UPSC-CMS 2025 - Internal Medicine Practice Questions

Q: What are the components to establish the diagnosis of Brain Death? I. Absent brain stem reflexes II. Apnoea in presence of elevated PCO_2 III. Hypothermia IV. Irreversible and unresponsive coma Select the correct answer using the code given below :

I, II and IV. ***I, II and IV*** - The diagnosis of **brain death** requires the demonstration of a complete and irreversible cessation of all brain and brainstem functions [2]. This includes **absent brainstem reflexes**, as the brainstem controls vital functions like breathing, pupil constriction, and gag reflex [3], [4]. - The **apnea test**, which involves demonstrating apnea in the presence of elevated PaCO2 (typically >60 mmHg or 20 mmHg above baseline), confirms irreversible loss of respiratory drive, a key brainstem function [4]. An **irreversible and unresponsive coma** signifies the complete loss of consciousness and cortical function [1]. *II and IV only* - This option is incomplete as it omits **absent brainstem reflexes**, which are crucial for the diagnosis of brain death and signify the loss of essential brainstem functions [3]. - While **apnea in the presence of elevated PaCO2** and **irreversible and unresponsive coma** are components, the absence of brainstem reflexes must also be confirmed [4]. *I, II and III* - This option incorrectly includes **hypothermia** as a diagnostic criterion for brain death. Hypothermia (<36°C) can mimic brain death by causing a reversible coma and suppressed brainstem reflexes, and thus must be excluded or corrected before brain death assessment [3]. - The diagnosis of brain death requires excluding conditions that can confound the clinical assessment, such as hypothermia or presence of central nervous system depressant drugs [3], [4]. *I, III and IV* - This option incorrectly includes **hypothermia** as a diagnostic criterion for brain death, which is a confounding factor that must be corrected before assessment [3]. - While **absent brainstem reflexes** and an **irreversible, unresponsive coma** are essential, the critical component of **apnea in the presence of elevated PaCO2** is missing, which is necessary to confirm the irreversible loss of respiratory drive [4].

Q: The most common cause for nontraumatic sub-arachnoid haemorrhage is

Saccular aneurysm rupture. ***Saccular aneurysm rupture*** - **Saccular (berry) aneurysms** are the most common cause of non-traumatic subarachnoid hemorrhage (SAH), accounting for about 85% of cases [1]. - Rupture of these aneurysms, often located at arterial bifurcations in the **Circle of Willis**, leads to sudden bleeding into the subarachnoid space [1]. *A-V malformation* - **Arteriovenous malformations (AVMs)** are a less common cause of non-traumatic SAH compared to saccular aneurysms. - While AVM rupture can cause SAH, it is typically responsible for a smaller percentage of cases. *Extension from primary intracerebral haemorrhage* - While an **intracerebral hemorrhage** can extend into the subarachnoid space, causing secondary SAH, this is not considered the primary or most common cause of non-traumatic SAH itself [2]. - The initial event for most SAH cases directly involves subarachnoid bleeding, not delayed extension from within the brain parenchyma. *Idiopathic* - An **idiopathic** diagnosis means the cause is unknown, which is only assigned after all known causes, such as aneurysm rupture or AVM, have been ruled out. - Given the high prevalence of saccular aneurysm rupture as a cause, true idiopathic SAH is relatively rare.

Q: Peri-operative respiratory failure is an example of

Type III respiratory failure. ***Type III respiratory failure*** - This is often termed **peri-operative respiratory failure**, characterized by **atelectasis**, **reduced functional residual capacity**, and abnormal gas exchange post-surgery. - It results from the effects of anesthesia, surgery, and pain on respiratory mechanics, leading to **poor lung expansion** and hypoxemia. *Type II respiratory failure* - Characterized by **hypercapnia (high PCO2)** and **hypoxemia (low PO2)**, indicating inadequate alveolar ventilation. - Common causes include conditions like **COPD exacerbations** or **neuromuscular disorders** impacting the respiratory pump. *Type I respiratory failure* - Defined by **hypoxemia (low PO2)** with normal or low PCO2, indicating a primary problem with oxygenation. - Examples include **pulmonary edema** or **pneumonia**, where gas exchange is impaired at the alveolar-capillary membrane. *Type IV respiratory failure* - This categorization refers to **shock-related respiratory failure**, where inadequate oxygen delivery to respiratory muscles leads to their failure. - It is typically seen in states of **severe circulatory collapse**, such as septic or cardiogenic shock, and is not directly related to the peri-operative period in the way Type III is.

