FMGE 2026 - Internal Medicine Practice Questions

Q: A young patient presents with persistently elevated blood pressure despite adequate lifestyle measures. Laboratory evaluation reveals hypokalemia associated with metabolic alkalosis. There is no history of diuretic intake, and renal function tests are within normal limits. Which of the following is the most likely diagnosis?

Conn syndrome. ### ***Conn syndrome*** - This condition, also known as **primary hyperaldosteronism**, typically presents with **hypertension**, **hypokalemia**, and metabolic alkalosis, driven by autonomous aldosterone secretion from an adrenal adenoma. - The absence of diuretic use and normal renal function supports an endocrine cause of **secondary hypertension**, where inappropriate mineralocorticoid activity leads to sodium retention and renal potassium wasting. *Pheochromocytoma* - While this condition causes hypertension, it typically presents with **paroxysmal episodes** of headache, palpitations, and sweating. - It is not routinely associated with the classic triad of hypokalemia and metabolic alkalosis seen in **primary hyperaldosteronism**. *Liddle syndrome* - This is an **autosomal dominant** disorder caused by a gain-of-function mutation in the **epithelial sodium channel (ENaC)**, causing early-onset hypertension and hypokalemia. - Crucially, Liddle syndrome is characterized by **suppressed plasma aldosterone** and low renin levels, whereas Conn syndrome presents with high aldosterone levels. *Carcinoid syndrome* - This condition arises from **neuroendocrine tumors** and is defined by the triad of flushing, diarrhea, and wheezing, rather than hypertensive endocrine workups. - There is no direct pathophysiological link between carcinoid syndrome and the development of **hypokalemia** in the setting of hypertension.

Q: A middle-aged woman presents with long -standing complaints of dryness of eyes and mouth, requiring frequent use of artificial tears and water while swallowing food. She also reports generalized pruritus and intermittent pain with stiffness in multiple small joints of the hands, suggestive of inflammatory arthritis. There is no history of skin tightening, Raynaud phenomenon, oral ulcers, or photosensitive rash. Based on this clinical presentation, what is the most likely diagnosis?

Sjogren syndrome. ***Sjogren syndrome*** - The presentation of **keratoconjunctivitis sicca** (dry eyes) and **xerostomia** (dry mouth) constitutes the classic **sicca complex** seen in Sjogren syndrome. - The associated **inflammatory polyarthritis** involving small joints of the hands is a common extraglandular manifestation of this autoimmune condition. *Systemic lupus erythematosus* - While SLE can cause arthralgias and sicca-like symptoms, the absence of **photosensitivity**, **oral ulcers**, and **malar rash** makes it less likely. - Serological markers such as **anti-dsDNA** or **anti-Smith antibodies** would typically be expected, but the clinical picture here is more localized to sicca and joint symptoms. *Rheumatoid arthritis* - While this patient has arthritis, the prominent and long-standing **sicca symptoms** suggest an underlying autoimmune process specifically affecting exocrine glands. - Rheumatoid arthritis typically presents with **symmetrical erosive arthritis** and **morning stiffness** lasting >1 hour, without the primary sicca complaints. *Scleroderma* - The absence of **Raynaud phenomenon**, **sclerodactyly** (skin tightening), and **telangiectasia** makes Scleroderma or systemic sclerosis an unlikely diagnosis. - While scleroderma can involve joint pain, it is characterized more by vascular and fibrotic changes rather than the primary glandular destruction seen here.

Q: A middle-aged male presents to the OPD with complaints of vague abdominei discomfort, intermittent diarrhea, and recent weight loss. There is no history of alcohol intake or gallstone disease. MRI abdomen reveals a diffusely enlarged c pancreas with a characteristic "sausage- shaped" appearance. Laboratory evaluation shows markedly elevated serum IGG4 Tevels. Which of the following is the best treatment for this patient?

Steroids. ***Steroids*** - This patient's presentation of a **diffusely enlarged pancreas** with a **sausage-shaped appearance** on imaging and **elevated serum IgG4** is diagnostic of **Autoimmune Pancreatitis (AIP)**. - **Glucocorticoids** (steroids) are the first-line treatment for AIP, typically resulting in rapid clinical and radiological improvement. *Antibiotics* - Antibiotics are not indicated as this condition is **immune-mediated** rather than a primary infectious process. - While patients with pancreatic insufficiency may receive supportive care, antibiotics do not address the underlying **autoimmune inflammation**. *Surgery* - Surgery is generally avoided unless there is a high suspicion of **pancreatic malignancy** or if the mass is refractory to maximal medical therapy. - Because AIP mimics pancreatic cancer, initial management focuses on **steroid trials** to avoid unnecessary, major pancreatic resections. *Pancreatic enzyme supplements* - These may be used for symptomatic relief of **exocrine pancreatic insufficiency** but do not treat the primary disease. - They do not address the **inflammatory process** or reduce the pancreatic swelling characteristic of IgG4-related disease.

