Test: Miscellaneous - NEET PG MCQ

The patient, who sustained a spinal cord injury above T6, experienced a significant sympathomimetic surge, resulting in splanchnic vasoconstriction and the onset of hypertension. This led to reflex bradycardia.

• Choice D is excluded due to the presence of bradycardia.
• As the patient currently shows no signs of target organ damage, such as papilledema or any CNS event, Choices A and B are also eliminated.
• Choice A is typically indicated for haemorrhagic stroke accompanied by hypertensive crisis, while Choice B is used in cases of hypertensive encephalopathy.

The management of a patient with supine hypertension involves positioning them upright and administering a buccal spray of NTG, followed by an NTG drip if necessary. The usual triggers for autonomic dysreflexia in individuals with spinal cord injuries include a blocked or kinked Foley catheter or stool impaction. Therefore, addressing these two conditions would be beneficial.

Management of anaphylaxis:

• Administer 0.3-0.5 ml of 1:1000 (1 mg/ml) Epinephrine subcutaneously or intramuscularly, with repeated doses as necessary at intervals of 5 to 20 minutes.
• If the antigenic substance was injected into a limb, apply a tourniquet and inject 0.2 ml of 1:1000 epinephrine at the injection site.
• Use volume expanders such as normal saline.
• Consider vasopressors like dopamine.
• Administer Diphenhydramine.
• Provide Aminophylline.
• Although Prednisolone is not effective for acute episodes, it helps to prevent future occurrences of bronchospasm.

The Modified Shock Index (MSI) is employed to forecast the onset of shock.

A high MSI signifies:

• low systemic vascular resistance,
• which reflects hypodynamic circulation.

In contrast, a low MSI suggests:

• high systemic vascular resistance,
• indicating hyperdynamic circulation.

Meta-analyses reveal that an MSI exceeding 1.3 correlates with a heightened likelihood of ICU admission and mortality. On the other hand, a low MSI also signifies increased mortality and is associated with:

• cerebrovascular accidents (CVA),
• arrhythmias.

Furthermore, it serves as a superior predictor of mortality compared to blood pressure and heart rate.

Balanced resuscitation aims to manage perfusion while minimising the risks of re-bleeding by allowing a blood pressure that is lower than normal. The key is to achieve a balance without inducing hypotension, as this could endanger tissue perfusion.

This approach is referred to as permissive hypotension, balanced resuscitation, or hypotensive resuscitation.

Urine output serves as a precise indicator of end organ perfusion.

Central venous pressure (CVP) can be affected by:

• Intra-thoracic pressures (such as PEEP from ventilation)
• Obstructive lung disease
• Valvular heart disease
• Pericardial disease (e.g., cardiac tamponade)

Therefore, it is not a dependable measure.

Heart rate (HR) may be influenced by medications and can be reduced in cases of neurogenic shock.

Blood pressure typically decreases only when physiological compensatory mechanisms are being overwhelmed.

The question relies on basic reasoning. The duration of cohabitation significantly influences how precisely a relative can articulate the patient's symptoms. For instance, if a son lives overseas and is detailing the progress of his father's symptoms of Huntington's disease to you, this account may not provide a trustworthy history.

• This is particularly true for conditions with a genetic component, where familial ties are crucial.
• Informed family members can often convey and understand the patient's experiences more effectively.

• Choice A and B: This quotation is taken directly from Bailey, page 17, 26th edition: 'On balance, there is little evidence to support the administration of colloids, which are more expensive and have worse side-effect profiles.' Most importantly, both crystalloids and colloids have zero oxygen carrying capacity.
• Choice C: In cases of blood loss, the most suitable replacement fluid is blood; however, crystalloid therapy may be necessary while waiting for blood products.
• Choice D: Fluid resuscitation needs to be completed prior to administering general anaesthesia, allowing the surgeon to proceed with immediate laparoscopy.

