A 6-year-old boy came to the hospital with complaints of sore throat and difficulty in swallowing. His left tonsil was pushed medially and had swelling over the left side upper part of neck. What will be the diagnosis?
A 40-year-old patient presents with a femur fracture, pulmonary infiltration, and respiratory distress. What is the most likely diagnosis?
A 27-year-old woman presents with 26 weeks of gestation with a thyroid lesion which is found to be papillary carcinoma of thyroid. Which is the best treatment for this patient?
A lady comes to OPD after fall from scooty. Her vitals are stable. She is having continuous, clear watery discharge from nose after 2 days. This is most likely a feature of?
A young male patient presents with dyspnea; auscultation reveals absent breath sounds on the right side, and he has hypotension. What is the immediate next step?
32-year-old man presented with fever and pain in upper right hypochondrium after food intake. Investigation of choice?
The complication which will not occur after PCNL surgery:
A lady with 50% TBSA burn with involvement of dermis and subcutaneous tissue came to the emergency department. The burns will be classified as:
What is the most common presentation of nasopharyngeal carcinoma?
Distal ileum was removed in a 20-year-old girl. Which absorption deficiency will be seen?
FMGE 2019 - Surgery FMGE Practice Questions and MCQs
Question 11: A 6-year-old boy came to the hospital with complaints of sore throat and difficulty in swallowing. His left tonsil was pushed medially and had swelling over the left side upper part of neck. What will be the diagnosis?
- A. Ludwig's angina
- B. Peritonsillar abscess (Correct Answer)
- C. Retropharyngeal abscess
- D. Parapharyngeal abscess
Explanation: ***Peritonsillar abscess*** - A **peritonsillar abscess** (quinsy) is the most common deep neck space infection and characteristically causes **medial displacement of the tonsil**, which is the key clinical finding in this case. - The patient presents with classic features: severe unilateral sore throat, difficulty swallowing, and the hallmark sign of **tonsillar displacement medially**. - The swelling in the **upper lateral neck** can occur with peritonsillar abscess, especially when there is significant inflammation extending into the surrounding tissues. - Other typical features include trismus, "hot potato voice," and uvular deviation (though not mentioned here). *Parapharyngeal abscess* - A **parapharyngeal abscess** can develop as an extension of a peritonsillar abscess, but the primary finding would be **bulging of the lateral pharyngeal wall** rather than medial displacement of the tonsil itself. - While neck swelling is prominent in parapharyngeal abscess, the specific finding of **medial tonsillar displacement** is more characteristic of peritonsillar abscess. - Parapharyngeal abscess typically presents with more systemic toxicity and can involve cranial nerve complications. *Retropharyngeal abscess* - A **retropharyngeal abscess** typically causes severe dysphagia and odynophagia with posterior pharyngeal wall bulging. - It does not cause **medial displacement of the tonsil**, which is the key finding in this case. - Neck swelling would be more posterior and midline, and patients often present with neck hyperextension and respiratory distress. *Ludwig's angina* - **Ludwig's angina** is a severe bilateral cellulitis of the floor of the mouth involving the submandibular, sublingual, and submental spaces. - It characteristically causes painful swelling and **elevation of the tongue**, creating a "bull neck" appearance. - It does not cause **tonsillar displacement** or localized unilateral upper neck swelling as described in this case.
Question 12: A 40-year-old patient presents with a femur fracture, pulmonary infiltration, and respiratory distress. What is the most likely diagnosis?
- A. Obstruction
- B. Pulmonary embolism
- C. Fat embolism (Correct Answer)
- D. Air embolism
Explanation: ***Fat embolism*** - A **femur fracture** significantly increases the risk of **fat embolism**, where fat globules from the bone marrow enter the bloodstream and lodge in the pulmonary capillaries. - The classic triad of **fat embolism syndrome** includes respiratory distress, neurological symptoms, and a petechial rash, but respiratory symptoms (pulmonary infiltration and distress) are usually the first to appear. *Obstruction* - While an obstruction could cause respiratory distress, it typically wouldn't be associated with diffuse **pulmonary infiltrates** following a long bone fracture. - **Airway obstruction** would present with stridor or wheezing, and is usually localized rather than systemic. *Pulmonary embolism* - A **pulmonary embolism** (PE) can cause respiratory distress and infiltrates, but given the context of a recent femur fracture, fat embolism is a more specific and likely diagnosis. - PE is usually due to a **venous thromboembolism** and can be suspected in immobilized patients, but the question points more strongly to fat release. *Air embolism* - **Air embolism** usually results from iatrogenic causes (e.g., central line insertion, surgery) or trauma to large veins, allowing a significant amount of air into the circulation. - While it can cause respiratory distress, it doesn't typically cause the diffuse **pulmonary infiltrates** described, which are characteristic of fat embolism.
