INI-CET 2025 Practice Questions

Q: A child presents with hepatosplenomegaly & cherry red spots in the eye. He also has developmental regression with normal startle response. Likely enzyme deficiency?

Sphingomyelinase. ***Sphingomyelinase (Correct Answer)*** - The triad of **hepatosplenomegaly**, **developmental regression**, and **cherry red spots** in the eye is the classic presentation of **Type A Niemann-Pick disease (NPD A)**. - **NPD A** is caused by the deficient activity of the lysosomal enzyme **sphingomyelinase**, leading to the accumulation of **sphingomyelin** in the reticuloendothelial system and CNS. - The **normal startle response** is a key distinguishing feature from Tay-Sachs disease. *Hexosaminidase A (Incorrect)* - Deficiency of **Hexosaminidase A** causes **Tay-Sachs disease**, which presents with **cherry red spots** and severe neurodegeneration, but **lacks hepatosplenomegaly**. - The **exaggerated startle response** (hyperacusis) is a classic feature of Tay-Sachs, which is noted as **normal** in this specific clinical presentation—making it a key differentiator. *Arylsulfatase A (Incorrect)* - Deficiency of **Arylsulfatase A** causes **Metachromatic Leukodystrophy (MLD)**, characterized by progressive demyelination and neurological regression. - **MLD** does not typically present with **cherry red spots** or significant **hepatosplenomegaly**. *Glucocerebrosidase (Incorrect)* - Deficiency of **Glucocerebrosidase** causes **Gaucher's disease**, which is characterized by massive **hepatosplenomegaly** and bone crises. - **Gaucher's disease** does **not** typically present with **cherry red spots** or the unique pattern of early neurodegeneration seen here (except for the rare Type 2 form).

Q: According to WHO, which rapid molecular test is recommended as the initial diagnostic investigation for tuberculosis (TB) spine?

CBNAAT. ***CBNAAT*** - The **WHO** strongly recommends **CBNAAT (GeneXpert or Truenat)** as the **initial rapid molecular diagnostic test** for extrapulmonary TB (EPTB), including **TB spine (Pott's disease)**, due to its rapid turnaround time and high sensitivity. - CBNAAT simultaneously detects **Mycobacterium tuberculosis** DNA and identifies resistance to **Rifampicin**, providing critical information for prompt treatment initiation, typically within 2 hours. - This rapid molecular test is preferred over traditional methods for initial diagnosis to enable early treatment decisions. *Incorrect: X-ray* - X-rays are imaging studies useful for detecting features like **vertebral destruction**, **paraspinal shadow**, and collapse leading to **gibbus deformity**, but they are not molecular diagnostic tests. - While X-rays are included in the diagnostic workup, they cannot confirm the presence of the organism or detect drug resistance, which is why they are not the WHO-recommended initial molecular test. *Incorrect: CT scan* - CT scans offer superior visualization of subtle bony changes, extent of destruction, and delineating **paraspinal cold abscesses**, often used for staging and guiding intervention. - Like X-ray, CT is an **imaging modality** that assists in identifying structural changes but is not a molecular diagnostic test and cannot provide microbiological confirmation or drug resistance information. *Incorrect: Culture and sensitivity* - **Culture (e.g., Lowenstein-Jensen, MGIT)** is considered the **gold standard** for definitive diagnosis and comprehensive Drug Susceptibility Testing (DST). - However, culture results are slow (taking 4–8 weeks), which delays crucial management decisions, leading the WHO to prioritize **rapid molecular tests** like CBNAAT for **initial diagnosis** over culture, though culture remains important for comprehensive DST.

