The severity of mitral stenosis can be judged by-
Wide pulse pressure is seen in all except which of the following?
All are seen in Nephrotic syndrome except
Which of the following is NOT a common cause of acute renal failure?
All are true about GFR except:
Which of the following conditions is a direct indication for initiating dialysis?
Polyuria with low fixed specific gravity urine is seen in ?
Which disease does not recur in the kidney after a renal transplant?
According to standard clinical practice guidelines, significant weight loss requiring medical evaluation is defined as:
Hepatic Encephalopathy is predisposed by all, Except:
NEET-PG 2015 - Internal Medicine NEET-PG Practice Questions and MCQs
Question 71: The severity of mitral stenosis can be judged by-
- A. Duration of murmur
- B. Intensity of murmur
- C. Presence of left ventricular S3
- D. Loud S1 (Correct Answer)
Explanation: ***Loud S1*** - A **loud S1** in mitral stenosis indicates that the **mitral valve leaflets are still mobile** and able to snap shut forcefully, which is characteristic of early to moderate stenosis [2]. - As mitral stenosis becomes more severe and the valve becomes calcified and rigid, the S1 sound may become diminished or even absent due to reduced leaflet mobility [1]. *Intensity of murmur* - The **intensity (loudness)** of the diastolic murmur in mitral stenosis **does not directly correlate with the severity** of the stenosis. - A loud murmur can be heard with mild stenosis, while a soft murmur in severe stenosis may be due to reduced cardiac output or left atrial pressure. *Duration of murmur* - While a **longer duration of the diastolic murmur** can coincide with more severe mitral stenosis, it is not as reliable a single indicator as other findings. - The duration is influenced by the pressure gradient across the valve and the length of diastole [2]. *Presence of left ventricular S3* - A **left ventricular S3** is typically associated with **left ventricular dysfunction** and volume overload, as seen in conditions like mitral regurgitation or dilated cardiomyopathy [3]. - It is **not a feature of mitral stenosis**, where the primary issue is obstruction to left ventricular filling.
Question 72: Wide pulse pressure is seen in all except which of the following?
- A. Aortic Regurgitation
- B. PDA
- C. A.V. malformation
- D. Aortic stenosis (Correct Answer)
Explanation: **Aortic stenosis** - In **aortic stenosis**, there is a fixed obstruction to left ventricular outflow, leading to a compensatory increase in systolic pressure to overcome the stenotic valve [2]. - The **reduced stroke volume** and impaired flow through the rigid valve cause a lower pulse pressure, often resulting in a **narrow pulse pressure**. *PDA (Patent Ductus Arteriosus)* - In **PDA**, blood flows from the aorta to the pulmonary artery during systole and diastole, causing a decrease in diastolic pressure. - This creates a **run-off phenomenon**, leading to a **wide pulse pressure** due to high systolic and low diastolic pressures. *Aortic Regurgitation* - **Aortic regurgitation** involves blood flowing back into the left ventricle during diastole, causing a rapid fall in diastolic pressure [1]. - The increased stroke volume from the left ventricle leads to a high systolic pressure, resulting in a **wide pulse pressure** [1]. *A.V. malformation (Arteriovenous Malformation)* - An **AV malformation** creates a shunt where arterial blood flows directly into the venous system, bypassing the capillary bed. - This leads to a **decrease in peripheral resistance** and an increased cardiac output, causing a higher systolic pressure and a lower diastolic pressure, thereby producing a **wide pulse pressure**.