Observe the red line (shown in the diagram) extending from the peak of the R wave to the LV waveform, which indicates the LV end diastolic pressure, appearing close to the normal range of 6-12 mm Hg. An increased LVEDP suggests left ventricular failure (LVF) or diastolic dysfunction, whereas a decreased LVEDP indicates hypovolemia.
When comparing the systolic pressure of the LV waveform with that of the aorta waveform:

• Both exhibit a similar value of approximately 120 mm Hg.
  ​

This leads to the conclusion that the systolic and diastolic pressures for both the LV and aorta, as recorded, are within normal limits:

• Normal LV pressure = 120/6-12 mm Hg
• Normal aortic pressure = 120/80 mm Hg
  ​

• At night: Simvastatin is preferred over atorvastatin which has a prolonged effect; the time of administration is not crucial for atorvastatin. However, due to the shorter duration of action of simvastatin, it is advisable to take it before bedtime. This recommendation is based on the fact that HMG CoA reductase is most active at night when food intake is minimal, making it ideal to administer simvastatin at this time.
• Eccentric dosing: isosorbide mononitrate tolerance can develop to the anti-anginal effects of nitrates if they are given at regular intervals, and increasing the dose does not effectively counteract this resistance. As noted in the 19th edition of Harrison, to mitigate nitrate tolerance, a drug-free interval at night should be implemented. To achieve this, an eccentric dosing schedule can be followed, such as taking 30 mg at 7 am, 12 pm, and 5 pm, thereby avoiding nocturnal blood levels.
• For exercise-induced asthma, the following strategies are employed in order of decreasing effectiveness:
  • Inhaled Steroids
  • Inhaled Ipratropium
  • Inhaled Sodium Cromoglycate
• In the morning, before breakfast and while sitting upright: Alendronate. Bisphosphonates may lead to the development of reflux esophagitis.

Revised Goldman Cardiac Risk Index (LEE RISK INDEX)

• High-risk surgical types include:
  • Intraperitoneal
  • Intrathoracic
  • Suprainguinal vascular procedures
• History of ischaemic heart disease, which includes:
  Patients who had coronary artery bypass grafting or percutaneous transluminal coronary angioplasty are considered only if they currently report chest pain thought to be due to ischaemia.
  • Previous myocardial infarction
  • Positive exercise stress test
  • Current reports of ischaemic chest pain or use of nitrate therapy
  • ECG showing Q waves
• History of congestive heart failure, characterised by:
  • Previous congestive heart failure
  • Pulmonary oedema
  • Paroxysmal nocturnal dyspnoea
  • Physical examination revealing bilateral rales or S₃
  • Chest radiograph indicating pulmonary vascular redistribution
• History of cerebrovascular disease
• Diabetes mellitus managed with insulin
• Preoperative serum creatinine levels exceeding 2 mg/dL

Myxomas are associated with general signs and symptoms such as:

• Fever
• Weight loss
• Cachexia, malaise, arthralgias, rash
• Digital clubbing
• Raynaud's phenomenon
• Hypergammaglobulinaemia

Atrial myxoma may cause damage to the mitral valve, resulting in a systolic murmur indicative of mitral regurgitation. The obstructive nature of the tumour can also lead to mitral stenosis, although this is less common. A distinctive low-pitched sound, referred to as a 'tumour plop', may be detected upon auscultation during early or mid-diastole. This sound is believed to occur due to the tumour's impact against the mitral valve or the ventricular wall in cases of ventricular myxoma. In both atrial and ventricular myxoma, the sound produced is diastolic.

Scleroderma may result in a small, rigid heart with diminished EF.

• However, PAH is more commonly linked with right ventricular failure.
• A deficiency of the lysosomal enzyme alpha-galactosidase A, an X-linked recessive condition, results in the accumulation of glycolipids in the heart, requiring biopsy and electron microscopy for diagnosis.
• Non-caseating granulomas in sarcoidosis can affect the heart, causing restrictive cardiomyopathy.

