AIIMS PG Nov 2018

Ans: B. Talocalcaneal

• Inversion: Medial border of the foot is raised so that sole faces inside.
• Eversion: Lateral border of the foot is raised so that the sole faces outside.
• Inversion and eversion occur mainly at intertarsal joint.
• Major movements occur at Talo-calcaneo-navicular joint.
• Other involved joints are Transverse Tarsal/Midtarsal joints

Movements at the Intertarsal Joint (Talocalcaneal, Transverse Tarsal Joint)

Ans. is ‘b’ i.e., Azygos vein

• Right superior intercostal vein drains into azygos vein.
• Left superior intercostal vein drains into left brachiocephalic vein.
• The right superior intercostal vein drains the 2nd, 3rd, and 4th posterior intercostal veins on the right side of the body. It flows into the azygos vein.
• The left superior intercostal vein drains the 2nd and 3rd posterior intercostal veins on the left side of the body. It drains into the azygos vein or left brachiocephalic vein.

Venous drainage of chest wall

• Similar to arteries, each upper nine intercostal space have one posterior intercostal and two anterior intercostal veins. The 10^th and 11^{`h</sup> spaces have only posterior intercostal vein.
• Posterior intercostal vein of first space is called highest intercostal vein and drains into brachiocephalic vein. 2′ to 4<sup>th</sup> posterior intercostal veins unite to form superior intercostal vein which drains into azygos vein on right side and into left brachiocephalic vein on left side. On right side 5<sup>th</sup> to 11<sup>`h} posterior intercostal veins drain into azygos vein. On left side 5′ to 8^th posterior intercostal veins drain into accessory hemiazygos vein and 9^th to 1 Ph posterior intercostal veins drain into hemiazygos vein.
• Anterior intercostal veins of r to 9^th space drain into musculophrenic vein (a tributary of internal thoracic vein). 1″ to 6^th anterior intercostal veins drain directly into internal thoracic vein.

Ans: C. Lateral pterygoids
Depression of the Mandible

• Depression of the mandible is brought about by contraction of the digastrics, the geniohyoids, and the mylohyoids; the lateral pterygoids play an important role by pulling the mandible forward.

Elevation of the Mandible

• Elevation of the mandible is brought about by contraction of the temporalis, the masseter, and the medial pterygoids. The head of the mandible is pulled backward by the posterior fibers of the temporalis.

Protrusion of the Mandible

• In protrusion, the lower teeth are drawn forward over the upper teeth, which is brought about by contraction of the lateral pterygoid muscles of both sides, assisted by both medial pterygoids.

Refraction of the Mandible

• The articular disc and the head of the mandible are pulled backward into the mandibular fossa. Retraction is brought about by contraction of the posterior fibers of the temporalis.

Lateral Chewing Movements

• These are accomplished by alternately protruding and retracting the mandible on each side. For this to take place, a certain amount of rotation occurs, and the muscles responsible on both sides work alternately like turning the chin to left side produced by left lateral pterygoid and right medial pterygoid and vice versa.

Ans. b. Ulna

Wrist Joint (Radiocarpal Joint)

• It is a synovial ellipsoid joint.
• It is formed by articulation of the distal end of the radius and the articular disc above and the scaphoid, lunate, and triquetral bones below.
• Ulna excluded from the wrist joint by the articular disc.

Ans. A. XII

Cranial Nerves — Components and Functions

Ans: D. i.e. Initiating & planning movements

• It presents near the midline encroaching upon the medial surface of the hemisphere and is the continuation of the pre-central and post-central gyri.
• The boundary of paracentral lobule needs to be elaborated, as it is the cortical (highest) center of micturition and defecation.
• The paracentral lobule controls the motor and sensory innervations of the contralateral lower limb and perineal region. So injury in this area can cause limb muscle weakness.

Ans: A. Both Assertion and Reason are true, and Reason is the correct explanation for Assertion
In neurosyphilis there is damage to the pretectal area resulting in Argyll Robertson pupil. In this case pupils are small bilaterally, light reflex is absent but accommodation is present. Other features of Argyll Robertson pupil are: vision is good, patches of iris atrophy are present, orbicularis reflex is retained, it is always associated with positive serological test for syphilis. 

Ans. D. Elastin

Ans. a. Supranuclear

• Serous cells have a pyramidal shape.
• They possess large amounts of rough endoplasmic reticulum (RER) with many ribosome free regions, supranuclear Golgi complex and numerous spherical secretory granules.

Ans. d. Papillary dermis

• Meissner corpuscles are encapsulated nerve endings present in dermal papillae.
• Merkel cells location: Stratum basale
• Pacinian corpuscle location: Reticular layer of dermis

Ans. B. Lordosis

Abnormal Curvatures of the Vertebral Column

Ans: A. Ganglion cell layer
The only cell type in the retina that has long axons which exhibit a self-propagated action potential is the ganglion cell.

Ans. is ‘d’ i.e., All of the above 
Structures passing through superior orbital fissure are :-

1. Middle part (within the ring) Upper and lower division of oculomotor nerve, nasociliary nerve, abducent nerve.
2. Lateral part (above the ring) :- Trochlear nerve, frontal nerve and lacrimal nerve, superior ophthalmic vein, recurrent menigeal branch of lacrimal artery, orbital branch of middle meningeal artery and sometimes meningeal branch of ophthalmic artery.
3.  Medial part (below the ring) :- Inferior ophthalmic vein, sympathetic nerves around ICA.

Ans. is ‘b’ i.e., Level 1B neck nodes 

• Division of neck nodes according to levels

Ans: D. 27

Formula – GFR = Kf l(PGC– PT) – (7r GC–RT)I

• K_f– Glomerular ultrafiltration coefficient.
  • Product of glomerular capillary wall hydraulic conductivity (i.e. its permeability) & effective filtration surface area.
• P_GC – Mean hydrostatic pressure in glomerular capillaries = 25
• P_T  –  Mean hydrostatic pressure in tubule (Bowman’s space) = 2
• p   GC – Oncotic pressure of plasma in glomerular capillaries
• p T  – Interstitial colloidal oncotic pressure   = 7
• In this question,
  • GFR, 3 = K_f [(25-2) – ⁽¹¹GC ^{–7)] K}f ^[23 – ⁿGC +7] K_f [30 –pGC].
  • pGC = 27 mm/Hg.

Ans: D. Prolactin secretion is tonically inhibited by the hypothalamus
Unique among the pituitary hormones, prolactin secretion is tonically inhibited by the hypothalamus. Prolactin is a single-chain protein secreted by the anterior pituitary whose principal physiologic effects involve breast development and milk production. Consistent with its role in lactogenesis, prolactin secretion increases during pregnancy Dopamine has many characteristics of the hypothalamic inhibitory factor, although it is not found in the hypothalamus.

Ans. is ‘d’ i.e., All of the above

• Puberty is triggered by a release of gonadotropins (FSH and LH) from pituitary gland.
• These hormones act as signals to the gonads (testes/ovaries) that trigger the production of –

1. Estrogen, progesterone and some testosterone in women.
2. Testosterone in men.

• In both males and females, testosterone is responsible for development of pubic hair, accelerated bone growth, body odor and acne during puberty. For boys, testosterone is responsible for the process of virilization, including the enlargement of the penis, increased libido and growth of facial and chest hair.
• Estrogen is the major hormone responsible for female puberal development. It causes development of breast and thickening of endometrium.
• Progesterone causes proliferation of acini in mammary glands and converts watery cervical secretion to viscid and scanty.
• Leptin facilitates release of gonadotropin releasing hormone (GnRH), thereby helping in pubertal onset.
• Other hormones which are involved in puberty are thyroxine and growth hormone.

Ans. a. CFU

• Kidney-derived cytokine erythropoietin stimulates the terminal proliferation and differentiation of CFU-Erythroid progenitors.
• BFU-E cells respond to many hormones in addition to erythropoietin, including SCF, IGF-1, glucocorticoids, IL-3 and IL-6.

Ans. b. S3

Ref Ganong’s Review of Medical Physiology 25¹¹‘ edn; Page no. 542

Heart Sounds

Ans. is ‘a’ i.e., Used in binding
Integrins have two main functions:-

• Attachment of the cell to the ECM
• Signal transduction from the ECM to the cell

Integrins are calcium-independent adhesion molecules.

• The extracellular domains of integrins bind to fibronectin which further binds to collagen; these are components of extracellular basement membrane.
• The cytoplasmic portions of integrins bind to actin filaments.

Ans. is ‘d’ i.e., All of the above 

• The two main inputs to the cerebellar cortex are climbing fibers and mossy fibers, which are excitatory.
• The climbing fibers come from a single source, the inferior olivary nuclei and directly projects to the primary dendrites of a purkinje cell.

Ans. is ‘a’ i.e., Substantia gelatinosa

• Analgesic action of morphine has spinal and supraspinal components.
• It acts in the substantia gelatinosa of dorsal horn to inhibit release of excitatory transmitters from primary afferent carrying pain impulses.

Ans. is ‘c’ i.e., Intensity of stimulus and sensation felt

Ans. C. Increased precisiveness of movements

Ref Ganong’s Review of Medical Physiology 25^th edn; Page no. 170

• In homunculus the largest areas represent the face, hands, and fingers, where precise localization is most important.

Fig: Motor homunculus in precentral gyrus (Area 4);
(Frontal lobe [Coronal section])

• In homunculus the size of the various parts is ProPortionate to the use ofthe part (skilled fine movement with precision).

Answer is D (Emphysema):

• Emphysema is associated with an increased static compliance but decreased dynamic compliance.
• `The effect of emphysema on compliance is unique in that it results in an increase in static compliance but a decrease in dynamic compliance.
• Static compliance increases due to destruction of elastic tissues in the alveolar walls. The reduction in elastic tissue makes it easier for the lung to expand in response to distending pressure, However the loss of elastic tissue in the walls of smaller airways makes them vulnerable to dynamic airway compression. This increases the airway resistance with consequent decrease in dynamic compliance – ‘Principles of Medical physiology’ by Sircar 1″ (2008)/320

Common causes of Rhonchi include:

• Bronchial Asthma
• COPD — Chronic bronchitis, Bronchiectasis, Emphysema
• Cardiac Asthma (Pulmonary Edema)
• Foreign body (Fixed monomorphic rhonchi – localized)
• Tumor (Fixed monomorrphic rhonchi — localized.)

Static Compliance

• Static compliance, indicates compliance when the lungs are at rest
• Static compliance values reflect true lung compliance alone
• Static compliance reflects elasticity of the lung and is not affected by airway resistance because there is no flow

Reduced static compliance indicates rigid lung tissue

• Interstitial fibrosis (Fibrosing al veolitis)
• Atelectosis
• Pulmonary edema
• Pneumonia
• ARDS

Dynamic Compliance

• Dynamic compliance indicates compliance when air flow is occurring
• Dynamic compliance values reflect lung compliance along with airway resistance
• Dynamic compliance is affected by both elasticity of the lung and airway resistance

Reduced Dynamic compliance (without change in static compliance) indicates Ted airway resistance

• Obstruction
• Bronchospasm (Allergic Asthma)
• Collapse of small airways etc

Dynamic Compliance

• Dynamic compliance indicates compliance when air flow is occurring
• Dynamic compliance values reflect lung compliance along with airway resistance
• Dynamic compliance is affected by both elasticity of the lung and airway resistance

Reduced Dynamic compliance (without change in static compliance) indicates Ted airway resistance

• Obstruction
• Bronchospasm (Allergic Asthma)
• Collapse of small airways etc
• Reduced static compliance is usually also associated with a decreased dynamic compliance due to associated airway resistance

Increased static compliance indicates easily expandible lung

• Emphysema
• Emphysema is associated with an increased static compliance but decreased dynamic compliance due to associated increased airway resistance.

Reduced Dynamic compliance with reduced static  compliance

• Most conditions where static compliance is reduced are also associated with reduced dynamic compliance due to associated increase in airway resistance.

Ans: D. 1

• The respiratory quotient (or RQ or respiratory coefficient), is a dimensionless number used in calculations of basal metabolic rate (BMR) when estimated from carbon dioxide production. It is calculated from the ratio of carbon dioxide produced by the body to oxygen consumed by the body. Such measurements, like measurements of oxygen uptake, are forms of indirect calorimetry. It is measured using a respirometer.
• The respiratory quotient (RQ) is the ratio:
• RQ = CO_{2 eliminated} / O_{2 consumed}

Answer is C. V max decreased; Km value normal

[Ref: Harper’s Illustrated Biochemistry 30^th edn; Page no. 82]

• Noncompetitive inhibitors bind to the enzyme or the enzyme-substrate complex at a site different from the active site, decreasing the activity of the enzyme. Thus, V_max is decreased.

