FMGE 2023 - Internal Medicine Practice Questions

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.

Q: Which of the following is not a component of qSOFA score?

LDH-Lactate dehydrogenase. ***LDH-Lactate dehydrogenase*** - The **quick Sequential Organ Failure Assessment (qSOFA) score** is a rapid bedside tool used to identify adult patients with suspected infection who are at high risk for poor outcomes, but it does not include laboratory markers like LDH. - qSOFA only includes three simple, readily available clinical criteria (respiratory rate, mental status, and systolic BP), therefore **LDH** is not a component. *Respiratory rate >22* - A **respiratory rate of 22 breaths per minute (or higher)** is one of the three components of the qSOFA score (a score of 1 point is given if RR ≥ 22) [1]. - This parameter indicates a potential compensatory mechanism for **metabolic acidosis** or severe underlying respiratory compromise due to infection. *Altered mental status* - **Altered mental status** (Glasgow Coma Scale score < 15 or any change from baseline) is a key component of the qSOFA score (1 point) [1]. - This reflects neurological **end-organ dysfunction** secondary to systemic inflammation and hypoperfusion (sepsis-associated encephalopathy). *Systolic blood pressure < 100 mmHg* - A systolic blood pressure (SBP) **less than 100 mmHg** is the third component of the qSOFA score (1 point) [1]. - This criterion indicates **hemodynamic compromise** and potential **shock**, reflecting severe circulatory dysfunction associated with sepsis.

Q: A patient presented to the OPD with liver damage. The picture depicts the patient having their eyes examined. Which of the following substances is responsible for this condition?

Copper. ***Copper*** - The image displays a **Kayser-Fleischer ring**, a greenish-gold ring at the corneal limbus, which is a hallmark sign of **Wilson's disease**. This condition, combined with liver damage, points to an issue with copper metabolism. - Wilson's disease is an autosomal recessive disorder caused by a mutation in the **ATP7B gene**, leading to impaired biliary excretion and subsequent toxic accumulation of **copper** in the liver, brain, and cornea. *Glucose* - Elevated **glucose** levels, as seen in diabetes mellitus, can cause ocular complications such as **diabetic retinopathy** and **cataracts**, but not Kayser-Fleischer rings. - While diabetes can be associated with liver disease (e.g., **NAFLD**), the combination of this specific eye finding and liver damage is not characteristic of glucose-related pathology. *Galactose* - Excess **galactose** is characteristic of **galactosemia**, an inherited metabolic disorder that can cause liver failure and cirrhosis, similar to Wilson's disease. - However, the classic ocular finding in galactosemia is the formation of **"oil-droplet" cataracts**, not the Kayser-Fleischer rings shown in the image. *Mannose* - Disorders of **mannose** metabolism are typically classified as **congenital disorders of glycosylation (CDGs)**. - These rare genetic disorders present with a wide spectrum of multi-systemic symptoms, including neurological and developmental issues, but are not associated with the development of Kayser-Fleischer rings.

Q: A 50-year-old smoker presents to the hospital with a painless oral lesion and white patch that develops in the oral cavity, as shown in the image. What is the diagnosis?

Leukoplakia. ***Leukoplakia*** - Leukoplakia is a clinical diagnosis for a white patch or plaque on the oral mucosa that **cannot be scraped off**, distinguishing it from other lesions like candidiasis. - It is strongly associated with chronic irritation, particularly **tobacco use** (as in this smoker), and is considered a **premalignant condition** with a risk of transforming into squamous cell carcinoma. *Candidiasis* - Oral candidiasis (thrush) presents as creamy white, curd-like plaques that **can typically be scraped off**, revealing an underlying erythematous and sometimes bleeding base. - It is an opportunistic fungal infection more common in **immunocompromised** patients, infants, or those using steroids or broad-spectrum antibiotics. *Lichen planus* - Oral lichen planus is a chronic inflammatory autoimmune disease that classically appears as a fine, lace-like network of white lines known as **Wickham's striae**. - While it can present as plaques, the typical reticular pattern is a key differentiating feature, and it is not primarily caused by smoking. *Oral cancer* - While this lesion could be oral cancer (squamous cell carcinoma), **leukoplakia** is the correct clinical descriptive term for the white patch itself. A definitive diagnosis of cancer requires a **biopsy**. - Oral cancers often present as **indurated ulcers**, red patches (erythroplakia), or fungating masses, which may or may not be painful, in addition to white patches.

