FMGE 2023 Practice Questions

Q: Identify the given histology slide:

Pancreas. ***Pancreas*** - The image displays a classic histological feature of the pancreas: a pale-staining cluster of endocrine cells, known as an **Islet of Langerhans**. - This islet is surrounded by more intensely stained, basophilic **acinar cells**, which constitute the exocrine component of the pancreas responsible for producing digestive enzymes. *Lymph node* - A lymph node has a distinct architecture with a **cortex** containing **lymphoid follicles** (often with germinal centers) and a **medulla**, which is not seen in this image. - The predominant cells would be lymphocytes, which appear as small, dark-staining cells, unlike the larger glandular cells shown here. *Glomerulus* - A glomerulus is a capillary tuft surrounded by **Bowman's capsule**, located within the renal cortex of the kidney. - The surrounding tissue would be composed of **renal tubules** (proximal and distal convoluted tubules), not the acinar cells seen in the slide. *Spleen* - The spleen is characterized by its division into **red pulp** (containing sinusoids and erythrocytes) and **white pulp** (lymphoid tissue surrounding a central artery). - The organized structure of islets and acini is distinct from the splenic architecture of lymphoid follicles and blood-filled sinuses.

Q: Which of the following structures marked in the image contains the splenic artery?

4. ***4*** - The pointer '4' indicates the **splenorenal ligament**, which contains the splenic artery and vein as they travel to the **splenic hilum**. - The **splenic artery** is a major branch of the celiac trunk and follows a tortuous course along the superior border of the pancreas before entering this ligament to reach the spleen. *2* - The pointer '2' indicates the **stomach**. - The splenic artery runs posterior to the stomach's lesser sac, but it is not contained within the stomach tissue itself. *1* - The pointer '1' indicates the **portal triad**, located within the **hepatoduodenal ligament**. - The portal triad consists of the **hepatic artery proper**, the **portal vein**, and the **common bile duct**, but not the splenic artery. *3* - The pointer '3' indicates the **spleen**, a lymphatic organ. - While the splenic artery's terminal branches ramify within the spleen, the main vessel is located within the splenorenal ligament (indicated by pointer 4) just before it enters the spleen.

Q: While doing an endoscopy, constriction is felt at the oesophageal junction at 25 cm from the incisor. This is due to?

b. Arch of aorta. ***b. Arch of aorta*** - The esophagus has **three normal anatomical constrictions** that are clinically important - At **25 cm from the incisors**, the esophagus is compressed by the **arch of aorta** crossing anteriorly, creating the **middle constriction** - This is the second of three constrictions and corresponds to the level of the **T4-T5 vertebrae** - These constrictions are sites where **foreign bodies may lodge** and where **strictures are more likely to develop** [1] *a. Inferior vena cava* - The IVC runs on the right side of the vertebral column and does **not cross anterior to the esophagus** - It does not cause any constriction of the esophagus *c. Right bronchus* - The **left main bronchus** (not right) crosses the esophagus anteriorly at approximately the same level as the aortic arch - The right bronchus does not come into contact with the esophagus *d. Diaphragmatic opening* - This causes the **third (lower) constriction** at approximately **40 cm from the incisors** - This is at the level of the **esophageal hiatus** in the diaphragm (T10 level) - Not at 25 cm as mentioned in the question

Q: On palpation at the site marked by the red arrow on the image, a bony ridge is felt. What is the vertebral level of the marked arrow?

T4-T5 intervertebral disc. ***T4-T5 intervertebral disc*** - The arrow points to the **sternal angle** (Angle of Louis), which is the palpable transverse ridge at the junction of the **manubrium** and the **body of the sternum**. - This important anatomical landmark is located at the level of the **intervertebral disc** between the **T4 and T5** thoracic vertebrae and marks the site of articulation of the **second costal cartilage**. *T3-T4 intervertebral disc* - This vertebral level is superior to the sternal angle. - The **spine of the scapula** is a surface landmark that corresponds approximately to the level of the **T3** vertebra. *T2-T3 intervertebral disc* - This vertebral level is significantly superior to the location marked. - The **suprasternal notch** (jugular notch) of the manubrium corresponds to the level of the intervertebral disc between **T2 and T3**. *T5-T6 intervertebral disc* - This level is inferior to the sternal angle. - It would correspond to a point lower on the body of the sternum, rather than the manubriosternal junction.

Q: A patient in the ICU with an endotracheal tube now needs a tracheostomy tube. Which type of tube will you use?

