INI-CET 2026 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.

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.

Q: A 21-year-old girl presents with primary amenorrhea. Examination shows absent uterus, present breast development, and sparse pubic and axillary hair. What is the genetic etiology?

MRKH. ***Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome*** - Characterized by **Müllerian agenesis** (absent uterus and upper two-thirds of the vagina), which explains the primary amenorrhea despite normal ovarian function. - Patients have a **46,XX** karyotype, normal breast development due to functional ovaries, and normal secondary sexual characteristics, though pubic hair may be lighter depending on individual variance. *Androgen insensitivity syndrome (AIS)* - Presents with **46,XY karyotype** and **testis** (often undescended) rather than ovaries, and markedly absent pubic and axillary hair due to lack of androgen effect. - While breast development is present, it is due to aromatization of testicular testosterone to estrogen; this is distinguished from MRKH by the presence of testes and absent uterus. *Turner's syndrome* - Presents with **streak gonads** and hypergonadotropic hypogonadism, meaning patients typically have **absent breast development** without hormone replacement therapy. - Associated with a **45,X karyotype**, short stature, and other phenotypic features like webbed neck, rather than normal development with absent uterus. *Congenital adrenal hyperplasia (CAH)* - Typically presents with **ambiguous genitalia** in infancy due to virilization, though late-onset forms may present later. - Patients usually have a uterus, and findings typically involve excessive androgen production (acne, hirsutism, menstrual irregularities) rather than absent Müllerian structures.

Q: Match the following conditions with their hormonal profiles: Condition Hormonal Profile 1. PCOS A. Normal FSH, Normal LH, Normal Estradiol B. Decreased FSH, Decreased LH, Decreased 2. Primary Ovarian Failure Estradiol C. Increased LH, Normal to Low FSH (High 3. Asherman Syndrome LH:FSH ratio) 4. Sheehan Syndrome D. Markedly Increased FSH, Low Estradiol

1-C, 2-D, 3-A, 4-B. ***1-C, 2-D, 3-A, 4-B*** - **PCOS (1-C)** is classically associated with an **increased LH:FSH ratio** (often >2:1 or >3:1) due to dysfunctional feedback mechanisms, while **Primary Ovarian Failure (2-D)** presents with **hypergonadotropic hypogonadism** characterized by **markedly elevated FSH** due to lack of negative feedback from the ovaries. - **Asherman Syndrome (3-A)** is an anatomical cause of amenorrhea due to intrauterine adhesions, meaning the **hypothalamic-pituitary-ovarian axis** remains intact, resulting in **normal hormonal levels**; conversely, **Sheehan Syndrome (4-B)** is caused by pituitary necrosis after postpartum hemorrhage, leading to **hypogonadotropic hypogonadism** (decreased FSH, LH, and Estradiol). *1-A, 2-B, 3-C, 4-D* - This sequence incorrectly maps **Asherman Syndrome** to PCOS and **Sheehan Syndrome** to ovarian failure. - Asherman Syndrome does not typically present with the hormonal dysregulation seen in PCOS or specific pituitary failure. *1-D, 2-C, 3-B, 4-A* - This sequence incorrectly associates **PCOS** with the high FSH of ovarian failure and **Primary Ovarian Failure** with the LH:FSH ratio pattern of PCOS. - These endocrine profiles are fundamentally reversed compared to their physiological mechanisms. *1-C, 2-A, 3-D, 4-B* - This sequence incorrectly identifies **Asherman Syndrome** as having the high FSH profile associated with ovarian failure. - Furthermore, it mistakenly suggests **Primary Ovarian Failure** has a normal hormonal profile, when it is actually defined by elevated gonadotropins.

Q: A woman presents with frothy green vaginal discharge, intense pruritus, and a negative Whiff test. What is seen on microscopy?

Motile flagellate organisms. ***Motile flagellate organisms*** - The clinical presentation of **frothy green vaginal discharge** and **intense pruritus** is classic for **Trichomoniasis**, caused by *Trichomonas vaginalis*. - Microscopy typically reveals **motile, flagellated protozoa** (pear-shaped) that are slightly larger than white blood cells, confirming the diagnosis. *Clue cells* - **Clue cells** (epithelial cells covered in bacteria) are the hallmark diagnostic finding for **Bacterial Vaginosis**. - Bacterial vaginosis typically presents with a **thin, grey-white discharge** and a **positive Whiff test**, which contrasts with this patient's negative test. *Yeasts with pseudo hyphae* - These are visualized in cases of **Vulvovaginal Candidiasis** (yeast infection) and indicate fungal colonization. - Candidiasis generally presents with a **thick, white, curd-like discharge** and intense external dysuria rather than frothy green fluid. *Candida* - *Candida albicans* is a fungal organism that typically requires pH testing or specific microscopic visualization (like potassium hydroxide prep) to confirm. - It is not the causative agent for green, frothy discharge, which is specifically characteristic of the protozoal infection **Trichomoniasis**.

