NEET-PG 2018 - Internal Medicine Practice Questions

Q: A 35-year-old male with history of 4 weeks of immobilization for fracture of femur develops sudden onset breathlessness and blood in sputum. CT angiography shows? (Recent NEET Pattem 2018-19)

Acute cor-pulmonale. ***Acute cor-pulmonale*** - **4 weeks of immobilization** is a major risk factor for **deep vein thrombosis (DVT)** leading to **pulmonary embolism (PE)** - **CT pulmonary angiography** is the gold standard investigation for PE, showing filling defects in pulmonary arteries - Massive or submassive PE causes acute **right ventricular strain** = **acute cor-pulmonale** - Clinical presentation of **sudden breathlessness** and **hemoptysis** is classic for pulmonary thromboembolism - The timing (4 weeks post-immobilization) fits thromboembolism, not fat embolism *Fat embolism* - Occurs **acutely within 24-72 hours** after long bone fracture (especially femur/tibia) - The **4-week delay** makes fat embolism extremely unlikely - Presents with **respiratory distress, petechial rash, and neurological symptoms** (Gurd's criteria) - CT findings show diffuse ground-glass opacities, not typical filling defects seen on CT angiography *Pulmonary oedema* - Caused by **left heart failure** or **ARDS**, showing bilateral interstitial and alveolar fluid - Would show diffuse bilateral infiltrates on imaging, not filling defects in pulmonary vessels - **Hemoptysis** is uncommon in cardiogenic pulmonary edema - No clear cardiac history or precipitant in this patient *Aortic dissection* - Involves a tear in the aortic intima with blood dissecting through the aortic wall - Presents with **sudden severe chest/back pain**, not primarily with hemoptysis - CT angiography would show **aortic flap and false lumen**, not pulmonary vascular abnormalities - Unrelated to femur fracture or prolonged immobilization

Q: All are true about the mid brain stroke syndrome shown except:

Anterior cerebral peduncle is involved. ***Anterior cerebral peduncle is involved*** - The **anterior cerebral peduncle (crus cerebri)** is located in the **ventral midbrain** and contains descending motor tracts, but the lesion shown affects the **dorsal midbrain structures**. - This statement is **false** because the lesion does not extend to involve the anterior cerebral peduncle, making this the correct answer for the "except" question. *Dorsal midbrain lesion* - The image clearly shows a lesion in the **dorsal aspect of the midbrain**, affecting structures such as the **red nucleus** and surrounding areas. - This statement is **true** as it accurately describes the anatomical location of the stroke shown in the image. *Ipsilateral 3rd nerve palsy* - **Weber's syndrome** (ventral midbrain stroke) commonly presents with ipsilateral 3rd nerve palsy, and some dorsal midbrain lesions can extend to affect **oculomotor nerve fascicles**. - This statement is **true** as 3rd nerve palsy can occur with midbrain strokes, particularly when the lesion affects nerve pathways in the midbrain. *Contralateral hemiplegia* - Midbrain strokes can cause **contralateral weakness** through involvement of **corticospinal tract fibers** that pass through or near the affected area. - This statement is **true** as motor deficits are commonly seen in midbrain stroke syndromes, even with dorsal lesions that may affect descending motor connections.

Q: A patient in ICU was given blood transfusion. 3 hours later SpO2 is reduced to 75% with respiratory difficulty. CVP is 15 cm water and PCWP is 25 mm Hg . CXR is shown below. What is the diagnosis?

Transfusion associated circulatory overload. ***Transfusion associated circulatory overload*** - The combination of **respiratory difficulty**, **reduced SpO2**, **elevated CVP (15 cm water)**, and **markedly elevated PCWP (25 mm Hg)** after a blood transfusion strongly indicates hydrostatic pulmonary edema due to fluid overload. - The CXR image showing **diffuse bilateral infiltrates** (pulmonary edema) further supports this diagnosis, especially with the elevated cardiac filling pressures. *Tension pneumothorax* - A tension pneumothorax would present with **unilateral lung collapse**, **tracheal deviation**, and potentially **hypotension**, none of which are explicitly described or suggested by the CXR. - While it causes respiratory distress, the hemodynamic parameters (CVP and PCWP) and bilateral CXR findings are inconsistent with a pneumothorax. *Transfusion related acute lung injury* - TRALI also causes acute respiratory distress and hypoxemia after transfusion, but it is characterized by **non-cardiogenic pulmonary edema** with a **normal or low CVP** and **normal or mildly elevated PCWP** (<18 mm Hg), differentiating it from TACO. - The elevated CVP and PCWP strongly point away from TRALI, which is immune-mediated and involves capillary leakage. *Mismatched blood transfusion* - An acute hemolytic transfusion reaction (mismatched blood transfusion) typically presents with symptoms such as **fever, chills, flank pain, hemoglobinuria**, and potentially **DIC** or **renal failure**. - While it's a serious transfusion reaction, the primary clinical presentation and elevated cardiac filling pressures are not characteristic of an acute hemolytic reaction.

