A) CPK
Uploaded by
Sajjal AliA) CPK
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1. Adirection,
25 year old female presents with generalized restriction of eye movement in all
intermittent ptosis, proximal muscle weakness and fatigability.Which is
the MOST useful test in making the diagnosis?
a) CPK
b) Edrophonium test
c) EMG
d) Muscle biopsy
Correct Answer - B
This patient is showing signs and symptoms of Myasthenia gravis. Edrophonium test is the
most useful test in making a diagnosis of this condition because of the rapid onset and
short duration of its effect. This test is considered to be positive if there is any improvement
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in the weakness of this patient after administration of edrophonium.
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Other diagnostic tests used for diagnosing myasthenia gravis are:
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Acetyl choline receptor antibodies: Presence of this antibodies is virtually diagnostic of
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MG, but a negative test does not exclude the disease.
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Rapid nerve stimulation test: In this test electric shocks are delivered at a rate of 2 or 3
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per second to the appropriate nerves, and action potentials are recorded from the muscles.
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In these patients there is a rapid reduction of >10–15% in the amplitude of the evoked
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responses.
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Ref: Drachman D.B. (2012). Chapter 386. Myasthenia Gravis and Other Diseases of the
Neuromuscular Junction. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L.
Jameson, J. Loscalzo (Eds), Harrison's Principles of Internal Medicine, 18e.
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2. Kayser- Fleischer rings (KF rings) are seen in:
a) Pterygium
b) Hematochromatosis
c) Wilson's disease
d) Menke's kinked hair syndrome
Correct Answer - C
Wilson's disease om
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3. All are features of Abetalipoproteinemia, EXCEPT:
a) Plasma levels of cholesterol and triglyceride are extremely low
b) Manifest in early childhood with diarrhea
c) Progressive pigmented retinopathy seen
d) Neurological manifestation as ataxia in first decade
Correct Answer - D
Plasma levels of cholesterol and triglyceride are extremely low in
this disorder, and chylomicrons. Abetalipoproteinemia usually
presents in early childhood with diarrhea and failure to thrive.
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The neurological manifestations like decreased distal lower
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extremity vibratory and proprioceptive sense, dysmetria, ataxia, and
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the development of a spastic gait, often by the third or fourth
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decade.
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Patients also develop a progressive pigmented retinopathy
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presenting with decreased night and color vision.
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Ref: Harrisons Principles of Internal Medicine, 18th Edition, Page
3153
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4. Which of the following findings is diagnostic of iron deficiency anemia?
a) Increased TIBC, decreased serum ferritin
b) Decreased TIBC, decreased serum ferritin
c) Increased TIBC, increased serum ferritin
d) Decreased TIBC, increased serum ferritin
Correct Answer - A
Iron deficiency anemia is associated with increased Total iron binding capacity (TIBC) and
decreased serum ferritin ( storage form of iron)
Ref: Harrison’s Principles of Internal Medicine, 17th Edition, Page 631, 663; Davidson’s
principles and practice of Medicine, 20th Edition, Chapter 24, Page 1025-1027 &1030
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5. Which of the following endocrine tumors is most commonly seen in MEN I?
a) Insulinoma
b) Gastrinoma
c) Glucagonoma
d) Somatostatmoma
Correct Answer - B
Amongst the options provided, gastrinomas are the most common enteropancreatic tumors
associated with MEN I with insulinomas being the second most common.
Ref: Harrison’s Principles of Internal Medicine, 17th Edition, Page 2358 & 2359; 16th/
2232; Davidson’s principles and practice of Medicine, 20th Edition, Chapter 20, Page 803
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6. All of the following statements regarding Sickle Cell Anemia is true, EXCEPT:
a) Patients require frequent blood transfusions
b) Patients usually presents before the age of 6 months
c) There is a positive correlation between HBS and polymerization
of HBS
d) Reccurent infections is the most common cause of death
Correct Answer - B
Sickle cell anemia is an autosomal recessive disorder, caused by an amino acid
substitution of valine for glutamine in the sixth position on the beta-globin chain. Onset of
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the disease starts during the first year of life especially after 6 months of age, when
hemoglobin F levels falls, as a signal is sent to switch from production of gamma globin to
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beta globin.
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Hemoglobin S is unstable and polymerizes during hypoxemia and acidosis, leading to
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sickling of red blood cells. Patients develops jaundice, pigmented gallstones,
spleenomegaly, and poorly healing ulcers over the lower tibia. Acute painful episodes can
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occur due to acute vaso-occlusion by clusters of sickled red cells during infection,
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dehydration, or hypoxia. Common sites of acute painful episodes include the bones and the
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chest.
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Ref: Current Medical Diagnosis and Treatment 2012, Chapter 13 ; Medical Assisting:
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Administrative and Clinical Competencies By Lucille Keir, 6th Edition, Page 471
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7. Leukoerythroblastic
except:
picture may be seen in all of the following conditions,
a) Myelofibrosis
b) Metastatic carcinoma
c) Gaucher's disease
d) Thalassemia
Correct Answer - D
Leukoerythroblastosis refers to the presence of immature nucleated RBCs, immature white
blood cells, and megakaryocyte fragments on the peripheral blood smear. It occur due to
bone marrow infiltration.
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When marrow infiltration causes anemia or pancytopenia, it is referred to as
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myelophthisic anemia. The most common cause of myelophthisis includes metastatic
carcinoma of the lung, breast, or prostate. Other causes include hematologic malignancies
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(leukemia, lymphoma), infections (tuberculosis, fungi), and metabolic diseases (Gaucher
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disease, Niemann-Pick disease). Thalassemia is not associated with leukoerythroblastosis.
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Ref: CURRENT Diagnosis & Treatment in Family Medicine, 3rd Edition, Chapter 31
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8. All of the following are major complications of massive transfusion, except:
a) Hypokalemia
b) Hypothermia
c) Hypomagnesemia
d) Hypocalcemia
Correct Answer - A
Ans:A.)Hypokalemia.
Complications usually seen with massive blood transfusion are
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1) hyperkalemia,
2) hypocalcemia,
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3)hypomagnesemia
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4) hyperammonemia,
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5) hypothermia,
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6) Acidosis
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7)dilutional coagulopathies and DIC (most worrisome problem after
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massive transfusion and is the usual cause of death after massive
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blood transfusion) and
8) ARDS.
The lethal triad of acidosis, hypothermia, and coagulopathy
associated with MT is associated with a high mortality rate.
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9. Richter’s syndrome refers to which of the following malignant transformation?
a) CLL evolving into aggressive lymphoma
b) Hairy cell leukemia evolving to AML
c) Blast crisis in CML
d) Splenic infiltration in NHL
Correct Answer - A
Ans. A. CLL evolving into aggressive lymphoma
Richter's transformation or Richter's syndrome is a complication
of B cell chronic lymphocytic leukemia (CLL) or hairy cell leukemia
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(HCL) in which the leukemia changes into a fast-growing diffuse
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large B cell lymphoma.
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10. Sickle cell anemia leads to resistance towards?
a) P. falciparum
b) P. ovale
c) P. malariae
d) P. vivax
Correct Answer - A
Individuals with sickle cell trait (hemoglobin genotype AS) are resistant to the lethal effects
of Plasmodium falciparum infection.
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This is because the sickle cell traits prevents the development of high parasitemia, probably
partly as a result of parasitized red cells sickling in the circulation and being removed by the
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spleen before they can develop into schizonts.
Absence of RBC Duffy antigen confers resistance to P. Vivax.
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Ref: Harrison's 17th ed chapter 213 ; Essentials of clinical immunology by Helen Chapel,
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Man;e. Haeney, Siraj Misbah, 5th edition, Page 48 ; Lecture
Notes: Tropical
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Medicine edited by G. V. Gill, Nick Beeching, 2011, Page 62.
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11. Romiplostim acts on which of the following receptors:
a) Thrombopoeitin
b) IL 6
c) IL 8
d) PGE 1
Correct Answer - A
Romiplostim: Genetically engineered protein in which the Fc component of a human
antibody is fused to two copies of a peptide that stimulates the thrombopoietin receptors;
approved for treatment of idiopathic thrombocytopenic purpura
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Ref: Katzung 11th edition Chapter 33.
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12. Oncogene associated with burkitt's lymphoma is:
a) BCL-1, IgH
b) BCL-2, IgH
c) C-MYC
d) ALK
Correct Answer - C
Disease Cytogenetic Abnormality Oncogene
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Mantle cell lymphoma t(11;14)(q13;q32) BCL-1, IgH
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Follicular lymphoma t(14;18)(q32;q21) BCL-2, IgH
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Diffuse large cell lymphoma t(3;-)(q27;-) BCL-6
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t(17;-)(p13;-) p53
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Burkitt's lymphoma, Burkitt's t(8;-)(q24;-) C-MYC
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leukemia
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CD30+ Anaplastic large cell t(2;5)(p23;q35) ALK
lymphoma
Lymphoplasmacytoid lymphoma t(9;14)(p13;q32) PAX5, IgH
Ref: Harrison, E-18,P-921
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13. FALSE statement regarding the ECG in acute pericarditis is:
a) T wave inversion develop before ST elevations return to
baseline
b) Global ST segment elevation is seen in early pericarditis
c) Sinus tachycardia is a common finding
d) PR segment depression is present in majority of patients
Correct Answer - A
T wave inversion develop after ST elevations return to baseline.
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There are four stages of ECG changes in the evolution of acute pericarditis. In stage 1,
there is widespread elevation of the ST segments, often with upward concavity, involving
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two or three standard limb leads and V2 to V6, with reciprocal depressions only in aVR and
sometimes V1, as well as depression of the PR segment Usually there are no significant
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changes in QRS complexes. In stage 2, after several days, the ST segments return to
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normal, and only then, or even later, do the T waves become inverted (stage 3). Ultimately,
weeks or months after the onset of acute pericarditis, the ECG returns to normal in stage 4.
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Ref: Harrisons principles of internal medicine, 18th edition, Page: 1971
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14. Omalizumab is used in treatment of:
a) Breast carcinoma
b) Asthma
c) Rheumatoid arthritis
d) None of the above
Correct Answer - B
Omalizumab is a blocking antibody that neutralizes circulating IgE without binding to cell-
bound IgE; it thus inhibits IgE-mediated reactions.
This treatment has been shown to reduce the number of exacerbations in patients with
severe asthma and may improve asthma control. However, the treatment is very
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expensive and only suitable for highly selected patients who are not controlled on maximal
doses of inhaler therapy and have a circulating IgE within a specified range.
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Ref: Harrison’s principle of internal medicine 17th edition, chapter 248.
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15. The pathognomonic finding in miliary TB is which of the following?
a) Bone marrow infiltrations
b) Choroid tubercles
c) Miliary mottling in chest X-Ray
d) Histological finding in liver biopsy
Correct Answer - B
Eye examination may reveal choroidal tubercles, which are pathognomonic of miliary TB, seen in up
to 30% of cases.
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Reference:
Harrisons Principles of Internal Medicine, 18th Edition, Page 1349
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16. All are important pathogens causing pneumonia in COPD patients, EXCEPT:
a) Haemophilus influenzae
b) Pseudomonas aeruginosa
c) Legionella spp
d) Klebsiella pneumoniae
Correct Answer - D
All are important pathogens causing pneumonia in COPD patients
Haemophilus influenzae
Pseudomonas aeruginosa
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Legionella spp
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S. pneumoniae
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Moraxella catarrhalis
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Chlamydia pneumoniae
Klebsiella is an important pathogen causing pneumonia in chronic alcoholism.
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Ref: Harrison, E-18, P-2132
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17. PNH patients will be having deficient surface proteins that normally protect the
red cells from activated compliments. What are the two deficient surface
proteins?
a) CD 45 and CD 59
b) CD 51 and CD 59
c) CD 55 and CD 59
d) CD58 and CD 59
Correct Answer - C
The definitive diagnosis of PNH is based on the demonstration that a
substantial proportion of the patient's red cells have an increased
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susceptibility to complement (C), due to the deficiency on their
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surface of proteins (particularly CD59 and CD55).
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Reference: Harrisons Principles of Internal Medicine, 18th Edition,
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Page 884
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18. Which of the following biochemical test is used to diagnose Dubin Johnson
syndrome?
a) Serum transaminases
b) Bromsulphalein test (BSP)
c) Hippurate test
d) Gamma glutamyl transferase level
Correct Answer - B
Bromsulphalein test (BSP) is the diagnostic test for Dubin-Johnson Syndrome. Biliary
excretion of numerous anionic compounds such as Bromsulphalein (BSP) is compromised
in Dubin-Johnson Syndrome (DJS). In this test, BSP is administered as IV bolus and its
clearance from plasma is determined. BSP levels show a characteristic rise in patients with
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DJS after 90 minutes of injection, due to reflux of conjugated BSP into the circulation from
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the hepatocyte.
Ref: Davidson’s principles and practice of Medicine, 20th Edition, Chapter 23, Page
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945; Harrison’s Principles of Internal Medicine, 16th Edition, Page 1821; Digestive
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Diseases and Sciences Vol/17 numbers 6.
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19. Cholecystokinin is produced from:
a) Hepatocyte
b) Gastric mucosa
c) Duodenal mucosa
d) Epithelial cells of distal common bile duct
Correct Answer - C
The major factor controlling the contraction of the gallbladder is the hormone
cholecystokinin (CCK), which is released from the duodenal mucosa (I cells) in response to
the ingestion of fats and amino acids.
Reference:
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Harrisons Principles of Internal Medicine, 18th Edition, Page 2616
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20. Esophageal manometry is useful all this conditions EXCEPT:
a) Achalasia
b) Diffuse esophageal spasm
c) To assess the peristaltic integrity prior to the surgery for GERD
d) Malignancy
Correct Answer - D
Esophageal manometry, or motility testing, entails positioning a pressure sensing catheter
within the esophagus.
Manometry is used to diagnose
1. Motility disorders (achalasia, diffuse esophageal spasm)
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2.To assess peristaltic integrity prior to the surgery for reflux disease.
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Esophageal malignancy is not diagnosed with esophageal manometry. Upper GI
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endoscopy is the effective method for malignancy and biopsy can be taken.
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Ref: Harrison, Edition-18,Page-2430
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21. Which of the following drugs is useful in the prophylaxis of migraine?
a) Propranolol
b) Sumatriptan
c) Domperidone
d) Ergotamine
Correct Answer - A
Drugs such as topiramate, valproate, propanolol, timolol, candesartan, verapamil and
amitryptilline are indicated in migraine prophylaxis.
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Migraine prophylaxis is indicated when migraine headaches occur more than two or three
times a month or when it is associated with significant disability. After initiation of therapy,it
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should be continued for several months. Once the patient remains headache free, the dose
is tapered and the drug is eventually withdrawn. Botulinum toxin type A was approved by
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the US Food and Drug Administration (FDA) for migraine prevention in late 2010.
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Ref: Current Medical Diagnosis and treatment 2012, Chapter 24
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22. All of the following are true about treatment of migraine, EXCEPT:
a) Naratriptan acts longer than sumatryptan
b) Sumatryptan is used in acute attack of migraine
c) Sumatryptan acts on 5HT 1B/1D receptors in great vessels
d) Sumatryptan is used for chronic migraine
Correct Answer - D
Sumatriptan is an agonist at 5-HT serotonin receptors, in particular 5HT 1B/1Dreceptors. It is used in
the treatment of acute migraine attacks but is not recommended for migraine prophylaxis. The drug
provides rapid relief of migraine headache as well as relief of the associated manifestations of
migraine including nausea, vomiting, photophobia and phonophobia.
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Short-acting, rapidly effective triptans include almotriptan, sumatriptan, rizatriptan, zolmitriptan,
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and eletriptan, whereas naratriptan and frovatriptan have the longest half-lives.
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5HT 1B/1Dreceptor agonists are sumatriptan, naratriptan, rizatriptan, and zolmitriptan.
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Ref: Instant Pharmacology By Kourosh Saeb-Parsy, Ravi G. Assomull, Fakhar Z. Khan,
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Kasra Saeb-Parsy, Eamonn Kelly, 1999, Page 300 ; Harrison's 17th ed chapter 15
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23. Lateral medullary syndrome is due to the occlusion of which of the following vessels?
a) Posterior superior cerebellar artery
b) Anterior inferior cerebellar artery
c) Basilar artery
d) Vertebral artery
Correct Answer - D
Lateral medullary syndrome is otherwise known as Wallenberg’s syndrome or PICA syndrome or
vertebral artery syndrome.
Occlusive disease of the intracranial segment of the vertebral artery is a much more frequent
cause of the lateral medullary syndrome.
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Signs and symptoms include:
Ipsilateral side
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Horner’s syndrome
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Decrease in pain and temperature sensation on ipsilateral side of face
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Cerebellar signs (ataxia)
Contralateral side:
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Decreased pain and temperature on contralateral body
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Dysphagia, dysarthria, hoarseness, paralysis of vocal cord
Vertigo, nausea, vomiting, hiccups
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Nystagmus, diplopia
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No facial or extremity muscle weakness seen in this syndrome.
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Ref: Physical Medicine and Rehabilitation Board Review By Sara Cuccurullo, 2004, Page
11 ; Harrison's Internal Medicine 17th ed Chapter 364. Cerebrovascular Diseases,
Brainstem disorders by Peter P Urban, Louis R Caplan page 205-207.
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24. POEMS Syndrome includes all, EXCEPT:
a) Polyneuropathy
b) Organomegaly
c) Endocrinopathy
d) Multiple sclerosis
Correct Answer - D
The features of this syndrome are polyneuropathy, organomegaly, endocrinopathy,
multiple myeloma, and skin changes (POEMS).
Patients usually have a severe, progressive sensorimotor polyneuropathy associated with
sclerotic bone lesions from myeloma. Polyneuropathy occurs in ~1.4% of myelomas, but
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the POEMS syndrome is only a rare subset of that group.
Unlike typical myeloma, hepatomegaly and lymphadenopathy occur in about two-thirds of
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patients, and splenomegaly is seen in one-third.
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Ref: Harrison’s principle of internal medicine 17th edition, Chapter 106.
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25. Barr body is found in the following phase
of the cell cycle:
a) Interphase
b) Metaphase
c) GI phase
d) Telophase
Correct Answer - A
A i.e. Interphase
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The inactive X can be seen in the interphase nucleus as a darkly
staining small mass in contact with the nuclear membrane known as
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the Barr body or X chromatin. Barr body is the inactivated X
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chromosome. In non dividing interphase cells it remains tightly coiled
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and can be seen as a dark staining body within the nucleus.
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26. All of the following statements about
Pulsus Bigeminus are true, except:
a) Must be distinguished from Pulsus Alternans
b) Is a sign of digitalis toxicity
c) Compensatory pause is absent
d) Rhythm is Irregular
Correct Answer - C
Answer is C (Compensatory pause is absent):
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Pulsus Bigeminus is associated with a compensatory Pause.
Compensatory pause is absent in Pulsus Alternans
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Pulsus Bigeminus is a disorder of rhythm (Irregular rhythm) caused
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by a normal heat alternating with a premature contraction and a
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compensatory pause resulting in alternation of the strength of pulse.
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The stroke volume of the premature beat is diminished in relation to
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that of the normal beats, and the pulse varies in amplitude
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accordingly. Pulsus Bigeminus most closely mimics Pulsus
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Alternans from which it must be distinguished. In Pulsus Alternans
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the rhythm is regular and the compensatory pause is absent.
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27. Pulsus Bigeminus is seen in therapy with:
a) Digitalis
b) Beta Blockers
c) ACE Inhibitors
d) Calcium Channel Blockers
Correct Answer - A
Answer is A (Digitalis)
Pulsus Bigeminus is recognized as a cause of digitalis toxicity.
Pulsus Bigeminus is a disorder of rhythm (Irregular rhythm;
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arrhythmia) most commonly caused by Premature Ventricular
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Contractions that results in a pulse with irregular rhythm that
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alternates in amplitude (pressure) from beat to beat. The most
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common cause of Pulsus Bigeminus is Digitalis and Pulsus
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Bigeminus is recognized as a cause of digitalis toxicity.
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28. Wide pulse pressure is seen in all except:
a) PDA
b) Aortic stenosis
c) Aortic Regurgitation
d) A.V. malformation
Correct Answer - B
Answer is B (Aortic Stenosis)
Aortic Stenosis is associated with a narrow pulse pressure.
Patent Ductus Arteriosus (PDA), Aortic Regurgitation and AV
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Malformations (Arteriovenous shunting) are all associated with a
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29. Erb's Point in cardiology refers to:
a) Right 2nd intercostal space
b) Left 2nd intercostal space
c) Right 3rd intercostal space
d) Left 2nd intercostal space
Correct Answer - C
Answer is C (Right 3rd intercostal space)
In cardiology, Erb's point refers to the third intercostal space on the
left sternal border where both components of S2 (A2 and P2) can be
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well appreciated.
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Both components of S2 (A2 and P2) are usually well transmitted to
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the Erb's point. The physiological splitting of S2 into A2 and P2 is
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believed to be appreciated best at the Erb's point or in the pulmonic
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area.
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A2 is best heard over the aortic area in the right second intercostal
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space
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P2 is best heard over the pulmonic area in the left second intercostal
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space
Second heart sound (S2) is best heard over the pulmonic area
(Since both A2 and P2 can be heard at the pulmonic area) and at
the Erb's Point. Note that even at the pulmonic area A2 is louder
than P2
Second intercostal space to the right of the
1. Aortic area
sternum (along right upper sternal border)
Pulmonic Second intercostal space to the left of the sternum
2.
area (along left upper sternal border)
Third intercostal to the left of the sternum(along left
3. Erb's point
sternal border)
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sternal border)
Tricuspid Fourth or Fifth intercostal space to the left of the
4.
area sternum (along left lower sternal border)
Mitral area
5. Fifth intercostal space on the left midclavicular line.
(Apex)
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30. S2 is best appreciated in:
a) 3rd left intercostal space
b) 2nd right intercostal space
c) 4th left intercostal space
d) 5 left intercostal space
Correct Answer - A
Answer is A (3rd left intercostal space)
Best areas to auscultate for both components of the second heart
sound (A2 and P2) are either the left sternal border at the level of
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second intercostal space (Pulmonic area) or the left sternal border at
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the level of third intercostal space (Erb's point).
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The second heart sound has two components A2 (from Aortic
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closure) and P2 (from pulmonary closure). P2 is a soft sound that is
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poorly transmitted. It is best heard at the pulmonic area and is
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transmitted only as far as the Erb's point. A2 is a loud sound best
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heard over the aortic area but since it is widely transmitted it may be
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heard across all areas of the chest even as far as the apex. Second
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heart sound (S2) is best heard over the pulmonic area (Since both
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A2 and P2 can be heard at the pulmonic area). Note that even at the
pulmonic area A2 is louder than P2. The other area to auscultate for
both components of the second heart sound is at the left sternal
border of the third intercostal space (Erb 's point)
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31. Paradoxical splitting of second heart
sound is seen in?
a) RBBB
b) ASD
c) LBBB
d) VSD
Correct Answer - C
Answer is C (LBBB)
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Left Bundle Branch Block (LBBB) is typically associated with
Reversed or Paradoxical Splitting of S2
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Paradoxical splitting of second heart sound is caused by delayed A2
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or early P2. Left Bundle Branch Block (LBBB) is associated with
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delayed Aortic closure (delayed A2) due to delayed electrical
tR
activation of the left ventricle.
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ASD and RBBB are associated with a wide physiological (non-
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paradoxical) split of second heart sound due to delayed pulmonic
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closure (Delayed P2) while VSD is associated with a wide
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physiological (non-paradoxical) split second heart sound from early
aortic closure (Early A2).
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32. All of the following statements about third
Heart sound (S3) are true, except:
a) Occurs due to rapid filling of the ventricles during atrial systole
b) Seen in in Constrictive Pericarditis
c) Seen in Atrial Septal Defect (ASD)
d) Seen in Ventricular Septal Defect (VSD)
Correct Answer - A
Answer is A (Occurs due to rapid filling of the ventricles during
om
atrial systole )
Third heart sound occurs at the end of early rapid filling phase of the
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ventricle but not at the time of atrial systole. The heart sound
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associated with ventricular filling during atrial systole is the fourth
an
heart sound (S4)
tR
Fourth Heart sound occurs in association with an effective atrial
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contraction() (It is presumably caused by in-rush of blood into the
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ventricles when the atria contracts and hence it is also called the
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'Atrial Heart Sound)
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Pathological Third Heart Sound (S3) may be associated with
ASD and VSD
`A pathological S3 is often present in large left to right shunts due to
high flow across the mitral valve with VSD or patent ductus
arteriosus and with high flow across the tricuspid valve with ASD.
The presence of this sound in these conditions does not imply
congestive heart failure, and such patients may maintain normal
myocardial contractility for years after the S3 is detected'- 'Hurst:
The Heart' 11th/271
Congenital Heart Diseases associated with Loud S3
Ventricular septal Defect (VSD)()
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Patent Ductus Arteriosus (PDA)Q
Atrial Septal Defect (ASD)Q
Pathological Third Heart Sound (S3) may be associated with
Constrictive Pericarditis
Constrictive pericarditis is characterixstically associated with
pericardial knock which is a distinct form of third heart sound (S3)
`Pericardial knock is S3 that occurs earlier (0.1 to 0.12 after A2)
and is higher pitched than normal. Its presence depends upon
the restrictive effects of the adherent pericardium which halts
diastolic filling abruptly'
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33. Left Axis Deviation is seen as
a) Positive in Lead I and Positive in Lead II
b) Positive in Lead I and Negative in Lead II
c) Negative in Lead I and Negative in Lead II
d) Negative in Lead I and positive in Lead II
Correct Answer - B
Answer is B (Positive in Lead I and Negative in Lead II)
Left axis deviation is seen as positive deflexion in Lead I and a
Negative deflection in Lead II.
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Calculating the cardiac axis:
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Right axis Left axis
Normal Axis
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deviation deviation
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Lead I Positive Negative Positive
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Positive or
Lead II Positive Negative
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negative
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Positive or
Lead III Positive Negative
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negative
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Note:
Lead I : POSITIVE BETWEEN -90 TO +90 (CLOCKWISE) Lead II :
POSITIVE BETWEEN -30 TO +150 (CLOCKWISE) Lead III :
POSITIVE BETWEEN +30 TO -150 (CLOCKWISE)
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34. P wave is due to:
a) Atrial depolarization
b) Atrial repolarization
c) Ventricular depolarization
d) Ventricular repolarization
Correct Answer - A
Answer is A (Atrial Depolarization)
P wave is produced due to atrial depolarization.
Intervals Events in the Heart During Interval
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P wave Atrial depolarization
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Atrial depolarization and conduction through
PR interval
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AV node
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Ventricular depolarization and atrial
QRS duration
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repolarization
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Ventricular depolarization plus ventricular
QT interval
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repolarization
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ST interval (QT
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Ventricular repolarization
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minus QRS)
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35. Absent P Wave is seen in:
a) Atrial Fibrillation
b) Cor-pulmonale
c) Mitral Stenosis
d) COPD
Correct Answer - A
Answer is A (Atrial Fibrillation)
P wave is typically absent in Atrial Fibrillation. COPD and Cor-
Pulmonale are associated with tall p waves from Right Atrial
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Enlargement (P-Pulmonale) while Mitral Stenosis is typically
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associated with a wide and notched p wave from Left Atrial
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Enlargement (P-Mitrale)
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Causes of Absent Wave:
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Atrial fibrillation (p' wave is absent or replaced by fibrillary T wave)
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Atrial flutter (p' wave is replaced by flutter wave, which shows saw-
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tooth appearance).
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SA block or sinus arrest
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Nodal rhythm (usually abnormal, small p wave).
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Ventricular ectopic and ventricular tachycardia.
Supraventricular tachycardia (p' wave is hidden within QRS, due to
tachycardia).
Hyperkalemia.
Idioventricular rhythm
Right Atrial Enlargement(RAE) is typically
P Pulmonale
associated with tall P waves
(COPD and Cor-Pulmonale are associated with
tall p waves from RAE)
Left Atrial enlargement(LAE) is typically
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associated with wide P waves P Mitrale
(Mitral Stenosis is typically associated with a wide
and notched p wave from LAE
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tR
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36. A patient in regular rhythm presents with
absent P waves on ECG. Leads II, III and
AVF reveal a Saw-Tooth Pattern. Which of
the following is the most likely diagnosis:
a) Atrial Fibrillation
b) Atrial Flutter with Variable Block
c) Atrial Flutter with Fixed Block
d) Multifocal Atrial Tachcardia
om
Correct Answer - C
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Answer is C (Atrial Flutter with Fixed Block)
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The absence of any discernible P waves on ECG, together with the
an
presence of Saw Tooth Flutter waves in inferior leads (Leads II, III
tR
and AVF) strongly suggests a diagnosis of Atrial Flutter. The
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presence of a regular rhyti,,o suggests a Fixed Block .
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Findings/Features Diagnosis
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Irregular Rhythm with no discernible P wave Atrial Fibrillation
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(Chaotic base line with fibrillary f waves)
Irregular rhythm with no discernible P wave Atrial Flutter with
(Saw tooth ,Ilutter waves especially in inferior variable block
leads and VI)
Regular rhythm with no discernible P waves Atrial Flutter with
(Saw tooth flutter waves especially in inferior fixed block
leads and V1)
Irregular Rhythm with multiple P wave Multifocal Atrial
morphologies (P waves Discernible) Tachycardia
and Varying PR intervals
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37. A wide and notched P wave is typically
seen in:
a) Mitral Stenosis
b) Cor-Pulmonale
c) COPD
d) Pulmonary embolism
Correct Answer - A
Answer is A (Mitral Stenosis)
om
Mitral Stenosis is typically associated with a Wide and Notched P
wave from Left Atrial Enlargement (LAE) Cor-Pulmonale, COPD and
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Pulmonary embolism are all associated with Right Atrial
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Enlargement resulting in a Tall P wave (not a wide p wave)
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tR
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38. A QRS duration between 100 and 120
milliseconds suggests all of the following,
Except:
a) Normal
b) Left anterior Fascicular Block
c) Left posterior Fascicular Block
d) Left Bundle Branch Block
Correct Answer - D
om
Answer is D (Left Bundle Branch Block)
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Left Bundle Branch block is typically associated with a QRS duration
greater than 120 milli seconds.
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Partial Blocks (Fascicular or hemiblocks) in the left bundle system
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(left anterior or posterior fascicular blocks) generally do not prolong
tR
the QRS duration substantially and QRS duration typically remains
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less than 120 milliseconds.
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39. Low QRS voltage on ECG with left
ventricular hypertrophy on
Echocardiography suggests a diagnosis
of:
a) Pericardial effusion
b) Cardiac Amyloidosis
c) Corpulmonale
d) Infective endocarditis
om
Correct Answer - B
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Answer is B (Cardiac Amyloidosis)
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Low QRS voltage on ECG with left ventricular hypertrophy on
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Echocardiography suggests a diagnosis of infiltrative
tR
cardiomyopathy like amyloidosis.
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The combination of low QRS voltage plus a thick left ventricle on
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echocardiogram strongly suggests the diagnosis of infiltrative
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cardiomyopathy like cardiac amyloidosis. The increased thickness is
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the amyloid. It is not muscle (not true hypertrophy), does not
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depolarize and therefore adds nothing to QRS voltage
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40. Tall T waves on ECG are seen in:
a) Hyperkalemia
b) Hypokalemia
c) Hypercalcemia
d) Hypocalcemia
Correct Answer - A
Answer is A (Hyperkalemia)
Hyperkalemia is typically associated with Tall peaked narrow based
frnted T wave.
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tR
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41. ST elevation is seen in all of the following
conditions except :
a) Myocardial infarction
b) Coronary artery spasm
c) Constrictive pericarditis
d) Ventricular aneurysm
Correct Answer - C
Answer is C (Constrictive pericarditis)
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ST segment is measured from the end of QRS complex to the
beginning of the T wave, and represents the time interval between
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ventricular depolarization and repolarization.
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tR
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42. The most common reentrant tachycardia
associated with WPW syndrome is
a) Orthodromic AV reentry
b) Antidromic AV reentry
c) Rapidly conducting AF
d) None
Correct Answer - A
Answer is A (Orthodromic AV reentry)
om
123.The most common macro-reentrant tachycardia associated
WPW syndrome is orthodromic AV reentry.
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The most common macro-reentrant tachycardia associated with
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WPW syndrome is referred to as Orthodromic AV reentry'
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tR
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43. Athletic syndrome is characterized by:
a) Increased amplitude of QRS
b) Tachycardia
c) Decreased QT interval
d) U-waves
Correct Answer - A
The answer is A (Increased amplitude of QRS complex):
Athletic Heart Syndrome
Athletic Heart Syndrome is a benign condition consisting of
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physiologic adaptations to the increased cardiac workload of
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exercise in trained athletes.
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It represents a constellation of clinical findings that are the result of
an
normal physiologic adaptation to strenuous physical activity.
tR
In response to the increased physical demand, the left ventricles
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dilate and wall thickness increases. The mass to volume ratio,
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however, does not change.
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Physical examination
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Decreased body fat and increased muscle mass (generally very
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physically fit)
Pulse slow and often irregular (sinus bradycardia or bradycardia with
first-and second-degree blocks)
Grade I or II mid-systolic murmurs (benign functional ejection
murmur resolves with Valsalva maneuver)
Third and fourth heart sounds very common (benign filling sounds)
Blood pressure typically remains normal
Electrocardiogram rhythm
Rhythm
- Sinus bradycardia of 40 to 55 beats /min while at rest
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- Sinus pauses of more than 2.0 seconds due to increased vagal
tone
- Wandering atrial pacemaker found only in dynamic athletes
- First degree atrioventricular block present only at rest; P-R interval
normalizes with exercise
- Second degree atrioventricular block present only at rest: Mobitz I
(wenckebach block) common in marathon runners; Mobitz II rare in
athlete's heart.
Voltage: TORS voltage (Amplitude)
- Left ventricular hypertrophy found in 85% of Olympic marathon
runners
- Right ventricular hypertrophy common in dynamic athletes but
rarely seen in sedentary controls and static athletes sedentary
control and static athletes
Repolarization
- S-T segment elevation with peaked T waves normalizes with
exertion
- S-T segment depression may be rarely found in athletes
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T-wave inversion in lateral leads associated with interventricular
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septal hypertrophy in static athletes (can be a normal finding in
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dynamic athletes)
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Chest radiography
tR
- The heart is globular in appearance, particularly in endurance
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athletes.
- Cardiomegaly (cardiothoracic ratio >0.50)
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44. Predisposing factors for coronary artery
disease include, all Except:
a) Homocysteinemia
b) ↑ Lipoprotein B
c) ↑ Fibrinogen
d) ↑ plasminogen activator inhibitors 1
Correct Answer - B
Answer is B (↑. Lipoprotein B)
om
Predisposing factors for coronary artery disease include an
increased lipoprotein 'a' and not lipoprotein '6'.
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45. 40 year old male patient presents to the
Emergency department with central chest
pain for 2 hours. The ECG shows ST
segment depression and cardiac
troponins are elevated. Patient has a
positive history of previous PCI 3 months
back. He is administered Aspirin,
Clopidogrel, Nitrates and LMWH, in the
Emergency Department and shifted to the
coronary are unit. The best recommended
course of further action should include.
a) Immediate Revascularization with Thrombolytics
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b) Early Revascularization with PCI
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c) Continue conservative management and monitoring of cardiac
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enzymes and ECG
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d) Continue conservation management and plan for delayed
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Revascularization procedure after patient is discharged
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Correct Answer - B
Answer is B (Early Revascularization with PCI)
The patient presenting as a case of NSTE M I to the emergency
department.
The presence of elevated cardiac troponins and history of previous
PCI place the patient into a high 'risk category'.
The Patient in question is th 10 a 'high risk' patient with NSTEMI
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Such patients are candidates for early invasive management with
PCl/CABG.
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46. The most common toxin causing Dilated
Cardiomyopathy is:
a) Alcohol
b) Chemotherapeutic agents
c) Heavy metal
d) Occupational exposure
Correct Answer - A
Answer is A (Alcohol)
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Chronic Alcohol Consumption is the most common cause of Toxic
Dilated Cardiomyopathy. Alcohol is the most common toxin
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implicated in chronic dilated cardiomyopathy'
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Note :
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Dilated cardiomyopathy is the most common type of cardiomyopathy
tR
The most common cause of dilated cardiomyopathy is Idiopathic
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(Two-Thirds) Alcohol Consumption is the most common cause of
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Toxic Dilated Cardiomyopathy
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47. The 9 month old child of a diabetic mother
presents with tachypnea and
hepatomegaly. Echocardiography of the
heart showed normal cardiac morphology
with asymmetric septal hypertrophy.
Which of the following you will give to
treat this child :
a) Digoxin
b) Frusemide
c) Propranolol
om
d) Isoptin
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tR
Correct Answer - C
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Answer is C (Propranolol)
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The symptoms of the patient and echocardiographic finding of
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asymmetrical septal hypertrophy almost confirms the diagnosis of
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Hypertrophic cardiomyopathy. Beta Blockers should be the initial
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drug Q in symptomatic individuals
Management of HOCM
Avoidance of strenuous physical activity
Beta Blockers should be the initial drug Q in symptomatic individuals.
They reduce:
- Heart rate
- Blood pressure
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- Stiffness of left ventricle
- Fatal arrythmias
Calcium channel BlockersQ (verapamil and diltiazem) are alternative
drugs.
- They reduce-stiffness of ventricle
- Elevated diastolic pressures
Amiadarone may be used to reduce arrythmias.
Surgical myomectomy
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48. Kussmaul's sign is classically described
in:
a) Restrictive Cardiomyopathy
b) Pericardial Tamponade
c) Constrictive pericarditis
d) Right Ventricular Infarct
Correct Answer - C
Answer is C (Constrictive pericarditis)
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Kussmaul's sign is classically described in association with
Constrictive Pericarditis.
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Kussmaul's sign refers to paradoxical elevation of JVP/CVP during
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inspiration (In healthy persons venous pressure falls during
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inspiration because pressures in the right heart decrease as
tR
intrathoracic pressures fall) The Kussmaul's sign is classically
irs
described in association with Constrictive pericarditis. Kussmaul's
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sign is however also seen in association with Right Ventricular
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Infarction, Restrictive Cardiomyopathy, Pulmonary Embolism and
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Advanced Systolic Severe Heart Failure
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49. Hypertension with Hypokalemia is seen
in:
a) Bartter Syndrome
b) Liddle's Syndrome
c) Gitelman's Syndrome
d) All of the above
Correct Answer - B
Answer is B (Liddle's Syndrome)
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Liddle's Syndrome is typically associated with Hypokalemia and
Hypertension. Rartter's Syndrome and Gitelman's Syndrome are
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also associated with hypokalemia but without hypertension.
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Liddle's Syndrome : Review
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Pathophysiology:
tR
• Autosomal dominant disorder.
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• Genetic defect in the collecting tubule sodium channel, resulting in increased so
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of inhibition by higher levels of intracellular sodium
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Age of Presentation
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• Often diagnosed at young age, but can present in adulthood due to phenotypic v
Clinical presentation
• Classic triad of hypertension, metabolic alkalosis, and hypokalemia.
• Consider iffamily history of hypertension and/or hypokalemia. at young age
Lab data
• Metabolic alkalosis, hrpokalemia (although some are low normal), low urinary a
Treatment:
• Lifelong. Potassium-sparing diuretic which closes the sodium channel (Amiloride
Spironolactone does not work because aldosterone is not causing the sodium chan
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50. Which of the following statements about
atrial myxomas is true
a) Most common in Left Atrium
b) More common in Males
c) Distant metastasis are seen
d) Most myxomas are familial
Correct Answer - A
Answer is A (Most common in Left Atrium)
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Cardiac Myxomas are usually located in the atria, most common in
the left.
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Cardiac myxomas
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Are the most common type of primary cardiac tumorsQ
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Occur at all ages and show no sex preference (mixes equally with
tR
both sexes)Q
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Most cardiac myxomas are sporadic, while some may be familial
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Sporadic myxomas :
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Are solitary Q
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Located in Atria, most commonly in the left Q
Unlikely to have post-op recurrence e
Occur in younger individuals Q
Familial myxomas :
Are multiple °
More likely to have post op recurrence e
Myxomas are benign tumors and therefore distant metastasis are
not seen.?
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51. Which condition is most commonly
associated with coarctation of aorta?
a) PDA
b) Bicuspid aortic valve
c) Aortic stenosis
d) VSD
Correct Answer - B
Answer is B (Bicuspid Aortic Valve)
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The most common associated cardiac anomaly with coarctation of
aorta is bicuspid aortic valve (Harrison's 17th /1462) Coarctation of
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aorta is associated with a bicuspid aortic valve in more than 70% of
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cases - (Nelson 18th / 1900)
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Associated anomalies with
tR
Shone complex
coarctation of Aorta Q
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• Bicuspid Aortic valve(' (commonest) Coarctation of Aorta
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• PDAQ
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Left sided obstructive
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VSDQ
• lesions
• Tubular hypoplasia of aortic arch(' (Mitral valve abnormalities
• Aortic stenosisQ (valvular / and subaortic stenosis)
subvalvular)
Other Associated lesions that have been asked previously
Mitral valve abnormalities (Subvalvular mitral ring /parachute mitral
valve)
Turner's syndrome('
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52. Acute Infective Endocarditis with abscess
formation is most commonly associated
with
a) Listeria
b) Staphylococcus
c) Streptococcus
d) Enterococcus
Correct Answer - B
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Answer is B (Staphylococcus)
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Acute Infective Endocarditis with abscess formation is most
commonly associated with staphylococcus.
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`The most common organism causing acute infective endocarditis
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overall is staphylococcus aureus. Staphylococcus aureus
tR
endocarditis is particularly virulent and associated with annular and
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myocardial abscess formation and a higher mortality'
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53. In Marfan's syndrome, Aortic aneurysm
occurs most commonly in:
a) Ascending aorta
b) Descending aorta
c) Abdominal aorta
d) Arch of aorta
Correct Answer - A
The answer is A (Ascending Aorta)
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Aortic aneurysms in Marfan's syndrome occur most frequently in the
ascending aorta.
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Cardiovascular lesions in Marfan's syndrome
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Cardiovascular lesions are the most life-threatening features of
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Marfan's syndrome.
tR
Mitral valve prolapse(MVP)
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Loss of connective tissue support in mitral valves leaflets makes
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them soft and blowy creating the so-called 'floppy valve'.
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Mitral regurgitation frequently results.
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Dilatation of Ascending Aortae
The media undergoes cystic necrosis (cystic medionecrosis).
Loss of medial support results in progressive dilatation of aortic
valve ring and root of the aorta
Severe aortic incompetence Aortic dissections
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54. Which of the following is not expected in a
case of Microcytic Hypochromic Anemia:
a) Reduced serum Iron
b) Reduced Total RBC distribution Width
c) Normal Ferritin levels
d) Increased TIBC
Correct Answer - B
Answer is B (Reduced Total RBC distribution width
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Microcytic Hypochromic Anemias are typically associated with a
Normal or High Red Cell Distribution Width
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Condition Iron Thalassemia Sideroblastic Anemia of chronic
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Test deficiency anemia disease
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(normal
tR
values)
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Microcytic Microcytic Microcytic Normocytic
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hypochromic hypochromic hypochromic normochromic
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Smear
>
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Microcytic
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Micro/hypochromic
(MCV<80)
(but Micro/Hypo
may be present)
Serum iron Low (<30) Normal Normal .1. (<50)
(50-
150n/d1)
TIBC High (>360) Normal Normal ,i, (<300)
(300-360 (Chandrasoma
µg/dl) Taylor)
% < 10 (J') N or Ted N or "I' 4,
Saturation
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Saturation
(30-50%) (30-80) (30-80) (10-20)
Ferritin < 15 (fed) T (50-300) T (50-300)
(R/1) Normal or T
(50-200 (30-200)
µg/L)
Hemoglobin
Normal Abnormal Normal Normal
pattern
Free Ted Normal Ted Ted
Erythrocyte
Protporphrin
RDW Ted Normal Normal Normal
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55. Megaloblastic anemia should be treated
with both folic acid vitamin B12 because :
a) Folic acid alone causes improvement of hematologic symptoms
but worsening of neurological symptoms
b) It is a Co factor
c) It is enzyme
d) None of the above
Correct Answer - A
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Answer is A (Folic acid alone causes improvement in hematologic in
symptoms but worsening of neurological symptoms)
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Megaloblastic anemia may be caused by a deficiency of vitamin B12
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(cobalamine) or deficiency of folate. Unless it is clearly established,
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which of the two deficienceis / folate or cobalamine) is the cause
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anemia treatment should include administration of both .folk acid
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and. vitamin Bp. If only folic acid is administered in a patient with
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mezaloblastic anemia due to vitamin BI2 deficiency, worseninz of
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neurological symptoms (cobalamine neuropathy) is seen despite an
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improvement in the hematological .symptoms (anemia)
'Although prompt hematologic response heralded by reticulocytosis
follows the administration of folic acid, it should he cautioned that the
hematologic symptoms of a vitamin B,2 deficiency anemia also
respond to folate therapy. However Mate does not prevent and may
even exacerbate the progression of neurological deficits typical of
vitamin B12 deficiency states'
Before large doses of folic acid are given, cobalamine deficiency
must be excluded and if present corrected, otherwise cobalamine
neuropathy may develop despite a response of the anemia of
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cobalamine deficiency to Palate therapy.
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56. Indirect Coomb's test detects:
a) Antibodies attached to RBC Surface
b) Antibodies in the serum
c) Antigens attached to RBC Surface
d) Antigens in the serum
Correct Answer - B
Answer is B (Antibodies in the serum)
Indirect Coomb's test detects IgG antibodies in the serum (e.g. Anti-
D Antibodies). Direct Coomb's test detects IgG Antibodies (or
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complements) attached to the surface of RBCs.
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Direct Antihuman Globulin Test Detects RBCs sensitized with
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IgG or Complements(C3B or C3d)
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(DAT; Coomb's; Direct Coomb's) Detects IgG Antibodies (or
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complements) attached to the surface of RBCs.
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Indirect Antihuman Globulin Test
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Direct Coomb's Test
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In the Direct Coomb's test, red blood cells (RBCs) sensitized with
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IgG antibodies (or C3b, C3d) are agglutinated when Coomb's
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reagent (Rabbit Anti-IgG antibody) is added to the test tube
Detects Antibodies in the Serum
Indirect Coomb's Test In the Indirect Coomb's test IgG antibodies
(e.g. Anti-D) in the serum must first bind to blood group Type 0 Test
RBCs added to the test tube. Addition of Coombs Reagent, then
causes the sensitized Type 0 Test RBCs to agglutinate, indicating
that IgG antibodies are present in the serum.
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57. Direct Coomb's test detects:
a) Antibodies attached to RBC Surface
b) Antibodies in the serum
c) Antigens attached to RBC Surface
d) Antigens in the serum
Correct Answer - A
Answer is A (Antibodies attached to RBC Surface)
Direct Coomb's test detects IgG Antibodies (or complements)
attached to the surface of RBCs. Indirect Coomb's test detects IgG
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antibodies in the serum (e.g. Anti-D Antibodies).
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58. Haemoglobin F is raised in:
a) Juvenile chronic myeloid leukemia
b) Hereditary spherocytosis
c) Congenital red cell aplasia
d) Mysthania gravis
Correct Answer - A
Answer is A (Juvenile CML)
Fetal Haemoglobin levels (HbF) are increased in most cases of
Juvenile CML –
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Causes of Raised HbF levels (Interpretation of Diagnostic Test
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8th/411, 412)
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Haemoglobinopathies
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- β thalassemia major
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- β thalassemia minor
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- Sickle cell disease
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Hereditary Persistance of HbF
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Anemia:
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- Non Hereditary refractory normoblastic anemia
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- Pernicious anemia
- Aplastic anemia
Leukemia specially Juvenile Myeloid Leukemia
Multiple myeloma
Molar pregnancy
Patients with Trisomy 13 or Trisomy 21 (Down's syndrome)
Some chronic viral infections (eg CMV, EBV)
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59. HAM test is based upon :
a) GPI Anchor Proteins
b) Complement
c) Spectrin protein
d) Mannose binding proteins
Correct Answer - B
Answer is B (Complements)
HAM test is based upon susceptibility of RBC's to complement
mediated lysis in patients with PNH.
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HAM test is usedfbr the diagnosis of PNH (Paroxysmal Nocturnal
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Haemoglobinuria). HAM test (Acidified serum lysis test)
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demonstrates lysis of RBC after activation of complement by acid. In
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acidified serum complement is activated by the alternate pathway. In
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patients with PNH, RBC are unusually susceptible to complement,
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and undergo lysis when incubated with acidified fresh serum.
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60. Which is the most common cytogenetic
abnormality in adult myelodysplastic
syndrome (MDS) -
a) Trisomy 8
b) 20q?
c) 5q?
d) Monosmy 7
Correct Answer - C
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Answer is C (5q-)
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`Monosomy 7 is by far the most common cytogenetic abnormality in
children (pediatric MDS) whereas 5q- is observed most frequent!,' in
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adults' – Myelodysplastic Syndromes by John Bennett (2002)/300
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Cytogenetic Abnormalities in MDS: Facts to Remember
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Monosomy 7 is the most frequent cytogenetic abnormality in
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children.Q Deletion 5q (5q) is the most frequent cytogenetic
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abnormality in adults Q. Trisomy 8 is the most frequent tri.somyQ.
