General Surgery Board Review Samples
Below you will find a sampling of the general surgery and high
yield board review
questions. Many of the questions include pearls of wisdom and key buzzwords,
statistics, and numbers you need for your exam
success. Many of the questions are case-style like you would find on the boards,
others test rapid recall for key clinical situations, and key buzzwords
you just have to know to get through your exam quickly and score your best!
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1. The 27 Year Old Female With Pain in the Iliac Fossa
A twenty seven year old lady presented with pain in right
iliac fossa and around umbilicus, associated with nausea, vomiting,
constipation, malaise and low grade fever of 12 hours duration. On examination
there was tenderness at umbilical region and right iliac fossa at Mcburneyís
point. Her periods are normal and there is no history of vaginal discharge. Her
routine blood counts showed raised leukocyte count with 78% polymorphs. Urine
examination and biochemistry were normal. The vital signs are blood pressure
110/70 mm Hg, temperature 99.5 F, pulse 90 per minute, and respiration 14 per
minute. Since x-ray abdomen and ultrasonography revealed nothing, clinical
diagnosis of acute appendicitis was kept. Abdomen was explored by Grid-iron
incision. Surprisingly appendix was normal so ileum was explored. A diverticular
structure about 2 feet from ileo-colic junction was found which was inflamed.
What is the right statement about this structure?
|A| It is a congenital anomaly which is found in 10% of
population, out of which 2% become symptomatic.
|B| The muscle coat is absent in this structure, since it is a false
|C| Most common complications of this structure is iron deficiency anemia,
malabsorption, foreign body impaction and strangulation in a hernia.
|D| Sometimes heterotopic tissue is found in this structure, especially when it
is symptomatic. Most commonly it is colonic.
|E| It arises from the antimesenteric border of the ileum resulting from an
incomplete obliteration of the yolk stalk.
Meckelís diverticulum occurs in approximately 2% of population and is the most
common congenital anomaly of the gastrointestinal tract. Meckel's is frequently
referred as the "disease of 2's as it occurs in 2% of the population, out of
which 2% become symptomatic, sex ratio is 2:1 male to female, and most of
the time symptoms will occur before the age of 2 years. Anatomically, it is
usually 2 inches in length, found 2 feet from the ileocecal valve, commonly
contains 2 types of ectopic tissue, gastric & pancreatic, and has 2 main
complications of bleeding & obstruction.
It is due to total or partial persistence of the vitelline
duct also called as omphalomesenteric duct or yolk stalk.
Meckelís diverticulum is a true diverticulum made up of all
layers of intestinal wall. Heterotopic tissue is found in approximately 50-80%
of symptomatic Meckelí diverticula. Gastric mucosa with parietal cell is the
most common heterotopic tissue and comprises 80% of cases; pancreas and mucosa
of the colonic, duodenal, or jejunal type are encountered with lesser frequency.
The most common clinical problem associated with Meckelís
diverticulum is bleeding, which usually presents as melena or bright red blood
per rectum. The usual source of the bleeding is a chronic ileal ulcer associated
with heterotopic gastric tissue within the diverticulum.
The second most common symptom associated with a Meckelís
diverticulum is intestinal obstruction. The cause of this obstruction may be
either volvulus of the small bowel around a diverticulum that is attached to the
anterior abdominal wall or intussusception.
Finally the next most common complication is
diverticulitis. It often presents as the picture of acute appendicitis and
failure to establish a prompt diagnosis may lead to perforation of the
diverticulum, peritonitis, and death. As a corollary to prompt intervention in
patients with Meckelís diverticulitis, when a patient is operated upon for acute
appendicitis and the appendix is found to be normal, it is imperative that the
distal 90 cm. of terminal be inspected for the presence of a Meckelís
diverticulum, which, if present, should be resected.
The least common complications of Meckelís
diverticulum include iron deficiency anemia, malabsorption, foreign body
impaction, perforation and incarceration or strangulation of the diverticulum in
a hernia (Littreís hernia).
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2. A 33 Year Old Gravid Woman With Severe Lower Abdominal Pain
A pregnant lady came with pain right lower abdomen, nausea,
vomiting, anorexia and slight fever of 12 hours duration. The pain started with
vague abdominal discomfort, was persistent and continuous but not severe, with
occasional mild epigastric cramps. She is discomforted on walking, moving, or
coughing. She is 33 years old and this is her second pregnancy. The third
trimester of pregnancy has just commenced. On examination there is very well
localized tenderness to one finger palpation and guarding just above the right
iliac fossa. Vital parameters are normal and investigations show only mild
leukocytosis. Urine and other investigations are normal. Which statement is true
for this patient?
|A| Treatment of choice for this patient is conservative,
as third trimester of pregnancy is a contraindication for surgery.
|B| Prescription of antacids should be considered to rule out acid-peptic
disease and she can be reviewed after some hours, even if appendicitis is
considered in the differential.
|C| Immediate appendectomy is treatment of choice for this patient, otherwise
complications will arise.
|D| Since pain and tenderness are not present at Mcburneyís point, diagnosis of
acute appendicitis does not exist.
|E| Acute pyelitis of pregnancy and torsion of an ovarian cyst are more common
and acute appendicitis is extremely rare diagnosis in pregnancy.
