FMGE 2019 - Internal Medicine Practice Questions

Q: Which heart sound is almost always considered pathological?

S4. ***S4*** - An **S4 heart sound**, or **atrial gallop**, is almost always indicative of **pathology**, specifically a **stiff or non-compliant ventricle**. - It occurs due to vigorous atrial contraction forcing blood into a **non-compliant ventricle**, commonly seen in conditions like **hypertensive heart disease**, **aortic stenosis**, and **hypertrophic cardiomyopathy**. *S2* - **S2** represents the **closure of the aortic and pulmonic valves** and is a normal physiological heart sound [2]. - While it can be altered in pathology (e.g., fixed splitting, paradoxical splitting), the sound itself is a normal component of the cardiac cycle [1]. *S1* - **S1** represents the **closure of the mitral and tricuspid valves** and is a normal physiological heart sound [1]. - Variations in its intensity or splitting can occur in disease states, but the presence of S1 itself is normal. *S3* - An **S3 heart sound**, or **ventricular gallop**, can be a normal finding in **children**, **young adults**, and **pregnant individuals**, often referred to as a **physiological S3**. - However, in adults over 40, an S3 often indicates **ventricular dysfunction** due to rapid filling into a dilated ventricle [3], as seen in **heart failure** [1].

Q: Prostatic cancer mostly seen in

Posterior. ***Posterior*** - The **peripheral zone** of the prostate, which is located posteriorly, is the most common site for the development of **prostatic adenocarcinoma**. - This anatomical location is why a **digital rectal exam (DRE)** is an important screening tool, as palpable nodules can be detected [1]. *Lateral* - While prostatic tissue extends laterally, this region is not the predominant site for cancer development. - Cancers originating here are less common than those in the posterior peripheral zone. *Anterior* - The **anterior fibromuscular stroma** and the anterior portion of the prostate are rarely the primary sites for prostate cancer. - Tumors found here are often extensions from more posteriorly located cancers. *Medial* - The **transition zone**, which is located medially and surrounds the urethra, is the most common site for **benign prostatic hyperplasia (BPH)**, not prostate cancer. - While cancer can occur in this zone, it is less frequent than in the peripheral zone.

Q: Abdominal pain, fever and jaundice. This triad is known as;

Charcot's triad. ***Charcot's triad*** - **Charcot's triad** consists of **abdominal pain**, **fever**, and **jaundice**, indicating **acute cholangitis** [1]. - This triad is a hallmark of **biliary tract obstruction** with concurrent infection [1]. *Renault's triad* - This is a **distractor** name; there is no recognized medical triad called "Renault's triad." - It does not describe any specific clinical presentation or set of symptoms. *Virchow triad* - **Virchow triad** describes factors that predispose to **thrombus formation**: **endothelial injury**, **stasis**, and **hypercoagulability**. - It is associated with conditions like **deep vein thrombosis (DVT)** and **pulmonary embolism**, not cholangitis. *Saint's triad* - **Saint's triad** refers to the co-occurrence of **gallstones**, **hiatal hernia**, and **diverticulosis**. - This triad describes three unrelated gastrointestinal conditions and is distinct from the symptoms of cholangitis.

Q: Which is not seen in Tumour lysis Syndrome?

Hypophosphatemia. ***Hypophosphatemia*** - **Tumor lysis syndrome (TLS)** is characterized by the rapid breakdown of tumor cells, leading to the release of intracellular components into the bloodstream. - This process typically results in **acute hyperphosphatemia**, not hypophosphatemia, due to the high phosphate content within tumor cells. *Hyperkalemia* - **Hyperkalemia** is a hallmark of TLS because potassium, a major intracellular cation, is released in large quantities as tumor cells lyse. - Excess potassium can lead to potentially life-threatening cardiac arrhythmias. *Hyperuricemia* - **Hyperuricemia** occurs in TLS because nucleic acids (DNA and RNA) released from dying tumor cells are metabolized into purines, which are then converted to uric acid [1]. - High uric acid levels can precipitate in the renal tubules, leading to **acute kidney injury** [1]. *Hypocalcemia* - **Hypocalcemia** develops in TLS secondary to the acute hyperphosphatemia. - The excess phosphate binds with serum calcium to form **calcium-phosphate precipitates**, effectively lowering the concentration of free ionized calcium.

Q: Which of the following is best for diagnosis of pheochromocytoma?

