FMGE 2025 Practice Questions

Q: An RTA patient has received 4 units of packed RBCs within a few hours. Which of the following will be seen?

Hypocalcemia. ***Hypocalcemia***- The anticoagulant used in packed RBCs, **citrate**, chelates (binds strongly to) **ionized calcium** in the recipient's plasma. - Rapid infusion during massive transfusion overwhelms the liver's capacity to metabolize citrate, causing a rapid decrease in **serum calcium** levels, potentially leading to immediate complications like paresthesias or prolonged QT interval.*Hypernatremia*- Packed RBCs are suspended in solutions that are typically isotonic or slightly hypotonic in sodium, making **Hypernatremia** an unlikely direct complication of transfusion.- Resuscitation fluids (like Normal Saline) used alongside transfused blood are the more common cause of slight hypernatremia in trauma patients, not the blood components themselves.*Hyponatremia*- Although some older blood preservatives might contain less sodium, **Hyponatremia** is not a primary biochemical disturbance associated with massive blood product transfusion.- Dilutional effects or the use of specific hypotonic fluids would be required to induce significant **Hyponatremia**, which is rare with standard trauma protocols.*Hyperkalemia*- Stored RBCs leak **potassium** (K+) into the supernatant fluid during storage, making hyperkalemia a risk, especially with older units or in patients with impaired renal function.- However, **Hypocalcemia** due to immediate **citrate toxicity** is generally considered the most frequent and immediate metabolic derangement requiring intervention during massive transfusion.

Q: A study was conducted among nursing staff to analyze the time spent on different aspects of patient care, such as bed preparation, monitoring vital signs, attending the doctor’s rounds, blood sampling, and drug administration. Which of the following management techniques is most appropriate for this type of analysis?

Work Sampling. ***Work Sampling*** - It is a statistical method used to determine the proportional time spent on different activities based on a large number of **random observations** - This technique is highly appropriate for analyzing nursing activities because it is **less costly and non-disruptive** than continuous detailed observation - Provides an accurate estimation of time allocated to diverse, irregular duties (like patient monitoring, rounds, and drug administration) - Ideal for studying varied activities over extended periods *Critical Path Method* - This technique is used primarily in **project management** to schedule and manage dependencies between activities in complex projects - It focuses on identifying the **critical path**, which is the longest sequence of dependent activities determining the minimum total time required for project completion - Not suitable for analyzing time distribution across multiple unrelated nursing activities *System Analysis* - This involves studying an organizational system (inputs, processes, outputs) to identify problems or propose solutions for general system improvement or efficiency - It is a broad approach focused on the *function* and *structure* of the organization rather than the precise **quantitative measurement** of time allocation across staff members' tasks - Does not provide the specific time-proportion data needed in this scenario *Time and Motion Study* - This involves continuous, detailed observation and measurement of specific, repetitive, short tasks to optimize work *methods* and establish **standard performance times** - It would be too invasive, resource-intensive, and less practical for measuring the varied, irregular, and often non-repetitive activities of nursing staff over a lengthy study period - Better suited for standardized, repetitive tasks in industrial settings

Q: A patient presents to the ER with central chest pain. He has a past medical history of heart disease. ECG is shown below. What is the diagnosis?

Anterolateral MI. ***Anterolateral MI*** - The ECG shows significant **ST-segment elevation** in the anterior leads (**V1-V4**) and the lateral leads (**I, aVL, V5, V6**), which is characteristic of an extensive anterolateral myocardial infarction. - This pattern typically indicates an occlusion of the proximal **Left Anterior Descending (LAD) artery**. The ST depression in the inferior leads (II, III, aVF) represents **reciprocal changes**. *Inferolateral MI* - An inferolateral MI would present with ST elevation in the **inferior leads (II, III, aVF)** and lateral leads (I, aVL, V5, V6). - This ECG shows **ST depression** in the inferior leads, which argues against an inferior wall infarction and instead supports an anterior MI as reciprocal changes. *Acute pericarditis* - Acute pericarditis typically causes **diffuse, concave ST elevation** across multiple territories, not localized to the anterolateral leads as seen here. - It is also often associated with **PR segment depression**, which is not a prominent feature in this ECG. The ST segments here are **convex (coved)**, which is more typical for MI. *Constrictive pericarditis* - This is a chronic condition and does not cause acute ST-segment elevation. Its ECG findings are usually non-specific. - Typical findings for constrictive pericarditis include **low-voltage QRS complexes** and generalized T-wave flattening or inversion, which are not present on this ECG.

