INI-CET 2022 Practice Questions

Q: What is the action of the superior oblique muscle?

Intorsion, abduction, depression. ***Intorsion, abduction, depression*** - The **superior oblique muscle** has three actions: **depression** (downward movement - primary action), **abduction** (movement away from the midline), and **intorsion** (medial/internal rotation of the globe) [1]. - The depressor action is most effective when the eye is **adducted** (turned inward), as the muscle's line of pull is then optimally aligned with the vertical axis. - Mnemonic: **SO-DAI** (Superior Oblique: Depression, Abduction, Intorsion) *Intorsion, adduction, elevation* - While **intorsion** is correct, this option incorrectly includes **adduction** and **elevation**. - The superior oblique causes **abduction** (not adduction) and **depression** (not elevation) [1]. - **Elevation** is performed by the superior rectus and inferior oblique muscles [1]. *Extorsion, adduction, elevation* - All three actions are incorrect for the superior oblique muscle. - The correct actions are **intorsion**, **abduction**, and **depression**. - **Extorsion** is performed by the inferior oblique and inferior rectus muscles [1]. *Extorsion, abduction, depression* - While **abduction** and **depression** are correct, **extorsion** is wrong. - The superior oblique causes **intorsion** (internal rotation), not extorsion (external rotation). - This is a common point of confusion - remember the superior oblique **intorts**, while the inferior oblique **extorts**.

Q: A 50-year-old male patient presented with left -sided hemiparesis. Damage to which part of the internal capsule leads to this presentation?

Posterior limb. Posterior limb - The posterior limb of the internal capsule contains the corticospinal tracts, which carry motor commands from the brain to the spinal cord [1]. - Damage to this area typically results in contralateral hemiparesis or hemiplegia, matching the patient's left-sided weakness. Anterior limb - The anterior limb of the internal capsule primarily contains tracts connecting the thalamus to the frontal lobe and the pontine nuclei to the cerebellum. - Lesions here typically cause dysarthria or behavioral changes, not hemiparesis. Retrolentiform - The retrolentiform part of the internal capsule carries visual (optic radiation) and auditory pathways. - Damage to this area would primarily cause contralateral visual field deficits or auditory agnosia, not motor weakness. Sublentiform - The sublentiform part of the internal capsule contains auditory radiations and temporopontine fibers. - Injury here would result in auditory symptoms or potentially aphasia if dominant hemisphere is affected, not hemiparesis.

Q: Identify the cell marked in the image below

Mast cell. ***Mast cell*** - The cell indicated by the arrow displays characteristic features of a **mast cell**, including its large size, prominent central nucleus, and cytoplasm densely packed with numerous large, basophilic (darkly stained) granules. - These granules contain powerful inflammatory mediators like **histamine** and **heparin**, which are key in allergic reactions and inflammation. *Macrophage* - Macrophages are typically larger than mast cells with an **irregular shape**, a kidney-shaped nucleus, and often contain phagocytosed material in their cytoplasm, which is not clearly visible here. - While they are also immune cells, they lack the characteristic dense, uniform basophilic granulation seen in the indicated cell. *Plasma cell* - Plasma cells are characterized by an **eccentric nucleus** with **chromatin clumping** (cartwheel or clock-face appearance) and a prominent Golgi apparatus (perinuclear halo), none of which are evident in the marked cell. - Their cytoplasm is typically basophilic but lacks the distinct large granules. *Fibroblast* - Fibroblasts are typically **spindle-shaped** or stellate cells with elongated nuclei and a sparse cytoplasm, responsible for producing extracellular matrix. - They do not possess the abundant, dense cytoplasmic granules that are a hallmark of the cell shown.

Q: A patient, who is a known case of HIV with a CD4 count of 200 cells/cu.mm, presents with 5 days of cough and high-grade fever without chills and rigors. There is no history of diarrhoea, vomiting, or nuchal rigidity. Chest x-ray is normal. What treatment will you give?

