INI-CET 2026 Practice Questions

Q: A patient presents to the emergency room with breathlessness. Cardiac causes are suspected but need to be differentiated from obstructive lung disease. Which of the following features is more characteristic of heart failure?

Air hunger. ***Air hunger*** - Air hunger, often described as a sensation of suffocation or inability to get enough air, is a classic, though non-specific, symptom commonly associated with heart failure and elevated pulmonary venous pressure. - Unlike the mechanical obstruction felt in lung diseases, air hunger in cardiac patients typically results from pulmonary congestion and the stimulation of J receptors in the lungs. *Chest tightness* - Chest tightness is a hallmark symptom of myocardial ischemia (angina) or severe bronchoconstriction seen in asthma/COPD. - While it can be associated with cardiac ischemia, it is not a specific descriptor for the symptom of breathlessness compared to obstructive lung disease. *Not able to take deep breath* - This description, often termed 'sighing dyspnea' or perception of restricted chest expansion, is frequently associated with anxiety or restrictive lung diseases. - It is less specific to the hemodynamically driven pulmonary congestion seen in chronic heart failure. *Intermittent wheezing* - Intermittent wheezing is a primary manifestation of obstructive airway diseases such as asthma or COPD, where airflow is obstructed. - 'Cardiac asthma' is a presentation of heart failure involving wheezing, but it is less characteristic and typically presents with other signs like orthopnea or PND rather than being a standalone differentiating feature.

Q: Which of the following is least likely to be considered a major independent risk factor for falls in the elderly?

Hearing impairment. ***Hearing impairment*** - While sensory deficits can contribute to balance issues, hearing loss is not considered a primary, major independent risk factor for falls compared to mobility-limiting conditions. - Most clinical screening tools for falls emphasize gait, balance, and strength over auditory function. *Muscle weakness (Sarcopenia)* - This is a **major risk factor** as it directly impairs postural control, gait speed, and the ability to recover from a trip or slip. - Maintenance of **lower extremity strength** is the single most important modifiable physical factor in fall prevention. *Advanced age* - Advancing age is a **strong independent risk factor** due to the cumulative decline in multisensory processing and reflex speed. - Physiological aging leads to a decline in **proprioception** and central processing, which significantly increases fall risk. *Arthritis* - Arthritis is a **major risk factor** because it causes chronic pain, joint stiffness, and limited range of motion, which restrict physical activity. - Impaired joint function often leads to altered gait mechanics and increased instability.

Q: A 35-year-old HIV-positive female on irregular ART presents with headache, confusion, fever, and right-sided weakness. Her CD4 count is 40 cells/mm³. MRI brain shows multiple ring-enhancing lesions in the basal ganglia. What is the most likely diagnosis?

Cerebral toxoplasmosis. ***Cerebral toxoplasmosis*** - This is the most common cause of **multiple ring-enhancing lesions** in HIV-positive patients with CD4 counts < 100 cells/mm³. - The clinical presentation of **fever**, **headache**, and focal neurologic deficits (like the patient's right-sided weakness) often localizing to the **basal ganglia** is classic for this opportunistic infection. *Primary CNS lymphoma* - Typically presents as a **solitary lesion** on MRI rather than multiple lesions, though it can occasionally be multifocal. - It is generally associated with **Epstein-Barr virus (EBV)** DNA detection in the cerebrospinal fluid and often appears as a **periventricular mass**. *Progressive multifocal leukoencephalopathy (PML)* - Caused by the **JC virus**, this condition typically presents with **non-enhancing** white matter lesions on MRI. - It usually leads to progressive cognitive decline, ataxia, and visual disturbances without the **mass effect** or **ring enhancement** seen with abscesses or tumors. *Neurocysticercosis* - Characterized by lesions in varying stages of development, often showing **calcified nodules** or **cysts with scolex** on imaging. - While it can manifest as ring-enhancing lesions, it is a **parasitic infection** (Taenia solium) not specifically linked to the profound immunosuppression and opportunistic profile seen in this HIV-positive case.

Q: A patient on long-term steroid therapy presents with centripetal obesity, buffalo hump, and abdominal striae. Dexamethasone suppression test confirms the diagnosis. What is the next investigation to identify the source?

