NEET-PG 2020 - Internal Medicine Practice Questions

Q: Which of the following is commonly seen in Pituitary apoplexy?

Headache. ***Headache*** - **Severe headache** is the most common symptom of pituitary apoplexy, resulting from the sudden expansion of a pituitary mass due to hemorrhage or infarction [1]. - The rapid increase in pressure within the sella turcica, especially on the **dura mater**, causes intense pain. *Hypertension* - While stress can elevate blood pressure, **hypertension** is not a characteristic or direct symptom of acute pituitary apoplexy itself. - Instead, the condition often leads to **adrenal insufficiency**, which is associated with hypotension [1]. *Hypotension* - **Hypotension** is a common and serious manifestation of pituitary apoplexy, often due to acute **adrenal insufficiency** caused by the destruction of ACTH-producing cells [1]. - Reduced ACTH leads to decreased cortisol production, impairing vascular tone and fluid balance. *Vomiting* - **Vomiting** is a common symptom in pituitary apoplexy, often accompanying the severe headache. - It results from the increased **intracranial pressure** and irritation of pathways in the brainstem.

Q: Which of the following statements regarding Huntington’s chorea is true?

It is a trinucleotide repeat expansion type of disorder. ***It is a trinucleotide repeat expansion type of disorder*** - Huntington's chorea is caused by an expansion of a **CAG trinucleotide repeat** in the **huntingtin gene (HTT)**. - This expansion leads to a misfolded protein and an **autosomal dominant** neurodegenerative disorder [1]. *There is a loss of function type of mutation.* - Huntington's chorea is primarily a **gain-of-function** mutation, where the expanded polyglutamine tract in the huntingtin protein leads to **toxic protein aggregation** and neuronal dysfunction. - While there might be some aspects of altered protein function, the core pathology is attributed to the **toxic effects** of the abnormal protein rather than a simple loss of its original function [1]. *It is an autosomal recessive disorder.* - Huntington's chorea is an **autosomal dominant** disorder, meaning only one copy of the mutated gene is sufficient to cause the disease. - Each child of an affected parent has a **50% chance** of inheriting the disease. *Increased number of CAA repeats.* - Huntington's chorea is characterized by an increased number of **CAG trinucleotide repeats**, not CAA repeats. - The expansion of these CAG repeats beyond a certain threshold (typically >35-40 repeats) in the huntingtin gene is directly responsible for the disease.

Q: A young man met with a motorbike accident and had injuries to ileum and jejunum. Therefore the entire ileum and partial jejunum were resected. Which of the following would the patient suffer from

Vitamin B12 malabsorption due to ileal resection. **Vitamin B12 malabsorption due to ileal resection** - The **terminal ileum** is the primary site for the absorption of **vitamin B12** (cobalamin) complexed with intrinsic factor [3]. - Its resection would directly lead to the inability to absorb this vitamin, resulting in **B12 deficiency** and associated symptoms like macrocytic anemia [3]. *Atrophic gastritis unrelated to resection* - **Atrophic gastritis** is a chronic inflammatory condition of the stomach lining leading to loss of glandular tissue and often impaired production of **intrinsic factor**. - While it can cause B12 malabsorption, it is an independent condition and not a direct consequence of ileum and jejunum resection. *Constipation due to dietary changes* - Resection of the ileum and jejunum primarily impacts **nutrient absorption** and can lead to diarrhea due or **short bowel syndrome** [1], rather than constipation. - While diet changes can affect bowel habits, prolonged **severe gastrointestinal resection** is more likely to cause malabsorption-related diarrhea [1], [2]. *No significant symptoms* - The **ileum** and **jejunum** are crucial for the absorption of most nutrients, including vitamins, minerals, fats, and carbohydrates [4]. - Resection of these segments, especially a significant portion, would lead to **malabsorption syndromes** with various severe symptoms, potentially including weight loss, diarrhea, and nutritional deficiencies [1], [4].

Q: MC location of gastrinoma in MEN-1 syndrome?

Duodenum. ***Duodenum*** - In **MEN-1 syndrome**, gastrinomas are most commonly located in the **duodenum**, typically presenting as **multiple small submucosal tumors**. - These duodenal gastrinomas in MEN-1 are characteristically **numerous and tiny**, often difficult to detect during surgery. *Jejunum* - The jejunum is an **uncommon location** for gastrinomas in both sporadic cases and MEN-1 syndrome. - Gastrinomas in the jejunum are typically **rare** and not associated with the characteristic presentation of MEN-1. *Ileum* - The ileum is an **extremely rare site** for gastrinomas in any context. - Gastrinomas developing in the ileum are usually **ectopic** and are not part of the typical MEN-1 syndrome presentation. *Pancreas* - While pancreatic gastrinomas can occur in **MEN-1**, they are **less common** than duodenal gastrinomas in this syndrome. - In **sporadic gastrinomas**, the pancreas is relatively more involved compared to MEN-1, where duodenal predominance is more pronounced.

