NEET-PG 2013 - Internal Medicine Practice Questions

Q: Treatment of choice for prinzmetal's angina

Calcium Channel Blockers (CCBs). ***Calcium Channel Blockers (CCBs)*** - **Dihydropyridine** CCBs like nifedipine or amlodipine, and **non-dihydropyridine** CCBs like diltiazem or verapamil, are the **first-line agents** for Prinzmetal's angina [1]. - They work by **relaxing coronary smooth muscle**, preventing the vasospasm that causes the angina [1]. *Nitroglycerin* - **Nitroglycerin is effective** for acute relief of Prinzmetal's angina symptoms due to its **vasodilatory properties**. - However, it's typically used as **rescue therapy** and not as a long-term preventative treatment. *Beta-blockers* - Beta-blockers are **contraindicated** in Prinzmetal's angina as they can **worsen coronary vasospasm** by blocking beta-2 mediated vasodilation, leaving unopposed alpha-1 vasoconstriction [2]. - They can increase the **frequency and severity of attacks**. *Prazosin* - Prazosin is an **alpha-1 adrenergic blocker** used primarily for **hypertension** and benign prostatic hyperplasia. - While it can cause vasodilation, it is **not the treatment of choice** for Prinzmetal's angina and is less effective than CCBs in preventing coronary spasm.

Q: What is the drug of choice for bleeding oesophageal varices?

Octreotide. ***Octreotide*** - **Octreotide** is an analogue of **somatostatin** that reduces splanchnic blood flow and portal pressure, thereby decreasing bleeding from esophageal varices. - It is often used in the acute management of **bleeding esophageal varices** due to its rapid onset of action and favorable safety profile. *Ethanolamine oleate* - **Ethanolamine oleate** is a **sclerosing agent** used for endoscopic sclerotherapy of esophageal varices, not typically as the initial drug of choice for acute bleeding [1]. - It acts by causing inflammation and fibrosis of the varices, which can be effective but carries risks such as **esophageal ulceration** or perforation. *Propranolol* - **Propranolol** is a **non-selective beta-blocker** used for the prophylactic prevention of variceal bleeding, not for acute management of active bleeding. - It works by reducing portal venous pressure by decreasing cardiac output and splanchnic vasoconstriction. *Phytonadione* - **Phytonadione** (vitamin K1) is used to reverse **coumarin anticoagulant effects** or to treat **vitamin K deficiency**, which can contribute to bleeding but is not a direct treatment for variceal bleeding itself. - It helps in the synthesis of **coagulation factors II, VII, IX, and X**, thereby improving clotting.

Q: Which of the following conditions is least commonly associated with Pneumocystis carinii in AIDS?

Otic polypoid mass. ***Otic polypoid mass*** - While *Pneumocystis jirovecii* (formerly *carinii*) can cause **extrapulmonary disease** in immunocompromised patients, an **otic polypoid mass** is an extremely rare and atypical presentation. - Extrapulmonary manifestations usually involve organs with rich vascular supply, but ear involvement in this form is not a characteristic feature. *Pneumonia* - **Pneumocystis pneumonia (PCP)** is the **most common opportunistic infection** and AIDS-defining illness caused by *Pneumocystis jirovecii* in individuals with AIDS [1]. - It typically manifests as **fever, cough, and dyspnea** with characteristic imaging findings [1]. *Ophthalmic choroid lesion* - **Choroid lesions** due to *Pneumocystis jirovecii* are a recognized, albeit less common, **extrapulmonary manifestation** in immunocompromised patients, particularly those with AIDS. - These lesions are usually **asymptomatic** and discovered incidentally on funduscopic examination. *Meningitis* - Although *Pneumocystis jirovecii* causing **meningitis** is rare, it has been reported in severely immunocompromised individuals with AIDS, often as part of disseminated disease. - Central nervous system involvement signifies **widespread dissemination** and advanced immunosuppression.

Q: Which of the following is NOT a characteristic feature of systemic sclerosis?

