FMGE 2023 Practice Questions

Q: A patient presents with erythematous streaks extending peripherally from a site of infection on the skin. Involvement of which of the following structures leads to this clinical presentation?

Superficial lymphatics. ***Superficial lymphatics*** (Assuming the image shows signs of **lymphangitis** or **cellulitis**, characterized by **red streaks** spreading from an infected site.)- The classic presentation of **acute lymphangitis** involves **erythematous streaks** extending peripherally from a site of infection (often a wound or cellulitis), which are typically visible superficial structures.- This pattern suggests inflammation and infection tracking along the **superficial lymphatic vessels** which drain the peripheral skin and subcutaneous tissues.*Deep lymphatics*- Involvement of the **deep lymphatics** (e.g., those alongside major blood vessels) typically leads to **lymphedema** (swelling) of the entire limb, rather than the visible **red streaking** seen in acute superficial lymphangitis.- They are located deeper and their inflammation is less likely to produce the superficial, linear rash visible on the skin.*Superficial veins*- Inflammation and thrombosis of superficial veins (**superficial thrombophlebitis**) typically presents as a localized, **palpable, tender cord** rather than multiple linear streaks that spread over distance, which are characteristic of lymphatic tracing.- This condition would primarily involve blood flow obstruction, not the characteristic infection tracking seen in lymphangitis.*Skin*- Although the signs are *visible* on the skin, the primary pathological process causing the streaks is the infection spreading *within* the **lymphatic vessels** beneath the skin surface, not solely a primary skin disease (like **erysipelas** or **cellulitis** alone).- Cellulitis is often the source, but the visible tracking (streaks) follows the path of the **superficial lymphatics**.

Q: A soldier presents to a referral hospital one day after sustaining a high-velocity shrapnel injury to his right thigh. He complains of severe pain at the wound site. On examination, crepitus is present. Which of the following organisms is the most likely cause of his condition?

Clostridium perfringens. ***Clostridium perfringens*** - *Clostridium perfringens* is the most common cause (80-90%) of **gas gangrene** (clostridial myonecrosis), especially following severe penetrating trauma such as that caused by a high-velocity shrapnel injury, which creates **anaerobic** conditions in deep tissue. - The organism produces potent toxins, primarily **alpha toxin** (a lecithinase), which causes rapid tissue necrosis, hemolysis, and the production of gas that manifests clinically as **crepitus**. *Incorrect: Clostridium septicum* - This organism is primarily associated with **spontaneous, non-traumatic gas gangrene**, often occurring in patients with underlying conditions like **colonic malignancy**, diabetes, or neutropenia. - While it can cause traumatic gas gangrene, it is significantly less frequent than *C. perfringens* in established wound infections. *Incorrect: Clostridium difficile* - *C. difficile* is the principal cause of **antibiotic-associated diarrhea** and **pseudomembranous colitis**. - It causes localized disease in the colon by producing **Toxin A (enterotoxin)** and **Toxin B (cytotoxin)** and does not typically cause myonecrosis or gas gangrene in penetrating wounds. *Incorrect: Clostridium novyi* - *C. novyi* is a recognized cause of gas gangrene but is less common than *C. perfringens* in traumatic settings and is sometimes associated with **intravenous illicit drug use**. - It is known for producing large amounts of **edema** compared to other clostridial species, causing a characteristic "malignant edema" syndrome rather than the primarily necrotizing and gas-producing infection seen with *C. perfringens*.

Q: Identify the given image of the placenta previa. ![img-50.jpeg](img-50.jpeg)

Marginal. ***Marginal*** - In **marginal placenta previa**, the edge of the placenta is at the margin of the **internal cervical os** but does not cover it, which is consistent with the depiction in the image. - This type can lead to **painless, bright red vaginal bleeding**, particularly in the third trimester as the cervix begins to efface and dilate, causing separation of the placental edge. *Low lying* - A **low-lying placenta** is implanted in the lower uterine segment, and its edge is within **2 cm** of the internal os but does not reach the os itself. - The image shows the placenta directly abutting the os, which distinguishes it from a low-lying placenta where there would be a gap. *Incomplete* - **Incomplete** or **partial placenta previa** occurs when the placenta partially covers the internal cervical os. - The provided image clearly shows the cervical os is not covered by any placental tissue, ruling out this diagnosis. *Complete* - In **complete placenta previa**, the placenta entirely covers the internal cervical os, obstructing the birth canal. - This is the most severe form and is not represented in the image, as the os is visibly unobstructed.

