FMGE 2025 Practice Questions

Q: A woman presents with a breast lump, associated with skin dimpling and nipple retraction. What is the most likely anatomical structure responsible for the skin dimpling?

Suspensory (Cooper’s) ligaments. ***Suspensory (Cooper’s) ligaments*** - These are fibrous septa that run from the deep pectoral fascia to the dermis of the skin, providing structural support to the breast [1]. - Invasion and shortening of these ligaments by a growing tumor pull on the overlying skin, causing the characteristic **skin dimpling** or peau d'orange appearance [1]. *Lactiferous ducts* - These are the milk ducts that converge and open at the nipple [1]. - Malignant infiltration of the lactiferous ducts is more commonly associated with **nipple retraction** and pathologic nipple discharge, rather than skin dimpling [2]. *Pectoral fascia* - This is a deep layer of connective tissue that covers the pectoralis major muscle, on which the breast lies [1]. - Tumor invasion into the pectoral fascia can cause the breast to become **fixed** to the chest wall, a sign of advanced disease, but does not directly cause superficial skin dimpling. *Subcutaneous fat* - This tissue makes up the bulk of the breast volume and surrounds the glandular components. - Subcutaneous fat itself lacks the tensile strength to pull the skin inward; it is the **fibrous ligaments** passing through the fat that cause retraction [1].

Q: In the image shown, identify the function of the marked structure on the endotracheal tube.

Prevention of air leakage and aspiration. ***Prevention of air leakage and aspiration*** - The marked structure is the **inflatable cuff** of the endotracheal tube, which, when inflated, creates a seal against the wall of the trachea. - This seal ensures that air delivered during **positive pressure ventilation** goes directly to the lungs without leaking and also prevents **aspiration** of gastric or pharyngeal contents into the lower airway. *Facilitation of vocal cord visualization* - Visualization of the vocal cords is accomplished using a **laryngoscope** during the process of intubation, before the cuff is inflated. - The cuff is located distal to the tip and is inflated only after the tube has been correctly positioned past the vocal cords. *Monitoring airway pressure* - Overall airway pressure (like peak inspiratory pressure) is monitored through the **ventilator circuit**, not by the cuff itself. - The **pilot balloon**, connected to the cuff, allows for monitoring of the **cuff pressure** to avoid tracheal injury, but it does not measure airway breathing pressure. *Suctioning of lower respiratory tract secretions* - Suctioning of secretions from the lower respiratory tract is performed by passing a **suction catheter** through the main lumen of the endotracheal tube. - The cuff's role is to prevent aspiration, not to actively remove secretions, although specialized tubes may have a separate **subglottic suction port** located above the cuff.

Q: Secondary prevention is most useful in the early detection and treatment of which of the following cancers?

Cervical cancer. ***Cervical cancer*** - Cervical cancer is a classic example of successful **secondary prevention** due to effective screening tests like the **Papanicolaou (Pap) test** and **Human Papillomavirus (HPV) testing**, which can detect precancerous lesions (**cervical intraepithelial neoplasia, CIN**). - The image displays a **colposcopy**, where **acetic acid** is applied to the cervix, causing abnormal cells with high nuclear density to turn white (**acetowhite changes**). This guides biopsy and allows for early treatment, preventing progression to invasive cancer. *Pancreatic cancer* - There is currently no effective or recommended screening test for **pancreatic cancer** in the asymptomatic, average-risk population. - It often presents with non-specific symptoms at a late stage due to its retroperitoneal location, leading to a delayed diagnosis and poor prognosis. *Ovarian cancer* - Routine screening with **CA-125** and **transvaginal ultrasound** is not recommended for the general population as it has not been proven to reduce mortality. - These screening methods have a high rate of **false positives**, leading to unnecessary invasive procedures and patient anxiety. *Glioblastoma* - There are no established screening protocols for **glioblastoma**, a highly aggressive primary brain tumor. - Diagnosis is typically made after the onset of neurological symptoms, such as headaches or seizures, at which point the tumor is usually advanced.

Q: A long-term study found that individuals who had high blood pressure (BP) during childhood continued to have high BP in adulthood, and those with low BP in childhood tended to maintain lower levels later in life. Which of the following epidemiological concepts does this pattern best represent?

