INI-CET 2025

202 Questions — Page 9 of 21

All (202)Anatomy (16)Anesthesiology (3)Biochemistry (10)Community Medicine (18)Dermatology (5)ENT (5)Forensic Medicine (8)Internal Medicine (31)Microbiology (11)Obstetrics and Gynecology (5)Ophthalmology (10)Orthopaedics (4)Pathology (8)Pediatrics (14)Pharmacology (17)Physiology (11)Psychiatry (5)Radiology (8)Surgery (13)

Internal Medicine

2 questions

Q81

Which of the following is wrongly matched with its classification?

Q82

What is the cause of hyponatremia in diarrhea-induced hypovolemia?

INI-CET 2025 - Internal Medicine INI-CET Practice Questions and MCQs

Question 81: Which of the following is wrongly matched with its classification?

A. Boston classification - Colon preparation for colonoscopy
B. Mannheim classification - Chronic pancreatitis
C. Miami classification - Parathyroid adenoma and hyperplasia differentiation
D. LA classification - Achalasia (Correct Answer)

Explanation: ***LA classification - Achalasia*** - The **Los Angeles (LA) classification** system is used to grade the severity of **reflux esophagitis** (Esme of the gastric mucosa, typically following **Gastroesophageal Reflux Disease (GERD)**). - **Achalasia** is typically classified using the **Chicago Classification** (based on high-resolution manometry findings) [1] or the older **Siewert classification** for surgical staging. ***Boston classification - Colon preparation for colonoscopy*** - The **Boston Bowel Preparation Scale (BBPS)** is a validated, widely used scoring system to assess the quality of **colon preparation** during colonoscopy, ranging from 0 (unprepared) to 3 (excellent) for each segment. - A high BBPS score (typically $\ge$ 7) indicates adequate preparation necessary for accurate polyp detection. ***Mannheim classification - Chronic pancreatitis*** - The **Mannheim Classification System** is used for grading the severity of **acute pancreatitis**, not chronic pancreatitis. - It assesses clinical parameters (e.g., organ failure, complications) to predict the prognosis and guide management of acute pancreatitis. ***Miami classification - Parathyroid adenoma and hyperplasia differentiation*** - The **Miami Criteria** is a histological classification system used to distinguish between **parathyroid adenoma** and **parathyroid hyperplasia** based on architectural and cellular features observed on surgical pathology. - It helps pathologists determine the underlying cause of primary hyperparathyroidism.

Question 82: What is the cause of hyponatremia in diarrhea-induced hypovolemia?

A. Decreased aldosterone (Correct Answer)
B. Decreased ADH
C. Decreased sodium absorption from gastrointestinal tract
D. Increased sodium absorption from kidney

Explanation: ***Decreased aldosterone*** * In scenarios where salt loss (e.g., due to diarrhea) leads to hypovolemia, a relative or true deficiency of **aldosterone** prevents maximal sodium reabsorption in the distal tubules and collecting ducts. * This failure to maximally conserve sodium leads to **renal salt wasting**, which exacerbates the volume deficit and, when coupled with ADH-mediated water retention, results in hyponatremia. ***Decreased ADH*** * Hypovolemia (volume depletion) is the strongest non-osmotic trigger for the release of **Antidiuretic Hormone (ADH)** from the posterior pituitary, overriding low plasma osmolality [1]. * Therefore, in diarrhea-induced hypovolemia, **ADH levels are actually increased**, which drives powerful free water reabsorption in the kidney, resulting in dilutional hyponatremia [1]. ***Decreased sodium absorption from gastrointestinal tract*** * This is the primary mechanism by which diarrhea causes salt and water loss, leading to the state of **hypovolemia**. * However, the mechanism driving the *hyponatremia* (low plasma sodium concentration) involves the kidney's disproportionate reabsorption of water relative to sodium, mediated by **ADH**. ***Increased sodium absorption from kidney*** * System mechanisms like the Renin-Angiotensin-Aldosterone System (RAAS) are activated by hypovolemia to increase **sodium and water absorption** in an attempt to restore blood volume [2]. * Increased renal sodium absorption is a compensatory mechanism that works against hyponatremia; thus, it is not the cause of low plasma sodium.

