Diagnosis
2 questionsWhat is the most appropriate initial investigation for a solitary thyroid nodule (STN)?
A female presents with a 1 × 1 cm thyroid swelling. What is the next best step in management?
NEET-PG 2024 - Diagnosis NEET-PG Practice Questions and MCQs
Question 61: What is the most appropriate initial investigation for a solitary thyroid nodule (STN)?
- A. I-123 scan
- B. Ultrasound (Correct Answer)
- C. Fine-needle aspiration (FNA) biopsy
- D. Thyroid function tests (TFTs)
- E. CT scan of the neck
Explanation: ***Ultrasound*** - **Ultrasound** is the initial investigation of choice for a solitary thyroid nodule (STN) because it can differentiate between **solid, cystic, or mixed lesions**, assess nodule size, and identify suspicious features (e.g., microcalcifications, irregular margins, internal vascularity). - It also helps to determine if there are other nodules not palpable on physical examination, allowing for a more complete assessment of the **thyroid gland**. *Fine-needle aspiration (FNA) biopsy* - **FNA biopsy** is the most accurate diagnostic tool for evaluating the malignant potential of a thyroid nodule, but it is typically performed *after* an initial ultrasound has characterized the nodule. - It requires guidance (often by ultrasound) to obtain an adequate sample for cytological analysis, making ultrasound a prerequisite for optimal FNA performance. *Thyroid function tests (TFTs)* - **TFTs (TSH, T3, T4)** are important for assessing the functional status of the thyroid gland (e.g., hyperthyroidism or hypothyroidism) and can provide context for the nodule. - However, TFTs do not directly evaluate the **morphology or malignant potential** of the nodule itself, making them less appropriate as an initial, stand-alone investigation for an STN. *I-123 scan* - An **I-123 scan** (radioactive iodine uptake and scan) is used to determine if a nodule is "hot" (hyperfunctioning/benign) or "cold" (non-functioning/potentially malignant). - It is typically reserved for cases where **TSH levels are suppressed**, suggesting a hyperfunctioning nodule, and is not the first-line imaging modality for initial characterization of all STNs. *CT scan of the neck* - **CT scan** can visualize thyroid nodules and assess for extrathyroidal extension or lymphadenopathy, but it is **not recommended as an initial investigation** for STN. - It involves **radiation exposure**, is more expensive than ultrasound, and provides **less detailed characterization** of nodule morphology compared to ultrasound, making it a less appropriate first-line modality.
Question 62: A female presents with a 1 × 1 cm thyroid swelling. What is the next best step in management?
- A. I-131
- B. TSH (Correct Answer)
- C. TSH & T4
- D. T3 & T4
- E. FNAC
Explanation: ***Correct Option: TSH*** - **Thyroid-stimulating hormone (TSH)** is the most sensitive initial test to assess thyroid function when a thyroid nodule is discovered. - An abnormal TSH level (either high or low) can guide further investigation into whether the nodule is associated with a functional thyroid disorder. - **TSH should be the first test** according to American Thyroid Association guidelines for thyroid nodule evaluation. *Incorrect Option: I-131* - **I-131 (radioactive iodine therapy)** is a treatment modality for hyperthyroidism or thyroid cancer, not a diagnostic step for initial thyroid swelling evaluation. - Administering I-131 before assessing thyroid function would be inappropriate and could lead to unnecessary or harmful intervention. *Incorrect Option: TSH & T4* - While TSH is crucial, adding **T4 (thyroxine)** as an initial step is often not necessary if TSH is normal, as TSH alone effectively screens for primary thyroid dysfunction. - Measuring both TSH and T4 is typically reserved for situations where TSH is abnormal or when central hypothyroidism is suspected. *Incorrect Option: T3 & T4* - Measuring **T3 (triiodothyronine)** along with T4 as an initial screening for a thyroid nodule is generally not recommended. - T3 levels are primarily used to diagnose **hyperthyroidism** or to evaluate the severity of thyrotoxicosis after an abnormal TSH and T4 have been identified. *Incorrect Option: FNAC* - While **Fine Needle Aspiration Cytology (FNAC)** is an essential diagnostic tool for thyroid nodules, it is typically performed after TSH assessment. - FNAC is indicated for nodules >1 cm with suspicious ultrasound features, but **functional assessment with TSH comes first** to rule out hyperfunctioning nodules.
Internal Medicine
1 questionsA patient presents to the OPD with recurrent diarrhea, abdominal pain, and foul-smelling stools. The colonoscopy reveals the following findings. What is the most likely diagnosis?