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Differences between Myelodysplastic Syndromes in children
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and Adults (`Myelodysplastic Syndromes' 2002/300; 'Childhood
Leukemias' 2'"/549)
Feature Children
Adults
• Frequency Less common More common
• Presence of Uncommon More common (,-
sideroblasts (<2%) -25%)
• Cytogenetic
Abervations
Most common Less common
-7/7q-
(r,30%) (,=-40%)
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-7/7q-
(r,30%) (,=-40%)
Uncommon (--L- Most common
-5/5q-
1-2%) (z20%)
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61. Gaisbock syndrome is known as
a) Primary Familial Polycythemia
b) High Altitude Erythrocytosis
c) Spurious Polycythemia
d) Polycythemia Vera
Correct Answer - C
Answer is C (Spurious Polycythemia)
Gaisbock syndrome refers to Spurious Polycythemia or Relative
Erythrocytosis due to decreased plasma volume.
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62. All of the following statements about
Burkitt's lymphoma are true, Except:
a) B cell lymphoma
b) 8, 14 translocation
c) Can present as an abdominal mass
d) Radiotherapy is the treatment of choice
Correct Answer - D
Answer is D (Radiotherapy is the treatment of choice)
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The treatment of choice for Burkitt's Lymphoma is chemotherapy
and not Radiotherapy.
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'Burkitt's lymphoma responds well to short term high dose
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chemotherapy. Treatment of Burkitt's lymphoma in both children and
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adults should begin within 48 hours of diagnosis and involves the
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use of intensive combination chemotherapy regimens' – Harrisons
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Burkitt's Lymphoma is a B cell lymphoma
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Burkitt's Lymphoma are tumors of mature B cells – Robbins 7th/677
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t (8;14) translocation is the most common translocation in Burkitt's
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Lymphoma Burkitt's lymphomas are associated with translocation of
the c-MYC gene on chromosome 8. Translocation
t (8; 14)
t (8; 22)
t (2; 8)
Burkitt's Lymphoma may present with an abdominal mass
Most Burkitt's Lymphoma presents at extranodal sites but may
present with lymphadenopathy
Extranodal sites of involvement include the mandible and abdominal
viscera
`Burkitt's Lymphomas may present with peripheral lymphadenopathy
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or an intraabdominal mass' – Harrison
CNS involvement is frequent
The disease is rapidly progressive and has a propensity to
metastasize to CNS, prophylactic therapy to CNS is therefore
mandatory.
Burkitt's Lymphoma is the most rapidly progressive human tumor
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63. 'Hairy cell leukemia' is a Neoplastic
proliferation of :
a) T. cells
b) B. cells
c) Myeloid cells
d) Macrophages
Correct Answer - B
Answer is B (B Cells)
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Wain' Cell is a rare hut distinctive B-cell neoplasm.
Hairy cell leukemia review :
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Presentation is with a triad of :
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1. Splenomegaly Q :often massive. However hepatomegaly is less
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common while lymphadenopathy is rare.
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2. Pancytopenia Q and thereby, resulting infections.
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3. Vasculitis like syndrome Q :Erythema nodosum and cutaneous
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nodules due to perivasculitis and PAN.
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Course : Hairy cell leukemia follows an indolent course.Q
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64. Chemotherapeutic Agent of Choice for the
treatment of CML is:
a) Imatinib
b) Vincristine
c) Cyclophosphamide
d) Methotrexate
Correct Answer - A
Answer is A (Imatinib):
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Tyrosine Kinase Inhibitors (Imatinib) are the chemotherapeutic
agents for choice in the management of CML. Tyrosine Kinase
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inhibitors target the 'constitutively active tyrosine kinase' implicated
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in the pathogenesis of CML. Although they do not cure the disease,
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these agents are able to achieve long term control of CML in the
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majority of patients. Most recent texts (Including Harrisons)
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recommend Tyrosine Kinase Inhibitors (Imatinib) as the initial
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treatment of choice for newly diagnosed CML reserving Allogeneic
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Stem Cell Transplantation (SCT) for those who develop Imatinib
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Resistance.
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65. The immunoglobulin most commonly
involved in Multiple Myeloma is :
a) IgG
b) IgM
c) IgA
d) IgD
Correct Answer - A
Answer is A(IgG)
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The M component in Multiple Myeloma can be made up of the
immunoglobulins IgG, IgM, IgD, IgA, and IgE; light chains alone; or
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heavy chains alone. IgG Myeloma is the most common form of
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Multiple Myeloma while IgD (2%) and IgE (Rare) are the least
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common.
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Distribution of immunoglobulin types in patients with multiple
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myeloma
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Type of protein Percentage (%)
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IgG 52
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IgA 22
IgM 12
IgD 2
IgE Rare
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66. The most common translocation seen in
patients with Multiple Myeloma is
a) t(11;14)
b) t(4;14)
c) t(14;16)
d) t(14;20)
Correct Answer - A
Answer is A (t(11;14))
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The most common translocation seen in patients with Multiple
Myeloma is 01;14).
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`The most common translocation seen in patients with Multiple
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Myeloma is t(11;14)(q13;q32) involving the BCL1 locus on
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chromosome 11g13 and the immunoglobulin heavy (IgH) chain
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locus on chromosome 14q13 which leads to overexpression of
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Cyclin D1 '- The Washington Manual of Surgical Pathology
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`The two most common translocation seen in patients with Multiple
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Myeloma are t(11;14)and t(4; 14). Both these translocations occur
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with almost similar frequencies, however the incidence of
translocation 1(11; 14) appears to be marginally higher. Patients
with t(4; 14) fall within a poor prognosis subgroup, while those with
1(11; 14) have a standard risk' - The Principles of Clinical
Cytogenetics
The two most common translocation seen in patients with Multiple
Myeloma
t(11;14)(q13;q32) : Associated with standard prognosis
t(4;14) (p16;q32) : Associated with aggressive behaviour and poor
prognosis
The most common translocation in multiple myeloma associated
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with a poor prognosis is translocation t(4;14)
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67. All the following are true about multiple
myeloma except:
a) Osteolytic bone disease
b) t(8-14) translocation
c) Light chain proliferation
d) Bence-Jones proteins in urine
Correct Answer - B
Answer is B (t (8-14) translocation)
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A variety of chromosomal alterations have been found in patients
with Multiple myeloma. The most common translocation is t (11; 14)
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(q 13; q32). 13q14 deletions and 17p13 deletions and 11 q
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abnormalities predominate. Translocation 1(8-14) has not been
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mentioned.
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Complete Immunoglobulin chain comprises of both heavy chains
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and light chains. But in Multiple myeloma there is excess production
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of light chains e over heavy chains.
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These light chains are eliminated in urine as Bence Jones proteinQ
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Protein cast in urine are thus made up of light chains only Q (not
complete immunoglobulin chains).
Bone lesions in multiple myeloma are lytic in nature and are rarely
associated with osteoblastic new bone formation.' - Harrison.
Bone lesions in MM are caused by the proliferation of tumor cells
and activation of osteoclasts that destroy the bone. 'Bone pain is the
most common symptom in MM affecting 70% of patients Q'-Harrison
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68. Converging point of both pathway in
coagulation is at:
a) Factor VIII
b) Stuart factor X
c) Factor IX
d) Factor VII
Correct Answer - B
Answer is B (Stuart factor X)
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The extrinsic and Intrinsic pathways in coagulation converge at the
Stuart factor X.
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69. Which of the following statements about
coagulation factor VII is not true
a) Deficiency is inherited as an Autosomal Recessive trait
b) Deficiency is associated with prolonged APTT
c) Deficiency can be managed by Fresh Frozen plasma
d) Has a shorter half life in comparison to Hageman factor (XII)
Correct Answer - B
Answer is B (Deficiency is associated with prolonged APTT)
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Factor VII deficiency is associated with isolated prolongation of PT,
APTT is normal in Factor VII deficiency
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Genetic and laboratory characteristic of inherited coagulation
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disorders
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Inheritance Laboratory Treatment
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Prevalence ' Minimum
Clotting Abnormality
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in General Hemostatic
factor aPTI
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Population le N els
deficiency PT TT
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I in
Fibrinogen AR 100 mg/dL Cryoprecipitate
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1.000,000 + + +
I in
ProthrombinAR 20-30% FFP/Pa's
2.000,000 + +
1 in
Factor V AR +/- +1- I 5-10"/a HP
1.000,000
1 in
Factor I II AR - + - 15-20% FFP/PCCs
500,000
FAINT
Factor VIII X-linked I in 5.000 30%
+ - concentrates
Factor IX X-linked I in 30.000 30% FIX concentrates
+ - -
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Factor IX X-linked I in 30.000 30% FIX concentrates
+ - -
I in
Factor X AR +1- +/- - 15-20% FFP/PCICs
1.000,000
I in
Factor XI AR 15-20% FFP
1,000,000
Factor XII AR 'SO + - h h
HK AR ND + Ii h
Prckallikrein AR ND _, 6 h
I in
Factor XIII AR +/- 2-5% Cryptoprecipitate
2,000,000
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Values within n srmal range (-) or prolonged (±) No risk for bleeding,
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treatment is not indicated
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HK, high-molecular weight kininogen; AR, autosomal recessive;
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aPTT, activated partial thromboplastin time; PT, prothrombin time;
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TT, thrombin time; ND, not determined; FFP. fresh frozen plasma;
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PCCs, prothrombin complex concentrates.
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70. Thrombotic thrombocytopenic purpura is
a syndrome characterized by:
a) Thrombocytosis, anemia, neurologic abnormalities, progressive
renal failure and fever.
b) Thrombocytopenia, anemia, neurologic abnormalities,
progressive hepatic failure and fever
c) Thrombocytosis, anemia neurologic abnormalities, progressive
renal failure and fever
d) Thrombocytopenia, anemia, neurological abnormalities,
progressive renal failure and fever
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Correct Answer - D
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Answer is D (Thrombocytopenia, anemia, neurological
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abnormalities, progressive renal failure and fever)
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Thrombotic Thrombocytopenic Purpura (TTP) is characterized
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clinically by the Pentad of Microangiopathic Hemolytic Anemia,
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Thrombocytopenia. Decreased Renal Function. Disturbed
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Neurological function and Fever.
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71. Hypercoagulability due to defective factor
V gene is called :
a) Lisbon mutation
b) Leiden mutation
c) Antiphospholipid syndrome
d) Inducible thrombocytopenia syndrome
Correct Answer - B
Answer is B (Leiden mutation)
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Hyper coagulability due to defective Factor V gene is called 'Leiden
mutation' and is named after the city in which it was described.
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Factor V Leiden
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Factor V Leiden is a variant (mutated) of normal clotting factor V and
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differs from normal clotting factor V by a single nucleotide.
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While Factor V Leiden is completely normal in terms of its ability to
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prevent bleeding, the one amino acid difference makes Factor V
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Leiden resistant to being degraded by activated protein C and
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protein S.
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Consequently factor V Leiden persists in the circulation longer and
contributes to formation of blood clots.
Factor V Leiden mutation is the most common underlying genetic
cause of thrombophilia (venous thrombosis)
Factor V Leiden mutation poses a life long risk of deep venous
thrombosis.
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72. The preferred test for confirming H. pylori
eradication is:
a) Urease breath test
b) Culture
c) Serological test
d) Biopsy urease test
Correct Answer - A
Answer is A (Urease Breath Test)
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The test of choice for documenting eradication is urease breath test.
Assessment of success of Treatment with Eradication of H. Pylori
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should be done at least 4 weeks after completion of anti H. Pylori
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therapy. Non-invasive tests are typically preferred for assessment of
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Eradication. The test of choice for documenting eradication is urease
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breath test. Urease breath test detects H. pylori infection by
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'bacterial urease activity' and remains positive till the bacteria has
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not been eradicated with treatment. Thus urease breath test
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becomes negative only aftereradication of organism following
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treatment and not with chronic infection.
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73. All of the following are used for treatment
of H.Pylori, except:
a) Gentamycin
b) Clarithromycin
c) Metronidazole
d) Amoxicillin
Correct Answer - A
Answer is A (Gentamycin):
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Gentamycin is not used in any of the successful multi-drug regimens
against H. Pylori Infection.
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74. Commonest site of peptic ulcer is :
a) 1st part of Duodenum
b) IInd part of duodenum
c) Distal 1/3 of stomach
d) Pylorus of the stomach
Correct Answer - A
Answer is A (1st part of Duodenum)
First part of duodenum is the most common site for peptic ulceration.
Sites in order of decreasing frequency :
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1. Duodenum, 1st portionQ
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2. Stomach, usually antrum Q
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3. At the gastro-esophageal junction, in the setting of
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gastroesophageal reflux Q
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4. Within the margins of a gastrojejunostomy Q
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5. In the duodenum, stomoch or jejunum of patients with Zollinger-
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Ellison Syndrome Q
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6. Within or adjacent to a Meckels diverticulum that contains ectopic
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gastric mucosa Q
Peptic ulcers are usually solitary lesions less than 4 cm in diameter
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75. Dumping syndrome is due to:
a) Diarrhoea
b) Presence of hypertonic content in small intestine
c) Vagotomy
d) Reduced gastric capacity
Correct Answer - B
Answer is B (Presence of Hypertonic Contents in small intestine)
DUMPING SYNDROME refers to a syndrome of abdominal and
vasomator symptoms which results from dumping of food stuffs with
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a high osmotic load, front the stomach, into the small bowel.
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Loss of storage capacity of stomach and ablation, by pass or
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destruction of pylorus, results in rapid emptying of hyperostnolar
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chyme into duodenummm and small intestine. Extracellular fluid
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then shifts into the intestinal lumen to restore isotonicity resulting in
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decreased intravascular volume, which gives rise to the vasomotor
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symptoms. Note that while reduced gastric capacity contributes,
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option (b) is a more accurate answer.
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Dumping Syndrome is actually of two types:
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Early dumping syndrome (as described above)
Late dumping syndrome: This is Reactive hypoglvcemiae. The
carbohydrate load in thesmall intestine later causes a rise in plasma
glucose, which in turn causes insulin levels to rise causing a
secondary hypoglycemia.
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76. Schilling test is Abnormal in:
a) Intrinsic factor deficiency
b) Amylase deficiency
c) Lipase deficiency
d) Pancreatic endocrine insufficiency
Correct Answer - A
Answer is A (Intrinsic factor deficiency)
Shilling's test is typically done to determine the cause of cobalamine
malabsorption (Vitamin B12 malabsorption) Vitamin B12 absorption
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(Schilling) test is typically used to diagnose conditions in which
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intrinsic factor (IF) may be absent, such as pernicious anemia or
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gastric atrophy. A diagnosis of Intrinsic factor deficiency can be
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established if radiolabelled cobalamine (Vitamin B12) appears in
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urine after administration of Intrinsic factor.
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Since cobalamine absorption requires multiple steps including
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gastric, pancreatic and ileal processes, the Schilling test can also
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be used to assess the integrity of these other organs.
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Dietary vitamin B 12 is bound in the stomach to an endogenous
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protein called R protein. Pancreatic enzymes degrade the R protein
in the proximal small bowel and lower its affinity for vitamin B12
resulting in the rapid transfer of B 12 to IF; The IF-B12 Complex
continues to the terminal ileum, where it binds to specific receptors
on the surface of the epithelial cells.
Thus lack of intrinsic factor, lack of sufficient pancreatic enzymes
(pancreatic exocrine dysfunction) or presence of terminal heal
mucosal disease may all result in abnormal vitamin B12 excretion.
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77. Which of the following statements
regarding the schilling test for vitamin
B12 malabsorption is most accurate?
a) The schilling test results are abnormal in patients with dietary
vitamin B12 deficiency.
b) In patients with pernicious anemia, the results of the schilling
test normalize after oral administration of intrinsic factor,
c) In patients with ileal disease, the results of the schilling test
normalize after oral administration of intrinsic factor
d) Pancreatic exocrine insufficiency does not cause schilling test
results to be abnormal.
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Correct Answer - B
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Answer is B (In patients with pernicious anemia, the results of the
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Schilling test normalize after oral administration of intrinsic factor):
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An abnormal Schilling's test that corrects or normalizes after
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administration of intrinsic factor suggests a diagnosis of Pernicious
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Anemia (Intrinsic Factor Deficiency).
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Shilling's test is done to determine the cause of cyanocobalamine
deficiency (Vitamin B12).Schilling test is
abnormal in conditions that affect cobalamine absorption including
Pernicious anemia, Chronic Pancreatitis, Bacterial overgrowth
syndrome and Ileal dysfunction.
An Abnormal Schilling's test that corrects after administration of
Intrinsic Factor indicates Pernicious Anemia
An Abnormal Schilling's test that corrects after administration of
Pancreatic Enzymes suggests Exocrine Pancreatic Insufficiency
(from Chronic Pancreatitis)
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An Abnormal Schilling's test that corrects after administration of five
days of antibiotics suggests Bacterial Overgrowth Syndrome
An Abnormal Schilling's test that does not correct after
administration of intrinsic factor, pancreatic enzymes and/or
antibiotics suggests Ileal mucosal dysfunction
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78. All of the following drugs may be used in
the treatment of ulcerative colitis Except:
a) Corticosteroids
b) Azathioprine
c) Sulfasalazine
d) Methotrexate
Correct Answer - D
Answer is D (Methotrexate)
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Methotrexate has not been shown to be effective fbr treating active
ulcerative colitis or for maintaining remission.
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79. Extraintestinal manifestations of
Inflammatory bowel disease include all of
the following, Except:
a) Uveitis
b) Sclerosing cholangitis
c) Osteoarthritis
d) Skin nodules
Correct Answer - C
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Answer is C (Osteoarthritis):
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Osteoarthritis is not an extraintestinal manifestation of inflammatory
bowel disease
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Uveitis, Sclerosing Cholangitis, and skin nodules (Erythema
an
nodosum) are all recognized extraintestinal manifestations of
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inflammatory bowel disease.
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80. Secretory diarrhea is not seen in:
a) Phenolphthalein
b) Celiac disease
c) Cholera
d) Addison's Disease
Correct Answer - B
Answer is B (Celiac Disease)
Celiac Disease is associated with Steatorrheal diarrhoea from
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mucosa! malabsorption.
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Secretory Diarrhea
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Certain Bacterial Infection
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Vibrio Cholera
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Enterotoxigenic E.Coli
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Non Osmotic Stimulant Laxatives
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Hormone Producing Endocrine Tumors
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Carcinoid,
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VlPomas,
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Gastrinomas,
Medullary Carcinoma Thyroid (Calcitonin)
Bile acids (endogenous laxatives)
Bowel resection / disease or fistula
Addison's Disease
Congenital Electrolyte Absorption defects
Chronic Alcohol Ingestion
Diabetic Diarrhea
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Steatorrheal Diarrhea
Intraluminal maldigestion
Pancreatic exocrine insufficiency,
Bacterial overgrowth,
Bariatric surgery,
Liver disease
Mucosal malabsorption
Celiac sprue,
Whipple's disease,
Infections,
Abetalipoproteinemia,
Ischemia
Postmucosal obstruction
(1° or 2° lymphatic obstruction)
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81. Which of the following is not a prognostic
factor for Acute Pancreatitis
a) Serum Amylase
b) Serum Calcium
c) Serum Glucose
d) Serum AST
Correct Answer - A
Answer is A (Serum Amylase) :
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Serum Amylase does not form any criteria for prognosis in Acute
Pancreatitis.
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Although elevated serum amylase level is important for establishing
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diagnosis of acute pancreatitis, it plays no role in predicting
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prognosis or severity.
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"There appears to be no definite correlation between severity of
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pancreatitis and the degree of serum amylase elevation. After 48 to
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72 hours, even with continuing evidence of pancreatitis, total serum
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amylase levels tend to return to normal." - Harrison
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Hyperglycemia (Glucose), Hypocalcemia (Calcium) and elevated
serum AST are all poor prognostic factors in accordance with
Ranson's criteria as elaborated in the previous question.
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82. Best provocative test for diagnosis of
Gastrinoma is:
a) Ca++ infusion test
b) Secretin injection test
c) ACTH stimulation test
d) Steroid assay
Correct Answer - B
Answer is B (Secretin injection test)
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Gastrinomas (Zollinger Ellison Syndrome) are characterized by
peptic ulceration due to hypersecretion of gastrin by a non-beta cell
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tumor. Secretin injection test is the most valuable provocative test in
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identifying patients with ZES.
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83. The most classical symptom of VIPOMA
is:
a) Gall stones
b) Secretory diarrhea
c) Steatorrhea
d) Flushing
Correct Answer - B
Answer is B (Secretory Diarrhoea)
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The principle feature of VIPOMA is large volume secretory
Diarrhoea.
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Diarrhoea is secretory in nature, persists during fasting and is almost
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always greater than > I Litre per day (>3 Litres per day in 70
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percent). A stool volume less than 700 ml per day is proposed to
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exclude the diagnosis. Most patients do not have accompanying
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Steatorrhea.
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VIPOMAS (Verner-Morrison Syndrome/ Pancreatic Cholera/WDHA
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Syndrome)
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VIPomas are tumours that secrete large amounts of Vasoactive
Intestinal Peptide (VIP)
VIP is an important neurotransmitter ubiquitously present in the CNS
and GIT
The most common location of VlPomas is the Pancreas
Most common site within the pancreas is the pancreatic tail
Usually Solitary
Usually Malignant (37-68 % have hepatic metastasis at diagnosis
VIP
Stimulates Small Intestinal chloride secretion
Stimulates smooth muscle contractility
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Inhibits acid secretion
Has vasodilatory effects
Typical Features
(WDHA)
Watery Diarrhoea (Large Volume Secretory
Diarrhoea leading to
dehydration)
Hypokalemia (Diarrhoea severe enough to
cause hypokalemia)
Achlorhydria (Hypochlorhydria from
increased small intestinal
chloride secretion)
The principle Symptoms are large volume
diarrhoea (100 %)
severe enough to cause hypokalemia (80-
100%), dehydration
(83%), hypochlorhydria (54-76%) and
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flushing (20%)
Most patients do not have accompanying
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Steatorrhea
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Other Features
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Increased stool Volume due to increased secretion of sodium and
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potassium which with the anion account for osmolality of the stool
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Hyperglycemia (25-50%
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Hypercalcemia (25-50%)
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The diagnosis requires demonstration of an elevated plasma VIP
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level and the presence of large volume secretory diarrhea.
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84. All following are at-risk group adults
meriting Hepatitis B vaccination in low
endemic areas except:
a) Patients on chronic hemodialysis
b) Diabetics on insulin
c) Medical/nursing personnel
d) Patients with chronic liver disease
Correct Answer - B
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Answer is B (Diabetics on Insulin):
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Behavioral: Sexually active persons who are not in a long-term,
mutually monogamous relationship (e.g., persons with more than
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one sex partner during the previous 5 months): persons seeking
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evaluation or treatment for a sexually transmitted disease (STD):
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current or recent injection-drug users; and men who have sex with
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men.
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Occupational: Healthcare personnel and public-safety workers who
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are exposed to blood or other potentially infectious body fluids.
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Medical: Persons with end-stage renal disease, including patients
receiving hemodialysis; person with HIV infection; and persons with
chronic liver disease.
Other: Household contacts and sex partners of persons with chronic
HBV infection; clients and staff members of institutions for persons
with developmental disabilities; and international travellers to
countries with high or intermediate prevalence of chronic HBV
infection.
Hepatitis B vaccination is recommended for all adults in the following
settings: STD treatment facilities; HIV testing and treatment facilities;
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facilities providing drug-abuse treatment and prevention services;
healthcare settings targeting services to injection—drug users or
men who have sex with men; correctional facilities; end-stage renal
disease programs and facilities for chronic hemodialysis patients;
and institutions and nonresidential day-care facilities for persons
with developmental disabilities.
Administer missing doses to complete a 3-dose series of hepatitis B
vaccine to those persons not vaccinated or not completely
vaccinated. These second dose should be administered 1 month
after the first dose; the third dose should be given at least 2 months
after the second dose (and at least 4 months after the first dose). If
the combined hepatitis A and hepatitis B vaccine (Twinrix) is used,
administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose
Twinrix schedule, administered on days 0, 7, and 21 to 30, followed
by a booster dose at month 12 may be used.
Adult patients receiving hemodialysis or with other
immunocompromising conditions should receive 1 dose of 40 pg/mL
(Recombivax HB) administered on a 3-dose schedule or 2 doses of
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20 Ug/mL (Engerix-B) administered simultaneously on a 4-dose
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schedule at 0, 1, 2, and 6 months.
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85. Extrahepatic Manifestations of Hepatitis C
include all of the following Except:
a) Lichen Planus
b) Celiac Disease
c) Glomerulonephritis
d) Cryoglobulinemia
Correct Answer - B
Answer is B (Celiac disease)
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Extrahepatic manifestations in viral hepatitis C: Wepatology' by
Kuntz
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Agranulocytosis
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Aplastic anaemia
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Corneal ulceration
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Ciyoglobillinaemia
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Diabetes mellitus (type I)
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Erythema exsudativum multiforme
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Glomerulonephritis
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Guillain-Barre syndrome
Hyperlipasaemia
Lichen planus
Non-Hodgkin lymphoma
Polyarteritis nodosa
Polyarthritis
Polyneuritis
Porphyria cutanea tarda
Sialadenitis
Sjogren's syndrome /Sicca syndrome
Thrombocytopenia
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Thyroiditis
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86. Which is not true about alcoholic hepatitis
:
a) Gamma glutamyl transferase is raised
b) SGPT is raised > SGOT
c) SGOT is raised > SGPT
d) Alkaline phosphatase is raised
Correct Answer - B
Answer is B
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SGOT/SGPT ratio greater than 2 is highly suggestive of alcoholic
hepatitis and cirrhosis.
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AST is synonymous with SGOT & ALT is synonymous with SGPT
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In general AST and ALT levels rise parallel to each other. In
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alcoholic liver disease the AST rises out of proportion to ALT such
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that the ratio of AST and ALT may become greater than 2:
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Stigmata of Alcoholic hepatitis / cirrhosis that aid in diagnosis :
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1. Bilateral enlarged parotids Q.
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2. GynaecomastiaQ
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3. Testicular atrophy with loss of body hairQ
4. Wasting of muscle massQ
5. Duputyrens contractureQ
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.
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Remember :GGT is the most sensitive indicator of bilian, tract
disease
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87. Hepatic Encephalopathy is predisposed
by all, Except:
a) Hyperkalemia
b) Dehydration
c) Constipation
d) GI Bleeding
Correct Answer - A
Answer is A (Hyperkalemia):
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Hepatic Encephalopathy is predisposed by Hypokalemia and not by
Hyperkalemia
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88. Features of Hepatorenal syndrome are
a) Urine sodium < 10 meq/1
b) Normal renal histology
c) Renal function abnormal even after liver become normal
d) a and b
Correct Answer - D
Answer is A & B (urine Na < 10 meq/l and Normal Renal
Histology)
Hepatorenal syndrome is associated with normal renal histology and
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supported by a urine sodium excretion l0meq/L
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Hepatorenal syndrome
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Hepatorenal syndrome is defined as a state of functional renal
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failure (Reduced GFR) in patients with severe liver disease
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Structurally /Histologically the kidneys are normal and recover
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function after successful liver transplantation.
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The pathogenetic hallmark of hepatorenal syndrome is intense renal
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vasoconstriction with coexistent systemic vasodilatation
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The diagnosis of hepatorenal syndrome is considered in accordance
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with the following diagnostic criteria.
Diagnostic of Hepatorenal Syndrome
Major criteria
Low glomerular filtration rate. as indicated by serum creatinine > 1.5
mg/dL or 24-hr creatinine clearance < 40 mL/min
Absence of shock, ongoing bacterial infection, fluid losses, and
current treatment with nephrotoxic drugs
No sustained improvement in renal function (decrease in serum
creatinine to 1.5 nig/dL or increase in creatinine clearance to 40
mL/min) after diuretic withdrawal and expansion of plasma volume
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with 1.5L of a plasma expander
Proteinuria mg/d1, and no uhrasonographic evidence of obstructive
uropathy or parenchymal renal disease Additional criteria
Urine volume < 500 mL/d
Urine sodium < 10 meq/L
Urine osmolality greater than plasma osmolality
Urine red blood cells <50/high- power. field
Serum sodium concentration < 130 niEqL
Note: All major criteria must be present for the diagnosis of
hepatorenal syndrome.
Additional criteria are not necessary for the diagnosis but provide
supportive evidence.
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89. All of the following statements about.
Wilson's disease are true, EXCEPT-
a) It is an autosomal recessive disorder
b) Serum ceruloplasmin level is < 20 mg/dl
c) Urinary copper excretion is
d) Zinc acetate is effective as maintenance therapy
Correct Answer - C
Answer is C (Urinary copper excretion is <100R/day)
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Urine copper is an important diagnostic too. Symptomatic patients
invariably have urine copper levels > 100 p (>1.6 umol) per 24
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hours.
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Wilson's disease is an autosomal recessive disorder
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It is caused by a mutation of a gene on chromosome BQ which
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promotes Cu excretion (ATP 7B gene)
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Symptomatic patients with Wilson's disease invariably have urinary
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copper excretion of >100 lig, per 24 hours (>1.6 innol /24 hr)
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Zinc is the treatment of choice for maintainance therapy in
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Wilson's disease
Zinc is the treatment of choice in Wilson's disease for
A. Initial therapy in patients with hepatitis without decompensation(2
A. Maintainance therapy
B. Presymptomatic patient
C. Pediatric patients
D. Pregnant patients
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90. A 14 year old boy presents wit recurrent
episodes of hepatitis Opthalmoscopic
evalution reveals KF rings and serum
ceruloplasmin levels are < 20 mg/dl.
The treatment of choice for initial therapy
is
a) Zinc
b) Penicillamine
c) Tetrathromolybdate
d) Hepatic transplantation
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Correct Answer - A
Answer is A (Zinc)
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Presence of KF rings and decreased ceruloplasmin levels suggest
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the diagnosis of Wilson 's disease.
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The patient in question is presenting with intial hepatic disease
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without any evidence of hepatic decompensation.
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Zinc is the therapy of choice for patients with hepatitis or cirrhosis
without evidence of hepatic decompensation or neuropsychiatric
symptoms.
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91. What is the uppermost intercostal space
used for hepatic biopsy :
a) 5th
b) 7th
c) 9th
d) 11th
Correct Answer - B
Answer is B 7th
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The right surface of the liver is in contact with the diaphragm
opposite the 7th to 11th ribs.
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In needle biopsy of the liver through the intercostal route, the needle
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may be inserted through the 6th 7th, 8th, 9th or 10th right intercostal
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space in the mid-axillary line.
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The 8th and 9th intercostal spaces are most commonly used.
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Insertion in the 6th or 7th intercostal space may also be used but is
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associated with risk of injury to the Lung.
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Needle is typically inserted at the end of expiration (Attempted
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Apnoea).
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92. Significant weight loss is defined as:
a) 5% weight loss in 1-2 months
b) 5% weight loss in 2-3 months
c) 10% weight loss in 1-2 months
d) 10% weight loss in 2-3 months
Correct Answer - A
Answer is A (5% weight loss in 1-2 months):
Significant weight loss is defined as 5% weight loss in I month.
Percent weight change over a period of time is calculated using
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the person's current body weight and person's usual body weight.
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Usual weight — Current weight Percent weight change = Usual
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weight
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93. CRF with anemia best treatment:
a) Oral Iron Therapy
b) Erythropoietin Stimulating Agents
c) Blood transfusion
d) Androgenic Steroids
Correct Answer - B
Answer is B (Erythropoietin Stimulating Agents):
Erythropoiesis-stimulating agents (ESAs) have emerged as the
treatment of choice for anemia in chronic renal disease.
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Erythropoiesis-stimulating agents (ESAs) should be given to all
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patients with chronic kidney disease (CKD) with haemoglobin levels
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consistently below II g/dl.
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This applies equally to:
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Patients with CKD (stages 1-5) developing anaemia
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Patients with CKD stage 5 treated with haemodialysis (HD) or
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peritoneal dialysis (PD)
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Transplant patients with chronic renal insufficiency and anaemia.
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Strategies for treatment of Anemia in Chronic Renal Failure
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Erythropoiesis-stimulating agents (ESAs)
Erythropoiesis-stimulating agents (ESAs) have emerged as the
treatment of choice for anemia in chronic renal disease.
They should be given to all patients with chronic kidney disease
(CKD) with haemoglobin (Hb) levels consistently below 11 g/dl
[haematocrit (Hct) <33%]
All chronic kidney disease (CKD) patients with renal anaemia
undergoing treatment with an erythropoiesis-stimulating agent (ESA)
should be given supplementary iron to maintain adequate bone
marrow iron stores
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Intravenous administration is the optimum route for the delivery of
iron to patients with CKD, as oral iron is poorly absorbed in uremic
individuals.
Blood Transfusion
Red blood cell transfusions should be avoided, if at all possible, in
patients with chronic kidney disease (CKD), especially those
awaiting kidney transplantation.
Transfusions should not be given unless patients have one or more
of the following: Symptomatic anaemia (fatigue, angina, dyspnoea)
and/or associated risk factors (diabetes, heart failure, coronary
artery disease, arteriopathy )
Acute worsening of anaemia due to blood loss (haemorrhage or
surgery) or haemolysis Severe resistance to, or hyporesponsiveness
to ESA therapy, e.g. due to the presence of a haematological
disease or severe inflammatory systemic disease.
Androgens
Prior to the introduction of ESA therapy, androgens were widely
used in the treatment of renal anaemia.
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There is evidence that androgens may potentiate the effect of
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exogenous erythropoietic protein and also stimulate erythropoiesis
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by enhancing erythrocyte stemcell differentiation
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The risk of liver disease and malignancy, virilisation and hirsutism in
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women, priapism in men and disfiguring acne in patients of both
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sexes may outweigh the benefits of androgen therapy in most
anaemic patients.
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Androgens may be an effective alternative therapy in countries
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where ESAs are not available
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94. The initial treatment of choice for
secondary hyperparathyroidism in renal
osteodystrophy is:
a) Cinacalcet
b) Bisphosphonates
c) Calcium restriction
d) Phosphate binders
Correct Answer - D
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Answer is D (Phosphate Binders)
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The initial treatment of secondary hyperparathyroidism in renal
osteodystrophy is management of high phosphate levels by dietary
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restriction and the use of Phosphate binders
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The objectives of management are to maintain blood levels of
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calcium and phosphorous to as close to normal as possible, to
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prevent or treat established hyperparathyroidism early and to
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prevent parathyroid hyperplasia.
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Phosphate retention begins early in the course of CKD, perhaps as
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early as in stage 2 and participates in the development of secondary
hyperparathyroidism.
Central to the management of high-turnover bone disease is
controlling the serum phosphate levels.
This may be achieved by dietary phosphate restriction or by the use
of phosphate binders.
Phosphate-binder therapy is recommended when serum phosphate
concentrations are elevated despite patient compliance with dietary
phosphate restriction.
Calcium-based phosphate binders are often recommended as the
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initial binder therapy.
High Bone Turnover Disease
Bone turnover (the formation and removal of bone) is increased due
to a process called secondary hyperparathyroidism (SHPT).
Secondary hyperparathyroidism represents a common disorder in
patients with CKD.
It develops as a result of hyperphosphatemia, hypocalcemia and
impaired renal vitamin D synthesis with reduction in serum calcitriol
levels
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95. The most common presentation for IgA
nephropathy is:
a) Nephritic syndrome
b) Nephritic syndrome
c) Microscopic hematuria
d) Repeated gross hematuria
Correct Answer - D
Answer is D (Repeated Gross Hematuria):
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The most common presentation of IgA Nephropathy is with recurrent
episodes of Gross (Macroscopic) Hematuria during or immediately
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following an upper respiratory tract infection
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'Recurrent attacks of Painless Gross Hematuria represent the
an
classic clinical presentation of IgA Nephropathy' — Rudolph's
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Paediatrics
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96. Disease, does not recur in the kidney after
renal transplant is :
a) Alport syndrome
b) Amyloidosis
c) Good Pasteur's syndrome
d) Diabetic nephropathy
Correct Answer - A
Answer is A (Alport's syndrome):
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Alport is syndrome has not been mentioned to recur in kidney after a
renal tansplant.
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97. True about light microscopy in minimal
change disease is:
a) Loss of foot process seen
b) Anti GBM Abs seen
c) IgA deposits seen
d) No change seen
Correct Answer - D
Answer is D (No change seen)
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No abnormality is evident on light microscopy in a case of minimal
change disease.
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Investigation
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Light microscopy Q
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Electron microscopy Q
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ImmunofluorescenceQ
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Observation
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No abnormality hence the term minimal change
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Fusion of foot processes
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Absence of immunoglobulin or complement
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98. HIV renal specific nephropathy is:
a) Focal Segmental Glomerulosclerosis
b) Membranoproliferative Glomerulonephritis
c) Mesangioproliferative Glomerulonephritis
d) Membranous Glomerulonephritis
Correct Answer - A
Answer is A (Focal Segmental Glomerulosclerosis):
The most characteristic glomerulopathy in HIV is Focal Segmental
Glomerulosclerosis (FSGS) which typically reveals collapse of the
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glomerular capillary tuft called collapsing glomerulopathy.
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HIV associated Nephropathy is a severe rapidly progressive
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collapsing form of FSGS.
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99. Distal renal tubular acidosis is associated
with:
a) Oxalate stones
b) Citrate
c) Calcium stones
d) Uric acid stones
Correct Answer - C
Answer is C (Calcium Stones):
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Distal Renal Tubular Acidosis is associated with increased in
cadence of Calcium Phosphate Stones Alkaline urine, Hypercalciuria
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and low levels of urinary citrate precipitate calcium phosphate
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stones in the kidney in patients with Distal Renal Tubular Acidosis
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(Typel).
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Proximal Renal Tubular Acidosis (Type-2) is not associated with
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increased incidence of Renal Stones despite Hypercalciuria because
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urinary citrate levels are normal or high.
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100. Which of the following statement about
Renal Cell Carcinoma (Hypemephroma)
is false:
a) Originate in the cortex
b) Histologically are usually Adenocarcinomas
c) May present with varicocele
d) Radiosensitive
Correct Answer - D
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Answer is D (Radiosensitive):
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Renal cell carcinoma is a relatively radioresistant tumor.
Renal cell carcinoma originates in the Renal cortex
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`Renal cell carcinoma originates in the Renal cortex and tends to
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grow out into perinephric tissue causing the typical bulge or mass
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effect that aids in their detection by diagnostic imaging studies' –
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Smith's Urology
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Renal Cell carcinoma are adenocarcinomas
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Histologically Renal cell carcinoma is most often a mixed
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adenocarcinoma — Smith's Urology
Renal cell carcinomas may present with varicocele
'Renal cell carcinomas may present with Rapidly developing
varicocele. Varicocele is usually observed on the left side. This
occurs because left gonadal vein is obstructed where it joins the left
renal vein.
Renal cell carcinomas are Relatively Radioresistant tumors
Renal cell carcinomas are generally considered radioresistant
tumors
Role of Radiotherapy in renal Cell carcinoma
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Preoperative Radiation has shown no impact on survival
Postoperative Radiation has also shown no evidence of improved
survival but may be used as it shows improvement in local control.
Palliative Radiotherapy has been shown to be effective in metastatic
disease to brain, bone and lungs.
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101. Classic triad inRenal cell carcinoma
includes all of the following, Except:
a) Hematuria
b) Hypertension
c) Flank mass
d) Abdominal Pain
Correct Answer - B
Answer is B (Hypertension):
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Hypertension may be seen in patients with Renal cell carcinoma but
it does not firm part of the classically described triad.
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Classic Triad of Renal cell carcinoma (seen in 10-20% of
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patients)
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Hematuria (Gross)
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Pain (Abdominal / Flank)
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Mass (Abdominal /Flank)
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102. FEVI/FVC is decrease in:
a) Asthma
b) Kyphosis
c) Scoliosis
d) Fibrosis
Correct Answer - A
Answer is A (Asthma):
Decreased FEV1/FVC suggests a diagnosis of Obstructive Lung
Disease.
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Amongst the options provided Asthma is the only condition that
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leads to Obstructive Pattern of Lung Disease and hence is the
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answer of choice Kyphosis, Scoliosis and Fibrosis are Restrictive
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Lung Diseases that are characterized by Normal or Elevated
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FEVI/FVC ratios.
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103. Aspirin-sensitive asthma is associated
with:
a) Obesity
b) Urticaria
c) Nasal polyp
d) Extrinsic asthma
Correct Answer - C
The answer is C (Nasal polyp):
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`Aspirin associated Asthma usually begins with perennial vasomotor
rhinitis that is followed by hyperplastic rhinosinusitis with nasal
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polyps' — Harrisons
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Aspirin associated Asthma:
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Primarily affects adults, although the condition may occur in
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childhood.
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Usually begins with perennial vasomotor rhinitis that is followed by
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hyperplastic rhinosinusitis with nasal polyps.
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Progressive asthma then appears.
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On exposure to even very small quantities of aspirin, affected
individuals typically develop ocular and nasal congestion and acute,
often severe episodes of airways obstruction.
Death may follow ingestion of aspirin.
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104. Feature of Acute severe Asthma include
all of the following, Except:
a) Tachycardia > 120/min
b) Pulsus paradoxus
c) Respiratory acidosis
d) Drowsy
Correct Answer - A
Answer is A. Tachycardia > 120/min
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Diaphoresis
Bradycardia
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Paradoxical throcobadominal movements
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PEER < 33%
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Hypotension
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Pulsus paradoxus
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Hypercapnea
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Silent chest
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105. An Adult with asthma presents with
asthma symptoms every day and wakes
up in the night approximately 2 to 3 days
in a week.
He can be classified as having :
a) Intermittent Asthma
b) Mild Persistent Asthma
c) Moderate Persistent Asthma
d) Severe Persistent Asthma
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Correct Answer - C
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Answer is C (Moderate Persistent Asthma):
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'Giudelines for the diagnosis and management of Asthma' Summary
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Report 2007 (N1H Publication Number 08-5846); Koda-Kimble and
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Young's Applied Therapeutics: The Clinical Use of Drugs
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10TH/568,569,570
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Moderate Persistent Asthma in an adult (>12 years) is defined as
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Day-Time Symptoms that occur daily and Night-Time Symptoms
occurring more than 1 night per week but not every night.
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106. In a Patient with clinical signs of Asthma
which of the following tests will confirm
the diagnosis:
a) Increase in FEV1/FVC
b) > 200 ml increase in FEVI after Methacholine
c) Diurnal variation in PEF > 20 Percent
d) Reduction of FEV I > 20 % after bronchodilators
Correct Answer - C
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Answer is C (Diurnal variation in PEF > 20 Percent):
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Demonstrate Outflow Obstruction
Decreased FEV1
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Decreased PEF
Decreased FEV1 /FVC
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While respiratory symptoms suggest asthma, the sine qua non for
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the diagnosis of asthma is the presence of Reversible Airflow
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Obstruction and/or Airway Hyper-responsiveness or Increased Peak
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Expiratory Flow (PEF) Variability in subjects without airways
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obstruction.
Reversible Airflow Obstruction
Reversibility is demonstrated by repeating spirometry results 15
minutes after administering a short acting bronchodilator
> 12% reversibility in FEV1
>200 ml increase in Baseline FEV1
Positive Reversibility Results Strongly (Considered Diagnostic)
Increased Peak Expiratory Flow Rate (PEF) Variability
Demonstration of Diurnal Variation in the Peak Expiratory Flow Rate
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A diurnal variation in PEF of more than 20 percent Strongly suggests
a diagnosis of Asthma (Considered Diagnostic)
Airway Hyper-responsiveness
Measured by Methacholine orHistamine challenge.
Increasing Concentrations of Methacholine are administered and if
the FEV1 drops to >20 percent of baseline with any standard dose
the test is consideredpositive.
Positive test strongly suggests a diagnosis of Asthma
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107. Antibody used in the treatment of
Bronchial Asthma is:
a) Omalizumab
b) Rituximab
c) Daclizumab
d) Transtusuzumab
Correct Answer - A
Answer is A (Omalizumab):
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Omalizumab is a recombinant IgE Antibody approved for use in
treatment of moderate and severe persistent asthma
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Omalizumab is a recombinant IgE blocking antibody that
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neutralizes circulating IgE.
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It prevents circulating IgE from binding to receptors on the surface of
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Basophils and Mast cells and thus inhibits IgE mediated reactions.
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Omalizumab is indicated for treatment of 'moderate to severe'
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persistent asthma in patients who react to perennial allergens
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(Allergic Asthma).
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Treatment with Omalizumab has shown to reduce the number of
exacerbations in patients with
severe asthma and may improve asthma control.
However this treatment is very expensive and is only suitable for
highly selected patients who are not controlled on maximal doses of
inhaler therapy and have a high circulating IgE (within a specified
range).
Omalizumab is usually given as a subcutaneous injection for 2 to 4
weeks and may be used in adults and adolescents more than 12
years of age.
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108. Which of the following is the least
common bacteria responsible for Acute
Exacerbation of Chronic Bronchitis
a) Streptococcus pneumoniae
b) Moraxella catarrhalis
c) Haemophilus influenza
d) Staphylocccus aureus
Correct Answer - D
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Answer is D (Staphylocccus aureus):
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The Global Initiative for Chronic Obstructive Lung Disease (GOLD);
Report produced by the National Heart, Lung, and Blood Institute
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(NHLBI) and the World Health Organization (WHO)
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Staphylococcus Aureus is not a common bacterial pathogen
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responsible for Acute Exacerbation of Chronic Bronchitis.
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Common Bacterial Pathogens (30%-50%) Responsible for Acute
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Exacerbations of COPD
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Haemophilus influenza
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Streptococcus pneumonia
Moraxella catarrhalis
Pseudomonas aeruginosa and Enterobacteriaceae are also
commonly isolated, particularly from patients with severe COPD.
Acute Exacerbation of COPD: Bacterial Infections
The GOLD, the NHLBI and the WHO, defines exacerbation of COPD
as acute increase in symptoms beyond normal day-to-day variation.
This generally includes one or more of the following cardinal
symptoms.
Cough increases in frequency and severity
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Sputum production increases in volume and/or changes character
Dyspnea increases
Constitutional symptoms, decrease in pulmonary function, and
tachypnea are variably present during an exacerbation, but the CXR
is usually unchanged.
In the presence of severe underlying airflow obstruction,
exacerbation can cause respiratory failure and death.
It is estimated that 70 to 80% of exacerbations of COPD are due to
respiratory infections.
The remaining 20 to 30% are due to environmental pollution or have
an unknown etiology. Viral and bacterial infections cause most
exacerbations
Bacterial infections appear to trigger 33% to 50% of COPD
exacerbations.
Non-typeable H. influenzae, M. catarrhalis, and S. pneumoniae are
the bacteria most frequently isolated bronchoscopically from patients
having an exacerbation of COPD
Pseudomonas aeruginosa and other members of family
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Enterobacteriaceae are also commonly isolated, particularly from
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patients with severe COPD.
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Exacerbations of COPD are strongly associated with acquisition of
an
new strain of H. influenzae, M. catarrhalis, S. pneumoniae, or P.
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aeruginosa.
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As a result, it has been proposed that acquisition of new bacterial
strain plays central role in the pathogenesis of an exacerbation.
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The idea that exacerbations of COPD are due to acquisition of new
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strain of bacteria has largely replaced older hypothesis that
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increases in concentration of colonizing bacteria are the primary
cause of exacerbations.
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109. Occupational Lung Disease commonly
seen in Textile Industry Workers is:
a) Byssinosis
b) Bagassosis
c) Farmer's Lung
d) Asbestosis
Correct Answer - A
Answer is A (Byssinosis)
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Occupational Lung Disease in Textile Industry Workers (Cotton
industry)
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Byssinosis is an asthma-like condition caused by inhalation of cotton
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fiber dust over prolonged period of time.
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Workers occupationally exposed to cotton dust (but also to flax,
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hemp or jute dust) in the production of yarns for textile and rope
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making are at risk of Byssinosis.
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Exposure occurs throughout the manufacturing process but is most
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pronounced in the portions of the factory involved with the treatment
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of cotton before spinning (blowing, mixing, carding or straightening)
Byssinosis is more common during milling and processing of cotton
than during spinning.
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110. All the following are features of Tropical
pulmonary Eosinophilia except-
a) Eosinophilia > 3000/mm3
b) Microfilaria in blood
c) Paroxysmal cough and wheeze
d) Bilateral chest mottling and increased bronchovascular
markings
Correct Answer - B
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Answer is B (Microfilaria in blood) :
In TPE, Microfilaria are rapidly cleared from the blood stream by the
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lungs.
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Thus, microfilariae are sequestrated in the lungs and are not found
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in the blood.
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Tropical Pulmonary Eosinophilia
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Tropical Pulmonary Eosinophilia (TPE) is a distinct syndrome that
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develops in individuals infected with Lymphatic filarial species.
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Clinical symptoms result from allergic and inflammatory reaction
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elicited by the cleared parasites.
Features of Tropical Pulmonary eosinophilia (TPE) :
Male more commonly affected than females (4: 1)
History of resistance in filarial endemic region
Paroxysmal cough and wheezing that are usually nocturnal
Weight loss, low grade fever, adenopathy
Eosinophilia > 3000 eosinophilia / ,uLe
Chest X-Ray : increased bronchovascular markings , diffuse miliary
lesions , or mottled opacities.
Restrictive changes on Pulmonary function test 2
Elevated levels of IgE e & Antifilarial antibody titers.
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In TPE, Microfilaria are rapidly cleared from the blood stream by the
lungs.
Thus, microfilariae are sequestrated in the lungs and are not found
in the blood.
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111. Most common pattern of Pneumonia
seen in Klebsiella infection is:
a) Lobar Pneumonia
b) Bronchopneumonia
c) Interstitial Pneumonia
d) Miliary Pneumonia
Correct Answer - A
Answer is A (Lobar Pneumonia):
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The most common pattern of Pneumonia seen in Klebsiella infection
is Lobar Pneumonia
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Streptococcus Pneumoniae (Pneumococcus) and Klebsiella are
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two common organisms that produce a lobar pattern of
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Pneumonia.
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The radiographic pattern of pneumonia.
