FMGE 2024 Practice Questions

Q: Which of the following structures does not form the boundary of Hesselbach's triangle?

Vas deferens. ***Correct: Vas deferens*** - The vas deferens is a component of the **spermatic cord**, which passes through the **deep inguinal ring**, located superior and lateral to Hesselbach's triangle - It does **not** form any of the boundaries of Hesselbach's triangle [1] - The spermatic cord is located deep to the inguinal canal and does not define any of the superficial boundaries *Incorrect: Inferior epigastric artery* - This vessel forms the **lateral border** (or superolateral border) of Hesselbach's triangle [1] - Its anatomical position differentiates between **direct inguinal hernias** (medial to the artery, through Hesselbach's triangle) and **indirect inguinal hernias** (lateral to it) *Incorrect: Rectus abdominis* - The lateral edge of the **rectus abdominis muscle** (or its sheath) defines the **medial boundary** of Hesselbach's triangle [1] - This medial boundary marks the point through which direct inguinal hernias can protrude medially *Incorrect: Inguinal ligament* - The **inguinal ligament** forms the **inferior boundary** (or base) of Hesselbach's triangle [1] - This ligament represents the thickened lower margin of the **external oblique aponeurosis** extending from the ASIS to the pubic tubercle [1]

Q: A 40-year-old man presents with gynecomastia. Ultrasound reveals a 1 cm solid mass within the body of the testis. Serum testosterone is 600 ng/dL, and estradiol is 35 pg/mL. What is the most likely diagnosis?

Leydig cell tumor. ***Correct: Leydig cell tumor*** - **Most common** sex cord-stromal tumor in adults, accounting for **1-3%** of all testicular tumors - Arises from interstitial cells that produce **testosterone and estradiol** through aromatization [2], [4] - Classic presentation: **Gynecomastia** (30-40% of cases) due to increased estrogen production or altered testosterone/estrogen ratio [1], [3] - Typically presents as a **small, benign solid mass** (90% are <5 cm and benign) [3] - Ultrasound shows **solid, well-circumscribed intratesticular mass** [3] - Laboratory findings: **Elevated estradiol**, testosterone may be normal or elevated [3] *Incorrect: Sertoli cell tumor* - Less common sex cord-stromal tumor (also can cause gynecomastia but **much rarer** than Leydig cell tumor) - Only **10-20%** present with endocrine manifestations - More likely to present with painless testicular mass without hormonal effects - When hormonal effects occur, usually **estrogen production** but less pronounced than Leydig cell tumor *Incorrect: Spermatocytic tumor* - Germ cell tumor that occurs in **older men** (mean age 50-55 years) - **Does NOT produce hormones** - no gynecomastia - Presents as painless testicular enlargement - Typically larger masses, good prognosis, virtually **never metastasizes** *Incorrect: Granulosa cell tumor* - **Extremely rare** in males (primarily an ovarian tumor) - When it occurs in males, can produce estrogen and cause gynecomastia - However, represents **<1%** of testicular tumors in males - Leydig cell tumor is far more common with this presentation

Q: Which among the following is most radiosensitive?

A. Testis. ***Testis*** - The testes contain actively proliferating **spermatogonial stem cells**, making them one of the most radiosensitive organs in the body after the lymphoid tissue and bone marrow. - According to the **Law of Bergonié and Tribondeau**, tissues with high mitotic activity and low differentiation are highly radiosensitive. *Bone* - Mature bone tissue is relatively radioresistant, particularly when compared to highly proliferative organs like the gonads or hematopoietic tissue. - While the red bone marrow within the bone is highly sensitive, the osteocytes and bone matrix are much more resistant to immediate radiation effects. *Nerve* - Nerve tissue is composed of highly specialized, terminally differentiated cells (neurons) that are non-proliferative. - Due to the lack of mitotic activity, the central nervous system and peripheral nerves exhibit very high radioresistance. *Muscle* - Muscle tissue (skeletal, cardiac, and smooth) is differentiated and consists of terminally post-mitotic cells. - Like nerve tissue, muscle is highly radioresistant, requiring large doses of radiation to induce functional or structural damage.

Q: Radioisotope used in PET-CT scan?

