FMGE 2023 - Internal Medicine Practice Questions

Q: A 65-year-old male presented with unexplained fever and prolonged respiratory distress despite appropriate treatment. A diagnosis of cryptic tuberculosis was made. Which of the following is the correct statement related to this condition?

Negative skin tuberculin test and negative chest X-ray. ***Negative skin tuberculin test and negative chest X-ray***- **Cryptic tuberculosis (TB)**, or occult TB, often presents with non-specific systemic symptoms (like prolonged unexplained fever) without typical clinical or radiological signs expected in classic TB [1].- In older patients or those with disseminated disease, the immune response is often diminished, leading to a false negative result (anergy) on the **tuberculin skin test (TST)**, alongside a frequently normal chest X-ray (CXR) [1]. *Positive skin tuberculin test and negative chest X-ray*- A **positive TST** indicates prior exposure to *M. tuberculosis* but doesn't necessarily confirm active, symptomatic disease like cryptic TB. - Although the CXR is negative (consistent with cryptic TB), the positive TST contradicts the common finding of **anergy** seen in severely ill or elderly patients with cryptic disease. *Positive skin tuberculin test and positive chest X-ray*- This combination is characteristic of typical, **active pulmonary tuberculosis**, where the disease is localized and clinically/radiologically apparent. - By definition, cryptic TB lacks the **classic radiological findings** on chest X-ray, making this option incorrect. *Negative skin tuberculin test and positive chest X-ray*- While a **negative TST** can occur in active TB due to anergy or immunosuppression, a **positive CXR** strongly indicates radiologically apparent TB. - If the TB is radiologically apparent, the designation "cryptic" (meaning hidden or obscure) is inappropriate.

Q: Which of the following is not a component of Child-Pugh scoring?

LFT. ***LFT (Correct Answer)*** - **LFT (Liver Function Tests)** is a general term encompassing various biochemical tests such as AST, ALT, ALP, and GGT [1], [2] - These specific liver enzymes are **not components** of the Child-Pugh scoring system - The Child-Pugh score specifically uses only **5 parameters**: Albumin, Bilirubin, Prothrombin Time/INR, Ascites, and Hepatic Encephalopathy - These five components assess both **synthetic function** (albumin, PT/INR) and **clinical manifestations** (ascites, encephalopathy) of chronic liver disease [3] *Albumin (Incorrect)* - Serum **albumin** is one of the five specific components of the Child-Pugh score - It reflects the liver's **synthetic function** capacity - Scoring: >3.5 g/dL (1 point), 2.8-3.5 g/dL (2 points), 3 mg/dL (3 points) - Elevated bilirubin indicates impaired hepatic clearance and correlates with severity of liver disease *Prothrombin Time (Incorrect)* - **Prothrombin Time (PT)** or **INR** measures the liver's ability to synthesize clotting factors [3] - It is a critical component reflecting hepatic **synthetic function** - Scoring: 6 sec or INR >2.3 (3 points) [4] - Prolonged PT/elevated INR indicates severely impaired synthesis of vitamin K-dependent clotting factors [3]

Q: A patient presented with a fever for 11 days with neck rigidity. A lumbar puncture was done, and it showed predominantly lymphocytes, sugar- 50mg, and protein- 3000mg/dl. Gram-staining was negative. The patient's chest X-ray shows upper lobe involvement with hilar lymph node enlargement. What is the probable diagnosis?

Tuberculous meningitis. ***Tuberculous meningitis***- The CSF analysis combines **lymphocytic predominance** (suggesting non-pyogenic cause), subacute onset (11 days of fever), and critically high protein (3000 mg/dL), which are hallmarks of TBM [1]. - The chest X-ray findings of **upper lobe involvement** and **hilar lymph node enlargement** confirm active systemic tuberculosis, providing the strongest evidence for TBM as the underlying cause of meningitis [4].*Bacterial meningitis*- Typically presents acutely (hours to a few days) and CSF analysis shows a predominance of **neutrophils** (neutrophilic pleocytosis) [3].- Although CSF protein is high and glucose is low, the presence of lymphocytes and a negative Gram stain makes typical pyogenic bacterial meningitis less likely [3].*Fungal meningitis*- Fungal infections like **Cryptococcosis** can cause lymphocytic pleocytosis and elevated protein, but the protein level (3000 mg/dL) is excessively high, even for fungal causes.- While systemic involvement can occur, the specific pulmonary findings (upper lobe infiltrates, hilar nodes) are classic diagnostic features of **Mycobacterium tuberculosis**.*Viral meningitis*- Viral meningitis typically causes an acute, self-limiting illness and is generally associated with relatively low protein levels (usually <100 mg/dL) and normal CSF glucose [2].- The protein level of 3000 mg/dL in this patient is incompatible with a typical viral etiology, which mostly resolves spontaneously [2].

