FMGE 2025 Practice Questions

Q: During general anesthesia, which nerve is commonly monitored using a nerve stimulator to assess neuromuscular blockade?

Ulnar nerve. ***Ulnar nerve*** - The **ulnar nerve** is the most common site for monitoring neuromuscular blockade because it is superficially located at the wrist, making it easily accessible for stimulation with surface electrodes. - Stimulation of the ulnar nerve causes contraction of the **adductor pollicis** muscle, leading to thumb adduction, which is a reliable and easily observable response to assess the degree of muscle relaxation. *Radial nerve* - The **radial nerve** is located deeper at the wrist compared to the ulnar nerve, making it more difficult to stimulate effectively with surface electrodes. - While it can be stimulated to produce wrist and finger extension, the response is generally less consistent and harder to quantify than the thumb adduction seen with ulnar nerve stimulation. *Median nerve* - Stimulation of the **median nerve** causes contraction of the thenar muscles, resulting in thumb opposition, which can be a more complex and sometimes painful response. - The median nerve lies between the tendons of the flexor carpi radialis and palmaris longus, making precise electrode placement more challenging and potentially leading to direct muscle stimulation. *Tibial nerve* - The **tibial nerve** can be stimulated behind the medial malleolus to elicit plantar flexion of the great toe (via the **flexor hallucis brevis** muscle). - However, the foot is often less accessible than the hand during surgery due to patient positioning and surgical draping, making the ulnar nerve a more practical choice.

Q: A patient under anesthesia is found to be in a “cannot intubate, cannot ventilate” (CICV) scenario. What is the next best step in management?

Perform a cricothyroidotomy. ***Perform a cricothyroidotomy*** - In a “cannot intubate, cannot ventilate” (**CICV**) scenario, immediate establishment of a surgical airway is life-saving to prevent **hypoxic brain injury** and death. - A **cricothyroidotomy** is the fastest and most definitive emergency procedure to secure the airway by making an incision through the **cricothyroid membrane** into the trachea, bypassing any upper airway obstruction. *Insert nasopharyngeal airway* - A nasopharyngeal airway is a basic airway adjunct designed to relieve soft tissue obstruction at the level of the pharynx. It does not provide a definitive airway for ventilation. - In a **CICV** situation, basic maneuvers and adjuncts like this have already been attempted and failed; it is an inadequate intervention for this life-threatening emergency. *Insert a laryngeal mask airway* - A laryngeal mask airway (**LMA**) is a supraglottic airway device. A **CICV** scenario is declared only after attempts to secure the airway with both an endotracheal tube and a supraglottic device have failed. - Wasting further time attempting to insert an LMA is inappropriate when ventilation is not possible and a surgical airway is urgently needed. *Perform a tracheostomy* - A **tracheostomy** is a formal, time-consuming surgical procedure that is more complex and has a higher complication rate in an emergency setting compared to a cricothyroidotomy. - While it is a definitive airway, it is not the procedure of choice for a time-critical airway emergency. A cricothyroidotomy is the standard emergent surgical airway.

Q: A patient undergoing surgery develops sudden deranged vitals following a failed attempt at subclavian vein catheterization. On examination, the trachea is shifted to one side and breath sounds are absent on the opposite side. What is the most likely diagnosis?

Tension pneumothorax. ***Correct: Tension pneumothorax*** - **Classic complication of subclavian vein catheterization** - inadvertent puncture of the pleura causes air accumulation in the pleural space - **Pathognomonic clinical features** present in this case: - **Tracheal deviation away from the affected side** (toward the opposite side where breath sounds are absent) - **Absent breath sounds on the affected side** due to complete lung collapse - **Hemodynamic instability** ("deranged vitals") from mediastinal shift compressing the great vessels and heart - **Medical emergency** requiring immediate needle decompression followed by chest tube insertion - The **tension** component occurs when air enters pleural space during inspiration but cannot escape during expiration (one-way valve effect), causing progressive pressure buildup *Incorrect: Aspiration pneumonitis* - Would present with bilateral crackles, hypoxia, and potential bronchospasm - Does **not cause tracheal deviation** or unilateral absent breath sounds - Typically occurs during induction or emergence from anesthesia, not during vascular access procedures *Incorrect: Pulmonary embolism* - Presents with sudden dyspnea, hypoxia, tachycardia, and possible hypotension - Does **not cause tracheal deviation** or unilateral absent breath sounds - Breath sounds remain present bilaterally (though may have localized crackles) - Not directly related to subclavian catheterization attempts *Incorrect: Bronchospasm* - Presents with **bilateral wheezing** and increased airway pressures - Does **not cause tracheal deviation** or unilateral findings - Breath sounds present bilaterally (though may be diminished with severe bronchospasm) - Would not explain the immediate temporal relationship with failed subclavian line attempt

