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NEET-SS practice questions

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Question 1Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A patient with acute decompensated heart failure has a serum sodium of 118 mmol/L and is having active seizures. What is the most appropriate initial management?

  1. Oral sodium chloride tablets
  2. Isotonic 0.9% saline infusion at 200 mL/hour
  3. Hypertonic 3% saline bolus with frequent sodium monitoring Correct answer.
  4. Fluid restriction to 800 mL/day

Explanation

Severe symptomatic hyponatremia with seizures constitutes a neurologic emergency requiring prompt correction with hypertonic 3% saline. Rapid but controlled elevation of serum sodium by 4-6 mmol/L is the goal to abort seizures while avoiding osmotic demyelination. Isotonic saline or fluid restriction act too slowly for an actively seizing patient.

Question 2Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which parameter is the primary determinant of oxygenation in a patient receiving mechanical ventilation?

  1. Respiratory rate
  2. Inspiratory-to-expiratory ratio
  3. Positive end-expiratory pressure and fraction of inspired oxygen Correct answer.
  4. Tidal volume

Explanation

Oxygenation is governed mainly by the mean airway pressure and the fraction of inspired oxygen, with PEEP recruiting collapsed alveoli and reducing shunt. Tidal volume, respiratory rate, and I:E ratio primarily influence carbon dioxide elimination and ventilation. Adjusting PEEP and FiO2 is therefore the first step when hypoxemia persists.

Question 3Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 28-year-old woman has recurrent pregnancy loss, a prolonged aPTT, and a positive dilute Russell viper venom test that does not correct with normal plasma. What is the most likely diagnosis?

  1. Factor VII deficiency
  2. Von Willebrand disease
  3. Antiphospholipid syndrome Correct answer.
  4. Hemophilia A

Explanation

A persistently positive dilute Russell viper venom test plus recurrent pregnancy loss meets the clinical and laboratory criteria for antiphospholipid syndrome. The failure to correct with normal plasma indicates a circulating inhibitor rather than a factor deficiency. Hemophilia, von Willebrand disease, and factor VII deficiency are inherited deficiencies that correct with normal plasma and do not cause this pattern.

Question 4Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which finding on renal biopsy is characteristic of minimal change disease in an adult with nephrotic syndrome?

  1. Diffuse effacement of podocyte foot processes on electron microscopy Correct answer.
  2. Mesangial IgA deposits
  3. Tram-track appearance of the glomerular basement membrane
  4. Subendothelial immune complex deposits

Explanation

Minimal change disease shows normal glomeruli on light microscopy but diffuse podocyte foot process effacement on electron microscopy. Subendothelial deposits suggest membranoproliferative or lupus nephritis, mesangial IgA deposits indicate IgA nephropathy, and tram-tracking is seen in membranoproliferative glomerulonephritis. These features distinguish the entities on biopsy.

Question 5Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

In a patient with septic shock who remains hypotensive despite adequate fluid resuscitation, which vasopressor is recommended as the first-line agent?

  1. Norepinephrine Correct answer.
  2. Dopamine
  3. Phenylephrine
  4. Vasopressin

Explanation

Norepinephrine is the recommended first-line vasopressor in septic shock because it raises mean arterial pressure with less arrhythmogenicity than dopamine. Vasopressin is added as a second agent to reduce norepinephrine requirements, and phenylephrine is generally reserved for specific situations such as tachyarrhythmias. Dopamine is no longer preferred owing to higher arrhythmia risk.

Question 6Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 55-year-old man with cirrhosis presents with hematemesis. After initial resuscitation, which agent should be started to reduce portal pressure before endoscopy?

  1. Propranolol
  2. Vitamin K
  3. Terlipressin Correct answer.
  4. Fresh frozen plasma

Explanation

Terlipressin or octreotide is started early in suspected variceal bleeding to reduce splanchnic blood flow and portal pressure before endoscopy. Propranolol is used for prophylaxis of variceal bleeding, not for acute control. Vitamin K and fresh frozen plasma address coagulopathy but do not lower portal pressure.

Question 7Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which feature best distinguishes diabetic ketoacidosis from hyperosmolar hyperglycemic state?