Gottron's papules. ***Gottron's papules*** - **Gottron's papules** are pathognomonic for **dermatomyositis**, not systemic sclerosis. They are red, scaling papules found over the extensor surfaces of the metacarpophalangeal (MCP) and interphalangeal (IP) joints. - While both systemic sclerosis and dermatomyositis are connective tissue diseases, their distinct cutaneous manifestations aid in differentiation. *Acroosteolysis* - **Acroosteolysis** refers to the resorption of the distal phalanges, a common feature in systemic sclerosis, particularly in severe cases. - This symptom contributes to the characteristic digital abnormalities seen in the disease. *Calcinosis cutis* - **Calcinosis cutis** is the deposition of calcium in the skin and subcutaneous tissues, often seen in subsets of systemic sclerosis, especially the CREST syndrome. - It can manifest as firm, white-yellow nodules or plaques and contribute to skin breakdown. *Digital ulcers* - **Digital ulcers** are a frequent and debilitating complication of systemic sclerosis, resulting from severe **vasculopathy** [1] and **ischemia** [1]. - They are often painful and can lead to significant tissue loss and infection.

Q: A 25 year old female presents with generalized restriction of eye movement in all direction, intermittent ptosis, proximal muscle weakness and fatigability.Which is the MOST useful test in making the diagnosis?

Edrophonium test. ***Edrophonium test*** - The **Edrophonium test** (Tensilon test) is highly useful for diagnosing **myasthenia gravis** due to its rapid onset and short duration of action. - In a patient with suspected myasthenia gravis, such as this one presenting with **generalized restriction of eye movement**, **intermittent ptosis**, and **fatigable proximal muscle weakness**, the administration of edrophonium will lead to a temporary but significant improvement in muscle strength. It works by inhibiting the breakdown of acetylcholine, thereby increasing its availability at the neuromuscular junction [1]. *CPK* - **Creatine phosphokinase (CPK)** levels are typically normal in myasthenia gravis, as it is a disorder of the **neuromuscular junction**, not a primary muscle disease. - Elevated CPK levels usually indicate muscle damage, seen in conditions like **myositis** or **muscular dystrophies**, which are not suggested by the patient's symptoms. *EMG* - **Electromyography (EMG)**, specifically **repetitive nerve stimulation (RNS)** or **single-fiber EMG (SFEMG)**, can show characteristic decremental responses or increased jitter/blocking in myasthenia gravis [2], but it is less direct and often more invasive than the Edrophonium test for initial diagnostic confirmation. - While supportive, it is generally considered a secondary diagnostic tool after a strong clinical suspicion and is not the *most useful* initial test compared to the rapid symptomatic improvement seen with edrophonium. *Muscle biopsy* - A **muscle biopsy** is generally not useful in diagnosing myasthenia gravis as the muscle tissue itself is structurally normal. - This diagnostic tool is reserved for primary **muscle disorders** like muscular dystrophies or inflammatory myopathies, which would show characteristic histological changes.

Q: What are the key characteristics of Evans syndrome?

Autoimmune hemolytic anemia and immune thrombocytopenia. ***Autoimmune hemolytic anemia and immune thrombocytopenia*** - **Evans syndrome** is defined by the simultaneous or sequential occurrence of **autoimmune hemolytic anemia (AIHA)** and **immune thrombocytopenia (ITP)** [1], [2]. - Both conditions involve the immune system mistakenly attacking and destroying **red blood cells** and **platelets**, respectively [1], [2]. *Low lymphocyte and red blood cell counts* - While **red blood cell counts** are low in Evans syndrome due to AIHA, **lymphocyte counts** are not a defining characteristic; they can vary. - This option does not fully capture the dual autoimmune destruction of red blood cells and platelets specific to Evans syndrome. *High platelet and lymphocyte counts* - **Platelet counts** are **low** in Evans syndrome due to ITP, not high. - **Lymphocyte counts** are not characteristically high; a high count might suggest other conditions like leukemias or lymphomas. *A reduction in all blood cell types* - A reduction in all (red blood cells, white blood cells, and platelets) is known as **pancytopenia**, which is not the defining feature of Evans syndrome. - Evans syndrome specifically involves the destruction of **red blood cells** and **platelets**, but not necessarily all white blood cell types.

