NEET-PG 2019 - Internal Medicine Practice Questions

Q: Patient with ascending paralysis, areflexia and sphincter sparing is seen in?

G.B.S. **G.B.S** - **Guillain-Barré Syndrome (GBS)** is characterized by **ascending paralysis** and **areflexia**, meaning loss of deep tendon reflexes [1]. - **Sphincter sparing** is also typical in GBS, differentiating it from other causes of paralysis where autonomic involvement can lead to bladder and bowel dysfunction [1]. *Botulism* - Botulism typically presents with **descending paralysis**, weakness starting in the cranial nerves and progressing downwards. - While it causes significant muscle weakness and can lead to **areflexia**, the pattern of paralysis (descending vs. ascending) and the presence of prominent cranial nerve involvement help distinguish it. *Snake bite* - Neurotoxic snake bites can cause **flaccid paralysis** and **areflexia**, but the paralysis often starts at the site of the bite or affects cranial nerves preferentially before generalized ascending paralysis. - The history of a **snake bite** and presence of **local envenomation signs** (swelling, pain) would also be prominent. *Polio* - Polio primarily causes **asymmetric flaccid paralysis** and **areflexia**, due to the destruction of anterior horn cells in the spinal cord. - Unlike GBS, polio does not typically present with an ascending pattern affecting both sides symmetrically and often involves sensory sparing.

Q: Not an AIDS defining illness?

Tertiary Syphilis. ***Tertiary Syphilis*** - While a serious late-stage manifestation of **syphilis**, it is not specifically listed as an **AIDS-defining illness** by the CDC, although HIV-positive individuals may be more susceptible to its complications [1]. - **Neurosyphilis**, a form of tertiary syphilis affecting the central nervous system, is also not an AIDS-defining condition on its own, unlike some other opportunistic infections [1]. *Progressive multifocal leukoencephalopathy (PML)* - PML, caused by the **JC virus**, is an **AIDS-defining illness** characterized by the progressive destruction of myelin in the brain, leading to severe neurological deficits. - It occurs almost exclusively in individuals with severe **immunodeficiency**, such as those with untreated HIV infection. *Lymphoma of brain < 60 years of age* - **Primary central nervous system (CNS) lymphoma** in individuals with HIV, especially those under 60 years of age, is an **AIDS-defining condition** [2]. - Its occurrence is strongly linked to severe immunosuppression in HIV-infected patients [2]. *Extrapulmonary Cryptococcosis* - **Cryptococcosis**, when it affects sites outside the lungs (e.g., **cryptococcal meningitis**), is an **AIDS-defining illness**. - This fungal infection is a common opportunistic infection in individuals with advanced HIV disease.

Q: Which of the following is not an AIDS defining illness?

Hodgkin's lymphoma. ***Hodgkin's lymphoma*** - While patients with HIV are at an increased risk of developing **Hodgkin's lymphoma**, it is not officially classified as an **AIDS-defining illness** by the CDC [3]. - AIDS-defining conditions primarily include certain opportunistic infections and specific malignancies [4]. *Cervical cancer* - **Invasive cervical cancer** is an AIDS-defining illness in HIV-positive women, indicating severe immunosuppression [4]. - This is because HIV infection can accelerate or worsen the progression of **HPV-related cervical dysplasia** to invasive cancer [4]. *Primary CNS lymphoma* - **Primary CNS lymphoma** (brain lymphoma) is an AIDS-defining illness, particularly when associated with **Epstein-Barr virus** [2]. - Its presence indicates a significant degree of **immunodeficiency** in HIV-infected individuals. *Kaposi sarcoma* - **Kaposi sarcoma** is a well-known and common AIDS-defining malignancy, caused by **Human Herpesvirus 8 (HHV-8)** [1]. - It presents as vascular lesions on the skin, mucous membranes, internal organs, and lymph nodes [1].

Q: Which of the following is the best treatment for refractory ITP?

Splenectomy. ***Splenectomy*** - **Splenectomy** is considered the most effective treatment for **refractory immune thrombocytopenic purpura (ITP)**, especially in patients who have failed multiple lines of medical therapy [1]. - The spleen is the primary site of **platelet destruction** and **antibody production** against platelets in ITP, so its removal can lead to a sustained increase in platelet count [1]. *Platelet transfusion* - While platelet transfusions can temporarily increase platelet counts, they are generally reserved for **acute, life-threatening bleeding** in ITP, not as a definitive treatment for refractory cases. - Transfused platelets are rapidly destroyed by the same **autoantibodies** that target endogenous platelets, making their effect short-lived. *Azathioprine* - **Azathioprine** is an **immunosuppressant** that can be used in ITP, but it is typically a **second-line** or **third-line agent** and its response takes time [1]. - It is not considered the "best" treatment for refractory ITP compared to splenectomy, which offers a more immediate and often sustained response [1]. *Prednisolone* - **Prednisolone** (corticosteroids) is often the **first-line treatment** for ITP due to its rapid immunosuppressive effects. - However, for **refractory ITP** (meaning it has not responded adequately to initial treatments), corticosteroids alone are usually insufficient to achieve long-term remission [1].

