FMGE 2024 — Internal Medicine
9 Previous Year Questions with Answers & Explanations
A 46-year-old male presents to the outpatient department with a history of lower back pain and painful urination. Upon investigation, he is found to have normocytic normochromic anemia and hypercalcemia. Serum protein electrophoresis reveals an M-spike in the gamma region. Which of the following tests is most appropriate to confirm the diagnosis of multiple myeloma?
A young woman presents with recurrent headaches, easy bruising, and episodes of visual blurring. Her platelet count is elevated, while her red blood cell (RBC) and white blood cell (WBC) counts are normal. What is the most likely diagnosis?
Which of the following is the diagnostic test for carcinoid tumors?
Which of the following microorganisms is likely responsible for causing bilateral infiltrates in an HIV-positive patient?
A 35-year-old patient presents with colicky abdominal pain, joint pain, and palpable purpura. Urinalysis shows only red blood cells with no other significant findings. Which of the following is the likely diagnosis?
What nutritional deficiency is commonly associated with a chronic alcoholic presenting with a pruritic, eczematous rash on the neck and dorsum of the hands?
Acute liver failure is a clinical feature of which of the following?
Which HLA is associated with Reiter syndrome?
A 40-year-old man presents with gynecomastia. Ultrasound reveals a 1 cm solid mass within the body of the testis. Serum testosterone is 600 ng/dL, and estradiol is 35 pg/mL. What is the most likely diagnosis?
FMGE 2024 - Internal Medicine FMGE Practice Questions and MCQs
Question 1: A 46-year-old male presents to the outpatient department with a history of lower back pain and painful urination. Upon investigation, he is found to have normocytic normochromic anemia and hypercalcemia. Serum protein electrophoresis reveals an M-spike in the gamma region. Which of the following tests is most appropriate to confirm the diagnosis of multiple myeloma?
- A. Liver function test
- B. Urine albumin-to-creatinine ratio (UACR) test
- C. Bone marrow examination (Correct Answer)
- D. Bence Jones protein in urine
Explanation: ***Bone marrow examination*** - The **definitive confirmatory test** for multiple myeloma is bone marrow examination showing **≥10% clonal plasma cells** (or presence of plasmacytoma on biopsy) [1]. - According to **International Myeloma Working Group (IMWG) criteria**, diagnosis requires: (1) clonal bone marrow plasma cells ≥10% OR biopsy-proven plasmacytoma AND (2) evidence of end-organ damage (CRAB criteria: hypercalcemia, renal insufficiency, anemia, bone lesions) [1]. - This patient has M-spike (monoclonal protein), hypercalcemia, anemia, and bone pain—bone marrow biopsy **confirms the diagnosis** by demonstrating clonal plasma cell proliferation [2]. *Liver function test* - These tests primarily evaluate **hepatic function** (e.g., ALT, AST, bilirubin) and are not diagnostic for multiple myeloma. - While some secondary abnormalities may occur (e.g., elevated **LDH** or **ALP** if bone involvement is extensive), LFTs lack the required specificity for confirming the diagnosis. *Urine albumin-to-creatinine ratio (UACR) test* - UACR is primarily used to screen for **microalbuminuria** in conditions such as **diabetic nephropathy** or hypertensive kidney disease. - The proteinuria seen in multiple myeloma is due to excretion of **kappa or lambda light chains** (Bence Jones protein), not albumin, making UACR inappropriate for MM diagnosis. *Bence Jones protein in urine* - Detection of **monoclonal free light chains** (Bence Jones protein) in urine is a **supportive finding** present in 50-60% of MM cases [1]. - While clinically significant and part of the diagnostic workup, it is **not confirmatory by itself**—bone marrow examination remains the gold standard. - Modern detection uses **urine immunofixation electrophoresis** or serum free light chain assays.
Question 2: A young woman presents with recurrent headaches, easy bruising, and episodes of visual blurring. Her platelet count is elevated, while her red blood cell (RBC) and white blood cell (WBC) counts are normal. What is the most likely diagnosis?
