INI-CET 2024 - Internal Medicine Practice Questions

Q: Which of the following is typically not associated with upper motor neuron (UMN) lesions?

Atrophy. ***Atrophy*** - **Severe atrophy** (significant muscle wasting) is a hallmark of **lower motor neuron (LMN) lesions**, where the direct innervation to the muscle is interrupted, leading to denervation and subsequent muscle mass loss [1]. - While some disuse atrophy can occur with UMN lesions due to **immobility**, it is typically not as pronounced or rapid as that seen with LMN lesions [1]. *DTR increased* - **Increased deep tendon reflexes (DTRs)**, also known as hyperreflexia, are a classic sign of **upper motor neuron (UMN) lesions** due to the loss of inhibitory control from higher centers on spinal reflex arcs [1]. - The stretch reflex arc becomes more excitable without descending modulation, leading to exaggerated responses. *Spasticity* - **Spasticity** is characterized by a **velocity-dependent increase in muscle tone** with increased resistance to passive stretch, often accompanied by hyperreflexia [1]. - This is a cardinal sign of **upper motor neuron (UMN) lesions**, resulting from the disinhibition of spinal reflex mechanisms. *Rigidity* - **Rigidity** is a form of hypertonia characterized by a **constant resistance to passive movement** throughout the entire range of motion, independent of the speed of movement [2]. - While it can be seen in some UMN conditions involving the basal ganglia (such as Parkinson's disease), it is **not a typical or direct consequence of UMN tract lesions** in the way spasticity is [2],[3].

Q: Which of the following is the MOST common complication associated with GERD?

Esophagitis. ***Esophagitis*** - **Reflux of gastric acid** into the esophagus directly irritates the esophageal lining, leading to inflammation and cellular damage, commonly presenting as esophagitis [1]. - This recurrent irritation causes histological changes such as **basal cell hyperplasia** and **elongation of papillae**, which are hallmarks of reflux-induced injury [1]. *Chronic cough* - While chronic cough can be a symptom of GERD, it is considered an **extraesophageal manifestation** rather than a direct complication of esophageal mucosal damage. - Its prevalence is lower than esophagitis among GERD complications and it's less direct consequence of acid exposure to the esophagus itself. *Dental erosion* - **Acid reflux** can lead to dental erosion due to the direct contact of acidic gastric contents with tooth enamel. - However, this is less common than esophagitis, which is a direct and frequent consequence of **mucosal acid exposure** within the esophagus [1].

Q: All of the following regarding ankylosing spondylitis are true except:

Non-erosive arthritis. ***Non-erosive arthritis*** - Ankylosing spondylitis is characterized by **erosive changes**, particularly at the discovertebral and sacroiliac joints, which can lead to **syndesmophyte formation** and eventual *ankylosis* (fusion) of the spine [1]. - The disease involves inflammation and subsequent **ossification of ligaments**, leading to structural damage rather than being purely non-erosive [1]. *HLA B27 is positive in >90%* - A strong association with **HLA-B27** is a hallmark of ankylosing spondylitis, with over 90% of Caucasian patients testing positive, making it a key diagnostic marker [1]. - While not universally present, its high prevalence further supports this statement as being true [1]. *More common in males than females* - Ankylosing spondylitis typically has a male-to-female predominance, with males generally experiencing **more severe disease progression** and spinal involvement. - While the diagnostic criteria have evolved to recognize a more equitable distribution, the classic presentation often highlights male prevalence. *Typically occurs in late teens to early adulthood (peak onset 20s-30s), but can present after 40 in rare cases* - The onset of ankylosing spondylitis symptoms most commonly occurs in **young adults**, typically between the ages of 20 and 40 [1]. - While less common, a small percentage of patients may experience symptom onset later in life, though this is less typical of the disease's natural history.

Q: A 50-year-old male with a history of chronic alcoholism presents with altered sensorium and signs of portal hypertension. What is the most appropriate initial management step?

