UPSC-CMS 2025 - Internal Medicine Practice Questions

Q: Consider the following with regard to Gilbert Syndrome : I. Autosomal recessive trait of a mutation in gene for UDPglucuronyl transferase enzyme II. Elevation of unconjugated bilirubin III. No stigmata of chronic liver disease other than jaundice IV. Early Liver biopsy recommended in patients with possible Gilbert Syndrome Which of the above are correct?

II and III only. ***II and III only*** - **Gilbert Syndrome** is characterized by an **elevation of unconjugated bilirubin** [1] due to reduced activity of the UGT1A1 enzyme [2]. - Patients typically present with **no stigmata of chronic liver disease** other than mild, fluctuating jaundice, often triggered by stress or fasting [2]. *I and II only* - While it involves **elevation of unconjugated bilirubin (II)** [1], Gilbert syndrome is an **autosomal recessive** condition due to a **polymorphism** in the promoter region of the **UGT1A1 gene**, leading to reduced enzyme activity [2], not a mutation that completely abolishes it. - The reduced enzyme activity is typically mild, resulting in only intermittent, mild hyperbilirubinemia. *III and IV* - **No stigmata of chronic liver disease other than jaundice (III)** is correct [2]. However, **early liver biopsy (IV)** is **not recommended** in patients with suspected Gilbert Syndrome. - Gilbert syndrome is a benign condition [1], and a liver biopsy is generally unnecessary and invasive for diagnosis in the absence of other liver disease signs. *I, II and III* - Although it features **elevation of unconjugated bilirubin (II)** and **no stigmata of chronic liver disease (III)**, the description of **I** is partially incorrect. - Gilbert syndrome is due to a **polymorphism** in the UGT1A1 gene promoter resulting in reduced enzyme activity [1], and it follows an **autosomal recessive inheritance pattern**, but the core issue is the **polymorphism**, not a standard mutation that significantly impairs the enzyme.

Q: The single most important treatment and prognostic factor in alcohol-related liver disease is

Cessation of alcohol consumption. ***Cessation of alcohol consumption*** - **Abstinence from alcohol** is the fundamental and most effective intervention for halting the progression of **alcohol-related liver disease (ARLD)** and significantly improving patient prognosis [1]. - Continued alcohol intake directly fuels liver damage, whereas stopping consumption allows the **liver to regenerate** and reduces inflammation, often leading to clinical improvement [1]. *N-acetyl cysteine* - While **N-acetyl cysteine (NAC)** is used in some liver conditions, particularly paracetamol overdose, its routine use for chronic ARLD is not supported by strong evidence as a primary treatment [3]. - It functions as an antioxidant and glutathione precursor, but **does not address the root cause** of alcohol-induced liver injury. *High dose vitamin E* - **High-dose vitamin E** is an antioxidant that has been investigated for various liver diseases, particularly non-alcoholic fatty liver disease (NAFLD) [2]. - However, there is **insufficient evidence** to support its widespread use as a primary or prognostic treatment in **alcohol-related liver disease** [2]. *Liver transplantation* - While **liver transplantation** can be a definitive treatment for end-stage ARLD, it is a **major surgical procedure** with strict criteria and is only considered after prolonged alcohol abstinence (typically 6 months) [1]. - It is a **salvage therapy** for irreversible damage, not the "single most important treatment and prognostic factor" in managing the disease from its earlier stages [1].

Q: Which of the following heart sounds are best heard with the bell of stethoscope? I. Opening snap II. Systolic click III. Third heart sound IV. Mid diastolic murmur Select the correct answer using the code given below :

III and IV. ***III and IV*** - The **bell of the stethoscope** is designed to auscultate **low-pitched sounds** due to its larger surface area and lighter application to the skin. - The **third heart sound (S3)** and **mid-diastolic murmurs** (e.g., from mitral stenosis) are classic examples of low-pitched sounds best heard with the bell [2]. *II and III only* - While the **third heart sound (S3)** is correctly identified as being heard with the bell, the **systolic click** is a high-pitched sound [1]. - **Systolic clicks**, often associated with mitral valve prolapse, are best heard with the **diaphragm** of the stethoscope [1]. *I, II and III* - This option incorrectly includes both the **opening snap** and **systolic click** as being best heard with the bell. - The **opening snap** (related to mitral stenosis) and **systolic click** (related to mitral valve prolapse) are typically **high-pitched sounds** and are better heard with the **diaphragm** [1], [3]. *I and IV* - This option incorrectly states that the **opening snap** is best heard with the bell. - Although the **mid-diastolic murmur** is correctly identified as a low-pitched sound [2], the **opening snap** is a high-pitched sound [1], [3], making the entire option incorrect.

Q: Consider the following statements for diagnosing ventricular aneurysm in a patient with recent myocardial infarction : I. Paradoxical impulse on chest wall II. Persistent ST elevation on ECG III. Unusual bulge from cardiac silhouette on X-ray IV. Presence of pulsus paradoxsus Which of the above are correct?

