Constitutional Symptoms and Their Differential Diagnosis — MCQs
An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis? - Hb - 6.9 g/dl
Central obesity is seen in;
Which of the following conditions is the most common cause of unintentional weight loss in elderly patients?
A 30-year-old male presents with chills and a high fever of 40°C. Which of the following symptoms would most likely suggest an infectious cause?
How many blood samples should be drawn in cases of fever of unknown origin to optimize detection of intermittent bacteremia?
In a patient with general fatigue, normal TLC/ DLC, and superficial discrete lymphadenopathy, with lymph node biopsy showing effaced architecture, atypical cells with indented nuclei and prominent nucleoli, positive for CD10 and BCL-2, which of the following is the most likely diagnosis?
Insane paresis is associated with -
Identify the condition given in the image below?
A patient presents with fatigue and is not gaining weight. The body temperature is warm. What would the investigation likely show?
Which of the following conditions is least likely to cause multiple painful ulcers on the tongue?
Constitutional Symptoms and Their Differential Diagnosis Indian Medical PG Practice Questions and MCQs
Question 1: An elderly woman presented with confusion, thirst, and abdominal pain symptoms. On examination, she had pallor and thoracic spine tenderness. X-ray spine showed osteolytic lesions. Her lab investigations showed the following findings. What is the most likely diagnosis? - Hb - 6.9 g/dl
- A. Vertebral compression fracture
- B. Metastatic carcinoma
- C. Osteoporosis
- D. Multiple myeloma (Correct Answer)
Explanation: ***Multiple myeloma*** - The combination of **osteolytic lesions** (bone pain, tenderness), **hypercalcemia** (confusion, thirst), **anemia** (Hb 69 g/dl, pallor), and **renal insufficiency** (confusion, thirst from dehydration) is highly suggestive of **multiple myeloma** [1]. - This plasma cell malignancy leads to excessive production of monoclonal antibodies and bone destruction [1]. *Vertebral compression fracture* - While **thoracic spine tenderness** and osteolytic lesions could be a component, it doesn't fully explain the systemic symptoms such as **anemia**, **confusion**, and **hypercalcemia**. - A simple compression fracture would not account for the profound **anemia** (Hb 69 g/dl) seen in this patient. *Metastatic carcinoma* - While metastatic carcinoma can cause **osteolytic lesions**, **anemia**, and sometimes **hypercalcemia**, the specific constellation of symptoms, particularly the severity of anemia and rapid progression, makes **multiple myeloma** a more fitting diagnosis. - Absence of primary tumor indicates that it is not a metastatic disease [1]. *Osteoporosis* - **Osteoporosis** can cause vertebral fractures and bone pain but typically does not lead to **osteolytic lesions**, **severe anemia**, or **hypercalcemia** [2]. - The bone changes in osteoporosis are primarily due to decreased bone density, not destructive lesions [2].
Question 2: Central obesity is seen in;
- A. Crohn's disease
- B. Celiac disease
- C. Cushing's disease (Correct Answer)
- D. Conn's disease
Explanation: ***Cushing's disease*** - **Cushing's disease** is characterized by **excessive cortisol production**, leading to fat redistribution, including **central obesity** with a 'buffalo hump' and 'moon face' [1]. - **Cortisol's metabolic effects** promote increased visceral fat accumulation and breakdown of peripheral fat [1]. *Crohn's disease* - **Crohn's disease** is an **inflammatory bowel disease** that typically causes **weight loss**, abdominal pain, and diarrhea due to malabsorption and inflammation. - While patients can develop complications like **fistulas** and **abscesses**, central obesity is not a primary feature. *Celiac disease* - **Celiac disease** is an **autoimmune disorder** triggered by gluten, leading to **malabsorption** and usually presenting with **weight loss**, diarrhea, and nutrient deficiencies. - Central obesity is **not a typical presentation** and would be contradictory to the malabsorptive state. *Conn's disease* - **Conn's disease**, or primary aldosteronism, involves **excessive aldosterone** production, primarily causing **hypertension** and hypokalemia. - It **does not directly cause central obesity**; its metabolic effects are unrelated to fat distribution.
Question 3: Which of the following conditions is the most common cause of unintentional weight loss in elderly patients?
- A. Hyperthyroidism
- B. Diabetes mellitus
- C. Malignancy (Correct Answer)
- D. Chronic obstructive pulmonary disease
Explanation: ***Malignancy*** - **Malignancy** is the most common cause of unintentional weight loss in elderly patients, accounting for 20-30% of cases [1]. - Cancers often increase **metabolic demand** and produce cytokines that can cause **cachexia**, leading to significant weight loss [1]. *Hyperthyroidism* - While hyperthyroidism can cause **unintentional weight loss** due to an increased metabolic rate, it is less common than malignancy as a cause in the elderly population. - Other typical symptoms of hyperthyroidism, such as **tachycardia**, **tremors**, and **heat intolerance**, would usually be present. *Diabetes mellitus* - **Uncontrolled diabetes** (especially type 1 or severe type 2) can lead to weight loss due to **glucosuria** and fat/muscle breakdown. - However, it is not as frequent a cause of unintentional weight loss in the elderly as malignancy, and would often be accompanied by symptoms like **polyuria**, **polydipsia**, and **blurred vision**. *Chronic obstructive pulmonary disease* - Severe **COPD** can lead to weight loss due to increased **work of breathing**, **systemic inflammation**, and reduced oral intake. - While a significant cause of weight loss in some elderly patients, overall prevalence as the primary cause of unintentional weight loss is lower than malignancy.
