A patient with known rheumatic heart disease is now found to have a 1–2 cm aneurysm on imaging. What is the most appropriate next step in management?
A patient with asthma on inhaled corticosteroids and LABA continues to have exacerbations. FEV1 is normal, and there is no improvement with salbutamol challenge. The symptoms worsen seasonally. Which of the following is the most appropriate next step?
A patient presents with blackish discoloration of the nasal cavity and posterior buccal mucosa. He has a history of high-dose steroid use. What is the most appropriate drug for treatment?
A patient with hypertension is taking anti-hypertensive drugs but BP is not controlled even after adding diuretics in treatment. Patient's serum electrolyte shows hypokalemia. What is the next step in treatment of this patient?
A patient presents with fever after returning from a forest trip. On examination, a black eschar is noted on the abdomen. Which of the following is the most likely diagnosis and its drug of choice?
A woman presents with sudden-onset high-grade fever, hypotension, diffuse rash, and a history of using a tampon for an extended period. What is the most likely diagnosis?
An AIDS-positive patient came with a history of fever, vomiting, and meningismus. Which of the following tests help in the rapid diagnosis of cryptococcal meningitis?
A 20-year-old male was admitted with fever, headache and retro-orbital pain with rash. The tourniquet test is positive. What is the diagnosis?
A mutation in the SOD1 gene is most commonly associated with which of the following conditions?
What is the eye manifestation seen in HLA B27-positive patients with ulcerative colitis?
FMGE 2025 - Internal Medicine FMGE Practice Questions and MCQs
Question 81: A patient with known rheumatic heart disease is now found to have a 1–2 cm aneurysm on imaging. What is the most appropriate next step in management?
- A. IV antibiotics (Correct Answer)
- B. Aspirin for 3 weeks
- C. Aspirin lifelong
- D. Aspirin + Clopidogrel
Explanation: ***IV antibiotics*** - In a patient with **rheumatic heart disease (RHD)**, the finding of an aneurysm on imaging should raise strong suspicion for a **mycotic aneurysm**, especially given the increased risk of **infective endocarditis (IE)** in RHD patients [1]. - **Mycotic aneurysms** are infected arterial wall dilations that occur as a complication of IE, resulting from septic emboli or direct bacterial invasion of the vessel wall [2]. - **First-line management** consists of **prolonged IV antibiotics** (4-6 weeks) targeting the causative organism, along with close monitoring for aneurysm expansion or rupture. - Blood cultures, echocardiography, and infectious disease consultation are essential components of the workup [1]. *Aspirin lifelong* - While **aspirin** is important for long-term secondary prevention in RHD patients to reduce thromboembolic risk, it is **not the immediate priority** when an aneurysm is discovered. - In the setting of a **mycotic aneurysm**, aspirin may actually **increase bleeding risk** if the aneurysm ruptures and should be used cautiously [3]. - Long-term antiplatelet therapy would be considered after the acute infectious complication is addressed. *Aspirin + Clopidogrel* - **Dual antiplatelet therapy (DAPT)** is reserved for acute coronary syndromes or post-percutaneous coronary intervention, not for routine management of aneurysms in RHD. - In the context of a potential **mycotic aneurysm**, DAPT would significantly increase the risk of **catastrophic bleeding** without providing benefit. *Aspirin for 3 weeks* - Short-term aspirin therapy does not address the underlying pathology of a **mycotic aneurysm**, which requires targeted antimicrobial therapy. - This duration is insufficient for either treating the infection or providing adequate long-term vascular protection in RHD.
Question 82: A patient with asthma on inhaled corticosteroids and LABA continues to have exacerbations. FEV1 is normal, and there is no improvement with salbutamol challenge. The symptoms worsen seasonally. Which of the following is the most appropriate next step?
- A. Increase dose of ICS (Correct Answer)
- B. Add Omalizumab
- C. Add Theophylline
- D. Add LAMA
Explanation: ***Increase dose of ICS*** - In the stepwise management of asthma, if a patient on a low or medium-dose **inhaled corticosteroid (ICS)** and **long-acting beta-agonist (LABA)** combination continues to have poor control or exacerbations, the next appropriate step is to increase the dose of the ICS [1]. - This addresses the underlying **airway inflammation**, which is the primary driver of asthma symptoms and exacerbations, especially in a patient with seasonal worsening suggesting an allergic component. *Add LAMA* - Adding a **long-acting muscarinic antagonist (LAMA)**, such as tiotropium, is typically considered at **Step 5** of asthma management, for patients who remain symptomatic despite being on a high-dose ICS-LABA. - It is not the next step after a standard-dose ICS-LABA and should only be considered after optimizing the ICS dose [1]. *Add Theophylline* - **Theophylline** is generally considered a low-preference alternative or add-on therapy due to its **narrow therapeutic index** and significant potential for side effects (e.g., cardiotoxicity, neurotoxicity). - Modern guidelines recommend other options, such as increasing the ICS dose or adding a LAMA, before considering theophylline [1]. *Add Omalizumab* - **Omalizumab** is a biologic agent (anti-IgE) reserved for **Step 5** management of severe, persistent **allergic asthma** that is poorly controlled on high-dose ICS-LABA. - Its initiation requires confirmation of an allergic phenotype (e.g., elevated IgE levels) and is not indicated before optimizing standard controller therapies [1].
