Surgery questions from past FMGE papers

1. Q1. A man in his forties develops bilateral gynaecomastia and is found to have a small solid intratesticular nodule with a raised serum oestradiol. Which tumour is most likely?

   • A. Classical seminoma
   • B. Mature teratoma
   • C. Embryonal carcinoma
   • D. Leydig cell tumour

   Answer: D. Leydig cell tumour

1. Q1. Ten years after mastectomy with axillary clearance, a woman with long-standing arm lymphoedema develops painless bluish-purple nodules on that arm. What has developed?

   • A. Angiosarcoma arising in chronic lymphoedema
   • B. Cutaneous metastases from the original breast cancer
   • C. Post-radiation fibrosis
   • D. Cellulitis complicating lymphoedema

   Answer: A. Angiosarcoma arising in chronic lymphoedema

1. Q1. A 4 cm enhancing renal mass confined to the kidney is found in a woman with a normal contralateral kidney. What is the preferred operation, and why?

   • A. Radical nephrectomy, because the risk of tumour spillage is unacceptable
   • B. Radical nephrectomy with adjuvant radiotherapy
   • C. Percutaneous biopsy followed by surveillance alone
   • D. Partial nephrectomy, because it preserves nephrons with equivalent oncological outcome at this size

   Answer: D. Partial nephrectomy, because it preserves nephrons with equivalent oncological outcome at this size

2. Q2. A young man has right-sided hydronephrosis. Urography shows the upper ureter deviating medially behind the inferior vena cava in a fish-hook shape. What is the cause?

   • A. Retrocaval ureter, from abnormal persistence of the posterior cardinal vein
   • B. Posterior urethral valves
   • C. Urethral stricture after instrumentation
   • D. Phimosis with chronic retention

   Answer: A. Retrocaval ureter, from abnormal persistence of the posterior cardinal vein

1. Q1. Hair must be removed from an operative site. Which method and timing minimise surgical site infection, and why?

   • A. Shaving with a razor the night before, to allow the skin to settle
   • B. Depilatory cream applied the previous evening
   • C. Clipping immediately before surgery, because razors create microabrasions that become colonised
   • D. Shaving on the operating table, because it gives the closest result

   Answer: C. Clipping immediately before surgery, because razors create microabrasions that become colonised

2. Q2. An open appendicectomy is planned. Which incision is centred on McBurney's point, running obliquely along the line of the external oblique fibres?

   • A. Lanz incision
   • B. Gridiron (McBurney) incision
   • C. Rutherford Morison incision
   • D. Lower midline incision

   Answer: B. Gridiron (McBurney) incision

1. Q1. An elderly man immobilised after a hip fracture develops unilateral calf swelling, warmth and tenderness. What is the most likely diagnosis, and which element of Virchow's triad predominates?

   • A. Deep vein thrombosis, with venous stasis predominating
   • B. Compartment syndrome, with raised fascial pressure
   • C. Cellulitis, with bacterial entry through skin
   • D. Arterial occlusion, with embolic obstruction

   Answer: A. Deep vein thrombosis, with venous stasis predominating

2. Q2. A 23-year-old woman has a firm, smooth, freely mobile 2 cm breast lump. Imaging and core biopsy confirm a fibroadenoma. What is the appropriate management?

   • A. Immediate wide local excision
   • B. Reassurance with follow-up, since excision is only needed for growth, symptoms or patient preference
   • C. Start tamoxifen
   • D. Mastectomy with sentinel node biopsy

   Answer: B. Reassurance with follow-up, since excision is only needed for growth, symptoms or patient preference

1. Q1. An elderly man has low back pain, weight loss and obstructive urinary symptoms. Radiographs show sclerotic vertebral lesions. Which malignancy is most likely, and why are the metastases sclerotic rather than lytic?

   • A. Renal cell carcinoma, which is typically lytic
   • B. Bladder carcinoma, spreading directly
   • C. Multiple myeloma, which is purely lytic
   • D. Prostatic carcinoma, whose metastases stimulate osteoblastic bone formation

   Answer: D. Prostatic carcinoma, whose metastases stimulate osteoblastic bone formation

2. Q2. A man with long-standing varicose veins has a healed ulcer above the medial malleolus, with surrounding pigmentation and induration. Which type of ulcer, and what is the underlying mechanism?

