GENERAL SURGERY – FINALS
SEM 6
Specify wrong concept
Select one:
a. Cardiogenic shock
b. Obstructive shock
c. Hypovolemic shock
d. Congenital shock
Which of the following statements are false?
Select one:
a. Multiorgan failure is the commonest cause of death in trauma.
b. 40 per cent of deaths from trauma
are due to torso injury.
c. Junctional zones help in the overall management.
d. Good history and understanding of the mechanism of injury will help
predict the type of injury.
The tension pneumothorax mostly can become a reason of:
Select one:
a. Obstructive shock
b. Septic shock
c. Cardiogenic shock
d. Hypovolemic shock
What is the most reliable way to ascertain correct placement of an
endotracheal tube?
Select one:
a. Detection of breath sounds on auscultation
b. Detection of a pressure waveform on
inflation
c. Direct visualization
d. Measurement of end-tidal carbon dioxide concentration
All of the following are causes of
hypovolaemic shock except?
Select one:
1. Haemorrhage;
2. Severe diarrhea;
3. Severe vomiting:
4. Constipation.
The indications for blood transfusion are:
Select one:
1. Acute blood loss, to replace circulating volume and maintain oxygen
delivery:
2. Perioperative anaemia, to ensure adequate oxygen delivery during
the perioperative phase;
3. Symptomatic chronic anaemia, without haemorrhage or impending
surgery:
4. All of them
5. None of them
In trauma, all of the following statements are true except?
Select one:
a. It is the third most common cause of death overall.
b. The 'imperative of time' dictates the
priority of treatment.
c. young patients are involved in road traffic accidents characterised by
low energy transfer.
d. It is the leading cause of death and disability below 40 years of age.
Complications from massive transfusion include all except:
Select one:
1. coagulopathy
2. hypocalcaemia
3. hyperkalaemia
4. hypokalaemia
5. hyperthermia.
Major determinants of the outcome of a burn are:
Select one:
a. All of them
b. Presence of an inhalational injury
c. Depth of burns
d. Percentage surface area involved
Shock is a clinical syndrome resulting from:
Select one:
a. All of them;
b. Inadequate tissue perfusion
c. Intensive metabolism of tissue
d. Starvation
An 75-year-old male has been complaining of increasing lower
abdominal pain for the past week. On examination he looks very unwell
with warm peripheries. He has signs of generalised peritonitis. His pulse
is 131/min and his BP 85/48 mmHg. What will be the correct diagnosis?
Select one:
a. Cardiogenic shock
b. Septic shock
c. Hypovolemic shock - hemorrhagic
d. Neurogenic shock
Which of the following are true of preoperative patient preparation?
Select one:
a. All of them;
b. It is to anticipate and plan for management of perioperative
problems.
c. It includes a thorough history-taking
and medical examination.
d. The patient's medical state is optimized
All of the following are a problem associated with surgery in the
jaundiced patient except?
Select one:
a. Myocardial infarction.
b. Clotting disorders
c. Hepatorenal syndrome
d. Poor wound healing
Which of the following statements regarding preoperative
management of specific medical problems are true?
Select one:
a. Elective surgery should be delayed until at least 1 year after a
myocardial infarction (MI).
□ b. Patients with a diastolic pressure above 95 mmHg should have
their elective operations postponed.
c. There is no need to control tachyarrhythmias preoperatively.
d. Preoperative transfusion should be considered if the Hb level <10
g/dL
A 18-year-old male is brought to the hospital after sustaining an
abdominal injury while playing rugby. He is complaining of left upper
abdominal pain and has some bruising over the same area. His pulse is
141/min and his BP is 101/80 mmHg. What will be the correct
diagnosis?
Select one:
a. Cardiogenic shock
b. Neurogenic shock
c. Septic shock
d. Hypovolaemic shock – haemorrhagic
Complications from a single transfusion include:
Select one:
1. Incompatibility haemolytic transfusion reaction
2. Febrile transfusion reaction
3. Allergic reaction
4. Infection
5. All of them
6. None of them
Which of the following causes of shock result from reduced systemic
vascular resistance?
Select one:
1. Haemorrhagic shock;
2. Septic shock;
3. Cardiogenic shock;
4. All of them;
All of the following is a problem associated with surgery in obese
patients except?
Select one:
a. Deep vein thrombosis (DVT)/embolism
b. Myocardial infarction
c. Pain control.
d. Aspiration
commonly used intravenous anesthetic agents are all of them
except: 0 Select one: a. Vancomycin; b. Propofol; c. Ketamine;
d. Thiopentone
10-Which of the following statements are false? Select one:
a. Multiorgan failure is the commonest cause of death in
trauma. b. 40 per cent of deaths from trauma are due to
torso injury. c. Junctional zones help in the overall
management. d. Good history and understanding of the
mechanism of injury will help predict the type of injury
Patients vary greatly in their requirement for postoperative
analgesia. What is the best way to assess adequacy of pain
relief? Select one: a. Assess the level of hypertension. b. Look
for tachypnea. c. Measure the degree of tachycardia. d. Ask the
patient to measure the pain
Which of the following is not part of the anesthetic triad
used during surgery? Select one: a. Amnesia b. Muscle
relaxation. c. Pain relief d. Unconsciousness
-
Which of the following statements regarding preoperative
investigations is false? Select one: a. A ventricular ejection
fraction of less than 35 per cent indicates a high risk of cardiac
complications. b. A body mass index (BMI) c. ECG is usually
required in patients above 65 years. d. Chest X-ray is routinely
requested in all patients over 60 years old
What is the most significant disadvantage of the laryngeal mask
airway (LMA) over an endotracheal tube? Select one: a.
