Internal Medicine
1 questionsA male patient presents with chronic diarrhea for 8 months. CT shows ahaustral appearance of the right colon. What is the most likely diagnosis?
INI-CET 2025 - Internal Medicine INI-CET Practice Questions and MCQs
Question 41: 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.
Pharmacology
1 questionsWhich of the following statements is incorrect?
INI-CET 2025 - Pharmacology INI-CET Practice Questions and MCQs
Question 41: Which of the following statements is incorrect?
- A. Alcohol in low dose causes brain stimulation and in higher doses, causes brain suppression
- B. Cannabis use can result in self-driven, repetitive behaviours (Correct Answer)
- C. Opioids are very effective analgesics
- D. Volatile inhalational agents (when abused) are mostly toxic to humans
Explanation: ***Cannabis use can result in self-driven, repetitive behaviours*** - This statement is **incorrect**. Repetitive, purposeless, or **stereotyped behaviors** (**stereotypies**) are typically associated with chronic use or intoxication with **stimulants** (e.g., cocaine, amphetamines/methamphetamine), not cannabis. - Cannabis (THC) primarily acts as a depressant/hallucinogen, often causing symptoms like impaired coordination, anxiety, paranoia, altered time perception, and the **amotivational syndrome**, rather than stimulant-like stereotypies. ***Alcohol in low dose causes brain stimulation and in higher doses, causes brain suppression*** - This statement is **correct**. In low doses, alcohol causes **disinhibition** and euphoria due to selective suppression of inhibitory neurons (apparent stimulation). - In higher doses, alcohol progressively depresses the entire Central Nervous System (CNS), leading to sedation, coma, and **respiratory suppression**. ***Opioids are very effective analgesics*** - This statement is **correct**. Opioids act by agonizing **mu-opioid receptors** in the CNS, spinal cord, and peripheral nerves, causing profound **analgesia**. - They are considered the gold standard for managing severe, acute, and chronic pain, though their use is limited by addiction potential and side effects. ***Volatile inhalational agents are mostly toxic to humans*** - This statement is **correct** for recreational/abused inhalational agents (like toluene, butane, nitrites). - Abuse of these agents can cause severe immediate toxicity (e.g., **sudden sniffing death**) and long-term damage, particularly to the brain (encephalopathy), liver, and kidneys.
Psychiatry
4 questionsWhich of the following is not an ICD-10 diagnostic criterion for depression?
All of the following statements are correct except:
A patient with schizophrenia says, "Lord Hanuman was celibate, I am celibate too, so I am Lord Hanuman." Which thought abnormality is present in this patient?
Which of the following drugs are used in the management of acute mania?
INI-CET 2025 - Psychiatry INI-CET Practice Questions and MCQs
Question 41: Which of the following is not an ICD-10 diagnostic criterion for depression?
- A. Low energy levels
- B. Low mood for most of the day
- C. Loss of interest in pleasurable things
- D. Persistent worry about everyday matters (Correct Answer)
Explanation: ***Persistent worry about everyday matters*** - This is a core feature of **Generalized Anxiety Disorder (GAD)**, not a diagnostic criterion for depression in ICD-10. - While anxiety and worry can coexist with depression, persistent excessive worry about multiple everyday events is characteristic of GAD (F41.1), not listed as a criterion for Depressive Episode (F32). - The ICD-10 criteria for depression focus on mood, interest, energy, and associated symptoms like guilt, sleep disturbance, and suicidal thoughts - not persistent worry. *Incorrect: Low energy levels* - This is one of the **three core (typical) symptoms** for Depressive Episode in ICD-10 (F32). - Described as "reduced energy or increased fatigability" and is essential for diagnosis. - Patients often report feeling tired, lacking vitality, or having diminished activity levels. *Incorrect: Low mood for most of the day* - This is the primary **core (typical) symptom** required for diagnosing a Depressive Episode in ICD-10. - Must be "depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, largely uninfluenced by circumstances." - Required for at least 2 weeks for diagnosis. *Incorrect: Loss of interest in pleasurable things* - Known as **anhedonia**, this is one of the **three core (typical) symptoms** for Depressive Episode in ICD-10. - Described as "loss of interest or pleasure in activities that are normally pleasurable." - A hallmark feature distinguishing depression from normal sadness.
