FMGE 2026 Practice Questions

Q: A 48-year-old woman with a 10-year history of rheumatoid arthritis (anti-CCP positive) presents with a rapidly progressive, extremely painful ulcer over the anterior aspect of the shin. The lesion began as a pustule and progressed to a deep ulcer with anecrotic black eschar and violaceous undermined margins. There is no history of trauma or diabetes. What is the most likely diagnosis?

Pyoderma gangrenosum. ***Pyoderma gangrenosum*** - The presence of a rapidly progressive, painful ulcer with **violaceous, undermined, and irregular margins** is the classic presentation of this condition. - It is strongly associated with underlying systemic inflammatory disorders, particularly **rheumatoid arthritis** and **inflammatory bowel disease**. *Cutaneous TB* - This usually presents as a slow-growing plaque or nodule, often manifesting as **lupus vulgaris** or **scrofuloderma**, rather than a rapid, necrotizing ulcer. - Diagnosis typically requires biopsy showing **caseating granulomas** and demonstration of mycobacteria, which is inconsistent with this acute clinical picture. *Ecthmya gangrenosum* - Primarily caused by **Pseudomonas aeruginosa** sepsis, typically affecting immunocompromised patients, and lacks the strong association with RA. - The lesions usually start as erythematous macules that evolve into bullae and then ulcers with a **central black eschar**, but are typically linked to systemic bacterial infection rather than chronic autoimmune disease. *Necrotising fasciitis* - A life-threatening surgical emergency characterized by **crepitus**, rapid spread along fascial planes, and systemic signs of **sepsis**. - It does not typically present as a localized, chronic-associated ulcer with distinctively **undermined borders** in an ambulatory patient.

Q: A 35-year-old man presents with headache and neck stiffness for 5 days. Lumbar puncture reveals the following CSF findings: 90% lymphocytes and 10% neutrophils with CSF glucose: 40 mg/dL (Plasma glucose: 100mg/dL), protein is 1 gm/dl. What is the most likely diagnosis?

Tubercular meningitis. ***Tubercular meningitis*** - The CSF profile shows **lymphocytic pleocytosis** with a **low glucose** (CSF:Blood glucose ratio < 0.5) and **markedly elevated protein**, which is the hallmark of **tuberculous meningitis**. - The clinical course of typically **subacute onset** (lasting days to weeks) and the specific CSF findings of **hypoglycorrachia** (low glucose) are classic indicators for this diagnosis. *Viral meningitis* - While CSF lymphocytosis is common, viral meningitis typically presents with **normal CSF glucose** levels. - Protein levels are usually **normal or only mildly elevated**, unlike the significant elevation seen in this patient. *Bacterial meningitis* - Characterized by a **neutrophilic pleocytosis** rather than lymphocytic, and usually presents with a much more **acute, fulminant onset**. - CSF glucose is typically very low, but the cell count composition in bacterial cases is predominantly **PMNs (polymorphonuclear leukocytes)**. *Fungal meningitis* - Fungal meningitis is less common in immunocompetent individuals and usually follows a very prolonged, chronic course often associated with **basal meningeal enhancement**. - While it can manifest similarly to tubercular meningitis, the epidemiologic context and the **specific clinical presentation** make tuberculosis a statistically more probable diagnosis in this scenario.

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 child presents with fever, conjunctival redness, and bluish -white spots on the buccal mucosa. What is the most likely diagnosis?

Measles. ***Measles*** - The presence of **Koplik spots** (bluish-white spots on the buccal mucosa) is a pathognomonic feature of **measles** (rubeola) infection. - The clinical triad of **cough, coryza, and conjunctivitis** (the 3 Cs) alongside high fever strongly supports this diagnosis. *Mumps* - Primarily presents with **parotitis** (swelling and tenderness of the parotid glands), not conjunctival redness or specific buccal spots. - It is caused by the **mumps virus**, which typically involves glandular structures like salivary glands, testes, or ovaries. *Chickenpox* - Characterized by a **vesicular rash** that appears in different stages (macules, papules, vesicles, crusts) simultaneously. - The hallmark is a **pruritic rash** that starts centrally and spreads peripherally, distinguishable from the morbilliform rash of measles. *Rubella* - Also known as German measles, it typically features a **fine, pink maculopapular rash** and marked **lymphadenopathy** (especially postauricular and suboccipital). - While it presents with fever, it lacks the classic **Koplik spots** seen in true measles and is generally a milder, shorter-lived illness.

Q: Due to persistence of the Moro reflex, a child will have difficulty achieving which of the following developmental milestones?

