INI-CET 2025 — Internal Medicine

Q: Which of the following is not a recognised cause of recurrent renal stone formation?

Hypercitraturia. ***Hypercitraturia*** - It is generally **protective** against calcium stone formation because **citrate** binds to calcium in the urine, making it more soluble and inhibiting crystal nucleation. [1] - **Hypocitraturia** (low urinary citrate), not hypercitraturia, is a well-recognized metabolic risk factor for the formation of **calcium oxalate stones**. *Hyperoxaluria* - **Oxalate** readily binds with calcium to form **calcium oxalate stones**, the most common type of kidney stone. - Both primary and secondary hyperoxaluria significantly increase the degree of urinary **supersaturation**, driving stone formation. *Hypercalciuria* - High levels of urinary calcium increases urine saturation, leading to the precipitation of calcium salts, primarily forming **calcium oxalate** or **calcium phosphate** stones. [1] - It is the most frequent metabolic abnormality observed in patients with **recurrent nephrolithiasis**. *Hyperuricosuria* - Excess urinary **uric acid** directly causes **uric acid stones**, especially in acidic urine. [1] - Importantly, uric acid crystals can also serve as a **nidus** for the heterogeneous nucleation of **calcium oxalate** stones, increasing overall stone risk. [1] [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following is one of the earliest presenting symptoms in a patient with Multiple Sclerosis?

Sensory disturbances. ***Sensory disturbances*** - **Sensory symptoms**, such as numbness, tingling (paresthesias), or hypoesthesia, are among the most common **initial complaints** (up to 40% of patients) in Multiple Sclerosis, often affecting the limbs or trunk [1]. - These symptoms occur due to demyelination in the **spinal cord** or **sensory pathways** in the brainstem. *Ataxia* - While **ataxia** (coordination problems) is a characteristic symptom of MS, usually resulting from cerebellar or posterior column involvement, it is less frequently the **absolute earliest** presentation [1]. - Ataxia often signifies later-stage progression or a focus of demyelination within the cerebellum or its connections [1]. *Vertigo* - **Vertigo** can occur in MS due to demyelination of the **vestibular pathways** in the brainstem (e.g., lesions affecting the **Medial Longitudinal Fasciculus (MLF)**) [1]. - However, isolated vertigo is typically a less common initial symptom compared to **sensory changes** or optic neuritis. *Facial palsy* - **Facial palsy** (Cranial Nerve VII involvement) can result from a plaque in the pons, but it is a relatively **rare** initial manifestation of Multiple Sclerosis. - Early cranial nerve involvement is more classically presented as **Optic Neuritis** or Diplopia (e.g., Internuclear Ophthalmoplegia). [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following is the most common clinical feature observed during the progression of systemic lupus erythematosus (SLE)?

Arthralgia & myalgia. ### Arthralgia & myalgia - **Arthralgia (joint pain)** and **myalgia (muscle pain)** are documented as the most common initial and persistent clinical features, occurring in over 90% of SLE patients [1]. - The arthritis in SLE is typically non-erosive and symmetrical, often affecting the small joints of the hands, wrists, and knees. *Photosensitivity* - While very common and a key diagnostic criterion, it occurs in about 40-50% of patients, making it less frequent than diffuse joint and muscle pain [1]. - It is a prominent feature of cutaneous involvement, often leading to the characteristic **malar rash** or discoid lesions after sun exposure [1]. *Nephrotic syndrome* - Renal involvement (**Lupus nephritis**) is serious, but clinically overt nephrotic syndrome (heavy proteinuria, edema) is found only in a subset of patients with Type III, IV, or V nephritis. - Overall, symptomatic renal disease affects about 50-60% of patients, less frequent than musculoskeletal symptoms. *Anemia and thrombocytopenia* - **Hematologic abnormalities** (anemia, leukopenia, and thrombocytopenia) are common and considered diagnostic criteria but occur in roughly 50% or less of patients. - **Anemia of chronic disease** is the most frequent hematologic finding, while **thrombocytopenia** is less common than arthralgia. [Practice more Internal Medicine PYQs on OnCourse]

Q: According to WHO, which of the following is the recommended diagnostic test for spinal tuberculosis?