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Lobar
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Lobular (bronchopneumonia)
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Interstitial
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112. All of the following are more commonly
seen in Klebsiella Pneumonia than in
Pneumococcal Pneumonia, Except:
a) Lower lobe involvement
b) Abscess Formation
c) Pleural Effusion
d) Cavitation
Correct Answer - A
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The answer is A (Lower Lobe Involvement):
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Pneumococcal pneumonia has a predilection to involve the right
lower lobe, whereas Klebsiella usually affects one of the upper
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lobes.
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Features Pneumococcal Klebsiella Pneumonia
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Pneumonia
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Consolidation • Lobar Consolidation • Lobar Consolidation with
.F
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Pattern with positive air positive air
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bronchogram sign bronchogram sign
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Lobe • The predilection to • The predilection to
Predilection involve Lower Lobe involve Upper Lobe
(Any lobe may be (Any lobe may be
involved) involved)
• Usually Unilobar • Often Multilobar
(Usually do not (Tendency to expand
expand involved lobe) involved lobe)
• Abscess formation • Abscess Formation
Abscess
uncommon common
Pleural • Pleural Effusion • Pleural Effusion
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Effusion uncommon common
Cavitation • Cavitation is rare • Cavitation is common
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113. Friedlander Pneumonia refers to
Pneumonia caused by:
a) Klebsiella
b) Pneumococcus
c) H. lnfluenzae
d) Staphylococcus
Correct Answer - A
Answer is A (Klebsiella):
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Klebsiella Pneumonia is also known as Friedlander Pneumonia.
Klebsiella initially described in 1882 by Friedlander was also known
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as Friedlander's bacillus. Community acquired Pneumonia caused
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by Friedlander's bacillus (Klebsiella) was termed as Friedlander
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Pneumonia.
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114. Atypical pneumonia can be caused by
the following microbial agents except?
a) Mycoplasma pneumoniae.
b) Legionella pemmophila
c) Human Corona virus
d) Klebsiella pneumoniae
Correct Answer - D
Answer is D (Kleibsella pneumonia) :
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Causes of Atypical pneumonias .
1. Mycoplasma pneumonias
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2. Viral pneumonias - Influenza
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- RSV
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- Adenovirus
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- Rhinovirus
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- Rubeola
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- Varicilla
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- Corona virus
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3. Chlamydia pneumonia
4. Coxiella bumetti
5. Pneumocystis carinii
6. Legionella
Corona virus is an infrequent cause of pneumonia.
SARS associated corona virus (SARS - CoV) caused epidemic of
pneumonia from Nov 2002 to July 2003 - Harrison
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115. The most definitive method of
diagnosing pulmonary embolism is :
a) Pulmonary arteriography
b) Radioisotope perfusion pulmonary scintigraphy
c) EKG
d) Venography
Correct Answer - A
Answer is A (Pulmonary arteriography):
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`Selective pulmonary angiography is the most specific examination
available for establishing the definitive diagnosis of PE.'-Harriosn
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16th/1563
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Most definitive investigation :Pulmonary angiography is an
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invasive procedure, and it is the most definitive procedure. It is
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however certainly not the initial investigation of choice.
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The initial investigation of choice in a case of suspected
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pulmonary embolism is either a lung ventilation perfusion scan or a
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CT of the chest with intravenous contrast.
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`CT scanning of the chest with intravenous contrast is the principal
imaging test for diagnosis of PE.' - Harrison `Lung scanning (V/Q
scan) is now a second line diagnostic test for PE'
Most definitive / specific test for PE Q Best
initial imaging test for diagnosis of PE°
Pulmonary angiographyQ CT scan
with intravenous contrast Q (Preferred choice, against a lung V-Q
scan)
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116. All of the following show low glucose in
pleural fluid, EXCEPT-
a) Empyema
b) Malignant pleural effusion
c) Rheumatoid arthritis
d) Dressler's syndrome
Correct Answer - D
Answer is D (Dressler's Syndrome):
om
Dressler syndrome is a secondary form of pericarditis that occurs
in the setting of injury to the heart or the pericardium (the outer lining
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of the heart). It consists of fever, pleuritic pain, pericarditis and/or
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pericardial effusion.
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The disease consists of persistent low-grade fever, chest
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pain (usually pleuritic), pericarditis and/or pericardial effusion. The
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symptoms tend to occur 2–3 weeks after myocardial infarction but
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can also be delayed a few months. It tends to subside in a few days,
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and very rarely leads to pericardial tamponade. Elevated ESR is an
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objective but nonspecific laboratory finding.
Dressler's Syndrome is not associated with low glucose in pleural
fluid.
Rheumatoid Arthritis, Malignancy and Empyema (Bacterial
infections) are all established causes of pleural effusion with low
glucose.
Pleural effusion with low glucose (< 60 mg/c11)
1. Malignancy
2. Bacterial infections
3. Rheumatoid pleuritis
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117. Which of the following statements about
Branchial cysts is true:
a) 50-70% are seen in lungs
b) Most common site is mediastinum
c) They are premalignant lesions
d) Infection is uncommon in Pulmonary bronchogenic cysts
Correct Answer - B
Answer is B (Most common site is mediastinum):
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Most common site of bronchial/bronchogenic cysts is mediastinum.
Only about 15% of bronchogenic cysts occur in the lungs
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(pulmonary bronchial cysts). Pulmonary bronchogenic cysts often
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become infected. Bronchogenic cysts are benign lesion and do not
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have malignant potential (not premalignant).
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Bronchial Cyst/Bronchogenic cysts: Review
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Bronchial cysts represent islands of bronchial tissue left behind
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during the branching of the airways during early fetal development.
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They arise due to abnormal budding of the tracheobronchial tree and
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foregut and are lined by bronchial epithelium.
The most common site of bronchial cysts is mediastinum.
The other site of bronchial cyst is within the pulmonary parenchyma
(lung) (Less common site - 15%)
Mediastinal bronchial cyst
Pulmonary parenchymal cyst (lungs)
Most common site for Less common site (- 15%)
bronchial cysts Most common site is the lower
Most common site is middle lobes
mediastinum Commonly arise when bronchial
Commonly arise when tissue is separated from airways
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bronchial tissue is late in gestation
separated from airways early Communication with
in gestation tracheobronchial tree is more
Communication with common than with mediastinal
tracheobronchial tree is rare cysts.
These cysts often become infected.
Most bronchogenic cysts are asymptomatic and discovered as
incidental radiographic findings in a young adult.
When symptoms do occur they result most commonly from infection.
Pulmonary parenchymal cysts often become infected – Rudolph
Bronchogenic cysts are not considered premalignant lesions.
However according to Rudolph's textbook there is a small risk of
malignant change and the best approach is removal and histological
examination.
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118. Which of the following drugs, is used for
Smoking Cessation?
a) Naltrexone
b) Bupropion
c) Buprenorphine
d) Methadone
Correct Answer - B
Answer is B (Bupropion):
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Bupropion (along with Varenicline and Nicotine replacement
therapy) is a USFDA approved first line agent for pharmacotherapy
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in Smoking Cessation.
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USFDA Approved Agents for Smoking Cessation
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Nicotine Replacement Therapy (Transdermal Patch, gum, lozenges,
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oral inhaler, nasal spray)
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Bupropion (Atypical Antidepressant with dopaminergic and
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noradrenergic activity)
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Varenicline (Selective partial agonist at the Alpha4-Beta2 Nicotinic
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A-Choline receptor that is believed to mediate nicotine dependence)
Clonidine and Nortriptyline are two other medications that have
efficacy but are NOT USFDA approved for this indication. These are
classified as second line agents.
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119. ANCA is NOT associated with which of
the following diseases :
a) Wegener's granulomatosis
b) Henoch schonlein purpura
c) Microscopic PAN
d) Churg Strauss syndrome
Correct Answer - B
Answer is B (H.S. Purpura) :
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H.S. purpura is not associated with any antinuclear cytoplasmic
antibody (ANCA). It is an example of ANCA negative vasculitis.
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ANCA (Antineutrophilic cytoplasmic Antibodies) arc Antibodies
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directed against certain proteins in cytoplasmic granules of
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Neutrophil & monocytes.
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These are two major categories of ANCA based on different targets
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for the antibodies.
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ANCA (Antineutrophic cytoplasmic antibodies):
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ANCA is of 2 types
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C-ANCA
(Cytoplasmic proteinase 3q is the target antigen)
Wegeners Granulomatosisq (90-95%)
P-ANCA
Q
(perinuclear myeloperoxidase is the major target antigen)
Microscopic PAN (microscopic polyangitis)
Churg-Strauss syndrome
Crescenteric glomerulonephritise
Good pasteur's syndrome
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120. Feature of microscopic polyangitis is:
a) IgG deposits in kidney
b) Bronchospasm
c) Renal involvement in 80% of cases
d) All of the above
Correct Answer - C
Answer is C (Renal involvement in 80% of cases):
Renal involvement is seen in at least 80% ofpatients with MPA.
Renal involvement is seen in at least 80% of patients with MPA
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Renal involvement is seen in at least 80% of patients with MPA -
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CRDT Glomerulonephritis occurs in atleast 79% of patients –
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Harrison
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Microscopic polyangitis is not associated with IgG Deposits in
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kidney
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Microscopic Polyangitis is a pauci-immune glomerulonephritis.
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Immunofluorescence and electron microscopy show no immune
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deposits
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Microscopic Polyangitis is not associated with bronchospasm
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Asthma (bronchospasm) and Eosinophilia are features of Churg-
Strauss Syndrome and are typically absent in microscopic
polyangitis.
Features H.S. Churg-
purpura Microscopic Wegner's Strauss
Polyangitis Granulomatosis syndrome
Deposits in -- nt (IgA
kidney deposits) -
Bronchospasm - -
-
(Asthma) +
Eosinophilia - - - +
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Eosinophilia - - - +
Predominant -
p-ANCA c-ANCA p-ANCA
ANCA
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121. Jaw tightness is typically seen in:
a) PAN
b) Coarctation of aorta
c) Giant cell arteritis
d) Wegner's Granulomatosis
Correct Answer - C
Answer is C (Giant Cell Arteritis):
Jaw Claudication (law Tightness) is a typical manifestation of
Temporal arteritis or Giant cell arteritis.
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122. Reversed Coarctation is seen in:
a) Giant cell Arteritis
b) Polyarteritis Nodosa
c) Takayasu Arteritis
d) Kawasaki Disease
Correct Answer - C
Answer is C (Takayasu Arteritis):
Takayasu arteritis is also known as 'Reversed Coarctation'.
Takayasu Arteritis
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Condition Coarctation of Aorta
(Reversed Coarctation)
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Obstruction is most
Obstruction is most
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commonly seen in proximal
commonly found just
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Pathology aspect of branches of the
distal to the origin of the
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(Site of aortic arch including the
left Subclavian artery
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Obstruction) Subclavian and Common
thereby sparing the
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Carotid thereby affecting the
upper limb vessels
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upper limb vessels
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Absence or diminished Absence or diminished pulse
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Pulses
pulse in the lower limbs in the upper limbs
Blood Increased blood pressure Decreased blood pressure in
Pressure in the upper limbs the upper limbs
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123. Takayasu arteritis mainly affects?
a) Pulmonary artery
b) Celiac artery
c) Subclavian artery
d) SMA
Correct Answer - C
Answer is C (Subclavian Artery):
Subclavian artery is the single most common artery involved in
Takayasu arteritis.
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Takayasu arteritis : Most common sites affected
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Takayasu arteritis typically involves medium and large sized arteries
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It has a strong predilection for the aortic arch and its branches.
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The involvement of the major branches of the aorta is much more
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marked at their origin than distally
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The most commonly affected arteries as seen by arteriography
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in order of frequency
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Coronary (<10%)
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Vertebral (35%)
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Coeliac axis (18%)
Pulmonary (10-40 %)
Superior Mesenteric (18%)
Iliac (17%)
Subclavian (93%)
Common Carotid (58%)
Abdominal Aorta (47%)
Renal (38%)
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124. Most common variant of Takayasu
Disease in India is:
a) Type-1
b) Type-2
c) Type-3
d) Type-4
Correct Answer - C
Answer is C (Type -3):
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The most common type of Takayasu arteritis reported in India is
Type III.
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Most studies from India have reported Type III as the most common
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form of Takayasu arteritis in India accounting for 53 to 76 percent of
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cases.
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Classification /
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Predominant Site Involved
Type
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Type-I (Shimizu-
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Arch of aorta and its branches
Savo)
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Thoraco-abdominal aorta and its branches without
Type-II (Kimoto)
involvement of the aortic arch
Type-III (Inada) Combined features of both Type-I & Type-II
Pulmonary involvement (in addition to features of
Type-I, II or III)
Type-IV (Oata)
Involvement of coronary arteries (in addition to
features of Type-1, II or III)
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125. Kawasaki disease is associated with all
of the following clinical features except
a) Truncal rash
b) Posterior cervical lymphadenopathy
c) Thrombocytopenia
d) Pericarditis
Correct Answer - C
Answer is C (Thrombocytopenia) :
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Kawasaki disease is associated with thrombocytosis and not
thrombocytopenia.
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Characteristic laboratory findings Treatment of
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Choice Prognosis include
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Increased ESR High dose
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intravenous Prognosis for uneventful recovery is
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Thrombocytosise immunoglobulinse
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excellente
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126. Treatment of choice for Kawasaki
Disease is:
a) IV Immunoglobulins
b) Steroids
c) Dapsone
d) Methotrexate
Correct Answer - A
Answer is A (IV Immunoglobulins):
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The treatment of choice in Kawasaki disease is intravenous
immunglobulins
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127. Features of SLE include all of the
following except:
a) Recurent abortion
b) Sterility
c) Coomb's positive hemolytic anemia
d) Psychosis
Correct Answer - B
Answer is B (Sterility):
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Systemic Lupus Erythematosus.
Recurrent Abortions in SLE may be seen as a manifestation of
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Antiphospholipid Antibody syndrome. Small proportion of patients
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with SLE may have a Coomb's Positive Haemolytic anemia.
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Psychosis is a known neurological manifestation of SLE.
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128. Shrinking Lung Syndrome is seen in:
a) SLE
b) Rheumatoid Arthritis
c) Scleroderma
d) Sarcoidosis
Correct Answer - A
Answer is A (SLE):
Shrinking lung syndrome refers to a condition typical of SLE that
consists of a purely restrictive respiratory disease with normal lung
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parenchyma and markedly decreased lung volumes.
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Shrinking lung syndrome
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Shrinking lung syndrome refers to a condition typical of SLE that consists of a pure
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respiratory disease with normal lung parenchyma and markedly decreased lung vo
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Pathogentic Mechanism
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Diaphragmatic dysfunction has been advocated as the main pathogenetic mechani
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shrinking lung syndrome
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Clinical Presentation
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Shrinking lung syndrome usually manifests as exertional dyspnea of variable sever
progress over a period of weeks or months. (Orthopnea attributed to diaphragmatic
may also occur).
Pleuritic chest pain is reported frequently, and a previous history of pleurisy and pe
common.
Physical examination is remarkably normal.
Investigations
Chest radiography typically shows elevated hemi-diaphragms, although this is not a
finding and its absence does not exclude the diagnosis. Pleural effusions, Pleural t
atelectasis may be also evident on plain films or CT scans.
Pulmonary function tests show a marked restrictive pattern, with decreased forced
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Pulmonary function tests show a marked restrictive pattern, with decreased forced
(FVC).
Carbon monoxide diffusion corrected by lung volumes is typically normal.
Anti-Ro antibodies may be present, although they do not offer an additional diagno
Prognosis
The prognosis of this syndrome is usually good (Most patients show long-term stab
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129. Antibodies most commonly seen in drug
induced lupus are:
a) Anti ds DNA Antibodies
b) Anti Sm Antibodies
c) Anti-Ro Antibodies
d) Antihistone Antibodies
Correct Answer - D
Answer is D (Antihistone Antibodies):
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The most commonly used marker for drug induced lupus is
Antihistone Antibodies.
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Drug Induced Lupus is characterized serologically by the presence
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of Anti-Histone Antibodies and the absence of antibodies against
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double stranded DNA (dsDNA Antibody Negative; Anti-Histone
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Antibody Positive). Anti-dsDNA
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Serology in Drug Induced Lupus Erythematosus
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Almost all patients with Drug Induced Lupus will test positive for
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Antinuclear Antibodies (Positive ANA Test)
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The spectrum of Antinuclear antibodies in Drug Induced Lupus
includes
Positive Antihistone antibodies (most common; not specific; also
seen in SLE)
Positive autoantibodies against single stranded DNA (common ; not
specific; also seen in SLE)
Negative (absence of) autoantibodies against double stranded
DNA(dsDNA)
The presence of autoantibodies against dsDNA strongly suggests a
diagnosis of SLE
Drug Induced Lupus is typically associated with a Homogeneous
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ANA pattern due to the presence of Antihistone Antibodies
Antibodies are seen in less than 5 percent of patients with Drug
Induced Lupus
The presence of Antihistone antibodies alone is not a specific test
for diagnosis of Drug Induced Lupus as Antibodies to histones may
also be seen in up to 50 to 80 percent of patients with idiopathic
SLE.
Note : Hypocomplementemia is uncommon in Drug Induced Lupus
but not in SLE.
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130. Bilateral parotid enlargement occurs in
all, Except:
a) Sjogren's syndrome
b) SLE
c) HIV
d) Chronic pancreatitis
Correct Answer - B
Answer is B (SLE):
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Bilateral parotid enlargement is not a feature of SLE.
Causes of Bilateral parotid enlargement
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Viral Metabolic
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Endocrinal Miscellaneous
infections causes
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• Mumps • Diabetes • Acromegaly • Sarcoidosis
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• Influenza • mellitus • Gonadal • Amyloidosis
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• Epstein • Hyper hypofunction • Sjogren
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barr virus • lipoproteinemia syndrome
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• Coxackie Chronic
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virus A pancreatitise
• CMV Cirrhosis
• HIV
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131. Lupus Pernio is seen in:
a) Tuberculosis
b) SLE
c) PAN
d) Sarcoidosis
Correct Answer - D
Answer is D (Sarcoidosis):
Pernio is a typical cutaneous manifestation of Sarcoidosis.
Lupus Pernio is the most typical and easily recognizable skin lesions
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of Sarcoidosis. It is characterized by the presence of violaceous,
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purple blue shiny swollen lesions over the bridge of nose, beneath
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the eyes and over the cheeks. This specific complex of involvement
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of the bridge of nose, the area beneath the eyes and the cheeks is
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considered diagnostic for a chronic form of Sarcoidosis.
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132. Keratoderma Blenorrhagica is typically
seen in
a) Rheumatoid Arthritis
b) Psoriatic Arthritis
c) Reactive Arthritis
d) Ankylosing spondylitis
Correct Answer - C
Answer is C (Reactive Arthritis):
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Keratoderma Blenorrhagica is the charachteristic skin lesion seen in
patients with Reactive Arthritis.
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'The charachteristic skin lesions in Reactive Arthritis, Keratoderma
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Blenorrha2ica, consist of vesicles that become hyperkeratotic,
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ultimately forming a crust before disappearing. In patients with HIV
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infection, these lesions are often extremely severe and extensive
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sometimes dominating the clinical picture '-
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133. Which of the following statements about
Hematochromatosis is not true
a) Hypogonadism may be seen
b) Arthropathy may occur
c) Diabetes Mellitus may develop
d) Desferrioxamine is treatment of choice
Correct Answer - D
Answer is D (Desferrioromine is treatment of choice):
om
The therapy of hematochromatosis involves removal of excess body
iron.
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Iron removal is best achieved by periodic phlebotomies which is the
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treatment of choice for Hematochromosis.
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Chelating agents like desferoxamine are less effective and indicated
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when anemia or hypoproteinemia is severe enough to preclude
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phlebotomy.
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Chelating agents are not the treatment of choice for
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Hematochromatosis.
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134. Renal artery stenosis may occur in all of
the following, except :
a) Atherosclerosis
b) Fibromuscular dysplasia
c) Takayasu's arteritis
d) Polyarteritis nodosa
Correct Answer - D
Answer is D (Polyarteritis nodosa)
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Amongst the options provided renal artery stenosis is least likely to
be seen in association with Polyarteritis nodosa.
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Atherosclerosis and Fibromuscular disease
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- Renal artery stenosis is produced predominantly by
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atherosclerotic occlusive disease (80% to 90% of patients) or
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tibromuscular dysplasia (10-15% of patients).- CMDT'06 p 460
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- he common cause of renal artery stenosis in the middle aged and
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elderly is an atheromatous plaque at origin of renal artery. Harrison
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- In younger women stenosis is due to intrinsic structural
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abnormalities of the arterial wall caused by a heterogenous group of
lesions called 'fibromuscular dysplasia'. - Harrison 16`" /1707
PAN or Takayasu arteritis ?
CMDT do not mention PAN or Takayasu arteritis as a cause for
renal artery stenosis.
However, Takayasu arteritis is certainly a more common cause of
renal artery stenosis than PAN.
Takayasu arteritis (Aorto-arteritis) is beleiveds to be the most
common of renovascular hypertension in India and China. –
Diseases of Kidney and Urinary Tract 8th/1279
A number of research publications, however show Takayasu arteritis
as a cause for renal artery stenosis.
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as a cause for renal artery stenosis.
PAN
Although renal involvement is seen in upto 60% of patients with PAN
its pathology does not involve renal artery stenosis.
The pathology involves arteritis without glomerulonephritis and is
characterised by aneurysms of small and medium sized arteries.
Stenosis of main renal artery is an unusual association'.
Causes of Renal artery stenosis :
1. Atherosclerosis
2. Fibromuscular dysplasia
3. Non specific Aorto arteritis
4. Takayasu arteritis and giant cell arteritis (Takayasu > Giant cell)
5. Antiphospholipid syndrome
6. Transplant renal artery stenosis
7. Renal artery embolism
8. Dissecting aneurysm of aorta
9. Radiation arteritis
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135. The most common cause of Cushing's
syndrome is:
a) Pituitary adenoma
b) Adrenal adenoma
c) Ectopic ACTH
d) Iatrogenic steroids
Correct Answer - D
Answer is D (Iatrogenic steroids):
om
"The most common cause of Cushing's syndrome is Iatrogenic
administration of steroids for a variety of reasons."
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136. Intake of exogenous steroid causes:
a) Addison's disease
b) Cushing's syndrome
c) Pheochromocytoma
d) Conn's syndrome
Correct Answer - B
Answer is B (Cushing's syndrome):
The most common cause of Cushing's syndrome is iatragenic
administration of steroids for a variety of reasons. - Harrison
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137. Most common cause of Addison's
Disease in India is:
a) Autoimmune
b) Postpartum
c) HIV
d) Tuberculosis
Correct Answer - D
Answer is D (Tuberculosis):
om
'The commonest cause of adrenal insufficiency (Addison's disease)
in underdeveloped countries is Tuberculosis
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138. Initial Drug of choice for suspected case
of acute adrenal insufficiency is:
a) Norepinephrine
b) Hydrocortisone
c) Dexamethasone
d) Fludrocortisones
Correct Answer - C
Answer is C (Dexamethasone):
om
The treatment of choice for acute adrenal insufficiency is
Glucocorticoid Replacement Therapy. In cases where the diagnosis
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of acute adrenal insufficiency is suspected (not confirmed)
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Dexamethasone is preferred as the initial steroid of choice because
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Dexamethasone does not compete with the cortisol assay.
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Cosyntropin stimulation testing may be performed while the patient
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is on treatment.
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139. Nelson's syndrome is most likely seen
after:
a) Hypophysectomy
b) Adrenalectomy
c) Thyroidectomy
d) Orchidectomy
Correct Answer - B
The answer is B (Adrenalectomy):
om
Adrenalectomy predisposes to the development of Nelson's
syndrome.
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Nelson syndrome
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Nelson syndrome is a disorder characterized by the rapid
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enlargement of a preexisting ACTH pituitary adenoma after
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adrenalectomy.
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This syndrome occurs because the following adrenalectomy, the
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suppressive effect of cortisol on ACTH secretion and tumor growth is
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removed resulting in increased ACTH secretion and tumor growth.
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Patients with Nelson's syndrome present with hyperpigmentation
and with the manifestation of an expanding intrasellar mass lesion
(visual field defects, headache, cavernous sinus invasion, etc.)
These tumors represent one of the most aggressive and rapidly
growing of all pituitary tumors.
ACTH levels are markedly elevated.
Preoperative Radiotherapy may be indicated to prevent the
development of Nelson's syndrome after adrenalectomy.
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140. Primary Hyperaldosteronism can be
diagnosed by all of the following criteria,
except:
a) Diastolic Hypertension without edema
b) Hyperaldosteronism which is not supressed by volume
expansion
c) Low Plasma Renin Activity
d) Metabolic Acidosis
om
Correct Answer - D
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Answer is D (Metabolic Acidosis)
Class,Triad of Biochemical Criteria for diagnosis of Primary
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Hyperaldoteronism
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Hypokalemia with inappropriate kaliuresis (Metabolic alkalosis)
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Suppressed plasma renin activity
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Elevated Aldosterone levels that do not fall appropriately in
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response to volume expansion or sodium load
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Taken from Manual of Endocrinology & Metabolism 41h/150
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141. Primary hyperparathyroidism is
suggested by all of the following, except:
a) Increased serum calcium
b) Low urinary calcium
c) Increased PTH
d) Increased C-AMP
Correct Answer - B
Answer is B (Low Urinary Calcium):
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Primary Hyperparathyroidism is associated with normal or increased
urinary calcium levels.
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Increased PTH and Increased Serum calcium in association with
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high levels of urinary calcium suggest a diagnosis of Primary
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Hyperparathyroidism
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Increased PTH and Increased Serum calcium in association with low
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levels of urinary calcium suggest a diagnosis of Familial
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Hvpocalciuric Hvpercalcemia (FHH)
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Disorder S- S- PTHrPUrine Urinary
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Ca2± PHOS Calcium Ca2+
Intact
Creatinine
PTH
Clearance
ratio
Primary HPTH 1' sl, (or 1' (or ,I, U-Ca2' > >0.02
N) N) 100mg/24h
Familial l' .I(or 1' (or ,I, U-Ca2+ <0.01
benign N) N) <100mg/24h
hypercalcemia
This clearance ratio is calculated from simultaneous fasting serum
and urine Ca and creatinine measurements. The urine sample can
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and urine Ca and creatinine measurements. The urine sample can
be from a spot or a 24 h collection. The clearance ratio is calculated
as follows:
Urine Ca (mg/24h)x plasma creatinine (mg/dl )/plasma Ca (mg/dL) x
urine creatinine (mg/24h)
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142. Hypophosphatemia is seen in:
a) Pseudohypoparathyroidism
b) Hyperparathyroidism
c) Hyperthyroidism
d) Hypoparathyroidism
Correct Answer - B
Answer is B (Hyperparathyroidism):
Hyperparathyroidism is typically associated with hypophosphatemia.
Primary Hyperparathyroidism is associated with Hypophosphatemia
om
and Hypercalcemia while Secondary Hyperparathyroidism is
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associated with Hypophosphatemia and Hypocalcemia.
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Hyperthyroidism is typical associated with normal phosphate levels
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Hypoparathyroidism and Pseudohypoparathyroidism are associated
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with Hyperphosphatemia
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143. Granulomatous condition causing
hypercalcemia include all of the
following, except:
a) TB
b) Sarciodosis
c) Berylliosis
d) SLE
Correct Answer - D
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Answer is D (SLE):
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SLE is not classified as a granulomatous disease and is a rare
cause of Hypercalcemia (Disseminated SLE). Sarcoidosis,
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Tuberculosis (TB) and Berylliosis are typical Granulomatous
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disorders causing hypercalcemia.
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Granulomatous causes of Hypercalcemia
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Infective Causes
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Tuberculosis
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Berylliosis
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Histoplasmosis
Coccidoimycosis
Pneumocystis
Granulomatous Leprosy
Cat-Scratch Disease
Non-Infective Cause
Sarcoidosis (Most common)
Wegner's Granulomatosis
Inflammatory Bowel Disease
Histiocytosis-X
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Foreign body Granulomas
Almost every single disease associated with Granuloma formation
has been reported to cause Hypercalcemia
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144. Osteoporosis is seen in all the following
except
a) Thyrotoxicosis
b) Rheumatoid arthritis
c) Hypoparathyroidism
d) Steroid therapy
Correct Answer - C
Answer is C (Hypoparathyroidism) :
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Osteoporosis as associated with lzyperparathyroidism (not
hypoparathyroidism).
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DISEASES ASSOCIATED WITH AN INCREASED RISK OF
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GENERALIZED OSTEOPOROSIS IN ADULTS :
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Nutritional and gastrointestinal
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Hypogonadal States disorders
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Turner Syndrome Malnutrition
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Klinefelter syndrome Parenteral nutrition
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Anorexia nervosa Malabsorption syndromes
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Hypothalmic amenorrhea Gastrectomy
Other primary or secondary Severe liver disease, especially
hypogonadal states biliary cirrhosis
Pernicious anemia
Hematologic disorders /
Endocrine disorders Malignancy
Cushing's syndrome Multiple disorders/malignancy
Hyperparathyroidism Lymphoma and leukemia
Malignancy-associated parathyroid
Thyrotoxicosis
hormone - related (PTHrP)
Insulin-dependent diabetes
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Insulin-dependent diabetes
production
mellitus
Acromegaly Mastocytosis
Adrenal insufficiency Hemophilia
Thalassemia
Selected inherited &
Miscellaneous
Rheumatologic disorders
Osteogenesis imperfectaQ ImmobilizationQ
Chronic obstructive pulmonary
Marfan syndromeQ
disease
Hemochromatosis Pregnancy and lactation
HypophosphatasiaQ Scoliosis
Glycogen storage diseases Multiple sclerosis
HomocystinuriaQ Sarcoidosis
Ehlers-Danlos syndrome Amyloidosis
Porphyria Alcoholism
Menkes' syndrome
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Epidermolysis bullosa
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Rheumatoid arthritis
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DRUGS ASSOCIATED WITH AN INCREASED RISK OF
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GENERALIZED OSTEOPOROSIS IN ADULTS :
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Glucocorticoids2 Excessive thyroxin
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CyclosporineQ Aluminium
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Cytotoxic drugs Gonadotropin-releasing
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hormone agonistsQ
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Anticonvulsants
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Excessive alcohol Heparin
Lithium
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145. Features of tumor lysis syndrome are:
a) Hypocalcemia
b) Hypophosphatemia
c) Alkalosis
d) Hypokalemia
Correct Answer - A
Answer is A (Hypocalcemia):
Tumor Lysis syndrome is associated with Hypocalcemia.
Tumor Lysis Syndrome is also associated with Hyperphosphatemia,
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Hyperkalemia and Acidosis.
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146. A pregnancy woman is diagnosed to
suffering from Graves' disease. The most
appropriate therapy for her would be:
a) Radioiodine therapy
b) Total thyroidectomy
c) Carbimazole parenteral
d) Propylthiouracil oral
Correct Answer - D
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Answer is D (Propylthiouracil):
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Propylthiouracil (PTU) is not associated with an increased risk of
congenital malformations and is considered the drug of choice for
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treating hyperthyroidism is Pregnancy.
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Hyperthyroidism in Pregnancy
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Maternal Hyperthyroidism in Pregnancy is usually due to Grave's
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Disease. TRAb crosses the placenta and if mother is thyrotoxic it
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must be assumed that the foetus is similarly affected
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The treatment of choice for thyrotoxicosis in Pregnancy is therapy
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with safe Antithyroid Drugs
Thionamides (Carbimazole/Propylthiouracil) are equally effective in
controlling Grave's Hyperthyroidism in Pregnancy and are
considered the drugs of choice.
Amongst Carbimazole (Methimazole) and Propylthiouracil,
Propylthiouracil is typically the preferred agent (Traditional drug of
choice)
Radioactive Iodine Therapy is contraindicated in pregnancy as it
may destroy the fetal thyroid Thyroidectomy (Surgery) is rarely
required during Pregnancy. When indicated preoperative treatment
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with antithyroid drugs and iodine is undertaken and surgery is
performed during the second trimester
Propylthiouracil
Effective in controlling Grave's Hyperthyroidism in Pregnancy
Not associated with increased risk of congenital malformation
(Aplasia Cutis Congenita has not reported with the use of
Propylthiouracil))
Considered the drug of choice for treatment of Hyperthyroidism in
pregnancy
Considered the drug of choice for mothers during Breast feeding
(Transferred to the milk one tenth as much as Carbimazole)
Effective in controlling Grave's Hyperthyroidism in Pregnancy
Aplasia Cutis Congenita is a rare disorder reported in neonates of
mothers who received Methimazole (Carbimazole) during
pregnancy.
(Consensus: Insufficient data to establish a direct causal relationship)
Considered as an effective alternative where Propylthiouracil is not
available or cannot be used for any reason
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May be used in mothers during breast feeding at a low dose
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(Transferred to milk more than Propylthiouracil but usually does not
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adversely affect the infant's thyroid function)
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147. Investigation of choice in
pheochromocytoma is:
a) CT scan
b) Urinary catecholamines
c) MIBG scan
d) MRI Scan
Correct Answer - B
Answer is B (Urinary Catecholamines):
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Pheochromocytomas synthesize and store catecholamines which
include norepinephrine, epinephrine and dopamine. The
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investigation of choice for diagnosis of Pheochromocytomas is
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determination of elevated levels of catecholamines and their
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methylated metabolites (metanephrines) in the plasma and urine.
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CT scan, MRI and MBIG Scintography are all useful diagnostic
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modalities for localization of pheochromocytoma once the diagnosis
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is established.
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148. The predominant symptom/sign of
pheochromocytoma is:
a) Sweating
b) Weight loss
c) Orthostatic hypotension
d) Episodic hypertension
Correct Answer - D
Answer is D (Episodic Hypertension):
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The predominant manifestation of Pheochromocytoma is
Hypertension which classically presents as Episodic Hypertension
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(Sustained Hypertension and Orthostatic Hypotension may also be
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seen).
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'The dominant sign is Hypertension. Classically patients have
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episodic hypertension, but sustained hypertension is also common' -
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Harrison
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149. The gold standard test for diagnosis of
Insulinoma is:
a) '72 hour' fast test
b) Plasma Glucose levels < 3 mmol/l
c) Plasma Insulin levels > 6µU/ml
d) C- peptide levels < 50 p mol/e
Correct Answer - A
The answer is A ('72 hour' fast test):
om
The Gold standard test for diagnosis of Insulinoma is a supervised
'72 hour fast' test
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Diagnosis of insulinoma requires demonstration of inappropriately
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high levels of plasma Insulin ( and C- peptide) in the presence of
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documented hypoglycemia (Achieved by 72-hour fast test).
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Absolute values of Insulin or C- peptide are not reliable in
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establishing a diagnosis unless hypoglycemia is documented The
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'72 hour fast test' allows demonstration of hypoglycemia, together
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will elevated levels of Insulin and C-peptide and thus becomes the
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most reliable – gold standard test for establishing a diagnosis of
Insulinoma
Diagnosis of Insulinoma: '72 hour fast' test
The diagnosis of Insulinoma requires the demonstration of an
inappropriately elevated plasma insulin (and C-peptide) at the time
of hypoglycemia.
The '72 hour fast' test involves supervised fasting for up to 72 hours
or until hypoglycemia can be documented.
The test is considered positive if at any time when blood glucose
levels drop to < 2.2mmo1/1 (40 mg/dl), the serum insulin levels are
recorded to be greater than 6µU/ml. (and C- peptide levels > 100
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pmo1/1)
Studies indicate that 100% of patients with insulinoma will be
detected after a supervised 72 hour fast and hence this test is
considered the gold standard test.
First 24 hours: 70-80% of patients with insulinoma can be
detected
Up to 48 hours: 98% of patients with insulinoma can be
detected
By 72 hours: 100% of patients with insulinoma can he
detected
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150. Diagnosis of carcinoid tumour is done
Urinary estimation of:
a) VMA
b) Metanephrines
c) Catecholamines
d) 5HIAA
Correct Answer - D
Answer is D (5HIAA):
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Carcinoid Tumors
Carcinoid tumors are associated with elevated levels of metabolites
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of Tryptophan/ serotonin which include 5HIAA, 5HT and5HTP.
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Pheochromocytomas
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Pheochromocytomas are associated with elevated levels of
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catecholamines and their metabolites which include Vanillylmandelic
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acid (VMA)and metanephrines
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The diagnosis of Typical carcinoid syndrome is suggested by
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elevated levels of 5HIAA The diagnosis of Atypical Carcinoid
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Syndrome is suggested by elevated levels of 5HTP. established by
elevated levels of 5HIAA.
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151. Carcinoid syndrome produces valvular
disease primarily of the
a) Venous valves
b) Tricuspid valve
c) Mitral valve
d) Aortic valve
Correct Answer - B
Answer is B (Tricuspid valve);
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The most common site of involvement is the – Ventricular surface of
Tricuspid valve.
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'Cardiac manifestations in carcinoid syndrome are due to fibrosis
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involving the endocardium, primarily on the right side although left
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side lesions also occur. Dense fibrous deposits are most commonly
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on the ventricular aspect of the tricuspid valve and less commonly
irs
on the pulmonary valve cusps.'
.F
They can result in either constriction of valves (stenosis) or
w
fixation of valves in open (regurgitation)
w
w
- Abnormality produced due to tricuspid valve involvement –
Tricuspid regurgitation Q
- Abnormality produced due to pulmonary valve involvement –
Pulmonary stenosis Q
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152. Most common cause of chronic
granulomatous disease in children is:
a) Myeloperoxidase deficiency
b) Defective phagocytosis
c) Defective H2O2 production
d) Job's disease
Correct Answer - C
Answer is C (Defective H2O2 production)
om
Chronic granulomatous disease is a 'disorder' of microbial killing'
characterized by decreased ability of neutrophils to produce H4)-Q
r.c
Chronic granulomatous disease is a 'disorder' of microbial killing' characterized by
ke
decreased ability of neutrophils to produce H,O2.Q Patients, here become
an
tR
susceptible to disease caused by organisms that produce `catalase', which destroy
irs
the small amount of H2O, present in these cells and leads to failure of bacterial
.F
killing.
w
The disease is called so, because granulomas, are formed in various tissues, as a
w
second line defence against organisms, that normally would be removed by the
w
acute inflammatory response.
Manifestations:
Recurrent infections with which catalase +ve Pyogenic bacteria e.g. staph/coliforms
Q
- catalase negative bacteria e.g. streptococcus, Pneumococcus are often handled
normally.Q
Normal humoral immune response? but
Defective killing process: Leucocytes are unable to kill bacteria after phagocytosis
the major reason being decreased production of H-O2.Q
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Screening method:
NBT test: Nitroblue retrazolium dye is not reduced by neutrophils in vitro.
om
r.c
ke
an
tR
irs
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153. In Turner's syndrome which of the
following is NOT seen :
a) Short stature
b) Widely spaced nipple
c) Webbed neck
d) Mental retardation
Correct Answer - D
Answer is D (Mental retardation):
om
Mental retardation is seen in Down & Klinefelter's syndrome but not
in Turner's syndrome. All other features mentioned as options may
r.c
be seen in Turner's syndrome.
ke
an
tR
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154. Broca's aphasia is?
a) Fluent aphasia
b) Non fluent aphasia
c) Sensory aphasia
d) Conduction aphasia
Correct Answer - B
Answer is B (Non-fluent Aphasia):
Broca's Aphasia is a Non-Fluent Expressive (Motor) Aphasia with
preserved comprehension and impaired repetition
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an
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155. All of the following are Fluent Aphasia's
Except:
a) Anomie Aphasia
b) Wernicke's Aphasia
c) Conduction Aphasia
d) Broca's Aphasia
Correct Answer - D
Answer is D (Broca's Aphasia):
om
Neurologic Differential Diagnosis: A Case-Based Approach
(Cambridge University Press, 2014)/ 36
r.c
Broca's Aphasia is a Non-Fluent Expressive (Motor) Aphasia with
ke
preserved comprehension and impaired repetition.
an
Non-Fluent Aphasias
tR
Global
irs
Broca's
.F
Mixed Transcortical
w
Transcortical Motor
w
w
Fluent Aphasias
Anomie
Wernicke's
Conduction
Transcortical Sensory
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156. Fluent Aphasia with preserved
comprehension and impaired repetition
is:
a) Broca's
b) Wernicke's
c) Anomie
d) Conduction
Correct Answer - D
om
Answer is D (conduction):
r.c
Conduction Aphasia is a 'Fluent' Aphasia with preserved
comprehension and impaired Repetition.
ke
Clinical
an
Non-Fluent Aphasias Fluent Aphas'as
Syndrome
tR
Features Wernicke's Transcortical
irs
TranscorticalMotor Sensory
.F
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Fluent NoNo No NoYesYes Yes Yes
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ComprehensionNoNo Yes YesYesYes No No
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Repeat NoYes Yes NoYes NoNo Yes
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157. Involvement of pyramidal tract leads to
all of the following except
a) Spasticity
b) Fasciculation
c) Hyper-reflexia
d) Positive Babinski sign
Correct Answer - B
Answer is B (Fasciculation):
om
Fasciculations are a feature of Lower Motor Neuron Lesions.
Involvement of Pyramidal tract indicates an Upper Motor Neuron
r.c
Lesion. Hypertonia with Spasticity, Hyper-reflexia and a Positive
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Babinski Sign with an Extensor Planter response are all features of
an
an upper motor neuron lesion (Pyramidal Tract Lesion).
tR
irs
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158. The following are components of Brown
Sequard syndrome except :
a) Ipsilateral extensor plantar response
b) Ipsilateral pyramidal tract involvement
c) Contralateral spinothalamic tract involvement
d) Contralateral posterior column involvement
Correct Answer - D
Answer is D (Contralateral posterior column involvement):
om
Brown – Sequard syndrome or hemisection of the spinal cord leads
to loss of joint position and vibratory sense (posterior coluntn
r.c
movement) on the ipsilateral side and not on the contralateral side. –
ke
Harrison 16th / 2441, 144
an
Brown sequard syndrome: Hemisection of spinal cord
tR
Ipsilateral involvement of corticospinal tract : ipsilateral loss of motor
irs
power.
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Ipsilateral involvement of posterior column : ipsilateral loss of joint
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position and vibratory sense.
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Contralateral involvement of spinothalamic tract : contralateral loss
of joint position and vibratory sense.
Segmental signs such as radicular pain muscle atrophy or loss of
deep tendon reflexes arc unilateral (Lower motor neuron signs at
level of lesion).
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159. Early loss of bladder control is seen in
a) Conus Medullaris
b) Cauda Equina
c) Gullain Barre Syndrome
d) Amyotrophic Lateral Sclerosis
Correct Answer - A
Answer is A (Conus Medullaris):
Harrison's 18th Loss of bladder control is an early and marked
feature of conus medullaris.
om
Cauda
Conus
r.c
Feature Equina GBS AMLS
Medullaris
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syndrome
an
Early and Late and less Absent
Bladder Uncommon
tR
Marked marked /uncommon
irs
'Bladder 'Bladder
'If bladder 'Even in late
.F
Involvement dysfunction involvement is
dysfunction a stages of
w
is a
w
w
late prominent
a prominent the illness
presentation feature and
feature and bowel and
in cauda- comes
early in the bladder
comes early equina
course, functions
in the syndrome
diagnostic are
course of possibilities preserved'
disease' other than
GBS
should be
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considered
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an
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160. Most common cause of embolic stroke
is?
a) Intra-Cardiac Thrombi
b) Particulate Matter From IV Drug Injections
c) Protein C deficiency
d) Antiphospholipid syndrome
Correct Answer - A
Answer is A (Intracardiac Thrombi):
om
The most common cause of embolic strokes are Intro-cardiac
Thrombi.
r.c
The most common sources of systemic embolism and embolic
ke
stroke are Intra-cardiac thrombi formed as a result of atrial
an
fibrillation, ST- elevation MI, left ventricular dysfunction or heart
tR
failure.
irs
Atrial Fibrillation is the single most important predisposing factor
.F
(Atrial Thrombus) followed by Myocardial Infarction (Left Ventricular
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Thrombus).
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161. The common cause of subarachnoid
hemorrhage is:
a) Arterio-venous malformation
b) Cavernous angioma
c) Aneurysm
d) Hypertension
Correct Answer - C
Answer is C (Aneurysm):
om
`The most common cause of subarachnoid haemorrhage is rupture
of a saccular aneurysm (excluding head trauma)' – Harrison.
r.c
Previously asked frequently as follows: (Excluding hand trauma)
ke
Most common cause of subarachnoid haemorrhage is rupture of a
an
saccular aneurysmQ
tR
Most common cause of subarachnoid haemorrhage is rupture of a
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Berry aneurysmQ
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Most common cause of subarachnoid haemorrhage is rupture of
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'Circle of Willis' aneurysmQ.
w
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(Saccular aneurysms are synonymous with Berry Aneurysms and
most commonly occur in the anterior circulation on the Circle of
Willis).
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162. Lateral medullary syndrome is caused by
thrombosis of:
a) Anterior inferior cerebral artery
b) Posterior inferior cerebellar artery
c) Vertebral artery
d) b and c
Correct Answer - D
Answer is C > B (Vertebral artery > Posterior inferior cerebellar
om
artery):
`Most cases result from ipsilateral vertebral artery occlusion; in the
r.c
reminder occlusion of posterior inferior cerebellar artery is
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responsible' – Harrison
an
Vessel occlusion that result in Lateral Medullary syndrome:
tR
- Vertebral (most common)
irs
- Posterior inferior cerebellar (2nd most common)
.F
- Superior, middle or Inferior lateral medullary arteries
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Vertebral artery
w
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The vertebral artery consists of four segments. The fourth segment
courses upward to joint the other vertebral artery to form the basilar
artery.
Only this segment gives rise to branches that supply the brainstem
and cerebellum.
Embolic occlusion or thrombosis of the fourth segment is
responsible for this syndrome Q
Posterior inferior cerebellar artery
Posterior inferior cerebellar artery in its proximal part supplies the
lateral medulla and in its distal branches the inferior surface of
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cerebellum.
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an
tR
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163. Which of the following statements about
the pathology in Alzheimer's disease is
not true:
a) Neuritic Plaques are formed of amyloid protein
b) Neurofibrillary tangles (NFT) are made of tau protein
c) NFTs appear extracellularly before intracellular appearance
d) Number of NFTs correlates with dementia
Correct Answer - C
om
Answer is C (NFTs appear extracellularly before intracellular
r.c
appearance):
NFTs are typically seen intracellularly within the soma and proximal
ke
dendrites of neurons.
an
Neurofibrillary Tangles (NFTs) are intracellular accumulations of
tR
hyperphosphorylated 'tau' proteins.
irs
Neurofibrillary Tangles are Intracellular Accumulations
.F
Neurofibrillary Tangles are intracellular accumulations of
w
w
hyperphosphorylated microtubule binding protein 'tau'.
w
Paired helical filaments of tau protein (NFTs) form intracellularly
within the soma and proximal dendrites of neurons.
These cytoskeletal protein tangles (NFTs), initially impede cellular
metabolism and axosplasmic transport leading to impaired synaptic
function and eventually to neuronal death.
These neurofibrillaty tangles may be seen as extracellular tangles
after degeneration of the neuron as evidence of the neuronal cell's
demise
Neurofibrillary Tangles are intracellular accumulations that may
appear extracellularly alter degeneration of neuron (neuronal death)
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Histopathological Hallmarks of Alzheimer's Disease
Amyloid Plaques (Extracellular)
Amyloid Neuritic Plaques are formed by extracellular accumulation
of beta amyloid deposits within the neutropil
'Neuritic' or 'Senile' I3-amyloid plaques are an early histopathological
sign of Alzheimer's disease (that occur rarely in healthy subjects)
The amyloid 13-protein accumulated in single neuritic plaques is
toxic to surrounding structures and adjacent neurons.
Clinicopathological studies have shown that amy/aid burden does
not directly correlate with severity or duration of dementia.
Neurofibrillary Tangles (Intracellular)
Neurofibrillary tangles arc formed by intracellular accumulation of
hyperphosphorylated microtubule binding protein 'tau'.
NFT's occur in many neurodegenerative diseases and /or a group of
diseases called laupathies'.
These include Frontotemporal dementia, Pick's disease etc. The
cooccurance of fi-amyloid plaques with NFT's suggests a diagnosis
of AD.
om
The NFT's are toxic to the neurons and neurons with NFT's
r.c
eventually die and degenerate leaving a residual `ghost tangle', in
ke
the extracellular space reminding of the pyramidal cell body in which
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it was initially formed.
tR
Clinicopathological studies have shown that dementia correlates
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more strongly with NFT's than with senile plaques (3-amyloid)
.F
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164. Which of the following metal ions is
associated with secondary
Parkinsonisms:
a) Mangnese (Mn)
b) Magnesium (Mg)
c) Selenium (Se)
d) Molybednum (Me)
Correct Answer - A
om
Answer is A (Mangnese (Mn)):
r.c
Manganese ion exposure is implicated in the free radical damage of
the basal ganglia causing Parkinsonism.
ke
Toxins Implicated in Parkinsonism (Harrison)
an
Manganese (Mn)
tR
MPTP (1 Methyl - > Phenyl –1, 2, 3, 6 tetrahydropyridine)
irs
Carbonmonoxide
.F
Carbondisulphide
w
w
Ctanide
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Hexane
Methanol
Toxins reported to induce Parkinonism: (Handbook of Atypical
Parkinsonism)
Betel nut (plus antiPsychotics)
Carbon monoxide
Contrast agent for cardiac catheterization
Cyanide
Ethanol intoxication, ethanol withdrawal
Ethylene glycol
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Herbicides (paraquat, diquat, glyphosate)
Heroin
Hydrogen sulfide
Kava-kava
Manganese
Maneb (Manganese Ethylene-Bis-Dithiocarbamate)
Mercury
Methanol
Methcathinone (manganese ephedrone)
MPTP (I-methyl-4-phenyl-1,2,3,6-tetrahydropyridine)
Organic solvents (carbon disulfide, n-hexane, toluene,
trichloroethylene)
Organophosphate insecticide poisoning
Petroleum products
om
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165. Which of the following sites is
responsible for the amnestic defect in
Wernicke's Korsakoff syndrome:
a) Mamillary body
b) Thalamus
c) Periventricular Grey matter
d) Hippocampus
Correct Answer - B
om
Answer is B (Thalamus):
r.c
The Amnestic effect in Wernicke's Korsakoff Syndrome is related to
lesions in the dorso-medial nuclei of the thalamus.
ke
`Lesions in the dorsomedial nucleus of the thalamus seem to be the
an
best correlate of the memory disturbance and confabulation' -
tR
Robbins
irs
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166. In children most common posterior fossa
tumour is:
a) Meningiomas
b) Astrocytoma
c) Medulloblastoma
d) Glioblastoma multiforme
Correct Answer - B
Answer is B (Astrocytoma):
om
Cerebellar Astrocytomas are the most common posterior .fossa
tumors in children.
r.c
Medulloblastoma are the second most common posterior fossa
ke
tumors in children and the most common malignant posterior fossa
an
tumors in children.
tR
Although CPDT and Nelson's textbook mention an equal incidence
irs
of cerebellar astrocytoma and medulloblastoma in the posterior
.F
fossa in children, most other standard textbooks mention cerebellar
w
astrocytomas as the most common posterior fossa tumors in
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w
children.
