FMGE 2019 — Internal Medicine

Q: Which of these conditions is classified as a nephritic syndrome?

Post Infectious Glomerulonephritis. ***Post infectious Glomerulonephritis*** - Characterized by **hematuria, hypertension, and edema**, typically following an infection, such as streptococcal pharyngitis [2]. - Immune-mediated response leads to **decreased GFR** and signs of nephritic syndrome [1][2]. *Focal segmental glomerulosclerosis* - Primarily causes **nephrotic syndrome**, characterized by proteinuria and edema rather than hematuria [2]. - Often associated with **secondary causes** like obesity or HIV, not typically post-infectious. *Membranous Glomerulopathy* - Results in significant **proteinuria** and is classified as a **nephrotic syndrome** rather than a nephritic one [2][3]. - It presents with **edema and hypoalbuminemia**, lacking the hallmark features of hematuria. *Minimal change disease* - Predominantly causes **nephrotic syndrome** with heavy proteinuria and little to no hematuria [2]. - Young children are commonly affected, and it responds well to **corticosteroid therapy** [1]. [Practice more Internal Medicine PYQs on OnCourse]

Q: A 20-year-old male presented with fatigue, weakness, and jaundice. What is the most likely diagnosis?

Acute myeloid leukemia. ***Acute myeloid leukemia*** - Presents with **fatigue** and **weakness** due to bone marrow infiltration and resultant cytopenias, typical in this age group [1]. - Often shows **myeloblasts** on peripheral blood smear, confirming the diagnosis [2]. *Chronic myeloid leukemia* - Usually occurs in **older adults** and characterized by **elevated white blood cell counts** with a predominance of mature neutrophils. - Symptoms like fatigue may arise, but there are distinct **Philadelphia chromosome** findings and typically a **longer symptom duration**. *Acute lymphoblastic leukemia* - More common in **younger children** and often associated with **lymphadenopathy** and **thrombocytopenia**, rather than fatigue alone. - Characteristically shows **lymphoblasts** in the blood, which are not mentioned in this patient's presentation. *Chronic lymphocytic leukemia* - Typically presents in adults over **50 years** and is characterized by **lymphocytosis** and often asymptomatic in early stages. - Fatigue may occur but lacks the acute presentation and findings seen in **acute leukemias**. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 607-608. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 621-622. [Practice more Internal Medicine PYQs on OnCourse]

Q: Hemolytic uraemic syndrome is associated with

E. coli 0157. ***E. coli O157*** - **Hemolytic uremic syndrome (HUS)** is most commonly associated with infection by **Shiga toxin-producing E. coli (STEC)**, particularly serotype O157:H7 [2]. - The Shiga toxin damages the **endothelium** of blood vessels, leading to **thrombotic microangiopathy**, which manifests as **hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury** [1], [2]. *Bartonella henselae* - This bacterium is the causative agent of **cat scratch disease**, characterized by **lymphadenopathy** and sometimes systemic symptoms. - It is not typically associated with hemolytic uremic syndrome. *Malaria* - Malaria is a **parasitic infection** transmitted by mosquitoes, causing **fever**, **chills**, and **anemia** due to red blood cell lysis. - While it can cause anemia, it does not directly lead to the thrombotic microangiopathy of HUS. *Parvovirus B19* - **Parvovirus B19** causes **erythema infectiosum (fifth disease)** in children and can cause **aplastic crisis** in individuals with underlying hemolytic disorders. - It primarily targets erythroid precursors in the bone marrow but is not directly linked to HUS. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following is the earliest finding seen in Diabetic nephropathy?