Q: A 60-year-old female presents with chronic breathlessness and cough for several years, which has progressively worsened. She has a significant smoking history of 30 pack-years. There is no history of atopy. Pulmonary function testing shows a post-bronchodilator FEV/FVC ratio of <0.7 with an 18% improvement in FEV1 after bronchodilator administration. CXR is shown below?

Asthma COPD overlap syndrome. ***Asthma COPD overlap syndrome (ACOS)*** - ACOS is defined by persistent **airflow limitation** (FEV1/FVC 12% and >200ml). - The combination of a chronic smoking history (COPD risk factor) and significant **reversibility** on spirometry, despite the absence of atopy, is characteristically diagnostic of **ACOS**. *Emphysema* - While typically associated with a 30 pack-year smoking history, emphysema is a subtype of **COPD** characterized by air trapping and usually shows **limited reversibility** following bronchodilation. - Patients with emphysema generally demonstrate **hyperinflation** on chest X-ray but do not meet the criteria for significant bronchodilator response seen in this patient. *ILD (Interstitial Lung Disease)* - ILD presents with a **restrictive** pattern on pulmonary function tests (decreased **TLC** and **DLCO**), rather than an obstructive pattern (low FEV1/FVC ratio). - Clinical features for ILD typically include **bibasal fine end-inspiratory crackles** on auscultation, which are not described in this patient with obstructive symptoms. *Asthma* - While asthma can present with significant bronchodilator reversibility, it is typically diagnosed in younger patients with a history of **atopy** and **variable symptoms**. - A 30 pack-year history in a 60-year-old strongly points towards fixed obstructive disease or an overlap syndrome rather than isolated allergic asthma.

Q: A 17-year-old boy presents with gradually progressive muscle weakness predominantly involving the proximal muscles of the lower limbs. He has difficulty climbing stairs and getting up from a squatting position. There is a significant family history and his elder brother had similar complaints and died around the age of 40 years. Based on the age of onset, pattern of inheritance, and survival, what is the most likely diagnosis?

BMD. ***Becker Muscular Dystrophy (BMD)*** - BMD is an **X-linked recessive** disorder characterized by a mutation (typically a deletion) in the **dystrophin gene** that results in the production of a truncated, partially functional protein rather than the complete absence seen in Duchenne. - The onset is typically in late childhood or adolescence with a slower progression of **proximal muscle weakness**, allowing patients to remain ambulatory into adulthood and live significantly longer than those with Duchenne Muscular Dystrophy. *Duchenne Muscular Dystrophy (DMD)* - DMD typically presents much earlier, often between **ages 2 and 5**, with severe muscle weakness resulting in the loss of ambulation before age 12-13. - It is caused by the complete absence of **dystrophin**, leading to a more severe and rapidly progressive clinical course than BMD, with life expectancy significantly shorter than 40 years without advanced care. *Charcot-Marie-Tooth (CMT)* - CMT is a group of **hereditary neuropathies** that primarily present with distal muscle wasting,

Q: A 65 year old man presents with sudden onset weakness of the left upper and lower limbs and slurred speech which started 2 hours ago. MRI of the brain is shown in the image. Which of the following is the most appropriate initial management?

Thrombolysis with alteplase (tPA). ***Thrombolysis with alteplase (tPA)*** - This patient presents within the **4.5-hour window** of symptom onset for an **acute ischemic stroke**, making them a candidate for intravenous thrombolysis to restore cerebral perfusion. - **Alteplase** (recombinant tissue plasminogen activator) is the standard treatment to dissolve the thrombus and improve functional outcomes, provided there are no contraindications such as hemorrhage. *Aspirin and clopidogrel* - While **dual antiplatelet therapy** is sometimes used for minor stroke or TIA, it is not the primary treatment for an acute stroke within the thrombolysis window. - Antiplatelets are typically initiated after excluding hemorrhage and usually 24 hours after tPA administration to reduce the risk of **secondary intracranial hemorrhage**. *Mannitol* - **Mannitol** is an osmotic diuretic used to lower **intracranial pressure** in cases of life-threatening cerebral edema or herniation, not for the acute management of ischemia. - It does not address the underlying **vascular occlusion** and has no role in reperfusion therapy. *Anticoagulation with warfarin* - **Warfarin** is a vitamin K antagonist with a slow onset of action and is inappropriate for the **hyperacute management** of ischemic stroke. - Acute anticoagulation with warfarin or heparin carries a high risk of **hemorrhagic transformation** in an ischemic infarct and is not indicated in the emergency setting.

