NEET-PG 2013 - Internal Medicine Practice Questions

Q: Which of the following is a characteristic finding in distal RTA?

Hypercalciuria. ***Hypercalciuria*** - **Hypercalciuria** is a characteristic finding in distal RTA (Type 1), leading to increased calcium in the urine. - This occurs due to reduced **distal tubular reabsorption of calcium** and increased bone resorption from chronic acidosis. *Urine pH 5.5** [1]. - A urine pH < 5.5 would suggest a normal kidney response to systemic acidosis, ruling out distal RTA. *Hypokalemia* - While hypokalemia can occur in distal RTA, it is not always present and is not the most definitive characteristic finding. - **Hypokalemia** is more characteristic of Type 1 RTA due to increased potassium excretion in an attempt to excrete H+ ions. *Nephrolithiasis* - **Nephrolithiasis** (kidney stones) is a common complication of distal RTA due to hypercalciuria and alkaline urine [2]. - However, hypercalciuria is the *reason* for the increased risk of nephrolithiasis, making it a more fundamental characteristic finding.

Q: Which of the following is not a feature of distal renal tubular acidosis

Hyperkalemia. ***Hyperkalemia*** - **Distal renal tubular acidosis (dRTA)** is characterized by impaired acid excretion, leading to metabolic acidosis. The impaired excretion of acid is often accompanied by impaired potassium secretion, resulting in **hypokalemia**, not hyperkalemia. - While hyperkalemia is a feature of **type 4 RTA**, which is characterized by hypoaldosteronism or renal tubular unresponsiveness to aldosterone, it is not a feature of **distal RTA (type 1)**. [1] *Normal anion gap* - **Distal RTA** is a form of **normal anion gap metabolic acidosis**, also known as **hyperchloremic metabolic acidosis**. [1] - The anion gap is calculated as [Na+] - ([Cl-] + [HCO3-]), and in dRTA, the bicarbonate loss is compensated by an increase in chloride, maintaining a normal anion gap. *Renal hypercalciuria* - **Distal RTA** is associated with **impaired acid excretion**, which leads to chronic metabolic acidosis. - This **acidosis** promotes the dissolution of bone, releasing calcium, and decreases tubular reabsorption of calcium, resulting in **hypercalciuria**. *Alkaline urine* - In **distal RTA**, the distal tubule is unable to acidify the urine due to a defect in hydrogen ion secretion. - This leads to a persistent **urine pH > 5.5** (typically alkaline or inappropriately normal) despite systemic acidosis, making it a key diagnostic feature. [1]

Q: Hyperkalemia aciduria is seen in

Type IV Renal Tubular Acidosis. Type IV Renal Tubular Acidosis - This condition is characterized by **hyperkalemia** and **aciduria**, often due to a deficiency in aldosterone or a renal tubular insensitivity to aldosterone [1]. - The impaired aldosterone action leads to reduced potassium excretion and decreased ammonium production, both contributing to **hyperkalemia** and metabolic acidosis [1]. *Type I Renal Tubular Acidosis* - Type I RTA (distal RTA) is characterized by a defect in acid secretion in the distal tubule, leading to **hypokalemia** and metabolic acidosis with persistently high urine pH [2]. - Patients typically excrete an alkaline urine despite systemic acidosis, contrasting with the aciduria seen with hyperkalemia [2]. *Sigmoidocolostomy procedure* - A sigmoidocolostomy can lead to **hyperchloremic metabolic acidosis** due to the reabsorption of chloride and excretion of bicarbonate by the colonic mucosa. - However, it typically causes **hypokalemia** as potassium is secreted into the colonic lumen from the blood. *Type II Renal Tubular Acidosis* - Type II RTA (proximal RTA) involves a defect in bicarbonate reabsorption in the proximal tubule, resulting in **hypokalemia** and metabolic acidosis. - The kidney's ability to acidify urine is still largely intact in the distal nephron once the bicarbonate buffer system is overwhelmed.

Q: A diabetic patient presents with hyperkalemia and urinary pH < 5.5. What is the MOST likely underlying cause?

Type IV RTA. ***Type IV RTA*** - Patients with **diabetes mellitus** frequently develop **hyporeninemic hypoaldosteronism**, leading to Type IV RTA [1]. - This condition is characterized by **hyperkalemia** and **acidosis** with a paradoxically low urinary pH (typically < 5.5). *Uremia* - **Uremia** can cause hyperkalemia and acidosis, but it is a broader term for severe kidney failure and not the most specific underlying cause for the given urinary findings. - While patients with uremia can have aciduria, the combination of **diabetic hyperkalemia** and acid urine points more directly to a specific tubular defect. *Primary hyperaldosteronism* - **Primary hyperaldosteronism** is characterized by **hypertension**, **hypokalemia**, and metabolic alkalosis, which is the opposite of the patient's presentation [1]. - This condition involves excessive aldosterone production, leading to increased potassium excretion [1]. *Type I Renal tubular acidosis* - **Type I RTA** (distal RTA) is characterized by the inability to acidify urine, resulting in a **urinary pH > 5.5** despite systemic acidosis [1]. - While it can cause hypokalemia (due to increased distal K+ secretion) and acidosis, the elevated urinary pH is a key differentiating factor from this patient's presentation [1].

