FMGE 2023 Practice Questions

Q: Which of the following is most suitable for intravenous regional anesthesia?

Lidocaine. ***Lidocaine***- It is the most commonly used agent for **intravenous regional anesthesia (IVRA)**, also known as a **Bier block**, due to its rapid onset and favorable safety profile upon systemic absorption.- Lidocaine is an intermediate-acting amide local anesthetic often supplied without epinephrine for IVRA to minimize the risks of **systemic vasoconstriction** should the tourniquet be released early.*Bupivacaine*- Bupivacaine is highly **cardiotoxic**; if the tourniquet fails or is released prematurely, high systemic concentrations can cause severe and potentially **lethal cardiac arrhythmias**.- This long-acting anesthetic is generally **contraindicated** for IVRA precisely due to its significant risk of systemic toxicity.*Mepivacaine*- While an intermediate-acting amide suitable for infiltration, mepivacaine is less commonly chosen than lidocaine for IVRA due to its similarity in properties but greater cost or lack of a clear safety advantage.- Some reports suggest mepivacaine may have slightly **higher neurotoxicity** compared to lidocaine, making lidocaine the preferred standard.*Procaine*- Procaine is an **ester-type** local anesthetic with a very short duration of action, making it unsuitable for procedures requiring sustained anesthesia (typically 45-60 minutes in IVRA).- Ester-type anesthetics are metabolized to **p-aminobenzoic acid (PABA)**, which increases the likelihood of **allergic reactions** compared to amide anesthetics.

Q: A 45-year-old patient with a history of smoking a pack of cigarettes for the past 15 years presents with hemoptysis. Chest X-ray shows a 3cm upper lobe mass near the apex of the lung. What is the next best step for managing this patient?

CT-guided biopsy. ***CT-guided biopsy***- This procedure is the preferred method for obtaining a definitive **tissue diagnosis** for a solitary **peripheral lung mass**, especially one highly suspicious of malignancy due to the patient's smoking history and hemoptysis [1].- Since the mass is **3cm** and located peripherally near the **apex**, a percutaneous **CT-guided transthoracic needle aspiration (TTNA)** provides the highest diagnostic yield compared to other non-invasive alternatives [2].*Bronchoscopy*- Bronchoscopy is primarily used to evaluate **central lesions** (proximal to segmental bronchi) or suspicious findings directly within the airway lumen.- It has a low diagnostic yield for discrete, small, or **peripheral masses** like this 3cm apical lesion, as the scope or biopsy instruments cannot reliably reach the target.*Sputum cytology*- Sputum cytology has low overall sensitivity, particularly for **peripheral lung masses** which are unlikely to shed sufficient malignant cells into the central airways.- While non-invasive, it often results in a non-diagnostic result and is therefore not the **next best step** for confirming the diagnosis of a discrete, radiographically apparent mass.*Sputum for AFB*- While an infectious process like tuberculosis (TB) can present as a mass, the patient's robust history of **heavy smoking** and the mass morphology strongly prioritize ruling out **lung carcinoma**.- Obtaining a tissue sample (biopsy) is mandatory due to the high suspicion of malignancy (indicated by hemoptysis and smoking) and takes precedence over attempting an infectious diagnosis first [3].

Q: Which of the following is seen in all kinds of shock?

Reduced tissue perfusion. ***Reduced tissue perfusion*** - **Shock** is fundamentally defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery, which results from inadequate or ineffective **tissue perfusion** [1]. - In all forms (hypovolemic, cardiogenic, distributive, and obstructive), the core pathophysiological defect is the inability to meet the metabolic demands of the tissues, hence **reduced tissue perfusion** is a universal finding [1], [2]. *Increased peripheral resistance*- This finding is characteristic of **compensatory shock** (e.g., early hypovolemic or cardiogenic) as part of the sympathetic response to maintain mean arterial pressure. - It is *not* seen in **distributive shock** (like septic or anaphylactic shock), which is characterized by profound **vasodilation** and thus marked *decreased* peripheral resistance [2]. *Decreased respiratory rate*- A decreased respiratory rate is *not* characteristic of shock; rather, **metabolic acidosis** (due to anaerobic metabolism) typically stimulates the respiratory center, leading to **compensatory tachypnea** (increased rate). - A decreased respiratory rate might only be seen if shock is severe and complicated by **CNS depression** from drugs or profound decompensation. *Cold clammy skin*- **Cold, clammy skin** is the classic presentation of **hypoperfusion** combined with sympathetic-driven peripheral **vasoconstriction**, typically seen in *hypovolemic* and *cardiogenic* shock. - In contrast, **distributive shock** (especially **septic shock**) presents with **warm, flushed skin** due to widespread peripheral vasodilation and increased cardiac output (hyperdynamic state).

