NEET-PG 2025 - Internal Medicine Practice Questions

Q: A 56-year-old diabetic patient is currently on Metformin and Insulin Glargine. His HbA1c is 8.2 %, indicating suboptimal glycemic control. Echocardiography reveals a reduced ejection fraction (EF) of 35 %. Which of the following is the most appropriate agent to add to his current regimen?

Empagliflozin. ***Empagliflozin*** - Empagliflozin, an SGLT2 inhibitor, is the preferred agent due to its confirmed benefit in reducing **cardiovascular mortality** and **hospitalization for heart failure** (HFrEF, EF 35%). - Current guidelines recommend SGLT2 inhibitors as the **first-line add-on** for patients with Type 2 DM and established HFrEF, regardless of baseline glycemic control. *Pioglitazone* - Thiazolidinediones like Pioglitazone are **contraindicated** in patients with symptomatic or established heart failure (NYHA Class III or IV, which this patient likely approaches) due to the risk of **fluid retention** [1]. - This fluid retention can worsen the patient's existing **reduced ejection fraction** and precipitate acute decompensation [1]. *Glimepiride* - Sulfonylureas significantly increase the risk of **hypoglycemia**, which can be dangerous, especially in patients with co-existing severe cardiac disease. - Glimepiride offers no benefit in reducing **cardiovascular events** or **heart failure hospitalization** compared to the benefits provided by SGLT2 inhibitors. *Sitagliptin* - DPP-4 inhibitors are generally **weight and CV neutral** (aside from Saxagliptin, which is associated with increased HF risk in some studies). - They lack the robust evidence of **cardioprotective and renovasculoprotective effects** seen with SGLT2 inhibitors and are consequently suboptimal for a patient with established HFrEF.

Q: A 60-year-old man with chronic kidney disease presents with complaints of increasing fatigue, dyspnea on exertion, and signs of congestive heart failure. On evaluation, he is found to have anemia. What is the most appropriate next step in management?

Intravenous iron infusion. Intravenous iron infusion - Patients with chronic kidney disease (CKD) and anemia often have associated iron deficiency, which is necessary to correct before starting erythropoiesis-stimulating agents (ESAs). [1] - Intravenous iron is strongly preferred over oral iron in CKD, especially in dialysis patients, due to poor gastrointestinal absorption and high risk of non-compliance. Oral iron therapy - Oral iron is less effective and poorly tolerated in patients with CKD due to altered absorption and potential for gastrointestinal side effects. - It is not the initial treatment of choice when a rapid and efficient iron correction is needed to prepare for ESA therapy. Blood transfusion - This is reserved for patients with symptomatic severe anemia (e.g., severe dyspnea, hemodynamic instability) that is refractory to other treatments or requires immediate intervention. - Transfusion carries risks like volume overload (especially in heart failure) and sensitization, making it unsuitable as a routine initial step. Darbepoetin alfa - Darbepoetin alfa (an ESA) is used to correct the underlying erythropoietin deficiency in CKD-related anemia. [1] - ESAs are typically initiated only after iron stores have been adequately replenished (target ferritin >500 ng/mL or transferrin saturation >30%) to maximize response and minimize dosing.

Q: A patient with COPD presents with progressive dyspnea. ABG shows pH: 7.32, pCO2: 60 mmHg, and HCO3⁻: 32 mEq/L. Which of the following acid-base disorders is present in this patient?

Chronic respiratory acidosis. ***Chronic respiratory acidosis*** - The high **pCO2 (60 mmHg)** indicates primary respiratory acidosis, while the relatively stable pH (**7.32** is mildly acidotic) implies significant renal compensation (elevated **HCO3-**) [1]. - This compensated state, where the pH is buffered despite chronic hypercapnia, is characteristic of a long-standing disease like **COPD** [1], [3]. *Acute respiratory acidosis* - If the acidosis were acute, there would be insufficient time for the kidneys to retain bicarbonate, resulting in a **more severe acidemia** (pH typically <7.25) for a pCO2 of 60 mmHg [2]. - An acute picture is less typical in a patient with stable COPD, which is inherently a **chronic condition** [1]. *Metabolic acidosis* - Metabolic acidosis is defined by a primary reduction in **HCO3-**, leading to a low pH [2]. - In this case, the acidemia is driven by the primary elevation of **pCO2** (hypercapnia), not a decrease in bicarbonate. *Metabolic alkalosis* - This condition is characterized by a primary increase in **HCO3-**, leading to an elevated pH (**alkalemia**). - Since the patient's pH is low (**acidemic**), and the primary driving force is CO2 retention, this diagnosis is incorrect.

Q: A patient with recurrent episodes of PSVT (Paroxysmal Supraventricular Tachycardia) is being considered for long-term prophylactic therapy to prevent future episodes. Which of the following is the most appropriate preventive treatment?

