FMGE 2025 - Internal Medicine Practice Questions

Q: A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?

Lamivudine. Lamivudine - This serological profile (HBsAg+, IgM anti-HBc-, IgG anti-HBc+, HBeAg+) indicates HBeAg-positive chronic Hepatitis B with active viral replication [1] - Among the given options, Lamivudine is the only agent with anti-HBV activity as a nucleoside reverse transcriptase inhibitor (NRTI) that inhibits HBV DNA polymerase - Important Note: While Lamivudine was historically used for chronic HBV, current guidelines (WHO, AASLD, EASL) recommend Tenofovir or Entecavir as first-line therapy due to higher potency and lower resistance rates [2] - Lamivudine is now considered second-line due to high resistance rates (up to 70% after 5 years) Incorrect Option: Ombitasvir - Ombitasvir is an NS5A inhibitor used exclusively for Hepatitis C (HCV) treatment in combination regimens - Has no activity against HBV and is inappropriate for this patient Incorrect Option: Ritonavir - Ritonavir is an HIV protease inhibitor used primarily as a pharmacokinetic booster in antiretroviral therapy - Has no direct anti-HBV activity and is not used for HBV treatment Incorrect Option: Abacavir - Abacavir is an NRTI used for HIV treatment as part of combination ART - Despite being an NRTI class drug, it lacks significant anti-HBV activity and is not approved or effective for chronic Hepatitis B management

Q: A patient with road traffic accident (RTA) is passing red color urine due to myoglobinuria. Which of the following will most likely be seen in this patient?

Hyperkalemia. ***Hyperkalemia***- Rhabdomyolysis involves massive breakdown of muscle cells, leading to the rapid release of intracellular contents, primarily **potassium (K+)**, into the circulation [1].- The associated **acute kidney injury (AKI)**, caused by myoglobin toxicity and sludge formation in the renal tubules, severely impairs K+ excretion, thus exacerbating the **hyperkalemia** [1].*Hypernatremia*- This condition is typically associated with states of significant **free water deficit** or inadequate fluid intake, not the massive tissue injury seen in rhabdomyolysis.- Fluid management of trauma patients often involves isotonic fluids, which are unlikely to cause severe dehydration leading to **hypernatremia**.*Hyponatremia*- While aggressive hydration with hypotonic fluids during resuscitation *could* potentially cause dilutional hyponatremia, the direct metabolic consequence of rhabdomyolysis is not primarily a state of **low serum sodium**.- Severe trauma leading to rhabdomyolysis is often associated with the release of ADH due to volume depletion, but this is less characteristic than the rapid rise in potassium.*Hypokalemia*- Hypokalemia, or low serum potassium, is the opposite of the predictable metabolic consequence of rhabdomyolysis.- Muscle cell death releases K+, making **hypokalemia** extremely unlikely in the acute setting of severe muscle injury and subsequent AKI.

Q: A patient after RTA had a renal shut down. Work-up shows: FeNa: $< 1\%$ , Urine osmolality: 300 mOsm/kg, Urinary sodium: 40 mEq/L. Most likely diagnosis?

Pre-renal AKI. Correct: Pre-renal AKI - **FeNa 500), and urinary sodium (40 mEq/L) is at the borderline, **FeNa remains the gold standard** differentiating parameter *Incorrect: Acute Tubular Necrosis (Renal AKI)* - ATN would show **FeNa >2%** due to tubular dysfunction and inability to reabsorb sodium [1] - Urinary sodium would typically be **>40 mEq/L** (here it's exactly 40, borderline) - Urine osmolality would be ** 2%, not <1% [1] *Incorrect: Post-renal AKI* - Implies obstruction (bladder, ureter, urethra) - Not suggested by the clinical scenario of post-trauma renal shutdown - Laboratory parameters don't help differentiate obstruction; needs imaging **Key Teaching Point:** When laboratory values seem mixed, **FeNa <1% is the most reliable indicator of pre-renal azotemia**, especially in trauma settings with likely hypovolemia.

Q: A patient presents with fever and altered sensorium. Peripheral smear shows multiple ring stages. Best treatment is?

