FMGE 2025 Practice Questions

Q: Which of the following substances, at the given concentration, makes water unsuitable for human consumption according to safety standards?

Cadmium – 0.3 mg/L. ***Cadmium – 0.3 mg/L*** - The maximum permissible limit for **Cadmium** in drinking water is extremely low, typically around **0.003 mg/L** (WHO standard), due to its high toxicity. - A concentration of 0.3 mg/L is 100 times the safe limit and poses severe health risks, particularly **kidney damage**. *Fluoride – 0.8 mg/L* - The optimal acceptable range for **Fluoride** is generally between **0.6 and 1.5 mg/L**, a concentration that helps prevent dental caries. - A concentration of 0.8 mg/L is well within the acceptable limit and is often considered optimal for public health. *Chloride – 200 mg/L* - The acceptable limit for **Chloride** is usually **250 mg/L** (or up to 1000 mg/L as the maximum permissible limit), with higher levels primarily affecting taste and causing corrosion. - 200 mg/L is below the acceptable range and does not render the water unsuitable for drinking. *Calcium – 7 mg/L* - **Calcium** is an essential mineral, and its typical acceptable limit for drinking water is much higher, often around **75 mg/L** (or related to overall water hardness). - This concentration is extremely low and poses no health risk; it is perfectly safe for consumption.

Q: A patient with chronic kidney disease presents with severe anemia. Laboratory tests reveal normocytic, normochromic anemia. What is the most appropriate treatment to manage this patient's anemia?

Darbepoetin alfa. ***Darbepoetin alfa*** - Anemia in **Chronic Kidney Disease (CKD)** is predominantly caused by decreased production of **erythropoietin** by the failing kidneys, resulting in normocytic, normochromic anemia [1] - **Darbepoetin alfa** is a long-acting **Erythropoiesis-Stimulating Agent (ESA)** that replaces the deficient hormone, directly correcting the underlying cause of anemia in CKD - This is the **standard of care** for managing anemia in CKD patients with normocytic, normochromic presentation *Folic acid supplementation* - Indicated for **megaloblastic anemia** due to **folate deficiency**, which presents as macrocytic anemia (high MCV) [2] - Does not stimulate red blood cell production directly and is ineffective against the primary defect of **erythropoietin deficiency** in CKD - The patient's normocytic anemia excludes folate deficiency [2] *Vitamin B12 injection* - Standard treatment for Vitamin B12 deficiency (e.g., **pernicious anemia**), which causes macrocytic, megaloblastic anemia [2] - The patient presents with **normocytic** anemia, indicating the deficiency is not related to B12 or folate metabolism - No indication for B12 supplementation in this clinical scenario *Iron chelation therapy* - **Iron chelation** is used to treat severe **iron overload** (hemochromatosis) or toxicity, not to treat anemia - Patients with CKD-related anemia often require supplemental **iron** to enhance their response to ESAs like Darbepoetin alfa - Using chelation would be counterproductive and worsen the anemia

Q: Which CD markers are typically positive in Chronic Lymphocytic Leukaemia (CLL)?

CD19, CD20, CD23, CD5. CD19, CD20, CD23, CD5 [1] - Chronic Lymphocytic Leukemia (CLL) is a malignancy of mature B-lymphocytes, which typically express the pan-B-cell markers CD19 and CD20 (often dimly), along with CD23 [1]. - A hallmark of CLL is the aberrant co-expression of the T-cell marker CD5 [2], which is crucial for differentiating it from other B-cell lymphomas. The peripheral smear in the image shows mature lymphocytes and a characteristic smudge cell, supporting the diagnosis of CLL [1]. CD3, CD5, CD8 - This profile is characteristic of a T-cell malignancy, as CD3 is a pan-T-cell marker and CD8 is a marker for cytotoxic T-cells [2]. - While CD5 is present in CLL, its combination with CD3 and CD8 excludes a B-cell disorder like CLL. CD10, CD19, CD22 - This combination of markers is more suggestive of other B-cell neoplasms like Follicular Lymphoma or Burkitt Lymphoma, which are characteristically CD10 positive [2]. - Typical CLL is negative for CD10 and positive for CD5 and CD23, which are key distinguishing features [1]. CD13, CD33, CD117 - These are markers associated with the myeloid lineage. CD13 and CD33 are classic myeloid antigens often seen in Acute Myeloid Leukemia (AML). - CD117 (c-kit) is a marker for hematopoietic progenitors and is also frequently positive in AML, making this immunophenotype inconsistent with a lymphoid neoplasm. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, p. 602. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, p. 598.

