Patient presents with hypertension and hypokalemic metabolic alkalosis. CT scan shows a unilateral adrenal mass with elevated ARR. What is the next best step for the management of this patient?
A 35-year-old male has had chronic hypercalcemia for the last 1.5 years, but PTH levels are normal. Which of the following is most likely the cause?
A female presents with amenorrhea and galactorrhea. Serum prolactin is elevated. MRI shows pituitary adenoma. Best management for this patient?
What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?
A 60-year-old female presents with weakness, back pain and repeated infections. Work up shows M spike on serum electrophoresis. Prognosis is determined by which of the following factors?
A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?
A patient with road traffic accident (RTA) is passing red color urine due to myoglobinuria. Which of the following will most likely be seen in this patient?
A patient after RTA had a renal shut down. Work-up shows: FeNa: $< 1\%$ , Urine osmolality: 300 mOsm/kg, Urinary sodium: 40 mEq/L. Most likely diagnosis?
A patient presents with fever and altered sensorium. Peripheral smear shows multiple ring stages. Best treatment is?
A patient presents with progressive shortness of breath for the last 6 months, accompanied by dry cough. Auscultation reveals bilateral basal end-inspiratory crepitations. There is no history of fever, joint pain, or occupational exposure. What is the diagnosis?
FMGE 2025 - Internal Medicine FMGE Practice Questions and MCQs
Question 51: Patient presents with hypertension and hypokalemic metabolic alkalosis. CT scan shows a unilateral adrenal mass with elevated ARR. What is the next best step for the management of this patient?
- A. Adrenalectomy (Correct Answer)
- B. Spironolactone on a lifelong basis
- C. Dexamethasone suppression test
- D. ACTH stimulation test
Explanation: ***Adrenalectomy*** - The combination of **hypertension**, **hypokalemic metabolic alkalosis**, elevated **Aldosterone-to-Renin Ratio (ARR)**, and a unilateral **adrenal mass** is diagnostic for Primary Aldosteronism, likely due to an Aldosterone-Producing Adenoma (**APA**) [1]. - **Unilateral adrenalectomy** is the definitive, potentially curative treatment for a confirmed APA, addressing the root cause of the hyperaldosteronism and hypertension [1]. *Spironolactone on a lifelong basis* - This treatment involves a **Mineralocorticoid Receptor Antagonist** and is the preferred therapy for patients with **Bilateral Adrenal Hyperplasia (BAH)** or for patients with an APA who are not surgical candidates [1]. - Since a likely unilateral adenoma is identified and surgery offers a cure, medical therapy is not the *next best step*. *ACTH stimulation test* - This test is used primarily to evaluate the reserve capacity of the adrenal cortex and diagnose **Adrenal Insufficiency** (e.g., Addison's disease or secondary adrenal insufficiency) [2]. - It is not indicated for the diagnosis or management of hyperaldosteronism. *Dexamethasone suppression test* - This test is the standard screening tool used to diagnose **Cushing's syndrome** (hypercortisolism) by assessing the feedback loop involving the hypothalamic-pituitary-adrenal axis [3]. - It is irrelevant in the workup for primary hyperaldosteronism.
Question 52: A 35-year-old male has had chronic hypercalcemia for the last 1.5 years, but PTH levels are normal. Which of the following is most likely the cause?
- A. Malignancy
- B. C.K.D
- C. Sarcoidosis (Correct Answer)
- D. Parathyroid hyperplasia
Explanation: ***Sarcoidosis*** - Causes hypercalcemia via ectopic synthesis of **1,25-dihydroxyvitamin D** (calcitriol) by activated macrophages in the granulomas, leading to increased intestinal calcium absorption [1]. - Although the resulting hypercalcemia usually suppresses PTH (making it low), in chronic, mild cases, the PTH level may appear in the lower end of the **normal reference range**, consistent with the clinical picture of a non-PTH-mediated cause [1]. *Malignancy* - Hypercalcemia related to solid tumors (Humoral Hypercalcemia of Malignancy) is typically mediated by **PTH-related peptide (PTHrP)**, resulting in high calcium. - This non-PTH mediated hypercalcemia leads to appropriate **suppression of the parathyroid glands**, meaning PTH levels would be significantly **low or undetectable**, not normal [1]. *Parathyroid hyperplasia* - This condition represents **primary hyperparathyroidism**, characterized by autonomous secretion of PTH [1]. - In primary hyperparathyroidism, PTH levels are typically inappropriately **elevated** (or grossly high-normal) despite the presence of hypercalcemia, which contradicts a normal PTH value [1]. *C.K.D* - Chronic kidney disease usually results in **hypocalcemia** due to impaired 1-alpha-hydroxylase function and resultant low 1,25(OH)₂D levels [2]. - If hypercalcemia were present (e.g., due to tertiary hyperparathyroidism), PTH levels would be markedly **elevated**, not normal, due to persistent glandular stimulation [2].
