AIIMS PG Nov 2017


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Anatomy

Question.1

All of the following are branches of the external carotid artery except?

AIIMS PG Nov-2017
A. Superior thyroid artery
B. Anterior Ethmoidal artery
C. Occipital artery
D. Posterior auricular artery
Correct Ans: A
Explanation

Ans: A. Superior thyroid artery

Anterior ethmoidal artery is a branch of the ophthalmic artery which is a branch of the internal carotid artery.


Question.2

Structure passing through the central tendon of diaphragm is:

AIIMS PG Nov-2017
A. Esophagus
B. Right Phrenic nerve
C. Subcostal nerve
D. Left phrenic nerve
Correct Ans: B
Explanation

Ans: B. Right Phrenic nerve

Venacaval opening lies in the central tendon of the diaphragm at the level of T8 and it transmits inferior vena cava and branches of right phrenic nerve

Diaphragm

  • T8 Level: Caval hiatus (through central tendon of the diaphragm) transmitting the inferior vena cava, branches of right phrenic nerve
  • T9 Level: Foramen of Morgagni also called stemocostal hiatus two on each side of the xiphoid process. Transmitting the superior epigastric vessels.
  • T10 Level: Esophageal hiatus (through muscular part) transmitting the esophagus, gastric (vagus) nerve and esophageal branches of the left gastric artery and accompanying veins
  • T12 Level: Aortic hiatus (osseoaponeurotic) transmitting the aorta, the azygous vein, and the thoracic duct.
  • A commonly used mnemonic to remember the level of the diaphragmatic apertures is this: Mnemonic
  • Aortic hiatus = 12 letters = T12
  • Oesophagus = 10 letters = T10
  • Vena cava = 8 letters = T8

Embryology:

  • The central tendinous portions are derived from the pleuroperitoneal folds and the septum transversum.
  • While the crura are derived from the dorsal esophageal mesentry, the peripheral muscular portions of the diaphragm are derived from the body wall.

Question.3

Ligament supporting the head of talus ?

AIIMS PG Nov-2017
A. Talonavicular ligament
B. Cervical ligament
C. Plantar calcaneonavicular ligament
D. Deltoid ligament
Correct Ans: C
Explanation

Ans: C. Plantar calcaneonavicular ligament

Plantar calcaneonavicular ligament

  • Spring ligament (Plantar calcaneonavicular ligament) connects the calcaneum with the navicular bone. o However, its principal job is to provide a sling for the talus, to support the head of talus (though it has no attachment to talus).
  • This aids in supporting the weight of the body.
  • Weaknes or lengthening along this ligament can cause flat foot.

Question.4

What is the rostral end of the corpus callosum called?

AIIMS PG Nov-2017
A. Genu
B. Splenium
C. Body
D. Anterior Horn
Correct Ans: A
Explanation

Ans: A. Genu

The corpus callosum is a large bundle of myelinated and non-myelinated fibers, the great white commissure that crosses the longitudinal cerebral fissure and interconnects the hemispheres. The body of the corpus callosum is arched; its anterior curved portion, the genu, continues antero ventrally as the rostrum. The thick posterior portion terminates in the curved splenium, which lies over the midbrain.

Also Know:
The corpus callosum is the largest of the interhemispheric commissures and is largely responsible for co-ordinating the activities of the two cerebral hemispheres.


Question.5

First paranasal sinus to develop at birth is:

AIIMS PG Nov-2017
A. Maxillary
B. Ethmoidal
C. Frontal
D. Sphenoidal
Correct Ans: A
Explanation

Ans: A. Maxillary

Development of Sinuses

Sinus

Gestational Month When Development Starts

Present in Clinically Significant Size

Fully Developed

Maxillary

Birth°

12 years°

Ethmoid

30

Birth°

12 years°

Frontal

3 years°

18-20 years°

Sphenoid

8 years°

12-15 years°



Question.6

A person receives a laceration along the anterior border of the trapezius muscle in the neck and subsequently the point of his shoulder (scapula) sags and he has some difficulty fully abducting his arm. What nerve appears to have been severed?

AIIMS PG Nov-2017
A. Accessory (Cr. N. XI)
B. Axillary
C. Dorsal scapular
D. Greater occipital
Correct Ans: A
Explanation

Ans: A. Accessory (Cr. N. XI)

If the accessory nerve is damaged and the trapezius is denervated, a person will no longer be able to raise the acromion of the shoulder. The dorsal scapular nerve innervates rhomboid major, rhomboid minor, and levator scapulae. If the dorsal scapular nerve is damaged, the rhomboids will be denervated, and retraction of the scapula will be weakened. An injury to the greater occipital nerve will result in a loss of sensation on the posterior scalp but no muscular deficit.
 
The axillary nerve and suprascapular nerve will be covered with the upper limb, but for completeness, note that the axillary nerve innervates the deltoid muscle. If this nerve is damaged, the deltoid may atrophy, and the person will be unable to abduct the arm. 



Question.7

Muscle which helps in this moment of the mandible

AIIMS PG Nov-2017
A. Lateral pterygoid
B. Medial pterygoid
C. Temporalis
D. Masseter
Correct Ans: B
Explanation

Ans: A. Lateral Pterygoid

Lateral Pterygoid

  • The primary function of the lateral pterygoid muscle is to pull the head of the condyle out of the mandibular fossa along the articular eminence to protrude the mandible.

Question.8

All  are true about skin except:

AIIMS PG Nov-2017
A. Both dermis & ectoderm are derived from ectoderm
B. Skin accounts for total of 15% of body weight
C. Most of the cells in skin are keratinocytes derived from ectoderm
D. Dermis is made up of type1 and type 3 collagen in 3:2 ratio
Correct Ans: A
Explanation

Ans:A. Both dermis & ectoderm are derived from ectoderm.

  • True fact: Dermis derived from mesoderm and epidermis from ectoderm. 


Question.9

Which of the following is a holocrine gland:

AIIMS PG Nov-2017
A. Sweat gland
B. Breast
C. Pancrea
D. Sebaceous gland
Correct Ans: D
Explanation

Ans: D. Sebaceous gland

  • Sebaceous gland is a  holocrine gland since the discharged secretion contains entire secreting cells.
  • Sweat glands are of two types: Eccrine (merocrine) is more common in occurence as compared to apocrine variety.
  • Breast (mammary gland) is modified sweat gland of apocrine variety.
  • Another example for similar type is ceruminous (wax) gland in the ear.
  • Pancreas is a mixed (exocrine & endocrine) gland.
  • Exocrine secretory units are usually merocrine type.

Question.10

Dorello’s canal transmits in tip of temporal bone

AIIMS PG Nov-2017
A. Middle maningeal artery
B. Mandibular nerve
C. Superior alveolar branch of maxillary
D. Abducent nerve
Correct Ans: D
Explanation

Ans: D. Abducent nerve

Dorello canal is an opening to cavernous sinus that transmit abducent nerve underneath the superior petrosal sinus.


Question.11

Which of the following nerve serve as the efferent limb for cremasteric reflex?

AIIMS PG Nov-2017
A. Hypogastric nerve
B. Genito femoral nerve
C. Ilioinguinal nerve
D. All of the above
Correct Ans: B
Explanation

Ans: B. Genito femoral nerve

Ilioinguinal nerve serve as the afferent limb and genitofemoral nerve serve as the efferent limb of cremasteric reflex.
 
Cremasteric reflex is elicited by gently stroking the skin on the upper inner side of the thigh from above downwards. A positive response refers to contraction of the cremasteric muscle and elevation of the testicle on that side. An upper motor neuron injury can cause diminished or loss of the reflex. 

The root value of cremasteric reflex is Ll-L2. The afferent fibers of cremasteric reflex arc travel in the femoral branch of the genitofemoral nerve (L1 and 2), and the efferent motor nerve fibers travel in the genital branch of the genitofemoral nerve.

“Cremaster is innervated by the genital branch of the genitofemoral nerve, derived from the first and second lumbar spinal nerves.



Question.12

All of the following are true about grey communicans except

AIIMS PG Nov-2017
A. U nmyel inated
B. Connects to spinal nerves
C. Pregang I ion ic
D. Present medial to the white ramus cornmunicans
Correct Ans: C
Explanation

Ans. c. Preganglionic

  • Each spinal nerve receives a branch called a gray ramus communicans from the adjacent paravertebral ganglion of the sympathetic trunk. The gray rami communicans contain postganglionic nerve fibers of the sympathetic nervous system and are composed of largely unmyelinated neurons. This is in contrast to the white rami communicans, in which heavily myelinated neurons give the rami their white appearance. 
  • “The gray ramus communicans connects the sympathetic trunk or a ganglion to the anterior ramus and contains the postganglionic sympathetic fibers. It appears gray because postganglionic fibers are nonmyelinated. The gray ramus communicans is positioned medial to the white ramus communicans.”

Question.13

True about semicircular canals is:

AIIMS PG Nov-2017
A. Submerged in a fluid called endolymph
B. Base of cupula is in close contact with afferent fibres of cochlear division of the eight cranial nerve
C. Arranged at right angles to each other
D. Associated with hearing
Correct Ans: C
Explanation

Ans. C: Arranged at right angles to each other

3 semicircular canals in each vestibular apparatus known as anterior, posterior and lateral (horizontal) semicircular canals. They are arranged at right angles to each other.

They are filled with endolymph

Base of cupula is in close contact with afferent fibers of vestibular division of the eight cranial nerve

Physiology

Question.1

Gastrointestinal stromal malignancy arises from which of the following ?

AIIMS PG Nov-2017
A. Smooth muscle
B. Nerve cells
C. Interstitial cells of Cajal
D. Vascular Endothelium
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Interstitial cells of Cajal 


Question.2

Which of the following physiological change take place by Bainbridge reflex?

AIIMS PG Nov-2017
A. Increase in HR
B. Decrease in HR
C. Increase in BP
D. Distension of large somatic veins
Correct Ans: A
Explanation
Ans: A. Increase in HR

Atrial A and B receptors are located at the venoatrial junctions and have distinct functions. Type A receptors react primarily to heart rate but adapt to long-term changes in atrial volume. Type B receptors increase their discharge during atrial distension. C fibers arise from receptors scattered through the atria; these discharge with a low frequency and respond with increased discharge to increase in atrial pressure. 
 
The A and B receptors are thought to mediate the increase in heart rate associated with atrial distension (such as can occur with intravenous infusions) known as the Bainbridge reflex. In contrast, activation of atrial C fibers generally produces a vasodepressor effect (bradycardia and peripheral vasodilation).
 
Ref: Hoit B.D., Walsh R.A. (2011). Chapter 5. Normal Physiology of the Cardiovascular System. In V. Fuster, R.A. Walsh, R.A. Harrington (Eds), Hurst’s The Heart, 13e.

Question.3

Study the graphs carefully.In the image,wave ‘C’ indicates?

AIIMS PG Nov-2017
A. REM Sleep
B. NREM Sleep
C. Awake
D. Quiet Wakefulness
Correct Ans: B
Explanation

Ans:B.)NREM sleep.

In the image,Wave A -represents awake stage,Wave B-represents REM sleep,Wave C-represents NREM sleep.

Sleep Cycle.

  • Sleep is generally divided into 2 broad types: nonrapid eye movement (NREM) sleep and REM sleep.
  • NREM and REM occur in alternating cycles, each lasting approximately 90-100 minutes, with a total of 4-6 cycles. In general, in the healthy young adult NREM sleep accounts for 75-90% of sleep time (3-5% stage I, 50-60% stage II, and 10-20% stages III and IV). REM sleep accounts for 10-25% of sleep time.
  • Based on EEG changes, NREM is divided further into 4 stages (stage I, stage II, stage III, stage IV).
    • Stage I sleep is also referred to as drowsiness or presleep and is the first or earliest stage of sleep.

      • The earliest indication of transition from wakefulness to stage I sleep (drowsiness) usually consists of a combination of drop out of alpha activity and slow rolling eye movements.
    • Stage II is the predominant sleep stage during a normal night’s sleep. The distinct and principal EEG criterion to establish stage II sleep is the appearance of sleep spindles or K complexes.
    • Stages III and IV sleep are usually grouped together as “slow wave sleep” or “delta sleep.
  • The different types and stages of sleep can be best identified using polysomnography, which simultaneously measures several body functions such as brain wave activity (electroencephalogram or EEG), eye movement (electrooculogram or EOG), muscle activity (electromyogram or EMG), respiration, heart rhythm, etc.
  • Electroencephalogram :
    • Non-REM sleep is characterized by very slow but relatively high amplitude or high voltage oscillations (with the frequency gradually slowing and the amplitude increasing as sleep deepens), while REM sleep shows a much faster and lower amplitude trace, much more similar to normal waking activity
    • Brain waves during non-REM sleep tend to be highly synchronized, and those during REM sleep much more unsynchronized.
  • Electrooculogram (EOG) :
    • Rapid eye movements during REM sleep, and little or no eye movement during non-REM sleep.
  • Electromyogram (EMG) :
    • The body is effectively completely paralyzed during REM sleep, the body does make some limited movements during non-REM sleep, including a major change in body position about once every twenty or thirty minutes on average.

Question.4

Feed forward inhibition synapse seen in ?

AIIMS PG Nov-2017
A. Medulla
B. Cerebellum
C. Basal ganglia
D. Hypothalamus
Correct Ans: B
Explanation

Ans. is `b’ i.e., Cerebellum

Feed forward control system is employed during the regulation of temperature.

In feed-forward inhibition, a neuron is connected through two pathways one excitatory and one inhibitory.

For example, in cerebellum the stimulation of Basket cells produces IPSPs (inhibitory postsynaptic potentials) in Purkinje cells.

However, the basket cells and the Purkinje cells are excited by the same parallel-fiber excitatory input.

This arrangement is called feed-forward inhibition and helps to prevent the duration of the excitation produced by any given afferent impulse.


Question.5

What is the effect of constriction of efferent arteriole and dilatation of afferent arteriole on glomerular filtration rate?

AIIMS PG Nov-2017
A. Increases GFR
B. Decreases GFR
C. No change to GFR
D. First increase then decreases GFR
Correct Ans: A
Explanation

Ans: A. Increases GFR

Increase in renal blood flow increases GFR. Afferent arteriole brings blood to the nephron hence its dilation will increase renal blood flow, and efferent arteriole takes blood away from the nephrons, hence its constriction will cause increase filtration, hence increase in GFR.

  • Constriction of afferent arteriole: decreases both renal blood flow and GFR, without change in filtration fraction.
  • Dilatation of afferent arteriole : increases both renal blood flow and GFR, without change in filtration fraction.
  • Constriction of efferent arteriole: decreases the renal blood flow and increases GFR and filtration fraction.
  • Dilatation of efferent arteriole: increases the renal blood flow and decreases the GFR and filtration fraction.

Question.6

Surfactant acts to maintain the lung compliance by decreasing the following factor:

AIIMS PG Nov-2017
A. Pleural pressure
B. Intrathoracic pressure
C. Surface tension
D. Pleural fluid secretion
Correct Ans: C
Explanation

Ans: C. Surface tension

Surfactant is a mixture of dipalmitoylphosphatidylcholine (DPPC), other lipids, and proteins. The low surface tension when the alveoli are small is due to the presence of surfactant in the fluid lining the alveoli. If the surface tension is not kept low when the alveoli become smaller during expiration, they collapse in accordance with the law of Laplace. Surfactant also helps to prevent pulmonary edema.
 
Ref: Barrett K.E., Barman S.M., Boitano S., Brooks H.L. (2012). Chapter 34. Introduction to Pulmonary Structure and Mechanics. In K.E. Barrett, S.M. Barman, S. Boitano, H.L. Brooks (Eds), Ganong’s Review of Medical Physiology, 24e.



Question.7

Absolute refractory period is due to:

AIIMS PG Nov-2017
A. Opening of calcium channels
B. Closure of potassium channels
C. Closure of active gates of sodium channel
D. Closure of inactive gates of sodium channel
Correct Ans: D
Explanation

Ans. d. Closure of inactive gates of sodium channel (Absolute refractory period is due to closure of inactive gates of sodium channel.

“Absolute Refractory Period; The Ne’ channels rapidly enter a closed state called the inactivated state and remain in this state for a few milliseconds before returning to the resting state, when they again can be activated.”

Compliance Curve

  • The curve has inspiratory & expiratory components
  • Inspiratory & expiratory compliance curves do not coincide. This difference is called hysteresis°.
  • The difference between inflation & deflation paths—hysteresis—exists because a greater trans-pulmonary pressure is required to open a previously closed airway, owing to a deficit of surfactant at the air-water interface, than to keep an open airway from closing, reflecting abundant surfactant
  • Lung volume at any given pressure is greater during expiration than during inspiration
  • Compliance is greatest at mid pressure range°
  • Pulmonary compliance = AV/ AP
  • AV is the change in volume or amount of air inhaled in mL or L
  • AP is the change in intrapleural pressure in cm H20

Question.8

X,Y,Z are the ee ions pet meaule..\ and V=-30. If at resting membrane potential (RMP), when there is no net electro genic transfer, what is the value of Z?

AIIMS PG Nov-2017
A. +20
B. –20
C. +80
D. –80
Correct Ans: C
Explanation

Ans. c. +80 Resting membrane potential (RMP) is the static state of a membrane, where the net transmembrane electric flux is zero. Non-electrogenic transfer at RMP means X+Y+Z = 0 . Since X = –50 and Y= –30, then Z must be +80 since (-80 +80 = 0)

Biochemistry

Question.1

which of the following amino acid does not include post-translational modification?

AIIMS PG Nov-2017
A. Selenocysteine
B. Triiodothyronine
C. Hydroxyproline
D. Hydroxylysine
Correct Ans: A
Explanation

Ans. a. Selenocysteine

Selenocysteine is not the product of post-translational modification. Unlike hydroxyproline or hydroxylysine, selenocysteine arises co-translationally during its incorporation into peptides.


Question.2

Which one of the following coenzyme is associated with glycogen phosphorylase?

AIIMS PG Nov-2017
A. Thiamine pyrophosphate
B. Tetrahydrofolate
C. Flavin mononuleotide
D. Pyridoxal phosphate
Correct Ans: D
Explanation

Ans: D. Pyridoxal phosphate

Glycogen phosphorylase has a pyridoxal phosphate (PLP, derived from Vitamin B6) at each catalytic site.

Pyridoxal phosphate links with basic residues and covalently forms a Schiff base.

Once the Schiff base linkage is formed, holding the PLP molecule in the active site, the phosphate group on the PLP readily donates a proton to an inorganic phosphate molecule, allowing the inorganic phosphate to in turn be deprotonated by the oxygen forming the a-1,4 glycosidic linkage.


Question.3

DNA double helix is maintained by: 

AIIMS PG Nov-2017
A. Hydrogen bond
B. Vanderwaal forces
C. Disulfide linkage
D. Covalent bond
Correct Ans: A
Explanation

Ans. A. Hydrogen bond 

In a DNA double helix, two polynucleotide strands come together through complementary pairing of the bases, which occurs by hydrogen bonding.

Each base forms hydrogen bonds readily to only one other — A to T and C to G — so that the identity of the base on one strand dictates what base must face it on the opposing strand.

Thus the entire nucleotide sequence of each strand is complementary to that of the other, and when separated, each may act as a template with which to replicate the other.


Question.4

Ketone body formation without glycosuria is seen in ?

AIIMS PG Nov-2017
A. Diabetes mellitus
B. Diabetes insipidus
C. Starvation
D. Obesity
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Starvation

Amongst the given options, DM and starvation are the causes of ketosis

  1. Diabetes :- Ketosis with hyperglycemia and glycosuria
  2. Prolonged starvation :- Ketosis with low or normal glucose and without glycosuria.
  • In diabetic Ketoacidosis:- (i) Positive Rothera’s test (due to ketone bodies) (ii) Positive Benedict’s test (due to presence of reducing sugar in urine)
  • In Starvation ketosis:- (i) Postive Rothera’s test (due to ketone bodies), (ii) Negative Benedict’s test (no sugar in urine)

Question.5

Which of the following disease is associated with adenosine deaminase deficiency?

AIIMS PG Nov-2017
A. Chronic granulomatous disease
B. X-linked agammaglobulinemia
C. Severe combined immunodeficiency (SCID)
D. Transient hypogammaglobulinemia of infancy
Correct Ans: C
Explanation
Ans: C. Severe combined immunodeficiency (SCID)

Adenosine deaminase deficiency is associated with the development of severe combined immunodeficiency.
Adenosine deaminase enzyme converts adenosine and deoxyadenosine into inosine and deoxyinosine.
In the absence of ADA, high intracellular levels of adenosine, deoxyadenosine, and their toxic phosphorylated metabolites cause apoptosis of lymphoid precursors, resulting in the virtual absence of T lymphocytes, that is usually associated with marked reduction of B and NK lymphocytes.
 
Ref: Williams Hematology, 8th Edition, Chapter 82; Harrisons  Internal Medicine, 18th Edition, Chapter 316

Question.6

Neurological Involvement with Acanthocytosis is seen in all of the following except:

AIIMS PG Nov-2017
A. Abetalipoprotenemia
B. Choreoacanthocytosis
C. McLeod Syndrome
D. Zellweger Syndrome
Correct Ans: D
Explanation

Answer is D (Zellweger Syndrome):

Zellweger Syndrome (Cerebro-hepato-renal syndrome) is typically not associated with Acanthocytosis

Zellweger’s (cerebrohepatorenal) syndrome is characterized by accumulation of very-long-chain fatty acids, abnormalities of the synthesis of bile acids, and a marked reduction of plasminogen.

Zellweger’s (cerebrohepatorenal) syndrome occurs in individuals with a rare inherited absence of peroxisomes in all tissues. They accumulate C26C38polyenoic acids in brain tissue and also exhibit a generalized loss of peroxisomal functions. The disease causes severe neurological symptoms, and most patients die in the .first year of life

Neurological Syndromes with Acanthocytosis

  • Abetalipoproteinemia ((Bassen-Kornzweig Disease)
  • Choreo-acanthocytosis (Levine-Critchley Syndrome; Neuroacanthocytosis)
  • McLeod Syndrome
  • Wolman Syndrome (Neurological involvement is generally mild)

Acanthocytes have also been reported in Hallervorden-Spatz disease and Huntington Disease Like 2 (HDL-2)

Acanthocytosis

The appearance of spiculated erythrocytes in a peripheral blood smear or electron microscopy may be caused by changes in the lipid composition or structure of the red blood cell membrane. Two basic types are distinguished

  • Echinocytes (burr cells) that have a serrated outline with small, uniform projections, and
  • Acanthocytes (spur cells) with few irregular spicules of varying size.

Differential diagnosis of Acanthocytosis and neurological Syndromes

Diagnosis

Clinical features

Age of onset                                     

Abetalipoproteinemia

Diarrhea, fat malabsorption, vitamin. deficiencies,

neurological abnormalities, ataxia, low cholesterol

and triglycerides

Neonatal period

Wolman disease

Diarrhea, failure to thrive, hepatosplenomegaly,

adrenal calcifications

Neonatal period

Choreo-Acanthocytosis

Progressive neurological symptoms, chorea,

epilepsy, dementia; TCK, normal lipoproteins;

Adolescence or adult life

 

VPS 1 3A mutations

 

McLeod phenotype,

McLeod syndrome

Little or no reaction with various antisera in the Kell blood group system; sometimes progressive neurological symptoms, chorea; TCK, normal lipoproteins; XK mutations

Adult life (neurological symptoms)


Question.7

Dried blood drop of an infant can be used to know:

AIIMS PG Nov-2017
A. Blood sugar
B. Inborn errors of metabolism
C. Hepatitis
D. Cataract
Correct Ans: B
Explanation

Ans. b. Inborn errors of metabolism

  • Dried blood drop of an infant can be used to know inborn errors of metabolism with the help of tandem mass spectrometry.
  • Tandem mass spectrometry can be used to screen blood samples from newborns for the presence and concentrations of amino acids, fatty acids, and other metabolites. Abnormalities in metabolite levels can serve as diagnostic indicators for variety of genetic disorders, such as phenylketonuria, ethylmalonic encephalopathy, and glutaric acidemia type I.

Microbiology

Question.1

All of the following are dimorphic fungi, except:

AIIMS PG Nov-2017
A. Sporotricum
B. Blastomycetes
C. Histoplasma
D. Cryptococcus
Correct Ans: D
Explanation

Ans. d. Cryptococcus


Question.2

Not true about Histoplasma capsulatum ?

AIIMS PG Nov-2017
A. Dimorphic fungus
B. May mimic TB
C. Capsulated
D. Mostly asymptomic
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Capsulated

Histoplasma capsulatum

  • A dimorphic fungus
  • Non encapsulated ? The only medically important capsulated fungus is cryptococcus.
  • Infection is acquired by inhalation of microconidia (small spores) in dust contaminated with bird or bat dropping.
  • It causes intracellular infection of reticuloendothelial system.
  • Clinical manifestations ? Majority of patients are asymptomatic

Histoplasma capsulatum

  • Dimorphic soil saprophyte, causes histoplasmosis°
  • Most prevalent pulmonary fungal infection in humans & animalsa.
  • Grows as a mold in soil mixed with bird feces (e.g., starling roosts, chicken houses) or bat guano (caves)a.
  • Appearance of yeast cells in histopathologic sections; does not have a capsule°.

Morphology & Identification:

Primary isolates develop brown mold colonies at temperatures <37°C.

Hyaline, septate hyphae produce microconidia & large, spherical thick-walled macroconidia with peripheral projections of cell wall materialQ.

In tissue or in vitro on rich medium at 37°C, hyphae conidia convert to small, oval yeast cellsQ.

In tissue, yeasts are typically seen within macrophages, as Histoplasma capsulatum is a facultative intracellular parasite.

