FMGE 2025 Practice Questions

Q: Identify the level of lymph nodes indicated in the marked region of the neck in the given anatomical image.

Level II. **Level II** - The arrow points to the **upper deep cervical lymph nodes**, also known as the **upper jugular nodes**, which correspond to **Level II** in the neck lymph node classification. - This level is located in the upper third of the neck, extending from the base of the skull down to the **hyoid bone**, and is a common site for metastasis from cancers of the oral cavity, pharynx, and larynx. *Level Ia* - **Level Ia** represents the **submental nodes**, located in the midline triangle between the anterior bellies of the digastric muscles and inferior to the chin. - The indicated region is lateral and superior to the location of **Level Ia**. *Level Ib* - **Level Ib** corresponds to the **submandibular nodes**, situated within the submandibular triangle, bounded by the mandible and the digastric muscles. - The arrow points to a region posterior and superior to the **submandibular triangle**. *Level IV* - **Level IV** represents the **lower deep cervical lymph nodes** or **lower jugular nodes**, located along the lower third of the internal jugular vein, extending from the cricoid cartilage down to the clavicle. - The marked area is in the upper part of the neck, significantly superior to **Level IV**.

Q: Spread of prostate cancer to lumbar vertebra is via?

Venous spread. ***Venous spread***- The most common route for prostate cancer metastasis to the vertebrae is via the **Batson's vertebral venous plexus**, a valveless network.- This plexus allows cancer cells to flow retrograde directly from the deep pelvic veins draining the prostate to the vertebral column, especially the **lumbar vertebrae**.*Arterial spread*- Arterial spread is a route for systemic metastasis but is less significant than the venous route involving **Batson's plexus** for the specific predilection of vertebral spread.- Given the direct connection of the prostate venous drainage to the vertebral system, venous dissemination is the main hematogenous pathway to the axial skeleton.*Local spread*- Local spread refers to the contiguous extension of the tumor to adjacent structures like the seminal vesicles or bladder neck, and it does not explain **distant metastasis** to the bone.- This type of spread dictates local staging but is not the mechanism for tumor cell deposition in the marrow of the spine.*Lymphatic spread*- Lymphatic spread is typically the initial route for spread to **regional lymph nodes** (e.g., pelvic and obturator nodes).- **Bone metastasis**, particularly to the spine, classically bypasses major lymph node groups and utilizes the direct venous connection provided by the Batson's system.

Q: Identify the structure marked in the image.

Right Hepatic artery. ***Right Hepatic artery*** - The marked structure is the **Right Hepatic artery**, a branch of the **proper hepatic artery**, which supplies arterial blood to the right lobe of the liver. - As depicted, the **cystic artery**, which supplies the gallbladder, commonly originates from the right hepatic artery within the triangle of Calot. *Cystic artery* - The **cystic artery** is a smaller branch that is shown originating from the marked vessel and running towards the gallbladder (green structure); the pointer is on the parent artery. - This artery is a critical structure to identify and ligate during a **cholecystectomy** (gallbladder removal) to prevent bleeding. *Hepatic duct* - The **hepatic ducts** are part of the biliary system (colored yellow/orange) and function to drain bile from the liver, not supply blood to it. - These ducts converge to form the **common hepatic duct**, which is distinct from the arterial system (colored red). *Cystic duct* - The **cystic duct** is the channel that connects the gallbladder to the common hepatic duct, allowing bile to flow in and out of the gallbladder. - It is a component of the biliary tract, not a blood vessel like the marked artery.

Q: What is the most appropriate treatment for severe acne?

