NEET-PG 2013 - Internal Medicine Practice Questions

Q: What is the drug of choice for bleeding oesophageal varices?

Octreotide. ***Octreotide*** - **Octreotide** is an analogue of **somatostatin** that reduces splanchnic blood flow and portal pressure, thereby decreasing bleeding from esophageal varices. - It is often used in the acute management of **bleeding esophageal varices** due to its rapid onset of action and favorable safety profile. *Ethanolamine oleate* - **Ethanolamine oleate** is a **sclerosing agent** used for endoscopic sclerotherapy of esophageal varices, not typically as the initial drug of choice for acute bleeding [1]. - It acts by causing inflammation and fibrosis of the varices, which can be effective but carries risks such as **esophageal ulceration** or perforation. *Propranolol* - **Propranolol** is a **non-selective beta-blocker** used for the prophylactic prevention of variceal bleeding, not for acute management of active bleeding. - It works by reducing portal venous pressure by decreasing cardiac output and splanchnic vasoconstriction. *Phytonadione* - **Phytonadione** (vitamin K1) is used to reverse **coumarin anticoagulant effects** or to treat **vitamin K deficiency**, which can contribute to bleeding but is not a direct treatment for variceal bleeding itself. - It helps in the synthesis of **coagulation factors II, VII, IX, and X**, thereby improving clotting.

Q: Treatment of choice for prinzmetal's angina

Calcium Channel Blockers (CCBs). ***Calcium Channel Blockers (CCBs)*** - **Dihydropyridine** CCBs like nifedipine or amlodipine, and **non-dihydropyridine** CCBs like diltiazem or verapamil, are the **first-line agents** for Prinzmetal's angina [1]. - They work by **relaxing coronary smooth muscle**, preventing the vasospasm that causes the angina [1]. *Nitroglycerin* - **Nitroglycerin is effective** for acute relief of Prinzmetal's angina symptoms due to its **vasodilatory properties**. - However, it's typically used as **rescue therapy** and not as a long-term preventative treatment. *Beta-blockers* - Beta-blockers are **contraindicated** in Prinzmetal's angina as they can **worsen coronary vasospasm** by blocking beta-2 mediated vasodilation, leaving unopposed alpha-1 vasoconstriction [2]. - They can increase the **frequency and severity of attacks**. *Prazosin* - Prazosin is an **alpha-1 adrenergic blocker** used primarily for **hypertension** and benign prostatic hyperplasia. - While it can cause vasodilation, it is **not the treatment of choice** for Prinzmetal's angina and is less effective than CCBs in preventing coronary spasm.

Q: Which of the following statements about polio is false?

Increased tendon reflexes. ***Increased tendon reflexes*** - Polio causes **lower motor neuron damage**, specifically to the anterior horn cells of the spinal cord [1]. - This damage leads to **flaccid paralysis** and **decreased or absent deep tendon reflexes**, not increased reflexes [3]. *99% non paralytic* - The vast majority of poliovirus infections (approximately 95-99%) are **asymptomatic** or cause only mild, non-specific symptoms. - Only a small percentage of infected individuals develop the more severe paralytic form of the disease. *Flaccid paralysis* - Poliovirus directly attacks and destroys **motor neurons** in the anterior horn of the spinal cord [1]. - This damage results in **muscle weakness** and loss of muscle tone, leading to **flaccid paralysis** [3]. *Aseptic meningitis* - About 1-5% of poliovirus infections can manifest as **aseptic meningitis**, characterized by symptoms like fever, headache, neck stiffness, and vomiting without bacterial infection [2]. - This form of meningitis is typically **self-limiting** and does not lead to paralysis [2].

Q: Pea soup diarrhea is seen in -

Typhoid. ***Typhoid*** - **Pea soup diarrhea** is a classic symptom of **typhoid fever**, caused by *Salmonella Typhi* [1]. - This characteristic stool is a greenish-yellow watery diarrhea due to inflammation and ulceration of the Peyer's patches in the small intestine [1]. *Cholera* - Characterized by **rice-water stools**, which are profuse, watery, and often contain flecks of mucus, resembling water in which rice has been rinsed [2]. - This type of diarrhea is due to the potent **cholera toxin** causing massive fluid and electrolyte secretion [2]. *Yersinosis* - Causes diarrhea that can range from watery to bloody, often associated with severe **abdominal pain** mimicking appendicitis. - While it can cause enterocolitis, the stool consistency is not typically described as "pea soup" like in typhoid. *Hepatitis* - Hepatitis primarily affects the **liver** and typically does **not cause diarrhea** as a prominent symptom. - Common symptoms include jaundice, dark urine, and pale stools due to impaired bilirubin metabolism.

Q: Which of the following is NOT an indication for a liver biopsy?

