General Surgery
Q1. A 72-year-old patient with a history of coronary artery disease and a left ventricular
ejection fraction of 35% is scheduled for an open sigmoid colectomy. According to the Revised
Cardiac Risk Index (RCRI), which of the following is NOT an independent risk factor for
perioperative cardiac complications?
A) High-risk surgery (intraperitoneal)
B) History of ischemic heart disease
C) Age > 70 years
D) Preoperative serum creatinine > 2.0 mg/dL
E) History of cerebrovascular disease
Detailed Answer:
Correct Answer: C
The Revised Cardiac Risk Index (RCRI) includes six independent risk factors: (1) high-risk surgery
(intrathoracic, intraperitoneal, or suprapubic), (2) history of ischemic heart disease, (3) history
of congestive heart failure, (4) history of cerebrovascular disease (stroke/TIA), (5) preoperative
insulin therapy for diabetes, and (6) preoperative creatinine > 2.0 mg/dL. Age > 70 years (C) is
NOT part of the RCRI; it is part of the older Goldman criteria. This patient has at least 3 risk
factors (high-risk surgery, ischemic heart disease, creatinine >2.0 is not stated but diabetes is
not insulin-requiring), placing them at intermediate-to-high risk.
Q2. A patient is receiving total parenteral nutrition (TPN) through a central venous catheter.
On postoperative day 7, she develops a fever of 38.8°C (101.8°F) and rigors that coincide with
the start of the TPN infusion. Blood cultures grow Candida albicans. The most appropriate
next step is:
A) Continue TPN and add fluconazole
B) Remove the central line and treat with an echinocandin
C) Change the TPN bag and add amphotericin B
D) Administer vancomycin and piperacillin-tazobactam
E) Convert to peripheral parenteral nutrition
Detailed Answer:
Correct Answer: B
This is a catheter-related bloodstream infection (CRBSI) with Candida. The standard of care is to
remove the central venous catheter (as it is the source) and initiate antifungal therapy (an
echinocandin such as micafungin or caspofungin is preferred for candidemia). Fluconazole (A)
may be used if the patient is stable and the organism is susceptible, but catheter removal is still
,required. Continuing TPN through the infected line (C) is unsafe. Antibiotics (D) do not cover
fungi. Peripheral parenteral nutrition (E) is not feasible for prolonged therapy.
Q3. A 65-year-old male undergoes an elective open repair of an infrarenal abdominal aortic
aneurysm. The surgery is uncomplicated, and the patient is extubated in the operating room.
On postoperative day 1, he develops acute-onset oliguria (urine output 15 mL/hr) and a
serum creatinine rise from 1.0 to 2.8 mg/dL. His blood pressure is 110/65 mmHg, heart rate
90 bpm, CVP 6 mmHg. Urinary sodium is 40 mEq/L, and FENa is 2.5%. The most likely
diagnosis is:
A) Prerenal azotemia
B) Acute tubular necrosis (ATN)
C) Contrast-induced nephropathy
D) Postrenal obstruction
E) Renal artery thrombosis
Detailed Answer:
Correct Answer: B
This patient has acute kidney injury (AKI) with a high FENa (>1%) and high urinary sodium (>20
mEq/L), which is consistent with intrinsic renal injury (acute tubular necrosis, ATN). Prerenal
azotemia (A) would show FENa <1% and low urine sodium (<10–20 mEq/L). Contrast
nephropathy (C) typically occurs within 24-48 hours after contrast administration but would also
show a low FENa if prerenal. Postrenal obstruction (D) would show hydronephrosis on
ultrasound. Renal artery thrombosis (E) after AAA repair is possible but less common and would
present with flank pain and hematuria.
Q4. A patient undergoing a laparoscopic cholecystectomy has an intraoperative
cholangiogram that reveals a filling defect in the common bile duct. The surgeon decides to
proceed with laparoscopic common bile duct exploration. Which of the following is the most
appropriate next step for stone extraction?
A) Perform a choledochotomy and stone extraction
B) Place a T-tube and perform postoperative ERCP
C) Use a choledochoscope with a basket or balloon
D) Perform a Roux-en-Y hepaticojejunostomy
E) Convert to an open procedure
Detailed Answer:
Correct Answer: C
,During laparoscopic common bile duct exploration (LCBDE), the most appropriate technique for
stone extraction is to use a choledochoscope with a basket or a balloon to retrieve the stones.
