NEET-PG 2020 - Internal Medicine Practice Questions

Q: Which is the most common site of gastrinoma in MEN 1 syndrome?

Duodenum. ***Duodenum*** - In **MEN 1 syndrome**, gastrinomas (gastrin-secreting tumors) are most commonly found in the **duodenum**, often multiple and small. - This location accounts for a significant majority of gastrinomas, particularly in patients with **Zollinger-Ellison syndrome (ZES)** associated with MEN 1. *Stomach* - While gastrinomas can occasionally be found in the stomach, this is a **much less common site** compared to the duodenum, especially in the context of MEN 1 syndrome. - Gastric gastrinomas are typically associated with conditions like **atrophic gastritis** and **pernicious anemia**, leading to G-cell hyperplasia and often hypergastrinemia, but tend to be less aggressive. *Ileum* - The **ileum** is an **uncommon site** for gastrinomas; these types of neuroendocrine tumors (NETs) are rarely found there. - NETs in the ileum are more typically associated with the secretion of other hormones, such as **serotonin**, leading to carcinoid syndrome, rather than gastrin. *Jejunum* - Gastrinomas in the **jejunum** are also **rare**, similar to the ileum. - While neuroendocrine tumors can arise throughout the small bowel, the jejunum is not a typical or primary location for gastrin-producing tumors within the context of **MEN 1**.

Q: Which of the following is true about polyaeritis nodosa?

HBsAg is positive in 30% patients. ### HBsAg is positive in 30% patients - **Polyarteritis nodosa (PAN)** is strongly associated with **hepatitis B virus (HBV)** infection; about 30% of patients with PAN have evidence of current or past HBV infection, particularly **HBsAg positivity**. - This association suggests that HBV infection can trigger the immune complex vasculitis characteristic of PAN. ### It shows fibrinoid necrosis in large blood vessels - PAN primarily affects **medium-sized muscular arteries**, not typically large blood vessels [1]. - The inflammation causes **fibrinoid necrosis** and aneurysmal dilations in these medium-sized arteries [1]. ### It has ANCA positivity - **Polyarteritis nodosa (PAN)** is generally considered an **ANCA-negative vasculitis**. - **ANCA positivity** (especially c-ANCA/PR3-ANCA or p-ANCA/MPO-ANCA) is characteristic of other small-vessel vasculitides like **Granulomatosis with polyangiitis** or **Microscopic polyangiitis**. ### Affected individuals have involvement of pulmonary circulation. - A defining characteristic of **Polyarteritis nodosa (PAN)** is that it generally **spares the pulmonary circulation** [1]. - Pulmonary involvement is more commonly seen in other vasculitides, such as **Granulomatosis with polyangiitis (Wegener's)** or **Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)**.

Q: A 25-year-old man presents for a routine physical examination. The patient is tall (6 ft. 5 in) and on examination he was found to have an early diastolic murmur. His family pedigree is as given below. Which of the following is the mode of inheritance by which the disease is likely to be transmitted?

Autosomal dominant. ***Autosomal dominant*** - The pedigree shows **affected individuals in every generation**, and transmission from an affected parent to approximately half of their children, which is characteristic of **autosomal dominant inheritance**. - The disease affects both males and females, and **affected fathers transmit the disease to both sons and daughters** (e.g., I-1 to II-1 and II-5), ruling out X-linked inheritance. *X linked dominant disorder* - This pattern would show affected fathers transmitting the trait to **all their daughters but no sons**, which is not seen here (e.g., father I-1 has an affected son II-1). - Also, affected mothers would transmit to half their sons and daughters, but the key discriminatory factor is the father-to-son transmission. *X-linked recessive* - X-linked recessive traits usually show **more males affected than females**, and affected sons are typically born to carrier mothers. - An affected father would **not transmit the disease to his sons**, but the pedigree clearly shows affected father I-1 transmitting to son II-1. *Autosomal recessive* - Autosomal recessive disorders typically **skip generations**, with affected individuals often born to unaffected carriers. - The pedigree shows **direct transmission** from affected parents to offspring in every generation, which is inconsistent with recessive inheritance.