  1. Serum osmolality
  2. Presence of significant ketonemia and metabolic acidosis Correct answer.
  3. Age of the patient
  4. Degree of hyperglycemia

Explanation

Diabetic ketoacidosis is defined by ketone body accumulation and high-anion-gap metabolic acidosis, whereas hyperosmolar hyperglycemic state has minimal ketosis and acidosis. Hyperglycemia and hyperosmolality may be more profound in hyperosmolar state, so glucose level alone does not differentiate. Age is not a reliable discriminator.

Question 8Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A newborn has ambiguous genitalia, hypotension, and hyponatremia with hyperkalemia. Which enzyme deficiency is most likely?

  1. 11-beta-hydroxylase deficiency
  2. 17-alpha-hydroxylase deficiency
  3. Aldosterone synthase deficiency
  4. 21-hydroxylase deficiency Correct answer.

Explanation

21-hydroxylase deficiency is the most common cause of congenital adrenal hyperplasia and presents with virilization plus salt-wasting from cortisol and aldosterone deficiency. 11-beta-hydroxylase deficiency causes hypertension with virilization, and 17-alpha-hydroxylase deficiency causes hypertension with undervirilization. Aldosterone synthase deficiency does not cause virilization.

Question 9Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which antibody is most specific for systemic lupus erythematosus?

  1. Antinuclear antibody
  2. Rheumatoid factor
  3. Anti-histone antibody
  4. Anti-double-stranded DNA Correct answer.

Explanation

Anti-double-stranded DNA is highly specific for systemic lupus erythematosus and correlates with disease activity and nephritis. Antinuclear antibody is sensitive but not specific, being positive in many autoimmune and non-autoimmune conditions. Rheumatoid factor is associated with rheumatoid arthritis, and anti-histone antibodies suggest drug-induced lupus.

Question 10Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A patient with a suspected pituitary macroadenoma has bitemporal hemianopia. Which structure is being compressed?

  1. Cavernous sinus
  2. Oculomotor nerve
  3. Optic tract
  4. Optic chiasm Correct answer.

Explanation

A pituitary macroadenoma expands upward and compresses the optic chiasm, where decussating nasal retinal fibers carry temporal visual fields, producing bitemporal hemianopia. Optic tract lesions produce homonymous defects, and cranial nerve or cavernous sinus involvement causes ophthalmoplegia rather than field loss. This localizes the lesion to the suprasellar region.

Question 11Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which is the definitive treatment for a patient with a first episode of primary spontaneous pneumothorax and hemodynamic instability?

  1. Tube thoracostomy Correct answer.
  2. High-flow nasal cannula
  3. Needle aspiration
  4. Observation with supplemental oxygen

Explanation

Hemodynamic instability indicates tension physiology or a large pneumothorax requiring urgent decompression, and tube thoracostomy provides definitive drainage. Needle aspiration is reserved for stable patients with small pneumothoraces. Observation and oxygen therapy are appropriate only for small, asymptomatic, stable pneumothoraces.

Question 12Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which tumor marker is most useful in monitoring treatment response of non-seminomatous germ cell tumors?

  1. CA 19-9
  2. CA 125
  3. Carcinoembryonic antigen
  4. Alpha-fetoprotein Correct answer.

Explanation

Alpha-fetoprotein, often along with beta-hCG, is used to monitor non-seminomatous germ cell tumors because levels correlate with tumor burden and response. CA 19-9 is used mainly for pancreatic and biliary tumors, CEA for colorectal cancer, and CA 125 for ovarian cancer. These are not relevant to germ cell tumor monitoring.

Question 13Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A neonate is noted to have bilious vomiting on the first day of life with a double-bubble sign on abdominal radiograph. What is the most likely diagnosis?

  1. Hypertrophic pyloric stenosis
  2. Hirschsprung disease
  3. Malrotation with volvulus
  4. Duodenal atresia Correct answer.

Explanation

Bilious vomiting in the first day of life with a double-bubble sign indicates duodenal obstruction, most commonly duodenal atresia. Pyloric stenosis presents at 3-6 weeks with non-bilious vomiting and no double bubble. Malrotation with volvulus and Hirschsprung disease have different presentations and radiographic findings.