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

Atlantoaxial dislocation. ***Atlantoaxial dislocation*** - **Rheumatoid arthritis (RA)** frequently affects the cervical spine, particularly the atlantoaxial joint, leading to **subsidence** of the atlas (C1) on the axis (C2). - **Atlantoaxial dislocation (AAD)** results in **spinal cord compression** (myelopathy) due to narrowing of the spinal canal, presenting as neck pain and neurological signs [1]. ***Osteoarthritis of vertebrae*** - While osteoarthritis causes neck pain, it is not the typical cause of **acute myelopathy** in RA patients. - Osteoarthritis usually affects the **lower cervical spine** and lacks the inflammatory destruction characteristic of RA involvement in the C1-C2 facets [2]. ***C2-C3 intervertebral stenosis*** - Stenosis typically involves the **lower cervical levels** (C5-C7) caused by osteophyte formation or disc disease, which is less common in RA [2]. - The hallmark **RA involvement** causing myelopathy is specifically **atlantoaxial subluxation** (dislocation). ***Disc herniation*** - Disc herniation is a common cause of radiculopathy and sometimes myelopathy in the general population, but it is **not the primary mechanism** of cervical myelopathy in RA. - The major instability and subsequent cord compression in RA patients occur due to **ligamentous laxity** and **pannus-related bone erosion** at the atlantoaxial joint.

Q: What is the most common complication of urinary tract infection (UTI) during pregnancy?

Preterm labor. ***Preterm labor*** - Asymptomatic bacteriuria and symptomatic UTIs (especially **pyelonephritis**) are strongly associated with an increased risk of **preterm labor** and subsequent **preterm delivery**, making it the most common serious complication. - The systemic inflammatory response caused by the infection triggers the release of **prostaglandins** and **cytokines**, which stimulate uterine contractility and lead to cervical changes. *Miscarriage* - While severe infections associated with high fever (like pyelonephritis) *can* increase the risk, miscarriage is primarily a first-trimester event and is a less direct and less common complication of routine UTI than late-pregnancy preterm labor. - The pathogenesis of UTI complications is more focused on the inflammatory pathway that induces uterine irritability rather than primarily affecting early embryonic development. *Chorioamnionitis* - **Chorioamnionitis** (infection of the fetal membranes and amniotic fluid) is a severe complication of ascending infection, but it is less frequently observed than the generalized inflammatory state leading to **preterm labor/delivery**. - This condition is more commonly associated with prolonged rupture of membranes or infections originating from the lower genital tract rather than purely from the urinary tract. *Neonatal mortality* - **Neonatal mortality** is a severe *outcome* or consequence, usually resulting from the preceding complication of **preterm birth** or associated **neonatal sepsis**. - The direct and most common maternal complication that obstetricians aim to prevent by screening and treating UTIs is **preterm labor/delivery**.

Q: Use of magnesium sulfate (MgSO4) in pre-eclampsia has all of the following effects except:

Prevent abruption of placenta. ***Prevent abruption of placenta*** - **Magnesium sulfate (MgSO4)** is primarily a **CNS depressant** (anticonvulsant) and a vasodilator, and its use is not directly associated with preventing **placental abruption**. - Placental abruption is linked to factors like short umbilical cord, trauma, and **severe hypertension**, which MgSO4 does not consistently mitigate. ***Neuroprotection*** - Administered to women at high risk of imminent **preterm birth** (less than 32 weeks), MgSO4 has a proven benefit in reducing the risk of developing **cerebral palsy** in the neonate. - This neuroprotective effect is thought to be mediated by stabilizing the blood-brain barrier and its **antioxidant properties**. ***Decrease seizure incidence*** - MgSO4 is the **drug of choice** for both the prophylaxis and treatment of seizures (eclampsia) in women with **severe pre-eclampsia**. - It works by decreasing **acetylcholine release** at the neuromuscular junction and acting as a central anticonvulsant. ***Prevent preterm labour*** - MgSO4 is a weak **tocolytic agent** and can be used to temporarily suppress uterine contractions in women presenting with threatened **preterm labor**. - Although effective for short-term suppression, it is not the primary tocolytic agent and is most famously used for its **neuroprotective** and anti-seizure properties.

Q: Which of the following does not cause fetal bradycardia?

