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: 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: A 30-year-old female presents with a painful red granular lesion on the vulva accompanied by bilateral lymphadenopathy. What is the most likely diagnosis?

Chancroid. ***Chancroid***- Caused by ***Haemophilus ducreyi***, it presents classically as a **painful, ragged, deep vulvar ulcer** (soft chancre) often described as having an erythematous or granular base.- The condition is characteristically associated with large, sometimes suppurative, **painful unilateral or bilateral inguinal lymphadenopathy** (**buboes**), which fits the combined clinical presentation of pain and lymphadenopathy.*Neisseria Gonorrhoeae Infection*- This infection primarily causes **mucopurulent urethritis** or **cervicitis** and is not typically associated with primary, ulcerative, or granular vulval lesions.- While regional lymphadenopathy may occur, it is usually not a prominent, painful finding defining the clinical presentation.*Granuloma Inguinale*- The characteristic lesion is a **painless, highly vascular, 'beefy red' ulcer** which bleeds easily, consistent with the term "granular" but contradicting the crucial feature of being **painful**.- True regional lymphadenopathy is rare; instead, subcutaneous granulomas may mimic lymph nodes (**pseudo-buboes**).*Lymphogranuloma Venereum*- The primary genital lesion is typically a small, **painless, transient papule** or vesicle that is often overlooked.- While it causes severe, painful inguinal lymphadenopathy, the initial vulval lesion is usually not a prominent, painful, granular ulcer as described.

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 29-year-old woman presents with abdominal pain, vaginal bleeding, and a history of amenorrhea for 6 weeks. Transvaginal ultrasound does not show an intrauterine gestational sac or features suggestive of ectopic pregnancy. Her serum $\beta$-hCG is 1,200 IU/L, which is below the discriminatory zone. What is the next step in management?

Repeat $\beta$-hCG after 48 hours. ***Repeat $\beta$-hCG after 48 hours*** - In a pregnancy of unknown location (PUL) with **β-hCG below the discriminatory zone** (1,500-2,000 IU/L), ultrasound cannot reliably visualize an intrauterine pregnancy - **Serial β-hCG monitoring at 48-hour intervals** is the standard approach to determine pregnancy viability and location - Expected β-hCG patterns help guide management: - **Rise >53% in 48 hours**: Suggests viable intrauterine pregnancy → repeat ultrasound when β-hCG reaches discriminatory zone - **Rise 50% in 48 hours**: Suggests spontaneous miscarriage → monitor to zero - Patient is **hemodynamically stable**, so expectant management with close monitoring is appropriate *Dilatation and curettage* - Premature intervention without knowing β-hCG trend - Reserved for cases where β-hCG plateaus or rises abnormally, suggesting either ectopic or abnormal intrauterine pregnancy - May be used for histological diagnosis (presence of chorionic villi confirms intrauterine pregnancy) *Methotrexate therapy* - Cannot be administered without **confirmed diagnosis of ectopic pregnancy** - Requires meeting specific criteria: hemodynamic stability, unruptured ectopic, β-hCG typically <5,000 IU/L, no fetal cardiac activity - Inappropriate when pregnancy location is unknown *Laparoscopy* - Too invasive as initial management for a **stable patient** - Reserved for hemodynamically unstable patients with suspected ruptured ectopic pregnancy - May be indicated later if ectopic pregnancy is confirmed and meets surgical criteria

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.

Q: A patient presents with lower right abdominal pain and rebound tenderness. Intraoperatively, an inflamed Meckel's diverticulum is found. This clinical presentation most closely mimics which condition?

Appendicitis. ***Appendicitis*** (Meckel's Diverticulitis Mimicking Appendicitis) - Inflammation of a Meckel's diverticulum (**Meckel's diverticulitis**) occurs in the right lower quadrant and is clinically indistinguishable from **acute appendicitis**. - Lower right abdominal pain and **rebound tenderness** are classic signs of localized **peritonitis** associated with inflammation of a structure near the ileocecal region. *Perforation* - Perforation causes signs of diffuse peritonitis, marked by generalized abdominal rigidity and severe systemic illness, rather than localized pain and rebound tenderness in the right lower quadrant. - It is generally a subsequent complication of severe diverticulitis, not the primary cause of this initial localized presentation. *Intestinal obstruction* - Obstruction due to Meckel's (e.g., intussusception or volvulus) presents with symptoms like **colicky pain**, abdominal distension, and **bilious vomiting**. - **Rebound tenderness** is not a primary feature unless the obstruction progresses to severe strangulation and localized ischemia. *Cholecystitis* - **Cholecystitis** is inflammation of the gallbladder, causing pain predominantly in the **right upper quadrant** or epigastrium, often linked to fatty meals. - This location is inconsistent with pain and rebound tenderness strictly localized to the **lower right abdomen**.

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

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 5

A 30-year-old female presents with a painful red granular lesion on the vulva accompanied by bilateral lymphadenopathy. What is the most likely diagnosis?

Accepted Answer

Chancroid

Answer

Neisseria Gonorrhoeae Infection

Answer

Lymphogranuloma Venereum

Answer

Granuloma Inguinale

Question 6

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 7

The ureter is safe in which type of hysterectomy?

Accepted Answer

Vaginal

Answer

Robotic

Answer

Laparoscopy

Answer

Open laparotomy

Question 8

A 29-year-old woman presents with abdominal pain, vaginal bleeding, and a history of amenorrhea for 6 weeks. Transvaginal ultrasound does not show an intrauterine gestational sac or features suggestive of ectopic pregnancy. Her serum $\beta$-hCG is 1,200 IU/L, which is below the discriminatory zone. What is the next step in management?

Accepted Answer

Repeat $\beta$-hCG after 48 hours

Answer

Dilatation and curettage

Answer

Methotrexate therapy

Answer

Laparoscopy

Question 9

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

Question 10

A patient presents with lower right abdominal pain and rebound tenderness. Intraoperatively, an inflamed Meckel's diverticulum is found. This clinical presentation most closely mimics which condition?

Accepted Answer

Appendicitis

Answer

Cholecystitis

Answer

Perforation

Answer

Intestinal obstruction

FMGE 2025

Anatomy

Dermatology

Obstetrics and Gynecology

Surgery