INI-CET 2023 Practice Questions

Q: Non-scarring alopecia is associated with all except?

Frontal fibrosing alopecia. ***Frontal fibrosing alopecia*** - This condition is a form of **lichen planopilaris**, which causes **scarring alopecia** due to destruction of hair follicles and replacement with fibrous tissue. - It results in a **receding hairline** and eyebrow loss, with irreversible hair loss. *Telogen effluvium* - This is a common cause of **non-scarring alopecia**, characterized by diffuse hair shedding triggered by various stressors like illness, stress, or medications. - The hair follicles enter the **telogen phase** prematurely, leading to increased shedding but typically regrowth once the trigger is removed. *Androgenetic alopecia* - Often referred to as **male or female pattern baldness**, this is a form of **non-scarring alopecia** driven by genetic predisposition and androgens. - It causes a progressive miniaturization of hair follicles, leading to thinning hair, but the follicles remain present and capable of producing hair. *Alopecia areata* - This is an **autoimmune condition** that causes **non-scarring hair loss** in patches on the scalp or other parts of the body. - The hair follicles are attacked by the immune system but are not permanently destroyed, allowing for potential regrowth.

Q: A 24-year-old male presents with asymptomatic scaly lesions over the body as shown in the image below. What is the likely diagnosis?

Pityriasis Rosea. ***Pityriasis Rosea*** - The image shows numerous **scaly, erythematous plaques** distributed over the trunk, with a characteristic "Christmas tree" pattern often observed in Pityriasis Rosea. - The lesions are described as **asymptomatic**, which is consistent with Pityriasis Rosea, although mild pruritus can occur. *Atopic Dermatitis* - Typically presents with **intensely pruritic, erythematous, and eczematous lesions** often found in flexural areas (e.g., antecubital and popliteal fossae). - While it can be widespread, the morphology of the lesions (eczematous vs. scaly plaques) and the absence of pruritus make this less likely. *Lichen planus* - Characterized by **pruritic, violaceous, polygonal papules** and plaques, often appearing on the flexor surfaces of wrists, ankles, and oral mucosa. - The appearance of the lesions in the image does not match the typical morphology of lichen planus. *Seborrheic Dermatitis* - Primarily affects areas with a high density of sebaceous glands, such as the **scalp, face (nasolabial folds, eyebrows), and chest**. - Presents with **greasy, yellowish scales** on an erythematous base, which is distinct from the dry, scaly plaques seen in the image.

Q: A 60-year-old female presents with eczematous itching lesions. Biopsy revealed a subepidermal cleft with Direct Immunofluorescence showing Linear C3 & IgG deposition along the basement membrane zone. What is the likely diagnosis?

Bullous Pemphigoid. ***Bullous Pemphigoid*** - The presence of **eczematous itching lesions**, a **subepidermal cleft**, and **linear C3 and IgG deposition along the basement membrane zone** on direct immunofluorescence (DIF) are classic diagnostic features of Bullous Pemphigoid. - This autoimmune blistering disease typically affects older individuals and is characterized by antibodies targeting components of the **hemidesmosomes**, specifically BP180 and BP230. *Pemphigus foliaceus* - This condition involves **intraepidermal blistering**, specifically within the granular layer, rather than a subepidermal cleft. - DIF in Pemphigus foliaceus shows **intercellular IgG deposition** in the epidermis, not linear deposition along the basement membrane zone. *Pemphigus Vulgaris* - Pemphigus Vulgaris is characterized by **intraepidermal blistering** above the basal cell layer (**suprabasal clefting**), leading to fragile bullae that rupture easily. - DIF typically reveals **intercellular IgG and C3 deposition** in a "chicken wire" pattern throughout the epidermis, which differs from the linear pattern seen in this case. *Dermatitis herpetiformis* - While Dermatitis herpetiformis is also an autoimmune blistering disease with itching lesions, its characteristic DIF finding is **granular IgA deposition** in the dermal papillae, not linear C3 and IgG at the basement membrane zone. - Histopathology in Dermatitis herpetiformis shows **subepidermal vesicles** with neutrophil infiltration in the dermal papillae, but the direct immunofluorescence pattern is distinct.

Q: Identify the ECG given below?

Torsades de pointes. ***Torsades de pointes*** - The ECG shows a polymorphic ventricular tachycardia where the **QRS complexes appear to twist around the baseline**, a classic feature of Torsades de pointes. - This condition is often associated with **QT prolongation**, which is evident in some of the strips preceding the tachyarrhythmia. *Viral myocarditis* - While viral myocarditis can lead to various ECG abnormalities, it typically doesn't present with this specific **polymorphic ventricular tachycardia** morphology. - Common ECG findings in myocarditis include non-specific ST-T wave changes, sinus tachycardia, or conduction blocks, rather than the characteristic "twisting" pattern seen here. *Cardiac tamponade* - Cardiac tamponade is characterized by **electrical alternans** (alternating QRS amplitude), low voltage, and sinus tachycardia on ECG. - It does not cause a polymorphic ventricular tachycardia with the appearance of QRS complexes twisting around the baseline. *Pericarditis* - Pericarditis typically presents with **diffuse ST-segment elevation** (often concave up) and PR-segment depression. - It does not manifest as a polymorphic ventricular tachycardia like Torsades de pointes.