Question 14Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which of the following is the most appropriate second-line antitubercular drug for a patient who develops optic neuritis on standard therapy?

  1. Pyrazinamide is stopped and replaced with amoxicillin
  2. Isoniazid is stopped and replaced with streptomycin
  3. Rifampicin is stopped and replaced with clarithromycin
  4. Ethambutol is stopped and replaced with levofloxacin Correct answer.

Explanation

Ethambutol is the first-line antitubercular drug associated with dose-related optic neuritis, so it is stopped and a fluoroquinolone such as levofloxacin is a common substitute. Isoniazid causes peripheral neuropathy, while rifampicin and pyrazinamide are not linked to optic neuritis. This avoids further ocular toxicity while maintaining an effective regimen.

Question 15Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A patient with known mitral stenosis develops sudden onset of atrial fibrillation with a rapid ventricular rate and pulmonary edema. Which management step is most appropriate?

  1. Observation with no intervention
  2. Immediate electrical cardioversion without anticoagulation
  3. Rate control with a beta-blocker or calcium channel blocker and treatment of pulmonary edema Correct answer.
  4. Digoxin loading alone

Explanation

In mitral stenosis, loss of atrial contraction and rapid ventricular rates reduce diastolic filling and precipitate pulmonary edema, so rate control plus treatment of congestion is the priority. Immediate cardioversion is avoided unless there is hemodynamic instability, because of thromboembolic risk. Digoxin alone is insufficient for rapid control.

Question 16Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which finding is most suggestive of acute aortic dissection on chest radiograph?

  1. Silhouette sign at the right heart border
  2. Air bronchogram
  3. Widened mediastinum Correct answer.
  4. Kerley B lines

Explanation

A widened mediastinum on chest radiograph is the classic though nonspecific sign of acute aortic dissection, prompting definitive imaging with CT angiography. Kerley B lines indicate interstitial edema, air bronchograms indicate alveolar disease, and loss of the right heart border reflects right middle lobe disease. These do not point to aortic dissection.

Question 17Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A patient with severe acute pancreatitis develops fever, leukocytosis, and a fluid collection containing gas on CT after two weeks. What is the most appropriate next step?

  1. Total parenteral nutrition and no drainage
  2. Immediate open necrosectomy
  3. Observation with antibiotics alone
  4. Percutaneous or endoscopic drainage of the infected collection Correct answer.

Explanation

An infected necrotic collection with gas on CT requires drainage, preferably by a step-up approach using percutaneous or endoscopic techniques before surgery. Immediate open necrosectomy carries high mortality and is reserved for failed drainage. Antibiotics alone or nutritional support without drainage will not control the infected collection.

Question 18Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which of the following is the most common cause of acute pancreatitis worldwide?

  1. Endoscopic retrograde cholangiopancreatography
  2. Hypertriglyceridemia
  3. Alcohol
  4. Gallstones Correct answer.

Explanation

Gallstones and alcohol are the two leading causes of acute pancreatitis, with gallstones being the most common overall. Hypertriglyceridemia and post-ERCP pancreatitis are less frequent causes. Identifying the etiology guides management such as early cholecystectomy for gallstone disease.

Question 19Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A patient on hemodialysis develops a fever during the session with rigors, and blood cultures grow Staphylococcus aureus. What is the most likely source?

  1. Air embolism
  2. Access recirculation
  3. Dialyzer membrane reaction
  4. Central venous catheter infection Correct answer.

Explanation

Fever and rigors during hemodialysis with Staphylococcus aureus bacteremia strongly suggest catheter-related bloodstream infection, especially with a tunneled or temporary central catheter. Dialyzer reactions present with hypersensitivity features and are culture-negative. Recirculation and air embolism do not produce staphylococcal bacteremia.

Question 20Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which parameter is used to assess the adequacy of dialysis in a patient on maintenance hemodialysis?

  1. Kt/V urea Correct answer.
  2. Hemoglobin
  3. Parathyroid hormone
  4. Serum creatinine

Explanation

Kt/V urea quantifies the clearance of urea during a dialysis session and is the standard measure of dialysis adequacy. Serum creatinine, hemoglobin, and parathyroid hormone reflect other aspects of uremia and bone mineral metabolism but not the delivered dialysis dose. A target Kt/V ensures adequate small solute clearance.

