Anesthesiology
1 questionsA patient is in ICU and there is a failed attempt of subclavian catheterization. Shortly after, BP drops and the pulse rises. What is the diagnosis?
FMGE 2025 - Anesthesiology FMGE Practice Questions and MCQs
Question 321: A patient is in ICU and there is a failed attempt of subclavian catheterization. Shortly after, BP drops and the pulse rises. What is the diagnosis?
- A. Air embolism
- B. Displacement of endotracheal tube (ET)
- C. Pneumothorax (Correct Answer)
- D. Hemothorax
Explanation: ***Pneumothorax*** - A failed attempt at **subclavian vein catheterization** carries a high risk of puncturing the **parietal pleura** (due to the proximity of the apex of the lung), leading to a pneumothorax. - The sudden drop in **blood pressure (hypotension)** and rise in **pulse (tachycardia)** indicate acute hemodynamic compromise, often resulting from a **tension pneumothorax** which impedes venous return to the heart. - This is the **most common mechanical complication** of subclavian catheterization. *Displacement of endotracheal tube (ET)* - Displacement means the tube moves from the correct **tracheal position** (e.g., into the esophagus or mainstem bronchus), leading to acute ventilation failure and hypoxia. - While displacement causes hemodynamic instability, it is a complication of **ventilator management or patient movement**, not directly related to a preceding failed attempt at a **central venous line insertion**. *Air embolism* - An air embolism occurs when air enters the venous circulation, usually when the central line tract or needle hub is open to the atmosphere (e.g., during line insertion or removal) and the patient takes a deep breath. - Although it can cause cardiovascular collapse, the presenting feature following a needle stick is classically **pneumothorax**, unless the catheter was successfully placed and air was entrained through the line. - Classic sign: **mill-wheel murmur** on auscultation. *Hemothorax* - Hemothorax results from **vascular injury** (subclavian artery or vein) during catheterization attempts, causing blood accumulation in the pleural space. - While it can occur with subclavian catheterization, it typically presents with **more gradual hemodynamic changes** and signs of blood loss (falling hematocrit), rather than the acute decompensation seen with tension pneumothorax. - Chest X-ray would show pleural fluid rather than air.
Internal Medicine
6 questionsA female presents with amenorrhea and galactorrhea. Serum prolactin is elevated. MRI shows pituitary adenoma. Best management for this patient?
What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?
A 60-year-old female presents with weakness, back pain and repeated infections. Work up shows M spike on serum electrophoresis. Prognosis is determined by which of the following factors?
A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?
A patient with road traffic accident (RTA) is passing red color urine due to myoglobinuria. Which of the following will most likely be seen in this patient?
A patient after RTA had a renal shut down. Work-up shows: FeNa: $< 1\%$ , Urine osmolality: 300 mOsm/kg, Urinary sodium: 40 mEq/L. Most likely diagnosis?
FMGE 2025 - Internal Medicine FMGE Practice Questions and MCQs
Question 321: A female presents with amenorrhea and galactorrhea. Serum prolactin is elevated. MRI shows pituitary adenoma. Best management for this patient?
- A. Bromocriptine (Correct Answer)
- B. Tamoxifen
- C. Goserelin
- D. Letrozole
Explanation: ***Bromocriptine***- It is a **dopamine agonist** and represents the initial and standard treatment for **prolactinomas**, effectively reducing tumor size and lowering prolactin levels [1].- Dopamine agonists resolve symptoms such as **amenorrhea** and **galactorrhea** by inhibiting prolactin secretion from the pituitary [1]. *Letrozole*- This is an **aromatase inhibitor** primarily used in the management of hormone-sensitive breast cancer or for ovulation induction in conditions like PCOS. - Its mechanism is unrelated to suppressing prolactin secretion from the pituitary or shrinking a prolactinoma. *Tamoxifen*- This is a **Selective Estrogen Receptor Modulator (SERM)** most commonly used in the treatment and prevention of estrogen receptor-positive breast cancer. - It does not act on dopamine receptors and is ineffective in reversing elevated prolactin levels or associated symptoms. *Goserelin*- This agent is a **Gonadotropin-Releasing Hormone (GnRH) agonist** used primarily for conditions like endometriosis, uterine fibroids, or prostate cancer by initially stimulating then desensitizing the GnRH receptor. - While it suppresses LH and FSH [2], it is not the primary treatment for hyperprolactinemia caused by a pituitary adenoma.
