Clinical Manifestations and Presentation of Diseases — MCQs

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

Question 191: A 26 year old female patient presented with fever, oral ulcers, sensitivity to light and rash over the malar area of the face sparing the nasolabial folds of both side. Which of the following indicates the condition associated with these manifestations?

A. Rosacea
B. Dermatomyositis
C. Psoriasis
D. SLE (Correct Answer)

Explanation: ***SLE*** - The combination of **fever**, **oral ulcers**, **photosensitivity**, and a **malar rash** (which typically spares the nasolabial folds), particularly in a young female, is classic for **Systemic Lupus Erythematosus (SLE)** [1]. - SLE is a **chronic autoimmune inflammatory disease** that can affect multiple organ systems [2]. *Rosacea* - Rosacea often presents with **facial erythema**, **telangiectasias**, and papulopustules, primarily on the central face, but it does not typically involve oral ulcers, fever, or photosensitivity in the same way as SLE [4]. - The rash of rosacea is usually not a classic malar rash sparing the nasolabial folds, and it is not an autoimmune systemic disease. *Dermatomyositis* - Dermatomyositis is characterized by **proximal muscle weakness** and specific skin manifestations like **Gottron's papules** (over joints), **heliotrope rash** (periorbital edema), and a **shawl sign**, which differ from the presented symptoms [3]. - While it can cause light sensitivity and a rash, the distribution and associated symptoms (like no mention of muscle weakness) are not typical for a primary presentation of dermatomyositis. *Psoriasis* - Psoriasis typically presents with **well-demarcated erythematous plaques** covered with **silvery scales**, commonly on extensor surfaces like elbows and knees, and can also affect nails and joints. - It does not typically cause fever, oral ulcers, or a malar rash with nasolabial fold sparing, which are hallmarks of SLE.

Question 192: Which is not seen in heart failure?

A. Cardiomegaly
B. Kerley B lines
C. Kerley A Lines
D. Oligemia (Correct Answer)

Explanation: ***Oligemia*** - **Oligemia** refers to a reduced blood volume or total blood flow to a region, which is typically not observed in **heart failure**. - In **heart failure**, the body often experiences **fluid overload** and **pulmonary congestion**, leading to increased blood volume in the lungs, not reduced [1]. *Cardiomegaly* - **Cardiomegaly**, or an enlarged heart, is a common finding in **heart failure** as the heart muscle remodels and dilates to compensate for impaired pumping function [1], [3]. - This can be seen on a chest X-ray as an **increased cardiothoracic ratio** [1], [2]. *Kerley B lines* - **Kerley B lines** are thin, horizontal lines visible on a chest X-ray, typically found at the lung periphery. - They indicate **interstitial edema** due to increased pulmonary venous pressure, a characteristic sign of **pulmonary congestion** in **heart failure** [1]. *Kerley A Lines* - **Kerley A lines** are longer, less common lines seen radiating from the hila towards the upper lobes. - These lines represent **distended anastomotic channels** between pulmonary and systemic venous systems, also indicative of **pulmonary edema** and **heart failure** [1], [4].

Question 193: Which of the following is not a clinical presentation of Pituitary Apoplexy?

A. Vomiting
B. Headache
C. Hypertension (Correct Answer)
D. Hypotension

Explanation: ***Hypertension*** - Pituitary apoplexy often leads to **adrenal insufficiency** due to damage to the pituitary gland, which in turn causes **hypotension**, not hypertension. - The sudden onset of severe pituitary dysfunction typically results in a drop in blood pressure rather than an increase. *Vomiting* - **Vomiting** is a common symptom of pituitary apoplexy, often accompanying severe headache due to increased intracranial pressure or hormonal imbalances [1]. - The sudden mass effect of the hemorrhage or infarction can irritate surrounding structures, leading to nausea and vomiting. *Headache* - A **sudden, severe headache** is the most common presenting symptom of pituitary apoplexy, often described as a "thunderclap" headache [1]. - This intense headache is caused by rapid expansion of the pituitary mass and irritation of the **dura mater**. *Hypotension* - **Hypotension** is a classic feature of pituitary apoplexy, resulting from acute **adrenal insufficiency** where insufficient ACTH leads to decreased cortisol production [1]. - This hormonal deficiency impairs the body's ability to maintain blood pressure and respond to stress [1].

Question 194: What is the Child-Pugh class for a patient who has a serum bilirubin of 2.5 mg/dL, serum albumin of 3 g/dL, INR of 2, mild ascites, but no encephalopathy?