Q: A patient with rheumatoid arthritis on Methotrexate, steroids and NSAIDs for past 4 months has had no retardation of disease progression. What is the next rational step in management?

Add Sulfasalazine. Focus on **Add Sulfasalazine**: - Since the patient has not responded to **Methotrexate** alone, adding a second conventional synthetic **disease-modifying antirheumatic drug (DMARD)** like **Sulfasalazine** is a common and appropriate step in a **treat-to-target strategy** for rheumatoid arthritis [1]. - This approach aims to achieve **disease remission** or **low disease activity** by combining therapies to enhance efficacy. *Continue Methotrexate and steroids at higher dose* - Increasing the dose of **Methotrexate** might be considered if the current dose is sub-optimal, but after 4 months with no improvement, simply continuing current medications at higher doses without adding another agent is less likely to significantly alter **disease progression** [1]. - Prolonged higher-dose **steroids** carry significant risks and are generally used for symptom control, not primary disease modification. *Stop oral Methotrexate and start parenteral Methotrexate* - Switching to **parenteral Methotrexate** is considered if **oral Methotrexate** absorption is an issue or if the patient experiences gastrointestinal side effects [1]. - While parenteral administration can improve bioavailability, it doesn't represent a change in therapeutic strategy for **uncontrolled disease activity**. *Start treatment with anti-TNF alpha drugs* - **Biologic DMARDs** like **anti-TNF alpha drugs** are typically reserved for patients who have failed **two or more conventional synthetic DMARDs**, including **Methotrexate**, or in cases of severe, rapidly progressing disease [2]. - While effective, they are more expensive and have different side effect profiles, making them a later-line treatment in the management algorithm [2].

Q: A man who is chronic alcoholic will develop which type of cardiomyopathy?

Dilated cardiomyopathy. ***Dilated cardiomyopathy*** - Chronic alcohol abuse is a major cause of **dilated cardiomyopathy**, where the heart's pumping chambers (ventricles) become enlarged and weakened, leading to reduced cardiac output [1]. - This condition often called **alcoholic cardiomyopathy**, is characterized by **ventricular dilation** and **systolic dysfunction**. *Hypertrophic cardiomyopathy* - This condition involves thickening of the heart muscle, often genetic, and is not directly caused by **chronic alcoholism**. - While alcohol can worsen pre-existing heart conditions, it does not typically lead to primary **hypertrophic cardiomyopathy**. *Myocarditis* - **Myocarditis** is an inflammation of the heart muscle, usually caused by viral infections or autoimmune processes. - Although heavy alcohol use can weaken the immune system, it is not a direct cause of viral or primary inflammatory myocarditis. *Pericarditis* - **Pericarditis** is the inflammation of the pericardium, the sac surrounding the heart, most commonly due to viral infections or autoimmune conditions. - While alcohol abuse can have various systemic effects, it is not a recognized direct cause of **pericarditis**.

Q: Which of the following is autosomal dominant in inheritance?

Achondroplasia. ***Achondroplasia*** - This condition is inherited in an **autosomal dominant** pattern, meaning only one copy of the mutated gene is needed to cause the disorder. - It is caused by a mutation in the **FGFR3 gene**, leading to abnormal bone growth and short-limbed dwarfism [1]. *Hemochromatosis* - This condition is primarily inherited in an **autosomal recessive** pattern, meaning two copies of the mutated gene (HFE gene) are required for the disease to manifest. - It leads to excessive iron absorption and organ damage. *Sickle cell disease* - This is an **autosomal recessive** disordertoo. - It results from a mutation in the **HBB gene**, affecting hemoglobin and causing red blood cells to become sickle-shaped. *Wiskott Aldrich syndrome* - This is an **X-linked recessive** disorder, meaning it primarily affects males. - It involves mutations in the **WAS gene**, leading to immunodeficiency, eczema, and thrombocytopenia.

Q: HIV patient presented with diarrhea. On stool examination, acid-fast organisms (Isospora belli) were seen. What is the drug of choice in this patient?

TMP-SMX. ***TMP-SMX*** - **Trimethoprim-sulfamethoxazole (TMP-SMX)** is the primary treatment for **Isospora belli** infections, especially in HIV-positive patients [1]. - It is highly effective in eradicating the parasite and preventing relapses in immunocompromised individuals [1]. *Niclosamide* - **Niclosamide** is an antihelminthic drug primarily used for treating **tapeworm infections** [2]. - It is not effective against protozoal parasites like *Isospora belli*. *Nitazoxanide* - **Nitazoxanide** is an antiparasitic drug that can be used for various protozoal and helminthic infections, including *Cryptosporidium* and *Giardia*. - While it has some efficacy against *Isospora belli*, it is generally considered a second-line agent, with **TMP-SMX** being the drug of choice [1]. *Primaquine* - **Primaquine** is an antimalarial drug specifically used to prevent relapse of **Plasmodium vivax** and **Plasmodium ovale** malaria by targeting hypnozoites. - It has no role in the treatment of **Isospora belli** infection.

