Internal Medicine
2 questionsA 23-year-old female visited the clinician with a solitary thyroid nodule and was advised for thyroid function tests where TSH level is 27.3 mU/L, T3 is 1.24 ng/mL, and T4 is 4.87 μg/dL. Which of the following manifestations is true regarding the condition?
A 60 y/o male suddenly experiences an intense headache, described as the worst headache of his life, followed by vomiting and photophobia. O/E he has neck stiffness and a dilated pupil on the right side. A CT scan reveals bleeding in the subarachnoid space. Which of the following is the most common cause of this condition?
FMGE 2025 - Internal Medicine FMGE Practice Questions and MCQs
Question 271: A 23-year-old female visited the clinician with a solitary thyroid nodule and was advised for thyroid function tests where TSH level is 27.3 mU/L, T3 is 1.24 ng/mL, and T4 is 4.87 μg/dL. Which of the following manifestations is true regarding the condition?
- A. Weight gain (Correct Answer)
- B. Diarrhea
- C. Tachycardia
- D. Heat intolerance
Explanation: ***Weight gain***- The patient's thyroid function tests (TFTs), showing a **highly elevated TSH** (27.3 mU/L) and **low T4** (4.87 μg/dL), confirm a diagnosis of **Primary Hypothyroidism** [1].- Weight gain is a classic symptom of hypothyroidism, resulting from reduced **basal metabolic rate** and frequently accompanied by **fluid retention** leading to *myxedema* [2]. *Heat intolerance*- Heat intolerance is a characteristic feature of **Hyperthyroidism**, where excess thyroid hormone increases heat production.- Patients with hypothyroidism typically experience **cold intolerance** due to decreased thermogenesis [2]. *Tachycardia*- **Tachycardia** (increased heart rate) is a common cardiovascular manifestation of **Hyperthyroidism** due to enhanced adrenergic effects [2].- Hypothyroidism generally leads to **bradycardia** (slow heart rate) and reduced cardiac contractility [2]. *Diarrhea*- Diarrhea is associated with **Hyperthyroidism** because of increased gastrointestinal motility.- Patients suffering from hypothyroidism commonly present with decreased bowel motility, leading to **constipation** [2].
Question 272: A 60 y/o male suddenly experiences an intense headache, described as the worst headache of his life, followed by vomiting and photophobia. O/E he has neck stiffness and a dilated pupil on the right side. A CT scan reveals bleeding in the subarachnoid space. Which of the following is the most common cause of this condition?
- A. Hypertension
- B. Intracranial aneurysm (Correct Answer)
- C. Brain tumour
- D. Arteriovenous malformation (AVM)
Explanation: ***Intracranial aneurysm***- Rupture of an intracranial **saccular (berry) aneurysm** accounts for approximately 85% of all non-traumatic subarachnoid hemorrhage (SAH) cases, making it the most common cause [2].- The classic presentation of the **"worst headache of his life"** (thunderclap headache), meningismus (**neck stiffness**), and potential Third nerve palsy (dilated pupil due to compression) are highly suggestive of aneurysmal SAH [1].*Hypertension*- Uncontrolled **chronic hypertension** is the leading cause of non-traumatic **intraparenchymal hemorrhage (ICH)**, typically affecting deep brain structures like the basal ganglia.- While hypertension is a major risk factor for SAH, it is not the primary mechanism of bleeding; the rupture of an aneurysm is the direct immediate cause [1].*Arteriovenous malformation (AVM)*- AVMs are abnormal connections that can rupture, causing hemorrhagic stroke, but they are the second most common cause of SAH, accounting for less than 10% of cases.- AVM rupture often leads to a combination of **intraparenchymal hemorrhage** and SAH, and they are typically associated with younger patients.*Brain tumour*- Tumors rarely cause acute, massive SAH; when they bleed, it typically occurs within the tumor mass itself (**intratumoral hemorrhage**).- The clinical presentation usually involves subacute onset of symptoms and progressive focal neurological deficits, rather than the sudden, dramatic thunderclap headache characteristic of SAH [1].
Pathology
1 questionsA 30-year-old female presents to the OPD with a 3 cm breast lump in the upper medial quadrant. The lump has an uneven, bosselated surface, and the overlying skin is mildly ulcerated. Microscopic examination reveals the given findings. What is the most likely diagnosis?
FMGE 2025 - Pathology FMGE Practice Questions and MCQs
Question 271: A 30-year-old female presents to the OPD with a 3 cm breast lump in the upper medial quadrant. The lump has an uneven, bosselated surface, and the overlying skin is mildly ulcerated. Microscopic examination reveals the given findings. What is the most likely diagnosis?
