FMGE 2025 — Internal Medicine

Q: A patient presents with breathlessness and is diagnosed with a Pancoast tumor. Which of the following findings is not typically associated with this condition?

Exophthalmos. ***Exophthalmos***- This finding, characterized by the **protrusion of the eyeball**, is typically associated with conditions like **Graves' disease** (hyperthyroidism) or orbital tumors.- It is *not* a component of **Horner's syndrome**, which is the classic neurological manifestation of a Pancoast tumor due to damage to the sympathetic chain.*Anhidrosis*- Pancoast tumors (superior sulcus tumors) often invade the **stellate ganglion** or other parts of the sympathetic chain.- Damage to sympathetic fibers causes reduced or absent sweating on the ipsilateral face and neck, manifesting as **anhidrosis**.*Miosis*- This refers to the **constriction of the pupil** and is a classic sign resulting from the loss of sympathetic input, which normally causes pupillary dilation.- The resulting unopposed action of the parasympathetic system leads to **miosis**.*Ptosis*- Ptosis, or the **drooping of the upper eyelid**, occurs due to paralysis of the **superior tarsal muscle** (Müller's muscle).- This small muscle is innervated by the sympathetic pathway, and its dysfunction results in mild **ptosis**, a core component of Horner's syndrome. [Practice more Internal Medicine PYQs on OnCourse]

Q: A young male presented with weakness in the lower half of the right side of his face, with drooping of the angle of his mouth. He is unable to raise his eyebrows and close his eyes on the right side. Which of the following is the most appropriate diagnosis?

Infranuclear facial palsy on right side. ***Infranuclear facial palsy on right side***- **Infranuclear (peripheral) facial palsy** involves the facial nerve (CN VII) distal to the nucleus, causing paralysis of the entire ipsilateral side of the face.- The inability to move the upper facial muscles (closing the eye, raising the eyebrow) combined with lower face weakness (mouth drooping) on the right side indicates complete paralysis of the **right facial nerve**.*Supranuclear facial palsy on left side*- A **supranuclear (central) lesion** (e.g., stroke) affects the face contralaterally, leading to weakness on the right face, but the upper face (forehead) would be spared [1].- The ability to move the forehead is preserved in supranuclear palsy because the upper facial nucleus receives bilateral cortical input, which contradicts the bilateral/right upper face involvement described here [1].*Infranuclear facial on left side*- This diagnosis would cause complete paralysis (upper and lower face) on the **left side**.- The patient presents with clinical signs of paralysis (drooping mouth, inability to raise eyebrow) primarily on the **right side**, making a left-sided lesion incorrect.*Supranuclear facial on right side*- A **supranuclear lesion** on the right side would cause weakness of the muscles of the **left lower face** (contralateral presentation).- Supranuclear lesions never cause involvement of the upper facial muscles (unable to raise eyebrows) as seen in this patient [1]. [Practice more Internal Medicine PYQs on OnCourse]

Q: A patient presents with the palsy of the face as shown. Which of the following is most likely involved?

7th nerve palsy. ***7th nerve palsy*** - The image shows features of a **lower motor neuron (LMN) lesion** of the **7th cranial (facial) nerve**, affecting both the upper and lower face. Note the inability to wrinkle the left forehead, incomplete eye closure, and drooping of the left corner of the mouth. - This condition, often idiopathic and termed **Bell's palsy**, results in paralysis of all ipsilateral muscles of facial expression, which are innervated by the facial nerve. *3rd nerve palsy* - A **3rd cranial nerve (oculomotor)** palsy would present with **ptosis** (drooping eyelid), a dilated pupil, and the eye positioned "down and out" due to unopposed action of the superior oblique and lateral rectus muscles. - It does not cause paralysis of the lower facial muscles, such as those involved in smiling. *Erb's palsy* - This is an injury to the **upper trunk (C5-C6)** of the **brachial plexus**, typically occurring at birth, which affects the muscles of the shoulder and arm. - It results in the characteristic "**waiter's tip**" posture of the arm and has no effect on the facial muscles. *Orbicularis oculi palsy* - This describes an isolated paralysis of the muscle that closes the eyelids. While this is a component of 7th nerve palsy, it is not the complete diagnosis. - The patient clearly has paralysis of other facial muscles, such as the **frontalis** (forehead) and **zygomaticus** (mouth), indicating a lesion of the main facial nerve trunk, not just a single branch. [Practice more Internal Medicine PYQs on OnCourse]

Q: A patient presents with respiratory difficulty and a history of chronic smoking. Pulmonary function testing shows a decrease in FEV1/FVC ratio. What is the most probable diagnosis?

