General Surgery Principles Practice Questions

Q: An elderly woman underwent a radical mastectomy with radiation to the axilla 20 years ago. For 25 years, she has had an open wound that has never healed. It is not a recurrence of breast cancer. What is the most likely diagnosis?

Squamous cell carcinoma. **Explanation:** The correct diagnosis is **Squamous Cell Carcinoma (SCC)**, specifically presenting as a **Marjolin’s ulcer**. **Why it is correct:** A Marjolin’s ulcer refers to a squamous cell carcinoma arising in a site of chronic inflammation, long-standing non-healing wounds, or old scars (most commonly post-burn scars). In this patient, the combination of a chronic open wound (25 years) and previous radiation therapy (which causes tissue ischemia and chronic dermatitis) creates the ideal environment for malignant transformation. While the latency period is typically 30 years, any ulcer persisting for decades must be biopsied to rule out SCC. **Why the other options are incorrect:** * **Basal Cell Carcinoma (BCC):** While BCC is the most common skin cancer, it typically arises on sun-exposed areas (face) and presents as a "pearly" nodule with telangiectasia. It is less commonly associated with chronic scars compared to SCC. * **Hypertrophic granulation tissue:** This is a benign reactive process seen in healing wounds ("proud flesh"). It would not persist for 25 years without either healing or showing signs of malignancy. * **Malignant melanoma:** This arises from melanocytes, usually triggered by UV exposure or genetic factors. It does not typically arise from chronic non-healing ulcers or radiation scars. **NEET-PG High-Yield Pearls:** * **Marjolin’s Ulcer:** Most common histological type is **well-differentiated SCC**. * **Characteristics:** It is more aggressive than typical SCC and has a higher rate of regional lymph node metastasis. * **Diagnosis:** Requires a wedge biopsy from the edge of the ulcer. * **Stewart-Treves Syndrome:** Do not confuse this with the clinical scenario. Stewart-Treves is **Angiosarcoma** arising in a limb with chronic lymphedema (post-mastectomy), not from a chronic ulcer or radiation scar itself.

Q: Which of the following is NOT an absolute indication for splenectomy?

Autoimmune hemolytic anemia. **Explanation:** The decision for splenectomy is categorized into absolute and relative indications. **Autoimmune Hemolytic Anemia (AIHA)** is a **relative indication** because the primary treatment is medical (corticosteroids, immunosuppressants, or Rituximab). Splenectomy is reserved only for refractory cases where medical therapy fails or is contraindicated. **Why the other options are Absolute Indications:** * **Splenic Abscess:** This is an absolute indication because abscesses in the spleen rarely respond to antibiotics alone and carry a high risk of rupture and life-threatening peritonitis. * **Hereditary Spherocytosis:** This is the **most common** indication for elective splenectomy. Since the spleen is the primary site of destruction for the abnormal spherical RBCs, splenectomy is curative for the anemia (though it doesn't fix the genetic defect). * **Fibrosarcoma (Primary Splenic Malignancy):** Any primary malignant tumor of the spleen requires total splenectomy for oncological clearance and to prevent metastasis. **NEET-PG High-Yield Pearls:** 1. **Most common indication for Splenectomy:** Trauma (specifically blunt trauma to the abdomen). 2. **Most common elective indication:** Hereditary Spherocytosis. 3. **Vaccination Protocol:** To prevent OPSI (Overwhelming Post-Splenectomy Infection), patients must be vaccinated against *Streptococcus pneumoniae*, *Haemophilus influenzae type B*, and *Neisseria meningitidis* at least **2 weeks before** elective surgery or **2 weeks after** emergency surgery. 4. **Post-Splenectomy Blood Picture:** Look for **Howell-Jolly bodies** (most characteristic), Pappenheimer bodies, Heinz bodies, and target cells.

Q: Which statement is NOT true regarding bone removal during impacted third molar extraction?

