FMGE 2023 - Internal Medicine PYQs Practice Questions

Q: A large 'V' wave on jugular venous pulse (JVP) examination is characteristic of:

Tricuspid regurgitation. ***Tricuspid regurgitation*** - A large **'V' wave** (ventricular systole) on JVP signifies increased pressure in the right atrium due to substantial **regurgitant flow** back from the right ventricle against a closed tricuspid valve.- This results in the rapid filling and distention of the right atrium during ventricular systole, often accompanied by the blunting or absence of the normal **'x' descent** (the 'x' descent is replaced by a systolic wave).*Aortic regurgitation* - Aortic regurgitation (AR) primarily affects the **left heart** and does not directly alter the established right heart pressure waveforms seen in the JVP [1].- Clinical signs of AR include a wide **pulse pressure**, **water-hammer pulse**, and diastolic murmur, but not specific waveform changes on JVP [3].*Tricuspid stenosis*- **Tricuspid stenosis** causes resistance to flow from the RA to the RV, leading to an exaggerated pressure rise during RA contraction, resulting in a prominent (tall) **'a' wave** [2].- The **'y' descent** is typically slow or attenuated because the rapid filling phase of the RV is impaired by the stenotic valve [2].*Atrial fibrillation* - In **atrial fibrillation (AFib)**, the uncoordinated atrial activity eliminates the mechanical contraction of the atria, causing the JVP tracing to lose the distinct **'a' wave**.- The ventricular rate is typically rapid and irregular, making JVP waveforms irregular, but it does not specifically cause a massive 'V' wave. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following is least likely to cause mucormycosis?

Broad spectrum antibiotics. ***Broad spectrum antibiotics*** - While broad-spectrum antibiotics predispose to many fungal infections (especially *Candida* infections) by disrupting the normal **microbiome**, they are not typically considered a direct, primary risk factor for **mucormycosis** [1]. - *Mucorales* are ubiquitous molds, and their pathogenicity is primarily related to defects in **phagocytic function** (like in neutropenia) [2] or **acidosis/iron overload** (like in DKA), not bacterial flora changes [2]. *Neutropenia* - Profound **neutropenia** (low neutrophil count) significantly impairs the host's ability to clear fungal spores, making it one of the most important risk factors for invasive mold infections, including **mucormycosis** [2]. - Neutrophils are crucial for the primary defense against **Mucorales** by killing the spores and hyphae. *Uncontrolled diabetes without DKA* - Even without **diabetic ketoacidosis (DKA)**, poorly controlled diabetes leads to impaired phagocyte function and immunosuppression, increasing the risk of invasive fungal infections like *Mucorales* and **Candida** [2], [3]. - The high glucose environment, especially in the **nasal mucosa**, can facilitate the growth and invasion of these fungi. *Prolonged use of steroid* - Glucocorticoids cause generalized **immunosuppression** by impairing the function of phagocytes and T-lymphocytes, thereby increasing susceptibility to opportunistic infections [3]. - High-dose or prolonged corticosteroid use is a well-established risk factor for severe and disseminated **mucormycosis** as it compromises the innate immune response. [Practice more Internal Medicine PYQs on OnCourse]

Q: A 35-year-old woman takes aspirin for a headache, later presented with wheezing and breathlessness. Along with these two symptoms, what other clinical findings are likely to be found in this condition?

Nasal polyp. ***Nasal polyp***- This clinical scenario is classic for **Aspirin-Exacerbated Respiratory Disease (AERD)**, also known as **Samter's Triad**, a condition characterized by three key components.- The three components of Samter's Triad are **asthma** (wheezing/breathlessness), chronic rhinosinusitis with **nasal polyps**, and sensitivity to aspirin/NSAIDs [1].*IgE release*- **Aspirin sensitivity** is a pseudoallergic reaction driven by abnormal metabolism of **arachidonic acid**, specifically involving the COX-1 pathway, and is thus typically **non-IgE mediated**.- This pathway disturbance leads to the overproduction of bronchoconstrictive **leukotrienes** (LTC4, LTD4, LTE4), which are the primary mediators of the reaction.*Extrinsic asthma*- **Extrinsic asthma** refers to allergic asthma, which relies on **IgE-mediated Type I hypersensitivity** reactions triggered by environmental allergens.- AERD is classified as a form of **intrinsic (non-allergic) asthma** because the trigger mechanism is pharmacological/metabolic rather than immunological (allergen-specific IgE) [1].*Drug interaction*- The adverse reaction seen here is an **idiosyncratic drug hypersensitivity reaction** stemming from the patient's underlying disease (AERD), not interaction with another drug.- A true **drug interaction** occurs when one drug alters the absorption, distribution, metabolism, or excretion of another drug, which is irrelevant to leukotriene overproduction. [Practice more Internal Medicine PYQs on OnCourse]