Microalbuminuria. ***Microalbuminuria*** - **Microalbuminuria** is defined as the excretion of 30-300 mg of albumin in urine per 24 hours and is the **earliest detectable sign** of diabetic nephropathy, preceding overt proteinuria [1], [3]. - Early detection allows for interventions to slow the progression of kidney damage, such as **strict glycemic control** and **blood pressure management** with ACE inhibitors or ARBs [3]. *Hematuria* - **Hematuria** (blood in the urine) is not typically an early or primary finding in diabetic nephropathy [2]. - While it can occur in some kidney diseases, it is more characteristic of conditions like **glomerulonephritis** or **urinary tract infections** [4]. *Exudates* - **Exudates** refer to leakage of fluid, protein, or cells into tissues, often associated with inflammation or injury, and are not a measure of kidney function. - It's possible this term is being confused with **retinal exudates** (hard exudates) which are a finding in diabetic retinopathy, but not diabetic nephropathy. *Macroalbuminuria* - **Macroalbuminuria** (or overt proteinuria) is the excretion of more than 300 mg of albumin per 24 hours, indicating more advanced kidney damage. - It is a **later finding** than microalbuminuria in the progression of diabetic nephropathy, signifying established kidney disease [3]. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following is not true regarding Wolff-Parkinson-White (WPW) syndrome?

Prolonged PR interval. ***Prolonged PR interval*** - In WPW syndrome, the presence of an **accessory pathway (Bundle of Kent)** allows for **pre-excitation** of the ventricles, bypassing the AV node's normal delay [1]. - This results in a **shortened PR interval** (typically < 0.12 seconds), not a prolonged one [1]. *Delta wave is seen on ECG* - The **delta wave** is a characteristic finding in WPW, representing the slurred upstroke of the QRS complex due to early ventricular activation via the accessory pathway [1]. - It indicates **ventricular pre-excitation** and is a key diagnostic feature [1], [2]. *Bundle of Kent connects atria to ventricles* - The **Bundle of Kent** is an anomalous muscle fiber bundle that forms an **accessory pathway** directly connecting the atria to the ventricles [1]. - This pathway bypasses the AV node, leading to the characteristic ECG findings and potential re-entrant arrhythmias. *Pre-excitation occurs via accessory pathway* - **Pre-excitation** is the hallmark of WPW syndrome, where electrical impulses bypass the normal conduction system (AV node) and activate ventricular tissue prematurely via an **accessory pathway** [1]. - This leads to the characteristic short PR interval and delta wave on the ECG [2]. [Practice more Internal Medicine PYQs on OnCourse]

46 Previous Year Questions with Answers & Explanations

Questions

Which of these conditions is classified as a nephritic syndrome?

A 20-year-old male presented with fatigue, weakness, and jaundice. What is the most likely diagnosis?

Hemolytic uraemic syndrome is associated with

Which of the following is the earliest finding seen in Diabetic nephropathy?

Which of the following is not true regarding Wolff-Parkinson-White (WPW) syndrome?

An 85-year-old patient was brought to the ER, BP: 180/100, right hemiparesis was seen. What is the next best step in management?

A farmer with pinpoint pupils, increased secretions and urination. What is the most likely diagnosis?

All of the following are types of Primary headache except:

A patient is having a continuous tremor and he has tendency to fall. Lesion is most commonly seen in?

Q10

What is the most likely diagnosis in an individual with normal serum alkaline phosphatase, normal PTH, normal Vitamin D3, and elevated serum calcium?

FMGE 2019 - Internal Medicine FMGE Practice Questions and MCQs

Question 1: Which of these conditions is classified as a nephritic syndrome?

A. Minimal Change Disease
B. Membranous Glomerulopathy
C. Post Infectious Glomerulonephritis (Correct Answer)
D. Focal Segmental Glomerulosclerosis

Explanation: ***Post infectious Glomerulonephritis*** - Characterized by **hematuria, hypertension, and edema**, typically following an infection, such as streptococcal pharyngitis [2]. - Immune-mediated response leads to **decreased GFR** and signs of nephritic syndrome [1][2]. *Focal segmental glomerulosclerosis* - Primarily causes **nephrotic syndrome**, characterized by proteinuria and edema rather than hematuria [2]. - Often associated with **secondary causes** like obesity or HIV, not typically post-infectious. *Membranous Glomerulopathy* - Results in significant **proteinuria** and is classified as a **nephrotic syndrome** rather than a nephritic one [2][3]. - It presents with **edema and hypoalbuminemia**, lacking the hallmark features of hematuria. *Minimal change disease* - Predominantly causes **nephrotic syndrome** with heavy proteinuria and little to no hematuria [2]. - Young children are commonly affected, and it responds well to **corticosteroid therapy** [1].

Question 2: A 20-year-old male presented with fatigue, weakness, and jaundice. What is the most likely diagnosis?