NEET-PG 2024 - Internal Medicine NEET-PG Practice Questions and MCQs
Question 61: A patient presents to the OPD with recurrent diarrhea, abdominal pain, and foul-smelling stools. The colonoscopy reveals the following findings. What is the most likely diagnosis?
- A. Pseudomembranous colitis (Correct Answer)
- B. FAP (Familial Adenomatous Polyposis)
- C. Ulcerative colitis
- D. Acute gastritis
Explanation: ***Pseudomembranous colitis*** - The image clearly shows **yellowish-white plaques or pseudomembranes** scattered over the inflamed colonic mucosa, which are characteristic endoscopic findings of **pseudomembranous colitis**. - The clinical symptoms of **recurrent diarrhea**, **abdominal pain**, and **foul-smelling stools** are consistent with this diagnosis, often caused by *Clostridioides difficile* infection. *FAP (Familial Adenomatous Polyposis)* - FAP is characterized by hundreds to thousands of **adenomatous polyps** throughout the colon, usually **smaller and more uniform** in appearance than the pseudomembranes seen here. - While it can cause diarrhea and abdominal pain, the endoscopic appearance of discrete polyps rather than diffuse pseudomembranes differentiates it from the image shown. *Ulcerative colitis* - Ulcerative colitis typically presents with **continuous inflammation** of the colon, often involving **ulcerations, friability, and loss of haustra**, without the distinct pseudomembranes. - Symptoms usually include **bloody diarrhea** and tenesmus, which differ from the foul-smelling stools mentioned. *Acute gastritis* - Acute gastritis is an inflammation of the **stomach lining**, not the colon, and would not be diagnosed via colonoscopy. - Symptoms are usually upper GI-related, such as **epigastric pain, nausea, and vomiting**, not recurrent diarrhea and foul-smelling stools.
Surgery
7 questionsA child presents to the OPD with the finding shown in the image. When should the first surgical repair be performed?
In the intraoperative image of congenital hernia repair, the structure marked by the red arrow is identified as which of the following?
An elderly patient presents with a non-healing ulcerative lesion on the lower lip, as shown in the image. The lesion has been gradually enlarging over the past few months. Suspecting squamous cell carcinoma (SCC), what is the most appropriate method to obtain a biopsy for definitive diagnosis?
How does a skin graft receive nutrition on day 3 after transplantation?
A patient presents with constant chest pain, and the radiological finding is as shown in the image. What is the most appropriate management?
Identify the procedure shown in the image, which is performed in a patient with recurrent GERD.
A patient presents with a penile lesion staged as T3, with clinically palpable lymph nodes. What is the most appropriate management?
NEET-PG 2024 - Surgery NEET-PG Practice Questions and MCQs
Question 61: A child presents to the OPD with the finding shown in the image. When should the first surgical repair be performed?
- A. 3 months (Correct Answer)
- B. 6 months
- C. 12 months
- D. 18 months
Explanation: ***3 months*** - Surgical repair of **cleft lip** is typically performed around **3 months of age** based on current practice guidelines. - The traditional **"Rule of 10s"** (10 weeks old, 10 pounds weight, 10 g/dL hemoglobin) has evolved to **3-6 months** as the optimal timing window, with **3 months** being most common. - Early repair helps with **feeding difficulties**, improves cosmesis, and facilitates normal **parent-infant bonding** while optimizing surgical outcomes. *6 months* - While 6 months is within the acceptable range for cleft lip repair, **3 months is preferred** as the optimal timing in most centers. - Delaying repair to 6 months may impact feeding mechanics and parental bonding, though outcomes remain good. - This timing is **earlier** than the recommended window for **cleft palate repair** (9-18 months). *12 months* - **Cleft palate repair** is typically performed around **9-18 months of age**, with 12 months being a common target to optimize speech development. - Performing **cleft lip repair** at 12 months is significantly **delayed** and would miss the benefits of earlier intervention for feeding, cosmesis, and bonding. *18 months* - 18 months is at the **upper limit** for **cleft palate repair** to minimize speech development issues. - This age is **too late** for the first surgical repair of a cleft lip, which should be performed in early infancy (3-6 months).
Question 62: In the intraoperative image of congenital hernia repair, the structure marked by the red arrow is identified as which of the following?
