FMGE 2026 - Internal Medicine Practice Questions

Q: A chronic alcohol abuser is brought to hospital with complains of chronic liver diease. Which of the following you will add in the treatment?

Vitamin B1. ### ***Vitamin B1 (Thiamine)*** - Chronic alcohol use leads to **thiamine deficiency** due to inadequate dietary intake and impaired GI absorption, necessitating prophylactic oral or parenteral supplementation. - Deficiency puts the patient at high risk for **Wernicke-Korsakoff syndrome**, a potentially irreversible neurological disorder characterized by confusion, ophthalmoplegia, and ataxia. *Vitamin A* - While patients with chronic liver disease might develop deficiencies due to impaired storage, routine supplementation is generally not indicated without evidence of deficiency. - Excessive Vitamin A supplementation can be **hepatotoxic**, worsening underlying liver damage in this patient population. *Vitamin C* - Vitamin C deficiency is not a primary or immediate concern in the management of chronic alcohol-associated liver disease. - It is water-soluble but does not carry the same critical neurological risk profile associated with alcohol misuse as thiamine does. *Vitamin D* - While patients with cirrhosis are at risk for metabolic bone disease and Vitamin D deficiency, it is not the immediate, life-saving prophylaxis required upon admission. - Supplementation is typically guided by serum **25-hydroxyvitamin D levels** rather than being a mandatory first-line intervention like thiamine for preventing neurological catastrophe.

Q: A trekker at high altitude develops ataxia and confusion, followed by pulmonary edema. What is the most appropriate management?

Rapid descent. ***Rapid descent*** - This patient is presenting with symptoms of both **high-altitude cerebral edema (HACE)**, indicated by **ataxia** and **confusion**, and **high-altitude pulmonary edema (HAPE)**. - Regardless of the altitude illness type, **immediate descent** to a lower altitude is the single most effective, life-saving intervention and the gold standard for treatment. *Spironolactone* - This is a potassium-sparing diuretic that is not indicated for the management of altitude illnesses. - It lacks the rapid therapeutic efficacy required to reduce pulmonary or cerebral edema in an acute emergency setting. *Steroids* - **Dexamethasone** is an important adjunct for treating **HACE**, as it reduces cerebral edema, but it does not treat the primary cause or the pulmonary component. - It should never delay the primary, definitive treatment, which is descent to lower elevation. *Acetazolamide* - This medication is primarily used for the **prophylaxis** of acute mountain sickness or as an adjunct to aid acclimatization. - While it may be used as an adjunct in mild cases, it is insufficient as a standalone treatment for life-threatening conditions like severe **HACE** and **HAPE**.

Q: Patient has slurred sleech, keeps speaking alot but speaks meaningless words. Lesion is in superior temporal gyrus. Which area is involved?

Wernicke's area. ***Wernicke's area*** - Located in the **superior temporal gyrus** of the dominant hemisphere, it is primarily responsible for **language comprehension**. - Damage here leads to **Wernicke’s aphasia** (receptive aphasia), characterized by **fluent, meaningless speech** or "word salad," but preserved articulation. *Broca's area* - Located in the **inferior frontal gyrus**, damage to this area results in **non-fluent aphasia** (expressive aphasia). - Patients typically demonstrate *halting, effortful speech* but maintain relatively normal comprehension of spoken language. *Arcuate fasciculus* - This white matter tract connects **Wernicke's area** to **Broca's area**. - Lesions here result in **conduction aphasia**, typified by inability to *repeat phrases* despite intact comprehension and fluency. *Angular gyrus* - Located in the **parietal lobe**, it is involved in **reading, writing, and interpretation** of visual symbols. - Damage is typically associated with **Gerstmann syndrome** (acalculia, agraphia, finger agnosia, left-right disorientation) rather than isolated speech fluency disturbances.

Q: A 45-year-old male with severe postoperative pain is administered morphine 5 mg intravenously. You are monitoring him for opioid toxicity. Based on which of the following findings would you make the diagnosis of opioid overdose?

