General Surgery Principles Practice Questions

Q: Which of the following is the best treatment for this condition?

Intralesional injection of triamcinolone. ***Intralesional injection of triamcinolone*** - **First-line treatment** for keloid scars, as **corticosteroids** reduce collagen synthesis and have anti-inflammatory effects that flatten the lesion. - **Minimally invasive intralesional treatment** with lower recurrence rates compared to surgical excision, making it the preferred initial treatment. *Wide excision and grafting* - **High recurrence rate** (up to 90%) when used alone for keloids, as surgical trauma can stimulate more aggressive scar formation. - **Grafting** does not address the underlying tendency for abnormal collagen production in keloid-prone individuals. *Wide excision and suturing* - **Surgical excision alone** has the highest recurrence rate for keloids, often resulting in larger lesions than the original. - **Primary closure** under tension can worsen keloid formation due to increased mechanical stress on the wound. *Deep X-ray therapy* - Used as **adjuvant therapy** following surgical excision, not as primary treatment for keloids. - **Radiation therapy** alone is not recommended as first-line treatment and carries risks of malignant transformation with prolonged use.

Q: Which of the following is the least likely complication after massive blood transfusion?

Metabolic acidosis. ### Explanation **Massive Blood Transfusion (MBT)** is defined as the replacement of one total blood volume within 24 hours or >10 units of PRBCs in 24 hours. **Why Metabolic Acidosis is the Correct Answer:** While stored blood is acidic due to the accumulation of lactic acid and pyruvic acid, **metabolic alkalosis** (not acidosis) is the more common complication following MBT. This occurs because the **citrate** used as an anticoagulant in stored blood is metabolized by the liver into **bicarbonate**. While transient acidosis may occur initially due to the load of stored blood, the compensatory metabolic response leads to alkalosis in the post-transfusion period. **Analysis of Other Options:** * **Hyperkalemia:** Stored RBCs gradually leak potassium into the plasma over time (the "storage lesion"). Rapid infusion of older blood can lead to dangerous elevations in serum potassium. * **Citrate Toxicity (Hypocalcemia):** Citrate binds to free calcium in the recipient's blood. In massive transfusions, the liver cannot metabolize citrate fast enough, leading to a drop in ionized calcium levels, which can cause arrhythmias or tetany. * **Hypothermia:** Stored blood is kept at 4°C. Rapidly infusing large volumes of cold blood without using a commercial warmer leads to a drop in core body temperature, which can impair coagulation and cardiac function. **High-Yield Clinical Pearls for NEET-PG:** * **Most common acid-base abnormality:** Metabolic Alkalosis (due to citrate-to-bicarbonate conversion). * **Electrolyte shifts:** Hypocalcemia (most common), Hyperkalemia (common with old blood), and Hypomagnesemia. * **Coagulopathy:** Dilutional thrombocytopenia is the most common cause of bleeding after MBT. * **Shift in Oxygen Dissociation Curve:** Stored blood is deficient in **2,3-DPG**, causing a **Left Shift** (increased oxygen affinity, decreased delivery to tissues).

Q: All are the features of rheumatoid arthritis except?