Question 21Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A patient with chronic kidney disease has a serum potassium of 6.9 mmol/L with peaked T waves and muscle weakness. Which intervention stabilizes the myocardium most rapidly?

  1. Oral sodium polystyrene sulfonate
  2. Intravenous calcium gluconate Correct answer.
  3. Intravenous furosemide
  4. Intravenous insulin with dextrose

Explanation

Intravenous calcium gluconate acts within minutes to stabilize the cardiac membrane in hyperkalemia with electrocardiographic changes, though it does not lower serum potassium. Insulin with dextrose shifts potassium intracellularly over 15-30 minutes, and binders or diuretics remove potassium slowly. Calcium is therefore the first drug given for cardiac protection.

Question 22Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which of the following is the most appropriate first-line treatment for a patient with newly diagnosed generalized anxiety disorder?

  1. Benzodiazepine monotherapy
  2. Selective serotonin reuptake inhibitor Correct answer.
  3. Mood stabilizer
  4. Antipsychotic

Explanation

Selective serotonin reuptake inhibitors are first-line pharmacotherapy for generalized anxiety disorder because of their efficacy and favorable long-term safety. Benzodiazepines are reserved for short-term use owing to dependence risk. Antipsychotics and mood stabilizers are not first-line for uncomplicated generalized anxiety disorder.

Question 23Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A patient with schizophrenia develops a high fever, muscle rigidity, and elevated creatine kinase after starting an antipsychotic. What is the most likely diagnosis?

  1. Serotonin syndrome
  2. Acute dystonia
  3. Neuroleptic malignant syndrome Correct answer.
  4. Malignant hyperthermia

Explanation

Neuroleptic malignant syndrome presents with fever, lead-pipe rigidity, autonomic instability, and elevated creatine kinase after dopamine antagonist exposure. Serotonin syndrome features hyperreflexia and clonus, malignant hyperthermia follows anesthetic exposure, and acute dystonia causes sustained muscle contractions without fever. The combination of rigidity and fever after an antipsychotic points to neuroleptic malignant syndrome.

Question 24Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

In a patient with major depressive disorder, which finding most strongly predicts a favorable response to electroconvulsive therapy?

  1. Coexisting personality disorder
  2. Presence of psychotic features Correct answer.
  3. Chronic mild dysthymia
  4. Substance use disorder

Explanation

Psychotic depression responds particularly well to electroconvulsive therapy, which is also indicated for severe or treatment-resistant depression. Coexisting personality disorders, chronic dysthymia, and substance use predict a poorer response. Recognizing these predictors helps select appropriate candidates for ECT.

Question 25Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

Which nerve is most commonly injured during thyroid surgery, causing hoarseness from vocal cord paralysis?

  1. Glossopharyngeal nerve
  2. Hypoglossal nerve
  3. Recurrent laryngeal nerve Correct answer.
  4. External branch of the superior laryngeal nerve

Explanation

The recurrent laryngeal nerve runs close to the inferior thyroid artery and is the most frequently injured nerve in thyroid surgery, causing vocal cord paralysis and hoarseness. The external branch of the superior laryngeal nerve affects pitch, while the glossopharyngeal and hypoglossal nerves are not at risk in this region. This anatomy guides careful ligation of the inferior thyroid vessels.

Question 26Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 62-year-old man with chronic obstructive pulmonary disease has a resting PaO2 of 54 mmHg and hematocrit of 56%. Which long-term oxygen therapy prescription is most appropriate?

  1. Nocturnal oxygen only if sleep study shows desaturation
  2. Oxygen for at least 15 hours per day to maintain SpO2 above 90% Correct answer.
  3. Oxygen only during symptomatic exacerbations
  4. Oxygen at 4 L/min continuously to keep PaO2 above 100 mmHg

Explanation

Long-term oxygen therapy improves survival in COPD with chronic hypoxemia (PaO2 ≤55 mmHg or SpO2 ≤88%), and the survival benefit requires at least 15 hours of use per day. The target is to maintain SpO2 around 90–92% to avoid worsening hypercapnia and oxygen toxicity. Continuous high-flow oxygen targeting supranormal PaO2 provides no added benefit and risks hypercapnia.

