NEET-PG 2018 - Internal Medicine Practice Questions

Q: Patient presenting with cutaneous vasculitis, glomerulonephritis, peripheral neuropathy, Which investigation is to be performed next that will help you diagnose the condition?

ANCA. ### ANCA - The combination of **cutaneous vasculitis**, **glomerulonephritis**, and **peripheral neuropathy** points towards a small-vessel vasculitis, for which **ANCA (anti-neutrophil cytoplasmic antibodies)** testing is crucial [1]. - ANCA is highly specific for conditions like **Granulomatosis with Polyangiitis (GPA)** and **Microscopic Polyangiitis (MPA)** [1]. ### RA factor - **Rheumatoid factor (RF)** is primarily associated with **rheumatoid arthritis**, which typically presents with symmetrical polyarthritis, not the constellation of symptoms described. - While RF can be positive in some vasculitides, it is not the most specific initial test for the given clinical presentation. ### Hbsag - **Hepatitis B surface antigen (HbsAg)** typically screens for **Hepatitis B infection**, which can cause **polyarteritis nodosa (PAN)**, a medium-vessel vasculitis. - However, the patient's symptoms (cutaneous vasculitis, glomerulonephritis) are more characteristic of **small-vessel vasculitis**, making ANCA a more direct investigation [1]. ### MIF - **MIF (Macrophage Migration Inhibitory Factor)** is a cytokine involved in inflammation, but it is not a routine diagnostic marker for vasculitis. - It is not used as a primary investigation to diagnose specific autoimmune or inflammatory conditions like vasculitis.

Q: Which drug is used as an adjunct to epinephrine in refractory ventricular fibrillation/ventricular tachycardia during cardiac arrest?

Amiodarone infusion. ***Amiodarone infusion*** - **Amiodarone** is a **Class III antiarrhythmic** drug commonly used in advanced cardiac life support (ACLS) protocols for refractory **ventricular fibrillation (VF)** or **pulseless ventricular tachycardia (VT)** that persists despite defibrillation and epinephrine [1]. - It works by blocking potassium channels, prolonging repolarization and the refractory period, which helps to stabilize the electrical activity of the heart. *Atropine* - **Atropine** is an anticholinergic drug primarily used to treat **symptomatic bradycardia** by increasing heart rate. - It is not indicated for the treatment of **ventricular fibrillation** or **ventricular tachycardia** during cardiac arrest. *High dose vasopressin* - **Vasopressin** was previously included in some ACLS algorithms as an alternative to epinephrine for **vasoconstrictive effects**, but recent guidelines do not support its routine use in cardiac arrest. - While it can cause **vasoconstriction**, there is no evidence that high-dose vasopressin improves outcomes in refractory VF/VT over epinephrine. *Adenosine* - **Adenosine** is an antiarrhythmic drug used to treat **supraventricular tachycardias (SVTs)** by transiently blocking the AV node. - It is not effective for **ventricular fibrillation** or **ventricular tachycardia** and can even be harmful in these rhythms.

Q: Which is not included in AIDS related complex?

Ectopic pregnancy. ***Ectopic pregnancy*** - **Ectopic pregnancy** is a gynecological condition related to reproductive health and is **not a direct manifestation** of HIV infection or one of the opportunistic infections/conditions characteristic of AIDS-related complex. - While HIV can affect overall health during pregnancy, an ectopic pregnancy itself is a different medical issue. *Recurrent genital candidiasis* - **Recurrent genital candidiasis** can be a sign of **diminished immune function** in HIV-positive women [1]. - It is often considered an AIDS-defining condition or a common opportunistic infection seen in the progression of HIV to AIDS-related complex [1]. *Generalised lymphadenopathy* - **Generalized lymphadenopathy**, specifically **persistent generalized lymphadenopathy (PGL)**, is a common early manifestation of HIV infection [1]. - It reflects ongoing immune activation and is part of the spectrum of conditions included in AIDS-related complex [1]. *Chronic diarrhea* - **Chronic diarrhea** (lasting more than one month) is a frequent and significant symptom in individuals with HIV infection, particularly as the disease progresses [1]. - It can be caused by various opportunistic infections or directly by HIV, and is a component of AIDS-related complex or AIDS-defining illness [1].