Q: A 26-year-old male with a history of respiratory tract infection 4 weeks ago is unable to stand or walk for the past 2 weeks and the weakness is progressive, ascending, and symmetrical in nature. The lower limbs were involved before and gradually the upper limbs were also affected. On examination you note areflexia. Pain and proprioception are preserved. What is the probable diagnosis?

Guillain Barre syndrome. ***Guillain Barre syndrome*** - **Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)** - most common GBS variant [1] - Classic presentation: **progressive, ascending, symmetrical weakness** starting in lower limbs [1] - **Areflexia** is a hallmark feature due to peripheral nerve involvement [1] - **Preceding infection** (respiratory or gastrointestinal) occurs in 60-70% of cases, typically 1-4 weeks prior [1] - **Preserved sensory examination** for pain and proprioception (though may have paresthesias) [1] - **Motor weakness predominates** over sensory symptoms [1] - Diagnosis confirmed by: CSF showing albuminocytologic dissociation, nerve conduction studies showing demyelination - Treatment: **IV immunoglobulin (IVIG)** or **plasmapheresis** *Myasthenia gravis* - Presents with **fatigable weakness**, worsens with activity - **Ocular and bulbar muscles** typically affected first (ptosis, diplopia, dysphagia) - **Reflexes are preserved** (not areflexia) - No ascending pattern of weakness - Positive acetylcholine receptor antibodies, abnormal repetitive nerve stimulation *Polymyositis* - **Proximal muscle weakness** (shoulder and hip girdle), not ascending pattern - **Subacute onset** over weeks to months (not acute 2 weeks) - **Elevated creatine kinase (CK)** levels - Reflexes typically preserved initially - Muscle biopsy shows inflammatory infiltrates *Multiple sclerosis* - **Relapsing-remitting pattern** with episodes separated in time and space - **Sensory symptoms prominent** (numbness, tingling, vision changes) - **Hyperreflexia** with upper motor neuron signs (not areflexia) - Does not present with acute ascending paralysis - MRI shows demyelinating plaques in CNS

Q: Which of the following is the class of shock where urine output is first decreased?

b. Moderate. Detailed assessment of shock states involves monitoring vital signs and organ perfusion metrics like urine output. In **moderate shock** (Class II hemorrhagic shock, ~15-30% blood loss), strong **sympathetic stimulation** leads to significant renal vasoconstriction to preserve perfusion to vital organs [1]. This causes a substantial reduction in glomerular filtration rate (**GFR**), resulting in the **first clinically significant decrease** in urine output (typically 20-30 mL/hr or **oliguria**) [1]. This is the earliest stage where urine output becomes measurably decreased. *Compensated/Mild* - In **compensated or mild shock** (Class I, 30 mL/hr) as the minimal volume deficit does not yet necessitate severe renal vasoconstriction. - Baroreceptor reflexes and mild tachycardia are sufficient to maintain renal perfusion. *Severe* - In **severe shock** (Class III-IV, >30% blood loss), there is dramatic reduction in cardiac output and marked hypotension, leading to profound oliguria or complete **anuria**. - While urine output is lowest here, the **initial measurable decrease** occurs earlier in moderate shock (Class II), before progression to cardiovascular collapse. - By this stage, multiple organ dysfunction is evident.

Q: An HIV-positive man presents with a high-grade fever. Examination reveals a positive Kernig's sign. CSF shows reduced glucose, increased protein, and increased leukocytes. A diagnosis of cryptococcal meningitis is made. What is the appropriate management for this patient?

