NEET-PG 2019 - Internal Medicine Practice Questions

Q: A 26 year old female patient presented with fever, oral ulcers, sensitivity to light and rash over the malar area of the face sparing the nasolabial folds of both side. Which of the following indicates the condition associated with these manifestations?

SLE. ***SLE*** - The combination of **fever**, **oral ulcers**, **photosensitivity**, and a **malar rash** (which typically spares the nasolabial folds), particularly in a young female, is classic for **Systemic Lupus Erythematosus (SLE)** [1]. - SLE is a **chronic autoimmune inflammatory disease** that can affect multiple organ systems [2]. *Rosacea* - Rosacea often presents with **facial erythema**, **telangiectasias**, and papulopustules, primarily on the central face, but it does not typically involve oral ulcers, fever, or photosensitivity in the same way as SLE [4]. - The rash of rosacea is usually not a classic malar rash sparing the nasolabial folds, and it is not an autoimmune systemic disease. *Dermatomyositis* - Dermatomyositis is characterized by **proximal muscle weakness** and specific skin manifestations like **Gottron's papules** (over joints), **heliotrope rash** (periorbital edema), and a **shawl sign**, which differ from the presented symptoms [3]. - While it can cause light sensitivity and a rash, the distribution and associated symptoms (like no mention of muscle weakness) are not typical for a primary presentation of dermatomyositis. *Psoriasis* - Psoriasis typically presents with **well-demarcated erythematous plaques** covered with **silvery scales**, commonly on extensor surfaces like elbows and knees, and can also affect nails and joints. - It does not typically cause fever, oral ulcers, or a malar rash with nasolabial fold sparing, which are hallmarks of SLE.

Q: A 55-year-old female on methotrexate presents with continuous pain and swelling of bilateral hand joints. What is the best treatment plan for this patient?

Methotrexate + Sulphasalazine + Hydroxychloroquine. ***Methotrexate + Sulphasalazine + Hydroxychloroquine*** - This combination, known as **triple therapy**, is a well-established and effective strategy for **rheumatoid arthritis** patients who have an inadequate response to methotrexate monotherapy. - The combination of **conventional synthetic DMARDs (csDMARDs)** targets different inflammatory pathways, leading to a synergistic effect and improved disease control. *Double the dose of methotrexate* - While methotrexate doses can be optimized, simply doubling the dose may not be the most effective next step for uncontrolled disease and could increase the risk of **toxicity** without significantly improving efficacy. - Current guidelines often advocate for adding another DMARD or switching to a biologic agent if maximum tolerated methotrexate is insufficient. *Methotrexate + high potency Oral steroids* - Oral steroids are primarily used for **short-term symptom control** during flares or as a bridge therapy, not as a long-term strategy for sustained disease modification due to their significant side effect profile. - Adding high-potency oral steroids long-term with methotrexate would increase the risk of adverse effects like osteoporosis, infections, and adrenal insufficiency. *Stop methotrexate and start Monotherapy with anti-TNF- drugs* - While **anti-TNF drugs** are a powerful next-line treatment, **monotherapy** is generally less effective than combination therapy, especially for patients with active disease. - **Methotrexate is often continued** in combination with anti-TNF drugs even when initiating biological therapies, as it can enhance their efficacy and reduce immunogenicity.

Q: A 65-year-old alcoholic is admitted to the ICU with diagnosis of acute pancreatitis. After 48 hours he is unconscious and has the following findings: $\mathrm{sPO}_{2}=$ $60 \%, \mathrm{pO}_{2}=60 \mathrm{~mm} \mathrm{Hg}, \mathrm{pCO}_{2}=30 \mathrm{~mm} \mathrm{Hg}$ and $\mathrm{HR}=$ 120 bpm . CXR was performed. Diagnosis is?

