FMGE 2026 Practice Questions

Q: A 55-year-old male presents with sudden onset of severe pain, redness, and swelling of the foot as shown in the image below. There is no history of trauma. Serum uric acid is 9 mg/dL. What is the best acute management at this stage?

Indomethacin 50 mg three times a day. ***Indomethacin 50 mg three times a day*** - **Nonsteroidal anti-inflammatory drugs (NSAIDs)** like indomethacin are considered the first-line treatment for **acute gouty arthritis** in patients without contraindications. - They work by inhibiting **prostaglandin synthesis**, effectively reducing the intense inflammation and joint pain characteristic of a gout flare. *Febuxostat* - This is a **xanthine oxidase inhibitor** used for long-term **urate-lowering therapy**. - Initiating urate-lowering therapy during an **acute attack** can precipitate further flares and should generally be avoided until the inflammation has resolved. *Colchicine 0.5 mg every 6 hours* - While used for acute gout, it has a narrow **therapeutic window** and carries a significant risk of **gastrointestinal toxicity** if not dosed correctly or if renal function is impaired. - It is typically reserved as an alternative when **NSAIDs** are contraindicated or if the patient presents within 24-36 hours of symptom onset. *Allopurinol 100 mg twice daily* - Like febuxostat, this is a **urate-lowering therapy** (xanthine oxidase inhibitor) used for the chronic prevention of gout. - Starting this medication during an active, painful flare is contraindicated as it may exacerbate or prolong the **acute gouty inflammation**.

Q: A 32-year-old man returned from a malaria -endemic area with high -grade fever for 5 days. On examination he is drowsy, confused, and has altered sensorium. Peripheral smear shows Plasmodium falciparum. What is the most appropriate treatment?

Intravenous artesunate. ***Intravenous artesunate*** - This patient presents with **severe malaria** manifested by **cerebral malaria** (altered sensorium, confusion), which is a medical emergency requiring parenteral therapy. - **Intravenous (IV) artesunate** is the **first-line treatment** of choice for severe *Plasmodium falciparum* malaria, as evidence shows it significantly reduces mortality compared to quinine. *Intravenous artesunate with sulfadoxine-pyrimethamine* - **Sulfadoxine-pyrimethamine** is an oral antimalarial primarily used for uncomplicated malaria or as intermittent preventive treatment during pregnancy. - Combining it with IV artesunate provides no additional clinical benefit for the management of the acute **severe malaria** emergency and adds unnecessary potential for adverse drug reactions. *Oral artemether-lumefantrine* - This combination is the **first-line therapy** for uncomplicated *Plasmodium falciparum* malaria. - It is unsuitable for this patient because **oral medications** are contraindicated in patients with **altered sensorium** or those who cannot tolerate oral intake due to the high risk of aspiration and failure of absorption. *Oral chloroquine* - **Chloroquine** is no longer the treatment of choice for *Plasmodium falciparum* malaria worldwide, given the widespread prevalence of **chloroquine-resistant Pf strains**. - Furthermore, this drug is strictly oral and inappropriate for treating a patient showing signs of **severe disease** and neurological impairment.

Q: A 28-year-old pregnant woman is found to be HBsAg positive with high HBV DNA levels during routine antenatal screening. She has no features of liver failure. What is the most appropriate treatment during pregnancy?

Tenofovir. ### ***Tenofovir*** - **Tenofovir** is the preferred antiviral agent for treating pregnant women with chronic hepatitis B infection who have high viral loads, as it is a pregnancy category B medication with a favorable safety profile. - It effectively reduces **HBV DNA levels**, significantly lowering the risk of **vertical transmission** (mother-to-child) when administered from the second or third trimester onward. *Pegylated interferon* - **Pegylated interferon** is generally contraindicated during pregnancy due to concerns regarding potential **teratogenicity** and anti-proliferative effects on fetal development. - It is typically avoided in women of childbearing age who are planning to conceive or are pregnant because of its known **adverse fetal outcomes**. *Zidovudine* - **Zidovudine** is a nucleoside reverse transcriptase inhibitor used specifically for the treatment of **HIV infection** to prevent vertical transmission. - While it has anti-viral properties, it is not an effective treatment for the **hepatitis B virus** and does not suppress **HBV DNA replication**. *Acyclovir* - **Acyclovir** is an antiviral medication indicated primarily for the treatment of **herpes simplex virus** (HSV) and **varicella-zoster virus** (VZV) infections. - It lacks efficacy against the **hepatitis B virus** and plays no role in the management of chronic HBV infection or the prevention of vertical transmission.

Q: Which of the following ECG change is most characteristically associated with lithium therapy?

