NEET-PG 2019 - Internal Medicine Practice Questions

Q: What are the essential major blood culture criteria for diagnosing infective endocarditis?

Single positive culture of Coxiella burnetii. ***Single positive culture of Coxiella burnetii*** - A single positive blood culture for **Coxiella burnetii** or **anti-phase I IgG antibody titer > 1:800** is considered a major criterion for infective endocarditis due to its highly pathogenic nature in this context [1], [2]. - This organism is a known cause of **culture-negative endocarditis**, and specific serology or molecular tests are often required for diagnosis [1]. *Single positive culture of Corynebacterium species* - **Corynebacterium species** are often considered **contaminants** in blood cultures, especially *Corynebacterium jeikeium*, and typically require multiple positive cultures, often from different sites, to be considered significant pathogens for infective endocarditis [2]. - A single positive culture of these organisms alone is generally insufficient to meet major diagnostic criteria for endocarditis [2]. *Both HACEK and Coxiella cultures* - While both **HACEK organisms** and **Coxiella burnetii** can cause endocarditis, the combination of both is not a specific major criterion in itself. - The diagnostic criteria address each organism individually [2]. *Single positive culture of HACEK group* - **HACEK organisms** (**H**aemophilus, **A**ggregatibacter, **C**ardiobacterium, **E**ikenella, **K**ingella) are well-known causes of endocarditis, but usually require **two separate positive blood cultures** for infective endocarditis major criteria [2]. - A single positive culture of a HACEK organism is typically classified as a minor criterion unless other supporting evidence is present.

Q: A patient presents with hoarseness of voice and a clinical condition as shown in the image. Identify the lesion:

Diphtheria. ***Diphtheria*** - The image shows a **thick, grayish-white pseudomembrane** covering the tonsils and likely extending to other parts of the pharynx, which is a classic sign of diphtheria. - **Hoarseness** indicates laryngeal involvement, a severe complication of diphtheria due to pseudomembrane formation extending to the larynx, potentially causing airway obstruction. *Follicular tonsillitis* - This condition presents with **pus-filled follicles** or spots on the tonsils, which are typically yellow or white, rather than a confluent membrane. - While it causes throat pain and fever, it generally does not lead to the formation of a **firm, adherent pseudomembrane** or significant hoarseness from laryngeal obstruction as seen in diphtheria. *Aphthous ulcer* - An aphthous ulcer is a **small, painful, shallow sore** with a white or yellowish center and a red border, typically found on the non-keratinized oral mucosa. - It does not present as a widespread, thick membranous lesion covering the tonsils and causing hoarseness. *Membranous tonsillitis* - While "membranous tonsillitis" describes the presence of a membrane on the tonsils, this term is often used generally. However, the specific characteristics in the image (thick, grayish, adherent membrane with severe symptoms like hoarseness) are pathognomonic for **diphtheria**. - Other causes of membranous tonsillitis, such as infectious mononucleosis, typically present with a less adherent membrane and often lack the severe systemic toxicity and potential for rapid airway compromise seen in diphtheria.

Q: Which murmur increases on standing?

HOCM. ***HOCM*** - Standing decreases **venous return** and **left ventricular volume**, which reduces the size of the LV outflow tract and thus exacerbates the obstruction in **hypertrophic obstructive cardiomyopathy (HOCM)**, making the murmur louder [1]. - This maneuver is a key diagnostic feature as reduced preload intensifies the dynamic obstruction. *MR* - **Mitral regurgitation (MR)** is typically a volume overload lesion, and standing (which reduces preload) generally causes the murmur to **decrease** in intensity due to less blood volume ejected back into the atrium [3]. - The murmur of MR is usually a holosystolic murmur radiating to the axilla [3]. *MS* - **Mitral stenosis (MS)** is a fixed obstruction to left ventricular filling. Changes in preload (like standing) do not significantly alter the gradient across the mitral valve or the intensity of the murmur [2]. - Its characteristic murmur is a **mid-diastolic rumble** with an opening snap [1]. *VSD* - A **ventricular septal defect (VSD)** murmur is caused by blood flowing from the high-pressure left ventricle to the low-pressure right ventricle. Standing, by reducing systemic vascular resistance, would typically cause the murmur to **decrease** in intensity as less blood shunts left-to-right. - The murmur is usually a **holosystolic murmur** best heard at the lower left sternal border.

