FMGE 2019 - Internal Medicine Practice Questions

Q: Which heart sound is almost always considered pathological?

S4. ***S4*** - An **S4 heart sound**, or **atrial gallop**, is almost always indicative of **pathology**, specifically a **stiff or non-compliant ventricle**. - It occurs due to vigorous atrial contraction forcing blood into a **non-compliant ventricle**, commonly seen in conditions like **hypertensive heart disease**, **aortic stenosis**, and **hypertrophic cardiomyopathy**. *S2* - **S2** represents the **closure of the aortic and pulmonic valves** and is a normal physiological heart sound [2]. - While it can be altered in pathology (e.g., fixed splitting, paradoxical splitting), the sound itself is a normal component of the cardiac cycle [1]. *S1* - **S1** represents the **closure of the mitral and tricuspid valves** and is a normal physiological heart sound [1]. - Variations in its intensity or splitting can occur in disease states, but the presence of S1 itself is normal. *S3* - An **S3 heart sound**, or **ventricular gallop**, can be a normal finding in **children**, **young adults**, and **pregnant individuals**, often referred to as a **physiological S3**. - However, in adults over 40, an S3 often indicates **ventricular dysfunction** due to rapid filling into a dilated ventricle [3], as seen in **heart failure** [1].

Q: Which is not seen in Tumour lysis Syndrome?

Hypophosphatemia. ***Hypophosphatemia*** - **Tumor lysis syndrome (TLS)** is characterized by the rapid breakdown of tumor cells, leading to the release of intracellular components into the bloodstream. - This process typically results in **acute hyperphosphatemia**, not hypophosphatemia, due to the high phosphate content within tumor cells. *Hyperkalemia* - **Hyperkalemia** is a hallmark of TLS because potassium, a major intracellular cation, is released in large quantities as tumor cells lyse. - Excess potassium can lead to potentially life-threatening cardiac arrhythmias. *Hyperuricemia* - **Hyperuricemia** occurs in TLS because nucleic acids (DNA and RNA) released from dying tumor cells are metabolized into purines, which are then converted to uric acid [1]. - High uric acid levels can precipitate in the renal tubules, leading to **acute kidney injury** [1]. *Hypocalcemia* - **Hypocalcemia** develops in TLS secondary to the acute hyperphosphatemia. - The excess phosphate binds with serum calcium to form **calcium-phosphate precipitates**, effectively lowering the concentration of free ionized calcium.

Q: Which of the following is best for diagnosis of pheochromocytoma?

24-hour urinary Fractionated Metanephrine. ***24-hour urinary Fractionated Metanephrine*** - This test measures the **metabolites of catecholamines** (epinephrine and norepinephrine), which are continuously produced by pheochromocytomas [1]. - As metanephrines are released continuously rather than episodically, their measurement in a 24-hour urine collection provides the **highest sensitivity and specificity** for diagnosing pheochromocytoma. *24-hour Urinary Hydroxy indole acetic acid* - This is a metabolite of **serotonin**, which is relevant to conditions like **carcinoid syndrome**, not pheochromocytoma. - Elevated levels would indicate a serotonin-producing tumor, not a catecholamine-producing tumor. *24-hour urinary Vanillyl Mandelic acid* - While VMA is a metabolite of both epinephrine and norepinephrine, it is a less specific and sensitive marker than fractionated metanephrines for pheochromocytoma. - Its measurement can be affected by various medications and dietary factors, leading to a higher rate of false positives and negatives compared to metanephrines. *24-hour Urinary Hydroxy tryptamine* - This refers to **serotonin**, which is not directly relevant to the diagnosis of pheochromocytoma. - Elevated levels would point towards conditions involving serotonin metabolism, such as carcinoid tumors.

Q: Hyperkalemia means more than

5.5 mEq/l. ***5.5 mEq/l*** - **Hyperkalemia** is defined as a serum potassium level greater than **5.5 mEq/L** [1]. - This elevated level can lead to significant cardiac and neurological complications if not promptly addressed. *4.5 mEq/l* - A potassium level of 4.5 mEq/L falls within the normal physiological range for serum potassium, which is typically **3.5 to 5.0 mEq/L** [1]. - Therefore, this value does not indicate hyperkalemia. *10.5 mEq/l* - While 10.5 mEq/L is indeed an elevated potassium level, it represents **severe hyperkalemia**, far exceeding the general threshold for diagnosis. - The definition of hyperkalemia begins at a lower threshold of **5.5 mEq/L** [1]. *7.5 mEq/l* - A potassium level of 7.5 mEq/L indicates **moderate to severe hyperkalemia** and is a critical finding requiring immediate medical intervention [2]. - However, the initial threshold for defining hyperkalemia is **5.5 mEq/L**, making this option too high for the general definition [1].

