INI-CET 2021 Practice Questions

Q: A young man presented with painful vesicular lesions distributed along a dermatomal pattern on one side of his body. What is the likely diagnosis?

Herpes Zoster. ***Herpes Zoster*** - This condition is characterized by a **unilateral rash** that respects the **dermatomal distribution**, meaning it follows the path of a single nerve. - The lesions are typically **painful vesicles** and crusts, often associated with a burning sensation due to reactivation of the **varicella-zoster virus** (chickenpox virus). *Lymphangioma circumscriptum* - This is a rare **lymphatic malformation** presenting as clusters of **vesicles** or papules, often described as 'frog spawn' or 'tapioca pudding' in appearance. - While it can be painful, it usually does not follow a dermatomal pattern and is a congenital condition, not an acute viral eruption. *Molluscum contagiosum* - This is a viral skin infection producing small, firm, **umbilicated papules** that are typically flesh-colored or pearly. - While contagious, these lesions are generally **asymptomatic** and do not present with the acute pain, blistering, or dermatomal distribution characteristic of herpes zoster. *Herpes simplex* - This infection causes localized clusters of painful **vesicles** on an erythematous base, most commonly around the mouth (cold sores) or genitals. - Unlike herpes zoster, herpes simplex lesions typically recur in the same small area and do **not follow a dermatomal distribution**.

Q: A patient presents with vertigo, tinnitus, and head tilt. He underwent myringoplasty for the safe type of chronic suppurative otitis media (CSOM) 6 months back. What is your diagnosis?

Perilymphatic fistula. ***Perilymphatic fistula*** - The combination of **vertigo**, **tinnitus**, and **head tilt** occurring after a **myringoplasty**, even for a safe type of CSOM, suggests a perilymphatic fistula. - Myringoplasty can occasionally involve trauma to the **oval or round window**, leading to a direct communication between the inner ear (perilymph) and the middle ear, causing these symptoms. *Paget disease* - This is a **bone remodeling disorder** that primarily affects the skull, pelvis, and long bones, leading to bone pain and deformities. - While it can cause hearing loss (due to otosclerosis) and a sense of imbalance, it does not typically present with the acute onset of **vertigo** and **tinnitus** following ear surgery. *Labyrinthitis* - **Labyrinthitis** is an inflammation of the inner ear, typically caused by a viral infection, leading to sudden, severe **vertigo**, **nausea**, and often **hearing loss** or **tinnitus**. - While the symptoms of vertigo and tinnitus are present, the history of recent myringoplasty makes a **structural compromise** like a perilymphatic fistula a more specific diagnosis than generalized inflammation. *Vestibular schwannoma* - Also known as an acoustic neuroma, this is a **benign tumor** on the eighth cranial nerve, causing **gradual unilateral hearing loss**, **tinnitus**, and **imbalance**, but rarely sudden, intense vertigo unless very large. - The presentation with a history of myringoplasty and acute symptoms makes a **spontaneous structural defect** more likely than a slowly growing tumor.

Q: Match the following weapons with their corresponding injury types: Weapons: A. Axe B. RTA (Road Traffic Accident) C. Blade D. Lathi Injury Types: 5. Incised wound 6. Tram track bruise 7. Grazed abrasion 8. Chop wound

A-8, B-7, C-5, D-6. ***A-8 (Axe - Chop wound), B-7 (RTA - Grazed abrasion), C-5 (Blade - Incised wound), D-6 (Lathi - Tram track bruise)*** - An **axe** is a heavy cutting tool that typically causes a **chop wound**, characterized by a combination of cutting and crushing. - A **Road Traffic Accident (RTA)** frequently results in **grazed abrasions** due to friction and shearing forces as the body slides against rough surfaces. - A **blade** (like a knife or razor) is designed to cut, producing an **incised wound** with clean, sharp edges. - A **lathi** (a heavy stick or baton) delivers blunt force trauma, often causing a **tram track bruise** due to the skin being crushed between the impactor and underlying bone, leading to parallel lines of bruising. *A-5, B-6, C-8, D-7* - This option incorrectly associates an **axe** with an **incised wound** (which is caused by a blade) and a **blade** with a **chop wound** (caused by an axe). - It also misattributes **RTA** to a **tram track bruise** and a **lathi** to a **grazed abrasion**, which are not the most typical injury patterns for these respective weapons/mechanisms. *A-6, B-8, C-7, D-5* - This pairing mistakenly links an **axe** with a **tram track bruise** and a **blade** with a **grazed abrasion**. - It also incorrectly associates an **RTA** with a **chop wound** and a **lathi** with an **incised wound**. *A-7, B-5, C-6, D-8* - This option incorrectly matches an **axe** with a **grazed abrasion** and a **lathi** with a **chop wound**. - It also inaccurately connects an **RTA** with an **incised wound** and a **blade** with a **tram track bruise**.