Q: A patient undergone a Solid organ transplant is having the following lesions which are present on oral mucosa and sites shown below. Which of the following is incriminated in causing the same?

KSHV. ***KSHV*** - The image shows multiple **violaceous cutaneous lesions** which are characteristic of **Kaposi's sarcoma (KS)**. - In a solid organ transplant recipient, KS is commonly associated with **Kaposi's sarcoma-associated herpesvirus (KSHV)**, also known as HHV-8. Immunosuppression due to antirejection medications can reactivate latent KSHV infection. *HHV6* - HHV-6 is primarily associated with **roseola infantum** (exanthem subitum) in children. - While HHV-6 can cause complications in immunocompromised individuals, its typical manifestations do not involve the characteristic violaceous skin lesions seen in Kaposi's sarcoma. *HHV7* - HHV-7 is also associated with **roseola-like illnesses** and is generally considered a less pathogenic virus compared to other human herpesviruses. - It does not cause Kaposi's sarcoma, and its clinical manifestations in transplant patients are typically different from the lesions depicted. *CMV* - **Cytomegalovirus (CMV)** is a common opportunistic infection in solid organ transplant recipients, causing a variety of clinical syndromes. - While CMV can lead to numerous symptoms (e.g., fever, leukopenia, pneumonitis, colitis), it does not directly cause the characteristic skin lesions of Kaposi's sarcoma.

Q: The finding shown below is used for diagnosis of CNS parasitic lesion. Which of the following best describes the condition?

***Major criteria*** - The image likely depicts **multiple calcified cysts**, which in the context of CNS parasitic lesions (e.g., neurocysticercosis), would be considered a **major diagnostic criterion** for the disease. - Major criteria are significant findings, often radiographic evidence of **cysts or calcifications**, that strongly support a diagnosis of neurocysticercosis when combined with other criteria. *Minor criteria* - Minor criteria include less specific findings, such as **seizures** or headaches, or findings that support the diagnosis but are not definitive on their own. - While supportive, these findings are typically not sufficient for diagnosis without major or other criteria. *Absolute criteria* - Absolute criteria are definitive findings, such as a **histopathological demonstration of the parasite** or direct visualization of the scolex on imaging, which are direct proof of infection. - The image shows calcifications, which are strong evidence but not necessarily "absolute" proof of active parasitic presence without further context like a viable cyst with a scolex. *Epidemiological criteria* - Epidemiological criteria relate to the patient's **exposure history** or origin from areas endemic for the parasite. - These criteria help in narrowing down the differential diagnosis but do not provide direct evidence of the lesion itself.

Q: The following appearance of esophagus is seen in:

Eosinophilic esophagitis. ***Eosinophilic esophagitis*** - The image clearly shows **trachealization** of the esophagus, characterized by **concentric rings** and **linear furrows**, which are hallmark endoscopic findings of eosinophilic esophagitis. - This condition is an **allergic inflammatory disorder** involving the esophagus, often leading to dysphagia and food impaction. *GERD* - While GERD can cause inflammation (esophagitis), it typically presents with **erosions**, **strictures**, or **Barrett's esophagus**, but not the characteristic ringed appearance seen here. - The presence of **longitudinal furrows** and a pale, corrugated appearance rather than the distinct circular rings would be less typical for classic GERD. *Stricture* - A stricture would appear as a **localized narrowing** of the esophageal lumen, which is not the predominant feature in this image. - While strictures can occur in chronic eosinophilic esophagitis, the primary morphological feature visualized is the **ringed esophagus**. *Radiation esophagitis* - This condition results from **radiation exposure** to the chest and typically presents with **mucosal edema**, **erythema**, **ulcerations**, or **fibrosis** in acute and chronic phases, respectively. - It does not commonly cause the distinctive **trachealization** or ringed appearance seen in the image.

