FMGE 2025 Practice Questions

Q: A patient presents with blackish discoloration of the nasal cavity and posterior buccal mucosa. He has a history of high-dose steroid use. What is the most appropriate drug for treatment?

Amphotericin B. ***Amphotericin B*** - The patient's signs (**blackish discoloration** of the nasal and buccal mucosa) coupled with profound immunosuppression (high-dose steroids) strongly suggest **Rhinocerebral mucormycosis**, an aggressive angioinvasive fungal infection caused by **Mucorales** [2]. - **Amphotericin B** (liposomal formulation preferred) is the drug of choice for empirical and definitive treatment of life-threatening mucormycosis due to its potent fungicidal activity against **Zygomycetes** [2]. - Early surgical debridement combined with Amphotericin B therapy is essential for optimal outcomes [2]. *Fluconazole* - **Fluconazole** has no reliable activity against **Mucorales** (causative agents of mucormycosis) [3]. - It is primarily used for *Candida* and *Cryptococcus* infections, completely lacking the spectrum needed for this severe angioinvasive process [1][3]. *Itraconazole* - **Itraconazole** is typically ineffective against **Mucorales** and is generally reserved for endemic mycoses (*Histoplasma, Blastomyces*) or step-down therapy for *Aspergillus* [3]. - It does not achieve adequate fungicidal activity needed for aggressive invasive fungal sinusitis. *Griseofulvin* - **Griseofulvin** is indicated only for **dermatophytosis** (superficial tinea infections of skin, hair, and nails). - It has no role or efficacy in treating severe, systemic, or angioinvasive fungal infections like mucormycosis.

Q: A patient with hypertension is taking anti-hypertensive drugs but BP is not controlled even after adding diuretics in treatment. Patient's serum electrolyte shows hypokalemia. What is the next step in treatment of this patient?

Spironolactone. ***Spironolactone*** - The combination of **resistant hypertension** (uncontrolled BP despite standard therapy including a diuretic) and **hypokalemia** strongly suggests **Primary Aldosteronism**. - **Spironolactone** is an **aldosterone antagonist** (potassium-sparing diuretic) and is the drug of choice for treating hypertension secondary to hyperaldosteronism, as it corrects both the hypokalemia and the high blood pressure [1]. *KCL* - **Potassium chloride** (KCL) would correct the hypokalemia temporarily, but it does not address the underlying cause (aldosterone excess) or control the **resistant hypertension** [1]. - Supplementation alone is insufficient when the source of hypokalemia is excessive renal potassium loss driven by high aldosterone levels. *Torasemide* - **Torasemide** is a **loop diuretic**; adding it to the regimen will significantly increase potassium excretion, thereby **worsening the existing hypokalemia**. - Loop diuretics are potent potassium-wasting agents and are contraindicated when the suspicion is high for Primary Aldosteronism presenting with hypokalemia. *Hydrochlorothiazide* - **Hydrochlorothiazide** (HCTZ) is a **thiazide diuretic** (also a potassium-wasting drug). - Similar to Torasemide, adding HCTZ would exacerbate the **hypokalemia** and is not the appropriate therapy for hypertension suspected to be caused by mineralocorticoid excess.

Q: A patient took a drug for migraine treatment, following which there was numbness, and his hand appeared as below. What is the possible drug that was taken?

Dihydroergotamine. ***Dihydroergotamine*** - Dihydroergotamine is an **ergot alkaloid** that causes potent, non-selective **vasoconstriction** of both arteries and veins. This can lead to severe peripheral ischemia, a condition known as **ergotism**. - The clinical presentation of numbness, tingling, and cold extremities, as suggested by the patient's symptoms and the appearance of the hand, is a classic manifestation of ergotamine-induced vasospasm. *Sumatriptan* - Sumatriptan is a **triptan**, which is a selective **5-HT1B/1D receptor agonist**. While it does cause vasoconstriction, its effects are more selective for **cranial arteries**. - Though it can cause paresthesias (tingling/numbness), severe peripheral ischemia leading to the signs seen in the image is a much rarer side effect compared to ergot alkaloids. *Butorphanol* - Butorphanol is an **opioid agonist-antagonist** used for pain relief. Its mechanism of action does not involve vasoconstriction. - Common side effects are related to the central nervous system, such as sedation, dizziness, and nausea, not peripheral vascular symptoms. *Aspirin* - Aspirin is a **nonsteroidal anti-inflammatory drug (NSAID)** that inhibits **cyclooxygenase (COX)** and has antiplatelet effects. It does not cause vasoconstriction. - Its primary side effects include **gastrointestinal irritation** and an increased risk of **bleeding**, which are unrelated to the patient's presentation.