Osteosclerosis of joint. **Explanation:** The hallmark of **Rheumatoid Arthritis (RA)** is chronic, symmetrical inflammatory synovitis. Because it is an **inflammatory** (non-weight-bearing) arthritis, it is characterized by bone loss rather than bone formation. **Why Option A is the Correct Answer:** **Osteosclerosis** (increased bone density/thickening) is a feature of **Osteoarthritis (OA)**, not RA. In OA, the mechanical stress on subchondral bone leads to sclerosis and osteophyte formation. In contrast, RA involves inflammatory cytokines (like TNF-α and IL-1) that activate osteoclasts, leading to bone erosion and decreased density. **Analysis of Incorrect Options:** * **B. Soft tissue swelling:** This is the earliest radiographic sign of RA, caused by synovial hypertrophy and effusion (pannus formation). * **C. Narrowing of joint space:** As the pannus destroys the articular cartilage, the space between the bones decreases symmetrically. * **D. Periarticular osteoporosis:** This is a classic early radiological feature of RA. Inflammatory hyperemia leads to local bone resorption near the affected joint before generalized bone loss occurs. **NEET-PG High-Yield Pearls:** * **Radiological Hallmarks of RA:** (1) Soft tissue swelling, (2) Periarticular osteopenia/osteoporosis, (3) Symmetrical joint space narrowing, and (4) Marginal erosions (Rat-bite erosions). * **Joints Spared:** RA typically **spares the Distal Interphalangeal (DIP) joints** and the thoracolumbar spine (except C1-C2). * **Key Deformities:** Swan-neck deformity, Boutonniere deformity, and Z-deformity of the thumb. * **Serology:** Anti-CCP (Cyclic Citrullinated Peptide) is more specific than Rheumatoid Factor (RF).

Q: An ulcer with undermined edges is seen in which condition?

Tubercular ulcer. **Explanation:** The morphology of an ulcer's edge is a high-yield diagnostic feature in surgery. An **undermined edge** is the hallmark of a **Tubercular ulcer**. This occurs because the tubercular process (caseous necrosis) originates in the subcutaneous plane or lymph nodes. As the infection destroys the subcutaneous tissue more rapidly than the overlying skin, the skin edges are left hanging over the floor of the ulcer, creating a "pocket" or undermining effect. **Analysis of Options:** * **Malignant Ulcer (Option A):** Characteristically presents with **everted (rolled-out) edges**. This is due to the rapid proliferation of neoplastic cells at the periphery, which outgrows the center and spills over the normal skin. * **Venous Ulcer (Option B):** Typically presents with **sloping edges**. These are usually shallow ulcers found in the "gaiter area" (medial malleolus) and heal by the gradual inward migration of epithelium. * **Diabetic/Trophic Ulcer (Option D):** Characterized by **punched-out edges**. These are deep, circular ulcers resulting from repeated trauma to insensitive (neuropathic) skin, often seen on the sole of the foot. **High-Yield Clinical Pearls for NEET-PG:** * **Undermined edge:** Tuberculosis. * **Punched-out edge:** Syphilis (Gummatous ulcer), Deep Trophic/Diabetic ulcers. * **Everted edge:** Squamous cell carcinoma (Marjolin’s ulcer). * **Rolled-in/Beaded edge:** Basal cell carcinoma (Rodent ulcer). * **Sloping edge:** Healing traumatic or venous ulcer.

Q: Schwann cells are derived from:

Neural crest cells. **Explanation:** The correct answer is **Neural crest cells**. Schwann cells are the primary glial cells of the peripheral nervous system (PNS), responsible for myelinating peripheral axons. During embryogenesis, the neural plate folds to form the neural tube; however, a specific population of cells at the "crests" of these folds migrates throughout the body. These **neural crest cells** are multipotent and give rise to various structures, including the sensory and autonomic ganglia, adrenal medulla, melanocytes, and Schwann cells. **Analysis of Incorrect Options:** * **Endoderm:** This layer primarily gives rise to the epithelial lining of the gastrointestinal and respiratory tracts, as well as organs like the liver and pancreas. * **Mesoderm:** This layer forms the "middle" structures, including muscles, bones, the circulatory system, dermis, and the urogenital system. * **Ectoderm:** While the nervous system originates from the ectoderm, it is specifically divided into the **surface ectoderm** (epidermis, lens) and **neuroectoderm**. The neuroectoderm further differentiates into the **neural tube** (CNS: brain, spinal cord, oligodendrocytes) and **neural crest cells** (PNS: Schwann cells). **Clinical Pearls for NEET-PG:** * **Schwannoma vs. Neurofibroma:** Both are nerve sheath tumors derived from Schwann cells. Schwannomas are typically encapsulated and push the nerve aside, while neurofibromas are unencapsulated and infiltrate the nerve. * **Myelination:** Remember that **Schwann cells** myelinate a single axon in the PNS, whereas **Oligodendrocytes** (derived from the neural tube) myelinate multiple axons in the CNS. * **Acoustic Neuroma:** This is a vestibular schwannoma (CN VIII) and is a classic high-yield association with Neurofibromatosis Type 2 (NF2).