Question 83: A patient presents with blackish discoloration of the nasal cavity and posterior buccal mucosa. He has a history of high-dose steroid use. What is the most appropriate drug for treatment?
- A. Amphotericin B (Correct Answer)
- B. Fluconazole
- C. Griseofulvin
- D. Itraconazole
Explanation: ***Amphotericin B*** - The patient's signs (**blackish discoloration** of the nasal and buccal mucosa) coupled with profound immunosuppression (high-dose steroids) strongly suggest **Rhinocerebral mucormycosis**, an aggressive angioinvasive fungal infection caused by **Mucorales** [2]. - **Amphotericin B** (liposomal formulation preferred) is the drug of choice for empirical and definitive treatment of life-threatening mucormycosis due to its potent fungicidal activity against **Zygomycetes** [2]. - Early surgical debridement combined with Amphotericin B therapy is essential for optimal outcomes [2]. *Fluconazole* - **Fluconazole** has no reliable activity against **Mucorales** (causative agents of mucormycosis) [3]. - It is primarily used for *Candida* and *Cryptococcus* infections, completely lacking the spectrum needed for this severe angioinvasive process [1][3]. *Itraconazole* - **Itraconazole** is typically ineffective against **Mucorales** and is generally reserved for endemic mycoses (*Histoplasma, Blastomyces*) or step-down therapy for *Aspergillus* [3]. - It does not achieve adequate fungicidal activity needed for aggressive invasive fungal sinusitis. *Griseofulvin* - **Griseofulvin** is indicated only for **dermatophytosis** (superficial tinea infections of skin, hair, and nails). - It has no role or efficacy in treating severe, systemic, or angioinvasive fungal infections like mucormycosis.
Question 84: A patient with hypertension is taking anti-hypertensive drugs but BP is not controlled even after adding diuretics in treatment. Patient's serum electrolyte shows hypokalemia. What is the next step in treatment of this patient?
- A. KCL
- B. Hydrochlorothiazide
- C. Spironolactone (Correct Answer)
- D. Torasemide
Explanation: ***Spironolactone*** - The combination of **resistant hypertension** (uncontrolled BP despite standard therapy including a diuretic) and **hypokalemia** strongly suggests **Primary Aldosteronism**. - **Spironolactone** is an **aldosterone antagonist** (potassium-sparing diuretic) and is the drug of choice for treating hypertension secondary to hyperaldosteronism, as it corrects both the hypokalemia and the high blood pressure [1]. *KCL* - **Potassium chloride** (KCL) would correct the hypokalemia temporarily, but it does not address the underlying cause (aldosterone excess) or control the **resistant hypertension** [1]. - Supplementation alone is insufficient when the source of hypokalemia is excessive renal potassium loss driven by high aldosterone levels. *Torasemide* - **Torasemide** is a **loop diuretic**; adding it to the regimen will significantly increase potassium excretion, thereby **worsening the existing hypokalemia**. - Loop diuretics are potent potassium-wasting agents and are contraindicated when the suspicion is high for Primary Aldosteronism presenting with hypokalemia. *Hydrochlorothiazide* - **Hydrochlorothiazide** (HCTZ) is a **thiazide diuretic** (also a potassium-wasting drug). - Similar to Torasemide, adding HCTZ would exacerbate the **hypokalemia** and is not the appropriate therapy for hypertension suspected to be caused by mineralocorticoid excess.
Question 85: A patient presents with fever after returning from a forest trip. On examination, a black eschar is noted on the abdomen. Which of the following is the most likely diagnosis and its drug of choice?