Question 27Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 28-year-old woman has recurrent episodes of hypoglycemia with a fasting glucose of 42 mg/dL, elevated insulin, and elevated C-peptide. Which localization study is most appropriate after biochemical confirmation of endogenous hyperinsulinism?

  1. Endoscopic ultrasound of the pancreas
  2. Selective arterial calcium stimulation with hepatic venous sampling
  3. MRI of the brain with pituitary protocol
  4. Contrast-enhanced multiphasic CT of the pancreas Correct answer.

Explanation

After biochemical confirmation of endogenous hyperinsulinism, multiphasic contrast-enhanced CT or MRI of the pancreas is the first-line localization study for an insulinoma. Selective arterial calcium stimulation is reserved for cases where noninvasive imaging is negative or discordant. Endoscopic ultrasound is an adjunct and is operator-dependent.

Question 28Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 45-year-old man with a history of recurrent calcium kidney stones has a serum calcium of 11.2 mg/dL and a parathyroid hormone level that is inappropriately normal. Which additional finding best supports the diagnosis of primary hyperparathyroidism?

  1. Hypercalciuria on a 24-hour urine collection Correct answer.
  2. Elevated serum phosphate
  3. Suppressed serum chloride
  4. Low 24-hour urinary calcium excretion

Explanation

Primary hyperparathyroidism typically causes hypercalcemia with hypercalciuria because the filtered calcium load exceeds tubular reabsorption. Serum phosphate is usually low-normal or low due to PTH-induced phosphaturia. A low urinary calcium would suggest familial hypocalciuric hypercalcemia instead.

Question 29Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 70-year-old woman with hypertension and diabetes has a serum creatinine of 2.8 mg/dL and estimated glomerular filtration rate of 20 mL/min/1.73 m². Which adjustment is required when prescribing metformin?

  1. Switch to a higher dose because insulin resistance increases in CKD
  2. Continue the current dose without change
  3. Discontinue metformin because eGFR is below 30 mL/min/1.73 m² Correct answer.
  4. Reduce the dose by half and monitor renal function every 3 months

Explanation

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73 m² because of the risk of lactic acidosis. Dose reduction and closer monitoring are recommended for eGFR between 30 and 45 mL/min/1.73 m². At an eGFR of 20, metformin should be stopped and an alternative agent used.

Question 30Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 34-year-old woman presents with fatigue, weight gain, and cold intolerance. Thyroid function tests show TSH 12 mIU/L and free T4 0.4 ng/dL. Which additional laboratory finding is most consistent with Hashimoto thyroiditis?

  1. Positive anti-thyroid peroxidase antibodies Correct answer.
  2. Elevated serum thyroglobulin
  3. Positive TSH receptor antibodies
  4. Low serum thyroglobulin

Explanation

Hashimoto thyroiditis is characterized by anti-thyroid peroxidase and anti-thyroglobulin antibodies, which are present in most patients. TSH receptor antibodies are characteristic of Graves disease. Serum thyroglobulin is not a diagnostic test for Hashimoto thyroiditis.

Question 31Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 58-year-old man with type 2 diabetes and a foot ulcer has a probe-to-bone positive finding. Which imaging modality is most specific for diagnosing osteomyelitis of the foot?

  1. Ultrasound of the foot
  2. Three-phase bone scan
  3. MRI of the foot Correct answer.
  4. Plain radiography

Explanation

MRI is the most specific imaging modality for diabetic foot osteomyelitis, with high sensitivity and specificity. Plain radiographs are initial but less sensitive and specific. Bone scans can be falsely positive in the setting of Charcot arthropathy or soft tissue infection.

Question 32Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 24-year-old man is brought to the emergency department with agitation, dilated pupils, and a heart rate of 130 beats/min after suspected cocaine use. Which agent is contraindicated for controlling agitation in this patient?

  1. Intravenous propofol
  2. Intravenous lorazepam
  3. Intravenous haloperidol Correct answer.
  4. Oral diazepam

Explanation

Butyrophenones such as haloperidol are relatively contraindicated in cocaine toxicity because they may lower the seizure threshold and increase the risk of arrhythmias. Benzodiazepines are the first-line treatment for agitation and sympathomimetic toxicity. Propofol may be used for severe agitation with caution.

