INI-CET 2021 Practice Questions

Q: Which of the following is not likely to be seen in a patient with Paroxysmal Nocturnal Hemoglobinuria (PNH)?

Leukemia. Leukemia - While PNH can transform into **acute myeloid leukemia (AML)** in a small percentage of cases, it is not a common or direct presentation, making it the *least likely* immediate finding among the options. - The primary pathophysiology of PNH involves a defect in hematopoietic stem cells leading to complement-mediated destruction, not malignant proliferation of myeloid or lymphoid cells as seen in leukemia. *Thrombosis* - **Thrombosis** is a major cause of morbidity and mortality in PNH, occurring due to complement activation and platelet activation on the surface of GPI-deficient cells. - It most commonly affects unusual sites like the **hepatic** or **mesenteric veins**, and cerebral venous sinuses. *Aplastic anemia* - **Aplastic anemia** is closely associated with PNH, as both with conditions can arise from a defect in hematopoietic stem cells. - PNH clones are often detectable in patients with aplastic anemia, and some cases of PNH evolve from or into aplastic anemia. *Hemolysis* - **Hemolysis** is a hallmark of PNH, caused by the absence of **GPI-anchored proteins (CD55 and CD59)** on red blood cells, making them susceptible to complement-mediated destruction [1]. - This leads to intravascular hemolysis, resulting in characteristic symptoms like **dark urine** (hemoglobinuria), especially in the morning [1].

Q: A female patient having frothy vaginal discharge was found to have a strawberry cervix. Which of the following is the drug of choice?

Metronidazole. ***Correct Option: Metronidazole*** - The combination of **frothy vaginal discharge** and a **strawberry cervix** (colpitis macularis) is highly indicative of **trichomoniasis**, caused by *Trichomonas vaginalis*. - **Metronidazole** is the drug of choice for treating trichomoniasis, effectively eradicating the protozoan parasite. - Alternative: **Tinidazole** is also highly effective for trichomoniasis treatment. *Incorrect Option: Cefixime* - **Cefixime** is a third-generation cephalosporin antibiotic primarily used to treat bacterial infections, particularly **gonorrhea** (*Neisseria gonorrhoeae*). - It is not effective against parasitic infections like **trichomoniasis**. *Incorrect Option: Tetracycline* - **Tetracycline** is a broad-spectrum antibiotic commonly used for bacterial infections like **chlamydia** and certain atypical organisms. - It is not indicated for the treatment of **trichomoniasis**, which requires antiprotozoal therapy. *Incorrect Option: Fluconazole* - **Fluconazole** is an antifungal medication specifically used to treat **yeast infections** (vulvovaginal candidiasis caused by *Candida* species). - It has no activity against the protozoan parasite *Trichomonas vaginalis*.

Q: A primigravida in her 10th week of gestation presents with spotting. On examination, the uterus corresponds to 12 weeks. Transvaginal ultrasound was done and it is given below. What is your diagnosis?

Hydatidiform mole. ***Hydatidiform mole*** - The ultrasound image shows a **"snowstorm" appearance**, characterized by multiple echogenic vesicles or cystic spaces within the uterine cavity, which is pathognomonic for a hydatidiform mole. - The clinical presentation of **vaginal spotting**, a uterus size **larger than expected for gestational age** (12 weeks uterus size at 10 weeks gestation), and possibly elevated hCG levels (though not given here) are all highly suggestive of a molar pregnancy. *Blighted ovum* - A blighted ovum, also known as an anembryonic pregnancy, involves a **gestational sac without an embryo**. - The ultrasound typically shows an empty gestational sac and does not feature the characteristic "snowstorm" pattern of a hydatidiform mole. *Ectopic pregnancy* - An ectopic pregnancy occurs when the **fertilized egg implants outside the uterus**, most commonly in the fallopian tube. - The ultrasound would typically show an **empty uterus** and a gestation outside the uterine cavity, usually with a mass in the adnexa, which is not seen here. *Missed abortion* - A missed abortion is characterized by the **death of the embryo or fetus but retention** within the uterus. - Ultrasound would show a **fetus without cardiac activity** or a gestational sac that is smaller than expected, without the typical vesicular pattern of a mole.

Q: Which of the following findings appear late in compartment syndrome?

