INI-CET 2025 Practice Questions

Q: A patient presents with painful ulcer in the mouth and a past history of recurrent vesicular lesions in the genitalia. Bedside test findings are shown. What is the most appropriate drug for management?

Acyclovir. ***Correct: Acyclovir*** - The clinical history of recurrent painful oral and genital vesicular lesions, combined with the **Tzanck smear** finding of **multinucleated giant cells** (as shown in the image), is classic for **Herpes Simplex Virus (HSV)** infection. - **Acyclovir** is a guanosine analog antiviral drug that inhibits viral DNA polymerase, making it the first-line treatment for HSV and Varicella-Zoster Virus (VZV) infections. *Incorrect: Penicillin* - **Penicillin** is an antibiotic used to treat bacterial infections, most notably **syphilis**, which is caused by the spirochete *Treponema pallidum*. - Syphilis typically presents with a single, **painless chancre**, not recurrent painful vesicles, and penicillin has no efficacy against viral pathogens like HSV. *Incorrect: Ceftriaxone* - **Ceftriaxone** is a third-generation cephalosporin antibiotic, primarily used for bacterial infections such as **gonorrhea** and meningitis. - It is ineffective for treating viral infections, and the clinical presentation does not align with the purulent discharge characteristic of gonorrhea. *Incorrect: Azithromycin* - **Azithromycin** is a macrolide antibiotic effective against bacteria that can cause genital ulcers, such as **Haemophilus ducreyi** (causing **Chancroid**) and *Chlamydia trachomatis*. - While Chancroid causes painful ulcers, it does not typically present with a vesicular stage or the recurrent pattern seen in this case, nor would it show multinucleated giant cells on a smear.

Q: A patient with asymptomatic annular skin lesion as shown presents to OPD. Which investigation should be done?

KOH mount. ***KOH mount*** - The image displays a classic **annular (ring-shaped) lesion** with a raised, erythematous, and scaly border with central clearing, which is pathognomonic for **Tinea corporis** (ringworm). - A **KOH mount** is the gold standard, rapid, and cost-effective diagnostic test for dermatophytosis, allowing visualization of **septate hyphae** from skin scrapings. ***HIV testing*** - While widespread or severe fungal infections can be associated with **immunocompromised states** like HIV, it is not the initial diagnostic step for a localized lesion. - This test would be considered only if the infection is unusually persistent, recurrent, or if there are other systemic signs suggesting immunosuppression. ***Biopsy*** - A **skin biopsy** is an invasive procedure and is not the first-line investigation for a typical presentation of tinea corporis. - It is reserved for atypical cases or when the diagnosis is uncertain after non-invasive tests, to rule out other annular dermatoses like **granuloma annulare** or **psoriasis**. ***Chest X-ray*** - A **Chest X-ray** is indicated for evaluating cardiopulmonary conditions and has no diagnostic value for a cutaneous fungal infection. - This investigation is entirely unrelated to the patient's presenting skin lesion.

Q: In an infant with scabies, what is the preferred treatment?

1, 3, 4 (Permethrin, Benzyl benzoate, Crotamiton). ***Correct: 1, 3, 4 (Permethrin, Benzyl benzoate, Crotamiton)*** - **Permethrin 5% cream** is the **first-line treatment** for scabies in infants and children over 2 months of age due to its high efficacy (>90%) and excellent safety profile - **Benzyl benzoate (10-25% emulsion)** is a safe and effective alternative topical agent, particularly useful in resource-limited settings or when permethrin is unavailable - **Crotamiton 10% cream** is another alternative topical treatment option, though it has lower efficacy compared to permethrin - All three agents are **safe for topical use in infants** and represent appropriate treatment choices *Incorrect: 2, 4 (Ivermectin, Crotamiton)* - This option excludes **permethrin**, the first-line and most effective treatment for infant scabies - **Ivermectin is contraindicated in infants** as it is generally reserved for children over 5 years old or weighing more than 15 kg - Relying on ivermectin and crotamiton alone is not standard practice for routine infant scabies *Incorrect: 1, 2, 3 (Permethrin, Ivermectin, Benzyl benzoate)* - While this includes the first-line agent **permethrin** and the alternative **benzyl benzoate**, it incorrectly includes **ivermectin** - **Ivermectin is not recommended for routine use in infants** due to safety concerns in children under 15 kg or under 5 years of age - Ivermectin is reserved for special circumstances such as crusted scabies, treatment failures, or institutional outbreaks in older children *Incorrect: 1, 2, 4 (Permethrin, Ivermectin, Crotamiton)* - Although this includes the first-line treatment **permethrin** and alternative **crotamiton**, it inappropriately includes **ivermectin** - **Ivermectin is not standard therapy for infant scabies** and should not be routinely used in this age group - The combination with ivermectin makes this a non-preferred choice for general infant scabies management

Q: Which of the following about lumbar puncture is incorrect?

