How surgery is examined
Adult health (surgery) is 20% of the AMC MCQ blueprint, about 30 of the 150 questions. The focus is on the decisions of a junior doctor and GP: recognising the surgical emergency, choosing the right first investigation, resuscitating, consenting and managing complications.
| Question type | Example |
|---|---|
| Imaging choice | Ultrasound first for suspected gallstones; CT for suspected diverticulitis in an older adult |
| Urgency | Which patient with abdominal pain needs theatre tonight |
| Perioperative | When to stop a DOAC before surgery; postoperative fever by day |
| Trauma | The next step in the primary survey |
| Referral | Which breast, thyroid or scrotal finding needs urgent specialist review |
The acute abdomen
| Condition | First imaging | Key point |
|---|---|---|
| Biliary colic and cholecystitis | Ultrasound | Murphy sign, fever and raised inflammatory markers suggest cholecystitis; early laparoscopic cholecystectomy |
| Ascending cholangitis | Ultrasound, then MRCP or ERCP | Charcot triad; IV antibiotics and urgent biliary drainage |
| Appendicitis | Clinical; ultrasound in children and pregnancy, CT in adults if unclear | Use a score such as Alvarado or AIR; laparoscopic appendicectomy |
| Diverticulitis | CT abdomen | Uncomplicated cases may not need antibiotics; abscess or perforation changes management |
| Bowel obstruction | CT abdomen | Adhesions and hernias are common causes; strangulation needs surgery |
| Perforated viscus | Erect chest X-ray or CT | Free gas; resuscitate, antibiotics, surgery |
| Mesenteric ischaemia | CT angiography | Pain out of proportion to signs, often with AF |
| Ruptured AAA | Bedside ultrasound or straight to theatre if unstable | Permissive hypotension and immediate vascular surgery |
Always check a pregnancy test in women of reproductive age with abdominal pain, and remember that older people and those on steroids may have few signs.
Trauma and the primary survey
Trauma questions follow the EMST (ATLS) sequence. The answer is almost always the next step in that order, not the most interesting investigation.
- Airway with cervical spine protection.
- Breathing: decompress tension pneumothorax clinically, before imaging.
- Circulation with haemorrhage control: two large-bore cannulas, blood products, pelvic binder, eFAST.
- Disability: GCS, pupils, glucose.
- Exposure and preventing hypothermia.
- Use the Canadian CT head rule and Canadian C-spine rule to decide on imaging in stable patients.
- Unstable patients with a positive eFAST go to theatre, not CT.
- Burns: assess total body surface area, give fluids by formula, and refer burns of the face, hands, genitals, joints or over 10% TBSA in adults to a burns unit.
Breast and endocrine surgery
Every breast lump is assessed with triple assessment: clinical examination, imaging (mammogram and ultrasound in women over 35; ultrasound alone in younger women) and core biopsy. The result is only reassuring if all three are concordant.
- Nipple discharge that is bloody, single-duct or spontaneous needs imaging and referral.
- Thyroid nodules: TSH first; if normal, ultrasound and fine-needle aspiration by ultrasound risk features.
- After thyroidectomy, watch for hypocalcaemia and recurrent laryngeal nerve injury.
- Primary hyperparathyroidism: surgery for symptomatic disease or complications such as stones or osteoporosis.
Vascular and urology
- Acute limb ischaemia: the 6 Ps; heparin and urgent vascular review. Irreversible ischaemia needs amputation.
- Abdominal aortic aneurysm: elective repair is usually considered at about 5.5 cm in men or rapid growth.
- Carotid stenosis: endarterectomy for recent symptoms with significant stenosis.
- Testicular torsion: a clinical diagnosis; explore surgically without delaying for ultrasound.
- Visible haematuria in adults needs CT urogram and cystoscopy to exclude urothelial cancer.
- Renal colic: low-dose non-contrast CT; obstruction with infection is an emergency needing drainage.
- PSA testing: discuss benefits and harms before testing, as recommended in Australian guidelines.
Orthopaedics and the back
- Use the Ottawa ankle and knee rules to decide who needs an X-ray.
- Suspected scaphoid fracture with a normal X-ray: immobilise and arrange MRI or repeat imaging.
- Displaced intracapsular neck of femur fractures in older adults usually need arthroplasty because of avascular necrosis risk.
- Septic arthritis: aspirate before antibiotics, then urgent washout.
- Back pain red flags: saddle anaesthesia, urinary retention, bilateral leg symptoms (cauda equina: urgent MRI), fever, weight loss, cancer history.