Ans. d. Phosphocreatine

[Ref: Harper’s Illustrated Biochemistry 30′ edn; Page no. 662]

• As the exercising muscle contracts, adenosine triphosphate (ATP) is utilized.
• Creatine phosphate provides a small reservoir of high-energy phosphate that readily regenerates ATP from adenosine diphosphate (ADP).
• Muscle glycogen is oxidized to produce ATP. Adnosine monophosphate (AMP) activates phosphorylase b, and Ca₂^tcalmodulin activates phosphorylase kinase. The hormone epinephrine causes the production of cAMP, which stimulates glycogen breakdown.
• Creatine phosphate plays an important role during the early stages of exercise in muscle.
• As blood flow to the exercising muscle increases, blood glucose and fatty acids are taken up and oxidized by muscle.
• At that time in the absence of insulin, an AMP-activated protein kinase in muscle will stimulate glucose uptake by muscle.
• So, blood glucose levels begin to decrease, the liver, by the processes of glycogenolysis and gluconeogenesis, acts to maintain blood glucose levels.

Ans. c. Very long-chain fatty acid

[Ref: Harper’s Illustrated Biochemistry 30^th edn; Page no. 241]

• Elevated levels of very long-chain polyenoic acids found in Zellweger (cerebrohepatorenal) syndrome.
• It is an X-linked disorder that affects the transport of very long-chain fatty acids into the peroxisomes for initial oxidation events.
• The loss of this activity leads to the accumulation of very long-chain fatty acids.
• Accumulate of C₂₆-C₃₈ polyenoic acids in brain tissue.
• The result, adrenal glands and the myelin sheath for destruction, through
• incorporation into the membrane lipids surrounding those structures.

Answer: C. Increased lipolysis

• Uncontrolled insulin-dependent diabetes mellitus (type I diabetes) involves decreased glucose utilization, with hyperglycemia, and increased fatty acid oxidation.
• Increased fatty acid oxidation leads to excessive production of acetoacetic and 3-hydroxybutyric acids and of acetone, which are known as ketone bodies.
• 2. Acetoacetic and 3-hydroxybutyric acids dissociate at body pH and release H leading to a metabolic acidosis.
• LCAT is the enzyme that esterifies the free cholesterol on HDL to cholesterol ester and allows the maturation of HDL.
• LCAT deficiency does not allow for HDL maturation resulting in its rapid catabolism of circulating apoA-1 and apoA-2. The remaining form of HDL resembles nascent HDL.

Ans: C. RNA

• Visualization of a specific DNA or RNA fragment among the many thousand of contaminating molecules requires the convergence of number of techniques collectively termed the blot transfer.
• Southern blot ? Detects DNA
• Northern blot ? Detects RNA
• Western blot ? Detects proteins (proteins are separated by electrophoresis, renatured and analysed for an interaction by hybridization with a specific labelled DNA probe).

Answer is C SGOT is raised > SGPT

AST is synonymous with SGOT & ALT is synonymous with SGPT

In general AST and ALT levels rise parallel to each other. In alcoholic liver disease the AST rises out of proportion to ALT such that the ratio of AST and ALT may become greater than 2:

Stigmata of Alcoholic hepatitis / cirrhosis that aid in diagnosis :

1. Bilateral enlarged parotids ^Q.
2. Gynaecomastia^Q
3. Testicular atrophy with loss of body hair^Q
4. Wasting of muscle mass^Q
5. Duputyrens contracture^Q

AST (SGOT) out of proportion to ALT (SGPT) seen in ^Q

1. Alcoholic hepatitis ^Q
2. Fatty liver in pregnancy ^Q

Gamma Glutamyl transferase levels correlate with levels of Alkaline phosphatase and are a sensitive indicater of biliary tract disease — obstructive jaundice. It is not an indicator of alcoholic liver disease.

Remember :GGT is the most sensitive indicator of bilian^, tract disease

Ans: C i.e. Na+ with glucose symport

• In this along with Na⁺, another substance is carried by the carrier protein called symport. The energy is obtained from diffusion process of Na⁺ due to concentration gradient across the cell membrane.
• Na* depended glucose co-transporters (SGLT, members of a large family transporter. Gene name SLC5A).
• Facilitative Na* independent sugar transporter (GLUT family, gene name SLC2A).
• The transport of most hexoses is dependent on Na’ in the intestinal lumen.
• The glucose and galactose both uses the same transport SGLT-1. SGLT-1 transports either glucose or galactose along with Na⁺from intestinal lumen to cell (Secondary active transport).
• Fructose is absorbed by facilitated diffusion from the intestinal lumen into the enterocytes by GLUT-5. This process is Na⁺independent.

Ans: D. Vibrio Parahaemolyticus

• It is the causative agent of food poisoning due to sea fish.
• Usual signs are abdominal pain, diarrhea, vomiting and fever.
• Feces contain cellular exudate and blood. Dehydration is moderate.
• Infections with V parahaemolyticus can result in two distinct gastrointestinal presentations (including nearly all cases in North America).
• The most common presentation is watery diarrhea, usually occurring in conjunction with abdominal cramps, nausea, and vomiting and accompanied in —25% of cases by fever and chills.
• Dysentery, the less common presentation, is characterized by severe abdominal cramps, nausea, vomiting, and bloody or mucoid stools.
• V parahaemolyticus contains two type III secretion systems, which directly inject toxic bacterial proteins into host cells.
• After an incubation period of 4 hours to 4 days, symptoms develop and persist for a median of 3 days.
• V parahaemolyticus is linked to its ability to cause hemolysis on Wagatsuma agar) i.e. is called as Kanagawa phenomenon.
• Recovery occurs in 1-3 days. Common in summer and in adults.

Ref: Ananthanarayan & Panicker’s, 8th Edition, Page 312

Ans. is ‘b’ i.e., Corynebacterium diphtheriae

• Albert’s stain is used for metachromatic granules, mostly found in corynebacterium diphtheriae.

Ans. d. Cryptosporidium hominis

• Opportunistic infections are extremely common post-transplant in the period starting from 1 month post-transplant to 6 months post-transplant.
• Clostridium difficle is usually seen within 1 month post-transplant because of profound antibiotic use.
• Kinoyn stain (Modified acid fast) positivity rules out Balantidium.
• Now it is between cryptosporidium vs cycloisospora. Size (smaller i.e., 2-6 microns) tells us that the organism is undoubtedly cryptosporidium hominis (previously parvum).

Ans: C. Entamoeba histolytica

• Entamoeba histolytica is the usual cause of intestinal amebiasis, and has the microscopic features described in the question stem.
• A particularly helpful (but not always present) feature of this organism is the presence of ingested red blood cells within the amoebae.
• These amoebae cause flask-shaped ulceration of the intestinal mucosa and submucosa, with a particular propensity for involving the cecum and ascending colon. The disease manifestations range from none (asymptomatic carriers) to mild chronic diarrhea, to severe, purging dysentery.
• In symptomatic cases, the liver may develop destructive amoebic liver abscesses that tend to become secondarily (and potentially life-threateningly) infected by bacteria.
• Acanthamoeba is a free-living amoebae that can cause amoebic meningocephalitis.
• Balantidium coli is a large ciliated intestinal parasite that can occasionally cause colonic disease resembling that caused by Entamoeba histolytica.
• Giardia lamblia is a small intestinal protozoa with a distinctive pear-shaped morphology that appears to have a “face.” 

Ans. is ‘d’ i.e., Effective against viral infection

Ans. b. Influenza

Vaccination Update 2016-2018

Ans: D. Listera monocytogenes
isteria monocytogenes cause meningitis < 2months and > 55yrs. 

Ref: Text Book of Pediatrics By Nelson, 17th Edition, Page 2038

Ans: B. Bordetella Pertussis
Bordetella Pertussis is an organism which shows Bisected pearls/ Mercury drops appearance of colonies on Regan-Lowe medium as shown in the  photograph above.
B. pertussis  is a very small Gram-negative aerobic coccobacillus that appears singly or in pairs. Its metabolism is respiratory, never fermentative, and taxonomically, Bordetella is placed among the “Gram-negative Aerobic Rods and Cocci” in Bergey’s Manual. Bordetella is not assigned to any family. The bacteria are nutritionally fastidious and are usually cultivated on rich media supplemented with blood. They can be grown in synthetic medium, however, which contains buffer, salts, an amino acid energy source, and growth factors such as nicotinamide (for which there is a strict requirement). Even on blood agar the organism grows slowly and requires 3-6 days to form pinpoint colonies.
Bordetella pertussis colonizes the cilia of the mammalian respiratory epithelium. Generally, it is thought that B. pertussis does not invade the tissues, but some recent work has shown the bacterium in alveolar macrophages. The bacterium is a pathogen for humans and possibly for higher primates, and no other reservoir is known. Whooping cough is a relatively mild disease in adults but has a significant mortality rate in infants. Until immunization was introduced in the 1930s, whooping cough was one of the most frequent and severe diseases of infants.

Ans. is ‘b’ i.e., Clindamycin

• Clindamycin does not require dose adjustment in renal failure.

Ans. is ‘d’ i.e., Hypoglycemia

• Inhaled β-agonists have very few side effects. These are : (i) Muscle tremer & palpitation most common;(ii) hypokalemia; (iii) hyperglycemia; (iv) Tolerance; (v) Throat irritation; (vi) Ankle edema; and (vii) others (anxiety, headache, muscle cramps, dry mouth, arrhythmias , flushing & vasodilatation, hypoxemia, MI, sleep disturbance).

Ans. is ‘a’ i.e., Volume of distribution
Loading dose is governed by volume of distribution and volume of distribution is affected by lipid solubility.
Maintenance dose is governed by clearance (excretion) of drug and half life.

Ans is ‘a’ i.e., Extracellular fluid

• A drug with high volume of distribution has more concentration in tissue and less in plasma.
• A drug with low volume of distribution has concentration only in plasma (intravascular)
• Relationship between volume of distribution and extent of distribution

Ans: B. Congenital cholangiopathy [ Ref Ghai G^h/e p 171-174 Nelson 17^th/e p 594-595] “Congenital cholangiopathv will cause conjugated hyperbilirubinemia”

Physiological jaundice

• Most neonates develop visible jaundice due to elevation of unconjugated bilirubin concentration during their first week
• This common condition is called physiological jaundice.
• This pattern of hyperbilirubinemia has been classified into two functionally distinct periods. 

Phase one

• Last for five days in term infants and about seven days in pretenn infants, when there is a rapid rise is serum bilirubin levels to 12 and 15 mg/dl respectively.

Phase two

• There is decline to about 2 mg/dl, which lasts for two weeks after which adult values are attained. Breastfeeding jaundice and Breastmilk jaundice
• There is strong association between exclusive breastfeeding and neonatal jaundice.
• A few babies who remain on exclusive breast feed develop jaundice in the second week of life and continue well into the third month. This is called breastmilk jaundice.
• A bilirubin level of over 20 mg/dl may be attained. (It is presumed to be due to inhibitory substances in the breastmilk that interfere with bilirubin conjugation e.g. pregananediol and free fatty acids).
• Temporary interruption of breastmilk feeds will dramatically reduce the serum levels of bilirubin and there may be slight increase in bilirubin when breast feeding is resumed, but it never reaches the previous levels. Hypothyroidism
• Persistent elevation of indirect bilirubin is the first sign of congenital hypothyroidism in neonates.
• This is due to decreased activity of UDPGT for weeks or months after birth.
• At least 10% of all infants with congenital hypothyroidism will have jaundice as the presenting symptom.
• Treatment with thyroxine promptly alleviates jaundice.

Cotrimoxazole  taken in 3rd trimester may  cause significant increase in the serum unconjugated bilirubin level.

Differential diagnosis of Breast milk jaundice

Differential diagnosis of unconjugated hyperbilirubinemia :

Increased production

• Fetomaternal blood group incompatibility Rh, ABO.
• Hereditary spherocytosis
• Non spherocytic hemolytic anemia, (G6PD) deficiency, pyruvate kinase deficiency, alpha thalassemia, vitamin K induced hemolysis.
• Sepsis
• Increased enterohepatic circulation, pyloric stenosis or large bowel obstruction.

Decreased clearance

• Inborn errors of metabolism. Criggler Najar Syndrome type I & II.
• Drugs and hormones, hypothyroidism, Breast milk jaundice.

Ans. is ‘a’ i.e., Conduction block

Adverse effects of CCBs

• Nausea, constipation and bradycardia are more common with verapamil.
• Verapamil can accentuate conduction defect-should be avoided in 2^nd & 3^rd degree block, in sick sinus syndrome and along with 13-blocker.
• Most common side effects of DHPs are palpitation, flushing, hypotension, headache, ankle edema, drowsiness and nausea.
• Nifedipine can paradoxically increase the frequency of angina in some patients.
• Nifedine can cause voiding difficulty in elderly (relaxant effect on bladder) and glucose intolerance (decreases insulin release).

Ans: A. Delayed diastolic depolarization

• Acetyl choline decreases heart rate primarily by inhibiting the spontaneous depolarization of cells in SA node; also known as diastolic depolarization. This is achieved by inhibition of the funny current in the SA node.

Ans. A: Decreases aqueous humor production
Acetazolamide(Daimox) is a noncompetitive antagonist of carbonic anhydrase. , which means that it forces the kidneys to excrete bicarbonate (HCO;), thus re-acidifying the blood.
It also lowers intraocular tension by decreased formation of aqueous humour (It is rich in bicarbonate)

Ans: C. Primaquine

[Ref: Goodman Gilman’s The Pharmacological Basis of Therapeutics 13″ edn; Page no. 980, NVBD Guidelines]

Ans: D i.e. Tamoxifen

Tamoxifen may cause macular edema/ retinopathyQ as an adverse effect, so it is not used for the treatment of diabetic macular edema/retinopathy.