Q: Which neurological condition is commonly associated with Alice in Wonderland Syndrome?

Epileptic seizures. ***Epileptic seizures*** - **Alice in Wonderland Syndrome (AIWS)**, characterized by distortions of visual perception, body image, and sense of time, is often reported as an **aura or part of focal epileptic seizures**, particularly those originating in the temporal or parietal lobes. - The **transient and episodic nature** of AIWS symptoms aligns well with the paroxysmal electrical activity seen in epilepsy. *Subacute sclerosing panencephalitis (SSPE)* - **SSPE** is a rare, fatal brain disorder caused by a persistent **measles virus infection**, primarily affecting children and young adults. - While it causes progressive neurological deterioration, including cognitive decline, motor dysfunction, and seizures, **Alice in Wonderland Syndrome** is not a characteristic or commonly associated symptom. *Cerebral hemorrhage* - A **cerebral hemorrhage** involves bleeding within the brain tissue, leading to acute neurological deficits depending on the location and size of the bleed. - Although it can cause a variety of symptoms, such as headache, weakness, and altered consciousness, **Alice in Wonderland Syndrome** is not a typical manifestation of acute hemorrhage. *Multiple sclerosis* - **Multiple sclerosis (MS)** is a chronic autoimmune disease affecting the central nervous system, leading to demyelination and neurological symptoms. - Common symptoms involve motor, sensory, visual, and cognitive deficits, but **Alice in Wonderland Syndrome** is not a recognized or common neurological manifestation of MS.

Q: What is the primary clinical feature of Henoch-Schonlein purpura?

Skin rash characterized by palpable purpura. ***Skin rash characterized by palpable purpura*** - **Palpable purpura** is the hallmark cutaneous manifestation of **Henoch-Schonlein purpura (HSP)**, a small-vessel vasculitis [1]. - This rash typically appears on the **lower extremities and buttocks**, reflecting the deposition of IgA in vessel walls [1]. *Abdominal pain due to vasculitis* - While **abdominal pain** is a common feature of HSP due to gastrointestinal vasculitis, it is not considered the primary clinical feature [1]. - Gastrointestinal involvement can manifest with pain, bleeding, and intussusception, but the **skin rash** is more consistently present and diagnostic. *Joint pain associated with the condition* - **Arthralgia** or **arthritis** (joint pain) is seen in a significant number of HSP patients, particularly in the knees and ankles. - However, it is a secondary manifestation, and not the **defining primary sign** of the disease. *Kidney involvement in the disease* - **Renal involvement**, presenting as hematuria and proteinuria, occurs in about one-third of HSP cases and can lead to serious long-term complications. - Despite its significance for prognosis, **kidney disease** is a later and not universally present feature, making the rash the most critical initial diagnostic clue.

Q: Interstitial nephritis is common with

Nonsteroidal anti-inflammatory drugs (NSAIDs). ***Nonsteroidal anti-inflammatory drugs (NSAIDs)*** - **NSAIDs** are a known cause of **acute interstitial nephritis** (AIN), an inflammatory condition affecting the tubules and interstitium of the kidney [1]. - This adverse reaction often manifests as **fever**, **rash**, **eosinophilia**, and **acute kidney injury**, typically 7-10 days after drug exposure. *Black water fever* - **Blackwater fever** is a severe complication of **malaria**, characterized by massive hemolysis leading to **hemoglobinuria**, which darkens the urine. - It primarily causes **acute kidney injury** through **acute tubular necrosis** due to hemoglobin precipitation in the renal tubules, not interstitial nephritis. *Rhabdomyolysis* - **Rhabdomyolysis** involves the breakdown of muscle tissue, releasing myoglobin into the bloodstream, which is toxic to the kidneys. [1] - This condition leads to **acute kidney injury** predominantly through **acute tubular necrosis** due to myoglobin casts obstructing tubules and direct toxicity, not interstitial inflammation. *Tumor lysis syndrome* - **Tumor lysis syndrome** occurs when large numbers of cancer cells are rapidly destroyed, releasing intracellular contents like potassium, phosphate, and nucleic acids. - The high concentration of **uric acid** and **phosphate** in the renal tubules leads to crystal formation, causing **acute kidney injury** primarily through **acute uric acid nephropathy** and **phosphate nephropathy**, rather than interstitial nephritis [1].

Q: What is the purpose of the Queckenstedt test?