Epidemiology

Highest incidence in the United States; also found in Africa & Far East

Mode of Transmission:

Inhalation of airborne environmental conidia by wind & dusty

Histoplasmosis is not communicable from person to persona

Histoplasma capsulatum

Pathogenesis:

  • Clinical Incubation Period: 3-17 days for acute manifestations; chronic manifestations over months to years
  • After inhalation, conidia develop into yeast cells & engulfed by alveolar macrophages & replicate°.
  • Within macrophages, yeasts may disseminate to reticuloendothelial tissues (liver, spleen, bone marrow & LNs)°
  • Initial inflammatory reaction becomes granulomatous°.

Clinical Features:

  • Chronic, systemic disease with fever, weight loss, fatigue, cytopenias, hepatosplenomegaly°
  • Chronic pulmonary disease similar to tuberculosis. Granulomatous nodules in the lungs or other sites heal with calcification°.
  • Severe disseminated histoplasmosis particularly in infants, elderly & immunosuppressed, including AIDS patients°.

Diagnosis

Gold-standard

Specimens:

& huffy

Culture

Dextrose

Serology:

Radiographic

diagnostic test: Fungal culture° Specimens for culture include sputum, urine, scrapings from superficial lesions, bone marrow coat blood cells°.

aspirates

Microscopic Examination

Blood films, bone marrow slides & biopsy specimens may be examined microscopically.

In disseminated histoplasmosis, bone marrow cultures are often positive°.

Small ovoid cells may be observed within macrophages in histologic sections stained with fungal stains, such as GMS or PAS, or in Giemsa-stained smears of bone marrow or blood°.

Specimens are cultured in rich media, such as glucose-cysteine blood agar at 37°C & on SDA (Sabouraud

Agar) or IMA (Inhibitory Mold Agar) at 25-30°C°.

Radioassay or enzyme immunoassay for circulating polysaccharide antigen of H. capsulatum°.

examination: Hilar lymphadenopathy & pulmonary infiltrates or nodules°.

Treatment:

  • Itraconazole: For the treatment of mild to moderate infection°
  • Amphotericin B: For the treatment of disseminated disease°

Prevention & Control:

  • Personal protective measures in selected high-risk environments (caves, pigeon roosts & chicken houses)
  • Spraying formaldehyde on infected soil may destroy H. capsulatum.

Question.3

An early diabetic has left sided orbital cellulitis CT scan of paranasal sinus shows evidence of left maxil­lary sinusitis. Gram stained smear of the orbital exu­date shows irregularly branching septate hyphae. The following is most likely etiological agent:

AIIMS PG Nov-2017
A. Aspergillus
B. Rhizopus
C. Mucor
D. Candida
Correct Ans: A
Explanation

Ans. (a) Aspergillus  Ref. Ananthanarayan 8/e, p 613, 9/e, p 609; Harrison 19/e, p 1345 – 1347, 18/e, p 1658

“Presence of branched septate hyphae in a patient of orbital cellulitis (occur as complication of sinusitis) suggest Asper­gillus.”

Aspergillus Sinusitis occur in three forms:

  1. Ball of hyphae may form in chronically obstructed paranasal sinus, without tissue invasion.
  2. A chronic fibrosing granulomatous inflammation begin in sinus and spread slowly to the orbit and brain.
  3. Allergic fungal sinusitis

Mucor and Rhizopus belong to family Zygomycetes and have non-septate hyphae.


Question.4

Sclerotic bodies is seen –

AIIMS PG Nov-2017
A. Sporothrix
B. Blastomycosis
C. Chromoblastomycosis
D. Coccidiodes
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Chromoblastomycosis


Question.5

1-3 beta-D-glucanassay for fungi is not used for?

AIIMS PG Nov-2017
A. Aspergillus species
B. Candida species
C. Cryptococcus species
D. Pneumocystis jirovecii
Correct Ans: C
Explanation

Ans. (c) Cryptococcus s(j. journal of  ,\,11crobiology 2013 Nov. 3478-3484

  • 13-D-glucan is the component of fungal cell-wall of all fungus (except cryptococcus, zygomycetes and blastomyces dermatidis) which is detectable in case of invasive infection.
  • Currently Fungitell assay is a FDA approved 13-DG assay which is positive in invasive candidiasis, Aspergillism and pneumocystis jirovecii.

False positive reaction may be seen with certain hemodialysis filters, beta lactam antimicrobials and immunoglobulins


Question.6

All are included in the diagnostic criteria for clostridium difficile infection, EXCEPT:

AIIMS PG Nov-2017
A. 3 unformed stools per 24h for 2days
B. Toxin A or B detected in the stool
C. Pseudo membranes in colonoscopy
D. Fever
Correct Ans: D
Explanation

Ans: D. Fever

ELISA that detects toxin A or B in stool is highly sensitive and specific for diagnosis of Clostridium difficile colitis.

The diagnosis of CDI is based on:

1. Diarrhea (3 unformed stools per 24 h for 2 days) with no other recognized cause
 
PLUS
 
2. Toxin A or B detected in the stool,
 
3. Toxin-producing C. difficile detected in the stool by polymerase chain reaction (PCR) or culture.
 
3. Pseudomembranes in the colon.
 
ALSO KNOW:
Endoscopy is a rapid diagnostic tool in seriously ill suspected patients
 
A negative test does not rule out infection
 
Ref: Harrison, Edition-18,page-1093.

Question.7

Tick is vector for:

AIIMS PG Nov-2017
A. Crimean congo fever
B. Rocky mountain spotted fever
C. Epidemic typhis
D. Endemic typhis
E. A and B
Correct Ans: E, A and B
Explanation

Ans is (a) Crimean congo fever and (b) Rocky mountain spotted fever

Crimean congo is a viral illness, caused by flavi virus and is transmitted by ticks.

Rocky mountain spotted fever is Hard Tick-borne disease

Kyanasur Forest disease is a febrile disease associated with haemorrhages caused by an arbovirus flavivirus and is transmitted to man by bile of infective hard ticks.



Question.8

Disinfectant used for blood spills

AIIMS PG Nov-2017
A. Phenol
B. Glutaraldehyde
C. Ethanol
D. Sodium hypochlorite
Correct Ans: D
Explanation

Ans: D. Sodium hypochlorite

Sodium hypochlorite Common Disinfectants for Hospital Use

Group

Examples and Usage

Advantages and Disadvantages

PHENOLICS

Clear-soluble phenolic

Good general purpose disinfectants, not readily

 

compounds. white fluids; 1.5%

inactivated by organic matter, active aginst wide

 

solutions; leave in contact for 1

range of organisms (including mycobacteria) but not

 

hour.

sporicidal.

HALOGENS

Hypochlorites (chloramine) eg

“Milton”, “Domestos”, bleaches.

Cheap, effective, act by release of free chlorine,

active against viruses and therefore recommended

 

Strong (2% Cl) to weak (0.02%

for disinfection of equipment soiled with blood

 

Cl) concentrations used according

(because of hepatitis risk), but rapidly inactivated

 

to degree of blood contamination;

leave in contact for 31) minutes.

by organic material and corrosive to metals.

ALCOHOLS

Ethyl alcohol (ethanol), isopropyl

Good choice for skin disinfection and for clean

 

alcohol (isopropanol).

surfaces, sometimes used in combination with iodine

or chlorhexidine, water must be present for bacterial

killing (i.e. 70% ethanol best), isopropanol preferred

for skin and articles in contact with patient.

ALDEHYDES

Glutaraldehyde (“Wavicide”,

“Aidel”); 1% solution, leave in

Kills vegetative organisms including mycobacteria

slowly but effectively. More active, less toxic than

 

contact for 30 minutes.

formaldehyde, sporicidal (within 6 hours when

fresh), irritant, used in alkaline solution which is

stable 1-2 weeks, expensive, limited use e.g.

disinfection of endoscopes.


Question.9

Microbiological test for diagnosing leptospira infection?

AIIMS PG Nov-2017
A. Cold agglutination
B. Standard agglutination
C. Microscopic agglutination test (MAT)
D. None of these
Correct Ans: C
Explanation

Answer: C. Microscopic agglutination test (MAT)

  • Dark-field microscopy or by immunofluorescence or light microscopy after appropriate staining used

  • Microscoplc agglutination test [MAT](Gold Standard) also Macroscopic agglutlnation test

  • Differential diagnosis list for leptospirosis is very large due to diverse symptoms.

Question.10

Biofilm forming bacteria causes antimicrobial resist-ance by all of the following except:

AIIMS PG Nov-2017
A. Mechanical barrier
B. Increased excretion of antibiotics
C. Altered metabolism
D. Adherence
Correct Ans: D
Explanation

Ans. d. Adherence

  • Biofilm in the bacteria leads antimicrobial resistance by acting as mechanical barrier, increased excretion of antibiotics and altered metabolism inside the biofilms.
  • Growth in biofilms leads to altered microbial metabolism, production of extra cellular virulence factors, and decreased susceptibility to biocides, antimicrobial agents, and host defense molecules and cells. P aeruginosa growing on the bronchial mucosa during chronic infection, staphylococci and other pathogens growing on implanted medical devices, and dental pathogens growing on tooth surfaces to form plaque are several examples of microbial biofilm growth associated with human disease.

Question.11

“Buff, rough, tough” colonies as seen on growth medium as shown in the photograph below is shown by ? 

AIIMS PG Nov-2017
A. Corynebacterium diphtheriae.
B. Mycobacterium leprae.
C. Mycobacterium tuberculosis.
D. Leptospira interrogans.
Correct Ans: C
Explanation

Ans: C. Mycobacterium tuberculosis.

“Buff, rough, tough” colonies as seen on Lowenstein – Jensen Medium (L.J. medium) as shown in the photograph above  is shown by Mycobacterium tuberculosis.


Question.12

Which is the largest intestinal protozoa found in humans?

AIIMS PG Nov-2017
A. Entamoeba coli
B. Balantidium coli
C. Giardia lamblia
D. Toxoplasma gondii
Correct Ans: B
Explanation

Ans: B. Balantidium coli

Balantidium coli is the only ciliated protozoan that causes human disease (i.e., diarrhea) and its length is up to 200 micro meter, making it the largest of the human intestinal protozoa.
Domestic animals, especially pigs, are the main reservoir for the organism, and humans are infected after ingesting the cysts in food or water contaminated with animal or human feces.
The trophozoites excyst in the small intestine, travel to the colon, and, by burrowing into the wall, cause an ulcer similar to that of Entamoeba histolytica.
However, unlike the case with E. histolytica, extraintestinal lesions do not occur.
 
Most infected individuals are asymptomatic.
Diagnosis is made by finding large ciliated trophozoites or large cysts with a characteristic V-shaped nucleus in the stool.
There are no serologic tests. The treatment of choice is tetracycline.
Prevention consists of avoiding contamination of food and water by domestic animal feces.
 
Ref: Levinson W. (2012). Chapter 53. Minor Protozoan Pathogens. In W. Levinson (Ed), Review of Medical Microbiology & Immunology, 12e.

Question.13

Which of the following is true with Giardia lamblia?

AIIMS PG Nov-2017
A. Malabsorption commonly seen
B. Trophozoite forms is binucleate
C. Diarrhea is seen
D. b and c
Correct Ans: D
Explanation

Ans. is ‘b’ i.e., Trophozoite forms is binucleate; ‘c’ i.e., Diarrhea is seen

  • Malabsorption is seen only in few cases, most patients are asymptomatic.
  • Most common presentation is diarrhea with abdominal pain, nausea and vomiting.
  • Trophozoite is bilateral, symmetrical and all organs of body are paired.
  • Axostyles                    
  • pairs of flagella
  • Nuclei                          
  • Sucking discs.
  • The gold – standard for diagnosis of giardiasis is microscopic demonstration of the trophozoite, cyst or both in faeces.       
  • Duodenal aspirate or jejunal biopsy (not Jejunal wash fluid) may be required for diagnosis——— Harrison p. 1200. Remember
  •  Metronidazole and tinidazole are drug of choice for Giardia lambia.

Question.15

In plasmodium vivax malaria, relapse is caused by:

AIIMS PG Nov-2017
A. Sporozoite
B. Schizont
C.
D. Gamteocyte
Correct Ans: C
Explanation

Ans: C i.e. Hypnozite

Malaria

  • In malaria, size of RBC is increased in: Vivax
  • Infective agent of malaria is: Sporozoite

Falciparum malaria

  • Gametocytes are seen in peripheral blood smear
  • Parasitemia is highest
  • Most virulent plasmodium species
  • Exo-erythrocytic stage is absent
  • Multiple infections of RBC’s
  • Splenic rupture is common

Pharmacology

Question.1

A patient requires ceftriaxone 180 mg. You have a 2 ml syringe with 10 divisions per ml. The vial contains 500 mg/5 ml of ceftriaxone. How many divisions in the 2 ml syringe will you fill to give 180 mg ceftriaxone?

AIIMS PG Nov-2017
A. 18
B. 1.8
C. 20
D. 2
Correct Ans: A
Explanation

Ans. a. 18

18 divisions in the 2 ml syringe should he filled to give 180 mg ceftriaxone.


Question.2

Drug acting on cell wall of gram positive bacteria:

AIIMS PG Nov-2017
A. Gentamycin
B. Ciprofloxacin
C. Tetracycline
D. Vancomycin
Correct Ans: D
Explanation

Ans. D: Vancomycin

Vancomycins bind to the peptides of the peptidoglycan monomers and block both the formation of gycosidic bonds between the sugars by the transgycosidase enzymes and the formation of the peptide cross-links by the transpeptidase enzymes. This results in a weak cell wall and osmotic lysis of the bacterium.

The fluoroquinolones (norfloxacin, lomefloxacin, fleroxacin, ciprofloxacin, enoxacin, trovafloxacin, gatifloxacin, etc.) work by inhibiting one or more of a group of enzymes called topoisomerase, enzymes needed for supercoiling, replication and separation of circular bacterial DNA.

For example, DNA gyrase is a topoisomerase that catalyzes the negative supercoiling of the circular DNA found in bacteria. Topoisomerase IV, on the other hand, is involved in the relaxation of the supercoiled circular DNA, enabling the separation of the interlinked daughter chromosomes at the end of bacterial DNA replication.

In gram-positive bacteria, the main target for fluoroquinolones is DNA gyrase (topoisomerase II), an enzyme responsible for supercoiling of bacterial DNA during DNA replication; in gram-negative bacteria, the primary target is topoisomerase IV, an enzyme responsible for relaxation of supercoiled circular DNA and separation of the inter-linked daughter chromosomes.

The tetracyclines (tetracycline, doxycycline, demeclocycline, minocycline, etc.) block bacterial translation by binding reversibly to the 30S subunit and distorting it in such a way that the anticodons of the charged tRNAs cannot align properly with the codons of the mRNA.

The aminoglycosides (streptomycin, neomycin, netilmicin, tobramycin, gentamicin, amikacin, etc.) bind irreversibly to the 30S subunit of bacterial ribosomes.


Question.3

Uses of atropine are AJE –

AIIMS PG Nov-2017
A. Organophoshorus poisoning
B. Mushroom poisoning
C. Arrhythmia
D. Miotic
Correct Ans: D
Explanation

Ans. is ‘d’ i.e., Miotic

CLINICAL USES OFATROPINE

Remember – ATROPA

A As mydriatic – cycloplegic

T ? ‘Traveller’s diarrhoea

R ? Rapid (early) onset mushroom poisoning

0 ? Organophosphate poisoning

P ? Preanaesthetic medication

A Arrhythmias (brady-arrhythmias)

Atropine is also used with neostigmine in mysthenia gravis to decrease anti,nuscarinic side effects of neostigmine —› As atropine blocks muscarinic receptors, use of atropine prevents muscarinic side effects of neostigmine, while neostigmine retains its benficial effects in mysthenics which are due to nicotinic receptors.


Question.4

A patient of septic shock was given intravenous norepinephrine. The response to this drug is best checked by:

AIIMS PG Nov-2017
A. Increase in heart rate
B. Decrease in heart rate
C. Increase in mean arterial pressure
D. Decreased renal perfusion and reduced urine output
Correct Ans: C
Explanation

Ans. c. Increase in mean arterial pressure

Noradrenaline is a powerful peripheral vasoconstrictor and inotrope and used in patients of septic shock and cardiogenic shock. Noradrenaline causes peripheral vasoconstriction thereby increasing diastolic blood pressure as well as venous return. The increase in diastolic blood pressure and systolic blood pressure can increase mean arterial pressure (MAP) which is the therapeutic outcome expected in any septic shock patient as a response to vasopressor.


Question.5

A 62-year-old Type 2 diabetic patient presents with complaints of malaise, myalgias, respiratory distress, and increased somnolence. If laboratory examination reveals an anion gap of 26mmol/L, HCO3- of 17 mmol/L and an arterial blood pH of 7.27. You suspect lactic acidosis. The patient is most likely receiving which of the following?

AIIMS PG Nov-2017
A. Glucagon
B. Glyburide
C. Metformin
D. Miglitol
Correct Ans: C
Explanation

Ans: C. Metformin

Lactic acidosis, characterized by elevated blood lactate, decreased arterial blood pH, decreabicarbonate, and electrolyte imbalances with an elevated anion gap (normal = 10 – 12), is a rare but serious complication of metformin administration. The onset of lactic acidosis is usually accompanied by several non-specific signs and symptoms including malaise, myalgias, respiratory distress and increased somnolence. There may be associated hypothermia, hypotension, and resistant bradyarrhythmias as the condition progresses.

Choice Glucagon is a polypeptide hormone produced by the alpha cells of the islets of Langerhans in the pancreas. It stimulates the conversion of glycogen to glucose in the liver. This hormone is available commercially to be administered in an intramuscular injection for the emergency treatment of severe hypoglycemia in diabetic patients when the administration of oral glucose is not possible. The most common adverse effects include pain at the site of the injection as well as hyperglycemia.

Choice Glyburide is a sulfonylurea associated with the development of hypoglycemia and cholestatic jaundice (a rare complication).

Miglitol (choice C) is an alpha-glucosidase inhibitor commonly associated with the development of abdominal discomfort and flatulence.


Question.6

A morbidly obese diabetic woman was on failed metformin therapy. She has the history of pancreatitis and family history of bladder cancer. Patient does not want to take injections. Which of the following would be suitable to reduce her glucose levels?

AIIMS PG Nov-2017
A. Liraglutide
B. Sitagliptin
C. Canagliflozin
D. Pioglitazone
Correct Ans: C
Explanation

Ans. C. Canagliflozin 

Canagliflozin is a Sodium-Glucose Co-Transporter 2 Inhibitor, given orally and reduces body weight. For the given clinical scenario, Canagliflozin is the preferred drug, as Sitagliptin increases the risk of acute pancreatitis, use of pioglitazone is associated with a small increased risk of bladder cancer and Liraglutide is given subcutaneously.


Question.7

An old man is having benign prostatic hypertrophy. Drug useful in such a patient would be:

AIIMS PG Nov-2017
A. Cyproterone acetate
B. Danazol
C. Bicalutamide
D. Finasteride
Correct Ans: D
Explanation

Ans: D i.e. Finasteride

Drugs and uses

  • Cyproterone has been clinically tested in precocious puberty in boys, inappropriate sexual behaviour in men, acne and virilisation in women, but is not marketed.
  • Danazol is useful in endometriosis, menorrhagia, fibrocystic breast disease and hereditary angioneurotic edema.
  • Bicalutamide (more potent and longer acting congener of flutamide) is suitable for once daily administration in metastatic carcinoma of prostrate.
  • Treatmentt with finasteride has resulted in decreased prostate size and increased peak urinary flow rate in nearly 50% patients with symptomatic benign hypertrophy of the prostrate (BHP). It is the only drug which can retard disease progression.

Question.8

A 1-year old infant presents with 10-12 episodes of watery stools per day for the last 9 days. Along with zinc supplementation, what else should be prescribed to the child?

AIIMS PG Nov-2017
A. ORS with antibiotics
B. ORS only
C. ORS with low-lactose diet
D. ORS with low-lactose diet and probiotics
Correct Ans: B
Explanation

Ans: B. ORS only

  • The infant is suffering from acute diarrhea and treatment includes oral rehydration therapy, zinc supplementation and continued breastfeeding.
  • Low lactose diet is required in management of persistent diarrhea.
  • Antibiotics are required in management of dysentery, i.e. blood in stools.
  • Routine use to probiotics in acute diarrhea is not recommended. 

Question.9

Which of the following is False about Pentazocine ?

AIIMS PG Nov-2017
A. Decreased vomiting and constipation as compared to morphine
B. Risk of addiction is less than that with morphine
C. Risk of addiction is more than that with morphine
D. It is agonist antagonist
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Risk of addiction is more than that with morphine

Pentazocine is agonist-antagonist with weak antagonistic and marked x agonistic action.

Pentazocine is a x (kappa) agonist with weak pi-antagonist or partial agonist properties. It is the oldest mixed agent available. It may be used orally or parenterally. However; because of its irritant properties, the injection of pentazocine subcutaneously is not recommended

  • Its profile of action is similar to morphine with the following difference :
  1. Analgesia is lower in efficacy than morphine and is different in character being mostly spinal (c1)
  2. Cardiac work is increased : It causes tachycardia & rise in BPdue to sympathetic stimulation and is better avoided in Coronary ischemia and Myocardial infarction.
  3. Sedation and respiratory depression is less than morphine.
  4. Vomiting is less frequent.
  5. Biliary spasm and constipation are less severe.
  6. Subjective effects are pleasurable and abuse liability is present although it is lower than that with morphine.

Question.10

All of the following drug may be used for motion sickness except –

AIIMS PG Nov-2017
A. Hyoscine
B. Dicyclomine
C. Domperidone
D. Scopolmine
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Domperidone

Drugs used are :

  1. a)         Anticholinergics —> Hyoscine (Scopolamine), Dicyclomine.
  2. b)      Hl-antihistaminic —> Promethazine, cyclizine, meclizine, cinnarizine, etc.
  • Hyoscine (scopolamine) is the most effective drug for motion sickness.

About option ‘c’

  • Domperidone is a prokinetic drug and acts by D2 blockade. It is ineffective in motion sickness as vestibular pathway does not involve dopaminergic link.

Question.11

Pyridoxine should be given when treating with ?

AIIMS PG Nov-2017
A. Isoniazid
B. Rifampicin
C. Pyrazinamide
D. Streptomycin
Correct Ans: A
Explanation

Ans. is ‘a’ i.e., Isoniazid

  • Peripheral neuritis associated with isoniaide probably relates to interference with pyridoxine (vitamin B6).
  • Thus when treating a patient with isoniazid it is essential to supplement with pyridoxine to reduce chances of peripheral neuritis.

Question.12

Which of the following is an example of placebo?

AIIMS PG Nov-2017
A. Herbal medication with no known effect
B. Physiotherapy
C. Sham surgery
D. Cognitive behavioral therapy
Correct Ans: C
Explanation

Ans. C. Sham surgery 

Sham surgery is a faked surgical intervention that omits the step thought to be therapeutically necessary. In clinical trials of surgical intervention, sham surgery is an important scientific. control. This is because it isolates the specific effects of the treatment as opposed to the incidental effects caused by anesthesia, the incisional trauma, pre- and post-operative care, and the patients perception of having had a regular operation. Thus, sham surgery serves an analogous purpose to placebo drugs, neutralizing biases such as the placebo effect.


Question.13

An unknown drug is being tested in experimental set­up. The results obtained are given in the table. From these actions, new drug is likely to be: Parameter Placebo treated New drug treated Heart rate 72 86 Systolic BP 110 150 Diastolic BP 80 68 Tremors Absent Present

AIIMS PG Nov-2017
A. Beta-I and beta-2 agonist
B. Alpha-1 antagonist and beta-2 agonist
C. M2 and M3 agonist
D. Alpha-1 and beta-1 agonist
Correct Ans: A
Explanation

Ans. A. Beta-1 and beta-2 agonist

Beta-1 stimulation increases heart rate and systolic blood pressure. Beta-2 stimulation cause vasodilation and thus decreases diastolic blood pressure and tremors. Hence, the drug appears to be beta-1 and beta-2 agonist.


Question.14

Which of the following instructions should be given to a lactating mother regarding drug usage?

AIIMS PG Nov-2017
A. No advice is required as most of the drugs are secreted negligibly in the milk
B. Take drugs with longer half-life
C. Tell her to feed the baby just before next dose
D. Tell mother to feed when it is least efficacious
Correct Ans: C
Explanation

Ans. C. Tell her to feed the baby just before next dose 

Regarding drug usage, lactating mother should be advised to feed the baby just before next dose because least plasma concentration of the drug will just before the next loading dose.

“Feeding the babyjust before the mother takes a drug results in the baby receiving the lowest possible drug concentration. “


Question.15

Drug of choice in anaphylactic shock is?

AIIMS PG Nov-2017
A. Subcutaneous Adrenalin
B. Intravenous Adrenaline
C. Steroids
D. Atropine
Correct Ans: B
Explanation

Ans: B. Intravenous Adrenaline REF: Harrison’s Internal Medicinel7th ed> Chapter 311. Allergies, Anaphylaxis, and Systemic M astocytosis

Anaphylaxis: Treatment

  • Mild symptoms such as pruritus and urticaria can be controlled by administration of 0.3 to 0.5 mL of 1:1000 (1.0 mg/mL) epinephrine SC or IM, with repeated doses as required at 5- to 20-min intervals for a severe reaction
  • An IV infusion should be initiated to provide a route for administration of 2.5 mL epinephrine, diluted 1:10,000, at 5- to 10-min intervals, volume expanders such as normal saline, and vasopressor agents such as dopamine if intractable hypotension occurs.
  • When epinephrine fails to control the anaphylactic reaction, hypoxia due to airway obstruction or related to a cardiac arrhythmia, or both, must be considered
  • Oxygen alone via a nasal catheter or with nebulized albuterol may be helpful, but either endotracheal intubation or a tracheostomy is mandatory for oxygen delivery if progressive hypoxia develops.
  • Ancillary agents such as the antihistamine diphenhydramine, 50 to 100 mgIM or IV, and aminophylline , 0.25 to 0.5 g IV, are appropriate for urticaria-angioedema and bronchospasm, respectively.
  • Intravenous glucocorticoids, 0.5-1.0 mg/kg of medrol, are not effective for the acute event but may alleviate later recurrence of bronchospasm, hypotension, or urticaria.