A. Child-Pugh Class B (Correct Answer)
B. Child-Pugh Class A
C. Child-Pugh Class D
D. Child-Pugh Class C

Explanation: ***Child-Pugh Class B*** - A serum bilirubin of **2.5 mg/dL** (2 points), serum albumin of **3 g/dL** (2 points), INR of **2** (2 points), and mild ascites (2 points), with no encephalopathy (1 point), sums up to a total of 9 points, which falls into the range for **Child-Pugh Class B** (7-9 points) [1]. - This class indicates **moderate hepatic dysfunction** and is characterized by a higher risk of complications and mortality compared to Class A. *Child-Pugh Class A* - This class is assigned for a total score of **5-6 points**, indicating **well-compensated hepatic disease**. - The patient's total score of 9 points exceeds the threshold for Class A, suggesting more significant liver impairment. *Child-Pugh Class D* - There is no Child-Pugh Class D; the classification system only includes classes A, B, and C. - This option is therefore incorrect based on the established Child-Pugh scoring system. *Child-Pugh Class C* - This class corresponds to a total score of **10-15 points**, indicative of **severe hepatic decompensation**. - The patient's calculated score of 9 points is below the minimum required for Child-Pugh Class C.

Question 195: Which is the most conspicuous sign in breast cancer?

A. Puckering
B. Nipple retraction
C. Cancer en-cuirasse
D. Peau d'orange (Correct Answer)

Explanation: ***Peau d'orange*** - This sign, characterized by **pitted, dimpled skin resembling an orange peel**, is the most conspicuous and widely recognized sign of breast cancer, particularly in locally advanced or inflammatory breast cancer. [1] - It results from **lymphatic obstruction** and **edema** of the skin due to tumor invasion, pulling on the suspensory ligaments. *Puckering* - While an important sign, **puckering** (also known as **dimpling**) is often more subtle and may require specific positioning or palpation to be evident. - It is caused by the tumor invading and shortening the **suspensory ligaments (Cooper's ligaments)**, which pull on the overlying skin. [1] *Nipple retraction* - **Nipple retraction** can be a significant sign of breast cancer, but it can also be a **normal variant** or due to benign conditions like **mastitis** or **mammary duct ectasia**. - Its presence alone is not as uniquely conspicuous or indicative of malignancy as *peau d'orange*. *Cancer en-cuirasse* - **Cancer en-cuirasse** is a rare and advanced form of *cutaneous metastasis* from breast cancer, where the chest wall becomes encased in a **hard, fibrotic, leathery tumor shell**. - While very conspicuous once developed, it represents a **late-stage manifestation** and is not the most common or earliest conspicuous sign of breast cancer.

Question 196: What is the name of this technique for palpation of thyroid where a thumb is placed on the lateral side of trachea and patient is swallowing?

A. Pizzilo method
B. Lahey's method
C. Crile method (Correct Answer)
D. Kocher's test

Explanation: Crile method - The Crile method for thyroid palpation involves placing a thumb on one side of the trachea and gently pushing the thyroid lobe to the opposite side to better assess it during swallowing. - This technique helps to stabilize the gland and makes it easier to feel for nodules or enlargement. Pizzilo method - There is no widely recognized or standardized thyroid palpation technique called the Pizzilo method in medical literature. - This term is therefore incorrect in the context of thyroid examination. Lahey's method - Lahey's method for thyroid examination involves standing behind the patient and palpating the thyroid gland as the patient swallows, using both hands [1]. - It differs from the Crile method by typically using both hands from behind the patient, rather than focusing on a single thumb on the lateral side of the trachea [1]. Kocher's test - Kocher's test is primarily used to assess for exophthalmos in patients with Graves' disease, by observing the involuntary retraction of the upper eyelid when gazing downwards. - It is not a technique for the palpation of the thyroid gland itself.

Question 197: All of the following should be avoided by a patient with lactose intolerance, EXCEPT:

A. Skimmed milk
B. Ice-cream
C. Condensed milk
D. Yoghurt (Correct Answer)

Explanation: ***Yoghurt*** - Yoghurt contains **lactic acid bacteria**, such as *Lactobacillus bulgaricus* and *Streptococcus thermophilus*, which produce **lactase** and break down the lactose into simpler sugars. - This enzymatic action makes yoghurt generally **better tolerated** by individuals with lactose intolerance compared to other dairy products [1]. *Skimmed milk* - **Skimmed milk** is still a dairy product and contains **lactose**, similar to whole milk, just with less fat [1], [2]. - Therefore, it will likely cause **digestive symptoms** in individuals with lactose intolerance due to the lack of lactase to break down the lactose [2], [3]. *Ice-cream* - **Ice cream** is rich in milk and cream, both of which are high in **lactose**. - Its high lactose content makes it a common trigger for **gastrointestinal discomfort** in lactose-intolerant individuals [1]. *Condensed milk* - **Condensed milk** is milk from which water has been removed, resulting in a concentrated product, often sweetened. - It contains a **high concentration of lactose**, making it unsuitable for individuals with lactose intolerance.