Unreliable placement b. Failure to provide a competent airway
c. Enhanced risk of tube obstruction d. Risk of pulmonary
aspiration
All of the following is a risk factor for thrombosis except? Select
one: a. Trauma b. Pregnancy c. Young age d. Smoking
What is the most reliable way to ascertain correct placement of
an endotracheal tube? Select one: a. Detection of a pressure
waveform on inflation b. Detection of breath sounds on
auscultation c. Measurement of end-tidal carbon dioxide
concentration d. Direct visualization
- Late complications of intubation can be all of them except:
Select one: a. Trauma to teeth, pharynx, larynx; b. Aspiration of
gastric contents during intubation c. Accidental bronchial
intubation; d. Tracheal stenosis
Complications from massive transfusion include: ●
coagulopathy; ● hypocalcaemia; ● hyperkalaemia; ●
hypokalaemia; ● hypothermia.
QUESTIONS FROM
BAILEY’S QN BANK
1. Which of the following statements regarding burns in
children in the UK are true?
A The majority are electrical or chemical.
B The majority are most commonly scalds.
C Hot water thermostat setting at 60ºC helps to improve
safety in homes.
D Intravenous (IV) resuscitation in children is required for
burns greater than 5 per cent of total body surface area
(TBSA) and less than 10 per cent.
E Non-accidental injury is common in children’s burns.
2. Regarding burn injury in adults in the UK, which of the
following statements are true?
A Electrical and chemical burns are common.
B Scalds in the home are more common than flame burns.
C Alcohol problems are rare in relation to burn injury.
D Effective care requires multidisciplinary input.
E Intravenous fluids are required for burns of 15 per cent
TBSA or more.
3. Which of the following statements regarding respiratory
problems in burns are true?
A Burn injury to this function may be lethal.
B Injury can be due to inhalation of hot or poisonous
gases.
C Burn injury is more common in the supraglottic than in
the lower airway.
D Haemoglobin combines with carbon monoxide less
easily than with oxygen.
E Hydrogen cyanide interferes with mitochondrial
respiration
4. Which of the following statements regarding smoke
inhalation are true?
A Inhaled smoke particles can cause a chemical alveolitis
and subsequent increased gaseous exchange.
B Inhaled smoke particles may be suspected with a
specific situation in an enclosed space.
C Early elective intubation is contraindicated.
D Symptoms can take 24 h or up to 5 days to develop.
E The result of carbon monoxide poisoning is a metabolic
alkalosis best treated by low inspired oxygen.
5. Which of the following statements are true in relation to
burns and TBSA?
A Epidermal destruction can occur when a surface
temperature of 70ºC is applied for 1 s.
B A child’s head comprises a smaller percentage of TBSA
than that of an adult.
C According to the Lund and Browder chart, an adult with
burns involving both sides of one upper limb as well as the
hand has been burned on 15 per cent of TBSA.
D The ‘rule of nines’ is an accurate guide to the size of a
burn outside the hospital environment.
E In small burns the patient’s whole hand is 1 per cent of
TBSA and is a useful guide to assess a burn
6. Which of the following statements regarding burn depth are true? A The
depth of a burn together with percentage of TBSA and smoke inhalation are
key parameters in the assessment and management of a burn. B Alkalis,
including cement, usually result in superficial burns. C Fat burns are deeper
than electrical contact burns. D Capillary filling is not present in superficial
burns. E Deep dermal burns take a maximum of 2 weeks to heal without
surgery
7. 7. Which of the following statements regarding the consequences of burns
are true? A As a result of a burn, complement causes degranulation of mast
cells and, subsequently, neutrophils. B Mast cells do not release primary
cytokines. C As a result of a burn, an increase in vascular permeability
occurs. D Following a burn, water only moves from intravascular to the
extravascular space. E In burns affecting more than 15 per cent TBSA in an
adult, fluid loss results in shock and the volume lost as fluids is directly
proportional to the area of burn.
8. 8. Which of the following statements regarding burn complications are
true? A Cell-mediated immunity is increased in major burns. B Infections
with bacteria and fungi are rare in large burns. C Malabsorption from gut
damage is a known complication in a burned patient. D Circumferential fullthickness burns of a limb can result in ischaemia. E A change in voice is an
important clinical sign in a burned patient
9. 9. Which of the following statements regarding the treatment of burns are
true? A Cooling of a scald for a minimum of 10 min is of no value in giving
analgesia or slowing the injury associated with a fresh burn. B Other nonburn injuries may coexist with a burn. C Major determinants of burn
outcome are percentage of TBSA, depth and the presence of any inhalation
injury. D Criteria for acute admission to a burns unit do not exist or are
unnecessary. E A significant hand burn should not be admitted to a burns
unit and can easily be managed as an outpatient.
10.10. Which of the following statements are true? A The depth of a burn can
initially be assessed from the offending temperature, time of application
and nature of the causative agent. B Electric contact burns are almost
certainly full-thickness. C Deep, partial-thickness burns involve destruction
of the whole dermis. D Sensation is totally absent in a fullthickness burn. E
Tangential shaving may be a useful diagnostic and management tool in
partial-thickness burns.
11.11. Which of the following statements are true? A Oral fluids containing no
salt are essential when given as fluid replacement in burns. B Fluids
required can be calculated from a standard formula. C Hyponatraemia can
be avoided in oral fluid management by rehydrating with a solution such as
Dioralite. D Urine output gives a major clue as to adequacy of fluid
replacement. E Three types of fluid can be used for IV fluid replacement in
burns: Ringer’s lactate, hypertonic saline or colloids.
12.Which of the following statements are true? A The simplest and most
commonly used crystalloid is Ringer’s lactate. B Hypertonic saline produces
an excess of intracellular water shifting to the extracellular space. C Human
albumin solution is a colloid which reduces protein leak out of cells, thereby
helping to reduce oedema. D The Parkland formula is the most widely used
formula in the UK and calculates the fluid replacement in the first 24 h. E
Using the Parkland formula, the fluid requirement in the first 24 h for a man
of 70 kg with a burn involving both upper limbs, including the hands, is
4800 mL.
