In a patient there is dyspnea in upright position which is relieved in supine position, Diagnosis ?
Clicking noise in Pneumomediastinum is known as
Which of the following is least likely to be associated with emphysema?
What is the most common cause of lung abscess in comatose patients?
In the context of ventricular tachycardia, what do extra systoles appear as on an electrocardiogram (ECG)?
What is the most common arrhythmia in ICU patients?
A patient with first-degree heart block presents with dizziness. What is the most appropriate management for this patient?
A patient involved in an accident presents with unconsciousness. Upon physical examination, there is unilateral pupillary dilatation. What is the most likely cause of this finding?
Which of the following is the most common type of multiple sclerosis?
Which of the following is NOT part of the classic triad of normal pressure hydrocephalus?
NEET-PG 2015 - Internal Medicine NEET-PG Practice Questions and MCQs
Question 91: In a patient there is dyspnea in upright position which is relieved in supine position, Diagnosis ?
- A. Tachypnea
- B. Orthopnea
- C. Platypnea (Correct Answer)
- D. Paroxysmal nocturnal dyspnea
Explanation: ***Platypnea*** - **Platypnea** is defined as **dyspnea that worsens in an upright position** and improves when lying down. - This condition is often associated with **hepatopulmonary syndrome**, **intracardiac shunts** (e.g., patent foramen ovale), or **pulmonary arteriovenous malformations**, where gravity affects blood flow and gas exchange. *Tachypnea* - **Tachypnea** refers to an **abnormally rapid rate of breathing**. - It describes the *rate* of respiration, not its variation with body position. *Orthopnea* - **Orthopnea** is **dyspnea that occurs when lying flat** and is relieved by sitting or standing up [1]. - It is often seen in conditions like **heart failure**, where fluid redistribution to the lungs is exacerbated in the supine position [2]. *Paroxysmal nocturnal dyspnea* - **Paroxysmal nocturnal dyspnea (PND)** is characterized by **sudden, severe shortness of breath at night** that awakens the person from sleep [2]. - It is typically caused by **left-sided heart failure** and is relieved by sitting upright or standing, which is the opposite of the described scenario.
Question 92: Clicking noise in Pneumomediastinum is known as
- A. Hamman's sign (Correct Answer)
- B. Traube's sign
- C. Kussmaul's sign
- D. None of the options
Explanation: Hamman's sign - Hamman's sign is a crunching, bubbling, or clicking sound synchronous with the heartbeat, audible on auscultation over the precordium. - It is pathognomonic for pneumomediastinum, caused by the heart beating against air-filled tissues. Traube's sign - Traube's sign refers to a pistol-shot sound heard over the femoral artery in severe aortic regurgitation [1]. - It is a vascular sign and not related to pneumomediastinum. Kussmaul's sign - Kussmaul's sign is a paradoxical rise in jugular venous pressure (JVP) during inspiration. - It is typically seen in conditions like constrictive pericarditis or right ventricular infarction, not pneumomediastinum. None of the options - This option is incorrect because Hamman's sign accurately describes the clicking noise associated with pneumomediastinum. - The other options refer to different clinical phenomena unrelated to pneumomediastinum.
Question 93: Which of the following is least likely to be associated with emphysema?
- A. Associated with smoking
- B. Type I respiratory failure (Correct Answer)
- C. Barrel shaped chest
- D. Cyanosis
Explanation: **Type I respiratory failure** - **Emphysema** primarily causes **Type II respiratory failure** (hypercapnic) due to impaired gas exchange and CO2 retention resulting from alveolar destruction and air trapping [2][4]. - While hypoxemia can occur in severe emphysema, it is the more prominent **hypercapnia** that defines its typical respiratory failure pattern, making pure Type I less likely [3][4]. *Associated with smoking* - **Cigarette smoking** is the leading cause of emphysema, directly linked to the destruction of alveolar walls and loss of elastic recoil [1]. - The inhaled toxins trigger an inflammatory response in the lungs, leading to the release of proteases that break down lung tissue [1][2]. *Barrel shaped chest* - This is a classic sign of advanced emphysema, caused by **chronic air trapping** and subsequent hyperinflation of the lungs [2]. - The diaphragm flattens, and the ribs become more horizontal, increasing the anterior-posterior diameter of the chest. *Cyanosis* - Often seen in patients with severe emphysema (especially in a subgroup referred to as "blue bloaters" for chronic bronchitis overlap) due to **significant hypoxemia** [3]. - Impaired gas exchange leads to insufficient oxygenation of hemoglobin, causing a bluish discoloration of the skin and mucous membranes [3].
Question 94: What is the most common cause of lung abscess in comatose patients?