Q: Which of the following is the MOST characteristic feature of ataxia telangiectasia?

Increases the risk of lymphoid malignancies. ***Increases the risk of lymphoid malignancies*** - Ataxia-telangiectasia (A-T) is characterized by a high predisposition to **lymphoid malignancies**, particularly lymphomas and leukemias, due to defective DNA repair mechanisms. - The **ATM gene mutation** in A-T leads to chromosomal instability, making cells more susceptible to uncontrolled proliferation associated with cancer. *Increase in serum alpha-fetoprotein (AFP) levels* - While elevated serum **alpha-fetoprotein (AFP)** is a biochemical hallmark of Ataxia-telangiectasia, it is a laboratory finding, not a direct clinical feature or primary characteristic of the disease pathology itself. - AFP elevation in A-T is thought to be related to **hepatic dysfunction** or impaired clearance, but not as directly defining as the increased malignancy risk. *Genetic inheritance pattern is autosomal recessive* - The **autosomal recessive** inheritance pattern describes how the disease is passed down through families, specifically requiring two copies of the mutated gene. - While fundamental to the genetics of A-T, it is a mode of inheritance and not a *characteristic clinical feature* or direct pathophysiological consequence of the disease. *None of the options* - This option is incorrect because the increased risk of lymphoid malignancies is indeed a highly characteristic and clinically significant feature of Ataxia-telangiectasia.

Q: Which condition is associated with the ECG pattern known as pseudo P pulmonale?

Hypercalcemia. ***Hypercalcemia*** - **Hypercalcemia** can cause a characteristic ECG pattern known as pseudo P pulmonale due to its effects on **myocardial repolarization**. - This condition leads to a **shortened QT interval** which causes the T wave to merge with the P wave, giving the appearance of a tall, peaked P wave. *Hypokalemia* - **Hypokalemia** typically presents with **flattened T waves**, prominent U waves, and ST-segment depression on an ECG [1]. - It can prolong repolarization, which is the opposite effect observed with pseudo P pulmonale [1]. *Hyponatremia* - **Hyponatremia** has a less defined direct effect on ECG patterns compared to other electrolyte imbalances. - Severe hyponatremia may lead to **QRS widening** or **bradycardia**, but not pseudo P pulmonale [1]. *Hypocalcemia* - **Hypocalcemia** characteristically causes **prolongation of the QT interval** on an ECG due to delayed ventricular repolarization [2]. - This is distinct from the shortened QT seen in hypercalcemia that contributes to pseudo P pulmonale.

Q: Choose the best method of diagnosis for the clinical sign represented in the image.

Serum ceruloplasmin. ***Serum ceruloplasmin*** - The image shows a **Kayser-Fleischer ring**, a greenish-brown discoloration in the periphery of the cornea, which is pathognomonic for **Wilson's disease**. - **Wilson's disease** is a genetic disorder of copper metabolism characterized by **low serum ceruloplasmin** levels (the primary copper-carrying protein in the blood) and increased copper deposition in various tissues. *Serum copper* - While Wilson's disease involves copper accumulation, **total serum copper** can be normal or even elevated due to widespread tissue damage releasing copper into the circulation, making it an unreliable diagnostic marker on its own. - A low serum copper level can be seen, but it is not as specific as low ceruloplasmin, as much of the copper in serum is bound to ceruloplasmin. *Karyotyping* - **Karyotyping** is used to analyze the number and structure of chromosomes and is primarily indicated for diagnosing chromosomal abnormalities, such as Down syndrome or Turner syndrome. - It is not relevant for diagnosing metabolic disorders like Wilson's disease, which is caused by a mutation in a single gene (ATP7B), not a chromosomal aberration. *PCR* - **PCR (Polymerase Chain Reaction)** is a technique used to amplify DNA sequences and can be used for genetic testing to identify specific mutations. - While genetic testing for the **ATP7B gene** mutation is a confirmatory test for Wilson's disease, it is not the primary or best method for initial diagnosis, especially when classic clinical signs and biochemical markers (like low ceruloplasmin) are present.

