LE 1 - SURGERY

Question 1

1 The sign is positive when pressure applied to the left lower quadrant results in right lower quadrant pain or tenderness
A. Obturator sign
B. Psoas sign
C. Rovsing’s sign
D. Murphy’s sign

Answer 1

C. Rovsing’s sign

Rovsing’s sign is a clinical sign that is positive when pressure applied to the left lower quadrant of the abdomen results in pain in the right lower quadrant. It is suggestive of acute appendicitis.

Question 2

2. Abdominal examination signs. Loss of abdominal tenderness when abdominal wall muscles are contracted
   A. Carnett sign
   B. Fothergill sign
   C. Claybrook sign
   D. Courvoisier sign

Answer 2

A. Carnett sign

Carnett’s sign is positive when there is a loss or persistence of abdominal tenderness when the patient tenses the abdominal wall muscles, such as by lifting their head and shoulders off the examining table. A positive Carnett’s sign suggests that the pain originates from the abdominal wall rather than from the intra-abdominal structures.

Question 3

3.Non surgical causes of abdominal pain
A. acute appendicitis
B. Perforated duodenal ulcer
C. Perforated sigmoid diverticulitis
D. Acute gastroenteritis

Answer 3

D. Acute gastroenteritis

Acute gastroenteritis is an inflammation of the stomach and intestines, usually caused by a viral, bacterial, or parasitic infection. It can lead to symptoms like nausea, vomiting, diarrhea, and abdominal pain. Unlike the other options listed, acute gastroenteritis is a non-surgical cause of abdominal pain. The other conditions (acute appendicitis, perforated duodenal ulcer, and perforated sigmoid diverticulitis) typically require surgical intervention.

Question 4

4. A 13 year old male grade six pupil complains of aching pain in the epigastric area, anorexia, nausea and vomiting. The pain later moves to the right lower quadrant and becomes worse. At the ER, he is found to have right lower quadrant tenderness, voluntary guarding, temperature of 38.5 degree centigrade and a white blood cell count of 14,500 with polymorphonuclear dominance. What is your working diagnosis? *
   A. Acute diverticulitis
   B. Small bowel obstruction
   C. Perforated duodenal ulcer
   D. Acute appendicitis

Answer 4

D. Acute appendicitis

The clinical presentation of aching pain that begins in the epigastric area and later migrates to the right lower quadrant, accompanied by symptoms such as anorexia, nausea, vomiting, right lower quadrant tenderness, fever, and an elevated white blood cell count with a predominance of polymorphonuclear leukocytes, is classic for acute appendicitis, especially in a young individual.

Question 5

5. Locations of referred pain and its causes-
   A. Right shoulder
   B. Heart
   C. Gallbladder
   D. Spleen
   E. Tail of pancreas

Answer 5

A. Right shoulder:

Referred pain from the diaphragm or the gallbladder (due to irritation of the phrenic nerve which shares sensory pathways with the nerves of the shoulder).
B. Heart:

Referred pain from the heart is typically felt in the left arm, jaw, and sometimes the upper abdomen or back. This is most commonly associated with conditions like angina or myocardial infarction (heart attack).
C. Gallbladder:

Referred pain from the gallbladder is typically felt in the right upper quadrant of the abdomen and can radiate to the right shoulder or scapular region, especially in conditions like cholecystitis or gallstones.
D. Spleen:

Referred pain from the spleen is typically felt in the left upper quadrant and can also radiate to the left shoulder, especially if there’s splenic irritation or rupture that affects the diaphragm.
E. Tail of pancreas:

Referred pain from the tail of the pancreas can be felt in the left upper quadrant and sometimes radiates to the back, especially in conditions like pancreatitis.

Question 6

6. A 67 year old grandmother presented with lower abdominal pain, fever and difficulty walking. The patient has noted change in bowel habits over the past 3 months. Physical exam exhibits temperature of 39.5 degrees centigrade. She is lying supine with left leg flexed at the hospital. No scars in the abdomen but with tenderness in the left lower quadrant. What do you think is happening to the patient? *
   A. Ischemia or rupture of vessels
   B. Bleeding or rupture of vessels
   C. Obstruction
   D. Inflammation

Answer 6

D. Inflammation

Rationale:
The presentation of the 67-year-old grandmother, including symptoms of lower abdominal pain, fever, and change in bowel habits over the past 3 months, combined with tenderness in the left lower quadrant and the posture of lying supine with the left leg flexed, suggests “diverticulitis.” Diverticulitis is an inflammation of the diverticula, small pouches that can form in the walls of the colon. The left lower quadrant tenderness is commonly associated with diverticulitis, and the patient’s posture could be an effort to relieve tension and discomfort from the inflamed area. The absence of scars suggests this is not post-operative, and the other options (ischemia, bleeding or rupture, obstruction) do not fit the presentation as closely as inflammation due to diverticulitis.

