PLAB 1 General Surgery Questions: 10 Free Practice MCQs
Ten PLAB 1-style general surgery questions with the answer and the reasoning behind it. They come from the UK.med bank, which has 16 general surgery questions and many more across every topic.
1 / 10
A 45-year-old female presents to the emergency department with a 12-hour history of severe right upper quadrant abdominal pain that radiates to her right shoulder, accompanied by nausea. On examination, she is pyrexial (38.1°C). Inspiration catches and causes severe pain when the examiner deep-palpates the right upper quadrant.
What is the most likely diagnosis?
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Answer: C. Acute cholecystitis
Why: Acute cholecystitis is inflammation of the gallbladder, usually caused by gallstone obstruction of the cystic duct. Key clinical features are persistent RUQ pain, fever, leucocytosis, and Murphy's sign (arrest of inspiration on palpation of the RUQ). It is distinguished from biliary colic by inflammatory features (fever, persistent pain) and from cholangitis by the absence of jaundice.
- A. Acute cholangitis typically presents with Charcot's triad (RUQ pain, fever, and jaundice). Jaundice is absent here.
- B. Biliary colic pain is self-limiting (usually lasting less than 6 hours) and is not associated with fever or inflammatory signs like a positive Murphy's sign.
- D. Pancreatitis pain typically radiates to the back and is associated with epigastric tenderness rather than a localized Murphy's sign.
Sources: Oxford Handbook of Clinical Surgery
2 / 10
A 50-year-old female presents with vomiting and distension. Abdominal X-ray shows dilated loops of bowel with valvulae conniventes visible entirely across the lumen.
What is the level of obstruction?
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Answer: B. Small Bowel
Why: On AXR, small bowel loops have valvulae conniventes (lines crossing the full width), whereas large bowel has haustra (lines crossing only part of the width).
- A. Show haustra (don't cross full width).
- C. Would show large gastric bubble.
- D. Coffee bean sign.
Sources: Radiopaedia
3 / 10
A 52-year-old male with acute pancreatitis is reviewed 24 hours after admission. His latest bloods and clinical markers reveal: PaO2 7.5 kPa, WBC 18 x 10^9/L, Urea 18.5 mmol/L, Calcium 1.9 mmol/L, blood glucose 11.5 mmol/L, and Albumin 29 g/L. His amylase on admission was 1200 U/L.
What is his Glasgow (Imrie) prognostic score, and how is it used to guide management?
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Answer: C. Score of 6; indicates severe acute pancreatitis, warranting urgent High Dependency Unit (HDU) or ICU referral
Why: The Glasgow (Imrie) prognostic scale is used to assess the severity of acute pancreatitis within 48 hours of admission. One point is given for each of the following (PANCREAS): P - PaO2 < 8 kPa; A - Age > 55; N - Neutrophilia (WBC > 15 x 10^9/L); C - Calcium < 2.0 mmol/L; R - Renal (Urea > 16 mmol/L); E - Enzymes (LDH > 600 U/L or AST/ALT > 200 U/L); A - Albumin < 32 g/L; S - Sugar (Glucose > 10 mmol/L). A score of >= 3 indicates severe pancreatitis.
- A. His score is 6, indicating severe acute pancreatitis. Mild pancreatitis is defined by a score of < 3.
- B. Amylase level is used for diagnosis, but it has no prognostic value and is not part of the Glasgow scoring criteria.
- D. The age threshold for a point in the Glasgow score is > 55 years, so he does not receive a point for his age (52).
Sources: British Society of Gastroenterology (BSG) Guidelines; NICE NG104
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4 / 10
A 64-year-old female presents to the surgical assessment unit with a 3-day history of worsening left lower quadrant abdominal pain, fever, and constipation. On examination, she is pyrexial (38.5°C), tachycardic (105 bpm), and has localized tenderness with guarding in the left iliac fossa. A CT scan of the abdomen and pelvis shows localized sigmoid colon wall thickening with surrounding fat stranding, but no free air or fluid collections.
What is the most appropriate initial management according to NICE guidelines?
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Answer: D. Admit the patient, make Nil-By-Mouth, start intravenous fluids and intravenous antibiotics (e.g. Co-amoxiclav)
Why: NICE guideline NG244 recommends managing suspected acute diverticulitis. Contrast-enhanced CT is the diagnostic imaging of choice. Inpatient admission and IV antibiotics are indicated if there is systemic upset, severe pain, or high risk of complications. Complicated diverticulitis (perforation, abscess) may require radiological drainage or surgical intervention (Hartmann's or primary anastomosis).
