INI-CET 2021 - Internal Medicine PYQs Practice Questions

Q: A forest officer develops the lesion as shown in the image. Which of the following is not a differential to consider?

KFD. ***KFD*** - **Kyasanur Forest Disease** (KFD) is a viral hemorrhagic fever, but it does **not** typically present with a **skin lesion** or eschar like the one shown. - KFD is characterized by fever, headache, myalgia, and gastrointestinal symptoms, with hemorrhagic manifestations in severe cases, but not a primary cutaneous lesion. *Cutaneous anthrax* - **Cutaneous anthrax** commonly presents as an **eschar**, often with surrounding edema and vesicles, which can resemble the lesion in the image. - Exposure through handling infected animal products or contact with contaminated soil is common, aligning with a forest officer's occupation. *Scrub typhus* - **Scrub typhus** characteristically causes an **eschar** (tache noire) at the bite site of the chigger mite. - The lesion in the image, an ulcer with a central black crust, is highly suggestive of such an eschar seen in rickettsial infections. *Healing brown recluse spider bite* - A **brown recluse spider bite** can cause a **necrotic ulcer** with a central dark eschar as the wound heals, fitting the appearance of the lesion. - The profession of a forest officer increases the likelihood of exposure to spiders in their natural habitat. [Practice more Internal Medicine PYQs on OnCourse]

Q: An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis? - Hb - 6.9 g/dl

Multiple myeloma. ***Multiple myeloma*** - The combination of **osteolytic lesions** (bone pain, tenderness), **hypercalcemia** (confusion, thirst), **anemia** (Hb 69 g/dl, pallor), and **renal insufficiency** (confusion, thirst from dehydration) is highly suggestive of **multiple myeloma** [1]. - This plasma cell malignancy leads to excessive production of monoclonal antibodies and bone destruction [1]. *Vertebral compression fracture* - While **thoracic spine tenderness** and osteolytic lesions could be a component, it doesn't fully explain the systemic symptoms such as **anemia**, **confusion**, and **hypercalcemia**. - A simple compression fracture would not account for the profound **anemia** (Hb 69 g/dl) seen in this patient. *Metastatic carcinoma* - While metastatic carcinoma can cause **osteolytic lesions**, **anemia**, and sometimes **hypercalcemia**, the specific constellation of symptoms, particularly the severity of anemia and rapid progression, makes **multiple myeloma** a more fitting diagnosis. - Absence of primary tumor indicates that it is not a metastatic disease [1]. *Osteoporosis* - **Osteoporosis** can cause vertebral fractures and bone pain but typically does not lead to **osteolytic lesions**, **severe anemia**, or **hypercalcemia** [2]. - The bone changes in osteoporosis are primarily due to decreased bone density, not destructive lesions [2]. [Practice more Internal Medicine PYQs on OnCourse]

Q: An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis? - Hb - 69 g/dl - WBC 4000/cm3 with normal differential count - Serum calcium 13 mg/dl - Creatinine 2.3 mg/dl - Total protein 9 g/dl - Albumin 2.4 g/dl

Multiple myeloma. ***Multiple myeloma*** - The combination of **anemia** (Hb - 69 g/dl), **renal insufficiency** (creatinine 2.3 mg/dl), **hypercalcemia** (serum calcium 13 mg/dl), and **osteolytic lesions** on X-ray spine is highly characteristic of multiple myeloma, often remembered by the acronym **CRAB** (Calcium elevation, Renal failure, Anemia, Bone lesions) [1]. - The **elevated total protein** (9 g/dl) with a relatively low albumin (2.4 g/dl) suggests a **paraproteinemia**, a hallmark of multiple myeloma caused by the overproduction of monoclonal antibodies [1]. *Milk alkali syndrome* - This syndrome is characterized by **hypercalcemia**, **metabolic alkalosis**, and **renal insufficiency**, usually due to excessive intake of calcium and absorbable alkali. While hypercalcemia and renal dysfunction are present, the absence of metabolic alkalosis and the presence of osteolytic lesions make this less likely. - It does not typically cause **anemia** or **osteolytic lesions**, and the high total protein is not a feature. *Metastatic breast cancer* - While metastatic breast cancer can cause **osteolytic lesions** and **hypercalcemia**, it typically presents with a primary breast mass or a history of breast cancer [2]. - The **elevated total protein** with a narrowed albumin-globulin gap is not a characteristic feature of metastatic breast cancer unless it also involves multiple myeloma, which is less common. *Primary hyperparathyroidism* - This condition is characterized by **elevated parathyroid hormone (PTH)** leading to **hypercalcemia** and, in severe cases, bone disease (osteitis fibrosa cystica). - Unlike the patient's presentation, primary hyperparathyroidism typically does not cause **anemia** or such pronounced **renal failure** (though kidney stones are common), nor does it lead to significantly elevated total protein with a low albumin. [Practice more Internal Medicine PYQs on OnCourse]

Q: During the discharge of a COVID patient treated with steroids and remdesivir, which of the following will you inform him about? 1. Repeat RT-PCR after 7 days of discharge 2. Watch for the persistence of Anosmia 3. Watch for headache and nasal discharge 4. Monitor glucose levels 5. Watch for Sinusitis symptoms