Q: Which of the following describes aortic regurgitation murmur?

Diastolic murmur. ***Diastolic murmur*** - Aortic regurgitation occurs when the **aortic valve does not close completely**, leading to blood flowing back into the **left ventricle during diastole** [1]. - This backflow of blood during the **relaxation phase** of the heart creates the characteristic diastolic murmur [1]. *Ejection systolic murmur* - This murmur type is typically heard during **systole** and is associated with conditions like **aortic stenosis**, where there is turbulent flow across a narrowed aortic valve during ejection [3]. - It does not describe the sound of blood flowing back into the ventricle during **diastole**, which characterizes aortic regurgitation. *Ventricular contraction* - **Ventricular contraction** occurs during **systole** and is the mechanism by which blood is ejected from the ventricles [2]. - While related to cardiac cycle, it does not directly describe the timing or nature of the murmur caused by aortic regurgitation. *Systolic murmur* - A **systolic murmur** is heard when the ventricles contract, such as in conditions like **aortic stenosis** or **mitral regurgitation** [3]. - Aortic regurgitation is specifically a **diastolic event** as blood leaks back into the left ventricle during ventricular relaxation [1].

Q: A 14 year old male presents with mushroom like tumor in the distal femur for past 2 years. Which of the following features suggest malignant transformation?

Cartilage thickness $>2 \mathrm{~cm}$. ***Cartilage thickness >2 cm*** - A **cartilage cap thickness greater than 2 cm** in an osteochondroma in an adult (or >3 cm in children) is a strong indicator of **malignant transformation** into a secondary peripheral **chondrosarcoma**. [2], [3] - **Key imaging finding:** Cartilage cap measured on MRI or CT scan - Other features suggesting malignant transformation include continued growth after skeletal maturity, new or increasing pain, cortical destruction, and new soft tissue mass. [2], [3] *Presence of cartilage cap* - All osteochondromas have a cartilage cap by definition - this is a normal feature, not a sign of malignancy. [1] - The **thickness** of the cap, not its presence, is what matters. *Location in metaphysis* - Osteochondromas typically arise from the metaphysis near the growth plate - this is a normal location. [3] - Location alone does not indicate malignant transformation. *Size less than 1 cm* - Small size suggests a benign, stable lesion. - Malignant transformation is suggested by **increasing size** and growth after skeletal maturity, not small size. [2] **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1202. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 672-673. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1202-1204.

Q: Abnormal accumulation of misfolded protein is seen in?

Creutzfeldt-Jakob disease. ***Creutzfeldt-Jakob disease*** - This is a neurodegenerative disease characterized by the accumulation of **abnormally folded prion proteins (PrPSc)** in the brain, leading to spongiform encephalopathy [1]. - The misfolding of normal cellular prion protein (PrPC) into its infectious and pathogenic form is central to the disease's pathology [2]. *Nephritic syndrome* - This syndrome is characterized by inflammation of the **glomeruli** in the kidneys, leading to hematuria, proteinuria, and hypertension. - It involves immune complex deposition and inflammation, not primarily the accumulation of misfolded proteins. *Sickle cell anemia* - This is a **genetic blood disorder** caused by a mutation in the beta-globin gene, leading to abnormal **hemoglobin S**. - While hemoglobin S can polymerize and deform red blood cells, it is not considered a disease of generalized misfolded protein accumulation in the same sense as prion diseases. *Megaloblastic anemia* - This condition is caused by impaired **DNA synthesis**, often due to **vitamin B12 or folate deficiency**, leading to large, immature red blood cells. - The pathology involves defective cell division and maturation, not the accumulation of misfolded proteins. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1284-1286. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 712-713.

Q: A 35-year-old male patient presents to surgery emergency with painful erection for past 7 hours. He has a history of mood disorder and was recently prescribed a medication by treating psychiatrist. Which is the likely offending drug?