Q: What is the suspected acid-base disorder based on the ABG analysis? pH 7.45 PaCO2 28 mmHg HCO3 20mEq/L

Compensated respiratory alkalosis. ***Compensated respiratory alkalosis*** - The arterial blood gas (ABG) shows a pH at the high end of normal (7.45), representing **respiratory alkalosis** due to the low **PaCO2** (28 mmHg). - The decreased **HCO3** (20 mEq/L) indicates renal **metabolic compensation**, which has brought the pH back toward a normal range. *Compensated Respiratory acidosis* - Respiratory acidosis would present with a primary increase in **PaCO2** (>45 mmHg). - Compensation for respiratory acidosis involves an increase in **HCO3** (bicarbonate retention), which is the opposite of the finding in this patient. *Uncompensated respiratory acidosis* - This would demonstrate an **acidemic** pH ( 7.45) rather than the normal range seen here. - The **HCO3** would be within the normal reference range, signifying a lack of renal **metabolic compensation**.

Q: A 35-year-old man presents with high-grade fever, severe myalgia (predominantly calf pain), and redness of eyes for the last 4 days. He gives a history of wading through flood water one week ago. On examination, conjunctival suffusion is noted. There isno jaundice or renal impairment at present. This clinical presentation most likely corresponds to which phase of leptospirosis?

Septicemic phase. ***Septicemic phase*** - This phase corresponds to the first 4–7 days of illness, characterized by the **sudden onset of fever**, severe **myalgia** (classically involving **calf muscles**), and **conjunctival suffusion** without purulent discharge. - During this period, the bacteria (leptospires) are actively circulating in the blood, making them detectable by **blood culture** or **PCR**, as the patient has not yet cleared the infection or developed high titers of **anti-leptospiral antibodies**. *Incubation phase* - This is the asymptomatic period lasting usually between **7 to 12 days** (range 2–30 days) following exposure to the **spirochete**. - There are no clinical symptoms or signs during this time as the organism is establishing its presence in the host's body. *Immune phase* - This phase typically begins after a short afebrile period, which marks the host's immune response characterized by the appearance of **IgM antibodies**. - Clinical features here are often milder, but complications like **aseptic meningitis** (severe headache, nuchal rigidity) may occur due to the inflammatory response even as the bacteria are cleared from the blood. *Weil's disease* - This is the severe form of leptospirosis, characterized by the triad of **jaundice**, **acute kidney injury**, and **hemorrhage**. - The patient explicitly lacks jaundice and renal impairment, excluding this severe pattern at the present time.

Q: A 35-year-old man presents with headache and neck stiffness for 5 days. Lumbar puncture reveals the following CSF findings: 90% lymphocytes and 10% neutrophils with CSF glucose: 40 mg/dL (Plasma glucose: 100mg/dL), protein is 1 gm/dl. What is the most likely diagnosis?

Tubercular meningitis. ***Tubercular meningitis*** - The CSF profile shows **lymphocytic pleocytosis** with a **low glucose** (CSF:Blood glucose ratio < 0.5) and **markedly elevated protein**, which is the hallmark of **tuberculous meningitis**. - The clinical course of typically **subacute onset** (lasting days to weeks) and the specific CSF findings of **hypoglycorrachia** (low glucose) are classic indicators for this diagnosis. *Viral meningitis* - While CSF lymphocytosis is common, viral meningitis typically presents with **normal CSF glucose** levels. - Protein levels are usually **normal or only mildly elevated**, unlike the significant elevation seen in this patient. *Bacterial meningitis* - Characterized by a **neutrophilic pleocytosis** rather than lymphocytic, and usually presents with a much more **acute, fulminant onset**. - CSF glucose is typically very low, but the cell count composition in bacterial cases is predominantly **PMNs (polymorphonuclear leukocytes)**. *Fungal meningitis* - Fungal meningitis is less common in immunocompetent individuals and usually follows a very prolonged, chronic course often associated with **basal meningeal enhancement**. - While it can manifest similarly to tubercular meningitis, the epidemiologic context and the **specific clinical presentation** make tuberculosis a statistically more probable diagnosis in this scenario.

Question 1

A young patient presents with persistently elevated blood pressure despite adequate lifestyle measures. Laboratory evaluation reveals hypokalemia associated with metabolic alkalosis. There is no history of diuretic intake, and renal function tests are within normal limits. Which of the following is the most likely diagnosis?