Q: Which of the following is classified as a probable sign of pregnancy? A. Hegar's sign B. Goodell's sign C. Braxton Hicks contractions D. Seitz sign

A, B and C only. ***A, B and C only*** - **Hegar’s sign** (softening of the uterine isthmus), **Goodell’s sign** (softening of the cervix), and **Braxton Hicks contractions** are all well-established **probable signs of pregnancy** identified during physical examination. - These signs rely on objective physical findings related to the physiological changes of pregnancy, though they are not considered diagnostic confirmation like a positive ultrasound or fetal heart tones. *A and B only* - While **Hegar’s sign** and **Goodell’s sign** are indeed probable signs, this option incorrectly excludes **Braxton Hicks contractions**, which are also categorized as probable. - Excluding valid clinical indicators makes this answer choice incomplete for identifying the classic group of probable pregnancy signs. *B, C and D only* - This option incorrectly includes **Seitz sign**, which is not a standard recognized clinical sign of pregnancy, and excludes **Hegar’s sign**. - **Hegar’s sign** is a classic physical finding occurring in the first trimester, making its omission scientifically incorrect. *A, B, C and D* - This option incorrectly includes **Seitz sign**; there is no medically recognized diagnostic sign of pregnancy by that name. - The classification of **probable signs** strictly includes physiological physical changes, among which only A, B, and C qualify.

Q: Which of the following statements regarding the HPV vaccine is correct?

Primary target age is 9-14 years. ***Primary target age is 9-14 years*** - The **World Health Organization (WHO)** recommendations prioritize girls aged 9–14 years to receive the vaccine before the onset of **sexual activity**. - Vaccinating at this age provides the most robust **immunogenic response** compared to older age groups. *One dose can be given instead of two* - While some regions have recently explored single-dose schedules based on emerging data, the standard **WHO-recommended** schedule remains a two-dose series for the 9-14 age group. - A single dose is not yet the universal standard of care; most guidelines still insist on the **two-dose regimen** for optimal long-term efficacy. *Live HPV vaccine is 100% protective for all HPV variants* - The HPV vaccine is a **recombinant, non-infectious** vaccine composed of virus-like particles, not a **live attenuated vaccine**. - It does not protect against all HPV types, but rather covers the most oncogenic strains, typically **types 16 and 18**, and sometimes others like 6 and 11 depending on the specific vaccine (e.g., Gardasil 9). *90% of 15-year-old girls to be vaccinated* - While 90% is a commendable goal for vaccination coverage, the **WHO's

Q: A primigravida delivers the fetal head but the shoulders fail to deliver despite routine traction. What is the first step in management?

McRoberts maneuver with suprapubic pressure. ***McRoberts maneuver with suprapubic pressure*** - This is the **first-line maneuver** for shoulder dystocia, involving hyperflexion of the maternal hips against the abdomen to flatten the sacrum and rotate the symphysis pubis cephalad. - **Suprapubic pressure** is applied simultaneously to dislodge the anterior shoulder from behind the symphysis pubis, which is the most effective initial combination to resolve impaction. *Wood's corkscrew maneuver* - This is a rotational maneuver used as a second-line intervention when initial measures fail to disimpact the anterior shoulder. - It involves applying pressure to the anterior aspect of the posterior shoulder to rotate the fetus into a more favorable diameter, and it is generally more invasive than the initial maneuvers. *Rubin maneuver* - This involves placing pressure on the accessible surface of the fetus's posterior shoulder to adduct the shoulders, thereby reducing the bisacromial diameter. - While effective, it is considered a secondary maneuver to be used after McRoberts and suprapubic pressure have proven unsuccessful. *Zavanelli maneuver* - This is a rescue maneuver of last resort that involves replacing the fetal head back into the vagina to perform an emergent cesarean section. - It is highly invasive and significantly associated with high rates of **fetal morbidity and mortality**, reserved only for cases where all other maneuvers have failed.

Q: A patient is unable to pass urine four hours after an instrumental vaginal delivery. Examination reveals a bluish cystic swelling in the vaginal wall. What is the most likely diagnosis?