Question.16

Which of the following is incorrect about Scrub typhus ?

AIIMS PG Nov-2017
A. Causative agent is R. tsutsugamushi
B. Important reservoir is trombiculoid mite
C. The adult mite feeds on vertebrate host
D. Tertacycline is drug of choice
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., The adult mite feeds on vertebrate host 

Scrub typhus

  • Caused by orientia tsutsugamushi
  • Reservoir of infection is the trombiculid mite.
  • It is transmitted to man by the bite of infected larval mites.
  • The nymphal and adult stages of the mite are free living in the soil; they do not feed on vertebrate host. It is the larva (chigger) that feed on vertebrate hosts and picks up the rickettsiae.
  • The infection is maintained in nature trans-ovarially from one generation of mite to next.

Mite Rats and mice ? Mite Rats and mice Man

Clinical featurs

  • I.P. ? 10-12 days.
  • Chills, fever, headache, malaise.
  • Macular rash appear on 5th day.
  • Punched out ulcer with black eschar at the site of bite. o T/t – Doxycycline is drug of choice for all rickettsial infections.

Question.17

Treatment of choice for a patient with gonococcal as well as non-gonococcal urethritis is:

AIIMS PG Nov-2017
A. Ceftriaxone 250 mg IM single dose
B. Cefixime 400 mg oral single dose
C. Ciprofloxacin 500 mg oral single dose
D. Azithromycin 2 gm oral single dose
Correct Ans: D
Explanation

Ans. d. Azithromycin 2 gm oral single dose 

Treatment of choice for a patient with gonococcal as well as non-gonococcal urethritis is Azithromycin 2 gm oral single dose.

“Gonococcal Infections: Because co-infection with C. trachomatis occurs frequently, initial treatment regimens must also incorporate an agent (e.g., azithromycin or doxycycline) that is effective against chlamydial infection. Pregnant women with gonorrhea, who should not take doxycycline, should receive concurrent treatment with a macrolide antibiotic for possible chlamydial infection. A single 1-g dose of azithromycin, which is effective therapy for uncomplicated chlamydial infections, results in an unacceptably low cure rate (93%) for gonococcal infections and should not be used alone. A single 2-g dose of azithromycin, particularly in the extended-release microsphere formulation, delivers azithromycin to the lower gastrointestinal tract, thereby improving tolerability.”


Question.18

All of the following statements about antianginal action of nitrates are true except?

AIIMS PG Nov-2017
A. Myocardial O2 consumption
B. Both pre and after load
C. Total coronary flow
D. Cause favourable redistribution of coronary flow
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Total coronary flow 

Mechanism of action of nitrates in Prinzmetal’s angina is endothelium independent coronary vasodilation. When metabolized, organic nitrates release nitric oxide (NO) that binds to guanylyl cyclase in vascular smooth muscle cells, leading to an increase in cyclic guanosine monophosphate, which causes relaxation of vascular smooth muscle.

“Nitrates benefit patients with variant (also known as Prinzmetal) angina by relaxing the smooth muscle of the epicardial coronary arteries and relieving coronary artery spasm.”

Pharmacological actions of nitrates

  • The only major action is direct nonspecific smooth muscle relaxation. Preload reduction – Nitrates dilate veins more than arteries decreased venous return (preload) ? decreased end diastolic size and pressure ? decreased O2 consumption.
  • The most prominant action is exerted on vascular smooth muscles.
  • Afterload reduction – Nitrates also produce some arteriolar dilatation ? slightly decreased total peripheral resistance (afterload).
  • Redistribution of coronary flow.
  • Other smooth muscles – Nitrates cause relaxation of bronchi, biliary tract, esophagus ? can be used in biliary colic and esophageal spasm.

Question.19

A patient presented with acute exacerbation of bronchial asthma. Salbutamol inhalation didn’t improve the condition of the patient. So, intravenous corticosteroids and aminophylline were added and the condition improved. What is the mechanism of action of corticosteroids in this condition?

AIIMS PG Nov-2017
A. They cause bronchodilatation when given with xanthines
B. They increase bronchial responsiveness to salbutamol
C. They increase the action of aminophylline on adenosine receptors
D. They increase the mucociliary clearance
Correct Ans: B
Explanation

Ans. b. They increase bronchial responsiveness to salbutamol 

  • Corticosteroids has a dual effect in acute asthma with an early facilitator effect on airway beta-2 adrenoreceptor sensitivity and a later effect on airway inflammation, which further emphasizes the need fir corticosteroids to he administered as early as possible during an acute asthma attack.
  • “he molecular mechanism of action of corticosteroids involves several effects on the inflammatory process. The major effect of corticosteroids is to switch off the transcription of multiple activated genes that encode inflammatory proteins such as cytokines, chemokines, adhesion molecules, and inflammatory enzymes. This effect involves several mechanisms, including inhibition of the transcription factor NF-KB, but an important mechanism is recruitment of HDAC2 to the inflammatory gene complex, which reverses the histone acetylation associated with increased gene transcription. Corticosteroids also activate anti-inflammatory genes, such as mitogen-activated protein (MAP) kinase phosphatase-1, and increase the expression of IQ-receptors. Most of the metabolic and endocrine side effects of corticosteroids are also mediated through transcriptional activation.

Forensic Medicine

Question.1

Which one of the following is related with ‘Mc Naughten’?

AIIMS PG Nov-2017
A. An accused
B. A witness
C. Private Secretary to PM
D. Prime Minister
Correct Ans: A
Explanation
Ans: A. An accused

Daniel Mc Naughten, a 29 year old Scotsman, suffering from paranoid schizophrenia. He was accused for plotting murder plans against Tories Prime Minister, Sir Robert Peel.
 
Mc Naughten Rule (the right or wrong test; the legal test):
 
It is included in Sec. 84, I.P.C. which is follows: “Nothing is an offence which is done by a person, who at the time of doing it, by reason of unsoundness of mind, is capable of knowing the nature of the act, or that he is doing what is either wrong or contrary to the law.”
 
Ref: The Essentials of Forensic Medicine and Toxicology by K S Narayan Reddy, 27th edition, Page 423.

Question.2

Nysten’s rule pertains to ?

AIIMS PG Nov-2017
A. Rigor mortis
B. Identification
C. Bullet injuries
D. Putrefaction
Correct Ans: A
Explanation

Ans. is ‘a’ i.e., Rigor mortis

Rigor mortis

  • It is defined as contraction, stiffening, shortenig and opacity of muscles after death.
  • It occurs after molecular (cellular) death. In tropical countries (e.g. india), it begins 1-2 hours after death, takes further 2 hours to develop, and lasts for 18-36 hours in summer and 24-48 hours in winter.
  • In temperate countries, it begins in 3-6 hours, takes further 2-3 hours to develop and lasts for 2-3 days.
  • All muscles of body are involved, i.e. voluntary or involuntary.
  • However, it does not start in all muscles simultaneously (nysten’s rule).
  • Involuntary muscles (heart) are involved first than voluntary muscles.
  • Sequence of muscles involvement is as follows : Heart > upper eyelid > neck > jaw > face > chest > upper limb > abdomen > lower limb > finger and toes.
  • It passes off in the same order in which it has appeared.

Question.3

A 14 years old rape victim with 22 weeks of gestation com­ing to hospital. All of the following can be done except:

AIIMS PG Nov-2017
A. Male doctor can examine her with female attendant
B. Gynecologist can abort the fetus upon the patient request
C. No need to collect vaginal swab
D. UPT not required
Correct Ans: B
Explanation

Ans. b. Gynecologist can abort the fetus upon the patient request

Consent of woman is required before conducting abortion. Written consent of guardian is required if the woman is a minor (<18 years) or mentally ill person. In the question, age of patient is 14 years only, so the consent of the guardian is required for termination. Termination is permitted upto 20 weeks of pregnancy only. So, gynecologist cannot abort the fetus upon the patient request.


Question.4

Ossification at two months:

AIIMS PG Nov-2017
A. Lunate
B. Capitate
C. Scaphoid
D. Hamate
Correct Ans: B
Explanation

Ans. B. Capitate

Capitate is the first carpal bone to ossify. Sequence of ossification in carpal bones: Capitate ? Hamate -Triquetral ?Lunate ? Scaphoid ? Trapezoid —*Trapezium ? Pisiform


Question.5

Blackfoot disease is caused by:

AIIMS PG Nov-2017
A. Arsenic
B. Cadmium
C. Lead
D. Mercury
Correct Ans: A
Explanation

Ans. A. Arsenic


Question.6

Match the following declarations: 1. Geneva a. Torture 2. Tokya b. Abortion 3. Oslo c. Human experimentation 4. Helsinki d. Ethics

AIIMS PG Nov-2017
A. 1 =a, 2=b, 3=c, 4=d
B. 1 =b, 2=c, 3=d, 4=a
C. 1 =d, 2=a, 3=b, 4=c
D. 1 =c, 2=d, 3=a, 4=b
Correct Ans: C
Explanation

Ans. c. 1 =d, 2=a, 3=b, 4=c 

 Geneva Ethics
2. Tokyo Torture
3. Oslo Abortion
4. Helsinki Human experimentation

 

Declaration of Geneva (1948) Modernized version of Hippocratic oath°
Declaration of London (1949) International code of medical ethics
Declaration of Helsinki (1964) Human experimentation & clinical trials°
Declaration of Sydney (1968) Definition of death & recovery of organs
Declaration of Oslo (1970) Therapeutic (legalized) abortion
Declaration of Munich (1973) Discrimination in medicine
Declaration of Tokyo (1975) Torture & medicine°
Declaration of Lisbon (1981) Rights of patients
Declaration of Venice (1983) Terminal illness
Declaration of Malta (1992) Role of doctors in hunger strikes
Declaration of Istanbul (2008) Organ trafficking & transplant tourism

Question.7

Match the following: 1. Cocaine a. Hunan hand 2. LSD b. White lady 3. Abrus c. Purple haze 4. Capsaicin d. Gunchi

AIIMS PG Nov-2017
A. 1 =a, 2=b, 3=c, 4=d
B. 1 =b, 2=c, 3=d, 4=a
C. 1 =d, 2=a, 3=b, 4=c
D. 1 =c, 2=d, 3=a, 4=b
Correct Ans: B
Explanation

Ans. b. 1 =b, 2=c, 3=d, 4=a 

1. Cocaine White lady
2. LSD Purple haze
3. Abrus Gunchi
4. Capsaicin Human hand

Question.8

In case of shot by bullet from a revolver, the presence of singeing of hair and charring of skin indicated a distance of:

AIIMS PG Nov-2017
A. 150 cm
B. 6 cm
C. 15 cm
D. 130 cm
Correct Ans: B
Explanation

Ans: B. 6 cm

Close shot is applied when the victim is within the range of flame, i.e., 5-8 cm.
The entrance wound is circular with inverted edges, but the rebounding gases may level up or even evert the margins.
The skin is burnt with singeing of the hair.
The skin surrounding the skin is hyperaemic and shows some bruising, burning, blackening and tattooing. 
 
If the discharge occurs at the distance of about 15 cm., the lacerating and burning effects of gases are usually lost due to the dispersion cooling of the gases before they reach the skin.
 
Ref: The Essentials of Forensic Medicine and Toxicology by KS Narayan Reddy, 27th edition, Page 195-196.

Question.9

Identify the mechanical asphyxia type shown in the picture below ? 

AIIMS PG Nov-2017
A. Garroting.
B. Bansdola.
C. Throttling.
D. Cafe coronary.
Correct Ans: C
Explanation

Ans:C.)Throttling.

The image shown is of a Manual Strangulation(Throttling)

Throttling is asphyxia by compression of neck by human hand.

STRANGULATION

 It is reduced air flow and/or blood flow to or from the brain via the intentional external compression of blood vessels or the airway in the neck. It is a type of Mechanical Asphyxia

  • Ligature strangulation: neck constricted with a ligature
  • Manual strangulation or Throttling: Neck constricted with hand
  • Garroting – victim attacked from behind, throat may be grasped or ligature thrown and neck constricted
  • Mugging – strangulation caused by holding the neck of the victim in the bend of the elbow.
  • Bandsola – neck constricted between two bamboo sticks

Neck injuries in strangulation

  • Skin – fingernail abrasions and/or fingertip bruises
  • Soft tissue bruising – manual greater than ligature-especially where hands are re-applied; chokeholds; including congestive stasis in salivary glands, and the base of the tongue; soft tissue bruising/contusion of neck muscles is seen at the same level as a ligature.
  • Laryngohyoid complex fracture is frequent -the most consistent morphological marker of homicidal neck compression(Most commonly seen in manual Strangulation)

Pathology

Question.1

Shelf life of blood with CPDA 

AIIMS PG Nov-2017
A. 2 weeks
B. 3 weeks
C. 5 weeks
D. 8 weeks
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., 5 weeks 

  • Once blood is removed from the donor, it starts a sequences of in vitro changes that change its physiological properties.
  • Ensuring the blood and its products transfusion safe, their storage is a must.
  • The main aim is to minimize damage to store blood.

Addition of some additive solutions increases the viability of blood, particularly RBCs:

Additive

Shelf life of RBC

Acid-citrate-dextrose (ACD) 21 days 
Citrate phosphate dextrose (CPD) 21 days 
Citrate phosphate dextrose-adenine (CPD-A)  35 days 
Saline-adenine-Glucose-Mannitol (SAG-M)

42 days


Question.2

In Prothrombin time (PT) estimation, on addition of calcium and thromboplastin to platelet poor plasma. which of the following pathway is activated?

AIIMS PG Nov-2017
A. Extrinsic
B. Intrinsic
C. Fibrinolysis
D. Common
Correct Ans: A
Explanation

Ans. a. Extrinsic

  • In Prothrombin time (PT) estimation, addition of calcium and thromboplastin to platelet poor plasma activates extrinsic pathway.
  • The prothrombin time (PT) assay assesses the function of the proteins in the extrinsic pathway (factors VII, X,
  • and .fibrinogen). In brief tissue factor, phospholipids, and calcium are added to plasma and the time for a fibrin clot to form is recorded.
  • Prothrombin time (PT): This test assesses the extrinsic and common coagulation pathways. The clotting of plasma after addition of an exogenous source of tissue thromboplastin (e.g., brain extract) and Ca” ions is measured in seconds. A prolonged PT can result from deficiency or dysfunction of factor V, factor VII, factor X, prothrombin. or fibrinogen

Question.3

What is the correct order of blood sampling? Verification of patient’s profile Labeling at bedside Sampling Identification of patient

AIIMS PG Nov-2017
A. 1, 2, 3, 4
B. 4, I, 3, 2
C. 4, 3, 1, 2
D. 1, 4, 2, 3
Correct Ans: B
Explanation

Ans. b. 4, 1, 3, 

Procedure for drawing blood (WHO)
Step Procedure
1 Assemble equipment, include needle & syringe or vacuum tube, depending on which is to be used.
2

Perform hand hygiene (if using soap & water, dry hands with single-use towels).

3 Identify & prepare the patient.
4

Select the site, preferably at the antecubital area. Warming the arm with a hot pack, or hanging the hand down may make it easier to see the veins. Palpate the area to locate the anatomic landmarks. Do not touch the site once alcohol or other antiseptic has been applied.

5

Apply a tourniquet, about 4-5 finger widths above the selected venepuncture site.

6  
7

Put on well-fitting, non-sterile gloves.

8 Disinfect the site using 70% isopropyl alcohol for 30 seconds & allow to dry completely (30 sec).
9 .,Anchor the vein by holding the patient’s arm & placing a thumb below the venepuncture site.
10

Enter the vein swiftly at a 30 degree angle.

11

Once sufficient blood has been collected, release the tourniquet before withdrawing the needle.

12

Withdraw the needle gently and then give the patient a clean gauze or dry cotton-wool ball to apply to the site

13

Discard the used needle & syringe or blood-sampling device into a puncture-resistant container.

14

Check the label & forms for accuracy.

15

Discard sharps & broken glass into the sharps container. Place items that can drip blood or body fluids into the infectious waste.

16

Remove gloves & place them in the general waste. Perform hand hygiene. If using soap & water, dry hands with single-use towels.


Question.4

Which of the following anticoagulant is used for electrolyte estimation?

AIIMS PG Nov-2017
A. EDTA
B. Citrate
C. Sodium fluoride
D. Lithium heparin
Correct Ans: D
Explanation

Ans. d. Lithium heparin 

Lithium heparin is the anticoagulant used for electrolyte estimation.

Lithium-heparin is the preferred anticoagulant for hematology in non-mammalians because EDTA causes in vitro hemolysis in some amphibian, reptile, and fish species; moreover, plasma harvested from blood anticoagulated with lithium-heparin can be used for routine chemistry/electrolyte analysis, which is especially advantageous with small sample volumes.

“Commonly used anticoagulants are heparin, EDTA, oxalates, citrate and fluoride. Of these, lithium heparin is best suited for most of the biochemical estimations. All other anticoagulants the/ate calcium and hence unsuitable for calcium estimation. The possibility of enzyme inhibition especially creatine kinase, ALP, ACP, amylase and LDH are observed with several of these anticoagulants. Oxalates are unsuitable for estimation of sodium and potassium also.”-


Question.5

A 42-year-old female presents with tinnitus and hearing loss, and is found to have a mass at the cerebellopontine angle. A biopsy section is shown here.What is the most likely diagnosis? 

AIIMS PG Nov-2017
A. Meningioma.
B. Glioblastoma.
C. Schwannoma.
D. Medulloblastoma.
Correct Ans: C
Explanation

Ans: C. Schwannoma.

The diagnosis in this case is Schwannoma. Most schwannomas occur at the cerebellopontine angle, attached to the eighth nerve. In this setting, the tumor is often referred to (inaccurately) as an acoustic neuroma. 

Schwannomas are usually well-circumscribed masses that are easily separated from the nerve to which they are attached.Histologically, the appearance is very cool-looking and very characteristic. Schwannomas have a mixture of two architectural patterns: a densely cellular “Antoni A” pattern and a less cellular “Antoni B” pattern.

In the Antoni A pattern , you see these elongated cells arranged in rows (fascicles) around a central zone containing cytoplasmic processes. Those central zones of processes between the regions of nuclear palisading are called Verocay bodies.

The Antoni B areas are less cellular and have a myxoid background.


Question.6

In alpha-thalassemia trait,electrophoresis shows:

AIIMS PG Nov-2017
A. Increased HbF and normal HbA2
B. Normal HbF and normal HbA2
C. Normal HbF and decreased HbA2
D. Decreased HbF and normal HbA2
Correct Ans: B
Explanation

Ans. B: Normal HbF and normal HbA2

Alpha (0) thalassemia -Individuals with this disorder are not able to produce any functional alpha-globin and thus are unable to make any functional hemoglobin A, F, or A2. This leads to the development of hydrops fetalis, also known as hemoglobin Bart, a condition that is incompatible with extra uterine life.

Alpha (+) thalassemia – genetic mutations that result in decreased production of alpha-globin usually due to the functional deletion of 1 of the 4 alpha globin genes. Based on the number of inherited alpha genes, it is subclassified into 3 general forms:

  • Thalassemia (-u/ a a) is characterized by inheritance of 3 normal a-genes. These patients are referred to clinically as silent carrier of alpha thalassemia. Other names for this condition are alpha thalassemia minima, alpha thalassemia-2 trait, and heterozygosity for alpha (+) thalassemia minor. The affected individuals exhibit no abnormality clinically and may be hematologically normal or have mild reductions in red cell mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH).
  • Inheritance of 2 normal alpha genes due to either heterozygosity for alpha (0) thalassemia (u a/ —) or homozygosity for alpha (+) thalassemia (-u/-a) results in the development of alpha thalassemia minor or alpha thalassemia-1 trait. The affected individuals are clinically normal but frequently have minimal anemia and reduced mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH).
  • Inheritance of one normal alpha gene (-a/ —) results in abundant formation of hemoglobin H. This condition is known as ElbH disease. The affected individuals have moderate to severe lifelong hemolytic anemia, modest degrees of ineffective erythropoiesis, splenomegaly and variable bony changes
  • Persons with alpha-thalassemia traits have normal HbA2 and HbF levels whereas beta- thalassemia patients have elevated HbA2

Question.7

Most important but nonspecific regulator of iron metabolism is:

AIIMS PG Nov-2017
A. Hepcidin
B. DMT I
C. Ferroportin
D. Ferritin
Correct Ans: A
Explanation

Ans: A. Hepcidin

(Ref Robbins 91e p650 848 8/e p660)

Hepcidin:

  • Main regulator protein for iron absorption.
  • Encoded by HAMP gene.
  • Small circulating peptide synthesized & released from liver in response to increased intrahepatic iron levels.

Proteins Involved in Iron Metabolism

  • Ceruloplasmin° (ferrioxidase activity)
  • DMT1°
  • Ferrireductase° (cytochrome reductase I)
  • Ferritin°

Ferroprtin

  • Heme transporter
  • Hemojuvelin
  • Hepcidin°
  • Hephaestin°

HFE°

  • Iron-responsive element-binding
  • protein°
  • Transferrin°
  • Transferrin receptors 1 & 2

Question.8

Which of the following is not correct regarding iron deficiency anemia?

AIIMS PG Nov-2017
A. Increased RDW (>14.5%)
B. Decreased serum iron (<75ug/mL)
C. Decreased TIBC (<350p.g/mL)
D. Decreased serum ferritin (<151.1g/dL)
Correct Ans: C
Explanation

Ans. c. Decreased TIBC (<350 mg/ml) (Re./: Winrrobes l2/e p795)

  • Iron deficienqt anemia, there is decreased MCV and MCH with an elevated red cell distribution width and increased TIBC, decreased serum iron and decreased serum ferritin.
  • Iron Deficiency Anemia:
  • Decreased MCV and MCH
  • Elevated red cell distribution width
  • Increased TIBC
  • Decreased serum iron
  • Decreased serum ferritin

Question.9

What is true about HER2/neu overexpression in Ca breast:

AIIMS PG Nov-2017
A. Good prognosis
B. Responds well to taxanes
C. Responds well to monoclonal antibodies
D. Seen only in breast cancer
Correct Ans: C
Explanation

Ans is ‘c’ i.e. Responds well to monoclonal antibodies 

The HER2 receptor (previously called HER2/neu, or ERBB-2 receptor) belongs to the epidermal growth factor receptor (EGFR) family of receptors, which are critical in the activation of subcellular signal transduction pathways controlling epithelial cell growth and differentiation and possibly angiogenesis.

Amplification of HER2 or overexpression of its protein product is observed in 18 to 20 percent of human breast cancers.

HER2 overexpression is also noted in other tumors such as esophagogastric tumors, lung, ovary & head and neck squamous cell ca. (In all of these sites, HER2 overexpression has been identified as a negative prognostic factor.)

Following points are to be noted about HER2 overexpression in breast Ca:

Prognostic value of HER2 — HER2 overexpression is a poor prognostic marker. HER2 overexpression is associated with high rates of disease recurrence and death in the absence of adjuvant systemic therapy.

Predictive value of HER2 — HER2 status predicts response to specific therapies:

  • Patients with high levels of HER2 expression benefit from treatment with agents that target HER2, such as trastuzumab (a monoclonal antibody) and lapatinib.
  • HER2 status appears to predict resistance or sensitivity to different types of chemotherapeutic agents, including anthracyclines and taxanes.

Women whose tumors overexpress HER2 appear to derive greater benefit from anthracycline-based adjuvant therapy than from adjuvant therapy that is alkylating agent-based, such as CMF (cycl ophosphami de, methotrexate, fluorouracil).

Relationship between HER2 overexpression and taxanes is still under study with various studies giving conflicting reports.

HER-2 positivity is associated with resistance to endocrine therapies.

Scoring of HER-2 Immunohistochemistry Assays

Score

HER-2 Status

Staining Pattern

0

Negative

No staining or membrane staining in <10% of tumor cells°

1+

Negative

faint barely perceptible membrane staining is detected in >10%

of tumor cells. The cells are only stained in part of the membrane°.

2+

Equivocal

Weak to moderate complete membrane staining is seen in >10% of

tumor cells or <30% with strong staininga

3+

Positive

Strong complete membrane staining is seen in >30% of tumor cells°


Question.10

All of the following are true about aspiration pneumonia except:

AIIMS PG Nov-2017
A. Aspiration of 20-30 mL of contents with pH < 2.5 is required
B. Fungal infection is the common cause of pneumonia
C. Posterior segment of the right upper lobe is most commonly affected in the recumbent position
D. Aspiration responsible for 5-15% of community acquired pneumonia
Correct Ans: B
Explanation

Answer- B.Fungal infection is the common cause of pneumonia

  • Mixed polymicrobial infection involving both aerobes and anaerobes are the common cause of aspiration pneumonia, not the fungal infection.
  • Incidence: It is common and may account for up to 15% of patients with community-acquired pneumonia.
  • Gastric pH of 2.5 or less with a gastric contents volume greater than 25 ml are critical values for causing aspiration pneumonia.
  • The posterior segments of the upper lobe and apical segments of lower lobes are most commonly involved when aspiration occurs in a supine position.
  • The basal segments of the lower lobes are usually affected in patients who aspirate in an upright or semirecumbent position.

Question.11

Chronic Lymphocytic Leukemia (CLL) is associated with:

AIIMS PG Nov-2017
A. Individuals > 50 years of age
B. Mature small lymphocytes in peripheral smear
C. Hepatosplenomegaly and lymphadenopathy
D. All of the above
Correct Ans: D
Explanation

Answer is D (All of the above)

Cell of origin of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) is naive B-cells in inter-follicular zones.

“DNA sequencing has revealed that the Ig genes of some CLL/SLL are somatically hypermutated, whereas others are not, suggesting that the cell of origin may be either a postgerminal center memory B cell or a naive B cell.”

Essentials in Hematology and clinical pathology’ by Naik, Ras, Gupta (JP) 2012/202, 205, 204

CLL is commonly seen in individuals > 50 years (median age is about 65 year) and are typically chrachterized by the presence of increased number of mature small lymphocytes in the peripheral smear. Hepatosplenomegaly and lymphadenopathy may be seen.