Q: A patient with hypertension, tachycardia and early renal involvement is prescribed an ARB (telmisartan). What is the most likely mechanism by which the drug helps improve heart rate and blood pressure?

By decreasing peripheral vascular resistance. ***By decreasing peripheral vascular resistance*** - ARBs (Angiotensin Receptor Blockers) like **telmisartan** selectively block AT1 receptors, preventing angiotensin II from binding - This blockade leads to **vasodilation** (reduced vasoconstriction) → decreased peripheral vascular resistance (afterload reduction) - Lower afterload reduces **blood pressure** and decreases cardiac workload, which secondarily **improves heart rate** - ARBs also provide **renoprotection** by reducing intraglomerular pressure, making them ideal for hypertension with early renal involvement *By decreasing cardiac output directly* - ARBs do not have direct negative inotropic effects on the heart - Any reduction in cardiac output is secondary to decreased afterload, not a primary mechanism *By directly blocking beta-1 receptors* - This describes the mechanism of **beta-blockers** (e.g., metoprolol, atenolol), not ARBs - Beta-blockers directly reduce heart rate and contractility; ARBs work via peripheral vasodilation *By increasing sodium excretion via loop diuretics* - This describes the mechanism of **loop diuretics** (e.g., furosemide), not ARBs - While ARBs may have mild diuretic effects, their primary mechanism is reducing peripheral vascular resistance through AT1 receptor blockade

Q: What is the preferred preoperative drug for managing blood pressure in a patient with pheochromocytoma?

Phenoxybenzamine. ***Phenoxybenzamine***- It is the standard first-line agent, administered 10–14 days preoperatively, because it is a **non-selective**, **irreversible alpha-adrenergic blocker**.- This irreversible blockade prevents the high concentrations of circulating **catecholamines** (epinephrine and norepinephrine) resulting in severe **hypertensive crisis** during surgical tumor manipulation.*Propranolol*- Propranolol and other pure **beta-blockers** should only be initiated *after* adequate **alpha-blockade** is established, typically to control tachycardia.- Giving a beta-blocker alone leaves the **alpha-1 receptors** unopposed, leading to unchecked systemic **vasoconstriction** and severe, potentially fatal, hypertension.*Prazosin*- Although Prazosin is an **alpha-1 selective blocker**, it is generally less preferred because it is a *reversible* antagonist.- **Phenoxybenzamine** is favored because its irreversible action provides superior, more stable, and prolonged protection against massive **catecholamine surges** during surgery.*Labetalol*- Labetalol is generally avoided for initial control because its **beta-blocking action** significantly outweighs its alpha-blocking action (high beta:alpha ratio).- This dominant beta blockade can induce **unopposed alpha vasoconstriction**, similar to pure beta-blockers, resulting in paradoxical and severe **hypertension**.

Q: A woman taking cetirizine for allergic rhinitis complains of excessive sleepiness. Which of the following is the best alternative with minimal sedative effect?

Fexofenadine. ***Fexofenadine***- It is a second-generation H1 antihistamine that has the **lowest lipophilicity** and is actively transported out of the central nervous system (CNS) by the **P-glycoprotein** pump.- This mechanism results in **minimal to virtually no sedative effects**, making it the best non-sedating alternative to cetirizine.*Hydroxyzine*- This is a first-generation H1 antihistamine that easily crosses the **blood-brain barrier** (BBB).- It is known for its significant **sedative** and **anxiolytic properties**, and would worsen the patient's complaint of excessive sleepiness.*Diphenhydramine*- As a highly lipophilic, first-generation antihistamine, it exhibits profound CNS penetration and causes profound **drowsiness** and cognitive impairment.- It also possesses potent **anticholinergic effects**, which contribute significantly to various side effects but not lack of sedation.*Promethazine*- This drug is a first-generation antihistamine known for its **strong antiemetic** and highly **sedative** properties.- It is structurally related to phenothiazine antipsychotics and would likely cause **more severe sleepiness** than cetirizine.

