General Medicine Practice Questions

Q: What is the most common electrolyte disorder encountered in clinical practice?

Hyponatremia. ***Hyponatremia*** - **Hyponatremia**, defined as serum sodium below **135 mEq/L**, is the most common electrolyte abnormality, occurring in approximately 15–30% of hospitalized patients. - Conditions such as **heart failure, cirrhosis, renal failure, and SIADH** cause non-osmotic ADH release or impaired free-water excretion, lowering serum sodium. *Hypernatremia* - **Hypernatremia** is less common because the **thirst mechanism** usually stimulates water intake and protects against rising serum sodium. - It typically occurs in **infants, elderly patients, or comatose patients** who cannot access water or communicate thirst. *Hypocalcemia* - **Hypocalcemia** can be common in specific settings such as the **ICU** or after thyroid surgery, but it is less prevalent overall. - It does not match the broad epidemiological frequency of **sodium disturbances**, particularly hyponatremia, encountered across clinical practice. *Hypokalemia* - **Hypokalemia** is very common, particularly with **diuretic therapy**, but it ranks second to hyponatremia in overall clinical frequency. - Although potassium depletion is frequent, disturbances in **water balance and ADH regulation** produce hyponatremia more broadly.

Q: What type of fever is a patient with the following temperature charting having?

Remittent fever. ***Remittent fever*** - **Remittent fever** fluctuates by more than 1°C (1.8°F) during the day but never returns to normal. - The chart varies from approximately **40.0°C to 38.9°C** while remaining febrile, matching the defining remittent pattern. *Continuous fever* - **Continuous fever** remains elevated with only minimal fluctuations, typically less than 1°C (1.8°F), without returning to normal. - The chart shows temperature variation exceeding **1°C**, so the fluctuations are too large for a continuous fever pattern. *Intermittent fever* - **Intermittent fever** includes febrile periods interrupted by temperatures that return to normal or below normal. - The charted temperature **never returns to normal**, remaining above approximately 37.2°C (99°F), which excludes intermittent fever. *Quotidian fever* - **Quotidian fever** is an intermittent pattern with a single daily febrile episode followed by a return to normal temperature. - Although the chart has daily peaks, the temperature **does not reach the normal baseline**, so it is not quotidian fever.

Q: A 25 -year-old soldier is trapped in an avalanche in Siachen Glacier. He is airlifted to the base hospital. On admission the pulse is thready and BP is unrecordable. ECG strip is shown below. All of the findings are seen except:

Atrial bigeminy. ***Atrial bigeminy*** - **Atrial bigeminy** requires alternating normal sinus beats and premature atrial beats, a pattern not shown on this ECG. - The tracing instead shows a **slow, regular rhythm** with hypothermic J-waves and abnormal QRS complexes, without the premature atrial pattern required for bigeminy. *Osborn wave* - An **Osborn wave** is a positive deflection at the QRS–ST junction and is visible on the ECG described here. - This **J-wave** is a classic electrocardiographic manifestation of severe hypothermia, particularly when core temperature falls below 32°C. *Bradycardia* - The ECG demonstrates a **slow rhythm**, with approximately 3–4 large squares between successive R waves and a rate near 40–50 beats per minute. - This **bradycardia** occurs in severe hypothermia because reduced temperature decreases metabolic activity and myocardial excitability. *Prolonged QT interval* - The ECG shows a **prolonged QT interval**, reflecting delayed ventricular repolarization in the setting of severe hypothermia. - This **QT prolongation** is a recognized hypothermic ECG abnormality and may increase susceptibility to ventricular arrhythmias.

Q: In the score shown below, alphabet P stands for?