Question 42: All of the following statements are correct except:
- A. Opioid withdrawal is rarely fatal
- B. Buprenorphine can be used for the management of opioid withdrawal
- C. Flumazenil is used for the management of long-term alcohol dependence syndrome (Correct Answer)
- D. Cannabis withdrawal is associated with minimal physical symptoms
Explanation: ***Flumazenil is used for the management of long-term alcohol dependence syndrome*** - This statement is incorrect because **Flumazenil** is a **GABA-A receptor antagonist** specifically used to reverse the effects of **benzodiazepine overdose** (acute intoxication or sedation), not for the management of chronic alcohol dependence syndrome. - Management of long-term alcohol dependence typically involves medications like **naltrexone, acamprosate, or disulfiram**, along with psychosocial therapies. ***Opioid withdrawal is rarely fatal*** - This statement is correct. While opioid withdrawal is highly distressing and uncomfortable (**flu-like symptoms, diarrhea, vomiting**), it is **not life-threatening** except in very rare cases due to severe dehydration or aspiration. - The primary concern in opioid dependence is the risk of **fatal overdose** upon relapse, especially after a period of abstinence. ***Buprenorphine can be used for the management of opioid withdrawal*** - This statement is correct. **Buprenorphine**, a **partial opioid agonist**, is a standard treatment for both acute opioid withdrawal and long-term maintenance treatment (Opioid Substitution Therapy). - It helps alleviate withdrawal symptoms and cravings while posing a lower risk of respiratory depression compared to full agonists like methadone. ***Cannabis withdrawal is associated with minimal physical symptoms*** - This statement is correct. Cannabis withdrawal primarily manifests as **psychological symptoms** such as irritability, anxiety, insomnia, and depressed mood. - Physical symptoms are generally mild, limited to temporary decreases in appetite, stomach pain, or tremors, and are **not medically significant** compared to alcohol or opioid withdrawal.
Question 43: A patient with schizophrenia says, "Lord Hanuman was celibate, I am celibate too, so I am Lord Hanuman." Which thought abnormality is present in this patient?
- A. Autistic thinking (Correct Answer)
- B. Verbigeration
- C. Neologism
- D. Loosening of association
Explanation: ***Autistic thinking*** - This term, introduced by **Eugen Bleuler**, refers to **preoccupation with an internal private world** (fantasy and delusion) and ignoring external reality, leading to illogical and idiosyncratic thought processes. - The patient's statement is an example of **paralogical thinking** where two unrelated or loosely related concepts (celibacy and being Lord Hanuman) are equated based on a forced, self-referential interpretation. *Verbigeration* - This refers to the **meaningless, often rhythmic, repetition of specific words or phrases**, similar to a verbal tic. - It is a disorder of speech (not primarily content) and does not explain the illogical content or structure of the patient's statement. *Neologism* - This involves the **creation of new words** or the appropriation of existing words to mean something entirely new, which is incomprehensible to others. - The patient's statement uses existing words and is structurally a complete (though illogical) sentence, not a newly coined word. *Loosening of association* - This refers to a **disturbance in the logical progression of thought** where there is a lack of connection between successive ideas, often leading to derailment or tangentiality. - While the statement is illogical, the central idea (faulty identification) is maintained; the primary pathology lies in the content and structure of the thought (faulty logic = **autistic thinking**), not the sequence of ideas.
Question 44: Which of the following drugs are used in the management of acute mania?