Q: Which of the following drugs acts by inhibiting the catechol-O-methyltransferase enzyme?

Tolcapone. ***Tolcapone***- **Tolcapone** is a potent inhibitor of **catechol-O-methyltransferase (COMT)**, an enzyme responsible for metabolizing dopamine and levodopa. - By inhibiting COMT, Tolcapone increases the bioavailability and half-life of **levodopa** in the brain, thereby improving motor symptoms in **Parkinson's disease**.*Amantadine*- Amantadine is thought to enhance the synthesis and release of **dopamine** from presynaptic nerve terminals. - It also acts as a non-competitive antagonist of the **N-methyl-D-aspartate (NMDA) receptor**, providing benefit primarily for **dyskinesia** associated with long-term levodopa use.*Rotigotine*- **Rotigotine** is classified as a non-ergot **dopamine agonist**, meaning it directly stimulates post-synaptic dopamine receptors (D2 and D3). - It is often administered as a **transdermal patch** for continuous dopamine stimulation, helping to manage motor fluctuations in Parkinson's disease.*Selegiline*- **Selegiline** is an inhibitor of **Monoamine Oxidase type B (MAO-B)**, an enzyme subgroup that preferentially metabolizes dopamine in the brain. - By selectively blocking MAO-B, it reduces the breakdown of dopamine, thereby potentiating the effects of endogenous and administered levodopa.

Q: A patient is brought to the emergency department with signs suggesting opioid poisoning. What is the antidote of choice?

Naloxone. ***Naloxone***- **Naloxone** is the drug of choice for treating opioid poisoning, acting as a competitive antagonist at **mu**, kappa, and delta opioid receptors [1]. - It reverses the life-threatening effects of opioid overdose, primarily **respiratory depression** and **central nervous system depression**, within minutes of administration [3].*Flumazenil*- Flumazenil is the specific antagonist used to reverse the effects of **benzodiazepine overdose**, acting at the GABA-A receptor.- It is generally ineffective and not indicated for pure opioid toxicity.*Atropine*- Atropine is an **anticholinergic agent** used primarily in the treatment of symptomatic **bradycardia** and **organophosphate poisoning** [2].- It does not antagonize opioid receptors and has no direct role in reversing opioid-induced respiratory depression.*Physostigmine*- Physostigmine is a **reversible acetylcholinesterase inhibitor** used mainly for reversing severe central nervous system effects of **anticholinergic poisoning** (e.g., tricyclic antidepressants).- Increasing acetylcholine is irrelevant and potentially counterproductive in treating opioid-induced respiratory depression.

Q: A 30 year old apparently healthy man who was carrying laxatives and enema apparatus developed abdominal pain at the airport and an x-ray was done which appears as shown below. Which of the following is the likely diagnosis?

Body packer syndrome. ***Body packer syndrome*** - This diagnosis is indicated by the presence of multiple, well-defined, uniformly shaped, and hyperdense foreign bodies within the gastrointestinal tract, as seen on the abdominal X-ray. - The clinical context of being at an airport with laxatives and enema apparatus is highly suggestive of an individual attempting to smuggle illicit drugs by ingesting them in packets. *Bezoar syndrome* - A **bezoar** is a mass of indigestible material (like hair or vegetable fibers) trapped in the GI tract, which appears on X-ray as a mottled, heterogeneous mass, not as multiple discrete, uniform packets. - Bezoars typically conform to the shape of the stomach or bowel lumen and lack the smooth, regular outlines seen in this image. *Pica due to anaemia* - **Pica** is the ingestion of non-nutritive substances and might show foreign objects on an X-ray, but these would typically be of varied shapes and sizes (e.g., coins, dirt, paint chips), not uniform packets. - The clinical presentation does not suggest anaemia, and the scenario points towards illegal activity rather than a compulsive eating disorder. *Constipation due to fecalith* - A **fecalith** is a hardened mass of stool that appears as a mottled density within the colon, consistent with retained feces. - The objects in the X-ray have sharp, smooth borders and a uniform density, which is inconsistent with the appearance of a fecalith.

Q: The X-ray image provided (img-41.jpeg) shows multiple cylindrical objects in the abdominal area. Which of the following conditions is most likely represented by this image?