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

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

Noradrenaline. ***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.

Q: For benzodiazepines and barbiturates, which of the following is true?

Both have effect on GABA-A chloride channel. ***Both have effect on GABA-A chloride channel*** Both benzodiazepines and barbiturates act as **positive allosteric modulators** of the **GABA-A receptor**, a **ligand-gated chloride channel**, leading to increased frequency (BZDs) or duration (Barbiturates) of channel opening [1]. This enhancement of the inhibitory neurotransmitter GABA results in **CNS depression**, which is the basis for their anxiolytic, sedative, and hypnotic effects [1].***Flumazenil is the antidote for barbiturate*** **Flumazenil** is a competitive antagonist used specifically to reverse the effects of **benzodiazepines** by blocking their binding site on the GABA-A receptor [1]. There is **no specific pharmacological antidote** for barbiturate overdose; management involves supportive care like airway protection and respiratory support.***Cause additive sedation with alcohol*** Although both drugs cause severe **synergistic CNS depression** when combined with alcohol, this is a property shared by many CNS depressants, not unique to this pair, whereas their shared molecular target (D) is a fundamental defining characteristic. The combination of either BZDs or barbiturates with ethanol significantly **potentiates sedation** and increases the risk of respiratory depression and coma.***Thiopentone has short duration of action due to metabolism*** The ultra-short action of **thiopentone** following a single intravenous dose is primarily due to rapid **redistribution** out of the brain into highly perfused tissues (muscle and fat) since it is highly lipid-soluble [1, 2]. While it is eventually metabolized by the liver, **hepatic metabolism** is not the factor responsible for the swift onset and termination of its hypnotic effect [1].

Q: A male patient with a history of MSM presents with urethral discharge. There is penicillin resistance on testing. Which drug should be given?

Ceftriaxone. ***Ceftriaxone*** - **Ceftriaxone** (a third-generation cephalosporin) is the current primary treatment for uncomplicated **gonorrhea**, especially due to rising penicillin and fluoroquinolone resistance globally. - Given the patient's presentation (urethral discharge in an **MSM** patient) strongly suggesting gonorrhea, and documented **penicillin resistance**, ceftriaxone remains the drug of choice. *Amoxiclav* - **Amoxicillin/clavulanic acid** (Amoxiclav) is ineffective for the treatment of *Neisseria gonorrhoeae* due to widespread $\beta$-lactamase production and insufficient coverage against resistant strains. - It is more commonly used for community-acquired respiratory tract infections or skin infections. *Tetracycline* - **Tetracyclines** (like doxycycline) are the preferred treatment for co-occurring **Chlamydia trachomatis** infection, but are not the primary single agent for resistant gonococcal infection. - Although historically used, tetracyclines have limited efficacy against many contemporary **gonococcal strains** and are not recommended as monotherapy for resistant gonorrhea. *Vancomycin* - **Vancomycin** is a glycopeptide antibiotic primarily used for serious infections caused by **Gram-positive** bacteria, particularly **MRSA** and *Clostridium difficile*. - It has no meaningful role or efficacy in treating **Gram-negative** infections like **gonorrhea**.

Q: What is the most useful investigation for localization of a parathyroid adenoma?

Sestamibi scan. ***Sestamibi scan*** - **Sestamibi scan (Tc-99m MIBI)** is the **gold standard** for preoperative localization of parathyroid adenomas, with a sensitivity of 80-95% when combined with SPECT. - The radiotracer is taken up by both thyroid and parathyroid tissue, but is **retained longer in the hyperfunctioning parathyroid adenoma**, allowing for differential washout imaging. - Can be enhanced with **SPECT/CT** for better anatomical localization, especially for ectopic glands. *USG* - **Ultrasound (USG)** is a useful anatomical localization tool, particularly for glands in typical locations, but its sensitivity (70-80%) is operator-dependent and limited by gland size/location. - Often used as a **complementary first-line investigation** alongside Sestamibi, especially for guiding needle aspiration or confirming location. - Less sensitive for ectopic or small adenomas compared to Sestamibi. *FDG PET* - **Fluorodeoxyglucose (FDG) PET** is generally not the primary investigation for typical parathyroid adenomas as they do not show intense FDG avidity. - Its use is reserved primarily for **parathyroid carcinoma** localization or in cases where other modalities have failed. - **C-11 Methionine PET** or **F-18 Choline PET** are specialized functional scans with better utility for adenomas than FDG PET, but are less commonly available than Sestamibi. *SPECT* - **SPECT (Single-Photon Emission Computed Tomography)** is an imaging technique that **enhances Sestamibi scan** anatomical resolution (Sestamibi-SPECT or SPECT/CT), especially for small or ectopic adenomas. - SPECT alone without a radiotracer like Sestamibi is not useful; it is the **combination of Sestamibi tracer with SPECT imaging** that provides superior localization. - The option likely refers to this combined modality, but Sestamibi scan (with or without SPECT) remains the most useful overall investigation.