Microbiology

1 questions

Q81

A white patch is observed in the oral cavity of an immunocompromised patient. Which of the following findings is most likely on microscopy?

Surgery

7 questions

Q81

Identify the procedure shown in the image.

Q82

Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?

Q83

Which of the following is not a contraindication for breast conservation surgery?

Q84

Which of the following is not included in T4b classification of breast cancer?

Q85

A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?

Q86

A 40-year-old male with head injury presents with respiratory distress and absent breath sounds on the right. GCS is 8/15. What is the most immediate next step in management?

Q87

A 65-year-old patient undergoes colonoscopy for altered bowel habits. A 6 cm colonic mass is biopsied and histopathology shows adenocarcinoma confined to the mucosa with no lymph node or distant metastasis. What is the most appropriate TNM stage of this tumor?

INI-CET 2025 - Surgery INI-CET Practice Questions and MCQs

Question 81: Identify the procedure shown in the image.

A. Dog ear excision (Correct Answer)
B. Keloid excision
C. Z plasty
D. Transposition flap

Explanation: ### **Explanation: Dog Ear Excision** **1. Why the Correct Answer is Right:** A **"Dog ear"** (also known as a cone or cutaneous redundancy) occurs during the closure of a circular or elliptical wound when one side of the wound is longer than the other, or when the closure angle is too obtuse. This results in a **puckered elevation of skin** at the ends of the suture line. * **The Procedure:** To correct this, the surgeon extends the incision slightly, creates a small triangular flap of the redundant tissue, and excises it to allow the skin to lie flat. This converts the wound into a slightly longer, but aesthetically pleasing, linear scar. **2. Why the Other Options are Wrong:** * **Keloid Excision:** Keloids are firm, rubbery lesions that extend beyond the boundaries of the original wound. Excision involves removing the entire bulk of hypertrophic tissue, often followed by adjuvant therapy (like intralesional steroids) to prevent recurrence. * **Z-plasty:** This is a transposition flap technique used to **lengthen a scar** or change its direction to align with Relaxed Skin Tension Lines (RSTLs). It involves creating two triangular flaps that are transposed. * **Transposition Flap:** This involves moving a flap of skin and subcutaneous tissue over an incomplete bridge of intact skin to a nearby defect (e.g., Limberg flap). It does not specifically address the puckering seen at the ends of a simple closure. **3. High-Yield Clinical Pearls for INI-CET:** * **Prevention:** To avoid dog ears, the length of an elliptical incision should ideally be **3 times its width**, and the apical angle should be **less than 30 degrees**. * **Rule of Halves:** When suturing, always start at the center of the wound and bisect the remaining segments to distribute tension evenly and minimize the risk of dog ears. * **Mnemonic:** Dog ears are most common in **convex surfaces** (like the scalp or nose) where skin tension is non-uniform.

Question 82: Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?

