Which of the following conditions should not be considered if JVP rises on deep inspiration?
Initial treatment for management of mild to moderate Crohn's disease is:
Which of the following leads to development of SIADH?
Which of the following is the best investigation for acute gout?
FMGE 2017 - Internal Medicine FMGE Practice Questions and MCQs
Question 11: Which of the following conditions should not be considered if JVP rises on deep inspiration?
- A. Complete heart block
- B. Constrictive pericarditis
- C. Restrictive cardiomyopathy
- D. Atrial fibrillation (Correct Answer)
Explanation: The phenomenon of JVP rising on deep inspiration is known as **Kussmaul's sign**, which is indicative of impaired right ventricular filling and is not typically associated with **atrial fibrillation**. In **complete heart block**, there is dissociation between atrial and ventricular contractions. This can lead to **cannon 'a' waves** in the JVP, which are large prominent 'a' waves caused by right atrial contraction against a closed tricuspid valve [1]. **Constrictive pericarditis** is characterized by a rigid pericardium that restricts diastolic filling of the right ventricle. This condition is a classic cause of **Kussmaul's sign**, where the JVP rises paradoxically during inspiration due to increased venous return that cannot be accommodated by the constricted ventricle. **Restrictive cardiomyopathy** involves impaired diastolic filling of the ventricles due to myocardial stiffness. It can also cause a paradoxical rise in JVP during inspiration (**Kussmaul's sign**) because the stiffened right ventricle cannot adequately accommodate the inspiratory increase in venous return.
Question 12: Initial treatment for management of mild to moderate Crohn's disease is:
- A. Mesalamine
- B. Infliximab
- C. Sulfasalazine
- D. Budesonide (Correct Answer)
Explanation: ***Budesonide*** - **Budesonide** is a **steroid** with high first-pass metabolism, meaning it works locally in the gastrointestinal tract with minimal systemic effects, making it suitable for mild to moderate Crohn's disease. - It is effective in inducing remission for mild to moderate ileocolonic Crohn's disease, with a better safety profile than systemic corticosteroids. *Mesalamine* - **Mesalamine (5-ASA)** is primarily used for **ulcerative colitis** and has limited efficacy in Crohn's disease, especially for moderate disease. - While it can be considered for very mild Crohn's disease, its role is often debated and not a first-line agent for moderate cases. *Infliximab* - **Infliximab** is a **biologic agent (anti-TNF-α)** used for moderate to severe Crohn's disease or for patients who have failed conventional therapy. - It works by blocking a key inflammatory cytokine and is not typically used as initial treatment for mild disease due to its potency and potential side effects. *Sulfasalazine* - **Sulfasalazine** is more effective in **colonic Crohn's disease** and **ulcerative colitis**, and its efficacy in small bowel Crohn's disease is limited [1]. - Many patients experience side effects such as **nausea**, **headaches**, and **allergic reactions**, limiting its use as a first-line agent.
Question 13: Which of the following leads to development of SIADH?
- A. Lung cancer
- B. Pituitary adenoma
- C. CNS disorders (Correct Answer)
- D. All of the options
Explanation: ***CNS disorders*** - Neurological conditions such as **stroke**, hemorrhage, infection, and trauma can cause inappropriate **ADH release** due to damage or irritation of the hypothalamus or posterior pituitary [2]. - This leads to increased water reabsorption and subsequent **hyponatremia** characteristic of SIADH [1]. *Lung cancer* - Certain types of **lung cancer**, particularly **small cell lung carcinoma (SCLC)**, are known to produce ADH ectopically, leading to SIADH. - This represents a **paraneoplastic syndrome**, where the tumor cells independently synthesize and secrete ADH. *Pituitary adenoma* - While pituitary adenomas can cause various endocrine dysfunctions, they are generally **not a direct cause of SIADH**. - **SIADH** typically results from unregulated ADH secretion rather than a primary pituitary tumor's overproduction of ADH itself. *All of the options* - Although **lung cancer** and **CNS disorders** are well-established causes of SIADH, **pituitary adenomas** are not a common or direct cause. - Therefore, choosing "all of the options" would be incorrect due to the inclusion of pituitary adenoma as a direct cause.
Question 14: Which of the following is the best investigation for acute gout?
- A. Uric acid in urine
- B. Anti CCP antibodies
- C. Serum uric acid
- D. Uric acid in synovial fluid (Correct Answer)
Explanation: ***Uric acid in synovial fluid*** - The definitive diagnosis of acute gout is established by identifying **negatively birefringent needle-shaped uric acid crystals** within the synovial fluid of the affected joint [1]. - This method directly confirms the presence of **monosodium urate crystals**, which are the hallmark of gout, offering diagnostic certainty [1]. *Uric acid in urine* - While urinary uric acid levels can help assess uric acid excretion, they are not diagnostic for acute gout and do not directly show the presence of **intra-articular crystals**. - This test is more relevant for investigating the **cause of hyperuricemia** (overproduction vs. underexcretion) rather than diagnosing an acute flare. *Anti CCP antibodies* - **Anti-cyclic citrullinated peptide (anti-CCP) antibodies** are markers for **rheumatoid arthritis** and are not relevant for the diagnosis of acute gout. - Their presence indicates an autoimmune inflammatory condition distinct from crystal-induced arthropathy. *Serum uric acid* - Serum uric acid levels are often elevated during an acute gout flare (**hyperuricemia**), but this is not diagnostic, as many individuals with hyperuricemia never develop gout [1]. - Approximately 30% of patients may have **normal serum uric acid levels** during an acute attack, making it an unreliable sole diagnostic criterion.