Inpatient Management — MCQs

10 questions

In an accident case, after the arrival of medical team, all should be done in early management except;

Which of the following is FALSE regarding Anorexia Nervosa:

A young girl hospitalised with anorexia nervosa is on treatment. Even after taking adequate food according to the recommended diet plan for last 1 week, there is no gain in weight. What is the next step in management:

What is considered the most effective treatment for Borderline Personality Disorder?

What is the primary reason for decreased energy production in thiamine deficiency?

Which of the following is not a complication of hypokalemia?

The most appropriate management approach for anorexia nervosa includes:

Disorder where amenorrhea was once needed for diagnosis is?

Hypocalcemia is characterized by all except

Q10

A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

Inpatient Management Indian Medical PG Practice Questions and MCQs

Question 1: In an accident case, after the arrival of medical team, all should be done in early management except;

A. Glasgow coma scale
B. Check BP (Correct Answer)
C. Stabilization of cervical vertebrae
D. Check Respiration

Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.

Question 2: Which of the following is FALSE regarding Anorexia Nervosa:

A. Decreased appetite (Correct Answer)
B. Body image distortion
C. Vigor exceeding physical ill being
D. Weight loss

Explanation: ***Decreased appetite*** - Patients with anorexia nervosa typically experience **increased hunger** and **preoccupation with food**, despite efforts to restrict intake, rather than a decreased appetite. - The sensation of hunger often intensifies due to severe caloric restriction, making the statement "decreased appetite" false. *Body image distortion* - This is a core diagnostic criterion of anorexia nervosa, where individuals perceive themselves as **overweight** even when they are severely underweight. - The distorted body image drives their relentless pursuit of thinness and fear of weight gain. *Vigor exceeding physical ill being* - Patients with anorexia nervosa often display surprising **energy and hyperactivity** despite severe physical debilitation and malnutrition. - This "vigor" can be a mechanism to burn calories, suppress hunger, or avoid rest, exceeding what would be expected given their poor health status. *Weight loss* - **Significant weight loss** or failure to gain weight during growth is a defining characteristic of anorexia nervosa. - This weight loss is intentionally achieved through severe dietary restriction, excessive exercise, or purging behaviors.

Question 3: A young girl hospitalised with anorexia nervosa is on treatment. Even after taking adequate food according to the recommended diet plan for last 1 week, there is no gain in weight. What is the next step in management:

A. Increase the caloric intake from 1500 kcal to 2000 kcal per day
B. Increase fluid intake
C. Increase the dose of anxiolytics
D. Observe patient for 2 hours after meal (Correct Answer)

Explanation: ***Observe patient for 2 hours after meal*** - Patients with **anorexia nervosa** often engage in compensatory behaviors like **purging** or extensive exercise, which would counteract the effects of increased caloric intake and lead to a lack of weight gain despite consuming an "adequate" diet. - Observing the patient post-meal helps identify these behaviors and ensures that the ingested calories are actually being retained and utilized for weight restoration. *Increase the caloric intake from 1500 kcal to 2000 kcal per day* - Increasing caloric intake is a valid long-term strategy but is not the immediate next step when there's **no weight gain despite adequate intake**; the primary concern is identifying *why* the initial intake isn't leading to weight gain. - Doing so without addressing potential compensatory behaviors might only increase patient distress or lead to more intense purging/exercise. *Increase fluid intake* - While adequate **hydration** is important, it does not directly address the issue of **lack of weight gain** in anorexia nervosa, which is fundamentally a caloric deficit problem. - Increased fluid intake would not provide the necessary calories for weight restoration. *Increase the dose of anxiolytics* - Anxiolytics may help manage **anxiety** related to eating, but they do not directly promote **weight gain** or prevent compensatory behaviors. - This step does not address the core issue of why the recommended diet is not leading to weight gain.

Question 4: What is considered the most effective treatment for Borderline Personality Disorder?