Tracking of blood pressure. ***Tracking of blood pressure***- This term refers to the phenomenon where an individual's **relative position** (e.g., high or low) within a distribution of a biological variable, such as blood pressure or cholesterol, is maintained over time from childhood into adulthood.- The observation that high childhood BP predicts high adult BP is the classic definition of **tracking**, implying that early life measurements have significant predictive value for later life risk.*Rule of halves*- This is a concept used in the management of chronic conditions, particularly **hypertension**, stating that only about half of the people affected are diagnosed, and only about half of those diagnosed are treated.- It describes an inefficiency in public health management effectiveness, not the **longitudinal stability** of a physiological measurement within an individual.*Regression to the mean*- This statistical phenomenon occurs when an extreme measurement on a variable is followed by a second measurement that is closer to the **population average** or mean.- This would suggest that extremely high BP moves towards the average upon repeat measurement, which contradicts the finding that the high BP *persists* over time (tracking).*Cohort effect*- A cohort effect is variation in outcomes that arise from the unique **temporal experiences** or exposure of a specific group (birth cohort) that differentiates them from other age groups.- While the study involves a cohort, the specific epidemiological term describing the maintenance of an individual's relative **rank** over time is **tracking**.

Q: What is the best diagnostic test for evaluating endometrial pathology?

Hysteroscopy-guided endometrial biopsy. ***Hysteroscopy-guided endometrial biopsy*** - This is considered the **gold standard** for evaluation as it allows for **direct visualization** of the endometrial cavity, facilitating the targeted biopsy of focal lesions such as polyps or localized carcinoma. - Targeting specific areas significantly improves **diagnostic yield** and accuracy, minimizing the risk of missing pathology compared to blind procedures. *Pipelle endometrial biopsy* - This is an effective, **office-based suction procedure** often used for initial screening of diffuse pathology (e.g., endometrial hyperplasia or carcinoma) due to its ease and tolerability. - It is a **blind procedure** and may fail to adequately sample or completely miss **focal lesions** like small polyps or carcinoma situated in the cornua. *Dilatation and curettage (D&C)* - D&C is also a **blind scraping procedure** that often yields incomplete tissue sampling, particularly of the **uterine cornua**, leading to potential false negatives. - While useful therapeutically (e.g., managing abortions), it is less accurate for **diagnostic evaluation** than hysteroscopy. *Transvaginal sonography* - TVS is an **initial screening test** used to measure **endometrial thickness** (ET), which can indicate the *need* for, but cannot replace, histological diagnosis. - It provides **structural information** (e.g., presence of fluid, fibroids) but cannot definitively diagnose the nature of the cellular pathology, requiring subsequent biopsy for **histological confirmation**.

Q: In which of the following conditions would the use of an intrauterine contraceptive device (IUCD) require the most careful consideration due to contraindication concerns?

HIV infection. ***HIV infection*** - According to WHO Medical Eligibility Criteria (MEC), HIV infection presents varying levels of concern depending on disease status: - **Stable HIV on ART**: MEC Category 2 (benefits generally outweigh risks) - **Severe/Advanced HIV (AIDS)**: MEC Category 3 (risks usually outweigh benefits) - The primary concern is the increased risk of **pelvic inflammatory disease (PID)** in immunocompromised patients - Among the options provided, HIV infection represents the **strongest relative contraindication** requiring careful clinical assessment before IUCD insertion - Recent guidelines emphasize individualized decision-making based on immune status, viral load, and ART adherence *Hypertension* - **Hypertension** is NOT a contraindication for IUCD use (MEC Category 1) - Neither copper IUDs nor levonorgestrel-releasing IUDs (LNG-IUD) affect blood pressure - IUCDs are safe contraceptive options for women with controlled or uncontrolled hypertension - No cardiovascular risk associated with IUD use *Hyperlipidemia* - **Hyperlipidemia** is NOT a contraindication for IUCD use (MEC Category 1) - IUDs do not affect lipid metabolism or lipid levels - Both copper and hormonal IUCDs can be safely used in women with abnormal lipid profiles *Diabetes mellitus* - **Diabetes mellitus** is NOT a contraindication for IUCD use (MEC Category 1/2) - Both copper and hormonal IUDs are safe and effective for diabetic patients - IUCDs are often preferred over combined hormonal contraceptives, which may affect **glycemic control** - No increased risk of complications with proper insertion technique

Q: A 12-year-old female presents with Tanner stage II breast development and white, odorless vaginal discharge. This discharge is most likely due to the action of which hormone?