Q: Identify the given image of the placenta previa.

Marginal. ***Marginal*** - The image illustrates **marginal placenta previa**, where the edge of the placenta is at the margin of the **internal cervical os** but does not cover it. - This position can lead to significant bleeding as the cervix dilates and effaces during labor, potentially tearing the placental edge. *Low lying* - A **low-lying placenta** is when the placental edge is implanted in the lower uterine segment, within **2 cm** of the internal os, but not reaching it. - The image clearly shows the placenta is directly at the edge of the os, which is characteristic of marginal, not low-lying previa. *Incomplete* - **Incomplete** or **partial placenta previa** occurs when the placenta partially covers the internal cervical os. - In the given diagram, the cervical os is not covered at all; the placenta only abuts its margin. *Complete* - **Complete placenta previa** is diagnosed when the placenta entirely covers the **internal cervical os**, obstructing the birth canal. - This is the most severe type and is an absolute indication for a **cesarean section**, whereas the image shows an uncovered os.

Q: What is the mechanism of action of dicumarol?

Inhibits vitamin K dependant Clotting factors. Inhibits vitamin K dependant Clotting factors- Dicumarol, a classic anticoagulant, acts as a **vitamin K antagonist** (VKA), preventing the utilization of vitamin K [1].- It inhibits the enzyme **vitamin K epoxide reductase**, which is essential for the activation (**gamma-carboxylation**) of factors II (prothrombin), VII, IX, and X [4]. *Activates antithrombin III.*- This mechanism is characteristic of **unfractionated heparin** and **low molecular weight heparins** (LMWH).- Heparin binds to **antithrombin III** (ATIII), greatly accelerating its ability to neutralize activated clotting factors, particularly Thrombin (IIa) and Factor Xa [2]. *Inhibits tissue plasminogen activator*- Dicumarol affects the synthesis of clotting factors and has no direct influence on the **fibrinolytic system** (clot breakdown).- Inhibition of **tissue plasminogen activator** (tPA) or plasmin is the role of anti-fibrinolytic drugs like **tranexamic acid**. *Inhibitor of factor Xa*- This is the specific mechanism utilized by the direct oral anticoagulants (DOACs), such as **rivaroxaban** and **apixaban** (referred to as 'xabans') [3].- While dicumarol ultimately reduces active **Factor X** levels, it acts indirectly by preventing its synthesis/activation, not by directly binding to and inhibiting the already formed Factor Xa.

Q: A male patient presented with complaints of hematuria and recurrent urinary tract infection. You notice the following finding in his CECT. What is the likely condition indicated by the arrow in the image?

Horseshoe kidney. ***Horseshoe kidney*** - The CECT image shows the **fusion of the lower poles** of the kidneys across the midline, anterior to the great vessels, forming a characteristic U-shape. This connecting bridge of renal tissue is called an **isthmus**. - This congenital anomaly is associated with an increased risk of complications like **recurrent UTIs**, **nephrolithiasis** (kidney stones), and **hematuria** due to impaired urinary drainage and vesicoureteral reflux, which aligns with the patient's presentation. *Polycystic kidney disease* - This genetic disorder is characterized by the presence of **multiple, bilateral cysts** throughout the renal parenchyma, causing massive enlargement of the kidneys. - The provided image shows a fusion anomaly with relatively normal-appearing renal parenchyma, not the cystic changes typical of polycystic kidney disease. *Hydronephrosis* - Hydronephrosis refers to the **dilation of the renal pelvis and calyces** due to an obstruction of urine outflow. It is a finding, not a primary diagnosis of a structural anomaly. - While a horseshoe kidney can lead to hydronephrosis, the primary abnormality indicated by the arrows is the **renal fusion**, not a dilated collecting system. *Pancake kidney* - A pancake (or fused pelvic) kidney is a rare anomaly where the kidneys are completely fused into a **single, disc-shaped mass** located in the pelvis. - In contrast, a horseshoe kidney involves fusion typically at the lower poles, with two distinct renal masses still identifiable, as seen in the image.