Q: A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?

IV thrombolysis. ***IV thrombolysis*** - This patient presents with **acute ischemic stroke** symptoms (right-sided weakness and aphasia) with an onset within 4.5 hours of symptom onset, making them a candidate for **IV thrombolysis** [1]. - A **clear NCCT** of the head within this timeframe rules out **hemorrhage**, confirming the safety profile for thrombolytic administration under appropriate blood pressure control [1]. *MRI Brain* - While an MRI brain is highly sensitive for **detecting acute ischemic changes**, it is typically not the initial emergent imaging choice in suspected stroke due to its longer acquisition time and limited availability compared to CT [1]. - The primary goal in acute stroke evaluation is to **rule out hemorrhage** quickly to determine eligibility for thrombolytics, which NCCT achieves effectively [1]. *Antihypertensive therapy* - While the patient's **blood pressure is elevated**, aggressive lowering is generally avoided in acute ischemic stroke unless it exceeds 220/120 mmHg (for non-thrombolysis candidates) or 185/110 mmHg (for thrombolysis candidates). - Rapidly lowering blood pressure can **reduce cerebral perfusion pressure** and worsen ischemic injury in the acute setting due to impaired autoregulation. *CT Angiography* - **CT angiography** can help identify large vessel occlusions that might be amenable to **endovascular thrombectomy** [1]. - However, the immediate priority after a clear NCCT and within the narrow time window is to initiate IV thrombolysis if no contraindications exist, as it provides systemic thrombolysis. CTA is usually performed concurrently or immediately after initial thrombolysis consideration/initiation if endovascular therapy is also being considered [1].

Q: Which of the following is not true about syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Urinary sodium <20 mEq/L. ***Urinary sodium <20 mEq/L*** - In **SIADH**, the inappropriate secretion of ADH leads to increased water reabsorption, causing **dilutional hyponatremia**. [1] - The kidneys respond by trying to excrete excess water and dilute the urine, leading to **increased urinary sodium concentration**, typically *greater than* 20 mEq/L. *Patient can be clinically euvolemic to hypovolemic* - Patients with **SIADH** are typically **euvolemic** because the excess water is retained intracellularly and extracellularly in balanced proportions, without significant edema or dehydration. [1] - While fluid retention occurs, it's not enough to cause significant clinical volume overload, and they are never truly hypovolemic. *Urine osmolality >100 mOsm/kg* - In **SIADH**, the continued action of **ADH** despite hypotonicity results in the reabsorption of water, leading to the production of **concentrated urine**. [1] - This elevated urine osmolality, typically **greater than 100 mOsm/kg**, indicates an inability to adequately excrete free water. [1] *Serum sodium <135 mEq/L* - **SIADH** is defined by **hyponatremia**, a serum sodium concentration **below 135 mEq/L**, due to the excessive retention of water. - This dilutes the extracellular fluid, leading to a reduction in the relative concentration of sodium.

