MyPasTest » MRCS A Online - Jan Exam 2015
15. Principles of Surgery in General; Postoperative Management & Critical Care (42Qs)
----------------------------------------------------------------------------------------------------------------------------
01. THEME: Investigations
A Endoscopic retrograde cholangiopancreatography
B Focused abdominal sonogram for trauma
C Diagnostic peritoneal lavage
D Computer tomography scan ± intervention
E Laparotomy
F Magnetic resonance cholangiopancreatography. Page
1152
For each of the clinical scenarios below choose the most appropriate investigation. Each option may be
used once, more than once, or not at all.
Scenario 1
A 26-year-old motorcyclist is brought into A+E following a collision with a motor vehicle at a combined speed of 40
mph. He is breathing spontaneously. His Glasgow Coma Score is 13/15, blood pressure 90/55, pulse 100 bpm.
He has an open left tibial fracture and bruising over the left side of his abdomen and back. He is complaining of
left epigastric pain.
A - Endoscopic retrograde cholangiopancreatography« YOUR ANSWER
B - Focused abdominal sonogram for trauma« CORRECT ANSWER.
Focused abdominal sonogram for trauma can be used quickly in A+E. In this case, the history could be
consistent with a splenic injury, but the shock may also be related to the fractured tibia. It is vital that a
coexisting injury such as this is not missed.
Scenario 2
A 69-year-old man with a history of atherosclerosis, hypertension. and cigarette smoking called an ambulance
complaining of back pain and vomiting. When the ambulance arrived, he was shivery, tachycardic, and
complaining of abdominal pain. Before arriving in A+E, he becomes unresponsive with no recordable blood
pressure.
B - Focused abdominal sonogram for trauma« YOUR ANSWER
E - Laparotomy« CORRECT ANSWER.
This patient is likely to have a bleeding abdominal aneurysm. It is not known if he has a history of
abdominal aneurysm, but he has risk factors and a presentation that fits. His only chance is an
emergency laparotomy to clamp and repair the aorta.
Scenario 3
A 44-year-old woman has a 3/7 history of ‘being yellow’ and complains of colicky right epigastric pain. Her blood
tests show an obstructive picture. She has a white cell count of 26, CRP of 210, and bilirubin of 76. She has
deteriorated over the last 4 h and is now acidotic with pH 7.2. She is also delirious.
C - Diagnostic peritoneal lavage« YOUR ANSWER
A - Endoscopic retrograde cholangiopancreatography« CORRECT ANSWER.
The history is consistent with ascending cholangitis; the bile duct must be decompressed as soon as
possible.
Scenario 4
A 55-year-old man had a Whipples procedure 8 d ago for pancreatic adenocarcinoma. In the last 48 h, he has
been pyrexial. Chest X-ray, urinalysis, and central line tip, which was sent for cultures 2 d ago when it was
removed, have not revealed a focus of infection.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
15. Principles of Surgery in General; Postoperative Management & Critical Care (42Qs)
----------------------------------------------------------------------------------------------------------------------------
D - Computer tomography scan ± intervention« CORRECT ANSWER.
The continuing temperature suggests a source of infection. Post-abdominal surgery, this patient is at risk
of an abdominal collection, these are usually amenable to computer tomography- or ultrasound-guided
drainage.
Scenario 5 Page
Six days after a gastric stapling performed for obesity, a 66-year-old woman has three episodes of frank 1153
haematemesis. The gastroenterologist sees the patient and is unhappy to perform an
oesophagogastroduodenoscopy. The patient feels nauseous and that she is likely to vomit again.
E - Laparotomy« CORRECT ANSWER.
This is a post-operative complication; sometimes bleeding vessels can be injected or embolised. There is
no option for radiological embolisation in the stem (as there would be in a hospital where no radiologist
was able to do it, so the patient needs to return to theatre for an exploratory laparotomy).
02. An 87-year-old arteriopath complains of heavy chest pain post-operatively and he is suspected of
having an MI. His blood examination reveals raised urea and creatinine. What type of renal failure is this
termed? Select one answer only.
Iatrogenic« YOUR ANSWER
Intrinsic renal failure
Pre-renal renal failure « CORRECT ANSWER
Post-renal renal failure
This is unlikely to be renal failure.
Renal failure is defined as failure of the kidneys to maintain the correct composition and volume of the
body's internal environment. Patients undergoing major surgery are at risk of developing renal failure,
particularly in the postoperative period where inadequate fluid rehydration is not uncommon. Cardiogenic
shock and hypoperfusion are the likely reasons for his renal failure in this example.
