UPSC-CMS 2020 — Internal Medicine
13 Previous Year Questions with Answers & Explanations
A 22-year female has presented with a history of malaise, cough, alternating constipation and diarrhoea with intermittent abdominal pain for last 6 months. She also complains of abdominal distension for last 2 days. On examination her abdomen has a doughy feel along with an ill defined mass over the right lower quadrant. She is most likely suffering from:
Consider the following statements regarding claudication: 1. It is a marker for silent coronary disease 2. Structured exercise program ( 2 hours per week for 3 months) leads to improvement in symptoms 3. Diabetes mellitus increases the risk and severity of claudication 4. Beta blockers may exacerbate claudication Which of the above statements are correct?
Medical management of thyrotoxic crisis includes all of the following EXCEPT:
First line hormone therapy for post-menopausal woman with metastatic carcinoma breast is:
The Child-Turcotte-Pugh (CTP) score for quantifying the severity of chronic liver disease includes all variables EXCEPT:
Which one of the following statements is NOT correct regarding Pyogenic Liver Abscess?
Which of the following are correct regarding splenic artery aneurysm? 1. Main arterial trunk is the common site 2. Palpable thrill can be felt 3. It is symptomless unless it ruptures Select the correct answer using the code given below:
Spontaneous bacterial peritonitis occurs due to:
Which one of the following is NOT a complication of massive blood transfusion?
Which one of the following is NOT correct regarding MEN-1 syndrome?
UPSC-CMS 2020 - Internal Medicine UPSC-CMS Practice Questions and MCQs
Question 1: A 22-year female has presented with a history of malaise, cough, alternating constipation and diarrhoea with intermittent abdominal pain for last 6 months. She also complains of abdominal distension for last 2 days. On examination her abdomen has a doughy feel along with an ill defined mass over the right lower quadrant. She is most likely suffering from:
- A. Ileocaecal tuberculosis (Correct Answer)
- B. Ovarian mass
- C. Appendicular lump
- D. Carcinoma caecum
Explanation: ***Ileocaecal tuberculosis*** - The combination of **constitutional symptoms** (malaise, cough), chronic gastrointestinal complaints (alternating constipation/diarrhea, abdominal pain), a **doughy abdomen**, and an **ill-defined right lower quadrant mass** is highly characteristic of ileocecal tuberculosis. - This presentation suggests chronic inflammation and potential **mass formation** in the ileocecal region, which is the most common site for intestinal tuberculosis. *Ovarian mass* - While an ovarian mass can cause abdominal distension and pain, it typically does not present with a **doughy feel** or the specific long-standing cough and alternating bowel habits described. - A definitive ovarian mass would usually be palpable as a more distinct, often mobile, pelvic mass rather than an ill-defined right lower quadrant mass that is sometimes seen with ileocecal tuberculosis. *Appendicular lump* - An appendicular lump is usually associated with **acute appendicitis** that has localized, leading to a firm, tender mass. - The patient's chronic symptoms over 6 months, fluctuating bowel habits, and doughy feel are not typical for an appendicular lump which is generally an acute or subacute process. *Carcinoma caecum* - Carcinoma of the caecum can present with an abdominal mass, changes in bowel habits, and abdominal pain. - However, the **doughy feel** and the presence of significant constitutional symptoms like persistent cough are less typical for early-stage caecal carcinoma and point more towards a chronic inflammatory or infectious process like tuberculosis.
Question 2: Consider the following statements regarding claudication: 1. It is a marker for silent coronary disease 2. Structured exercise program ( 2 hours per week for 3 months) leads to improvement in symptoms 3. Diabetes mellitus increases the risk and severity of claudication 4. Beta blockers may exacerbate claudication Which of the above statements are correct?
