FMGE 2017 — Internal Medicine

Q: Heberden's arthropathy affects:

Distal interphalangeal joint. ***Distal interphalangeal joint*** - **Heberden's nodes** are pathognomonic bony enlargements that occur on the **distal interphalangeal (DIP) joints** of the fingers [1]. - They are a classic sign of **osteoarthritis**, resulting from cartilage degeneration and new bone formation [1]. *Lumbar spine involvement* - While osteoarthritis can affect the **lumbar spine**, it presents as **back pain** and stiffness, not as nodules on the fingers [1]. - **Heberden's nodes** are specifically associated with peripheral joint involvement, not axial skeleton [1]. *Sacroiliac joint involvement* - **Sacroiliac joint involvement** is characteristic of **spondyloarthropathies** like ankylosing spondylitis, causing inflammatory back pain [1]. - It does not present with bony nodes on the fingers, which are typical of osteoarthritic changes [1]. *Knee joint involvement* - **Knee joint involvement** is common in osteoarthritis, causing pain, swelling, and reduced range of motion [1]. - However, **Heberden's nodes** are distinct from knee symptoms and refer specifically to changes in the DIP joints [1]. [Practice more Internal Medicine PYQs on OnCourse]

Q: Meningococcal meningitis is seen with which of the following complement deficiency?

C5. ***C5*** - Deficiencies in terminal complement components (C5-C9) lead to impaired formation of the **membrane attack complex (MAC)**, which is crucial for lysing Neisseria species [1]. - This significantly increases susceptibility to recurrent infections, particularly by **encapsulated bacteria** like *Neisseria meningitidis*, causing diseases such as meningococcal meningitis [2]. *C4* - C4 deficiency is primarily associated with **lupus-like syndromes** and **vasculitis**, due to impaired clearance of immune complexes. - While it can lead to some increased risk of infection, it is not specifically linked to a marked predisposition to meningococcal disease. *C1q* - C1q deficiency also leads to impaired **immune complex clearance** and is strongly associated with **systemic lupus erythematosus (SLE)**. - Like C4 deficiency, it does not typically present with recurrent meningococcal infections as the primary manifestation. *C2* - C2 deficiency is the **most common complement deficiency** and is associated with **lupus-like syndromes** and increased susceptibility to **pyogenic bacterial infections**. - Though it can lead to some increased infection risk, C2 deficiency is not as strongly or specifically linked to recurrent meningococcal meningitis as deficiencies in the terminal complement pathway [2]. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following is not associated with pulmonary arterial hypertension?

Left ventricular hypertrophy. ***Left ventricular hypertrophy*** - **Left ventricular hypertrophy** is typically caused by conditions that increase the workload on the left ventricle, such as **systemic hypertension** or **aortic stenosis** [1]. - Pulmonary arterial hypertension directly affects the **pulmonary vasculature**, leading to increased pressure in the pulmonary circuit and ultimately right heart strain, not left ventricular hypertrophy. *Cor pulmonale* - **Cor pulmonale** is defined as **right ventricular enlargement** secondary to lung disease or pulmonary vascular disease. - Pulmonary arterial hypertension increases the afterload on the right ventricle, causing it to dilate and hypertrophy, eventually leading to **right heart failure** (cor pulmonale) [2]. *Mitral Stenosis* - **Mitral stenosis** causes an obstruction to blood flow from the left atrium to the left ventricle, leading to increased pressure in the left atrium and pulmonary veins. - This elevated pressure can be transmitted backward into the pulmonary arteries, leading to **pulmonary arterial hypertension** [3]. *Interstitial lung disease* - **Interstitial lung disease** (ILD) can lead to destruction and remodeling of the pulmonary capillaries, increasing pulmonary vascular resistance [2]. - This increased resistance causes the pulmonary arterial pressure to rise, resulting in **pulmonary arterial hypertension**. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of these is least effective as first-line treatment for dangerous hyperkalemia?

