INI-CET 2017 Practice Questions

Q: A 30-year-old construction worker had a partial traumatic nail avulsion. 3 weeks later he presents with the presentation shown below. What is the diagnosis?

Pyogenic granuloma. ***Pyogenic granuloma*** - The image shows a **fleshy, red, often ulcerated nodule** following a partial traumatic nail avulsion, which is highly characteristic of a pyogenic granuloma. - These lesions are **reactive vascular proliferations** that typically develop rapidly at sites of trauma or inflammation. *Pyoderma gangrenosum* - Pyoderma gangrenosum characteristically presents as a rapidly enlarging, painful **ulcer with violaceous undermined borders** and often a purulent base, which differs from the described lesion. - It is typically associated with **systemic diseases**, such as inflammatory bowel disease or hematologic malignancies, and does not typically present as a focal, exophytic growth after localized trauma. *Pott's puffy tumor* - Pott's puffy tumor is a subperiosteal abscess of the frontal bone, usually caused by sinusitis, leading to a **forehead swelling** with osteomyelitis and epidural abscess. - This condition involves the **skull** and brain, not the nail bed, and presents with different clinical features like fever, headache, and periorbital edema. *Acute paronychia* - Acute paronychia is an **infection of the nail fold**, presenting with pain, redness, and swelling around the nail, often with pus accumulation. - While it can follow minor trauma, it is characterized by **inflammatory signs of infection** in the paronychial area, not a rapidly growing, exuberant granulation-like tissue as shown.

Q: A 50-year-old smoker and hypertensive patient presents with the lesion shown below. It is painful and present bilaterally. Peripheral pulses are palpable. What is the diagnosis?

Martorell ulcer. ***Martorell ulcer*** - This is a **hypertensive ischemic leg ulcer** primarily associated with uncontrolled hypertension, often seen in older patients who smoke. - Key features include extreme pain, location on the **anterolateral aspect of the lower leg**, and frequently bilateral presentation, despite palpable peripheral pulses. *Arterial ulcer* - **Arterial ulcers** are typically caused by **peripheral artery disease (PAD)**, leading to reduced blood flow. - While they can be painful, PAD is usually associated with **diminished or absent peripheral pulses**, which are present in this case. *Trophic ulcer* - A **trophic ulcer** is a general term for an ulcer caused by **poor nutrition** to the tissues, often due to neuropathy or chronic venous insufficiency. - While they can be chronic, the specific presentation with palpable pulses, severe pain, and association with hypertension points away from a generic trophic ulcer. *Bairnsdale ulcer* - Also known as **Buruli ulcer**, this is a **mycobacterial infection** caused by *Mycobacterium ulcerans*. - It typically starts as a painless nodule and slowly progresses to a large, often painless ulcer with undermined edges, which is not consistent with the painful lesion described.

Q: The image shows:

Bladder exstrophy. ***Bladder exstrophy*** - The image clearly displays an **exposed bladder mucosa** projecting from the lower abdominal wall, which is characteristic of bladder exstrophy. - This congenital anomaly results from a **failure of fusion of the anterior abdominal wall** and bladder during embryonic development. *Urachal anomalies* - Urachal anomalies involve persistent remnants of the **urachus**, connecting the bladder to the umbilicus, leading to cysts, sinuses, or fistulas. - They typically appear as lesions at or near the **umbilicus** and do not involve the direct exposure of the bladder. *Systolic bladder* - "Systolic bladder" is **not a recognized medical term** for a congenital anomaly. - Bladder function is described in terms of contraction (systole) and relaxation (diastole) but does not refer to a structural malformation. *Congenital adrenal hyperplasia* - This is an **endocrine disorder** affecting hormone production by the adrenal glands, leading to ambiguous genitalia in some cases. - It does not involve a **visible external defect of the bladder** or abdominal wall.

Q: Identify the instrument shown in the image:

Asepto syringe. ***Asepto syringe*** - The image displays a **red rubber bulb** attached to a glass or plastic barrel ending in a nozzle, which is characteristic of an **Asepto syringe**. - Asepto syringes are commonly used for **irrigation** of wounds or surgical sites, and for various procedures where precise suction or fluid delivery is needed without a needle. *Trocar for tapping hydrocele* - A **trocar** is a pointed medical instrument with a sharp tip, typically used with a cannula to introduce instruments or drain fluids from a body cavity. - Trocars for hydrocele tapping would differ significantly in appearance, featuring a pointed tip and often a stylet, which are absent here. *Czerny retractor* - A **Czerny retractor** is a surgical instrument with two blades, used primarily to hold back tissue during surgery to provide a clear view of the surgical field. - The instrument shown here is focused on fluid suction/delivery, not on tissue retraction. *Malecot catheter* - A **Malecot catheter** is a type of self-retaining catheter, typically made from soft, flexible material, with a distinctive mushroom-shaped tip that helps anchor it within a viscus. - This image clearly depicts a syringe-like device with a bulb, not a flexible catheter with a four-winged tip.

