UPSC-CMS 2013 — Internal Medicine

Q: Factors important in the formation of gall stones include all of the following except :

Gall bladder motility. ***Gall bladder motility*** - While factors like gallbladder **stasis** or **hypomotility** can *contribute* to gallstone formation by allowing bile to concentrate, normal gallbladder motility itself does not directly form stones. - Efficient gallbladder emptying helps prevent the supersaturation and precipitation of cholesterol and bilirubin that lead to stone formation [2]. *Obesity* - Obesity increases the **hepatic secretion of cholesterol**, leading to more cholesterol in the bile [1]. - This increased cholesterol can lead to **supersaturation** of bile, making it prone to forming cholesterol gallstones. *Cholesterol saturation in bile* - When bile contains more cholesterol than can be kept in solution by bile salts and phospholipids, it becomes **supersaturated** [3]. - This supersaturation is a primary driver for the **precipitation of cholesterol crystals**, which aggregate to form gallstones [1]. *The size of micelles* - Micelles are small aggregates of bile salts and phospholipids that solubilize cholesterol in bile [3]. - If the **micelle size is insufficient** or their number is reduced, they cannot adequately solubilize the cholesterol, leading to its precipitation and stone formation [3]. [Practice more Internal Medicine PYQs on OnCourse]

Q: The complications of ascaris lumbricoides infestation include all of the following except :

peptic ulcer disease. ***Peptic ulcer disease*** - **Peptic ulcer disease** is not a commonly recognized direct complication of *Ascaris lumbricoides* infestation. - While *Ascaris* can cause gastrointestinal symptoms, it does not typically lead to the formation of peptic ulcers. *Lower gastrointestinal bleed* - Heavy worm burdens can cause irritation and inflammation of the intestinal lining, potentially leading to **mucosal erosions** and **lower gastrointestinal bleeding**. - In rare cases, worms might erode into blood vessels, contributing to bleeding. *Cholangitis and obstructive jaundice* - Adult worms can migrate from the small intestine into the **biliary tree**, obstructing bile flow and causing **cholangitis** or **obstructive jaundice**. - They can also enter the pancreatic duct, leading to **pancreatitis**. *Acute intestinal obstruction* - A large bolus of adult worms can form a tangled mass (bolus) within the small intestine, leading to **complete or partial acute intestinal obstruction**. - This is a serious surgical emergency, especially in children with heavy worm loads. [Practice more Internal Medicine PYQs on OnCourse]

Q: Deep vein thrombosis of calf is best managed by :

anticoagulants. ***Anticoagulants*** - **Anticoagulation** therapy is the cornerstone of DVT management, preventing clot extension and reducing the risk of **pulmonary embolism** [1]. - Medications like **heparin**, **low molecular weight heparin**, or **direct oral anticoagulants (DOACs)** are commonly used [1]. *active physiotherapy* - While physical activity can prevent DVT, it is generally **contraindicated in acute DVT** due to the risk of dislodging the clot. - Mobilization is introduced gradually once anticoagulation is therapeutic and the risk of **embolization** is reduced. *thrombolysis* - **Thrombolysis** (clot dissolution) is usually reserved for **proximal, extensive DVT** [1] or DVT with **limb-threatening ischemia** [2]. - It carries a **higher risk of bleeding** compared to anticoagulation and is not typically necessary for isolated calf DVT [2]. *surgical venous thrombectomy* - **Surgical thrombectomy** is rarely performed for DVT and is generally reserved for **massive iliocaval thrombosis** with severe limb threat. - It is an **invasive procedure** with significant risks and is not indicated for typical calf DVT. [Practice more Internal Medicine PYQs on OnCourse]

Q: To differentiate pancreatic ascites from ascites secondary to cirrhosis of the liver, the most important test is :

Abdominal paracentesis. ***Abdominal paracentesis*** - This procedure involves analyzing the **ascitic fluid**, which is crucial for distinguishing between pancreatic ascites and cirrhosis-related ascites [1]. - In **pancreatic ascites**, the fluid will have a very high **amylase** content and often a high protein level (>2.5 g/dL), whereas in **cirrhosis**, the amylase is typically normal and the protein is usually low (<2.5 g/dL) [1]. *Abdominal ultrasound* - While useful for detecting ascites and underlying liver disease (cirrhosis), it cannot definitively determine the **cause of ascites** or the specific content of the ascitic fluid [2]. - Ultrasound can visualize the pancreas but cannot reliably differentiate pancreatic ascites from other causes without **fluid analysis**. *Endoscopic retrograde cholangiopancreatography (ERCP)* - This is an **invasive procedure** primarily used for diagnosing and treating disorders of the bile ducts and pancreatic duct, such as strictures or stones. - It is not the most important or initial test for differentiating the cause of ascites, as its main role is in identifying **ductal leaks** that might lead to pancreatic ascites, rather than direct fluid analysis. *Computed tomogram (CT) scan* - CT can confirm the presence of ascites, evaluate the **pancreas** for inflammation or pseudocysts, and assess the **liver** for signs of cirrhosis [2]. - However, like ultrasound, a CT scan cannot provide the definitive **biochemical analysis** of the ascitic fluid that is necessary to distinguish pancreatic ascites from other causes. [Practice more Internal Medicine PYQs on OnCourse]