A low speed, low torque drill is used for bone removal.. ### Explanation The surgical removal of an impacted third molar requires precise bone guttering to create a path of exit for the tooth. **1. Why Option A is the Correct Answer (The False Statement):** In modern oral surgery, bone removal is performed using a **high-speed, high-torque** handpiece (often air-driven or electric). High torque is essential to maintain cutting efficiency against dense cortical bone without stalling. Conversely, low-speed or low-torque drills are inefficient, cause more mechanical trauma, and increase surgical time, which leads to greater postoperative edema and pain. **2. Analysis of Other Options:** * **Option B:** Bone is traditionally removed from the **buccal and occlusal** surfaces to expose the crown. **Distal** bone removal is often necessary for distoangular impactions. This creates a "gutter" that allows for the application of elevators. * **Option C:** Bone removal from the **lingual aspect** is strictly avoided to prevent injury to the **lingual nerve**, which lies in close proximity to the lingual plate in the third molar region. * **Option D:** Continuous, copious irrigation with sterile saline or Ringer’s lactate is mandatory. It prevents **thermal osteonecrosis** (which occurs if bone temperature exceeds 47°C) and clears debris to maintain visibility. **3. High-Yield Clinical Pearls for NEET-PG:** * **Thermal Threshold:** Bone death occurs if heated above **47°C for 1 minute**. * **Bur Type:** Round burs (size 8) or fissure burs (702/703) are typically used for guttering. * **Lingual Nerve Protection:** The "Lingual Split Technique" (Ward’s) is an older method, but modern practice emphasizes protecting the lingual plate to avoid permanent paresthesia of the tongue. * **Handpiece Safety:** Surgical handpieces must not exhaust air into the wound to prevent **tissue emphysema**.

Q: When using colloid infusion for the treatment of shock, what is the ratio at which blood loss is compensated?

1:1. ### Explanation The correct answer is **1:1 (Option B)**. **Why it is correct:** The goal of fluid resuscitation in shock is to restore intravascular volume. Colloids (such as Albumin, Dextran, or Hydroxyethyl starch) consist of large molecules that do not easily cross the semi-permeable capillary membrane. Because these molecules remain within the intravascular compartment, they exert a high oncotic pressure, effectively "holding" the fluid in the bloodstream. Therefore, to replace a specific volume of blood loss, an equal volume of colloid is required (a **1:1 ratio**). **Why the other options are incorrect:** * **1:3 (Option C):** This is the traditional ratio used for **Crystalloids** (like Normal Saline or Ringer’s Lactate). Crystalloids freely distribute between the intravascular and interstitial spaces. Only about 25-30% of infused crystalloid remains in the vessels after 20 minutes; thus, 3 mL of crystalloid is needed to replace 1 mL of blood loss. * **1:2 and 1:5 (Options A & D):** These ratios do not correspond to standard resuscitation protocols for acute blood loss. While some modern guidelines suggest a 1.5:1 or 2:1 ratio for crystalloids to avoid fluid overload, 1:1 remains the definitive physiological rule for colloids. **High-Yield Clinical Pearls for NEET-PG:** * **Crystalloid vs. Colloid:** Crystalloids are the first-line fluid for hemorrhagic shock (ATLS guidelines). Colloids are more expensive and carry risks of coagulopathy and anaphylaxis. * **The "3-for-1" Rule:** Always associate the 3:1 ratio with crystalloids and the 1:1 ratio with colloids or blood products. * **Albumin:** The most commonly used natural colloid; 5% albumin is iso-oncotic, while 25% albumin is hyper-oncotic (draws fluid from the interstitium). * **Dextran Warning:** Can interfere with blood cross-matching and may decrease platelet aggregation.

Q: What is the first step in performing a pneumonectomy for cancer of the bronchus?

Ligate the pulmonary artery. In surgery for bronchogenic carcinoma, the sequence of vessel ligation is critical to prevent the hematogenous spread of tumor cells. **Why the Pulmonary Artery is ligated first:** The standard surgical principle in oncological pneumonectomy is to **ligate the pulmonary artery first**. By cutting off the inflow (arterial supply) while keeping the outflow (venous drainage) intact for a few moments, the surgeon prevents the "congestion" of the lung. More importantly, it minimizes the risk of squeezing tumor emboli into the systemic circulation, which could occur if the veins were ligated while the artery continued to pump blood into the tumor-bearing lung. **Analysis of Incorrect Options:** * **Ligate the pulmonary vein:** If the vein is ligated first, the arterial pressure continues to engorge the lung, potentially forcing malignant cells into the capillary bed or dislodging them into the left atrium once the vein is manipulated. * **Divide the bronchus:** This is typically the final major step of the resection. Early division would obscure the hilar anatomy and increase the risk of contamination. * **Perform lymph node clearance:** While essential for staging and prognosis, formal lymphadenectomy (mediastinal nodal dissection) is performed during or after the mobilization and resection of the lung, not as the very first step. **High-Yield Clinical Pearls for NEET-PG:** * **Exception to the Rule:** In cases of **highly vascular tumors** or when there is significant manipulation required, some surgeons advocate for early venous ligation to prevent "shedding," but for the purpose of standard surgical exams, **Artery First** remains the classic teaching. * **Order of structures in the Hilum (Anterior to Posterior):** Vein, Artery, Bronchus (**VAB**). * **Order of structures in the Hilum (Superior to Inferior):** * Right side: Bronchus, Artery, Vein (**BAV**) * Left side: Artery, Bronchus, Vein (**ABV**)

Q: A 45-year-old male with a history of polyuria presents with a foot condition. What is the most likely diagnosis?

