NEET-PG 2013 - Internal Medicine Practice Questions

Q: A 25 year old female presents with generalized restriction of eye movement in all direction, intermittent ptosis, proximal muscle weakness and fatigability.Which is the MOST useful test in making the diagnosis?

Edrophonium test. ***Edrophonium test*** - The **Edrophonium test** (Tensilon test) is highly useful for diagnosing **myasthenia gravis** due to its rapid onset and short duration of action. - In a patient with suspected myasthenia gravis, such as this one presenting with **generalized restriction of eye movement**, **intermittent ptosis**, and **fatigable proximal muscle weakness**, the administration of edrophonium will lead to a temporary but significant improvement in muscle strength. It works by inhibiting the breakdown of acetylcholine, thereby increasing its availability at the neuromuscular junction [1]. *CPK* - **Creatine phosphokinase (CPK)** levels are typically normal in myasthenia gravis, as it is a disorder of the **neuromuscular junction**, not a primary muscle disease. - Elevated CPK levels usually indicate muscle damage, seen in conditions like **myositis** or **muscular dystrophies**, which are not suggested by the patient's symptoms. *EMG* - **Electromyography (EMG)**, specifically **repetitive nerve stimulation (RNS)** or **single-fiber EMG (SFEMG)**, can show characteristic decremental responses or increased jitter/blocking in myasthenia gravis [2], but it is less direct and often more invasive than the Edrophonium test for initial diagnostic confirmation. - While supportive, it is generally considered a secondary diagnostic tool after a strong clinical suspicion and is not the *most useful* initial test compared to the rapid symptomatic improvement seen with edrophonium. *Muscle biopsy* - A **muscle biopsy** is generally not useful in diagnosing myasthenia gravis as the muscle tissue itself is structurally normal. - This diagnostic tool is reserved for primary **muscle disorders** like muscular dystrophies or inflammatory myopathies, which would show characteristic histological changes.

Q: Subclavian steal syndrome is

Reversal of blood flow in the ipsilateral vertebral artery. ***Reversal of blood flow in the ipsilateral vertebral artery*** - Subclavian steal syndrome occurs due to a **proximal stenosis** or **occlusion of the subclavian artery**. - This causes blood to be "stolen" from the **ipsilateral vertebral artery**, flowing retrograde to supply the arm and thereby reducing blood flow to the brainstem. *Reversal of blood flow in the contralateral carotid artery* - The carotid arteries supply blood to the brain directly and are typically not directly involved in thesteal phenomenon in this specific syndrome. - Reversal of flow in the carotid artery would indicate a much more severe and different pathology, not characteristic of subclavian steal. *Reversal of blood flow in the contralateral vertebral artery* - The steal phenomenon specifically involves the vertebral artery on the **same side (ipsilateral)** as the subclavian artery obstruction. - The contralateral vertebral artery would typically continue to supply blood to the brain without a reversed flow in this syndrome. *B/L reversal of blood flow in vertebral arteries* - Subclavian steal syndrome is generally a **unilateral phenomenon**, affecting the vertebral artery ipsilateral to the subclavian artery stenosis. - Bilateral reversal would imply bilateral subclavian artery obstruction or other severe cerebrovascular disease, which is not the definition of subclavian steal syndrome itself.

Q: Isolated painful third nerve palsy is a feature of aneurysms of:

Aneurysm of the posterior communicating artery. ***Aneurysm of the posterior communicating artery*** - An aneurysm of the **posterior communicating artery (PCOM)** can compress the ipsilateral **oculomotor nerve (CN III)** as it exits the brainstem. - This compression typically affects the **superficial parasympathetic fibers** first, leading to a **dilated pupil** (mydriasis) along with ophthalmoplegia and ptosis, making the third nerve palsy "painful" and "isolated" without other focal neurological deficits. *Aneurysm of the anterior communicating artery* - Aneurysms of the **anterior communicating artery (ACoM)** are more commonly associated with **subarachnoid hemorrhage** and can cause **visual field defects** or **frontal lobe dysfunction**, but generally not isolated CN III palsy. - While rupture can lead to various neurological deficits, isolated painful third nerve palsy due to ACoM aneurysm is atypical. *Aneurysm of the vertebrobasillary artery* - Aneurysms in the **vertebrobasillar system** typically present with symptoms related to **brainstem compression** or ischemia, such as cranial nerve palsies beyond the third nerve, ataxia, or motor/sensory deficits. - Isolated third nerve palsy is an uncommon presentation for vertebrobasilar aneurysms compared to PCOM aneurysms. *Aneurysm of the ophthalmic artery* - **Ophthalmic artery aneurysms** are usually **intraorbital** and can cause **visual loss** due to direct compression of the **optic nerve (CN II)** or orbital structures. - They are less likely to cause isolated painful third nerve palsy, as the third nerve's course is generally not directly compromised by ophthalmic artery aneurysms.

Q: In Wilson's disease, copper deposition primarily occurs in which part of the brain?

Basal ganglia. ***Basal ganglia*** - The **basal ganglia**, particularly the **putamen** and **globus pallidus**, are the most common sites for copper deposition in the brain in Wilson's disease [1]. - This deposition leads to **neurological symptoms** such as dystonia [2], tremor, and dysarthria. *Pons* - While copper can accumulate in various brain regions, the **pons** is not a primary or characteristic site of significant copper deposition. - Neurological symptoms associated with pontine damage are not typical presenting features of Wilson's disease. *Cerebellum* - The **cerebellum** can show some copper accumulation in advanced stages, but it is not the primary site. - Cerebellar signs like **ataxia** can occur in Wilson's disease, but usually secondary to more widespread pathology rather than primary cerebellar copper deposition. *Medulla* - The **medulla oblongata** is generally spared from significant copper deposition in Wilson's disease. - Involvement of the medulla would typically manifest with severe autonomic or brainstem dysfunction, which is not a hallmark of early Wilson's disease.

Q: Genitourinary complication of ulcerative colitis

Urinary calculi. ***Urinary calculi*** - Patients with ulcerative colitis are at an increased risk of developing **urinary calculi** due to several factors, including chronic dehydration, malabsorption of fats leading to increased oxalate absorption (enteric hyperoxaluria), and altered urine composition. - The inflammatory process and potential for surgical interventions (e.g., colectomy with ileostomy) can further predispose individuals to kidney stone formation. *Cystitis* - While cystitis (bladder inflammation) can occur in the general population, it is not considered a specific or significantly elevated genitourinary complication directly linked to the pathogenesis of ulcerative colitis itself. - It results primarily from bacterial infection, and there is no direct evidence suggesting UC patients have a higher intrinsic risk compared to the general population. *Pyelonephritis* - Pyelonephritis (kidney infection) is not a direct or common complication of ulcerative colitis. - It is typically caused by bacterial ascent from the lower urinary tract and is not specifically promoted by the inflammatory processes or metabolic changes associated with UC. *Urethritis* - Urethritis (inflammation of the urethra) is primarily associated with sexually transmitted infections or irritation and is not a recognized genitourinary complication directly caused by ulcerative colitis. - There is no increased incidence of urethritis in UC patients compared to the general population.

Q: A diabetic patient presents with sensory involvement, tingling, numbness, ankle swelling, and absence of pain. What is the most likely diagnosis?