Q: A woman presents with a history of headaches for the past 9 months that worsen in a recumbent position and improves as the day progresses. She also gives a history of taking oral contraceptives. Fundal examination shows papilledema. There are no focal neurological deficits. What is the probable cause of her headaches?

Pseudotumor cerebri. ***Pseudotumor cerebri*** - The presentation of headache that worsens in the **recumbent position** (due to increased intracranial pressure, ICP) and improves when upright is highly characteristic of **Idiopathic Intracranial Hypertension (IIH)** [1]. - Confirmation of **papilledema** (swollen optic disc) in a young, likely obese female taking **oral contraceptives** (a risk factor) without other focal signs confirms the diagnosis of **pseudotumor cerebri** [1]. *Myasthenia gravis* - This disease is a neuromuscular disorder characterized by fluctuating **muscle weakness** (diplopia, ptosis, difficulty chewing) that worsens with activity and improves with rest. - It is not associated with primary headache or signs of increased intracranial pressure like **papilledema**. *Temporal arteritis* - This diagnosis is reserved for older patients (usually >50 years) presenting with severe localized headache, **jaw claudication**, tenderness over the temporal artery, and elevated inflammatory markers (ESR/CRP) [2]. - The positional nature of the headache and the patient's young age (implied by OCP use, a risk factor for IIH) make this diagnosis unlikely. *Chronic migraine* - Migraine is a diagnosis of exclusion that typically involves severe, often **pulsatile** headaches, sometimes with aura, photophobia, or nausea [3]. - While chronic migraine involves frequent headaches, it does not cause **papilledema** or have headaches classically exacerbated by the **recumbent position**, which points instead toward a structural or ICP-related etiology [2].

Q: Which of the following is not included in the Gaisböck syndrome?

Hypotension. Hypotension- Gaisböck syndrome, often called stress polycythemia or relative polycythemia, is strongly associated with hypertension due to the hemoconcentration and reduced plasma volume [1].- Hypotension is not a feature of this syndrome, which typically presents in middle-aged men with cardiovascular risk factors.*Erythrocytosis*- Relative erythrocytosis (or pseudopolycythemia) is the defining characteristic of Gaisböck syndrome [1].- This increase in hematocrit is due to a decrease in plasma volume (hemoconcentration) rather than an absolute increase in red cell mass.*Normal leukocyte counts*- Maintaining normal white blood cell (WBC) counts is typical in Gaisböck syndrome [1].- This feature helps exclude Polycythemia Vera, where both leukocytes and platelets are often elevated along with the absolute erythrocytosis.*Obesity*- Obesity is a common and significant component of the syndrome, along with other metabolic risk factors like hyperlipidemia.- The patient group is often described as overweight, anxious, and highly prone to cardiovascular events.

Q: A patient presents with dyspnea and distended neck veins that increase on inspiration. There is no murmur. What is the diagnosis?