3,4 and 5. **3, 4, and 5** - For patients treated with **steroids**, it is crucial to monitor **glucose levels** due to the potential for steroid-induced hyperglycemia [1]. - Symptoms like **headache** and **nasal discharge** (and by extension **sinusitis symptoms**) could indicate conditions like **mucormycosis**, a serious fungal infection seen in immunocompromised COVID-19 patients, especially those having received steroids. *1, 3, and 4* - A **repeat RT-PCR after 7 days** of discharge is generally not recommended as per current guidelines, as viral shedding can persist without infectivity. - While monitoring for headache, nasal discharge, and glucose levels is appropriate, omitting the direct vigilance for **sinusitis symptoms** is less comprehensive. *2, 3, and 4* - While **anosmia** (loss of smell) can persist post-COVID, it is primarily a lingering symptom of the infection itself and typically resolves spontaneously, not usually requiring specific discharge instructions for monitoring its persistence to prevent complications. - The focus should be on new or worsening symptoms that might indicate post-COVID complications or secondary infections. *1, 2, 3, 4, and 5* - Including **repeat RT-PCR** and solely "watch for the persistence of Anosmia" without emphasizing resolution or specific actions makes this option less pertinent for discharge advice. - The priority for discharge instructions should be preventable complications and warning signs of serious conditions. [Practice more Internal Medicine PYQs on OnCourse]

Q: A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?

IV thrombolysis. ***IV thrombolysis*** - This patient presents with **acute ischemic stroke** symptoms (right-sided weakness and aphasia) with an onset within 4.5 hours of symptom onset, making them a candidate for **IV thrombolysis** [1]. - A **clear NCCT** of the head within this timeframe rules out **hemorrhage**, confirming the safety profile for thrombolytic administration under appropriate blood pressure control [1]. *MRI Brain* - While an MRI brain is highly sensitive for **detecting acute ischemic changes**, it is typically not the initial emergent imaging choice in suspected stroke due to its longer acquisition time and limited availability compared to CT [1]. - The primary goal in acute stroke evaluation is to **rule out hemorrhage** quickly to determine eligibility for thrombolytics, which NCCT achieves effectively [1]. *Antihypertensive therapy* - While the patient's **blood pressure is elevated**, aggressive lowering is generally avoided in acute ischemic stroke unless it exceeds 220/120 mmHg (for non-thrombolysis candidates) or 185/110 mmHg (for thrombolysis candidates). - Rapidly lowering blood pressure can **reduce cerebral perfusion pressure** and worsen ischemic injury in the acute setting due to impaired autoregulation. *CT Angiography* - **CT angiography** can help identify large vessel occlusions that might be amenable to **endovascular thrombectomy** [1]. - However, the immediate priority after a clear NCCT and within the narrow time window is to initiate IV thrombolysis if no contraindications exist, as it provides systemic thrombolysis. CTA is usually performed concurrently or immediately after initial thrombolysis consideration/initiation if endovascular therapy is also being considered [1]. [Practice more Internal Medicine PYQs on OnCourse]

Question 1

A forest officer develops the lesion as shown in the image. Which of the following is not a differential to consider?

Accepted Answer

KFD

Answer

Cutaneous anthrax

Answer

Scrub typhus

Answer

Healing brown recluse spider bite

Question 2

An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis?

- Hb - 6.9 g/dl

Accepted Answer

Multiple myeloma

Answer

Vertebral compression fracture

Answer

Metastatic carcinoma

Answer

Osteoporosis

Question 3

An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis?

- Hb - 69 g/dl
- WBC 4000/cm3 with normal differential count
- Serum calcium 13 mg/dl
- Creatinine 2.3 mg/dl
- Total protein 9 g/dl
- Albumin 2.4 g/dl

Accepted Answer

Multiple myeloma

Answer

Milk alkali syndrome

Answer

Metastatic breast cancer

Answer

Primary hyperparathyroidism

Question 4

During the discharge of a COVID patient treated with steroids and remdesivir, which of the following will you inform him about?

1. Repeat RT-PCR after 7 days of discharge
2. Watch for the persistence of Anosmia
3. Watch for headache and nasal discharge
4. Monitor glucose levels
5. Watch for Sinusitis symptoms

Accepted Answer

3,4 and 5

Answer

1,3 and 4

Answer

2,3 and 4

Answer

1,2,3,4 and 5

Question 5

A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?

Accepted Answer

IV thrombolysis

Answer

MRI Brain

Answer

Antihypertensive therapy

Answer

CT Angiography

Question 6

Which of the following is not true about syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Accepted Answer

Urinary sodium <20 mEq/L

Answer

Patient can be clinically euvolemic to hypovolemic

Answer

Urine osmolality >100 mOsm/kg

Answer

Serum sodium <135 mEq/L

Question 7

Treatment of choice for an acute attack of cluster headache is:

Accepted Answer

100 % oxygen at 6 L / minute

Answer

Subcutaneous sumatriptan

Answer

Oral sumatriptan

Answer

Prophylactic verapamil

Question 8

A 35-year-old female patient with class II pulmonary hypertension presents with a negative vasoreactive test. Which of the following is used in the next step of management?

Accepted Answer

Ambrisentan

Answer

Epoprostenol

Answer

Nifedipine

Answer

Iloprost

Question 9

Which of the following drugs is preferred in the management of primary progressive multiple sclerosis?

Accepted Answer

Ocrelizumab

Answer

Natalizumab

Answer

Alemtuzumab

Answer

Fingolimod

Question 10

A 60-year-old male patient with critical mitral stenosis presented with atrial fibrillation. He has a history of multiple episodes of transient ischemic attacks. Which of the following are true regarding preventing stroke in this patient?

1. Only aspirin is given
2. Warfarin is given
3. Direct oral anticoagulants are not indicated
4. Mitral valvotomy should be recommended

Accepted Answer

2 and 3

Answer

1 only

Answer

1,2,3 and 4

Answer

2,3 and 4

INI-CET 2021 — Internal Medicine