Q: The murmur of mitral regurgitation is best heard at

Cardiac apex. ***Cardiac apex*** - The **mitral valve** is located at the cardiac apex, and the murmur of **mitral regurgitation** is typically loudest at this point [1]. - Mitral regurgitation creates a **holosystolic murmur** that radiates to the axilla [1]. *Tricuspid area* - This area is located at the **lower left sternal border** and is where murmurs originating from the **tricuspid valve** are best heard, such as tricuspid regurgitation [2]. - Murmurs heard here are not characteristic of mitral valve dysfunction. *Aortic area* - The aortic area is at the **right upper sternal border**, primarily for auscultation of the **aortic valve**. - Conditions like **aortic stenosis** or **aortic regurgitation** are best heard here [3]. *Pulmonary area* - This area is located at the **left upper sternal border** and is where murmurs related to the **pulmonic valve** are best heard. - Examples include **pulmonic stenosis** or **pulmonic regurgitation**.

Q: A 28 year female presented to emergency with fever, agitation and delirium. She was on regular medication of Carbimazole 40 mg daily, but missed her doses for the last 2 days. Which of the following scoring systems would you like to do to assess severity of disease?

Burch-Wartofsky score. ***Burch-Wartofsky score*** - The patient's symptoms of **fever, agitation, and delirium** following missed carbimazole doses are highly suggestive of **thyroid storm** [1]. - The **Burch-Wartofsky score** is specifically designed to assess the **likelihood and severity of thyroid storm**, evaluating symptoms related to thermoregulation, central nervous system, gastrointestinal/hepatic dysfunction, cardiovascular dysfunction, and precipitating factors. *Sequential Organ Failure Assessment Score* - The **SOFA score** is used to track the progression of organ dysfunction and predict mortality in critically ill patients, often in the context of **sepsis or general critical illness**. - While thyroid storm can lead to multi-organ dysfunction, the SOFA score does not specifically diagnose or assess the severity of **thyroid storm** itself. *DAS 28 score* - The **DAS28 (Disease Activity Score 28)** is a validated tool for measuring disease activity in patients with **rheumatoid arthritis**. - It assesses joint count, patient global assessment, and inflammatory markers, which are irrelevant to the clinical picture of **fever and delirium**. *Expanded Disability Status Scale* - The **Expanded Disability Status Scale (EDSS)** is a method of quantifying disability in **multiple sclerosis**. - It evaluates neurological function in various systems and is not applicable to an acute presentation of **fever, agitation, and delirium** [2].

Q: Out of the following areas of brain, which area is most commonly affected on brain imaging in Wilson's disease?

Basal ganglia. ***Basal ganglia*** - The **basal ganglia**, particularly the **putamen** and **globus pallidus**, are the most commonly affected brain regions due to their high susceptibility to **copper deposition** in Wilson's disease. - Imaging findings like **hyperintense lesions** on T2-weighted MRI in these areas are characteristic of neurodegeneration and edema caused by copper accumulation. *Thalamus* - While the **thalamus** can be affected in later stages of Wilson's disease, it is not typically the primary or most common site of involvement compared to the basal ganglia. - Thalamic lesions are usually seen in more advanced cases and may contribute to cognitive deficits and motor symptoms. *Sub-cortex* - The term **sub-cortex** refers to a broad region beneath the cerebral cortex, encompassing many structures, including the basal ganglia, thalamus, and white matter. - While structures within the sub-cortex are affected, "basal ganglia" is a more specific and accurate answer for the most commonly affected area. *Cerebellum* - **Cerebellar involvement** is less common than basal ganglia involvement in Wilson's disease, though it can occur in some patients. - When affected, it can lead to **ataxia** and coordination problems, but it is not the most consistently or severely damaged area.