Intravenous sodium bicarbonate. ***Intravenous sodium bicarbonate*** - While it can drive potassium into cells, its effect is often **delayed and unreliable** in acute, dangerous hyperkalemia, especially without concurrent acidosis. - Its efficacy is most pronounced when hyperkalemia is associated with **metabolic acidosis**, which is not always the primary driving factor of dangerous hyperkalemia. *Calcium chloride injection* - This is a **first-line treatment** for dangerous hyperkalemia, as it **stabilizes the cardiac membrane** by antagonizing the direct effects of potassium on myocardial excitability [1]. - It does not lower serum potassium levels but **protects the heart** from life-threatening arrhythmias, buying time for other therapies to reduce potassium [1]. *Beta-2 agonist (Salbutamol)* - **Beta-2 agonists** like salbutamol are effective in shifting potassium **intracellularly**, thereby lowering serum potassium levels. - This effect is mediated by stimulating the **Na+/K+-ATPase pump** on cell membranes. *Dialysis (Hemodialysis)* - **Hemodialysis** is the **most effective and rapid** method for removing excess potassium from the body, especially in cases of severe or refractory hyperkalemia. - It provides definitive treatment by directly **filtering potassium** from the blood, and is often considered when other measures fail or in patients with kidney failure. [Practice more Internal Medicine PYQs on OnCourse]

Q: All of the following syndromes are seen with obesity except:

Carcinoid syndrome. ***Carcinoid syndrome*** - Carcinoid syndrome is caused by **neuroendocrine tumors** that secrete **serotonin** and other vasoactive substances, leading to symptoms like flushing, diarrhea, and bronchospasm [2]. **Obesity is not a primary feature** of this syndrome. - The symptoms are directly related to the **hormonal effects** of the secreted substances, not to metabolic alterations associated with obesity. *Laurence Moon - Biedl syndrome* - This is a **rare genetic disorder** characterized by **obesity**, retinitis pigmentosa, polydactyly, intellectual disability, and hypogonadism [1]. - Obesity is a **consistent and prominent feature** of this syndrome, often present from childhood. *Cohen syndrome* - Cohen syndrome is a rare genetic disorder characterized by **obesity** (especially truncal obesity), intellectual disability, microcephaly, characteristic facial features, and hypotonia. - While not as universally severe as in some other syndromes, **obesity is a common clinical feature** of Cohen syndrome. *Prader - Willi syndrome* - Prader-Willi syndrome is a genetic disorder caused by a deletion on chromosome 15, leading to **insatiable hunger (hyperphagia)** and chronic overeating, which results in **severe obesity** [1]. - **Obesity is a cardinal feature** of this syndrome, developing in early childhood due to hypothalamic dysfunction affecting appetite control. [Practice more Internal Medicine PYQs on OnCourse]

14 Previous Year Questions with Answers & Explanations

Questions

All Subjects Anatomy (10)Biochemistry (4)Community Medicine (2)Dental (1)Dermatology (1)Internal Medicine (14)Microbiology (2)Obstetrics and Gynecology (3)Ophthalmology (2)Orthopaedics (2)Pathology (5)Pediatrics (2)Pharmacology (16)Physiology (5)Psychiatry (6)Radiology (1)Surgery (2)

Heberden's arthropathy affects:

Meningococcal meningitis is seen with which of the following complement deficiency?

Which of the following is not associated with pulmonary arterial hypertension?

Which of these is least effective as first-line treatment for dangerous hyperkalemia?

All of the following syndromes are seen with obesity except:

Tropical pulmonary eosinophilia is most characteristically seen due to which of the following infections?

Which of the following is true about carcinoid tumor?

Fatty liver with hepatomegaly is seen in:

Painless burn in hand is seen in:

Q10

Which type of anemia is seen in patients of rheumatoid arthritis?

FMGE 2017 - Internal Medicine FMGE Practice Questions and MCQs

Question 1: Heberden's arthropathy affects:

A. Distal interphalangeal joint (Correct Answer)
B. Lumbar spine involvement
C. Sacroiliac joint involvement
D. Knee joint involvement

Explanation: ***Distal interphalangeal joint*** - **Heberden's nodes** are pathognomonic bony enlargements that occur on the **distal interphalangeal (DIP) joints** of the fingers [1]. - They are a classic sign of **osteoarthritis**, resulting from cartilage degeneration and new bone formation [1]. *Lumbar spine involvement* - While osteoarthritis can affect the **lumbar spine**, it presents as **back pain** and stiffness, not as nodules on the fingers [1]. - **Heberden's nodes** are specifically associated with peripheral joint involvement, not axial skeleton [1]. *Sacroiliac joint involvement* - **Sacroiliac joint involvement** is characteristic of **spondyloarthropathies** like ankylosing spondylitis, causing inflammatory back pain [1]. - It does not present with bony nodes on the fingers, which are typical of osteoarthritic changes [1]. *Knee joint involvement* - **Knee joint involvement** is common in osteoarthritis, causing pain, swelling, and reduced range of motion [1]. - However, **Heberden's nodes** are distinct from knee symptoms and refer specifically to changes in the DIP joints [1].

