FMGE 2025

595 Questions — Page 30 of 60

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Community Medicine

1 questions

Q291

During the assessment of drinking water from a village tank, which of the following parameters is not within the acceptable limits for safe drinking water?

Internal Medicine

9 questions

Q291

A 65-year-old male with chronic stable angina presents with worsening chest pain during routine activities. His current medications include aspirin, clopidogrel, metoprolol, and atorvastatin, but his symptoms persist. ECG shows ST-segment depression in V5-V6, and coronary angiography reveals 80% stenosis of the left anterior descending (LAD) artery. What is the most appropriate intervention?

Q292

A 72 y/o woman presents with severe chest pain and shortness of breath after a stressful argument. She is post-menopausal with no history of heart disease. O/E, she is slightly tachycardic with normal blood pressure. An echocardiogram shows left ventricular ballooning during systole, and cardiac enzymes are minimally elevated. What is the most likely diagnosis?

Q293

A 68-year-old male patient with a history of hypertension presents to the emergency department in acute distress. He is diaphoretic, tachycardic, and complains of severe chest pain. His vital signs show a heart rate of 180 bpm with a regular, wide-complex tachycardia consistent with ventricular tachycardia. The patient appears hemodynamically unstable. What is the most appropriate immediate management for this patient?

Q294

A 62-year-old woman with a history of chronic obstructive pulmonary disease (COPD) presents with increased breathlessness, cough, and sputum production over the last two days. She appears distressed and has a respiratory rate of 28 breaths per minute. Her oxygen saturation is 88% on room air. Which of the following management strategies is most appropriate for her immediate treatment?

Q295

A 55-year-old woman with a history of type 2 diabetes presents for a routine follow-up. Her serum creatinine and potassium levels are normal, but she has microalbuminuria and an HbA1c of 8%. Her blood pressure and pulse are within normal limits, and she is currently on metformin for diabetes management. What should be the next step in her management?

Q296

A 38-year-old male presents with a one-week history of fever, headache, retro-orbital pain, and myalgia. Skin examination reveals multiple purpura and petechiae on the left shoulder, trunk, and legs. Similar cases have been reported linked to increased incidence of mosquito breeding. What is the most common neurological complication associated with this condition?

Q297

An alcoholic patient presents with palpitations, dizziness, and syncopal attacks. On examination, irregularly irregular pulse is seen. What will be seen on JVP?

Q298

A 25-year-old female with a previous history of rheumatic fever. Examination shows a loud S1 and mid-diastolic murmur. Which of the following valvular heart diseases does she have?

Q299

A patient with a history of rheumatic fever presents with a loud S1 and a low-pitched mid-diastolic murmur at the apex (best heard with the patient in the left lateral position). What is the most likely diagnosis?

FMGE 2025 - Internal Medicine FMGE Practice Questions and MCQs

Question 291: A 65-year-old male with chronic stable angina presents with worsening chest pain during routine activities. His current medications include aspirin, clopidogrel, metoprolol, and atorvastatin, but his symptoms persist. ECG shows ST-segment depression in V5-V6, and coronary angiography reveals 80% stenosis of the left anterior descending (LAD) artery. What is the most appropriate intervention?

A. Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) (Correct Answer)
B. Add ranolazine to medical therapy
C. Increase the dose of beta-blockers
D. Refer for coronary artery bypass grafting (CABG)

