INI-CET 2023 — Internal Medicine
18 Previous Year Questions with Answers & Explanations
Calculate Anion Gap? Na: 145 K: 4 CI: 90 HCO3 : 15
History of a woman with skin features like limited cutaneous systemic sclerosis (scleroderma) was given. What is the most specific marker?
Which type of amyloidosis is seen in the patients going through dialysis?
A 62-year-old patient presents with pain in the calf muscles while walking. The pain subsides with rest. Which of the following is not typically seen in intermittent claudication?
A 55-year-old female smoker presents with a breast lump and is seeking medical evaluation. On examination, a palpable mass is detected in the breast. The patient's smoking history is significant, with a 30-year smoking habit. Which of the following conditions is strongly associated with smoking in relation to breast health?
What is/are the characterstics of Iron defficiency Anemaia(IDA)?
Patient presented with following features: - ipsilateral loss of pain and temperature sensation in the face - Contralateral loss of pain and temperature sensation in the body - Horner's syndrome - Dysphagia and hoarseness - Ataxia and vertigo Which artery is involved in syndrome based on above clinical features?
An ICU patient is suffering from Rhinovirus infection. How do we treat the patient?
A 40-year-old man presents with daytime sleepiness and impaired concentration and memory. On examination his BMI is 41 kg/m2, BP is 160/100 mm Hg. His awake ABG analysis is given: PaO2=66 mm Hg, PaCO2=50 mm Hg, HCO3=28 mEq/L. What is the most likely diagnosis?
A 35-year-old female presents with skin thickening and muscle weakness. Her peripheries became pale on exposure to cold. Her ANA is positive and creatine kinase is increased. Scl-70 is positive and perifascicular infiltration is noted in biopsy. What is the antibody associated with this condition?
INI-CET 2023 - Internal Medicine INI-CET Practice Questions and MCQs
Question 1: Calculate Anion Gap? Na: 145 K: 4 CI: 90 HCO3 : 15
- A. 28
- B. 35
- C. 12
- D. 40 (Correct Answer)
Explanation: ***40*** - The anion gap is calculated using the formula: **Na - (Cl + HCO3)**. - Plugging in the values: **145 - (90 + 15) = 145 - 105 = 40**. *28* - This value would result if there were a different **bicarbonate** or **chloride** level or a miscalculation. - For example, if the bicarbonate was 30 instead of 15, the calculation would be 145 - (90 + 30) = 145 - 120 = 25, which is closer but still not 28. *35* - This value is obtained if there's an error in summing the **anions** or subtracting from **sodium**. - For instance, if the bicarbonate was incorrectly taken as 20, the calculation would be 145 - (90 + 20) = 145 - 110 = 35. *12* - A value of 12 represents a **normal anion gap**, indicating that the patient in this scenario has a high anion gap [1]. - This result would only occur if the sum of **chloride and bicarbonate** were around 133, which is not the case here.
Question 2: History of a woman with skin features like limited cutaneous systemic sclerosis (scleroderma) was given. What is the most specific marker?
- A. Anti centromere (Correct Answer)
- B. Anti U1 Rnp
- C. Anti Jo
- D. Anti La
Explanation: ***Anti centromere*** - **Anti-centromere antibodies** are highly specific for **limited cutaneous systemic sclerosis** (lcSSc), also known as CREST syndrome. - Their presence correlates with a higher risk of **pulmonary hypertension** and less severe organ involvement compared to diffuse SSc [1]. *Anti U1 Rnp* - **Anti-U1 RNP antibodies** are primarily associated with **mixed connective tissue disease** (MCTD) [2]. - While MCTD can have features overlapping with scleroderma, anti-U1 RNP is not the most specific marker for a pure scleroderma presentation. *Anti Jo* - **Anti-Jo-1 antibodies** are characteristic of **polymyositis** and **dermatomyositis**, diseases involving muscle inflammation [2]. - They are primarily associated with the **anti-synthetase syndrome**, which includes myositis, interstitial lung disease, and Raynaud's phenomenon, not directly limited cutaneous systemic sclerosis. *Anti La* - **Anti-La (SS-B) antibodies** are commonly found in patients with **Sjögren's syndrome**, an autoimmune disorder affecting moisture-producing glands [2]. - They can also be present in systemic lupus erythematosus, but are not specific for scleroderma.
Question 3: Which type of amyloidosis is seen in the patients going through dialysis?