• CO poisoning:- Presents with hypotension, coma, seizures and cherry red lips
• Severe:- Presents with pallor and cyanosis is milder and can anemia be absent.
• Drinking water contaminated with nitrates:- Acquired methemoglobinemia is caused by toxins that oxidize heme iron nitrate and nitrite containing compounds.
  Methemoglobin is generated by oxidations of the heme iron moieties of the ferric state causing bluish brown muddy color resembling cyanosis Methemoglobin has such high oxygen affinity hence no oxygen is delivered
  Levels >50-60% are often fatal
  Methemoglobin should be suspected in patients with hypoxic symptoms who appear cyanotic but PaO2 and oxygen saturation are normal.
  Muddy appearance of freshly drawn blood can be a critical clue.
• Lead poisoning:- Presents with colicky abdominal pain, anemia, constipation, irritability, headache, convulsions and Corna

As per the AHA 2010 guidelines, the fundamental life support consists of C-A-B, marking a transition from the ABC protocol. Thus, the initial action is to perform chest compressions at a rate of 100 times per minute.

• The depth of sternal compression should be 2 inches (5 cm).
• It is also important to note that in Advanced Cardiac Life Support, the medications administered include epinephrine and amiodarone.
• ATROPINE has been removed from the protocol, reflecting a change from the 2005 guidelines.

When serum potassium levels exceed 5.5 mEq/L, it is linked to abnormalities in repolarisation:

• Peaked T waves, which are typically the first indication of hyperkalemia.
  Serum potassium levels above 6.5 mEq/L are related to progressive paralysis of the atria, characterised by:
• Widening and flattening of the P wave.
• Lengthening of the PR segment.
• Eventually, P waves may completely vanish.

When serum potassium surpasses >7.0 mEq/L, it is associated with conduction issues and bradycardia, including:

• Prolonged QRS interval with abnormal QRS morphology.
• High-grade AV block, resulting in slow junctional and ventricular escape rhythms.
• Any type of conduction block, such as bundle branch blocks or fascicular blocks.
• Sinus bradycardia or slow atrial fibrillation.
• Appearance of a sine wave pattern, which indicates a pre-terminal rhythm.

A serum potassium level greater than 9.0 mEq/L leads to cardiac arrest due to:

• Asystole.
• Ventricular fibrillation.

• The initial ECG observation in hyperkalemia is elevated, tented T waves.
• This is followed by a deceleration in the heart's depolarisation.
• As a result, the PR interval extends and the QRS complex widens.
• Eventually, the P waves begin to diminish in size.
• A sine wave pattern may emerge, potentially leading to ventricular fibrillation or diastolic arrest of the heart.

A pericardial cyst is typically found at the right costophrenic angle and is often discovered incidentally during a chest X-ray.

Edema is characterised as a noticeable swelling resulting from an increase in the volume of interstitial fluid. The primary cause of leg edema in individuals over the age of 50 is venous insufficiency. The key reason for unilateral pedal edema is also venous insufficiency, which should be assessed through a Doppler examination.

• Vitamin B1 deficiency causes Beri-Beri which is of two types- WET BERI-BERI having cardiac failure and DRY BERI-BERI causing CNS problems like Wernicke encephalopathy and Korsakoff psychosis.
• Gingival bleeding and delayed wound healing (choice A) is seen with scurvy. Memory loss is seen with niacin deficiency.

• In a clinical setting of hyperkalemia in 1-year-old child, cardiac arrhythmias associated with hyperkalemia include sinus bradycardia, sinus arrest, slow idioventricular rhythms, ventricular tachycardia, ventricular fibrillation, and asystole
• Intravenous calcium serves to protect the heart while measures are taken to correct hyperkalemia.
• Calcium raises the action potential threshold and reduces excitability without changing the resting membrane potential. By restoring the difference between the resting and threshold potentials, calcium reverses the depolarization blockade caused by hyperkalemia.
• The recommended dose of treatment of hyperkalemia is 10 mL of 10% calcium gluconate (3-4 mL of calcium chloride), infused intravenously over 2 to 3 min with cardiac monitoring.
• The effect of the infusion starts in 1-3 min and lasts 30-60 min; the dose should be repeated if there is no change in ECG findings or if they recur after initial improvement.