Culture and Sensitivity. Culture and Sensitivity - It is considered the gold standard for definitive diagnosis of tuberculosis (TB) as it allows the isolation and confirmation of viable Mycobacterium tuberculosis organisms [2]. - It is essential for performing comprehensive Drug Susceptibility Testing (DST), which is critical for guiding the management of complex cases like spinal TB and detecting any drug resistance [3]. X-ray - X-rays are primarily useful for initial screening and assessing the extent of bony destruction, such as vertebral collapse (Pott's spine), but are not confirmatory [1]. - They are limited as they cannot provide bacteriological evidence or detect the presence of the M. tuberculosis organism, which is required for definitive diagnosis. CT scan - CT scans offer detailed imaging of bony morphology, disc involvement, and soft tissue pathology (e.g., paraspinal abscesses) superior to X-rays. - It remains an imaging modality and cannot replace the necessity of histopathological or microbiological confirmation and Drug Susceptibility Testing. CB-NAAT - CB-NAAT (e.g., Xpert MTB/RIF) is highly recommended by WHO for rapid diagnosis and detection of Rifampicin resistance from samples [3]. - While highly accurate, it detects nucleic acid and does not enable full Drug Susceptibility Testing against all first and second-line drugs, which Culture and Sensitivity provides. [Practice more Internal Medicine PYQs on OnCourse]

Q: A 12-year-old child is diagnosed with systemic lupus erythematosus (SLE) and presents with nephrotic-range proteinuria. Renal biopsy reveals "wire loop lesions." Which of the following is the drug of choice in this case?

IV Steroids + cyclophosphamide. ***IV Steroids + cyclophosphamide*** - The presence of "wire loop lesions" on renal biopsy signifies **Diffuse Proliferative Lupus Nephritis (Class IV)**, which is the most common and severe form of Lupus Nephritis. - Induction therapy for Class IV LN requires a combination of high-dose corticosteroids (IV methylprednisolone) and a potent cytotoxic agent, making **cyclophosphamide** the standard aggressive regimen [1]. *IV Steroids only* - Although high-dose steroids (pulses) are essential for controlling acute inflammation, they are **insufficient as monotherapy** for the severe, widespread immune complex deposition seen in **Class IV LN** [1]. - Steroid monotherapy is typically used for less aggressive forms, such as Class I or II (minimal or mesangial) LN. *Mycophenolate mofetil* - **Mycophenolate mofetil (MMF)**, combined with steroids, is an alternative induction therapy, particularly favored for maintenance but is less reliably potent than cyclophosphamide in severe, life-threatening flares of **Class IV** in some regimens. - MMF alone is never used for induction; it must be administered with high-dose **corticosteroids** to manage acute disease activity. *Cyclophosphamide only* - **Cyclophosphamide** is a powerful induction agent, but it must always be combined with high-dose **corticosteroids** during the induction phase to maximize anti-inflammatory effects and achieve remission effectively [1]. - Administration of a cytotoxic agent without simultaneous acute inflammation control is substandard care. [Practice more Internal Medicine PYQs on OnCourse]

31 Previous Year Questions with Answers & Explanations

Questions

Which of the following is not a recognised cause of recurrent renal stone formation?

Which of the following is one of the earliest presenting symptoms in a patient with Multiple Sclerosis?

Which of the following is the most common clinical feature observed during the progression of systemic lupus erythematosus (SLE)?

According to WHO, which of the following is the recommended diagnostic test for spinal tuberculosis?

A 12-year-old child is diagnosed with systemic lupus erythematosus (SLE) and presents with nephrotic-range proteinuria. Renal biopsy reveals "wire loop lesions." Which of the following is the drug of choice in this case?

Which of the following is the most common inherited bleeding disorder?

A male patient presents with chronic diarrhea for 8 months. CT shows ahaustral appearance of the right colon. What is the most likely diagnosis?

Which of the following about lumbar puncture is incorrect?

In a septic shock patient who remains hypotensive despite adequate fluid resuscitation, what would be the next drug of choice?