Rolling over. ***Rolling over*** - The persistent **Moro reflex** causes involuntary abduction and extension of the arms, which interferes with the integration of motor patterns required for independent **rolling over**. - Typically, the Moro reflex integrates (disappears) by **3 to 4 months** of age, which coincides closely with the timing of when an infant should be mastering the skill of rolling. *Neck holding* - **Neck holding** (or head control) is typically achieved by **2 to 3 months** of age, which overlaps with the later stages of the Moro reflex persistence. - Because the Moro reflex is triggered by a sudden change in head position or support, it primarily affects limb movement rather than the primary strengthening of the neck muscles required for head control. *Sitting with support* - **Sitting with support** is generally achieved around **5 to 6 months** of age, well after the Moro reflex should have integrated. - Persistence of the reflex at this age would indicate a severe **neurological disorder** rather than just a simple delay in motor development. *Sitting without support* - **Sitting without support** is a later developmental milestone, typically reached by **7 to 8 months** of age. - By this stage, the Moro reflex should have long since disappeared; if present, it is pathognomonic for **cerebral palsy** or other significant brain injury, not merely a hurdle for this specific milestone.

Q: A newborn has blue skin, heart rate less than 80/min, absent reflexes, and irregular respiration. What is the Apgar score?

2. ***2*** - The score is calculated as follows: Appearance (blue color) = 0, Pulse (<100 bpm) = 1, Grimace (no response) = 0, Activity (limp) = 0, and Respiration (irregular/slow) = 1, totaling **2**. - An Apgar score of 2 indicates that the newborn is experiencing **severe depression** and requires immediate **resuscitative measures**. *1* - A score of 1 would imply even more severe compromise, likely with an absent heart rate or complete apnea. - Scoring systems are strictly additive based on the **five categories** of Appearance, Pulse, Grimace, Activity, and Respiration. *4* - A score of 4 would require better scores, such as some **flexion of extremities** and a stronger heart rate. - Infants with a score of 4 are typically considered to have **moderate depression** compared to this case. *5* - A score of 5 suggests that the neonate is breathing regularly or has a higher heart rate and better muscle tone. - Five is within the range that might improve with **tactile stimulation** and routine care, unlike score 2 cases needing active resuscitation.

Q: A preterm infant presents with respiratory distress soon after birth. The chest X -ray is given below. What is the most likely diagnosis?

Hyaline membrane disease. ***Hyaline membrane disease*** - Also known as **Respiratory Distress Syndrome (RDS)**, it is primarily caused by **surfactant deficiency** in premature infants, leading to alveolar collapse. - The characteristic chest X-ray findings include **diffuse reticulogranular opacities** (ground-glass appearance) and **air bronchograms**. *Transient tachypnea of the newborn* - Typically occurs in **late preterm or term infants** due to delayed resorption of fetal lung fluid. - Chest X-ray typically shows **perihilar streaking** and **fluid in the interlobar fissures** rather than the diffuse opacification seen in RDS. *Pneumothorax* - Presents with a sudden, localized **collapse of the lung**, often visible on X-ray as a **hyperlucent area** devoid of lung markings. - The clinical picture involves sudden clinical deterioration, decreased unilateral breath sounds, and shifted mediastinum, distinct from the global lung disease of RDS. *Diaphragmatic hernia* - A congenital defect where abdominal viscera herniate into the thoracic cavity, typically presenting with a **scaphoid abdomen** and **loops of bowel** seen within the chest on X-ray. - This condition causes severe respiratory distress due to **pulmonary hypoplasia** and mechanical compression of the lung, unrelated to surfactant deficiency.

Question 1

A 48-year-old woman with a 10-year history of rheumatoid arthritis (anti-CCP positive) presents with a rapidly progressive, extremely painful ulcer over the anterior aspect of the shin. The lesion began as a pustule and progressed to a deep ulcer with anecrotic black eschar and violaceous undermined margins. There is no history of trauma or diabetes. What is the most likely diagnosis?

Accepted Answer

Pyoderma gangrenosum

Answer

Cutaneous TB

Answer

Ecthmya gangrenosum

Answer

Necrotising fasciitis

Question 2

A 35-year-old man presents with headache and neck stiffness for 5 days. Lumbar puncture reveals the following CSF findings: 90% lymphocytes and 10% neutrophils with CSF glucose: 40 mg/dL (Plasma glucose: 100mg/dL), protein is 1 gm/dl. What is the most likely diagnosis?

Accepted Answer

Tubercular meningitis

Answer

Viral meningitis

Answer

Bacterial meningitis

Answer

Fungal meningitis

Question 3

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 4

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 5

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 6

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 7

A child presents with fever, conjunctival redness, and bluish -white spots on the buccal mucosa. What is the most likely diagnosis?

Accepted Answer

Measles

Answer

Mumps

Answer

Chickenpox

Answer

Rubella

Question 8

Due to persistence of the Moro reflex, a child will have difficulty achieving which of the following developmental milestones?

Accepted Answer

Rolling over

Answer

Neck holding

Answer

Sitting with support

Answer

Sitting without support

Question 9

A newborn has blue skin, heart rate less than 80/min, absent reflexes, and irregular respiration. What is the Apgar score?

Accepted Answer

2

Answer

1

Answer

4

Answer

5

Question 10

A preterm infant presents with respiratory distress soon after birth. The chest X -ray is given below. What is the most likely diagnosis?

Accepted Answer

Hyaline membrane disease

Answer

Transient tachypnea of the newborn

Answer

Pneumothorax

Answer

Diaphragmatic hernia

FMGE 2026

Dermatology

Internal Medicine

Pediatrics