INI-CET 2025 - Internal Medicine Practice Questions

Q: A 56-year-old diabetic male presents with a complicated urinary tract infection and is found to be hypotensive. His blood pressure does not respond to intravenous fluids. Which of the following is the most appropriate antibiotic to manage his condition?

Meropenem. ***Meropenem*** - This patient has **septic shock** secondary to a complicated UTI (hypotension unresponsive to fluids), requiring prompt, broad-spectrum coverage against probable **Gram-negative bacilli** and potential extended-spectrum beta-lactamase (ESBL) producers, common in diabetic patients with complicated UTIs [1]. - **Meropenem**, a carbapenem, provides excellent empirical coverage for **multi-drug resistant (MDR) organisms** and is a first-line agent for critically ill patients with suspected septic shock of unknown or complicated origin [1]. ***Amoxicillin-Clavulanate*** - This combination (a moderate-spectrum penicillin-beta-lactamase inhibitor) lacks reliable coverage against common hospital-acquired or complicatd UTI pathogens, such as **_Pseudomonas aeruginosa_** or ESBL-producing Enterobacteriaceae [1]. - It is unsuitable for treating septic shock due to an inadequate spectrum and potential for **resistance** in this clinical setting [1]. ***Nitrofurantoin*** - This drug is concentrated in the urine and is only suitable for treating **uncomplicated cystitis** as it does not achieve adequate systemic levels for treating pyelonephritis, deep-seated infection, or **urosepsis**. - It has a narrow spectrum limited primarily to **Gram-positive cocci** and susceptible **_E. coli_** and is contraindicated in systemic infections or septic shock. ***Ceftriaxone*** - Ceftriaxone (a third-generation cephalosporin) is often used for complicated UTIs (pyelonephritis) but is generally not adequate as **monotherapy** for treating **septic shock** in a high-risk (diabetic) patient [2]. - There is a high risk of resistance, including from ESBL-producers, which necessitates broader coverage, like a **carbapenem**, in critically ill patients before susceptibility results are known.

Q: A 65-year-old known case of Parkinsons disease presents with oropharyngeal dysphagia and recurrent episodes of aspiration pneumonitis, along with excessive respiratory secretions. Chest imaging reveals bilateral bronchiectasis. What is the most appropriate long-term management for this patient?

Percutaneous endoscopic gastrostomy (PEG) tube placement. ***Percutaneous endoscopic gastrostomy (PEG) tube placement*** - This patient, with Parkinson's disease, suffers from severe **oropharyngeal dysphagia**, leading to recurrent **aspiration pneumonitis** and **bilateral bronchiectasis** (suggesting chronic aspiration). - **PEG placement** is the most appropriate long-term management to ensure adequate nutrition and hydration while **bypassing the compromised swallowing mechanism**, thereby preventing further aspiration and subsequent respiratory complications. ***High-frequency chest wall oscillation therapy*** - This technique is used primarily to mobilize **thick secretions** in patients with conditions like **cystic fibrosis** or severe COPD exacerbations. - While the patient has excessive secretions and bronchiectasis, this therapy **does not address the root cause** (aspiration due to dysphagia) and is not a substitute for safe feeding. ***Nebulized N-acetylcysteine to reduce secretions*** - **N-acetylcysteine (NAC)** is a mucolytic agent used to reduce the viscosity of respiratory secretions, aiding elimination. - Although helpful for symptom relief, it **does not prevent chronic aspiration** from dysphagia and can sometimes **trigger bronchospasm** in susceptible individuals. ***Macrolide therapy*** - Long-term low-dose macrolides (e.g., azithromycin) are used for their **anti-inflammatory** and **immunomodulatory effects** in chronic lung diseases, such as **bronchiectasis without cystic fibrosis** [1]. - While useful for managing the bronchiectasis, macrolides **do not treat the underlying dysphagia** or the source of the recurrent aspiration and subsequent infections [1].

Q: A 20-year-old female diagnosed with septic shock presents with a blood pressure of 58/30 mmHg. After receiving 3 liters of crystalloid fluid, her mean arterial pressure (MAP) remains 58 mmHg. What is the next best step in management?