Pulse rate. ***Pulse rate*** - In the **APGAR score**, “P” stands for **pulse**, assessing the newborn’s heart rate after birth. - A **pulse rate above 100 beats/minute** scores 2, below 100 scores 1, and an absent pulse scores 0. *Physical activity* - **Activity** in the APGAR score represents **muscle tone** and is denoted by the second “A,” not “P.” - The letter **P** specifically denotes **pulse rate**, so physical activity does not fit this component of the score. *Pressure* - The APGAR score assesses **Appearance, Pulse, Grimace, Activity, and Respiration**, with no component for pressure. - **Blood pressure** or pressure measurement is not included among the five APGAR parameters, so this option does not fit. *Pallor severity* - **Appearance**, represented by the first “A,” assesses **skin colour**, including pallor or cyanosis, rather than using the letter “P.” - **Pallor severity** is therefore evaluated under appearance, while “P” in APGAR denotes **pulse rate**.

Q: A comatose person is brought to the hospital. On examination his respiratory rate is 8 / min with pulse rate of 75 bpm with BP of 110 / 70 mm Hg. His Pupils are shown below. Body temperature is 96°F. There are no focal neurological deficits. What is the probable diagnosis?

Opioid overdose. ***Opioid overdose*** - The combination of **pinpoint pupils**, severe **respiratory depression**, and coma is highly characteristic of opioid overdose. - Mild **hypothermia** can accompany opioid use, while the absence of focal deficits further supports a toxic cause over structural brain lesions. *Uncal herniation* - **Uncal herniation** typically causes an **ipsilateral dilated pupil** from oculomotor nerve compression, rather than the pinpoint pupils shown here. - It often produces **focal neurological findings**, such as hemiparesis or decerebrate posturing, which are absent in this comatose patient. *Metabolic encephalopathy* - **Metabolic encephalopathy** causes global cerebral dysfunction and may produce normal or small reactive pupils, but **pinpoint pupils** are not usually the defining finding. - Severe **respiratory depression** with a rate of 8/min is more characteristic of opioid toxicity than a nonspecific metabolic encephalopathy. *Pontine stroke* - A **pontine stroke** can cause pinpoint pupils by disrupting sympathetic pathways, but usually produces major **focal deficits**, such as quadriplegia or locked-in syndrome. - The absence of focal neurological findings and the combination of **miosis, coma, and hypoventilation** favor opioid toxicity over pontine stroke.

Q: All are correct regarding this technique for administration of intramuscular iron administered by the Z-track technique except:

Massage the site for even distribution of medicine. ***Massage the site for even distribution of medicine*** - **Massage is contraindicated** after intramuscular iron administration because it can disperse the preparation toward the skin and increase staining. - The Z-track technique is intended to **prevent leakage** of irritating iron into subcutaneous tissue; massaging the site can undermine this protective effect. *Pull the skin and subcutaneous tissue laterally to site of injection* - **Pulling the skin laterally** is an essential step in the Z-track technique, displacing the skin and subcutaneous tissue before needle insertion. - This creates a **zigzag track** that helps prevent leakage of irritating iron into subcutaneous tissue and reduces skin irritation or discoloration. *Pull back plunger to check for blood return if required by the protocol being followed, then inject the drug slowly; an air-lock may be used at the end if specified by the protocol* - Injecting the preparation **slowly** helps reduce pain and tissue trauma during intramuscular iron administration. - **Aspiration** and an **air-lock** may be used when specified by the protocol; these steps help limit intravascular administration and medication leakage. *Holding the skin taut with the non-dominant hand, insert the needle at a $90^{\circ}$ angle at the spot where the finger was placed initially* - Inserting the needle at a **90° angle** directs it into the muscle, which is required for proper intramuscular administration. - Maintaining the displaced skin position during insertion supports the **Z-track setup** and helps prevent medication tracking back into superficial tissues.

Q: Hypocalcemia is seen with which of the following conditions?

