NEET-PG 2013 - Internal Medicine Practice Questions

Q: Which of the following is associated with WPW syndrome?

Ebstein anomaly. ***Ebstein anomaly*** - **Ebstein anomaly** is a congenital heart defect characterized by apical displacement of the septal and posterior leaflets of the tricuspid valve, which is strongly associated with **Wolff-Parkinson-White (WPW) syndrome.** - WPW syndrome, involving an **accessory pathway** that bypasses the AV node [1], is found in 5-25% of patients with Ebstein anomaly, predisposing them to re-entrant tachycardias [3]. *TOF* - **Tetralogy of Fallot (TOF)** is a complex cyanotic congenital heart defect that includes four main features: VSD, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy [2]. - There is no direct or strong association between TOF and WPW syndrome. *VSD* - A **Ventricular Septal Defect (VSD)** is a common congenital heart defect where there is an opening in the interventricular septum, allowing blood to flow between the ventricles [4]. - While VSDs can occur with other cardiac anomalies, there is no specific or frequent association with WPW syndrome. *TAPVC* - **Total Anomalous Pulmonary Venous Connection (TAPVC)** is a rare congenital heart defect where all four pulmonary veins connect to the systemic venous circulation instead of the left atrium. - This condition does not have a recognized association with WPW syndrome.

Q: Calciphylaxis is a severe life-threatening condition. Which of the following is most commonly associated with it?

End stage Renal disease. ***End stage Renal disease*** - Calciphylaxis frequently occurs in patients with **end-stage renal disease**, primarily associated with **secondary hyperparathyroidism** [1] and **calcium-phosphate imbalance**. - It leads to **cutaneous ischemia** and necrosis, often requiring aggressive management due to its high **mortality rate**. *Parathyroidectomy* - While parathyroidectomy may affect calcium levels, it is not directly linked to calciphylaxis. - Calciphylaxis more commonly develops due to underlying **chronic renal failure** [1] rather than surgical interventions. *Hyperthyroidism* - Hyperthyroidism primarily causes symptoms related to metabolism, **thyroid hormone excess**, and does not lead to calciphylaxis. - There is no direct correlation between hyperthyroid states and the pathophysiology of calciphylaxis. *Medullary carcinoma thyroid* - This condition involves **medullary thyroid carcinoma**, associated with calcitonin production and does not cause calciphylaxis. - Patients typically experience **thyroid-related symptoms** rather than the vascular complications seen in calciphylaxis.

Q: Which of the following conditions is associated with megaloblastic anemia?

Pernicious anemia. a and b - Megaloblastic anemia is commonly associated with **vitamin B12** [1] and **folate deficiencies** [2], which can occur due to various causes. - Conditions leading to malabsorption (such as those related to the gastrointestinal tract) contribute significantly to megaloblastic anemia [1, 2]. *ileal resection* - Ileal resection can indeed lead to **malabsorption** of vitamin B12 [1], particularly if the distal ileum is removed. - However, it is important to note that megaloblastic anemia specifically reflects a broader range of potential deficiencies, thus it is not an exclusive answer. *Crohn's disease* - Crohn's disease can cause **malabsorption** and result in vitamin B12 deficiency but is not a direct cause of megaloblastic anemia on its own. - The anemia may occur due to complications like **ileo-pouch anastomosis** rather than the disease itself. *Intestinal lymphatic ectasia* - This condition leads to **protein-losing enteropathy**, potentially causing deficiencies but not specifically leading to megaloblastic anemia. - The anemia associated with this condition is typically due to **hypoalbuminemia** and not a result of any vitamin deficiency directly.

Q: In Wilson's disease, copper deposition primarily occurs in which part of the brain?

Basal ganglia. ***Basal ganglia*** - The **basal ganglia**, particularly the **putamen** and **globus pallidus**, are the most common sites for copper deposition in the brain in Wilson's disease [1]. - This deposition leads to **neurological symptoms** such as dystonia [2], tremor, and dysarthria. *Pons* - While copper can accumulate in various brain regions, the **pons** is not a primary or characteristic site of significant copper deposition. - Neurological symptoms associated with pontine damage are not typical presenting features of Wilson's disease. *Cerebellum* - The **cerebellum** can show some copper accumulation in advanced stages, but it is not the primary site. - Cerebellar signs like **ataxia** can occur in Wilson's disease, but usually secondary to more widespread pathology rather than primary cerebellar copper deposition. *Medulla* - The **medulla oblongata** is generally spared from significant copper deposition in Wilson's disease. - Involvement of the medulla would typically manifest with severe autonomic or brainstem dysfunction, which is not a hallmark of early Wilson's disease.