This is a standard minimally invasive approach. Choledochotomy (A) is an open or laparoscopic
technique but is more invasive. T-tube placement (B) is used if stones cannot be cleared or for
biliary drainage. Roux-en-Y (D) is for biliary reconstruction or stricture. Conversion to open (E) is
a bailout option if laparoscopic exploration fails.
Q5. A patient with a perforated peptic ulcer undergoes an emergency Graham patch repair
(omental patch). Postoperatively, she develops a fever, tachycardia, and a left-sided pleural
effusion. An upper GI series with water-soluble contrast shows extravasation from the
duodenal stump. The most appropriate next step is:
A) Intravenous antibiotics and nasogastric tube decompression
B) Endoscopic stenting
C) Reoperation with definitive ulcer surgery
D) Percutaneous drainage of the fluid collection
E) Total parenteral nutrition and octreotide
Detailed Answer:
Correct Answer: A
A contained duodenal leak (extravasation on water-soluble contrast without free intraperitoneal
spillage) in a stable patient can often be managed conservatively with bowel rest (NG tube
decompression), intravenous antibiotics, and nutritional support. Reoperation (C) is reserved for
patients with diffuse peritonitis or hemodynamic instability. Endoscopic stenting (B) is used for
esophageal or gastric leaks. Percutaneous drainage (D) is for abscesses. Octreotide (E) is for
pancreatic fistulas.
Q6. A 50-year-old woman with a history of breast cancer (ER+/PR+, HER2-neu negative) status
post-lumpectomy and radiation therapy 5 years ago now presents with a new 2 cm mass in
the ipsilateral breast. Core needle biopsy shows recurrent invasive ductal carcinoma. She has
no distant metastases. What is the most appropriate surgical management?
A) Repeat lumpectomy with re-excision
B) Total mastectomy with sentinel lymph node biopsy
C) Total mastectomy with axillary lymph node dissection
D) Modified radical mastectomy
E) Neoadjuvant chemotherapy followed by surgery
, Detailed Answer:
Correct Answer: B
For a patient with ipsilateral breast tumor recurrence (IBTR) after lumpectomy and radiation,
the standard of care is a total mastectomy (simple mastectomy) with sentinel lymph node
biopsy (SLNB). Re-excision lumpectomy (A) is not appropriate because the breast has already
been irradiated and further radiation is not feasible. Axillary lymph node dissection (C/D) may
be performed if the sentinel node is positive or if the prior axillary surgery was not performed.
Neoadjuvant chemotherapy (E) is used for locally advanced or inflammatory breast cancer, not
as primary management.
Q7. A 70-year-old male with a history of chronic obstructive pulmonary disease (COPD) and a
BMI of 18.5 is scheduled for an elective right hemicolectomy for colon cancer. Which of the
following preoperative interventions has the strongest evidence for reducing postoperative
pulmonary complications?
A) Preoperative smoking cessation for 4 weeks
B) Incentive spirometry and early ambulation
C) Preoperative nutritional supplementation
D) Preoperative pulmonary rehabilitation
E) Use of a laparoscopy approach
Detailed Answer:
Correct Answer: B
Postoperative incentive spirometry, early ambulation, and aggressive pulmonary hygiene are
the most effective interventions to reduce postoperative pulmonary complications (PPCs) in
high-risk patients. Preoperative smoking cessation (A) should ideally be at least 4-6 weeks to
reduce risk. Nutritional supplementation (C) is important but does not directly reduce PPCs.
Pulmonary rehabilitation (D) may help but is less practical. Laparoscopy (E) reduces PPCs
compared to open surgery, but the intervention with the strongest direct evidence is
postoperative pulmonary care (B).
Q8. A patient undergoes a thyroidectomy for a 4 cm follicular neoplasm. Final pathology
reveals a minimally invasive follicular thyroid carcinoma. The tumor is 4 cm, with no vascular
invasion and negative margins. What is the most appropriate management?