Shock lung. ***Shock lung*** - The rapid progression to severe hypoxemia (sPO2 60%, pO2 60 mmHg), tachycardia, and the CXR findings of **bilateral diffuse infiltrates** in a patient with severe pancreatitis is highly suggestive of **Acute Respiratory Distress Syndrome (ARDS)**, which is colloquially known as "shock lung". - **Acute pancreatitis** is a common cause of ARDS due to the systemic inflammatory response leading to increased pulmonary vascular permeability and non-cardiogenic pulmonary edema. *Mendelson syndrome* - This syndrome refers to **chemical pneumonitis** caused by aspiration of gastric contents, typically during anesthesia or in patients with impaired consciousness. - While aspiration is a concern in an unconscious patient, the diffuse, widespread infiltrates seen on CXR and the context of severe pancreatitis point more strongly to ARDS. *Nosocomial pneumonia* - Nosocomial pneumonia is an infection acquired in a hospital setting, often characterized by **new onset fever, purulent sputum, and new infiltrate on chest X-ray**. - While possible in an ICU patient, the rapid deterioration, severe hypoxemia, and acute onset after 48 hours of admission with acute pancreatitis are more classic for ARDS than typical nosocomial pneumonia. *Sympathetic pleural effusion* - **Sympathetic pleural effusions** can occur in acute pancreatitis, particularly on the left side, due to localized inflammation. - However, the chest X-ray shows **diffuse bilateral parenchymal infiltrates** rather than predominant pleural fluid, and the severe hypoxemia is indicative of significant lung tissue involvement, not just an effusion.

Q: Comment on the diagnosis of the patient?

Ventricular flutter. ***Ventricular flutter*** - This ECG shows a very rapid, regular ventricular rhythm with **sine-wave-like morphology** and no discernible P waves or T waves, characteristic of ventricular flutter. - The rate is typically between **250-350 bpm**, and the QRS complexes are wide and uniform but merge with the T waves to create a continuous undulating pattern. *Ventricular tachycardia* - While ventricular tachycardia (VT) is a fast ventricular rhythm, it usually presents with **discrete QRS complexes** and identifiable (although wide) QRS and ST-T segments. - The rate in VT is typically **100-250 bpm**, and the complexes often show some degree of variability in morphology or R-R interval. *Ventricular fibrillation* - Ventricular fibrillation (VF) is characterized by **chaotic, irregular electrical activity** with no identifiable QRS complexes, P waves, or T waves. - The waveforms are highly variable in shape and amplitude, representing uncoordinated ventricular muscle activity, unlike the regular, undulating pattern seen here. *Electromechanical dissociation* - **Electromechanical dissociation (EMD)**, also known as pulseless electrical activity (PEA), occurs when there is organized electrical activity on the ECG but no palpable pulse. - The ECG in EMD can show a variety of rhythms, including normal sinus rhythm or bradycardia, but it will always show **discernible electrical complexes**, unlike the continuous sinusoidal pattern of ventricular flutter.

Q: A 25-year-old female presents with history of fever and oral ulcers and has developed erythematous lesions on her face. Comment on the diagnosis?

Systemic Lupus Erythematosus (SLE). ***Systemic Lupus Erythematosus (SLE)*** - The combination of **fever**, **oral ulcers**, and **malar rash** (butterfly-shaped erythematous lesions across the cheeks and nose) represents classic triad of **SLE** according to **ACR/EULAR diagnostic criteria**. - SLE is a **multisystem autoimmune disease** affecting young women (female:male ratio 9:1) with systemic manifestations including constitutional symptoms and mucocutaneous involvement. *Discoid Lupus Erythematosus (DLE)* - DLE presents with **chronic scarring plaques** with **follicular plugging** and **atrophy**, typically without systemic features like fever. - Lacks **systemic manifestations** such as fever and oral ulcers that are characteristic of systemic lupus. *Dermatomyositis* - Characterized by **heliotrope rash** (violaceous discoloration around eyelids) and **Gottron's papules** over knuckles, not malar distribution. - Associated with **proximal muscle weakness** and elevated **creatine kinase levels**, which are absent in this presentation. *Rosacea* - A **chronic inflammatory skin condition** affecting central face with **persistent erythema** and **papulopustular lesions**. - Does **not** present with systemic symptoms like **fever** or **oral ulcers**, and typically occurs in middle-aged adults.