- A. 1, 3 and 4 only
- B. 1, 2, 3 and 4 (Correct Answer)
- C. 1 and 2 only
- D. 2, 3 and 4 only
Explanation: ***1, 2, 3 and 4*** - All four statements are correct regarding **claudication**, a symptom of **peripheral arterial disease (PAD)**, where reduced blood flow to the limbs causes pain during exercise [1]. - **Claudication** is a significant marker for systemic **atherosclerosis** and **coronary artery disease**, increasing the risk of cardiovascular events, and **structured exercise programs** are a cornerstone of treatment [1]. *1, 3 and 4 only* - This option is incorrect because it omits statement 2. **Structured exercise programs** are unequivocally beneficial in improving claudication symptoms and functional capacity. - Omitting the beneficial effect of exercise contradicts current clinical guidelines for managing **PAD**. *1 and 2 only* - This option is incorrect as it fails to include statements 3 and 4. **Diabetes mellitus** is a major risk factor that significantly worsens PAD and claudication, while **beta-blockers** can indeed exacerbate symptoms in some patients due to their vasoconstrictive effects. - Ignoring the impact of **diabetes** and the potential adverse effects of **beta-blockers** provides an incomplete understanding of claudication management. *2, 3 and 4 only* - This option is incorrect because it excludes statement 1. **Claudication** is a strong indicator of widespread **atherosclerosis** and thus a marker for **silent coronary disease**, warranting investigation for broader cardiovascular risk [1]. - Failing to recognize claudication as a marker for **coronary disease** overlooks a critical aspect of its clinical significance and patient management.
Question 3: Medical management of thyrotoxic crisis includes all of the following EXCEPT:
- A. IV propanolol
- B. IV antibiotics (Correct Answer)
- C. IV hydrocortisone
- D. IV fluids
Explanation: ***IV antibiotics*** - **Antibiotics** are not a primary treatment for **thyrotoxic crisis** itself unless there's an underlying infection triggering the crisis, which is not indicated as a universal management step [1]. - The crisis is caused by an acute exacerbation of **hyperthyroidism**, not bacterial infection, so antibiotics would not address the core pathophysiology. *IV propanolol* - **Propranolol** (or other beta-blockers) helps control the adrenergic symptoms of thyrotoxic crisis, such as **tachycardia**, **tremors**, and **anxiety** [1]. - It also inhibits the peripheral conversion of **T4 to T3**, providing an additional therapeutic effect. *IV hydrocortisone* - **Glucocorticoids** like **hydrocortisone** are crucial in thyrotoxic crisis to inhibit the peripheral conversion of **T4 to T3**, stabilize cell membranes, and provide adrenal support. - They also help manage potential adrenal insufficiency, which can be an exacerbating factor or complication. *IV fluids* - **Intravenous fluids** are essential for correcting **dehydration**, which is often present due to increased metabolic rate, fever, sweating, and vomiting in patients with thyrotoxic crisis [1]. - They also help address **electrolyte imbalances** and support cardiovascular stability.
Question 4: First line hormone therapy for post-menopausal woman with metastatic carcinoma breast is:
- A. Ovarian suppression by surgery
- B. Antiprogestins
- C. Tamoxifen
- D. Anastrazole (Correct Answer)
Explanation: ***Anastrazole*** - **Aromatase inhibitors** like anastrozole are the preferred first-line hormone therapy for **post-menopausal women** with **hormone-receptor-positive metastatic breast cancer**. - They work by **blocking the aromatase enzyme**, which is responsible for estrogen production in peripheral tissues in post-menopausal women. *Ovarian suppression by surgery* - Ovarian suppression is primarily used in **pre-menopausal women** to reduce estrogen production by the ovaries. - Since the patient is **post-menopausal**, her ovaries are no longer the primary source of estrogen production. *Antiprogestins* - **Antiprogestins** are not standard first-line hormone therapy for metastatic breast cancer. - While some progestational agents have been used in breast cancer treatment, **antiprogestins** are not established as a primary treatment. *Tamoxifen* - **Tamoxifen** is a **selective estrogen receptor modulator (SERM)** that has been widely used in breast cancer treatment. - While effective, **aromatase inhibitors** are generally preferred over tamoxifen as first-line therapy for **post-menopausal metastatic breast cancer** due to superior efficacy and tolerability profiles in this demographic.