- A. Essential Thrombocythemia (Correct Answer)
- B. Polycythemia Vera
- C. Chronic Myeloid Leukemia (CML)
- D. Acute Myeloid Leukemia (AML)
Explanation: ***Essential Thrombocythemia*** - This **myeloproliferative neoplasm (MPN)** is characterized by isolated, persistent elevation of the **platelet count** (thrombocytosis) with relatively normal RBC and WBC counts, fitting the clinical picture. - Symptoms like headaches, visual blurring, and bruising are common because the functionally abnormal platelets can cause both **microvascular thrombosis** and bleeding tendencies. *Polycythemia Vera* - PV is primarily defined by **erythrocytosis** (elevated RBC count or hematocrit), which is inconsistent with this patient's normal red blood cell count. - Although PV often causes thrombocytosis, the core diagnostic feature involves a panmyelosis dominated by excessive **RBC mass** leading to hyperviscosity symptoms. *Chronic Myeloid Leukemia (CML)* - CML is hallmarked by significant **leukocytosis** (elevated WBC count, especially neutrophils and their precursors) due to the **BCR-ABL fusion gene**. - The patient's normal WBC count makes CML an unlikely diagnosis. *Acute Myeloid Leukemia (AML)* - AML typically presents with signs of **bone marrow failure**, such as anemia, neutropenia, and thrombocytopenia (low platelets), indicating acute lack of mature blood cells. - The lab findings in AML usually show cytopenia or the presence of immature **myeloblasts**, not isolated thrombocytosis.
Question 3: Which of the following is the diagnostic test for carcinoid tumors?
- A. Serum chromogranin A
- B. Serum calcitonin levels
- C. Urinary 5-hydroxyindoleacetic acid (Correct Answer)
- D. 24-hour urinary catecholamines
Explanation: ***Urinary 5-hydroxyindoleacetic acid***- Carcinoid tumors actively produce **serotonin**, which is rapidly metabolized by **monoamine oxidase** into the inactive metabolite **5-hydroxyindoleacetic acid (5-HIAA)**.- A **24-hour urinary collection** for 5-HIAA is the most specific and confirms the functional diagnosis of **carcinoid syndrome** [1].*24-hour urinary catecholamines*- This test is primarily used for the diagnosis of **pheochromocytoma**, which secretes excess **norepinephrine** and **epinephrine**.- High levels of catecholamine metabolites, such as **metanephrines** and **vanillylmandelic acid (VMA)**, are diagnostic for pheochromocytoma, not carcinoid tumors, which primarily produce serotonin.*Serum calcitonin levels*- **Calcitonin** secretion is the key diagnostic and monitoring marker for **medullary thyroid carcinoma (MTC)**, a non-related neuroendocrine tumor originating from C-cells.- This marker is not specific or elevated in typical **carcinoid tumors** originating from the small bowel or lungs.*Serum chromogranin A*- **Chromogranin A (CgA)** is a general biomarker for **neuroendocrine tumors (NETs)** and is useful for screening and monitoring disease burden [2].- While sensitive for carcinoid tumors, it lacks the specificity of **5-HIAA** for diagnosing **carcinoid syndrome** and can be falsely elevated in conditions like PPI use or renal failure.
Question 4: Which of the following microorganisms is likely responsible for causing bilateral infiltrates in an HIV-positive patient?
- A. Pneumocystis Jirovecii (Correct Answer)
- B. Histoplasma
- C. Aspergillus
- D. Cryptococcus
Explanation: ***Pneumocystis Jirovecii***- **Pneumocystis Pneumonia (PCP)** is the most common AIDS-defining infection affecting the lungs, typically presenting with **diffuse, bilateral, perihilar interstitial infiltrates** in HIV patients [1]. - This infection is strongly associated with a **CD4 cell count below 200 cells/mm³** and often manifests clinically with gradual onset of dyspnea, fever, and a non-productive cough [1].*Cryptococcus*- Although *Cryptococcus neoformans* is a common opportunistic infection in HIV, it predominantly causes **meningitis** or **meningoencephalitis**. - Pulmonary involvement usually presents as **nodules** or localized consolidations, not the classic diffuse bilateral interstitial pattern seen with PCP.*Histoplasmosis*- *Histoplasma capsulatum* is an endemic pathogen (e.g., Ohio and Mississippi River Valleys) that typically causes **disseminated disease** in advanced HIV. - While pulmonary infection may occur, it often presents with **hilar/mediastinal lymphadenopathy** [2] or a miliary pattern, rather than isolated bilateral interstitial infiltrates.*Aspergillus*- **Invasive Aspergillosis** generally occurs in patients with profound and prolonged **neutropenia** (e.g., following chemotherapy or transplantation), which is less common in typical AIDS patients with low CD4 counts. - Pulmonary findings usually involve localized **cavities** or **nodules with a halo sign** (angioinvasive disease), contrasting with the diffuse bilateral infiltrates of PCP.