Accepted Answer

Conn syndrome

Answer

Pheochromocytoma

Answer

Liddle syndrome

Answer

Carcinoid syndrome

Question 2

A patient was detected to have a medullary carcinoma of thyroid and has a family history of endocrine tumors, and genetic counseling is advised. The clinician plans further evaluation to identify associated inherited syndromes and guide family screening. Which of the following statements regarding this condition is correct?

Accepted Answer

Patients should be screened for RET gene mutations associated with MEN 2A and MEN 2B

Answer

Menin proto-oncogene mutation is associated with MEN 1

Answer

Medullary thyroid carcinoma arises from follicular cells and is associated with BRAF mutation

Answer

Prophylactic thyroidectomy is not indicated in asymptomatic family members

Question 3

A middle-aged woman presents with long -standing complaints of dryness of eyes and mouth, requiring frequent use of artificial tears and water while swallowing food. She also reports generalized pruritus and intermittent pain with stiffness in multiple small joints of the hands, suggestive of inflammatory arthritis. There is no history of skin tightening, Raynaud phenomenon, oral ulcers, or photosensitive rash. Based on this clinical presentation, what is the most likely diagnosis?

Accepted Answer

Sjogren syndrome

Answer

Systemic lupus erythematosus

Answer

Rheumatoid arthritis

Answer

Scleroderma

Question 4

A middle-aged male presents to the OPD with complaints of vague abdominei discomfort, intermittent diarrhea, and recent weight loss. There is no history of alcohol intake or gallstone disease. MRI abdomen reveals a diffusely enlarged c pancreas with a characteristic "sausage- shaped" appearance. Laboratory evaluation shows markedly elevated serum IGG4 Tevels. Which of the following is the best treatment for this patient?

Accepted Answer

Steroids

Answer

Antibiotics

Answer

Surgery

Answer

Pancreatic enzyme supplements

Question 5

A 60-year-old female presents with chronic breathlessness and cough for several years, which has progressively worsened. She has a significant smoking history of 30 pack-years. There is no history of atopy. Pulmonary function testing shows a post-bronchodilator FEV/FVC ratio of <0.7 with an 18% improvement in FEV1 after bronchodilator administration. CXR is shown below?

Accepted Answer

Asthma COPD overlap syndrome

Answer

Emphysema

Answer

ILD

Answer

Asthma

Question 6

A 17-year-old boy presents with gradually progressive muscle weakness predominantly involving the proximal muscles of the lower limbs. He has difficulty climbing stairs and getting up from a squatting position. There is a significant family history and his elder brother had similar complaints and died around the age of 40 years. Based on the age of onset, pattern of inheritance, and survival, what is the most likely diagnosis?

Accepted Answer

BMD

Answer

DMD

Answer

CMT

Answer

ALS

Question 7

A 65 year old man presents with sudden onset weakness of the left upper and lower limbs and slurred speech which started 2 hours ago. MRI of the brain is shown in the image. Which of the following is the most appropriate initial management?

Accepted Answer

Thrombolysis with alteplase (tPA)

Answer

Aspirin and clopidogrel

Answer

Mannitol

Answer

Anticoagulation with warfarin

Question 8

What is the suspected acid-base disorder based on the ABG analysis? pH 7.45 PaCO2 28 mmHg HCO3 20mEq/L

Accepted Answer

Compensated respiratory alkalosis

Answer

Compensated Respiratory acidosis

Answer

Uncompensated respiratory acidosis

Answer

Uncompensated Respiratory alkalosis

Question 9

A 35-year-old man presents with high-grade fever, severe myalgia (predominantly calf pain), and redness of eyes for the last 4 days. He gives a history of wading through flood water one week ago. On examination, conjunctival suffusion is noted. There isno jaundice or renal impairment at present. This clinical presentation most likely corresponds to which phase of leptospirosis?

Accepted Answer

Septicemic phase

Answer

Incubation phase

Answer

Immune phase

Answer

Weil's disease

Question 10

A 35-year-old man presents with headache and neck stiffness for 5 days. Lumbar puncture reveals the following CSF findings: 90% lymphocytes and 10% neutrophils with CSF glucose: 40 mg/dL (Plasma glucose: 100mg/dL), protein is 1 gm/dl. What is the most likely diagnosis?

Accepted Answer

Tubercular meningitis

Answer

Viral meningitis

Answer

Bacterial meningitis

Answer

Fungal meningitis

FMGE 2026 — Internal Medicine