   • A. Arterial ulcer, from large-vessel occlusion
   • B. Venous ulcer, from sustained ambulatory venous hypertension
   • C. Neuropathic ulcer, from loss of protective sensation
   • D. Tuberculous ulcer, from direct inoculation

   Answer: B. Venous ulcer, from sustained ambulatory venous hypertension

1. Q1. A man with metastatic prostate cancer is started on goserelin. What is its mechanism, and what must be co-prescribed initially?

   • A. An LHRH agonist causing an initial testosterone surge, so an anti-androgen is added to prevent tumour flare
   • B. A direct androgen receptor blocker needing no cover
   • C. A 5-alpha reductase inhibitor reducing prostate volume
   • D. A cytotoxic agent requiring antiemetics

   Answer: A. An LHRH agonist causing an initial testosterone surge, so an anti-androgen is added to prevent tumour flare

2. Q2. Which serum tumour marker is used to monitor pancreatic adenocarcinoma, and what limits its diagnostic use?

   • A. Alpha-fetoprotein, raised in pregnancy
   • B. CA 15-3, raised in benign breast disease
   • C. Carcinoembryonic antigen, raised in smokers
   • D. CA 19-9, which is also raised in obstructive jaundice and is absent in Lewis-negative individuals

   Answer: D. CA 19-9, which is also raised in obstructive jaundice and is absent in Lewis-negative individuals

1. Q1. A man has right upper quadrant pain after fatty meals with fever. Which imaging test should be done first, and why?

   • A. CT with contrast, for the best anatomical detail
   • B. MRCP, to map the biliary tree
   • C. Ultrasound, because it detects gallstones and wall thickening cheaply without radiation
   • D. HIDA scan, as the initial screening test

   Answer: C. Ultrasound, because it detects gallstones and wall thickening cheaply without radiation

2. Q2. Two days after femoral shaft fixation a young man becomes confused and hypoxic with a petechial rash over the axilla and conjunctiva. What is the diagnosis?

   • A. Pulmonary thromboembolism
   • B. Fat embolism syndrome
   • C. Air embolism
   • D. Transfusion-related acute lung injury

   Answer: B. Fat embolism syndrome

1. Q1. A man after a road accident is agitated, with a respiratory rate of 40, blood pressure 90/40, absent breath sounds and a hyperresonant left chest with tracheal deviation to the right. What is the immediate action?

   • A. Urgent intravenous fluids
   • B. Obtain a chest radiograph first
   • C. Intubate the patient
   • D. Immediate needle decompression, followed by a chest drain

   Answer: D. Immediate needle decompression, followed by a chest drain

2. Q2. How should a conscious patient be positioned for nasogastric tube insertion, and why?

   • A. Supine with the neck extended, to straighten the airway
   • B. Supine with the neck flexed, to close the glottis
   • C. Sitting upright with the neck slightly flexed, which closes the airway and directs the tube towards the oesophagus
   • D. Lateral with the neck extended

   Answer: C. Sitting upright with the neck slightly flexed, which closes the airway and directs the tube towards the oesophagus

1. Q1. What is the commonest immediate complication after splenectomy?

   • A. Reactionary haemorrhage, often from a slipped hilar ligature or short gastric vessel
   • B. Pancreatic fistula
   • C. Overwhelming post-splenectomy infection
   • D. Portal vein thrombosis

   Answer: A. Reactionary haemorrhage, often from a slipped hilar ligature or short gastric vessel

2. Q2. An elderly farmer has a slowly growing indurated ulcer with everted edges on the lower lip and a firm submental node. What is the diagnosis, and why is the lower lip typically affected?

   • A. Basal cell carcinoma, which spares mucosa
   • B. A plunging ranula, arising from the sublingual gland
   • C. An epulis, arising from the gingiva
   • D. Squamous cell carcinoma, because the lower lip receives the greatest cumulative sun exposure

   Answer: D. Squamous cell carcinoma, because the lower lip receives the greatest cumulative sun exposure

Every FMGE session paper, all 19 subjects together, is on our previous year questions page.