FMGE 2025 Practice Questions

Q: An elderly man presents with leg deformities and skeletal abnormalities. On examination, he is using crutches and has visible bowing of the legs. It is also noted that several other villagers exhibit similar symptoms. Considering the cluster of cases in the same geographic area, which of the following is the most appropriate next step in the investigation?

Collect and analyze water samples for fluoride content. ***Collect and analyze water samples for fluoride content*** - The presentation of a cluster of cases with **skeletal deformities** (bowing of the legs) in a single geographic area strongly suggests an endemic condition related to an **environmental exposure**, such as a contaminated water source. - The clinical picture is highly consistent with **skeletal fluorosis**, and the accompanying image showing mottled enamel is a classic sign of **dental fluorosis**, both caused by chronic high intake of fluoride. *Check serum vitamin D levels* - Vitamin D deficiency causes **osteomalacia** in adults, which can lead to bone deformities, but it does not cause the specific **dental fluorosis** seen in the image. - While a community-wide nutritional deficiency is possible, the combination of skeletal and dental findings makes an environmental toxin a more specific and likely cause to investigate first. *Measure serum calcium levels* - Serum calcium levels are typically **normal** in patients with skeletal fluorosis, so this test would have low diagnostic yield for the suspected condition. - While metabolic bone diseases can present with abnormal calcium, they do not explain the endemic nature of the presentation or the characteristic dental findings. *Perform parathyroid hormone (PTH) assay* - **Hyperparathyroidism** is an endocrine disorder that is unlikely to affect multiple individuals in the same village simultaneously. - The clinical and radiological features of hyperparathyroidism, such as **osteitis fibrosa cystica**, differ from those of skeletal fluorosis, and it is not associated with dental fluorosis.

Q: A patient presents with increased consumption of Bajra (pearl millet) roti and now complains of drowsiness and giddiness. What is the most likely diagnosis?

Ergotism. ***Ergotism*** - This condition results from ingesting grains, such as **pearl millet (Bajra)**, contaminated by the fungus *Claviceps fusiformis*. - The neurotoxic effects of **ergot alkaloids** cause the central nervous system (CNS) symptoms of the convulsive form, including **drowsiness** and **giddiness**. *Epidemic Dropsy* - This toxicity is caused by ingesting edible oils (typically mustard oil) contaminated with **argemone oil**. - The cardinal features are non-pitting **edema** (dropsy), skin pigmentation, and rarely, secondary glaucoma, not primarily CNS giddiness. *Botulism* - This illness is caused by the potent neurotoxin produced by *Clostridium botulinum*, usually found in improperly canned or preserved food. - The defining clinical presentation is a classic descending, symmetric **flaccid paralysis** often starting with cranial nerve symptoms (**diplopia, dysphagia**). *Fusarium Toxicity* - This involves various mycotoxins (e.g., **fumonisins, T-2 toxin**) contaminating cereals, most commonly maize. - Clinical syndromes include severe immunosuppression (Alimentary Toxic Aleukia) or liver/kidney damage, not the primary presentation of acute drowsiness and giddiness.

Q: In a group, the mean blood glucose level is 105 mg/dL with a standard deviation of 10 mg/dL. Assuming a normal distribution, what is the expected range of blood glucose values for approximately 95% of the population?

85 – 125 mg/dL. ***85 – 125 mg/dL*** - This range is calculated using the **Empirical Rule** ($\text{Mean} \pm 2 \text{ SD}$), which states that approximately 95% of observations in a **normal distribution** fall within two standard deviations of the mean. - Calculation: $105 \text{ mg/dL} \pm (2 \times 10 \text{ mg/dL}) = 105 \pm 20 \text{ mg/dL}$, resulting in the range **85 – 125 mg/dL**. *101 – 110 mg/dL* - This range is too narrow, only covering values $5 \text{ mg/dL}$ above and below the mean, and does not represent the required **95%** coverage for a 10 mg/dL standard deviation. - Using this small range indicates an incorrect application of the **standard deviation** multiplier necessary for determining large confidence intervals. *90 – 125 mg/dL* - While the upper limit ($125 \text{ mg/dL}$) is correct ($\text{Mean} + 2 \text{ SD}$), the lower limit ($90 \text{ mg/dL}$) is incorrect, as it must be symmetrical around the mean in a **normal distribution**. - This asymmetrical range does not accurately represent the **95% confidence interval** defined by $\text{Mean} \pm 2 \text{ SD}$. *95 – 115 mg/dL* - This range is calculated using $\text{Mean} \pm 1 \text{ SD}$ ($105 \pm 10 \text{ mg/dL}$), which only includes approximately **68%** of the data according to the **Empirical Rule**, not 95%. - To capture **95%** of the population data, clinicians and students must use **two standard deviations** from the mean.