Chronic Obstructive Pulmonary Disease (COPD). ***Chronic Obstructive Pulmonary Disease (COPD)*** - COPD is the most likely diagnosis given the history of **chronic smoking** and pulmonary function tests showing a **decreased FEV1%**, which is a hallmark of an **obstructive lung disease**. - The pathophysiology involves **bronchiolar obstruction** leading to **air trapping**, which results in an elevated **Residual Volume (RV)** and **Total Lung Capacity (TLC)**, consistent with the provided flowchart. *Pulmonary Fibrosis* - This is a **restrictive lung disease**, characterized by scarring of the lung tissue, which would cause a **decrease**, not an increase, in Total Lung Capacity (TLC). - Spirometry in pulmonary fibrosis typically shows a **normal or increased FEV1/FVC ratio**, as both FEV1 and FVC are reduced proportionally. *Interstitial Lung Disease* - This is a broad category of **restrictive lung diseases**, which includes pulmonary fibrosis. These conditions make the lungs stiff and difficult to expand. - The characteristic PFT finding is a **restrictive pattern** (decreased TLC, FVC, and FEV1) with a normal or high FEV1/FVC ratio, which contradicts the patient's results. *Asthma* - Although asthma is an **obstructive disease** that can cause a low FEV1%, the airflow limitation is typically **reversible** with bronchodilators. - While both can present similarly, the patient's history of **chronic smoking** makes COPD, a progressive and largely irreversible condition, the more probable diagnosis. [Practice more Internal Medicine PYQs on OnCourse]

Q: A young female has episodes of binge eating followed by self-induced vomiting. Which of the following acid- base disturbance is she likely to have?

Metabolic alkalosis. ***Metabolic alkalosis***- Self-induced vomiting results in the significant loss of **gastric hydrochloric acid (HCl)**, leading to a net gain of bicarbonate (HCO3-) in the blood, causing metabolic alkalosis [1, 2].- This condition is often exacerbated by **volume depletion** (due to fluid loss), leading to a state known as "**contraction alkalosis**," where the kidneys attempt to conserve volume even at the expense of excreting bicarbonate [1].*Respiratory acidosis*- This condition is characterized by **hypoventilation** leading to the retention of **carbon dioxide (CO2)** and an increase in carbonic acid, lowering the pH [2].- It is typically seen in conditions compromising respiratory drive or function, such as COPD exacerbations, narcotic overdose, or severe pneumonia.*Respiratory alkalosis*- This disturbance is caused by **hyperventilation**, which results in excessive loss of **carbon dioxide (CO2)**, leading to low PCO2 and elevated pH [3].- While anxiety may be a component of eating disorders, the primary physiologic effect of vomiting is related to acid loss, not sustained hyperventilation causing respiratory alkalosis.*Metabolic acidosis*- This is caused by either the **addition of fixed acids** (e.g., lactic acidosis, diabetic ketoacidosis) or the **loss of bicarbonate** (e.g., severe diarrhea or renal tubular dysfunction) [2].- Vomiting directly causes loss of acid, which is the opposite mechanism needed to induce metabolic acidosis [2]. [Practice more Internal Medicine PYQs on OnCourse]

91 Previous Year Questions with Answers & Explanations

Questions

A patient presents with breathlessness and is diagnosed with a Pancoast tumor. Which of the following findings is not typically associated with this condition?

A young male presented with weakness in the lower half of the right side of his face, with drooping of the angle of his mouth. He is unable to raise his eyebrows and close his eyes on the right side. Which of the following is the most appropriate diagnosis?

A patient presents with the palsy of the face as shown. Which of the following is most likely involved?

A patient presents with respiratory difficulty and a history of chronic smoking. Pulmonary function testing shows a decrease in FEV1/FVC ratio. What is the most probable diagnosis?

A young female has episodes of binge eating followed by self-induced vomiting. Which of the following acid- base disturbance is she likely to have?

