FMGE 2018 - Internal Medicine Practice Questions

Q: A patient presented with sudden onset of thunderclap headache & dilated pupils. Findings are consistent with:

Acute aneurismal hemorrhage. ***Acute aneurismal hemorrhage*** - **Thunderclap headache** is the hallmark symptom, often described as the "worst headache of life," due to sudden elevation of intracranial pressure [2]. - **Dilated pupils**, especially unilateral, can indicate compression of the **oculomotor nerve (CN III)** by an expanding aneurysm in the posterior communicating artery region, a direct effect of subarachnoid hemorrhage [1]. *Brain stem encephalitis* - This condition involves inflammation of the brainstem, which typically presents with a range of neurological deficits such as **ataxia**, **cranial nerve palsies**, and **altered consciousness**. - While headaches can occur, a characteristic **thunderclap headache** is not a typical feature, and pupillary abnormalities would be more varied depending on the extent of brainstem involvement. *Acute ischemia of midbrain* - **Midbrain ischemia** would present with brainstem symptoms like **vertigo**, **diplopia**, **hemiparesis**, or **oculomotor nerve palsy** [3]. - Although it could lead to pupillary changes if the oculomotor nucleus is affected, it typically does not cause a sudden, severe **thunderclap headache**. *Meningitis* - **Meningitis** presents with headache, fever, **neck stiffness**, and altered mental status [2]. - While headache is common, a sudden **thunderclap headache** is less typical, and **dilated pupils** are not a primary diagnostic feature unless there is severe herniation or other complications.

Q: Treatment of choice for recurrent thyrotoxicosis after surgery is:-

Radioiodine. ***Radioiodine*** - **Radioiodine therapy (RAI)** is the preferred treatment for recurrent **thyrotoxicosis** after prior surgery, especially if the patient is elderly or has comorbidities, due to its effectiveness and safety profile. [1] - It works by destroying overactive thyroid cells, reducing hormone production and mitigating the risk of further surgical complications. *Observation & follow-up* - This approach is generally **insufficient** for managing recurrent thyrotoxicosis, which requires active treatment to control hormone levels. - Delaying proper treatment can lead to serious complications such as **cardiac arrhythmias**, **osteoporosis**, and **thyroid storm**. *Radioiodine followed by surgery* - Administering radioiodine followed by surgery is **not typically a standard approach** for recurrent thyrotoxicosis and may increase patient burden and risk. - Surgery after radioiodine therapy is usually reserved for cases of **malignancy** or large goiters with compressive symptoms that persist despite RAI. [1] *Further surgery* - **Repeat thyroid surgery** carries a significantly **higher risk of complications** such as recurrent laryngeal nerve injury, hypoparathyroidism, and excessive bleeding due to altered anatomy and scar tissue from the initial surgery. [1] - The efficacy may also be reduced compared to RAI, particularly in diffuse or widespread recurrence.

Q: MC cause of nephrotic syndrome in adults:-

Focal segmental glomerulosclerosis. **Focal segmental glomerulosclerosis** - **Focal segmental glomerulosclerosis (FSGS)** is the most common cause of **primary nephrotic syndrome in adults**, particularly in African Americans and individuals with HIV or obesity [1]. - It involves **scarring** of some glomeruli (focal) and only parts of affected glomeruli (segmental), leading to **proteinuria** and progression to end-stage renal disease [2]. *Minimal change disease* - While it is the most common cause of **nephrotic syndrome in children**, it accounts for a smaller proportion of adult cases [1]. - Characterized by normal-appearing glomeruli on light microscopy but **effacement of foot processes** on electron microscopy. *Good-pasture syndrome* - This is an **autoimmune disease** causing rapidly progressive glomerulonephritis, often associated with **pulmonary hemorrhage** [3]. - It is a much rarer cause of nephrotic syndrome and is characterized by **anti-GBM antibodies** [3]. *Membranous GN* - It is a common cause of **nephrotic syndrome in adults**, particularly in Caucasians, but **Focal Segmental Glomerulosclerosis (FSGS)** has surpassed it as the overall most common primary cause. - Characterized by thickening of the **glomerular basement membrane** due to immune complex deposition, often detected by **anti-PLA2R antibodies** [2].

Q: Which is NOT a feature of pleural effusion?

Muffled heart sound. ***Muffled heart sound*** - This is **NOT a feature of pleural effusion** and is the correct answer to this negation question. - Muffled heart sounds are characteristic of **pericardial effusion** or **cardiac tamponade**, where fluid accumulates in the pericardial sac around the heart itself. - Pleural effusion involves fluid in the pleural space surrounding the lungs, not the heart. - While massive pleural effusions can displace mediastinal structures, they do not typically cause muffled heart sounds. *Horizontal fluid level* - This **IS a feature** when air is also present in the pleural space (**hydropneumothorax**). - In **simple pleural effusion** (fluid only), the fluid typically forms a **meniscus-shaped curve** with blunting of the costophrenic angles on upright chest X-ray, not a horizontal level. - However, when both air and fluid are present, a distinct horizontal air-fluid level is visible on upright imaging. - Since the question asks about pleural effusion broadly, and effusions can be associated with air (empyema with gas-forming organisms, post-thoracentesis), this can be considered a radiological feature in certain contexts. *Low lung volume* - This **IS a feature** of pleural effusion. - The accumulating pleural fluid causes **compression atelectasis** of the adjacent lung parenchyma. - This results in **reduced functional lung volume** on the affected side, visible on chest imaging. *Decreased chest movements* - This **IS a feature** of pleural effusion. - Fluid in the pleural space restricts normal lung expansion and chest wall movement. - On physical examination, there are **diminished respiratory excursions** on the affected side. - This is one of the classic clinical signs of pleural effusion.

Question 1

A patient presented with sudden onset of thunderclap headache & dilated pupils. Findings are consistent with:

Accepted Answer

Acute aneurismal hemorrhage

Answer

Brain stem encephalitis

Answer

Acute ischemia of midbrain

Answer

Meningitis

Question 2

Treatment of choice for recurrent thyrotoxicosis after surgery is:-

Accepted Answer

Radioiodine

Answer

Observation & follow-up

Answer

Radioiodine followed by surgery

Answer

Further surgery

Question 3

MC cause of nephrotic syndrome in adults:-

Accepted Answer

Focal segmental glomerulosclerosis

Answer

Minimal change disease

Answer

Good-pasture syndrome

Answer

Membranous GN

Question 4

Which is NOT a feature of pleural effusion?

Accepted Answer

Muffled heart sound

Answer

Horizontal fluid level

Answer

Low lung volume

Answer

Decreased chest movements

FMGE 2018 — Internal Medicine