ACTH level. ***ACTH level*** - Measuring the plasma **ACTH level** is the crucial next step to differentiate between ACTH-dependent (e.g., Cushing's disease, ectopic ACTH syndrome) and ACTH-independent (e.g., adrenal adenoma, exogenous steroid use) causes of **Cushing's syndrome**. - If the ACTH is suppressed (undetectable), it points toward an adrenal source or exogenous steroid administration, whereas high or inappropriately normal levels suggest a pituitary or ectopic source. *CECT adrenal* - A **Contrast-Enhanced CT (CECT)** of the adrenal glands is typically reserved for later stages of the diagnostic algorithm, specifically after biochemical testing has confirmed an ACTH-independent cause. - While it can visualize adrenal masses, it is not the primary discriminatory test for determining the etiology (pathophysiology) of the hypercortisolism. *Non-contrast CT adrenal* - **Non-contrast CT** is generally less sensitive than dedicated adrenal CT protocols for characterizing adrenal lesions, and therefore is not the immediate test of choice. - Similar to CECT, this is an anatomical imaging modality that should only be ordered after the biochemical classification (ACTH-dependent vs. independent) is established. *MRI pituitary gland* - **MRI of the pituitary gland** is the imaging modality of choice for suspected **Cushing's disease** (pituitary adenoma). - This investigation should only be ordered if the biochemical workup confirms an **ACTH-dependent** cause, as imaging early in the diagnostic process can lead to misinterpretation due to incidentalomas.

Q: A 5-year-old child presents with recurrent episodes since age 3, characterized by sudden behavioral arrest, repetitive picking movements of the right hand, and goosebumps. The child is unresponsive during episodes and has no memory of them afterward. Which of the following is correct? 1. Focal seizure with intact awareness 2. Focal seizure with impaired awareness 3. Frontal lobe semiology 4. Temporal lobe semiology

2 and 4. ***2 and 4*** - These episodes manifest as a **focal seizure with impaired awareness** because the patient is unresponsive during the event and lacks subsequent memory of it, which is the defining clinical feature. - The symptoms, specifically **behavioral arrest**, **automatisms** (repetitive picking movements), and **autonomic features** (goosebumps/piloerection), are classic hallmarks of temporal lobe seizures. *1 and 3* - A **focal seizure with intact awareness** implies the patient would be able to report the experience and interact with their surroundings, which is not the case here. - While **frontal lobe seizures** often involve sudden onset and behavioral phenomena, they differ from these findings by typically having a very short duration and hyperkinetic or tonic motor patterns rather than picking automatisms. *2 and 3* - While the description of **impaired awareness** is accurate for this case, the semiology is characteristic of the temporal lobe, not the frontal lobe. - **Frontal lobe seizures** are more commonly associated with nocturnal occurrence, bicycling movements, or sudden vocalization or thrashing, rather than the specific autonomic and automatism-heavy presentation seen here. *1 and 4* - The premise of **intact awareness** is incorrect as the child is clearly stated to be unresponsive during the episodes. - While the localization to the **temporal lobe** is correct, the overall classification of the seizure type must include the fact that consciousness or awareness is impaired during the behavioral arrest.

Q: In which of the following conditions is cyanosis most likely to be a clinical finding?

Eisenmenger syndrome. ***Eisenmenger syndrome*** - This condition represents the late stage of a **left-to-right shunt** where chronic pulmonary hypertension leads to increased pulmonary vascular resistance, causing the shunt to reverse into a **right-to-left shunt**. - The resulting **deoxygenated blood** enters the systemic circulation directly, causing profound, clinically apparent **central cyanosis**. *Atrioventricular septal defect* - In children, this often presents as a **left-to-right shunt** leading to **pulmonary overcirculation** and symptoms of congestive heart failure, rather than cyanosis. - Cyanosis only occurs in this condition if it progresses to the Eisenmenger stage or is associated with complex defects like **Tetralogy of Fallot**. *Partial anomalous pulmonary venous connection* - This is primarily an **acyanotic** congenital heart defect where pulmonary veins drain into systemic veins or the right atrium, leading to **pulmonary overcirculation**. - There is no right-to-left shunting of deoxygenated blood into the systemic circulation, so patients typically do not manifest **cyanosis**. *Advanced aortic stenosis* - This condition causes **left ventricular outflow tract obstruction**, leading to symptoms like **syncope, angina, and dyspnea** due to low cardiac output. - While patients may appear pale or gray due to **hypoperfusion**, they do not develop central cyanosis, as the defect is not related to systemic **deoxygenated blood shunting**.

Q: A 38-year-old male presents with sudden onset palpitations. He has no known comorbidities and his vitals are stable. ECG shows an irregularly irregular rhythm with no identifiable P waves and a ventricular rate of 130 beats per minute. What is the most likely diagnosis?

