Hyperpigmentation is seen with which hormone?
Which of the following is NOT a criterion for the diagnosis of Primary Hyperaldosteronism?
Most common cause of Addison's Disease in India is:
Female with blood sugar of 600 mg% and sodium of 110 mEq. Insulin was given, what will happen to serum sodium levels ?
What condition is characterized by hypertension and hypokalemia?
Which of the following is the MOST common condition caused by hypernatremia?
In a patient with hypoglycemia, what is the appropriate dose adjustment of insulin?
In the context of ventricular tachycardia, what do extra systoles appear as on an electrocardiogram (ECG)?
What is the most common arrhythmia in ICU patients?
A patient with first-degree heart block presents with dizziness. What is the most appropriate management for this patient?
NEET-PG 2015 - Internal Medicine NEET-PG Practice Questions and MCQs
Question 51: Hyperpigmentation is seen with which hormone?
- A. TSH
- B. ACTH (Correct Answer)
- C. FSH
- D. LH
Explanation: ***ACTH*** - In conditions like **Addison's disease**, the adrenal glands' inability to produce cortisol leads to increased **ACTH** (adrenocorticotropic hormone) secretion due to a lack of negative feedback [3], [4]. - ACTH is derived from proopiomelanocortin (POMC), which also gives rise to alpha-melanocyte-stimulating hormone (α-MSH). Elevated ACTH levels can thus stimulate melanocytes, causing **hyperpigmentation** in skin folds, buccal mucosa, and pressure points [4]. *FSH* - **FSH** (follicle-stimulating hormone) primarily regulates the development of **follicles in the ovaries** and sperm production in the testes [1]. - There is no known direct association between excessive FSH levels and **hyperpigmentation**. *TSH* - **TSH** (thyroid-stimulating hormone) stimulates the **thyroid gland** to produce thyroid hormones (T3 and T4) [1]. - While thyroid disorders can affect skin texture and moisture, there is no direct link between elevated TSH and **hyperpigmentation**. *LH* - **LH** (luteinizing hormone) plays a key role in **ovulation** in females and testosterone production in males [2]. - High LH levels are not associated with **hyperpigmentation**.
Question 52: Which of the following is NOT a criterion for the diagnosis of Primary Hyperaldosteronism?
- A. Diastolic Hypertension without edema
- B. Low Plasma Renin Activity
- C. Hyperkalemia (Correct Answer)
- D. Hyperaldosteronism which is not suppressed by volume expansion
Explanation: Primary hyperaldosteronism is typically characterized by **hypokalemia** due to excessive aldosterone-mediated potassium excretion in the urine, not hyperkalemia [1]. Hyperkalemia would suggest other conditions, such as **adrenal insufficiency** or kidney disease, rather than primary hyperaldosteronism [2]. *Diastolic Hypertension without edema* - **Diastolic hypertension** is a common presentation of primary hyperaldosteronism due to increased **sodium and water retention**, leading to expanded extracellular volume. - The absence of significant edema is also common, as the body often develops an **"escape phenomenon"** where natriuresis occurs despite high aldosterone, preventing overt fluid overload [3]. *Low Plasma Renin Activity* - In primary hyperaldosteronism, the high aldosterone levels **suppress renin secretion** through negative feedback mechanisms. - Therefore, a **low plasma renin activity** (PRA) or plasma renin concentration (PRC) is a key diagnostic feature [4]. *Hyperaldosteronism which is not suppressed by volume expansion* - Normally, volume expansion would suppress aldosterone secretion. However, in primary hyperaldosteronism, aldosterone production is **autonomous** and remains elevated even after volume expansion. - This lack of suppression is a critical diagnostic criterion, often assessed through various **confirmatory tests** like saline infusion or oral sodium loading.
Question 53: Most common cause of Addison's Disease in India is:
- A. Autoimmune
- B. HIV
- C. Tuberculosis (Correct Answer)
- D. Malignancy
Explanation: ***Tuberculosis*** - In India, **tuberculosis** is the most common cause of **Addison's disease** due to the high prevalence of TB infections. - Adrenal involvement in TB can lead to gradual destruction of the adrenal cortex, resulting in **adrenal insufficiency**. *Autoimmune* - **Autoimmune adrenalitis** is the leading cause of Addison's disease in developed Western countries. - It involves the destruction of adrenal cortical cells by the body's own immune system, often associated with other autoimmune conditions. *Malignancy* - **Malignancy**, particularly metastatic cancer to the adrenals, can cause adrenal insufficiency but is a less common primary cause of Addison's disease overall. - While possible, it is not the most prevalent cause in India compared to infectious etiologies. *HIV* - **HIV infection** can lead to adrenal dysfunction, but it's typically through opportunistic infections like CMV, cryptococcosis, or direct HIV effects, rather than being the direct cause of widespread adrenal destruction. - It increases the risk of adrenal insufficiency but is not the most common etiology in India for Addison's disease.