Q: A follow-up patient of GERD on endoscopy was having a nodule in the 2nd part of the duodenum, which hormone are you suspecting to be raised?

Gastrin. ***Gastrin*** - The presence of a nodule in the second part of the duodenum, a common location within the **gastrinoma triangle** (Passaro's triangle), combined with GERD, strongly suggests a **gastrinoma**. - Gastrinomas cause **Zollinger-Ellison Syndrome (ZES)** by secreting excessive **gastrin**, which leads to gastric acid hypersecretion, resulting in refractory peptic ulcers and severe GERD [1]. *Inulin* - **Inulin** is a polysaccharide, not a hormone, and it is used clinically to measure the **glomerular filtration rate (GFR)**. - If this option meant **insulin**, an insulinoma would cause symptoms of **hypoglycemia**, such as sweating, tremors, and confusion, not GERD. *VIP* - A tumor secreting **Vasoactive Intestinal Peptide (VIPoma)** causes **WDHA syndrome**, characterized by **W**atery **D**iarrhea, **H**ypokalemia, and **A**chlorhydria. - This condition is associated with **low stomach acid** (achlorhydria), which is contrary to the hyperacidity that causes GERD. *Glucagon* - A **glucagonoma** is a tumor that secretes excess glucagon, leading to a syndrome characterized by **diabetes mellitus** and a classic skin rash known as **necrolytic migratory erythema**. - It is not associated with gastric acid hypersecretion or duodenal nodules presenting with GERD.

Q: During assisted vaginal delivery, where is the vacuum device typically applied?

3 cm anterior to the posterior fontanelle. ***3 cm anterior to the posterior fontanelle***- This exact point is known as the **flexion point** (or optimum traction point), which is essential for ensuring that traction causes the fetal head to flex, thus presenting the smallest diameter for delivery.- Applying the vacuum cup at the flexion point ensures that the pull is along the axis of the **fetal head**, minimizing cephalhematoma and increasing the efficacy of the vacuum pull.*At 3 cm behind the anterior fonatnelle*- This position corresponds to the **sinciput** and is too far forward on the fetal head.- Applying traction here could lead to **extension** of the fetal head, making delivery more difficult and increasing the risk of fetal injury or cap detachment.*On the posterior fontanelle*- Placing the cup directly on the **posterior fontanelle** is incorrect as it is a small, soft area and the application would be off-center from the optimal traction point.- This off-center placement could result in **deflecting** the fetal head upon traction, making the pull less effective and potentially causing scalp damage.*Between the anterior and posterior fontanelle*- While the ideal position lies along the sagittal suture between the fontanelles, this description is too vague and does not pinpoint the specific **flexion point** (3 cm anterior to the posterior fontanelle).- Vague placement often results in applied traction that is not fully conducive to optimal **head flexion** and descent.

Q: What is the co-test in cervical cancer screening?

HPV and PAP smear. ***HPV and PAP smear*** - **Co-testing** is the simultaneous use of the **hrHPV DNA test** (to detect oncogenic virus presence) and the **Papanicolaou (PAP) smear** (to detect cytological abnormalities). - This combination provides the highest sensitivity for detecting high-grade cervical intraepithelial neoplasia (**CIN 2/3**) and is recommended for screening women aged 30-65 years in many guidelines. *Pap smear and VIA* - **Visual Inspection with Acetic acid (VIA)** is typically used as a primary screening method in settings where laboratory infrastructure for cytology or HPV testing is limited, not as a standard co-test. - The combination of **PAP smear** (cytology) and **HPV testing** (molecular) offers a superior and more risk-stratified approach than combining cytology with simple visual inspection. *HPV and VIA* - This combination lacks the necessary **specificity** provided by the PAP smear, as VIA relies on subjective visual assessment of acetowhite changes rather than objective cytological classification. - Standard screening protocols often require detailed cytological results (e.g., **ASCUS, LSIL, HSIL**) from the PAP smear to guide subsequent triage and management decisions when HPV is positive. *PAP smear and colposcopy* - **Colposcopy** is a **diagnostic and evaluation procedure** performed *after* an abnormal screening result (e.g., abnormal PAP or positive HPV), not a screening test to be paired with the PAP smear. - Colposcopy allows for directed biopsy and is crucial for definitive diagnosis and staging of **cervical intraepithelial neoplasia (CIN)**.

