INI-CET 2026 - Internal Medicine PYQs Practice Questions

Q: A 58-year-old male presents with crushing chest pain radiating to the jaw. His ECG reveals ST- segment elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Right coronary artery. ***Right coronary artery*** - ST-segment elevation in leads II, III, and aVF indicates an **inferior wall myocardial infarction**, which is most commonly supplied by the **Right Coronary Artery (RCA)** in right-dominant circulation. - Occlusion of the RCA can lead to bradycardias or heart blocks due to ischemia of the **AV node**, which is typically supplied by the RCA. *Posterior descending artery* - While the **Posterior Descending Artery (PDA)** supplies the inferior wall of the heart, it is usually a distal branch of the RCA (in right-dominant circulation) rather than the primary vessel involved in an acute occlusion leading to this pattern. - An isolated occlusion of the PDA is less common than an occlusion of the proximal or mid-RCA that also involves the right ventricular branches. *Left circumflex artery* - The **Left Circumflex Artery (LCx)** typically supplies the lateral wall of the heart, corresponding to ECG leads I, aVL, V5, and V6. - Occlusion of the LCx would likely present with ST elevations in the **lateral leads** rather than the inferior leads observed in this patient. *Anterior interventricular artery* - Also known as the Left Anterior Descending (LAD) artery, this vessel supplies the **anterior wall** and the apex of the heart. - Occlusion of the LAD typically manifests as ST elevations in leads **V1–V4**, not the inferior leads (II, III, aVF) seen in this case. [Practice more Internal Medicine PYQs on OnCourse]

Q: A patient presents with hypercalcemia due to malignancy. According to the correct sequence of management, what should be the first step?

Intravenous rehydration with normal saline. ***Intravenous rehydration with normal saline*** - **Volume expansion** with intravenous normal saline is the first-line treatment for **hypercalcemia of malignancy** to restore intravascular volume and promote **calciuresis**. - This step is critical because patients are often dehydrated due to **nephrogenic diabetes insipidus** and vomiting induced by high calcium levels, which exacerbates the hypercalcemia. *Administration of loop diuretics* - Loop diuretics, such as **furosemide**, should only be considered after the patient has been **adequately rehydrated**. - Routine use is discouraged unless there is evidence of **fluid overload** or renal failure, as they can cause further electrolyte imbalances like hypokalemia and hypomagnesemia. *Administration of bisphosphonates* - Bisphosphonates like **zoledronic acid** or **pamidronate** are essential for long-term control by inhibiting **osteoclast** activity. - However, they have a **delayed onset of action** (typically 2-4 days), so they are not the initial treatment step for acute stabilization. *Other supportive measures* - Measures such as **calcitonin** or **dialysis** are reserved for refractory cases or severe symptoms where rapid calcium reduction is required alongside saline and bisphosphonates. - These are not the first-line initial interventions as they do not address the primary issue of fluid volume depletion immediately. [Practice more Internal Medicine PYQs on OnCourse]

Q: A patient presents to the emergency room with breathlessness. Cardiac causes are suspected but need to be differentiated from obstructive lung disease. Which of the following features is more characteristic of heart failure?

Air hunger. ***Air hunger*** - Air hunger, often described as a sensation of suffocation or inability to get enough air, is a classic, though non-specific, symptom commonly associated with heart failure and elevated pulmonary venous pressure. - Unlike the mechanical obstruction felt in lung diseases, air hunger in cardiac patients typically results from pulmonary congestion and the stimulation of J receptors in the lungs. *Chest tightness* - Chest tightness is a hallmark symptom of myocardial ischemia (angina) or severe bronchoconstriction seen in asthma/COPD. - While it can be associated with cardiac ischemia, it is not a specific descriptor for the symptom of breathlessness compared to obstructive lung disease. *Not able to take deep breath* - This description, often termed 'sighing dyspnea' or perception of restricted chest expansion, is frequently associated with anxiety or restrictive lung diseases. - It is less specific to the hemodynamically driven pulmonary congestion seen in chronic heart failure. *Intermittent wheezing* - Intermittent wheezing is a primary manifestation of obstructive airway diseases such as asthma or COPD, where airflow is obstructed. - 'Cardiac asthma' is a presentation of heart failure involving wheezing, but it is less characteristic and typically presents with other signs like orthopnea or PND rather than being a standalone differentiating feature. [Practice more Internal Medicine PYQs on OnCourse]

Q: Which of the following is least likely to be considered a major independent risk factor for falls in the elderly?

Hearing impairment. ***Hearing impairment*** - While sensory deficits can contribute to balance issues, hearing loss is not considered a primary, major independent risk factor for falls compared to mobility-limiting conditions. - Most clinical screening tools for falls emphasize gait, balance, and strength over auditory function. *Muscle weakness (Sarcopenia)* - This is a **major risk factor** as it directly impairs postural control, gait speed, and the ability to recover from a trip or slip. - Maintenance of **lower extremity strength** is the single most important modifiable physical factor in fall prevention. *Advanced age* - Advancing age is a **strong independent risk factor** due to the cumulative decline in multisensory processing and reflex speed. - Physiological aging leads to a decline in **proprioception** and central processing, which significantly increases fall risk. *Arthritis* - Arthritis is a **major risk factor** because it causes chronic pain, joint stiffness, and limited range of motion, which restrict physical activity. - Impaired joint function often leads to altered gait mechanics and increased instability. [Practice more Internal Medicine PYQs on OnCourse]

Q: A 35-year-old HIV-positive female on irregular ART presents with headache, confusion, fever, and right-sided weakness. Her CD4 count is 40 cells/mm³. MRI brain shows multiple ring-enhancing lesions in the basal ganglia. What is the most likely diagnosis?