Q: Drug of choice for following infection (as shown in image) in a HIV patient: (NEET Pattern 2019)

Cotrimoxazole. ***Cotrimoxazole*** - The image shows numerous **dark-stained cysts** and **trophozoites** within lung tissue, characteristic of **Pneumocystis jirovecii pneumonia (PCP)**, a common opportunistic infection in HIV patients. - **Cotrimoxazole (trimethoprim-sulfamethoxazole)** is the drug of choice for the treatment and prophylaxis of PCP. *INH + Rifampicin* - This combination is used for the treatment of **tuberculosis**, characterized by **acid-fast bacilli** and granulomas, which are not seen in this image. - While TB is common in HIV patients, the morphology in the image is not consistent with Mycobacterium tuberculosis. *Doxycycline* - Doxycycline is a broad-spectrum antibiotic used for various bacterial infections, including atypical pneumonia, but it is not effective against **Pneumocystis jirovecii.** - It is also used for malaria prophylaxis and Rickettsial infections. *Azithromycin* - Azithromycin is an antibiotic primarily effective against atypical bacteria like **Mycoplasma** and **Chlamydia**, and it is used for **MAC (Mycobacterium avium complex)** prophylaxis in advanced HIV. - It has no role in the treatment of Pneumocystis jirovecii pneumonia.

Question 1

A 26 year old female patient presented with fever, oral ulcers, sensitivity to light and rash over the malar area of the face sparing the nasolabial folds of both side. Which of the following indicates the condition associated with these manifestations?

Accepted Answer

SLE

Answer

Rosacea

Answer

Dermatomyositis

Answer

Psoriasis

Question 2

A 55-year-old female on methotrexate presents with continuous pain and swelling of bilateral hand joints. What is the best treatment plan for this patient?

Accepted Answer

Methotrexate + Sulphasalazine + Hydroxychloroquine

Answer

Double the dose of methotrexate

Answer

Methotrexate + high potency Oral steroids

Answer

Stop methotrexate and start Monotherapy with anti-TNF- drugs

Question 3

A 65-year-old alcoholic is admitted to the ICU with diagnosis of acute pancreatitis. After 48 hours he is unconscious and has the following findings: $\mathrm{sPO}_{2}=$ $60 \%, \mathrm{pO}_{2}=60 \mathrm{~mm} \mathrm{Hg}, \mathrm{pCO}_{2}=30 \mathrm{~mm} \mathrm{Hg}$ and $\mathrm{HR}=$ 120 bpm . CXR was performed. Diagnosis is?

Accepted Answer

Shock lung

Answer

Mendelson syndrome

Answer

Nosocomial pneumonia

Answer

Sympathetic pleural effusion

Question 4

Comment on the diagnosis of the patient?

Accepted Answer

Ventricular flutter

Answer

Ventricular tachycardia

Answer

Ventricular fibrillation

Answer

Electromechanical dissociation

Question 5

A 25-year-old female presents with history of fever and oral ulcers and has developed erythematous lesions on her face. Comment on the diagnosis?

Accepted Answer

Systemic Lupus Erythematosus (SLE)

Answer

Discoid Lupus Erythematosus (DLE)

Answer

Dermatomyositis

Answer

Rosacea

Question 6

Drug of choice for following infection (as shown in image) in a HIV patient: (NEET Pattern 2019)

Accepted Answer

Cotrimoxazole

Answer

INH+ Rifampicin

Answer

Doxycycline

Answer

Azithromycin

NEET-PG 2019 — Internal Medicine