INI-CET 2025 - Internal Medicine Practice Questions

Q: Which of the following is not a cause of high anion gap metabolic acidosis?

Diarrhea. Diarrhea causes non-anion gap metabolic acidosis (NAGMA) because the excessive loss of bicarbonate-rich fluid (HCO3-) from the lower GI tract requires the retention of chloride (Cl-) to maintain electrical neutrality, leading to hyperchloremia (HCO3- loss replaced by Cl-) [2]. The resulting acidosis has a normal anion gap because the lost bicarbonate is effectively replaced by another unmeasured ion (chloride), keeping the calculated gap ([Na+] - ([Cl-] + [HCO3-])) within the normal range [1]. Severe acute kidney injury (AKI) causes high anion gap metabolic acidosis (HAGMA) due to the retention of unmeasured organic acids resulting from decreased glomerular filtration rate (GFR) [2]. Ketoacidosis (Diabetic, Alcoholic, Starvation) is a classic cause of high anion gap metabolic acidosis (HAGMA) [3]. The metabolic acidosis results from the overproduction and accumulation of ketone bodies (beta-hydroxybutyrate and acetoacetate), which are unmeasured organic acids [3]. Many toxins, such as Methanol, Ethylene glycol, and high doses of Salicylates, cause high anion gap metabolic acidosis (HAGMA) [1].

Q: Choose the correct statement(s): 1. Metformin is contraindicated in patients with severe renal impairment (eGFR <30 mL/min/1.73m²) 2. ACE inhibitors should be discontinued immediately if serum creatinine increases by any amount after initiation 3. Beta-blockers are first-line therapy for heart failure with reduced ejection fraction 4. Statins are recommended for primary prevention in patients with diabetes mellitus aged 40-75 years

1, 3, 4 are correct. ***1, 3, 4 are correct*** - **Metformin** is contraindicated when eGFR 30%**, not for any increase. *1, 2, 3 are correct* - While statements 1 and 3 are correct, statement 2 is **medically inaccurate** regarding ACE inhibitor management. - A creatinine rise up to **30%** is acceptable with ACE inhibitors and doesn't require discontinuation. *1, 2, 3, 4 are correct* - This option is incorrect because statement 2 contains **false information** about ACE inhibitor discontinuation criteria. - **Immediate discontinuation** for any creatinine rise would prevent beneficial use of ACE inhibitors in appropriate patients. *1, 4 are correct* - While statements 1 and 4 are accurate, this option incorrectly excludes statement 3 about **beta-blockers**. - **Beta-blockers** (carvedilol, metoprolol succinate, bisoprolol) are indeed **first-line therapy** for heart failure with reduced ejection fraction.

Q: Which of the following malignancies is unrelated to obesity?

Multiple myeloma. ***Multiple myeloma*** - While obesity is a risk factor for several cancers, there is limited or conflicting evidence directly linking **multiple myeloma** to high BMI, making it the most unrelated option among the choices provided. - The primary established risk factors for multiple myeloma include age (over 65), African descent, male sex, and a history of monoclonal gammopathy of undetermined significance (**MGUS**). [1] ***Stomach*** - Obesity, particularly abdominal obesity, increases the risk of developing **gastric cardia adenocarcinoma** due to increased prevalence of **gastroesophageal reflux disease (GERD)** and subsequent Barrett's esophagus. - Chronic inflammation and hormonal changes associated with high body fat contribute to the oncogenesis of stomach cancer. ***Pancreas*** - Obesity is a well-established risk factor for **pancreatic cancer**, increasing the risk by approximately 20-50% compared to healthy-weight individuals. [2] - The mechanism involves chronic low-grade inflammation, **insulin resistance**, and altered levels of adipokines (like leptin) and insulin-like growth factors. ***Meningioma*** - **Meningioma**, the most common primary central nervous system tumor, has a clear association with obesity. - High BMI contributes to increased risk, possibly mediated by elevated levels of **leptin** and **estrogen** (especially in postmenopausal women) which can act as growth factors.

Q: A 32-year-old woman presents with easy bruising and petechiae. Her platelet count is 18,000 / mm³. Hemoglobin and total leukocyte count are normal. She recently recovered from a mild upper respiratory tract infection. Peripheral smear shows no abnormal cells. What is the most appropriate next step in management?

Oral corticosteroids. ***Oral corticosteroids*** - This is the **first-line treatment** for newly diagnosed Immune Thrombocytopenic Purpura (ITP), especially when the platelet count is severely low (typically <30,000/mm³) and the patient exhibits bleeding symptoms like **petechiae** and easy bruising [1]. - Corticosteroids reduce the clearance of antibody-coated platelets by the **reticuloendothelial system** (primarily splenic macrophages) and suppress autoantibody production. ***Platelet transfusion*** - Platelet transfusions are generally **contraindicated** in ITP because the transfused platelets are rapidly destroyed by the same autoantibodies that target the patient's native platelets [1]. - They are reserved only for **life-threatening hemorrhage** (e.g., intracranial bleeding) or for pre-operative stabilization, usually given concurrently with high-dose IVIG or corticosteroids. ***Bone marrow biopsy*** - A **bone marrow biopsy** is usually not required for a young patient with classic ITP presentation (isolated thrombocytopenia, normal Hb/TLC, recent infection, and normal peripheral smear). - It is typically mandatory only if the patient is older (e.g., >60), has unexplained cytopenias in other lineages, or is **refractory** to first-line treatment. ***Splenectomy*** - Splenectomy is a **second-line treatment** option, typically reserved for patients with chronic ITP who fail to respond adequately to medical therapy (corticosteroids and IVIG) after 6 to 12 months [2]. - Although the spleen is the primary site of autoantibody production and platelet destruction, it is not the **most appropriate immediate next step** in initial management [2].

Question 1

Which of the following is not a cause of high anion gap metabolic acidosis?

Accepted Answer

Diarrhea

Answer

Ketoacidosis

Answer

Acute kidney injury

Answer

Toxins

Question 2

Choose the correct statement(s):
1. Metformin is contraindicated in patients with severe renal impairment (eGFR <30 mL/min/1.73m²)
2. ACE inhibitors should be discontinued immediately if serum creatinine increases by any amount after initiation
3. Beta-blockers are first-line therapy for heart failure with reduced ejection fraction
4. Statins are recommended for primary prevention in patients with diabetes mellitus aged 40-75 years

Accepted Answer

1, 3, 4 are correct

Answer

1, 2, 3 are correct

Answer

1, 2, 3, 4 are correct

Answer

1, 4 are correct

Question 3

What is the role of Procalcitonin in pneumonia?

Accepted Answer

Early antibiotic discontinuation

Answer

Requirement of further investigation

Answer

Guiding initiation of antibiotic

Answer

No role

Question 4

Which of the following malignancies is unrelated to obesity?

Accepted Answer

Multiple myeloma

Answer

Pancreas

Answer

Stomach

Answer

Meningioma

Question 5

A 32-year-old woman presents with easy bruising and petechiae. Her platelet count is 18,000 / mm³. Hemoglobin and total leukocyte count are normal. She recently recovered from a mild upper respiratory tract infection. Peripheral smear shows no abnormal cells. What is the most appropriate next step in management?

Accepted Answer

Oral corticosteroids

Answer

Platelet transfusion

Answer

Splenectomy

Answer

Bone marrow biopsy

INI-CET 2025 — Internal Medicine