Q: 2-year-old with fever, lymphadenopathy and H&E shows hallmark cells. The diagnosis of anaplastic large cell lymphoma was made. Most likely translocation?

t(2;5). ***Correct: t(2;5)*** - This is the **most common and classic translocation** found in systemic **Anaplastic Large Cell Lymphoma (ALCL)**, especially in children [1] - Occurs in approximately **60-85% of systemic ALCL cases** - Fuses the **NPM (Nucleophosmin)** gene on chromosome 5 with the **ALK** gene on chromosome 2 [1] - Results in constitutively active **ALK tyrosine kinase** that drives cell proliferation [1] - **ALK-positive ALCL** has a better prognosis, particularly in pediatric patients [1] *Incorrect: t(8;14)* - This is the hallmark translocation of **Burkitt Lymphoma (BL)**, not ALCL [2] - Juxtaposes the **MYC oncogene** on chromosome 8 to the **IgH promoter** on chromosome 14 [2] - Burkitt Lymphoma presents with rapidly growing masses and characteristic **"starry sky"** microscopic appearance [3] - Distinct from ALCL's hallmark cells (large cells with eccentric horseshoe/kidney-shaped nuclei) *Incorrect: t(8;22)* - A variant translocation associated with **Burkitt Lymphoma (BL)** [2] - Translocates **MYC gene** to the **kappa light chain locus** on chromosome 22 [2] - Results in MYC overexpression, which is pathognomonic for Burkitt Lymphoma - Not associated with Anaplastic Large Cell Lymphoma *Incorrect: t(14;18)* - Characteristic translocation of **Follicular Lymphoma (FL)** - Leads to overexpression of the **BCL2 anti-apoptotic protein** - Follicular Lymphoma is typically seen in adults and is a **B-cell lymphoma** - ALCL is a **T-cell/null-cell lymphoma**, making this translocation irrelevant **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 565-566. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 324-325. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, p. 606.

Q: In Barrett's oesophagus, which of the following epithelial transformations occurs?

Squamous to intestinal columnar epithelium. ***Squamous to intestinal columnar epithelium*** - Barrett's esophagus is a complication of chronic **gastroesophageal reflux disease (GERD)**, where the normal stratified **squamous epithelium** of the lower esophagus is replaced by metaplastic columnar epithelium [1]. - This metaplastic epithelium is specifically an **intestinal type**, characterized by the presence of **goblet cells**, which is considered a premalignant condition for esophageal adenocarcinoma [1]. *Columnar to squamous epithelium* - This describes the reverse process of what happens in Barrett's esophagus. - This type of metaplasia can occur in other organs, for example, in the endocervix (squamous metaplasia) or the bronchi of chronic smokers. *Transitional to squamous epithelium* - **Transitional epithelium** (urothelium) is the characteristic lining of the urinary tract (e.g., bladder, ureters) and is not found in the esophagus. - This type of metaplastic change is seen in the bladder in response to chronic irritation, such as from stones or **Schistosoma haematobium** infection. *Cuboidal to columnar epithelium* - The normal esophageal lining is stratified squamous epithelium, not cuboidal epithelium. - While metaplasia involving cuboidal cells can occur in glandular ducts or bronchioles, it is not the transformation that defines Barrett's esophagus. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 347-349.

Q: Bernard-Soulier syndrome is caused by a defect in which of the following platelet glycoproteins?

