NEET-PG 2022 - Internal Medicine Practice Questions

Q: A patient diagnosed to be HIV-positive was started on highly active antiretroviral therapy (HAART). Which of the following can be used to monitor treatment efficacy?

Viral load. ***Viral load*** - **Viral load** (HIV RNA copies per milliliter of plasma) is the most direct and sensitive measure of HAART efficacy, as it indicates the amount of actively replicating virus [1]. - A successful HAART regimen aims to reduce the **viral load** to undetectable levels, signaling effective suppression of viral replication [1]. *CD4+ T cell count* - While important for monitoring immune status and disease progression, **CD4+ T cell count** changes more slowly than viral load [1]. - An increase in **CD4+ T cell count** is a positive sign of immune reconstitution but is a lagging indicator of immediate treatment efficacy [1]. *p24 antigen* - **p24 antigen** is a core structural protein of HIV, primarily detectable early in acute infection and in advanced stages when viral replication is very high. - It is generally not used for routine monitoring of HAART efficacy in chronic HIV infection because its levels fluctuate and become undetectable as the immune system produces antibodies. *Viral serotype* - **Viral serotype** refers to the specific strain or subtype of HIV (e.g., HIV-1 vs. HIV-2, or different clades within HIV-1). - It is determined at diagnosis to understand the specific virus but does not change significantly during the course of treatment and is not used to monitor HAART efficacy.

Q: A male patient presents to the emergency department. The arterial blood gas report is as follows: pH, 7.2; pCO2, 81 mmHg; and HCO3, 40 meq/L. Which of the following is the most likely diagnosis?

Respiratory acidosis. ***Respiratory acidosis*** - The **pH of 7.2** indicates **acidemia**, while the **elevated pCO2 (81 mmHg)** points to a primary respiratory problem [2]. - The elevated **HCO3 (40 meq/L)** suggests **renal compensation** attempting to buffer the increased carbonic acid [1]. *Respiratory alkalosis* - This condition presents with an **elevated pH (alkalemia)** and a **decreased pCO2**, which is opposite to the given ABG values [2]. - While there might be metabolic compensation with a decreased HCO3, the primary disturbance is an increase in respiratory rate leading to excessive CO2 exhalation. *Metabolic acidosis* - Metabolic acidosis is characterized by a **low pH** and a **low HCO3**, with a compensatory decrease in pCO2 [1]. - The given ABG shows a high HCO3, which rules out primary metabolic acidosis. *Metabolic alkalosis* - This condition would typically show an **elevated pH** and an **elevated HCO3**, with a compensatory increase in pCO2. - While both HCO3 and pCO2 are high in the given ABG, the low pH points to a primary acidosis, not alkalosis.

Q: A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely diagnosis?

Lupus nephritis. ***Lupus nephritis*** - The combination of **fever, arthralgia, oral ulcers, and fatigue** lasting for six months is highly suggestive of **systemic lupus erythematosus (SLE)** [1]. - The new-onset **hematuria, proteinuria, and RBC casts** indicate **glomerulonephritis**, which is a common and serious renal manifestation of SLE, known as lupus nephritis [2]. *Acute interstitial nephritis* - Characterized by acute kidney injury, often following exposure to **medications** (e.g., NSAIDs, antibiotics) or infections. - Typically presents with sterile pyuria, eosinophilia, and white cell casts, not hemorrhagic urine and RBC casts. *Poststreptococcal glomerulonephritis* - Occurs **1-3 weeks after a streptococcal infection** (e.g., pharyngitis, impetigo) and presents with acute nephritic syndrome. - While it causes hematuria and proteinuria, the prolonged systemic symptoms (arthralgia, ulcers, fatigue) and the absence of a recent streptococcal infection make it less likely. *IgA nephropathy* - Often presents with **recurrent episodes of gross hematuria**, usually developing within days of an upper respiratory tract infection. - It does not typically present with the broad array of systemic symptoms like chronic fever, arthralgia, and oral ulcers seen in this patient.

Q: A patient with diabetes mellitus for the past 5 years presents with vomiting and abdominal pain. She is non-compliant with medication and appears dehydrated. Investigations revealed a blood sugar value of 500 mg/dl and the presence of ketone bodies. What is the next best step in management of this patient?

