FMGE 2025 Practice Questions

Q: A female patient complains of chest pain while waking up in the morning. Pain is more in winter months. Which of the following best describes this patient?

Ach-induced coronary vasoconstriction. ***Ach-induced coronary vasoconstriction***- This clinical presentation—chest pain at rest (especially in the morning hours) and exacerbation during winter months (due to cold exposure)—is the hallmark of **Variant (Prinzmetal's) angina**, which is caused by transient **coronary vasospasm**. [1]- The mechanism involves underlying endothelial dysfunction leading to hyperreactivity of coronary smooth muscle, which can be demonstrated via provoked spasm using agents like **Acetylcholine (ACh)** during diagnostic tests. [1]*Fixed plaque obstruction*- This pathology defines **Stable Angina**, where chest pain is typically predictable and primarily brought on by physical **exertion** when myocardial oxygen demand exceeds fixed supply. [1]- Stable angina rarely occurs exclusively at rest upon waking and does not typically exhibit marked seasonal variation associated with **vasospasm** triggers like cold.*Subendocardial ischemia due to increased demand of myocardium*- Demand ischemia results from factors that increase myocardial workload (e.g., high heart rate, exercise), leading to supply-demand mismatch, which is minimized during rest/sleep. [1]- Prinzmetal's angina is a *supply* problem (vasospasm) causing acute, severe **transmural ischemia**, often presenting with transient **ST elevation** on ECG, differentiating it from typical subendocardial demand ischemia.*Increased sympathomimetic drive in morning hours*- While the natural circadian rhythm involves an increase in sympathetic tone upon waking, potentially triggering cardiac events, this does not describe the specific mechanism of the chest pain.- The symptoms described are most diagnostic of **Prinzmetal's angina**, a distinct disorder defined by localized arterial hyperreactivity rather than general sympathetic increase.

Q: CSF shows abundant PMNs with low sugar and elevated proteins. Diagnosis is?

Acute bacterial meningitis. ***Acute bacterial meningitis*** - The findings of abundant **Polymorphonuclear leukocytes (PMNs)**, **low CSF glucose** (due to bacterial consumption), and **elevated protein** are the classic triad for an acute bacterial infection of the meninges [1]. - A high PMN count indicates an acute inflammatory response, and the profound hypoglycemia and marked protein elevation distinguish it from most viral etiologies [1]. *Tubercular Meningitis* - While also associated with **low CSF glucose** and **elevated protein**, the predominant cell type is typically **lymphocytic** (mononuclear cells), not PMNs [3]. - The CSF often appears xanthochromic, and organisms like *M. tuberculosis* generally cause a subacute or chronic presentation rather than the acute presentation suggested by abundant PMN presence [3]. *Viral encephalitis* - CSF analysis usually reveals a **lymphocytic pleocytosis** (a higher proportion of lymphocytes), not a PMN predominance. - Glucose levels are typically **normal**, and protein elevation is usually mild to moderate, not markedly elevated. *Viral meningitis* - Similar to viral encephalitis, viral meningitis primarily causes a **lymphocytic pleocytosis** with a transient PMN phase early on, which quickly shifts to lymphocytes [2]. - The defining feature differentiating it from bacterial or tubercular meningitis is the **normal CSF glucose** level and milder protein elevation [2].

Q: The finding seen in the image is:

Herbert's pits. ***Herbert's pits*** - These are pathognomonic signs of **cicatricial trachoma**, representing shallow, depressed scars located at the superior corneoscleral junction (limbus). - They are formed by the resolution and scarring of **limbal follicles**, which are characteristic of the active inflammatory stage of trachoma. *Horner-Trantas spots* - These are small, white, gelatinous nodules seen at the limbus, composed of degenerated eosinophils and epithelial cells. - They are a characteristic finding in **vernal keratoconjunctivitis (VKC)**, an allergic eye condition, and are not seen in trachoma. *Pannus* - Pannus refers to the growth of fibrovascular tissue from the limbus onto the peripheral cornea. - While a **superior pannus** is a common finding in trachoma, the specific depressions shown in the image are Herbert's pits, not the pannus itself. *Arlt's line* - This is a horizontal line of scar tissue found on the **tarsal conjunctiva** of the upper eyelid. - It is another sign of cicatricial trachoma but is located on the inner surface of the eyelid, not at the limbus as seen in the image.