Vaginal hematoma. ***Vaginal hematoma*** - A **bluish cystic swelling** in the vaginal wall appearing shortly after an instrumental delivery is pathognomonic for a vaginal hematoma caused by hemorrhage into the paravaginal tissues. - Urinary retention occurs due to **mass effect** and compression of the urethra or bladder, preventing normal voiding. *Perineal tear* - A perineal tear involves **laceration of the skin** and subcutaneous tissue, typically presenting with visible tissue disruption rather than a discrete cystic swelling. - While it may cause pain, it does not typically present as a distinct **bluish cystic mass** or specifically cause the described obstructive urinary symptoms. *Bartholin's cyst* - A Bartholin's cyst results from an obstruction of the Bartholin gland duct, presenting as a **fluctuant swelling** at the four or eight o'clock position of the vaginal introitus. - These are usually not associated with acute postpartum trauma or instrumental delivery and are typically **not bluish** in color unless complicated by an abscess. *Cystocoele* - A cystocoele is a **prolapse of the bladder** into the anterior vaginal wall, typically presenting as a soft bulge that may increase with straining. - It would appear as a **skin-colored or mucosa-colored protrusion** rather than a bluish cystic mass and is usually chronic rather than an acute post-procedural complication.

Q: What is the primary cause of mild breathlessness experienced during normal pregnancy?

Progesterone-induced stimulation of the respiratory centre. ***Progesterone-induced stimulation of the respiratory centre*** - Pregnancy leads to a significant increase in **progesterone** levels, which directly stimulates the **medullary respiratory center**. - This increase in **minute ventilation** leads to a drop in arterial PCO2 (respiratory alkalosis), which is subjectively perceived by the pregnant patient as **dyspnea** or breathlessness. *Decreased tidal volume* - This is incorrect as **tidal volume** actually increases significantly (by about 40%) during pregnancy to meet increased oxygen demands. - A decreased tidal volume would lead to hypoventilation, which is the opposite of the hyperventilation observed in normal pregnancy. *Reduced oxygen intake* - Oxygen consumption increases during pregnancy due to the needs of the **fetus**, the **placenta**, and maternal tissues, not a reduction in intake. - Pregnant women compensate for these increased metabolic demands by increasing **minute ventilation**, ensuring adequate oxygen delivery. *Increased arterial PCO2 levels* - Arterial PCO2 levels actually decrease in pregnancy (typically to 27-32 mmHg) due to increased **alveolar ventilation**. - An increase in arterial PCO2 would signify respiratory acidosis or hypoventilation, which contradicts the normal physiological adaptations of pregnancy.

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 21-year-old girl presents with primary amenorrhea. Examination shows absent uterus, present
breast development, and sparse pubic and axillary hair. What is the genetic etiology?

Accepted Answer

MRKH

Answer

Androgen insensitivity

Answer

Turner's syndrome

Answer

CAH

Question 4

Match the following conditions with their hormonal profiles:

Condition Hormonal Profile

1. PCOS A. Normal FSH, Normal LH, Normal Estradiol

B. Decreased FSH, Decreased LH, Decreased
2. Primary Ovarian Failure
Estradiol

C. Increased LH, Normal to Low FSH (High
3. Asherman Syndrome
LH:FSH ratio)

4. Sheehan Syndrome D. Markedly Increased FSH, Low Estradiol

Accepted Answer

1-C, 2-D, 3-A, 4-B

Answer

1-A, 2-B, 3-C, 4-D

Answer

1-D, 2-C, 3-B, 4-A

Answer

1-C, 2-A, 3-D, 4-B

Question 5

A woman presents with frothy green vaginal discharge, intense pruritus, and a negative Whiff
test. What is seen on microscopy?

Accepted Answer

Motile flagellate organisms

Answer

Clue cells

Answer

Yeasts with pseudo hyphae

Answer

Candida

Question 6

Which of the following is classified as a probable sign of pregnancy?
A. Hegar's sign
B. Goodell's sign
C. Braxton Hicks contractions
D. Seitz sign

Accepted Answer

A, B and C only

Answer

A and B only

Answer

B, C and D only

Answer

A, B, C and D

Question 7

Which of the following statements regarding the HPV vaccine is correct?

Accepted Answer

Primary target age is 9-14 years

Answer

One dose can be given instead of two

Answer

Live HPV vaccine is 100% protective for all HPV variants

Answer

90% of 15-year-old girls to be vaccinated

Question 8

A primigravida delivers the fetal head but the shoulders fail to deliver despite routine traction.
What is the first step in management?

Accepted Answer

McRoberts maneuver with suprapubic pressure

Answer

Wood's corkscrew maneuver

Answer

Rubin maneuver

Answer

Zavanelli maneuver

Question 9

A patient is unable to pass urine four hours after an instrumental vaginal delivery. Examination
reveals a bluish cystic swelling in the vaginal wall. What is the most likely diagnosis?

Accepted Answer

Vaginal hematoma

Answer

Perineal tear

Answer

Bartholin's cyst

Answer

Cystocoele

Question 10

What is the primary cause of mild breathlessness experienced during normal pregnancy?

Accepted Answer

Progesterone-induced stimulation of the respiratory centre

Answer

Decreased tidal volume

Answer

Reduced oxygen intake

Answer

Increased arterial PCO2 levels

INI-CET 2026

Internal Medicine

Obstetrics and Gynecology