Oral Verapamil. ***Oral Verapamil*** - This is a non-dihydropyridine **Calcium Channel Blocker** that effectively slows conduction and increases refractoriness in the **AV node**. - It is a standard oral medication used for the **long-term prevention (prophylaxis)** of recurrent PSVT, especially in cases of AVNRT or AVRT. *IV lignocaine* - Lignocaine (Lidocaine) is a **Class IB antiarrhythmic** primarily used to treat and prevent **ventricular arrhythmias** (premature ventricular contractions, VT). - It is generally ineffective for chronic prophylaxis of supraventricular tachycardias like PSVT. *IV Adenosine* - **Adenosine** is the preferred drug for the **acute termination** of PSVT due to its potent, transient block of the AV node (half-life of <10 seconds). - It has an extremely short half-life, making it unsuitable for a chronic, **oral preventive regimen**. *Oral Nifedipine* - Nifedipine is a **dihydropyridine Calcium Channel Blocker** primarily acting as a **peripheral vasodilator**. - It has minimal effects on the **AV nodal conduction** properties required for PSVT prophylaxis and is therefore not used for this purpose.

Q: A young man presents with chronic lower back pain and morning stiffness and pain on bending that improves with activity. X ray of LS spine is normal. Ocular examination shows anterior uveitis. Which diagnostic modality will pick up the disease process at the earliest?

MRI of the sacroiliac joints. ***MRI of the sacroiliac joints*** - **MRI** is the most sensitive and specific tool for detecting early inflammatory changes in the **sacroiliic joints** (sacroiliitis), such as bone marrow edema (osteitis) [1]. - It is crucial when plain radiography is normal, as it detects inflammatory lesions years before structural bony changes become visible on X-ray or CT scan, facilitating early diagnosis of **Ankylosing Spondylitis**. *Anti CCP antibody* - The **Anti-Cyclic Citrullinated Peptide (Anti-CCP)** antibody is highly specific for **Rheumatoid Arthritis (RA)**, which presents differently, typically affecting small peripheral joints [2]. - The clinical presentation of chronic back pain, morning stiffness improving with activity, and anterior uveitis is classic for **Spondyloarthritis** (like Ankylosing Spondylitis), not RA [3]. *CT scan of the sacroiliac joints* - **CT scan** is excellent for visualizing bony erosions, sclerosis, and joint fusion, which are **late structural changes** in sacroiliitis. - However, it is less sensitive than MRI in detecting the **early, active inflammatory phase** (bone marrow edema) that occurs before joint damage is established. *Bone scan* - A **Bone scan** (Technetium-99m) is sensitive but **not site-specific**; it shows increased tracer uptake in inflamed areas but cannot distinguish between degenerative, traumatic, or inflammatory causes [2]. - Its use in diagnosing sacroiliitis is largely superseded by **MRI** due to the latter's superior spatial resolution and ability to depict active inflammation directly.

Q: A patient with a known history of bronchial asthma is currently on salbutamol and ipratropium via MDI. He now presents with nocturnal worsening of symptoms and night time awakening. What is the next best step in management?

Start L.A.B.A + inhaled corticosteroids. ***Start L.A.B.A + inhaled corticosteroids*** - Nocturnal symptoms and night-time awakening indicate persistent or **partially controlled asthma**, necessitating a step-up in therapy (Step 3 or higher treatment based on GINA guidelines) [1]. - The preferred step-up involves adding a daily **low-dose inhaled corticosteroid (ICS)**, often combined with a **Long-Acting Beta Agonist (LABA)**, to address underlying inflammation and provide long-acting bronchodilation [1]. *Increase the dose of salbutamol* - **Salbutamol is a Short-Acting Beta Agonist (SABA)**, used for quick relief (rescue medication), not for controlling chronic inflammation or preventing nocturnal symptoms. - Increasing SABA use without adding anti-inflammatory medication (ICS) is an inappropriate strategy for managing **persistent asthma** and signals poor control. *Add theophylline* - Theophylline is a non-selective phosphodiesterase inhibitor, which is a **less preferred add-on therapy** (Step 4/5) due to its narrow therapeutic index and significant risk of **adverse effects** (e.g., arrhythmias, seizures). - This option is generally reserved for patients who remain symptomatic despite adequate ICS/LABA combination therapy. *Add Montelukast* - Montelukast (a **leukotriene receptor antagonist**) is an optional, less potent add-on therapy typically considered if symptoms persist despite ICS use or if the patient has significant **allergic rhinitis**. - It is **less effective** than adding an ICS-LABA combination when stepping up treatment for poorly controlled persistent asthma.

Q: The patient presents with fatigue and pruritus. LFT shows gross SALP elevation and elevated conjugated bilirubin. AMA is seen with liver biopsy shows florid bile ductular lesions. Diagnosis is

PBC. ***PBC*** - The presentation of **fatigue** and **pruritus**, severe **SALP elevation** (indicative of cholestasis), and a positive **Anti-Mitochondrial Antibody (AMA)** titer is the classic diagnostic hallmark of Primary Biliary Cholangitis [1], [3]. - The liver biopsy finding of **florid bile ductular lesions** (destruction of small to medium-sized intrahepatic bile ducts) is the pathognomonic histological feature of this disease [3]. *PSC* - While PSC (Primary Sclerosing Cholangitis) also causes cholestasis, it is typically **AMA-negative** and highly associated with Ulcerative Colitis [2], [3]. - Diagnosis of PSC requires imaging (MRCP/ERCP) showing characteristic **bile duct strictures** and **"beading"**, which are not implied by the provided histological description [2]. *UC* - Ulcerative Colitis is an **Inflammatory Bowel Disease (IBD)** affecting the colon, not a primary cholestatic liver disease itself. - Although UC is strongly linked to PSC, it does not explain the patient's **AMA positivity** or the specific destructive **florid bile duct lesions** seen on biopsy [3]. *CD* - Crohn's Disease is also an IBD, characterized by **transmural inflammation** and often affecting the terminal ileum and colon. - The primary features (pruritus, high SALP, AMA+) point directly to PBC, not the common clinical manifestations or liver associations typically seen with **Crohn's Disease**.