Q10

A patient with rheumatoid arthritis presents with neck pain and clinical signs of myelopathy. What is the most likely diagnosis?

INI-CET 2025 - Internal Medicine INI-CET Practice Questions and MCQs

Question 1: Which of the following is not a recognised cause of recurrent renal stone formation?

A. Hypercalciuria
B. Hypercitraturia (Correct Answer)
C. Hyperuricosuria
D. Hyperoxaluria

Explanation: ***Hypercitraturia*** - It is generally **protective** against calcium stone formation because **citrate** binds to calcium in the urine, making it more soluble and inhibiting crystal nucleation. [1] - **Hypocitraturia** (low urinary citrate), not hypercitraturia, is a well-recognized metabolic risk factor for the formation of **calcium oxalate stones**. *Hyperoxaluria* - **Oxalate** readily binds with calcium to form **calcium oxalate stones**, the most common type of kidney stone. - Both primary and secondary hyperoxaluria significantly increase the degree of urinary **supersaturation**, driving stone formation. *Hypercalciuria* - High levels of urinary calcium increases urine saturation, leading to the precipitation of calcium salts, primarily forming **calcium oxalate** or **calcium phosphate** stones. [1] - It is the most frequent metabolic abnormality observed in patients with **recurrent nephrolithiasis**. *Hyperuricosuria* - Excess urinary **uric acid** directly causes **uric acid stones**, especially in acidic urine. [1] - Importantly, uric acid crystals can also serve as a **nidus** for the heterogeneous nucleation of **calcium oxalate** stones, increasing overall stone risk. [1]

Question 2: Which of the following is one of the earliest presenting symptoms in a patient with Multiple Sclerosis?

A. Ataxia
B. Vertigo
C. Facial palsy
D. Sensory disturbances (Correct Answer)

Explanation: ***Sensory disturbances*** - **Sensory symptoms**, such as numbness, tingling (paresthesias), or hypoesthesia, are among the most common **initial complaints** (up to 40% of patients) in Multiple Sclerosis, often affecting the limbs or trunk [1]. - These symptoms occur due to demyelination in the **spinal cord** or **sensory pathways** in the brainstem. *Ataxia* - While **ataxia** (coordination problems) is a characteristic symptom of MS, usually resulting from cerebellar or posterior column involvement, it is less frequently the **absolute earliest** presentation [1]. - Ataxia often signifies later-stage progression or a focus of demyelination within the cerebellum or its connections [1]. *Vertigo* - **Vertigo** can occur in MS due to demyelination of the **vestibular pathways** in the brainstem (e.g., lesions affecting the **Medial Longitudinal Fasciculus (MLF)**) [1]. - However, isolated vertigo is typically a less common initial symptom compared to **sensory changes** or optic neuritis. *Facial palsy* - **Facial palsy** (Cranial Nerve VII involvement) can result from a plaque in the pons, but it is a relatively **rare** initial manifestation of Multiple Sclerosis. - Early cranial nerve involvement is more classically presented as **Optic Neuritis** or Diplopia (e.g., Internuclear Ophthalmoplegia).

Question 3: Which of the following is the most common clinical feature observed during the progression of systemic lupus erythematosus (SLE)?

A. Nephrotic syndrome
B. Arthralgia & myalgia (Correct Answer)
C. Anemia and thrombocytopenia
D. Photosensitivity

Explanation: ### Arthralgia & myalgia - **Arthralgia (joint pain)** and **myalgia (muscle pain)** are documented as the most common initial and persistent clinical features, occurring in over 90% of SLE patients [1]. - The arthritis in SLE is typically non-erosive and symmetrical, often affecting the small joints of the hands, wrists, and knees. *Photosensitivity* - While very common and a key diagnostic criterion, it occurs in about 40-50% of patients, making it less frequent than diffuse joint and muscle pain [1]. - It is a prominent feature of cutaneous involvement, often leading to the characteristic **malar rash** or discoid lesions after sun exposure [1]. *Nephrotic syndrome* - Renal involvement (**Lupus nephritis**) is serious, but clinically overt nephrotic syndrome (heavy proteinuria, edema) is found only in a subset of patients with Type III, IV, or V nephritis. - Overall, symptomatic renal disease affects about 50-60% of patients, less frequent than musculoskeletal symptoms. *Anemia and thrombocytopenia* - **Hematologic abnormalities** (anemia, leukopenia, and thrombocytopenia) are common and considered diagnostic criteria but occur in roughly 50% or less of patients. - **Anemia of chronic disease** is the most frequent hematologic finding, while **thrombocytopenia** is less common than arthralgia.

