INI-CET 2024 - Internal Medicine PYQs Practice Questions

Q: All of the following can occur in rheumatic fever except?

Tricuspid regurgitation as the primary valve lesion. ***Tricuspid regurgitation as the primary valve lesion*** - While **rheumatic fever** can affect any heart valve, the **tricuspid valve** is rarely affected as the **primary or sole lesion**. - It is most commonly seen in conjunction with more severe **mitral and aortic valve disease**. *Mitral regurgitation* - **Mitral regurgitation** is a common manifestation of **acute rheumatic fever**, occurring due to **inflammation** of the valve leaflets and **chordae tendineae** [1]. - This leads to incompetence of the valve, causing blood to flow back into the left atrium during systole [1]. *Mitral stenosis* - **Mitral stenosis** is a classic **long-term complication** of **rheumatic fever**, typically developing years to decades after the initial acute episode. - Repeated inflammation and scarring lead to **thickening and fusion of the mitral valve leaflets**, restricting blood flow. *Pericarditis* - **Pericarditis**, inflammation of the **pericardium** (the sac surrounding the heart), is a possible manifestation of **rheumatic carditis** in acute rheumatic fever [1]. - It can cause chest pain and may be accompanied by a **pericardial effusion** [1]. [Practice more Internal Medicine PYQs on OnCourse]

Q: What is the mode of inheritance for the most common form of hypophosphatemic rickets?

X-Linked Dominant (XD). ***X-Linked Dominant (XD)*** - The most common form of hypophosphatemic rickets is **X-linked hypophosphatemic rickets (XLH)**, which is inherited in an X-linked dominant pattern. - This condition is caused by mutations in the **PHEX gene** on the X chromosome, leading to impaired phosphate reabsorption in the kidneys. *Autosomal Recessive (AR)* - While some rare forms of hypophosphatemic rickets exist with **autosomal recessive** inheritance, they are not the most common. - These forms typically involve mutations in genes affecting phosphate transport or vitamin D metabolism, distinct from the primary defect in XLH. *Autosomal Dominant (AD)* - There are also rare **autosomal dominant** forms of hypophosphatemic rickets, such as hereditary hypophosphatemic rickets with hypercalciuria (HHRH) or autosomal dominant hypophosphatemic rickets (ADHR). - However, these are less common than the X-linked dominant form (XLH). *X-Linked Recessive (XR)* - **X-linked recessive** inheritance typically affects males more severely and exclusively, with carrier females usually unaffected or mildly affected. - In X-linked dominant conditions like XLH, both males and females are affected, though females may exhibit variable expressivity. [Practice more Internal Medicine PYQs on OnCourse]

Q: An 11-year-old boy presented with a cough for 15 days. On examination, he was found to have cervical lymphadenopathy. Lymph node biopsy showed the following findings. What could be the diagnosis?

Tuberculosis. ***Tuberculosis*** - The image likely displays **granulomatous inflammation** with **caseous necrosis**, which is highly characteristic of **tuberculosis**, especially in someone presenting with a persistent cough and lymphadenopathy. - The presence of **cervical lymphadenopathy** along with a **cough** for 15 days in an 11-year-old boy points towards extrapulmonary tuberculosis or primary tuberculosis infection affecting the mediastinal lymph nodes with cervical involvement. *Leprosy* - While leprosy also causes granulomas, it typically manifests as skin lesions and nerve involvement, and lymphadenopathy is less common or specific as the primary initial presentation. - The granulomas in leprosy are often **epithelioid** with **foamy histiocytes** and numerous acid-fast bacilli, which are not explicitly described or obvious in the provided context for a definitive diagnosis without special stains. *Sarcoidosis* - Sarcoidosis involves **non-caseating granulomas**, meaning there is no central necrosis, which is a key differentiating feature from the caseating necrosis often seen in tuberculosis. - Although sarcoidosis can cause lymphadenopathy and cough, the microscopic features in the image, particularly if showing necrosis, would argue against sarcoidosis. *Syphilis* - Syphilis can cause lymphadenopathy (especially in secondary syphilis), but the characteristic histological finding is usually a **plasma cell-rich infiltrate** with **endarteritis obliterans**, not typically prominent granulomas with caseous necrosis. - Clinical presentation with cough and chronic lymphadenopathy in an 11-year-old would also make syphilis a less likely primary consideration without other suggestive signs. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following is a known risk factor for cholangiocarcinoma?

Clonorchis sinensis infestation. ***Clonorchis sinensis infestation*** - **Clonorchis sinensis**, also known as the Chinese liver fluke, is a well-established and significant risk factor for the development of **cholangiocarcinoma**. - Chronic inflammation and irritation of the bile ducts caused by the parasite are believed to promote malignant transformation. *Giardia lamblia (intestinal protozoa) infection* - **Giardia lamblia** is a common intestinal parasite causing giardiasis, characterized by diarrhea and malabsorption. - While it affects the gastrointestinal tract, there is **no known association** between *Giardia* infection and an increased risk of cholangiocarcinoma. *Paragonimus westermani infestation* - **Paragonimus westermani** is a lung fluke that primarily causes paragonimiasis, affecting the lungs and leading to cough and hemoptysis. - This parasite is not associated with direct bile duct inflammation or an increased risk of **cholangiocarcinoma**. *Ascaris lumbricoides (roundworm) infection* - **Ascaris lumbricoides** is a large intestinal roundworm that can cause intestinal obstruction or nutrient deficiencies. - Although it can occasionally migrate into the biliary tree, it is **not considered a risk factor** for cholangiocarcinoma [1]. [Practice more Internal Medicine PYQs on OnCourse]

Q: In folate deficiency, which of the following statements is true?