Pulselessness. ***Pulselessness*** - **Pulselessness** is a very late and ominous sign in compartment syndrome, indicating severe arterial compromise that has progressed beyond simple venous and lymphatic outflow obstruction. - Its presence suggests **irreversible tissue damage** has likely already occurred due to prolonged ischemia. *Paralysis* - **Paralysis** is a late sign, indicating significant nerve ischemia and damage due to sustained pressure within the compartment. - While it's a serious finding, it typically appears before pulselessness, as nerves are sensitive to ischemia but arteries are more resistant to complete occlusion until very high pressures are reached. *Pain on passive stretch* - **Pain on passive stretch** is considered one of the earliest and most reliable clinical signs of early compartment syndrome. - It results from the stretching of ischemic muscle fibers within the confined compartment. *Pallor* - **Pallor** (skin paleness) is also a relatively late sign, occurring when capillary perfusion is significantly reduced due to rising intracompartmental pressure. - It usually manifests when the pressure is high enough to restrict blood flow but often precedes the complete absence of pulses.

Q: Following a femoral shaft fracture, your consultant asks you to provide tibia traction. Which of the following will you request from the nurse? 1. Thomas splint 2. K-wire 3. Steinmann pin 4. Denham's pin 5. Bohler's stirrup 6. Bohler Braun splint

$3,5,6$. ***3,5,6*** - For **tibia traction** in a femoral shaft fracture, you would need a **Steinmann pin** for skeletal traction, a **Bohler's stirrup** to apply the traction force, and a **Bohler-Braun splint** to support the limb. - The **Steinmann pin** is inserted into the proximal tibia, the **Bohler's stirrup** attaches to the pin, and the **Bohler-Braun splint** provides a fixed structure for the traction system. *1,2,3,4,5,6* - This option incorrectly includes items not specifically used for applying **tibia traction** (e.g., K-wire is for internal fixation, Thomas splint is for early femur fracture management but not specifically for tibia traction application). - While some components might be used in general fracture management, not all are directly involved in setting up tibia traction as requested. *3,4,5* - This option correctly includes the **Steinmann pin** and **Bohler's stirrup** but incorrectly replaces the **Bohler-Braun splint** with a **Denham's pin**. - A **Denham's pin** is an alternative to a Steinmann pin for skeletal traction, but a **Bohler-Braun splint** is crucial for supporting the limb in this setup, which is missing here. *1,2,4* - This option includes a **Thomas splint** (used for femur fracture support, not tibia traction application), a **K-wire** (used for internal fixation, not traction), and a **Denham's pin** (an alternative to Steinmann pin, but lacks the necessary support and traction application equipment). - These items are not suitable for setting up comprehensive **tibia traction** for a femoral shaft fracture.

Q: A boy presents with fever, night sweats, and neck swelling. The biopsy of swelling showed a starry sky appearance. What is the most likely genetic abnormality seen in this case?

MYC. ***MYC*** - The clinical presentation of **fever, night sweats, and neck swelling** in a child, coupled with a **starry sky appearance** on biopsy, is highly suggestive of **Burkitt lymphoma** [2, 3]. - **Burkitt lymphoma** is characterized by a **translocation involving the *MYC* gene** on chromosome 8, most commonly t(8;14), which leads to its overexpression and uncontrolled cell proliferation [1]. *RAS* - Mutations in the **RAS family of genes (HRAS, KRAS, NRAS)** are commonly found in a wide variety of cancers, including **leukemias, pancreatic cancer, and colorectal cancer**. - While *RAS* mutations drive proliferation, they are **not the primary genetic driver** of Burkitt lymphoma, nor are they linked to the characteristic starry sky appearance. *BCR-ABL* - The **BCR-ABL fusion gene**, resulting from the **Philadelphia chromosome (t(9;22))**, is the defining genetic abnormality of **chronic myeloid leukemia (CML)**. - CML presents with different symptoms and a distinct peripheral blood and bone marrow morphology, **not the "starry sky" appearance** seen in Burkitt lymphoma. *p53* - The **p53 tumor suppressor gene** is frequently mutated or inactivated in over half of all human cancers, leading to a loss of cell cycle control and apoptosis. - While **p53 mutations can occur in aggressive lymphomas**, including Burkitt lymphoma, the **primary and characteristic genetic abnormality** associated with Burkitt lymphoma and its presentation is the *MYC* translocation, not solely *p53* mutations. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 324-325. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 605-606. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, p. 606.

Q: Which of the following is given as a part of the therapy for a child with severe COVID?