18F-FDG. ***18F-FDG*** - It is a **glucose analogue** labeled with the positron-emitting isotope **Fluorine-18**, making it the ideal tracer for measuring metabolic activity in tissues. - It is widely used in PET-CT because highly metabolic cells (like cancer cells and active neurons) accumulate it, allowing visualization of **hypermetabolic activity**. *Iodine* - Refers typically to **Iodine-131** or **Iodine-123**, which are primarily used in **thyroid imaging** and therapy. - These isotopes are **gamma emitters** detected by SPECT, not positron emitters required for PET. *Radium* - **Radium-223** (Radium chloride) is an **alpha emitter** used therapeutically for **metastatic prostate cancer** affecting the bone. - It is not a positron emitter and is not designed for diagnostic functional imaging scans like PET. *Cesium-131* - **Cesium-131** is a low-energy **gamma emitter** primarily used in **brachytherapy seeds** for localized radiation treatment. - It does not undergo positron decay and is therefore unsuitable for generating the specific annihilation photons required for PET scanning.

Q: Ideal thickness of lead aprons to be worn by workers in radiology department?

0.5mm. ***0.5mm***- This thickness is considered the standard and ideal lead equivalent for the front of protective aprons worn by radiology personnel, providing adequate shielding against **scatter radiation**.- A **0.5 mm** lead equivalent attenuates approximately 97% of the scatter radiation generated during standard fluoroscopic procedures (at 100 kVp), offering optimal protection balanced against manageable weight.*1mm*- A **1mm** lead equivalent apron provides marginally greater attenuation but is significantly heavier, leading to high risk of **musculoskeletal injury** due to the excessive load.- This high thickness is generally unnecessary, as the additional protection gained does not outweigh the ergonomic burden imposed by the increased **weight and stiffness**.*0.75mm*- While offering adequate protection, **0.75mm** is heavier than the standardized 0.5mm minimum requirement for routine fluoroscopy and general radiography protection.- The current standards and practice focus on using **0.5mm** lead equivalent to minimize staff injury and fatigue while ensuring sufficient protection against diagnostic X-rays.*2mm*- A **2mm** lead equivalent apron is extremely heavy and completely impractical for daily operational use due to the severe restrictions on mobility and the significant **physical strain**.- Protection levels that high are typically unnecessary because departmental personnel are protected primarily against low-energy **scatter radiation**, not the high-intensity primary X-ray beam.

Q: Which of the following is not an indication for splenectomy?

Bone marrow failure. ***Bone marrow failure*** - In bone marrow failure (e.g., aplastic anemia), the spleen serves as an important site of **extramedullary hematopoiesis** (compensatory blood cell production outside the bone marrow) - Splenectomy would **remove this compensatory mechanism** and worsen the patient's condition - Therefore, bone marrow failure is a **contraindication**, not an indication for splenectomy *Hairy cell leukemia* - This is a chronic B-cell lymphoproliferative disorder with massive splenomegaly - Splenectomy is indicated when medical treatment fails or for symptomatic relief *Thrombocytopenia* - Immune thrombocytopenic purpura (ITP) is a classic indication for splenectomy - Performed when medical management (steroids, IVIG) fails - Spleen is the primary site of platelet destruction in ITP *Iatrogenic splenic trauma* - Intraoperative injury to the spleen during abdominal surgery - Splenectomy is indicated when hemostasis cannot be achieved or injury is severe (Grade IV-V)

Q: A patient underwent surgery for pilonidal sinus, which type of flap is used in this surgery?