Protein Kinase C inhibitor ruboxistaurin; aldose reductase inhibitor pyridazinones and ; lipid soluble derivative of vitamin B1/ thiamin – benfotiamine; anti VEGF agents bevacizumab, ranibizumab & pegaptanib and intra vitreal long acting steroids are emerging drugs for medical intervention of diabetic retinopathy.

Tamoxifen (a non steroidal anti-oestrogen) is used in treatment of breast cancer. Retinotoxicity / retinopathy associated with high dose is characterized by symptomatic decrease in vision and crystalline maculopathys (crystal deposition & macular edema). The characteristic fundus findings were bilateral, superficial, fine (small), white / yellow refractile, crystalline deposits in inner layers of retina particularly in perimacular area and punctate grey lesions in outer retina & RPE. Fluorescein angiography shows macular edema in most cases. Retinopathy a/w low dose may include macular crystals, RPE irrigularity, and macular edema. FA shows window defects & / or cystoid macular edema. Optical coherence tomography (OCT) demonstrate a foveolar cystoid space, loss of photoreceptors and lack of macular thickening.

Ans: A. Cardiac anomaly [Ref: K.D.T. 6/e p. 436; Katzung 11/e p. 503]

• Lithium is a weak teratogen in human.
• The main effects attributable to lithium are increased cardiac malfonnation in the fetus especially “Ebsteins anomaly”.
• Lithium may increase the incidence of Ebstein’s anomaly in fetus but it is not contraindicated during pregnancy. Lithium is not considered a major human teratogen and the risk _.for Ebstein’s anomaly is only .5% for babies whose mother takes lithium during pregnancy.
• Therefore lithium is not contraindicated during pregnancy. It is however advisable to perform a “fetal echocardiography” to exclude the possibilities of cardiac anomaly.
• Evaluation of studies on lithium in pregnancy shows that lithium therapy throughout pregnancy does not seem to increase the general rate of major anomalies and apparently add only a small risk for cardiovascular defects notably Ebstein’s anomaly.
• It can be concluded that whenever lithium is the drug of choice in women with bipolar disorder, it may be  continued even in pregnancy.
• Moreover it is advised not to discontinue lithium as it may subsequently lead to replapse of the disorder.
• In addition, pregnancy of lithium treated women should he considered high risk and therefore monitoring during pregnancy has to include “fetal echocardiography”.
• Pregnancy interruption in lithium treated mothers can probably be considered only if severe cardiac anomaly is diagnosed.

According to K.D.T.

• Lithium is contraindicated during pregnancy.
• But all other hooks states that lithium can be administered is during pregnancy.

Ans. is ‘b’ i.e., Carnitine

• Valprate is a hepatotoxic drug.
• Valproate is metabolized by CYP450 enzymes in to a minor metabolite 2-propy1-4-pentenoic acid (4-ene-VPA) which is hepatotoxic.
• Enzyme inducers like carbamazepine, phenytoin and phenobarbital can induce the microsomal enzymes and increase production of this metabolite. This increases the risk of hepatotoxicity if carbamazepine is used along with valproate.
• Valprate hepatotoxicity is more common in persons with mitochondrial enzyme deficiency and may be ameliorated by administration of Carnitine, which valproate therapy can deplete.

Ans. C: Acetazolamide

The CDC advises that Dexamethasone be reserved for treatment of AMS and High-altitude cerebral edema (HACE) during descents, and notes that Nifedipine may prevent High-altitude pulmonary edema (HAPE).

Despite their popularity, antioxidant treatments have not been found to be effective medications for prevention of AMS.

Interest in phosphodiesterase inhibitors such as sildenafil has been limited by the possibility that these drugs might worsen the headache of mountain sickness

Ans. is `c’ i.e., 16-24 months

• Multi drug resistance TB (MDR TB) is referred to resistance to “isoniazid and rifampiein” with or without resistance to other drugs. MDR-TB is classified as category IV under DOTS ( DOTS -PLUS)
• Treatment of Category IV (MDR-TB) includes;-
• Intensive phase ( 4 months): KOCZEEt
• Continuation phase (12-18 months): OCEEt
• Total duration 16-24 months [letter:-E-Ethambutol, Z-Pyrazinamide, K-Kanamycin, 0-0floxacin, Et-Ethionamide, C-Cycloserine]
• In general treatment of MDR -TB is based on sensitivity of drugs and 5 or 6 of the drugs should be chosen in following order of preference ( based on known sensitivity) –
• An aminoglycoside ( amikacin or kanamycin) or capreomycin > Pyrazinamide > Ethambutol > Flouroquinolones. (moxifloxacin preferred) > rifabutin > cycloserine > ethionamide > PAS > clarithromycin > Linezolid > IFN – a >
• thioridazine.
• Extensive drug resistance TB ( XDR — TB) is referred to resistance to rifampicin and isoniazid as well as to quinolone and at least one of the following second line drug kanamycin, capreomycin or amikacin.
• XDR — TB = resistance to INH, rifampcin, Quinolone, and capreomycin/kanamycin/ amikacin

Following information has been added in 22nd/e of Park

• Treatment of XDR-TB under daily DOTS : –

1. Intensive phase (6-12 months) : – Capreomycin, PAS, moxifloxacin, clofazimine, linezolid, amoxicillin/ clavulinic acid.
2. Continuation phase (18 months) : – PAS, moxifloxacin (high dose), INH, clofazimine, linezolid, amoxicillin/ clavulinic acid.

Ans: B. Section H

[REF: Forensic Medicine and Toxicology by R.N. Karmakar page. 42]

As per drug and cosmetic rule 1945, Drugs are classified into different schedule as follows:

Ans. is ‘b’ i.e., 36 weeks

• In pregnancy warfarin should be replaced by heparin prior to conception and continued throughout the first trimester (In early pregnancy , warfarin damages organogenesis in fetus).
• After the first trimester heparin should he replaced by warfarin and continued upto term (continued exposure to heparin cause osteoporosis).
• Warfarin should be discontinued near term and heparin can be substituted at this stage (warfarin exacerbates neonatal hypoprothrombinemia and its control is too imprecise to be safe in labour where as heparin can be discontiuned just before labour and its anticoagulant effect wears off in about 6 hrs).

Ans. c. Phase I trial (Ref KDT 7/e p79, 6/e p77)
Phase I: Human Pharmacology and safety

• The emphasis is on safety and tolerability, while the purpose is to observe the pharmacodynamic effects in man, characterize absorption, and to distribution, metabolism and excretion

Ans. is ‘b’ i.e., Increases Guanyl Cyclase

• “Nitroprusside dilates both arterial and venous vessels, resulting in reduced peripheral vascular resistance and venous return. The action occurs as a result of activation of guanylyl cyclase, either via release of nitric oxide or by direct stimulation of enzyme. The result is increased intracellular cGMP, which relaxes vascular smooth muscle”.

Ans. is ‘a’ i.e., Dermatitis herpetiformis

• Dapsone is first line anti-leprotic drug.
• Dapsone is also used in dermatitis herpatiformis (drug of choice), P. jiroveci infection in AIDS, actinomycetoma, rhinosporidiosis, toxoplasmosis and leishmaniasis.

MOA :

• Dapsone is an analog of para-aminobenzoic acid (PABA) and hence competitively inhibits dihydropteroate synthase (DHPS) required for folic acid synthesis.

Ans. is ‘c’ i.e., Rifampicin, ofloxacin and minocyclin single dose 

• For patients with single – lesion paucibacillary leprosy, the who recommends as an alternative a single dose of rifampicin, ofloxacin and minocycline.

PB adult treatment:

• Once a month: Day 1

• 2 capsules of rifampicin (300 mg x 2)
• 1 tablet of dapsone (100 mg) Once a day: Day 2-28
• 1 tablet of dapsone (100 mg) Full course: 6 blister packs

MB adult treatment:

• Once a month: Day 1

• 2 capsules of rifampicin (300 mg x 2)
• 3 capsules of clofazimine (100 mg x 3)
• 1 tablet of dapsone (100 mg) Once a day: Day 2-28
• 1capsule of clofazimine (50 mg)
• 1 tablet of dapsone (100 mg) Full course: 6 blister packs

Ans. is ‘c’ i.e., Myocardial infarction 

• Morphine should be given promptly in myocardial infarction to allay apprehension and reflex sympathetic stimulation.
• Morphine should be used cautiously in gall bladder and biliary tract dysfunction as it causes spasm of sphincter of oddi and can cause acute rise of intrabiliary pressure.
• Used during labour, morphine can cause neonatal respiratory distress.
• Head injury is a contraindication for morphine use.

Ans: b. It acts on transcription factor

[Ref: Goodman Gilman’s The Pharmacological Basis of Therapeutics 1.3′ edn; Page no. 791]

• Thyrotropin releasing hormone (TRH) acts on Gq subtype of receptors on thyrotrope cells in pituitary; this activates protein kinase C which increases synthesis of TSH.
• TSH acts on Gs subtype of receptors on thyroid cells and increases cyclic AMP, which leads to an increase in production of sodium iodide symporter, thyroid peroxidase and thiol endopeptidase. All these are crucial for synthesis and release of T3 and T4.
• T3 and T4 act on thyroid receptors which are nuclear receptors and hence act via modulating the transcription factors.
• Increased T3 and T4 levels decrease release of TSH by decreasing the transcription factors for both TSH and TRH.

Answer: c. Continue valproate and serial drug monitoring in blood (Ref Harrison I9/e p2544, 18/e p3269)
Continue valproate with serial drug monitoring in the blood of the 4-month old patient having history of juvenile myoclonic epilepsy.

Ans. C: Ethambutol

Causes of nutritional optic neuropathy include tobacco, ethanol, thiamine, and vitamin B-12.

• Causes of toxic optic neuropathy include chemicals and drugs, such as methanol, ethylene glycol, ethambutol, isoniazid, digitalis, cimetidine, vincristine, cyclosporine, toluene, and amiodarone.
• Chloroquine causes loss of vision due to retinal damage. Corneal deposits may also occur and affect vision, but are reversible on discontinuation.

Ans. is ‘ d ‘ i.e., Griseofulvin

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. is ‘c’ i.e., Specific antibody

• Hybridomas are cells that have been engineered to produce a specific antibody in huge numbers.

Hybridomas

• Hybridomas are cells that have been engineered to produce a specific antibody in huge numbers 
• To achieve this, qualities of two types of cells have to be combined together i.e.
• Cells which can produce large amount of pure antibody and
• Cells which have the ability to grow continually.
• These two types of cells are then fused together to form hybridoma.

Procedure

• The pure antibody secreting cells are produced by injecting specific antigen in a mouse and obtaining the antigen specific plasma cells (antibody producing cell) from the mouse’s spleen.
• Cell which can grow indefinitely in culture are myeloma cells (cancerous cells).
• These two cell lines are fused together. The hybrid cell which is thus produced can be cloned to produce large number of identical daughter clones.
• These daughter clone cells then produce antibodies. Since these antibodies come from only one type of cell (hybridoma cell) they are called monoclonal antibodies.
• HAT (hypoxanthine, Aminopterin and thymidine) medium is used for preparation of monoclonal antibodies because it allows only fused hybridoma cells to grow. It does not allow the unfused myeloma and unfused antibody cells to grow. So HAT medium is a selective medium which allows (which allow selective growth of fused hybridoma)
• How does this happen ?
• Before we move on with the discussion, remember these few points about purine synthesis.
• Purine synthesis is essential for the survival of cells.
• Purine can be synthesized in two way i.e.
• De novo synthesis (dihydrofolate reductase enzyme is required for this pathway).
• Salvage pathway (an enzyme hypoxanthine – guanine phosphoribosyl transferase is required for salvage pathways)
• Myeloma cells lack HGPRTase enzyme therefore they cannot synthesize purine by salvage pathways. o Antibody cells have HGPRTase enzyme so they can use the salvage pathways.
• Aminopterin inhibits dihydrofolate reductase an enzyme used in denovo synthesis of purine
• When two cell lines i.e. antibody producing cell and myeloma cells are grown in HAT medium only the fused hybridoma cells survive.
• Myeloma cells die because they lack the enzyme HGPRTase so they cannot use the salvage pathways for purine synthesis. They also cannot use de-novo pathway, because Aminopterin present in the HAT medium inhibits dihydrofolate reductase (an enzyme essential for denovo synthesis ofpurine).
• The unfused antibody producing cells die as they cannot grow indefinitely because of their limited life span.
• Only fused hybridoma cells grow indefinitely because the antibody cell partner supplies HGPRTase and the myeloma partner gives it immortality. (as it is a cancer cell)

Ans: d. 8°-15°

[Ref: Vogel Drug Discovery/Page no. 235]

Drug Storage Temperature

Ans. A. Threatening

Ref: KSN Reddy’s The Essentials of Forensic Medicine and Toxicology 33^rd edn; Page no. 36

• As per Protection of Children from Sexual Offences (POCSO) Act, an offence is treated as “Aggravated” when committed by a person in a position of trust or authority of child, such as member of security forces, police officers, public servant, etc.