Q: What is a potential cause of cardiogenic shock other than myocardial infarction (MI)?

Acute mitral regurgitation. ***Acute mitral regurgitation*** - **Acute mitral regurgitation** is a severe form of valvular heart disease where the mitral valve fails to close properly, leading to a sudden backflow of blood into the left atrium during systole. [1] - This significantly reduces **forward cardiac output** and increases left atrial pressure, which can rapidly lead to pulmonary edema and cardiogenic shock, even in the absence of MI. [1] *Ventricular septal rupture* - While a **ventricular septal rupture** can cause cardiogenic shock, it is typically a **complication of myocardial infarction**, meaning it would fall under MI as the underlying cause. [2] - This condition involves a hole in the septum separating the ventricles, leading to a shunt and increased workload on the right ventricle, causing cardiogenic shock. *Isolated right ventricular shock* - **Isolated right ventricular shock** is often caused by conditions like a **massive pulmonary embolism** or a right ventricular infarction. [2] - While it can lead to shock, it is distinct from general cardiogenic shock which often implies left ventricular dysfunction or severe myocardial compromise, and the question asks for a cause *other than* MI, which can cause right ventricular shock. *None of the options* - This option is incorrect because **acute mitral regurgitation** is a distinct and significant cause of cardiogenic shock, independent of MI. [1]

Q: What is the earliest feature of third cranial nerve involvement in a patient with diabetes mellitus?

Normal light reflex. **Normal light reflex** - Third cranial nerve palsy in diabetes mellitus is often due to **ischemic infarction** affecting the vasa nervorum that supply the nerve [1]. - This typically spares the **superficial parasympathetic fibers** responsible for pupillary constriction, leading to a normal light reflex [2]. *Abnormal light reflex* - An abnormal light reflex (dilated pupil) would indicate involvement of the **parasympathetic fibers** on the surface of the third nerve [2]. - Such involvement is less typical in diabetic neuropathy unless the lesion is very extensive or non-ischemic [1]. *Normal light and accommodation reflex* - While the light reflex is typically normal, **accommodation reflex** can be variably affected, as it also involves the ciliary muscle which is innervated by parasympathetic fibers [2]. - If accommodation is completely normal, it suggests very minimal or no neurological deficit related to the third nerve. *Abnormal light and accommodation reflex* - Abnormalities in both reflexes would suggest significant involvement of the **parasympathetic fibers**, indicating a more widespread or compressive lesion [3]. - This presentation is more characteristic of mass lesions (e.g., aneurysms) rather than isolated diabetic ischemic neuropathy [3].

Q: Stunning of myocardium without any acute coronary syndrome is:-

Takotsubo cardiomyopathy. ***Takotsubo cardiomyopathy*** - This condition involves **transient systolic dysfunction** of the left ventricle, often triggered by severe emotional or physical stress, mimicking a heart attack but without **coronary artery obstruction**. - The apical and mid-ventricular segments of the left ventricle become akinetic or hypocinetic, causing the heart to take on a shape resembling an octopus trap (**takotsubo**). *Restrictive cardiomyopathy* - This is a condition where the walls of the ventricles become **stiff** and **lose their flexibility**, preventing the heart from filling properly. - It is typically caused by conditions like **amyloidosis** or **sarcoidosis**, leading to impaired diastolic function, not transient stunning. *Subendocardial infarction* - This refers to a **heart attack** that affects only the **inner layer** of the heart muscle (**subendocardium**) due to reduced blood flow [2]. - It is a form of **acute coronary syndrome** where there is irreversible myocardial necrosis, unlike the temporary dysfunction in stunning [1]. *Transmural infarction* - This is a **severe form of heart attack** where the entire thickness of the heart muscle wall is affected, usually due to a **complete blockage of a coronary artery** [2]. - This also represents **acute coronary syndrome** with widespread myocardial necrosis, which is fundamentally different from a reversible stunning of the myocardium [1].