Which drug is preferred for management of diabetes in a patient with cardiac and renal failure?

A TB patient with HIV begins ART and experiences deterioration in health after 2 months. What is the likely cause?

A patient presents with acute onset symmetric lower limb flaccid paralysis and absent deep tendon reflexes. Which condition is most likely?

In a patient with electric burns and stable vital signs, red-colored urine is observed. What is the most likely finding in the patient's blood work?

Q10

A patient admitted with fever and nuchal rigidity. CSF analysis shows decreased glucose and increased protein and neutrophils. Which is the MOST IMPORTANT antibiotic for initial empirical treatment?

FMGE 2025 - Internal Medicine FMGE Practice Questions and MCQs

Question 1: A patient presents with breathlessness and is diagnosed with a Pancoast tumor. Which of the following findings is not typically associated with this condition?

A. Ptosis
B. Miosis
C. Exophthalmos (Correct Answer)
D. Anhidrosis

Explanation: ***Exophthalmos***- This finding, characterized by the **protrusion of the eyeball**, is typically associated with conditions like **Graves' disease** (hyperthyroidism) or orbital tumors.- It is *not* a component of **Horner's syndrome**, which is the classic neurological manifestation of a Pancoast tumor due to damage to the sympathetic chain.*Anhidrosis*- Pancoast tumors (superior sulcus tumors) often invade the **stellate ganglion** or other parts of the sympathetic chain.- Damage to sympathetic fibers causes reduced or absent sweating on the ipsilateral face and neck, manifesting as **anhidrosis**.*Miosis*- This refers to the **constriction of the pupil** and is a classic sign resulting from the loss of sympathetic input, which normally causes pupillary dilation.- The resulting unopposed action of the parasympathetic system leads to **miosis**.*Ptosis*- Ptosis, or the **drooping of the upper eyelid**, occurs due to paralysis of the **superior tarsal muscle** (Müller's muscle).- This small muscle is innervated by the sympathetic pathway, and its dysfunction results in mild **ptosis**, a core component of Horner's syndrome.

Question 2: A young male presented with weakness in the lower half of the right side of his face, with drooping of the angle of his mouth. He is unable to raise his eyebrows and close his eyes on the right side. Which of the following is the most appropriate diagnosis?

A. Supranuclear facial palsy on left side
B. Infranuclear facial palsy on right side (Correct Answer)
C. Infranuclear facial on left side
D. Supranuclear facial on right side

Explanation: ***Infranuclear facial palsy on right side***- **Infranuclear (peripheral) facial palsy** involves the facial nerve (CN VII) distal to the nucleus, causing paralysis of the entire ipsilateral side of the face.- The inability to move the upper facial muscles (closing the eye, raising the eyebrow) combined with lower face weakness (mouth drooping) on the right side indicates complete paralysis of the **right facial nerve**.*Supranuclear facial palsy on left side*- A **supranuclear (central) lesion** (e.g., stroke) affects the face contralaterally, leading to weakness on the right face, but the upper face (forehead) would be spared [1].- The ability to move the forehead is preserved in supranuclear palsy because the upper facial nucleus receives bilateral cortical input, which contradicts the bilateral/right upper face involvement described here [1].*Infranuclear facial on left side*- This diagnosis would cause complete paralysis (upper and lower face) on the **left side**.- The patient presents with clinical signs of paralysis (drooping mouth, inability to raise eyebrow) primarily on the **right side**, making a left-sided lesion incorrect.*Supranuclear facial on right side*- A **supranuclear lesion** on the right side would cause weakness of the muscles of the **left lower face** (contralateral presentation).- Supranuclear lesions never cause involvement of the upper facial muscles (unable to raise eyebrows) as seen in this patient [1].

Question 3: A patient presents with the palsy of the face as shown. Which of the following is most likely involved?

