Clinical Manifestations and Presentation of Diseases — MCQs
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A chronic smoker presents with mild haemoptysis, and also reports a history of hypertension and obesity. Laboratory data reveal raised ACTH levels that are not suppressed by dexamethasone, leading to a diagnosis of Cushing's syndrome. Which of the following is the cause of Cushing's syndrome in this patient?
Most common cause of postural hypotension is
25-year-old male having fever and malaise for 2 weeks, arthritis of the ankle joint, and tender erythematous nodules over the shin. What is the diagnosis?
Which of the following is NOT typically associated with carcinoma of the pancreas?
Kartagener's syndrome includes all of the following conditions except.
Which of the following conditions is associated with acanthosis nigricans?
A patient complains of loss of visual acuity, deafness, and enlargement of the maxilla.
A 20-year-old girl presents with abdominal pain and a purpuric rash all over the body, and the most probable diagnosis is?
Which of the following conditions can be associated with the presence of erythema nodosum?
Clinical examination of a symptomatic patient shows a Sister Mary Joseph nodule. It is most commonly associated with which of the following?
Clinical Manifestations and Presentation of Diseases Indian Medical PG Practice Questions and MCQs
Question 311: A chronic smoker presents with mild haemoptysis, and also reports a history of hypertension and obesity. Laboratory data reveal raised ACTH levels that are not suppressed by dexamethasone, leading to a diagnosis of Cushing's syndrome. Which of the following is the cause of Cushing's syndrome in this patient?
- A. Ectopic ACTH secreting tumor (Correct Answer)
- B. MEN I
- C. Pituitary adenoma
- D. Adrenal cortical adenoma
Explanation: Ectopic ACTH secreting tumor - The combination of **hemoptysis** in a **chronic smoker** points towards a **lung tumor**, which can produce ACTH ectopically [1]. - **High ACTH** levels that are **not suppressed by dexamethasone** are characteristic of ectopic ACTH production, as these tumors are generally not regulated by the normal feedback mechanisms [1]. *MEN I* - **Multiple Endocrine Neoplasia type 1 (MEN I)** often includes pituitary tumors, but the presentation with hemoptysis and the specific lack of ACTH suppression point away from a pituitary-driven Cushing's. - MEN I is associated with tumors of the **parathyroid**, **pituitary**, and **pancreatic islet cells**, and while it can cause Cushing's, the **hemoptysis** is a strong differentiator. *Pituitary adenoma* - While a **pituitary adenoma** (Cushing's disease) causes ACTH-dependent Cushing's, the ACTH levels are typically **suppressed by high-dose dexamethasone**. - The patient's history of **hemoptysis** in a smoker strongly suggests a primary pulmonary pathology, not a pituitary tumor [1]. *Adrenal cortical adenoma* - An **adrenal cortical adenoma** causes **ACTH-independent Cushing's syndrome**, meaning ACTH levels would be **low or undetectable**, not elevated [1], [2]. - The primary problem in this case is high ACTH, ruling out adrenal adenoma as the direct cause of Cushing's syndrome [2].
Question 312: Most common cause of postural hypotension is
- A. Progressive cerebellar degeneration
- B. Adrenal insufficiency
- C. Striatonigral degeneration
- D. Peripheral neuropathy (Correct Answer)
Explanation: ***Peripheral neuropathy*** - Damage to **autonomic nerve fibers** in peripheral neuropathy can impair the body's ability to regulate **blood pressure** in response to gravitational changes upon standing [1]. - This leads to a failure of **vasoconstriction** and an inadequate increase in **heart rate**, resulting in a significant drop in blood pressure. *Progressive cerebellar degeneration* - This condition primarily affects **coordination** and **balance**, often leading to **ataxia** and dysarthria. - While it can manifest with various neurological symptoms, **postural hypotension** is not its most common or direct consequence. *Adrenal insufficiency* - **Adrenal insufficiency** results in inadequate production of **cortisol** and **aldosterone**, leading to **hypotension** and **volume depletion**. - While it causes hypotension, it is not the most frequent cause of **postural hypotension** across the general population. *Striatonigral degeneration* - Also known as **multiple system atrophy** (MSA-P), this condition involves the degeneration of neurons in the **striatum** and **substantia nigra**. - It often leads to **parkinsonism** and **autonomic dysfunction**, including postural hypotension, but it is less common overall than peripheral neuropathy as a cause.
