NEET-PG 2012 - Internal Medicine Practice Questions

Q: Ataxia, nystagmus, and ophthalmoplegia are seen in which of the following conditions?

Wernicke encephalopathy. ***Wernicke encephalopathy*** - This condition is characterized by the classic triad of **ataxia**, **nystagmus**, and **ophthalmoplegia** (often presenting as external ophthalmoplegia), alongside confusion [2]. - It results from a **thiamine (vitamin B1) deficiency** [2], [3], commonly seen in chronic alcoholics or individuals with severe malnutrition. *Myasthenia gravis* - This is an **autoimmune disorder** affecting the neuromuscular junction, leading to fluctuating muscle weakness that worsens with activity [1]. - While it can cause **ophthalmoplegia** (especially ptosis and diplopia), it does not typically present with ataxia or nystagmus. *3rd nerve palsy* - A **third nerve palsy** specifically affects the oculomotor nerve, causing a constellation of symptoms including ptosis, pupillary dilation, and inability to move the eye up, down, or medially. - While it causes **ophthalmoplegia** affecting one eye, it does not typically cause nystagmus or ataxia. *Chronic progressive external ophthalmoplegia* - This is a mitochondrial disorder characterized by **slowly progressive weakness** of the extraocular muscles, leading to bilateral ptosis and limitation of eye movements. - It causes a specific type of **ophthalmoplegia** but is not typically associated with nystagmus or prominent ataxia.

Q: What is the most common cause of ophthalmoplegia in adults?

Cranial nerve palsy. ***Cranial nerve palsy*** - **Cranial nerve palsies**, particularly those affecting cranial nerves III, IV, or VI, are the most frequent causes of isolated ophthalmoplegia in adults [1]. - They can result from various etiologies like **ischemia**, **compression**, or **inflammation**, directly impairing the nerves responsible for eye movement [1]. *Myasthenia gravis* - While it frequently causes **ocular symptoms** (ptosis and diplopia), it typically presents with **fluctuating weakness** that worsens with sustained effort [1]. - It's a neuromuscular junction disorder, not a primary cranial nerve issue, and often affects other muscle groups beyond the eyes. *Diabetes mellitus* - **Diabetic ophthalmoplegia** is a specific type of cranial nerve palsy (often CN III or VI) caused by microvascular ischemia. - While common in diabetics, it is a *cause* of cranial nerve palsy, not the overarching most common cause of ophthalmoplegia itself. *Trauma* - **Trauma** can certainly cause ophthalmoplegia, often due to direct damage to **extraocular muscles**, **orbital fractures**, or **cranial nerve injury**. - However, in the general adult population, non-traumatic cranial nerve palsies are more frequently encountered as the cause of ophthalmoplegia.

Q: Serological testing of patient shows HBsAg, IgM anti-HBc and HBeAg positive. The patient has -

Acute hepatitis B with high infectivity. ***Acute hepatitis B with high infectivity*** - The presence of **HBsAg** (hepatitis B surface antigen) indicates active infection, while **IgM anti-HBc** (IgM antibody to hepatitis B core antigen) is a marker of recent or acute infection [1]. - **HBeAg** (hepatitis B e-antigen) positivity signifies active viral replication and a high likelihood of infectivity [1]. *Chronic hepatitis B with low infectivity (not acute)* - **Chronic hepatitis B** is characterized by the presence of **HBsAg for more than six months**, but **IgM anti-HBc** would typically be negative; instead, **IgG anti-HBc** would be positive [1]. - **Low infectivity** would be indicated by the absence of **HBeAg**, replaced by **anti-HBe** (antibody to HBeAg) [1]. *Chronic hepatitis with high infectivity* - This diagnosis would show positive **HBsAg and HBeAg**, but the absence of **IgM anti-HBc** (presence of **IgG anti-HBc** instead) would distinguish it from acute infection [1]. - The presence of **IgM anti-HBc** is a crucial marker for an acute phase of hepatitis B rather than chronic. *Acute on chronic hepatitis* - This scenario would involve a patient with pre-existing **chronic hepatitis B** (positive HBsAg, IgG anti-HBc) experiencing a new acute flare-up, which could involve a resurgence of **HBeAg** or a new acute viral insult. - While **HBsAg** and **HBeAg** would be positive, the key differentiator would be the presence of both **IgM anti-HBc** (indicating the acute component) and **IgG anti-HBc** (indicating the chronic component), which is not fully described here to confirm acute on chronic.