Co-trimoxazole only. ***Co-trimoxazole only*** - The patient has a CD4 count of 200 cells/cu.mm with cough and fever and a normal chest X-ray, all of which are highly suggestive of **Pneumocystis jirovecii pneumonia (PJP)**, even without classic infiltrates. Therefore, **co-trimoxazole** (trimethoprim-sulfamethoxazole) is the first-line treatment [1]. - In a patient with HIV and a CD4 count below 200, **PJP prophylaxis** with co-trimoxazole should also be considered [2], and its empirical treatment is indicated in this scenario. *Co-trimoxazole + steroids* - While co-trimoxazole is the correct treatment for PJP, **steroids** are typically reserved for patients with more severe disease, indicated by **hypoxia** (PaO2 35 mmHg) or diffuse interstitial infiltrates on chest imaging, neither of which are described here [1]. - Adding steroids without clear indications could increase the risk of side effects in an immunocompromised patient. *Amoxicillin-clavulanic acid + Azithromycin* - This combination targets typical **bacterial community-acquired pneumonia**, which is less likely given the patient's HIV status, low CD4 count, and normal chest X-ray. - This regimen would not effectively treat **PJP**, which is the most probable diagnosis in this immunocompromised setting. *Antitubercular treatment* - While tuberculosis is common in HIV patients, the normal chest X-ray makes pulmonary tuberculosis less likely, especially without other classic symptoms like night sweats, weight loss, or hemoptysis. In patients with CD4 counts below 200, the clinical presentation of TB differences substantially from those without HIV [1]. - **Antitubercular treatment** would not address the immediate concern of possible PJP, which can rapidly progress if untreated.

Q: Thrombolysis can be considered in all of these conditions, except:

Blood pressure of more than 185/110 mmHg. ***Blood pressure of more than 185/110 mmHg*** - A **blood pressure** greater than **185/110 mmHg** is an absolute contraindication for thrombolysis due to the significantly increased risk of developing **hemorrhagic transformation**. - **Aggressive blood pressure control** is necessary to reduce the risk of intracranial hemorrhage before considering thrombolytics. *Ischemic stroke within 2 hours* - This is within the **therapeutic window** for thrombolysis, which typically extends up to **4.5 hours** from symptom onset [1]. - Earlier administration of thrombolytics within this window generally leads to **better outcomes** and reduced disability [1]. *Onset of symptoms <4 hours* - An onset of symptoms less than **4.5 hours** is a primary **inclusion criterion** for intravenous thrombolysis in acute ischemic stroke [1]. - This timeframe allows for the maximum benefit from **clot dissolution** while minimizing the risk of adverse events. *MRI showing density in less than 1/3rd of the area supplied by MCA* - A **diffusion-weighted MRI** showing an infarct core of less than one-third of the **Middle Cerebral Artery (MCA)** territory is an indicator that the amount of **irreversibly damaged tissue** is small. - This suggests a larger volume of **salvageable penumbra**, making thrombolysis more likely to be beneficial.

Q: A young patient presents to the clinic with erythematous lesions over the exposed areas of the skin like hands, arms, chest, etc. she also complaints of arthralgia and breathlessness. Which among the following antibodies will be useful in diagnosing this condition?

Anti-dsDNA antibodies. Anti-dsDNA antibodies - The clinical presentation with erythematous lesions in sun-exposed areas (consistent with photosensitivity [1] or malar rash), arthralgia, and breathlessness (suggesting serositis [4] or pulmonary involvement) is highly suggestive of Systemic Lupus Erythematosus (SLE) [3]. - Anti-dsDNA antibodies are highly specific for SLE and are included in the diagnostic criteria [4]. Their levels often correlate with disease activity, especially in lupus nephritis. *Anti-centromere antibodies* - These antibodies are typically associated with CREST syndrome (a limited form of systemic sclerosis), characterized by Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasias. - This clinical picture does not align with the patient's symptoms, which point more towards an inflammatory multi-systemic disease. *Anti-RNP antibodies* - Anti-ribonucleoprotein (RNP) antibodies are characteristic of Mixed Connective Tissue Disease (MCTD) [2], which features overlapping symptoms of SLE, systemic sclerosis, and polymyositis [3]. - While some features like arthralgia might overlap, the classic erythematous lesions and breathlessness are more directly linked to SLE in this presentation, and anti-dsDNA is more specific for distinguishing SLE. *Anti-Scl 70 antibodies* - Also known as anti-topoisomerase I antibodies, these are highly specific for diffuse cutaneous systemic sclerosis. - This condition is characterized by widespread skin thickening, interstitial lung disease, and other visceral organ involvement, which is not fully supported by the patient's primary symptoms of prominent erythematous rashes and isolated arthralgia.