Artesunate. Artesunate - The clinical presentation of fever and altered sensorium, along with a peripheral smear showing multiple ring stages (characteristic of P. falciparum), indicates severe malaria [1]. Intravenous artesunate is the recommended first-line treatment [1]. - Artesunate is a potent and rapidly acting artemisinin derivative that quickly reduces the parasite burden, leading to lower mortality rates compared to quinine in severe malaria cases [1]. Primaquine - Primaquine is primarily used to eradicate the dormant liver stages (hypnozoites) of P. vivax and P. ovale to prevent relapse, not for treating acute, severe falciparum malaria. - It is ineffective against the asexual erythrocytic stages of P. falciparum and can cause severe hemolysis in patients with G6PD deficiency. Quinine - Quinine is a second-line agent for severe malaria and is only used if artesunate is unavailable, due to its inferior efficacy and greater toxicity [1]. - Its use is associated with adverse effects known as cinchonism (tinnitus, headache, nausea) and can cause severe hypoglycemia and cardiac arrhythmias [1]. Chloroquine - Widespread resistance of P. falciparum to chloroquine makes it an ineffective choice for treating this infection in most malaria-endemic regions. - Chloroquine is typically reserved for the treatment of uncomplicated malaria caused by chloroquine-sensitive species like P. malariae, _P. ovale, or P. vivax (in areas without resistance).

Q: A patient presents with progressive shortness of breath for the last 6 months, accompanied by dry cough. Auscultation reveals bilateral basal end-inspiratory crepitations. There is no history of fever, joint pain, or occupational exposure. What is the diagnosis?

IPF. ### IPF - The presentation of progressive **shortness of breath**, dry cough, and characteristic **bilateral basal end-inspiratory crepitations** (**Velcro crackles**) strongly suggests Idiopathic Pulmonary Fibrosis [1]. - IPF is a diagnosis of exclusion, supported here by the absence of fever, joint pain, or known occupational/environmental exposures (making it **idiopathic**) [1][2]. *Cor-pulmonale* - *Cor-pulmonale* is **right ventricular failure** secondary to pulmonary hypertension caused by underlying lung disease, and typically presents with signs of systemic venous congestion (e.g., peripheral edema, elevated JVP). - While advanced IPF can *cause* cor-pulmonale, it is not the primary process causing the initial restrictive pattern and bilateral basal **crepitations**. *Sarcoidosis* - Sarcoidosis often involves **bilateral hilar lymphadenopathy** and systemic features (e.g., skin or eye findings), which are absent in this presentation [4]. - Pulmonary fibrosis associated with sarcoidosis typically has an **upper lobe predominance**, unlike the basal findings described here [4]. *Hypersensitivity pneumonitis* - This diagnosis requires a history of exposure to an inhaled **antigen** (e.g., birds, molds) in the home or workplace, which is explicitly excluded in the patient history [3]. - Acute or subacute forms of HP often involve systemic symptoms like fever and chills, which are not mentioned in this slowly progressive presentation [3].

Q: A patient presents with contralateral face, arm, and leg weakness. NCCT shows intracerebral hemorrhage (ICH). What is the most likely location of the CNS bleed?

Basal ganglia. ***Basal ganglia*** - The **basal ganglia**, particularly the **putamen**, is the most common site for hypertensive intracerebral hemorrhage, which aligns perfectly with the deep parenchymal bleed seen on the provided NCCT scan. - A lesion in this location classically damages the adjacent **internal capsule**, where motor fibers for the face, arm, and leg are tightly packed, resulting in **contralateral hemiparesis**. *Midbrain* - A midbrain hemorrhage would present with distinct cranial nerve deficits, most notably **oculomotor nerve (CN III) palsy**, causing a "down and out" eye position, ptosis, and a dilated pupil. - Other characteristic signs include altered consciousness and **vertical gaze palsy** (Parinaud syndrome), which are absent in this patient's pure motor presentation. *Pons* - Pontine hemorrhages have a catastrophic presentation, typically causing a rapid descent into **coma**, **quadriplegia**, and classic **pinpoint pupils** due to disruption of descending sympathetic pathways. - The patient's presentation of contralateral hemiparesis without coma or pupillary changes is inconsistent with a pontine bleed. *Medulla* - Medullary hemorrhages are rare and cause specific brainstem syndromes like **Wallenberg syndrome**, characterized by vertigo, nystagmus, dysphagia, and ipsilateral facial numbness. - These syndromes involve complex crossed sensory and motor deficits, not the uniform contralateral motor weakness described in the question.

Q: What is the management of undulant fever?