Question 73: All are seen in Nephrotic syndrome except
- A. Atherosclerosis
- B. Thrombo-embolism
- C. Lipiduria
- D. Increased protein C levels (Correct Answer)
Explanation: ***Increased protein C levels*** - In **nephrotic syndrome**, there is an **increased urinary loss of anticoagulant proteins**, including **Protein C** and **Protein S**, leading to a state of **hypercoagulability**. [1] - Therefore, **Protein C levels are decreased**, not increased, making this the exception. *Atherosclerosis* - **Hyperlipidemia**, a hallmark of nephrotic syndrome, contributes significantly to **accelerated atherosclerosis** due to dysregulation of lipid metabolism. - The increased levels of **LDL cholesterol** and other lipoproteins promote plaque formation and arterial stiffening. *Thrombo-embolism* - Patients with nephrotic syndrome are at a significantly **increased risk of thromboembolic events**, such as deep vein thrombosis and pulmonary embolism, due to a **hypercoagulable state**. - This state results from the **urinary loss of anticoagulant proteins** (e.g., antithrombin III, Protein C, Protein S) and increased levels of procoagulant factors (e.g., fibrinogen, factor V, factor VIII). *Lipiduria* - **Lipiduria**, the presence of lipids in the urine, is a characteristic feature of nephrotic syndrome, often manifested as **oval fat bodies** and **fatty casts**. [1] - This occurs due to the increased glomerular permeability that allows lipoproteins to filter into the urine. [1]
Question 74: Which of the following is NOT a common cause of acute renal failure?
- A. Chronic kidney disease due to analgesic nephropathy (Correct Answer)
- B. Acute pyelonephritis
- C. Acute kidney injury from snakebite
- D. Acute kidney injury due to rhabdomyolysis
Explanation: Chronic kidney disease due to analgesic nephropathy - This is a cause of chronic kidney disease, characterized by gradual, irreversible kidney damage over a long period due to prolonged use of certain analgesics. [1] - It does not present as an acute, sudden decline in kidney function, which is the hallmark of acute renal failure. [1] Acute pyelonephritis - Severe cases of acute pyelonephritis (kidney infection) can lead to acute kidney injury due to sepsis, inflammation, and potential obstruction. [1] - The systemic inflammatory response and direct tissue damage can impair kidney function rapidly. [1] Acute kidney injury from snakebite - Snake envenomation can cause acute kidney injury through various mechanisms, including hemolysis, rhabdomyolysis, direct nephrotoxicity, and systemic hypotension. - These effects can lead to rapid and severe kidney damage. Acute kidney injury due to rhabdomyolysis - Rhabdomyolysis involves the breakdown of skeletal muscle tissue, releasing large amounts of myoglobin into the bloodstream. [1] - Myoglobin is toxic to the renal tubules, leading to acute tubular necrosis and rapid onset of acute kidney injury. [1]
Question 75: All are true about GFR except:
- A. 30-40% decrease after 70 years of age
- B. GFR is dependent on height in children
- C. Chronic Kidney Disease (CKD) is defined as GFR < 60 ml/min/1.73 m² for 3 months or more.
- D. Best estimated by creatinine clearance (Correct Answer)
Explanation: ***Best estimated by creatinine clearance*** - While **creatinine clearance** can be used as a measure of GFR, it is not the *best* estimate; it tends to slightly **overestimate** GFR due to tubular secretion of creatinine. [1] - The gold standard for measuring GFR involves methods like **inulin clearance**, but in clinical practice, GFR is often *estimated* using equations based on **serum creatinine** (e.g., CKD-EPI, MDRD). [2] *30-40% decrease after 70 years of age* - **Aging** is associated with a physiological decline in GFR, with a general decrease often cited as 30-40% after the age of 70 years. - This decline is part of the normal **age-related changes in renal function**. *GFR is dependent on height in children* - In children, GFR is often adjusted for **body surface area (BSA)**, which is calculated based on both **height and weight**, making height an important factor. [1] - This adjustment is crucial for accurate assessment of renal function in a growing pediatric population. *Chronic Kidney Disease (CKD) is defined as GFR < 60 ml/min/1.73 m² for 3 months or more.* - This statement accurately reflects the widely accepted definition of **Chronic Kidney Disease (CKD)** according to clinical guidelines. [3] - A GFR below this threshold sustained for more than three months indicates persistent kidney damage or dysfunction.
Question 76: Which of the following conditions is a direct indication for initiating dialysis?
