Internal Medicine
9 questionsMatch the following ECG findings (1-4) with their corresponding arrhythmias (A-D): 1. Sawtooth pattern in leads II, III, aVF with regular ventricular response 2. Irregularly irregular rhythm with absent P waves 3. Narrow QRS tachycardia with abrupt onset/termination 4. Wide QRS tachycardia with AV dissociation A. Atrial fibrillation B. PSVT (Paroxysmal Supraventricular Tachycardia) C. Atrial flutter D. Ventricular tachycardia What is the correct matching?
A patient presents with shortness of breath. Vitals are HR = 120/min with BP = 90/60 mm Hg. Echocardiography shows diastolic collapse of the ventricles. What is the best management for this patient?
A patient is pulseless with the following rhythm shown in the ECG. What is the next best step in management?
A hypertensive patient presents with an irregularly irregular pulse and a loud P2 on auscultation. Which JVP finding is likely to be seen in this patient?
A 60-year-old lady presents with shortness of breath (SOB) and episodes of angina pectoris. Work-up reveals aortic stenosis. Which of the following is the most likely reason behind these chest pain episodes?
A 15-year-old patient presents with joint swelling, a pan-systolic murmur, negative rheumatoid factor (RF), and elevated ESR. The patient also reports a recent history of sore throat and exhibits subcutaneous nodules and erythema marginatum on physical examination. What is the most likely diagnosis?
A patient presents with wheezing that improves with as-needed use of albuterol. Spirometry shows FEV1 ranging from 70 % to 83 %, and the patient experiences nighttime chest tightening twice a week. What is the most appropriate treatment?
A farmer presents with severe leg pain, fever, chills, retro-orbital pain, and bilateral conjunctival suffusion. What is the most likely diagnosis?
A patient presents with hypotension, hyponatremia, and blackening of the palmar creases. Which of the following conditions is most likely associated with these symptoms?
NEET-PG 2024 - Internal Medicine NEET-PG Practice Questions and MCQs
Question 21: Match the following ECG findings (1-4) with their corresponding arrhythmias (A-D): 1. Sawtooth pattern in leads II, III, aVF with regular ventricular response 2. Irregularly irregular rhythm with absent P waves 3. Narrow QRS tachycardia with abrupt onset/termination 4. Wide QRS tachycardia with AV dissociation A. Atrial fibrillation B. PSVT (Paroxysmal Supraventricular Tachycardia) C. Atrial flutter D. Ventricular tachycardia What is the correct matching?
- A. A-2, B-1, C-3, D-4
- B. A-1, B-2, C-4, D-3
- C. A-2, B-3, C-1, D-4 (Correct Answer)
- D. A-4, B-3, C-2, D-1
- E. A-1, B-2, C-3, D-4
Explanation: The correct matching is **A-2, B-3, C-1, D-4**: ***C-1: Atrial flutter - Sawtooth pattern*** - Atrial flutter is characterized by a **sawtooth pattern** of flutter waves, particularly prominent in leads II, III, and aVF - Represents rapid, organized atrial depolarization at 250-350 bpm - Regular ventricular response due to **AV block** (commonly 2:1 or 4:1) - The sawtooth pattern is the pathognomonic feature ***A-2: Atrial fibrillation - Irregularly irregular rhythm*** - Identified by an **irregularly irregular rhythm** with absent distinct P waves - Replaced by chaotic fibrillatory waves showing disorganized atrial activity - Ventricular rate is rapid and unpredictable - No organized atrial pattern unlike the regular flutter waves ***B-3: PSVT - Narrow QRS with abrupt onset/termination*** - Presents with **narrow QRS complex tachycardia** (QRS < 0.12 seconds) with regular rhythm - Atrial rate usually 150-250 bpm - **Abrupt onset and termination** is the characteristic feature differentiating it from other supraventricular arrhythmias - P waves may be hidden within or immediately after QRS complexes ***D-4: Ventricular tachycardia - Wide QRS with AV dissociation*** - Defined by **wide QRS complex tachycardia** (QRS > 0.12 seconds) - **AV dissociation** is a key diagnostic feature showing independent atrial and ventricular activity - Originates from ventricular tissue, not supraventricular structures - Lacks the organized P wave patterns seen in atrial arrhythmias
Question 22: A patient presents with shortness of breath. Vitals are HR = 120/min with BP = 90/60 mm Hg. Echocardiography shows diastolic collapse of the ventricles. What is the best management for this patient?