Q: A patient after MI develops a broad QRS complex tachycardia. His BP is 120/85 mm Hg. ECG is given below. Best management?

Amiodarone iv. ***Amiodarone iv*** - The ECG shows a **monomorphic wide-complex tachycardia** in a patient with a history of myocardial infarction, which is presumed to be **ventricular tachycardia (VT)** until proven otherwise. - For a **hemodynamically stable** patient (BP 120/85 mm Hg), intravenous antiarrhythmics like **amiodarone** or procainamide are the first-line treatment for terminating the arrhythmia. *Labetalol iv* - Intravenous beta-blockers like labetalol are generally avoided in the acute management of VT, especially in patients with structural heart disease. - Their **negative inotropic** effects can precipitate **hemodynamic collapse** and cardiogenic shock in a heart already compromised by a recent MI. *Metoprolol iv* - Similar to labetalol, metoprolol is a beta-blocker that is not recommended for the acute termination of VT. - While crucial for long-term management post-MI, its administration during an active VT episode can lead to severe **hypotension** and cardiac decompensation. *Nitroglycerin iv* - Nitroglycerin is a vasodilator used for ischemic chest pain and has no **antiarrhythmic properties** to terminate VT. - Its use could cause significant **vasodilation** and hypotension, potentially destabilizing the patient and converting a stable VT into an unstable one requiring immediate cardioversion.

Q: A young female presents with ptosis showing diurnal variation. CT chest shows an anterior mediastinal mass identified as thymus gland cancer. Which receptor is affected in this patient?

Post-synaptic ACh Receptor. ***Post-synaptic ACh Receptor*** - The clinical presentation of **ptosis** with **diurnal variation** (worsening weakness throughout the day) and an associated **thymoma** are hallmark features of **Myasthenia Gravis** [1]. - Myasthenia Gravis is an autoimmune disorder characterized by antibodies that bind to and block or destroy **post-synaptic nicotinic acetylcholine (ACh) receptors** at the neuromuscular junction, leading to impaired muscle contraction [2]. *Presynaptic ACh Receptor* - Autoantibodies in common neuromuscular junction disorders do not target presynaptic ACh receptors. These receptors are typically involved in modulating neurotransmitter release via feedback mechanisms. - The primary presynaptic autoimmune disorder, **Lambert-Eaton Myasthenic Syndrome**, involves antibodies against voltage-gated calcium channels, not ACh receptors [3]. *Voltage-gated calcium channels at the NMJ* - This is the pathological target in **Lambert-Eaton Myasthenic Syndrome (LEMS)**, where antibodies inhibit presynaptic calcium influx, reducing acetylcholine release [3]. - LEMS is clinically distinct, often presenting with weakness that **improves with activity** (incremental response) and is strongly associated with **small cell lung cancer** [3]. *Acetylcholinesterase* - **Acetylcholinesterase (AChE)** is the enzyme responsible for degrading acetylcholine in the synaptic cleft; it is not the target of autoimmunity in Myasthenia Gravis. - In fact, **AChE inhibitors** (e.g., pyridostigmine) are a primary treatment for Myasthenia Gravis, as they increase the concentration and duration of ACh in the synapse to better activate the reduced number of receptors [2].

Q: A 35-year-old female with progressive limb weakness for the past 1 year. On examination, muscle fasciculations and hypertonia are noted, and the sensory system is intact. What is the diagnosis?

ALS. ***Correct: ALS (Amyotrophic Lateral Sclerosis)*** - This patient presents with the classic triad of ALS: **progressive limb weakness, fasciculations (LMN sign), and hypertonia/spasticity (UMN sign)** [1] - The combination of **both upper and lower motor neuron signs** is pathognomonic for ALS [1] - **Sensory sparing** is characteristic - ALS affects motor neurons only [1] - Age and progressive course over 1 year fits the typical presentation - El Escorial criteria require UMN + LMN signs in multiple regions *Incorrect: Multifocal motor neuropathy* - This is a **pure lower motor neuron disorder** with conduction block - Would present with fasciculations and weakness but **NO hypertonia** (no UMN involvement) [1] - Treatable with immunotherapy, making it an important differential to exclude [1] *Incorrect: Becker muscular dystrophy* - This is a **primary muscle disease**, not a motor neuron disorder - **No fasciculations** would be present (fasciculations indicate motor neuron pathology) [2] - Predominantly affects males (X-linked), presents with proximal weakness and calf pseudohypertrophy - Elevated CK levels would be expected *Incorrect: Spinal muscular atrophy* - This is a **pure lower motor neuron disorder** due to anterior horn cell degeneration - Would NOT present with **hypertonia or UMN signs** - Typically presents in childhood/early life with symmetric proximal weakness - Associated with SMN1 gene mutations

