Clinical Manifestations and Presentation of Diseases Practice Questions

Q: A 55-year-old male presents with sudden onset of severe pain, redness, and swelling of the foot as shown in the image below. There is no history of trauma. Serum uric acid is 9 mg/dL. What is the best acute management at this stage?

Indomethacin 50 mg three times a day. ***Indomethacin 50 mg three times a day*** - **Nonsteroidal anti-inflammatory drugs (NSAIDs)** like indomethacin are considered the first-line treatment for **acute gouty arthritis** in patients without contraindications. - They work by inhibiting **prostaglandin synthesis**, effectively reducing the intense inflammation and joint pain characteristic of a gout flare. *Febuxostat* - This is a **xanthine oxidase inhibitor** used for long-term **urate-lowering therapy**. - Initiating urate-lowering therapy during an **acute attack** can precipitate further flares and should generally be avoided until the inflammation has resolved. *Colchicine 0.5 mg every 6 hours* - While used for acute gout, it has a narrow **therapeutic window** and carries a significant risk of **gastrointestinal toxicity** if not dosed correctly or if renal function is impaired. - It is typically reserved as an alternative when **NSAIDs** are contraindicated or if the patient presents within 24-36 hours of symptom onset. *Allopurinol 100 mg twice daily* - Like febuxostat, this is a **urate-lowering therapy** (xanthine oxidase inhibitor) used for the chronic prevention of gout. - Starting this medication during an active, painful flare is contraindicated as it may exacerbate or prolong the **acute gouty inflammation**.

Q: A patient (drug abuser) presents with pain in the right upper quadrant, fever, chills with rigor, anorexia. The patient was HIV positive with increased enzymes. What is the likely diagnosis?

Liver abscess. ***Liver abscess*** - The classic triad of **right upper quadrant pain**, **fever with chills/rigors**, and potential hepatomegaly points strongly toward **liver abscess**, particularly in immunocompromised patients (e.g., **HIV**). - Intravenous **drug abuse** is a significant risk factor for pyogenic abscesses due to the potential for seeded infection or compromised immune status. *HCC* - Usually presents with **weight loss**, abdominal mass, or decompensation in patients with underlying **cirrhosis** or chronic hepatitis B/C. - While liver enzymes may be elevated, the acute febrile illness with rigors is more characteristic of an infectious process rather than a malignancy. *Hydatid cyst* - Typically presents as an **asymptomatic abdominal mass** or localized pain due to mass effect; it is not commonly associated with systemic symptoms like high fever and rigors unless there is superinfection or rupture. - Generally manifests as a fluid-filled cystic lesion on imaging with specific signs like **daughter cysts** rather than abscess features. *Liver METS* - Often presents with hepatomegaly, anorexia, and **weight loss**, but fever is a less common presenting feature unless the primary tumor is necrotic or there is extensive disease burden. - Usually diagnosed by identifying a primary malignancy elsewhere, and clinical presentation is typically chronic/subacute rather than acute infectious mimicry.

Q: A patient presents with signs of early vitamin A deficiency. Based on clinical findings, which of the following is the earliest manifestation on the skin or eyes?

Night blindness. ***Night blindness*** - **Night blindness** (nyctalopia) is the earliest clinical manifestation of **vitamin A deficiency** due to the depletion of **rhodopsin** in the rod cells of the **retina**. - It represents a functional impairment of dark adaptation before any structural ocular changes occur in the conjunctiva or cornea. *Conjunctival xerosis* - This finding appears after night blindness and manifests as dryness, thickening, and wrinkling of the **conjunctiva**, often followed by **Bitot spots**. - It is a structural abnormality resulting from keratinization of the epithelial cells, which happens later in the progression of the deficiency. *Corneal xerosis* - This condition involves the drying of the **cornea** due to reduced production of **mucus**-secreting goblet cells and subsequent **keratinization**. - It is a more advanced sign than conjunctival xerosis and indicates a significant, prolonged lack of **retinol**. *Corneal ulceration* - This is a severe, late-stage complication known as **keratomalacia**, which leads to liquefactive necrosis and potential permanent blindness. - It represents the terminal phase of ocular involvement in **vitamin A deficiency** and is significantly preceded by earlier signs like xerosis and Bitot spots.

Q: A 35-year-old man presents with headache and neck stiffness for 5 days. Lumbar puncture reveals the following CSF findings: 90% lymphocytes and 10% neutrophils with CSF glucose: 40 mg/dL (Plasma glucose: 100mg/dL), protein is 1 gm/dl. What is the most likely diagnosis?