Q: Most common hematological malignancy associated with Rheumatoid Arthritis (RA)?

Large granular lymphocytic leukemia (LGLL). ***Large granular lymphocytic leukemia (LGLL)*** - **LGLL** is the most common hematological malignancy strongly associated with **rheumatoid arthritis (RA)**, often presenting with features such as **neutropenia** and splenomegaly. - Approximately 80% of patients with LGLL have a **T-cell phenotype**, and a significant subset experiences **autoimmune diseases**, with RA being the most frequent. *Diffuse large B cell lymphoma* - While patients with **RA** have an increased risk of **lymphoma**, **diffuse large B-cell lymphoma (DLBCL)** is a more aggressive type but not the most common hematologic malignancy directly associated with the disease itself in terms of prevalence [3]. - Inflammatory conditions like **RA** can contribute to chronic immune stimulation, increasing the risk of certain lymphomas, but LGLL holds a more direct and prevalent association [1]. *Chronic lymphocytic leukemia* - **Chronic lymphocytic leukemia (CLL)** is a lymphoproliferative disorder of **B lymphocytes**, but it does not have a particularly strong or common association with **RA** compared to LGLL [2]. - The elevated risk of hematological malignancies in RA patients typically points more towards lymphoproliferative disorders driven by specific immune dysregulations characteristic of RA. *T-cell prolymphocytic leukemia* - **T-cell prolymphocytic leukemia (T-PLL)** is a rare and aggressive **T-cell leukemia** that generally presents with a high white blood cell count and splenomegaly, but it is not commonly linked with **RA**. - Its clinical presentation and biology are distinct from the more indolent leukemias like LGLL that are often seen in conjunction with autoimmune conditions.

Q: What is the primary cause of Waterhouse-Friderichsen syndrome?

Adrenal hemorrhage after meningococcal infection. ***Adrenal hemorrhage after meningococcal infection*** - **Waterhouse-Friderichsen syndrome** is characterized by **massive, bilateral adrenal hemorrhage**, leading to acute adrenal insufficiency [1]. - It is most commonly associated with overwhelming **meningococcal sepsis**, particularly due to *Neisseria meningitidis* [1]. *Adrenal hemorrhage post malignancy* - While malignancies can cause adrenal hemorrhage, it is not the primary cause of **Waterhouse-Friderichsen syndrome**. - This syndrome is specifically linked to severe **bacterial sepsis**, not typically cancer-related adrenal bleeding [1]. *Congenital adrenal deficiency* - **Congenital adrenal hyperplasia (CAH)** involves genetic defects affecting cortisol synthesis, leading to chronic adrenal insufficiency. - It does not involve acute **adrenal hemorrhage** as seen in Waterhouse-Friderichsen syndrome. *Adrenal hemorrhage after corticosteroid withdrawal* - Abrupt withdrawal of corticosteroids can precipitate an **adrenal crisis** due to suppression of the hypothalamic-pituitary-adrenal (HPA) axis [2]. - However, it does not typically cause the characteristic **massive adrenal hemorrhage** seen in Waterhouse-Friderichsen syndrome [2].

Q: In inflammatory myopathy, which group of muscles is not affected

Ocular. ***Ocular*** - The **extraocular muscles** responsible for eye movement are generally spared in typical inflammatory myopathies, distinguishing them from other neuromuscular disorders. - Inflammatory myopathies primarily affect **skeletal muscles**, but **ocular muscles** have unique immunological and physiological properties that often protect them. *Facial* - While less commonly affected early in the disease, some inflammatory myopathies, particularly **dermatomyositis**, can eventually involve **facial muscles**, leading to weakness. - Involvement of **facial muscles** can manifest as difficulty with smiling, whistling, or closing the eyelids. *Proximal muscles of limb* - Inflammatory myopathies characteristically cause **proximal muscle weakness**, affecting muscles of the **shoulders, hips, and thighs** [1]. - This weakness often presents as difficulty climbing stairs, getting up from a chair, or lifting objects overhead [1]. *Distal muscles of limb* - While less common than proximal involvement, **distal muscle weakness** (affecting hands and feet) can occur in some subsets of inflammatory myopathies, such as **inclusion body myositis**. - This can lead to difficulties with fine motor tasks or foot drop.

