General Surgery Principles Practice Questions

Q: What is the concentration of sodium (in mEq/L) in normal saline?

154. Normal Saline (0.9% NaCl) is a crystalloid solution widely used for fluid resuscitation and maintenance. The concentration of 0.9% means there are 9 grams of Sodium Chloride per liter of water. ### **Why 154 is Correct** To calculate the milliequivalents (mEq) of Sodium ($Na^+$) in Normal Saline: 1. The molecular weight of NaCl is approximately 58.5 g/mol. 2. In 1 liter of 0.9% NaCl, there are 9,000 mg of NaCl. 3. $9,000 \text{ mg} / 58.5 \approx 154 \text{ mEq/L}$. Since NaCl dissociates into equal parts $Na^+$ and $Cl^-$, Normal Saline contains **154 mEq/L of Sodium** and **154 mEq/L of Chloride**. ### **Analysis of Incorrect Options** * **A (77 mEq/L):** This is the sodium concentration of **Half-Normal Saline (0.45% NaCl)**. * **B (109 mEq/L):** This is the chloride concentration in **Ringer’s Lactate**. * **C (130 mEq/L):** This is the sodium concentration in **Ringer’s Lactate** (Hartmann’s Solution), which is more physiological than Normal Saline. ### **High-Yield Clinical Pearls for NEET-PG** * **Osmolarity:** Normal Saline has an osmolarity of **308 mOsm/L**, making it slightly hypertonic compared to plasma (285–295 mOsm/L). * **Hyperchloremic Metabolic Acidosis:** Large volumes of Normal Saline can lead to this condition due to the high chloride content (154 mEq/L vs. plasma 100 mEq/L). * **Fluid of Choice:** It is the preferred fluid for resuscitation in patients with **hypochloremic hypokalemic metabolic alkalosis** (e.g., Gastric Outlet Obstruction/Pyloric Stenosis) and for traumatic brain injury to maintain cerebral perfusion pressure.

Q: Which of the following hormones are increased due to stress during surgery, especially in patients with Diabetes Mellitus?

All of the above. **Explanation:** The surgical procedure acts as a potent physical and psychological stressor, triggering a complex neuroendocrine response aimed at maintaining homeostasis and mobilizing energy substrates. This is often referred to as the **"Stress Response to Surgery."** **Why "All of the above" is correct:** During surgery, the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system are activated, leading to a surge in **counter-regulatory hormones**. These hormones oppose the action of insulin, leading to hyperglycemia—a significant concern in patients with Diabetes Mellitus. 1. **Epinephrine (Option A):** Stress triggers the sympathetic-adrenal medullary axis, releasing catecholamines. Epinephrine increases glycogenolysis and gluconeogenesis while inhibiting insulin secretion. 2. **Growth Hormone (Option B):** GH levels rise rapidly during surgical stress. It contributes to insulin resistance and stimulates lipolysis, providing alternative fuel sources. 3. **Glucocorticoids (Option C):** Cortisol levels rise significantly due to ACTH stimulation. Cortisol promotes protein catabolism and gluconeogenesis, further elevating blood glucose levels. **Clinical Pearls for NEET-PG:** * **The "Diabetes of Injury":** Surgical stress induces a state of transient insulin resistance and hyperglycemia even in non-diabetic patients; however, in diabetics, this can lead to severe metabolic derangements like DKA or HHS. * **Insulin is the "Odd One Out":** While counter-regulatory hormones (Glucagon, GH, Cortisol, Epinephrine) increase, insulin secretion is often suppressed or its peripheral action is impaired during the acute stress phase. * **ADH (Vasopressin):** Also increases during surgery to maintain blood volume, often leading to postoperative fluid retention. * **Cytokines:** IL-6 is the primary cytokine responsible for stimulating the acute-phase response during surgery.

Q: Which of the following diseases is effectively treated by splenectomy and does not typically present with splenomegaly?