Intravenous fluids with regular insulin. Detailed management of diabetic ketoacidosis (DKA) requires both fluid resuscitation and insulin therapy. ***Intravenous fluids with regular insulin*** - The patient presents with classic signs of **diabetic ketoacidosis (DKA)**: hyperglycemia (blood sugar 500 mg/dl), ketone bodies, dehydration, and a history of diabetes non-compliance [1]. - Initial management for DKA involves aggressive **intravenous fluid resuscitation** to correct dehydration and then **intravenous regular insulin** to lower blood glucose and resolve ketosis [2]. *Intravenous fluids with long-acting insulin* - While fluids are essential, **long-acting insulin** is not appropriate for the acute management of DKA because its slow onset of action makes it inefficient for rapidly correcting hyperglycemia and ketosis. - **Regular insulin** is preferred as it has a quicker onset and shorter duration, allowing for more precise titration in an acute setting [2]. *Intravenous fluids* - Although crucial for correcting **dehydration** and improving renal perfusion, fluids alone will not address the underlying **insulin deficiency** and **ketosis** that define DKA. - Without insulin, the body will continue to produce ketones, exacerbating acidosis [3]. *Intravenous insulin* - Giving intravenous insulin without prior or concomitant **fluid resuscitation** can be dangerous, as it can worsen **hypovolemia** and potentially lead to circulatory collapse by shifting glucose and potassium into cells. - It is critical to first restore **circulating volume** before initiating insulin therapy [2].

Q: A patient on anti-depressants presented to you with hypotension. An ECG was done, which showed wide QRS complexes and right axis deviation. How will you manage this patient?

Intravenous sodium bicarbonate for TCA-induced arrhythmias. Intravenous sodium bicarbonate for TCA-induced arrhythmias - The patient's presentation with **hypotension**, **wide QRS complexes**, and **right axis deviation** in the context of antidepressant use is highly suggestive of **Tricyclic Antidepressant (TCA) toxicity**. [1] - **Sodium bicarbonate** improves cardiac function by increasing plasma sodium and alkalizing the blood, which reduces the binding of TCAs to myocardial fast sodium channels and alleviates cardiotoxicity. [1] *Use of antiarrhythmics* - Many antiarrhythmics, particularly **Class IA and IC agents**, block sodium channels and could exacerbate TCA-induced cardiotoxicity. [1] - Furthermore, antiarrhythmics may worsen hypotension and prolong the QRS interval in TCA overdose. *Administration of propranolol* - **Propranolol** is a non-selective beta-blocker that can worsen **hypotension** and **bradycardia**, which are common in TCA overdose. - It would not address the primary issue of **sodium channel blockade** caused by TCAs. *Use of phenytoin* - **Phenytoin** acts by blocking sodium channels and is used for certain arrhythmias, but its efficacy in TCA toxicity is limited and can be proarrhythmic. - **Sodium bicarbonate** is the preferred treatment as it is more effective at reversing the cardiotoxic effects of TCAs. [1]

Q: A hypertensive patient who is non-compliant with medication presents to you with sudden onset breathlessness. A chest x-ray was done, which is shown below. How will you manage this patient?

Intravenous nitroglycerin. ***Intravenous nitroglycerin*** - The chest X-ray shows diffuse bilateral infiltrates and **cardiomegaly**, consistent with **pulmonary edema** due to **acute decompensated heart failure** in a hypertensive patient. - **Intravenous nitroglycerin** is crucial for patients with acute cardiogenic pulmonary edema, as it **reduces preload and afterload**, thereby decreasing pulmonary congestion and improving breathlessness. *Intravenous salbutamol* - **Salbutamol** is a **bronchodilator** used for bronchospasm in conditions like asthma or COPD. - It would not address the underlying pathology of **pulmonary edema** and could potentially worsen the condition by causing **tachycardia** and increasing myocardial oxygen demand. *Nebulization with salbutamol* - Similar to intravenous salbutamol, nebulized salbutamol is used for **bronchospasm** and is ineffective in treating **cardiogenic pulmonary edema**. - There is no indication of airway constriction, and its systemic effects could paradoxically **exacerbate heart failure**. *Oxygen and antibiotics* - While **oxygen** is always indicated for hypoxemia, it alone is insufficient to manage severe **pulmonary edema**. - **Antibiotics** are used to treat bacterial infections, but there are no signs of infection (e.g., fever, purulent sputum) to suggest **pneumonia** as the primary cause of breathlessness; the X-ray findings are more typical of edema.