- A. Femoral vein
- B. Obturator vein
- C. Testicular vein (Correct Answer)
- D. Inferior epigastric vein
Explanation: ***Testicular vein*** - The **testicular vein** is clearly visible within the **spermatic cord** structures, which are typically identified and often dissected during congenital hernia repair. - Its position coursing with the testicular artery and vas deferens is consistent with its anatomical location within the inguinal canal. *Femoral vein* - The **femoral vein** lies more inferiorly and medially within the femoral canal, distinct from the inguinal canal contents visualized in this image. - Identification of the femoral vein would be in the context of a femoral hernia repair, not typically a congenital (indirect inguinal) hernia. *Obturator vein* - The **obturator vein** is located deep within the pelvis, accompanying the obturator nerve and artery through the obturator foramen. - It is not typically encountered or visible during a standard open or laparoscopic inguinal hernia repair. *Inferior epigastric vein* - The **inferior epigastric vein** runs superiorly and medially, forming the medial border of the **inguinal triangle (Hesselbach's triangle)**. - While it's an important landmark in hernia repair (differentiating direct vs. indirect hernias), its anatomical position and trajectory are distinct from the structure indicated by the arrow, which is part of the spermatic cord.
Question 63: An elderly patient presents with a non-healing ulcerative lesion on the lower lip, as shown in the image. The lesion has been gradually enlarging over the past few months. Suspecting squamous cell carcinoma (SCC), what is the most appropriate method to obtain a biopsy for definitive diagnosis?
- A. Incisional (Correct Answer)
- B. Excisional
- C. Deep tissue biopsy
- D. Superficial biopsy from the border with normal tissue
Explanation: ***Incisional*** - An **incisional biopsy** is the most appropriate method for obtaining a definitive diagnosis of suspected squamous cell carcinoma (SCC) of the lip. - This technique involves removing a **wedge-shaped portion of the lesion** that includes both the tumor tissue and a margin extending into normal tissue, with adequate depth to assess invasion. - Incisional biopsy provides sufficient tissue for **histopathological examination**, including assessment of tumor grade, depth of invasion, and other prognostic factors critical for staging and treatment planning. - For larger or suspicious lesions where complete excision might cause significant cosmetic deformity, incisional biopsy allows for **diagnosis confirmation before definitive surgical management**. *Superficial biopsy from the border with normal tissue* - A superficial or shave biopsy is **inadequate for SCC diagnosis** as it does not provide information about the depth of invasion, which is crucial for staging and prognosis. - Squamous cell carcinoma requires assessment of invasion into underlying dermis and deeper structures, which cannot be evaluated with superficial sampling. - Superficial biopsies may lead to **underdiagnosis** or incomplete staging, potentially compromising treatment planning. *Excisional* - While excisional biopsy (complete removal with margins) can be appropriate for **small, well-defined lesions** (<1 cm), it may not be the first choice for larger or gradually enlarging lesions. - Complete excision without prior histological confirmation might result in **inadequate margins** if malignancy is confirmed, requiring re-excision. - For lip lesions, unnecessary wide excision can cause **significant cosmetic and functional defects** if the lesion proves benign or requires specialized reconstruction. *Deep tissue biopsy* - This is not standard terminology in the context of lip lesions and lacks specificity regarding the sampling technique. - The term "deep tissue biopsy" is more commonly used for suspected soft tissue tumors or deep-seated lesions, not for mucocutaneous SCC.
Question 64: How does a skin graft receive nutrition on day 3 after transplantation?
- A. Imbibition
- B. Inosculation (Correct Answer)
- C. Neovascularization
- D. A & B
Explanation: ***Inosculation*** - **Inosculation** is the process where host capillaries directly connect with the graft's existing vessels (or newly formed ones) around day 2-3 post-transplantation. - This establishes blood flow and is the primary mechanism for **nutrient delivery** and waste removal by day 3. *Imbibition* - **Imbibition** is the initial phase (first 24-48 hours) where the graft passively absorbs nutrients from the recipient bed through diffusion. - While essential for initial survival, it is typically insufficient for sustained graft viability by day 3. *Neovascularization* - **Neovascularization** involves the formation of entirely new blood vessels into the graft, a process that typically begins after inosculation and continues for several days to weeks. - On day 3, while *initiation* of new vessel formation may be occurring, the main nutritional support is primarily from established connections through inosculation. *A & B* - While **imbibition** plays a role in the initial survival of the graft, by day 3, **inosculation** is the dominant and more effective mechanism for nutrient supply. - Therefore, selecting both A and B would be incorrect as imbibition's role diminishes significantly as inosculation progresses.
Question 65: A patient presents with constant chest pain, and the radiological finding is as shown in the image. What is the most appropriate management?