Administer lactulose. ***Administer lactulose*** - The patient's presentation with altered sensorium and chronic alcoholism, coupled with signs of portal hypertension, strongly suggests **hepatic encephalopathy**. [1] - **Lactulose** is the most appropriate initial management step because it helps to reduce ammonia absorption from the gut by acidifying the colon and acting as an osmotic laxative, thereby improving neurological function. [1] *Perform upper gastrointestinal endoscopy (UGIE)* - While **portal hypertension** can lead to varices and bleeding, an UGIE is an invasive procedure and not the immediate priority for a patient presenting with altered sensorium due to suspected hepatic encephalopathy. - UGIE would be indicated if there were active **gastrointestinal bleeding** (e.g., hematemesis, melena) or hemodynamic instability, which are not explicitly mentioned as the primary concern. *Administer chlordiazepoxide* - **Chlordiazepoxide** is a benzodiazepine used to treat **alcohol withdrawal syndrome** (delirium tremens), which can also cause altered mental status. - However, given the signs of portal hypertension, **hepatic encephalopathy** is a more likely cause of altered sensorium, and benzodiazepines can worsen it by precipifying sedation. *Administer thiamine* - **Thiamine** administration is crucial in chronic alcoholics to prevent and treat **Wernicke-Korsakoff syndrome**, which can cause altered mental status, ophthalmoplegia, and ataxia. [2] - While important in all chronic alcoholics, addressing the potentially life-threatening ammonia toxicity in **hepatic encephalopathy** with lactulose takes precedence in the immediate management of altered sensorium.

Q: Best blood product to be given in a patient of multiple clotting factor deficiency with active bleeding:

Fresh frozen plasma. ***Fresh frozen plasma*** - **Fresh frozen plasma (FFP)** contains all coagulation factors, including labile factors V and VIII, making it the best choice for patients with multiple clotting factor deficiencies and active bleeding. - It rapidly replenishes clotting factors, which is critical in scenarios of **acute hemorrhage** due to global coagulopathy. *Whole blood* - **Whole blood** contains red blood cells, plasma, and platelets, but its clotting factor concentration is lower than FFP and deteriorates over storage. - It is preferred for massive hemorrhage with significant blood volume loss, but less effective for isolated clotting factor deficiencies without substantial volume depletion. *Packed RBCs* - **Packed red blood cells (PRBCs)** are primarily used to increase oxygen-carrying capacity by raising hemoglobin levels in anemic patients. - They lack significant amounts of clotting factors and are therefore not effective in treating active bleeding due to coagulation factor deficiencies. *Cryoprecipitate* - **Cryoprecipitate** contains specific clotting factors, namely factor VIII, von Willebrand factor, fibrinogen, and factor XIII. - While useful for deficiencies in these specific factors (e.g., hemophilia A, DIC with low fibrinogen), it does not provide a broad spectrum of all clotting factors needed for general multiple factor deficiencies.

Q: Allergic salute is seen in -

Allergic rhinitis. ***Allergic rhinitis*** - The **allergic salute** is a characteristic physical finding in allergic rhinitis [1], where individuals repeatedly push their nose upward with their hand to relieve nasal itching and clear obstruction. - This repetitive gesture can lead to a visible transverse crease on the dorsum of the nose, known as the **nasal crease**. *Nasal Myiasis* - **Nasal myiasis** is an infestation of the nasal cavity by fly larvae, causing symptoms like nasal discharge, epistaxis, and local pain. - It does not involve nasal itching that would provoke the "allergic salute" action. *Chronic sinusitis* - **Chronic sinusitis** is a prolonged inflammation of the sinuses, causing facial pain/pressure, nasal obstruction, and discharge. - While it can cause nasal obstruction, it typically doesn't present with the intense nasal itching that would lead to the "allergic salute." *Chronic conjunctivitis* - **Chronic conjunctivitis** is an inflammation of the conjunctiva, primarily affecting the eyes with symptoms like redness, itching, and discharge. - It does not directly affect the nasal passages or provoke nasal symptoms like itching that would result in an allergic salute.