- Compartment syndrome: pain out of proportion and pain on passive stretch; fasciotomy, do not wait for pulses to disappear.
Perioperative care
| Topic | Australian practice to know |
|---|---|
| Fasting | Usually 6 hours for food and 2 hours for clear fluids before elective anaesthesia |
| Anticoagulants | Stop DOACs 1 to 3 days or more before surgery depending on the drug, renal function and bleeding risk; warfarin usually 5 days, with bridging only for high thrombotic risk |
| Diabetes | Withhold SGLT2 inhibitors for at least 2 to 3 days before surgery because of ketoacidosis risk |
| VTE prophylaxis | Assess every surgical patient and use mechanical and drug prophylaxis as indicated |
| Consent | Explain material risks, alternatives and the option of no treatment |
| Day after surgery | Common cause of fever |
|---|---|
| 0 to 2 | Inflammatory response, atelectasis |
| 3 to 5 | Pneumonia, urinary tract infection |
| 5 to 7 | Wound infection, anastomotic leak, abscess |
| After 7 | Deep collection, venous thromboembolism |
Perioperative medicine timings vary between drugs and institutions; always follow local protocols and current product information.
Surgical oncology
- Colorectal cancer: change in bowel habit, rectal bleeding or iron deficiency anaemia needs colonoscopy; the national bowel screening program uses iFOBT every 2 years from 45 to 74.
- Oesophageal and gastric cancer: dysphagia, weight loss or upper GI bleeding needs prompt endoscopy.
- Skin cancer: excision with appropriate margins; sentinel node biopsy is considered for melanoma by thickness.
- Pancreatic cancer: painless jaundice with a palpable gallbladder (Courvoisier sign).
Choosing the first imaging test
| Clinical question | First imaging | Why |
|---|---|---|
| Right upper quadrant pain | Ultrasound | Best for gallstones and duct dilatation, no radiation |
| Suspected renal colic | Low-dose non-contrast CT KUB (ultrasound in pregnancy and children) | Most sensitive for stones |
| Suspected appendicitis in a child or pregnant woman | Ultrasound, then MRI in pregnancy if unclear | Avoids radiation |
| Left iliac fossa pain with fever in an older adult | CT abdomen and pelvis with contrast | Confirms diverticulitis and shows complications |
| Suspected bowel obstruction | CT abdomen | Shows cause, level and strangulation |
| Head injury meeting Canadian CT head rule criteria | Non-contrast CT brain | Detects bleeding |
| Breast lump under 35 | Ultrasound | Dense breast tissue limits mammography |
| Scrotal pain with suspected torsion | None: surgical exploration | Imaging delays salvage |
Postoperative fluids, electrolytes and pain
- Maintenance fluids: roughly 25 to 30 mL/kg/day of water with sodium, potassium and glucose; reassess daily and switch to oral intake as early as possible.
- Hyponatraemia after surgery is common with hypotonic fluids and ADH release; prefer isotonic fluids and monitor sodium.
- Hypokalaemia slows gut recovery and causes arrhythmias; replace with oral or IV potassium within safe infusion rates.
- Oliguria: check the catheter, assess volume status, give a fluid challenge if hypovolaemic and look for AKI causes.
- Pain: multimodal analgesia (paracetamol, NSAIDs if safe, regional techniques), with opioids at the lowest effective dose for the shortest time and a plan for stopping at discharge.
- Local anaesthetic toxicity: perioral numbness, seizures and arrhythmias; stop the injection, support the airway and give lipid emulsion.
Head and neck injuries in more detail
Most AMC head injury questions ask who needs a CT. The Canadian CT head rule applies to adults with a GCS of 13 to 15 after witnessed loss of consciousness, amnesia or disorientation.
High risk: CT needed
- GCS below 15 two hours after injury
- Suspected open or depressed skull fracture
- Signs of base of skull fracture
- Two or more episodes of vomiting
- Age 65 or more
Medium risk: CT needed
- Amnesia for more than 30 minutes before impact
- Dangerous mechanism: pedestrian struck, ejection from a vehicle, fall from over 1 metre or 5 stairs
Patients on anticoagulants have a lower threshold for imaging. The Canadian C-spine rule decides cervical spine imaging in alert, stable patients.
Hernias, anorectal problems and lumps
- Inguinal hernia: elective repair for symptoms; an irreducible, tender hernia is strangulated until proven otherwise and needs urgent surgery.
- Femoral hernia: more common in women and more likely to strangulate; repair promptly.
- Haemorrhoids: fibre, fluids and topical treatment; banding for persistent bleeding. Rectal bleeding over 45 to 50 or with risk factors still needs colonoscopy.