Q: A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Cor pulmonale. ***Cor pulmonale*** - **Cor pulmonale** is right heart failure secondary to pulmonary disease, which perfectly explains the constellation of **tachypnea**, **pulmonary hypertension**, and **elevated JVP**. - The pathophysiology involves underlying lung disease leading to **pulmonary hypertension**, causing **right heart strain** and eventual right heart failure. *Tension pneumothorax* - Characterized by **severe dyspnea**, **hypotension**, and **tracheal deviation**, none of which are explicitly mentioned here. - While it causes tachypnea, it would typically present with **unilateral absent breath sounds** and **hemodynamic instability**, not chronic pulmonary hypertension. *Aortic dissection and rupture* - Typically presents with **sudden onset severe chest pain**, **pulse deficits**, and often **blood pressure differences** between arms. - Does not primarily cause **pulmonary hypertension** or **elevated JVP** as its initial and predominant symptoms. *Right ventricular hypertrophy* - This represents a **structural adaptation** to chronic pressure overload rather than the primary cause of the clinical syndrome. - **RVH** is a consequence and manifestation of **cor pulmonale**, not the underlying diagnosis explaining the patient's presentation.

Q: Which type of gout is seen in a patient who is on treatment of CML?

Secondary gout. ***Secondary gout*** - **Secondary gout** occurs when a high uric acid level is a consequence of another medical condition or its treatment, such as **chronic myelogenous leukemia (CML)** [1]. - The increased cell turnover in CML, especially during treatment, leads to a significant release of **purines**, which are then metabolized into **uric acid**, causing hyperuricemia and gout [1]. *Pseudogout* - **Pseudogout** is caused by the deposition of **calcium pyrophosphate dihydrate (CPPD)** crystals, not uric acid crystals, in the joints [2]. - While it can mimic gout attacks, it has a different underlying pathophysiology and is not directly linked to CML or its treatment. *Acute gout* - **Acute gout** describes the sudden onset of severe pain, swelling, and redness in a joint, which is a common presentation of any type of gout, whether primary or secondary. - This term refers to a **gout flare** rather than the underlying cause of the hyperuricemia. *Primary gout* - **Primary gout** occurs due to an intrinsic metabolic defect in purine metabolism or renal excretion of uric acid, without an identifiable underlying disease [1]. - In this scenario, the gout is secondary to CML and its treatment, making **primary gout** an incorrect classification [1].

Q: A 32-year-old lady presents with shoulder tip pain. She is diagnosed with Pancoast tumor and presents with miosis. What is the most likely associated diagnosis?

Horner syndrome. Horner syndrome - The presence of miosis (constricted pupil) in a patient with a Pancoast tumor is a classic sign of Horner syndrome. - Pancoast tumors are apical lung tumors that can invade the sympathetic chain, leading to the triad of ptosis, miosis, and anhidrosis. Upper trunk of brachial plexus injury - While Pancoast tumors can involve the brachial plexus, an injury to the upper trunk (C5-C6) typically causes symptoms like weakness in shoulder abduction and external rotation, and sensory loss over the lateral arm. - It does not directly explain miosis unless the sympathetic chain is also involved, which is characteristic of Horner syndrome. Thoracic outlet syndrome - This syndrome involves compression of the neurovascular structures as they exit the thoracic outlet, often causing pain, paresthesias, and weakness in the arm and hand. - It does not directly account for the symptom of miosis, which points to sympathetic nerve involvement. Aberrant right subclavian artery - An aberrant right subclavian artery is a congenital anomaly where the right subclavian artery arises from the distal aortic arch, often causing dysphagia lusoria or being asymptomatic. - It has no direct association with Pancoast tumors or the development of miosis.

Q: Reversible dementia is seen in?

