General Medicine — MCQs

General Medicine Indian Medical PG Practice Questions and MCQs

Question 61: For comparison grading of pain the scale used is -

A. Visual scale (Correct Answer)
B. Face's scale
C. CHEOPS
D. Numerical charts

Explanation: ***Visual scale*** - The **Visual Analog Scale (VAS)** is a psychometric response scale used to measure subjective characteristics, like pain intensity, that cannot be directly measured. - Patients mark a point on a **10-cm line** between "no pain" and "worst pain imaginable," allowing for continuous comparison. *Face's scale* - The **Wong-Baker FACES Pain Rating Scale** is primarily used in children or adults with communication difficulties. - It uses **facial expressions** to depict different levels of pain intensity, making it easier for individuals to express their pain. *CHEOPS* - **CHEOPS** stands for the Children's Hospital of Eastern Ontario Pain Scale and is specifically designed for assessing **postoperative pain in infants and young children**. - It observes **behavioral indicators** such as crying, facial expression, and verbal cues, rather than direct self-reporting [1]. *Numerical charts* - **Numerical Rating Scales (NRS)** ask patients to rate their pain intensity on a scale from 0 (no pain) to 10 (worst pain possible). - While commonly used, NRS provides discrete values rather than a continuous visual representation for comparison like the VAS.

Question 62: A 50-year old woman complains of leakage of urine. Other than genuine stress urinary incontinence, the most common cause of urinary leakage is ?

A. Vesico vaginal fistula
B. Overflow incontinence
C. Detrusor dyssynergia
D. Urge incontinence (Correct Answer)

Explanation: ***Urge incontinence*** - **Urge incontinence**, characterized by an **involuntary leakage of urine accompanied or immediately preceded by urgency**, is the most common form of urinary incontinence after stress urinary incontinence, especially in older women [1]. - It results from **detrusor overactivity**, leading to sudden, strong urges to void that are difficult to defer. *Vesico vaginal fistula* - A **vesicovaginal fistula** involves an abnormal connection between the bladder and the vagina, leading to continuous and spontaneous leakage of urine into the vagina, which would present differently from typical urge symptoms [1]. - While it causes leakage, it's a relatively rare cause compared to urge incontinence and is often associated with prior surgery or radiation. *Overflow incontinence* - **Overflow incontinence** occurs when the bladder is overfilled and unable to empty properly, leading to continuous leakage of small amounts of urine due to retention [1]. - This is often caused by **bladder outlet obstruction** or **neurogenic bladder**, and the patient might report difficulty voiding or a sensation of incomplete emptying [1]. *Detrusor dyssynergia* - **Detrusor dyssynergia** describes a lack of coordination between the detrusor muscle contraction and external urethral sphincter relaxation, typically seen in neurological disorders [2]. - This condition is a specific type of voiding dysfunction that can lead to incontinence but is not the most common cause of leakage after stress incontinence in the general population.

Question 63: Flapping tremors are seen in all EXCEPT:

A. CO2 narcosis
B. Hepatic encephalopathy
C. Uremia
D. Thyrotoxicosis (Correct Answer)

Explanation: ***Thyrotoxicosis*** - **Thyrotoxicosis** is characterized by an **exaggerated physiological tremor**, which is typically fine and rapid, and differs from the slow, irregular flapping tremor (asterixis). - The tremor in thyrotoxicosis is primarily due to increased metabolic rate and enhanced sympathetic activity, not impaired motor control secondary to metabolic encephalopathy. *CO2 narcosis* - **CO2 narcosis**, a severe complication of hypercapnia, can lead to asterixis due to the depressive effects of high CO2 levels on the central nervous system. - The elevated **pCO2** results in cerebral vasodilation and increased intracranial pressure, contributing to impaired neurological function. *Hepatic encephalopathy* - **Hepatic encephalopathy** is a classic cause of **asterixis (flapping tremor)**, due to the liver's inability to detoxify ammonia and other neurotoxins. - These neurotoxins interfere with neurotransmission and neuronal activity, particularly in the motor cortex and basal ganglia. *Uremia* - **Uremia**, a manifestation of severe kidney failure, can cause **asterixis** due to the accumulation of uremic toxins that impair central nervous system function. - These toxins disrupt normal neuronal excitability and metabolism, leading to a variety of neurological symptoms.