Question 13: A 27-year-old woman presents with 26 weeks of gestation with a thyroid lesion which is found to be papillary carcinoma of thyroid. Which is the best treatment for this patient?
- A. Hemi-thyroidectomy
- B. Total thyroidectomy
- C. Thyroid ablation using radioactive Iodine
- D. Observation (Correct Answer)
Explanation: ***Observation*** - For **papillary thyroid carcinoma** diagnosed at **26 weeks of gestation**, **observation with close monitoring** is the best management approach. - At 26 weeks (late second trimester/approaching third trimester), the optimal surgical window (14-24 weeks) has passed, and surgery in the third trimester carries increased risk of preterm labor and maternal complications. - **Papillary thyroid carcinoma** has an **indolent course**, and delaying definitive treatment by 3-4 months until after delivery poses **minimal risk** to the mother. - **Close monitoring with ultrasound** should be performed, and **total thyroidectomy** should be planned for **after delivery**. - Surgery during pregnancy is only indicated for **rapidly growing tumors** or evidence of **aggressive features**, which are not mentioned in this case. *Total thyroidectomy* - While **total thyroidectomy** is the definitive treatment for papillary thyroid carcinoma, the **timing is critical** during pregnancy. - Surgery is ideally performed in the **second trimester (14-24 weeks)** to minimize risks to both mother and fetus. - At **26 weeks**, the patient is beyond the optimal surgical window, and performing surgery at this stage or in the third trimester increases the risk of **preterm labor** and other obstetric complications. - Definitive surgery should be **deferred until after delivery** unless there are aggressive features requiring urgent intervention. *Hemi-thyroidectomy* - **Hemi-thyroidectomy** is inadequate for papillary thyroid carcinoma and is only considered for very low-risk papillary microcarcinomas (<1 cm). - It does not provide adequate oncological control for diagnosed papillary carcinoma. *Thyroid ablation using radioactive Iodine* - **Radioactive iodine ablation** is absolutely **contraindicated during pregnancy** due to the risk of fetal thyroid destruction, leading to congenital hypothyroidism or cretinism. - While it is used as adjuvant therapy post-thyroidectomy in non-pregnant patients, it must be delayed until after delivery and cessation of breastfeeding.
Question 14: A lady comes to OPD after fall from scooty. Her vitals are stable. She is having continuous, clear watery discharge from nose after 2 days. This is most likely a feature of?
- A. CSF rhinorrhoea (Correct Answer)
- B. Acute respiratory infection
- C. Rhinitis
- D. Middle cranial fossa fracture
Explanation: ***CSF rhinorrhoea*** - **Clear watery discharge** appearing **two days after head trauma** (fall from scooty) is highly suggestive of **cerebrospinal fluid (CSF) rhinorrhoea**. - This occurs due to a breach in the **skull base**, allowing CSF to leak from the subarachnoid space into the nasal cavity. *Acute respiratory infection* - An acute respiratory infection typically presents with symptoms like **fever, cough**, and **nasal discharge** that is often thicker and discolored, not clear and watery. - The onset of discharge two days after trauma without other signs of infection also makes this less likely. *Rhinitis* - Rhinitis involves inflammation of the nasal mucosa, leading to watery discharge, sneezing, and congestion. - However, the traumatic etiology and the specific timing of the discharge make **CSF leak** a more pertinent diagnosis than simple rhinitis. *Middle cranial fossa fracture* - While a **middle cranial fossa fracture** can cause CSF leakage, the discharge from the nose (rhinorrhoea) typically originates from an **anterior cranial fossa fracture**. - A middle cranial fossa fracture is more commonly associated with **otorrhoea** (CSF leakage from the ear) if the temporal bone is involved.