Question 322: What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?
- A. Horner syndrome (Correct Answer)
- B. Argyll Robertson pupil
- C. Marcus Gunn pupil
- D. Adie's tonic pupil
Explanation: No changes were made to the text as none of the provided references reached the relevance threshold of 7/10 for the specific topic of Horner syndrome diagnosis and its differentials. The provided references largely discussed coagulation (mislabeled chapters), neurological signs of intracranial pressure, or general pupillary reflexes without specific diagnostic criteria for Horner syndrome or its differentiating features like anhidrosis.
Question 323: A 60-year-old female presents with weakness, back pain and repeated infections. Work up shows M spike on serum electrophoresis. Prognosis is determined by which of the following factors?
- A. Albumin and LDH
- B. IgM and albumin
- C. IgG and albumin
- D. Albumin and $\beta_{2}$-microglobulin (Correct Answer)
Explanation: ***Albumin and $\beta_{2}$-microglobulin*** - These two serum markers are the cornerstones of the **International Staging System (ISS)**, the most widely used system for determining prognosis in Multiple Myeloma. - High **$\beta_{2}$-microglobulin** levels reflect a high tumor burden and/or renal dysfunction, while low **serum albumin** indicates a more advanced disease state and poorer prognosis [1]. *IgG and albumin* - While **albumin** is a key prognostic factor, the specific type of immunoglobulin, such as **IgG**, is not a primary component of the main prognostic staging systems like the ISS. - The *quantity* of the monoclonal protein is used to monitor disease response, but the *type* is less critical for staging than **$\beta_{2}$-microglobulin**. *IgM and albumin* - A monoclonal gammopathy involving **IgM** is the hallmark of **Waldenström macroglobulinemia**, not Multiple Myeloma [1]. - Multiple Myeloma is characterized by the monoclonal proliferation of plasma cells that typically produce **IgG** or **IgA**, not **IgM** [1]. *Albumin and LDH* - While elevated **Lactate Dehydrogenase (LDH)** is an adverse prognostic factor, it is used in the **Revised-ISS (R-ISS)**, which builds upon the original ISS. - The foundational ISS, which is universally applied, is based on the combination of **serum albumin** and **$\beta_{2}$-microglobulin** levels.
Question 324: A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?
- A. Ritonavir
- B. Ombitasvir
- C. Lamivudine (Correct Answer)
- D. Abacavir
Explanation: Lamivudine - This serological profile (HBsAg+, IgM anti-HBc-, IgG anti-HBc+, HBeAg+) indicates HBeAg-positive chronic Hepatitis B with active viral replication [1] - Among the given options, Lamivudine is the only agent with anti-HBV activity as a nucleoside reverse transcriptase inhibitor (NRTI) that inhibits HBV DNA polymerase - Important Note: While Lamivudine was historically used for chronic HBV, current guidelines (WHO, AASLD, EASL) recommend Tenofovir or Entecavir as first-line therapy due to higher potency and lower resistance rates [2] - Lamivudine is now considered second-line due to high resistance rates (up to 70% after 5 years) Incorrect Option: Ombitasvir - Ombitasvir is an NS5A inhibitor used exclusively for Hepatitis C (HCV) treatment in combination regimens - Has no activity against HBV and is inappropriate for this patient Incorrect Option: Ritonavir - Ritonavir is an HIV protease inhibitor used primarily as a pharmacokinetic booster in antiretroviral therapy - Has no direct anti-HBV activity and is not used for HBV treatment Incorrect Option: Abacavir - Abacavir is an NRTI used for HIV treatment as part of combination ART - Despite being an NRTI class drug, it lacks significant anti-HBV activity and is not approved or effective for chronic Hepatitis B management
Question 325: A patient with road traffic accident (RTA) is passing red color urine due to myoglobinuria. Which of the following will most likely be seen in this patient?