Question 53: A female presents with amenorrhea and galactorrhea. Serum prolactin is elevated. MRI shows pituitary adenoma. Best management for this patient?
- A. Bromocriptine (Correct Answer)
- B. Tamoxifen
- C. Goserelin
- D. Letrozole
Explanation: ***Bromocriptine***- It is a **dopamine agonist** and represents the initial and standard treatment for **prolactinomas**, effectively reducing tumor size and lowering prolactin levels [1].- Dopamine agonists resolve symptoms such as **amenorrhea** and **galactorrhea** by inhibiting prolactin secretion from the pituitary [1]. *Letrozole*- This is an **aromatase inhibitor** primarily used in the management of hormone-sensitive breast cancer or for ovulation induction in conditions like PCOS. - Its mechanism is unrelated to suppressing prolactin secretion from the pituitary or shrinking a prolactinoma. *Tamoxifen*- This is a **Selective Estrogen Receptor Modulator (SERM)** most commonly used in the treatment and prevention of estrogen receptor-positive breast cancer. - It does not act on dopamine receptors and is ineffective in reversing elevated prolactin levels or associated symptoms. *Goserelin*- This agent is a **Gonadotropin-Releasing Hormone (GnRH) agonist** used primarily for conditions like endometriosis, uterine fibroids, or prostate cancer by initially stimulating then desensitizing the GnRH receptor. - While it suppresses LH and FSH [2], it is not the primary treatment for hyperprolactinemia caused by a pituitary adenoma.
Question 54: What is the probable diagnosis for a patient who exhibits miosis, anhidrosis, mild ptosis, and a persistent small pupil even in low light conditions?
- A. Horner syndrome (Correct Answer)
- B. Argyll Robertson pupil
- C. Marcus Gunn pupil
- D. Adie's tonic pupil
Explanation: No changes were made to the text as none of the provided references reached the relevance threshold of 7/10 for the specific topic of Horner syndrome diagnosis and its differentials. The provided references largely discussed coagulation (mislabeled chapters), neurological signs of intracranial pressure, or general pupillary reflexes without specific diagnostic criteria for Horner syndrome or its differentiating features like anhidrosis.
Question 55: A 60-year-old female presents with weakness, back pain and repeated infections. Work up shows M spike on serum electrophoresis. Prognosis is determined by which of the following factors?
- A. Albumin and LDH
- B. IgM and albumin
- C. IgG and albumin
- D. Albumin and $\beta_{2}$-microglobulin (Correct Answer)
Explanation: ***Albumin and $\beta_{2}$-microglobulin*** - These two serum markers are the cornerstones of the **International Staging System (ISS)**, the most widely used system for determining prognosis in Multiple Myeloma. - High **$\beta_{2}$-microglobulin** levels reflect a high tumor burden and/or renal dysfunction, while low **serum albumin** indicates a more advanced disease state and poorer prognosis [1]. *IgG and albumin* - While **albumin** is a key prognostic factor, the specific type of immunoglobulin, such as **IgG**, is not a primary component of the main prognostic staging systems like the ISS. - The *quantity* of the monoclonal protein is used to monitor disease response, but the *type* is less critical for staging than **$\beta_{2}$-microglobulin**. *IgM and albumin* - A monoclonal gammopathy involving **IgM** is the hallmark of **Waldenström macroglobulinemia**, not Multiple Myeloma [1]. - Multiple Myeloma is characterized by the monoclonal proliferation of plasma cells that typically produce **IgG** or **IgA**, not **IgM** [1]. *Albumin and LDH* - While elevated **Lactate Dehydrogenase (LDH)** is an adverse prognostic factor, it is used in the **Revised-ISS (R-ISS)**, which builds upon the original ISS. - The foundational ISS, which is universally applied, is based on the combination of **serum albumin** and **$\beta_{2}$-microglobulin** levels.
