FMGE 2019 Practice Questions

Q: Celiac vessel is seen at which vertebral level?

T12. T12 - The celiac trunk arises from the abdominal aorta at the level of the twelfth thoracic vertebra (T12), just below the aortic hiatus of the diaphragm. - This is typically at the level of the upper border of L1 or lower border of T12. - It is the first major unpaired visceral branch and supplies the foregut organs (stomach, proximal duodenum, liver, spleen, pancreas). L2 - The renal arteries, which supply the kidneys, typically originate from the aorta at the level of the L1-L2 vertebra. - The inferior mesenteric artery (IMA) arises at approximately L3 level. - This level is significantly lower than the origin of the celiac trunk. T9 - At the level of T9, no major visceral branches arise from the aorta. - This level is above the aortic hiatus (at T12), so the aorta is still in the thoracic cavity. - The celiac trunk has not yet branched at this higher level. T10 - At T10, the aorta is still in the thoracic cavity, passing through the posterior mediastinum. - The aortic hiatus of the diaphragm is at T12, not T10. - No major unpaired visceral branches originate at this level.

Q: Endotracheal tube in the esophagus is best assessed by:

CO2 Exhalation. ***CO2 Exhalation*** - Measuring **CO2 exhalation** (capnography) is the most reliable method to confirm endotracheal tube placement, as CO2 is present in the trachea but not in the esophagus. - A persistent **waveform on the capnograph** indicates proper tracheal intubation. *Direct laryngoscopy* - While helpful for initial visualization during intubation, **direct laryngoscopy** cannot confirm continuous tracheal placement after the tube is advanced. - It only confirms the tube passing through the vocal cords, not its final position in the trachea versus esophagus. *Auscultation* - **Auscultation** can be misleading because stomach sounds can be transmitted to the chest, and breath sounds can be heard in the epigastrium even with esophageal intubation. - It relies on subjective interpretation and is less definitive than capnography. *Chest wall movement* - Observing **chest wall movement** is not a definitive sign, as the chest can still rise with esophageal intubation due to air entering the stomach. - This method is unreliable and can be mistaken for proper ventilation, leading to dangerous delays in correcting tube misplacement.

Q: Which structure of protein is not denatured after heating up to 100 degrees Celsius?

Primary. ***Primary*** - The **primary structure** refers to the specific linear sequence of **amino acids** forming the polypeptide chain, linked by **covalent peptide bonds**. - These strong **peptide bonds** are generally resistant to heat denaturation at 100°C, meaning the amino acid sequence remains intact. *Quaternary* - The **quaternary structure** involves the arrangement of multiple polypeptide subunits and is maintained by weaker interactions like **hydrophobic interactions**, hydrogen bonds, and salt bridges. - These interactions are highly susceptible to disruption by heat, causing the subunits to dissociate and the quaternary structure to be lost. *Tertiary* - The **tertiary structure** describes the three-dimensional folding of a single polypeptide chain, stabilized by various non-covalent interactions (e.g., hydrogen bonds, ionic bonds, hydrophobic interactions) and **disulfide bonds**. - Heat disrupts these weaker non-covalent interactions and can even break disulfide bonds, leading to the unfolding and loss of the specific 3D shape. *Secondary* - The **secondary structure** (e.g., **alpha-helices** and **beta-pleated sheets**) arises from hydrogen bonds between the backbone atoms of the polypeptide chain. - While peptide bonds remain intact, these vital **hydrogen bonds** are easily broken by heat, causing the unraveling of helices and sheets.

Q: The primary function of NIH (National Institutes of Health) is

Medical research. ***Medical research*** - The **National Institutes of Health (NIH)** is the primary biomedical research agency of the United States, comprising 27 institutes and centers - Its stated mission is to seek fundamental knowledge about living systems and apply that knowledge to **enhance health, lengthen life, and reduce illness and disability** - The NIH conducts and funds **medical research** across virtually all areas of medicine and public health, making this its core primary function - It is the world's largest public funder of biomedical research, with a budget primarily dedicated to research grants and intramural research programs *Disease surveillance* - Disease surveillance is primarily the responsibility of the **CDC (Centers for Disease Control and Prevention)**, not the NIH - While NIH research may inform surveillance strategies, **monitoring and tracking disease patterns** is not the NIH's primary organizational function - The NIH focuses on understanding disease mechanisms and developing interventions through research *Public health policy* - The NIH provides **evidence-based research** that informs public health policy but does not primarily create or enforce policy - Policy-making authority rests with the **Department of Health and Human Services (HHS)** and other regulatory agencies like the FDA - The NIH's role is to generate the scientific knowledge base that guides policy decisions *Clinical trials* - The NIH conducts and funds extensive **clinical trials** through its Clinical Center and grant mechanisms - However, clinical trials are a **methodology of medical research**, not a separate primary function - Clinical trials serve the broader mission of medical research by testing hypotheses and interventions developed through basic and translational research

Q: What is the most likely diagnosis in an individual with normal serum alkaline phosphatase, normal PTH, normal Vitamin D3, and elevated serum calcium?