13.13. Which of the following statements are true? A In resuscitation, a urine
output of 0.5 mL/kg body weight per h does not mean that the rate of
infusion should be altered B In resuscitation, a urine output of 1 mL/kg
body weight per h indicates the fluid rate infusion is too low C In
resuscitation, hypoperfusion is recognised by cool extremities D Urine
output in excess of 2 mL/kg body weight per h is associated with a low
haematocrit. E In large burns, monitoring tissue perfusion by a central line
may be required even though there is increased infection risk.
14.14. Which of the following statements are true? A Escharotomy is
associated with noncircumferential superficial burns. B Significant blood
loss is not a feature to be considered when escharotomy is contemplated C
Damage to major nerves will not be the result of incorrect escharotomy
incisions. D Escharotomy of the hand and fingers is best done outside of a
main operating theatre. E In the lower limb, for escharotomy, the incision
should be anterior to the ankle medially
15.15. Which of the following statements are true? A Superficial burns can be
treated by a variety of simple dressings, such as Vaseline gauze, or by the
exposure method, particularly for small burns of the face, when the climate
is hot and intensive nursing support is readily available. B Deep dermal
burns, or those that are nearly deep dermal, require dressings in order to
reduce pain, reduce or treat infection, reduce scarring, and operations. C
Hydrocolloid dressings such as Duoderm can be left on for 14 days. D Silver
sulphadiazine (1 per cent) can be used effectively as a broad
spectrumantibiotic but not for methicillin-resistant Staphylococcus aureus
(MRSA). E An optimal healing environment can make a difference to the
outcome in borderline-depth burns.
16. 16. Which of the following statements are true? A Biological dressings and
synthetic ones such as Biobrane do not need to be changed and are useful
in deep and mixed-depth burns. B Amniotic membranes are ideal dressings
for one-stop management of superficial burns but not for deep burns. C A
fenestrated silicone sheet such as Mepitel can be used in superficial burns
and is non-permeable. D Honey or boiled potato peel are unusual dressings
for superficial burns but can be effective E Pseudomonas aeruginosa is not
treatable by 1 per cent silver sulphadiazine cream
17.17. Which of the following statements are true? A Analgesia is a vital part
of burn management. B For large burns over 10 per cent TBSA,
intramuscular (IM) injections of opiates are best. C Removing the burn
tissue and achieving healing reduce pain and are also effective in stopping
the catabolic drive. D In adults with burns covering 15 per cent TBSA or
more, extra feeding is required. E The greatest nitrogen losses in burns
occurs between 20 and 25 days.
18.18. Which of the following statements are true? A Infection control requires
attention to handwashing and cross-contamination prevention. B A rise or
fall in white cell count and a decreasing clinical status are signs of infection.
C Swabs taken from the burn and sputum are of no use in building a picture
of the patient’s flora. D Antibiotics given should be ideally based on
cultures and on discussion with a microbiologist. E Catheter tips are a
possible source of an infection
19.19. Which of the following statements regarding allied therapy in burn
patients are true? A Success or failure of both physical and psychological
care of the burn patient is dependent on intensive nursing and
physiotherapy management. B Physiotherapy can be best done after 2–3
weeks C Post traumatic stress disorder can occur as a result of burns. D
Psychological help may be required for relatives of the burned patient. E
Elevation of hands that have sustained burns is not indicated.
20.20. Which of the following statements are true? A The management of
blisters – leaving them intact or removing them – remains debatable. B
Initial cleaning of a burn wound with chlorhexidine solution is
contraindicated. C If a burn has not healed within 3 weeks, it is worth
avoiding debridement and skin grafting D Any burn of indeterminate depth
should be reassessed after 2 weeks. E Deep dermal burns need tangential
shaving and split-skin grafting while all but the smallest full thickness burns
need surgical excision and grafting if possible.
21.21. Which of the following statements regarding surgical management of
burns are true? A The anaesthetist is of great assistance and essential in the
management of a major burn. B Blood loss is not a feature of surgery in
major burns. C Blood loss may be reduced by use of a tourniquet or by
application of a skin graft or topical or subcutaneous diluted solution of
adrenaline. D A core temperature below 36ºC may affect blood clotting. E
Synthetic dermis, including Integra or homografts, may provide temporary
stable cover following excision of larger burns.
22.22. Which of the following statements are true? A Physiotherapy and
splintage are important in maintaining range of movement and reducing
joint contracture B It is not necessary to splint the hand after skin grafting.
C Supervised movement by physiotherapists under direct vision of any
affected joints should begin after about 2 weeks. D Escharotomy of the
circumferential burn of the upper trunk should help respiratory function. E
Early care must be taken when eyelids are burned
23.23. Which of the following statements are true? A Early surgery is indicated
in the hands and axilla. B Contractures are best treated with splitskin grafts.
C Tissue expansion is useful in treating alopecia caused by a burn. D A Zplasty is a useful technique for reconstruction of broad areas of burn
scarring causing restricted movement. E Full-thickness grafts or
vascularised tissue, as in a free flap, are generally unnecessary in burn scar
management when good vascularised tissue is available in the treated burn
scar.
24.24. Which of the following statements regarding scar management of burns
are true? A Hypertrophy of a burn scar can be treated by the use of
pressure garments worn for a month. B Intralesional steroid injection or
silicon patches may be useful in small areas of burn scar hypertrophy. C
Pharmacological treatment of itchy burn scars is not important. D Use of
Integra to resurface a healed fullthickness burn scar can improve scar
quality. E Flamazine cream should not be used as a topical agent in
pregnant or nursing mothers.