A) Total thyroidectomy (already done), with radioactive iodine ablation
B) Total thyroidectomy, with observation and TSH suppression
C) Completion thyroidectomy (if only a lobectomy was performed)
Q1. A 72-year-old patient with a history of coronary artery disease and a left ventricular
ejection fraction of 35% is scheduled for an open sigmoid colectomy. According to the Revised
Cardiac Risk Index (RCRI), which of the following is NOT an independent risk factor for
perioperative cardiac complications?
A) High-risk surgery (intraperitoneal)
B) History of ischemic heart disease
C) Age > 70 years
D) Preoperative serum creatinine > 2.0 mg/dL
E) History of cerebrovascular disease
Detailed Answer:
Correct Answer: C
The Revised Cardiac Risk Index (RCRI) includes six independent risk factors: (1) high-risk surgery
(intrathoracic, intraperitoneal, or suprapubic), (2) history of ischemic heart disease, (3) history
of congestive heart failure, (4) history of cerebrovascular disease (stroke/TIA), (5) preoperative
insulin therapy for diabetes, and (6) preoperative creatinine > 2.0 mg/dL. Age > 70 years (C) is
NOT part of the RCRI; it is part of the older Goldman criteria. This patient has at least 3 risk
factors (high-risk surgery, ischemic heart disease, creatinine >2.0 is not stated but diabetes is
not insulin-requiring), placing them at intermediate-to-high risk.
Q2. A patient is receiving total parenteral nutrition (TPN) through a central venous catheter.
On postoperative day 7, she develops a fever of 38.8°C (101.8°F) and rigors that coincide with
the start of the TPN infusion. Blood cultures grow Candida albicans. The most appropriate
next step is:
A) Continue TPN and add fluconazole
B) Remove the central line and treat with an echinocandin
C) Change the TPN bag and add amphotericin B
D) Administer vancomycin and piperacillin-tazobactam
E) Convert to peripheral parenteral nutrition
Detailed Answer:
Correct Answer: B
This is a catheter-related bloodstream infection (CRBSI) with Candida. The standard of care is to
remove the central venous catheter (as it is the source) and initiate antifungal therapy (an
echinocandin such as micafungin or caspofungin is preferred for candidemia). Fluconazole (A)
may be used if the patient is stable and the organism is susceptible, but catheter removal is still
,required. Continuing TPN through the infected line (C) is unsafe. Antibiotics (D) do not cover
fungi. Peripheral parenteral nutrition (E) is not feasible for prolonged therapy.
Q3. A 65-year-old male undergoes an elective open repair of an infrarenal abdominal aortic
aneurysm. The surgery is uncomplicated, and the patient is extubated in the operating room.
On postoperative day 1, he develops acute-onset oliguria (urine output 15 mL/hr) and a
serum creatinine rise from 1.0 to 2.8 mg/dL. His blood pressure is 110/65 mmHg, heart rate
90 bpm, CVP 6 mmHg. Urinary sodium is 40 mEq/L, and FENa is 2.5%. The most likely
diagnosis is:
A) Prerenal azotemia
B) Acute tubular necrosis (ATN)
C) Contrast-induced nephropathy
D) Postrenal obstruction
E) Renal artery thrombosis
Detailed Answer:
Correct Answer: B
This patient has acute kidney injury (AKI) with a high FENa (>1%) and high urinary sodium (>20
mEq/L), which is consistent with intrinsic renal injury (acute tubular necrosis, ATN). Prerenal
azotemia (A) would show FENa <1% and low urine sodium (<10–20 mEq/L). Contrast
nephropathy (C) typically occurs within 24-48 hours after contrast administration but would also
show a low FENa if prerenal. Postrenal obstruction (D) would show hydronephrosis on
ultrasound. Renal artery thrombosis (E) after AAA repair is possible but less common and would
present with flank pain and hematuria.
Q4. A patient undergoing a laparoscopic cholecystectomy has an intraoperative
cholangiogram that reveals a filling defect in the common bile duct. The surgeon decides to
proceed with laparoscopic common bile duct exploration. Which of the following is the most
appropriate next step for stone extraction?
A) Perform a choledochotomy and stone extraction
B) Place a T-tube and perform postoperative ERCP
C) Use a choledochoscope with a basket or balloon
D) Perform a Roux-en-Y hepaticojejunostomy
E) Convert to an open procedure
Detailed Answer:
Correct Answer: C
,During laparoscopic common bile duct exploration (LCBDE), the most appropriate technique for
stone extraction is to use a choledochoscope with a basket or a balloon to retrieve the stones.