03. Theme: Arterial blood gases
A Metabolic acidosis
B Metabolic alkalosis
C Respiratory acidosis
D Respiratory alkalosis.
For each of the following scenarios, select the most likely expected abnormality from the list above. Each
option may be used once, more then once or not at all.
Scenario 1
A 60-year-old man presents with a distended abdomen and a 4-day history of vomiting and absolute constipation.
A - Metabolic acidosis« YOUR ANSWER
B - Metabolic alkalosis« CORRECT ANSWER.
Intestinal obstruction and prolonged vomiting lead to a loss of hydrogen, chloride and potassium,
resulting in a metabolic alkalosis.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
15. Principles of Surgery in General; Postoperative Management & Critical Care (42Qs)
----------------------------------------------------------------------------------------------------------------------------
Scenario 2
Five days following an anterior resection, a 67-year-old woman complains of a sudden onset of right-sided chest
pain and shortness of breath. An ECG shows a sinus tachycardia.
B - Metabolic alkalosis« YOUR ANSWER
D - Respiratory alkalosis« CORRECT ANSWER.
Sudden onset of chest pain, shortness of breath and tachycardia in a postoperative patient are Page
suggestive of pulmonary embolism. Tachypnoea leads to a reduction in p(CO2) and a subsequent 1154
respiratory alkalosis.
Scenario 3
An 18-year-old diabetic man is referred with an acute abdomen. His white cell count is 17 and plasma glucose is
36 mmol/l.
C - Respiratory acidosis« YOUR ANSWER
A - Metabolic acidosis« CORRECT ANSWER.
Diabetic ketoacidosis can be mistaken for an acute abdomen, leading to unnecessary surgery. Build up of
ketones will lead to a metabolic acidosis.
Scenario 4
A 24-year-old man is involved in a road traffic accident (RTA). On arrival, he is pale with a pulse of 120 and blood
pressure of 100/80. His abdomen is bruised over the left upper quadrant (LUQ) and tender throughout.
D - Respiratory alkalosis« YOUR ANSWER
A - Metabolic acidosis« CORRECT ANSWER.
This 24-year-old man is shocked following an RTA. Reduced circulating volume leads to tissue
hypoperfusion and a build up of lactate, resulting in a metabolic acidosis.
04. Theme: Post-operative hypoxia
A Adult respiratory distress syndrome
B Basal atelectasis
C Bronchospasm
D Cardiogenic pulmonary oedema
E Lobar collapse
F Opiate overdose
G Pleural effusion
H Pneumonia
I Pneumothorax
J Pulmonary embolism
K Upper airway obstruction.
The following are descriptions of patients with post-operative hypoxia. Please select the most appropriate
diagnosis from the above list. The items may be used once, more than once, or not at all.
Scenario 1
A 62-year-old woman undergoes a sigmoid colectomy for left-sided colonic carcinoma. She is given an epidural
for pain relief, but this becomes dislodged. On day 1 post-operation she is dyspnoeic with a rapid pulse and mild
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
15. Principles of Surgery in General; Postoperative Management & Critical Care (42Qs)
----------------------------------------------------------------------------------------------------------------------------
pyrexia; auscultation reveals reduced breath sounds at the left base. Arterial blood gases are: pH 7.35, pA(O2) 9.6
kPa, pA(CO2) 5.0 kPa. She has a non-productive cough.
A - Adult respiratory distress syndrome « YOUR ANSWER
B - Basal atelectasis « CORRECT ANSWER.
Post-operative atelectasis is commonly observed in the early post-operative period, especially after
prolonged surgery in the supine position; diaphragmatic dysfunction and reduced surfactant are Page
consequences of general anaesthesia and surgical manipulation that can lead to atelectasis. In addition, 1155
inadequate analgesia leads to reduced respiratory excursion and coughing. The resultant hypoventilation
of the lung bases leads to localised small airway collapse and is usually accompanied by a low-grade
pyrexia.
Scenario 2
A 74-year-old man with a previous history of ischaemic heart disease undergoes an anterior resection for rectal
carcinoma. On day 4 post-operation he is severely dyspnoeic, tachypnoeic but apyrexial; auscultation reveals
bilateral fine crepitations. Arterial blood gases are: pH 7.35, pA(O2) 8.0 kPa, pA(CO2) 5.5 kPa.
