INI-CET 2023 Practice Questions

Q: Non-scarring alopecia is associated with all except?

Frontal fibrosing alopecia. ***Frontal fibrosing alopecia*** - This condition is a form of **lichen planopilaris**, which causes **scarring alopecia** due to destruction of hair follicles and replacement with fibrous tissue. - It results in a **receding hairline** and eyebrow loss, with irreversible hair loss. *Telogen effluvium* - This is a common cause of **non-scarring alopecia**, characterized by diffuse hair shedding triggered by various stressors like illness, stress, or medications. - The hair follicles enter the **telogen phase** prematurely, leading to increased shedding but typically regrowth once the trigger is removed. *Androgenetic alopecia* - Often referred to as **male or female pattern baldness**, this is a form of **non-scarring alopecia** driven by genetic predisposition and androgens. - It causes a progressive miniaturization of hair follicles, leading to thinning hair, but the follicles remain present and capable of producing hair. *Alopecia areata* - This is an **autoimmune condition** that causes **non-scarring hair loss** in patches on the scalp or other parts of the body. - The hair follicles are attacked by the immune system but are not permanently destroyed, allowing for potential regrowth.

Q: A 24-year-old male presents with asymptomatic scaly lesions over the body as shown in the image below. What is the likely diagnosis?

Pityriasis Rosea. ***Pityriasis Rosea*** - The image shows numerous **scaly, erythematous plaques** distributed over the trunk, with a characteristic "Christmas tree" pattern often observed in Pityriasis Rosea. - The lesions are described as **asymptomatic**, which is consistent with Pityriasis Rosea, although mild pruritus can occur. *Atopic Dermatitis* - Typically presents with **intensely pruritic, erythematous, and eczematous lesions** often found in flexural areas (e.g., antecubital and popliteal fossae). - While it can be widespread, the morphology of the lesions (eczematous vs. scaly plaques) and the absence of pruritus make this less likely. *Lichen planus* - Characterized by **pruritic, violaceous, polygonal papules** and plaques, often appearing on the flexor surfaces of wrists, ankles, and oral mucosa. - The appearance of the lesions in the image does not match the typical morphology of lichen planus. *Seborrheic Dermatitis* - Primarily affects areas with a high density of sebaceous glands, such as the **scalp, face (nasolabial folds, eyebrows), and chest**. - Presents with **greasy, yellowish scales** on an erythematous base, which is distinct from the dry, scaly plaques seen in the image.

Q: A 40 year male patient presented to the ER with a history of fall and C/O pain and swelling in right shoulder region. The x-ray of the patients suggests tear in which of the following ligament?

Acromioclavicular ligament. ***Acromioclavicular ligament*** - A fall on an outstretched arm or direct trauma to the shoulder can cause an **acromioclavicular joint separation**, leading to a tear in the acromioclavicular ligament. - Pain and swelling in the right shoulder region are classic symptoms, and an X-ray can confirm the **widening of the AC joint space**. *Coracoacromial ligament* - This ligament forms the roof of the **subacromial space** and is rarely torn in isolation from trauma. - Tears are more commonly associated with **impingement syndrome** or **rotator cuff pathology**, not primarily with a traumatic fall leading to joint pain and swelling. *Coracoclavicular ligament* - While it helps stabilize the acromioclavicular joint, a tear of the **coracoclavicular ligament** is usually present in more severe acromioclavicular joint dislocations (Type III and above). - Its rupture would result in a more pronounced **superior displacement of the clavicle** compared to an isolated AC ligament tear. *Glenohumeral ligament* - These ligaments reinforce the **glenohumeral joint capsule** and are primarily involved in stabilizing the shoulder against dislocation. - A tear would typically present with symptoms of **shoulder instability** or a **dislocation**, rather than just pain and swelling from a fall focused on the AC joint.

Q: A 14 year old male presents with mushroom like tumor in the distal femur for past 2 years. Which of the following features suggest malignant transformation?