- A. Surgical management (Correct Answer)
- B. Vasodilator
- C. Beta blocker
- D. Beta blocker plus vasodilator
Explanation: ***Surgical management*** - The chest X-ray shows a **widened mediastinum** and abnormal aortic contour, highly suggestive of **aortic dissection involving the ascending aorta (Type A)**. - **Type A aortic dissection** (involving the ascending aorta) is a **surgical emergency** requiring immediate operative repair to prevent life-threatening complications such as cardiac tamponade, acute aortic regurgitation, or rupture. - The constant chest pain with these radiological findings indicates urgent surgical intervention is the definitive management. *Vasodilator* - Vasodilators **alone** should never be used in aortic dissection as they can increase aortic wall shear stress and propagate the dissection. - They must always be preceded by beta-blockade to prevent reflex tachycardia. - Vasodilators do not address the structural defect requiring surgical correction in Type A dissection. *Beta blocker* - Beta-blockers are essential for **initial medical stabilization** to reduce heart rate (target <60 bpm) and blood pressure, thereby decreasing aortic wall stress (dP/dt). - However, in **Type A dissection**, beta-blockers alone do not address the structural defect and are used as a bridge to emergency surgery, not as definitive treatment. - For Type B dissections (descending aorta), medical management with beta-blockers may be definitive in uncomplicated cases. *Beta blocker plus vasodilator* - This combination represents optimal **medical management** for blood pressure and heart rate control in aortic dissection. - In **Type B (descending) aortic dissections**, this is often the definitive treatment for uncomplicated cases. - However, in **Type A dissections** (as indicated by the widened mediastinum suggesting ascending aortic involvement), this serves only as initial stabilization before **mandatory surgical repair**, not as definitive therapy. - Surgery cannot be delayed in Type A dissection due to high mortality risk (1-2% per hour).
Question 66: Identify the procedure shown in the image, which is performed in a patient with recurrent GERD.
- A. Nissen fundoplication (Correct Answer)
- B. Partial gastrectomy
- C. Esophageal banding
- D. Toupet fundoplication
Explanation: ***Nissen fundoplication*** - The image clearly depicts the **fundus of the stomach** being wrapped completely around the lower esophagus and sutured in place, which is the hallmark of a **360-degree Nissen fundoplication**. - This procedure aims to strengthen the **lower esophageal sphincter (LES)** to prevent reflux in patients with recurrent GERD. *Partial gastrectomy* - This procedure involves the **surgical removal of a portion of the stomach** and is typically performed for conditions like gastric cancer or severe ulcers, not primarily for GERD. - The image shows the stomach intact and being wrapped, not resected. *Esophageal banding* - Esophageal banding is a procedure used to treat **esophageal varices** by placing elastic bands around dilated veins, not a surgical intervention for GERD that alters stomach anatomy. - The image shows a gastric maneuver, not banding of the esophagus. *Toupet fundoplication* - A Toupet fundoplication involves a **partial (270-degree) wrap** of the fundus around the esophagus, leaving a small portion unwrapped. - The image distinctly illustrates a **complete 360-degree wrap**, distinguishing it from a Toupet fundoplication.
Question 67: A patient presents with a penile lesion staged as T3, with clinically palpable lymph nodes. What is the most appropriate management?
- A. Penectomy
- B. Penectomy with superficial node dissection
- C. Penectomy with deep ilioinguinal node dissection (Correct Answer)
- D. Chemoradiotherapy
Explanation: ***Penectomy with deep ilioinguinal node dissection*** - A **T3 penile lesion** indicates invasion of the corpus cavernosum or corpus spongiosum, which is an aggressive stage requiring **radical local excision (penectomy)**. - **Clinically palpable lymph nodes** alongside a T3 tumor suggest nodal involvement (N1-N3), necessitating a **deep ilioinguinal lymph node dissection** to remove affected deeper lymph nodes that are not readily accessible by superficial dissection. *Penectomy* - While penectomy addresses the primary tumor, it does not manage the **clinically palpable lymph nodes**, which are crucial for staging and prognosis in advanced penile cancer. - This option would be insufficient given the documented **nodal involvement**, leading to likely recurrence and progression of the disease. *Penectomy with superficial node dissection* - This approach is inadequate for **palpable lymph nodes**, especially with a T3 lesion, because such nodes often indicate involvement of **deeper lymphatics (deep ilioinguinal)**. - Superficial dissection alone would likely leave residual disease, failing to properly stage and treat the extent of the cancer. *Chemoradiotherapy* - **Chemoradiotherapy** is typically reserved for patients who are not surgical candidates, or as a neoadjuvant/adjuvant therapy, not as primary treatment for a **T3 lesion with palpable nodes** where surgical intervention is the standard of care for optimal local and regional control. - While it may be used in certain settings, surgery (penectomy with lymph node dissection) offers the best chance for cure in this scenario.