A patient is diagnosed with acromegaly. Transsphenoidal surgery is not feasible. Which of the following drugs is preferred for the medical management of this patient?
A patient presents with complaints of sudden onset headache, palpitation, and profuse sweating. The patient has had multiple similar episodes in the past. During these episodes, the patient's blood pressure is elevated. A 24-hour urinary metanephrine is elevated. What is the most likely diagnosis?
A 70-year-old patient with a smoking history presents with high-grade fever, cough, confusion, and diarrhea. Chest X-ray shows bilateral infiltrates in bilateral lower lung fields. On sputum gram stain, no organisms were detected. Laboratory results reveal Na: 126mEq/L, AST:62, ALT:56, RBS:112 mg/dl, serum bilirubin of 0.8mg%, and a positive HIV test. Which of the following organisms is responsible?
A 45-year-old patient with a history of smoking a pack of cigarettes for the past 15 years presents with hemoptysis. Chest X-ray shows a 3cm upper lobe mass near the apex of the lung. What is the next best step for managing this patient?
Which of the following is seen in all kinds of shock?
A woman presents with a history of headaches for the past 9 months that worsen in a recumbent position and improves as the day progresses. She also gives a history of taking oral contraceptives. Fundal examination shows papilledema. There are no focal neurological deficits. What is the probable cause of her headaches?
Which of the following is the most common cause of mortality in diabetic ketoacidosis?
Which of the following is not included in the Gaisböck syndrome?
A patient presents with dyspnea and distended neck veins that increase on inspiration. There is no murmur. What is the diagnosis?
What is the most common cause of Cushing's disease in a 60-year-old male?
FMGE 2023 - Internal Medicine FMGE Practice Questions and MCQs
Question 21: A patient is diagnosed with acromegaly. Transsphenoidal surgery is not feasible. Which of the following drugs is preferred for the medical management of this patient?
- A. Terlipressin
- B. Ketoconazole
- C. Leuprolide
- D. Lanreotide depot formulation (Correct Answer)
Explanation: ***Lanreotide depot formulation***- It is a **somatostatin analog** (SSA) and a first-line medical therapy for acromegaly, particularly when surgery fails or is contraindicated [1].- SSAs normalize **GH (Growth Hormone)** and **IGF-1 (Insulin-like Growth Factor-1)** levels by inhibiting pituitary GH secretion [1].*Terlipressin*- It is primarily an analog of **vasopressin** used to treat **esophageal variceal bleeding** and hepatorenal syndrome.- It has no role in reducing pituitary growth hormone hypersecretion characteristic of acromegaly.*Ketoconazole*- It is an **antifungal agent** that also inhibits **steroidogenesis** (glucocorticoids, androgens).- Its primary hormonal use is in treating **Cushing's syndrome** (due to cortisol inhibition), not acromegaly.*Leuprolide*- This is a **GnRH agonist** used primarily to treat conditions like **prostate cancer**, **endometriosis**, and **precocious puberty**.- It acts on the hypothalamic-pituitary-gonadal axis and does not directly target GH-secreting tumors.
Question 22: A patient presents with complaints of sudden onset headache, palpitation, and profuse sweating. The patient has had multiple similar episodes in the past. During these episodes, the patient's blood pressure is elevated. A 24-hour urinary metanephrine is elevated. What is the most likely diagnosis?
- A. Renal artery stenosis
- B. Pheochromocytoma (Correct Answer)
- C. Hyperthyroidism
- D. Addison's disease
Explanation: ***Pheochromocytoma***- This clinical presentation—paroxysmal episodes of headache, palpitations, and profuse sweating (the classic triad)—coupled with elevated blood pressure strongly suggests a **pheochromocytoma** (a tumor of the adrenal medulla secreting catecholamines). - The definitive biochemical confirmation is the elevated 24-hour urinary **metanephrines** and normetanephrines, which are breakdown products of epinephrine and norepinephrine. *Addison's disease* - This condition involves primary adrenal *insufficiency* (hypocortisolism), which typically presents with **hypotension**, fatigue, weight loss, and **hyperpigmentation**, not hypertensive crises. - It involves decreased production of adrenal hormones, not the episodic overproduction of **catecholamines** seen here. *Renal artery stenosis* - This is a cause of secondary hypertension due to chronic activation of the **Renin-Angiotensin-Aldosterone System (RAAS)**, leading to persistent, non-paroxysmal elevation of blood pressure. - It would not cause the specific triad of episodic symptoms (headache, sweating, palpitations) or lead to elevated **urinary metanephrines**. *Hyperthyroidism* - While it can cause palpitations, tremor, and systolic hypertension, these symptoms are typically chronic and sustained, lacking the sudden paroxysmal nature described. - The primary biochemical abnormality involves elevated **T3/T4 hormones**, not the excessive urinary excretion of **metanephrines** as detailed in this case.