- A. Ceftriaxone
- B. Penicillin
- C. Artesunate
- D. Doxycycline (Correct Answer)
Explanation: ***Doxycycline (Scrub Typhus)*** - The clinical presentation of fever following a forest trip, along with a characteristic **black eschar** (tache noire), is highly suggestive of **scrub typhus**, a rickettsial infection caused by *Orientia tsutsugamushi*. - **Doxycycline** is the drug of choice for rickettsial diseases, including scrub typhus, as it effectively inhibits protein synthesis in these obligate intracellular bacteria. - The diagnosis is scrub typhus, and doxycycline is the first-line treatment with rapid clinical response typically within 24-48 hours. *Penicillin* - Penicillin targets bacterial **cell wall synthesis** and is primarily effective against gram-positive organisms like *Streptococcus* and *Staphylococcus*. - It is ineffective against intracellular pathogens like *Orientia tsutsugamushi*, which lack a typical peptidoglycan cell wall targeted by penicillins. *Ceftriaxone* - Ceftriaxone is a third-generation cephalosporin used for a wide range of bacterial infections, such as meningitis and community-acquired pneumonia, but it is not the standard treatment for rickettsial diseases. - Clinical trials have shown that tetracyclines like doxycycline result in faster defervescence and better outcomes for scrub typhus compared to cephalosporins. *Artesunate* - Artesunate is a potent **antimalarial** drug used for treating severe malaria caused by *Plasmodium* species. - While malaria can cause fever after travel, it does not produce a necrotic eschar, which is a key diagnostic feature distinguishing scrub typhus from malaria.
Question 86: A woman presents with sudden-onset high-grade fever, hypotension, diffuse rash, and a history of using a tampon for an extended period. What is the most likely diagnosis?
- A. Septic shock
- B. Pelvic Inflammatory Disease
- C. Toxic Shock Syndrome (Correct Answer)
- D. Streptococcal pharyngitis
Explanation: Toxic Shock Syndrome - This diagnosis is defined by the sudden onset of **high fever**, **hypotension** (shock), and a **diffuse erythematous rash** (often described as sunburn-like), strongly supported by the history of prolonged **tampon use** (a common source for *Staphylococcus aureus* producing **TSST-1** superantigen). [1] - TSS is a life-threatening illness caused by toxins that induce massive cytokine release, leading rapidly to shock and potential multi-organ failure. [1] Septic shock - While TSS is a specific diagnosis within the broader category of **sepsis/septic shock**, the acute presentation with the classic **diffuse rash** and clear association with prolonged tampon use makes TSS the most accurate diagnosis. - Septic shock is a general condition of infection-induced circulatory failure but lacks the specific **sunburn-like rash** and classic toxin etiology that defines TSS. Pelvic Inflammatory Disease - PID typically presents with **lower abdominal pain**, **cervical motion tenderness**, and purulent vaginal discharge, rather than rapid-onset systemic shock and generalized diffuse rash. - Although PID is an ascending infection often causing fever, it rarely leads to the swift and profound **hypotension** and multi-organ dysfunction characteristic of TSS. Streptococcal pharyngitis - This infection primarily presents with **sore throat**, fever, and sometimes exudates on the tonsils; it is locally confined and generally does not cause sudden, severe **hypotension** or systemic collapse. - While *Streptococcus pyogenes* can also cause a toxic shock syndrome, simple pharyngitis lacks the multi-system involvement, hypotensive crisis, and definitive association with **tampon usage** seen in this presentation. [1]
Question 87: An AIDS-positive patient came with a history of fever, vomiting, and meningismus. Which of the following tests help in the rapid diagnosis of cryptococcal meningitis?
- A. CSF culture
- B. India ink preparation of CSF
- C. Urine lateral flow assay for cryptococcal antigen (Correct Answer)
- D. Blood culture
Explanation: ***Urine lateral flow assay for cryptococcal antigen*** - The **Cryptococcal Antigen (CrAg) lateral flow assay (LFA)**, performed on various body fluids (CSF, serum, or urine), allows for rapid diagnosis, often yielding results in 10 minutes. - Detection of CrAg is highly sensitive in patients with extensive disease, such as those with AIDS and high fungal burdens, facilitating quick initiation of life-saving antifungal therapy. *India ink preparation of CSF* - Although relatively quick, the **India ink preparation** has low sensitivity (50-75%) in HIV-associated cryptococcal meningitis, leading to potential false-negative results. - This test identifies the yeast by visualizing the characteristic **capsule** against a black background, but its utility has largely been replaced by the more sensitive CrAg assay. *Blood culture* - Blood cultures confirm **cryptococcemia** (disseminated infection), which is common in AIDS patients with meningitis, but require several days (3–7 or more) for growth and identification. - Due to the prolonged incubation time, blood culture is unsuitable for the **rapid diagnosis** required to manage acute meningeal symptoms promptly. *CSF culture* - CSF culture remains the **gold standard** for definitive diagnosis, confirmation of viability, and performance of antifungal susceptibility testing. - Similar to blood culture, CSF culture takes multiple days (typically 2–7 days) to provide results, thus delaying immediate treatment needed for **meningitis**.