A. Acute lymphoblastic leukemia
B. Chronic myeloid leukemia
C. Chronic lymphocytic leukemia
D. Acute myeloid leukemia (Correct Answer)

Explanation: ***Acute myeloid leukemia*** - Presents with **fatigue** and **weakness** due to bone marrow infiltration and resultant cytopenias, typical in this age group [1]. - Often shows **myeloblasts** on peripheral blood smear, confirming the diagnosis [2]. *Chronic myeloid leukemia* - Usually occurs in **older adults** and characterized by **elevated white blood cell counts** with a predominance of mature neutrophils. - Symptoms like fatigue may arise, but there are distinct **Philadelphia chromosome** findings and typically a **longer symptom duration**. *Acute lymphoblastic leukemia* - More common in **younger children** and often associated with **lymphadenopathy** and **thrombocytopenia**, rather than fatigue alone. - Characteristically shows **lymphoblasts** in the blood, which are not mentioned in this patient's presentation. *Chronic lymphocytic leukemia* - Typically presents in adults over **50 years** and is characterized by **lymphocytosis** and often asymptomatic in early stages. - Fatigue may occur but lacks the acute presentation and findings seen in **acute leukemias**. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 607-608. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 621-622.

Question 3: Hemolytic uraemic syndrome is associated with

A. Bartonella henselae
B. Malaria
C. E. coli 0157 (Correct Answer)
D. Parvovirus B19

Explanation: ***E. coli O157*** - **Hemolytic uremic syndrome (HUS)** is most commonly associated with infection by **Shiga toxin-producing E. coli (STEC)**, particularly serotype O157:H7 [2]. - The Shiga toxin damages the **endothelium** of blood vessels, leading to **thrombotic microangiopathy**, which manifests as **hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury** [1], [2]. *Bartonella henselae* - This bacterium is the causative agent of **cat scratch disease**, characterized by **lymphadenopathy** and sometimes systemic symptoms. - It is not typically associated with hemolytic uremic syndrome. *Malaria* - Malaria is a **parasitic infection** transmitted by mosquitoes, causing **fever**, **chills**, and **anemia** due to red blood cell lysis. - While it can cause anemia, it does not directly lead to the thrombotic microangiopathy of HUS. *Parvovirus B19* - **Parvovirus B19** causes **erythema infectiosum (fifth disease)** in children and can cause **aplastic crisis** in individuals with underlying hemolytic disorders. - It primarily targets erythroid precursors in the bone marrow but is not directly linked to HUS.

Question 4: Which of the following is the earliest finding seen in Diabetic nephropathy?

A. Hematuria
B. Exudates
C. Microalbuminuria (Correct Answer)
D. Macroalbuminuria

Explanation: ***Microalbuminuria*** - **Microalbuminuria** is defined as the excretion of 30-300 mg of albumin in urine per 24 hours and is the **earliest detectable sign** of diabetic nephropathy, preceding overt proteinuria [1], [3]. - Early detection allows for interventions to slow the progression of kidney damage, such as **strict glycemic control** and **blood pressure management** with ACE inhibitors or ARBs [3]. *Hematuria* - **Hematuria** (blood in the urine) is not typically an early or primary finding in diabetic nephropathy [2]. - While it can occur in some kidney diseases, it is more characteristic of conditions like **glomerulonephritis** or **urinary tract infections** [4]. *Exudates* - **Exudates** refer to leakage of fluid, protein, or cells into tissues, often associated with inflammation or injury, and are not a measure of kidney function. - It's possible this term is being confused with **retinal exudates** (hard exudates) which are a finding in diabetic retinopathy, but not diabetic nephropathy. *Macroalbuminuria* - **Macroalbuminuria** (or overt proteinuria) is the excretion of more than 300 mg of albumin per 24 hours, indicating more advanced kidney damage. - It is a **later finding** than microalbuminuria in the progression of diabetic nephropathy, signifying established kidney disease [3].

Question 5: Which of the following is not true regarding Wolff-Parkinson-White (WPW) syndrome?

