NEET-PG 2020 - Internal Medicine Practice Questions

Q: What is the diagnosis of a 55-year-old woman with chronic low backache?

Osteoporosis. ***Osteoporosis*** - The image shows **loss of bone density** and **vertebral compression fractures**, especially visible in the lumbar spine, which are characteristic findings in osteoporosis. - Osteoporosis is common in post-menopausal women, and **chronic low backache** is a frequent symptom due to microfractures or vertebral collapse. *Hurler's syndrome* - This is a lysosomal storage disease (mucopolysaccharidosis type I) that primarily affects **children** and presents with distinct **skeletal deformities** (dysostosis multiplex), facial features, and organ involvement. - It would not typically present as chronic low backache in a 55-year-old woman, and the radiological findings are not consistent with Hurler's syndrome. *Paget’s disease* - Paget's disease of bone involves abnormal bone remodeling, leading to **enlarged and weakened bones**, often with a characteristic **cotton wool appearance** on X-ray, which is not seen here. - While it can cause bone pain and affect the spine, the primary radiological features seen in this image are more consistent with generalized bone density loss and fractures rather than focal expansion and abnormal bone architecture. *Renal osteodystrophy* - This condition occurs in patients with **chronic kidney disease** and results from imbalances in calcium, phosphate, and parathyroid hormone. - Radiographic features include **osteosclerosis (rugger jersey spine)**, bone erosions, or osteomalacia, which are different from the generalized osteopenia and compression fractures observed in this X-ray.

Q: Which of the following criteria is used to assess the prognosis of liver conditions?

Child-Pugh score. ***Child-Pugh score*** - The **Child-Pugh score** is a widely used scoring system to assess the **prognosis of chronic liver disease**, primarily cirrhosis. - It categorizes patients into classes A, B, or C based on five clinical measures of liver function: **bilirubin**, **albumin**, **INR**, **ascites**, and **hepatic encephalopathy**. *Milan criteria* - The **Milan criteria** are used to select patients with **hepatocellular carcinoma (HCC)** for **liver transplantation**. - They are not a general prognostic tool for all liver conditions, but rather specific to HCC and transplant eligibility. *MELD score* - The **Model for End-Stage Liver Disease (MELD) score** is used to assess the **severity of chronic liver disease** and predict short-term survival. - It is primarily used for **prioritizing patients for liver transplantation**, not for general prognosis in all liver conditions, and includes bilirubin, creatinine, and INR. *Alvarado score* - The **Alvarado score** is a clinical scoring system used to assess the **likelihood of acute appendicitis**. - It is entirely unrelated to liver conditions and is not used for assessing liver prognosis.

Q: What is the Child-Pugh class for a patient who has a serum bilirubin of 2.5 mg/dL, serum albumin of 3 g/dL, INR of 2, mild ascites, but no encephalopathy?

Child-Pugh Class B. ***Child-Pugh Class B*** - A serum bilirubin of **2.5 mg/dL** (2 points), serum albumin of **3 g/dL** (2 points), INR of **2** (2 points), and mild ascites (2 points), with no encephalopathy (1 point), sums up to a total of 9 points, which falls into the range for **Child-Pugh Class B** (7-9 points) [1]. - This class indicates **moderate hepatic dysfunction** and is characterized by a higher risk of complications and mortality compared to Class A. *Child-Pugh Class A* - This class is assigned for a total score of **5-6 points**, indicating **well-compensated hepatic disease**. - The patient's total score of 9 points exceeds the threshold for Class A, suggesting more significant liver impairment. *Child-Pugh Class D* - There is no Child-Pugh Class D; the classification system only includes classes A, B, and C. - This option is therefore incorrect based on the established Child-Pugh scoring system. *Child-Pugh Class C* - This class corresponds to a total score of **10-15 points**, indicative of **severe hepatic decompensation**. - The patient's calculated score of 9 points is below the minimum required for Child-Pugh Class C.