Diabetic foot ulcer. ***Diabetic foot ulcer*** - **Polyuria** is a classic symptom of **diabetes mellitus**, indicating poor glycemic control that predisposes to diabetic complications. - Diabetic foot ulcers typically occur over **pressure points** (metatarsal heads, heels) due to **peripheral neuropathy** and **vascular compromise**. *Venous ulcer* - Typically occurs in the **medial malleolar region** and is associated with **chronic venous insufficiency** and **edema**. - History of **polyuria** does not correlate with venous pathology, making this diagnosis unlikely. *Buerger's disease* - Primarily affects **young male smokers** and involves **small to medium-sized arteries** with inflammatory occlusion. - Presents with **claudication** and **rest pain**, but lacks association with **polyuria** or metabolic disorders. *Frostbite* - Results from **cold exposure** causing tissue freezing and subsequent **necrosis** and **gangrene**. - Has no relationship to **polyuria** or metabolic conditions, and requires a clear history of cold exposure.

Q: What is the primary treatment for a perforated peptic ulcer?

Vagotomy and repair of perforation. **Explanation:** The primary goal in managing a perforated peptic ulcer is twofold: addressing the acute surgical emergency (peritonitis) and treating the underlying acid-peptic disease. **Why Option C is Correct:** In the context of traditional surgical teaching for NEET-PG, **Vagotomy and repair of perforation** is considered the definitive treatment. While the perforation is closed (usually with an omental patch), the **Vagotomy** (typically Truncated or Selective) addresses the etiology by reducing gastric acid secretion, thereby preventing recurrence. This combined approach manages both the complication and the disease. **Analysis of Incorrect Options:** * **Option A & B (Vagotomy with Pyloroplasty/Antrectomy):** These are definitive acid-reduction surgeries but are generally too extensive and time-consuming in the setting of acute bacterial peritonitis. Performing a resection (Antrectomy) or altering gastric emptying (Pyloroplasty) in an unstable, septic patient increases morbidity significantly. * **Option D (Graham’s Repair):** This refers to the placement of a pedicled omental patch over the perforation. While it is the **most common emergency procedure** performed today (especially in the era of PPIs), it is technically a "repair" only. Without a vagotomy or long-term medical management, it does not address the underlying hyperacidity. **NEET-PG High-Yield Pearls:** * **Investigation of Choice:** X-ray Erect Abdomen (shows free gas under the diaphragm in 75% of cases). * **Gold Standard Investigation:** NCCT Abdomen (most sensitive). * **Modified Graham’s Patch:** The current standard where the omentum is placed *over* the primary sutures rather than plugged into the hole. * **Conservative Management:** Known as **Taylor’s Method** (aspirations, antibiotics, and fluids), reserved only for stable patients with "sealed" perforations.

Q: Indications for surgery in Bronchiectasis include all of the following except?

Severe hemoptysis. In the management of bronchiectasis, surgery is primarily reserved for patients who fail medical therapy and have **localized disease** that can be safely resected. ### **Explanation of the Correct Answer** **Option A (Severe hemoptysis)** is the correct answer because it is generally considered a **contraindication** or a situation where surgery is deferred in favor of less invasive interventions. In the acute setting of massive/severe hemoptysis, the first-line treatment is **Bronchial Artery Embolization (BAE)**. Surgery in an unstable patient with active bleeding carries high mortality and morbidity. Resection is only considered electively once the patient is stabilized and the site of bleeding is localized. ### **Analysis of Other Options** * **B. Copious symptoms with localized disease:** This is the classic indication. If a patient has persistent cough and sputum production confined to a single lobe/segment that doesn't respond to antibiotics and chest physiotherapy, surgical resection (e.g., lobectomy) offers a potential cure. * **C. Recurrent or severe bleeding:** While "severe" bleeding is managed by BAE initially, **recurrent** episodes of significant bleeding from a localized area are a strong indication for elective surgery to prevent future life-threatening events. * **D. Recurrent infections:** Patients suffering from frequent, localized exacerbations that lead to lung scarring or abscess formation despite optimal medical management are ideal candidates for surgery. ### **NEET-PG High-Yield Pearls** * **Gold Standard Investigation:** High-Resolution CT (HRCT) scan (shows "Signet ring sign" or "Tram-track opacities"). * **Most Common Cause (Worldwide):** Post-infectious (Tuberculosis). * **Surgical Prerequisite:** Adequate pulmonary reserve (FEV1 > 1L) and disease localization to one or two lobes. * **Kartagener Syndrome:** A subset of bronchiectasis (Triad: Situs inversus, Bronchiectasis, Sinusitis).