Bradypnea. ***Bradypnea*** - **Respiratory depression** (manifesting as bradypnea) is the most critical and reliable sign of **opioid overdose**. - A **decreased respiratory rate** is the primary cause of morbidity and potential mortality in cases of opioid toxicity. *Tachycardia* - Opioids typically cause **bradycardia** due to increased vagal tone, rather than tachycardia. - Tachycardia is not a clinical feature of opioid toxicity and is more suggestive of withdrawal or other drug ingestions like **sympathomimetics**. *Constriction of pupil* - While **miosis** (pinpoint pupils) is a hallmark sign of opioid toxicity due to **parasympathetic activation**, it is a clinical sign but **not the specific diagnostic criterion** used to measure the severity or acute overdose status compared to the life-threatening respiratory depression. - Miosis can also be absent or less prominent in mixed overdoses or with specific opioids like meperidine, making **respiratory depression** the more definitive indicator of toxicity. *Dilation of pupil* - **Mydriasis** (pupil dilation) is characteristically seen in **sympathomimetic** (e.g., cocaine, amphetamines) or anticholinergic overdose. - It is generally contraindicated in opioid toxicity and usually suggests **hypoxia** or the ingestion of substances that antagonize opioid effects.

Q: A 52-year-old diabetic patient with poorly controlled blood glucose presents with facial pain, nasal blockage, and a black necrotic lesion over the nasal turbinate (black sinus) along with fever. Imaging shows involvement of the maxillary sinus. What is the most appropriate management?

Surgical debridement with antifungal therapy. ***Surgical debridement with antifungal therapy*** - This patient presents with classic signs of **rhino-orbital-cerebral mucormycosis**, characterized by necrotic black eschars on the nasal turbinates in the setting of **uncontrolled diabetes**. - The cornerstone of management is **aggressive surgical debridement** of infected tissue combined with systemic **antifungal therapy** (typically **liposomal amphotericin B**), as tissue necrosis limits drug penetration. *Surgical debridement only* - While surgery is vital to remove necrotic tissue and reduce organism burden, relying on surgery alone is insufficient to address the **invasive fungal infection**. - Without concurrent **antifungal systemic therapy**, the infection risk of disseminating to the brain or orbit remains critically high. *Surgical debridement with antibiotics* - **Antibiotics** are ineffective against fungal pathogens like *Mucorales*. - Using antibiotics instead of antifungals allows the **fungal infection** to propagate unchecked, likely leading to rapid progression and high morbidity. *Antibiotics only* - Mucormycosis is a fulminant **fungal** infection which does not respond to antibacterial drugs. - Delaying antifungal treatment and surgical intervention due to a reliance on antibiotics is life-threatening, as the infection exhibits **angioinvasion** and rapid tissue necrosis.

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 patient with HIV infection who is also on immunosuppressive therapy presents with dry cough, progressive weight loss, and generalized weakness. What is the most likely diagnosis?

Pneumocystis jirovecii. ***Pneumocystis jirovecii*** - This organism remains the most common **opportunistic infection** in patients with HIV and significantly low **CD4 counts** (<200 cells/µL). - Classically presents with an **insidious onset** of non-productive (dry) **cough**, progressive dyspnea, and systemic symptoms like fever and **weight loss**. *Histoplasma capsulatum* - Typically presents with symptoms resembling **tuberculosis**, such as fever, cough, and hepatosplenomegaly, often in endemic areas like the **Ohio and Mississippi River valleys**. - Diagnosis usually requires detecting **urinary antigen** or visualization of small yeasts in macrophages, which is less specific to the presentation of dry cough without other endemic findings. *Candida albicans* - Primarily associated with **oropharyngeal candidiasis** (thrush) or **esophagitis** in HIV patients, not pulmonary disease. - Pulmonary involvement is extremely rare and usually superficial, not causing the profound systemic **respiratory symptoms** described here. *Mycobacterium tuberculosis* - While a major consideration, it typically presents with **hemoptysis**, night sweats, and **upper lobe cavitation** or miliary patterns on chest imaging. - Distinguishing features often include a more chronic course and specific exposures, whereas *Pneumocystis* is the classic cause of **interstitial pneumonia** in this clinical context.

Q: Foreigner with rice water stool

Cholera toxin. ***Cholera toxin*** - The **rice-water stool** is pathognomonic for **Vibrio cholerae** infection, which is mediated by the **cholera toxin**. - This toxin increases **cAMP** levels within enterocytes, leading to massive, secretory, non-inflammatory diarrhea and profound fluid loss. *Shigella toxin* - Associated with **bacillary dysentery**, characterized by **bloody stools**, mucus, and abdominal cramps rather than watery diarrhea. - This toxin, known as **Shiga toxin**, primarily inhibits protein synthesis by targeting the **60S ribosomal subunit**. *Heat labile E.Coli* - Also known as **Enterotoxigenic E. coli (ETEC)**, it causes **traveler's diarrhea** that is generally much milder than the epidemic cholera. - While it acts via a similar mechanism of increasing **cAMP**, it typically does not produce the extreme, rapidly dehydrating **rice-water stool** characteristic of cholera. *Rotavirus* - A major cause of **viral gastroenteritis** in infants and young children, typically presenting with watery diarrhea, fever, and vomiting. - Transmission is usually fecal-oral, and it is distinct from the **bacterial toxin**-mediated pathology seen in adult cholera cases.