Question 4: A 30-year-old male presents with chills and a high fever of 40°C. Which of the following symptoms would most likely suggest an infectious cause?
- A. Rigors (Correct Answer)
- B. Excessive sweating
- C. Skin rash
- D. Vomiting
Explanation: ***Rigors*** - **Rigors** (generalized shivering with a sensation of cold) are strong indicators of a rapid and significant rise in body temperature, often seen with **bacteremia** or other severe infections [1]. - The body's defense mechanisms are fighting off a severe infection, leading to an exaggerated physiological response. *Excessive sweating* - **Excessive sweating (diaphoresis)** typically occurs as the body attempts to cool down during the defervescence (fever reduction) phase [1]. - While associated with fever, it is less specific for the *onset* or active phase of an infection compared to rigors [1]. *Skin rash* - A **skin rash** can be a symptom of certain infections (e.g., viral exanthems, meningococcemia) but is not a universal or primary indicator of *any* infectious cause [2]. - Many febrile illnesses do not present with a rash, and rashes can also be non-infectious in origin (e.g., allergic reactions). *Vomiting* - **Vomiting** can accompany many illnesses, both infectious (e.g., gastroenteritis, meningitis) and non-infectious (e.g., migraine, drug reaction). - It is a non-specific symptom that does not singularly point to an infectious etiology as strongly as rigors in the context of a high fever.
Question 5: How many blood samples should be drawn in cases of fever of unknown origin to optimize detection of intermittent bacteremia?
- A. 2
- B. 3 (Correct Answer)
- C. 1
- D. 4
Explanation: ***3*** - Drawing **three separate blood samples** significantly increases the likelihood of detecting intermittent bacteremia, as bacteria may not always be present in high concentrations in the bloodstream. - This practice maximizes the diagnostic yield while minimizing the risk of false positives from contamination. *1* - A single blood sample has a **low sensitivity** for detecting intermittent bacteremia, as transient presence of bacteria might be missed. - Relying on one sample increases the chance of a **false negative**, delaying appropriate treatment. *2* - While two samples are better than one, they still may not be sufficient to reliably detect **intermittent bacteremia** which can fluctuate. - This quantity might be acceptable for some conditions but is suboptimal for robust exclusion of **bacteremia in FUO** [1]. *4* - While four samples might slightly increase sensitivity over three, the **incremental benefit** in diagnostic yield is often negligible. - This approach adds to the **patient discomfort** and increases resource utilization without substantial additional diagnostic value.
Question 6: In a patient with general fatigue, normal TLC/ DLC, and superficial discrete lymphadenopathy, with lymph node biopsy showing effaced architecture, atypical cells with indented nuclei and prominent nucleoli, positive for CD10 and BCL-2, which of the following is the most likely diagnosis?
- A. Mycosis Fungoides
- B. Burkitt's Lymphoma
- C. Follicular Lymphoma (Correct Answer)
- D. Hodgkin Lymphoma
Explanation: ***Follicular Lymphoma*** - The description of **atypical cells with indented nuclei** (cleaved cells) and **prominent nucleoli**, along with **CD10** and **BCL-2 positivity**, are classic features of follicular lymphoma [1], [2]. - **Effaced architecture** of the lymph node, and **superficial discrete lymphadenopathy** in an adult, further support this diagnosis [1]. *Mycosis Fungoides* - This is a **cutaneous T-cell lymphoma** characterized by skin lesions (patches, plaques, tumors) and rarely involves lymph nodes in the early stages. - It would show **CD3+ T-cells** on immunophenotyping, not CD10+ B-cells. *Burkitt's Lymphoma* - Characterized by rapidly growing tumors and a **"starry sky"** histological pattern with numerous macrophages [3]. - While it is CD10 positive, it would typically be **BCL-2 negative** due to the specific translocation involved (t(8;14) c-MYC/IgH). *Hodgkin Lymphoma* - Defined by the presence of **Reed-Sternberg cells** (large, multinucleated cells with prominent nucleoli, often described as "owl's eye" appearance). - These cells are typically **CD15+ and CD30+**, and BCL-2 expression is less specific and CD10 is not characteristic. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 561-562. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 602-604. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, p. 606.