This is a standard minimally invasive approach. Choledochotomy (A) is an open or laparoscopic
technique but is more invasive. T-tube placement (B) is used if stones cannot be cleared or for
biliary drainage. Roux-en-Y (D) is for biliary reconstruction or stricture. Conversion to open (E) is
a bailout option if laparoscopic exploration fails.
Q5. A patient with a perforated peptic ulcer undergoes an emergency Graham patch repair
(omental patch). Postoperatively, she develops a fever, tachycardia, and a left-sided pleural
effusion. An upper GI series with water-soluble contrast shows extravasation from the
duodenal stump. The most appropriate next step is:
A) Intravenous antibiotics and nasogastric tube decompression
B) Endoscopic stenting
C) Reoperation with definitive ulcer surgery
D) Percutaneous drainage of the fluid collection
E) Total parenteral nutrition and octreotide
Detailed Answer:
Correct Answer: A
A contained duodenal leak (extravasation on water-soluble contrast without free intraperitoneal
spillage) in a stable patient can often be managed conservatively with bowel rest (NG tube
decompression), intravenous antibiotics, and nutritional support. Reoperation (C) is reserved for
patients with diffuse peritonitis or hemodynamic instability. Endoscopic stenting (B) is used for
esophageal or gastric leaks. Percutaneous drainage (D) is for abscesses. Octreotide (E) is for
pancreatic fistulas.
Q6. A 50-year-old woman with a history of breast cancer (ER+/PR+, HER2-neu negative) status
post-lumpectomy and radiation therapy 5 years ago now presents with a new 2 cm mass in
the ipsilateral breast. Core needle biopsy shows recurrent invasive ductal carcinoma. She has
no distant metastases. What is the most appropriate surgical management?
A) Repeat lumpectomy with re-excision
B) Total mastectomy with sentinel lymph node biopsy
C) Total mastectomy with axillary lymph node dissection
D) Modified radical mastectomy
E) Neoadjuvant chemotherapy followed by surgery
, Detailed Answer:
Correct Answer: B
For a patient with ipsilateral breast tumor recurrence (IBTR) after lumpectomy and radiation,
the standard of care is a total mastectomy (simple mastectomy) with sentinel lymph node
biopsy (SLNB). Re-excision lumpectomy (A) is not appropriate because the breast has already
been irradiated and further radiation is not feasible. Axillary lymph node dissection (C/D) may
be performed if the sentinel node is positive or if the prior axillary surgery was not performed.
Neoadjuvant chemotherapy (E) is used for locally advanced or inflammatory breast cancer, not
as primary management.
Q7. A 70-year-old male with a history of chronic obstructive pulmonary disease (COPD) and a
BMI of 18.5 is scheduled for an elective right hemicolectomy for colon cancer. Which of the
following preoperative interventions has the strongest evidence for reducing postoperative
pulmonary complications?
A) Preoperative smoking cessation for 4 weeks
B) Incentive spirometry and early ambulation
C) Preoperative nutritional supplementation
D) Preoperative pulmonary rehabilitation
E) Use of a laparoscopy approach
Detailed Answer:
Correct Answer: B
Postoperative incentive spirometry, early ambulation, and aggressive pulmonary hygiene are
the most effective interventions to reduce postoperative pulmonary complications (PPCs) in
high-risk patients. Preoperative smoking cessation (A) should ideally be at least 4-6 weeks to
reduce risk. Nutritional supplementation (C) is important but does not directly reduce PPCs.
Pulmonary rehabilitation (D) may help but is less practical. Laparoscopy (E) reduces PPCs
compared to open surgery, but the intervention with the strongest direct evidence is
postoperative pulmonary care (B).
Q8. A patient undergoes a thyroidectomy for a 4 cm follicular neoplasm. Final pathology
reveals a minimally invasive follicular thyroid carcinoma. The tumor is 4 cm, with no vascular
invasion and negative margins. What is the most appropriate management?
A) Total thyroidectomy (already done), with radioactive iodine ablation
B) Total thyroidectomy, with observation and TSH suppression
C) Completion thyroidectomy (if only a lobectomy was performed)