- A. Start diuretic with BP monitoring
- B. Intra-aortic balloon pump
- C. Pericardiocentesis (Correct Answer)
- D. Ventricular assist device
Explanation: **Pericardiocentesis** * The constellation of **tachycardia**, **hypotension**, and **diastolic collapse of the ventricles** on echocardiography is highly suggestive of **cardiac tamponade**, a life-threatening condition [1]. * **Pericardiocentesis** is the definitive treatment for cardiac tamponade, as it relieves the pressure on the heart by draining the pericardial fluid, thereby restoring cardiac output and improving hemodynamics [1]. * *Start diuretic with BP monitoring* * Administering **diuretics** would further decrease intravascular volume and worsen already compromised cardiac output in the setting of hypotension due to cardiac tamponade. * While **blood pressure monitoring** is essential, diuretics are contraindicated and would exacerbate the patient's hemodynamic instability. * *Intra-aortic balloon pump* * An **intra-aortic balloon pump (IABP)** primarily assists in improving **coronary perfusion** and reducing **afterload** in conditions like cardiogenic shock or severe heart failure. * An IABP does not address the fundamental problem of external compression of the heart in cardiac tamponade and would not relieve the diagnostic finding of diastolic collapse of the ventricles. * *Ventricular assist device* * A **ventricular assist device (VAD)** is used to support failing ventricles by pumping blood from the heart to the rest of the body, typically in cases of advanced heart failure. * A VAD does not resolve the external compression on the heart caused by pericardial fluid in cardiac tamponade and is an invasive measure not indicated as a primary treatment in this scenario.
Question 23: A patient is pulseless with the following rhythm shown in the ECG. What is the next best step in management?
- A. Defibrillate and continue chest compression (Correct Answer)
- B. Defibrillate and check pulse
- C. Check pulse and give synchronized DC
- D. Give synchronized DC and continue chest compressions
- E. Start chest compressions and give epinephrine
Explanation: ***Defibrillate and continue chest compression*** - This scenario describes a **pulseless ventricular tachycardia (pVT)**, which is a **shockable rhythm**. - Immediate defibrillation is crucial, followed by resuming **chest compressions** without delay, as per advanced cardiac life support (ACLS) guidelines. - The correct sequence is: shock → immediate CPR for 2 minutes → rhythm/pulse check. *Defibrillate and check pulse* - While defibrillation is the correct initial intervention for a shockable rhythm, checking the pulse immediately after is incorrect. - Chest compressions should be resumed immediately after a shock for 2 minutes before stopping to check a pulse. - Minimizing interruptions in chest compressions is critical for survival. *Check pulse and give synchronized DC* - Checking a pulse before any intervention wastes critical time in a pulseless patient with a shockable rhythm; immediate defibrillation is indicated. - Synchronized direct current (DC) cardioversion is used for unstable patients **with a pulse** (e.g., unstable ventricular tachycardia with a pulse), not for pulseless rhythms. *Give synchronized DC and continue chest compressions* - Synchronized DC cardioversion is inappropriate for a **pulseless rhythm**; unsynchronized defibrillation is required. - Synchronization requires an R wave to time the shock, which is not feasible in pulseless VT management. *Start chest compressions and give epinephrine* - While chest compressions are essential, the **immediate priority** for a shockable rhythm (pVT/VF) is **defibrillation**. - Epinephrine is given during CPR cycles (after the first shock), but defibrillation must come first for shockable rhythms. - This would be the approach for **non-shockable rhythms** (PEA/asystole), not pulseless VT.
Question 24: A hypertensive patient presents with an irregularly irregular pulse and a loud P2 on auscultation. Which JVP finding is likely to be seen in this patient?