A. 0.3 (Correct Answer)
B. 0.9
C. 0.7
D. 0.5

Explanation: ### **Explanation** The **Ankle-Brachial Pressure Index (ABPI)** is a non-invasive tool used to assess Peripheral Arterial Disease (PAD). It is calculated by dividing the higher systolic blood pressure at the ankle (PTA or DPA) by the higher systolic blood pressure of the arms. **1. Why 0.3 is the Correct Answer:** An ABPI of **<0.3** indicates **critical limb ischemia (CLI)** and **imminent gangrene**. At this level, the perfusion pressure is insufficient to maintain tissue viability even at rest. This stage is clinically characterized by **rest pain**, non-healing ischemic ulcers, and impending tissue necrosis (gangrene). **2. Analysis of Incorrect Options:** * **0.9 (Option B):** This is the lower limit of **normal**. An ABPI between 0.9 and 1.2 is considered healthy. Values between 0.7 and 0.9 indicate mild PAD, often asymptomatic. * **0.7 (Option C):** This indicates **mild to moderate PAD**. Patients at this level typically present with **intermittent claudication** (pain on walking that relieved by rest). * **0.5 (Option D):** This signifies **severe PAD**. While patients have significant symptoms and a high risk of cardiovascular events, "imminent gangrene" is specifically associated with values dropping below 0.4 or 0.3. --- ### **High-Yield Clinical Pearls for NEET-PG / INI-CET** * **ABPI Interpretation Summary:** * **>1.2:** Calcified, non-compressible vessels (commonly seen in **Diabetes Mellitus** and elderly patients). Use Toe-Brachial Index (TBI) instead. * **0.9 – 1.2:** Normal. * **0.5 – 0.9:** Intermittent Claudication. * **<0.4:** Rest Pain. * **<0.3:** Imminent Gangrene / Critical Limb Ischemia. * **Fontaine Classification:** Remember that ABPI <0.3 correlates with Fontaine Stage IV (Ulceration/Gangrene). * **Management Tip:** Patients with ABPI <0.5 or rest pain require urgent surgical or endovascular intervention to prevent limb loss.

Question 83: Which of the following is not a contraindication for breast conservation surgery?

A. Scleroderma
B. History of radiation
C. Multiple cancer in one quadrant (Correct Answer)
D. Persistent positive margin

Explanation: ### **Explanation: Contraindications for Breast Conservation Surgery (BCS)** Breast Conservation Surgery (BCS) followed by radiotherapy is the standard of care for early breast cancer. However, certain conditions make the procedure oncologically unsafe or technically impossible. #### **Why "Multiple cancer in one quadrant" is the Correct Answer** The key distinction in breast surgery is between **Multifocal** and **Multicentric** tumors: * **Multifocal Cancer:** Multiple tumor foci within the **same quadrant** of the breast. This is **not** a contraindication for BCS, provided the tumors can be excised through a single incision with clear margins and an acceptable cosmetic result. * **Multicentric Cancer:** Multiple tumors in **different quadrants**. This is an **absolute contraindication** because it would require multiple wide excisions, leading to poor cosmesis and a high risk of local recurrence. #### **Analysis of Incorrect Options (Absolute Contraindications)** * **Scleroderma (Option A):** Connective tissue diseases (specifically Scleroderma and Systemic Lupus Erythematosus) are contraindications because these patients tolerate radiotherapy poorly, often developing severe **soft tissue fibrosis** and necrosis. * **History of Radiation (Option B):** If a patient has previously received mantle field radiation (e.g., for Hodgkin’s Lymphoma) or prior breast radiation, they cannot receive the mandatory post-operative radiotherapy required after BCS due to **cumulative dose toxicity**. * **Persistent Positive Margin (Option D):** The goal of BCS is "no tumor at the ink." If clear margins cannot be achieved after repeated re-excisions, a mastectomy is mandatory to ensure oncological safety. --- ### **High-Yield Clinical Pearls for NEET-PG / INI-CET** * **Absolute Contraindications for BCS:** 1. **Pregnancy** (Radiotherapy is teratogenic; however, BCS can sometimes be done in the 3rd trimester if radiation is delayed until after delivery). 2. **Multicentricity** (Tumors in different quadrants). 3. **Diffuse Malignant Microcalcifications** on mammography. 4. **Persistent positive margins** after re-excision. * **Relative Contraindications:** Large tumor-to-breast ratio, tumors >5cm (T3), and active smoking (increases flap necrosis risk). * **Standard Protocol:** BCS is always followed by **Whole Breast Irradiation (WBI)** to reduce the risk of local recurrence.

Question 84: Which of the following is not included in T4b classification of breast cancer?