Estrogen. ***Estrogen*** - **Estrogen** levels rise during the initial phases of puberty (Tanner stage II), primarily driving secondary sexual characteristics like **breast development** and maturation of the vaginal epithelium. - Increased estrogen levels lead to enhanced mucus production by cervical glands and increased desquamation of vaginal epithelial cells, resulting in the normal, odorless, white discharge known as **physiologic leukorrhea** seen premenarche. *GnRH* - **Gonadotropin-releasing hormone (GnRH)** is the hypothalamic hormone that initiates puberty by stimulating the pituitary to release **FSH** and **LH**. - While GnRH initiates the hormonal cascade, it is the downstream production of **estrogen** by the ovaries that directly causes the changes in the genital tract mucosa resulting in vaginal discharge. *Inhibin B* - **Inhibin B** is predominantly produced by the **granulosa cells** of the developing ovarian follicles. - Its main function is to provide negative feedback to the pituitary gland, selectively inhibiting the secretion of **Follicle-Stimulating Hormone (FSH)**, and is not directly implicated in causing vaginal discharge. *Progesterone* - **Progesterone** is primarily produced by the corpus luteum after ovulation and plays a key role in preparing the endometrium for implantation. - In early puberty (Tanner stage II), progesterone levels are typically low as ovulatory cycles have not yet been established, and it does not directly cause the vaginal discharge seen at this stage.

Q: A 36-year-old P2L2 patient diagnosed with severe endometriosis shows pelvic adhesions on laparoscopy. She has undergone tubal ligation and adhesiolysis previously. What is the most appropriate management during laparoscopy?

Total hysterectomy and bilateral salpingo-oophorectomy. ***Total hysterectomy and bilateral salpingo-oophorectomy***- This is the **definitive surgical treatment** for symptomatic **severe endometriosis** (Grade IV) in patients who have completed childbearing, offering the highest chance of cure and symptom relief.- Removing both the uterus and the ovaries eliminates the sources of **menstruation** and **estrogen**, which fuel the remaining endometriotic lesions, thereby minimizing the risk of recurrence.*Observation only, no intervention*- This approach is inappropriate for **severe, symptomatic endometriosis**, especially given the history of failed prior intervention (adhesiolysis) and chronic symptoms.- Failing to intervene surgically can lead to persistent **chronic pelvic pain** and potential organ dysfunction due to extensive adhesions and deep infiltrating endometriosis.*Total laparoscopic hysterectomy*- While removing the uterus addresses pain related to menses and potential adenomyosis, leaving the ovaries intact ensures continued **estrogen production**.- Continued estrogen stimulation significantly increases the risk of endometriosis recurrence (up to 50%) from any residual deposits, contraindicating ovarian preservation in this severe case.*Oophorectomy*- Simple oophorectomy (unilateral or bilateral) without concomitant **hysterectomy** is generally inadequate for severe endometriosis.- If the uterus is left behind, the patient may still experience cyclical bleeding and pain related to **adenomyosis** or pain fibers, and surgical staging remains incomplete for definitive care.

Q: After an initial serum $\beta$-hCG test in a patient with suspected pregnancy, when should the repeat $\beta$-hCG level ideally be checked to assess viability or progression?

48 hours. ***Correct: 48 hours*** - In a viable, intrauterine pregnancy, serum β-hCG levels typically **double approximately every 48 hours** (or show a rise of at least 35% in 48 hours) during the initial weeks. - This standard **48-hour interval** is critical as it provides the most timely and appropriate benchmark to determine if the required doubling is occurring, aiding in the assessment of viability. - This is the **gold standard timing** for repeat β-hCG testing in early pregnancy monitoring. *Incorrect: 24 hours* - This interval is generally **too short** to observe the significant rise needed to confidently distinguish a normal, viable doubling rate from an abnormal or insufficient rate. - Due to natural variations in hormone secretion, a 24-hour reading often yields an overlapping range, making interpretation of the trend difficult. *Incorrect: 72 hours* - Although a check at 72 hours is sometimes used (as doubling can take up to 72 hours), waiting this long can **delay critical diagnosis** of urgent conditions like a non-ruptured **ectopic pregnancy** or ongoing miscarriage. - The 48-hour check remains the standard benchmark providing the earliest necessary data for management decisions. *Incorrect: 96 hours* - Waiting 96 hours (4 days) is generally **too long** and could significantly delay necessary intervention or further management for a non-viable or **ectopic pregnancy**. - While β-hCG doubling slows down significantly after approximately 6 weeks of gestation, the initial assessment requires the tighter 48-hour timeframe.