• The patient is exceptionally tall and possesses long arms, alongside exhibiting pectus excavatum and pronounced lumbar lordosis.
• This raises concerns regarding the possibility of Marfan syndrome, which is associated with a defect in the fibrillin protein located on chromosome 15.
• The primary cause of mortality in these individuals is typically aortic dissection.

• It is associated with vascular conditions such as atherosclerotic disease, coarctation of the aorta, fibromuscular dysplasia, and hypertension.
• Neurofibromatosis is linked with pheochromocytomas and vascular stenosis, including renal artery stenosis due to fibromuscular dysplasia.
• In Marfan's syndrome, dural ectasia is observed in about 90% of patients, with severity increasing as they age.
• Mulibrey Nanism Syndrome is an extremely rare inherited disorder marked by dwarfism, pericardial constriction, and yellow spots in the fundus of the eye.

• Complications of implantable cardioverter defibrillator (ICD) include:
• Lead dislodgment, which typically occurs within a few days of implantation, may be detected on chest X-rays since the leads are radio-opaque.
• Free-floating ventricular leads can provoke serious arrhythmias.
• While device-related venous thrombosis is uncommon, it often manifests as swelling in one arm. Treatment involves elevating the limb and administering anticoagulants.
• Pneumothorax, or lung collapse, occurs in approximately 1% of cases and can generally be treated by placing a chest tube.
• Heart perforation can lead to a build-up of blood within the pericardial sac, resulting in pericardial effusion or tamponade.
• Bleeding may occur beneath the skin surrounding the defibrillator, potentially necessitating drainage.
• Premature battery exhaustion or device malfunction may happen. Although ICD systems are very dependable, they function like any electronic device and can sometimes fail unexpectedly.

Details about an ICD:

• The ICD is roughly the size of a pager and consists of several main components:
• The ICD: Powered by a battery, it generates electrical shocks. It is also known as the battery, device, or pulse generator. This single unit is typically inserted into a 'pocket' created under the skin (or muscle) in the chest, just below the collarbone (in the pectoral area). Its lifespan is determined by the battery, which usually lasts between three to five years.
• The leads: These are flexible, insulated wires that monitor electrical impulses and relay the heart's electrical activity back to the ICD. They also transmit electrical charges from the generator to the heart muscle when necessary. During the implantation, the ICD leads are threaded through a vein into the heart, connecting to the ICD. When the ICD requires replacement after the battery depletes, the original leads are typically left in place and attached to the new device. The leads may endure for 20 years or longer.

The potentially fatal DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) syndrome is defined by the presence of at least three of the following symptoms:

• fever
• exanthema
• eosinophilia
• atypical circulating lymphocytes
• lymphadenopathy
• hepatitis

DRESS syndrome is most commonly triggered by aromatic anticonvulsants such as phenytoin, phenobarbital, and carbamazepine. However, other medications, including sulfonamides, metronidazole, minocycline, sulfasalazine, allopurinol, and antiretrovirals like nevirapine and abacavir, have also been linked to this condition. There have been reports of encephalitis associated with HHV 6.

The organ involvement in DRESS syndrome, listed in descending order of frequency, includes:

• Liver - hepatitis, which can range from enzyme derangement to a fulminant course leading to encephalopathy.
• Kidney - hematuria due to interstitial nephritis.
• Colitis.
• Pneumonitis.
• Myocarditis.
• Encephalitis.
• Arthritis.
• Myositis.

For treatment, the most critical steps in managing patients with DRESS involve recognising the syndrome and promptly discontinuing the offending medication. Management is primarily supportive, and the use of corticosteroids and intravenous immunoglobulins in treating DRESS syndrome remains a topic of debate.

PST-Phenolsulfotransferase activity. Individuals experiencing dietary migraines exhibited significantly reduced levels of platelet phenolsulphotransferase activity compared to both migrainous patients without a dietary provocation history and normal controls.

