A 45-year-old male patient was brought to the emergency department following a road traffic accident. O/E, he had multiple injuries all over his body and was found to be in class III hemorrhagic shock. The percentage of blood loss would be between:
A 20-year-old male presents to the outpatient department with a swelling on his wrist. He reports fluctuation in size, mild numbness in the hand, and occasional pain. What is the most likely diagnosis?
A patient with dilated tortuous veins of the leg presented to the OPD and is diagnosed with varicose vein of grade C4a. What is the best preferred treatment?
In a follow-up case of prostate cancer, what do we need to check?
On examination, a person has distended neck veins, absent breath sounds, hyperresonance, and a shift of the trachea. What is the management?
A patient presents with severe respiratory distress, hyperresonance and absent breath sounds on one side of the chest, distended neck veins, and tracheal shift away from the affected side. What is the best immediate management for this life-threatening condition?
A 2-month-old male infant presents with a scrotal swelling that has been present since birth. Now, the swelling has become suddenly painful, red, and irreducible. What is the most likely diagnosis?
A patient underwent split-thickness skin grafting for a burn injury on the arm. On post-operative day 6, he develops stiffness of the arm during physiotherapy. What is the most appropriate next step in management?
Identify the type of suture?
A 46-year-old male had a tumor in his left lobe of liver, so left sided hemi hepatectomy was planned. Which of the following segments of the liver will be resected in this procedure?
FMGE 2025 - Surgery FMGE Practice Questions and MCQs
Question 21: A 45-year-old male patient was brought to the emergency department following a road traffic accident. O/E, he had multiple injuries all over his body and was found to be in class III hemorrhagic shock. The percentage of blood loss would be between:
- A. >40%
- B. 30-40% (Correct Answer)
- C. 5-15%
- D. 15-30%
Explanation: ***30-40%***- **Class III hemorrhagic shock** is defined by an estimated blood loss of **30-40%** (approximately 1500 to 2000 mL in an adult).- Clinically, patients in Class III shock present with **marked tachycardia** (>120 bpm), significant **hypotension**, and altered **mental status** (confusion).*5-15%*- This range corresponds to **Class I hemorrhagic shock**, which involves minimal blood loss (up to 750 mL).- Patients in **Class I** typically present with near-normal vital signs or mild **tachycardia** only, not the severe clinical picture described.*>40%*- This defines **Class IV hemorrhagic shock**, representing extremely severe and **life-threatening** blood loss (over 2000 mL).- Patients in **Class IV** present with profound **hypotension** and absent peripheral pulses; they are often unresponsive.*15-30%*- This range characterizes **Class II hemorrhagic shock**, which involves moderate blood loss (750 to 1500 mL).- Patients exhibit **tachycardia** (100–120 bpm) and decreased **pulse pressure**, but usually maintain adequate blood pressure and good mental status, unlike the patient described.
Question 22: A 20-year-old male presents to the outpatient department with a swelling on his wrist. He reports fluctuation in size, mild numbness in the hand, and occasional pain. What is the most likely diagnosis?
- A. Dermoid cyst
- B. Lipoma
- C. Ganglion cyst (Correct Answer)
- D. Hematoma
Explanation: ***Ganglion cyst*** - This is the most common benign soft-tissue tumor of the hand and wrist, often arising from a **joint capsule** or **tendon sheath**. The classic presentation includes a smooth, round swelling on the wrist that can fluctuate in size. - Symptoms like mild pain and numbness can occur due to **nerve compression**, which is consistent with the patient's presentation. On examination, they are typically firm and **transilluminate**. *Lipoma* - A lipoma is a benign tumor composed of **adipose tissue** (fat). It typically presents as a soft, mobile, and “doughy” subcutaneous mass, which differs from the usually firm consistency of a ganglion cyst. - Lipomas do not fluctuate in size and are less likely to be found on the dorsal aspect of the wrist compared to ganglion cysts. *Dermoid cyst* - A dermoid cyst is a **congenital** lesion (a type of teratoma) containing dermal structures like hair follicles and sebaceous glands. They are most commonly found in the midline, face, or neck. - Their presence on the wrist is extremely rare, and they do not typically fluctuate in size like a ganglion cyst. *Hematoma* - A hematoma is a localized collection of blood, usually resulting from **trauma**. The patient's history does not mention any injury. - An acute hematoma would be tender and associated with **ecchymosis** (bruising), and it would be expected to resolve over time rather than fluctuate.