Q: A 15-year-old boy presents with abdominal cramps and diarrhea for 8 weeks along with delayed puberty. Perianal examination reveals the following. What is the diagnosis? (NEET Pattern 2018)

Crohn's disease. ***Crohn's disease*** - The combination of **chronic abdominal cramps and diarrhea**, **delayed puberty**, and the presence of **perianal lesions** (like skin tags, fissures, or abscesses, as depicted) is highly indicative of Crohn's disease. - Delayed puberty suggests **malabsorption** and chronic inflammation, which are characteristic systemic effects of Crohn's disease, particularly when it affects the small bowel. *Celiac disease* - While celiac disease can cause **abdominal cramps**, **diarrhea**, and **growth delays** (potentially leading to delayed puberty due to malabsorption), it typically does **not present with perianal lesions**. - It is an **autoimmune response to gluten**, not an inflammatory bowel disease presenting with perianal manifestations. *Ulcerative colitis* - This condition is characterized by **colonic inflammation**, causing symptoms like **bloody diarrhea** and abdominal pain. - While it can manifest with some **extraintestinal symptoms**, **perianal disease** is rare and less severe compared to Crohn's disease, and delayed puberty is less commonly associated. *Irritable bowel syndrome* - IBS is a **functional gastrointestinal disorder** without underlying structural or biochemical abnormalities, presenting with abdominal pain and altered bowel habits. - It does **not cause perianal lesions**, malabsorption, or systemic complications like delayed puberty.

Q: The given endoscopy of the patient shows? (NEET Pattern 2018)

Eosinophilic esophagitis. **Eosinophilic esophagitis** - The endoscopic image displays prominent **concentric rings** (trachealization) and **linear furrows**, which are classic findings in eosinophilic esophagitis. - These features result from chronic inflammation and fibrosis caused by an allergic reaction leading to significant eosinophil infiltration in the esophageal wall. *Radiation esophagitis* - Endoscopic findings in radiation esophagitis typically include **erythema**, **edema**, **ulcerations**, or **strictures** in the irradiated field. - The characteristic ringed appearance seen in the image is not typical for radiation-induced injury. *GERD* - Endoscopic signs of GERD often include **erosions**, **ulcerations**, **strictures**, or **Barrett's esophagus**, usually in the distal esophagus. - While chronic GERD can cause inflammation, it typically does not produce the pronounced concentric rings and linear furrows characteristic of eosinophilic esophagitis. *Carcinoma esophagus* - Esophageal carcinoma typically presents with a **mass**, **ulceration**, **stricture**, or an **irregular, friable lesion**. - The image does not show any focal mass or destructive lesion suggestive of malignancy.

Q: Which of the following will best describe this patient?

Fever, weight loss, night sweats and elevated ESR. ***Fever, weight loss, night sweats and elevated ESR*** - The CT scan shows numerous **small, diffuse nodules** throughout both lung fields, consistent with **miliary tuberculosis (TB)**. - The systemic symptoms of **fever, weight loss, night sweats**, and an **elevated ESR** are classic constitutional symptoms of disseminated TB. *Rusty sputum with gram positive diplococci* - This description is characteristic of **Streptococcus pneumoniae (pneumococcal pneumonia)**. - Pneumococcal pneumonia typically presents with lobar consolidation on imaging, not diffuse miliary nodules. *Acute dyspnea, elevated JVP and long history of air travel* - This constellation of symptoms (acute dyspnea, elevated JVP) and risk factor (long history of air travel) strongly suggests **pulmonary embolism (PE)**. - Imaging findings for PE would typically include a filling defect in the pulmonary arteries, rather than diffuse nodularity. *Acute dyspnea, pink frothy sputum and mid-diastolic rumble* - These symptoms point towards **left-sided heart failure (acute pulmonary edema)**, often associated with **mitral stenosis** (suggested by the mid-diastolic rumble). - Pulmonary edema on CT would show ground-glass opacities, septal thickening, and pleural effusions, not diffuse nodular infiltrates.