- A. A-beta
- B. AL
- C. A-beta 2 (Correct Answer)
- D. aTTR
Explanation: ***A-beta 2*** - **A-beta 2 microglobulin amyloidosis** (also known as dialysis-related amyloidosis) occurs because **beta-2 microglobulin** is not effectively cleared by dialysis and accumulates in tissues [1]. - This condition primarily affects **joints, bones**, and **tendons** in long-term dialysis patients, leading to carpal tunnel syndrome, arthropathy, and bone cysts. *A-beta* - **A-beta amyloidosis** refers to the accumulation of **amyloid-beta peptides** that are characteristic of **Alzheimer's disease**, primarily affecting the brain. - This type of amyloidosis is not directly associated with renal dialysis or systemic amyloid deposits in other organs. *AL* - **AL (light chain) amyloidosis** results from the deposition of **monoclonal immunoglobulin light chains** produced by plasma cells, often associated with multiple myeloma. - While it can affect the kidneys, it is a primary amyloidosis and not caused by dialysis itself, though it can occur in patients who also have kidney failure. *aTTR* - **aTTR (transthyretin) amyloidosis** involves the deposition of **abnormal transthyretin protein**, which can be hereditary (mutated TTR) or wild-type (aging-related) [1]. - This form primarily affects the heart and nervous system and is not typically associated with chronic dialysis as its direct cause.
Question 4: A 62-year-old patient presents with pain in the calf muscles while walking. The pain subsides with rest. Which of the following is not typically seen in intermittent claudication?
- A. Pain gradually increases
- B. Caused most commonly by atherosclerosis
- C. Level of occlusion cannot be decided based on symptoms
- D. Rest pain at night in advanced stages (Correct Answer)
Explanation: ***Rest pain at night in advanced stages*** - Intermittent claudication is defined by pain with exercise that resolves with rest [1]. **Rest pain** indicates critical limb ischemia, a more advanced stage of peripheral artery disease, and is distinct from intermittent claudication itself, although it can develop from it [1]. - While rest pain can occur in patients with severe peripheral artery disease, it is **not typically seen in intermittent claudication**, but rather represents progression to a more severe form of the disease. *Pain gradually increases* - The pain of intermittent claudication typically **gradually increases** during physical activity as the oxygen demand of the muscles exceeds the compromised blood supply. - This progressive pain forces the patient to stop activity, at which point the pain subsides with rest. *Caused most commonly by atherosclerosis* - **Atherosclerosis** is the underlying pathology in the vast majority of cases of peripheral artery disease, leading to stenosis or occlusion of the arteries that supply the lower limbs [1]. - This narrowing of the arterial lumen restricts blood flow, causing inadequate oxygen delivery to muscles during exertion. *Level of occlusion cannot be decided based on symptoms* - The **anatomical level of arterial occlusion** can often be inferred to some extent by the location of the claudication pain (e.g., buttock claudication suggests aortoiliac disease, calf claudication suggests femoropopliteal disease) [1]. - However, the precise extent and severity of the occlusion cannot be solely determined by symptoms, and imaging studies like **duplex ultrasound** or angiography are required for definitive diagnosis.
Question 5: A 55-year-old female smoker presents with a breast lump and is seeking medical evaluation. On examination, a palpable mass is detected in the breast. The patient's smoking history is significant, with a 30-year smoking habit. Which of the following conditions is strongly associated with smoking in relation to breast health?
- A. Duct ectasia
- B. Fibroadenoma
- C. Mondor disease
- D. Breast cancer (Correct Answer)
Explanation: ***Breast cancer*** - **Smoking** is a well-established risk factor for various cancers, including **breast cancer**, due to the presence of carcinogens in tobacco smoke [1]. - The patient's age and palpable lump further raise suspicion for malignancy, prompting thorough investigation. [1] *Duct ectasia* - Characterized by widening and inflammation of the **milk ducts**, which can cause nipple discharge, tenderness, and a palpable mass. - While smoking can be a risk factor, the more significant association in this age group and with a palpable lump leans towards malignancy. *Fibroadenoma* - These are **benign breast tumors** composed of glandular and stromal tissue, most common in younger women. - They are typically rubbery, mobile masses and are not strongly linked to smoking. *Mondor disease* - This is a rare, **benign condition** characterized by thrombophlebitis of the superficial veins of the breast or chest wall. - It typically presents as a painful, cord-like structure and is not directly associated with smoking.
Question 6: What is/are the characterstics of Iron defficiency Anemaia(IDA)?
