General Medicine — MCQs

An 86-year-old lady presented with severe constipation. She was a known hypertensive on medications for 10 years. In clinic, her BP was 157/98 mm Hg with a heart rate of 58/min. On taking her BP in the supine position, it was found to be 90/60 mm Hg. She had a recent history of depression. She is taking atenolol, thiazide, imipramine, haloperidol, and docusate. What is the next best step in the management?

Q88

A 45-year-old patient presents with progressive dyspnea, orthopnea, and bilateral pedal edema. On examination, there is elevated JVP, S3 gallop, and hepatomegaly. What is the most likely underlying pathophysiology?

Q89

What is the primary electrolyte found in Oral Rehydration Salts (ORS) at a concentration of 75 mEq/L?

Q90

Which of the following is an acquired condition?

General Medicine Indian Medical PG Practice Questions and MCQs

Question 81: Reduced osmolarity ORS does not contain which of the following ions?

A. Sodium
B. Potassium
C. Lactate (Correct Answer)
D. Citrate

Explanation: ***Lactate*** - The **reduced osmolarity ORS** formulation replaced **bicarbonate** with **citrate** and does not contain lactate. - **Citrate** is preferred over lactate / bicarbonate due to its stability, longer shelf life, and ease of dissolution. *Sodium* - **Sodium** is a crucial component of ORS, as it is co-transported with glucose into enterocytes, facilitating water absorption through **solvent drag**. - Reduced osmolarity ORS has a **lower sodium concentration** (75 mEq/L) compared to standard ORS (90 mEq/L) to minimize hypernatremia risk and enhance water absorption. *Potassium* - **Potassium** is included in ORS to replace intestinal losses, as **diarrhea** leads to significant potassium depletion. - Maintaining adequate **potassium levels** is essential for normal cellular function and preventing hypokalemia-related complications. *Citrate* - **Citrate** is a component of ORS that serves as an **alkalinizing agent** to correct metabolic acidosis often associated with dehydration in diarrheal diseases. - It also enhances the absorption of sodium and water in the intestine.

Question 82: Which of the following conditions does not typically cause subconjunctival hemorrhages?

A. Whooping cough
B. Scurvy
C. Pellagra (Correct Answer)
D. Purpura

Explanation: ***Pellagra*** - Pellagra is a **nutritional deficiency disease** caused by a lack of **niacin (vitamin B3)**, characterized by symptoms affecting the **skin, gastrointestinal tract, and nervous system** (dermatitis, diarrhea, dementia, and death if untreated) [1]. - It does **not typically cause subconjunctival hemorrhages** as it primarily affects other organ systems and isn't associated with vascular fragility in the conjunctiva like the other conditions listed [2]. *Whooping cough* - **Violent coughing paroxysms** in whooping cough (pertussis) can significantly increase **venous pressure in the head and neck**. - This elevated pressure can rupture small conjunctival blood vessels, leading to **subconjunctival hemorrhages**. *Scurvy* - Scurvy is caused by **vitamin C deficiency**, which is essential for collagen synthesis and maintaining **blood vessel integrity**. - Lack of vitamin C leads to **fragile capillaries**, making patients prone to bleeding, including **subconjunctival hemorrhages**. *Purpura* - Purpura refers to **purple-colored spots on the skin caused by bleeding underneath the skin**. It is a general term for various conditions characterized by **small vessel bleeding**. - These conditions often involve **vascular fragility or platelet abnormalities**, making individuals susceptible to bleeding in different sites, including the conjunctiva, resulting in **subconjunctival hemorrhages**.

Question 83: Choking is a medical emergency that can occur due to various causes. Which of the following is a common cause of choking in adults?