Q: A 30-year-old female patient involved in a road traffic accident had nausea and vomiting. She was brought unconscious to the emergency room. The NCCT brain reveals the following findings. What is the most likely diagnosis? ![img-49.jpeg](img-49.jpeg)

a. Extradural hemorrhage. ***Extradural hemorrhage*** - The NCCT image displays a classic **biconvex** or **lens-shaped** hyperdense collection of blood, which is the hallmark radiological feature of an extradural (epidural) hemorrhage. - This type of hemorrhage is most commonly caused by trauma leading to a skull fracture that tears the **middle meningeal artery**, and the hematoma is confined by suture lines where the dura is tightly attached to the skull. *Subdural hemorrhage* - A subdural hemorrhage typically appears as a **crescent-shaped** collection of blood on a CT scan, as it spreads along the contour of the cerebral hemisphere. - It is usually caused by the tearing of **bridging veins** and, unlike an extradural hemorrhage, it can cross suture lines but is limited by dural reflections. *Intra-parenchymal hemorrhage* - This refers to bleeding **within the brain tissue** itself, which would appear as a hyperdense lesion located inside the brain parenchyma, often with surrounding edema. - While it can be caused by trauma (contusion), it is frequently associated with non-traumatic causes like **hypertension** or **amyloid angiopathy**. *Subarachnoid hemorrhage* - A subarachnoid hemorrhage is characterized by blood in the **subarachnoid space**, appearing as hyperdensity within the cerebral **sulci**, **fissures**, and **basal cisterns** on a CT scan. - It is commonly caused by the rupture of a **berry aneurysm** or trauma, but its appearance is distinctly different from the localized, lens-shaped collection seen in the image.

Q: A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?

Esmolol and urgent surgery. ***Esmolol and urgent surgery*** - The CT image shows an intimal flap in the ascending aorta, confirming a **Stanford Type A aortic dissection**. This is a surgical emergency requiring immediate intervention. - The initial management goals are to lower heart rate and blood pressure to reduce aortic wall shear stress. This is achieved with intravenous **beta-blockers** (like **esmolol**), followed by urgent surgical repair. *Urgent surgery* - While surgery is the definitive treatment, it should not be performed without first medically stabilizing the patient. - Failure to control **blood pressure** and **heart rate** pre-operatively increases the risk of dissection propagation or aortic rupture during induction of anesthesia or the surgical procedure itself. *Wait and watch* - A **Type A aortic dissection** is a life-threatening condition with a very high mortality rate (approximately 1-2% per hour for the first 48 hours) if left untreated. - Delaying treatment drastically increases the risk of fatal complications such as **cardiac tamponade**, **acute aortic regurgitation**, or **malperfusion syndromes**. *Blood transfusion* - Blood transfusion is not the primary treatment unless the patient is hemodynamically unstable due to massive hemorrhage from an aortic rupture. - The priority is to prevent rupture and further dissection through **hemodynamic control** and definitive **surgical repair**, not to replace blood volume unless significant loss has already occurred.

Q: A 32-year-old patient who is a chronic tobacco chewer presents with a whitish lesion on the gingivobuccal sulcus for 7 months. What is the next best step in the management of this condition?

Local excision and biopsy. ***Local excision and biopsy*** - The clinical presentation of a persistent white patch in a chronic tobacco user is highly suspicious for **oral leukoplakia**, which is a **premalignant** condition. A **biopsy** is mandatory to establish a definitive histological diagnosis and rule out dysplasia or **squamous cell carcinoma**. - An **excisional biopsy** for a localized lesion is both diagnostic and therapeutic, as it removes the potentially malignant tissue and allows for microscopic examination. *Avoid smoking; wait and watch* - While smoking cessation is a critical part of management, a "wait and watch" approach is inappropriate for a lesion that has persisted for 7 months due to the significant risk of underlying malignancy. - Delaying a definitive diagnosis could allow a potential early-stage cancer to progress, leading to a worse prognosis. *Steroidal injection* - Steroids are used to treat **inflammatory** or **autoimmune** oral lesions like oral lichen planus or pemphigus vulgaris, not potentially neoplastic conditions like leukoplakia. - Using steroids could mask the progression of the lesion and delay the diagnosis of a malignancy. *Sclerotherapy* - Sclerotherapy is a treatment used for **vascular lesions**, such as **hemangiomas** or venous malformations, where a sclerosing agent is injected to cause thrombosis and fibrosis. - This modality is completely inappropriate for an **epithelial** lesion like leukoplakia.