A. Delta wave is seen on ECG
B. Bundle of Kent connects atria to ventricles
C. Prolonged PR interval (Correct Answer)
D. Pre-excitation occurs via accessory pathway

Explanation: ***Prolonged PR interval*** - In WPW syndrome, the presence of an **accessory pathway (Bundle of Kent)** allows for **pre-excitation** of the ventricles, bypassing the AV node's normal delay [1]. - This results in a **shortened PR interval** (typically < 0.12 seconds), not a prolonged one [1]. *Delta wave is seen on ECG* - The **delta wave** is a characteristic finding in WPW, representing the slurred upstroke of the QRS complex due to early ventricular activation via the accessory pathway [1]. - It indicates **ventricular pre-excitation** and is a key diagnostic feature [1], [2]. *Bundle of Kent connects atria to ventricles* - The **Bundle of Kent** is an anomalous muscle fiber bundle that forms an **accessory pathway** directly connecting the atria to the ventricles [1]. - This pathway bypasses the AV node, leading to the characteristic ECG findings and potential re-entrant arrhythmias. *Pre-excitation occurs via accessory pathway* - **Pre-excitation** is the hallmark of WPW syndrome, where electrical impulses bypass the normal conduction system (AV node) and activate ventricular tissue prematurely via an **accessory pathway** [1]. - This leads to the characteristic short PR interval and delta wave on the ECG [2].

Question 6: An 85-year-old patient was brought to the ER, BP: 180/100, right hemiparesis was seen. What is the next best step in management?

A. Reduce BP
B. NCCT (Correct Answer)
C. MRI
D. Aspirin 300mg and anticoagulants

Explanation: ***NCCT*** - A **non-contrast CT (NCCT) scan of the brain** is the most crucial initial step to differentiate between **ischemic stroke** and **hemorrhagic stroke** [1]. - This distinction is vital because management, especially the use of thrombolytics or anticoagulants, differs significantly based on stroke type [1]. *Reduce BP* - While blood pressure management is important in stroke, immediate and aggressive lowering of BP in acute ischemic stroke can **worsen cerebral perfusion** and **increase infarct size**. - In hemorrhagic stroke, BP control is often necessary, but the decision to lower BP and by how much depends on the cause and extent of the bleed, and this can only be determined after imaging [1]. *MRI* - **MRI** is more sensitive for detecting acute ischemic changes than CT, especially in the posterior fossa [1]. - However, **MRI is not typically the first-line imaging** in an emergency setting for an acute stroke due to its longer acquisition time and potential contraindications (e.g., pacemakers, metallic implants) [1]. *Aspirin 300mg and anticoagulants* - These medications are indicated for **ischemic stroke** (aspirin is an antiplatelet, anticoagulants may be used in specific cases like cardioembolic stroke). - Administering these agents in the event of a **hemorrhagic stroke** would be contraindicated and could significantly worsen the bleeding, leading to severe neurological damage or death [1].

Question 7: A farmer with pinpoint pupils, increased secretions and urination. What is the most likely diagnosis?

A. Alcohol poisoning
B. Organophosphate poisoning (Correct Answer)
C. Opioid poisoning
D. Atropine poisoning

Explanation: ***Organophosphate poisoning*** - **Pinpoint pupils (miosis)**, **increased secretions** (salivation, lacrimation, bronchial secretions), and **urination** are classic signs of cholinergic crisis caused by organophosphate toxicity [1]. - The patient's profession as a **farmer** increases the likelihood of exposure to pesticides, which often contain organophosphates [1], [2]. *Alcohol poisoning* - While alcohol poisoning can cause CNS depression, it does not typically present with **pinpoint pupils** or **increased secretions** like salivation and urination. - Common signs include **ataxia**, **slurred speech**, **nausea**, and **vomiting**. *Opioid poisoning* - Opioid poisoning also causes **pinpoint pupils** and **CNS depression**, but it typically leads to **decreased secretions** and **urinary retention**, not increased urination [2]. - **Respiratory depression** is a hallmark feature, which is not highlighted here as a primary symptom. *Atropine poisoning* - Atropine is an anticholinergic agent, meaning it would cause the opposite effects of organophosphate poisoning [2]. - Symptoms would include **dilated pupils (mydriasis)**, **dry mouth**, **decreased secretions**, and **urinary retention**.