Q: A pregnant woman with a short cervix undergoes a cervical cerclage procedure. The image shows a key step during the procedure. What is the most likely procedure being performed?

Modified Shirodkar. ***Modified Shirodkar*** - The image displays the dissection of the **vesicocervical mucosa** (bladder flap) which is a crucial step in the Shirodkar procedure, allowing the suture to be placed high on the cervix near the **internal os**. - This technique involves a submucosal placement of a non-absorbable suture (like Mersilene tape) which is then buried, providing better support for an incompetent cervix compared to lower-placed sutures. *Modified McDonald's* - The McDonald's procedure and its modifications are simpler techniques that place a **purse-string suture** around the cervix without any dissection of the cervical mucosa. - This procedure is less invasive but the suture is placed lower on the cervix, which might offer less support than a high cerclage like the Shirodkar. *McDonald's* - This is a transvaginal **purse-string suture** placed around the body of the cervix, cinching it closed. It is a common and relatively simple method of cerclage. - Crucially, it does not involve the **bladder dissection** shown in the image, which is the key differentiating feature of the Shirodkar technique. *Shirodkar* - While the procedure shown is a Shirodkar type, the **Modified Shirodkar** is the version most commonly performed today and is therefore the most precise answer. - The original Shirodkar technique often involved a permanent suture requiring a **cesarean delivery**, whereas the modified version uses a suture that can be removed to allow for a trial of vaginal delivery.

Question 1

A woman presents with a breast lump, associated with skin dimpling and nipple retraction. What is the most likely anatomical structure responsible for the skin dimpling?

Accepted Answer

Suspensory (Cooper’s) ligaments

Answer

Lactiferous ducts

Answer

Subcutaneous fat

Answer

Pectoral fascia

Question 2

In the image shown, identify the function of the marked structure on the endotracheal tube.

Accepted Answer

Prevention of air leakage and aspiration

Answer

Suctioning of lower respiratory tract secretions

Answer

Monitoring airway pressure

Answer

Facilitation of vocal cord visualization

Question 3

Secondary prevention is most useful in the early detection and treatment of which of the following cancers?

Accepted Answer

Cervical cancer

Answer

Pancreatic cancer

Answer

Ovarian cancer

Answer

Glioblastoma

Question 4

A long-term study found that individuals who had high blood pressure (BP) during childhood continued to have high BP in adulthood, and those with low BP in childhood tended to maintain lower levels later in life. Which of the following epidemiological concepts does this pattern best represent?

Accepted Answer

Tracking of blood pressure

Answer

Rule of halves

Answer

Cohort effect

Answer

Regression to the mean

Question 5

What is the best diagnostic test for evaluating endometrial pathology?

Accepted Answer

Hysteroscopy-guided endometrial biopsy

Answer

Transvaginal sonography

Answer

Pipelle endometrial biopsy

Answer

Dilatation and curettage (D&C)

Question 6

In which of the following conditions would the use of an intrauterine contraceptive device (IUCD) require the most careful consideration due to contraindication concerns?

Accepted Answer

HIV infection

Answer

Diabetes mellitus

Answer

Hypertension

Answer

Hyperlipidemia

Question 7

A 12-year-old female presents with Tanner stage II breast development and white, odorless vaginal discharge. This discharge is most likely due to the action of which hormone?

Accepted Answer

Estrogen

Answer

Inhibin B

Answer

GnRH

Answer

Progesterone

Question 8

A 36-year-old P2L2 patient diagnosed with severe endometriosis shows pelvic adhesions on laparoscopy. She has undergone tubal ligation and adhesiolysis previously. What is the most appropriate management during laparoscopy?

Accepted Answer

Total hysterectomy and bilateral salpingo-oophorectomy

Answer

Observation only, no intervention

Answer

Total laparoscopic hysterectomy

Answer

Oophorectomy

Question 9

After an initial serum $\beta$-hCG test in a patient with suspected pregnancy, when should the repeat $\beta$-hCG level ideally be checked to assess viability or progression?

Accepted Answer

48 hours

Answer

96 hours

Answer

24 hours

Answer

72 hours

Question 10

A pregnant woman with a short cervix undergoes a cervical cerclage procedure. The image shows a key step during the procedure. What is the most likely procedure being performed?

Accepted Answer

Modified Shirodkar

Answer

Shirodkar

Answer

Modified McDonald's

Answer

McDonald's

FMGE 2025

Anatomy

Anesthesiology

Community Medicine

Obstetrics and Gynecology