INI-CET 2025 Practice Questions

Q: Which of the following is wrongly matched with its classification?

LA classification - Achalasia. ***LA classification - Achalasia*** - The **Los Angeles (LA) classification** system is used to grade the severity of **reflux esophagitis** (Esme of the gastric mucosa, typically following **Gastroesophageal Reflux Disease (GERD)**). - **Achalasia** is typically classified using the **Chicago Classification** (based on high-resolution manometry findings) [1] or the older **Siewert classification** for surgical staging. ***Boston classification - Colon preparation for colonoscopy*** - The **Boston Bowel Preparation Scale (BBPS)** is a validated, widely used scoring system to assess the quality of **colon preparation** during colonoscopy, ranging from 0 (unprepared) to 3 (excellent) for each segment. - A high BBPS score (typically $\ge$ 7) indicates adequate preparation necessary for accurate polyp detection. ***Mannheim classification - Chronic pancreatitis*** - The **Mannheim Classification System** is used for grading the severity of **acute pancreatitis**, not chronic pancreatitis. - It assesses clinical parameters (e.g., organ failure, complications) to predict the prognosis and guide management of acute pancreatitis. ***Miami classification - Parathyroid adenoma and hyperplasia differentiation*** - The **Miami Criteria** is a histological classification system used to distinguish between **parathyroid adenoma** and **parathyroid hyperplasia** based on architectural and cellular features observed on surgical pathology. - It helps pathologists determine the underlying cause of primary hyperparathyroidism.

Q: What is the cause of hyponatremia in diarrhea-induced hypovolemia?

Decreased aldosterone. ***Decreased aldosterone*** * In scenarios where salt loss (e.g., due to diarrhea) leads to hypovolemia, a relative or true deficiency of **aldosterone** prevents maximal sodium reabsorption in the distal tubules and collecting ducts. * This failure to maximally conserve sodium leads to **renal salt wasting**, which exacerbates the volume deficit and, when coupled with ADH-mediated water retention, results in hyponatremia. ***Decreased ADH*** * Hypovolemia (volume depletion) is the strongest non-osmotic trigger for the release of **Antidiuretic Hormone (ADH)** from the posterior pituitary, overriding low plasma osmolality [1]. * Therefore, in diarrhea-induced hypovolemia, **ADH levels are actually increased**, which drives powerful free water reabsorption in the kidney, resulting in dilutional hyponatremia [1]. ***Decreased sodium absorption from gastrointestinal tract*** * This is the primary mechanism by which diarrhea causes salt and water loss, leading to the state of **hypovolemia**. * However, the mechanism driving the *hyponatremia* (low plasma sodium concentration) involves the kidney's disproportionate reabsorption of water relative to sodium, mediated by **ADH**. ***Increased sodium absorption from kidney*** * System mechanisms like the Renin-Angiotensin-Aldosterone System (RAAS) are activated by hypovolemia to increase **sodium and water absorption** in an attempt to restore blood volume [2]. * Increased renal sodium absorption is a compensatory mechanism that works against hyponatremia; thus, it is not the cause of low plasma sodium.

Q: A white patch is observed in the oral cavity of an immunocompromised patient. Which of the following findings is most likely on microscopy?

Pseudo-hyphae. ***Pseudo-hyphae*** - The clinical presentation of a white patch in an immunocompromised patient is highly suggestive of **oral candidiasis** (thrush), typically caused by *Candida albicans*. - In tissue samples (like oral scrapings), *Candida albicans* characteristically appears as **budding yeast** cells along with distinct chains of elongated yeast cells known as **pseudo-hyphae**. ***Branching septate hyphae*** - These structures are characteristic of filamentous fungi, such as **Aspergillus** species or dermatophytes (e.g., *Tinea* infections). - While *Candida* can form true hyphae under certain conditions, **pseudo-hyphae** are the hallmark feature observed in routine smear microscopy for oral candidiasis. ***Budding yeast with capsule*** - This microscopic finding is pathognomonic for **Cryptococcus neoformans**, which causes cryptococcosis. - The capsule is often visualized using special stains like mucicarmine or India ink, and *Cryptococcus* typically causes systemic disease or **meningoencephalitis**, not simple oral thrush. ***Sulfur granules*** - **Sulfur granules** are characteristic aggregates of filamentous bacteria seen in infections caused by **Actinomyces israelii**, leading to **Actinomycosis**. - Actinomycosis usually presents as chronic, indolent abscesses that drain sinus tracts, most commonly in the cervicofacial region.

Q: Identify the procedure shown in the image.