Question 7

7.A 65 year old woman comes to the emergency room complaining of severe , crampy periumbilical pain that began 3 days ago. This was accompanied by nausea, episodes of vomiting dark, thick, greenish fluid. Her last bowel movement was 3 days ago and has not passed flatus for the past 36 hours. Her temperature is 38.5 degrees centigrade and abdomen is distended, symmetrical and tympanitic with minimal tenderness. Her bowel sounds are hyperactive. There is a well healed midline abdominal scar from an exploratory laparotomy secondary to ruptured appendicitis 10 years ago. What do you think is happening to the patient?
A. Obstruction
B. Bleeding or rupture of vessels
C. Ischemia or perforation
D. Perforation

Answer 7

A. Obstruction

Rationale:

Severe, crampy periumbilical pain is a classic symptom of bowel obstruction.
Nausea and vomiting of a dark, thick, greenish fluid (likely bilious vomiting) also points towards an upper intestinal obstruction.
Absence of bowel movement and flatus are suggestive of complete bowel obstruction.
The abdomen being distended, symmetrical, and tympanitic upon examination are consistent with obstruction.
Hyperactive bowel sounds are often heard initially with an obstruction.
The presence of a well-healed midline abdominal scar from a previous surgery can indicate adhesions, which are a common cause of bowel obstruction in those with prior abdominal surgeries.
Thus, the presentation is most consistent with a bowel obstruction, possibly due to post-operative adhesions from her prior surgery.

Question 8

8. Obturator sign
   A. Detection of increased abdominal muscle tone during palpation
   B. Passively extending the hip or actively flexing the hip against resistance causes
   pain
   C. Sudden withdrawal of the hand after pressing the abdomen may cause increase in the abdominal tenderness
   D. Internal or external rotation of the flexed hip causes pain

Answer 8

D. Internal or external rotation of the flexed hip causes pain

The obturator sign is used in clinical examination to suggest the presence of an inflamed appendix that is located against the obturator internus muscle.

Question 9

9. A 15 year old male grade 10 senior high school student complains of aching pain in the epigastric area, anorexia, nausea and vomiting. The pain later moves to the right lower quadrant and becomes worse. At the ER, he is found to have right lower quadrant tenderness, voluntary guarding, temperature of 38.5 degree centigrade and a white blood cell count of 14,500 with polymorphonuclear dominance. What do you think is happening to this patient? *
   A. Bleeding or rupture of vessels
   B. Perforation
   C. Inflammation or Infection
   D. Obstruction

Answer 9

C. Inflammation or Infection

The clinical presentation described is classic for acute appendicitis. The symptoms of an initially epigastric pain that migrates to the right lower quadrant, accompanied by nausea, vomiting, right lower quadrant tenderness, fever, and an elevated white blood cell count with polymorphonuclear dominance, strongly suggest an inflammation or infection of the appendix.

Question 10

10.A careful menstrual history is important in patients with abdominal pain
A. 75 Year Old Female Patient
B. 25 Year Old Male Patient
C. 35 Year Old Female Patient
D. 7 Year Old Female Patient

Answer 10

C. 35 Year Old Female Patient

A careful menstrual history is especially relevant in reproductive-age females, as several gynecological conditions that relate to menstruation can cause abdominal pain. The 35-year-old female patient falls within this age group, making a menstrual history pertinent for her in the context of abdominal pain.

Question 11

11. The blood supply to the midgut
    A. Inferior Mesenteric Artery
    B. Celic Artery
    C. Superior Mesenteric Artery
    D. Portal Vein

Answer 11

C. Superior Mesenteric Artery

The Superior Mesenteric Artery (SMA) supplies blood to the midgut, which includes parts of the small intestine and the early parts of the colon.

Question 12

12 Abdominal Examinaton Signs. Varicose veins at umbilicus (caput medusae)
A. Cruveilhier Sign
B. Kehr Sign
C. Danforth Sign
D. Bassler Sign

Answer 12

A. Cruveilhier Sign

Caput medusae refers to the appearance of distended and engorged paraumbilical veins, which can be a sign of portal hypertension. The presence of these veins is known as Cruveilhier Sign.

Question 13

13 Findings associated with surgical disease in the setting of acute abdominal pain. Diagnostic peritoneal lavage (1000ml) …*
A. >30,000 red blood cells per milliliter of aspirate
B. >300,000 red blood cells per milliliter of aspirate
C. <25 white blood cells per milliliter of aspirate
D. >25 white blood cells per milliliter of aspirate

Answer 13

B. >300,000 red blood cells per milliliter of aspirate

Diagnostic peritoneal lavage (DPL) is a procedure that was historically used to determine if there was blood in the abdominal cavity, suggesting injury to intra-abdominal organs that might necessitate surgery.
A finding of more than 100,000 red blood cells per milliliter of aspirate was traditionally considered positive, indicating a potential injury.
The threshold of >300,000 red blood cells per milliliter is a more stringent criterion, further suggesting a surgical injury.