Q: A female patient has been on lithium for bipolar disorder for 6 months. After fasting for several days due to religious reasons, she presents with seizures, tremors, confusion, and weakness. What is the most appropriate investigation to diagnose her condition?

Serum lithium levels. **Serum lithium levels** - The patient's symptoms (seizures, tremors, confusion, weakness) are classic for **lithium toxicity**. - **Fasting** can lead to dehydration and electrolyte imbalance, which can increase lithium concentrations and toxicity [1]. *Serum electrolytes* - While **electrolyte imbalances** can occur with fasting and contribute to symptoms, measuring serum electrolytes alone will not directly diagnose lithium toxicity. - Electrolyte disturbances might be a predisposing factor or a concomitant issue, but not the primary diagnostic test for lithium toxicity itself [1]. *ECG* - An **ECG** can reveal cardiac effects of lithium toxicity, such as T-wave flattening or inversion, but it is not the most appropriate direct diagnostic test for the condition itself. - ECG changes are secondary manifestations and may not always be present or specific. *MRI* - While an **MRI** of the brain might be considered to rule out other causes of neurological symptoms like a stroke or brain lesion, it is not the initial or most appropriate investigation for suspected lithium toxicity. - The clinical picture strongly points to a pharmacological cause, making laboratory tests more relevant first-line diagnostics than imaging.

Q: Esophageal manometry was performed - it revealed panesophageal pressurization with distal contractile integrity as >450mm Hg pressure in the body. What will be the diagnosis?

Type 3 achalasia. The diagnosis is Type 3 achalasia. This condition is characterized by panesophageal pressurization, indicating diffuse, simultaneous contractions throughout the esophagus. The high distal contractile integrity (>450 mmHg pressure) further supports Type 3 achalasia, which involves significant spastic contractions. In contrast, while high-resolution manometry allows for the accurate classification of these motility abnormalities [1], other types present differently. Type 1 achalasia (classic achalasia) is marked by failed esophageal peristalsis and absent or minimal esophageal pressurization [1]. The primary characteristic is incomplete or absent lower esophageal sphincter (LES) relaxation, not hypercontractility [1]. Type 2 achalasia is identified by esophageal panesophageal pressurization (simultaneous contractions), but with normal to high contractile pressures, not the extremely high values seen here. Jackhammer esophagus involves hypercontractility (distal contractile integral >8000 mmHg·cm·s) and is characterized by rapid, repetitive, and fragmented contractions, rather than the diffuse panesophageal pressurization and spasticity typical of Type 3 achalasia [2].

Q: The patient presents with unilateral proptosis and bilateral abducent nerve palsy. What is the most likely cause?

Cavernous sinus pathology. The patient presents with unilateral proptosis and bilateral abducent nerve palsy. What is the most likely cause? ***Cavernous sinus pathology*** - **Unilateral proptosis** combined with **bilateral abducens nerve palsy** is a classic presentation consistent with cavernous sinus involvement, as the abducens nerves (CN VI) pass through both cavernous sinuses and are vulnerable to pathology there. [1] - The cavernous sinus contains multiple cranial nerves (**III, IV, V1, V2, VI**) and the internal carotid artery, making it a critical anatomical location where lesions can cause complex neurological deficits affecting orbital structures and eye movements. [1] *Orbital cellulitis* - Typically presents with **unilateral proptosis**, pain, eyelid swelling, and fever, often following a sinus infection. - It primarily affects the **orbital contents anterior to the orbital septum** and would not explain bilateral abducens nerve palsy. *Orbital pseudotumor* - Characterized by **unilateral proptosis**, pain, and diplopia due to idiopathic inflammation of orbital tissues. - While it can cause ophthalmoplegia, **bilateral abducens nerve palsy** is not a typical presentation for a condition usually confined to one orbit. *Orbital lymphoma* - Presents with **painless, slowly progressive unilateral proptosis** or an orbital mass. - While it can cause compressive symptoms, **bilateral abducens nerve palsy** is an atypical presentation as the disease usually remains confined to a single orbit.

Q: A Patient falls down often with behavioral change and enuresis. What is the condition associated with him?

