NEET-PG 2017 Practice Questions

Q: A 10-year-old child with Valvular heart disease on heart failure treatment, has the following ECG tracing. What is the diagnosis?

Non paroxysmal atrial tachycardia with regular AV block. ***Non paroxysmal atrial tachycardia with regular AV block*** - The ECG shows a sustained atrial tachycardia with a **consistent P-P interval**, indicating a non-paroxysmal origin. - There is a **fixed ratio between P waves and QRS complexes** (e.g., 2:1 or 3:1), demonstrating a regular AV block, likely due to increased vagal tone or AV nodal dysfunction, often seen in cases of **digoxin toxicity** (given the patient is on heart failure treatment for valvular heart disease). *Tall tented T-wave* - **Tall, tented T-waves** are characteristic of **hyperkalemia**, but the ECG tracing does not exhibit this morphology. - While hyperkalemia can cause rhythm disturbances, the predominant feature here is a regular atrial tachycardia with AV block, not T-wave changes typical of electrolyte imbalance. *Ventricular bigeminy* - **Ventricular bigeminy** would manifest as alternating normal QRS complexes with premature ventricular contractions (PVCs). - The ECG shows a narrow complex tachycardia with visible P waves, which are not characteristic of PVCs or ventricular bigeminy. *Non paroxysmal atrial tachycardia with irregular AV block* - Although there is non-paroxysmal atrial tachycardia, the **AV block is regular** (e.g., a consistent 2:1 or 3:1 conduction ratio), not irregular. - An irregular AV block would suggest variability in AV nodal conduction, such as in AV Wenckebach or Mobitz type II with variable conduction, which is not what is seen in this tracing.

Q: A 50-year-old woman with rheumatic heart disease is on medication for heart disease. She feels unwell for most part of the day. Which of the following medicine is responsible for the ECG changes shown below? (Recent NEET Pattern 2016-17)

Digoxin. ***Digoxin*** - The ECG shows changes characteristic of **digoxin toxicity**, specifically **downsloping ST depressions (scooping)** and **flattened or inverted T waves**, particularly in leads with dominant R waves. - The patient's symptoms of feeling "unwell for most part of the day" are consistent with **digoxin toxicity**, which can include nausea, fatigue, and cardiac arrhythmias. *ACE inhibitor* - ACE inhibitors primarily affect the **renin-angiotensin-aldosterone system** and do not typically cause these specific ECG changes. - Common side effects include cough and **hyperkalemia**, not the "scooped" ST segments seen here. *Diuretics* - Diuretics can cause **electrolyte imbalances**, such as hypokalemia, which might manifest as **flattened T waves** or **prominent U waves** on ECG, but not the characteristic "scooped" ST depression. - The symptoms of malaise are non-specific and while possible with electrolyte disturbances, the specific ECG pattern points away from diuretics as the primary cause. *Ivabradine* - Ivabradine is a **selective If channel inhibitor** that primarily reduces heart rate, without affecting myocardial contractility or repolarization significantly. - It does not cause the **ST segment changes** characteristic of digoxin effect or toxicity.

Q: A 60-year-old hypertension patient presents with breathlessness. ECG was performed. What is the diagnosis? (Recent NEET Pattern 2016-17)

Left ventricular hypertrophy. ***Left ventricular hypertrophy*** - The ECG shows significantly **increased QRS voltage in leads V1-V6**, particularly prominent R waves in V5/V6 and deep S waves in V1/V2, indicating left ventricular hypertrophy as per criteria like **Sokolow-Lyon index** (S in V1 + R in V5/V6 > 35mm). - The presence of **T-wave inversion and ST depression** (strain pattern) in lateral leads (V5, V6), especially in a patient with **hypertension**, further supports the diagnosis of left ventricular hypertrophy. *LBBB* - **LBBB** (Left Bundle Branch Block) is characterized by a **wide QRS complex** (>120 ms) with a **notched or slurred R wave** in lateral leads (I, aVL, V5, V6) and a deep S wave in V1, none of which are definitively seen here. - The QRS duration is not significantly widened, and the morphology is not typical for LBBB. *Normal tracing* - This ECG is not normal due to the **grossly elevated QRS voltages** in precordial leads and the presence of **ST-T wave abnormalities** (strain pattern). - A normal ECG would not exhibit such pronounced voltage criteria for chamber enlargement. *Complete heart block* - Complete heart block is characterized by **dissociation between atrial (P waves) and ventricular (QRS complexes) activity**, where P waves and QRS complexes occur independently. - This ECG shows a regular rhythm with P waves followed by QRS complexes, indicating normal AV conduction and **absence of AV dissociation**. *Right ventricular hypertrophy* - **Right ventricular hypertrophy** (RVH) is characterized by **tall R waves in V1-V2** with **right axis deviation** and **deep S waves in V5-V6**. - This ECG shows the opposite pattern (tall R waves in V5-V6 and deep S waves in V1-V2), which is consistent with **left ventricular** rather than right ventricular hypertrophy.

