FMGE 2019 Practice Questions

Q: An 85-year-old patient was brought to the ER, BP: 180/100, right hemiparesis was seen. What is the next best step in management?

NCCT. ***NCCT*** - A **non-contrast CT (NCCT) scan of the brain** is the most crucial initial step to differentiate between **ischemic stroke** and **hemorrhagic stroke** [1]. - This distinction is vital because management, especially the use of thrombolytics or anticoagulants, differs significantly based on stroke type [1]. *Reduce BP* - While blood pressure management is important in stroke, immediate and aggressive lowering of BP in acute ischemic stroke can **worsen cerebral perfusion** and **increase infarct size**. - In hemorrhagic stroke, BP control is often necessary, but the decision to lower BP and by how much depends on the cause and extent of the bleed, and this can only be determined after imaging [1]. *MRI* - **MRI** is more sensitive for detecting acute ischemic changes than CT, especially in the posterior fossa [1]. - However, **MRI is not typically the first-line imaging** in an emergency setting for an acute stroke due to its longer acquisition time and potential contraindications (e.g., pacemakers, metallic implants) [1]. *Aspirin 300mg and anticoagulants* - These medications are indicated for **ischemic stroke** (aspirin is an antiplatelet, anticoagulants may be used in specific cases like cardioembolic stroke). - Administering these agents in the event of a **hemorrhagic stroke** would be contraindicated and could significantly worsen the bleeding, leading to severe neurological damage or death [1].

Q: Which of the following is seen in retinitis pigmentosa?

Arteriolar attenuation. ***Arteriolar attenuation*** - **Arteriolar attenuation** is a classic finding in retinitis pigmentosa, reflecting the progressive loss of retinal tissue and the associated reduction in metabolic demand, leading to narrowing of the retinal arterioles. - This sign indicates the ongoing degeneration of photoreceptors and the underlying retinal layers, which is characteristic of the disease. *Neovascularization* - **Neovascularization** (abnormal new blood vessel growth) is typically associated with conditions like proliferative diabetic retinopathy or age-related macular degeneration. - It is not a primary feature of retinitis pigmentosa, which is a degenerative disease rather than an ischemic or proliferative one. *Papilledema* - **Papilledema** is swelling of the optic disc due to increased intracranial pressure. - It is not a feature of retinitis pigmentosa; rather, the optic disc in retinitis pigmentosa often appears waxy pale due to optic atrophy. *Retinal artery thrombosis* - **Retinal artery thrombosis** involves the sudden blockage of a retinal artery, leading to acute vision loss and often presenting with a 'cherry-red spot' on the macula. - This is an acute vascular event and is not characteristic of the chronic, progressive degeneration seen in retinitis pigmentosa.

Q: All of the following can result in gynecomastia except:

Aromatase inhibitors. ***Aromatase inhibitors*** - **Aromatase inhibitors** block the conversion of androgens to estrogens, thereby **decreasing estrogen levels** which would prevent rather than cause gynecomastia. - They are used in estrogen-sensitive breast cancers to reduce estrogen-dependent growth. *Spironolactone* - **Spironolactone** is an aldosterone antagonist that also possesses anti-androgenic effects and can inhibit androgen synthesis, leading to an **increased estrogen-to-androgen ratio** and gynecomastia. - It can also directly stimulate the estrogen receptor in male breast tissue. *Sulphonamides* - Certain **sulphonamides**, particularly sulfasalazine, have been associated with gynecomastia, possibly due to direct toxic effects on testicular function leading to a **relative increase in estrogen activity**. - While less common than with some other drugs, it can alter the estrogen-androgen balance. *Digoxin* - **Digoxin** can cause gynecomastia by mimicking estrogen physiologically or by inhibiting androgen production, leading to an **alteration in the estrogen-to-androgen ratio**. - The risk of gynecomastia is especially noted with prolonged use and higher doses of digoxin.

Q: Mechanism of action of atropine in treatment of organophosphate poisoning is?

