General Surgery Principles Practice Questions

Q: All of the following are true about sportsman's hernia except:

Sac is palpable. **Explanation:** **Sportsman’s Hernia** (also known as Gilmore’s Groin or Athletic Pubalgia) is a clinical syndrome characterized by chronic groin pain. Despite the name, it is **not a true hernia** because there is no actual defect in the abdominal wall and no protrusion of a peritoneal sac. 1. **Why Option B is correct:** Since there is no actual herniation of intra-abdominal contents, there is **no palpable sac**. The condition involves a tear or strain of the soft tissues (muscles, tendons, or ligaments) in the groin area, specifically the posterior inguinal wall or the insertion of the rectus abdominis. 2. **Why Option A is incorrect:** Inguinal pain is the hallmark symptom. It is typically unilateral, exercise-induced, and aggravated by sudden movements like kicking, twisting, or sprinting. 3. **Why Option C is incorrect:** **MRI** is the Investigation of Choice (IOC) as it can identify bone marrow edema in the pubic symphysis, muscle tears (adductor longus or rectus abdominis), and help rule out other causes of groin pain. 4. **Why Option D is incorrect:** If conservative management (rest and physiotherapy) fails, surgical intervention is indicated. Both open and **laparoscopic inguinal hernia repairs** (using mesh to reinforce the posterior wall) are standard treatments to stabilize the groin. **Clinical Pearls for NEET-PG:** * **Pathophysiology:** Often involves a "tug-of-war" imbalance between the strong adductor muscles and weak abdominal muscles. * **Physical Exam:** Pain is often elicited by resisted adduction or a resisted sit-up. * **Differential Diagnosis:** Must be distinguished from Osteitis Pubis (inflammation of the pubic symphysis).

Q: In a given case if the skin over a swelling is fixed to the swelling, which of the following is NOT a differential diagnosis?

Lipoma. In clinical surgery, the relationship between a swelling and the overlying skin is a critical diagnostic feature. **Why Lipoma is the Correct Answer:** A **Lipoma** is a benign tumor of adipose tissue located in the subcutaneous plane. A characteristic feature of a lipoma is that it is **not fixed to the skin**. On examination, the skin can be easily moved over the swelling. Furthermore, when the skin is pinched over a lipoma, it often exhibits "dimpling" or "puckering" (the **Slip Sign**), but the tumor itself remains mobile relative to the dermis. **Analysis of Incorrect Options:** * **Sebaceous Cyst:** These arise from the hair follicle and are located within the dermis. The hallmark clinical sign is a **punctum**, which represents the opening of the sebaceous duct. Because it is intradermal, the skin is inherently fixed to the cyst. * **Papilloma:** This is a benign epithelial tumor growing outward from the skin surface. Since it originates from the skin layers, it is by definition attached to/part of the skin. * **Epithelioma (Squamous Cell Carcinoma):** This is a malignant tumor of the epithelial cells. Malignancies of the skin or those invading the skin from deeper structures cause fixation due to infiltration and desmoplastic reactions. **High-Yield Clinical Pearls for NEET-PG:** * **Slip Sign:** Pathognomonic for Lipoma. As you gently press the edge of the swelling, it slips away from the finger. * **Punctum:** Pathognomonic for Sebaceous Cyst (Epidermoid cyst). * **Dermoid Cyst:** Unlike sebaceous cysts, these are located deep to the skin (subcutaneous) and do **not** have a punctum or skin fixation. * **Fixity to deeper structures:** Tested by contracting the underlying muscle (e.g., Pectoralis major for breast lumps). If the lump becomes less mobile upon muscle contraction, it is fixed to the muscle/fascia.

Q: Spring water cyst is another name for which of the following?

Pleuropericardial cyst. ### Explanation **Correct Answer: C. Pleuropericardial cyst** **Why it is correct:** A **Pleuropericardial cyst** (also known as a pericardial cyst) is a benign, congenital malformation resulting from the failure of the primitive pleuropericardial lacunae to fuse. These cysts are typically filled with a clear, straw-colored, or water-like fluid, which gives them the classic descriptive name **"Spring water cyst."** On imaging, they are most commonly located at the **right cardiophrenic angle** (70% of cases), followed by the left cardiophrenic angle. **Why the other options are incorrect:** * **A. Hydatid cyst of lung:** Caused by *Echinococcus granulosus*, these are characterized by signs like the "Water lily sign" (Casoni’s test is historical). They contain "hydatid sand" rather than simple spring water fluid. * **B. Lung amoebic cyst:** These are usually complications of hepatic amoebiasis (Entamoeba histolytica) rupturing through the diaphragm. They are characterized by **"Anchovy sauce"** sputum/pus, not clear fluid. * **D. Enterogenous cyst:** These are posterior mediastinal masses derived from the primitive foregut. They are often associated with vertebral anomalies and contain mucoid material, not clear "spring water." **High-Yield Pearls for NEET-PG:** * **Most common location:** Right cardiophrenic angle. * **Clinical presentation:** Usually asymptomatic and discovered incidentally on a chest X-ray. * **Differential Diagnosis of Anterior Mediastinal Mass (The 4 Ts):** Thymoma, Teratoma, Thyroid (Retrosternal Goiter), and "Terrible" Lymphoma. Note that pericardial cysts are technically located in the **middle mediastinum** (specifically the anterior-inferior portion). * **Management:** Observation if asymptomatic; surgical excision or percutaneous aspiration if symptomatic (causing chest pain or arrhythmias).

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.

Question 1

All of the following are true about sportsman's hernia except:

Accepted Answer

Sac is palpable

Answer

Has inguinal pain

Answer

IOC is MRI

Answer

Laparoscopic inguinal hernia surgery

Question 2

In a given case if the skin over a swelling is fixed to the swelling, which of the following is NOT a differential diagnosis?

Accepted Answer

Lipoma

Answer

Sebaceous cyst

Answer

Papilloma

Answer

Epithelioma

Question 3

Spring water cyst is another name for which of the following?

Accepted Answer

Pleuropericardial cyst

Answer

Hydatid cyst of lung

Answer

Lung amoebic cyst

Answer

Enterogenous cyst

Question 4

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 5

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 6

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

Accepted Answer

ALP

Answer

Bilirubin

Answer

Ascites

Answer

INR

Question 7

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 8

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 9

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 10

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

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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