Clinical Manifestations and Presentation of Diseases — MCQs

Clinical Manifestations and Presentation of Diseases Indian Medical PG Practice Questions and MCQs

Question 91: Consider the following pleural fluid analysis : pH-7.6 Pleural fluid protein -0.5 g / dL Serum total protein -6.5 g / dL Pleural fluid LDH - 100 U / L Serum LDH - 300 U / L What is the most likely diagnosis?

A. Sarcoidosis
B. Myxedema (Correct Answer)
C. Rheumatoid arthritis
D. Pancreatitis

Explanation: ***Myxedema*** - The pleural fluid analysis shows a **transudative effusion** (pleural fluid protein/serum protein ratio < 0.5 and pleural fluid LDH/serum LDH ratio < 0.6), a characteristic of myxedema (hypothyroidism) [1]. - While other causes of transudates exist, a **high pH** in a transudate, as seen here (pH 7.6), is suggestive of myxedema or a parapneumonic effusion that is not infected, but the latter would likely be an exudate [1]. *Sarcoidosis* - Sarcoidosis typically causes an **exudative pleural effusion**, characterized by higher protein and LDH levels in the pleural fluid. - The pleural fluid pH in sarcoidosis is usually normal to slightly low, but not as high as 7.6 in an exudative process. *Rheumatoid arthritis* - Pleural effusions due to rheumatoid arthritis are typically **exudative**, with low glucose and very low pH (often <7.0 to 7.1) [1]. - The given pleural fluid composition does not match the typical findings of a rheumatoid effusion. *Pancreatitis* - Pancreatitis can cause an **exudative pleural effusion**, particularly on the left side, with very high amylase levels. - The protein and LDH ratios in this case are consistent with a transudate, not an exudate as seen in pancreatitis.

Question 92: A typical case of Iron Deficiency Anaemia (IDA) in pregnancy will show which of the following? 1. Hb less than 10 g/dL 2. PCV less than 30% 3. MCHC more than 30% 4. Microcytic hypochromic picture on peripheral blood smear (PBS). Select the correct answer using the code given below:

A. 1, 2 and 4 (Correct Answer)
B. 1, 2 and 3
C. 2, 3 and 4
D. 1 and 4 only

Explanation: ***1, 2 and 4*** - All three options (Hb < 10 g/dL, PCV < 30%, and microcytic hypochromic picture on PBS) are characteristic features of **iron deficiency anemia (IDA)** in pregnancy [1]. - While exact thresholds can vary, these values generally indicate significant anemia and the classic morphological changes associated with IDA [1]. *1, 2 and 3* - This option incorrectly includes "MCHC more than 30%." IDA is characterized by **hypochromia**, meaning **MCHC (mean corpuscular hemoglobin concentration)** is typically *less than* 30%, not more [1]. - The other two points (Hb < 10 g/dL and PCV < 30%) are consistent with IDA [1]. *2, 3 and 4* - This option incorrectly includes "MCHC more than 30%," which is contrary to the **hypochromic** nature of IDA [1]. - While PCV < 30% and microcytic hypochromic picture on PBS are correct, the inclusion of incorrect MCHC value makes this choice invalid. *1 and 4 only* - This option correctly identifies Hb less than 10 g/dL and a microcytic hypochromic picture on PBS as features of IDA [1]. - However, it omits **PCV less than 30%**, which is also a common finding in IDA, making it an incomplete answer compared to the most comprehensive correct option.

Question 93: Consider the following clinical features : 1. Low back pain 2. Saddle anaesthesia 3. Motor weakness in the lower extremities 4. Variable rectal and urinary symptoms Which of the above features may be present in a patient with Cauda Equina syndrome ?