Corticosteroids. ***Correct: Corticosteroids*** - **Corticosteroids** (specifically **dexamethasone**) are the **most established evidence-based therapy** for severe COVID-19 in children requiring oxygen support or mechanical ventilation - They reduce **mortality** by suppressing the hyperinflammatory response and cytokine storm associated with severe COVID-19 - Recommended by **WHO, NIH, and Indian Academy of Pediatrics (IAP)** for hospitalized children with severe COVID-19 requiring supplemental oxygen - The **RECOVERY trial** demonstrated significant mortality reduction in patients receiving oxygen therapy *Incorrect: Ivermectin* - **Ivermectin** is **NOT recommended** for COVID-19 treatment by WHO, FDA, NIH, or IAP - Multiple large randomized controlled trials (including TOGETHER trial) showed **no significant benefit** in preventing severe disease, hospitalization, or mortality - Initial in-vitro activity did not translate to clinical efficacy - Not part of standard therapy for severe COVID-19 in children *Incorrect: Remdesivir* - **Remdesivir** is an antiviral that may shorten recovery time in hospitalized adults - Evidence in **pediatric patients** is limited compared to adults - While used in some hospitalized patients, it is **not as universally recommended** as corticosteroids for severe disease - The **primary established therapy** for severe COVID-19 remains corticosteroids *Incorrect: All of the options* - Only **corticosteroids** represent standard, evidence-based therapy for severe pediatric COVID-19 - Ivermectin lacks efficacy evidence and is not recommended - The question asks what "is given as part of therapy" - corticosteroids are the definitive answer

Q: A child presents with fever and vesicular lesions on the upper limb and the lower limb. Neck stiffness was present. Similar lesions were present on the palms, soles, and oral cavity. CSF analysis revealed normal glucose levels and elevated lymphocytes and protein. What is the most likely diagnosis?

Coxsackie viral meningitis and Hand Foot Mouth disease. Coxsackie viral meningitis and Hand Foot Mouth disease - The presence of **vesicular lesions** on the palms, soles, and oral cavity, along with fever, is highly characteristic of **Hand Foot Mouth Disease (HFMD)** caused by Coxsackievirus. - The CSF findings of **normal glucose**, **elevated lymphocytes** (pleocytosis), and **elevated protein** are typical for **aseptic meningitis**, which is often caused by enteroviruses like Coxsackievirus [2]. *Bacterial meningitis with sepsis* - **Bacterial meningitis** would typically present with **low CSF glucose**, **high protein**, and a predominance of **neutrophils**, not lymphocytes [2]. - The characteristic vesicular rash of HFMD is not seen in bacterial meningitis. *Tuberculous meningitis* - **Tuberculous meningitis** typically has **very low CSF glucose**, **markedly elevated protein**, and a pleocytosis with a high percentage of lymphocytes. - The vesicular lesions on the palms, soles, and oral cavity are not a feature of tuberculous meningitis. *Herpes simplex gingivostomatitis and meningoencephalitis* - While **Herpes simplex** can cause **vesicular lesions** (gingivostomatitis) and **meningoencephalitis** with similar CSF findings (lymphocytic pleocytosis, elevated protein), the widespread nature of the lesions on the palms and soles is **not characteristic of HSV** [1]. - HSV lesions are typically clustered and localized to specific dermatomes or mucosal surfaces.

Q: Which of the following congenital heart disease has equal saturation in all heart chambers?

Total anomalous pulmonary venous circulation. ***Total anomalous pulmonary venous circulation*** - In this condition, all **pulmonary veins drain abnormally** into the systemic venous circulation, mixing oxygenated and deoxygenated blood before it reaches the left atrium. - This complete mixing results in **equal oxygen saturation** throughout all four heart chambers and the great arteries, as there is a single common mixing chamber. *Tetralogy of Fallot* - This condition involves **four defects**: pulmonary stenosis, ventricular septal defect (VSD), overriding aorta, and right ventricular hypertrophy, leading to right-to-left shunting. - Oxygen saturations would be **lower in the systemic circulation** and aorta compared to the pulmonary circulation (if measurable), but not equal across all chambers due to deoxygenated blood mixing in the systemic flow. *Transposition of great arteries* - Characterized by the **aorta arising from the right ventricle** and the pulmonary artery from the left ventricle, creating two parallel circulations. - Without mixing lesions (like a VSD or patent foramen ovale), the systemic circulation would be severely desaturated and the pulmonary circulation fully saturated, resulting in **highly disparate saturations** between chambers. *Tricuspid atresia* - Involves the **absence of a tricuspid valve**, preventing blood flow from the right atrium to the right ventricle, necessitating an atrial septal defect (ASD) or patent foramen ovale (PFO) for survival. - Blood from the right atrium goes directly to the left atrium, and then via a VSD to the pulmonary artery, leading to **different saturations** in the systemic and pulmonary circulations and not equal saturation in all chambers.