Q: A patient presents with symmetrical leg weakness and areflexia. He had developed diarrhoea 2 weeks ago. He was diagnosed as having GBS. What is the cause?

Demyelination of A, B-fibers. ***Demyelination of A, B-fibers***- GBS is an acute **demyelinating polyneuropathy** primarily affecting the myelin sheath of peripheral nerves and nerve roots (PNS involvement) [1].- Demyelination of large myelinated **A-fibers** (motor and sensory) explains the severe **symmetrical weakness** and **areflexia** [1]; demyelination of **B-fibers** contributes to common **autonomic dysfunction**.*Demyelination of B-fibers*- B-fibers are primarily **preganglionic autonomic fibers**; their demyelination causes autonomic instability (e.g., blood pressure fluctuation) but does not account for the profound motor weakness and areflexia that define GBS [2].- The cardinal features of GBS (weakness and areflexia) result from damage to the larger **A-fibers** (motor nerves) [1]. *Demyelination of the spinal cord*- GBS is a disease of the **Peripheral Nervous System (PNS)**, affecting nerve roots and peripheral nerves [2].- Demyelination confined to the spinal cord is characteristic of **Central Nervous System (CNS)** demyelinating diseases, such as **Transverse Myelitis** or **Multiple Sclerosis** [3]. *Cord inflammation*- **Spinal cord inflammation** or myelitis is a CNS process and typically results in upper motor neuron signs (spasticity, brisk reflexes) or distinct sensory levels, which are not seen in GBS.- GBS involves inflammation and attack on the **peripheral nerve myelin** or axons, specifically in the nerve roots and distal peripheral nerves [1].

Q: A patient has developed a cough and weight loss for the last 3 months. Biopsy of lung mass shows expression of chromogranin and synaptophysin. Which paraneoplastic syndrome will most likely occur in this patient?

SIADH. ***SIADH*** - The biopsy findings of positive **chromogranin** and **synaptophysin** are characteristic of a **neuroendocrine tumor**, with **Small Cell Lung Cancer (SCLC)** being the most likely diagnosis given the clinical presentation. - **SCLC** is well-known for causing paraneoplastic syndromes, the most common of which is the **Syndrome of Inappropriate Antidiuretic Hormone (SIADH)**, resulting from ectopic **ADH** production [1]. *Hypercalcemia* - Paraneoplastic hypercalcemia is most frequently associated with **Squamous Cell Carcinoma** of the lung [2]. - This occurs due to the tumor's production of **Parathyroid Hormone-related Peptide (PTHrP)**, which is not a typical feature of SCLC [2]. *Cushing syndrome* - Paraneoplastic Cushing syndrome results from the ectopic production of **Adrenocorticotropic Hormone (ACTH)**, which can also be seen in **SCLC** [1]. - However, **SIADH** is a more common paraneoplastic endocrine syndrome associated with SCLC compared to Cushing syndrome. *Gynaecomastia* - Gynaecomastia as a paraneoplastic syndrome is classically associated with **Large Cell Carcinoma** of the lung. - This is due to the ectopic secretion of **human chorionic gonadotropin (hCG)** by the tumor cells.

Q: In Myasthenia gravis, which of the following is the primary target of autoantibodies at the neuromuscular junction?