A. Erb's palsy
B. 3rd nerve palsy
C. 7th nerve palsy (Correct Answer)
D. Orbicularis oculi palsy

Explanation: ***7th nerve palsy*** - The image shows features of a **lower motor neuron (LMN) lesion** of the **7th cranial (facial) nerve**, affecting both the upper and lower face. Note the inability to wrinkle the left forehead, incomplete eye closure, and drooping of the left corner of the mouth. - This condition, often idiopathic and termed **Bell's palsy**, results in paralysis of all ipsilateral muscles of facial expression, which are innervated by the facial nerve. *3rd nerve palsy* - A **3rd cranial nerve (oculomotor)** palsy would present with **ptosis** (drooping eyelid), a dilated pupil, and the eye positioned "down and out" due to unopposed action of the superior oblique and lateral rectus muscles. - It does not cause paralysis of the lower facial muscles, such as those involved in smiling. *Erb's palsy* - This is an injury to the **upper trunk (C5-C6)** of the **brachial plexus**, typically occurring at birth, which affects the muscles of the shoulder and arm. - It results in the characteristic "**waiter's tip**" posture of the arm and has no effect on the facial muscles. *Orbicularis oculi palsy* - This describes an isolated paralysis of the muscle that closes the eyelids. While this is a component of 7th nerve palsy, it is not the complete diagnosis. - The patient clearly has paralysis of other facial muscles, such as the **frontalis** (forehead) and **zygomaticus** (mouth), indicating a lesion of the main facial nerve trunk, not just a single branch.

Question 4: A patient presents with respiratory difficulty and a history of chronic smoking. Pulmonary function testing shows a decrease in FEV1/FVC ratio. What is the most probable diagnosis?

A. Interstitial Lung Disease
B. Pulmonary Fibrosis
C. Asthma
D. Chronic Obstructive Pulmonary Disease (COPD) (Correct Answer)

Explanation: ***Chronic Obstructive Pulmonary Disease (COPD)*** - COPD is the most likely diagnosis given the history of **chronic smoking** and pulmonary function tests showing a **decreased FEV1%**, which is a hallmark of an **obstructive lung disease**. - The pathophysiology involves **bronchiolar obstruction** leading to **air trapping**, which results in an elevated **Residual Volume (RV)** and **Total Lung Capacity (TLC)**, consistent with the provided flowchart. *Pulmonary Fibrosis* - This is a **restrictive lung disease**, characterized by scarring of the lung tissue, which would cause a **decrease**, not an increase, in Total Lung Capacity (TLC). - Spirometry in pulmonary fibrosis typically shows a **normal or increased FEV1/FVC ratio**, as both FEV1 and FVC are reduced proportionally. *Interstitial Lung Disease* - This is a broad category of **restrictive lung diseases**, which includes pulmonary fibrosis. These conditions make the lungs stiff and difficult to expand. - The characteristic PFT finding is a **restrictive pattern** (decreased TLC, FVC, and FEV1) with a normal or high FEV1/FVC ratio, which contradicts the patient's results. *Asthma* - Although asthma is an **obstructive disease** that can cause a low FEV1%, the airflow limitation is typically **reversible** with bronchodilators. - While both can present similarly, the patient's history of **chronic smoking** makes COPD, a progressive and largely irreversible condition, the more probable diagnosis.

Question 5: A young female has episodes of binge eating followed by self-induced vomiting. Which of the following acid- base disturbance is she likely to have?

A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis (Correct Answer)

Explanation: ***Metabolic alkalosis***- Self-induced vomiting results in the significant loss of **gastric hydrochloric acid (HCl)**, leading to a net gain of bicarbonate (HCO3-) in the blood, causing metabolic alkalosis [1, 2].- This condition is often exacerbated by **volume depletion** (due to fluid loss), leading to a state known as "**contraction alkalosis**," where the kidneys attempt to conserve volume even at the expense of excreting bicarbonate [1].*Respiratory acidosis*- This condition is characterized by **hypoventilation** leading to the retention of **carbon dioxide (CO2)** and an increase in carbonic acid, lowering the pH [2].- It is typically seen in conditions compromising respiratory drive or function, such as COPD exacerbations, narcotic overdose, or severe pneumonia.*Respiratory alkalosis*- This disturbance is caused by **hyperventilation**, which results in excessive loss of **carbon dioxide (CO2)**, leading to low PCO2 and elevated pH [3].- While anxiety may be a component of eating disorders, the primary physiologic effect of vomiting is related to acid loss, not sustained hyperventilation causing respiratory alkalosis.*Metabolic acidosis*- This is caused by either the **addition of fixed acids** (e.g., lactic acidosis, diabetic ketoacidosis) or the **loss of bicarbonate** (e.g., severe diarrhea or renal tubular dysfunction) [2].- Vomiting directly causes loss of acid, which is the opposite mechanism needed to induce metabolic acidosis [2].