Question 23: A 70-year-old patient with a smoking history presents with high-grade fever, cough, confusion, and diarrhea. Chest X-ray shows bilateral infiltrates in bilateral lower lung fields. On sputum gram stain, no organisms were detected. Laboratory results reveal Na: 126mEq/L, AST:62, ALT:56, RBS:112 mg/dl, serum bilirubin of 0.8mg%, and a positive HIV test. Which of the following organisms is responsible?
- A. Klebsiella
- B. Streptococcus
- C. Legionella (Correct Answer)
- D. Pneumocystis jeroveci
Explanation: ***Legionella***- This clinical picture, characterized by **high fever**, **atypical pneumonia** (bilateral infiltrates), and systemic symptoms including **confusion** (CNS involvement), **diarrhea** (GI involvement), **hyponatremia** and mildly elevated **LFTs**, is highly suggestive of **Legionella pneumophila** (Legionnaires' disease) [1].- *Legionella* is an **atypical bacterium** that requires specialized culture media and therefore typically results in a Gram stain showing **no organisms detected** through standard methods [1].*Streptococcus*- *Streptococcus pneumoniae* (the most common cause of typical community-acquired pneumonia) typically presents with an abrupt onset, pleurisy, and a consolidation pattern (**lobar pneumonia**) on CXR, differentiating it from this diffuse, atypical presentation.- It is a readily detectable **Gram-positive diplococcus** on sputum Gram stain, which contrasts with the microbiological report of no organisms seen [1].*Pneumocystis jeroveci*- While highly relevant in HIV-positive individuals, **Pneumocystis pneumonia (PJP)** typically presents with subacute onset, severe **hypoxemia**, and diffuse **interstitial infiltrates**, not typically associated with prominent hyponatremia or severe diarrhea [2].- PJP is diagnosed via special staining (e.g., silver stain) on induced sputum or bronchoalveolar lavage, and it does not usually cause the multisystem failure (hyponatremia and transaminitis) characteristic of Legionnaires' disease [2].*Klebsiella*- **Klebsiella pneumoniae** typically causes destruction and necrosis leading to classic **lobar pneumonia** (often in the upper lobes), classically associated with **currant jelly sputum** in immunocompromised individuals, especially alcoholics.- *Klebsiella* is a large encapsulated **Gram-negative rod** that would be easily visible and identifiable on a standard sputum Gram stain.
Question 24: A 45-year-old patient with a history of smoking a pack of cigarettes for the past 15 years presents with hemoptysis. Chest X-ray shows a 3cm upper lobe mass near the apex of the lung. What is the next best step for managing this patient?
- A. Bronchoscopy
- B. Sputum cytology
- C. Sputum for AFB
- D. CT-guided biopsy (Correct Answer)
Explanation: ***CT-guided biopsy***- This procedure is the preferred method for obtaining a definitive **tissue diagnosis** for a solitary **peripheral lung mass**, especially one highly suspicious of malignancy due to the patient's smoking history and hemoptysis [1].- Since the mass is **3cm** and located peripherally near the **apex**, a percutaneous **CT-guided transthoracic needle aspiration (TTNA)** provides the highest diagnostic yield compared to other non-invasive alternatives [2].*Bronchoscopy*- Bronchoscopy is primarily used to evaluate **central lesions** (proximal to segmental bronchi) or suspicious findings directly within the airway lumen.- It has a low diagnostic yield for discrete, small, or **peripheral masses** like this 3cm apical lesion, as the scope or biopsy instruments cannot reliably reach the target.*Sputum cytology*- Sputum cytology has low overall sensitivity, particularly for **peripheral lung masses** which are unlikely to shed sufficient malignant cells into the central airways.- While non-invasive, it often results in a non-diagnostic result and is therefore not the **next best step** for confirming the diagnosis of a discrete, radiographically apparent mass.*Sputum for AFB*- While an infectious process like tuberculosis (TB) can present as a mass, the patient's robust history of **heavy smoking** and the mass morphology strongly prioritize ruling out **lung carcinoma**.- Obtaining a tissue sample (biopsy) is mandatory due to the high suspicion of malignancy (indicated by hemoptysis and smoking) and takes precedence over attempting an infectious diagnosis first [3].
Question 25: Which of the following is seen in all kinds of shock?
