FMGE 2019 — Surgery
21 Previous Year Questions with Answers & Explanations
Which finding is assigned 2 points in the Alvarado scoring system for appendicitis assessment?
Bell clapper deformity (abnormal testicular fixation) predisposes to which of the following conditions?
A 62-year-old female had a kidney stone and was treated with PCNL. After 2 days, she comes to the OPD with chills and fever. What is the complication?
A 6-month-old child presents with an umbilical hernia measuring 3 cm in diameter. What is the management protocol?
What is the most common tumor of the mediastinum?
Investigations used for CSF rhinorrhea are all except:
A patient who underwent gastrectomy develops sweating and diarrhea within 20 minutes after eating. What could be the cause?
A patient with varicose veins came to the hospital; an intern was on duty. Which test should he perform to assess the competency of deep veins?
What is the most common anterior mediastinal tumor?
In an accident case, after the arrival of medical team, all should be done in early management except;
FMGE 2019 - Surgery FMGE Practice Questions and MCQs
Question 1: Which finding is assigned 2 points in the Alvarado scoring system for appendicitis assessment?
- A. Low-grade fever
- B. Leukocytosis (Correct Answer)
- C. Nausea and vomiting
- D. Rebound tenderness
Explanation: **Leukocytosis** - An elevated **white blood cell count** (typically greater than 10,000 cells/mm³) is a significant indicator of inflammation, assigned **2 points** in the Alvarado score. - This finding reflects the body's systemic response to the infection and inflammation associated with **appendicitis**. *Low-grade fever* - A low-grade fever (oral temperature of 37.3-38.0°C) is assigned **1 point** in the Alvarado score. - While indicative of inflammation, it is less specific and less weighted than leukocytosis. *Nausea and vomiting* - These gastrointestinal symptoms are common in appendicitis and are assigned **1 point** in the Alvarado score. - They are non-specific and can be present in many other abdominal conditions. *Rebound tenderness* - This clinical sign, indicating **peritoneal irritation**, is assigned **1 point** in the Alvarado score. - It is a physical exam finding, not a laboratory finding, and suggests localized inflammation.
Question 2: Bell clapper deformity (abnormal testicular fixation) predisposes to which of the following conditions?
- A. Hydrocele
- B. Testicular torsion (Correct Answer)
- C. Testicular atrophy
- D. Varicocele
Explanation: ***Testicular torsion*** - The **bell clapper deformity** describes an abnormally high attachment of the tunica vaginalis, leaving the testis and epididymis free to rotate within the scrotal sac. - This anatomical variation allows the spermatic cord to twist, cutting off blood supply to the testis, which is the mechanism of **testicular torsion**. *Hydrocele* - A **hydrocele** is a collection of fluid in the tunica vaginalis, resulting from an imbalance in fluid production and absorption, or a patent processus vaginalis. - It is not directly caused by abnormal testicular fixation. *Testicular atrophy* - **Testicular atrophy** is a reduction in testicular size, often due to conditions like cryptorchidism, mumps orchitis, or prolonged testicular torsion, but not predisposed by the bell clapper deformity itself unless torsion occurs. - While torsion can lead to atrophy if not promptly treated, the deformity directly predisposes to the torsion event, rather than atrophy itself. *Varicocele* - A **varicocele** is an abnormal dilation of the veins of the pampiniform plexus within the scrotum, usually due to incompetent valves or venous obstruction. - This condition is not associated with testicular fixation abnormalities.
Question 3: A 62-year-old female had a kidney stone and was treated with PCNL. After 2 days, she comes to the OPD with chills and fever. What is the complication?
- A. Bacterial sepsis (Correct Answer)
- B. Acute pancreatitis
- C. Ureteric stricture
- D. Splenic injury
Explanation: ***Bacterial sepsis*** - **Chills and fever** two days after a **Percutaneous Nephrolithotomy (PCNL)** are highly suggestive of a systemic infection, specifically **bacterial sepsis**, as this procedure carries a risk of introducing bacteria into the bloodstream. - Urinary tract manipulation, especially in a patient with a potentially *infected kidney stone*, can lead to bacteremia and subsequent **sepsis** if not properly managed. *Acute pancreatitis* - **Acute pancreatitis** is not a common complication of PCNL. It typically presents with severe **epigastric pain** radiating to the back, often with nausea and vomiting, and is usually associated with gallstones or alcohol abuse. - While it can cause fever, the clinical presentation and context do not strongly support **pancreatitis** as the primary issue following a PCNL. *Ureteric stricture* - A **ureteric stricture** is a *late complication* of kidney stone treatment and typically leads to symptoms of **urinary obstruction**, such as flank pain, rather than acute fever and chills two days post-procedure. - It would not cause acute systemic signs like **chills and fever** within such a short timeframe after PCNL. *Splenic injury* - **Splenic injury** is a rare but possible complication of procedures around the left kidney; however, it would typically present with **abdominal pain**, signs of **hemorrhage** (e.g., hypotension), and sometimes shoulder pain, not primarily with fever and chills as the immediate post-operative concern. - While fever can occur with internal injuries, the primary and most immediate concern with fever and chills after a urological procedure is **infection**.