Cerebral toxoplasmosis. ***Cerebral toxoplasmosis*** - This is the most common cause of **multiple ring-enhancing lesions** in HIV-positive patients with CD4 counts < 100 cells/mm³. - The clinical presentation of **fever**, **headache**, and focal neurologic deficits (like the patient's right-sided weakness) often localizing to the **basal ganglia** is classic for this opportunistic infection. *Primary CNS lymphoma* - Typically presents as a **solitary lesion** on MRI rather than multiple lesions, though it can occasionally be multifocal. - It is generally associated with **Epstein-Barr virus (EBV)** DNA detection in the cerebrospinal fluid and often appears as a **periventricular mass**. *Progressive multifocal leukoencephalopathy (PML)* - Caused by the **JC virus**, this condition typically presents with **non-enhancing** white matter lesions on MRI. - It usually leads to progressive cognitive decline, ataxia, and visual disturbances without the **mass effect** or **ring enhancement** seen with abscesses or tumors. *Neurocysticercosis* - Characterized by lesions in varying stages of development, often showing **calcified nodules** or **cysts with scolex** on imaging. - While it can manifest as ring-enhancing lesions, it is a **parasitic infection** (Taenia solium) not specifically linked to the profound immunosuppression and opportunistic profile seen in this HIV-positive case. [Practice more Internal Medicine PYQs on OnCourse]

Question 1

A 58-year-old male presents with crushing chest pain radiating to the jaw. His ECG reveals ST-
segment elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Accepted Answer

Right coronary artery

Answer

Posterior descending artery

Answer

Left circumflex artery

Answer

Anterior interventricular artery

Question 2

A patient presents with hypercalcemia due
to malignancy. According to the correct sequence of management, what should be the first step?

Accepted Answer

Intravenous rehydration with normal saline

Answer

Administration of loop diuretics

Answer

Administration of bisphosphonates

Answer

Other supportive measures

Question 3

A patient presents to the emergency room with breathlessness. Cardiac causes are suspected
but need to be differentiated from obstructive lung disease. Which of the following features is more
characteristic of heart failure?

Accepted Answer

Air hunger

Answer

Chest tightness

Answer

Not able to take deep breath

Answer

Intermittent wheezing

Question 4

Which of the following is least likely to be considered a major independent risk factor for falls in
the elderly?

Accepted Answer

Hearing impairment

Answer

Muscle weakness (Sarcopenia)

Answer

Advanced age

Answer

Arthritis

Question 5

A 35-year-old HIV-positive female on irregular ART presents with headache, confusion, fever, and
right-sided weakness. Her CD4 count is 40 cells/mm³. MRI brain shows multiple ring-enhancing
lesions in the basal ganglia. What is the most likely diagnosis?

Accepted Answer

Cerebral toxoplasmosis

Answer

Primary CNS lymphoma

Answer

Progressive multifocal leukoencephalopathy (PML)

Answer

Neurocysticercosis

Question 6

A patient on long-term steroid therapy presents with centripetal obesity, buffalo hump, and
abdominal striae. Dexamethasone suppression test confirms the diagnosis. What is the next
investigation to identify the source?

Accepted Answer

ACTH level

Answer

CECT adrenal

Answer

Non-contrast CT adrenal

Answer

MRI pituitary gland

Question 7

A 5-year-old child presents with recurrent episodes since age 3, characterized by sudden
behavioral arrest, repetitive picking movements of the right hand, and goosebumps. The child is
unresponsive during episodes and has no memory of them afterward. Which of the following is
correct?
1. Focal seizure with intact awareness
2. Focal seizure with impaired awareness
3. Frontal lobe semiology
4. Temporal lobe semiology

Accepted Answer

2 and 4

Answer

1 and 3

Answer

2 and 3

Answer

1 and 4

Question 8

In which of the following conditions is cyanosis most likely to be a clinical finding?

Accepted Answer

Eisenmenger syndrome

Answer

Atrioventricular septal defect

Answer

Partial anomalous pulmonary venous connection

Answer

Advanced aortic stenosis

Question 9

A 38-year-old male presents with sudden onset palpitations. He has no known comorbidities and
his vitals are stable. ECG shows an irregularly irregular rhythm with no identifiable P waves and a
ventricular rate of 130 beats per minute. What is the most likely diagnosis?

Accepted Answer

Atrial fibrillation

Answer

Multifocal atrial tachycardia

Answer

Atrial flutter

Answer

Supraventricular tachycardia

Question 10

A 45-year-old farmer from Northeast India presents with low-grade fever, progressive weight
loss, night sweats, and productive cough. Chest CT reveals upper lobe cavitary lesions. Lung
biopsy shows granulomatous inflammation with caseous necrosis and abundant histiocyte
infiltration. What is the most likely diagnosis?

Accepted Answer

Histoplasmosis

Answer

Aspergillosis

Answer

Sarcoidosis

Answer

Cryptococcosis

INI-CET 2026 — Internal Medicine