FMGE 2026 - Internal Medicine Practice Questions

Q: A patient had an occlusion of the artery marked as " A " in the given image. Which part of the heart is most likely affected?

Anterior wall. ***Anterior wall*** - Occlusion of the **Left Anterior Descending (LAD) artery**—typically responsible for supplying the anterior wall of the left ventricle and the anterior two-thirds of the interventricular septum—leads to **anterior wall myocardial infarction**. - This is a common and clinically significant infarct pattern often associated with **ST-segment elevation** in leads **V1–V4** on an ECG. *Posterior wall* - The posterior wall of the heart is usually supplied by the **left circumflex artery (LCx)** or the **posterior descending artery (PDA)**, depending on **coronary dominance**. - Infarction here typically manifests as ST elevation in leads **V7–V9** and is often associated with involvement of the lateral or inferior walls. *Inferior wall* - The inferior wall of the heart is primarily supplied by the **Right Coronary Artery (RCA)** in the majority of individuals (right-dominant circulation). - An isolated inferior wall myocardial infarction typically results in ST-segment elevation in leads **II, III, and aVF**. *Lateral wall* - The lateral wall of the left ventricle is typically supplied by branches of the **left circumflex artery (LCx)**, specifically the **obtuse marginal branches**. - Infarction of the lateral wall often correlates with ST-segment changes in leads **I, aVL, V5, and V6**.

Q: A 52 year old man with the past history of Type-2 DM & Chronic sinusitis presented with continuous high grade fever for 2 days along with severe headache, photophobia, nuchal rigidity, confusion and vomiting. Kernig’s sign is positive. Which among the following is the most appropriate empirical therapy?

Ceftriaxone + Vancomycin. ### **Ceftriaxone + Vancomycin** - This combination covers the most common pathogens causing **community-acquired bacterial meningitis** in adults, specifically *Streptococcus pneumoniae* and *Neisseria meningitidis*. - The addition of **Vancomycin** is critical to provide adequate coverage for potential **penicillin-resistant Streptococcus pneumoniae** strains, while **Ceftriaxone** (or another third-generation cephalosporin) provides excellent bactericidal activity against common meningeal pathogens. *Clindamycin* - This antibiotic is primarily effective against **anaerobes** and certain Gram-positive cocci but lacks significant **meningeal penetration** and activity against common meningitis pathogens. - It is not indicated for the empirical treatment of **acute bacterial meningitis**. *Vancomycin* - While it provides coverage against resistant *Streptococcus pneumoniae*, it is **insufficient as monotherapy** because it does not adequately cover *Neisseria meningitidis* or *Haemophilus influenzae*. - Empirical treatment for suspected meningitis must include a coverage regimen that addresses the most frequent **Gram-negative** and **Gram-positive** causative organisms. *Meropenem* - While a potent antibiotic, it is typically reserved for cases of **hospital-acquired meningitis** or when *Pseudomonas aeruginosa* is suspected, given its broad-spectrum profile. - It is not the standard first-line empirical choice for **community-acquired** presentations without specific risk factors like recent neurosurgery or trauma.

Q: A known Type II DM, 70 year old patient was under medication. He aslo takes Telmisartan. Patients current lab values: HbA1c-8.5, eGFR-50 mL/min/1.73 m. Normal potassium levels. What is the next appropriate step to decrease the risk of further eGFR decrement?

Increase Telmisartan dose. ***Increase Telmisartan dose*** - In patients with **diabetic nephropathy** and chronic kidney disease, optimizing the dose of **Angiotensin Receptor Blockers (ARBs)** like telmisartan to maximum tolerated levels is crucial to achieve maximal **renoprotection** and reduce **albuminuria**. - Since the patient has normal potassium and an eGFR of 50 mL/min/1.73 m², there is room for dosage titration to further suppress the **renin-angiotensin-aldosterone system (RAAS)** and slow the progression of renal decline. *Shift to Ramipril* - This patient is already on an ARB; shifting to an **ACE inhibitor (ACEi)** like Ramipril does not provide superior **renoprotective benefits** compared to ARBs in the context of diabetic nephropathy. - Dual therapy with an ACEi and an ARB is contraindicated due to increased risks of **hyperkalemia** and acute kidney injury without added clinical benefit. *Increase the dose of antidiabetic meds* - While glycemic control is vital (targeting HbA1c < 7.0%), simply increasing the dose of non-specific antidiabetic medications does not directly address hemodynamics to prevent **hyperfiltration** in the way RAAS inhibition does. - Specific agents like **SGLT2 inhibitors** or **GLP-1 receptor agonists** should be preferred for renal protection, rather than focusing solely on increasing existing medication doses. *Start Carvedilol* - **Carvedilol**, a non-selective beta-blocker, is indicated for heart failure or hypertension control but does not provide primary renal protection for diabetic patients with stable blood pressure. - Introducing a beta-blocker does not address the underlying **glomerular hyperfiltration** mechanism causing the eGFR decline as effectively as maximizing RAAS blockade.

