Key points
- Practice questions written for revision, not copies of any exam. They follow the single-best-answer vignette style of final and licensing exams.
- Topics: acute abdomen, trauma (ATLS principles), hernias, burns, thyroid, breast lumps, bowel obstruction, perioperative care and surgical infection.
- Each explanation covers why the answer is right and why the distractors are wrong.
- Management follows widely used international guidance. Check your local protocol before treating a patient.
Questions
1. A 20-year-old has 24 hours of central abdominal pain that moved to the right iliac fossa, with anorexia, vomiting and a temperature of 37.9 °C. What is the most likely diagnosis?
A. Acute cholecystitis
B. Acute appendicitis
C. Ureteric colic
D. Perforated peptic ulcer
E. Mesenteric adenitis in all cases
Answer: B. Pain that starts around the umbilicus and migrates to the right iliac fossa with anorexia and low-grade fever is classic for acute appendicitis. Ureteric colic gives loin-to-groin pain that comes in waves. Treat with appendicectomy and antibiotics. Imaging is used when the picture is unclear, particularly in women of childbearing age.
2. In the primary survey of a trauma patient, what is the correct order of priorities?
A. Circulation, airway, breathing, disability, exposure
B. Airway with cervical spine control, breathing, circulation with haemorrhage control, disability, exposure
C. Disability first, then airway
D. Breathing, airway, exposure
E. Exposure, circulation, airway
Answer: B. The ATLS approach is airway with cervical spine protection, breathing, circulation with control of external bleeding, disability (neurological status) and exposure with environment control. Life-threatening problems are treated as they are found. Catastrophic external haemorrhage is controlled first in many modern algorithms.
3. A man is stabbed in the chest and has a distended neck, low blood pressure, muffled heart sounds and clear lungs. What is the diagnosis?
A. Tension pneumothorax
B. Cardiac tamponade
C. Massive haemothorax
D. Flail chest
E. Pulmonary contusion
Answer: B. Hypotension, raised jugular venous pressure and muffled heart sounds (Beck's triad) indicate cardiac tamponade after penetrating chest trauma. Treat with emergency pericardiocentesis or thoracotomy. Tension pneumothorax also gives neck vein distension but with absent breath sounds and a deviated trachea.
4. A 70-year-old has colicky abdominal pain, vomiting, distension and has not passed stool or flatus for 3 days. There is an old midline scar. What is the most likely cause?
A. Adhesions
B. Gallstone ileus
C. Pancreatitis
D. Crohn's disease
E. Intussusception
Answer: A. Small bowel obstruction in a patient with previous abdominal surgery is most often due to adhesions. Resuscitate with fluids, a nasogastric tube and a urinary catheter, and operate if there are signs of strangulation, peritonitis or failure to settle. The commonest cause overall in a patient with no surgical history is an obstructed hernia.
5. A 45-year-old woman has a firm, painless 3 cm lump in the upper outer quadrant of the breast. What is the correct approach?
A. Reassure and review in 6 months
B. Triple assessment: clinical examination, imaging and core biopsy
C. Antibiotics for 2 weeks
D. Immediate mastectomy
E. Mammography alone
Answer: B. Any persistent breast lump requires triple assessment: clinical examination, imaging (ultrasound or mammogram, depending on age) and core needle biopsy. Fine needle cytology alone is no longer preferred. Treatment is planned after the pathology result.
6. A 30-year-old has a smooth, painless midline neck swelling that moves up on swallowing and on tongue protrusion. What is the diagnosis?
A. Branchial cyst
B. Thyroglossal cyst
C. Lymph node
D. Cystic hygroma
E. Carotid body tumour
Answer: B. A midline swelling that rises with tongue protrusion is a thyroglossal cyst, which is a remnant of the thyroid's descent. The Sistrunk procedure, which removes the cyst and the central part of the hyoid bone, reduces recurrence. A branchial cyst lies at the anterior border of the sternocleidomastoid.