Cartilage thickness $>2 \mathrm{~cm}$. ***Cartilage thickness >2 cm*** - A **cartilage cap thickness greater than 2 cm** in an osteochondroma in an adult (or >3 cm in children) is a strong indicator of **malignant transformation** into a secondary peripheral **chondrosarcoma**. [2], [3] - **Key imaging finding:** Cartilage cap measured on MRI or CT scan - Other features suggesting malignant transformation include continued growth after skeletal maturity, new or increasing pain, cortical destruction, and new soft tissue mass. [2], [3] *Presence of cartilage cap* - All osteochondromas have a cartilage cap by definition - this is a normal feature, not a sign of malignancy. [1] - The **thickness** of the cap, not its presence, is what matters. *Location in metaphysis* - Osteochondromas typically arise from the metaphysis near the growth plate - this is a normal location. [3] - Location alone does not indicate malignant transformation. *Size less than 1 cm* - Small size suggests a benign, stable lesion. - Malignant transformation is suggested by **increasing size** and growth after skeletal maturity, not small size. [2] **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1202. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 672-673. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, pp. 1202-1204.

Q: Abnormal accumulation of misfolded protein is seen in?

Creutzfeldt-Jakob disease. ***Creutzfeldt-Jakob disease*** - This is a neurodegenerative disease characterized by the accumulation of **abnormally folded prion proteins (PrPSc)** in the brain, leading to spongiform encephalopathy [1]. - The misfolding of normal cellular prion protein (PrPC) into its infectious and pathogenic form is central to the disease's pathology [2]. *Nephritic syndrome* - This syndrome is characterized by inflammation of the **glomeruli** in the kidneys, leading to hematuria, proteinuria, and hypertension. - It involves immune complex deposition and inflammation, not primarily the accumulation of misfolded proteins. *Sickle cell anemia* - This is a **genetic blood disorder** caused by a mutation in the beta-globin gene, leading to abnormal **hemoglobin S**. - While hemoglobin S can polymerize and deform red blood cells, it is not considered a disease of generalized misfolded protein accumulation in the same sense as prion diseases. *Megaloblastic anemia* - This condition is caused by impaired **DNA synthesis**, often due to **vitamin B12 or folate deficiency**, leading to large, immature red blood cells. - The pathology involves defective cell division and maturation, not the accumulation of misfolded proteins. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1284-1286. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 712-713.

Q: What is the treatment for HER-2 positive trastuzumab resistant breast cancer?

Lapatinib. ***Lapatinib*** - Lapatinib is a **dual tyrosine kinase inhibitor** that targets both **HER-2** and **epidermal growth factor receptor (EGFR)**, acting as a **small molecule inhibitor** that binds to the intracellular domain of these receptors. - Unlike trastuzumab (a monoclonal antibody targeting the extracellular domain), Lapatinib's **intracellular mechanism of action** allows it to overcome common mechanisms of trastuzumab resistance, such as receptor truncation or masking of the extracellular epitope. - It is specifically approved for the treatment of **HER-2 positive metastatic breast cancer** in combination with capecitabine after progression on trastuzumab-containing regimens. *Sorafenib* - Sorafenib is a **multi-kinase inhibitor** primarily targeting RAF, VEGFR, and PDGFR, and is used in renal cell carcinoma and hepatocellular carcinoma. - It does not specifically target HER-2 and is **not indicated** for HER-2 positive trastuzumab-resistant breast cancer. *Vemurafenib* - Vemurafenib is a **BRAF inhibitor** used for treating BRAF V600E mutation-positive melanoma. - This drug has no direct indications or demonstrated efficacy for **HER-2 positive breast cancer** and does not address trastuzumab resistance mechanisms. *Erlotinib* - Erlotinib is an **EGFR tyrosine kinase inhibitor** primarily used for non-small cell lung cancer with activating EGFR mutations. - While it targets EGFR, it does **not effectively target HER-2** and lacks the dual inhibition necessary to overcome trastuzumab resistance in HER-2 positive breast cancer.

Q: Which nomogram scale is used for aminoglycoside dosage?

