FMGE 2023 - Internal Medicine Practice Questions

Q: An elderly male on bed rest for many months presented with breathlessness and chest pain. What is the next best step in the management of this patient?

CT pulmonary angiogram. ***CT pulmonary angiogram***- This is the **gold standard** imaging investigation for diagnosing **pulmonary embolism (PE)**, offering rapid confirmation of emboli within the pulmonary arteries [1].- The patient's history of prolonged **bed rest** (immobilization) makes them high-risk for **Deep Vein Thrombosis (DVT)**, predisposing them to PE, which manifests as acute breathlessness and chest pain [2].*ECG*- An ECG is a standard initial test (often alongside chest X-ray) to exclude cardiac causes like **myocardial infarction** and assess for features of right ventricular strain (e.g., **S1Q3T3 pattern**) associated with PE [1].- However, ECG findings are non-specific and cannot definitively confirm or exclude the diagnosis of PE; imaging is required.*CT thorax*- A standard non-contrast CT thorax is effective for evaluating lung parenchyma (e.g., pneumonia or malignancy).- It is inadequate for diagnosing PE, which requires intravenous contrast specifically timed to opacify the pulmonary arteries (a **CT pulmonary angiogram**).*Echocardiography*- Echocardiography is primarily used to assess the functional and prognostic impact of PE, specifically looking for **right ventricular (RV) dilation** and dysfunction.- It may be utilized in critically **hemodynamically unstable** patients suspected of PE (where immediate transport to CTPA is dangerous), but for a stable patient, CTPA provides the definitive anatomical diagnosis.

Q: A chronic smoker presented with bilateral pitting pedal edema, and abdominal distension. On examination, he had ascites and auscultation revealed an S3. Which of the following defects can be seen in this patient?

Tricuspid regurgitation. ***Tricuspid regurgitation*** - This patient presents with **classic signs of right heart failure**: bilateral pitting pedal edema, ascites, and abdominal distension indicating systemic venous congestion [1] - **Chronic smoking → COPD → pulmonary hypertension → functional tricuspid regurgitation** is a common pathophysiological sequence - **S3 gallop** indicates ventricular volume overload, which occurs in TR due to regurgitant flow - TR leads to **hepatic congestion** (causing ascites) and **peripheral edema** from elevated systemic venous pressure - Clinical triad: **elevated JVP, hepatomegaly, and peripheral edema** points to TR *Incorrect: Aortic stenosis* - Causes **left-sided heart failure**, not right-sided [2] - Classic presentation: **angina, syncope, and dyspnea** (not peripheral edema and ascites) [2] - Would not explain the systemic venous congestion seen in this patient *Incorrect: Mitral regurgitation* - Primarily causes **left-sided heart failure** with pulmonary congestion [1] - Initial presentation includes **dyspnea and pulmonary edema**, not peripheral edema [1] - While chronic MR can eventually lead to right heart failure, the **predominant right-sided signs** make this less likely *Incorrect: Aortic regurgitation* - Causes **left-sided heart failure** [3] - Classic signs include **wide pulse pressure, bounding pulses**, and water-hammer pulse [3] - Does not explain the **right-sided failure** picture with ascites and bilateral pedal edema

Q: What is the most common cause of death in children with Diabetic ketoacidosis?

Cerebral edema. ***Cerebral edema*** - It is the **most common cause of mortality** in pediatric DKA, occurring in 0.5-1% of cases with a mortality rate of 20-25% [1] - Occurs due to rapid changes in **plasma osmolality** during treatment - the rapid decrease of blood glucose and effective osmolarity creates an osmotic gradient, causing fluid shifts into brain cells - Leads to potentially fatal **intracranial pressure** elevation with clinical features of headache, altered mental status, bradycardia, and respiratory depression - Risk factors include: new-onset diabetes, younger age, severe acidosis, and rapid fluid administration *Hypokalemia* - Potassium levels often drop dramatically during DKA treatment as insulin drives potassium into cells, potentially causing life-threatening **cardiac arrhythmias** [1] - This complication is highly anticipated and routinely managed by **potassium replacement therapy** with close monitoring [3] - While potentially fatal if unrecognized, it is a **preventable and treatable** condition with proper electrolyte management *Dehydration* - Severe dehydration causing **hypovolemic shock** is a major factor contributing to morbidity in DKA [2] - Effectively managed by aggressive **IV fluid resuscitation** with careful monitoring [3] - In treated pediatric DKA, the failure leading to death is typically the development of **cerebral edema** rather than persistent volume depletion [1] *Sepsis* - While sepsis can precipitate DKA, it is an underlying **trigger** or precipitating factor, not the direct physiological cause of death during DKA itself - The overwhelming fatality **in** pediatric DKA (as opposed to from the precipitating illness) is generally attributed to **cerebral edema** from rapid fluid shifts leading to central nervous system complications [1]

Question 1

An elderly male on bed rest for many months presented with breathlessness and chest pain. What is the next best step in the management of this patient?

Accepted Answer

CT pulmonary angiogram

Answer

ECG

Answer

CT thorax

Answer

Echocardiography

Question 2

A chronic smoker presented with bilateral pitting pedal edema, and abdominal distension. On examination, he had ascites and auscultation revealed an S3. Which of the following defects can be seen in this patient?

Accepted Answer

Tricuspid regurgitation

Answer

Aortic stenosis

Answer

Mitral regurgitation

Answer

Aortic regurgitation

Question 3

What is the most common cause of death in children with Diabetic ketoacidosis?

Accepted Answer

Cerebral edema

Answer

Hypokalemia

Answer

Dehydration

Answer

Sepsis

FMGE 2023 — Internal Medicine