25.25. Which of the following statements are true? A Low-tension electrical
burn injury is most likely to be found in accidents in the home. B Underlying
heart muscle damage is likely in low-tension injuries. C Large amounts of
damage to subcutaneous tissues and muscle are associated with hightension electrical burns. D Myoglobinuria is a serious complication of lowtension burns. E Severe alkalosis is common in large electrical burns
26.26. Which of the following statements are true? A Copious water lavage is
the best first-aid measure for phosphorus burns. B Elemental sodium burns
should not be treated by water lavage. C Damage from alkalis is usually less
than with acids. D Hydrofluoric acid burns can be associated with
hypercalcaemia. E Local radiation burns causing ulceration need excision
and split-skin graft repair
SHOCK AND BLOOD
TRANSFUSION
1. 1. Which of the following statements are true? A Cells change
from aerobic to anaerobic metabolism when perfusion to tissues
is reduced. B The product of aerobic respiration is lactic acid. C
The product of anaerobic respiration is carbon dioxide. D The
accumulation of lactic acid in the blood produces systemic
respiratory acidosis. E Lack of oxygen and glucose in the cell will
eventually lead to failure of sodium/ potassium pumps in the cell
membrane and intracellular organelles
2. 2. Which of the following statements regarding hypovolaemic
shock are true? A It is associated with high cardiac output. B The
vascular resistance is high. C The venous pressure is low. D The
mixed venous saturation is high. E The base deficit is low.
3. 3. Which of the following statements about ischaemiareperfusion syndrome is correct? A This refers to the cellular
injury because of the direct effects of tissue hypoxia. B It is seen
after the normal circulation is restored to the tissues following
an episode of hypoperfusion. C The increased sodium load can
lead to myocardial depression. D This is influenced by the
duration and extent of tissue hypoperfusion. E It usually does
not cause death
4. 4. In which of the following cases might tachycardia accompany
shock? A Hypovolaemia due to gastrointestinal (GI) bleeds B
Patients on alpha-blockers C Patients with implanted
pacemakers D Fit young adults with normal pulse rate of 50/min
E Cardiogenic shock.
5. 5. Which of the following regarding blood pressure in shock are
false? A Elderly patients who are normally hypertensive may
present with a ‘normal’ blood pressure. B Children and fit young
6.
7.
8.
9.
adults are able to maintain blood pressure until the final stages
of shock. C Hypotension is one of the first signs of shock. D Betablockers may prevent a tachycardic response. E Blood pressure is
increased by reduction in stroke volume and peripheral
vasoconstriction.
6. Which of the following statements about compensated shock
are false? A The preload is preserved by the cardiovascular and
endocrinal compensatory responses. B Tachycardia and cool
peripheries may be the only clinical signs. C The perfusion to the
skin, muscle and GI tract is increased D Systemic respiratory
acidosis is seen. E Patients with occult hypoperfusion for more
than 12 hours have a significantly higher mortality rate.
7. Which of the following statements are false? A Administration
of inotropic agents to an empty heart will help to increase
diastolic filling and coronary perfusion. B In all cases, regardless
of classification, hypovolaemia and preload must be addressed
first. C Long, wide-bore catheters allow rapid infusion of fluids. D
The oxygen-carrying capacity of both colloids and crystalloids is
zero. E Hypotonic solutions are poor volume expanders and
should not be used in shock except in conditions of free water
loss or sodium overload
8. Which of the following are true regarding inotropic support in
shock? A This is the first-line therapy in hypovolaemic shock. B
Phenylephrine and noradrenaline are indicated in distributive
shock states. C Dobutamine is the agent of choice in cardiogenic
shock or septic shock complicated by low cardiac output. D
Vasopressin may be used when the vasodilatation is resistant to
catecholamines. E Use in the absence of adequate preload may
be harmful.
9. Which of these statements about mixed venous saturation are
false? A The percentage saturation of oxygen returning to the
heart from the body is a measure of the oxygen delivery and
extraction by the tissues. B The normal mixed oxygen saturation
levels are 30–40 per cent C Accurate measurements are via
analysis of blood drawn from a line placed in the superior vena
cava (SVC). D Levels below 50 per cent indicate inadequate
oxygen delivery consistent with hypovolaemic shock. E High
mixed venous saturation levels are seen in sepsis.
10.
10. Which of the following about reactionary haemorrhage
are false? A This is delayed haemorrhage occurring within 24 h
after operation. B It is usually caused by dislodgement of clot,
normalisation of blood pressure or slippage of ligature. C It is
associated with infection. D It can be significant, requiring reexploration. E It is usually venous.
11.
11. Which of the following about blood transfusion are
false? A A haemoglobin level of 10 g/dL or less is now considered
a typical indication. B Fresh frozen plasma (FFP) is considered as
the first-line therapy in coagulopathic haemorrhage. C
Cryoprecipitate is useful in lowfibrinogen states and in factor VIII
deficiency. D Platelets have a shelf life of 3 weeks. E Patients can
pre-donate blood up to 3 weeks before surgery for autologous
transfusion
12.
12. Which of the following is a complication of massive
blood transfusions? A Coagulopathy B Hypercalcaemia C
Hyperkalaemia D Hypokalaemia E Hypothermia.
13.
1 A 7-year-old boy with nut allergy develops stridor and
collapses after eating a snack. He requires airway and breathing
support. His BP is 60/38 mmHg: Anaphylactic shock
14.
A 78-year-old man with known ischaemic heart disease (IHD)
complains of chest pain and collapses. His pulse is irregular and
BP is 74/48 mmHg. ECG shows features of an anterolateral
myocardial infarction (MI): Cardiogenic shock
15.