Q: A patient undergoes bilateral adrenalectomy in view of bilateral pheochromocytoma. A day after surgery patient develops lethargy, fatigue and loss of appetite. On examination BP is 90/ 60 mmHg, pulse rate of 74 beats/min. No evidence of loss of volume. The likely cause is?

Cortisol deficiency. ***Cortisol deficiency*** - Following **bilateral adrenalectomy**, the body loses its primary source of **cortisol**, a critical hormone for maintaining blood pressure and energy levels. [1] - The symptoms of **lethargy, fatigue, loss of appetite, and hypotension** are classic signs of **acute adrenal insufficiency** or **adrenal crisis** due to cortisol deficiency. [1] *Cardiogenic shock* - This condition involves severe pump failure of the heart, leading to **reduced cardiac output**. - While hypotension is present, the symptom complex of fatigue and loss of appetite shortly after adrenal surgery points away from primary cardiac dysfunction in the absence of preceding cardiac events. *Septic shock* - Characterized by hypotension, signs of infection, and organ dysfunction due to a systemic inflammatory response. - There is no mention of fever, leukocytosis, or other signs of infection in the patient's presentation. *Hypovolemic shock* - Caused by a significant reduction in circulating blood volume, often due to hemorrhage or severe dehydration. - The question explicitly states "No evidence of loss of volume," ruling out hypovolemic shock.

Q: Which of the following is not done in high altitude sickness?

Digoxin. ***Digoxin*** - **Digoxin** is a cardiac glycoside used for heart conditions like **atrial fibrillation** and **heart failure**. It has no role in the treatment of high altitude sickness. - Its primary actions are to increase **myocardial contractility** and decrease heart rate, which are not beneficial in addressing the hypobaric hypoxia of high altitude. *Rapid descent* - **Rapid descent** is the most effective and often immediate treatment for severe forms of high altitude sickness, such as **High Altitude Cerebral Edema (HACE)** or **High Altitude Pulmonary Edema (HAPE)** [2]. - It involves moving the affected individual to a significantly lower altitude to alleviate the effects of **hypoxia** [2]. *Acetazolamide* - **Acetazolamide** is a **carbonic anhydrase inhibitor** commonly used for the prevention and treatment of high altitude sickness [2]. - It works by inducing a **metabolic acidosis**, which stimulates **respiration** and increases **oxygenation**. *Oxygen* - Administering **supplemental oxygen** is a crucial treatment for high altitude sickness, especially in more severe cases [2]. - It directly counteracts the **hypoxia** experienced at high altitudes, improving symptoms and preventing progression [1], [2].

Q: Pulmonary Plethora is seen in -

TAPVC. ***TAPVC*** - **Total Anomalous Pulmonary Venous Connection (TAPVC)** leads to all pulmonary veins draining into the systemic circulation, causing a left-to-right shunt at the atrial level back into the right atrium. - This persistent shunting results in increased blood flow to the lungs, manifesting as **pulmonary plethora** on chest X-ray due to engorged pulmonary vessels [3]. *Tricuspid Atresia* - **Tricuspid atresia** results in an absence of the tricuspid valve, severely limiting blood flow from the right atrium to the right ventricle. - This condition typically leads to **pulmonary oligemia** (reduced blood flow to the lungs), not pulmonary plethora. *CoA* - **Coarctation of the aorta (CoA)** is a narrowing of the aorta, typically distal to the left subclavian artery [2]. - While it can lead to complications like heart failure, it generally does not directly cause **pulmonary plethora** unless there are associated shunts. *TOF* - **Tetralogy of Fallot (TOF)** is characterized by four defects: ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy [1]. - The most significant hemodynamic feature is **pulmonary stenosis**, which reduces blood flow to the lungs, leading to **pulmonary oligemia**, often described as a "boot-shaped" heart on X-ray [1].

