GS Talk

Question 1

Surgical wound classification

A 65 years old woman undergoes an elective colectomy for colon cancer
which of the following wound classes best describes this procedure?
A. Class 1 clean
B. Class 2 Clean/contaminated
C. Class 3 contaminated
D. Class 4 dirty

They didnt mention any spillage

Answer 1

B. Class 2 Clean/contaminated

Question 2

Surgical wound classification

A 35 Years old woman undergoes and elective lapchole for biliary colic.
Which of the following wound classes best describes this procedure?
A. Class 1 clean
B. Class 2 Clean/contaminated
C. Class 3 contaminated
D. Class 4 dirty

Answer 2

**B. Class 2 Clean/contaminated
**

Question 3

Surgical wound classification

A 65 years old woman undergoes an emergency colectomy for perforated colon
which of the following wound classes best describes this procedure?
A. Class 1 clean
B. Class 2 Clean/contaminated
C. Class 3 contaminated
D. Class 4 dirty

Its perforated, infection already established before surgery

Answer 3

D. Class 4 dirty

Question 4

Antibiotics usage

A 65 years old woman undergoes an emergency colectomy for perforated colon
which of the folowing is true in regard to prevention of surgical site infection?
A. Empirical Antibiotics are needed
B. Prophylactic antibiotics, 1 Hours prior to incision
C. Cephalosporins are safe for patients allergic to penicillins
D. Prophylactic antibiotics for 3 days peri-operatively

This is class 4 in this case we give theraputic

Answer 4

**A. Empirical Antibiotics are needed **

Question 5

Important side questions

Post cholecystectomy, presented with surgical site infection.
What is the most commonly isolated organism?

Its Upper GI -/+ , here in acute cholecystitis we thing gram -ve

Answer 5

**Escgerichia coli =E.coli **

Aeroic Gram -ve

Question 6

Important side questions

What is the period of Surgical site infection presentation?
for example patient had wound infeciton after 5 days of surgery is it SSI?

Answer 6

Yes within 30 days after surgery
or 90 days with procedures with prosthesis (Forgein body like implants)

Question 7

Important side questions

Post appendectomy, presented with surgical site infection.
What is the most commonly isolated organism?
what is the Abx used?

Lower GI= Anerobes and Gram -ve

Answer 7

**Bacteroides fragilis
**(Obligate anaerobic gram -ve bacillus)

what is the Abx used?
**Metronidazole or flagil
**
the second most common organism in case of appendicitis?
**E.coli **
(Gram -ve)

Question 8

Endocarditis prophylaxis

Which of the following patients needs Prophylaxis for endocarditis?
A. Mitral valve prolapse but without murmur for lithotripsy for renal calculi
B. Hx of rhumatic fever and normal cardiac valves for prostatic biopsy
C. Prosthetic aortic valve for wisdom tooth extraction
D. Severe hypertrophic cardiomyopathy for ERCP (Biliary obstruction)

Answer 8

**C. Prosthetic aortic valve for wisdom tooth extraction **

The rest of the answers theres no indication

Question 9

Endocarditis prophylaxis

What are the antibiotcs used to cover Gram+ cocci?

Answer 9

Penicillins
Cephalosporins
Clindamycin

These are to start with

Question 10

Endocarditis prophylaxis

A patient was having prostethic heart valve and undergoing a dental procedure you will give prophylactic antibiotics
A. Doxycycline
b. Ampicilin
c. Ceprofloxacin

Answer 10

b. Ampicilin is the first choise
A. Doxycycline if theres an alergy to ampicillin

both covering gram +ve

Ceprofloxacin covering Gram -ve

Question 11

Wound healing phases

At day 6 post resection and anastomosis of small bowel, patient developed abdominal pain, tachycardia and fever.
* WBC 16,000
* CT scan with contrast showed** anastomaotic leak**
where does this patient drop among these phases of wound healing?
A. Hemostatic phase
B. Inflammatory phase
C. Proliferative phase
D. Remodeling phase

day 6 between phase 1 and 2 , anastomaotic leak is another clue

Answer 11

C. Proliferative phase

Question 12

Wound healing phases

What is the main (predominant) type of collagen in the inflammatory phase of wound healing?

