FMGE 2025 - Internal Medicine Practice Questions

Q: Which medication can be administered to reduce the frequency of future headache episodes in a 26-year-old female patient who experiences one-sided pulsating headaches accompanied by nausea, vomiting, and sensitivity to light and finds relief in a dimly lit environment?

Propranolol. ***Propranolol***- This is a non-selective **beta-blocker** and is considered a first-line prophylactic agent for the reduction of frequency and severity in patients with **episodic migraine** [1].- The patient's symptoms (unilateral, pulsating headache, **nausea, vomiting, and photophobia**) [2] are classic features of migraine, making **Propranolol** an appropriate choice for maintenance therapy [3].*Alprazolam*- This medication is a **short-acting benzodiazepine** primarily indicated for the acute management of anxiety and panic disorders [3].- It has **no established role** in the long-term prophylactic management of migraine and carries risks of sedation and dependence.*Diazepam*- This is a **long-acting benzodiazepine** commonly used as a muscle relaxant, anxiolytic, and for acute seizure management.- Similar to Alprazolam, it is **not recommended** for headache prophylaxis due to lack of efficacy and significant abuse potential [3].*Fluoxetine*- This drug is a selective serotonin reuptake inhibitor (**SSRI**) primarily used to treat **major depressive disorder** and anxiety [3].- While some antidepressants (like TCAs) are used for migraine prophylaxis, **Fluoxetine** is generally not considered a standard or preferred first-line agent for preventing migraine attacks.

Q: A patient presents with complaints of excessive thirst and increased urination of around 6–7 liters per day. He had a history of cerebral trauma one month ago. What is the most appropriate treatment?

Desmopressin. ***Desmopressin***- This clinical presentation of excessive thirst and massive polyuria (6–7 L/day) following **cerebral trauma** strongly suggests **Central Diabetes Insipidus (CDI)**, which results from inadequate production or release of **Antidiuretic Hormone (ADH)/Vasopressin** in the posterior pituitary or hypothalamus.- **Desmopressin** (DDAVP) is a synthetic ADH analog and acts as the highly effective hormone replacement therapy [1], directly addressing the underlying deficiency and drastically reducing urine output.- This causes water permeability of the collecting ducts to increase through binding of ADH to the V2 receptor, which enhances collecting duct water permeability through the insertion of aquaporin (AQP-2) channels into the luminal cell membrane [2].*Hydrochlorothiazide*- This medication is paradoxically used in the treatment of **Nephrogenic Diabetes Insipidus (NDI)**, where the renal tubules fail to respond to ADH [1].- It works by inducing mild volume depletion, which leads to increased proximal tubule reabsorption of solutes and water, thereby decreasing fluid delivery to the collecting duct.*Tolvaptan*- **Tolvaptan** is a **V2 vasopressin receptor antagonist** primarily used to promote water excretion in conditions like **SIADH** (Syndrome of Inappropriate ADH) to correct hyponatremia.- Administering an ADH antagonist in a state of ADH deficiency (Diabetes Insipidus) would be contraindicated, as it would worsen polyuria and potentially cause severe **hypernatremia**.*Insulin*- **Insulin** is the definitive treatment for **Diabetes Mellitus**, a condition characterized by high blood glucose levels and subsequent osmotic diuresis leading to polyuria.- While Diabetes Mellitus can cause polyuria, the history of recent **cerebral trauma** and the absence of expected accompanying symptoms like persistent hyperglycemia and glycosuria make CDI the far more likely diagnosis.

Q: A patient with known rheumatic heart disease is now found to have a 1–2 cm aneurysm on imaging. What is the most appropriate next step in management?