Q: Identify the condition in the ECG based on the provided image.

Atrial flutter. ***Atrial flutter*** - The distinctive **sawtooth pattern** between QRS complexes is characteristic of atrial flutter, representing rapid and regular atrial depolarization. - The ventricular response here appears to be a 4:1 block, meaning every fourth flutter wave is conducted to the ventricles, resulting in a regular ventricular rhythm. *Atrial fibrillation* - Characterized by **irregularly irregular R-R intervals** and the absence of distinct P waves, replaced by chaotic fibrillatory waves. - The ECG shows a regular ventricular rhythm with clear flutter waves, which is not consistent with atrial fibrillation. *Arrhythmia* - This is a broad term for any abnormal heart rhythm. While atrial flutter is an arrhythmia, this option is too general and does not identify the specific condition. - The question asks to identify the specific condition, not just categorize it as an abnormal rhythm. *Cardiomyopathy* - Cardiomyopathy refers to diseases of the **heart muscle** that can lead to heart failure or arrhythmias, but it is a structural diagnosis, not an ECG rhythm diagnosis. - An ECG for cardiomyopathy might show signs like chamber enlargement, Q waves, or conduction disturbances, but not the specific sawtooth pattern seen in this tracing.

Q: Which of the following is a risk factor for Alzheimer's disease?

Down’s syndrome. ***Down’s syndrome*** - Individuals with **Down's syndrome** have an extra copy of chromosome 21, which carries the **amyloid precursor protein (APP) gene**. - This **triplication of the APP gene** leads to increased production of **beta-amyloid protein**, a key component of the plaques found in Alzheimer's disease [1]. *Klinefelter syndrome* - **Klinefelter syndrome** is a genetic condition characterized by an extra X chromosome (XXY), primarily affecting males. - While it can be associated with various health issues, it is **not a known risk factor** for Alzheimer's disease. *Low blood pressure* - **Low blood pressure** (hypotension) is generally not considered a direct risk factor for Alzheimer's disease. - In fact, some studies suggest that **midlife hypertension** (high blood pressure) is a risk factor for later cognitive decline and Alzheimer's. *None of the options* - This option is incorrect because **Down's syndrome** is a well-established and significant risk factor for Alzheimer's disease due to the genetic link involving the APP gene.

Q: A child with history of fever, photosensitivity, rash sparing nasolabial fold presents to OP. Identify the condition?

SLE. ***SLE*** - The combination of **fever**, **photosensitivity**, and a **rash sparing the nasolabial folds** (malar rash or butterfly rash) is highly characteristic of Systemic Lupus Erythematosus (SLE). - Childhood-onset SLE can present with similar mucocutaneous and systemic features as adult-onset disease. *Polymorphous light eruption* - This condition is primarily characterized by **photosensitive skin lesions** but typically does not involve systemic symptoms like fever. - While it presents with rash in sun-exposed areas, it generally lacks the distinct malar rash appearance and systemic involvement seen in SLE. *Discoid lupus* - Discoid lupus is a form of **cutaneous lupus** characterized by chronic, scaly, disfiguring plaques, often on the face and scalp. - It usually **lacks systemic symptoms** like fever and does not present as a widespread malar rash sparing nasal folds. *Skin tuberculosis* - Skin tuberculosis (lupus vulgaris or scrofuloderma) presents with **nodular, plaque-like lesions** or cold abscesses, often with ulceration and scarring. - It is not typically associated with **photosensitivity** or a malar rash, and fever, if present, is usually due to systemic Mycobacterium infection.

Q: Identify the diagnosis based on the provided ECG image.