Q: Factor VIII level of 50% in a patient with bleeding disorder is most suggestive of?

Von Willebrand disease. ***Von Willebrand disease*** - Type 1 Von Willebrand disease often presents with **reduced levels** of Von Willebrand factor (vWF), which serves as a carrier protein for **Factor VIII**. Because vWF protects Factor VIII from premature degradation in the plasma, mild to moderate deficiencies of vWF can lead to a secondary, proportional drop in **Factor VIII levels**. - A Factor VIII level of 50% is too high to be diagnostic of classic **Hemophilia A** (which typically presents with much lower levels, often <1%) and is more consistent with the partial deficiency seen in **vWD**, especially during stress or pregnancy where levels fluctuate. *Hemophilia A* - This is an X-linked recessive disorder characterized by a severe, primary deficiency of **Factor VIII clotting activity**; patients usually have levels significantly lower than 50% (commonly <5%). - Clinical presentation involves **deep tissue bleeding**, hemarthroses, and a prolonged **activated partial thromboplastin time (aPTT)** that does *not* correct with mixing studies, unlike vWD. *Glanzmann thrombasthenia* - This is a rare quantitative or qualitative defect of the **GPIIb/IIIa receptor** on the surface of platelets, which affects platelet aggregation. - Factor VIII levels are typically **normal** in this condition, as it is a pathology of primary hemostasis (platelet function) rather than secondary hemostasis (clotting factors). *Bernard–Soulier syndrome* - This condition is caused by a deficiency or dysfunction of the **GPIb/IX/V receptor** (von Willebrand factor receptor) on platelets, leading to impaired platelet adhesion. - Similar to Glanzmann thrombasthenia, this is a disorder of **platelet function**, and patients typically maintain **normal coagulation factor levels**, including Factor VIII.

Question 1

A chronic alcohol abuser is brought to hospital with complains of chronic liver diease. Which of the following you will add in the treatment?

Accepted Answer

Vitamin B1

Answer

Vitamin A

Answer

Vitamin C

Answer

Vitamin D

Question 2

A trekker at high altitude develops ataxia and confusion, followed by pulmonary edema. What is the most appropriate management?

Accepted Answer

Rapid descent

Answer

Spironolactone

Answer

Steroids

Answer

Acetazolamide

Question 3

Patient has slurred sleech, keeps speaking alot but speaks meaningless words. Lesion is in superior temporal gyrus. Which area is involved?

Accepted Answer

Wernicke's area

Answer

Broca's area

Answer

Arcuate fasciculus

Answer

Angular gyrus

Question 4

A 45-year-old male with severe postoperative pain is administered morphine 5 mg intravenously. You are monitoring him for opioid toxicity. Based on which of the following findings would you make the diagnosis of opioid overdose?

Accepted Answer

Bradypnea

Answer

Tachycardia

Answer

Constriction of pupil

Answer

Dilation of pupil

Question 5

A 52-year-old diabetic patient with poorly controlled blood glucose presents with facial pain, nasal blockage, and a black necrotic lesion over the nasal turbinate (black sinus) along with fever. Imaging shows involvement of the maxillary sinus. What is the most appropriate management?

Accepted Answer

Surgical debridement with antifungal therapy

Answer

Surgical debridement only

Answer

Surgical debridement with antibiotics

Answer

Antibiotics only

Question 6

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 7

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 8

A patient with HIV infection who is also on immunosuppressive therapy presents with dry cough, progressive weight loss, and generalized weakness. What is the most likely diagnosis?

Accepted Answer

Pneumocystis jirovecii

Answer

Histoplasma capsulatum

Answer

Candida albicans

Answer

Mycobacterium tuberculosis

Question 9

Foreigner with rice water stool

Accepted Answer

Cholera toxin

Answer

Shigella toxin

Answer

Heat labile E.Coli

Answer

Rotavirus

Question 10

Factor VIII level of 50% in a patient with bleeding disorder is most suggestive of?

Accepted Answer

Von Willebrand disease

Answer

Hemophilia A

Answer

Glanzmann thrombasthenia

Answer

Bernard–Soulier syndrome

FMGE 2026 — Internal Medicine