- A. Phyllodes tumor (Correct Answer)
- B. Fibroadenoma
- C. Paget's disease
- D. Galactocele
Explanation: ***Phyllodes tumor*** - The histology shows a classic **leaf-like (phyllodes)** architecture, which is pathognomonic [1]. This is a fibroepithelial lesion characterized by an overgrowth of the stromal component forming these projections [1]. - Clinically, these tumors often present as large, rapidly growing, bosselated masses [1]. Skin ulceration, as seen in this patient, can occur with larger or more aggressive (borderline/malignant) phyllodes tumors. *Galactocele* - A galactocele is a milk-filled cyst, typically occurring during or after lactation. Histologically, it would appear as a cyst lined by flattened epithelium containing **inspissated, eosinophilic material**, not a complex stromal proliferation. - Clinically, it presents as a smooth, mobile, and often tender cyst, which is inconsistent with the uneven, bosselated mass described. *Fibroadenoma* - While also a fibroepithelial tumor, a fibroadenoma has a less cellular stroma and lacks the prominent **leaf-like structures** and stromal overgrowth seen in the image [1]. The glands are typically compressed by a paucicellular stroma [2]. - Fibroadenomas are usually smaller, well-circumscribed, rubbery, and highly mobile masses (often called a **'breast mouse'**) that rarely cause skin changes like ulceration [2]. *Paget's disease* - Paget's disease is an adenocarcinoma affecting the epidermis of the nipple-areolar complex. Histology would show malignant **Paget cells** infiltrating the epidermis, which is not seen here. - The clinical presentation involves an eczematous, crusted, or ulcerating lesion of the **nipple and areola**, not a distinct lump in a breast quadrant [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, p. 1074. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 448-449. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 443-444.
Pediatrics
2 questionsIn a child presenting with a beaded appearance in the chest with the following X-ray, what is the diagnosis? 
A newborn male presents with urinary retention, lethargy and a distended bladder. Antenatal ultrasound showed a "keyhole sign" with a thickened bladder wall. Which of the following is the most likely diagnosis?
FMGE 2025 - Pediatrics FMGE Practice Questions and MCQs
Question 271: In a child presenting with a beaded appearance in the chest with the following X-ray, what is the diagnosis? 
- A. Beri Beri
- B. Pellagra
- C. Rickets (Correct Answer)
- D. Scurvy
Explanation: ***Rickets*** - The clinical finding of a "beaded appearance" in the chest refers to **rachitic rosary**, which is a classic sign of rickets caused by the enlargement of the costochondral junctions. - The wrist X-ray confirms the diagnosis by showing characteristic features of defective bone mineralization, including **cupping**, **fraying**, and widening of the distal metaphysis of the radius and ulna. *Scurvy* - Scurvy, caused by **vitamin C deficiency**, typically presents with **bleeding gums**, poor wound healing, and perifollicular hemorrhage, not skeletal deformities like a rachitic rosary. - Radiographic findings in scurvy include a **white line of Fraenkel** (a dense metaphyseal line) and subperiosteal hemorrhages, which are absent in the provided X-ray. *Beri Beri* - Beri Beri is a result of **thiamine (vitamin B1) deficiency** and primarily manifests with neurological (dry beriberi) or cardiovascular (wet beriberi) symptoms. - This condition does not cause the characteristic skeletal abnormalities or radiographic changes seen in rickets. *Pellagra* - Pellagra is caused by **niacin (vitamin B3) deficiency** and is characterized by the classic triad of **dermatitis**, **diarrhea**, and **dementia** (the "3 Ds"). - It is a systemic illness that does not involve the skeletal system in the manner described or shown in the X-ray.
Question 272: A newborn male presents with urinary retention, lethargy and a distended bladder. Antenatal ultrasound showed a "keyhole sign" with a thickened bladder wall. Which of the following is the most likely diagnosis?
- A. Posterior urethral valves (Correct Answer)
- B. Hypospadias
- C. Vesicoureteral reflux
- D. Neurogenic bladder
Explanation: ***Posterior urethral valves***- The **"keyhole sign"** seen on antenatal ultrasound, characterized by a dilated posterior urethra and a thickened, distended bladder, is highly specific for **posterior urethral valves (PUV)**.- PUV is the most common cause of severe **lower urinary tract obstruction** in male newborns, leading directly to symptoms like lethargy, a palpable **distended bladder**, and urinary retention.*Hypospadias*- *Hypospadias* is an abnormal location of the **urethral meatus** on the ventral aspect of the penis.- It does not cause the severe **obstructive uropathy** (like urinary retention and bladder distension) or the **keyhole sign** observed in this patient.*Vesicoureteral reflux*- *Vesicoureteral reflux* (VUR) involves the reflux of urine from the bladder back up to the ureters and is typically a **non-obstructive** cause of hydronephrosis and UTIs.- While VUR can coexist with PUV, it is the secondary phenomenon, and VUR itself does not cause the primary **urethral obstruction** or the characteristic **keyhole appearance**.*Neurogenic bladder*- A *neurogenic bladder* results from impaired nerve supply, often due to conditions like **spina bifida**, leading to poor bladder emptying.- While it can cause retention, the unique finding of the **keyhole sign** points specifically to a fixed, **anatomical obstruction** in the posterior urethra, which is not characteristic of neurological issues.