IV antibiotics. ***IV antibiotics*** - In a patient with **rheumatic heart disease (RHD)**, the finding of an aneurysm on imaging should raise strong suspicion for a **mycotic aneurysm**, especially given the increased risk of **infective endocarditis (IE)** in RHD patients [1]. - **Mycotic aneurysms** are infected arterial wall dilations that occur as a complication of IE, resulting from septic emboli or direct bacterial invasion of the vessel wall [2]. - **First-line management** consists of **prolonged IV antibiotics** (4-6 weeks) targeting the causative organism, along with close monitoring for aneurysm expansion or rupture. - Blood cultures, echocardiography, and infectious disease consultation are essential components of the workup [1]. *Aspirin lifelong* - While **aspirin** is important for long-term secondary prevention in RHD patients to reduce thromboembolic risk, it is **not the immediate priority** when an aneurysm is discovered. - In the setting of a **mycotic aneurysm**, aspirin may actually **increase bleeding risk** if the aneurysm ruptures and should be used cautiously [3]. - Long-term antiplatelet therapy would be considered after the acute infectious complication is addressed. *Aspirin + Clopidogrel* - **Dual antiplatelet therapy (DAPT)** is reserved for acute coronary syndromes or post-percutaneous coronary intervention, not for routine management of aneurysms in RHD. - In the context of a potential **mycotic aneurysm**, DAPT would significantly increase the risk of **catastrophic bleeding** without providing benefit. *Aspirin for 3 weeks* - Short-term aspirin therapy does not address the underlying pathology of a **mycotic aneurysm**, which requires targeted antimicrobial therapy. - This duration is insufficient for either treating the infection or providing adequate long-term vascular protection in RHD.

Q: A patient with asthma on inhaled corticosteroids and LABA continues to have exacerbations. FEV1 is normal, and there is no improvement with salbutamol challenge. The symptoms worsen seasonally. Which of the following is the most appropriate next step?

Increase dose of ICS. ***Increase dose of ICS*** - In the stepwise management of asthma, if a patient on a low or medium-dose **inhaled corticosteroid (ICS)** and **long-acting beta-agonist (LABA)** combination continues to have poor control or exacerbations, the next appropriate step is to increase the dose of the ICS [1]. - This addresses the underlying **airway inflammation**, which is the primary driver of asthma symptoms and exacerbations, especially in a patient with seasonal worsening suggesting an allergic component. *Add LAMA* - Adding a **long-acting muscarinic antagonist (LAMA)**, such as tiotropium, is typically considered at **Step 5** of asthma management, for patients who remain symptomatic despite being on a high-dose ICS-LABA. - It is not the next step after a standard-dose ICS-LABA and should only be considered after optimizing the ICS dose [1]. *Add Theophylline* - **Theophylline** is generally considered a low-preference alternative or add-on therapy due to its **narrow therapeutic index** and significant potential for side effects (e.g., cardiotoxicity, neurotoxicity). - Modern guidelines recommend other options, such as increasing the ICS dose or adding a LAMA, before considering theophylline [1]. *Add Omalizumab* - **Omalizumab** is a biologic agent (anti-IgE) reserved for **Step 5** management of severe, persistent **allergic asthma** that is poorly controlled on high-dose ICS-LABA. - Its initiation requires confirmation of an allergic phenotype (e.g., elevated IgE levels) and is not indicated before optimizing standard controller therapies [1].

Q: A patient presents with blackish discoloration of the nasal cavity and posterior buccal mucosa. He has a history of high-dose steroid use. What is the most appropriate drug for treatment?