Explanation: ***Percutaneous coronary intervention (PCI) with drug-eluting stent (DES)*** - The patient has clinical features (worsening angina, ST depression) and angiographic evidence (80% LAD stenosis) indicating **high-risk unstable angina** (or NSTEMI equivalent) refractory to guideline-directed medical therapy (GDMT). [1] - Given the critical, symptomatic **single-vessel disease** (80% LAD stenosis), revascularization is necessary, and PCI with DES is the preferred, less invasive option compared to CABG for isolated critical lesions. [2] *Increase the dose of beta-blockers* - Beta-blockers are part of GDMT, but simply increasing the dose is insufficient when the patient has a **critical coronary lesion** (80% LAD) causing symptoms despite existing optimal anti-ischemic and antiplatelet drugs. - Optimization of medical therapy primarily treats symptoms, but definitive treatment for this high-grade stenosis requires **revascularization** (PCI or CABG). *Add ranolazine to medical therapy* - Ranolazine is a second-line anti-anginal agent used primarily for refractory symptoms in **chronic stable angina** or when beta-blockers are contraindicated or not tolerated. - It does not address the underlying **critical, high-risk anatomical burden** (80% LAD stenosis) confirmed by angiography, which necessitates mechanical intervention. *Refer for coronary artery bypass grafting (CABG)* - CABG is generally indicated for left main coronary artery disease, **multi-vessel disease** (especially in diabetics), or highly complex anatomy (high **SYNTAX score**) unsuitable for PCI. [2] - For an isolated, non-complex, critical LAD lesion, PCI is typically the favored revascularization strategy due to lower invasiveness and comparable outcomes to CABG in single-vessel disease.

Question 292: A 72 y/o woman presents with severe chest pain and shortness of breath after a stressful argument. She is post-menopausal with no history of heart disease. O/E, she is slightly tachycardic with normal blood pressure. An echocardiogram shows left ventricular ballooning during systole, and cardiac enzymes are minimally elevated. What is the most likely diagnosis?

A. Pulmonary Embolism
B. Coronary Artery Disease
C. Hypertensive Heart Disease
D. Takotsubo Cardiomyopathy (Correct Answer)

Explanation: ***Takotsubo Cardiomyopathy*** - **Stress-induced cardiomyopathy** (broken heart syndrome) typically affects **post-menopausal women** following emotional or physical stress [2]. - Classic presentation: **chest pain mimicking acute MI** with **minimal cardiac enzyme elevation** (troponin may be mildly elevated but disproportionately low for the degree of wall motion abnormality) - **Pathognomonic finding**: **Apical ballooning** (or mid-ventricular ballooning) on echocardiography during systole, with **hyperkinetic basal segments** creating characteristic "octopus trap" appearance - Usually **reversible** within weeks to months with supportive care - Coronary angiography shows **normal or non-obstructive coronary arteries** *Incorrect: Coronary Artery Disease* - Would show **significantly elevated cardiac enzymes** (troponin, CK-MB) proportionate to myocardial damage [1]. - Echo would show wall motion abnormalities in **coronary artery distribution** (not apical ballooning pattern) - Risk factors and chronic history more common [3]. *Incorrect: Pulmonary Embolism* - Would present with **right ventricular strain** on echo, not left ventricular ballooning - Different chest pain character (pleuritic), associated with **hypoxemia** and **tachypnea** - D-dimer elevated, cardiac enzymes usually normal unless massive PE *Incorrect: Hypertensive Heart Disease* - Patient has **normal blood pressure** on examination - Would show **left ventricular hypertrophy** and diastolic dysfunction, not acute ballooning - Chronic presentation, not acute stress-related event

Question 293: A 68-year-old male patient with a history of hypertension presents to the emergency department in acute distress. He is diaphoretic, tachycardic, and complains of severe chest pain. His vital signs show a heart rate of 180 bpm with a regular, wide-complex tachycardia consistent with ventricular tachycardia. The patient appears hemodynamically unstable. What is the most appropriate immediate management for this patient?

