INI-CET 2017 Practice Questions

Q: A child has a pruritic rash as shown below. His mother is an asthmatic. Comment on the diagnosis:

Atopic dermatitis. ***Atopic dermatitis*** - The image shows a classic presentation of **eczematous rash** in the **flexural areas** (knees), which is characteristic of atopic dermatitis. - The history of a **mother with asthma** suggests an **atopic diathesis**, increasing the likelihood of atopic dermatitis in the child due to its strong genetic component and association with other atopic conditions (asthma, allergic rhinitis). *Seborrheic dermatitis* - Typically presents as **greasy, yellowish scales** on an erythematous base, commonly affecting the scalp, face (eyebrows, nasolabial folds), and chest. - While it can occur in infants ("cradle cap"), its morphology and locations are distinct from the rash seen in the image. *Allergic contact dermatitis* - This rash would typically be localized to areas of direct contact with an **allergen** and would not necessarily show the typical flexural distribution seen in the image. - It often presents with more acute **vesicles, bullae, and intense pruritus** strictly limited to the exposure site. *Erysipelas* - Erysipelas is a **superficial bacterial skin infection** characterized by a **well-demarcated, erythematous, raised, and warm plaque**, often with systemic symptoms like fever and chills. - The rash in the image does not present with the characteristic features of an acute bacterial infection.

Q: A middle-aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? (AIIMS Nov 2017)

Decompressive surgery. ***Decompressive surgery*** - The NCCT image shows a **large, well-demarcated hypodensity in the right cerebral hemisphere**, characteristic of a **subacute to chronic ischemic infarct with significant edema and mass effect**. This is evidenced by the effaced sulci, compressed ventricles on the right, and likely midline shift, causing the patient's **drowsiness** and **left-sided weakness**. - Given the patient's **drowsiness** (indicating rising intracranial pressure) and significant mass effect from the large infarct, **decompressive craniectomy** is often a life-saving measure to reduce intractable intracranial pressure and prevent further herniation in cases of malignant middle cerebral artery (MCA) infarction. *Aspirin/Clopidogrel* - These are **antiplatelet medications used for secondary stroke prevention** after an acute ischemic event. - They are not the primary treatment for an **existing large infarct with mass effect and neurological deterioration** (drowsiness), as they do not address the acute intracranial pressure. *Mechanical thrombectomy* - This procedure is indicated for **acute ischemic stroke due to large vessel occlusion**, typically performed within a very narrow time window (usually up to 6-24 hours) from symptom onset. - The patient presents two days after symptom onset, and the CT findings suggest a **subacute to chronic infarct that has completed evolution**, making thrombectomy ineffective and potentially harmful. *Mannitol* - Mannitol is an **osmotic diuretic used to acutely reduce intracranial pressure (ICP)** in situations like cerebral edema. - While it can provide temporary relief, it is often insufficient for profound edema and mass effect from a **large, evolving infarct** that is causing significant neurological decline (drowsiness), and it does not treat the underlying structural issue.

Q: A 50-year-old man presents with frontal bossing, enlarged tongue and following appearance of hand. Which of the following tests should be done in this patient?

Insulin like growth factor. ***Insulin like growth factor*** - The patient's symptoms of **frontal bossing**, **enlarged tongue (macroglossia)**, and the image showing an **enlarged hand** (suggestive of **acral enlargement**) are classic features of **acromegaly**. - **Insulin-like growth factor 1 (IGF-1)** is the best screening test for acromegaly because its levels are stable throughout the day and reflect integrated GH secretion; elevated IGF-1 is indicative of the condition. *Thyroid hormone assay* - This test measures **thyroid function** and is primarily used to diagnose conditions like **hypothyroidism** or **hyperthyroidism**. - While some symptoms of thyroid disorders can overlap with other conditions, the specific constellation of **acral enlargement**, **macroglossia**, and **frontal bossing** is not typical for thyroid dysfunction. *Serum prolactin* - **Serum prolactin** is primarily used to assess for **hyperprolactinemia**, which can cause symptoms like **galactorrhea** or **hypogonadism**. - While a **prolactinoma** (a pituitary tumor secreting prolactin) can sometimes coexist with a **growth hormone-secreting tumor**, prolactin itself is not the direct cause of acromegalic features, and its assay is not the initial diagnostic test for acromegaly. *Serum Testosterone* - **Serum testosterone** levels are assessed in cases of suspected **hypogonadism** or other **androgen-related disorders**. - The clinical presentation with **acral enlargement** and **facial changes** is not characteristic of testosterone deficiency or excess.