Q: A patient with pituitary adenoma compressing the optic chiasma now presents with loss of visual field. What visual field defect will be seen in the patient?

Bitemporal hemianopia. ***Bitemporal hemianopia*** - A **pituitary adenoma** most commonly compresses the **optic chiasma**, where the nasal retinal fibers from both eyes decussate (cross over). - Damage to these crossing fibers specifically leads to the loss of the **temporal visual fields** in both eyes, which is the definition of bitemporal hemianopia. *Homonymous anopia* - This is a less specific term. **Homonymous** defects refer to the loss of the same side of the visual field in both eyes (e.g., the left side in both eyes). - These types of defects are caused by lesions located **posterior** (behind) the optic chiasma, not at the chiasma itself. *Homonymous hemianopia* - This defect describes the loss of the same half (either left or right) of the visual field in both eyes. - It results from a lesion in the visual pathway **posterior** to the optic chiasma, such as in the **optic tract**, **optic radiations**, or the **visual cortex**. *Superior quadrantanopia* - This refers to the loss of vision in the upper quadrant of the visual field, often described as a "pie in the sky" defect. - This is typically caused by a lesion affecting the contralateral **temporal lobe** (damaging **Meyer's loop** of the optic radiation), not the optic chiasma.

Q: A patient presents with complaints of eye strain. The given image shows the focus of light rays in different meridians in the eye. Which refractive error is present in this patient?

Astigmatism. ***Astigmatism*** - The image illustrates that light rays passing through different meridians (vertical and horizontal) of the eye are focused at two separate points, which is the defining feature of **astigmatism**. - This refractive error, typically caused by an irregularly shaped **cornea** or lens, results in the formation of a **conoid of Sturm** (the interval between the two focal lines), causing blurred vision and symptoms like **eye strain**. *Amblyopia* - **Amblyopia**, or lazy eye, is a neurodevelopmental condition where vision is reduced in one eye because the eye and the brain are not working together properly; it is not a refractive error itself. - It can be caused by untreated refractive errors (like severe astigmatism) or **strabismus** during early childhood, but the diagram depicts an optical-physical phenomenon, not a neurological one. *Hypermetropia* - In **hypermetropia** (farsightedness), parallel light rays from all meridians would focus at a single point **behind the retina**, not at two different points as shown. - The image's depiction of two distinct focal lines for vertical and horizontal planes is inconsistent with the uniform focusing seen in simple hypermetropia. *Presbyopia* - **Presbyopia** is the age-related loss of **accommodation**, which is the eye's ability to change focus for near objects due to hardening of the **lens**. - It does not involve different refractive powers in different meridians and therefore is not represented by the optical diagram shown.

Q: A myopic patient presents with complaints of flashes and floaters. On examination, a deep anterior chamber is seen. What is the likely diagnosis?

Rhegmatogenous retinal detachment. ***Rhegmatogenous retinal detachment***- The presence of **flashes (photopsia)** and **floaters** signifies acute **vitreoretinal traction** leading to a retinal break (*rhegma*), a classic presentation of RRD, especially in a **myopic** eye.- A **deep anterior chamber** can indicate **hypotony** (low intraocular pressure), which frequently occurs in RRD due to increased uveoscleral outflow from the fluid egress through the retinal break.*Exudative retinal detachment*- This type is caused by underlying processes like inflammation or tumors and is characterized by a lack of **retinal break** and, therefore, typically does **not** cause flashes or floaters associated with vitreous traction.- The subretinal fluid in this condition classically **shifts** upon changing head position, which is a key differentiating feature.*Tractional retinal detachment*- This form is caused by the contraction of **fibrovascular membranes** on the retinal surface, most commonly seen in advanced **proliferative diabetic retinopathy**.- It is usually slowly progressive and does **not** typically present acutely with the prominent **flashes** and **floaters** that suggest a fresh retinal tear.*Central serous retinopathy*- This condition involves fluid accumulation localized beneath the macula, leading to symptoms like **metamorphopsia** and central scotoma, without involving the peripheral retina.- It does **not** cause a generalized retinal detachment, significant **flashes** and **floaters**, or changes in the **anterior chamber depth**.