Question 7: Insane paresis is associated with -
- A. Leishmaniasis
- B. Yellow fever
- C. Syphilis (Correct Answer)
- D. Neisseria meningitidis
Explanation: ***Syphilis*** - **General paresis**, or "insane paresis," is a neuropsychiatric manifestation of **tertiary syphilis**, resulting from chronic meningoencephalitis. - It presents with progressive **dementia**, personality changes, delusions, and neurological deficits. *Leishmaniasis* - This parasitic disease is characterized by various forms including **cutaneous**, **mucocutaneous**, and **visceral leishmaniasis** (kala-azar). - It typically causes skin lesions, mucocutaneous destruction, or systemic symptoms like fever, hepatosplenomegaly, and pancytopenia, but not general paresis. *Yellow fever* - **Yellow fever** is a viral hemorrhagic disease transmitted by mosquitoes, primarily affecting the liver and kidneys. - Symptoms include fever, jaundice, hemorrhage, and shock, but not the neurological degeneration seen in general paresis. *Neisseria meningitidis* - This bacterium causes **meningococcal meningitis** and **meningococcemia**, which are acute and severe infectious diseases. - While it can lead to acute neurological symptoms due to meningitis, it does not cause the chronic, progressive neuropsychiatric syndrome known as general paresis.
Question 8: Identify the condition given in the image below?
- A. Chronic lymphedema (Correct Answer)
- B. Cushing syndrome
- C. Osteoporosis
- D. None of the options
Explanation: ***Chronic lymphedema*** - The image shows a **swollen foot** with **thickened, dry, and hyperkeratotic skin**, and **deep skin folds**, particularly between the toes. This is characteristic of **chronic lymphedema** due to impaired lymphatic drainage. - The presence of the **Stemmer's sign** (inability to pinch and lift the skin at the base of the second toe) is a common finding in lymphedema, which can be inferred from the overall appearance of the toes. *Cushing syndrome* - Cushing syndrome is characterized by **central obesity**, **moon facies**, **buffalo hump**, and **thin, fragile skin** with **striae**, not typically severe localized edema and skin changes as seen in the image. - While fluid retention can occur, it does not manifest as the characteristic cutaneous changes of chronic lymphedema. *Osteoporosis* - Osteoporosis is a condition of **decreased bone density**, making bones fragile and prone to fractures. - It does not present with visible skin changes or edema as depicted in the image. *None of the options* - The image clearly shows severe manifestations identifiable as **chronic lymphedema**, therefore one of the provided options is correct.
Question 9: A patient presents with fatigue and is not gaining weight. The body temperature is warm. What would the investigation likely show?
- A. High TSH with normal T3 and T4
- B. Low TSH with elevated T3 and/or T4 (Correct Answer)
- C. Elevated T4 with suppressed T3
- D. Normal TSH with low T3 and T4
Explanation: **Low TSH with elevated T3 and/or T4** - **Fatigue** not gaining weight, and a **warm body temperature** are classic symptoms of **hyperthyroidism** [1]. - In hyperthyroidism, the thyroid gland overproduces T3 and T4, leading to a compensatory **decrease in TSH** from the pituitary gland [1]. *High TSH with normal T3 and T4* - This profile, known as **subclinical hypothyroidism**, would typically present with symptoms of reduced metabolism, such as **weight gain** and **cold intolerance**, which contradict the patient's presentation [1]. - While fatigue can be present in hypothyroidism, the **warm body temperature** and lack of weight gain point away from this diagnosis. *Elevated T4 with suppressed T3* - This scenario is uncommon and points towards an issue with the **conversion of T4 to T3**, which is generally not the primary mechanism behind classic hyperthyroidism symptoms. - In most hyperthyroid states, both T3 and T4 levels are elevated, or T3 elevation is more predominant, reflecting increased thyroid hormone production. *Normal TSH with low T3 and T4* - This pattern is inconsistent with normal thyroid function and does not fit the typical presentation of either hyperthyroidism or hypothyroidism. - **Low T3 and T4** with normal TSH could indicate **central hypothyroidism**, but this would typically present with hypothyroid symptoms like weight gain and cold intolerance, not a warm body temperature [1].
Question 10: Which of the following conditions is least likely to cause multiple painful ulcers on the tongue?
- A. TB
- B. Herpes
- C. Behcet disease
- D. Sarcoidosis (Correct Answer)
Explanation: ***Sarcoidosis*** - While sarcoidosis can affect any organ, **oral involvement is rare** and typically presents as **nodules, plaques, or generalized swelling**, not usually multiple painful ulcers on the tongue. - The lesions, when they occur, are often **painless** and appear as submucosal nodules, red patches, or diffuse swelling. *TB* - Oral tuberculosis can present as **multiple painful ulcers** on the tongue, often with a **granulomatous appearance** mimicking squamous cell carcinoma. - These ulcers are typically **irregular, undermined, and persistent**, often associated with pulmonary TB. *Herpes* - **Herpes simplex virus (HSV)** infection, particularly primary herpetic gingivostomatitis, commonly causes **multiple painful ulcers** on the tongue, gums, and other oral mucosa. - These ulcers begin as vesicles that **rupture to form painful erosions** and are a classic presentation of oral herpes. *Behcet disease* - **Oral aphthous ulcers** are a hallmark feature of Behcet disease, commonly presenting as **multiple, recurrent, painful ulcers** on the tongue and other oral mucosal surfaces. - These ulcers are clinically indistinguishable from common aphthous stomatitis but are more frequent and often associated with genital ulcers, skin lesions, and ocular inflammation.
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