T-wave inversion. ***T-wave inversion*** - **Lithium** therapy is well-recognized for causing benign and reversible ECG changes, most characteristically **T-wave flattening or inversion**. - These changes are generally considered **non-specific** and typically do not require discontinuation of the medication unless associated with clinical cardiac symptoms or toxicity. *ST-segment elevation* - **ST-segment elevation** is much more characteristic of conditions like **acute myocardial infarction** or **pericarditis**, not lithium use. - It is not a common side effect of mood stabilizers and would necessitate a thorough investigation for **ischemic heart disease**. *ST-segment depression* - **ST-segment depression** is a classic sign of **myocardial ischemia** or **digoxin toxicity**. - This finding is not associated with lithium therapy and would indicate a different underlying pathology requiring separate investigation. *QT interval prolongation* - While **QT interval prolongation** is a serious adverse effect of many antipsychotic medications and antidepressants, it is not the primary ECG change associated with **lithium**. - Prolongation of the **QT interval** poses a risk for **torsades de pointes**, and its absence is a distinguishing feature of lithium compared to many other psychotropic agents.

Q: Which of the following best describes the mechanism of action of colchicine in acute attack of gout?

Inhibit migration of neutrophil chemotaxis. ***Inhibit migration of neutrophil chemotaxis*** - Colchicine binds to **tubulin**, preventing its polymerization into microtubules, which disrupts the **cytoskeletal function** required for neutrophil motility and migration. - By inhibiting the **chemotaxis** and phagocytosis of neutrophils into the affected joint, it reduces the **inflammatory response** triggered by urate crystals. *Inhibition of xanthine oxidase* - This is the primary mechanism of **allopurinol** and **febuxostat**, which are used for chronic gout management to lower serum uric acid levels. - It does not provide significant anti-inflammatory relief during an **acute gouty flare**. *Inhibition of cyclooxygenase (COX)* - This describes the mechanism of **NSAIDs** (like indomethacin or naproxen), which reduce prostaglandin synthesis to provide analgesia. - While NSAIDs are used for acute gout, they act through a completely different pathway than the microtubule-inhibiting effects of colchicine. *Blockade of IL-1 receptors* - This is the mechanism of **anakinra**, a biological DMARD, which targets the interleukin-1 pathway involved in the inflammatory cascade. - While the **NLRP3 inflammasome** (which produces IL-1beta) is indirectly inhibited by the downstream effects of colchicine, it is not a direct blockade of the IL-1 receptor itself.

Q: A 65-year-old woman with breast cancer is receiving combination chemotherapy including methotrexate. To reduce toxicity, leucovorin is administered alongside methotrexate. Which of the following enzymes is bypassed by leucovorin rescue during methotrexa te therapy?

Dihydrofolate reductase. ***Dihydrofolate reductase*** - **Methotrexate** inhibits the enzyme **dihydrofolate reductase (DHFR)**, which prevents the conversion of **dihydrofolate** to its active form, **tetrahydrofolate**. - **Leucovorin** (folinic acid) acts as a derivative of tetrahydrofolate that does not require the activity of **DHFR** to provide the necessary folate pool for DNA synthesis, effectively bypassing the enzyme block. *Thymidylate synthase* - **Thymidylate synthase** is the enzyme responsible for converting **dUMP** to **dTMP**, which is a downstream target inhibited by **5-fluorouracil (5-FU)**, not methotrexate. - Providing leucovorin during **5-FU** therapy actually enhances the binding of **5-fdUMP** to thymidylate synthase, potentiating its toxicity rather than rescuing the cells. *Dihydropteroate synthase* - **Dihydropteroate synthase** is a bacterial enzyme involved in the synthesis of folate from **p-aminobenzoic acid (PABA)** and is the target of **sulfonamides**. - This enzyme is not present in humans, and its inhibition is the basis for the **antibacterial** effect of sulfa drugs, making it irrelevant to methotrexate chemotherapy. *Purine nucleoside phosphorylase* - **Purine nucleoside phosphorylase** is involved in the degradation of purine nucleosides, specifically converting **inosine** and **guanosine** to their respective bases. - Deficiency of this enzyme leads to **T-cell immunodeficiency**, but it is not a pharmacological target for methotrexate or leucovorin rescue therapies.

Q: Which of the following best describes the mechanism of action of memantine when used for Alzheimer's disease?

NMDA receptor antagonist. ***NMDA receptor antagonist*** - Memantine acts as an uncompetitive **NMDA (N-methyl-D-aspartate) receptor antagonist**, which helps to reduce the excitotoxic effects of **glutamate** in the brain. - By modulating glutamate activity, it prevents the chronic overstimulation of these receptors, which is associated with **neurodegeneration** in Alzheimer's disease. *Acetylcholinesterase inhibition* - This is the mechanism of action for drugs like **donepezil**, **rivastigmine**, and **galantamine**. - These drugs increase the availability of **acetylcholine** in the synaptic cleft to improve cognitive function, rather than acting on NMDA receptors. *Blockade of A-beta amyloid* - Monoclonal antibodies such as **aducanumab** or **lecanemab** are designed to target and clear **amyloid-beta plaques** in the brain. - This approach focuses on disease modification (clearing pathological proteins) rather than the symptomatic modulation of neuronal excitability provided by memantine. *Dopamine D2 receptor antagonism* - This is the mechanism characteristic of most **antipsychotic medications** (e.g., risperidone, haloperidol). - Blocking D2 receptors is primarily used to manage psychiatric symptoms like hallucinations or agitation, not for the primary cognitive symptoms of Alzheimer's disease.