24-hour urinary Fractionated Metanephrine. ***24-hour urinary Fractionated Metanephrine*** - This test measures the **metabolites of catecholamines** (epinephrine and norepinephrine), which are continuously produced by pheochromocytomas [1]. - As metanephrines are released continuously rather than episodically, their measurement in a 24-hour urine collection provides the **highest sensitivity and specificity** for diagnosing pheochromocytoma. *24-hour Urinary Hydroxy indole acetic acid* - This is a metabolite of **serotonin**, which is relevant to conditions like **carcinoid syndrome**, not pheochromocytoma. - Elevated levels would indicate a serotonin-producing tumor, not a catecholamine-producing tumor. *24-hour urinary Vanillyl Mandelic acid* - While VMA is a metabolite of both epinephrine and norepinephrine, it is a less specific and sensitive marker than fractionated metanephrines for pheochromocytoma. - Its measurement can be affected by various medications and dietary factors, leading to a higher rate of false positives and negatives compared to metanephrines. *24-hour Urinary Hydroxy tryptamine* - This refers to **serotonin**, which is not directly relevant to the diagnosis of pheochromocytoma. - Elevated levels would point towards conditions involving serotonin metabolism, such as carcinoid tumors.

Q: Hyperkalemia means more than

5.5 mEq/l. ***5.5 mEq/l*** - **Hyperkalemia** is defined as a serum potassium level greater than **5.5 mEq/L** [1]. - This elevated level can lead to significant cardiac and neurological complications if not promptly addressed. *4.5 mEq/l* - A potassium level of 4.5 mEq/L falls within the normal physiological range for serum potassium, which is typically **3.5 to 5.0 mEq/L** [1]. - Therefore, this value does not indicate hyperkalemia. *10.5 mEq/l* - While 10.5 mEq/L is indeed an elevated potassium level, it represents **severe hyperkalemia**, far exceeding the general threshold for diagnosis. - The definition of hyperkalemia begins at a lower threshold of **5.5 mEq/L** [1]. *7.5 mEq/l* - A potassium level of 7.5 mEq/L indicates **moderate to severe hyperkalemia** and is a critical finding requiring immediate medical intervention [2]. - However, the initial threshold for defining hyperkalemia is **5.5 mEq/L**, making this option too high for the general definition [1].

Q: A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Cor pulmonale. ***Cor pulmonale*** - **Cor pulmonale** is right heart failure secondary to pulmonary disease, which perfectly explains the constellation of **tachypnea**, **pulmonary hypertension**, and **elevated JVP**. - The pathophysiology involves underlying lung disease leading to **pulmonary hypertension**, causing **right heart strain** and eventual right heart failure. *Tension pneumothorax* - Characterized by **severe dyspnea**, **hypotension**, and **tracheal deviation**, none of which are explicitly mentioned here. - While it causes tachypnea, it would typically present with **unilateral absent breath sounds** and **hemodynamic instability**, not chronic pulmonary hypertension. *Aortic dissection and rupture* - Typically presents with **sudden onset severe chest pain**, **pulse deficits**, and often **blood pressure differences** between arms. - Does not primarily cause **pulmonary hypertension** or **elevated JVP** as its initial and predominant symptoms. *Right ventricular hypertrophy* - This represents a **structural adaptation** to chronic pressure overload rather than the primary cause of the clinical syndrome. - **RVH** is a consequence and manifestation of **cor pulmonale**, not the underlying diagnosis explaining the patient's presentation.

Q: The following serological status is noted in a patient: HbsAg positive and HbeAg positive. Diagnosis is?

Active hepatitis B with high infectivity. ***Active hepatitis B with high infectivity*** - The presence of **HBsAg** indicates ongoing **hepatitis B infection** (either acute or chronic) [1]. - The presence of **HBeAg** signifies active **viral replication** and **high infectivity**, meaning the patient can easily transmit the virus [1]. *Chronic viral hepatitis* - While the patient does have hepatitis B, simply stating "chronic viral hepatitis" is less specific and doesn't fully capture the **infectivity status**. - **Chronic hepatitis B** is defined by **HBsAg persistence** for more than six months, but a high infectivity state is specifically implied by HBeAg positivity [1]. *Remote infection* - **Remote infection** would typically be indicated by the presence of **anti-HBs** and **anti-HBc IgG** antibodies, with no detectable HBsAg [1]. - The patient's **HBsAg positive** status rules out a remote infection where the virus has been cleared [1]. *Resolved hepatitis B infection* - A resolved hepatitis B infection is characterized by **loss of HBsAg** and the development of **anti-HBs antibodies**, indicating immunity [1]. - The patient's **HBsAg positive** status definitively indicates that the infection is not resolved and is still active [1].

Q: Chronic viral hepatitis is seen with all of the following viruses, except?