‘The physical examination may be unremarkable but common. findings are hepatosplenomegaly and enlarged non tender, farm mobile lymph nodes in the cervical axillary and inguinal areas’

Diagnostic criteria of CLL are (Wintrobe’s Atlas of Clinical Hematology)

  1. An absolute Lymphocytosis > 5x I 09/L
  2. > 30% Lymphocytosis in a normocellular or hypercellular bone marrow
  3. Monoclonal B cells with low levels of surface immunoglobulins and CD5 positivity

Question.12

The most common cause of bilateral proptosis in children is:

AIIMS PG Nov-2017
A. Cavernous hemangioma
B. Fibrous Histocytoma
C. Chloroma (Leukemia)
D. Rhabdomyosarcoma
Correct Ans: C
Explanation

Ans: C i.e. Chloroma (Leukemia)

  • Most common cause of bilateral proptosis in children are thyroid ophthalmopathy and secondary or metastatic malignancy (from neuroblastoma > myeloid sarcoma/leukemia/ chloroma)Q.
  • Orbital lesions in childhood & adolescence (0 – 20 years) a/t frequency (%): Capillary hemangioma (mc. 100%) > Rhabdomyosarcoma (98) > Cystic lesions or dermoid cyst (77) > Infection eg orbital cellulitis (35) > Fibrous histiocytoma (25) > Adenoid cystic carcinoma of lacrimal gland (18) > Inflammatory lesions (12) > Cavernous hemangioma (10) > Trauma (7) > Lymphangioma > (6) > optic nerve glioma (5) > Optic nerve meningioma (4) > = Thyroid orbitopathy (4) > Secondaries & metastasis (1) = Lympho proliferative diseases (1).
  • So most common cause of unilateral proptosis in childhood is capillary hemangioma >
  • Rhabdomyosarcoma > Dermoid cyst > Orbital cellulitis > Fibrious histiocytoma.
  • Thyroid ophthalmopathy is always bilateral whereas only 4% of orbital metastates are bilateral. In children, metastases are more likely to be embryonal tumors of neural origin and sarcomas. Neuroblastoma is 2nd most common orbital tumor in children, after rhabdomyosarcoma. 40% of the orbital lesions in neuroblastoma are bilateral. Myeloid (granulocytic) sarcoma or chloroma (from myeloid leukemia) is 2nd most common metastatic lesion in children.
  • Orbital lesions in middle age (21-60 years) : Pleomorphic adenoma of lacrimal gland (89) > Optic nerve meningioma (88) > Cavernous hemangioma (75) > Adenoidcystic carcinoma of lacrimal gland (73) > Thyroid orbitopathy (60) > Fibrous histiocytoma (50)
  • Orbital lesion in later adult life (61 + years) : Thyroid orbitopathyQ (40) > Fibrous histiocytoma (25) > Cavernous hemangioma (15) > Lymphoproliferative disorder (12) > Pleomorphic adenoma of lacrimal gland (11) > Secondary (9) = Inflammatory (9)
  • However, many books consider thyroid ophthalmopathy as the most common cause of unilateral as well as bilateral proptosis in adults.

Question.13

Following are seen in polycythemia vera except:

AIIMS PG Nov-2017
A. Most common cause of polycythemia
B. Increased erythropoietin
C. Erythropoietin independent growth of red cell progenitors
D. Intrinsic abnormality of hematopoietic precursors
Correct Ans: B
Explanation

Ans. B: Increased erythropoietin

The combination of iron deficiency anemia, glossitis and esophageal dysphagia usually related to the webs is known as the Plummer Vinson syndrome or Paterson Kelly syndrome.

Plummer-Vinson syndrome/PVS/Paterson-Brown-Kelly syndrome/sideropenic dysphagia

PCV is associated with a low serum level of the hormone erythropoietin (EPO). 

polycythemia vera results from an essential decrease in erythrocyte production, patients have a low erythropoietin (EPO) level.

It presents as a triad of dysphagia (due to esophageal webs), glossitis, and iron deficiency anemia.

  • In primary polycythemia, there may be 8 to 9 million and occasionally 11 million erythrocytes per cubic millimeter of blood (a normal range for adults is 4-6), and the hematocrit may be as high as 70 to 80%.
  • In addition, the total blood volume sometimes increases to as much as twice normal.

Question.14

A patient presented with difficulty in swallowing solids and liquids.Esophageal picture is given in the image.What can be the most probable diagnosis?

AIIMS PG Nov-2017
A. Barrett’s Esophagus
B. Adenocarcinoma
C. Basal Cell Carcinoma
D. Squamous Cell carcinoma
Correct Ans: D
Explanation

Ans:D.)Squamous Cell carcinoma

Image shows:Esophageal squamous cell carcinoma. A, Squamous cell carcinoma most frequently is found in the midesophagus, where it commonly causes strictures. B, Squamous cell carcinoma composed of nests of malignant cells that partially recapitulate the stratified organization of squamous epithelium.

Squamous Cell Carcinoma of Esophagus

  • Risk factors include alcohol and tobacco use, poverty, caustic esophageal injury, achalasia, Plummer-Vinson syndrome, frequent consumption of very hot beverages, and previous radiation therapy to the mediastinum.
  • It is nearly 6 times more common in African Americans than in whites.

MORPHOLOGY:

  • In contrast to the distal location of most adenocarcinomas, half of squamous cell carcinomas occur in the middle third of the esophagus .
  • Squamous cell carcinoma begins as an in situ lesion in the form of squamous dysplasia. Early lesions appear as small, gray-white plaque like thickenings.
  • Over months to years they grow into tumor masses that may be polypoid and protrude into and obstruct the lumen.
  • Other tumors are either ulcerated or diffusely infiltrative lesions that spread within the esophageal wall, where they cause thickening, rigidity, and luminal narrowing.
  • These cancers may invade surrounding structures including the respiratory tree, causing pneumonia; the aorta, causing catastrophic exsanguination; or the mediastinum and pericardium.

Question.15

Diagnostic feature in rheumatic heart disease is :

AIIMS PG Nov-2017
A. Aschoff’s nodule
B. Mc Callman patch
C. Adeno Carcinoma
D. Alveolar cell Carcinoma
Correct Ans: A
Explanation

Answer is A (Aschoff nodule)

“Aschoffs body is pathognomic of Rheumatic fever” – Robbins

Aschoff s bodies are focal inflammatory lesions, that may be found in any of the three layers of the heart Pericardium, Myocardium and Endocardium, during acute Rheumatic fever.

Aschoff bodies consist of foci of swollen eosinophillic collagen surrounded by

  • Lymphocytes (primarily T cells)
  • Occasional plasma cells
  • Aschoff giant cells (macrophages of rheumatic fever)
  • Antitschkow cells

(Antischkow cells are modified macrophages with abundant cytoplasm and central round to ovoid nuclei in which the chromatin is disposed in the central, slender wavy ribbon like pattern — caterpillar cells)


Question.16

Which of the following most significantly increases the risk of hepatocellular carcinoma

AIIMS PG Nov-2017
A. Hepatitis B virus
B. Hepatitis A virus
C. Cytomegala virus
D. Epstein-Barr virus
Correct Ans: Select
Explanation

Ans.a. Hepatitis B virus

132.Ref Subiston 19/e p1453-1454; Schwartz 9/e p1121; Bailey 26/e pl 05, 25/c 1)1099; 13hangart 5/e p1284: Shackelford 7/e p1565-1568)

Hepatitis B virus most significantly increases the risk of hepatocellular carcinoma

The DNA of the HBV integrates randomly into hepatocyte chromosomes and acts as a nonselective insertional mutagenic agent. Integration of HBV DNA into the host genome occurs in 90% of HBV-related HCC and has been postulated as an early event in chronic viral infection.


Question.17

Which of the following statement is not true about glomerular basement membrane?

AIIMS PG Nov-2017
A. Type III collagen is present
B. Glomerular basement membrane is stained with PAS
C. Glomerular basement membrane acts as filtration barrier
D. Glomerular basement membrane is involved in charge dependent filtration
Correct Ans: A
Explanation

Ans. a. Type III collagen is present 

Type IV collagens (not the type HI collagen) are the main components of the basement membrane, together with laminin.

“The basement membrane is synthesized by contributions from the overlying epithelium and underlying mesenchymal cells, forming a flat lamellar “chicken wire” mesh (although labeled as a membrane; it is quite porous). The major constituents are amorphous nonfibrillar type IV collagen and lantinin.” ‘

“Type IV collagens have long but interrupted triple-helical domains and form sheets instead of fibrils; they are the main components of the basement membrane, together with laminin

ENT

Question.1

Noise induced hearing toss inosto affects:

AIIMS PG Nov-2017
A. Inner hair cell
B. Outer hair cell
C. Macula
D. Cupula
Correct Ans: B
Explanation

Ans. b. Outer hair cell 

Noise induced hearing loss mostly affects outer hair cell.

  • “Noise induced hearing loss (NIHL) causes damage to hair cells, starting in the basal turn of cochlea. Outer hair cells are affected before the inner hair cells.”
  • “Noise-induced hearing loss damages hair cells, which begin at the basal turn of cochlea. Outer hair cells are affected earlier than the inner hair cells.”

Question.2

Target sign is seen in:

AIIMS PG Nov-2017
A. Spontaneous CSF rhinorrhea
B. Traumatic CSF rhinorrhea
C. Traumatic epistaxis
D. Petrositis
Correct Ans: B
Explanation

Ans. b. Traumatic CSF rhinorrhea

Target sign is seen in traumatic CSF rhinorrhea.

“CSF rhinorrhoea: There is history of clear watery discharge from the nose on bending the head or straining. It may be seen on rising in the morning when patient bends his head (reservoir sign fluid which had collected in the sinuses, particularly sphenoid, empties into the nose).”

“CSF rhinorrhoea after head trauma is mixed with blood and shows double target sign when collected on a piece of filter paper. It shows central red spot (blood) and peripheral lighter halo. 

Ophthalmology

Question.1

Most common tumor of lacrimal gland:

AIIMS PG Nov-2017
A. Trans-scaphoid perilunate fracture
B. Scaphoid fracture
C. Distal radius fracture
D. Hamate fracture
Correct Ans: D
Explanation

Ans. d. Hamate fracture

  • Most common tumor of lacrimal gland is Non-Hodgkin’s lymphoma (37%)> Pleomorphic adenoma (25%). Most common
  • malignant epithelial tumor of the lacrimal gland is adenoid cystic carcinoma.
Lacrimal Gland Tumor
MC tumor of lacrimal gland Non-Hodgkin’s lymphoma°
MC epithelial tumor of lacrimal gland Pleomorphic adenoma°
MC malignant epithelial tumor of lacrimal gland Adenoid cystic carcinoma°

Question.2

Most common cause of anterior staphyloma 

AIIMS PG Nov-2017
A. High myopia
B. Scleritis
C. Corneal ulcer
D. Trauma
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Corneal ulcer

Staphyloma

  • Staphyloma is an abnormal protrusion of uveal tissue through a weak and thin portion of cornea or sclera.
  • So, a staphyloma is lined internally by uveal tissue and externally by weak cornea or sclera.
  • Staphyloma is divided anatomically into : ?

1. Anterior staphyloma : – Protrusion and adhesion of iris to ectatic cornea. The most common cause is a sloughing corneal ulcer which perforates and heals with the      formation of pseudocornea by the organization of exudates and laying down of fibrous tissue. It is lined internally by iris.

2.  Intercalary staphyloma : – It occurs at the limbus. It is lined internally by the root of iris and the anterior

most portion of the ciliary body. The causes are perforating injuries to limbus, marginal corneal ulcer,

anterior scleritis, Scleromalacia perforans, Complicated cataract surgery, secondary angle closure

glaucoma.

3.  Ciliary staphyloma : – This affects the ciliary zone that includes the region upto 8 mm behind the limbus. The ciliary body is incarcerated in the region of scleral ectasia. Causes are Developmental glaucoma, Primary or secondary glaucoma end stage, scleritis, trauma to ciliary region.

4. Equatorial staphyloma : – This occurs at the equatorial region of the eye with incarceration of the choroid. Causes are scleritis, degenerative myopia and chronic      uncontrolled glaucoma.

5.   Posterior staphyloma : – Occurs at posterior pole and is lined internally by choroid. Degenerative high axial myopia is the most common cause


Question.3

Capillary microaneurysms is an earliest sign of:

AIIMS PG Nov-2017
A. Vitreous hemorrhage
B. Non-proliferative diabetic retinopathy
C. Trauma
D. Hypertensive retinopathy
Correct Ans: B
Explanation

Ans. B i.e. Non-proliferative diabetic retinopathy

Diabetic retinopathy

  • Fundus examination in DM:
  • NIDDM: As early as possible
  • IDDM: 5 years after diagnosis of DM
  • Incidence of diabetic retinopathy increases with disease duration

Question.4

Endophthalmitis involves inflammation of all of the following, Except

AIIMS PG Nov-2017
A. Sclera
B. Uvea
C. Retina
D. Vitreous
Correct Ans: A
Explanation

Ans: A i.e. Sclera

Sclera is not involved in endophthalmitis. Involvement of sclera suggests a more severe inflammation or panophthalmitis.

Endopthalmitis

  • It is inflammation of one or more coats of the eye and adjacent cavities. Inflammation characteristically involves the inner structures of eye ball i.e. uveal tissue (i.e. iris, ciliary body and choroid) and retina associated with pourine of exudates in the vitreous cavity (vitritis)/ posterior or anterior chamberQ
  • Sclera is sparedQ
  • Most clinicians require a vitritis before calling an ocular inflammation (eg corneal ulcer with hypopyon or iritis with aqueous cells) an endopthalmitis.
  • Topical antibiotics: Commonly used topical antibiotics are fortified cefazolin (5%) or vancomycin (5%) with gentamicin or amikacin (1.3%) 1 hourly, alternating every half hour. Cycloplegia is achieved initially with topical atropine 1 % twice a day substituted by short-acting agents after 3-4 days.-
  • “Intravitreal antibiotics are the treatment of choice and are injected after taking a 0.2-0.3 ml vitreous aspirate for preparing smears and obtaining cultures. A combination of amikacin (0.4 mg in 0.1 ml) or gentamicin (0.4 mg in 0.1 ml) and ceftriaxone (2 mg in 0.1 ml) or vancomycin (1.0 mg in 0.1m1) is generally recommended
  • Vitrectomy: Recovery from bacterial and fungal endophthalmitis is hastened by the removal of infected vitreous (vitrectomy) and the introduction of intravitreal antibiotics.”

Panopthalmitis

  • It is inflammation of all three coats of eyeQ (& adjacent cavities i.e. anterior (aqueous) &/or posterior (vitreous) segments). Panopthalmitis often starts as an endopthalmitis that then involves the sclera, tenon’s capsuleQ and may also spread to orbital tissue.

Question.5

A patient presented to an opthalmologist with the following seen on clinical examination of a right eye.Which among the following best represents the condition shown in the picture below?

AIIMS PG Nov-2017
A. Conjunctivitis.
B. Trachoma.
C. Pinguecula.
D. Pterygium.
Correct Ans: D
Explanation

Ans:D.)Pterygium.

The condition shown in the picture above represents Pterygium.

Ptervgium

  • Pterygium is a non-cancerous (non-neoplastic) growth of conjunctiva, characterized by a wing-shaped fold of conjunctiva encroaching upon the cornea from either side within the interpalpebral fissure. Pterygium is always situated in the palpebral aperture.
  • Pathologically Pterygium is a degenerative and hyperplastic condition of conjunctiva. The subconjunctival tissue undergoes elastotic degeneration and proliferates as vascularized granulation tissue under the epithelium, which ultimately encroaches the cornea. The corneal epithelium, Bowman’s layer and stroma are destroyed.

Etiology & Clinical features

  • Pterygium is more common in people with excess outdoor exposure to sunlight (UV rays), dry heat, high wind and abundance of dust. Therefore it is more common in those who work outdoors.
  • Clinically it presents as a triangular fold of conjunctiva encroaching the cornea in the area of palpebral aperture, usually on the nasal side. Other findings are stocker’s line (deposition of iron)
  • Ptergyium is an asymptomatic condition in the early stages, except for cosmetic intolerance. Visual disturbance or corneal astigmatism may occur. Visual disturbances are due to encroachment of pterygium on pupillary area or corneal astigmatism. Occasionally diplopia may occur due to limitation of ocular movements.

Treatment

  • Asymptomatic pterygium which is not progressive is best left alone. Surgical excision is the only satisfactory treatment and is indicated for : – (1) Cosmetic reasons, (2) Continued progression threatening to encroach onto the pupillary area (once the pterygium has encroached pupillary area, wait till it crosses on the other side), (3) Diplopia due to interference in ocular movement.

Preventive & Social Medicine

Question.1

In a JubLeitter arca pith crude birth rate of 211, what would be the expected number of ANC registrations?

AIIMS PG Nov-2017
A. 60
B. 80
C. 100
D. 120
Correct Ans: A
Explanation

Ans. a. 60

In a subcenter area with crude birth rate of 20, the expected number of ANC registrations should be approximately 55.

Number of Expected Pregnancies per Year 
 Expected no. of live-births (Y)/year= Birth rate (per 1000 population) x Population of the area/1000

 

Number of Expected Pregnancies per Year

  • As some pregnancies may not result in a live birth (i.e., abortions & stillbirth may occur), the expected number of live births would be an under-estimation of the total number of pregnancies. Hence, a correction factor of 10% is required, i.e., add 10% to the figure obtained above.
  • Total number of Expected Pregnancies Z = Y + 10% of Y
  • Population under the subcentre = 5000
  • Birth rate = 20
  • Expected no. of live-births (Y)/year = 20 x 5000/1000 = 100
  • Total number of Expected Pregnancies Z = Y + 10% of Y =100 + 10% of 100 = 110
  • Expected number of ANC registrations will be half of yearly calculation = 55

Question.2

OPV can be used if vaccine vial monitor is showing?

AIIMS PG Nov-2017
A. Colour of outer circle is same as inner square
B. Colour of outer circle is darker than inner square
C. Colour of outer circle is lighter than inner square
D. None of the above
Correct Ans: B
Explanation

Ans. is ‘b’ i.e., Colour of outer circle is darker than inner square


Question.3

If the grading of diabetes is classified as “mild”, “moderate” and “severe” the scale of measurement used is –

AIIMS PG Nov-2017
A. Interval
B. Nominal
C. Ordinal
D. Ratio
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Ordinal scale 

A. Categorial scale

1. Nominal scale

  • Nominal scale data are divided into qualitative categories or groups, such as male /female, black / white, died / cured, attacked / not attacked, vaccinated / not vaccinate, urban / sub urban / rural.
  • Example are Race/ethnicity (black/white), marital status (married/unmarried), Religion (Hindu, Muslim/ …..), country of birth (India/Nepal ABO blood group, Gender (male/female), disease outcome (cured/ died), vaccination status (vaccinated/not vaccinated), Types of anemia (macrocytic/microcytic), and place of living (rural/urban) etc.
  • There is no implication of order or ratio, means that the data cannot be placed in a meaningful order.

2. Ordinal Scale

  • Here the data can be placed into categories that can be rank ordered (eg. students may be ranked 1″ / 2nd / 3rd / 4th in their class or into grades A/B/C, the activity of an animal can be rated on a scale of 1 to 6, hardness scale for water etc.)
  • However, there is no information about the size of the interval ie no conclusion can be drawn about whether the difference between the first and second students is the same as the difference between the second and third.
  • Example are TAW staging of cancers, Severity of disease (mild, moderate, severe), social class (low, middle, high), classification of person on the base of height (short, medium, tall).

3. Dichotomous Scale is a type of nominal scale in which nominal data fall into only two groups eg black / white, died / cured, failed / passed.

B. Metric scale

1. Interval scale

  • Interval scale data are like ordinal data in that they can be placed in a meaningful order; in addition, they have meaningful intervals between items, which can be measured.
  • eg: Temperature on the Celsius scale (the difference between 80° and 70° is the same as between 40° and 30°)
  • However, interval scale data do not have an absolute zero, ratios of the scores are not meaningful ie 80° C of
  • Celsius temperature is not twice as hot as 40°C because 0°C does not indicate a complete absence of heat.

2. Ratio Scale

  • A ratio scale has the same properties as an interval scale, however, because it has an absolute zero, meaningful ratio do exist.
  • eg. weights, Height, Pulse rate, serum cholesterol, blood glucose, hemoglobin level, time, blood pressure, temperature on the Kelvin scale (not Celsius scale) On the Kelvin scale, zero degrees indicate an absolute absence of heat, just as a zero pulse indicates an absolute absence of heartbeat.
  • Ratio of one value to other is meaningful. For example, pulse rate of 120 beats/minute is twice as fast as a pulse rate of 60 beats per minute, and 300°k is twice as hot as 150°k.
  • In this question data on diabetes are placed into categories that are ordered mild, moderate, sever —> ordinal scale should be used.

Note ?

  • Temprature in celsius or fahrenheit is measured on interval scale because 0°C does not indicate a complete absence of heat.
  • The temprature on kelvin scale (a ratio scale) —) zero degree refer to the absence of heat (purely a theoritical concept that has never been attained).

Also know

  • Statistically most preferable scale of measurement metric scale
  • Statistically least preferable scale of measurement –4 nominal scale.

Question.4

A clinical trail was conducted with 15225 hypertensive patients alloted in the intervention group (New drug) and control group (Old drug) respectively. Results of the research study are given in the following table. Calculate the absolute risk reduction (ARR) and relative risk (RR):   Control group (old drug) Intervention group (new drug) Developed HT complications 1800 1620 Did not develop HT complications 13425 13605 Total subjects 15225 15225

AIIMS PG Nov-2017
A. ARR = 10% and RR = 0.9
B. ARR = 1% and IZR = 9
C. ARR = 1% and RR = 0.9
D. ARIZ = 10% and RR = 9
Correct Ans: C
Explanation

Ans. C. ARR = 1% and RR = 0.9

(Ref. Park 24/e p83)

In the given situation, absolute risk reduction (ARR) is 1% and relative risk (RR) is 0.9.

Relative Risk (RR)

Attributable Risk (AR)

Population Attributable Risk (PAR)

RR=IExp/INon-Exp

 AR=(IExp-INon-Exp)/INon-ExpX100  AR=(Total-INon-exp)/ITotalX100
  • RR is the ratio of the risk in the exposed divided by the risk in the unexposed.
  • AR indicates the number of cases of a disease among exposed individuals that can be attributed to that exposure
  • It is excess risk or risk difference
  • Useful measure of extent of public health problem caused by an exposure
 PAR indicates the number (or proportion) of cases that would not occur in a population if the factor were eliminated.

 

  Control group (old drug) Intervention group (New drug)
Developed HT complications 1800 1620
Did not develop HT complications 13425 13605
Total subjects 15225 15225
  • IC = Incidence of events (hypertensive complications) in the control group = 1800/15225 = 0.118 = 11.8%
  • IT = Incidence of events (hypertensive complications) in the treatment group = 1620/15225 = 0.106 = 10.6%
  • Absolute risk reduction (ARR) is also known as risk difference.
  • ARR = IC–IT = 11.8 –10.6 = 1.2%
  • Relative risk (RR) = IT/IC = 0.106/0.118 = 0.9

Question.5

High sensitive –

AIIMS PG Nov-2017
A. Low false positive
B. Low false negative
C. Low true negative
D. Low true positive
Correct Ans: B
Explanation

Ans. is ‘b’ i.e., Low False negative 

  • True positive is directly related to sensitivity o False negative is inversely related to sensitivity
  • True negative is directly related to specificity o False positive is inversely related to specificity
  • If a test has high sensitivity ? more true positive, less false negative, and also more false positive. o If a test has high specificity ? more true negative, less false positive and also more false negative

Question.6

Annual new case detection rate of leprosy as on 31st March, 2016 is:

AIIMS PG Nov-2017
A. 0.66 /10,000 population
B. 0.66/1,00,000 population
C. 9.7/10,000 population
D. 9.7/1,00,000 population
Correct Ans: D
Explanation

Ans. d. 9.7/1,00,000 population

Annual new case detection rate of leprosy as on 31″ March, 2016 is 9.7/1,00,000 population.

NLEP – Annual Report for the year 2015-16:

  • Based on the reports received from all the States and UTs for the year of 2015 -16 (Annexure –I), current leprosy situation in the country is as below:
  • total of 127334 new cases were detected during the year 2015-16, which gives Annual New Case Detection Rate (ANCDR) of 9.71 per 100,000 population, as against 125785 cases in 2014-15.
  • A total of 86028 leprosy cases are on record as on 1st April 2016, giving a Prevalence Rate (PR) of 0.66 per 10,000 population, as against 88833 cases in 1 ‘April 2015.
  • Detailed information on new leprosy cases detected during 2015-16 indicates the proportion of MB (51.27%), Female (38.33%), Child (8.94%), Grade II Deformity (4.60%), ST cases (18.79%) and SC cases (18.57%).
  • A total of 5851 Gr. II disability detected amongst the New Leprosy Cases during 2015-16, indicating the Gr. II Disability Rate of 4.46 / million population (Annexure-II)
  • A total of 11389 child cases were recorded, indicating the Child Case rate of 8.94% (Annexure-III).

Question.7

Mid-day meals provided in schools provide ?

AIIMS PG Nov-2017
A. 1/2 of total calories & 1/2 of protein
B. 1/3 of total calories & 1/2 of protein
C. 1/2 of total calories & 1/3 of protein
D. 1/3 of total calories & 1/4 of protein
Correct Ans: B
Explanation

Ans. is `b’ i.e., 1/3rd of total calories & 1/2 of daily protein requirement


Question.8

Sampling error is classified as:

AIIMS PG Nov-2017
A. Alpha error
B. Beta error
C. Gamma error
D. Alpha error and Beta error
Correct Ans: D
Explanation

Ans: D. Alpha error and Beta error

Sampling error is a type of variation between one sample to another.