Amoebic hepatitis. ***Amoebic hepatitis*** - Liver biopsy is **not routinely indicated** for amoebic hepatitis as diagnosis is typically made through clinical history and serological tests. - The condition is usually managed with **medications** rather than requiring invasive procedures like a biopsy. *Wilson's disease* - Liver biopsy is important for assessing **copper accumulation** in Wilson's disease, establishing a diagnosis. - It may also provide information regarding the extent of **hepatocellular damage**. *Chronic hepatitis B and C* - In chronic hepatitis B and C, liver biopsy is crucial to evaluate the **degree of fibrosis** and hepatic inflammation. - It assists in determining the need for **antiviral therapy** and prognostication. *Autoimmune hepatitis* - Liver biopsy helps confirm the diagnosis of autoimmune hepatitis and assess the **severity of liver damage**. [1] - It also aids in monitoring the response to **immunosuppressive therapy**. [1] **Note on technique:** Percutaneous liver biopsy requires specific conditions for safety, such as cooperative patients and adequate coagulation profiles. [2]

Q: All of the following are features of Obstructive jaundice except:

Normal alkaline phosphatase. ***Normal alkaline phosphatase*** - In obstructive jaundice, alkaline phosphatase is typically **elevated** due to bile duct obstruction [2]. - A **normal level** suggests that the jaundice may not be of obstructive origin. *Pruritis* - Often seen in obstructive jaundice due to **bile salts** accumulating in the bloodstream, leading to itching. - It is a common symptom associated with **cholestasis**. *Mildly elevated serum aminotransferases level* - In obstructive jaundice, serum aminotransferases are usually elevated, though may be mildly in early cases [1]. - This reflects liver involvement, which is consistent with biliary obstruction [2]. *Clay colour stools* - Clay-colored stools arise from the absence of **bile** in the intestines, indicative of obstruction [3]. - This is a direct result of blockage in the bile duct system affecting stool pigmentation [3].

Q: Diagnose the underlying medical disorder based on the ECG changes.

ECG changes due to hypocalcemia. ***ECG changes due to hypocalcemia*** - **Hypocalcemia** characteristically causes a **prolonged QT interval** on the ECG due to delayed repolarization of ventricular myocytes. - This prolongation is primarily due to the lengthening of the **ST segment**, while the T wave itself is usually unchanged. *ECG changes due to hypokalemia* - **Hypokalemia** typically presents with prominent **U waves**, T wave flattening or inversion, and sometimes ST segment depression. - While it can also prolong the QT interval, the primary distinguishing feature is the presence of U waves, which are not mentioned as the main finding. *ECG changes due to hypercalcemia* - **Hypercalcemia** is associated with a **shortened QT interval** on the ECG due to accelerated repolarization. - It can also cause a shortened ST segment and widened QRS complex in severe cases. *ECG changes due to hyperkalemia* - **Hyperkalemia** classically manifests as tall, **peaked T waves**, followed by a prolonged PR interval, widened QRS complex, and eventual sine wave pattern as it worsens. - These changes are distinctly different from the prolonged QT interval seen in hypocalcemia.

Q: A 25 year old female presents with generalized restriction of eye movement in all direction, intermittent ptosis, proximal muscle weakness and fatigability.Which is the MOST useful test in making the diagnosis?

Edrophonium test. ***Edrophonium test*** - The **Edrophonium test** (Tensilon test) is highly useful for diagnosing **myasthenia gravis** due to its rapid onset and short duration of action. - In a patient with suspected myasthenia gravis, such as this one presenting with **generalized restriction of eye movement**, **intermittent ptosis**, and **fatigable proximal muscle weakness**, the administration of edrophonium will lead to a temporary but significant improvement in muscle strength. It works by inhibiting the breakdown of acetylcholine, thereby increasing its availability at the neuromuscular junction [1]. *CPK* - **Creatine phosphokinase (CPK)** levels are typically normal in myasthenia gravis, as it is a disorder of the **neuromuscular junction**, not a primary muscle disease. - Elevated CPK levels usually indicate muscle damage, seen in conditions like **myositis** or **muscular dystrophies**, which are not suggested by the patient's symptoms. *EMG* - **Electromyography (EMG)**, specifically **repetitive nerve stimulation (RNS)** or **single-fiber EMG (SFEMG)**, can show characteristic decremental responses or increased jitter/blocking in myasthenia gravis [2], but it is less direct and often more invasive than the Edrophonium test for initial diagnostic confirmation. - While supportive, it is generally considered a secondary diagnostic tool after a strong clinical suspicion and is not the *most useful* initial test compared to the rapid symptomatic improvement seen with edrophonium. *Muscle biopsy* - A **muscle biopsy** is generally not useful in diagnosing myasthenia gravis as the muscle tissue itself is structurally normal. - This diagnostic tool is reserved for primary **muscle disorders** like muscular dystrophies or inflammatory myopathies, which would show characteristic histological changes.

Q: A 40-year-old male patient presents to the Emergency department with central chest pain for 2 hours. The ECG shows ST segment depression and cardiac troponins are elevated. The patient has a positive history of previous PCI 3 months back. He is administered Aspirin, Clopidogrel, Nitrates, and LMWH in the Emergency Department and shifted to the coronary care unit. What is the best recommended course of further action?

