FMGE 2023 - Internal Medicine Practice Questions

Q: 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?

Pseudotumor cerebri. ***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].

Q: Which of the following is not included in the Gaisböck syndrome?

Hypotension. 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.

Q: A patient presents with dyspnea and distended neck veins that increase on inspiration. There is no murmur. What is the diagnosis?

Constrictive pericarditis. ***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].

Q: What is the most common cause of Cushing's disease in a 60-year-old male?

Pituitary microadenoma. ***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.

Q: A 50-year-old woman presented with difficulty in activities like climbing stairs, getting up from a chair, and combing hair. Violaceous erythema of the upper eyelids was noted. What is the most probable diagnosis?

Dermatomyositis. ***Dermatomyositis***- The combination of **proximal muscle weakness** (difficulty climbing stairs, rising from a chair, combing hair) and the pathognomonic **Heliotrope sign** (violaceous erythema of the upper eyelids) is highly indicative of **Dermatomyositis** [1], [2].- Dermatomyositis is a type of idiopathic inflammatory **myopathy** that also features characteristic skin findings like **Gottron papules** (over MCPs, PIPs, and elbows) [1], [2].*Inclusion body myositis*- Primarily affects men older than 50 and often involves **distal muscle weakness** (e.g., finger flexors) in addition to proximal muscles, which is not described here [3].- Characterized by early loss of **deep tendon reflexes** and may show **rimmed vacuoles** on muscle biopsy, features distinct from this presentation [3].*Polymyositis*- Presents with similar **proximal muscle weakness** but **lacks the characteristic skin manifestations** like the Heliotrope sign or Gottron papules [1].- Diagnosis is supported by elevated muscle enzymes (CK) and inflammatory changes on muscle biopsy, but the absence of skin findings rules it out in favor of dermatomyositis.*Scleroderma*- Characterized by **skin thickening** and **fibrosis**, often involving the hands and face, and potentially internal organs (lung, GI tract).- Muscle weakness, if present (**Myositis overlap**), is usually less prominent than the distinctive **cutaneous and systemic features** of scleroderma.

Q: Bell's palsy involves

Ipsilateral upper and lower halves of the face.. ***Ipsilateral upper and lower halves of the face.*** - **Bell's palsy** is the most common cause of **idiopathic peripheral (Lower Motor Neuron - LMN)** facial nerve paralysis [1]. - A peripheral (LMN) lesion affects the **entire distribution** of the facial nerve on the affected side, resulting in paralysis of all muscles, including those controlling the forehead and eye closure. - Facial nerve palsies affect the **ipsilateral** side of the face relative to the site of peripheral nerve injury or brainstem nuclear lesion. *Contralateral upper and lower halves of the face.* - This presentation would imply a **bilateral upper and lower facial paralysis**, which is highly unusual for a single lesion like Bell's palsy. - Facial nerve palsies affect the **ipsilateral** side of the face, not contralateral. *Ipsilateral lower half of the face.* - Paralysis limited to the **ipsilateral lower half of the face** while sparing the upper face (forehead) is characteristic of a **Central (Upper Motor Neuron - UMN)** lesion (like a stroke) located in the contralateral cortex [1]. - This does not define Bell's palsy, which is a **peripheral (LMN)** lesion affecting the entire face. *Contralateral lower half of the face.* - This pattern, involving **paralysis of the lower face contralateral** to the lesion while sparing the forehead, is the classic presentation of a **Central (Upper Motor Neuron - UMN)** lesion [1]. - UMN lesions spare the upper face because the **facial nerve nucleus** receives bilateral cortical input for the muscles of the forehead.

Q: Which of the following drugs reduces mortality in a patient with heart failure?