Q: A 50-year-old smoker comes with complaints of ankle edema for last 3 months. The ECG shows all except: (Recent NEET Pattern 2016-17)

Right bundle branch block. ***Right bundle branch block*** - This ECG does **NOT** show features of right bundle branch block, which would require a **wide QRS (≥120 ms)** with an **RSR' (M-shaped) pattern in V1-V3** and wide, slurred S waves in lateral leads (I, V5-V6). - In cor pulmonale, the QRS is typically **narrow** without the RBBB morphology, making RBBB the finding that is **absent** — the correct "EXCEPT" answer. *P pulmonale* - The P waves in leads II, III, and aVF are **tall and peaked** (amplitude ≥2.5 mm in lead II), characteristic of **P pulmonale**, indicating right atrial enlargement/increased right atrial pressure. - This is consistent with **cor pulmonale** from chronic obstructive pulmonary disease (COPD) in a long-term smoker presenting with ankle edema. *Right axis deviation* - The QRS complex is **predominantly negative in lead I** and **positive in aVF**, indicating a **right axis deviation** (axis > +90°). - This reflects **right ventricular hypertrophy or strain**, classic in cor pulmonale due to COPD-induced pulmonary hypertension. *Left axis deviation* - The ECG shows **right axis deviation**, not left axis deviation. - Left axis deviation (axis −30° to −90°) would show a **predominantly positive QRS in lead I and negative in aVF** — the opposite of what is seen here. - Left axis deviation is therefore **NOT present** on this ECG; it is a distracter option. *T wave inversion in II, III, V1-V2* - The ECG shows **T wave inversions** in leads II, III, and V1-V2. - These inversions over the inferior and right precordial leads reflect **right ventricular strain/hypertrophy**, a well-recognised pattern in cor pulmonale.

Q: The patient with the following hematological abnormality presents with severe chest pain and difficulty in breathing. All are useful for managing this emergency except:

Packed RBC. ***Packed RBC*** - Transfusing **packed red blood cells** will increase the overall hemoglobin concentration, which can paradoxically increase blood viscosity and worsen vaso-occlusion in sickle cell crisis, especially in the setting of acute chest syndrome where fluid overload is a concern. - This is generally avoided as a first-line treatment for acute chest syndrome in sickle cell anemia unless the patient has severe anemia with a hemoglobin level significantly below their baseline. *Partial exchange transfusion* - **Partial exchange transfusion** is a critical intervention during sickle cell crises with severe complications like acute chest syndrome. - It rapidly reduces the percentage of **sickle hemoglobin (HbS)** and concurrently provides normal red blood cells, improving oxygen-carrying capacity and reducing blood viscosity without significantly increasing total red blood cell mass. *Morphine* - **Morphine** is essential for effective pain management in sickle cell crisis, including the severe chest pain associated with acute chest syndrome. - Adequate pain control helps reduce patient distress and can indirectly prevent worsening of the crisis by reducing stress-induced sympathetic activation. *Hydroxyurea* - **Hydroxyurea** is a long-term disease-modifying therapy for sickle cell anemia, increasing the production of **fetal hemoglobin (HbF)**, which reduces sickling. - While crucial for preventing future crises and complications, it is not an acute treatment for an emergency like acute chest syndrome, as its effects take weeks to months to manifest.