Q: Identify the ocular condition shown in the image.

Herbert's pits. ***Herbert's pits*** - The image displays shallow, scalloped depressions at the superior corneoscleral junction (limbus), which are characteristic of **Herbert's pits**. - These pits are pathognomonic for **trachoma**, representing the cicatricial remains of resolved limbal follicles. *Horner-Trantas spots* - These are distinct gelatinous nodules or dots at the limbus composed of degenerated epithelial cells and **eosinophils**. - They are a hallmark sign of **vernal keratoconjunctivitis (VKC)**, an allergic eye disease, and do not appear as pitted scars. *Pannus* - Pannus is the ingrowth of fibrovascular tissue and **neovascularization** onto the cornea, typically from the superior limbus. - While pannus is also a sign of **trachoma**, the image specifically highlights the pitted scarring of Herbert's pits, not a sheet of blood vessels. *Arlt's line* - This refers to a line of scarring on the **tarsal conjunctiva**, which is the inner surface of the eyelid. - It is a sign of cicatricial **trachoma** but would only be visible upon eversion of the eyelid, not on the globe itself as shown in the image.

Q: A skin graft was performed on an immunocompromised patient using tissue from another immunocompromised individual. Weeks later, the patient developed contractures and systemic symptoms. What is the most likely cause?

Graft-versus-host disease. ***Correct: Graft-versus-host disease (GVHD)*** - GVHD occurs when **immunocompetent donor T lymphocytes** from the graft recognize recipient tissues as foreign and mount an immune attack [1] - Key scenario: **Immunocompromised recipient** receiving tissue from another person (even if donor is immunocompromised, donor T cells in the graft can still be functional) - The recipient's compromised immune system **cannot eliminate donor lymphocytes**, allowing them to engraft and attack host tissues [1] - **Contractures** are characteristic of chronic GVHD affecting skin and connective tissue - **Systemic symptoms** (fever, diarrhea, hepatitis) reflect multi-organ involvement typical of GVHD - Timeline of **weeks** fits both acute (2-100 days) and chronic (>100 days) GVHD *Incorrect: Delayed wound healing* - Would present as local wound complications, not systemic symptoms - Does not explain contractures or multi-organ involvement - Typically occurs within days, not weeks *Incorrect: Rejection due to recipient T8 cells* - This describes **host-versus-graft** (rejection), not graft-versus-host - Patient is **immunocompromised**, so recipient T cells are impaired and unlikely to mount effective rejection - Would cause graft loss, not systemic symptoms in the recipient *Incorrect: Graft failure* - Non-specific term that doesn't explain the clinical presentation - Would present as loss of graft function/wound dehiscence, not systemic symptoms - Does not account for contractures or multi-organ disease **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 244-245.

Q: A 5 year old boy presented with hematemesis and was found to have splenomegaly, on examination. There was a past history of exchange transfusion in this child for neonatal jaundice. What is the probable diagnosis?

