UPSC-CMS 2017 — Internal Medicine
8 Previous Year Questions with Answers & Explanations
A 60 year old man presents with painless progressive jaundice for two months. He has a history of weight loss. On examination, his gallbladder is palpable which is smooth, non‐tender and globular. His serum bilirubin is 18.2 mg/dL. He is most likely suffering from:
Which of the following is NOT true regarding ‘Renal Carbuncle’?
In endoscopic retrograde cholangiopancreatography endoscope used is:
Oliguria is defined as:
Which of the following is NOT a feature of Systemic Inflammatory Response Syndrome?
A 35 year old woman presented with a lump in her upper abdomen for two months which was slightly increasing. She also complained of early satiety. She gave a history of acute severe pain in upper abdomen for which she was admitted in hospital for 10 days, about three months ago. On examination, the mass was firm, smooth surfaced and not moving with respiration. She was most likely suffering from:
Which of the following is NOT a symptom of atherosclerotic occlusive disease at the bifurcation of aorta (Leriche syndrome)?
Fitz‐Hugh‐Curtis syndrome involving perihepatitis is present in the following:
UPSC-CMS 2017 - Internal Medicine UPSC-CMS Practice Questions and MCQs
Question 1: A 60 year old man presents with painless progressive jaundice for two months. He has a history of weight loss. On examination, his gallbladder is palpable which is smooth, non‐tender and globular. His serum bilirubin is 18.2 mg/dL. He is most likely suffering from:
- A. Carcinoma head of pancreas (Correct Answer)
- B. Carcinoma stomach
- C. Choledocholithiasis
- D. Klatskin tumour
Explanation: A 60 year old man presents with painless progressive jaundice for two months. He has a history of weight loss. On examination, his gallbladder is palpable which is smooth, non‐tender and globular. His serum bilirubin is 18.2 mg/dL. He is most likely suffering from: ***Carcinoma head of pancreas*** - The classic triad of **painless progressive jaundice**, **weight loss**, and a **palpable, non-tender gallbladder** (Courvoisier's sign) strongly indicates carcinoma of the head of the pancreas due to obstruction of the common bile duct [1]. - The high serum bilirubin value further supports a severe obstructive process, typical of a pancreatic head mass compressing the bile duct [1]. *Carcinoma stomach* - Carcinoma of the stomach typically presents with upper abdominal pain, dyspepsia, early satiety, and weight loss, but **jaundice is rare** unless there is extensive metastasis to the liver or porta hepatis. - It usually does not directly lead to **obstructive jaundice** with a palpable gallbladder, as the tumor's location is remote from the common bile duct. *Choledocholithiasis* - While choledocholithiasis can cause obstructive jaundice, it is often associated with **pain** (biliary colic) and fluctuating jaundice rather than the painless, progressive pattern described. - A gallbladder obstructed by a stone would typically be **tender** if inflamed, or decompressed if the obstruction is intermittent, rather than smooth and non-tender due to chronic distal obstruction. *Klatskin tumour* - A Klatskin tumor (hilar cholangiocarcinoma) causes obstructive jaundice, but it typically obstructs the bile ducts above the cystic duct insertion, meaning the **gallbladder would usually be decompressed and non-palpable** [2]. - These tumors often present with **jaundice and itching**, but the presence of a palpable gallbladder makes a pancreatic head mass more likely [2].
Question 2: Which of the following is NOT true regarding ‘Renal Carbuncle’?
- A. It occurs in diabetic patient
- B. It occurs in intravenous drug abusers
- C. It is a type of renal tuberculosis (Correct Answer)
- D. It is an abscess in renal parenchyma
Explanation: A **renal carbuncle** is essentially a **renal abscess** caused by bacterial infection, typically *Staphylococcus aureus* or *Escherichia coli*, not *Mycobacterium tuberculosis*. Renal tuberculosis manifests differently, often with **sterile pyuria** and granulomatous inflammation, and is not synonymous with a carbuncle. Patients with **diabetes mellitus** are at an increased risk of developing bacterial infections, including **renal carbuncles**, due to impaired immune function and glucose-rich urine. Poorly controlled diabetes is a significant **predisposing factor** for severe renal infections. **Intravenous drug users** are at higher risk of bloodstream infections, including **septic emboli** that can disseminate to the kidneys and form renal carbuncles. **Skin contaminants** and unsterile injection practices can introduce bacteria into the bloodstream that eventually localize in renal tissue. A **renal carbuncle** is defined as a focal collection of **pus** and necrotic tissue within the renal parenchyma, essentially a **renal abscess**. It results from the **hematogenous spread** of bacteria or, less commonly, from an ascending urinary tract infection [1].