Q: What is true about Marjolin's ulcer?

Ulcer over a scar. **Explanation:** **Marjolin’s ulcer** refers to a specific type of **Squamous Cell Carcinoma (SCC)** that arises in areas of chronic inflammation, long-standing scars, or non-healing wounds. 1. **Why Option A is Correct:** The hallmark of a Marjolin’s ulcer is its development over a **pre-existing scar**, most commonly a **post-burn contracture scar**. It can also occur in chronic osteomyelitis sinuses, venous ulcers, or vaccination scars. The malignant transformation occurs due to constant irritation and poor lymphatic drainage in the scarred tissue. 2. **Why Other Options are Incorrect:** * **B. Rapid growth:** Marjolin’s ulcers are typically characterized by a **slow growth rate** and a very long latent period (averaging 25–30 years) between the initial injury and the onset of malignancy. * **C. Rodent ulcer:** This is a clinical term for **Basal Cell Carcinoma (BCC)**, which typically occurs on sun-exposed skin (above the line joining the tragus to the angle of the mouth). Marjolin’s ulcer is histologically a Squamous Cell Carcinoma. * **D. Painful:** Interestingly, Marjolin’s ulcers are characteristically **painless** because the scar tissue in which they develop is devoid of sensory nerve fibers. **NEET-PG High-Yield Pearls:** * **Most common site:** Lower limb (due to chronic venous ulcers or burn scars). * **Lymphadenopathy:** Usually absent initially because the dense scar tissue acts as a barrier to lymphatic spread. However, if it does spread, it is highly aggressive. * **Diagnosis:** Confirmed by edge biopsy. * **Treatment:** Wide local excision (with a 2 cm margin) or amputation.

Question 1

An elderly woman underwent a radical mastectomy with radiation to the axilla 20 years ago. For 25 years, she has had an open wound that has never healed. It is not a recurrence of breast cancer. What is the most likely diagnosis?

Accepted Answer

Squamous cell carcinoma

Answer

Basal cell carcinoma

Answer

Hypertrophic granulation tissue

Answer

Malignant melanoma

Question 2

Which of the following is NOT an absolute indication for splenectomy?

Accepted Answer

Autoimmune hemolytic anemia

Answer

Splenic abscess

Answer

Hereditary spherocytosis

Answer

Fibrosarcoma

Question 3

To prevent pressure ulcers, which intervention should be included in the plan of care?

Accepted Answer

Post a turning schedule at the patient's bedside.

Answer

Vigorously massage lotion into bony prominences.

Answer

Turn and re-position the patient at least once every 8 hours.

Answer

Slide the patient, rather than lifting, when turning.

Question 4

Which statement is NOT true regarding bone removal during impacted third molar extraction?

Accepted Answer

A low speed, low torque drill is used for bone removal.

Answer

Bone is removed from the buccal, occlusal, and sometimes distal aspects of the impacted tooth.

Answer

Bone removal from the lingual aspect of the tooth is not advisable.

Answer

Bone removal is accompanied by continuous, copious irrigation to remove bone debris from the bur and keep the temperature under control.

Question 5

When using colloid infusion for the treatment of shock, what is the ratio at which blood loss is compensated?

Accepted Answer

1:1

Answer

1:2

Answer

1:3

Answer

1:5

Question 6

What is the first step in performing a pneumonectomy for cancer of the bronchus?

Accepted Answer

Ligate the pulmonary artery

Answer

Ligate the pulmonary vein

Answer

Divide the bronchus

Answer

Perform lymph node clearance

Question 7

A 45-year-old male with a history of polyuria presents with a foot condition. What is the most likely diagnosis?

Accepted Answer

Diabetic foot ulcer

Answer

Venous ulcer

Answer

Buerger's disease

Answer

Frostbite

Question 8

What is the primary treatment for a perforated peptic ulcer?

Accepted Answer

Vagotomy and repair of perforation

Answer

Vagotomy and Pyloroplasty

Answer

Vagotomy and Antrectomy

Answer

Graham's repair

Question 9

Indications for surgery in Bronchiectasis include all of the following except?

Accepted Answer

Severe hemoptysis

Answer

Copious symptoms with localized disease

Answer

Recurrent or severe bleeding

Answer

Recurrent infections

Question 10

What is true about Marjolin's ulcer?

Accepted Answer

Ulcer over a scar

Answer

Rapid growth

Answer

Rodent ulcer

Answer

Painful

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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