Question 2: Meningococcal meningitis is seen with which of the following complement deficiency?

A. C4
B. C1q
C. C5 (Correct Answer)
D. C2

Explanation: ***C5*** - Deficiencies in terminal complement components (C5-C9) lead to impaired formation of the **membrane attack complex (MAC)**, which is crucial for lysing Neisseria species [1]. - This significantly increases susceptibility to recurrent infections, particularly by **encapsulated bacteria** like *Neisseria meningitidis*, causing diseases such as meningococcal meningitis [2]. *C4* - C4 deficiency is primarily associated with **lupus-like syndromes** and **vasculitis**, due to impaired clearance of immune complexes. - While it can lead to some increased risk of infection, it is not specifically linked to a marked predisposition to meningococcal disease. *C1q* - C1q deficiency also leads to impaired **immune complex clearance** and is strongly associated with **systemic lupus erythematosus (SLE)**. - Like C4 deficiency, it does not typically present with recurrent meningococcal infections as the primary manifestation. *C2* - C2 deficiency is the **most common complement deficiency** and is associated with **lupus-like syndromes** and increased susceptibility to **pyogenic bacterial infections**. - Though it can lead to some increased infection risk, C2 deficiency is not as strongly or specifically linked to recurrent meningococcal meningitis as deficiencies in the terminal complement pathway [2].

Question 3: Which of the following is not associated with pulmonary arterial hypertension?

A. Cor - pulmonale
B. Left ventricular hypertrophy (Correct Answer)
C. Mitral Stenosis
D. Interstitial lung disease

Explanation: ***Left ventricular hypertrophy*** - **Left ventricular hypertrophy** is typically caused by conditions that increase the workload on the left ventricle, such as **systemic hypertension** or **aortic stenosis** [1]. - Pulmonary arterial hypertension directly affects the **pulmonary vasculature**, leading to increased pressure in the pulmonary circuit and ultimately right heart strain, not left ventricular hypertrophy. *Cor pulmonale* - **Cor pulmonale** is defined as **right ventricular enlargement** secondary to lung disease or pulmonary vascular disease. - Pulmonary arterial hypertension increases the afterload on the right ventricle, causing it to dilate and hypertrophy, eventually leading to **right heart failure** (cor pulmonale) [2]. *Mitral Stenosis* - **Mitral stenosis** causes an obstruction to blood flow from the left atrium to the left ventricle, leading to increased pressure in the left atrium and pulmonary veins. - This elevated pressure can be transmitted backward into the pulmonary arteries, leading to **pulmonary arterial hypertension** [3]. *Interstitial lung disease* - **Interstitial lung disease** (ILD) can lead to destruction and remodeling of the pulmonary capillaries, increasing pulmonary vascular resistance [2]. - This increased resistance causes the pulmonary arterial pressure to rise, resulting in **pulmonary arterial hypertension**.

Question 4: Which of these is least effective as first-line treatment for dangerous hyperkalemia?

A. Calcium chloride injection
B. Beta-2 agonist (Salbutamol)
C. Intravenous sodium bicarbonate (Correct Answer)
D. Dialysis (Hemodialysis)

Explanation: ***Intravenous sodium bicarbonate*** - While it can drive potassium into cells, its effect is often **delayed and unreliable** in acute, dangerous hyperkalemia, especially without concurrent acidosis. - Its efficacy is most pronounced when hyperkalemia is associated with **metabolic acidosis**, which is not always the primary driving factor of dangerous hyperkalemia. *Calcium chloride injection* - This is a **first-line treatment** for dangerous hyperkalemia, as it **stabilizes the cardiac membrane** by antagonizing the direct effects of potassium on myocardial excitability [1]. - It does not lower serum potassium levels but **protects the heart** from life-threatening arrhythmias, buying time for other therapies to reduce potassium [1]. *Beta-2 agonist (Salbutamol)* - **Beta-2 agonists** like salbutamol are effective in shifting potassium **intracellularly**, thereby lowering serum potassium levels. - This effect is mediated by stimulating the **Na+/K+-ATPase pump** on cell membranes. *Dialysis (Hemodialysis)* - **Hemodialysis** is the **most effective and rapid** method for removing excess potassium from the body, especially in cases of severe or refractory hyperkalemia. - It provides definitive treatment by directly **filtering potassium** from the blood, and is often considered when other measures fail or in patients with kidney failure.