- A. Endoscopy is strictly contraindicated during an acute episode of diverticulitis due to the high risk of converting an inflamed diverticulum into a perforation.
- B. While mild uncomplicated diverticulitis without systemic features can be managed in the community, this patient has signs of systemic infection (fever, tachycardia) and local guarding, requiring inpatient IV therapy.
- C. Surgical resection (Hartmann's procedure) is reserved for patients with purulent or faecal peritonitis (perforated diverticulitis) or failure of medical management, not uncomplicated acute diverticulitis.
Sources: NICE NG244
5 / 10
A 22-year-old woman presents to the emergency department with a 24-hour history of abdominal pain, which started around her umbilicus and has now localized to the right iliac fossa. She reports loss of appetite and nausea. On examination, she has tenderness and guarding in the right iliac fossa. Her urine pregnancy test is negative.
What is the most appropriate next step in investigation in the UK setting to confirm the diagnosis and rule out common mimics?
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Answer: D. Perform a transabdominal and pelvic ultrasound scan
Why: In the UK, the diagnostic pathway for suspected appendicitis differs by patient group. For young women, a pelvic and abdominal ultrasound scan is recommended first-line to evaluate the appendix and exclude gynaecological mimics. For men and older adults, CT scan is preferred. In all cases, initial bloods (FBC, CRP) and a pregnancy test are mandatory.
- A. Diagnostic laparoscopy is invasive. While it is the definitive method of diagnosis and treatment, non-invasive imaging (ultrasound) should be attempted first to avoid negative laparoscopies.
- B. Contrast-enhanced CT is highly sensitive for appendicitis and is first-line in males and older adults, but ultrasound is preferred first-line in young females to avoid pelvic radiation exposure.
- C. Abdominal X-rays are not diagnostic for appendicitis. An erect chest X-ray is useful for excluding perforation but does not diagnose appendicitis.
Sources: Royal College of Surgeons Guidelines; NICE CKS Appendicitis
6 / 10
A 48-year-old woman presents to the surgical assessment unit with recurrent episodes of severe, crampy right upper quadrant pain that radiates to her back, typically occurring after eating fatty meals and lasting 2-3 hours. On examination, she is afebrile and has mild right upper quadrant tenderness without guarding. An ultrasound confirms multiple gallstones within the gallbladder, but no wall thickening or ductal dilation.
What is the recommended definitive management plan according to NICE guidelines?
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Answer: A. Arrange an elective laparoscopic cholecystectomy
Why: NICE guideline CG188 recommends laparoscopic cholecystectomy for patients with diagnosed gallstones who have symptoms (biliary colic) or complications (cholecystitis, pancreatitis, cholangitis). Patients with asymptomatic gallstones found incidentally do not require surgery unless they have specific risk factors (e.g. gallbladder polyps or calcified 'porcelain' gallbladder).
- B. Ursodeoxycholic acid has poor efficacy, high recurrence rates, and is not recommended by NICE for symptomatic gallstones unless the patient is completely unfit for surgery.
- C. ERCP is indicated for ductal stones (common bile duct obstruction) or ascending cholangitis, not for uncomplicated biliary colic where the gallstones are confined to the gallbladder.
- D. While dietary modification helps manage symptoms, it does not treat the underlying pathology. Discharging without offering surgical referral is incorrect, as biliary colic will recur.
Sources: NICE CG188
7 / 10
A 62-year-old female presents with a 3-day history of left lower quadrant abdominal pain, fever (38.3°C), and altered bowel habit. On examination, she has localized tenderness and guarding in the left iliac fossa.
What is the diagnostic investigation of choice to confirm acute diverticulitis?
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Answer: C. CT abdomen and pelvis with contrast
Why: NICE guideline NG243 recommends contrast-enhanced CT of the abdomen and pelvis as the primary imaging investigation to confirm acute diverticulitis. It allows staging of severity (e.g. Hinchey classification) and guides management (e.g. identifying abscesses suitable for radiological drainage). Endoscopy is avoided in the acute phase.