- Anal fissure: pain on defecation with bright blood; stool softeners and topical glyceryl trinitrate or diltiazem.
- Perianal abscess: incision and drainage, not antibiotics alone.
- Neck lumps: a persistent lump over 3 weeks in an adult needs assessment for malignancy, including ultrasound and FNA.
Worked examples
Worked example 1 · Trauma
A 30-year-old motorcyclist is brought in with a respiratory rate of 34, oxygen saturation of 85%, absent breath sounds on the right and a blood pressure of 80/50 mmHg. The trachea is deviated to the left. What is the most appropriate immediate step?
- A Urgent chest X-ray
- B CT chest with contrast
- C Needle or finger thoracostomy on the right
- D Intubation before any other step
- E Two units of O-negative blood, then reassess
Show the reasoning
Answer C. This is a tension pneumothorax, a clinical diagnosis in the breathing step of the primary survey. Decompress immediately; imaging would delay life-saving treatment. Blood products are part of circulation, which comes after the breathing problem is treated.
Worked example 2 · Perioperative
A 66-year-old man taking empagliflozin and metformin for type 2 diabetes is booked for elective bowel surgery in 5 days. What is the most appropriate advice about empagliflozin?
- A Continue it up to and including the day of surgery
- B Stop it at least 2 to 3 days before surgery
- C Stop it 4 weeks before surgery
- D Double the dose the day before surgery
- E Replace it with a sulfonylurea permanently
Show the reasoning
Answer B. SGLT2 inhibitors increase the risk of perioperative ketoacidosis, which may occur with near-normal glucose. Current Australian advice is to withhold them for at least 2 days before major surgery (3 for some agents) and restart when eating and drinking normally.
Common surgical traps
| Trap | Better answer |
|---|---|
| Imaging an unstable trauma patient | Resuscitate and go to theatre |
| Ultrasound before exploring a suspected torsion | Immediate surgical exploration |
| Antibiotics for every diverticulitis | Selective use in uncomplicated cases, by current guidance |
| Reassurance after a normal mammogram in a palpable lump | Complete triple assessment |
| Forgetting a pregnancy test | Beta-hCG in every woman of reproductive age with abdominal pain |
See our reasoning mistakes guide for more patterns.
How to study surgery
- Give surgery about 20% of your hours.
- Learn by presentation (the acute abdomen, the lump, the injured patient) rather than by operation.
- Memorise decision rules: Ottawa, Canadian CT head and C-spine, Glasgow-Blatchford, Alvarado.
- Practise ordering imaging: write down your first test before reading the options.
- Revise perioperative medicine, which overlaps with medicine and pharmacology.
Free sample adult surgery questions
Questions from our AMC MCQ bank. Choose your answer, then open the explanation.
A 79-year-old man presents with 1 year of difficulty initiating swallowing, a gurgling sensation in his neck, halitosis and regurgitation of undigested food several hours after meals. He has had two chest infections this year. Examination is unremarkable. What is the most appropriate initial investigation?
- AFlexible upper gastroscopy
- BCT scan of the neck
- CHigh-resolution oesophageal manometry
- DBarium swallow
- EChest X-ray
Show answer and explanation
Answer D. The features suggest a pharyngeal pouch (Zenker's diverticulum) arising through Killian's dehiscence above cricopharyngeus. A barium swallow is the safest initial investigation, demonstrating the pouch and its size. Blind endoscopic intubation risks entering and perforating the pouch, so endoscopy should be undertaken carefully once the anatomy is known.
Learning point: Suspected pharyngeal pouch is investigated first with barium swallow to avoid endoscopic perforation.
A 63-year-old postmenopausal woman has completed breast-conserving surgery and radiotherapy for a 1.8 cm grade 2 invasive ductal carcinoma that is oestrogen receptor-positive and HER2-negative, with negative sentinel nodes. Her oncologist plans to start letrozole. Which baseline investigation is most important before starting treatment?
- ATransthoracic echocardiogram
- BPelvic ultrasound for endometrial thickness
- CBone mineral density (DEXA) scan
- DOphthalmology review for cataracts
- EPulmonary function tests
Show answer and explanation
Answer C. Aromatase inhibitors such as letrozole and anastrozole lower oestrogen levels and accelerate bone loss, increasing osteoporosis and fracture risk. A baseline DEXA scan, vitamin D and calcium assessment, and periodic monitoring are recommended, with antiresorptive therapy if needed. Arthralgia is another common side effect.
Learning point: Before starting an aromatase inhibitor, obtain a baseline DEXA because these drugs cause bone loss.