Question 23: A patient with dilated tortuous veins of the leg presented to the OPD and is diagnosed with varicose vein of grade C4a. What is the best preferred treatment?
- A. Non endothermal non tumescent ablation
- B. Open surgery
- C. Compression
- D. Endothermal ablation (Correct Answer)
Explanation: ***Endothermal ablation***- Guidelines recommend **endothermal ablation** (e.g., **EVLA** or **RFA**) as the first-line definitive treatment for symptomatic varicose veins (C2-C6), especially those causing **C4a skin changes** due to underlying reflux.- This technique is minimally invasive, highly effective at eliminating **saphenous vein reflux**, and leads to faster recovery and reduced recurrence rates compared to surgery.*Compression*- Compression therapy is mandated for all CEAP classifications (C0 to C6) but only serves as **conservative management** to alleviate symptoms and manage edema and skin changes (C4a).- It does not address the underlying **venous valve incompetence** leading to the venous hypertension and is therefore not the definitive preferred treatment.*Non endothermal non tumescent ablation*- These techniques, such as **mechanochemical ablation** (MOCA) or **cyanoacrylate glue**, are effective and avoid the need for general anesthesia or tumescent local anesthesia, making them suitable alternatives.- However, endothermal modalities are often preferred as first-line due to extensive long-term data supporting their effectiveness and durability in treating major **truncal reflux**.*Open surgery*- **High ligation and stripping** used to be the gold standard but is now generally reserved for complex cases where ablation is not technically feasible, such as large tributary veins or extreme **tortuosity**.- Open surgery involves greater morbidity, longer hospital stays, and potentially higher risks of **injury to nerves** (e.g., saphenous nerve) compared to endothermal methods.
Question 24: In a follow-up case of prostate cancer, what do we need to check?
- A. Acid phosphatase
- B. PSA (Correct Answer)
- C. Alkaline phosphatase
- D. Testosterone
Explanation: ***PSA***- **Prostate-Specific Antigen** is the primary biomarker used for routine surveillance and follow-up after definitive treatment (like prostatectomy or radiation) for prostate cancer. - A sustained rise in PSA levels, known as **biochemical recurrence**, is the earliest sign that prostate cancer may have returned locally or metastasized. *Alkaline phosphatase* - **Alkaline phosphatase (ALP)** levels are primarily followed when there is suspicion of **bony metastasis**, as high ALP reflects increased osteoblastic activity. - It is used to stage and evaluate advanced disease or monitor response to treatment for bone mets, but it is not the primary marker for general recurrence detection. *Testosterone* - **Testosterone** levels are monitored primarily in patients receiving **androgen deprivation therapy (ADT)** to ensure that castrate levels of androgens are being maintained. - Changes in circulating testosterone do not reliably indicate cancer recurrence or progression in patients not undergoing hormonal manipulation. *Acid phosphatase* - **Acid phosphatase (ACP)**, specifically prostatic acid phosphatase (PAP), is a historical tumor marker that has been superseded by PSA in nearly all aspects of follow-up. - Elevated ACP is usually associated with **advanced or metastatic disease** but lacks the sensitivity of PSA for detecting early biochemical recurrence.
Question 25: On examination, a person has distended neck veins, absent breath sounds, hyperresonance, and a shift of the trachea. What is the management?
