Clinical Manifestations and Presentation of Diseases — MCQs

Which of the following statements regarding lymphoedema are correct? 1. Patients experience constant dull ache and even severe pain sometimes 2. Manual lymphatic drainage has a role 3. Primary lymphoedema is caused by congenital lymphatic dysplasia 4. Nonne Milroy's disease is a type of primary lymphoedema Select the correct answer using the code given below:

Q128

A 45-year-old man presents with the following skin changes (as shown in the image). What relevant history should be taken to diagnose this condition?

Q129

Frontal headache is due to inflammation of which sinus?

Q130

Gynecomastia is seen in all except;

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

Question 121: Smoking is associated with all the following diseases except:

A. Sarcoidosis (Correct Answer)
B. Emphysema
C. Cardiovascular disease
D. Lung cancer

Explanation: ***Sarcoidosis*** - **Smoking** has been found to have a protective or null effect on the development of **sarcoidosis**, and it is generally *not* considered a risk factor. - The etiology of sarcoidosis is unknown, but it is thought to involve a combination of genetic predisposition and environmental triggers, none of which strongly implicate smoking. *Emphysema* - **Smoking** is the leading cause of **emphysema**, a type of **COPD**, by causing chronic inflammation and destruction of alveolar walls. - Toxins and irritants in smoke activate inflammatory cells and enzymes, leading to the breakdown of elastic fibers in the lungs. *Cardiovascular disease* - **Smoking** is a major risk factor for various **cardiovascular diseases**, including **atherosclerosis**, **coronary artery disease**, and stroke. - It damages blood vessel walls, increases **blood pressure**, and promotes clot formation, significantly increasing the risk of cardiovascular events. *Lung cancer* - **Smoking** is the primary cause of the vast majority of **lung cancer** cases, with dose-dependent effects on risk [1]. - Carcinogens in tobacco smoke directly damage DNA in lung cells, leading to uncontrolled cell growth and tumor formation [1].

Question 122: Which one of the following is the investigation of choice in a patient with haematemesis?

A. Flexible upper gastrointestinal endoscopy (Correct Answer)
B. Contrast enhanced CT scan
C. Barium meal for stomach and duodenum
D. Selective left gastric angiography

Explanation: ***Flexible upper gastrointestinal endoscopy*** - This is the **investigation of choice** for haematemesis as it allows for direct visualization of the upper gastrointestinal tract to identify the source of bleeding [1]. - It also enables **therapeutic intervention**, such as injection sclerotherapy, banding, or clip application, to stop the bleeding [1]. *Contrast enhanced CT scan* - A CT scan is generally **not the primary investigation** for acute haematemesis because it offers less diagnostic accuracy for mucosal lesions and cannot provide therapeutic intervention [1]. - While it can identify large bleeds or structural abnormalities, it is **less sensitive for smaller bleeds** or subtle mucosal abnormalities compared to endoscopy. *Barium meal for stomach and duodenum* - A barium meal is **contraindicated in acute gastrointestinal bleeding** as the barium can obscure endoscopic views and interfere with subsequent attempts at endoscopy or angiography [1]. - It provides **limited diagnostic information** about the active bleeding site and offers no therapeutic capabilities. *Selective left gastric angiography* - Angiography is typically reserved for cases of **severe, persistent bleeding** where endoscopy has failed to locate or control the bleed. - It is an **invasive procedure** with potential complications and is not indicated as the initial diagnostic investigation.