A 26-year-old man falls 4 metres from scaffolding, landing astride a beam. A pelvic binder is applied and he is now haemodynamically stable. He has a perineal and scrotal haematoma, blood at the urethral meatus and is unable to void. Pelvic X-ray shows fractures of the superior and inferior pubic rami. What is the most appropriate next step regarding his urinary tract?
- AGentle attempt to pass a 12 Fr urethral catheter
- BInsert a three-way irrigating urethral catheter
- CPerform an intravenous pyelogram
- DPerform a retrograde urethrogram
- EArrange urgent cystoscopy under anaesthesia
Show answer and explanation
Answer D. Blood at the meatus, perineal haematoma and inability to void after pelvic or straddle injury suggest urethral injury. A retrograde urethrogram should be performed before any urethral catheter is attempted, because blind catheterisation can convert a partial tear into a complete one. If a tear is shown, bladder drainage is by suprapubic catheter.
Learning point: Blood at the urethral meatus after pelvic trauma: retrograde urethrogram before any urethral catheter.
Practise more adult surgery questions free
Every adult surgery subtopic in our bank
The bank holds 614 adult surgery questions across 85 subtopics. You can filter by any of them, build a custom block and track your accuracy subtopic by subtopic.
- Abdominal & pelvic trauma10
- Abdominal aortic aneurysm8
- Abdominal imaging choice10
- Achalasia10
- Acute angle-closure glaucoma5
- Anaesthesia basics & local anaesthetic toxicity10
- Ankle fractures and Ottawa rules7
- Anorectal disorders10
- Appendicitis10
- Back pain red flags and cauda equina7
- Bariatric surgery basics10
- Bladder and kidney cancer7
- Bone tumours6
- Bowel obstruction10
- BPH and urinary retention7
- Brain tumours5
- Breast cancer management10
- Breast lumps and triple assessment11
- Burns12
- Carotid disease7
- Carpal tunnel and hand5
- Cataract5
- Central retinal artery/vein occlusion5
- Chest trauma10
- Cholecystitis and biliary colic10
- Choledocholithiasis and cholangitis10
- Clavicle fractures4
- Colorectal cancer10
- Compartment syndrome5
- Diabetic foot7
- Diabetic retinopathy5
- Dislocations7
- Diverticulitis10
- DVT surgical aspects7
- Dysphagia work-up10
- Epistaxis5
- Erectile dysfunction7
- Extradural & subdural haematoma5
- Eye trauma & chemical injury5
- Fracture complications5
- Haematuria work-up7
- Hand conditions3
- Hand injuries & infections5
- Head & neck cancer5
- Head injury10
- Hearing loss5
- Hernias10
- Hip fractures6
- Hydrocephalus5
- Knee injuries7
- Macular degeneration2
- Mesenteric ischaemia10
- Neck lumps5
- Oesophageal and gastric cancer10
- Open fractures5
- Osteoarthritis surgical options5
- Osteomyelitis and septic arthritis7
- Otitis externa & media5
- Pain management & opioid safety10
- Parathyroid surgery10
- Perforated viscus10
- Peripheral arterial disease and acute limb ischaemia8
- Postoperative complications10
- Postoperative fluids & electrolytes10
- Preoperative assessment & anticoagulant management10
- Pressure injuries2
- Primary survey (EMST/ATLS)10
- Prostate cancer and PSA counselling7
- Red eye6
- Renal colic and stones7
- Retinal detachment5
- Shoulder pain6
- Sinusitis5
- Skin and soft tissue lumps3
- Skin lesion excision & flaps5
- Sports injuries6
- Surgical sepsis10
- Testicular cancer7
- Testicular torsion and scrotal masses7
- Thyroid nodules and thyroid surgery complications10
- Tonsillitis & quinsy5
- Varicose veins and venous ulcers7
- Vertebral fractures and spinal trauma6
- Wound healing5
- Wrist and scaphoid fractures6
Common questions
How many surgery questions are in the AMC MCQ?
Adult health (surgery) is 20% of the blueprint, about 30 of 150 questions.
Does the AMC MCQ test operative technique?
Rarely. It tests recognition, investigation, urgency, consent and perioperative management at junior doctor and GP level.
What is triple assessment?
Clinical examination, imaging and core biopsy of a breast lump. Cancer is only excluded when all three are concordant and benign.
Which trauma framework does the AMC use?
Questions follow the EMST (ATLS) primary survey: airway with c-spine, breathing, circulation, disability and exposure.
Sources
Clinical content is summarised from current Australian guidance at the date above. Guidelines change, so always check the latest edition.