FMGE 2025 Practice Questions

Q: 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?

Cadmium – 0.03 mg/L. ***Cadmium – 0.03 mg/L***- The World Health Organization (WHO) and Indian standards for safe drinking water set the acceptable limit for **Cadmium** at **0.003 mg/L** (or 3 µg/L).- A level of 0.03 mg/L is **ten times higher** than the permissible limit and thus not acceptable, indicating potential chronic toxicity (e.g., **Itai-Itai disease** or renal damage).*Fluoride – 0.8 mg/L*- The acceptable limit for **Fluoride** in drinking water is generally between **0.6 to 1.0 mg/L** (or up to 1.5 mg/L as per WHO), making 0.8 mg/L acceptable.- Levels exceeding 1.5 mg/L or 2.0 mg/L can cause dental or skeletal **fluorosis**, but 0.8 mg/L falls within the recommended range for preventing dental caries.*Total Dissolved Solids (TDS) – 300 mg/L*- The acceptable limit for **TDS** is typically **500 mg/L**, extendable up to 2000 mg/L in the absence of an alternate source, making 300 mg/L acceptable.- High TDS affects the **palatability** of water but 300 mg/L is well below the threshold that causes taste concerns or health issues.*Nitrate – 20 mg/L*- The maximum acceptable limit for **Nitrate** is typically **45 mg/L** (or 50 mg/L as per certain standards), making 20 mg/L acceptable.- Excess nitrates, especially above 50 mg/L, pose a risk of causing **methemoglobinemia** (blue baby syndrome) in infants.

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 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?

Start an ACE inhibitor. ***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.

Q: 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?

Encephalopathy. ***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].

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

Absent a wave. ***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**.

Q: 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?

MS. ***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.

Q: 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?

Mitral Stenosis (MS). ***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.

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.

Question 1

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?

Accepted Answer

Cadmium – 0.03 mg/L

Answer

Total Dissolved Solids (TDS) – 300 mg/L

Answer

Fluoride – 0.8 mg/L

Answer

Nitrate – 20 mg/L

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 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?

Accepted Answer

Start nebulised bronchodilator therapy with salbutamol and ipratropium

Answer

Order a chest X-ray before any treatment is provided

Answer

Initiate high-flow oxygen therapy to maintain oxygen saturation above 95%

Answer

Begin intravenous glucocorticoids immediately

Question 4

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?

Accepted Answer

Start an ACE inhibitor

Answer

Start insulin therapy

Answer

Stop Metformin and start a different OHA

Answer

Begin a thiazide diuretic

Question 5

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?

Accepted Answer

Encephalopathy

Answer

Stroke

Answer

Encephalitis

Answer

Guillain-Barré Syndrome

Question 6

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

Accepted Answer

Absent a wave

Answer

Steep y descent

Answer

Large a wave

Answer

Canon a wave

Question 7

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?

Accepted Answer

MS

Answer

TS

Answer

MR

Answer

AR

Question 8

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?

Accepted Answer

Mitral Stenosis (MS)

Answer

Tricuspid Stenosis (TS)

Answer

Mitral Regurgitation (MR)

Answer

Aortic Regurgitation (AR)

Question 9

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 10

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

FMGE 2025

Community Medicine

Internal Medicine