Question 3: In endoscopic retrograde cholangiopancreatography endoscope used is:
- A. Side viewing (Correct Answer)
- B. End viewing
- C. Front viewing
- D. Rigid
Explanation: ***Side viewing*** - **Side-viewing endoscopes** are specifically designed for ERCP, allowing the endoscopist to visualize the **ampulla of Vater** en face for precise cannulation [1]. - The side-viewing optic facilitates the passage of accessories like **catheters, guidewires**, and **sphincterotomes** into the bile and pancreatic ducts [1]. *End viewing* - **End-viewing endoscopes** (like standard gastroscopes or colonoscopes) have the camera directly at the tip, providing a straight-ahead view. - This design makes cannulation of the **ampulla of Vater** challenging, as it would be viewed tangentially, not directly. *Front viewing* - This term is synonymous with **end-viewing** and describes the typical orientation of standard gastrointestinal endoscopes. - While suitable for examining the lumen of organs, it lacks the specialized optics needed for the complex angulation and cannulation required in **ERCP**. *Rigid* - **Rigid endoscopes** are generally used for procedures where flexibility is not required, such as laparoscopy or cystoscopy [2]. - They are unsuitable for **ERCP**, which requires a highly flexible instrument to navigate the esophagus, stomach, duodenum, and access the **ampulla of Vater**.
Question 4: Oliguria is defined as:
- A. Less than 400 ml of urine excreted in a day (Correct Answer)
- B. 600 ml to 700 ml of urine excreted in a day
- C. More than 900 ml of urine excreted in a day
- D. Absence of urine production
Explanation: ***Less than 400 ml of urine excreted in a day*** - **Oliguria** is medically defined as a daily urine output that is **less than 400 ml** in adults. [1] - This level of urine production is often insufficient to effectively excrete metabolic waste products. [1] *600 ml to 700 ml of urine excreted in a day* - This range of urine output is generally considered within the **normal limits**, not oliguric. - Normal daily urine production for an adult typically ranges from **800 to 2000 ml**. *More than 900 ml of urine excreted in a day* - An output of **more than 900 ml** per day for an adult indicates normal urine production, well above the threshold for oliguria. - This level suggests adequate kidney function in terms of fluid excretion. *Absence of urine production* - The complete absence of urine production is known as **anuria**, which is a more severe condition than oliguria. [1] - Anuria is typically defined as **less than 50 ml of urine** per day. [1]
Question 5: Which of the following is NOT a feature of Systemic Inflammatory Response Syndrome?
- A. Hypothermia (less than 36°C)
- B. Hyperthermia (more than 38°C)
- C. Bradycardia (Correct Answer)
- D. Leucocytosis
Explanation: ***Bradycardia*** - **Bradycardia** (a slow heart rate) is **not** a typical diagnostic criterion for **Systemic Inflammatory Response Syndrome (SIRS)**. - SIRS is usually associated with **tachycardia** (heart rate >90 beats/min) due to the body's increased metabolic demand and stress response [2]. *Hypothermia (less than 36°C)* - **Hypothermia** (<36°C) is a recognized diagnostic criterion for **SIRS**, indicating a dysregulated thermoregulatory response. - It often suggests a more severe or decompensated inflammatory state. *Hyperthermia (more than 38°C)* - **Hyperthermia** (>38°C) is a common and primary diagnostic criterion for **SIRS**, reflecting the body's inflammatory response to infection or injury [2], [3]. - This elevated core temperature is part of the systemic response to pathogens or tissue damage. *Leucocytosis* - **Leucocytosis** (white blood cell count >12,000 cells/mm³) is a key diagnostic criterion for **SIRS**, indicating a robust innate immune response [1], [2]. - A WBC count <4,000 cells/mm³ (leucopenia) or >10% immature neutrophils ("bands") also fulfills this criterion.
