FMGE 2023 - Internal Medicine Practice Questions

Q: A 65-year-old male presented with unexplained fever and prolonged respiratory distress despite appropriate treatment. A diagnosis of cryptic tuberculosis was made. Which of the following is the correct statement related to this condition?

Negative skin tuberculin test and negative chest X-ray. ***Negative skin tuberculin test and negative chest X-ray***- **Cryptic tuberculosis (TB)**, or occult TB, often presents with non-specific systemic symptoms (like prolonged unexplained fever) without typical clinical or radiological signs expected in classic TB [1].- In older patients or those with disseminated disease, the immune response is often diminished, leading to a false negative result (anergy) on the **tuberculin skin test (TST)**, alongside a frequently normal chest X-ray (CXR) [1]. *Positive skin tuberculin test and negative chest X-ray*- A **positive TST** indicates prior exposure to *M. tuberculosis* but doesn't necessarily confirm active, symptomatic disease like cryptic TB. - Although the CXR is negative (consistent with cryptic TB), the positive TST contradicts the common finding of **anergy** seen in severely ill or elderly patients with cryptic disease. *Positive skin tuberculin test and positive chest X-ray*- This combination is characteristic of typical, **active pulmonary tuberculosis**, where the disease is localized and clinically/radiologically apparent. - By definition, cryptic TB lacks the **classic radiological findings** on chest X-ray, making this option incorrect. *Negative skin tuberculin test and positive chest X-ray*- While a **negative TST** can occur in active TB due to anergy or immunosuppression, a **positive CXR** strongly indicates radiologically apparent TB. - If the TB is radiologically apparent, the designation "cryptic" (meaning hidden or obscure) is inappropriate.

Q: Which of the following is not a component of Child-Pugh scoring?

LFT. ***LFT (Correct Answer)*** - **LFT (Liver Function Tests)** is a general term encompassing various biochemical tests such as AST, ALT, ALP, and GGT [1], [2] - These specific liver enzymes are **not components** of the Child-Pugh scoring system - The Child-Pugh score specifically uses only **5 parameters**: Albumin, Bilirubin, Prothrombin Time/INR, Ascites, and Hepatic Encephalopathy - These five components assess both **synthetic function** (albumin, PT/INR) and **clinical manifestations** (ascites, encephalopathy) of chronic liver disease [3] *Albumin (Incorrect)* - Serum **albumin** is one of the five specific components of the Child-Pugh score - It reflects the liver's **synthetic function** capacity - Scoring: >3.5 g/dL (1 point), 2.8-3.5 g/dL (2 points), 3 mg/dL (3 points) - Elevated bilirubin indicates impaired hepatic clearance and correlates with severity of liver disease *Prothrombin Time (Incorrect)* - **Prothrombin Time (PT)** or **INR** measures the liver's ability to synthesize clotting factors [3] - It is a critical component reflecting hepatic **synthetic function** - Scoring: 6 sec or INR >2.3 (3 points) [4] - Prolonged PT/elevated INR indicates severely impaired synthesis of vitamin K-dependent clotting factors [3]

Q: A patient presented with a fever for 11 days with neck rigidity. A lumbar puncture was done, and it showed predominantly lymphocytes, sugar- 50mg, and protein- 3000mg/dl. Gram-staining was negative. The patient's chest X-ray shows upper lobe involvement with hilar lymph node enlargement. What is the probable diagnosis?

