FMGE 2025 Practice Questions

Q: A 2-week-old infant is brought to the hospital. Parents report a history of a single fall, but X-ray reveals multiple fractures at different stages of healing. What is the most likely diagnosis?

Battered baby syndrome. ***Battered baby syndrome*** - The presence of **multiple fractures** at **different stages of healing** is the most definitive radiological sign of non-accidental injury, indicating repeated trauma over time. - There is a significant discrepancy between the history provided by the parents (a single fall) and the clinical findings, which is a major red flag for child abuse. *Osteogenesis imperfecta* - This is a genetic disorder characterized by brittle bones due to defective **collagen synthesis**, leading to fractures with minimal trauma. However, it does not explain the different stages of healing, which point to injuries occurring at different times. - Other clinical features, such as **blue sclerae**, hearing loss, and dentinogenesis imperfecta, would typically be present but are not mentioned in this case. *Accidental fall* - A single accidental fall would result in injuries that are all in the **same stage of healing**, which contradicts the X-ray findings in this infant. - The pattern and number of fractures are inconsistent with a simple fall, which usually causes a single, isolated injury like a linear skull fracture. *Birth trauma* - Injuries sustained during birth, such as a fractured **clavicle** or humerus, would all have occurred at the same time and thus be in the same healing phase. - At two weeks of age, any new fractures or fractures at different healing stages could not be attributed to the birth event.

Q: A 16-year-old boy presents with multiple episodes of abdominal pain and a history of passing blood in his stools. On examination, he has darkly pigmented spots on his lips and oral mucosa. Endoscopy reveals multiple hamartomatous polyps in the small intestine. What is the most likely diagnosis?

Peutz-Jeghers Syndrome. ***Peutz-Jeghers Syndrome*** - This is an autosomal dominant disorder characterized by the classic triad of **hamartomatous polyps** in the GI tract (especially the small intestine), **mucocutaneous hyperpigmentation** (dark spots on lips, oral mucosa), and an increased risk of cancer [1]. - The patient's symptoms of abdominal pain and GI bleeding are common complications due to the polyps, which can lead to **intussusception** or ulceration. *Familial Adenomatous Polyposis* - This syndrome is defined by the presence of hundreds to thousands of **adenomatous polyps** in the colon, not hamartomatous polyps as seen in this patient [1]. - It is not associated with the characteristic **perioral mucocutaneous pigmentation** which is a hallmark feature of Peutz-Jeghers syndrome. *Juvenile Polyposis Syndrome* - This condition also involves **hamartomatous polyps**, but they are most commonly found in the colon and rectum, and the syndrome lacks the distinct mucocutaneous pigmentation [1]. - While patients can present with GI bleeding, the combination of small intestine polyps and pigmented lip spots points away from this diagnosis. *Cronkhite-Canada Syndrome* - This is a rare, non-hereditary syndrome typically affecting older adults, characterized by GI polyposis along with ectodermal changes like **alopecia** (hair loss) and **onychodystrophy** (nail changes). - Patients often present with severe diarrhea and **protein-losing enteropathy**, which are not features described in this case.

Q: A young adult patient presents with a fracture of the neck of the femur. What is the most appropriate management?

Internal fixation. ***Internal fixation*** - This is the treatment of choice in young adults to **preserve the native femoral head**, which is crucial for long-term function and avoiding prosthetic complications. - It involves stabilizing the fracture with hardware like **cannulated screws** or a **sliding hip screw**, promoting bone healing while maintaining the patient's own joint. *External fixation* - Primarily used for **temporary stabilization** in polytrauma patients or for highly comminuted or open fractures, not as a definitive treatment for a simple femoral neck fracture. - It provides less rigid fixation compared to internal methods and carries a significant risk of **pin-site infections**. *Hemiarthroplasty* - This procedure, which replaces only the femoral head, is typically reserved for **elderly patients** with displaced fractures and lower functional demands. - In a young, active patient, it can lead to **acetabular erosion** and pain, making preservation of the native joint the preferred approach. *Total hip replacement* - Reserved for patients with pre-existing severe **osteoarthritis** or for some active elderly patients, not for an acute fracture in a young individual. - Due to the **limited lifespan of the prosthesis**, performing a total hip replacement in a young patient would likely necessitate multiple complex **revision surgeries** in the future.

Q: A patient presents with a ring-shaped (lytic) lesion in the bone. Which of the following is the most likely diagnosis?

