INI-CET 2023 Practice Questions

Q: Which of the following statements given below is incorrect regarding CPR?

Ventilation 22-25/ min. ***Ventilation 22-25/ min*** - A ventilation rate of 22-25 breaths/min is **too high** for CPR, which typically recommends 10-12 breaths/min, corresponding to 2 breaths after every 30 compressions. - Excessive ventilation can lead to **hyperventilation**, increasing intrathoracic pressure and reducing venous return, thus decreasing cardiac output. *Chest compression rate 100-120/min* - The recommended chest compression rate for adults in CPR is **100-120 compressions per minute**, ensuring adequate blood flow to vital organs. - Maintaining this rate is crucial for maximizing the effectiveness of chest compressions by providing sufficient circulation. *Depth of chest compression up to 5-6 cm* - The recommended depth for adult chest compressions is at least 5 cm (2 inches), but no more than **6 cm (2.4 inches)** to prevent injury. - This depth ensures that enough pressure is exerted to circulate blood effectively without causing excessive trauma. *Allow adequate chest recoil* - Complete chest recoil is essential to allow the heart to **fully refill with blood** between compressions. - Leaning on the chest between compressions prevents adequate recoil, which can reduce pulmonary and coronary perfusion and **decrease the effectiveness of CPR**.

Q: Patient of pneumonia on ventilator with wt. 50 kg. RR 14/min, bicarbonate - 18, pH 7.3, pCO2 48 mmHg, pO2 110 mmHg, PEEP 12 cm H2O, tidal volume 420 mL, SpO2 - 100% with FiO2 90%. What is next step in management?

Decrease fio2. **Decrease FiO2** - The patient has an **SpO2 of 100% with a FiO2 of 90%**, indicating **hyperoxia** induced by excessive oxygen delivery. - Decreasing FiO2 is the appropriate next step to prevent **oxygen toxicity** (e.g., absorption atelectasis, free radical damage) while maintaining adequate oxygenation. *Increase PEEP* - The patient's **PaO2 of 110 mmHg** is already well within the normal to high range, suggesting that oxygenation is adequate. - Increasing PEEP would be considered if the patient had **refractory hypoxemia**, not hyperoxia. *Increase tidal volume* - The current tidal volume of **420 mL for a 50 kg patient (8.4 mL/kg)** is already at the higher end of lung-protective ventilation (typically 6-8 mL/kg). - Increasing tidal volume further could lead to **ventilator-induced lung injury** (VILI) due to volutrauma, especially in a patient with pneumonia. *Decrease RR* - The patient has a **pCO2 of 48 mmHg** and a **pH of 7.3**, indicating **respiratory acidosis** (hypoventilation). - Decreasing the respiratory rate would further exacerbate the acidosis by reducing minute ventilation and increasing pCO2, which is inappropriate.

Q: A man presents with a rash on his flank with itching for the past 2 weeks. The patient has tried several over-the-counter medications, including lotrimin and hydrocortisone, without any improvement. In physical examination, the rash is seen on his palms and the sole of one foot, but no oral lesions are found. What is the likely diagnosis?

Secondary syphilis. ***Secondary syphilis*** - The rash presenting on the **palms and soles** is highly characteristic of **secondary syphilis**, which helps differentiate it from many other dermatological conditions. - The lack of improvement with antifungal (Lotrimin) and corticosteroid (hydrocortisone) treatments further supports a diagnosis other than a fungal infection or inflammatory dermatitis. *Tinea corporis* - This fungal infection typically presents as an **annular (ring-shaped) rash** with central clearing and well-demarcated borders, often on the trunk or limbs. - It would likely show some improvement, even if partial, with **Lotrimin (an antifungal medication)**, which is not the case here. *Pityriasis rosea* - This condition is characterized by an initial **"herald patch"** followed by smaller, oval, pinkish-red patches that often align along skin cleavage lines in a **"Christmas tree" pattern** on the trunk. - It typically spares the palms and soles, which are involved in this patient's presentation. *Contact dermatitis* - This is an inflammatory skin reaction due to contact with an allergen or irritant, presenting as **pruritic (itchy) erythematous (red) patches, possibly with vesicles or bullae**, limited to exposed areas. - While hydrocortisone might offer some relief, the presentation on palms and soles without clear exposure and the lack of response to treatment make it less likely.