Question 14

14.Pain caused by gentle traction of right testicle/spermatic cord *
A. Grey Turner sign
B. Cullen Sign
C. Kehr sign
D. Ten Horn sign

Answer 14

D. Ten Horn sign

Question 15

15. Extreme lower abdominal pain and pelvic pain with movement of cervix
    A. Fothergill sign
    B. Aaron sign
    C. Chandelier sign
    D. Cullen sign

Answer 15

C. Chandelier sign

Question 16

16. Transient abdominal wall rebound tenderness
    A. Ransohoff sign
    B. Cullen sign
    C. Bassler sign
    D. Blumberg sign

Answer 16

D. Blumberg sign

Question 17

7.Gynecologic cause of hemoperitoneum
A. Ruptured ectopic pregnancy
B. Ruptured Spleen
C. Ruptured aneurysm: Aortoiliac
D. Ruptured bladder

Answer 17

A. Ruptured ectopic pregnancy

Question 18

18.The most common non-obstetric disease requiring surgery, occurring in 1/1500 pregnancies. *
A. Acute Cholecystitis
B. Acute Salpingitis
C. Acute Pancreatitis
D. Acute Appendicitis

Answer 18

D. Acute Appendicitis

Question 19

19.Radiographic findings associated with surgical disease in the setting of Acute Abdominal pain
A. Pneumoperitoneum
B. Fat stranding or thickened bowel wall with systemic sepsis
C. All of the above
D. None of the above

Answer 19

C. All of the above

Question 20

0 .During inspiration the inflamed gallbladder touches the examiners fingers resulting in the sudden cessation of inspiration
A. Charcot sign
B. Obturator sign
C. Rovsing sign
D. Murphys sign

Answer 20

D. Murphys sign

Question 21

21. Steps in physical examination for Acute Abdomen (SEQUENCE) *
    a. Inspection, Auscultation, Percussion, Palpation
    b. Palpation, Percussion, Inspection, Auscultation
    c. Auscultation, Palpation, Percussion, Inspection
    d. Inspection, Palpation, Auscultation, Percussion

Answer 21

a. Inspection, Auscultation, Percussion, Palpation

Question 22

22. Featured Symptoms in Modified
    Alvarado Scoring System for Appendicitis except
    A. Anorexia
    B. Right iliac fossa pain
    C. loose stools(diarrhea)
    D. Nausea,Vomiting

Answer 22

C. loose stools(diarrhea)

Question 23

23.Non-surgical causes of the Acute Abdomen *
A. Hemorrhagic pancreatitis
B. Buerger disease
C. Sickle cell crisis
D. Meckel’s diverticulitis

Answer 23

C. Sickle cell crisis

Question 24

24.The mainstays of determining the correct diagnosis and management in Acute Abdomen
A. Laboratory work-ups
B. Laparoscopy
C. Imaging studies
D. History and Physical Examination

Answer 24

D. History and Physical Examination

Question 25

25. The patient has an uncertain diagnosis that does not necessitate immediate or urgent laparotomy and that may prove to be non surgical
    A. Suspected nonsurgical abdomen
    B. Acute abdominal pain requiring observation
    C. Acute surgical abdomen
    D. Sub acute surgical abdomen

Answer 25

A. Suspected nonsurgical abdomen

Question 26

26.During evaluation of a male patient with right lower quadrant pain the following are included in the differential diagnosis.
A. Acute mesenteric adenitis, gastroenteritis and acute appendicitis
B. Gastroenteritis, ovarian cyst, acute
appendicitis
C. Acute appendicitis, ovarian cyst, acute gastroenteritis
D. Acute mesenteric adenitis, torsion of the fallopian tube, acute appendicitis

Answer 26

A. Acute mesenteric adenitis, gastroenteritis and acute appendicitis

Acute mesenteric adenitis can mimic the symptoms of appendicitis, especially in younger individuals, and gastroenteritis can also cause right lower quadrant pain, making these appropriate differential diagnoses for a male patient with right lower quadrant pain.

Question 27

27.A 48 year old woman presented with lower abdominal pain, fever and difficulty walking. The patient has noted change in bowel habits over the past 3 months. Physical exam exhibits temperature of 39.5 degrees centigrade. She is lying supine with left leg flexed at the hospital. No scars in the abdomen but with tenderness in the left lower quadrant. What is your working impression.
a. acute pancreatitis
b.acute diverticulitis
c.acute cholecysitis
d.acute appendicitis

Answer 27

b. acute diverticulitis

Rationale:
The patient’s symptoms of lower abdominal pain, fever, and a change in bowel habits over the past 3 months, combined with tenderness in the left lower quadrant, are suggestive of acute diverticulitis. Diverticulitis is an inflammation or infection of small pouches (diverticula) that can form in the walls of the colon. The condition commonly affects the left lower quadrant of the abdomen, especially in Western populations. The patient’s position of lying supine with the left leg flexed might be an attempt to relieve pain associated with diverticulitis. The other options (acute pancreatitis, acute cholecystitis, and acute appendicitis) are less consistent with the patient’s presentation and physical exam findings.

