Clinical Manifestations and Presentation of Diseases — MCQs

Clinical Manifestations and Presentation of Diseases Indian Medical PG Practice Questions and MCQs

Question 321: Which of the following is not seen in chronic regional pain syndrome?

A. Anhidrosis (Correct Answer)
B. Severe Pain
C. Swelling
D. Osteoporosis

Explanation: ***Anhidrosis*** - **Anhidrosis**, or the **absence of sweating**, is generally *not* a characteristic feature of chronic regional pain syndrome (CRPS); rather, **hyperhidrosis** (excessive sweating) is often observed in the affected limb. - CRPS typically involves sympathetic nervous system dysfunction, which can lead to changes in sudomotor activity, usually resulting in increased rather than decreased sweating. *Severe Pain* - **Severe, unremitting pain** is the cardinal symptom of CRPS and is disproportionate to the initial injury, if any. - The pain is often described as burning, throbbing, or aching and can spread beyond the site of injury. *Swelling* - **Edema** or **swelling** of the affected limb is a common finding in CRPS, especially in the early stages. - This swelling can be accompanied by changes in skin temperature and color due to vasomotor dysfunction. *Osteoporosis* - **Osteoporosis** or **bone demineralization** is a common complication in CRPS, particularly in later stages. - It results from increased osteoclastic activity and reduced bone formation, which can be seen on imaging as patchy or diffuse bone loss.

Question 322: Clinical examination of a symptomatic patient shows a Sister Mary Joseph nodule. It is most commonly associated with which of the following?

A. Ovarian cancer
B. Stomach cancer (Correct Answer)
C. Colon cancer
D. Pancreatic cancer

Explanation: ***Stomach cancer*** - A **Sister Mary Joseph nodule** is a **periumbilical metastatic nodule**, most commonly associated with **gastric adenocarcinoma** due to its propensity for peritoneal spread. - While it can originate from other abdominal malignancies, stomach cancer is statistically the most frequent primary source of this metastatic sign. *Ovarian cancer* - Ovarian cancer can metasatasize to the peritoneum and sometimes cause Sister Mary Joseph nodules, but it is not the most common primary source [1]. - Instead, ovarian cancer more frequently presents with symptoms like **abdominal distension**, **pelvic pain**, or **ascites** [1]. *Colon cancer* - **Colorectal cancer** can also metastasize to the peritoneum, potentially leading to a Sister Mary Joseph nodule, though less commonly than gastric cancer [2]. - It often manifests with changes in **bowel habits**, **rectal bleeding**, or **unexplained weight loss** [2]. *Pancreatic cancer* - Pancreatic cancer can produce a Sister Mary Joseph nodule, particularly in advanced stages with **peritoneal dissemination**. - However, it is primarily known for other metastatic patterns and often presents with **jaundice** (if the head of the pancreas is affected) or **epigastric pain**.

Question 323: For the following causes of sexual dysfunction, select the most likely clinical feature that can be caused by vascular disease.

A. failure of erection with absent nocturnal penile tumescence (NPT) (Correct Answer)
B. absence of orgasm with normal libido and erectile function
C. ejaculatory dysfunction
D. decreased libido

Explanation: **_failure of erection with absent nocturnal penile tumescence (NPT)_** - **Vascular disease** often impairs blood flow to the penis, which is essential for achieving and maintaining an erection [1]. - **Absent nocturnal penile tumescence (NPT)** indicates an organic cause of erectile dysfunction, frequently due to vascular insufficiency rather than psychological factors [1], [2]. *ejaculatory dysfunction* - While ejaculatory dysfunction can occur with sexual health issues, it is less directly linked to the **vascular supply** than erectile function [2]. - Conditions like **neurological damage** or medication side effects are more common causes of ejaculatory dysfunction [2]. *absence of orgasm with normal libido and erectile function* - An inability to achieve orgasm with intact libido and erectile function typically suggests a **neurological** or **psychological** etiology. - **Vascular disease** primarily affects the physical ability to achieve an erection, not the sensory or psychological components of orgasm [1]. *decreased libido* - **Decreased libido (sex drive)** is more commonly associated with hormonal imbalances (e.g., low testosterone), psychological stress, depression, or certain medications [1]. - While vascular disease can contribute to overall poor health, it is not a direct or primary cause of **reduced sexual desire** [1].

Question 324: Blumberg's sign is

A. Rebound tenderness during abdominal palpation (Correct Answer)
B. Board-like rigidity of abdomen
C. Pressure over left iliac fossa causing pain in right iliac fossa
D. Pressure over right iliac fossa causing pain in left iliac fossa

Explanation: ***Rebound tenderness during abdominal palpation*** - Blumberg's sign refers specifically to **rebound tenderness**, which is pain experienced upon the rapid release of pressure applied to the abdomen. - It is a classic sign indicating **peritoneal irritation** or inflammation, often seen in conditions like appendicitis. *Board-like rigidity of abdomen* - **Board-like rigidity** describes a state of involuntary abdominal muscle contraction, making the abdomen feel hard and inflexible. - This is a sign of **generalized peritonitis**, a more severe and widespread inflammation of the peritoneum than what typically elicits Blumberg's sign alone. *Pressure over left iliac fossa causing pain in right iliac fossa* - This describes **Rovsing's sign**, where palpation of the left lower quadrant causes pain in the right lower quadrant. - Rovsing's sign is another indicator of **peritoneal irritation** in the right lower quadrant and is commonly associated with appendicitis. *Pressure over right iliac fossa causing pain in left iliac fossa* - Applying pressure to the right iliac fossa usually causes pain in that same area if **appendicitis** is present (e.g., McBurney's point tenderness). - This specific pain pattern (pain in the left iliac fossa from right iliac fossa pressure) is not a recognized named sign for **abdominal pathology**.