The Protection of Children from Sexual Offences (POSCO) Act, 2012

• It is applicable to the whole India.
• It defines a child as any person below the age of 18 years and provides protection to all children <18 years from sexual abuse.
• Offences against children covered under this Act:

1. Penetrative and aggravated penetrative sexual assault.
2. Sexual and aggravated sexual assault.
3. Sexual harassment.
4. Using a child for prolonged purposes.

• It is now mandatory for police to register an FIR in all cases of child abuse.
• The child’s medical examination can be conducted even prior to registration of an FIR. The I0 has to get the child medically examined in a government hospital or local hospital within 24 hours of receiving information about the offence with consent of the child or parent or a competent person whom the child trusts and in their presence.
• Some child-friendly procedure envisaged:

1. At night no child to be detained in the police station.
2. The statement of the child to be recorded as spoken by the child.
3. Frequent breaks for the child during trial.
4. Child not to be called repeatedly to testify.

Punishment

Ans. is ‘d’ i.e., All of the above

There is no fixed list of conduct constituting professional misconduct, however some important examples are 😕

1. Criminal abortion
2. Treating the patient in drunk state
3. Unnecessory advertisement
4. Adultery
5. Being drug addict
6. Dichotomy (fee-sharing)
7. Avoiding consultation on religious ground viii)Issuing false certificates
8. Association with drug manufacturing firms
9. Assisting unquilified person (covering)
10. Appointing unquilified staff
11. Keeping agents to get patients
12. Neglet of patient or not attending emergency
13. Selling drugs or instruments
14. Wrong investigation or treatment
15. Not explaning the prognosis
16. Experimentation on patient.

• As per Code of Medical Ethics by MCI, every physician shall maintain the medical records of indoor patients for a period of 3 years from the date of commencement of the treatment in a standard prescribed format. If any request is made either by the patients/authorized attendants or legal authorities involved, the records shall be issued within 72 hours. If the medical records are not issue, it amounts to misconduct.
• As per MCI (3 letter word) medical record to be stored for 3 years and give within 3 days (72 Hours)

Ans: C. Presence of semen in the posterior fornix in a girl age 14 Years

Ans: C. Complete description of injury as seen

[Ref KSN Reddy’s The Essentials of Forensic Medicine and Toxicology 33′ edn; Page no. 97]

• Important: The order of Bite mark investigation: C > B > A> D

Bite Mark Investigation

• Complete description of injury as seen
• Photograph: Keep scale for measuring below the mark and take photo from different angle.
• Swabbing of saliva: To identify or exclude assailant from secretor status who exude blood group substance in the saliva.
• Impression of bite mark: Plastic substance (rubber or silicone based) or plaster of Paris is laid over the bite mark that hardens and produces permanent negative cast of the lesion.
• Skin carrying the bite is removed and preserved in formalin during autopsy.

Ans: A i.e. Identification of weapon

• Primary markings (class characteristics) and secondary markings (metallic fouling, individual or accidental characteristics) on a bullet can be used for identification of weaponQ.
• Bullet is picked up with handsQ. Gunshot residue on hands can be detected by Dermal nitrate testQ.

Ans: b. False virgin

[Ref: KSN Reddy’s The Essentials of Forensic Medicine and Toxicology 33′ edn; Page no. 392]

False Virgin

• Hymen is intact but thick and the woman has had sexual intercourse. Labia majora: Flabby, may gap on abduction of thigh
• Labia minora: Loose, blackish-brown, cutaneous
• Vagina deep, roomy, dilated and capacious with less rugosed wall Vagina easily admits two fingers.

True Virgin

• Labia majora: Firm, rounded and complete
• Labia minora: Soft, sensitive and pink in color
• Fourchette and posterior commissure: Intact • Vaginal wall: Closely approximated
• Vagina mucosa: Rugose, reddish, sensitive to touch
• Hymen: Intact

Ans: B i.e. Hinge fracture of base of skull
Guide to forensic medicine & toxicology: Jain (2004) p 98] Hinge fracture of base of skull, in which the base of skull is divided into two halvesQ, each moving independently of each other like a hinge, is termed as motor cyclest’s facture.

Guide to forensic medicine & toxicology: Jain (2004) p 98] Hinge fracture of base of skull, in which the base of skull is divided into two halvesQ, each moving independently of each other like a hinge, is termed as motor cyclest’s facture.

Ans:A.)Carbon Monoxide
Post mortem lividity shows Bright red cherry discolouration of Skin.
Postmortem lividity

• Livor mortis (postmortem lividity / hypostasis / suggillation)is the fourth stage and one of the signs of death. 
• Purple coloration of dependent parts, except in areas of contact pressure, appearing within 30 minutes to 2 hours after death, as a result of gravitational movement of deoxygenated blood within the vessels.

Colour of post mortem lividity (hypostasis)

• Normal – Bluish pink which later turns into bluish purple
• Carbon monoxide – Bright cherry red
• Cyanide – Pink
• Phosphorous – Dark brown
• Nitrates – Reddish brown
• Chlorates – Chocolate brown
• Hydrogen sulphide – Bluish Green
• Aniline – Deep blue
• Opiates – Black

Postmortem findings of CO-poisoning

• Fine froth at mouth and nose.
• Bright cherry red discolouration of skin, mucous membranes, nail-beds, blood, tissues and internal organs as shown in the picture above. Cyanide poisoning and exposure to cold causes similar redness.
• Blood is fluidish thin, hyperemia (congestion) is general, and serous effusion are common.
• Skin blisters or red patches due to hypoxia in areas that contact the ground or appositional skin e.g. axilla, inner thigh, buttock, calves, knee.
• Lungs show congestion with pink fluid blood, followed by pulmonary edema and bronchopulmonary consolidation.
  Pleural and pericardial anoxic haemorrhage, tiny focal necroses in myocardium are late changes (5 days).
• Bilateral symmetrical necrosis and cavitation of basal ganglia (esp globus pallidus and putamen)
• Spectroscopic examination, Hoppe – Seyler’s test (10% NaOH), kunkel’s (tannic acid) test and adding water (15 ml) in 2 drops of blood can detect CO.

Ans: B. Arsenic poisoning
The image shows raindrop pigmentation as characterstically seen in Arsenic Poisoining 

There is patchy brown (not black) pigmentation of skin.

Chronic arsenic poisoning has four stages :

• First stage (nutritional and gastrointestinal disturbances) : The earliest sign is gradual emaciation. There is loss of appetite, nausea and intermittent vomiting and diarrhea.
• Second stage (catarrhal changes) : It resembles common cold, i.e. conjunctivitis, running nose and eyes, coughing etc.
• Third stage (skin rash) : There is classical ‘rain drop pigmentation’, i.e. patchy brown pigmentation of skin. At initial stages, there is a vesicular eruption which may resemble nettle rash. Hyperkeratosis of palms and soles occur. There are white transverse bands crossing the nails, known as Mee’s line, and indicate periods of arrested growth due to interference with normal metabolism. There is alopecia and exfoliative dermatitis.
• Fourth stage (nervous disturbances) : There is sensory and motor (i.e. mixed) polyneuropathy, with painful paresthesia of hands and feet and muscle tenderness.

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: A. Cytokeratin

[Ref: Robbins and Cotran Pathologic Basis of Disease 9^th edn; Page no. 627]

• Cytokeratin is an epithelial cell marker (absent in lymphoma).
• Thymomas have T cells and mediastinal ALL is mostly T-ALL. So the marker which will help to distinguish is the Cytokeratin.

1. Positive in thymoma
2. Negative in ALL

• CD la is positive for langerhans cells and thymic Lymphocytes and can be positive in some Lymphomas.
• CD3: Signal transduction complement of T-cells

Ans. is ‘a’ i.e., Langerhans cells; ‘c’ i.e., Dendritic cells

Ans. is ‘d’ i.e., HHV – 8

Castleman disease is group of lymphoproliferative disorders.

Disease is caused by hypersecretion of IL-6.

Release of these cytokines may be caused by HHV-8 in HHV-8 associated Multicentric Castleman Disease (MCD).

• Castleman disease (CD) has been divided into a solitary and a multicentric form.
  • The solitary form presents as a mass located most commonly in the mediastinum, neck, lung, axilla, mesentery, broad ligaments and retroperitoneum.

Grossly, it is round, well circumscribed, with a solid gray cut surface and can measure 15 cm in diameter.

The follicles show marked vascular proliferation and hyalinization of their abnormal or atrophic germinal centers, surrounded by concentrically arranged small lymphocytes imparting an “onion-skin” appearance.

• Remember angiolymphoid hyperplasia show thick walled blood vessels with
  prominent endothelial cells and inflammatory eosinophilia infiltrates.

Ans. is ‘a’ i.e., Cell shrinkage
Morphological changes in apoptosis
Features of apoptosis are 😕

1. Cell shrinkage : It is the earliest changes. It is due to damage to cytoskeletal proteins.
2. Chromatin condensation (pyknosis)/nuclear compaction : It is the most characteristic feature.
3. Formation of cytoplasmic blebs : It is the end stage of apoptosis.
4. Cytoplasmic eosinophilia.
5. Chromosomal DNA fragmentation : It is due to activity of endonuclease and caspases.
6. Formation of apoptotic bodies : These are membrane bound round masses of eosinophilic cytoplasm with tightly packed orgaelles which may contain nuclear debries. Important examples of apoptotic bodies are civatte bodies, kamino bodies, councilman bodies, Tingible bodies, sunburn cells, satellite dyskeratotic cells, and eosinophilic globules.
7. Phagocytosis of apoptotic cells and bodies by adjacent macrophages or healthy parenchymal cells.
8. Considerable apoptosis may occur before it becomes apparent on histological section.

Two very important differentiating features from necrosis are 😕

• Absence of inflammation.
• Intact cell membrane.

Answer is D (Celiac sprue)

A Positive d-xylose test suggests a diagnosis of celiac disease

Decreased urinary excretion of d- xylose (<5.0 gm) 5 hours after administration of 25 gm D- xylose (positive test) suggests malabsorption due to intestinal mucosal disease in the proximal small bowel (duodenum and jejunum).

Celiac disease is a charachteristic cause for positive d-xylose test and the single best answer amongst the options provided

Modestly abnormal d-xylase test may also be seen in cases of bacterial overgrowth syndrome, however patients with bacterial overgrowth syndrome may also have normal d-xylose excretion, and hence this is not considered as the most likel^y diagnosis

Ans: A. O negative
Since this patient’s blood group is not known and there is no much time to match blood groups he should be given O negative blood.
O negative blood is otherwise known as universal donor as it does not contain any antigen it can be transfused into blood of any other ABO group without any chance of transfusion reaction.
Since this blood is Rh negative it does not contain Rh antigen which may cause Rh mismatching on transfusion.  
AB blood group does not contain any antibody. So it can receive blood of any other ABO group without any chance of transfusion reaction. So group AB is known as universal recipient. Rh positive blood does not contain Anti D antibody. So there is no chance of Rh mismatching when Rh positive blood receives transfusion. Therefore AB positive blood group is universal recipient.

Ans: D. NK cells, neutrophils & macrophage

[Ref: Robbins and Cotran Pathologic Basis of Disease edn; Page no. 784]

• Antibody depended cell-mediated cytotoxicity (ADCC) is the killing of an antibody-coated target cell by a cytotoxic effector cell through a non­phagocytic process, characterised by release of content of cytotoxic granules Tor by expression of cell death-inducing molecules.
• ADCC is triggered through interaction of target bound antibodies (IgA, IgG or IgE) with certain Fc receptors, glycoproteins present on the effectors cell surface that binds the Fc region of Ig.
• Effector cells that mediate ADCC include NK Cells, monocytes, macrophages, neutrophils, eosinophils and dendrite cells.

Ans: D. Toll like receptor

[Refi Robbins and Cotran Pathologic Basis of Disease edn; Page no. 188]

• Phagocyte has many types of receptors on its surface that are used to bind material.
  They include opsonin receptors, scavenger receptors, and Toll-like receptors.
  Binding to Toll-like receptors increases phagocytosis and causes the phagocyte to release a group of hormones that cause inflammation.

Receptors of the Innate Immune System

Ans: b. Seminiferous tubules

[Ref Robbins and Cotran Pathologic Basis of Disease 9^th edn; Page no. 214]

• Cornea, brain and testes are the immune privilege sites.
• The above are called immune privilege site because it is difficult to induce immune response to antigen introduced into these sites.
• In testis there occurs segregation of antigens in the seminiferous tubules from immune cells in the interstitial space by a layer of Sertoli cells connected by impermeable tight junctions which form a blood-testis barrier.

Answer is C (Wire loop lesions):

Wire loop lesions are characteristic of Lupus nephritis.