Question 28

28. In patients under 50 years old, with acute abdominal pain, the most common diagnosis is:
    A. Acute appendicitis
    B. Nonspecific abdominal pain
    C. Small bowel obstruction
    D. Acute cholecystitis

Answer 28

B. Nonspecific abdominal pain

Question 29

29.A 98 year old woman with a history of coronary artery bypass surgery and myocardial infarction is brought to the hospital because of severe abdominal excruciating pain that suddenly began 8 hours ago. She is confused and disoriented. The patient appears gravely ill with unstable vital signs. Abdomen is distended without muscle guarding and tenderness is difficult to evaluate. What do you think is happening to the patient with regard to her abdomen?
A.Perforation
B. Obstruction
C. Inflammation
D. Ischemia or infarction

Answer 29

A. Perforation

Rationale:
A perforation refers to a hole or tear in the wall of an organ, often the gastrointestinal tract. When there’s a perforation, contents from the tract can spill into the abdominal cavity, leading to peritonitis (inflammation of the peritoneum, the lining of the abdominal cavity). This can be life-threatening. The patient’s sudden severe abdominal pain, distended abdomen, and gravely ill appearance are consistent with a perforation. The absence of muscle guarding might be due to the patient’s age and altered mental status, making it difficult to evaluate. Given the acute presentation and the patient’s overall condition, a perforation is a likely diagnosis.

Question 30

30. Findings Associated with surgical disease in the setting of acute abdominal pain. Physical examination and Laboratory Findings…
    A. Abdominal compartment pressures >10 mm Hg
    B. Gastrointestinal hemorrhage requiring >2 units of blood without stabilization
    C. Gastrointestinal hemorrhage requiring 2 units of blood without stabilization
    D. Abdominal compartment pressures >30 mm Hg

Answer 30

D. Abdominal compartment pressures >30 mm Hg

Elevated abdominal compartment pressures can indicate intra-abdominal hypertension or abdominal compartment syndrome, which may require surgical intervention.
An abdominal compartment pressure greater than 20 mm Hg with new organ dysfunction or failure is typically considered diagnostic of abdominal compartment syndrome.
If the pressure is greater than 30 mm Hg, it is highly concerning and may necessitate surgical decompression.

Question 31

31.Abdominal pain is conveniently divided into visceral and parietal components. This pain corresponds to the segmental nerve roots innervating the peritoneum and tends to be sharper and better localized.
A. Visceral pain
B. Referred pain
C. Phantom pain
D. Parietal pain

Answer 31

D. Parietal pain

Question 32

32. The preferred treatment for acute appendicitis is
    A. appendectomy
    B. pain relievers
    C. antibiotic and observation
    D. observation and bowel rest

Answer 32

A. appendectomy.

Rationale:
Acute appendicitis refers to the inflammation of the appendix, which if left untreated, can rupture and lead to complications such as peritonitis (inflammation of the peritoneum) and abscess formation. Appendectomy, which is the surgical removal of the appendix, is the definitive treatment and is typically performed urgently to prevent rupture. While there have been some studies suggesting that certain cases of acute appendicitis can be treated with antibiotics, surgical removal remains the gold standard and most widely accepted treatment for uncomplicated acute appendicitis.

Question 33

33. The normal frequency of bowel sounds
    A. 30-50/ min
    B. 5-34/ min
    C. 10-20/ min
    D. 5-10/ min

Answer 33

B. 5-34/ min

Bowel sounds, or borborygmi, represent the movement of the contents of the bowel (mainly gas and fluid) secondary to peristaltic activity. Normal bowel sounds typically range from 5 to 34 per minute.

Question 34

34. Surgical Acute Abdominal conditions
    A. Intestinal ulceration
    B. Uremia
    C. Acute intermittent porphyria
    D. Acute Leukemia

Answer 34

A. Intestinal ulceration

Question 35

35. Acute appendicitis is most commonly associated with which of the following signs and symptoms.
    A. Anorexia, abdominal pain, and right lower quadrant tenderness
    B. Temperature above 40C
    C. Frequent loose tools
    D. White blood cell count greater than 20,000

Answer 35

A. Anorexia, abdominal pain, and right lower quadrant tenderness.

Rationale:
Acute appendicitis typically presents with anorexia (loss of appetite), a generalized or peri-umbilical abdominal pain that later localizes to the right lower quadrant, and tenderness in the right lower quadrant (often at the McBurney’s point). While fever can be a symptom of acute appendicitis, a temperature above 40°C is not specifically characteristic of it. Frequent loose stools are not a typical sign of acute appendicitis. An elevated white blood cell count can be indicative of an infection or inflammation, but a count greater than 20,000 is not specifically characteristic of acute appendicitis.

Question 36

36.Gram staining of discharge from a carbuncle at the nape of a diabetic showed blue staining cocci in clusters. What is the LEAST likely etiologic agent?
A. Staphylococcus saprophyticus
B. Streptococcus pyogenes
C. Staphylococcus epidermidis,
D. Staphylococcus aureus, methicillin resistant

Answer 36

A. Staphylococcus saprophyticus

Question 37

37. What segment of intestinal tract is relatively sterile?
    A. stomach due to pumping mechanism of the diaphragm
    B. oral cavity due to presence of microflora
    C. esophagus due to trapping of bacteria
    D. duodeno jejunal sgement due to acid secretion

Answer 37

D. duodenojejunal segment due to acid secretion

The stomach and the duodenojejunal segment are not truly sterile, but they have fewer bacteria compared to other parts of the gastrointestinal tract. The acidic environment of the stomach due to the secretion of gastric acid and the rapid transit of chyme into the duodenum helps to limit bacterial colonization in these areas. However, the term “relatively sterile” is used because even in these areas, small numbers of bacteria can be found.

