FMGE 2018 — Internal Medicine
29 Previous Year Questions with Answers & Explanations
How many blood samples should be drawn in cases of fever of unknown origin to optimize detection of intermittent bacteremia?
Which of the following diseases is MOST likely to present with proteinuria?
Which of the following statements is true regarding von Willebrand disease?
All of the following are features of Zollinger Ellison syndrome except:
Refractory Septic shock is defined as?
On ECG, ST segment elevation is seen in all of the following conditions EXCEPT:
Single heart sound (S2) is heard in:
Most common cause of facial nerve palsy:
Most common site of intracranial metastasis is from primary carcinoma of
A child with diarrhea has deep & rapid respiration. Most likely diagnosis is:
FMGE 2018 - Internal Medicine FMGE Practice Questions and MCQs
Question 1: How many blood samples should be drawn in cases of fever of unknown origin to optimize detection of intermittent bacteremia?
- A. 2
- B. 3 (Correct Answer)
- C. 1
- D. 4
Explanation: ***3*** - Drawing **three separate blood samples** significantly increases the likelihood of detecting intermittent bacteremia, as bacteria may not always be present in high concentrations in the bloodstream. - This practice maximizes the diagnostic yield while minimizing the risk of false positives from contamination. *1* - A single blood sample has a **low sensitivity** for detecting intermittent bacteremia, as transient presence of bacteria might be missed. - Relying on one sample increases the chance of a **false negative**, delaying appropriate treatment. *2* - While two samples are better than one, they still may not be sufficient to reliably detect **intermittent bacteremia** which can fluctuate. - This quantity might be acceptable for some conditions but is suboptimal for robust exclusion of **bacteremia in FUO** [1]. *4* - While four samples might slightly increase sensitivity over three, the **incremental benefit** in diagnostic yield is often negligible. - This approach adds to the **patient discomfort** and increases resource utilization without substantial additional diagnostic value.
Question 2: Which of the following diseases is MOST likely to present with proteinuria?
- A. Aneurysms
- B. Polycystic kidney disease
- C. Diabetic nephropathy (Correct Answer)
- D. Glomerulonephritis
Explanation: ***Glomerulonephritis*** [1], [2] - It is characterized by **inflammation of the glomeruli**, leading to significant **proteinuria** due to increased permeability [1]. - Commonly associated with **hematuria** and **edema**, which further supports its presence in renal pathology [1], [2]. *Polycystic kidney disease* - Mainly presents with **renal cysts** and may have **hematuria** but does not typically cause significant proteinuria early on. - Proteinuria can occur later due to renal insufficiency, but is not a hallmark feature of the disease. *Pyelonephritis* - This condition primarily causes **inflammatory changes** in the kidney due to infection, leading to **fever** and **flank pain**, rather than proteinuria. - While mild proteinuria may occur, it is usually characterized by **white blood cells** and bacteria in the urine rather than significant protein loss. *Ateriitis* - Typically refers to **inflammation of the arteries**, which does not involve kidney structures directly related to proteinuria [3]. - This condition is associated with other systemic symptoms but rarely presents with notable **urinary protein loss** [3].
Question 3: Which of the following statements is true regarding von Willebrand disease?
- A. Factor VIII levels are always normal.
- B. Platelet count is consistently decreased.
- C. Bleeding time is prolonged due to impaired platelet adhesion. (Correct Answer)
- D. Activated partial thromboplastin time (aPTT) is always normal.
Explanation: Normal prothrombin time (PT) - In von Willebrand disease, **PT remains normal**, which indicates that the extrinsic pathway of coagulation is unaffected [1]. - This disorder primarily affects **platelet function** and vWF levels, not prothrombin time. *Platelet count may be decreased in some cases* - While platelet count can be low, it is not a consistent finding in von Willebrand disease; often, **platelet count is normal**. - The disorder primarily involves **qualitative abnormalities** in platelets due to impaired vWF function, rather than quantitative [3]. *Bleeding time is prolonged* - Bleeding time is typically **prolonged** in von Willebrand disease, which reflects platelet dysfunction, but this statement does not correctly state its context. - The disease affects **hemostasis**, leading to increased bleeding tendencies rather than maintaining normal bleeding times. *Normal activated partial thromboplastin time (aPTT)* - In von Willebrand disease, **aPTT may be prolonged** due to the deficiency of factor VIII, which is carried by vWF [2]. - The presence of normal aPTT does not reflect the disease's impact on the intrinsic pathway of coagulation.