Q: What is the correct order for cardiac auscultation on the left side, from superior to inferior? a. Pulmonary b. Tricuspid c. Mitral

a>b>c (Pulmonary > Tricuspid > Mitral). **a>b>c (Pulmonary > Tricuspid > Mitral)** - This order accurately reflects the anatomical positions of the **auscultation points** on the left side of the chest, moving from the superior aspect (second intercostal space) down to the inferior aspect (fifth intercostal space). - The **pulmonary area** is auscultated at the second left intercostal space, the **tricuspid area** at the fourth or fifth left intercostal space near the sternum, and the **mitral (apical) area** at the fifth left intercostal space at the midclavicular line [1]. *c>b>a (Mitral > Tricuspid > Pulmonary)* - This order is incorrect as it places the **mitral area** (inferior) superior to the **tricuspid** and **pulmonary areas**, which contradicts the anatomical arrangement for auscultation. - Auscultating in this sequence would involve moving from an inferior left position upwards, which is not the standard superior-to-inferior left-sided auscultation approach. *b>a>c (Tricuspid > Pulmonary > Mitral)* - This order is incorrect because it places the **tricuspid area** superior to the **pulmonary area**, which is factually wrong. - The **pulmonary area** is at the second left intercostal space, making it superior to the tricuspid area (fourth or fifth left intercostal space) [1]. *c>a>b (Mitral > Pulmonary > Tricuspid)* - This order is incorrect as it incorrectly positions the **mitral area** as the most superior point on the left side, which is anatomically inaccurate for auscultation. - The **pulmonary area** is located more superiorly than both the tricuspid and mitral areas in the standard auscultation sequence [1].

Q: Match the following: A) Caplan syndrome- 1) Found first in coal worker B) Asbestosis- 2) Upper lobe predominance C) Mesothelioma- 3) Involves lower lobe D) Sarcoidosis- 4) Pleural effusion is seen

A-1, B-4, C-3, D-2. **A-1, B-4, C-3, D-2** - **Caplan syndrome** was first described in **coal workers** with **rheumatoid arthritis** and progressive massive fibrosis. - **Asbestosis** is often associated with **pleural effusion**, which can be benign or malignant. - **Mesothelioma** typically involves the **lower lobes** of the lungs, specifically the pleura, and is strongly linked to asbestos exposure. - **Sarcoidosis** is characterized by **non-caseating granulomas**, which have a predilection for the **upper lobes** of the lungs. *A-3, B-4, C-2, D-1* - This option incorrectly states that Caplan syndrome involves the lower lobe; **Caplan syndrome** is defined by the presence of large nodules in the lungs of coal workers with rheumatoid arthritis, and their specific lobar distribution is not a defining characteristic. - This option incorrectly states that Mesothelioma has an upper lobe predominance; **Mesothelioma** is a pleural malignancy and typically involves the **lower lobes**, extending along the pleura. *A-4, B-2, C-3, D-1* - This option incorrectly associates Caplan syndrome with pleural effusion; **Caplan syndrome** manifests as rheumatoid nodules in the lungs, not primarily pleural effusion. - This option incorrectly states that Asbestosis has an upper lobe predominance; **Asbestosis** predominantly affects the **lower lobes** of the lungs, causing interstitial fibrosis. *A-2, B-4, C-3, D-1* - This option incorrectly states that Caplan syndrome has an upper lobe predominance; the defining feature of **Caplan syndrome** is the combination of rheumatoid arthritis and pneumoconiosis, not specific lobar involvement. - This option correctly identifies pleural effusion with asbestosis and lower lobe involvement with mesothelioma, but **Caplan syndrome** is not characterized by upper lobe predominance.

Q: A patient presented with complaints of pain in the flank region with hematuria. On investigation, X-ray shows multiple calcification (stones) in both kidneys. What is the probable diagnosis?

