General Medicine Practice Questions

Q: A patient presents with the following lesions on the elbows and his blood work shows lactescent plasma. Which is correct about the lesions?

Leads to increased risk for pancreatitis. ***Leads to increased risk for pancreatitis*** - The lesions shown are **eruptive xanthomas**, which are associated with severe hypertriglyceridemia, often indicated by **lactescent plasma**. - Markedly elevated triglyceride levels (typically >1000 mg/dL) significantly increase the risk of developing **acute pancreatitis**. *Molluscum contagiosum* - **Molluscum contagiosum** lesions are typically flesh-colored, dome-shaped papules with a characteristic **umbilicated center**. - These lesions are distinct from the yellowish-red papules seen in eruptive xanthomas, and **molluscum contagiosum** is not associated with hyperlipidemia or lactescent plasma. *Leads to decreased risk for coronary atherosclerosis* - The condition described (eruptive xanthomas and lactescent plasma) indicates **severe hypertriglyceridemia**, which is a significant risk factor for **coronary artery disease (atherosclerosis)**, not a decreased risk. - High triglyceride levels contribute to the formation of **atherosclerotic plaques**. *Due to increased LDL cholesterol* - While high LDL cholesterol can cause **xanthomas** (e.g., tendinous, tuberous), **eruptive xanthomas** and **lactescent plasma** are specifically linked to extremely high **triglyceride levels**, often part of chylomicronemia, rather than primarily increased LDL cholesterol. - The "lactescent" or milky appearance of plasma is due to the high concentration of **chylomicrons** and **VLDL**, which are rich in triglycerides.

Q: Which of the following sites in the most common site of intraparenchymal bleeding?

B. ***B*** - Label B points to the **lenticulostriate arteries** territory, specifically within the **basal ganglia**, including the putamen. The **putamen** is the **most common site** for spontaneous intraparenchymal hemorrhages, often due to **hypertensive vasculopathy** affecting these small penetrating arteries. - Hypertensive hemorrhages typically occur in areas supplied by small-caliber perforating arteries, which are particularly susceptible to the effects of chronic hypertension, leading to **lipohyalinosis** and microaneurysms (Charcot-Bouchard aneurysms) that rupture. *A* - Label A points to the **corona radiata** or surrounding white matter. While intraparenchymal bleeds can occur here, it is less common than in the basal ganglia. - Hemorrhages in the corona radiata would be more consistent with **lobar hemorrhages** which are often associated with **cerebral amyloid angiopathy** in older patients. *C* - Label C points towards the **thalamus**. The thalamus is one of the common sites for intraparenchymal hemorrhage, particularly due to hypertension, but it is less frequent than the putamen. - Thalamic hemorrhages often present with distinct clinical syndromes, such as **sensory deficits** and eye movement abnormalities, due to the critical structures located here. *D* - Label D points to the **temporal lobe cortex** and subcortical white matter. Lobar hemorrhages can occur in the temporal lobe, but they are not the most common site overall for intraparenchymal bleeding from all causes. - Temporal lobe hemorrhages can be caused by various factors, including **cerebral amyloid angiopathy**, vascular malformations, or trauma, but hypertensive bleeds rarely occur in the cortex.

Q: A comatose person is brought to the hospital. On examination his respiratory rate is 8 / min with pulse rate of 75 bpm with BP of 110 / 70 mm Hg. His Pupils are shown below. Body temperature is 96°F. What is the probable diagnosis?

Opioid overdose. ***Opioid overdose*** - The constellation of **pinpoint pupils** (as shown in the image), **respiratory depression** (rate 8/min), and **coma** is highly characteristic of opioid overdose. - While **hypothermia** (96°F) can be seen with opioid use, the critical findings are the miosis and severe hypoventilation. *Uncal herniation* - **Uncal herniation** typically presents with a **dilated pupil** on the side of the herniation due to compression of the oculomotor nerve (CN III). - It often involves neurological deficits like hemiparesis and decerebrate posturing, along with changes in consciousness. *Pontine stroke* - A **pontine stroke** can cause pinpoint pupils due to disruption of sympathetic pathways, but it is also commonly associated with severe neurological deficits like **quadriplegia**, locked-in syndrome, and distinct respiratory patterns (e.g., apneustic breathing). - The provided vital signs and pupil presentation are more classically aligned with opioid toxicity than an isolated pontine stroke. *Metabolic encephalopathy* - **Metabolic encephalopathy** usually presents with **reactive, but often small, pupils** or normal pupils. - It leads to a global depression of brain function but rarely causes pinpoint pupils or severe respiratory depression as the primary distinguishing features.

