UPSC-CMS 2016 — Internal Medicine
14 Previous Year Questions with Answers & Explanations
A patient has recurrent abdominal pain and jaundice. The blood investigations reveal reticulocytosis and hyperbilirubinemia. What is the clinical diagnosis?
The following conditions are associated with high incidence of pigment gallstones except:
The most common route of spread in a case of pyogenic liver abscess is:
The most common complication of pancreas divisum is:
At present, treatment is recommended for H. pylori in association with the following except:
Which of the following is not a clinical feature of tetanus?
The ideal temperature to store the whole blood in blood-bank is
Glasgow coma scale (GCS) score ranges between:
Consider the following statements: Haemophilia A (haemophilia) and Haemophilia B (christmas disease) 1. are variants of the same disease process 2. are due to congenital deficiency of factor VIII and factor IX respectively 3. both are sex linked characteristics and transmitted by asymptomatic females 4. can occur both in males and females Select the correct answer using the code given below:
Consider the following statements: Poor prognostic indicators in advanced germ cell tumours show 1. primary sites in mediastinum 2. non-pulmonary metastasis 3. lactate dehydrogenase more than 10 times of normal value Which of the statements given above are correct?
UPSC-CMS 2016 - Internal Medicine UPSC-CMS Practice Questions and MCQs
Question 1: A patient has recurrent abdominal pain and jaundice. The blood investigations reveal reticulocytosis and hyperbilirubinemia. What is the clinical diagnosis?
- A. Hereditary spherocytosis (Correct Answer)
- B. Mirizzi's syndrome
- C. Sclerosing cholangitis
- D. Choledochal cyst
Explanation: ***Hereditary spherocytosis*** - The combination of **recurrent abdominal pain**, **jaundice**, **reticulocytosis**, and **hyperbilirubinemia** is highly suggestive of hereditary spherocytosis, which causes chronic hemolytic anemia [1, 3]. - **Jaundice** and **abdominal pain** can result from pigment gallstones (due to chronic hemolysis) and splenic enlargement, both common in this condition [2, 3]. *Mirizzi's syndrome* - Characterized by **extrinsic compression of the common hepatic duct** by a stone impacted in the cystic duct or gallbladder neck. - While it causes jaundice and abdominal pain, it does not typically present with **reticulocytosis** or **hemolysis** [1]. *Sclerosing cholangitis* - A chronic cholestatic liver disease characterized by **inflammation and fibrosis** of the bile ducts. - While it causes jaundice and abdominal pain, it is not associated with **reticulocytosis** or signs of **hemolysis** [1]. *Choledochal cyst* - A **congenital dilation of the bile ducts**, leading to recurrent abdominal pain, jaundice, and a palpable mass. - It does not involve **hemolysis** or **reticulocytosis**, making it less likely in this context.
Question 2: The following conditions are associated with high incidence of pigment gallstones except:
- A. Prosthetic heart valve (Correct Answer)
- B. Cirrhosis
- C. Thalassemia
- D. Ileal disease
Explanation: The following conditions are associated with high incidence of pigment gallstones except: ***Prosthetic heart valve*** - A prosthetic heart valve is not directly associated with an increased incidence of **pigment gallstones**. Conditions leading to pigment gallstones typically involve **hemolysis** or biliary stasis/infection. - While complications like endocarditis or hemolysis can occur with prosthetic valves, they are not a primary driver of pigment gallstone formation. *Cirrhosis* - **Cirrhosis** is associated with an increased risk of pigment gallstones due to altered bile composition and bile stasis. - The impaired liver function in cirrhosis leads to increased **bilirubin excretion** and precipitation. *Thalassemia* - **Thalassemia** is a hematologic disorder characterized by **chronic hemolysis**, which leads to an overload of unconjugated bilirubin. - This excess bilirubin is then excreted into the bile, increasing the risk of forming **pigment gallstones** [1]. *Ileal disease* - **Ileal disease** (e.g., Crohn's disease affecting the ileum, ileal resection) is primarily associated with an increased risk of **cholesterol gallstones**, not pigment gallstones. - Damage to the ileum impairs bile salt reabsorption, leading to a decreased bile salt pool and supersaturation of cholesterol in the bile.
Question 3: The most common route of spread in a case of pyogenic liver abscess is:
- A. Hepatic artery
- B. Ascending infection through biliary duct
- C. Local spread
- D. Haematogenous through portal vein (Correct Answer)
Explanation: Haematogenous through portal vein - Pyogenic liver abscesses commonly result from bacterial translocation from the gut, reaching the liver via the portal venous system. - This route accounts for a significant proportion of cases, especially when associated with conditions like diverticulitis or appendicitis. *Hepatic artery* - While possible, spread via the hepatic artery is less common and usually seen in cases of septicemia or endocarditis. - It would imply a more generalized systemic infection rather than a localized abdominal source. *Ascending infection through biliary duct* - This mechanism is characteristic of cholangitis and often leads to multiple small abscesses or a subcapsular collection, not typically a solitary pyogenic liver abscess. - It occurs due to obstruction to biliary flow from stones or strictures. *Local spread* - Local spread can occur from adjacent infected organs like a subphrenic abscess or an infected gallbladder, but it is not the most common route for the initial development of a pyogenic liver abscess. - This typically results in direct extension into the liver parenchyma.