Question 6: Which drug is preferred for management of diabetes in a patient with cardiac and renal failure?

A. Pioglitazone
B. Metformin
C. SGLT2 inhibitors (Correct Answer)
D. Sulfonylureas

Explanation: ***SGLT2 inhibitors*** - These agents are strongly recommended due to their proven benefits in reducing **heart failure (HF)** hospitalizations and **cardiovascular (CV) mortality**. - They also offer robust **reno-protection**, slowing the decline of **eGFR** and reducing albuminuria, making them ideal when both cardiac and renal failure coexist. *Pioglitazone* - This drug class (**thiazolidinediones**) is known to cause **fluid retention** and peripheral edema, thus potentially exacerbating or precipitating **congestive heart failure (CHF)**; it is therefore generally avoided [1]. - It is not associated with improved long-term renal or cardiovascular outcomes in the way that SGLT2 inhibitors are. *Metformin* - While a foundational drug, Metformin is contraindicated in severe **renal failure** (e.g., eGFR <30 mL/min/1.73m²) due to the increased risk of potentially fatal **lactic acidosis**. - Although safe in mild to moderate CKD, it lacks the specific, compelling evidence for reducing progression of **heart failure** or **CKD** compared to SGLT2 inhibitors. *Sulfonylureas* - These drugs primarily increase the risk of **hypoglycemia**, which is heightened in patients with **renal insufficiency** due to altered drug metabolism and clearance. - They provide no demonstrated **cardiovascular** or **renal protective benefits** and may be associated with weight gain.

Question 7: A TB patient with HIV begins ART and experiences deterioration in health after 2 months. What is the likely cause?

A. Development of drug resistance to ART
B. Development of drug resistance to TB drugs
C. Immunological changes in the body (Correct Answer)
D. Drug-drug interactions between TB and ART medications

Explanation: ***Immunological changes in the body*** - The patient's deterioration 2 months after initiating ART is highly suggestive of **Immune Reconstitution Inflammatory Syndrome (IRIS)** [1]. - IRIS occurs when the partially restored immune system mounts an intense, often paradoxical, inflammatory response against high existing **Mycobacterium tuberculosis** antigen loads [1]. *Development of drug resistance to TB drugs* - If resistance developed, the patient would typically fail to improve or experience gradual worsening, consistent with inadequate **TB coverage**, not an acute, paradoxical inflammatory reaction. - Worsening due to drug resistance is usually not temporally linked to the start of ART and would require specific **drug sensitivity testing (DST)** for confirmation [1]. *Drug-drug interactions between TB and ART medications* - Significant drug-drug interactions (e.g., between **rifampicin** and certain ART drugs) typically lead to systemic toxicity or subtherapeutic drug levels, manifesting as virologic failure or liver injury, not acute inflammatory worsening of the underlying TB. - Interactions lead to either rapid ART failure or toxicity, but not the specific clinical picture of **paradoxical TB-IRIS** where infectious signs temporarily worsen. *Development of drug resistance to ART* - Resistance to ART typically manifests as a failure of the **HIV viral load** to decrease or subsequent increase, leading to chronic progression of AIDS, not acute deterioration via inflammation of latent or subclinical TB [1]. - Developing drug resistance often requires prolonged exposure to a suboptimal regimen and usually takes longer than 2 months to cause significant clinical decline via **virologic failure**.

Question 8: A patient presents with acute onset symmetric lower limb flaccid paralysis and absent deep tendon reflexes. Which condition is most likely?