Idiopathic thrombocytopenic purpura. **Explanation:** The correct answer is **Idiopathic Thrombocytopenic Purpura (ITP)**. **1. Why ITP is the correct answer:** In ITP, anti-platelet IgG antibodies (produced in the spleen) coat the platelets, leading to their premature destruction by splenic macrophages. Splenectomy is a highly effective second-line treatment because it removes both the primary site of antibody production and the main site of platelet sequestration. Crucially, the spleen in ITP is **not typically enlarged**; if significant splenomegaly is present, a clinician should investigate alternative diagnoses like leukemia or lymphoma. **2. Analysis of Incorrect Options:** * **Sickle Cell Disease:** While splenectomy may be indicated for acute sequestration crises, these patients typically undergo **autosplenectomy** (shrunken, fibrotic spleen) by adulthood due to repeated infarctions. It is not a primary "treatment" for the underlying disease. * **Aplastic Anaemia:** This is a bone marrow failure syndrome. Splenectomy has no role in its management, as the pathology lies in the marrow's inability to produce cells, not their peripheral destruction. * **Thalassemia:** Splenectomy is often indicated for Thalassemia Major to reduce transfusion requirements, but these patients characteristically present with **massive splenomegaly** due to extramedullary hematopoiesis and secondary hypersplenism. **3. NEET-PG High-Yield Pearls:** * **Most common indication for elective splenectomy:** ITP. * **Most common indication for emergency splenectomy:** Trauma (Splenic rupture). * **Vaccination Protocol:** Post-splenectomy patients must be vaccinated against encapsulated organisms (*S. pneumoniae, H. influenzae, N. meningitidis*) ideally 2 weeks before elective surgery or 2 weeks after emergency surgery. * **Peripheral Smear Findings:** Look for **Howell-Jolly bodies**, Pappenheimer bodies, and Heinz bodies post-splenectomy.

Q: Trophic ulcers are caused by all of the following except?

Varicose veins. ### Explanation The core concept behind a **trophic ulcer** is a lack of nutrition to the tissues resulting from **denervation** (loss of sensory/nerve supply) or **prolonged pressure**. **1. Why Varicose Veins is the correct answer:** Varicose veins lead to **Venous Ulcers** (Gaiter’s ulcers), not trophic ulcers. The pathophysiology involves venous hypertension and valvular incompetence, leading to blood stasis and fibrin cuff formation. Unlike trophic ulcers, venous ulcers are typically painful, associated with skin changes like lipodermatosclerosis and hemosiderin staining, and occur in areas with intact sensation. **2. Analysis of Incorrect Options (Causes of Trophic Ulcers):** * **Syringomyelia:** This is a neurological condition causing a "dissociated sensory loss." The loss of pain and temperature sensation leads to repetitive unnoticed trauma, resulting in trophic ulcers (typically in the upper limbs). * **Leprosy:** The most common cause of trophic ulcers in India. It involves peripheral nerve destruction (e.g., tibial nerve), leading to an insensitive foot. Constant pressure on bony prominences during walking causes tissue necrosis. * **Prolonged Recumbency:** This leads to **Pressure Sores (Decubitus ulcers)**, which are a subtype of trophic ulcers. Constant pressure on areas like the sacrum or heels exceeds capillary perfusion pressure, causing ischemic necrosis. ### NEET-PG High-Yield Pearls: * **Classic Site:** Trophic ulcers occur at pressure-bearing, denervated areas (e.g., the ball of the great toe, heel, or ischial tuberosity). * **Characteristics:** They are typically **painless**, "punched out" in appearance, and have a non-mobile base fixed to underlying bone. * **Management Principle:** The most important step in treating a trophic ulcer is **offloading** (removing pressure), often via a Total Contact Cast (TCC). * **Other Causes:** Diabetes Mellitus (Diabetic foot), Tabes dorsalis, and Spina bifida.

Q: A female developed a well-circumscribed swelling on the nape of her neck. It is not transilluminant, painless, and easily movable. Which of the following conditions is NOT brilliantly transilluminant?