Q: What is the mechanism of action of finasteride?

5-alpha reductase inhibition. ***5-alpha reductase inhibition*** - Finasteride inhibits the **Type II 5-alpha reductase enzyme**, which is responsible for converting **testosterone** to the more potent **dihydrotestosterone (DHT)**. - By reducing intraprostatic DHT levels, it leads to a decrease in **prostate volume** and improves symptoms of **Benign Prostatic Hyperplasia (BPH)**. *Adrenergic α1A receptor antagonism* - This mechanism is characteristic of **alpha-blockers** like **tamsulosin**, not finasteride. - Alpha-blockers work by relaxing the **smooth muscle** of the prostate and bladder neck, providing immediate symptom relief by reducing **dynamic obstruction**. *Androgen receptor blockade* - This describes drugs like **flutamide** or **bicalutamide**, which compete with androgens for binding sites on **androgen receptors**. - These are typically used for **prostate cancer** management rather than for treating BPH symptoms via enzyme inhibition. *Phosphodiesterase inhibition* - This mechanism applies to **phosphodiesterase-5 (PDE5) inhibitors** like **sildenafil** or **tadalafil** used for erectile dysfunction or pulmonary hypertension. - While tadalafil is sometimes used in BPH, it works by increasing **cyclic GMP** levels to cause smooth muscle relaxation, not by affecting hormonal pathways.

Question 1

A 55-year-old male presents with sudden onset of severe pain, redness, and swelling of the foot as shown in the image below. There is no history of trauma. Serum uric acid is 9 mg/dL. What is the best acute management at this stage?

Accepted Answer

Indomethacin 50 mg three times a day

Answer

Febuxostat 40 mg once daily

Answer

Colchicine 0.5 mg every 6 hours

Answer

Allopurinol 100 mg twice daily

Question 2

A 32-year-old man returned from a malaria -endemic area with high -grade fever for 5 days. On examination he is drowsy, confused, and has altered sensorium. Peripheral smear shows Plasmodium falciparum. What is the most appropriate treatment?

Accepted Answer

Intravenous artesunate

Answer

Intravenous artesunate with sulfadoxine -pyrimethamine

Answer

Oral artemether-lumefantrine

Answer

Oral chloroquine

Question 3

A 28-year-old pregnant woman is found to be HBsAg positive with high HBV DNA levels during routine antenatal screening. She has no features of liver failure. What is the most appropriate treatment during pregnancy?

Accepted Answer

Tenofovir

Answer

Pegylated interferon

Answer

Zidovudine

Answer

Acyclovir

Question 4

Which of the following ECG change is most characteristically associated with lithium therapy?

Accepted Answer

T-wave inversion

Answer

ST-segment elevation

Answer

ST-segment depression

Answer

QT interval prolongation

Question 5

Which of the following best describes the mechanism of action of gabapentin?

Accepted Answer

Blockage of the α2δ subunit of voltage -gated calcium channels

Answer

Sodium channel blockade

Answer

Opioid receptor blockade

Answer

NMDA receptor antagonism

Question 6

Which of the following best describes the mechanism of action of colchicine in acute attack of gout?

Accepted Answer

Inhibit migration of neutrophil chemotaxis

Answer

Inhibition of xanthine oxidase

Answer

Inhibition of cyclooxygenase (COX)

Answer

Blockade of IL-1 receptors

Question 7

A 65-year-old woman with breast cancer is receiving combination chemotherapy including methotrexate. To reduce toxicity, leucovorin is administered alongside methotrexate. Which of the following enzymes is bypassed by leucovorin rescue during methotrexa te therapy?

Accepted Answer

Dihydrofolate reductase

Answer

Thymidylate synthase

Answer

Dihydropteroate synthase

Answer

Purine nucleoside phosphorylase

Question 8

Which of the following best describes the mechanism of action of memantine when used for Alzheimer's disease?

Accepted Answer

NMDA receptor antagonist

Answer

Acetylcholinesterase inhibition

Answer

Blockade of A-beta amyloid

Answer

Dopamine D2 receptor antagonism

Question 9

What is the mechanism of action of finasteride?

Accepted Answer

5-alpha reductase inhibition

Answer

Adrenergic α1A receptor antagonism

Answer

Androgen receptor blockade

Answer

Phosphodiesterase inhibition

Question 10

A 45-year-old man with bronchial asthma is on regular theophylline therapy. He develops a fungal infection and is started on ketoconazole. After 4 –5 days, he presents with nausea, vomiting, tremors, palpitations, and restlessness. His serum theophylline level is found to be elevated. What is the most likely reason for this toxicity?

Accepted Answer

Ketoconazole inhibits CYP450 enzymes, decreasing theophylline metabolism

Answer

Ketoconazole induces CYP450 enzymes, increasing theophylline metabolism

Answer

Theophylline induces ketoconazole metabolism

Answer

Additive pharmacodynamic effect of both drugs

FMGE 2026

Internal Medicine

Obstetrics and Gynecology

Pharmacology