Q: A patient presented with weakness of the right side of the face. There is associated ipsilateral loss of pain and temperature of face and contralateral body. The lesion is most likely located at

Lateral pons. ***Lateral pons*** - A lesion in the **lateral pons** would affect the **facial nerve nucleus** (VII) causing ipsilateral facial weakness. It would also damage the **spinal trigeminal nucleus** (V) leading to ipsilateral facial loss of pain and temperature [1]. - The involvement of the **spinothalamic tract** in the lateral pons would result in contralateral body loss of pain and temperature [1]. *Lateral medulla* - A lesion in the **lateral medulla** (Wallenberg syndrome) typically causes ipsilateral facial sensory loss (due to involvement of the spinal trigeminal nucleus), but would not affect the facial nerve nucleus directly to cause facial weakness [1]. - It also presents with **vertigo, nystagmus, ataxia**, and **dysphagia**, which are not mentioned in the patient's presentation. *Medial pons* - A lesion in the **medial pons** would primarily affect the **corticospinal tract** causing contralateral weakness and the **abducens nerve** (VI) causing ipsilateral gaze palsy, which are not described. - It would not typically involve the facial nerve directly to cause significant facial weakness or the spinal trigeminal nucleus for ipsilateral facial sensory loss. *Medial medulla* - A lesion in the **medial medulla** (Dejerine syndrome) usually affects the **pyramidal tract** causing contralateral hemiparesis and the **hypoglossal nerve** (XII) causing ipsilateral tongue deviation. - It does not explain the ipsilateral facial weakness or the ipsilateral facial loss of pain and temperature.

Q: A 26 year old female after her delivery develops features of headache, nausea, visual complaints, fatigue. What is the most probable diagnosis?

Sheehan's syndrome. ***Sheehan's syndrome*** - This syndrome is caused by **ischemic necrosis of the pituitary gland** due to severe postpartum hemorrhage or hypovolemic shock, leading to **pituitary dysfunction** [1]. - Symptoms like **headache, nausea, visual complaints, and fatigue** are consistent with panhypopituitarism developing after delivery, often presenting in the postpartum period due to the large, vulnerable pregnancy-enlarged pituitary [1]. *Waterhouse-Friderichsen syndrome* - This is a rare, life-threatening condition caused by overwhelming **bacterial infection (often meningococcal)**, leading to **adrenal gland hemorrhage** and acute adrenal insufficiency. - It presents with rapid onset of fever, petechial rash, hypotension, and shock, which are not described in the patient's symptoms. *Hyperprolactinemia* - While hyperprolactinemia can cause headaches and visual disturbances (if due to a pituitary tumor) [1], it typically presents with **galactorrhea**, **amenorrhea**, or **oligomenorrhea**, and is not directly linked to the postpartum period unless caused by a new or existing pituitary adenoma. - It does not account for the widespread pituitary failure implied by the patient's general fatigue and other symptoms after delivery, which is more characteristic of Sheehan's [2]. *Pituitary adenoma* - A pituitary adenoma can cause headaches, visual disturbances (due to **mass effect on the optic chiasm**) [1], and hormone deficiencies or excesses, but its onset is not specifically tied to the postpartum period like Sheehan's syndrome. - While it's a possibility for these symptoms, the history of recent delivery strongly points to Sheehan's syndrome over a newly symptomatic or pre-existing pituitary adenoma without specific features like galactorrhea or Cushing's symptoms that would hint at a specific type of adenoma.

Q: After a renal transplant, what is the most common opportunistic infection?

Cytomegalovirus (CMV). ***Cytomegalovirus (CMV)*** - **CMV** is the most common opportunistic infection after renal transplantation, particularly in the first 6 months due to immunosuppression [1]. - It can cause a range of clinical syndromes, including **fever**, **leukopenia**, **gastroenteritis**, **pneumonitis**, and **hepatitis**, and can also have indirect effects that increase the risk of graft rejection. *Varicella Zoster Virus (VZV)* - While VZV can cause opportunistic infections in transplant recipients (e.g., **shingles**), it is less common than CMV [1]. - VZV typically occurs later post-transplant and is characterized by a **vesicular rash** in a dermatomal distribution. *Coxsackie Virus* - **Coxsackie virus** infections are less frequently reported as significant opportunistic infections in renal transplant recipients compared to other viral pathogens. - They are generally associated with hand-foot-and-mouth disease, herpangina, or myocarditis, which are not the most common post-transplant complications. *Epstein-Barr Virus (EBV)* - **EBV** can cause post-transplant lymphoproliferative disorder (PTLD), which is a serious complication, but EBV infection itself is not the most common opportunistic infection overall [1]. - PTLD is more common in the first year after transplant and often presents with **lymphadenopathy**, **fever**, or **graft dysfunction**.

