INI-CET 2022 Practice Questions

Q: What is the action of the superior oblique muscle?

Intorsion, abduction, depression. ***Intorsion, abduction, depression*** - The **superior oblique muscle** has three actions: **depression** (downward movement - primary action), **abduction** (movement away from the midline), and **intorsion** (medial/internal rotation of the globe) [1]. - The depressor action is most effective when the eye is **adducted** (turned inward), as the muscle's line of pull is then optimally aligned with the vertical axis. - Mnemonic: **SO-DAI** (Superior Oblique: Depression, Abduction, Intorsion) *Intorsion, adduction, elevation* - While **intorsion** is correct, this option incorrectly includes **adduction** and **elevation**. - The superior oblique causes **abduction** (not adduction) and **depression** (not elevation) [1]. - **Elevation** is performed by the superior rectus and inferior oblique muscles [1]. *Extorsion, adduction, elevation* - All three actions are incorrect for the superior oblique muscle. - The correct actions are **intorsion**, **abduction**, and **depression**. - **Extorsion** is performed by the inferior oblique and inferior rectus muscles [1]. *Extorsion, abduction, depression* - While **abduction** and **depression** are correct, **extorsion** is wrong. - The superior oblique causes **intorsion** (internal rotation), not extorsion (external rotation). - This is a common point of confusion - remember the superior oblique **intorts**, while the inferior oblique **extorts**.

Q: A 50-year-old male patient presented with left -sided hemiparesis. Damage to which part of the internal capsule leads to this presentation?

Posterior limb. ***Posterior limb*** - The **posterior limb** of the internal capsule contains the **corticospinal tracts**, which carry motor commands from the primary motor cortex to the spinal cord. - Damage to this area results in **contralateral hemiparesis** or hemiplegia, explaining the patient's left-sided weakness from right brain damage. *Anterior limb* - Contains **frontopontine fibers** and **anterior thalamic radiations**, which connect the frontal cortex to pontine nuclei and thalamus. - Lesions here typically cause **dysarthria**, **behavioral changes**, or **executive dysfunction**, not motor weakness. *Retrolentiform* - Contains the **optic radiations** (visual pathways) and some **auditory fibers** from the temporal lobe. - Damage results in **contralateral homonymous hemianopia** or **visual field deficits**, not hemiparesis. *Sublentiform* - Contains **auditory radiations** from the medial geniculate body and **temporopontine fibers**. - Lesions cause **auditory processing deficits** or **conduction aphasia** if dominant hemisphere affected, not motor weakness.

Q: A person presents to the hospital with fever and chills. Fever profile is ordered and is found to be negative for malaria and dengue. Rk39 test is found to be positive. What is the treatment of choice?

Amphotericin B. Amphotericin B - A positive RK39 test suggests visceral leishmaniasis (kala-azar), especially with fever and chills in an endemic area [1]. - Amphotericin B (specifically liposomal Amphotericin B) is a highly effective and often the drug of choice for treating visceral leishmaniasis, particularly in severe cases or regions with antimonial resistance. Dapsone - Dapsone is primarily used in the treatment of leprosy and بعض forms of dermatitis (e.g., dermatitis herpetiformis). - It has no significant role in treating leishmaniasis. Hydroxychloroquine - Hydroxychloroquine is an antimalarial drug also used for certain autoimmune diseases like lupus and rheumatoid arthritis [2]. - It is ineffective against leishmaniasis. Griseofulvin - Griseofulvin is an antifungal medication used to treat dermatophyte infections (e.g., ringworm of the skin, hair, or nails). - It has no activity against Leishmania parasites.

Q: A patient, who is a known case of HIV with a CD4 count of 200 cells/cu.mm, presents with 5 days of cough and high-grade fever without chills and rigors. There is no history of diarrhoea, vomiting, or nuchal rigidity. Chest x-ray is normal. What treatment will you give?