Question 4: All of the following are features of Zollinger Ellison syndrome except:
- A. Severe diarrhoea
- B. Beta cell tumours of the pancreas (Correct Answer)
- C. Very high acid output
- D. Intractable peptic ulcers
Explanation: ***Beta cell tumours of the pancreas*** - Zollinger-Ellison syndrome (ZES) is caused by **gastrinomas**, which are **neuroendocrine tumors** that typically arise from the **gastrin-producing G cells**, not the insulin-producing beta cells, of the pancreas or duodenum. - While pancreatic tumors are common in ZES, they are specifically **gastrinomas**, leading to excessive gastrin secretion. *Severe diarrhoea* - This is a common feature of ZES resulting from the **high acid output** reaching the small intestine. - The excessive acid inactivates pancreatic lipase, leading to **maldigestion** and stimulates fluid and electrolyte secretion, causing secretory diarrhea. *Very high acid output* - ZES is characterized by the **overproduction of gastrin**, which stimulates the parietal cells of the stomach to secrete large amounts of **hydrochloric acid**. - This leads to a significantly **increased basal and maximal acid output** in the stomach. *Intractable peptic ulcers* - The extremely high gastric acid secretion in ZES causes **multiple, recurrent, and often refractory peptic ulcers**, which can be located in atypical sites such as the jejunum. - These ulcers are typically difficult to treat with standard anti-ulcer medications due to the persistent gastric hypersecretion.
Question 5: Refractory Septic shock is defined as?
- A. Shock requiring mechanical ventilation and inotropic support
- B. Shock with lactate levels >4 mmol/L despite treatment
- C. Shock that does not respond to initial fluid bolus within 1 hour
- D. Shock persisting despite adequate fluid resuscitation and vasopressor support (Correct Answer)
Explanation: ***Shock persisting despite adequate fluid resuscitation and vasopressor support*** - This is the **standard definition** of refractory septic shock according to current **Surviving Sepsis Campaign Guidelines** and critical care literature. - It specifically refers to the failure of **both fluid resuscitation and vasopressor therapy** to restore adequate mean arterial pressure and tissue perfusion. *Shock that does not respond to initial fluid bolus within 1 hour* - This describes **early non-response** to fluid therapy, which is concerning but not the complete definition of refractory shock. - Refractory shock requires failure of **comprehensive standard therapy** (fluids AND vasopressors), not just initial fluid bolus failure. *Shock requiring mechanical ventilation and inotropic support* - This describes a patient in **severe septic shock** with multi-organ support but does not define its **refractory nature**. - The need for these interventions indicates **organ dysfunction** and severity, not necessarily refractoriness to standard resuscitation efforts. *Shock with lactate levels >4 mmol/L despite treatment* - **Elevated lactate** indicates tissue hypoperfusion and ongoing shock, but it is a **severity marker**, not the definition of refractoriness. - High lactate levels can occur even in shock that is **responsive to standard therapy** and doesn't specifically indicate failure of resuscitation efforts.
Question 6: On ECG, ST segment elevation is seen in all of the following conditions EXCEPT:
- A. Acute pericarditis
- B. Myocardial infarction
- C. Left ventricular aneurysm
- D. Hypocalcemia (Correct Answer)
Explanation: ***Hypocalcemia*** - While hypocalcemia affects cardiac electrical activity by prolonging the **QT interval**, it is not typically associated with **ST segment elevation**. [3] - The primary ECG finding in hypocalcemia is a **prolonged ST segment**, which then leads to a prolonged QT interval, not an elevated ST segment. *Acute pericarditis* - Characteristically presents with **diffuse concave ST segment elevation** in many leads, often accompanied by **PR segment depression**. - This is due to inflammation of the pericardium affecting the epicardial layer of the myocardium. *Myocardial infarction* - **ST segment elevation** is a hallmark of an acute **ST-segment elevation myocardial infarction (STEMI)**, indicating transmural ischemia. [1], [2] - The location of ST elevation corresponds to the affected coronary artery and myocardial territory. [4] *Left ventricular aneurysm* - Can cause **persistent ST segment elevation** in the leads corresponding to the aneurysm, even after the acute phase of a myocardial infarction. - This persistent elevation is thought to be due to **dyskinetic or akinetic wall motion** and altered repolarization in the scarred tissue.