Renal calculi. ***Renal calculi*** - The presence of **flank pain**, **hematuria**, and **multiple calcifications (stones) in both kidneys** on X-ray directly points to a diagnosis of renal calculi (kidney stones) [1]. - These stones can cause pain due to obstruction and irritation, leading to blood in the urine [1]. *Polycystic kidney disease* - This condition is characterized by the development of numerous **cysts in the kidneys**, which are fluid-filled sacs, not calcifications or stones [2]. - While it can cause flank pain and hematuria, the imaging finding of **multiple calcifications** is inconsistent with typical PCKD presentation [2]. *Parathyroid Adenoma* - A parathyroid adenoma leads to **hyperparathyroidism**, which can cause **hypercalcemia** and subsequently increase the risk of **calcium kidney stones** [1]. - However, the diagnosis directly relates to the presence of stones as seen on X-ray, not the underlying cause of stone formation, and the question does not provide enough information to confirm hyperparathyroidism. *CKD* - **Chronic kidney disease (CKD)** is a progressive loss of kidney function over time, representing a *spectrum* of kidney damage. - While kidney stones can lead to CKD, and CKD can present with various symptoms, the direct finding of **multiple calcifications (stones)** on imaging is a specific indicator of renal calculi rather than CKD itself as the primary diagnosis.

Q: KEYNOTE-189 trial for pembrolizumab is done for?

Pembrolizumab with chemo given for NSCLC. ***Pembrolizumab with chemo given for NSCLC*** - The **KEYNOTE-189 trial** investigated the efficacy of **pembrolizumab** in combination with chemotherapy as first-line treatment for **metastatic nonsquamous non-small cell lung cancer (NSCLC)**. - This trial demonstrated significant improvements in overall survival and progression-free survival, leading to the approval of pembrolizumab in this setting. *Nivolumab with chemo given for NSCLC* - **Nivolumab** is another PD-1 inhibitor, but studies specifically combining nivolumab with chemotherapy for NSCLC (e.g., CheckMate 227) are distinct from KEYNOTE-189. - While both drugs are used in NSCLC, their pivotal trials and specific combination regimens differ. *Only Pembrolizumab for NSCLC* - Although pembrolizumab monotherapy is approved for certain NSCLC patients with high PD-L1 expression, the **KEYNOTE-189 trial specifically focused on a combination approach** with chemotherapy. - Other KEYNOTE trials, like KEYNOTE-024, evaluated pembrolizumab monotherapy in NSCLC. *Only nivolumab for NSCLC* - **Nivolumab monotherapy** has been studied and approved for NSCLC, particularly in the second-line setting or for patients with high PD-L1 expression, but this was not the focus of the KEYNOTE-189 trial. - Trials like CheckMate 017 and 057 investigated nivolumab as a single agent in NSCLC.

Q: A female patient presented with vulvovaginal pruritus. On detailed history taking, it was found that she was on some antidiabetic drugs. Which antidiabetic drug can cause the above-mentioned side effect?

Canagliflozin. ***Canagliflozin*** - Canagliflozin is a **sodium-glucose co-transporter 2 (SGLT2) inhibitor**. These drugs work by increasing **urinary glucose excretion**. - The increased glucose in the urine (glycosuria) creates a favorable environment for fungal and bacterial growth, leading to common side effects such as **vulvovaginal candidiasis** (yeast infections) and urinary tract infections, which manifest as pruritus. *Metformin* - Metformin is a **biguanide** that primarily reduces hepatic glucose production and increases insulin sensitivity. - Its common side effects are gastrointestinal, such as **diarrhea, nausea, and abdominal discomfort**, but it does not typically cause genitourinary infections or pruritus. *Linagliptin* - Linagliptin is a **dipeptidyl peptidase-4 (DPP-4) inhibitor** that increases endogenous GLP-1 and GIP levels, enhancing glucose-dependent insulin secretion. - Common side effects include **nasopharyngitis** and **headache**, but it is not associated with vulvovaginal pruritus. *Liraglutide* - Liraglutide is a **glucagon-like peptide-1 (GLP-1) receptor agonist** that increases glucose-dependent insulin secretion, suppresses glucagon secretion, and slows gastric emptying. - Its most common side effects are **gastrointestinal (nausea, vomiting), decreased appetite, and pancreatitis (rare)**, but it generally does not cause vulvovaginal pruritus.

Q: The first drug approved for Rett syndrome is?