Question 38

38. The least accurate statement regarding goals in management of severe sepsis,
    A.Start resuscitation within 3 hours upon ICU arrival
    B. Urine output of 0.5 ml/ kg/ hour
    C.Mean arterial pressure < 65 mmHg
    D. CVP target of 8-12 mmHg

Answer 38

C. Mean arterial pressure < 65 mmHg

Rationale:
In the management of severe sepsis, the goal is typically to maintain or achieve a mean arterial pressure (MAP) of at least 65 mmHg, not less than that. A MAP below 65 mmHg can compromise organ perfusion and function. The other statements A, B, and D are consistent with guidelines for the management of severe sepsis and septic shock.

Question 39

39. How does the body protect itself from the spread of infection in ruptured viscus?
    A. All of the above
    B. Shedding of epithelial mucosal lining
    C. Resident microflora prevent growth of bacteria
    D. Attraction of omentum

Answer 39

D. Attraction of omentum

Rationale:
The omentum is a large apron-like fold of visceral peritoneum that hangs down from the stomach. When there is inflammation, injury, or a ruptured viscus in the abdomen, the omentum often moves to that area and adheres to it. This phenomenon is sometimes referred to as the omentum acting like the “policeman of the abdomen.” Its migration and adherence to areas of injury or inflammation can help to seal off the area, potentially limiting the spread of infection or other substances from a ruptured organ.

Question 40

40.When there is fever, tachycardia , tachypnea and hypotesion in a diabetic patient with carbuncle, what is the possible degree of microbial invasion ?
A. Eradication
B. Containment
C. Loco regional infection
D. Bacteremia

Answer 40

C. Loco regional infection

Rationale:
Loco-regional infection refers to an infection that is more advanced than a simple localized infection but has not yet spread systemically. Fever, tachycardia, tachypnea, and hypotension in a diabetic patient with a carbuncle suggest that the infection has progressed beyond the initial site (the carbuncle) but may not yet be fully systemic as in bacteremia or sepsis. Diabetic patients are at increased risk for complications from skin infections, and a carbuncle can serve as a source for more widespread infection, especially if not treated promptly.

Question 41

41. What physiologic response is expected from the patient with secondary peritonitis?
    a.An influx of polymorphonuclears and inflammatory fluids
    b.Microbial destruction by opsonization and phagocytosis
    c.All of the above
    d. Cytokine release by macrophages

Answer 41

c.All of the above

Question 42

42. Aerobic culture of the peritoneal fluid showed red staining bacillus, what is the most likely diagnosis?
    A. Escherichia coli
    B. Clostridium defficile
    C. Klebsiella pneumonia
    D. Bacteroides fragilis

Answer 42

C. Klebsiella pneumonia

Question 43

43. Which of the following practices is least appropriate prior to elective surgical operation?
    A. Shaving of operative site immediately prior to surgery
    B. Application of antimicrobial to the operative site
    C. Antibiotics given only for the duration of surgery
    D. Start antibiotic prophylaxis 30 minutes before incision

Answer 43

D. Start antibiotic prophylaxis 30 minutes before incision

Question 44

44.What is the most probable source of a pyogenic liver abscess? *
A. Gastritis
B. Appendicitis
C. Diverticulitis
D. Cholecystitis

Answer 44

D. Cholecystitis.

In terms of the clinical context, cholecystitis (inflammation of the gallbladder) can lead to the formation of a liver abscess due to the close anatomical proximity of the gallbladder to the liver and the potential for bacterial spread. Appendicitis and diverticulitis can also be sources, but they are less likely than cholecystitis. Gastritis is inflammation of the stomach lining and is not typically associated with the formation of liver abscesses.

Question 45

45.A 75 year old diabetic woman has low gut obstruction propbaly secondary to ruptured diverticulitis, her bital signs are, BP dropped from 140/90 to 90/60, tachycardic and respiratory rate was 25/ minute, urine output is borderline normal to 30-40 ml per CT scan revealed localized abscess on the left lower quadrant, what management will you do?
A. Get blood culture and start antibiotics depending on gram staining
B. Get stool culture and start antibiotics once results are available
C. Exploratory laparotomy
D. Start broad-spectrum antibiotics immediately

Answer 45

D. Start broad-spectrum antibiotics immediately.

Rationale:
In the setting of sepsis secondary to a suspected intra-abdominal source (such as ruptured diverticulitis), immediate initiation of broad-spectrum antibiotics is crucial. Delaying antibiotic administration until culture results are available could be detrimental. The choice of antibiotics would ideally cover gram-negative, gram-positive, and anaerobic organisms, given the polymicrobial nature of intra-abdominal infections.

Question 46

46.The most important key to improve outcome in intraabdominal infection is, *
a. Use a mechanical ventilator with 6 ml/kg tidal volume
b. Source control
c. Transfuse RBC if hemoglobin is below 7 gm/liter
d. Give insulin for hyperglycemia

Answer 46

b. Source control

This means identifying and eradicating the origin of the infection, such as abscess drainage or surgical removal of an infected organ. Proper source control can halt the progression of the infection and allow for healing. Without effective source control, even if other supportive measures are taken, the infection may continue to progress.