Question 6: A 35 year old woman presented with a lump in her upper abdomen for two months which was slightly increasing. She also complained of early satiety. She gave a history of acute severe pain in upper abdomen for which she was admitted in hospital for 10 days, about three months ago. On examination, the mass was firm, smooth surfaced and not moving with respiration. She was most likely suffering from:
- A. Pseudocyst pancreas (Correct Answer)
- B. Cancer colon
- C. Splenic cyst
- D. Cancer stomach
Explanation: Pseudocyst pancreas - The history of **acute severe upper abdominal pain** followed by a progressively enlarging, firm, smooth-surfaced upper abdominal mass points strongly towards a pancreatic pseudocyst, a common complication of **pancreatitis** [1]. - **Early satiety** can occur due to the mass effect of the pseudocyst compressing the stomach [1]. *Cancer colon* - A rapidly growing upper abdominal mass is **not a typical presentation** of colon cancer, which usually presents with changes in bowel habits, rectal bleeding, or weight loss. - Colon cancer does not typically cause a history of **acute, severe generalized abdominal pain** preceding mass formation in this manner. *Splenic cyst* - While a splenic cyst could present as an abdominal mass, it is **less likely to follow a history of acute severe abdominal pain** (unless trauma-related). - A history of acute pancreatitis is a strong indicator away from a splenic cyst as the primary diagnosis [1]. *Cancer stomach* - Gastric cancer can present with early satiety and an upper abdominal mass, but the specific history of **acute severe pain followed by a mass** is less characteristic of gastric cancer's typical insidious onset. - The "firm, smooth surfaced, not moving with respiration" description, especially in the context of prior pancreatitis, is more aligned with a **pancreatic pseudocyst** [1].
Question 7: Which of the following is NOT a symptom of atherosclerotic occlusive disease at the bifurcation of aorta (Leriche syndrome)?
- A. Claudication of the calf (Correct Answer)
- B. Sexual impotence
- C. Claudication of the buttock and thigh
- D. Gangrene localised to the feet
Explanation: ***Claudication of the calf*** - In Leriche syndrome, the occlusion is at the **aortic bifurcation**, affecting blood flow to the iliac arteries and their branches, typically presenting with **buttock and thigh claudication** [1]. - **Calf claudication** alone is usually indicative of more distal occlusive disease, such as in the popliteal or tibial arteries, and not typically the primary or most characteristic symptom of Leriche syndrome [1]. *Sexual impotence* - **Atherosclerotic occlusive disease** at the aortic bifurcation often reduces blood flow to the internal iliac arteries, which supply the penile arteries. - This results in **erectile dysfunction** due to insufficient blood supply during erection, making sexual impotence a characteristic symptom of Leriche syndrome. *Claudication of the buttock and thigh* - The partial or complete blockage of the **aortic bifurcation** impairs blood flow to both common iliac arteries, leading to ischemia in the major muscle groups of the buttocks and thighs [1]. - This **ischemia** manifests as pain, cramping, or fatigue during exercise, which is relieved by rest, making it a classic symptom of Leriche syndrome [1]. *Gangrene localised to the feet* - Severe and chronic **ischemia** resulting from significant atherosclerotic occlusion at the aortic bifurcation can lead to critical limb ischemia, especially in the lower extremities [1]. - Reduced blood flow to the feet can cause tissue necrosis, ultimately leading to **gangrene**, particularly in advanced stages of Leriche syndrome [1].
Question 8: Fitz‐Hugh‐Curtis syndrome involving perihepatitis is present in the following:
- A. Syphilis
- B. Tuberculosis
- C. Moniliasis
- D. Gonorrhoea (Correct Answer)
Explanation: **Gonorrhoea** - **Fitz-Hugh-Curtis syndrome** is a complication of **pelvic inflammatory disease (PID)**, which is predominantly caused by sexually transmitted infections like *Neisseria gonorrhoeae* and *Chlamydia trachomatis*. - Perihepatitis, or inflammation of the liver capsule, occurs when bacteria from the pelvic infection spread to the liver surface. *Syphilis* - **Syphilis** primarily presents with chancres, rashes, and neurological or cardiovascular complications in later stages. - It does not typically cause **perihepatitis** as a direct complication of the infection itself. *Tuberculosis* - **Tuberculosis** is caused by *Mycobacterium tuberculosis* and usually affects the lungs, but can spread to other organs. - While it can cause peritonitis, it is not associated with **perihepatitis** in the context of **Fitz-Hugh-Curtis syndrome**. *Moniliasis* - **Moniliasis** (candidiasis) is a fungal infection caused by *Candida* species. - It is commonly associated with vaginal yeast infections or thrush but does not cause **Fitz-Hugh-Curtis syndrome** or perihepatitis.