A. Synchronized cardioversion (Correct Answer)
B. Amiodarone
C. Radiofrequency catheter ablation
D. Digoxin

Explanation: Detailed Analysis of Ventricular Tachycardia Management: ***Synchronized cardioversion*** - The ECG shows a regular, wide-complex tachycardia, consistent with **ventricular tachycardia (VT)**. The patient's clinical presentation with severe chest pain and diaphoresis indicates **hemodynamic instability** [1]. - For any unstable tachyarrhythmia, including VT, immediate **synchronized electrical cardioversion** is the first-line treatment to restore sinus rhythm and prevent cardiovascular collapse [2]. *Amiodarone* - Amiodarone is an antiarrhythmic medication that is appropriate for **stable ventricular tachycardia**, where the patient has adequate blood pressure and is not in acute distress. - In an unstable patient, electrical cardioversion should not be delayed for a trial of pharmacologic therapy, as this can lead to further deterioration [2]. *Radiofrequency catheter ablation* - This is an elective, invasive procedure used for the long-term prevention of recurrent arrhythmias, not for the acute management of an unstable patient. - Catheter ablation is typically considered after the patient has been stabilized and if they experience recurrent episodes of VT. *Digoxin* - Digoxin is primarily used for rate control in supraventricular tachycardias like **atrial fibrillation** and is not effective for treating ventricular tachycardia [3]. - Administering digoxin in this setting is inappropriate and can potentially worsen the arrhythmia or cause toxicity [3].

Question 294: A 62-year-old woman with a history of chronic obstructive pulmonary disease (COPD) presents with increased breathlessness, cough, and sputum production over the last two days. She appears distressed and has a respiratory rate of 28 breaths per minute. Her oxygen saturation is 88% on room air. Which of the following management strategies is most appropriate for her immediate treatment?

A. Order a chest X-ray before any treatment is provided
B. Initiate high-flow oxygen therapy to maintain oxygen saturation above 95%
C. Start nebulised bronchodilator therapy with salbutamol and ipratropium (Correct Answer)
D. Begin intravenous glucocorticoids immediately

Explanation: ***Correct: Start nebulised bronchodilator therapy with salbutamol and ipratropium*** - This represents an **acute exacerbation of COPD (AECOPD)** requiring immediate bronchodilation - **Nebulized SABA (salbutamol) + SAMA (ipratropium)** is the first-line immediate treatment as per GOLD guidelines [1] - Provides rapid relief of bronchospasm and improves airflow in acute distress [1] - Can be administered immediately without delaying for investigations - Combined therapy is more effective than either agent alone in acute exacerbations [1] *Incorrect: Order a chest X-ray before any treatment is provided* - While chest X-ray is important to rule out complications (pneumonia, pneumothorax), **treatment should not be delayed** in an acutely distressed patient - Investigations can be performed after stabilization begins - Clinical assessment is sufficient to initiate bronchodilator therapy *Incorrect: Initiate high-flow oxygen therapy to maintain oxygen saturation above 95%* - COPD patients require **controlled oxygen therapy** with target SpO2 of **88-92%** - High oxygen concentrations can suppress hypoxic respiratory drive and lead to **CO2 retention** and hypercapnic respiratory failure - Venturi masks (24-28% oxygen) are preferred for controlled delivery [2] *Incorrect: Begin intravenous glucocorticoids immediately* - While **systemic corticosteroids** are important in AECOPD management, **bronchodilators take priority** as immediate treatment - Oral prednisolone (30-40 mg for 5-7 days) is typically preferred unless patient cannot take oral medication - Steroids are given after initial bronchodilation is started

Question 295: A 55-year-old woman with a history of type 2 diabetes presents for a routine follow-up. Her serum creatinine and potassium levels are normal, but she has microalbuminuria and an HbA1c of 8%. Her blood pressure and pulse are within normal limits, and she is currently on metformin for diabetes management. What should be the next step in her management?