Q: Which of the following are secondary iron overload conditions? I. Transfusion related iron load II. Thalassemia III. Hepatitis C associated liver disease Select the correct answer using the code given below :

I, II and III. ***I, II and III*** - All three listed conditions—**transfusion-related iron load**, **thalassemia**, and **Hepatitis C associated liver disease**—are well-recognized causes of secondary iron overload. - Secondary iron overload occurs due to external factors or underlying diseases that cause increased iron absorption or repeated administration of iron. [1] *I and II only* - This option is incomplete as **Hepatitis C associated liver disease** can also lead to secondary iron overload due to impaired iron metabolism and chronic inflammation. - It dismisses a known cause of secondary iron accumulation. *I and III only* - This option is incomplete because **thalassemia**, particularly **transfusion-dependent thalassemia**, is a classic example of secondary iron overload due to frequent blood transfusions and ineffective erythropoiesis. - It overlooks a major cause of transfusion-related iron accumulation. [1] *II and III only* - This option is incomplete as **transfusion-related iron load** is a direct and common cause of secondary iron overload, especially in patients requiring regular blood transfusions for conditions like anemia. [1] - It ignores the most direct mechanism of iron accumulation in many chronic diseases.

Q: Which of the following are features of Alzheimer's disease? I. It is a disorder of cerebral cortical function II. Only short term memory is affected III. Patients deny that there is anything wrong IV. Depression is commonly present Select the correct answer using the code given below :

I, III and IV. ***I, III and IV*** - Alzheimer's disease is indeed a **disorder of cerebral cortical function** [1], primarily affecting areas responsible for memory, language, and executive functions. - Patients often exhibit **anosognosia** (denial of illness), failing to recognize their cognitive deficits, and **depression** is a common comorbidity [2] that can complicate diagnosis and management. *II, III and IV* - This option incorrectly states that **only short-term memory is affected** in Alzheimer's disease; both short-term and long-term memory are progressively impaired [2]. - While denial of illness and depression are common, the underlying memory impairment is more global than just short-term memory [2]. *I, II and III* - This option incorrectly includes the statement that **only short-term memory is affected**, which is not characteristic of Alzheimer's disease. - Alzheimer's patients experience a decline in various cognitive domains, including **long-term memory** [2], language, and executive functions. *I, II and IV* - This option incorrectly includes the statement that **only short-term memory is affected**; Alzheimer's disease impacts both short-term and long-term memory [2]. - While cerebral cortical dysfunction and depression are relevant features, the denial of illness (anosognosia) is also a significant clinical presentation not included here.

Q: Which of the following are causes of reversible dementia? I. Hypothyroidism II. Vitamin B12 deficiency III. Dementia with lewy body IV. Thiamine deficiency Select the correct answer using the code given below :

I, II and IV. ***I, II and IV*** - **Hypothyroidism** can cause cognitive impairment, including memory loss and slowed thinking, which are often reversible with **thyroid hormone replacement**. - **Vitamin B12 deficiency** can lead to neurological symptoms such as memory problems and cognitive decline, which can improve significantly with **B12 supplementation** [1]. - **Thiamine deficiency**, particularly in the context of Wernicke-Korsakoff syndrome, can cause severe amnesia and cognitive deficits that may be partially or fully reversible with **thiamine repletion** [1], [2]. *II, III and IV* - This option incorrectly includes **Dementia with Lewy bodies (DLB)** as a reversible cause. DLB is a progressive and irreversible neurodegenerative disease. - While II and IV are correct, the inclusion of III makes this option incorrect. *I, III and IV* - This option incorrectly includes **Dementia with Lewy bodies (DLB)** as a reversible cause. DLB is a progressive neurodegenerative dementia. - Although I and IV are correct, the presence of III makes this an invalid choice. *I, II and III* - This option incorrectly includes **Dementia with Lewy bodies (DLB)** as a reversible cause. DLB is an **irreversible neurodegenerative disorder**. - While I and II are correct, the miscategorization of III leads to this option being incorrect.