- A. Severe metabolic acidosis
- B. Fluid overload
- C. Severe hyperkalemia (Correct Answer)
- D. Acute kidney injury
Explanation: ### Severe hyperkalemia - **Severe hyperkalemia** (potassium levels typically >6.5 mEq/L or rapidly rising, especially with ECG changes) is an immediate life-threatening indication for dialysis when conservative measures fail or are insufficient [1]. - Dialysis effectively removes **excess potassium** from the blood, preventing fatal cardiac arrhythmias. *Severe metabolic acidosis* - While **severe metabolic acidosis** (pH <7.1-7.2) can be an indication, it is often managed first with bicarbonate administration and is typically not a stand-alone **direct** *emergency* indication for dialysis unless accompanied by other severe features or resistance to medical therapy. - The decision to dialyze for acidosis often depends on the underlying cause, degree of renal failure, and response to initial management [2]. *Fluid overload* - **Fluid overload** is a common complication of kidney failure, but it becomes a *direct* indication for dialysis when it is **refractory to diuretic therapy** and causes life-threatening symptoms such as **pulmonary edema** [2]. - Without such refractory state and immediate danger, fluid overload itself is not always an *immediate* trigger for dialysis compared to severe hyperkalemia. *Acute kidney injury* - **Acute kidney injury** (AKI) is the underlying *condition* that can lead to indications for dialysis, but AKI itself is not a *direct indication* for dialysis. - Dialysis is initiated for the *complications* of AKI, such as refractory hyperkalemia, severe metabolic acidosis, or fluid overload, rather than the diagnosis of AKI alone [2].
Question 77: Polyuria with low fixed specific gravity urine is seen in ?
- A. Diabetes mellitus
- B. Diabetes insipidus
- C. Chronic glomerulonephritis (Correct Answer)
- D. Potomania
Explanation: ***Chronic glomerulonephritis*** - Damage to the **renal tubules** in chronic glomerulonephritis impairs their ability to concentrate urine, leading to polyuria with a **low, fixed specific gravity**. [1] - This fixed specific gravity reflects the kidneys' inability to adjust urine concentration in response to hydration status, a hallmark of **chronic kidney disease**. [2] *Diabetes mellitus* - Polyuria in diabetes mellitus is caused by **osmotic diuresis** due to high glucose levels in the urine, leading to increased urinary volume. [2] - While there is polyuria, the specific gravity is not necessarily fixed and can vary, often being high due to the presence of glucose. *Diabetes insipidus* - Diabetes insipidus causes polyuria and dilute urine due to either a deficiency of **ADH (central DI)** or renal unresponsiveness to ADH **(nephrogenic DI)**. - While it causes polyuria with low specific gravity, it's typically *not* fixed; the urine specific gravity can still fluctuate to some extent depending on the patient's hydration, or in response to ADH if it's central DI. *Potomania* - Potomania, or **primary polydipsia**, is excessive water intake that leads to dilutional hyponatremia and polyuria. - The kidneys are otherwise healthy and can still concentrate urine to some extent if water intake is restricted, preventing a truly fixed low specific gravity.
Question 78: Which disease does not recur in the kidney after a renal transplant?
- A. Alport syndrome (Correct Answer)
- B. Amyloidosis
- C. Goodpasture's syndrome
- D. Diabetic nephropathy (due to uncontrolled diabetes)
Explanation: **Alport syndrome** * **Alport syndrome** is a genetic disorder affecting type IV collagen, primarily in the kidney; recurrence is not observed in a renal allograft because the transplanted kidney provides new, healthy type IV collagen [2]. * The disease is due to a genetic defect in the recipient's collagen genes, so the transplanted kidney, which is genetically distinct, is not susceptible to the same primary disease process [2]. *Amyloidosis* * **Amyloidosis** can recur in the transplanted kidney, as it is a systemic disease where abnormal proteins continue to deposit in various organs, including the new kidney. * The underlying cause of amyloid production is typically not cured by a kidney transplant, making the new organ vulnerable to recurrence. *Goodpasture's syndrome* * **Goodpasture's syndrome** is an autoimmune disease where antibodies target type IV collagen in the glomerular basement membrane; these autoantibodies can attack the new kidney if they are still present at the time of transplant or re-emerge [1]. * Recurrence is a significant concern, although it can often be prevented by ensuring the patient is antibody-negative before transplantation and through immunosuppression [1]. *Diabetic nephropathy (due to uncontrolled diabetes)* * **Diabetic nephropathy** almost invariably recurs in the transplanted kidney if the recipient's diabetes remains uncontrolled after transplantation. * The metabolic environment, characterized by hyperglycemia, directly contributes to the damage of the new kidney, leading to the development of diabetic nephropathy over time.