Surgery
5 questionsA 34-year-old male undergoes an open appendectomy for acute appendicitis. The choice of incision was McBurney's incision. Postoperatively, after a few days, he presents with pain and bulging in the right lower quadrant, which is diagnosed as an indirect inguinal hernia. Which nerve injury during the appendectomy is most likely responsible for this complication?
A 45-year-old male patient was brought to the emergency department following a road traffic accident. O/E, he had multiple injuries all over his body and was found to be in class III hemorrhagic shock. The percentage of blood loss would be between:
A 20-year-old male presents to the outpatient department with a swelling on his wrist. He reports fluctuation in size, mild numbness in the hand, and occasional pain. What is the most likely diagnosis?
A patient with dilated tortuous veins of the leg presented to the OPD and is diagnosed with varicose vein of grade C4a. What is the best preferred treatment?
In a follow-up case of prostate cancer, what do we need to check?
FMGE 2025 - Surgery FMGE Practice Questions and MCQs
Question 271: A 34-year-old male undergoes an open appendectomy for acute appendicitis. The choice of incision was McBurney's incision. Postoperatively, after a few days, he presents with pain and bulging in the right lower quadrant, which is diagnosed as an indirect inguinal hernia. Which nerve injury during the appendectomy is most likely responsible for this complication?
- A. Ilioinguinal nerve (Correct Answer)
- B. Pudendal nerve
- C. Genitofemoral nerve
- D. Femoral nerve
Explanation: ***Ilioinguinal nerve*** - The **ilioinguinal nerve** (L1) runs between the internal oblique and transversus abdominis muscles in the inguinal region and passes through the superficial inguinal ring - During **McBurney's incision** (muscle-splitting incision at McBurney's point), the ilioinguinal nerve is at risk of injury as it traverses the layers of the anterior abdominal wall - **Mechanism of hernia formation:** Injury to the ilioinguinal nerve causes denervation and atrophy of the internal oblique and transversus abdominis muscles, which weakens the posterior wall of the inguinal canal - This muscular weakness predisposes to **indirect inguinal hernia** formation through the internal inguinal ring - **Classic presentation:** Pain and bulging in the inguinal region post-appendectomy *Pudendal nerve* - Arises from S2-S4 and runs through the **pelvis and perineum** (pudendal canal) - Not at risk during appendectomy as it is far from the surgical field - Injury would cause perineal sensory loss and sphincter dysfunction, not hernia *Genitofemoral nerve* - Runs on the psoas muscle and divides into genital and femoral branches - While the genital branch passes through the inguinal canal, injury typically causes **sensory loss** in the groin and scrotum/labia - Does **not** cause motor weakness or hernia formation *Femoral nerve* - Runs beneath the **inguinal ligament** in the femoral triangle - Not at risk during McBurney's incision - Injury would cause quadriceps weakness and loss of knee extension, not hernia
Question 272: A 45-year-old male patient was brought to the emergency department following a road traffic accident. O/E, he had multiple injuries all over his body and was found to be in class III hemorrhagic shock. The percentage of blood loss would be between:
- A. >40%
- B. 30-40% (Correct Answer)
- C. 5-15%
- D. 15-30%
Explanation: ***30-40%***- **Class III hemorrhagic shock** is defined by an estimated blood loss of **30-40%** (approximately 1500 to 2000 mL in an adult).- Clinically, patients in Class III shock present with **marked tachycardia** (>120 bpm), significant **hypotension**, and altered **mental status** (confusion).*5-15%*- This range corresponds to **Class I hemorrhagic shock**, which involves minimal blood loss (up to 750 mL).- Patients in **Class I** typically present with near-normal vital signs or mild **tachycardia** only, not the severe clinical picture described.*>40%*- This defines **Class IV hemorrhagic shock**, representing extremely severe and **life-threatening** blood loss (over 2000 mL).- Patients in **Class IV** present with profound **hypotension** and absent peripheral pulses; they are often unresponsive.*15-30%*- This range characterizes **Class II hemorrhagic shock**, which involves moderate blood loss (750 to 1500 mL).- Patients exhibit **tachycardia** (100–120 bpm) and decreased **pulse pressure**, but usually maintain adequate blood pressure and good mental status, unlike the patient described.