Q: Treatment of choice for an acute attack of cluster headache is:

100 % oxygen at 6 L / minute. The treatment of choice for an acute attack of cluster headache is 100% oxygen at 6 L / minute. High-flow 100% oxygen delivered via a non-rebreather mask for 15-20 minutes is a highly effective and rapid treatment for acute cluster headache attacks [1]. Its mechanism of action is thought to involve cerebral vasoconstriction, which helps to alleviate the pain. While subcutaneous sumatriptan is effective for acute cluster headache [1], its use is limited to 2 injections per 24 hours due to the risk of coronary vasoconstriction. Oxygen therapy is generally preferred as a first-line acute treatment due to its rapid onset and favorable side-effect profile. Oral sumatriptan has a slower onset of action compared to subcutaneous administration and oxygen, making it less suitable for the rapid relief required for an acute cluster headache attack. The rapid and severe nature of cluster headache pain necessitates treatments with a quick therapeutic effect [1]. Verapamil is a calcium channel blocker used as a prophylactic treatment to prevent cluster headache attacks [1], not to treat an acute attack. Prophylactic medications are taken regularly to reduce the frequency and severity of attacks, whereas abortive treatments are used during an attack.

Q: A 35-year-old female patient with class II pulmonary hypertension presents with a negative vasoreactive test. Which of the following is used in the next step of management?

Ambrisentan. ***Ambrisentan*** - For patients with **Class II pulmonary hypertension** and a **negative vasoreactive test**, initial management typically involves **endothelin receptor antagonists (ERAs)**, phosphodiesterase-5 inhibitors (PDE5i), or guanylate cyclase stimulators (GCS). - **Ambrisentan** is an ERA that improves exercise capacity and delays clinical worsening in these patients. *Epoprostenol* - This is a **parenteral prostacyclin analog** reserved for patients with more severe pulmonary hypertension (WHO Class III or IV) or those who fail initial oral therapy. - Due to its continuous intravenous infusion, **high cost**, and side effects, it is not a first-line treatment for Class II PH. *Nifedipine* - **Calcium channel blockers (CCBs)** like nifedipine are only indicated for patients with a **positive vasoreactive test**, as they selectively dilate pulmonary arteries in these individuals. - For patients with a negative vasoreactive test, CCBs are **ineffective** and can be harmful due to systemic vasodilation causing hypotension. *Iloprost* - **Iloprost** is an inhaled prostacyclin analog used for patients with moderate to severe pulmonary hypertension (WHO Class III or IV), often in combination with other therapies. [1] - Its **inhalation route** and frequent dosing make it less practical for initial management of Class II disease compared to oral agents.

Q: Which of the following drugs is preferred in the management of primary progressive multiple sclerosis?

Ocrelizumab. ***Ocrelizumab*** - **Ocrelizumab** is the first and only FDA-approved disease-modifying therapy for **primary progressive multiple sclerosis (PPMS)**, demonstrating a reduction in disability progression. - It is a **monoclonal antibody** that selectively targets CD20-positive B cells, believed to play a critical role in the pathogenesis of MS. *Natalizumab* - **Natalizumab** is approved for **relapsing-remitting multiple sclerosis (RRMS)**, not primary progressive MS [1]. - It works by blocking the migration of immune cells into the **central nervous system**, but carries a risk of **progressive multifocal leukoencephalopathy (PML)**. *Alemtuzumab* - **Alemtuzumab** is used for **relapsing forms of MS**, particularly in patients who have had an inadequate response to other MS drugs [1]. - It is known for its durable efficacy but also its significant side effects, including **autoimmune conditions** and **infusion reactions**. *Fingolimod* - **Fingolimod** is an oral medication approved for **relapsing forms of MS**, but not for primary progressive MS [1]. - It acts by trapping lymphocytes in the **lymph nodes**, preventing them from entering the central nervous system.

Q: A 60-year-old male patient with critical mitral stenosis presented with atrial fibrillation. He has a history of multiple episodes of transient ischemic attacks. Which of the following are true regarding preventing stroke in this patient? 1. Only aspirin is given 2. Warfarin is given 3. Direct oral anticoagulants are not indicated 4. Mitral valvotomy should be recommended