Charcot's joint. ***Charcot's joint*** - This condition is characterized by **neuropathic arthropathy**, resulting from nerve damage (often due to **diabetes**), leading to sensory involvement, **numbness**, and **absence of pain** [1]. - The loss of protective sensation and repeated microtrauma contribute to joint destruction, often manifesting as **swelling** and deformity, particularly in the feet and ankles [1]. *Gout* - Gout typically presents with sudden, severe episodes of **pain**, redness, and swelling in a single joint, most commonly the **big toe**. - It is caused by **uric acid crystal deposition** and is not primarily associated with sensory deficits or chronic painless swelling. *Rheumatoid arthritis* - This is a **chronic autoimmune** inflammatory disease primarily affecting the **small joints** of the hands and feet symmetrically, causing pain, stiffness, and swelling. - It does not typically present with sensory neuropathy or painless joint destruction in the way described. *Ankylosing spondylitis* - This is a **chronic inflammatory disease** primarily affecting the **spine and sacroiliac joints**, causing progressive stiffness and pain that improves with activity. - It is not associated with peripheral joint neuropathy, numbness, or painless ankle swelling [1].

Q: Which of the following is a sign of Bartter's syndrome?

Low potassium levels. ***Low potassium levels*** * Bartter's syndrome is characterized by **renal salt wasting** and subsequent volume depletion, which activates the **renin-angiotensin-aldosterone system** [1]. * This leads to increased aldosterone levels, causing increased potassium secretion in the collecting ducts, resulting in **hypokalemia** [2]. *High potassium levels* * **Hyperkalemia** is not a feature of Bartter's syndrome; instead, it is marked by persistent potassium loss [1]. * Conditions causing hyperkalemia typically involve impaired renal potassium excretion or increased potassium release from cells. *Acidic blood* * Bartter's syndrome usually presents with **metabolic alkalosis** due to hydrogen ion loss in the urine, not acidic blood [2]. * Acidic blood (**acidemia**) would imply a state of respiratory or metabolic acidosis. *High sodium levels* * Bartter's syndrome primarily involves **renal salt wasting**, leading to **normal or low sodium levels** rather than high sodium levels. * High sodium levels (**hypernatremia**) are usually due to inadequate water intake or excessive water loss.

Q: Use of spironolactone in liver cirrhosis is

Decrease edema. ***Decrease edema*** - Spironolactone is an **aldosterone antagonist** that blocks the effects of aldosterone, which is often elevated in liver cirrhosis. - By antagonizing aldosterone, spironolactone promotes **sodium and water excretion**, directly leading to a reduction in **ascites and peripheral edema** [1]. *May improve liver function indirectly* - While spironolactone manages complications of liver cirrhosis, it does **not directly improve liver function** or reverse liver damage. - Its primary role is in **symptom management**, particularly fluid retention, not in healing the underlying liver disease. *May decrease afterload* - Spironolactone's primary action is on the **kidneys** to promote diuresis; it is **not a vasodilator** and therefore does not directly decrease cardiac afterload. - Any effect on systemic vascular resistance would be minimal and secondary to volume changes rather than a direct vasodilatory property. *May decrease intravascular volume* - Spironolactone **decreases total body sodium and water**, leading to a reduction in extravascular fluid (edema and ascites) [1]. - While it decreases the total amount of fluid in the body, its main effect is on **extravascular volume**, and it's chosen over loop diuretics in cirrhosis to prevent **excessive intravascular depletion** which can worsen renal function.

Q: Which neurological condition is commonly associated with Alice in Wonderland Syndrome?

Epileptic seizures. ***Epileptic seizures*** - **Alice in Wonderland Syndrome (AIWS)**, characterized by distortions of visual perception, body image, and sense of time, is often reported as an **aura or part of focal epileptic seizures**, particularly those originating in the temporal or parietal lobes. - The **transient and episodic nature** of AIWS symptoms aligns well with the paroxysmal electrical activity seen in epilepsy. *Subacute sclerosing panencephalitis (SSPE)* - **SSPE** is a rare, fatal brain disorder caused by a persistent **measles virus infection**, primarily affecting children and young adults. - While it causes progressive neurological deterioration, including cognitive decline, motor dysfunction, and seizures, **Alice in Wonderland Syndrome** is not a characteristic or commonly associated symptom. *Cerebral hemorrhage* - A **cerebral hemorrhage** involves bleeding within the brain tissue, leading to acute neurological deficits depending on the location and size of the bleed. - Although it can cause a variety of symptoms, such as headache, weakness, and altered consciousness, **Alice in Wonderland Syndrome** is not a typical manifestation of acute hemorrhage. *Multiple sclerosis* - **Multiple sclerosis (MS)** is a chronic autoimmune disease affecting the central nervous system, leading to demyelination and neurological symptoms. - Common symptoms involve motor, sensory, visual, and cognitive deficits, but **Alice in Wonderland Syndrome** is not a recognized or common neurological manifestation of MS.