Portal vein thrombosis. ***Portal vein thrombosis***- This is the most probable diagnosis because **extrahepatic portal vein thrombosis (EHPVO)** is the most common cause of portal hypertension and variceal bleeding in pediatric patients.- A past history of **exchange transfusion** (which often utilizes umbilical vein catheterization) is a major risk factor for initiating ascending thrombophlebitis that leads to the development of a **portal vein thrombus**.- Manifestations include **splenomegaly** (due to portal hypertension) and **hematemesis** (due to bleeding from esophageal varices).*Splenic vein thrombosis*- **Isolated splenic vein thrombosis** causes *segmental portal hypertension*, typically resulting in localized high pressure leading mainly to **isolated gastric varices**.- While it causes **splenomegaly**, it is less likely to cause the severe, diffuse portal hypertension and extensive esophageal varices responsible for large-volume hematemesis seen in EHPVO.*Budd-Chiari syndrome*- This syndrome involves obstruction of the **hepatic veins** (or suprahepatic inferior vena cava), leading acutely to symptoms like tender **hepatomegaly**, intractable ascites, and often signs of **liver failure**.- The patient's presentation is characterized by isolated signs of *pre-hepatic portal hypertension* (splenomegaly and variceal bleeding), not the typical constellation of liver congestion seen in Budd-Chiari.*Liver cirrhosis*- Although cirrhosis causes portal hypertension, the history in a 5-year-old points toward a specific **pre-hepatic vascular etiology** (PVT) secondary to a neonatal event rather than a parenchymal disease.- Cirrhosis usually is accompanied by signs of chronic liver failure, such as **jaundice**, **synthetic dysfunction**, or **ascites**, which are absent in this typical EHPVO presentation.

Question 1

A female patient complains of chest pain while waking up in the morning. Pain is more in winter months. Which of the following best describes this patient?

Accepted Answer

Ach-induced coronary vasoconstriction

Answer

Fixed plaque obstruction

Answer

Increased sympathomimetic drive in morning hours

Answer

Subendocardial ischemia due to increased demand of myocardium

Question 2

CSF shows abundant PMNs with low sugar and elevated proteins. Diagnosis is?

Accepted Answer

Acute bacterial meningitis

Answer

Viral encephalitis

Answer

Tubercular Meningitis

Answer

Viral meningitis

Question 3

The finding seen in the image is:

Accepted Answer

Herbert's pits

Answer

Arlt's line

Answer

Pannus

Answer

Horner-Trantas spots

Question 4

A patient with pituitary adenoma compressing the optic chiasma now presents with loss of visual field. What visual field defect will be seen in the patient?

Accepted Answer

Bitemporal hemianopia

Answer

Superior quadrantanopia

Answer

Homonymous hemianopia

Answer

Homonymous anopia

Question 5

A patient presents with complaints of eye strain. The given image shows the focus of light rays in different meridians in the eye. Which refractive error is present in this patient?

Accepted Answer

Astigmatism

Answer

Presbyopia

Answer

Amblyopia

Answer

Hypermetropia

Question 6

A myopic patient presents with complaints of flashes and floaters. On examination, a deep anterior chamber is seen. What is the likely diagnosis?

Accepted Answer

Rhegmatogenous retinal detachment

Answer

Central serous retinopathy

Answer

Tractional retinal detachment

Answer

Exudative retinal detachment

Question 7

Identify the ocular condition shown in the image.

Accepted Answer

Herbert's pits

Answer

Arlt's line

Answer

Pannus

Answer

Horner-Trantas spots

Question 8

An elderly female presents with sudden onset of pain, redness, and decreased vision. On examination, hazy cornea, fixed mid-dilated pupil, and shallow anterior chamber are noted. What is the diagnosis?

Accepted Answer

Acute congestive glaucoma

Answer

Central retinal artery occlusion

Answer

Acute conjunctivitis

Answer

Acute uveitis

Question 9

A skin graft was performed on an immunocompromised patient using tissue from another immunocompromised individual. Weeks later, the patient developed contractures and systemic symptoms. What is the most likely cause?

Accepted Answer

Graft-versus-host disease

Answer

Delayed wound healing

Answer

Rejection due to recipient T8 cells

Answer

Graft failure

Question 10

A 5 year old boy presented with hematemesis and was found to have splenomegaly, on examination. There was a past history of exchange transfusion in this child for neonatal jaundice. What is the probable diagnosis?

Accepted Answer

Portal vein thrombosis

Answer

Splenic vein thrombosis

Answer

Liver cirrhosis

Answer

Budd-Chiari syndrome

FMGE 2025

Internal Medicine

Ophthalmology

Pathology

Pediatrics