Question 4: The most common complication of pancreas divisum is:
- A. Obstructive jaundice
- B. Peptic ulcer
- C. Recurrent acute pancreatitis (Correct Answer)
- D. Duodenal obstruction
Explanation: ***Recurrent acute pancreatitis*** - **Pancreas divisum** is a congenital anomaly where the dorsal and ventral pancreatic ducts fail to fuse, leading to the **majority of pancreatic secretions draining through the smaller, narrower minor papilla**. - This anatomical variation can cause relative **obstruction to pancreatic exocrine flow**, particularly during periods of increased secretion, predisposing to **recurrent episodes of acute pancreatitis** [1]. *Obstructive jaundice* - **Obstructive jaundice** typically results from **biliary tract obstruction**, such as gallstones or tumors, affecting the common bile duct. - While pancreatic disease can cause jaundice, **pancreas divisum primarily affects the pancreatic duct system** and is not a common direct cause of biliary obstruction. *Peptic ulcer* - **Peptic ulcers** are lesions in the lining of the stomach or duodenum, usually caused by **_H. pylori_ infection** or **NSAID use**. - There is **no direct causal relationship** between pancreas divisum and the development of peptic ulcers. *Duodenal obstruction* - **Duodenal obstruction** can result from various causes such as **mass lesions (_e.g._, pancreatic head tumor), strictures, or malrotation**. - Pancreas divisum is an **anatomical variation of the pancreatic ducts**, and it does not directly cause mechanical obstruction of the duodenum itself.
Question 5: At present, treatment is recommended for H. pylori in association with the following except:
- A. Functional dyspepsia without alarm features (Correct Answer)
- B. MALT lymphoma
- C. Duodenal ulcer
- D. Peptic ulcer disease
Explanation: ***Functional dyspepsia without alarm features*** - While *H. pylori* eradication can be considered for some patients with **functional dyspepsia**, it is not universally recommended as a primary treatment given the **variable and often limited symptomatic improvement**. - The decision to treat in this specific scenario often depends on individual patient factors and local epidemiology, and it's not a standard indication compared to other *H. pylori*-associated conditions. *MALT lymphoma* - **Eradication of *H. pylori*** is a cornerstone of treatment for **gastric MALT lymphoma**, often leading to remission [1]. - This is a well-established indication for *H. pylori* therapy due to the direct pathogenic link [1]. *Duodenal ulcer* - All patients with **duodenal ulcers** who test positive for *H. pylori* should receive eradication therapy [2]. - *H. pylori* infection is a major cause of **duodenal ulcers**, and eradication significantly reduces recurrence [2]. *Peptic ulcer disease* - **Eradication of *H. pylori*** is strongly recommended for all patients with **peptic ulcer disease** (gastric or duodenal) found to be *H. pylori* positive [2]. - This intervention is crucial for **healing ulcers** and preventing future recurrences and complications [2].
Question 6: Which of the following is not a clinical feature of tetanus?
- A. Risus sardonicus
- B. Respiratory failure
- C. Loss of consciousness (Correct Answer)
- D. Opisthotonus
Explanation: ***Loss of consciousness*** - Tetanus is characterized by **spasms** and increased muscle tone, but patients typically remain **fully conscious** throughout the disease course. - The disease primarily affects the **motor neurons**, not the brain structures responsible for consciousness. *Risus sardonicus* - This is a characteristic feature of tetanus, referring to a **sustained, grotesque grin** caused by spasms of the facial muscles. - It is a classic clinical sign resulting from the **excitatory effects** of tetanospasmin on motor neurons [1]. *Respiratory failure* - This is a common and serious complication of tetanus, often leading to death, caused by **spasms of the respiratory muscles** [1]. - **Laryngeal spasms** and rigidity of the chest wall muscles impair breathing, necessitating mechanical ventilation. *Opisthotonus* - This refers to a severe, sustained **arching of the back** due to muscle spasms, causing the head and heels to bend backward. - It is a hallmark sign of generalized tetanus, reflecting profound **muscle rigidity** and uncontrolled muscle contractions [1].
Question 7: The ideal temperature to store the whole blood in blood-bank is
- A. -4°C
- B. 8°C
- C. 4°C (Correct Answer)
- D. 0°C
Explanation: ***4°C*** - Whole blood is typically stored at **1 to 6°C**, with **4°C** being the optimal compromise to preserve red blood cell viability and minimize bacterial growth [1]. - This temperature range allows for a standard storage duration of **21 to 42 days**, depending on the anticoagulant-preservative solution used [1]. *-4°C* - Temperatures below freezing point (**0°C**) would cause **hemolysis** due to ice crystal formation within the red blood cells, making the blood unsuitable for transfusion. - While frozen storage is used for specific blood components (e.g., cryopreserved red blood cells or plasma), it requires different protocols and cryoprotectants. *8°C* - Storing whole blood at **8°C** is above the recommended range and would significantly decrease the storage time due to increased metabolic activity and **bacterial proliferation**. - This temperature also leads to a faster decline in **red blood cell viability** and function. *0°C* - Storing whole blood at **0°C** is at the freezing point of water and close to the freezing point of blood, which can lead to initial **ice crystal formation** and subsequent hemolysis. - Although it's within the recommended 1-6°C range, maintaining exactly 0°C without fluctuations into freezing territory is challenging and poses a risk to blood quality [1].