Q: Primary hyper-aldosteronism presents with all of the following except :

Hyperkalemia. ***Hyperkalemia*** - Primary hyperaldosteronism is characterized by **excessive aldosterone secretion**, which promotes sodium reabsorption and potassium excretion in the renal tubules [1]. - Therefore, patients typically present with **hypokalemia**, not hyperkalemia, due to increased urinary potassium loss [1]. *Hypertension* - **Elevated aldosterone** leads to increased **sodium reabsorption** and water retention, resulting in expanded extracellular fluid volume and **hypertension** [2]. - This is a hallmark clinical feature of primary hyperaldosteronism, often severe and resistant to conventional therapy. *Frontal headache* - **Hypertension**, a common manifestation of primary hyperaldosteronism, can cause various symptoms, including **headaches**, which can be frontal. - While not specific to hyperaldosteronism, it is a frequent symptom secondary to the elevated blood pressure. *Periodic paralysis* - **Severe hypokalemia**, a characteristic feature of primary hyperaldosteronism, can lead to muscle weakness and **periodic paralysis** [3]. - This occurs because potassium is essential for normal muscle function, and its depletion impairs nerve and muscle excitability [3]. [Practice more Internal Medicine PYQs on OnCourse]

8 Previous Year Questions with Answers & Explanations

Questions

All Subjects Anatomy (4)Community Medicine (23)Forensic Medicine (1)Internal Medicine (8)Microbiology (1)Obstetrics and Gynecology (31)Ophthalmology (1)Orthopaedics (3)Pathology (3)Pediatrics (2)Pharmacology (7)Physiology (5)Psychiatry (1)Radiology (1)Surgery (17)

Factors important in the formation of gall stones include all of the following except :

The complications of ascaris lumbricoides infestation include all of the following except :

Deep vein thrombosis of calf is best managed by :

To differentiate pancreatic ascites from ascites secondary to cirrhosis of the liver, the most important test is :

Primary hyper-aldosteronism presents with all of the following except :

Consider following statements in respect of parenteral nutrition : 1. indicated in patients when enteral nutrition cannot be given 2. parenteral route is a better choice than enteral route 3. abnormalities of liver functions can occur on prolonged use 4. hyperglycemia is common Which of the above statements are correct ?

Carcinoma of pyriform fossa usually presents with :

Dehydration is not a feature of one of the following diseases :

UPSC-CMS 2013 - Internal Medicine UPSC-CMS Practice Questions and MCQs

Question 1: Factors important in the formation of gall stones include all of the following except :

A. Obesity
B. The size of micelles
C. Cholesterol saturation in bile
D. Gall bladder motility (Correct Answer)

Explanation: ***Gall bladder motility*** - While factors like gallbladder **stasis** or **hypomotility** can *contribute* to gallstone formation by allowing bile to concentrate, normal gallbladder motility itself does not directly form stones. - Efficient gallbladder emptying helps prevent the supersaturation and precipitation of cholesterol and bilirubin that lead to stone formation [2]. *Obesity* - Obesity increases the **hepatic secretion of cholesterol**, leading to more cholesterol in the bile [1]. - This increased cholesterol can lead to **supersaturation** of bile, making it prone to forming cholesterol gallstones. *Cholesterol saturation in bile* - When bile contains more cholesterol than can be kept in solution by bile salts and phospholipids, it becomes **supersaturated** [3]. - This supersaturation is a primary driver for the **precipitation of cholesterol crystals**, which aggregate to form gallstones [1]. *The size of micelles* - Micelles are small aggregates of bile salts and phospholipids that solubilize cholesterol in bile [3]. - If the **micelle size is insufficient** or their number is reduced, they cannot adequately solubilize the cholesterol, leading to its precipitation and stone formation [3].

