INI-CET 2026 Practice Questions

Q: A pregnant woman with SLE delivers a neonate who is found to have a heart rate of 45 beats per minute. ECG confirms complete heart block. Which maternal antibody is most likely responsible?

Anti-Ro antibody. ***Anti-Ro antibody*** - These antibodies (also known as **anti-SSA/Ro**) can cross the **placenta** and cause **neonatal lupus erythematosus**. - The most serious complication associated with transplacental passage is **congenital complete heart block**, caused by antibody-mediated damage to the **fetal AV node**. *Anti-dsDNA antibody* - These are highly specific for **Systemic Lupus Erythematosus (SLE)** and correlate with **disease activity**. - While they are diagnostic markers for active SLE, they are not primarily associated with the development of **congenital heart block**. *Anti-histone antibody* - These are the hallmark diagnostic findings seen in **drug-induced lupus**. - Drug-induced lupus typically presents with arthralgia, myalgia, and fever, but it is not associated with **neonatal heart block**. *Anti-Smith antibody* - These are highly specific for **Systemic Lupus Erythematosus (SLE)** but do not correlate with disease activity. - They do not represent the mechanism underlying the fetal or neonatal cardiac complications like **congenital heart block**.

Q: Which of the following is NOT a recognized diagnostic feature of Kawasaki disease?

Purulent conjunctivitis. ***Purulent conjunctivitis*** - Kawasaki disease is characterized by **bilateral conjunctival injection** that is notably **non-purulent** (non-exudative). - The presence of **purulent discharge** strongly suggests a bacterial cause, making it an exclusionary criterion for the clinical diagnosis of Kawasaki disease. *Non-purulent (bilateral) conjunctivitis* - This is a cardinal clinical criterion, typically appearing early in the course of the illness. - The inflammation involves the **bulbar conjunctiva** without exudate or limbal sparing. *Cervical lymphadenopathy* - This is a recognized diagnostic criterion, usually defined as a node greater than **1.5 cm** in diameter, which is typically unilateral and cervical. - It is often the least frequently observed criterion among the classic features. *Fever lasting more than 5 days* - Persistent, high-grade fever of at least **5 days' duration** is the sine qua non (essential) diagnostic criterion. - Fever in Kawasaki disease is often high and typically unresponsive to standard **antipyretics** and **antibiotics**.

Q: A child presents with fever, altered level of consciousness, and signs of meningeal irritation. Cerebrospinal fluid (CSF) analysis reveals the following findings: - Cell differential: Predominantly lymphocytes - Protein: Elevated - Glucose: Low Based on these CSF findings, what is the most likely diagnosis?

Tuberculous meningitis. ***Tuberculous meningitis*** - The combination of **lymphocytic pleocytosis** with **elevated protein** (often very high) and **low glucose** (hypoglycorrhachia) is a classic CSF profile for tuberculous meningitis. - Patients often present with a subacute course involving **fever**, **altered mental status**, and meningeal signs, which distinguishes it from the more acute bacterial or viral etiologies. *Pyogenic (bacterial) meningitis* - Typically presents with a **neutrophilic pleocytosis** rather than lymphocytic, reflecting a profound acute inflammatory response. - Glucose levels are generally very low, but the cell count is usually significantly higher compared to tuberculosis, showing thousands of cells per microliter. *Viral meningitis* - While this also presents with **lymphocytic pleocytosis**, glucose levels are almost always **normal** because viruses do not consume glucose from the CSF. - Protein levels are typically normal or only mildly elevated, unlike the significant elevation seen in this patient. *Fungal meningitis* - Although it can present with low glucose and high protein, it is generally an **opportunistic infection** found in immunocompromised patients rather than a typical presentation in a standard pediatric case. - While the CSF profile can overlap, clinical context (such as known HIV status or chemotherapy) is usually required to differentiate it from TB; TB remains the most likely cause for this specific triad of CSF findings in most clinical settings.

Q: Which of the following electrolyte or metabolic abnormalities is NOT a component of the lethal triad associated with massive blood transfusion?

Hyponatremia. ***Hyponatremia*** - While electrolyte imbalances can occur during massive blood transfusion due to citrated blood products, hyponatremia is not a primary component of the classic **lethal triad**. - The lethal triad specifically refers to the interrelated pathophysiological processes that exacerbate **hemorrhagic shock** and mortality in trauma patients. *Acidosis* - **Metabolic acidosis** is a key pillar of the lethal triad, often resulting from poor tissue perfusion, anaerobic metabolism, and shock. - It contributes to coagulopathy by inhibiting the activity of **clotting factors**, thereby worsening bleeding. *Hypothermia* - **Hypothermia** significantly disrupts the enzymatic reactions of the **coagulation cascade**, making it a critical component of the lethal triad. - It is frequently caused by blood loss, fluid resuscitation with un-warmed fluids, and exposure in the trauma bay. *Coagulopathy* - **Coagulopathy** of trauma is characterized by decreased clotting factor activity, platelet dysfunction, and hyperfibrinolysis. - It is intrinsically linked to the other two components, as acidosis and hypothermia both directly inhibit **hemostasis**.