- A. Only 1 (Lithium)
- B. 1, 2 & 3 (Lithium, Valproate & Haloperidol) (Correct Answer)
- C. 1, 2 & 4 (Lithium, Valproate & Amitriptyline)
- D. 2 & 4 (Valproate & Amitriptyline)
Explanation: ***Correct: 1, 2 & 3 (Lithium, Valproate & Haloperidol)*** **Drugs used in acute mania management:** **Lithium** - First-line mood stabilizer with proven efficacy in acute mania. It reduces manic symptoms and prevents recurrence. Therapeutic level: 0.8-1.2 mEq/L for acute phase. **Valproate (Sodium valproate/Divalproex)** - First-line mood stabilizer, particularly effective for mixed episodes and rapid cycling. Often preferred when rapid control is needed due to faster onset than lithium. **Haloperidol** - Typical antipsychotic effective for acute manic episodes, especially when rapid tranquilization is required for agitation and psychotic symptoms. Second-generation antipsychotics (olanzapine, risperidone, quetiapine) are also commonly used. *Incorrect: Amitriptyline* Amitriptyline is a **tricyclic antidepressant (TCA)** that is **contraindicated in acute mania**. Antidepressants can precipitate or worsen manic episodes, induce rapid cycling, and destabilize mood in bipolar disorder. They should only be used (if at all) in the depressive phase of bipolar disorder, and always with a mood stabilizer. **Clinical Pearl:** The acute management of mania typically involves mood stabilizers (lithium, valproate, carbamazepine) and/or antipsychotics. Antidepressants are avoided as they can trigger manic switching.
Radiology
4 questionsBased on the provided X-ray image, identify the type of thyroid malignancy.
Eye of the tiger appearance on MRI is associated with:
Honda or H sign on STIR MRI is characteristic of which condition?
Identify the investigation modality shown in the image.
INI-CET 2025 - Radiology INI-CET Practice Questions and MCQs
Question 41: Based on the provided X-ray image, identify the type of thyroid malignancy.
- A. Papillary carcinoma
- B. Hurthle cell carcinoma
- C. Follicular carcinoma (Correct Answer)
- D. Thyroid lymphoma
Explanation: ***Follicular carcinoma*** - This is the **correct answer** based on the X-ray showing bone metastases. - Follicular carcinoma characteristically spreads via **hematogenous (bloodstream) route** to distant sites, particularly **bones and lungs**. - Bone metastases from thyroid cancer are **most commonly** due to follicular carcinoma, presenting as **lytic lesions** on X-ray. - Follicular carcinoma accounts for 10-15% of thyroid cancers but is responsible for the majority of thyroid cancer bone metastases. *Incorrect: Papillary carcinoma* - Although papillary carcinoma is the **most common thyroid malignancy** (80% of cases), it predominantly spreads via **lymphatic route** to regional lymph nodes. - Distant hematogenous metastases to bone are **uncommon** in papillary carcinoma. - When papillary carcinoma does metastasize distantly, lungs are more commonly affected than bones. *Incorrect: Hurthle cell carcinoma* - This is an **aggressive variant of follicular carcinoma** (Hürthle cell or oncocytic variant). - While it can spread hematogenously, it is significantly **rarer** than conventional follicular carcinoma. - It represents only 3-5% of differentiated thyroid cancers. *Incorrect: Thyroid lymphoma* - Primary thyroid lymphoma is a **rare malignancy** typically presenting as a rapidly enlarging neck mass. - Usually occurs in elderly patients with a history of **Hashimoto's thyroiditis**. - Distant bone metastases are **not characteristic** of primary thyroid lymphoma.