Wire loop lesions:

• Wire loop lesions represent local PAS – Positive thickening of glomerular capillary walls and are characteristically seen in Lupus Nephritis (SLE)
• These lesions result from subendothelial deposits between endothelium and basement membrane.
• When extensive and confluent, these subendothelial deposits create a homogenous thickening of the capillary wall which can be seen in light microscopy as ‘Wire loop lesion’
• Wire loop lesions are most characteristic of Lupus Nephritis Class IV or Diffuse Lupus Nephritis These may however also be seen in Class III (Focal Lupus Nephritis) and Class V (membranous) Lupus Nephritis.

Ans: D. Sodium hypochlorite
Sodium hypochlorite Common Disinfectants for Hos^pital Use

Ans. is ‘a’ i.e., Diffuse periosteal reaction

Skin involvement in systemic sclerosis

• Skin involvement is a nearly universal feature of systemic sclerosis (SSc).
• It is characterized by variable extent and severity of skin. Thickening and hardening.
• The fingers, hands, and face are generally the earliest areas of the body involved.
• Edematous swelling and erythema may preceede skin induration.

Other prominent skin manifestations include :

• Pruritus in the early stages
• Edema in the early stages
• Sclerodactyly
• Digital ulcers
• Pitting at the fingertips
• Telangiectasia
• Calcinosis cutis

Radiographs of the hands may reveal

• Soft tissue calcifications (calcinosis cutis).
• Resorption of the distal phalangeal tufts (acro-osteolysis).

Less common radiographic findings are :

• Articular erosions
• Joint space narrowing
• Demineralization
• The symptoms of the female and presence of antinuclear antibody points towards the diagnosis of systemic sclerosis. It is a case of systemic sclerosis or scleroderma.

The clues to the diagnosis of scleroderma are :

• Sclerodactyly
• Raynaud’s phenomenon
• Dysphagia
• Presence of antinuclear antibody
• Though systemic sclerosis is a multisystem disease, the two most distinguishing features of systemic sclerosis are:

o Striking cutaneous changes

• Notable skin thickening. This is the most easily recognized manifestation of scleroderma.

Raynaud’s phenomenon

• This is the first manifestation of disease in almost every patients.

Dysphagia

• Attributable to esophageal fibrosis and its resultant hypomotlity is present in more than 50% of patients.
• Remember,
• Whenever skin thickening is present along with Raynaud’s phenomenon, it is almost always a case of scleroderma”.
• These two features are not present in any other multisystem disease whose clinical features overlap with that of systemic sclerosis e.g. SLE, rheumatoid arthritis, inflammatory myopathy, Sjogren syndrome”.
• Although skin changes and Raynaud’s phenomenon are the major diagnostic clues, scleroderma is a multisystem disease that most commonly targets peripheral circulation, muscles, joints, gastrointestinal tract, lung, heart and kidney.
• So, the symptoms encountered in early presentation of scleroderma include musculoskeletal discomfort, fatigue, weight loss, and heart burn and dysphagia associated with gastroesophageal reflex disease (GERD).
• When these symptoms are accompanied by the skin thickness and Raynaud c phenomenon, diagnosis ofscleroderma
• should be considered.
• Role of autoantibodies in the diagnosis of scleroderma
• Autoantibodies are found in nearly every patient with scleroderma (sensitivity >95%), but they are not specific for scleroderma0.
• Scleroderma is associated with wide array of autoantibodies.

Two ANA’S which are more or less unique to scleroderma are:

• Lipofuscin or lipochrome is yellowish-brown intracellular lipid pigment (lipo = fat, fuscus = brown).
• The pigment is often found in atrophied cells of old age and hence the name ‘wear and tear pigment’.
• It is seen in the myocardial fibres, hepatocytes, Leydig cells of the testes and in neurons in senile dementia.
• However, the pigment may, at times, accumulate rapidly in different cells in wasting diseases unrelated to aging.

By light microscopy, the pigment is coarse, golden-brown granular and often accumulates in the central part of the cells around the nuclei.

• In the heart muscle, the change is associated with wasting of the muscle and is commonly referred to as ‘brown atrophy’ .
• The pigment can be stained by fat stains but differs from other lipids in being fluorescent and having acid-fastness.

By electron microscopy, lipofuscin appears as intralysosomal electron-dense granules in perinuclear location.

• These granules are composed of lipid-protein complexes.
• Lipofuscin represents the collection of indigestible material in the lysosomes after intracellular lipid peroxidation and is therefore an example of residual bodies.
• Unlike in normal cells, in aging or debilitating diseases the phospholipid endproducts of membrane damage mediated by oxygen free radicals fail to get eliminated and hence are deposited as lipofuscin pigment.

Ans:D.)X linked recessive.
Modes of Inheritance

• Inheritance patterns for single gene disorders are classified based on whether they are autosomal or X-linked and whether they have a dominant or recessive pattern of inheritance. These disorders are called Mendelian disorders.

Autosomal Dominant Inheritance

• Only one copy of a disease allele is necessary for an individual to be susceptible to expressing the phenotype.
• With each pregnancy, there is a one in two (50%) chance the offspring will inherit the disease allele.
• Unless a new mutation has occurred, all affected individuals will have at least one parent who carries the disease allele.
• Autosomal dominant inheritance is often called vertical inheritance because of the transmission from parent to offspring.
• Across a population, the proportion of affected males should be equal to the proportion of affected females.
• Male-to-male transmission can be observed.
• Examples of diseases with autosomal dominant inheritance include myotonic muscular dystrophy and Huntington disease.

Autosomal Recessive Inheritance

• In autosomal recessive inheritance, two copies of a disease allele are required for an individual to be susceptible to expressing the phenotype.
• Typically, the parents of an affected individual are not affected but are gene carriers.
• With each pregnancy of carrier parents:
• There is a one in four (25%) chance the offspring will inherit two copies of the disease allele and will therefore have the phenotype.
• There is a one in two (50%) chance the offspring will inherit one copy of the disease allele and will be a carrier.
• There is a one in four (25%) chance the offspring will inherit no copies of the disease allele and will not express the phenotype or be a carrier. This individual would not be at risk for passing the disorder on to his/her offspring.
• As with autosomal dominant inheritance, the proportion of affected males should be equal to the proportion of affected females in a given population.
• Examples of diseases with autosomal recessive inheritance include sickle cell anemia and cystic fibrosis.

X-Linked Dominant Inheritance

• As in autosomal dominant inheritance, only one copy of a disease allele on the X chromosome is required for an individual to be susceptible to an X-linked dominant disease.
• Both males and females can be affected, although males may be more severely affected because they only carry one copy of genes found on the X chromosome. 
• When a female is affected, each pregnancy will have a one in two (50%) chance for the offspring to inherit the disease allele. When a male is affected, all his daughters will be affected, but none of his sons will be affected.
• Examples of diseases with X-linked dominant inheritance are hypophosphatemic ricketsm, oral-facial-digital syndrome type I, and Fragile X syndrome.

X-Linked Recessive Inheritance

• Two copies of a disease allele on the X chromosome are required for an individual with two X chromosomes (a female) to be affected with an X-linked recessive disease.
• Since males are hemizygous for X-linked genes (they have only one X chromosome), any male with one copy of an X-linked recessive disease allele is affected.
• Females are usually carriers because they only have one copy of the disease allele. Affected males are related through carrier females.
• For a carrier female, with each pregnancy there is a one in two (50%) chance her sons will inherit the disease allele and a one in two (50%) chance her daughters will be carriers.
• Affected males transmit the disease allele to all of their daughters, who are then carriers, but to none of their sons.
• Women are affected when they have two copies of the disease allele. All of their sons will be affected, and all of their daughters will be unaffected carriers.
• Examples of diseases with X-linked recessive inheritance include Duchenne muscular dystrophy, hemophilia A and hypohidrotic or anhidrotic ectodermal dysplasia.

Ans: A. Benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo (BPPV) is vertigo that is precipitated by head position. It can be precipitated by trauma, but often no precipitating factor is identified. It generally abates after weeks to months. On exam, patients display nystagmus and the symptoms can be reproduced by head movement. In addition, the symptoms show latency, fatigability and habituation.

Ans: A. Stage I

Staging of angiofibroma

Radkowski Classifications:

Ans: C. Congenital glaucoma

Ans. is ‘c’ i.e., Damage to oculomotor nuclei

Ophthalmoplegia

• Ophthalmoplegia is paralysis of the eye muscles. Three common types are :-

1. External ophthalmoplegia :- If only extraocular muscles are paralysed.
2. Internal ophthalmoplegia :- If only intrinsic muscles (ciliar muscles and iris) are paralysed.
3. Total ophthalmoplegia :- All extrinsic and intrinsic muscles are affected.

• Certain other types of ophthalmoplegia are :-

1. Nuclear ophthalmoplegia :- It is paralysis of extraocular muscles due to lesion of the third cranial nerve nuclei. They are more often bilateral.
2. Ophthalmoplegic migraine or Episodic ophthalmoplegia :- It is characterized by recurrent attacks of headaches associated with paralysis of third, fourth and sixth cranial nerves. The incidence of involvement of the third cranial nerve is the most common and it persists for days or weeks after the attack. It is often unilateral and tends to become permanent.
3. Chronic progressive external ophthalmoplegia (CPEO) CPEO is the most common feature of mitochondrial myopathy. It occurs in > 50% cases of all mitochondrial myopathies.Typical presentation is B/L ptosis without diplopia in early adulthood. Ophthalmoplegia is usually symmetrical & slowly progressive so diplopia is not often a complaint because all eye movements are reduced equally. The progressive ophtha lmoplegia is unnoticed till decreased ocular motility limits peripheral vision. Ciliary muscles & iris muscles are often unaffected by CPEO. Other variable symptoms are:

• Exercise intolerance
• Hearing loss
• Ataxia 
• Hypogonadism
• Cataract 
• Sensory axonal neuropathy
• Clinical depression
• Parkinsonism

Answer is D (Empty sella):

• The clinical hallmark in the form of convulsions, Rail road tract appearance on X-ray and unilateral cortical atrophy (hemiatrophy) on CT scan are diagnosis of Sturge-Weber syndrome.

Sturge weber syndrome

• It results from the anomalous development of primordial vascular bed during early stages of cerebral vascularization.
• The leptomeninges are richly vascularized and the brain beneath becomes atrophied and calcified, particularly in molecular layer of cortex.
• Glaucoma may develop at any time from infancy to adulthood.
• Glaucoma seen in 30% cases.
• Buphthalmos occurs in 60% cases due to IOP elevation occurs before the age of 2 years.
• Symptoms may be large and cloudy eye, photophobia and lacrimation.
• It is related to anterior chamber malformations, high episcleral venous pressure and change in ocular hemodynamics

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: A i.e. Common in young age group

Presbyopia (eye sight of old age) is physiological insufficiency of accommodation (not refraction) seen in advanced (not young) ageQ and resulting in blurred near visionQ. To manage it always find out and correct refractive error for distance firstQ. And then find out and add presbyopic correction to it. In general the weakest convex (plus) lensesQ for near work either in a bifocal, multifocal progressive or variable focus lenses (in patients with refractive errors for distance) or unifocal (reading glasses)Q which will allow adequate vision should be used.

Ans. A. 1 minute

• A Snellen chart is an eye chart that can be used to measure visual acuity. Snellen charts are named after the Dutch ophthalmologist Herman Snellen, who developed the chart in 1862.^[1] Many ophthalmologists and vision scientists now use an improved chart known as the LogMAR chart.

• Angle subtended by the biggest letter of Snellen’s chart at 60 meters is 5 minutes of arc therefore at 6 meters = 5 x 10 = 50 meters.

Ans. is ‘d’ i.e., Plague

NVBDCP includes 6 vector borne diseases of public health importance in India :

• Malaria
• Kala-azar
• Dengue
• Japenese encephalitis
• Filaria
• Chikungunya fever

Ans. b. Increased specificity and decreased sensitivity

Ans. is ‘a’ i.e., Paired t-test 

• In this question :-

1. Data is quantitative (BP)
2. Paired sample from same patients, before and after treatment.

• So, Paired t-test is the best.

Ans. A. Paired t-test

Ans. A: Yellow

Colour coded biomedical waste bags ?

• Yellow plastic bags for human anatomical, animal, microbiological and soiled waste.
• Red disinfected container or plastic bags microbiological waste, solid waste (IV tubes, catheters, etc.)
• Blue or White plastic bag or puncture proof containers sharps, disposable tubings, etc .
• Black Plastic bag or puncture proof containers discarded medicines, incineration ash, chemical waste.

Categories of bio-medical waste in India

Ans. B: 5 days

Ans. is ‘c’ i.e., Negatively shewed 

• Until now we have discussed about normal standard distribution where the curve is bilaterally symmetrical, with no tail, i.e. values are equally distributed on both higher and lower side of the mean.
• Now we will discuss skewed distribution.
• Skewed distribution (deviation)
• Skewed distribution means data is assymmetrically distributed around the mean with either large number of low values & less high values, or large number of high values & less number of low values.
• So, the distribution curve has a tail towards the values which are in lower number.
• Depending upon the values (high or low) skewed distribution can be divided into two types ?