Q: Which of the following is a contraindication to subdermal contraceptive implant?

Undiagnosed genital bleeding. ***Undiagnosed genital bleeding*** - Undiagnosed abnormal genital bleeding is a key contraindication because hormonal methods, including the implant, may mask potentially serious underlying causes such as **endometrial or cervical cancer**. - Comprehensive evaluation must be completed and a definitive diagnosis established before initiating the implant to ensure patient safety. *Hypertension* - **Mild to moderate hypertension** is generally not a contraindication for progestin-only methods like the contraceptive implant, which has minimal effect on blood pressure. - Progestin implants are often a good alternative for women with hypertension who have contraindications to **estrogen-containing contraceptives**. *Diabetes mellitus* - **Diabetes mellitus** (uncomplicated by vascular disease) is not a contraindication for progestin-only contraceptives, which are safe for diabetic management. - The implant has minimal adverse effects on **glucose metabolism** and is classified as a Category 2 (benefits generally outweigh risks) method by WHO MEC criteria. *PID* - A **history of Pelvic Inflammatory Disease (PID)** is not a contraindication for the contraceptive implant, as it is a systemic hormonal method and not an intrauterine device. - Unlike IUDs, the subdermal implant does not interact with the uterine cavity or tubes, thus posing no risk of inducing or exacerbating **pelvic infection**.

Q: A patient with a previous history of cesarean section is in labor and has contractions of 3/10, no fetal distress and membranes are intact. What is the next step in management?

Perform artificial rupture of membranes (ARM) and monitor. ***Perform artificial rupture of membranes (ARM) and monitor*** - In a patient undergoing **Trial of Labor After Cesarean (TOLAC)**, with adequate contractions (3/10) and intact membranes, **ARM may be performed** to assess amniotic fluid and facilitate closer monitoring of fetal well-being - ARM allows for **placement of internal monitors** (fetal scalp electrode and intrauterine pressure catheter) if needed for more accurate assessment during TOLAC - **Continuous electronic fetal monitoring (EFM)** is mandatory during TOLAC to detect early signs of **uterine rupture** (fetal heart rate abnormalities) or fetal distress - Once ARM is performed, close observation of labor progress and fetal status continues *Oxytocin* - While labor augmentation may be needed later, **oxytocin should be used cautiously** in TOLAC due to increased risk of **uterine hyperstimulation** and **uterine rupture** - Current contractions at 3/10 are adequate; oxytocin is reserved for **inadequate uterine contractions** or **labor dystocia** - If used, oxytocin should be at **lower doses** with careful titration in patients with prior cesarean section *Proceed with instrumental delivery* - Instrumental delivery (vacuum or forceps) is indicated only during the **second stage of labor** for specific indications such as **prolonged second stage**, **maternal exhaustion**, or **non-reassuring fetal status** - This patient is in the **first stage of labor**; instrumental delivery is not applicable at this stage *Perform a repeat cesarean section* - The patient is successfully undergoing **TOLAC** with adequate contractions and no fetal distress; immediate cesarean section is **not indicated** - Repeat cesarean section is reserved for **failed TOLAC** (arrested labor), **non-reassuring fetal heart rate patterns**, or **suspected uterine rupture** - Approximately 60-80% of appropriate TOLAC candidates achieve successful vaginal delivery

Q: A 30-year-old female presented with pain in the right upper quadrant of the abdomen after 4 days of cholecystectomy. On USG, it showed a significant collection in RUQ. What will you do further?

