INI-CET 2023 Practice Questions

Q: A 14-year-old female patient presents to the ENT OPD and complains that she can hear sounds clearly but has difficulty processing and understanding what is being said. Her Pure tone audiometry and ABR are normal. What is the likely diagnosis in this patient?

Central Auditory Processing Disorder (CAPD). ***Central Auditory Processing Disorder (CAPD)*** - **CAPD** is characterized by difficulty processing and understanding auditory information despite normal peripheral hearing, as indicated by normal pure tone audiometry and ABR. - The patient's inability to comprehend spoken words despite hearing them clearly is a hallmark symptom of **CAPD**. *Auditory cortex lesion* - While an **auditory cortex lesion** could impair sound processing, it would likely result in more profound and specific deficits in sound localization, discrimination, or recognition, rather than just difficulty understanding speech with otherwise normal hearing tests. - **Unilateral lesions** might cause mild or transient auditory issues, but bilateral lesions typically lead to **cortical deafness**, which contradicts the patient's ability to "hear sounds clearly." *Malingering* - **Malingering** involves deliberately fabricating or exaggerating symptoms for secondary gain, which is unlikely given the consistent presentation of difficulty understanding speech despite normal, objective hearing tests like ABR. - There are no indications in the case of **inconsistent test results** or other behaviors suggestive of feigned symptoms. *Sensorineural hearing loss* - **Sensorineural hearing loss** involves damage to the inner ear or auditory nerve, which would result in abnormal pure tone audiometry results and/or abnormal ABR findings. - The patient's **normal pure tone audiometry and ABR** rule out sensorineural hearing loss as the primary cause of her symptoms.

Q: 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?

Obstructive sleep apnea. ***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

Q: 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?

Anti PM scl antibody. ***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.

Q: What is the possible cause of irreversible dementia?

Lewy body. ***Lewy body*** - **Lewy body dementia** is a progressive, irreversible neurodegenerative disorder characterized by the abnormal accumulation of **alpha-synuclein proteins** within neurons [1]. - It presents with fluctuating cognition, recurrent visual hallucinations, and spontaneous **parkinsonism**, eventually leading to severe and irreversible cognitive decline [1]. *Vitamin B12 deficiency* - **Vitamin B12 deficiency** can cause cognitive impairment and dementia-like symptoms, but these are often **reversible** with appropriate B12 supplementation [2]. - Symptoms include **anemia**, peripheral neuropathy, and psychiatric changes, which can improve with treatment. *NPH* - **Normal Pressure Hydrocephalus (NPH)** presents with a classic triad of gait disturbance, urinary incontinence, and dementia [2]. - While it causes dementia, it is often **reversible** with surgical placement of a **ventriculoperitoneal shunt** to drain excess CSF [2]. *Hypothyroid* - **Hypothyroidism** can lead to cognitive slowing, memory impairment, and confusion, resembling dementia. - These symptoms are typically **reversible** and improve significantly with **thyroid hormone replacement therapy**.

Q: With the lack of CD40 in B cells, which immunological abnormality is seen?

Decreased IgG and increase in IgM. ***Decreased IgG and increase in IgM*** - The interaction between **CD40 on B cells** and **CD40L (CD154) on T helper cells** is crucial for **B cell activation**, proliferation, and **class switch recombination** (CSR). - Without this interaction, B cells cannot undergo CSR, leading to a failure to produce **IgG, IgA, or IgE**, while **IgM levels remain high** because IgM production is the initial default. *Total lack of NK cells* - **Natural Killer (NK) cells** are part of the innate immune system and their development is largely independent of CD40-CD40L signaling. - The absence of CD40 on B cells primarily affects adaptive humoral immunity, not NK cell numbers or function. *Lack of CD8 mediated cytotoxicity* - **CD8+ T cells** mediate cytotoxicity against infected or cancerous cells and their activation is primarily dependent on antigen presentation by **MHC class I molecules** and costimulation, not directly on B cell CD40. - While B cells can act as APCs, their CD40 interaction is more critical for T helper cell help for humoral responses. *Inability of neutrophil against infections* - **Neutrophils** are phagocytic cells important in innate immunity, and their function is largely independent of CD40 on B cells. - Neutrophil activity relies on pathogen recognition, phagocytosis, and degranulation, which are not directly regulated by the B cell CD40-CD40L pathway.

Q: Arrange the following parts of sarcomere from periphery to center. 1. Z line 2. M line 3. A band 4. H zone

1,3,4,2. ***1,3,4,2*** - The **Z line** is found at the **periphery** of the sarcomere, defining its boundaries and anchoring the **actin filaments**. - Moving inwards, the **A band** is next, representing the entire length of the **myosin filament**, which may also overlap with actin. - The **H zone** is located within the A band, comprising only **myosin filaments** without actin overlap. - Finally, the **M line** is at the **center** of the sarcomere, bisecting the H zone and anchoring the myosin filaments. *2,3,4,1* - This sequence is incorrect because the **M line** is at the **center** and the **Z line** is at the **periphery**, which is the reverse of the expected order for from periphery to center. - Such an arrangement would place the innermost structure first and outermost last, not reflecting the correct spatial organisation. *4,2,3,1* - This order is incorrect as the **H zone** and **M line** are more central, while the **Z line** is peripheral. - Placing structures like the H zone and M line at the beginning does not align with arrangement from periphery to center. *3,1,4,2* - This option is incorrect because the **A band** includes both actin and myosin filaments, while the **Z line** is at the periphery of the sarcomere. - The given order does not represent a progression from the periphery to the center of the sarcomere.