Trofinetide. ***Trofinetide*** - **Trofinetide** (marketed as Daybue) is the first drug specifically approved by the FDA for the treatment of Rett syndrome, receiving approval in March 2023. - It is an analog of the **N-terminal tripeptide of insulin-like growth factor-1 (IGF-1)** and is thought to reduce neuroinflammation and support synaptic function in the brain, improving core symptoms of Rett syndrome. *L-carnitine* - **L-carnitine** is a nutritional supplement that has been studied in Rett syndrome for potential mitochondrial dysfunction, but it is not a primary treatment or an FDA-approved drug for the condition. - While sometimes used adjunctively, there is limited evidence for its efficacy as a standalone therapy in Rett syndrome. *Naltrexone* - **Naltrexone** is an opioid antagonist typically used to treat opioid and alcohol dependence. - It has been explored in some neurodevelopmental disorders, but it is not approved for or considered a primary treatment for Rett syndrome. *Folinic acid* - **Folinic acid** is a form of folic acid that can bypass metabolic blocks in folate pathways, sometimes used in conditions with cerebral folate deficiency. - While metabolic abnormalities can occur in Rett syndrome, folinic acid is not an FDA-approved drug for Rett syndrome.

Question 1

Which of the following statements given below is incorrect regarding CPR?

Accepted Answer

Ventilation 22-25/ min

Answer

Chest compression rate 100-120/min

Answer

Depth of chest compression up to 5-6 cm

Answer

Allow adequate chest recoil

Question 2

Patient of pneumonia on ventilator with wt. 50 kg. RR 14/min, bicarbonate - 18, pH 7.3, pCO2 48 mmHg, pO2 110 mmHg, PEEP 12 cm H2O, tidal volume 420 mL, SpO2 - 100% with FiO2 90%. What is next step in management?

Accepted Answer

Decrease fio2

Answer

Increase PEEP

Answer

Increase tidal volume

Answer

Decrease RR

Question 3

A man presents with a rash on his flank with itching for the past 2 weeks. The patient has tried several over-the-counter medications, including lotrimin and hydrocortisone, without any improvement. In physical examination, the rash is seen on his palms and the sole of one foot, but no oral lesions are found. What is the likely diagnosis?

Accepted Answer

Secondary syphilis

Answer

Tinea corporis

Answer

Pityriasis rosea

Answer

Contact dermatitis

Question 4

What is the correct order for cardiac auscultation on the left side, from superior to inferior?
a. Pulmonary
b. Tricuspid
c. Mitral

Accepted Answer

a>b>c (Pulmonary > Tricuspid > Mitral)

Answer

c>b>a (Mitral > Tricuspid > Pulmonary)

Answer

b>a>c (Tricuspid > Pulmonary > Mitral)

Answer

c>a>b (Mitral > Pulmonary > Tricuspid)

Question 5

Match the following: A) Caplan syndrome- 1) Found first in coal worker B) Asbestosis- 2) Upper lobe predominance C) Mesothelioma- 3) Involves lower lobe D) Sarcoidosis- 4) Pleural effusion is seen

Accepted Answer

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

Answer

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

Answer

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

Answer

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

Question 6

A patient presented with complaints of pain in the flank region with hematuria. On investigation, X-ray shows multiple calcification (stones) in both kidneys. What is the probable diagnosis?

Accepted Answer

Renal calculi

Answer

Polycystic kidney disease

Answer

Parathyroid Adenoma

Answer

CKD

Question 7

KEYNOTE-189 trial for pembrolizumab is done for?

Accepted Answer

Pembrolizumab with chemo given for NSCLC

Answer

Nivolumab with chemo given for NSCLC

Answer

Only Pembrolizumab for NSCLC

Answer

Only nivolumab for NSCLC

Question 8

A female patient presented with vulvovaginal pruritus. On detailed history taking, it was found that she was on some antidiabetic drugs. Which antidiabetic drug can cause the above-mentioned side effect?

Accepted Answer

Canagliflozin

Answer

Metformin

Answer

Linagliptin

Answer

Liraglutide

Question 9

The first drug approved for Rett syndrome is?

Accepted Answer

Trofinetide

Answer

L-carnitine

Answer

Naltrexone

Answer

Folinic acid

Question 10

Which of the following is true about clinical therapeutic index?

Accepted Answer

Dose in which efficacy and toxicity can be balanced in an individual

Answer

Therapeutic index is LD50/ED50

Answer

It is only used for a specific individual

Answer

It measures therapeutic index in populations rather than individuals

INI-CET 2023

Anesthesiology

Dermatology

Internal Medicine

Pharmacology