Question 33Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 68-year-old woman with atrial fibrillation is started on warfarin. Which laboratory test is most appropriate for monitoring the therapeutic effect of warfarin?

  1. Thrombin time
  2. Prothrombin time with INR Correct answer.
  3. Activated partial thromboplastin time
  4. Bleeding time

Explanation

Warfarin inhibits vitamin K-dependent clotting factors (II, VII, IX, X), and the prothrombin time with INR is the standard test for monitoring its anticoagulant effect. The activated partial thromboplastin time is used for unfractionated heparin monitoring. Thrombin time and bleeding time are not used for warfarin monitoring.

Question 34Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 55-year-old man with alcoholic cirrhosis presents with ascites. Diagnostic paracentesis shows a serum-ascites albumin gradient of 2.0 g/dL. Which mechanism best explains the ascites?

  1. Portal hypertension Correct answer.
  2. Pancreatic ascites
  3. Peritoneal carcinomatosis
  4. Tuberculous peritonitis

Explanation

A serum-ascites albumin gradient of ≥1.1 g/dL indicates portal hypertension as the cause of ascites, commonly due to cirrhosis. Peritoneal carcinomatosis, pancreatic ascites, and tuberculous peritonitis typically produce a gradient <1.1 g/dL. The gradient reflects the difference between serum and ascitic albumin and correlates with portal pressure.

Question 35Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 32-year-old woman with systemic lupus erythematosus has a serum creatinine of 1.8 mg/dL and active urinary sediment. Which finding on renal biopsy is most indicative of a poor prognosis?

  1. Focal segmental glomerulosclerosis
  2. Minimal change disease
  3. Mesangial proliferation
  4. Diffuse proliferative glomerulonephritis Correct answer.

Explanation

Diffuse proliferative lupus nephritis (class IV) is associated with a high risk of progression to end-stage renal disease if untreated. Mesangial proliferation (class II) generally has a benign course. Focal segmental glomerulosclerosis and minimal change disease are not typical lupus nephritis patterns.

Question 36Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 45-year-old man with a history of recurrent nephrolithiasis has a serum calcium of 10.8 mg/dL and a parathyroid hormone level of 85 pg/mL (normal 10–65). Which finding on 24-hour urine studies would most strongly suggest familial hypocalciuric hypercalcemia rather than primary hyperparathyroidism?

  1. Elevated urinary calcium
  2. Low urinary citrate
  3. Elevated urinary phosphate
  4. Low urinary calcium with a calcium-to-creatinine clearance ratio <0.01 Correct answer.

Explanation

Familial hypocalciuric hypercalcemia is characterized by mild hypercalcemia with inappropriately low urinary calcium excretion, reflected by a calcium-to-creatinine clearance ratio <0.01. Primary hyperparathyroidism typically causes hypercalciuria. Urinary phosphate and citrate do not differentiate these conditions.

Question 37Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 60-year-old man with a 40-pack-year smoking history presents with hemoptysis and a central lung mass. Which paraneoplastic syndrome is most associated with small cell lung carcinoma?

  1. Hypoglycemia
  2. Hypercalcemia
  3. Syndrome of inappropriate antidiuretic hormone secretion Correct answer.
  4. Carcinoid syndrome

Explanation

Small cell lung carcinoma is a neuroendocrine tumor that commonly causes paraneoplastic syndromes, most notably SIADH and ectopic ACTH secretion. Hypercalcemia is more typically associated with squamous cell carcinoma via PTH-related peptide. Carcinoid syndrome is associated with carcinoid tumors, and hypoglycemia can occur with large mesenchymal tumors.

Question 38Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 50-year-old woman with rheumatoid arthritis on methotrexate develops a dry cough and progressive dyspnea. High-resolution CT shows ground-glass opacities and consolidation. Which diagnosis is most likely?

  1. Pulmonary embolism
  2. Pneumocystis jirovecii pneumonia
  3. Rheumatoid arthritis-associated interstitial lung disease
  4. Methotrexate-induced pneumonitis Correct answer.

