NEET-PG 2013 - Internal Medicine Practice Questions

Q: A diabetic patient presents with sensory involvement, tingling, numbness, ankle swelling, and absence of pain. What is the most likely diagnosis?

Charcot's joint. ***Charcot's joint*** - This condition is characterized by **neuropathic arthropathy**, resulting from nerve damage (often due to **diabetes**), leading to sensory involvement, **numbness**, and **absence of pain** [1]. - The loss of protective sensation and repeated microtrauma contribute to joint destruction, often manifesting as **swelling** and deformity, particularly in the feet and ankles [1]. *Gout* - Gout typically presents with sudden, severe episodes of **pain**, redness, and swelling in a single joint, most commonly the **big toe**. - It is caused by **uric acid crystal deposition** and is not primarily associated with sensory deficits or chronic painless swelling. *Rheumatoid arthritis* - This is a **chronic autoimmune** inflammatory disease primarily affecting the **small joints** of the hands and feet symmetrically, causing pain, stiffness, and swelling. - It does not typically present with sensory neuropathy or painless joint destruction in the way described. *Ankylosing spondylitis* - This is a **chronic inflammatory disease** primarily affecting the **spine and sacroiliac joints**, causing progressive stiffness and pain that improves with activity. - It is not associated with peripheral joint neuropathy, numbness, or painless ankle swelling [1].

Q: Which of the following is a sign of Bartter's syndrome?

Low potassium levels. ***Low potassium levels*** * Bartter's syndrome is characterized by **renal salt wasting** and subsequent volume depletion, which activates the **renin-angiotensin-aldosterone system** [1]. * This leads to increased aldosterone levels, causing increased potassium secretion in the collecting ducts, resulting in **hypokalemia** [2]. *High potassium levels* * **Hyperkalemia** is not a feature of Bartter's syndrome; instead, it is marked by persistent potassium loss [1]. * Conditions causing hyperkalemia typically involve impaired renal potassium excretion or increased potassium release from cells. *Acidic blood* * Bartter's syndrome usually presents with **metabolic alkalosis** due to hydrogen ion loss in the urine, not acidic blood [2]. * Acidic blood (**acidemia**) would imply a state of respiratory or metabolic acidosis. *High sodium levels* * Bartter's syndrome primarily involves **renal salt wasting**, leading to **normal or low sodium levels** rather than high sodium levels. * High sodium levels (**hypernatremia**) are usually due to inadequate water intake or excessive water loss.

Q: Use of spironolactone in liver cirrhosis is

Decrease edema. ***Decrease edema*** - Spironolactone is an **aldosterone antagonist** that blocks the effects of aldosterone, which is often elevated in liver cirrhosis. - By antagonizing aldosterone, spironolactone promotes **sodium and water excretion**, directly leading to a reduction in **ascites and peripheral edema** [1]. *May improve liver function indirectly* - While spironolactone manages complications of liver cirrhosis, it does **not directly improve liver function** or reverse liver damage. - Its primary role is in **symptom management**, particularly fluid retention, not in healing the underlying liver disease. *May decrease afterload* - Spironolactone's primary action is on the **kidneys** to promote diuresis; it is **not a vasodilator** and therefore does not directly decrease cardiac afterload. - Any effect on systemic vascular resistance would be minimal and secondary to volume changes rather than a direct vasodilatory property. *May decrease intravascular volume* - Spironolactone **decreases total body sodium and water**, leading to a reduction in extravascular fluid (edema and ascites) [1]. - While it decreases the total amount of fluid in the body, its main effect is on **extravascular volume**, and it's chosen over loop diuretics in cirrhosis to prevent **excessive intravascular depletion** which can worsen renal function.

Q: Metabolic change in severe vomiting is

Metabolic alkalosis due to loss of gastric acid. **Metabolic alkalosis due to loss of gastric acid** - Severe vomiting leads to the loss of **hydrochloric acid (HCl)** from the stomach, causing an increase in plasma bicarbonate and subsequently **metabolic alkalosis** [1], [3]. - This condition is often accompanied by **hypokalemia** due to renal compensation and increased aldosterone activity [1]. *Respiratory alkalosis due to hyperventilation* - **Hyperventilation** causes a decrease in arterial partial pressure of carbon dioxide (PaCO2), leading to **respiratory alkalosis** [2]. - While vomiting can sometimes cause mild hyperventilation due to discomfort, the primary metabolic derangement from severe vomiting is related to acid loss, not CO2 expulsion [4]. *Hyperkalemia due to renal dysfunction* - **Hyperkalemia** is an elevated potassium level, typically associated with **renal failure** or certain medications. - In severe vomiting, the loss of gastric fluid and subsequent fluid shifts tend to cause **hypokalemia** as the kidneys try to conserve hydrogen and excrete potassium [1]. *Metabolic acidosis due to renal failure* - **Metabolic acidosis** is characterized by a decrease in blood pH and bicarbonate, often caused by the accumulation of acids or loss of bicarbonate [3]. - **Renal failure** is a common cause of metabolic acidosis due to impaired acid excretion, which is not the primary issue in severe vomiting.