HEV. ***HEV*** - While HEV can cause acute hepatitis, it **rarely progresses to chronic infection** in immunocompetent individuals. - Chronic HEV infection is primarily seen in **immunocompromised patients**, such as organ transplant recipients. *HCV* - **Hepatitis C virus** is well-known for its high propensity to establish chronic infection, with about 75-85% of acutely infected individuals developing **chronic hepatitis** [1]. - Chronic HCV infection can lead to **cirrhosis**, liver failure, and hepatocellular carcinoma [1]. *HBV* - **Hepatitis B virus** is a major cause of chronic hepatitis worldwide, especially when acquired perinatally or in early childhood [1]. - Approximately 5-10% of immunocompetent adults who acquire acute HBV infection progress to **chronic hepatitis** [1]. *HDV* - **Hepatitis D virus** is a defective virus that requires co-infection with HBV to replicate; therefore, chronic HDV infection only occurs in individuals with chronic HBV. - Co-infection or superinfection with HDV often **accelerates the progression of liver disease** to cirrhosis and liver failure.

Q: Which type of gout is seen in a patient who is on treatment of CML?

Secondary gout. ***Secondary gout*** - **Secondary gout** occurs when a high uric acid level is a consequence of another medical condition or its treatment, such as **chronic myelogenous leukemia (CML)** [1]. - The increased cell turnover in CML, especially during treatment, leads to a significant release of **purines**, which are then metabolized into **uric acid**, causing hyperuricemia and gout [1]. *Pseudogout* - **Pseudogout** is caused by the deposition of **calcium pyrophosphate dihydrate (CPPD)** crystals, not uric acid crystals, in the joints [2]. - While it can mimic gout attacks, it has a different underlying pathophysiology and is not directly linked to CML or its treatment. *Acute gout* - **Acute gout** describes the sudden onset of severe pain, swelling, and redness in a joint, which is a common presentation of any type of gout, whether primary or secondary. - This term refers to a **gout flare** rather than the underlying cause of the hyperuricemia. *Primary gout* - **Primary gout** occurs due to an intrinsic metabolic defect in purine metabolism or renal excretion of uric acid, without an identifiable underlying disease [1]. - In this scenario, the gout is secondary to CML and its treatment, making **primary gout** an incorrect classification [1].

Question 1

Which heart sound is almost always considered pathological?

Accepted Answer

S4

Answer

S2

Answer

S1

Answer

S3

Question 2

Prostatic cancer mostly seen in

Accepted Answer

Posterior

Answer

Lateral

Answer

Answer

Medial

Question 3

Abdominal pain, fever and jaundice. This triad is known as;

Accepted Answer

Charcot's triad

Answer

Renault's triad

Answer

Virchow triad

Answer

Saint's triad

Question 4

Which is not seen in Tumour lysis Syndrome?

Accepted Answer

Hypophosphatemia

Answer

Hyperkalemia

Answer

Hyperuricemia

Answer

Hypocalcemia

Question 5

Which of the following is best for diagnosis of pheochromocytoma?

Accepted Answer

24-hour urinary Fractionated Metanephrine

Answer

24-hour Urinary Hydroxy indole acetic acid

Answer

24-hour urinary Vanillyl Mandelic acid

Answer

24-hour Urinary Hydroxy tryptamine

Question 6

Hyperkalemia means more than

Accepted Answer

5.5 mEq/l

Answer

4.5 mEq/l

Answer

10.5 mEq/l

Answer

7.5 mEq/l

Question 7

A 40-year-old male presents with tachypnea. Examination reveals a respiratory rate of 32/min, pulmonary hypertension, blood pressure of 132/90 mmHg, and elevated JVP. What is the most likely cause of these findings?

Accepted Answer

Cor pulmonale

Answer

Tension pneumothorax

Answer

Aortic dissection and rupture

Answer

Right ventricular hypertrophy

Question 8

The following serological status is noted in a patient: HbsAg positive and HbeAg positive. Diagnosis is?

Accepted Answer

Active hepatitis B with high infectivity

Answer

Chronic viral hepatitis

Answer

Remote infection

Answer

Resolved hepatitis B infection

Question 9

Chronic viral hepatitis is seen with all of the following viruses, except?

Accepted Answer

HEV

Answer

HCV

Answer

HBV

Answer

HDV

Question 10

Which type of gout is seen in a patient who is on treatment of CML?

Accepted Answer

Secondary gout

Answer

Pseudogout

Answer

Acute gout

Answer

Primary gout

FMGE 2019 — Internal Medicine