Constrictive pericarditis. ***Constrictive pericarditis***- The combination of dyspnea, distended neck veins, and the increase of neck vein distension on inspiration (**Kussmaul sign**) is highly suggestive of constrictive physiology, such as **constrictive pericarditis** [2].- This condition involves a rigid pericardium impairing diastolic filling, leading to elevated right atrial pressure and fixed cardiac volume, hence the characteristic **Kussmaul sign** [2].*Aortic regurgitation*- Typically presents with symptoms of left-sided heart failure (e.g., paroxysmal nocturnal dyspnea) and is characterized by a prominent **diastolic decrescendo murmur** [3].- Peripheral signs usually include **wide pulse pressure** and a bounding pulse (**water-hammer pulse**), none of which explain the Kussmaul sign [3].*Tricuspid stenosis*- This condition would cause right heart failure symptoms (JVD) but is always associated with a **diastolic rumbling murmur** best heard at the left sternal border or xiphoid area.- While **Kussmaul sign** can sometimes be seen in severe tricuspid stenosis, the primary feature is the presence of the characteristic murmur, which is noted as absent here.*Pulmonary arterial hypertension*- This condition causes right-sided heart failure (leading to JVD) but lacks the mechanical restriction of filling necessary to reliably produce the specific **Kussmaul sign** [1].- It is often associated with signs of secondary **tricuspid regurgitation** (a holosystolic murmur) due to right ventricular dilation [1].

Q: Which of the following is the most common cause of mortality in diabetic ketoacidosis?

Cerebral edema. ***Cerebral edema*** - This is the most catastrophic and frequent cause of death, particularly in children and adolescents being treated for DKA [2].- It is often linked to the **rapid administration of hypotonic fluids** or overly quick correction of **hyperglycemia**, causing rapid shifts in **osmolality** that lead to brain swelling [3]. *Acute respiratory distress syndrome*- While DKA is a risk factor for ARDS (often secondary to severe systemic inflammation or associated **sepsis**), it is not the most common direct cause of death [2].- Focus remains on metabolic management; respiratory failure is less common than neurological compromise as a fatal event. *Cardiac arrhythmia*- Severe **hypokalemia** (often unmasked or worsened by insulin therapy) can precipitate fatal cardiac arrhythmias, such as **ventricular fibrillation** [2].- Though a serious complication, carefully monitored electrolyte management generally prevents this, making it less common than cerebral edema as the leading cause of mortality. *Acute kidney injury*- AKI is highly common in DKA, primarily driven by severe **volume depletion** and resulting **prerenal azotemia** [1].- This is reversible with fluid resuscitation and, while it increases overall morbidity, it rarely causes acute mortality more frequently than cerebral edema during the initial hospitalization phase.

Q: A man came with complaints of recurrent discharge and pain due to lesions around the anus for 3 years. A diagnosis of fistula-in-ano is made. What is the gold standard investigation for this condition?

MRI. ***MRI*** - **Gold standard investigation** for fistula-in-ano for preoperative assessment - Provides **superior soft tissue contrast** and multiplanar imaging capabilities - Accurately delineates the **fistula tract, internal and external openings** - Detects **secondary tracts, horseshoe extensions, and abscesses** - Helps in **Parks classification** (intersphincteric, trans-sphincteric, suprasphincteric, extrasphincteric) - Essential for **surgical planning** and predicting recurrence risk - MRI with fat suppression sequences (T2-weighted) provides best visualization *Fistulogram* - Outdated investigation with **limited accuracy** (40-50%) - Cannot adequately assess sphincter involvement or secondary tracts - Invasive and uncomfortable for the patient - Risk of extravasation and infection *USG (Endoanal/Transperineal Ultrasound)* - Useful adjunct but **not gold standard** - Operator-dependent with limited field of view - Difficulty visualizing high or complex fistulas - Less accurate for secondary extensions *CECT* - Not routinely used for fistula-in-ano assessment - **Inferior soft tissue resolution** compared to MRI - Radiation exposure - Limited differentiation of sphincter anatomy

Q: Identify the given instrument.

Linear stapler. ***Linear stapler*** - The instrument shown has a long shaft with two jaws that apply staples in a straight line, which is characteristic of a **linear stapler**. - It is primarily used in **abdominal** and **thoracic surgery** for transecting tissue or closing internal organs like the stomach, intestines, or lung parenchyma. *Skin stapler* - A **skin stapler** is a much smaller, handheld device used exclusively for closing skin incisions externally and has a distinctly different appearance. - It applies single, wide staples and is not used for internal tissue anastomosis or transection. *Circular stapler* - A **circular stapler** has a round head at the distal end designed to create a circular, end-to-end anastomosis, typically in **colorectal** or **esophageal** surgery. - The instrument in the image lacks this circular head and is designed for a linear staple line. *Curved stapler* - This term most commonly refers to a **circular stapler** or a **curved linear cutter**, which has a curved head to facilitate access in locations like the pelvis. - The instrument shown has straight jaws, not a curved head, and is designed for creating a straight line of staples.