Question 64: In a patient who has diarrhoea and vomiting with inadequate water intake is suffering from –

A. Extracellular dehydration with hypernatremia
B. Intracellular dehydration with hyponatremia
C. Intracellular dehydration with hypernatremia
D. Extracellular dehydration with hyponatremia (Correct Answer)

Explanation: ***Extracellular dehydration with hyponatremia*** - Diarrhea and vomiting primarily lead to a loss of **isotonic fluid** from the **extracellular space**, resulting in **extracellular dehydration** (hypovolemia) [1]. - While both water and sodium are lost, the replacement with inadequate water intake or plain water can dilute the remaining extracellular fluid, leading to relatively more water than sodium, thus causing **hyponatremia** [1]. *Extracellular dehydration with hypernatremia* - Although there is **extracellular dehydration** due to fluid loss, **hypernatremia** would occur if water loss significantly exceeded sodium loss, or if the water deficit was not adequately replaced, leading to a concentration of existing sodium. - In this scenario, the combination of fluid loss and insufficient water intake is more likely to cause a relative decrease in sodium concentration or an isotonic loss leading to subsequent hyponatremia [1]. *Intracellular dehydration with hyponatremia* - **Intracellular dehydration** occurs primarily due to a shift of water out of cells into the extracellular space, often as a result of **hypernatremia** in the extracellular fluid. - **Hyponatremia** would typically cause water to shift *into* cells, leading to cellular swelling, not intracellular dehydration [1]. *Intracellular dehydration with hypernatremia* - **Intracellular dehydration** is indeed often associated with **hypernatremia** in the extracellular fluid, as the increased extracellular osmolarity pulls water out of the cells [1]. - However, the primary effect of diarrhea and vomiting is directly on the **extracellular fluid volume**, and the subsequent alterations in sodium concentration are more complex than simple intracellular dehydration with hypernatremia.

Question 65: The highest concentration of potassium is in -

A. Ringer lactate
B. Darrow's solution (Correct Answer)
C. Isotonic saline
D. Plasma

Explanation: ***Darrow's solution*** - **Darrow's solution** is specifically formulated for patients with significant **potassium and fluid deficits**, often seen in conditions like severe diarrhea. - It contains a high concentration of potassium (typically around **35 mEq/L**) along with sodium and lactate, making it suitable for aggressive repletion. *Ringer lactate* - **Ringer lactate** (also known as Hartmann's solution) is an **isotonic crystalloid** used for fluid resuscitation and maintenance [1]. - While it contains potassium, its concentration is relatively low (typically around **4-5 mEq/L**), similar to physiological plasma levels, to prevent hyperkalemia during large-volume infusions [1]. *Isotonic saline* - **Isotonic saline** (0.9% NaCl) is a basic crystalloid solution primarily used for **volume expansion** and does not contain any potassium [1]. - It provides sodium and chloride, making it useful for extracellular fluid replacement but offers no potassium supplementation. *Plasma* - **Plasma** is the liquid component of blood and has a physiological potassium concentration that is tightly regulated, typically ranging from **3.5 to 5.0 mEq/L** [2]. - This concentration is maintained within a narrow range by renal excretion and cellular shifts to prevent cardiac arrhythmias and other electrolyte disturbances [2].

Question 66: A 30-year-old woman with a history of allergic rhinitis presents with bilateral watery nasal discharge and itchy eyes. What is the most appropriate first-line treatment?

A. Nasal saline irrigation
B. Antibiotics
C. Oral antihistamine
D. Intranasal corticosteroids (Correct Answer)

Explanation: **Intranasal corticosteroids** - **Intranasal corticosteroids** are considered the **first-line treatment** for allergic rhinitis due to their broad anti-inflammatory effects on nasal mucosa [1]. - They effectively reduce symptoms such as **nasal congestion**, **rhinorrhea**, **sneezing**, and **itching** [1]. *Nasal saline irrigation* - **Nasal saline irrigation** can help clear irritants and mucus from the nasal passages, providing symptomatic relief. - However, it is primarily an **adjunctive therapy** and not the most potent first-line treatment for managing moderate to severe allergic rhinitis symptoms alone. *Antibiotics* - **Antibiotics** are used to treat bacterial infections, which are not indicated in this case as the symptoms (watery discharge, itchy eyes) are classic for **allergic rhinitis**, not a bacterial infection. - Unnecessary antibiotic use contributes to **antibiotic resistance** and provides no benefit for allergic conditions. *Oral antihistamine* - **Oral antihistamines** are effective for relieving sneezing, itching, and rhinorrhea in allergic rhinitis [1]. - While useful, intranasal corticosteroids generally offer **superior efficacy**, particularly for nasal congestion, and are often preferred as initial monotherapy for persistent symptoms [1].

Question 67: A 22-year-old female with bulimia nervosa presents with fatigue and muscle weakness. Laboratory results show decreased potassium and increased bicarbonate levels. The EKG reveals U waves. What is the most appropriate immediate next step in management?

A. IV potassium replacement (Correct Answer)
B. Administer oral potassium supplements
C. Initiate intravenous fluids with dextrose
D. Start refeeding protocol

Explanation: ***IV potassium replacement*** - The presence of **fatigue, muscle weakness, hypokalemia**, and **U waves on EKG** indicates profound potassium depletion which requires urgent intravenous replacement to prevent life-threatening **cardiac arrhythmias**. [1] - **U waves** are pathognomonic for severe hypokalemia, and immediate intervention is crucial. *Administer oral potassium supplements* - While oral potassium is appropriate for mild to moderate hypokalemia, it is **too slow** and insufficient for severe or symptomatic hypokalemia with EKG changes. - The patient's symptoms and EKG findings suggest a more acute and severe deficiency requiring rapid correction. *Initiate intravenous fluids with dextrose* - Dextrose solutions alone do not address the primary issue of **potassium depletion** and can potentially worsen hypokalemia by stimulating insulin release, which drives potassium into cells. [2] - While intravenous fluids may be needed for hydration, they must be combined with potassium replacement. [1] *Start refeeding protocol* - Refeeding syndrome is a concern in patients with eating disorders, but it is not the immediate priority for a patient with **symptomatic hypokalemia** and EKG changes. - Addressing the critical electrolyte imbalance takes precedence over starting a refeeding protocol, which should be initiated cautiously later.