Amphotericin B. ***Amphotericin B*** - The patient's signs (**blackish discoloration** of the nasal and buccal mucosa) coupled with profound immunosuppression (high-dose steroids) strongly suggest **Rhinocerebral mucormycosis**, an aggressive angioinvasive fungal infection caused by **Mucorales** [2]. - **Amphotericin B** (liposomal formulation preferred) is the drug of choice for empirical and definitive treatment of life-threatening mucormycosis due to its potent fungicidal activity against **Zygomycetes** [2]. - Early surgical debridement combined with Amphotericin B therapy is essential for optimal outcomes [2]. *Fluconazole* - **Fluconazole** has no reliable activity against **Mucorales** (causative agents of mucormycosis) [3]. - It is primarily used for *Candida* and *Cryptococcus* infections, completely lacking the spectrum needed for this severe angioinvasive process [1][3]. *Itraconazole* - **Itraconazole** is typically ineffective against **Mucorales** and is generally reserved for endemic mycoses (*Histoplasma, Blastomyces*) or step-down therapy for *Aspergillus* [3]. - It does not achieve adequate fungicidal activity needed for aggressive invasive fungal sinusitis. *Griseofulvin* - **Griseofulvin** is indicated only for **dermatophytosis** (superficial tinea infections of skin, hair, and nails). - It has no role or efficacy in treating severe, systemic, or angioinvasive fungal infections like mucormycosis.

Q: A patient with hypertension is taking anti-hypertensive drugs but BP is not controlled even after adding diuretics in treatment. Patient's serum electrolyte shows hypokalemia. What is the next step in treatment of this patient?

Spironolactone. ***Spironolactone*** - The combination of **resistant hypertension** (uncontrolled BP despite standard therapy including a diuretic) and **hypokalemia** strongly suggests **Primary Aldosteronism**. - **Spironolactone** is an **aldosterone antagonist** (potassium-sparing diuretic) and is the drug of choice for treating hypertension secondary to hyperaldosteronism, as it corrects both the hypokalemia and the high blood pressure [1]. *KCL* - **Potassium chloride** (KCL) would correct the hypokalemia temporarily, but it does not address the underlying cause (aldosterone excess) or control the **resistant hypertension** [1]. - Supplementation alone is insufficient when the source of hypokalemia is excessive renal potassium loss driven by high aldosterone levels. *Torasemide* - **Torasemide** is a **loop diuretic**; adding it to the regimen will significantly increase potassium excretion, thereby **worsening the existing hypokalemia**. - Loop diuretics are potent potassium-wasting agents and are contraindicated when the suspicion is high for Primary Aldosteronism presenting with hypokalemia. *Hydrochlorothiazide* - **Hydrochlorothiazide** (HCTZ) is a **thiazide diuretic** (also a potassium-wasting drug). - Similar to Torasemide, adding HCTZ would exacerbate the **hypokalemia** and is not the appropriate therapy for hypertension suspected to be caused by mineralocorticoid excess.

Q: A patient presents with fever after returning from a forest trip. On examination, a black eschar is noted on the abdomen. Which of the following is the most likely diagnosis and its drug of choice?

Doxycycline. ***Doxycycline (Scrub Typhus)*** - The clinical presentation of fever following a forest trip, along with a characteristic **black eschar** (tache noire), is highly suggestive of **scrub typhus**, a rickettsial infection caused by *Orientia tsutsugamushi*. - **Doxycycline** is the drug of choice for rickettsial diseases, including scrub typhus, as it effectively inhibits protein synthesis in these obligate intracellular bacteria. - The diagnosis is scrub typhus, and doxycycline is the first-line treatment with rapid clinical response typically within 24-48 hours. *Penicillin* - Penicillin targets bacterial **cell wall synthesis** and is primarily effective against gram-positive organisms like *Streptococcus* and *Staphylococcus*. - It is ineffective against intracellular pathogens like *Orientia tsutsugamushi*, which lack a typical peptidoglycan cell wall targeted by penicillins. *Ceftriaxone* - Ceftriaxone is a third-generation cephalosporin used for a wide range of bacterial infections, such as meningitis and community-acquired pneumonia, but it is not the standard treatment for rickettsial diseases. - Clinical trials have shown that tetracyclines like doxycycline result in faster defervescence and better outcomes for scrub typhus compared to cephalosporins. *Artesunate* - Artesunate is a potent **antimalarial** drug used for treating severe malaria caused by *Plasmodium* species. - While malaria can cause fever after travel, it does not produce a necrotic eschar, which is a key diagnostic feature distinguishing scrub typhus from malaria.

