General Medicine Practice Questions

Q: All of the following are true about refeeding syndrome except?

Occurs with TPN only, not seen in enteral nutrition. Refeeding syndrome is a potentially fatal metabolic complication that occurs when nutrition is reintroduced too rapidly in patients with severe, chronic malnutrition (e.g., anorexia nervosa, chronic alcoholism, or prolonged starvation). **1. Why Option A is the Correct Answer (The Exception):** Refeeding syndrome is **not** exclusive to Total Parenteral Nutrition (TPN). It can occur regardless of the route of administration—including **enteral (tube) feeding and oral intake**. The trigger is the sudden availability of glucose, which leads to a massive surge in **insulin**. This shifts electrolytes (phosphorus, potassium, and magnesium) from the extracellular space into the cells, causing dangerous serum deficiencies [1]. **2. Analysis of Other Options:** * **Option B:** True. Severe hypokalemia and hypomagnesemia prolong the QT interval and predispose the patient to fatal cardiac **arrhythmias** and heart failure. * **Option C:** True. The syndrome is specifically triggered by the **rapid and excessive** reintroduction of calories in a body that has adapted to a catabolic state. * **Option D:** True. **Hypophosphatemia** is the biochemical hallmark of refeeding syndrome [1]. Along with hypomagnesemia and hypokalemia, these must be aggressively monitored and replaced to prevent multi-organ failure. **High-Yield Clinical Pearls for NEET-PG:** * **Hallmark:** Hypophosphatemia [1]. * **Vitamin Deficiency:** Thiamine (Vitamin B1) deficiency is often exacerbated, as it is a co-factor for glucose metabolism; its depletion can lead to Wernicke’s encephalopathy. * **Prevention:** "Start low and go slow." Begin at 10–15 kcal/kg/day and supplement with Thiamine before starting nutrition. * **Most common cause of death:** Cardiac arrhythmias.

Q: Which of the following is NOT a feature of hypermagnesemia?

Tetany. **Explanation:** Hypermagnesemia (Serum $Mg^{2+} > 2.5$ mEq/L) acts primarily as a **neuromuscular and CNS depressant**. Magnesium blocks the release of acetylcholine at the neuromuscular junction and acts as a calcium channel antagonist. **Why Tetany is the correct answer:** Tetany is a state of increased neuromuscular excitability (hyperexcitability) characterized by involuntary muscle contractions. It is a hallmark feature of **hypomagnesemia** and **hypocalcemia**, not hypermagnesemia. In hypermagnesemia, the excess magnesium inhibits nerve impulse transmission, leading to muscle weakness rather than spasms. **Analysis of incorrect options:** * **Hypotension:** Magnesium causes peripheral vasodilation and can block sympathetic ganglia, leading to a significant drop in blood pressure. * **Ileus:** By inhibiting smooth muscle contraction in the gastrointestinal tract, high magnesium levels lead to decreased motility, resulting in paralytic ileus. * **Decreased deep tendon reflexes (DTRs):** This is often the **earliest clinical sign** of magnesium toxicity (typically seen at 4–6 mEq/L). As levels rise, it progresses to complete flaccid paralysis and respiratory depression. **NEET-PG High-Yield Pearls:** * **Antidote:** The immediate treatment for magnesium toxicity is **IV Calcium Gluconate** (antagonizes the membrane effects of Mg). * **Sequence of Toxicity:** Loss of DTRs $\rightarrow$ Respiratory depression $\rightarrow$ Heart block/Cardiac arrest. * **Common Cause:** Most frequently seen in patients with **renal failure** or those receiving magnesium sulfate for **Eclampsia**.

Q: An 18-year-old female complains of breathlessness, fainting, and a tingling sensation over her lips. She has a history of similar episodes in the past. What is the diagnosis?