3 A 76-year-old male is brought to the hospital with
persistent diarrhoea and vomiting for the past 4 days. He has
been unable to keep his food down and feels very tired. On
examination he is very dehydrated. His pulse is 128/min and his
BP is 88/52 mmHg.: Hypovolaemic shock – non-haemorrhagic
16.
4 A 55-year-old woman with poorly controlled
hypothyroidism is found comatose. She is hypothermic. Her
pulse is irregular and her BP is 96/70 mmHg. : Endocrinal shock
17.
5 An 86-year-old male has been complaining of increasing
lower abdominal pain for the past week. On examination he
looks very unwell with warm peripheries. He has signs of
generalised peritonitis. His pulse is 130/min and his BP 84/50
mmHg. : Septic shock
18.
6 A 28-year-old motorist is brought to the A&E after a road
traffic accident (RTA). He has sustained an isolated injury to his
back and has motor and sensory deficits in both lower limbs. His
pulse is 122/min and his BP 100/62 mmHg. : Neurogenic shock
19.
7 A 19-year-old male is brought to the hospital after
sustaining an abdominal injury while playing rugby. He is
complaining of left upper abdominal pain and has some bruising
over the same area. His pulse is 140/min and his BP is 100/82
mmHg.: Hypovolaemic shock – haemorrhagic
20.
1 A 86-year-old woman is admitted with a haemoglobin (Hb)
of 5.6 g/dL. The HO prescribes 4 units of blood. These 4 units are
transfused over a period of 6 h. Four hours later the patient is
found to be having difficulty in breathing. Chest examination
reveals fine creps bilaterally. Chest X-ray confirms pulmonary
oedema. : Fluid overload
21.
2 A 28-year-old male is taken to a nearby hospital after
sustaining injuries while on a safari in Africa. He has lost a lot of
blood and is hence given 2 units of blood transfusion. He
develops fever and chills with rigors the next day. Peripheral
blood smear demonstrates malarial parasite. : Infection
22.
3 A 38-year-old man requires several units of blood
transfusion due to multiple injuries sustained as a result of a fall.
He develops tetany and complains of cicumoral tingling. :
Hypocalcaemia
23.
4 A 34-year-old motorcyclist sustains multiple injuries after
an RTA. He is brought to the hospital in severe shock and
requires multiple blood transfusions. It is observed that the
bleeding is still uncontrolled and the blood fails to clot. :
Disseminated intravascular coagulation (DIC)
24.
5 The ward is very busy and quite a few staff have phoned in
sick. There are two patients (with the same surnames) needing
blood transfusions. The staff nurse points to the blood units on
the table and asks the HCA to start them as she is just going off
for her break. The blood transfusion is started. Within a few
minutes the patient is unwell and his urine is haemorrhagic. He
collapses and becomes anuric. He is also found to be jaundiced
Haemolytic transfusion reaction due to incompatibility
25.
1 Cardiogenic shock when myocardial depression
complicates shock state. : Dobutamine
26.
2 Distributive shock due to sepsis. : Noradrenaline
27.
3 Vasodilatation resistant to catecholamines due to relative
or absolute steroid deficiency.: Vasopressin
28.
4 Hypovolaemic shock due to splenic injury. : No role for
vasopressor or inotropic agent
29.
5 Distributive shock due to spinal cord injury: Phenylephrine
SURGICAL INFECTION
1.
1. Which of the following are part of Koch’s postulates? A It must be found in considerable
numbers in the septic focus. B A reduction in the organisms should be achieved by using
appropriate antibiotics. C It should be possible to culture it in a pure form from the septic
focus. D Healing of a wound is possible without pus formation. E It should be able to
produce similar lesions when injected into another host.
2.
2. Which of the following is a natural barrier to infection? A Intact epithelial surface B High
gastric pH C Antibodies D Antibiotics E Macrophages
3.
3. Which of the following is a cause of reduced host resistance to infection? A
Malnutrition B Heart failure C Cancer D AIDS E Systemic sclerosis
4.
4. Which of the following is a risk factor for wound infection? A Poor perfusion B Use of
skin clips for wound closure. C Poor surgical technique D Not using prophylactic antibiotics
E Uraemia
5.
5. Which of the following is a cause of secondary (or exogenous) infection? A Poor handwashing technique B Community C Perforated diverticular disease D Anastomotic leak E
Inadequate air filtration in the theatre.
6.
6. Which of the following statements about surgical site infections (SSIs) are true? A
Infection in the musculofascial tissues is known as deep SSI. B The patient may have
systemic signs in a minor SSI. C Infection causing delay in hospital discharge is a major SSI.
D The differentiation between major and minor SSIs is not important. E Surveillance for
surgical site infection should be done for a year after implanted joint surgery
7.
7. Which of the following statements regarding abscesses are true? A Staphylococcus
aureus is one of the most common causative organisms. B The abscess wall is composed
of epithelium. C Most wound-site abscesses occur before the patient is discharged from
the hospital. D Antibiotics are indicated if there is evidence of cellulitis. E Actinomyces can
cause a chronic abscess.
8.
8. Which of the following statements regarding cellulitis are true? A This is nonsuppurative invasive infection of tissues. B It is poorly localised. C It is commonly caused
by Clostridium perfringens. D Systemic signs are not present. E Blood culture is usually
positive
9.
9. Which if the following can be seen in SIRS? A Hypothermia ( < 4 1000/dL C No
documented infection D Tachycardia ( >90/min) E Tachypnoea ( >20/min).
10.
10. Which of the following statements about severe sepsis (sepsis syndrome) are true?
A Acute respiratory distress syndrome (ARDS) is common. B There is absence of
documented infection. C Multiple organ dysfunction syndrome (MODS) is the systemic
effect of infection. D Multiple system organ failure (MSOF) is the end stage of
uncontrolled MODS. E MSOF is mediated by released cytokines such as interleukins (IL-6)
and tumour necrosis factor (TNF)-alpha
11.