Liposomal amphotericin B. ***Liposomal amphotericin B***- **Liposomal amphotericin B** (often combined with **flucytosine**) is the standard of care for the **induction phase** (first 2 weeks) of severe cryptococcal meningitis treatment in HIV-positive patients due to its potent fungicidal activity [1].- The severity of the presentation (high fever, positive **Kernig's sign**, and abnormal CSF findings) necessitates this regimen to rapidly reduce the fungal burden in the central nervous system.*Vancomycin*- **Vancomycin** is an antibiotic used specifically to treat severe infections caused by **Gram-positive bacteria**, notably **MRSA**.- This drug has absolutely no therapeutic efficacy against the fungal pathogen *Cryptococcus neoformans*.*High dose fluconazole with flucytosine*- While fluconazole is an effective antifungal against *Cryptococcus*, this regimen is typically reserved for the **consolidation phase** (post-induction) or for milder disease.- Severe meningitis, indicated by the clinical signs and CSF profile, requires the superior fungicidal activity of **amphotericin B** during the induction phase [1].*Voriconazole*- **Voriconazole** is a broad-spectrum triazole mainly used for treating invasive **Aspergillus** and some *Candida* infections [1], [2].- It has **limited efficacy** against *Cryptococcus neoformans* and is not recommended as primary induction therapy for cryptococcal meningitis.

Q: A chronic alcoholic presents to the emergency room with acute abdominal pain in the epigastric region radiating to the back with nausea, anorexia, and occasional vomiting. Investigations showed elevated amylase levels and total count. Likely diagnosis is

b.Acute pancreatitis. ***Acute pancreatitis*** (Keep the correct option at the top and the incorrect options in the order they are provided in the input) - The clinical presentation of severe **epigastric pain radiating to the back**, associated with nausea and vomiting, is classic for **acute pancreatitis** [1]. - **Alcohol abuse** is a major risk factor, and the diagnosis is supported by findings of significantly elevated serum **amylase and/or lipase** levels [1]. *Acute hepatitis* - Typically presents with **jaundice**, fatigue, dark urine, and right upper quadrant discomfort, not the referred back pain seen here. - Key laboratory findings would include severely elevated **liver transaminases (AST/ALT)**, not primarily amylase. *Acute Cholecystitis* - Characterized by acute pain in the **right upper quadrant** or epigastrium, often radiating to the **right shoulder or scapula**, not the back [2]. - This condition is usually associated with gallstones and is diagnosed via imaging showing gallbladder wall thickening and pericholecystic fluid, though amylase can be mildly elevated secondarily. *Acute appendicitis* - Presents typically with periumbilical pain that migrates to the **right lower quadrant (RLQ)**, often associated with low-grade fever and localized tenderness. - The pain is not classically described as severe epigastric pain radiating to the back, and initial lab markers include leukocytosis but not specific elevation of amylase.

Q: A 60-year-old male presents with claudication and blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis? ![img-25.jpeg](img-25.jpeg)

Atherosclerosis. ***Atherosclerosis*** - Atherosclerosis is the most common cause of **peripheral artery disease (PAD)** in patients over 50, leading to stenosis of arteries and causing symptoms like **claudication** (pain on exertion). - Severe, progressive disease results in **critical limb ischemia**, characterized by insufficient blood flow to meet metabolic demands at rest, which can lead to tissue necrosis and **gangrene** (blackening of the toes) as seen in the image. *Buerger's disease* - This condition, also known as **thromboangiitis obliterans**, is a non-atherosclerotic inflammatory vasculitis that typically affects **young male smokers** (usually under 45 years old). - It characteristically involves small-to-medium-sized arteries and veins and is often associated with superficial thrombophlebitis, which is not typical for this patient's demographic. *Raynaud's disease* - This is a functional vascular disorder characterized by episodic **vasospasm** of digital arteries, usually triggered by cold or stress, leading to well-demarcated color changes (white, blue, and red). - It does not cause claudication, which is a symptom of fixed arterial obstruction, and rarely results in the extensive, progressive gangrene seen in this case. *Giant cell arteritis* - This is a vasculitis of large and medium-sized arteries, primarily affecting branches of the **carotid artery** (e.g., temporal artery), leading to headache, jaw claudication, and visual loss. - While it can involve limb arteries, isolated severe lower limb ischemia with gangrene is an uncommon presentation; **atherosclerosis** is a far more frequent cause in this age group.

Q: A 73 year old male smoker with a past history of coronary artery disease presents with blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis?