A. 1, 2, 3 and 4 (Correct Answer)
B. 1, 2 and 3 only
C. 1 and 2 only
D. 3 and 4 only

Explanation: ***1, 2, 3 and 4*** - **Cauda equina syndrome** is a serious neurological condition involving compression of the cauda equina nerve roots, typically manifesting with **low back pain**, **saddle anesthesia**, and **motor weakness** in the lower extremities [1]. - The compression of the nerve roots can also lead to varying degrees of **rectal and urinary dysfunction**, including incontinence or retention, depending on which nerve roots are affected [2]. *1, 2 and 3 only* - While **low back pain**, **saddle anesthesia**, and **motor weakness** are prominent features of cauda equina syndrome, this option incorrectly excludes the crucial symptom of **rectal and urinary dysfunction**. - **Bladder and bowel dysfunction**, along with sexual dysfunction, are hallmark symptoms resulting from the involvement of sacral nerve roots in cauda equina compression [2]. *1 and 2 only* - This option correctly identifies **low back pain** and **saddle anesthesia** as features but omits two critical components of cauda equina syndrome: **motor weakness** and **rectal/urinary symptoms** [1]. - Without considering **motor weakness** and **sphincter dysfunction**, the diagnostic picture of cauda equina syndrome is incomplete, potentially delaying necessary surgical intervention [3]. *3 and 4 only* - This option incorrectly suggests that **motor weakness** and **rectal/urinary symptoms** are the only relevant features, excluding the highly characteristic **low back pain** and **saddle anesthesia**. - **Low back pain** is almost universally present and **saddle anesthesia** is a key indicator of sacral nerve root involvement, crucial for distinguishing cauda equina syndrome from other neurological conditions [1].

Question 94: Which of the following are included in the classical clinical presentation of pericardial tamponade ?

A. Muffled heart sounds (Correct Answer)
B. Collapsed neck veins
C. Tachycardia
D. Decreased arterial pressure (Correct Answer)

Explanation: ***Muffled heart sounds*** - Pericardial tamponade involves an accumulation of fluid in the **pericardial sac**, which dampens sound transmission and results in **muffled heart sounds** [1]. - This is a key component of **Beck's triad**, indicating compromised cardiac filling. *Collapsed neck veins* - In pericardial tamponade, there is a significant increase in **intrapericardial pressure**, which impedes venous return to the heart [1]. - This typically leads to **distended neck veins** (elevated jugular venous pressure), not collapsed ones. *Tachycardia* - While **tachycardia** can be present as a compensatory mechanism due to reduced cardiac output in tamponade, it is a non-specific finding. - It is not considered part of the **classical Beck's triad**, which specifically focuses on the triad of muffled heart sounds, hypotension, and elevated jugular venous pressure. ***Decreased arterial pressure*** - The increased intrapericardial pressure in tamponade severely restricts **ventricular filling**, leading to a reduction in stroke volume and subsequently **decreased cardiac output** [1], [2]. - This reduction in cardiac output manifests as systemic **hypotension** (decreased arterial pressure), which is a critical finding in tamponade.

Question 95: Which one of the following is a cause of exudative ascites ?

A. Nephrotic syndrome
B. Peritoneal malignancy (Correct Answer)
C. Portal vein thrombosis
D. Congestive cardiac failure

Explanation: ***Peritoneal malignancy*** - **Malignant cells** can directly or indirectly increase capillary permeability and fluid production within the peritoneal cavity. - This leads to a **high protein content** in the ascitic fluid, characteristic of exudate [1]. *Nephrotic syndrome* - Causes **transudative ascites** due to severe **hypoalbuminemia**, leading to decreased plasma oncotic pressure [1]. - The liver is healthy, and there is no direct inflammation or increased capillary permeability in the peritoneum. *Portal vein thrombosis* - Results in **increased hydrostatic pressure** within the portal circulation, leading to the transudation of fluid into the peritoneal cavity. - The ascitic fluid typically has a **low protein content** as it's a transudate, not an exudate [1]. *Congestive cardiac failure* - Leads to **increased systemic venous pressure** and consequently elevated hepatic sinusoidal and splanchnic capillary pressures [1]. - This causes **transudative ascites** with low protein content due to passive fluid leakage rather than inflammation or direct vascular damage [1].