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167. All the following are true of
Craniopharyngioma except
a) Derived from Rathke's pouch
b) Contains epithelial cells
c) Present in sella or infra-sellar location
d) Causes visual disturbances
Correct Answer - C
Answer is C (Present in sella or infrasellar location):
om
Some of these lesions arise from the sella, but most are suprasellar
Q (Not infra-sellar). They arise from near the pituitary stalk and
r.c
commonly extend into the supra sellar cistern.
ke
Craniopharyngiomas arise from Rathke's pouch and constitute 3-5%
an
of all intracranial neoplasms.
tR
Some of these lesions arise from the sella, but most are suprasellar
irs
Q (Not infra-sellar). They arise from near the pituitary stalk and
.F
commonly extend into the supra sellar cistern.
w
Consists of nests of cords of stratified squamous or columnar
w
w
epithelium embedded in a spongy reticulum — Robbins 61h/1129
Visual complaints are the presenting feature in about 80% of adults
and 60% of children.
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168. Predominantly sensory neuropathy is/are
caused by:
a) Cisplatin
b) Pyridoxine excess
c) Suramin
d) a and b
Correct Answer - D
Answer is A and B (Cisplatin and Pyridoxine excess):
om
Cisplatin and Pyridoxine are associated with predominantly sensory
neuropathies.
r.c
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an
tR
irs
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169. Which one of the following is correct
regarding Eaton-Lambert syndrome-
a) It commonly affects the ocular muscle
b) Neostigmine is the drug of choice for this syndrome
c) Repeated electrical stimulation enhances muscle power in it.
d) It is commonly associated with adenocarcinoma of lung
Correct Answer - C
Answer is C (Repeated electrical stimulation enhances muscle
om
power):
'Patients with Lambert – Eaten myaethenic syndrome show
r.c
incremental rather than decremental response on repeated nerve
ke
stimulation' – Harrison 17th/2674
an
'Muscle response to stimulation of its motor nerve increases
tR
remarkably if nerve is stimulated repeatedly even in muscles that are
irs
clinically weak' - CMDT
.F
Lambert Eaten Myasthenia Syndrome commonly involves
w
proximal limb muscles and muscles of trunk
w
w
Extraocular muscles are the most commonly involved in
Myaesthenia Gravis and not in Lambert Eaten Myasthenia
Syndrome
Neostigmine is not considered the drug of choice
Plasmapharesis and immunosuppression form mainstay of
treatment 3, 4 Diaminopyridine is the drug of choice for
enhancement of neuromuscular transmission.
Pyridostigmine (or Neostigmine) may be sympatomatically helpful
but their response is variable – Harrison & CMDT
Lambert Eaten Myasthenia Syndrome is associated with small
cell carcinoma of lung
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Lambert Eaten Myasthenia Syndrome is associated with small cell
carcinoma of lung and not adenocarcinoma
om
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170. All of the following are feature of
dermatomyositis, Except:
a) Salmon Patch
b) Gottron's patch
c) Mechanic finger
d) Periungual telengiectasias
Correct Answer - A
Answer is A (Salmon Patch):
om
Salmon patch is not a feature of dermatomyositis.
Cutaneous features of dermatomvositis
r.c
Cutaneous
ke
Description
feature
an
Heliotrope Periocular or facial erythema and edema with
tR
Rash° pink/purple /blue (heliotrope) hue
irs
(blue purple discoloration on upper eve lids with
.F
edema)
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Gottren's Violaceous papules over the knuckles
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Papules Q Erythema of the knuckles with a raised violaceous
(Gottren's sign) scaly eruption
Ervthematous rash over other body surfaces such
`V' sign as anterior chest (often in a V form)
Shawl sign Erythematous rash over other body surfaces
including the upper trunk, neck, back & shoulders
(shawl pattern)
Periungual Dilated capillary loops at the base offingernails
Telengiectasiase
Mechanic's Irregular, thickened, distorted cuticles, with rough
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handsQ and cracked areas over the lateral and palmar
areas offingers with irregular dirty horizontal lines
resembling mechanic 's hand.
Calcinosis
Presence of hard calcium deposits in the skin
Cutise
om
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an
tR
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171. Best prognostic factor for head injury is :
a) Glasgow coma scale
b) Age
c) Mode of injury
d) CT
Correct Answer - A
Answer is A (Glasgow coma scale):
Amongst the option provided GCS is the single best answer of
choice.
om
Determining the patient prognosis after TBI (Traumatic Brain
r.c
Injury) is difficult and complex.
ke
Several independent variables have been identified that correlate
an
with severity.
tR
Most studies have indicated Glasgow Coma Scale in the field and at
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arrival at the emergency department as a highly predictive indicator
of prognosis. Harrison 17th / 2601
.F
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In severe head injury eye opening, the best motor response and
w
verbal output have been found to be roughly predictive of outcome.
w
There have been summarized using the Glasgow coma scale.
Coma score = E + M + V
Patient scoring 3 or 4 have an 85% chance of dying or remaining
vegetative.
Patients scoring 11 or above have only a 5 — 10% chance of dying
or remaining vegetative.
Intermediate scores correlate with proportional chances of recovery.
Other Poor prognosis
indicators : Harrison
CT evidence of compression of
•Older age •
cisterns / midline shift
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• Older age •
cisterns / midline shift
Delayed evacuation of large
• Increase ICP •
intracerebral hemorrhage
Carrier status for apolipoprotein E-4
• Hypoxia & Hypotension •
allele
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172. Impotence is a feature of which of the
following :
a) Multiple sclerosis
b) Poliomyelitis
c) Amyotropic lateral sclerosis
d) Meningitis
Correct Answer - A
Answer is A (Multiple sclerosis):
om
Multiple sclerosis is associated with erectile dy.slitnction or
impotence.
r.c
Neurological disorders associated with Erectile dysfunction
ke
include:
an
Spinal cord injury
tR
Multiple sclerosis
irs
Peripheral neuropathy
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173. Which of the following is the most
common initial presenting feature of
multiple sclerosis:
a) Optic Neuritis
b) Cerebellar Ataxia
c) Internuclear ophthalmoplegia
d) Diplopia
Correct Answer - A
om
Answer is A (Optic Neuritis):
r.c
Optic Neuritis is the most frequent initial presenting feature of MS
amongst the options provided.
ke
The most common earliest presenting features of multiple sclerosis
an
are transient sensory defects followed by visual disturbances due to
tR
optic neuritis.
irs
Initial Symptoms of MS
.F
Percent of Percent of
w
Symptom Symptom
w
Cases Cases
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Sensory loss 37 Lhermitte's 3
Optic neuritis 36 Pain 3
Weakness 35 Dementia 2
Paresthesias 24 Visual loss 2
Diplopia 15 Facial palsy 1
Ataxia 11 Impotence 1
Vertigo 6 Myokymia 1
Paroxysmal
4 Epilepsy 1
attacks
4 1
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4 1
Bladder Falling
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174. "Prosopagnosia" is characterized by :
a) Inability to read
b) Inability to identify faces
c) Inability to write
d) Inability to speak
Correct Answer - B
Ans. B. Inability to identify faces
Prosopagnosia is a recognition deficit in which the patient is unable
to recognize familiar faces.
om
Face and object recognition deficits are known as prosopagnosia
r.c
and visual object agnosia respectively.
ke
The characteristic lesions in prosopagnosia and visual object
an
agnosia consists of a bilateral infarction in the territory of the
tR
posterior cerebral arteries and involve lingual and fusiform gyri.
irs
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175. Criteria for Brainstem death includes:
a) Positive Doll's eye Reflex
b) Absent pupillary light reflex and delated pupils
c) Pinpoint pupils
d) Positive vestibulo-ocular reflex
Correct Answer - B
Answer is B (Absent pupillary light reflex and delated pupils):
Brainstem death is defined by the absence of all brainstem mediated
cranial nerve reflexes.
om
Pupillary Light Reflex is a brainstem mediated cranial nerve reflex
r.c
that is absent in brainstem death. The pupils are usually midsized
ke
but may be dilated (should not however be small).
an
Occulo-cephalic (Doll's eye) reflex and Vestibulo-ocular (Caloric)
tR
reflex are both brainstem mediated cranial nerve reflexs that should
irs
be absent in Brainstem death.
.F
Criteria for Brain Death/Brainstem death
w
The definition of Brain stem death requires simultaneous
w
demonstration that the patient has irreversibly lost the capacity of
w
consciousness (Coma) and the capacity to breathe (Apnoea) both of
which are dependent on intact brainstem.
Clinical assessment of the integrity of Brainstem has two
components including assessment of the integrity of brainstem
mediated cranial nerve reflexes and the Apnea test.
Deep Unresponsive Coma
Patients with brain death show the deepest coma possible with total
unresponsiveness to all stimuli.
No spontaneous movement
No response to external stimuli (Verbal/ Deep pain)
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Absence of all Brainstem Cranial Reflexes
All reflexes mediated by cranial nerve must be absent
Absent Pupillary Light reflex (CN II, III)
(Pupils are usually midsized but may be enlarged but they should
not be small)
Absent Corneal Reflex (CN V, VII)
Absent Vestibulocochlear Reflex (CN III, IV, VI, VIII) (No eye
movement in response to caloric irrigation of ears)
Absent Oculocephalic Reflex
(Absent Doll's eye reflex) Eyes will move with the head
(No occular movements on rapid turning of head).
Absent Gag Reflex (CNIX, X)
Absent Tracheal Cough Reflex (CNX)
Absent Central Motor Response to Pain (CN V, VII) (No response to
deep somatic stimulation).
Complete Aponea in pressure of hypercarbia (Absence of
Brainstem Respiratory Reflex)
No respiratory effort in response to hypercarbia needs to be
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demonstrated to show that aponea is due to brainstem (medullary)
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damage
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Absent respiratory movement during disconnection from the
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ventilator with the PaCO2 > 60 mm Hg is required for the test to be
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valid
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Cranial nerve reflexes in Brain Stem Death testing:
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Cranial
Reflex Notes
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nerves
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Pupillary light HAI Use bright light source (not
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reflex ophthalmoscope) in a dimmed
environment. Look for both
direct and consensual reaction.
Important reflex that interrogates at level of
midbrain
Stroke cornea with gauze, whilst gently
Corneal reflex V, VII holding eyes open; avoid trauma to
cornea.
The various nuclei of V are found
throughout the whole length of the
brainstem, whilst
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brainstem, whilst
that of VII (facial nerve) is in the upper
medulla.
Central Apply deep pressure stimulation centrally
V, VII
response to (e.g. supra-orbital ridge) and peripherally
(e.g. nail bed). Look for central motor
deep somatic response in the distribution of the facial
nerve.
Peripheral stimulation may illicit peripheral
stimulation
spinal reflexes.
III, IV, VI, Check patency of external auditory canal
Cold caloric
VIII with auroscope. Flex head to 30° (or apply
30° head up tilt if cervical spine injury is
vestibulo-
suspected). Slowly irrigate canal with
ocular
5OrriL
reflex ice-cold water over 60s. Observe for
nystagmus for a further 30s. Contra-
om
indicated in
trauma-related otorrhea.
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The nuclei of III and IV lie withjin the
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midbrain, whilst those of VI and VIII are in
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the
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medulla.
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Oculocephalic Rapid lateral movement of the head
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VIII, Ill, VI
reflex normally results in eye deviation to the
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(Doll's eye contralateral side, testing brainstem gaze
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reflex) mechanism.
In brainstem death eyes remain in a fixed
position within the orbit.
Gag reflex IX, X Stimulate uvula under direct vision with
throat spatula, observing for contraction of
soft palate.
The nuclei of IX and X lie in the medulla.
Tracheal X Expose patient to umblicus. Stimulate
cough reflex trachea to level of carina by introduction of
sterile suction catheter down endotracheal
tube. Observe for cough response
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tube. Observe for cough response
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176. Renal papillary necrosis is almost always
associated with one of the following
conditions:
March 2004
a) Diabetes mellitus
b) Analgesic nephropathy
c) Chronic pyelonephritis
d) Post streptococcal glomerulonephritis
om
Correct Answer - A
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Ans. A i.e. Diabetes mellitus
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`Renal papillary necrosis, an accompaniment of acute pyelonephritis
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is most often seen in diabetics and is characterised by necrosis of
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renal papillae of one or both kidneys with sharped demarcation
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between necrotic and living tissue' — Dorlands
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Thus while papillary necrosis is a feature of more than one
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conditions mentioned in the question, it is most commonly seen with
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diabetes mellitus.
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177. Renal vein thrombosis is associated with
all of the following except:
September 2011
a) Trauma
b) Sickle cell anemia
c) Nephrotic syndrome
d) Dehydration
Correct Answer - B
om
Ans. B: Sickle cell anemia
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Conditions associated with RVT are: Trauma, extrinsic compression
(lymoh nodes, aneurysm), invasion by renal cell carcinoma,
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dehydration (infants), nephritic syndrome and Pregnancy/ oral
an
contraceptives
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RVT:
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Acute cases occurs in children and presents with sudden loss of
.F
renal function
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Gradual thrombosis occurs in elderly and only manifestation may be
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recurrent pulmonary emboli or development of hypertension
Definitive diagnosis can be done through selective renal venography
with visualization of the occluding thrombus
Treatment options consists of anticoagulation and thrombectomy
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178. Best marker to assess prognosis after
Surgery for colon carcinoma:
March 2005
a) CA 19-9
b) CA-125
c) Alpha fetoprotein
d) CEA
Correct Answer - D
om
Ans. D: CEA
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CEA is a family of related glycoproteins initially found in embryonic
tissue and colon malignancies.
ke
The half-life of CEA is approximately 2 weeks. Plasma levels of CEA
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can be determined readily by radioimmunoassay. However, its
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usefulness in colon carcinogenesis screening is limited because of
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its high level in the plasma of a patient's malignancies originating
.F
from other sites such as breast, pancreas, stomach and lung.
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Furthermore, CEA plasma levels may also be increased in smokers
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or patients with chronic diseases, such as inflammatory bowel
disease, bronchitis and alcoholic liver disease.
The clinical usefulness of CEA for screening purposes is further
limited by the fact that its increase in level typically occurs only when
the tumor penetrates through the serosa. Thus, early lesions may
not be detected by serum CEA level changes. CEA is typically
elevated with metastatic liver disease, but rarely with peritoneal
involvement. Thus, while the specificity for CEA to identify occult
CRCs is high, the sensitivity is low in most studies for screening.
Accordingly, CEA is not a useful test for the screening of CRC.
Regardless of the clinicopathologic stage, a preoperative elevation
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Regardless of the clinicopathologic stage, a preoperative elevation
of the plasma CEA level predicts eventual tumour recurrence.
High level of CA 19-9 is seen in the plasma of a patient's
malignancies originating from colon, breast and pancreas
om
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179. All of the following are features of
Obstructive jaundice except:
September 2007
a) Normal alkaline phosphatase
b) Mildly elevated serum aminotransferases level
c) Clay colour stools
d) Pruritis
Correct Answer - A
om
Ans. A: Normal alkaline phosphatase
r.c
Obstruction to the flow of bile in common bile duct may result from
choledocholithiasis, malignancy od head of pancreas, bile ducts or
ke
ampulla of Vater.
an
Charcot's triad of intermittent fever, pain and jaundice is
tR
characteristic of ascending cholangitis and indicates biliary
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obstruction.
.F
Hepatomegaly is present in most cases of obstructive jaundice and
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is due to congestion and stretching out of intrahepatic biliary spaces.
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A palpable gall bladder usually indicates obstruction of the distal
CBD, due to other causes like underlying malignancy, than stone
(Courvoisier's law).
Hepatic bile flow suppression leads to jaundice accompanied by
dark urine (bilirubinuria) and light coloured (alcoholic) stools.
Bile salts and pigments in urine and absent urobilinogen also favour
the diagnosis of obstructive jaundice.
Serum albumin and prothrombin time are good indicators of liver
function derangement. Serum bilirubin levels indicate severity of
jaundice and high direct bilirubin rules out hemolytic jaundice.
Mild elevation of SGPT levels are also seen in obstructive jaundice
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Mild elevation of SGPT levels are also seen in obstructive jaundice
consistent with liver dysfunction. An elevated alkaline phosphatase
is, always present in obstructive jaundice.
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180. Chvostek sign is seen in:
March 2013
a) Hypercalcemia
b) Hypoparathyroidism
c) Insulinoma
d) Diabetes mellitus
Correct Answer - B
Ans. B i.e. Hypoparathyroidism
om
Hypocalcemia
Idiopathic hypoparathyroidism is associated with:
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Genetic syndrome of hypoparathyroidism,
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- Addison's disease and
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– Mucocutaneous candid iasis
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Pseudohypoparathyroidism: No deficiency of parathormone, but
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target organ (bone and kidney) are unresponsive to its action
.F
Chvostek's sign: Contraction of facial muscles, elicited by light
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tapping of the facial nerve
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ECG changes: Prolongation of QT interval
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181. ECG pattern seen in pulmonary
embolism is:
September 2009, March 2013
a) S3Q3T1
b) S1Q1T3
c) S1Q3T3
d) S3Q3T3.
Correct Answer - C
om
Ans. C: S1Q3T3
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182. Specific antibody associated with
primary biliary cirrhosis is:
a) Anti-myosin
b) Anti-nuclear
c) Anti-mitochondrial
d) Anti-endomysial
Correct Answer - C
Ans. C: Anti-mitochondrial
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Primary biliary cirrhosis is strongly associated with the presence of
anti-mitochondrial antibodies (AMA), which are diagnostic
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PBC:
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* Associated with CREST syndrome, sicca syndrome, auto-immune
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thyroiditis, type I DM and IgA deficiency
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* IgG AMA is detected in more than 90% of patients with PBC
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* 90% of women are between 35 - 60 years
.F
* Earliest symptom is pruritis
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* Eventually hepatocellular failure and portal hypertension develops
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* Lab findings:
- Increased serum alkaline phosphatase
- Increased serum 5-nucleotidase activity
- Increased gamma-glutamyl transpeptidase
- Serum bilirubin is usually normal
- Aminotransferase levels minimally increased
- Treatment: Ursodiol
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183. 'v' Wave in JVP is due to ?
a) Right atrial contraction
b) Left atrial contraction
c) Right atrial relaxation
d) Closure of tricuspid valve
Correct Answer - A
Ans. is A
The first elevation (a wave) corresponds to the slight rise in atrial
pressure resulting from atrial contraction.
om
The first descent (x descent) reflects a fall in atrial pressure that
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starts with atrial relaxation.
ke
The second elevation (v wave) corresponds to ventricular
an
systole when blood is entering the right atrium from the vena
tR
cavae while the tricuspid valve is closed.
irs
Finally, the second descent (y descent) reflects falling right atrial
.F
pressure as the tricuspid valve opens and blood drains from the
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atrium into the ventricle.
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184. Gene for Rh antigen is located on
chromosome ?
a) 1
b) 4
c) 9
d) 19
Correct Answer - A
Ans. is 'a' i.e., 1
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185. Mannitol infusion causes increase in
a) Blood viscosity
b) Osmolarity
c) Intra-ocular tension
d) Intercranial tension
Correct Answer - B
Ans. is 'b' i.e., Omolarity om
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186. Normal QRS axis ?
a) +30 to 110°
b) -30 to +110°
c) +110° to +150°
d) -110° to -150°
Correct Answer - B
Ans. is 'b' i.e., -30 to +110°
In a normal heart, the average direction of the vector during spread
of the depolarization wave through the ventricles, called the mean
om
QRS vector, is about +59 degrees.
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This means that during most of the depolarization wave, the apex of
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the heart remains positive with respect to the base of the heart.
an
The normal electrical axis of the heart (mean electrical axis or mean
tR
QRS vector) lies between -30° and + 100°.
irs
If the axis is more negative than -30° it is called left axis deviation,
.F
whereas if the axis is more positive than + 100°, it is called right axis
w
deviation.
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187. Acrodermatitis hemorrhagica is due to
deficiency of
a) Zinc
b) Manganese
c) Copper
d) Selenium
Correct Answer - A
Ans. is 'a' i.e., Zinc
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Symptoms of Zinc Deficiency
Mild deficiency Severe dificiency
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Growth retardation Dwarfism
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Cardiomyopathy
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Hypogonadism
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Infertility
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Loss of taste
.F
Poor wound healing
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Deformed bones
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Diarrhoea
Alopecia
Night blindness
Skin striae
Nail changes
Acrodermatitis enteropathica is an inherited autosomal recessive
disorder with imapired intestinal disorder and transport of Zinc.
Patient suffers with pustular and bullous dermatitis, alopecia, growth
retardation diarrhoes, secondary infection, lethargy, irritability and
depression. Oral Zinc supplementation leads to remission.
Zinc
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2nd most abundant trace element in the body.
Most common catalytic metal ion in the cell cytoplasm.
Component of more than 100 enzymes like DNA polymerase, RNA
polymerase, transfer RNA synthetase.
It plays role in all stages of insulin metabolism.
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188. Which of the following is not seen in
Secondary Adrenal insufficiency
a) Pigmentation
b) Postural hypotension
c) Hypoglycemia
d) Lassitude
Correct Answer - A
Secondary adrenal insufficiency is adrenal hypofunction due to a
om
lack of adrenocorticotropic hormone (ACTH).
Secondary adrenal insufficiency may occur in
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Panhypopituitarism
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Isolated failure of adrenocorticotropic hormone (ACTH) production
an
Patients receiving corticosteroids (by any route, including high doses
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of inhaled, intra-articular, or topical corticosteroids)
irs
Patients who have stopped taking corticosteroids
.F
Symptoms are the same as for Addison disease and include fatigue,
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weakness, weight loss, nausea, vomiting, and diarrhea, but there is
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usually less hypovolemia.
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189. Typhoid is treated by all except
a) Erythromycin
b) Ceftriaxone
c) Amikacin
d) Ciprofloxacin
Correct Answer - A
Ans. is 'a' i.e., Erythromycin
The older agents used for the treatment of typhoid were :
Chloramphenicol
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Ampicilin
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Trimethoprim Sulfamethoxazole
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Beta lactam
an
Parenteral → Ceftriaxone
tR
Orall → Cefixime
irs
These drugs are not used nowdays because of widespread
.F
resistance. o Nowdays the drug of choice for Typhoid all over the
w
world is a "Fluroquinolone" (Ciprofloxacin, ofloxacin).
w
An important point to remember
w
High level of fluoroquinolone resistance (ciprofloxacin) have been
reported from India and other parts of South East Asia in S.
paratyphi and S.typhi infection.
Nalidixic acid resistant S.typhi (NARST) have decreased
ciprofloxacin sensitivity and are less effectively treated with
fluoroquinolones.
The fluroquinolones should not be used as first line treatment for
typhoid fevers in patients from India and other parts of South Asia
with high rates of fluroquinolone resistance unless antibiotic
susceptibility data demonstrates fluoroquinolone or nalidixic acid
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sensitivity.
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190. Drug treatment is given for how many
days in pneumococcal meningitis
a) 5 days
b) 7 days
c) 14 days
d) 21 days
Correct Answer - C
Ans. is 'c' i.e., 14 days
om
Recommendations for duration of treatment
Pneumococcal meningitis —> 10-14 days
r.c
Meningococcal meningitis 5-7 days
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Hib meningitis —> 7-14 days
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Listeria meningitis —> 21 days
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191. Marker of acute kidney injury all except
a) Clusterin
b) Osteopontin
c) Alanine aminopeptidase
d) Acid phosphatase
Correct Answer - D
Ans. is 'd' i.e., Acid phosphatase
Alanine aminopeptidase (AAP) Kidney injury
molecule-1 (KIM-1)
om
Alkaline phosphatase (AP) Clusterin
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utathione-S-transferase (a-GST) Neutrophil
ke
gelatinase associated lipocalin (NGAL)
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yglutamyl transpeptidase (TGT) Interleukin-18 (IL-
tR
18)
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N-acetyl-0-glucosaminidase (NAG) Cysteine-rich
.F
protein (CYR-61)
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2-microglobulin Osteopontin (OPN)
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microglobulin o Retinol-binding protein (RBP) Fatty acid binding
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protein (FABP
Cystatin C Sodium/hydrogen
exchanger isoform (NHE3) o
Microalbumin Exosomal fetuin-A
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192. The treatment of choice in acute
hyperkalemia of life threatening to
cardiac myocytes is
a) Infusion of calcium gluconate
b) Oral resins
c) Intravenous infusion of insulin
d) β blocker
Correct Answer - A
om
Ans. is `a' i.e. Infusion of calcium gluconate
r.c
Emergent t/t of hyperkalemia is needed in conditions with
severe hyperkalemia (IC >7 meq/L). In these cases cardiac
ke
toxicity or muscular paralysis is present.
an
Calcium gluconate is the fastest acting agent among the agents
tR
used in the t/t of hyperkalemia°.
irs
It acts within minutes but an important point to note is that it
.F
does not cause transcellular movement of potassium, instead,
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it acts on cardiac cell membrane
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193. Vitamin E causes
a) Hemorrhagic stroke
b) Cardiac failure
c) Ataxia
d) Megalablastic anemia
Correct Answer - C
Ans. is 'c' i.e., Ataxia
Vitamin E (tocopherol) is a fat-soluble vitamin with antioxidant
properties; It protects cell membranes from oxidation and
om
destruction.
r.c
Vitamin E is found in a variety of food including oils, meat, eggs, and
ke
leafy vegatables.
an
There are multiple forms and isomers of tocopherol and the related
tR
compounds, tocotrienols.
irs
The current evidence the primary bioactive form of Vitamin E is alfa-
.F
tocopherol.
w
Serum vitamin E levels are strongly influenced by concentration of
w
serum lipids, and do not accurately reflect tissue vitamin levels.
w
Effective vitamin E levels are calculated as the ratio of serum alpha-
tocopherol per gram total lipids.
Absorption of dietary vitamin E requires effective pancreatic exocrine
function and fat absorption, unless provided in a synthetic water-
soluble form.
Vitamin
Vitamin E deficiency is uncommon in humans except in special
circumstances.
This is due to the abundance of tocopherols in the diet.
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194. Which of the following circulating
antibodies has the best sensitivity and
sepcificity for the diagnosis of celiac
disease ?
a) Anti Saccharomyces antibody
b) Anti-tissue transglutaminase antibody
c) Anti-gliadin antibody
d) Anti-gliadin antibody antibody
om
Correct Answer - A
r.c
Ans. is 'a' i.e. Anti saccharomyces antibody
ke
Serologic evaluation in celiac disease
an
Immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody
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is the single preferred test for detection of celiac disease in
irs
individuals over the age of two years.
.F
Serum antibody assays
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A variety of serologic studies have been described to aid in the
w
diagnosis of celiac disease, including:
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IgA endomysial antibody (IgA EMA)
IgA tissue transglutaminase antibody (IgA tTG)
IgG tissue transglutaminase antibody (IgG tTG)
IgA deamidated gliadin peptide (IgA DGP)
IgG deamidated gliadin peptide (IgG DGP)
Serum IgA endomysial and tissue transglutaminase antibody testing
have the highest diagnostic accuracy.
The IgA and IgG antigliadin antibody tests have lower diagnostic
accuracy with frequent false positive results as compared with IgA
tTG and IgA DGP assays and are therefore no longer recommended
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for initial diagnostic evaluation or screening
However, the newer anti-deamidated gliadin peptide (DGP) assays
described above show high diagnostic accuracy.
IgA EMA, IgA tTG,IgA DGP and IgG DGP levels fall with treatment;
as a result, these assays can be used as a noninvasive means of
monitoring the response to a gluten-free diet.
Assay sensitivity and specificity
IgA endomysial antibodies- → Sensitivity 85 to 98
percent; specificity 97 to 100 percent
IgA tissue transglutaminase antibodies → Sensitivity 90 to 98
percent; specificity 95 to 97 percent --
IgA deamidated gliadin peptide → Sen sitivity 94
percent; specificity 99 percent
IgG deamidated gliadin peptide → Sensitivity 92
percent; specificity 100 percent om
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195. Aseptic meningitis caused by
a) Indomethacin
b) Ibuprofen
c) Aspirin
d) Icatibant
Correct Answer - B
Ans. is 'b' i.e., Ibuprofen
Medications known to cause aseptic meningitis Medications
Medication Common Uncommon
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Sulindac Naproxen
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NSAIDs Ibuprofen Diclofenac
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Rofecoxib
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Antimicrobials Trimethoprim/sulfamethoxazoleSulfonamides
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Immunomodulating Monoclonalantibody
Azathioprine
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agents OKT3Intravenous IgG
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Metrizamide
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Cytarabine
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Intrahecal agents
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Methylprednisolone
acetate
Other Carbamazepine
Causes of acute aseptic meningitis
Infectious
cases
Lyne disease
Leptospirosis
Mycobacterium tuberculosis
infection
Bacterial Subacute bacterial endocarditis
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Subacute bacterial endocarditis
Parameningeal infection
(epidural subdural abcess, sinus
or ear infection) Partially treated
bacterial meningitis
Echovirus infection
Coxaackie virus infection
Mumps
St. Louis encephalitis
Eastern equine encephalitis
Viral Western equine encephalitis
Calcifornia encerphalitis
Herpes simplex virus type 2
infection HIV infection
Lymphocytic choriomeningitis
Poliovirus infection
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196. High Steppage Gait is seen in
a) Foot drop
b) Frontal lobe stroke
c) Tabes dorsalis
d) Leprosy
Correct Answer - C
Ans. is 'c' i.e., Tabes dorsalis
High stepping gait or steppage gait or foot drop gait is due to foot
drop -+ leg is lifted more in order to get clearance and first to touch
om
the ground is fore foot (not the heel as occur in normal gait).
r.c
It may occur in all motor peripheral neuropathies involving common
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peroneal nerve —> Tabes dorsalis, leprosy etc.
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[Ref Harrison 18th/e chapter 377]
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197. In a patient with bronchial asthma silent
chest signifies
a) Good Prognosis
b) Bad Prognosis
c) Grave Prognosis
d) Not a Prognostic sign
Correct Answer - C
Ans. is 'c' i.e., Grave Prognosis
om
Silent chest (Little/no air movement without wheezes in Bronchial
Asthma suggests a grave prognosis/impending respiratory failure
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(Life threatening Asthma).
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Signs of impending respiratory failure include :
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Drowsiness or confusion
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Diaphoresis
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Bradycardia
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Paradoxical thoraco abdominal
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Signs of impending respiratory failure in Asthma
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Drowsiness or confusion
Diaphoresis
Bradycardia
Paradoxical thracoabdominal movements
PEFR < 33%
Hypotension
Pulsus paradoxus
Hypercapnea
Silent chest
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198. Which is correct about pneumonia
a) Bronchophonia
b) Decreased vocal fremitus
c) Shifting of trachea
d) Amphoric breathing
Correct Answer - A
Ans. is 'a' i.e., Bronchophonia
Physical examination findings of Common pulmonary
conditions
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Endobronchial
Pleural effusion Pneumonia
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tumor Pneumothorax
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Tracheal Shifted or Shifted or
Midline Shifted or midline
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position midline midline
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Reduced or Reduced or Reduced or
Chest wall Reduced
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normal normal normal
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Normal or
Fremitus Decreased Increased None
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decreased
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PercussionDull Dull Normal or Dull Hyperresonant
Breath Normal or
Decreased Increased Decreased/absent
sounds Decreased
Crackles None None None None
Wheeze None None Possible None
Band above
Egophony Present None None
effusion(skodiac)
Tracheal
position
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Deviated
Away from
Pneumo
thorax
Effusion
Deviated
towards
Collapse
Consolidation
Tactile vocal fremitus
Tactile vocal fremitus is vibration felt on the patients chest during low
frequency vocalisation.
Commonly the patient is asked to repeat a phrase while the
examiner feels for vibtations by placing a hand over the patient chest
or back.
Tactile fremitus is normally more intense in the right second
intercostal space as well as in the interscapular region as these :
Tactile fremitus
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Increased → Consolidation
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Decreased or absent → Pleural effusion or Pneumothorax
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Reason for increased fremitus in a consolidated lung is the fact that
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the sound waves are transmitted with less decay in solid or fluid
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medium (consolidation) than in a gaseous medium (consolidation)
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than in a gaseous medium (aerated lung). Conversely the reason for
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decreased fremitus in a pleural effusion or pneumothorax (or any
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pathology separating the lung tissue itself from the body wall) is that
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this increased space diminishes or prevents entirely sound
transmission
Egophony is a change in timbre (E0 to A) but not pitch or volume.
It is due to decrease in the amplitude and an increase in the
frequency of the second formant produced by solid (including
compressed lung) interposed between the resonator and the
stethoscope head.
The sound of a spoken "E" change to "A" over an area of
consolidation. The spoken "E" is heared as "A" when listening over
the consolidation because the frequencies of the vibrations are
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altered by the consolidation. Egophony or "E" to "A" changes may
also occur in small band like area just above a pleural effusion
because of compression of lung tissue that occurs just above the
effusion.
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199. Systemic Millary TB spreads via
a) Artery
b) Vein
c) Bronchus
d) Lymphatic
Correct Answer - A
. Ans. is 'a' i.e., Artery
Systemic miliary ensues when infective foci in the lungs seed the
pulmonary venous return to the heart; the organisms subsequently
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disseminate through the systemic arterial system.
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200. DOC for acute attack of Hereditary
angioneurotic edema
a) Danazol
b) Cl, inhibitor concentrate
c) Icatibant
d) Methylprednisolone
Correct Answer - B
Ans. is 'b' i.e., Cl inhibitor concentrate
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Medication
C1 inhibitor concentrate (Plasma-derived) (Berinert, Berinert P,
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Cinryze.
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Recombinant C1 inhibitor Conestat alfa (Ruconest, Rhucin).
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Bradykinin Bzreceptor antagonist Icatibant (Firazyr).
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Kallikrein inhibitor Ecallantide (Kalbitor)
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Plasma
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201. Type 5 Hypersensitivity mimics
a) Type 1
b) Type 2
c) Type 3
d) Type 4
Correct Answer - B
Ans. is 'b' i.e., Type 2
Type V hypersensitivity reactions were additionally added to the
scheme originally described by Coombs and Gell. Contrary to type
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IV and in agreement with types I, 11 and III respectively, they are
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mediated by antibodies too.
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The type V reactions are sometimes considered as a subtype of
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the type II hypersensitivity.
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As its mechanisms do not destroy target cells, they are responsible
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for induction of organ/tissue dysfunctions only most of authors prefer
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it to be and independent, the 5' type of hypersensitivity reactions
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202. Which is best for plaque morphology
a) CCTA
b) MRI
c) CMR
d) IVUS
Correct Answer - A
Ans. is 'a' i.e., CCTA
Coronary lesions prone to rupture have a distinct morphology
compared with stable plaques, and provide a unique opportunity for
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noninvasive imaging to identify vulnerable plques before they lead to
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clinical events. This can be achieved using a non-invasive cardiac
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imaging using coronary CT angiography.
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o Large plaque volume, low CT attenuation, napkin-ring sign,
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positive re-moedlling, and spotty calcification are all associated with
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a high risk of acute cardiovascular events in patients. Intravascular
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USG can give comparable results but is an invasive test
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203. Most common cause of heart block in
infants is
a) SLE
b) Surgery for congentital heart disease
c) Viral myocarditis
d) Rheumatic fever
Correct Answer - B
Ans. is 'b' i.e., Surgery for congentital heart disease
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In children, the most common cause of permanent acquired
complete AV block is surgery for congenital heart disease.
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Postsurgical completer atrioventricular block (A VB) is the most
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common cause for acquired AV block in children, resulting from
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trauma to the AV node at time of surgery (i.e., hemorrhage,
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ischemia, necrosis, inflammation, traumatic disruption).
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The second most common cause is congenital herat disease
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associated with complete AV block.
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Other etiologies of acquired AV block are often reversible and
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include :
Digitalis and other drug intoxications.
Viral myocarditis.
Acute rheumatic fever, Lyme disease, and infectious mononucleosis.
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204. Aphasia which affects the arcuate fibres
is called
a) Global aphasia
b) Anomie aphasia
c) Conduction aphasia
d) Broca's aphasia
Correct Answer - C
Ans. is 'c' i.e., Conduction aphasia
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Arcuate fibers are bundle of nerve fibres that connect Brocas area to
the Wernicke 's area.
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Damage to the arcuate fasciculus causes a disorder called
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conduction aphasia
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205. Drug for management of hypertension in
Phaeochromocytoma
a) Phenoxybenzamine
b) Phentolamine
c) Labetalol
d) Esmolol
Correct Answer - A
Ans. is 'a' i.e., Phenoxybenzamine
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Once a pheochromocytoma is diagnosed, all patients should
undergo a resection of the pheochromocytoma following appropriate
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medical preparation.
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Resetting a pheochromocytoma is a high-risk surgical procedure
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and an experienced surgeon/anesthesiologist team is required.
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Some form of preoperative pharmacologic preparation is indicated
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for all patients with catecholamine-secreting neoplasms.
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Preoperative medical therapy is aimed at:
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Controlling hypertension (including preventing a hypertensive crisis
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during surgery) o Volume expansion
In patients with undiagnosed pheochromocytomas who undergo
surgery for other reasons (and who therefore have not undergone
preoperative medical therapy), surgical mortality rates are high due
to lethal hypertensive crises, malignant arrhythmias, and multiorgan
failure.
Combined alpha- and beta-adrenergic blockade
Combined alpha- and beta-adrenergic blockade is the most common
approach to control blood pressure and prevent intraoperative
hypertensive crises.
Alpha-adrenergic blockade
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An alpha-adrenergic blocker is given 10 to 14 days preoperatively to
normalize blood pressure and expand the contracted blood volume.
Phenoxybenzamine is the preferred drug for preoperative
preparation to control blood pressure and arrhythmia in most centers
in the United States. It is an irreversible, long-acting, nonspecific
alpha-adrenergic blocking agent.
The initial dose is 10 mg once or twice daily, and the dose is
increased by 10 to 20 mg in divided doses every two to three days
as needed to control blood pressure and spells.
The final dose of phenoxybenzamine is typically between 20 and
100 mg daily.
Beta-adrenergic blockade
After adequate alpha-adrenergic blockade has been achieved, beta-
adrenergic blockade is initiated, which typically occurs two to three
days preoperatively.
The beta-adrenergic blocker should never be started first because
blockade of vasodilatory peripheral betaadrenergic receptors with
unopposed alpha-adrenergic receptor stimulation can lead to a
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further elevation in blood pressure.
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The alternatives to a and 13 adrenergic agents are calcium
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channel blockers and metyrosine.
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Calcium channel blockers
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Although perioperative alpha-adrenergic blockade is widely
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recommended, a second regimen that has been utilized involves the
administration of a calcium channel blocker.
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Nicardipine is the most commonly used calcium channel blocker in
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this setting; the starting dose is 30 mg twice daily of the sustained
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release preparation.
Metyrosine
Another approach involves the administration of metyrosine (alpha-
methyl Para-tyrosine), which inhibits catecholamine synthesis.
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206. Causes of hyperparathyroidism are all
except
a) Solitary adenoma
b) Malignant
c) Thyroid malignancy
d) Parathyroid hyperplasia
Correct Answer - C
Ans.:C.)Thyroid malignancy
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Hyperparathyroidism
Pathology
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Increased levels of the PTH lead to increased osteoclastic activity.
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The resultant bone resorption produces cortical thinning
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(subperiosteal resorption) and osteopaenia.
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Subtypes
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primary hyperparathyroidism
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parathyroid adenoma (~80%)
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multiple parathyroid adenomas (4%)
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parathyroid hyperplasia (10-15%)
parathyroid carcinoma (1-5%)
secondary hyperparathyroidism
caused by chronic hypocalcaemia with renal osteodystrophy being
the most common cause (others include malnutrition, vitamin D
deficiency)
results in parathyroid hyperplasia
tertiary hyperparathyroidism
autonomous parathyroid adenoma caused by the chronic
overstimulation of hyperplastic glands in renal insufficiency
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207. Mentzer index more than 13 suggests a
diagnosis of
a) Iron deficiency anemia
b) Thalassemia
c) Hereditary Spherocytosis
d) Autoimmune Hemolytic Anemia
Correct Answer - A
Ans. is 'a' i.e., Iron deficiency Anemia
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Mentzer index more than 13 suggests a diagnosis of Iron-deficiency
anemia.
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Mentzer index
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The Mentzer index is used to help in differentiating iron deficiency
an
anemia from beta thalassemia.
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The index is calculated as the quotient of the mean corpuscular
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volume (MCV, in fL) divided by the red blood cell count (RBC, in
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millions per microleter).
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If the Mentzer index is less than 13, thallassemia is said to be more
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likely.
If the Mentzer Index is greater than 13, Then iron-deficiency anemia
is said to be more likely.
Principle
In iron deficiency, the marrow cannot produce as many RBCs and
they are small (imcrocytic), so the RBC count and the MCV will both
be low, and as a result, the index will be greater than 13.
Conversely, in thalassemia, which is a disorder of globin synthesis,
the number of RBCs produced is normal, but the cells are smaller
and more fragile. Therefore, the RBC count is normal, but the MCV
is low, so the index will be less than 13.
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In practice, the Mentzer index is not a reliable indicator and should
not, by itself be used to differentiate the two conditions.
Value for
Value for
iron
Index Formula iron
deficiency
thalassemia
anemia
Mentzer MC V/RBC
> 13 < 13
index count
Shine and MCV2 x
> 1530 < 1530
Lal index MCH x 0.01
MCV – RBC
England and
- (5 x Hb) > 0 <0
Fraser index
5.19
Srivastava
MCH/RBC > 3.8 < 3.8
index
MCV2 x
Green and
RDW x > 65 < 65
king index
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Hb/100
Red cell
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MCV x
distribution > 220 < 220
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RDW/RBC
width index
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208. Which of the following statements about
iron deficiency anemia is correct
a) Decreased TIBC
b) Increased ferritin levels
c) Bone marrow iron is decreased after serum iron is decreased
d) Bone marrow iron is decreased earlier than serum iron
Correct Answer - D
Ans. is 'D' i.e., Bone marrow iron is decreased earlier than serum
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iron
"In iron deficiency anemia the first change is decrease in iron stores
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"
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The decrease in iron stores is demonstrated by decreased serum
an
ferritin level.
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Remember,
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Serum ferritin reflects the amount of storage iron in the body.
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As the total body iron level begins to fall a characteristic,
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sequence of events ensue :
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First Stage or Prelatent Stage of Iron Depletion
When iron loss exceeds absorption, a negative iron balance exists.
Stored iron begins to be, mobilized from stores. The iron present in
the macrophages of liver, spleen and bone marrow are depleted
Decrease in stored iron is reflected by decrease in serum ferritin.
At this stage all other parameters of iron status are normal.
Second Stage or Stage of Latent Iron Deficiency :
Iron stores are exhausted but the blood hemoglobin level remains
higher than the lower limit of normal. o After the exhaustion of iron
stores :
The plasma iron concentration fallsQ.
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Plasma iron binding capacity increases2.
Percentage saturation falls below 15%Q.
The percentage of sideroblast decreases in the bone marrowQ.
Third Stage or Stage of Apparent Iron Deficiency Anemia
Supply of iron to marrow becomes inadequate for normal
hemoglobin production,
So the blood hemoglobin concentration fallsQ below the lower limit of
normal and iron deficiency anemia is apparent.
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209. Persistent priapism is due to
a) Sickle cell anaemia
b) Hairy cell leukaemia
c) Paraphimosis
d) Urethral stenosis
Correct Answer - A
Ans. is 'a' i.e., Sickle cell anemia
Priapism is defined as erection lasting for > 4 hours.
Low-flow priapism may be due to any of the following:
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An excessive release of neurotransmitters
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Blockage of draining venules (eg, mechanical interference in sickle
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cell crisis, leukemia, or excessive use of intravenous parenteral
an
lipids)
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Paralysis of the intrinsic detumescence mechanism
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Prolonged relaxation of the intracavernous smooth muscles (most
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often caused by the use of exogenous smooth-muscle relaxants
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such as injectable intra-cavernosal prostaglandin E I)
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Prolonged low-flow priapism leads to a painful ischemic state, which
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can cause fibrosis of the corporeal smooth muscle and cavernosal
artery thrombosis. The degree of ischemia is a function of the
number of emissary veins involved and the duration of occlusion
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210. The type of arteritis which may lead to
myocardial infarction in children is
a) Kawasaki disease
b) Takayasu arteritis
c) Polyarteritis nodosa
d) Microscopic polyangitis
Correct Answer - A
Ans. is 'a' i.e., Kawasaki disease
om
o Kawasaki disease is an acute, self limited vasculitis of unknown
etiology that occurs predominantly in infants and young children of
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all races.
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Coronary artery aneyrysms or ectasia develops in 15-25% of
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untreated children with the disease and may lead to ischemic heart
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disease, myocardial infarction, or even sudden death. In the USA,
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Kawasaki disease has surpassed acture rheumatic fever as teh
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leading cause of acquited heart disease in children
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211. Onion skin spleen is seen in
a) ITP
b) Thalassemia
c) SLE
d) Scleroderma
Correct Answer - C
Ans. is 'c' i.e., SLE
The characterisitc histopathologic picture of the spleen in SLE
is periaterial fibrosis or anion skin lesion.
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First described by Libman and Sacks, this lesion is defined as the
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presene of 3 to as many as 20 seperated layers of the normally
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densely packed periarterial collagen of the penicillary or follicular
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arteries producing the appearance of concentric rings (onion peel).
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212. Most common pulmonary manifestation
in AIDS
a) TB
b) Pneumonia
c) Bronchiectasis
d) Mycobacterial avium intracellular
Correct Answer - B
Ans. is 'b' i.e., Pneumonia
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Respiratory complications in AIDS
Respiratory diseases in AIDS include
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A) Acute bronchitis and sinusitis
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They are caused by S. pneumoniae and H influenzae and are very
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common.
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B) Pulmonary diseases
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Pulmonary diseases are :-
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1. Pneumonia
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Most common pulmonary manifestation is pneumonia :
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Bacterial pneumonia : It is caused most commonly by S pneumoniae
and pneumococcal infection is the earliest serious infection in AIDS.
H influenzae is also a common cause.
P canna pneumonia : It is the most common cause of pneumonia in
AIDS. Risk is greater when CD4 count less than 200/ml.
2. Tuberculosis
In developing countries like India, most important pathogen is M
tuberculosis. Other common pathogen causing TB is MAC (atypical
mycobacteria).
3. Other pulmonary diseases
These are fungal infections (cryptococcus, histoplasma, aspergillus),
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neopasms (Kaposi sarcoma, lymphoma) and idiopathic interstitial
pneumonia.
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213. Chronic hemodialysis in ESRD patient is
done
a) Once per week
b) Twice per week
c) Thrice per week
d) Daily
Correct Answer - C
Ans. is 'c' i.e., Thrice per week
om
For the majority of patients with ESRD, between 9 and 12 h of
dialysis are required each week, usually divided into three equal
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sessions.
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Current targets of hemodialvsis
an
Urea reduction ratio (the fractional reduction in blood urea nitrogen
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per hemodialysis session) of > 65-70%.
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Body water-indexed clearance x time product (KT/V) above 1.2 or
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1.05.
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214. Interstitial nephritis is common with
a) NSAID
b) Black water fever
c) Rhabdomyolysis
d) Tumor lysis syndrome
Correct Answer - A
Ans. is 'a' i.e., NSAID
DRUGS CAUSING INTERSTITIAL NEPHRITIS
Antibiotics Diuretics AnticonvulsantsMiscellaneous
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β Lactams Thiazide Phenytoin Captopril
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H2 receptor
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Sulfonamides Furosemide Phenobarbitone
blockers
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Quinolones TriamtereneCarbamazepine Omeprazole
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Vancomycin NSAIDS Valproic acid Mesalazine
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Erythromycin Indinavir
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Minocycline Allopurinol
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Rifampicin
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Ethambutol
Acyclovir
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215. Best test for lung fibrosis
a) Chest x-ray
b) MRI
c) HRCT
d) Biopsy
Correct Answer - C
Ans. is 'c' i.e., HRCT
Lung fibrosis is a diffuse parenchymal lung disease.
Idiopathic pulmonary fibrosis is the most common form of idiopathic
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interstitial pneumonia.