Answer 12

Type 3 collagen

Question 13

Types of wound healing

Diabetic patient underwent incision and drainage of an abscess at his back.
The wound is left open for daily packing.
Wound got smaller with time, and eventually healed.
Which of the following terms descibe this method of wound healing?
A. Primary intention
B. Secondary intention
C. Tertiary intention
D. Delayed primary closure

c and d are the same

Answer 13

**B. Secondary intention **

Question 14

Types of wound healing / Abscess mx

a 35 years old other wise healthy gentleman, presented to ER with right gluteal abscess of 3x4 cm associated with fever.
he underwent incision and drainage procedure.
which of the following is true regarding management?
A. close the wound using clips
B. Keep wound open and apply dressing
C. Keep wound open and apply VAC immediately (not on infected wounds, Not immediately)
D. Therapeutic antibiotic is indicated (no indications it will be mentioned on another q)

VAC is not indicated on infected wound norantibiotics

open for drainage, vac and anitbiotics not indicated

Answer 14

B. Keep wound open and apply dressing

Question 15

Types of wound healing / Abscess mx

what are the indications for Therapeutic antibiotic in abscess?

Answer 15

**1- Extensive cellulitis
2- immunocomprimsed **

Question 16

Other options for wound closure

Few days after laparotomy, patient had pus discharge from the wound, for which it was opened to allow drainage.
Few days later, wound looked healthy with good granulation tissue.
It was large and deep with intact abdominal fascia, No signs of infection.
Most appropriate management option?
A. Open the fascia
B. Antibiotics
C. Place a vacuum-assisted closure (VAC) device
D. Wound debridement

good granulation tissue exclude D

Answer 16

C. Place a vacuum-assisted closure (VAC) device

No CI and its large wound

Question 17

Other options for wound closure

A patient presented with knife injury to the hand on examination the laceration is reaching the tendon and nerve exposed?
A. Debriment with 2ry intetion
B. Apply VAC
C. Primary intention

Answer 17

C. Primary intention

theres no indication to leave it open , no pus no nothing , VAC is CI

Question 18

Other options for wound closure

Elderly patient in ICU with multiple Comorbidites, develop sacral ulcer with pus discharge and necrosis area and Fat exposed
A. Primary closure
B. Debridement and primary closure
C. Debridement and graft later on (Elderly in ICU cause graft need a good Blood supply)
D. Debridement and VAC (Later on)

we dont use VAC in an infected wound but this is bad recall

Answer 18

D. Debridement and VAC

later on would be a perfect answer

debridement with secondary intention is also right

Question 19

Other options for wound closure

Trauma patient with a* dirty wound* on his thigh
Skin and subcutaneous fat is lost and vasculature underneath is exposed
What provides the best management?
A. Primary closure
B. Debridement and primary closure
C. Debridement and graft later on
D. Debridement and VAC

multiple CI for primary and VAC

Answer 19

C. Debridement and graft later on

graft is ok good vasculature later on and no comorbidites mentioned

Question 20

Lymphangitis

An 8 years old boy cuts his hand on a piece of glass.
2 days later there is an open sore surrounded by swelling.
His forearm is tender with red streakes extending towards the axilla.
What is the most likey organism?
A. Staphylococcus aureus
B. Pseudomonas aeruginosa
C. Streptococcus pyogenes (Group A)
D. Escherichia coli

Red streakes is a clue

Answer 20

C. Streptococcus pyogenes (Group A)

This is a case of lymphangitis = inflammation proximal to the infection site
The most common organism is C
Tx= Cephalosporins to cover strept
if didnt improve = vancomaycin to cover MRSA

Question 21

Tetanus

A 24 years old male presents to the emergency department after sustaining a puncture wound to his left foot 7 hours ago.
On exam: Small metal nail protruding from the plantar aspect of his left foot
with moderate surrounding erythema (infection) and a little bleeding, No significant purulence
He is unsure about his tetanus vaccination status.
Managment?
A. Local wound care , IV metronidazole or penicillin
B. Local wound care, IV metornidazole or penicillin, Tetanus toxoid
C. Local wound care, IV metronidazole or penicillin, Tetanus toxoid, Tetanus Igs
D. Reassure only

its a T prone wound for the infection we give Abx

Answer 21

C. Local wound care, IV metronidazole or penicillin, Tetanus toxoid, Tetanus Igs

Question 22

Post operative fever (5Ws)

On postoperative Day 5, an otherwise healthy 55 yearsold man recovering from an abdominal surgery is noted to have a fever of 38.6C
Which of the following is the most common Nosocomial infection postoperatively?
A. Wound infection
B. Pneumonia
C. Urinary tract infection
D. Intra-abdominal abscess

