FMGE 2019 - Surgery Practice Questions

Q: A 40-year-old patient presents with a femur fracture, pulmonary infiltration, and respiratory distress. What is the most likely diagnosis?

Fat embolism. ***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.

Q: 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?

CSF rhinorrhoea. ***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.

Q: 32-year-old man presented with fever and pain in upper right hypochondrium after food intake. Investigation of choice?

Ultrasound. ***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.

Q: The complication which will not occur after PCNL surgery:

Urethral stricture. ***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.

Q: A lady with 50% TBSA burn with involvement of dermis and subcutaneous tissue came to the emergency department. The burns will be classified as:

3rd degree burn. ***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.

Q: What is the most common presentation of nasopharyngeal carcinoma?

Neck lymph node. ***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.

Q: Distal ileum was removed in a 20-year-old girl. Which absorption deficiency will be seen?

Bile salts. ***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.

Question 1

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?

Accepted Answer

Peritonsillar abscess

Answer

Ludwig's angina

Answer

Retropharyngeal abscess

Answer

Parapharyngeal abscess

Question 2

A 40-year-old patient presents with a femur fracture, pulmonary infiltration, and respiratory distress. What is the most likely diagnosis?

Accepted Answer

Fat embolism

Answer

Obstruction

Answer

Pulmonary embolism

Answer

Air embolism

Question 3

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?

Accepted Answer

Observation

Answer

Hemi-thyroidectomy

Answer

Total thyroidectomy

Answer

Thyroid ablation using radioactive Iodine

Question 4

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?

Accepted Answer

CSF rhinorrhoea

Answer

Acute respiratory infection

Answer

Rhinitis

Answer

Middle cranial fossa fracture

Question 5

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?

Accepted Answer

Needle insertion in 2nd intercostal space, midclavicular line

Answer

Chest X-ray

Answer

Intubate the patient

Answer

Urgent IV fluid administration

Question 6

32-year-old man presented with fever and pain in upper right hypochondrium after food intake. Investigation of choice?

Accepted Answer

Ultrasound

Answer

CT scan

Answer

ERCP (Endoscopic Retrograde Cholangiopancreatography)

Answer

MRCP (Magnetic Resonance Cholangiopancreatography)

Question 7

The complication which will not occur after PCNL surgery:

Accepted Answer

Urethral stricture

Answer

Organ injury

Answer

Bleeding

Answer

Sepsis

Question 8

A lady with 50% TBSA burn with involvement of dermis and subcutaneous tissue came to the emergency department. The burns will be classified as:

Accepted Answer

3rd degree burn

Answer

2nd degree superficial

Answer

2nd degree deep

Answer

1st degree

Question 9

What is the most common presentation of nasopharyngeal carcinoma?

Accepted Answer

Neck lymph node

Answer

Loss of smell

Answer

Blockage of nose

Answer

Blood tinged discharge

Question 10

Distal ileum was removed in a 20-year-old girl. Which absorption deficiency will be seen?

Accepted Answer

Bile salts

Answer

Iron

Answer

Copper

Answer

Zinc

FMGE 2019 — Surgery