GpIb/IX complex. ***GpIb/IX complex***- Bernard-Soulier syndrome (BSS) is a rare, autosomal recessive bleeding disorder caused by a quantitative or qualitative defect in the **platelet GpIb/IX/V complex** [1].- This complex acts as the essential high-affinity receptor for **von Willebrand factor (vWF)**, mediating initial **platelet adhesion** to the injured vessel wall, which is impaired in BSS [1], [2].*GpIIb/IIIa*- A defect in **GpIIb/IIIa** (integrin $\alpha_{IIb}\beta_3$) causes **Glanzmann thrombasthenia**, which presents with impaired **platelet aggregation**, not adhesion [1].- GpIIb/IIIa is the receptor for **fibrinogen**, which is necessary to link aggregating platelets [1], [2].*GpIa/IIa*- **GpIa/IIa** (integrin $\alpha_2\beta_1$) is primarily a receptor for **collagen** on the platelet surface, mediating adhesion in parallel with GpIb/vWF.- While important for hemostasis, defects in this receptor generally cause only mild bleeding and not the characteristic **giant platelets** or severe adhesion defect seen in BSS.*GpIV*- **GpIV** (also known as CD36) is a scavenger receptor that binds to **thrombospondin** and sometimes collagen.- Platelet defects related to GpIV are rare and usually involve mild aggregation defects, distinct from the severe adhesion failure defined by BSS. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Red Blood Cell and Bleeding Disorders, pp. 668-669. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, p. 128.

Q: A patient with renal disease undergoes a biopsy. On Congo red staining, the deposits show apple-green birefringence under polarised light. What is the most likely diagnosis?

Amyloidosis. ***Amyloidosis***- This feature is the **pathognomonic microscopic manifestation** of amyloid deposition, where the Congo red stain binds specifically to the parallel **cross-beta sheet** configuration of amyloid fibrils [1].- When viewed under **polarized light**, this interaction results in the classic **apple-green birefringence** due to the ordering of the deposited protein [1], [2]. *Minimal change disease*- The diagnosis of minimal change disease relies primarily on **electron microscopy**, which shows **effacement of podocyte foot processes**.- On **light microscopy**, the glomeruli appear virtually normal, and there are no deposits present that would stain positively with Congo red. *Diabetic nephropathy*- Characteristic findings on light microscopy include **diffuse mesangial expansion** and the formation of **Kimmelstiel-Wilson nodules** (nodular glomerulosclerosis).- The thickening of the glomerular basement membrane and mesangial expansion are due to hyperglycemia and associated metabolic changes, not amyloid deposition. *Membranous nephropathy*- This nephropathy is defined by the presence of **subepithelial immune complex deposits** that result in a uniformly thickened glomerular basement membrane (GBM).- Silver stains often reveal a classic **"spike and dome"** pattern on the GBM, which is distinct from amyloid fibrils. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 268-269. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 533-534.

Q: A child presents with abdominal distension and an enlarged liver by 8cm below the costal margin. The liver is smooth on palpation. Which of the following is the most likely diagnosis?

Glycogen Storage Disease (GSD). ***Glycogen Storage Disease (GSD)***- GSDs, particularly Type I (**Von Gierke Disease**), cause massive, **smooth hepatomegaly** due to the accumulation of normal or abnormal glycogen within hepatocytes.- The presentation in childhood with severe abdominal distension and an enlarged, non-tender, **smooth liver** is highly characteristic of these metabolic disorders.*Lysosomal Storage Disease (LSD)*- While LSDs (e.g., Gaucher, Niemann-Pick) can cause hepatomegaly, they often involve the **Reticuloendothelial system**, leading to prominent **splenomegaly** as well, which is not mentioned here.- Clinical features usually include severe **neurological impairment** or **skeletal abnormalities**, differentiating them from GSDs which primarily affect the liver and glucose metabolism initially.*Hepatocellular Carcinoma (HCC)*- HCC usually results in a **firm, nodular, or irregular** liver surface on palpation, reflecting tumor growth, rather than a uniformly smooth enlargement.- Although rare in children, when it occurs, it is typically associated with rapidly worsening symptoms, weight loss, and often underlying conditions like **cirrhosis** or **hepatitis**.*Autoimmune Hepatitis*- This condition involves chronic **inflammation and destruction of hepatocytes**, often leading to symptoms of liver failure (jaundice) and elevated **transaminases**.- Long-standing autoimmune hepatitis progresses to cirrhosis, resulting in a **fibrotic or nodular** liver, rarely presenting as primary, massive, smooth hepatomegaly in a child.

Q: A 12-year-old child presents with palpitations, tremors, dry mouth, heart rate 130 bpm, respiratory rate 34/min. Which of the following substances is most likely responsible?

