UPSC-CMS 2009 — Internal Medicine

Q: Which one of the following is not a correct statement regarding Raynaud's disease ?

The lower extremity involvement is symmetrical. ***The lower extremity involvement is symmetrical*** - **Raynaud's phenomenon** primarily affects the **fingers and toes**, but it is characterized by **asymmetrical involvement**, affecting different digits or limbs to varying degrees. Symmetrical involvement of the lower extremities is not a typical characteristic. - While it can affect the lower extremities, the hallmark of Raynaud's is its **episodic, asymmetrical, and often acral distribution** in response to triggers. *It commonly affects women* - **Raynaud's phenomenon** is indeed more prevalent in **women** than men, with an estimated prevalence of 5-10% in the general population. - This higher incidence in women is a well-documented epidemiological feature of the condition. *Exposure to cold precipitates vasoconstriction* - **Cold exposure** is the most common and classic trigger for **Raynaud's phenomenon**, leading to an exaggerated **vasoconstrictive response** in the small arteries and arterioles of the extremities. - This extreme vasoconstriction results in the characteristic color changes (pallor, cyanosis, and rubor) due to reduced blood flow. *It is idiopathic* - **Raynaud's disease**, also known as **primary Raynaud's phenomenon**, is indeed considered **idiopathic**, meaning its cause is unknown. - It occurs in the absence of any underlying medical condition, distinguishing it from secondary Raynaud's phenomenon, which is associated with autoimmune diseases or other factors. [Practice more Internal Medicine PYQs on OnCourse]

Q: What is the best and most sensitive investigation for hypothyroidism ?

TSH levels. TSH levels - **Thyroid-Stimulating Hormone (TSH)** is the most sensitive and specific test for diagnosing **primary hypothyroidism** because even slight decreases in thyroid hormone levels cause significant increases in TSH [1]. - TSH is released from the **pituitary gland** and acts as a direct feedback mechanism to regulate thyroid hormone production [1]. A high TSH level indicates that the thyroid gland is not producing enough hormones. *T3, T4 levels* - While **T3 (triiodothyronine)** and **T4 (thyroxine)** levels are direct measures of thyroid hormones, their values may remain within the normal range in early or subclinical hypothyroidism [1]. - They are less sensitive than TSH for initial screening and often become abnormal only after hypothyroidism is well-established [1]. *TRH levels* - **Thyrotropin-Releasing Hormone (TRH)** is produced by the hypothalamus and stimulates TSH release from the pituitary [1]. - Measuring TRH levels is generally not used as a primary diagnostic test for hypothyroidism due to its complexity and lack of direct clinical utility in routine screening. *Radioactive I2 uptake* - **Radioactive iodine uptake (RAIU)** measures the thyroid gland's ability to take up iodine, which is used to produce thyroid hormones. - It is primarily used to differentiate causes of hyperthyroidism (e.g., Graves' disease vs. thyroiditis), not as a diagnostic test for hypothyroidism [1]. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which one of the following is not a common feature of bile duct stone ?

Distended gall bladder. ***Distended gall bladder*** - A distended gallbladder is **less common** when the obstruction is caused by a stone in the **common bile duct (CBD)** because the gallbladder can often decompress through the cystic duct if it is patent. [1] - Furthermore, **Mirizzi syndrome**, which can cause gallbladder distension due to an impacted stone in the cystic duct compressing the CBD, is a specific and less frequent scenario than simple choledocholithiasis. [2] *Clay colored stools* - **Clay-colored stools** (acholic stools) are a common feature of bile duct obstruction as it prevents bilirubin from reaching the intestines to be converted into **stercobilin**, which gives stool its normal brown color. - The absence of bilirubin in the gut results in stools appearing pale or gray. *Itching* - **Pruritus (itching)** is a very common symptom of bile duct obstruction due to the systemic accumulation of **bile salts** and other pruritic substances that are normally excreted in bile. [3] - These substances deposit in the skin, irritating nerve endings. *Obstructive jaundice* - **Obstructive jaundice** is a hallmark feature of bile duct stones. The obstruction prevents the flow of conjugated bilirubin into the intestine, leading to its reabsorption into the bloodstream. [1] - This results in elevated **conjugated bilirubin** and **icterus**, causing yellow discoloration of the skin and sclera. [Practice more Internal Medicine PYQs on OnCourse]