Post-synaptic ACh Receptor. ***Post-synaptic ACh Receptor*** - Myasthenia gravis is an autoimmune disorder where **IgG autoantibodies** are produced against the nicotinic **acetylcholine receptors (AChR)** on the post-synaptic muscle membrane [1], [2]. - These antibodies block acetylcholine from binding and also cause **complement-mediated destruction** and accelerated degradation of the receptors, leading to fatigable muscle weakness [1]. *Presynaptic ACh receptor* - Presynaptic acetylcholine receptors are involved in modulating the release of acetylcholine, but they are not the primary target of autoantibodies in Myasthenia Gravis. - Conditions targeting presynaptic components, like **Lambert-Eaton Myasthenic Syndrome**, involve a different pathophysiology. *Voltage-gated calcium channels at NMJ* - Autoantibodies against presynaptic **P/Q-type voltage-gated calcium channels (VGCCs)** are the hallmark of **Lambert-Eaton Myasthenic Syndrome (LEMS)**, not Myasthenia Gravis. - The blockade of these channels impairs the presynaptic release of acetylcholine, leading to a distinct clinical picture of weakness that often improves with activity. *Acetylcholinesterase* - **Acetylcholinesterase** is the enzyme that breaks down acetylcholine in the synaptic cleft; it is not the target of autoantibodies in this disease [3]. - **Acetylcholinesterase inhibitors**, such as pyridostigmine, are a primary treatment for Myasthenia Gravis because they increase the availability of acetylcholine at the neuromuscular junction [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 213-214. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Peripheral Nerves and Skeletal Muscles, pp. 1237-1238. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Peripheral Nerves and Skeletal Muscles, pp. 1238-1239.

Question 1

An RTA patient has received 4 units of packed RBCs within a few hours. Which of the following will be seen?

Accepted Answer

Hypocalcemia

Answer

Hyperkalemia

Answer

Hypernatremia

Answer

Hyponatremia

Question 2

A study was conducted among nursing staff to analyze the time spent on different aspects of patient care, such as bed preparation, monitoring vital signs, attending the doctor’s rounds, blood sampling, and drug administration. Which of the following management techniques is most appropriate for this type of analysis?

Accepted Answer

Work Sampling

Answer

System Analysis

Answer

Critical Path Method

Answer

Time and Motion Study

Question 3

A patient presents to the ER with central chest pain. He has a past medical history of heart disease. ECG is shown below. What is the diagnosis?

Accepted Answer

Anterolateral MI

Answer

Inferolateral MI

Answer

Constrictive pericarditis

Answer

Acute pericarditis

Question 4

A patient after MI develops a broad QRS complex tachycardia. His BP is 120/85 mm Hg. ECG is given below. Best management?

Accepted Answer

Amiodarone iv

Answer

Nitroglycerin iv

Answer

Metoprolol iv

Answer

Labetalol iv

Question 5

A young female presents with ptosis showing diurnal variation. CT chest shows an anterior mediastinal mass identified as thymus gland cancer. Which receptor is affected in this patient?

Accepted Answer

Post-synaptic ACh Receptor

Answer

Acetylcholinesterase

Answer

Voltage-gated calcium channels at the NMJ

Answer

Presynaptic ACh Receptor

Question 6

A 35-year-old female with progressive limb weakness for the past 1 year. On examination, muscle fasciculations and hypertonia are noted, and the sensory system is intact. What is the diagnosis?

Accepted Answer

ALS

Answer

Multifocal motor neuropathy

Answer

Becker muscular dystrophy

Answer

Spinal muscular atrophy

Question 7

A patient presents with symmetrical leg weakness and areflexia. He had developed diarrhoea 2 weeks ago. He was diagnosed as having GBS. What is the cause?

Accepted Answer

Demyelination of A, B-fibers

Answer

Cord inflammation

Answer

Demyelination of the spinal cord

Answer

Demyelination of B-fibers

Question 8

A patient has developed a cough and weight loss for the last 3 months. Biopsy of lung mass shows expression of chromogranin and synaptophysin. Which paraneoplastic syndrome will most likely occur in this patient?

Accepted Answer

SIADH

Answer

Gynaecomastia

Answer

Cushing syndrome

Answer

Hypercalcemia

Question 9

A patient presents with weight gain, thinning of hair, and dry skin. Diagnosis is Hashimoto’s thyroiditis. Which antibody is seen in this case?

Accepted Answer

Anti-TPO antibody

Answer

Anti TBG

Answer

Long-acting thyroid-stimulating antibody

Answer

Anti-TSH receptor antibody

Question 10

In Myasthenia gravis, which of the following is the primary target of autoantibodies at the neuromuscular junction?

Accepted Answer

Post-synaptic ACh Receptor

Answer

Acetylcholinesterase

Answer

Voltage-gated calcium channels at NMJ

Answer

Presynaptic ACh receptor

FMGE 2025

Anesthesiology

Community Medicine

Internal Medicine

Pathology