Dog ear excision. ### **Explanation: Dog Ear Excision** **1. Why the Correct Answer is Right:** A **"Dog ear"** (also known as a cone or cutaneous redundancy) occurs during the closure of a circular or elliptical wound when one side of the wound is longer than the other, or when the closure angle is too obtuse. This results in a **puckered elevation of skin** at the ends of the suture line. * **The Procedure:** To correct this, the surgeon extends the incision slightly, creates a small triangular flap of the redundant tissue, and excises it to allow the skin to lie flat. This converts the wound into a slightly longer, but aesthetically pleasing, linear scar. **2. Why the Other Options are Wrong:** * **Keloid Excision:** Keloids are firm, rubbery lesions that extend beyond the boundaries of the original wound. Excision involves removing the entire bulk of hypertrophic tissue, often followed by adjuvant therapy (like intralesional steroids) to prevent recurrence. * **Z-plasty:** This is a transposition flap technique used to **lengthen a scar** or change its direction to align with Relaxed Skin Tension Lines (RSTLs). It involves creating two triangular flaps that are transposed. * **Transposition Flap:** This involves moving a flap of skin and subcutaneous tissue over an incomplete bridge of intact skin to a nearby defect (e.g., Limberg flap). It does not specifically address the puckering seen at the ends of a simple closure. **3. High-Yield Clinical Pearls for INI-CET:** * **Prevention:** To avoid dog ears, the length of an elliptical incision should ideally be **3 times its width**, and the apical angle should be **less than 30 degrees**. * **Rule of Halves:** When suturing, always start at the center of the wound and bisect the remaining segments to distribute tension evenly and minimize the risk of dog ears. * **Mnemonic:** Dog ears are most common in **convex surfaces** (like the scalp or nose) where skin tension is non-uniform.

Q: Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?

0.3. ### **Explanation** The **Ankle-Brachial Pressure Index (ABPI)** is a non-invasive tool used to assess Peripheral Arterial Disease (PAD). It is calculated by dividing the higher systolic blood pressure at the ankle (PTA or DPA) by the higher systolic blood pressure of the arms. **1. Why 0.3 is the Correct Answer:** An ABPI of **<0.3** indicates **critical limb ischemia (CLI)** and **imminent gangrene**. At this level, the perfusion pressure is insufficient to maintain tissue viability even at rest. This stage is clinically characterized by **rest pain**, non-healing ischemic ulcers, and impending tissue necrosis (gangrene). **2. Analysis of Incorrect Options:** * **0.9 (Option B):** This is the lower limit of **normal**. An ABPI between 0.9 and 1.2 is considered healthy. Values between 0.7 and 0.9 indicate mild PAD, often asymptomatic. * **0.7 (Option C):** This indicates **mild to moderate PAD**. Patients at this level typically present with **intermittent claudication** (pain on walking that relieved by rest). * **0.5 (Option D):** This signifies **severe PAD**. While patients have significant symptoms and a high risk of cardiovascular events, "imminent gangrene" is specifically associated with values dropping below 0.4 or 0.3. --- ### **High-Yield Clinical Pearls for NEET-PG / INI-CET** * **ABPI Interpretation Summary:** * **>1.2:** Calcified, non-compressible vessels (commonly seen in **Diabetes Mellitus** and elderly patients). Use Toe-Brachial Index (TBI) instead. * **0.9 – 1.2:** Normal. * **0.5 – 0.9:** Intermittent Claudication. * **<0.4:** Rest Pain. * **<0.3:** Imminent Gangrene / Critical Limb Ischemia. * **Fontaine Classification:** Remember that ABPI <0.3 correlates with Fontaine Stage IV (Ulceration/Gangrene). * **Management Tip:** Patients with ABPI <0.5 or rest pain require urgent surgical or endovascular intervention to prevent limb loss.

Q: A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?

7. The **Alvarado Score** (MANTRELS) is a clinical scoring system used to diagnose **Acute Appendicitis**. It is a high-yield topic for NEET-PG/INI-CET as it helps determine the need for observation, imaging, or surgery. ### **Calculation for this Patient:** The score is calculated based on the **MANTRELS** mnemonic: 1. **M**igration of pain to RIF: **1 point** (Present) 2. **A**norexia: 1 point (Not mentioned) 3. **N**ausea/Vomiting: **1 point** (Present) 4. **T**enderness in RIF: **2 points** (Present) 5. **R**ebound tenderness: 1 point (Not mentioned) 6. **E**levated temperature (>37.3°C): **1 point** (Present/Fever) 7. **L**eukocytosis (>10,000/cmm): **2 points** (Present: 14,000) 8. **S**hift to the left (Neutrophilia): 1 point (Not mentioned) **Total Score: 1 + 1 + 2 + 1 + 2 = 7** --- ### **Why the other options are incorrect:** * **Options A (6) and C (5):** These scores underestimate the weightage of **RIF Tenderness** and **Leukocytosis**, which are the only two parameters that carry **2 points** each. * **Option B (4):** A score of 4 or less makes appendicitis unlikely, whereas this patient presents with classic "textbook" symptoms and significant leukocytosis. --- ### **Clinical Pearls for INI-CET:** * **Interpretation:** * **5–6:** Possible (Equivocal); observation/CT scan recommended. * **7–8:** Probable; surgery usually indicated. * **9–10:** Very probable; immediate appendectomy. * **Modified Alvarado Score:** Excludes "Shift to the left" (Total score out of 9). * **Most common symptom:** Anorexia (often the first sign). * **Most common sign:** Tenderness at **McBurney’s point**. * **Pediatric Alternative:** The **Pediatric Appendicitis Score (PAS)** is often preferred for children.