Question 5: A 35-year-old patient presents with colicky abdominal pain, joint pain, and palpable purpura. Urinalysis shows only red blood cells with no other significant findings. Which of the following is the likely diagnosis?
- A. IgA vasculitis (Correct Answer)
- B. Behçet's disease
- C. Granulomatosis with polyangiitis
- D. Microscopic polyangiitis
Explanation: ***IgA vasculitis***- The presentation of **palpable purpura**, **colicky abdominal pain**, and **joint pain** (arthralgia/arthritis), along with evidence of renal disease (**hematuria**), is the classic tetrad of **IgA vasculitis** (Henoch-Schönlein purpura) [1]. - This condition involves deposits of **IgA-containing immune complexes** in the walls of small vessels across various organ systems, including the skin, joints, gastrointestinal tract, and kidneys [1]. *Granulomatosis with polyangiitis* - This primarily affects the **upper and lower respiratory tract** (e.g., sinus inflammation, pulmonary nodules/hemorrhage) and the kidneys, often presenting without classic palpable purpura. - It is strongly associated with circulating **c-ANCA** antibodies targeting proteinase 3 (PR3). *Microscopic polyangiitis* - This is a non-necrotizing small-vessel vasculitis [2] typically presenting with **rapidly progressive glomerulonephritis** and often pulmonary capillary involvement causing hemorrhage. - It is usually associated with **p-ANCA** antibodies targeting myeloperoxidase (MPO) and rarely causes the prominent skin and GI symptoms seen here. *Behçet's disease* - The cardinal features of Behçet’s disease are recurrent **oral aphthous ulcers**, **genital ulcers**, and **ocular inflammation** (uveitis). - While it can cause vasculitis, it primarily involves large veins and arteries, and the combination of palpable purpura and colicky pain strongly favors IgA vasculitis over this diagnosis.
Question 6: What nutritional deficiency is commonly associated with a chronic alcoholic presenting with a pruritic, eczematous rash on the neck and dorsum of the hands?
- A. Vit D
- B. Vit C
- C. Vit B3 (Correct Answer)
- D. Vit B1
Explanation: ***Vit B3*** - This presentation is classic for **pellagra**, the syndrome caused by **niacin (Vitamin B3)** deficiency, characterized by the 3 Ds: **Dermatitis**, **Diarrhea**, and **Dementia** [1], [2]. - The described **pruritic, eczematous rash** on sun-exposed areas (neck, hands, often called Casal's necklace if circumferential on the neck) is the typical **photosensitive dermatitis** associated with pellagra [1], [2]. *Vit B1* - Deficiency in **thiamine (B1)** causes **Beriberi** or **Wernicke-Korsakoff syndrome**, which primarily affects the nervous and cardiovascular systems [3], [4]. - Clinical features include **ataxia**, **ophthalmoplegia**, and high-output heart failure, but not this characteristic eczematous rash [3], [4]. *Vit D* - Deficiency leads to defective bone mineralization, causing **Rickets** in children and **Osteomalacia** in adults (resulting in bone pain and fractures). - While common in alcoholics, **Vitamin D** deficiency is not the cause of the specific, widespread, photosensitive eczematous rash described. *Vit C* - **Ascorbic acid (Vitamin C)** deficiency causes **Scurvy**, which presents with symptoms related to impaired collagen synthesis. - Hallmark features include **gingival bleeding**, **perifollicular hemorrhages**, and **impaired wound healing**, without the specific photosensitive dermatitis seen in pellagra.
Question 7: Acute liver failure is a clinical feature of which of the following?