Q: A 40-year-old man with a known case of hypertension presented with multiple episodes of hematuria and loin pain. His elder brother passed away due to a stroke at the age of 40. What is the probable diagnosis based on the clinical presentation?

Autosomal dominant polycystic kidney disease. ***Autosomal dominant polycystic kidney disease*** - The patient's presentation with **pain**, **hematuria**, and **hypertension** is typical for **ADPKD**. The family history of a brother dying of a **stroke** at a young age suggests a genetic predisposition to vascular abnormalities, common in ADPKD. - **Cerebral aneurysms**, which can lead to stroke, are a known extranal manifestation of ADPKD, and early onset stroke in a sibling strengthens the diagnosis despite it not being the defining feature of ADPKD itself. *Renal cell carcinoma* - While **hematuria**, **loin pain**, and **hypertension** can be symptoms of renal cell carcinoma, the bilateral nature of the cysts seen in the image and the family history of **early stroke** make ADPKD a more probable diagnosis. - Renal cell carcinoma usually presents as a **unilateral** solid mass, not diffuse cystic changes in both kidneys. *Tuberculosis of the kidney* - Renal tuberculosis would present with symptoms like sterile pyuria, dysuria, and flank pain, but less commonly with the dramatic cystic changes and family history of stroke seen here. - The imaging would typically show cavitary lesions or hydronephrosis rather than widespread bilateral cysts. *Autosomal recessive polycystic kidney disease* - **ARPKD** typically presents in **infancy or childhood** with severe renal failure and liver involvement. - The patient's age (40 years) makes ARPKD highly unlikely, as individuals with this condition rarely survive into adulthood without significant medical intervention.

Q: Which of the following is the MOST common complication of untreated hypertension?

Stroke. ***Stroke*** - **Untreated hypertension** is a major risk factor for both **ischemic** and **hemorrhagic strokes**, damaging blood vessels in the brain [1]. - Sustained high blood pressure can lead to **atherosclerosis** and weakened blood vessel walls, increasing the likelihood of a stroke [1]. *Heart failure* - While hypertension is a leading cause of **heart failure**, it typically develops over a longer period as the heart works harder against elevated pressure, leading to remodeling and dysfunction [2]. - In terms of acute, severe complications, a stroke is often considered more immediately catastrophic. *Kidney damage* - **Hypertensive nephropathy** is a significant long-term complication where high blood pressure damages the small blood vessels in the kidneys, impairing their function. - This process is gradual and contributes to **chronic kidney disease**, but stroke often emerges as a more common and acute serious event. *Vision loss* - **Hypertensive retinopathy** involves damage to the blood vessels in the retina, which can lead to vision problems including **vision loss** or **blindness**. - This is a serious complication, but **stroke** generally has a higher prevalence and more immediate impact in terms of overall morbidity and mortality associated with untreated hypertension.

Q: What is the initial treatment for most patients with growth hormone-secreting pituitary adenoma?

Transphenoidal surgical resection. ***Transphenoidal surgical resection*** - This is the **preferred initial treatment** for most growth hormone (GH)-secreting pituitary adenomas, as it offers the best chance for **cure** and rapid reduction in GH levels [1]. - Success rates are high, especially for **smaller tumors** (microadenomas), and it can quickly relieve mass effect symptoms [1]. *Somatostatin analogs* - These are typically used as **second-line therapy** if surgery is unsuccessful or contraindicated, or in patients not surgical candidates. - They work by **inhibiting GH secretion** but do not usually achieve a complete cure like surgery. *GH receptor antagonists* - These medications, such as pegvisomant, **block the action of GH** at its receptor, normalizing IGF-1 levels. - They are primarily used when other treatments, including surgery and somatostatin analogs, have failed to control GH excess. *Dopamine agonists* - While dopamine agonists (e.g., cabergoline) can **sometimes reduce GH secretion** in a minority of patients, they are significantly less effective for GH-secreting tumors compared to prolactinomas [1]. - They are occasionally used as **adjunctive therapy** or in specific cases where the GH-secreting tumor also co-secretes prolactin [1].

Q: A 40-year-old woman with rheumatoid arthritis presents with eye pain and redness. Examination reveals scleritis. What is the most likely associated systemic complication?