USG guided aspiration of content. ***USG guided aspiration of content***- A significant, symptomatic intra-abdominal collection post-cholecystectomy (4 days) strongly suggests a localized **abscess**, **hematoma**, or **biloma**, demanding urgent **source control**.- **Percutaneous drainage** guided by ultrasound or CT is the gold standard, minimally invasive treatment for accessible, well-defined fluid collections in the immediate postoperative period.*Re-explore laparoscopically*- Surgical **re-exploration** is more invasive and is typically reserved for cases where percutaneous drainage fails, or if there is diffuse peritonitis or active bleeding.- Since the USG shows a localized collection, the less invasive **percutaneous approach** is the initial management choice.*Higher antibiotics*- Antibiotics alone are insufficient to manage a significant, symptomatic fluid collection, especially if it is an **abscess** (pus collection).- Drainage (source control) followed by appropriate antibiotics is the required sequence to prevent systemic infection and **sepsis**.*MRCP*- **MRCP** (Magnetic Resonance Cholangiopancreatography) is a diagnostic test primarily used to evaluate the **biliary tree** for leaks or strictures.- While biliary tree integrity is important, the immediate therapeutic priority for a defined, symptomatic collection is drainage, not further imaging, unless a large, high-pressure **biloma** is highly suspected and the patient is stable.

Question 1

A patient is scheduled for laparoscopic surgery under general anesthesia in a day care setting. Which of the following factors makes him unsuitable for day care surgery?

Accepted Answer

No attendant is available at home to care for the patient postoperatively

Answer

The patient has had general anesthesia in the past without complications

Answer

The surgical procedure is expected to last slightly over 1 hour

Answer

Home is 45 minutes away from the hospital

Question 2

During general anesthesia, which nerve is commonly monitored using a nerve stimulator to assess neuromuscular blockade?

Accepted Answer

Ulnar nerve

Answer

Tibial nerve

Answer

Median nerve

Answer

Radial nerve

Question 3

A patient under anesthesia is found to be in a “cannot intubate, cannot ventilate” (CICV) scenario. What is the next best step in management?

Accepted Answer

Perform a cricothyroidotomy

Answer

Insert a laryngeal mask airway

Answer

Insert nasopharyngeal airway

Answer

Perform a tracheostomy

Question 4

A patient undergoing surgery develops sudden deranged vitals following a failed attempt at subclavian vein catheterization. On examination, the trachea is shifted to one side and breath sounds are absent on the opposite side. What is the most likely diagnosis?

Accepted Answer

Tension pneumothorax

Answer

Aspiration pneumonitis

Answer

Pulmonary embolism

Answer

Bronchospasm

Question 5

A follow-up patient of GERD on endoscopy was having a nodule in the 2nd part of the duodenum, which hormone are you suspecting to be raised?

Accepted Answer

Gastrin

Answer

Inulin

Answer

Glucagon

Answer

VIP

Question 6

During assisted vaginal delivery, where is the vacuum device typically applied?

Accepted Answer

3 cm anterior to the posterior fontanelle

Answer

Between the anterior and posterior fontanelle

Answer

On the posterior fontanelle

Answer

At 3 cm behind the anterior fontanelle

Question 7

What is the co-test in cervical cancer screening?

Accepted Answer

HPV and PAP smear

Answer

PAP smear and colposcopy

Answer

HPV and VIA

Answer

Pap smear and VIA

Question 8

Which of the following is a contraindication to subdermal contraceptive implant?

Accepted Answer

Undiagnosed genital bleeding

Answer

PID

Answer

Diabetes mellitus

Answer

Hypertension

Question 9

A patient with a previous history of cesarean section is in labor and has contractions of 3/10, no fetal distress and membranes are intact. What is the next step in management?

Accepted Answer

Perform artificial rupture of membranes (ARM) and monitor

Answer

Perform a repeat cesarean section

Answer

Proceed with instrumental delivery

Answer

Oxytocin

Question 10

A 30-year-old female presented with pain in the right upper quadrant of the abdomen after 4 days of cholecystectomy. On USG, it showed a significant collection in RUQ. What will you do further?

Accepted Answer

USG guided aspiration of content

Answer

Re-explore laparoscopically

Answer

MRCP

Answer

Higher antibiotics

FMGE 2025

Anesthesiology

Internal Medicine

Obstetrics and Gynecology

Surgery