FMGE 2024 - Internal Medicine PYQs Practice Questions

Q: 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?

Bone marrow examination. ***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. [Practice more Internal Medicine PYQs on OnCourse]

Q: 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?

Essential Thrombocythemia. ***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. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following is the diagnostic test for carcinoid tumors?

Urinary 5-hydroxyindoleacetic acid. ***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. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following microorganisms is likely responsible for causing bilateral infiltrates in an HIV-positive patient?

Pneumocystis Jirovecii. ***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. [Practice more Internal Medicine PYQs on OnCourse]

Q: 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?

IgA vasculitis. ***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. [Practice more Internal Medicine PYQs on OnCourse]

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?

Accepted Answer

Bone marrow examination

Answer

Liver function test

Answer

Urine albumin-to-creatinine ratio (UACR) test

Answer

Bence Jones protein in urine

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?

Accepted Answer

Essential Thrombocythemia

Answer

Polycythemia Vera

Answer

Chronic Myeloid Leukemia (CML)

Answer

Acute Myeloid Leukemia (AML)

Question 3

Which of the following is the diagnostic test for carcinoid tumors?

Accepted Answer

Urinary 5-hydroxyindoleacetic acid

Answer

Serum chromogranin A

Answer

Serum calcitonin levels

Answer

24-hour urinary catecholamines

Question 4

Which of the following microorganisms is likely responsible for causing bilateral infiltrates in an HIV-positive patient?

Accepted Answer

Pneumocystis Jirovecii

Answer

Histoplasma

Answer

Aspergillus

Answer

Cryptococcus

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?

Accepted Answer

IgA vasculitis

Answer

Behçet's disease

Answer

Granulomatosis with polyangiitis

Answer

Microscopic polyangiitis

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?

Accepted Answer

Vit B3

Answer

Vit D

Answer

Vit C

Answer

Vit B1

Question 7

Acute liver failure is a clinical feature of which of the following?

Accepted Answer

B. Amanita Phalloides poisoning

Answer

C. Belladonna poisoning

Answer

D. Morphine poisoning

Answer

A. OP poisoning

Question 8

Which HLA is associated with Reiter syndrome?

Accepted Answer

HLA-B27

Answer

HLA-DQ8

Answer

HLA-DR3

Answer

HLA-DR4

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?

Accepted Answer

Leydig cell tumor

Answer

Sertoli cell tumor

Answer

Spermatocytic tumor

Answer

Granulosa cell tumor

FMGE 2024 — Internal Medicine