Q: Risk factors for Alzheimer's include:-

Down's syndrome. ***Down's syndrome*** - Individuals with **Down's syndrome** have an extra copy of chromosome 21, which includes the **amyloid precursor protein (APP) gene**. - Overexpression of APP leads to increased production of **beta-amyloid plaques**, a hallmark pathology of Alzheimer's disease. *Parkinson's disease* - Parkinson's disease is a **neurodegenerative disorder** characterized by motor symptoms due to loss of dopaminergic neurons. - While it can be associated with **dementia (Parkinson's disease dementia)**, it is a distinct condition with different primary pathological mechanisms (alpha-synucleinopathy). *Vascular dementia* - **Vascular dementia** is caused by brain damage from conditions that impair blood flow to the brain, such as strokes or small vessel disease. - It is a **different type of dementia** with distinct etiology and neuropathology compared to Alzheimer's disease. *Huntington's disease* - **Huntington's disease** is a genetic neurodegenerative disorder characterized by involuntary movements (**chorea**), cognitive decline, and psychiatric problems. - It is caused by a mutation in the **Huntingtin gene** and has a specific pathological course unrelated to Alzheimer's.

Q: Which chamber of the heart is enlarged first in a patient with mitral stenosis?

Left atrium. ***Left atrium*** - **Mitral stenosis** obstructs blood flow from the left atrium to the left ventricle, leading to a build-up of pressure in the left atrium [1]. - This chronic pressure overload causes the **left atrium to dilate and hypertrophy** in an attempt to pump blood through the narrowed valve [1]. *Left ventricle* - In **mitral stenosis**, the left ventricle typically receives a reduced volume of blood, leading to a **smaller, underfilled left ventricle**, rather than enlargement. - Its workload is decreased due to reduced preload, so it does not hypertrophy or dilate primarily. *Right ventricle* - **Right ventricular enlargement** can eventually occur in severe and chronic mitral stenosis due to **pulmonary hypertension** caused by back pressure from the left atrium, but it is not the *first* chamber to be affected [1], [2]. - Increased pressure in the pulmonary circulation increases the workload on the right ventricle, leading to hypertrophy and dilation over time [1], [2]. *Right atrium* - **Right atrial enlargement** is a consequence of chronic and severe pulmonary hypertension affecting the right ventricle, which then causes back pressure into the right atrium [1]. - This is a very late manifestation of mitral stenosis, occurring after significant involvement of the left atrium and pulmonary vasculature.

Question 1

Patient with ascending paralysis, areflexia and sphincter sparing is seen in?

Accepted Answer

G.B.S

Answer

Botulinism

Answer

Snake bite

Answer

Polio

Question 2

Not an AIDS defining illness?

Accepted Answer

Tertiary Syphilis

Answer

Progressive multifocal leukoencephalopathy

Answer

Lymphoma of brain < 60 years of age

Answer

Extrapulmonary Cryptococcosis

Question 3

Which of the following is not an AIDS defining illness?

Accepted Answer

Hodgkin's lymphoma

Answer

Cervical cancer

Answer

Primary CNS lymphoma

Answer

Kaposi sarcoma

Question 4

Which of the following is the best treatment for refractory ITP?

Accepted Answer

Splenectomy

Answer

Platelet transfusion

Answer

Azathioprine

Answer

Prednisolone

Question 5

A patient with rheumatoid arthritis on Methotrexate, steroids and NSAIDs for past 4 months has had no retardation of disease progression. What is the next rational step in management?

Accepted Answer

Add Sulfasalazine

Answer

Continue Methotrexate and steroids at higher dose

Answer

Stop oral Methotrexate and start parenteral Methotrexate

Answer

Start treatment with anti-TNF alpha drugs

Question 6

A man who is chronic alcoholic will develop which type of cardiomyopathy?

Accepted Answer

Dilated cardiomyopathy

Answer

Hypertrophic cardiomyopathy

Answer

Myocarditis

Answer

Pericarditis

Question 7

Which of the following is autosomal dominant in inheritance?

Accepted Answer

Achondroplasia

Answer

Hemochromatosis

Answer

Sickle cell disease

Answer

Wiskott Aldrich syndrome

Question 8

HIV patient presented with diarrhea. On stool examination, acid-fast organisms (Isospora belli) were seen. What is the drug of choice in this patient?

Accepted Answer

TMP-SMX

Answer

Niclosamide

Answer

Nitazoxanide

Answer

Primaquine

Question 9

Risk factors for Alzheimer's include:-

Accepted Answer

Down's syndrome

Answer

Parkinson's disease

Answer

Vascular dementia

Answer

Huntington's disease

Question 10

Which chamber of the heart is enlarged first in a patient with mitral stenosis?

Accepted Answer

Left atrium

Answer

Left ventricle

Answer

Right ventricle

Answer

Right atrium

NEET-PG 2019 — Internal Medicine