Q: A teenage boy, who was previously raised as a girl, presents with primary amenorrhea and lack of secondary sexual characteristics. On examination, he has tall stature, small testes, and gynecomastia. Which of the following is the most likely genotype?

47,XXY. ***Correct: 47,XXY (Klinefelter Syndrome)*** - This patient presents with **classic features of Klinefelter syndrome**: tall stature, small firm testes, gynecomastia, and hypogonadism [1]. - The **47,XXY karyotype** results from meiotic nondisjunction leading to an extra X chromosome. - **Hypogonadism** causes decreased testosterone, leading to lack of secondary sexual characteristics and increased FSH/LH [1]. - Patients typically have **eunuchoid body proportions** (tall stature with long limbs) due to delayed epiphyseal closure [1]. - The presence of **gynecomastia** is due to relative estrogen excess compared to testosterone [1]. - Primary amenorrhea mentioned here likely refers to the lack of pubertal development (developmental delay). *Incorrect: 47,XYY (Supermale Syndrome)* - These individuals are **tall males with normal virilization** and normal-sized testes - No gynecomastia or hypogonadism - Often associated with learning difficulties but normal sexual development *Incorrect: 45,X (Turner Syndrome)* - Presents in **phenotypic females** with **short stature** (not tall) [2]. - Features include webbed neck, shield chest, coarctation of aorta - Primary amenorrhea present but patient would be raised as female throughout - Does not explain male phenotype or gynecomastia in this case *Incorrect: 46,XX (Normal Female Karyotype)* - Normal female karyotype would not explain **male phenotype** with testes - Does not account for gynecomastia or the clinical presentation described

Q: A newborn presents with jaundice, conjugated hyperbilirubinemia, intrahepatic cholestasis, and elevated alkaline phosphatase. Liver biopsy reveals eosinophilic, PAS-positive cytoplasmic granules in hepatocytes. What is the most likely diagnosis?

Neonatal hepatitis. ***Neonatal hepatitis***- **Neonatal hepatitis** is a broad term encompassing various causes of **intrahepatic cholestasis** in infants, including viral infections and metabolic disorders like **Alpha 1 AT deficiency**.- The presence of eosinophilic, **PAS-positive cytoplasmic granules** in the liver biopsy is virtually pathognomonic for **Alpha 1 AT deficiency**, which is a leading identifiable cause grouped under this overall diagnosis.*Hypoplasia of the biliary tract*- This refers to a reduction or paucity of bile ducts (e.g., in **Alagille syndrome**) leading to cholestasis, but it is less common than other causes of intrahepatic cholestasis.- While it causes conjugated hyperbilirubinemia, the damage pattern is primarily related to duct paucity rather than the specific hepatocyte injury and granule accumulation of **A1AT deficiency**.*Choledochal cyst*- A **choledochal cyst** is an extrahepatic cause of cholestasis resulting from obstruction and dilatation of the **common bile duct**.- It typically presents with extrahepatic obstruction, and while it causes conjugated hyperbilirubinemia, it would not explain the classic **intrahepatic cellular findings** (PAS-positive granules) seen with A1AT deficiency.*Physiological*- **Physiological jaundice** is caused by the inability of the immature liver to process bilirubin, resulting exclusively in **unconjugated hyperbilirubinemia**.- Since this neonate presents with **conjugated hyperbilirubinemia**, physiological jaundice is excluded, as this finding always mandates immediate investigation for underlying pathology (**cholestasis**).

Q: A 4-month-old infant is brought to the emergency department with a respiratory rate of 66 breaths per minute, along with chest indrawing and nasal flaring. There are no other significant findings. What is the most likely diagnosis?