PSVT. ***PSVT*** - The ECG shows a **narrow complex tachycardia** with a regular rhythm and a high heart rate, characteristic of **paroxysmal supraventricular tachycardia (PSVT)**. - P waves are often **buried within the QRS complex** or T waves, or may be retrograde, which can be seen as small deflections or changes in the baseline in some leads. *VT* - **Ventricular tachycardia** is characterized by a **wide QRS complex** (>0.12 seconds), which is not observed in this ECG. - While VT can be regular, the primary distinguishing feature is the QRS duration. *AT* - **Atrial tachycardia (AT)** is another form of supraventricular tachycardia, but it typically shows **distinct P waves** with an abnormal morphology, often separate from the T wave, which are not clearly visible or consistently distinct in this tracing. - While it can present with narrow complex tachycardia, the mechanism differs from re-entrant PSVT. *Ventricular fibrillation* - **Ventricular fibrillation** is characterized by **chaotic, irregular electrical activity** with no distinguishable P waves, QRS complexes, or T waves, representing disorganized ventricular depolarization. - The ECG in the image shows a consistent, regular rhythm with identifiable, albeit narrow, QRS complexes.

Q: A 65-year-old alcoholic is admitted to the ICU with a diagnosis of acute pancreatitis. After 48 hours, he is unconscious and has the following findings: SpO2= 60%, PO2= 60 mmHg, PCO2=50 mmHg, and HR= 120 bpm. A chest X-ray was performed and is given below. What is the diagnosis of the following condition?

Shock lung. ***Shock lung*** - The patient's presentation with **acute pancreatitis**, followed by rapid onset **severe hypoxemia** (SpO2 60%, PO2 60 mmHg), and **bilateral infiltrates** on chest X-ray are classic signs of **Acute Respiratory Distress Syndrome (ARDS)**, historically known as "shock lung". Pancreatitis is a common cause of ARDS. - The term "shock lung" was used to describe this condition in the context of various forms of shock or severe systemic illness, accurately reflecting the patient's deteriorating state. *Mendelson syndrome* - This syndrome refers to **chemical pneumonitis** caused by the aspiration of gastric contents, often seen in obstetric patients or those with impaired consciousness. - While aspiration is possible in an unconscious alcoholic, the widespread bilateral infiltrates and severe hypoxemia in the context of pancreatitis make ARDS a more fitting diagnosis. *Nosocomial pneumonia* - This is a lung infection acquired in a hospital setting, typically after 48 hours of admission. - While possible in an ICU patient, the rapid onset of severe respiratory failure and the specific context of acute pancreatitis predisposing to ARDS make nosocomial pneumonia less likely as the primary diagnosis for these acute findings, though it could occur later. *Sympathetic pleural effusion* - A sympathetic pleural effusion is a collection of fluid in the pleural space secondary to inflammation in an adjacent organ, such as the pancreas (pancreatic pleural effusion). - While acute pancreatitis can cause pleural effusions, these typically appear as isolated fluid collections and do not account for the severe hypoxemia and widespread bilateral pulmonary infiltrates seen on the X-ray, which are characteristic of ARDS.

Q: A 25-year-old female presented to ER unconscious. Her mother tells you about her having recurrent syncopal episodes. Her BP is 80/60 mm Hg and you order an ECG. Treatment is

DC shock. ***DC shock*** - The ECG shows a **wide complex tachycardia** with alternating morphology in the QRS complex, consistent with **Torsades de Pointes**. - Given the patient's **unconsciousness** and **hypotension (80/60 mmHg)**, she is hemodynamically unstable, making immediate **electrical cardioversion (DC shock)** the treatment of choice irrespective of the cause. *Catheter Ablation* - **Catheter ablation** is an invasive procedure used for definitive treatment of recurrent arrhythmias, often considered in patients who are *hemodynamically stable*. - It is not an acute, emergency treatment for an **unstable patient** in a life-threatening arrhythmia. *Adenosine* - **Adenosine** is primarily used to terminate **supraventricular tachycardias (SVTs)** and can be harmful in wide complex tachycardias, especially if due to ventricular tachycardia or Wolff-Parkinson-White syndrome. - Its use is contraindicated in wide complex tachycardias like Torsades de Pointes, and it would not be effective in an **unstable patient** with Torsades de Pointes. *Radiofrequency ablation* - **Radiofrequency ablation** is a type of catheter ablation, which ablates or destroys abnormal electrical pathways in the heart. - Similar to other ablative therapies, it is a **definitive treatment** for recurrent arrhythmias in *stable patients*, not an emergency measure for an unconscious, hypotensive patient with an acute arrhythmia.

