FMGE 2023 Practice Questions

Q: In the sagittal section of the brain given below the colored area represents the paracentral lobule. Which of the following structures are affected in a lesion to this area?

Perineum and leg. ***Perineum and leg*** - The **paracentral lobule**, located on the medial surface of the cerebral hemisphere, contains the primary motor and somatosensory cortical areas for the contralateral **leg**, **foot**, and **perineum**. - A lesion in this area, often due to an **anterior cerebral artery (ACA) stroke**, typically results in motor and sensory deficits in the contralateral leg and foot, and may also cause **urinary incontinence** due to involvement of the cortical micturition center. *Scapular region and neck* - The cortical representations for the scapular region and neck are located on the **superolateral surface** of the precentral and postcentral gyri, not on the medial surface where the paracentral lobule lies. - These areas are supplied by the **middle cerebral artery (MCA)**, not the ACA. *Trunk and shoulder* - According to the **motor and sensory homunculus**, the trunk and shoulder areas are located more superiorly and laterally on the cerebral cortex, lateral to the paracentral lobule. - A lesion affecting these areas would involve the superolateral convexity of the hemisphere, which has a different vascular supply (MCA). *Face and neck* - The cortical areas for the face and neck are situated on the **inferolateral aspect** of the precentral and postcentral gyri. - Lesions here are characteristic of an **MCA stroke** and would result in contralateral facial weakness and sensory loss, sparing the lower limbs.

Q: A 2-year-old child was brought to the emergency department. The child was having difficulty in speaking and breathing. An X-ray was performed, given below. Which among the following is the best treatment for this condition?

Esophagoscopy. ***Esophagoscopy*** - The flat, circular appearance of the coin on an AP X-ray is characteristic of a foreign body in the **esophagus** (coins in the trachea appear sagittal/linear on AP view). - An **esophageal foreign body** can compress the trachea from behind, causing respiratory distress, especially in young children with a narrow airway. - **Esophagoscopy** is the definitive treatment for removing esophageal foreign bodies and will relieve both the mechanical obstruction and the tracheal compression causing respiratory symptoms. - This should be performed urgently in a child with respiratory compromise, with anesthesia support ready to secure the airway if needed. *Tracheostomy* - A **tracheostomy** would be indicated for direct **tracheal or laryngeal obstruction** that cannot be relieved by other means. - However, in this case, the foreign body is in the **esophagus** (not the trachea), and the respiratory distress is due to external compression of the trachea. - Performing a tracheostomy would not remove the foreign body and is unnecessarily invasive when the definitive treatment (esophagoscopy) can address both the obstruction and the symptoms. *Laryngoscopy* - A **laryngoscopy** is used to visualize the larynx and can remove foreign bodies at or above the vocal cords. - The X-ray findings indicate an **esophageal** foreign body, not a laryngeal one, making laryngoscopy inappropriate for definitive management. *Oxygen* - Supplemental **oxygen** is an important supportive measure to improve oxygen saturation in any patient with respiratory distress. - However, it does not address the underlying mechanical problem (the esophageal foreign body compressing the trachea) and is not definitive treatment.

Q: An elderly male on bed rest for many months presented with breathlessness and chest pain. What is the next best step in the management of this patient?

CT pulmonary angiogram. ***CT pulmonary angiogram***- This is the **gold standard** imaging investigation for diagnosing **pulmonary embolism (PE)**, offering rapid confirmation of emboli within the pulmonary arteries [1].- The patient's history of prolonged **bed rest** (immobilization) makes them high-risk for **Deep Vein Thrombosis (DVT)**, predisposing them to PE, which manifests as acute breathlessness and chest pain [2].*ECG*- An ECG is a standard initial test (often alongside chest X-ray) to exclude cardiac causes like **myocardial infarction** and assess for features of right ventricular strain (e.g., **S1Q3T3 pattern**) associated with PE [1].- However, ECG findings are non-specific and cannot definitively confirm or exclude the diagnosis of PE; imaging is required.*CT thorax*- A standard non-contrast CT thorax is effective for evaluating lung parenchyma (e.g., pneumonia or malignancy).- It is inadequate for diagnosing PE, which requires intravenous contrast specifically timed to opacify the pulmonary arteries (a **CT pulmonary angiogram**).*Echocardiography*- Echocardiography is primarily used to assess the functional and prognostic impact of PE, specifically looking for **right ventricular (RV) dilation** and dysfunction.- It may be utilized in critically **hemodynamically unstable** patients suspected of PE (where immediate transport to CTPA is dangerous), but for a stable patient, CTPA provides the definitive anatomical diagnosis.

Q: A chronic smoker presented with bilateral pitting pedal edema, and abdominal distension. On examination, he had ascites and auscultation revealed an S3. Which of the following defects can be seen in this patient?

Tricuspid regurgitation. ***Tricuspid regurgitation*** - This patient presents with **classic signs of right heart failure**: bilateral pitting pedal edema, ascites, and abdominal distension indicating systemic venous congestion [1] - **Chronic smoking → COPD → pulmonary hypertension → functional tricuspid regurgitation** is a common pathophysiological sequence - **S3 gallop** indicates ventricular volume overload, which occurs in TR due to regurgitant flow - TR leads to **hepatic congestion** (causing ascites) and **peripheral edema** from elevated systemic venous pressure - Clinical triad: **elevated JVP, hepatomegaly, and peripheral edema** points to TR *Incorrect: Aortic stenosis* - Causes **left-sided heart failure**, not right-sided [2] - Classic presentation: **angina, syncope, and dyspnea** (not peripheral edema and ascites) [2] - Would not explain the systemic venous congestion seen in this patient *Incorrect: Mitral regurgitation* - Primarily causes **left-sided heart failure** with pulmonary congestion [1] - Initial presentation includes **dyspnea and pulmonary edema**, not peripheral edema [1] - While chronic MR can eventually lead to right heart failure, the **predominant right-sided signs** make this less likely *Incorrect: Aortic regurgitation* - Causes **left-sided heart failure** [3] - Classic signs include **wide pulse pressure, bounding pulses**, and water-hammer pulse [3] - Does not explain the **right-sided failure** picture with ascites and bilateral pedal edema

Q: What is the most common cause of death in children with Diabetic ketoacidosis?