Start noradrenaline. ***Start noradrenaline*** - **Noradrenaline (Norepinephrine)** is the preferred first-line vasopressor in **septic shock** to achieve a target Mean Arterial Pressure (MAP) of $\ge 65$ mmHg, especially when fluid resuscitation (3L of crystalloids given) is inadequate [1]. - It primarily acts as an $\alpha$-agonist, causing significant **vasoconstriction** which increases systemic vascular resistance (SVR) and improves blood pressure. ***Start dopamine*** - Dopamine is considered a second-line agent due to its potential to cause more **tachyarrhythmias** compared to noradrenaline. - It is often reserved for patients with a low risk of tachyarrhythmias or relative **bradycardia** in addition to hypotension. ***Repeat crystalloid fluid*** - The current fluid challenge (3L) is substantial; administering more fluid without a pressor in refractory shock can lead to detrimental effects like **pulmonary edema** and fluid overload, which has diminishing returns on MAP [1]. - The patient's persistent hypotension (MAP 58 mmHg) despite significant fluid resuscitation indicates inadequate peripheral vascular tone (**vasoplegia**), requiring immediate vasopressor support [1]. ***Start vasopressin*** - **Vasopressin** is generally added as a second-line agent to noradrenaline (**vasopressor weaning**) to potentially reduce the dose of noradrenaline needed. - It is not recommended as the initial monotherapy for hypotension in septic shock because it lacks the potent $\alpha$-agonist effect of noradrenaline.

Q: Mitral stenosis murmur corresponds to which wave of ECG?

P wave. ***P wave*** - The **P wave** on the ECG represents **atrial depolarization** and precedes atrial contraction (atrial systole) [3]. - In **mitral stenosis (MS)**, the characteristic presystolic accentuation (a later component of the diastolic murmur) is caused by the force of atrial contraction just prior to the QRS complex, correlating with the P wave [4]. ***QRS complex*** - The **QRS complex** represents **ventricular depolarization** and precedes ventricular contraction (ventricular systole) [3]. - The mitral stenosis murmur is a **diastolic murmur**; it occurs after the T wave and ends before the QRS complex (or is accentuated just before it by atrial kick) [1], [4]. ***T wave*** - The **T wave** represents **ventricular repolarization** [3]. - The T wave marks the end of systole; the mitral stenosis murmur begins *after* the T wave, during the period of isovolumetric relaxation and subsequent rapid ventricular filling [2]. ***ST segment*** - The **ST segment** represents the period between ventricular depolarization and repolarization (plateau phase of the action potential). - This segment is part of systole, whereas the mitral stenosis murmur is strictly a **diastolic event** [1], [4].

Q: A 45-year-old chronic smoker presents with complaints of dyspnea. Pulmonary function tests reveal FEV1/FVC ratio of 65% and RV/ TLC ratio of 141%. Which of the following best describes the underlying pathophysiology?

Air trapping with hyperinflation of lungs. ***Air trapping with hyperinflation of lungs*** - The FEV1/FVC ratio is **65% (below 70%)**, confirming an **obstructive lung disease** (e.g., COPD/emphysema) due to irreversible airflow limitation [2]. - An RV/TLC ratio of **141% (above 120%)** signifies **hyperinflation** (increased **Residual Volume** and **Total Lung Capacity**), which is the direct result of air trapping in the distal airspaces due to airway obstruction [1]. ***Decreased lung compliance*** - Decreased compliance is characteristic of **restrictive lung diseases** (e.g., pulmonary fibrosis), where the lungs are stiff and difficult to inflate. - In obstructive diseases like emphysema, the underlying pathophysiology often involves **destruction of alveolar walls**, which *increases* lung compliance. ***Restrictive lung disease*** - Restrictive diseases are characterized by a **normal or increased FEV1/FVC ratio** and decreased lung volumes (low FVC and TLC), which contradicts the PFT findings (low FEV1/FVC) [3]. - The main physiological problem is difficulty *expanding* the lungs, not difficulty *expelling* air. ***Increased lung compliance*** - While increased compliance is seen in pure emphysema, the PFT findings specifically point to the *consequences* of airway obstruction, which is **air trapping** and subsequent **hyperinflation** (increased RV/TLC ratio) [1]. - Describing the underlying pathophysiology as only 'increased lung compliance' is incomplete, as the most immediate and defining physiological result of severe obstruction leading to dyspnea is the high residual volume due to trapped air.