Question 47

47.The patient a week after colectomy due to perforated diverticulitis is febrile, tachypneic and despite aggressive hydration is tachycardic 120 beats per minute, and there are episodes of hypotension to as low as 80/50. His creatinine levels are elevated. What is his likely condition? *
A. Sepsis
B. SIRS
C. Septic shock
D. Severe sepsis

Answer 47

C. Septic shock

Rationale:
Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to increase mortality. The patient’s signs and symptoms, such as hypotension not responsive to fluid resuscitation (as evident from the aggressive hydration yet hypotension), elevated creatinine levels indicating renal dysfunction, and systemic signs of inflammation following a surgical procedure for perforated diverticulitis, are consistent with septic shock.

Question 48

48. What is the recommended management for nosocomial pneumonia most probably due to Pseudomonas aeuroginosa?
    A. Tigecycline
    B. Penicillin high dose
    C. Meropenem
    D. Cefuroxime

Answer 48

B. Penicillin high dose

Question 49

49 The most important key to improve outcome in intraabdominal infection is,
A. Use a mechanical ventilator with 6 ml/kg tidal volume
B. Transfuse RBC if hemoglobin is below 7 gm/liter
C. Source control
D. Give insulin for hyperglycemia

Answer 49

C. Source control

Question 50

50. What is the drug of choice for anaerobic bacteria? *
    A. Clindamycin
    B. Co-amoxiclav
    C. Metronidazole
    D. Cefoxitin

Answer 50

C. Metronidazole

Question 51

51. What is the most effective and efficient technique to lower the incidence of infection?
    A. Handwashing with hypochlorite water
    B. Use of faceshield and alcohol wipes
    C. Use of 70% alcohol spray
    D. Handwashing with soap and water

Answer 51

D. Handwashing with soap and water

Question 52

52. What is the most likely procedure recommended for localized pelvic abscess due to ruptured diverticulitis in a elderly diabetic? *
    A. Image guided tube drainage
    B. Surgical colon resection and loop colostomy
    C. Exploratory laparotomy, resection, and anastomosis of the colon
    D. Intensive medical care with antibiotics

Answer 52

A. Image guided tube drainage

Question 53

53.Which of the following statement regarding the duration of antibiotic treatment is true?
A. Give antibiotics for 10 days
B. Discontinue antibiotics once WBC count is normal without bands on the smear
C. Give antibiotics for 20 days
D. Give antibiotics for 7 days

Answer 53

D. Give antibiotics for 7 days

Question 54

54.Transmission of HIV and hepatitis to a surgical team can be minimized by the following,EXCEPT
A. Careful disposal of blade and needles
B. Wash skin surface immediately after contact with body fluids
C. Use of gloves and goggles
D. Use of caps and gowns

Answer 54

D. Use of caps and gowns

Rationale:
While caps and gowns can protect surgical teams from splashes or spills of body fluids, they aren’t specifically designed to minimize the transmission of bloodborne pathogens like HIV and hepatitis. On the other hand, careful disposal of sharp objects (blades and needles), washing skin immediately after contact with potentially infectious body fluids, and using gloves and goggles are more direct measures to minimize exposure to such pathogens.

Question 55

55. Patient dies from the body’s inflammatory response to infection rather from the infection itself is proposed by whom? *
    A. Ignaz Semmelweis
    B. William Altemeier
    C. William Osler
    D. Charles Mcburney

Answer 55

C. William Osler

Question 56

56.Bacterial anaerobic culture suggest Bacteroides species, What is the preferred antibiotic ?
A. Clindamycin
B. Metronidazole
C. Cefoxitin
D. Co-amoxiclav

Answer 56

B. Metronidazole

Metronidazole is a preferred antibiotic for the treatment of Bacteroides species infections, as these are anaerobic bacteria. While some of the other options also have activity against anaerobes, metronidazole is frequently the first choice for Bacteroides infections.

Question 57

57. Patient had developed localized left lower quadrant pain with purulent drainage at the incision site 6 days post resection of sigmoid for cancer, what type of peritonitis is present
    A. Secondary
    B. Tertiary
    C. Primary Peritonitis
    D. Superficial surgical site infection

Answer 57

A. Secondary

Rationale:
Secondary peritonitis arises from a disease or malfunction in an abdominal organ, often due to events like surgery, trauma, or perforation. In this scenario, the patient developed symptoms following a surgical procedure (resection of sigmoid for cancer), which suggests the peritonitis is secondary to the surgery or a complication associated with it.

