Master Pathology
for FMGE

What the FMGE Tests in Pathology

The FMGE Pathology exam tests your ability to diagnose and manage common and life-threatening conditions using histopathology, clinical biochemistry, and haematology. You must demonstrate knowledge of disease mechanisms, diagnostic criteria, and first-line treatments. Expect questions on tumour markers (e.g., PSA >4 ng/mL, CEA in colorectal cancer), acute coronary syndrome (troponin I >0.04 ng/mL, ECG changes), and infectious diseases (e.g., TB: GeneXpert, AFB smear, Mantoux test >10 mm in high-risk). You will be asked to interpret lab values (e.g., HbA1c ≥6.5% for diabetes, INR 2-3 for warfarin), identify classic histology (e.g., Reed-Sternberg cells in Hodgkin lymphoma), and apply WHO classification for tumours. Emphasis is on clinical decision-making: when to biopsy, which stain to order, and how to interpret results for management.

High-Yield Concepts

• Tumour Markers and Their Clinical Use: PSA >4 ng/mL prompts prostate biopsy; CEA >5 ng/mL suggests colorectal cancer recurrence; CA-125 >35 U/mL raises suspicion for ovarian cancer; AFP >500 ng/mL indicates hepatocellular carcinoma; hCG >1000 IU/L with no pregnancy suggests choriocarcinoma. Always consider false positives (e.g., CEA in smokers).
• Acute Myocardial Infarction Diagnosis: Universal definition: troponin I/T rise >99th percentile (typically >0.04 ng/mL) with at least one of: ischaemic symptoms, new ST elevation (≥1 mm in limb leads, ≥2 mm in V2-V3), new LBBB, or imaging evidence. First-line: aspirin 300 mg, ticagrelor 180 mg, heparin, urgent revascularisation.
• Diabetes Mellitus Diagnostic Criteria: HbA1c ≥6.5% (48 mmol/mol) or fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) or 2-hour OGTT ≥11.1 mmol/L (200 mg/dL) or random glucose ≥11.1 mmol/L with symptoms. First-line metformin 500 mg BD, target HbA1c <7% (53 mmol/mol) for most adults.
• Tuberculosis Diagnosis and Treatment: Sputum AFB smear (Ziehl-Neelsen) and GeneXpert MTB/RIF. Mantoux test ≥10 mm induration in high-risk groups (e.g., HIV, close contacts). First-line: rifampicin, isoniazid, pyrazinamide, ethambutol for 2 months, then rifampicin/isoniazid for 4 months. Drug-resistant TB requires second-line agents.
• Hodgkin Lymphoma Histology and Staging: Reed-Sternberg cells (CD15+, CD30+) in appropriate background. Staging by Ann Arbor: I (single node), II (≥2 nodes same side diaphragm), III (both sides), IV (extranodal). Treatment: ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) ± radiotherapy.
• Deep Vein Thrombosis and Pulmonary Embolism: Wells score: DVT (≥2 points = likely), PE (≥4 points = likely). D-dimer >500 ng/mL (age-adjusted: >age×0.1 mg/L if >50 years). First-line: low-molecular-weight heparin (e.g., enoxaparin 1.5 mg/kg/day) then warfarin (INR 2-3) or DOAC (rivaroxaban 15 mg BD for 3 weeks, then 20 mg OD).
• Chronic Lymphocytic Leukaemia Diagnostic Criteria: Diagnosis: absolute lymphocyte count ≥5×10^9/L for ≥3 months, smear shows smudge cells. Immunophenotype: CD5+, CD23+, CD19+, weak surface Ig. Rai staging: 0 (lymphocytosis), I (lymphadenopathy), II (splenomegaly), III (Hb <11 g/dL), IV (platelets <100×10^9/L). Treatment: ibrutinib or venetoclax ± rituximab.
• Liver Cirrhosis and Portal Hypertension: Child-Pugh score (bilirubin, albumin, INR, ascites, encephalopathy) class A (5-6), B (7-9), C (10-15). MELD score for transplant listing. First-line for ascites: spironolactone 100 mg OD, furosemide 40 mg OD; for variceal bleeding: terlipressin 2 mg IV q6h, band ligation, prophylactic antibiotics (ceftriaxone 1 g IV).

Common Traps in Pathology Questions

• Confusing troponin I and T cut-offs: both use >99th percentile, but lab-specific values vary; always use local reference range.
• Assuming a positive Mantoux test alone diagnoses active TB; it only indicates infection, not active disease — confirm with sputum culture or GeneXpert.
• Misinterpreting HbA1c in anaemia or haemoglobinopathies; use fasting glucose or OGTT if unreliable.
• Forgetting that D-dimer is non-specific; elevated in pregnancy, cancer, infection, and recent surgery — never use alone to rule in DVT/PE.
• Thinking Reed-Sternberg cells are pathognomonic for Hodgkin lymphoma; they can also appear in EBV infection and other lymphomas (e.g., T-cell rich B-cell lymphoma).
• Using warfarin without checking INR 2-3; supratherapeutic INR >5 increases bleeding risk, and subtherapeutic <2 increases thrombosis risk.

How to Revise Pathology for the FMGE

Prioritise tumour markers, acute MI criteria, diabetes diagnosis, TB workup, and haematological malignancies (lymphoma, leukaemia). Questions often present a clinical vignette with lab values or histology images; you must identify the condition and next best step (e.g., biopsy, stain, drug). Practice interpreting cut-offs (e.g., HbA1c, troponin, D-dimer) and staging systems (Ann Arbor, Child-Pugh, Rai). Focus on first-line treatments and common pitfalls in diagnosis. Review WHO classification for common tumours and the use of immunohistochemistry (e.g., CD markers). Spend time on anticoagulation guidelines and INR targets. Avoid rote memorisation of rare diseases; exam emphasis is on high-prevalence, high-stakes conditions.

Practise it: MedLumen has 50 Pathology questions for the FMGE, each with a full explanation and references.