Answer 22

C. Urinary tract infection

Day 3-5 = UTI which is the most common nosocomial post op fever

Question 23

Abscess mx

Few days after open cholecystectomy, the patient developed fever and localized tenderness around the wound (Cellulitis), with pus discharge from the wound
What is your managmenet?
A. Laproscopic drainage
B. Laparotomy and drainage
C. Send pus for culture and start antibiotics
D. Open some clips for drainage

drainage only

Answer 23

D. Open some clips for drainage cause its wound infection
another right answer is wound exploration which is open the wound basically
or inspect the wound

for
C. not indicated cellulitis not extensive (large) but if it says 10 cm then its large and its not enough for treating abscess
B. and A. no intra-abdominal collections so no indications

Question 24

Sepsis

Post op fever, tachycardia and urine culture positive for Ecoli
what is this?
A. septic shock
B. SIRS
c. Sepsis

Answer 24

c. Sepsis

Question 25

Abscess mx

Few days after** open cholecystectomy for medically free lady** , the patient developed **fever **and localized tenderness around the wound (Cellulitis), No signs of extensive cellulitis around the surgical site.
Some clips were removed to allow drainage.
Which is true regarding managemet?
A. closure of wound under local anesthesia
B. Keep wound open and start antibiotics
C. Theraputic antibiotics is not indicated
D. Ultrasound to check for possible remnant pus at the wound

Answer 25

C. Theraputic antibiotics is not indicated

Indications are
-Extensive cellulitis
-Immunocompromised

Not even prophylactic
A. we dont close the wound while we have infection
B. No indications
D. killing the investigations not indicated

Question 26

Central line infection

Post laparotomy and graham patch for perforated peptic ulcer.
Patient was admitted to ICU and kept intubated, On TPN.
A week later, he has discharged from ICU to regular ward and stated to have higher blood glucose levels and fever.
Patient had no other complains.
Abdominal examination, wound and central line site were reassuring. عشان يضيعك
What is the next step in management?
A. Abdominal CT
B. incentive spirometry
C. Send blood cultures
D. Start empirical antibiotics

No other complains ruling out the 5w

Answer 26

C. Send blood cultures
then D BUT AFTER THE CULTURES

Question 27

Important side questions

A 74 years old woman with a history of a previous total abdominal hysterectomy presents with abdominal pain and sistention for 3 days and diagnosed to have complete** bowel obstruction** and taken later to operation room for exploration and adhesiolysis.
Which of the following inhalational anesthetics should be avoided?
A. Diethyl ether
B. Nitrous oxide
C. Halothane
D. Propofol

Answer 27

B. Nitrous oxide

it accumulates in air filled cavities for example bowel nitrous oxide will accumulate in the already distended bowel so we avoid it

Question 28

VTE prophylaxis

76 years old obese gentleman in orthopedic ward.
He is planned for total knee replacement tomorrow.
What is the Anti DVT prophylactic measure of choice?
A. Elastic stockings alone
B. Low molecullar weight heparin
C. Assisted mobilization
D. Aspirin

Answer 28

B. Low molecullar weight heparin

a. is not enough alone
c. cant be
D. its antiplatelet not anticoagulatnt

Question 29

VTE prophylaxis

ICU patient intra-cranial hemorrhage what is the recomnded VTE prophylaxis?
A. moblization
B. Elastic/pneumatic compression
C. Anti-coagulants

Answer 29

B. Elastic/pneumatic compression
only mechanical cause theres hemorrhage

Question 30

VTE prophylaxis

RTA victim with hip fracture and Grade 2 splenic injury.
He is stable.
Planned for observation of splenic injury, How would you prevent DVT?
A. Enoxaparin SQ BID
B. Early ambulation alone
C. Heparin SQ BID

Answer 30

C. Heparin SQ BID

high risk patient , bleeding but stable and not bleeding right now
A. Enoxaparin SQ BID (this is theraputic dose)
B. Early ambulation alone (he cant and he is high risk)
C. Heparin SQ BID (so this is prophylactic) and this is right

Question 31

VTE prophylaxis

Admitted for retinal surgery (or hernia surgery).
DVT prophylaxis?
A. Enoxaparin SQ BID
B. Early ambulation alone
C. Heparin SQ BID

Answer 31

B. Early ambulation alone

cause its not indicated and theres no risk and he can moblize
IF A patient is pregnant or on OCP then this is moderate to high risk we give prophylaxis LMWH

Question 32

PE

40 year old lady on oral contraceptive pills since 10 years.
She underwent a smooth laparoscopic cholecystectomy 2 days ago,
she was discharged home.
She presented to ER with chest pain, shortness of breath and palpitation.
On examination, she is** tachycardic, hypotensive and hypoxic**

What is your impression?
What is the inital step of management?