Question 88: A 20-year-old male was admitted with fever, headache and retro-orbital pain with rash. The tourniquet test is positive. What is the diagnosis?
- A. Dengue hemorrhagic fever (Correct Answer)
- B. Malaria
- C. Japanese encephalitis
- D. Measles
Explanation: ***Dengue hemorrhagic fever***- The combination of high fever, **headache**, **retro-orbital pain**, and rash is characteristic of classic Dengue fever (breakbone fever) [1].- A **positive tourniquet test** suggests increased capillary fragility, which, along with the other symptoms, strongly indicates progression toward **Dengue hemorrhagic fever (DHF)** [1].*Malaria*- Malaria is characterized by cyclical fever patterns (such as tertian or quartan), often associated with severe chills and sweats, which are not mentioned here.- It typically does not cause prominent retro-orbital pain or lead to a positive **tourniquet test** as a primary finding.*Measles*- Measles is typically preceded by a prodrome including cough, coryza, and conjunctivitis, followed by the appearance of **Koplik spots** (buccal lesions).- The rash starts on the face and spreads downwards, and while fever is present, the key combination of **retro-orbital pain** and a positive tourniquet test is not characteristic.*Japanese encephalitis*- This is primarily a **neuroinvasive disease** transmitted by Culex mosquitoes, leading to symptoms like altered mental status, seizures, and focal neurological deficits.- Simple fever, headache, and rash without significant encephalopathy make this diagnosis less likely, and it is not typically associated with the **tourniquet test**.
Question 89: A mutation in the SOD1 gene is most commonly associated with which of the following conditions?
- A. Parkinson's disease
- B. Multiple sclerosis
- C. Huntington's disease
- D. Amyotrophic lateral sclerosis (ALS) (Correct Answer)
Explanation: ***Amyotrophic lateral sclerosis (ALS)*** - **SOD1 (Superoxide dismutase 1)** gene mutations are responsible for approximately **20% of familial ALS** cases and 1-2% of sporadic cases - SOD1 enzyme normally protects cells from oxidative damage by converting superoxide radicals to hydrogen peroxide - Mutations lead to **toxic gain of function** causing motor neuron degeneration, affecting both upper and lower motor neurons [1] - Clinical features include progressive muscle weakness, fasciculations, spasticity, and bulbar symptoms [1] - This is one of the **most well-established genetic associations** in neurodegenerative disease *Parkinson's disease* - Associated with mutations in **SNCA (α-synuclein), LRRK2, and Parkin** genes, not SOD1 - Characterized by dopaminergic neuron loss in substantia nigra - Presents with bradykinesia, rigidity, resting tremor, and postural instability *Multiple sclerosis* - An **autoimmune demyelinating disease** with complex genetic susceptibility involving HLA-DRB1 and other immune-related genes - Not linked to SOD1 mutations - Presents with relapsing-remitting neurological symptoms and white matter lesions *Huntington's disease* - Caused by **CAG trinucleotide repeat expansion** in the huntingtin (HTT) gene on chromosome 4 - Autosomal dominant inheritance with anticipation - Presents with chorea, cognitive decline, and psychiatric symptoms
Question 90: What is the eye manifestation seen in HLA B27-positive patients with ulcerative colitis?
- A. Iridocyclitis
- B. Scleritis
- C. Uveitis (Correct Answer)
- D. Conjunctivitis
Explanation: ***Uveitis***- **Anterior uveitis** (or iritis) is the most common ocular manifestation associated with **HLA-B27 positive spondyloarthropathies** (like ankylosing spondylitis), which frequently co-occur with **ulcerative colitis** (UC) [1].- This association highlights a shared inflammatory pathway between the gut, joints, and eyes, typical of **extra-intestinal manifestations of IBD** [2]. *Conjunctivitis*- **Conjunctivitis** is a non-specific, less severe eye manifestation sometimes seen in IBD, but it does not carry the strong, specific association with the **HLA-B27** genotype.- It typically involves inflammation of the conjunctiva and is generally self-limiting, unlike the vision-threatening nature of uveitis.*Scleritis*- **Scleritis** involves painful, severe inflammation of the sclera and is a less frequent, though severe, ocular complication of IBD.- While associated with UC, scleritis is clinically distinct from uveitis and is more strongly linked to systemic vasculitides like **Polyarteritis Nodosa** or **Rheumatoid Arthritis** rather than the primary HLA-B27/IBD link.*Iridocyclitis*- **Iridocyclitis** is anatomically synonymous with **anterior uveitis**, describing inflammation of the iris and ciliary body.- As **Uveitis** is the standard, encompassing term used in MCQs for the classic HLA-B27 associated ocular pathology, it is the best fit, even though iridocyclitis describes the pathology precisely.