Cerebral edema. ***Cerebral edema*** - It is the **most common cause of mortality** in pediatric DKA, occurring in 0.5-1% of cases with a mortality rate of 20-25% [1] - Occurs due to rapid changes in **plasma osmolality** during treatment - the rapid decrease of blood glucose and effective osmolarity creates an osmotic gradient, causing fluid shifts into brain cells - Leads to potentially fatal **intracranial pressure** elevation with clinical features of headache, altered mental status, bradycardia, and respiratory depression - Risk factors include: new-onset diabetes, younger age, severe acidosis, and rapid fluid administration *Hypokalemia* - Potassium levels often drop dramatically during DKA treatment as insulin drives potassium into cells, potentially causing life-threatening **cardiac arrhythmias** [1] - This complication is highly anticipated and routinely managed by **potassium replacement therapy** with close monitoring [3] - While potentially fatal if unrecognized, it is a **preventable and treatable** condition with proper electrolyte management *Dehydration* - Severe dehydration causing **hypovolemic shock** is a major factor contributing to morbidity in DKA [2] - Effectively managed by aggressive **IV fluid resuscitation** with careful monitoring [3] - In treated pediatric DKA, the failure leading to death is typically the development of **cerebral edema** rather than persistent volume depletion [1] *Sepsis* - While sepsis can precipitate DKA, it is an underlying **trigger** or precipitating factor, not the direct physiological cause of death during DKA itself - The overwhelming fatality **in** pediatric DKA (as opposed to from the precipitating illness) is generally attributed to **cerebral edema** from rapid fluid shifts leading to central nervous system complications [1]

Q: A patient presented to OPD with complaints of fatigue, loss of appetite, constipation, urinary symptoms of kidney stone, and increased urination. The patient has a history of psychiatric disorder; you suspect a case of hyperparathyroidism. Which of the following investigations is useful in this condition?

Sestamibi scan. ***Sestamibi scan*** - This is the standard **nuclear medicine study** used for localizing hyperfunctioning **parathyroid adenomas** prior to surgery (parathyroidectomy), essential for confirming the source of hypercalcemia [1]. - The scan is highly sensitive because the tracer (**Technetium-99m Sestamibi**) is retained longer in the hyperactive parathyroid tissue than in the surrounding thyroid tissue [1]. *USG neck* - **Ultrasonography** is an anatomical study that is often used as a basic initial imaging step due to its non-invasiveness, but it has lower overall sensitivity (50-80%) in localization. - It is poor at locating **ectopic or deep-seated adenomas** and cannot confirm if the lesion is truly hyperfunctioning, which is critical for diagnosis. *CT neck* - **Computed Tomography** is generally reserved for situations where non-invasive methods fail, especially when trying to localize **ectopic glands** deep in the **mediastinum** or neck. - It is not preferred as a first-line investigation due to the associated **radiation exposure** and lack of functional information regarding the glandular activity. *PET scan* - Standard **FDG-PET scans** are mostly ineffective for localizing benign parathyroid adenomas because they rarely exhibit the high metabolic activity required for tracer uptake. - Specialized PET tracers, such as **11C-methionine**, may be used in complicated cases of persistent or recurrent hyperparathyroidism, but are not routine for initial diagnosis. Note: The patient's presentation of kidney stones, psychiatric symptoms, and polyuria is consistent with primary hyperparathyroidism secondary to hypercalcemia [2, 3].

Question 1

In the sagittal section of the brain given below the colored area represents the paracentral lobule. Which of the following structures are affected in a lesion to this area?

Accepted Answer

Perineum and leg

Answer

Face and neck

Answer

Trunk and shoulder

Answer

Scapular region and neck

Question 2

A 2-year-old child was brought to the emergency department. The child was having difficulty in speaking and breathing. An X-ray was performed, given below. Which among the following is the best treatment for this condition?

Accepted Answer

Esophagoscopy

Answer

Oxygen

Answer

Tracheostomy

Answer

Laryngoscopy

Question 3

An elderly male on bed rest for many months presented with breathlessness and chest pain. What is the next best step in the management of this patient?

Accepted Answer

CT pulmonary angiogram

Answer

ECG

Answer

CT thorax

Answer

Echocardiography

Question 4

A chronic smoker presented with bilateral pitting pedal edema, and abdominal distension. On examination, he had ascites and auscultation revealed an S3. Which of the following defects can be seen in this patient?

Accepted Answer

Tricuspid regurgitation

Answer

Aortic stenosis

Answer

Mitral regurgitation

Answer

Aortic regurgitation

Question 5

What is the most common cause of death in children with Diabetic ketoacidosis?

Accepted Answer

Cerebral edema

Answer

Hypokalemia

Answer

Dehydration

Answer

Sepsis

Question 6

A patient presented to OPD with complaints of fatigue, loss of appetite, constipation, urinary symptoms of kidney stone, and increased urination. The patient has a history of psychiatric disorder; you suspect a case of hyperparathyroidism. Which of the following investigations is useful in this condition?

Accepted Answer

Sestamibi scan

Answer

USG neck

Answer

CT neck

Answer

PET scan

FMGE 2023

Anatomy

ENT

Internal Medicine

Pediatrics

Radiology