- A. Increased TIBC
- B. Low serum ferritin
- C. All of the options (Correct Answer)
- D. Low serum iron
- E. Low transferrin saturation
Explanation: ***All of the options*** - **Iron deficiency anemia (IDA)** characteristically presents with a combination of these markers due to a true depletion of the body's iron stores [2]. - A comprehensive evaluation of iron studies, including **TIBC**, **ferritin**, **serum iron**, and **transferrin saturation**, is essential for an accurate diagnosis of IDA [3]. *Increased TIBC* - **Total iron-binding capacity (TIBC)** is typically **elevated in IDA** as the body attempts to maximize iron absorption and transport by increasing the production of transferrin [1]. - Transferrin, the primary iron-binding protein, is less saturated with iron, leading to an **increased capacity to bind more iron**. *Low serum ferritin* - **Serum ferritin** is a direct measure of **iron storage** in the body and is considered the most sensitive and specific marker for iron deficiency. - In IDA, **ferritin levels are markedly decreased**, indicating depleted iron reserves. *Low serum iron* - **Serum iron** measures the amount of iron circulating in the blood, primarily bound to transferrin [4]. - In IDA, the **absolute amount of circulating iron is reduced** due to insufficient iron supply [1]. *Low transferrin saturation* - **Transferrin saturation** represents the percentage of transferrin binding sites occupied by iron. - In IDA, due to **low serum iron** and **high transferrin (indicated by increased TIBC)**, the transferrin saturation is significantly reduced.
Question 7: Patient presented with following features: - ipsilateral loss of pain and temperature sensation in the face - Contralateral loss of pain and temperature sensation in the body - Horner's syndrome - Dysphagia and hoarseness - Ataxia and vertigo Which artery is involved in syndrome based on above clinical features?
- A. Posterior inferior cerebellar artery (Correct Answer)
- B. Basilar artery.
- C. Superior cerebellar artery
- D. Anterior inferior cerebellar artery
Explanation: ***Posterior inferior cerebellar artery*** - The constellation of **ipsilateral facial numbness**, **contralateral body numbness**, **Horner's syndrome**, **dysphagia**, **hoarseness**, **ataxia**, and **vertigo** is characteristic of Wallenberg syndrome, also known as **lateral medullary syndrome**, which results from occlusion of the **posterior inferior cerebellar artery (PICA)** [1]. - This artery supplies the **lateral medulla** and **inferior cerebellum**, affecting the **spinal trigeminal nucleus and tract**, **spinothalamic tract**, **descending sympathetic fibers**, **nucleus ambiguus**, and **inferior cerebellar peduncle** [1], [2]. *Basilar artery* - **Basilar artery occlusions** typically cause more extensive deficits, including **quadriplegia**, **locked-in syndrome**, and **cranial nerve palsies**, due to its supply to the brainstem and cerebellum. - While it can affect the PICA territory, a sole PICA occlusion does not result in the widespread deficits seen with a **main basilar artery occlusion**. *Superior cerebellar artery* - Occlusion of the **superior cerebellar artery (SCA)** typically causes **ipsilateral cerebellar ataxia**, **dysarthria**, and sometimes **contralateral spinothalamic deficits** and **Horner's syndrome**, but usually spares the dysphagia and hoarseness associated with the nucleus ambiguus. - The SCA supplies the **superior cerebellum** and parts of the **pons**, which would generally not produce the full symptom complex described. *Anterior inferior cerebellar artery* - Occlusion of the **anterior inferior cerebellar artery (AICA)** typically results in **ipsilateral hearing loss/tinnitus**, **facial paralysis**, and **cerebellar ataxia**, often with **contralateral pain and temperature loss in the body**. - While it shares some features, the prominent dysphagia and hoarseness are less common with AICA strokes than with **PICA strokes**, as the AICA primarily supplies the **lateral pontine region** and **labyrinthine artery**.
Question 8: An ICU patient is suffering from Rhinovirus infection. How do we treat the patient?
- A. Piperacillin + Tazobactam + Azithromycin
- B. Clarithromycin
- C. Cephalosporin + Ganciclovir
- D. Supportive care only (Correct Answer)
Explanation: ***Supportive care only*** - **Rhinovirus** is a common cause of the **common cold**, and there is no specific antiviral treatment available for it. [1] - Management focuses on alleviating symptoms such as fever, congestion, and cough to ensure patient comfort and prevent secondary complications, especially in an ICU setting. *Piperacillin + Tazobactam + Azithromycin* - This combination is a broad-spectrum antibiotic regimen (piperacillin/tazobactam is an extended-spectrum penicillin, and azithromycin is a macrolide) targeting bacterial infections. [2] - **Rhinovirus is a virus**, and antibiotics are ineffective against viral infections, making this an inappropriate treatment. *Clarithromycin* - **Clarithromycin** is a macrolide antibiotic primarily used to treat bacterial infections, such as respiratory tract infections caused by **atypical bacteria** or community-acquired pneumonia. [2] - It has no activity against **Rhinovirus**, a common cold virus. *Cephalosporin + Ganciclovir* - **Cephalosporins** are a class of beta-lactam antibiotics used for various bacterial infections. [2] - **Ganciclovir** is an antiviral agent specifically used to treat **cytomegalovirus (CMV)** infections, not Rhinovirus.