Acute pancreatitis. ***Acute pancreatitis*** - **Acute pancreatitis** causes fat necrosis, allowing released fatty acids to bind calcium and form insoluble calcium soaps through **saponification**. - The resulting **hypocalcemia** is a recognized metabolic complication and contributes to severity assessment in **Ranson’s criteria**. *Addison disease* - **Adrenal insufficiency** is generally associated with **hypercalcemia**, rather than hypocalcemia, due to reduced renal calcium clearance and increased bone resorption from glucocorticoid deficiency. - Therefore, **Addison disease** does not fit the expected association in this question, although calcium abnormalities can vary with individual clinical circumstances. *Hyperparathyroidism* - **Primary hyperparathyroidism** increases bone resorption, renal calcium reabsorption, and intestinal calcium absorption, producing **hypercalcemia** rather than hypocalcemia. - Thus, **hyperparathyroidism** has the opposite calcium association from the one described, except in unusual secondary or advanced clinical contexts. *Thyrotoxicosis* - **Thyrotoxicosis** increases bone turnover through thyroid hormone excess and may cause mild **hypercalcemia** from enhanced osteoclastic activity. - Consequently, **thyrotoxicosis** is not the best explanation for hypocalcemia among these choices; acute pancreatitis has the characteristic mechanism.

Q: Which of the following does NOT cause hyperkalemia?

Intestinal obstruction. ***Intestinal obstruction*** - **Intestinal obstruction** commonly causes vomiting and third-spacing, producing loss of gastric fluid and potassium rather than potassium retention or release. - Associated **metabolic alkalosis** shifts potassium into cells, while volume depletion activates **RAAS**, increasing renal potassium excretion; therefore it generally causes hypokalemia. *Renal failure* - **Renal failure** reduces the kidneys’ ability to excrete potassium, causing potassium retention and hyperkalemia. - Reduced **GFR** is particularly important in significant hyperkalemia because the kidney is responsible for most potassium excretion. *Hemolysis* - **Hemolysis** destroys red blood cells, which contain a high intracellular potassium concentration, releasing potassium into plasma. - In-vitro hemolysis can produce **pseudohyperkalemia**, while intravascular hemolysis can cause genuine extracellular potassium elevation. *Crush syndrome* - **Crush syndrome** causes extensive muscle destruction and rhabdomyolysis, releasing intracellular potassium into the extracellular fluid. - Because potassium is the main **intracellular cation**, massive myocyte injury can produce clinically important hyperkalemia.

Q: A 68-year-old man with severe peripheral arterial disease presents with rest pain and tissue loss in his right foot. Angiography shows multilevel disease with poor runoff. He has significant cardiac comorbidities and limited life expectancy. His family wants limb salvage, but he expresses preference for amputation. Evaluate the decision-making process.

Multidisciplinary discussion with patient and family. ***Multidisciplinary discussion with patient and family*** - A **multidisciplinary discussion** integrates vascular, medical, palliative, and patient perspectives, allowing the team to assess feasibility, prognosis, quality of life, and treatment burdens. - It respects the patient's **autonomy** while addressing family concerns and clarifying that severe comorbidities, limited life expectancy, multilevel disease, and poor runoff may limit limb-salvage benefit. *Proceed with amputation per patient preference* - The patient's **autonomy** supports amputation when his preference is informed, consistent, and based on understanding the prognosis, alternatives, and consequences of limb loss. - However, proceeding immediately may not address the family's concerns or ensure comprehensive exploration of **palliative care**, goals, and shared understanding; multidisciplinary discussion should precede the decision. *Defer decision to vascular surgery specialist* - Vascular surgery is important for assessing technical options, but sole deferral ignores the patient's **values**, preferences, and broader medical circumstances. - A specialist-only decision may emphasize procedural feasibility over **quality of life**, comorbidity burden, prognosis, and palliative goals that require broader shared decision-making. *Attempt endovascular intervention as compromise* - Endovascular treatment may expose the patient to repeated procedures and complications, with limited likelihood of durable success because of **multilevel disease** and poor runoff. - It is not an appropriate compromise if it conflicts with his informed **goals of care** and offers burdensome intervention despite significant cardiac comorbidities and limited life expectancy.

Q: What characterizes the sick cell syndrome?