Early Revascularization with PCI. ***Early Revascularization with PCI*** - The patient presents with **NSTEMI** (ST depression, elevated troponins) and is already on antiplatelet and anticoagulant therapy. **Early revascularization** (ideally within 24 hours for high-risk NSTEMI) is indicated to restore blood flow and prevent further myocardial damage [1]. - Given the patient's history of prior **PCI** and the current NSTEMI presentation, this suggests possible **in-stent restenosis** or progression of coronary artery disease, making revascularization crucial. *Continue conservative management and monitoring of cardiac enzymes and ECG* - While initial conservative management with medications is appropriate, simply continuing monitoring without definitive intervention is insufficient for a **high-risk NSTEMI** patient. - The elevated troponins and ST depression indicate ongoing myocardial injury that requires active management beyond just observation [1]. *Continue conservative management and plan for outpatient follow-up* - This approach is entirely inappropriate for a patient presenting with an **acute coronary syndrome (NSTEMI)**. - Outpatient follow-up is for stable conditions, not for an ongoing cardiac event that requires urgent hospital-based intervention. *Immediate Revascularization with Coronary Angiography* - **Immediate revascularization** (within 90 minutes) is primarily indicated for **STEMI** (ST elevation myocardial infarction). - While coronary angiography will precede PCI, the term "immediate" in this context usually refers to the urgency seen in STEMI; NSTEMI typically warrants "early" rather than "immediate" intervention (within 12-24 hours for high-risk patients like this one) [1].

Q: What is the recommended rate of correction for sodium deficit in patients with chronic hyponatremia?

0.5 mmol/hour. ***0.5 mmol/hour*** [1] - This rate of correction is recommended to avoid **osmotic demyelination syndrome (ODS)**, also known as central pontine myelinolysis [1]. - The aim is to correct the sodium deficit gradually, with a maximum increase not exceeding **8-10 mmol/L in any 24-hour period** [1]. *1 mmol/hour* - This rate is generally considered too rapid for chronic hyponatremia and increases the risk of **osmotic demyelination syndrome**. - While acceptable in some acute severe cases, it is typically avoided in chronic settings where the brain has adapted to lower osmolality. *1.5 mmol/hour* - This rate would lead to an even faster correction of sodium, significantly elevating the risk of **osmotic demyelination syndrome**. - It would result in a correction of 36 mmol/L over 24 hours, far exceeding the recommended daily limit of 8-10 mmol/L. *2.0 mmol/hour* - Such a rapid correction rate is highly dangerous and almost guarantees the development of **osmotic demyelination syndrome**. - This aggressive correction would lead to severe brain injury due to rapid osmotic shifts.

Question 1

What is the drug of choice for bleeding oesophageal varices?

Accepted Answer

Octreotide

Answer

Ethanolamine oleate

Answer

Propanolol

Answer

Phytonadione

Question 2

Treatment of choice for prinzmetal's angina

Accepted Answer

Calcium Channel Blockers (CCBs)

Answer

Nitroglycerin

Answer

Prazosin

Answer

Beta-blockers

Question 3

Which of the following statements about polio is false?

Accepted Answer

Increased tendon reflexes

Answer

99% non paralytic

Answer

Aseptic meningitis

Answer

Flaccid paralysis

Question 4

Pea soup diarrhea is seen in -

Accepted Answer

Typhoid

Answer

Cholera

Answer

Yersinosis

Answer

Hepatitis

Question 5

Which of the following is NOT an indication for a liver biopsy?

Accepted Answer

Amoebic hepatitis

Answer

Chronic hepatitis B and C

Answer

Autoimmune hepatitis

Answer

Wilson's disease

Question 6

All of the following are features of Obstructive jaundice except:

Accepted Answer

Normal alkaline phosphatase

Answer

Clay colour stools

Answer

Pruritis

Answer

Elevated serum aminotransferases level

Question 7

Diagnose the underlying medical disorder based on the ECG changes.

Accepted Answer

ECG changes due to hypocalcemia

Answer

ECG changes due to hypokalemia

Answer

ECG changes due to hypercalcemia

Answer

ECG changes due to hyperkalemia

Question 8

A 25 year old female presents with generalized restriction of eye movement in all direction, intermittent ptosis, proximal muscle weakness and fatigability.Which is the MOST useful test in making the diagnosis?

Accepted Answer

Edrophonium test

Answer

CPK

Answer

EMG

Answer

Muscle biopsy

Question 9

A 40-year-old male patient presents to the Emergency department with central chest pain for 2 hours. The ECG shows ST segment depression and cardiac troponins are elevated. The patient has a positive history of previous PCI 3 months back. He is administered Aspirin, Clopidogrel, Nitrates, and LMWH in the Emergency Department and shifted to the coronary care unit. What is the best recommended course of further action?

Accepted Answer

Early Revascularization with PCI

Answer

Continue conservative management and monitoring of cardiac enzymes and ECG

Answer

Continue conservative management and plan for outpatient follow-up

Answer

Immediate Revascularization with Coronary Angiography

Question 10

What is the recommended rate of correction for sodium deficit in patients with chronic hyponatremia?

Accepted Answer

0.5 mmol/hour

Answer

1 mmol/hour

Answer

1.5 mmol/hour

Answer

2.0 mmol/hour

NEET-PG 2013 — Internal Medicine