Hartford nomogram. ***Hartford nomogram*** - The **Hartford nomogram** is the standard tool for determining **once-daily (extended-interval) aminoglycoside dosing** based on **creatinine clearance**. - It helps clinicians optimize aminoglycoside therapy by allowing for less frequent dosing while maintaining therapeutic drug levels and minimizing **nephrotoxicity** and **ototoxicity**. - Developed at Hartford Hospital, this nomogram guides dosing intervals (24, 36, or 48 hours) based on a single serum level drawn 6-14 hours post-dose. *Hallstead scale* - The **Hallstead scale** is not a standard nomogram used in clinical practice for drug dosing. - This term does not correspond to a recognized clinical tool for medication management or aminoglycoside therapy. *Salazar scale* - The **Salazar-Corcoran equation** is used for estimating **creatinine clearance in obese patients**, not as a nomogram for aminoglycoside dosing. - While it may be used in the pharmacokinetic assessment before aminoglycoside dosing, it is not a dosing nomogram itself. *Rumack Matthew nomogram* - The **Rumack-Matthew nomogram** is used for assessing the risk of **hepatotoxicity** after an **acetaminophen overdose** by plotting plasma acetaminophen levels against time. - It is not used for aminoglycoside dosage or therapeutic drug monitoring.

Q: Osimertinib is used in NSCLC with which mutation?

T790M mutation. ***T790M mutation*** - **Osimertinib** is a third-generation **EGFR tyrosine kinase inhibitor (TKI)** specifically designed to overcome resistance to earlier generation EGFR TKIs. - The **T790M mutation** in the EGFR gene is the most common mechanism of acquired resistance to first and second-generation EGFR TKIs in non-small cell lung cancer (NSCLC). *L858R mutation* - The **L858R mutation** is an activating **EGFR mutation** typically sensitive to first and second-generation EGFR TKIs. - While patients with **L858R** may eventually develop resistance, **osimertinib** is primarily used in the setting of acquired resistance, often mediated by **T790M**. *M790T mutation* - This is not a recognized common or clinically significant activating or resistance mutation in the **EGFR gene** for NSCLC. - The correct resistance mutation that **osimertinib** targets is **T790M**, not **M790T**. *T890M mutation* - This is a typographical error for the clinically relevant **T790M mutation**. - The number sequence is critical for identifying specific amino acid substitutions in gene mutations.

Q: Match the following: Column A: a. Beta 1 b. Beta 2 c. Beta 3 Column B: 1. Mirabegron 2. Betaxolol 3. Salbutamol

a-2, b-3 ,c-1. ***a-2, b-3, c-1*** - This pairing correctly matches **Betaxolol** with **Beta 1 selective** antagonism, **Salbutamol** with **Beta 2 selective** agonism, and **Mirabegron** with **Beta 3 selective** agonism. - **Betaxolol** is a beta-1 selective adrenergic receptor antagonist, primarily used in ophthalmology to reduce intraocular pressure and as an antihypertensive. **Salbutamol** is a selective beta-2 adrenergic agonist used as a bronchodilator in asthma and COPD, causing relaxation of bronchial smooth muscle. **Mirabegron** is a selective beta-3 adrenergic agonist used to treat overactive bladder by relaxing the detrusor muscle. *a-2, b-1, c-3* - This option incorrectly assigns **Mirabegron** to Beta 2. Mirabegron is a **Beta 3 selective agonist**. - It also incorrectly assigns **Salbutamol** to Beta 3. Salbutamol is a **Beta 2 selective agonist**. *a-3, b-2, c-1* - This option incorrectly assigns **Salbutamol** to Beta 1. Salbutamol is a **Beta 2 selective agonist**. - It also incorrectly assigns **Betaxolol** to Beta 2. Betaxolol is a **Beta 1 selective antagonist**. *a-3, b-1, c-2* - This option incorrectly assigns **Salbutamol** to Beta 1 and **Betaxolol** to Beta 3. - **Salbutamol** is a Beta 2 selective agonist, and **Betaxolol** is a Beta 1 selective antagonist.