Q: Identify the sleep stage in the following Polysomnograph.

NREM stage 2. ***NREM stage 2*** - The **EEG** shows prominent **sleep spindles** (bursts of 12-14 Hz waves) and **K-complexes** (high-amplitude biphasic waves), which are characteristic features of NREM stage 2 sleep. - The EOG channels indicate slow eye movements or an absence of rapid eye movements, consistent with NREM sleep, while the **EMG shows moderate muscle tone**, higher than in REM sleep but lower than wakefulness. *NREM stage 3* - This stage is characterized by **delta waves**, which are slow waves with high amplitude (0.5-2 Hz, often >75 μV) on the EEG, comprising 20% or more of the epoch, and are not significantly visible here. - While muscle tone is still present, the EEG would primarily show widespread **slow-wave activity**, distinguishing it from the sleep spindles and K-complexes seen in the image. *REM* - **Rapid eye movements** would be clearly visible on the EOG channels, which are not prevalent in this polysomnograph. - The **EMG would show very low muscle tone** (atonia), which is not the case here, and the EEG would largely consist of low-voltage, mixed-frequency activity, similar to wakefulness. *NREM stage 1* - This stage is typically characterized by a **disappearance of alpha waves** from the EEG and the presence of **theta waves** (4-7 Hz). - While there may be slow eye movements on the EOG, **sleep spindles and K-complexes are absent** in NREM stage 1, making it distinct from the presented polysomnograph.

Q: A patient presents with complaints of fever and abdominal distention. He is having history of bloody diarrhea off and on for previous 6 months. X-ray abdomen is shown below. What is the diagnosis?

Toxic megacolon. ***Toxic megacolon*** - The image shows **marked dilation of the colon** with loss of haustral markings, consistent with megacolon. - The clinical picture of fever, abdominal distention, and bloody diarrhea in a patient with a history of inflammatory bowel disease (implied by chronic bloody diarrhea) strongly suggests **toxic megacolon**. - Toxic megacolon is a life-threatening complication of IBD requiring urgent management. *Pneumatosis intestinalis* - This condition involves **gas within the wall of the bowel**, which would appear as characteristic lucencies outlining the bowel wall on X-ray. - While it can be seen in severe bowel ischemia, it is not the primary finding of diffuse colonic dilation seen here. *Volvulus* - Volvulus is a **twisting of a loop of intestine** around its mesentery, leading to obstruction and ischemia. - While it can cause colonic dilation, the dilation is typically localized to the twisted segment (e.g., a "coffee bean" sign in sigmoid volvulus) rather than the diffuse involvement seen here. *Intestinal perforation* - Intestinal perforation is characterized by the presence of **free air under the diaphragm** (pneumoperitoneum) on an upright chest X-ray or lateral decubitus abdominal film. - While a severely dilated and inflamed colon can perforate, there is no clear evidence of free air outside the bowel wall in this X-ray. *Paralytic ileus* - Paralytic ileus causes **generalized bowel dilation** and can present with abdominal distention. - However, it typically involves both small and large bowel, lacks the **loss of haustral markings** specific to toxic megacolon, and does not typically present with **fever and bloody diarrhea** in the context of chronic inflammatory bowel disease.