Multiple myeloma. ***Multiple myeloma*** [4] - This condition is often associated with **osteolytic lesions** that lead to the release of calcium into the blood, causing **hypercalcemia**. - **PTH**, **alkaline phosphatase**, and **Vitamin D3** levels are typically normal in this scenario because their regulatory pathways are not primarily affected [1]. *Nutritional rickets* [2] - Characterized by **low calcium** and **phosphate levels**, usually with **elevated alkaline phosphatase** and **PTH** due to inadequate vitamin D or calcium intake [3]. - This patient exhibits **elevated serum calcium**, ruling out rickets. *Hyperparathyroidism* - Both **primary** and **secondary hyperparathyroidism** would present with **elevated PTH** levels, which is stated as normal in the case description [1]. - **Hypercalcemia** in hyperparathyroidism is caused by bone resorption and increased renal reabsorption of calcium, driven by high PTH [5]. *Vitamin D intoxication* - Would lead to **hypercalcemia** and **elevated Vitamin D3** levels, alongside **suppressed PTH** levels, which contradicts the described normal PTH and normal Vitamin D3 [1]. - The excessive vitamin D would increase calcium absorption from the gut and bone resorption not seen here.

Q: Which heart sound is almost always considered pathological?

S4. ***S4*** - An **S4 heart sound**, or **atrial gallop**, is almost always indicative of **pathology**, specifically a **stiff or non-compliant ventricle**. - It occurs due to vigorous atrial contraction forcing blood into a **non-compliant ventricle**, commonly seen in conditions like **hypertensive heart disease**, **aortic stenosis**, and **hypertrophic cardiomyopathy**. *S2* - **S2** represents the **closure of the aortic and pulmonic valves** and is a normal physiological heart sound [2]. - While it can be altered in pathology (e.g., fixed splitting, paradoxical splitting), the sound itself is a normal component of the cardiac cycle [1]. *S1* - **S1** represents the **closure of the mitral and tricuspid valves** and is a normal physiological heart sound [1]. - Variations in its intensity or splitting can occur in disease states, but the presence of S1 itself is normal. *S3* - An **S3 heart sound**, or **ventricular gallop**, can be a normal finding in **children**, **young adults**, and **pregnant individuals**, often referred to as a **physiological S3**. - However, in adults over 40, an S3 often indicates **ventricular dysfunction** due to rapid filling into a dilated ventricle [3], as seen in **heart failure** [1].

Q: Angle of cut in episiotomy is?

60 degrees at the midline. ***60 degrees at the midline*** - A **mediolateral episiotomy** is recommended at a **60-degree angle** from the midline, directed towards the ischial tuberosity. - This angle is based on **RCOG guidelines** and standard obstetric practice, providing optimal protection against **third- and fourth-degree perineal tears**. - The 60-degree angle effectively directs the incision away from the **anal sphincter** and **rectum**, while maintaining adequate surgical access. *45 degrees at the midline* - While sometimes used, this angle is **less protective** than 60 degrees against anal sphincter injuries. - Studies show that angles less than 60 degrees have a **higher risk** of extension into the anal sphincter complex compared to the recommended 60-degree angle. *30 degrees at the midline* - This angle is **too shallow** and provides insufficient protection against tearing towards the anal sphincter. - The risk of uncontrolled extension into the **anal sphincter complex** is significantly increased with such a small angle. *15 degrees at the midline* - This angle is **far too shallow** and would provide minimal expansion of the vaginal outlet. - It offers virtually no protection from extension into the **anal sphincter** and would likely result in an uncontrolled tear, making it an impractical choice for episiotomy.

Q: A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?

Atony. ***Atonic*** - **Uterine atony** is the most common cause of **postpartum hemorrhage (PPH)**, accounting for approximately 70-80% of cases. The uterus fails to contract adequately after placental delivery, leading to continuous bleeding from the placental bed. - Risk factors for uterine atony include multiparity, prolonged labor, rapid labor, polyhydramnios, and multiple gestations, which can lead to overdistension and fatigue of the uterine muscle. *Clotting factor deficiency* - While **coagulopathies** (clotting factor deficiencies) can cause PPH, they are a less common primary cause than uterine atony. - This cause would be suspected if there is a history of bleeding disorders, liver disease, or if PPH persists despite a well-contracted uterus. *Traumatic PPH* - **Traumatic PPH** results from lacerations of the cervix, vagina, or perineum, or from uterine rupture. These are less common than uterine atony. - This cause is typically suspected when the uterus feels firm but bleeding continues, or when visible trauma is present. *Retained tissues* - **Retained placental tissue** can prevent the uterus from contracting effectively, leading to PPH. However, it is less common than atony. - This cause is usually identified by the presence of placental fragments or membranes in the uterine cavity upon examination.