A. Start insulin therapy
B. Stop Metformin and start a different OHA
C. Begin a thiazide diuretic
D. Start an ACE inhibitor (Correct Answer)

Explanation: ***Start an ACE inhibitor***- **ACE inhibitors** (or **ARBs**) are the cornerstone of treatment for **microalbuminuria** in patients with **Type 2 Diabetes Mellitus**, regardless of blood pressure, due to their **renoprotective** effects [2].- They are preferred because they reduce **glomerular capillary pressure** and mitigate the progression of early **diabetic nephropathy** (as indicated by microalbuminuria) [2].*Begin a thiazide diuretic*- Thiazide diuretics are primarily indicated for the management of **hypertension** and **edema**.- The patient is currently normotensive, and thiazides do not offer the specific **renoprotective benefits** mediated by **ACE inhibitors** in diabetic kidney disease.*Start insulin therapy*- Although the **HbA1c of 8%** indicates suboptimal glycemic control, initiating **ACE inhibition** is the most critical next step due to the presence of **microalbuminuria**.- Insulin therapy is usually reserved for higher A1c levels (e.g., >10%) or after failure of combination oral/injectable non-insulin therapy [1].*Stop Metformin and start a different OHA*- **Metformin** is the appropriate first-line drug of choice, and given her normal serum creatinine, there is no contraindication to its continuation [1].- The treatment strategy is usually to add a second agent (like the ACE inhibitor for kidney protection, and potentially another **OHA/SGLT-2 inhibitor/GLP-1 RA** for glycemic control) rather than discontinuing Metformin.

Question 296: A 38-year-old male presents with a one-week history of fever, headache, retro-orbital pain, and myalgia. Skin examination reveals multiple purpura and petechiae on the left shoulder, trunk, and legs. Similar cases have been reported linked to increased incidence of mosquito breeding. What is the most common neurological complication associated with this condition?

A. Encephalopathy (Correct Answer)
B. Stroke
C. Encephalitis
D. Guillain-Barré Syndrome

Explanation: ***Encephalopathy***- **Encephalopathy** is the most frequent neurological complication in severe **Dengue fever**, often resulting from systemic factors like **shock**, **hypoxia**, **hepatic dysfunction**, or **hyponatremia** rather than direct viral invasion [1].- The presented symptoms (fever, retro-orbital pain, myalgia, hemorrhagic signs/purpura) are classic for severe Dengue, where multorgan failure and systemic derangements frequently lead to altered consciousness [1].*Guillain-Barré Syndrome*- **GBS** is a **post-infectious** demyelinating condition that typically manifests after recovery from the acute viral illness, presenting as progressive, ascending paralysis.- While Dengue is a recognized trigger for GBS, it is much less common than acute encephalopathy occurring during the febrile or critical phase of the illness.*Stroke*- **Stroke** (ischemic or hemorrhagic) can occur in severe dengue due to complications like **vasculitis**, **coagulopathy**, or profound **thrombocytopenia**, leading to focal neurological deficits.- Although the hemorrhagic signs (purpura/petechiae) indicate a risk for bleeding complications, stroke is generally less common than systemic **encephalopathy** in the overall spectrum of dengue neuro-complications [1].*Encephalitis*- **Encephalitis** refers to inflammation of the brain caused by **direct viral invasion** of the central nervous system by the Dengue virus.- While possible, primary dengue encephalitis due to neurotropism is considered a relatively rare neurological manifestation compared to secondary **dengue-associated encephalopathy** [1].

Question 297: An alcoholic patient presents with palpitations, dizziness, and syncopal attacks. On examination, irregularly irregular pulse is seen. What will be seen on JVP?