Question 58

58. Appropriate antibiotic guide to lower mortality for sepsis, EXCEPT:
    A. The initial antibiotic should be started within one hour of admission
    B. The initial antibiotic of choice depends on the presumed source
    C. Initial antibiotic therapy is based on culture
    D. Reassess choice of antibiotic daily

Answer 58

D. Reassess choice of antibiotic daily

Question 59

59 What is the expected infection rate seen after a colon resection and anastomosis for acute diverticulitis?
A. 10%
B. 2%
C. 15%
D. 5%

Answer 59

D. 5%

Question 60

60.Which type of antibiotics will kill bacteria by inhibiting cell wall synthesis? *
A. Cephalosporins
B. Aminoglycosides
C. Flouroquinolones
D. Tetracycline

Answer 60

A. Cephalosporins

Question 61

61 What antibiotic has LEAST activity against MRSA?
A. Penicillin
B. Vancomycin
C. Floucloxacillin
D. Linezolid

Answer 61

B. Vancomycin

Question 62

62. Needlestick injury sustained during surgery of a patient with HIV is best managed by
    A. Take a culture of the needle and discard appropriately
    B. Start empiric antibiotics immediately
    C. Washing of hands and skin exposed to body fluids
    D. Post-exposure prophylaxis within 3 hours

Answer 62

D. Post-exposure prophylaxis within 3 hours

Question 63

63. Which of the following is the LEAST appropriate regarding the management of nosocomial infection?
    A. Wean patients from the ventilator as soon as feasible
    B. Use multiple lumen indwelling intravascular catheters
    C. Apply abdominal binder for midline supraumbilical incision
    D. Remove the urinary catheter within 1-2 days

Answer 63

C. Apply abdominal binder for midline supraumbilical incision

Question 64

64.What is the most likely causative agent of pneumonia developing after a complicated appendicitis? *
A. Streptococcus pneumonia
B. mycoplasma pneumonia
C. Klebsiella pneumonia
D. Haemophilus pneumonia

Answer 64

A. Streptococcus pneumonia

Question 65

65 The patient developed peritonitis due to delayed management of acute appendicitis, he is febrile, tachycardic, tachypneic, with leukocytosis a day after an appendectomy, his urine output was decreased, and was intubated due to hypoxemia. His blood pressure is 120/80. What is your diagnosis?
A. Septic shock
B Severe sepsis
C. Sepsis
D. SIRS

Answer 65

D. SIRS

Question 66

66 Which of the following case is best managed by source control procedure?
A. Perforated diverticulitis
B. Pulmonary tuberculosis
C. Enteric fever
D. Bilateral pleural effusion

Answer 66

A. Perforated diverticulitis

Question 67

67. When is open surgical drainage indicated for intraabdominal abscess?
    a. Multiple abscesses less than 1 cm
    b. large solitary abscess
    c. ongoing contamination is identified
    d. the good window for percutaneous puncture

Answer 67

c. ongoing contamination is identified

Question 68

68. Which of the following is NOT true for primary microbial peritonitis?
    A. Gram stain of microbes with single morphology
    B. Peritoneal fluid WBC more than 100 /ml
    C. Diffuse abdominal tenderness and guarding
    D. Presence of pneumoperitoneum

Answer 68

A. Gram stain of microbes with single morphology

Question 69

70.Patients with soft tissue necrotizing infection had hypotension, hypoxemia, and oliguria. Which of the following is the LEAST appropriate management? *
a. use dopamine for renal secretion
b. Initiate crystalloids or colloids upon admission to achieve normal CVP
c. Use norepinephrine if BP is unresponsive to fluids
d. Use hydrocortisone below 300 mg/ day

Answer 69

a. use dopamine for renal secretion

Question 70

71. Compute for IBW.
    A. 68.4 kg
    B. 66.3 kg
    C. 61.8 kg
    D. 63.9 kg

Answer 70

A. 68.4 kg

Question 71

72. Compute for BMI
    A. 21.8
    B. 21.4
    C. 19
    D. 18.3

Answer 71

D. 18.3

Question 72

73. Compute the adjusted body weight.
    A. 59.8
    B. 63
    C. 57
    D. 58.4

Answer 72

B. 63

AdjBW=IBW+0.25×(Actual weight−IBW)

Question 73

74. What will be the patient’s daily caloric requirement using IBW and considering the stress factor (i.e. mild-1.0, moderate - 1.4, severe - 1.6, major burns -2.0
    A. 2052 kcal/day
    B. 3283 kcal/day
    C. 2873 kcal/day
    D. 4104 kcal/day

Answer 73

B. 3283 kcal/day

BEE = Calorie Factor (30kcal/kg/day) x Weight in kg

AdjEE = BEE x Stress Factor

Question 74

75. What will be the patients protein caloric requirement base on the IBW and severity of stress protein adjustment (ie. mild 1.0, moderate 1.5, severity 2.0, major burn 2.5)
    A.273.6 kcal/day
    B. 547.2 kcal/day
    C. 684 kcal/day
    D. 410.4 kcal/day

Answer 74

B. 547.2 kcal/day

Formula for Protein Requirement based on IBW:
Protein Requirement (grams) = Protein Factor (grams/kg/day) × IBW in kg

Formula for Protein Caloric Requirement:
Protein Caloric Requirement (kcal) = Protein Requirement (grams) × 4kcal/g

Question 75

76. What will be the patient’s non protein caloric requirement. (based on your computation above)
    A. 2326 kcal/day
    B. 1779 kcal/day
    C. 2735.8 kcal/day
    D. 3120 kcal/day