Cuffed tracheostomy tube. ***Cuffed tracheostomy tube*** - A **cuffed tracheostomy tube** is mandatory in the ICU setting, especially when transitioning from an endotracheal tube, because it provides a seal necessary for **positive pressure ventilation** (PPCV). - The cuff also provides crucial protection against the aspiration of **oral secretions** and **gastric contents**, which is a high risk in critically ill, often sedated, ICU patients. *Uncuffed tracheostomy tube* - *Uncuffed tubes* are inadequate for patients requiring mechanical ventilation as they cannot create the necessary sealed circuit to deliver **tidal volume**. - These tubes are generally reserved for stable patients who require a chronic airway, are not on ventilation, and have a low risk of **aspiration**. *Metallic tracheostomy tube.* - **Metallic tracheostomy tubes** (like those used historically or specific specialized tubes) are typically uncuffed and are not suitable for patients requiring mandatory **mechanical ventilation** or aspiration protection in the acute ICU setting. - They are primarily used for *long-term placement* in ambulatory patients who require a stable, durable airway and often need their tube removed and cleaned frequently. *Endotracheal tube* - An **endotracheal tube (ETT)** is the device currently in use and is being *replaced* by a tracheostomy, making this option incorrect. - While the ETT provides airway management, a tracheostomy tube offers advantages for **long-term airway maintenance** (e.g., improved comfort, easier weaning, better oral hygiene).

Q: Which of the following is a dimension of the medical device shown?

Diameter. ***Diameter*** - Endotracheal tubes (ETTs) are primarily sized by their **internal diameter (ID)**, measured in millimeters (mm). This measurement is crucial for selecting the appropriate tube size to ensure adequate ventilation and minimize airway trauma. - The ID directly affects **airway resistance** and the work of breathing; a larger ID results in lower resistance. The size is clearly marked on the tube, for example, 'ID 7.5'. *Curvature* - While ETTs have a pre-formed curve (often called a **Magill curve**) to facilitate passage through the airway anatomy, this is a design feature, not a sizing dimension. - The curvature can be temporarily modified with a **stylet** to aid in difficult intubations, but it is not a standardized measurement used for selecting a tube. *Circumference* - Circumference is mathematically related to the diameter (Circumference = π × Diameter), but it is not the standard clinical measurement used for sizing ETTs. - The universal convention in anesthesiology and critical care is to refer to the tube's **internal diameter**, not its circumference, for selection and documentation. *Length* - The length of the ETT is important for determining the correct **depth of insertion** into the trachea, which is guided by the centimeter markings along the tube. - However, length is a secondary parameter related to placement, whereas the **internal diameter** is the primary dimension used to select the correct *size* of the tube for the patient.

Q: Resistance of the tube shown below is primarily because of

Diameter. ***Diameter*** - According to **Poiseuille's law**, resistance to laminar flow is inversely proportional to the radius raised to the fourth power (r⁴). Therefore, even a small change in the tube's **diameter** has a profound effect on airflow resistance. - The image shows an endotracheal tube, where the internal diameter is the most critical factor determining the work of breathing for a patient, as it dictates the primary resistance to gas flow. *Curvature* - The curvature of the tube can induce **turbulent flow**, especially at high flow rates, which does increase resistance. - However, its contribution to total resistance is significantly less than that of the tube's internal **diameter**. *Circumference* - Circumference is directly proportional to the diameter (Circumference = π × Diameter), so it is related to resistance. - However, the physical principle governing flow resistance, **Poiseuille's law**, specifically uses the **radius (or diameter)** to the fourth power, making it the primary determinant, not circumference. *Length* - Resistance is directly proportional to the **length** of the tube. A longer tube will have more resistance than a shorter one of the same diameter. - While length is a factor, its effect is linear, whereas the effect of the **diameter** is exponential (to the fourth power), making diameter a much more significant variable.

Q: A patient is referred to a higher center with the diagnosis of fracture. On examination, the forearm pulses were not palpable. An upper arm X-ray was done, which is given below. Which artery is most likely to be injured in this condition?

Brachial artery. ***Brachial artery*** - The **brachial artery** runs in the anterior compartment of the arm, in close proximity to the humeral shaft. A mid-shaft humeral fracture, as shown in the X-ray, can directly injure or compress this vessel. - The clinical finding of impalpable **radial** and **ulnar pulses** strongly suggests a vascular injury proximal to the elbow, pointing directly to the brachial artery, which is the main arterial supply to the forearm. *Radial artery* - The **radial artery** is a terminal branch of the brachial artery located in the forearm. The fracture is in the humerus (upper arm), making a direct injury to the radial artery unlikely. - An absent radial pulse in this context is a *consequence* of the proximal brachial artery injury, not the primary site of damage. *Ulnar artery* - The **ulnar artery**, like the radial artery, is a major artery of the forearm that arises from the bifurcation of the brachial artery in the cubital fossa. It is not located near the humeral shaft fracture. - Injury to the ulnar artery alone would typically spare the radial pulse; the absence of both pulses points to a more proximal vascular compromise. *Anterior interosseous artery* - The **anterior interosseous artery** is a deep branch of the ulnar artery in the forearm. It is anatomically well-protected and distant from the site of the humeral fracture. - This artery is most commonly injured in association with complex forearm fractures, not humeral shaft fractures.

Q: Which of the following does not suggest a medical cause of mental illness?