Q: Which of the following is not a symptom of cardiac failure?

Non-pulsatile elevation of JVP. ***Non-pulsatile elevation of JVP*** - In cardiac failure, **JVP is elevated but remains pulsatile**, showing normal **a, c, and v waves** from the transmitted cardiac cycle. - **Non-pulsatile JVP elevation** is characteristic of **superior vena cava (SVC) syndrome**, where complete venous obstruction blocks pulsation transmission, not cardiac failure. *Right hypochondriac pain* - This **is a symptom** of **right-sided heart failure** due to **hepatic congestion** and stretching of **Glisson's capsule**. - Results from **passive liver engorgement** secondary to elevated right atrial pressure and systemic venous congestion. *Orthopnea* - Classic symptom of **left-sided heart failure** characterized by breathlessness when lying flat due to **pulmonary venous congestion**. - Worsens in supine position as **venous return increases** and is relieved by sitting upright. *Paroxysmal nocturnal dyspnea* - Sudden severe **shortness of breath** that wakes patients from sleep, typically **1-2 hours** after falling asleep. - Caused by **delayed resorption of peripheral edema** and increased venous return while supine, leading to acute **pulmonary congestion**.

Q: A 58-year-old male presents with burning micturition. Prostatic examination is normal. Urinalysis shows >50 pus cells per high power field, but urine culture shows no growth. What is the most likely diagnosis?

Sterile pyuria. ***Sterile pyuria*** - The combination of **pyuria** (>50 pus cells/HPF) and a **negative urine culture (no growth)** is known as sterile pyuria. This can be idiopathic or indicate conditions like **urethritis**, **tuberculosis**, or non-bacterial infections [1]. - The presence of symptoms (burning micturition) combined with pyuria and a normal prostate examination rules out typical bacterial prostatitis scenarios [1]. ***Chronic bacterial prostatitis*** - While chronic bacterial prostatitis involves recurrent symptomatic episodes and may sometimes show pyuria, it is characterized by **recurrent positive urine cultures** (often *E. coli*) and localization of bacteria to prostatic fluid. - The prostatic examination is often normal, but the hallmark is the presence of bacteria in the urine/prostatic fluid, which is absent here. ***Acute bacterial prostatitis*** - This presents with signs of systemic infection (fever, chills) and a very tender, boggy prostate, which is not mentioned, and the exam here is noted as **normal** [1]. - It always involves a **positive urine culture** due to the high bacterial load in the urine. ***Granulomatous prostatitis*** - This is a rare inflammatory condition, often related to fungal infections or **BCG therapy**, and typically manifests as a firm, nodular prostate that mimics prostate cancer. - While it can cause sterile pyuria, the presentation is usually dominated by prostatic enlargement or hardness, which is contradicted by the **normal prostatic examination** given in the prompt.

Q: A 20-year-old male presents with fever, severe headache, vomiting, and photophobia. On examination, neck rigidity and Brudzinskis sign are positive. CT scan of the brain shows hydrocephalus. What is the most likely diagnosis?

Bacterial Meningitis. ***Bacterial Meningitis*** - The clinical triad of **fever**, **headache**, and **neck rigidity** (nuchal rigidity) is classic for acute meningitis [1]. - Positive meningeal signs like **Brudzinski's sign** confirm meningeal irritation, and hydrocephalus may occur due to impaired CSF flow or absorption (communicating or non-communicating) [1]. ***Normal Pressure Hydrocephalus*** - Characterized by the triad of gait disturbance, urinary incontinence, and **dementia** (Wacky, Wobbly, Wet). - Does not typically present with acute systemic symptoms like **fever** or acute signs of meningeal irritation (neck rigidity/Brudzinski's). ***Viral Encephalitis*** - While it presents with fever and headache, the hallmark is altered mental status (confusion, seizures) and focal neurological deficits, indicating **parenchymal involvement**. - Severe, rigid **neck stiffness** (a major sign of meningeal irritation) is usually less prominent compared to bacterial meningitis [1]. ***Subarachnoid Hemorrhage*** - Presents with a sudden worst headache of life (**thunderclap headache**) and meningeal signs (neck rigidity, photophobia) [1]. - **Fever** is usually low-grade (if present) and develops later, unlike the often high fever seen in bacterial meningitis.