Q: The following cell type is seen in peripheral smear of a patient with membrane over the tonsils. All can be used in treatment except?

Acyclovir. ***Acyclovir*** - The image depicts an **atypical lymphocyte** (Downey cell), characteristic of **infectious mononucleosis**, commonly caused by the **Epstein-Barr virus (EBV)**. - Acyclovir is an **antiviral medication** primarily used for **herpes simplex virus (HSV)** and **varicella-zoster virus (VZV)** infections, and it is **not effective against EBV**. *Prednisolone* - **Corticosteroids** like prednisolone may be used in severe cases of infectious mononucleosis, especially when complications such as **airway obstruction** due to tonsillar hypertrophy, **hemolytic anemia**, or **thrombocytopenia** are present. - They help to **reduce inflammation** and suppress the immune response. *IVIG* - **Intravenous immunoglobulin (IVIG)** can be used in rare, severe, or complicated cases of infectious mononucleosis, particularly if there are significant **hematologic complications** (e.g., severe thrombocytopenia, severe hemolytic anemia) or in patients with **immunodeficiency**. - IVIG provides **passive immunity** and modulates the immune response. *Acetaminophen* - **Acetaminophen (paracetamol)** is a common **analgesic** and **antipyretic** used to manage symptomatic relief for fever, sore throat, and muscle aches associated with infectious mononucleosis. - It helps to **alleviate discomfort** and improve patient well-being during the acute phase of the illness.

Question 1

A 35-year-old male with history of 4 weeks of immobilization for fracture of femur develops sudden onset breathlessness and blood in sputum. CT angiography shows? (Recent NEET Pattem 2018-19)

Accepted Answer

Acute cor-pulmonale

Answer

Pulmonary oedema

Answer

Aortic dissection

Answer

Fat embolism

Question 2

All are true about the mid brain stroke syndrome shown except:

Accepted Answer

Anterior cerebral peduncle is involved

Answer

Dorsal midbrain lesion

Answer

Contralateral tremor and ataxia

Answer

Red nucleus involvement causes movement disorders

Question 3

A patient in ICU was given blood transfusion. 3 hours later SpO2 is reduced to 75% with respiratory difficulty. CVP is 15 cm water and PCWP is 25 mm Hg . CXR is shown below. What is the diagnosis?

Accepted Answer

Transfusion associated circulatory overload

Answer

Tension pneumothorax

Answer

Transfusion related acute lung injury

Answer

Mismatched blood transfusion

Question 4

A patient undergone a Solid organ transplant is having the following lesions which are present on oral mucosa and sites shown below. Which of the following is incriminated in causing the same?

Accepted Answer

KSHV

Answer

HHV6

Answer

HHV7

Answer

CMV

Question 5

The finding shown below is used for diagnosis of CNS parasitic lesion. Which of the following best describes the condition?

Answer

Minor criteria

Answer

Absolute criteria

Answer

Epidemiological criteria

Answer

Major criteria

Question 6

The following appearance of esophagus is seen in:

Accepted Answer

Eosinophilic esophagitis

Answer

GERD

Answer

Stricture

Answer

Radiation esophagitis

Question 7

A 15-year-old boy presents with abdominal cramps and diarrhea for 8 weeks along with delayed puberty. Perianal examination reveals the following. What is the diagnosis? (NEET Pattern 2018)

Accepted Answer

Crohn's disease

Answer

Celiac disease

Answer

Ulcerative colitis

Answer

Irritable bowel syndrome

Question 8

The given endoscopy of the patient shows? (NEET Pattern 2018)

Accepted Answer

Eosinophilic esophagitis

Answer

Radiation esophagitis

Answer

GERD

Answer

Carcinoma esophagus

Question 9

Which of the following will best describe this patient?

Accepted Answer

Fever, weight loss, night sweats and elevated ESR

Answer

Rusty sputum with gram positive diplococci

Answer

Acute dyspnea, elevated JVP and long history of air travel

Answer

Acute dyspnea, pink frothy sputum and mid-diastolic rumble

Question 10

The following cell type is seen in peripheral smear of a patient with membrane over the tonsils. All can be used in treatment except?

Accepted Answer

Acyclovir

Answer

Prednisolone

Answer

IVIG

Answer

Acetaminophen

NEET-PG 2018 — Internal Medicine