Q: Comment on the diagnosis of the image shown below. (AIIMS Nov 2017)

Hypothyroidism. ***Hypothyroidism*** - The image depicts **myxoedema**, characterized by localized, non-pitting edema and thickened skin, typically on the shins, which is a classic manifestation of severe **hypothyroidism**. - This condition results from the accumulation of **hyaluronic acid** and chondroitin sulfate in the dermis, causing a characteristic doughy texture. *Hyperthyroidism* - While hyperthyroidism (specifically Graves' disease) can cause **pretibial myxoedema**, the image alone showing generalized myxoedematous changes is more indicative of **hypothyroidism**. - Pretibial myxoedema associated with hyperthyroidism typically presents as elevated, firm, non-pitting plaques, whereas the image shows a more widespread thickening. *Sarcoidosis* - Sarcoidosis involves the formation of **non-caseating granulomas** in various organs, including the skin. - Skin manifestations of sarcoidosis can include **erythema nodosum**, plaques, or lupus pernio, which do not match the generalized thickening seen in the image. *Diabetes* - Diabetes mellitus can cause various skin manifestations such as **diabetic dermopathy**, necrobiosis lipoidica diabeticorum, and acanthosis nigricans. - These conditions present with different visual characteristics, like hyperpigmented atrophic macules or waxy yellow plaques, unlike the diffuse thickening shown.

Q: Phonocardiogram tracing is shown below with corresponding ECG. Identify the phase corresponding with $S_{2}$ in phonocardiogram.

Isovolumetric relaxation. ***Isovolumetric relaxation*** - **S₂ (second heart sound)** occurs due to closure of the **aortic and pulmonary semilunar valves** at the end of systole, marking the onset of isovolumetric relaxation. - On the **ECG**, S₂ corresponds to the **end of the T wave**, when ventricular pressure drops below aortic pressure causing valve closure. *Isovolumetric contraction* - This phase corresponds to **S₁ (first heart sound)** caused by closure of the **mitral and tricuspid valves** at the beginning of systole. - Occurs on the ECG around the **QRS complex**, not at the timing of S₂. *Rapid ejection* - This phase occurs **between S₁ and S₂** when blood is actively ejected from the ventricles into the aorta and pulmonary artery. - The **semilunar valves are open** during this phase, so no heart sounds are produced. *Rapid ventricular filling* - This phase occurs **after S₂** during early diastole when the **AV valves open** and blood rapidly fills the ventricles. - May be associated with **S₃ gallop** in pathological conditions, but not with S₂.

Q: A patient presented with sudden onset difficulty in breathing with RR 28/min, normal blood pressure. X-ray was taken which is given below. What is the diagnosis?

Hydro-pneumothorax. ***Hydro-pneumothorax*** - The chest X-ray clearly shows a **horizontal air-fluid level** in the right hemithorax, indicating the presence of both air (pneumothorax) and fluid (hydrothorax) within the pleural space. - The patient's sudden onset **difficulty in breathing** and **tachypnea (RR 28/min)** are consistent with significant lung pathology like a hydropneumothorax, which compromises lung function. *Pneumothorax* - A simple pneumothorax would show only **air in the pleural space**, characterized by a visible visceral pleural line and absence of lung markings beyond it. - While there is air present, the prominent **fluid level** rules out a diagnosis of pneumothorax alone. *Pleural effusion* - Pleural effusion presents as a **blunting of the costophrenic angles** and a meniscus sign, where fluid conforms to the shape of the thorax. - This image shows a **straight air-fluid level**, not a typical meniscus, indicating the presence of air in addition to fluid. *Consolidation* - Consolidation refers to the **filling of alveolar spaces with fluid or exudate**, appearing as an opacification within the lung parenchyma. - Consolidations typically do not present with a **horizontal fluid level** in the pleural space; they are intraparenchymal.

Q: A car accident patient complains of breathlessness. On examination BP is $110 / 70 \mathrm{mmHg}$ with GCS of 15/15. On examination, trachea is deviated to the right side, with reduced breath sounds in left infra-axillary area and inframammary areas. $S_{1}$ and $S_{2}$ are normal in intensity and splitting. CXR is shown below. What is the best step in management of the patient?