Question 325: What is the ratio of pleural fluid protein to serum protein in transudative pleural effusion?

A. < 0.4
B. < 0.5 (Correct Answer)
C. < 0.6
D. < 0.3

Explanation: ***< 0.5*** - A pleural fluid protein to serum protein ratio of **less than 0.5** is a key criterion for defining a **transudative pleural effusion** according to Light's criteria [1]. - This low ratio indicates that the fluid accumulation is due to systemic factors affecting hydrostatic or oncotic pressures, rather than inflammation of the pleura causing increased capillary permeability [1], [2]. *< 0.3* - While a very low ratio might suggest a transudate, Light's criteria specifically set the threshold at **less than 0.5**, making < 0.3 an unnecessarily restrictive and less accurate cut-off [1]. - Using < 0.3 could lead to misclassification of some transudates as exudates, as the more inclusive < 0.5 criterion is widely accepted. *< 0.4* - This ratio is within the range that would be considered a transudate, but it is not the universally accepted and most specific cut-off point used in **Light's criteria** [1]. - Using < 0.4 instead of < 0.5 might still allow for misclassification in some cases, as the standard diagnostic threshold is less than 0.5. *< 0.6* - A ratio greater than or equal to **0.5** (including 0.6) typically indicates an **exudative pleural effusion**, where the fluid is high in protein due to local inflammation or malignancy [1]. - Therefore, a ratio of < 0.6 would encompass both transudates and some exudates, making it an incorrect and non-specific criterion for defining a transudate.

Question 326: Sarcoidosis is least likely to be associated with:

A. Pericardial effusion (Correct Answer)
B. Uveitis
C. Erythema nodosum
D. Lymphadenopathy

Explanation: ### Pericardial effusion - While cardiac involvement in **sarcoidosis** can occur, leading to **cardiomyopathy** or **arrhythmias**, **pericardial effusions** are relatively rare [1]. - Less than 5% of patients with sarcoidosis develop pericardial effusions, making it the **least likely** among the given options [1]. ### Uveitis - **Uveitis** (inflammation of the uvea of the eye) is a common ocular manifestation of **sarcoidosis**, affecting 25-50% of patients [1]. - It can manifest as acute or chronic anterior uveitis, or posterior uveitis, and can lead to **vision impairment**. ### Erythema nodosum - **Erythema nodosum** is a common dermatological manifestation of **sarcoidosis**, particularly in acute forms like **Lofgren's syndrome** [1]. - It presents as **painful, tender red nodules** typically on the shins [1]. ### Lymphadenopathy - **Lymphadenopathy**, particularly **bilatéral mediastinal and hilar lymphadenopathy**, is a hallmark of **sarcoidosis** and is present in over 90% of cases [1]. - It is often one of the first findings on **chest X-ray** in pulmonary sarcoidosis [1].

Question 327: Which of the following conditions is least likely to cause hypercalcemia?

A. SLE (Correct Answer)
B. Berylliosis
C. TB
D. Sarcoidosis

Explanation: ***SLE*** - **Systemic lupus erythematosus (SLE)** is an autoimmune disease rarely associated with hypercalcemia. While various electrolyte imbalances can occur in SLE, hypercalcemia is not a typical manifestation, and other calcium-related issues like hypocalcemia (due to renal involvement or vitamin D deficiency) might be more common [3], [4]. - The inflammatory and immune mechanisms in SLE do not generally promote the increased production of activated **vitamin D** or significant bone resorption seen in other causes of hypercalcemia. *TB* - **Tuberculosis (TB)**, particularly disseminated forms, can cause hypercalcemia due to **granuloma formation** [1]. - These **granulomas** contain **macrophages** that have aberrant 1-alpha-hydroxylase activity, leading to increased production of **1,25-dihydroxyvitamin D**, which enhances calcium absorption from the gut and bone resorption [1]. *Berylliosis* - **Berylliosis** is a chronic inflammatory disease caused by exposure to beryllium, characterized by **granuloma formation** in various organs, most commonly the lungs. - Similar to sarcoidosis and TB, the **granulomas** in berylliosis can produce **1,25-dihydroxyvitamin D**, leading to increased calcium absorption and subsequent **hypercalcemia** [1]. *Sarcoidosis* - **Sarcoidosis** is known to cause **hypercalcemia** in a significant percentage of patients (around 10-20%) [1], [2]. - The mechanism involves **macrophages** within the **granulomas** producing **1,25-dihydroxyvitamin D**, which leads to increased intestinal calcium absorption and bone resorption [1].