Q: Adrenal reserve is best tested by means of infusion with

ACTH. ACTH - The **ACTH stimulation test**, also known as the **cosyntropin test**, is the most common dynamic test for assessing adrenal reserve. - Exogenous ACTH (cosyntropin) stimulates the adrenal glands to produce cortisol; a subnormal response indicates adrenal insufficiency. *Corticosteroids* - **Corticosteroids** are hormones (like cortisol) produced by the adrenal glands, or synthetic versions used as medications; they do not test adrenal reserve but rather *replace* adrenal function. - Administering corticosteroids would interfere with, rather than assess, the adrenal gland's ability to produce its own hormones. *LHRH* - **Luteinizing hormone-releasing hormone (LHRH)** is used to assess the function of the anterior pituitary gland and gonads, not the adrenal glands. - An LHRH stimulation test evaluates the pituitary's ability to release LH and FSH, which in turn stimulate gonadal hormone production. *Metyrapone* - The **metyrapone test** assesses the integrity of the **hypothalamic-pituitary-adrenal axis** by blocking cortisol synthesis, which should lead to an increase in ACTH and 11-deoxycortisol [1]. - While it evaluates a part of adrenal function, it is primarily used to differentiate between primary and secondary adrenal insufficiency, and not a direct measure of cortisol production capacity in response to stimulation.

Q: What is the recommended time frame for completing a blood transfusion after initiation?

1-4 hours. ***1-4 hours*** - This timeframe is recommended to **minimize the risk of bacterial growth** in the blood product, as bacteria can multiply quickly at room temperature. - Completing the transfusion within 4 hours also reduces the likelihood of **red blood cell degeneration** and loss of efficacy. *3-6 hours* - This period extends beyond the recommended maximum of 4 hours, increasing the risk of **bacterial proliferation** in the blood product. - Prolonged infusion times can also lead to a **decrease in the viability and function** of transfused cells. *4-8 hours* - Transfusing over 4-8 hours significantly elevates the risk of **bacterial contamination** and potential septic reactions. - The extended duration compromises the **quality and safety** of the blood product. *8-12 hours* - This timeframe is unacceptably long for a blood transfusion, posing a **critical risk of severe bacterial growth** and infection. - Blood products should not be administered beyond 4 hours due to the rapid decline in **cell integrity and increased adverse reaction potential**.

Q: What is the recommended rate of correction for sodium deficit in patients with chronic hyponatremia?

0.5 mmol/hour. ***0.5 mmol/hour*** [1] - This rate of correction is recommended to avoid **osmotic demyelination syndrome (ODS)**, also known as central pontine myelinolysis [1]. - The aim is to correct the sodium deficit gradually, with a maximum increase not exceeding **8-10 mmol/L in any 24-hour period** [1]. *1 mmol/hour* - This rate is generally considered too rapid for chronic hyponatremia and increases the risk of **osmotic demyelination syndrome**. - While acceptable in some acute severe cases, it is typically avoided in chronic settings where the brain has adapted to lower osmolality. *1.5 mmol/hour* - This rate would lead to an even faster correction of sodium, significantly elevating the risk of **osmotic demyelination syndrome**. - It would result in a correction of 36 mmol/L over 24 hours, far exceeding the recommended daily limit of 8-10 mmol/L. *2.0 mmol/hour* - Such a rapid correction rate is highly dangerous and almost guarantees the development of **osmotic demyelination syndrome**. - This aggressive correction would lead to severe brain injury due to rapid osmotic shifts.

Q: Graham Steell murmur is associated with which of the following conditions?

Pulmonary Regurgitation (PR). ***Pulmonary Regurgitation (PR)*** - The **Graham Steell murmur** is a high-pitched, decrescendo early diastolic murmur heard best at the left sternal border associated with **pulmonary hypertension**. [1] - It results from dilation of the pulmonary artery due to **elevated pulmonary pressures**, leading to functional pulmonary valve regurgitation. [1] *Tricuspid Regurgitation (TR)* - TR typically presents as a **holosystolic murmur** best heard at the left lower sternal border, often increasing with inspiration (Carvallo's sign). - It is caused by improper coaptation of the tricuspid valve leaflets, often due to **right ventricular dilation**. *Tricuspid Stenosis (TS)* - TS is characterized by a **diastolic rumble** heard best at the lower left sternal border, often with an opening snap. [2] - It is relatively rare and often associated with **rheumatic heart disease**. *Pulmonary Stenosis (PS)* - PS typically produces a **systolic ejection murmur** heard at the upper left sternal border, often radiating to the back. - It is caused by **obstruction to blood flow** from the right ventricle to the pulmonary artery.