Q: The following are complications of gall stone except

Haemobilia. ***Haemobilia*** - **Haemobilia** refers to bleeding into the biliary tree, often caused by trauma, surgery, or vascular malformations, and is **not a direct complication of gallstones**. [1] - While gallstones can lead to inflammation and erosion, they typically do not cause bleeding into the bile ducts as a primary complication. *Acute pancreatitis* - **Gallstones** are a common cause of **acute pancreatitis** when a stone obstructs the ampulla of Vater, leading to reflux of bile into the pancreatic duct or obstruction of the pancreatic duct itself [1]. - This obstruction causes premature activation of pancreatic enzymes and autodigestion of the pancreas. *Cholangitis* - **Cholangitis** is an inflammation of the bile ducts, usually caused by bacterial infection, which is often precipitated by an obstruction of the biliary tree, most commonly by **gallstones** [1]. - The obstruction leads to stasis of bile, allowing bacteria to ascend from the duodenum and proliferate. *Biliary enteric fistula* - A **biliary enteric fistula** (e.g., cholecystoduodenal fistula) is a pathological connection between the gallbladder or bile duct and the gastrointestinal tract, which can occur due to chronic inflammation and erosion caused by **gallstones** [1]. - This can lead to gallstone ileus if the stone passes into the bowel and obstructs it [1]. [Practice more Internal Medicine PYQs on OnCourse]

10 Previous Year Questions with Answers & Explanations

Questions

All Subjects Anatomy (3)Anesthesiology (1)Biochemistry (6)Community Medicine (25)Dermatology (1)Internal Medicine (10)Microbiology (5)Obstetrics and Gynecology (24)Pathology (4)Pediatrics (1)Pharmacology (6)Physiology (3)Radiology (1)Surgery (17)

Following the immunotherapy, in patients undergoing renal transplantation, the skin cancer most commonly seen is

Which one of the following is not a correct statement regarding Raynaud's disease ?

What is the best and most sensitive investigation for hypothyroidism ?

Which one of the following is not a common feature of bile duct stone ?

The following are complications of gall stone except

Consider the following prognostic parameters of acute pancreatitis : 1. Rise in blood urea nitrogen over 5 mg/dl 2. Hematocrit decrease over 10% 3. Base deficit more than 4 mmol/L 4. Blood glucose over 10 mmol/L Which of the above parameters are important during initial 48 hours ?

Motility disorders of the oesophagus are best diagnosed by

Consider the following statements : Systemic Inflammatory Response Syndrome is characterised by 1. Temperature either above 38°C or below 36°C. 2. Heart rate less than 80/minute. 3. Tachypnoea > 20/min. 4. Leucocyte count > 4 x 109/L. Which of the statements given above are correct ?

Consider the following statements: 1. The placenta is usually located in the upper uterine segment. 2. The placenta is usually located in the lower uterine segment. 3. The placenta is usually located in the fundus. 4. The placenta is usually located in the anterior uterine wall. Which one of the statements given above are correct ?

Q10

Which one of the following investigations is considered to be "Gold standard" technique for diagnosis of arterial occlusive disease ?