Question 4: According to WHO, which of the following is the recommended diagnostic test for spinal tuberculosis?

A. CT scan
B. CB-NAAT
C. Culture and Sensitivity (Correct Answer)
D. X-ray

Explanation: Culture and Sensitivity - It is considered the gold standard for definitive diagnosis of tuberculosis (TB) as it allows the isolation and confirmation of viable Mycobacterium tuberculosis organisms [2]. - It is essential for performing comprehensive Drug Susceptibility Testing (DST), which is critical for guiding the management of complex cases like spinal TB and detecting any drug resistance [3]. X-ray - X-rays are primarily useful for initial screening and assessing the extent of bony destruction, such as vertebral collapse (Pott's spine), but are not confirmatory [1]. - They are limited as they cannot provide bacteriological evidence or detect the presence of the M. tuberculosis organism, which is required for definitive diagnosis. CT scan - CT scans offer detailed imaging of bony morphology, disc involvement, and soft tissue pathology (e.g., paraspinal abscesses) superior to X-rays. - It remains an imaging modality and cannot replace the necessity of histopathological or microbiological confirmation and Drug Susceptibility Testing. CB-NAAT - CB-NAAT (e.g., Xpert MTB/RIF) is highly recommended by WHO for rapid diagnosis and detection of Rifampicin resistance from samples [3]. - While highly accurate, it detects nucleic acid and does not enable full Drug Susceptibility Testing against all first and second-line drugs, which Culture and Sensitivity provides.

Question 5: A 12-year-old child is diagnosed with systemic lupus erythematosus (SLE) and presents with nephrotic-range proteinuria. Renal biopsy reveals "wire loop lesions." Which of the following is the drug of choice in this case?

A. IV Steroids + cyclophosphamide (Correct Answer)
B. Mycophenolate mofetil
C. Cyclophosphamide only
D. IV Steroids only

Explanation: ***IV Steroids + cyclophosphamide*** - The presence of "wire loop lesions" on renal biopsy signifies **Diffuse Proliferative Lupus Nephritis (Class IV)**, which is the most common and severe form of Lupus Nephritis. - Induction therapy for Class IV LN requires a combination of high-dose corticosteroids (IV methylprednisolone) and a potent cytotoxic agent, making **cyclophosphamide** the standard aggressive regimen [1]. *IV Steroids only* - Although high-dose steroids (pulses) are essential for controlling acute inflammation, they are **insufficient as monotherapy** for the severe, widespread immune complex deposition seen in **Class IV LN** [1]. - Steroid monotherapy is typically used for less aggressive forms, such as Class I or II (minimal or mesangial) LN. *Mycophenolate mofetil* - **Mycophenolate mofetil (MMF)**, combined with steroids, is an alternative induction therapy, particularly favored for maintenance but is less reliably potent than cyclophosphamide in severe, life-threatening flares of **Class IV** in some regimens. - MMF alone is never used for induction; it must be administered with high-dose **corticosteroids** to manage acute disease activity. *Cyclophosphamide only* - **Cyclophosphamide** is a powerful induction agent, but it must always be combined with high-dose **corticosteroids** during the induction phase to maximize anti-inflammatory effects and achieve remission effectively [1]. - Administration of a cytotoxic agent without simultaneous acute inflammation control is substandard care.

Question 6: Which of the following is the most common inherited bleeding disorder?