Hypothyroidism. ***Hypothyroidism*** - **Hypothyroidism** can lead to cognitive impairment, including memory loss, slowed thinking, and executive dysfunction, which are reversible with appropriate **thyroid hormone replacement therapy**. - This condition is often characterized by other systemic symptoms like fatigue, weight gain, and cold intolerance, which also improve with treatment. *Pick's disease* - **Pick's disease** is a type of **frontotemporal dementia** caused by progressive degeneration of brain cells, primarily in the frontal and temporal lobes. - It is a **neurodegenerative** disorder, meaning it is progressive and irreversible. *Alzheimer's disease* - **Alzheimer's disease** is the most common cause of dementia, characterized by the accumulation of **amyloid plaques** and **neurofibrillary tangles** in the brain [1]. - It is a **progressive and irreversible neurodegenerative disease** with no cure [2]. *Subacute demyelination of spinal cord* - **Subacute demyelination of the spinal cord** typically refers to conditions like **subacute combined degeneration** due to **vitamin B12 deficiency** [1]. - While this can cause neurological symptoms, including cognitive changes, its primary impact is on the spinal cord and peripheral nerves, and "dementia" in the classic sense is not the primary or defining feature of spinal cord demyelination itself, although B12 deficiency can cause broader cognitive issues [1].

Q: A patient after valve replacement will require follow up treatment with

Warfarin. ***Warfarin*** - Patients with **mechanical prosthetic heart valves** require lifelong anticoagulation with **warfarin** to prevent life-threatening thromboembolic complications [1]. - The target **international normalized ratio (INR)** typically ranges from 2.5 to 3.5, depending on the valve type and position. *ACE inhibitors* - **ACE inhibitors** are primarily used for managing **hypertension**, **heart failure**, and **renal protection**, not as routine post-valve replacement prophylaxis [2]. - While they may be used if these co-morbidities exist, they are not a universal requirement after valve surgery. *Beta blockers* - **Beta blockers** are often prescribed to control heart rate, manage **hypertension**, or reduce myocardial oxygen demand, but they are not the primary follow-up treatment for all valve replacement patients. - They do not address the critical need for **anticoagulation** in mechanical valve recipients. *Thiazide* - **Thiazide diuretics** are used to treat **hypertension** and **edema** by increasing salt and water excretion. - They do not play a direct role in preventing **thromboembolism** post-valve replacement and are not generally indicated unless chronic heart failure or hypertension is present.

Question 1

Which heart sound is almost always considered pathological?

Accepted Answer

S4

Answer

S2

Answer

S1

Answer

S3

Question 2

Which is not seen in Tumour lysis Syndrome?

Accepted Answer

Hypophosphatemia

Answer

Hyperkalemia

Answer

Hyperuricemia

Answer

Hypocalcemia

Question 3

Which of the following is best for diagnosis of pheochromocytoma?

Accepted Answer

24-hour urinary Fractionated Metanephrine

Answer

24-hour Urinary Hydroxy indole acetic acid

Answer

24-hour urinary Vanillyl Mandelic acid

Answer

24-hour Urinary Hydroxy tryptamine

Question 4

Hyperkalemia means more than

Accepted Answer

5.5 mEq/l

Answer

4.5 mEq/l

Answer

10.5 mEq/l

Answer

7.5 mEq/l

Question 5

A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Accepted Answer

Cor pulmonale

Answer

Tension pneumothorax

Answer

Aortic dissection and rupture

Answer

Right ventricular hypertrophy

Question 6

Which type of gout is seen in a patient who is on treatment of CML?

Accepted Answer

Secondary gout

Answer

Pseudogout

Answer

Acute gout

Answer

Primary gout

Question 7

A 32-year-old lady presents with shoulder tip pain. She is diagnosed with Pancoast tumor and presents with miosis. What is the most likely associated diagnosis?

Accepted Answer

Horner syndrome

Answer

Upper trunk of brachial plexus injury

Answer

Thoracic outlet syndrome

Answer

Aberrant right subclavian artery

Question 8

Following statement are true about tremors except:

Accepted Answer

Essential tremor is an uncommon movement disorder affecting 5%of population

Answer

Normal individuals can have physiologic tremor that manifest as mild high frequency, postural or action tremors.

Answer

PD is characterised by resting tremor

Answer

Tremor consist of alternate contraction of agonist and antagonist muscle in oscillating rhythmic manner

Question 9

Reversible dementia is seen in?

Accepted Answer

Hypothyroidism

Answer

Pick's disease

Answer

Alzheimer's disease

Answer

Subacute demyelination of spinal cord

Question 10

A patient after valve replacement will require follow up treatment with

Accepted Answer

Warfarin

Answer

ACE inhibitors

Answer

Beta blockers

Answer

Thiazide

FMGE 2019 — Internal Medicine