7. A man has burns covering the whole of his anterior trunk and one entire arm (adult). Using the rule of nines, what is the approximate total body surface area?
A. 9%
B. 18%
C. 27%
D. 36%
E. 54%
Answer: C. The anterior trunk is 18% and one arm is 9%, so the total is 27%. Resuscitate with crystalloid using the Parkland formula (4 mL x weight in kg x %TBSA over 24 hours, half in the first 8 hours from the time of the burn) and monitor urine output.
8. A 65-year-old has a tender, irreducible lump in the groin that does not transmit a cough impulse, with vomiting. What should be done?
A. Elective repair next month
B. Urgent surgery for an obstructed or strangulated hernia
C. Truss
D. Antibiotics and review
E. Watchful waiting
Answer: B. An irreducible, tender hernia with vomiting suggests obstruction or strangulation of bowel, which needs emergency surgery. Femoral hernias lie below and lateral to the pubic tubercle and strangulate frequently, especially in women. Reducible, painless hernias are repaired electively.
9. A 50-year-old has sudden severe epigastric pain, a rigid abdomen and gas under the diaphragm on an erect chest X-ray. What is the diagnosis?
A. Acute pancreatitis
B. Perforated peptic ulcer
C. Small bowel obstruction
D. Biliary colic
E. Mesenteric ischaemia
Answer: B. Sudden severe pain with board-like rigidity and free air under the diaphragm indicates a perforated hollow viscus, most often a peptic ulcer. Resuscitate, give broad-spectrum antibiotics and a proton pump inhibitor, and proceed to surgery. Test for Helicobacter pylori and review the use of NSAIDs afterwards.
10. A patient has a wound infection 5 days after bowel surgery with erythema, purulent discharge and fever. What is the first step?
A. Antibiotics only
B. Open the wound, drain pus and send a swab, then give antibiotics if there is cellulitis or systemic signs
C. Close the wound tighter
D. Observe for a week
E. Remove all sutures from the abdomen
Answer: B. The mainstay of treating a surgical site infection with pus is drainage by opening the wound, with cultures and antibiotics for spreading cellulitis or systemic illness. Prevention includes appropriate antibiotic prophylaxis within an hour of incision, good skin preparation and maintaining normothermia.
11. A 55-year-old man has painless jaundice, weight loss and a palpable gallbladder. What is the sign called, and what is the likely cause?
A. Murphy's sign; gallstones
B. Courvoisier's sign; pancreatic head carcinoma
C. Cullen's sign; pancreatitis
D. Grey Turner's sign; trauma
E. Rovsing's sign; appendicitis
Answer: B. Courvoisier's law states that a palpable, non-tender gallbladder with jaundice is unlikely to be due to gallstones, and points to a malignant obstruction such as carcinoma of the head of the pancreas. Gallstones cause a fibrosed, contracted gallbladder that does not distend.
12. A patient with a blood pressure of 80/50 mmHg and a pulse of 130/min after a road traffic accident has a pelvic fracture. What is the most appropriate initial fluid strategy?
A. Large volumes of crystalloid until blood pressure normalises
B. Early blood products with permissive hypotension until bleeding is controlled
C. Oral fluids
D. No fluids
E. Dextrose 5% only
Answer: B. Damage control resuscitation uses early blood products and limits crystalloid, accepting a lower blood pressure until haemorrhage is controlled, except in head injury. Large volumes of crystalloid dilute clotting factors and worsen the lethal triad of acidosis, hypothermia and coagulopathy. Tranexamic acid should be given within 3 hours.
References
- American College of Surgeons. Advanced Trauma Life Support (ATLS) manual.
- Bailey and Love's Short Practice of Surgery. CRC Press.
- Browse's Introduction to the Symptoms and Signs of Surgical Disease. CRC Press.
- World Health Organization. Surgical Safety Checklist and guidelines for the prevention of surgical site infection.