Question 96: The best position to palpate the minimal enlargement of spleen is :

A. Bimanual palpation in supine position
B. Palpation of left subcostal area in right lateral decubitus position
C. Supine with lower limbs extended (Correct Answer)
D. Palpation of left subcostal area in knee-elbow position

Explanation: ***Supine with lower limbs extended*** - This position allows for optimal relaxation of the abdominal muscles, making it easier to **palpate the spleen** as it descends during inspiration. - In a supine position, the examiner can effectively use techniques like the **hooking method** or palpation from the right side of the patient to detect minimal splenic enlargement. *Bimanual palpation in supine position* - While bimanual palpation is useful for organs like the kidneys, it is generally less effective for detecting minimal splenic enlargement compared to other specialized techniques. - The goal is to feel the spleen as it descends, which is better achieved with precise contact during inspiration rather than a bimanual 'capture'. *Palpation of left subcostal area in right lateral decubitus position* - The **right lateral decubitus position** (Lieper's or Opeczky's position) is indeed used to make a slightly enlarged spleen more prominent by shifting it anteriorly and inferiorly. - However, while helpful for a potentially palpable spleen, the combined supine position with relaxed abdominal muscles can be overall more sensitive for **minimal enlargement** when initially assessing. *Palpation of left subcostal area in knee-elbow position* - The knee-elbow position is primarily used for rectal or vaginal examinations and is not suitable for abdominal palpation, especially for organs like the spleen. - It would make abdominal muscle contraction more likely, hindering effective palpation of the left subcostal area.

Question 97: Which of the following are components of "Klippel-Trenaunay syndrome" ? 1. Cutaneous Naevus 2. Subcutaneous Lipomas 3. Varicose veins 4. Soft tissue hypertrophy Select the correct answer using the code given below :

A. 1, 2 and 3
B. 1, 3 and 4 (Correct Answer)
C. 2, 3 and 4
D. 1, 2 and 4

Explanation: ***1, 3 and 4*** - Klippel-Trenaunay syndrome is characterized by a triad of **capillary malformations (cutaneous naevus)**, **venous malformations (varicose veins)**, and **limb overgrowth (soft tissue hypertrophy)**. - These features are typically present at birth and often affect a single limb or a region of the body. *1, 2 and 3* - This option incorrectly includes **subcutaneous lipomas** as a core component of Klippel-Trenaunay syndrome, which are not typically associated with the condition. - While capillary malformations and varicose veins are characteristic, the inclusion of lipomas makes this option incorrect. *2, 3 and 4* - This option incorrectly includes **subcutaneous lipomas** and omits the essential feature of **cutaneous naevus (capillary malformation)**. - The absence of cutaneous naevus, a hallmark of the syndrome, makes this selection inaccurate. *1, 2 and 4* - This option incorrectly includes **subcutaneous lipomas** and omits **varicose veins**, a key component of the syndrome. - The presence of capillary malformations and soft tissue hypertrophy are correct, but the missing varicose veins and incorrect inclusion of lipomas render this option incorrect.

Question 98: Consider the following clinical features : 1. Raised ICP 2. Seizures 3. Focal deficit 4. Headache Which of the above clinical features are related to most brain tumours?