Severe pneumonia. ***Severe pneumonia*** - According to **WHO/IMCI guidelines**, pneumonia in infants (2-12 months) is classified based on clinical signs. - This 4-month-old has a respiratory rate of **66 breaths/minute** (tachypnea, as RR ≥ 50 is abnormal) along with **chest indrawing** and **nasal flaring**. - The presence of **chest indrawing** is the defining feature that classifies this as **severe pneumonia** rather than simple fast-breathing pneumonia. - WHO classification: Fast breathing alone = pneumonia; Fast breathing + chest indrawing = **severe pneumonia**; danger signs (inability to feed, lethargy, cyanosis) = very severe disease. *Pneumonia* - Simple **pneumonia** (or fast-breathing pneumonia) would be diagnosed if the infant had only **tachypnea** (RR ≥ 50/min) **without** chest indrawing or other danger signs. - Since this infant has **chest indrawing**, it automatically upgrades the classification to severe pneumonia per WHO/IMCI criteria. - This distinction is clinically important as it determines management (severe pneumonia requires hospitalization and parenteral antibiotics). *Severe asthma* - **Asthma** is very uncommon in a 4-month-old infant, as it typically develops later following sensitization and recurrent episodes, often associated with atopy. - The hallmark feature of asthma is audible **wheezing**, which is not mentioned in this presentation. - While respiratory distress can occur in asthma, the absence of wheezing and the age make this diagnosis unlikely. *Common cold* - A **common cold** is a mild upper respiratory tract infection (URTI) that presents with nasal congestion, rhinorrhea, and possibly mild cough. - It does not cause significant respiratory distress such as severe **tachypnea** (RR 66/min) or **chest indrawing**. - The degree of respiratory compromise described here is far beyond what would be expected in a common cold.

Q: A 2-week-old infant presents with high conjugated (direct) bilirubin, dark-colored urine, and clay-colored stools. On examination, the infant appears jaundiced, but is feeding normally. What is the most likely diagnosis?

Biliary atresia. ***Biliary atresia*** - High **conjugated hyperbilirubinemia** combined with characteristic signs of biliary obstruction, such as **acholic (clay-colored) stools** and **dark urine**, is the classic presentation of **biliary atresia** in infants typically presenting after the first week of life. - This condition involves progressive obliteration of the extrahepatic **biliary tree**, requiring urgent diagnosis and treatment (Kasai procedure) before 60 days of age to prevent irreversible **cirrhosis**. *Crigler-Najjar syndrome* - This disorder results from a severe deficiency or absence of **UGT1A1** activity, leading exclusively to severe **unconjugated hyperbilirubinemia** and a high risk of **kernicterus**. - It does not involve excretion issues causing **conjugated hyperbilirubinemia** or evidence of biliary blockage like **acholic stools**. *Gilbert's syndrome* - This syndrome is characterized by **unconjugated hyperbilirubinemia** due to reduced activity of the hepatic enzyme **UDP-glucuronosyltransferase (UGT1A1)**, not the conjugated form seen here. - It is generally an inherited, benign condition that presents later in life (adolescence/adulthood) and does not cause **biliary obstruction** symptoms (clay stools, dark urine). *Physiological jaundice* - **Physiological jaundice** typically presents with **unconjugated hyperbilirubinemia**, begins *after* 24 hours of life, peaks around 3-5 days, and usually resolves by 1-2 weeks. - The presentation at 2 weeks with *conjugated* hyperbilirubinemia (which is always pathological) and signs of obstruction rules out this benign, self-limiting cause.

Q: A child presents with recurrent sinusitis and repeated lung infections. Genetic testing shows a mutation in the CFTR gene. Which test is considered the gold standard to confirm the diagnosis?

Sweat chloride test. ***Sweat chloride test*** - It is recognized as the **gold standard** test for diagnosing Cystic Fibrosis in patients with suggestive symptoms or positive genetic screening (CFTR mutation). - The test measures non-reabsorbed chloride ions in the sweat, with levels **≥ 60 mEq/L** typically confirming the diagnosis due to **CFTR protein dysfunction**. *Lung biopsy* - This is an **invasive procedure** with significant risk and is not required for the standard diagnosis of Cystic Fibrosis. - While it might show findings consistent with severe CF (e.g., **bronchiectasis**), genetic testing and the sweat test provide definitive, less invasive confirmation. *Chest X-ray* - A Chest X-ray is a **radiographic imaging tool** used to monitor the progression of lung disease (e.g., presence of **hyperinflation** or **bronchiectasis**). - It is not a diagnostic test for the underlying CFTR defect and cannot definitively confirm the diagnosis of Cystic Fibrosis. *Nasal swab culture* - This test is used to identify common pathogens such as **Pseudomonas aeruginosa** or **Staphylococcus aureus**, which frequently colonize the airways of CF patients. - It is essential for managing **pulmonary exacerbations** and guiding antibiotic selection but does not assess CFTR function or establish the primary diagnosis.

Q: A mother brings her 9-month-old baby, concerned that no BCG scar has appeared, although the baby received the BCG vaccine at birth. What is the next best step?