Due chance and concern either incorrect acceptance or rejection of null hypothesis.

Sampling errors arises because it is based on a part and not on the whole.

There are two types of sampling errors Type I or alpha error and type II or beta error.

The question is not specific, as it does not mention sampling error type I or type II we choose both alpha and delta.

Ref: Biostatistics By I.Saha and B. Paul, Page 74 ; Park’s Textbook of Preventive and Social Medicine By K.Park, 18th Edition, Page 648

Skin

Question.1

Hutchinson’s triad of congenital syphilis includes all of the following except

AIIMS PG Nov-2017
A. Eighth nerve deafness
B. Interstitial keratitis
C. Hutchinson’s teeth
D. Saddle nose
Correct Ans: D
Explanation

Ans. D. Saddle nose


Question.2

A child presented with complaint of severe itching over the web of fingers, more at night. Examination revealed burrows. Most probable diagnosis is:

AIIMS PG Nov-2017
A. Tinea cruris
B. Scabies
C. Infantile eczema
D. Papular urticaria
Correct Ans: B
Explanation

Ans. B: Scabies

Scabies is essentially a disease of the children. The itching appears a few days after infestation. It may occur within a few hours if the mite is caught a second time.

The itch is characteristically more severe at night and affects the trunk and limbs.

It does not usually affect the scalp.

Burrow is the pathognomic lesion of scabies.

Scabies burrows appear as tiny grey irregular tracks between the fingers and on the wrists.

They may also be found in armpits, buttocks, on the penis, insteps and backs of the heels. Microscopic examination of the contents of a burrow may reveal mites, eggs or mite faeces (scybala).


Question.3

All are true about Basal Cell Carcinoma EXCEPT:

AIIMS PG Nov-2017
A. MC site is upper lip
B. MC predisposing factor is UV rays
C. Fast growing malignant tumour
D. Basal cell carcinomas usually present as pearly papules
Correct Ans: C
Explanation

Ans: C. Fast growing malignant tumour

Most common site is upper eye lid REF: Bailey & Love’s 25th edition page 609, REF: Sabiston Textbook of Surgery, 18th ed, http:// emedicine.medscape.com/article/276624-overview

“Although most common cancer of the upper lip is basal cell carcinoma, most common site of basal cell carcinoma is not upper lip but nose”

BASAL CELL CARCINOMA:

  • Usually a slow-growing, locally invasive malignant tumour of pluripotential epithelial cells arising from basal epidermis and hair follicles, hence affecting the pilosebaceous skin
  • Epidemiology: The strongestpredisposing factor to BCC is UV Rays. The incidence of BCC therefore increases with proximity to the equator. It occurs in the middle-aged or elderly, with 90% of lesions found on the face above a line from the lobe of the ear to the corner of the mouth. Other predisposing factors include exposure to arsenical compounds, coal tar, aromatic hydrocarbons, IR and genetic skin cancer syndromes. White skinned people are almost exclusively affected.

Body distribution:

  • On the head (most frequently on the face ; most common location is the nose, specifically the nasal tip and alae) — 70%
  • On the trunk — 25%
  • On the penis, vulva, or perianal skin – 5%

Spread:

  • BCCs commonly infiltrate locally but rarely metastasize (0.028-0.55%).

Characteristics:

  • Lesion near inner canthus with raised, pearly borders and central crust and with telangiectasia on surface of the lesion is highly suggestive of basal cell carcinoma.
  • “Basal cell carcinomas usually present as pearly papules containing prominent dilated subepidermal blood vessels (telangiectasias). Some tumors contain melanin and superficially resemble melanocytic nevi or melanomas. Advanced lesions may ulcerate, and extensive local invasion of bone or facial sinuses may occur after many years of neglect or in unusually aggressive tumors, explaining the archaic designation rodent ulcers.”                                                                       

Question.4

Condition shown in the Photograph is a late complication of 

AIIMS PG Nov-2017
A. Lung cancer
B. Pancreatic cancer
C. Grave’s disease
D. Addison’s disease
Correct Ans: C
Explanation

Ans:C.) Graves disease

Condition shown in the image is Pretibial Myxoedema

Pretibial myxedema /thyroid dermopathy

  • It is a term used to describe localized lesions of the skin resulting from the deposition of hyaluronic acid, usually as a component of thyroid disease.
  • Although it is most often confined to the pretibial area, it may occur anywhere on the skin, especially the ankle, dorsum of the foot, knees, shoulders, elbows, upper back, pinnae, nose, and neck.
  • It is nearly always associated with autoimmune thyroid disease (ie, Graves Disease).Pretibial myxedema occurs in 0.5-4.3% of patients with Graves disease.
  • It has also been reported, but much less frequently, in patients with Hashimoto thyroiditis, primary hypothyroidism, and euthyroidism. 
  • Peak incidence occurs in the fifth to sixth decades of life.
  • Women are affected more frequently than men, with a female-to-male ratio of 3.5:1.

Question.5

A Patient Presented with Blister as shown in the diagram on their hand , feet and Mouth ? Most Probable Causative Organism 

AIIMS PG Nov-2017
A. Coxsackie – A virus
B. Coxsackie – B virus
C. EBV
D. CMV
Correct Ans: A
Explanation

Ans: A. Coxsackie – A virus

It is Hand Foot Mouth disease

Psychiatry

Question.1

A 30 year old manic patient was prescribed haloperidol one week back. For last two days he has become restless and kept pacing in the room for a day. One examination he was found to have tremors of hand. he is most likely suffering from-

AIIMS PG Nov-2017
A. Anhedonia
B. Dystonia
C. Restless leg syndrome
D. Akathisia
Correct Ans: D
Explanation

Ans. is ‘d’ i.e., Akathisia

Akathisia

  • Restlessness, feeling of discomfort, agitation (complete desire to move about), but without anxiety.
  • Between 1-8 weeks of therapy.
  • Treatment ? Propranolol is DOC (central anticholinergic is alternative).

Question.2

A patient believes he is the most important person in the world than anyone so his neighbors and family is trying to harm him as they are jealous of him. His wife says otherwise and says he behaves like this recently only before he was working as a school-teacher peacefully and brought to OPD. He is suffering from:

AIIMS PG Nov-2017
A. Delusion of grandiosity
B. Delusion of persecution
C. Delusion of grandiosity and persecution
D. Delusion of grandiosity, persecution and reference
Correct Ans: D
Explanation

Ans. d. Delusion of grandiosity, persecution and reference 

The given description suggests that the patient is having delusion of grandiosity, persecution and reference.

Delusion of grandeur

  • Exaggerated conception of one’s importance, power, or identity.

Delusion of persecution

  • False belief of being harassed or persecuted; often found in litigious patients who have a pathological tendency to take legal action because of imagined mistreatment.
  • MC delusion.

Delusion of reference

  • False belief that behavior of others refers to oneself or that events, objects, or other people have a particular unusual significance, usually of a negative nature
  • Derived from idea of reference, in which persons falsely feel that others are talking about them (e.g., belief that people on television or radio are talking to or about the person).

Question.3

The deliusion which involves replacement of a familiar person by someone else is ?

AIIMS PG Nov-2017
A. Capgras syndrome
B. Cotard syndrome
C. Othello syndrome
D. None
Correct Ans: A
Explanation

Ans. is ‘a’ i.e., Capgras syndrome

  • DSM is characterized by misidentification delusions of other or self. Four main syndromes are differentiated : ?
  1. Capgras syndrome (Delusion of double) : – Patient falsely sees a familiar person as a complete stranger who is importing on him as a familiar person.
  2. Fregoli syndrome (illusion de fregoli) : – The patient falsely identifies stranger as familiar person.
  3. Syndrome of subjective double : – The patients own self is perceived as being replaced by a double.
  4. Syndrome of intermetamorphosis : – A false belief that a person can transform into another person.
  • These syndrome most commonly appear in schizophrenia. Other causes are Alzheimer syndrome, head injuries, and delusional disorders.

Question.4

Which of the following is the test for immediate

AIIMS PG Nov-2017
A. Serial (100-7) subtraction test up to 5 steps
B. Digit span forward up to 7 digits with 2 skips allowed
C. Digit span backwards upto 5 digits with 2 skips allow ed
D. Serial (20-1) subtraction test up to 5 steps
Correct Ans: B
Explanation

Ans. b. Digit span forward up to 7 digits with 2 skips allowed

Test for immediate memory is digit span forward up to 7 digits with 2 skips allowed.

“Digit span forward is a good test of attention, concentration, and immediate memory. The examiner gives the patient a series of numbers of increasing length, beginning with 3 or 4, at a rate of about one per second; the patient is asked to repeat them. The numbers should be random, nor following any identifiable pattern, for example, a phone number. Backward digit span, having the patient repeat a series of numbers in reverse order, is a more complex mental process that involves working memory; it requires the ability to retail, and manipulate the string of numbers. Expected performance is 7 ± 2 forward and 5 ± I backward. Reverse digit span should not be more than two digits less than the forward span. Forward digit span is also a test of repetition and may be impaired in aphasic patients. Another test of attention and concentration is a three-step task. For instance, tear a piece of paper in half, then tear half of it in half then tear one half in half again, so that there are three different sizes. Give the patient an instruction such as, “Give the large piece of paper to me, put the small piece on the bed, and keep the other piece.” Another multistep task might be, “Stand up, face the door, and hold out your arms.”-


Question.5

A 50 year old male presents with a 3 year history of irritability, low mood, lack of interest in Surroundings and general dissatisfaction with everything. There is no significant disruption in his sleep or appetite. He is likely to be suffering from:

AIIMS PG Nov-2017
A. Major depression
B. No psychiatric disorder
C. Dysthymia
D. Chronic fatigue syndrome
Correct Ans: C
Explanation

Ans: C i.e. Dysthymia

Long standing atleast for 2 years (1 year in children & adolescents) of low grade subthreshold depressive symptoms (not severe enough to be called major depression) exclusive of indicators of severity (such as suicidality and psychomotor disturbance and featuring symptoms more than signs (i.e. more subjective than objective)Q indicate diagnosis of dysthymic disorder. Absence of psychomotor agitation or retardation and uncharacteristic (very very rare) presence of marked disturbances in libido & appetite differentiate it from major depression in which these features are relatively more commonQ.

Dysthymia (Meaning bad mood/ill humored) Disorder

Clinical Pincture

  • Long standing insidious onset sub threshold depression of fluctuating or persistent nature dating back to late childhood or the teens, preceding any major depressive episodes by years, even decades.A return to low grade depressive pattern is the rule following recovery from superimposed major depressive episodes, if any, hence the name double depression.
  • Low grade chronic depressive profile marked by fluctuating complaint consisting of gloominess, pessimism, lethargy (low drive), self doubt, lack of joie de vivre (i.e. low enjoyment of life), yet endowed with self critical attitudes & suffering for others.
  • Typically work hard (back bone of society), devoting their lives to jobs that require dependability & great attention to detail, but do not enjoy their work. At their best, they invest what ever energy they have in work, leaving none for leisure or social activities.
  • They are satisfied with nothing, complain of everything and brood about their usefullness of existence. Their entire existence is a burden for them.
  • Often complain of having been depressed since birth. They view themselves as belonging to an aristocracy of suffering. These hyperbolic descriptions of suffering in absence of more objective signs of depression label them characterological depression.
  • Both ICD-10 & DSM-IV stipulate a 2 year duration of low grade depressive symptoms (not severe enough to be called major depression) exclusive of such indicators of severity as suicidality and psychomotor disturbance
  • Differs from major depression in that symptoms tend to outnumber signs (more subjective than objective depression)Q. So marked disturbances in libido and appetite are uncharacteristic, and psychomotor agitation or retardation is not observedQ.
  • Other differential diagnosis, chronic fatigue syndrome present with disabling fatigue & typically deny depressive symptoms; patients with fibromyalgia complain of pain; by contrast typical dysthymic patient cannot stop relating to physician their titany of depressive symptoms. Polysomnography may differentiate fibromyalgia from dysthymia

Radiology

Question.1

A patient presented with shortness of breath and chest pain after falling from a height and trauma over the chest region.Chest Xray shows the following features.What can be the most probable diagnosis?

AIIMS PG Nov-2017
A. Pleural Effusion
B. Normal X ray
C. Pneumothorax
D. Subcutaneous Emphysema
Correct Ans: C
Explanation

Ans:C.)Pneumothorax.

Chest Xray in the image shows:

  • Visible pleural edge (green arrow)
  • Lung markings not visible beyond this edge.
  • Left sided rib fracture (yellow arrow)
  • The trachea and mediastinal structures are not displaced so there is no ‘tension’.
  • Probable diagnosis is Left sided Pneumothorax due to rib fracture.

Question.2

Which of the following is most frequently associated with the typical form of carcinoid syndrome ?

AIIMS PG Nov-2017
A. Foregut carcinoid
B. Midgut carcinoid
C. Hindgut carcinoid
D. None of the above
Correct Ans: B
Explanation

Ans: B. Midgut carcinoid

Midgut carcinoids are argentaffin-positive and have a high serotonin content. They most frequently cause the typical carcinoid syndrome when they metastasize.

Reference: Harrisons Principles of Internal Medicine, 18th Edition, Page 3058


Question.3

A 60 year old woman ,suffering from hypertension and with a history of smoking presented with a severe headache,which is according to her,the worst headache felt in her life.CT scan findings are shown in the image.In the second image,the site of hemoorhage in the brain is shown.What can be the most common cause for this condition?

AIIMS PG Nov-2017
A. AV malformation.
B. Aneurysm.
C. Hypertension.
D. Cavernous angioma.
Correct Ans: B
Explanation

Ans:B.)Aneurysm.

The condition shown in the picture above represents Subarachnoid hemorrhage.

CT scan in the image shows:

  • There is high-attenuation blood in the Sylvian fissures (blue arrows) and the interhemispheric fissure (red arrow) seen on this non-contrast enhanced CT of the brain. Do not confuse normal, physiologic calcifications (white and black arrows) for blood. There is high-attenuation blood in the Sylvian fissures (blue arrows) and the interhemispheric fissure (red arrow) seen on this non-contrast enhanced CT of the brain. Do not confuse normal, physiologic calcifications (white and black arrows) for blood.

Most common cause of subarachnoid hemorrhage is Aneurysm.

Subarachnoid hemorrhage

Clinical presentation

  • Patients typically present with a thunderclap headache, usually the worst headache of their lives. It is often associated with photophobia and meningism. In a substantial number of patients (almost half 2), it is associated with collapse and loss of consciousness, even in those patients who subsequently regain consciousness and have a good grade.
  • Focal neurological deficits often present either at the same time as a headache or soon thereafter .
  • Patients can be graded into 5 groups based on their clinical presentation, using the commonly employed Hunt and Hess grading system, which is predictive of outcome.

Aetiology

  • trauma (with associated cerebral contusion): traumatic subarachnoid haemorrhage
  • spontaneous
  • ruptured berry aneurysm: 85%
  • perimesencephalic haemorrhage :10%
  • arteriovenous malformation
  • dural arteriovenous fistula
  • spinal arteriovenous malformation
  • venous infarction
  • intradural arterial dissection
  • pituitary apoplexy
  • cocaine use
  • cerebral vasculitis

Risk factors

  • Vasculitis
  • Fibromuscular dysplasia (FMD)
  • Hypertension
  • History of polycystic kidney disease
  • Smoking
  • heavy alcohol consumption

Anaesthesia

Question.1

Afferent nerve fibre affected by local anesthesia first

AIIMS PG Nov-2017
A. Type A
B. Type Il – B
C. Type C
D. Type II
Correct Ans: C
Explanation

Ans: C i.e. Type C


Question.2

Which of the following is a controlled delivery device which is used to deliver a fixed concentration of oxygen?

AIIMS PG Nov-2017
A. Venturi mask
B. Nasal cannula
C. Nasal mask
D. Non breathing mask
Correct Ans: A
Explanation

Ans: A. Venturi mask

Venturi mask is a type of HAFOEmask (High Air Flow Oxygen Enrichment Devices).

It is used to deliver a controlled oxygen concentration to a patient.

The patient breathes a fixed concentration of oxygen enriched air because

the gas flow is greater than the peak inspiratory flow rate of the patient.

Thus there is minimal dilution from atmospheric air.

The high gas flow flushes expired gas from the mask preventing rebreathing.

Nasal cannula isused when a low-flow of oxygen is indicated.

These do not increase dead space.

Inspiratory oxygen concentration depends on the flow rate. No rebreathing occurs.

Non-rebreathing mask has a one way valve prevents the exhaled air from entering the reservoir bag.

It provides the patient with enriched oxygen during inhalations.

Nasal masks are effective interfaces for non invasive positive pressure ventilation (NIPPV) in most pediatric patients.

It allows better removal of CO2.



Question.3

During rapid induction of anesthesia ?

AIIMS PG Nov-2017
A. Sellick’s maneuver is not required
B. Pre-oxygenation is mandatory
C. Suxamethonium is contraindicated
D. Patient is mechanically ventilated before endotracheal intubation
Correct Ans: B
Explanation

Ans. is ‘b’ i.e., Pre-oxygenation is mandatory

  • During rapid sequence induction preoxygenation is done for full 3 minutes. Sch is the muscle relaxant of choice for intubation. Sallieck’s maneuver is done to prevent aspiration. Manual ventilation before intubation is avoided as this inflates the stomach and encourages regurgitation & aspiration.

Rapid sequence anaesthesia

  • When anaesthesia is given for emergency surgery, it is called a “rapid sequence anaesthesia”. The patients have full stomach because there is no starvation for anaesthesia (it is an emergency surgery) and gastric emptying is delayed due to trauma, acute abdomen. Therefore, the objective of rapid sequence anaesthesia is to secure the airway rapidly and prevent aspiration of gastric contents.
  • Procedure of rapid sequence has following steps : –
  • Li The patient is preoxygenatedfor full 3 minutes.
  • Intravenous induction agent (thiopentone or propofol) is given.
  • Sellick’s maneuver (cricoid/pressure) is done to prevent aspiration.
  • After ensuring the correct position of tube cricoid pressure is released and maintenance anaesthesia (NCO 66%, 02% 33%, & inhalational agent) is given. A non-depolarizing blocker is now added.
  • Suxamethenium (succinylcholine) is given as it quickly relaxes the laryngeal muscles so that rapid intubation can be done.
  • Not done during rapid sequence anaesthesia : ?
  1.  Manual ventilation before intubation is avoided as this inflates the stomach and encourages regurgitation & aspiration.
  2.  Premedications are not given.

Question.4

Tracheal secretions should be suctioned for:

AIIMS PG Nov-2017
A. 10-15 seconds
B. 60 seconds
C. 30 seconds
D. 3 minutes
Correct Ans: A
Explanation

Ans. a. 10-15 seconds

(Ref Current DiMMOCIC and Treatment Critical Care 3/e p255)

  • Tracheal secretions should he suctioned limiting the time to less than 10-15 seconds. The patient should be preoxygenated with 100% oxygen for at least a minute, and the total suction time should be limited to no more than 10-15 seconds on each attempt.

Question.5

All of the following are induction agents except: 

AIIMS PG Nov-2017
A. Thiormtal
B. Halothane
C. Nitrous oxide
D. Propofol
Correct Ans: C
Explanation

Ans. C: Nitrous oxide

  • General anaesthesia can be induced by intravenous (IV) injection, or breathing a volatile anaesthetic through a facemask (inhalational induction).
  • Onset of anaesthesia is faster with IV injection than with inhalation, taking about 10-20 seconds to induce total unconsciousness.
  • This has the advantage of avoiding the excitatory phase of anaesthesia, and thus reduces complications related to induction of anaesthesia.
  • An inhalational induction may be chosen by the anesthesiologist where IV access is difficult to obtain, where difficulty maintaining the airway is anticipated, or due to patient preference (e.g. children).
  • Commonly used IV induction agents include propofol, sodium thiopental, etomidate, and ketamine.
  • The most commonly-used agent for inhalational induction is sevoflurane because it causes less irritation than other inhaled gases
  • In order to prolong anaesthesia for the required duration (usually the duration of surgery), anaesthesia must be maintained. Usually this is achieved by allowing the patient to breathe a carefully controlled mixture of oxygen, nitrous oxide, and a volatile anaesthetic agent or by having a carefully controlled infusion of medication, usually propofol, through an IV.

Induction Characteristics & Dosage Requirements for Currently Available

Sedative & Hypnotic Drugs

Drug Name

Induction Dose (mg/kg)

Onset (sec)

Duration (min)

Thiopental

3-6

<30

5-10

Methohexital

1-3

<30

5-10

Propofol

1.5-2.5

15-45

5-10

Midazolam

0.2-0,4

30-90

10-30

Diazepam

0.3-0.6

45-90

15-30

Lorazepam

0.03-0.06

60-120

60-120

Etomidate

0.2-0.3

3-12

3-12

Ketamine

1-2

10-20

10-20


Question.6

A patient who was on ventilator and being ventilated for past few days, suddenly pulls out the endotracheal tube. What is the next step of management?

AIIMS PG Nov-2017
A. Assess the patient, give bag and mask ventilation and look for spontaneous breathin
B. Start bag and mask ventilation and reintubate
C. Sedate and reintubate
D. Make him sit and do physiotherapy
Correct Ans: A
Explanation

Ans. a. Assess the patient, give bag and mask ventilation and look for spontaneous breathing

In self-extubation, assess the patient, give bag and mask ventilation and look for spontaneous breathing.

Unplanned Extubation

  • Unplanned extubation of mechanically ventilated patients is relatively common
  • Self-extubation refers to the patient’s action, who deliberately removes the endotracheal tube (MC type of unplanned extubation, typically occur at night)
  • Accidental extubation is attributed either to personnel’s inappropriate manipulation of the tube during patient care or to a non-purposeful patient’s action, e.g. coughing (mostly occur in the morning)

 

Risk Factors for Unplanned Extubation
Patient factors Staff factors

Male

Delirium

Light sedation

Difficulty in securing tube (e g. facial swelling, facial burns)

Previous unplanned extubation

Junior staff

Nurse-to-patient ratio

Inadequately secured endotracheal tube

and/or checks

Internal Medicine

Question.1

Absent P Wave is seen in:

AIIMS PG Nov-2017
A. Atrial Fibrillation
B. Cor-pulmonale
C. Mitral Stenosis
D. COPD
Correct Ans: A
Explanation

Answer is A (Atrial Fibrillation)

P wave is typically absent in Atrial Fibrillation. COPD and Cor-Pulmonale are associated with tall p waves from Right Atrial Enlargement (P-Pulmonale) while Mitral Stenosis is typically associated with a wide and notched p wave from Left Atrial Enlargement (P-Mitrale)

Causes of Absent Wave:

  • Atrial fibrillation (p’ wave is absent or replaced by fibrillary T wave)
  • Atrial flutter (p’ wave is replaced by flutter wave, which shows saw-tooth appearance).
  • SA block or sinus arrest
  • Nodal rhythm (usually abnormal, small p wave).
  • Ventricular ectopic and ventricular tachycardia.
  • Supraventricular tachycardia (p’ wave is hidden within QRS, due to tachycardia).
  • Hyperkalemia.
  • Idioventricular rhythm 

Right Atrial Enlargement(RAE) is typically associated with tall P waves

P Pulmonale

(COPD and Cor-Pulmonale are associated with tall p waves from RAE)

 

Left Atrial enlargement(LAE) is typically associated with wide P waves

P Mitrale

(Mitral Stenosis is typically associated with a wide and notched p wave from LAE

 


Question.2

The most sensitive index for renal tubular function is:

AIIMS PG Nov-2017
A. Specific gravity of urine
B. Blood urea
C. GFR
D. Creatinine clearance
Correct Ans: A
Explanation

Ans: A i.e. Specific gravity of urine

The main function of renal tubules is concentration of urine and this can be measured by specific gravity of urine.


Question.3

A patient developed sudden severe headache two hours ago and become unconscious. Upon regaining conscious, patient developed photophobia and neck rigidity, What is the next line of management?

AIIMS PG Nov-2017
A. Non-contrast CT scan
B. IV antibiotics
C. Lumbar puncture
D. IV mannitol
Correct Ans: A
Explanation

Answer- A. Non-contrast CT scan

Diagnosis:

  • Noncontrast CT scan: Investigation of choice (Lumbar puncture is not indicated prior to an imaging procedure)
  • CSF picture: Hallmark of aneurysmal rupture is blood in CSF (Xanthochromic spinal fluid)
  • Lumbar puncture should be performed if the CT scan fails to establish the diagnosis of SAH and no mass lesion or obstructive hydrocephalus is found to establish the presence of subarachnoid blood.

Question.4

Loud S1 in Mitral stenosis is seen in-

AIIMS PG Nov-2017
A. Prolonged flow through mitral valve
B. 1st degree heart block
C. Calcification of the valve
D. Immobilization of the valve
Correct Ans: A
Explanation

Ans. is ‘a’ i.e., Prolonged flow through mitral valve

  • Siis louder in Mitral stenosis because AV flow is prolonged.
  • The loud Si in mitral stenosis usually signifies that the mitral valve is pliable and that it remains open at the onset of isovolumetric contraction because of the elevated left atrial pressure.

S1 can be soft even in the presence of mitral stenosis, when the anterior mitral leaflet is immobile and rigid due to calcification.


Question.5

Which of the following physical signs is seen in a patient with severe aortic stenosis:

AIIMS PG Nov-2017
A. Opening snap
B. Diastolic rumble
C. Holosystolic murmur
D. Delayed peak of systolic murmur
Correct Ans: D
Explanation

Answer is D (Delayed peak of systolic murmur)

The ejection systolic murmur starts after the ejection click reaches a peak in midsystole.

With increasing severity of aortic stenosis the peak gets delayed so that the maximum intensity of the murmur is closer to the end rather than being midsystolic.

The murmur of aortic stenosis (AS) is characteristically an ejection (mid) systolic murmur that commences shortly after the S,, increases in intensity to reach a peak toward the middle of ejection, and ends just before aortic valve closure. It is characteristically low-pitched, rough and rasping in character, and loudest at the base of the heart, most commonly in the second right intercostal space. It is transmitted upward along the carotid arteries. Occasionally it is transmitted downward and to the apex, where it may be confused with the systolic murmur of mitral regurgitation (MR) (Gallavardin effect).