11. Which of the following statements regarding clostridial wound infections are true? A
Clostridia are Gram-positive aerobic spore-bearing cocci. B Thin, brown and sweetsmelling exudate is seen in gas gangrene C Necrotic and foreign material in wounds
increase risk. D The spores are widely spread in soil and manure. E The signs and
symptoms are due to the endotoxins
12.
12. Which of the following statements are true? A Identification of the causative
organism should be done before starting antibiotics. B Wounds are best managed by
delayed primary or secondary closure. C Subcuticular continuous skin closure decreases
the incidence of wound infection. D Polymeric films can be useful in infected wounds. E
Administration of antibiotic preparations locally is more effective than the oral route
13.
13. Which of the following affects the choice of prophylactic antibiotic? A The expected
spectrum of organisms likely to be encountered B Cost C Personal preference D Hospital
policies E Local resistance strains.
14.
14. Which of the following may require more than one dose of prophylactic antibiotic? A
Prolonged operations B Excessive blood loss C Gastrointestinal surgery D Insertion of
prosthesis E Unexpected contamination.
15.
15. Which of the following measures is useful in reducing surgical wound infection? A
Antiseptic skin preparation B Shaving of area C Avoid hypothermia perioperatively D
Increasing hospital stay to detect more infections E Supplemental oxygen in recovery
room.
16.
16. Which of the following statements about types of wounds are true? A The infection
rate in a ‘clean wound’ is between 1 and 2 per cent. B The wound after a biliary surgery is
classified as ‘contaminated’. C A ‘clean-contaminated wound’ has an infection rate of less
than 10 per cent. D Antibiotic prophylaxis would be mandatory in ‘dirty wounds’. E The
role of prophylactic antibiotics in non-prosthetic clean surgery is controversial
17.
17. Which of the following statements regarding bacteria in surgical infection are true?
A Beta-haemolytic Streptococcus is always associated with infection. B All streptococci are
sensitive to penicillin and erythromycin. C Staphylococci are normally resident in the
nasopharynx of up to 15 per cent of the population. D Staphylococcal epidermidis is a
commensal and does not cause clinical infection. E Gram-negative bacilli are a major cause
of infection related to urethral catheterisation.
18.
18. Which of the following statements regarding antimicrobial treatment of surgical
infections are true? A Antibiotics are mandatory in all SSIs. B Antibiotics should not be
started before knowing the causative organism and sensitivity. C A ‘broad-spectrum’
approach is used while treating methicillin-resistant Staphylococcus aureus (MRSA)
infections. D Antibiotics can be used as a replacement for surgical drainage. E Rotating
antibiotics may be required in the treatment of ‘resident opportunists’.
19.
19. Which of the following statements regarding antibiotics in surgical infections are
true? A Tetracycline is a bactericidal antibiotic. B Flucloxacillin is useful in treating
community-acquired staphylococcal infections. C Cephalosporins are not effective against
Streptococcus faecalis. D Serum levels should be monitored if aminoglycoside therapy is
continued for more than 1 week. E Vancomycin is effective against both MRSA and
Clostridium difficile
20.
20. Which of the following statements regarding AIDS are true? A After exposure, the
virus binds to CD4 receptors. B The gut-associated lymphoid tissue (GALT) is not affected.
C The HIV transmission risk is low during the stage of seroconversion. D Most antiviral
drugs (HAART) act by inhibiting reverse transcriptase and protease synthesis. E Within 2
years, progression of HIV infection to AIDS is seen in 25–35 per cent of patient
21.
22.
1 Second-generation cephalosporin (or gentamicin) and metronidazole: Colorectal.
2 Broad-spectrum cephalosporin (with anti-staphylococcal action) or gentamicin beads:
Orthopaedic
23.
3 Flucloxacillin with or without gentamicin, vancomycin or rifampicin, if MRSA is a risk :
Vascular
24.
25.
4 Second-generation cephalosporin.: Biliary
1 Lactose-fermenting Gram-negative bacillus, which is the most common cause of UTI. :
Clostridium
26.
2 Gram-negative bacillus, which tends to colonise burns and tracheostomy wounds.
These can also case UTI. Hospital strains can acquire resistance transferred through
plasmids. : Pseudomonas
27.
3 Non-spore-bearing anaerobes that colonise the colon, vagina and oropharynx. :
Bacteroides
28.
4 Gram-positive cocci which form chains; causes cellulitis and spreading tissue
destruction by release of enzymes. : Streptococcus
29.
5 Non-lactose-fermenting Gram-negative bacillus which is a normal resident of the
colon and is a cause of intra-abdominal infection after bowel surgery. : Staphylococcus
30.
6 Gram-positive, obligate anaerobes which produce spores; causes serious infections
such as gas gangrene, tetanus and pseudomembranous colitis. : E. coli
31.
7 Gram-positive aerobic coccus, which forms grape-like clumps; causes wound and
prosthesis infection. Resistant strains (MRSA) can cause epidemics: Proteus
32.
1 A 78-year-old nursing home resident who has finished a course of antibiotics recently
presents with severe diarrhoea for the past 3 days. On examination, he is very unwell and
in shock. Abdominal examination reveals generalised distension and tenderness. :
Pseudomembranous colitis
1C, 2F, 3G, 4A, 5B, 6D, 7E
33.
2 A 16-year-old boy who had an appendicectomy for a gangrenous appendix 1 week ago
presents with diarrhoea, fever and lower abdominal pain.: Pelvic abscess
34.