Answer 75

C. 2735.8 kcal/day

Non-protein Caloric Requirement=Total Caloric Requirement−Protein Caloric Requirement

Question 76

80. Which of the following will be the most appropriate frequency and duration of feeding.
    A. Bolus every 6 hours
    B. Bolus at least every 4 hours
    C. Drip of 4 hours every 6 hours
    D. Drip for 24 hours

Answer 76

D. Drip for 24 hours

Question 77

81. Which of the following biochemical test will provide the latest protein status of surgical patient.
    A. absolute lymphocytic count
    B. transferrin
    C. globulin
    D. albumin

Answer 77

D. albumin

Question 78

82. Which of the following micronutrient/s is/are avoided in patient in renal failure patients.
    A. Vit. A
    B. Vit. C
    C. Omega 3 fatty acid
    D. A and B
    E. A and C

Answer 78

A. Vit. A

Question 79

83. Which of the following statement is TRUE regarding enteral feeding.
    A. Malnourished patient expected to be unable to eat adequately for > 5-7 days
    B. Adequately nourished patient expected to be unable to eat > 7-9 days
    C. Following severe trauma or burns
    D. A and B
    E. All of the above

Answer 79

E. All of the above

Rationale:
Enteral nutrition (EN) or tube feeding is generally preferred over parenteral nutrition because of the advantages associated with maintaining gut function, such as preserving the integrity of the gut mucosa, maintaining gut immunity, and preventing bacterial translocation.

A. Malnourished patient expected to be unable to eat adequately for > 5-7 days: Malnourished patients are already at a nutritional deficit, so if they’re expected to not eat adequately for more than 5-7 days, it’s crucial to start enteral feeding early to prevent further deterioration of their nutritional status.

B. Adequately nourished patient expected to be unable to eat > 7-9 days: Even in patients who are not malnourished, if they are expected to be without adequate oral intake for more than 7-9 days, EN should be considered to prevent malnutrition and its associated complications.

C. Following severe trauma or burns: Patients with severe trauma or burns have significantly increased metabolic demands. EN can be crucial in these patients to meet their nutritional needs, support healing, and improve outcomes.

Thus, all of the above statements are valid indications for considering enteral feeding.

Question 80

84. The 1st line formula for stable patient with intact GI tract
    A. Low residue isotonic formula
    B. Isotonic formula with fiber
    C. Calorie dense formula
    D. High protein formula

Answer 80

A. Low residue isotonic formula

Question 81

85. Which enteral formula has glutamine, arginine omega 3 fatty acid.
    A. Low residue isotonic formula
    B. Isotonic formula with fiber
    C. Calorie Dense formula
    D. Immune enhancing formula

Answer 81

D. Immune enhancing formula

Question 82

86. Which type of access will require continuous feeding only to avoid dumping syndrome?
    A. PEG
    B. Surgical Gastrostomy
    C. Surgical jejunostomy
    D. All of the above

Answer 82

A. PEG

Question 83

99. What is the appropriate nutritional access for the patient?
    A. Central venous line
    B. Peripheral venous line
    C. PEG
    D. Jejunostomy

Answer 83

A. Central venous line

Question 84

100. The most appropriate nutrition formula for this patient is:
     A. Osterized feeding low residue isotonic formula for this patient
     B. Elemental diet
     C. Amino acid, lipid, dextrose solution thru Peripheral iv line
     D. amino acid, lipid, dextrose solution thru Central iv line

Answer 84

B. Elemental diet

Rationale:
The patient has had a significant surgical intervention with injuries to crucial organs such as the liver and duodenum. This has implications on his ability to digest and absorb nutrients.

An elemental diet provides essential nutrients in their simplest forms, requiring minimal digestive processing. These formulas contain predigested nutrients, making them easily assimilable for patients who have impaired digestion and absorption. Given that there’s an injury to the 4th portion of the duodenum, the digestion and absorption might be compromised.

Question 85

93. Deficiency of this vitamin can lead to rickets and osteomalacia
    A. Vitamin A
    B. Vitamin E
    C. Vitamin D
    D. Riboflvain

Answer 85

B. Vitamin E

Question 86

94. The most common fatal complication of Internal Jugular catheter insertion
    A. Pneumothorax
    B. Cardiac Arrythmia
    C. Sepsis
    D. Hemothorax

Answer 86

C. Sepsis

Question 87

A 42 year old male who underwent Laparoscopic Cholecystectomy 1 day ago is afebrile, no abdominal pain and distention, with BM and flatus. Wt= 55kg Ht=5’5”

87. When is the best time to feed the patient?
    A. Immediately
    B. After 48hours
    C. After 24hours
    D. After 72 hours

Answer 87

A. Immediately

Question 88

A 42 year old male who underwent Laparoscopic Cholecystectomy 1 day ago is afebrile, no abdominal pain and distention, with BM and flatus. Wt= 55kg Ht=5’5”

88. What is the most approriate route of feeding?
    A. NGT
    B. Nasojejunostomy
    C. Peripheral venous line
    D. Oral

Answer 88

D. Oral