Spinal block. ***Spinal block*** - The Queckenstedt test was historically used to evaluate for a **spinal block**, which is an obstruction to the free flow of **cerebrospinal fluid (CSF)** in the subarachnoid space. - It involves observing the rise in **CSF pressure** in response to compression of the jugular veins; a blunted or absent rise suggests a block. *Glomus tumor* - **Glomus tumors** are usually benign and arise from glomus bodies, often presenting as painful lesions in the nail bed. - Their diagnosis is typically made through **imaging** and **biopsy**, not specific pressure tests. *Otosclerosis* - **Otosclerosis** is a condition causing progressive hearing loss due to abnormal bone growth in the middle ear. - Diagnosis involves **audiometry** and **tympanometry**, and it is unrelated to CSF flow or spinal blocks. *Acoustic neuroma* - An **acoustic neuroma** is a benign tumor of the vestibulocochlear nerve (cranial nerve VIII) that causes hearing loss, tinnitus, and balance issues. - Diagnosis relies on **MRI of the brain**, and the Queckenstedt test has no role in its evaluation.

Q: Where is Schatzki's Ring present?

Lower end of esophagus. ***Lower end of esophagus*** - **Schatzki's Ring** is a localized narrowing that can occur at the **gastroesophageal junction**, specifically at the squamocolumnar junction. - This ring is a common cause of intermittent **dysphagia** for solid foods. [2] *Upper end of trachea* - The upper end of the trachea is the **larynx** or a region just below it, which is anatomically distinct from the esophagus. - Constrictions in this area are generally unrelated to Schatzki's Ring and typically involve conditions like **subglottic stenosis**. *Upper end of esophagus* - The upper end of the esophagus contains the **upper esophageal sphincter** (UES), which is a muscular structure. [3] - While strictures can occur here, they are not referred to as Schatzki's Ring. *Lower end of trachea* - The lower end of the trachea **bifurcates into the bronchi** and is part of the respiratory system. [1] - Anatomically, it is separate from the esophagus, and issues here would be related to respiratory conditions, not Schatzki's Ring.

Q: In head injury, unilateral dilatation of the pupil is seen due to?

Oculomotor nerve compression. Oculomotor nerve compression - Unilateral pupillary dilation, often referred to as a **blown pupil**, is a classic sign of **oculomotor nerve (CN III) compression** due to increased intracranial pressure, typically from a **herniating uncus** [1]. - The parasympathetic fibers responsible for pupillary constriction run on the superficial aspect of the oculomotor nerve and are thus vulnerable to extrinsic compression [1], [2]. *Ophthalmic N. compression* - The **ophthalmic nerve (CN V1)** is a sensory nerve responsible for sensation to the forehead, scalp, upper eyelid, and cornea, not pupillary control. - Compression of this nerve would cause **sensory deficits** in its distribution and potentially abolish the **corneal reflex**, but not pupillary dilation. *Trigeminal N. compression* - The **trigeminal nerve (CN V)** is primarily responsible for sensation to the face and motor control of the muscles of mastication. - Compression would lead to **facial numbness or pain** and **weakness in chewing**, with no direct impact on pupillary size. *None of the options* - This option is incorrect because oculomotor nerve compression is a well-established cause of unilateral pupillary dilation in head injuries [1].

Question 1

Which of the following is a characteristic finding in distal RTA?

Accepted Answer

Hypercalciuria

Answer

Urine pH < 5.5

Answer

Hypokalemia

Answer

Nephrolithiasis

Question 2

Which of the following is not a feature of distal renal tubular acidosis

Accepted Answer

Hyperkalemia

Answer

Renal hypercalciuria

Answer

Normal anion gap

Answer

Alkaline urine

Question 3

Hyperkalemia aciduria is seen in

Accepted Answer

Type IV Renal Tubular Acidosis

Answer

Type I Renal Tubular Acidosis

Answer

Sigmoidocolostomy procedure

Answer

Type II Renal Tubular Acidosis

Question 4

A diabetic patient presents with hyperkalemia and urinary pH < 5.5. What is the MOST likely underlying cause?

Accepted Answer

Type IV RTA

Answer

Uremia

Answer

Primary hyperaldosteronism

Answer

Type I Renal tubular acidosis

Question 5

Which neurological condition is commonly associated with Alice in Wonderland Syndrome?

Accepted Answer

Epileptic seizures

Answer

Subacute sclerosing panencephalitis (SSPE)

Answer

Cerebral hemorrhage

Answer

Multiple sclerosis

Question 6

What is the primary clinical feature of Henoch-Schonlein purpura?

Accepted Answer

Skin rash characterized by palpable purpura

Answer

Abdominal pain due to vasculitis

Answer

Joint pain associated with the condition

Answer

Kidney involvement in the disease

Question 7

Interstitial nephritis is common with

Accepted Answer

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Answer

Black water fever

Answer

Rhabdomyolysis

Answer

Tumor lysis syndrome

Question 8

What is the purpose of the Queckenstedt test?

Accepted Answer

Spinal block

Answer

Glomus tumor

Answer

Otosclerosis

Answer

Acoustic neuroma

Question 9

Where is Schatzki's Ring present?

Accepted Answer

Lower end of esophagus

Answer

Upper end of trachea

Answer

Upper end of esophagus

Answer

Lower end of trachea

Question 10

In head injury, unilateral dilatation of the pupil is seen due to?

Accepted Answer

Oculomotor nerve compression

Answer

Ophthalmic N. compression

Answer

Trigeminal N. compression

Answer

None of the options

NEET-PG 2013 — Internal Medicine