Hyperventilation. **Explanation:** The clinical presentation of an 18-year-old female with recurrent episodes of breathlessness, syncope (fainting), and **perioral paresthesia** (tingling over the lips) is a classic description of **Hyperventilation Syndrome**, often associated with anxiety or panic attacks [1]. **Why Hyperventilation is correct:** Hyperventilation leads to excessive "blowing off" of $CO_2$, resulting in **Respiratory Alkalosis**. This rise in blood pH causes a shift in calcium binding; more ionized calcium binds to albumin, leading to **acute hypocalcemia**. Hypocalcemia increases neuronal excitability, manifesting as tingling (paresthesia) around the mouth and in the fingertips (carpopedal spasm) [1]. The rapid reduction in $PaCO_2$ also causes cerebral vasoconstriction, which explains the fainting or lightheadedness [3]. **Why other options are incorrect:** * **Myocardial Infarction:** Highly unlikely in an 18-year-old without significant risk factors [2]. It typically presents with crushing chest pain rather than perioral tingling. * **ARDS:** This is a severe, acute inflammatory lung injury presenting with profound hypoxemia and respiratory failure, usually requiring ICU admission. It is not episodic or associated with tingling. * **Upper Respiratory Tract Infection:** Presents with cough, rhinorrhea, and fever. It does not cause fainting or paresthesia. **Clinical Pearls for NEET-PG:** * **Trousseau’s sign and Chvostek’s sign** may be positive during an acute hyperventilation episode due to transient hypocalcemia. * **Management:** Reassurance and breathing into a paper bag (to increase $PaCO_2$ levels) was traditionally taught, though simple calming and controlled breathing are now preferred. * **Differential Diagnosis:** Always rule out pulmonary embolism in patients presenting with sudden onset dyspnea and respiratory alkalosis [1].

Q: Alcohol consumption is associated with all of the following conditions EXCEPT:

Coronary artery disease. The correct answer is **Coronary Artery Disease (CAD)**. While heavy alcohol consumption is a major risk factor for various systemic pathologies, moderate alcohol consumption (specifically 1–2 drinks per day) has historically been associated with a **cardioprotective effect**. It is known to increase HDL-cholesterol levels, decrease platelet aggregation, and improve insulin sensitivity, thereby potentially reducing the risk of CAD. In contrast, heavy consumption leads to alcoholic cardiomyopathy and arrhythmias (Holiday Heart Syndrome) rather than traditional atherosclerotic CAD. **Why the other options are incorrect:** * **Gastric or esophageal carcinoma:** Alcohol is a potent carcinogen. It acts as a solvent for tobacco smoke (synergistic effect) and its metabolite, acetaldehyde, causes DNA damage. It is a primary risk factor for Squamous Cell Carcinoma of the esophagus and is associated with gastric malignancies. * **Acute pancreatitis:** Alcohol is the second most common cause of acute pancreatitis (after gallstones). It causes premature activation of digestive enzymes within the pancreatic acini and increases the permeability of ductules. * **Chronic liver disease:** Alcohol is a direct hepatotoxin [1]. Chronic ingestion leads to a predictable progression from steatosis (fatty liver) to alcoholic hepatitis and eventually micronodular cirrhosis [1]. **High-Yield Clinical Pearls for NEET-PG:** * **CAGE Questionnaire:** Most sensitive screening tool for alcohol dependence (Cut down, Annoyed, Guilty, Eye-opener). * **Wernicke’s Encephalopathy:** Triad of Ataxia, Ophthalmoplegia, and Confusion (due to Thiamine/B1 deficiency) [2]. * **MCV:** An elevated Mean Corpuscular Volume (macrocytosis) is often the earliest laboratory indicator of chronic alcohol abuse, even in the absence of anemia. * **AST:ALT Ratio:** A ratio >2:1 is highly suggestive of alcoholic liver disease.

Q: A patient presents with tachycardia, BP < 100 mm Hg systolic, and postural hypotension. What is the most likely diagnosis?