Isotretinoin. ***Isotretinoin***- This is the most effective and definitive treatment for **severe nodular or cystic acne** that has failed to respond to conventional treatments like topical agents and oral antibiotics. - It is a systemic retinoid that targets all four major pathogenic factors of acne: reducing **sebum production**, normalizing follicular keratinization, inhibiting *Cutibacterium acnes*, and providing anti-inflammatory effects.*Topical Tretinoin*- Topical retinoids are the first-line agents, primarily effective for **mild to moderate comedonal acne**. - They lack the necessary systemic penetration and potency to resolve deep-seated inflammation and nodules characteristic of **severe acne**.*Steroids*- Systemic steroids are generally reserved for highly specific, severe, and acute inflammatory complications of acne, such as **acne fulminans**, or used short-term to manage Isotretinoin-induced flares. - They are not the standard long-term treatment for severe acne due to significant systemic side effects and the fact that they do not address the underlying pathology of **sebum hypersecretion**.*Antibiotics*- Oral antibiotics (e.g., **doxycycline, minocycline**) are indicated for **moderate inflammatory acne**, often combined with topical retinoids. - They are typically insufficient as monotherapy for severe, scarring, nodulocystic acne, and overuse contributes significantly to **antibiotic resistance**.

Q: A 60-year-old person presented with an ulcer on the medial canthus. The ulcer has rolled-out, beaded margins. Histopathology shows nesting cells with peripheral palisading patterns. What is the most likely diagnosis?

Basal Cell Carcinoma (BCC). ***Basal Cell Carcinoma (BCC)***- The clinical presentation of a slow-growing ulcer with **rolled-out, beaded margins** on a sun-exposed area like the medial canthus is classic for the nodular variant of BCC.- Histopathology showing nests of **basaloid cells** originating from the epidermis, with characteristic **peripheral palisading** of nuclei, is the pathognomonic microscopic description for BCC.*Squamous Cell Carcinoma (SCC)*- SCC often presents as a **firm, hyperkeratotic nodule** or plaque that frequently ulcerates, but it typically lacks the pearly, beaded margins characteristic of BCC.- Histologically, SCC consists of **squamous differentiation**, demonstrating **keratin pearls** and intercellular bridges, not peripheral palisading.*Nevus*- A nevus (mole) is a benign proliferation of **melanocytes**; it is usually a pigmented macule or papule and does not typically present as a destructive ulcer with rolled borders.- Histopathology shows uniform nests of nevus cells, confined to the junction or dermis, lacking the malignant architecture and the **basaloid cells** seen here.*Melanoma*- Melanoma often presents as an **asymmetrical, irregularly bordered**, and variably pigmented lesion (ABCDE criteria), which differs from the non-pigmented ulcer described.- Histopathology would reveal atypical **melanocytes** with characteristic nuclear features and dermal invasion, not the nested, palisading basaloid cells of BCC.

Q: For the diagnosis of typhus, an antigen of Proteus is used. What is this type of antigen called?

Heterophile antigen. ***Heterophile antigen*** - These are antigens shared between different species, such as the antigenic determinants shared by *Rickettsia* (causing typhus) and certain strains of **Proteus** (used in the Weil-Felix test). - The diagnosis of typhus relies on the **Weil-Felix reaction**, which detects anti-rickettsial antibodies that cross-react and agglutinate with the non-motile *Proteus* antigens (e.g., **OX-19**). *Sequestered antigen* - This term refers to self-antigens that are normally hidden from the immune system (e.g., in the eye or testicles) but can cause **autoimmunity** if released (e.g., post-trauma). - They are involved in the loss of **self-tolerance** and are not used in diagnostic agglutination tests for external infections like typhus. *Super antigen* - These are powerful microbial toxins, such as **Toxic Shock Syndrome Toxin-1**, that cause massive, non-specific activation of T cells. - They bind directly to the outside of the MHC Class II molecules and the T-cell receptor (TCR) Vβ chain, leading to a dangerous **cytokine storm**, unrelated to the agglutination reaction. *Iso antigen* - Also called **alloantigens**, these are specific antigens found in some individuals of a species but not others (e.g., **blood group antigens**). - They are relevant to transfusion reactions and graft rejection but do not describe the cross-species reactivity utilized in the Weil-Felix test for typhus.

Q: A woman, a few weeks after delivery, complains of bloody discharge from nipple and fever. On examination, diffuse lump under areola. What is the diagnosis?

