FMGE 2026 - Internal Medicine PYQs Practice Questions

Q: A pregnant woman has anemia despite adequate treatment with iron and folic acid. Her hemoglobin remains 9 g/dL but she is still asymptomatic. What is the most likely diagnosis?

Thalassemia trait. ***Thalassemia trait*** - This condition presents with **microcytic hypochromic anemia** that is typically refractory to **iron supplementation** because it is a genetic defect in globin synthesis, not an iron deficiency. - It is frequently identified during pregnancy as **asymptomatic, mild anemia** that fails to respond to standard **hematinics**. *Sickle cell anemia* - Usually presents with more severe clinical manifestations like **vaso-occlusive crises**, **hemolysis**, and **jaundice**, rather than being asymptomatic. - Often diagnosed earlier in life, and the blood smear typically shows **sickled cells** or **target cells** along with evidence of chronic hemolysis. *Thalassemia major* - Presents with severe, **transfusion-dependent anemia** starting from childhood, making it unlikely for a patient to remain asymptomatic during pregnancy. - Associated with significant complications like **hepatosplenomegaly**, **skeletal deformities**, and **iron overload**. *Hereditary spherocytosis* - Characterized by **hemolytic anemia** with findings of **jaundice** and **splenomegaly** due to extravascular hemolysis. - Peripheral blood smears typically reveal **spherocytes** and an increased **mean corpuscular hemoglobin concentration (MCHC)**. [Practice more Internal Medicine PYQs on OnCourse]

Q: A child presents with easy bruising and bleeding. Physical examination reveals multiple ecchymoses and purpuric lesions over the body, as shown in the image. Hemarthrosis is absent. Deficiency of which vitamin best explains these findings?

Vitamin C. ***Vitamin C*** - Deficiency leads to **scurvy**, characterized by defective **collagen synthesis** due to the inability to hydroxylate proline and lysine residues. - Clinical features include **perifollicular hemorrhages**, swollen/bleeding gums, **petechiae**, and easy bruising, which aligns with the child's presentation. *Vitamin K* - Deficiency primarily causes coagulopathy, leading to deep tissue bleeding or **hemarthrosis** rather than exclusively cutaneous findings. - It relies on clotting factors II, VII, IX, and X, typically resulting in an elevated **prothrombin time (PT)** and PTT. *Vitamin D* - Deficiency leads to **rickets** in children or osteomalacia in adults due to impaired calcium and phosphate absorption, causing **bone deformities** and fractures. - It does not cause bleeding diathesis or spontaneous purpuric lesions in the absence of severe liver disease or complications. *Vitamin A* - Deficiency typically presents with **night blindness**, dry eyes (xerophthalmia), and **keratomalacia** due to impaired ocular epithelial maintenance. - Dermatological manifestations involve **follicular hyperkeratosis** (phrynoderma), not purpura or easy bruising. [Practice more Internal Medicine PYQs on OnCourse]

Q: Eruptive xanthomas with a prominent chylomicron band on lipid electrophoresis are most commonly seen due to:

Lipoprotein lipase (LPL) deficiency. ***Lipoprotein lipase (LPL) deficiency*** - This condition, classified as **Familial Chylomicronemia Syndrome (Type I Hyperlipoproteinemia)**, is characterized by the accumulation of **chylomicrons** in the plasma due to defective hydrolysis of triglycerides. - Clinically, it presents with **eruptive xanthomas**, **pancreatitis**, and **hepatosplenomegaly**, often appearing in childhood with extremely high **serum triglyceride levels**. *LDL receptor defect* - This pathology causes **Familial Hypercholesterolemia (Type IIa Hyperlipoproteinemia)**, characterized by elevated **LDL cholesterol**. - It typically results in **tendon xanthomas** and **xanthelasma**, not eruptive xanthomas, and presents primarily with increased risk of premature **coronary artery disease**. *Apo B-100 deficiency* - This leads to **hypobetalipoproteinemia**, where there is an inability to assemble VLDL, resulting in very low levels of **LDL** and **VLDL**. - It does not cause hypertriglyceridemia or eruptive xanthomas; instead, it is associated with **fat malabsorption** and **vitamin E deficiency**. *Apo E deficiency* - This is associated with **Familial Dysbetalipoproteinemia (Type III Hyperlipoproteinemia)**, which results in the accumulation of **remnant particles** (IDL and chylomicron remnants). - Characteristic findings include **tuberoeruptive** and **palmar xanthomas**, rather than the acute eruptive xanthomas seen in classic Chylomicronemia syndrome. [Practice more Internal Medicine PYQs on OnCourse]

Q: A patient presents with ataxia, ichthyosis, retinitis pigmentosa, and cardiac conduction defects. Laboratory evaluation reveals increased phytanic acid levels. What is the most likely diagnosis?

Refsum disease. ***Refsum disease*** - Caused by a deficiency of **peroxisomal phytanoyl-CoA hydroxylase**, leading to the accumulation of **phytanic acid**, which is toxic to the nervous system. - The classic clinical tetrad includes **ataxia**, **ichthyosis** (scaling of the skin), **retinitis pigmentosa** (causing night blindness), and **cardiac conduction defects** (arrhythmias). *Zellweger disease* - This is a severe peroxisome biogenesis disorder characterized by the **absence of functional peroxisomes** entirely rather than a specific enzyme defect. - Patients typically present with **craniofacial dysmorphism**, hypotonia, and seizures in early infancy with a much poorer prognosis. *Adrenoleukodystrophy* - Results from a mutation in the **ABCD1 gene**, leading to impaired beta-oxidation and the accumulation of **very-long-chain fatty acids (VLCFAs)**. - Clinical features primarily involve **adrenal insufficiency** (Addison disease) and progressive **neurological deterioration** rather than ichthyosis or elevated phytanic acid. *Metachromatic leukodystrophy* - Caused by a deficiency of **arylsulfatase A**, leading to the accumulation of **sulfatides** in the central and peripheral nervous system. - It is characterized by progressive **demyelination** leading to ataxia, dementia, and seizures, without the feature of elevated phytanic acid levels. [Practice more Internal Medicine PYQs on OnCourse]

Q: A chronic alcoholic who consumes a non -vegetarian diet presents with confusion, gait disturbance, and eye movement abnormalities.Deficiency of which vitamin is most likely responsible for these findings?