A. Combination of DBT and pharmacotherapy
B. Cognitive Behavioural Therapy (CBT)
C. Pharmacotherapy alone
D. Dialectical Behaviour Therapy (DBT) (Correct Answer)

Explanation: ***Dialectical Behaviour Therapy (DBT)*** - **DBT** is the **gold standard** and most evidence-based psychotherapy specifically developed for Borderline Personality Disorder - Developed by **Marsha Linehan** specifically to target the core symptoms of BPD including emotional dysregulation, impulsivity, and interpersonal difficulties - Combines **cognitive-behavioral techniques** with mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills - Has the **strongest research evidence** for reducing suicidal behavior, self-harm, and improving overall functioning in BPD patients - Multiple RCTs demonstrate DBT's superiority in treating BPD compared to standard care *Cognitive Behavioural Therapy (CBT)* - While **CBT** is effective for many mental health conditions and can help with certain BPD symptoms, it was not specifically designed for BPD - DBT is actually a specialized adaptation of CBT tailored for BPD, making it more targeted and effective for this specific condition - Generic CBT may help with co-occurring conditions like depression or anxiety but lacks the comprehensive approach needed for core BPD features *Combination of DBT and pharmacotherapy* - This combination is clinically useful, especially when treating **co-morbid conditions** like depression, anxiety, or severe mood instability - However, psychotherapy (particularly DBT) remains the **cornerstone** of BPD treatment, with medications serving an adjunctive role - The question asks for the single most effective treatment, which is DBT alone *Pharmacotherapy alone* - **No medication** is FDA-approved specifically for BPD - Pharmacotherapy may help manage specific symptoms (mood swings, impulsivity, brief psychotic episodes) but does not address the core **personality pathology** - Generally not recommended as monotherapy for BPD; should always be combined with psychotherapy

Question 5: What is the primary reason for decreased energy production in thiamine deficiency?

A. It is involved in the metabolism of branched-chain amino acids.
B. It is essential for the conversion of pyruvate to acetyl-CoA. (Correct Answer)
C. It is a co-factor in the citric acid cycle.
D. It is required for the process of glycolysis.

Explanation: ***It is essential for the conversion of pyruvate to acetyl-CoA.*** - Thiamine, in its active form **thiamine pyrophosphate (TPP)**, is a crucial coenzyme for the **pyruvate dehydrogenase complex**. - Without thiamine, pyruvate cannot be converted to **acetyl-CoA**, thereby blocking its entry into the **citric acid cycle** for energy generation. - This represents the **primary and most significant block** in energy production, as it prevents glucose-derived pyruvate from entering oxidative metabolism. *It is a co-factor in the citric acid cycle.* - Thiamine pyrophosphate (TPP) **is indeed a direct cofactor** for **α-ketoglutarate dehydrogenase** within the citric acid cycle itself. - However, the **primary reason** for decreased energy production in thiamine deficiency is the earlier blockage at pyruvate dehydrogenase, which prevents substrate entry into the cycle. - Even with α-ketoglutarate dehydrogenase affected, the more critical bottleneck occurs upstream at pyruvate conversion. *It is involved in the metabolism of branched-chain amino acids.* - Thiamine is indeed a coenzyme for the **branched-chain alpha-keto acid dehydrogenase complex**, which is involved in branched-chain amino acid metabolism. - However, the **primary impact** on energy production in thiamine deficiency stems from its role in glucose metabolism rather than amino acid metabolism. - Glucose metabolism is the body's primary energy source, making the pyruvate dehydrogenase block more significant. *It is required for the process of glycolysis.* - **Glycolysis** is the metabolic pathway that breaks down glucose into pyruvate, and it does **not require thiamine** as a coenzyme. - Thiamine's role in glucose metabolism begins *after* glycolysis, at the step where pyruvate is converted to acetyl-CoA. - Glycolysis can proceed normally in thiamine deficiency, but the products cannot enter oxidative metabolism efficiently.