Q: Polyuria in adults is commonly defined as urine output exceeding:

40 ml / Kg/ day. ***40 ml / Kg/ day*** - **Polyuria** is clinically defined as urine output exceeding 3 liters per 24 hours (L/day) in adults. - Converting this to a weight-based measurement for an average 75 kg adult, 3 L/day equates to approximately **40 ml/kg/day**. *50 ml/ kg / day* - This value represents a significantly higher urine output than the standard clinical definition of **polyuria**, making it an unlikely threshold. - While excessive, it would indicate a more severe and less common degree of diuresis, not the general definition. *30 ml / Kg/ day* - This value is below the typical threshold for **polyuria** and is closer to what might be considered normal or slightly elevated urine output. - Normal urine output is typically between **0.5-1 ml/kg/hour**, which translates to 12-24 ml/kg/day. *60 ml/ kg / day* - This is a substantially high urine output, indicating a profound level of **diuresis**, well beyond the standard definition of polyuria. - While possible in extreme cases, it is not the common cutoff used for defining polyuria.

Question 1

What are the essential major blood culture criteria for diagnosing infective endocarditis?

Accepted Answer

Single positive culture of Coxiella burnetii

Answer

Single positive culture of Corynebacterium species

Answer

Both HACEK and Coxiella cultures

Answer

Single positive culture of HACEK group

Question 2

A patient presents with hoarseness of voice and a clinical condition as shown in the image. Identify the lesion:

Accepted Answer

Diphtheria

Answer

Follicular tonsillitis

Answer

Aphthous ulcer

Answer

Membranous tonsillitis

Question 3

Which murmur increases on standing?

Accepted Answer

HOCM

Answer

MR

Answer

MS

Answer

VSD

Question 4

Identify the condition in the ECG based on the provided image.

Accepted Answer

Atrial flutter

Answer

Atrial fibrillation

Answer

Arrhythmia

Answer

Cardiomyopathy

Question 5

Which of the following is a risk factor for Alzheimer's disease?

Accepted Answer

Down’s syndrome

Answer

Low blood pressure

Answer

Klinefelter syndrome

Answer

None of the options

Question 6

A child with history of fever, photosensitivity, rash sparing nasolabial fold presents to OP. Identify the condition?

Accepted Answer

SLE

Answer

Polymorphous light eruption

Answer

Discoid lupus

Answer

Skin tuberculosis

Question 7

Identify the diagnosis based on the provided ECG image.

Accepted Answer

PSVT

Answer

VT

Answer

AT

Answer

Ventricular fibrillation

Question 8

A 65-year-old alcoholic is admitted to the ICU with a diagnosis of acute pancreatitis. After 48 hours, he is unconscious and has the following findings: SpO2= 60%, PO2= 60 mmHg, PCO2=50 mmHg, and HR= 120 bpm. A chest X-ray was performed and is given below. What is the diagnosis of the following condition?

Accepted Answer

Shock lung

Answer

Mendelson syndrome

Answer

Nosocomial pneumonia

Answer

Sympathetic pleural effusion

Question 9

A 25-year-old female presented to ER unconscious. Her mother tells you about her having recurrent syncopal episodes. Her BP is 80/60 mm Hg and you order an ECG. Treatment is

Accepted Answer

DC shock

Answer

Cathether Ablation

Answer

Adenosine

Answer

Radiofrequency ablation

Question 10

Polyuria in adults is commonly defined as urine output exceeding:

Accepted Answer

40 ml / Kg/ day

Answer

50 ml/ kg / day

Answer

30 ml / Kg/ day

Answer

60 ml/ kg / day

NEET-PG 2019 — Internal Medicine