Co-trimoxazole only. ***Co-trimoxazole only*** - The patient has a CD4 count of 200 cells/cu.mm with cough and fever and a normal chest X-ray, all of which are highly suggestive of **Pneumocystis jirovecii pneumonia (PJP)**, even without classic infiltrates. Therefore, **co-trimoxazole** (trimethoprim-sulfamethoxazole) is the first-line treatment [1]. - In a patient with HIV and a CD4 count below 200, **PJP prophylaxis** with co-trimoxazole should also be considered [2], and its empirical treatment is indicated in this scenario. *Co-trimoxazole + steroids* - While co-trimoxazole is the correct treatment for PJP, **steroids** are typically reserved for patients with more severe disease, indicated by **hypoxia** (PaO2 35 mmHg) or diffuse interstitial infiltrates on chest imaging, neither of which are described here [1]. - Adding steroids without clear indications could increase the risk of side effects in an immunocompromised patient. *Amoxicillin-clavulanic acid + Azithromycin* - This combination targets typical **bacterial community-acquired pneumonia**, which is less likely given the patient's HIV status, low CD4 count, and normal chest X-ray. - This regimen would not effectively treat **PJP**, which is the most probable diagnosis in this immunocompromised setting. *Antitubercular treatment* - While tuberculosis is common in HIV patients, the normal chest X-ray makes pulmonary tuberculosis less likely, especially without other classic symptoms like night sweats, weight loss, or hemoptysis. In patients with CD4 counts below 200, the clinical presentation of TB differences substantially from those without HIV [1]. - **Antitubercular treatment** would not address the immediate concern of possible PJP, which can rapidly progress if untreated.

Q: Thrombolysis can be considered in all of these conditions, except:

Blood pressure of more than 185/110 mmHg. ***Blood pressure of more than 185/110 mmHg*** - A **blood pressure** greater than **185/110 mmHg** is an absolute contraindication for thrombolysis due to the significantly increased risk of developing **hemorrhagic transformation**. - **Aggressive blood pressure control** is necessary to reduce the risk of intracranial hemorrhage before considering thrombolytics. *Ischemic stroke within 2 hours* - This is within the **therapeutic window** for thrombolysis, which typically extends up to **4.5 hours** from symptom onset [1]. - Earlier administration of thrombolytics within this window generally leads to **better outcomes** and reduced disability [1]. *Onset of symptoms <4 hours* - An onset of symptoms less than **4.5 hours** is a primary **inclusion criterion** for intravenous thrombolysis in acute ischemic stroke [1]. - This timeframe allows for the maximum benefit from **clot dissolution** while minimizing the risk of adverse events. *MRI showing density in less than 1/3rd of the area supplied by MCA* - A **diffusion-weighted MRI** showing an infarct core of less than one-third of the **Middle Cerebral Artery (MCA)** territory is an indicator that the amount of **irreversibly damaged tissue** is small. - This suggests a larger volume of **salvageable penumbra**, making thrombolysis more likely to be beneficial.

Q: Which triad is seen after an acute attack of angle-closure glaucoma?

Vogt's triad. ***Vogt's triad*** - **Vogt's triad** refers to the classical findings seen after an acute attack of **angle-closure glaucoma**. - The triad consists of: **glaukomflecken** (anterior subcapsular lens opacities from ischemic necrosis of lens epithelium), **iris stromal atrophy** (sectoral iris atrophy in the area of ischemia), and **fixed mid-dilated pupil** (due to iris sphincter damage). - These signs indicate **ischemic damage** to the anterior segment following the acute episode of elevated intraocular pressure. *Gaucher triad* - **Gaucher triad** refers to the characteristic systemic symptoms of **Gaucher disease**, an inherited lipid storage disorder. - It involves **hepatosplenomegaly**, **bone pain**, and **thrombocytopenia**, which are unrelated to glaucoma. *Virchow triad* - The **Virchow triad** describes the three main factors contributing to **thrombus formation**: **stasis** of blood flow, **endothelial injury**, and **hypercoagulability**. - This triad is relevant to cardiovascular pathology, not the effects of angle-closure glaucoma. *Hutchinson's triad* - **Hutchinson's triad** is a set of symptoms associated with **congenital syphilis**. - It includes **interstitial keratitis**, **Hutchinson's teeth**, and **eighth nerve deafness**, which are entirely distinct from ocular hypertension.