Q: A patient presented to OPD with complaints of fatigue, loss of appetite, constipation, urinary symptoms of kidney stone, and increased urination. The patient has a history of psychiatric disorder; you suspect a case of hyperparathyroidism. Which of the following investigations is useful in this condition?

Sestamibi scan. ***Sestamibi scan*** - This is the standard **nuclear medicine study** used for localizing hyperfunctioning **parathyroid adenomas** prior to surgery (parathyroidectomy), essential for confirming the source of hypercalcemia [1]. - The scan is highly sensitive because the tracer (**Technetium-99m Sestamibi**) is retained longer in the hyperactive parathyroid tissue than in the surrounding thyroid tissue [1]. *USG neck* - **Ultrasonography** is an anatomical study that is often used as a basic initial imaging step due to its non-invasiveness, but it has lower overall sensitivity (50-80%) in localization. - It is poor at locating **ectopic or deep-seated adenomas** and cannot confirm if the lesion is truly hyperfunctioning, which is critical for diagnosis. *CT neck* - **Computed Tomography** is generally reserved for situations where non-invasive methods fail, especially when trying to localize **ectopic glands** deep in the **mediastinum** or neck. - It is not preferred as a first-line investigation due to the associated **radiation exposure** and lack of functional information regarding the glandular activity. *PET scan* - Standard **FDG-PET scans** are mostly ineffective for localizing benign parathyroid adenomas because they rarely exhibit the high metabolic activity required for tracer uptake. - Specialized PET tracers, such as **11C-methionine**, may be used in complicated cases of persistent or recurrent hyperparathyroidism, but are not routine for initial diagnosis. Note: The patient's presentation of kidney stones, psychiatric symptoms, and polyuria is consistent with primary hyperparathyroidism secondary to hypercalcemia [2, 3].

Question 1

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 2

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 3

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

Accepted Answer

Metoprolol

Answer

Prazosin

Answer

Torsemide

Answer

Furosemide

Question 4

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 5

Hamman sign is seen in

Accepted Answer

Pneumomediastinum

Answer

Pneumoperitoneum

Answer

Hydropneumothorax

Answer

Pneumopericardium

Question 6

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

Question 7

Which of the following is not a component of qSOFA score?

Accepted Answer

LDH-Lactate dehydrogenase

Answer

Systolic blood pressure < 100 mmHg

Answer

Respiratory rate >22

Answer

Altered mental status

Question 8

A patient presented to the OPD with liver damage. The picture depicts the patient having their eyes examined. Which of the following substances is responsible for this condition?

Accepted Answer

Copper

Answer

Glucose

Answer

Galactose

Answer

Mannose

Question 9

A 50-year-old smoker presents to the hospital with a painless oral lesion and white patch that develops in the oral cavity, as shown in the image. What is the diagnosis?

Accepted Answer

Leukoplakia

Answer

Candidiasis

Answer

Lichen planus

Answer

Oral cancer

Question 10

A patient presented to OPD with complaints of fatigue, loss of appetite, constipation, urinary symptoms of kidney stone, and increased urination. The patient has a history of psychiatric disorder; you suspect a case of hyperparathyroidism. Which of the following investigations is useful in this condition?

Accepted Answer

Sestamibi scan

Answer

USG neck

Answer

CT neck

Answer

PET scan

FMGE 2023 — Internal Medicine