Question 15: A young male patient presents with dyspnea; auscultation reveals absent breath sounds on the right side, and he has hypotension. What is the immediate next step?
- A. Needle insertion in 2nd intercostal space, midclavicular line (Correct Answer)
- B. Chest X-ray
- C. Intubate the patient
- D. Urgent IV fluid administration
Explanation: ***Needle insertion in 2nd intercostal space, midclavicular line*** - The combination of **dyspnea**, **absent breath sounds** on one side, and **hypotension** points to a **tension pneumothorax**, which is a medical emergency. - **Needle decompression** at the 2nd intercostal space, midclavicular line is the immediate life-saving intervention to relieve the pressure. *Chest X-ray* - While a Chest X-ray would confirm the diagnosis, it would **delay the urgent intervention** required for a tension pneumothorax. - The clinical picture dictates immediate treatment rather than diagnostic confirmation when a life-threatening condition is suspected. *Intubate the patient* - **Intubation** is not the primary treatment for a tension pneumothorax; it addresses airway compromise but not the underlying lung collapse and mediastinal shift. - It might even worsen the condition if **positive pressure ventilation** is applied before decompression. *Urgent IV fluid administration* - **IV fluids** are important for managing hypotension, but they do not address the **mechanical compression** of the heart and good lung by the tension pneumothorax. - Without relieving the tension, fluid administration alone will not improve the patient's cardiorespiratory status.
Question 16: 32-year-old man presented with fever and pain in upper right hypochondrium after food intake. Investigation of choice?
- A. Ultrasound (Correct Answer)
- B. CT scan
- C. ERCP (Endoscopic Retrograde Cholangiopancreatography)
- D. MRCP (Magnetic Resonance Cholangiopancreatography)
Explanation: ***Ultrasound*** - **Ultrasound** is the initial and often definitive investigation for suspected **gallbladder pathology** like cholecystitis, especially given the symptoms of fever and **right upper quadrant pain post-meals**. - It effectively visualizes **gallstones**, gallbladder wall thickening, and **pericholecystic fluid**, which are key indicators of cholecystitis. *CT scan* - A **CT scan** is generally not the first-line investigation for acute cholecystitis due to **radiation exposure** and its **lower sensitivity** for gallstones compared to ultrasound. - While it can identify complications like abscesses or perforations, it is usually reserved for **ambiguous ultrasound findings** or suspected complications. *ERCP (Endoscopic Retrograde Cholangiopancreatography)* - **ERCP** is an **invasive procedure** primarily used therapeutically for the removal of **bile duct stones** or for stent placement in cases of obstruction. - It carries risks of **pancreatitis** and perforation, making it unsuitable as an initial diagnostic tool for simple cholecystitis. *MRCP (Magnetic Resonance Cholangiopancreatography)* - **MRCP** is a **non-invasive imaging technique** that provides detailed images of the **biliary and pancreatic ducts** without radiation, primarily useful for confirming suspected bile duct stones or strictures. - While excellent for ductal anatomy, it is **not typically the first choice** for acute cholecystitis, as ultrasound is quicker, cheaper, and sufficient for initial diagnosis.
Question 17: The complication which will not occur after PCNL surgery:
- A. Organ injury
- B. Urethral stricture (Correct Answer)
- C. Bleeding
- D. Sepsis
Explanation: ***Urethral stricture*** - **Urethral stricture** is a complication typically associated with transurethral procedures involving instrumentation through the urethra, such as a **Transurethral Resection of the Prostate (TURP)** or repeated urethral catheterisation. - **PCNL (Percutaneous Nephrolithotomy)** involves direct access to the kidney through the skin in the flank, bypassing the urethra entirely, therefore, making urethral stricture not a direct complication of this procedure. *Organ injury* - **Organ injury**, particularly to adjacent organs like the **colon**, **pleura**, or **spleen/liver**, can occur during PCNL if the access tract is misdirected or during instrumentation. - This is a well-recognised but infrequent complication requiring careful pre-operative planning and imaging guidance. *Bleeding* - **Bleeding** is a common complication of PCNL due to the invasive nature of the procedure, involving puncture of the kidney and fragmentation of stones. - It can range from minor self-limiting bleeding to significant haemorrhage requiring transfusion or further intervention such as **angiography** and **embolization**. *Sepsis* - **Sepsis** is a serious potential complication, particularly if the patient has pre-existing urinary tract infection or if bacteria are dislodged during stone fragmentation. - **Infection** can disseminate into the bloodstream, leading to severe systemic inflammatory response syndrome and septic shock.
