General Medicine — MCQs

General Medicine Indian Medical PG Practice Questions and MCQs

Question 171: A patient with following peripheral smear and X-ray spine will present with:

A. Hand-foot syndrome (Correct Answer)
B. Black urine
C. Elevated haptoglobin
D. Splenomegaly with gallstones

Explanation: ***Hand-foot syndrome*** - The peripheral smear shows numerous **sickle cells** (elongated, crescent-shaped red blood cells), indicating **sickle cell anemia**. The X-ray depicts **H-shaped vertebrae** or "fish-mouth vertebrae", which is a characteristic finding in sickle cell disease due to chronic bone infarcts. - **Hand-foot syndrome (dactylitis)** is an initial presentation of sickle cell anemia in infants and young children, characterized by painful swelling of the hands and feet caused by **vaso-occlusion** in the small bones. *Black urine* - **Black urine (alkaptonuria)** is associated with an inborn error of metabolism where homogentisic acid accumulates, leading to ochronosis, not sickle cell disease. - This symptom is not typical for the peripheral smear and X-ray findings presented. *Elevated haptoglobin* - Haptoglobin binds to **free hemoglobin** and is *decreased* in hemolytic anemias like sickle cell disease, as accelerated red blood cell destruction leads to its consumption. - Therefore, an elevated haptoglobin level would argue against **hemolytic anemia**. *Splenomegaly with gallstones* - While chronic hemolysis in sickle cell disease can lead to **gallstones** (pigment gallstones), most patients with sickle cell anemia develop **autosplenectomy** (functional asplenia) by childhood or early adulthood due to repeated splenic infarcts, rather than persistent splenomegaly. - Splenomegaly can occur in early childhood but typically regresses as the spleen undergoes fibrosis.

Question 172: A 6-year-old Afro-American boy presents with acute abdomen and nonhealing ulcer on medial malleolus. Peripheral smear is shown. The most likely cause of this condition is:

A. Trinucleotide repeat
B. Antibody to RBC membrane
C. Substitution of single amino acid base (Correct Answer)
D. Genomic imprinting

Explanation: ***Substitution of single amino acid base*** - The image shows numerous **sickle cells** (elongated, crescent-shaped red blood cells), which are characteristic of **sickle cell anemia**. - Sickle cell anemia is caused by a **point mutation** (a single amino acid substitution) in the beta-globin gene, where valine replaces glutamic acid at the sixth position. *Trinucleotide repeat* - **Trinucleotide repeat disorders** (e.g., Huntington's disease, Fragile X syndrome) involve an abnormal expansion of three-nucleotide sequences. - They present with neurological or developmental symptoms, not the hematological features of sickle cell disease. *Antibody to RBC membrane* - **Antibodies to RBC membrane** cause conditions like **autoimmune hemolytic anemia**, where red blood cells are destroyed by the immune system. - While it can cause anemia, the characteristic **sickle shape** of the red blood cells, as seen in the smear, is not a feature of autoimmune hemolytic anemia. *Genomic imprinting* - **Genomic imprinting** is an epigenetic phenomenon where certain genes are expressed in a parent-of-origin-specific manner (e.g., Prader-Willi syndrome). - This mechanism is not involved in the pathogenesis of sickle cell disease.

Question 173: A 34-year-old lady presents with high-grade fever with chills and rigors. On examination, a firm spleen is felt 3 cm below costal margin. Peripheral smear was prepared. Diagnosis is:

A. Plasmodium vivax (Correct Answer)
B. Plasmodium falciparum
C. Amebic liver abscess
D. Infectious mononucleosis

Explanation: ***Plasmodium vivax*** - The image distinctly shows **amoeboid trophozoites**, **enlarged red blood cells** with **Schüffner's dots**, and various stages of parasites within the red blood cells, which are characteristic of *P. vivax* infection. Additionally, a **banana-shaped gametocyte** is visible (indicated by the arrow), which can be seen in *P. vivax* but is more typically associated with *P. falciparum* (though it's not the primary distinguishing feature here). - Clinical features like **high-grade fever with chills and rigors** and a **firmly palpable spleen** are consistent with malaria, and the microscopic findings on the peripheral smear confirm *P. vivax*. *Plasmodium falciparum* - While *P. falciparum* causes severe malaria with similar systemic symptoms and can feature **banana-shaped gametocytes**, it typically does not cause **enlargement of red blood cells** or prominent **Schüffner's dots**. - Its trophozoites are often **ring forms**, and multiple parasites can infect a single red blood cell; the morphology in the image is more consistent with *P. vivax*. *Amebic liver abscess* - This condition is caused by *Entamoeba histolytica* and primarily presents with **fever** and **right upper quadrant pain**, sometimes referred to the shoulder. - Diagnosis is usually made by imaging (e.g., ultrasound, CT scan) and serology; it does not involve parasites in red blood cells on a peripheral smear. *Infectious mononucleosis* - Caused by the **Epstein-Barr virus**, it presents with fever, fatigue, **lymphadenopathy**, and **splenomegaly**, but not with parasitic forms in red blood cells. - The characteristic finding on a peripheral smear would be **atypical lymphocytes** (Downey cells), not malarial parasites.

Question 174: All are true about the condition shown except:

A. Bilateral hilar lymphadenopathy with caseating granulomas (Correct Answer)
B. Kveim-Siltzbach procedure is an intradermal test
C. Increased CD4/CD8 Ratio >3.5 in Bronchoalveolar Lavage
D. Lofgren syndrome leads to uveitis

Explanation: ***Bilateral hilar lymphadenopathy with caseating granulomas*** - Sarcoidosis, depicted in the images (bilateral hilar lymphadenopathy on chest X-ray and **non-caseating granulomas** on histology), is characterized by **non-caseating** (not caseating) granulomas. - **Caseating granulomas** are typical of tuberculosis and certain fungal infections, not sarcoidosis. *Kveim-Siltzbach procedure is an intradermal test* - The Kveim-Siltzbach test is an **intradermal injection** of sarcoidosis tissue extract, which would reliably induce a granulomatous reaction in patients with active sarcoidosis. - While historically used, it is now rarely performed due to unavailability of standardized antigen and the risk of disease transmission. *Increased CD4/CD8 Ratio >3.5 in Bronchoalveolar Lavage* - An elevated **CD4/CD8 ratio**, typically greater than 3.5, in **bronchoalveolar lavage (BAL)** fluid is a characteristic finding in active pulmonary sarcoidosis. - This indicates an accumulation of helper T cells in the lungs, contributing to granuloma formation. *Lofgren syndrome leads to uveitis* - **Löfgren syndrome** is an acute form of sarcoidosis characterized by the triad of **hilar lymphadenopathy**, **erythema nodosum**, and **arthralgia**. - While it is a specific presentation of sarcoidosis, **uveitis** is also a known manifestation of sarcoidosis but is not a defining characteristic of Löfgren syndrome itself; however, sarcoidosis can cause uveitis.

Question 175: Which of the following is the most common cause of death in this condition?

A. Cardiac failure (Correct Answer)
B. Bacterial endocarditis
C. Ball thrombus in left atria
D. Acute coronary insufficiency

Explanation: ***Cardiac failure*** - The image reveals **myocarditis** with **inflammatory infiltrates** and **myocyte necrosis**, indicative of direct myocardial injury. - Severe myocarditis can lead to significant impairment of cardiac function, resulting in **dilated cardiomyopathy** and ultimately **heart failure**, which is the most common cause of death. *Bacterial endocarditis* - This condition involves **vegetations on heart valves**, often leading to **valvular insufficiency** or **embolism**, but it is not primarily a disease of the myocardium itself causing widespread failure as depicted. - The image does not show evidence of valvular vegetations or bacterial colonies typical of endocarditis. *Ball thrombus in left atria* - A ball thrombus typically forms in the **left atrium** due to conditions like **mitral stenosis** or atrial fibrillation, potentially causing **embolic events** or sudden obstruction. - This is a sequela of other cardiac diseases and not a primary myocardial pathology leading to widespread inflammation and necrosis as seen. *Acute coronary insufficiency* - Acute coronary insufficiency is characterized by **ischemia** due to reduced blood flow through the **coronary arteries**, usually caused by **atherosclerotic plaque rupture** and thrombosis. - The histological features of myocarditis, with diffuse inflammatory cells and scattered myocyte damage in the image, are distinct from the typical pattern of **ischemic necrosis** found in myocardial infarction.