UPSC-CMS 2009 - Internal Medicine UPSC-CMS Practice Questions and MCQs

Question 1: Following the immunotherapy, in patients undergoing renal transplantation, the skin cancer most commonly seen is

A. Non-melanoma skin cancers (Squamous cell carcinoma and Basal cell carcinoma) (Correct Answer)
B. Hepatomas
C. Kaposi's sarcoma
D. Mycosis fungoides

Explanation: ***Non-melanoma skin cancers (Squamous cell carcinoma and Basal cell carcinoma)*** - **Immunosuppression** following renal transplantation significantly increases the risk of skin cancers, with non-melanoma types like **squamous cell carcinoma (SCC)** and **basal cell carcinoma (BCC)** being the most common [1]. - This increased risk is due to the impaired immune surveillance against oncogenic viruses (e.g., HPV) and DNA damage from UV radiation [2]. *Hepatomas* - While patients with chronic liver disease are at risk for hepatocellular carcinoma (hepatomas), they are **not the most common cancer** specifically associated with immunosuppression after renal transplantation. - The primary risk factors for hepatomas are chronic **hepatitis B** or **C infection**, alcohol abuse, and **cirrhosis**, not directly the immunosuppressive regimen itself. *Kaposi's sarcoma* - **Kaposi's sarcoma (KS)** is associated with **human herpesvirus 8 (HHV-8)** infection and is more prevalent in immunosuppressed individuals, especially those with AIDS or solid organ transplant recipients [2]. - Although its incidence is increased, it is still **less common** than non-melanoma skin cancers in this patient population. *Mycosis fungoides* - **Mycosis fungoides** is a type of **cutaneous T-cell lymphoma**, characterized by malignant T-lymphocytes infiltrating the skin. - It is a **rare cancer** and is not typically considered the most common skin cancer to occur in transplant recipients undergoing immunotherapy.

Question 2: Which one of the following is not a correct statement regarding Raynaud's disease ?

A. It commonly affects women
B. Exposure to cold precipitates vasoconstriction
C. It is idiopathic
D. The lower extremity involvement is symmetrical (Correct Answer)

Explanation: ***The lower extremity involvement is symmetrical*** - **Raynaud's phenomenon** primarily affects the **fingers and toes**, but it is characterized by **asymmetrical involvement**, affecting different digits or limbs to varying degrees. Symmetrical involvement of the lower extremities is not a typical characteristic. - While it can affect the lower extremities, the hallmark of Raynaud's is its **episodic, asymmetrical, and often acral distribution** in response to triggers. *It commonly affects women* - **Raynaud's phenomenon** is indeed more prevalent in **women** than men, with an estimated prevalence of 5-10% in the general population. - This higher incidence in women is a well-documented epidemiological feature of the condition. *Exposure to cold precipitates vasoconstriction* - **Cold exposure** is the most common and classic trigger for **Raynaud's phenomenon**, leading to an exaggerated **vasoconstrictive response** in the small arteries and arterioles of the extremities. - This extreme vasoconstriction results in the characteristic color changes (pallor, cyanosis, and rubor) due to reduced blood flow. *It is idiopathic* - **Raynaud's disease**, also known as **primary Raynaud's phenomenon**, is indeed considered **idiopathic**, meaning its cause is unknown. - It occurs in the absence of any underlying medical condition, distinguishing it from secondary Raynaud's phenomenon, which is associated with autoimmune diseases or other factors.

Question 3: What is the best and most sensitive investigation for hypothyroidism ?

A. T3, T4 levels
B. TRH levels
C. Radioactive I2 uptake
D. TSH levels (Correct Answer)

Explanation: TSH levels - **Thyroid-Stimulating Hormone (TSH)** is the most sensitive and specific test for diagnosing **primary hypothyroidism** because even slight decreases in thyroid hormone levels cause significant increases in TSH [1]. - TSH is released from the **pituitary gland** and acts as a direct feedback mechanism to regulate thyroid hormone production [1]. A high TSH level indicates that the thyroid gland is not producing enough hormones. *T3, T4 levels* - While **T3 (triiodothyronine)** and **T4 (thyroxine)** levels are direct measures of thyroid hormones, their values may remain within the normal range in early or subclinical hypothyroidism [1]. - They are less sensitive than TSH for initial screening and often become abnormal only after hypothyroidism is well-established [1]. *TRH levels* - **Thyrotropin-Releasing Hormone (TRH)** is produced by the hypothalamus and stimulates TSH release from the pituitary [1]. - Measuring TRH levels is generally not used as a primary diagnostic test for hypothyroidism due to its complexity and lack of direct clinical utility in routine screening. *Radioactive I2 uptake* - **Radioactive iodine uptake (RAIU)** measures the thyroid gland's ability to take up iodine, which is used to produce thyroid hormones. - It is primarily used to differentiate causes of hyperthyroidism (e.g., Graves' disease vs. thyroiditis), not as a diagnostic test for hypothyroidism [1].

