INI-CET 2025 - Internal Medicine Practice Questions

Q: Which of the following is wrongly matched with its classification?

LA classification - Achalasia. ***LA classification - Achalasia*** - The **Los Angeles (LA) classification** system is used to grade the severity of **reflux esophagitis** (Esme of the gastric mucosa, typically following **Gastroesophageal Reflux Disease (GERD)**). - **Achalasia** is typically classified using the **Chicago Classification** (based on high-resolution manometry findings) [1] or the older **Siewert classification** for surgical staging. ***Boston classification - Colon preparation for colonoscopy*** - The **Boston Bowel Preparation Scale (BBPS)** is a validated, widely used scoring system to assess the quality of **colon preparation** during colonoscopy, ranging from 0 (unprepared) to 3 (excellent) for each segment. - A high BBPS score (typically $\ge$ 7) indicates adequate preparation necessary for accurate polyp detection. ***Mannheim classification - Chronic pancreatitis*** - The **Mannheim Classification System** is used for grading the severity of **acute pancreatitis**, not chronic pancreatitis. - It assesses clinical parameters (e.g., organ failure, complications) to predict the prognosis and guide management of acute pancreatitis. ***Miami classification - Parathyroid adenoma and hyperplasia differentiation*** - The **Miami Criteria** is a histological classification system used to distinguish between **parathyroid adenoma** and **parathyroid hyperplasia** based on architectural and cellular features observed on surgical pathology. - It helps pathologists determine the underlying cause of primary hyperparathyroidism.

Q: What is the cause of hyponatremia in diarrhea-induced hypovolemia?

Decreased aldosterone. ***Decreased aldosterone*** * In scenarios where salt loss (e.g., due to diarrhea) leads to hypovolemia, a relative or true deficiency of **aldosterone** prevents maximal sodium reabsorption in the distal tubules and collecting ducts. * This failure to maximally conserve sodium leads to **renal salt wasting**, which exacerbates the volume deficit and, when coupled with ADH-mediated water retention, results in hyponatremia. ***Decreased ADH*** * Hypovolemia (volume depletion) is the strongest non-osmotic trigger for the release of **Antidiuretic Hormone (ADH)** from the posterior pituitary, overriding low plasma osmolality [1]. * Therefore, in diarrhea-induced hypovolemia, **ADH levels are actually increased**, which drives powerful free water reabsorption in the kidney, resulting in dilutional hyponatremia [1]. ***Decreased sodium absorption from gastrointestinal tract*** * This is the primary mechanism by which diarrhea causes salt and water loss, leading to the state of **hypovolemia**. * However, the mechanism driving the *hyponatremia* (low plasma sodium concentration) involves the kidney's disproportionate reabsorption of water relative to sodium, mediated by **ADH**. ***Increased sodium absorption from kidney*** * System mechanisms like the Renin-Angiotensin-Aldosterone System (RAAS) are activated by hypovolemia to increase **sodium and water absorption** in an attempt to restore blood volume [2]. * Increased renal sodium absorption is a compensatory mechanism that works against hyponatremia; thus, it is not the cause of low plasma sodium.

Q: A 56-year-old diabetic male presents with a complicated urinary tract infection and is found to be hypotensive. His blood pressure does not respond to intravenous fluids. Which of the following is the most appropriate antibiotic to manage his condition?