Q: All of the following are features of Obstructive jaundice except:

Normal alkaline phosphatase. ***Normal alkaline phosphatase*** - In obstructive jaundice, alkaline phosphatase is typically **elevated** due to bile duct obstruction [2]. - A **normal level** suggests that the jaundice may not be of obstructive origin. *Pruritis* - Often seen in obstructive jaundice due to **bile salts** accumulating in the bloodstream, leading to itching. - It is a common symptom associated with **cholestasis**. *Mildly elevated serum aminotransferases level* - In obstructive jaundice, serum aminotransferases are usually elevated, though may be mildly in early cases [1]. - This reflects liver involvement, which is consistent with biliary obstruction [2]. *Clay colour stools* - Clay-colored stools arise from the absence of **bile** in the intestines, indicative of obstruction [3]. - This is a direct result of blockage in the bile duct system affecting stool pigmentation [3].

Question 1

Treatment of choice for prinzmetal's angina

Accepted Answer

Calcium Channel Blockers (CCBs)

Answer

Nitroglycerin

Answer

Prazosin

Answer

Beta-blockers

Question 2

What is the drug of choice for bleeding oesophageal varices?

Accepted Answer

Octreotide

Answer

Ethanolamine oleate

Answer

Propanolol

Answer

Phytonadione

Question 3

Which of the following conditions is least commonly associated with Pneumocystis carinii in AIDS?

Accepted Answer

Otic polypoid mass

Answer

Meningitis

Answer

Pneumonia

Answer

Ophthalmic choroid lesion

Question 4

Which of the following is NOT a characteristic feature of systemic sclerosis?

Accepted Answer

Gottron's papules

Answer

Calcinosis cutis

Answer

Digital ulcers

Answer

Acroosteolysis

Question 5

A 25 year old female presents with generalized restriction of eye movement in all direction, intermittent ptosis, proximal muscle weakness and fatigability.Which is the MOST useful test in making the diagnosis?

Accepted Answer

Edrophonium test

Answer

CPK

Answer

EMG

Answer

Muscle biopsy

Question 6

What are the key characteristics of Evans syndrome?

Accepted Answer

Autoimmune hemolytic anemia and immune thrombocytopenia

Answer

Low lymphocyte and red blood cell counts

Answer

High platelet and lymphocyte counts

Answer

A reduction in all blood cell types

Question 7

Most common hematological malignancy associated with Rheumatoid Arthritis (RA)?

Accepted Answer

Large granular lymphocytic leukemia (LGLL)

Answer

Diffuse large B cell lymphoma

Answer

Chronic lymphocytic leukemia

Answer

T-cell prolymphocytic leukemia

Question 8

What is the primary cause of Waterhouse-Friderichsen syndrome?

Accepted Answer

Adrenal hemorrhage after meningococcal infection

Answer

Adrenal hemorrhage post malignancy

Answer

Adrenal hemorrhage after corticosteroid withdrawal

Answer

Congenital adrenal deficiency

Question 9

In inflammatory myopathy, which group of muscles is not affected

Accepted Answer

Ocular

Answer

Facial

Answer

Proximal muscles of limb

Answer

Distal muscles of limb

Question 10

All of the following are features of Obstructive jaundice except:

Accepted Answer

Normal alkaline phosphatase

Answer

Clay colour stools

Answer

Pruritis

Answer

Elevated serum aminotransferases level

NEET-PG 2013 — Internal Medicine