Question 4: Which one of the following is not a common feature of bile duct stone ?

A. Clay colored stools
B. Distended gall bladder (Correct Answer)
C. Itching
D. Obstructive jaundice

Explanation: ***Distended gall bladder*** - A distended gallbladder is **less common** when the obstruction is caused by a stone in the **common bile duct (CBD)** because the gallbladder can often decompress through the cystic duct if it is patent. [1] - Furthermore, **Mirizzi syndrome**, which can cause gallbladder distension due to an impacted stone in the cystic duct compressing the CBD, is a specific and less frequent scenario than simple choledocholithiasis. [2] *Clay colored stools* - **Clay-colored stools** (acholic stools) are a common feature of bile duct obstruction as it prevents bilirubin from reaching the intestines to be converted into **stercobilin**, which gives stool its normal brown color. - The absence of bilirubin in the gut results in stools appearing pale or gray. *Itching* - **Pruritus (itching)** is a very common symptom of bile duct obstruction due to the systemic accumulation of **bile salts** and other pruritic substances that are normally excreted in bile. [3] - These substances deposit in the skin, irritating nerve endings. *Obstructive jaundice* - **Obstructive jaundice** is a hallmark feature of bile duct stones. The obstruction prevents the flow of conjugated bilirubin into the intestine, leading to its reabsorption into the bloodstream. [1] - This results in elevated **conjugated bilirubin** and **icterus**, causing yellow discoloration of the skin and sclera.

Question 5: The following are complications of gall stone except

A. Acute pancreatitis
B. Cholangitis
C. Biliary enteric fistula
D. Haemobilia (Correct Answer)

Explanation: ***Haemobilia*** - **Haemobilia** refers to bleeding into the biliary tree, often caused by trauma, surgery, or vascular malformations, and is **not a direct complication of gallstones**. [1] - While gallstones can lead to inflammation and erosion, they typically do not cause bleeding into the bile ducts as a primary complication. *Acute pancreatitis* - **Gallstones** are a common cause of **acute pancreatitis** when a stone obstructs the ampulla of Vater, leading to reflux of bile into the pancreatic duct or obstruction of the pancreatic duct itself [1]. - This obstruction causes premature activation of pancreatic enzymes and autodigestion of the pancreas. *Cholangitis* - **Cholangitis** is an inflammation of the bile ducts, usually caused by bacterial infection, which is often precipitated by an obstruction of the biliary tree, most commonly by **gallstones** [1]. - The obstruction leads to stasis of bile, allowing bacteria to ascend from the duodenum and proliferate. *Biliary enteric fistula* - A **biliary enteric fistula** (e.g., cholecystoduodenal fistula) is a pathological connection between the gallbladder or bile duct and the gastrointestinal tract, which can occur due to chronic inflammation and erosion caused by **gallstones** [1]. - This can lead to gallstone ileus if the stone passes into the bowel and obstructs it [1].

Question 6: Consider the following prognostic parameters of acute pancreatitis : 1. Rise in blood urea nitrogen over 5 mg/dl 2. Hematocrit decrease over 10% 3. Base deficit more than 4 mmol/L 4. Blood glucose over 10 mmol/L Which of the above parameters are important during initial 48 hours ?

