FMGE 2023 - Surgery PYQs Practice Questions

Q: Which of the following is associated with CSF otorrhea?

Battle sign. ***Battle sign***- **Battle sign** (ecchymosis over the mastoid process) is highly indicative of a **basilar skull fracture**, specifically involving the **temporal bone**.- Fractures of the petrous portion of the temporal bone often breach the **dura mater** and middle ear cavity, leading directly to leakage of cerebrospinal fluid (**CSF otorrhea**).*Traumatic rupture of the tympanic membrane*- While rupture of the **tympanic membrane (TM)** is often present, it is usually a consequence of the underlying **temporal bone fracture**, not the primary source of the CSF leak.- CSF otorrhea fundamentally requires a fracture allowing communication between the **subarachnoid space** and the middle ear; TM rupture solely allows fluid egress.*Penetrating injury to the eye*- These injuries involve the orbit and structures of the eye, typically causing orbital trauma, globe rupture, or associated **facial fractures**.- They are not the usual mechanism for basilar skull fractures involving the **middle cranial fossa** or temporal bone, which are necessary for CSF otorrhea.*Fracture of the roof of the nose*- Fractures of the skull base involving the anterior cranial fossa, such as the **cribriform plate** (roof of the nose), classically cause **CSF rhinorrhea** (CSF leakage through the nose).- This anatomical location is functionally separate from the temporal bone pathology required to produce **CSF otorrhea**. [Practice more Surgery PYQs on OnCourse]

Q: How long should a couple use contraception post-vasectomy?

12-16 weeks. ***12-16 weeks***- Contraception is mandatory post-vasectomy until a follow-up semen analysis confirms **azoospermia** (complete absence of sperm).- The 12-16 week period accounts for the time needed for all existing sperm distal to the occlusion site to be ejaculated and cleared from the system.*4-6 weeks*- This time frame is generally too short to ensure complete clearance of all viable **sperm** stored in the **vas deferens** and related structures.- Relying on this duration significantly increases the risk of early **contraceptive failure** before azoospermia is achieved.*9-11 weeks*- While many men achieve clearance by the 9-week mark, the standard clinical protocol usually mandates waiting until **12 weeks** for the first definitive **semen analysis**.- Stopping contraception prematurely based on an estimated time frame, rather than laboratory confirmation, increases the hazard of unwanted pregnancy.*16-20 weeks*- Although safe, this duration unnecessarily exceeds the typical time required for the successful confirmation of **azoospermia**.- If the semen analysis at 12 weeks confirms **azoospermia**, contraception can typically cease immediately, making further delay unwarranted. [Practice more Surgery PYQs on OnCourse]

Q: A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Partial nephrectomy. ***Partial nephrectomy*** - For localized renal tumors measuring **≤ 4 cm (T1a)**, such as the one described, partial nephrectomy is the gold standard treatment, aiming to preserve renal function. - This approach, also known as **nephron-sparing surgery**, offers equivalent cancer control to radical nephrectomy for small tumors but with a lower risk of long-term **chronic kidney disease (CKD)** and associated cardiovascular morbidity. *Partial nephrectomy + neoadjuvant chemotherapy* - **Renal cell carcinoma (RCC)**, the most common type of kidney cancer, is notoriously resistant to conventional chemotherapy, so neoadjuvant chemotherapy is not a standard treatment for localized disease. - Neoadjuvant approaches for RCC, when used, typically involve **targeted therapy** or **immunotherapy** in the context of clinical trials for larger or more advanced tumors, not for a small 4cm mass. *Radical nephrectomy* - **Radical nephrectomy**, the removal of the entire kidney, is considered overtreatment for a small 4cm mass and is generally reserved for larger tumors (**>7 cm**) or when a partial nephrectomy is not technically feasible. - Performing a radical nephrectomy when a partial is possible unnecessarily sacrifices nephrons, increasing the patient's risk of developing **CKD** in the future. *Radical nephrectomy + postoperative radiotherapy* - RCC is largely **radioresistant**, and adjuvant radiotherapy after surgery has not been shown to improve survival or prevent recurrence for non-metastatic disease. - Radiotherapy is typically reserved for palliative care in cases of metastatic RCC, for example, to control symptoms from **bone** or **brain metastases**. [Practice more Surgery PYQs on OnCourse]

Q: Which of the following will have unilateral hydronephrosis?