Q: The pattern of inheritance of the hematological disorder shown is:

X-linked recessive. ***X-linked recessive*** - This pattern is characterized by affected males, unaffected females who can be carriers, and the absence of male-to-male transmission [1]. - The disorder is passed from an affected father to all his daughters (who become carriers) and from a carrier mother to 50% of her sons (who are affected) and 50% of her daughters (who are carriers) [1]. *Autosomal recessive* - In this pattern, affected individuals typically have unaffected parents, and both males and females are affected equally. - The disorder often skips generations, and consanguinity increases the risk. *Autosomal dominant* - This pattern shows affected individuals in every generation, with affected individuals having at least one affected parent. - Both males and females are affected equally, and male-to-male transmission can occur. *X-linked dominant* - This pattern is characterized by affected fathers passing the trait to all their daughters but none of their sons. - Affected mothers have a 50% chance of passing the trait to each child, regardless of sex. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Genetic Disorders, p. 151.

Q: A 70-year-old man presents with painless cervical lymphadenopathy with progressive pallor and petechiae on ankles. Peripheral smear shows presence of:

CLL. ***CLL*** - The presentation of **painless cervical lymphadenopathy**, progressive **pallor** (due to anemia), and **petechiae** (due to thrombocytopenia) in an elderly patient is highly suggestive of **Chronic Lymphocytic Leukemia (CLL)** [2]. - Peripheral smear in CLL typically shows a proliferation of mature-appearing **small lymphocytes** and characteristic **smudge cells** [1]. *Acute ITP* - Acute ITP is characterized by sudden onset of **thrombocytopenia** and bleeding, often following a viral infection, and is more common in children. - It does not typically present with **lymphadenopathy** or progressive pallor as a primary feature. *Chronic ITP* - Chronic ITP is characterized by isolated **thrombocytopenia** and bleeding symptoms, usually without lymphadenopathy or significant anemia unless bleeding is severe. - The presence of **lymphadenopathy** points away from isolated ITP and towards a systemic hematological malignancy. *Richter syndrome* - Richter syndrome is the transformation of CLL into a more aggressive lymphoma, most commonly **diffuse large B-cell lymphoma (DLBCL)**. - While it can present with rapidly enlarging lymph nodes and systemic symptoms, the initial presentation described (painless lymphadenopathy, progressive pallor, petechiae) is more typical of **untreated CLL** before transformation [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, p. 602. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 612-613.

Q: A 12-year-old child with renal tubular acidosis type I is having muscle cramps and weakness. ECG shows all except:

Absent P waves. ***Absent P waves*** - **Hypokalemia (low potassium)**, common in renal tubular acidosis type I, does not typically cause absent P waves. Absent P waves are characteristic of certain **atrial arrhythmias** or severe **hyperkalemia** with sine wave formation. - The image provided clearly shows visible P waves before each QRS complex, indicating **sinus rhythm** and normal atrial depolarization. *T wave inversion with U waves* - **Hypokalemia** can cause characteristic ECG changes including **T wave flattening**, **T wave inversion**, and prominent **U waves**, especially in leads V2-V4. - The provided ECG shows evidence of T wave flattening or inversion and visible U waves, which are consistent with hypokalemia. *ST depression* - **ST depression** can occur in cases of significant **hypokalemia**, particularly when potassium levels are very low. - The ECG shows some subtle **ST segment depression**, especially in leads like V3, which is a recognized finding in hypokalemia. *Heart rate of 75 beats per minute* - To calculate the heart rate, count the number of large squares between two R waves (e.g., in V5, there are approximately 4 large squares). The heart rate is 300 / number of large squares = 300 / 4 = **75 bpm**. - A heart rate of 75 bpm is a **normal sinus rhythm** and is not inconsistent with hypokalemia.

Q: A 3-year-old child presents with the clinical features shown in the image. What is the most likely diagnosis?