Question 5: All of the following syndromes are seen with obesity except:

A. Laurence Moon - Biedl syndrome
B. Cohen syndrome
C. Prader - Willi syndrome
D. Carcinoid syndrome (Correct Answer)

Explanation: ***Carcinoid syndrome*** - Carcinoid syndrome is caused by **neuroendocrine tumors** that secrete **serotonin** and other vasoactive substances, leading to symptoms like flushing, diarrhea, and bronchospasm [2]. **Obesity is not a primary feature** of this syndrome. - The symptoms are directly related to the **hormonal effects** of the secreted substances, not to metabolic alterations associated with obesity. *Laurence Moon - Biedl syndrome* - This is a **rare genetic disorder** characterized by **obesity**, retinitis pigmentosa, polydactyly, intellectual disability, and hypogonadism [1]. - Obesity is a **consistent and prominent feature** of this syndrome, often present from childhood. *Cohen syndrome* - Cohen syndrome is a rare genetic disorder characterized by **obesity** (especially truncal obesity), intellectual disability, microcephaly, characteristic facial features, and hypotonia. - While not as universally severe as in some other syndromes, **obesity is a common clinical feature** of Cohen syndrome. *Prader - Willi syndrome* - Prader-Willi syndrome is a genetic disorder caused by a deletion on chromosome 15, leading to **insatiable hunger (hyperphagia)** and chronic overeating, which results in **severe obesity** [1]. - **Obesity is a cardinal feature** of this syndrome, developing in early childhood due to hypothalamic dysfunction affecting appetite control.

Question 6: Tropical pulmonary eosinophilia is most characteristically seen due to which of the following infections?

A. Roundworm
B. Trichinella
C. Ancylostoma
D. Filaria (Correct Answer)

Explanation: *Filaria* - **Tropical pulmonary eosinophilia (TPE)** is a hypersensitivity reaction to microfilariae from filarial nematodes like *Wuchereria bancrofti* and *Brugia malayi* [1]. - It is characterized by cough, dyspnea, wheezing, and marked **peripheral eosinophilia**, with interstitial infiltrates on chest X-ray [1]. *Roundworm* - **Ascaris lumbricoides** can cause **Loeffler's syndrome**, a transient pulmonary infiltration with eosinophilia during larval migration, but not chronic TPE [2]. - Symptoms are usually less severe and self-limiting compared to TPE [2]. *Trichinella* - **Trichinella spiralis** causes **trichinellosis**, presenting with muscle pain, fever, and periorbital edema, possibly with eosinophilia, but typically does not manifest as TPE. - Pulmonary involvement is rare and not the characteristic feature. *Ancylostoma* - **Hookworm (Ancylostoma duodenale, Necator americanus)** larvae can cause mild pulmonary symptoms and eosinophilia during migration through the lungs [3]. - However, they also do not typically lead to the severe and chronic pulmonary symptoms seen in TPE [3].

Question 7: Which of the following is true about carcinoid tumor?

A. Presentation is hypotension and diaphoresis
B. Intestinal carcinoids are of high malignant potential
C. Best diagnosed by elevated urinary vanillymandelic acid levels
D. Can occur throughout the gastrointestinal tract (Correct Answer)

Explanation: ***Can occur throughout the gastrointestinal tract*** - Carcinoid tumors (neuroendocrine tumors) are most commonly found in the **gastrointestinal tract**, particularly in the small intestine, appendix, rectum, and stomach [2]. - They arise from **enterochromaffin cells** and can secrete various vasoactive substances. *Presentation is hypotension and diaphoresis* - The classic presentation of **carcinoid syndrome** includes episodes of **flushing**, **diarrhea**, and **bronchospasm**, often accompanied by **hypertension** rather than hypotension due to the release of serotonin and other vasoactive peptides [1]. - While diaphoresis can occur, **hypotension** is not a primary or characteristic feature. *Intestinal carcinoids are of high malignant potential* - The malignant potential of carcinoid tumors varies depending on their primary site and size but is generally considered to be of **low-to-moderate malignant potential**, particularly for appendiceal and rectal carcinoids [2]. - Liver metastases significantly increase morbidity and mortality, but many small intestinal carcinoids may grow slowly or remain localized for extended periods [1]. *Best diagnosed by elevated urinary vanillymandelic acid levels* - Elevated **urinary vanillymandellic acid (VMA)** levels are primarily used to diagnose **pheochromocytoma**, a tumor of the adrenal medulla that secretes catecholamines. - Carcinoid tumors are best diagnosed by measuring **urinary 5-hydroxyindoleacetic acid (5-HIAA)**, a breakdown product of serotonin.