Auditory hallucination. ***Auditory hallucination***- **Auditory hallucinations** (especially voices commenting or conversing) are highly characteristic features of **primary psychiatric disorders** like schizophrenia.- In contrast, hallucinations associated with underlying medical conditions (organic causes or delirium) are typically **visual**, **tactile**, or **olfactory**.*Elderly age*- New onset of psychiatric symptoms (e.g., psychosis, acute confusion) in an **elderly patient** should raise suspicion for a **medical or neurological etiology** until proven otherwise.- The risk of conditions like **delirium**, **vascular dementia**, or adverse drug effects contributing to psychiatric symptoms is significantly higher in this age group.*Loss of consciousness*- **Loss of consciousness (LOC)** is a critical sign of a **neurological insult** or severe systemic medical illness (e.g., seizures, syncope, metabolic coma).- Primary psychiatric illnesses, by definition, do not cause true **unresponsiveness** or **altered sensorium** associated with genuine LOC.*Acute onset*- A syndrome that appears with **acute or sudden onset** (especially involving cognitive changes, confusion, or marked mood shifts) is often highly suggestive of **delirium** or an **acute medical/toxic etiology**.- Many classic primary psychiatric disorders, such as **Schizophrenia**, typically have a more **insidious** or gradual development, often over months or years.

Q: A 25-year-old patient presents to the surgical OPD with a painless left inguinal reducible mass. On examination cough impulse is positive. After further investigations, the patient is diagnosed with an inguinal hernia. What is the surgical management of this patient?

b.Hernioplasty. ***Hernioplasty***- **Hernioplasty**, which utilizes a prosthetic mesh (e.g., **Lichtenstein technique**), is the universally accepted standard for repairing adult inguinal hernias to achieve a tension-free repair.- This method provides a **tension-free repair** of the posterior inguinal wall, leading to significantly lower recurrence rates compared to traditional suture repairs.*Herniotomy*- **Herniotomy** involves only the excision of the hernia sac and is typically reserved for **indirect inguinal hernias in children**, where the muscle wall is robust.- In an adult, failing to repair the inherent weakness of the **inguinal canal floor** after sac removal results in an unacceptably high risk of hernia recurrence.*Wait and watch*- This approach is mainly reserved for **elderly or comorbid patients** with minimally symptomatic or asymptomatic reducible hernias who are considered high risk for surgery.- For a fit 25-year-old, surgery is recommended to prevent future potentially life-threatening complications like **strangulation** or chronic pain.*Emergency laparotomy*- A full **laparotomy** is an extensive abdominal incision utilized for exploring the acute abdomen or managing complicated intra-abdominal sepsis.- This procedure is unnecessary as the hernia is described as **reducible** and **painless**, indicating an elective repair is warranted, not an emergency exploration.

Question 1

Identify the given histology slide:

Accepted Answer

Pancreas

Answer

Lymph node

Answer

Spleen

Answer

Glomerulus

Question 2

Which of the following structures marked in the image contains the splenic artery?

Accepted Answer

4

Answer

3

Answer

2

Answer

1

Question 3

While doing an endoscopy, constriction is felt at the oesophageal junction at 25 cm from the incisor. This is due to?

Accepted Answer

b. Arch of aorta

Answer

d. Diaphragmatic opening

Answer

c. Right bronchus

Answer

a. Inferior vena cava

Question 4

On palpation at the site marked by the red arrow on the image, a bony ridge is felt. What is the vertebral level of the marked arrow?

Accepted Answer

T4-T5 intervertebral disc

Answer

T5-T6 intervertebral disc

Answer

T3-T4 intervertebral disc

Answer

T2-T3 intervertebral disc

Question 5

A patient in the ICU with an endotracheal tube now needs a tracheostomy tube. Which type of tube will you use?

Accepted Answer

Cuffed tracheostomy tube

Answer

Metallic tracheostomy tube

Answer

Endotracheal tube

Answer

Uncuffed tracheostomy tube

Question 6

Which of the following is a dimension of the medical device shown?

Accepted Answer

Diameter

Answer

Curvature

Answer

Circumference

Answer

Length

Question 7

Resistance of the tube shown below is primarily because of

Accepted Answer

Diameter

Answer

Curvature

Answer

Length

Answer

Circumference

Question 8

A patient is referred to a higher center with the diagnosis of fracture. On examination, the forearm pulses were not palpable. An upper arm X-ray was done, which is given below. Which artery is most likely to be injured in this condition?

Accepted Answer

Brachial artery

Answer

Radial artery

Answer

Anterior interosseous artery

Answer

Ulnar artery

Question 9

Which of the following does not suggest a medical cause of mental illness?

Accepted Answer

Auditory hallucination

Answer

Acute onset

Answer

Elderly age

Answer

Loss of consciousness

Question 10

A 25-year-old patient presents to the surgical OPD with a painless left inguinal reducible mass. On examination cough impulse is positive. After further investigations, the patient is diagnosed with an inguinal hernia. What is the surgical management of this patient?

Accepted Answer

b.Hernioplasty

Answer

a.Herniotomy

Answer

c.Wait and watch

Answer

d.Emergency laparotomy

FMGE 2023

Anatomy

Anesthesiology

Orthopaedics

Psychiatry

Surgery