Question 68: Which of the following conditions is most commonly associated with high anion gap metabolic acidosis?

A. Diabetic ketoacidosis (Correct Answer)
B. Renal tubular acidosis
C. Severe diarrhea
D. Salicylate intoxication

Explanation: ***Diabetic ketoacidosis*** - In **diabetic ketoacidosis (DKA)**, the body produces **ketoacids** (ketones) due to insulin deficiency, which are unmeasured anions causing a **high anion gap metabolic acidosis** [2]. - The accumulation of these organic acids lowers the **bicarbonate** level and pH, increasing the calculated anion gap. *Renal tubular acidosis* - **Renal tubular acidosis (RTA)** typically causes a **normal anion gap metabolic acidosis**, as the kidney's inability to excrete acid or reabsorb bicarbonate does not involve the accumulation of unmeasured anions [1]. - It results from specific defects in acid-base handling by the renal tubules, leading to hyperchloremic metabolic acidosis [1]. *Severe diarrhea* - Severe diarrhea causes **metabolic acidosis** due to the loss of **bicarbonate** in the stool. - This loss of bicarbonate without a corresponding increase in unmeasured anions results in a **normal anion gap (hyperchloremic) metabolic acidosis**. *Salicylate intoxication* - Salicylate intoxication is complex and often causes a **mixed acid-base disorder**, initially stimulating the respiratory center leading to **respiratory alkalosis** [1]. - As the intoxication progresses, it can cause **high anion gap metabolic acidosis** due to uncoupling of oxidative phosphorylation and impaired renal function, but DKA remains a more classic and distinct cause of solely high anion gap metabolic acidosis.

Question 69: A 60-year-old female with diabetes presents with recurrent carbuncles on her neck and poor glycemic control. What is the best management?

A. Optimize glucose, start systemic abx (Correct Answer)
B. Immediate drainage w/o abx
C. Topical abx, daily wound care
D. Observation, follow-up

Explanation: ***Optimize glucose, start systemic abx*** - **Poorly controlled diabetes** compromises the immune system and is a significant risk factor for recurrent **bacterial skin infections** like carbuncles [2], necessitating immediate glycemic optimization [1]. - **Carbuncles** are deeper, more extensive infections than furuncles [3], often requiring **systemic antibiotics** in addition to incision and drainage, especially in immunocompromised individuals [1]. *Immediate drainage w/o abx* - While **drainage** is a crucial step for carbuncles to remove pus and relieve pressure, it is insufficient alone for a patient with diabetes and recurrent infections [1]. - **Systemic antibiotics** are typically required to treat the extensive infection and prevent further spread or recurrence in immunocompromised patients [1]. *Topical abx, daily wound care* - **Topical antibiotics** are generally not effective for **carbuncles**, which are deep-seated infections extending into the subcutaneous tissue and often accompanied by systemic symptoms [3]. - While **daily wound care** is important, it cannot address the underlying systemic infection or the predisposing factor of poorly controlled diabetes. *Observation, follow-up* - **Observation** is an inappropriate management strategy for a diabetic patient with **recurrent carbuncles** and **poor glycemic control**. - Such a presentation indicates a severe, ongoing infection requiring prompt medical intervention to prevent complications like **sepsis** or spread of infection.

Question 70: A 35-year-old male with a history of chronic alcohol use is at risk for developing liver cirrhosis. What is the primary prevention strategy for liver cirrhosis?

A. Alcohol cessation programs (Correct Answer)
B. Liver function tests
C. Treatment of cirrhosis
D. Liver transplant

Explanation: ***Alcohol cessation programs*** - **Abstinence from alcohol** is the most effective primary prevention strategy, as it directly addresses the cause of alcohol-related liver damage [1]. - Participating in **alcohol cessation programs** helps individuals stop drinking, thereby preventing the progression to cirrhosis [1]. *Liver function tests* - **Liver function tests (LFTs)** are diagnostic tools used to assess liver damage or dysfunction, not preventive measures [1]. - While LFTs can monitor liver health, they do not prevent the initial development of **cirrhosis** itself. *Treatment of cirrhosis* - This option refers to **tertiary prevention**, which involves managing an existing disease to prevent complications or slow its progression. - The question asks for **primary prevention**, which aims to prevent the disease from occurring in the first place. *Liver transplant* - A **liver transplant** is a treatment for end-stage liver disease, including severe cirrhosis, and is a last resort [2]. - This is a **tertiary prevention** or treatment strategy, not a primary prevention method to stop the onset of cirrhosis [2].

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