A. Hemophilia
B. Von Willebrand Disease (Correct Answer)
C. Factor V Deficiency
D. Disseminated Intravascular Coagulation

Explanation: ***Von Willebrand Disease*** - VWD is the most common inherited bleeding disorder, with a prevalence estimated to be as high as 1% of the population, often showing an **autosomal dominant** inheritance pattern. - It results from a quantitative or qualitative defect in **von Willebrand factor (vWF)**, which impairs platelet adhesion and stabilizes **Factor VIII** [1][2]. *Disseminated Intravascular Coagulation* - DIC is an **acquired** life-threatening condition caused by systemic activation of coagulation, usually triggered by underlying severe diseases like **sepsis** or trauma, not inheritance. - It is characterized by simultaneous widespread thrombosis and severe bleeding due to the consumption of clotting factors and platelets. *Factor V Deficiency* - Factor V deficiency (Parahemophilia) is an extremely rare inherited bleeding disorder, transmitted in an **autosomal recessive** manner. - While inherited, its overall prevalence is substantially lower compared to VWD, making it not the most common. *Hemophilia* - Hemophilia (A and B) is the most common severe inherited bleeding disorder, known for causing deep tissue bleeding (e.g., **hemarthroses**). - It is an **X-linked recessive** condition, meaning it is less prevalent overall in the population compared to the high frequency of mild, often undiagnosed, VWD cases.

Question 7: A male patient presents with chronic diarrhea for 8 months. CT shows ahaustral appearance of the right colon. What is the most likely diagnosis?

A. Ulcerative colitis
B. Tubercular colitis
C. Crohns disease (Correct Answer)
D. Pseudomembranous enterocolitis

Explanation: ***Crohns disease*** - Crohn's disease is characterized by **transmural inflammation**, which can lead to fibrosis and rigidity of the bowel wall, resulting in an ahaustral appearance. Its predilection for the **ileocecal region** makes right-sided colon involvement a classic presentation. - The disease course is chronic with relapsing and remitting symptoms like non-bloody diarrhea and abdominal pain. It is also known for its **skip lesions**, where inflamed segments of the bowel are interspersed with normal tissue. ***Ulcerative colitis*** - While chronic ulcerative colitis can cause an ahaustral or "**lead pipe**" colon, it classically starts in the **rectum** and extends proximally in a continuous manner. Isolated right colon involvement is very rare. - Inflammation in UC is limited to the **mucosa and submucosa**, unlike the transmural inflammation seen in Crohn's disease. ***Tubercular colitis*** - Intestinal tuberculosis commonly affects the **ileocecal region**, mimicking Crohn's disease clinically and radiologically. It can cause bowel wall thickening and strictures. - Differentiating features include the presence of **caseating granulomas** on histology, constitutional symptoms like fever and night sweats, and often a gaping ileocecal valve (**Fleischner sign**). ***Pseudomembranous enterocolitis*** - This is an **acute inflammatory condition** caused by *Clostridium difficile* toxins, usually following antibiotic therapy. It does not present as a chronic illness lasting for months. - Typical CT findings are acute, such as severe colonic wall thickening and edema (the "**accordion sign**"), not the chronic fibrotic changes that lead to an ahaustral appearance.

Question 8: Which of the following about lumbar puncture is incorrect?

A. Urgent indication if suspected SAH with inconclusive CT
B. Can be done in thrombocytopenia (platelet count >10,000 )
C. Meningitis is an unusual complication
D. Post-tap headache is more common in females and old age (Correct Answer)