- A. C. Belladonna poisoning
- B. D. Morphine poisoning
- C. A. OP poisoning
- D. B. Amanita Phalloides poisoning (Correct Answer)
Explanation: Correct Option B: Amanita Phalloides poisoning - This is due to the presence of potent hepatotoxins, primarily **alpha-amanitin**, which severely damages hepatocytes by inhibiting **RNA polymerase II**. - Ingestion often leads to a delayed presentation of **fulminant hepatic failure** (acute liver failure), necessitating aggressive supportive care and often liver transplantation [1]. *Incorrect Option A: OP poisoning* - Organophosphate poisoning primarily causes a **cholinergic crisis** by inhibiting acetylcholinesterase, leading to massive accumulation of acetylcholine (e.g., SLUDGE syndrome) [2]. - While severe hypoxia or shock might secondarily damage the liver, **acute liver failure** is not the characteristic or primary toxicity of organophosphates [2]. *Incorrect Option C: Belladonna poisoning* - Belladonna contains **atropine** and other anticholinergic compounds, causing profound **anticholinergic syndrome** (e.g., delirium, mydriasis, tachycardia, urinary retention). - Hepatic necrosis or **acute liver failure** is not a feature of anticholinergic toxicity. *Incorrect Option D: Morphine poisoning* - Morphine, an opioid, causes toxicity characterized by the classic triad of **respiratory depression**, altered mental status, and **pinpoint pupils** (miosis). - Opioid toxicity is centered on the central nervous system and respiratory system; it does not directly cause primary **acute liver failure**.
Question 8: Which HLA is associated with Reiter syndrome?
- A. HLA-DQ8
- B. HLA-DR3
- C. HLA-DR4
- D. HLA-B27 (Correct Answer)
Explanation: ***HLA-B27*** - **HLA-B27** is the major histocompatibility complex (MHC) class I allele strongly associated with **Reiter syndrome** (now termed **Reactive Arthritis**) a component of the **seronegative spondyloarthropathies** [1]. - Approximately 60-80% of patients with Reactive Arthritis who present with the classic triad (urethritis, conjunctivitis, arthritis) are positive for **HLA-B27** [1]. *HLA-DR3* - **HLA-DR3** is primarily associated with several autoimmune disorders, including **Celiac Disease**, **Graves' Disease**, and **Systemic Lupus Erythematosus** (SLE). - It is an MHC class II allele, distinguishing it from the MHC class I linkage observed in Reactive Arthritis. *HLA-DQ8* - **HLA-DQ8** (often with HLA-DQ2) is a key genetic risk factor for **Celiac Disease**, playing a role in presenting gliadin peptides to T cells. - This allele is also associated with **Type 1 Diabetes Mellitus** but lacks a significant established association with the pathogenesis of the spondyloarthropathies. *HLA-DR4* - **HLA-DR4** carries the strongest genetic risk for **Rheumatoid Arthritis** (RA), particularly in individuals prone to developing severe, erosive disease. - While associated with generalized autoimmunity, **HLA-DR4** is not the primary marker for the seronegative spondyloarthropathies like Reactive Arthritis [2].
Question 9: A 40-year-old man presents with gynecomastia. Ultrasound reveals a 1 cm solid mass within the body of the testis. Serum testosterone is 600 ng/dL, and estradiol is 35 pg/mL. What is the most likely diagnosis?
- A. Leydig cell tumor (Correct Answer)
- B. Sertoli cell tumor
- C. Spermatocytic tumor
- D. Granulosa cell tumor
Explanation: ***Correct: Leydig cell tumor*** - **Most common** sex cord-stromal tumor in adults, accounting for **1-3%** of all testicular tumors - Arises from interstitial cells that produce **testosterone and estradiol** through aromatization [2], [4] - Classic presentation: **Gynecomastia** (30-40% of cases) due to increased estrogen production or altered testosterone/estrogen ratio [1], [3] - Typically presents as a **small, benign solid mass** (90% are <5 cm and benign) [3] - Ultrasound shows **solid, well-circumscribed intratesticular mass** [3] - Laboratory findings: **Elevated estradiol**, testosterone may be normal or elevated [3] *Incorrect: Sertoli cell tumor* - Less common sex cord-stromal tumor (also can cause gynecomastia but **much rarer** than Leydig cell tumor) - Only **10-20%** present with endocrine manifestations - More likely to present with painless testicular mass without hormonal effects - When hormonal effects occur, usually **estrogen production** but less pronounced than Leydig cell tumor *Incorrect: Spermatocytic tumor* - Germ cell tumor that occurs in **older men** (mean age 50-55 years) - **Does NOT produce hormones** - no gynecomastia - Presents as painless testicular enlargement - Typically larger masses, good prognosis, virtually **never metastasizes** *Incorrect: Granulosa cell tumor* - **Extremely rare** in males (primarily an ovarian tumor) - When it occurs in males, can produce estrogen and cause gynecomastia - However, represents **<1%** of testicular tumors in males - Leydig cell tumor is far more common with this presentation