I, II and III. ***I, II and III*** - A **paradoxical impulse** on the chest wall (statement I) is a classic physical finding, indicating dyskinetic movement of the aneurysm during systole [1]. - **Persistent ST segment elevation** on ECG weeks to months after a myocardial infarction (statement II) is a hallmark sign, often reflecting the fibrous scar tissue of the aneurysm [1]. - An **unusual bulge** from the cardiac silhouette on X-ray (statement III) can indicate an enlarged left ventricular contour due to the aneurysm [1]. *II, III and IV* - While statements II and III are correct for diagnosing ventricular aneurysm, **pulsus paradoxus** (statement IV) is typically associated with **cardiac tamponade** or severe asthma/COPD, not directly with ventricular aneurysms. *I and II only* - Statements I and II are indeed correct indicators, but statement III, the **cardiac silhouette bulge on X-ray**, is also a valid and often observed finding for ventricular aneurysm [1]. *I and IV* - Statement I is correct, but **pulsus paradoxus** (statement IV) is not a diagnostic feature of ventricular aneurysm; it suggests conditions like **pericardial effusion** with tamponade.

Q: Which one of the following is correct with regard to Carey Coombs murmur?

Soft mid-diastolic murmur due to mitral valvulitis. ***Soft mid-diastolic murmur due to mitral valvulitis*** - The **Carey Coombs murmur** is a soft, mid-diastolic murmur heard in acute rheumatic fever, characterized by inflammation of the mitral valve (mitral valvulitis) [4]. - It is distinct from the Austin Flint murmur and indicates active **rheumatic carditis** [4]. *Harsh early diastolic murmur due to aortic regurgitation* - An early diastolic murmur, especially a harsh one, typically indicates **aortic regurgitation**, which is a different valvular pathology [3]. - The Carey Coombs murmur is described as soft and mid-diastolic, not harsh and early diastolic. *Soft systolic murmur due to mitral regurgitation* - A soft systolic murmur suggests **mitral regurgitation**, which is a backflow of blood during systole [2]. - The Carey Coombs murmur is specifically a diastolic murmur, differentiating it from systolic murmurs [3]. *Blowing late systolic murmur due to aortic stenosis* - A blowing late systolic murmur is characteristic of **aortic stenosis**, where there is narrowing of the aortic valve. - The Carey Coombs murmur is an early to mid-diastolic murmur, related to mitral valve inflammation, not aortic stenosis [1].

Q: Under the Stepwise Approach to the management of Bronchial Asthma, which one of the following is the correct initial treatment at Step 1 for a patient diagnosed with Asthma?

Low dose inhaled corticosteroid only. ***Low dose inhaled corticosteroid only*** - For newly diagnosed asthma patients requiring daily controller therapy (Step 1 or 2 as per GINA 2021+), a **low-dose inhaled corticosteroid (ICS)** is the recommended initial monotherapy [1]. - ICS addresses the underlying inflammation in asthma, which is crucial even in mild persistent cases. *Low dose inhaled corticosteroid plus leukotriene antagonist* - This combination is typically considered at **higher steps** (e.g., Step 3 or 4) if control is not achieved with low-dose ICS alone or if there are specific indications like **aspirin-exacerbated respiratory disease** [1]. - Initiating with two controller medications at Step 1 is generally not recommended as per guideline. *Low dose inhaled corticosteroid plus long acting anti-muscarinic agents* - **Long-acting muscarinic antagonists (LAMAs)** are primarily used in **severe asthma** that remains uncontrolled despite ICS/LABA therapy, usually at Step 4 or 5. - They are not considered a first-line addition to ICS at Step 1. *Low dose inhaled corticosteroid plus oral corticosteroid* - **Oral corticosteroids** are reserved for asthma **exacerbations** or very severe, uncontrolled asthma, used for short periods due to significant systemic side effects [1]. - They are never used as initial daily maintenance therapy at Step 1 due to their high side effect profile.

Q: A 62-year old male chronic smoker has been diagnosed with Chronic Obstructive Pulmonary Disease (COPD). On pulmonary function testing, the ratio of Forced Expiratory Volume in 1 second (FEV1) to Forced Vital Capacity (FVC) was 0.6 and FEV1 was 70 % of predicted. What is the severity of airflow obstruction in this patient as per GOLD criteria?

Stage II - Moderate. **Stage II - Moderate** - According to GOLD criteria, an FEV1/FVC ratio of less than 0.70 confirms airflow obstruction [1]. In this case, the ratio is 0.6. - A predicted FEV1 between 50% and 79% (inclusive) indicates **moderate COPD**, which aligns with the patient's FEV1 of 70% predicted [1]. *Stage III - Severe* - This stage is characterized by a **post-bronchodilator FEV1** between 30% and 49% of predicted [1]. - The patient's FEV1 of 70% predicted is too high for Stage III, indicating less severe obstruction. *Stage IV - Very severe* - This is the most severe stage, defined by a **post-bronchodilator FEV1** less than 30% of predicted, or FEV1 less than 50% predicted with signs of respiratory failure [1]. - The patient's FEV1 of 70% predicted is significantly higher than the threshold for very severe COPD. *Stage I - Mild* - Stage I is diagnosed when the **post-bronchodilator FEV1** is 80% or greater than predicted [1]. - The patient's FEV1 of 70% predicted falls below this criterion, indicating a more significant obstruction than mild.