- A. Absent a wave (Correct Answer)
- B. Cannon a wave
- C. Rapid $x$ descent
- D. Rapid $y$ descent
- E. Prominent v wave
Explanation: ***Absent a wave*** - An **irregularly irregular pulse** and **loud P2** suggest **atrial fibrillation** with **pulmonary hypertension**. In atrial fibrillation, there is chaotic atrial activity, meaning the atria do not contract in a coordinated fashion. - The **"a" wave** on the JVP tracing represents **atrial contraction**. Since the atria are fibrillating and not contracting effectively, the normal "a" wave will be absent. *Cannon a wave* - **Cannon a waves** occur when the **right atrium contracts against a closed tricuspid valve**, such as during **ventricular tachycardia** or **complete heart block** (AV dissociation). - This patient's irregularly irregular pulse suggests **atrial fibrillation**, not a condition typically associated with cannon a waves. *Rapid $x$ descent* - A **rapid x descent** primarily reflects **atrial relaxation** and **right ventricular systole**, which pulls the tricuspid annulus downwards. - While a rapid x descent can be seen in various conditions, it is not the most specific JVP finding for the described clinical picture, which points strongly to absent atrial contraction. *Rapid $y$ descent* - A **rapid y descent** signifies rapid filling of the right ventricle during early diastole, often associated with a **compliant right ventricle** and unobstructed tricuspid inflow. It can be prominent in conditions like **constrictive pericarditis** or **restrictive cardiomyopathy**. - This finding is not directly or specifically linked to the irregularly irregular pulse and absent atrial contraction seen in atrial fibrillation. *Prominent v wave* - A **prominent v wave** occurs with **tricuspid regurgitation**, where blood regurgitates back into the right atrium during ventricular systole, causing venous distension. - While pulmonary hypertension can eventually lead to right ventricular dysfunction and tricuspid regurgitation, the most characteristic JVP finding for **atrial fibrillation itself** is the **absence of the "a" wave** due to lack of coordinated atrial contraction.
Question 25: A 60-year-old lady presents with shortness of breath (SOB) and episodes of angina pectoris. Work-up reveals aortic stenosis. Which of the following is the most likely reason behind these chest pain episodes?
- A. Increased pressure in aorta
- B. Decreased pressure in aorta
- C. Increased oxygen consumption in the heart (Correct Answer)
- D. Increase in volume overload of the heart
- E. Decreased coronary blood flow
Explanation: ***Increased oxygen consumption in the heart*** - In **aortic stenosis**, the left ventricle must generate significantly higher pressures to eject blood through the narrowed aortic valve, leading to **left ventricular hypertrophy**. This increased workload significantly raises the **myocardial oxygen demand**. - Angina pectoris occurs when this increased oxygen demand surpasses the oxygen supply, leading to **myocardial ischemia**. - This is the **primary mechanism** of angina in aortic stenosis. *Increased pressure in aorta* - While there is **increased pressure within the left ventricle** to overcome the stenotic valve, the pressure in the aorta *distal* to the stenosis is often normal or even slightly reduced due to the obstruction. - Increased aortic pressure itself is not the primary direct cause of angina in aortic stenosis; rather, it's the compensatory ventricular workload. *Decreased pressure in aorta* - A **decreased pressure in the aorta** could actually worsen coronary perfusion, but the primary reason for angina in aortic stenosis is the vastly **increased myocardial demand**, not necessarily a critical drop in aortic pressure. - The elevated left ventricular pressure required to overcome the stenosis is the key factor driving the angina. *Increase in volume overload of the heart* - **Aortic stenosis primarily causes pressure overload**, not volume overload, on the left ventricle due to the obstruction to outflow. - Volume overload typically occurs in conditions like **aortic regurgitation** or **mitral regurgitation**, which have different pathophysiological mechanisms for angina. *Decreased coronary blood flow* - While **decreased coronary perfusion** can be a contributing factor in aortic stenosis (due to reduced aortic pressure and shortened diastolic filling time), it is a **secondary mechanism**. - The **primary cause** of angina in aortic stenosis is the markedly **increased myocardial oxygen demand** from left ventricular hypertrophy and increased workload, rather than a primary reduction in coronary blood flow.
Question 26: A 15-year-old patient presents with joint swelling, a pan-systolic murmur, negative rheumatoid factor (RF), and elevated ESR. The patient also reports a recent history of sore throat and exhibits subcutaneous nodules and erythema marginatum on physical examination. What is the most likely diagnosis?