Question 6: Which of the following is not a complication of hypokalemia?

A. Quadriparesis
B. Cerebral edema (Correct Answer)
C. Ventricular Tachycardia
D. Diabetes insipidus

Explanation: ***Cerebral edema*** - **Cerebral edema** is typically associated with **hyponatremia** (low sodium levels), which causes hypotonicity in the extracellular fluid leading to water shifting into brain cells. - Hypokalemia primarily impacts neuromuscular and cardiac function and does not directly cause brain swelling due to fluid shifts. *Quadriparesis* - **Severe hypokalemia** can lead to **muscle weakness**, which can progress to flaccid paralysis affecting all four limbs (quadriparesis). - This occurs due to alterations in the **resting membrane potential** of muscle cells, making them less excitable. *Ventricular Tachycardia* - Hypokalemia can cause **cardiac arrhythmias**, including **ventricular tachycardia** and **fibrillation**, by prolonging repolarization and increasing myocardial excitability. - It can also lead to characteristic electrocardiogram (ECG) changes such as **flattened T waves**, **ST segment depression**, and prominent **U waves**. *Diabetes insipidus* - **Nephrogenic diabetes insipidus** can be a complication of chronic hypokalemia, where the kidneys become resistant to the effects of **antidiuretic hormone (ADH)**. - This results in the inability to concentrate urine, leading to **polyuria** (excessive urination) and **polydipsia** (excessive thirst).

Question 7: The most appropriate management approach for anorexia nervosa includes:

A. Immediate high-calorie diet with rapid weight gain
B. Strict bed rest with minimal physical activity
C. Antipsychotic medications as first-line treatment
D. Multidisciplinary approach with psychological therapy and nutritional rehabilitation (Correct Answer)

Explanation: ***Multidisciplinary approach with psychological therapy and nutritional rehabilitation*** - This is the **gold standard** and most appropriate management approach for **anorexia nervosa** according to all major guidelines (APA, NICE, IPS). - The multidisciplinary team includes: **psychiatrists, psychologists, dietitians, physicians**, and social workers working collaboratively. - **Psychological therapy** (particularly **CBT-E** for adults and **Family-Based Therapy/FBT** for adolescents) addresses distorted body image, eating behaviors, and underlying psychological factors. - **Nutritional rehabilitation** involves gradual, monitored weight restoration to prevent **refeeding syndrome** while addressing nutritional deficiencies. - **Medical monitoring** for complications (cardiovascular, electrolyte imbalances, bone health) is integrated throughout treatment. - This comprehensive approach addresses both the acute medical needs and long-term recovery, with evidence showing best outcomes. *Strict bed rest with minimal physical activity* - While temporary bed rest may be used in cases of **severe medical instability** (very low heart rate, severe electrolyte disturbances), it is not the overall management "approach." - Prolonged bed rest can worsen outcomes by causing **muscle wasting**, **bone density loss**, and psychological dependence. - Modern guidelines emphasize **gradual mobilization** with medical supervision rather than strict bed rest. - Bed rest is a specific medical intervention, not a comprehensive management strategy. *Immediate high-calorie diet with rapid weight gain* - Rapid refeeding is dangerous and can cause **refeeding syndrome**, characterized by severe shifts in **phosphate, potassium, and magnesium** levels. - Complications include **cardiac arrhythmias**, **respiratory failure**, and **seizures**. - Proper nutritional rehabilitation starts with **lower calories** (30-40 kcal/kg/day initially) and increases gradually under close monitoring. *Antipsychotic medications as first-line treatment* - **Antipsychotics are NOT first-line treatment** for anorexia nervosa. - Limited evidence for efficacy; **olanzapine** may be used as adjunct for severe anxiety or obsessive thoughts about food. - Medications alone are insufficient; psychological and nutritional interventions are essential. - May be considered for comorbid conditions but not as primary treatment.

Question 8: Disorder where amenorrhea was once needed for diagnosis is?