Tis may cause differnce in Blood pressure recording in left and right arms.


Question.6

Which of the following condition is associated with normal anion gap metabolic acidosis?

AIIMS PG Nov-2017
A. Cholera
B. Starvation
C. Lactic acidosis
D. Ethylene glycol poisoning
Correct Ans: A
Explanation

Ans: A. Cholera

A normal anion gap metabolic acidosis is caused by the loss of bicarbonate with a reciprocal increase in chloride concentration.

It is also known as hyperchloremic acidosis. It most commonly results from abnormal gastrointestinal or renal losses of HCO3–.

Diarrhea is the most common cause of hyperchloremic metabolic acidosis.

Cholera is associated with massive diarrhea.

This diarrheal fluid consist of small bowel, biliary, and pancreatic fluids which contains 20–50 mEq/L of HCO 3 –. This loss of large volumes of fluids lead to hyperchloremic metabolic acidosis.  

Ref: Harrison’s Internal Medicine, 18th Edition, Chapter 47 ; Current Diagnosis & Treatment Emergency Medicine, 7th Edition, Chapter 44

Question.7

A patient suffers from shortness of breath, weakness, lightheadedness, and cough 24 hours after a heart surgery.ECG shows the following features.What can be the most probable diagnosis?

AIIMS PG Nov-2017
A. Myocardial Infarction
B. Complete Heart Block
C. Myocardial Ischemia
D. Cardiac Tamponade
Correct Ans: D
Explanation

Ans:D.)Cardiac Tamponade.

ECG in the image shows: Electrical alternans as seen by changing QRS amplitudes best seen in lead II ,it is suggestive of Cardiac Tamponade.

Cardiac tamponade.

  • It is when fluid in the pericardium (the sac around the heart) builds up and results in compression of the heart.

Symptoms:

  • typically include those of cardiogenic shock including shortness of breath, weakness, lightheadedness, and cough.

Cause:

  • Cardiac tamponade is caused by a large or uncontrolled pericardial effusion, i.e. the buildup of fluid inside the pericardium.
  • This commonly occurs as a result of chest trauma (both blunt and penetrating), but can also be caused by myocardial rupture, cancer, uremia, pericarditis, or cardiac surgery,retrograde aortic dissection

Diagnosis:

  • It may be suspected based on low blood pressure, jugular venous distension, pericardial rub, or quiet heart sounds.
  • The diagnosis may be further supported by specific electrocardiogram (ECG) changes, chest X-ray, or Echocardiography

ECG findings shows a triad of:

  • Low QRS voltage
  • Tachycardia
  • Electrical alternans.
    • Electrical alternans occurs when consecutive, normally-conducted QRS complexes alternate in height.
    • the heart swings backwards and forwards within a large fluid-filled pericardium.

Treatment:

  • When tamponade results in symptoms, drainage is necessary.
  • This can be done by pericardiocentesis, surgery to create a pericardial window, or a pericardiectomy

Question.8

Coxsackie group A does not cause ?

AIIMS PG Nov-2017
A. Conjunctivits
B. Aseptic meningitis
C. Hepatitis
D. H.F.M.D
Correct Ans: B
Explanation

Ans. is ‘b’ i.e., Aseptic meningitis

  • In general, group A coxsackieviruses tend to infect the skin and mucous membranes, causing herpangina; acute hemorrhagic conjunctivitis; and hand, foot, and mouth (HFM) disease.
  • Both group A and group B coxsackieviruses can cause nonspecific febrile illnesses, rashes, upper respiratory tract disease, and aseptic meningitis.
  • Group B coxsackieviruses tend to infect the heart, pleura, pancreas, and liver, causing pleurodynia, myocarditis, pericarditis, and hepatitis (inflammation of the liver not related to the hepatotropic viruses). Coxsackie B infection of the heart can lead to pericardial effusion.
  • Aseptic meningitis is caused by all types group B Coxackies viruses and by many group ‘A’ Coxsakie viruses most commonly A7 and A9.
  • History of fever and headache with neck stiffness suggest the diagnosis of meningitis. C’SF analysis findings of increased opening pressure, mildly increased proteins, normal glucose, increased lymphocytes are highly suggestive of viral (Coxsackie virus) meningitis. Meningitis with normal glucose is highly suggestive of viral meningitis
  • Acute hemorrhagic conjuctivitis can be caused by Coxsackie virus A-24, but it is not common. Mostly it is caused by enterovirus – 70.
  • Myocarditis and hepatitis are mainly caused by Coxsackie virus group B.

Question.9

An alcoholic patient presented with the following condition of Abdomen.On examination,fluid thrill is present.SAAG is more than 1.1 g/dL.What can be the probable cause out of following options?

AIIMS PG Nov-2017
A. Cirrhosis
B. Primary peritoneal carcinomatosis
C. Pancreatitis.
D. Serositis
Correct Ans: A
Explanation

Ans:A.)Cirrhosis.

The patient in question is suffering from Ascites.

Ascites

  • It is a gastroenterological term for an accumulation of fluid in the peritoneal cavity that exceeds 25 mL.

Physical examination:

  • Ascites is detected on physical examination of the abdomen by visible bulging of the flanks in the reclining patient (“flank bulging”), “shifting dullness” (difference in percussion note in the flanks that shifts when the patient is turned on the side) or in massive ascites with a “fluid thrill” or “fluid wave” (tapping or pushing on one side will generate a wave-like effect through the fluid that can be felt in the opposite side of the abdomen).

Causes
Serum-ascites albumin gradient (SAAG) :

  • A high gradient (> 1.1 g/dL) indicates the ascites is due to portal hypertension. A low gradient (< 1.1 g/dL) indicates ascites of non-portal hypertensive as a cause.

Causes of high SAAG (“transudate”) are:

  • Cirrhosis – 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%)
  • Heart failure – 3%
  • Hepatic venous occlusion: Budd–Chiari syndrome or veno-occlusive disease
  • Constrictive pericarditis
  • Kwashiorkor (childhood protein-energy malnutrition)

Causes of low SAAG (“exudate”) are:

  • Cancer (metastasis and primary peritoneal carcinomatosis) – 10%
  • Infection: Tuberculosis – 2% or spontaneous bacterial peritonitis
  • Pancreatitis – 1%
  • Serositis
  • Nephrotic syndrome
  • Hereditary angioedema

Other rare causes:

  • Meigs syndrome
  • Vasculitis
  • Hypothyroidism
  • Renal dialysis
  • Peritoneum mesothelioma
  • Abdominal tuberculosis

Complications of Ascites:

  • Spontaneous bacterial peritonitis(most common)
  • Hepatorenal Syndrome
  • Thrombosis

Question.10

A young donor came to the blood bank for the first time for platelet apheresis with platelet count of 1.9L. During the course he developed paresthesias, circumoral numbness during donation. His vitals remain stable though. ECG showed tachycardia with ST-T changes. What is the reason for his symptoms?

AIIMS PG Nov-2017
A. Hypovolemic shock
B. Hypocalcemia
C. Seizures
D. Allergic reaction
Correct Ans: B
Explanation

Ans. b. Hypocalcemia

  • Clinical findings of paresthesias, circumoral numbness and ECG showing tachycardia with ST-T changes are highly suggestive of hypocalcemia, which has been caused by extensive transfusion of citrated blood.
  • “Citrate, commonly used to anticoagulate blood components, chelates calcium and thereby inhibits the coagulation cascade. Hypocalcemia, manifested by circumoral numbness and/or tingling sensation of the fingers and toes, may result from multiple rapid transfusions.”-H,
  • “Transient hypocalcemia is seen with severe sepsis, burns, acute kidney injury, and extensive transfusions with citrated blood.

Question.11

A fifth to sixth decade male patient presented with the following clinical examination of an eye as shown in the picture below.The most probable diagnosis is? 

AIIMS PG Nov-2017
A. Myasthenia gravis.
B. Graves disease.
C. Polymyalgia rheumatica.
D. Sjogren’s syndrome.
Correct Ans: A
Explanation

Ans: A. Myasthenia gravis.

A drooping eye-lid is the most frequent early sign of Myasthenia gravis as represented in the picture above.

Myasthenia gravisis a rare long-term condition that causes certain muscles to become weak.It mainly affects muscles that are controlled voluntarily – often those controlling eye and eyelid movement, facial expression, chewing, swallowing and speaking.Sometimes, the muscles that control breathing, neck and limb movements are also affected. The muscle weakness associated with myasthenia gravis is usually worse during, or just after, physical activity and improves with rest. The symptoms are often described as being at their worst when a person is tired, for example, at the end of the day.

Clinical Features

  • Weakness and fatigability of skeletal muscles.
  • Fluctuating weakness of voluntary muscle.
  • Lids and extracocular muscle of eyelid- diplopia and ptosis.

There may be eyelid drooping (ptosis due to weakness of levator palpebrae superioris) and double vision (diplopia) due to weakness of the extraocular muscles).
The term “ocular myasthenia gravis” describes a subtype of MG where muscle weakness is confined to the eyes, i.e. extraocular muscles, levator palpebrae superioris, and orbicularis oculi.

  • Facial weakness produces snarling expression.
  • Tongue weakness leads to dysarthric mushy quality.
  • Bulbar weakness.
  • Myaesthenic crisis

Question.12

Drugs not used for treatment of acute hyperkalemia –

AIIMS PG Nov-2017
A. Insulin + glucose
B. Potassium exchange resins
C. Calcium carbonate
D. Sodium bicarbonate
Correct Ans: B
Explanation

Ans: B. Potassium exchange resins

Potassium exchange resins [Ref : Harrison 17’Ve p. 84; CMDT 2007 p. 899] Repeat from May 10 Q no. 101.

EMERGENCY

Modality

Mechanism of action

Onset

Duration

Calcium

gluconate

Antagonizes cardiac

conduction abnormalities

0-5 minutes

1 hour

Sodium

Bicarbonate

Distributes K+ into cells (only

indicated with acidosis )

15-30 minutes

1-2 hours

Insulin

Distributes K+ into cells

15-60 minutes

4-6 hours

Albuterol

Distributes K+ into cells

15-30 minutes

2-4 hours

NONEMERGENCY

Modality

Mechanism of action

Duration of treatment

Loop diuretic

I Renal K+ excretion

0.5-2 hours

Sodium polystyrene

sulfonate (kayexalate)

Ion-exchange resin binds K+

1-3 hours

Hemodialysis

Extracorporeal K+ removal

48 hours

Peritoneal dialysis

Peritoneal K+ removal

48 hours

Surgery

Question.1

Which of these is the most reliable method for monitoring fluid resuscitation?

AIIMS PG Nov-2017
A. Urine output
B. CVP
C. Pulse rate
D. Blood pressure
Correct Ans: A
Explanation

Ans: A. Urine output

(Ref Harrison 19/e p1747, 18/e p2219; Sabiston 20/e p520, I9/e p72-84; Schwartz 10/e p169, 9/e p91-102; Bailey 27/e p17, 26/e p18, 25/e p13-16)

Goal of treatment:

  • Restore cellular and organ perfusion.
  • Hence, monitoring of organ perfusion should guide the management of shock.
  • The best measures of organ perfusion and the best monitor of the adequacy of shock therapy remains the urine output.

Question.2

Shock index (HR/SBP) can be used to know the severity of the bleeding in cases of hemorrhage. Which of the following is most indicative for significant PPH

AIIMS PG Nov-2017
A. 0.3-0.5
B. 0.5-0.7
C. 0.7-0.9
D. 0.9-1.1
Correct Ans: D
Explanation

Ans. d. 0.9-1.1

  • elevated shock index (heart rate/systolic blood pressure >0.9) maybe signs of tissue hypoperfusion

Shock Index

  • Shock index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP).
  • Shock index >0.9: Sign of tissue hypoperfusionQ
  • Shock index (SI) = Heart rate (HR)/ Systolic blood pressure (SBP)

Question.3

A patient had a massive bleeding during surgery. Which sized cannula should be used?

AIIMS PG Nov-2017
A. 16 Gauge
B. 20 Gauge
C. 22 Gauge
D. 24 Gauge
Correct Ans: A
Explanation

Ans: A. 16 Gauge

(Ref Bailey 25/e p291)

  • In a patient with massive bleeding, there is always a risk of patient going into shock and widest bore cannula available showed be used for cannulation.
  • The ACLS guidelines recommend securing intravenous access with two large-bore cannulae (14–I6G) in patient needing resuscitation.

Gauge

Color code

External Diameter

Length

Flow Rate

14G

Orange°

2.1 mm

45 mm

240 ml/min

16G

Grey(‘

1.8 mm

45 mm

180 ml/min

18G

Green°

1.3 mm

32/45 mm

90 ml/min

20G

Pink°

1.1 mm

32 mm

60 ml/min

22G

Blue°

0.9 mm

25 mm

36 ml/min

24G

Yellow°

0.7 mm

19 mm

20 ml/min

26G

Violee

0.6 mm

19 mm

13 ml/min


Question.4

For the transport of traumatized and conscious patient all the following are done except:

AIIMS PG Nov-2017
A. On a hard board with head/spine stabilized
B. In lateral lying position
C. Talk to patient while he is on board
D. Rolling without moving the spine
Correct Ans: B
Explanation

Ans. b. In lateral lying position

  • In patients of trauma, maintaining the patient in a supine flat position at all times protects the thoracic, lumbar, and sacral segments of the spine. That’s why patient should not be put in lateral lying down position.
  • “Cervical spine protection includes the use of a hard cervical collar and the maintenance of the log roll technique for all movement of the patient
  • “Spinal immobilization with a rigid cervical collar and a long spine board is an immediate priority far pre-hospital personnel as a scene is approached.

Question.5

In a school bus accident, which of the following victim you will attend first?

AIIMS PG Nov-2017
A. A child with airway obstruction
B. A child with shock
C. A child with flail chest
D. A child with severe head injury
Correct Ans: A
Explanation

Ans. a. A child with airway obstruction

  • The first priority in management of a case trauma is airway maintenance. Ensuring an adequate airway is the first priority in the primary survey of trauma.
  • “Following a defined order of assessment, life-threatening conditions are immediately addressed at the time of identification. This initial assessment, also termed the primary survey, follows the mnemonic ABODE: Airway and cervical spine protection, Breathing, Circulation , Disability or neurologic condition, Exposure and environmental control.”

Question.6

Black colour code is used in four colour code system of triage management in disaster for: 

AIIMS PG Nov-2017
A. Ambulatory patients
B. Low priority patients
C. Dead patients
D. High priority patients
Correct Ans: C
Explanation

Ans. C: Dead patients

Black colour in triage indicates dead/ moribund persons Triage

  • After disasters such as earthquakes, hurricanes and train wrecks, triage often includes a system of color coding.
  • The code changes in different countries and regions but four colors are almost universal:
  • Black indicates dead,
  • Red indicates that the patient needs immediate attention,
  • Green indicates that a patient has only minor injuries.
  • Yellow signals medium priority
  • Sometimes the coding medium is as simple as rolls of colored tape.
  • A person with some medical training–and a checklist–goes among the injured and wraps a strip of tape around the leg of an injured person.
  • The checklists for disaster situations tend to be simple and omit injuries that might be hidden by clothing.
  • Most ambulances are required to carry disaster triage checklists and color coding material

Question.7

A patient with head injury opens eyes on painful stimulus, uses inappropriate words and localizes pain. What is his GCS score:

AIIMS PG Nov-2017
A. 8
B. 10
C. 12
D. 14
Correct Ans: B
Explanation

Ans. B i.e. 10


Question.8

The 2010 AHA Guidelines for CPR during Basic Life Support for neonates Recommends:

AIIMS PG Nov-2017
A. Airway – Breathing – Compression (A-B-C)
B. Compression – Breathing- Airway (C-B-A)
C. Compression- Airway – Breathing (C-A-B)
D. Breathing – Airway – Compression (B –A-C)
Correct Ans: A
Explanation

Answer is A (Airway – Breathing – Compression (A-B-C))

The A-B-C (Airway – Breathing – Compression) sequence is still retained for neonates since cardiac arrests in neonates are nearly always from asphyxia.

The major Highlight of the 2010 AHA Guidelines for CPR is the Change from “A-B-C” to “C-A-B”. The newest development in the 2010 AHA Guidelines for CPR and ECC is a change in the basic life support (BLS) sequence of steps from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adults and paediatric patients (children and infants, excluding new-borns). However the A-B-C (Airway – Breathing –Compression) sequence is still retained for neonates since cardiac arrests in neonates are nearly always from asphyxia.

 

Adult Basic Life Support (BLS) Algorithm

Safety

Make sure you, the victim and any bystanders are safe

Response

Check the victim for a response

Airway

4

Open the airway

Breathing

Look, listen and feel for normal breathing for no more than 10 seconds°

Dial 999

,

Call an ambulance (999)

Send For AED

Send someone to get an AED if available

Circulation

Start chest compressions

 

Place heel of one hand in lower half of victim’s sternum Q

 

Place heel of your other hand on top of first hand°

 

Interlock the fingers of your hands & ensure that pressure is not applied over the victim’s ribs

 

Keep your arms straight; Position your shoulders vertically above the victim’s chest

 

Press down on sternum to a depth of 5-6 emQ

 

After each compression, release all the pressure on chest without losing contact between your hands

 

 

& sternum

 

Repeat at a rate of 100-120/min°

Give Rescue

After 30 compressions open the airway again using head tilt chin lift give 2 rescue breaths°

Breaths

 

•           Do not interrupt compressions by more than 10 seconds to deliver two breaths. Then

return your hands without delay to correct position on sternum give a further 30 chest

compressions Q

 

 

•           Continue with chest compressions rescue breaths in a ratio of 30:2°

 

If you are untrained or unable to do rescue breaths, give chest compression only CPR (i.e. continuous

compressions at a rate of at least 100-120/minQ)

If an AED

Switch on the AED follow the spoken/visual directions

Arrives

Ensure that nobody is touching the victim while AED is analyzing the rhythm

 

If a shock is indicated, deliver shock ensure that nobody is touching the victim

 

Immediately restart CPR at a ratio of 30:2°

 

If no shock is indicated, continue CPR°

 

Continue CPR

Do not interrupt resuscitation until:

 

A health professional tells you to stop ; You become exhausted

 

The victim is definitely waking up, moving, opening eyes and breathing normally

 

It is rare for CPR alone to restart the heart. Unless you are certain the person has recovered continue

 

 

CPR

Recovery

 

If you are certain the victim is breathing normally but is still unresponsive, place in the recovery

Position

 

position°


Question.9

Foley’s Catheter of size 16 F in French gauge system represents the measure:

AIIMS PG Nov-2017
A. 16 mm diameter at the tip
B. 16 mm inner diameter
C. 16 mm outer diameter
D. 16 mm circumference
Correct Ans: C
Explanation

Ans: C. 16 mm outer diameter

French scale or French gauge system is commonly used to measure the size (outside diameter) of a catheter.

It is most often abbreviated as Fr, but can often abbreviated as FR or F. 1 Fr = 0.33 mm, and therefore the diameter of the catheter in millimeters can be determined by dividing the French size by 3.

And since circumference is equal to the one third of diameter, catheter size of 16 F means 16 mm in diameter.
 
Foley’s catheter is sterilized by gamma radiation. Usually Foley’s catheter is kept for 7 days.
 
Size:
  • Adults— 16 F
  • Children— 8 F or 10 F

Question.10

All of the following are the components of WHO’s 19 point Surgical Safety Checklist, EXCEPT:

AIIMS PG Nov-2017
A. To have an Oximeter
B. Mark the correct site for surgery
C. Give an antibiotic within 60 minutes of making an incision
D. None of the above
Correct Ans: Select
Explanation

Ans: D. None of the above

WHO’s 19 point Surgical Safety Checklist,

prompts the surgical team at crucial moments to mark the correct site for surgery,

give an antibiotic within 60 minutes of making an incision,

check the patient for allergies, and count sponges and needles to ensure that none are left in a patient.

It has reduced complications by more than 30%.

The oximeter is a key component of WHO’s 19 point Surgical Safety Checklist,

 which substantially lowers deaths and complications from surgery.

The oximeter is the only thing on the checklist that must be paid for. 

Ref: Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med2009;360:491-9; A pulse oximeter for every operating theatre in India ; BMJ 2013;346:f676.

Question.11

Balanced resuscitation in trauma management is:

AIIMS PG Nov-2017
A. Giving colloids and crystalloids ratio of 1:1
B. Maintaining pH by ensuring acid base are balanced
C. Maintaining permissible hypotension to avoid bleed­ing
D. Maintaining airway, breathing and circulation simul­taneously
Correct Ans: C
Explanation

Ans. c. Maintaining permissible hypotension to avoid bleeding

  • Balanced resuscitation in trauma management is maintaining permissible hypotension to avoid bleeding.
  • “One of the most widely lauded and discussed advances in combat trauma care over the past decade has been a radical change in resuscitation strategy, now known as damage control resuscitation (DCR). The core principle of this strategy is to replace blood loss with a balanced resuscitation of red blood cells, plasma, platelets, and clotting factors. This is achieved by either the use of fresh whole blood or with component therapy including PRBCs, fresh frozen or thawed plasma, and platelets. The optimal ratio of administration of each type of product remains a matter of debate, with the current practice being to aim for 1:1:1 ratio starting with the initial administration and continuing through the early resuscitation period

Question.12

A lump in the abdomen has been diagnised as ‘desmoid tumor’. What is the most appropraite treatment?

AIIMS PG Nov-2017
A. Chemotherapy
B. Radiation
C. Chemotherapy and Radiation
D. Surgery
Correct Ans: D
Explanation

Ans: D. Surgery

  • Desmoid tumor arises from the musculoaponeurotic structures of abdominal wall.
  • It is removed by wide excision.
  • Desmoid tumor arises from the musculoaponeurotic structures of abdominal wall.
  • It is removed by wide excision.

Desmoid Tumour

Pathology:

  • Tumour is composed of fibrous tissue containing multinucleated plasmodia! masses resembling foreign body giant cells°.
  • Usually of very slow growth, it tends to infiltrate muscle in the immediate area°.
  • Eventually it undergoes a myxomatous change and it then increases in size more rapidly.
  • Metastasis does not occur°, no sarcomatous change°

Clinical Features:

  • Desmoids classically arise in pregnancy as an abdominal mass independent of uterus.
  • MC presentation: Abdominal mass
  • Affected patients may present with a painful versus asymptomatic firm mass, bowel obstruction, or bowel ischemia.

Diagnosis:

  • MRI is investigation of choice for extremity abdominal wall desmoids°.
  • Biopsy is required to establish the diagnosis.

Treatment:

  • Wide local excision (with 2 cm margin) is treatment of choice°.
  • Surgery Radiotherapy: For recurrent desmoid tumors°
  • Doxorubicin, dacarbazine, or carboplatin can produce remission in up to 50% of patients.

Prognosis:

  • Involvement of margins is associated with recurrence rates as high as 80%.

Question.13

Infection of all the following structures can be cause of Psoas abscess except-

AIIMS PG Nov-2017
A. Vertebrae
B. Appendix
C. Hip joint
D. Ribs
Correct Ans: D
Explanation

Ans is d. i.e. Ribs 

“Psoas Abscesses: The psoas muscle is another location in which abscesses are encountered. Psoas abscesses may arise from a hematogenous source, by contiguous .spread from an intra-abdominal or pelvic process, or by contiguous spread from nearby bony structures (e.g., vertebral bodies). Associated osteomyelitis due to spread from bone to muscle or from muscle to bone is common in psoas abscesses. When Pott’s disease was common, Mycobacterium tuberculosis was a frequent cause of psoas abscess. Currently, either S. aureus or a mixture of enteric organisms including aerobic and anaerobic gram-negative bacilli is usually isolated from psoas abscesses in the United States. S. aureus is most likely to be isolated when a psoas abscess arises from hematogenous spread or a contiguous focus of osteomyelitis; a mixed enteric flora is the most likely etiology when the abscess has an intra- abdominal or pelvic source. Patients with psoas abscesses frequently present with fever, lower abdominal or back pain, or pain referred to the hip or knee. CT is the most useful diagnostic technique


Question.14

Patient with history of tachyarrhythmias is on implantable cardioverter defibrillator. He develops shock. Best method to know the position and integrity of ICD is:

AIIMS PG Nov-2017
A. CECT
B. MRI
C. USG
D. Plain radiograph
Correct Ans: A
Explanation

Ans: A. CECT 

(Ref Hurst ‘s The Heart 13/e p1050)

Plain radiograph:

  • Best method to know ICD position & integrity.

ICD Lead dislodgement:

  • Radiographically visible.
  • Significant increase in pacing threshold /decline in electrogram amplitude.

Question.15

Follow ing a blunt trauma abdomen, a patient had renal laceration and urinoma. Even after 12 days, urinoma persisted, but patient was stable and there was no fever. Next step in management would be:

AIIMS PG Nov-2017
A. Percutaneous exploration and repair
B. Wait and watch
C. J-shaped urinary stent
D. Percutaneous nephrostomy
Correct Ans: C
Explanation

Ans. c. J-shaped urinary stent

  • Management of urinoma is by endoscopic intervention, with cystoscopy, retrograde pyelography, placement of a ureteral stent, urethral catheter drainage, and intravenous antibiotics.
  • “Although most post-traumatic urinomas are asymptomatic and have a spontaneous resolution rate approaching 85%, urinomas will occasionally persist.
  • Symptomatic urinomas will develop a classic triad of findings: ipsilateral flank pain, adynainic ileus, and a low-grade temperature.
  • Management of these patients is by endoscopic intervention, with cystoscopy, retrograde pyelography, placement of a ureteral stent, urethral catheter drainage, and intravenous antibiotics. When a ureteral stent is placed in conjunction with temporary placement of a urethral catheter, greater than 90% of the symptomatic urinomas will resolve.