Question 5: The Child-Turcotte-Pugh (CTP) score for quantifying the severity of chronic liver disease includes all variables EXCEPT:
- A. INR (International Normalised Ratio)
- B. Serum creatinine (Correct Answer)
- C. Serum bilirubin
- D. Serum albumin
Explanation: ***Body Mass Index (BMI)*** - The Child-Turcotte-Pugh (CTP) score is an established clinical tool for assessing prognosis in **chronic liver disease**, and it does not include **Body Mass Index (BMI)** as one of its parameters. - The CTP score focuses on liver function and complications of portal hypertension, which are reflected by specific laboratory values and clinical signs, not nutritional status as measured by BMI [1]. *International Normalized Ratio (INR)* - **INR** is a crucial component of the Child-Turcotte-Pugh (CTP) score, as it reflects the liver's synthetic function, specifically its ability to produce clotting factors [1]. - An elevated INR indicates **impaired liver synthetic function** and contributes to a higher CTP score, signifying more severe liver disease. *Serum bilirubin* - **Serum bilirubin** is a key laboratory parameter included in the Child-Turcotte-Pugh (CTP) score [1]. - Elevated bilirubin levels indicate **impaired liver excretory function** and hepatocellular damage, directly correlating with the severity of liver disease. *Serum albumin* - **Serum albumin** is a vital component of the Child-Turcotte-Pugh (CTP) score, reflecting the liver's synthetic capacity [1]. - Low serum albumin levels indicate **reduced liver synthesis**, often seen in advanced liver disease, and contribute to a higher CTP score [1].
Question 6: Which one of the following statements is NOT correct regarding Pyogenic Liver Abscess?
- A. It is more common in elderly, diabetics and immunocompromised patients
- B. Treatment is with oral antibiotics alone (Correct Answer)
- C. Streptococcus milleri and escherichia coli are the most common causative organisms
- D. Anorexia, fever, malaise and right upper quadrant abdominal discomfort are the most common presenting features
Explanation: ***Treatment is with oral antibiotics alone*** - This statement is incorrect because pyogenic liver abscesses typically require **drainage** (percutaneous or surgical) in addition to **intravenous antibiotics** initially. Oral antibiotics alone are generally insufficient for definitive treatment. - The goal is to eradicate the infection, which often involves both source control (drainage) and systemic antimicrobial therapy. *It is more common in elderly, diabetics and immunocompromised patients* - This statement is correct. Factors such as **age**, **diabetes mellitus**, and **immunocompromised states** weaken the immune response, making individuals more susceptible to developing pyogenic liver abscesses [1]. - These conditions can impair the body's ability to clear bacteria effectively, increasing the risk of infection and abscess formation. *Streptococcus milleri and escherichia coli are the most common causative organisms* - This statement is correct. **_Streptococcus milleri_ (now _Streptococcus anginosus_)** is frequently implicated due to its ability to form abscesses, while **_Escherichia coli_** is common because many liver abscesses arise from biliary or enteric sources. - Other common pathogens include other **Gram-negative bacilli** and **anaerobes**, reflecting the varied etiologies. *Anorexia, fever, malaise and right upper quadrant abdominal discomfort are the most common presenting features* - This statement is correct. These are classic symptoms of liver abscess, reflecting the inflammatory process and the location of the infection [1]. - **Fever** and **right upper quadrant pain** are particularly prominent and should raise suspicion for a liver abscess [1].
Question 7: Which of the following are correct regarding splenic artery aneurysm? 1. Main arterial trunk is the common site 2. Palpable thrill can be felt 3. It is symptomless unless it ruptures Select the correct answer using the code given below:
- A. 2 and 3 only
- B. 1 and 2 only
- C. 1, 2 and 3
- D. 1 and 3 only (Correct Answer)
Explanation: ***1 and 3 only*** - The **main arterial trunk** is indeed the most common site for splenic artery aneurysms, accounting for approximately 60% of cases. - Splenic artery aneurysms are typically **asymptomatic** until rupture, which can be a life-threatening event. *1, 2 and 3* - While the main arterial trunk is a common site and these aneurysms are often symptomless until rupture, a **palpable thrill** is generally not a feature of splenic artery aneurysms. - Thrills are usually associated with **arteriovenous fistulas** or very large, superficial aneurysms with turbulent flow, which is less common for the splenic artery. *2 and 3 only* - A **palpable thrill** is not a typical finding for splenic artery aneurysms. - While they are often symptomless until rupture, the statement that the **main arterial trunk is a common site** is also correct and should be included. *1 and 2 only* - Although the main arterial trunk is a common site, a **palpable thrill** is not a characteristic sign of splenic artery aneurysms. - The crucial point that they are **symptomless unless they rupture** is omitted from this option.