Explanation: ***Post-tap headache is more common in females and old age*** - **Post-dural puncture headache (PDPH)** is more common in **younger patients** (adolescents and young adults) and **females**. - The incidence decreases significantly with increasing age, making the statement that it is more common in **old age** incorrect. ***Urgent indication if suspected SAH with inconclusive CT*** - If a patient presents with a **thunderclap headache** suggestive of **Subarachnoid Hemorrhage (SAH)**, and the initial **CT scan is negative**, an urgent lumbar puncture is mandatory to rule out SAH (looking for **xanthochromia**) [1], [2]. - This confirms the diagnosis in up to 3% of patients with negative CT scans or those presenting late after symptom onset. ***Can be done in thrombocytopenia (platelet count >10,000 )*** - While the ideal platelet count for an LP is >50,000, LPs can often be safely performed with extreme caution in patients with platelets as low as **20,000 to 50,000**. - A platelet count of **>10,000** would typically be considered a relative contraindication unless the risk of **intracranial pathology** outweighs the risk of spinal hematoma, but the statement implies feasibility and is technically not the most incorrect option regarding general practice guidelines. ***Meningitis is an unusual complication*** - Post-procedural **bacterial meningitis** due to contamination is an extremely rare complication of lumbar puncture when standard sterile techniques are meticulously followed. - The risk is very low (often cited as less than 1 in 10,000 procedures), hence it is considered an **unusual complication**.

Question 9: In a septic shock patient who remains hypotensive despite adequate fluid resuscitation, what would be the next drug of choice?

A. Noradrenaline (Correct Answer)
B. Adrenaline
C. Dopamine
D. Hydrocortisone

Explanation: ***Noradrenaline*** - **Noradrenaline (Norepinephrine)** is the preferred first-line vasopressor for septic shock, recommended to target a mean arterial pressure (MAP) of at least **65 mmHg** [1]. - It is the vasoconstrictor with the most potent **alpha-1 adrenergic agonist effects**, effectively raising systemic vascular resistance (SVR) and blood pressure while having less tachycardia compared to adrenaline. ***Adrenaline*** - **Adrenaline (Epinephrine)** is typically a second-line agent, added when noradrenaline alone is insufficient, due to its mixed alpha and potent **beta-1 effects** (which can increase heart rate and the risk of arrhythmias). - Its use as a first-line agent is generally reserved for situations like **anaphylactic shock** or severe cardiogenic shock, not routine septic shock management. ***Dopamine*** - **Dopamine** is no longer recommended as the primary vasopressor in septic shock because it is associated with a higher incidence of **tachyarrhythmias** compared to noradrenaline. - It may be considered only in highly selected patients with a low risk of tachyarrhythmias and **absolute or relative bradycardia**. ***Hydrocortisone*** - **Hydrocortisone** (low-dose corticosteroids) is indicated only if the patient remains hypotensive despite adequate fluid resuscitation and **high-dose vasopressor therapy** (e.g., noradrenaline and likely a second agent like vasopressin or adrenaline). - This treatment addresses potential **critical illness-related corticosteroid insufficiency (CIRCI)**, but it is not the immediate next step after initial fluid failure.

Question 10: A patient with rheumatoid arthritis presents with neck pain and clinical signs of myelopathy. What is the most likely diagnosis?

A. Osteoarthritis of vertebrae
B. Disc herniation
C. Atlantoaxial dislocation (Correct Answer)
D. C2-C3 intervertebral stenosis

Explanation: ***Atlantoaxial dislocation*** - **Rheumatoid arthritis (RA)** frequently affects the cervical spine, particularly the atlantoaxial joint, leading to **subsidence** of the atlas (C1) on the axis (C2). - **Atlantoaxial dislocation (AAD)** results in **spinal cord compression** (myelopathy) due to narrowing of the spinal canal, presenting as neck pain and neurological signs [1]. ***Osteoarthritis of vertebrae*** - While osteoarthritis causes neck pain, it is not the typical cause of **acute myelopathy** in RA patients. - Osteoarthritis usually affects the **lower cervical spine** and lacks the inflammatory destruction characteristic of RA involvement in the C1-C2 facets [2]. ***C2-C3 intervertebral stenosis*** - Stenosis typically involves the **lower cervical levels** (C5-C7) caused by osteophyte formation or disc disease, which is less common in RA [2]. - The hallmark **RA involvement** causing myelopathy is specifically **atlantoaxial subluxation** (dislocation). ***Disc herniation*** - Disc herniation is a common cause of radiculopathy and sometimes myelopathy in the general population, but it is **not the primary mechanism** of cervical myelopathy in RA. - The major instability and subsequent cord compression in RA patients occur due to **ligamentous laxity** and **pannus-related bone erosion** at the atlantoaxial joint.