Kawasaki disease. ***Kawasaki disease*** * The image displays classic signs of **Kawasaki disease**, including **bilateral conjunctivitis without exudates** (top left), **erythema of the palms and soles with desquamation** (top right), **cervical lymphadenopathy** (bottom left, indicated by swelling in the neck region), and a **strawberry tongue** (bottom right). * These clinical features, especially in a young child, are diagnostic for **Kawasaki disease**, which is a vasculitis affecting medium-sized arteries, most notably the coronary arteries. *Scarlet fever* * While **scarlet fever** can cause a **strawberry tongue** and a rash, the rash is typically a **fine, sandpaper-like rash** that blanches with pressure, not usually characterized by the distinct palm/sole erythema and desquamation seen in the image. * **Conjunctivitis** is not a prominent feature of scarlet fever, and the lymphadenopathy is typically less pronounced and may be tender. *Kikuchi disease* * **Kikuchi disease** (histiocytic necrotizing lymphadenitis) primarily presents with **cervical lymphadenopathy, fever**, and often rash, but it does **not typically involve conjunctivitis or changes in the hands, feet, or tongue** as dramatically depicted. * It is a self-limiting condition of unknown etiology, distinct from the systemic vasculitis of Kawasaki disease. *Rosai-Dorfman disease* * **Rosai-Dorfman disease** (sinus histiocytosis with massive lymphadenopathy) is characterized by **massive, painless lymphadenopathy**, particularly cervical, with fever and other systemic symptoms. * However, it does **not present with the specific mucocutaneous findings** of conjunctivitis, strawberry tongue, or characteristic hand/foot changes seen in the images indicative of Kawasaki disease.

Question 1

A 10-year-old child with Valvular heart disease on heart failure treatment, has the following ECG tracing. What is the diagnosis?

Accepted Answer

Non paroxysmal atrial tachycardia with regular AV block

Answer

Tall tented T-wave

Answer

Ventricular bigeminy

Answer

Non paroxysmal atrial tachycardia with irregular AV block

Question 2

A 50-year-old woman with rheumatic heart disease is on medication for heart disease. She feels unwell for most part of the day. Which of the following medicine is responsible for the ECG changes shown below? (Recent NEET Pattern 2016-17)

Accepted Answer

Digoxin

Answer

ACE inhibitor

Answer

Diuretics

Answer

Ivabradine

Question 3

A 60-year-old hypertension patient presents with breathlessness. ECG was performed. What is the diagnosis? (Recent NEET Pattern 2016-17)

Accepted Answer

Left ventricular hypertrophy

Answer

LBBB

Answer

Normal tracing

Answer

Complete heart block

Answer

Right ventricular hypertrophy

Question 4

A 50-year-old smoker comes with complaints of ankle edema for last 3 months. The ECG shows all except: (Recent NEET Pattern 2016-17)

Accepted Answer

Right bundle branch block

Answer

P pulmonale

Answer

Right axis deviation

Answer

T wave inversion in II,III, V1-V2

Answer

Left axis deviation

Question 5

The patient with the following hematological abnormality presents with severe chest pain and difficulty in breathing. All are useful for managing this emergency except:

Accepted Answer

Packed RBC

Answer

Partial exchange transfusion

Answer

Morphine

Answer

Hydroxyurea

Question 6

The pattern of inheritance of the hematological disorder shown is:

Accepted Answer

X-linked recessive

Answer

Autosomal dominant

Answer

Mitochondrial inheritance

Answer

Autosomal recessive

Answer

X-linked dominant

Question 7

A 70-year-old man presents with painless cervical lymphadenopathy with progressive pallor and petechiae on ankles. Peripheral smear shows presence of:

Accepted Answer

CLL

Answer

Acute ITP

Answer

Chronic ITP

Answer

Richter syndrome

Answer

Hairy cell leukemia

Question 8

The following bone marrow specimen is suggestive of diagnosis of:

Accepted Answer

Aplastic anemia

Answer

Pure red cell aplasia

Answer

Myelodysplasia

Answer

Normal marrow

Answer

Hairy cell leukemia

Question 9

A 12-year-old child with renal tubular acidosis type I is having muscle cramps and weakness. ECG shows all except:

Accepted Answer

Absent P waves

Answer

T wave inversion with U waves

Answer

ST depression

Answer

Heart rate of 75 beats per minute

Question 10

A 3-year-old child presents with the clinical features shown in the image. What is the most likely diagnosis?

Accepted Answer

Kawasaki disease

Answer

Scarlet fever

Answer

Kikuchi disease

Answer

Rosai-Dorfman disease

NEET-PG 2017

Internal Medicine

Pathology

Pediatrics