Question 54: Female with blood sugar of 600 mg% and sodium of 110 mEq. Insulin was given, what will happen to serum sodium levels ?
- A. Sodium levels may appear to increase (Correct Answer)
- B. Sodium levels decrease
- C. Sodium levels remain unchanged
- D. Relative sodium deficiency may occur
Explanation: ***Sodium levels may appear to increase*** - The patient's initial presentation with severe hyperglycemia (600 mg%) and hyponatremia (110 mEq/L) suggests **hyperglycemia-induced pseudohyponatremia**. - **Insulin administration** will lower blood glucose, causing water to shift back into the cells from the extracellular space, thereby correcting the dilutional effect and leading to an **apparent increase in serum sodium levels**. *Sodium levels decrease* - This is incorrect because the hyponatremia in this scenario is largely **dilutional** due to hyperglycemia. - As glucose levels decrease with insulin, the osmotic drive for water movement out of cells diminishes, leading to **normalization**, not further decrease, of sodium concentration. *Sodium levels remain unchanged* - This is incorrect because the underlying cause of the initial low sodium is dilution from high glucose. - Once **hyperglycemia is treated**, the osmotic gradient changes, and water shifts, directly impacting and changing the serum sodium concentration. *Relative sodium deficiency may occur* - This option is incorrect because the initial hyponatremia is not primarily due to an absolute lack of sodium in the body but rather a **dilutional effect** caused by the osmotic pull of glucose. - As hyperglycemia resolves, the extracellular fluid becomes less diluted, and the measured sodium concentration will **rise**, not indicate a deficiency.
Question 55: What condition is characterized by hypertension and hypokalemia?
- A. Gitelman's Syndrome
- B. Liddle's Syndrome (Correct Answer)
- C. Bartter Syndrome
- D. All of the options
Explanation: ***Liddle's Syndrome*** - This syndrome is characterized by **overactivity of the epithelial sodium channel (ENaC)** in the collecting ducts, leading to increased sodium reabsorption and potassium excretion. [1] - The resulting **sodium retention causes hypertension**, while the **potassium excretion leads to hypokalemia**. *Gitelman's Syndrome* - This is an **autosomal recessive kidney disorder** causing a defect in the **thiazide-sensitive NaCl cotransporter** in the distal convoluted tubule. - It presents with **hypokalemia and hypomagnesemia**, but typically with **normal or low blood pressure**, not hypertension. *Bartter Syndrome* - This is a group of **autosomal recessive salt-wasting tubulopathies** affecting the **Na-K-2Cl cotransporter** in the thick ascending limb of the loop of Henle. - It leads to **hypokalemia, metabolic alkalosis, and normal or low blood pressure**, similar to chronic loop diuretic use. *All of the options* - While all mentioned conditions involve **hypokalemia**, only **Liddle's Syndrome** is consistently associated with **hypertension**. - **Gitelman's and Bartter syndromes** typically present with **normal or low blood pressure**.
Question 56: Which of the following is the MOST common condition caused by hypernatremia?
- A. Altered mental status
- B. Brain hemorrhage
- C. Seizure (Correct Answer)
- D. Central pontine myelinosis
Explanation: ***Seizure*** - While not the *most* common initial symptom, **seizure** can be a severe manifestation of hypernatremia, particularly when the serum sodium levels rise rapidly or to very high concentrations leading to significant neuronal dehydration. - **Rapid correction of severe hypernatremia** can also induce seizures if the brain cells swell too quickly. *Altered mental status* - **Altered mental status** such as lethargy, confusion, or irritability, is a very common and often an earlier symptom of hypernatremia due to neuronal dehydration and intracellular water shifts, but it generally precedes more severe neurological complications like seizures.[1] - It is a broad term that encompasses a range of neurological dysfunctions, and while frequent, it is not as specific a severe endpoint as a seizure. *Brain hemorrhage* - **Brain hemorrhage** is a rare and severe complication of hypernatremia, primarily seen when extreme osmotic shifts cause significant brain shrinkage, leading to tension on bridging veins and potential rupture. - This is not a common presentation and typically occurs only in very severe cases of hypernatremia or during overly rapid correction. *Central pontine myelinosis* - **Central pontine myelinolysis (CPM)** is a neurological disorder caused by too rapid correction of *chronic hyponatremia*, not hypernatremia.[1] - It results from osmotic damage to myelin sheaths in the pons, leading to severe neurological deficits such as dysphagia, dysarthria, and even locked-in syndrome.[1]
Question 57: In a patient with hypoglycemia, what is the appropriate dose adjustment of insulin?