Q: What is the first line of treatment for osteoporosis in postmenopausal women?

Bisphosphonates. ***Bisphosphonates*** - **Bisphosphonates** are the **first-line therapy** for osteoporosis in postmenopausal women due to their proven efficacy in reducing the risk of fragility fractures [1]. - They work by inhibiting **osteoclast activity**, thereby decreasing bone resorption and increasing bone mineral density [1]. *Ulipristal* - **Ulipristal** is a **selective progesterone receptor modulator** primarily used as an emergency contraceptive or for the treatment of uterine fibroids. - It has no role in the direct treatment or prevention of osteoporosis. *Estrogen* - **Estrogen therapy** can prevent bone loss but is generally not considered first-line for osteoporosis due to potential risks like increased incidence of **venous thromboembolism**, stroke, and certain cancers [1]. - It is typically reserved for women with severe menopausal symptoms who also need osteoporosis prevention [1]. *Calcium and vitamin D supplementation* - While essential for **bone health**, **calcium and vitamin D supplementation** alone is not sufficient to treat established osteoporosis [2]. - They are crucial adjuncts to pharmacotherapy, ensuring adequate building blocks for bone formation, but do not directly address the underlying bone loss mechanism effectively enough as a monotherapy for osteoporosis [1].

Question 1

Which is the most common site of gastrinoma in MEN 1 syndrome?

Accepted Answer

Duodenum

Answer

Stomach

Answer

Ileum

Answer

Jejunum

Question 2

Which of the following is true about polyaeritis nodosa?

Accepted Answer

HBsAg is positive in 30% patients

Answer

It shows fibrinoid necrosis in large blood vessels

Answer

It has ANCA positivity

Answer

Affected individuals have involvement of pulmonary circulation.

Question 3

A 25-year-old man presents for a routine physical examination. The patient is tall (6 ft. 5 in) and on examination he was found to have an early diastolic murmur. His family pedigree is as given below. Which of the following is the mode of inheritance by which the disease is likely to be transmitted?

Accepted Answer

Autosomal dominant

Answer

X linked dominant disorder

Answer

X-linked recessive

Answer

Autosomal recessive

Question 4

A patient undergoes bilateral adrenalectomy in view of bilateral pheochromocytoma. A day after surgery patient develops lethargy, fatigue and loss of appetite. On examination BP is 90/ 60 mmHg, pulse rate of 74 beats/min. No evidence of loss of volume. The likely cause is?

Accepted Answer

Cortisol deficiency

Answer

Cardiogenic shock

Answer

Septic shock

Answer

Hypovolemic shock

Question 5

Which of the following is not done in high altitude sickness?

Accepted Answer

Digoxin

Answer

Rapid descent

Answer

Acetazolamide

Answer

Oxygen

Question 6

Pulmonary Plethora is seen in -

Accepted Answer

TAPVC

Answer

Tricuspid Atresia

Answer

CoA

Answer

TOF

Question 7

A patient presented with weakness of the right side of the face. There is associated ipsilateral loss of pain and temperature of face and contralateral body. The lesion is most likely located at

Accepted Answer

Lateral pons

Answer

Lateral medulla

Answer

Medial pons

Answer

Medial medulla

Question 8

A 26 year old female after her delivery develops features of headache, nausea, visual complaints, fatigue. What is the most probable diagnosis?

Accepted Answer

Sheehan's syndrome

Answer

Waterhouse-Friderichsen syndrome

Answer

Hyperprolactinemia

Answer

Pituitary adenoma

Question 9

After a renal transplant, what is the most common opportunistic infection?

Accepted Answer

Cytomegalovirus (CMV)

Answer

Varicella Zoster Virus (VZV)

Answer

Coxsackie Virus

Answer

Epstein-Barr Virus (EBV)

Question 10

What is the first line of treatment for osteoporosis in postmenopausal women?

Accepted Answer

Bisphosphonates

Answer

Ulipristal

Answer

Estrogen

Answer

Calcium and vitamin D supplementation

NEET-PG 2020 — Internal Medicine