Maternal fever. ***Maternal fever*** - Maternal fever causes **fetal tachycardia** or fetal heart rate acceleration, as the physiological response to fever is increased metabolism and heart rate. - The resulting fetal tachycardia is often a sign of impending or current **maternal infection** (e.g., chorioamnionitis). *Abruptio placenta* - Associated with acute fetal distress due to placental separation, leading to fetal **hypoxia** and **acidosis**. - Fetal hypoxia triggers a reflex bradycardia (late decelerations with bradycardia) to conserve oxygen and energy. *Meconium passage/staining* - Passage of meconium in utero is often a sign of **fetal distress** or hypoxia during labor. - Severe fetal distress and resultant cerebral hypoxia/acidosis can lead to prolonged or terminal **fetal bradycardia**. - Note: Meconium aspiration syndrome occurs postnatally, but meconium-stained amniotic fluid indicates antecedent fetal compromise. *Fetal head compression* - Leads to a transient increase in **intracranial pressure**, stimulating the **vagus nerve** mediated by the baroreceptors. - This **vagal stimulation** results in a brief, reflex slowdown of the fetal heart rate, known as **early decelerations**.

Q: A labourer falls on an outstretched hand and complains of pain in the anatomical snuff box. Which of the following is the most appropriate next step?

Thumb spica cast and follow-up after 10-14 days. ***Thumb spica cast and follow-up after 10-14 days*** - The combination of a **fall on an outstretched hand (FOOSH)** and pain in the **anatomical snuff box** is highly suggestive of a **scaphoid fracture**, even if initial X-rays are negative. - The most appropriate initial management is immobilization with a **thumb spica cast** (to prevent non-union) and re-evaluation with a repeat X-ray or advanced imaging in **10–14 days**, as the fracture line often becomes visible after bone resorption. ***NSAIDs and discharge*** - Discharging the patient with only NSAIDs is inappropriate as it risks missing a potentially serious injury like an occult scaphoid fracture, which can lead to complications such as **non-union** and **avascular necrosis (AVN)**. - Scaphoid fractures are the most common carpal fracture and require prompt immobilization due to their precarious blood supply. ***MRI of the wrist*** - While MRI is the **most sensitive and specific** imaging modality for diagnosing an occult scaphoid fracture, it is often not the first line of management in resource-limited or non-critical settings due to cost and availability. - Immobilization and delayed X-ray is the standard, cost-effective initial approach, reserving MRI for cases where early definitive diagnosis is surgically important or when repeat X-rays are inconclusive. ***CT scan of the wrist*** - CT scans are excellent for evaluating **complex fractures**, **comminution**, and defining fragment displacement, but they are less sensitive than MRI or bone scan for detecting acute, undisplaced, occult fractures. - CT is typically used pre-operatively to better plan fixation or distinguish between acute and chronic non-union, rather than as the immediate next step for presumed occult scaphoid injury.

Q: What is the preferred treatment for an inter-trochanteric fracture in a 72-year-old female?

Hemiarthroplasty / Dynamic Hip Screw (DHS). ***Hemiarthroplasty / Dynamic Hip Screw (DHS)*** - **DHS** is the standard treatment for stable (Type I and II) inter-trochanteric fractures, providing controlled collapse and compression at the fracture site. - For unstable fractures (Type III and IV), especially in elderly patients with poor bone quality, **Intramedullary (IM) nailing** is often preferred over DHS due to superior biomechanical stability, though the combination option provided suggests the widely applicable stabilization principles for this age group. ***Intramedullary nailing*** - **IM nailing** is generally the preferred choice for unstable inter-trochanteric fractures (e.g., reverse oblique pattern or severe comminution) as it resists varus collapse more effectively than DHS. - While highly effective, it is not the *only* preferred treatment, and DHS remains primary for stable patterns, making the combined option more comprehensive for standard fracture care in the elderly. ***Open Reduction and Internal Fixation (ORIF) with plating*** - ORIF with plate fixation (other than DHS) is rarely used for inter-trochanteric fractures today, as it involves extensive soft tissue stripping and offers inferior biomechanical stability compared to compression screws (DHS) or nails. - This technique is typically reserved for highly unusual fracture patterns or as a salvage procedure, not as the primary 'preferred' method. ***Boot and bar*** - **Traction (boot and bar)** is historical and obsolete for treating hip fractures, including inter-trochanteric fractures. - Modern management mandates operative fixation as soon as the patient is medically optimized to allow early mobilization, reduce pain, and prevent complications like **deep vein thrombosis (DVT)** and pneumonia.

Q: A neonate is found to have multiple hypopigmented macules and ash-leaf spots on Wood's lamp examination. Which of the following is the most likely diagnosis?