Tubercular meningitis. ***Tubercular meningitis*** - The CSF profile shows **lymphocytic pleocytosis** with a **low glucose** (CSF:Blood glucose ratio < 0.5) and **markedly elevated protein**, which is the hallmark of **tuberculous meningitis**. - The clinical course of typically **subacute onset** (lasting days to weeks) and the specific CSF findings of **hypoglycorrachia** (low glucose) are classic indicators for this diagnosis. *Viral meningitis* - While CSF lymphocytosis is common, viral meningitis typically presents with **normal CSF glucose** levels. - Protein levels are usually **normal or only mildly elevated**, unlike the significant elevation seen in this patient. *Bacterial meningitis* - Characterized by a **neutrophilic pleocytosis** rather than lymphocytic, and usually presents with a much more **acute, fulminant onset**. - CSF glucose is typically very low, but the cell count composition in bacterial cases is predominantly **PMNs (polymorphonuclear leukocytes)**. *Fungal meningitis* - Fungal meningitis is less common in immunocompetent individuals and usually follows a very prolonged, chronic course often associated with **basal meningeal enhancement**. - While it can manifest similarly to tubercular meningitis, the epidemiologic context and the **specific clinical presentation** make tuberculosis a statistically more probable diagnosis in this scenario.

Q: Interpret the acid-base status for the following lab values. HCO3-14; PaCO2 -24; pH-7.4.

Metabolic acidosis with compensation. ***Metabolic acidosis with compensation*** - The **bicarbonate (HCO3) of 14 mEq/L** is low, indicating a **primary metabolic acidosis**. - The **pH of 7.4** is within the normal range, indicating **complete respiratory compensation** via hyperventilation, which is reflected by the low PaCO2. *Respiratory acidosis without compensation* - This condition would present with a **low pH ( 7.45)** and a low PaCO2, typically caused by hyperventilation without an underlying metabolic disturbance. - In this scenario, the primary abnormality is the **low HCO3**, not the PaCO2. *Metabolic alkalosis with compensation* - This disorder typically presents with an **elevated HCO3 (>28 mEq/L)** as the primary finding. - Patients with metabolic alkalosis would manifest a **high pH**, which is not observed in this case.

Q: A child presents with easy bruising and bleeding. Physical examination reveals multiple ecchymoses and purpuric lesions over the body, as shown in the image. Hemarthrosis is absent. Deficiency of which vitamin best explains these findings?

Vitamin C. ***Vitamin C*** - Deficiency leads to **scurvy**, characterized by defective **collagen synthesis** due to the inability to hydroxylate proline and lysine residues. - Clinical features include **perifollicular hemorrhages**, swollen/bleeding gums, **petechiae**, and easy bruising, which aligns with the child's presentation. *Vitamin K* - Deficiency primarily causes coagulopathy, leading to deep tissue bleeding or **hemarthrosis** rather than exclusively cutaneous findings. - It relies on clotting factors II, VII, IX, and X, typically resulting in an elevated **prothrombin time (PT)** and PTT. *Vitamin D* - Deficiency leads to **rickets** in children or osteomalacia in adults due to impaired calcium and phosphate absorption, causing **bone deformities** and fractures. - It does not cause bleeding diathesis or spontaneous purpuric lesions in the absence of severe liver disease or complications. *Vitamin A* - Deficiency typically presents with **night blindness**, dry eyes (xerophthalmia), and **keratomalacia** due to impaired ocular epithelial maintenance. - Dermatological manifestations involve **follicular hyperkeratosis** (phrynoderma), not purpura or easy bruising.

Q: A pregnant woman has anemia despite adequate treatment with iron and folic acid. Her hemoglobin remains 9 g/dL but she is still asymptomatic. What is the most likely diagnosis?