Q: Blood pressure changes in radial artery were measured. Which of the following is the reason for initial rise in BP while performing Valsalva maneuver?

Increase in aortic pressure. ***Increase in aortic pressure*** - During the initial phase (Phase I) of the Valsalva maneuver, the sudden **increase in intrathoracic pressure** is transmitted directly to the aorta and other large arteries. - This transient increase in external pressure on the great vessels directly causes a brief **rise in aortic blood pressure** before other compensatory mechanisms take effect. *Increase in Left ventricular volume* - The Valsalva maneuver actually **decreases left ventricular volume** over time due to reduced venous return. - An increase in left ventricular volume would typically lead to a sustained increase in cardiac output and blood pressure, which is not what is observed initially during the Valsalva maneuver. *Increase in Left ventricular pressure* - While increased intrathoracic pressure can transiently affect left ventricular pressure, the initial blood pressure rise is primarily due to direct compression of the **aorta and systemic arteries**, not an intrinsic increase in myocardial contractility or ventricular filling pressure. - Ultimately, the Valsalva maneuver generally leads to a decrease in **left ventricular preload** and subsequent decrease in stroke volume during the prolonged straining phase. *Decrease in aortic pressure* - The graph clearly shows an **initial spike in mean aortic pressure** (Phase I) at the onset of the Valsalva maneuver. - A decrease in aortic pressure is characteristic of the later part of the straining phase (Phase II) due to **reduced cardiac output**.

Q: CO poisoning causes which type of hypoxia?

Anemic hypoxia. ***Anemic hypoxia*** - **Carbon monoxide (CO)** binds to **hemoglobin** with an affinity much higher than oxygen, forming **carboxyhemoglobin**. - This effectively reduces the **oxygen-carrying capacity of the blood**, mimicking a severe anemia, despite normal arterial PO2. *Hypoxic hypoxia* - Occurs when there is **insufficient oxygen delivery to the blood** due to low arterial PO2, as seen in high altitudes or respiratory diseases. - In CO poisoning, **arterial PO2 is typically normal**, distinguishing it from hypoxic hypoxia. *Stagnant hypoxia* - Results from **inadequate blood flow** to tissues, leading to reduced oxygen delivery, as observed in heart failure or shock. - CO poisoning primarily affects oxygen transport by hemoglobin, not the **rate of blood flow**. *Histotoxic hypoxia* - Characterized by the **inability of tissues to utilize oxygen** effectively, even when oxygen delivery is adequate, as seen in cyanide poisoning inhibiting cytochrome oxidase. - In CO poisoning, tissues can utilize oxygen; the problem is the **reduced availability of oxygen** from hemoglobin.

Question 1

A 14-year-old female patient presents to the ENT OPD and complains that she can hear sounds clearly but has difficulty processing and understanding what is being said. Her Pure tone audiometry and ABR are normal. What is the likely diagnosis in this patient?

Accepted Answer

Central Auditory Processing Disorder (CAPD)

Answer

Auditory cortex lesion

Answer

Malingering

Answer

Sensorineural hearing loss

Question 2

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?

Accepted Answer

Obstructive sleep apnea

Answer

Narcolepsy

Answer

Obesity hypoventilation syndrome

Answer

Central sleep apnea

Question 3

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?

Accepted Answer

Anti PM scl antibody

Answer

Anti Jo1 antibody

Answer

Anti centromere antibody

Answer

Antinuclear antibody

Question 4

What is the possible cause of irreversible dementia?

Accepted Answer

Lewy body

Answer

Vitamin B12 deficiency

Answer

NPH

Answer

Hypothyroid

Question 5

With the lack of CD40 in B cells, which immunological abnormality is seen?

Accepted Answer

Decreased IgG and increase in IgM

Answer

Total lack of NK cells

Answer

Lack of CD8 mediated cytotoxicity

Answer

Inability of neutrophil against infections

Question 6

All of the following are tests done for Turner mosaic screening except?

Accepted Answer

Serum FSH

Answer

Karyotype

Answer

FISH

Answer

Buccal smear

Question 7

Arrange the following parts of sarcomere from periphery to center.

1. Z line
2. M line
3. A band
4. H zone

Accepted Answer

1,3,4,2

Answer

2,3,4,1

Answer

4,2,3,1

Answer

3,1,4,2

Question 8

Blood pressure changes in radial artery were measured. Which of the following is the reason for initial rise in BP while performing Valsalva maneuver?

Accepted Answer

Increase in aortic pressure

Answer

Increase in Left ventricular volume

Answer

Increase in Left ventricular pressure

Answer

Decrease in aortic pressure

Question 9

Assertion: RMP depends on proteins and phosphate ions.
Reason: Diffusion potential can be calculated using nernst equation.
Choose the best statement regarding the assertion and reason.

Accepted Answer

Both true, Reason is not the explanation of assertion

Answer

Assertion false, Reason true

Answer

Both true, Reason is the explanation of assertion

Answer

Assertion true, Reason false

Question 10

CO poisoning causes which type of hypoxia?

Accepted Answer

Anemic hypoxia

Answer

Hypoxic hypoxia

Answer

Stagnant hypoxia

Answer

Histotoxic hypoxia

INI-CET 2023

ENT

Internal Medicine

Microbiology

Pathology

Physiology