Atrial fibrillation. ***Atrial fibrillation*** - Characterized by an **irregularly irregular rhythm** and the complete absence of **discrete P waves**, which is the hallmark ECG finding. - The atria undergo rapid, chaotic electrical activity, leading to varying ventricular response rates, such as the **130 beats per minute** seen in this patient. *Multifocal atrial tachycardia* - Requires the presence of at least **three distinct P-wave morphologies** on ECG, which contradicts the finding of "no identifiable P waves." - Usually associated with severe **chronic obstructive pulmonary disease (COPD)** rather than isolated idiopathic presentation in healthy individuals. *Atrial flutter* - Typically displays a **regular (or regularly irregular)** rhythm with a classic **'sawtooth'** pattern of atrial activity. - Represents a form of macro-reentrant tachycardia rather than the chaotic, disorganized electrical activity seen in fibrillation. *Supraventricular tachycardia* - Typically presents as a **regular, narrow-complex tachycardia** with a sudden onset and offset. - Unlike the irregular rhythm described, SVT (such as AVNRT) usually maintains a fixed rhythm without the beat-to-beat variability characteristic of atrial fibrillation.

Q: A 45-year-old farmer from Northeast India presents with low-grade fever, progressive weight loss, night sweats, and productive cough. Chest CT reveals upper lobe cavitary lesions. Lung biopsy shows granulomatous inflammation with caseous necrosis and abundant histiocyte infiltration. What is the most likely diagnosis?

Histoplasmosis. ***Histoplasmosis*** - In endemic areas, chronic pulmonary histoplasmosis commonly presents in older adults with pre-existing lung disease, manifesting with symptoms mimicking tuberculosis such as **fever**, **weight loss**, and **productive cough**. - The histopathological finding of **granulomatous inflammation with caseous necrosis** is characteristic of fungal infections, and the specific geography and presentation support a diagnosis of disseminated or chronic pulmonary fungal infection. *Aspergillosis* - Pulmonary aspergillosis, particularly aspergilloma, occurs in pre-existing cavities and typically presents with **hemoptysis** rather than systemic granulomatous disease. - Histopathology would reveal **septate hyphae with acute angle branching**, not the caseous granulomas seen in this patient. *Sarcoidosis* - Sarcoidosis presents with **non-caseating granulomas**, which helps distinguish it from infectious causes like tuberculosis or fungal infections that typically create caseous necrosis. - While it can manifest with cough and weight loss, the classic association with **caseous necrosis** strongly points away from this diagnosis. *Cryptococcosis* - Pulmonary cryptococcosis is often asymptomatic or mild in immunocompetent hosts, and when it does cause disease, it typically presents with **gelatinous pseudocysts** or localized nodules rather than classic upper lobe cavitary lesions. - The causative organism, *Cryptococcus neoformans*, would show **narrow-based budding yeast with thick polysaccharide capsules** on staining, distinct from the histiocytic granulomatous reaction described.

Q: The given disorders are associated with dystonia and basal ganglia involvement. Which one requires a fundamentally different treatment approach than the others?

Wilson disease. ***Wilson disease*** - This is a disorder of **copper metabolism** caused by mutations in the **ATP7B gene**, leading to accumulation of copper in the liver and basal ganglia. - The treatment is fundamentally different from the others, requiring **chelating agents** (e.g., penicillamine, trientine) or **zinc therapy** to lower copper levels, rather than focusing solely on symptom management for dystonia. *PKAN (Pantothenate kinase-associated neurodegeneration)* - This is a type of **NBIA (Neurodegeneration with Brain Iron Accumulation)** disorder caused by PANK2 gene mutations. - Treatment is primarily supportive; while **pantothenate supplementation** or iron chelation (like deferiprone) are sometimes investigated, they do not reverse the metabolic defect as definitively as specific therapy does in Wilson disease. *PLAN (PLA2G6-associated neurodegeneration)* - Also classified under **NBIA disorders**, characterized by dystonia, parkinsonism, and cognitive decline. - As with other neurodegenerative storage disorders, there is no curative, disease-altering therapy; management is purely **symptomatic** (e.g., baclofen, botulinum toxin for dystonia). *Dopa-responsive dystonia* - Caused by a defect in **dopamine synthesis** (typically GCH1 mutation), it is characterized by diurnal fluctuation of symptoms. - It is unique because it shows a dramatic and sustained response to **low-dose levodopa/carbidopa**, which serves as both the diagnostic test and the definitive treatment.

Q: What causes the resting tremors in Parkinson's disease?

