AIIMS PG Nov 2017

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

Ans:B.)NREM sleep.

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

• 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.

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.

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.

Ans: C. Surface tension

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.”

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)

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.

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.

Ans. A. Hydrogen bond 

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.

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)

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 C₂₆^—C₃₈polyenoic 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

Ans. b. Inborn errors of metabolism

Ans. d. Cryptococcus

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

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.

Ans. is ‘c’ i.e., Chromoblastomycosis

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

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:

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.

Ans: D. Sodium hypochlorite

Sodium hypochlorite Common Disinfectants for Hos^pital Use

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.

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.

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.

Ans: B. Balantidium coli

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.

Ans: C i.e. Hypnozite

• 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

Ans. a. 18

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

Ans. D: Vancomycin

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.

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.

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.

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.

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.

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.

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.

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.

Ans. is ‘c’ i.e., Domperidone

Drugs used are :

1. a)         Anticholinergics —> Hyoscine (Scopolamine), Dicyclomine.
2. b)      H_l-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.

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.

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.

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.

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. “

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.

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.

Ans. d. Azithromycin 2 gm oral single dose 

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.

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.

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.

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.

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

Ans. A. Arsenic

Ans. c. 1 =d, 2=a, 3=b, 4=c 

Ans. b. 1 =b, 2=c, 3=d, 4=a 

Ans: B. 6 cm

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)

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:

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

Ans. b. 4, 1, 3, 2 

Ans. d. Lithium heparin 

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.

Ans. B: Normal HbF and normal HbA2

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

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.

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

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.

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.

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 l^ymph nodes in the cervical axillar^y 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

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.

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.

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.

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)

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.

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

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.”

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.

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.

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

Ans. B i.e. Non-proliferative 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

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.

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.

Ans. a. 60

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

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

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 / 4^th 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.

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.

• 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

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

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:
• A 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 ‘^t 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).

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

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

Ans. D. Saddle nose

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).

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.”

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.

Ans: A. Coxsackie – A virus

It is Hand Foot Mouth disease

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).

Ans. d. Delusion of grandiosity, persecution and reference 

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

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.

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.”-

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

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.

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

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

Ans: C i.e. Type C

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.

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.

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.

Ans. C: Nitrous oxide

• 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.

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.

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

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.

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.

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

• S_iis louder in Mitral stenosis because AV flow is prolonged.
• The loud S_i 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.

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.

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.

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

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.

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

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.

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.

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

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.

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.

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 hypoperfusion^Q
• Shock index (SI) = Heart rate (HR)/ Systolic blood pressure (SBP)

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.

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.

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.”

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

Ans. B i.e. 10

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.

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.

• Adults— 16 F
• Children— 8 F or 10 F

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.

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

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.

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

Ans: A. CECT

(Ref Hurst ‘s The Heart 13/e p1050)

Plain radiograph:

• Best method to know ICD position & integrity.

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

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.

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

Answer is B (Hypercalcemia):

Tumor Lysis syndrome is characterized with hypocalcemia and not hypercakemia.

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.

Ans: C. 40 cm

Ans. D. Pinprick is not painful

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)

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

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

Ans. is ‘b’ i.e., Respiratory rate

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 3^rd 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 3^rd dose), OPV-1 (next two doses one month apart each and booster after 1 year of 3^rddose), 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 3^rd 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 3^rd dose), Measles (if not sufferedfrom measles disease previously) and Vitamin A (2 Lac 1U).

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.”

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 o 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).

Ans: A. 20 microgm/d

Ans. A.  Naloxone

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

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.

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.

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.

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 done^Q
• It is performed between 16 to 18 weeks.Q

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.

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.

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.

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.

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.

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.

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

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 (1^s1 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.

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.

Ans. C: 40 weeks

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.

Ans. is d i.e. Dysgerminoma 

Placental alkaline phosphatase and LDH are tumour markers of dysgerminoma.

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 ¹ n^r m^r)ro hnurs.

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

Multiparous            Dilatation and descent > 10 cm/hr°.

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.

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.

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.

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.

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

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.

Ans. is ‘a’ i.e., Pain

• 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.

Ans: D. Proximal humerus fracture.

Fracture shown in the picture above represents proximal humerus fracture.

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

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.

Ans: C i.e Prevents posterior dislocation of tibia

Ans. d. d (Ref Gray’s 40/e p1016)

Development of heart is from the structure labeled as `II’.

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.

Ans. C. C

Stratum spinosum or prickle cell layer contains abundant desmosomes marked with the legend ‘C’ in the image.

Ans. b. Hepatitis

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

Ans. d. Polyps in gallbladder

The diagnosis of the given gross specimen is gallbladder polyp

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.”

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.

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.