Q: Meningitis with rash is seen in -

Neisseria meningitidis. **Neisseria meningitidis** - **Meningococcal meningitis** is classically associated with an acute onset of fever, headache, stiff neck, and a characteristic **petechial or purpuric rash** [1]. - The rash is due to widespread **vasculitis** and disseminated intravascular coagulation (DIC) caused by the bacteria. *H. influenzae* - While *H. influenzae* type b (Hib) was a major cause of bacterial meningitis before vaccination, it typically does not cause a *rash*. - Meningitis caused by *H. influenzae* presents with fever, headache, stiff neck, and altered mental status without dermatological manifestations. *Strepto. agalactiae* - *Streptococcus agalactiae* (Group B Strep) is a common cause of meningitis in **neonates** and infants. - It usually presents with non-specific symptoms like fever, lethargy, and poor feeding, and a rash is not a typical feature of GBS meningitis. *Pneumococcus* - *Streptococcus pneumoniae* (Pneumococcus) is another leading cause of bacterial meningitis in adults and children [1]. - Symptoms include fever, headache, stiff neck, and altered mental status, but a cutaneous rash is not characteristic of pneumococcal meningitis [1].

Q: Madarosis is seen in ?

Hypothyroidism. ***Hypothyroidism*** - **Madarosis**, specifically the loss of the **outer third of the eyebrows**, is a classic sign of **hypothyroidism** due to decreased thyroid hormone levels affecting hair follicle growth [1]. - Other common symptoms include **fatigue**, **weight gain**, **cold intolerance**, and **dry skin**. *Addison's disease* - This condition involves **adrenal insufficiency**, primarily causing symptoms like **hyperpigmentation**, low blood pressure, and fatigue. - **Hair loss** is generally not a prominent feature, and madarosis is not typically seen. *Acromegaly* - Characterized by excessive **growth hormone** production, leading to enlargement of hands, feet, and facial features. - While it can cause some changes in hair texture, **madarosis** is not a common clinical manifestation. *None of the options* - This option is incorrect because **Hypothyroidism** is a direct cause of madarosis due to its impact on **hair follicle metabolism** [1]. - The other conditions listed do not typically present with this specific type of eyebrow hair loss.

Q: Which of the following is NOT typically seen in 3rd nerve palsy?

Loss of abduction. ***Loss of abduction*** - The **oculomotor nerve (CN III)** controls adduction, elevation, and depression of the eye, but **not abduction**. [2] - **Abduction** is primarily controlled by the **abducens nerve (CN VI)**, so its loss would indicate a CN VI palsy. *Mydriasis* - The **oculomotor nerve (CN III)** innervates the **parasympathetic fibers** to the pupillary constrictor muscles. [3] - Palsy of these fibers leads to unopposed action of the sympathetic dilator muscles, causing **mydriasis (pupil dilation)**. [4] *Ptosis* - The **oculomotor nerve (CN III)** innervates the **levator palpebrae superioris muscle**, which lifts the eyelid. - Dysfunction of this nerve leads to **ptosis (drooping of the eyelid)**. [1] *Loss of light reflex* - The **efferent pathway** for the **pupillary light reflex** travels via the **oculomotor nerve (CN III)** to constrict the pupil. [3] - A 3rd nerve palsy, particularly affecting the parasympathetic fibers, **impairs pupillary constriction**, resulting in a loss of the direct and consensual light reflex in the affected eye. [4]

Q: Which type of malaria is most commonly associated with renal failure?

Falciparum. ***Falciparum*** - **Plasmodium falciparum** is notorious for its ability to cause severe and complicated malaria, including **renal failure** due to its high parasitic biomass and tendency to block microvasculature [1]. - The parasite causes red blood cells to become **sticky**, leading to sequestration in capillaries of vital organs, including the kidneys, resulting in acute tubular necrosis [1]. *Vivax* - **Plasmodium vivax** typically causes milder forms of malaria, though it can occasionally lead to severe manifestations, **renal complications are rare** compared to P. falciparum [1]. - While it can cause some organ dysfunction, it generally does not cause the severe multi-organ involvement, particularly **acute renal failure**, that P. falciparum is known for [1]. *Malariae* - **Plasmodium malariae** is associated with a chronic form of malaria and is known to cause **nephrotic syndrome** (specifically malarial nephropathy) due to immune complex deposition, rather than acute renal failure [1]. - The renal pathology in P. malariae infection is typically a **glomerulonephritis** that develops after repeated infections, which is distinct from the acute renal failure seen with P. falciparum [1]. *Ovale* - **Plasmodium ovale** is the least common type of malaria and causes a benign form of the disease, similar to P. vivax [1]. - It rarely, if ever, causes severe complications like **renal failure** [1].

Q: Which species of malaria is associated with nephrotic syndrome?