Lipoma. **Explanation:** The clinical presentation described—a well-circumscribed, painless, and mobile swelling on the nape of the neck—is classic for a **Lipoma**. The core concept being tested here is **transillumination**, a clinical sign where light passes through a swelling containing clear fluid, making it appear "brilliant" or glowing. **1. Why Lipoma is the Correct Answer:** A lipoma is a benign tumor composed of mature adipocytes (fat cells). Because it consists of solid, fatty tissue rather than clear fluid, it is **opaque** and does not transilluminate. Lipomas are often referred to as "Universal Tumors" and typically present with a characteristic "slip sign." **2. Analysis of Incorrect Options (Brilliantly Transilluminant Conditions):** * **Vaginal hydrocele:** This is a collection of clear serous fluid within the tunica vaginalis. Since the fluid is clear and the covering is thin, it transilluminates brilliantly. * **Cystic hygroma:** This is a congenital lymphatic malformation (usually in the neck) containing clear lymph. Its thin-walled multilocular cysts allow light to pass through easily. * **Sacral meningocele:** This involves the protrusion of meninges containing Cerebrospinal Fluid (CSF). As CSF is a clear, water-like fluid, these swellings are transilluminant. **Clinical Pearls for NEET-PG:** * **Rule of Thumb:** For a swelling to be transilluminant, it must contain **clear fluid** and have **thin skin/coverings**. * **Non-transilluminant fluids:** Swellings containing blood (haematocele), pus (abscess), or thick chyle will not transilluminate. * **Mnemonic for Transilluminant Swellings:** **"CHiPS"** – **C**ystic hygroma, **H**ydrocele, **P**haryngeal pouch (sometimes), **S**pina bifida (meningocele). * **The Slip Sign:** This is a pathognomonic clinical feature of lipomas where the edge of the tumor slips away from the examining finger.

Q: What is the typical behavior of an eruption cyst?

Regresses after the eruption of the tooth.. ### Explanation An **eruption cyst** is a soft tissue analogue of a dentigerous cyst. It occurs when the dental follicle separates from the crown of an erupting tooth within the soft tissues overlying the alveolar bone. **Why Option B is Correct:** The eruption cyst is a self-limiting condition. As the tooth continues its natural erupting path, it pierces the roof of the cyst. Once the tooth crown breaks through the gingival surface into the oral cavity, the cystic fluid drains, and the lesion **regresses spontaneously**. No surgical intervention is usually required unless the cyst becomes infected or symptomatic. **Analysis of Incorrect Options:** * **Option A:** It does not transform into a dentigerous cyst; rather, it is considered the extra-osseous (soft tissue) counterpart of one. * **Option C:** This describes a **primordial cyst**, which develops in place of a tooth that failed to form. Eruption cysts occur specifically over a tooth that is currently erupting. * **Option D:** While histologically similar, an eruption cyst is technically an **extra-alveolar** lesion, whereas a dentigerous cyst is **intra-osseous** (enclosing the crown of an unerupted tooth within the bone). **NEET-PG High-Yield Pearls:** * **Clinical Appearance:** Presents as a soft, fluctuant, often bluish-purple swelling (if filled with blood, it is called an **eruption hematoma**) on the alveolar ridge. * **Common Site:** Most frequently seen in the deciduous maxillary incisors and first permanent molars. * **Management:** "Masterly inactivity" (observation). If eruption is delayed, a simple incision (fenestration) of the cyst roof may be performed.

Q: Which of the following is NOT a complication of massive blood transfusion?