Doxycycline plus rifampicin. ***Doxycycline plus rifampicin***- This is the **standard and preferred oral combination regimen** for treating **Brucellosis** (undulant fever), typically administered for 6 weeks [1].- The combination is crucial because it uses antibiotics that penetrate macrophages and have a **synergistic effect**, significantly reducing the risk of relapse compared to monotherapy.*Doxycycline*- **Doxycycline** is the cornerstone of treatment due to its excellent **intracellular penetration**, but **monotherapy** is associated with high rates of **relapse**.- It must be combined with a second agent (like **rifampicin** or **streptomycin**) to achieve adequate cure rates and prevent recurrence.*Doxycycline with azithromycin*- While macrolides like **azithromycin** show *in vitro* activity against *Brucella*, clinical data supporting this combination as a first-line treatment are generally lacking.- This combination is **less effective** and not recommended by major professional guidelines compared to regimens using **rifampicin** or aminoglycosides.*Doxycycline plus ceftriaxone*- **Ceftriaxone** (a third-generation cephalosporin) is used primarily for complicated brucellosis, especially **neurobrucellosis** (often added to the standard regimen).- It is **not recommended** as part of the standard initial **oral** regimen for uncomplicated brucellosis due to inferior efficacy compared to rifampicin.

Q: A patient has cheilosis with koilonychia and anemia. Diagnosis is?

Plummer-Vinson syndrome. ***Plummer-Vinson syndrome***- This syndrome is defined by the classic triad of **dysphagia** (due to esophageal webs), **iron deficiency anemia**, and mucosal changes, which include **cheilosis** (angular stomatitis) and **koilonychia** (spoon nails) [1].- It is most common in middle-aged women and results from chronic, severe **iron deficiency**, which causes the epithelial atrophy leading to the observed symptoms [1].*Esophageal cancer*- While **Plummer-Vinson syndrome** is a pre-malignant condition that increases the risk of **esophageal squamous cell carcinoma**, the current presentation describes the syndrome's classic signs, not confirmed malignancy.- Malignancy typically causes progressive **dysphagia** and severe **weight loss**, and the specific triad of **cheilosis** and **koilonychia** is not the primary diagnostic feature.*Achalasia cardia*- This is a **primary esophageal motility disorder** characterized by the poor relaxation of the **lower esophageal sphincter (LES)** and aperistalsis of the esophageal body.- The main symptoms are **dysphagia** (to both solids and liquids) and **regurgitation**, but it is not associated with the systemic features of **iron deficiency anemia**, **cheilosis**, or **koilonychia**.*Tylosis palmaris*- **Tylosis palmaris** is a form of **palmoplantar keratoderma**, an inherited disorder causing marked hyperkeratosis (thickening) of the palms and soles.- Although it is strongly associated with an increased risk for **esophageal squamous cell carcinoma** (Howel-Evans syndrome), it does not cause the specific features of **iron deficiency anemia**, **cheilosis**, and **koilonychia**.

Q: Which classification is used for Barrett esophagus?

Prague classification. ***Prague classification***- This classification is specifically designed for the standardized endoscopic assessment and documentation of **Barrett esophagus** (BE).- It uses two main parameters: the maximal extent (M) and the circumferential extent (C) of the columnar-lined esophagus, ensuring consistent reporting for surveillance.*Savary-Miller classification*- This classification system is used to grade the severity of **reflux esophagitis** (erosive esophagitis), not Barrett esophagus.- It categorizes esophageal mucosal injury based on the extent and depth of erosions.*Johnson classification*- This classification is generally not a recognized standard system for classifying key GI pathology like Barrett esophagus, unlike established systems such as the **Prague classification** or **Los Angeles classification** for reflux esophagitis.- *Note: A Johnson classification exists for pediatric hip dysplasia, but it is unrelated to GI endoscopy.* *Forrest classification*- This system is used exclusively to classify the appearance of **peptic ulcer bleeding** (or other upper GI bleed sources) seen during endoscopy.- It helps predict the risk of rebleeding and guides interventions, such as those performed for ulcers with adherent clots or active oozing.

Q: A female patient complains of chest pain while waking up in the morning. Pain is more in winter months. Which of the following best describes this patient?