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We have already discussed that best investigation for interstitial lung
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disease is HRCT
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Estimated relative frequency of the interstitial lung disease
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Relative frequency,
Diagnosis
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%
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Idiopathic interstitial
40
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pneumonias
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Idiopathic pulmonary fibrosis 55
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Nonspecific interstitial
25
pneumonia
Respiratory bronchiolitis-ILD
15
and
Cryptogenic organizing
3
pneumonia
Acute interstitial pneumonia <1
Occupational and environmental 26
Sarcoidosis 10
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Sarcoidosis 10
Connective tissue diseases 9
Drug and radiation 1
Pulmonary hemorrhage
<1
syndromes
Other 13
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216. Which of the following is a
Channelopathy
a) Ataxia Telangiectasia
b) Frederich Ataxia
c) Spinocerebellar ataxia
d) Anderson Tawil Syndrome
Correct Answer - D
Ans. is 'd' i.e., Anderson Tawil Syndrome
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Anderson syndrome (Anderson-Tawi syndrome) is a potassium
channel channelopathy.
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217. Good syndrome is
a) Thymoma with immunodeficiency
b) Thymoma with M. Gravis
c) Thymoma with serum sickness
d) Thymoma with pure red cell aplasia
Correct Answer - A
Ans. is 'a' i.e., Thymoma with immunodeficiency
Good's syndrome (thymoma with immunodeficiency) is a rare cause
of combined B and T cell immunodeficiency in adults.
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Clinical features of Good's syndrome are :-
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Increased susceptibility to bacterial infections with encapsulated
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organisms and opportunistic viral and fungal infection.
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The most consistent immunological abnormalities are :-
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Hypogammaglobulinaemia and
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Reduced or absent B cells
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Treatment
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Resection of the thymoma and immunoglobulin replacement to
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maintain adequate through IgG values
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218. Patient diagnosed with HIV and
Tuberculosis. How to start ATT and c-
A.R.T
a) Start ATT first
b) Start cART first
c) Start both simultaneously
d) Start cART only
Correct Answer - A
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Ans. is 'a' i.e., Start ATT first
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In a case when HIV and TB are diagnosed together ATT should be
started first.
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ATT started first, because of IRIS (Immune Reconstitution
an
Inflammatory syndrome).
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If ART started first, it may improve CD4 cells at first, but later a
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previously acquired infection (TB, Herpes), responds with an
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overshelming inflammatory response that paradoxically makes the
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symptom of infection worse.
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Therefore, starting of ATT-2 weeks before ART, have shown to
decrease the incidence of IRIS.
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219. Most common cause of lung abscess
a) Staph aureus
b) Oral anaerobes
c) Klebsiella
d) Tuberculosis
Correct Answer - B
Ans. is 'b' i.e., Oral Anaerobes
Most nonspecific lung abscesses are presumed to be due to
anaerobic bacteria.
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220. Normal CRP with elevated ESR seen in
a) RA
b) SLE
c) Scleroderma
d) Polymyalgia rheumatica
Correct Answer - B
Ans. is 'b' i.e., SLE
Both ESR and CRP are markers of inflammation
Erythrocyte sedimentation rate or ESR is used to separate
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inflammation from non-inflammation.
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Another sign of inflammation is the rise in blood level of number of
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proteins called as acute phase proteins.
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One of the proteins is C-reactive protein (CRP).
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Like ESR and other acute phase proteins, CRP also goes up in
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inflammation.
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In systemic lupus however the level does not rise unless there is
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infection associated.
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The normal response to active inflammatory disease is an increase
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in plasma CRP concentration. o For reasons that remain unclear tht
response is either significantly lower in magnitude or entirely absent
in a few inflammatory conditions.
This has proven diagnostically useful because there are very few
inflammatory conditions in which ESR is significantly raised
(reflecting an inflammatory process) but plasma CRP is only slightly
raised or even normal.
One ofthese conditions is systemic lupus erythematosus (SLE or
lupus), a relatively common chronic autoimmune disease that
predominantly affects women of child-bearing age.
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When this inflammation occurs in the lupus patient it is accompanied
as expected by a marked increase in ESR. However in contrst to
most other inflammatory condition, the plasma CRP remains
resolutely normal. The combination of raised ESR and normal CRP
is a useful diagnostic feature of SLE.
Other disorders where CRP is not increased
Osteoarthritis, leukemia, anemia
Polycythemia, viral infection
Ulcerative colitis, pregnancy, estrogen
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221. Restrictive and constrictive pericarditis
occurs together in
a) Radiation
b) Adriamycin
c) Amyloidosis
d) Post cardiotomy syndrome
Correct Answer - A
Ans. is 'a' i.e., Radiation
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Progressive fibrosis can cause restrictive myocardial disease without
dilation. Thoracic radiation, common for breast and lung cancer or
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mediastinal lymphoma, can produce early or late restrictive
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cardiomyopathy. Patients with radiation cardiomyopathy may
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present with a possible diagnosis of contrictive pericarditis, as the
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two conditions often coexist.
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222. All form boundaries of triangle of
auscultation except
a) Trapezius
b) Latissmusdorsi
c) Scapula
d) Rhomboid major
Correct Answer - D
Ans. is 'd' i.e., Rhomboid major
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Triangle of auscultation has the following boundaries
Superiorly and medially, by the inferior portion of the Trapezius.
r.c
Inferiorly, by the Latissimus Dorsi.
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Laterally, by the medial border of the scapula.
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The superficial floor of the triangle is formed by the Serratus anterior
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and the lateral portion of the erector spinae muscles.
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Deep to these muscles are the osseous portions of the 6" and 7th
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ribs and the internal and external intercostal muscles.
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Typically, the Triangle of Auscultation is covered by the Scapula.
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To better expose the triangle and listen to respiratory sounds with a
stethoscope, patients are asked to fold their arms across their chest,
medially rotating the scapulae, while bending forward at the trunk,
somewhat resembling a fetal position.
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223. Rytand's murmur is seen in
a) A-V Block
b) Mitral stenosis
c) Aortic stenosis
d) Aortic regurgitation
Correct Answer - A
Ans. is 'a' i. e.,A-V Block
Rytand Murmur
Rytan 's murmur is mid-diastolic (or late-diastolic) murmur that is
om
heard in patients with complete artioventricular heart block.
r.c
Rytand's murmur is best heard at the apex and may be
ke
confused with mitral stenosis.
an
The slow heart rate, variable duration of the murmur changing
tR
intensity of the S I and lack of opening snap are helpful
irs
Also know
.F
Carey Coombs murmur → Rheumatic fever
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Austin Flint murmur → Aortic regurgitation
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Graham-Steel murmur → Pulmonary regurgitation
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Rytands murmur → Complete heart block
Docks murmur → Left Anterior Descending
(LAD) artery stenosis
Mill wheel murmur → Due to air emboli (air in PV
cavity)
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224. Not associated with diabetes mellitus
a) Cushing syndrome
b) Acromegaly
c) Hypothyroidism
d) Pheochromocytoma
Correct Answer - C
Ans. is 'c' i.e., Hypothyroidism om
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an
tR
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225. Fever increase water losses by mUday
per degree Celsius
a) 100
b) 200
c) 400
d) 800
Correct Answer - B
Ans. is `b' i.e., 200 ml/day per degree Celsius
om
r.c
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an
tR
irs
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226. Most common cause of hypernatremia
a) Adipsic diabetes insipidus
b) Carcinoid syndrome
c) Renal losses
d) Sweating
Correct Answer - C
Ans. is `c' i.e., Renal losses
Major causes of hypernatremia
Unreplaced water loss (which requires an impairment in either
om
thirst or access to water)
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Insensible and sweat losses
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Gastrointestinal losses
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Central or nephrogenic diabetes insipidus o Osmotic diuresis
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Glucose in uncontrolled diabetes mellitus
irs
Urea in high-protein tube feedings
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Mannitol
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Hypothalamic lesions impairing thirst or osmoreceptor function
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Primary hypodipsia
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Reset osmostat in mineralocorticoid excess
Water loss into cells
Severe exercise or seizures
Sodioutn overload
Intake or administration of hypertonic sodium solutions
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227. Rarest type of Von Willebrand disease :
a) vWD type 1
b) vWD type 2A
c) vWD type 2N
d) vWD type 3
Correct Answer - D
Ans. is 'd' i.e., vWD type 3
ConditionDefect
Mild to moderate quantitative
om
vWD
deficiency of vWF (ie, about 20-
type 1
r.c
25% of normal levels).
ke
The most common qualitative
an
vWD abnormality of vWF, is associated
tR
type 2A withselective loss of large and
irs
medium-sized multimers
.F
Loss of only large multimers as
w
vWD mutant vWF spontaneously binds
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type 2B to Gplb in the absence of
subendothelial contact
Characterized by a defect residing
vWD within the patient 's plasma vWF
type 2N that interferes with its ability to
bind FVIII
Involves qualitative variants with
decreased platelet-dependent
vWD
function not resulting from
type 2M
absence of highmolecular weight
multimers
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multimers
A severe, quantitative deficiency
associated with very little or no
vWD
detectable plasma or platelet
type 3
vWF, have a profound bleeding
disorder
om
r.c
ke
an
tR
irs
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228. A patient has ecchymosis and petechiae
all over the body with no hepato-
splenomegaly. All are true except
a) Increased megakaryocytes in bone narrow
b) Bleeding into the joints
c) Decreased platelet in blood
d) Disease resolves itself in 80% of Patients in 2-6
Correct Answer - B
om
Ans. is 'b' i.e., Bleeding into the joints
r.c
Features of Acute and Chronic Idiopathic Thrombocytopenic
Purpura
ke
Feature Acute ITP Chronic ITP
an
Peak age of Children 2-6 Adults, 20-40
tR
incidence year year
irs
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3:1 female to
Sex predilection None
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male
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Antecedent Common 1-2
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Unusual
infection week
Onset of
Before Abrupt Insidious
bleeding
Hemorrhagic Present in
Usually absent
bullae in mouth severe cases
Platelet count < 20000/4 3000-80000/8L
Eosinophilia and
Common Rare
yphocytosis
Spontaneous Occurs in Months or years
remission 80% cases Uncommon
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remission 80% cases Uncommon
om
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ke
an
tR
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229. All of the following are true about
Rheumatoid arthritis, except
a) PIP and DIP joints involved equally
b) Pathology limited to articular cartilage
c) Women are affected 3 times more commonly than men
d) 20% of patients have extra articular manifestations
Correct Answer - D
Ans. is 'd' i.e., 20% of patients have extra articular manifestations
om
Association of Rheumatoid Arthritis with HLA DR-4
The class II major histocompatibility complex allele HLA-DR4 and
r.c
related alleles are known to be a major genetic risk factor for
ke
Rheumatoid arthritis.
an
Rheumatoid Arthritis is strongly associated with HLA DR4
tR
The genetic risk for Rheumatoid arthritis is associated with allelic
irs
variation in the HLA-DRBI "gene i.e. DRB1 0401, 04, 05".
.F
Some of the HLA DRB1 alleles bestow a high risk of disease
w
w
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Clinical features:
It occurs between the age of 20 to 50 years.
Women are affected about 3 times more commonly than men.
Following presentations are common:
a) An acute, symmetrical polyarthritis:
Pain and stiffness in multiple joints (at least four)
Symptoms of articular inflammation.
Common in-
MP joints of hand
PIP joints of fingers
Wrists, knees, elbows, ankles
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om
r.c
ke
an
tR
irs
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230. Development of Lymphoma in Sjogren's
syndrome is suggested by all of the
following except
a) Persistent parotid gland enlargement
b) Cyoglobilinemia
c) Leukopenia
d) High C4 compement levels
Correct Answer - D
om
Ans. is 'd' i.e., High C4 complement levels
r.c
Lymphoa is a well-known complication of Sjogren's syndrome Most
lymphomas are extra-nodal, low grade marginal B cell lymphomas.
ke
Development of Lymphoma in Sjogren's syndrome is suggested by
an
low C4 complement levels.
tR
Lymphoma in Sjogren's syndrome
irs
The development ofLymphomas in patients with Sjogren
.F
syndrome is suggested by : -
w
w
Persistent parotid gland enlargement
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Purpura
Leukopenia
Cryoglobulinemia
Low C4 complement levels
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231. Hemodialysis can be performed for long
periods from the same site due to
a) Arteriovenous fistula reduces bacterial contamination of site
b) Arteriovenous fistula results in arterialization of vein
c) Arteriovenous fistula reduces chances of graft failure
d) Aretiovenous fistula facilitates small bore needles for high flow
rates
Correct Answer - B
om
Ans. is 'b' i.e., Arteriovenous fistula results in arterialization of vein
The tstu/a graft, or catheter hemodialvsis is often referred to as
r.c
a dialysis access.
ke
A native fistula created by the anastomosis of an artery to a vein
an
(e.g. the Bresica-Cimino fistula, in which the cephalic vein is
tR
anastomosed end-to-side to the radial artery) results in
irs
arterialization of the vein.
.F
This facilitates its subsequent use in the placement of large needles
w
(typically 15 Gauge) to access the circulation.
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Fistulas have the highest long-term patency rate of all dialysis
access options.
The most important complication of arteriovenous grafts is
thrombosis of the graft and graft failure, due principally to intimal
hyperplasia at the anastomosis between the graft and recipient vein.
Many patients undergo placement of an arteriovenous graft (i.e., the
interposition of prosthetic material, usually polytetrafluoroethylene,
between an artery and a vein) or a tunneled dialysis catheter.
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232. In AIDS patient presenting with fever,
cough a diagnosis of pneumocystin
pneumonia is best established by
a) CT scan chest
b) Bronchoalveolar lavage
c) Staining of intra-nuclear inclusion with silver staining
d) Aspiration and culture
Correct Answer - B
om
Ans. is 'b' i.e., Bronchoalveolar lavage
r.c
Diagnosis of PCP requires
Demonstration of the organism in samples obtained from induced
ke
sputum.
an
Bronchoalveolar lavage, transbronchial biopsy, or open-lung biopsy.
tR
If the histological examination fails :?
irs
u PCR is required to make the diagnosis
.F
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233. The most common neurological disorder
seen in CRF patients
a) Dementia
b) Peripheral neuropathy
c) Bakes intestinal dilator.
d) Restless leg syndrome
Correct Answer - B
Ans. is 'b' i.e., Peripheral neuropathy
om
Peripheral neuropathy is the most common neurological problem in
CRF, which may be?
r.c
i) Uremic peripheral neuropathy (due to uremia).
ke
ii) More often a presenting feature of the cause of CRF Diabetic
an
neuropathy (DM is the most common cause of CRF).
tR
irs
.F
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234. ECG image,U wave seen, patient is on
furosemide & beta blocker. Diagnosis
a) Hypocalcemia
b) Hypokalemia
c) Hyperkalemia
d) Hypercalcemia
Correct Answer - B
Ans. is 'b' i.e., Hypokalemia
E.C.G. manifestations of electrolyte disorders
om
Hvperkalemia
r.c
A tall peaked and symmetrical T-waves is the first change seen on
ke
ECG in patients with hyperkalemia. o RR interval lengthens and
an
QRS duration increases.
tR
Flattening or disappearance of P wave.
irs
ST elevation.
.F
Widening of the QRS complexes due to a severe conduction delay
w
and may become 'sine wave'.
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The progresion and the severity of the E. C. G change do not
correlate well with the serum potassiam concentration.
Hvpokalemia
Similar to hyperkalemia, hypokalemia produce changes on the E. C.
G which are not necessary related to serum potassiam level.
Depression of the ST segment
Decrease in amplitude of T waves
Increase in amplitude of U waves
U and T wave merge in some cases to form a T-U wave which may
be misdiagnosed as prolonged QT interval.
P wave can become larger and wider and PR interval prolong
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slightly.
QRS duration may increase when hypokalemia becomes more
severe.
Hvpocalcemia
Prolongation of the QT interval
Due to prolongation of the phase 2 of the ventricular action potential
and lengthening of the ST segment while the T wave (which
correlate with time for repolarisation remains unaltered).
Hvpercalcemia
Shortening of the QT interval
(Primarily due to a decrease in phase 2 of the ventricular action
potential and resultant decrease in ST segment duration).
Iltpothermia
Causes slow impulse conduction through all cardial tissues resulting
in :?
Prolongation of all the ECG intervals
RR
PR
om
QRS'
r.c
QT
ke
There is also "elevation of the J point" (Only if the ST segment is
an
unaltered producing characteristics T or osborne wave.)
tR
irs
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235. In Zollinger Ellison syndrome what is
raised?
a) Insulin
b) VIP
c) Gastrin
d) Glucagon
Correct Answer - C
Ans. is 'c' i.e., Gastrin
om
Zollinger Ellison syndrome ?
Severe peptic ulcer disease secondary to gastric acid
r.c
hypersecretion due to unregulated gastrin release from a non 13 cell
ke
endocrine tumour (gastrinoma), defines the components of Zollinger
an
Ellison syndrome.
tR
Pathophysiology of Zollinger Ellison syndrome
irs
The driving force responsible for clinical manifestations of Zollinger
.F
Ellison syndrome is hypergastrinemia originating from Gastrinoma
w
(autonomus neoplasm, non [3 cell neoplasm)
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w
Gastrinoma
Hyper gastrinemia
Hyper acidemia
Peptic ulcer, erosive esophagitis and diarrhoea
Other important characteristic of Gastrinoma
o Over 80% of these tumours are seen in Gastrinoma triangle°
(triangle formed between duodenum and pancreas) most of them
are seen in the head of pancreas.
o About 2/3'of these tumours are malignant°.
o About one half of these tumours are multiple°.
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o About one fourth of the patients have multiple endocrine neoplasia
(MEN I) syndrome with tumours of parathyroid, pituitary and
pancreatic islets being present.
Remember :
Most common site of gastrinoma's is →
Duodenum (50-70%), (Pancreas 20-40%)
Most common hormone to be secreted → ACTH
besides gastrin is
Most common site of peptic ulcers produced is → ls' part of
Duodenum.
Most valuable provocative test in → The Secretin
injection tests. identifying patients with ZES is
Basal acid output is greater than 60% of out pu → BAO> MAO
induced by maximal stimulation
The term pancreatic endocrine tumour is misnomer because these
tumours can occur either almost exclusively in the pancreas or at
both pancreatic and extrapancreatic sites
om
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an
tR
irs
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236. Menke's disease" is a disease of
a) Impaired zinc transport
b) Impaired copper transport
c) Impaired magnesium transport
d) Impaired molybdenum transport
Correct Answer - B
Ans. is 'b' i.e., Impaired copper transport
Menke's disease is caused due to defect in the copper
transport.
om
There is defect in the transport of copper present in the intestinal
r.c
mucosa to the blood stream.
ke
The mucosal lining of intestine contains high level of copper bound
an
to metallothionein protein.
tR
Rather than being transporated to bloodstream, the copper
irs
remained in the mucosa and was lost when intestinal cells were
.F
naturally soughed off.
w
Menkes disease is caused due to defect in the "MNK" gene.
w
The protein normally function by moving copper from the intestinal
w
mucosal cells into the blood stream, where it is hound by proteins
such as albumin and transported to organs and tissues.
Serum copper is critical for the functioning of several enzymes
Lysyl oxidase → It is important for the cross linking of collagen and
elastin such that deficiencies lead to problems in connective tissues
such as bones
Cytochrome oxidase → Involved in temperature maintenance
Tyrosinase → Necessary for pigmentation
Clinical features of menkes disease
Growth retardation
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Coarse hair, brittle and ivory white (result of depigmentations). The
hair fibres are twiisted and broken helically (kinky hair).
Seizures
Cerebral and cerebellar degeneration (postmortem analysis)
Hypothermia
Thrombosis
Poor bone development
Increased tendency towards aneurysms
om
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an
tR
irs
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237. Anosmia is early clinical feature of
a) Alzheimer
b) Parkinson's disease
c) Huntington's chorea
d) All of the above
Correct Answer - D
Ans. is 'd' i.e., All of the above
Main causes of anosmia
Main causes of anosmia
om
Nasal.
r.c
Smoking.
ke
Chronic rhinitis (allergic, atrophic, cocaine, infectious-Herpes,
an
influenza).
tR
Overuse of nasal vasoconstrictors.
irs
Olfactory epithelium.
.F
Head injury with tearing of olfactory, filaments
w
Cranial surgery.
w
Subarachnoid hemorrhage, meningitis.
w
Toxic (organic solvents, certain antibiotics-am inoglycosides,
tetracyclines, corticosteroids, methotrexate,
opiates, 1-dopa).
Metabolic (thiamine deficiency, adrenal and thyroid deficiency,
cirrhosis, renal failure, menses).
Wegener granulomatosis.
Compressive and infiltrative lesions (craniopharyngioma,
meningioma, aneurysm, meningoencephalocele).
Degenerative disease (Parkinson, Alzheimer, Huntington
Temporal lobe epilepsy.
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Malingering and hysteria
om
r.c
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an
tR
irs
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238. DOC of GTCS in pregnancy
a) Lamotrigine
b) CBZ
c) Levetiracetam
d) Valproate
Correct Answer - A
Ans. is 'a' i.e., Lamotrigine
Lamotrigine is often better tolerated and is less teratogenic than
valproate.
om
Lamotrigine has been increasingly prescribed in pregnancy over
r.c
older antiepileptic drugs such as carbamazepine and sodium
ke
valproate.
an
tR
irs
.F
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239. A Patient with history of shortness of
breath has Decreased FEV1/FVC Ratio,
Normal DLCO. A 200 ml increase in
baseline FEVI is observed 15 minutes
after administration of bronchodilators.
The likely diagnosis is
a) Asthma
b) Chronic Bronchitis
c) Emphysema
d) Interstitial Lung Disease
om
r.c
ke
an
Correct Answer - A
Ans. is 'a' i.e., Asthma
tR
irs
Diagnosis of Asthma require
.F
w
Demonstration of Airways obstruction
w
Decrease in the ratio of FEVI/FVC
w
Demonstration of acute reversibility of airflow Administer 2-4 puffs of
quick acting bronchodilator e.g., albuterol and repreat spirometry 10-
15 min An increase in FEV1 of 12% or more accompanied by an
absolute increase in FEV lof at least 20 ml
A bronchoprovocator (Methacholine) is administered
hyperresponsiveness of the airway is demonstrated by reduction of
FEV1 to 20%
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240. Pseudo-hemoptysis is seen mostly with
a) Streptococcus
b) E. coli
c) Serratia marcescens
d) R.S.V
Correct Answer - C
Ans. is 'C' i.e., Serratia marcesens
Pseudo-hemoptysis is expectoration of blood other than the
respiratory tract i.e. GIT or blood draining from the larynx.
om
Serratia marcescens is a cause of pseudohemoptysis.
r.c
ke
an
tR
irs
.F
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241. Finger is glove sign is seen in
a) Pulmonary alveolar Proteinosis
b) Pneumocystis Carinii
c) Tuberculosis
d) Bronchocele
Correct Answer - D
Ans. is 'd' i.e., Bronchocele
Rabbit ear appearance
Mickey mouse appearance
om
Toothpaste shaped opacities
r.c
Y-shaped opacities
ke
V-shaped opacities
an
Aetiology
tR
Obstructive
irs
In bronchial obstruction, the portion of the bronchus distal to the
.F
obstruction is dilated with the presence of mucous secretions
w
(mucus plugging). Causes of bronchial obstruction include :
w
Bronchial hamartoma
w
Bronchial lipoma
Bronchial carcinoid
Bronchogenic carcinoma
Congenital bronchial atresia (rarely)
Non obstructive
Causes include .-
Asthma
Allergic bronchopulmonary aspergillosis (ABPA)
Cystic fibrosis
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242. Which of the following disorders is least
likely associated with progression to
lymphoma
a) Sjogren's syndrome
b) Araxia telangiectasia
c) Severe combined immunodeficiency
d) Lynch II syndrome
Correct Answer - C
om
Ans. is 'c' i.e., Severe combined immunodeficiency
r.c
Choice Cancers associated
ke
NHL mainly MALT-oma
Sjogren
an
involving salivary
syndrome
glands>stomach
tR
irs
Elevated incidence of
.F
cancers, approximately
w
100-fold in comparison
w
to the general
w
population. In children,
more than 85% of
Ataxia
neoplasm cases are
telengectasia
acute lymphocytic
leukemia or lymphoma.
In adults with ataxia-
telangiectaisa, solid
tumors are more
frequent
Gastrointestinal cancer
associated with
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associated with
endometrial/ovarian
Lynch-II
carcinoma. Early onset
syndrome
brain tumor and
lymphoma also seen in
children
om
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an
tR
irs
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243. Woman of 30-years with Raynaud's
phenomenon, polyarthritis, dysphagia of
5-years and mild Sclerodactyl, blood
showing Anti-centromere antibody
positive, the likely cause is
a) CREST
b) Mixed connective tissue disorder
c) SLE
d) Rheumatoid arthritis
om
r.c
Correct Answer - A
ke
Ans. is 'a' i.e., CREST
an
The disease is divided into two categories :?
tR
1) Diffuse scleroderma
irs
. There is wide-spread involvement of skin at onset. There is
.F
rapid progression with early visceral involvement. It is associated
w
with Anti-DNA topoisomerase (anti-Scl 70) antibodies.
w
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2) Limited (localized) scleroderma (morphea)
. Skin involvement is confined to finges, forearm and face. It
is associated with slow progression and late visceral involvement.
Some patients develop CREST syndrome (Cacinosis, Raynaud's
phenomenon, esophageal dysmotility,
sclerodactyly, and telangiactasia). It is associated with
anticentromere antibodies.
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244. Most common mechanism of arrhythmia
a) Re-entry
b) Early after depolarization
c) Late after depolarization
d) Automaticity
Correct Answer - A
Ans. is 'a' i.e., Re-entry
The most common arrhythmia mechanism is re-entry.
Fundamentally, re-entry is defined as the circulation of an activation
om
wave around an inexcitable obstacle.
r.c
Re-entry appears to be the basis for most abnormal sustained Supra
ke
Ventricular Tachycardias (SVTs) and Ventricular tachycardia.
an
Examples of re-entry are:-
tR
Polymorphic Ventricular tachycardia in patients with a genetically
irs
determined ion channel abnormality such as the Brugada syndrome,
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catecholaminergic polymorphic Ventricular tachycardia.
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245. -30 to -90 degree axis deviation indicates
a) Left Axis Deviation
b) Right Axis Deviation
c) Extrene Right Axis Deviation
d) Normal Cardiac Axis
Correct Answer - A
Ans. is 'a' i.e., Left Axis Deviation
Cardiac axis
The electrical signal recorded on the electrocardiogram (ECG)
om
contains information relative to direction and magnitude of the
r.c
various complexes.
ke
The average direction of any of the complexes can be determined.
an
Normal Cardiac Axis
tR
The normal QRS electrical axis, as established in the frontal plane,
irs
is between -30 and 90° (directed downward or inferior and to the left)
.F
in adults.
w
Left Axis Deviation
w
An axis between -30° and -90° (directed superior and to the left) is
w
termed left axis deviation. Right Axis Deviation
If the axis is between 90° and 180° (directed inferior and to the
right), then right axis deviation is present. Extreme Right Axis
Deviation
An axis between -90' and -180° (directed superior and to the right) is
referred to as extreme right or left axis. Indeterminate
If the QRS is equiphasic in all leads with no dominant QRS
deflection, it is indeterminate axis.
Causes of axis deviation include
Right axis Left axis deviation
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deviation
Normal variation
Normal variation (physiologic,
(vertical heart with
often with age)
an axis of 90°)
Mechanical shifts, Mechanical shifts, such as
such as expiration, high diaphragm
inspiration and (pregnancy, ascites, abdominal
emphysema tumor)
Right ventricular
Left ventricular hypertrophy
hypertrophy
Left posterior
Left bundle branch block
fascicular block
Dextrocardia Left anterior fascicular block
Congenital heart disease (prim
Ventricular ectopic
um atrial septal Hefect,
rhythms
endocardial cushion defect)
Ventricular ectopic
Emphysema
om
rhythms
Pre-excitation
r.c
syndrome (Wolff- Hyperkalemia
ke
Parkinson-White
an
Lateral wall
tR
myocardial Ventricular ectopic rhythms
irs
infarction
.F
Secundum atrial Pre-excitation syndromes
w
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septal defect (Wolff-Parkinson-White
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Inferior wall myocardial
infarction
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246. Which of the following is not a sign of
upper motor neuron paralysis
a) Babinski sign
b) Spastic paralysis
c) Denervation potential in EMG
d) Exaggeration of tendon reflexes
Correct Answer - C
Ans. is 'c' i.e., Denervation potential in EMG
om
Difference between upper and lower motor neuron paralysis
r.c
Upper motor
ke
Lower motor neuron
neuron
an
paralysis
paralysis
tR
Muscles
irs
affected in
.F
Individual muscles may
groups never
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be affected
individual
w
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muscles
o Atrophy
Atrophy pronounced up
slight and due
to 70% of the total bulk
to disuse
Spasticity with
Flaccidity and hypotoniaQ
hyperactivity of
of affected muscles with
the tendon
loss of tendon reflexes
reflexes and
Extensor
Plantar reflex if present is
plantar reflex
of normal flexor type
(Babinski sign)
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(Babinski sign)
Fascicular
Fasciculation may be
twitches
present
absent
Normal nerve Abnormal nerve
conduction conduction studies;
studies; no denervation potential
denervation (fibrillations,
potentials in fasciculations positive
E.M.G. sharp waves) in EMG
om
r.c
ke
an
tR
irs
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247. Most common oral infection in diabetes
mellitus
a) Candida
b) Aspergillus
c) Streptococcus
d) Stphylococcus
Correct Answer - A
Ans. is 'a' i.e., Candida
om
Individuals with DM have a greater frequency and severity of the
infection. The reasons for this include incompletely defined
r.c
abnormalities in cell-mediated immunity and phagocyte function
ke
associated with hyperglycemia, as well as diminished
an
vascularization. Hyperglycemia aids the colonization and growth of a
tR
variety of organisms (candida and other fungal species).
irs
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248. All are features of hypernatremia except
a) Convulsions
b) Elevated intracranial tension
c) Periodic paralysis
d) Doughy skin
Correct Answer - C
Ans. is 'c' i.e., Periodic paralysis
Periodic paralysis, is seen in hyponatermia
Clinical features of Hypernatremia :?
om
Most patients with hypernatremia are dehydrated and have the
r.c
typical signs and symptoms of dehydration.
ke
Hypernatremia even without dehydration causes central nervous
an
system symptoms that tend to parallel the degree of sodium
tR
elevation and the acuity of the increase.
irs
Patients are irritable, restless weak and lethargic
.F
Some have high pitched cry and hyperpnea.
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Alert patient are very thirsty.
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Hypernatremia causes fever although many patients have
w
underlying process that contributes to the fever
Except for dehydration, there is no clear direct effect of
hypernatremia on other organs or tissues except the brain.
Complication of hypernatremia :?
Brain hemorrhage is the most devastating consequence of
hypernatremia. As the extracellular osmolarity increases water
moves out of brain cells, resulting in decrease in brain volume. This
can result in tearing of intra cerebral veins and bridging vessels as
the brain moves away from the skull and the meninges. Patient may
have subarachnoid, subdural and parenchymal hemorrhage.
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Seizure and coma are possible sequale of the hemorrhage even
though seizures are more common during t/t.
Thrombotic complications are common in severe hypernatremic
dehydration and include stroke, dural sinus thrombosis, peripheral
thrombosis and renal vein thrombosis.
The intracranial tension can be increased due to hemorrhage
om
r.c
ke
an
tR
irs
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249. Doughy skin and woody induration of
tongue is seen in
a) Hypernatremia
b) Hyponatremia
c) Hypokalemia
d) Hyperkalemia
Correct Answer - A
Ans. is 'a' i.e., Hypernatremia
om
Because of intracellular water loss (hypernatremic dehydration), the
pinched abdominal skin of a hypernatremic dehydrated patient has a
r.c
"doughy" feel and there is dry woody tongue.
ke
an
tR
irs
.F
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250. Which of the following is MOST
commonly affected by Crohn's Disease
a) Cecum
b) Rectum
c) Sigmoid colon
d) Terminal Ileum
Correct Answer - D
Ans. is 'd' i.e., Terminal ileum
om
Inflammatory Bowel disease site of involvement
Ulcerative
r.c
Crohn's
cocitis
ke
Any part of the
an
Limited to the
Gout from mouth
tR
colon
to anus
irs
Involves the
.F
Most commonly entire colon
w
w
affected is small starting from the
w
intestine rectum
particularly ileum (retrograde
manner)
Rectum is most
Terminal ileitis or commonly
affected
Ileum not
involved may get
Granulomatous involvedmay get
colitis involved in some
cases
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cases
(backwash ileitis).
Rectum spared
Full thickness of
the intestine
involved but in
patchy manner
skip lesions
om
r.c
ke
an
tR
irs
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251. All of following cause intravascular
hemolysis, except
a) Mismatched blood transfusion
b) Paroxysmal cold hemoglobinuria
c) Thermal burns
d) Hereditary spherocytosis
Correct Answer - D
Ans. is 'd' i.e., Hereditary spherocytosis
om
Blood transfusion
ABO mismatched transfusion
r.c
Infected blood
ke
Thermal burns
an
Snake bites
tR
Sepsis
irs
Bacterial/parasitic infections
.F
Clostridial sepsis
w
Malaria
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Bartonellosis
Mycoplasma pneumoniae
Mechanical heart valves
Paroxysmal hemoglobinuria
PNH
PCH
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252. Blood transfusion should be completed
within hours of initiation
a) 1- 4 hours
b) 3- 6 hours
c) 4- 8 hours
d) 8- 12 hours
Correct Answer - A
Ans. is 'a' i.e., 1-4 hours
om
From starting the infusion (puncturing the blood with the infusion set)
to completion, infusion pack should take a maximum of 4 hours.
r.c
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an
tR
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253. Vitamin B level in chronic myeloid
leukemia is
a) Elevated'
b) Decreased
c) Normal
d) Markedly
Correct Answer - A
Ans. is 'a' i.e., Elevated
om
CML there will be rise in
B1, level
r.c
LDH level
ke
And decreased levels of ALP.
an
tR
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254. Which is the most common organ
involved in sarcoidosis
a) Lung
b) Liver
c) CNS
d) Eye
Correct Answer - A
Ans. is 'a' i.e., Lung
om
Following organs are commonly affected :?
r.c
1) Lung and lymph nodes (95%)
ke
2) Skin (24%-43%)
an
3) Eye (12-29%
tR
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255. Following statements about sarcoidosis
is false
a) Elevated level of angiotensin converting enzyme (ACE)
b) Bilateral parotid enlargement is the rule
c) Pleural effusion is common
d) Facial nerve palsy may be seen
Correct Answer - C
Ans. is 'c' i.e., Pleural effusion is common
om
Diffuse Effusion is an uncommon atypical manifestation in
Sarcoidosis reported in up to 5% of patients.
r.c
Parotid enlargement is a classic feature of sarcoidosis and bilateral
ke
involvement is the rule
an
Neurological disease is reported in 5-10% of patients with
tR
sarcoidosis
irs
Facial nerve palsy is the single most common neurological
.F
manifestation of sarcoidosis seen in up to 50% of patients with
w
Neurosarcoidosis.
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Angiotensin converting enzyme (ACE) levels are raised in
sarcoidosis
Lung involvement in sarcoidosis
Most common involved organ (90%).
Characterized by B/L hilar adenopathy.
Cavitations are rare
Pleural effusion are rare (1-2%)
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256. The most common cause of seizures in a
patient of AIDS is
a) Toxoplasmosis
b) Cryptococcal meningitis
c) Progressive multifocal leucoencephalopathy
d) CNS lymphoma
Correct Answer - A
Ans. is 'a' i.e., Toxoplasmosis
om
Neurological manifestations of H.I.V.
AIDS dementia complex (HIV encephalopathy) is a result of direct
r.c
effects of HIV on CNS (not an opportunistic disease). It is subcortical
ke
dementia.
an
Most common cause of seizures —> Toxoplasma
tR
Most common cause of meningitis —> Cryptococcus
irs
M.C. cause of focal neurological deficit —> Toxoplasma
.F
Toxoplasmosis is the most common CNS infection in AIDS.
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CNS lymphoma and prograssive multifocal leukoencephalopathy
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may occur.
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257. Gene responsible for resistance to
rifampicin
a) Rpo B gene
b) Kat G gene
c) Rpm B gene
d) Emb B gene
Correct Answer - A
Ans. is 'a' i.e., Rpo B gene
om
Gene
ATT Drug responsible for
r.c
drug resistance
ke
inhA and Kat G
an
INH
gene
tR
Ethambutol emb B gene
irs
Rifampicin rpoB gene
.F
PyrazinamidepncA gene
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258. Lepsroy causes ?
a) Membranous GN
b) Focal glomerulosclerosis
c) Membranoproliferative GN
d) Mesangioproliferative GN
Correct Answer - A
Ans. is 'a' i.e., Membranous GN
Infectious diseases causing membranous GN
• Hepatitis B
om
• Hydatid disease •Leprosy
and C
r.c
• Filariasis • Syphilis •Enterococcal
ke
• Malaria • Endocarditis •Schistosomiasis
an
tR
irs
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259. Nephrotic syndrome is the hall mark of
the following primary kidney diseases
except
a) Membranous Glomerulopathy
b) IgA nephropathy
c) Minimal change disease
d) Focal segmental Glomerulosclerosis
Correct Answer - B
om
Ans. is 'b' i.e., IgA nephropathy
r.c
Most common presentation of IgA nephropathy is grass hematuria.
It is the most common form of glomerulonephritis worldwide
ke
Causes of Nephrotic syndrome
an
Minimal change disease
tR
Focal segmental glomerulosclerosis o Membranous
irs
glomerulonephritis o Diabetes nephropathy
.F
AL and AA amyloidosis
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Light chain deposition disease
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Fibrillary immunotactoid disease
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260. Bechterews disease also known as
a) Rheumatoid arthritis
b) Ankylosing spondylitis
c) Osteoarthritis
d) Syphilitic arthritis
Correct Answer - B
Ans. is 'b' i.e., Ankylosing spondylitis
ANKYLOSING SPONDYLITIS (MARIE - STRUMPELL DISEASE)
Ankylosing spondylitis is a chronic progressive inflammatory disease
om
of the sacroiliac joints and the axial skeleton.
r.c
Prototype of seronegative (absence of rheumatoid factor)
ke
spondyloarthropathies.
an
Inflammatory disorder of unknown cause.
tR
Usually begins in the second or third decade with a median age of
irs
23, in 5% symptoms begin after 40. o Male to female ratio is 2-3 : 1
.F
Strong correlation with HLA-B27
w
90-95% of cases are positive for HLA B27.
w
Joints involved in ankvlosing spondylitis
w
Ankylosing spondylitis primarily affects axial skeleton.
The disease usually begins in the sacro-iliac joints and usually
extends upwards to involve the lumbar, thoracic, and often cervical
spine.
In the worst cases the hips or shoulders are also affected. Hip joint
is the most commonly affected peripheral joint. o Rarely knee
(Ebenzar 4thie 593) and ankle (Apley's 9th/e 67) are also involved.
Clinical features
Low back pain of insidious onset
Duration usually less than 3 months
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Significant morning stiffness and improvement with exercise o
Limited chest expansion
Diffuse tenderness over the spine and sacroiliac joints
Loss of lumbar lordosis, increased thoracic kyphosis
Decreased spinal movements (especially extension) in all directions.
Radiological features of ankvlosing spondvlitis
Radiographic evidence of sacroiliac joint is the most consistent
finding in ankylosing spondylitis and is crucial for diagnosis. The
findings are :?
Sclerosis of the articulating surfaces of SI joints
Widening of the sacroiliac joint space
Bony ankylosis of the sacroiliac joints
Calcification of the sacroiliac ligament and sacro-tuberous ligaments
Evidence of enthesopathy - calcification at the attachment of the
muscles, tendons and ligaments, particularly around the pelvis and
around the heel.
o X-ray of lumbar spine may show :-
Squaring of vertebrae : The normal anterior concavity of the
om
vertebral body is lost because of calcification of the anterior
r.c
longitudinal ligament.
ke
Loss of the lumbar lordosis
an
Bridging `osteophytes' (syndesmophytes)
tR
Bamboo spine appearance
irs
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261. Comprehension in intact with aphasia in
a) Wernicke's
b) Broca's
c) Global aphasia
d) Transcortical sensory
Correct Answer - B
Ans. is 'b' i.e., Broca's om
r.c
ke
an
tR
irs
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262. Following statements about sarcoidosis
is false
a) The first manifestation of the disease is an accumulation of
mononuclear inflammatory cells, mostly CD8 + THI
lymphocytes in affected organs
b) The Heerfordt-Waldenstrom syndrome describes individuals
with fever, parotid enlargement, anterior uveitis, and facial
nerve palsy
c) Elevated level of angiotensin converting enzyme (ACE) are a
feature
d) Bilateral parotid involment is the rule
om
r.c
ke
Correct Answer - A
an
Ans. is 'a' i.e., The first manifestation of the disease is an
tR
accumulation of mononuclear inflammatory cells, mostly CD8 + THI
irs
lymphocytes in affected organs
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263. The treatment options for patients with
RRMS (relapsing-remitting multiple
sclerosis) are all except
a) IFN - 1 b
b) IFN - 1 a
c) Glatiramer acetate
d) TNF - a
Correct Answer - D
om
Ans. is 'd' i.e., TNF - a
r.c
Treatment of RRMS is divided into:-
i) In acute attack: Corticosteroids are given
ke
ii) Prophylaxis of acute attack (relapse) during remission: Disease
an
modifying agents for MS are used to reduce the biological activity.
tR
Treatment is started by IFN-P la or IFN-[31b or Glatiramer or
irs
fingalimod. If there is poor response or intolerance to these drugs,
.F
Natalizumab is started.
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264. DOC for Tourette syndrome
a) Haloperidol
b) Valproate
c) B complex
d) Clonidine
Correct Answer - D
Ans. is 'd' i.e., Clonidine
Earlier Haloperidol was considered as DOC for Tourette syndrome.
Clonidine is considered as DOC for Tourette syndrome
om
r.c
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tR
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Treatment
There's no cure for Tourette syndrome. Treatment is aimed at
controlling tics that interfere with everyday activities and functioning.
When tics aren't severe, treatment might not be necessary.
Medication
Medications that block or lessen dopamine. Fluphenazine,
haloperidol (Haldol), risperidone (Risperdal) and pimozide (Orap)
can help control tics.
Botulinum (Botox) injections
Central adrenergic inhibitors. Medications such as clonidine
(Catapres, Kapvay) and guanfacine (Intuniv) — typically prescribed
for high blood pressure — might help control behavioral symptoms
such as impulse control problems and rage attacks.
Antidepressants. Fluoxetine (Prozac, Sarafem, others)
Antiseizure medications.
Therapy
om
Behavior therapy. Cognitive Behavioral Interventions for Tics,
r.c
including habit-reversal training, can help you monitor tics, identify
ke
premonitory urges and learn to voluntarily move in a way that's
an
incompatible with the tic.
Psychotherapy. In addition to helping you cope with Tourette
tR
syndrome, psychotherapy can help with accompanying problems,
irs
such as ADHD, obsessions, depression or anxiety.
.F
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Deep brain stimulation (DBS). For severe tics that don't respond to
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other treatment, DBS might help. DBS involves implanting a battery-
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operated medical device in the brain to deliver electrical stimulation
to targeted areas that control movement.
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265. SSPE is not diagnosed by
a) EEG
b) Antibodies to measles in CSF
c) Antibodies to measles in blood
d) Antigen in brain biopsy
Correct Answer - C
Ans. is 'c' i.e., Antibodies to measles in blood [Ref. Nelson l8n/e
chapter 2431]
The diagnosis of SSPE can be establisheil througlt documentation of
om
a compatible clinical course and at least I of the following
r.c
supportingfindings.
ke
Measles antibody detected in CSF.
an
Characteristic electroencephalographic findings.
tR
Typical histologic fndings and/or isolation of viurs or viral antigen in
irs
brain tissue obtained by biopsy or post-mortem examination.
.F
CSF analysis reveals normal cells but elevated IgG and IgM
w
antibody titers in dilutions of >1.8. Electroencephaloraphic patterns
w
are normal in stagel, but in the myclonic phase suppression-burst
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episodes are seen that are characteristic ofbut not
pathognomic for,SSPE. Brain biopsy is no longer routinely indicated
for diagnosis o/SSPE.
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266. Bronchiectasis Sicca is seen with
a) Tuberculosis
b) Pertussis
c) Cystic fibrosis
d) Kartagener syndrome
Correct Answer - A
Ans. is 'a' i.e., Tuberculosis
Bronchiectasis Sicca or Dry Bronchiectasis is typically
associated with Tuberculosis.
om
Tuberculosis is associted with a type of dry bronchiectasis called
r.c
Bronchiectasis Sicca, which is predominantly seen in upper lobes.
ke
Dry Bronchiectasis (Bronchiectasis Sicca) is typically characterized
an
by absence of copious amount of sputum which is usually a hall
tR
mark of bronchiectasis.
irs
Dry cough associated with hemoptysis is the typical presentation
.F
Endobronchial tuberculosis commonly leads to bronchiectasis, either
w
from bronchial stenosis or secondary traction from fibrosis. Traction
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bronchiectasis characteristically affects peripheral bronchi (which
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lack cartilage support) in areas of end-stage fibrosis
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267. Brock's Syndrome is
a) Bronchiectasis Sicca
b) Middle Labe Bronchiectasis
c) Kartagener's Syndrome
d) Sarcoidosis
Correct Answer - B
Ans. is 'b' i.e., Middle Lobe Bronchiectasis
Brock's Syndrome
Right middle lobe bronchiectasis occurring as a late sequel ofprimaiy
om
tuberculosis is known as Brock's syndrome or middle lobe
r.c
syndrome.
ke
Brock's syndrome is believed to be caused by pressure of lymph
an
nodes in primary tuberculosis on the middle lobe bronchus.
tR
It has been described as a typical outcome of hilar node involvement
irs
by tuberculosis in childhood.
.F
This term is also applied to recurrent atelectasis of the right middle
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lobe in the absence of endobronchial obstruction.
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Bronchiectasis develops after recurrent episodes of atelectasis and
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fibrosis
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268. Central bronchiectasis is seen with
a) Cystic Adenomatoid Malformation
b) Cystic fibrosis
c) Broncho carcinoma
d) Tuberculosis
Correct Answer - B
Ans. is'b' i.e., Cystic fibrosis
The distribution ()I. bronchiectasis mar be important diagnostically
A central → Perihilar
om
allergic bronchopulmonary aspergillosis.
r.c
Predominant upper lobe o Middle and lower lobe → Cystic
ke
fibrosis or one of its variants. Distribution is consistent with PCD
an
Lower lobe involvement is → Middle lobe and lingular segment of
tR
the LUL involvement is characteristic of non tuberculous
irs
mycobacteria (NTM). Idiopathic bronchiectasis
.F
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269. Type 3 respiratory failure occurs due to ?
a) Post-operative atelectasis
b) Kyphoscoliosis
c) Flail chest
d) Pulmonary fibrosis
Correct Answer - A
Ans. is 'a' i.e., Post-operative atelectasis
om
r.c
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an
tR
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270. Bilateral Painless parotid enlargement is
seen in all except
a) Mumps
b) Alcoholics
c) Sarcoidosis
d) Diabetes mellitus
Correct Answer - A
Ans. is 'a' i.e., Mumps
om
Bilateral parotid enlargement is seen in
Viral
r.c
Metabolic causes Endocrinal Sarcoidosis
infectionQ
ke
Mumps Diabetes mcuitus Gonadal Amyloidosis
an
Sjogren's
tR
Influenza Hyperlipoproteinemiahypofunction
syndrome
irs
Epstein
.F
Chronic pancreatitis Acromegaly
barr virus
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Coxackie
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Hepatic cirrhosis
virus A
CMV
HIV
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271. All of the following are features of
Scleroderma are following except
a) Diffuse periosteal reaction
b) Esophageal dysmotility
c) Erosion of tip of phalanges
d) Lung Nodular infiltrates
Correct Answer - A
Ans. is 'a' i.e., Diffuse periosteal reaction
om
Skin involvement in systemic sclerosis
Skin involvement is a nearly universal feature of systemic sclerosis
r.c
(SSc).
ke
It is characterized by variable extent and severity of skin. Thickening
an
and hardening.
tR
The fingers, hands, and face are generally the earliest areas of the
irs
body involved.
.F
Edematous swelling and erythema may preceede skin induration.
w
Other prominent skin manifestations include :
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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 :
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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.
om
Dysphagia
r.c
Attributable to esophageal fibrosis and its resultant hypomotlity is
ke
present in more than 50% of patients.
an
Remember,
tR
Whenever skin thickening is present along with Raynaud's
irs
phenomenon, it is almost always a case of scleroderma".
These two features are not present in any other multisystem disease
.F
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whose clinical features overlap with that of systemic sclerosis e.g.
w
SLE, rheumatoid arthritis, inflammatory myopathy, Sjogren
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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
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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:
Seen in patients with
Antitopoisomerase
diffuse systemic
antibody (20-40%)
sclerosis
Patients with this
autoantibody are more
likely to havepulmonary
.fibrosis and peripheral
vascular disease
Patients with these
om
autoantibodies have
poor prognosis
r.c
These autoantibodies
ke
Anticentromere are seen in patients with
an
antibody (20-40%) limited systemic
tR
sclerosis
irs
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272. LBBB is seen with all except
a) Acute MI
b) Ashmann syndrome
c) Hypokalemia
d) Hyperkalemia
Correct Answer - C
Ans. is 'c' i.e., Hypokalemia
Causes of LBBB are :-
Aortic stenosis
om
Ischaemic heart disease
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Hypertension
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Dilated cardiomyopathy
an
Anterior MI
tR
Primary degenerative disease (fibrosis) of the conducting system
irs
(Lenergre disease)
.F
Hyperkalaemia
w
Digoxin toxicity
w
Ashmann phenomenon (has both LBBB and RBBB)
w
Atrial fibrillation has a narrow complex qRS but Ashmann
phenomenon seen in atrialfibrillation is characterized by broad
complex qRS with usually a RBBB morphology. Thus if an impulse
lands on the bundle of HIS and finds the right bundle refractory then
RBBB will occur. Also remember that the refractory period of right
fascicle ix more than that of the left fascicle resulting in RBBB mostly
in these patients.