Question 7: Single heart sound (S2) is heard in:
- A. Transposition of great vessels
- B. Ebstein's anomaly
- C. Tetralogy of Fallot (Correct Answer)
- D. TAPVC
Explanation: ***Tetralogy of Fallot*** - A **single S2 heart sound** is characteristic of Tetralogy of Fallot due to the **pulmonary stenosis** (or atresia) which prevents the closure sound of the pulmonary valve from being heard [1]. - The single S2 heard is typically the **aortic component** (A2), as the pulmonary component (P2) is diminished or absent [1]. *Transposition of great vessels* - This condition is often associated with a **loud, single S2** because the aorta arises from the right ventricle, but a split S2 can occur if there is a large patent ductus arteriosus or ventricular septal defect. - The S2 is usually composed mainly of the **aortic component**, which is anteriorly placed. *Ebstein's anomaly* - Characterized by the downward displacement of the **tricuspid valve leaflets** into the right ventricle. - This typically results in a **wide, fixed splitting of S2** and can be associated with a gallop rhythm due to S3 and S4 sounds [2]. *TAPVC (Total Anomalous Pulmonary Venous Connection)* - TAPVC typically presents with a **widely split and fixed S2** due to increased blood flow through the pulmonary circulation. - When there is an obstruction, the P2 component can be louder, and a **gallop rhythm** might be present, but a single S2 is not a primary feature.
Question 8: Most common cause of facial nerve palsy:
- A. Mastoid surgery
- B. Herpes zoster oticus
- C. Chronic suppurative Otitis media
- D. Idiopathic Bell's palsy (Correct Answer)
Explanation: ***Idiopathic Bell's palsy*** - **Bell's palsy** is the most common cause of **facial nerve palsy**, accounting for approximately 60-75% of cases. - It is an **idiopathic** condition, meaning its exact cause is unknown, although it is often linked to viral infections (e.g., herpes simplex virus). [1] *Mastoid surgery* - **Iatrogenic facial nerve injury** during mastoidectomy is a known complication, but it is a relatively rare cause of facial nerve palsy. - While it can cause significant palsy, the incidence is low compared to Bell's palsy. *Herpes zoster oticus* - This condition, also known as **Ramsay Hunt syndrome**, is a cause of facial nerve palsy associated with a **vesicular rash** (zoster) in the ear canal or on the face. - While it is a significant cause of viral-induced facial palsy, it is less common than idiopathic Bell's palsy. *Chronic suppurative Otitis media* - **Chronic otitis media** can, in rare cases, lead to facial nerve palsy due to persistent inflammation spreading to the facial nerve. [2] - This is a less common etiology than Bell's palsy and would typically present with a history of recurrent ear discharge and hearing loss.
Question 9: Most common site of intracranial metastasis is from primary carcinoma of
- A. Testes
- B. Stomach
- C. Breast
- D. Lungs (Correct Answer)
Explanation: ***Lungs*** - **Lung cancer** is the most common primary tumor to metastasize to the brain, accounting for approximately **40-50% of all intracranial metastases**. - This high incidence is due to the advanced stage at diagnosis for many lung cancers and the rich vascular supply of the brain. [1] *Testes* - While germ cell tumors of the testes can metastasize to the brain, it is a relatively rare event compared to lung cancer. - Brain metastases from testicular cancer are more common with **choriocarcinoma** histology. *Stomach* - **Gastric cancer** can metastasize to the brain, but it is uncommon, occurring in less than 1% of cases. - When it does occur, it generally indicates widespread disease and a poor prognosis. *Breast* - **Breast cancer** is another common source of brain metastases, but it ranks **second to lung cancer** as a primary source. - The incidence of brain metastases from breast cancer is increasing, partly due to improved systemic treatments extending patient survival.
Question 10: A child with diarrhea has deep & rapid respiration. Most likely diagnosis is:
- A. Metabolic acidosis (Correct Answer)
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Explanation: ***Metabolic acidosis*** - Diarrhea leads to a loss of **bicarbonate** from the gastrointestinal tract, causing a decrease in blood pH [1]. - **Deep and rapid respirations** (Kussmaul breathing) are a compensatory mechanism to blow off CO2 and raise the blood pH [1], [2]. *Respiratory acidosis* - This condition results from **hypoventilation**, leading to CO2 retention and a reduced pH [2]. - Deep and rapid breathing would actually improve respiratory acidosis by expelling CO2. *Metabolic alkalosis* - Characterized by an **excess of bicarbonate** and an elevated blood pH [3]. - Compensatory mechanisms would involve decreased respiration to retain CO2, not increased [3]. *Respiratory alkalosis* - This is caused by **hyperventilation**, which leads to excessive CO2 expulsion and an elevated pH [2]. - While hyperventilation causes deep and rapid breathing, it leads to alkalosis, not acidosis (which is indicated by compensatory breathing in this scenario).