- A. Reduced tissue perfusion (Correct Answer)
- B. Increased peripheral resistance
- C. Cold clammy skin
- D. Decreased respiratory rate
Explanation: ***Reduced tissue perfusion*** - **Shock** is fundamentally defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery, which results from inadequate or ineffective **tissue perfusion** [1]. - In all forms (hypovolemic, cardiogenic, distributive, and obstructive), the core pathophysiological defect is the inability to meet the metabolic demands of the tissues, hence **reduced tissue perfusion** is a universal finding [1], [2]. *Increased peripheral resistance*- This finding is characteristic of **compensatory shock** (e.g., early hypovolemic or cardiogenic) as part of the sympathetic response to maintain mean arterial pressure. - It is *not* seen in **distributive shock** (like septic or anaphylactic shock), which is characterized by profound **vasodilation** and thus marked *decreased* peripheral resistance [2]. *Decreased respiratory rate*- A decreased respiratory rate is *not* characteristic of shock; rather, **metabolic acidosis** (due to anaerobic metabolism) typically stimulates the respiratory center, leading to **compensatory tachypnea** (increased rate). - A decreased respiratory rate might only be seen if shock is severe and complicated by **CNS depression** from drugs or profound decompensation. *Cold clammy skin*- **Cold, clammy skin** is the classic presentation of **hypoperfusion** combined with sympathetic-driven peripheral **vasoconstriction**, typically seen in *hypovolemic* and *cardiogenic* shock. - In contrast, **distributive shock** (especially **septic shock**) presents with **warm, flushed skin** due to widespread peripheral vasodilation and increased cardiac output (hyperdynamic state).
Question 26: A woman presents with a history of headaches for the past 9 months that worsen in a recumbent position and improves as the day progresses. She also gives a history of taking oral contraceptives. Fundal examination shows papilledema. There are no focal neurological deficits. What is the probable cause of her headaches?
- A. Myasthenia gravis
- B. Temporal arteritis
- C. Chronic migraine
- D. Pseudotumor cerebri (Correct Answer)
Explanation: ***Pseudotumor cerebri*** - The presentation of headache that worsens in the **recumbent position** (due to increased intracranial pressure, ICP) and improves when upright is highly characteristic of **Idiopathic Intracranial Hypertension (IIH)** [1]. - Confirmation of **papilledema** (swollen optic disc) in a young, likely obese female taking **oral contraceptives** (a risk factor) without other focal signs confirms the diagnosis of **pseudotumor cerebri** [1]. *Myasthenia gravis* - This disease is a neuromuscular disorder characterized by fluctuating **muscle weakness** (diplopia, ptosis, difficulty chewing) that worsens with activity and improves with rest. - It is not associated with primary headache or signs of increased intracranial pressure like **papilledema**. *Temporal arteritis* - This diagnosis is reserved for older patients (usually >50 years) presenting with severe localized headache, **jaw claudication**, tenderness over the temporal artery, and elevated inflammatory markers (ESR/CRP) [2]. - The positional nature of the headache and the patient's young age (implied by OCP use, a risk factor for IIH) make this diagnosis unlikely. *Chronic migraine* - Migraine is a diagnosis of exclusion that typically involves severe, often **pulsatile** headaches, sometimes with aura, photophobia, or nausea [3]. - While chronic migraine involves frequent headaches, it does not cause **papilledema** or have headaches classically exacerbated by the **recumbent position**, which points instead toward a structural or ICP-related etiology [2].
Question 27: Which of the following is the most common cause of mortality in diabetic ketoacidosis?
- A. Cardiac arrhythmia
- B. Cerebral edema (Correct Answer)
- C. Acute kidney injury
- D. Acute respiratory distress syndrome
Explanation: ***Cerebral edema*** - This is the most catastrophic and frequent cause of death, particularly in children and adolescents being treated for DKA [2].- It is often linked to the **rapid administration of hypotonic fluids** or overly quick correction of **hyperglycemia**, causing rapid shifts in **osmolality** that lead to brain swelling [3]. *Acute respiratory distress syndrome*- While DKA is a risk factor for ARDS (often secondary to severe systemic inflammation or associated **sepsis**), it is not the most common direct cause of death [2].- Focus remains on metabolic management; respiratory failure is less common than neurological compromise as a fatal event. *Cardiac arrhythmia*- Severe **hypokalemia** (often unmasked or worsened by insulin therapy) can precipitate fatal cardiac arrhythmias, such as **ventricular fibrillation** [2].- Though a serious complication, carefully monitored electrolyte management generally prevents this, making it less common than cerebral edema as the leading cause of mortality. *Acute kidney injury*- AKI is highly common in DKA, primarily driven by severe **volume depletion** and resulting **prerenal azotemia** [1].- This is reversible with fluid resuscitation and, while it increases overall morbidity, it rarely causes acute mortality more frequently than cerebral edema during the initial hospitalization phase.