Question 123: The most common complication of pancreas divisum is:

A. Obstructive jaundice
B. Peptic ulcer
C. Recurrent acute pancreatitis (Correct Answer)
D. Duodenal obstruction

Explanation: ***Recurrent acute pancreatitis*** - **Pancreas divisum** is a congenital anomaly where the dorsal and ventral pancreatic ducts fail to fuse, leading to the **majority of pancreatic secretions draining through the smaller, narrower minor papilla**. - This anatomical variation can cause relative **obstruction to pancreatic exocrine flow**, particularly during periods of increased secretion, predisposing to **recurrent episodes of acute pancreatitis** [1]. *Obstructive jaundice* - **Obstructive jaundice** typically results from **biliary tract obstruction**, such as gallstones or tumors, affecting the common bile duct. - While pancreatic disease can cause jaundice, **pancreas divisum primarily affects the pancreatic duct system** and is not a common direct cause of biliary obstruction. *Peptic ulcer* - **Peptic ulcers** are lesions in the lining of the stomach or duodenum, usually caused by **_H. pylori_ infection** or **NSAID use**. - There is **no direct causal relationship** between pancreas divisum and the development of peptic ulcers. *Duodenal obstruction* - **Duodenal obstruction** can result from various causes such as **mass lesions (_e.g._, pancreatic head tumor), strictures, or malrotation**. - Pancreas divisum is an **anatomical variation of the pancreatic ducts**, and it does not directly cause mechanical obstruction of the duodenum itself.

Question 124: The most common route of spread in a case of pyogenic liver abscess is:

A. Hepatic artery
B. Ascending infection through biliary duct
C. Local spread
D. Haematogenous through portal vein (Correct Answer)

Explanation: Haematogenous through portal vein - Pyogenic liver abscesses commonly result from bacterial translocation from the gut, reaching the liver via the portal venous system. - This route accounts for a significant proportion of cases, especially when associated with conditions like diverticulitis or appendicitis. *Hepatic artery* - While possible, spread via the hepatic artery is less common and usually seen in cases of septicemia or endocarditis. - It would imply a more generalized systemic infection rather than a localized abdominal source. *Ascending infection through biliary duct* - This mechanism is characteristic of cholangitis and often leads to multiple small abscesses or a subcapsular collection, not typically a solitary pyogenic liver abscess. - It occurs due to obstruction to biliary flow from stones or strictures. *Local spread* - Local spread can occur from adjacent infected organs like a subphrenic abscess or an infected gallbladder, but it is not the most common route for the initial development of a pyogenic liver abscess. - This typically results in direct extension into the liver parenchyma.

Question 125: A patient has recurrent abdominal pain and jaundice. The blood investigations reveal reticulocytosis and hyperbilirubinemia. What is the clinical diagnosis?

A. Hereditary spherocytosis (Correct Answer)
B. Mirizzi's syndrome
C. Sclerosing cholangitis
D. Choledochal cyst

Explanation: ***Hereditary spherocytosis*** - The combination of **recurrent abdominal pain**, **jaundice**, **reticulocytosis**, and **hyperbilirubinemia** is highly suggestive of hereditary spherocytosis, which causes chronic hemolytic anemia [1, 3]. - **Jaundice** and **abdominal pain** can result from pigment gallstones (due to chronic hemolysis) and splenic enlargement, both common in this condition [2, 3]. *Mirizzi's syndrome* - Characterized by **extrinsic compression of the common hepatic duct** by a stone impacted in the cystic duct or gallbladder neck. - While it causes jaundice and abdominal pain, it does not typically present with **reticulocytosis** or **hemolysis** [1]. *Sclerosing cholangitis* - A chronic cholestatic liver disease characterized by **inflammation and fibrosis** of the bile ducts. - While it causes jaundice and abdominal pain, it is not associated with **reticulocytosis** or signs of **hemolysis** [1]. *Choledochal cyst* - A **congenital dilation of the bile ducts**, leading to recurrent abdominal pain, jaundice, and a palpable mass. - It does not involve **hemolysis** or **reticulocytosis**, making it less likely in this context.