Q: A 65-year-old patient was diagnosed with papillary carcinoma of thyroid. He underwent total thyroidectomy with radical neck dissection. On post-op day 3 he complains of ants crawling sensation on his lips. On deployment of BP cuff in the arm and inflating to 20 mm Hg above SBP, you notice that he develops following posture of his hand. All are true about the condition and its management except:

Cause of death in hypocalcemia is systolic arrest of heart. ***Cause of death in hypocalcemia is systolic arrest of heart*** - The primary cause of death in severe hypocalcemia is **laryngospasm** and **bronchospasm**, which lead to respiratory arrest, not primarily cardiac arrest. - While hypocalcemia can affect cardiac function, it typically causes **QT prolongation** and may lead to ventricular arrhythmias, but **diastolic arrest** is more commonly associated with severe hypocalcemia than systolic arrest. *10% calcium gluconate under cardiac monitoring is used* - **10% calcium gluconate** is indeed the appropriate treatment for severe acute hypocalcemia and is administered intravenously. - **Cardiac monitoring** is crucial during its administration due to the risk of arrhythmias, especially if the patient is also on digoxin. *Tetany is due to repetitive spontaneous action potentials in nerves* - **Hypocalcemia** leads to neuronal hyperexcitability because reduced extracellular calcium decreases the threshold for neuronal depolarization. - This results in **spontaneous and repetitive firing** of action potentials in both motor and sensory nerves, causing the characteristic muscle spasms and sensory disturbances (like the "ants crawling sensation"). *Ionized calcium is affected by pH of blood* - **Acidosis decreases protein binding** of calcium, leading to an **increase in ionized calcium** levels. - Conversely, **alkalosis increases protein binding** (primarily to albumin), thereby **decreasing ionized calcium** concentrations, even if total calcium levels remain stable.

Q: All are correct regarding this technique for administration of parenteral iron except:

Massage the site for even distribution of medicine. ***Massage the site for even distribution of medicine*** - Massaging the injection site after administering parenteral iron via **intramuscular injection** is **contraindicated** as it can increase the risk of the iron preparation staining the overlying skin. - The Z-track technique, often used for iron injections, aims to **prevent leakage** of the irritating solution into the subcutaneous tissue and skin, and massage would undermine this purpose. *Pull the skin and subcutaneous tissue laterally to site of injection* - This step is part of the **Z-track technique**, where the skin is pulled to one side before injection to create a zigzag path that seals the medication in the muscle. - This technique helps to **prevent leakage** of the medication into subcutaneous tissue upon withdrawal of the needle, thus reducing irritation and discoloration. *Holding the skin taut with the non-dominant hand, insert the needle at a $90^{\circ}$ angle at the spot where the finger was placed initially* - Inserting the needle at a **$90^{\circ}$ angle** ensures the medication reaches the muscle tissue for intramuscular injection. - Holding the skin taut also helps in smooth needle insertion and is part of the **Z-track technique** setup. *Pull back plunger to rule out possibility of a vessel breach, inject the drug slowly, followed by the air* - **Aspirating the plunger** (pulling back) before injection is crucial to ensure the needle is not in a blood vessel, preventing accidental intravenous administration. - Injecting **slowly** reduces pain and tissue trauma, and injecting a small air bubble at the end can help clear the needle of medication, preventing leakage back into the subcutaneous tissue (air-lock technique).