Question 8: Fatty liver with hepatomegaly is seen in:

A. Marasmus
B. Nutmeg liver
C. Metabolic syndrome (Correct Answer)
D. Wilson disease

Explanation: ***Metabolic syndrome*** - **Metabolic syndrome** is characterized by a cluster of conditions, including **insulin resistance**, obesity, hypertension, and dyslipidemia, which frequently lead to **non-alcoholic fatty liver disease (NAFLD)** and subsequent hepatomegaly [1]. - The accumulation of fat in the liver is a direct consequence of the metabolic derangements, leading to hepatic steatosis, inflammation, and potential fibrosis, with **hepatomegaly** often being a palpable clinical sign [1]. *Marasmus* - **Marasmus** is a form of severe protein-energy malnutrition characterized by significant **weight loss** and muscle wasting, but typically **does not involve fatty liver** or hepatomegaly. - In marasmus, caloric intake is severely deficient, leading to the mobilization of fat stores rather than accumulation in the liver [2]. *Nutmeg liver* - **Nutmeg liver** is a characteristic pathological finding in **congestive hepatopathy**, most often due to **right-sided heart failure**. - It results from chronic passive venous congestion, causing a mottled appearance with alternating areas of congestion and normal parenchyma, but not primarily **fatty infiltration**. *Wilson disease* - **Wilson disease** is a rare genetic disorder of **copper metabolism** that leads to excessive copper accumulation in various organs, including the liver, brain, and eyes. - While it can cause hepatomegaly and liver disease, the primary pathology is copper overload, not **fatty infiltration**, though steatosis can occur secondary to chronic liver injury. *Additional Note* - Enlargement of the liver due to fatty infiltration occurs when triacylglycerol accumulation exceeds the liver's capacity to secrete VLDL, a process seen in conditions like uncontrolled diabetes and certain metabolic stresses [2].

Question 9: Painless burn in hand is seen in:

A. SLE
B. Mononeuritis multiplex
C. Diabetes mellitus
D. Syringomyelia (Correct Answer)

Explanation: ***Syringomyelia*** - Syringomyelia is characterized by a fluid-filled cavity (syrinx) within the **spinal cord**, which can damage nerve fibers responsible for pain and temperature sensation. - This damage leads to a **dissociated sensory loss**, where patients lose the ability to feel pain and temperature but retain touch and vibration, making them susceptible to **painless burns** or injuries. *SLE* - **Systemic lupus erythematosus (SLE)** is an autoimmune disease that can affect various organs, but it does not typically cause a dissociated sensory loss leading to painless burns. - Neurological manifestations in SLE are diverse, ranging from headaches to seizures, but they rarely involve selective loss of pain and temperature sensation in a way that causes painless burns. *Mononeuritis multiplex* - **Mononeuritis multiplex** involves damage to at least two distinct nerve areas, often causing pain, weakness, and sensory loss in a patchy distribution, but usually includes pain. - This condition is not typically characterized by a complete and selective loss of **pain and temperature sensation** in a way that would lead to painless burns without other significant sensory deficits. *Diabetes mellitus* - **Diabetic neuropathy** commonly causes sensory loss, often a "stocking-glove" distribution, which can lead to painless injuries due to reduced pain sensation. - However, diabetic neuropathy primarily affects **small fiber nerves** and is more generalized, unlike the more selective **dissociated sensory loss** seen in syringomyelia that specifically explains painless burns.

Question 10: Which type of anemia is seen in patients of rheumatoid arthritis?

A. Normocytic and normochromic anemia (Correct Answer)
B. Normocytic and hypochromic anemia
C. Sideroblastic anemia
D. Macrocytic anemia

Explanation: The anemia seen in **rheumatoid arthritis (RA)** is typically **anemia of chronic disease**, characterized by **normal-sized red blood cells (normocytic)** and **normal hemoglobin content (normochromic)**. This type of anemia is caused by **chronic inflammation** leading to impaired iron utilization and reduced erythropoiesis [1], [2]. This type of anemia is associated with inflammation-mediated upregulation of hepcidin [1]. Although iron deficiency can coexist in RA patients, the primary anemia of chronic disease mechanism generally results in normochromic cells [2].