1) Negative skewed (left handed) distribution

• Large number of high values (right sided values) with less no. of low values (left sided values).
• So, the tail is on left side.
• Called negative skewed because tail is in negative direction (left side).
• Mode > median > mean

2) Positive skewed (right handed) distribution

• Large number of low values (left sided values) with few high values (right sided values).
• So, the tail is on right side.
• Called positived skewed because tail is in positive direction (right side).
• Mean > median > mode
• In this question median (140 mm Hg) is greater than the mean (130 mm of Hg) -4 negatively skewed (left handed) dispersion.

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

Ans. a. Shake test

Shake test is used to check if freeze-sensitive vaccines (e.g. Pentavalent, _S PCV-10, TT or Hep. B have been subjected to freezing temperature likely to damage them.

Steps

• Prepare a frozen control vial (same type, batch number and manufacturer as the vaccine to be tested frozen for at least 10 hours at -10°C. and then let it thaw.
• Choose the suspected frozen test vial.
• Shake the control and test vials vigorously for 10-15 seconds.
• Allow the vials to rest on table side by side.
• If the vaccine in the suspected test vial shows a much slower sedimentation rate than the vaccine in the frozen control vial, we conclude that the test vaccine has most probably not been frozen and can be used.

Ans. C. Endemic

[Ref: Park’s Text book Preventive & Social Medicine 24^th edn; Page no. 98 Endemic]

• Constant presence of a disease or infectious agent in a defined geographical area.
• It is the usual or expected frequency of a disease in a population.

Ans:B.)Biohazard waste.
Biological hazards(also known as biohazards).

• It refer to biological substances that pose a threat to the health of living organisms, primarily that of humans.
• This can include medical waste or samples of a microorganism, virus or toxin (from a biological source) that can affect human health. It can also include substances harmful to other animals.

Levels of biohazard
The United States Centers for Disease Control and Prevention (CDC) categorizes various diseases in levels of biohazard, Level 1 being minimum risk and Level 4 being extreme risk. 

• Biohazard Level 1: Bacteria and viruses including Bacillus subtilis, canine hepatitis, Escherichia coli, varicella (chicken pox), as well as some cell cultures and non-infectious bacteria.
• Biohazard Level 2: Bacteria and viruses that cause only mild disease to humans, or are difficult to contract via aerosol in a lab setting, such as hepatitis A, B, and C, some influenza A strains, Lyme disease, salmonella, mumps, measles, scrapie, dengue fever, HIV. 
• Biohazard Level 3: Bacteria and viruses that can cause severe to fatal disease in humans, but for which vaccines or other treatments exist, such as anthrax, West Nile virus, Venezuelan equine encephalitis, SARS virus, MERS coronavirus, hantaviruses, tuberculosis, typhus, Rift Valley fever, Rocky Mountain spotted fever, yellow fever, and malaria.
• Biohazard Level 4: Viruses that cause severe to fatal disease in humans, and for which vaccines or other treatments are not available, such as Bolivian and Argentine hemorrhagic fevers, Marburg virus, Ebola virus, Lassa fever virus, Crimean–Congo hemorrhagic fever, and other hemorrhagic diseases and rishibola. Currently there are no bacteria classified at this level.

Ans. (A) Orpharynx candidiasis 

Candidiasis of bronchi, trachea, lung, oesophagus comes under AIDS defining criteria. Infections listed in the AIDS surveillance case definition

• Candidiasis of bronchi, trachea, lungs, oesophagus
• Coccidioidomycosis, disseminated or extrapulmonary
• Cryptococcosis, extrapulmonary
• Cryptosporidiosis, chronic, intestinal (> 1 month’s duration)
• Cytomegalovirus disease (other than liver, spleen, or nodes)
• Cytomegalovirus retinitis (with loss of vision)
• Encephalopathy, HIV-related
• Herpes simplex: chronic ulcer(s) (> 1 month’s duration); orbronchitis, pneumonia, or esophagitis
• Disseminated or extrapulmonary histoplasmosis
• Isosporiasts, chronic intestinal (> 1 month’s duration)
• Mycobacterium avium complex or M.kansosil, disseminated or extrapulmonary
• Mycobacterium tuberculosis, any site (pulmonarya or extrapulmonary)
• Mycobacterium, other species or unidentitled species, disseminated or extrapulmonary.
• Pneumonocystis jiroved pneumonia
• Salmonella septicemia, recurrent
• Toxoplasmosis of brain
• Wasting syndrome due to HIV

Ans: C. Drugs
(Ref. Neena Khanna 4/e p83)

• Typical of Steven-Johnson syndrome & toxic epidermal necrolysis.

Toxic epidermal necrolysis (TEN):

• Also referred as “Lyeln syndrome”.
• Rare, life-threatening skin condition.
• Usually caused by drug reaction.

Ans:B. Pemphigus Vulgaris.
PEMPHIGUS VULGARIS

• Pemphigus vulgaris is an autoimmune, intraepithelial, blistering disease affecting the skin and mucous membranes. It is mediated by circulating autoantibodies directed against keratinocyte cell surfaces.
• Drugs reported most significantly in association with pemphigus vulgaris include penicillamine, captopril, cephalosporin, pyrazolones, nonsteroidal anti-inflammatory drugs (NSAIDs), and other thiol-containing compounds.

Presentation:

• The diagnosis of pemphigus vulgaris should be considered in any patient with persistent oral erosive lesions.
• Most patients with pemphigus vulgaris develop cutaneous lesions. The primary lesion of pemphigus vulgaris is a flaccid blister, which usually arises on healthy-appearing skin but may be found on erythematous skin. 

Differentiating features of major immunobullous disease

Ans. d. Molluscum contagiosum.
The skin lesion as marked by a red arrow in the picture above represents Molluscum contagiosum.

Molluscum contagiosum (MC)

• It is a viral infection of the skin or occasionally of the mucous membranes, sometimes called water warts.
• It is caused by a DNA poxvirus called the molluscum contagiosum virus (MCV).
• MCV has no nonhuman-animal reservoir (infecting only humans).
• There are four types of MCV, MCV-1 to -4; MCV-1 is the most prevalent and MCV-2 is seen usually in adults.
• The virus that causes molluscum is spread from person to person by touching the affected skin.
• The virus may also be spread by touching a surface with the virus on it, such as a towel, clothing, or toys.
• Molluscum can be spread from one person to another by sexual contact.
• This common viral disease has a higher incidence in children, sexually active adults, and those who are immunodeficient, and the infection is most common in children aged one to ten years old.
• MC can affect any area of the skin but is most common on the trunk of the body, arms, groin, and legs.
• It is spread through direct contact or shared items such as clothing or towel.

Ans. is ‘d’ i.e., All the above 

Drugs used for treatment of Acne

• Topical

1. Comedolytics : – Act by removing follicular plug, thereby reopen pilosebaceous ostia. Comedolytics are ; Retinoic acid, Adapalene, Azelaic acid, Tazarotene.
2. Antibiotics : – Decrease bacterial population and have anti-inflammatory effect. Topical antibiotics for acne are ; Erythromycin, clindamycin, Benzoyl peroxide.

Systemic

1. Antibiotics : – Decrease bacterial population and have anti-inflammatory effect. Systemic antibiotics for Acne vulgaris are; Tetracycline, minocycline, doxycycline, Erythromycin, Roxithromycin, Cotrimoxazole, Dapsone.
2. Retinoids [Isotretinoin (11-cis retinoic acid)J :- Removes follicular obstruction, and also suppresses sebum secretion (Sebostatic).
3. Antiandrogens : – Decrease sebum secretion by decreasing androgens. Examples; Cyproterone, Ethinylestranol, Spironolactone. Cyproterone acetate (along with ethinylestranol) is particularly useful in teenage girls with mensural irregularities.

Ans. C. Acute meningococcemia
Palpable  purpura  means  purpura  that  does  not blanch in diascopy. The causes are:

• Vasculitis: PAN
• Emboli: Acute meningococcaernia. Erythema gangrenosum disseminated gonococcal infection, Rocky Mountain spotted fever.

Ans: C. Screening family members

WHO’s Mental Health Gap Action Program (MHGAP)

It is scaling up of service for mental, neurological and substance use disorders, especially in low- and middle-income countries.

• It focuses on a limited number of conditions and includes both pharmacological and non-pharmacological first-line treatment options for depression, including interpersonal therapy (IPT).
• Problem management plus (PM+) is a scalable psychological intervention called for adults impaired by distress in communities who are exposed to adversity.
• Without prejudice to the generality of range of services under sub-section, such services shall include:
• Provision of acute mental healthcare services such as outpatient and inpatient services
• Provision of half-way homes, sheltered accommodation, supported accommodation as may be prescribed
• Provision for mental health services to support family of person with mental illness or home based rehabilitation
• Hospital and community based rehabilitation establishments and services as may be prescribed
• Provision for child mental health services and old age mental health services

Ans: b. Communication with patients/attendants regarding bad news

• It is for breaking bad news to patients/attendants. Six steps involved are:

1. STEP 1: S—SETTING UP the Interview
2. STEP 2: P—Assessing the patient’s PERCEPTION
3. STEP 3: I—Obtaining the patient’s INVITATION
4. STEP 4: K—Giving KNOWLEDGE and information to the patient
5. STEP 5: E—Addressing the patient’s EMOTIONS with EMPATHIC responses
6. STEP 6: S—STRATEGY and SUMMARY

Ans: A. Advance directive

Advance directive Chapter-III, Section 5 of The Mental Health Care Act, 2017

Every person who is not minor, shall have right to make an advance directive in specifying any or all of the following, namely:

• The way the person wishes to be cared for and treated for a mental illness
• The way the person wishes not to be cared for and treated for a mental illness
• To appoint his nominated reprehensive
• An Advance Directive shall be made in writing on a plain manner of milking paper with persons signature or thumb impression on it and attested by two witness and be:

Registered with board

• Signed by a medical practitioner certifying that the person has capacity
• to make mental health care and treatment decisions at the time of making
• the advance directive and that the person has made the advance directive of his own free will.

Ans. D. Radiography

Ans: A. Arachnoiditis

• The empty thecal sac sign or empty sac sign is when the thecal sac appears empty on MRI of the lumbar spine. If the empty thecal sac sign is present, a diagnosis of adhesive arachnoiditis can be made.
• It is best seen on T2-weighted images.

• MRI findings: It can be present throughout the subarachnoid space, it is most easily seen in the lumbar region where the cauda equina usually floats in ample CSF.

Ans. A. Cervical rib.
The disorder shown in the photograph above represents cervical rib.
A cervical rib in humans is an extra rib which arises from the seventh cervical vertebra. Sometimes known as “neckribs”, their presence is a congenital abnormality located above the normal first rib. A cervical rib is estimated to occur in 0.6% (1 in 150 people) to 0.8% of the population.

Ans. A. Rectal Tube.
The surgical tube shown in the picture above represents Ryle’s naso-gastric tube.

• A nasogastric tube is a narrow bore tube passed into the stomach via the nose. It is used for short- or medium-term nutritional support, and also for aspiration of stomach contents – eg, for decompression of intestinal obstruction
• A wide bore tube is used if drainage is needed; otherwise, a finer bore tube is used. Fine bore feeding tubes (gauge less than 9) cause less discomfort and less risk of rhinitis, pharyngitis or oesophageal erosion.
• Ideal position is sitting with neck flexed (If conscious)
• In Comatose patients – Supine with neck flexed Note: Supine with Neck extended is ideal for ET intubation

Ans: A. Ventricular dysrhythmias are uncommon in children

• Ventricular dysrhythmias are not a common cause of cardiac arrest in children.
• Hypoxia induced bradycardia are more important cause and that is why rescue breaths are more important in pediatric resuscitation.
• The ratio of ventilation to compression in an infant is 3:1 and in children with 2 rescuers is 15:2.

Ans: B i.e. Prominent X descent with absent ‘Y’ descent

Ans. is ‘a’ i.e., Insertion of wide bore needle in the inter costal space
should be immediately released by placement of a large bore needle followed immediately by insertion of a thoracostomy tube.

Ans. is ‘a’ i.e., Inadequate control of hyperthyroidism 

• Thyroid storm is condition of hyperthyroidism accompanied by fever, central
  nervous system agitation or depression and cardiovascular dysfunction.
• Spontaneous thyroid storm in patient with Grave’s most commonly occours due to infection.
• Thyroid storm after thyroidectomy mainly occurs due to inadequate pre­operative preparation.

Occasionally, thyroid storm may result from amiodarone administration or exposure to iodinated contrast agent or following RIA therapy

Ans. C. Negative immune regulation

Ans. is ‘d’ i.e., All are true
SLE (sytemic lupus Erythematosus)

• Autoimmune disorder
• Inflammation of blood vessel
• Childhood SLE had poor pnognosis than adult SLE

Hall mark of SLE is presence of antinuclean antibody (ANA)

• More common in female.
• Malar rash in pathognomic of SLE
• Non – erosive arthritis
• Nephritis
• Encephalopathy
• Pleuritis / Pericarditis
• Cytopenia

Ans. is ‘a’ i.e., Bronchitis

• Kartagener syndrome is a subset of primary ciliary dyskinesia, an autosomal recessive condition characterized by abnormal ciliary structure and/or function leading impaired mucociliary clearance.
• Kartagener is a primary ciliary disorder and as such the sperms have abnormal/reduced motility (Asthenozoospermia).
• Blockage of epididymis is a feature of Young syndrome (But there is no Situs inversus like Kartagener syndrome and patients tends to have normal sperm motility)

Clinical presentation

• Kartagener syndrome is characterised by the clinical triad of 1
• Situs inversus
• Chronic sinusitis and/or nasal polyposis
• Bronchiectasis

Other features include

• Telecanthus: widened interpupillary distance by a nasal polyp
• Infertility in males
• Subfertility in females

Ans. b. Breath normally

• Paradoxus requires the patient to breathe normally and does not require any special maneuver.
• BP is best measured in the seated position with the arm at the level of the
• heart, using an appropriately sized cuff, after 5-10 minutes of relaxation.
• In Supine position: The arm should be raised to bring it to level of mid-tight atrium.