B - Basal atelectasis « YOUR ANSWER
D - Cardiogenic pulmonary oedema« CORRECT ANSWER.
This is the result of either increased hydrostatic pressure (eg volume overload – as in this scenario, and
left ventricular failure) or decreased oncotic pressure (eg hypoalbuminaemia). Regardless of aetiology,
the fluid accumulates around the lung parenchyma, especially in the dependant basal regions of the lower
lobes, causing alveolar collapse.
Scenario 3
A 59-year-old man undergoes a palliative bypass of an unresectable gastric carcinoma. Several days later he is
dyspnoeic, mildly tachycardic and apyrexial; auscultation reveals absent breath sounds at the left base and
decreased left-sided vocal resonance. Arterial blood gases are: pH 7.37, pA(O2) 10.1 kPa, pA(CO2) 6.0 kPa. His
serum albumin is 20 g/litre.
C - Bronchospasm« YOUR ANSWER
G - Pleural effusion« CORRECT ANSWER.
Fluid in the pleural space can be either a transudate (< 30 g/litre), secondary to either increased
hydrostatic pressure (eg from volume overload and left ventricular failure) or decreased oncotic pressure
(from hypoalbuminaemia, as in this scenario); or an exudate (> 30 g/litre), secondary to capillary
hyperpermeability (from malignancy, Gram-negative sepsis or other inflammatory change, etc). Fluid fills
the basal aspect of the pleural space, inhibiting gross lung expansion.
Scenario 4
A 43-year-old woman is being managed for severe acute pancreatitis. Over the past 48 h she has become
increasingly dyspnoeic and tachycardic; auscultation reveals bilateral fine crepitations. Arterial blood gases are:
pH 7.37, pA(O2) 8.2 kPa, pA(CO2) 4.9 kPa. Chest radiology shows bilateral diffuse infiltrates.
D - Cardiogenic pulmonary oedema« YOUR ANSWER
A - Adult respiratory distress syndrome « CORRECT ANSWER.
Adult respiratory distress syndrome, or non-cardiogenic pulmonary oedema, is often an early
manifestation of the systemic inflammatory response syndrome and later development of multi-organ
dysfunction. It represents progressive combined ventilatory, perfusion and diffusional pathology.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
15. Principles of Surgery in General; Postoperative Management & Critical Care (42Qs)
----------------------------------------------------------------------------------------------------------------------------
01. THEME: Investigations
A Endoscopic retrograde cholangiopancreatography
B Focused abdominal sonogram for trauma
C Diagnostic peritoneal lavage
D Computer tomography scan ± intervention
E Laparotomy
F Magnetic resonance cholangiopancreatography. Page
1152
For each of the clinical scenarios below choose the most appropriate investigation. Each option may be
used once, more than once, or not at all.
Scenario 1
A 26-year-old motorcyclist is brought into A+E following a collision with a motor vehicle at a combined speed of 40
mph. He is breathing spontaneously. His Glasgow Coma Score is 13/15, blood pressure 90/55, pulse 100 bpm.
He has an open left tibial fracture and bruising over the left side of his abdomen and back. He is complaining of
left epigastric pain.
A - Endoscopic retrograde cholangiopancreatography« YOUR ANSWER
B - Focused abdominal sonogram for trauma« CORRECT ANSWER.
Focused abdominal sonogram for trauma can be used quickly in A+E. In this case, the history could be
consistent with a splenic injury, but the shock may also be related to the fractured tibia. It is vital that a
coexisting injury such as this is not missed.
Scenario 2
A 69-year-old man with a history of atherosclerosis, hypertension. and cigarette smoking called an ambulance
complaining of back pain and vomiting. When the ambulance arrived, he was shivery, tachycardic, and
complaining of abdominal pain. Before arriving in A+E, he becomes unresponsive with no recordable blood
pressure.
B - Focused abdominal sonogram for trauma« YOUR ANSWER
E - Laparotomy« CORRECT ANSWER.
This patient is likely to have a bleeding abdominal aneurysm. It is not known if he has a history of
abdominal aneurysm, but he has risk factors and a presentation that fits. His only chance is an
emergency laparotomy to clamp and repair the aorta.
Scenario 3
A 44-year-old woman has a 3/7 history of ‘being yellow’ and complains of colicky right epigastric pain. Her blood
tests show an obstructive picture. She has a white cell count of 26, CRP of 210, and bilirubin of 76. She has
deteriorated over the last 4 h and is now acidotic with pH 7.2. She is also delirious.