A. Multiple sclerosis
B. Spinal cord injury
C. Amyotrophic lateral sclerosis
D. Guillain-Barré syndrome (Correct Answer)

Explanation: ***Guillain-Barré syndrome*** - This acute disorder is a **peripheral neuropathy** characterized by ascending, rapidly worsening, **symmetric weakness (flaccidity)** [1]. - The key distinguishing feature is the early and profound loss of deep tendon reflexes known as **areflexia**, corresponding to the damage of peripheral motor nerves/roots (a true lower motor neuron syndrome) [1]. *Multiple sclerosis* - MS is a **central nervous system** disorder causing demyelination in the brain and spinal cord, typically resulting in **upper motor neuron signs**. - Symptoms typically include spasticity, hyperreflexia, and sensory deficits, which directly contrast with the flaccidity and areflexia seen in this patient. *Amyotrophic lateral sclerosis* - ALS involves damage to both upper and lower motor neurons; while it causes LMN symptoms like flaccidity and atrophy, there is often concurrent **hyperreflexia or mixed reflexes** (UMN involvement) [2]. - It is a chronic, progressive neuronal disorder, not primarily defined by the acute, global **areflexia** consistent with GBS [2]. *Spinal cord injury* - Acute spinal cord injury leads to **spinal shock**, causing transient flaccid paralysis and areflexia below the level of the lesion, which eventually evolves into **spasticity and hyperreflexia**. - Unless the injury involves the **cauda equina** (LMN structure), persistent LMN signs with areflexia below the injury level are usually temporary or localized.

Question 9: In a patient with electric burns and stable vital signs, red-colored urine is observed. What is the most likely finding in the patient's blood work?

A. Decreased hemoglobin levels
B. Increased potassium levels (Correct Answer)
C. Increased creatinine levels
D. RBCs in urine

Explanation: ***Increased potassium levels***- Electric burns cause extensive muscle breakdown (known as **rhabdomyolysis**), releasing high concentrations of intracellular contents, especially **potassium**.- This release results in **hyperkalemia**, which is the most immediate and life-threatening electrolyte abnormality observed after massive muscle injury. *Increased creatinine levels*- While rhabdomyolysis often leads to **acute kidney injury (AKI)** due to myoglobin deposition [1], causing increased creatinine, hyperkalemia is the earlier and more acutely dangerous serological derangement.- Increased creatinine reflects impaired renal function and usually develops hours to days after the initial injury. *RBCs in urine*- The red color in the urine is primarily due to **myoglobinuria** (free myoglobin released from damaged muscle) and not typically due to **hematuria** (intact red blood cells).- Urine dipstick tests will be positive for blood because myoglobin and hemoglobin are structurally similar, but microscopy shows few or no red blood cells [1]. *Decreased hemoglobin levels*- Decreased hemoglobin (anemia) is usually a consequence of severe hemorrhage, which is not the primary complication of electrical injury causing rhabdomyolysis.- In the acute burn phase, patients often experience fluid shifts that can lead to **hemoconcentration**, potentially resulting in a transient increase in relative hemoglobin levels.

Question 10: A patient admitted with fever and nuchal rigidity. CSF analysis shows decreased glucose and increased protein and neutrophils. Which is the MOST IMPORTANT antibiotic for initial empirical treatment?

A. Ceftriaxone (Correct Answer)
B. Vancomycin
C. Penicillin
D. Ampicillin

Explanation: Ceftriaxone - Ceftriaxone, a third-generation cephalosporin, is the most essential component of empirical treatment for bacterial meningitis due to its excellent CSF penetration and broad coverage [1]. - It effectively covers the most common bacterial causes of community-acquired meningitis: Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae [1]. - Note: Current guidelines recommend Ceftriaxone + Vancomycin as the optimal empirical regimen to cover penicillin-resistant S. pneumoniae (PRSP), but Ceftriaxone remains the primary/essential antibiotic in this combination [1]. Vancomycin - Vancomycin is critical for covering penicillin-resistant S. pneumoniae (PRSP) and is typically used in combination with Ceftriaxone in the empirical regimen. - It is not used as monotherapy due to poor CSF penetration and incomplete coverage of other common pathogens like N. meningitidis. Penicillin - Penicillin is no longer recommended for empirical treatment due to high prevalence of penicillin-resistant S. pneumoniae (PRSP) globally. - While effective against sensitive N. meningitidis, the need for broader coverage necessitates third-generation cephalosporins. Ampicillin - Ampicillin is added to cover Listeria monocytogenes in specific high-risk groups: patients >50 years, immunocompromised, pregnant women, or neonates. - It is ineffective as monotherapy for routine bacterial meningitis and lacks coverage for resistant strains of common pathogens.