It has antimuscarinic activity. ***It has antimuscarinic activity*** - **Organophosphate poisoning** leads to **excessive acetylcholine** at muscarinic receptors, causing symptoms like miosis, bradycardia, and increased secretions. - **Atropine** is a **competitive antagonist** at these muscarinic receptors, thereby blocking the effects of excess acetylcholine. *It inhibits secretion of acetylcholine* - Atropine does not directly inhibit the secretion of **acetylcholine** from nerve terminals. - Its action is postsynaptic, specifically at the **receptor level**. *It is reactivator of acetylcholine esterase enzyme* - **Pralidoxime (2-PAM)** and other **oximes** are the drugs that reactivate **acetylcholinesterase**. - Atropine does not reactivate the enzyme; it only blocks the effects of acetylcholine. *It is agonist of acetylcholine receptors* - An **agonist** would mimic the effects of acetylcholine, which would worsen the symptoms of organophosphate poisoning. - Atropine is an **antagonist**, meaning it blocks the receptors.

Q: Which of the following is the shortest-acting corticosteroid?

Hydrocortisone. ***Hydrocortisone***- **Hydrocortisone** is considered a **short-acting corticosteroid** with a biological half-life of 8-12 hours [1].- It is a naturally occurring glucocorticoid, acting as a direct replacement for cortisol.- Among the given options, it has the shortest duration of action.*Dexamethasone*- **Dexamethasone** is a **long-acting corticosteroid** with a biological half-life of 36-72 hours.- Its potent and prolonged action makes it suitable for conditions requiring sustained anti-inflammatory or immunosuppressive effects.*Triamcinolone*- **Triamcinolone** is an **intermediate-acting corticosteroid** with a biological half-life typically ranging from 18-36 hours.- It is commonly used for its anti-inflammatory effects in conditions like allergies, asthma, and skin disorders.*Deflazacort*- **Deflazacort** is an **intermediate-acting corticosteroid** with a duration of action of approximately 12-18 hours.- It is a prodrug that is metabolized to 21-desacetyl deflazacort, the active form, often used in conditions like Duchenne muscular dystrophy and inflammatory disorders.

Q: What is the principal stimulus for vasopressin secretion?

Hyperosmolality. ***Hyperosmolality*** - An increase in **plasma osmolality**, even by a small percentage (1-2%), is the **most potent and PRINCIPAL stimulus** for ADH (vasopressin) release. - This is detected by **osmoreceptors** in the hypothalamus (particularly in the organum vasculosum of the lamina terminalis), which are extremely sensitive and respond rapidly. - This response is the primary mechanism for day-to-day regulation of water balance. *Hypovolemia* - A significant decrease in **blood volume** (typically >10%) also stimulates vasopressin release, but it is **much less sensitive** than hyperosmolality and serves as a secondary/backup mechanism. - This response is mediated by **baroreceptors** in the carotid sinuses and aortic arch. - Only activated during substantial volume loss (hemorrhage, severe dehydration). *Hypoosmolality* - **Decreased plasma osmolality** actively **inhibits** vasopressin secretion as the body aims to excrete excess water. - This helps to prevent overhydration and maintain proper fluid balance. *Hypervolemia* - **Increased blood volume** (hypervolemia) **inhibits** vasopressin secretion, as the body needs to excrete excess fluid. - This contributes to diuresis and the lowering of blood pressure.

Q: A 62-year-old female had a kidney stone and was treated with PCNL. After 2 days, she comes to the OPD with chills and fever. What is the complication?

Bacterial sepsis. ***Bacterial sepsis*** - **Chills and fever** two days after a **Percutaneous Nephrolithotomy (PCNL)** are highly suggestive of a systemic infection, specifically **bacterial sepsis**, as this procedure carries a risk of introducing bacteria into the bloodstream. - Urinary tract manipulation, especially in a patient with a potentially *infected kidney stone*, can lead to bacteremia and subsequent **sepsis** if not properly managed. *Acute pancreatitis* - **Acute pancreatitis** is not a common complication of PCNL. It typically presents with severe **epigastric pain** radiating to the back, often with nausea and vomiting, and is usually associated with gallstones or alcohol abuse. - While it can cause fever, the clinical presentation and context do not strongly support **pancreatitis** as the primary issue following a PCNL. *Ureteric stricture* - A **ureteric stricture** is a *late complication* of kidney stone treatment and typically leads to symptoms of **urinary obstruction**, such as flank pain, rather than acute fever and chills two days post-procedure. - It would not cause acute systemic signs like **chills and fever** within such a short timeframe after PCNL. *Splenic injury* - **Splenic injury** is a rare but possible complication of procedures around the left kidney; however, it would typically present with **abdominal pain**, signs of **hemorrhage** (e.g., hypotension), and sometimes shoulder pain, not primarily with fever and chills as the immediate post-operative concern. - While fever can occur with internal injuries, the primary and most immediate concern with fever and chills after a urological procedure is **infection**.