C - Diagnostic peritoneal lavage« YOUR ANSWER
A - Endoscopic retrograde cholangiopancreatography« CORRECT ANSWER.
The history is consistent with ascending cholangitis; the bile duct must be decompressed as soon as
possible.
Scenario 4
A 55-year-old man had a Whipples procedure 8 d ago for pancreatic adenocarcinoma. In the last 48 h, he has
been pyrexial. Chest X-ray, urinalysis, and central line tip, which was sent for cultures 2 d ago when it was
removed, have not revealed a focus of infection.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
15. Principles of Surgery in General; Postoperative Management & Critical Care (42Qs)
----------------------------------------------------------------------------------------------------------------------------
D - Computer tomography scan ± intervention« CORRECT ANSWER.
The continuing temperature suggests a source of infection. Post-abdominal surgery, this patient is at risk
of an abdominal collection, these are usually amenable to computer tomography- or ultrasound-guided
drainage.
Scenario 5 Page
Six days after a gastric stapling performed for obesity, a 66-year-old woman has three episodes of frank 1153
haematemesis. The gastroenterologist sees the patient and is unhappy to perform an
oesophagogastroduodenoscopy. The patient feels nauseous and that she is likely to vomit again.
E - Laparotomy« CORRECT ANSWER.
This is a post-operative complication; sometimes bleeding vessels can be injected or embolised. There is
no option for radiological embolisation in the stem (as there would be in a hospital where no radiologist
was able to do it, so the patient needs to return to theatre for an exploratory laparotomy).
02. An 87-year-old arteriopath complains of heavy chest pain post-operatively and he is suspected of
having an MI. His blood examination reveals raised urea and creatinine. What type of renal failure is this
termed? Select one answer only.
Iatrogenic« YOUR ANSWER
Intrinsic renal failure
Pre-renal renal failure « CORRECT ANSWER
Post-renal renal failure
This is unlikely to be renal failure.
Renal failure is defined as failure of the kidneys to maintain the correct composition and volume of the
body's internal environment. Patients undergoing major surgery are at risk of developing renal failure,
particularly in the postoperative period where inadequate fluid rehydration is not uncommon. Cardiogenic
shock and hypoperfusion are the likely reasons for his renal failure in this example.
03. Theme: Arterial blood gases
A Metabolic acidosis
B Metabolic alkalosis
C Respiratory acidosis
D Respiratory alkalosis.
For each of the following scenarios, select the most likely expected abnormality from the list above. Each
option may be used once, more then once or not at all.
Scenario 1
A 60-year-old man presents with a distended abdomen and a 4-day history of vomiting and absolute constipation.
A - Metabolic acidosis« YOUR ANSWER
B - Metabolic alkalosis« CORRECT ANSWER.
Intestinal obstruction and prolonged vomiting lead to a loss of hydrogen, chloride and potassium,
resulting in a metabolic alkalosis.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
15. Principles of Surgery in General; Postoperative Management & Critical Care (42Qs)
----------------------------------------------------------------------------------------------------------------------------
Scenario 2
Five days following an anterior resection, a 67-year-old woman complains of a sudden onset of right-sided chest
pain and shortness of breath. An ECG shows a sinus tachycardia.
B - Metabolic alkalosis« YOUR ANSWER
D - Respiratory alkalosis« CORRECT ANSWER.
Sudden onset of chest pain, shortness of breath and tachycardia in a postoperative patient are Page
suggestive of pulmonary embolism. Tachypnoea leads to a reduction in p(CO2) and a subsequent 1154
respiratory alkalosis.
Scenario 3
An 18-year-old diabetic man is referred with an acute abdomen. His white cell count is 17 and plasma glucose is
36 mmol/l.
C - Respiratory acidosis« YOUR ANSWER
A - Metabolic acidosis« CORRECT ANSWER.
Diabetic ketoacidosis can be mistaken for an acute abdomen, leading to unnecessary surgery. Build up of
ketones will lead to a metabolic acidosis.
Scenario 4
A 24-year-old man is involved in a road traffic accident (RTA). On arrival, he is pale with a pulse of 120 and blood
pressure of 100/80. His abdomen is bruised over the left upper quadrant (LUQ) and tender throughout.
D - Respiratory alkalosis« YOUR ANSWER
A - Metabolic acidosis« CORRECT ANSWER.