A. Food obstruction (Correct Answer)
B. Laryngospasm
C. Anaphylaxis
D. Aspiration of liquids

Explanation: ***Food obstruction*** - **Food obstruction** is the most frequent cause of choking in adults, often due to large, poorly chewed pieces of food becoming lodged in the airway [1]. - This typically happens during meals, especially when talking or laughing while eating, or consuming alcohol which impairs coordination [1], [2]. *Laryngospasm* - **Laryngospasm** is an involuntary spasm of the vocal cords that temporarily closes the airway, but it typically resolves spontaneously and is not usually the primary cause of sustained choking in adults from foreign body obstruction [1]. - While it can cause transient difficulty breathing, it's often a protective reflex or a complication of intubation/anesthesia, rather than a common choking event. *Anaphylaxis* - **Anaphylaxis** is a severe allergic reaction that can cause airway swelling (angioedema and bronchospasm), leading to difficulty breathing and a sensation of choking. - However, it is a systemic allergic response with other symptoms like rash, hypotension, and gastrointestinal distress, not a direct mechanical obstruction of the airway by a foreign body. *Aspiration of liquids* - **Aspiration of liquids** occurs when fluids enter the trachea and lungs, which can cause coughing, gagging, and lead to aspiration pneumonia. - While it can be a serious event, it rarely causes complete and sudden airway obstruction that is characteristic of choking on a solid object.

Question 84: In which condition is the Albumin to Globulin (A:G) ratio maintained?

A. Nephritic syndrome (Correct Answer)
B. Cirrhosis
C. Protein losing enteropathy
D. Multiple myeloma

Explanation: ***Nephritic syndrome*** - In nephritic syndrome, the **glomerular filtration is often preserved**, allowing for the maintenance of A:G ratio despite the presence of hematuria and proteinuria [1]. - The condition typically leads to a **moderate degree of proteinuria**, retaining a relatively normal serum albumin level [1]. *Multiple myeloma* - In multiple myeloma, there is often a **high level of paraproteins** leading to a significant drop in albumin, affecting the A:G ratio. - Patients frequently exhibit **renal impairment**, resulting in a disrupted A:G ratio due to increased urinary protein loss. *Protein losing enteropathy* - This condition causes **loss of proteins** like albumin through the gastrointestinal tract, leading to **hypoalbuminemia** and altered A:G ratio. - It is characterized by **diarrhea** and fluid accumulation, further impacting the protein status in circulation. *Cirrhosis* - Cirrhosis leads to **decreased albumin synthesis**, resulting in a low serum albumin and an altered A:G ratio. - The condition is associated with **portal hypertension** and ascites, complicating the biochemical status.

Question 85: What is the BMI range that defines preobesity?

A. 18.5-24.9
B. 30-34.9
C. 35-39.9
D. 25-29.9 (Correct Answer)

Explanation: ***25-29.9*** - A **Body Mass Index (BMI)** between 25 and 29.9 kg/m² is classified as **overweight** [1] or **preobesity**. - This range indicates an increased risk of developing various health problems associated with higher body weight [1]. *18.5-24.9* - This BMI range is considered **normal weight**, which is generally ideal for health [1]. - Individuals within this range typically have the lowest risk of weight-related health complications [1]. *30-34.9* - A BMI in this range is classified as **obesity class I** [1]. - This category indicates a significantly increased risk of developing co-morbidities such as type 2 diabetes and cardiovascular disease [1]. *35-39.9* - This BMI range represents **obesity class II** (severe obesity) [1]. - Individuals in this category face a high risk of serious health issues and often require more aggressive intervention strategies [1].

Question 86: Which of the following statements about obesity is FALSE?

A. There is no genetic predisposition to obesity. (Correct Answer)
B. Smoking is associated with weight loss
C. Obesity affects only females.
D. The prevalence of obesity decreases with age.