Question 4: A 6-month-old child presents with an umbilical hernia measuring 3 cm in diameter. What is the management protocol?
- A. Immediate surgical repair
- B. Elective surgery at 5 years of age
- C. Hernioplasty for repair
- D. Observation until 2 years of age, then surgery if unresolved (Correct Answer)
Explanation: ***Observation until 2 years of age, then surgery if unresolved*** - Most **umbilical hernias** in infants and young children **resolve spontaneously** by the age of 2 years, making observation the initial management for uncomplicated cases. - Surgical intervention is typically considered if the hernia persists beyond **2-4 years of age**, is symptomatic, or demonstrates features of incarceration regardless of age. *Immediate surgical repair* - Immediate surgery is reserved for cases with **incarceration** or **strangulation**, which are not indicated by a "symptomatic" hernia in this context. - Given the high rate of spontaneous closure, most umbilical hernias do not require urgent intervention. *Elective surgery at 5 years of age* - Waiting until 5 years of age to consider surgery might delay treatment for some children whose hernias are unlikely to close spontaneously after the age of 2-4 and could lead to prolonged parental anxiety. - The general consensus is to recommend surgery if the hernia persists beyond **2-4 years**, rather than a fixed age of 5. *Hernioplasty for repair* - While hernioplasty is the surgical technique for repair, the question asks about the overall management protocol, which includes initial observation. - Applying this term as an immediate solution for a 6-month-old's uncomplicated umbilical hernia would bypass the recommended period of **conservative management**.
Question 5: What is the most common tumor of the mediastinum?
- A. Thymoma
- B. Lymphoma
- C. Neuroblastic tumor
- D. Neurogenic tumor (Correct Answer)
Explanation: ***Neurogenic tumor*** - **Neurogenic tumors** are the **most common primary tumors of the mediastinum** overall, accounting for approximately **35-40%** of all mediastinal masses. - They are the most common tumors of the **posterior mediastinum** and arise from nerve sheaths (e.g., **schwannomas, neurofibromas**) or sympathetic ganglia. - These tumors occur across all age groups, with higher prevalence when including both pediatric and adult populations. *Thymoma* - **Thymomas** are the most common primary tumor of the **anterior mediastinum** in adults, accounting for about **40-50%** of anterior mediastinal masses. - However, they represent only about **20-25%** of all mediastinal tumors overall. - Often associated with paraneoplastic syndromes like **myasthenia gravis** (30-50% of cases). *Lymphoma* - **Lymphoma** is a common mediastinal tumor, particularly **Hodgkin lymphoma** in young adults, accounting for approximately **15-20%** of mediastinal masses. - It often presents with bulky mediastinal masses and symptoms like **dyspnea, cough, or superior vena cava syndrome**. - While very common, it ranks second or third overall after neurogenic tumors. *Neuroblastic tumor* - **Neuroblastic tumors** (e.g., neuroblastoma, ganglioneuroblastoma) are a subset of neurogenic tumors more common in **children**. - They arise from the sympathetic nervous system and typically occur in the posterior mediastinum. - While important in pediatric populations, they are less common than all neurogenic tumors combined.
Question 6: Investigations used for CSF rhinorrhea are all except:
- A. Skull X-ray (Correct Answer)
- B. CT cisternogram
- C. Beta-2 transferrin
- D. Nasal endoscopy
Explanation: ***Skull X-ray*** - A **skull X-ray** is generally not useful for diagnosing **CSF rhinorrhea** as it lacks the detailed soft tissue resolution needed to identify CSF leaks. - It cannot visualize small defects in the skull base or detect the presence of CSF distinct from other nasal secretions. *CT cisternogram* - A **CT cisternogram** is a highly effective imaging modality for localizing **CSF leaks**, involving an intrathecal injection of contrast followed by CT scanning. - It can pinpoint the exact site of the leak in the skull base, which is crucial for surgical planning. *Beta-2 transferrin* - **Beta-2 transferrin** is a protein found almost exclusively in **cerebrospinal fluid (CSF)**, making its detection in nasal discharge diagnostic of CSF rhinorrhea. - This biochemical test offers high specificity for confirming the presence of CSF. *Nasal endoscopy* - **Nasal endoscopy** allows direct visualization of the nasal cavity and can help identify the source of the leak, especially if active dripping is observed. - During the procedure, the Valsalva maneuver or changes in head position can sometimes provoke or increase the flow of CSF, aiding in localization.
