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Sample 1·General Surgery
A 67-year-old woman presents with a 3-day history of steady left lower quadrant (LLQ) pain, fever to 38.4°C, and nausea. She has had a change in bowel habits, with constipation. On examination, there is localized tenderness in the LLQ. A CT scan confirms sigmoid diverticulitis with localized wall thickening and surrounding fat stranding, but no abscess or perforation. What is the most appropriate management?
- AImmediate sigmoid colectomy.
- ✓Outpatient management with a clear liquid diet and oral antibiotics.
- CAdmission for bowel rest, IV fluids, and IV antibiotics.
- DUrgent colonoscopy to assess the extent of the disease.
Explanation
Correct: This patient has uncomplicated acute diverticulitis. Current guidelines support outpatient management for stable patients without signs of complicated disease (abscess, perforation, obstruction). This includes oral antibiotics and a clear liquid diet. A) Wrong because surgery is reserved for complicated or recurrent disease. C) Wrong because admission is typically for patients who are septic, immunosuppressed, have high-risk comorbidities or cannot tolerate oral intake; this patient is a candidate for outpatient care. D) Wrong because colonoscopy is contraindicated in the acute phase due to the risk of perforation.
Sample 2·General Surgery
A 70kg patient is on post-operative day 1 following a hemicolectomy and is being kept NPO (nil per os). Over the past 8 hours, his nasogastric tube has drained 400 mL of gastric fluid, and his urinary output has been 320 mL. Which intravenous fluid is most appropriate for maintenance and replacement therapy in this patient?
- A0.9% Normal Saline.
- B5% Dextrose in water (D5W).
- ✓Lactated Ringer's solution.
- D3% Hypertonic Saline.
Explanation
Correct: Lactated Ringer's is a balanced crystalloid solution that closely resembles the electrolyte composition of plasma. It is preferred for volume resuscitation and replacement in surgical patients as it avoids the hyperchloremic metabolic acidosis associated with large volumes of Normal Saline. A) Wrong because large volumes of 0.9% Normal Saline can cause hyperchloremic metabolic acidosis. B) Wrong because D5W provides free water without electrolytes and is not suitable for volume replacement. D) Wrong because hypertonic saline is a medication used for specific conditions like severe hyponatremia or cerebral edema, not for routine fluid maintenance.
Sample 3·General Surgery
A 48-year-old obese woman presents with a 24-hour history of severe, constant right upper quadrant (RUQ) pain, radiating to her right shoulder, associated with nausea and fever. On examination, she has a temperature of 38.5°C and a positive Murphy's sign. An ultrasound shows gallstones, a thickened gallbladder wall of 5 mm, and pericholecystic fluid. What is the optimal management?
- AIV antibiotics and delayed cholecystectomy in 6-8 weeks.
- BUrgent ERCP with sphincterotomy.
- ✓Laparoscopic cholecystectomy within the same hospital admission.
- DPercutaneous cholecystostomy.
Explanation
Correct: The patient has acute cholecystitis. The gold standard treatment is early laparoscopic cholecystectomy (within 72 hours of symptom onset) as it reduces overall morbidity and hospital stay. A) Wrong because delaying surgery leads to longer hospital stays and potential complications. B) Wrong because ERCP is indicated for cholangitis or choledocholithiasis, not uncomplicated cholecystitis. D) Wrong because percutaneous cholecystostomy is reserved for patients who are too unstable or unfit for surgery.
Sample 4·General Surgery
A 62-year-old man with a known inguinal hernia presents with a 6-hour history of severe groin pain and vomiting. On examination, he has a tender, non-reducible mass in his right groin. The overlying skin is red. What is the most likely diagnosis and required management?
- AIncarcerated hernia; attempt manual reduction after sedation.
- ✓Strangulated hernia; requires urgent surgical exploration.
- CEpididymitis; treat with antibiotics.
- DInguinal adenitis; perform a biopsy.
Explanation
Correct: The combination of an irreducible hernia with signs of ischemia (severe pain, tenderness, skin changes) and bowel obstruction (vomiting) strongly suggests strangulation. This is a surgical emergency requiring immediate exploration to prevent bowel necrosis. A) Wrong because attempting to reduce a strangulated hernia is dangerous as it can push non-viable bowel back into the abdomen. C) Wrong because the presentation is classic for a hernia complication, not epididymitis. D) Wrong because the history points clearly to a hernia, not lymph node inflammation.
Sample 5·General Surgery
A 45-year-old truck driver complains of painless, bright red rectal bleeding with bowel movements. He also feels a bulge that protrudes from his anus when he strains, which he has to manually push back in. Based on this description, what is the grade of his internal hemorrhoids?
- AGrade I
- BGrade II
- ✓Grade III
- DGrade IV
Explanation
Correct: Hemorrhoid grading is based on their degree of prolapse. Grade III hemorrhoids prolapse with defecation or straining and require manual reduction. A) Wrong because Grade I hemorrhoids bleed but do not prolapse. B) Wrong because Grade II hemorrhoids prolapse but reduce spontaneously. D) Wrong because Grade IV hemorrhoids are prolapsed and cannot be manually reduced (incarcerated).