Tuberculous meningitis. ***Tuberculous meningitis***- The CSF analysis combines **lymphocytic predominance** (suggesting non-pyogenic cause), subacute onset (11 days of fever), and critically high protein (3000 mg/dL), which are hallmarks of TBM [1]. - The chest X-ray findings of **upper lobe involvement** and **hilar lymph node enlargement** confirm active systemic tuberculosis, providing the strongest evidence for TBM as the underlying cause of meningitis [4].*Bacterial meningitis*- Typically presents acutely (hours to a few days) and CSF analysis shows a predominance of **neutrophils** (neutrophilic pleocytosis) [3].- Although CSF protein is high and glucose is low, the presence of lymphocytes and a negative Gram stain makes typical pyogenic bacterial meningitis less likely [3].*Fungal meningitis*- Fungal infections like **Cryptococcosis** can cause lymphocytic pleocytosis and elevated protein, but the protein level (3000 mg/dL) is excessively high, even for fungal causes.- While systemic involvement can occur, the specific pulmonary findings (upper lobe infiltrates, hilar nodes) are classic diagnostic features of **Mycobacterium tuberculosis**.*Viral meningitis*- Viral meningitis typically causes an acute, self-limiting illness and is generally associated with relatively low protein levels (usually <100 mg/dL) and normal CSF glucose [2].- The protein level of 3000 mg/dL in this patient is incompatible with a typical viral etiology, which mostly resolves spontaneously [2].

Q: A 26-year-old male with a history of respiratory tract infection 4 weeks ago is unable to stand or walk for the past 2 weeks and the weakness is progressive, ascending, and symmetrical in nature. The lower limbs were involved before and gradually the upper limbs were also affected. On examination you note areflexia. Pain and proprioception are preserved. What is the probable diagnosis?

Guillain Barre syndrome. ***Guillain Barre syndrome*** - **Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)** - most common GBS variant [1] - Classic presentation: **progressive, ascending, symmetrical weakness** starting in lower limbs [1] - **Areflexia** is a hallmark feature due to peripheral nerve involvement [1] - **Preceding infection** (respiratory or gastrointestinal) occurs in 60-70% of cases, typically 1-4 weeks prior [1] - **Preserved sensory examination** for pain and proprioception (though may have paresthesias) [1] - **Motor weakness predominates** over sensory symptoms [1] - Diagnosis confirmed by: CSF showing albuminocytologic dissociation, nerve conduction studies showing demyelination - Treatment: **IV immunoglobulin (IVIG)** or **plasmapheresis** *Myasthenia gravis* - Presents with **fatigable weakness**, worsens with activity - **Ocular and bulbar muscles** typically affected first (ptosis, diplopia, dysphagia) - **Reflexes are preserved** (not areflexia) - No ascending pattern of weakness - Positive acetylcholine receptor antibodies, abnormal repetitive nerve stimulation *Polymyositis* - **Proximal muscle weakness** (shoulder and hip girdle), not ascending pattern - **Subacute onset** over weeks to months (not acute 2 weeks) - **Elevated creatine kinase (CK)** levels - Reflexes typically preserved initially - Muscle biopsy shows inflammatory infiltrates *Multiple sclerosis* - **Relapsing-remitting pattern** with episodes separated in time and space - **Sensory symptoms prominent** (numbness, tingling, vision changes) - **Hyperreflexia** with upper motor neuron signs (not areflexia) - Does not present with acute ascending paralysis - MRI shows demyelinating plaques in CNS

Q: An HIV-positive man presents with a high-grade fever. Examination reveals a positive Kernig's sign. CSF shows reduced glucose, increased protein, and increased leukocytes. A diagnosis of cryptococcal meningitis is made. What is the appropriate management for this patient?

Liposomal amphotericin B. ***Liposomal amphotericin B***- **Liposomal amphotericin B** (often combined with **flucytosine**) is the standard of care for the **induction phase** (first 2 weeks) of severe cryptococcal meningitis treatment in HIV-positive patients due to its potent fungicidal activity [1].- The severity of the presentation (high fever, positive **Kernig's sign**, and abnormal CSF findings) necessitates this regimen to rapidly reduce the fungal burden in the central nervous system.*Vancomycin*- **Vancomycin** is an antibiotic used specifically to treat severe infections caused by **Gram-positive bacteria**, notably **MRSA**.- This drug has absolutely no therapeutic efficacy against the fungal pathogen *Cryptococcus neoformans*.*High dose fluconazole with flucytosine*- While fluconazole is an effective antifungal against *Cryptococcus*, this regimen is typically reserved for the **consolidation phase** (post-induction) or for milder disease.- Severe meningitis, indicated by the clinical signs and CSF profile, requires the superior fungicidal activity of **amphotericin B** during the induction phase [1].*Voriconazole*- **Voriconazole** is a broad-spectrum triazole mainly used for treating invasive **Aspergillus** and some *Candida* infections [1], [2].- It has **limited efficacy** against *Cryptococcus neoformans* and is not recommended as primary induction therapy for cryptococcal meningitis.

