a dual-axis approach: **Grades (0-3)** based on the depth of the wound and **Stages (A-D)** based on the presence of infection, ischemia, or both. By incorporating vascular status (ischemia) and infection—the two primary drivers of limb loss—it provides a better prognostic value for healing compared to systems that only look at depth. **Explanation of Incorrect Options:** * **B. Wagner Classification:** While historically the most common, it is now considered less ideal because it primarily focuses on wound depth and does not adequately account for ischemia or infection in its early stages. However, it is still frequently tested (Grade 0: Pre-ulcerative; Grade 5: Extensive gangrene). * **C. Insulinoma:** This is a neuroendocrine tumor of the pancreas that secretes insulin, leading to hypoglycemia. It is unrelated to the classification of foot ulcers. **Clinical Pearls for NEET-PG:** * **Wagner Grade 3:** Characterized by deep ulcer with osteomyelitis or abscess. * **Wagner Grade 4:** Localized gangrene (forefoot/heel). * **Wagner Grade 5:** Entire foot gangrene. * **Monckeberg’s Sclerosis:** Often seen in diabetic patients, involving medial calcific sclerosis of arteries, leading to falsely elevated Ankle-Brachial Index (ABI) readings. * **Gold Standard for Ischemia:** While ABI is a screening tool, **Toe Pressure** or **Transcutaneous Oxygen Tension (TcPO2)** are more reliable in diabetics due to non-compressible vessels.

Q: Stereotactic surgery is used for the treatment of which of the following conditions?

Brain tumor. **Explanation:** **Stereotactic surgery** (or stereotactic radiosurgery/biopsy) is a minimally invasive technique that uses a three-dimensional coordinate system to locate small targets inside the body and perform actions such as biopsies, injections, or radiation delivery with high precision. **Why Option A is Correct:** The skull provides a fixed, rigid frame of reference, making the **brain** the ideal organ for stereotactic procedures. By using a stereotactic frame (like the Lexsell frame) or frameless neuronavigation based on CT/MRI scans, neurosurgeons can reach deep-seated brain tumors with millimeter precision, minimizing damage to surrounding eloquent brain tissue. It is the gold standard for brain biopsies and Gamma Knife surgery. **Why Other Options are Incorrect:** * **Options B, C, and D (Lungs, Cervix, Renal):** These organs are located in the thorax and abdomen/pelvis. Unlike the brain, these organs are not encased in a rigid bony structure and are subject to **physiological motion** (respiration, peristalsis, and bladder filling). While "Stereotactic Body Radiotherapy" (SBRT) exists for these areas, the term "Stereotactic Surgery" classically refers to intracranial procedures where a fixed spatial coordinate system is applied to a stationary target. **Clinical Pearls for NEET-PG:** * **Gamma Knife:** A form of stereotactic radiosurgery (SRS) specifically used for intracranial lesions (e.g., Acoustic Neuroma, AVMs, Trigeminal Neuralgia). * **Key Components:** Requires a stereotactic frame, an imaging modality (CT/MRI), and a mathematical target localization software. * **Advantages:** Reduced hospital stay, ability to reach "inoperable" deep-seated lesions, and avoidance of large craniotomies.

Question 1

What is true about pelvic abscess?

Accepted Answer

May spontaneously drain via the rectum.

Answer

An uncommon cause of intraperitoneal abscess.

Answer

Identified by CT scan if there is a full bladder.

Answer

Associated with pyothorax.

Question 2

A 30-year-old lady presents with fever and pain in the right hypochondrium, with a positive breath catch on palpation. What is the most likely clinical diagnosis?

Accepted Answer

Acute cholecystitis

Answer

Acute pancreatitis

Answer

Acute appendicitis

Answer

Acute mediastinitis

Question 3

Which of the following findings indicates hypoperfusion?

Accepted Answer

All of the above

Answer

Systolic BP < 90 mm Hg

Answer

Lactic acidosis

Answer

Oliguria

Question 4

To avoid suture marks, when should sutures on the face be removed?

Accepted Answer

3-5 days

Answer

72 hours

Answer

1 week

Answer

2 weeks

Question 5

Splenectomy is not indicated in which of the following pathologies?

Accepted Answer

Sarcoidosis

Answer

Trauma

Answer

ITP

Answer

Hereditary spherocytosis

Question 6

What is the best management for a contaminated wound with necrotic material?

Accepted Answer

Debridement

Answer

Tetanus toxoid

Answer

Gas gangrene serum

Answer

Broad spectrum antibiotics

Question 7

Which of the following is a cause of secondary hemorrhage?

Accepted Answer

Sloughing of the blood vessel wall

Answer

Dislodgement of clot within 24 hours

Answer

Normalisation of blood pressure

Answer

All of the above

Question 8

Which of the following is NOT used in the treatment of Marjolin's ulcer?

Accepted Answer

Radiotherapy

Answer

Wide excision

Answer

Amputation

Answer

Resection

Question 9

Which classification is commonly used for diabetic foot gangrene?

Accepted Answer

Texas classification

Answer

Wagner classification

Answer

Insulinoma

Answer

None of the above

Question 10

Stereotactic surgery is used for the treatment of which of the following conditions?

Accepted Answer

Brain tumor

Answer

Lungs carcinoma

Answer

Cervix cancer

Answer

Renal carcinoma

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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