Question 56: A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?
- A. Ritonavir
- B. Ombitasvir
- C. Lamivudine (Correct Answer)
- D. Abacavir
Explanation: Lamivudine - This serological profile (HBsAg+, IgM anti-HBc-, IgG anti-HBc+, HBeAg+) indicates HBeAg-positive chronic Hepatitis B with active viral replication [1] - Among the given options, Lamivudine is the only agent with anti-HBV activity as a nucleoside reverse transcriptase inhibitor (NRTI) that inhibits HBV DNA polymerase - Important Note: While Lamivudine was historically used for chronic HBV, current guidelines (WHO, AASLD, EASL) recommend Tenofovir or Entecavir as first-line therapy due to higher potency and lower resistance rates [2] - Lamivudine is now considered second-line due to high resistance rates (up to 70% after 5 years) Incorrect Option: Ombitasvir - Ombitasvir is an NS5A inhibitor used exclusively for Hepatitis C (HCV) treatment in combination regimens - Has no activity against HBV and is inappropriate for this patient Incorrect Option: Ritonavir - Ritonavir is an HIV protease inhibitor used primarily as a pharmacokinetic booster in antiretroviral therapy - Has no direct anti-HBV activity and is not used for HBV treatment Incorrect Option: Abacavir - Abacavir is an NRTI used for HIV treatment as part of combination ART - Despite being an NRTI class drug, it lacks significant anti-HBV activity and is not approved or effective for chronic Hepatitis B management
Question 57: A patient with road traffic accident (RTA) is passing red color urine due to myoglobinuria. Which of the following will most likely be seen in this patient?
- A. Hypokalemia
- B. Hyponatremia
- C. Hypernatremia
- D. Hyperkalemia (Correct Answer)
Explanation: ***Hyperkalemia***- Rhabdomyolysis involves massive breakdown of muscle cells, leading to the rapid release of intracellular contents, primarily **potassium (K+)**, into the circulation [1].- The associated **acute kidney injury (AKI)**, caused by myoglobin toxicity and sludge formation in the renal tubules, severely impairs K+ excretion, thus exacerbating the **hyperkalemia** [1].*Hypernatremia*- This condition is typically associated with states of significant **free water deficit** or inadequate fluid intake, not the massive tissue injury seen in rhabdomyolysis.- Fluid management of trauma patients often involves isotonic fluids, which are unlikely to cause severe dehydration leading to **hypernatremia**.*Hyponatremia*- While aggressive hydration with hypotonic fluids during resuscitation *could* potentially cause dilutional hyponatremia, the direct metabolic consequence of rhabdomyolysis is not primarily a state of **low serum sodium**.- Severe trauma leading to rhabdomyolysis is often associated with the release of ADH due to volume depletion, but this is less characteristic than the rapid rise in potassium.*Hypokalemia*- Hypokalemia, or low serum potassium, is the opposite of the predictable metabolic consequence of rhabdomyolysis.- Muscle cell death releases K+, making **hypokalemia** extremely unlikely in the acute setting of severe muscle injury and subsequent AKI.
Question 58: A patient after RTA had a renal shut down. Work-up shows: FeNa: $< 1\%$ , Urine osmolality: 300 mOsm/kg, Urinary sodium: 40 mEq/L. Most likely diagnosis?