A. Satellite nodule
B. Ulceration
C. Peau d'orange
D. Cellulitis/erythema over one-third of the breast (inflammatory breast cancer) (Correct Answer)

Explanation: ### **Explanation: TNM Staging of Breast Cancer (T4 Category)** The **T4 stage** in breast cancer refers to a tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules). It is subdivided into four specific categories (T4a–T4d). #### **Why Option D is the Correct Answer** **Option D (Cellulitis/erythema over one-third of the breast)** describes **Inflammatory Breast Cancer (IBC)**. According to the AJCC 8th Edition, IBC is specifically classified as **T4d**. * **Key Criterion:** T4d requires diffuse erythema and edema (peau d'orange) involving **at least one-third or more** of the skin of the breast, often without a palpable mass. #### **Analysis of Incorrect Options (T4b Criteria)** **T4b** is defined as edema (including peau d'orange) or ulceration of the skin of the breast, or satellite skin nodules confined to the same breast. * **A. Satellite nodules:** These are ipsilateral skin nodules distinct from the primary tumor; they fall under T4b. * **B. Ulceration:** Direct skin involvement with breakdown of the epidermis is a classic T4b feature. * **C. Peau d'orange:** This "orange peel" appearance is caused by **dermal lymphatic invasion** leading to skin edema. If it does not meet the "one-third of the breast" threshold for inflammatory cancer, it is classified as T4b. #### **High-Yield Clinical Pearls for INI-CET** * **T4a:** Extension to the **chest wall** (defined as involvement of serratus anterior, ribs, or intercostal muscles). *Note: Involvement of the pectoralis muscle alone is NOT T4.* * **T4c:** Presence of both T4a and T4b features. * **Dimpling vs. Peau d'orange:** Skin dimpling (tethering) is due to involvement of **Cooper’s ligaments** and does not constitute T4 disease; Peau d'orange is due to **lymphatic obstruction** and is T4. * **Inflammatory Breast Cancer (T4d):** Is a **clinical diagnosis**. While dermal lymphatic invasion on biopsy supports it, its absence does not exclude the diagnosis if clinical criteria are met.

Question 85: A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?

A. 6
B. 4
C. 5
D. 7 (Correct Answer)

Explanation: The **Alvarado Score** (MANTRELS) is a clinical scoring system used to diagnose **Acute Appendicitis**. It is a high-yield topic for NEET-PG/INI-CET as it helps determine the need for observation, imaging, or surgery. ### **Calculation for this Patient:** The score is calculated based on the **MANTRELS** mnemonic: 1. **M**igration of pain to RIF: **1 point** (Present) 2. **A**norexia: 1 point (Not mentioned) 3. **N**ausea/Vomiting: **1 point** (Present) 4. **T**enderness in RIF: **2 points** (Present) 5. **R**ebound tenderness: 1 point (Not mentioned) 6. **E**levated temperature (>37.3°C): **1 point** (Present/Fever) 7. **L**eukocytosis (>10,000/cmm): **2 points** (Present: 14,000) 8. **S**hift to the left (Neutrophilia): 1 point (Not mentioned) **Total Score: 1 + 1 + 2 + 1 + 2 = 7** --- ### **Why the other options are incorrect:** * **Options A (6) and C (5):** These scores underestimate the weightage of **RIF Tenderness** and **Leukocytosis**, which are the only two parameters that carry **2 points** each. * **Option B (4):** A score of 4 or less makes appendicitis unlikely, whereas this patient presents with classic "textbook" symptoms and significant leukocytosis. --- ### **Clinical Pearls for INI-CET:** * **Interpretation:** * **5–6:** Possible (Equivocal); observation/CT scan recommended. * **7–8:** Probable; surgery usually indicated. * **9–10:** Very probable; immediate appendectomy. * **Modified Alvarado Score:** Excludes "Shift to the left" (Total score out of 9). * **Most common symptom:** Anorexia (often the first sign). * **Most common sign:** Tenderness at **McBurney’s point**. * **Pediatric Alternative:** The **Pediatric Appendicitis Score (PAS)** is often preferred for children.

Question 86: A 40-year-old male with head injury presents with respiratory distress and absent breath sounds on the right. GCS is 8/15. What is the most immediate next step in management?