Question 126: The capillary refill time is prolonged in all types of shock EXCEPT:

A. Septic shock (Correct Answer)
B. Obstructive shock
C. Hypovolaemic shock
D. Cardiogenic shock

Explanation: ***Septic shock*** - In **warmed septic shock**, capillary refill time may be **normal or even brisk** due to peripheral vasodilation caused by inflammatory mediators. - While other forms of shock present with decreased peripheral perfusion and prolonged capillary refill, early septic shock can manifest with a **hyperdynamic circulation**. *Obstructive shock* - This type of shock, often due to conditions like **tension pneumothorax** or **cardiac tamponade**, leads to reduced cardiac output and poor peripheral perfusion. - Reduced peripheral blood flow results in a **prolonged capillary refill time**. *Hypovolemic shock* - Characterized by a significant **loss of circulating blood volume**, leading to reduced cardiac output and vasoconstriction. - This peripheral vasoconstriction directly causes a **prolonged capillary refill time** as blood flow to the capillaries is diminished. *Cardiogenic shock* - Results from **primary heart failure**, leading to decreased cardiac output and systemic hypoperfusion. - The reduced effective circulating volume and compensatory vasoconstriction cause impaired peripheral perfusion, manifesting as a **prolonged capillary refill time**.

Question 127: Which of the following statements regarding lymphoedema are correct? 1. Patients experience constant dull ache and even severe pain sometimes 2. Manual lymphatic drainage has a role 3. Primary lymphoedema is caused by congenital lymphatic dysplasia 4. Nonne Milroy's disease is a type of primary lymphoedema Select the correct answer using the code given below:

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

Explanation: ***1, 2, 3 and 4*** - All four statements are correct regarding lymphoedema. Patients often experience **constant dull ache and severe pain** due to the swelling and tissue changes. - **Manual lymphatic drainage (MLD)** is a key component of complete decongestive therapy for lymphoedema, aiming to reduce swelling and improve lymphatic flow. **Primary lymphoedema** is indeed caused by **congenital lymphatic dysplasia**, which refers to abnormalities in lymphatic system development from birth. **Milroy's disease** (also known as Nonne-Milroy disease) is a specific type of primary lymphoedema characterized by early-onset lymphatic dysfunction. *1 and 2 only* - This option is incomplete as statements 3 and 4 are also correct. - It correctly identifies the role of manual lymphatic drainage and the presence of pain in lymphoedema but omits other accurate facts. *3 and 4 only* - This option is incomplete as statements 1 and 2 are also correct. - While correctly identifying the nature of primary lymphoedema and Milroy's disease, it misses other important aspects of lymphoedema. *1, 2, and 3 only* - This option is incomplete because statement 4, concerning Milroy's disease as a type of primary lymphoedema, is also correct. - It provides correct information about pain, MLD, and the cause of primary lymphoedema but omits a specific example of primary lymphoedema.

Question 128: A 45-year-old man presents with the following skin changes (as shown in the image). What relevant history should be taken to diagnose this condition?

A. Dementia
B. History of dietary pattern, dementia, and diarrhea (Correct Answer)
C. Dietary history
D. Depression

Explanation: ***History of dietary pattern, dementia, and diarrhea*** - The image displays skin changes consistent with a "Casal's necklace" pattern, characteristic of **pellagra**, a disease caused by **niacin (Vitamin B3) deficiency**. - Pellagra is classically associated with the "3 Ds": **dermatitis** (the observed skin changes), **diarrhea**, and **dementia**. A comprehensive history should therefore include questions about dietary patterns (especially corn-based diets lacking tryptophan and niacin), gastrointestinal symptoms like diarrhea, and neurological/psychiatric symptoms indicative of dementia. *Dementia* - While **dementia** is one of the classic "3 Ds" of pellagra (niacin deficiency), it is only one component of the presentation and insufficient on its own to guide a complete diagnostic history for this condition. - Focusing solely on dementia would miss crucial aspects like dietary intake and gastrointestinal symptoms that are integral to diagnosing pellagra. *Dietary history* - A **dietary history** is indeed very relevant for diagnosing pellagra, as it helps identify potential niacin deficiency, commonly associated with diets heavily reliant on corn without proper preparation. - However, pellagra is not only characterized by dermatological signs and dietary insufficiency but also by gastrointestinal and neurological symptoms. Limiting the history to diet alone would therefore be incomplete. *Depression* - **Depression** can be a symptom of various nutritional deficiencies and other medical conditions, but it is not one of the classic "3 Ds" of pellagra, which are dermatitis, diarrhea, and dementia. - While mood changes might be present in some patients with niacin deficiency, focusing solely on depression would not encompass the full clinical picture of pellagra and could lead to misdiagnosis.