Q: Which of the following are clinical features of Fronto-Temporal dementia ? I. Personality change II. Language disturbance III. Memory may be preserved in early stages IV. Anti-cholinesterases are the drug of choice for treatment Select the correct answer using the code given below :

I, II and III. ***Correct Answer: I, II and III*** - **Fronto-temporal dementia (FTD)** is characterized by prominent **personality and behavioral changes** (disinhibition, apathy, loss of empathy) and **language disturbances** (progressive non-fluent aphasia or semantic variant aphasia). - Unlike Alzheimer's disease, **memory is often relatively preserved in the early stages** of FTD, with executive function, behavior, and social cognition being more affected initially. - **Statement IV is incorrect**: Anti-cholinesterases (donepezil, rivastigmine, galantamine) are the treatment for Alzheimer's disease and are **generally ineffective or may even worsen behavioral symptoms in FTD**. There is no FDA-approved pharmacological treatment specifically for FTD; management focuses on behavioral interventions and symptomatic treatment. *Incorrect: II, III and IV* - This option incorrectly includes **Statement IV (anti-cholinesterases)** as a clinical feature or appropriate treatment. - Anti-cholinesterases are not the drug of choice for FTD and may exacerbate behavioral symptoms. *Incorrect: I, III and IV* - This option incorrectly includes **Statement IV (anti-cholinesterases)** while missing the important language disturbance feature. - Language disturbances are a core feature of FTD, particularly in the language-variant subtypes. *Incorrect: I, II and IV* - This option incorrectly includes **Statement IV (anti-cholinesterases)** while missing the fact that memory preservation in early stages is characteristic. - The preservation of memory early on is a key distinguishing feature between FTD and Alzheimer's disease.

Question 1

What are the components to establish the diagnosis of Brain Death?
I. Absent brain stem reflexes
II. Apnoea in presence of elevated PCO_2
III. Hypothermia
IV. Irreversible and unresponsive coma

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

II and IV only

Answer

I, II and III

Answer

I, III and IV

Question 2

The most common cause for nontraumatic sub-arachnoid haemorrhage is

Accepted Answer

Saccular aneurysm rupture

Answer

A-V malformation

Answer

Extension from primary intracerebral haemorrhage

Answer

Idiopathic

Question 3

Peri-operative respiratory failure is an example of

Accepted Answer

Type III respiratory failure

Answer

Type II respiratory failure

Answer

Type I respiratory failure

Answer

Type IV respiratory failure

Question 4

The murmur of mitral regurgitation is best heard at

Accepted Answer

Cardiac apex

Answer

Tricuspid area

Answer

Aortic area

Answer

Pulmonary area

Question 5

A 28 year female presented to emergency with fever, agitation and delirium. She was on regular medication of Carbimazole 40 mg daily, but missed her doses for the last 2 days. Which of the following scoring systems would you like to do to assess severity of disease?

Accepted Answer

Burch-Wartofsky score

Answer

Sequential Organ Failure Assessment Score

Answer

DAS 28 score

Answer

Expanded Disability Status Scale

Question 6

Out of the following areas of brain, which area is most commonly affected on brain imaging in Wilson's disease?

Accepted Answer

Basal ganglia

Answer

Thalamus

Answer

Sub-cortex

Answer

Cerebellum

Question 7

Which of the following are secondary iron overload conditions?
I. Transfusion related iron load
II. Thalassemia
III. Hepatitis C associated liver disease

Select the correct answer using the code given below :

Accepted Answer

I, II and III

Answer

I and II only

Answer

I and III only

Answer

II and III only

Question 8

Which of the following are features of Alzheimer's disease?
I. It is a disorder of cerebral cortical function
II. Only short term memory is affected
III. Patients deny that there is anything wrong
IV. Depression is commonly present

Select the correct answer using the code given below :

Accepted Answer

I, III and IV

Answer

II, III and IV

Answer

I, II and III

Answer

I, II and IV

Question 9

Which of the following are causes of reversible dementia?
I. Hypothyroidism
II. Vitamin B12 deficiency
III. Dementia with lewy body
IV. Thiamine deficiency

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

II, III and IV

Answer

I, III and IV

Answer

I, II and III

Question 10

Which of the following are clinical features of Fronto-Temporal dementia ?
I. Personality change
II. Language disturbance
III. Memory may be preserved in early stages
IV. Anti-cholinesterases are the drug of choice for treatment
Select the correct answer using the code given below :

Accepted Answer

I, II and III

Answer

II, III and IV

Answer

I, III and IV

Answer

I, II and IV

UPSC-CMS 2025 — Internal Medicine