Question 273: A 20-year-old male presents to the outpatient department with a swelling on his wrist. He reports fluctuation in size, mild numbness in the hand, and occasional pain. What is the most likely diagnosis?
- A. Dermoid cyst
- B. Lipoma
- C. Ganglion cyst (Correct Answer)
- D. Hematoma
Explanation: ***Ganglion cyst*** - This is the most common benign soft-tissue tumor of the hand and wrist, often arising from a **joint capsule** or **tendon sheath**. The classic presentation includes a smooth, round swelling on the wrist that can fluctuate in size. - Symptoms like mild pain and numbness can occur due to **nerve compression**, which is consistent with the patient's presentation. On examination, they are typically firm and **transilluminate**. *Lipoma* - A lipoma is a benign tumor composed of **adipose tissue** (fat). It typically presents as a soft, mobile, and “doughy” subcutaneous mass, which differs from the usually firm consistency of a ganglion cyst. - Lipomas do not fluctuate in size and are less likely to be found on the dorsal aspect of the wrist compared to ganglion cysts. *Dermoid cyst* - A dermoid cyst is a **congenital** lesion (a type of teratoma) containing dermal structures like hair follicles and sebaceous glands. They are most commonly found in the midline, face, or neck. - Their presence on the wrist is extremely rare, and they do not typically fluctuate in size like a ganglion cyst. *Hematoma* - A hematoma is a localized collection of blood, usually resulting from **trauma**. The patient's history does not mention any injury. - An acute hematoma would be tender and associated with **ecchymosis** (bruising), and it would be expected to resolve over time rather than fluctuate.
Question 274: A patient with dilated tortuous veins of the leg presented to the OPD and is diagnosed with varicose vein of grade C4a. What is the best preferred treatment?
- A. Non endothermal non tumescent ablation
- B. Open surgery
- C. Compression
- D. Endothermal ablation (Correct Answer)
Explanation: ***Endothermal ablation***- Guidelines recommend **endothermal ablation** (e.g., **EVLA** or **RFA**) as the first-line definitive treatment for symptomatic varicose veins (C2-C6), especially those causing **C4a skin changes** due to underlying reflux.- This technique is minimally invasive, highly effective at eliminating **saphenous vein reflux**, and leads to faster recovery and reduced recurrence rates compared to surgery.*Compression*- Compression therapy is mandated for all CEAP classifications (C0 to C6) but only serves as **conservative management** to alleviate symptoms and manage edema and skin changes (C4a).- It does not address the underlying **venous valve incompetence** leading to the venous hypertension and is therefore not the definitive preferred treatment.*Non endothermal non tumescent ablation*- These techniques, such as **mechanochemical ablation** (MOCA) or **cyanoacrylate glue**, are effective and avoid the need for general anesthesia or tumescent local anesthesia, making them suitable alternatives.- However, endothermal modalities are often preferred as first-line due to extensive long-term data supporting their effectiveness and durability in treating major **truncal reflux**.*Open surgery*- **High ligation and stripping** used to be the gold standard but is now generally reserved for complex cases where ablation is not technically feasible, such as large tributary veins or extreme **tortuosity**.- Open surgery involves greater morbidity, longer hospital stays, and potentially higher risks of **injury to nerves** (e.g., saphenous nerve) compared to endothermal methods.
Question 275: In a follow-up case of prostate cancer, what do we need to check?
- A. Acid phosphatase
- B. PSA (Correct Answer)
- C. Alkaline phosphatase
- D. Testosterone
Explanation: ***PSA***- **Prostate-Specific Antigen** is the primary biomarker used for routine surveillance and follow-up after definitive treatment (like prostatectomy or radiation) for prostate cancer. - A sustained rise in PSA levels, known as **biochemical recurrence**, is the earliest sign that prostate cancer may have returned locally or metastasized. *Alkaline phosphatase* - **Alkaline phosphatase (ALP)** levels are primarily followed when there is suspicion of **bony metastasis**, as high ALP reflects increased osteoblastic activity. - It is used to stage and evaluate advanced disease or monitor response to treatment for bone mets, but it is not the primary marker for general recurrence detection. *Testosterone* - **Testosterone** levels are monitored primarily in patients receiving **androgen deprivation therapy (ADT)** to ensure that castrate levels of androgens are being maintained. - Changes in circulating testosterone do not reliably indicate cancer recurrence or progression in patients not undergoing hormonal manipulation. *Acid phosphatase* - **Acid phosphatase (ACP)**, specifically prostatic acid phosphatase (PAP), is a historical tumor marker that has been superseded by PSA in nearly all aspects of follow-up. - Elevated ACP is usually associated with **advanced or metastatic disease** but lacks the sensitivity of PSA for detecting early biochemical recurrence.