Q: Which of the following are causes of neonatal seizures? 1. Hypernatremia 2. Hypomagnesemia 3. Hypocalcemia 4. Hyponatremia

1, 2, 3, and 4. ***1, 2, 3, and 4*** - **All listed electrolyte imbalances** can disrupt neuronal function and lead to neonatal seizures. - **Severe shifts** in sodium, calcium, and magnesium levels directly impact neuronal excitability. *2, 4 only* - This option is incorrect because **hypernatremia** and **hypocalcemia** are also significant causes of neonatal seizures. - Electrolyte disturbances such as **hypomagnesium** and **hyponatremia** can cause neonatal seizures, but they are not the only ones. *1, 3, 4 only* - This choice is incorrect as it **excludes hypomagnesemia**, which is a known cause of neonatal seizures. - **Severely deranged sodium and calcium levels** are important causes, but magnesium disturbances also contribute. *1, 2, 3 only* - This option is incorrect because **hyponatremia** is a well-established cause of neonatal seizures. - While hypernatremia, hypomagnesemia, and hypocalcemia can cause seizures, **hyponatremia** can also lead to cerebral edema and subsequent seizure activity.

Question 1

Which of the following is not likely to be seen in a patient with Paroxysmal Nocturnal Hemoglobinuria (PNH)?

Accepted Answer

Leukemia

Answer

Thrombosis

Answer

Aplastic anemia

Answer

Hemolysis

Question 2

A female patient having frothy vaginal discharge was found to have a strawberry cervix. Which of the following is the drug of choice?

Accepted Answer

Metronidazole

Answer

Cefixime

Answer

Tetracycline

Answer

Fluconazole

Question 3

A primigravida in her 10th week of gestation presents with spotting. On examination, the uterus corresponds to 12 weeks. Transvaginal ultrasound was done and it is given below. What is your diagnosis?

Accepted Answer

Hydatidiform mole

Answer

Blighted ovum

Answer

Ectopic pregnancy

Answer

Missed abortion

Question 4

Which of the following findings appear late in compartment syndrome?

Accepted Answer

Pulselessness

Answer

Paralysis

Answer

Pain on passive stretch

Answer

Pallor

Question 5

Following a femoral shaft fracture, your consultant asks you to provide tibia traction. Which of the following will you request from the nurse?

1. Thomas splint
2. K-wire
3. Steinmann pin
4. Denham's pin
5. Bohler's stirrup
6. Bohler Braun splint

Accepted Answer

$3,5,6$

Answer

$1,2,3,4,5,6$

Answer

$3,4,5$

Answer

$1,2,4$

Question 6

A boy presents with fever, night sweats, and neck swelling. The biopsy of swelling showed a starry sky appearance. What is the most likely genetic abnormality seen in this case?

Accepted Answer

MYC

Answer

RAS

Answer

BCR-ABL

Answer

p53

Question 7

Which of the following is given as a part of the therapy for a child with severe COVID?

Accepted Answer

Corticosteroids

Answer

Ivermectin

Answer

Remdesivir

Answer

All of the options

Question 8

A child presents with fever and vesicular lesions on the upper limb and the lower limb. Neck stiffness was present. Similar lesions were present on the palms, soles, and oral cavity. CSF analysis revealed normal glucose levels and elevated lymphocytes and protein. What is the most likely diagnosis?

Accepted Answer

Coxsackie viral meningitis and Hand Foot Mouth disease

Answer

Bacterial meningitis with sepsis

Answer

Tuberculous meningitis

Answer

Herpes simplex gingivostomatitis and meningoencephalitis

Question 9

Which of the following congenital heart disease has equal saturation in all heart chambers?

Accepted Answer

Total anomalous pulmonary venous circulation

Answer

Tetralogy of Fallot

Answer

Transposition of great arteries

Answer

Tricuspid atresia

Question 10

Which of the following are causes of neonatal seizures?

1. Hypernatremia
2. Hypomagnesemia
3. Hypocalcemia
4. Hyponatremia

Accepted Answer

1, 2, 3, and 4

Answer

2,4 only

Answer

1, 3, 4 only

Answer

1, 2, 3 only

INI-CET 2021

Internal Medicine

Obstetrics and Gynecology

Orthopaedics

Pathology

Pediatrics