Q: A 27-year-old female patient presents with sudden diminishing vision associated with a relative afferent pupillary defect in the right eye. On examination, the left eye is normal. Which of the following combinations of investigations would be most appropriate?

MRI brain and orbits + Visual evoked potentials + Blood tests. ***MRI brain and orbits + Visual evoked potentials + Blood tests*** - The combination of **sudden diminishing vision** and a **relative afferent pupillary defect (RAPD)** in one eye strongly suggests **optic neuritis**. - **MRI brain and orbits** is crucial to identify demyelinating lesions characteristic of **multiple sclerosis** and to rule out other causes of optic neuropathy, while **visual evoked potentials (VEPs)** confirm optic nerve dysfunction and can detect subclinical demyelination. **Blood tests** are essential to exclude other inflammatory or autoimmune conditions that can mimic optic neuritis. *MRI brain and orbits + Visual evoked potentials* - While these two investigations are critical for diagnosing **optic neuritis** and assessing for **multiple sclerosis**, they might miss systemic causes of optic neuropathy that can be identified via targeted **blood tests**. - Excluding systemic inflammatory or autoimmune conditions is crucial for complete patient management and preventing recurrence or progression. *Visual evoked potentials + Blood tests* - This combination is insufficient as it omits the **MRI brain and orbits**, which is vital for visualizing the optic nerve and brain for demyelinating lesions and ruling out compressive or infiltrative etiologies. - An **MRI** provides structural information that VEPs and blood tests alone cannot, making it indispensable in this clinical scenario. *MRI brain and orbits + Blood tests* - This combination lacks **Visual evoked potentials (VEPs)**, which provide objective evidence of **optic nerve demyelination** and can detect subclinical involvement, aiding in diagnosis and prognosis. - VEPs are particularly valuable in diagnosing **optic neuritis** and monitoring its recovery or progression.

Q: Which of the following drugs is not used for the emergency (immediate) management of hyperkalaemia?

Injection MgSO4. ***Injection MgSO4*** - Magnesium sulfate is not a direct treatment for hyperkalaemia; its primary use is for conditions like **eclampsia**, **asthma exacerbations**, or **torsades de pointes**. - It does not directly affect potassium levels or cardiac membrane stability in the context of hyperkalaemia. *10% calcium gluconate over 10 min* - **Calcium gluconate** is used for immediate cardioprotection in hyperkalaemia by stabilizing the **cardiac membrane**, thereby reducing the risk of arrhythmias. - It does not lower serum potassium levels but mitigates the dangerous cardiac effects. *Insulin-dextrose* - This combination is an effective treatment for hyperkalaemia as **insulin** drives potassium from the extracellular to the intracellular space. - **Dextrose** is administered concurrently to prevent hypoglycaemia induced by insulin. *Salbutamol nebulisation* - **Beta-2 agonists** like salbutamol promote the uptake of potassium into cells, thus lowering serum potassium levels. - While effective, its action is generally less rapid and potent than insulin-dextrose or calcium gluconate in severe cases.