Q: The common cause of subarachnoid hemorrhage is:

Aneurysm. ***Aneurysm*** - Aneurysms, particularly **saccular** or **berry aneurysms**, are the most frequent cause of **spontaneous subarachnoid hemorrhage (SAH)**, accounting for about 80-85% of cases [2]. - The sudden rupture of an intracranial aneurysm leads to blood spilling into the **subarachnoid space**, causing characteristic symptoms like a "thunderclap headache" [1]. *Arterio-venous malformation* - While AV malformations (AVMs) can cause SAH, they are a less common cause than aneurysms, accounting for approximately 5-10% of cases. - AVMs are abnormal direct connections between arteries and veins that bypass the capillary system and can rupture, leading to SAH or intraparenchymal hemorrhage. *Cavernous angioma* - Cavernous angiomas are abnormal clusters of dilated, thin-walled capillaries that can lead to hemorrhage, but they primarily cause **intraparenchymal hemorrhage** rather than SAH. - They are much less likely to result in diffuse bleeding into the subarachnoid space compared to ruptured aneurysms. *Hypertension* - Hypertension is a significant risk factor for the formation and rupture of aneurysms [1], but it is not a direct cause of SAH itself in the same way an aneurysm rupture is. - While uncontrolled hypertension is often associated with **intracerebral hemorrhage** (bleeding within the brain tissue), its direct role in causing SAH is usually secondary to an underlying vascular abnormality like an aneurysm.

Q: The physiological marker of the last stage of acute asthma is

Increased carbon dioxide levels (Hypercapnia). ***Increased carbon dioxide levels (Hypercapnia)*** - In severe, acute asthma, **air trapping** and **muscle fatigue** lead to inadequate ventilation and impaired gas exchange [1]. - This results in a buildup of carbon dioxide in the blood, indicating impending **respiratory failure** and a critical stage of the asthma exacerbation [3]. *Hypocapnia* - **Hypocapnia**, or low blood CO2, is common in the **early stages** of an asthma attack due to **tachypnea** (rapid breathing) in an effort to compensate [1]. - As the condition worsens, the ability to ventilate adequately diminishes, leading to CO2 retention [3]. *Hyperoxia* - **Hyperoxia** means abnormally high levels of oxygen in the blood, which is generally not a physiological marker of acute asthma. - Patients with acute asthma typically experience **hypoxemia** (low oxygen levels) due to ventilation-perfusion mismatch [1]. *Alkalosis* - **Respiratory alkalosis** (high pH due to low CO2) can occur in the early stages as patients **hyperventilate**. - However, in the late stages, as CO2 builds up (**hypercapnia**), the patient shifts towards **respiratory acidosis** (low pH), which is a sign of severe compromise [2], [3].

Q: Torsades de pointes is seen in all except

Hyponatremia. ***Hyponatremia*** - **Hyponatremia** (low sodium levels) primarily affects neuronal function and can lead to neurological symptoms like seizures and altered mental status [1]. - It does not directly cause **QT prolongation** or **Torsades de Pointes (TdP)**, which are typically associated with electrolyte imbalances affecting cardiac repolarization. *Hypocalcemia* - **Hypocalcemia** (low calcium levels) can prolong the **QT interval** on an electrocardiogram. - Prolongation of the QT interval increases the risk of developing **Torsades de Pointes**, a life-threatening polymorphic ventricular tachycardia [2]. *Hypomagnesemia* - **Hypomagnesemia** (low magnesium levels) is a common cause and aggravator of **Torsades de Pointes**. - Magnesium plays a crucial role in cardiac ion channel function, and its deficiency can lead to significant **QT prolongation** and ventricular arrhythmias. *Hypokalemia* - **Hypokalemia** (low potassium levels) can prolong the **QT interval** and increase the risk of developing ventricular arrhythmias, including **Torsades de Pointes** [1]. - Potassium channels are essential for cardiac repolarization, and their dysfunction due to low potassium can destabilize myocardial electrical activity [1].

Q: Graham Steell murmur is associated with which of the following conditions?

Pulmonary Regurgitation (PR). ***Pulmonary Regurgitation (PR)*** - The **Graham Steell murmur** is a high-pitched, decrescendo early diastolic murmur heard best at the left sternal border associated with **pulmonary hypertension**. [1] - It results from dilation of the pulmonary artery due to **elevated pulmonary pressures**, leading to functional pulmonary valve regurgitation. [1] *Tricuspid Regurgitation (TR)* - TR typically presents as a **holosystolic murmur** best heard at the left lower sternal border, often increasing with inspiration (Carvallo's sign). - It is caused by improper coaptation of the tricuspid valve leaflets, often due to **right ventricular dilation**. *Tricuspid Stenosis (TS)* - TS is characterized by a **diastolic rumble** heard best at the lower left sternal border, often with an opening snap. [2] - It is relatively rare and often associated with **rheumatic heart disease**. *Pulmonary Stenosis (PS)* - PS typically produces a **systolic ejection murmur** heard at the upper left sternal border, often radiating to the back. - It is caused by **obstruction to blood flow** from the right ventricle to the pulmonary artery.

Q: What is the expected Transtubular Potassium Gradient (TTKG) in a patient with hypokalemia due to extrarenal losses?