Question 8: Spontaneous bacterial peritonitis occurs due to:
- A. duodenal stump blowout
- B. infection via fallopian tubes
- C. acute bacterial infection of ascites (Correct Answer)
- D. peptic ulcer perforation
Explanation: ***acute bacterial infection of ascites*** - **Spontaneous bacterial peritonitis (SBP)** is a common and serious complication in patients with **cirrhosis and ascites**, characterized by an infection of the **ascitic fluid** without an obvious source within the abdominal cavity. - The infection typically arises from the **translocation of bacteria** from the gut lumen into the mesenteric lymph nodes and then into the ascitic fluid. *duodenal stump blowout* - A **duodenal stump blowout** is a rare but severe complication following gastric surgery (e.g., gastrectomy with Billroth II reconstruction) where the closed end of the duodenum ruptures. - This complication leads to **peritonitis**, but it is a **secondary bacterial peritonitis** due to leakage of GI contents, not spontaneous. *infection via fallopian tubes* - While bacteria can access the peritoneal cavity via the fallopian tubes, leading to **pelvic inflammatory disease (PID)** or **peritonitis**, this mechanism is specific to females and typically involves sexually transmitted infections ascending from the lower genital tract. - This pathway does not describe the typical pathogenesis of SBP, which is primarily associated with **ascites** in cirrhotic patients and gut bacterial translocation. *peptic ulcer perforation* - A **perforated peptic ulcer** involves a breach in the wall of the stomach or duodenum, leading to the leakage of gastric or duodenal contents into the peritoneal cavity. - This causes an acute abdomen and **secondary bacterial peritonitis**, which is distinguishable from SBP as it has an identifiable intrabdominal source of infection.
Question 9: Which one of the following is NOT a complication of massive blood transfusion?
- A. Hyperthermia (Correct Answer)
- B. Hyperkalemia
- C. Hypocalcaemia
- D. Coagulopathy
Explanation: ***Hyperthermia*** - **Hypothermia** is a more common complication of massive blood transfusion due to the administration of large volumes of cold blood products. - While theoretical, hyperthermia in this context would be rare and not a direct complication of the blood components themselves, unless equipment malfunction or infection occurs. [1] *Hyperkalemia* - Stored red blood cells **leak potassium** as they age, leading to higher potassium levels in the transfusion product. - Rapid infusion of large volumes can overwhelm the body's compensatory mechanisms, resulting in **elevated serum potassium**. *Hypocalcaemia* - **Citrate**, an anticoagulant used in blood storage, binds to ionized calcium in the recipient's blood. - Massive transfusions can lead to significant citrate accumulation, causing a drop in **ionized calcium levels**. *Coagulopathy* - Massive transfusions dilute clotting factors and platelets, which are not proportionally replaced in standard transfusion protocols. - This dilution can lead to impaired **hemostasis** and increased bleeding tendencies. [1]
Question 10: Which one of the following is NOT correct regarding MEN-1 syndrome?
- A. It involves pancreas
- B. It involves pituitary gland
- C. It involves pineal gland (Correct Answer)
- D. It involves parathyroid glands
Explanation: ***It involves pineal gland*** - MEN-1 syndrome, also known as Wermer's syndrome, is characterized by tumors of the **parathyroid glands**, **pituitary gland**, and **pancreatic islet cells** [1]. - The **pineal gland** is not typically associated with MEN-1 syndrome. *It involves pancreas* - **Pancreatic islet cell tumors** are a hallmark of MEN-1, often leading to diseases like **Zollinger-Ellison syndrome** (gastrinomas) or insulinomas [1]. - These tumors can cause significant endocrine dysfunction due to excessive hormone production [1]. *It involves pituitary gland* - **Pituitary adenomas**, particularly prolactinomas, are a common manifestation of MEN-1 syndrome [1]. - They can cause symptoms related to hormone excess (e.g., galactorrhea) or mass effects (e.g., visual disturbances) [1]. *It involves parathyroid glands* - **Hyperparathyroidism** due to parathyroid adenomas or hyperplasia is the most common manifestation of MEN-1 syndrome, affecting nearly all patients [2]. - This leads to elevated **calcium levels** and can cause symptoms like kidney stones, bone pain, and fatigue.