Question 1

A patient underwent cardiac surgery and was admitted to the ICU. He later developed ventilator-associated pneumonia and was started on empirical antibiotics. A few hours later, the patient developed acute kidney injury. Serum procalcitonin was sent. Which of the following statements regarding procalcitonin is correct?

Accepted Answer

It helps in determining the duration of antibiotic therapy

Answer

It can be used to confirm source of infection

Answer

It is used to differentiate bacterial from fungal cause

Answer

It helps in identifying which empirical antibiotics to be started

Question 2

A 56-year-old diabetic male presents with a complicated urinary tract infection and is found to be hypotensive. His blood pressure does not respond to intravenous fluids. Which of the following is the most appropriate antibiotic to manage his condition?

Accepted Answer

Meropenem

Answer

Amoxicillin-Clavulanate

Answer

Nitrofurantoin

Answer

Ceftriaxone

Question 3

A 65-year-old known case of Parkinsons disease presents with oropharyngeal dysphagia and recurrent episodes of aspiration pneumonitis, along with excessive respiratory secretions. Chest imaging reveals bilateral bronchiectasis. What is the most appropriate long-term management for this patient?

Accepted Answer

Percutaneous endoscopic gastrostomy (PEG) tube placement

Answer

High-frequency chest wall oscillation therapy

Answer

Nebulized N-acetylcysteine to reduce secretions

Answer

Macrolide therapy

Question 4

A 20-year-old female diagnosed with septic shock presents with a blood pressure of 58/30 mmHg. After receiving 3 liters of crystalloid fluid, her mean arterial pressure (MAP) remains 58 mmHg. What is the next best step in management?

Accepted Answer

Start noradrenaline

Answer

Start vasopressin

Answer

Start dopamine

Answer

Repeat crystalloid fluid

Question 5

Mitral stenosis murmur corresponds to which wave of ECG?

Accepted Answer

P wave

Answer

QRS complex

Answer

ST segment

Answer

T wave

Question 6

A 45-year-old chronic smoker presents with complaints of dyspnea. Pulmonary function tests reveal FEV1/FVC ratio of 65% and RV/ TLC ratio of 141%. Which of the following best describes the underlying pathophysiology?

Accepted Answer

Air trapping with hyperinflation of lungs

Answer

Increased lung compliance

Answer

Restrictive lung disease

Answer

Decreased lung compliance

Question 7

Which of the following is not a symptom of cardiac failure?

Accepted Answer

Non-pulsatile elevation of JVP

Answer

Right hypochondriac pain

Answer

Orthopnea

Answer

Paroxysmal nocturnal dyspnea

Question 8

A 62-year-old male presents with sudden onset of shortness of breath and bilateral pedal edema. He is compliant with antihypertensive medications. Echocardiography reveals ejection fraction of 60 %, concentric left ventricular hypertrophy, left atrial enlargement, and grade 2 diastolic dysfunction. What is the most appropriate next step to improve his condition?

Accepted Answer

Initiate loop diuretics and SGLT2 inhibitors for management of HFpEF

Answer

Start digoxin to enhance myocardial contractility

Answer

Perform coronary angiography to rule out ischemic cardiomyopathy

Answer

Initiate ivabradine to reduce heart rate and improve diastolic filling

Question 9

A 58-year-old male presents with burning micturition. Prostatic examination is normal. Urinalysis shows >50 pus cells per high power field, but urine culture shows no growth. What is the most likely diagnosis?

Accepted Answer

Sterile pyuria

Answer

Granulomatous prostatitis

Answer

Chronic bacterial prostatitis

Answer

Acute bacterial prostatitis

Question 10

A 20-year-old male presents with fever, severe headache, vomiting, and photophobia. On examination, neck rigidity and Brudzinskis sign are positive. CT scan of the brain shows hydrocephalus. What is the most likely diagnosis?

Accepted Answer

Bacterial Meningitis

Answer

Viral Encephalitis

Answer

Subarachnoid Hemorrhage

Answer

Normal Pressure Hydrocephalus

INI-CET 2025 — Internal Medicine