ECG findings of LBBB
Normally the septum is activated from left to right, producing small Q
waves in the lateral leads. In LBBB, the normal direction of septal
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depolarisation is reversed (becomes right to left), as the impulse
spreads first to the RV via the right bundle branch and them to the
LV via the septum.
This sequence of activation extends the qRS duration to > 120 ms
and eliminates the normal septal Q waves in the lateral leads.
The overall direction of depolarisation (from right to left) produces
tall R waves in the lateral leads (IaVLV5V6) deep S waves in the
right precordial leads (V4 R) and usually leads to left axis deviation.
As the ventricles are activated sequentially (right, then left) rather
than simultaneously, this produces a broad or notched (`W-shaped)
R wave in the lateral leads.
Non-concordance in ST segment and T wave changes.
The point is that the two fasciles of bundle of his have different
refractory periods with the right fascicle having higher refractory
period than the left.
This means that if an impulse lands on the bundle of HIS and finds
the right bundle refractory then RBBB will occur.
In atrial fibrillation because of faster conduction, normally we see
om
narrow complex qRS but sometimes we may see broad complex
r.c
qRS also which is technically called Ashmann phenomenon.
ke
Mostly in Ashmann phenomenon RBBB is seen based on the
an
physiological principle of refractory period of right fascicle more than
tR
the left one. However, rarely LBBB can also be seen if the impulse
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lands to find the left fascicle refractory. Irrespective of RBBB or
.F
LBBB, broad complex qRS will occur in case of atrial fibrillation and
w
Ashmann phenomenon is occurrence of broad complex qRS in atrial
w
fibrillation and not the occurrence of RBBB as is the popular
w
perception.
Hyperkalemia can cause defective repolarization and hence cause
Bundle branch block that culminates in sine wave pattern.
In acute MI, ischemia can damage the left bundle leading to LBBB.
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273. Therapeutic hypothermia is of benefit in
preventing neurological complications in
a) Sepsis
b) Poly-trauma
c) Cardiac arrest
d) lschemic stroke
Correct Answer - C
Ans. is 'c' i.e., Cardiac arrest
om
Inducing mild therapeutic hypothermia in selected patients surviving
out-of-hospital sudden cardiac arrest can
r.c
significantly improve rates of long-term neurologically intact survival
ke
and may prove to be one of the important
an
clinical advancements in the science of resuscitation.
tR
The types of medical events that hypothermic therapies may
irs
effectively treat fall into four primary categories:
.F
Cardiac arrest
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Ischemic stroke
w
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Trumatic brain or spinal cord injury without fever.
Neurogenic fever following brain trauma
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274. Distribution of weakness in Pyrimidal
tract lesions?
a) Extensors more than flexors in lower limb
b) Flexors more than extensors in upper limb
c) Antigravity muscles are affected
d) Antigravity muscles are spared
Correct Answer - D
Ans. is 'd' i.e., Antigravity muscles are spared
om
The following clinical features characterize a UMN lesion:
Increased tone (spasticitv)
r.c
Initially, UMN weakness may be flaccid, with absent or diminished
ke
deep tendon reflexes. There is little understanding of the reasons
an
behind this initial flaccidity and it is often referred to as 'shock'.
tR
Increased tone of a UMN type is called spasticity. It may develop
irs
several hours, days or even weeks after the initial lesion has
.F
occurred. Spasticity is manifested by :
w
Spastic catch' :
w
w
Mild spasticity may be detected as a resistance to passive
movement or 'catch' in the pronators on passive supination of the
forearm and in the flexors of the hand/forearm on extension of the
wrist/elbow.
The 'clasp-knife' phenomenon:
In more severe lesions, following strong resistance to passive flexion
of the knee or extension of the elbow, there is a sudden relaxation of
the extensor muscles of the leg and flexor muscles in the arm.
Clonus:
Rhythmic involuntary muscular contractions follow an abruptly
applied and sustained stretch stimulus, e.g. at the ankle following
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sudden passive dorsiflexion of the foot.
`Pyramidal-pattern' weakness
The antigravity muscles are preferentially spared and stronger
The flexors of the upper limbs and the extensors of the lower limbs.
The patient can develop a characteristic posture of flexed and
pronated arms with clenched fingers, and extended and adducted
legs with plantar flexion of the feet.
In upper extremiteis
Relative sparing of the flexors
More involvement of the extensor
In lower extremities
Predominant invovlement of the flexors with
Relative sparing of the extensor or
Absence of muscle wasting and fasciculations
Focal muscle wasting andjasciculations are features of an LMN
lesion. With chronic disuse, some loss of muscle bulk can occur
after a UMN lesion, but this is rarely severe or focal.
Brisk tendon reflexes and extensor plantar responses
om
The tendon reflexes are brisk. The cremasteric and abdominal or
r.c
'cutaneous' reflexes are depressed or absent. The plantar responses
ke
are extensor (upgoing toes' or 'positive' babinski sign).
an
Anti-gravity muscles are typically spared in pyramidal tract lesions.
tR
Weakness, in pyramidal tract lesions is often termed as 'pyramidal'
irs
in distribution affecting extensors more than flexors in the upper
limb, and flexors more than extensors in the lower limb (Anti-gravity
.F
w
muscles are spared).
w
Pyramidal weakness → Loss of power most marked in the
w
extensors muscles in the arms and flexors in the legs
Proximal weakness → Shoulders, hips, trunks, neck and
sometimes face. Associated with myopathy.
Distal weakness → Affects hands and feets. Associated
with peripheral motor neuropathy.
Global weakness → Generalized weakness in limbs
which may result from severe pathologies.
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275. Aldose reductase inhibitor drugs are
useful in
a) Cataract
b) Diabetes mellitus
c) Hereditary fructose intolerance
d) Essential fructosuria
Correct Answer - B
Ans. is 'b' i.e., Diabetes mellitus
om
Aldose reductase catalyzes the NADPH-dependent conversion of
glucose to sorbitol, the first step in polyol pathway of glucose
r.c
metabolism.
ke
Aldose reductase inhibitors are a class of drugs being studied as a
an
way to prevent eye and nerve damage in people with diabetes
tR
mellitus.
irs
Examples of aldose reductase inhibitors include:
.F
Tolrestat (withdrawn from market)
w
Apalrestat
w
w
Ranirestat
Fidarestat
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276. Not a cause of hypernatremia
a) Adipsic diabetes insipidus
b) Decreased insensible losses
c) Nephrogenic diabetes insipidus
d) Carcinoid syndrome
Correct Answer - B
Ans. is 'b' i.e., Decreased insensible losses
Major causes of hypernatremia
Unreplaced water loss (which requires an impairment in either thirst
om
or access to water)
r.c
Insensible and sweat losses
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Gastrointestinal losses
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Central or nephrogenic diabetes insipidus
tR
Osmotic diuresis
irs
Glucose in uncontrolled diabetes mellitus
.F
Urea in high-protein tube feedings
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Mannitol
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Hypothalamic lesions impairing thirst or osmoreceptor function
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Primary hypodipsia
Reset osmostat in mineralocorticoid excess
Water loss into cells
Severe exercise or seizures
Sodioum overload
Intake or administration of hypertonic sodium solutions
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277. Backwash ileitis is seen in
a) Ulcerative colitis
b) Crohn's disease
c) Colonic carcinoma
d) heal polyp
Correct Answer - A
Ans. is 'a' i.e., Ulcerative colitis
Ulcerative colitis always involves the rectum and extends proximally
in continuous fashion to involve part or all part of the colon.
om
Involvement of terminal ileum in ulcerative colitis is called backwash
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ileitis
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an
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278. Which of the following is not seen in
Hereditary Spherocytosis
a) Direct Coomb's Positive
b) Increased Osmotic Fragility
c) Splenomegaly
d) Gall stones
Correct Answer - A
Ans. is 'a' i.e., Direct Coomb's positive
om
Hereditary Spherocytosis
Membrane cytoskeleton that lies closely opposed to the internal
r.c
surface of the plasma membrane, is responsible for elasticity and
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maintenance of RBC shape.
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Membrane skeleton consists :?
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Spectrin → The chief protein component
irs
responsible for biconcave shape.
.F
Ankyrin and band 4-2 → Binds spectrin to band 3
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Band 3 → A transmembrane ion transport
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protein.
Band 4.1 → Binds spectrin to glycophorin A,
atransmembrane protein.
Hereditary spherocytosis is an autosomal dominant disorder
characterized by intrinsic defects in red cell membrane. This results
in production of red cells that are sphere (spherocytes) rather than
biconcave.
The mutation most commonly involves the gene coding for ankyrin,
followed by Band-3 (anionic transport channel), spectrin, and Band
4.2 (also called palladin).
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Also know
Most common, defect in hereditary elliptocytosis is in spectrin
Pathogensis of Hereditary spherocytosis
Loss of membrane cytoskeleton proteins (ankyrin, spectrin, Band 3,
4.2) results in reduced membrane stability. Reduced membrane
stability leads to spontaneous loss of membrane fragments during
exposure to shear stresses in the circulation. The loss of membrane
relative to cytoplasm forces the cells to assume the smallest
possible diameter for a given volume cells become
microspherocytes.
Because of their spheroidal shape and reduced membrane plasticity,
red cells become less deformable and are trapped in to spleen as
they are unable to pass through the interendothelial fenestrations of
the venous sinusoids. In the splenic sinusoides, red cells are
phagocytosed by RE cells Extravascular hemolysis.
Clinical features of Hereditory spherocytosis
The clinical features are those of extravascular hemolysis :
Anemia → Mild to moderate
om
Jaundice (Mainly indirect bilirubin) → Splenomegaly
r.c
Gall stones → Elevated excretion of
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bilirubin promotes formation of pigment stone.
an
Leg ulcer → Rare clinical
tR
manifestation.
irs
Aplastic crisis → Triggered by parvo-
virus infection.
.F
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Laboratory findings
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Spherocytosis --> Peripheral smear shows microspherocytes which
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are small RBCs without central pallor (Normally central 1/3 pallor is
present in red cells).
MCV4
MCHC r
Increased unconjugate bilirubin
Urine urobilinogen 1'
Stool stercobilinogen
Reticulocytosis -4 As seen with any type of hemolytic anemia.
Hemoglobin 1
Serum Heptoglobin --> Nonnal to decreased.
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Increased osmotic fragility on pink test.
Coomb's test is used to distinguish hereditary spherocytosis from
autoimmune hemolytic anemias.
Autoimmune hemolytic anemias are coomb's positive_ whereas
hereditary spherocytosis is coomb's negative.
om
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an
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279. Usually associated with parvovirus B19
infection in those with hereditary
spherocytosis
a) Mild to moderate splenomegaly
b) Aplastic crisis
c) Gallstones
d) Hemolytic crisis
Correct Answer - B
om
Ans. is 'b' i.e., Aplastic crisis
r.c
Parvovirus B19 selectively infects erythroid precursors and is the
most common aetiological agent that induces
ke
aplastic crisis in patients with hereditary spherocytosis (and other
an
Hemolytic disorders).
tR
Transient aplastic crisis
irs
Persons with decreased erythrocytes caused by conditions such as
.F
iron deficiency anemia, human immunodeficiency virus sickle cell
w
w
disease, spherocytosis or thalassemia are at risk of transient
w
aplastic crisis if infected with parvovirus B19.
The virus causes a cessation of erythrocyte production.
Parvovirus infection may be the first manifestation in HS.
It begins with reticulocytosis and thrombocytosis
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280. Which of the following is given to treat
thrombocytopenia secondary to anti-
cancer therapy and is known to stimulate
progenitor megakaryocytes
a) Filgrastim
b) Oprelvekin
c) Erythropoietin
d) Anagrelide
om
Correct Answer - B
r.c
Ans. is 'b' i.e., Oprelvekin
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Oprelvekin ( IL-11) is used to prevent and treat thrombocytopenia.
an
[Ref Harrison's 18th chapter 85 and Katzung 11th 580-581]
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irs
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281. Lambda - Panda sign is typically seen in
a) Sarcoidosis
b) Tuberculosis
c) Histoplasmosis
d) Leishmaniasis
Correct Answer - A
Ans. is 'a' i.e., Sarcoidosis
Lambda sign and Panda sign on Gallium scan are typically
described for sarcoidosis.
om
Active pulmonary and/or mediastinal sarcoidosis is gallium avid and
r.c
a positive gallium scan can support the diagnosis of sarcoidosis.
ke
Typical patterns of uptake have been described as 'panda' and
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'lambda' signs.
tR
Lambda sign → Formed from increased uptake in bilateral hilar
irs
and right paratracheal nodes
.F
Panda sign → Formed from increased uptake in the parotids
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and lacrimal glands
w
A Lambda sign in combination with a so-called Panda sign (Lambda-
w
Panda Sign) is a highly specific pattern for sarcoidosis.
The degree of uptake typically depends on the activity of disease
and gallium scan is positive only in the setting of active parenchymal
disease and negative in remission
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282. All are indications for stopping effending
ATT drug permanently except
a) Gout
b) Autoimmune thrombocytopenia
c) Optic neuritis
d) Hepatitis
Correct Answer - D
Ans. is 'd' i.e., Hepatitis
om
For patients with symptomatic hepatitis and those with marked (five
to six fold) elevations in serum levels of aspartate aminotransferase,
r.c
treatment should be immediately stopped and drugs reintroduced
ke
one at a time after liver function has returned to normal.
an
Indications for stopping the A.T.T. permanently
tR
Hyperuricemia and arthralgia
irs
Optic neuritis
.F
Autoimmune thrombocytopenia
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283. Interferon gamma release assay
measures IFN release against which M.
TB antigen
a) ESAT-6
b) E SAT-7
c) CF-11
d) CF-12
Correct Answer - A
om
Ans. is 'a' i.e., ESAT-6
r.c
3 Interferon-gamma release assays (IGRAs) are diagnostic tools
for latent tuberculosis infection (LTBI).
ke
They are surrogate markers of Mycobacterium tuberculosis infection
an
and indicate a cellular immune response to M. tuberculosis.
tR
a IGRAs cannot distinguish between latent infection and active
irs
tuberculosis (TB) disease and should not be used for diagnosis of
.F
active TB, which is a microbiological diagnosis. A positive IGRA
w
w
result may not necessarily indicate active TB, and a negative IGRA
w
result may not rule out active TB .
3 Because IGRAs are not affected by Bacille Calmette-Guerin
(BCG) vaccination status, IGRAs are useful for evaluation of LTBI in
BCG-vaccinated individuals, particularly in settings where BCG
vaccination is administered after infancy or multiple (booster) BCG
vaccinations are given.
Assay antigens
M. tuberculosis-specific antigens include :-
Early secreted antigenic target 6 (ESAT-6) and
Culture filtrate protein 10 (CFP-10).
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These are encoded by genes located within the region of difference
1 (RD1) segment of the M. tuberculosis genome.
They are more specific for M. tuberculosis than purified protein
derivative (PPD) because they are not shared with any BCG vaccine
strains or most species of NTM other than M marinum, M. kansasii,
M szulgai, and M. flavescens.
Types of assays
Two IGRAs are available in many countries :-
The QuantiFERON-TB Gold In-Tube (QFT-GIT) assay, which has
replaced the second-generation QuantiferonTB Gold (QFT-G)
assay, and the T-SPOTTB assay.
The QFT-GIT assay is an enzyme-linked immunosorbent assay
(ELISA)-based, whole-blood test that uses peptides from three TB
antigens i.e.,
CFP-10, and
TB7.7) in an in-tube format
The result is reported as quantification of interferon (IFN)-gamma in
international units (IU) per mL.
om
A newer assay, the QuantiFERON-TB Gold Plus (QFT-Plus),
r.c
became available in 2015.
ke
This test is available in Europe but not in North America. The QFT-
an
Plus assay has two TB antigen tubes, unlike the QFT assay (which
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has a single TB antigen tube).
irs
Sensitivity and specificity
IGRAs have specificity >95 percent for diagnosis of latent TB
.F
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infection. The sensitivity for T-SPOTTB appears to be higher than for
w
QFT-GIT or TST (approximately 90, 80, and 80 percent,
w
respectively) [2]. The higher sensitivity of T-SPOTTB may be useful
for evaluating individuals with immunosuppressive conditions.
TST specificity is high in populations not vaccinated with BCG (97
percent). Among populations where BCG is administered, it is much
lower although variable (approximately 60 percent).
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284. The term end-stage renal disease (ESRD)
is considered appropriate when GFR
falls to
a) 50% of normal
b) 25% of normal
c) 10-25% of normal
d) 5-10% of normal
Correct Answer - D
om
Ans. is 'd' i.e., 5-10% of normal
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285. Muehrcke lines in nails are seen in
a) Nephrotic syndrome
b) Barrter syndrome
c) Nail patella syndrome
d) Acute tubular necrosis
Correct Answer - A
Ans. is 'a' i.e., Nephrotic syndrome
Muehrcke's lines are characteristic of hypoalbuminemia. Nephrotic
syndrome causes hypoalbunemia.
om
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an
tR
irs
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286. Not true obstructive sleep appoea
a) Nocturnal asphyxia
b) Alcoholism is a cofactor
c) Prone to hypertension
d) Overnight oximetry is diagnostic to replace polysomnography
Correct Answer - D
Ans. is 'd' i.e., Overnight oximetry is diagnostic to replace
polysomnography
Cardinal features in adults include:
om
Obstructive apneas, hypopneas, or respiratory effort related
r.c
arousals
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Daytime symptoms attributable to disrupted sleep, such as
an
sleepiness, fatigue, or poor concentration
tR
Signs of disturbed sleep, such as snoring, restlessness, or
irs
resuscitative snorts
.F
Clinical presentation
w
Most patients with OSA first come to the attention of a clinician
w
because the patient complains of daytime sleepiness, or the bed
w
partner reports loud snoring, gasping, snorting, or interruptions in
breathing while sleeping.
Daytime sleepiness, distinct from fatigue, is a common feature of
OSA
Sleepiness is the inability to remain fully awake or alert during the
wakefulness portion of the sleep-wake cycle.
Snoring is the other common feature of OSA. While snoring is
associated with a sensitivity of 80 to 90 percent for the diagnosis of
OSA, its specificity is below 50 percent.
Clinical features of obstructive sleep apnea (OSA)
Daytime sleepiness Obesity
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Daytime sleepiness Obesity
Large neck
Nonrestorative sleep
circumference
Systemic
Loud snoring
hypertension
Witnessed apneas by
Hypercapnia
bed partner
Awakening with Cardiovascular
choking disease
Nocturnal Cerebrovascular
restlessness disease
Insomnia with Cardiac
frequent awakenings dysrhythmias
Narrow or
Lack of concentration "crowded"
airway
Pulmonary
Cognitive deficits
hypertension
om
Changes in mood Cor pulmonale
r.c
Morning headaches Polycythemia
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Vivid, strange, or Floppy eyelid
an
threatening dreams syndrome
tR
Gastroesophageal
irs
Nocturia
reflux
.F
Polysomnography
w
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Full-night, attended, in-laboratory polysomnography is considered
w
the "gold-standard diagnostic" test for OSA.
It involves monitoring the patient during a full night's sleep.
Unattended, out of centre sleep "(OCST) may be used as an
alternative to polysomnography for the diagnosis of OSA in patients
with a high pre-test probability of moderate to severe OSA, provided
there are no medical comorbidities such as heart failure that
predispose to alternative or additional sleep related breathing
disorders.
The diagnosis of OSA is based upon the presence or absence of
related symptoms, as well as the frequency of respiratory events
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during sleep (ie, apneas, hypopneas, and respiratory effort related
arousals IRERAsJ as measured by polysomnography or out-of-
center sleep testing (OCST).
In adults, the diagnosis of OSA is confirmed if either of the two
conditions exists:
There are "fil_y" or more predominantly obstructive respiratory
events (obstructive and mixed apneas, hypopneas, or RERAs) per
hour of sleep (for polysomnography) or recording time (for OCST) in
a patient with one or more of the following:
Sleepiness, nonrestorative sleep, fatigue, or insomnia symptoms.
Waking up with breath holding, gasping, or choking.
Habitual snoring, breathing interruptions, or both noted by a bed
partner or other observer
Hypertension, mood disorder, cognitive dysfunction, coronary artery
disease, stroke, congestive heart failure, atrial fibrillation, or type 2
diabetes mellitus
There are 15 or more predominantly obstructive respiratory events
(apneas, hypopneas, or RERAs) per hour of sleep (for
om
polysomnography) or recording time (for OCST), regardless of the
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presence of associated symptoms or comorbidities
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287. Obstructive sleep apnoea may result in
all of thefollowing except
a) Systemic hypertension
b) Pulmonary hypertension
c) Cardiac arrhythmia
d) Impotence
Correct Answer - C
Ans. is 'c' i.e., Cardiac arrhythmia
om
Daytime function and cognition
OSA is associated with excessive daytime sleepiness, inattention,
r.c
and fatigue, which may impair daily function, induce or exacerbate
ke
cognitive deficits, and increase the likelihood of errors and
an
accidents.
tR
Cardiovascular morbidity
irs
Patients with OSA, are at increased risk for a broad range of
.F
cardiovascular morbidities, including systemic hypertension,
w
pulmonary arterial hypertension, coronary artery disease, cardiac
w
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arrhythmias, heart failure, and stroke.
Metabolic syndrome and type 2 diabetes
Patients with OSA have an increased prevalence of insulin
resistance and type 2 diabetes.
Nonalcoholic fatty liver disease
Intermittent nocturnal hypoxia due to OSA may contribute to the
development and severity of nonalcoholic fatty liver disease
(NAFLD), independent of shared risk factors such as obesity.
Perioperative complications
Patients with OSA may be at greater risk for perioperative
complications such as postoperative oxygen desaturation, acute
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respiratory failure, postoperative cardiac events, and intensive care
unit transfers.
Mortality
Patients with untreated severe OSA (ie, AHI 30 events per hour)
have a two- to three fold increased risk of all-cause mortality
compared with individuals without OSA, independent of other risk
factors such as obesity and cardiovascular disease.
om
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288. Tophi in gout found in all regions except
a) Prepatellar bursae
b) Muscle
c) Helix of ear
d) Synovial membrane
Correct Answer - B
Ans. is 'b' i.e., Muscle
Location of Tophi
They are classically located along the helix of the ear.
om
Can also be seen in :-
r.c
Fingers
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Toes
an
Prepattelar bursa
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Olecranon
irs
Although gout typically cuases joint inflammation, it can also cause
.F
inflammation in other synovial-based structures, such as bursae and
w
tendons.
w
Tophi are collections of urate crystals in the soft tissues. They tend
w
to develop after about a decade in untreated patients who develop
chronic gouty arthritis.
Tophi may develop earlier in older women, particularly those
receiving diuretics.
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289. All drugs used in treatment of acute gout
except
a) Allopurinol
b) Aspirin
c) Colchicine
d) Naproxen
Correct Answer - A
Ans. is 'a' i.e., Allopurinol
om
Management of gout
Treatment of acute gout
r.c
To provide rapid and safe pain relief
ke
Drugs used are :
an
i) NSAIDs:
tR
These are the most frequently used drugs to treat gout because they
irs
are so well tolerated.
.F
Indomethacin is the agent of choice but other NSAIDs may be just
w
as effective. Aspirin is usually avoided because low doses of aspirin
w
w
aggravate hyperuricemia.
ii) Colchicinee:
Colchicine is effective but less well tolerated than NSAIDs
iii) GlucocorticoidsQ:
Usually reserved for patients in whom colchicines or NSAIDs are
contraindicated or ineffective.
Treatment of chronic gout (maintain serum urate levels at 5.0
mg/dl or less) AllopurinolQ:
Xanthine oxidase inhibitor
Agent of choice for most patients with gouty'
Uricosuric agents
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Probenecid2
SulfinpyrazoneQ
Treatment of gout according to the stage
No treatment indicated, the
causes should be
Asymptomatic
determined and any
hyperuricemia
associated problem should
be addressed rigorously)
Acute gouty NSAIDs or colchicines or
arthritis glucocorticoid
Intercritical Prophylactic colchicines (to
period reduce further attacks)
Acute Urate lowering
tophoaecous drug
gout (allopurinol or probenecid,
sulfinpyrinazole)
om
r.c
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an
tR
irs
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290. Wrong abour continuous murmur
a) Seen with coarctation of aorta
b) Peaks at S2
c) Heard both in systole and diastole
d) Increase on squatting
Correct Answer - D
Ans. is 'd' i.e., Increase on squatting
A continuous murmur is defined as one that begins in systole and
extends through S2 into part or all of diastole.
om
It need not occupy the entire cardiac cycle.
r.c
Continuous murmurs are not affected by dynamic auscultation
ke
maneuvers like squatting etc.
an
They can oftern be difficult to distinguish from individual systolic and
tR
diastolic murmurs in patients with mixed valvular heart disease.
irs
The classic example of a continuous murmur is that associated with
.F
a patent ductus arteriosus, which usually is heard in the second or
w
third interspace at a slight distance from the sternal border.
w
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291. Banana shaped left ventricle is seen in
a) HOCM
b) DCM
c) RCM
d) Takotsubo cardiomyopathy
Correct Answer - A
Ans. is 'a' i.e., HOCM
Spherical Dilated
ventricle cardiomyopathy
om
Stress
Apical
r.c
cardiomyopathy /
ballooning
ke
Tako-Tsubo
an
Spade-
Apical hypertrophic
tR
shaped
cardiomyopathy
irs
ventricle
.F
Myocardial
w
Distortion infarctions /
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of ventricle aneurysms /
remodeling
Banana -
Hypertrophic
shaped
cardiomyopathy
ventricle
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292. Wide QRS complex 0.12 seconds may be
seen in all of the following, except
a) Hyperkalemia
b) Wolf Parkinson White Syndrome
c) Ventricular Tachycaridia
d) Left Anterior Fascicular Block
Correct Answer - D
Ans. is 'd' i.e., Left Anterior Fascicular Block
om
Left Anterior Fascicular Block is a partial block in the left bundle
system and does not prolong the QRS duration
r.c
significantly. Typically the QRS duration is slightly prolonged and
ke
remains between 0.10 to 0.12 seconds.
an
Major causes of a wide ORS complex
tR
Intrinsic intraventricular conduction delay o Left bundle branch block
irs
and variants
.F
Right bundle branch block and variants o Other nonspecific IVCD
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patterns
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Extrinsic intraventricular conduction delay
Hyperkalemia
Drug-induced - type 1 antiarrhythmic drugs and related sodium
channel blocking agents (eg, tricyclic antidepressants and
phenothiazines)
Ventricular beat o Premature o Escape
Paced
Ventricular preexcitation
Wolff:Parkinson-White (WPW) pattern and variants
Factitious
ECG unintentionally recorded at fast paper speeds (50 or 100 mm/s)
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Wide QRS complex tachyarrhythmias
Ventricular tachycardia
Supraventricular tachycardia or atrial fibrillation or flutter with
aberrant intraventricular conduction due to:
Bundle branch block
Atrioventricular bypass tract (preexcitation syndromes with
orthodromic conduction
om
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tR
irs
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293. Subacture combined degeneration of
cord is caused due to deficiency of
a) Vitamin B1
b) Vitamin B5
c) Vitamin B6
d) Vitamin B12
Correct Answer - D
Ans. is 'd' i.e., Vitamin B12
om
Subacate combined degeneration of the spinal cord is the term used
for the degeneration of the spinal cord due to vitamin B12 deficiency.
r.c
The spinal cord, brain, optic nerves, peripheral nerves may all be
ke
affected in vitamin B12 deficiency but the spinal cord is usually
an
affected first and exclusively.
tR
The tracts mainly involved in the spinal cord are: o Posterior
irs
column
.F
Corticospinal tract
w
w
Later on peripheral nerves are involved
w
Clinical features of vitamin B deficiency or subacute combined
degeneration of the cord :
Patient first notices mild general weakenss and paresthesia
consisting of tingling 'pins and needle'.
As the illness progresses the gait becomes unsteady and stiffness
and weakenss of the limbs and legs develop. If the disease remains
untreated ataxic paraplegia evolve.
Sometimes there may be loss of superficial sensations, such as
tactile, pain and thermal sensations, but these signs are rare.
Loss of "vibration sense" is the most consistent sign and is usually
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accompanied by loss of position sensee.
Motor signs seen are:-
Loss of strength in proximal limb muscles
Spasticity, changes in tendon reflexes
Clonus and extensor plantar responses
Sometimes tendon reflexes may be absente (due to involvement of
peripheral nerve) o Gait is ataxic
Now,
The Clinicopathological Correlation
Clinical Tracts
features involved
Paresthesia,
inpairment of Due to lesion
deep in posterior
sensation and column
ataxia
Weakness,
Due to
spasticity and
om
corticospinal
increased
r.c
tract
tendon
involvement
ke
reflexes
an
Due to
Occasional
tR
spinothalamic
findings of
irs
tract
loss of pain
.F
involvement
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and
(rarely
w
temperature
w
involved)
Distal and Involvement of
symmetrical peripheral
impairmeat of nerve
superficial (occassionally)
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294. Foot ulcers in diabetes are due to all
except
a) Decreased immunity
b) Neuropathy
c) Microangiopathy
d) Macroangiopathy
Correct Answer - A
Ans. is 'a' i.e., Decreased immunity
om
The reasons for the increased incidence of foot ulcers in DM involve
the interaction of several pathogenic factors
r.c
Neuropathy (Microvascular complication)
ke
Motor and sensory neuropathy lead to abnormal foot muscle
an
mechanics and structural changes in the foot (hammertoe, claw toe
tR
deformity, prominent metatarsal heads, Charcot joint).
irs
Autonomic neuropathy
.F
Results in anhidrosis and altered superficial blood flow in the foot,
w
which promote drying of the skin and fissure formation. PAD and
w
w
poor wound healing impede the resolution of minor breaks in the
skin, allowing them to enlarge and to become infected.
Abnormal foot biomechanics.
P.A.D. (Macrovascular complication)
This leads to occlusive arterial disease that results in ischemia in the
lower extremity and an increased risk of ulceration in diabetic
patients.
Poor wound healing.
Grades of diabetic foot ulcers
Grade 0 skin intact but bony deformities produce a "foot at risk".
Grade 1 localized, superficial ulcer.
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Grade 2 deep ulcer to tendon, bone, ligament, or joint.
Grade 3 deep abscess, osteomyelitis
Grade 4 gangrene of toes or forefoot
Grade 5 gangrene of the entire foot
om
r.c
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tR
irs
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295. Not a cause of Gynaecomastia
a) Hypothyroidism
b) Kallman
c) obesity
d) Klinefelter syndrome
Correct Answer - A
. Ans. is 'a' i.e., Hypothyroidism
Causes of Gynaecomastia
Puberty
om
During puberty, the serum oestradiol rises to adult levels before
r.c
testosterone, causing transient gynaecomastia. This normally
ke
resolves within six months to two years.
an
Cirrhosis
tR
Gynaecomastia occurs due to altered sex hormone metabolism, and
irs
an increase in the oestradiol; free testosterone ratio.
.F
Hypogonadism
w
Primary hypogonadism causes a compensatory rise in LH, in turn
w
causing increased peripheral aromatization of testosterone to
w
oestradiol.
Secondary hypogonadism, due to pituitary or hypothalamic disease
(e.g. prolactin excess, Kallman's syndrome haemachromatosis),
may also cause gynaecomastia despite LH deficiency, since the
adrenal cortex continues to produce oestrogen precursors, which
are converted to oestrogens in peripheral tissues.
Tumours
Testicular tumours:
Germ cell tumours account for over 95% testicular tumours.
Gynaecomatia occurs in 5% of patients, due to hCG secretion
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stimulating oestradol production by the testes.
Leydig cell tumours cause gynaecomastia in 20 – 30% of cases.
These tumours present with precocious puberty in boys, or poot
libido and gynaecomastia in young males. Approximately 10% of
these tumours are malignant.
Sertoli cell turnours cause gynaecomastia through excess
aromatization of androgents to oestrogens. These turnours may
occur in Peutz- Jeger 's syndrome.
Adrenocortical turnours may cause gynaecomastia through
overproduction of androgens such as androstenedione, which are
converted to oestrogens in peripheral tissues.
Ectopic hCG-secreting tumours include lung, gastric, renal, and
hepatocellular carcinomas.
Hypogonadism from chemotherapy or radiotherapy may also cause
gynaecomastia in patients with testicular tumours.
Graves disease
Gynaecomastia may occur due to increased sex hormone-binding
globulin (SHBG), and decreased free testosterone levels.
om
Chronic renal failure:
r.c
Half of patients receiving haemodialysis develop gynaecomastia due
ke
to decreased leydig cell function. Gynaecomastia may also occur
an
following kidney transplantation due to ciclosporin use.
tR
Androgen insensitivity syndrome :
irs
Complete androgen insensitivity, .formerly termed 'testicular
feminization syndrome', causes a femalephynotype in patients who
.F
w
are genotype males. These patients are regarded as female, and
w
therefore present with infertility and amenorrhoea rather
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gynaecomastia. Partial androgen receptor defects maycause
gynaecomastia in phenotypic males.
Drugs cause gvnaecomastia
Anti-androgens
Cyproterone acetate
Finasteride/dutasteride
Gastrointestinal drugs
Cimetidine / ranitidine
Cancer chemotherapy
Alkylating agents/vinca alkaloids (due to testicular damage and
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hypogonadism)
Imatinib (tyrosine kinase inhibitor used for chronic myeloid leukemia
(CML) and gastrointestinal stromal tumour (GIST).
Cardiovascular drugs
Spironolactone (displaces oestrogen from SHBG, increasing free
oestrogen: testosterone ratio)
Digoxin
Amiodarone
Methyl-dopa
Antimicrobial drugs
Isoniazid
Ketoconazole
Metronodazole
Anti-viral drugs
Highly active anti-retroviral (HAART) therapy (especially protease
inhibitors)
Neurological drugs
Phenothiazines
om
Metoclopramide
r.c
Tricyclic anti-depressants
ke
Opiates
an
tR
irs
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296. Brain tumor causing hypernatremia in
children
a) Medulloblastoma
b) Cerebellar astrocytoma
c) Craniophyrangioma
d) Brain stem glioma
Correct Answer - C
Ans. is 'c' i.e., Craniophyrangioma
om
Craniophyrangioma leads to central diabetes mellitus and resultant
loss of water leads to hypernatremia.
r.c
ke
an
tR
irs
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297. Poorly controlled diabetes with blood
sugar of 450 mg% is associated with:
a) Hyponatremia
b) Hypernatremia
c) Hypokalemia
d) Hypomagnesemia
Correct Answer - A
Ans. is 'a' i.e., Hyponatremia
om
Poorly controlled diabetes draws water out of cells resulting in
hyponatremia.
r.c
n Plasma concentration falls by 1.4 mmol/L for every 100mg/d1 rise
ke
in plasma glucose concentration of sodium.
an
tR
irs
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298. All of the following drugs may be used in
the treatment of ulcerative colitis Except
a) Corticosteroids
b) Azathioprine
c) Sulfasalazine
d) Methotrexate
Correct Answer - D
Ans. is 'd' i.e., Methotrexate
om
Methotrexate in crohn's disease
Methotrexate has been shown to be effective for inducing remission
r.c
in patients with steroid dependent and steroid refractory crohn's
ke
disease.
an
Agents that may be used for treatment of ulcerative colitis
tR
5-ASA
irs
Glucocorticoids
.F
Azathioprine and 6 mercaptopurine
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Cyclosporine or TNF alpha therapy (Infliximab).
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Tacrolimus is a macrolide antibody that has shown to be effective in
adults with steroid dependent or refractory ulcerative colitis.
Drugs used in crohn's disease
Cyclosporine or infliximab
6-Mercaptopurine or azathioprine
Glucocorticoid IV
Glucocorticoid oral
Glucocorticoid rectal
5-ASA rectal or oral
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299. With regards to hereditary
spherocytosis, which of the following is
false
a) Usually has autosomal dominant inheritance
b) Caused by mutations in genes for proteins such as spectrin,
ankrin or band 3
c) Red blood cells are destroyed in the spleen
d) Aplastic crises are common
om
Correct Answer - D
r.c
Ans. is 'd' i.e., Aplastic Crisis are common
Aplastic crisis are a rare/uncommon complication of Hereditary
ke
Spherocytosis typically caused by virally induced
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bone marrow suppression.
tR
The most common aetiological agent that induces Aplastic Crisis in
irs
patients with Hereditary Spherocytosis is Parvovirus B19
.F
Hereditary spherocvtosis usually has autosomal dominant
w
w
inheritance caused by mutation in genes for proteins such as
w
spectrin. ankrin or band 3.
The genes responsible for HS include akyrin, b spectrin, band-3-
protein, a-spectrin, and protein 4.2. In approximately two-thirds to
three-quarter of HS patients, inheritance is autosomal dominant. In
the remaining patients, inheritance is non-dominant due to
autosomal recessive inheritance of a de novo mutation.
In patients with hereditary spherocvtosis Red blood cells are
destroyed in the spleen
The spleen plays a critical role in the pathobiology of HS, as
destruction of spherocytes in the spleen is the primary cause of
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hemolysis in HS patients.
Aplastic Crisis is an Uncommon Complication
Aplastic crisis following virally induced bone marrow suppression are
uncommon, but may result in severe anaemia with serious
complications including congestive heart failure or even death.
The most common aetiological agent in these cases is parvovirus
B19.
Parvovirus selectively infects erythropoietic progenitor cells and
inhibits their growth
om
r.c
ke
an
tR
irs
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300. All of the following are true regarding
splenectomy in patients with hereditary
spherocytosis, except ?
a) Avoid in mild cases
b) Delay splenectomy until at least 4 years old age
c) Anti-pneumococcal vaccination must be given before
splenectomy
d) Prolonged anti-pneumococcal antibiotic prophylaxis must be
given after splenectomy om
r.c
Correct Answer - D
Ans. is 'd' i.e., Prolonged Anti-pneumococcal Antibiotic Prophylaxis
ke
must be given after splenectomy
an
Splencectomv in patients with Hereditary spherocytosis
tR
Avoid splenectomy in mild cases.
irs
Delay splenectomy until at least 4 years of age after the risk of
.F
severe sepsis has peaked.
w
w
Anti-pneumococcal vaccination befoe splenectomy is imperative
w
while anti-pneumococcal prophylaxis post-splenectomy is
controversial.
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301. Most common heavy chain disease is
a) Franklin disease
b) Seligmann disease
c) Mu heavy chain disease
d) Waldenstrom cryoglobulinemia
Correct Answer - B
Ans. is 'b' i.e., Seligmann Disease (Alpha heavy chain disease)
There are four forms:
* Alpha chain disease (Seligmann's disease)- most common type
om
* Gamma chain disease (Franklin's disease)
r.c
* Mu chain disease
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* Delta chain disease
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302. Treatment of choice in acute sarcoidosis
is
a) Prednisolone
b) Cyclosporin
c) Infliximab
d) IV immunoglobulins
Correct Answer - A
Ans. is 'a' i.e., Prednisolone
om
Prednisolone (corticosteroid) is the treatment of choice for both
acute and chronic phase of sarcoidosis that requires treatment.
r.c
ke
an
tR
irs
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303. MDR TB must be treated for at least ?
a) 12 months
b) 18 months
c) 20 months
d) 36 months
Correct Answer - C
Ans. is 'c' i.e., 20 months
Resistance
(or Throughout
om
RZE
intolerance) (6)
r.c
to H
ke
Resistance
an
(or Throughout
HZEQ
tR
intolerance) (12-18)
irs
to R
.F
ZEQ + S (for
Throughout
w
Resistance another
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(at least 20
to H + R injectable
w
months)
agents)
1 injectable
agent + 3 of
Resistance Throughout of these
to all first- (at least 20 4
line drugs months ethionamide
cycloserine,
Q, PAS
Intolerance
HRE
to Z
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irs
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304. The following are the complication of
haemodialysis except -
a) Hypotension
b) Peritonitis
c) Hypertension
d) bleeding tendency
Correct Answer - B
Ans. is 'b' i.e., Peritonitis
om
Patients with endstage renal disease (ESRD) on long term dialysis
therapy have very high mortality due to predominantly
r.c
cardiovascular causes.
ke
'Sudden cardiac death is the single most common form of death in
an
hemodialysis, accounting for 20% to 30 all deaths in this cohort.'
tR
Dialysis patients have extraordinarity high mortailty rates with cardic
irs
disease accounting for 43 percent deaths
.F
in this population. Data indicates that approximately 27% of the
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mortailties are due to sudden cardic death.
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More on cardiovascular complications in dialysis
Cardiovasucular disease is the major cause of death in ESRD
patients and atheroscleroses is present in all long term dialysis
patients.
Premature cardiac death has reached epidemic levels in world
dialysis population occurring five to ten times as commonly as in age
matched general population and accounting for at least half of all
patients death. o Hypertension is a major risk factor
Other risk factor are :-
Hyperphosphetemia and elevated calcium phosphorus with calcium
deposition in coronary arteries.
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Anemia
Hypertriglyceridemia
Low HDL cholesterol
Increased lipoprotein (a)
Insulin deficiency or resistance
Hyperhomocysteinem
Also know
Complications of dialysis
Acute
Long term
complications of
complications
hemodialysis
o Hypotension o Cardiovascular
o Cramps o Anemia
Secondary
Nausea and
hyperparathyrodism
vomiting
and
Headache o Malnutrition
om
o Hepatitis (A, B, C,
Chest pain o
D, E
r.c
Back pain Depression
ke
o Dialysis
an
Itching
encephalopathy
tR
Fever and chills Malignant tumours
irs
Carpal tunnel
.F
syndrome
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Uremic neurophty
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305. The most likely diagnosis in the case of a
patient with multiple pulmonary cavities,
hematuria and red cell casts is
a) Anti-GBM disease
b) Churg-Strauss
c) Systemic lupus erythematousus
d) Wegner's granulomatosis
Correct Answer - D
om
Ans. is 'd' i.e., Wegner's granulomatosis
r.c
Multi lung cavities and hematuria are characteristic of Wegner's
granulomatosis.
ke
Anti-GBM disease (Goodpasture's syndrome) usually does not
an
cause lung cavities.
tR
Churg-strauss syndrome usually does not cause hematuria.
irs
SLE is not a usual cause of lung cavities.
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306. Hung-up reflexes are seen in
a) Chorea
b) Atheotosis
c) Cerebral palsy
d) Cerebellar palsy
Correct Answer - A
Ans. is 'a' i.e., Chorea
Hung up knee jerk
When patellor tendon is tapped while the foot is hanging free, the leg
om
may be held in extension for few seconds before relaxing owing to
r.c
prolonged contraction of quadriceps.
ke
This is seen in "chorea".
an
Other neurological signs associated with chorea
tR
Milkmaids grip
irs
Piano sign
.F
Handwriting
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Milkmaid's grip
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Inability to maintain sustained voluntary contraction of muscle group
w
at a constant level.
Inability to apply steady pressure during handshake leading to a
characteristic squeeze and release of grip.
Patient's have difficulty maintaining sustained eyelid closure and
sustained tongue protrusion
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307. Arsenic poisoning causes
a) Polyneuritis
b) Mononeuritis multiplex
c) Radiculopathy
d) Myelopathy
Correct Answer - A
Ans. is 'a' i.e., Polyneuritis
There is sensory and motor (i.e. mixed) polyneuropathy, with painful
paresthesia of hands and feet and muscle tenderness.
om
r.c
ke
an
tR
irs
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308. Tropical pulmonary eosinophilia is
caused because of
a) Occult filariasis
b) Cerebral melaria
c) Penumonic plague
d) Asthmatic bronchitis
Correct Answer - A
Ans. is 'a' i.e., Occult filariasis
om
Occult filariasis is a rare condition which is caused by
hypersensitivity reaction to filarial antigen.
r.c
Micro filatia are absent in the blood.
ke
Lymphatic filariasis is absent.
an
Indirect evidence of filarial infection is obtained by demonstrating
tR
antifilarial antibodies
irs
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309. Characteristic ECG finding of pulmonary
embolism
a) Sinus tachycardia
b) S Q3T3
c) T wave inversion
d) Epsilon waves
Correct Answer - B
Ans. is `b' i.e., SJQ3T3
om
E.C.G. changes of pulmonary embolism ?
Sinus tachycardia is the most frequent and nonspecific finding on
r.c
electrocardiography in acute pulmonary embolism.
ke
Features suggesting acute right heart strain on the ECG occur
an
relatively infrequently, these include.
tR
Acute right axis deviation
irs
P pulmonale
.F
Right bundle branch block
w
Inverted T waves
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ST segment changes in right sided leads.
Earlier the following E.C.G. changes were considered highly
predictive of acute pulmonary embolism, but these observations
were found in less than 12% of patients with pulmonary emboli in
recent studies. These E.C.G. features are -
S wave in lead I
Q wave in lead III
Inverted Tin lead III ("S1Q31.3")
S waves in lead I, II and III ("Si,S2 S3")
Also know
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Areterial blood gas analysis in pulmonary embolism :
Arterial blood gas analysis shows
Mid to moderate hypoxemia
Increased P (A - a) 0,
Mildly reduced PaCO2
Almost all patients with pulmonary embolism have PaO, < 80 mm Hg
but no absolute level of Pa02 can be used to exclude the diagnosis.
om
r.c
ke
an
tR
irs
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310. Pleural effusion in rheumatoid arthritis is
typically associated with the following
features except
a) Glucose > 60 mg/dl
b) Protein > 3 gm/di
c) Pleural fluid protien to serum protein ratio of >0 .5
d) Pleural fluid LDH to serum LDH ratio of >0.6
Correct Answer - A
om
Ans. is 'a' i.e., Glucose > 60 mg/dl
r.c
Causes of low glucose pleural fluid
Malignancy
ke
Rheumatoid arthritis
an
Empyema
tR
Hemothorax
irs
Paragonimiasis
.F
Churg strauss syndrome
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Lupus pleuritis (occasionally)
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311. In anklyosing spondylitis joint
involvement is least in?
a) Wrist and hand
b) Sacroiliac joint
c) Acromio-clavicular joint
d) Costochondral junction
Correct Answer - A
Ans. is 'a' i.e., Wrist and hand
om
Ankylosing spondylitis (marie - strumpell disease)
Ankylosing spondylitis is a chronic progressive inflammatory disease
r.c
of the sacroiliac joints and the axial skeleton.
ke
Prototype of seronegative (absence of rheumatoid factor)
an
spondyloarthropathies.
tR
Inflammatory disorder of unknown cause.
irs
Usually begins in the second or third decade with a median age of
.F
23, in 5% symptoms begin after 40.
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Male to female ratio is 2-3 : 1
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Strong correlation with HLA-B27
90-95% of cases are positive for HLA - B27.
Joints involved in ankylosing spondylitis
Primarily affects axial skeleton.
The disease usually begins in the sacro-iliac joints and usually
extends upwards to involve the lumbar, thoracic, and often cervical
spine
In the worst cases the hips or shoulders are also affected. o Hip joint
is the most commonly affected peripheral joint. o Rarely knee and
ankle are also involved.
Pathology
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Enthesitis i.e. inflammation of the insertion points of tendons,
ligaments or joint capsule on bone is one of the hallmarks of this
entity of disease.
Primarily affects axial (spinal) skeleton and sacroiliitis is often the
earliest manifestation of A.S..
Involvement of costovertebral joints frequently occur, leading to
diminished chest expansion (normal 5 cm)
Peripheral joints e.g. shoulders, and hips are also involved in 1/3rd
patients.
Extraarticular manifestations like acute anterior uveitis (in 5%); rarely
aortic valve disease, carditis and pulmonary fibrosis also occur.
Pathological changes proceed in three stages?
Inflammation with granulation tissue formation and erosion of
adjacent bone.
Fibrosis of granulation tissue
Ossification of the fibrous tissue, leading to ankylosis of the joint.
Inflammatory bowel disease (CD, UC) may also be seen.
Clinicalfeatures (symptoms)
om
Low back pain of insidious onset
r.c
Duration usually less than 3 months
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Significant morning stiffness and improvement with exercise
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Limited chest expansion
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Diffuse tenderness over the spine and sacroiliac joints
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Loss of lumbar lordosis, increased thoracic kyphosis
Decreased spinal movements (especially extension) in all directions.
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Radiological features of an kvlasing spondylitis
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Radiographic evidence of sacroiliac joint is the most consistent
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finding in ankylosing spondylitis and is crucial for diagnosis.
The findings are :-
D Sclerosis of the articulating surfaces of SI joints
Widening of the sacroiliac joint space
Bony ankylosis of the sacroiliac joints
Calcification of the sacroiliac ligament and sacro-tuberous ligaments
Evidence of enthesopathy - calcification at the attachment of the
muscles, tendons and ligaments, particularly around the pelvis and
around the heel.
X-ray of lumbar spine may show :-
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Li Squaring of vertebrae : The normal anterior concavity of the
vertebral body is lost because of calcification of the anterior
longitudinal ligament.
Loss of the lumbar lordosis.
Bridging 'osteophytes' (syndesmophytes)
Bamboo spine appearance
In the early disease process, plain x-rays may be read as normal.
More accurate and early diagnosis can be done by using MR1
and/or CT scan.
Dynamic MRI with fat saturation, either short tau inversion recovery
(STIR) sequnece or TI weighted images with contrast enhancement
is highly sensitive and specific for identifying early intra-articular
inflammation, cartilage changes, and underlying bone marrow
edema in sacroilitis.