Question 328: Which condition is characterized by the presence of Kayser-Fleischer rings?

A. Wilson's disease (Correct Answer)
B. Von Gierke's disease
C. Phenylketonuria (PKU)
D. Diabetes mellitus

Explanation: ***Wilson's disease*** - **Kayser-Fleischer rings** are a hallmark sign of Wilson's disease, caused by the deposition of **copper in the Descemet's membrane** of the cornea [1]. - This is a genetic disorder of **copper metabolism**, leading to excessive copper accumulation in various organs, including the liver, brain, and eyes [1]. *Von Gierke's disease* - This is a **glycogen storage disease (Type I)** characterized by a deficiency in **glucose-6-phosphatase**, leading to an inability to convert glycogen to free glucose. - Clinical features include **hypoglycemia**, hepatomegaly, and lactic acidosis, not copper accumulation or Kayser-Fleischer rings. *Phenylketonuria (PKU)* - PKU is an inherited metabolic disorder where the body cannot process **phenylalanine**, an amino acid, due to a deficiency of the enzyme **phenylalanine hydroxylase**. - Untreated PKU can lead to severe intellectual disability, but it does not involve copper metabolism or the formation of corneal rings. *Diabetes mellitus* - Diabetes mellitus is a metabolic disorder characterized by **high blood sugar levels** (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both [2]. - Its complications affect various organs but do not include the deposition of copper in the cornea to form Kayser-Fleischer rings.

Question 329: Muehrcke lines in nails are seen in:

A. Nephrotic syndrome (Correct Answer)
B. Guillain-Barré syndrome
C. Nail-patella syndrome
D. Acute tubular necrosis (ATN)

Explanation: ***Nephrotic syndrome*** - **Muehrcke lines** are characterized by paired, white transverse lines separated by normal pink nail beds, which do not move with nail growth. - They are associated with **hypoalbuminemia**, a hallmark of nephrotic syndrome [1], due to decreased protein synthesis in the nail matrix. *Guillain-Barré syndrome* - This is an **acute demyelinating polyneuropathy** primarily affecting the peripheral nervous system. - It does not typically manifest with nail changes like Muehrcke lines, which are related to systemic metabolic derangements. *Nail-patella syndrome* - This rare genetic disorder is characterized by a **tetrad of abnormalities**: nail dysplasia, patellar hypoplasia/aplasia, elbow abnormalities, and iliac horns. - The nail changes are primarily **dysplastic or absent** rather than the transverse white lines seen in Muehrcke lines. *Acute tubular necrosis (ATN)* - ATN is an intrinsic kidney injury characterized by **damage to the renal tubules**, often leading to acute kidney failure. - While it affects kidney function, it does not typically cause the systemic hypoalbuminemia or nail changes seen in nephrotic syndrome.

Question 330: Carpal tunnel syndrome is caused by all, except?

A. Hypothyroidism
B. Diabetes mellitus
C. Amyloidosis
D. Addison's disease (Correct Answer)

Explanation: As specified in the choice-based analysis, carpal tunnel syndrome is caused by all except Addison's disease. ***Addison's disease*** - **Addison's disease** is characterized by primary adrenal insufficiency, leading to symptoms like fatigue, weight loss, and hypovolemia, but it is **not directly associated** with the development of carpal tunnel syndrome. - Carpal tunnel syndrome is caused by **compression of the median nerve** within the carpal tunnel, which is typically due to localized swelling or thickening of tissues, a mechanism not linked to Addison's disease. *Amyloidosis* - **Amyloidosis** can lead to the deposition of **amyloid protein** in various tissues, including the carpal tunnel, which can cause narrowing and compression of the median nerve [1]. - The accumulation of amyloid can result in **thickening of the synovium** and other structures within the wrist, leading to the symptoms of carpal tunnel syndrome [1]. *Hypothyroidism* - **Hypothyroidism** can cause the accumulation of **mucopolysaccharides** (specifically hyaluronic acid and chondroitin sulfate) in the interstitial tissues, including the synovium of the carpal tunnel. - This **fluid retention and tissue swelling** can increase pressure on the median nerve, leading to carpal tunnel syndrome. *Diabetes mellitus* - **Diabetes mellitus** is a common cause of carpal tunnel syndrome, primarily due to **neuropathy** and metabolic changes that affect the median nerve's health and the surrounding tissues. - High blood glucose levels can lead to **glycation of proteins** and increased **inflammation**, contributing to nerve swelling and tissue thickening within the carpal tunnel.

Practice by Chapter

Approach to Common Symptoms (Fever, Pain, Fatigue)

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Constitutional Symptoms and Their Differential Diagnosis

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Syncope and Presyncope

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Dizziness and Vertigo

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Dyspnea and Respiratory Distress

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Chest Pain Evaluation

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Abdominal Pain Assessment

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Headache Classification and Management

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Weight Loss and Cachexia

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Edema and Fluid Retention

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