Q: What is the most common tumor of the mediastinum?

Neurogenic tumor. ***Neurogenic tumor*** - **Neurogenic tumors** are the **most common primary tumors of the mediastinum** overall, accounting for approximately **35-40%** of all mediastinal masses. - They are the most common tumors of the **posterior mediastinum** and arise from nerve sheaths (e.g., **schwannomas, neurofibromas**) or sympathetic ganglia. - These tumors occur across all age groups, with higher prevalence when including both pediatric and adult populations. *Thymoma* - **Thymomas** are the most common primary tumor of the **anterior mediastinum** in adults, accounting for about **40-50%** of anterior mediastinal masses. - However, they represent only about **20-25%** of all mediastinal tumors overall. - Often associated with paraneoplastic syndromes like **myasthenia gravis** (30-50% of cases). *Lymphoma* - **Lymphoma** is a common mediastinal tumor, particularly **Hodgkin lymphoma** in young adults, accounting for approximately **15-20%** of mediastinal masses. - It often presents with bulky mediastinal masses and symptoms like **dyspnea, cough, or superior vena cava syndrome**. - While very common, it ranks second or third overall after neurogenic tumors. *Neuroblastic tumor* - **Neuroblastic tumors** (e.g., neuroblastoma, ganglioneuroblastoma) are a subset of neurogenic tumors more common in **children**. - They arise from the sympathetic nervous system and typically occur in the posterior mediastinum. - While important in pediatric populations, they are less common than all neurogenic tumors combined.

Question 1

An 85-year-old patient was brought to the ER, BP: 180/100, right hemiparesis was seen. What is the next best step in management?

Accepted Answer

NCCT

Answer

Reduce BP

Answer

MRI

Answer

Aspirin 300mg and anticoagulants

Question 2

A 67-year-old female with hypertension and diabetes presents with heavy vaginal bleeding. What is the next step in management?

Accepted Answer

Endometrial biopsy

Answer

Pelvic ultrasound

Answer

Detailed history and physical examination

Answer

Complete blood count and coagulation studies

Question 3

Which of the following is seen in retinitis pigmentosa?

Accepted Answer

Arteriolar attenuation

Answer

Neovascularization

Answer

Papilledema

Answer

Retinal artery thrombosis

Question 4

All of the following can result in gynecomastia except:

Accepted Answer

Aromatase inhibitors

Answer

Spironolactone

Answer

Digoxin

Answer

Sulphonamides

Question 5

Mechanism of action of atropine in treatment of organophosphate poisoning is?

Accepted Answer

It has antimuscarinic activity

Answer

It inhibits secretion of acetylcholine

Answer

It is reactivator of acetylcholine esterase enzyme

Answer

It is agonist of acetylcholine receptors

Question 6

Which of the following is the shortest-acting corticosteroid?

Accepted Answer

Hydrocortisone

Answer

Dexamethasone

Answer

Triamcinolone

Answer

Deflazacort

Question 7

What is the principal stimulus for vasopressin secretion?

Accepted Answer

Hyperosmolality

Answer

Hypovolemia

Answer

Hypoosmolality

Answer

Hypervolemia

Question 8

A 62-year-old female had a kidney stone and was treated with PCNL. After 2 days, she comes to the OPD with chills and fever. What is the complication?

Accepted Answer

Bacterial sepsis

Answer

Acute pancreatitis

Answer

Ureteric stricture

Answer

Splenic injury

Question 9

A 6-month-old child presents with an umbilical hernia measuring 3 cm in diameter. What is the management protocol?

Accepted Answer

Observation until 2 years of age, then surgery if unresolved

Answer

Immediate surgical repair

Answer

Elective surgery at 5 years of age

Answer

Hernioplasty for repair

Question 10

What is the most common tumor of the mediastinum?

Accepted Answer

Neurogenic tumor

Answer

Thymoma

Answer

Lymphoma

Answer

Neuroblastic tumor

FMGE 2019

Internal Medicine

Obstetrics and Gynecology

Ophthalmology

Pharmacology

Physiology

Surgery