Question 9: A 40-year-old man presents with daytime sleepiness and impaired concentration and memory. On examination his BMI is 41 kg/m2, BP is 160/100 mm Hg. His awake ABG analysis is given: PaO2=66 mm Hg, PaCO2=50 mm Hg, HCO3=28 mEq/L. What is the most likely diagnosis?
- A. Obstructive sleep apnea (Correct Answer)
- B. Narcolepsy
- C. Obesity hypoventilation syndrome
- D. Central sleep apnea
Explanation: ***Obstructive Sleep Apnea (Correct Answer)*** - Classic triad: **morbid obesity (BMI 41 kg/m²)**, **excessive daytime somnolence**, and **systemic hypertension (160/100 mmHg)** — hallmarks of OSA - **ABG findings** (PaO2=66 mmHg, PaCO2=50 mmHg, HCO3=28 mEq/L) indicate **chronic nocturnal hypoxemia and hypercapnia** with compensatory **metabolic alkalosis** from repeated apneic episodes - **Cognitive impairment** (impaired concentration and memory) results from **sleep fragmentation** and intermittent nocturnal hypoxia - Obesity promotes **pharyngeal fat deposition** → upper airway narrowing and collapse during sleep → recurrent obstructive events *Narcolepsy* - Causes excessive daytime sleepiness but is **not associated with obesity, hypertension, or ABG abnormalities** - Hallmarks include **cataplexy**, sleep paralysis, and hypnagogic/hypnopompic hallucinations — none present here - Caused by **orexin (hypocretin) deficiency**; associated with **HLA-DQB1*06:02**; ABG is normal *Obesity Hypoventilation Syndrome (OHS / Pickwickian Syndrome)* - Defined as **awake PaCO2 >45 mmHg + BMI >30 kg/m²** with exclusion of other causes of hypoventilation - OHS frequently coexists as an **overlap with and consequence of severe OSA** rather than being the primary diagnosis - In this setting, **OSA is the most prevalent and primary diagnosis**; OHS is specifically considered when awake hypoventilation persists despite adequate OSA treatment *Central Sleep Apnea* - Results from **failure of central respiratory drive** (brainstem), not upper airway obstruction - Associated with **congestive heart failure, opioid use, high-altitude exposure, or neurological disease** — none present here - Not characteristically associated with morbid obesity; clinical and ABG picture here favors an **obstructive** rather than central pattern
Question 10: A 35-year-old female presents with skin thickening and muscle weakness. Her peripheries became pale on exposure to cold. Her ANA is positive and creatine kinase is increased. Scl-70 is positive and perifascicular infiltration is noted in biopsy. What is the antibody associated with this condition?
- A. Anti Jo1 antibody
- B. Anti centromere antibody
- C. Antinuclear antibody
- D. Anti PM scl antibody (Correct Answer)
Explanation: ***Anti PM scl antibody*** - The constellation of **skin thickening** [2], **muscle weakness** [1], **Raynaud's phenomenon** (pale peripheries on cold exposure) [3], **elevated creatine kinase**, and **perifascicular infiltration** on muscle biopsy indicates an overlap syndrome between **systemic sclerosis** and **polymyositis/dermatomyositis** [3]. - **Anti-PM/Scl antibodies** are highly specific markers for this **overlap syndrome**, explaining the mixed features of scleroderma and myositis. *Anti Jo1 antibody* - This antibody is primarily associated with **polymyositis** or **dermatomyositis**, especially with the **anti-synthetase syndrome**, which includes features like **interstitial lung disease**, **Raynaud's**, and **arthritis** [1]. - While muscle weakness is present, the prominent skin thickening and positive Scl-70 point away from isolated myositis. *Anti centromere antibody* - This antibody is characteristic of **limited cutaneous systemic sclerosis (CREST syndrome)**, which involves **calcinosis**, **Raynaud's phenomenon**, esophageal dysmotility, sclerodactyly, and telangiectasias. - While Raynaud's is present, the widespread skin thickening, muscle weakness, and perifascicular infiltration are not typical of limited cutaneous systemic sclerosis. *Antinuclear antibody* - A **positive antinuclear antibody (ANA)** is a general screening test for **autoimmune diseases** and is present in a wide range of conditions, including systemic sclerosis, lupus, and myositis [4]. - While ANA is positive in this patient, it is not specific enough to diagnose the exact overlap syndrome with its unique clinical and laboratory findings.