Q: Deep vein thrombosis most commonly occurs at which site?

Femoral vein. ***Femoral vein*** - The **femoral vein**, along with the **popliteal** and **iliac veins**, are the most common sites for **deep vein thrombosis (DVT)** in the lower extremities [1]. - Due to their size and the dynamics of blood flow in these regions, they are prone to clot formation, especially in the presence of **Virchow's triad**. *Subclavian vein* - While DVT can occur in the subclavian vein (an **upper extremity DVT**), it is less common than in the lower extremities [1]. - Upper extremity DVTs are often associated with **central venous catheters** or **thoracic outlet syndrome**. *External jugular vein* - **External jugular vein thrombosis** is rare and usually associated with local trauma, infection, or central line placement, not typically primary DVT [1]. - It is a superficial vein and not considered a common site for typical deep vein thrombosis. *Internal jugular vein* - **Internal jugular vein thrombosis** is also uncommon as a primary DVT and often secondary to neck infections, malignancies, or indwelling catheters [1]. - Like the subclavian vein, it's considered an upper extremity DVT site, but less frequent than lower extremity sites.

Q: Decreased CVP is seen in

Bacterial sepsis. ***Bacterial sepsis*** - In **sepsis**, widespread **vasodilation** and increased capillary permeability lead to significant fluid redistribution out of the intravascular space [3]. - This results in a decrease in **venous return** and thus a lower **central venous pressure (CVP)** due to relative hypovolemia [2]. *Pneumothorax* - A **pneumothorax** causes increased intrathoracic pressure, compressing the great veins and heart. - This leads to **reduced venous return** and typically an *increase* in CVP, or at least a minimal change, due to obstructed outflow from the right atrium, not a decrease [2]. *PEEP* - **Positive end-expiratory pressure (PEEP)** increases intrathoracic pressure, which impedes venous return to the right atrium [2]. - This elevated pressure can artificially *increase* the measured CVP reading, and it does not typically cause a decrease in intrinsic CVP [2]. *Heart failure* - In **heart failure**, particularly right-sided heart failure or biventricular failure, the heart's pumping efficiency is reduced [1]. - This leads to **venous congestion** and an *increase* in CVP due to fluid overload and the inability of the right ventricle to effectively pump blood forward [2].

Question 1

A diabetic patient presents with sensory involvement, tingling, numbness, ankle swelling, and absence of pain. What is the most likely diagnosis?

Accepted Answer

Charcot's joint

Answer

Gout

Answer

Rheumatoid arthritis

Answer

Ankylosing spondylitis

Question 2

Which of the following is a sign of Bartter's syndrome?

Accepted Answer

Low potassium levels

Answer

High potassium levels

Answer

Acidic blood

Answer

High sodium levels

Question 3

Use of spironolactone in liver cirrhosis is

Accepted Answer

Decrease edema

Answer

May improve liver function indirectly

Answer

May decrease afterload

Answer

May decrease intravascular volume

Question 4

Metabolic change in severe vomiting is

Accepted Answer

Metabolic alkalosis due to loss of gastric acid

Answer

Respiratory alkalosis due to hyperventilation

Answer

Hyperkalemia due to renal dysfunction

Answer

Metabolic acidosis due to renal failure

Question 5

Adrenal reserve is best tested by means of infusion with

Accepted Answer

ACTH

Answer

Metyrapone

Answer

Corticosteroids

Answer

LHRH

Question 6

What is the recommended time frame for completing a blood transfusion after initiation?

Accepted Answer

1-4 hours

Answer

3-6 hours

Answer

4-8 hours

Answer

8-12 hours

Question 7

What is the recommended rate of correction for sodium deficit in patients with chronic hyponatremia?

Accepted Answer

0.5 mmol/hour

Answer

1 mmol/hour

Answer

1.5 mmol/hour

Answer

2.0 mmol/hour

Question 8

Graham Steell murmur is associated with which of the following conditions?

Accepted Answer

Pulmonary Regurgitation (PR)

Answer

Tricuspid Regurgitation (TR)

Answer

Tricuspid Stenosis (TS)

Answer

Pulmonary Stenosis (PS)

Question 9

Deep vein thrombosis most commonly occurs at which site?

Accepted Answer

Femoral vein

Answer

Subclavian vein

Answer

External jugular vein

Answer

Internal jugular vein

Question 10

Decreased CVP is seen in

Accepted Answer

Bacterial sepsis

Answer

PEEP

Answer

Heart failure

Answer

Pneumothorax

NEET-PG 2013 — Internal Medicine