A. Steep y descent
B. Absent a wave (Correct Answer)
C. Large a wave
D. Canon a wave

Explanation: ***Absent a wave*** - The clinical presentation of an alcoholic with palpitations and an **irregularly irregular pulse** is highly suggestive of **Atrial Fibrillation (AFib)** [1]. - The **'a' wave** in the Jugular Venous Pressure (JVP) corresponds to **atrial contraction**. In AFib, coordinated atrial contraction is lost, leading to the absence of the 'a' wave. *Large a wave* - A large or "giant" 'a' wave indicates that the right atrium is contracting against an increased resistance, forcing it to generate higher pressure. - This is classically seen in conditions such as **tricuspid stenosis**, **pulmonary stenosis**, and severe **pulmonary hypertension**. *Canon a wave* - Cannon 'a' waves are intermittent, very large 'a' waves that occur when the atria contract against a **closed tricuspid valve**. - This finding is characteristic of **AV dissociation**, which can be seen in **complete heart block**, ventricular tachycardia, or junctional rhythms. *Steep y descent* - A steep 'y' descent, also known as **Friedreich's sign**, reflects rapid, unimpeded filling of the right ventricle from the right atrium. - It is a classic sign of **constrictive pericarditis** and can also be present in severe **right-sided heart failure** or **tricuspid regurgitation**.

Question 298: A 25-year-old female with a previous history of rheumatic fever. Examination shows a loud S1 and mid-diastolic murmur. Which of the following valvular heart diseases does she have?

A. MS (Correct Answer)
B. TS
C. MR
D. AR

Explanation: ***MS*** - The combination of a history of **rheumatic fever** (the most common cause of MS globally) and the specific auscultatory findings are highly diagnostic of **mitral stenosis** [1]. - A **loud S1** results from the abrupt closure of the stiffened, high-pressure mitral valve, and a **mid-diastolic murmur** is caused by turbulent flow across the stenotic valve during rapid ventricular filling [2], [3]. *TS* - Tricuspid Stenosis (TS) is a rare sequelae of rheumatic fever and typically presents with a mid-diastolic murmur that *increases* with **inspiration** (**Carvallo's sign**) [2]. - The murmur of TS is best heard at the **left sternal border** (tricuspid area) and is usually accompanied by prominent signs of systemic congestion (e.g., ascites). *MR* - **Mitral Regurgitation** produces a high-pitched, blowing **holosystolic murmur** that typically radiates to the axilla, not a mid-diastolic murmur. - A loud S1 is often *absent* in significant MR as the valve leaflets do not coapt properly; S1 is usually normal or soft. *AR* - **Aortic Regurgitation** is characterized by a high-pitched **diastolic decrescendo murmur** best heard along the left sternal border [4]. - AR is frequently associated with signs of increased stroke volume and wide pulse pressure, such as the **Water-hammer pulse**, none of which are characteristic of this presentation.

Question 299: A patient with a history of rheumatic fever presents with a loud S1 and a low-pitched mid-diastolic murmur at the apex (best heard with the patient in the left lateral position). What is the most likely diagnosis?

A. Mitral Stenosis (MS) (Correct Answer)
B. Tricuspid Stenosis (TS)
C. Mitral Regurgitation (MR)
D. Aortic Regurgitation (AR)

Explanation: ***Mitral Stenosis (MS)*** - The classic auscultatory findings include a **loud S1** (due to forceful closure of the stiff mitral valve) and a low-pitched, rumbling **mid-diastolic murmur** at the apex, which are pathognomonic for MS [3]. - A history of **rheumatic fever** is the most common cause of mitral stenosis worldwide. The murmur is best heard in the **left lateral decubitus position**, and an **opening snap (OS)** may be heard after S2 [1], [3]. *Tricuspid Stenosis (TS)* - TS produces a mid-diastolic murmur, but it is best heard at the **left lower sternal border**, not the apex [2]. - The murmur of TS characteristically **intensifies with inspiration** (Carvallo's sign), a feature not described in this patient. *Mitral Regurgitation (MR)* - MR causes a **holosystolic (pansystolic) murmur**, meaning it occurs throughout systole, not diastole. - In chronic MR, the S1 sound is typically **soft or absent**, not loud, due to incomplete closure of the mitral valve leaflets. *Aortic Regurgitation (AR)* - AR is characterized by a high-pitched, blowing, **early diastolic decrescendo murmur** best heard along the left sternal border [4]. - It is associated with signs of a wide pulse pressure, such as **bounding peripheral pulses** (Corrigan's pulse), not a loud S1 or a mid-diastolic murmur at the apex.