Q: A known case of COPD with acute exacerbation of symptoms. On examination patient was conscious and alert, pulse was 110 beats/ min and bilateral wheeze present. All of the following are true in the management of the patient except:

Non invasive ventilation is contraindicated. ***Non invasive ventilation is contraindicated*** - This statement is **false**, therefore the correct exception. **Non-invasive ventilation (NIV)** is often indicated and beneficial in the management of acute exacerbations of COPD, especially in patients with **respiratory acidosis** or persistent dyspnea, as it can reduce the need for intubation and improve outcomes [2]. - The patient's presentation (conscious, alert, wheeze, tachycardia) suggests an acute exacerbation, for which NIV is a key intervention unless there are absolute contraindications like cardiac arrest or inability to protect the airway [3]. *Permissible hypercapnia allowed* - **Permissive hypercapnia** is a valid strategy in managing acute exacerbations of COPD, particularly during mechanical ventilation. The goal is to maintain an adequate pH (e.g., >7.20-7.25) rather than normalizing CO2, to avoid **barotrauma** and **volutrauma** from aggressive ventilation [3]. - This approach acknowledges that some CO2 retention is acceptable as long as acidosis is not severe, protecting the lungs from excessive pressure. *Inhalation with salbutamol* - **Inhaled bronchodilators**, such as **salbutamol (a short-acting beta-agonist)**, are a cornerstone of treatment for acute COPD exacerbations [1]. They act rapidly to relieve **bronchospasm** and improve airflow, addressing the wheeze observed in the patient. - Frequent administration of these agents is crucial in the initial management to open up the airways and reduce air trapping. *I/V steroids* - **Systemic corticosteroids**, such as intravenous methylprednisolone or oral prednisone, are essential in managing acute COPD exacerbations. They reduce **airway inflammation** and swelling, leading to improved lung function and reduced recovery time. - Steroids are typically given for a short course (e.g., 5-7 days) to minimize side effects while maximizing therapeutic benefits.

Q: Which of the following is not a clinical presentation of Pituitary Apoplexy?

Hypertension. ***Hypertension*** - Pituitary apoplexy often leads to **adrenal insufficiency** due to damage to the pituitary gland, which in turn causes **hypotension**, not hypertension. - The sudden onset of severe pituitary dysfunction typically results in a drop in blood pressure rather than an increase. *Vomiting* - **Vomiting** is a common symptom of pituitary apoplexy, often accompanying severe headache due to increased intracranial pressure or hormonal imbalances [1]. - The sudden mass effect of the hemorrhage or infarction can irritate surrounding structures, leading to nausea and vomiting. *Headache* - A **sudden, severe headache** is the most common presenting symptom of pituitary apoplexy, often described as a "thunderclap" headache [1]. - This intense headache is caused by rapid expansion of the pituitary mass and irritation of the **dura mater**. *Hypotension* - **Hypotension** is a classic feature of pituitary apoplexy, resulting from acute **adrenal insufficiency** where insufficient ACTH leads to decreased cortisol production [1]. - This hormonal deficiency impairs the body's ability to maintain blood pressure and respond to stress [1].

Q: Which of the following is NOT the feature of secondary ACTH deficiency?

Hyperpigmentation. ***Hyperpigmentation*** - **Hyperpigmentation** occurs in **primary adrenal insufficiency** (Addison's disease) due to high levels of **ACTH** and co-secreted **melanocyte-stimulating hormone (MSH)** [1]. - In **secondary ACTH deficiency**, ACTH levels are low, so there is no increased stimulation of melanocytes, and thus **hyperpigmentation is absent** [2]. *Anorexia* - **Anorexia** can be a feature of both **primary** and **secondary adrenal insufficiency** due to the general catabolic effects of **cortisol deficiency** and overall endocrine dysfunction. - Reduced cortisol can lead to altered metabolism and appetite, contributing to loss of appetite [2]. *Fatigue* - **Fatigue** is a common and prominent symptom in both **primary** and **secondary adrenal insufficiency** due to **cortisol deficiency** [2]. - Lack of adequate cortisol affects energy metabolism, muscle function, and overall well-being, leading to profound tiredness. *Hypotension* - **Hypotension** is more characteristic of **primary adrenal insufficiency** due to both **cortisol** and **aldosterone deficiency** [1]. - In **secondary ACTH deficiency**, aldosterone secretion is typically preserved (as it's regulated by the **renin-angiotensin system**), but severe **cortisol deficiency** can still contribute to mild hypotension [2].