Question.16

A female patient presented with left iliac fossa pain for the past 6 months. On investigation, a 3 cm left renal pelvic stone was found with no hydroureteronephrosis, normal functioning kidneys on both sides and no distal obstruction. The ideal management would be

AIIMS PG Nov-2017
A. Percutaneous nephrolithotomy (PCNL)
B. Extra-corporeal shock wave lithotripsy (ESWL)
C. Laparoscopic nephrolithotomy
D. Medical dissolution therapy with oral potassium citrate
Correct Ans: A
Explanation

Ans. a. Percutaneous nephrolithotomy

(Ref Campbell 10/e p1380-1381, 1399-1405; Bailey 26/e p1294, 25/e p1300-1302)

For patients with stone between 10 and 20 mm, ESWL can still be considered a first-line treatment unless factors of stone composition, location, or renal anatomy suggests that a more optimal outcome may he achieved with a more invasive treatment modality (PCNL or ureteroscopy). 

Patients with stone larger than 20 mm should primarily be treated by PCNL, unless specific indications for ureteroscopy are present (e.g. bleeding diathesis, obesity).”- Campbell 10/e p1381


Question.17

True about tumor lysis syndrome are A/E:

AIIMS PG Nov-2017
A. Hyperuricemia
B. Hypercalcemia
C. Hyperkalemia
D. Hyperphosphatemia
Correct Ans: B
Explanation

Answer is B (Hypercalcemia):

Tumor Lysis syndrome is characterized with hypocalcemia and not hypercakemia.


Question.18

The most common cause of SVC syndrome is ?

AIIMS PG Nov-2017
A. Thrombosis
B. Extrinsic compression
C. Mediastinal lymphoma
D. Teratoma
Correct Ans: B
Explanation

Ans. is ‘b’ i.e., Extrinsic compression

Superior venacava syndrome

  • ‘Superior vena caval syndrome’ or ‘SVCS’ is the clinical manifeststion of superior vena cava obstruction with severe reduction in venous return from head, neck and upper extremities.
  • Most common cause (90%) appears to be extrinsic compression from malignant tumors such as Lung cancer, Lymphoma, and Metastatic tumors. of the malignant tumors, most common tumors is Lung cancer or Bronchogenic Carcinoma, especially small cell Ca
  • In young adults, malignant lymphoma is the leading cause of SVCS.
  • Non-malignant causes of SVCS are include benign tumors, aortic aneurysm, thyromegaly, thrombosis and fibrosing mediastinitis from prior irradiation or histoplosmosis.
  • The diagnosis of superior vena cava (SVC) syndrome (SVCS) is a clinical one. The most significant chest radiographic finding is widening of the superior mediastinum, most commonly on the right side. Pleural effusion occurs in only 25% of patients, often on the right side. The majority of these effusions are exudative and occasionally chylous. However, a normal chest radiograph is still compatible with the diagnosis if other characteristic findings are present. Computed tomography (CT) provides the most reliable view of the mediastinal anatomy. The diagnosis of SVCS requires diminished or absent °pacification of central venous structures with prominent collateral venous circulation.

Question.19

While putting nasogastric tube, the length is measured from upper incisors. What is the distance from upper incisors to cardia of the stomach?

AIIMS PG Nov-2017
A. 15 cm
B. 25 cm
C. 40 cm
D. 60 cm
Correct Ans: C
Explanation

Ans: C. 40 cm

The esophagus is about 25 cm (10 in.) long. The distance from the upper incisor teeth to the beginning of the esophagus (cricoid cartilage) is about 15 cm (6 in.); from the upper incisors to the level of the bronchi, 22 to 23 cm (9 in.); and to the cardia, 40 cm (16 in.).
The commonly used method to measure nasogastric tube length is the NEX method. NEX: Nose–Ear–Xiphisternum.

“To measure the required length of tube, measure from the tip of the patient’s nose, to their ear, and then down to the xiphisternuni.”


Question.20

Characteristic features of superficial burns are all, except: 

AIIMS PG Nov-2017
A. Damage no deeper than papillary dermis
B. Blisters absent
C. Loss of epidermis
D. Pinprick is not painful
Correct Ans: D
Explanation

Ans. D. Pinprick is not painful

Pediatrics

Question.1

A 3 year old boy with normal developmental milestones with delayed speech and difficulty in communication and concentration. He is not making friends. Most probable diagnosis is ?

AIIMS PG Nov-2017
A. Autism
B. ADHD
C. Mental retardation
D. Specific learning disability
Correct Ans: A
Explanation

Ans. is ‘A’ i.e., Autism

Delayed speech, difficulty in communication and concentration in a 3 year old child suggests the diagnosis of autism.

Autism is characterized by impaired social interaction and communication, and by restricted and repetitive behavior. These signs all begin before a child is three years old.

Autism affects information processing in the brain by altering how nerve cells and their synapses connect and organize

It is one of three recognized disorders in the autism spectrum, the other two being Asperger syndrome, which lacks delays in cognitive development and language, and pervasive developmental Disorder-not otherwise specified (commonly abbreviated as PDD-NOS)


Question.2

Menke’s disease” is a disease of

AIIMS PG Nov-2017
A. Impaired zinc transport
B. Impaired copper transport
C. Impaired magnesium transport
D. Impaired molybdenum transport
Correct Ans: B
Explanation

Ans. is ‘b’ i.e., Impaired copper transport

Menke’s disease is caused due to defect in the copper transport.

  • There is defect in the transport of copper present in the intestinal mucosa to the blood stream.
  • The mucosal lining of intestine contains high level of copper bound to metallothionein protein.
  • Rather than being transporated to bloodstream, the copper remained in the mucosa and was lost when intestinal cells were naturally soughed off.

Menkes disease is caused due to defect in the “MNK” gene.

  • The protein normally function by moving copper from the intestinal mucosal cells into the blood stream, where it is hound by proteins such as albumin and transported to organs and tissues.

Serum copper is critical for the functioning of several enzymes

  • Lysyl oxidase  ? It is important for the cross linking of collagen and elastin such that deficiencies lead to problems in connective tissues such as bones
  • Cytochrome oxidase  ? Involved in temperature maintenance
  • Tyrosinase  ?  Necessary for pigmentation

Clinical features of menkes disease

  • Growth retardation
  • Coarse hair, brittle and ivory white (result of depigmentations). The hair fibres are twiisted and broken helically (kinky hair).
  • Seizures
  • Cerebral and cerebellar degeneration (postmortem analysis)
  • Hypothermia
  • Thrombosis
  • Poor bone development
  • Increased tendency towards aneurysms

Question.3

A 50-hour old full-term breast-fed newborn boy weighing 3100g presents with clinically evident jaundice. Physical examination is otherwise normal. The total bilirubin is 8.0 mg/dl with a direct bilirubin of 0.4 mg/dl. What would be the correct treatment –

AIIMS PG Nov-2017
A. Continue breast feeds and review after 48 hours
B. Stop breast feeds and review after 24 hours
C. Continue breast feeds and start blue-light phototherapy
D. Arrange for a double-volume exchange transfusion
Correct Ans: C
Explanation

Ans. is ‘c’ i.e., Continue breast feeds and start blue-light phototherapy

  • This is a case of breast milk jaundice.
  • Preferred treatment option for a 4 days old baby with bilirubin of 8 mg/dL is to continue breastfeeding and phototherapy.
  • Breast milk jaundice is a different disorder that causes persistently high indirect bilirubin in a thriving healthy baby that become evident later than breastfeeding jaundice, but which generally declines in the 2″d to 3′d week of life.
  • Infants with severe or persistent jaundice should be evaluated for problems such as galactosemia, hypothyroidism, urinary tract infection, and hemolysis before ascribing the jaundice to breast milk that might contain inhibitors of glucuronyl transferase or enhanced absorption of bilirubin from the gut.
  • Persistently high bilirubin can require changing from breast milk to infant formula for 24-48 hr and/or phototherapy without cessation of breastfeeding.
  • Breastfeeding should resume after the decline in serum bilirubin. Parents should be reassured and encouraged to continue collecting breast milk during the period when the infant is taking formula

Question.4

APGAR score – include A/E

AIIMS PG Nov-2017
A. Heart rate
B. Respiratory rate
C. Muscle tone
D. Color
Correct Ans: B
Explanation

Ans. is ‘b’ i.e., Respiratory rate


Question.5

A 3 yr old completely unimmunised child comes to an immunization clinic at PHC for the first time. He should receive –

AIIMS PG Nov-2017
A. BCG, Measles, Vitamin-A
B. DT-1, OPV-1, Measles, Vitamin-A
C. BCG, DPT-1, OPV-1, Measles, Vitamin-A
D. DPT-1, OPV-1, Measles, Vitamin-A
Correct Ans: D
Explanation

Ans. is ‘d’ i.e., DT-1, OPV-1, Measles, Vitamin-A 

Cases of Delayed Immunization:

  • A completely unimmunized child 9 months of age should receive: BCG, DPT-1 (next two doses one month apart each and booster after 1 year of 3rd dose), OPV-1 (next two doses one month apart each and booster after 1 year of r dose), HepB -1 (next two doses one month apart each), Measles, and Vitamin A (1 Lac IU)
  • A completely unimmunized child 18 months of age should receive: BCG (Only after Mantoux Test: Indirect BCG), DPT-1 (next two doses one month apart each and booster after 1 year of 3rd dose), OPV-1 (next two doses one month apart each and booster after 1 year of 3rddose), Measles (if not suffered from measles disease previously), and Vitamin A (2 Lac IU).
  • A completely unimmunized child 30 months of age should receive: BCG (Only after Mantoux Test: Indirect BCG), DT-1 (NOT DPT; next two doses one month apart each and booster after 1 year of 3rd dose), OPV-1 (next two doses one month apart each and booster after 1 year ofr dose), Measles (if sufferedfrom measles disease previously), and Vitamin A (2 Lac IU).
  • A completely unimmunized child 4 years of age should receive: BCG (Only after Mantoux Test: Indirect BCG), DT-1 (NOT DPT; next two doses one month apart each and booster after 1 year of r dose), OPV-1 (next two doses one month apart each and booster after 1 year of 3rd dose), Measles (if not sufferedfrom measles disease previously) and Vitamin A (2 Lac 1U).

Question.6

Which of the following does not establish a diagnosis of congenital CMV infection in a neonate ?

AIIMS PG Nov-2017
A. Urine culture of CMV
B. IgG CMV antibodies in blood
C. Intra-nuclear inclusion bodies in hepatocytes
D. CMV viral DNA in blood by polymerase chain reaction
Correct Ans: B
Explanation

Ans. is `b’ i.e. IgG CMV antibodies in blood 

” Ig G antibody test is of little diagnostic value as positive results also reflects maternal antibodies.”


Question.7

An infant has hepatorenomegaly, hypoglycemia, hyperlipidemia, acidosis and normal structured glycogen deposition in liver. What is the diagnosis ?

AIIMS PG Nov-2017
A. Her’s disease
B. Von Gierke’s disease
C. Cori’s disease
D. Anderson’s disease
Correct Ans: B
Explanation

Ans. is ‘b’ i.e., Von Gierke’s disease

Von-Gierke disease (Type I glvcogenosis)

  • It is an autosomal recessive disorder.
  • It is due to absent or deficient activity of glucose-6-phosphatase in Liven Kidney, Intestinal mucosa It can be divided into two subtypes ?
  1. Type Ia  ?  glucose – 6 – phosphatase is defective
  2. Type Ib  ?  Translocase is defective (translocase transports glucose-6-phosphatase across microsomal membrane).

Obs / Gyne

Question.1

What is the rate of release of levonorgestrel into the uterus from Mirena, a progestin releasing intrauterine device?

AIIMS PG Nov-2017
A. 20 microgm/d
B. 30 microgm/d
C. 50 microgm/d
D. 70 microgm/d
Correct Ans: A
Explanation

Ans: A. 20 microgm/d

Mirena is a progestin releasing device, it releases levonorgestrel into the uterus at a rate of 20  microgm/d. It has a T-shaped radiopaque frame, with its stem wrapped with a cylinder reservoir, composed of a polydimethylsiloxane-levonorgestrel mixture.

For emergency contraception levonorgestrel is used, 0.75 mg initially, followed by another 0.75 mg 12 hours later.

Cu T 380A is another progestin releasing device. It has a polyethylene and barium sulfate, T-shaped frame wound with copper.
 
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 32. Contraception.

Question.2

Opium poisoning is treated with:

AIIMS PG Nov-2017
A. Naloxone
B. Atropine
C. Neostigmine
D. Physostigmine
Correct Ans: A
Explanation

Ans. A.  Naloxone


Question.3

Hypergonadotropic hypogonadism ?

AIIMS PG Nov-2017
A. Decrease FSH and LH
B. Decrease FSH and increase LH
C. Increase FSH increase LH
D. Increase FSH decrease LH
Correct Ans: C
Explanation

Ans. is ‘-c’ i.e., Increase FSH increase LH

Hypergonadotropic hypogonadism

  • Also K/a primary or peripheral hypogonadism.
  • Characterised by hypogonadism due to an impaired response of the gonads to the gonadotropin, FSH and LH.
  • In turn a lack of sex steroid production and elevated gonadotropin level(FSH and LH).

Causes : Chromosomal abnormalitis

  • Turner’s syndrome
  • Klinefelter syndrome
  • Swyer’s syndrome

Enzyme defect

  • 17 , hydroxylase
  • 17, 20 lyase deficiency

Question.4

All are causes of hyperprolactinemia, except

AIIMS PG Nov-2017
A. Bromocriptine
B. Phenothiazine
C. Methyldopa
D. Metoclopramide
Correct Ans: A
Explanation

Answer is A (Bromocriptine):

Bromocriptine is a potent dopamine agonist. It decreases prolactin release from pituitary by activating inhibitory dopaminergic receptors on lactotrope cells, a strong anti-galactopoietics action.

All others are known to cause increased Prolactin.


Question.5

Injury to which of the following deep part of perinea! body causes cystocele, enterocele and urethral descent?

AIIMS PG Nov-2017
A. Pubococcygeus
B. Ischiocavernosus
C. Bulbospongiosus
D. Sphincter of urethra and anus
Correct Ans: A
Explanation

Ans. a. Pubococcygeus 

When the pubococcygeus muscle contracts, it pulls the rectum, vagina, and urethra anteriorly toward the pubic bone and constricts the lumens of these pelvic organs. It is this contractile property that is so important in maintaining urinary and fecal continence and in providing support for the genital organs (vagina, cervix, uterus) that lie upon and are supported by the levator plate. Injury to pubococcygeus can lead to rectocele, cystocele and urinary incontinence.


Question.6

An 18 years old girl presents with primary amenorrhea. On evaluation, she was having a karyotype of 45X0 and infantile uterus. What should he done next?

AIIMS PG Nov-2017
A. HRT to induce puberty
B. Vaginoplasty
C. Clitoroplasty
D. Bilateral gonadectomy
Correct Ans: D
Explanation

Ans. d. Bilateral gonadectomy

History of primary amenorrhea, karyotype of 45X0 & infantile uterus is suggestive of Turner’s syndrome. Approximately 5% of women with Turner’s syndrome have a karyotype with Y chromosome (45X/46XY). It is important to identify’ a Y chromosome because affected individuals are at significant risk of gonadoblastoma (20 to 30%). Therefore, prophylactic gonadectomy should be performed.


Question.7

Triple test for diagnosis of down’s syndrome includes all of the following except :

AIIMS PG Nov-2017
A. ß – HCG
B. a- Fetoprotein
C. Serum HPL level
D. Serum oestriol level
Correct Ans: C
Explanation

Answer is C (Serum HPL levels)

Serum HPL is not included as a parameter within the ‘triple test’ fir downs syndrome

Triple Test :

  • It is used in the detection of Downs syndrome. Q
  • In an affected pregnancy : – level of MSAFP is decreased Q
  • level of oestriol is decreased Q
  • levels of hCG is High (increased) Q
  • This test only gives a risk ratio and result is considered positive if risk ratio is 1 : 2 For confirmation Amniocentesis has to be doneQ
  • It is performed between 16 to 18 weeks.Q

Question.8

Increased calories required during pregnancy:

AIIMS PG Nov-2017
A. 300
B. 400
C. 550
D. 800
Correct Ans: A
Explanation

Ans. A i.e. 300

The increased calorie requirement is to the extent of 300 over the non pregnancy state during second half of pregnancy.


Question.9

Pregnant women with following is called systemic hypertension:

AIIMS PG Nov-2017
A. Hypertension diagnosed at 10 weeks of gestation
B. Diabetic retinopathy
C. Diabetic nephropathy
D. Episode of seizure
Correct Ans: A
Explanation

Ans. a. Hypertension diagnosed at 10 weeks of gestation

Chronic underlying hypertension or systemic hypertension is diagnosed in women with documented blood pressures > 140/90 mm Hg before pregnancy or before 20 weeks’ gestation, or both.


Question.10

Investigation of choice in postcoital bleeding in a 60 years old lady is :

AIIMS PG Nov-2017
A. Pap smear
B. Colposcopy and biopsy
C. Pelvic ultrasound
D. Cone excision of cervix
Correct Ans: B
Explanation

Ans. is b i.e. Colposcopy and biopsy

investigation of choice in post-coital bleeding in a 60 years old lady (which suggests carcinoma cervix) is Colposcopy and Biopsy.

The aim of Colposcopy is : – to confirm the diagnosis

  1. to identify the extent of lesion
  2. it allows conservative treatment in case of precancerous lesions.
  • Pap smear is not the investigation of choice, as it is a screening procedure. If pap smear is negative in this case (In postmenopausal females, where there are less metaplastic changes at squamo columnar junction) we still have to confirm by Colposcopy.
  • Cone biopsy is a destructive method and is advised only if diagnosis cannot be confirmed by colposcopy or SCJ is not visualised.

Question.11

Maneuver shown in the photograph below is known as ? 

AIIMS PG Nov-2017
A. Fundal Palpation
B. Lateral Palpation
C. Deep pelvic Palpation
D. Pawlik’s grip
Correct Ans: D
Explanation

Ans: D. Pawlik’s grip

Maneuver shown in the photograph  above represents Pawlik’s grip.

Pawlik’s Grip

Purpose- To determine engagement of presenting part.

Procedure-Using thumb and finger, grasp the lower portion of the abdomen above symphisis pubis, press in slightly and make gentle movements from side to side.

Findings-The presenting part is engaged if it is not movable.It is not yet engaged if it is still movable.


Question.12

The deliusion which involves replacement of a familiar person by someone else is ?

AIIMS PG Nov-2017
A. Capgras syndrome
B. Cotard syndrome
C. Othello syndrome
D. None
Correct Ans: A
Explanation

Ans. is ‘a’ i.e., Capgras syndrome

  • DSM is characterized by misidentification delusions of other or self. Four main syndromes are differentiated : ?
  1. Capgras syndrome (Delusion of double) : – Patient falsely sees a familiar person as a complete stranger who is importing on him as a familiar person.
  2. Fregoli syndrome (illusion de fregoli) : – The patient falsely identifies stranger as familiar person.
  3. Syndrome of subjective double : – The patients own self is perceived as being replaced by a double.
  4. Syndrome of intermetamorphosis : – A false belief that a person can transform into another person.
  • These syndrome most commonly appear in schizophrenia. Other causes are Alzheimer syndrome, head injuries, and delusional disorders.

Question.13

Advantages of median episiotomy over mediolateral episiotomy are all except:

AIIMS PG Nov-2017
A. Less blood loss
B. Easy repair
C. Extension of the incision is easy
D. Muscles are not cut
Correct Ans: C
Explanation

Ans. C: Extension of the Incision is Easy

Mediolateral episiotomy is performed by making a diagonal incision across the midline between the vagina and anus This method is used much less often.

The disadvantages are:

  • Apposition of the tissues is not so good.
  • May require more healing time than the midline incision.
  • Blood loss is little more
  • Postoperative discomfort is more
  • Relative increased incidence of wound disruption
  • Dyspareunia is comparatively more

The advantages are:

  • If necessary the incision can be extended.
  • Relative safety from rectal involvement from extension.

Question.14

In the normal condition, the graph shown in the picture below include all of the following EXCEPT ? 

AIIMS PG Nov-2017
A. Cervical dilatation in X-axis.
B. Descent of head in Y-axis.
C. Sigmoid shaped curve.
D. Alert line followed 4 hours later by action line.
Correct Ans: A
Explanation

Ans: A .Cervical dilatation in X-axis.

  • Normal partogram does not include Cervical dilatation in X-axis.

Partogram is:

  • Graphical representation of stages of labour;
  •  Assessment of labour
  • Cervicograph is: Graph showing relationship between cervical dilatation & labour.
  • Partograph is a composite graphical record of cervical dilatation in centimeters & descent of head against duration of labor in hours
  • Introduce as an early warning system to detect labour that was progressing normally, for timely transfer to a referral center
  • In a partograph the labor process is divided into
    • Latent phase that ends when the cervix is 3 cm dilate &
    • Active phase starts with cervical dilation of 3 cm. Cervix should dilate at least 1cm/hour in this active phaseQ
  • Cervical dilation rate (cervicograph) is plotted in relation to alert line & action lineQ.
  • Concept of Alert line & Action line given by Philpott

Alert line

Action line

Alert line starts at the end of latent phase (3 cm

Action line is drawn four hours to the right of the

cervical dilation) & ends with full dilation of the

alert line. An    interval of 4 hours    is allowed to

cervix (10cm) in 7 hours (1cm/hour dilation rate)°

diagnose delay in active phase and then appropriate intervention is done°.

Labor is considered abnormal when cervicograph crosses the alert line & falls on zone 2°.

Intervention is required when it crosses the action line & falls on zone 3°.


Question.15

Cervical smear fixation is done by :

AIIMS PG Nov-2017
A. Ethyl alcohol
B. Acetone
C. Xyline
D. Formalin
Correct Ans: A
Explanation

Ans: A. Ethyl alcohol

  • Pap smear is the most effective method of screening for cervical cancer.
  • Technique of preparing pap smear : A speculum is introduced in the vagina without lubricant and material from cervix is collected using Ayer’s spatula. Whole of the squamocolumnar junction has to be scrapped i.e. rotate the spatula through 360° and spread it on a slide (1s1 slide) and material is also collected from posterior wall of vagina (2″ slide) which acts as a control.
  • The glass slide is not air rie as it gets damaged.
  • The slide is fixed using ethyl alcohol.

The main problem with conventional pap smears are that they are of variable thickness and may get obscured by mucus, blood and other debris. This results in cell and nuclear overlap, causing problems with detection and interpretation.

To overcome this problem – Liquid based cytology has been developed.

Liquid based cytology :

Advantages ?

  • They decrease the number of false negative results.
  • They decrease the number of inadequate smear collection.
  • Can also be used for HPV typing and testing.

Method : From Gynaecology for PG and Practitioners 2/e, p 620 –

A plastic sampling device is used to collect the cells in the usual manner but instead of smearing it on a glass slide, the device  is rinsed in a buffered methanol solution for transfer to the laboratory. It is subsequently tittered’ to separate mucus and debris.


Question.16

HPV vaccine is?

AIIMS PG Nov-2017
A. Monovalent
B. Trivalent
C. Both bivalent and Quadrivalent
D. Only Quadrivalent
Correct Ans: C
Explanation

Ans: C. Both bivalent and Quadrivalent

Approximately 70% of cervical cancers are caused by the high cancer risk types 16 and 18.

Over 90% of genital warts are caused by low cancer risk types 6 and 11.

Two HPV vaccines are
1) Quadrivalent HPV vaccine (HPV4) types 6, 11, 16, and 18 (Gardasil, Merck) is approved for females and males 9 through 26 years of age.
2) Bivalent HPV (HPV 2) types 16 and 18 vaccine (Cervarix, GlaxoSmithKline) is approved for females 10 through 25 years of age.
Routine vaccination of females and males aged 11–12 years is recommended.
 

Types of HPV Vaccines

Bivalent Vaccine (Cervarix)

Quadrivalent Vaccine (Gardasil)

Nanovalent Vaccine (Gardasil 9)

Prevention  against   HPV types 16 18°

Prevention against HPV types 6, 11, 16, 18°

Prevention against HPV types 6, 11, 16, 18, 31, 33, 45, 52, 58°

Only used for girls°

s    Used for both for boys & girls°

Used for both boys girls°

Age 9-26 years°

•      Age 9-26 years°

3 doses given at 0, 2 & 6 months

 

 

0.5 ml given IM

Ref: Daley M.F., O’Leary S.T., Nyquist A. (2012). Chapter 10. Immunization. In W.W. Hay, Jr., M.J. Levin, R.R. Deterding, J.J. Ross, J.M. Sondheimer (Eds),CURRENT Diagnosis & Treatment: Pediatrics, 21e. 

Question.17

Exact number of weeks between last menstrual period [LMP] and expected date of delivery [EDD]:

AIIMS PG Nov-2017
A. 38 weeks
B. 39 weeks
C. 40 weeks
D. 41 weeks
Correct Ans: C
Explanation

Ans. C: 40 weeks

Childbirth usually occurs about 38 weeks after conception; i.e., approximately 40 weeks from the last normal menstrual period (LNMP).

The World Health Organization defines normal term for delivery as between 37 weeks and 42 weeks

  • EDD is calculated by Naegele’s rule
  • Add 7 days to the first day of the last period and subtract 3 months
  • Naegele’s rule is based on 28 days regular cycle.
  • If the cycle is shorter or longer than 28 days, EDD will be corrected and written as corrected EDD.
  • Examples:

40 days cycle regularly, to get corrected EDD, add 12 days (40-28) with the EDD calculated from LMP.

21 days cycle regularly, to get corrected EDD, subtract 7 days (28-21) with the EDD calculated from LMP.


Question.18

Placental alkaline phosphatase is marker of:

AIIMS PG Nov-2017
A. Theca cell tumor
B. Teratoma
C. Choriocarcinoma
D. Dysgerminoma
Correct Ans: D
Explanation

Ans. is d i.e. Dysgerminoma 

Placental alkaline phosphatase and LDH are tumour markers of dysgerminoma.