Q: Acute orchitis is characterized by all of the following except:

Decreased blood flow. ***Decreased blood flow*** - **Acute orchitis** is an inflammatory process that typically leads to increased blood flow (hyperemia) to the affected testis due to the inflammatory response. - Decreased blood flow would be more characteristic of conditions like **testicular torsion**, which is an emergent condition causing ischemia. *Increased local temperature* - **Inflammation** is characterized by the classic signs of rubor (redness) and calor (heat), leading to an **increased local temperature** in the affected area. - This is a common finding in acute orchitis due to the inflammatory response. *Erythematous scrotum* - The inflammatory process in orchitis causes **vasodilation** and increased vascular permeability, leading to redness and swelling of the overlying scrotal skin. - An **erythematous scrotum** is a typical clinical sign of acute orchitis. *Raised TLC* - **TLC (Total Leukocyte Count)** is often elevated in cases of acute infection or inflammation, such as orchitis. - A **raised TLC** indicates a systemic inflammatory response to the infection.

Question 1

A 25 year old female presents with generalized restriction of eye movement in all direction, intermittent ptosis, proximal muscle weakness and fatigability.Which is the MOST useful test in making the diagnosis?

Accepted Answer

Edrophonium test

Answer

CPK

Answer

EMG

Answer

Muscle biopsy

Question 2

Subclavian steal syndrome is

Accepted Answer

Reversal of blood flow in the ipsilateral vertebral artery

Answer

Reversal of blood flow in the contralateral carotid artery

Answer

Reversal of blood flow in the contralateral vertebral artery

Answer

B/L reversal of blood flow in vertebral arteries

Question 3

Isolated painful third nerve palsy is a feature of aneurysms of:

Accepted Answer

Aneurysm of the posterior communicating artery

Answer

Aneurysm of the anterior communicating artery

Answer

Aneurysm of the vertebrobasillary artery

Answer

Aneurysm of the ophthalmic artery

Question 4

In Wilson's disease, copper deposition primarily occurs in which part of the brain?

Accepted Answer

Basal ganglia

Answer

Cerebellum

Answer

Pons

Answer

Medulla

Question 5

Genitourinary complication of ulcerative colitis

Accepted Answer

Urinary calculi

Answer

Pyelonephritis

Answer

Urethritis

Answer

Cystitis

Question 6

A diabetic patient presents with sensory involvement, tingling, numbness, ankle swelling, and absence of pain. What is the most likely diagnosis?

Accepted Answer

Charcot's joint

Answer

Gout

Answer

Rheumatoid arthritis

Answer

Ankylosing spondylitis

Question 7

Which of the following is a sign of Bartter's syndrome?

Accepted Answer

Low potassium levels

Answer

High potassium levels

Answer

Acidic blood

Answer

High sodium levels

Question 8

Use of spironolactone in liver cirrhosis is

Accepted Answer

Decrease edema

Answer

May improve liver function indirectly

Answer

May decrease afterload

Answer

May decrease intravascular volume

Question 9

Which neurological condition is commonly associated with Alice in Wonderland Syndrome?

Accepted Answer

Epileptic seizures

Answer

Subacute sclerosing panencephalitis (SSPE)

Answer

Cerebral hemorrhage

Answer

Multiple sclerosis

Question 10

Acute orchitis is characterized by all of the following except:

Accepted Answer

Decreased blood flow

Answer

Increased local temperature

Answer

Erythematous scrotum

Answer

Raised TLC

NEET-PG 2013 — Internal Medicine