A. 2 and 3 only
B. 1, 2 and 3
C. 1, 3 and 4
D. 1 and 2 only (Correct Answer)

Explanation: ***1 and 2 only*** - A **rise in blood urea nitrogen over 5 mg/dL** and a **hematocrit decrease over 10%** within the initial 48 hours are significant early indicators of fluid sequestration and systemic inflammation, which are critical prognostic factors in acute pancreatitis [1]. - These parameters are part of common prognostic scoring systems, like the **Modified Glasgow Score** or **Ranson's Criteria**, used to assess the severity and predict outcomes [1]. *2 and 3 only* - While a **hematocrit decrease over 10%** is a relevant early prognostic indicator, a **base deficit more than 4 mmol/L** (indicating metabolic acidosis) typically emerges later or reflects more severe, established organ dysfunction. - Early prognostic assessment focuses on parameters measurable within the first 48 hours that reflect initial systemic impact. *1, 2 and 3* - **Rise in blood urea nitrogen over 5 mg/dL** and **hematocrit decrease over 10%** are valid early indicators, but a **base deficit more than 4 mmol/L** is not included in the standard initial 48-hour prognostic criteria for acute pancreatitis severity assessment for the first two days [1]. - This option incorrectly includes base deficit as a primary early prognostic parameter. *1, 3 and 4* - **Rise in blood urea nitrogen over 5 mg/dL** is a correct early prognostic parameter. However, a **base deficit more than 4 mmol/L** and **blood glucose over 10 mmol/L** are less specifically emphasized as *initial 48-hour* critical parameters in all common scoring systems. - While hyperglycemia can be present, its specific prognostic cutoff often varies, and it typically contributes to overall severity rather than being a standalone early change in the first 48 hours.

Question 7: Motility disorders of the oesophagus are best diagnosed by

A. Barium meal
B. Endoscopy
C. Radiography
D. Manometry (Correct Answer)

Explanation: ***Manometry*** - Oesophageal manometry is the **gold standard** for diagnosing motility disorders by directly measuring the pressure activity and coordination of oesophageal muscle contractions and sphincter function [1]. - It provides **physiologic data** critical for identifying conditions like achalasia, diffuse oesophageal spasm, and ineffective oesophageal motility; high-resolution manometry specifically allows for the accurate classification of these abnormalities [1]. *Barium meal* - A barium meal provides **structural and morphological information** and can show gross motility abnormalities, but it does not quantitatively measure pressure or coordination of contractions [1]. - It is often used as a **screening tool** and can suggest motility disorders, but manometry is needed for definitive diagnosis [1]. *Endoscopy* - Endoscopy is primarily used to visualize the **mucosa** and lumen of the oesophagus, stomach, and duodenum to rule out structural abnormalities like strictures, masses, or inflammation [1, 5]. - While it can indirectly reveal some motility issues (e.g., retained food in achalasia), it does not directly assess the **functional contractile activity** of the oesophageal muscle [1]. *Radiography* - General radiography (X-rays) of the chest or abdomen is primarily used to evaluate **gross anatomical structures** or identify abnormalities like pneumomediastinum or foreign bodies [2]. - It has **limited utility** for evaluating specific oesophageal motility disorders, unlike specialized imaging with contrast (barium swallow) or functional studies (manometry) [1, 4].

Question 8: Consider the following statements : Systemic Inflammatory Response Syndrome is characterised by 1. Temperature either above 38°C or below 36°C. 2. Heart rate less than 80/minute. 3. Tachypnoea > 20/min. 4. Leucocyte count > 4 x 109/L. Which of the statements given above are correct ?