Rhomboid flap. ***Rhomboid flap***- The **Limberg flap** is a classic type of rhomboid transposition flap widely used for closing the deep, large defect left after wide excision of a pilonidal sinus.- This flap provides excellent tissue coverage, shifts the scar away from the midline natal cleft, and significantly reduces tension, leading to lower rates of **recurrence**.*Advanced flap*- An advancement flap involves moving tissue linearly forward, which often results in high tension when used to close the typical wide, ovoid defect remaining after pilonidal sinus excision.- They are less suitable for deep and wide midline defects compared to rotational or transposition flaps because they do not effectively flatten the **natal cleft** or distribute tension laterally.*Rotational flap*- While rotational flaps (like the **Karydakis flap**) are effective for pilonidal disease by excising the disease and closing the defect laterally, the **Limberg flap** is specifically a rhomboid transposition flap and is arguably the most classic answer for a geometric local flap used in this surgery.- Simple rotational flaps might be used, but the effectiveness and precision provided by the rhomboid geometry for large defects make the Limberg (rhomboid) technique particularly notable.*Free flap*- **Free flaps** involve microsurgical anastomosis to connect tissue from a distant site, a level of surgical complexity unnecessary for standard pilonidal sinus reconstruction.- These flaps are reserved for very large, complex defects, often requiring coverage where local tissue has been destroyed by cancer or **osteomyelitis**, which is usually not the case in routine pilonidal surgery.

Q: Which nerve is most commonly injured during indirect inguinal hernia surgery?

Ilioinguinal nerve. ***Ilioinguinal nerve*** - This nerve travels superficial to the **external oblique aponeurosis** along the inguinal canal, making it extremely susceptible to direct trauma from surgical incisions, suture placement, or mesh fixation near the **pubic tubercle**. - Injury results in chronic pain and paresthesia (burning sensation) along its distribution, affecting the groin, lateral base of the penis/scrotum, and medial aspect of the thigh (**ilioinguinal neuralgia**). *Femoral nerve* - The femoral nerve lies deep to the **inguinal ligament** lateral to the femoral artery (part of the **NAVEL** bundle), a position deep and lateral to the primary operative field for indirect hernia repair. - Injury is rare in standard open inguinal hernia repair but can occur during deep retraction, or if the hernia dissection extends deeply and laterally below the inguinal ligament. *Genitofemoral nerve* - The genital branch traverses the inguinal canal within the **spermatic cord** and can be injured; however, the ilioinguinal nerve is more frequently involved due to its proximity to the surgical incision lines. - Injury to the genital branch specifically causes loss of the **cremaster reflex** and sensory loss over the anterior scrotum or labia. *Obturator nerve* - This nerve is located deep within the pelvis, passing through the **obturator canal** to supply the adductor muscles and medial thigh skin. - It is anatomically remote from the standard superficial and anterior approach required during routine indirect inguinal hernia repair.

Question 1

Which of the following structures does not form the boundary of Hesselbach's triangle?

Accepted Answer

Vas deferens

Answer

Inferior epigastric artery

Answer

Inguinal ligament

Answer

Rectus abdominis

Question 2

A 40-year-old man presents with gynecomastia. Ultrasound reveals a 1 cm solid mass within the body of the testis. Serum testosterone is 600 ng/dL, and estradiol is 35 pg/mL. What is the most likely diagnosis?

Accepted Answer

Leydig cell tumor

Answer

Sertoli cell tumor

Answer

Spermatocytic tumor

Answer

Granulosa cell tumor

Question 3

Which among the following is most radiosensitive?

Accepted Answer

A. Testis

Answer

D. Muscle

Answer

B. Bone

Answer

C. Nerve

Question 4

Radioisotope used in PET-CT scan?

Accepted Answer

18F-FDG

Answer

Iodine

Answer

Radium

Answer

Cesium-131

Question 5

Ideal thickness of lead aprons to be worn by workers in radiology department?

Accepted Answer

0.5mm

Answer

0.75mm

Answer

2mm

Answer

1mm

Question 6

Which of the following is not an indication for splenectomy?

Accepted Answer

Bone marrow failure

Answer

Hairy cell leukemia

Answer

Thrombocytopenia

Answer

Iatrogenic splenic trauma

Question 7

A patient underwent surgery for pilonidal sinus, which type of flap is used in this surgery?

Accepted Answer

Rhomboid flap

Answer

Free flap

Answer

Rotational flap

Answer

Advancement flap

Question 8

Which nerve is most commonly injured during indirect inguinal hernia surgery?

Accepted Answer

Ilioinguinal nerve

Answer

Genitofemoral nerve

Answer

Obturator nerve

Answer

Femoral nerve

FMGE 2024

Anatomy

Internal Medicine

Radiology

Surgery