This 24-year-old man is shocked following an RTA. Reduced circulating volume leads to tissue
hypoperfusion and a build up of lactate, resulting in a metabolic acidosis.
04. Theme: Post-operative hypoxia
A Adult respiratory distress syndrome
B Basal atelectasis
C Bronchospasm
D Cardiogenic pulmonary oedema
E Lobar collapse
F Opiate overdose
G Pleural effusion
H Pneumonia
I Pneumothorax
J Pulmonary embolism
K Upper airway obstruction.
The following are descriptions of patients with post-operative hypoxia. Please select the most appropriate
diagnosis from the above list. The items may be used once, more than once, or not at all.
Scenario 1
A 62-year-old woman undergoes a sigmoid colectomy for left-sided colonic carcinoma. She is given an epidural
for pain relief, but this becomes dislodged. On day 1 post-operation she is dyspnoeic with a rapid pulse and mild
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
15. Principles of Surgery in General; Postoperative Management & Critical Care (42Qs)
----------------------------------------------------------------------------------------------------------------------------
pyrexia; auscultation reveals reduced breath sounds at the left base. Arterial blood gases are: pH 7.35, pA(O2) 9.6
kPa, pA(CO2) 5.0 kPa. She has a non-productive cough.
A - Adult respiratory distress syndrome « YOUR ANSWER
B - Basal atelectasis « CORRECT ANSWER.
Post-operative atelectasis is commonly observed in the early post-operative period, especially after
prolonged surgery in the supine position; diaphragmatic dysfunction and reduced surfactant are Page
consequences of general anaesthesia and surgical manipulation that can lead to atelectasis. In addition, 1155
inadequate analgesia leads to reduced respiratory excursion and coughing. The resultant hypoventilation
of the lung bases leads to localised small airway collapse and is usually accompanied by a low-grade
pyrexia.
Scenario 2
A 74-year-old man with a previous history of ischaemic heart disease undergoes an anterior resection for rectal
carcinoma. On day 4 post-operation he is severely dyspnoeic, tachypnoeic but apyrexial; auscultation reveals
bilateral fine crepitations. Arterial blood gases are: pH 7.35, pA(O2) 8.0 kPa, pA(CO2) 5.5 kPa.
B - Basal atelectasis « YOUR ANSWER
D - Cardiogenic pulmonary oedema« CORRECT ANSWER.
This is the result of either increased hydrostatic pressure (eg volume overload – as in this scenario, and
left ventricular failure) or decreased oncotic pressure (eg hypoalbuminaemia). Regardless of aetiology,
the fluid accumulates around the lung parenchyma, especially in the dependant basal regions of the lower
lobes, causing alveolar collapse.
Scenario 3
A 59-year-old man undergoes a palliative bypass of an unresectable gastric carcinoma. Several days later he is
dyspnoeic, mildly tachycardic and apyrexial; auscultation reveals absent breath sounds at the left base and
decreased left-sided vocal resonance. Arterial blood gases are: pH 7.37, pA(O2) 10.1 kPa, pA(CO2) 6.0 kPa. His
serum albumin is 20 g/litre.
C - Bronchospasm« YOUR ANSWER
G - Pleural effusion« CORRECT ANSWER.
Fluid in the pleural space can be either a transudate (< 30 g/litre), secondary to either increased
hydrostatic pressure (eg from volume overload and left ventricular failure) or decreased oncotic pressure
(from hypoalbuminaemia, as in this scenario); or an exudate (> 30 g/litre), secondary to capillary
hyperpermeability (from malignancy, Gram-negative sepsis or other inflammatory change, etc). Fluid fills
the basal aspect of the pleural space, inhibiting gross lung expansion.
Scenario 4
A 43-year-old woman is being managed for severe acute pancreatitis. Over the past 48 h she has become
increasingly dyspnoeic and tachycardic; auscultation reveals bilateral fine crepitations. Arterial blood gases are:
pH 7.37, pA(O2) 8.2 kPa, pA(CO2) 4.9 kPa. Chest radiology shows bilateral diffuse infiltrates.
D - Cardiogenic pulmonary oedema« YOUR ANSWER
A - Adult respiratory distress syndrome « CORRECT ANSWER.
Adult respiratory distress syndrome, or non-cardiogenic pulmonary oedema, is often an early
manifestation of the systemic inflammatory response syndrome and later development of multi-organ
dysfunction. It represents progressive combined ventilatory, perfusion and diffusional pathology.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