Question 313: 25-year-old male having fever and malaise for 2 weeks, arthritis of the ankle joint, and tender erythematous nodules over the shin. What is the diagnosis?
- A. Erythema nodosum (Correct Answer)
- B. Weber- Christian disease
- C. Nodular Vasculitis
- D. Hansen's disease
Explanation: ***Erythema nodosum*** - Erythema nodosum presents with **tender, erythematous nodules** on the shins, often associated with a **prodrome of fever and malaise**, and can be accompanied by **arthralgia or arthritis**, particularly in the ankle joint [1]. - It is a **panniculitis** (inflammation of subcutaneous fat) that can be triggered by various systemic conditions, infections, or drugs. *Hansen's disease* - Also known as **leprosy**, this infectious disease primarily affects the skin, peripheral nerves, upper respiratory tract, eyes, and testes, typically presenting with **hypopigmented skin lesions** with loss of sensation. - While it can cause skin nodules (lepromas) and nerve damage leading to joint deformities, the acute onset of tender erythematous shin nodules accompanying a generalized inflammatory response is **not characteristic** of its initial presentation. *Weber-Christian disease* - This is a rare, relapsing, febrile **panniculitis** that causes subcutaneous fat inflammation, often resulting in tender nodules or plaques, but it is not typically associated with prominent arthralgia/arthritis as primary symptoms. - The lesions tend to be more widespread than just the shins and can involve visceral fat, and it lacks the specific association with ankle arthritis seen in erythema nodosum. *Nodular Vasculitis* - This condition is a form of **cutaneous vasculitis** that presents with multiple, tender, often ulcerating nodules, typically on the lower legs, which are characterized by inflammation of blood vessels. - While it involves nodules, it is fundamentally a vasculitic process and usually presents with symptoms of **vascular damage** such as ulcers, purpura, or livedo reticularis, which are not described in the patient's presentation of fever, malaise, and arthritis.
Question 314: Which of the following is NOT typically associated with carcinoma of the pancreas?
- A. Hypercalcemia
- B. Erythrocytosis
- C. Syndrome of inappropriate secretion of ADH
- D. Hypoglycemia (Correct Answer)
Explanation: ***Hypoglycemia*** - **Hypoglycemia** is generally not a direct paraneoplastic syndrome or common complication of typical pancreatic adenocarcinoma. - While **insulinomas** (a rare type of pancreatic neuroendocrine tumor) cause hypoglycemia, they are distinct from pancreatic adenocarcinoma [1]. *Syndrome of inappropriate secretion of ADH* - **SIADH** can be a paraneoplastic syndrome, causing **hyponatremia** due to excessive ADH secretion. - Although less common than in small cell lung cancer, some pancreatic cancers can produce **ectopic ADH**. *Erythrocytosis* - Some tumors, including certain pancreatic cancers, can produce **erythropoietin** leading to **erythrocytosis** (an increase in red blood cell mass). - This is a paraneoplastic syndrome reflecting excessive red blood cell production. *Hypercalcemia* - **Hypercalcemia of malignancy** is a well-recognized paraneoplastic syndrome that can occur with various cancers, including pancreatic cancer. - It can result from **parathyroid hormone-related peptide (PTHrP) production** by the tumor or extensive bony metastases.
Question 315: Kartagener's syndrome includes all of the following conditions except.