Q: Which triad is seen after an acute attack of angle-closure glaucoma?

Vogt's triad. ***Vogt's triad*** - **Vogt's triad** refers to the classical findings seen after an acute attack of **angle-closure glaucoma**. - The triad consists of: **glaukomflecken** (anterior subcapsular lens opacities from ischemic necrosis of lens epithelium), **iris stromal atrophy** (sectoral iris atrophy in the area of ischemia), and **fixed mid-dilated pupil** (due to iris sphincter damage). - These signs indicate **ischemic damage** to the anterior segment following the acute episode of elevated intraocular pressure. *Gaucher triad* - **Gaucher triad** refers to the characteristic systemic symptoms of **Gaucher disease**, an inherited lipid storage disorder. - It involves **hepatosplenomegaly**, **bone pain**, and **thrombocytopenia**, which are unrelated to glaucoma. *Virchow triad* - The **Virchow triad** describes the three main factors contributing to **thrombus formation**: **stasis** of blood flow, **endothelial injury**, and **hypercoagulability**. - This triad is relevant to cardiovascular pathology, not the effects of angle-closure glaucoma. *Hutchinson's triad* - **Hutchinson's triad** is a set of symptoms associated with **congenital syphilis**. - It includes **interstitial keratitis**, **Hutchinson's teeth**, and **eighth nerve deafness**, which are entirely distinct from ocular hypertension.

Q: A 27-year-old female patient presents with sudden diminishing vision associated with a relative afferent pupillary defect in the right eye. On examination, the left eye is normal. Which of the following combinations of investigations would be most appropriate?

MRI brain and orbits + Visual evoked potentials + Blood tests. ***MRI brain and orbits + Visual evoked potentials + Blood tests*** - The combination of **sudden diminishing vision** and a **relative afferent pupillary defect (RAPD)** in one eye strongly suggests **optic neuritis**. - **MRI brain and orbits** is crucial to identify demyelinating lesions characteristic of **multiple sclerosis** and to rule out other causes of optic neuropathy, while **visual evoked potentials (VEPs)** confirm optic nerve dysfunction and can detect subclinical demyelination. **Blood tests** are essential to exclude other inflammatory or autoimmune conditions that can mimic optic neuritis. *MRI brain and orbits + Visual evoked potentials* - While these two investigations are critical for diagnosing **optic neuritis** and assessing for **multiple sclerosis**, they might miss systemic causes of optic neuropathy that can be identified via targeted **blood tests**. - Excluding systemic inflammatory or autoimmune conditions is crucial for complete patient management and preventing recurrence or progression. *Visual evoked potentials + Blood tests* - This combination is insufficient as it omits the **MRI brain and orbits**, which is vital for visualizing the optic nerve and brain for demyelinating lesions and ruling out compressive or infiltrative etiologies. - An **MRI** provides structural information that VEPs and blood tests alone cannot, making it indispensable in this clinical scenario. *MRI brain and orbits + Blood tests* - This combination lacks **Visual evoked potentials (VEPs)**, which provide objective evidence of **optic nerve demyelination** and can detect subclinical involvement, aiding in diagnosis and prognosis. - VEPs are particularly valuable in diagnosing **optic neuritis** and monitoring its recovery or progression.

Q: Which of the following is false about bipolar disorder?