Magnetic resonance imaging allows for visualization of acute
sacroilitis, spondylitis, and spondylodiscitis, and can also detect
acute inflammation of the entheses, bone and synovium. The ability
to detect early inflammatiion and acurately visualize cartilaginous
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and enthesal lesions makes magnetic resonance imaging a useful
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assessment tool in the spondyloarthropathies.
ke
an
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312. Least common site involved in
osteoarthritis is
a) Hip joint
b) Knee joint
c) Carpometacarpal joint of thumb
d) Distal carpophalangeal joint
Correct Answer - C
Ans. is 'C'
om
In the hand the joints specifically involved are ?
Distal interphalangeal join& (of particular importance is the point that
r.c
this joint is not involved in rheumatoid arthritis).
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Proximal interphalangeal join&
an
First carpometacarpal jointsQ
tR
Remember these two important features of joint involvement in
irs
osteoarthritis
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It does not involve the metacarpophalangeal jointso
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It does not involve the wrist joINTEGER(2. It also does not involve
w
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the carpometacarpalQ joint (except at the base of thumb).
Osteoarthritis involves the carpometacarpal joint at the base of
thumb, infact it is the second most common area of involvement in
osteoarthritis.
Other joints which are commonly involved in osteoarthritis are
Hips,
Knees,
Lower lumbar
Cervical.
Joints which are usually spared in osteoarthritis are
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WristsQ, carpometacarpale
ElbowsQ
Shoulder joint
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313. Inverted T waves are seen in
a) Hyperkalemia
b) Hyperthermia
c) Wellen syndrome
d) Coronary syndrome
Correct Answer - C
Ans. is 'c' i.e., Wellen syndrome
Severe anterior wall Ischemia (with or without infarction) may cause
prominent T-wave inversions in the precordial leads. This pattern
om
(sometimes referred to as Wellens T-waves) is usually associated
r.c
with a high-grade stenosis of the left anterior descending coronary
ke
artery.
an
Hyperkalemia has tall Tented T-waves.
tR
Coronary syndrome Xis characterised by blockage of perforators
irs
while the epicardial coronary artery is normal. In these patients
.F
stenting of coronaries is not useful. Nitrates are mainstay of therapy.
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314. Wide QRS complex is typically seen in
a) Bundle Branch block
b) Sick sinus syndrome
c) Mobitz type I block
d) Mobithz type II block
Correct Answer - A
Ans. is 'a' i.e., Bundle Branch block
Repeat from previous session.
Intrinsic intraventricular conduction delays such as left bundle block
om
and right bundle branch block are associated with wide QRS
r.c
complex.
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an
tR
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315. Low QRS voltage on ECG indicates ?
a) Pulmonary embolism
b) Pericardial effusion
c) Cor pulmonale
d) Infective endocarditis
Correct Answer - B
Ans. is 'b' i.e., Pericardial effusion
Causes of low voltage QRS complexes
Adrenal insufficiency
om
Anasarca
r.c
Artifactual or spurious, eg, unrecognized standardization of ECG at
ke
one-half the usual gain (i.e., 5 mm/mv)
an
Cardiac infiltration or replacement (e.g., amyloidosis, tumor)
tR
Cardiac transplantation, especially with acute or chronic rejection
irs
Cardiomyopathy, idiopathic or secondary
.F
Chronic obstructive pulmonary disease
w
Constrictive pericarditis
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Hypothyroidism, usually with sinus bradycardia
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Left pneumothorax (mid-left chest leads)
Myocardial infarction, extensive
Myocarditis, acute or chronic
Normal varian
Obesity
Pericardial effusion
Pericardial tamponade, usually with sinus tachycardia
Pleural effusions
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316. 65-year-old man presents with anemia,
posterior columan dysfunction, and
planter extensor. Which of the following
is the likely cause
a) Tabes dorsalis
b) Frederich's ataxia
c) Vitamin B1 deficiency
d) Vitamin B 12 deficiency
om
Correct Answer - D
r.c
Ans. is 'd' i.e., Vitamin B12 deficiency
ke
Anemia along with involvement of posterior column is characteristic
an
of subacute combined degeneration of spinal cord caused by vitamin
tR
B12 deficiency.
irs
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317. Proptosis is not seen in
a) Grave's disease
b) Sarcoidosis
c) Pituitary adenoma
d) Myxoedema
Correct Answer - D
Ans. is 'd' i.e., Myxoedema
Proptosis occurs in thyrotoxicosis not in hypothyroidism
Choices Logic
om
Cytokines appear to
r.c
play a major role in
ke
thyroid-associated
an
ophthalmopathy There
tR
is infiltration of the
irs
extraocular muscles
.F
by activated T cells;
w
the release of
w
cytokines such as
w
Grave's IFN-alpha and TNF
results in fibroblast
activation and
increased
synthesis of
glycosaminoglycans
that trap water,
thereby leading to
characteristic muscle
swelling
Approximately 20%, of
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Approximately 20%, of
patients with
ophthalmic findings of
sarcoid have soft
tissue involvement of
Sarcoidosis
the orbit or lacrimal
gland and present as
a mass lesion with
proptosis, ptosis, or
ophthalmoplegia.
Macro-adenoma
Pituitary associated with
adenoma pituitary apoplexy can
lead to proptosis.
om
r.c
ke
an
tR
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318. True about obesity
a) Seen mostly in females
b) Prevalence decrease upto 40 years of age
c) No genetic predisposition
d) Smoking is a risk factor
Correct Answer - D
Ans. is 'd' i.e., Smoking is a risk factor
Cessation of smoking
Weight gain is very common when people stop smoking.
om
This is thought to be mediated at least in part by nicotine withdrawal,
r.c
which is associated with increased food intake and reduced energy
ke
expenditure.
an
Weight gain of 1 to 2 kg in the first two weeks is often followed by an
tR
additional 2 to 3 kg weight gain over the next four to five months.
irs
The average weight gain is 4 to 5 kg but can be much greater.
.F
Obesity is common in both men and women (more common in
w
women).
w
Etiologic Classification of Obesity
w
latrogenic causes
Drugs that cause weight gain
Hypothalamic surgery
Dietary obesity
Infant feeding practices
Progressive hyperplastic obesity
Frequency of eating
High fat diets
Overeating
Neuroendocrine obesities
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Hypothalamic obesity
Seasonal affective disorder
Cushing's syndrome
Polycystic ovary syndrome
Hypogonadism
Growth hormone deficiency
Pseudohypoparathyroidism
Social and behavioral factors
Socioeconomic status
Ethnicity
Psychological factors
Restrained eaters
Night eating syndrome
Binge-eating
Sedentary lifestyle
Enforced inactivity (post-operative)
Aging
Genetic (dysmorphic) obesities
om
Autosomal recessive traits
r.c
Autosomal dominant traits
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X-linked traits
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Chromosomal abnormalities
tR
Other
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Low birth weight
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319. What is the of correction of sodium
deficit
a) 0.5 mmol/hour
b) 1 mmol/hour
c) 1.5 mmol/hour
d) 2.0 mmol/hour
Correct Answer - A
Ans. is 'a' i.e., 0.5 mmol/Hr
om
For serious symptomatic hyponatremia, the first line of treatment is
prompt intravenous infusion of hypertonic saline, with a target
r.c
increase of 6 mmol/L over 24 hours (not exceeding 12 mmol/L) and
ke
an additional 8 mmol/L during every 24 hours thereafter until the
an
patient's serum sodium concentration reaches 130 mmol/L.
tR
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320. Maximum loss of sodium in a child
occurs in
a) Gastric juice
b) Ileal fluid
c) Non cholera Diarrhoea
d) Cholera
Correct Answer - B
Ans. is 'b' i.e., heal fluid
om
Cations and anions in biological fluids in meq/dl
Fluid Sodium Potassium Chloride
r.c
Gastric
ke
60 10 85
juice
an
heal
tR
130 10 115
fluid
irs
Diarrhea
.F
10-90 10-80 10-110
stool
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321. With regards to G6PD deficiency, which
of the following in false
a) Affects the pentose phosphate pathway
b) Associated with neonatal jaundice
c) Acute haemolysis can be precipitated by broad beans
d) X-linked recessive disorder that does not affect heterozygous
famales
Correct Answer - D
om
Ans. is 'd' i.e., X-linked recessive disorder that does not affect
heterozygous famales
r.c
Glucose 6-phosphate dehydrogenase (G6PD) deficiency, an X-
ke
linked disorder, is the most common enzymatic disorder of red blood
an
cells in humans, affecting 400 million people worldwide.
tR
Clinical spectrum
irs
The clinical expression of G6PD variants encompasses a spectrum
.F
of hemolytic syndromes
w
The four forms of symptomatic G6PD deficiency :
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Acute hemolytic anemia
Favism
Congenital nonspherocytic hemolytic anemia
Neonatal hyperbilirubinemia
G6PD deficiency is expressed in males carrying a variant gene that
results in sufficient enzyme deficiency to lead to symptoms.
Acute hemolytic anemia
Almost all individuals with the most prevalent G6PD variants, G6PD
A- and G6PD Mediterranean, are asymptomatic in the steady state.
They have neither anemia, evidence of increased red cell
destruction, nor an alteration in blood morphology,. o However
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sudden destruction of enzyme deficient erythrocytes can be
triggered by certain drugs or chemicals, by selected infections, and
rarely by metabolic abnormalities (eg, diabetic ketoacidosis).
Clinical course
At two to four days after drug ingestion, there is the sudden onset of
jaundice, pallor, and dark urine, with or without abdominal and back
pain.
This is associated with an abrupt fall in the hemoglobin
concentration of 3 to 4 g/dL, during which time the
peripheral blood smear reveals red cell fragments,
microspherocytes, and eccentrocytes or "bite" cells.
The anemia induces an appropriate stimulation of erythropoiesis,
characterized by an increase in reticulocytes that is apparent within
five days and is maximal at 7 to 10 days after the onset of
hemolysis.
Even with continued drug exposure, the acute hemolytic process
ends after about one week, with ultimate reversal of the anemia.
Inciting events
om
Patients with class II or III variants develop intermittent hemolysis
r.c
only after one or more of the following inciting events.
ke
Infection
an
Oxidant drugs
tR
Chemical agents (eg, moth balls, aniline dyes, henna compounds)
irs
Diabetic ketoacidosis
Ingestion of fava beans
.F
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Drugs and chemicals
w
Primaquine, dapsone, and a number of other drugs can precipitate
w
hemolysis in G6PD deficient subjects.
Foods: fava beans and bitter melon
G6PD deficiency can also be precipitated by the the ingestion of
fresh fava beans (favism).
Manifestation offavism begins 5-24 hrs after fava bean ingestion and
include headache, nausea, back pain.
Congenital nonspherocytic hemolytic anemia
Patients with class I G6PD variants have such severe G6PD
deficiency that lifelong hemolysis occurs in the absence of infection
or drug exposure.
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Such patients fall under the category of having congenital
nonspherocytic hemolytic anemia.
These G6PD variants have low in vitro activity and/or marked
instability of the molecule, and most have DNA mutations at the
glucose-6-phosphate or NADP binding sites.
These sites are central to the function of G6PD, which oxidizes
glucose-6-phosphate and reduces NADP to NADPH. It is presumed
that the functional defect is so severe that the red cells cannot
withstand even the normal oxidative stresses encountered in the
circulation.
Anemia and jaundice are often first noted in the newborn period, and
the degree of hyperbilirubinemia is frequently of sufficient severity to
require exchange transfusion.
After infancy, hemolytic manifestations are subtle and inconstant.
Most individuals have mild to moderate anemia (hemoglobin 8 to 10
g/dL) with a reticulocyte count of 10 to 15 percent. Pallor is
uncommon, scleral icterus is intermittent, splenomegaly is rare, and
splenectomy generally is of little benefit.
om
Hemolysis can be exaggerated by exposure to drugs or chemicals
r.c
with oxidant potential or exposure to fava beans.
ke
Some drugs with relatively mild oxidant potential that are safe in
an
patients with class II or class III G6PD variants may increase
tR
hemolysis in patients with class I variants.
irs
Neonatal hyperbilirubineinia
.F
The clinical picture of neonatal jaundice due to G6PD deficiency
w
differs from neonatal jaundice seen in hemolytic disease of the fetus
w
and newborn (HDFN) associated with Rh(D) incompatibility in two
w
main respects.
G6PD deficiency-related neonatal jaundice is rarely present at birth;
the peak incidence of clinical onset is between days two and three.
a There is more jaundice than anemia, and the anemia is rarely
severe. The severity ofjaundice varies widely, from being subclinical
to imposing the threat of kernicterus if not treated
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322. All of the following statements about
genetics of G6PD deficiency are true,
except
a) X-linked inheritance
b) More severe in Men
c) Contradicts Lyon Hypothesis
d) May affect Heterozygous females
Correct Answer - C
om
Ans. is 'c' i.e., Contradicts Lyon Hypothesis
r.c
Genetics of G6PD
The gene for G6PD is located on the X chromosome (band X q28)
ke
[8] and has been cloned and sequenced. o Even though females
an
have two X chromosomes per cell, normal males and females have
tR
the same enzyme activity
irs
in their red cells because one of the X chromosomes in each cell of
.F
the female embryo is inactivated and remains
w
w
inactive throughout subsequent cell divisions (Lyon hypothesis).
w
G6PD deficiency is expressed in males carrying a variant gene,
while heterozygous females are usually clinically normal.
However, the mean red blood cell enzyme activity in heterozygous
females may be normal, moderately reduced, or grossly deficient
depending upon the degree of lyonization and the degree to which
the abnormal G6PD variant is expressed.
G6PD supports Lyon's hypothesis :-
According to lyon's hypothesis one of the two chromosome in each
cell of the female embryo is inactivated and remains inactive
throughout subsequent cell division.
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G6PD is inherited as an X-linked (recessive) disorder, it is more
common in males.
Heterozygous Female may also be affected depend on the extent of
lyonisation (inactivation of one X-chromosome) but the overall
average degrees of hemolysis in heterozygous female is less.
A heterozygous female with 50 percent normal G6PD activity has 50
percent normal red cells and 50 percent G6PD-deficient red cells.
The deficient cells are as vulnerable to hemolysis as the enzyme-
deficient red blood cells in males.
Male
Males, who have only one copy of the X chromosome, are either
normal or hemizygous for the variant glucose 6-phosphate
dehydrogenase (G6PD) gene.
Thus, G6PD deficiency is expressed in males carrying a variant
gene on their X chromosome that produces sufficient enzyme
deficiency to lead to symptoms. All of the red cells in affected males
are vulnerable to hemolysis.
Female
om
Females, who have two copies of the X chromosome, are either
r.c
normal, heterozygous, or homozygous for the variant gene.
ke
Heterozygous females are usually clinically normal.
an
However, their mean red blood cell enzyme activity may be normal,
tR
moderately reduced, or grossly deficient depending upon the degree
irs
of X chromosome inactivation (lyonization) and the degree to which
the abnormal G6PD variant is expressed.
.F
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A female with 50 percent normal G6PD activity, due to inactivation of
w
one X chromosome in each cell via lyonization, has 50 percent
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normal red cells and 50 percent G6PD-deficient red cells.
The deficient cells are as vulnerable to hemolysis as the enzyme-
deficient red blood cells in males.
Homozygous females are as severely affected clinically as
hemizygous males. All of their red cells are vulnerable to hemolysis
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323. Platelets in stored blood do not live after
a) 24 hours
b) 48 hours
c) 72 hours
d) 96 hours
Correct Answer - C
Ans. is 'c' i.e., 72 hours
Platelets are provided as a pooled preparation from one or several
donors, usually as a 6-unit bag, which is the
om
usual amount given to an average-sized adult.
r.c
Each unit contains approximately 8 x 101° platelets and should
ke
increase the platelet count by about 7000-10,000/ pL in a 75kg adult.
an
Platelets stored at room temperature can be used for up to 5 days
tR
and have a life span of 8 days.
irs
Those stored at 4°C are useful for only 24 hours (only 50-70% of
.F
total platelet activity is present at 6 hours) and have a life span of
w
only 2-3 days.
w
ABO compatibility should be observed for platelets, but is not
w
essential. For each donor used, there is a similar risk of transmitting
hepatitis and HIV as for one unit of blood.
Platelet should be administered through a 170pm filter.
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324. Earliest and often the only presentation
of TB kidney is
a) Increased frequency
b) Colicky pain
c) Hematuria
d) Renal calculi
Correct Answer - A
Ans. is 'a' i.e., Increased frequency
om
Urinary frequency, dysuria, nocturia, hematuria, and flank or
abdominal pain is common presentations.
r.c
However, patients may be asymptomatic and the disease is
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discovered only after severe destructive lesions of the kidneys have
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developed.
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Urinalysis gives abnormal results in 90% of cases, revealing pyuria
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and hematuria.
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The documentation of culture-negative pyuria in acidic urine raises
w
the suspicion of TB.
w
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IV pyelography, abdominal CT, or MRI may show deformities and
obstruction, and calcifications and ureteral strictures are suggestive
findings.
Culture of three morning urine specimens yields a definitive
diagnosis in nearly 90% of cases.
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325. Most common cause of diarrhea in AIDS
patients?
a) Salmonella typhimurium
b) Cryptosporidium
c) Candida
d) isophora
Correct Answer - B
Ans. is 'b' i.e., Cryptosporidium
om
Most common cause of diarrhea in HIV → Cryptosporidium.
Diseases of Oropharvnx and GI system in H.I.V.
r.c
These are :?
ke
Oral lesions : Thrush (oral candidiasis), oral Hairy leukoplakia
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(caused by EBV), and aphthous ulcer. Esophageal : Esophagitis by
tR
CMV, HSV or candida.
irs
Diarrhea : Diarrhea is caused by :-
.F
Bacteria : Salmonella, Shigella, Campylobacter, and mycobacteria
w
avium intracellulare.
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Fungal : Histoplasma, Coccidioides, penicillium.
Other : CMV, microsporidia, isospora helli, and cryptosporidia.
AIDS enteropathy (HIV enteropathy)
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326. Not seen with uremic lung
a) alveolar injury
b) Pulmonary edema
c) Interstitial fibrosis
d) Fibrinous exudate in alveoli
Correct Answer - C
Ans. is 'c' i.e., Interstitial fibrosis
Uremic lung is referred to abnormalities expressed chest x-ray
abnormalities seen in patients with CKD.
om
The pathogenesis was believed to be related to blood urea nitrogen
r.c
and creatinine retention.
ke
There is :
an
Its pathophysiology is based on uremia-induced increased
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permeability of pulmonary alveolo-capillary interfaces, leading to
irs
Interstitial and intra-alveolar edema
.F
Atelectasis
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Alveolar hemorrhage
w
Pulmonary hyaline membrane formation.
w
These changes are compounded by bleeding diathesis secondary to
platelet dysfunction in advanced renal disease.
The pulmonary symptoms and radiographic findings are reversible
with hemodialysis.
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327. Oliguric phase of ARF is characterized
by A/E
a) Chest pain
b) Acidosis
c) Hypertension
d) Hypokalemia
Correct Answer - D
Ans. is 'd' i.e., Hypokalemia
om
Maintenance phase (Oliguric phase) (Lasts for 1-2 weeks) Uremic
r.c
complications and electrolyte abnormalities arise during this phase-
ke
• GFR reaches its lowest point, urine output is lowest (typically 5-10
an
ml/min)
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• Due to fluid overload and decreased electrolyte excretion, following
irs
electrolyte abnormalities are seen
.F
• Hyperkalemia - (d/t reduced excretion)
w
. Hyponatremia -s (d/t volume overload)
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. Hyperphosphatemia 4 (d/t reduced excretion)
. Hypermagnesemia - (d/t reduced excretion)
. Hyperuricemia -> (d/t reduced excretion)
. Hypocalcemia -> (d/t deposition of calcium phosphate)
. Elevation of B. U.N. 4 (d/t reduced excretion)
. Hyposmolality -> (d/t volume overload)
. Anemia 4 (d/t Impaired erythropoiesis Hemolysis, bleeding Dilution)
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328. In EEG type of wave seen in metabolic
encephalophathy
a) Alpha
b) Beta
c) Gamma
d) Delta
Correct Answer - D
Ans. is 'cl' i.e., Delta
om
E.E.G. changes in metabolic encephalopathy
In metabolic encephalopathy changes are typically nonfocal
r.c
E.E.G. has been widely used to evaluate metabolic encephalopathy.
ke
The E.E.G .findings are abnormal in acute encephalopathic stages.
an
It is difficult to establish a diagnosis of metabolic encephalopathy
tR
with certainity through E.E.G.
irs
There is generalized slowing of the E.E.G with an excess of the
.F
delta and theta waves with suppression of normal alpha and beta
w
wave activity and occasionally bilateral spikes and waves complexes
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occurring in absence of seizure activity".
In metabolic encephalopathies, the E.E.G evolution correlates well
with the severity of encephalopathy. o However EEG has little
specificity in differentiating etiologies in metabolic encephalopathy.
For example, though triphasic waves are most frequently mentioned
in hepatic encephalopathy, they can also be seen in uremic
encephalopathy or even in aged psychiatric patients treated with
lithium. o Spikes and waves may appear in hypo or hyperglycemia
uremic encephalopathy or vitamin deficiencies.
Common principles of EEG changes in metabolic
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encephalopathy are : -
Varied degrees of slowing
Associated mixtures of epileptic discharge
High incidence of triphasic waves
Reversibility after treatment of underlying causes
Metabolic
EEG rythm
encephalopathy
Dominant activity is
Grade I (almost
alpha rhythm with
normal)
minimal teta activity
Dominant teta
Grade II (mildly background with
abnormal) some alpha and
delta activities.
Continuous delta
Grade II activity
(moderately predominates, little
abnormal) activity of faster
om
frequencies
r.c
Low-amplitude delta
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Grade IV
activity or
an
(severely
suppression-burst
abnormal)
tR
pattern
irs
Grade V Nearly"flat" tracing
.F
(extremely or electrocerebral
w
abnormal) inactivity.
w
w
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329. Asbestosis causes all except
a) Shaggy heart borders
b) Honeycombing
c) Hilar lymphadenopathy
d) Basal peribronchial fibrosis
Correct Answer - C
Ans. is 'c' i.e., Hilar lymphadenopathy
Asbestosis causes fibrosis in the lower lobes of the lung.
Pleural plaque formed by asbestosis most commonly affects
om
anterolateral and posterolateral aspects of parietal pleura and over
r.c
the dome of diaphragm
ke
an
tR
irs
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330. The most common cause of sudden
death in sarcoidosis is
a) Pneumonia
b) Cor pulmonale
c) Arrythmias
d) Liver failure
Correct Answer - C
Ans. is 'c' i.e., Arrhythmias
om
Cardiac involvement occurs initially with inflammation and
granuloma formation followed by scarring. The initial inflammation
r.c
can lead to triggered ventricular arrhythmias with subsequent
ke
scarring resulting in the substrate for reentrant monomorphic
an
ventricular tachycardia.
tR
irs
.F
w
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331. Most common cause of unilateral Hilar
lymphadenopathy
a) Histoplasmosis
b) Sarcoidosis
c) Aspergillosis
d) Tuberculosis
Correct Answer - D
Ans. is 'd' i.e., Tuberculosis
om
Primary TB most commonly presents with focal alveolar pneumonia
and associated unilateral hilar or mediastinal adenopathy.
r.c
ke
an
tR
irs
.F
w
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332. Which of the following is cause of RBBB
a) It can occur in a normal person
b) Pulmonary embolism
c) Corpulmonale
d) All of the above
Correct Answer - D
Ans. is 'd' i.e., All of the above
Causes of RBBB
Normal physiological
om
Pulmonary embolism/corpulmonale
r.c
Pulmonary artery hypertension
ke
ASD
an
Rheumatic heart disease
tR
irs
.F
w
w
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333. Alternating RBBB with Left anterior
hemiblock is seen in
a) 1' degree heart block
b) Complete heart block
c) Mobitz type II block
d) Bi-fascicular block
Correct Answer - D
Ans. is 'd' i.e., Bi-fascicular block
om
Bifascicular block → combination of RBBB with
either left anterior hemiblock or left posterior hemiblock.
r.c
Tri fascicular block → RBBB plus either
ke
LAHB/LPHB+ first degree AV block.
an
Complete heart block destruction of → AV node leading to AV
tR
dissociation
irs
.F
w
w
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334. In LVH, SV1 +RV6 is more than mm
a) 25
b) 30
c) 35
d) 45
Correct Answer - C
Ans. is 'c' i.e., 35
Arrhythmias by Kathryn Lewis p. 219] o In LVH, SV-1 plus RV-6
is more than 15 mm.
om
To diagnose the left ventricular hypertrophy on ECG one of the
r.c
following criteria should be met :?
ke
The sokolow-lyon criteria is most often used -
an
R in V, or V6 + 5 in V > 35 mm in men
tR
irs
The cornell-criteria has different values
.F
R in aVL and S in V3 > 28 mm in men
w
R in aVL and S in V3 > 20 mm in women
w
As the left ventricular wall becomes thicker QRS complexes are
w
larger in leads V1-V6
S wave is deep in V,
R wave is high in V4
ST depression in V„-V, (strain pattern)
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335. Most common site for berry aneurysm
rupture
a) Anterior circulation of brai
b) Posterior circulation of brain
c) Ascending aorta
d) Descending aorta
Correct Answer - A
Ans. is 'a' i.e., Anterior circulation of brain
om
The most common sites in descending order of frequency are -
Li Proximal portion of anterior communicating artery (at the junction
r.c
of anterior communicating artery with cerebral artery)
ke
At the origin of the posterior communicating artery from the stem of
an
the internal carotid artery.
tR
At the first major bifurcation of middle cerebral artery.
irs
At the bifurcation of internal carotid into middle and anterior cerebral
.F
arteries.
w
Vertibrobasilar bifurcation (3%)
w
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336. Obesity is seen in all except
a) Cushing syndrome
b) Pickwinian syndrome
c) Prader willi syndrome
d) Sipple syndrome
Correct Answer - D
Ans. is `d' i.e., Sipple syndrome
Important syndromes associated with obesity
Albright hereditary osteodystrophy (pseudohypoparathyroidism type
om
la)
r.c
Alstrom syndrome
ke
Bardet-Biedl syndrome
an
Beckwith-Wiedemann syndrome
tR
Carpenter syndrome
irs
Cohen syndrome • Prader-willi syndrome
.F
w
w
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337. Cause of death in diabetic ketoacidosis
in children
a) Cerebral edema
b) Hypokalemia
c) Infection
d) Acidosis
Correct Answer - A
Ans. is 'a' i.e., Cerebral edema
om
High blood sugar will cross the blood-brain barrier and
simultaneously will draw water inside leading to cerebral edema.
r.c
Cerebral edema accounts for 60-90% of all DKA related deaths in
ke
children.
an
Infection is a precipitator for the development of DKA.
tR
Other precipitating factors can be tissue ischemia, inadequate
irs
insulin administration, drugs (cocaine) and pregnancy.
.F
w
w
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338. Acute hyponatremia becomes
symptomatic at
a) < 135 mEq
b) < 125 mEq
c) < 120 mEq
d) < 110 mEq
Correct Answer - B
Ans. is 'b' i.e., < 125 mEq
om
Serum level of sodium at which symptoms develop
Acute < 125 meq/L
r.c
Chronic < 120 meq/L
ke
Hyponatremia is commonly defined as a serum sodium < 135
an
mmol/L (< 135 mEq/L). Neurological symptoms
tR
occur at different levels of low sodium, depending not only on the
irs
absolute value but also on the rate of fall.
.F
In patients with hyponatremia that develops over hours, life-
w
threatening seizures and cerebral edema may occur
w
w
at values as high as 125 mmol/L.
In contrast, some patients with more chronic hyponatremia that has
slowly developed over months to years may be asymptomatic even
with serum levels < 110 mmol.
Acute or hvperacute hvponatremia
The hyponatremia developed within the previous 24 hours, it is
called "acute."
If the hyponatremia developed over just a few hours due to a
marked increase in water intake (self-induced water intoxication, as
may be seen in marathon runners, psychotic patients, and users of
ecstasy), it is called "hyperacute."
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Chronic hyponatremia
If it is known that the hyponatremia has been presentfbr more than
48 hours, or if the duration is unknown (such as in patients who
develop hyponatremia at home), it is called "chronic."
Mild to moderate hyponatremia
Mild hyponatremia is usually defined as a serum sodium
concentration between 130 and 135 meq/L.
Moderate hyponatremia is often defined as a serum sodium
concentration between 121 and 129 meq/L.
Severe hvponatremia
Severe hyponatremia can be defined as a serum sodium of 120
meq/L or less.
Symptoms of hvponatremia
Absent symptoms
Patients with hyponatremia are frequently asymptomatic, particularly
if the hyponatremia is chronic and of mild or moderate severity (ie,
serum sodium >120 meq/L).
However, such patients may have subclinical impairments in
om
mentation and gait.
r.c
Mild to moderate symptoms
ke
Mild to moderate symptoms of hyponatremia are relatively
an
nonspecific and include headache, nausea, vomiting, fatigue, gait
tR
disturbances, and confusion.
irs
In patients with chronic hyponatremia (ie, >48 hours duration), these
findings are not associated with impending herniation; however, in
.F
w
patients with more acute hyponatremia, such symptoms should be
w
considered ominous and may evolve without warning to seizures,
w
respiratory arrest, and herniation.
Severe symptoms
Severe symptoms of hyponatremia include
u Seizures
Obtundation
Coma
Respiratory arrest.
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339. Hyponatremia is seen in
a) Hyperthyroidism
b) Hypothyroidism
c) Diabetes insipidus
d) Increased insensible losses
Correct Answer - B
Ans. is 'b' i.e., Hypothyroidism [RefHarrison's 18th
Hypothyroidism is characterised by low cardiac output leading to
increased AVP production and resultant hyponatremia.
om
Addison disease must be ruled out in chronic cases of hyponatremia
r.c
Major causes of hyponatremia
ke
Disorders in which ADH levels are elevated
an
Effective circulating volume depletion
tR
True volume depletion
irs
Heart failure
.F
Cirrhosis
w
Thiazide diuretics
w
Syndrome of inappropriate ADH secretion, including reset osmostat
w
pattern
Hormonal changes
Adrenal insufficiency
Hypothyroidism
Pregnancy
Disorders in which ADH levels may be appropriately
suppressed
Advanced renal failure
Primary polydipsia
Beer drinker's potomama
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Hyponatremia with normal or elevated plasma osmolality
High plasma osmolality (effective osmols)
Hyperglycemia
Mannitol
High plasma osmolality (ineffective osmols)
Renal failure
Alcohol intoxication with an elevated serum alcohlo concentration
Normal plasma osmolality
Psedohyponatremia (laboratory artifact)
High triglycerides
Chloestatic and obstructive jaundice (lipoprotein x)
Multiple myeloma
Absorption of irrigant solutions
Glycine Sorbitol Mannitol
om
r.c
ke
an
tR
irs
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340. Chronic Non-Spherocytic hemolytic
anemia is seen in which class of G6PD
deficiency
a) Class I
b) Class II
c) Class III
d) Class IV
Correct Answer - A
om
Ans. is 'a' i.e., Class I
r.c
The four forms of symptomatic G6PD deficiency :
Acute hemolytic anemia
ke
Favism
an
Congenital nonspherocytic hemolytic anemia
tR
Neonatal hyperbilirubinemia
irs
Congenital nonspherocvtic hemolytic anemia
.F
Patients with class I G6PD variants have such severe G6PD
w
w
deficiency that lifelong hemolysis occurs in the absence of infection
w
or drug exposure.
Such patients fall under the category of having congenital
nonspherocvtic hemolytic anemia.
These G6PD variants have low in vitro activity and/or marked
instability of the molecule, and most have DNA mutations at the
glucose-6-phosphate or NADP binding sites.
These sites are central to the function of G6PD, which oxidizes
glucose-6-phosphate and reduces NADP to NADPH. It is presumed
that the functional defect is so severe that the red cells cannot
withstand even the normal oxidative stresses encountered in the
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circulation.
Anemia and jaundice are often first noted in the newborn period, and
the degree of hyperbilirubinemia is frequently of sufficient severity to
require exchange transfusion.
After infancy, hemolytic manifestations are subtle and inconstant.
Most individuals have mild to moderate anemia (hemoglobin 8 to 10
g/dL) with a reticulocyte count of 10 to 15 percent. Pallor is
uncommon, scleral icterus is intermittent, splenomegaly is rare, and
splenectomy generally is of little benefit.
Hemolysis can be exaggerated by exposure to drugs or chemicals
with oxidant potential or exposure to fava beans.
Some drugs with relatively mild oxidant potential that are safe in
patients with class II or class III G6PD variants may increase
hemolysis in patients with class I variants.
Disease variants of Glucose 6 phosphate dehvdrogenase
deficiency
The World Health Organization has classified the different G6PD
variants according to the magnitude of the enzyme deficiency and
om
the severity of hemolysis. Classes IV and V are of no clinical
r.c
significance.
ke
TypesFeatures
an
Variants have severe enzyme
tR
deficiency (less than 10 percent
Class
irs
of normal) and have chronic
I
.F
(nonspherocytic) hemolytic
w
anemia.
w
Variants, such as G6PD
w
Mediterranean, also have
severe enzyme deficiency, but
Class
there are, usually only
II
intermittent episodes of acute
hemolysis associated with
infection, drugs, or chemicals.
Variants, such as G6PD A-,
have moderate enzyme
Class deficiency (10 to 60 percent of
normal) with intermittent
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III episodes of acute hemolysis
usually associated with
infection, drugs, or chemicals
Class Variants have no
IV enzyme.deficiency or hemolysis.
Class Variants have increased
V enzyme activity
om
r.c
ke
an
tR
irs
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341. What is the Neutrophil count for
moderate neutropenia
a) < 500/mm'
b) 500-1000/mm'
c) > 1000/mm3
d) 100/mm3
Correct Answer - B
Ans. is 'b' i.e., 500-1000mm'
om
Mild neutropenia → Is present when the ANC is 1000-
15000 cells/µL
r.c
Moderate neutropenia → Is present with an ANC of 500-1000/4
ke
Severe neutropenia ANC lower than 500 cells/pL.
an
The risk of bacterial infection is related to both the severity and
tR
duration of the neutropenia.
irs
.F
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342. Gout can be precipitated by all of the
following
a) Thiazides
b) Furosemide
c) Cyclosporine
d) High dose salicylates
Correct Answer - D
Ans. is 'd' i.e., High dose salicylates
om
High dose Salicylates are uricosuric and do not cause
Hyperuricemia.
r.c
Diuretics including Thiazides and Furosemide are known to cause
ke
Hyperuricemia. Cyclosporine and Tacrolimus are also associated
an
with Hyperuricemia.
tR
High Doses of Salicylates > 3.0 g/day are uricosuric, while Low
irs
doses (0.3 to 3.0 g/day) are associated with uric acid retention and
.F
Hyperuricemia.
w
Also know
w
w
Causes of drug or diet induced hvperuricemia.
Diuretics (thiazides and loop diuretics)
Cyclosporine and tacrolimus.
Low dose salicylates.
Ethambutol.
Pyrazinamide.
Ethanol.
Levodopa.
Methoxyflurane.
Laxative abuse (alkalosis).
Salt restriction.
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om
r.c
ke
an
tR
irs
.F
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343. Relative risk of developing TB in patients
already infected with TB bacilus is
highest in
a) Diabetes
b) Recent infection
c) Post transplantation
d) Malnutrition
Correct Answer - C
om
Ans. is 'c' i.e., Post transplantation
r.c
Relative risk of developing T.B.
ke
Post 20-
transplantation 70
an
HIV 30
tR
irs
Silicosis 30
.F
Recent infection 12
w
Diabetes 3-4
w
Malnutrition 2-3
w
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344. I.R.I.S. is
a) Immune reconstitution idiopathic syndrome
b) Immune reconstitution immunological syndrome
c) Immune reconstitution inflammatory syndrome
d) Inflammatory reconstitution immune syndrome
Correct Answer - C
Ans. is 'c' i.e., Immune reconstitution inflammatory syndrome
Causes of bone marrow suppression in patients with HIV
infection
om
HIV infection Medications
r.c
Mycobacterial
Zidovudine
ke
infections
an
Fungal
Dapsone
tR
infections
irs
B 19
.F
parvovirus Trimethoprim/Sulfamethoxazole
w
infection
w
w
Pyrimethamine
5-Flucytosine
Lymphoma Ganciclovir Interferon a
Trimetrexate
Foscarnet
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345. In renal failure, metabolic acidosis is due
to
a) Increased fr production
b) Loss of HCO,
c) Decreased ammonia synthesis
d) Use of diuretics
Correct Answer - C
Ans. is 'c' i.e., Decreased ammonia synthesis
om
The predominant reason for metabolic acidosis in C.R.E is
decreased ammonia production.
r.c
Metabolic acidosis is a common disturbance in advanced chronic
ke
kidney disease
an
The majority of patients can still acidly the urine but they produce
tR
less ammonia and, therefore, cannot excrete the normal quantity of
irs
protons in combination with this urinary buffer.
.F
w
w
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346. Diagnostic feature of CRF is
a) Broad casts in urine
b) Elevated blood urea
c) Proteinuria
d) Bleeding diathesis
Correct Answer - A
Ans. is 'a' i.e., Broad casts in urine
Casts ?
Urinary casts are formed only in the distal convoluted tubulee (DCT)
om
or the collecting dude (distal nephron).
r.c
The proximal convoluted tubule and loop of henle are not the
ke
locations for cast formation.
an
Casts are
tR
formed through the solidification of materials in the tubules of
irs
nephrons
.F
Later the material is flushed out of the kidney upon the production of
w
more urine leaving a small solidified microscopic cylinder that can
w
also contain what ever other materials that might be within the
w
tubules of the kidneys at the time of cast formation.
The microscopic detection of various types of casts can often be
helpful diagnostic tool in the study of various types of renal diseases
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347. Eosinophilic meningitis is seen with all
except?
a) Coccidiomycosis
b) Cryptococcal meningitis
c) Lepto meningeal metastasis
d) Helminthic infections
Correct Answer - B
Ans. is 'b' i.e., Cryptococcal meningitis
om
Causes of eosinophilic meningitis
Infectious, parasitic causes
r.c
Roundworm (nematode) infections - commonly present as
ke
eosinophilic meningitis
an
Angiotronglylus cantonensis - migrating larvae inherently neurotropic
tR
Gnathostoma spinigerum - migrating larvae in visceral and/or neural
irs
tissues
.F
Baylisascaris procyonis - migrating larvae inherently neurotropic
w
Tapeworm (cestode) infections - may present as eosinophilic
w
w
meningitis
Cysticercosis -Cysts develop in CNS and/or visceral tissues
Fluke (trematode) infections - occasionally cause eosinophilic
meningitis
Paragonimus westermani - ectopic spinal or cerebral localization.
Schistosomiasis - ectopic spinal or cerebral localization.
Fascioliasis - ectopic CNS localization.
Other roundworm infections which occasionally cause
eosinophilic meningitis
Toxocariasis - migrating larvae
Nonparasitic, infectious causes
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Coccidioidomycosis
Cryptococcosis - CSF eosinophilia rare
Myiasis - with CNS penetration
Virus and bacteria - are of uncertain causality
Noninfectious causes
Idiopathic hypereosinophilic syndromes
Ventriculoperitoneal shunts
Leukemia or lymphoma with CNS involvement (Hodgkin's)
Nonsteroidal antiinflammatory drugs
Antibiotics - ciprofloxacin, trimethoprim - sulfamethoxazole,
intraventricular gentamicin or vancomycin
Myelography contrast agents
om
r.c
ke
an
tR
irs
.F
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348. Christmas tree appearance of urinary
bladder is seen in
a) Neurogenic bladder
b) Stress incontinence
c) Autonomous bladder
d) Enuresis
Correct Answer - A
Ans. is 'a' i.e., Neurogenic bladder
om
Christmas tree appearance of the bladder is seen in neurogenic
bladder caused by detrusor hyperreflexia.
r.c
Detrusor hyperreflexia is caused by lesions of the spinal cord above
ke
the sacral segments but below the pons. Such patients have
an
noperception of bladder filling or emptying and voluntary voiding is
tR
not possible.
irs
Voiding when it does occur is involuntary with simultaneous
.F
contractions of the detrusor and external sphincter muscles.
w
Common neurological condition resulting in detrusor hyperreflexia
w
w
include
Multiple sclerosis
Myelodysplasia,
Spinal cord trauma
Spinal cord tumours,
A-V malformatio not the spinal cord
Radiologically, patients with long terms untreated detrusor
hyperreflaxia have characteristic changes of the urinary tact.
Bladder is vertically oriented, with an irregular contours, consistent
with trabeculation. There are frequently multipel diverticula, Such a
bladder is referred to as a christmas tree.
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Automatic Autonomous
bladder bladder
Cauda equina
Above T5 or damage /
Lesion site
higher lower motero
neuron
Small spastic damage Large
Manifestation
bladder flaccid bladder
Has no urge
sensation and
urge comes continuous
again and DRIBBLING
again due to occurs, So it is
repeated like the
Why this contractions bladder is
name and hence working all the
empties time but Brain
repeatedly has no control
om
after some over it and
r.c
time hence called
ke
autonomous
an
bladder
tR
No VUR but
irs
Christmas still bladder is
Radiological
.F
tree large and
data
w
appearance holds lots of
w
w
residual urine
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349. the diffusion capacity of lung (DL) is
decreased in all of the following
conditions except
a) Inerstitial lung diseas
b) Goodpasture's syndrome
c) Pneumocystis Jiroveci
d) Primary pulmonary hypertension
Correct Answer - B
om
Ans. is 'b' i.e., Goodpasture's syndrome
r.c
Gas diffusion tests :
Gas diffusion tests measure the amount of oxygen and other gases
ke
that cross the alveoli into the blood.
an
These tests evaluate how well gases are being absorbed into the
tR
blood from lungs. Gas diffusion tests include.
irs
Carbon monoxide diffusing capacity (transfer factor DLcy)
.F
Arterial blood gases
w
w
Carbon monoxide diffusing capacity (DL):
w
This measures how well the lung transfers a small amount of carbon
monoxide into the blood0.
Normally, in the lung, a gas has to cross the alveolar membrane,
capillary membrane to reach the blood where it combines with
hemoglobin.
So quiet obviously the diffusion capacity of gas depends upon
Driving pressure of the gas
Surface area of alveolar capillary membrane
Thickness of alveolar capillary membrane
Diffusion coefficient of the gas
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Red blood cell volume.
Reaction rate with hemoglobin and hemoglobin level of patient.
Degree of V/Q mismatching.
om
r.c
ke
an
tR
irs
.F
w
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350. Keratoderma-Blenorrhagicum is
pathogno-monic of
a) Behcet's disease
b) Reiter's disease
c) Lyme's disease
d) Glucagonoma
Correct Answer - B
Ans. is 'b' i.e., Reiter's disease
om
Keratoderma Blenorrhagica is the characteristic skin lesion
seen in patients with Reactive Arthritis.
r.c
"The Characteristic skin lesions in Reactive Arthritis, Keratoderma
ke
Blenorrhagica, consist of vesicles that become hyperkeratotic,
an
ultimately forming a crust before disappearing. These are seen in
tR
palms and soles.
irs
.F
w
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351. In Takayasu's arteritis there is
a) Intimal fibrosis
b) Renal hypertension
c) Coronary aneurysm
d) All of the above
Correct Answer - B
Ans. is `b' i.e., Renal hypertension
Potential
Artery clinical
om
manifestation
r.c
Arm
ke
claudication,
Subclavian
an
Raynaud's
tR
phenomenon
irs
Visual
.F
changes,
w
syncope
w
Commoncarotid
transient,
w
ischaemic
attacks stroke
Abdominal
AbdominalAorta pain, nausea
vomiting
Hypertension,
renal failure,
aortic
Renal
insufficiency,
congestive
heart failure
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heart failure
Visual
Vertebral changes,
dizziness
Abdominal
Coeliac axis pain, nausea
vomiting
Iliac Leg
claudication
Atypical chest
Pulmonary
pain dyspnea
Chest pain
Coronary myocardial
infarction
om
r.c
ke
an
tR
irs
.F
w
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352. Which is not a high pitched heart sound
a) Mid systolic click
b) Pericardial shudder
c) Opening snap
d) Tumor plop sound
Correct Answer - D
Ans. is 'd' i.e., Tumor plop sound
Low pitch heart sounds are :
S3
om
S4
r.c
Tumor plop sound
ke
Mid systolic clicks are
an
Heard in mitral valve prolapse during systole and are high pitch
tR
sounds.
irs
The pericardial knock (PK) is
.F
Also high-pitched and occurs slightly later than the opening snap,
w
corresponding in timing to the abrupt cessation of ventricular
w
expansion after tricuspid valve opening and to an exaggerated y
w
descent seen in the jugular venous waveform in patients with
constrictive pericarditis.
A tumor plop is
A lower-pitched sound that can be heard in patients with atrial
myxoma.
It may be appreciated only in certain positions and arises from the
diastolic prolapse of the tumor across the mitral valve
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353. Broad complex tachycardia, due to
ventricular tachycardia is suggested by
all except
a) Fusion beats
b) AV dissociation
c) Capture beats
d) Termination of tachycardia by carotid sinus massage
Correct Answer - D
om
Ans. is `d' i.e., Termination of tachycardia by carotid sinus massage
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354. Rupture of berry aneurysm most
commonly results in
a) Subarachnoid hemorrhage
b) Subdural hemorrhage
c) Extradural hemorrhage
d) Intra-parenchymal hemorrhage
Correct Answer - A
Ans. is 'a' i.e., Subarachnoid hemorrhage
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Most common cause of
Trauma
subarachnoid hemorrhage
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Rupture of
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Berry
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Most common cause of
aneurysm
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spontaneoussubarachnoid
(or
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hemorrhage
Saccular
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aneurysm)
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Also know
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Mycotic aneurysm ?
Mycotic aneurysm is caused by a septic embolus that weakens the
wall of the vessel in which it lodges.
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355. Target BP before thrombolysis in
ischemic stroke is below
a) 185/110 mmHg
b) 165/100 mm Hg
c) 145/100 Hg
d) 120/80 mm Hg
Correct Answer - A
Ans. is 'a' i.e., 185/110 mm Hg
om
Recommended target blood pressure before thrombolysis in patients
with ischemic stroke is less than 185/110mm Hg.
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an
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356. The most common cause of malignant
adrenal mass is
a) Adrenocortical carcinoma
b) Malignant phaeochromocytoma
c) Lymphoma
d) Metastasis from another solid tissue tumor
Correct Answer - D
Ans. is 'd' i.e., Metastasis from another solid tissue tumor
om
The most common cause of adrenal tumors is metastasis from
another solid tumor like breast cancer and lung cancer.
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Malignant Percentage
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Adrenocortical carcinoma 2-5%
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Malignant
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<I%
pheochromocytoma
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Adrenal neuroblastoma <0- 1%
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Lymphomas (incl. primary
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<1%
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adrena lymphoma)
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Metastases (most frequent :
15%
Breast, lung)
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357. The drug used in the management of
medullary carcinoma thyroid is
a) Cabozantinib
b) Rituximab
c) Tenofovir
d) Anakinra
Correct Answer - A
Ans.is 'a' i.e., Cabozantinib
om
Medullary thyroid cancers (MTCs) are neuroendocrine tumors
of thyroid paraf011icular cells that do not concentrate iodine.
r.c
The primary treatment for MTC is extensive and meticulous surgical
ke
resection.
an
There is a limited role for external-beam radiotherapy.
tR
For patients with asymptomatic metastatic tumors generally
irs
less than 1 to 2 cm in diameter, growing in diameter less than
.F
20 percent per year
w
Systemic therapy is not required
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Such patients should be monitored for disease progression. Known
sites of metastatic disease should be imaged by CT or MRI every 6
to 12 months, and potential new sites of disease should be imaged
every 12 to 24 months.
For patients with metastatic tumors at least 1 to 2 cm in diameter,
growing by at least 20 percent per year, or Or patients with
symptoms related to multiple metastatic foci that cannot be
alleviated with surgery or external beam radiotherapy
Administer systemic treatment as part of a clinical trial.
Forpatients with metastatic tumors at least I to 2 cm in diameter,
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growing by at least 20 percent per year, or
for patients with .symptoms related to multiple metastatic foci
who cannot participate in a clinical trial
An oral tyrosine kinase inhibitor (TKI) is suggested, rather than
traditional cytotoxic chemotherapy.
For initial TKI therapy
Cabozantinib or vandetanib rather than sorafenib or sunitinib.
Cytotoxic chemotherapy, of which dacarbazine-based regimens
such as cyclophosphamide-vincristinedacarbazine are preferable, is
an alternative option for patients who cannot tolerate or who fail
multiple TKIs
Drugs used in medullary carcinoma thyroid
Tyrosine
Cvtotoxic
kinase
chemotherapy
inhibitors
CabozanitibCyclophosphamide
Vandetanib Vincristine
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Sorafenib Dacarbazine
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Sunitinib
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358. Incorrect about cerebral salt wasting
syndrome
a) Urine sodium > 20mEq/d1
b) Hyponatremia
c) Fludrocortisone is used
d) Expansion of plasma volume
Correct Answer - D
Ans. is 'd' i.e., Expansion of plasma volume
om
Cerebral salt wasting syndrome (renal salt wasting)
Cerebral salt wasting (CSW) is characterized by hyponatremia and
r.c
extracellular fluid depletion due to inappropriate sodium wasting in
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the urine in the setting of acute disease in central nervous system
an
(CNS), usually subarachnoid hemorrhage.
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CSW is a much less common cause of hyponatremia in patients with
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cerebral injury than the syndrome of inappropriate ADH secretion
.F
(SIADH).
w
The pathophysiology of CSW is related to impaired sodium
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reabsorption, possibly due to the release of brain natriuretic
peptide and/or diminished central sympathetic activity.
Regardless of the mechanism, sodium wasting can lead sequentially
to volume depletion, increased ADH release, hyponatremia due to
the associated water retention, and possibly increased neurologic
injury.