- A. Situs inversus
- B. Bronchiectasis
- C. Sinusitis
- D. Cystic fibrosis (Correct Answer)
Explanation: ***Cystic fibrosis*** - Cystic fibrosis is a genetic disorder affecting mucus and sweat glands, characterized by excessive secretions that lead to blockages in various organs, including the lungs and pancreas. This is a distinct condition from Kartagener's syndrome. - While both conditions can present with chronic respiratory infections, **cystic fibrosis** is caused by mutations in the **CFTR gene**, and is not a component of Kartagener's syndrome or primary ciliary dyskinesia [1]. *Situs inversus* - **Situs inversus** is a characteristic feature of Kartagener's syndrome, occurring in about 50% of affected individuals due to immotile cilia during embryonic development, leading to reversed organ placement. - The abnormal ciliary function prevents the proper rotation of organs during embryogenesis, resulting in **dextrocardia** and the transposition of abdominal organs. *Bronchiectasis* - **Bronchiectasis** is a common complication of Kartagener's syndrome, resulting from chronic inflammation and infection in the airways due to impaired mucociliary clearance. - The inability of cilia to effectively clear mucus and pathogens leads to recurrent infections, chronic inflammation, and irreversible dilation of the bronchi, a hallmark of **bronchiectasis** [1]. *Sinusitis* - **Sinusitis** is frequently observed in patients with Kartagener's syndrome because the dysfunctional cilia in the paranasal sinuses fail to clear mucus and trapped pathogens, leading to chronic inflammation and infection. - This chronic inflammation often presents as **recurrent or persistent sinus infections** and can be severe and difficult to treat due to the underlying ciliary defect.
Question 316: Which of the following conditions is associated with acanthosis nigricans?
- A. Obesity
- B. Gastric adenocarcinoma
- C. Type 2 Diabetes Mellitus (Correct Answer)
- D. All of the options
Explanation: Acanthosis nigricans is characterized by velvety, hyperpigmented skin lesions, often in intertriginous areas, and is a common cutaneous marker for insulin resistance, which is central to Type 2 Diabetes Mellitus [1]. The elevated insulin levels stimulate epidermal keratinocytes and dermal fibroblast proliferation, leading to the characteristic skin changes. While malignant acanthosis nigricans is associated with internal malignancies, particularly adenocarcinomas of the gastrointestinal tract (like gastric), it is a less common cause than insulin resistance. This form is usually more extensive and rapidly progressing than the benign variant. Obesity is strongly associated with insulin resistance, making it an indirect cause of acanthosis nigricans. However, acanthosis nigricans is a direct indicator of insulin resistance, which can occur with or without significant obesity. While all listed conditions can be associated with acanthosis nigricans, Type 2 Diabetes Mellitus is the most direct and common condition explicitly linked to the underlying pathophysiology of insulin resistance [1]. Gastric adenocarcinoma causes a malignant form, and obesity is a risk factor for insulin resistance, but T2DM directly reflects the metabolic state responsible for the skin changes.
Question 317: A patient complains of loss of visual acuity, deafness, and enlargement of the maxilla.
- A. Fibrous dysplasia
- B. Osteogenesis imperfecta
- C. Paget's disease (Correct Answer)
- D. Osteomalacia
Explanation: ***Paget's disease*** [1] - Characterized by abnormal **bone remodeling**, leading to an increase in bone size and deformity, particularly in the **maxilla**, causing enlargement [1]. - Associated with complications such as **loss of visual acuity** (due to involvement of the skull) and **deafness** from auditory canal changes [1][2], making this the most fitting diagnosis. *Fibrous dysplasia* - Typically presents with **fibrous replacement** of bone, not specifically causing deafness or visual acuity loss. - Customarily involves the **classic "ground glass" appearance** on imaging, not the structural enlargement seen in Paget's disease. *Osteogenesis imperfecta* - Mainly causes **brittle bones** and frequent fractures, not associated with **maxillary enlargement** or changes in auditory function. - Rarely causes visual acuity loss, which is not a feature of this condition. *Osteomalacia* - Primarily characterized by **softening of bones** due to vitamin D deficiency, leading to weakness rather than structural changes like maxillary enlargement. - Symptoms like **bone pain** or **muscle weakness** occur, but not specifically loss of auditory function or visual acuity. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1192-1194. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 669-670.
Question 318: A 20-year-old girl presents with abdominal pain and a purpuric rash all over the body, and the most probable diagnosis is?