Question 2: The complications of ascaris lumbricoides infestation include all of the following except :

A. lower gastro intestinal bleed
B. cholangitis and obstructive jaundice
C. peptic ulcer disease (Correct Answer)
D. acute intestinal obstruction

Explanation: ***Peptic ulcer disease*** - **Peptic ulcer disease** is not a commonly recognized direct complication of *Ascaris lumbricoides* infestation. - While *Ascaris* can cause gastrointestinal symptoms, it does not typically lead to the formation of peptic ulcers. *Lower gastrointestinal bleed* - Heavy worm burdens can cause irritation and inflammation of the intestinal lining, potentially leading to **mucosal erosions** and **lower gastrointestinal bleeding**. - In rare cases, worms might erode into blood vessels, contributing to bleeding. *Cholangitis and obstructive jaundice* - Adult worms can migrate from the small intestine into the **biliary tree**, obstructing bile flow and causing **cholangitis** or **obstructive jaundice**. - They can also enter the pancreatic duct, leading to **pancreatitis**. *Acute intestinal obstruction* - A large bolus of adult worms can form a tangled mass (bolus) within the small intestine, leading to **complete or partial acute intestinal obstruction**. - This is a serious surgical emergency, especially in children with heavy worm loads.

Question 3: Deep vein thrombosis of calf is best managed by :

A. active physiotherapy
B. anticoagulants (Correct Answer)
C. thrombolysis
D. surgical venous thrombectomy

Explanation: ***Anticoagulants*** - **Anticoagulation** therapy is the cornerstone of DVT management, preventing clot extension and reducing the risk of **pulmonary embolism** [1]. - Medications like **heparin**, **low molecular weight heparin**, or **direct oral anticoagulants (DOACs)** are commonly used [1]. *active physiotherapy* - While physical activity can prevent DVT, it is generally **contraindicated in acute DVT** due to the risk of dislodging the clot. - Mobilization is introduced gradually once anticoagulation is therapeutic and the risk of **embolization** is reduced. *thrombolysis* - **Thrombolysis** (clot dissolution) is usually reserved for **proximal, extensive DVT** [1] or DVT with **limb-threatening ischemia** [2]. - It carries a **higher risk of bleeding** compared to anticoagulation and is not typically necessary for isolated calf DVT [2]. *surgical venous thrombectomy* - **Surgical thrombectomy** is rarely performed for DVT and is generally reserved for **massive iliocaval thrombosis** with severe limb threat. - It is an **invasive procedure** with significant risks and is not indicated for typical calf DVT.

Question 4: To differentiate pancreatic ascites from ascites secondary to cirrhosis of the liver, the most important test is :

A. Abdominal ultrasound
B. Endoscopic retrograde cholangio pancreatography (ERCP)
C. Computed tomogram (CT) scan
D. Abdominal paracentesis (Correct Answer)

Explanation: ***Abdominal paracentesis*** - This procedure involves analyzing the **ascitic fluid**, which is crucial for distinguishing between pancreatic ascites and cirrhosis-related ascites [1]. - In **pancreatic ascites**, the fluid will have a very high **amylase** content and often a high protein level (>2.5 g/dL), whereas in **cirrhosis**, the amylase is typically normal and the protein is usually low (<2.5 g/dL) [1]. *Abdominal ultrasound* - While useful for detecting ascites and underlying liver disease (cirrhosis), it cannot definitively determine the **cause of ascites** or the specific content of the ascitic fluid [2]. - Ultrasound can visualize the pancreas but cannot reliably differentiate pancreatic ascites from other causes without **fluid analysis**. *Endoscopic retrograde cholangiopancreatography (ERCP)* - This is an **invasive procedure** primarily used for diagnosing and treating disorders of the bile ducts and pancreatic duct, such as strictures or stones. - It is not the most important or initial test for differentiating the cause of ascites, as its main role is in identifying **ductal leaks** that might lead to pancreatic ascites, rather than direct fluid analysis. *Computed tomogram (CT) scan* - CT can confirm the presence of ascites, evaluate the **pancreas** for inflammation or pseudocysts, and assess the **liver** for signs of cirrhosis [2]. - However, like ultrasound, a CT scan cannot provide the definitive **biochemical analysis** of the ascitic fluid that is necessary to distinguish pancreatic ascites from other causes.

Question 5: Primary hyper-aldosteronism presents with all of the following except :

A. Hyperkalemia (Correct Answer)
B. Hypertension
C. Frontal headache
D. Periodic paralysis

Explanation: ***Hyperkalemia*** - Primary hyperaldosteronism is characterized by **excessive aldosterone secretion**, which promotes sodium reabsorption and potassium excretion in the renal tubules [1]. - Therefore, patients typically present with **hypokalemia**, not hyperkalemia, due to increased urinary potassium loss [1]. *Hypertension* - **Elevated aldosterone** leads to increased **sodium reabsorption** and water retention, resulting in expanded extracellular fluid volume and **hypertension** [2]. - This is a hallmark clinical feature of primary hyperaldosteronism, often severe and resistant to conventional therapy. *Frontal headache* - **Hypertension**, a common manifestation of primary hyperaldosteronism, can cause various symptoms, including **headaches**, which can be frontal. - While not specific to hyperaldosteronism, it is a frequent symptom secondary to the elevated blood pressure. *Periodic paralysis* - **Severe hypokalemia**, a characteristic feature of primary hyperaldosteronism, can lead to muscle weakness and **periodic paralysis** [3]. - This occurs because potassium is essential for normal muscle function, and its depletion impairs nerve and muscle excitability [3].