Q: A 65-year-old patient undergoes colonoscopy for altered bowel habits. A 6 cm colonic mass is biopsied and histopathology shows adenocarcinoma confined to the mucosa with no lymph node or distant metastasis. What is the most appropriate TNM stage of this tumor?

Stage 0. ### **Explanation** The correct answer is **Stage 0**. #### **1. Why Stage 0 is Correct** In the TNM staging of colorectal cancer, the depth of invasion is the primary determinant of the 'T' stage. * **Carcinoma in situ (Tis):** This is defined as cancer cells confined to the **mucosa** (epithelium or lamina propria) without extension through the **muscularis mucosae** into the submucosa. * Because the colonic mucosa lacks lymphatic channels (which begin in the submucosa), tumors confined to the mucosa have essentially **zero risk of regional lymph node metastasis**. * According to the AJCC staging system, **Tis N0 M0** is classified as **Stage 0**. #### **2. Why Other Options are Incorrect** * **Stage I (T1-T2 N0 M0):** Requires invasion into the **submucosa** (T1) or the **muscularis propria** (T2). * **Stage II (T3-T4 N0 M0):** Occurs when the tumor invades through the muscularis propria into the subserosa (T3) or perforates the visceral peritoneum/invades adjacent organs (T4), but without nodal involvement. * **Stage III (Any T, N1-N2 M0):** This stage is defined by the presence of **regional lymph node metastasis**, regardless of the depth of T invasion. #### **3. High-Yield Clinical Pearls for INI-CET** * **The "No Lymphatics" Rule:** Unlike the stomach or esophagus, the colonic lamina propria has no lymphatic vessels. Therefore, "intramucosal carcinoma" in the colon is biologically equivalent to carcinoma in situ. * **Management:** Most Stage 0 lesions can be managed via **endoscopic mucosal resection (EMR)** or polypectomy rather than formal colectomy, provided margins are clear. * **TNM Staging Quick Recall:** * **T1:** Submucosa * **T2:** Muscularis propria * **T3:** Subserosa/Pericolonic fat * **T4:** Perforation of serosa or invasion of other organs.

Question 1

Which of the following is wrongly matched with its classification?

Accepted Answer

LA classification - Achalasia

Answer

Boston classification - Colon preparation for colonoscopy

Answer

Mannheim classification - Chronic pancreatitis

Answer

Miami classification - Parathyroid adenoma and hyperplasia differentiation

Question 2

What is the cause of hyponatremia in diarrhea-induced hypovolemia?

Accepted Answer

Decreased aldosterone

Answer

Decreased ADH

Answer

Decreased sodium absorption from gastrointestinal tract

Answer

Increased sodium absorption from kidney

Question 3

A white patch is observed in the oral cavity of an immunocompromised patient. Which of the following findings is most likely on microscopy?

Accepted Answer

Pseudo-hyphae

Answer

Branching septate hyphae

Answer

Budding yeast with capsule

Answer

Sulfur granules

Question 4

Identify the procedure shown in the image.

Accepted Answer

Dog ear excision

Answer

Keloid excision

Answer

Z plasty

Answer

Transposition flap

Question 5

Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?

Accepted Answer

0.3

Answer

0.9

Answer

0.7

Answer

0.5

Question 6

Which of the following is not a contraindication for breast conservation surgery?

Accepted Answer

Multiple cancer in one quadrant

Answer

Scleroderma

Answer

History of radiation

Answer

Persistent positive margin

Question 7

Which of the following is not included in T4b classification of breast cancer?

Accepted Answer

Cellulitis/erythema over one-third of the breast (inflammatory breast cancer)

Answer

Satellite nodule

Answer

Ulceration

Answer

Peau d'orange

Question 8

A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?

Accepted Answer

7

Answer

6

Answer

4

Answer

5

Question 9

A 40-year-old male with head injury presents with respiratory distress and absent breath sounds on the right. GCS is 8/15. What is the most immediate next step in management?

Accepted Answer

Secure airway

Answer

Contrast-enhanced CT (CECT)

Answer

Oxygen by nasal prongs

Answer

Intercostal chest drain (ICD)

Question 10

A 65-year-old patient undergoes colonoscopy for altered bowel habits. A 6 cm colonic mass is biopsied and histopathology shows adenocarcinoma confined to the mucosa with no lymph node or distant metastasis. What is the most appropriate TNM stage of this tumor?

Accepted Answer

Stage 0

Answer

Stage II

Answer

Stage III

Answer

Stage I

INI-CET 2025

Internal Medicine

Microbiology

Surgery