Answer 32

• What is your impression?
  **Pulmonary embolism
  **
• What is the inital step of management?
  ABC, spiral chest CT, CT angio of the chest

Question 33

VTE

40 years old female, known to have Crohn’s disease.
she was admitted for abdominal sepsis, underwent laparotomy with bowel resection and anastomosis.
she was on VTE prophylaxis (Pneumatic compression device and LMWH).
On post-op day 3, she develped lower limb DVT with pulmonary embolism.
Vitally stable apart from HR 120.
How would you manage?
A. Thrombolysis
B. Continue the current dose of LMWH
C. Increase the dose of LMWH
D. continue the current dose of LMWH and start Warfrain

Answer 33

C. Increase the dose of LMWH (which is 1mg/kg bid)

Crohns is high risk

A. Thrombolysis (Not indicated , and patient is post- op we never give Tpa its dangerous)
B. Continue the current dose of LMWH (No its prophylactic and it should be theraputic)
C. Increase the dose of LMWH (which is 1mg/kg bid)
D. continue the current dose of LMWH and start Warfrain (Always avoid starting warfrain in a surgical patient cause any time they might have complication and go back to surgery)

Question 34

VTE

Post laparotomy day 3, developed DVT OR PE
initial mx?
A. LMWH or Heparin
B. Warfarin
C. Thromobolysis
D. IVC filter

Answer 34

A. LMWH or Heparin

recent post-op

Question 35

VTE

Pregnant lady, post lapchole day 3, develped DVT or PE.
Initial mx?
A. Heparin
B. LMWH
C. Thrombolysis (alteplase infusion)
D. IVC filter

Answer 35

B. LMWH

consider for pregnancy

Question 36

VTE

(medical patient not surgical) a patient with DVT (Extensive: illeofemoral) with painful cyanosed lower extremity
managment?
A. Heparin
B. LMWH
C. thrombolysis (alteplase infusion)
D. IVC filter

Answer 36

C. thrombolysis
Consider for extensive DVT (ileo-femoral) with threatened limb
Unstable PE
-BUT! risk of bleeding (avoid post-op)

Question 37

VTE

Post laparotomy. Developed DVT in recovery room (Immediate post-op)
A. heparin
B. LMWH
C. Thrombolysis (alteplase infusion)
D. IVC filter

Answer 37

D. IVC filter
Consider if anti-coagulation is needed but contraindicated

you cant start theraputic anti coagulation immediately after surgery so its contraindiacted

Question 38

Warfarin

Patient on Warfarin, presented to ER with complete small bowel obstruction (adhesive etiology is suspected). An emergency surgery is decided. Current INR is 2.7
What is the next step regarding reversal of anti-coagulation?
A. Proceed to the emergency surgery
B. Administer protamine sulfate
C. Administer Vitamin K alone
D. Administer vitamin k + FFP

Answer 38

D. Administer vitamin k + FFP

ffp or prothrombin is the most important cause its an emergency

Question 39

Warfarin

1 week post lapchole, on warfarin for atrial fibrillation, presented to ER with **large biloma , **
Which was evident on ultrasound.
He complains of mild to moderated abdominal pain and he is vitally stable.
Current INR 2.5
The plan is to attempt CT-Guided drainage the following Day
How should his INR be corrected?
A. Oral vitamin K
B. IV push of vitamin k (over 2-3 mins) !! dont use
C. Fresh frozen plasma FFP
D. Allow warfarin to autocorrect

Answer 39

A. Oral vitamin K

For semi-urgent procedure for next day (drain catheter next day

Question 40

Nutritional support

Recent closed head injury, absent gag reflex what Nutritional support would you choose?
A. NGT
B.NJT
C. Jejunostomy
D. Gastrostomy

Answer 40

B.NJT
Recent closed head injury might improve within a month or so
theres a risk of aspiration

Question 41

Nutritional support

Trauma victim, intubated for head injury , has aspiration pneumonia
A. NGT
B.NJT
C. Jejunostomy
D. Gastrostomy

Answer 41

B.NJT
he aspirated already

Question 42

Nutritional support

Basal ganglia disorder, absent gag reflex
A. NGT
B.NJT
C. Jejunostomy
D. Gastrostomy