Q: A 52-year-old man presents with gradually progressive asymmetric limb weakness, muscle wasting, and fasciculations. Examination reveals a combination of upper and lower motor neuron signs. Sensory examination is normal. Which of the following is the most appropriate disease-modifying treatment?

Riluzole. ### ***Riluzole*** - This medication is a **glutamate antagonist** that is the standard disease-modifying therapy for **Amyotrophic Lateral Sclerosis (ALS)**, the condition described by the mixed **Upper Motor Neuron (UMN)** and **Lower Motor Neuron (LMN)** signs. - While it does not cure the disease, it has been shown to modestly **prolong survival** in patients with ALS by inhibiting glutamatergic neurotransmission. *Levodopa* - This is a dopamine precursor primarily used for the treatment of **Parkinson's disease**. - It addresses dopaminergic deficiency rather than the motor neuron degeneration seen in ALS. *Pyridostigmine* - This is an **acetylcholinesterase inhibitor** used as the first-line treatment for **Myasthenia Gravis**. - While it helps muscle weakness in Myasthenia Gravis, it is ineffective for the progressive motor neuron degeneration characterized by fasciculations and muscle wasting in ALS. *Interferon-β* - This agent is a disease-modifying therapy for **Multiple Sclerosis (MS)**, where it acts as an immunomodulator. - MS typically presents with sensory deficits and relapsing-remitting patterns, unlike the **pure motor** involvement seen in ALS.

Q: A patient presents with signs of early vitamin A deficiency. Based on clinical findings, which of the following is the earliest manifestation on the skin or eyes?

Night blindness. ***Night blindness*** - **Night blindness** (nyctalopia) is the earliest clinical manifestation of **vitamin A deficiency** due to the depletion of **rhodopsin** in the rod cells of the **retina**. - It represents a functional impairment of dark adaptation before any structural ocular changes occur in the conjunctiva or cornea. *Conjunctival xerosis* - This finding appears after night blindness and manifests as dryness, thickening, and wrinkling of the **conjunctiva**, often followed by **Bitot spots**. - It is a structural abnormality resulting from keratinization of the epithelial cells, which happens later in the progression of the deficiency. *Corneal xerosis* - This condition involves the drying of the **cornea** due to reduced production of **mucus**-secreting goblet cells and subsequent **keratinization**. - It is a more advanced sign than conjunctival xerosis and indicates a significant, prolonged lack of **retinol**. *Corneal ulceration* - This is a severe, late-stage complication known as **keratomalacia**, which leads to liquefactive necrosis and potential permanent blindness. - It represents the terminal phase of ocular involvement in **vitamin A deficiency** and is significantly preceded by earlier signs like xerosis and Bitot spots.

Q: A 65-year-old man presents with dysphagia, halitosis, and regurgitation of undigested food several hours after eating. What is the likely diagnosis of this barium study?

Zenker's diverticulum. ***Zenker's diverticulum*** - Occurs due to a herniation of the pharyngeal mucosa through the **Killian’s dehiscence** (a weakened area between the thyropharyngeus and cricopharyngeus muscles). - Typical presentation involves **oropharyngeal dysphagia**, **halitosis** (due to food stagnation), and **regurgitation** of undigested food, often occurring hours after meals. *Killian-Jamieson Diverticulum* - Represents a rare protrusion through the anterior cervical esophagus, inferior to the **cricopharyngeus muscle**. - Unlike Zenker's, these tend to be smaller, generally asymptomatic, or manifest as localized **neck swelling** rather than the severe dysphagia and halitosis seen here. *Achalasia* - Characterized by the failure of the **lower esophageal sphincter (LES)** to relax, typically causing dysphagia to both solids and liquids. - On imaging, it often presents with a **bird-beak appearance** of the distal esophagus, rather than a pulsion diverticulum in the proximal neck. *Laryngocele* - A dilation of the **ventricle of the larynx** that communicates with the laryngeal lumen. - It typically presents as a neck mass that increases in size with **Valsalva maneuver** or increased intrathoracic pressure, not with dysphagia and food regurgitation.