Q: All of the following are sites for giving insulin except:

D. ***D*** - While the **thigh** is an acceptable site for subcutaneous insulin injection, the image labels "D" specifically to the **anterior lateral thigh**. This region is commonly used. - However, the question asks for the site that is *not* for insulin administration. Given the other choices are valid, "D" represents the **upper outer thigh area**, which is a standard injection site. *This answer is incorrect based on the assumption that D refers to the inner thigh/genital area, but if D refers to the entire upper external thigh, it is a valid site.* *However, considering the options to be mutually exclusive areas, D might be pointing to an area that is generally avoided, such as too close to the groin or an area with less subcutaneous tissue, or it could be a distractor.* If we consider all other options are valid insulin injection areas, then D is the site that is generally avoided. In typical clinical practice, only specific parts of the thigh are used, avoiding areas with less fat or increased nerve/blood vessel proximity. *A* - Site A corresponds to the **back of the upper arm**, which is a common and appropriate site for insulin injection. - The **subcutaneous tissue** in this region allows for good absorption of insulin. *B* - Site B indicates the **abdomen**, specifically the area around the navel, which is the **preferred site** for insulin injection due to consistent absorption and ample subcutaneous fat. - This area provides a large surface for **rotation of sites**, which is important to prevent lipohypertrophy. *C* - Site C points to the **lateral aspect of the upper thigh**, which is a suitable area for insulin injection. - The **large muscle mass** and subcutaneous fat in this region make it a good option, particularly for self-injection.

Q: All are correct about the condition shown below except:

Calcification of interosseous membrane. ***Calcification of interosseous membrane*** - The image shows features consistent with **fluorosis**, a condition caused by excessive fluoride intake. While fluorosis can lead to widespread calcification of ligaments and tendons, **calcification of the interosseous membrane** is a characteristic but often later finding. - The patient exhibits **genu valgum** (knock-knees) and the radiograph of the forearm shows diffuse increased bone density and osteosclerosis, typical of fluorosis. *Multiple lytic lesions in vertebra* - **Fluorosis** primarily causes **osteosclerosis** (increased bone density) and periosteal bone formation, not lytic lesions. - **Lytic lesions in vertebrae** are more often associated with conditions like multiple myeloma, metastatic cancer, or infections, which involve bone destruction rather than excessive bone formation. *Barrel chest* - **Barrel chest** is typically associated with chronic obstructive pulmonary disease (COPD) or other respiratory conditions that cause hyperinflation of the lungs. - While **skeletal deformities** are common in advanced fluorosis, a "barrel chest" is not a direct or characteristic manifestation of the condition. *Bony exostosis in limb bones* - **Bony exostoses** (osteochondromas) are generally seen in hereditary multiple exostoses or can be isolated benign bone tumors. - While fluorosis causes irregular new bone formation and thickening of long bones, specific, discrete **bony exostoses** are not a typical feature; rather, it's a more generalized osteosclerosis and periostitis.

Q: A 50-year-old smoker and hypertensive patient presents with the lesion shown below. It is painful and present bilaterally. Peripheral pulses are palpable. What is the diagnosis?

Martorell ulcer. ***Martorell ulcer*** - This is a **hypertensive ischemic leg ulcer** primarily associated with uncontrolled hypertension, often seen in older patients who smoke. - Key features include extreme pain, location on the **anterolateral aspect of the lower leg**, and frequently bilateral presentation, despite palpable peripheral pulses. *Arterial ulcer* - **Arterial ulcers** are typically caused by **peripheral artery disease (PAD)**, leading to reduced blood flow. - While they can be painful, PAD is usually associated with **diminished or absent peripheral pulses**, which are present in this case. *Trophic ulcer* - A **trophic ulcer** is a general term for an ulcer caused by **poor nutrition** to the tissues, often due to neuropathy or chronic venous insufficiency. - While they can be chronic, the specific presentation with palpable pulses, severe pain, and association with hypertension points away from a generic trophic ulcer. *Bairnsdale ulcer* - Also known as **Buruli ulcer**, this is a **mycobacterial infection** caused by *Mycobacterium ulcerans*. - It typically starts as a painless nodule and slowly progresses to a large, often painless ulcer with undermined edges, which is not consistent with the painful lesion described.

Q: This condition shown below is dependent on development of pH of urine. Which of the following subtype development is insensitive to pH of urine?