Question 8: Glasgow coma scale (GCS) score ranges between:
- A. 1 and 15
- B. 2 and 15
- C. 3 and 15 (Correct Answer)
- D. 0 and 15
Explanation: **3 and 15** * The **Glasgow Coma Scale (GCS)** is a neurological scale that aims to give a reliable and objective way of recording the conscious state of a person [2]. * A score of **3 represents the lowest possible level of consciousness**, indicating a severe injury [1], while **15 represents full consciousness** [1]. * *1 and 15* * The GCS assesses three components: **eye opening, verbal response, and motor response** [2]. Each component has a minimum score of 1. * Therefore, a total score of 1 is not possible as the minimum score for any individual component is 1, and there are three components. * *2 and 15* * The lowest possible score for any single component in the GCS is 1 (e.g., no eye opening, no verbal response, no motor response). * With three components, the sum of the minimum scores (1+1+1) is 3, making a total score of 2 impossible. * *0 and 15* * The GCS is designed with a minimum score of 1 for each of its three categories. * A score of 0 is not used in the GCS scoring system; the lowest possible score for any component is 1, even in an unresponsive state.
Question 9: Consider the following statements: Haemophilia A (haemophilia) and Haemophilia B (christmas disease) 1. are variants of the same disease process 2. are due to congenital deficiency of factor VIII and factor IX respectively 3. both are sex linked characteristics and transmitted by asymptomatic females 4. can occur both in males and females Select the correct answer using the code given below:
- A. 1, 2 and 4
- B. 2 and 3 (Correct Answer)
- C. 2 only
- D. 3 only
Explanation: ***2 and 3*** - Hemophilia A is caused by a deficiency of **Factor VIII**, and Hemophilia B is caused by a deficiency of **Factor IX** [1]. These are distinct but clinically similar genetic disorders of the coagulation cascade. - Both hemophilia A and B are **X-linked recessive disorders**, meaning they predominantly affect males and are transmitted by asymptomatic female carriers [2]. *1, 2 and 4* - While both hemophilia A and B result in similar bleeding phenotypes, they are due to deficiencies in different **coagulation factors** (Factor VIII and Factor IX, respectively), making them distinct diseases, not variants of the same process [2]. - While hemophilia mainly affects males, a female can be affected if she inherits two affected X chromosomes (one from each parent) or has **Turner syndrome** (XO) with an affected X chromosome, but this is extremely rare. *2 only* - This option correctly identifies the specific factor deficiencies for Hemophilia A (**Factor VIII**) and Hemophilia B (**Factor IX**) [1]. - However, it omits the crucial aspect of their **sex-linked inheritance** and transmission by asymptomatic females, which is a fundamental characteristic of both conditions [2]. *3 only* - This option correctly states that both hemophilia A and B are **sex-linked characteristics** and are transmitted by **asymptomatic females** [2]. - However, it fails to mention the specific deficient factors (Factor VIII and Factor IX), which is key to understanding the underlying pathology of these two distinct disorders.
Question 10: Consider the following statements: Poor prognostic indicators in advanced germ cell tumours show 1. primary sites in mediastinum 2. non-pulmonary metastasis 3. lactate dehydrogenase more than 10 times of normal value Which of the statements given above are correct?
- A. 1 and 2 only
- B. 2 and 3 only
- C. 1, 2 and 3 (Correct Answer)
- D. 1 and 3 only
Explanation: ***1, 2 and 3*** - **All three statements** represent poor prognostic indicators in advanced germ cell tumors, as defined by the **International Germ Cell Cancer Collaborative Group (IGCCCG)** classification. - A primary site in the **mediastinum**, the presence of **non-pulmonary visceral metastases**, and **LDH levels >10 times the upper limit of normal** are all independent factors associated with a worse prognosis. *1 and 2 only* - This option is incorrect because it excludes a critically important poor prognostic indicator: **markedly elevated lactate dehydrogenase (LDH)**. - While mediastinal primary and non-pulmonary metastases are poor prognostic factors, high LDH further defines the **poor risk group**. [1] *2 and 3 only* - This option is incorrect as it omits the significance of a **mediastinal primary site** as a poor prognostic factor in advanced germ cell tumors. - **Mediastinal germ cell tumors** are known to have a worse prognosis compared to testicular primaries, even in the absence of other poor risk factors. *1 and 3 only* - This option is incorrect because it fails to include **non-pulmonary metastases** as a distinct poor prognostic factor for advanced germ cell tumors. - The presence of metastases to sites like the **liver, brain, or bone** significantly worsens the prognosis compared to lung-only metastases.