Unipolar mania is more common than bipolar disorder. ***Unipolar mania is more common than bipolar disorder*** - This statement is **false** because **unipolar mania is extremely rare**, while **bipolar disorder (which includes both manic and depressive episodes)** is significantly more common. - **Unipolar mania** refers to recurrent manic episodes without any depressive episodes, a presentation that is seldom observed clinically. *Genetic factors play important role* - This statement is **true**, as **bipolar disorder has a strong genetic component**, with **heritability estimated between 60-80%**. - **First-degree relatives** of individuals with bipolar disorder are at a significantly higher risk of developing the condition. *Rapid cycling is more common in females* - This statement is **true**; **rapid cycling (4 or more mood episodes per year)** occurs more frequently in females with bipolar disorder. - **Women with bipolar disorder** are also more likely to experience **mixed features** and **more depressive episodes** compared to males. *Age of onset is earlier than unipolar depression* - This statement is **true** because the **typical age of onset for bipolar disorder is in early adulthood (late teens to early 20s)**, whereas **unipolar depression often has a later average onset**, though both can occur at any age. - An earlier age of onset in bipolar disorder is linked to poorer prognosis and more severe illness course.

Question 1

What is the action of the superior oblique muscle?

Accepted Answer

Intorsion, abduction, depression

Answer

Intorsion, adduction, elevation

Answer

Extorsion, adduction, elevation

Answer

Extorsion, abduction, depression

Question 2

A pregnant woman presents with fever, retroorbital pain, headache, pulsatile proptosis of the right eye, and tinnitus. BP and fundus were normal. Which of the following structures are involved?

Accepted Answer

Abducens nerve, Oculomotor nerve, Internal carotid artery, Cavernous sinus

Answer

Oculomotor nerve, Internal carotid artery, Cavernous sinus

Answer

Abducens nerve, Internal carotid artery, Cavernous sinus

Answer

Abducens nerve, Oculomotor nerve, Internal carotid artery

Question 3

A 50-year-old male patient presented with left -sided hemiparesis. Damage to which part of the internal capsule leads to this presentation?

Accepted Answer

Posterior limb

Answer

Anterior limb

Answer

Retrolentiform

Answer

Sublentiform

Question 4

Identify the cell marked in the image below

Accepted Answer

Mast cell

Answer

Macrophage

Answer

Plasma cell

Answer

Fibroblast

Question 5

A patient, who is a known case of HIV with a CD4 count of 200 cells/cu.mm, presents with 5 days of cough and high-grade fever without chills and rigors. There is no history of diarrhoea, vomiting, or nuchal rigidity. Chest x-ray is normal. What treatment will you give?

Accepted Answer

Co-trimoxazole only

Answer

Co-trimoxazole + steroids

Answer

Amoxicillin-clavulanic acid + Azithromycin

Answer

Antitubercular treatment

Question 6

Thrombolysis can be considered in all of these conditions, except:

Accepted Answer

Blood pressure of more than 185/110 mmHg

Answer

Ischemic stroke within 2 hours

Answer

Onset of symptoms <4 hours

Answer

MRI showing density in less than 1/3rd of the area supplied by MCA

Question 7

A young patient presents to the clinic with erythematous lesions over the exposed areas of the skin like hands, arms, chest, etc. she also complaints of arthralgia and breathlessness. Which among the following antibodies will be useful in diagnosing this condition?

Accepted Answer

Anti-dsDNA antibodies

Answer

Anti-centromere antibodies

Answer

Anti-RNP antibodies

Answer

Anti-Scl 70 antibodies

Question 8

Which triad is seen after an acute attack of angle-closure glaucoma?

Accepted Answer

Vogt's triad

Answer

Gaucher triad

Answer

Virchow triad

Answer

Hutchinson's triad

Question 9

A 27-year-old female patient presents with sudden diminishing vision associated with a relative afferent pupillary defect in the right eye. On examination, the left eye is normal.

Which of the following combinations of investigations would be most appropriate?

Accepted Answer

MRI brain and orbits + Visual evoked potentials + Blood tests

Answer

MRI brain and orbits + Visual evoked potentials

Answer

Visual evoked potentials + Blood tests

Answer

MRI brain and orbits + Blood tests

Question 10

Which of the following is false about bipolar disorder?

Accepted Answer

Unipolar mania is more common than bipolar disorder

Answer

Genetic factors play important role

Answer

Rapid cycling is more common in females

Answer

Age of onset is earlier than unipolar depression

INI-CET 2022

Anatomy

Internal Medicine

Ophthalmology

Psychiatry