Q: A woman presents with sudden-onset high-grade fever, hypotension, diffuse rash, and a history of using a tampon for an extended period. What is the most likely diagnosis?

Toxic Shock Syndrome. Toxic Shock Syndrome - This diagnosis is defined by the sudden onset of **high fever**, **hypotension** (shock), and a **diffuse erythematous rash** (often described as sunburn-like), strongly supported by the history of prolonged **tampon use** (a common source for *Staphylococcus aureus* producing **TSST-1** superantigen). [1] - TSS is a life-threatening illness caused by toxins that induce massive cytokine release, leading rapidly to shock and potential multi-organ failure. [1] Septic shock - While TSS is a specific diagnosis within the broader category of **sepsis/septic shock**, the acute presentation with the classic **diffuse rash** and clear association with prolonged tampon use makes TSS the most accurate diagnosis. - Septic shock is a general condition of infection-induced circulatory failure but lacks the specific **sunburn-like rash** and classic toxin etiology that defines TSS. Pelvic Inflammatory Disease - PID typically presents with **lower abdominal pain**, **cervical motion tenderness**, and purulent vaginal discharge, rather than rapid-onset systemic shock and generalized diffuse rash. - Although PID is an ascending infection often causing fever, it rarely leads to the swift and profound **hypotension** and multi-organ dysfunction characteristic of TSS. Streptococcal pharyngitis - This infection primarily presents with **sore throat**, fever, and sometimes exudates on the tonsils; it is locally confined and generally does not cause sudden, severe **hypotension** or systemic collapse. - While *Streptococcus pyogenes* can also cause a toxic shock syndrome, simple pharyngitis lacks the multi-system involvement, hypotensive crisis, and definitive association with **tampon usage** seen in this presentation. [1]

Q: A 20-year-old male was admitted with fever, headache and retro-orbital pain with rash. The tourniquet test is positive. What is the diagnosis?

Dengue hemorrhagic fever. ***Dengue hemorrhagic fever***- The combination of high fever, **headache**, **retro-orbital pain**, and rash is characteristic of classic Dengue fever (breakbone fever) [1].- A **positive tourniquet test** suggests increased capillary fragility, which, along with the other symptoms, strongly indicates progression toward **Dengue hemorrhagic fever (DHF)** [1].*Malaria*- Malaria is characterized by cyclical fever patterns (such as tertian or quartan), often associated with severe chills and sweats, which are not mentioned here.- It typically does not cause prominent retro-orbital pain or lead to a positive **tourniquet test** as a primary finding.*Measles*- Measles is typically preceded by a prodrome including cough, coryza, and conjunctivitis, followed by the appearance of **Koplik spots** (buccal lesions).- The rash starts on the face and spreads downwards, and while fever is present, the key combination of **retro-orbital pain** and a positive tourniquet test is not characteristic.*Japanese encephalitis*- This is primarily a **neuroinvasive disease** transmitted by Culex mosquitoes, leading to symptoms like altered mental status, seizures, and focal neurological deficits.- Simple fever, headache, and rash without significant encephalopathy make this diagnosis less likely, and it is not typically associated with the **tourniquet test**.

Q: What is the eye manifestation seen in HLA B27-positive patients with ulcerative colitis?