Elevated homocysteine & normal methylmalonic acid. ***Elevated homocysteine & normal methylmalonic acid*** - In **folate deficiency**, the conversion of homocysteine to methionine is impaired, leading to **elevated homocysteine** levels. - Unlike vitamin B12 deficiency, **methylmalonic acid (MMA)** levels remain normal in folate deficiency because folate is not involved in its metabolism. *B12 supplementation is recommended along with folate* - Supplementation with B12 alongside folate is crucial when **macrocytic anemia** is diagnosed, as it can mask a coexisting **B12 deficiency**, potentially worsening neurological symptoms if only folate is given. - However, in confirmed isolated folate deficiency, B12 supplementation is not strictly necessary unless there is suspicion or diagnosis of co-existing B12 deficiency. *Purine and pyrimidine synthesis are affected* - While folate is essential for **DNA synthesis**, indirectly affecting purine and pyrimidine production, this statement is a consequence rather than the primary diagnostic or distinguishing feature of folate deficiency. - **Folate** acts as a coenzyme in transferring one-carbon units, vital for the synthesis of **thymidylate** (a pyrimidine base) and **purine precursors**. *Hemolytic anemia is not a feature* - **Hemolytic anemia** is not typically a feature of folate deficiency; instead, it is characterized by **macrocytic, megaloblastic anemia**. - Conditions like **glucose-6-phosphate dehydrogenase (G6PD) deficiency** or **autoimmune disorders** are commonly associated with hemolytic anemia. [Practice more Internal Medicine PYQs on OnCourse]

Question 1

All of the following can occur in rheumatic fever except?

Accepted Answer

Tricuspid regurgitation as the primary valve lesion

Answer

Mitral regurgitation

Answer

Mitral stenosis

Answer

Pericarditis

Question 2

What is the mode of inheritance for the most common form of hypophosphatemic rickets?

Accepted Answer

X-Linked Dominant (XD)

Answer

Autosomal Recessive (AR)

Answer

Autosomal Dominant (AD)

Answer

X-Linked Recessive (XR)

Question 3

An 11-year-old boy presented with a cough for 15 days. On examination, he was found to have cervical lymphadenopathy. Lymph node biopsy showed the following findings. What could be the diagnosis?

Accepted Answer

Tuberculosis

Answer

Leprosy

Answer

Sarcoidosis

Answer

Syphilis

Question 4

Which of the following is a known risk factor for cholangiocarcinoma?

Accepted Answer

Clonorchis sinensis infestation

Answer

Giardia lamblia (intestinal protozoa) infection

Answer

Ascaris lumbricoides (roundworm) infection

Answer

Paragonimus westermani infestation

Question 5

In folate deficiency, which of the following statements is true?

Accepted Answer

Elevated homocysteine & normal methylmalonic acid

Answer

B12 supplementation is recommended along with folate

Answer

Purine and pyrimidine synthesis are affected

Answer

Hemolytic anemia is not a feature

Question 6

A male patient with purple striae, thin skin, non-healing wound, and pedunculated abdomen, most probable cause?

Accepted Answer

Hypercortisolism

Answer

Insulin resistance

Answer

Hypothyroidism

Answer

Genetic connective tissue disorder

Question 7

A 20-year-old chronic alcoholic presents with severe hematemesis. USG shows distension of portal vein and the liver appears hyperechoic. Pantoprazole has been initiated. What is the next step in management?

Accepted Answer

Perform an endoscopy to identify and treat varices

Answer

Administer IV fluids and electrolytes to stabilize hemodynamics

Answer

Order a liver biopsy to assess for fibrosis

Answer

Initiate a course of broad-spectrum antibiotics

Question 8

Which of the following statements about atrial fibrillation is correct?

Accepted Answer

Discrepancy in pulse rate and heart rate are reliable for diagnosis

Answer

Rarely seen in heart with normal morphology

Answer

Cardioversion is used for all cases of atrial fibrillation

Answer

Only digoxin used for rate control

Question 9

A patient presents with the following arterial blood gas (ABG) and electrolyte values: pH: 7.34, Na: 135 mEq/L, Cl: 93 mEq/L, HCO3: 20 mEq/L, Random Blood Sugar (RBS): 420 mg/dl. What is the most likely acid-base disturbance?

Accepted Answer

High Anion Gap Metabolic Acidosis (HAGMA)

Answer

Normal Anion Gap Metabolic Acidosis (NAGMA)

Answer

Respiratory Acidosis

Answer

Metabolic Alkalosis

Question 10

Which of the following is not a complication of hypokalemia?

Accepted Answer

Cerebral edema

Answer

Quadriparesis

Answer

Ventricular Tachycardia

Answer

Diabetes insipidus

INI-CET 2024 — Internal Medicine