- A. Colonoscopy is strictly contraindicated in acute diverticulitis due to the high risk of bowel perforation from insufflation of air into inflamed tissues.
- B. Barium enemas are obsolete in the acute setting and carry a risk of barium peritonitis if a micro-perforation is present.
- D. Ultrasound can identify diverticulitis but is operator-dependent and less sensitive than CT for evaluating severity and staging complications.
Sources: NICE NG243; Association of Coloproctology of GB & Ireland
8 / 10
A 64-year-old male is undergoing an elective open repair of an inguinal hernia. During the dissection of the inguinal canal, the surgeon identifies the inferior epigastric artery.
Which anatomical relationship determines whether the hernia is direct or indirect?
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Answer: B. Direct hernias occur medial to the inferior epigastric artery, while indirect hernias occur lateral to it
Why: The relationship to the inferior epigastric vessels defines direct vs indirect inguinal hernias. Direct inguinal hernias protrude directly through a defect in the posterior wall of the inguinal canal (Hesselbach's triangle), which lies medial to the inferior epigastric vessels. Indirect inguinal hernias enter the deep inguinal ring, which lies lateral to the inferior epigastric vessels, and travel down the inguinal canal.
- A. This is anatomically reversed.
- C. Indirect hernias pass through both rings; direct hernias bypass the deep ring and emerge near the superficial ring.
- D. Both direct and indirect inguinal hernias lie superior to the inguinal ligament; femoral hernias lie inferior to it.
Sources: Gray's Anatomy
9 / 10
A 52-year-old male is admitted with acute pancreatitis. On day 2, his lab results show: Age 52, PaO2 7.2 kPa (low), WBC 16 x 10^9/L, Urea 18 mmol/L, Calcium 1.8 mmol/L, Glucose 12 mmol/L, Albumin 28 g/L, and LDH 650 IU/L.
Using the Glasgow (Imrie) prognostic criteria, what is the severity classification of his pancreatitis?
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Answer: C. Severe pancreatitis (score of 3 or more)
Why: The Glasgow (Imrie) criteria assess severity in acute pancreatitis within 48 hours of admission. The acronym PANCREAS stands for: PaO2 < 8 kPa, Age > 55, Neutrophils (WBC > 15 x 10^9/L), Calcium < 2 mmol/L, Renal function (Urea > 16 mmol/L), Enzymes (AST > 200 or ALT > 480), Albumin < 32 g/L, and Sugar (Glucose > 10 mmol/L). A score of 3 or more within 48 hours indicates severe acute pancreatitis, warranting escalation to HDU/ICU.
- A. The patient meets 6 of the Glasgow criteria, indicating severe pancreatitis with a high risk of systemic complications.
- B. Glasgow score does not have a formal 'moderate' category; a score of >=3 is classified as severe.
- D. The key parameters (PaO2, age, WBC, urea, calcium, glucose, albumin, LDH) are provided, allowing calculation.
Sources: BSG Guidelines on Acute Pancreatitis
10 / 10
A 72-year-old man presents with a painful groin lump that has been present for 3 years but became irreducible and excruciatingly painful 6 hours ago. He has since developed nausea and vomiting. On examination, there is a tense, tender, non-reducible swelling in the right groin. The skin overlying the swelling is erythematous and warm.
What is the most appropriate next step in management?
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Answer: A. Arrange immediate emergency surgical exploration and hernia repair
Why: A strangulated hernia occurs when the blood supply to the herniated tissue is compromised. This is a surgical emergency. Clinical signs include irreducibility, severe pain, local tenderness, skin changes (erythema/warmth indicating underlying tissue necrosis), and systemic symptoms (nausea, vomiting, tachycardia). Management is emergency surgery. Delaying operation to obtain ultrasound or attempting manual reduction must be avoided.
- B. Manual reduction is contraindicated in a suspected strangulated hernia, as reducing ischemic/necrotic bowel back into the peritoneal cavity can cause perforation and faecal peritonitis.
- C. Delaying management for imaging in a clinically obvious strangulated hernia increases the risk of bowel gangrene and mortality.
- D. A strangulated hernia is a life-threatening emergency. Sending the patient home with analgesia is unsafe and will result in bowel necrosis.
Sources: Royal College of Surgeons Guidelines on Groin Hernia; Association of Surgeons of Great Britain and Ireland
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Exam-style questions written by MedHub for practice. They are not official exam questions.