Q: A 35-year-old male patient presents to surgery emergency with painful erection for past 7 hours. He has a history of mood disorder and was recently prescribed a medication by treating psychiatrist. Which is the likely offending drug?

Trazodone. ***Trazodone*** - **Trazodone** is a commonly known antidepressant that can cause **priapism** as a side effect, especially at higher doses, due to its alpha-adrenergic blocking activity. [1] - The patient's presentation of a **painful erection lasting 7 hours** after starting a new psychiatric medication strongly points towards a drug-induced cause, for which trazodone is a well-established culprit. [1] *Venlafaxine* - **Venlafaxine** is an SNRI antidepressant that generally does not cause priapism as a recognized side effect. - Its adverse effect profile primarily includes nausea, insomnia, and sexual dysfunction (e.g., erectile dysfunction, anorgasmia), rather than prolonged erections. *Tianeptine* - **Tianeptine** is an atypical antidepressant that is not known to cause priapism. - It works by enhancing serotonin reuptake and is more commonly associated with side effects such as nausea, constipation, and dizziness. *Mirtazapine* - **Mirtazapine** is a tetracyclic antidepressant that works by blocking alpha-2 adrenergic receptors and certain serotonin receptors. - While it can cause sedation and weight gain, priapism is not a typical or recognized side effect of mirtazapine.

Question 1

Non-scarring alopecia is associated with all except?

Accepted Answer

Frontal fibrosing alopecia

Answer

Telogen effluvium

Answer

Androgenetic alopecia

Answer

Alopecia areata

Question 2

A 24-year-old male presents with asymptomatic scaly lesions over the body as shown in the image below. What is the likely diagnosis?

Accepted Answer

Pityriasis Rosea

Answer

Atopic Dermatitis

Answer

Lichen planus

Answer

Seborrheic Dermatitis

Question 3

A 40 year male patient presented to the ER with a history of fall and C/O pain and swelling in right shoulder region. The x-ray of the patients suggests tear in which of the following ligament?

Accepted Answer

Acromioclavicular ligament

Answer

Coracoacromial ligament

Answer

Coracoclavicular ligament

Answer

Glenohumeral ligament

Question 4

A 14 year old male presents with mushroom like tumor in the distal femur for past 2 years. Which of the following features suggest malignant transformation?

Accepted Answer

Cartilage thickness $>2 \mathrm{~cm}$

Answer

Presence of cartilage cap

Answer

Location in metaphysis

Answer

Size less than 1 cm

Question 5

Abnormal accumulation of misfolded protein is seen in?

Accepted Answer

Creutzfeldt-Jakob disease

Answer

Nephritic syndrome

Answer

Sickle cell anemia

Answer

Megaloblastic anemia

Question 6

What is the treatment for HER-2 positive trastuzumab resistant breast cancer?

Accepted Answer

Lapatinib

Answer

Sorafenib

Answer

Vemurafenib

Answer

Erlotinib

Question 7

Which nomogram scale is used for aminoglycoside dosage?

Accepted Answer

Hartford nomogram

Answer

Hallstead scale

Answer

Salazar scale

Answer

Rumack Matthew nomogram

Question 8

Osimertinib is used in NSCLC with which mutation?

Accepted Answer

T790M mutation

Answer

L858R mutation

Answer

M790T mutation

Answer

T890M mutation

Question 9

Match the following:

Column A:
a. Beta 1
b. Beta 2
c. Beta 3

Column B:
1. Mirabegron
2. Betaxolol
3. Salbutamol

Accepted Answer

a-2, b-3 ,c-1

Answer

a-2, b-1, c-3

Answer

a-3, b-2, c-1

Answer

a-3, b-1, c-2

Question 10

A 35-year-old male patient presents to surgery emergency with painful erection for past 7 hours. He has a history of mood disorder and was recently prescribed a medication by treating psychiatrist. Which is the likely offending drug?

Accepted Answer

Trazodone

Answer

Venlafaxine

Answer

Tianeptine

Answer

Mirtazapine

INI-CET 2023

Dermatology

Orthopaedics

Pathology

Pharmacology