FMGE 2025 Practice Questions

Q: 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?

Pneumothorax. ***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.

Q: Which is the best confirmatory method to ensure the central line is in the jugular vein?

Chest x-ray. ***Chest x-ray (Correct)*** - This is the **gold standard confirmatory method** to verify central venous catheter tip position, ensuring it rests appropriately in the **superior vena cava (SVC)** or at the cavoatrial junction - Post-procedure CXR is essential to screen for **mechanical complications** such as **pneumothorax** or hemothorax, which is paramount for patient safety - Provides anatomical confirmation of proper catheter placement *Blood pH (Incorrect)* - While blood gas analysis can differentiate an **arterial sample** from a venous sample (if accidental arterial puncture occurs), it does **not confirm the anatomical location** of the catheter tip within the venous system - Blood pH is a chemical test for systemic acid-base status, not an imaging technique for assessing catheter placement - Cannot verify the catheter tip is in the appropriate position (SVC/cavoatrial junction) *Blood color (Incorrect)* - Visual inspection of blood color (bright red for arterial, dark red for venous) is **unreliable and subjective** - Especially inaccurate in patients who are hypotensive, septic, or significantly hypoxic, as these conditions can darken arterial blood - Provides **no information** about the final resting location of the catheter tip, which is critical to avoid complications like cardiac perforation or malposition *ETCO2 (Incorrect)* - **End-tidal carbon dioxide (ETCO2)** measurement is used to monitor ventilatory status and efficiency of gas exchange - Primarily used for confirming **tracheal intubation** in airway management - This measurement is **completely unrelated** to the physical placement or confirmation of a central venous catheter

Q: 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?

Albumin and $\beta_{2}$-microglobulin. ***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.

Q: 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?

Lamivudine. 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

Q: 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?

Hyperkalemia. ***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.

Q: 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?

Pre-renal AKI. Correct: Pre-renal AKI - **FeNa 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 ** 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.

Q: A patient presents with fever and altered sensorium. Peripheral smear shows multiple ring stages. Best treatment is?

Artesunate. Artesunate - The clinical presentation of fever and altered sensorium, along with a peripheral smear showing multiple ring stages (characteristic of P. falciparum), indicates severe malaria [1]. Intravenous artesunate is the recommended first-line treatment [1]. - Artesunate is a potent and rapidly acting artemisinin derivative that quickly reduces the parasite burden, leading to lower mortality rates compared to quinine in severe malaria cases [1]. Primaquine - Primaquine is primarily used to eradicate the dormant liver stages (hypnozoites) of P. vivax and P. ovale to prevent relapse, not for treating acute, severe falciparum malaria. - It is ineffective against the asexual erythrocytic stages of P. falciparum and can cause severe hemolysis in patients with G6PD deficiency. Quinine - Quinine is a second-line agent for severe malaria and is only used if artesunate is unavailable, due to its inferior efficacy and greater toxicity [1]. - Its use is associated with adverse effects known as cinchonism (tinnitus, headache, nausea) and can cause severe hypoglycemia and cardiac arrhythmias [1]. Chloroquine - Widespread resistance of P. falciparum to chloroquine makes it an ineffective choice for treating this infection in most malaria-endemic regions. - Chloroquine is typically reserved for the treatment of uncomplicated malaria caused by chloroquine-sensitive species like P. malariae, _P. ovale, or P. vivax (in areas without resistance).

Q: What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?

Horner syndrome. 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.

Q: A patient had a road traffic accident (RTA). NCCT head was normal on admission. The patient later died after several days in the ICU due to coma. Brain biopsy revealed multiple punctate hemorrhages. What is the diagnosis?

Diffuse axonal injury. ***Diffuse axonal injury*** - This condition is caused by **traumatic shearing forces** due to sudden acceleration-deceleration, as seen in RTAs, leading to widespread axonal damage [1][2]. - A key feature is a discrepancy between clinical severity (e.g., coma) and initial imaging, as non-contrast CT scans are often normal [2]. The presence of **multiple punctate hemorrhages** on biopsy or sensitive MRI sequences (like the one shown) is characteristic [2]. *Ischemic injury* - This results from reduced blood flow causing a stroke, not direct trauma, and presents with focal neurological deficits corresponding to an arterial territory [3]. - Pathologically, it leads to **liquefactive necrosis** in a specific vascular distribution, not diffuse punctate hemorrhages [3]. *Intraventricular bleeding* - This refers to hemorrhage within the ventricular system and would be clearly visible as a **hyperdensity** on an initial NCCT head scan [3]. - It is a distinct type of intracranial bleed and does not present as microscopic, diffuse parenchymal hemorrhages [3]. *Subdural hemorrhage* - This involves bleeding into the space between the dura and arachnoid mater, usually from torn bridging veins. - It appears as a **crescent-shaped** hyperdensity on a CT scan and is typically evident immediately after trauma. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 700-701. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 701-702. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 706-707.

Q: 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?

Wide bore needle in 2nd ICS. ***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.

Question 1

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?

Accepted Answer

Pneumothorax

Answer

Air embolism

Answer

Displacement of endotracheal tube (ET)

Answer

Hemothorax

Question 2

Which is the best confirmatory method to ensure the central line is in the jugular vein?

Accepted Answer

Chest x-ray

Answer

ETCO2

Answer

Blood color

Answer

Blood pH

Question 3

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?

Accepted Answer

Albumin and $\beta_{2}$-microglobulin

Answer

Albumin and LDH

Answer

IgM and albumin

Answer

IgG and albumin

Question 4

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?

Accepted Answer

Lamivudine

Answer

Ritonavir

Answer

Ombitasvir

Answer

Abacavir

Question 5

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?

Accepted Answer

Hyperkalemia

Answer

Hypokalemia

Answer

Hyponatremia

Answer

Hypernatremia

Question 6

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?

Accepted Answer

Pre-renal AKI

Answer

Renal AKI

Answer

Acute Tubular Necrosis

Answer

Post-renal AKI

Question 7

A patient presents with fever and altered sensorium. Peripheral smear shows multiple ring stages. Best treatment is?

Accepted Answer

Artesunate

Answer

Chloroquine

Answer

Primaquine

Answer

Quinine

Question 8

What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?

Accepted Answer

Horner syndrome

Answer

Argyll Robertson pupil

Answer

Marcus Gunn pupil

Answer

Adie's tonic pupil

Question 9

A patient had a road traffic accident (RTA). NCCT head was normal on admission. The patient later died after several days in the ICU due to coma. Brain biopsy revealed multiple punctate hemorrhages. What is the diagnosis?

Accepted Answer

Diffuse axonal injury

Answer

Subdural hemorrhage

Answer

Intraventricular bleeding

Answer

Ischemic injury

Question 10

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?

Accepted Answer

Wide bore needle in 2nd ICS

Answer

Bedside CXR in casualty followed by chest tube insertion

Answer

Pleurodesis with doxycycline

Answer

Pericardiocentesis

FMGE 2025

Anesthesiology

Internal Medicine

Ophthalmology

Pathology

Surgery