Trazodone. ***Trazodone*** - **Trazodone** is a commonly known antidepressant that can cause **priapism** as a side effect, especially at higher doses, due to its alpha-adrenergic blocking activity. [1] - The patient's presentation of a **painful erection lasting 7 hours** after starting a new psychiatric medication strongly points towards a drug-induced cause, for which trazodone is a well-established culprit. [1] *Venlafaxine* - **Venlafaxine** is an SNRI antidepressant that generally does not cause priapism as a recognized side effect. - Its adverse effect profile primarily includes nausea, insomnia, and sexual dysfunction (e.g., erectile dysfunction, anorgasmia), rather than prolonged erections. *Tianeptine* - **Tianeptine** is an atypical antidepressant that is not known to cause priapism. - It works by enhancing serotonin reuptake and is more commonly associated with side effects such as nausea, constipation, and dizziness. *Mirtazapine* - **Mirtazapine** is a tetracyclic antidepressant that works by blocking alpha-2 adrenergic receptors and certain serotonin receptors. - While it can cause sedation and weight gain, priapism is not a typical or recognized side effect of mirtazapine.

Q: What should be done as an immediate measure for ongoing bleeding in a patient with pelvic bone fracture?

Use Pelvic Binders. **Use Pelvic Binders** - **Pelvic binders** apply circumferential compression, which helps to stabilize the fracture and reduce the pelvic volume. - This mechanical stabilization significantly reduces ongoing hemorrhage from venous and bone surface bleeding in unstable pelvic fractures. *Rapid blood transfusion* - While critically important for managing **hemorrhagic shock**, blood transfusion alone does not address the source of ongoing bleeding. - It is a supportive measure, not an immediate means to stop the bleeding from an unstable pelvic fracture. *Internal definitive fixation* - **Internal definitive fixation** is a surgical procedure aimed at permanently stabilizing the fracture and would typically be performed after initial resuscitation and bleeding control. - It is not an immediate measure for **ongoing life-threatening hemorrhage** and carries procedural risks. *External fixation* - **External fixation** can stabilize an unstable pelvic fracture and helps in controlling bleeding, but applying a **pelvic binder** is a quicker and less invasive initial step. - External fixation is usually performed by a surgeon in a controlled environment, not as the very first immediate bedside measure to stop bleeding.

Question 1

Non-scarring alopecia is associated with all except?

Accepted Answer

Frontal fibrosing alopecia

Answer

Telogen effluvium

Answer

Androgenetic alopecia

Answer

Alopecia areata

Question 2

A 24-year-old male presents with asymptomatic scaly lesions over the body as shown in the image below. What is the likely diagnosis?

Accepted Answer

Pityriasis Rosea

Answer

Atopic Dermatitis

Answer

Lichen planus

Answer

Seborrheic Dermatitis

Question 3

Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split.
Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.

Accepted Answer

Statements 1 & 2 are correct, 2 is not explaining 1

Answer

Statements 1 and 2 are correct and 2 is the correct explanation for 1

Answer

Statements 1 and 2 are incorrect

Answer

Statement 1 is incorrect

Question 4

A 60-year-old female presents with eczematous itching lesions. Biopsy revealed a subepidermal cleft with Direct Immunofluorescence showing Linear C3 & IgG deposition along the basement membrane zone. What is the likely diagnosis?

Accepted Answer

Bullous Pemphigoid

Answer

Pemphigus foliaceus

Answer

Pemphigus Vulgaris

Answer

Dermatitis herpetiformis

Question 5

Identify the ECG given below?

Accepted Answer

Torsades de pointes

Answer

Viral myocarditis

Answer

Cardiac tamponade

Answer

Pericarditis

Question 6

Which of the following describes aortic regurgitation murmur?

Accepted Answer

Diastolic murmur

Answer

Ejection systolic murmur

Answer

Ventricular contraction

Answer

Systolic murmur

Question 7

A 14 year old male presents with mushroom like tumor in the distal femur for past 2 years. Which of the following features suggest malignant transformation?

Accepted Answer

Cartilage thickness $>2 \mathrm{~cm}$

Answer

Presence of cartilage cap

Answer

Location in metaphysis

Answer

Size less than 1 cm

Question 8

Abnormal accumulation of misfolded protein is seen in?

Accepted Answer

Creutzfeldt-Jakob disease

Answer

Nephritic syndrome

Answer

Sickle cell anemia

Answer

Megaloblastic anemia

Question 9

A 35-year-old male patient presents to surgery emergency with painful erection for past 7 hours. He has a history of mood disorder and was recently prescribed a medication by treating psychiatrist. Which is the likely offending drug?

Accepted Answer

Trazodone

Answer

Venlafaxine

Answer

Tianeptine

Answer

Mirtazapine

Question 10

What should be done as an immediate measure for ongoing bleeding in a patient with pelvic bone fracture?

Accepted Answer

Use Pelvic Binders

Answer

Rapid blood transfusion

Answer

External fixation

Answer

Internal definitive fixation

INI-CET 2023

Dermatology

Internal Medicine

Pathology

Pharmacology

Surgery