INI-CET 2025

202 Questions — Page 9 of 21

All (202)Anatomy (16)Anesthesiology (3)Biochemistry (10)Community Medicine (18)Dermatology (5)ENT (5)Forensic Medicine (8)Internal Medicine (31)Microbiology (11)Obstetrics and Gynecology (5)Ophthalmology (10)Orthopaedics (4)Pathology (8)Pediatrics (14)Pharmacology (17)Physiology (11)Psychiatry (5)Radiology (8)Surgery (13)

Internal Medicine

2 questions

Q81

Which of the following is wrongly matched with its classification?

Q82

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

INI-CET 2025 - Internal Medicine INI-CET Practice Questions and MCQs

Question 81: Which of the following is wrongly matched with its classification?

A. Boston classification - Colon preparation for colonoscopy
B. Mannheim classification - Chronic pancreatitis
C. Miami classification - Parathyroid adenoma and hyperplasia differentiation
D. LA classification - Achalasia (Correct Answer)

Explanation: ***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.

Question 82: What is the cause of hyponatremia in diarrhea-induced hypovolemia?

A. Decreased aldosterone (Correct Answer)
B. Decreased ADH
C. Decreased sodium absorption from gastrointestinal tract
D. Increased sodium absorption from kidney

Explanation: ***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.

Microbiology

1 questions

Q81

A white patch is observed in the oral cavity of an immunocompromised patient. Which of the following findings is most likely on microscopy?

Surgery

7 questions

Q81

Identify the procedure shown in the image.

Q82

Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?

Q83

Which of the following is not a contraindication for breast conservation surgery?

Q84

Which of the following is not included in T4b classification of breast cancer?

Q85

A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?

Q86

A 40-year-old male with head injury presents with respiratory distress and absent breath sounds on the right. GCS is 8/15. What is the most immediate next step in management?

Q87

A 65-year-old patient undergoes colonoscopy for altered bowel habits. A 6 cm colonic mass is biopsied and histopathology shows adenocarcinoma confined to the mucosa with no lymph node or distant metastasis. What is the most appropriate TNM stage of this tumor?

INI-CET 2025 - Surgery INI-CET Practice Questions and MCQs

Question 81: Identify the procedure shown in the image.

A. Dog ear excision (Correct Answer)
B. Keloid excision
C. Z plasty
D. Transposition flap

Explanation: ***Dog ear excision*** - The image illustrates the surgical correction of a **"dog ear" deformity**, which is a pucker of redundant skin and fat that can form at the end of a linear wound closure. - The technique shown involves excising a triangle of excess skin and subcuticular tissue to flatten the closure and improve the cosmetic outcome, which is characteristic of this procedure. *Keloid excision* - A **keloid** is a type of raised scar that grows beyond the boundaries of the original wound. Excision of a keloid involves removing pathologic scar tissue, not correcting a pucker of normal skin. - Keloid management often requires adjuvant therapies like **intralesional steroids** or **radiation** to prevent recurrence, which is not part of the simple excision shown. *Z plasty* - A **Z-plasty** is a scar revision technique used to lengthen a contracted scar or reorient it along natural skin lines. It involves creating and transposing two triangular flaps in a 'Z' shape. - The procedure in the image does not involve the characteristic **'Z'-shaped incisions** or the transposition of flaps seen in a Z-plasty. *Transposition flap* - A **transposition flap** is a surgical technique where a segment of skin and underlying tissue is moved from a donor site to cover an adjacent defect, while remaining attached to its original blood supply. - The image shows removal of excess tissue at the site of a primary closure, not the transfer of tissue to cover a separate wound.

Question 82: Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?

A. 0.3 (Correct Answer)
B. 0.9
C. 0.7
D. 0.5

Explanation: ***Correct: 0.3*** - An ABPI value of ≤ **0.4** is indicative of **severe peripheral artery disease (PAD)**, which is associated with critical limb ischemia (CLI). - **Critical Limb Ischemia (CLI)** is defined as ABI < **0.4** or toe pressure < 30 mmHg, which corresponds to severe compromise in blood flow, often leading to **imminent gangrene** or rest pain. *Incorrect: 0.5* - An ABPI of **0.5** to **0.9** indicates **moderate PAD**. At this stage, patients typically experience **intermittent claudication** during exertion, but not imminent rest pain or tissue loss. - While significant, it does not represent the severe flow reduction required for *imminent* tissue necrosis like gangrene. *Incorrect: 0.7* - An ABPI of **0.7** falls within the range of **mild to moderate PAD** (0.5–0.9), where symptoms are usually limited to claudication. - This value indicates only moderate compromise in blood supply, far above the threshold for **critical limb ischemia**. *Incorrect: 0.9* - An ABPI of **0.9** to **1.3** is considered **normal** or almost normal. Values below 0.9 signify the presence of PAD. - This level of blood flow provides adequate perfusion and certainly poses **no risk of gangrene**.