- A. Staph aureus
- B. Oral anaerobes (Correct Answer)
- C. Klebsiella
- D. Tuberculosis
Explanation: Oral anaerobes - **Comatose patients** are at high risk for **aspiration** of oropharyngeal flora, which predominantly consists of anaerobic bacteria. [1] - Aspiration of these organisms, especially in compromised lung tissue, frequently leads to **necrotizing pneumonia** and subsequent abscess formation. [1] *Staph aureus* - While *Staphylococcus aureus* can cause lung abscesses, particularly in the context of **hematogenous spread** (e.g., endocarditis) or nosocomial infections, it is not the most common cause in *comatose patients* who typically aspirate oral flora. [2] - *S. aureus* lung abscesses are often associated with multiple, smaller lesions rather than a single, large abscess from aspiration. *Klebsiella* - *Klebsiella pneumoniae* can cause severe, **rapidly progressive pneumonia** that may lead to abscess formation, especially in individuals with **alcoholism** or **diabetes**. - However, it is less common than oral anaerobes as the primary cause of abscess in the general population of comatose patients, whose main risk factor is aspiration of normal oral flora. [1] *Tuberculosis* - **Mycobacterium tuberculosis** can cause cavitary lung lesions, but these are typically chronic and result from primary or reactivated tuberculosis disease, not acute aspiration. [3] - Lung abscesses caused by tuberculosis are histologically distinct from pyogenic abscesses and are characterized by **granulomatous inflammation** and caseous necrosis.
Question 95: In the context of ventricular tachycardia, what do extra systoles appear as on an electrocardiogram (ECG)?
- A. P wave
- B. QRS complex (Correct Answer)
- C. T wave
- D. R wave
Explanation: ***QRS complex*** - Extra systoles, particularly **premature ventricular contractions (PVCs)**, originate in the ventricles and result in a **wide and bizarre QRS complex** on an ECG [2]. - The QRS complex represents **ventricular depolarization**, and in ventricular tachycardia, the *ventricular activity* dominates the ECG tracing [2]. *P wave* - The **P wave** represents **atrial depolarization** and is typically either absent or dissociated from the QRS complex in ventricular tachycardia [1], [2]. - Its presence or absence helps differentiate supraventricular from ventricular arrhythmias. *T wave* - The **T wave** represents **ventricular repolarization**, which typically follows the QRS complex [1]. - While it will be present, it often appears abnormal or discordant in ventricular tachycardia due to the altered ventricular depolarization. *R wave* - The **R wave** is part of the QRS complex, specifically the first positive deflection. - While an R wave is present within the QRS complex of an extrasystole, referring to the entire **QRS complex** is more accurate as it encompasses the complete ventricular depolarization in an abnormal morphology.
Question 96: What is the most common arrhythmia in ICU patients?
- A. Atrial flutter
- B. Atrial fibrillation (Correct Answer)
- C. Atrial Tachycardia
- D. Supraventricular Tachycardia
Explanation: ***Atrial fibrillation*** - **Atrial fibrillation (AF)** is the most prevalent arrhythmia in the general population [1], and its incidence is significantly higher in critically ill patients due to various stressors. - Factors like **sepsis**, **hypoxemia**, **electrolyte imbalances**, **myocardial ischemia**, and **inflammatory states** common in the ICU are known triggers for new-onset AF. *Atrial flutter* - While atrial flutter is a common arrhythmia, its overall incidence in the ICU setting is **less frequent than atrial fibrillation**. - It often involves a **re-entrant circuit** in the right atrium [2], leading to characteristic "sawtooth" waves on ECG. *Atrial Tachycardia* - Atrial tachycardia is a form of **supraventricular tachycardia (SVT)** that originates in the atria but is **less common** than AF in the ICU [2]. - It often presents as a **regular, narrow-complex tachycardia** with discrete P waves. *Supraventricular Tachycardia* - This is a broad term encompassing arrhythmias that originate **above the ventricles** [3], including AF, atrial flutter, and atrial tachycardia. - While SVT as a category is common, **atrial fibrillation is the single most frequent specific arrhythmia** within this group in the ICU.
Question 97: A patient with first-degree heart block presents with dizziness. What is the most appropriate management for this patient?