Q: Post-menopausal woman, fell down in washroom. What is the most common fracture she may suffer?

Colles fracture. ***Colles fracture*** - This fracture commonly occurs in **post-menopausal women** due to **osteoporosis** and typically results from a fall onto an **outstretched hand**. - It involves a **distal radius fracture** with **dorsal displacement** and often radial angulation. *Smith fracture* - A Smith fracture involves a **distal radius fracture** with **volar displacement**, usually caused by a fall onto the back of the hand. - While it can occur in post-menopausal women, it is less common than a Colles fracture in such a scenario. *Monteggia's fracture* - This fracture involves a **fracture of the ulna** with **dislocation of the radial head**. - It usually results from a direct blow to the forearm or a fall with extreme pronation, which is less typical for a simple fall in a post-menopausal woman. *Galeazzi fracture* - A Galeazzi fracture involves a **fracture of the radius** with **dislocation of the distal radioulnar joint (DRUJ)**. - This injury is less common and typically results from a fall onto an outstretched hand with the forearm in pronation, and it is not the most common fracture in this demographic.

Q: A patient with varicose veins came to the hospital; an intern was on duty. Which test should he perform to assess the competency of deep veins?

Perthes test. ***Perthes test*** - The Perthes test assesses the **patency and competency of the deep venous system** in the leg by observing changes in superficial varicosities during muscle activity. - If the varicosities diminish or disappear with ambulation and a tourniquet applied to compress superficial veins, it indicates that the **deep veins are competent** and can handle venous return. *Ober test* - The Ober test is used to assess the **tightness of the iliotibial band**, not venous competency. - It involves abducting and extending the hip while the patient lies on their side. *Thomas test* - The Thomas test evaluates for **hip flexion contracture**, especially of the iliopsoas muscle. - It is performed by having the patient lie supine and flexing one hip fully while observing the contralateral leg. *Brodie Trendelenburg test* - The Brodie Trendelenburg test is primarily used to assess the **competency of the valves of the saphenofemoral junction and perforating veins** to distinguish between superficial and deep venous insufficiency. - It involves elevating the leg, applying a tourniquet, and then observing refilling patterns of varicose veins upon standing.

Question 1

Celiac vessel is seen at which vertebral level?

Accepted Answer

T12

Answer

L2

Answer

T9

Answer

T10

Question 2

Endotracheal tube in the esophagus is best assessed by:

Accepted Answer

CO2 Exhalation

Answer

Direct laryngoscopy

Answer

Auscultation

Answer

Chest wall movement

Question 3

Which structure of protein is not denatured after heating up to 100 degrees Celsius?

Accepted Answer

Primary

Answer

Quaternary

Answer

Tertiary

Answer

Secondary

Question 4

The primary function of NIH (National Institutes of Health) is

Accepted Answer

Medical research

Answer

Public health policy

Answer

Clinical trials

Answer

Disease surveillance

Question 5

What is the most likely diagnosis in an individual with normal serum alkaline phosphatase, normal PTH, normal Vitamin D3, and elevated serum calcium?

Accepted Answer

Multiple myeloma

Answer

Nutritional rickets

Answer

Hyperparathyroidism

Answer

Vitamin D intoxication

Question 6

Which heart sound is almost always considered pathological?

Accepted Answer

S4

Answer

S2

Answer

S1

Answer

S3

Question 7

Angle of cut in episiotomy is?

Accepted Answer

60 degrees at the midline

Answer

45 degrees at the midline

Answer

30 degrees at the midline

Answer

15 degrees at the midline

Question 8

A multigravida woman in labor room, after delivery and placenta removal, uncontrolled bleeding was seen. What is the most common cause of PPH in this woman?

Accepted Answer

Atony

Answer

Clotting factor deficiency

Answer

Traumatic PPH

Answer

Retained tissues

Question 9

Post-menopausal woman, fell down in washroom. What is the most common fracture she may suffer?

Accepted Answer

Colles fracture

Answer

Smith fracture

Answer

Monteggia's fracture

Answer

Galeazzi fracture

Question 10

A patient with varicose veins came to the hospital; an intern was on duty. Which test should he perform to assess the competency of deep veins?

Accepted Answer

Perthes test

Answer

Ober test

Answer

Thomas test

Answer

Brodie Trendelenburg test

FMGE 2019

Anatomy

Anesthesiology

Biochemistry

Community Medicine

Internal Medicine

Obstetrics and Gynecology

Orthopaedics

Surgery