A. 2, 3 and 4 only
B. 1 and 2 only
C. 1, 2, 3 and 4 (Correct Answer)
D. 1, 2 and 3 only

Explanation: ***1, 2, 3 and 4*** - All four clinical features—**raised ICP**, **seizures**, **focal neurological deficits**, and **headache**—are commonly associated with brain tumors [1]. - Brain tumors can cause **increased intracranial pressure** through mass effect, edema, or CSF flow obstruction, leading to headaches and, less commonly, seizures [1]. **Focal deficits** result from direct tissue destruction or compression depending on the tumor's location [2]. *2, 3 and 4 only* - This option incorrectly omits **raised ICP**, which is a frequent and significant symptom of brain tumors, contributing to headaches, nausea, vomiting, and altered mental status [1]. - While seizures, focal deficits, and headaches are common, **raised ICP** often underlies many of these symptoms. *1 and 2 only* - This option excludes **focal deficits** and **headache**, both of which are very common presentations of brain tumors. - The specific location of a tumor often dictates **focal deficits** [2], and **headache** is one of the most prevalent symptoms. *1, 2 and 3 only* - This option incorrectly omits **headache**, which is a classic and highly prevalent symptom in patients with brain tumors, often severe and resistant to common analgesics. - Headaches can result from **mass effect**, **increased ICP** [1], or irritation of pain-sensitive structures within the brain.

Question 99: Heavy menstrual bleeding is a common presentation in which of the following? 1. Clotting factor deficiency 2. Fibroid uterus 3. Adenomyosis 4. Prolactinoma.

A. 1, 2 and 3 (Correct Answer)
B. 2, 3 and 4
C. 1, 2 and 4
D. 1, 3 and 4

Explanation: ***1, 2 and 3*** - **Clotting factor deficiencies** (e.g., von Willebrand disease, factor XI deficiency) impair normal hemostasis, leading to prolonged and heavy menstrual bleeding. - **Fibroid uterus** causes heavy menstrual bleeding due to increased endometrial surface area, impaired uterine contractility, and dilated underlying vessels. - **Adenomyosis**, characterized by endometrial tissue within the myometrium, leads to an enlarged, boggy uterus and causes heavy and painful menstruation. *2, 3 and 4* - This option correctly identifies fibroid uterus and adenomyosis, which are common causes of heavy menstrual bleeding. - However, **prolactinoma** typically causes **amenorrhea** or oligomenorrhea, not heavy menstrual bleeding, due to its inhibitory effect on gonadotropin-releasing hormone (GnRH). *1, 2 and 4* - While clotting factor deficiency and fibroid uterus are valid causes of heavy menstrual bleeding, **prolactinoma** is an incorrect inclusion. - Prolactinoma often leads to **hypogonadism** and anovulation, resulting in irregular or absent menstrual periods. *1, 3 and 4* - This option includes clotting factor deficiency and adenomyosis, which are causes of heavy menstrual bleeding. - However, **prolactinoma** is not associated with heavy menstrual bleeding; instead, it is known to cause **menstrual irregularities** including amenorrhea.

Question 100: Which organ is PRIMARILY involved in cystic fibrosis?

A. Pancreas
B. Kidney
C. Liver
D. Lungs (Correct Answer)

Explanation: Lungs - The lungs are **primarily affected** in cystic fibrosis due to the dysfunction of the **CFTR protein**, leading to the production of thick, sticky mucus [1]. - This thick mucus obstructs the airways, causing **recurrent infections**, inflammation, and progressive lung damage, which is the leading cause of morbidity and mortality [1], [2]. *Pancreas* - The pancreas is also significantly affected in cystic fibrosis, leading to **exocrine pancreatic insufficiency** and malabsorption. - However, while pancreatic issues are prominent, the **pulmonary complications** are typically the primary cause of severe illness and death [2]. *Kidney* - The kidneys are generally **not directly affected** by the primary pathology of cystic fibrosis. - Renal complications are usually secondary to treatments or long-term systemic effects of the disease. *Liver* - The liver can be affected in cystic fibrosis, leading to **focal biliary cirrhosis** and other hepatobiliary issues. - However, severe liver disease is less common than pulmonary or pancreatic manifestations and usually does not represent the primary organ involved in the acute or chronic progression of the disease.

Practice by Chapter

Approach to Common Symptoms (Fever, Pain, Fatigue)

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Constitutional Symptoms and Their Differential Diagnosis

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Syncope and Presyncope

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Dizziness and Vertigo

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Dyspnea and Respiratory Distress

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Chest Pain Evaluation

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Abdominal Pain Assessment

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Headache Classification and Management

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Weight Loss and Cachexia

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Edema and Fluid Retention

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