A. metabolic syndrome
B. bulimia nervosa
C. Binge eating disorder
D. Anorexia nervosa (Correct Answer)

Explanation: ***Anorexia nervosa*** - Historically, **amenorrhea** (absence of menstruation) was a diagnostic criterion for **anorexia nervosa**, reflecting the severe physiological impact of malnutrition and low body weight on the **endocrine system**. - While still common in patients with anorexia, it is **no longer a mandatory diagnostic criterion** in the DSM-5. *Metabolic syndrome* - Metabolic syndrome is a cluster of conditions that includes **increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels**. - It is **not directly associated with amenorrhea** and does not have amenorrhea as a diagnostic criterion. *Bulimia nervosa* - Bulimia nervosa is characterized by **recurrent episodes of binge eating** followed by compensatory behaviors such as self-induced vomiting, excessive exercise, or misuse of laxatives. - While it can be associated with menstrual irregularities due to nutritional imbalances, **amenorrhea is not a diagnostic criterion** for bulimia nervosa. *Binge eating disorder* - Binge eating disorder involves **recurrent episodes of eating large quantities of food**, often rapidly and to the point of discomfort, without the regular use of inappropriate compensatory behaviors. - This disorder is **not directly linked to amenorrhea as a diagnostic feature**, although nutritional status can affect menstrual cycles.

Question 9: Hypocalcemia is characterized by all except

A. Carpopedal spasm
B. Hyperactive tendon reflexes
C. Numbness and tingling of circumoral region
D. Shortening of Q-T interval in ECG (Correct Answer)

Explanation: ***Shortening of Q-T interval in ECG*** - Hypocalcemia typically causes **prolongation of the QT interval** on an ECG due to delayed repolarization of ventricular myocardial cells. - A **shortened QT interval** is usually associated with hypercalcemia or conditions like short QT syndrome. *Carpopedal spasm* - This is a classic sign of hypocalcemia, known as **Trousseau's sign**, elicited by inflating a blood pressure cuff above systolic pressure, which causes spasm of the hand and foot. - It results from increased neuromuscular irritability due to lower calcium levels. *Hyperactive tendon reflexes* - Hypocalcemia leads to **increased neuromuscular excitability**, which manifests as hyperactive or brisk deep tendon reflexes. - This heightened reflex activity is a common neurological symptom of low calcium. *Numbness and tingling of circumoral region* - This symptom, known as **paresthesia**, is a very common and early manifestation of hypocalcemia. - It occurs due to the increased excitability of peripheral nerves caused by reduced extracellular calcium.

Question 10: A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than 1. Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this patient?

A. Hypophosphatemia (Correct Answer)
B. Hypoglycemia
C. Hyperkalemia
D. Hypermagnesemia

Explanation: ***Hypophosphatemia*** * This patient with severe malnutrition (albumin <1, 60lb weight loss) is at high risk for **refeeding syndrome** when TPN is initiated [1]. * Upon refeeding, **insulin release** causes intracellular shifts of electrolytes, particularly phosphate, leading to severe hypophosphatemia [1]. * *Hypoglycemia* * TPN contains dextrose, which typically causes **hyperglycemia**, not hypoglycemia, especially given its continuous infusion. * Hypoglycemia would be more likely if TPN was abruptly discontinued, causing a rapid drop in glucose levels as basal insulin continues to be secreted. * *Hyperkalemia* * Refeeding syndrome typically causes a rapid **intracellular shift of potassium**, leading to **hypokalemia**, not hyperkalemia [1]. * Hyperkalemia would be a concern in patients with renal insufficiency or those receiving potassium-sparing diuretics. * *Hypermagnesemia* * Similar to potassium and phosphate, refeeding syndrome usually causes an **intracellular shift of magnesium**, leading to **hypomagnesemia** [1]. * Hypermagnesemia is rare and typically seen in patients with severe renal failure or excessive exogenous magnesium intake (e.g., antacids).

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