Q: A 32-year-old female undergoes emergency laparotomy for perforation peritonitis. Which of the following is the surest sign of wound dehiscence?

Copious sero-sanguinous discharge. ***Copious sero-sanguinous discharge*** - An abrupt increase in **sero-sanguinous fluid** (often described as salmon-colored or pink-brown) soaking the dressing is the **surest clinical sign** of underlying fascial dehiscence. - This discharge represents peritoneal fluid leaking through the broken-down **fascial closure**, usually preceding full **evisceration**. - Typically occurs 5-10 days post-operatively and is the most specific early warning sign. *Rebound tenderness* - **Rebound tenderness** is a sign of **peritonitis** or intra-abdominal inflammation, which is related to the primary pathology (perforation) but not a direct sign of **fascial integrity loss**. - If present post-operatively, it usually indicates persistent or recurrent **intra-abdominal sepsis**, abscess, or ongoing peritonitis. *Hemorrhage* - **Hemorrhage** (frank bleeding) indicates vascular injury or a defect in **hemostasis**, not mechanical failure of the fascial layer itself. - Significant wound bleeding is common in the immediate post-operative period but is not the specific pathognomonic finding for **wound dehiscence**. *Hypotension* - **Hypotension** is a non-specific sign of severe systemic compromise, such as **sepsis**, **hypovolemic shock**, or ongoing internal bleeding. - Although a major dehiscence could lead to sepsis and subsequent hypotension, it is not the initial or most **specific indicator** of the structural breakdown of the wound.

Question 1

A patient presents with erythematous streaks extending peripherally from a site of infection on the skin. Involvement of which of the following structures leads to this clinical presentation?

Accepted Answer

Superficial lymphatics

Answer

Skin

Answer

Superficial veins

Answer

Deep lymphatics

Question 2

A soldier presents to a referral hospital one day after sustaining a high-velocity shrapnel injury to his right thigh. He complains of severe pain at the wound site. On examination, crepitus is present. Which of the following organisms is the most likely cause of his condition?

Accepted Answer

Clostridium perfringens

Answer

Clostridium novyi

Answer

Clostridium difficile

Answer

Clostridium septicum

Question 3

Identify the given image of the placenta previa. ![img-50.jpeg](img-50.jpeg)

Accepted Answer

Marginal

Answer

Incomplete

Answer

Low lying

Answer

Complete

Question 4

Identify the given image of the placenta previa.

Accepted Answer

Marginal

Answer

Complete

Answer

Low lying

Answer

Incomplete

Question 5

What is the mechanism of action of dicumarol?

Accepted Answer

Inhibits vitamin K dependant Clotting factors

Answer

Inhibitor of factor Xa

Answer

Activates antithrombin III.

Answer

Inhibits tissue plasminogen activator

Question 6

A male patient presented with complaints of hematuria and recurrent urinary tract infection. You notice the following finding in his CECT. What is the likely condition indicated by the arrow in the image?

Accepted Answer

Horseshoe kidney

Answer

Polycystic kidney disease

Answer

Pancake kidney

Answer

Hydronephrosis

Question 7

A 30-year-old female patient involved in a road traffic accident had nausea and vomiting. She was brought unconscious to the emergency room. The NCCT brain reveals the following findings. What is the most likely diagnosis? ![img-49.jpeg](img-49.jpeg)

Accepted Answer

a. Extradural hemorrhage

Answer

b. Subdural hemorrhage

Answer

c. Intra-parenchymal hemorrhage

Answer

d. Subarachnoid hemorrhage

Question 8

A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?

Accepted Answer

Esmolol and urgent surgery

Answer

Urgent surgery

Answer

Blood transfusion

Answer

Wait and watch

Question 9

A 32-year-old patient who is a chronic tobacco chewer presents with a whitish lesion on the gingivobuccal sulcus for 7 months. What is the next best step in the management of this condition?

Accepted Answer

Local excision and biopsy

Answer

Steroidal injection

Answer

Sclerotherapy

Answer

Avoid smoking; wait and watch

Question 10

A 32-year-old female undergoes emergency laparotomy for perforation peritonitis. Which of the following is the surest sign of wound dehiscence?

Accepted Answer

Copious sero-sanguinous discharge

Answer

Rebound tenderness

Answer

Hypotension

Answer

Hemorrhage

FMGE 2023

Dermatology

Microbiology

Obstetrics and Gynecology

Pharmacology

Radiology

Surgery