Body packer syndrome. ***Body packer syndrome*** - The X-ray shows multiple, well-defined, uniformly shaped, dense, cylindrical objects throughout the gastrointestinal tract, a classic radiographic finding for **body packer syndrome**. - These objects are ingested packets containing illicit drugs, often showing a "double-condom sign" (a thin lucent rim of air trapped in the wrapping), confirming their manufactured nature. *Bezoar* - A **bezoar** is a mass of indigestible material (like hair or vegetable fiber) that appears as a single, mottled, intraluminal mass on X-ray, not multiple discrete packets. - The objects in the image have a uniform shape and density, which is inconsistent with the heterogeneous appearance of a bezoar. *Pica due to anaemia* - **Pica** involves the ingestion of non-nutritive substances, which would result in radiopaque foreign bodies of various, irregular shapes (e.g., coins, stones), not uniform cylindrical packets. - While associated with conditions like **iron-deficiency anaemia**, the radiographic findings of pica do not match the organized, manufactured appearance of the objects shown. *Constipation due to fecalith* - A **fecalith** is a hardened mass of stool that appears as a mottled density within the colon, conforming to the haustral pattern, and lacks the smooth, well-defined borders seen here. - While severe **constipation** leads to significant stool burden, it does not present as multiple, encapsulated, geometrically regular objects.

Question 1

A patient presents with blackish discoloration of the nasal cavity and posterior buccal mucosa. He has a history of high-dose steroid use. What is the most appropriate drug for treatment?

Accepted Answer

Amphotericin B

Answer

Fluconazole

Answer

Griseofulvin

Answer

Itraconazole

Question 2

A patient with hypertension is taking anti-hypertensive drugs but BP is not controlled even after adding diuretics in treatment. Patient's serum electrolyte shows hypokalemia. What is the next step in treatment of this patient?

Accepted Answer

Spironolactone

Answer

KCL

Answer

Hydrochlorothiazide

Answer

Torasemide

Question 3

A patient took a drug for migraine treatment, following which there was numbness, and his hand appeared as below. What is the possible drug that was taken?

Accepted Answer

Dihydroergotamine

Answer

Sumatriptan

Answer

Aspirin

Answer

Butorphanol

Question 4

A patient with hypertension, tachycardia and early renal involvement is prescribed an ARB (telmisartan). What is the most likely mechanism by which the drug helps improve heart rate and blood pressure?

Accepted Answer

By decreasing peripheral vascular resistance

Answer

By decreasing cardiac output directly

Answer

By directly blocking beta-1 receptors

Answer

By increasing sodium excretion via loop diuretics

Question 5

What is the preferred preoperative drug for managing blood pressure in a patient with pheochromocytoma?

Accepted Answer

Phenoxybenzamine

Answer

Prazosin

Answer

Propranolol

Answer

Labetalol

Question 6

A woman taking cetirizine for allergic rhinitis complains of excessive sleepiness. Which of the following is the best alternative with minimal sedative effect?

Accepted Answer

Fexofenadine

Answer

Promethazine

Answer

Diphenhydramine

Answer

Hydroxyzine

Question 7

Which of the following drugs acts by inhibiting the catechol-O-methyltransferase enzyme?

Accepted Answer

Tolcapone

Answer

Amantadine

Answer

Selegiline

Answer

Rotigotine

Question 8

A patient is brought to the emergency department with signs suggesting opioid poisoning. What is the antidote of choice?

Accepted Answer

Naloxone

Answer

Flumazenil

Answer

Physostigmine

Answer

Atropine

Question 9

A 30 year old apparently healthy man who was carrying laxatives and enema apparatus developed abdominal pain at the airport and an x-ray was done which appears as shown below. Which of the following is the likely diagnosis?

Accepted Answer

Body packer syndrome

Answer

Pica due to anaemia

Answer

Bezoar syndrome

Answer

Constipation due to fecalith

Question 10

The X-ray image provided (img-41.jpeg) shows multiple cylindrical objects in the abdominal area. Which of the following conditions is most likely represented by this image?

Accepted Answer

Body packer syndrome

Answer

Pica due to anaemia

Answer

Bezoar

Answer

Constipation due to fecalith

FMGE 2025

Internal Medicine

Pharmacology

Radiology