- A. Hypokalemia
- B. Hyponatremia
- C. Hypernatremia
- D. Hyperkalemia (Correct Answer)
Explanation: ***Hyperkalemia***- Rhabdomyolysis involves massive breakdown of muscle cells, leading to the rapid release of intracellular contents, primarily **potassium (K+)**, into the circulation [1].- The associated **acute kidney injury (AKI)**, caused by myoglobin toxicity and sludge formation in the renal tubules, severely impairs K+ excretion, thus exacerbating the **hyperkalemia** [1].*Hypernatremia*- This condition is typically associated with states of significant **free water deficit** or inadequate fluid intake, not the massive tissue injury seen in rhabdomyolysis.- Fluid management of trauma patients often involves isotonic fluids, which are unlikely to cause severe dehydration leading to **hypernatremia**.*Hyponatremia*- While aggressive hydration with hypotonic fluids during resuscitation *could* potentially cause dilutional hyponatremia, the direct metabolic consequence of rhabdomyolysis is not primarily a state of **low serum sodium**.- Severe trauma leading to rhabdomyolysis is often associated with the release of ADH due to volume depletion, but this is less characteristic than the rapid rise in potassium.*Hypokalemia*- Hypokalemia, or low serum potassium, is the opposite of the predictable metabolic consequence of rhabdomyolysis.- Muscle cell death releases K+, making **hypokalemia** extremely unlikely in the acute setting of severe muscle injury and subsequent AKI.
Question 326: A patient after RTA had a renal shut down. Work-up shows: FeNa: $< 1\%$ , Urine osmolality: 300 mOsm/kg, Urinary sodium: 40 mEq/L. Most likely diagnosis?
- A. Renal AKI
- B. Pre-renal AKI (Correct Answer)
- C. Acute Tubular Necrosis
- D. Post-renal AKI
Explanation: Correct: Pre-renal AKI - **FeNa <1%** is the most specific parameter and definitively indicates **pre-renal azotemia** [1] - Post-RTA setting suggests **hypovolemia/shock** leading to hypoperfusion [1] - Kidneys are structurally intact and attempting to conserve sodium (FeNa <1%) - Though urine osmolality (300 mOsm/kg) is lower than classic pre-renal (>500), and urinary sodium (40 mEq/L) is at the borderline, **FeNa remains the gold standard** differentiating parameter *Incorrect: Acute Tubular Necrosis (Renal AKI)* - ATN would show **FeNa >2%** due to tubular dysfunction and inability to reabsorb sodium [1] - Urinary sodium would typically be **>40 mEq/L** (here it's exactly 40, borderline) - Urine osmolality would be **<350 mOsm/kg** and close to plasma (isosthenuria ~300) [1] - The **FeNa <1% excludes ATN** as the primary diagnosis *Incorrect: Renal AKI* - This is essentially the same as ATN (intrinsic renal injury) - Would present with FeNa >2%, not <1% [1] *Incorrect: Post-renal AKI* - Implies obstruction (bladder, ureter, urethra) - Not suggested by the clinical scenario of post-trauma renal shutdown - Laboratory parameters don't help differentiate obstruction; needs imaging **Key Teaching Point:** When laboratory values seem mixed, **FeNa <1% is the most reliable indicator of pre-renal azotemia**, especially in trauma settings with likely hypovolemia.
Pediatrics
1 questionsA child with progressive pallor and bone pain has an elevated HbS based on the HPLC report. Which is the best treatment to manage hemolysis in this patient?
FMGE 2025 - Pediatrics FMGE Practice Questions and MCQs
Question 321: A child with progressive pallor and bone pain has an elevated HbS based on the HPLC report. Which is the best treatment to manage hemolysis in this patient?
- A. Azacytidine
- B. Hydroxyurea
- C. Bortezomib
- D. Voxelotor (Correct Answer)
Explanation: ***Voxelotor*** - It is a **hemoglobin polymerization inhibitor** that stabilizes the oxygenated form of red blood cells, preventing **sickling** and subsequent hemolytic anemia, thereby directly managing the hemolysis. - It significantly improves **hemoglobin levels** and reduces markers of hemolysis, such as **indirect bilirubin** and **reticulocyte count**. *Hydroxyurea* - Its primary mechanism is inducing the production of **fetal hemoglobin (HbF)**, thereby diluting the concentration of HbS and *indirectly* reducing hemolysis over time. - Although crucial for managing **vaso-occlusive crises** (VOCs), it is not as direct an anti-hemolytic agent as Voxelotor. *Azacytidine* - This is a **DNA methyltransferase inhibitor**, primarily used in high-risk **Myelodysplastic Syndrome (MDS)** and Acute Myeloid Leukemia (AML). - While it can induce HbF like Hydroxyurea, it is not a standard or approved frontline treatment for the routine management of Sickle Cell Disease (SCD). *Bortezomib* - This drug is a **proteasome inhibitor** used exclusively in the treatment of **Multiple Myeloma** and certain related plasma cell dyscrasias. - It has no therapeutic role or clinical indication in the specific management of hemolysis or the underlying pathophysiology of SCD.