Meropenem. ***Meropenem*** - This patient has **septic shock** secondary to a complicated UTI (hypotension unresponsive to fluids), requiring prompt, broad-spectrum coverage against probable **Gram-negative bacilli** and potential extended-spectrum beta-lactamase (ESBL) producers, common in diabetic patients with complicated UTIs [1]. - **Meropenem**, a carbapenem, provides excellent empirical coverage for **multi-drug resistant (MDR) organisms** and is a first-line agent for critically ill patients with suspected septic shock of unknown or complicated origin [1]. ***Amoxicillin-Clavulanate*** - This combination (a moderate-spectrum penicillin-beta-lactamase inhibitor) lacks reliable coverage against common hospital-acquired or complicatd UTI pathogens, such as **_Pseudomonas aeruginosa_** or ESBL-producing Enterobacteriaceae [1]. - It is unsuitable for treating septic shock due to an inadequate spectrum and potential for **resistance** in this clinical setting [1]. ***Nitrofurantoin*** - This drug is concentrated in the urine and is only suitable for treating **uncomplicated cystitis** as it does not achieve adequate systemic levels for treating pyelonephritis, deep-seated infection, or **urosepsis**. - It has a narrow spectrum limited primarily to **Gram-positive cocci** and susceptible **_E. coli_** and is contraindicated in systemic infections or septic shock. ***Ceftriaxone*** - Ceftriaxone (a third-generation cephalosporin) is often used for complicated UTIs (pyelonephritis) but is generally not adequate as **monotherapy** for treating **septic shock** in a high-risk (diabetic) patient [2]. - There is a high risk of resistance, including from ESBL-producers, which necessitates broader coverage, like a **carbapenem**, in critically ill patients before susceptibility results are known.

Q: A 65-year-old known case of Parkinsons disease presents with oropharyngeal dysphagia and recurrent episodes of aspiration pneumonitis, along with excessive respiratory secretions. Chest imaging reveals bilateral bronchiectasis. What is the most appropriate long-term management for this patient?

Percutaneous endoscopic gastrostomy (PEG) tube placement. ***Percutaneous endoscopic gastrostomy (PEG) tube placement*** - This patient, with Parkinson's disease, suffers from severe **oropharyngeal dysphagia**, leading to recurrent **aspiration pneumonitis** and **bilateral bronchiectasis** (suggesting chronic aspiration). - **PEG placement** is the most appropriate long-term management to ensure adequate nutrition and hydration while **bypassing the compromised swallowing mechanism**, thereby preventing further aspiration and subsequent respiratory complications. ***High-frequency chest wall oscillation therapy*** - This technique is used primarily to mobilize **thick secretions** in patients with conditions like **cystic fibrosis** or severe COPD exacerbations. - While the patient has excessive secretions and bronchiectasis, this therapy **does not address the root cause** (aspiration due to dysphagia) and is not a substitute for safe feeding. ***Nebulized N-acetylcysteine to reduce secretions*** - **N-acetylcysteine (NAC)** is a mucolytic agent used to reduce the viscosity of respiratory secretions, aiding elimination. - Although helpful for symptom relief, it **does not prevent chronic aspiration** from dysphagia and can sometimes **trigger bronchospasm** in susceptible individuals. ***Macrolide therapy*** - Long-term low-dose macrolides (e.g., azithromycin) are used for their **anti-inflammatory** and **immunomodulatory effects** in chronic lung diseases, such as **bronchiectasis without cystic fibrosis** [1]. - While useful for managing the bronchiectasis, macrolides **do not treat the underlying dysphagia** or the source of the recurrent aspiration and subsequent infections [1].

Q: A 20-year-old female diagnosed with septic shock presents with a blood pressure of 58/30 mmHg. After receiving 3 liters of crystalloid fluid, her mean arterial pressure (MAP) remains 58 mmHg. What is the next best step in management?

Start noradrenaline. ***Start noradrenaline*** - **Noradrenaline (Norepinephrine)** is the preferred first-line vasopressor in **septic shock** to achieve a target Mean Arterial Pressure (MAP) of $\ge 65$ mmHg, especially when fluid resuscitation (3L of crystalloids given) is inadequate [1]. - It primarily acts as an $\alpha$-agonist, causing significant **vasoconstriction** which increases systemic vascular resistance (SVR) and improves blood pressure. ***Start dopamine*** - Dopamine is considered a second-line agent due to its potential to cause more **tachyarrhythmias** compared to noradrenaline. - It is often reserved for patients with a low risk of tachyarrhythmias or relative **bradycardia** in addition to hypotension. ***Repeat crystalloid fluid*** - The current fluid challenge (3L) is substantial; administering more fluid without a pressor in refractory shock can lead to detrimental effects like **pulmonary edema** and fluid overload, which has diminishing returns on MAP [1]. - The patient's persistent hypotension (MAP 58 mmHg) despite significant fluid resuscitation indicates inadequate peripheral vascular tone (**vasoplegia**), requiring immediate vasopressor support [1]. ***Start vasopressin*** - **Vasopressin** is generally added as a second-line agent to noradrenaline (**vasopressor weaning**) to potentially reduce the dose of noradrenaline needed. - It is not recommended as the initial monotherapy for hypotension in septic shock because it lacks the potent $\alpha$-agonist effect of noradrenaline.