- A. Acute rheumatic fever (Correct Answer)
- B. Seronegative rheumatoid arthritis
- C. Juvenile idiopathic arthritis
- D. Ankylosing spondylitis
Explanation: **Acute rheumatic fever** - The combination of **joint swelling**, a recent **sore throat**, **pan-systolic murmur** (indicating carditis), **subcutaneous nodules**, and **erythema marginatum** meets the **Jones criteria** for acute rheumatic fever [1]. - An **elevated ESR** is a common inflammatory marker, and a **negative rheumatoid factor** helps differentiate it from other rheumatic conditions. - Carditis often presents with new or changed murmurs, such as a soft systolic murmur due to mitral regurgitation [1]. Acute rheumatic carditis is also a principal cause of valve regurgitation [2]. *Seronegative rheumatoid arthritis* - This typically presents with chronic inflammatory arthritis, but lacks specific features like **carditis** or characteristic skin rashes like **erythema marginatum** and **subcutaneous nodules**. - While it has a negative RF, the acute presentation with a preceding sore throat points away from chronic arthropathy. *Juvenile idiopathic arthritis* - This is a diagnosis of exclusion for chronic arthritis in children under 16, lacking acute rheumatic fever's hallmark cardiac involvement, **subcutaneous nodules**, or **erythema marginatum**. - While it can cause joint swelling and elevated ESR, the constellation of symptoms strongly points to an acute systemic illness. *Ankylosing spondylitis* - This primarily affects the **axial skeleton** (spine and sacroiliac joints) and is characterized by back pain and stiffness, predominantly in young adults. - It does not typically present with a **pan-systolic murmur**, **subcutaneous nodules**, or **erythema marginatum**, and is rarely seen in 15-year-old patients with this acute presentation.
Question 27: A patient presents with wheezing that improves with as-needed use of albuterol. Spirometry shows FEV1 ranging from 70 % to 83 %, and the patient experiences nighttime chest tightening twice a week. What is the most appropriate treatment?
- A. Continue with albuterol
- B. Replace with salmeterol twice daily
- C. Start Tab prednisolone
- D. Add an inhaled corticosteroid (Correct Answer)
- E. Add a leukotriene modifier
Explanation: ***Add an inhaled corticosteroid*** * The patient has persistent asthma as evidenced by symptoms occurring twice a week (nighttime chest tightening), and **FEV1 variability** despite current albuterol use. * Adding a **low-dose inhaled corticosteroid** is the recommended *first-line controller treatment* for persistent asthma to reduce inflammation and prevent exacerbations per **GINA guidelines**. *Continue with albuterol* * Continuing albuterol alone is insufficient for persistent asthma, as it only provides **symptomatic relief** and does not address the underlying inflammation. * This approach would lead to continued symptoms and potential **asthma exacerbations**. *Replace with salmeterol twice daily* * Salmeterol is a **long-acting beta-agonist (LABA)**, and while it provides prolonged bronchodilation, it should never be used as monotherapy in asthma due to the risk of severe exacerbations. * LABAs should always be prescribed in combination with an **inhaled corticosteroid**. *Start Tab prednisolone* * **Oral prednisolone** is a systemic corticosteroid typically reserved for **severe asthma exacerbations** or for patients whose symptoms are not controlled by high-dose inhaled corticosteroids and other controller medications. * It carries more significant **side effects** with long-term use compared to inhaled corticosteroids. *Add a leukotriene modifier* * While **leukotriene receptor antagonists** (e.g., montelukast) can be used as alternative controller therapy for mild persistent asthma, they are considered **less effective** than inhaled corticosteroids. * They are typically reserved as an alternative for patients who cannot use or tolerate inhaled corticosteroids, or as **add-on therapy** in more severe cases.
Question 28: A farmer presents with severe leg pain, fever, chills, retro-orbital pain, and bilateral conjunctival suffusion. What is the most likely diagnosis?
- A. Dengue fever
- B. Leptospirosis (Correct Answer)
- C. Malaria
- D. Rickettsia infection
Explanation: **Leptospirosis** - The combination of **leg pain**, **fever**, chills, **retro-orbital pain**, and **bilateral conjunctival suffusion** (red eyes without frank pus) in a farmer (occupational exposure to contaminated water/soil) is highly suggestive of **leptospirosis** [1]. - **Conjunctival suffusion** is a classic and distinctive sign of leptospirosis, differentiating it from many other febrile illnesses [1]. *Dengue fever* - While dengue fever can present with **fever**, **retro-orbital pain**, and **myalgia**, **conjunctival suffusion** is not a typical feature, and severe leg pain is less emphasized compared to leptospirosis [2]. - Dengue is also common in tropical/subtropical regions but the specific constellation of symptoms points away from it [2]. *Malaria* - Malaria presents with classic **cyclic fevers**, **chills**, and **sweats**, often accompanied by headache and muscle aches, and sometimes hepatosplenomegaly. - **Conjunctival suffusion** and severe leg pain are not characteristic features of uncomplicated malaria [2]. *Rickettsia infection* - Rickettsial infections (e.g., Rocky Mountain spotted fever, scrub typhus) often present with **fever**, **headache**, and a **rash**, which can be maculopapular or petechial [3]. - **Retro-orbital pain** and **conjunctival suffusion** are not typical symptoms, and a distinctive rash is generally a key diagnostic clue for rickettsial diseases [3].