Surgery
2 questionsOn examination, a person has distended neck veins, absent breath sounds, hyperresonance, and a shift of the trachea. What is the management?
A patient presents with severe respiratory distress, hyperresonance and absent breath sounds on one side of the chest, distended neck veins, and tracheal shift away from the affected side. What is the best immediate management for this life-threatening condition?
FMGE 2025 - Surgery FMGE Practice Questions and MCQs
Question 321: On examination, a person has distended neck veins, absent breath sounds, hyperresonance, and a shift of the trachea. What is the management?
- A. Wide bore needle in 2nd ICS (Correct Answer)
- B. Pericardiocentesis
- C. Bedside CXR in casualty followed by chest tube insertion
- D. Pleurodesis with doxycycline
Explanation: ***Wide bore needle in 2nd ICS***- The constellation of absent breath sounds, **hyperresonance**, distended neck veins, and tracheal deviation indicates **tension pneumothorax**, which requires immediate definitive management before imaging can be done via a **needle decompression**.- This emergent procedure involves inserting a large-bore needle (e.g., 14-gauge) into the **second intercostal space (ICS)** in the midclavicular line to immediately relieve the pleural pressure and convert it to a simple pneumothorax.*Bedside CXR in casualty followed by chest tube insertion*- Obtaining a **CXR** is contraindicated as it significantly delays the urgent, life-saving decompression required for a clinically diagnosed **tension pneumothorax**.- While **chest tube insertion** is the definitive management, initial stabilization via needle decompression must precede this step in unstable patients with tension pneumothorax.*Pericardiocentesis*- This procedure is indicated for **cardiac tamponade**, which presents with features such as Beck's triad (hypotension, muffled heart sounds, elevated JVP), not the hyperresonance and absent breath sounds seen here.- Cardiac tamponade is a fluid accumulation issue impacting cardiac function, distinct from the life-threatening air accumulation and massive pressure shift seen in **tension pneumothorax**.*Pleurodesis with doxycycline*- **Pleurodesis** is an elective, definitive procedure used to prevent the recurrence of pleural effusions or pneumothorax by fusing the pleural layers, not an immediate emergency intervention.- This is typically reserved for stable patients with recurrent pneumothorax or chronic conditions like refractory **malignant pleural effusion**.
Question 322: A patient presents with severe respiratory distress, hyperresonance and absent breath sounds on one side of the chest, distended neck veins, and tracheal shift away from the affected side. What is the best immediate management for this life-threatening condition?
- A. Wide bore needle in 2nd ICS (Correct Answer)
- B. Bedside CXR in casualty followed by chest tube insertion
- C. Pleurodesis with doxycycline
- D. Pericardiocentesis
Explanation: ***Wide bore needle in 2nd ICS*** - This is the immediate, life-saving intervention for a **tension pneumothorax**, a clinical diagnosis based on the triad of respiratory distress, hemodynamic instability, and unilateral chest signs. - Needle decompression rapidly converts the **tension pneumothorax** into a simple pneumothorax by relieving intrapleural pressure, and is a temporizing measure followed by definitive chest tube insertion. *Bedside CXR in casualty followed by chest tube insertion* - Delaying treatment for a chest X-ray in a clinically evident and unstable **tension pneumothorax** is dangerous and can lead to cardiovascular collapse and death. - The diagnosis is **clinical**, and immediate decompression should precede any imaging. *Pericardiocentesis* - This procedure is indicated for **cardiac tamponade**, which presents with muffled heart sounds, not the unilateral hyperresonance and absent breath sounds seen in pneumothorax. - While both conditions can cause obstructive shock with distended neck veins, the pulmonary findings are key to differentiating them. *Pleurodesis with doxycycline* - Pleurodesis is a procedure to prevent the **recurrence** of a pneumothorax or pleural effusion, not a treatment for an acute, life-threatening event. - It is performed electively after the lung has been fully re-expanded with a chest tube.