Q: A chronic alcoholic presents to the emergency room with acute abdominal pain in the epigastric region radiating to the back with nausea, anorexia, and occasional vomiting. Investigations showed elevated amylase levels and total count. Likely diagnosis is

b.Acute pancreatitis. ***Acute pancreatitis*** (Keep the correct option at the top and the incorrect options in the order they are provided in the input) - The clinical presentation of severe **epigastric pain radiating to the back**, associated with nausea and vomiting, is classic for **acute pancreatitis** [1]. - **Alcohol abuse** is a major risk factor, and the diagnosis is supported by findings of significantly elevated serum **amylase and/or lipase** levels [1]. *Acute hepatitis* - Typically presents with **jaundice**, fatigue, dark urine, and right upper quadrant discomfort, not the referred back pain seen here. - Key laboratory findings would include severely elevated **liver transaminases (AST/ALT)**, not primarily amylase. *Acute Cholecystitis* - Characterized by acute pain in the **right upper quadrant** or epigastrium, often radiating to the **right shoulder or scapula**, not the back [2]. - This condition is usually associated with gallstones and is diagnosed via imaging showing gallbladder wall thickening and pericholecystic fluid, though amylase can be mildly elevated secondarily. *Acute appendicitis* - Presents typically with periumbilical pain that migrates to the **right lower quadrant (RLQ)**, often associated with low-grade fever and localized tenderness. - The pain is not classically described as severe epigastric pain radiating to the back, and initial lab markers include leukocytosis but not specific elevation of amylase.

Q: A patient is diagnosed with acromegaly. Transsphenoidal surgery is not feasible. Which of the following drugs is preferred for the medical management of this patient?

Lanreotide depot formulation. ***Lanreotide depot formulation***- It is a **somatostatin analog** (SSA) and a first-line medical therapy for acromegaly, particularly when surgery fails or is contraindicated [1].- SSAs normalize **GH (Growth Hormone)** and **IGF-1 (Insulin-like Growth Factor-1)** levels by inhibiting pituitary GH secretion [1].*Terlipressin*- It is primarily an analog of **vasopressin** used to treat **esophageal variceal bleeding** and hepatorenal syndrome.- It has no role in reducing pituitary growth hormone hypersecretion characteristic of acromegaly.*Ketoconazole*- It is an **antifungal agent** that also inhibits **steroidogenesis** (glucocorticoids, androgens).- Its primary hormonal use is in treating **Cushing's syndrome** (due to cortisol inhibition), not acromegaly.*Leuprolide*- This is a **GnRH agonist** used primarily to treat conditions like **prostate cancer**, **endometriosis**, and **precocious puberty**.- It acts on the hypothalamic-pituitary-gonadal axis and does not directly target GH-secreting tumors.

Q: A patient presents with complaints of sudden onset headache, palpitation, and profuse sweating. The patient has had multiple similar episodes in the past. During these episodes, the patient's blood pressure is elevated. A 24-hour urinary metanephrine is elevated. What is the most likely diagnosis?