Q: A 30-year-old man develops an increase in shoe size with coarse facies and large hands. IGF1 is elevated. What is the investigation of choice?

Failure to suppress GH by OGTT. ***Failure to suppress GH by OGTT*** - This is the **gold standard dynamic test** for confirming acromegaly, as it proves autonomous and unregulated **Growth Hormone (GH)** secretion [1]. - In healthy individuals, glucose load suppresses GH levels (typically to <1 ng/mL), but this suppression fails in patients with GH-secreting tumors [1]. *IGF-1 levels* - While highly sensitive for screening and monitoring, elevated **Insulin-like Growth Factor 1 (IGF-1)** levels alone are not definitive for diagnosis [2]. - IGF-1 levels must be confirmed with a dynamic test because they can be influenced by other factors like malnutrition or chronic liver failure [2]. *Failure to suppress IGF-1 by OGTT* - The definitive OGTT suppression test measures the suppression of **GH**, not IGF-1; IGF-1 reflects integrated GH production [1]. - While IGF-1 levels are used for diagnosis and monitoring, measuring its failure to suppress during OGTT is not the primary definition of diagnostic test failure. *GH levels* - A single random measurement of **Growth Hormone (GH)** is unreliable for diagnosis because GH is secreted in a highly pulsatile manner [1]. - Dynamic testing, such as the **Oral Glucose Tolerance Test (OGTT)**, is mandatory to confirm the pathological non-suppressibility of GH [1].

Question 1

A 56-year-old diabetic patient is currently on Metformin and Insulin Glargine. His HbA1c is 8.2 %, indicating suboptimal glycemic control. Echocardiography reveals a reduced ejection fraction (EF) of 35 %. Which of the following is the most appropriate agent to add to his current regimen?

Accepted Answer

Empagliflozin

Answer

Sitagliptin

Answer

Glimepiride

Answer

Pioglitazone

Question 2

A 60-year-old man with chronic kidney disease presents with complaints of increasing fatigue, dyspnea on exertion, and signs of congestive heart failure. On evaluation, he is found to have anemia. What is the most appropriate next step in management?

Accepted Answer

Intravenous iron infusion

Answer

Blood transfusion

Answer

Darbepoetin alfa

Answer

Oral iron therapy

Question 3

A patient with COPD presents with progressive dyspnea. ABG shows pH: 7.32, pCO2: 60 mmHg, and HCO3⁻: 32 mEq/L. Which of the following acid-base disorders is present in this patient?

Accepted Answer

Chronic respiratory acidosis

Answer

Metabolic acidosis

Answer

Metabolic alkalosis

Answer

Acute respiratory acidosis

Question 4

A patient with recurrent episodes of PSVT (Paroxysmal Supraventricular Tachycardia) is being considered for long-term prophylactic therapy to prevent future episodes. Which of the following is the most appropriate preventive treatment?

Accepted Answer

Oral Verapamil

Answer

IV Adenosine

Answer

Oral Nifedipine

Answer

IV lignocaine

Question 5

A young man presents with chronic lower back pain and morning stiffness and pain on bending that improves with activity. X ray of LS spine is normal. Ocular examination shows anterior uveitis. Which diagnostic modality will pick up the disease process at the earliest?

Accepted Answer

MRI of the sacroiliac joints

Answer

CT scan of the sacroiliac joints

Answer

Bone scan

Answer

Anti CCP antibody

Question 6

A patient with a known history of bronchial asthma is currently on salbutamol and ipratropium via MDI. He now presents with nocturnal worsening of symptoms and night time awakening. What is the next best step in management?

Accepted Answer

Start L.A.B.A + inhaled corticosteroids

Answer

Add theophylline

Answer

Add Montelukast

Answer

Increase the dose of salbutamol

Question 7

The patient presents with fatigue and pruritus. LFT shows gross SALP elevation and elevated conjugated bilirubin. AMA is seen with liver biopsy shows florid bile ductular lesions. Diagnosis is

Accepted Answer

PBC

Answer

UC

Answer

CD

Answer

PSC

Question 8

A 30-year-old man develops an increase in shoe size with coarse facies and large hands. IGF1 is elevated. What is the investigation of choice?

Accepted Answer

Failure to suppress GH by OGTT

Answer

Failure to suppress IGF-1 by OGTT

Answer

GH levels

Answer

IGF-1 levels

NEET-PG 2025 — Internal Medicine