Explanation

Methotrexate can cause a hypersensitivity pneumonitis with dry cough, dyspnea, and ground-glass opacities on HRCT, often with peripheral eosinophilia. The temporal relationship to methotrexate initiation and the pattern on imaging support this diagnosis. Rheumatoid arthritis-associated interstitial lung disease is usually a more chronic process, and PJP is less likely without profound immunosuppression.

Question 39Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 70-year-old man with hypertension and diabetes has a serum creatinine of 2.5 mg/dL and a urinalysis showing broad waxy casts. Which finding is most specific for chronic kidney disease rather than acute kidney injury?

  1. Fractional excretion of sodium <1%
  2. Serum creatinine increase of 0.5 mg/dL over 48 hours
  3. Urine sodium <20 mEq/L
  4. Renal ultrasound showing small echogenic kidneys Correct answer.

Explanation

Small, echogenic kidneys on ultrasound indicate chronic scarring and are a reliable marker of chronic kidney disease. A low fractional excretion of sodium and low urine sodium suggest prerenal physiology and can occur in both acute and chronic settings. An acute rise in creatinine defines AKI, not CKD.

Question 40Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 35-year-old woman with a history of recurrent venous thrombosis has a prolonged aPTT that does not correct with mixing study. Which test is most appropriate to confirm the diagnosis of antiphospholipid syndrome?

  1. Factor VIII level
  2. Protein C activity
  3. Antithrombin III level
  4. Lupus anticoagulant assay Correct answer.

Explanation

Antiphospholipid syndrome is confirmed by the presence of a lupus anticoagulant, anticardiolipin antibodies, or anti-beta2-glycoprotein I antibodies. A prolonged aPTT that does not correct with mixing suggests an inhibitor, and the lupus anticoagulant assay is the specific test. Factor VIII, protein C, and antithrombin III levels assess other coagulopathies.

Question 41Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 28-year-old man presents with sudden onset of severe headache, neck stiffness, and photophobia. CT scan of the head is normal. Which is the next most appropriate step in management?

  1. Start empiric antibiotics and discharge
  2. MRI of the brain with contrast
  3. Lumbar puncture for cerebrospinal fluid analysis Correct answer.
  4. Reassurance and outpatient follow-up

Explanation

In suspected subarachnoid hemorrhage with a normal CT, lumbar puncture is indicated to detect xanthochromia or red blood cells in the cerebrospinal fluid. MRI may be useful later but is not the immediate next step. Empiric antibiotics without diagnosis and reassurance are inappropriate.

Question 42Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 65-year-old man with Parkinson disease has been on levodopa-carbidopa for 5 years and now experiences predictable wearing-off episodes. Which strategy is most appropriate to manage these motor fluctuations?

  1. Discontinue levodopa and start a dopamine agonist alone
  2. Add a COMT inhibitor such as entacapone Correct answer.
  3. Start an anticholinergic agent
  4. Increase the interval between doses

Explanation

Adding a COMT inhibitor like entacapone prolongs the half-life of levodopa and reduces wearing-off. Increasing the dosing interval would worsen fluctuations. Anticholinergics are more useful for tremor and are not first-line for wearing-off, and discontinuing levodopa is not appropriate.

Question 43Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 45-year-old woman with bipolar disorder is started on lithium. Which monitoring parameter is most important to check regularly to prevent lithium toxicity?

  1. Complete blood count
  2. Liver function tests
  3. Serum lithium level and renal function Correct answer.
  4. Thyroid-stimulating hormone only

Explanation

Lithium has a narrow therapeutic index, and regular monitoring of serum lithium levels and renal function is essential to prevent toxicity. Lithium is excreted by the kidneys, and renal impairment increases toxicity risk. Liver function and CBC are not primary monitoring parameters for lithium.

Question 44Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 30-year-old woman with a history of recurrent panic attacks is prescribed sertraline. Which adverse effect is most important to counsel her about at the start of therapy?

  1. Transient increase in anxiety and gastrointestinal upset Correct answer.
  2. Weight loss and insomnia
  3. Immediate reduction in anxiety
  4. Hypertensive crisis with tyramine-rich foods

Explanation

SSRIs like sertraline can cause a transient increase in anxiety and gastrointestinal upset early in treatment before the therapeutic effect occurs. Hypertensive crisis with tyramine is associated with MAO inhibitors. Weight loss and insomnia can occur but are not the most important early counseling point.