Q: A 45-year-old Caucasian male with a history of chronic myeloid leukemia for which he is receiving chemotherapy presents to the emergency room with oliguria and colicky left flank pain. His serum creatinine is 3.0 mg/dL and his urine pH is 5.0. You diagnose nephrolithiasis. His kidney stones, however, are not visible on abdominal x-ray. His stone is most likely composed of which of the following?

Uric acid. ***Uric acid*** - The patient has **chronic myeloid leukemia (CML)** and is receiving **chemotherapy**, which can cause a rapid turnover of cells, leading to **hyperuricemia** and the formation of uric acid stones. - Uric acid stones are **radiolucent** (not visible on X-ray) and are associated with a **low urine pH** (5.0 in this case). *Cystine* - Cystine stones are caused by a **genetic defect** in amino acid transport, leading to high urinary cystine levels. - While they are also **radiolucent**, there is no clinical information to suggest a genetic predisposition for cystinuria in this patient. *Calcium phosphate* - Calcium phosphate stones are typically **radio-opaque** and usually form in alkaline urine, which contradicts the patient's low urine pH [1]. - They are often associated with conditions like **renal tubular acidosis** or hyperparathyroidism [1]. *Magnesium ammonium phosphate* - These are also known as **struvite stones** and are highly suggestive of **urinary tract infections** with urea-splitting organisms (e.g., *Proteus*) [1]. - They tend to grow large, form **staghorn calculi**, and are **radio-opaque** [1]. *Calcium oxalate* - Calcium oxalate stones are the **most common type** of kidney stone and are **radio-opaque**, making them visible on X-ray. - They are typically associated with conditions causing **hypercalciuria** or hyperoxaluria, which are not explicitly indicated here, and they would be visible on the X-ray.

Question 1

Which of the following is typically not associated with upper motor neuron (UMN) lesions?

Accepted Answer

Atrophy

Answer

DTR increased

Answer

Spasticity

Answer

Rigidity

Question 2

Which of the following is the MOST common complication associated with GERD?

Accepted Answer

Esophagitis

Answer

Chronic cough

Answer

Dental erosion

Answer

None of the options

Question 3

All of the following regarding ankylosing spondylitis are true except:

Accepted Answer

Non-erosive arthritis

Answer

HLA B27 is positive in >90%

Answer

More common in males than females

Answer

Typically occurs in late teens to early adulthood (peak onset 20s-30s), but can present after 40 in rare cases

Question 4

A 50-year-old male with a history of chronic alcoholism presents with altered sensorium and signs of portal hypertension. What is the most appropriate initial management step?

Accepted Answer

Administer lactulose

Answer

Perform upper gastrointestinal endoscopy (UGIE)

Answer

Administer chlordiazepoxide

Answer

Administer thiamine

Question 5

Best blood product to be given in a patient of multiple clotting factor deficiency with active bleeding:

Accepted Answer

Fresh frozen plasma

Answer

Whole blood

Answer

Packed RBCs

Answer

Cryoprecipitate

Question 6

Allergic salute is seen in -

Accepted Answer

Allergic rhinitis

Answer

Nasal Myiasis

Answer

Chronic sinusitis

Answer

Chronic conjunctivitis

Question 7

A 45-year-old Caucasian male with a history of chronic myeloid leukemia for which he is receiving chemotherapy presents to the emergency room with oliguria and colicky left flank pain. His serum creatinine is 3.0 mg/dL and his urine pH is 5.0. You diagnose nephrolithiasis. His kidney stones, however, are not visible on abdominal x-ray. His stone is most likely composed of which of the following?

Accepted Answer

Uric acid

Answer

Cystine

Answer

Calcium phosphate

Answer

Magnesium ammonium phosphate

Answer

Calcium oxalate

INI-CET 2024 — Internal Medicine