Question 79: According to standard clinical practice guidelines, significant weight loss requiring medical evaluation is defined as:
- A. 5% weight loss in 1-2 months
- B. 10% weight loss in 2-3 months (Correct Answer)
- C. 5% weight loss in 2-3 months
- D. 10% weight loss in 1-2 months
Explanation: ***10% weight loss in 2-3 months*** - **Unexplained weight loss** of **10%** or more of usual body weight over a period of **2-3 months** is generally considered a significant amount requiring medical evaluation. - This degree of weight loss can be indicative of underlying serious medical conditions like cancer, gastrointestinal disorders, endocrine disorders, or chronic infections [1]. *5% weight loss in 1-2 months* - While any unexplained weight loss should be noted, a **5% loss** in this timeframe is usually not considered immediately "significant" enough to warrant an aggressive workup unless other concerning symptoms are present. - It might be due to minor lifestyle changes, temporary illness, or benign factors. *5% weight loss in 2-3 months* - A **5% weight loss** over **2-3 months** is a less critical threshold than 10% for initiating an extensive medical evaluation for serious underlying disease. - This level of weight change could be due to a variety of less severe causes or even normal fluctuations. *10% weight loss in 1-2 months* - While a **10% weight loss** is significant, the **1-2 month** timeframe is generally considered slightly too short to immediately classify it as "requiring medical evaluation" in the strictest sense compared to the 2-3 month period which allows for better observation. - Rapid weight loss over a very short period might sometimes be related to acute illness or dehydration rather than chronic underlying conditions, though still warrants attention.
Question 80: Hepatic Encephalopathy is predisposed by all, Except:
- A. Constipation
- B. GI Bleeding
- C. Dehydration
- D. Hyperkalemia (Correct Answer)
Explanation: ***Hyperkalemia*** - **Hyperkalemia** is not a known trigger for hepatic encephalopathy; in fact, **hypokalemia** is a more common electrolyte disturbance that can precipitate it due to its effect on renal ammonia excretion. - Electrolyte imbalances that contribute to hepatic encephalopathy usually involve **hypokalemia**, **hyponatremia**, or **alkalosis**, which affect **ammonia metabolism** and neuronal excitability [1]. *Dehydration* - **Dehydration** can lead to **reduced renal perfusion**, impairing the kidneys' ability to clear **ammonia** and other toxins, thus increasing their concentration in the blood. - It also contributes to **hemoconcentration**, elevating blood **ammonia levels** and increasing the risk of hepatic encephalopathy [1]. *Constipation* - **Constipation** allows for a longer transit time of stool in the colon, providing more opportunity for **intestinal bacteria** to produce **ammonia** from protein breakdown [1]. - The increased production and absorption of ammonia from the gut contribute significantly to the **nitrogenous load** in the bloodstream, predisposing to hepatic encephalopathy [1]. *GI Bleeding* - **Gastrointestinal bleeding** (GI bleeding) introduces a large protein load (blood) into the GI tract, which is then broken down by bacterial action. - This breakdown generates a significant amount of **ammonia** and other nitrogenous compounds, which are then absorbed into the bloodstream, overwhelming the impaired liver's ability to detoxify them and precipitating hepatic encephalopathy [1].