Calcium oxalate. ***Calcium oxalate*** - **Calcium oxalate stones** are the most common type and form **independently of urine pH**, although they can form in a wide range of pH conditions. - Precipitation of calcium oxalate is primarily influenced by concentrations of **calcium and oxalate** in urine, not pH. *Triple phosphate* - **Triple phosphate (struvite) stones** are highly sensitive to **alkaline urine** (pH > 7.0), as they typically form in the presence of urea-splitting bacteria. - These stones are often large, grow rapidly, and are associated with **urinary tract infections**. *Uric acid* - **Uric acid stones** are highly dependent on urine pH, typically forming in **acidic urine** (pH < 5.5). - Alkalinizing the urine (e.g., with potassium citrate) can help **dissolve existing uric acid stones** and prevent new formation. *Cystine* - **Cystine stones** are also pH-sensitive, forming primarily in **acidic urine**, due to the reduced solubility of cystine at lower pH levels. - Urine alkalinization is a key therapeutic strategy for managing cystine stone formation.

Question 1

A patient presents with the following lesions on the elbows and his blood work shows lactescent plasma. Which is correct about the lesions?

Accepted Answer

Leads to increased risk for pancreatitis

Answer

Molluscum contagiosum

Answer

Leads to decreased risk for coronary atherosclerosis

Answer

Due to increased LDL cholesterol

Question 2

Which of the following sites in the most common site of intraparenchymal bleeding?

Accepted Answer

B

Answer

A

Answer

C

Answer

D

Question 3

A comatose person is brought to the hospital. On examination his respiratory rate is 8 / min with pulse rate of 75 bpm with BP of 110 / 70 mm Hg. His Pupils are shown below. Body temperature is 96°F. What is the probable diagnosis?

Accepted Answer

Opioid overdose

Answer

Uncal herniation

Answer

Pontine stroke

Answer

Metabolic encephalopathy

Question 4

A 65-year-old patient was diagnosed with papillary carcinoma of thyroid. He underwent total thyroidectomy with radical neck dissection. On post-op day 3 he complains of ants crawling sensation on his lips. On deployment of BP cuff in the arm and inflating to 20 mm Hg above SBP, you notice that he develops following posture of his hand. All are true about the condition and its management except:

Accepted Answer

Cause of death in hypocalcemia is systolic arrest of heart

Answer

10% calcium gluconate under cardiac monitoring is used

Answer

Tetany is due to repetitive spontaneous action potentials in nerves

Answer

Ionized calcium is affected by pH of blood

Question 5

A 8-year-old child from central India presents with fever off and on for last 4 weeks without any chills or rigors. On examination massively enlarged spleen is noted. Bone marrow aspiration was performed. All are correct about the condition shown except:

Accepted Answer

Oral miltefosine has a short half-life and is not given as monotherapy

Answer

LD bodies in the marrow shown are nonflagellated amastigote form

Answer

Liposomal amphotericin B is given with regimen of 3 mg/kg daily on days 1-5, 14, and 21

Answer

Paromomycin has antileishmanial activity

Question 6

All are correct regarding this technique for administration of parenteral iron except:

Accepted Answer

Massage the site for even distribution of medicine

Answer

Pull the skin and subcutaneous tissue laterally to site of injection

Answer

Holding the skin taut with the non-dominant hand, insert the needle at a $90^{\circ}$ angle at the spot where the finger was placed initially

Answer

Pull back plunger to rule out possibility of a vessel breach, inject the drug slowly, followed by the air

Question 7

All of the following are sites for giving insulin except:

Accepted Answer

D

Answer

A

Answer

B

Answer

C

Question 8

All are correct about the condition shown below except:

Accepted Answer

Calcification of interosseous membrane

Answer

Multiple lytic lesions in vertebra

Answer

Barrel chest

Answer

Bony exostosis in limb bones

Question 9

A 50-year-old smoker and hypertensive patient presents with the lesion shown below. It is painful and present bilaterally. Peripheral pulses are palpable. What is the diagnosis?

Accepted Answer

Martorell ulcer

Answer

Arterial ulcer

Answer

Trophic ulcer

Answer

Bairnsdale ulcer

Question 10

This condition shown below is dependent on development of pH of urine. Which of the following subtype development is insensitive to pH of urine?

Accepted Answer

Calcium oxalate

Answer

Triple phosphate

Answer

Uric acid

Answer

Cystine

General Medicine — MCQs

General Medicine — MCQs

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