INI-CET 2025 - Internal Medicine PYQs Practice Questions

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]

Question 1

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

Accepted Answer

Hypercitraturia

Answer

Hypercalciuria

Answer

Hyperuricosuria

Answer

Hyperoxaluria

Question 2

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

Accepted Answer

Sensory disturbances

Answer

Ataxia

Answer

Vertigo

Answer

Facial palsy

Question 3

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

Accepted Answer

Arthralgia & myalgia

Answer

Nephrotic syndrome

Answer

Anemia and thrombocytopenia

Answer

Photosensitivity

Question 4

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

Accepted Answer

Culture and Sensitivity

Answer

CT scan

Answer

CB-NAAT

Answer

X-ray

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?

Accepted Answer

IV Steroids + cyclophosphamide

Answer

Mycophenolate mofetil

Answer

Cyclophosphamide only

Answer

IV Steroids only

Question 6

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

Accepted Answer

Von Willebrand Disease

Answer

Hemophilia

Answer

Factor V Deficiency

Answer

Disseminated Intravascular Coagulation

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?

Accepted Answer

Crohns disease

Answer

Ulcerative colitis

Answer

Tubercular colitis

Answer

Pseudomembranous enterocolitis

Question 8

Which of the following about lumbar puncture is incorrect?

Accepted Answer

Post-tap headache is more common in females and old age

Answer

Urgent indication if suspected SAH with inconclusive CT

Answer

Can be done in thrombocytopenia (platelet count >10,000 )

Answer

Meningitis is 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?

Accepted Answer

Noradrenaline

Answer

Adrenaline

Answer

Dopamine

Answer

Hydrocortisone

Question 10

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

Accepted Answer

Atlantoaxial dislocation

Answer

Osteoarthritis of vertebrae

Answer

Disc herniation

Answer

C2-C3 intervertebral stenosis

INI-CET 2025 — Internal Medicine