Question 176: If the mean QRS vector in lead I is positive and in lead III is negative, what is the axis deviation?

A. Normal axis
B. Left axis deviation (Correct Answer)
C. Right axis deviation
D. Extreme axis deviation

Explanation: ***Left axis deviation*** - A **positive QRS vector in lead I** means the overall electrical activity is moving towards the positive pole of lead I (i.e., towards the patient's left). - A **negative QRS vector in lead III** means the overall electrical activity is moving away from the positive pole of lead III. When combined, these findings indicate the axis is shifted to the left, typically between -30° and -90°. *Normal axis* - A normal axis would typically show **positive QRS vectors in both lead I and lead III**. - The electrical forces are directed generally downwards and to the left, usually between -30° and +90°. *Right axis deviation* - Right axis deviation is characterized by a **negative QRS vector in lead I** and a positive QRS vector in lead aVF or lead III. - This signifies the electrical axis is shifted to the right, usually between +90° and +180°. *Extreme axis deviation* - Extreme axis deviation (also known as "indeterminate" or "northwest" axis) is indicated by **negative QRS vectors in both lead I and lead aVF**. - This represents an axis between -90° and -180°, an unusual and often pathological finding.

Question 177: The ECG shows a heart rate of 40 bpm, left axis deviation, and QRS duration >120 msec. There are deep monophasic S waves in V1-V3, broad monophasic R waves in lateral leads I, aVL, V5-V6, and absent Q waves in lateral leads with M shaped notch in peak of R wave in V5-V6. What is the diagnosis?

A. LBBB (Correct Answer)
B. RBBB
C. Left anterior fascicular block
D. Left posterior fascicular block

Explanation: ***LBBB*** - The ECG criteria for **LBBB** include a **QRS duration >120 msec** (broad QRS), a **broad, monophasic R wave** or "M-shaped" R wave (sometimes called rabbit ears) in **lateral leads (I, aVL, V5-V6)** signifying delayed activation of the left ventricle, and **deep S waves in V1-V3**. - The presence of **left axis deviation** can also be associated with LBBB, although not a primary diagnostic criterion. The absence of Q waves in lateral leads further supports delayed septal activation. *RBBB* - **RBBB** is characterized by a widened QRS complex (>120 msec) with an **RSR' pattern (M-shaped)** in leads **V1 and V2**, representing delayed right ventricular activation. - It typically presents with a **wide, slurred S wave in lateral leads (I, aVL, V5-V6)**, which is opposite to the findings described in the question. *Left anterior fascicular block* - **Left anterior fascicular block (LAFB)** is characterized by **left axis deviation (usually -45 to -90 degrees)** and a **normal QRS duration** (<120 msec), along with an absent Q wave and tall r wave in aVL, and a qR pattern in lead I. - It does not involve significant QRS widening or the specific morphology (broad R waves in lateral leads, deep S waves in V1-V3) seen in this ECG. *Left posterior fascicular block* - **Left posterior fascicular block (LPFB)** is rare and is characterized by **right axis deviation** and a **normal QRS duration** (<120 msec). - It does not present with the specific wide QRS and characteristic QRS morphology in precordial and lateral leads observed in this ECG tracing.

Question 178: A patient presented with TCA toxicity. The ECG shows broad complex QRS with duration of 160 msec and ST segment elevation in V1 and V2. What is the most appropriate management?