Q: Which is correct about hematemesis (upper GI bleeding) in this patient?

Rockall scoring is used for risk stratification. ***Rockall scoring is used for risk stratification*** - The image shows a patient with significant **hematemesis**, indicating an upper gastrointestinal bleed. The **Rockall score** is a validated tool used to assess the risk of rebleeding and mortality in patients with upper GI bleeding. - This scoring system considers factors such as **age**, **shock**, **comorbidity**, and endoscopic findings to guide management. *Most common is variceal bleeding* - While variceal bleeding is a serious cause of upper GI hemorrhage, **peptic ulcer disease** (gastric or duodenal ulcers) is the most common cause of non-variceal upper GI bleeding, accounting for 40-50% of cases. - Variceal bleeding is common in patients with **portal hypertension**, often due to liver cirrhosis. *Occurs only if bleeding occurs proximal to ampulla of Vater* - **Hematemesis** (vomiting blood) specifically indicates bleeding **proximal to the ligament of Treitz**, which is superior to the ampulla of Vater. - Bleeding from the small intestine distal to the ligament of Treitz or the colon typically results in **melena** or **hematochezia**, not hematemesis. *MC management is endoscopic banding* - **Endoscopic banding** is the primary treatment for **esophageal variceal bleeding**. - For non-variceal bleeding, such as from **peptic ulcers**, the most common endoscopic management is **epinephrine injection** followed by **thermal coagulation** or **clip placement**.

Q: What type of choledochal cyst is shown in the image?

2. ***2*** - The image displays a **diverticulum** protruding from the side of the **common bile duct (CBD)**, which is characteristic of a **Type II choledochal cyst**. - Type II choledochal cysts are rare, focal diverticula of the CBD, typically managed by excision. *1* - Type I choledochal cysts involve **fusiform or cystic dilation** of the extrahepatic bile duct, not a diverticulum protruding from the side. - They are the most common type and are usually treated with cyst excision and Roux-en-Y hepaticojejunostomy. *3* - Type III choledochal cysts, also known as **choledochoceles**, involve **dilation of the intraduodenal portion** of the CBD. - This typically appears as an intraduodenal cyst, which is not depicted in the image. *4* - Type IV choledochal cysts involve **multiple dilations** of the intrahepatic and/or extrahepatic bile ducts. - The image shows a single diverticular outpouching, not multiple dilations.

Q: A patient with chronic cholelithiasis develops the complication shown in the image below. This leads to development of:

Bouveret syndrome. ***Bouveret syndrome*** - The image shows gallstones in the gallbladder (GB) moving into the duodenum through a **cholecystoenteric fistula**, specifically into the stomach and duodenum, which is the mechanism leading to **Bouveret syndrome** [3]. - **Bouveret syndrome** is a rare form of gastric outlet obstruction caused by a large gallstone eroding through the gallbladder wall into the duodenum or stomach [3]. *Emphysematous cholecystitis* - This condition is characterized by the presence of **gas in the gallbladder wall or lumen** due to infection by gas-forming organisms, which is not depicted in the image. - It's a severe form of acute cholecystitis, often seen in diabetics or immunocompromised patients, and does not involve stone migration into the gut as shown. *Cholesterolosis* - **Cholesterolosis** (also known as "strawberry gallbladder") is a benign condition characterized by an accumulation of cholesterol esters in the macrophages of the gallbladder wall. - It does not involve the migration of gallstones into the gastrointestinal tract or the formation of fistulas and is not represented by the stones shown entering the duodenum. *Carcinoma of gallbladder* - **Gallbladder carcinoma** is a malignant tumor arising from the epithelial lining of the gallbladder [1]. - While chronic gallstones can be a risk factor for gallbladder cancer, the image specifically illustrates a mechanical complication of gallstone migration, not a neoplastic process [1][2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 886. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 883-884. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 404-405.

Q: Which classification is used to evaluate the condition shown in the image below?