Q: A patient presented with clinical features of ataxia and incoordination. It is most likely due to involvement of which artery among the following.

Superior cerebellar. ***Superior cerebellar*** - The superior cerebellar artery supplies the **superior cerebellum**, which is critical for **coordination** and balance [1]. - Involvement of this artery commonly leads to **ataxia**, **dysarthria**, and **ipsilateral limb incoordination** [3]. *Middle cerebral* - The middle cerebral artery primarily supplies the **lateral surface of the cerebrum**, including motor and sensory cortices. - Strokes in this territory typically cause **contralateral hemiparesis**, **aphasia**, and **hemianopia**, not ataxia as a primary symptom [2]. *Posterior cerebellar* - The posterior cerebral artery supplies the **occipital lobe**, **thalamus**, and parts of the temporal lobe. - Occlusion often results in **visual field defects** (hemianopia), **memory deficits**, and sometimes **sensory loss**, but not isolated ataxia [2]. *Anterior cerebral* - The anterior cerebral artery supplies the **medial frontal and parietal lobes**. - Its occlusion typically causes **contralateral leg weakness** (hemiparesis), **behavioral changes**, and **urinary incontinence**.

Q: What is the differentiating feature between irritable bowel syndrome and inflammatory bowel disease?

Stool calprotectin. ***Stool calprotectin*** - **Stool calprotectin** is a reliable biomarker used to differentiate between **Inflammatory Bowel Disease (IBD)** and **Irritable Bowel Syndrome (IBS)**. It's a protein released by neutrophils during intestinal inflammation. - Elevated levels of **calprotectin** strongly suggest **mucosal inflammation** characteristic of IBD (Crohn's disease or ulcerative colitis), while normal levels are typical in IBS, which lacks inflammation [1]. *pain in abdomen* - **Abdominal pain** is a common symptom in both IBS and IBD. In IBS, it's often linked to altered bowel habits and is a key diagnostic criterion [1]. - In IBD, abdominal pain is typically due to inflammation, strictures, or abscesses, but its presence alone does not differentiate the conditions . *Diarrhoea* - **Diarrhea** is a prominent symptom in both IBS and IBD. In IBS, it can be a predominant feature (IBS-D), often associated with urgency [1]. - In IBD, diarrhea is usually due to inflammation disrupting normal absorption and secretion, and it may contain blood or mucus . *Mucus in stools* - The presence of **mucus in stools** can occur in both IBS and IBD. In IBS, it's often present without blood and is generally considered part of altered bowel function [1]. - In IBD, mucus in stools, particularly when accompanied by blood, strongly suggests active intestinal inflammation and mucosal damage .

Q: A 32-year-old patient with Restless leg syndrome comes to the OPD. What is the most appropriate first line treatment?

Gabapentin. ***Gabapentin*** - **Gabapentin** and other alpha-2-delta ligands (e.g., pregabalin) are considered **first-line agents** for moderate to severe Restless Legs Syndrome (RLS), particularly when symptoms are bothersome and daily. - They work by modulating **calcium channels** and are effective in reducing RLS symptoms with a generally favorable side effect profile. *Iron Supplementation* - **Iron supplementation** is appropriate as first-line treatment only if **serum ferritin levels** are below 75 mcg/L, indicating iron deficiency. - While RLS is associated with **iron deficiency**, it's not the universal first-line treatment without biochemical confirmation [1]. *Pramipexole* - **Dopamine agonists** like pramipexole are effective for RLS but are generally **second-line treatments** due to concerns about augmentation (worsening of RLS symptoms) and impulse control disorders. - Augmentation is a significant side effect where symptoms worsen paradoxically with continued use, particularly with higher doses. *Vitamin B12* - **Vitamin B12 deficiency** can cause neurological symptoms, but it is **not a primary cause or treatment** for Restless Legs Syndrome. - Supplementation with **Vitamin B12** would only be considered if a confirmed deficiency exists, which is not stated as a contributing factor in this patient.