Hyperthermia. ### Explanation **Massive Blood Transfusion (MBT)** is defined as the replacement of >10 units of PRBCs in 24 hours or 1 blood volume in 24 hours. **Why Hyperthermia is the Correct Answer:** Massive transfusion typically leads to **Hypothermia**, not hyperthermia. This occurs because stored blood is kept at 4°C. Rapid infusion of large volumes of cold blood overrides the body’s thermoregulatory mechanisms, shifting the oxyhemoglobin dissociation curve to the left and potentially causing cardiac arrhythmias. **Analysis of Incorrect Options:** * **Septicemia:** Every unit of blood carries a risk of bacterial contamination (more common in platelets due to room temperature storage). In MBT, the sheer volume and multiple donors significantly increase the cumulative risk of transfusion-transmitted infections and sepsis. * **Thrombocytopenia:** Stored whole blood or PRBCs are deficient in viable platelets and clotting factors (V and VIII). Large-scale replacement with deficient blood leads to **dilutional thrombocytopenia** and coagulopathy. * **ARDS:** This can occur as part of **TRALI (Transfusion-Related Acute Lung Injury)**, a leading cause of transfusion-related mortality. It involves donor antibodies reacting against recipient neutrophils, leading to non-cardiogenic pulmonary edema. **High-Yield Clinical Pearls for NEET-PG:** * **Electrolyte Triad of MBT:** Hypocalcemia (citrate toxicity), Hyperkalemia (leaking from stored RBCs), and Metabolic Alkalosis (citrate converted to bicarbonate). * **Hypocalcemia:** Citrate used as an anticoagulant binds to the patient's ionized calcium. * **Lethal Triad of Trauma:** Hypothermia, Acidosis, and Coagulopathy (all exacerbated by MBT). * **Management:** Use blood warmers and follow a **1:1:1 ratio** (PRBC:FFP:Platelets) to prevent dilutional coagulopathy.

Question 1

What is the concentration of sodium (in mEq/L) in normal saline?

Accepted Answer

154

Answer

77

Answer

109

Answer

130

Question 2

Which of the following is true about chylothorax?

Accepted Answer

The treatment of choice is excision and ligation of the thoracic duct.

Answer

It is more common on the left side.

Answer

The fluid is clear.

Answer

Immediate thoracotomy should be performed.

Question 3

No-touch technique of suturing should be undertaken to reduce the risk of what?

Accepted Answer

Needle stick injuries

Answer

Hematoma formation

Answer

Abscess formation

Answer

None of the above

Question 4

A 25-year-old female presents with a diffuse, non-progressive, and non-tender swelling of the right maxilla, measuring approximately 2 x 1.5 cm, extending from the canine to the first molar region. Radiography reveals a ground glass appearance of the bone in the affected area. What is the appropriate surgical treatment?

Accepted Answer

Surgical cosmetic recontouring only

Answer

Total excision of the lesion

Answer

Curettage of the area with extraction of the involved teeth

Answer

Surgical excision followed by radiotherapy

Question 5

Which of the following hormones are increased due to stress during surgery, especially in patients with Diabetes Mellitus?

Accepted Answer

All of the above

Answer

Epinephrine

Answer

Growth Hormone (GH)

Answer

Glucocorticoids

Question 6

Which of the following diseases is effectively treated by splenectomy and does not typically present with splenomegaly?

Accepted Answer

Idiopathic thrombocytopenic purpura

Answer

Sickle cell disease

Answer

Aplastic anaemia

Answer

Thalassemia

Question 7

Trophic ulcers are caused by all of the following except?

Accepted Answer

Varicose veins

Answer

Syringomyelia

Answer

Leprosy

Answer

Prolonged recumbency

Question 8

A female developed a well-circumscribed swelling on the nape of her neck. It is not transilluminant, painless, and easily movable. Which of the following conditions is NOT brilliantly transilluminant?

Accepted Answer

Lipoma

Answer

Vaginal hydrocele of an infant

Answer

Cystic hygroma

Answer

Sacral meningocele

Question 9

What is the typical behavior of an eruption cyst?

Accepted Answer

Regresses after the eruption of the tooth.

Answer

Transforms into a dentigerous cyst.

Answer

Is found in the location of a missing tooth.

Answer

Is a type of dentigerous cyst.

Question 10

Which of the following is NOT a complication of massive blood transfusion?

Accepted Answer

Hyperthermia

Answer

Septicemia

Answer

Thrombocytopenia

Answer

ARDS

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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