A. 1 and 3
B. 3, 4 and 1 (Correct Answer)
C. 1, 4, 3 and 2
D. 2, 4 and 3

Explanation: ***3, 4 and 1*** - **SIRS criteria** include a temperature above 38°C or below 36°C [1], and tachypnea with a respiratory rate greater than 20 breaths/minute. - Additionally, a white blood cell count greater than 12,000 cells/mm³ (12 x 10⁹/L) or less than 4,000 cells/mm³ (4 x 10⁹/L), or the presence of more than 10% immature band forms, are part of the criteria. *1 and 3* - This option correctly identifies **temperature** [1] and **tachypnea** as SIRS criteria but omits the leukocyte count, which is also a key component. - It is an incomplete set of correct criteria, missing one crucial element. *1, 4, 3 and 2* - This option incorrectly states a heart rate **less than 80/minute** as a SIRS criterion; the correct criterion for SIRS is a heart rate **greater than 90/minute**. - While it includes other correct criteria, the inclusion of an incorrect heart rate makes this option wrong. *2, 4 and 3* - This option incorrectly states a heart rate **less than 80/minute** as a SIRS criterion. The correct criterion for SIRS is a heart rate **greater than 90/minute**. - It also misses the **temperature** criterion, which is a fundamental component of SIRS [1].

Question 9: Consider the following statements: 1. The placenta is usually located in the upper uterine segment. 2. The placenta is usually located in the lower uterine segment. 3. The placenta is usually located in the fundus. 4. The placenta is usually located in the anterior uterine wall. Which one of the statements given above are correct ?

A. 1, 3 and 4
B. 1 and 3 only (Correct Answer)
C. 1, 2 and 3
D. 2 and 3 only

Explanation: ***1 and 3 only*** - The placenta typically implants in the **upper uterine segment** and often extends to the **fundus**, providing a robust blood supply and optimal conditions for fetal growth. - An implantation in the **upper uterine segment** or **fundus** ensures that as the uterus grows, the placenta moves away from the cervix, reducing the risk of placenta previa. *1, 3 and 4* - While the placenta can be located in the **anterior uterine wall**, this is not a universal characteristic as it can also be posterior, lateral, or even fundal. - The core locations for healthy placental implantation are the **upper uterine segment** and **fundus**, which are accurately captured in statements 1 and 3. *1, 2 and 3* - The statement that the placenta is usually located in the **lower uterine segment** (statement 2) is incorrect; this location is associated with **placenta previa**, a complication [1]. - Healthy placental implantation avoids the **lower uterine segment** to prevent issues during labour and delivery. *2 and 3 only* - This option incorrectly states that the placenta is usually located in the **lower uterine segment** (statement 2), which is generally considered abnormal. - While location in the **fundus** (statement 3) is correct, combining it with an incorrect primary location makes this option invalid.

Question 10: Which one of the following investigations is considered to be "Gold standard" technique for diagnosis of arterial occlusive disease ?

A. Duplex imaging
B. Doppler ultrasound blood flow detection
C. Treadmill
D. Digital Subtraction Angiography (DSA) (Correct Answer)

Explanation: ***Digital Subtraction Angiography (DSA)*** - **DSA** remains the gold standard for diagnosing arterial occlusive disease as it provides **high-resolution images** of the arterial lumen, accurately depicting stenoses and occlusions [1]. - It allows for precise localization and quantification of arterial lesions, which is crucial for treatment planning, especially for **interventional procedures** [1]. *Duplex imaging* - While useful for screening and follow-up, **duplex ultrasound** is operator-dependent and may not always provide the detailed anatomical information required for definitive diagnosis or pre-procedural planning, especially in complex cases. - It assesses blood flow and vessel patency but can be limited by factors such as patient body habitus, calcification, and bowel gas. *Doppler ultrasound blood flow detection* - **Doppler ultrasound** is an excellent tool for assessing blood flow characteristics and detecting changes indicative of arterial disease, but it provides less anatomical detail compared to angiography. - It is often used for **screening** and monitoring, but it does not offer the precise visualization of the arterial lumen needed to be a gold standard for diagnosis. *Treadmill* - A **treadmill test** (exercise stress test) is used to assess the functional impact of arterial occlusive disease, particularly **intermittent claudication**, by measuring the ankle-brachial index (ABI) after exertion. - It is a physiological test that indicates the presence and severity of flow-limiting lesions, but it does not provide anatomical information about the location or nature of the arterial occlusion.