Retrocaval ureter. ***Retrocaval ureter*** - This is a rare congenital anomaly where the **right ureter** passes behind the inferior vena cava (IVC), causing extrinsic compression and obstruction. - Since only the right ureter is involved in this pathway abnormality, it inherently results in **unilateral hydronephrosis** of the right kidney. *Phimosis* - Phimosis is the inability to retract the foreskin; severe cases can cause distal urinary outflow obstruction. - If obstruction is severe enough to cause hydronephrosis, the resulting high intravesical pressure would be transmitted equally to both kidneys, usually causing **bilateral hydronephrosis**. *Posterior urethral valves* - **Posterior urethral valves (PUV)** are congenital folds in the posterior urethra, causing obstruction distal to the bladder neck. - This obstruction leads to high intravesical pressure, which impairs drainage from both kidneys, inevitably resulting in **bilateral hydronephrosis**. *Urethral strictures* - Urethral strictures are narrowings of the urethra, usually acquired, which obstruct urine flow distal to the bladder. - Significant obstruction at this level causes increased back pressure in the bladder and ureters, usually leading to pressure effects and subsequent **bilateral hydronephrosis**. [Practice more Surgery PYQs on OnCourse]

Q: A 60-year-old patient presents with painless hematuria. He is diagnosed with bladder cancer involving the muscle layer. What is the next best step in the treatment of this patient?

Radical cystectomy. ***Radical cystectomy***- Because this tumor involves the **muscle layer**, it is classified as **muscle-invasive bladder cancer (MIBC)** (T2 stage or higher), for which radical cystectomy is the gold standard treatment for patients who are surgical candidates.- This procedure involves complete removal of the bladder and adjacent pelvic lymph nodes, followed by urinary diversion, offering the best survival and curative rates for localized MIBC.*Intravesical administration of BCG*- This immunotherapy is used primarily for **high-risk non-muscle-invasive bladder cancer (NMIBC)**, particularly carcinoma in situ (CIS) or high-grade T1 tumors, to reduce recurrence.- It cannot achieve adequate penetration or tumor clearance in tumors that have already invaded the **detrusor muscle**.*Radiotherapy*- Radiotherapy is typically used as part of a **bladder-preserving trimodality therapy** (TMT) when the patient is unable or unwilling to undergo surgery.- For fit patients with MIBC, **radical cystectomy** generally provides superior long-term survival rates compared to radiotherapy alone.*Neoadjuvant chemotherapy with Mitomycin C*- **Mitomycin C** is an agent used *intravesically* for NMIBC, similar to BCG, to prevent recurrence after TURBT.- Standard **neoadjuvant chemotherapy** for MIBC (given before cystectomy) consists of **systemic platinum-based regimens** (like Gemcitabine/Cisplatin) and not local Mitomycin C. [Practice more Surgery PYQs on OnCourse]

Question 1

Which of the following is associated with CSF otorrhea?

Accepted Answer

Battle sign

Answer

Traumatic rupture of the tympanic membrane

Answer

Penetrating injury to the eye

Answer

Fracture of the roof of the nose

Question 2

How long should a couple use contraception post-vasectomy?

Accepted Answer

12-16 weeks

Answer

4-6 weeks

Answer

9-11 weeks

Answer

16-20 weeks

Question 3

A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Accepted Answer

Partial nephrectomy

Answer

Partial nephrectomy + neoadjuvant chemotherapy

Answer

Radical nephrectomy + postoperative radiotherapy

Answer

Radical nephrectomy

Question 4

Which of the following will have unilateral hydronephrosis?

Accepted Answer

Retrocaval ureter

Answer

Phimosis

Answer

Posterior urethral valves

Answer

Urethral strictures

Question 5

A 60-year-old patient presents with painless hematuria. He is diagnosed with bladder cancer involving the muscle layer. What is the next best step in the treatment of this patient?

Accepted Answer

Radical cystectomy

Answer

Radiotherapy

Answer

Neoadjuvant chemotherapy with Mitomycin C

Answer

Intravesical administration of BCG

Question 6

Which of the following is the class of shock where urine output is first decreased?

Accepted Answer

b. Moderate

Answer

a. Compensated

Answer

c. Mild

Answer

d. Severe

Question 7

A 60-year-old male presents with claudication and blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis? ![img-25.jpeg](img-25.jpeg)

Accepted Answer

Atherosclerosis

Answer

Buerger's disease

Answer

Raynaud's disease

Answer

Giant cell arteritis

Question 8

A 73 year old male smoker with a past history of coronary artery disease presents with blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis?

Accepted Answer

Atherosclerosis

Answer

Giant cell arteritis

Answer

Buerger's disease

Answer

Raynaud's disease

Question 9

A 50-year-old woman after thyroidectomy comes to you for a 2nd opinion for further treatment of papillary thyroid cancer. What would you recommend for this patient?

Accepted Answer

Radioactive iodine (RAI) ablation

Answer

Wait and watch.

Answer

Radiotherapy

Answer

Chemotherapy

Question 10

A 51-year-old lady presents with complaints of a mass in the right breast. On examination, the mass was larger than 5 cm and ipsilateral mobile axillary lymph nodes were present. What is the staging, considering the mass is malignant?

Accepted Answer

cT3N1M0

Answer

pT4N1M0

Answer

cT4N1M0

Answer

pT3N1M0

FMGE 2023 — Surgery