Q: Mean transformation time for HIV to AIDS is:-

10 years. ***10 years*** - The mean transformation time from initial **HIV infection** to the development of **AIDS** in untreated individuals is approximately 10 years [1]. - This time frame represents the average duration of the **clinical latency period**, during which the viral load increases and CD4+ T-cell count gradually declines [1]. *12 years* - While some individuals may progress to AIDS later than 10 years, 12 years is not recognized as the **mean transformation time**. - This longer period might be seen in individuals with slower disease progression or those initiating **antiretroviral therapy (ART)** at later stages. *9 years* - This duration is slightly shorter than the generally accepted mean, though some individuals may progress more rapidly. - Factors like **higher viral load** at infection, coinfections, or certain genetic predispositions can accelerate progression. *5 years* - A transformation time of 5 years is considered a **rapid progression** to AIDS. - This rapid progression is typically seen in a minority of HIV-infected individuals, often associated with factors such as high baseline viral load, genetic susceptibility, or co-infection with other pathogens.

Question 1

Patient presenting with cutaneous vasculitis, glomerulonephritis, peripheral neuropathy, Which investigation is to be performed next that will help you diagnose the condition?

Accepted Answer

ANCA

Answer

RA factor

Answer

Hbsag

Answer

MIF

Question 2

Which drug is used as an adjunct to epinephrine in refractory ventricular fibrillation/ventricular tachycardia during cardiac arrest?

Accepted Answer

Amiodarone infusion

Answer

Atropine

Answer

Adenosine

Answer

High dose vasopressin

Question 3

Which is not included in AIDS related complex?

Accepted Answer

Ectopic pregnancy

Answer

Recurrent genital candidiasis

Answer

Generalised lymphadenopathy

Answer

Chronic diarrhea

Question 4

Which of the following is the MOST characteristic feature of ataxia telangiectasia?

Accepted Answer

Increases the risk of lymphoid malignancies

Answer

Increase in serum alpha-fetoprotein (AFP) levels

Answer

Genetic inheritance pattern is autosomal recessive

Answer

None of the options

Question 5

Which condition is associated with the ECG pattern known as pseudo P pulmonale?

Accepted Answer

Hypercalcemia

Answer

Hyponatremia

Answer

Hypocalcemia

Answer

Hypokalemia

Question 6

Choose the best method of diagnosis for the clinical sign represented in the image.

Accepted Answer

Serum ceruloplasmin

Answer

Serum copper

Answer

Karyotyping

Answer

PCR

Question 7

What is a potential cause of cardiogenic shock other than myocardial infarction (MI)?

Accepted Answer

Acute mitral regurgitation

Answer

Ventricular septal rupture

Answer

Isolated right ventricular shock

Answer

None of the options

Question 8

What is the earliest feature of third cranial nerve involvement in a patient with diabetes mellitus?

Accepted Answer

Normal light reflex

Answer

Normal light and accommodation reflex

Answer

Abnormal light reflex

Answer

Abnormal light and accommodation reflex

Question 9

Stunning of myocardium without any acute coronary syndrome is:-

Accepted Answer

Takotsubo cardiomyopathy

Answer

Restrictive cardiomyopathy

Answer

Subendocardial infarction

Answer

Transmural infarction

Question 10

Mean transformation time for HIV to AIDS is:-

Accepted Answer

10 years

Answer

12 years

Answer

9 years

Answer

5 years

NEET-PG 2018 — Internal Medicine