Bleeding peptic ulcer. ### Explanation The clinical presentation of **tachycardia, hypotension (SBP 20 mmHg or DBP >10 mmHg upon standing) is an early sign of volume depletion (approx. 10-20% loss). * **Tachycardia and resting hypotension** signify more severe blood loss (>20-30% of circulating volume). The body compensates for decreased stroke volume by increasing the heart rate (tachycardia) to maintain cardiac output. **2. Why other options are incorrect:** * **Vasovagal attack:** This typically presents with **bradycardia** (due to excess vagal tone) and transient hypotension. It is a paroxysmal event, not a sustained state of shock. * **Diabetic neuropathy & Shy-Drager syndrome (Multiple System Atrophy):** Both cause autonomic dysfunction leading to orthostatic hypotension. However, they are characterized by a **lack of compensatory tachycardia** (fixed heart rate) because the autonomic nervous system cannot respond to the drop in blood pressure. **3. NEET-PG High-Yield Pearls:** * **Class I Hemorrhage:** <15% loss; Vitals usually normal. * **Class II Hemorrhage:** 15-30% loss; **Tachycardia** and increased respiratory rate; Orthostatic hypotension. * **Class III Hemorrhage:** 30-40% loss; **Hypotension (SBP <100)**, marked tachycardia, and oliguria. * **Management Priority:** In a bleeding ulcer with shock, the first step is always **hemodynamic stabilization** (IV fluids/crystalloids) before endoscopy.

Q: In a patient receiving total parenteral nutrition, what is monitored daily?

Body weight. **Explanation:** Monitoring a patient on Total Parenteral Nutrition (TPN) is critical to prevent metabolic and fluid-related complications. **Why Body Weight is the Correct Answer:** Daily measurement of **body weight** is the most sensitive and practical bedside indicator of a patient's **fluid status**. In the initial phase of TPN, rapid weight gain (e.g., >0.5–1.0 kg/day) usually signifies fluid overload or pulmonary edema rather than true tissue accretion. Conversely, weight loss may indicate inadequate caloric intake or dehydration. Therefore, it is the primary parameter monitored **daily** to adjust fluid and electrolyte administration. **Analysis of Incorrect Options:** * **Plasma Protein (B):** Albumin and pre-albumin have long half-lives (approx. 20 days and 2 days, respectively). They reflect nutritional trends over weeks or several days, making daily monitoring unnecessary and clinically unhelpful. * **Complete Blood Count (C):** CBC is typically monitored 1–2 times per week to check for signs of infection (leukocytosis) or anemia, unless an acute complication is suspected. * **Plasma Osmolality (D):** While TPN is hypertonic, plasma osmolality is generally monitored via indirect markers like serum glucose and electrolytes. It is not a routine daily requirement unless the patient is at high risk for hyperosmolar non-ketotic states. **High-Yield Clinical Pearls for NEET-PG:** * **Daily Monitoring:** Body weight, Intake/Output (I/O) charts, and Blood Glucose (often 6-hourly initially). * **Bi-weekly/Weekly Monitoring:** Electrolytes (BUN, Cr, Na, K), Liver Function Tests (LFTs), and CBC. * **Refeeding Syndrome:** Watch for sudden drops in **Phosphate, Magnesium, and Potassium** when starting TPN in malnourished patients. * **Most common complication:** Catheter-related sepsis (specifically *Staphylococcus aureus* or *Candida*).

Q: Capillary fill is fast in which of the following types of shock?