Thalassemia trait. ***Thalassemia trait*** - This condition presents with **microcytic hypochromic anemia** that is typically refractory to **iron supplementation** because it is a genetic defect in globin synthesis, not an iron deficiency. - It is frequently identified during pregnancy as **asymptomatic, mild anemia** that fails to respond to standard **hematinics**. *Sickle cell anemia* - Usually presents with more severe clinical manifestations like **vaso-occlusive crises**, **hemolysis**, and **jaundice**, rather than being asymptomatic. - Often diagnosed earlier in life, and the blood smear typically shows **sickled cells** or **target cells** along with evidence of chronic hemolysis. *Thalassemia major* - Presents with severe, **transfusion-dependent anemia** starting from childhood, making it unlikely for a patient to remain asymptomatic during pregnancy. - Associated with significant complications like **hepatosplenomegaly**, **skeletal deformities**, and **iron overload**. *Hereditary spherocytosis* - Characterized by **hemolytic anemia** with findings of **jaundice** and **splenomegaly** due to extravascular hemolysis. - Peripheral blood smears typically reveal **spherocytes** and an increased **mean corpuscular hemoglobin concentration (MCHC)**.

Q: A 45-year-old farmer from Northeast India presents with low-grade fever, progressive weight loss, night sweats, and productive cough. Chest CT reveals upper lobe cavitary lesions. Lung biopsy shows granulomatous inflammation with caseous necrosis and abundant histiocyte infiltration. What is the most likely diagnosis?

Histoplasmosis. ***Histoplasmosis*** - In endemic areas, chronic pulmonary histoplasmosis commonly presents in older adults with pre-existing lung disease, manifesting with symptoms mimicking tuberculosis such as **fever**, **weight loss**, and **productive cough**. - The histopathological finding of **granulomatous inflammation with caseous necrosis** is characteristic of fungal infections, and the specific geography and presentation support a diagnosis of disseminated or chronic pulmonary fungal infection. *Aspergillosis* - Pulmonary aspergillosis, particularly aspergilloma, occurs in pre-existing cavities and typically presents with **hemoptysis** rather than systemic granulomatous disease. - Histopathology would reveal **septate hyphae with acute angle branching**, not the caseous granulomas seen in this patient. *Sarcoidosis* - Sarcoidosis presents with **non-caseating granulomas**, which helps distinguish it from infectious causes like tuberculosis or fungal infections that typically create caseous necrosis. - While it can manifest with cough and weight loss, the classic association with **caseous necrosis** strongly points away from this diagnosis. *Cryptococcosis* - Pulmonary cryptococcosis is often asymptomatic or mild in immunocompetent hosts, and when it does cause disease, it typically presents with **gelatinous pseudocysts** or localized nodules rather than classic upper lobe cavitary lesions. - The causative organism, *Cryptococcus neoformans*, would show **narrow-based budding yeast with thick polysaccharide capsules** on staining, distinct from the histiocytic granulomatous reaction described.

Q: A patient presents to the emergency room with breathlessness. Cardiac causes are suspected but need to be differentiated from obstructive lung disease. Which of the following features is more characteristic of heart failure?

Air hunger. ***Air hunger*** - Air hunger, often described as a sensation of suffocation or inability to get enough air, is a classic, though non-specific, symptom commonly associated with heart failure and elevated pulmonary venous pressure. - Unlike the mechanical obstruction felt in lung diseases, air hunger in cardiac patients typically results from pulmonary congestion and the stimulation of J receptors in the lungs. *Chest tightness* - Chest tightness is a hallmark symptom of myocardial ischemia (angina) or severe bronchoconstriction seen in asthma/COPD. - While it can be associated with cardiac ischemia, it is not a specific descriptor for the symptom of breathlessness compared to obstructive lung disease. *Not able to take deep breath* - This description, often termed 'sighing dyspnea' or perception of restricted chest expansion, is frequently associated with anxiety or restrictive lung diseases. - It is less specific to the hemodynamically driven pulmonary congestion seen in chronic heart failure. *Intermittent wheezing* - Intermittent wheezing is a primary manifestation of obstructive airway diseases such as asthma or COPD, where airflow is obstructed. - 'Cardiac asthma' is a presentation of heart failure involving wheezing, but it is less characteristic and typically presents with other signs like orthopnea or PND rather than being a standalone differentiating feature.

Q: A patient presents with hypercalcemia due to malignancy. According to the correct sequence of management, what should be the first step?