Lactational mastitis. ***Lactational mastitis***- This condition is common during the **puerperium** (a few weeks after delivery) and is typically caused by retrograde infection (usually *Staphylococcus aureus*) entering through damaged nipples.- The classic presentation includes **fever**, warmth, pain, and a painful, diffuse, indurated area in the breast (the lump). **Bloody discharge** can occur due to severe inflammation or coexisting bleeding/damage related to the infection.*Galactocele*- This is a retention cyst resulting from an *obstructed lactiferous duct*, characterized by a firm, discrete, and movable lump.- It is usually **painless** and **afebrile**, and the discharge, if present, is typically milky or oily, not bloody and associated with fever.*Mondor disease*- This is a rare, benign condition, involving **thrombophlebitis of the superficial veins** of the breast or chest wall.- It presents as a palpable, painful, **cord-like structure** but is not associated with fever, systemic symptoms, or nipple discharge.*Fibrocystic disease*- This is a benign condition characterized by **lumpiness** and often cyclical pain, typically *before* menstruation.- It does not present acutely post-delivery with fever and bloody discharge, and it lacks the acute inflammatory signs characteristic of infection.

Q: The ureter is safe in which type of hysterectomy?

Vaginal. ***Vaginal*** - The lack of deep **lateral pelvic dissection** in a vaginal approach minimizes the surgical field near the area where the **ureter** crosses the **uterine artery**. - The main approach is through the vaginal cuff and supporting structures, placing the ureter at the **lowest risk** of **ligation** or **transection** compared to abdominal routes. - This is the **safest approach** for the ureter among all hysterectomy types. *Open laparotomy* - This approach requires extensive dissection of the **cardinal ligaments** and **parametrium**, placing the ureter (which runs under the uterine artery) in close proximity to the operative field, increasing the risk of injury. - The ureter can be easily inadvertently clamped or ligated during securement of the **uterine pedicles**. *Laparoscopy* - Despite magnified visualization, laparoscopic dissection requires the use of energy devices (e.g., electrocautery) near the **uterine vessels**, potentially exposing the ureter to a higher risk of **thermal injury**. - Deep lateral dissection near the cervix increases the risk of mechanical injury, often compounded by difficulty in **depth perception** during pedicle clamping. *Robotic* - Similar to laparoscopy, robotic assistance involves deep dissection of the broad and **cardinal ligaments** where the **ureter** is vulnerable as it passes near the **uterine artery**. - Although visualization and dexterity are improved, the instruments still operate close to the ureter during securing of the **uterine pedicles**, maintaining a significant risk of injury.

Q: A 4-year-old unvaccinated child presents with fever, rash, and Bitot spots. What is the appropriate line of management?

Vitamin A Supplementation. ***Vitamin A Supplementation*** - **Bitot spots** are pathognomonic for **xerophthalmia** due to **Vitamin A deficiency**, a serious complication of measles in malnourished children - **High-dose Vitamin A supplementation** (200,000 IU on two consecutive days per WHO guidelines) is the **critical priority** to prevent blindness and reduce measles-related mortality - Supportive care (hydration, fever management, nutrition) is also essential but the key differentiator in this question is recognizing and treating the **Vitamin A deficiency** indicated by Bitot spots *Measles Vaccine + Vitamin A Supplementation* - While **Vitamin A** is correct, the **measles vaccine is contraindicated** during acute febrile illness with active measles infection - Vaccination is prophylactic, not treatment for active disease - After recovery, catch-up vaccination should be considered if child remains unvaccinated *Measles Vaccine* - Administering measles vaccine during **acute measles infection** is inappropriate - This option ignores the **urgent need for Vitamin A** when Bitot spots are present - Missing Vitamin A supplementation risks **irreversible blindness** *Supportive Care* - While supportive care (hydration, fever control, nutrition) is essential in measles management, it does not address the **specific deficiency** indicated by Bitot spots - **Vitamin A supplementation is mandatory** when xerophthalmia signs are present - Supportive care alone without Vitamin A carries high risk of **permanent ocular damage**

Q: A 22-year-old male presents to the emergency department with a strong urge to urinate but is unable to do so. He has a history of perineal trauma. On examination, blood is noted at the external urethral meatus. Which structure is most likely injured?