Question 6: Consider following statements in respect of parenteral nutrition : 1. indicated in patients when enteral nutrition cannot be given 2. parenteral route is a better choice than enteral route 3. abnormalities of liver functions can occur on prolonged use 4. hyperglycemia is common Which of the above statements are correct ?

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

Explanation: ***1, 3 and 4 only*** - **Parenteral nutrition (PN)** is used when the gastrointestinal tract is non-functional or inaccessible, making **enteral nutrition (EN)** impossible or inadequate. - **Hyperglycemia** is a common complication due to the high glucose content in PN solutions, and **liver function abnormalities** (e.g., cholestasis, steatosis) can develop with prolonged use. *2, 3 and 4 only* - This option incorrectly states that the parenteral route is better than the enteral route. **Enteral nutrition** is generally preferred due to being more physiological, safer, and less expensive [1]. - While hyperglycemia and liver dysfunction are correct complications, the assertion about the superiority of the parenteral route is false. *1, 2 and 3 only* - This option incorrectly claims that **parenteral nutrition** is a better choice than the enteral route (statement 2). **Enteral nutrition** is always the preferred route if the gut works [1]. - It also omits **hyperglycemia**, which is a frequent and significant complication of parenteral nutrition. *1, 2, 3 and 4* - This option incorrectly includes statement 2, which suggests the parenteral route is superior to the enteral route. **Enteral nutrition** is always preferred when feasible [1]. - While statements 1, 3, and 4 are correct, the inclusion of statement 2 makes this option incorrect.

Question 7: Carcinoma of pyriform fossa usually presents with :

A. Lump in the neck
B. Cough
C. Dysphagia (Correct Answer)
D. Hoarseness

Explanation: ***Dysphagia*** - Carcinoma of the **pyriform fossa** is a type of hypopharyngeal cancer, and given its anatomical location, it commonly interferes with swallowing [1]. - The pyriform fossa lies immediately lateral to the laryngeal inlet, and involvement here directly impacts the ability to form a **food bolus** and propel it into the esophagus. *Lump in the neck* - A neck lump can occur, especially if there is **lymph node metastasis**, but it's often a later symptom [1]. - **Dysphagia** usually precedes the development of a palpable neck mass as the primary tumor expands within the pyriform fossa [1]. *Cough* - While aspiration might lead to coughing, it's not the primary presenting symptom. - Cough is more commonly associated with laryngeal involvement or **tracheal invasion**, which can occur with advanced disease. *Hoarseness* - **Hoarseness** is a prominent symptom if the **vocal cords** or recurrent laryngeal nerve are directly involved [2]. - The pyriform fossa is adjacent but distinct from the vocal cords, so hoarseness is not typically the initial or most common symptom unless the tumor extends medially.

Question 8: Dehydration is not a feature of one of the following diseases :

A. Cerebral malaria (Correct Answer)
B. MDR-TB
C. Pertussis
D. Cholera

Explanation: ***Cerebral malaria*** - This condition is characterized by neurological symptoms, including **impaired consciousness** and **seizures**, resulting from parasitic infection of the brain. - While patients may have fever and fluid loss from sweating, severe **dehydration is not a primary or defining feature** compared to other diseases listed. *MDR-TB* - Patients with **multidrug-resistant tuberculosis (MDR-TB)** often experience constitutional symptoms such as fever, night sweats, and significant anorexia. - These symptoms can lead to **severe weight loss** and **malnutrition**, contributing to chronic dehydration in advanced stages. *Pertussis* - **Pertussis**, or **whooping cough**, is characterized by severe paroxysmal coughing fits accompanied by inspiratory "whoops" and post-tussive vomiting. - The recurrent vomiting, especially in infants and young children, can quickly lead to **significant fluid loss** and **dehydration**. *Cholera* - **Cholera** is an acute diarrheal illness caused by *Vibrio cholerae*, leading to profuse, watery diarrhea and vomiting [1]. - The rapid and severe fluid loss in cholera can cause **life-threatening dehydration** and electrolyte imbalances within hours if untreated [1].