Question 83: Which of the following is not a contraindication for breast conservation surgery?

A. Scleroderma
B. History of radiation
C. Multiple cancer in one quadrant (Correct Answer)
D. Persistent positive margin

Explanation: ***Multiple cancer in one quadrant*** - This presentation is defined as **multifocal carcinoma**, where multiple tumor foci are located within the same quadrant of the breast. - Unlike true multicentric disease (carcinoma in two or more quadrants), multifocal disease is **not an absolute contraindication** for breast conservation surgery (BCS), provided all lesions can be excised with clear margins and the planned cosmetic result is acceptable. ***Scleroderma*** - Active connective tissue disorders like **scleroderma** or active **Systemic Lupus Erythematosus (SLE)** are absolute contraindications for BCS due to a high risk of adverse reactions to post-operative radiotherapy. - Radiation in these patients can lead to severe complications, including high rates of **fibrosis**, edema, and poor cosmetic outcomes. ***History of radiation*** - A **previous history of therapeutic radiation** to the breast or chest wall (e.g., for Hodgkin's lymphoma or previous breast cancer) is an absolute contraindication. - Re-irradiating the same tissue increases the risk of severe cumulative dose toxicity, local complications, and potentially **radiation-induced malignancy**. ***Persistent positive margin*** - The inability to achieve tumor-free margins of excision, even after **multiple re-excisions** (usually 2-3 attempts), remains an absolute contraindication to BCS. - Performing BCS despite persistently positive margins results in an unacceptably high risk of local recurrence, necessitating a complete **mastectomy**.

Question 84: Which of the following is not included in T4b classification of breast cancer?

A. Satellite nodule
B. Ulceration
C. Peau d'orange
D. Cellulitis/erythema over one-third of the breast (inflammatory breast cancer) (Correct Answer)

Explanation: ***Cellulitis/erythema over one-third of the breast (inflammatory breast cancer)*** - This description corresponds to a **T4d** tumor, which is classified as **Inflammatory Breast Cancer (IBC)**. - IBC is a separate classification from T4b and is characterized by erythema, edema, and peau d'orange involving at least one-third of the breast, often with rapid onset. - T4d is **not included in T4b classification**; it is a distinct category within T4 tumors. *Incorrect: Satellite nodule* - **Satellite skin nodules** are a feature that can be included in **T4b** classification according to AJCC staging. - T4b includes ulceration and/or ipsilateral satellite nodules and/or edema of the skin (including peau d'orange). *Incorrect: Ulceration* - **Skin ulceration** is a specific defining feature of **T4b** tumors. - It represents direct tumor extension causing breakdown of the overlying skin. *Incorrect: Peau d'orange* - **Peau d'orange** (skin edema due to lymphatic obstruction) is a characteristic feature of **T4b** classification. - It gives the skin an orange-peel appearance and indicates locally advanced disease.

Question 85: A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?

A. 6
B. 4
C. 5
D. 7 (Correct Answer)

Explanation: ***7*** - The Alvarado score (MANTRELS) is a clinical scoring system used to diagnose **acute appendicitis** based on symptoms, signs, and laboratory findings. - **Components present in this patient:** - **M**igration of pain (umbilicus → RIF): **1 point** - **A**norexia/Nausea (nausea present): **1 point** - **T**enderness in right iliac fossa: **2 points** - **R**ebound tenderness: **0 points** (not mentioned) - **E**levated temperature (fever): **1 point** - **L**eukocytosis (WBC 14,000 > 10,000/cmm): **2 points** - **S**hift to left (neutrophilia): **0 points** (not provided) - **Total score: 1 + 1 + 2 + 1 + 2 = 7 points** - A score of **7-8 indicates probable appendicitis** and typically warrants surgical intervention or further imaging based on clinical judgment. *4* - A score of 4 suggests **low probability of appendicitis**. - This score indicates that appendicitis is unlikely, warranting observation or alternative diagnosis consideration. *5* - A score of 5 indicates **intermediate/equivocal probability** of appendicitis. - Patients typically require **active observation, serial examinations**, or imaging (ultrasound/CT) for confirmation. *6* - A score of 6 also falls into the **intermediate risk category** with higher suspicion than score 5. - Usually warrants **imaging or close observation** but is lower than the calculated score for this patient.