Ans. C i.e. Hemorrhagic stroke

Thrombolytic agents

• They are used for the treatment of myocardial infarction (heart attack), thromboembolic strokes, deep vein thrombosis and pulmonary embolism to clear a blocked artery and avoid permanent damage to the perfused tissue (e.g. myocardium, brain, leg) and death.
• They may also be used to clear blocked catheters that are used in long-term medical therapy.
• Thrombolytic therapy in hemorrhagic strokes is contraindicated, as its use in that situation would prolong bleeding into the intracranial space and cause further damage.

Ans. C. aVF

• 90° cardiac axis corresponds straight to lead aVF and hence as such maximum ‘It’ wave amplitude would be seen in that lead only.

Ans. C. Flexion of wrist

• While taking ABG — wrist is generally kept in hyperextension. This is to make the vessel straight and to fix the position (because of tension in hyperextension).
• Flexion will make the vessel loose and the vessel will slip easily while poking.
• ABG is painful, and radial artery spasm can result in ischemia of the hand in patients with radial dominant circulation.

Ans: D. It has a fulminant demyelinating process and progress to death in 1-2 year
Devic’s disease is a variant of multiple sclerosis. Fulminant demyelinating process is seen with another variant called Marburg’s variant.

Ans. D. High anion gap metabolic acidosis with metabolic alkalosis 

• Even though ABG looks completely normal – clinical history is the key here.
• CKD patients generally have high AG metabolic acidosis. On the background of that he has developed vomiting (which is an alkalotic state). Both opposing disorders have normalized the ABG. But the patient is actually having a double disorder.

Ans. C. Urinary NGAL

• RIFLE originally used urinary sodium, urine osmolarity, Fe_Na to define tubular dysfunction/injury.
• Currently urinary NGAL/Kim-1/Cystatin C/L-FABP all are being evaluated as more sensitive and specific markers of tubular injury (KDIGO 2017/18).

Ans. b. Anemic hypoxia

• In smoke/fire patient generally dies of excess CO poisoning (most frequent cause of death).
• If there is low PaO, – it is called as hypoxic hypoxia.
• In smoke (CO poisoning) PaO, will be normal and the problem is COHb.
• An abnormal Hb or Reduced Hb concentration comes under anemic  hypoxia.

Ans. d. Stop BT and do clerical check

• The patient has ominous signs of a major Acute Hemolytic transfusion reaction ( Backache/anxiety). 
• STOP THE TRANSFUSION WITHOUT ANY DELAY.
• Also further work up is mandatory(especially the basic clerical work like checking the blood product details and cross matching reports) and do not restart transfusion until it is complete

Ans: D i.e. Electrical impedance cardiograph technology

• PA catheter & thermodilution technique are invasive procedure.
• Echo is noninvasive old technique to measure cardiac output
• Recent noninvasive advance to measure C.O. is electrical impedance Cardiographs technology.

Ans. C. Malaria

• Relative bradycardia at the peak of high fever is the early findings in <50% cases of typhoid.
• The presentation of Brucellosis often fits three patterns, among one febrile illness that resembles to thyroid, but it is less severe. Relative bradycardia seen in this case.
• In malaria relative bradycardia is uncommon.

Ans: B. Foley’s catheter.
The catheter shown in the picture above represents Foley’s catheter.
A Foley catheter (named for its designer, Frederic Foley) is a flexible tube that is passed through the urethra and into the bladder to drain urine. It is the most common type of indwelling urinary catheter. The tube of a Foley catheter has two separated channels, or lumens, running down its length.

Ans is ‘a’ ie. IV Fluids only 

30% loss of blood volume is a moderate grade of hypovolemia and can be managed adequately by IV fluids only. Cardiac stimulants, dopamine or vasopressor agents are required only in severe hypovolemia (> 40% loss).

 Treatment of hypovolemic shock [Ref Harrison 17/e p1693 (16/e pI603, 1604)]

• “Initial resucitation requires rapid reexpansion of the cirulating blood volume along with interventions to control ongoing loss.
• Volume resuscitation is initated with the rapid infusion of isotonic saline or a balanced salt solution such as

Ringers lactate through large bore IV lines. No distinct benefit from the use of colloids have been demonstrated and in trauma patients, it is associated with a higher mortality. The infusion of 2 to 3 lt. over 20 to 30 min should restore normal hemodynamic parameters.

• Continued hemodynamic instability implies that shock has not been reversed and/or that there are significant ongoing blood or volume losses.
• Continued blood loss, with haemoglobin concentration declining to 10 g/dl should initiate blood transfusion.
• In the presence of severe and for prolonged hypovolemia, inotropic support with dopamine vasopressin or dobutamine may be required to maintain adequate ventricular performance, after blood volume has been restored.

Infusion of norepinephrine to increase arterial pressure by raising peripheral resistance is inappropriate, other than as a temporizing measure in severe shock while blood volume is reexpanded.”

[Refi ATLS 18^th edn; 2018, Chapter 3 Shock]

• First preference is PRBC followed by platelets
• In mean time, store platelets at room temperature.

Ans. A i.e. 8

Orotracheal or nasotracheal intubation can be attempted with cervical spine precautions if a second person maintains axial immobiliza­tion of the head to prevent destabilization of the spine.

In this patient, GCS score was 8, so endotracheal intubation was done to secure airway.

You don’t have to calculate the GCS score of this patient after intubation.

Ans: B. Green 

used for routine blood transfusions, transfusing large volumes of fluid, intravenous feeding of patients and the harvesting and separation of stem cells.

[Refi ATLS 18^th edn; 2018, Chapter 3 Shock]

Ans: C. Grey

Grey is 16G cannula and wider the bore, higher the flow rate. Here the key is the rapid fluid replacement.

External diameter(mm)- 1.8 mm

Length(mm)- 45 mm

Water flow rate (mL/min)-^—180 mL/min

uses- Rapid fluid replacement, trauma, rapid blood transfusion

Green- Large volumes of fluid,  trauma, rapid blood transfusion

Ans: C. Cecum

• Cecum is always the first structure which should be seen in bowel obstruction. If it is dilated, then it suggests large bowel obstruction, where as if it is collapsed, then it is signifying small bowel obstruction.

Ans: C. Clock wise method

[Ref Mayo Foundation for Medical Research and https://www.slideshare.net/rajud521/ breast-self-examination]

Breast Self Examination

Ans. B: Obstruction of lymphatic ducts

This type of breast cancer is called “inflammatory” because the breast often looks swollen and red, or “inflamed”, sometimes overnight, and can be misdiagnosed as mastitis.

Invasion of the local lymphatic ducts impairs drainage and causes edematous swelling of the breast. Because the skin of the breast is tethered by the suspensory ligament of Cooper, the accumulation of fluid may cause the skin of the breast to assume a dimpled appearance similar to an orange peel (peau d’orange).

IBC is sometimes misdiagnosed as an insect bite or breast infection. In the case of IBC, a lump is usually not present as in other forms of breast cancer.

Ans. is ‘b’ i.e., Carcinoma Breast 

Sentinel node is first node to receive drainage from the tumor site. The node is most likely to contain metastasis, if metastasis to that regional lymph node basin is present.

Thus the biopsy of sentinel lymph node, helps to decide whether lymph node dissection of that lymphatic region should be done or not. This thus avoids the morbidity of lymph node dissection in patients with negative nodes.

• Sentinel lymph node biopsy is done in
• Melanoma
• Breast cancer
• The utility of sentinel lymph node biopsy is being examined in other cancers such as esophageal, gastric, colon and head and neck cancers. (Ref. Schwartz 8/e)

Ans: B. Vulval carcinoma
Sentinel node is a lymph node that is first to receive drainage from a malignancy. Sentinel lymph node biopsy is used in breast carcinoma, melanoma, vulval carcinoma.    

Ref: Novak, 14th edition, page; 1425-1426

Ans. is ‘d’ i.e. Treatment of choice is surgical excision of sinus tract

Pilonidal disease

• It is an acquired disease

Althouth earlier it was thought to be a congenital disease, it is now considered to be an acquired infection of natal cleft hair follicles. The hair follicles become infected and rupture into the subcutaneous tissues to form a pilonidal abscess. Hair from surrounding skin is pulled into the abscess cavity by the friction generated by the gluteal muscles during walking.

• More common in males
• Treatment of choice is surgery

Pilonidal sinus should be excised along with the secondary openings. (But only after controlling acute infection). Acute pilonidal abscesses and sinus ds can be managed by simple incision and drainage (under local anaesthesia).

• Prognosis after surgery is excellent (Ref: CSDT, I2/e p757)

Recurrent or persistent disease has been reported to be 0-15% and is likely due to inadequate excision. Inadequate postoperative hygiene with ingrowth of hair into the wound also leads to recurrance.

Ans. D: Cortisone

Ans: B. Iduronate sulphatase

• Inheritence- X-linked Recessive
• Defective enzyme- Iduronate Sulphatase

Clinical Features-

• slower progression of somatic and central nervous system (CNS) deterioration
• large tongue
• prominent forehead
• joint stiffness
• short stature
• skeletal dysplasia
• obstructive airways
• Valvular heart disease
• Mental retardation

Ans. is ‘d’ i.e., All of the above 

• Contraindications : – Unless specifically indicated, BCG should not be given to patients suffering from.
• Generalized eczema
• Infective dermatosis
• Hypogammaglobulinaemia
• Patient with history of deficient immunity
• Being a live vaccine, it is also contraindicated in pregnancy.

Ans. is ‘c’ i.e., Preductalcoarctation of aorta

Turner’s syndrome

• Turner’s syndrome is the most common sex chromosomal disorder in phenotypic females.
• Turner’s syndrome results from complete or partial loss of one X chromosome (45, X) and is characterised by hypogonadism in phenotypic females

Features of Turner syndrome in children 😕

• The most severely affected patients generally present during infancy with edema (owing to lymph stasis) of the dorsum of the hand and foot and sometimes swelling of the nape f the neck.
• Swelling of the neck is related to markedly distended lymphatic channels, producing so called cystic hygroma.
• As these infants develop, the swelling subsides but often leave bilateral neck webbing and persistent looseness of skin on the back of the neck.
• Congenital heart disease is also common, particularly preductal coarctation of Aorta and bicuspid Aortic valve.
• C. VS abnormalities are most important cause of mortality in children with Turner ‘s syndrome.
• Features of Turner’s syndrome in Adolescents and Adult:-
• At puberty there is failure to develop normal secondary sex characteristics.
• The genitalia remains infantile, breast development is inadequate and there is little pubic hair. Nipples are widely spaced.
• Turner syndrome is the single most important cause of primary amenorrhoea accounting for approximately  ¹/3 of the cases.
• Short stature (height rarely exceeds 150 cm).
• The mental status of these patients is usually normal but subtle defects in nonverbal, visual spatial information processing have been noted (mental retardation is associated with the presence of extra chromosome not with loss of X chromosome).
• About 50% of the patients develop autoantibodies directed to the thyroid gland and upto one half of these patients develop hypothyroidism.
• Other features include low posterior hairline, webbing of neck, cubitus valgus, streak ovaries. o Glucose intolerance, obesity and insulin resistance are also seen.

Ans. is `c’ i.e., 5

Assessment of respiratory depression

The severity of respiratory distress is assessed by Silverman- Anderson score and Downes’ score. While the Silverman Anderson Retraction Score is more suited for preterms with HMD, the Downes’ score is more comprehensive and can be applied to any gestational age and condition.

Silverman Anderson retraction score 

• A score of >6 is indicative of impending respiratory failure o Now analyzing our question data :-

1. Upper chest   ? Lag on inspiration present  ? score 1
2. Lower chest ? No retraction ? score 0
3. Xiphoid ? No retraction ? score 0
4. Nasal flaring ? Present ?  score 2
5. Grunting ? Present ? score 2? So, total score is 5.

Downers’s score 

• A score of > 6 is indicative of impending respiratory failure.