Pheochromocytoma. ***Pheochromocytoma***- This clinical presentation—paroxysmal episodes of headache, palpitations, and profuse sweating (the classic triad)—coupled with elevated blood pressure strongly suggests a **pheochromocytoma** (a tumor of the adrenal medulla secreting catecholamines). - The definitive biochemical confirmation is the elevated 24-hour urinary **metanephrines** and normetanephrines, which are breakdown products of epinephrine and norepinephrine. *Addison's disease* - This condition involves primary adrenal *insufficiency* (hypocortisolism), which typically presents with **hypotension**, fatigue, weight loss, and **hyperpigmentation**, not hypertensive crises. - It involves decreased production of adrenal hormones, not the episodic overproduction of **catecholamines** seen here. *Renal artery stenosis* - This is a cause of secondary hypertension due to chronic activation of the **Renin-Angiotensin-Aldosterone System (RAAS)**, leading to persistent, non-paroxysmal elevation of blood pressure. - It would not cause the specific triad of episodic symptoms (headache, sweating, palpitations) or lead to elevated **urinary metanephrines**. *Hyperthyroidism* - While it can cause palpitations, tremor, and systolic hypertension, these symptoms are typically chronic and sustained, lacking the sudden paroxysmal nature described. - The primary biochemical abnormality involves elevated **T3/T4 hormones**, not the excessive urinary excretion of **metanephrines** as detailed in this case.

Q: A 45-year-old patient with a history of smoking a pack of cigarettes for the past 15 years presents with hemoptysis. Chest X-ray shows a 3cm upper lobe mass near the apex of the lung. What is the next best step for managing this patient?

CT-guided biopsy. ***CT-guided biopsy***- This procedure is the preferred method for obtaining a definitive **tissue diagnosis** for a solitary **peripheral lung mass**, especially one highly suspicious of malignancy due to the patient's smoking history and hemoptysis [1].- Since the mass is **3cm** and located peripherally near the **apex**, a percutaneous **CT-guided transthoracic needle aspiration (TTNA)** provides the highest diagnostic yield compared to other non-invasive alternatives [2].*Bronchoscopy*- Bronchoscopy is primarily used to evaluate **central lesions** (proximal to segmental bronchi) or suspicious findings directly within the airway lumen.- It has a low diagnostic yield for discrete, small, or **peripheral masses** like this 3cm apical lesion, as the scope or biopsy instruments cannot reliably reach the target.*Sputum cytology*- Sputum cytology has low overall sensitivity, particularly for **peripheral lung masses** which are unlikely to shed sufficient malignant cells into the central airways.- While non-invasive, it often results in a non-diagnostic result and is therefore not the **next best step** for confirming the diagnosis of a discrete, radiographically apparent mass.*Sputum for AFB*- While an infectious process like tuberculosis (TB) can present as a mass, the patient's robust history of **heavy smoking** and the mass morphology strongly prioritize ruling out **lung carcinoma**.- Obtaining a tissue sample (biopsy) is mandatory due to the high suspicion of malignancy (indicated by hemoptysis and smoking) and takes precedence over attempting an infectious diagnosis first [3].

Q: Which of the following is seen in all kinds of shock?

Reduced tissue perfusion. ***Reduced tissue perfusion*** - **Shock** is fundamentally defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery, which results from inadequate or ineffective **tissue perfusion** [1]. - In all forms (hypovolemic, cardiogenic, distributive, and obstructive), the core pathophysiological defect is the inability to meet the metabolic demands of the tissues, hence **reduced tissue perfusion** is a universal finding [1], [2]. *Increased peripheral resistance*- This finding is characteristic of **compensatory shock** (e.g., early hypovolemic or cardiogenic) as part of the sympathetic response to maintain mean arterial pressure. - It is *not* seen in **distributive shock** (like septic or anaphylactic shock), which is characterized by profound **vasodilation** and thus marked *decreased* peripheral resistance [2]. *Decreased respiratory rate*- A decreased respiratory rate is *not* characteristic of shock; rather, **metabolic acidosis** (due to anaerobic metabolism) typically stimulates the respiratory center, leading to **compensatory tachypnea** (increased rate). - A decreased respiratory rate might only be seen if shock is severe and complicated by **CNS depression** from drugs or profound decompensation. *Cold clammy skin*- **Cold, clammy skin** is the classic presentation of **hypoperfusion** combined with sympathetic-driven peripheral **vasoconstriction**, typically seen in *hypovolemic* and *cardiogenic* shock. - In contrast, **distributive shock** (especially **septic shock**) presents with **warm, flushed skin** due to widespread peripheral vasodilation and increased cardiac output (hyperdynamic state).