Question 18: A lady with 50% TBSA burn with involvement of dermis and subcutaneous tissue came to the emergency department. The burns will be classified as:
- A. 3rd degree burn (Correct Answer)
- B. 2nd degree superficial
- C. 2nd degree deep
- D. 1st degree
Explanation: ***3rd degree burn*** - **Third-degree burns** involve the entire thickness of the skin (dermis and epidermis) and often extend into the **subcutaneous tissue**, muscle, or bone. - These burns typically appear dry, leathery, and often lack pain sensation due to nerve destruction. *2nd degree superficial* - **Superficial second-degree burns** involve the epidermis and the superficial part of the dermis, often presenting with **blisters** and painful, red, moist skin. - They do not extend to the subcutaneous tissue, which is a key feature of the burn described. *2nd degree deep* - **Deep second-degree burns** involve the epidermis and deeper layers of the dermis, but not the entire dermis or subcutaneous tissue. - While they can be less painful and appear dry, the involvement of **subcutaneous tissue** pushes the classification to third-degree. *1st degree* - **First-degree burns** only affect the epidermis, causing redness and pain but **no blistering** or damage to deeper layers. - These are typically sunburns or minor scalds and do not involve the dermis or subcutaneous tissue.
Question 19: What is the most common presentation of nasopharyngeal carcinoma?
- A. Loss of smell
- B. Blockage of nose
- C. Neck lymph node (Correct Answer)
- D. Blood tinged discharge
Explanation: ***Neck lymph node*** - The most common initial symptom of nasopharyngeal carcinoma is a **painless neck mass** due to metastasis to cervical lymph nodes. - This occurs in a significant percentage of patients, often even before local symptoms from the primary tumor are prominent. *Loss of smell* - While possible in advanced stages if the tumor invades the **olfactory nerves** or directly obstructs the nasal cavity, it is not typically the initial or most common presentation. - This symptom is more indicative of conditions directly affecting the **olfactory epithelium** or nerves, not early nasopharyngeal carcinoma. *Blockage of nose* - **Nasal obstruction** or stuffiness can occur as the tumor grows and localizes within the nasopharynx, but it is less common as an initial symptom than a palpable neck mass. - This symptom might also be attributed to other common conditions like sinusitis or allergies, delaying diagnosis. *Blood tinged discharge* - **Epistaxis (nosebleeds)** or blood-tinged sputum/discharge can be a symptom, especially with later-stage tumors that are ulcerating or bleeding. - However, it is reported less frequently as the presenting symptom compared to cervical lymphadenopathy.
Question 20: Distal ileum was removed in a 20-year-old girl. Which absorption deficiency will be seen?
- A. Bile salts (Correct Answer)
- B. Iron
- C. Copper
- D. Zinc
Explanation: ***Bile salts*** - The **distal ileum** is the primary site for the active reabsorption of **bile salts** back into the enterohepatic circulation. - Their malabsorption leads to **fat malabsorption** and steatorrhea, and can lead to gallstones due to changes in bile composition. *Iron* - The majority of **iron absorption** primarily occurs in the **duodenum** and proximal jejunum, not the distal ileum. - Iron deficiency would typically result from issues higher up in the small intestine or from chronic blood loss. *Copper* - **Copper absorption** mainly occurs in the **stomach** and **duodenum**. - Deficiency typically arises from dietary inadequacy or specific genetic disorders, not distal ileal resection. *Zinc* - **Zinc absorption** occurs throughout the **small intestine**, with significant absorption in the **jejunum**. - While some zinc is absorbed in the ileum, its primary absorption site is not limited to or predominantly in the distal ileum, making malabsorption less likely with isolated distal ileum removal.