Q: Mitral stenosis murmur corresponds to which wave of ECG?

P wave. ***P wave*** - The **P wave** on the ECG represents **atrial depolarization** and precedes atrial contraction (atrial systole) [3]. - In **mitral stenosis (MS)**, the characteristic presystolic accentuation (a later component of the diastolic murmur) is caused by the force of atrial contraction just prior to the QRS complex, correlating with the P wave [4]. ***QRS complex*** - The **QRS complex** represents **ventricular depolarization** and precedes ventricular contraction (ventricular systole) [3]. - The mitral stenosis murmur is a **diastolic murmur**; it occurs after the T wave and ends before the QRS complex (or is accentuated just before it by atrial kick) [1], [4]. ***T wave*** - The **T wave** represents **ventricular repolarization** [3]. - The T wave marks the end of systole; the mitral stenosis murmur begins *after* the T wave, during the period of isovolumetric relaxation and subsequent rapid ventricular filling [2]. ***ST segment*** - The **ST segment** represents the period between ventricular depolarization and repolarization (plateau phase of the action potential). - This segment is part of systole, whereas the mitral stenosis murmur is strictly a **diastolic event** [1], [4].

Q: A 45-year-old chronic smoker presents with complaints of dyspnea. Pulmonary function tests reveal FEV1/FVC ratio of 65% and RV/ TLC ratio of 141%. Which of the following best describes the underlying pathophysiology?

Air trapping with hyperinflation of lungs. ***Air trapping with hyperinflation of lungs*** - The FEV1/FVC ratio is **65% (below 70%)**, confirming an **obstructive lung disease** (e.g., COPD/emphysema) due to irreversible airflow limitation [2]. - An RV/TLC ratio of **141% (above 120%)** signifies **hyperinflation** (increased **Residual Volume** and **Total Lung Capacity**), which is the direct result of air trapping in the distal airspaces due to airway obstruction [1]. ***Decreased lung compliance*** - Decreased compliance is characteristic of **restrictive lung diseases** (e.g., pulmonary fibrosis), where the lungs are stiff and difficult to inflate. - In obstructive diseases like emphysema, the underlying pathophysiology often involves **destruction of alveolar walls**, which *increases* lung compliance. ***Restrictive lung disease*** - Restrictive diseases are characterized by a **normal or increased FEV1/FVC ratio** and decreased lung volumes (low FVC and TLC), which contradicts the PFT findings (low FEV1/FVC) [3]. - The main physiological problem is difficulty *expanding* the lungs, not difficulty *expelling* air. ***Increased lung compliance*** - While increased compliance is seen in pure emphysema, the PFT findings specifically point to the *consequences* of airway obstruction, which is **air trapping** and subsequent **hyperinflation** (increased RV/TLC ratio) [1]. - Describing the underlying pathophysiology as only 'increased lung compliance' is incomplete, as the most immediate and defining physiological result of severe obstruction leading to dyspnea is the high residual volume due to trapped air.

Q: Which of the following is not a symptom of cardiac failure?

Non-pulsatile elevation of JVP. ***Non-pulsatile elevation of JVP*** - In cardiac failure, **JVP is elevated but remains pulsatile**, showing normal **a, c, and v waves** from the transmitted cardiac cycle. - **Non-pulsatile JVP elevation** is characteristic of **superior vena cava (SVC) syndrome**, where complete venous obstruction blocks pulsation transmission, not cardiac failure. *Right hypochondriac pain* - This **is a symptom** of **right-sided heart failure** due to **hepatic congestion** and stretching of **Glisson's capsule**. - Results from **passive liver engorgement** secondary to elevated right atrial pressure and systemic venous congestion. *Orthopnea* - Classic symptom of **left-sided heart failure** characterized by breathlessness when lying flat due to **pulmonary venous congestion**. - Worsens in supine position as **venous return increases** and is relieved by sitting upright. *Paroxysmal nocturnal dyspnea* - Sudden severe **shortness of breath** that wakes patients from sleep, typically **1-2 hours** after falling asleep. - Caused by **delayed resorption of peripheral edema** and increased venous return while supine, leading to acute **pulmonary congestion**.