3 An 80-year-old male presents with a week-long history of left iliac fossa (LIF) pain. This
has increased significantly over the last couple of days and is associated with fever and
urinary irritation. On examination he is very unwell and has signs of peritonitis over the LIF
with a vaguely palpable tender mass. : Diverticular abscess
35.
4 A young soldier injured in combat develops severe pain over his leg wound.
Examination reveals thin, brown, sweet-smelling exudate with oedema and crepitus. : Gas
gangrene
36.
5 An immunocompromised patient develops rapidly spreading infection of the
abdominal wall after a laparotomy for peritonitis. He complains of severe pain.
Examination reveals extensive cellulitis with crepitus. Culture swab reveals mixed aerobic
and anaerobic growth. : Necrotising fasciitis
37.
6 A 45-year-old male who sustained minor injury 3 weeks ago while gardening presents
with difficulty in swallowing and jaw movements followed by generalised motor spasms.
He is finding it difficult to breathe. On examination you find opisthotonus and respiratory
failure: Tetanus.
38.
7 A 30-year-old female underwent an appendicectomy for an inflamed appendix 4 days
ago. The wound appears red with some seropurulent discharge at one end. She has been
febrile over the past couple of days.: Surgical wound infection
PRICIPLES OF ONCOLOGY
1.
1. Which of the following statements about malignant transformation in cells are
true? A Cells become immortal. B Cells acquire angiogenic competence. C Cells
increase apoptosis. D Cells resist signals that inhibit growth. E Cells evade
detection/elimination.
2.
2. Which of the following statements are true with regard to Gompertzian growth? A
The majority of the growth of the tumour occurs before it is clinically detectable. B
‘Early tumours’ are genetically old. C The rate of regression of a tumour depends upon
its age. D By the time of clinical detection, the window during which tumours are most
sensitive to antiproliferative drugs would have passed. E The growth of the tumour
has an exponential relationship.
3.
3. Which of the following statements about the causation of cancer are true? A
Environmental factors have been implicated in more than 80 per cent of cancers. B
HPV infection is associated with cancer of the penis. C Familial breast cancer involving
BRCA1 and BRCA2 has an autosomal recessive inheritance. D Wood dust is associated
with paranasal sinus cancers. E Pituitary tumours are a part of MEN type 2A syndrome
4.
4. Which of the following cancers is associated with obesity? A Breast B Kidney C
Colon D Oesophagus E Endometrium
5.
5. Which of the following are criteria for cancer screening? A Sensitive and specific
test B Acceptable to the screened population C Rare disorders D Recognisable early
stage E Treatment at an early stage to be as effective as that at a later stage.
6.
6. Which of the following concerning the staging of colorectal cancer are true? A T3b
refers to invasion of between 5 and 15 mm beyond the muscularis propia. B N2 means
involvement of four or more regional lymph nodes. C V1 means intramural vascular
invasion. D T0 means tumour limited to mucosa. E R0 means complete surgical
resection with adequate margins.
7.
7. Which of the following statements regarding surgery for cancer are true? A The
diagnosis of cancer should always be confirmed before surgery. B Ultraradical surgery
has a significant role in reducing the incidence of distant metastases C Up to one-third
of patients can expect long-term survival after successful resection of colorectal liver
metastases. D Surgery has no role in palliation. E Laparoscopic approach has been
shown to be equally effective as open surgery in colorectal cancer
8.
8. Which of the following statements regarding radiotherapy (RT) for cancer are true?
A Delivering RT in fractions facilitates cell repair. B Hypoxic cells are more
radiosensitive than others. C Repopulation phenomenon suggests that longer overall
treatment time is more beneficial than shorter. D The fractions should be timed to
coincide with the late G2 and M phases of the cell cycle. E Early laryngeal cancers can
be cured by RT alone.
9.
9. Which of the following can be cured without surgery? A Leukaemia B Lymphoma C
Breast cancer D Anal cancer E Medulloblastoma.
10.
10. Which of the following statements regarding chemotherapy in cancer
treatment are true? A Cytotoxic drugs are usually used as single agents. B Cis-platinum
acts by inhibition of thymidylate synthase. C Imatinib is useful in gastrointestinal
stromal tumours (GIST). D Spatial cooperation refers to the combined use of
chemotherapy and radiotherapy. E Synergy refers to use of agents with different
modes of actions.
11.
11. Which of the following statements regarding palliative therapy in cancer are
true? A It may involve surgery. B An early referral may be distressing and hence should
be delayed as much as possible. C Quality-of-life assessment is an important aspect. D
Spiritual support is outside its remit. E Palliative care is essentially pain control.
12.
12. Which of the following are end-of-life issues? A Active intervention with
curative intent B Euthanasia C Living wills D Spirituality E Bereavement
13.
1 A 60-year-old man has had a right hemicolectomy for a caecal carcinoma. The
pathologist has graded it to be a Duke’s C tumour T3 N1 (2/20) M0 R0. He is fit and
keen on any further treatment if indicated. : Adjuvant chemotherapy
14.
2 A 92-year-old man who underwent a previous operation for rectal cancer
presents with symptoms of intestinal obstruction. CT scan reveals disseminated intraabdominal cancer with multiple liver and lung metastases. : palliative care
15.
3 A 50-year-old female presents with anaemia. Colonoscopy reveals a small
caecal tumour confirmed on biopsy to be malignant. CT scan does not show any
evidence of local or distant spread. : curative surgery
16.
4 A 56-year-old fit male who underwent surgery for colonic carcinoma 3 years
ago is observed to have raised carcinoembryonic antigen (CEA) levels. CT scan shows a
small solitary leftlobe metastasis. Positron emission tomography (PET) scan does not
show any evidence of extrahepatic spread. : Surgery for secondaries
17.