- A. Increase insulin dosage
- B. Decrease insulin dosage (Correct Answer)
- C. Maintain current insulin dosage
- D. Add a different medication
Explanation: ***Decrease insulin dosage*** - Hypoglycemia indicates that the current insulin dose is too high, causing blood glucose levels to drop excessively [1]. - Reducing the insulin dosage helps prevent future episodes of low blood sugar by allowing blood glucose to remain within a healthier range [1]. *Increase insulin dosage* - Increasing insulin would further lower blood glucose, exacerbating the **hypoglycemia** and potentially leading to a more severe and dangerous state. - This action is appropriate for **hyperglycemia**, not hypoglycemia. *Maintain current insulin dosage* - Maintaining the current dose would not address the problem, as it has already proven to be too much for the patient, causing the **hypoglycemic episodes** [1]. - This approach would leave the patient at continued risk for recurrent hypoglycemia. *Add a different medication* - While other medications might be used in diabetes management, adding a new one without adjusting the existing insulin dose could further complicate blood glucose control. - The immediate and most direct action for **hypoglycemia** caused by insulin is to adjust the insulin itself [1].
Question 58: In the context of ventricular tachycardia, what do extra systoles appear as on an electrocardiogram (ECG)?
- A. P wave
- B. QRS complex (Correct Answer)
- C. T wave
- D. R wave
Explanation: ***QRS complex*** - Extra systoles, particularly **premature ventricular contractions (PVCs)**, originate in the ventricles and result in a **wide and bizarre QRS complex** on an ECG [2]. - The QRS complex represents **ventricular depolarization**, and in ventricular tachycardia, the *ventricular activity* dominates the ECG tracing [2]. *P wave* - The **P wave** represents **atrial depolarization** and is typically either absent or dissociated from the QRS complex in ventricular tachycardia [1], [2]. - Its presence or absence helps differentiate supraventricular from ventricular arrhythmias. *T wave* - The **T wave** represents **ventricular repolarization**, which typically follows the QRS complex [1]. - While it will be present, it often appears abnormal or discordant in ventricular tachycardia due to the altered ventricular depolarization. *R wave* - The **R wave** is part of the QRS complex, specifically the first positive deflection. - While an R wave is present within the QRS complex of an extrasystole, referring to the entire **QRS complex** is more accurate as it encompasses the complete ventricular depolarization in an abnormal morphology.
Question 59: What is the most common arrhythmia in ICU patients?
- A. Atrial flutter
- B. Atrial fibrillation (Correct Answer)
- C. Atrial Tachycardia
- D. Supraventricular Tachycardia
Explanation: ***Atrial fibrillation*** - **Atrial fibrillation (AF)** is the most prevalent arrhythmia in the general population [1], and its incidence is significantly higher in critically ill patients due to various stressors. - Factors like **sepsis**, **hypoxemia**, **electrolyte imbalances**, **myocardial ischemia**, and **inflammatory states** common in the ICU are known triggers for new-onset AF. *Atrial flutter* - While atrial flutter is a common arrhythmia, its overall incidence in the ICU setting is **less frequent than atrial fibrillation**. - It often involves a **re-entrant circuit** in the right atrium [2], leading to characteristic "sawtooth" waves on ECG. *Atrial Tachycardia* - Atrial tachycardia is a form of **supraventricular tachycardia (SVT)** that originates in the atria but is **less common** than AF in the ICU [2]. - It often presents as a **regular, narrow-complex tachycardia** with discrete P waves. *Supraventricular Tachycardia* - This is a broad term encompassing arrhythmias that originate **above the ventricles** [3], including AF, atrial flutter, and atrial tachycardia. - While SVT as a category is common, **atrial fibrillation is the single most frequent specific arrhythmia** within this group in the ICU.
Question 60: A patient with first-degree heart block presents with dizziness. What is the most appropriate management for this patient?
- A. Observation and investigation of other causes (Correct Answer)
- B. Pacemaker insertion
- C. Isoprenaline
- D. Atropine
Explanation: ***Observation and investigation of other causes*** - **First-degree heart block** is usually **asymptomatic** and benign, rarely causing dizziness or other symptoms. - The dizziness experienced by the patient is likely due to another underlying condition and warrants **further investigation** rather than direct intervention for the heart block [2], [3]. *Pacemaker insertion* - **Pacemaker insertion** is reserved for **symptomatic heart blocks** of higher degrees (e.g., Mobitz II or complete heart block) or those with significant hemodynamic compromise [1]. - Given that first-degree heart block is typically asymptomatic, inserting a pacemaker would be an **overtreatment** and unnecessary for this condition alone. *Isoprenaline* - **Isoprenaline** is a **beta-agonist** that increases heart rate and AV conduction, sometimes used in certain bradyarrhythmias. - However, for first-degree heart block, which is generally benign, pharmacologic intervention with agents like **isoprenaline** is not typically indicated and carries risks of adverse effects [2]. *Atropine* - **Atropine** is an anticholinergic drug used to **increase heart rate** by blocking vagal stimulation of the SA and AV nodes. - While it can improve AV conduction, it is not indicated for **asymptomatic first-degree heart block** or when symptoms like dizziness are unlikely to be directly caused by the block itself.