Metoprolol. ***Correct: Metoprolol*** - *Beta-blockers* like **Metoprolol succinate** (extended-release form) reduce mortality in patients with **HFrEF** (Heart Failure with reduced Ejection Fraction) by blocking the deleterious effects of chronic sympathetic nervous system activation on the myocardium [1]. - These drugs prevent ventricular remodeling, reduce **sudden cardiac death** by lowering heart rate and improving oxygen demand/supply balance, and are cornerstone therapies alongside **ACE inhibitors/ARBs/ARNI** [1]. *Incorrect: Furosemide* - Furosemide is a **loop diuretic** used primarily for **symptom relief** (reducing edema, dyspnea) by promoting diuresis and natriuresis to manage volume overload. - It does not modify the underlying disease progression or cardiac remodeling and, thus, has **no demonstrated mortality benefit** in heart failure trials. *Incorrect: Prazosin* - Prazosin is an **alpha-1 adrenergic blocker** used primarily as a vasodilator or for hypertension, but it has not shown benefit and may even increase adverse events in long-term heart failure management. - Unlike approved vasodilator therapies (like hydralazine/nitrate combination in certain populations), Prazosin is **not recommended** for chronic HF therapy due to lack of mortality data and potential for **orthostatic hypotension**. *Incorrect: Torsemide* - Torsemide is a **high-ceiling loop diuretic** similar to Furosemide, typically used to manage symptoms of congestion and fluid retention in heart failure patients. - While some studies suggest better bioavailability than Furosemide, it ultimately functions as a diuretic and **does not confer a mortality benefit** in heart failure.

Q: A 49-year-old male presents with recurrent episodes of watery diarrhoea, dehydration, hypokalemia, and achlorhydria. Which of the following neuroendocrine tumours can be responsible for these symptoms?

VIPoma. A 49-year-old male presents with recurrent episodes of watery diarrhoea, dehydration, hypokalemia, and achlorhydria. Which of the following neuroendocrine tumours can be responsible for these symptoms? ***VIPoma***- The constellation of symptoms—watery diarrhoea, dehydration, hypokalemia, and achlorhydria—is known as **WDHA syndrome** (Watery Diarrhea, Hypokalemia, Achlorhydria), which is pathognomonic for a VIP-secreting tumour. [1] - **Vasoactive Intestinal Peptide (VIP)** acts as an intestinal secretagogue, leading to massive secretion of water and electrolytes, causing profound secretory diarrhea and subsequent life-threatening **hypokalemia** and dehydration. [1] *Insulinoma* - This tumour hypersecretes **insulin**, leading to severe symptoms of **hypoglycemia** (neuroglycopenic symptoms) which are typically worse in the fasting state. [2] - Insulinoma does not cause secretory diarrhea, hypokalemia, or achlorhydria. [2] *Somatostatinoma* - This tumor typically presents with the classic triad of **diabetes mellitus**, **gallstones (cholelithiasis)**, and **steatorrhea** (due to inhibition of pancreatic enzyme secretion). - While diarrhea can occur due to malabsorption, the overwhelming secretory diarrhea and achlorhydria defining this case are not characteristic. *Glucagonoma* - The primary clinical manifestations of glucagonoma include **necrolytic migratory erythema** (a distinctive skin rash), mild **diabetes mellitus**, and often **weight loss**. - It does not cause massive watery diarrhea leading to hypokalemia and achlorhydria.

Q: Hamman sign is seen in

Pneumomediastinum. ***Pneumomediastinum*** - Hamman sign (or Hamman's crunch) is the classic auscultatory finding associated with **pneumomediastinum** (air in the mediastinum). - It is described as a **crunching, grating, or rasping sound** over the pre-cordium, synchronous with the heartbeat, caused by the heart beating against adjacent air-filled tissue. *Pneumoperitoneum* - This condition involves free air within the **peritoneal cavity**, commonly presenting with signs of **acute abdomen** and rigidity. - It is diagnosed radiographically by finding **free gas under the dome of the diaphragm**, without causing pre-cordial crunching sounds. *Pneumopericardium* - This refers to air accumulating within the **pericardial sac** surrounding the heart. - While air near the heart exists, the specific Hamman sign is due to air in the surrounding **mediastinal tissue planes**, not within the confined pericardium. *Hydropneumothorax* - This involves the presence of both fluid (*hydro*) and air (*pneumo*) within the **pleural space**, outside the mediastinum. - Clinical features are typically related to compromised lung function, demonstrating signs of both pleural effusion and **pneumothorax**, without the characteristic Hamman sign.