Q: A patient with a thyroid nodule undergoes FNAC, which yields a result suggestive of follicular carcinoma. What is the most appropriate next step in management?

Hemithyroidectomy. ***Hemithyroidectomy*** - Fine-needle aspiration cytology (FNAC) cannot distinguish between **follicular adenoma** (benign) and **follicular carcinoma** (malignant) because the distinction requires histopathologic evidence of **capsular or vascular invasion**. - Therefore, a **hemithyroidectomy** (lobectomy) is the standard initial management to obtain a definitive tissue diagnosis while offering potential curative treatment if the lesion is benign or minimally invasive. *Total thyroidectomy* - This is not the initial procedure of choice because the majority of **follicular neoplasms** are eventually diagnosed as benign **adenomas**. - Total thyroidectomy is reserved for cases where histopathology confirms **invasive follicular carcinoma** or if there is clinical evidence of extensive multifocal disease. *Radioactive iodine therapy* - This therapy is used postoperatively for **differentiated thyroid cancer** (follicular or papillary) to ablate residual thyroid tissue or treat metastases, not as a primary management for a nodule. - It is never indicated when the diagnosis remains uncertain based solely on **FNAC** findings. *Repeat FNAC* - Repeating the FNAC is not helpful because it would likely yield the same **indeterminate result** (follicular neoplasm) and cannot evaluate for **invasion**. - Delaying surgical excision in a patient with a

Q: Match each of the following clinical conditions with its most appropriate diagnostic investigation: Clinical Condition Investigation A. Pancreatic pseudocyst 1. FNAC B. Thyroid nodule 2. MRCP C. Prostate cancer 3. PET scan D. Obstructive jaundice 4. CT scan Which of the following is the correct match?

A-4, B-1, C-3, D-2. ***A-4, B-1, C-3, D-2*** - **Pancreatic pseudocysts** are typically evaluated and characterized using **CT scanning (A-4)**, which provides excellent visualization of the collection and its relationship to surrounding structures. - **Thyroid nodules** are best evaluated for malignancy risk using fine-needle aspiration cytology (**FNAC**) (**B-1**), which remains the **gold standard** for diagnosis. - **Prostate cancer** staging or evaluation of recurrence/metastasis increasingly utilizes **PSMA-PET scanning (C-3)** for high sensitivity and specificity in detecting nodal or distant spread. - **Obstructive jaundice** requires detailed imaging of the biliary tree to determine the cause of obstruction, for which **magnetic resonance cholangiopancreatography (MRCP) (D-2)** is the investigation of choice. *A-3, B-1, C-4, D-2* - While **MRCP (D-2)** is correctly identified for obstructive jaundice, this option incorrectly pairs the **pancreatic pseudocyst** with a **PET scan (A-3)**, which is not the primary diagnostic modality for fluid collections. - It also mismatches **prostate cancer** with a **CT scan (C-4)** as the primary investigation, which is less sensitive than specialized functional imaging like PET for detecting small metastases. *A-2, B-1, C-4, D-3* - This option incorrectly identifies the diagnostic test for **obstructive jaundice** as a **PET scan (D-3)** rather than **MRCP**. - It also suggests a **CT scan (C-4)** for prostate cancer, which is inferior to **PET/MRI** imaging protocols for staging and disease assessment. *A-4, B-2, C-3, D-1* - This option incorrectly assigns **MRCP (B-2)** to the **thyroid**; MRCP is used for biliary anatomy, whereas **FNAC** is specific for thyroid nodules. - It incorrectly suggests **FNAC (D-1)** for the workup of **obstructive jaundice**, as FNAC is not a diagnostic tool for biliary anatomy or stone disease.

Q: On defecography, a rectocele is considered clinically significant when there is anterior bulging of the rectal wall into the posterior vaginal wall measuring more than:

2 cm. ***2 cm*** - A rectocele is defined as an anterior bulging of the rectal wall into the posterior vaginal wall, and it is considered clinically significant on **defecography** when this protrusion exceeds **2 cm**. - While smaller protrusions may be seen on imaging, they are often asymptomatic and do not require surgical intervention unless the patient presents with specific symptoms like **obstructed defecation**. *1 cm* - A rectocele measuring **1 cm** is typically considered to be within the range of physiologic or normal findings on defecography. - Many asymptomatic women show minimal bulging of this size, so it does not meet the criteria for **clinical significance** or surgical correction. *3 cm* - Although a **3 cm** rectocele would certainly fit the criteria for a clinically significant finding, it is not the minimum threshold for that clinical diagnosis. - Using a higher threshold would result in missing diagnosis and potentially undertreating patients who have symptomatic outlet obstruction related to a **2 cm** rectocele. *4 cm* - A **4 cm** rectocele is a large defect, but setting the diagnostic threshold this high would be inaccurate. - Clinical guidelines use the **2 cm** cutoff to balance diagnostic sensitivity with the correlation of patient-reported symptoms like **rectal digitation**.