Q: A 22 year old male patient sustained a burn and presented to the emergency department, on examination nasal hair were singed, on blood investigation Carboxy Hb was raised to 18.5%, and oxygen saturation was 81%, what is the next best step?

Intubation. ***Intubation*** - The patient presents with **singed nasal hair**, which is a significant clinical indicator of **upper airway inhalation injury**, necessitating early airway protection. - A **Carboxyhemoglobin (COHb) level >10-15%** associated with inhalation injury, combined with clinical signs of airway compromise, mandates **prophylactic endotracheal intubation** to prevent airway obstruction due to evolving edema. *100% O2 with NVA* - While **100% oxygen** is the definitive treatment for **carbon monoxide poisoning** to shorten the half-life of COHb, it does not secure the airway in a patient with impending respiratory obstruction from inhalation injury. - This intervention is insufficient as the primary management step when there is an immediate threat to airway patency evidenced by **singed nasal hair** and associated burn stigmata. *Fluid resuscitation according to parkland formula* - Although aggressive **fluid resuscitation** is vital for burn management to prevent hypovolemic shock, it is secondary to **Airway (A)** management in the A-B-C priority framework. - Ensuring a patent airway takes precedence over initiating the **Parkland formula**, even though fluid resuscitation will be required shortly thereafter. *Tracheostomy* - A **tracheostomy** is an invasive surgical procedure typically reserved for cases where **endotracheal intubation** fails or is impossible due to severe upper airway anatomy distortion. - It is not the first-line intervention for immediate airway management in a patient presenting to the emergency department; **orotracheal intubation** is the standard for rapid airway control.

Q: Diagnosis?

Crohn's disease. ***Crohn's disease*** - Characterized by **transmural inflammation** that can affect any part of the gastrointestinal tract, often with **skip lesions** and a **cobblestone appearance** on endoscopy. - Frequently presents with **terminal ileitis**, leading to complications like **anemia** due to malabsorption of B12 and iron, as well as strictures and **fistulae**. *UC* - Typically limited to the **mucosa and submucosa** and involves only the **colon and rectum** in a continuous pattern. - Hallmark symptoms include **bloody diarrhea** and **tenesmus** without the perianal involvement or transmural complications seen in Crohn's. *Ileal cancer* - Rarer than inflammatory bowel disease and typically presents with symptoms akin to bowel obstruction, such as **weight loss**, **abdominal pain**, and **vomiting**. - Usually diagnosed via imaging or colonoscopy showing a localized mass rather than the widespread, patchy inflammation found in Crohn's. *Gut malrotation* - A congenital anomaly often presenting in infancy with **bilious vomiting** and signs of midgut volvulus, though it can occasionally present in adults. - Diagnosis relies on imaging studies like a **barium swallow** or **CT scan** showing the abnormal positioning of the bowel loops, distinct from the inflammatory pathologies of IBD.

Q: A patient (drug abuser) presents with pain in the right upper quadrant, fever, chills with rigor, anorexia. The patient was HIV positive with increased enzymes. What is the likely diagnosis?

Liver abscess. ***Liver abscess*** - The classic triad of **right upper quadrant pain**, **fever with chills/rigors**, and potential hepatomegaly points strongly toward **liver abscess**, particularly in immunocompromised patients (e.g., **HIV**). - Intravenous **drug abuse** is a significant risk factor for pyogenic abscesses due to the potential for seeded infection or compromised immune status. *HCC* - Usually presents with **weight loss**, abdominal mass, or decompensation in patients with underlying **cirrhosis** or chronic hepatitis B/C. - While liver enzymes may be elevated, the acute febrile illness with rigors is more characteristic of an infectious process rather than a malignancy. *Hydatid cyst* - Typically presents as an **asymptomatic abdominal mass** or localized pain due to mass effect; it is not commonly associated with systemic symptoms like high fever and rigors unless there is superinfection or rupture. - Generally manifests as a fluid-filled cystic lesion on imaging with specific signs like **daughter cysts** rather than abscess features. *Liver METS* - Often presents with hepatomegaly, anorexia, and **weight loss**, but fever is a less common presenting feature unless the primary tumor is necrotic or there is extensive disease burden. - Usually diagnosed by identifying a primary malignancy elsewhere, and clinical presentation is typically chronic/subacute rather than acute infectious mimicry.

Q: Which option correctly matches both thyroid conditions with their associated antibodies?