Brodie's abscess. ***Brodie's abscess*** - This is a localized, subacute or chronic form of **osteomyelitis** that presents radiographically as a well-circumscribed, **lytic lesion** with a thick, **sclerotic** rim, perfectly matching the “ring-shaped” appearance in the image. - It most commonly affects the **metaphysis** of long bones, particularly the tibia, and is often caused by *Staphylococcus aureus*. *Simple bone cyst* - A **simple bone cyst** (or unicameral bone cyst) is a fluid-filled lesion that typically appears as a central, lytic lesion causing **cortical thinning**, but it usually lacks the prominent sclerotic margin seen in a Brodie's abscess. - It is most common in the proximal **humerus** and **femur** of children and may show a **"fallen leaf" sign** if a pathological fracture has occurred. *Aneurysmal bone cyst* - An **aneurysmal bone cyst** (ABC) is a blood-filled, **expansile** lytic lesion that often has a multiloculated or **"soap bubble"** appearance on radiographs. - Unlike the contained lesion shown, an ABC is typically more aggressive, causing significant bony expansion and cortical thinning. *Osteoid osteoma* - An **osteoid osteoma** is a benign bone tumor characterized by a small radiolucent **nidus** (less than 1.5 cm) surrounded by a large area of extensive, dense reactive **sclerosis**. - Clinically, it is associated with characteristic **night pain** that is promptly relieved by **NSAIDs**, a key diagnostic feature not mentioned here.

Q: A 7-year-old male child was brought to the EMR 6 hours after a burn and was having 22% BSA burns. On examination, cool extremities, BP - 92/50mmHg, PR - 56 BPM. Urine output since burn episode: 30ml. What is the next step in management?

Give crystalloid bolus of 10-20 ml/kg. ***Give crystalloid bolus of 10-20 ml/kg*** - Child presents with **hypovolemic shock** (cool extremities, hypotension, bradycardia, oliguria) - Signs indicate inadequate initial resuscitation despite 6 hours post-burn - Immediate management: **rapid crystalloid bolus of 10-20 ml/kg** (Ringer's lactate or normal saline) over 20-60 minutes - After stabilization, continue calculated Parkland formula resuscitation - Target urine output: **1-2 ml/kg/hr** in children *Give a colloid bolus* - Colloids (albumin, plasma) are **not first-line** in initial burn resuscitation - Crystalloids (Ringer's lactate) are preferred initially due to better efficacy and lower cost - Colloids may be considered later if crystalloid requirements are excessive *Give bolus at 30ml/kg/hr* - This rate is **excessively high** and inappropriate - Risk of fluid overload, pulmonary edema, and compartment syndrome - Standard bolus is 10-20 ml/kg given rapidly, not as an hourly rate *Surgical Intervention* - Not the **immediate priority** in shock management - **Resuscitation before surgery** is the principle in trauma care - Surgical debridement/escharotomy may be needed later after stabilization

Q: After an RTA patient has severe Maxillofacial trauma with SpO2 80% at room air, and the patient cannot be intubated or ventilated, what should be your immediate step for this?

Cricothyrotomy. ***Cricothyrotomy***- This is the required immediate intervention in a "Cannot Intubate, Cannot Ventilate" (**CICV**) scenario, especially when severe maxillofacial trauma makes standard intubation impossible.- The SpO2 of **80%** indicates impending respiratory arrest and the urgent need for a definitive surgical airway below the level of obstruction/injury.*Tracheostomy*- A tracheostomy is a more complex surgical procedure that takes significantly longer than a **cricothyrotomy** and is not suitable in a crashing patient with immediate, life-threatening hypoxia.- It is typically reserved for elective or planned long-term airway management, not for initial **emergency airway access** in trauma.*ICD insertion*- An ICD (Intercostal Drain) insertion is used to treat **pneumothorax** or **hemothorax**, which addresses pulmonary/chest issues, not the primary problem of failed upper airway management due to maxillofacial trauma.- While chest injuries may coexist, airway management (A in **ATLS**) always takes immediate priority over breathing management (B) when the former is compromised to this extent.*Do suction and again try intubation*- The scenario explicitly states the patient **cannot be intubated or ventilated**, suggesting that maximal attempts, possibly including suctioning, have already failed or are deemed futile due to massive trauma/distortion.- Repeating futile attempts only prolongs the period of severe **hypoxia** (SpO2 80%), increasing the risk of cardiac arrest and neurologic damage.

Q: A 13-year-old male was brought to OPD with pain right side testes after being hit by a cricket ball 2 hours back. On examination, severe testicular pain and an absent cremasteric reflex. What is the next step?