Bulbar urethra. ***Bulbar urethra***- Perineal trauma, such as a **straddle injury**, typically compresses the **bulbar urethra** (part of the anterior urethra) against the inferior aspect of the pubic symphysis, leading to rupture or contusion.- The classic presentation of **blood at the external urethral meatus** combined with **urinary retention (inability to void)** following perineal trauma is pathognomonic for a suspected anterior urethral injury, most commonly involving the bulbar segment.*Posterior urethral valve*- This condition is a **congenital anomaly** causing obstruction almost exclusively in male **infants** and neonates, resulting in chronic hydronephrosis.- It is not a traumatic injury and therefore cannot explain the sudden onset of urinary retention in a 22-year-old male following **perineal trauma**.*Intraperitoneal Bladder rupture*- This type of rupture usually occurs due to blunt trauma to the **suprapubic region** when the bladder is full, leading to urine leakage into the abdominal cavity.- Although it causes inability to urinate and hematuria, the history of isolated **perineal trauma** and prominent **blood at the meatus** makes a primary urethral injury significantly more likely.*Membranous urethra*- The **membranous urethra** is part of the posterior urethra and its injury is highly associated with severe blunt trauma causing **pelvic fractures**.- Perineal or straddle injuries typically affect the **anterior urethra** (bulbar segment) because the posterior urethra is protected by the surrounding bony pelvis and supportive ligaments.

Question 1

Identify the level of lymph nodes indicated in the marked region of the neck in the given anatomical image.

Accepted Answer

Level II

Answer

Level Ib

Answer

Level Ia

Answer

Level IV

Question 2

Spread of prostate cancer to lumbar vertebra is via?

Accepted Answer

Venous spread

Answer

Local spread

Answer

Arterial spread

Answer

Lymphatic spread

Question 3

Identify the structure marked in the image.

Accepted Answer

Right Hepatic artery

Answer

Cystic duct

Answer

Cystic artery

Answer

Hepatic duct

Question 4

What is the most appropriate treatment for severe acne?

Accepted Answer

Isotretinoin

Answer

Topical Tretinoin

Answer

Antibiotics

Answer

Steroids

Question 5

A 60-year-old person presented with an ulcer on the medial canthus. The ulcer has rolled-out, beaded margins. Histopathology shows nesting cells with peripheral palisading patterns. What is the most likely diagnosis?

Accepted Answer

Basal Cell Carcinoma (BCC)

Answer

Nevus

Answer

Melanoma

Answer

Squamous Cell Carcinoma (SCC)

Question 6

For the diagnosis of typhus, an antigen of Proteus is used. What is this type of antigen called?

Accepted Answer

Heterophile antigen

Answer

Iso antigen

Answer

Super antigen

Answer

Sequestered antigen

Question 7

A woman, a few weeks after delivery, complains of bloody discharge from nipple and fever. On examination, diffuse lump under areola. What is the diagnosis?

Accepted Answer

Lactational mastitis

Answer

Fibrocystic disease

Answer

Galactocele

Answer

Mondor disease

Question 8

The ureter is safe in which type of hysterectomy?

Accepted Answer

Vaginal

Answer

Robotic

Answer

Laparoscopy

Answer

Open laparotomy

Question 9

A 4-year-old unvaccinated child presents with fever, rash, and Bitot spots. What is the appropriate line of management?

Accepted Answer

Vitamin A Supplementation

Answer

Measles Vaccine

Answer

Supportive Care

Answer

Measles Vaccine + Vitamin A Supplementation

Question 10

A 22-year-old male presents to the emergency department with a strong urge to urinate but is unable to do so. He has a history of perineal trauma. On examination, blood is noted at the external urethral meatus. Which structure is most likely injured?

Accepted Answer

Bulbar urethra

Answer

Intraperitoneal Bladder rupture

Answer

Posterior urethral valve

Answer

Membranous urethra

FMGE 2025

Anatomy

Dermatology

Microbiology

Obstetrics and Gynecology

Pediatrics

Surgery