Q: A 17-year-old woman with no comorbidities presents with numbness and paraesthesia of the fingers along with the characteristic finding as shown in the image below. She has no history of smoking or history of other illnesses. She mentions the episodes occur when she is under excess stress or during cold temperatures. What is the most likely diagnosis?

a. Raynaud's phenomenon. ***Raynaud's phenomenon*** (Keep the correct option at the top and the incorrect options in the order they are provided in the input) - The clinical picture of episodic digital **numbness**, paraesthesia, and color changes specifically triggered by **cold temperatures** or **stress** is pathognomonic for Raynaud's phenomenon. - Given the patient's young age (17) and lack of underlying illness (no comorbidities), this is strongly suggestive of **Primary Raynaud's phenomenon** (Raynaud's disease). *Buerger's disease* - **Buerger's disease** (Thromboangiitis obliterans) is highly associated with heavy **tobacco use**, which conflicts with the patient's history of no smoking. - This condition involves inflammation and thrombosis of medium and small arteries, typically leading to more severe fixed ischemia, ulcers, and **gangrene**, rather than transient vasospastic episodes. *Atherosclerosis* - **Atherosclerosis** is a fixed obstruction due to plaque buildup and is extremely rare in a healthy, young 17-year-old patient. - When present, it causes symptoms like **intermittent claudication** or rest pain, which are constant and exertional, unlike the acute, episodic nature of vasospasm. *Peripheral arterial disease* - **Peripheral arterial disease (PAD)** typically refers to occlusive disease (often atherosclerotic) that leads to reduced blood flow, causing symptoms that worsen with **exertion**. - Unlike Raynaud's, PAD does not typically cause acute, reversible, triphasic color changes in response to **cold** or emotional stress.

Question 1

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?

Accepted Answer

Pseudotumor cerebri

Answer

Myasthenia gravis

Answer

Temporal arteritis

Answer

Chronic migraine

Question 2

Which of the following is not included in the Gaisböck syndrome?

Accepted Answer

Hypotension

Answer

Normal leukocyte counts

Answer

Obesity

Answer

Erythrocytosis

Question 3

A patient presents with dyspnea and distended neck veins that increase on inspiration. There is no murmur. What is the diagnosis?

Accepted Answer

Constrictive pericarditis

Answer

Pulmonary arterial hypertension

Answer

Tricuspid stenosis

Answer

Aortic regurgitation

Question 4

What is the most common cause of Cushing's disease in a 60-year-old male?

Accepted Answer

Pituitary microadenoma

Answer

Small-cell lung cancer

Answer

Adrenal tumor

Answer

Ectopic ACTH syndrome

Question 5

A 50-year-old woman presented with difficulty in activities like climbing stairs, getting up from a chair, and combing hair. Violaceous erythema of the upper eyelids was noted. What is the most probable diagnosis?

Accepted Answer

Dermatomyositis

Answer

Inclusion body myositis

Answer

Polymyositis

Answer

Scleroderma

Question 6

Bell's palsy involves

Accepted Answer

Ipsilateral upper and lower halves of the face.

Answer

Contralateral upper and lower halves of the face.

Answer

Ipsilateral lower half of the face.

Answer

Contralateral lower half of the face.

Question 7

Which of the following drugs reduces mortality in a patient with heart failure?

Accepted Answer

Metoprolol

Answer

Prazosin

Answer

Torsemide

Answer

Furosemide

Question 8

A 49-year-old male presents with recurrent episodes of watery diarrhoea, dehydration, hypokalemia, and achlorhydria. Which of the following neuroendocrine tumours can be responsible for these symptoms?

Accepted Answer

VIPoma

Answer

Glucagonoma

Answer

Insulinoma

Answer

Somatostatinoma

Question 9

Hamman sign is seen in

Accepted Answer

Pneumomediastinum

Answer

Pneumoperitoneum

Answer

Hydropneumothorax

Answer

Pneumopericardium

Question 10

A 17-year-old woman with no comorbidities presents with numbness and paraesthesia of the fingers along with the characteristic finding as shown in the image below. She has no history of smoking or history of other illnesses. She mentions the episodes occur when she is under excess stress or during cold temperatures. What is the most likely diagnosis?

Accepted Answer

a. Raynaud's phenomenon

Answer

b. Buerger's disease

Answer

c. Atherosclerosis

Answer

d. Peripheral arterial disease

FMGE 2023 — Internal Medicine