Both Hyperthyroidism - LATS and Hypothyroidism - Anti-TPO. ***Both Hyperthyroidism - LATS and Hypothyroidism - Anti-TPO*** - **Long-Acting Thyroid Stimulator (LATS)** is an autoantibody historically identified in **Graves' disease**, which acts as a thyroid-stimulating immunoglobulin (TSI) by activating the **TSH receptor**. - **Anti-thyroid peroxidase (Anti-TPO)** antibodies are the hallmark serological marker for **Hashimoto's thyroiditis**, which is the most common cause of autoimmune primary hypothyroidism. *Hyperthyroidism - LATS only* - While LATS is associated with hyperthyroidism (Graves' disease), this option is incomplete because the question asks for the correct match for *both* conditions, and LATS is not the exclusive antibody associated with hyperthyroidism (TSH receptor antibodies are the modern nomenclature). - This option ignores the accurate association of Anti-TPO with hypothyroidism, making it less comprehensive than the correct choice. *Hypothyroidism - Anti-TPO only* - Although Anti-TPO is correctly linked to hypothyroidism (Hashimoto's), this option is incomplete because it fails to acknowledge the LATS association with hyperthyroidism. - The premise of the question requires identifying both valid associations, rendering this option incorrect by omission. *Neither pair is correct* - This option is incorrect because both presented associations represent classic, well-established immunological markers for their respective thyroid pathologies. - Recognizing these specific autoantibodies is essential for the serological diagnosis of common autoimmune thyroid disorders.

Question 1

A patient had an occlusion of the artery marked as " A " in the given image. Which part of the heart is most likely affected?

Accepted Answer

Anterior wall

Answer

Posterior wall

Answer

Inferior wall

Answer

Lateral wall

Question 2

A 52 year old man with the past history of Type-2 DM & Chronic sinusitis presented with continuous high grade fever for 2 days along with severe headache, photophobia, nuchal rigidity, confusion and vomiting. Kernig’s sign is positive. Which among the following is the most appropriate empirical therapy?

Accepted Answer

Ceftriaxone + Vancomycin

Answer

Clindamycin

Answer

Vancomycin

Answer

Meropenem

Question 3

A known Type II DM, 70 year old patient was under medication. He aslo takes Telmisartan. Patients current lab values: HbA1c-8.5, eGFR-50 mL/min/1.73 m. Normal potassium levels. What is the next appropriate step to decrease the risk of further eGFR decrement?

Accepted Answer

Increase Telmisartan dose

Answer

Shift to Ramipril

Answer

Increase the dose of antidiabetic meds

Answer

Start Carvedilol

Question 4

A 52-year-old man presents with gradually progressive asymmetric limb weakness, muscle wasting, and fasciculations. Examination reveals a combination of upper and lower motor neuron signs. Sensory examination is normal. Which of the following is the most appropriate disease-modifying treatment?

Accepted Answer

Riluzole

Answer

Levodopa

Answer

Pyridostigmine

Answer

Interferon-β

Question 5

A patient presents with signs of early vitamin A deficiency. Based on clinical findings, which of the following is the earliest manifestation on the skin or eyes?

Accepted Answer

Night blindness

Answer

Conjunctival xerosis

Answer

Corneal xerosis

Answer

Corneal ulceration

Question 6

A 65-year-old man presents with dysphagia, halitosis, and regurgitation of undigested food several hours after eating. What is the likely diagnosis of this barium study?

Accepted Answer

Zenker's diverticulum

Answer

Killian-Jamieson Diverticulum

Answer

Achalasia

Answer

Laryngocele

Question 7

A 22 year old male patient sustained a burn and presented to the emergency department, on examination nasal hair were singed, on blood investigation Carboxy Hb was raised to 18.5%, and oxygen saturation was 81%, what is the next best step?

Accepted Answer

Intubation

Answer

100% O2 with NVA

Answer

Fluid resuscitation according to parkland formula

Answer

Tracheostomy

Question 8

Diagnosis?

Accepted Answer

Crohn's disease

Answer

UC

Answer

Ileal cancer

Answer

Gut malrotation

Question 9

A patient (drug abuser) presents with pain in the right upper quadrant, fever, chills with rigor, anorexia. The patient was HIV positive with increased enzymes. What is the likely diagnosis?

Accepted Answer

Liver abscess

Answer

HCC

Answer

Hydatid cyst

Answer

Liver METS

Question 10

Which option correctly matches both thyroid conditions with their associated antibodies?

Accepted Answer

Both Hyperthyroidism - LATS and Hypothyroidism - Anti-TPO

Answer

Hyperthyroidism - LATS only

Answer

Hypothyroidism - Anti-TPO only

Answer

Neither pair is correct

FMGE 2026 — Internal Medicine