• Among the two known human variants of this enzyme, the phenol-inactivating P form—whose endogenous substrate has yet to be identified—was found to be more severely affected than the M enzyme, which inactivates monoamines (including tyramine).
• Common dietary triggers, such as chocolate and cheese, may harbour unidentified phenolic substrates for phenolsulphotransferase P.
• If the deficiency of the platelet enzyme is reflected by reduced activity in the gut, there is a risk that unusually high levels of potentially harmful substances could enter the bloodstream as a result.

Every five years, the American Heart Association convenes to establish new CPR and ACLS guidelines based on data gathered from the preceding five years.
ACLS: De-emphasis of Devices, Drugs and other Distractors

• Atropine is no longer advised for routine use in the management of PEA/asystole, and it has been removed from the pulseless arrest algorithm.
• Chronotropic drug infusions are now suggested as an alternative to pacing for symptomatic and unstable bradycardia.
• Adenosine is endorsed as safe and possibly effective for the treatment and diagnosis during the initial management of undifferentiated regular monomorphic wide-complex tachycardia.
• Routine use of sodium bicarbonate is not advised (Class III, LOE B).
• Routine administration of calcium for cardiac arrest treatment is no longer recommended (Class III, LOE B).

Adrenaline: 1 mg i.v. every 3-5 minutes, repeated every 10 minutes. This increases coronary perfusion. Vasopressin: 40 Units i.v. may replace the second or third dose of epinephrine, enhancing cerebral perfusion. For refractory VT/VF, amiodarone is administered as a 300 mg i.v. bolus for the first dose, followed by a repeat of 150 mg i.v.

• Provide 8-10 breaths per minute along with continuous chest compressions.
• The compression rate should be at least 100 per minute.
• Compress to a depth of at least 2 inches (the previous recommendation was between 1 and 2 inches).

The shift to the C-A-B sequence aims to minimise delays in CPR, starting with skills that everyone can perform. It underscores the primary importance of chest compressions for professional rescuers.
Supplemental oxygen is unnecessary for patients without signs of respiratory distress if the oxy-haemoglobin saturation is <94%.

Any patient experiencing shock must receive a prompt working diagnosis, followed by a strategy for urgent resuscitation, and subsequently confirmation of the initial diagnosis. The following considerations should be kept in mind for the early diagnosis of sepsis:

• Sepsis can manifest in numerous ways, thus a heightened clinical suspicion is essential to recognise subtle signs.
• Patients with sepsis should be evaluated for indications of tissue hypoperfusion.
• Signs of tissue hypoperfusion may include cool or clammy skin, mottling, and an elevated shock index (heart rate/systolic blood pressure > 0.9).
• A lactic acid level exceeding 4 m mol/dL is often used as a criterion for initiating early goal-directed therapy and as a marker of severe tissue hypoperfusion.

Kerley B lines are short, parallel lines found at the lung periphery. These lines depict interlobular septa, typically measuring less than 1 cm in length and aligned parallel to each other at right angles to the pleura. They are situated peripherally in contact with the pleura, yet are usually absent along fissural surfaces. They can be observed in any lung zone, but are most commonly seen at the bases of the lungs, particularly at the costophrenic angles on PA radiographs, and in the substernal area on lateral radiographs. Kerley B lines are indicative of Congestive Heart Failure (CHF) and Interstitial Lung Diseases (ILD).
Kerley A lines are longer, measuring at least 2 cm and up to 6 cm, and are unbranching lines that extend diagonally from the hila to the lung periphery. These lines arise from the distension of anastomotic channels connecting peripheral and central lymphatics in the lungs. Kerley A lines are less frequently observed than Kerley B lines and are never present without Kerley B or C lines.
Kerley C lines are the rarest of the Kerley lines. They appear as short, fine lines scattered throughout the lungs, presenting a reticular appearance. These lines may indicate thickening of anastomotic lymphatics or the superimposition of multiple Kerley B lines.

• Subclavian: 93% - Possible clinical symptoms include arm claudication and Raynaud's phenomenon.
• Common carotid: 58% - May lead to visual disturbances, syncope, transient ischemic attacks, or stroke.
• Abdominal aorta: 47% - Associated with abdominal pain, nausea, and vomiting.
• Renal: 38% - Can result in hypertension and renal failure.