Dermatology
3 questionsA 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?
A patient with asymptomatic annular skin lesion as shown presents to OPD. Which investigation should be done?
In an infant with scabies, what is the preferred treatment?
INI-CET 2025 - Dermatology INI-CET Practice Questions and MCQs
Question 51: 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?
- A. Ceftriaxone
- B. Azithromycin
- C. Penicillin
- D. Acyclovir (Correct Answer)
Explanation: ***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.
Question 52: A patient with asymptomatic annular skin lesion as shown presents to OPD. Which investigation should be done?
- A. Biopsy
- B. Chest X-ray
- C. HIV testing
- D. KOH mount (Correct Answer)
Explanation: ***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.
Question 53: In an infant with scabies, what is the preferred treatment?
- A. 1, 3, 4 (Permethrin, Benzyl benzoate, Crotamiton) (Correct Answer)
- B. 1, 2, 4 (Permethrin, Ivermectin, Crotamiton)
- C. 1, 2, 3 (Permethrin, Ivermectin, Benzyl benzoate)
- D. 2, 4 (Ivermectin, Crotamiton)
Explanation: ***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
Internal Medicine
2 questionsWhich 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?
INI-CET 2025 - Internal Medicine INI-CET Practice Questions and MCQs
Question 51: 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 52: 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.
Pharmacology
2 questionsFor benzodiazepines and barbiturates, which of the following is true?
A male patient with a history of MSM presents with urethral discharge. There is penicillin resistance on testing. Which drug should be given?
INI-CET 2025 - Pharmacology INI-CET Practice Questions and MCQs
Question 51: For benzodiazepines and barbiturates, which of the following is true?
- A. Flumazenil is the antidote for barbiturate
- B. Cause additive sedation with alcohol
- C. Thiopentone has short duration of action due to metabolism
- D. Both have effect on GABA-A chloride channel (Correct Answer)
Explanation: ***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].
Question 52: A male patient with a history of MSM presents with urethral discharge. There is penicillin resistance on testing. Which drug should be given?
- A. Ceftriaxone (Correct Answer)
- B. Amoxiclav
- C. Tetracycline
- D. Vancomycin
Explanation: ***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**.
Radiology
2 questionsWhat is the most useful investigation for localization of a parathyroid adenoma?
A child presents with seizures. Contrast-enhanced CT reveals a cystic lesion with a dot sign. What is the most likely diagnosis?
INI-CET 2025 - Radiology INI-CET Practice Questions and MCQs
Question 51: What is the most useful investigation for localization of a parathyroid adenoma?
- A. Sestamibi scan (Correct Answer)
- B. USG
- C. FDG PET
- D. SPECT
Explanation: ***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.
Question 52: A child presents with seizures. Contrast-enhanced CT reveals a cystic lesion with a dot sign. What is the most likely diagnosis?
- A. Tuberculoma
- B. Neurocysticercosis (Correct Answer)
- C. Brain abscess
- D. Cerebral metastasis
Explanation: **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
Surgery
1 questionsA 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?
INI-CET 2025 - Surgery INI-CET Practice Questions and MCQs
Question 51: 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?
- A. Ureteroscopy
- B. Non-contrast CT KUB (Correct Answer)
- C. Ultrasonography KUB
- D. Contrast-enhanced CT KUB
Explanation: ***Correct: Non-contrast CT KUB*** - It is currently the **gold standard** imaging modality for diagnosing acute **urolithiasis** (renal or ureteral stones) due to its superior sensitivity and specificity for detecting calculi. - NCCT KUB detects virtually all stone compositions (including radiolucent **uric acid stones**) and accurately determines their size, location, and secondary signs like **hydronephrosis**. *Incorrect: Ultrasonography KUB* - While useful for detecting **hydronephrosis** and large stones, USG has low sensitivity for smaller calculi, particularly those located in the **mid-ureter**. - It is often reserved for initial screening or cases where **radiation avoidance** is necessary, such as in pregnant patients or children. *Incorrect: Contrast-enhanced CT KUB* - The use of intravenous **contrast material** is unnecessary for diagnosing simple stones and can potentially obscure the visualization of small stone margins, making it less ideal than NCCT. - CECT is typically reserved for evaluating complex cases, such as suspected **pyelonephritis**, collecting system injury, or other non-calculous causes of obstruction. *Incorrect: Ureteroscopy* - Ureteroscopy is primarily a minimally invasive **therapeutic/surgical procedure** used for stone fragmentation and removal, not the default initial non-invasive diagnostic imaging tool. - Although it can confirm the presence of stones, it is invasive and should follow thorough non-invasive imaging like NCCT KUB to plan treatment effectively.