Ans. b. Multifocal clonic

Morphology of Neonatal Seizures

• Subtle seizures: They are called subtle because the clinical manifestations are mild and are often missed. They are the commonest type, constituting about 50% of all seizures. Common examples of subtle seizures include:
• Ocular: Tonic horizontal deviation of eyes or sustained eye opening with ocular fixation or cycled fluttering
•  Oral-facial-lingual movements: Chewing, tongue-thrusting, lip-smacking, etc.
• Limb movements: Cycling, paddling, boxing-jabs, etc.
• Autonomic phenomena: Tachycardia or bradycardia

Apnea

• Focal clonic seizures: They are rhythmic jerks of one arm, or one leg, or one arm and one leg on the same side of the body. They have both fast and slow components, occur with a frequency of 1-3 jerks per second, and are commonly associated with EEG changes.
• Multifocal clonic seizures: Characterized by jerks in limbs on both sides of the body. May even involve neck or facial muscles in some cases. May show migration from one side to another or simultaneously occur at multiple sites. Often associated with significant asphyxia and may be seen in sick babies.
• Tonic seizures: This type refers to a sustained flexion or extension of axial or appendicular muscle groups. Not associated with EEG abnormalities and are rare.
• Tonic-Clonic seizures are rare to absent in neonates.

Ans. d. Suburethral Nodule
Suburethral Nodule is an unusual indicator of postmolar choriocarcinoma. All others are very well seen in the conversion of a complete hydatidiform mole into choriocarcinoma.

Suburethral nodule may be a manifestation of vaginal metastasis from choriocarcinoma.
Metastatic choriocarcinoma is however seen in only about 4% of patients after evacuation of a complete mole and vaginal metastasis that may present with suburethral nodule occur in only 30% of patients with such metastatic disease. Hence it is an unusual indicator.

Ref: Novok’s, 14th Edition, Page 1588, 1591, 1592 ; William’s Gynaecology, 1st Edition, Page 764 ; COGDT, 10th Edition, Page 1890 ; Gynecological Cancer Management : Identification, Diagnosis and Treatment By Daniel Clarke-Pearson, John Soper, 2011.

Ans. A. 40 weeks

• In diabetic mothers, the fetal lung maturation delays due to delay in the completion of surfactant formation in fetal lung. Hence 40 weeks is the choice, the expected delivery can be delayed up to 40 weeks.

Ans: A. Early cord clamping

Triple swab test is the investigation of choice to establish the diagnosis of a suspected vesico vaginal fistula.
It  confirms the presence of vesico vaginal fistula, and also differentiate it from uretero vaginal and urethro vaginal fistula. 

Ans. a. Estrogen

• Estrogens are a steroid hormone which exists in three forms each of unique significance during a woman’s life.
• Estradiol is the most common moiety during the non-pregnant reproductive years. It is converted from androgens (produced from cholesterol in the follicular theca cells), which diffuse into the follicular granulosa cells containing the aromatase enzyme that completes the transformation into estradiol.

Ans. D. Uterine synechiae
Since the lady in the question is having secondary amenorrhea following an abortion, uterine synechiae is the most likely cause.
Low normal FSH level is consistent with uterine abnormality. (Normal serum FSH value in adult is woman is 5-20 mlU). 

Ans: D. PAPP
[REF: Fernando arias 3^rd e p. 44-45]

The triple test measures the following three levels in the maternal serum:

1. Alpha-fetoprotein (AFP)
2. Human chorionic gonadotropin (hCG)
3. Unconjugated estriol (UE3)

The levels may indicate increased risk for certain conditions:

Furthermore, the triple test may be combined with an ultrasound measurement of nuchal translucency.

The Triple test measures serum levels of AFP, estriol, and beta-hCG, with a 70% sensitivity and 5% false-positive rate. It is complemented in some regions of the United States, as the Quad test (adding inhibin A to the panel, resulting in 81% sensitivity and 5% false-positive rate for detecting Down syndrome)

Ans. B: 100,000 live births
The maternal mortality rate is the number of maternal deaths due to childbearing per 100,000 live births. The crude death rate is the total number of deaths per year per 1000 people.

The perinatal mortality rate is the sum of neonatal deaths and fetal deaths (stillbirths) per 1000 births. The infant mortality rate is the number of deaths of children less than 1 year old per 1000 live births.

The child mortality rate is the number of deaths of children less than 5 years old per 1000 live births.

The standardised mortality rate (SMR)- This represents a proportional comparison to the numbers of deaths that would have been expected if the population had been of a standard composition in terms of age, gender, etc.. The age-specific mortality rate (ASMR) – This refers to the total number of deaths per year per 1000 people of a given age (e.g. age 62 last birthday).

Ans: A. 20 microgm/d

Ans: B. Hysterectomy

Ans: B. Colposcopy and LEEP

Ans. b. Laparoscopic tubal ligation

• Intrauterine device (IUD), also known as long-acting reversible contraception (LARC).
• Laparoscopic tubal ligation is the most common modality of pregnancy prevention. It is irreversible in nature.
• Spring-loaded clip (Filshie clip, Hulka clip) or Silastic rubber band (Falope ring) are most commonly used.
• Destruction or removal of a segment of the oviduct is performed in an operating room through a transabdominal approach usually using a laparoscopy or minilaparotomy.
• An ectopic pregnancy should be ruled out; if the procedure fails.
• Failure rate is 1 in 200.

Ans. a. Dexamethasone and terminate after 48 hours

• Antenatal Corticosteroid Therapy
• A single dose of corticosteroids is recommended for pregnant women with gestational age 23-34 weeks of gestation who are at risk of preterm delivery within 7 days.
• A complete course is
• Betamethasone two 1M 12 mg doses given 24 hours apart
• OR
• Dexamethasone four IM 6 mg doses given 12 hours apart.

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.

• Patellar Clunk Syndrome is a painful condition associated with a mechanical catching or clunking during active extension following total knee arthroplasty (TKA).
• The syndrome is caused by growth of interposing soft tissue usually at the superior pole of the patella.
• This interposed soft tissue cannot be visualized on plain radiographs.

Ans: A i.e. Sign of recovery from spinal shock

Spinal Shock

• Some times physical energy of the injury mechanism causes immediate depolarization of axonal membranes in the neural tissue. This results in functional neurological defecit that exceeds the actual tissue disruption. This condition is refered to as spinal shock.
• The presence of spinal shock causes the absence of all reflexesQ. And it typically lasts upto 24- 48 hours after the injuryQ.
• The bulbocavernosus reflex is the reflex that returns first, thus marking the end of spinal shockQ.
• This point has prognostic importance because recovery from a complete neurological deficit that is still present at the end of spinal shock is extremely unlikely. In other words, a total absence of sensation & voluntary motor functions caudal to the level of spinal cord injury in the absence of spinal shock (i.e. bulbocavernosus reflex has recovered) is indicative of complete spinal cord injury and there is virtually no likelihood of functional spinal cord recovery.

Ans: A. Fibrosarcoma

• Phosphatonin (FGF-23) oncogenic osteomalacia (paraneoplastic syndrome) seen in fibrosarcoma.

Ans:A.)Giant Cell Tumor
DIFFERENTIAL DIAGNOSIS OF A SOLITARY BONE LESION

 RADIOLOGICAL FEATURES OF GIANT CELL TUMOR(OSTEOCLASTOMA)

• A solitary, may be loculated, lytic lesion.
• Eccentric location, often subchondral .
• Expansion of the overlying cortex (expansile lesion).
• ‘Soap-bubble’ appearance – the tumour is homogeneously lytic with trabeculae of the remnants of bone traversing it, giving rise to a loculated appearance.
• No calcification within the tumour .
• None or minimal reactive sclerosis around the tumour.
• Cortex may be thinned out, or perforated at places.
• Tumour usually does not enter the adjacent joint.

Ans:C.)Chronic Osteomyelitis.
Image shows:

• First:Sequestrum:Large Devascularised fragment of bone seperated from healthy bone after undergoing ischemic necrosis.
• Second:Involucrum:New bone deposited aroud a sequestrum,resulting from cortical damage stimulating the periosteum to lay down new bone,and surround the sequestrum.
• Third:Brodie’s Abscess:Focal Abscess,most commonly found in metaphyses of long bone.

Ans:C.)Mallet Finger.
MALLET FINGER

• A finger deformity caused by disruption of the terminal extensor tendon distal to DIP joint : the disruption may be bony or tendinous
• Also known as baseball finger, dropped finger, dolphin finger.

Treatment

• Nonoperative

• extension splinting of DIP joint for 6-8 weeks

• Operative

• Closed Reduction and Percutaneous Pin Fixation /Open Reduction & Internal Fixation Surgery /surgical reconstruction of terminal tendon/DIP arthrodesis

Ans. C. Dense irregular

• The marked area is reticular dermis.
• It is composed of dense irregular collagenous connective tissue (most commonly type I collagen) containing the usual array of connective tissue elements, including cells, blood and lymphatic vessels.

Ans. D. Lysosome

• The marking areas are centrally placed nuclei.
• The single nucleus of the cardiac muscle cell is located in the center of the cell.
• Myofibrils pass around the nucleus, producing a biconical juxtanuclear region in which the other organelles are concentrated.
• This perinuclear region is rich in mitochondria and contains a Golgi apparatus, glycogen granules, and lipofuscin granules.

Ans. d. Body gets this infection through filariform larvae 

Jawetz’s Medical Microbiology 27^t) edn; Page no. 730

• The video depicts Rhabdtiform larvae of Strongyloides stercoralis.
• S. stercoralis is Dioecious and the organism related with parthenogenesis.
• Infective form is: filariform larvae (Eggs give rise to larva and develop into filariform larvae).
• Transmitted by skin penetration of filariform larvae

Ans: b. Emperipolesis

Refi Robbins and Cotran Pathologic Basis of Disease 9^th edn; Page no. 840

• Emperipolesis is the active penetration of one cell by another which remains intact.
• It differs from phagocytosis in that an engulfed cell exists temporarily within another cell and with an intact normal structure while in phagocytosis, the engulfed cell is destroyed by the protective action of lysosomal enzymes.

Ans. C. Nipah virus

• Nipah virus infection, also known as Nipah virus encephalitis, was first isolated and described in 1999. The name Nipah is derived from the village in Malaysia where the person from whom the viruses first isolated succumbed to the disease.

Reservoir:

• Zoonotic disease
• Large fruit bats (flying foxes) are the natural reservoirs of Nipah virus.

Mode of transmission

1. Pig to human
2. Bat to human
3. Human to human

• Consumption of bat bitten fruits
• Pigs – amplifying hosts and intermediate host.
• Incubation period: 5-18 days

Ans. b. Mean = Median, not equal to Mode

Ref: Park’s Text book Preventive & Social Medicine 24`^h edn; Page no. 886

• Red line indicates normal distribution hence Mean = Median
• Blue line indicates bimodal distribution hence 2 Modes.
• So Mean = Median # Mode

Ans. d. MAT

• ECG shows narrow complex tachycardia with irregular rhythm.
• Since P waves are seen it rules out AE
• Different morphologies of P waves (3) in lead II rules out Sinus arrhythmia.
• All the above said features confirm MAT.
• Also absence of chest pain and significant ST elevations rules out AMI.

Multifocal Atrial Tachycardia (MAT)

ECG Findings

• Heart rate typically between 100 and 150 bpm.
• Irregularly irregular rhythm with varying PP, PR and RR intervals.
• At least 3 distinct P-wave morphologies in the same lead.
• Isoelectric baseline between P-waves (i.e. no flutter waves).

Ans: A. Pneumatic compression stockings to prevention of DVT

Ans. C. Esophageal temperature probe

• This is a rectal temperature probe used in neonates in NICU
• It can also be used to measure the esophageal temperature

Ans: C. Gray

• Gray vacutainer contains Sodium fluoride (for glucose estimation).
• NaF inhibits glycolysis.

Blood Draw Tube Order Chart Phlebotomy Tube Colors

Ans: A. Coxa vara

• Coxa vara: Reduced neck shaft angle (<120°)
• Coxa valga: Increased neck shaft angle (>135°)
• Coxa saltans: It is also known as snapping hip, caused by motion of muscles and tendons over bony structures around the hip joint
• Coxa magna: It is the asymmetrical, circumferential enlargement and deformation of the femoral head and neck.

Ans: b. Hemophilic pseudotumor

• X-ray is useful in diagnosing intraosseous pseudotumors.
• Unilocular or multiloculated, lytic, expansile lesions of variable size appearance in X-ray.
• Pathological fractures can also be present.
• Metaphysis, diaphysis and epiphysis of long bones are involved in this case.

Ans: A. Aspergillus

• Dermatophytes are fungi that require keratin for growth.
• These fungi can cause superficial infections of the skin, hair and nails.
• These anamorphic (asexual or imperfect fungi) mold genera are: Microsporum, epidermophyton and trichophyton.
• Dermatophytes are spread by direct contact from other people (anthropophagic organisms), animals (zoophilic organisms) and soil (geophilic organisms).
• Diagnosis is based on the history, physical examination and potassium hydroxide (KOH) microscopy. Wood lamp examination and fungi culture or histologic examinations are occasionally required.
• Tenia crusis: Rashes appear red, scaly and pustular, often accompanied by itch. Men > women. Exacerbated by sweet and tight clothing (hence the term jock -itch). Can extend from the groin to the peripheral skin and gluteal cleft.
• Invasive infection with aspergillus most commonly seen during acute periods of neutropenia, but shifts in conditioning regimens and other strategies to promote earlier engraftment have led to infections after 30-40 days post-transplantation.