Q: Incorrect statement regarding the management of frostbite:

Antibiotics and analgesics not used. ***Antibiotics and analgesics not used*** - This statement is incorrect as **antibiotics are used** in the management of frostbite for prophylaxis against infection, especially in severe cases or open wounds. - **Analgesics are also crucial** to manage the significant pain associated with frostbite and the rewarming process [1]. *Amputation in severe cases* - **Amputation** is a necessary intervention for severe, irreversible tissue damage and necrosis caused by frostbite, typically reserved as a last resort [1]. - This decision is usually made after sufficient time has passed to demarcate viable from non-viable tissue, often several weeks post-injury [1]. *Rewarming is done* - **Rapid rewarming** of the affected area in a warm water bath (37-39°C) is the most critical initial treatment for frostbite to minimize tissue damage. - This process is painful and should be done only when there is no risk of refreezing. *The area is dried and cleaned* - After rewarming, the affected area should be **gently dried** to prevent further skin breakdown and the development of maceration. - **Cleaning the wound** helps prevent infection and maintains a sterile environment for healing.

Question 1

What is the action of the superior oblique muscle?

Accepted Answer

Intorsion, abduction, depression

Answer

Intorsion, adduction, elevation

Answer

Extorsion, adduction, elevation

Answer

Extorsion, abduction, depression

Question 2

A pregnant woman presents with fever, retroorbital pain, headache, pulsatile proptosis of the right eye, and tinnitus. BP and fundus were normal. Which of the following structures are involved?

Accepted Answer

Abducens nerve, Oculomotor nerve, Internal carotid artery, Cavernous sinus

Answer

Oculomotor nerve, Internal carotid artery, Cavernous sinus

Answer

Abducens nerve, Internal carotid artery, Cavernous sinus

Answer

Abducens nerve, Oculomotor nerve, Internal carotid artery

Question 3

A 50-year-old male patient presented with left -sided hemiparesis. Damage to which part of the internal capsule leads to this presentation?

Accepted Answer

Posterior limb

Answer

Anterior limb

Answer

Retrolentiform

Answer

Sublentiform

Question 4

A person presents to the hospital with fever and chills. Fever profile is ordered and is found to be negative for malaria and dengue. Rk39 test is found to be positive. What is the treatment of choice?

Accepted Answer

Amphotericin B

Answer

Dapsone

Answer

Hydroxychloroquine

Answer

Griseofulvin

Question 5

A patient, who is a known case of HIV with a CD4 count of 200 cells/cu.mm, presents with 5 days of cough and high-grade fever without chills and rigors. There is no history of diarrhoea, vomiting, or nuchal rigidity. Chest x-ray is normal. What treatment will you give?

Accepted Answer

Co-trimoxazole only

Answer

Co-trimoxazole + steroids

Answer

Amoxicillin-clavulanic acid + Azithromycin

Answer

Antitubercular treatment

Question 6

Thrombolysis can be considered in all of these conditions, except:

Accepted Answer

Blood pressure of more than 185/110 mmHg

Answer

Ischemic stroke within 2 hours

Answer

Onset of symptoms <4 hours

Answer

MRI showing density in less than 1/3rd of the area supplied by MCA

Question 7

Which triad is seen after an acute attack of angle-closure glaucoma?

Accepted Answer

Vogt's triad

Answer

Gaucher triad

Answer

Virchow triad

Answer

Hutchinson's triad

Question 8

A 27-year-old female patient presents with sudden diminishing vision associated with a relative afferent pupillary defect in the right eye. On examination, the left eye is normal.

Which of the following combinations of investigations would be most appropriate?

Accepted Answer

MRI brain and orbits + Visual evoked potentials + Blood tests

Answer

MRI brain and orbits + Visual evoked potentials

Answer

Visual evoked potentials + Blood tests

Answer

MRI brain and orbits + Blood tests

Question 9

Which of the following drugs is not used for the emergency (immediate) management of hyperkalaemia?

Accepted Answer

Injection MgSO4

Answer

10% calcium gluconate over 10 min

Answer

Insulin-dextrose

Answer

Salbutamol nebulisation

Question 10

Incorrect statement regarding the management of frostbite:

Accepted Answer

Antibiotics and analgesics not used

Answer

Amputation in severe cases

Answer

Rewarming is done

Answer

The area is dried and cleaned

INI-CET 2022

Anatomy

Internal Medicine

Ophthalmology

Pharmacology

Surgery