A. Broad complex QRS: Soda bicarbonate (Correct Answer)
B. Narrow complex QRS: Lidocaine
C. ST segment elevation: Aspirin
D. T wave inversion: Beta-blockers

Explanation: ***Broad complex QRS: Soda bicarbonate*** - The ECG shows a **broad QRS complex** (160 msec), which is a characteristic finding in TCA toxicity due to the drug's **sodium channel blocking effects**. - **Sodium bicarbonate** is the treatment of choice for TCA toxicity with QRS widening, as it **increases extracellular sodium concentration** and **alkalinizes the blood**, thereby overcoming the sodium channel blockade. *Narrow complex QRS: Lidocaine* - This patient presents with a **broad complex QRS**, making lidocaine an inappropriate first-line treatment for this specific ECG finding in TCA toxicity. - Lidocaine is generally contraindicated in TCA toxicity because it can exacerbate the **sodium channel blockade** and arrhythmogenic effects. *ST segment elevation: Aspirin* - While ST segment elevation can be seen in TCA toxicity (due to direct myocardial effects or coronary vasospasm), the primary and most life-threatening ECG finding requiring immediate intervention is the **broad QRS complex**. - Aspirin is a **platelet aggregation inhibitor** and would not address the underlying cardiotoxicity of TCAs, nor would it correct the wide QRS or arrhythmias. *T wave inversion: Beta-blockers* - T-wave inversion can occur in various cardiac conditions, including TCA toxicity, but it is not the most critical or specific finding warranting immediate intervention in this context. - **Beta-blockers** are generally **contraindicated** in TCA toxicity because they can worsen **hypotension** and heart block already caused by the overdose.

Question 179: A 30-year-old lady with scleroderma presents with progressive dyspnea on exertion. Which of the following is incorrect about the ECG finding?

A. Heart rate of 75 bpm (Correct Answer)
B. Right axis deviation
C. T wave inversion in V1-V3
D. rSR' pattern in V1

Explanation: ***Heart rate of 75 bpm*** - This ECG shows a heart rate of approximately 100 bpm (one large box is 0.2 seconds; 300/3 = 100). Therefore, a heart rate of 75 bpm is **incorrect**. - The rhythm is generally regular, and the calculation of heart rate involves counting the number of R waves in a 6-second strip and multiplying by 10, or by dividing 300 by the number of large squares between R waves. *Right axis deviation* - The QRS complex in lead I is predominantly negative, and in aVF it is predominantly positive, which indicates **right axis deviation**. - Right axis deviation suggests possible **right ventricular hypertrophy** or strain, consistent with pulmonary hypertension which can occur in scleroderma. *T wave inversion in V1-V3* - The ECG clearly shows **T-wave inversions** in leads V1, V2, and V3. - This pattern can be suggestive of **right ventricular strain** or hypertrophy, commonly seen in pulmonary hypertension. *rSR' pattern in V1* - In lead V1, there is a small initial r wave, followed by an S wave, and then a larger R' wave, forming an **rSR' pattern**. - This morphology is characteristic of an **incomplete right bundle branch block (IRBBB)**, which is often associated with right ventricular volume or pressure overload, such as in pulmonary hypertension.

Question 180: What is the axis in the ECG provided?

A. Normal
B. Left axis deviation (Correct Answer)
C. Right axis deviation
D. Extreme axis deviation

Explanation: ***Left axis deviation*** - The **QRS complex** is predominantly **positive in Lead I** and predominantly **negative in Lead aVF**. - This combination indicates that the mean QRS electrical vector lies between **-30° and -90°**, which is characteristic of left axis deviation. *Normal* - A **normal axis** typically shows a predominantly **positive QRS complex** in both Lead I and Lead aVF. - This ECG shows a negative QRS in aVF, ruling out a normal axis. *Right axis deviation* - **Right axis deviation** is characterized by a predominantly **negative QRS complex** in Lead I and a predominantly **positive QRS complex** in Lead aVF. - This ECG shows the opposite pattern in Lead I (positive), ruling out right axis deviation. *Extreme axis deviation* - **Extreme axis deviation**, sometimes called "northwest axis," is present when the **QRS complex** is predominantly **negative in both Lead I and Lead aVF**. - In this ECG, Lead I is positive, so extreme axis deviation is not present.

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