Q: Which one of the following terms denotes the extensive sclerosis of the skin of the chest wall which restricts chest wall movement and is seen as a rare complication of systemic sclerosis?

Hidebound Chest. ***Hidebound Chest*** - This term precisely describes the **extensive cutaneous sclerosis** over the chest wall seen in **systemic sclerosis**, leading to restricted chest movement [1]. - The hardened, thickened skin reduces chest wall compliance, making breathing difficult [1]. *Barrel Chest* - Characterized by an **increased anterior-posterior diameter** of the chest, commonly seen in chronic obstructive pulmonary disease (COPD) due to hyperinflation. - It is not primarily caused by skin sclerosis but rather by lung pathology. *Flail Chest* - Occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. - This results in **paradoxical movement** of the chest wall during respiration, and is an acute traumatic injury. *Pigeon Chest* - Also known as **Pectus Carinatum**, this chest wall deformity is characterized by a **protrusion of the sternum and costal cartilages**. - It is typically a developmental anomaly rather than a consequence of skin sclerosis.

Question 1

Consider the following with regard to Gilbert Syndrome :
I. Autosomal recessive trait of a mutation in gene for UDPglucuronyl transferase enzyme
II. Elevation of unconjugated bilirubin
III. No stigmata of chronic liver disease other than jaundice
IV. Early Liver biopsy recommended in patients with possible Gilbert Syndrome

Which of the above are correct?

Accepted Answer

II and III only

Answer

I and II only

Answer

III and IV

Answer

I, II and III

Question 2

The single most important treatment and prognostic factor in alcohol-related liver disease is

Accepted Answer

Cessation of alcohol consumption

Answer

N -acetyl cysteine

Answer

High dose vitamin E

Answer

Liver transplantation

Question 3

Which of the following heart sounds are best heard with the bell of stethoscope?
I. Opening snap
II. Systolic click
III. Third heart sound
IV. Mid diastolic murmur

Select the correct answer using the code given below :

Accepted Answer

III and IV

Answer

II and III only

Answer

I, II and III

Answer

I and IV

Question 4

Consider the following statements for diagnosing ventricular aneurysm in a patient with recent myocardial infarction :
I. Paradoxical impulse on chest wall
II. Persistent ST elevation on ECG
III. Unusual bulge from cardiac silhouette on X-ray
IV. Presence of pulsus paradoxsus

Which of the above are correct?

Accepted Answer

I, II and III

Answer

II, III and IV

Answer

I and II only

Answer

I and IV

Question 5

Which one of the following statements is correct for subcutaneous nodules in Rheumatic fever?

Accepted Answer

They typically appear more than 3 weeks after onset of other clinical manifestations

Answer

They are present over flexor aspect of forearm

Answer

They are painful tender nodules

Answer

The usual size of these nodules is 3-5 cm

Question 6

Which one of the following is correct with regard to Carey Coombs murmur?

Accepted Answer

Soft mid-diastolic murmur due to mitral valvulitis

Answer

Harsh early diastolic murmur due to aortic regurgitation

Answer

Soft systolic murmur due to mitral regurgitation

Answer

Blowing late systolic murmur due to aortic stenosis

Question 7

Which of the following statements is correct regarding the Opening Snap (OS) in a patient of mitral stenosis?

Accepted Answer

OS moves closer to the second sound (S2) as the stenosis becomes more severe

Answer

OS is best heard at the second left intercostal space

Answer

OS is best heard with the bell of stethoscope

Answer

Intensity of OS becomes louder when the valve is calcified

Question 8

Under the Stepwise Approach to the management of Bronchial Asthma, which one of the following is the correct initial treatment at Step 1 for a patient diagnosed with Asthma?

Accepted Answer

Low dose inhaled corticosteroid only

Answer

Low dose inhaled corticosteroid plus leukotriene antagonist

Answer

Low dose inhaled corticosteroid plus long acting anti-muscarinic agents

Answer

Low dose inhaled corticosteroid plus oral corticosteroid

Question 9

A 62-year old male chronic smoker has been diagnosed with Chronic Obstructive Pulmonary Disease (COPD). On pulmonary function testing, the ratio of Forced Expiratory Volume in 1 second (FEV1) to Forced Vital Capacity (FVC) was 0.6 and FEV1 was 70 % of predicted. What is the severity of airflow obstruction in this patient as per GOLD criteria?

Accepted Answer

Stage II - Moderate

Answer

Stage III - Severe

Answer

Stage IV - Very severe

Answer

Stage I - Mild

Question 10

Which one of the following terms denotes the extensive sclerosis of the skin of the chest wall which restricts chest wall movement and is seen as a rare complication of systemic sclerosis?

Accepted Answer

Hidebound Chest

Answer

Barrel Chest

Answer

Flail Chest

Answer

Pigeon Chest

UPSC-CMS 2025 — Internal Medicine