A. Secure airway (Correct Answer)
B. Contrast-enhanced CT (CECT)
C. Oxygen by nasal prongs
D. Intercostal chest drain (ICD)

Explanation: ### **Explanation** The management of a trauma patient follows the **ATLS (Advanced Trauma Life Support) protocol**, which prioritizes life-threatening conditions in the order of **A (Airway), B (Breathing), and C (Circulation)**. **1. Why "Secure Airway" is the correct answer:** * The patient has a **GCS of 8/15**. In trauma management, the gold-standard rule is: **"GCS 8 or less, Intubate."** * A GCS ≤ 8 indicates that the patient is unable to maintain or protect their own airway, posing a high risk of aspiration and secondary brain injury due to hypoxia. * According to the **ABCDE priority**, Airway (A) must be secured before addressing Breathing (B) or Circulation (C). **2. Why the other options are incorrect:** * **CECT (Option B):** This is part of the secondary survey. A patient must be **hemodynamically stable** and have a secured airway before being sent for imaging. * **Oxygen by nasal prongs (Option C):** While oxygenation is necessary, nasal prongs are insufficient for a patient with a GCS of 8 who requires definitive airway protection (Endotracheal Intubation). * **Intercostal chest drain (Option D):** Absent breath sounds suggest a pneumothorax or hemothorax (Breathing issue). However, following the **ATLS hierarchy**, you must secure the **Airway (A)** before performing a procedure for **Breathing (B)**. --- ### **High-Yield Clinical Pearls for INI-CET:** * **Definitive Airway:** Defined as a tube placed in the trachea with the cuff inflated below the vocal cords, connected to oxygen-enriched ventilation. * **The "A" before "B" Rule:** Even if a tension pneumothorax is suspected, if the airway is compromised (GCS ≤ 8), securing the airway/intubation is the immediate priority unless the breathing difficulty is so severe it prevents oxygenation during the intubation attempt. * **Cervical Spine:** Always assume a C-spine injury in head trauma; use **Manual Inline Stabilization (MILS)** during intubation. * **Hard Sign for Intubation:** GCS < 9, massive midface fractures, or signs of airway obstruction (stridor).

Question 87: A 65-year-old patient undergoes colonoscopy for altered bowel habits. A 6 cm colonic mass is biopsied and histopathology shows adenocarcinoma confined to the mucosa with no lymph node or distant metastasis. What is the most appropriate TNM stage of this tumor?

A. Stage 0 (Correct Answer)
B. Stage II
C. Stage III
D. Stage I

Explanation: ### **Explanation** The correct answer is **Stage 0**. #### **1. Why Stage 0 is Correct** In the TNM staging of colorectal cancer, the depth of invasion is the primary determinant of the 'T' stage. * **Carcinoma in situ (Tis):** This is defined as cancer cells confined to the **mucosa** (epithelium or lamina propria) without extension through the **muscularis mucosae** into the submucosa. * Because the colonic mucosa lacks lymphatic channels (which begin in the submucosa), tumors confined to the mucosa have essentially **zero risk of regional lymph node metastasis**. * According to the AJCC staging system, **Tis N0 M0** is classified as **Stage 0**. #### **2. Why Other Options are Incorrect** * **Stage I (T1-T2 N0 M0):** Requires invasion into the **submucosa** (T1) or the **muscularis propria** (T2). * **Stage II (T3-T4 N0 M0):** Occurs when the tumor invades through the muscularis propria into the subserosa (T3) or perforates the visceral peritoneum/invades adjacent organs (T4), but without nodal involvement. * **Stage III (Any T, N1-N2 M0):** This stage is defined by the presence of **regional lymph node metastasis**, regardless of the depth of T invasion. #### **3. High-Yield Clinical Pearls for INI-CET** * **The "No Lymphatics" Rule:** Unlike the stomach or esophagus, the colonic lamina propria has no lymphatic vessels. Therefore, "intramucosal carcinoma" in the colon is biologically equivalent to carcinoma in situ. * **Management:** Most Stage 0 lesions can be managed via **endoscopic mucosal resection (EMR)** or polypectomy rather than formal colectomy, provided margins are clear. * **TNM Staging Quick Recall:** * **T1:** Submucosa * **T2:** Muscularis propria * **T3:** Subserosa/Pericolonic fat * **T4:** Perforation of serosa or invasion of other organs.