Excitation of globus interna. ***Excitation of globus interna*** - In **Parkinson's disease**, the loss of dopaminergic neurons in the **substantia nigra pars compacta** removes the inhibitory influence on the **indirect pathway**. - This leads to increased activity of the subthalamic nucleus, which subsequently results in excessive **excitation of the globus pallidus internus (GPi)**, contributing to the characteristic parkinsonian tremor. *Loss of inhibition of globus externa* - The **globus pallidus externus (GPe)** is normally inhibited by the **striatum** via dopamine-D2 receptors. - While pathology in Parkinson's affects the entire basal ganglia circuit, the specific driver of the resting tremor is the excessive output from the GPi, not a primary failure of GPe inhibition. *Loss of inhibition of globus interna* - This describes a state that would actually reduce the output of the **basal ganglia**, potentially leading to hyperkinetic movements rather than the hypokinetic state seen in Parkinson's. - The GPi is the main **output nucleus** of the basal ganglia, and in Parkinson's, its activity is pathologically increased, not decreased. *Excitation of globus externa* - The **globus pallidus externus** is typically inhibited rather than excited in the pathological circuit of Parkinson's disease due to overactivity of the indirect pathway. - Increased activity of the GPe would inhibit the **subthalamic nucleus**, which contradicts the mechanism of increased GPi output that drives tremor and bradykinesia.

Question 1

A patient presents to the emergency room with breathlessness. Cardiac causes are suspected
but need to be differentiated from obstructive lung disease. Which of the following features is more
characteristic of heart failure?

Accepted Answer

Air hunger

Answer

Chest tightness

Answer

Not able to take deep breath

Answer

Intermittent wheezing

Question 2

Which of the following is least likely to be considered a major independent risk factor for falls in
the elderly?

Accepted Answer

Hearing impairment

Answer

Muscle weakness (Sarcopenia)

Answer

Advanced age

Answer

Arthritis

Question 3

A 35-year-old HIV-positive female on irregular ART presents with headache, confusion, fever, and
right-sided weakness. Her CD4 count is 40 cells/mm³. MRI brain shows multiple ring-enhancing
lesions in the basal ganglia. What is the most likely diagnosis?

Accepted Answer

Cerebral toxoplasmosis

Answer

Primary CNS lymphoma

Answer

Progressive multifocal leukoencephalopathy (PML)

Answer

Neurocysticercosis

Question 4

A patient on long-term steroid therapy presents with centripetal obesity, buffalo hump, and
abdominal striae. Dexamethasone suppression test confirms the diagnosis. What is the next
investigation to identify the source?

Accepted Answer

ACTH level

Answer

CECT adrenal

Answer

Non-contrast CT adrenal

Answer

MRI pituitary gland

Question 5

A 5-year-old child presents with recurrent episodes since age 3, characterized by sudden
behavioral arrest, repetitive picking movements of the right hand, and goosebumps. The child is
unresponsive during episodes and has no memory of them afterward. Which of the following is
correct?
1. Focal seizure with intact awareness
2. Focal seizure with impaired awareness
3. Frontal lobe semiology
4. Temporal lobe semiology

Accepted Answer

2 and 4

Answer

1 and 3

Answer

2 and 3

Answer

1 and 4

Question 6

In which of the following conditions is cyanosis most likely to be a clinical finding?

Accepted Answer

Eisenmenger syndrome

Answer

Atrioventricular septal defect

Answer

Partial anomalous pulmonary venous connection

Answer

Advanced aortic stenosis

Question 7

A 38-year-old male presents with sudden onset palpitations. He has no known comorbidities and
his vitals are stable. ECG shows an irregularly irregular rhythm with no identifiable P waves and a
ventricular rate of 130 beats per minute. What is the most likely diagnosis?

Accepted Answer

Atrial fibrillation

Answer

Multifocal atrial tachycardia

Answer

Atrial flutter

Answer

Supraventricular tachycardia

Question 8

A 45-year-old farmer from Northeast India presents with low-grade fever, progressive weight
loss, night sweats, and productive cough. Chest CT reveals upper lobe cavitary lesions. Lung
biopsy shows granulomatous inflammation with caseous necrosis and abundant histiocyte
infiltration. What is the most likely diagnosis?

Accepted Answer

Histoplasmosis

Answer

Aspergillosis

Answer

Sarcoidosis

Answer

Cryptococcosis

Question 9

The given disorders are associated with dystonia and basal ganglia involvement. Which one
requires a fundamentally different treatment approach than the others?

Accepted Answer

Wilson disease

Answer

PKAN (Pantothenate kinase-associated neurodegeneration)

Answer

PLAN (PLA2G6-associated neurodegeneration)

Answer

Dopa-responsive dystonia

Question 10

What causes the resting tremors in Parkinson's disease?

Accepted Answer

Excitation of globus interna

Answer

Loss of inhibition of globus externa

Answer

Loss of inhibition of globus interna

Answer

Excitation of globus externa

INI-CET 2026

Internal Medicine