- A. Wide bore needle in 2nd ICS (Correct Answer)
- B. Pericardiocentesis
- C. Bedside CXR in casualty followed by chest tube insertion
- D. Pleurodesis with doxycycline
Explanation: ***Wide bore needle in 2nd ICS***- The constellation of absent breath sounds, **hyperresonance**, distended neck veins, and tracheal deviation indicates **tension pneumothorax**, which requires immediate definitive management before imaging can be done via a **needle decompression**.- This emergent procedure involves inserting a large-bore needle (e.g., 14-gauge) into the **second intercostal space (ICS)** in the midclavicular line to immediately relieve the pleural pressure and convert it to a simple pneumothorax.*Bedside CXR in casualty followed by chest tube insertion*- Obtaining a **CXR** is contraindicated as it significantly delays the urgent, life-saving decompression required for a clinically diagnosed **tension pneumothorax**.- While **chest tube insertion** is the definitive management, initial stabilization via needle decompression must precede this step in unstable patients with tension pneumothorax.*Pericardiocentesis*- This procedure is indicated for **cardiac tamponade**, which presents with features such as Beck's triad (hypotension, muffled heart sounds, elevated JVP), not the hyperresonance and absent breath sounds seen here.- Cardiac tamponade is a fluid accumulation issue impacting cardiac function, distinct from the life-threatening air accumulation and massive pressure shift seen in **tension pneumothorax**.*Pleurodesis with doxycycline*- **Pleurodesis** is an elective, definitive procedure used to prevent the recurrence of pleural effusions or pneumothorax by fusing the pleural layers, not an immediate emergency intervention.- This is typically reserved for stable patients with recurrent pneumothorax or chronic conditions like refractory **malignant pleural effusion**.
Question 26: A patient presents with severe respiratory distress, hyperresonance and absent breath sounds on one side of the chest, distended neck veins, and tracheal shift away from the affected side. What is the best immediate management for this life-threatening condition?
- A. Wide bore needle in 2nd ICS (Correct Answer)
- B. Bedside CXR in casualty followed by chest tube insertion
- C. Pleurodesis with doxycycline
- D. Pericardiocentesis
Explanation: ***Wide bore needle in 2nd ICS*** - This is the immediate, life-saving intervention for a **tension pneumothorax**, a clinical diagnosis based on the triad of respiratory distress, hemodynamic instability, and unilateral chest signs. - Needle decompression rapidly converts the **tension pneumothorax** into a simple pneumothorax by relieving intrapleural pressure, and is a temporizing measure followed by definitive chest tube insertion. *Bedside CXR in casualty followed by chest tube insertion* - Delaying treatment for a chest X-ray in a clinically evident and unstable **tension pneumothorax** is dangerous and can lead to cardiovascular collapse and death. - The diagnosis is **clinical**, and immediate decompression should precede any imaging. *Pericardiocentesis* - This procedure is indicated for **cardiac tamponade**, which presents with muffled heart sounds, not the unilateral hyperresonance and absent breath sounds seen in pneumothorax. - While both conditions can cause obstructive shock with distended neck veins, the pulmonary findings are key to differentiating them. *Pleurodesis with doxycycline* - Pleurodesis is a procedure to prevent the **recurrence** of a pneumothorax or pleural effusion, not a treatment for an acute, life-threatening event. - It is performed electively after the lung has been fully re-expanded with a chest tube.
Question 27: A 2-month-old male infant presents with a scrotal swelling that has been present since birth. Now, the swelling has become suddenly painful, red, and irreducible. What is the most likely diagnosis?
- A. Incarcerated inguinal hernia
- B. Strangulated inguinal hernia (Correct Answer)
- C. Acute epididymo-orchitis
- D. Testicular torsion
Explanation: **Strangulated inguinal hernia** - The presence of a scrotal swelling since birth strongly suggests an underlying indirect inguinal hernia, common due to a **patent processus vaginalis** in infants. - Sudden onset of severe pain, marked **irreducibility**, and **erythema** (redness) indicates vascular compromise of the contents (often bowel), classifying it as a surgical emergency (strangulation). *Acute epididymo-orchitis* - This condition is exceedingly rare in 2-month-old infants unless associated with underlying **urinary tract anomalies** or sepsis, and typically presents acutely without a long-standing mass. - The pain and swelling would usually involve the testicle/epididymis itself, accompanied by fever, and is less likely to present with the history of a mass existing **since birth**. *Testicular torsion* - Torsion usually presents with an extremely rapid onset of severe testicular pain without a history of a chronic mass, and often occurs due to inadequate fixation (**bell-clapper deformity**). - While painful, torsion involves the testicle and is generally diagnosed by absence of flow on **Doppler ultrasound**, unlike a hernia mass. *Incarcerated inguinal hernia* - An incarcerated hernia is irreducible because the contents are trapped, but the key differentiating factor is the lack of **vascular compromise**. - The presence of severe pain, tenderness, and redness (erythema) indicates progression beyond simple incarceration to **strangulation**, necessitating immediate intervention.