TCA (tricyclic antidepressant). ***TCA (tricyclic antidepressant)***- The constellation of tachycardia (palpitations, HR 130 bpm), tremors, and dry mouth suggests a severe mixed toxidrome, highly characteristic of a TCA overdose.- TCAs exhibit potent **anticholinergic effects** (dry mouth, tachycardia) combined with severe **sodium channel blockade** (contributing to CNS symptoms like tremors and cardiovascular instability) resulting in this critical presentation [1].*Lithium*- Lithium toxicity primarily presents with progressive **neurological symptoms** like ataxia, coarse tremors, lethargy, and seizures.- While tremor is present, the severe **tachycardia** and pronounced **dry mouth** are not typical primary features of the lithium toxidrome.*Opioid*- Opioid toxicity is defined by the classic triad of **miosis** (pinpoint pupils), **respiratory depression** (bradypnea), and altered consciousness.- The patient is profoundly **tachycardic** (130 bpm) and **tachypneic** (34/min), which directly contradicts the expected findings of an opioid overdose.*Propranolol*- Propranolol is a **beta-blocker**, and its overdose typically causes **bradycardia**, hypotension, and potential non-cardiogenic pulmonary edema.- The patient's presentation of significant **tachycardia** (130 bpm) rules out poisoning by a beta-blocking agent.

Question 1

Which of the following substances, at the given concentration, makes water unsuitable for human consumption according to safety standards?

Accepted Answer

Cadmium – 0.3 mg/L

Answer

Calcium – 7 mg/L

Answer

Chloride – 200 mg/L

Answer

Fluoride – 0.8 mg/L

Question 2

A 39-year-old male with symptoms of stress and work-life imbalance is diagnosed with Stage 2 hypertension (blood pressure 150/95 mmHg on three separate occasions) and impaired fasting glucose (120 mg/dL). What is the most appropriate pharmacological management?

Accepted Answer

Start telmisartan

Answer

Start thiazide diuretic

Answer

Advise rest only, no pharmacological treatment

Answer

Start glucocorticoids

Question 3

A patient with chronic kidney disease presents with severe anemia. Laboratory tests reveal normocytic, normochromic anemia. What is the most appropriate treatment to manage this patient's anemia?

Accepted Answer

Darbepoetin alfa

Answer

Vitamin B12 injection

Answer

Folic acid supplementation

Answer

Iron chelation therapy

Question 4

Which CD markers are typically positive in Chronic Lymphocytic Leukaemia (CLL)?

Accepted Answer

CD19, CD20, CD23, CD5

Answer

CD10, CD19, CD22

Answer

CD13, CD33, CD117

Answer

CD3, CD5, CD8

Question 5

2-year-old with fever, lymphadenopathy and H&E shows hallmark cells. The diagnosis of anaplastic large cell lymphoma was made. Most likely translocation?

Accepted Answer

t(2;5)

Answer

t(14;18)

Answer

t(8;22)

Answer

t(8;14)

Question 6

In Barrett's oesophagus, which of the following epithelial transformations occurs?

Accepted Answer

Squamous to intestinal columnar epithelium

Answer

Cuboidal to columnar epithelium

Answer

Transitional to squamous epithelium

Answer

Columnar to squamous epithelium

Question 7

Bernard-Soulier syndrome is caused by a defect in which of the following platelet glycoproteins?

Accepted Answer

GpIb/IX complex

Answer

GpIV

Answer

GpIa/IIa

Answer

GpIIb/IIIa

Question 8

A patient with renal disease undergoes a biopsy. On Congo red staining, the deposits show apple-green birefringence under polarised light. What is the most likely diagnosis?

Accepted Answer

Amyloidosis

Answer

Diabetic nephropathy

Answer

Membranous nephropathy

Answer

Minimal change disease

Question 9

A child presents with abdominal distension and an enlarged liver by 8cm below the costal margin. The liver is smooth on palpation. Which of the following is the most likely diagnosis?

Accepted Answer

Glycogen Storage Disease (GSD)

Answer

Autoimmune Hepatitis

Answer

Hepatocellular Carcinoma (HCC)

Answer

Lysosomal Storage Disease (LSD)

Question 10

A 12-year-old child presents with palpitations, tremors, dry mouth, heart rate 130 bpm, respiratory rate 34/min. Which of the following substances is most likely responsible?

Accepted Answer

TCA (tricyclic antidepressant)

Answer

Opioid

Answer

Propranolol

Answer

Lithium

FMGE 2025

Community Medicine

Internal Medicine

Pathology

Pediatrics

Pharmacology