Question 45Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 55-year-old man with alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be administered immediately?

  1. Intravenous glucose alone
  2. Intravenous naloxone
  3. Oral multivitamins
  4. Intravenous thiamine Correct answer.

Explanation

The triad of confusion, ataxia, and ophthalmoplegia suggests Wernicke encephalopathy, which requires immediate intravenous thiamine to prevent irreversible neurological damage. Glucose alone can precipitate or worsen Wernicke encephalopathy. Oral multivitamins are insufficient for acute treatment, and naloxone is for opioid overdose.

Question 46Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 62-year-old man with chronic obstructive pulmonary disease has an acute exacerbation with increased sputum purulence and dyspnea. Which antibiotic is most appropriate for outpatient management?

  1. Ciprofloxacin
  2. Trimethoprim-sulfamethoxazole
  3. Amoxicillin-clavulanate Correct answer.
  4. Azithromycin

Explanation

For outpatient COPD exacerbations with purulent sputum, amoxicillin-clavulanate is a first-line antibiotic because it covers common respiratory pathogens including Haemophilus influenzae and Moraxella catarrhalis. Fluoroquinolones are reserved for more severe cases or those with risk factors for Pseudomonas. Azithromycin is an alternative but resistance is increasing.

Question 47Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 70-year-old woman with a hip fracture has a serum calcium of 7.8 mg/dL and a serum phosphate of 4.5 mg/dL. Which additional laboratory finding would most suggest secondary hyperparathyroidism due to vitamin D deficiency?

  1. Elevated parathyroid hormone Correct answer.
  2. Hypercalciuria
  3. Elevated 1,25-dihydroxyvitamin D
  4. Low parathyroid hormone

Explanation

Vitamin D deficiency leads to hypocalcemia and hypophosphatemia, which stimulate parathyroid hormone secretion, causing secondary hyperparathyroidism. Parathyroid hormone is typically elevated. 1,25-dihydroxyvitamin D is low or inappropriately normal, and hypercalciuria is not a feature.

Question 48Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 40-year-old woman with a history of Graves disease treated with radioactive iodine presents with fatigue and weight gain. Labs show TSH 8.5 mIU/L and free T4 0.6 ng/dL. Which is the most appropriate management?

  1. Repeat radioactive iodine
  2. Start levothyroxine Correct answer.
  3. Restart methimazole
  4. Observation only

Explanation

Post-ablative hypothyroidism is common after radioactive iodine for Graves disease and requires levothyroxine replacement. Methimazole would worsen hypothyroidism. Repeat radioactive iodine is not indicated for hypothyroidism, and observation alone would allow symptoms to persist.

Question 49Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 55-year-old man with cirrhosis and ascites is started on spironolactone and furosemide. Which monitoring parameter is most important to check within the first week of therapy?

  1. Prothrombin time
  2. Serum amylase
  3. Serum potassium and creatinine Correct answer.
  4. Urine protein

Explanation

Spironolactone can cause hyperkalemia, especially in patients with cirrhosis and impaired renal function, and furosemide can cause hypokalemia and renal dysfunction. Monitoring serum potassium and creatinine early is essential to adjust therapy. Amylase, prothrombin time, and urine protein are not primary monitoring parameters for diuretic therapy in ascites.

Question 50Super Specialty (DrNB/Fellowship) entrance content as conducted by NBEMS

A 28-year-old woman with a history of intravenous drug use presents with fever and a new systolic murmur. Blood cultures grow Staphylococcus aureus. Which finding on echocardiography is most specific for infective endocarditis?

  1. Pericardial effusion
  2. Mitral valve prolapse
  3. Left ventricular hypertrophy
  4. Vegetation on a cardiac valve Correct answer.

Explanation

The presence of a vegetation on echocardiography is a major Duke criterion for infective endocarditis. Mitral valve prolapse, left ventricular hypertrophy, and pericardial effusion are nonspecific findings and do not confirm endocarditis. Vegetations are best visualized with transesophageal echocardiography.