Hospital Medicine — MCQs

Hospital Medicine Indian Medical PG Practice Questions and MCQs

Question 31: What is the single most useful clinical sign of severity in a person without underlying lung disease?

A. Systolic BP less than 90 mm/Hg (Correct Answer)
B. Temp more than 38.5°C
C. No significant clinical sign
D. Heart rate more than 100 bpm

Explanation: ***Systolic BP less than 90 mm/Hg*** - A **systolic blood pressure below 90 mm/Hg** indicates **hypotension**, reflecting inadequate tissue perfusion and potential **shock**, which is a critical sign of severity in any acute illness [1]. - This suggests **cardiovascular compromise** and requires immediate medical attention to prevent organ damage [1]. *Temp more than 38.5°C* - A **fever above 38.5°C** (101.3°F) indicates an infection or inflammatory process but is not as immediate a sign of life-threatening severity as profound hypotension. - While concerning, fever alone rarely signals imminent circulatory collapse in individuals without underlying conditions. *No significant clinical sign* - This option is incorrect because **systolic blood pressure less than 90 mm/Hg** is a highly significant clinical sign of severity, indicating potential decompensation. - Relying on the absence of signs can lead to delays in critical care for patients exhibiting clear signs of distress [1]. *Heart rate more than 100 bpm* - A **heart rate greater than 100 bpm** (**tachycardia**) can be a response to various stressors, including fever, pain, or anxiety, and is less specific for severe circulatory compromise than hypotension [1]. - While it may indicate an underlying problem, it is often a compensatory mechanism that does not, on its own, signify immediate danger without other signs of organ dysfunction.

Question 32: About Transfusion-Related Acute Lung Injury (TRALI), all of the following are true except:

A. Steroids have a doubtful role in management
B. Mortality is less than 10%
C. Signs and symptoms usually subside within 2-3 weeks of onset (Correct Answer)
D. Supportive care is the mainstay of treatment

Explanation: ***Signs and symptoms usually subside within 2-3 weeks of onset*** - TRALI is characterized by **acute onset**, typically within 6 hours of transfusion, and symptoms often resolve within **48-96 hours**. - A resolution period of **2-3 weeks** is significantly longer than the typical course for TRALI, suggesting a different underlying process. *Supportive care is the mainstay of treatment* - **Supportive care**, including oxygen therapy and mechanical ventilation if needed, is indeed the primary treatment for TRALI. - There is no specific antidote or targeted therapy for TRALI, making symptomatic management crucial. *Steroids have a doubtful role in management* - The use of **corticosteroids** in TRALI management is **controversial** and generally not recommended. - Current evidence does not support their routine use, and they are typically reserved for specific situations or not used at all. *Mortality is less than 10%* - While TRALI is a serious complication, its **mortality rate has significantly decreased** over the years due to improved recognition and mitigation strategies, now typically ranging from 5-10%. - This statement is generally considered true in contemporary medical practice.

Question 33: Which of the following statements about normal saline is false?

A. fluid of choice for hypovolemic shock
B. lead to hyperchloremic metabolic acidosis
C. fluid of choice for head injury patient
D. normal saline 0.9% is most suitable to treat acute severe hyponatremia (Correct Answer)

Explanation: normal saline 0.9% is most suitable to treat acute severe hyponatremia - While 0.9% normal saline can be used in some hyponatremia cases, **acute severe hyponatremia** (especially with neurological symptoms) typically requires **hypertonic saline (3%)** to rapidly increase serum sodium and prevent cerebral edema. [2] - Normal saline contains 154 mEq/L of sodium, which is often insufficient to correct severe hyponatremia quickly enough [1]. *fluid of choice for head injury patient* - **Normal saline (0.9%) is often *not* the fluid of choice for head injuries**; rather, **hypertonic saline** is often preferred as it can decrease intracranial pressure (ICP) by drawing water out of brain cells. - Isotonic fluids like normal saline can contribute to cerebral edema if given in large quantities, though it's still safer than hypotonic fluids. *fluid of choice for hypovolemic shock* - **Normal saline (0.9%) is generally considered the fluid of choice for initial resuscitation in hypovolemic shock** as it is an isotonic crystalloid that effectively expands intravascular volume [1]. - It readily distributes across the extracellular fluid compartment, restoring circulating blood volume. *lead to hyperchloremic metabolic acidosis* - **Normal saline (0.9%) contains a higher concentration of chloride (154 mEq/L) than plasma (98-106 mEq/L)**, and when infused in large volumes, it can lead to **hyperchloremia** [1]. - This excess chloride can shift the bicarbonate buffer system, resulting in a **non-anion gap (hyperchloremic) metabolic acidosis**.