- A. Hemolytic Uremic Syndrome (HUS)
- B. Kawasaki Syndrome
- C. Immune Thrombocytopenic Purpura (ITP)
- D. Henoch-Schönlein Purpura (HSP) (Correct Answer)
Explanation: ***Henoch-Schönlein Purpura (HSP)*** - The classic triad of **abdominal pain**, **arthralgia** (often knee and ankle), and a **palpable purpuric rash**, particularly on the lower extremities and buttocks, strongly points to HSP [2]. - This is a **small vessel vasculitis** mediated by IgA immune complex deposition [1], [2]. *Hemolytic Uremic Syndrome (HUS)* - HUS is characterized by a triad of **microangiopathic hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury**, often preceded by bloody diarrhea due to Shiga-toxin producing *E. coli* [3]. - While it can cause abdominal pain and purpura-like lesions (due to thrombocytopenia), the specific presentation here is more indicative of HSP. *Kawasaki Syndrome* - Kawasaki disease is a **medium-vessel vasculitis** primarily affecting young children, characterized by fever, conjunctivitis, oral mucosal changes, rash, lymphadenopathy, and extremity changes [4]. - It does not typically present with the same type of palpable purpuric rash or severe abdominal pain described in this case. *Immune Thrombocytopenic Purpura (ITP)* - ITP is an **isolated thrombocytopenia** (low platelet count) leading to increased bleeding tendency, presenting as petechiae, purpura, and mucosal bleeding. - While purpura is present, the additional finding of significant **abdominal pain** points away from isolated ITP and towards a systemic vasculitis like HSP.
Question 319: Which of the following conditions can be associated with the presence of erythema nodosum?
- A. Tuberculosis
- B. Sarcoidosis
- C. Malignancies
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - **Erythema nodosum** is a common panniculitis that can be associated with a wide range of underlying conditions, including infections, inflammatory diseases, and malignancies. - Therefore, **tuberculosis**, **sarcoidosis**, and various types of **malignancies** are all known causes or associations of erythema nodosum [1]. *Tuberculosis* - **Tuberculosis (TB)**, particularly primary infection or reactivation, is a well-established infectious cause of **erythema nodosum**, especially in endemic areas. - The immune response to the **mycobacterial antigens** can trigger the characteristic tender, red nodules, often on the shins. *Sarcoidosis* - **Sarcoidosis** is a systemic granulomatous disease that frequently presents with **erythema nodosum**, particularly in acute forms like **Löfgren's syndrome** [1]. - In such cases, erythema nodosum is often accompanied by **hilar adenopathy** and **arthralgia**. *Malignancies* - Various **malignancies**, including **lymphomas**, **leukemias**, and even some solid tumors, can rarely be associated with **erythema nodosum** as a paraneoplastic phenomenon [1]. - The development of erythema nodosum in these contexts is thought to be due to immune reactions to **tumor antigens** or direct involvement of skin by the malignancy.
Question 320: Clinical examination of a symptomatic patient shows a Sister Mary Joseph nodule. It is most commonly associated with which of the following?
- A. Ovarian cancer
- B. Stomach cancer (Correct Answer)
- C. Colon cancer
- D. Pancreatic cancer
Explanation: ***Stomach cancer*** - A **Sister Mary Joseph nodule** is a **periumbilical metastatic nodule**, most commonly associated with **gastric adenocarcinoma** due to its propensity for peritoneal spread. - While it can originate from other abdominal malignancies, stomach cancer is statistically the most frequent primary source of this metastatic sign. *Ovarian cancer* - Ovarian cancer can metasatasize to the peritoneum and sometimes cause Sister Mary Joseph nodules, but it is not the most common primary source [1]. - Instead, ovarian cancer more frequently presents with symptoms like **abdominal distension**, **pelvic pain**, or **ascites** [1]. *Colon cancer* - **Colorectal cancer** can also metastasize to the peritoneum, potentially leading to a Sister Mary Joseph nodule, though less commonly than gastric cancer [2]. - It often manifests with changes in **bowel habits**, **rectal bleeding**, or **unexplained weight loss** [2]. *Pancreatic cancer* - Pancreatic cancer can produce a Sister Mary Joseph nodule, particularly in advanced stages with **peritoneal dissemination**. - However, it is primarily known for other metastatic patterns and often presents with **jaundice** (if the head of the pancreas is affected) or **epigastric pain**.
Practice by Chapter
Approach to Common Symptoms (Fever, Pain, Fatigue)
Practice Questions
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
Practice Questions
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