Q: Identify the suturing technique shown in the image.

Simple Interrupted suture. ***Simple Interrupted suture*** - The image shows multiple individual stitches, each placed and tied separately. This is the defining characteristic of the **simple interrupted** technique. - This method provides excellent **wound edge approximation** and allows for the removal of individual sutures if a wound infection develops. *Vertical Mattress* - This technique uses a **"far-far, near-near"** bite pattern in a vertical plane to strongly evert wound edges, which is not depicted. - It is ideal for closing wounds under tension or on lax skin, such as the neck or areas over joints. *Horizontal mattress* - A horizontal mattress suture runs **parallel** to the wound incision line, creating a "box stitch" appearance. The sutures in the image are perpendicular. - It is used for **everting** wound edges and can also act as a temporary tension-relieving stitch. *Subcuticular suture* - This technique involves placing sutures within the **dermis** layer, with no external suture material visible except at the entry and exit points. - It provides superior **cosmetic outcomes** by eliminating skin suture marks, which is clearly not the case in the illustrated technique.

Q: Identify the type of suture?

Simple Interrupted suture. ***Simple Interrupted suture*** - The image displays multiple, separate sutures, each individually placed and tied, which is characteristic of the **simple interrupted** technique. - This is the most common suturing method, providing good **wound apposition** and allowing for selective removal of single sutures if a localized infection develops. *Vertical Mattress* - A **vertical mattress suture** involves a 'far-far, near-near' stitching pattern in a plane perpendicular to the wound, which is not depicted in the image. - This technique is specifically used for everting wound edges and closing wounds under tension, creating a different surface appearance. *Horizontal mattress* - A **horizontal mattress suture** runs parallel to the wound edge on the skin surface, creating a box-like stitch to distribute tension. - It is primarily used for wounds under high tension or for providing **hemostasis**, and its appearance is distinctly different from the simple loops shown. *Subcuticular suture* - A **subcuticular suture** is placed entirely within the dermis, leaving no visible suture material on the skin surface except for the entry and exit points. - This method is used for optimal cosmetic results, whereas the image clearly shows external knots for each individual stitch.

Q: A 20-year-old male presents to the outpatient department with a swelling on his wrist. He reports fluctuation in size, mild numbness in the hand, and occasional pain. What is the most likely diagnosis?

Ganglion cyst. ***Ganglion cyst*** - This is the most common benign soft-tissue tumor of the hand and wrist, often arising from a **joint capsule** or **tendon sheath**. The classic presentation includes a smooth, round swelling on the wrist that can fluctuate in size. - Symptoms like mild pain and numbness can occur due to **nerve compression**, which is consistent with the patient's presentation. On examination, they are typically firm and **transilluminate**. *Lipoma* - A lipoma is a benign tumor composed of **adipose tissue** (fat). It typically presents as a soft, mobile, and “doughy” subcutaneous mass, which differs from the usually firm consistency of a ganglion cyst. - Lipomas do not fluctuate in size and are less likely to be found on the dorsal aspect of the wrist compared to ganglion cysts. *Dermoid cyst* - A dermoid cyst is a **congenital** lesion (a type of teratoma) containing dermal structures like hair follicles and sebaceous glands. They are most commonly found in the midline, face, or neck. - Their presence on the wrist is extremely rare, and they do not typically fluctuate in size like a ganglion cyst. *Hematoma* - A hematoma is a localized collection of blood, usually resulting from **trauma**. The patient's history does not mention any injury. - An acute hematoma would be tender and associated with **ecchymosis** (bruising), and it would be expected to resolve over time rather than fluctuate.