Question 8: All of the following are types of Primary headache except:

A. Migraine
B. Tension
C. Cluster
D. Temporal arteritis (Correct Answer)

Explanation: ***Temporal arteritis*** - **Temporal arteritis** is a **secondary headache** caused by inflammation of the **temporal arteries**, not a primary headache type [1]. - It is often associated with symptoms like **jaw claudication**, **scalp tenderness**, and is more common in elderly individuals. *Migraine* - **Migraine** is a common type of **primary headache**, characterized by moderate to severe pain, often unilateral and pulsating [1]. - It can be accompanied by symptoms like **nausea, vomiting**, and sensitivity to light and sound [1]. *Tension* - **Tension-type headache** is the most common type of **primary headache**, typically described as a mild to moderate, bilateral, pressing or tightening pain [1]. - It usually lacks associated symptoms like nausea or vomiting, which differentiates it from migraine. *Cluster* - **Cluster headache** is a severe form of **primary headache**, known for its excruciating unilateral pain, often around the eye or temple [1]. - It is characterized by specific autonomic symptoms on the affected side, such as **lacrimation, rhinorrhea, and ptosis** [1].

Question 9: A patient is having a continuous tremor and he has tendency to fall. Lesion is most commonly seen in?

A. Putamen
B. Substantia Nigra (Correct Answer)
C. Globus pallidus
D. Caudate nucleus

Explanation: ***Substantia Nigra*** - A lesion in the **substantia nigra** leads to a deficiency of **dopamine**, which is characteristic of **Parkinson's disease** [1]. - Symptoms like **continuous tremor (resting tremor)**, **postural instability (tendency to fall)**, rigidity, and bradykinesia are hallmark features of Parkinson's disease, linked to substantia nigra degeneration [1], [2]. *Putamen* - While the putamen is part of the basal ganglia and involved in motor control, its primary lesion is not typically associated with the classic triad of **Parkinsonian symptoms** (tremor, rigidity, bradykinesia) [1]. - Lesions here might instead contribute to involuntary movements like **dystonia** or **chorea**, which are not described. *Globus pallidus* - The globus pallidus is involved in regulating voluntary movement, and lesions here can cause various movement disorders, including **dystonia**, **chorea**, or **hemiballismus** [2]. - However, isolated pallidal lesions are less commonly the primary cause of the specific combination of **resting tremor** and **falls** seen in Parkinson's. *Caudate nucleus* - The caudate nucleus plays a crucial role in cognitive and motor functions and is primarily affected in diseases like **Huntington's disease**, leading to **chorea** and cognitive decline [2]. - Lesions in the caudate nucleus do not typically present with a **continuous tremor** and **tendency to fall** as the predominant symptoms.

Question 10: What is the most likely diagnosis in an individual with normal serum alkaline phosphatase, normal PTH, normal Vitamin D3, and elevated serum calcium?

A. Nutritional rickets
B. Hyperparathyroidism
C. Multiple myeloma (Correct Answer)
D. Vitamin D intoxication

Explanation: ***Multiple myeloma*** [4] - This condition is often associated with **osteolytic lesions** that lead to the release of calcium into the blood, causing **hypercalcemia**. - **PTH**, **alkaline phosphatase**, and **Vitamin D3** levels are typically normal in this scenario because their regulatory pathways are not primarily affected [1]. *Nutritional rickets* [2] - Characterized by **low calcium** and **phosphate levels**, usually with **elevated alkaline phosphatase** and **PTH** due to inadequate vitamin D or calcium intake [3]. - This patient exhibits **elevated serum calcium**, ruling out rickets. *Hyperparathyroidism* - Both **primary** and **secondary hyperparathyroidism** would present with **elevated PTH** levels, which is stated as normal in the case description [1]. - **Hypercalcemia** in hyperparathyroidism is caused by bone resorption and increased renal reabsorption of calcium, driven by high PTH [5]. *Vitamin D intoxication* - Would lead to **hypercalcemia** and **elevated Vitamin D3** levels, alongside **suppressed PTH** levels, which contradicts the described normal PTH and normal Vitamin D3 [1]. - The excessive vitamin D would increase calcium absorption from the gut and bone resorption not seen here.