Question 7: A patient who underwent gastrectomy develops sweating and diarrhea within 20 minutes after eating. What could be the cause?
- A. Late dumping syndrome
- B. Hyperglycemia
- C. Early dumping syndrome (Correct Answer)
- D. Hypoglycemia
Explanation: ***Early dumping syndrome*** - Occurs **15-30 minutes after eating** in patients who have undergone **gastric surgery**, such as gastrectomy, due to rapid emptying of hyperosmolar chyme into the small intestine. - Symptoms include **sweating**, **diarrhea**, **nausea**, **cramping**, and **tachycardia** due to fluid shifts and hormonal responses. *Late dumping syndrome* - Typically occurs **1-3 hours after eating**, not within 20 minutes. - It is characterized by **hypoglycemia** due to an exaggerated insulin response to the rapid absorption of glucose, leading to symptoms like weakness, confusion, and tremor. *Hyperglycemia* - While a rapid influx of glucose can initially cause hyperglycemia, the symptoms described (sweating, diarrhea) are more indicative of the systemic effects of rapid gastric emptying rather than simple hyperglycemia itself. - Hyperglycemia post-meal is a normal physiological response, and the constellation of symptoms points to a post-surgical complication. *Hypoglycemia* - Hypoglycemia is characteristic of **late dumping syndrome**, occurring hours after a meal, not within 20 minutes. - The symptoms of early dumping syndrome are primarily driven by fluid shifts and neurovascular responses, not low blood glucose.
Question 8: A patient with varicose veins came to the hospital; an intern was on duty. Which test should he perform to assess the competency of deep veins?
- A. Ober test
- B. Thomas test
- C. Perthes test (Correct Answer)
- D. Brodie Trendelenburg test
Explanation: ***Perthes test*** - The Perthes test assesses the **patency and competency of the deep venous system** in the leg by observing changes in superficial varicosities during muscle activity. - If the varicosities diminish or disappear with ambulation and a tourniquet applied to compress superficial veins, it indicates that the **deep veins are competent** and can handle venous return. *Ober test* - The Ober test is used to assess the **tightness of the iliotibial band**, not venous competency. - It involves abducting and extending the hip while the patient lies on their side. *Thomas test* - The Thomas test evaluates for **hip flexion contracture**, especially of the iliopsoas muscle. - It is performed by having the patient lie supine and flexing one hip fully while observing the contralateral leg. *Brodie Trendelenburg test* - The Brodie Trendelenburg test is primarily used to assess the **competency of the valves of the saphenofemoral junction and perforating veins** to distinguish between superficial and deep venous insufficiency. - It involves elevating the leg, applying a tourniquet, and then observing refilling patterns of varicose veins upon standing.
Question 9: What is the most common anterior mediastinal tumor?
- A. Bronchogenic cyst
- B. Neurofibroma
- C. Pericardial cyst
- D. Thymoma (Correct Answer)
Explanation: ***Thymoma*** - **Thymomas** are the most common primary tumor of the **anterior mediastinum** in adults. - They originate from the epithelial cells of the **thymus gland**, which is located in the anterior mediastinum. *Bronchogenic cyst* - **Bronchogenic cysts** are typically found in the **middle mediastinum**, although they can occasionally occur in the anterior or posterior mediastinum. - They are congenital anomalies resulting from abnormal budding of the **tracheobronchial tree**. *Neurofibroma* - **Neurofibromas** are nerve sheath tumors that typically occur in the **posterior mediastinum**, arising from spinal nerves. - They are often associated with **neurofibromatosis type 1**. *Pericardial cyst* - **Pericardial cysts** are benign, fluid-filled sacs most commonly found in the **middle mediastinum**, specifically in the cardiophrenic angle. - They are usually asymptomatic and are often discovered incidentally.
Question 10: In an accident case, after the arrival of medical team, all should be done in early management except;
- A. Glasgow coma scale
- B. Check BP (Correct Answer)
- C. Stabilization of cervical vertebrae
- D. Check Respiration
Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.