Answer 42

C. Jejunostomy definitive

B.NJT and it can be right if its intial can be right but it might take more than 1 month

basal ganglia disorder= medical disease might take time

Question 43

Nutritional support

Short bowel syndorme (<100 cm). What management strategy can lead to better bowel adaptation?
A. Enteral feeding
B. TPN
C. Jejunal feeding tube

Answer 43

A. Enteral feeding

piece of knowledge
c. no indication

Question 44

Nutritional support

Malnuritied starved patient for any reason started on TPN , what is the expected electrolytes balance?
الحرب الفيتناميه

Answer 44

Refeeding syndrome
Hypokalemia
Hypomagnesmia
Hypophosphtemia

Question 45

High index of suspecion Questions

A patient of **(ulcerative colitis or rhumatoid arthritis, SLE) **underwent an emergency colectomy. (stress major surgery)
Post operative, he is lethargic and confused.
BP 90/40 mmHg
RBS 45 mg/dl
Serum Na+ 121 mEq/L
Serum K+ 5.3 mEq/L
Hbg 11.2 mg/dl
Which of the following is the most likely cause?
A. volume overload
B. Acute adrenal insufficiency
C. Internal bleeding
D. Pulmonary embolism

Answer 45

B. Acute adrenal insufficiency
they will have low serum osmolirity with elevated urine and serum Na+

we should give them stress dose of IV hydrocortisone

Which is more potent Iv steriod or oral? Oral is 5x more potent

(ulcerative colitis or rhumatoid arthritis, SLE) all uses of **steriod therapy **
HPA axis suppression (hypothalamic- pitutary- adrenal axis suppresion)
with chronic use of exogenous steriod it will reduce cortisol response and it will cause impairment in stress response and it will be inadequate against stress like surgery or infection

Question 46

Mx

in patient with shock (Acute adrenal insufficiency) what is the 1st step in management?
A. IV fluids
B. Steriods

Answer 46

A. IV fluids

always start with it

Question 47

MX

In trauma patients should we use peripheral or central line to deliver fluids?

Answer 47

**2 large bore peripheral lines **
why?
1- central line will take time
2- Physics and diamter (Read about it) ATLS related

Question 48

Pre-operative PCI (Percutaneous coronary intervention)

70 years old patient was seen at surgery clinic for a chronically incarcerated umbilical hernia reparied. (Elective if its acute then we do emergency)
2 days ago, he underwent ballon angioplasty with placement of a bare metal coronary artery stent (BMS) for unstable angina. When can you book him for elective hernia repair?
A. 2 weeks
B. 6 weeks
C. 6 months
D. 1 Year

Answer 48

B. 6 weeks

dual anti coagulation is needed 4-6 weeks in BMS
IF its DES then 6 months

Question 49

Important side questions

A patient is admitted for elective laparoscopic ventral hernia repair.
Examination revealed raised JVP and bilateral lower limb edema.
What is the appropriate action?
A. P roceed for laparoscopic surgery
B. Do open surgery now
C. Delay surgery, to investgate and treat this condition
D. Cancel surgery (totally) for high risk condtion

Answer 49

C. Delay surgery, to investgate and treat this condition

its signs of CHF so we need to investgate this newly and its elective not urgent

Question 50

Important side questions

During laparosscopic appendectomy and during gas insufflation, the anesthetis informed the surgeon that patients heart rate decreased to 45 beats/min . What is the most appropriate next step?
A. Continue the procedure
B. Covert to open surgery
C. Stop gas insufflation till this condtion resolves
D. Cancel the procedure

Answer 50

C. Stop gas insufflation till this condtion resolves
if it didnt resolve we give anti cholenrgic drug

Question 51

Important side questions

While surgeon was operating on a hepatitis C patient, He had needle-stick injury. What is his risk to acquire hepatitis C infection?
A. 0.3%
B. 3%
C. 30%
D. 100%

Answer 51

B. 3%

1- HIV : 1 in 300 or 0.33% risk

2- HCV : 1 in 30 or 3.3% risk

3- HBV : 1 in 3 or 33.3% risk

Question 52

Important side questions

a 26 years old man, a victim of road traffic accident and pelvic fracture.
He was resuscitated with units of PRBCs. A few hours later her became hypotensive, oliguric and febrile.
On examination: Profuse oozing of blood from his nose and intravenous (IV) sites.
Which of the following is the most likely diagnosis?
A. Hypovolemic shock
B. Acute adrenal insufficiency
C. Gram negative bacteremia
D. Transfusion reaction

Answer 52

D. Transfusion reaction