Intravenous rehydration with normal saline. ***Intravenous rehydration with normal saline*** - **Volume expansion** with intravenous normal saline is the first-line treatment for **hypercalcemia of malignancy** to restore intravascular volume and promote **calciuresis**. - This step is critical because patients are often dehydrated due to **nephrogenic diabetes insipidus** and vomiting induced by high calcium levels, which exacerbates the hypercalcemia. *Administration of loop diuretics* - Loop diuretics, such as **furosemide**, should only be considered after the patient has been **adequately rehydrated**. - Routine use is discouraged unless there is evidence of **fluid overload** or renal failure, as they can cause further electrolyte imbalances like hypokalemia and hypomagnesemia. *Administration of bisphosphonates* - Bisphosphonates like **zoledronic acid** or **pamidronate** are essential for long-term control by inhibiting **osteoclast** activity. - However, they have a **delayed onset of action** (typically 2-4 days), so they are not the initial treatment step for acute stabilization. *Other supportive measures* - Measures such as **calcitonin** or **dialysis** are reserved for refractory cases or severe symptoms where rapid calcium reduction is required alongside saline and bisphosphonates. - These are not the first-line initial interventions as they do not address the primary issue of fluid volume depletion immediately.

Question 1

A 55-year-old male presents with sudden onset of severe pain, redness, and swelling of the foot as shown in the image below. There is no history of trauma. Serum uric acid is 9 mg/dL. What is the best acute management at this stage?

Accepted Answer

Indomethacin 50 mg three times a day

Answer

Febuxostat 40 mg once daily

Answer

Colchicine 0.5 mg every 6 hours

Answer

Allopurinol 100 mg twice daily

Question 2

A patient (drug abuser) presents with pain in the right upper quadrant, fever, chills with rigor, anorexia. The patient was HIV positive with increased enzymes. What is the likely diagnosis?

Accepted Answer

Liver abscess

Answer

HCC

Answer

Hydatid cyst

Answer

Liver METS

Question 3

A patient presents with signs of early vitamin A deficiency. Based on clinical findings, which of the following is the earliest manifestation on the skin or eyes?

Accepted Answer

Night blindness

Answer

Conjunctival xerosis

Answer

Corneal xerosis

Answer

Corneal ulceration

Question 4

A 35-year-old man presents with headache and neck stiffness for 5 days. Lumbar puncture reveals the following CSF findings: 90% lymphocytes and 10% neutrophils with CSF glucose: 40 mg/dL (Plasma glucose: 100mg/dL), protein is 1 gm/dl. What is the most likely diagnosis?

Accepted Answer

Tubercular meningitis

Answer

Viral meningitis

Answer

Bacterial meningitis

Answer

Fungal meningitis

Question 5

Interpret the acid-base status for the following lab values. HCO3-14; PaCO2 -24; pH-7.4.

Accepted Answer

Metabolic acidosis with compensation

Answer

Respiratory acidosis without compensation

Answer

Respiratory alkalosis without compensation

Answer

Metabolic alkalosis with compensation

Question 6

A child presents with easy bruising and bleeding. Physical examination reveals multiple ecchymoses and purpuric lesions over the body, as shown in the image. Hemarthrosis is absent. Deficiency of which vitamin best explains these findings?

Accepted Answer

Vitamin C

Answer

Vitamin K

Answer

Vitamin D

Answer

Vitamin A

Question 7

A pregnant woman has anemia despite adequate treatment with iron and folic acid. Her hemoglobin remains 9 g/dL but she is still asymptomatic. What is the most likely diagnosis?

Accepted Answer

Thalassemia trait

Answer

Sickle cell anemia

Answer

Thalassemia major

Answer

Hereditary spherocytosis

Question 8

A 45-year-old farmer from Northeast India presents with low-grade fever, progressive weight
loss, night sweats, and productive cough. Chest CT reveals upper lobe cavitary lesions. Lung
biopsy shows granulomatous inflammation with caseous necrosis and abundant histiocyte
infiltration. What is the most likely diagnosis?

Accepted Answer

Histoplasmosis

Answer

Aspergillosis

Answer

Sarcoidosis

Answer

Cryptococcosis

Question 9

A patient presents to the emergency room with breathlessness. Cardiac causes are suspected
but need to be differentiated from obstructive lung disease. Which of the following features is more
characteristic of heart failure?

Accepted Answer

Air hunger

Answer

Chest tightness

Answer

Not able to take deep breath

Answer

Intermittent wheezing

Question 10

A patient presents with hypercalcemia due
to malignancy. According to the correct sequence of management, what should be the first step?

Accepted Answer

Intravenous rehydration with normal saline

Answer

Administration of loop diuretics

Answer

Administration of bisphosphonates

Answer

Other supportive measures

Clinical Manifestations and Presentation of Diseases — MCQs

Clinical Manifestations and Presentation of Diseases — MCQs

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