< 3-4. ***< 3-4*** - A **Transtubular Potassium Gradient (TTKG)** of less than 3-4 indicates appropriate renal potassium conservation in response to hypokalemia. - This suggests that the hypokalemia is likely due to **extrarenal losses**, such as gastrointestinal losses (diarrhea, vomiting) or inadequate dietary intake, as the kidneys are working to retain potassium. *3-4* - A TTKG value in this range is typically considered indeterminate but could still point towards appropriate renal conservation if other clinical signs of extrarenal losses are present. - However, it does not as strongly confirm appropriate renal conservation as a value clearly below 3. *> 4-5* - A TTKG greater than 4-5 suggests **inappropriate renal potassium excretion** for a patient with hypokalemia. - This would indicate that the kidneys are complicit in the potassium loss, pointing towards renal causes of hypokalemia, such as **mineralocorticoid excess** or **diuretic use**. *> 5-6* - A TTKG greater than 5-6 strongly indicates significant **renal potassium wasting**. - This would be seen in conditions where the kidneys are actively secreting potassium despite hypokalemia, thereby contributing to the low potassium levels rather than conserving it.

Q: Most common hematological malignancy associated with Rheumatoid Arthritis (RA)?

Large granular lymphocytic leukemia (LGLL). ***Large granular lymphocytic leukemia (LGLL)*** - **LGLL** is the most common hematological malignancy strongly associated with **rheumatoid arthritis (RA)**, often presenting with features such as **neutropenia** and splenomegaly. - Approximately 80% of patients with LGLL have a **T-cell phenotype**, and a significant subset experiences **autoimmune diseases**, with RA being the most frequent. *Diffuse large B cell lymphoma* - While patients with **RA** have an increased risk of **lymphoma**, **diffuse large B-cell lymphoma (DLBCL)** is a more aggressive type but not the most common hematologic malignancy directly associated with the disease itself in terms of prevalence [3]. - Inflammatory conditions like **RA** can contribute to chronic immune stimulation, increasing the risk of certain lymphomas, but LGLL holds a more direct and prevalent association [1]. *Chronic lymphocytic leukemia* - **Chronic lymphocytic leukemia (CLL)** is a lymphoproliferative disorder of **B lymphocytes**, but it does not have a particularly strong or common association with **RA** compared to LGLL [2]. - The elevated risk of hematological malignancies in RA patients typically points more towards lymphoproliferative disorders driven by specific immune dysregulations characteristic of RA. *T-cell prolymphocytic leukemia* - **T-cell prolymphocytic leukemia (T-PLL)** is a rare and aggressive **T-cell leukemia** that generally presents with a high white blood cell count and splenomegaly, but it is not commonly linked with **RA**. - Its clinical presentation and biology are distinct from the more indolent leukemias like LGLL that are often seen in conjunction with autoimmune conditions.

Question 1

Which of the following is associated with WPW syndrome?

Accepted Answer

Ebstein anomaly

Answer

TOF

Answer

VSD

Answer

TAPVC

Question 2

Calciphylaxis is a severe life-threatening condition. Which of the following is most commonly associated with it?

Accepted Answer

End stage Renal disease

Answer

Parathyroidectomy

Answer

Medullary carcinoma thyroid

Answer

Hyperthyroidism

Question 3

Which of the following conditions is associated with megaloblastic anemia?

Accepted Answer

Pernicious anemia

Answer

Iron deficiency anemia

Answer

Intestinal lymphatic ectasia

Answer

Chronic kidney disease

Question 4

In Wilson's disease, copper deposition primarily occurs in which part of the brain?

Accepted Answer

Basal ganglia

Answer

Cerebellum

Answer

Pons

Answer

Medulla

Question 5

The common cause of subarachnoid hemorrhage is:

Accepted Answer

Aneurysm

Answer

Arterio-venous malformation

Answer

Cavernous angioma

Answer

Hypertension

Question 6

The physiological marker of the last stage of acute asthma is

Accepted Answer

Increased carbon dioxide levels (Hypercapnia)

Answer

Hypocapnia

Answer

Hyperoxia

Answer

Alkalosis

Question 7

Torsades de pointes is seen in all except

Accepted Answer

Hyponatremia

Answer

Hypomagnesemia

Answer

Hypokalemia

Answer

Hypocalcemia

Question 8

Graham Steell murmur is associated with which of the following conditions?

Accepted Answer

Pulmonary Regurgitation (PR)

Answer

Tricuspid Regurgitation (TR)

Answer

Tricuspid Stenosis (TS)

Answer

Pulmonary Stenosis (PS)

Question 9

What is the expected Transtubular Potassium Gradient (TTKG) in a patient with hypokalemia due to extrarenal losses?

Accepted Answer

< 3-4

Answer

3-4

Answer

> 4-5

Answer

> 5-6

Question 10

Most common hematological malignancy associated with Rheumatoid Arthritis (RA)?

Accepted Answer

Large granular lymphocytic leukemia (LGLL)

Answer

Diffuse large B cell lymphoma

Answer

Chronic lymphocytic leukemia

Answer

T-cell prolymphocytic leukemia

NEET-PG 2013 — Internal Medicine