Question 1

Which of the following is wrongly matched with its classification?

Accepted Answer

LA classification - Achalasia

Answer

Boston classification - Colon preparation for colonoscopy

Answer

Mannheim classification - Chronic pancreatitis

Answer

Miami classification - Parathyroid adenoma and hyperplasia differentiation

Question 2

What is the cause of hyponatremia in diarrhea-induced hypovolemia?

Accepted Answer

Decreased aldosterone

Answer

Decreased ADH

Answer

Decreased sodium absorption from gastrointestinal tract

Answer

Increased sodium absorption from kidney

Question 3

A 58-year-old male presents to a PHC for a routine check-up. His blood pressure readings on two separate occasions are 148 / 90 mmHg and 152 / 96 mmHg. He is asymptomatic and has no known comorbidities. What is the most appropriate next step in management according to current hypertension guidelines?

Accepted Answer

Start Amlodipine 5 mg once daily and advise follow-up after a month

Answer

Initiate treatment only if BP exceeds 160 / 100 mmHg

Answer

Start the patient on IV anti-hypertensive drugs

Answer

Refer to a higher center for further evaluation

Question 4

A patient underwent cardiac surgery and was admitted to the ICU. He later developed ventilator-associated pneumonia and was started on empirical antibiotics. A few hours later, the patient developed acute kidney injury. Serum procalcitonin was sent. Which of the following statements regarding procalcitonin is correct?

Accepted Answer

It helps in determining the duration of antibiotic therapy

Answer

It can be used to confirm source of infection

Answer

It is used to differentiate bacterial from fungal cause

Answer

It helps in identifying which empirical antibiotics to be started

Question 5

A 56-year-old diabetic male presents with a complicated urinary tract infection and is found to be hypotensive. His blood pressure does not respond to intravenous fluids. Which of the following is the most appropriate antibiotic to manage his condition?

Accepted Answer

Meropenem

Answer

Amoxicillin-Clavulanate

Answer

Nitrofurantoin

Answer

Ceftriaxone

Question 6

A 65-year-old known case of Parkinsons disease presents with oropharyngeal dysphagia and recurrent episodes of aspiration pneumonitis, along with excessive respiratory secretions. Chest imaging reveals bilateral bronchiectasis. What is the most appropriate long-term management for this patient?

Accepted Answer

Percutaneous endoscopic gastrostomy (PEG) tube placement

Answer

High-frequency chest wall oscillation therapy

Answer

Nebulized N-acetylcysteine to reduce secretions

Answer

Macrolide therapy

Question 7

A 20-year-old female diagnosed with septic shock presents with a blood pressure of 58/30 mmHg. After receiving 3 liters of crystalloid fluid, her mean arterial pressure (MAP) remains 58 mmHg. What is the next best step in management?

Accepted Answer

Start noradrenaline

Answer

Start vasopressin

Answer

Start dopamine

Answer

Repeat crystalloid fluid

Question 8

Mitral stenosis murmur corresponds to which wave of ECG?

Accepted Answer

P wave

Answer

QRS complex

Answer

ST segment

Answer

T wave

Question 9

A 45-year-old chronic smoker presents with complaints of dyspnea. Pulmonary function tests reveal FEV1/FVC ratio of 65% and RV/ TLC ratio of 141%. Which of the following best describes the underlying pathophysiology?

Accepted Answer

Air trapping with hyperinflation of lungs

Answer

Increased lung compliance

Answer

Restrictive lung disease

Answer

Decreased lung compliance

Question 10

Which of the following is not a symptom of cardiac failure?

Accepted Answer

Non-pulsatile elevation of JVP

Answer

Right hypochondriac pain

Answer

Orthopnea

Answer

Paroxysmal nocturnal dyspnea

INI-CET 2025 — Internal Medicine