Ach-induced coronary vasoconstriction. ***Ach-induced coronary vasoconstriction***- This clinical presentation—chest pain at rest (especially in the morning hours) and exacerbation during winter months (due to cold exposure)—is the hallmark of **Variant (Prinzmetal's) angina**, which is caused by transient **coronary vasospasm**. [1]- The mechanism involves underlying endothelial dysfunction leading to hyperreactivity of coronary smooth muscle, which can be demonstrated via provoked spasm using agents like **Acetylcholine (ACh)** during diagnostic tests. [1]*Fixed plaque obstruction*- This pathology defines **Stable Angina**, where chest pain is typically predictable and primarily brought on by physical **exertion** when myocardial oxygen demand exceeds fixed supply. [1]- Stable angina rarely occurs exclusively at rest upon waking and does not typically exhibit marked seasonal variation associated with **vasospasm** triggers like cold.*Subendocardial ischemia due to increased demand of myocardium*- Demand ischemia results from factors that increase myocardial workload (e.g., high heart rate, exercise), leading to supply-demand mismatch, which is minimized during rest/sleep. [1]- Prinzmetal's angina is a *supply* problem (vasospasm) causing acute, severe **transmural ischemia**, often presenting with transient **ST elevation** on ECG, differentiating it from typical subendocardial demand ischemia.*Increased sympathomimetic drive in morning hours*- While the natural circadian rhythm involves an increase in sympathetic tone upon waking, potentially triggering cardiac events, this does not describe the specific mechanism of the chest pain.- The symptoms described are most diagnostic of **Prinzmetal's angina**, a distinct disorder defined by localized arterial hyperreactivity rather than general sympathetic increase.

Question 1

A young male patient has the following serological status: HbsAg positive, IgM anti Hbc negative, IgG Anti-Hbc positive and HBeAg positive. Select the best treatment for this patient?

Accepted Answer

Lamivudine

Answer

Ritonavir

Answer

Ombitasvir

Answer

Abacavir

Question 2

A patient with road traffic accident (RTA) is passing red color urine due to myoglobinuria. Which of the following will most likely be seen in this patient?

Accepted Answer

Hyperkalemia

Answer

Hypokalemia

Answer

Hyponatremia

Answer

Hypernatremia

Question 3

A patient after RTA had a renal shut down. Work-up shows: FeNa: $< 1\%$ , Urine osmolality: 300 mOsm/kg, Urinary sodium: 40 mEq/L. Most likely diagnosis?

Accepted Answer

Pre-renal AKI

Answer

Renal AKI

Answer

Acute Tubular Necrosis

Answer

Post-renal AKI

Question 4

A patient presents with fever and altered sensorium. Peripheral smear shows multiple ring stages. Best treatment is?

Accepted Answer

Artesunate

Answer

Chloroquine

Answer

Primaquine

Answer

Quinine

Question 5

A patient presents with progressive shortness of breath for the last 6 months, accompanied by dry cough. Auscultation reveals bilateral basal end-inspiratory crepitations. There is no history of fever, joint pain, or occupational exposure. What is the diagnosis?

Accepted Answer

IPF

Answer

Hypersensitivity pneumonitis

Answer

Sarcoidosis

Answer

Cor-pulmonale

Question 6

A patient presents with contralateral face, arm, and leg weakness. NCCT shows intracerebral hemorrhage (ICH). What is the most likely location of the CNS bleed?

Accepted Answer

Basal ganglia

Answer

Pons

Answer

Midbrain

Answer

Medulla

Question 7

What is the management of undulant fever?

Accepted Answer

Doxycycline plus rifampicin

Answer

Doxycycline

Answer

Doxycycline plus ceftriaxone

Answer

Doxycycline with azithromycin

Question 8

A patient has cheilosis with koilonychia and anemia. Diagnosis is?

Accepted Answer

Plummer-Vinson syndrome

Answer

Esophageal cancer

Answer

Achalasia cardia

Answer

Tylosis palmaris

Question 9

Which classification is used for Barrett esophagus?

Accepted Answer

Prague classification

Answer

Johnson classification

Answer

Forrest classification

Answer

Savary-Miller classification

Question 10

A female patient complains of chest pain while waking up in the morning. Pain is more in winter months. Which of the following best describes this patient?

Accepted Answer

Ach-induced coronary vasoconstriction

Answer

Fixed plaque obstruction

Answer

Increased sympathomimetic drive in morning hours

Answer

Subendocardial ischemia due to increased demand of myocardium

FMGE 2025 — Internal Medicine