Q: A child presents with seizures. Contrast-enhanced CT reveals a cystic lesion with a dot sign. What is the most likely diagnosis?

Neurocysticercosis. **Neurocysticercosis (Correct Answer)** - This is the most common parasitic infection of the central nervous system, caused by the larval stage of the pork tapeworm, *Taenia solium* - The contrast-enhanced CT shows a cystic lesion with an eccentric hyperdense focus, which is the **pathognomonic "hole-with-dot" sign**, representing the scolex within the cyst - This imaging finding is highly specific for neurocysticercosis and is commonly seen in endemic areas *Tuberculoma (Incorrect)* - Tuberculomas typically present as single or multiple ring-enhancing lesions, often with a central nidus of calcification, known as the **"target sign"** - They are usually associated with significant vasogenic edema and are more common in patients with a history of tuberculosis or immunosuppression - The "dot sign" is not characteristic of tuberculomas *Brain abscess (Incorrect)* - A brain abscess appears as a well-defined, smooth, ring-enhancing lesion with a central area of necrosis and is typically surrounded by marked vasogenic edema - Clinically, patients often present with fever, headache, and focal neurological deficits - The pathognomonic scolex ("dot sign") is absent in brain abscesses *Cerebral metastasis (Incorrect)* - Metastases typically appear as multiple solid or ring-enhancing lesions located at the gray-white matter junction, often with edema out of proportion to the lesion size - While they can be cystic, the "hole-with-dot" sign is not a feature - Cerebral metastases are less common in children compared to adults with a known primary malignancy

Question 1

A patient presents with painful ulcer in the mouth and a past history of recurrent vesicular lesions in the genitalia. Bedside test findings are shown. What is the most appropriate drug for management?

Accepted Answer

Acyclovir

Answer

Ceftriaxone

Answer

Azithromycin

Answer

Penicillin

Question 2

A patient with asymptomatic annular skin lesion as shown presents to OPD. Which investigation should be done?

Accepted Answer

KOH mount

Answer

Biopsy

Answer

Chest X-ray

Answer

HIV testing

Question 3

In an infant with scabies, what is the preferred treatment?

Accepted Answer

1, 3, 4 (Permethrin, Benzyl benzoate, Crotamiton)

Answer

1, 2, 4 (Permethrin, Ivermectin, Crotamiton)

Answer

1, 2, 3 (Permethrin, Ivermectin, Benzyl benzoate)

Answer

2, 4 (Ivermectin, Crotamiton)

Question 4

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 5

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 6

For benzodiazepines and barbiturates, which of the following is true?

Accepted Answer

Both have effect on GABA-A chloride channel

Answer

Flumazenil is the antidote for barbiturate

Answer

Cause additive sedation with alcohol

Answer

Thiopentone has short duration of action due to metabolism

Question 7

A male patient with a history of MSM presents with urethral discharge. There is penicillin resistance on testing. Which drug should be given?

Accepted Answer

Ceftriaxone

Answer

Amoxiclav

Answer

Tetracycline

Answer

Vancomycin

Question 8

What is the most useful investigation for localization of a parathyroid adenoma?

Accepted Answer

Sestamibi scan

Answer

USG

Answer

FDG PET

Answer

SPECT

Question 9

A child presents with seizures. Contrast-enhanced CT reveals a cystic lesion with a dot sign. What is the most likely diagnosis?

Accepted Answer

Neurocysticercosis

Answer

Tuberculoma

Answer

Brain abscess

Answer

Cerebral metastasis

Question 10

A 35-year-old patient presents with colicky pain and is diagnosed with a ureteric stone. Which of the following is the best diagnostic investigation in this case?

Accepted Answer

Non-contrast CT KUB

Answer

Ureteroscopy

Answer

Ultrasonography KUB

Answer

Contrast-enhanced CT KUB

INI-CET 2025

Dermatology

Internal Medicine

Pharmacology

Radiology

Surgery