Question 34: Cavitating lesions in the lung are seen in:

A. Polyarteritis nodosa (PAN)
B. Systemic lupus erythematosus (SLE)
C. Goodpasture's syndrome
D. Granulomatosis with polyangiitis (GPA) (Correct Answer)

Explanation: ***Granulomatosis with polyangiitis (GPA)*** - **Granulomatosis with polyangiitis (GPA)**, previously known as Wegener's granulomatosis, classically presents with a **triad of upper airway disease**, **lower airway disease**, and **glomerulonephritis** [1]. - **Cavitating lung lesions** are a hallmark feature of GPA due to the necrotizing vasculitis and granuloma formation in the pulmonary parenchyma [1]. *Polyarteritis nodosa (PAN)* - **Polyarteritis nodosa** is a necrotizing vasculitis of **medium-sized arteries**, but it typically **spares the pulmonary circulation** [1]. - Its clinical manifestations usually involve the skin, peripheral nerves, kidneys, and gastrointestinal tract, with **pulmonary involvement being rare**. *Systemic lupus erythematosus (SLE)* - **Systemic lupus erythematosus** can affect the lungs, causing pleurisy, pneumonitis, or interstitial lung disease, but **cavitating lesions are highly unusual** [1]. - **Pulmonary hemorrhage** or **thromboembolism** can occur, but these do not typically lead to cavitation [1]. *Goodpasture's syndrome* - **Goodpasture's syndrome** is characterized by rapidly progressive **glomerulonephritis** and **pulmonary hemorrhage** due to anti-GBM antibodies [1]. - While it causes lung disease, it typically manifests as **diffuse alveolar hemorrhage** rather than cavitating lesions [1].

Question 35: MC late complication of central venous line is:

A. Sepsis (Correct Answer)
B. Thromboembolism
C. Cardiac arrhythmias
D. Air embolism

Explanation: **Sepsis** - **Catheter-related bloodstream infections (CRBSIs)** are the most common late complication of central venous lines, leading to sepsis [1]. - The risk of sepsis increases with the **duration** of catheter placement, frequency of line access, and inadequate aseptic technique [1]. *Air embolism* - An **air embolism** is typically an immediate or early complication during insertion or removal of the central line, or connection/disconnection of administration sets. - It is not considered a late complication as it occurs due to a sudden entry of air into the venous system. *Thromboembolism* - While **thrombosis** can complicate central venous lines, leading to potential thromboembolism, it is less common than sepsis as a late complication [2]. - The formation of a thrombus is often localized to the catheter tip or vessel wall and may or may not lead to a symptomatic embolism [2]. *Cardiac arrhythmias* - **Cardiac arrhythmias** can occur during central venous line insertion if the guidewire or catheter tip irritates the myocardium, making it an immediate or early complication. - This is usually a transient event and not a long-term or late complication associated with the mere presence of the catheter.

Question 36: What is the most common complication of blood transfusion that can lead to death?

A. Hyperkalemia
B. Citrate toxicity
C. T.R.A.L.I (Correct Answer)
D. Hypothermia

Explanation: ***T.R.A.L.I*** - **Transfusion-Related Acute Lung Injury (TRALI)** is the leading cause of transfusion-related mortality, characterized by sudden onset of **non-cardiogenic pulmonary edema** within 6 hours of transfusion [1]. - It is thought to be mediated by **donor antibodies** that activate recipient neutrophils in the pulmonary vasculature, leading to capillary leakage [1]. *Hyperkalemia* - Can occur, especially in massive transfusions or rapid infusion of stored blood, but it is less common and typically less lethal than TRALI [1]. - Often manageable with interventions to shift potassium intracellularly or remove it from the body. *Citrate toxicity* - Associated with **massive transfusions** or in patients with **liver dysfunction**, as the liver metabolizes citrate. - Leads to **hypocalcemia** due to citrate chelating calcium, but is rarely fatal and reversible with calcium administration. *Hypothermia* - Can occur with rapid infusion of large volumes of cold blood products, particularly in trauma or surgical settings. - While it can exacerbate coagulopathy and arrhythmias, it is generally preventable with blood warmers and rarely a direct cause of death compared to TRALI.

Question 37: Which of the following is a step that should not be performed before an arterial blood gas (ABG) analysis?

A. Allen's test
B. Heparin to rinse the syringe
C. Poking at 45deg angle
D. Flexion of wrist (Correct Answer)

Explanation: Flexion of wrist - **Flexion of the wrist** compresses the radial artery and surrounding structures, making it difficult to locate and successfully access the artery for ABG sampling. - To facilitate arterial puncture, the wrist should be **slightly extended** to make the radial artery more prominent and easier to palpate and access. *Allen's test* - The **Allen's test** is a crucial step performed prior to radial artery puncture to assess the patency of the ulnar artery and ensure adequate collateral circulation to the hand. - If the ulnar artery is not patent, radial artery puncture could lead to **ischemia** of the hand. *Heparin to rinse the syringe* - **Heparin** is used to rinse the syringe to prevent the blood sample from clotting, which would render the ABG analysis inaccurate. - A small amount of **anticoagulant** ensures the blood remains liquid until it reaches the analyzer. *Poking at 45deg angle* - An insertion angle of **45 degrees** (or 30-45 degrees) is the standard technique for obtaining an ABG sample from the radial artery. - This angle allows for optimal access to the artery while minimizing the risk of puncturing through both vessel walls or causing hematoma formation.

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