5 A 68-year-old male presents with rectal bleeding and alteration in his bowels.
Investigations reveal a low rectal cancer and MRI scan stages this as T3b N1. There is
no evidence of distant spread.: Neoadjuvant chemoradiotherapy followed by surgery
18.
6 A 78-year-old male presents with a lump at the anal margin. Biopsies from
these confirm a squamous cell carcinoma (SCC). He is very keen to avoid a stoma.:
Chemoradiotherapy
19.
7 A 46-year-old female with known ovarian carcinoma presents with features of
intestinal obstruction. CT suggests a localised mass which is causing the obstruction.
She is otherwise fit and keen on any treatment for her bowel problem.: D Palliative
surgery
BURNS TEXTBOOK
KEYPOINTS
Prevention of burns A significant proportion of burns can be prevented by:
● Implementing good health and safety regulations
● Educating the public
● Introducing of effective legislation
Warning signs of burns to the respiratory system
● Burns around the face and neck
● A history of being trapped in a burning room
● Change in voice
● Stridor
Dangers of smoke, hot gas or steam inhalation
● Inhaled hot gases can cause supraglottic airway burns and laryngeal oedema
● Inhaled steam can cause subglottic burns and loss of respiratory epithelium
● Inhaled smoke particles can cause chemical alveolitis and respiratory failure
● Inhaled poisons, such as carbon monoxide, can cause metabolic poisoning
● Full-thickness burns to the chest can cause mechanical blockage to rib movement
The shock reaction after burns
● Burns produce an inflammatory reaction
● This leads to vastly increased vascular permeability
● Water, solutes and proteins move from the intra- to the extravascular space
● The volume of fluid lost is directly proportional to the area of the burn
● Above 15% of surface area, the loss of fluid produces shock
Other complications of burns
● Infection from the burn site, lungs, gut, lines and catheters
● Malabsorption from the gut
● Circumferential burns may compromise circulation to a limb
Major determinants of the outcome of a burn
● Percentage surface area involved
● Depth of burns
● Presence of an inhalational injury
The criteria for acute admission to a burns unit.
 Suspected airway or inhalational injury
 Any burn likely to require fluid resuscitation
 Any burn likely to require surgery
 Patients with burns of any significance to the hands, face, feet or perineum
 Patients whose psychiatric or social background makes it inadvisable to send them
home
 Any suspicion of non-accidental injury
 Any burn in a patient at the extremes of age
 Any burn with associated potentially serious sequelae, including high-tension
electrical burns and concentrated hydrofluoric acid burns
Initial management of the burned airway
● Early elective intubation is safest
● Delay can make intubation very difficult because of swelling
● Be ready to perform an emergency cricothyroidotomy, if intubation is delayed
Recognition of the potentially burned airway
● A history of being trapped in the presence of smoke or hot gases
● Burns on the palate or nasal mucosa, or loss of all the hairs in the nose
● Deep burns around the mouth and neck
Assessing the area of a burn
● The patient’s whole hand is 1% TBSA, and is a useful guide in small burns
● The Lund and Browder chart is useful in larger burns
● The ‘rule of nines’ is adequate for a first approximation only
Assessing the depth of a burn
● The history is important – temperature, time and burning material ● Superficial
burns have capillary filling
● Deep partial-thickness burns do not blanch, but have some sensation
● Full-thickness burns feel leathery and have no sensation
Fluids for resuscitation
● In children with burns over 10% TBSA and adults with burns over 15% TBSA,
consider the need for intravenous fluid resuscitation
● If oral fluids are to be used, salt must be added
● Fluids needed can be calculated from a standard formula
● The key is to monitor urine output
 Options for topical treatment of deep burns. 1% silver
sulphadiazine cream 0.5% silver nitrate solution Mafenide
acetate cream Serum nitrate, silver sulphadiazine and cerium
nitrate
Principles of dressings for burns
● Full-thickness and deep dermal burns need antibacterial
dressings to delay colonisation prior to surgery
● Superficial burns will heal and need simple dressings
● An optimal healing environment can make a difference to
outcome in borderline depth burns
Nutrition in burns patients
● Burns patients need extra feeding
● A nasogastric tube should be used in all patients with burns over 15% of TBSA
● Removing the burn and achieving healing stops the catabolic drive
Infection control in burns patients ● Burns patients are immunocompromised ● They are susceptible to
infection from many routes ● Sterile precautions must be rigorous ● Swabs should be taken regularly ●
A rise in white blood cell count, thrombocytosis and increased catabolism are warnings of infection
Surgical treatment of deep burns ● Deep dermal burns need tangential shaving and split-skin ● grafting
● All but the smallest full-thickness burns need surgery ● The anesthetist needs to be ready for
significant blood loss ● Topical adrenaline reduces bleeding ● All burnt tissue needs to be excised ●
Stable cover, permanent or temporary, should be applied at once to reduce burn load
Delayed reconstruction of burns ● Eyelids must be treated before exposure keratitis arises ●
Transposition flaps and Z-plasties with or without tissue expansion are useful ● Full-thickness grafts and
free flaps may be needed for large or difficult areas ● Hypertrophy is treated with pressure garments ●
Pharmacological treatment of itch is important
Electrical burns ● Low-voltage injuries cause small, localised, deep burns ● They can cause cardiac arrest
through pacing interruption without significant direct myocardial damage ● High-voltage injuries
damage by flash (external burn) and conduction (internal burn) ● Myocardium may be directly damaged
without pacing interruption ● Limbs may need fasciotomies or amputation ● Look for and treat acidosis
and myoglobinuria
Chemical burns ● Damage is from corrosion and poisoning ● Copious lavage with water helps in most
cases ● Then identify the chemical and assess the risks of absorption
Radiation burns ● Local burns causing ulceration need excision and vascularised flap cover, usually with
free flaps ● Systemic overdose needs supportive treatment