Question 28: A patient underwent split-thickness skin grafting for a burn injury on the arm. On post-operative day 6, he develops stiffness of the arm during physiotherapy. What is the most appropriate next step in management?
- A. Continue physiotherapy without intervention
- B. Surgical excision of contracture
- C. Remove the graft and regraft the area
- D. Passive extension of the joint under direct visualization of the graft (Correct Answer)
Explanation: ***Passive extension of the joint under direct visualization of the graft***- Stiffness noted around post-op day 6 points to the formation of an **early, immature fibrous band** crossing the joint, often seen after split-thickness skin grafting.- Gentle but firm **passive extension** at this time is the standard management to **break the fibrous band** before it matures into a fixed contracture, while direct visualization prevents graft avulsion.*Surgical excision of contracture*- This intervention is reserved for **mature, established contractures** that have failed conservative management, typically occurring months post-injury.- Performing surgical release on post-op day 6 is premature and risks **damaging the viable graft** and exposing underlying structures.*Continue physiotherapy without intervention*- If **early stiffness** is present, continuing standard physiotherapy alone will not overcome the developing fibrous tether and will likely result in a **fixed joint contracture**.- **Forced extension** is needed at this stage to actively address the limitation in **range of motion (ROM)**.*Remove the graft and regraft the area*- This approach is indicated only for complications like **graft necrosis** or **complete graft failure**, not for the formation of stiffness or contractures.- The graft is viable and the issue relates to peri-articular scar formation, making **graft removal unnecessary** and harmful.
Question 29: Identify the type of suture?
- A. Horizontal mattress
- B. Vertical Mattress
- C. Subcuticular suture
- D. Simple Interrupted suture (Correct Answer)
Explanation: ***Simple Interrupted suture*** - The image displays multiple, separate sutures, each individually placed and tied, which is characteristic of the **simple interrupted** technique. - This is the most common suturing method, providing good **wound apposition** and allowing for selective removal of single sutures if a localized infection develops. *Vertical Mattress* - A **vertical mattress suture** involves a 'far-far, near-near' stitching pattern in a plane perpendicular to the wound, which is not depicted in the image. - This technique is specifically used for everting wound edges and closing wounds under tension, creating a different surface appearance. *Horizontal mattress* - A **horizontal mattress suture** runs parallel to the wound edge on the skin surface, creating a box-like stitch to distribute tension. - It is primarily used for wounds under high tension or for providing **hemostasis**, and its appearance is distinctly different from the simple loops shown. *Subcuticular suture* - A **subcuticular suture** is placed entirely within the dermis, leaving no visible suture material on the skin surface except for the entry and exit points. - This method is used for optimal cosmetic results, whereas the image clearly shows external knots for each individual stitch.
Question 30: A 46-year-old male had a tumor in his left lobe of liver, so left sided hemi hepatectomy was planned. Which of the following segments of the liver will be resected in this procedure?
- A. 1, 2 & 3
- B. 5, 6, 7 & 8
- C. 2, 3 & 4 (Correct Answer)
- D. 2, 3, 4 & 5
Explanation: ***2, 3 and 4***- **Left hemi hepatectomy** involves the surgical removal of the entire **left functional lobe** of the liver, which contributes to approximately 40% of the total liver volume.- In the **Couinaud segmental classification**, the left functional lobe includes segments **II** (left lateral superior), **III** (left lateral inferior), and **IV** (left medial segment/quadrate lobe). *1, 2 & 3*- Segment **I** is the **caudate lobe**, which is typically considered functionally distinct and often preserved during a standard left hemi hepatectomy, unless the tumor involves this segment. - Resecting only segments II and III is known as a **left lateral sectionectomy** or left bisegmentectomy (corresponding to the anatomical left lobe). *5, 6, 7 & 8*- These segments constitute the **right functional lobe** of the liver (segments **V** and **VIII** are anterior; **VI** and **VII** are posterior). - Resection of these four segments would be classified as a **right hemi hepatectomy** (right lobectomy). *2, 3, 4 & 5*- This combination includes the entire left functional lobe (2, 3, 4) plus segment **V**, which is the **anterior inferior segment** of the right lobe. - Removing the left lobe plus segment V constitutes an **extended left hemi hepatectomy** (or left trisectionectomy), exceeding the definition of a standard left hemi hepatectomy.