Question 86: A 40-year-old male with head injury presents with respiratory distress and absent breath sounds on the right. GCS is 8/15. What is the most immediate next step in management?

A. Secure airway (Correct Answer)
B. Contrast-enhanced CT (CECT)
C. Oxygen by nasal prongs
D. Intercostal chest drain (ICD)

Explanation: ***Secure airway*** - In a patient with **head injury** (GCS 8/15) and **respiratory distress**, establishing a definitive, protected airway is the **absolute priority** following **ABC** principles of trauma management. - A GCS of **≤8** is a clear indication for **endotracheal intubation** to prevent aspiration, ensure adequate ventilation, and protect the airway. - While absent breath sounds suggest **pneumothorax**, the absence of hemodynamic instability (hypotension, tachycardia) or other signs of **tension pneumothorax** (JVD, tracheal deviation) suggests this is likely a **simple pneumothorax** rather than tension. - In simple pneumothorax with severe head injury, **airway securement takes precedence** per ATLS guidelines, followed immediately by chest decompression. - **Note:** If clinical signs of **tension pneumothorax** were present (cardiovascular collapse, severe hypotension), immediate needle decompression would take priority even before intubation, as positive pressure ventilation in untreated tension pneumothorax can be fatal. *Incorrect: Intercostal chest drain (ICD)* - While the patient shows signs of **pneumothorax** or **hemothorax** (absent breath sounds on right), and ICD placement is definitely required, it comes *after* securing the airway in this scenario. - The **critical GCS of 8** makes airway protection the immediate priority to prevent aspiration and respiratory arrest. - ICD placement should follow immediately after intubation, as the patient needs both interventions urgently. *Incorrect: Contrast-enhanced CT (CECT)* - Imaging studies are necessary for definitive diagnosis but are **secondary to resuscitation** and addressing immediate life threats. - Transporting an unstable patient with GCS 8 and an unprotected airway to CT scanner is dangerous and violates **ATLS principles**. - **"Treat first, scan later"** is the rule in unstable trauma patients. - CT is performed after airway is secured, breathing is stabilized, and patient is hemodynamically stable. *Incorrect: Oxygen by nasal prongs* - While oxygen supplementation is important, **nasal prongs** provide inadequate oxygenation for a patient in severe respiratory distress with GCS 8. - This passive method does not address the **unprotected airway** or provide adequate ventilation support. - With GCS 8, the patient cannot protect their airway and requires **definitive airway management** (endotracheal intubation), not just supplemental oxygen.

Question 87: A 65-year-old patient undergoes colonoscopy for altered bowel habits. A 6 cm colonic mass is biopsied and histopathology shows adenocarcinoma confined to the mucosa with no lymph node or distant metastasis. What is the most appropriate TNM stage of this tumor?

A. Stage 0 (Correct Answer)
B. Stage II
C. Stage III
D. Stage I

Explanation: ***Stage 0*** - In the TNM staging system for colorectal cancer, a tumor that is **confined to the mucosa** (Carcinoma in situ) is classified as **Tis**. - Stage 0 is specifically defined by the staging combination **Tis, N0, M0**, indicating tumor confined to the mucosa with no nodal involvement (N0) or distant metastasis (M0). *Incorrect: Stage I* - Stage I encompasses tumors that invade the **submucosa (T1)** or the **muscularis propria (T2)**, provided there is no lymph node or distant spread (N0, M0). - Since this tumor is confined only to the mucosa (Tis), it has not met the criteria for T1 or T2 required for Stage I. *Incorrect: Stage II* - Stage II refers to tumors with deeper wall penetration, classified as **T3** (invasion through muscularis propria into subserosa) or **T4** (invasion into adjacent structures or peritoneum). - Although Stage II also requires N0 and M0, the depth of invasion (T3 or T4) far exceeds the mucosal confinement (Tis) seen in this patient. *Incorrect: Stage III* - Stage III is defined by the presence of **regional lymph node metastasis** (N1 or N2), regardless of the depth of the primary tumor (Any T). - The case description explicitly states **no lymph node or distant metastasis**, ruling out any N staging higher than N0.