Surgical exploration. ***Surgical exploration*** - This patient presents with **severe testicular pain** and **absent cremasteric reflex**, which has approximately **99% positive predictive value for testicular torsion** - The combination of these clinical findings constitutes a **surgical emergency** requiring **immediate scrotal exploration** without delay for imaging - **Time is critical**: testicular salvage rates are >90% if detorsion occurs within 6 hours, dropping to ~50% at 6-12 hours and <10% after 12 hours - In cases with **high clinical suspicion** (classic presentation with absent cremasteric reflex), imaging should **NOT delay surgical intervention** - Standard of care: proceed directly to the operating room for exploration and detorsion *USG Arterial Doppler* - While Doppler ultrasound can assess testicular blood flow, it is indicated only when the **diagnosis is equivocal** or clinical findings are unclear - Doppler has significant limitations: false negatives occur with intermittent or partial torsion, and arranging the study delays definitive treatment - In this case with **pathognomonic clinical findings** (absent cremasteric reflex + severe pain), imaging would inappropriately delay life-saving surgery - **"Time is testicle"** - every minute of delay reduces the chance of testicular salvage *USG Venous Doppler* - Venous Doppler is not the appropriate imaging modality for suspected testicular torsion - Arterial blood flow assessment is more relevant than venous drainage in diagnosing ischemia - However, with classic clinical presentation, neither imaging modality should delay surgical exploration *NSAIDS* - Administering analgesics alone is inappropriate management for suspected testicular torsion - Pain control does not address the underlying vascular compromise and will lead to **testicular loss** - NSAIDs may mask symptoms and create false reassurance while ischemic damage progresses

Q: A 30-year-old male presented to EMT with H/o Penetrating chest trauma. On examination, severe tracheal deviation was present. What is the immediate step of management?

Needle decompression. ***Needle decompression*** - The presence of **tracheal deviation** in a patient with penetrating chest trauma is a hallmark sign of a **tension pneumothorax**, a life-threatening condition that requires immediate intervention. - Needle decompression is the emergent, life-saving procedure performed to relieve the intrathoracic pressure by allowing the trapped air to escape, thereby correcting the mediastinal shift and restoring hemodynamic stability. *Chest X-ray* - A chest X-ray is a diagnostic tool used to confirm a pneumothorax but should **not** delay treatment in a hemodynamically unstable patient with clear clinical signs of tension. - Waiting for radiological confirmation in this emergency scenario can lead to cardiovascular collapse and death; the diagnosis is made clinically. *E-FAST* - The **Extended Focused Assessment with Sonography for Trauma (E-FAST)** can rapidly diagnose a pneumothorax at the bedside by showing an absence of **lung sliding**. - However, like a chest X-ray, it is a diagnostic step. In a patient with obvious signs of tension, proceeding directly to decompression is the priority over further imaging. *O2 support at 100%* - While supplemental oxygen is a crucial part of resuscitation in any trauma patient to treat hypoxia, it does not address the underlying mechanical problem. - The primary issue in a tension pneumothorax is the **compressive effect** of trapped air on the heart and great vessels, which can only be relieved by decompression.

Q: Identify the pathology in the child.

Umbilical Hernia. ***Umbilical Hernia*** - This is a protrusion of abdominal contents through a weak spot at the **umbilicus** (belly button), which is clearly depicted in the image. It occurs due to the incomplete closure of the umbilical ring after birth. - Umbilical hernias are very common in infants, particularly those born prematurely, and most resolve spontaneously without intervention by the age of 4-5 years. *Spigelian Hernia* - A Spigelian hernia occurs through the **Spigelian fascia**, located at the lateral edge of the rectus abdominis muscle, typically below the umbilicus. The bulge in the image is midline, not lateral. - This type of hernia is rare, especially in the pediatric population, and presents as a palpable mass on the side of the lower abdomen. *Inguinal Hernia* - An inguinal hernia involves the protrusion of abdominal contents through the **inguinal canal**, resulting in a bulge in the groin or scrotum. The location in the image is the umbilicus, not the groin. - While common in children, inguinal hernias are anatomically distinct and are located inferior and lateral to the umbilicus. *Femoral Hernia* - A femoral hernia occurs through the **femoral canal**, presenting as a bulge in the upper thigh, just below the inguinal ligament. This location is significantly different from the periumbilical bulge shown. - These hernias are rare in children and are more commonly seen in adult females due to the wider pelvis.

Q: A child comes after a train accident with stable vitals but a big laceration on the leg. Which triage category does the patient come under?