Q: Superior temporal gyrus lesion leads to?

Wernicke's aphasia. ***Wernicke's aphasia*** - A lesion in the **superior temporal gyrus** (Wernicke's area) leads to Wernicke's aphasia, characterized by impaired **comprehension of language** [1]. - Patients with Wernicke's aphasia exhibit **fluent but meaningless speech** (word salad) and are often unaware of their deficits [1]. *Anomic aphasia* - Characterized by difficulty finding words, particularly nouns and verbs, and is often associated with lesions in the **angular gyrus** or **temporal lobe** [1]. - Speech remains fluent and grammatically correct, but it is marked by frequent pauses and circumlocutions as the individual struggles to retrieve specific words. *Broca's aphasia* - Results from damage to **Broca's area** in the posterior inferior frontal gyrus, causing **non-fluent speech** and difficulty with speech production [1]. - While comprehension is relatively preserved, patients struggle to form complete sentences and may exhibit agrammatism. *Non-fluent aphasia* - A broad category of aphasias, including Broca's aphasia, where speech production is notably impaired, and the output is effortful and characterized by **agrammatism** and **short, telegraphic sentences**. - **Wernicke's aphasia** is typically considered a **fluent aphasia**, as speech production itself is not interrupted, though its content is often incomprehensible [1].

Question 1

What is the diagnosis of a 55-year-old woman with chronic low backache?

Accepted Answer

Osteoporosis

Answer

Hurler's syndrome

Answer

Paget’s disease

Answer

Renal osteodystrophy

Question 2

Which of the following criteria is used to assess the prognosis of liver conditions?

Accepted Answer

Child-Pugh score

Answer

Milan criteria

Answer

MELD score

Answer

Alvarado score

Question 3

What is the Child-Pugh class for a patient who has a serum bilirubin of 2.5 mg/dL, serum albumin of 3 g/dL, INR of 2, mild ascites, but no encephalopathy?

Accepted Answer

Child-Pugh Class B

Answer

Child-Pugh Class A

Answer

Child-Pugh Class D

Answer

Child-Pugh Class C

Question 4

A known case of COPD with acute exacerbation of symptoms. On examination patient was conscious and alert, pulse was 110 beats/ min and bilateral wheeze present. All of the following are true in the management of the patient except:

Accepted Answer

Non invasive ventilation is contraindicated

Answer

Permissible hypercapnia allowed

Answer

Inhalation with salbutamol

Answer

I/V steroids

Question 5

Which of the following is not a clinical presentation of Pituitary Apoplexy?

Accepted Answer

Hypertension

Answer

Vomiting

Answer

Headache

Answer

Hypotension

Question 6

Which of the following is NOT the feature of secondary ACTH deficiency?

Accepted Answer

Hyperpigmentation

Answer

Anorexia

Answer

Fatigue

Answer

Hypotension

Question 7

A patient presented with clinical features of ataxia and incoordination. It is most likely due to involvement of which artery among the following.

Accepted Answer

Superior cerebellar

Answer

Middle cerebral

Answer

Posterior cerebral

Answer

Anterior cerebral

Question 8

What is the differentiating feature between irritable bowel syndrome and inflammatory bowel disease?

Accepted Answer

Stool calprotectin

Answer

pain in abdomen

Answer

Diarrhoea

Answer

Mucus in stools

Question 9

A 32-year-old patient with Restless leg syndrome comes to the OPD. What is the most appropriate first line treatment?

Accepted Answer

Gabapentin

Answer

Iron Supplementation

Answer

Pramipexole

Answer

Vitamin B12

Question 10

Superior temporal gyrus lesion leads to?

Accepted Answer

Wernicke's aphasia

Answer

Anomic aphasia

Answer

Broca's aphasia

Answer

Non-fluent aphasia

NEET-PG 2020 — Internal Medicine