Q: During laparoscopic inguinal hernia repair, what is the minimum distance of dissection required below the inguinal ligament to adequately expose the myopectineal orifice?

2 cm. ***2 cm*** - Dissection at least 2 cm below the **inguinal ligament** is essential to fully expose the **myopectineal orifice** (MPO), ensuring that the inferior border of the mesh can extend well below the **Cooper's ligament**. - This margin is critical to prevent **recurrence**, as it provides adequate coverage of the inferior space where direct or indirect hernias may originate. *0.5 cm* - This distance is insufficient for safe and effective **mesh placement**, as it fails to cover the entire **myopectineal orifice**. - Inadequate dissection at the inferior aspect risks leaving a gap through which a primary or recurrent hernia can easily develop. *1 cm* - While slightly broader than 0.5 cm, 1 cm of dissection usually proves inadequate to expose **Cooper's ligament** sufficiently for proper mesh fixation. - Most surgical guidelines emphasize a more generous inferior dissection to ensure the **mesh** lies flat and covers the potential hernial spaces. *4 cm* - Dissecting 4 cm below the **inguinal ligament** is excessive and increases the risk of injury to structures such as the **femoral vessels** and **obturator nerve**. - Excessive dissection beyond the required 2 cm creates unnecessary space that may lead to **seroma formation** or injury to neurovascular bundles below the **pubic ramus**.

Question 1

A pregnant woman with SLE delivers a neonate who is found to have a heart rate of 45 beats per
minute. ECG confirms complete heart block. Which maternal antibody is most likely responsible?

Accepted Answer

Anti-Ro antibody

Answer

Anti-dsDNA antibody

Answer

Anti-histone antibody

Answer

Anti-Smith antibody

Question 2

Which of the following is NOT a recognized diagnostic feature of Kawasaki disease?

Accepted Answer

Purulent conjunctivitis

Answer

Non-purulent (bilateral) conjunctivitis

Answer

Cervical lymphadenopathy

Answer

Fever lasting more than 5 days

Question 3

A child presents with fever, altered level of consciousness, and signs of meningeal irritation.
Cerebrospinal fluid (CSF) analysis reveals the following findings:
- Cell differential: Predominantly lymphocytes
- Protein: Elevated
- Glucose: Low
Based on these CSF findings, what is the most likely diagnosis?

Accepted Answer

Tuberculous meningitis

Answer

Pyogenic (bacterial) meningitis

Answer

Viral meningitis

Answer

Fungal meningitis

Question 4

A 3-hour-old newborn is found to have a blood glucose level of 38 mg/dL on routine screening.
The neonate is asymptomatic. What is the most appropriate next step in management?

Accepted Answer

Continue breastfeeding and reassess blood glucose after the next feed

Answer

Initiate 5% dextrose infusion intravenously

Answer

Leave as is and reassure the parents

Answer

Administer a 5% dextrose bolus and reassess

Question 5

A 20-month-old child walks independently without support, scribbles spontaneously, and
appropriately follows and obeys simple commands. However, the child speaks only one meaningful
word. What is the most appropriate next step in management?

Accepted Answer

Suspect isolated speech delay and arrange a formal hearing assessment

Answer

Reassure the parents and schedule a routine follow-up at 5 years of age

Answer

Evaluate the child for autism spectrum disorder (ASD)

Answer

Reassess in 3 months to allow for spontaneous improvement

Question 6

Which of the following electrolyte or metabolic abnormalities is NOT a component of the lethal
triad associated with massive blood transfusion?

Accepted Answer

Hyponatremia

Answer

Acidosis

Answer

Hypothermia

Answer

Coagulopathy

Question 7

A patient with a thyroid nodule undergoes FNAC, which yields a result suggestive of follicular
carcinoma. What is the most appropriate next step in management?

Accepted Answer

Hemithyroidectomy

Answer

Total thyroidectomy

Answer

Radioactive iodine therapy

Answer

Repeat FNAC

Question 8

Match each of the following clinical conditions with its most appropriate diagnostic
investigation:

Clinical Condition Investigation

A. Pancreatic pseudocyst 1. FNAC

B. Thyroid nodule 2. MRCP

C. Prostate cancer 3. PET scan

D. Obstructive jaundice 4. CT scan

Which of the following is the correct match?

Accepted Answer

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

Answer

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

Answer

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

Answer

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

Question 9

On defecography, a rectocele is considered clinically significant when there is anterior bulging
of the rectal wall into the posterior vaginal wall measuring more than:

Accepted Answer

2 cm

Answer

1 cm

Answer

3 cm

Answer

4 cm

Question 10

During laparoscopic inguinal hernia repair, what is the minimum distance of dissection required
below the inguinal ligament to adequately expose the myopectineal orifice?

Accepted Answer

2 cm

Answer

0.5 cm

Answer

1 cm

Answer

4 cm

INI-CET 2026

Pediatrics

Surgery