Question 198: Which finding best predicts poor outcome in acute pancreatitis at admission?

A. Ranson score >3 (Correct Answer)
B. Serum lipase >1000
C. Blood glucose >200
D. Pleural effusion

Explanation: ***Ranson score >3*** - A **Ranson score** greater than 3 on admission is a strong predictor of **severe acute pancreatitis** and increased **mortality** [1]. - The Ranson criteria assess multiple parameters, including age, WBC count, LDH, AST, and glucose, providing a comprehensive risk assessment [1]. *Serum lipase >1000* - An elevated **serum lipase level** is highly diagnostic of acute pancreatitis but does not directly correlate with disease severity or prognosis. - While reflecting pancreatic inflammation, lipase levels often do not predict the development of **organ failure** or **necrotizing pancreatitis** [1]. *Blood glucose >200* - **Hyperglycemia** at admission is one of the Ranson criteria, but as a single parameter, it is not as strong a predictor of poor outcome as the complete score. - Isolated high glucose can be due to stress or pre-existing **diabetes**, contributing to some severity but not sufficient for widespread poor prognosis without other factors. *Pleural effusion* - **Pleural effusion** can be a complication of severe pancreatitis, indicating surrounding inflammation. - However, its presence at admission, without other markers of severity, is less predictive of overall poor outcome than a validated scoring system like the Ranson score which assesses multiple systemic factors.

Question 199: A 42-year-old man with diabetes presents with memory loss, confusion, and irritability. He denies alcohol use. What is the likely cause?

A. Alcohol dependence
B. Hypoglycemia (Correct Answer)
C. Wernicke's encephalopathy
D. Alzheimer’s disease

Explanation: ***Hypoglycemia*** - Patients with **diabetes** are prone to episodes of **hypoglycemia**, which can manifest with neuropsychiatric symptoms like confusion, memory loss, and irritability. - **Glucose deficiency** in the brain impairs cognitive function, leading to symptoms that can mimic other neurological or psychiatric conditions. *Alcohol dependence* - Although alcohol dependence can cause cognitive impairment and confusion, the patient **denies alcohol use**, making this less likely. - Alcohol-related cognitive issues typically develop over a longer period and are associated with **chronic heavy drinking**. *Wernicke's encephalopathy* - This condition is primarily caused by **thiamine deficiency**, most commonly seen in severe alcoholics or individuals with malnutrition [1], [2]. - Key symptoms include the classic triad of **ophthalmoplegia**, **ataxia**, and **confusion**, not just memory loss and irritability [1]. *Alzheimer’s disease* - Alzheimer's disease is a **progressive neurodegenerative disorder** characterized by gradual memory loss and cognitive decline, typically in older individuals [3]. - The acute presentation of confusion and irritability, particularly in a 42-year-old with diabetes, is less characteristic of early Alzheimer's and more suggestive of an acute metabolic derangement.

Question 200: Least common cause for bilateral pedal edema

A. CKD
B. Chronic vascular insufficiency (Correct Answer)
C. CLD
D. HF with reduced ejection fraction

Explanation: ***Chronic vascular insufficiency*** - While chronic venous insufficiency is a common cause of bilateral pedal edema, **arterial insufficiency** (a type of chronic vascular insufficiency) is a much less common cause of pure edema and is more often associated with **ischemic pain**, **ulcers**, and **skin atrophy** [1]. - **Arterial insufficiency** primarily causes limb ischemia rather than significant edema, differentiating it from situations where fluid retention is the primary issue [2]. *CKD* - **Chronic kidney disease (CKD)** leads to impaired fluid and sodium excretion, causing generalized fluid overload. - This fluid overload commonly manifests as **bilateral pedal edema** due to gravity-dependent fluid accumulation. *CLD* - **Chronic liver disease (CLD)**, particularly cirrhosis, results in **portal hypertension** and decreased hepatic synthesis of **albumin**. - This leads to reduced oncotic pressure and increased hydrostatic pressure, driving fluid into the extravascular space, often causing **ascites** and **bilateral pedal edema**. *HF with reduced ejection fraction* - **Heart failure with reduced ejection fraction (HFrEF)** impairs the heart's ability to pump blood effectively, leading to fluid backup in the venous system [2]. - This increased hydrostatic pressure in the peripheral capillaries directly causes **bilateral pedal edema** as fluid extravasates into the interstitial space [2].

Practice by Chapter

Approach to Common Symptoms (Fever, Pain, Fatigue)

Practice Questions

Constitutional Symptoms and Their Differential Diagnosis

Practice Questions

Syncope and Presyncope

Practice Questions

Dizziness and Vertigo

Practice Questions

Dyspnea and Respiratory Distress

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Chest Pain Evaluation

Practice Questions

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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