Question.19

During active labour cervical dilatation per hour, in primi is :

AIIMS PG Nov-2017
A. 1.2 cms
B. 1.5 cms d
C. 1.7 cms
D. cms
Correct Ans: A
Explanation

Ans. is a i.e. 1.2 cms

Labour is said to active when :

  • Cervix is dilated to at least 3 — 4 cms.°
  • Regular uterine contractions are present.°
  • Rate of dilatation is at least 1.2 cm/hr° for nulliparous and 1.5 cm/hr° for parous women.

The pattern of cervical dilatation during the latent and active phase of normal labour is a sigmoid curve.

This curve is called as Friedman curve.

Friedman subdivided the active phase into :

  • Acceleration phase — 3 – 4 cm of cervical dilatation
  • Phase of maximum slope — 4 – 9 cm
  • Deceleration phase — 9 – 10 cm

Remember :

Latent phase is mainly concerned with cervical effacement active chase with cervical dilatation and the second stage with descent of the head.

In the nulliparous/ prirni gravida –> rate of cervical dilatation ranges between 1.2-6.8 cms/hr, minimum should be 1.2 cm/hr.

In multipara minimum rate of cervical dilatation is 1.5 cms/hr.

If dilatation is less than these, then it is called as protracted active phase.

Abnormalities of active phase: Protracted active phase (Le. slow rate of cervical dilatation or descent of head).

Features                 Cervical dilatation Descent of head

Nulliparous                  < 1.2 cm/hr                       < 1 cm/hr

Multiparous                 < 1.5 cm/hr                    < 2 crn/hr

Arrest of dilatation : Cessation of dilatation for 2 or more hours.

Arrest of descent            : Cessation of descent for nr mr)ro hnurs.

Precipitate labour           : Nulliparous              Dilatation and descent > 5 cm/hr°.

Multiparous            Dilatation and descent > 10 cm/hr°.


Question.20

What is the ideal treatment for a 55 yr female with Simple Hyperplasia of endometrium with Atypia?

AIIMS PG Nov-2017
A. Simple hysterectomy
B. Medroxy progesterone Acetate (MPA)
C. Levonorgesterol (LNG)
D. IUCD
Correct Ans: A
Explanation

Ans: A. Simple hysterectomy

Among all the given options for the patient in the clinical scenario, the best treatment option would be simple hysterectomy. There are chances of about 60-70% for simple hyperplasia of endometrium with Atypia to progress into endometrial cancer. While abdominal hysterectomy with or without oophrectomy is preferred in elderly, medical management is used in younger patients who would not prefer hysterectomy.

Ref: Shaws textbook of Gynaecology 13 edition, page 395

Orthopedics

Question.1

Congenital elevation of scapula is called ?

AIIMS PG Nov-2017
A. Sprengel shouder
B. Bouchard
C. Boutennier
D. None of the above
Correct Ans: A
Explanation

Ans. is ‘a’ i.e., Sprengel shoulder

Congenital high scapula (sprengel’s shoulder)

  • Congenital high scapula is an uncommon congenital deformity characterized by an abnormally high position and relative fixity of scapula.
  • The anomaly represents a failure of the scapula to descend during development to its normal thoracic position.

Question.2

A 68 yr old man came with pain and swelling of right knee. Ahlbeck grade 2 osteoarthritic changes were found on investigation. What is the further management:

AIIMS PG Nov-2017
A. Conservative
B. Arthroscopic washout
C. High tibial osteotomy
D. Total knee replacement
Correct Ans: D
Explanation

Ans: D i.e. Total knee replacement 

  • Ahlbeck grade 2 osteoarthritis (i.e. complete or almost complete obliterated joint space) with symptoms of pain and swelling in a sedentary patient (>65 years of age) is managed by knee replacementQ
  • Old (65 yrs) age, long standing history of pain & swelling interfering activities of daily living and grade III radiological grade of OA [i.e. moderate 50-75% joint space narrowing with definite osteophytes (a/t Kellgren / Brandt) and Minor < 5 nun bone attrition (a/t Ahlblack)] indicate moderately severe OA and is best managed by Total knee arthroplasty. Although it must be remembered that TKA is done only after conservative treatment measures have been exhausted. And in this case we have presumed that conservative treatment must have been tried (b/o long course) & failed.
  • Because arthroscopic lavage (wash out) provides symptomatic improvements in patients with normal alignment, joint space >3mmQ, stable ligaments, unicompartmental OA with relevant osteophytes at the site of symptom, loose bodies, minimal Fair bank lesions, meniscal flap tear, chondral fracture/flap and outerbridge I or II lesions. And patients with bi/tri compartmental OA, malalignment, irrelevant osteophytes  away from symptom site, diffuse chondrosis, degenerative meniscus, significant Fair bank lesion and outbridge III or IV are poor prognostic factors for arthroscopic debridement. So obliterated joint space rules out the possibility of conservative and arthroscopic treatments.
  • High tibial osteotomy is indicated in physiologically young (years) and active patients with unicompartmental OA of tibiofemoral jointsQ.

Radiological Grading Scale of OA of Tibiofemoral Joint

Arthroscopic Grading of Articular Cartilage Defect of knee joint

 

Ahlback

Kellgren Lawrence

Brandt

 

Noyes

0

No radiographic findings of osteoarthritis

No radiographic findings of osteoarthritis

No radiographic findings of osteoarthritis

0

Normal articular cartilage

1

Joint space

Minute osteophytes of

 

lA

Mild softening or discoloration of

 

narrowing < 3mm

doubtful clinical significance

with secondary features

 

articular cartilage

2

Joint space

Definite osteophytes

50-75% joint space narrowing

1B

Severe softening or discoloration of

 

obliterated or almost obliterated

with unimpaired joint space

without secondary features

 

articular cartilage

3

Minor bone attrition

Definite osteophytes

50-75% joint space narrowing

2A

Partial-thickness defect of

 

(

with moderate joint space narrowing

with secondary features

 

the total thickness of articular cartilage

4

Moderate bone

Definite osteophytes

>75% joint space narrowing

2B

Partial-thickness defect of >50% of

 

attrition (5-15 mm)

with severe joint space narrowing, subchondral sclerosis and definite deformity of bone contour.

with secondary features Severe subchondral sclerosis and definite deformity of bone contour

 

the total thickness of articular cartilage

5

Severe bone attrition (>15 mm)

 

 

3A

Full-thickness articular cartilage defect with normal subchondral bone

*       Secondary radiological features of OA include osteophytes, subchondral

3B

Full-thickness articular cartilage

sclerosis & subchondral

 

defect with erosion of subchondral bone

Surgical Management Plan of Arthritis Knee

  • Before surgery is considered, conservative management (including anti-inflammatory medications, modification of daily activities, weight reduction for obese patients, and use of cane for ambulation) should be exhausted (adequately tried). Intra arterial injections of hyaluronic acid & steroid may be helpful in early minimal arthritis.
  • Arthroscopic lavage (wash out) provides symptomatic improvements in patients with normal alignment, joint space >3mmQ, stable ligaments, unicompartmental OA with relevant osteophytes at the site of symptom, loose bodies, minimal Fair bank lesions, meniscal flap tear, chondral fracture/flap and outerbridge I or II lesions. And patients with bi/tri compartmental OA, malalignment, irrelevant osteophytes away from symptom site, diffuse chondrosis, degenerative meniscus, significant Fair bank lesion and outbridge III or IV are poor prognostic factors for arthroscopic debridement.

Total (Tricompartmental) Knee Replacement (TKR) : Indications

  • Primary indication of TKR is to relieve pain caused by severe arthritis with or without significant deformityQ. Radiological finding must correlate with clinical impression of knee arthritis. Patient who do not have complete cartilage space loss before surgery tend to be less satisfied with their clinical result after TKR.
  • Severe pain from chondrocalcinosis & pseudogout in an elderly patient is an occasional indication of TKR in absence of complete cartilage space loss. Severe patellofemoral arthritis in elderly may justify TKR because the expected outcome is better than that of patellectomy in these patients.
  • Osteonecrosis with subchondral collapse of femoral condyle.
  • Because knee replacement has a finite expected survival that is adversely affected by activity level, it generally is indicated in older patients with more sedentary life styles. It is preferable that patients undergoing TKA have a remaining normal life expectancy of between 20 & 30 years so that need for a repeat arthroplasty for a failed TKA will be minimal. It is clearly indicated in young patients who have limited function b/o systemic arthritis (eg rheumatoid arthritis) with multiple joint involvement. But the patient must understand the limitations of the procedure, be willing to modify life style to prolong the life of prosthesis and be willing to risk the lower success rate in a revision TKA.
  • Deformity can become the principle indication for TKR in patient with moderate arthritis & variable levels of pain when the progression of deformity begins to threaten the expected outcome of an anticipated TKR. This includes flexion contractures beyond 20° and vurus/ valgus laxity. However, deformity without pain is not a suitable indication for surgery as it may be well tolerated by elderly.
  • Indications for leaving the patella unresurfaced are, a primary diagnosis of OA, satisfactory patellar cartilage with no eburnated bone, congruent patello femoral tracking, a normal anatomical patellar shape and no evidence of crystalline or inflammatory arthropathy and lighter weight of patient.

TKR: Contraindications

  • Absolute contraindications include recent or current knee infection; a remote source of ongoing infection; extensor mechanism discontinuity or severe dysfunction; recurvatum deformity secondary to muscular weakness; and presence of painless, well functioning knee arthrodesis.
  • Relative contraindications include fragile medical conditions, severe atherosclerotic disease of operative leg, skin conditions such as psoriasis within the operative field, venous stasis disease with recurrent cellulitis, neuropathic arthropathy, morbid obesity, recurrent UTI, and a h/o osteomyelitis in the proximity of knee.

Question.3

A patient came with complaints of lower limb weak­ness. Examiner places one hand under the patient’s heel and patient is asked to raise his other leg against downward resistance. What is the name of this test?

AIIMS PG Nov-2017
A. Hoover test
B. Waddell’s test
C. O’Donoghue test
D. McBride test
Correct Ans: A
Explanation

Ans. a. Hoover test

  • In Hoover test, the subject relaxes in a supine position on the table while the examiner places both of the subject’s heels into the palm of the examiners hands.
  • Test positioning: The subject relaxes in a supine position on the table while the examiner places both of the subject’s heels into the palm of the examiners hands.
  • Action: The subject is asked to perform a unilateral straight leg raise
  • Positive finding: Inability to lift the leg may reflect a neuromuscular weakness. A positive finding is also noted when the examiner does not feel increased pressure in the palm that underlies the resting leg

Question.4

Sectoral sign is positive in ?

AIIMS PG Nov-2017
A. Avascular necrosis of femur head
B. Osteoarthritis of hip
C. Protrusio acetabuli
D. Slipped capital femoral epiphyses
Correct Ans: A
Explanation

Ans. is ‘a’ i.e., Avascular necrosis of femur head

Clinical features of AVN

In the earlier stages of AVN, the patient is asymptomatic, and by the time patient presents, the lesion is well advanced.

Common histories patient gives (Any of the following) : –

  1. Dislocation of Hip
  2. Alcoholism
  3. Steroid intake for any disorder
  4. Nephrotic syndrome
  • Pain is a common complaint. Pain is felt in the grain and may radiate to knee.
  • Decreased range of motion especially internal rotation followed by abduction.
  • Sectoral sign or Differential rotation : – Internal rotation is possible in extended position of hip, but as seen as the hip is flexed to 90° no internal rotation is possible. This is the characteristic sign of AVN. o Limp with antalgic gait.
  • Trendelenberg’s test positive.

Question.5

First sign of compartment syndrome is ?

AIIMS PG Nov-2017
A. Pain
B. Tingling
C. Loss of pulse
D. Loss of movement
Correct Ans: A
Explanation

Ans. is ‘a’ i.e., Pain

Clinical features of compartment syndrome

  • Four signs are reliable in diagnosing a compartment syndrome :-
  1. Paresthesia or hypesthesia in nerves traversing the compartment
  2. Pain with passive stretching of the involved muscles (stretch pain)
  3. Pain with active flexion of the muscles
  4. Tenderness over the compartment
  • Amongst these, stretch pain is the earliest sign of impending compartment syndrome. The ischemic muscles, when stretched, give rise to pain.
  • Passive extension of fingers (streching the fingers) produce pain in flexor compartment of forearm.
  • Other features are Pulselessness, paralysis, Pallor and pain out of proportion to physical findings.
  • Peripheral pulses, are present initially and disappear later. Therefore, pulse is not a reliable indicator for compartment syndrome.

Question.6

Fracture shown in the picture below is a type of ? 

AIIMS PG Nov-2017
A. Acromioclavicular displacement
B. Sternoclavicular displacement.
C. Lateral 1/3 clavicular fracture.
D. Proximal humerus fracture.
Correct Ans: D
Explanation

Ans: D. Proximal humerus fracture.

Fracture shown in the picture above represents proximal humerus fracture.

 

Neer Classification for Shoulder Fractures

Type

Description

I

Minimally displaced, one-part fracture, fracture lines involve 1-4 parts

Account for –70-80% of all proximal humeral fractures

II

Two-part fracture, fracture lines involve 2-4 parts, one part is displaced (Anatomical neck)

III

Three-part fracture, fracture lines involve 3-4 parts, two parts are displaced (Surgical neck)

IV

Four-part fracture, fracture lines involve more than 4 parts & three parts are displaced (Greater tuberosity)

V

Lesser tuberosity fractures

VI

Fracture dislocations 


Question.7

A patient presented with a history of fall on outstretched hand. There is pain & swelling over the radial aspect of the wrist without any obvious deformity. Radial styloid process is at a lower level than the ulnar styloid process. Tenderness can be elicited in anatomical snuff box. Findings are consistent with the diagnosis of: 

AIIMS PG Nov-2017
A. Fracture scaphoid
B. Fracture Colle’s
C. Fracture pisiform
D. Wrist osteoarthritis
Correct Ans: A
Explanation

Ans. A i.e. Fracture scaphoid

Scaphoid

  • Only carpal bone to undergo fracture as well as AVN: Scaphoid
  • Fragment undergoing necrosis in fracture scaphoid: Proximal
  • MC site of fracture scaphoid: Waist

Question.8

Vascular repair to be done in which Gustilo Anderson type?

AIIMS PG Nov-2017
A. Inc
B. I
C. II
D. IlIb
Correct Ans: A
Explanation

Ans. is ‘a’ i.e., Inc

Treatment of Open Fractures

  • Gustilo’s classification of open fractures :

Type I

  • Small clean puncture wound with/ without protruded bone spike.
  • Low energy non-comminuted fracture(low energy trauma).
  • Little soft tissue injury with no crushing.

Type II

  • More than 1 cm long wound.
  • Moderate soft tissue damage and crushing.
  • Low to moderate energy trauma with moderate comminution.

Type III    

  • Large laceration, skin flap, crushing.
  • IIIA: fractured bone can be adequately covered by soft tissue despite laceration.
  • IIIB: extensive periosteal stripping and fracture cover is not possible without use of local or distant flaps.
  • IIIC: associated arterial injury that needs to be repaired regardless of the amount of other soft tissue damage.

Question.9

Posterior cruciate ligament- true statement is

AIIMS PG Nov-2017
A. Attached to the lateral femoral condyle
B. Intra synovial
C. Prevents posterior dislocation of tibia
D. Relaxed in full flexion
Correct Ans: C
Explanation

Ans: C i.e Prevents posterior dislocation of tibia


Image Based Questions

Question.1

Development the of heart is from which of the following marked structure?

AIIMS PG Nov-2017
A. a
B. b
C. c
D. d
Correct Ans: D
Explanation

Ans. d. d (Ref Gray’s 40/e p1016)

Development of heart is from the structure labeled as `II’.

Structures Marked in the Diagram
a Pharyngeal arches
b Developing forebrain
c Upper limb bud
d Developing heart


Question.2

Which of the follow ing junctional complexes are not seen in the marked region of the given slide?

AIIMS PG Nov-2017
A. Gap junction (communicating junctions)
B. Zonula occludens (tight junction)
C. Fascia adherens (adhering junction)
D. Macula adherens (desmosomes)
Correct Ans: B
Explanation

Ans. b. Zonula occludens

  • The arrow in the given diagram is showing intercalated discs of cardiac muscle, which contains all types of cellular junctions except occluding tight junction (Zonula occludens). Cardiac muscle cells are connected by fascia adherens (the structural analog of zonula adherens), gap junctions & macula adherens.

Question.3

Which of the following layer contains abundant desmosomes?

AIIMS PG Nov-2017
A. A
B. B
C. C
D. D
Correct Ans: C
Explanation

Ans. C. C

Stratum spinosum or prickle cell layer contains abundant desmosomes marked with the legend ‘C’ in the image.

Picture shows layers of epidermis
A Stratum corneum
B Stratum granulosum
C Stratum spinosum
D Stratum basale
  • “The epidermis can be divided into a number of layers from deep to superficial as follows: basal layer (stratum basale), spinous or prickle cell layer (.stratum spinosum), granular layer (stratum granulosum), clear layer (stratum lucidum) and cornified layer (stratum corneum.”-
  • “The prickle cell layer (stratum spinosum) consists of several layers of closely packed keratinocytes that interdigitate with each other by means of numerous cell surface projections. The cells are anchored to each other by desmosomes that provide tensile strength and cohesion to the layer. These suprabasal cells are committed to terminal differentiation and gradually move upwards towards the cornified layer as more cells are produced in the basal layer. When skin is processed for routine light microscopy, the cells tend to shrink away from each other except where they are joined by desmosomes, which gives them their characteristic spiny appearance. Prickle cell cytoplasm contains prominent bundles of keratin filaments, (mostly K1 and KIO keratin proteins) arranged concentrically around a euchromatic nucleus, and attached to the dense plaques qt. desmosomes. The cytoplasm also contains melanosomes, either singly or aggregated within membrane-bound organelles (compound melanosomes). Langerhans cells and the occasional associated lymphocyte are the only non-keratinocytes present in the prickle cell layer. “
Layers of Epidermis
Stratum basale
  • Also known as stratum germinativum°
  • It contains mitotically active keratinocytes containing house keeping organelles° (RER, golgi complex, mitochondria, lysosomes, ribosomes)
  • Give rise to superficial layer°
Stratum spinosum
  • Spine like appearance° of cell margins in histological sections
  • These spines are abundant desmosomes°, calcium dependent cell surface modifications that promote adhesion of epidermal cells & resistance to mechanical stresses.
Stratum granulosum
  • Characterized by buildup of components necessary for the process of programmed cell death & formation of superficial water impermeable barrier°.
  • Mostapparent structure within these cells is basophilic contain keratohyaline granules° 
Stratum lucidum
  • Clear layer, seen only in thick skin°
Stratum corneum
  • Formed ofcornified or horny cells (largest cell of epidermis) and have highest concentration 

Question.4

Identify the hormone from the picture:

AIIMS PG Nov-2017
A. Growth hormone
B. Cortisol
C. Estrogen
D. Insulin
Correct Ans: A
Explanation

Ans. a. Growth hormone 

  • Release of growth hormone is stimulated by strenuous exercise. During sleep, large pulsatile bursts of growth hormone secretion occur.
  • “Growth hormone is found at relatively low levels during the day, unless specific triggers for its release are present. During sleep, on the other hand, large pulsatile bursts of growth hormone secretion occur.

Question.5

Identify the Virus based on the given cycle:

AIIMS PG Nov-2017
A. HIV
B. Hepatitis
C. Influenza
D. Herpes simplex
Correct Ans: B
Explanation

Ans. b. Hepatitis

The given lifecycle is of hepatitis B virus.

“HB V attachment to a receptor on the surface of hepatocytes occurs via a portion of the pre-S region of hepatitis B sur­face antigen (HBsAg). After uncoating of the virus, unidentified cellular enzymes convert the partially double- stranded DNA to covalent closed circular (ccc) DNA that can be detected in the nucleus. The cccDNA serves as the template for the production of HBV mRNAs and the 3.5-kb RNA pre-genome. The pre-genome is encapsidated by a packaging signal located near the 5′ end of the RNA into newly synthesized core particles, where it serves as template for the HBV reverse tran­scriptase encoded within the polymerase gene. An RNase H activity of the polymerase removes the RNA template as the negative-strand DNA is being synthesized. Positive-strand DNA synthesis does not proceed to completion within the core. resulting in replicative intermediates consisting of full-length minus-strand DNA plus variable-length (20-80%) positive-strand DNA. Core particles containing these DNA replicative intermediates bud from pre-Golgi membranes (acquiring HBsAg in the process) and may either exit the cell or reenter the intracellular infection cycle.” ,ivetz 27/e p501)


Question.6

A 53 years old man is admitted with a history of CVA 2 days ago. Patient is drowsy with minimal response. CT picture is shown as in the figure. What will be your next line of management?

AIIMS PG Nov-2017
A. Aspirin and clopidogrel
B. Mannitol
C. Decompressive surgery
D. Mechanical thrombectomy
Correct Ans: C
Explanation

Ans. c. Decompressive surgery

  • The patient is having a low GCS with CT showing significant edema in the MCA territory (at least >50%). In such cases brain herniation is impending and need to be referred for decompressive neurosurgery.
  • “Stroke is a common cause of neurologic critical illness. Hypertension must be managed carefully, since abrupt reductions in blood pressure may be associated with further brain ischemia and injury. Acute ischemic stroke treated with tissue plasminogen activator (tPA) has an improved neurologic outcome when treatment is given within 3 h of onset of symptoms. The mortality rate is not reduced when tPA is compared with placebo, despite the improved neurologic outcome. The risk of cerebral hemorrhage is significantly higher in patients given tPA. No benefit is seen when tPA therapy is given beyond 3 h after symptom onset. Heparin has not been convincingly shown to improve outcomes in patients with acute ischemic stroke. Decompressive craniectomy is a surgical procedure that relieves increased intracranial pressure in the setting of space-occupying brain lesions or brain swelling from stroke; available evidence suggests that this procedure may improve survival among select patients (<55 years or age), albeit at a cost of increased disability for some

Question.7

Identify the diagnosis of the given gross specimen:

AIIMS PG Nov-2017
A. Cancer gallbladder
B. Cholesterolosis
C. Strawberry gallbladder
D. Polyps in gallbladder
Correct Ans: D
Explanation

Ans. d. Polyps in gallbladder

The diagnosis of the given gross specimen is gallbladder polyp 

Polypoid Lesions of the Gallbladder
Cholesterol polyps Adenomatous polyp

Cholesterol polyps (MC°)

Usually <10 mm in size°

Have a characteristic echogenic pedunculated° 

appearance on USG

Multiple (30% of cases)°

Malignant potential°.

Difficult to distinguish from adenocarcinoma of GB

Main differentiating feature is a lack of transmural invasion on USG°

Risk factors associated with malignancy

Age >60 years”

Coexistence of gall stones°

Documented increase in size°

Size >10 mm” 


Question.8

Identify the refractive error:

AIIMS PG Nov-2017
A. Myopia
B. Hypermetropia
C. Compound astigmatism
D. Mixed astigmatism
Correct Ans: A
Explanation

Ans. a. Myopia

  • In the given image, incident parallel rays come to a focus anterior to the light-sensitive layer of the retina, seen in myopia.
  • “Myopia, also known as ‘short sight’, is that dioptric condition of the eye in which, with the accommodation at rest, incident parallel rays come to a focus anterior to the light-sensitive layer of the retina. The majority of cases merely result as variants in the frequency curve of axial length and curvature, the former being the more important, although curvature myopia occurs comtnonly as a factor in astigmatism.”

Question.9

Following picture exhibit which cranial nerve palsy?

AIIMS PG Nov-2017
A. Oculomotor nerve
B. Abducent nerve
C. Trochlear nerve
D. Facial nerve
Correct Ans: B
Explanation

Ans. b. Abducent nerve

  • In the given picture, abduction limitation is there on left side. Lateral gaze palsy is due to paralysis of lateral rectus, which is supplied by the abducens nerve. So, the given picture shows left (abducent) sixth nerve palsy.

Question.10

A 40 years old female came to OPD with the history of fever, joint pain and rash. NSAIDs were prescribed. After one week, the patient developed brownish discoloration over nose. This was due to:

AIIMS PG Nov-2017
A. Melasma
B. Dengue
C. Chikungunya
D. Fixed drug eruption186
Correct Ans: C
Explanation

Ans. C. Chikungunya 

Clinical history of fever, joint pain and rash and after one week of NSAIDs use, the patient developed brownish discoloration over nose as given in the image, the most probable diagnosis is pigmentation caused by Chikungunya. Nose pigmentation is striking in the cases of CKG, which has not been reported in any other viral exanthem. For fixed drug eruption, mucocutaneous junction (lip, glans) is most frequently involved, genital skin (glans) is the most commonly involved site.

Chikungunya fever
  • Chikungunya fever is a re-emerging disease characterized by fever with arthralgia.
  • Abrupt onset of chikungunya virus disease follows an incubation period of 2-10 days.

Etiology & Epidemiology:

  • Etiology: Chikungunya virus
  • Aedes aegypti & A. albopictus mosquito bites; primarily in Africa & Indian Ocean region
  • Maternal–fetal transmission has been reported

Clinical Syndrome:

  • Most common among adults
  • Fever (often severe) with a saddleback pattern & severe arthralgia; accompanied by chills & constitutional symptoms
  • & signs (abdominal pain, anorexia, conjunctival injection, headache, nausea & photophobia)
  • Severe polyarticular, migratory arthralgias, especially involving small joints (e.g., hands, wrists, ankles)
  • Recovery may require weeks, and some elderly patients may continue to experience joint pain, recurrent effusions, or stiffness for several years
 Description of Rash
  •  Maculopapular eruption; prominent on upper extremities & face, but can also occur on trunk & lower extremities

Diagnosis:

  • Viral isolation (in mosquito cell lines) & RT-PCR are best for early diagnosis.
  • Serum antibody detection: MAC-ELISA is the best serology test.
  • Markers like IL-113 & IL-6 are increased & RANTES level are decreased

 Treatment:

  • NSAIDs & sometimes chloroquine for refractory arthritis.

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