Todani classification. ***Todani classification*** - The image provided shows an **ERCP (Endoscopic Retrograde Cholangiopancreatography)** with contrast in the biliary tree, demonstrating a dilated common bile duct (CBD) marked with an arrow. This appearance is characteristic of a **choledochal cyst**. - The **Todani classification** is a widely used system for categorizing choledochal cysts, which are congenital dilations of the biliary tree. *Bismuth classification* - The Bismuth classification is used to categorize **cholangiocarcinomas** (cancers of the bile ducts), particularly those affecting the hepatic confluence (Klatskin tumors). - It describes the extent of involvement of the hepatic duct bifurcation, which is distinct from the diffuse or localized dilations seen in choledochal cysts. *Johnson classification* - The Johnson classification is used for categorizing **duodenal ulcers**, specifically related to their location within the duodenum (e.g., gastric acid hypersecretion vs. normal acid production). - This classification is entirely unrelated to biliary tree pathologies. *Maastricht classification* - The Maastricht classification is used for grading **hepatic encephalopathy**, which is a neuropsychiatric complication of liver failure. - It describes the severity of neurological symptoms in patients with liver disease and has no relevance to imaging findings of biliary anomalies.

Q: An HIV positive patient presents with symptoms of toxemia and foul smelling discharge from the lesion shown below. What is the diagnosis?

Necrotizing fasciitis. ***Necrotizing fasciitis*** - The image shows an extensive, deep soft tissue infection with a large area of **tissue necrosis**, which is characteristic of necrotizing fasciitis. - The patient's **HIV-positive status** puts them at higher risk for severe infections, and the symptoms of **toxemia** and **foul-smelling discharge** further support this aggressive, rapidly spreading bacterial infection. *Trophic ulcer* - Trophic ulcers are typically caused by **neuropathic or vascular insufficiency**, leading to chronic, poorly healing wounds, often located on the lower limbs. - They do not usually present with the rapid onset, extensive tissue destruction, toxemia, and foul-smelling discharge seen here. *Pyogenic granuloma* - A pyogenic granuloma is a **benign vascular lesion** that typically presents as a small, red, rapidly growing, pedunculated or sessile papule, prone to bleeding. - It does not involve widespread tissue destruction, toxemia, or a foul-smelling discharge. *Martorell ulcer* - A Martorell ulcer (or ischemic hypertensive leg ulcer) is a **painful, full-thickness ulcer** typically located on the lateral aspect of the lower leg, associated with poorly controlled **hypertension and peripheral arterial disease**. - While it is an ulcer, it doesn't typically present with the broad, necrotizing appearance, toxemia, or foul-smelling discharge indicative of such a severe, spreading infection.

Question 1

A 30-year-old construction worker had a partial traumatic nail avulsion. 3 weeks later he presents with the presentation shown below. What is the diagnosis?

Accepted Answer

Pyogenic granuloma

Answer

Pyoderma gangrenosum

Answer

Pott's puffy tumor

Answer

Acute paronychia

Question 2

A 50-year-old smoker and hypertensive patient presents with the lesion shown below. It is painful and present bilaterally. Peripheral pulses are palpable. What is the diagnosis?

Accepted Answer

Martorell ulcer

Answer

Arterial ulcer

Answer

Trophic ulcer

Answer

Bairnsdale ulcer

Question 3

Which is incorrect about the procedure shown in the patient with right flank pain?

Accepted Answer

No anesthesia is required

Answer

Done as outpatient procedure

Answer

Contraindicated in hard stones

Answer

Shockwaves pass through a water bath

Question 4

The image shows:

Accepted Answer

Bladder exstrophy

Answer

Urachal anomalies

Answer

Systolic bladder

Answer

Congenital adrenal hyperplasia

Question 5

Identify the instrument shown in the image:

Accepted Answer

Asepto syringe

Answer

Trocar for tapping hydrocele

Answer

Czerny retractor

Answer

Malecot catheter

Question 6

Which is correct about hematemesis (upper GI bleeding) in this patient?

Accepted Answer

Rockall scoring is used for risk stratification

Answer

Most common is variceal bleeding

Answer

Occurs only if bleeding occurs proximal to ligament of Treitz

Answer

MC management is endoscopic banding

Question 7

What type of choledochal cyst is shown in the image?

Accepted Answer

2

Answer

1

Answer

3

Answer

4

Question 8

A patient with chronic cholelithiasis develops the complication shown in the image below. This leads to development of:

Accepted Answer

Bouveret syndrome

Answer

Emphysematous cholecystitis

Answer

Cholesterolosis

Answer

Carcinoma of gallbladder

Question 9

Which classification is used to evaluate the condition shown in the image below?

Accepted Answer

Todani classification

Answer

Bismuth classification

Answer

Johnson classification

Answer

Maastricht classification

Question 10

An HIV positive patient presents with symptoms of toxemia and foul smelling discharge from the lesion shown below. What is the diagnosis?

Accepted Answer

Necrotizing fasciitis

Answer

Trophic ulcer

Answer

Pyogenic granuloma

Answer

Martorell ulcer

INI-CET 2017

Dermatology

General Medicine

Surgery