Normal pressure hydrocephalus (NPH). ***Normal pressure hydrocephalus (NPH)*** - NPH is characterized by the classic triad of symptoms: **gait disturbance** (leading to falls), **dementia/behavioral changes**, and **urinary incontinence** (enuresis) [1]. - These symptoms arise from the accumulation of cerebrospinal fluid (CSF) in the brain's ventricles without a corresponding increase in intracranial pressure [2]. *Parkinson's disease (PD)* - While PD causes **gait instability** and falls, its primary symptoms include **bradykinesia**, **rigidity**, and **resting tremor**, which are not mentioned. - Behavioral changes can occur later in the disease, but **enuresis** is not a hallmark symptom. *Alzheimer's disease (AD)* - AD primarily presents with **progressive memory loss** and cognitive decline, not gait disturbances or enuresis as early or prominent features. - Falls usually occur much later due to advanced cognitive impairment and not as an initial triad component. *Frontotemporal dementia (FTD)* - FTD is characterized by early and prominent **behavioral and personality changes** or language difficulties. - While falls can occur due to executive dysfunction, **gait disturbance** and **enuresis** as part of a triad are not typical presenting features.

Q: Which is the most common pancreatic endocrine neoplasm?

Insulinoma. ***Insulinoma*** - It is the **most common pancreatic endocrine neoplasm**, characterized by excessive insulin production leading to hypoglycemia. - Most patients present with **symptoms of hypoglycemia**, such as sweating, confusion, and palpitations due to overproduction of insulin [1]. *Gastrinoma* - Generally implicated in **Zollinger-Ellison syndrome**, it causes excessive gastric acid secretion, leading to severe ulcers but is less common than insulinoma. - Associated with **diarrhea and abdominal pain**, not typically causing hypoglycemia [1]. *Glucagonoma* - Rarely seen, it causes **hyperglycemia** and characteristic **necrotizing migratory erythema**, rather than hypoglycemic episodes. - Comprises a minority of pancreatic endocrine tumors and is not the most common type. *VIPoma* - Produces **vasoactive intestinal peptide**, leading to profuse watery diarrhea and severe electrolyte imbalance. - It is uncommon compared to insulinoma and primarily causes gastrointestinal symptoms rather than hypoglycemia.

Question 1

Which of the following is commonly seen in Pituitary apoplexy?

Accepted Answer

Headache

Answer

Hypertension

Answer

Hypotension

Answer

Vomiting

Question 2

What is the cause of loss of pain and temperature sensation on the ipsilateral face and contralateral body due to thrombosis?

Accepted Answer

Thrombosis of the posterior inferior cerebellar artery (PICA)

Answer

Thrombosis of the superior cerebellar artery

Answer

Thrombosis of the anterior inferior cerebellar artery (AICA)

Answer

Thrombosis of the posterior cerebral artery

Question 3

Which of the following statements regarding Huntington’s chorea is true?

Accepted Answer

It is a trinucleotide repeat expansion type of disorder

Answer

There is a loss of function type of mutation.

Answer

It is an autosomal recessive disorder.

Answer

Increased number of CAA repeats.

Question 4

A young man met with a motorbike accident and had injuries to ileum and jejunum. Therefore the entire ileum and partial jejunum were resected. Which of the following would the patient suffer from

Accepted Answer

Vitamin B12 malabsorption due to ileal resection

Answer

Atrophic gastritis unrelated to resection

Answer

Constipation due to dietary changes

Answer

No significant symptoms

Question 5

MC location of gastrinoma in MEN-1 syndrome?

Accepted Answer

Duodenum

Answer

Jejunum

Answer

Ileum

Answer

Pancreas

Question 6

A female patient has been on lithium for bipolar disorder for 6 months. After fasting for several days due to religious reasons, she presents with seizures, tremors, confusion, and weakness. What is the most appropriate investigation to diagnose her condition?

Accepted Answer

Serum lithium levels

Answer

Serum electrolytes

Answer

ECG

Answer

MRI

Question 7

Esophageal manometry was performed - it revealed panesophageal pressurization with distal contractile integrity as >450mm Hg pressure in the body. What will be the diagnosis?

Accepted Answer

Type 3 achalasia

Answer

Type 2 achalasia

Answer

Jackhammer esophagus

Answer

Type 1 achalasia (classic achalasia)

Question 8

The patient presents with unilateral proptosis and bilateral abducent nerve palsy. What is the most likely cause?

Accepted Answer

Cavernous sinus pathology

Answer

Orbital cellulitis

Answer

Orbital pseudotumor

Answer

Orbital lymphoma

Question 9

A Patient falls down often with behavioral change and enuresis. What is the condition associated with him?

Accepted Answer

Normal pressure hydrocephalus (NPH)

Answer

Parkinson's disease (PD)

Answer

Alzheimer's disease (AD)

Answer

Frontotemporal dementia (FTD)

Question 10

Which is the most common pancreatic endocrine neoplasm?

Accepted Answer

Insulinoma

Answer

Gastrinoma

Answer

VIPoma

Answer

Glucagonoma

NEET-PG 2020 — Internal Medicine