2 and 3. ***2 and 3*** - In patients with **mitral stenosis** and **atrial fibrillation**, **warfarin** is the recommended anticoagulant for stroke prevention due to its efficacy in preventing thrombus formation in the left atrium [1]. - **Direct oral anticoagulants (DOACs)** are generally **contraindicated** in patients with moderate to severe mitral stenosis, as their effectiveness and safety in this specific population have not been established. *1 only* - **Aspirin monotherapy** is insufficient for stroke prevention in patients with **atrial fibrillation** and **mitral stenosis**, as their risk of thromboembolism is significantly higher [1]. - Aspirin has a lower efficacy compared to warfarin in preventing cardioembolic strokes originating from left atrial thrombi in this demographic. *1,2,3 and 4* - While warfarin is indicated and DOACs are not, recommending **mitral valvotomy** should be considered in conjunction with anticoagulation, but it is not the sole or primary measure for acute stroke prevention [2]. - The combination of all four statements is incorrect because DOACs are contraindicated, and aspirin alone is inadequate. *2,3 and 4* - Although **warfarin** is indicated and **DOACs** are not, recommending **mitral valvotomy** is a therapeutic intervention for the underlying structural heart disease, not a direct acute stroke prevention medication [2]. - Valvotomy improves hemodynamics and may reduce future thrombus risk, but immediate stroke prevention heavily relies on effective anticoagulation [2].

Question 1

A young man presented with painful vesicular lesions distributed along a dermatomal pattern on one side of his body. What is the likely diagnosis?

Accepted Answer

Herpes Zoster

Answer

Lymphangioma circumscriptum

Answer

Molluscum contagiosum

Answer

Herpes simplex

Question 2

A patient presents with vertigo, tinnitus, and head tilt. He underwent myringoplasty for the safe type of chronic suppurative otitis media (CSOM) 6 months back. What is your diagnosis?

Accepted Answer

Perilymphatic fistula

Answer

Paget disease

Answer

Labyrinthitis

Answer

Vestibular schwannoma

Question 3

Match the following weapons with their corresponding injury types:

Weapons:
A. Axe
B. RTA (Road Traffic Accident)
C. Blade
D. Lathi

Injury Types:
5. Incised wound
6. Tram track bruise
7. Grazed abrasion
8. Chop wound

Accepted Answer

A-8, B-7, C-5, D-6

Answer

A-5, B-6, C-8, D-7

Answer

A-6, B-8, C-7, D-5

Answer

A-7, B-5, C-6, D-8

Question 4

A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?

Accepted Answer

IV thrombolysis

Answer

MRI Brain

Answer

Antihypertensive therapy

Answer

CT Angiography

Question 5

Which of the following is not true about syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Accepted Answer

Urinary sodium <20 mEq/L

Answer

Patient can be clinically euvolemic to hypovolemic

Answer

Urine osmolality >100 mOsm/kg

Answer

Serum sodium <135 mEq/L

Question 6

Treatment of choice for an acute attack of cluster headache is:

Accepted Answer

100 % oxygen at 6 L / minute

Answer

Subcutaneous sumatriptan

Answer

Oral sumatriptan

Answer

Prophylactic verapamil

Question 7

A 35-year-old female patient with class II pulmonary hypertension presents with a negative vasoreactive test. Which of the following is used in the next step of management?

Accepted Answer

Ambrisentan

Answer

Epoprostenol

Answer

Nifedipine

Answer

Iloprost

Question 8

Which of the following drugs is preferred in the management of primary progressive multiple sclerosis?

Accepted Answer

Ocrelizumab

Answer

Natalizumab

Answer

Alemtuzumab

Answer

Fingolimod

Question 9

A 60-year-old male patient with critical mitral stenosis presented with atrial fibrillation. He has a history of multiple episodes of transient ischemic attacks. Which of the following are true regarding preventing stroke in this patient?

1. Only aspirin is given
2. Warfarin is given
3. Direct oral anticoagulants are not indicated
4. Mitral valvotomy should be recommended

Accepted Answer

2 and 3

Answer

1 only

Answer

1,2,3 and 4

Answer

2,3 and 4

Question 10

Which cell acts as the primary effector cell in type IV (delayed-type) hypersensitivity reactions?

Accepted Answer

Macrophage

Answer

Neutrophil

Answer

Dendritic cell

Answer

Cytotoxic T cell

INI-CET 2021

Dermatology

ENT

Forensic Medicine

Internal Medicine

Pathology