Question 1

A 65-year-old male presented with unexplained fever and prolonged respiratory distress despite appropriate treatment. A diagnosis of cryptic tuberculosis was made. Which of the following is the correct statement related to this condition?

Accepted Answer

Negative skin tuberculin test and negative chest X-ray

Answer

Positive skin tuberculin test and negative chest X-ray

Answer

Positive skin tuberculin test and positive chest X-ray

Answer

Negative skin tuberculin test and positive chest X-ray

Question 2

Which of the following is not a component of Child-Pugh scoring?

Accepted Answer

LFT

Answer

Albumin

Answer

Bilirubin

Answer

Prothrombin Time

Question 3

A patient presented with a fever for 11 days with neck rigidity. A lumbar puncture was done, and it showed predominantly lymphocytes, sugar- 50mg, and protein- 3000mg/dl. Gram-staining was negative. The patient's chest X-ray shows upper lobe involvement with hilar lymph node enlargement. What is the probable diagnosis?

Accepted Answer

Tuberculous meningitis

Answer

Bacterial meningitis

Answer

Fungal meningitis

Answer

Viral meningitis

Question 4

A 26-year-old male with a history of respiratory tract infection 4 weeks ago is unable to stand or walk for the past 2 weeks and the weakness is progressive, ascending, and symmetrical in nature. The lower limbs were involved before and gradually the upper limbs were also affected. On examination you note areflexia. Pain and proprioception are preserved. What is the probable diagnosis?

Accepted Answer

Guillain Barre syndrome

Answer

Myasthenia gravis

Answer

Polymyositis

Answer

Multiple sclerosis

Question 5

An HIV-positive man presents with a high-grade fever. Examination reveals a positive Kernig's sign. CSF shows reduced glucose, increased protein, and increased leukocytes. A diagnosis of cryptococcal meningitis is made. What is the appropriate management for this patient?

Accepted Answer

Liposomal amphotericin B

Answer

High dose fluconazole with flucytosine

Answer

Voriconazole

Answer

Vancomycin

Question 6

A chronic alcoholic presents to the emergency room with acute abdominal pain in the epigastric region radiating to the back with nausea, anorexia, and occasional vomiting. Investigations showed elevated amylase levels and total count. Likely diagnosis is

Accepted Answer

b.Acute pancreatitis

Answer

a.Acute hepatitis

Answer

d.Acute appendicitis

Answer

c.Acute Cholecystitis

Question 7

A patient is diagnosed with acromegaly. Transsphenoidal surgery is not feasible. Which of the following drugs is preferred for the medical management of this patient?

Accepted Answer

Lanreotide depot formulation

Answer

Terlipressin

Answer

Ketoconazole

Answer

Leuprolide

Question 8

A patient presents with complaints of sudden onset headache, palpitation, and profuse sweating. The patient has had multiple similar episodes in the past. During these episodes, the patient's blood pressure is elevated. A 24-hour urinary metanephrine is elevated. What is the most likely diagnosis?

Accepted Answer

Pheochromocytoma

Answer

Renal artery stenosis

Answer

Hyperthyroidism

Answer

Addison's disease

Question 9

A 45-year-old patient with a history of smoking a pack of cigarettes for the past 15 years presents with hemoptysis. Chest X-ray shows a 3cm upper lobe mass near the apex of the lung. What is the next best step for managing this patient?

Accepted Answer

CT-guided biopsy

Answer

Bronchoscopy

Answer

Sputum cytology

Answer

Sputum for AFB

Question 10

Which of the following is seen in all kinds of shock?

Accepted Answer

Reduced tissue perfusion

Answer

Increased peripheral resistance

Answer

Cold clammy skin

Answer

Decreased respiratory rate

FMGE 2023 — Internal Medicine