Thiamine (Vitamin B1). ***Thiamine (Vitamin B1)*** - This clinical triad of **confusion**, **ataxia** (gait disturbance), and **ophthalmoplegia** (eye movement abnormalities) is the classic presentation of **Wernicke encephalopathy**. - Chronic alcohol use impairs **thiamine absorption**, and the deficiency leads to metabolic dysfunction in the brain, particularly in the **thalamus** and **mammillary bodies**. *Vitamin B12* - Deficiency typically presents with **megaloblastic anemia** and **subacute combined degeneration of the spinal cord**, manifesting as sensory deficits and weakness, rather than acute ophthalmoplegia. - While confusion can occur (megaloblastic madness), it is not associated with the classic triad seen in alcohol-induced neurological decline. *Niacin* - Causes **pellagra**, characterized by the 3 D's: **dermatitis** (photosensitive rash), **diarrhea**, and **dementia** (not isolated ataxia or eye movement issues). - Symptoms are usually dermatological and gastrointestinal before severe neurological impairment occurs. *Pyridoxine* - Deficiency typically presents with **peripheral neuropathy** (burning sensation, tingling) and **sideroblastic anemia**. - It is not associated with movement disorders like ataxia or the specific oculomotor deficits seen in Wernicke encephalopathy. [Practice more Internal Medicine PYQs on OnCourse]

Question 1

A pregnant woman has anemia despite adequate treatment with iron and folic acid. Her hemoglobin remains 9 g/dL but she is still asymptomatic. What is the most likely diagnosis?

Accepted Answer

Thalassemia trait

Answer

Sickle cell anemia

Answer

Thalassemia major

Answer

Hereditary spherocytosis

Question 2

A child presents with easy bruising and bleeding. Physical examination reveals multiple ecchymoses and purpuric lesions over the body, as shown in the image. Hemarthrosis is absent. Deficiency of which vitamin best explains these findings?

Accepted Answer

Vitamin C

Answer

Vitamin K

Answer

Vitamin D

Answer

Vitamin A

Question 3

Eruptive xanthomas with a prominent chylomicron band on lipid electrophoresis are most commonly seen due to:

Accepted Answer

Lipoprotein lipase (LPL) deficiency

Answer

LDL receptor defect

Answer

Apo B-100 deficiency

Answer

Apo E deficiency

Question 4

A patient presents with ataxia, ichthyosis, retinitis pigmentosa, and cardiac conduction defects. Laboratory evaluation reveals increased phytanic acid levels. What is the most likely diagnosis?

Accepted Answer

Refsum disease

Answer

Zellweger disease

Answer

Adrenoleukodystrophy

Answer

Metachromatic leukodystrophy

Question 5

A chronic alcoholic who consumes a non -vegetarian diet presents with confusion, gait disturbance, and eye movement abnormalities.Deficiency of which vitamin is most likely responsible for these findings?

Accepted Answer

Thiamine (Vitamin B1)

Answer

Vitamin B12

Answer

Niacin

Answer

Pyridoxine

Question 6

Interpret the acid-base status for the following lab values. HCO3-14; PaCO2 -24; pH-7.4.

Accepted Answer

Metabolic acidosis with compensation

Answer

Respiratory acidosis without compensation

Answer

Respiratory alkalosis without compensation

Answer

Metabolic alkalosis with compensation

Question 7

A 58-year-old man presents to the emergency department with sudden onset severe retrosternal chest pain associated with diaphoresis and nausea. ECG shows ST elevation in leads II, III, aVF. His BP is 80/60 mmHg with cool extremities, but lung fields clear on ausculataion. What is the next best step in management?

Accepted Answer

IV normal saline

Answer

Nitroglycerine

Answer

Diuretics

Answer

Vasopressors

Question 8

Middle aged male presented with gradually progressive effort intolerance and awareness of forceful heartbeats over the last few moths. On geneal physical examination, there is a visibly strong, bounding pulasation in the neck with prominent carotid upstroke. Careful inspection of the nail beds reveals rhythmic pulsatile blanching synchronous with cardiac cycle. Which of the following auscultatory findings best corresponds to this clinical presentation?

Accepted Answer

Early diastolic murmur

Answer

Late diastolic murmur

Answer

Systolic crescendo decresendo

Answer

Mid systolic murmur

Question 9

You are asked to assess the pulse tracing of the patient. The following pulse corresponds to involvement of which of the following heart valves?

Accepted Answer

Aortic valve

Answer

Mitral valve

Answer

Tricuspid valve

Answer

Pulmonary valve

Question 10

A patient presents with complaints of shortness of breath and effort intolerance. On auscultation a loud opening snap with mid diastolic murmur is heard. Echocardiography shows an EF of 38%. ECG is shown below. Diagnosis is?

Accepted Answer

Critical mitral stenosis

Answer

Aortic stenosis

Answer

Mitral Regurgitation

Answer

Aortic regurgitation

FMGE 2026 — Internal Medicine