Septic shock. **Explanation:** The correct answer is **Septic shock**. **1. Why Septic Shock is Correct:** Septic shock is a type of **distributive shock**. In its early phase (Warm Shock), systemic vasodilation occurs due to the release of inflammatory mediators (like Nitric Oxide). This leads to decreased systemic vascular resistance (SVR) and increased cardiac output. Because the peripheral vessels are dilated, blood flow to the skin is increased, resulting in warm extremities and a **brisk or fast capillary refill time (<2 seconds)**. **2. Why the Other Options are Incorrect:** * **Hypovolemic and Hemorrhagic Shock:** These involve a primary loss of fluid or blood volume. The body compensates via the sympathetic nervous system, causing **peripheral vasoconstriction** to divert blood to vital organs. This results in cold, clammy skin and a **prolonged (delayed) capillary refill time**. * **Obstructive Shock:** Conditions like tension pneumothorax or cardiac tamponade physically obstruct blood flow. Similar to hypovolemic shock, this leads to low cardiac output and compensatory peripheral vasoconstriction, resulting in **delayed capillary refill**. **3. NEET-PG High-Yield Pearls:** * **Warm Shock vs. Cold Shock:** Septic shock is the only major shock that presents as "Warm Shock" initially. All other types (Hypovolemic, Cardiogenic, Obstructive) typically present as "Cold Shock." * **Hemodynamic Profile of Septic Shock:** Low SVR, High Cardiac Output (initially), and Low PCWP (Pulmonary Capillary Wedge Pressure). * **Clinical Marker:** Capillary refill time >2 seconds is a sensitive indicator of poor peripheral perfusion in most shock states, except early distributive shock.

Question 1

All of the following are true about refeeding syndrome except?

Accepted Answer

Occurs with TPN only, not seen in enteral nutrition

Answer

Associated with increased risk of arrhythmia

Answer

Occurs with rapid and excessive feeding of patients with severe underlying malnutrition

Answer

Hypophosphatemia and hypomagnesemia require treatment

Question 2

A 45-year-old, healthy nonsmoking woman with a normal BMI (24) has been found on two occasions to have a blood pressure of 145/95. She has no family history of premature coronary artery disease. For this patient, what is the most important next step to take to reduce morbidity and mortality from common medical conditions such as diabetes and cardiovascular disease?

Accepted Answer

Recommend an exercise program such as brisk walking for at least 30 minutes per day and a low salt, Dietary Approaches to Stop Hypertension (DASH) diet.

Answer

Urge the patient to quit smoking and discuss the various available medications to assist in the process.

Answer

Prescribe a low-cholesterol diet and statin drug.

Answer

Recommend aspirin (81 mg) daily.

Question 3

Which of the following is NOT a feature of hypermagnesemia?

Accepted Answer

Tetany

Answer

Hypotension

Answer

Ileus

Answer

Decreased deep tendon reflexes

Question 4

A lady presents with difficulty in breathing and appearance of hives after taking an NSAID tablet. Her pulse rate is 100/min and BP is 90/60 mm Hg. What is the most likely diagnosis?

Accepted Answer

Anaphylaxis

Answer

Massive pulmonary embolism

Answer

Neurogenic shock

Answer

Disseminated intravascular coagulation

Question 5

An 18-year-old female complains of breathlessness, fainting, and a tingling sensation over her lips. She has a history of similar episodes in the past. What is the diagnosis?

Accepted Answer

Hyperventilation

Answer

Myocardial infarction

Answer

ARDS

Answer

Upper respiratory tract infection

Question 6

Alcohol consumption is associated with all of the following conditions EXCEPT:

Accepted Answer

Coronary artery disease

Answer

Gastric or esophageal carcinoma

Answer

Acute pancreatitis

Answer

Chronic liver disease

Question 7

A patient presents with tachycardia, BP < 100 mm Hg systolic, and postural hypotension. What is the most likely diagnosis?

Accepted Answer

Bleeding peptic ulcer

Answer

Vasovagal attack

Answer

Diabetic neuropathy

Answer

Shy-Drager syndrome

Question 8

In a patient receiving total parenteral nutrition, what is monitored daily?

Accepted Answer

Body weight

Answer

Plasma protein

Answer

Complete blood count (CBC)

Answer

Plasma osmolality

Question 9

Capillary fill is fast in which of the following types of shock?

Accepted Answer

Septic shock

Answer

Hypovolemic shock

Answer

Hemorrhagic shock

Answer

Obstructive shock

Question 10

A patient diagnosed with sepsis from a urinary tract infection is being discharged. What do you plan to include in her discharge teaching?

Accepted Answer

Drink 8 to 10 eight-ounce glasses of water daily

Answer

Take cool baths

Answer

Avoid tampon use

Answer

Avoid sexual activity

General Medicine — MCQs

General Medicine — MCQs

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