Explanation: There is no genetic predisposition to obesity. - This statement is false because genetic factors play a significant role in an individual's susceptibility to obesity, influencing metabolism, appetite, and fat storage [1]. - While environment and lifestyle are crucial, polygenic influences and certain single-gene disorders can heavily predispose individuals to weight gain [1]. *Smoking is associated with weight loss* - Smoking can lead to appetite suppression and an increased metabolic rate, which may result in weight loss or lower body weight compared to non-smokers. - However, this is not a healthy or recommended method for weight control due to the numerous severe health risks associated with smoking. *Obesity affects only females.* - This statement is false; obesity affects both males and females across all age groups and demographics [2]. - Although there can be differences in fat distribution and associated health risks between sexes, obesity is a global health issue impacting everyone [2]. *The prevalence of obesity decreases with age.* - This statement is generally false; the prevalence of obesity tends to increase with age through middle adulthood before possibly leveling off or slightly declining in older age. - Factors like decreased physical activity, changes in metabolism, and chronic disease accumulation contribute to weight gain later in life [3].

Question 87: An 86-year-old lady presented with severe constipation. She was a known hypertensive on medications for 10 years. In clinic, her BP was 157/98 mm Hg with a heart rate of 58/min. On taking her BP in the supine position, it was found to be 90/60 mm Hg. She had a recent history of depression. She is taking atenolol, thiazide, imipramine, haloperidol, and docusate. What is the next best step in the management?

A. Change atenolol and thiazide to calcium channel blocker and ACE inhibitor and add bisacodyl for constipation
B. Change imipramine and haloperidol to fluoxetine and risperidone and add bisacodyl for constipation (Correct Answer)
C. Only add bisacodyl for constipation and continue rest of the medications
D. Discontinue all her medications and start her on steroids

Explanation: ***Change imipramine and haloperidol to fluoxetine and risperidone and add bisacodyl for constipation*** - The patient's presentation with **severe constipation** and **orthostatic hypotension** (supine BP 90/60 mmHg from 157/98 mmHg) strongly suggests drug-induced side effects. Older people are especially sensitive to drugs that can cause postural hypotension, and for any presenting problem in old age, the possibility that medication is a contributory factor should be considered [1]. Both **imipramine** (a tricyclic antidepressant) and **haloperidol** (an antipsychotic) have significant **anticholinergic effects**, which can cause severe constipation and worsen orthostatic hypotension. - Switching to **fluoxetine** (an SSRI with fewer anticholinergic effects) and **risperidone** (an atypical antipsychotic with less anticholinergic burden than haloperidol) would mitigate these side effects. Postural hypotension in older adults is defined as a drop in blood pressure of >20 mmHg systolic or >10 mmHg diastolic upon standing [2]. Adding **bisacodyl**, a stimulant laxative, directly addresses her severe constipation. *Change atenolol and thiazide to calcium channel blocker and ACE inhibitor and add bisacodyl for constipation* - While atenolol and thiazide can contribute to orthostatic hypotension, the primary drivers of her severe constipation and marked anticholinergic side effects are likely **imipramine** and **haloperidol**. - Changing the antihypertensive medications alone would not adequately address the severe constipation or the underlying pharmacological cause of her symptoms. *Only add bisacodyl for constipation and continue rest of the medications* - Simply adding a **laxative** without addressing the underlying drug-induced issues would not resolve the root cause of her severe constipation and orthostatic hypotension. Failure to recognise ADRs may lead to the use of further drugs to treat the problem, making matters worse [1]. - Continuing **imipramine** and **haloperidol** would perpetuate the significant anticholinergic side effects, leading to ongoing symptoms and potential complications. *Discontinue all her medications and start her on steroids* - **Discontinuing all medications** without a clear rationale is generally unsafe, especially in an elderly patient with multiple comorbidities like hypertension and depression. - **Steroids** are not indicated for constipation or orthostatic hypotension in this context and could introduce a new set of serious side effects.

Question 88: A 45-year-old patient presents with progressive dyspnea, orthopnea, and bilateral pedal edema. On examination, there is elevated JVP, S3 gallop, and hepatomegaly. What is the most likely underlying pathophysiology?