Question 29: A patient presents with hypotension, hyponatremia, and blackening of the palmar creases. Which of the following conditions is most likely associated with these symptoms?
- A. Conn syndrome
- B. Cushing's syndrome
- C. Primary ACTH deficiency
- D. Addison disease (Correct Answer)
- E. Sheehan syndrome
Explanation: ***Addison disease*** - **Hypotension**, **hyponatremia**, and **hyperpigmentation** (blackening of palmar creases) are classic symptoms of **primary adrenal insufficiency** or Addison disease, due to deficient cortisol and aldosterone. - The lack of **cortisol** leads to hypotension and fatigue, while the absence of **aldosterone** causes hyponatremia and hyperkalemia. *Conn syndrome* - This condition involves **primary hyperaldosteronism**, typically leading to **hypertension** and **hypokalemia**, which contradicts the patient's symptoms of hypotension and hyponatremia. - Pigmentation changes are not a feature of Conn syndrome. *Cushing's syndrome* - Characterized by **excess cortisol**, leading to symptoms like **hypertension**, **hyperglycemia**, and central obesity, not hypotension or hyperpigmentation. - **Hyponatremia** is also not typical in Cushing's syndrome. *Primary ACTH deficiency* - Also known as **secondary adrenal insufficiency**, this condition results in low cortisol but typically spares aldosterone production, meaning **hyponatremia** and **hyperkalemia** are less common. - **Hyperpigmentation** does not occur in primary ACTH deficiency because ACTH levels are low. *Sheehan syndrome* - This is **postpartum pituitary necrosis** causing panhypopituitarism, which can lead to secondary adrenal insufficiency with hypotension and hyponatremia. - However, **hyperpigmentation does not occur** in Sheehan syndrome because ACTH levels are low (secondary insufficiency), not elevated as in Addison disease. - The clinical context would typically include a history of postpartum hemorrhage and failure to lactate.
Surgery
1 questionsA hypertensive patient presents with excruciating chest pain and unequal radial pulses. Which of the following is the correct management for this patient?
NEET-PG 2024 - Surgery NEET-PG Practice Questions and MCQs
Question 21: A hypertensive patient presents with excruciating chest pain and unequal radial pulses. Which of the following is the correct management for this patient?
- A. Emergency surgical repair (Correct Answer)
- B. BP control and monitoring
- C. Stenting
- D. Balloon dilatation
Explanation: ***Emergency surgical repair*** - The combination of **excruciating chest pain**, a history of **hypertension**, and **unequal radial pulses** is highly suggestive of an **acute aortic dissection**. - **Unequal radial pulses** indicate involvement of the **ascending aorta** (Type A dissection), affecting the brachiocephalic or subclavian arteries that branch proximally from the aortic arch. - **Type A aortic dissections**, involving the ascending aorta, are life-threatening emergencies requiring immediate **surgical repair** to prevent rupture, cardiac tamponade, aortic regurgitation, and organ malperfusion. *BP control and monitoring* - While **blood pressure control** is a crucial initial step in managing aortic dissection to reduce shear stress on the aorta and prevent propagation, it is insufficient as the primary treatment for an **ascending (Type A) aortic dissection**. - Continuous monitoring is necessary but cannot resolve a progressing dissection that poses an immediate threat to life. - Medical management alone is reserved for **uncomplicated Type B dissections**. *Stenting* - **Endovascular stenting** (thoracic endovascular aortic repair, TEVAR) is primarily used for **Type B aortic dissections** (involving the descending aorta) in stable patients or those with complicated features. - It is generally not the first-line treatment for **Type A dissections** due to the anatomical challenges and urgent need for surgical repair in this location. *Balloon dilatation* - **Balloon dilatation** or angioplasty is a procedure used to open narrowed arteries, typically in the context of atherosclerotic disease (e.g., coronary artery disease or peripheral artery disease). - It has no role in the management of an **aortic dissection**, which involves a tear in the aortic wall rather than a simple narrowing.