- A. Renal AKI
- B. Pre-renal AKI (Correct Answer)
- C. Acute Tubular Necrosis
- D. Post-renal AKI
Explanation: Correct: Pre-renal AKI - **FeNa <1%** is the most specific parameter and definitively indicates **pre-renal azotemia** [1] - Post-RTA setting suggests **hypovolemia/shock** leading to hypoperfusion [1] - Kidneys are structurally intact and attempting to conserve sodium (FeNa <1%) - Though urine osmolality (300 mOsm/kg) is lower than classic pre-renal (>500), and urinary sodium (40 mEq/L) is at the borderline, **FeNa remains the gold standard** differentiating parameter *Incorrect: Acute Tubular Necrosis (Renal AKI)* - ATN would show **FeNa >2%** due to tubular dysfunction and inability to reabsorb sodium [1] - Urinary sodium would typically be **>40 mEq/L** (here it's exactly 40, borderline) - Urine osmolality would be **<350 mOsm/kg** and close to plasma (isosthenuria ~300) [1] - The **FeNa <1% excludes ATN** as the primary diagnosis *Incorrect: Renal AKI* - This is essentially the same as ATN (intrinsic renal injury) - Would present with FeNa >2%, not <1% [1] *Incorrect: Post-renal AKI* - Implies obstruction (bladder, ureter, urethra) - Not suggested by the clinical scenario of post-trauma renal shutdown - Laboratory parameters don't help differentiate obstruction; needs imaging **Key Teaching Point:** When laboratory values seem mixed, **FeNa <1% is the most reliable indicator of pre-renal azotemia**, especially in trauma settings with likely hypovolemia.
Question 59: A patient presents with fever and altered sensorium. Peripheral smear shows multiple ring stages. Best treatment is?
- A. Artesunate (Correct Answer)
- B. Chloroquine
- C. Primaquine
- D. Quinine
Explanation: Artesunate - The clinical presentation of fever and altered sensorium, along with a peripheral smear showing multiple ring stages (characteristic of P. falciparum), indicates severe malaria [1]. Intravenous artesunate is the recommended first-line treatment [1]. - Artesunate is a potent and rapidly acting artemisinin derivative that quickly reduces the parasite burden, leading to lower mortality rates compared to quinine in severe malaria cases [1]. Primaquine - Primaquine is primarily used to eradicate the dormant liver stages (hypnozoites) of P. vivax and P. ovale to prevent relapse, not for treating acute, severe falciparum malaria. - It is ineffective against the asexual erythrocytic stages of P. falciparum and can cause severe hemolysis in patients with G6PD deficiency. Quinine - Quinine is a second-line agent for severe malaria and is only used if artesunate is unavailable, due to its inferior efficacy and greater toxicity [1]. - Its use is associated with adverse effects known as cinchonism (tinnitus, headache, nausea) and can cause severe hypoglycemia and cardiac arrhythmias [1]. Chloroquine - Widespread resistance of P. falciparum to chloroquine makes it an ineffective choice for treating this infection in most malaria-endemic regions. - Chloroquine is typically reserved for the treatment of uncomplicated malaria caused by chloroquine-sensitive species like P. malariae, _P. ovale, or P. vivax (in areas without resistance).
Question 60: A patient presents with progressive shortness of breath for the last 6 months, accompanied by dry cough. Auscultation reveals bilateral basal end-inspiratory crepitations. There is no history of fever, joint pain, or occupational exposure. What is the diagnosis?
- A. Hypersensitivity pneumonitis
- B. Sarcoidosis
- C. Cor-pulmonale
- D. IPF (Correct Answer)
Explanation: ### IPF - The presentation of progressive **shortness of breath**, dry cough, and characteristic **bilateral basal end-inspiratory crepitations** (**Velcro crackles**) strongly suggests Idiopathic Pulmonary Fibrosis [1]. - IPF is a diagnosis of exclusion, supported here by the absence of fever, joint pain, or known occupational/environmental exposures (making it **idiopathic**) [1][2]. *Cor-pulmonale* - *Cor-pulmonale* is **right ventricular failure** secondary to pulmonary hypertension caused by underlying lung disease, and typically presents with signs of systemic venous congestion (e.g., peripheral edema, elevated JVP). - While advanced IPF can *cause* cor-pulmonale, it is not the primary process causing the initial restrictive pattern and bilateral basal **crepitations**. *Sarcoidosis* - Sarcoidosis often involves **bilateral hilar lymphadenopathy** and systemic features (e.g., skin or eye findings), which are absent in this presentation [4]. - Pulmonary fibrosis associated with sarcoidosis typically has an **upper lobe predominance**, unlike the basal findings described here [4]. *Hypersensitivity pneumonitis* - This diagnosis requires a history of exposure to an inhaled **antigen** (e.g., birds, molds) in the home or workplace, which is explicitly excluded in the patient history [3]. - Acute or subacute forms of HP often involve systemic symptoms like fever and chills, which are not mentioned in this slowly progressive presentation [3].