P. malariae. ***P. malariae*** - *P. malariae* infection is classically associated with **quartan fever** and can lead to **nephrotic syndrome**, particularly in children [1]. - The mechanism involves the deposition of immune complexes in the glomeruli, causing **membranoproliferative glomerulonephritis**. *P. vivax* - *P. vivax* is known for causing **benign tertian malaria** and frequently leads to **relapses** due to hypnozoites in the liver [1]. - While it can cause renal dysfunction, **nephrotic syndrome** is not a characteristic complication. *P. falciparum* - *P. falciparum* is responsible for the most severe form of malaria, often complicated by **cerebral malaria**, **acute renal failure**, and **blackwater fever** [1]. - Renal complications typically present as **acute tubular necrosis** rather than nephrotic syndrome. *P. ovale* - *P. ovale* causes **mild tertian malaria** similar to *P. vivax* and is also known for **relapses** due to hypnozoites [1]. - It is the least common form of malaria and is not typically associated with **nephrotic syndrome**.

Q: What condition is caused by the intake of exogenous steroids?

Cushing's syndrome. ***Cushing's syndrome*** - **Exogenous steroid intake** is the most common cause of Cushing's syndrome, leading to symptoms associated with **excess cortisol** [1]. - This occurs because the steroids mimic the effects of **cortisol**, suppressing the body's natural production and leading to its characteristic signs and symptoms [2]. *Addison's disease* - This condition is characterized by **adrenal insufficiency**, meaning the adrenal glands produce too little **cortisol** and often **aldosterone**. - It is typically caused by autoimmune destruction of the adrenal glands, not by exogenous steroid intake. *Pheochromocytoma* - This is a rare tumor of the **adrenal medulla** that causes the overproduction of **catecholamines** (epinephrine and norepinephrine). - Symptoms include sudden, severe episodes of hypertension, palpitations, and sweating, unrelated to steroid intake. *Conn's syndrome* - Also known as **primary hyperaldosteronism**, this condition involves the overproduction of **aldosterone** by the adrenal glands. - It typically results in hypertension and hypokalemia and is not directly caused by exogenous steroid administration.

Question 1

Ataxia, nystagmus, and ophthalmoplegia are seen in which of the following conditions?

Accepted Answer

Wernicke encephalopathy

Answer

3rd nerve palsy

Answer

Myasthenia gravis

Answer

Chronic progressive external ophthalmoplegia

Question 2

What is the most common cause of ophthalmoplegia in adults?

Accepted Answer

Cranial nerve palsy

Answer

Myasthenia gravis

Answer

Diabetes mellitus

Answer

Trauma

Question 3

Serological testing of patient shows HBsAg, IgM anti-HBc and HBeAg positive. The patient has -

Accepted Answer

Acute hepatitis B with high infectivity

Answer

Chronic hepatitis with high infectivity

Answer

Acute on chronic hepatitis

Answer

Chronic hepatitis B with low infectivity (not acute)

Question 4

Meningitis with rash is seen in -

Accepted Answer

Neisseria meningitidis

Answer

H. influenzae

Answer

Strepto. agalactae

Answer

Pneumococcus

Question 5

Madarosis is seen in ?

Accepted Answer

Hypothyroidism

Answer

None of the options

Answer

Addison's disease

Answer

Acromegaly

Question 6

Which of the following is NOT typically seen in 3rd nerve palsy?

Accepted Answer

Loss of abduction

Answer

Mydriasis

Answer

Ptosis

Answer

Loss of light reflex

Question 7

An 86-year-old lady presented with severe constipation. She was a known hypertensive on medications for 10 years. In clinic, her BP was 157/98 mm Hg with a heart rate of 58/min. On taking her BP in the supine position, it was found to be 90/60 mm Hg. She had a recent history of depression. She is taking atenolol, thiazide, imipramine, haloperidol, and docusate. What is the next best step in the management?

Accepted Answer

Change imipramine and haloperidol to fluoxetine and risperidone and add bisacodyl for constipation

Answer

Change atenolol and thiazide to calcium channel blocker and ACE inhibitor and add bisacodyl for constipation

Answer

Only add bisacodyl for constipation and continue rest of the medications

Answer

Discontinue all her medications and start her on steroids

Question 8

Which type of malaria is most commonly associated with renal failure?

Accepted Answer

Falciparum

Answer

Vivax

Answer

Malariae

Answer

Ovale

Question 9

Which species of malaria is associated with nephrotic syndrome?

Accepted Answer

P. malariae

Answer

P. vivax

Answer

P. falciparum

Answer

P. ovale

Question 10

What condition is caused by the intake of exogenous steroids?

Accepted Answer

Cushing's syndrome

Answer

Addison's disease

Answer

Pheochromocytoma

Answer

Conn's syndrome

NEET-PG 2012 — Internal Medicine