Q: A 20-year-old male presented with yellowish discoloration of his skin and sclera. He is otherwise normal. He gives a history of viral infection 10 days ago, which was resolved 2 days back. He also gives a history of similar episodes in the past following any illness. Lab values are given below. What is the most likely diagnosis? Serum bilirubin: 2.4 mg/dL Unconjugated bilirubin: 2.1mg/dL Conjugated bilirubin: 0.3mg/dL Serum AST and ALT: Normal

Gilbert syndrome. ***Gilbert syndrome*** - This condition is characterized by **unconjugated hyperbilirubinemia** (as seen by 2.1 mg/dL unconjugated vs. 0.3 mg/dL conjugated) that is mild, typically <3 mg/dL, and intermittent. [1] The history of similar episodes following **stress**, **vigorous exercise**, or **illness** (like the recent viral infection) is a classic trigger for this condition, which is caused by reduced activity of the **UGT1A1 enzyme**. [1] *Dubin-Johnson syndrome* - This syndrome results in **conjugated (direct) hyperbilirubinemia** due to defective excretion of conjugated bilirubin (MRP2 transporter defect). *Criggler-Najar type 1 syndrome* - This is a severe congenital deficiency of the **UGT1A1 enzyme**, leading to markedly and persistently elevated **unconjugated bilirubin** (often >20 mg/dL) and usually resulting in **kernicterus** and death in infancy. [1] The patient presents later in life (20 years old) with only mild, fluctuating unconjugated hyperbilirubinemia, ruling out Type 1 severity. *Rotor syndrome* - Similar to Dubin-Johnson, Rotor syndrome causes **conjugated (direct) hyperbilirubinemia** due to hepatocyte storage and transport defects, which contradicts the patient's lab findings of predominantly unconjugated bilirubin. Unlike Dubin-Johnson, Rotor syndrome does **not** cause black pigmentation of the liver. [Practice more Internal Medicine PYQs on OnCourse]

Q: A 25-year-old male presents with mild jaundice noticed during a recent febrile illness. He gives a history of similar episodes in the past following any illness or periods of fasting. Physical examination reveals mild icterus with no hepatosplenomegaly. Lab values are given below: Serum bilirubin: 2.4 mg/dL Unconjugated bilirubin: 2.1 mg/dL Conjugated bilirubin: 0.3 mg/dL Serum AST and ALT: Normal What is the most likely diagnosis?

Gilbert syndrome. ***Gilbert syndrome*** - It is characterized by isolated, mild, intermittent **unconjugated hyperbilirubinemia** (total bilirubin <4 mg/dL), often triggered by stress, fasting, illness, or dehydration, matching the patient's history of episodes following illness [1]. - The underlying cause is reduced activity (typically 30%) of the enzyme **uridine diphosphoglucuronate glucuronosyltransferase (UGT1A1)**, necessary for conjugating bilirubin, but liver function (AST/ALT) remains normal [1], [3]. *Dubin-Johnson syndrome* - This is characterized by **conjugated (direct) hyperbilirubinemia** due to defective excretion of bilirubin into the bile canaliculi, contrasting with the predominantly unconjugated pattern seen here [2]. - The liver tissue typically shows **black pigmentation** due to epinephrine metabolite accumulation, which is a key pathological feature. *Criggler-Najar type 1 syndrome* - This syndrome involves a severe or complete absence of the **UGT1A1 enzyme**, leading to very high levels of **unconjugated bilirubin** (often >20 mg/dL) that cause **kernicterus** and usually death in infancy, which is not consistent with a history of recurrent mild episodes in an adult [1]. - It requires lifelong treatment, typically with **phototherapy** and **liver transplantation**, due to the severe defect [1]. *Rotor syndrome* - Similar to Dubin-Johnson syndrome, Rotor syndrome also causes **conjugated (direct) hyperbilirubinemia** due to impaired hepatic storage and excretion of conjugated bilirubin, which contradicts the laboratory findings of mostly unconjugated bilirubin. [Practice more Internal Medicine PYQs on OnCourse]