Tuberous Sclerosis. ***Tuberous Sclerosis*** - **Ash-leaf spots** (hypopigmented macules shaped like an ash leaf) are the most common cutaneous manifestation of **Tuberous Sclerosis Complex (TSC)** and are best visualized under a **Wood's lamp**. - TSC is an autosomal dominant neurocutaneous disorder characterized by hamartomatous lesions in multiple organs, including the brain (**subependymal giant cell astrocytomas**), kidneys (**angiomyolipomas**), and heart (**rhabdomyomas**). *Sturge-Weber Syndrome* - Characterized by a **port-wine stain** (capillary malformation) typically in the distribution of the ophthalmic branch of the **trigeminal nerve (V1)**. - Associated features include **leptomeningeal angioma** (causing seizures) and ocular abnormalities like **glaucoma**. *Neurofibromatosis Type 1* - The characteristic pigmented lesions are **café-au-lait spots** (uniform, light-brown macules), typically six or more, along with **axillary or inguinal freckling**. - Associated with **Lisch nodules** (iris hamartomas) and **neurofibromas**. *Incontinentia Pigmenti* - A rare X-linked dominant disorder, usually lethal in males, presenting with characteristic skin lesions in phases (vesicular, verrucous, hyperpigmented, and atrophic). - The hyperpigmented phase consists of swirling, marble-cake patterns of brown-gray macules along the **Blaschko lines**, not ash-leaf spots.

Question 1

A child presents with hepatosplenomegaly & cherry red spots in the eye. He also has developmental regression with normal startle response. Likely enzyme deficiency?

Accepted Answer

Sphingomyelinase

Answer

Arylsulfatase A

Answer

Glucocerebrosidase

Answer

Hexosaminidase A

Question 2

According to WHO, which rapid molecular test is recommended as the initial diagnostic investigation for tuberculosis (TB) spine?

Accepted Answer

CBNAAT

Answer

X-ray

Answer

CT scan

Answer

Culture and sensitivity

Question 3

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

Question 4

What is the most common complication of urinary tract infection (UTI) during pregnancy?

Accepted Answer

Preterm labor

Answer

Chorioamnionitis

Answer

Miscarriage

Answer

Neonatal mortality

Question 5

Use of magnesium sulfate (MgSO4) in pre-eclampsia has all of the following effects except:

Accepted Answer

Prevent abruption of placenta

Answer

Prevent preterm labour

Answer

Neuroprotection

Answer

Decrease seizure incidence

Question 6

Which of the following does not cause fetal bradycardia?

Accepted Answer

Maternal fever

Answer

Fetal head compression

Answer

Abruptio placenta

Answer

Meconium passage

Question 7

A labourer falls on an outstretched hand and complains of pain in the anatomical snuff box. Which of the following is the most appropriate next step?

Accepted Answer

Thumb spica cast and follow-up after 10-14 days

Answer

NSAIDs and discharge

Answer

CT scan of the wrist

Answer

MRI of the wrist

Question 8

What is the preferred treatment for an inter-trochanteric fracture in a 72-year-old female?

Accepted Answer

Hemiarthroplasty / Dynamic Hip Screw (DHS)

Answer

Intramedullary nailing

Answer

Open Reduction and Internal Fixation (ORIF) with plating

Answer

Boot and bar

Question 9

A neonate is found to have multiple hypopigmented macules and ash-leaf spots on Wood's lamp examination. Which of the following is the most likely diagnosis?

Accepted Answer

Tuberous Sclerosis

Answer

Sturge-Weber Syndrome

Answer

Neurofibromatosis Type 1

Answer

Incontinentia Pigmenti

Question 10

Which of the following best explains the mechanism of breast milk jaundice?

Accepted Answer

Enhanced enterohepatic circulation due to beta-glucuronidase in breast milk deconjugating bilirubin

Answer

Increased RBC breakdown producing more unconjugated bilirubin

Answer

Reduced intestinal absorption of bilirubin

Answer

Hepatocellular injury by breast milk

INI-CET 2025

Biochemistry

Community Medicine

Internal Medicine

Obstetrics and Gynecology

Orthopaedics

Pediatrics