Atherosclerosis. ***Atherosclerosis*** - The patient's advanced age (73), history of **smoking**, and **coronary artery disease** are all major risk factors for atherosclerosis, the most common cause of peripheral arterial disease (PAD). - The blackening of the toes is indicative of **dry gangrene**, a form of tissue necrosis resulting from severe, chronic ischemia due to atherosclerotic occlusion of the arteries supplying the foot. *Buerger's disease* - This condition, also known as **thromboangiitis obliterans**, is a non-atherosclerotic vasculitis that typically affects **young male smokers**, usually under the age of 45. - The patient's advanced age makes Buerger's disease a much less likely diagnosis compared to atherosclerosis. *Raynaud's disease* - Raynaud's disease is characterized by episodic **vasospasm** of digital arteries, usually triggered by cold or stress, leading to distinct color changes (white, blue, and red), which is not the primary presentation here. - While severe secondary Raynaud's phenomenon can lead to gangrene, it is not the most probable cause in an elderly patient with multiple risk factors for atherosclerosis. *Giant cell arteritis* - This is a **large-vessel vasculitis** that typically affects patients over 50 and presents with symptoms like headache, jaw claudication, and visual disturbances. - While it can cause limb claudication, isolated digital gangrene is a very uncommon manifestation, and the patient's presentation is classic for atherosclerotic PAD.

Question 1

A 65-year-old male presented with unexplained fever and prolonged respiratory distress despite appropriate treatment. A diagnosis of cryptic tuberculosis was made. Which of the following is the correct statement related to this condition?

Accepted Answer

Negative skin tuberculin test and negative chest X-ray

Answer

Positive skin tuberculin test and negative chest X-ray

Answer

Positive skin tuberculin test and positive chest X-ray

Answer

Negative skin tuberculin test and positive chest X-ray

Question 2

Which of the following is not a component of Child-Pugh scoring?

Accepted Answer

LFT

Answer

Albumin

Answer

Bilirubin

Answer

Prothrombin Time

Question 3

A patient presented with a fever for 11 days with neck rigidity. A lumbar puncture was done, and it showed predominantly lymphocytes, sugar- 50mg, and protein- 3000mg/dl. Gram-staining was negative. The patient's chest X-ray shows upper lobe involvement with hilar lymph node enlargement. What is the probable diagnosis?

Accepted Answer

Tuberculous meningitis

Answer

Bacterial meningitis

Answer

Fungal meningitis

Answer

Viral meningitis

Question 4

A 26-year-old male with a history of respiratory tract infection 4 weeks ago is unable to stand or walk for the past 2 weeks and the weakness is progressive, ascending, and symmetrical in nature. The lower limbs were involved before and gradually the upper limbs were also affected. On examination you note areflexia. Pain and proprioception are preserved. What is the probable diagnosis?

Accepted Answer

Guillain Barre syndrome

Answer

Myasthenia gravis

Answer

Polymyositis

Answer

Multiple sclerosis

Question 5

Which of the following is the class of shock where urine output is first decreased?

Accepted Answer

b. Moderate

Answer

a. Compensated

Answer

c. Mild

Answer

d. Severe

Question 6

An HIV-positive man presents with a high-grade fever. Examination reveals a positive Kernig's sign. CSF shows reduced glucose, increased protein, and increased leukocytes. A diagnosis of cryptococcal meningitis is made. What is the appropriate management for this patient?

Accepted Answer

Liposomal amphotericin B

Answer

High dose fluconazole with flucytosine

Answer

Voriconazole

Answer

Vancomycin

Question 7

A chronic alcoholic presents to the emergency room with acute abdominal pain in the epigastric region radiating to the back with nausea, anorexia, and occasional vomiting. Investigations showed elevated amylase levels and total count. Likely diagnosis is

Accepted Answer

b.Acute pancreatitis

Answer

a.Acute hepatitis

Answer

d.Acute appendicitis

Answer

c.Acute Cholecystitis

Question 8

A 60-year-old male presents with claudication and blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis? ![img-25.jpeg](img-25.jpeg)

Accepted Answer

Atherosclerosis

Answer

Buerger's disease

Answer

Raynaud's disease

Answer

Giant cell arteritis

Question 9

A 73 year old male smoker with a past history of coronary artery disease presents with blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis?

Accepted Answer

Atherosclerosis

Answer

Giant cell arteritis

Answer

Buerger's disease

Answer

Raynaud's disease

Question 10

Genetic testing for BRCA 1/BRCA 2 is indicated for all of the following except:

Accepted Answer

Breast cancer diagnosed in a postmenopausal female >50 years of age

Answer

Breast and ovarian cancer

Answer

Male breast cancer

Answer

Bilateral breast cancer

FMGE 2023 — Internal Medicine