Reassure the mother. ***Reassure the mother*** - The absence of a characteristic **BCG scar** up to 9 months later is common and does not indicate **vaccination failure** if the vaccine was properly administered and documented. - Standard vaccination protocols generally recommend **no re-vaccination** or immediate investigation solely based on the lack of a scar in an otherwise healthy infant. *Give the BCG vaccine immediately* - **Re-vaccination** without evidence of non-conversion (which is not routinely assessed) is not standard practice and carries the risk of increased **local adverse reactions**. - Current public health policies consider a single documented BCG dose adequate protection, regardless of the subsequent **cutaneous reaction**. *Do the Mantoux test & wait for the result* - The **Mantoux test (TST)** is not recommended solely for assessing BCG efficacy or scar absence in asymptomatic children due to difficulties in defining a protective threshold. - Finding a negative TST result does not currently mandate **re-vaccination**, as international guidelines prioritize coverage reliability over scar/TST status. *Refer the baby for a chest X-ray & further evaluation* - Extensive investigations, including a **chest X-ray**, are reserved for children presenting with signs or symptoms highly suggestive of **active tuberculosis disease**. - Performing aggressive workups on an asymptomatic child solely for an absent scar constitutes an excessive response and is not supported by clinical guidelines.

Question 1

An elderly man presents with leg deformities and skeletal abnormalities. On examination, he is using crutches and has visible bowing of the legs. It is also noted that several other villagers exhibit similar symptoms. Considering the cluster of cases in the same geographic area, which of the following is the most appropriate next step in the investigation?

Accepted Answer

Collect and analyze water samples for fluoride content

Answer

Perform parathyroid hormone (PTH) assay

Answer

Check serum vitamin D levels

Answer

Measure serum calcium levels

Question 2

A patient presents with increased consumption of Bajra (pearl millet) roti and now complains of drowsiness and giddiness. What is the most likely diagnosis?

Accepted Answer

Ergotism

Answer

Fusarium Toxicity

Answer

Botulism

Answer

Epidemic Dropsy

Question 3

Out of the MR & Pentavalent vaccine, which can be reused, and which one should be discarded when the vial is opened according to the open vial policy?

Accepted Answer

Discard MR, reuse Pentavalent

Answer

Reuse both MR and Pentavalent

Answer

Discard both MR and Pentavalent

Answer

Discard Pentavalent, reuse MR

Question 4

In a group, the mean blood glucose level is 105 mg/dL with a standard deviation of 10 mg/dL. Assuming a normal distribution, what is the expected range of blood glucose values for approximately 95% of the population?

Accepted Answer

85 – 125 mg/dL

Answer

101 – 110 mg/dL

Answer

95 – 115 mg/dL

Answer

90 – 125 mg/dL

Question 5

A teenage boy, who was previously raised as a girl, presents with primary amenorrhea and lack of secondary sexual characteristics. On examination, he has tall stature, small testes, and gynecomastia. Which of the following is the most likely genotype?

Accepted Answer

47,XXY

Answer

47,XYY

Answer

45,X

Answer

46,XX

Question 6

A newborn presents with jaundice, conjugated hyperbilirubinemia, intrahepatic cholestasis, and elevated alkaline phosphatase. Liver biopsy reveals eosinophilic, PAS-positive cytoplasmic granules in hepatocytes. What is the most likely diagnosis?

Accepted Answer

Neonatal hepatitis

Answer

Physiological

Answer

Hypoplasia of the biliary tract

Answer

Choledochal cyst

Question 7

A 4-month-old infant is brought to the emergency department with a respiratory rate of 66 breaths per minute, along with chest indrawing and nasal flaring. There are no other significant findings. What is the most likely diagnosis?

Accepted Answer

Severe pneumonia

Answer

Pneumonia

Answer

Severe asthma

Answer

Common cold

Question 8

A 2-week-old infant presents with high conjugated (direct) bilirubin, dark-colored urine, and clay-colored stools. On examination, the infant appears jaundiced, but is feeding normally. What is the most likely diagnosis?

Accepted Answer

Biliary atresia

Answer

Crigler-Najjar syndrome

Answer

Gilbert’s syndrome

Answer

Physiological jaundice

Question 9

A child presents with recurrent sinusitis and repeated lung infections. Genetic testing shows a mutation in the CFTR gene. Which test is considered the gold standard to confirm the diagnosis?

Accepted Answer

Sweat chloride test

Answer

Chest X-ray

Answer

Lung biopsy

Answer

Nasal swab culture

Question 10

A mother brings her 9-month-old baby, concerned that no BCG scar has appeared, although the baby received the BCG vaccine at birth. What is the next best step?

Accepted Answer

Reassure the mother

Answer

Do the Mantoux test & wait for the result

Answer

Refer the baby for a chest X-ray & further evaluation

Answer

Give the BCG vaccine immediately

FMGE 2025

Community Medicine

Internal Medicine

Pathology

Pediatrics