Hyponatremia. ***Hyponatremia*** - **Hyponatremia** is the characteristic finding because reduced cellular ATP impairs the Na⁺-K⁺ pump, allowing sodium to enter cells. - Intracellular sodium accumulation draws in **water**, producing dilutional or redistributional hyponatremia that reflects the underlying severe illness. *Hypokalemia* - **Hypokalemia** does not characterize sick cell syndrome because impaired Na⁺-K⁺ pump function and membrane leakage do not produce a primary fall in extracellular potassium. - The expected electrolyte disturbance is **hyponatremia**, caused by intracellular sodium entry and water movement rather than potassium depletion. *Hypernatremia* - **Hypernatremia** suggests water loss or excess sodium, which is opposite to the intracellular sodium redistribution described in sick cell syndrome. - With **Na⁺-K⁺ ATPase failure**, sodium shifts into cells and water follows, lowering extracellular sodium concentration. *Hyperkalemia* - **Hyperkalemia** may occur when potassium leaks from dysfunctional cells, but it is not the primary characteristic electrolyte abnormality used to identify sick cell syndrome. - The defining exam finding is **hyponatremia**, resulting from sodium redistribution and cellular swelling rather than potassium release alone.

Question 1

What is the most common electrolyte disorder encountered in clinical practice?

Accepted Answer

Hyponatremia

Answer

Hypocalcemia

Answer

Hypernatremia

Answer

Hypokalemia

Question 2

What type of fever is a patient with the following temperature charting having?

Accepted Answer

Remittent fever

Answer

Quotidian fever

Answer

Intermittent fever

Answer

Continuous fever

Question 3

A 25 -year-old soldier is trapped in an avalanche in Siachen Glacier. He is airlifted to the base hospital. On admission the pulse is thready and BP is unrecordable. ECG strip is shown below. All of the findings are seen except:

Accepted Answer

Atrial bigeminy

Answer

Bradycardia

Answer

Osborn wave

Answer

Prolonged QT interval

Question 4

In the score shown below, alphabet P stands for?

Accepted Answer

Pulse rate

Answer

Pressure

Answer

Pallor severity

Answer

Physical activity

Question 5

A comatose person is brought to the hospital. On examination his respiratory rate is 8 / min with pulse rate of 75 bpm with BP of 110 / 70 mm Hg. His Pupils are shown below. Body temperature is 96°F. There are no focal neurological deficits. What is the probable diagnosis?

Accepted Answer

Opioid overdose

Answer

Uncal herniation

Answer

Metabolic encephalopathy

Answer

Pontine stroke

Question 6

All are correct regarding this technique for administration of intramuscular iron administered by the Z-track technique except:

Accepted Answer

Massage the site for even distribution of medicine

Answer

Pull the skin and subcutaneous tissue laterally to site of injection

Answer

Holding the skin taut with the non-dominant hand, insert the needle at a $90^{\circ}$ angle at the spot where the finger was placed initially

Answer

Pull back plunger to check for blood return if required by the protocol being followed, then inject the drug slowly; an air-lock may be used at the end if specified by the protocol

Question 7

Hypocalcemia is seen with which of the following conditions?

Accepted Answer

Acute pancreatitis

Answer

Thyrotoxicosis

Answer

Hyperparathyroidism

Answer

Addison disease

Question 8

Which of the following does NOT cause hyperkalemia?

Accepted Answer

Intestinal obstruction

Answer

Crush syndrome

Answer

Hemolysis

Answer

Renal failure

Question 9

A 68-year-old man with severe peripheral arterial disease presents with rest pain and tissue loss in his right foot. Angiography shows multilevel disease with poor runoff. He has significant cardiac comorbidities and limited life expectancy. His family wants limb salvage, but he expresses preference for amputation. Evaluate the decision-making process.

Accepted Answer

Multidisciplinary discussion with patient and family

Answer

Defer decision to vascular surgery specialist

Answer

Attempt endovascular intervention as compromise

Answer

Proceed with amputation per patient preference

Question 10

What characterizes the sick cell syndrome?

Accepted Answer

Hyponatremia

Answer

Hypernatremia

Answer

Hypokalemia

Answer

Hyperkalemia

General Medicine — MCQs

General Medicine — MCQs

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