Interstitial lung disease. ***Interstitial lung disease*** - **Scleritis** in a patient with **rheumatoid arthritis** often indicates a more severe, systemic form of the disease. - **Interstitial lung disease (ILD)** is a common and serious **extra-articular manifestation** of rheumatoid arthritis, associated with higher disease activity and worse prognosis. *Cardiomyopathy* - While cardiac involvement can occur in RA (e.g., pericarditis, myocarditis), **cardiomyopathy** is less directly correlated with scleritis as a linked severe systemic complication. - **Rheumatoid arthritis** can increase the risk of cardiovascular disease due to accelerated atherosclerosis and systemic inflammation, but cardiomyopathy itself is not typically the direct systemic complication associated with scleritis. *Renal failure* - **Renal involvement** in rheumatoid arthritis is uncommon, usually related to complications from treatment (e.g., NSAID-induced nephropathy) or secondary amyloidosis, not directly with scleritis. - Scleritis itself does not directly predispose to **renal failure** as a primary systemic complication of RA. *Peripheral neuropathy* - **Peripheral neuropathy** can be a complication of rheumatoid arthritis, particularly in severe cases or vasculitis. - However, it is not as strongly or directly linked to the presence of **scleritis** as **interstitial lung disease** is, in terms of signifying systemic disease severity.

Question 1

A patient diagnosed to be HIV-positive was started on highly active antiretroviral therapy (HAART). Which of the following can be used to monitor treatment efficacy?

Accepted Answer

Viral load

Answer

CD4+ T cell count

Answer

p24 antigen

Answer

Viral serotype

Question 2

A male patient presents to the emergency department. The arterial blood gas report is as follows: pH, 7.2; pCO2, 81 mmHg; and HCO3, 40 meq/L. Which of the following is the most likely diagnosis?

Accepted Answer

Respiratory acidosis

Answer

Respiratory alkalosis

Answer

Metabolic acidosis

Answer

Metabolic alkalosis

Question 3

A woman presents to you with fever, arthralgia, ulcers, fatigue for the past six months, and    new-onset hematuria. Urine examination reveals RBC casts and proteinuria. What is the likely    diagnosis?

Accepted Answer

Lupus nephritis

Answer

Acute interstitial nephritis

Answer

Poststreptococcal glomerulonephritis

Answer

IgA nephropathy

Question 4

A patient with diabetes mellitus for the past 5 years presents with vomiting and abdominal pain. She is non-compliant with medication and appears dehydrated. Investigations revealed a blood sugar value of 500 mg/dl and the presence of ketone bodies. What is the next best step in management of this patient?

Accepted Answer

Intravenous fluids with regular insulin

Answer

Intravenous fluids

Answer

Intravenous insulin

Answer

Intravenous fluids with long-acting insulin

Question 5

A patient on anti-depressants presented to you with hypotension. An ECG was done, which    showed wide QRS complexes and right axis deviation. How will you manage this patient?

Accepted Answer

Intravenous sodium bicarbonate for TCA-induced arrhythmias

Answer

Use of antiarrhythmics

Answer

Administration of propranolol

Answer

Use of phenytoin

Question 6

A hypertensive patient who is non-compliant with medication presents to you with sudden onset breathlessness. A chest x-ray was done, which is shown below. How will you manage this patient?

Accepted Answer

Intravenous nitroglycerin

Answer

Intravenous salbutamol

Answer

Nebulization with salbutamol

Answer

Oxygen and antibiotics

Question 7

A 40-year-old man with a known case of hypertension presented with multiple episodes of hematuria and loin pain. His elder brother passed away due to a stroke at the age of 40. What is the probable diagnosis based on the clinical presentation?

Accepted Answer

Autosomal dominant polycystic kidney disease

Answer

Renal cell carcinoma

Answer

Tuberculosis of the kidney

Answer

Autosomal recessive polycystic kidney disease

Question 8

Which of the following is the MOST common complication of untreated hypertension?

Accepted Answer

Stroke

Answer

Kidney damage

Answer

Heart failure

Answer

Vision loss

Question 9

What is the initial treatment for most patients with growth hormone-secreting pituitary adenoma?

Accepted Answer

Transphenoidal surgical resection

Answer

Somatostatin analogs

Answer

Dopamine agonists

Answer

GH receptor antagonists

Question 10

A 40-year-old woman with rheumatoid arthritis presents with eye pain and redness. Examination reveals scleritis. What is the most likely associated systemic complication?

Accepted Answer

Interstitial lung disease

Answer

Cardiomyopathy

Answer

Renal failure

Answer

Peripheral neuropathy

NEET-PG 2022 — Internal Medicine