Uveitis. ***Uveitis***- **Anterior uveitis** (or iritis) is the most common ocular manifestation associated with **HLA-B27 positive spondyloarthropathies** (like ankylosing spondylitis), which frequently co-occur with **ulcerative colitis** (UC) [1].- This association highlights a shared inflammatory pathway between the gut, joints, and eyes, typical of **extra-intestinal manifestations of IBD** [2]. *Conjunctivitis*- **Conjunctivitis** is a non-specific, less severe eye manifestation sometimes seen in IBD, but it does not carry the strong, specific association with the **HLA-B27** genotype.- It typically involves inflammation of the conjunctiva and is generally self-limiting, unlike the vision-threatening nature of uveitis.*Scleritis*- **Scleritis** involves painful, severe inflammation of the sclera and is a less frequent, though severe, ocular complication of IBD.- While associated with UC, scleritis is clinically distinct from uveitis and is more strongly linked to systemic vasculitides like **Polyarteritis Nodosa** or **Rheumatoid Arthritis** rather than the primary HLA-B27/IBD link.*Iridocyclitis*- **Iridocyclitis** is anatomically synonymous with **anterior uveitis**, describing inflammation of the iris and ciliary body.- As **Uveitis** is the standard, encompassing term used in MCQs for the classic HLA-B27 associated ocular pathology, it is the best fit, even though iridocyclitis describes the pathology precisely.

Question 1

Which medication can be administered to reduce the frequency of future headache episodes in a 26-year-old female patient who experiences one-sided pulsating headaches accompanied by nausea, vomiting, and sensitivity to light and finds relief in a dimly lit environment?

Accepted Answer

Propranolol

Answer

Diazepam

Answer

Fluoxetine

Answer

Alprazolam

Question 2

A patient presents with complaints of excessive thirst and increased urination of around 6–7 liters per day. He had a history of cerebral trauma one month ago. What is the most appropriate treatment?

Accepted Answer

Desmopressin

Answer

Hydrochlorothiazide

Answer

Tolvaptan

Answer

Insulin

Question 3

A patient with known rheumatic heart disease is now found to have a 1–2 cm aneurysm on imaging. What is the most appropriate next step in management?

Accepted Answer

IV antibiotics

Answer

Aspirin for 3 weeks

Answer

Aspirin lifelong

Answer

Aspirin + Clopidogrel

Question 4

A patient with asthma on inhaled corticosteroids and LABA continues to have exacerbations. FEV1 is normal, and there is no improvement with salbutamol challenge. The symptoms worsen seasonally. Which of the following is the most appropriate next step?

Accepted Answer

Increase dose of ICS

Answer

Add Omalizumab

Answer

Add Theophylline

Answer

Add LAMA

Question 5

A patient presents with blackish discoloration of the nasal cavity and posterior buccal mucosa. He has a history of high-dose steroid use. What is the most appropriate drug for treatment?

Accepted Answer

Amphotericin B

Answer

Fluconazole

Answer

Griseofulvin

Answer

Itraconazole

Question 6

A patient with hypertension is taking anti-hypertensive drugs but BP is not controlled even after adding diuretics in treatment. Patient's serum electrolyte shows hypokalemia. What is the next step in treatment of this patient?

Accepted Answer

Spironolactone

Answer

KCL

Answer

Hydrochlorothiazide

Answer

Torasemide

Question 7

A patient presents with fever after returning from a forest trip. On examination, a black eschar is noted on the abdomen. Which of the following is the most likely diagnosis and its drug of choice?

Accepted Answer

Doxycycline

Answer

Ceftriaxone

Answer

Penicillin

Answer

Artesunate

Question 8

A woman presents with sudden-onset high-grade fever, hypotension, diffuse rash, and a history of using a tampon for an extended period. What is the most likely diagnosis?

Accepted Answer

Toxic Shock Syndrome

Answer

Septic shock

Answer

Pelvic Inflammatory Disease

Answer

Streptococcal pharyngitis

Question 9

A 20-year-old male was admitted with fever, headache and retro-orbital pain with rash. The tourniquet test is positive. What is the diagnosis?

Accepted Answer

Dengue hemorrhagic fever

Answer

Malaria

Answer

Japanese encephalitis

Answer

Measles

Question 10

What is the eye manifestation seen in HLA B27-positive patients with ulcerative colitis?

Accepted Answer

Uveitis

Answer

Iridocyclitis

Answer

Scleritis

Answer

Conjunctivitis

FMGE 2025 — Internal Medicine