Yellow. ***Yellow (Correct Answer)*** - This category is used for casualties with **serious, non-life-threatening injuries** who require medical attention but whose treatment can be **delayed** for a few hours without causing immediate death or major morbidity. - A stable patient following trauma, despite having a **big laceration**, is categorized as Yellow because the immediate risk to life (indicated by **stable vitals**) is low, allowing for prioritized care after Red category patients are addressed. - The combination of **stable vitals + significant injury** = Yellow/Delayed category. *Red (Incorrect)* - This category is reserved for patients needing **immediate life-saving intervention** (within minutes), such as those with unstable vitals, airway obstruction, or uncontrolled severe hemorrhage leading to shock. - Since the patient has **stable vitals** (implying adequate circulation and respiration), they do not meet the criteria for immediate criticality required for the Red category. *Green (Incorrect)* - Green is assigned to the **'walking wounded'** or minor injuries like sprains, abrasions, or small cuts, where definitive treatment can be delayed indefinitely. - A **"big laceration"** implies a significant injury needing prompt management, ruling out the minor nature associated with the Green category. *Black (Incorrect)* - This category is for patients who are either confirmed **deceased** or have catastrophic injuries where survival is deemed highly unlikely (expectant categorization), and resources are better spent on higher priority patients. - Given the child has **stable vitals** and is salvageable with appropriate care, this category is inappropriate.

Question 1

A 2-week-old infant is brought to the hospital. Parents report a history of a single fall, but X-ray reveals multiple fractures at different stages of healing. What is the most likely diagnosis?

Accepted Answer

Battered baby syndrome

Answer

Accidental fall

Answer

Birth trauma

Answer

Osteogenesis imperfecta

Question 2

A 16-year-old boy presents with multiple episodes of abdominal pain and a history of passing blood in his stools. On examination, he has darkly pigmented spots on his lips and oral mucosa. Endoscopy reveals multiple hamartomatous polyps in the small intestine. What is the most likely diagnosis?

Accepted Answer

Peutz-Jeghers Syndrome

Answer

Cronkhite-Canada Syndrome

Answer

Juvenile Polyposis Syndrome

Answer

Familial Adenomatous Polyposis

Question 3

A young adult patient presents with a fracture of the neck of the femur. What is the most appropriate management?

Accepted Answer

Internal fixation

Answer

Total hip replacement

Answer

External fixation

Answer

Hemiarthroplasty

Question 4

A patient presents with a ring-shaped (lytic) lesion in the bone. Which of the following is the most likely diagnosis?

Accepted Answer

Brodie's abscess

Answer

Aneurysmal bone cyst

Answer

Simple bone cyst

Answer

Osteoid osteoma

Question 5

A 7-year-old male child was brought to the EMR 6 hours after a burn and was having 22% BSA burns. On examination, cool extremities, BP - 92/50mmHg, PR - 56 BPM. Urine output since burn episode: 30ml. What is the next step in management?

Accepted Answer

Give crystalloid bolus of 10-20 ml/kg

Answer

Give a colloid bolus

Answer

Give bolus at 30ml / kg / hr

Answer

Surgical Intervention

Question 6

After an RTA patient has severe Maxillofacial trauma with SpO2 80% at room air, and the patient cannot be intubated or ventilated, what should be your immediate step for this?

Accepted Answer

Cricothyrotomy

Answer

ICD insertion

Answer

Tracheostomy

Answer

Do suction and again try intubation

Question 7

A 13-year-old male was brought to OPD with pain right side testes after being hit by a cricket ball 2 hours back. On examination, severe testicular pain and an absent cremasteric reflex. What is the next step?

Accepted Answer

Surgical exploration

Answer

USG Venous Doppler

Answer

NSAIDS

Answer

USG Arterial Doppler

Question 8

A 30-year-old male presented to EMT with H/o Penetrating chest trauma. On examination, severe tracheal deviation was present. What is the immediate step of management?

Accepted Answer

Needle decompression

Answer

E-FAST

Answer

Chest X-ray

Answer

O2 support at 100%

Question 9

Identify the pathology in the child.

Accepted Answer

Umbilical Hernia

Answer

Inguinal Hernia

Answer

Femoral Hernia

Answer

Spigelian Hernia

Question 10

A child comes after a train accident with stable vitals but a big laceration on the leg. Which triage category does the patient come under?

Accepted Answer

Yellow

Answer

Black

Answer

Green

Answer

Red

FMGE 2025

Forensic Medicine

Internal Medicine

Orthopaedics

Pediatrics

Surgery