Question 28: Which of the following is not included in the Gaisböck syndrome?
- A. Normal leukocyte counts
- B. Obesity
- C. Erythrocytosis
- D. Hypotension (Correct Answer)
Explanation: Hypotension- Gaisböck syndrome, often called stress polycythemia or relative polycythemia, is strongly associated with hypertension due to the hemoconcentration and reduced plasma volume [1].- Hypotension is not a feature of this syndrome, which typically presents in middle-aged men with cardiovascular risk factors.*Erythrocytosis*- Relative erythrocytosis (or pseudopolycythemia) is the defining characteristic of Gaisböck syndrome [1].- This increase in hematocrit is due to a decrease in plasma volume (hemoconcentration) rather than an absolute increase in red cell mass.*Normal leukocyte counts*- Maintaining normal white blood cell (WBC) counts is typical in Gaisböck syndrome [1].- This feature helps exclude Polycythemia Vera, where both leukocytes and platelets are often elevated along with the absolute erythrocytosis.*Obesity*- Obesity is a common and significant component of the syndrome, along with other metabolic risk factors like hyperlipidemia.- The patient group is often described as overweight, anxious, and highly prone to cardiovascular events.
Question 29: A patient presents with dyspnea and distended neck veins that increase on inspiration. There is no murmur. What is the diagnosis?
- A. Pulmonary arterial hypertension
- B. Tricuspid stenosis
- C. Constrictive pericarditis (Correct Answer)
- D. Aortic regurgitation
Explanation: ***Constrictive pericarditis***- The combination of dyspnea, distended neck veins, and the increase of neck vein distension on inspiration (**Kussmaul sign**) is highly suggestive of constrictive physiology, such as **constrictive pericarditis** [2].- This condition involves a rigid pericardium impairing diastolic filling, leading to elevated right atrial pressure and fixed cardiac volume, hence the characteristic **Kussmaul sign** [2].*Aortic regurgitation*- Typically presents with symptoms of left-sided heart failure (e.g., paroxysmal nocturnal dyspnea) and is characterized by a prominent **diastolic decrescendo murmur** [3].- Peripheral signs usually include **wide pulse pressure** and a bounding pulse (**water-hammer pulse**), none of which explain the Kussmaul sign [3].*Tricuspid stenosis*- This condition would cause right heart failure symptoms (JVD) but is always associated with a **diastolic rumbling murmur** best heard at the left sternal border or xiphoid area.- While **Kussmaul sign** can sometimes be seen in severe tricuspid stenosis, the primary feature is the presence of the characteristic murmur, which is noted as absent here.*Pulmonary arterial hypertension*- This condition causes right-sided heart failure (leading to JVD) but lacks the mechanical restriction of filling necessary to reliably produce the specific **Kussmaul sign** [1].- It is often associated with signs of secondary **tricuspid regurgitation** (a holosystolic murmur) due to right ventricular dilation [1].
Question 30: What is the most common cause of Cushing's disease in a 60-year-old male?
- A. Small-cell lung cancer
- B. Adrenal tumor
- C. Pituitary microadenoma (Correct Answer)
- D. Ectopic ACTH syndrome
Explanation: ***Pituitary microadenoma*** - Cushing's **Disease** is specifically defined as hypercortisolism caused by an ACTH-secreting tumor of the pituitary gland, which is typically a **microadenoma** (<10 mm) [2]. - Pituitary adenomas are the most common cause of **endogenous** ACTH-dependent hypercortisolism (Cushing's Disease), regardless of the patient's age or sex [1]. *Small-cell lung cancer* - This is the most common cause of **ectopic ACTH syndrome**, which is a form of Cushing's **Syndrome**, not Cushing's Disease [1]. - Ectopic secretion generally leads to rapidly progressive, severe hypercortisolism and is often associated with hypokalemic metabolic alkalosis. *Adrenal tumor* - Adrenal tumors (adenomas or carcinomas) cause **ACTH-independent** Cushing's syndrome by directly overproducing cortisol [1]. - In this etiology, the pituitary gland is suppressed, resulting in very low or undetectable plasma **ACTH levels** [3]. *Ectopic ACTH syndrome* - While ectopic ACTH syndrome (often from bronchial carcinoids or small-cell lung cancer) is a significant cause of Cushing's **Syndrome** in elderly males, it is not the definition of Cushing's **Disease**. [1] - Ectopic sources produce ACTH unresponsive to **high-dose dexamethasone suppression** tests, unlike most cases of Cushing's Disease.