Chest tube insertion. ***Chest tube insertion*** - The patient's symptoms (breathlessness, tracheal deviation to the right, reduced breath sounds in the left infra-axillary and inframammary areas) combined with the CXR findings indicate a **left-sided hemothorax or pneumothorax** causing mediastinal shift. - A chest tube will **drain the accumulated air or fluid**, re-expand the lung, and relieve the mediastinal shift, thereby improving breathing. - This is **NOT a tension pneumothorax** (patient is hemodynamically stable with BP 110/70 mmHg), so definitive chest tube insertion is preferred over needle decompression. *Needle aspiration* - Needle thoracostomy is indicated for **tension pneumothorax**, which presents with hemodynamic instability, severe respiratory distress, and requires immediate decompression. - This patient is **hemodynamically stable** (normal BP, GCS 15/15), indicating a simple pneumothorax or hemothorax that requires **chest tube** for definitive drainage rather than temporary needle aspiration. *Pericardiocentesis* - **Pericardiocentesis** is indicated for **cardiac tamponade**, which presents with muffled heart sounds, hypotension, and distended neck veins (Beck's triad). - The patient's **normal blood pressure, normal heart sounds** (S₁ and S₂ normal), and clinical findings pointing to pleural pathology rule out cardiac tamponade. *Immediate thoracotomy* - **Immediate thoracotomy** is reserved for massive hemothorax with **>1500 mL initial drainage** or **>200 mL/hour persistent bleeding** after chest tube insertion, or for major vessel/cardiac injuries. - Initial management should be **chest tube insertion** for drainage and assessment before proceeding to thoracotomy.

Question 1

A child has a pruritic rash as shown below. His mother is an asthmatic. Comment on the diagnosis:

Accepted Answer

Atopic dermatitis

Answer

Seborrheic dermatitis

Answer

Allergic contact dermatitis

Answer

Erysipelas

Question 2

A middle-aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? (AIIMS Nov 2017)

Accepted Answer

Decompressive surgery

Answer

Aspirin/Clopidogrel

Answer

Mechanical thrombectomy

Answer

Mannitol

Question 3

A 50-year-old man presents with frontal bossing, enlarged tongue and following appearance of hand. Which of the following tests should be done in this patient?

Accepted Answer

Insulin like growth factor

Answer

Thyroid hormone assay

Answer

Serum prolactin

Answer

Serum Testosterone

Question 4

This 50-year-old patient developed syncope after having a coffee. ECG was done .Which is the most appropriate therapy for a patient suffering from the condition shown below?

Accepted Answer

DC shock

Answer

Lignocaine

Answer

Amiodarone

Answer

Esmolol

Answer

Magnesium sulfate

Question 5

Identify the sleep stage in the following Polysomnograph.

Accepted Answer

NREM stage 2

Answer

NREM stage 3

Answer

REM

Answer

NREM stage 1

Question 6

A patient presents with complaints of fever and abdominal distention. He is having history of bloody diarrhea off and on for previous 6 months. X-ray abdomen is shown below. What is the diagnosis?

Accepted Answer

Toxic megacolon

Answer

Pneumatosis intestinalis

Answer

Volvulus

Answer

Intestinal perforation

Answer

Paralytic ileus

Question 7

Comment on the diagnosis of the image shown below. (AIIMS Nov 2017)

Accepted Answer

Hypothyroidism

Answer

Hyperthyroidism

Answer

Sarcoidosis

Answer

Diabetes

Question 8

Phonocardiogram tracing is shown below with corresponding ECG. Identify the phase corresponding with $S_{2}$ in phonocardiogram.

Accepted Answer

Isovolumetric relaxation

Answer

Isovolumetric contraction

Answer

Rapid ejection

Answer

Rapid ventricular filling

Question 9

A patient presented with sudden onset difficulty in breathing with RR 28/min, normal blood pressure. X-ray was taken which is given below. What is the diagnosis?

Accepted Answer

Hydro-pneumothorax

Answer

Pneumothorax

Answer

Pleural effusion

Answer

Consolidation

Question 10

A car accident patient complains of breathlessness. On examination BP is $110 / 70 \mathrm{mmHg}$ with GCS of 15/15. On examination, trachea is deviated to the right side, with reduced breath sounds in left infra-axillary area and inframammary areas. $S_{1}$ and $S_{2}$ are normal in intensity and splitting. CXR is shown below. What is the best step in management of the patient?

Accepted Answer

Chest tube insertion

Answer

Needle aspiration

Answer

Pericardiocentesis

Answer

Immediate thoracotomy

INI-CET 2017

Dermatology

Internal Medicine

Pediatrics

Physiology

Radiology

Surgery