Question 1

A large 'V' wave on jugular venous pulse (JVP) examination is characteristic of:

Accepted Answer

Tricuspid regurgitation

Answer

Aortic regurgitation

Answer

Tricuspid stenosis

Answer

Atrial fibrillation

Question 2

Which of the following is least likely to cause mucormycosis?

Accepted Answer

Broad spectrum antibiotics

Answer

Neutropenia

Answer

Uncontrolled diabetes without DKA

Answer

Prolonged use of steroid

Question 3

A 35-year-old woman takes aspirin for a headache, later presented with wheezing and breathlessness. Along with these two symptoms, what other clinical findings are likely to be found in this condition?

Accepted Answer

Nasal polyp

Answer

IgE release

Answer

Extrinsic asthma

Answer

Drug interaction

Question 4

A 20-year-old male presented with yellowish discoloration of his skin and sclera. He is otherwise normal. He gives a history of viral infection 10 days ago, which was resolved 2 days back. He also gives a history of similar episodes in the past following any illness. Lab values are given below. What is the most likely diagnosis? Serum bilirubin: 2.4 mg/dL Unconjugated bilirubin: 2.1mg/dL Conjugated bilirubin: 0.3mg/dL Serum AST and ALT: Normal

Accepted Answer

Gilbert syndrome

Answer

Criggler-Najar type 1 syndrome

Answer

Rotor syndrome

Answer

Dubin-Johnson syndrome

Question 5

A 25-year-old male presents with mild jaundice noticed during a recent febrile illness. He gives a history of similar episodes in the past following any illness or periods of fasting. Physical examination reveals mild icterus with no hepatosplenomegaly. Lab values are given below:

Serum bilirubin: 2.4 mg/dL
Unconjugated bilirubin: 2.1 mg/dL
Conjugated bilirubin: 0.3 mg/dL
Serum AST and ALT: Normal

What is the most likely diagnosis?

Accepted Answer

Gilbert syndrome

Answer

Dubin-Johnson syndrome

Answer

Rotor syndrome

Answer

Criggler-Najar type 1 syndrome

Question 6

Which of the following is a sensitive and specific marker of intestinal inflammation?

Accepted Answer

Fecal lactoferrin

Answer

Procalcitonin

Answer

High-sensitivity C-reactive protein

Answer

Tissue transglutaminase IgA

Question 7

A patient comes to you with increased cough, increased breathlessness, and decreased exercise capacity. Chest X-ray shows pulmonary fibrosis. Which drug can be administered in the given condition?

Accepted Answer

Pirfenidone

Answer

Imatinib

Answer

Bortezomib

Answer

Roflumilast

Question 8

A 50-year-old female patient with a known case of ovarian cancer presents with difficulty in activities like climbing stairs, getting up from a chair, combing hair, etc. The following characteristic sign was found on examination. The most probable diagnosis is:

Accepted Answer

Dermatomyositis

Answer

Systemic lupus erythematosus

Answer

Systemic sclerosis

Answer

Cushing syndrome

Question 9

A young male patient presents with ptosis and muscle weakness, which reportedly worsens in the evening and improves in the morning. This is relieved by neostigmine. What is the likely diagnosis?

Accepted Answer

Myasthenia gravis

Answer

Huntington chorea

Answer

Amyotrophic lateral sclerosis

Answer

External ophthalmoplegia

Question 10

A diabetic patient developed DVT with a necrolytic migratory rash. What is the most likely diagnosis?

Accepted Answer

Glucagonoma

Answer

VIPoma

Answer

Insulinoma

Answer

Gastrinoma

FMGE 2023 — Internal Medicine