- A. Observation and investigation of other causes (Correct Answer)
- B. Pacemaker insertion
- C. Isoprenaline
- D. Atropine
Explanation: ***Observation and investigation of other causes*** - **First-degree heart block** is usually **asymptomatic** and benign, rarely causing dizziness or other symptoms. - The dizziness experienced by the patient is likely due to another underlying condition and warrants **further investigation** rather than direct intervention for the heart block [2], [3]. *Pacemaker insertion* - **Pacemaker insertion** is reserved for **symptomatic heart blocks** of higher degrees (e.g., Mobitz II or complete heart block) or those with significant hemodynamic compromise [1]. - Given that first-degree heart block is typically asymptomatic, inserting a pacemaker would be an **overtreatment** and unnecessary for this condition alone. *Isoprenaline* - **Isoprenaline** is a **beta-agonist** that increases heart rate and AV conduction, sometimes used in certain bradyarrhythmias. - However, for first-degree heart block, which is generally benign, pharmacologic intervention with agents like **isoprenaline** is not typically indicated and carries risks of adverse effects [2]. *Atropine* - **Atropine** is an anticholinergic drug used to **increase heart rate** by blocking vagal stimulation of the SA and AV nodes. - While it can improve AV conduction, it is not indicated for **asymptomatic first-degree heart block** or when symptoms like dizziness are unlikely to be directly caused by the block itself.
Question 98: A patient involved in an accident presents with unconsciousness. Upon physical examination, there is unilateral pupillary dilatation. What is the most likely cause of this finding?
- A. Uncal herniation (Correct Answer)
- B. Tonsillar herniation
- C. Cingulate herniation
- D. Transcalvarial herniation
Explanation: ***Uncal herniation*** - **Uncal herniation** compresses the **ipsilateral oculomotor nerve (CN III)**, leading to **pupillary dilation** due to predominant parasympathetic fiber damage [1], [2]. - This condition occurs when the **medial temporal lobe (uncus)** is forced over the tentorial notch, often as a result of a **supratentorial mass effect** [2]. *Tonsillar herniation* - **Tonsillar herniation** is the downward displacement of the **cerebellar tonsils** through the **foramen magnum** [1], [2]. - This compression primarily affects the **brainstem** and **cardiorespiratory centers**, causing **respiratory arrest** or **cardiac dysfunction**, not direct pupillary dilation [1]. *Cingulate herniation* - **Cingulate herniation** involves the displacement of the **cingulate gyrus** under the **falx cerebri**. - While it can lead to **hydrocephalus** and **cognitive changes**, it does not directly cause **unilateral pupillary dilation**. *Transcalvarial herniation* - **Transcalvarial herniation** occurs when **brain tissue** extends through a **skull defect** (e.g., following a craniectomy or skull fracture). - This type of herniation is typically visible externally and does not inherently cause **unilateral pupillary dilation** through direct nerve compression.
Question 99: Which of the following is the most common type of multiple sclerosis?
- A. Relapsing remitting type (Correct Answer)
- B. Progressive relapsing multiple sclerosis
- C. Primary progressive multiple sclerosis
- D. Secondary progressive multiple sclerosis
Explanation: ***Relapsing remitting type*** - **Relapsing-remitting multiple sclerosis (RRMS)** is characterized by clearly defined attacks of worsening neurological function (relapses) followed by periods of partial or complete recovery (remissions). - Approximately **85%** of people with MS are initially diagnosed with RRMS, making it the most common form [1]. *Progressive relapsing multiple sclerosis* - This is a rare form of MS characterized by a **steady neurological decline** from the onset, with superimposed acute relapses. - Unlike RRMS, there are **no periods of remission** in PRMS. *Primary progressive multiple sclerosis* - **Primary progressive multiple sclerosis (PPMS)** is characterized by slowly worsening neurological function from the onset, without early relapses or remissions [1]. - It accounts for roughly **15%** of all MS cases, making it less common than RRMS [1]. *Secondary progressive multiple sclerosis* - **Secondary progressive multiple sclerosis (SPMS)** typically develops in individuals who initially had RRMS, where the disease begins to progress steadily, with or without occasional relapses. - It is a **later stage** of MS and not the most common initial presentation.
Question 100: Which of the following is NOT part of the classic triad of normal pressure hydrocephalus?
- A. Dementia
- B. Gait disturbance
- C. Urinary incontinence
- D. Headache (Correct Answer)
Explanation: ***Headache*** - Headache is **not a typical symptom** of normal pressure hydrocephalus (NPH) and is generally absent, differentiating NPH from other forms of hydrocephalus. - While headaches can occur in other brain conditions, they are **not part of the classic diagnostic triad** for NPH. *Dementia* - **Cognitive impairment**, often manifesting as **subcortical dementia** with executive dysfunction and memory problems, is a core feature of NPH [1]. - This symptom typically progresses and can be a significant cause of disability in affected individuals. *Gait disturbance* - An **ataxic gait** or "magnetic gait" (difficulty lifting feet off the floor) is often the **earliest and most prominent symptom** in NPH. - It significantly impacts mobility and balance, contributing to falls. *Urinary incontinence* - **Urinary urgency and incontinence**, often appearing later than gait disturbance but earlier than dementia, is the third component of the classic triad [1]. - This symptom results from the pressure effects on the **sacral micturition centers** [1].