Q: Identify the part of the ulcer indicated by the arrow in the image.

Edge. ***Edge*** - The arrow correctly identifies the **edge** of the ulcer, which is the **side wall extending from the margin down to the floor**. - The characteristics of the edge (e.g., sloping, punched-out, undermined, rolled, everted) are crucial for determining the ulcer's etiology and whether it is healing or progressing. - Edge characteristics help differentiate between **healing ulcers** (sloping edge), **tuberculous ulcers** (undermined edge), **malignant ulcers** (everted/rolled edge), and **syphilitic ulcers** (punched-out edge). *Margin* - The **margin** is the junction line that separates the ulcer from the surrounding normal tissue. - It represents the **outermost perimeter** of the ulcer. The arrow points inside this boundary, specifically to the wall of the ulcer, not the margin itself. *Floor* - The **floor** is the visible **bottom surface** of the ulcer crater, composed of exposed subcutaneous tissue or deeper structures. - The arrow is pointing to the **side wall**, not the bottom surface. - The floor can be covered by healthy granulation tissue (pink, healing), slough (yellow), or necrotic debris (black eschar). *Base* - The **base** refers to the **tissue upon which the ulcer rests** and is assessed by **palpation**, not visualization. - It describes the deep aspect beneath the floor - can be indurated (hardened, suggests malignancy), mobile, or fixed to deeper structures like fascia, tendon, or bone.

Question 1

In an elective laparoscopic cholecystectomy with no gross spillage, what is the recommended antibiotic prophylaxis?

Accepted Answer

A single dose of preoperative intravenous antibiotic only

Answer

A single dose of preoperative intravenous antibiotic followed by a 5-day course of oral antibiotics

Answer

Postoperative intravenous antibiotics for 1 day followed by a 5-day course of oral antibiotics

Answer

A 5-day course of oral antibiotics only

Question 2

Which of the following is the best treatment for this condition?

Accepted Answer

Intralesional injection of triamcinolone

Answer

Wide excision and grafting

Answer

Deep X-ray therapy

Answer

Wide excision and suturing

Question 3

Which of the following is the least likely complication after massive blood transfusion?

Accepted Answer

Metabolic acidosis

Answer

Hyperkalemia

Answer

Citrate toxicity

Answer

Hypothermia

Question 4

All are the features of rheumatoid arthritis except?

Accepted Answer

Osteosclerosis of joint

Answer

Soft tissue swelling

Answer

Narrowing of joint space

Answer

Periarticular osteoporosis

Question 5

An ulcer with undermined edges is seen in which condition?

Accepted Answer

Tubercular ulcer

Answer

Malignant ulcer

Answer

Venous ulcer

Answer

Diabetic ulcer

Question 6

Schwann cells are derived from:

Accepted Answer

Neural crest cells

Answer

Endoderm

Answer

Mesoderm

Answer

Ectoderm

Question 7

Identify the suturing technique shown in the image.

Accepted Answer

Simple Interrupted suture

Answer

Vertical Mattress

Answer

Subcuticular suture

Answer

Horizontal mattress

Question 8

Identify the type of suture?

Accepted Answer

Simple Interrupted suture

Answer

Horizontal mattress

Answer

Vertical Mattress

Answer

Subcuticular suture

Question 9

A 20-year-old male presents to the outpatient department with a swelling on his wrist. He reports fluctuation in size, mild numbness in the hand, and occasional pain. What is the most likely diagnosis?

Accepted Answer

Ganglion cyst

Answer

Dermoid cyst

Answer

Lipoma

Answer

Hematoma

Question 10

Identify the part of the ulcer indicated by the arrow in the image.

Accepted Answer

Edge

Answer

Floor

Answer

Margin

Answer

Base

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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