A. DALEY
B. HALE (Correct Answer)
C. OALY
D. None of the options

Explanation: ***HALE*** - This acronym stands for **Heart-failure Associated Lung Edema**. The symptoms of **progressive dyspnea**, **orthopnea**, **bilateral pedal edema**, **elevated JVP**, **S3 gallop**, and **hepatomegaly** are classic signs of **congestive heart failure** leading to fluid overload and pulmonary congestion [1]. - The pathophysiology involves the heart's inability to pump blood effectively, causing a buildup of pressure in the pulmonary and systemic circulations, leading to the observed symptoms [1]. *DALEY* - This is not a recognized acronym in medical pathophysiology. The symptoms presented are strongly indicative of a specific cardiovascular condition. - There is no clinical scenario where "DALEY" would accurately describe the underlying pathophysiology of dyspnea, edema, and heart failure signs. *OALY* - This is not a recognized acronym in medical pathophysiology. The presented clinical picture requires a well-established and specific pathophysiological explanation. - Using an unrecognized term would not provide an accurate or helpful description of the patient's condition. *None of the options* - The acronym HALE (Heart-failure Associated Lung Edema) accurately captures the core pathophysiology evident from the patient's symptoms and signs. - Given the strong clinical presentation of congestive heart failure with pulmonary and systemic congestion, one of the provided options *does* accurately describe the situation.

Question 89: What is the primary electrolyte found in Oral Rehydration Salts (ORS) at a concentration of 75 mEq/L?

A. Sodium (Correct Answer)
B. Potassium
C. Glucose
D. Chloride

Explanation: ***Sodium*** - The primary electrolyte in **Oral Rehydration Salts (ORS)** is **sodium**, which is crucial for replacing losses due to diarrhea and facilitating water absorption in the intestines [1]. - The standard ORS formulation, recommended by the WHO, contains **75 mEq/L of sodium** to effectively rehydrate individuals with acute watery diarrhea [1]. *Potassium* - While **potassium** is an essential electrolyte found in ORS, its concentration is typically lower than sodium, usually around **20 mEq/L**. - Potassium helps replenish intracellular losses and supports normal cellular function, but it is not the primary electrolyte at the 75 mEq/L concentration. *Glucose* - **Glucose** is a crucial component of ORS, but it is a sugar, not an electrolyte. - Its role is to facilitate the co-transport of **sodium and water** across the intestinal wall, enhancing fluid absorption, but it does not contribute to the electrolyte concentration in mEq/L [1]. *Chloride* - **Chloride** is an electrolyte present in ORS, primarily to balance the charge of **sodium** and prevent hyynatremia. - Its concentration is typically around **65 mEq/L**, making it slightly less concentrated than sodium but still vital for maintaining electrolyte balance.

Question 90: Which of the following is an acquired condition?

A. Polymastia (supernumerary breasts)
B. Polythelia (extra nipples)
C. Mastitis (Correct Answer)
D. Amastia (absence of breast tissue)

Explanation: ***Mastitis*** - **Mastitis** is an **inflammatory condition** of the breast, often caused by bacterial infection, particularly common during **lactation** [1]. - It is an **acquired condition** as it develops after birth due to external or internal factors, not present at birth. *Polymastia (supernumerary breasts)* - **Polymastia** is a **congenital condition** where additional breast tissue develops along the **milk line**. - This condition is present at birth and results from *embryological development anomalies*, not acquired later in life. *Polythelia (extra nipples)* - **Polythelia** refers to the presence of **accessory nipples** along the embryonic milk line and is a **congenital anomaly**. - Like polymastia, it is present from birth due to *developmental errors* and is not an acquired condition. *Amastia (absence of breast tissue)* - **Amastia** is a rare **congenital anomaly** characterized by the complete absence of breast tissue, nipple, and areola. - It is a **birth defect**, meaning it is present from birth and not an acquired condition.

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