Question 129: Frontal headache is due to inflammation of which sinus?

A. Sphenoid
B. Ethmoidal
C. Frontal (Correct Answer)
D. Maxillary

Explanation: ***Frontal*** - Inflammation of the **frontal sinuses** typically causes pain and pressure over the forehead, known as a **frontal headache**. - The pain is often worse in the morning, when bending over, or with changes in **barometric pressure**. *Sphenoid* - **Sphenoid sinusitis** usually causes a headache behind the eyes, at the **vertex of the head**, or in the occipital region. - It is less common than other forms of sinusitis and often presents with more diffuse, deep-seated pain. *Ethmoidal* - **Ethmoidal sinusitis** typically results in pain and pressure between the eyes or over the **bridge of the nose**. - It can also cause eye pain and is sometimes mistaken for a **tension headache**. *Maxillary* - **Maxillary sinusitis** commonly causes pain and pressure in the cheeks, under the eyes, and in the upper teeth, often exacerbated by **chewing or biting**. - This pain can radiate to the temples or ears, but it typically does not manifest as a **frontal headache**.

Question 130: Gynecomastia is seen in all except;

A. Kidney failure
B. Liver failure
C. Stilbestrol therapy for prostate cancer
D. Teratoma of the testis
E. Hormonal
F. Leprosy (Correct Answer)
. Idiopathic
. Anorchism and After castration
. Klinefelter's syndrome

Explanation: Leprosy - While leprosy can affect various endocrine glands, **gynecomastia is not a typical or direct manifestation** of the disease. - Its primary impact is on the peripheral nerves, skin, and upper respiratory tract, not directly on estrogen-androgen balance. *Kidney failure* - **Chronic kidney disease** often leads to **hormonal imbalances**, including increased prolactin and decreased testosterone, which can cause gynecomastia. - The altered metabolism and excretion of hormones contribute to this endocrine dysfunction. *Liver failure* - The liver is crucial for metabolizing **estrogens** and other hormones; **liver failure** leads to reduced estrogen breakdown and elevated circulating levels. - This **increased estrogen-to-androgen ratio** promotes breast tissue development in males. *Stilbestrol therapy for prostate cancer* - **Stilbestrol is a synthetic estrogen** often used as part of androgen deprivation therapy for prostate cancer. - Administering exogenous estrogen directly **stimulates breast tissue growth**, causing gynecomastia. *Teratoma of the testis* - Certain **testicular tumors**, including some teratomas, can produce **human chorionic gonadotropin (hCG)** [1]. - Elevated hCG can **stimulate Leydig cells to produce estrogen** and can also directly stimulate aromatase activity, leading to gynecomastia. *Hormonal* - This category generally refers to conditions where there is an **imbalance between estrogen and androgen levels**, favoring estrogenic effects. - **Any condition that increases estrogen or decreases testosterone** can lead to gynecomastia. *Idiopathic* - **Idiopathic gynecomastia** refers to cases where no identifiable underlying cause can be found despite thorough investigation. - It's a diagnosis of exclusion, signifying that the exact hormonal imbalance or mechanism remains unknown. *Anorchism and After castration* - Both anorchism (absence of testes) and castration (surgical removal of testes) result in a **severe deficiency of testosterone**. - Without sufficient androgen production, the **relative effect of even normal estrogen levels becomes dominant**, leading to gynecomastia. *Klinefelter's syndrome* - **Klinefelter's syndrome (47, XXY)** is a chromosomal disorder characterized by **testicular dysfunction**, leading to primary hypogonadism [2]. - This results in **low testosterone and relatively high estrogen levels** [3], a classic hormonal imbalance that causes gynecomastia.

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