Q: A patient was brought to the emergency department following a road traffic accident. Skin grafting was done wherein the graft was taken from the same person. Which type of graft is it?

Autograft. ***Autograft*** - An **autograft** is a type of graft where tissue is transplanted from one site to another on the **same individual**, which matches the clinical scenario described. - This is the most common type of skin graft because there is no risk of an **immunological rejection** by the recipient's body, as the tissue is genetically identical. *Xenograft* - A **xenograft** (or heterograft) involves the transplantation of tissue between individuals of **different species**, such as using pig skin for a temporary burn dressing on a human. - This is incorrect as the graft was taken from the patient themselves, not from an animal source. *Allograft* - An **allograft** (or homograft) is a graft of tissue between two genetically **non-identical individuals** of the **same species**, such as a cadaveric skin graft. - This is not the correct answer because the donor and recipient are the same person, not two different people. *Isograft* - An **isograft** (or syngeneic graft) is a tissue transplant between two genetically **identical individuals**, specifically **identical twins**. - While isografts also avoid immune rejection, this is incorrect because the graft was from the patient's own body, not from their identical twin.

Question 1

Which of the following is most suitable for intravenous regional anesthesia?

Accepted Answer

Lidocaine

Answer

Bupivacaine

Answer

Mepivacaine

Answer

Procaine

Question 2

A 45-year-old patient with a history of smoking a pack of cigarettes for the past 15 years presents with hemoptysis. Chest X-ray shows a 3cm upper lobe mass near the apex of the lung. What is the next best step for managing this patient?

Accepted Answer

CT-guided biopsy

Answer

Bronchoscopy

Answer

Sputum cytology

Answer

Sputum for AFB

Question 3

Which of the following is seen in all kinds of shock?

Accepted Answer

Reduced tissue perfusion

Answer

Increased peripheral resistance

Answer

Cold clammy skin

Answer

Decreased respiratory rate

Question 4

A woman presents with a history of headaches for the past 9 months that worsen in a recumbent position and improves as the day progresses. She also gives a history of taking oral contraceptives. Fundal examination shows papilledema. There are no focal neurological deficits. What is the probable cause of her headaches?

Accepted Answer

Pseudotumor cerebri

Answer

Myasthenia gravis

Answer

Temporal arteritis

Answer

Chronic migraine

Question 5

Which of the following is not included in the Gaisböck syndrome?

Accepted Answer

Hypotension

Answer

Normal leukocyte counts

Answer

Obesity

Answer

Erythrocytosis

Question 6

A patient presents with dyspnea and distended neck veins that increase on inspiration. There is no murmur. What is the diagnosis?

Accepted Answer

Constrictive pericarditis

Answer

Pulmonary arterial hypertension

Answer

Tricuspid stenosis

Answer

Aortic regurgitation

Question 7

Which of the following is the most common cause of mortality in diabetic ketoacidosis?

Accepted Answer

Cerebral edema

Answer

Cardiac arrhythmia

Answer

Acute kidney injury

Answer

Acute respiratory distress syndrome

Question 8

A man came with complaints of recurrent discharge and pain due to lesions around the anus for 3 years. A diagnosis of fistula-in-ano is made. What is the gold standard investigation for this condition?

Accepted Answer

MRI

Answer

Fistulogram

Answer

USG

Answer

CECT

Question 9

Identify the given instrument.

Accepted Answer

Linear stapler

Answer

Curved stapler

Answer

Circular stapler

Answer

Skin stapler

Question 10

A patient was brought to the emergency department following a road traffic accident. Skin grafting was done wherein the graft was taken from the same person. Which type of graft is it?

Accepted Answer

Autograft

Answer

Isograft

Answer

Xenograft

Answer

Allograft

FMGE 2023

Anesthesiology

Internal Medicine

Pediatrics

Surgery