Question 42: Eye of the tiger appearance on MRI is associated with:
- A. Pantothenate kinase-associated degeneration (Correct Answer)
- B. Wilson disease
- C. Krabbe disease
- D. Huntington chorea
Explanation: ***Pantothenate kinase-associated degeneration*** - The "eye of the tiger" sign is pathognomonic for **Pantothenate kinase-associated neurodegeneration (PKAN)**, a form of Neurodegeneration with Brain Iron Accumulation (NBIA). - It appears as a central area of high signal intensity (oedema/gliosis) surrounded by a rim of low signal intensity (iron deposition) in the **globus pallidus** on T2-weighted MRI. ***Wilson disease*** - Characterized by **copper deposition** in the liver, brain (e.g., basal ganglia, thalamus), and cornea (**Kayser-Fleischer rings**). - MRI findings typically show increased T2 signal intensity in the putamen, midbrain, and basal ganglia, but do not produce the classic "eye of the tiger" sign. ***Krabbe disease*** - This is a lysosomal storage disease (leukodystrophy) caused by a deficiency of the enzyme **galactocerebrosidase**. - MRI typically shows extensive white matter abnormalities and atrophy, but it is not associated with the **globus pallidus** changes seen in the "eye of the tiger" sign. ***Huntington chorea*** - A progressive brain disorder characterized by prominent atrophy of the **caudate nucleus** and putamen (striatum). - MRI primarily demonstrates severe **caudate atrophy** and is not associated with the characteristic PKAN finding in the globus pallidus.
Question 43: Honda or H sign on STIR MRI is characteristic of which condition?
- A. Multiple myeloma
- B. Sacral insufficiency fracture (Correct Answer)
- C. Acute osteomyelitis
- D. Bone marrow edema
Explanation: ***Sacral insufficiency fracture*** - The **Honda sign** (also known as the H sign or butterfly sign) is a characteristic finding on **STIR MRI** of the sacrum, particularly suggestive of a **sacral insufficiency fracture** caused by chronic microtrauma in osteoporotic bone. - It represents bilateral vertical fracture lines through the sacral alae connected by a horizontal fracture line through the body of S3 (or S2/S4), showing **medullary edema**/fracture line hyperintensity on STIR sequences. ***Multiple myeloma*** - Myeloma typically presents on MRI as multiple **focal lesions** (plasmacytomas) or diffuse marrow infiltration, often showing low signal intensity on T1 and variable T2/STIR signals. - While sacral involvement is possible, the classic H sign or Honda sign is not a typical presentation; rather, it often shows **lytic lesions** on plain films/CT. ***Acute osteomyelitis*** - Acute osteomyelitis of the sacrum would show localized **marrow edema** with corresponding T1 hypointensity and contrast-enhancing soft tissue/periosteal reaction. - It is usually unilateral and focal, lacking the characteristic H pattern of stress or insufficiency fractures. ***Bone marrow edema*** - Bone marrow edema is a generalized finding on STIR, indicating pathology such as trauma, infection, tumor infiltration, or avascular necrosis (AVN). - While the H sign is a type of bone marrow edema pattern, the sign itself is specific to a **sacral insufficiency fracture**, not a general edema observation.
Question 44: Identify the investigation modality shown in the image.
- A. X-ray defecogram (Correct Answer)
- B. Barium swallow
- C. MR defecogram
- D. X-ray barium enema
Explanation: ***X-ray defecogram*** - This is a dynamic fluoroscopic study, also known as **evacuation proctography**, which visualizes the rectum and anal canal during the act of defecation. - The images show contrast material within the rectum and its expulsion, allowing for the assessment of anorectal angle, pelvic floor descent, and identification of pathologies like **rectocele**, **enterocele**, or **intussusception**. *Barium swallow* - A barium swallow is a radiographic study used to examine the **upper gastrointestinal tract**, specifically the pharynx, esophagus, and stomach. - The image clearly depicts the pelvic anatomy and rectum, not the upper GI tract. *MR defecogram* - While also a dynamic study of defecation, an MR defecogram utilizes **magnetic resonance imaging (MRI)**, which provides superior soft-tissue contrast and does not use ionizing radiation. - The image shown is a plain radiograph (X-ray), which has a different appearance compared to an MRI scan. *X-ray barium enema* - A barium enema is used to visualize the anatomy of the **entire large intestine** to detect structural abnormalities like polyps, tumors, or diverticula. - It is typically a static study of the colon's morphology, whereas a defecogram is a functional study focused on the dynamics of evacuation.