The incidence of appendicitis in during pregnancy parallels that in nonpregnant
women of the same age. Appendicitis is the most common extrauterine condition
requiring an abdominal operation during pregnancy. During the first 6
months of pregnancy, symptoms of appendicitis do not differ much from those in
the nonpregnant woman. This fact needs emphasis, since the manifestations of
appendicitis often are assumed to be markedly different, even during early
Appendectomy should be performed upon suspicion of the
presence of appendicitis, just as if the pregnancy is not present. If performed
before the appendix ruptures, appendectomy often does not disturb the pregnancy.
Furthermore, the effects of a negative laparotomy are sufficiently minor that
early operation for acute appendicitis should be carried out whenever the
diagnosis is entertained.
During the third trimester, the clinical picture is
slightly altered; displacement and lateral rotation of the cecum and appendix by
the enlarged uterus leads to localization of pain higher in the abdomen or in
the right flank. In addition, appendicitis during the final trimester tends to
be more serious, since delay in diagnosis leads to an increased incidence of
perforation, and the normal responses within the peritoneal cavity are impaired.
The displaced omentum often is unable to reach the area of the inflamed appendix
to help contain the infection. In addition, contractions of the nearby uterus
serve to impair localization. Rupture is often followed by diffuse peritonitis.
Premature labor occurs in about half of women who develop
appendicitis during the third trimester; the prognosis for the infant in cases
of uncomplicated appendicitis is directly related to the infantís birth weight.
In cases of appendicitis with peritonitis and other septic complications, fetal
loss is much higher and is due not only to prematurity but also to the effects
of sepsis on the fetus.
Acute pyelitis of pregnancy and torsion of an ovarian cyst,
when they occur during pregnancy, can be difficult to distinguish from
appendicitis. However confusing differential diagnosis may be, one fact must be
kept in mind: the mortality of appendicitis in pregnancy is due to delayed
diagnosis and operation. Early appendectomy is the treatment of choice for
appendicitis at all stages of pregnancy.
3. A 69 Year Old Woman With Dysphagia
A 69-year-old, white woman presented to her family
physicianís office with a complaint of one and a half years of progressive
dysphagia. She has lost about 15 lb weight in this duration. Although she can
drink liquids without difficulty, she feels a ďsticky sensationĒ in the middle
of his throat when she eats solid food. She also regurgitates food particles for
as long as 2-3 days after she has eaten the meal. On physical examination, the
patientís vital signs are within normal range. Examination of the oropharynx is
normal. She has no neck mass or other abnormality. Examination of the thorax and
the abdomen is unremarkable. The antero-posterior and lateral barium-swallow
views of the upper esophagus demonstrate a large outpouching at the posterior
aspect of the pharyngoesophageal junction that retains barium. What is the
correct statement regarding this condition?
|A| This is a congenital condition.
|B| It contains all layers of esophagus.
|C| It occurs at an area of potential weakness of muscles.
|D| The condition usually occurs in children and adolescents.
|E| This is usually anterior outpouching.
It was named by
Friedrich Albert von Zenker.
A pharyngeal pouch is a pulsion diverticulum of the
pharyngeal mucosa through Killian's dehiscence, an area of weakness between the
two parts of the inferior pharyngeal constrictor - the thyropharyngeus and the
cricopharyngeus - at their posterior margin.
The pouch probably arises as a result of a relative
obstruction at the level of the cricopharyngeus. At first, it develops
posteriorly but then it protrudes to one side, usually the left. As it enlarges,
it displaces the oesophagus laterally.
A pharyngeal pouch arises as a result of increased
cricopharyngeal pressure over a long period of time. Spasm or failure of
relaxation results in increased pressure during deglutition by contraction of
the pharyngeal constrictor muscles at the start of swallowing.
The esophageal mucosa and submucosa herniates posteriorly
between the cricopharyngeus muscle and the inferior pharyngeal constrictor
muscles; therefore, Zenkerís is a false diverticulum as all the layers of
esophagus are not present. True diverticula contain all layers of the intestinal
tract wall. False diverticula, also known as pseudodiverticula, occur when
herniation of mucosa and submucosa through a defect in the muscular wall occurs.
This is an acquired condition.
Most esophageal diverticula occur in middle-aged adults and
elderly people, although presentation in infants and children is rarely seen.
Zenkerís diverticula typically present in people older than 50 years and
especially present during the seventh and eighth decades of life.
1.Dahnet W. Radiology review manual. Philadelphia,
Lippincott, Williams and Wilkins; 1999:720.
2. Ellis FH Jr. Pharyngoesophageal (Zenkerís) diverticulum. Adv Surg
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