Laboratory findings
Hyponatremia with a low plasma osmolality
An inappropriately elevated urine osmolality (above 100
mosmol/kgand usually above 300mosmol/kg)
A urine sodium concentration above 40meq/L, and
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A low serum uric acid concentration due to urate wasting in the
urine.
CSW mimics all of the laboratory findings in the SIADH
The only clue to the presence of CSW rather than SIADH is clinical
evident of extracellular volume depletion, such as hypotension and
decreased skin turgor, and/or increased hematocrit, in a patient with
a urine sodium concentration above 40meq/L
Unlike SIADH, volume repletion in CSW leads to a dilute urine, due
to removal of the hypovolemic stimulus to ADH release, and
subsequent correction of the hyponatremia.
Treatment
IV hypertonic saline solutions are employed to correct intravascular
vloume depletion and hyponatremia and to replace ongoing urinary
sodium loss
Flurocortisone promotes sodium re-absorption
om
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359. A 70 kg adult male presents with serum
sodium of 110 meq/dl. Calculate
correction required in 24 hours
a) 100 mEq
b) 200 mEq
c) 300 mEq
d) 400 mEq
Correct Answer - D
om
Ans. is `d' i.e., 400 mEq
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Goals of therapy in hyponatremia
In patients who are treated to increase the serum sodium, the goal
ke
of initial therapy is to raise the serum sodium concentration by 4 to 6
an
meq/L in a 24-hour period.
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In patients who require emergency therapy, this goal should be
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achieved quickly, over six hours or less; thereafter, the serum
.F
sodium can be maintained at a constant level for the remainder of
w
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the 24-hour period to avoid overly rapid correction.
w
Every effort should be made to keep the rise in serum sodium
less than 9 meq/L in anv 24-hour period.
In general, the same rate of rise can be continued on subsequent
days until the sodium is normal or near normal. The rationale for
these recommendations is as follows:
Sodium deficit = Total body water x desired SNa - Actual SNa = .6 x
70 x 120 - 110 =420 mEq
Treatment of hvponatrentia
Aprviatitleaet_uIsupon risk stratification
The following general approach for treating patients with
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hyponatremia is based upon the duration and severity of the
hyponatremia and upon the presence and severity of symptoms:
Disposition
Patients with acute or hyperacute hyponatremia, most patients with
severe hyponatremia, and many symptomatic patients with
moderate hyponatremia should be treated in the hospital.
In contrast, patients with mild hyponatremia and asymptomatic
patients with moderate hyponatremia usually do not require
hospitalization.
Emergency therapy
Aggressive therapy to raise the serum sodium as soon as possible
(typically with hypertonic saline) is indicated in the following settings.
Patients with severe symptoms due to hyponatremia, such as
seizures or obtundation.
Patients with acute hyponatremia who have symptoms due to
hyponatremia, even if such symptoms are mild. Because of
osmotically driven water flow across the blood-brain barrier, an
acute onset of hyponatremia can result in life-threatening cerebral
om
edema. Thus, even mild symptoms in acute hyponatremia present a
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medical emergency that requires prompt and aggressive treatment
ke
with hypertonic saline to prevent brain herniation.
an
Patients with hyperacute hyponatremia due to self-induced water
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intoxication, even if there are no symptoms at the time of initial
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evaluation. Brain herniation has been reported in such patients, and
the serum sodium may worsen spontaneously due to delayed
.F
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absorption of ingested water
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Symptomatic patients who have either acute postoperative
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hyponatremia or hyponatremia associated with intracranial
pathology. As with hyperacute hyponatremia, herniation may occur;
and the serum sodium may decrease further because of absorption
of ingested water or the excretion of high concentrations of sodium
in the urine (desalination).
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360. Which of the following is a quantitative
defect in globin synthesis
a) Thalassemia
b) Sickle cell hemoglobinopathy
c) G6PD deficiency
d) Diamond-Black fan syndrome
Correct Answer - A
Ans. is 'a' i.e., Thalassemia
om
The thalassemia syndromes are a heterogeneous group of disorders
caused by inherited mutations that decrease the synthesis of either
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the c-globin or p-globin chains that compose adult hemoglobin, HbA
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(c2p2), leading to anemia, tissue hypoxia, and red cell hemolysis
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related to the imbalance in globin chain synthesis.
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361. The most important diagnositic feature
for beta thalassemia trait
a) Raised HbF
b) Reduced MCH
c) Reduced MCV
d) Raised HbA2
Correct Answer - D
Ans. is 'd' i.e., Raised HbA2
om
An abnormal increase in the level of HbA2 is the most significant
parameter in the diagnosis of beta-thalassemia carriers. HbA-2 is
r.c
constanly elevated in heterozygous carriers of [3-thalassemia in all
ke
the ethnic groups studied. The values range from 3.5 to 7%.
an
Investigations in thalassemia
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Hemoglobin electrophoresis should always be the first investigation
irs
to include/exclude the diagnosis of thalasemia. The level of normal
.F
adult hemoglobin HbA is markedly decreased with proportionate
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increase in HbA2 and HbF.
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X-ray skull shows :?
i) Crew-cut appearance
ii) Hair on end appearance
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362. Uricase used in the treatment of chronic
gout is
a) Allopurinol
b) Benzbromarone
c) Pegloticase
d) Methotrexate
Correct Answer - C
Ans. is 'c' i.e., Pegloticase
om
Pegloticase is a recombinant mammalian Uricase linked to
polyethylene glycol (PEG) approved for the treatment
r.c
of Hyperuricemia in patients with treatment refractory gout.
ke
Pegloticase facilitates the conversion of Uric acid into allantoin,
an
which is far more soluble. Pegloticase is approved for intravenous
tR
administration and its use is associated with rapid and marked
irs
decline in serum uric acid levels.
.F
Agents inhibiting IL-1 action are used for the treatment of
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refractory Gout
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Anakinra
Canakinumab
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363. All are seen in acute HiV syndrome
except
a) Diarrhoea
b) Pneumonia
c) Wight loss
d) Myelopathy
Correct Answer - B
Ans. is 'b' i.e., Pneumonia
om
Clinical findings in the acute HIV syndrome
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General Neurologic Dermatology rash
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Fever Meningitis Erythematous ulceration
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Pharyngitis Encephalitis maculo-papular
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Lymphadenopathy Peripheral Mucocutaneous
irs
Headache/retroorbital neuropathy
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pain Myelopathy
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Arthralgias/myalgias
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Lethargy/malaise
Anorexia/weight loss
Nausea/vomiting/diarrhea
[Ref Harrison 19th/e p. 1249]
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364. Nephrocalcinosis is seen in all except
a) Polycystic kidney
b) Hyperparathyroidism
c) Medullary sponge kidney
d) Renal tubular acidosis
Correct Answer - A
Ans. is 'a' i.e., Polycystic kidney
Causes of Nephrocalcinosis
Medullary sponge kidney
om
Hyperparathyroidism
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Hypoparathyroidism
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Renal tubular acidosis (specifically distal RTA)
an
Renal tuberculosis
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Renal papillary necrosis
irs
Hyperoxaluria
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Immobilization
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Milk-alkali syndrome
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Hypervitaminosis D
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Sarcoidosis
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365. Most common acute complication of
dialysis is
a) Hypotension
b) Bleeding
c) Dementia
d) Muscle cramps
Correct Answer - A
Ans. is 'a' i.e., Hypotension
om
Hypotension is the most common acute complication of
hemodialysis particularly among patients with diabetes mellitus.
r.c
Factors involved are :-
ke
Excessive ultrafiltration, with inadequate compensatory vascular
an
filling, impaired vasoactive or autonomic response, osmolar shifts,
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overzealous use of antihypertensives
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366.
om
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Characteristic features of a lesion in the
lateral part of the medulla include all except
a) Ipsilateral Homer's syndrome
b) Contralateral loss of proprioception to the body and limbs
c) Nystagmus
d) Dysphagia
Correct Answer - B
Ans. is 'b' i.e., Contralateral loss of proprioception to the body and
om
limbs
Damage to lateral part of medulla (lateral medullary syndrome or
r.c
wallenberg syndrome) causes :?
ke
1) Ipsilateral : Facial sensory loss, facial pain, ataxia, nystagmus,
an
homer syndrome.
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2) Contralateral
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Other features are nausea & vomitng, vertigo dysphagia and
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horseness.
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367. Round pneumonia is seen with
a) Streptococcal pneumonia
b) Kerosene oil aspiration
c) Lung cancer
d) Mendelson syndrome
Correct Answer - A
Ans. is 'a' i.e., Streptococcal pneumonia
Streptococcus Pneumoniae (pneumococcus) is the most common
organism responsible for round pneumonia.
om
Round Pneumonia is spherical pneumonia that is usually seen in
r.c
children due to the lack of collateral air drift.
ke
Streptococcus Pneumoniae (pneumococcus) is the most common
an
organism responsible for round pneumonia.
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Round pneumonia is important as they may simulate a tumor mass
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from which they must be differentiated
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368. An elderly male admitted for Pneumonia
presents with diarrhea and gripping
abdominal pain five days after discharge
from the hospital. Drug which is likely to
benefit is
a) Imodium
b) Metranidozole
c) Diphenoxylate
d) Levofloxacin
om
r.c
Correct Answer - D
ke
Ans. is 'd' i.e., Levofloxacin
an
Development of pneumonia and gastrointestinal symptoms (diarrhea
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& gripping abdominal pain) within 10 days after discharge from
irs
hospital hints to a possible diagnosis of Legionnaire's disease. The
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drugs of choice for legionnairs's disease include Azithromycin and
w
Respiratory Fluoroquinolones such as levofloxacin, gatifloxacin,
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Gemifloxacin and Moxifloxacin
It is a case of legionnaire's disease.
Legionnaires disease usually presents as atypical pneumoniae.
The unique feature of legionnaires disease is that the clinical
manifestation of this disease are usually more severe than those of
most atypical pneumonias and the course and prognosis of
legionella pneumonia more closely resemble those of bacteremic
pneumococcal pneumonia than those ofpneumonia due to other
organisms
Think about the diagnosis as legionaire's disease whenever the
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question talks about a pneumonia like picture along with any of
the following -
Gastrointestinal disturbances such as diarrhoea.
Neurological abnormalities such as confusion and headache altered
sensorium.
High fever (> 40°C or > 104°F)
Numerous neutrophils, but no organisms revealed by gram's staining
of respiratory secretions.
Failure to respond to $ lactam drugs (penicillins and cephalosporins)
and aminoglycoside antibiotics. Hyponatremia (S.Na- < 131 meq/1)
Elevation in liver function tests.
Occurrence of illness in an environment in which the potable water
supply is known to be contaminated with legionella.
Onset of symptoms within 10 days of discharge from hospital.
Occurence of illness in immunocompromised individual
om
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an
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369. Duration of apnea in obstructive sleep
apnea is
a) <10 sec
b) <20 sec
c) <30 sec
d) <60 sec
Correct Answer - A
Ans. is 'a' i.e., <10 sec
om
Sleep apnea ?
o Sleep apnea is defined as intermittent cessation of airflow at the
r.c
nose and mouth during sleep.
ke
o By convention apneas of at least 10 seconds duration have been
an
considered important but in most patients the apneas are 20s to 30
tR
seconds in duration and may be as long as 2-3 minutes.
irs
o Sleep apnea is of two types -
.F
Sleep apnea
w
Obstructive sleep apnea Central sleep apnea
w
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Occurs due to
Occurs due to occlusion of transient abolition
upperairway at the level of ofthe central neural
oropharynx drive to the respiratory
muscles
Primary and
secondary central
alveolarhypoventilation
Conditions associated are syndrome, hypoxia
adenotonsillarhypertrophy, (high altitude)
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retrognathia, cardiovascular
macroglossiaalcohol, disease, pulmonary
obesity congestion, central
nervous system
disease, prolonged
circulation time.
Clinical features of sleep apnea -
Excessive daytime sleepiness
Cardiorespiratory disturbances which include
Recurrent respiratory failure
Pulmonary hypertension
Heart failure
Systemic hypertension 7 Chronic hypoventilation
Polycythemia
om
o Arterial blood gas analysis reveals hypoxemia and hypercapnia.
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an
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370. Causes of haemorrhagic pleural effusion
are all except
a) Pulmonary infarction
b) Mesothelioma
c) Bronchial adenoma
d) Tuberculosis
Correct Answer - C
Ans. is 'c' i.e., Bronchial adenoma
om
Causes of hemorrhagic pleural effusion
Trauma
r.c
Malignancy
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Postpericardiotomy syndrome
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Asbestos related effusion
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Tuberculosis
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371. Following is characteristic neurologic
finding in primary amyloidosis
a) Peripheral motor and sensory neuropathy
b) Peripheral neuropathy associated with cerebral manifestation
c) Guillain - Barre type of syndrome
d) Spinal cord compression in thoracic region
Correct Answer - A
Ans. is 'a' i.e., Peripheral motor and sensory neuropathy
om
ATTR usually presents as a syndrome of familial amyloidotic
polyneuropathy or familial amyloidotic cardiomyopathy.
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Peripheral neuropathy usually begins as a lower-extremity sensor
ke
and motor neuropathy and progresses to the upper extremities.
an
Autonomic neuropathy is manifest by gastrointestinal symptoms of
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diarrhea with weight loss and orthostatic hypotension.
irs
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372. Reactive arthritis is usually caused by
a) Shigella flexneri
b) Shigella boydii
c) Shigela shiga
d) Shigela dysentriae
Correct Answer - A
Ans. is 'a' i.e., Shigella Flexneri
Organisms that have been associated with ReiterArthritis
include the following:
om
C trachomatis (L2b serotype)
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Ureaplasma urealyticum
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Neisseria gonorrhoeae
an
Shigella flexneri
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Salmonella enterica serovars Typhimurium
irs
Mycoplasma pneumoniae
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Mycobacterium tuberculosis
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Yersinia enterocolitica and pseudotuberculosis
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Campylobacter jejuni
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Clostridium difficile
Beta-hemolytic (example, group A) and viridans streptococci
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373. Which of the following arrhythmia is
most commonly associated with alcohol
binge in the alcoholics
a) Ventricular fibrillations
b) Ventricular premature contractions
c) Atrial flutter
d) Atrial fibrilation
Correct Answer - D
om
Ans. is 'd' i.e., Atrial fibrilation
r.c
When ever the pulse is irregularly irregular atrial fibrillation is
almost always the diagnosis.
ke
Arrythmia occuring after a drinking binge is k/a Holiday heart
an
syndrome.
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Arrythmias known to follow drinking Binge in order of
irs
frequency
.F
Atrial fibrillation (MC)
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Atrial flutter
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Ventricular premature Contractions
Also know
The most common cardiac effect of chronic drinking is Dilated
Cardiomyopathy
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374. Treatment of asymptomatic bradycardia
is
a) No treatment is required
b) Give atropine
c) Isoprenaline
d) Cardiac pacing
Correct Answer - A
Ans. is 'a' i.e., No treatment is required
om
The normal heart rate has been considered historically to range from
60 to 100 beats per minute, with sinus bradycardia being defined as
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a sinus rhythm with a rate below 60 beats per minute.
ke
Treatment is not indicated in asymptomatic patients with sinus
an
bradycardia.
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n Pharmacologic therapy may be important in an acute
irs
myocardial infarction when the SA node is depressed by excessive
.F
parasympathomimetic activity or possibly ischemia. Treatment is
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indicated when Sinus bradycardia results in hemodynamic
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compromise.
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375. WPW syndrome is caused by
a) Bundle Branch Block
b) Right sided accessory pathway
c) Ectopic pacemaker in atrium
d) Left budle Branch block
Correct Answer - B
Ans. is 'b' i.e., Right sided accessory pathway
Anatomy (Location ofAccessory pathway) in W.R W syndrome
Electrophysiological studies and mapping have shown that
om
accessory. Atrioventricular pathways may be located anywhere
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along the A-V rign or groove in the septum.
ke
The most frequent locations are : -
an
Left lateral (50%), posteroseptal (30%) right anteroseptal (10%).
tR
Right lateral (10%).
irs
Preexcitation resulting from left sided accessory is called type A
.F
preexcitation.
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Preexcitation resulting from right sided accessory pathway is called
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type B preexcitation.
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376. Dose of rTPA in ischaemic stroke is
a) 60 mg
b) 90 mg
c) 100 mg
d) 120 mg
Correct Answer - B
Ans. is 'b' i.e., 90 mg
Recommended dose for thrombolysis with IV TPA is 0.9 mg/kg with
the maximum dose being 90 mg. 10% should be given as a bolus
om
over one minute, followed by remaining 90% as a continuous
r.c
infusion over 60 minutes.
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an
tR
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377. Cerebral angiography was performed by
a) Sir Walter Dandy
b) George Moore
c) Seldinger
d) Egas Moniz
Correct Answer - D
Ans. is 'd' i.e., Egas Moniz
Egas Moniz first performed cerebral Angiography in 1927. n He
received the Nobel Prize for developing for developing frontal
om
leucotomy as a treatment for psychiatric diseases.
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ke
an
tR
irs
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378. Mauriac's syndrome is characterized by
all except
a) Diabetes
b) Obesity
c) Dwarfism
d) Cardiomegaly
Correct Answer - D
Ans. is D i.e., Cardiomegaly
om
Mauriac Syndrome
Children with poorly controlled type I diabetes may develop Mauriac
r.c
syndrome. It is characterized by : -
ke
Growth attenuation
an
Delayed puberty
tR
Hepatomegaly
irs
Abnormal glycogen storage and steatosis
.F
Cushingoid features
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Rare in the modern era of insulin therapy but is occasionally
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reported.
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379. Which of the following is associated with
hyponatremia and low osmolality
a) Hyperlipidemia
b) SIADH
c) CHF
d) CKD
Correct Answer - C
Ans. is 'c' i.e., CHF
om
CHF is characterised by low perfusion of kidneys stimulating
R.A.A.S and resultant absorption of salt and disproportionate amout
r.c
of water would lead to hyponatremia with decreased osmolality.
ke
Isotonic hyponatremia is seen with hyperlipidemia and
an
hvperproteinemia like in paraproteinemia.
tR
Intravenous immunoglobulin therapy also interferes with
irs
measurement of serum sodium.
.F
Major causes of hyponatremia
w
Disorders in which ADH levels are elevated
w
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Effective circulating volume depletion
True volume depletion
Heart failure
Cirrhosis
Thiazide diuretics
Syndrome of inappropriate ADH secretion, including reset osmostat
pattern
Hormonal changes
Adrenal insufficiency
Hypothyroidism
Pregnancy
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Disorders in which ADH levels may be appropriately
suppressed
Advanced renal failure
Primary polydipsia
Beer drinker's potomania
Hyponatremia with normal or elevated plasma osmolality
High plasma osmolality (effective osmols)
Hyperglycemia
Mannitol
High plasma osmolality (ineffective osmols)
Renal failure
Alcohol intoxication with an elevated serum alcohlo concentration
Normal plasma osmolality
Psedohyponatremia (laboratory artifact)
High triglycerides
Chloestatic and obstructive jaundice (lipoprotein x)
Multiple myeloma
Absorption of irrigant solutions
om
Glycine Sorbitol Mannitol
r.c
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an
tR
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380. Deletion of one alpha globin gene on one
chromosome is best defined as
a) Hb Barts hydrops fetails
b) Alpha thalassemia major
c) Alpha thalassemia trait
d) Alpha thalassemia silent carrier
Correct Answer - D
Ans. is 'd' i.e., Alpha thalassemia silent carrier
om
Clinical
Condition Defect Genotype
syndrome
r.c
Deletion of 1
ke
Silent Thalassemia -a/aa Normal
alpha genes
an
Deletion of 2 -a/-a Microscopic
tR
Thalessemia trait
alpha genes (homogygous) hypochromic
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Blood picture
.F
(heterogenous)
but
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w
No/Minimal
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Anemia
Deletion of 3 Hemolytic
HbH disease --/-a
alpha genes anemia
Hydrops fetalis (Hb Deletion of 4 --/-- Fatal in utero or
Barts) alpha genes at birth
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381. Which of the following is caused by
deletion of all four alpha globin genes
a) Beta thalassemia major
b) Hb Barts
c) HbH
d) a° thalassemia trait
Correct Answer - B
Ans. is 'b' i.e., Hb Barts
om
Clinical
Condition Defect Genotype
syndrome
r.c
Deletion of 1
ke
Silent Thalassemia -a/aa Normal
alpha genes
an
Deletion of 2 -a/-a Microscopic
tR
Thalessemia trait
alpha genes (homogygous) hypochromic
irs
Blood picture
.F
(heterogenous)
but
w
w
No/Minimal
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Anemia
Deletion of 3 Hemolytic
HbH disease --/-a
alpha genes anemia
Hydrops fetalis (Hb Deletion of 4 --/-- Fatal in utero or
Barts) alpha genes at birth
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382. In Beta thalassemia, the most common
gene mutation is
a) Intron 1 inversion
b) Intron 22
c) 619 bp deletion
d) 3.7 bp deletion
Correct Answer - A
Ans. is 'a' i.e., Intron 1 inversion
om
Thalassemias are autosomal recessive disorder
The most common mutation causing 13 thalassemias is
r.c
intron/inversion
ke
Also know:
an
Synthesis of alpha chain is controlled by 2 gene clusters on →
tR
Chromosome 16
irs
Synthesis of beta chain is controlled by 2 gene clusters on →
.F
Chromosome 11
w
Thalassemia mutations in India
w
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Multations Frequency
IVS1-5 (G —>C) 48%
619 bp defection 18%
IVS-1 (G T) 9%
FR41/42(TCTT) 9%
FR8/9 (+G) 5%
Codonl5 (G --> A) 6%
Others 100%
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383. Bence jones proteinuria is best detected
by
a) Dipstick method
b) Sulfosalicylic acid
c) Heat test
d) Electrophoresis
Correct Answer - D
Ans. is `d' i.e., Electrophoresis
om
Bence Jones proteins are seen in multiple myeloma.
Urinary protein electrophoresis will exhibit a discrete protein peak.
r.c
In myeloma plasma cells produce immuno-globulin of a single heavy
ke
and light chain, a monoclonal protein commonly referred to as a
an
paraprotein.
tR
Heat test is false negative in 50% of patients with light chain
irs
myeloma.
.F
Dipstick detects albumin and not paraproteins.
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384. HIV RNA by PCR can detect as low as
a) 30 copies viral RNA/ml of blood
b) 40 copies viral RNA/ml of blood
c) 50 copies of viral RNA/ml of blood
d) 60 copies of viral RNA/ml of blood
Correct Answer - B
Ans. is 'b' i.e., 40 copies viral RNA/ml of blood
This assay generates data in the form of number of copies of HIV
RNA per milli litre of serum or plasma and can reliably detect as few
om
as 40 copies of HIV RNA per mili litre of plasma.
r.c
Research based assay can detect down to one copy/ml.
ke
an
tR
irs
.F
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385. Most common cause of pleural effusion
in AIDS patients
a) Kaposi sarcoma
b) TB
c) Pneumocystis Jiroveci
d) Mycoplasma
Correct Answer - A
Ans. is 'a' i.e., Kaposi sarcoma
om
Ophthalmological diseases
The most common abnormal findings on fundoscopic examination
r.c
are cotton wool spots.
ke
CMV retinitis is the most severe ocular complication and occurs
an
when CD4 T-cells count is less than 50/ml. It typical presents as
tR
perivascular hemorrhage and exudae with Cottage-Cheese
irs
appearance.
.F
Acute retinal necrosis syndrome, also called progressive outer
w
retinal necrosis (PORN) is caused by HSV and VZV
w
w
Other manifestations are chorioretinitis by toxoplasma and P carinii,
kaposi sarcoma of eyelid, and lymphoma.
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386. Biomarker not involved in acute kidney
injury is
a) NGAL
b) KIM 1
c) Micro RNA 122
d) Cystatin C
Correct Answer - C
Ans. is 'c' i.e., Micro RNA 122
om
Biomarkers of acute kidney injury
Alanine aminopeptidase (AAP)
r.c
Alkaline phosphatase (AP)
ke
a-glutathione-S-transferase (a-GST)
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y-glutamyl transpeptidase (yGT)
tR
N-acetyl-13-glucosaminidase (NAG)
irs
pfmicroglobulin
.F
a imicroglobulin
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Retinol-binding protein (RBP)
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Cystatin C
Microalbumin
Kidney injury molecule-1 (KIM-1)
Clusterin
Neutrophil gelatinase associated lipocalin (NGAL)
Interleukin-18 (IL-18)
Cysteine-rich protein (CYR-61)
Osteopontin (OPN)
Fatty acid binding protein (FABP)
Sodium/hydrogen exchanger isoform (NHE3)
Exosomal fetuin-A
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om
r.c
ke
an
tR
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387. Most common site of cerebral infarction
is in the territory of
a) Anterior cerebral artery
b) Middle cerebral artery
c) Posterior cerebral artery
d) Posterior inferior cerebellar artery
Correct Answer - B
Ans. is 'b' i.e., Middle cerebral artery
om
Hemiplegia most commonly occurs due to lesion of middle cerebral
artery
r.c
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388. Hemiplegia is most often caused by
thrombosis of ?
a) Anteiror cerebral artery
b) Middle cerebral artery
c) Posterior cerebral artery
d) Basiliar artery
Correct Answer - B
Ans. is 'b' i.e., Middle cerebral artery
om
Middle Cerebral Artery
Deep branches of the middle cerebral artery on the lenticulostriate
r.c
branches supply the internal capsule (posterior limb).
ke
Motor tracts are densely packed in this region and hence occlusion
an
of deep branches or lenticulostrials branches leads to Densse
tR
Hemiplegia/Pure motor Hemiplegia.
irs
Anterior choroidal artery supplies the posterior limb of internal
.F
capsule (and not anterior limb of internal capsule).
w
Anterior chorodial artery arises from the internal carotid artery and
w
w
supplies the posterior limb of internal capsule. The complete
syndrome of anterior choroidal artery occlusion consists of
contralateral hemiplegia hemianesthesia (hypoesthesia) and
homonymous hemianopia
Posterior Cerebral Artery
The posterior cerebral artery supplies the midbrain, thalamus lateral
geniculate bodies, posterior of chroid plexus, occipital lobes, inferior
and medial aspect of the temporal lobe and posterior inferior areas
of the parietal lobe
Occlusion of the Posterior Cerebral Artery usually results in
two common clinical syndrome depending on the areas
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involved
P1 Syndrome P2 Syndrome
Occlusion of
the
Occlusion of the distalsegment
proximal segment of PCA
ofPCA from its origin to distal to the
its union withthe junction of
posterior PCA with
communicating artery theposterior
communicating
artery
P2 syndrome
P1 syndrome present presents
primarily withthe primarily
following signs withthe
following signs
Temporal lobe
om
Midbrain signs
signs
r.c
Thalamic signs Occipital lobe
ke
Subthalamic signs signs
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tR
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389. Indication for prophylaxis in
pneumocystis carini pneumonia include
a) CD4 count < 200
b) Tuberculosis
c) Viral load > 25,000 copies/ml
d) Oral candidiasis
Correct Answer - A
Ans. is 'A' i.e., CD4 count < 200
om
PROPHYLAXIS OF PNEUMOCYSTIC CARINI PNEUMONIA
Primary prophylaxis is indicated for
r.c
Patients with CD4- cell counts of< 200/4
ke
History of oropharyngeal candidiasis
an
Secondary prophylaxis is indicated for
tR
Both HIV infected and non-HIV infected patients.
irs
Who has recovered from pneumocystosis
.F
Primary and secondary prophylaxis may be discontinued in HIV
w
w
infected persons once.
w
CD4+ counts have risen to > 200/p1 and remained at that level for 3
months.
Also know
First choice agent for prophylaxis
Trimethoprim, sulphamethoxazole.
Other agents used in prophylaxis.
Dapsone, pentamidine.
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390. Canon 'a' wave is seen in
a) Junctional rhythm
b) Atrial fibrillation
c) Atrial flutter
d) Ventricular fibrillation
Correct Answer - A
Ans. is 'a' i.e., Junctional rhythm
Regularly –> During junctional rhythm
• Irregularly A- V dissociation with ventricular
om
tachycardia complete heart block.
r.c
ke
an
tR
irs
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391. Most common cause of unilateral pedal
edema
a) Pregnancy
b) Lymphedema
c) Venous insufficiency
d) Milroy disease
Correct Answer - C
Ans. is 'c' i.e., Venous insufficiency
om
The most likely cause of leg edema in patients over age 50 is
venous insufficiency.
r.c
Venous insufficiency affects up to 30% of the population, whereas
ke
heart failure affects only approximately 1%.
an
The most important cause of unilateral pedal edema is venous
tR
insufficiency.
irs
Milroys disease :
.F
The defect in Milroy's disease is present from birth and symptoms
w
are usually first experienced in childhood.
w
w
The most common problem is one-sided leg swelling, unilateral
edema, which is progressive and can affect both legs.
Impaired intestinal lymphatics can cause steatorrhea due to
impaired transport of chylomicrons
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392. Grisel syndrome all are true except
a) Post-adenoidectomy
b) Conservation treatment
c) Inflammation of cervical spine ligaments
d) No need for neurosurgeon
Correct Answer - D
Ans. d. No need for neurosurgeon
Grisel Syndrome:
Non-traumatic atlanto-axial subluxation may occur secondary to any
om
inflammatory process in the upper neck
r.c
It is described following tonsillectomy and adenoidectomy
ke
Conservation treatment: Cervical immobilization, Analgesia and
an
Antibiotics to reduce the risk of neurological deficit
tR
Grisel Syndrome
irs
Non-traumatic atlanto-axial subluxation may occur secondary to any
inflammatory process in the upper neckQ
.F
w
Due infection in the peri-odontoid vascular plexusQ that drains the
w
region, bringing about paraspinal ligament laxity
w
Described following tonsillectomy and adenoidectomyQ
It maybe associated with overuse of diathermy either for removal of
adenoid or following curettageQ, when used for hemostasis.
Children with Down syndrome° have atlanto-axial instability
Treatment:
Cervical immobilizationQ
AnalgesiaQ
AntibioticsQ to reduce the risk of neurological deficit
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393. A female patient of 26 years, presents
with oral ulcers, photosensitivity and
skin malar rash in face sparing the
nasolabial folds of both side.
a) Sturge weber syndrome
b) SLE
c) Dermatitis
d) Psoriasis
om
Correct Answer - B
r.c
Answer- B (SLE)
ke
Common symptoms include painful and swollen joints, fever, chest
an
pain, hair loss, mouth ulcers, swollen lymph nodes, feeling tired, and
tR
a red rash which is most commonly on the face.
irs
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394. Most characteristic cardiovascular defect
seen in Rubella-
a) Pulmonary artery stenosis
b) Coarctation of aorta
c) Ankylosis spondylitis
d) Rheumatic fever
Correct Answer - A
Answer. A. Pulmonary artery stenosis
om
The classic triad for congenital rubella syndrome is:
Sensorineural deafness (58% of patients)
r.c
Eye abnormalities? especially retinopathy, cataract, and
ke
microphthalmia Congenital heart disease? especially pulmonary
an
artery stenosis and patent ductus arteriosus.
tR
irs
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395. Osborn J waves is seen in-
a) Hypothermia
b) Hyperkalemia
c) Hypocalemia
d) Hypokalemia
Correct Answer - A
Answer. A. Hypothermia
Cause people suffering from hypothermia with a temperature of less
than 32°C (90°F).
om
r.c
ke
an
tR
irs
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396. Which is not related to HIV
a) Primary CNS lymphoma
b) Tertiary syphilis
c) Oesophageal candidasis
d) None
Correct Answer - B
Answer. B. Tertiary syphilis
Tertiary Syphilis has no relation to HIV status and primarily based on
the duration of the infection and complications of Syphilis.
om
r.c
ke
an
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397. Essential major blood culture criteria for
infective endocarditis.
a) Single positive culture of hacek
b) Single positive culture of coxiella
c) Single positive culture of cornybacterium
d) Both a & b
Correct Answer - A
Answer. A. Single positive culture of HACEK
om
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398. Respiratory centres are stimulated by
a) Oxygen
b) Lactic acid
c) Carbon dioxide
d) Calcium
Correct Answer - C
Answer. C. Carbon dioxide
The body’s respiratory center in the medulla is normally stimulated
by an increased concentration of carbon dioxide, and to a lesser
om
extent, by decreased levels of oxygen in arterial blood. Stimulation
r.c
of the respiratory center causes an increase in the rate and depth of
ke
breathing, thus blowing off excess carbon dioxide and reducing
an
blood acidity.
tR
irs
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399. Alcoholic shows which type of
cardiomyopathy-
a) Hyper cardiomyopathy
b) Dilated cardiomyopathy
c) Pericarditis
d) Myocarditis
Correct Answer - B
Answer. B. Dilated cardiomyopathy
om
Alcoholic cardiomyopathy is a disease in which the chronic long-
term abuse of alcohol (i.e., ethanol) leads to heart failure.Alcoholic
r.c
cardiomyopathy is a type of dilated cardiomyopathy.
ke
an
tR
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400. Which murmur increases on standing?
a) HOCM
b) MR
c) MS
d) VSD
Correct Answer - A
Answer. A. HOCM
Murmur will get softer with Valsalva or standing from squatting
because less blood is being ejected through the aortic valve. Rapid
om
squatting from a standing position forces increased venous return
r.c
and would have the opposite effect of Valsalva or rapid standing.
ke
an
tR
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401. Which wall of heart enlargement can be
seen on barium swallow in patient with
mitral stenosis-
a) Left atrium
b) Right atrium
c) Left ventricle
d) Right ventricle
Correct Answer - D
om
Answer. D. Right ventricle
r.c
Mitral stenosis is associated with right ventricular hypertrophy.
Left ventricular diastolic pressure is normal in isolated MS.
ke
Mitral stenosis : Features
an
left atrial pressure is increased
tR
pulmonary arterial pressure is increased
irs
Increased right ventricular afterload impedes the emptying of this
.F
chamber and Right ventricular end diastolic pressure and volume
w
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increase.
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Right ventricular hypertrophy occurs.
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402. Which of the following statements is true
about the bundle of kent?
a) Abnormal pathway between two atria
b) It is muscular or nodal pathway between the atria and ventricle
in WPW syndrome
c) It is slower than the AV nodal pathway
d) None
Correct Answer - B
om
Answer. B. It is muscular or nodal pathway between the atria
and ventricle in WPW syndrome
r.c
The Wolff-Parkinson-White syndrome is defined by the combination
ke
of an atrioventricular pre-excitation (bundle of Kent) and paroxysmal
an
supraventricular tachycardias. The diagnosis of atrioventricular pre-
tR
excitation in sinus rhythm is established on the association between
irs
a short PR interval, a wide QRS, a delta wave, a normal terminal
.F
QRS portion and frequent repolarization disorders.
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403. Deep venous thrombosis which is
incorrect –
a) Clinical assessment highly reliable
b) Mostly bilateral
c) Most common clinically presents as pain and tenderness in calf
d) Some cases may directly present as pulmonary
thromboembolism
Correct Answer - B
om
Answer. B. Mostly bilateral
Wells score or criteria: (possible score -2 to 9)
r.c
Active cancer (treatment within last 6 months or palliative): +1 point
ke
Calf swelling = 3 cm compared to asymptomatic calf (measured 10
an
cm below tibial tuberosity): +1 point
tR
Swollen unilateral superficial veins (non-varicose, in symptomatic
irs
leg): +1 point
.F
Unilateral pitting edema (in symptomatic leg): +1 point
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Previous documented DVT: +1 point
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Swelling of entire leg: +1 point
Localized tenderness along the deep venous system: +1 point
Paralysis, paresis, or recent cast immobilization of lower extremities:
+1 point
Recently bedridden = 3 days, or major surgery requiring regional or
general anesthetic in the past 12 weeks: +1 point
Alternative diagnosis at least as likely: -2 points
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404. Punched out ulcer in esophagus is seen
in
a) herpes
b) cmv
c) Oesophagitis
d) candida
Correct Answer - C
Answer. C. Oesophagitis
om
It is likely to present with a single, large shallow linear ulcer as
opposed to the multiple vesicular/ “punched-out” ulcers seen in
r.c
herpes esophagitis.
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405. Type of sensation lost on same side of
Brown Sequard syndrome-
a) Pain
b) Touch
c) Proprioception
d) Temperature
Correct Answer - C
Answer. C. Proprioception
om
Damage to one half of the spinal cord, resulting in paralysis and loss
of proprioception on the same (or ipsilateral) side as the injury or
r.c
lesion, and loss of pain and temperature sensation on the opposite
ke
(or contralateral) side as the lesion.
an
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406. Achondroplasia shows which type
inheritance-
a) XLR
b) XLD
c) Autosomal recessive
d) Autosomal dominant
Correct Answer - D
Answer. D. Autosomal dominant
om
Achondroplasia is inherited in an autosomal dominant pattern,
which means one copy of the altered gene in each cell is sufficient to
r.c
cause the disorder.
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407. MELD score includes
a) Serum creatinine
b) Transaminase
c) Albumin
d) Alkaline phosphatase
Correct Answer - A
Answer. A. Serum creatinine
The Model for End-stage Liver Disease (MELD) is a prospectively
developed and validated chronic liver disease severity scoring
om
system that uses a patient’s laboratory values for –
r.c
Li Serum bilirubin
ke
Serum creatinine
an
The international normalized ratio (INR) for prothrombin time to
tR
predict three month survival.
irs
Patients with cirrhosis, and increasing MELD score is associated
.F
with increasing severity of hepatic dysfunction and increased three-
w
month mortality risk.
w
Given its accuracy in predicting short-term survival among patients
w
with cirrhosis, MELD was adopted by the United network for organ
sharing (UNOS) in 2002 for prioritization or patients awaiting liver
transplantation in the United states.
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408. Infarcts involving which portion of the
myocardium cause aneurysm as a post-
MI complication-
a) Subendocardial
b) Anterior transmural
c) Posterior transmural
d) Inferior wall
Correct Answer - D
om
Answer. D. Inferior wall
r.c
Left ventricular aneurysm formation:
Left ventricular apical aneurysm formation usually occurs following
ke
antero-apical myocardial infarction, after LAD occlusion.
an
This weakening of the apical wall results in an outpouching or
tR
“dyskinesis” of the apex of the heart during systole.
irs
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409. Risk factors for alzheimer’s disease
include-
a) Klinefelter syndrome
b) Low BP
c) Down’s syndrome
d) None
Correct Answer - C
Answer. C. Down’s syndrome
om
People with Down syndrome are born with an extra copy of
chromosome 21, which carries the APP gene. This gene produces a
r.c
specific protein called amyloid precursor protein (APP) with age
ke
these get accumulated in the brain cell and affects the functioning of
an
the brain leading to alzheimer’s dementia.
tR
irs
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410. A patient with native aortic valve disease
came with right hemiparesis. What will
you do to prevent further stroke?
a) Antiplatelet only
b) Anticoagulant only
c) Both antiplatelet and anticoagulant
d) One dose of low molecular weight heparin sub-cutaneously
followed by dual antiplatelet therapy
om
Correct Answer - A
r.c
Answer- A. Antiplatelet only
* Aspirin is the only antiplatelet agent that has been proven
ke
elfectivefor the acute treatment of ischemic stroke; use of aspirin
an
within 48 hoars of stroke onset reduced both stroke recurrence risk
tR
and mortality minimally.
irs
* Asprin is the only antiplatelet agent that has been proven effecfive
.F
for the acute treatment of ischemic stroke; there are several
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antiplatelet agents proven for the secondary prevention of stroke.
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* Two layer trials, the International Stroke Trial (IST) and the
Chinese Acute Stroke Trial (CAST),found that the use ofaspirin
within 48 hours ofstroke onset reduced both stroke recurrence risk
and mortality minimally.
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411. The most common subtype of Non-
Hodgkin's lymphoma in India is:
a) Diffuse small cell lymphocytic lymphoma
b) Diffuse large B cell lymphoma
c) Follicular lymphoma
d) Burkitt's lymphoma
Correct Answer - B
Answer- B. Diffuse large B cell lymphoma
om
The most common subtype of Non-Hodgkin's lymphomt in India is
dilfuse large B cell lymphoma.
r.c
Diffuse large B-cell lymphoma: MC subtype (34%)
ke
Follicular centre-cell lymphomas: 12.6% .
an
B-celf small lymphocytic lymphoma:.5.7%
tR
Mantle-cell lymphoma: 3.4%
irs
Marginal zone B-cell lymphomas (including MALT lymphomas):
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8.2%
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412. Which of the following drug can be given
in patients of primary pulmonary
hypertension?
a) Icatibant
b) Bosentan
c) Labetolol
d) Sodium nitroprusside
Correct Answer - B
om
Answer- B. Bosentan
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Treatment for Primary pulmonary hypertension:
CALCIUM CHANNEL BLOCKERS:
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Patients who respond to short-acting vasodilators at the time of
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cardiac catheterization should be treated with calcium channel
tR
blockers.
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The endothelin receptor antagonists bosentan and ambrisentan are
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approved treatments of PAH
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Bosentan is contraindicated in patients who are on cyclosporine or
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glyburide concurrently.
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413. An 86 years old lady presented with
severe constipation. She was a known
hypertensive on medications for 10
years. In clinic, her BP was 157/98 mm
Hg with a heart rate of 58/min. On taking
here BP in the supine position it was
found to be 90/60 mm Hg. She had the
recent history of depression. She is
taking atenolol, thiazide, imipramine,
haloperidol and docusate. What will be
the next best step in the management?
a) Change atenolol and thiazide to calcium channel blocker and
om
ACE inhibitor and add bisacodyl for constipation
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b) Change imipramine and haloperidol to fluoxetine and
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risperidone and add bisacodyl for constipation
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c) Only add bisacodyl for constipation and continue rest of the
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medications
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d) Discontinue all her medications and start her on steroids
Correct Answer - B
Ans: B. Change imipramine and haloperidol to fluoxetine and
risperidone and add bisacodyl for constipation
(Ref Harrison 19/e p1623-1624, 18/e p3531: Goodman Gilman 12/e
p410. 1333)
Effects of Imipramine:
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Postural hypotension - Due to alpha blockade by Imipramine &
thiazides interaction.
Anti-cholinergic side-effect.
Hence, Imipramine (TCA) must be discontinued.
Should be started on SSRI, fluoxetin & laxative (existing
constipation).
Effect of haloperidol:
Anti-cholinergic side effects.
Should start on atypical antipsychotic Risperidone.
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414. pANCA positive vasculitis is
a) Wegener's granulomatosis
b) Churg - Strauss syndrome
c) Polyarteritis nodosa
d) All of the above
Correct Answer - B
Answer- b. Churg - Strauss syndrome
PANCA
Typically found in:
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Microscopicpolyangiitis
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Churg-Strausssyndrome
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Idiopathiccrescenticglomerulonephritis
an
Goodpasteur'ssyndrome.
tR
pANCA's are also associated with certain non-vasculitic entities such
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as certain rheumatic and nonrheumatic autoimmune diseases,
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Inflammatory bowel diseases, certain drugs. Infections such as
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endocarditis and bacterial airway infection in patients with cystic
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fibrosis
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415. Levine sign is seen in
a) Stable angina pectoris
b) Acute bronchial asthma
c) Hemolytic anemia
d) Gastroesophageal reflux disease
Correct Answer - A
Answer- A. Stable angina pectoris
Stable Angina Pectoris:
This episodic clinical syndrome is due to transient myocardial
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ischemia
r.c
When the patient is asked to localize the sensation, he or she
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typically places a hand over the sternum, sometimes with a clenched
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fist, to indicate a squeezing, central, substernal discomfort (Levine's
tR
sign).
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416. Which of the following complications is
not seen in mitral valve prolapse?
a) Stroke
b) Infective endocarditis
c) Mitral stenosis
d) Ventricular arrhythmia
Correct Answer - C
Answer- C. Mitral stenosis
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Surface marking of the mitral valve is Behind sternal end of left
4th costal cartilage.
r.c
Infective endocarditis
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Mitral insuficiency (mitral regurgitation)
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Stroke or other systemic infarct resulting from embolism of leaflet
tR
thrombi
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Arrhythmias
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417. HbA1c control for how much time
a) 2 -3 weeks
b) 3 - 6 weeks
c) 6 - 8 weeks
d) 14 - 18 weeks
Correct Answer - C
Answer- C. 6 - 8 weeks
The half-life of an erythrocyte is typically 60 days, the level of
glycated hemoglobin (HbA1c) reflects the mean blood glucose
om
concentration over the preceding 6-8 weeks.
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418. All are seen in MEN IIA syndrome
except
a) Medullary carcinoma of thyroid is seen in 100% of the patients
b) 40 - 30% patients have phaeochromocytoms
c) Caused by loss of function mutation in IIRT protooncogene
d) Primary hyperparathyroidism is the most variable feature of
MEN II A syndrome
Correct Answer - C
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Answer- C. Caused by loss of function mutation in IIRT
protooncogene
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MEN-2A or Sipple syndrome, is characterized by
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pheochromocytoma, medullary carcinoma of the thyroid, and
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parathyroid hyperplasia.
tR
Parathyroid hyperplasia and evidence of hypercalcemia or renal
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stones.
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MEN-2A is clinically and genetically distinct from MEN-I and is
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caused by germline gain-of-function mutations in the
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RET proto-oncogene on chromosome l0qll.2.
40% to 50% have pheochromocytomas.
Primary hyperparathyroidism is the most variable feature of MEN 2A
syndrome.
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419. Hypoxic pulmonary vasoconstriction due
to -
a) Irreversible pulmonary vasocontriction hypoxia
b) Reversible pulmonary vasoconstriction due to hypoxia
c) Direct blood to poorly ventilated areas
d) Occurs hours after pulmonary vasoconstriction
Correct Answer - B
Answer- b. Reversible pulmonary vasoconstriction due to
om
hypoxia
Hypoxic pulmonary vasoconstriction (HPV) is an adaptive vasomotor
r.c
response to alveolar hypoxia which redistributes blood to optimally
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ventilatid lung segments by an active process of 'vasoconstriction,
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particularly involving the small muscular resistance pulmonary
tR
arteries (PA).
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420. Polyuria with low fixed specific gravity
urine is seen in ?
a) Diabetes mellitus
b) Diabetes insipidus
c) Chronic glomerulonephritis
d) Potomania
Correct Answer - C
Answer- C. Chronic glomerulonephritis
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Polyuria with fixed low specific gravity is a feature of chronic glomerulonephritis.
Specific gravity measures the kidney's ability to concentrate or dilute urine about plasma.
r.c
Because urine is a solution of minerals, salts, and compounds dissolved in water, the
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specific gravity is greater than 1.000. The more concentrated the urine, the higher the urine
an
specific gravity.
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An adult's kidneys have a remarkable ability to concentrate or dilute urine.
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In infants, the range for specific gravity is less because immature kidneys are not able to
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concentrate urine as effectively as mature kidneys.
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A low specific gravity occurs in three situations.
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In diabetes insipidus, there is an absence or decrease of anti-diuretic hormone. Without
anti-diuretic hormone, the kidneys produce an excessive amount of urine, often up to 15 to
20 liters per day with low specific gravity.
Glomerulonephritis and pyelonephritis cause decreased urine volume and low specific
gravity. In these diseases, damage to the kidney's tubules affects the ability of the kidney to
re-absorb water. As a result, the urine remains to dilute.
The third reason for low specific gravity is renal failure, which results in a fixed specific
gravity between 1.007 and 1.010. In renal failure, the remaining functional nephrons
undergo compensatory structural and hypertrophic changes. These compensatory changes
result in urine that is almost isotonic with plasma. Therefore, a patient experiencing renal
failure will present with specimens measuring the same, or fixed, specific gravity regardless
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of water intake.
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421. DOC for treatment of SSPE -
a) Abacavir
b) Inosine pranobex
c) Glatiramer
d) Interferon
Correct Answer - B
Answer- B. Inosine pranobex
Inosine pranobex is used as an immune-modulator for the
management of patients with-
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Immune-depression sufereing from viral infections as SSPE
r.c
recurrent herpes simplex genital warts.
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422. Rademecker complex in EEG is seen in -
a) SSPE
b) vCJD
c) cCJD
d) Kuru
Correct Answer - A
Answer- A. SSPE
Characteristic periodic activity (Rademecker complex) is seen on
EEG showing widespread cortical dysfunction in SSPE.
om
It is characterised by high voltage spike occuning at higlr lrequency
r.c
of 0.5- 1.5 seconds.
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423. Charcot's joint in diabetes affects
commonly -
a) Shoulder joint
b) Knee joint
c) Hip joint
d) Tarsal joint
Correct Answer - D
Answer- D. Tarsal joint
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Tabes dorsalis → Knees, hip & ankles
Loose body in joint
r.c
A loose body is a free-floating piece of bone, cartilage or foreign
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object in a joint.
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The knee is the most common joint where one would find a loose
tR
body.
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Causes of loose bodies include :-
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i) Osteoarthritis iii) Osteochondral
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fracture(injury) v) Synovial chondromatosis
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ii) Osteochondritisdessicans iv) Charcot's disease
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424. Shelf life of platelets to blood bank is
a) 5 days
b) 7 days
c) 10 days
d) 21 days
Correct Answer - A
Answer- A. 5 days
Platelets are approved by FDA for stored upto 5days at 20-24
(RoomTemperature) because of risk of bacterial contamination.
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425. DOC for listeria meningitis -
a) Ampicillin
b) Cefotaxime
c) Cefotriaxone
d) Ciprofloxacin
Correct Answer - A
Answer- A. Ampicillin
The antibiotic of choice for listeria infection is ampicillin or penicillin
G.
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426. Dent's disease is characterized by all
except
a) Chloride channel defect
b) Males are affected
c) Nephrolithiasis
d) Defect in limb of Loop of Henle
Correct Answer - D
Answer- D. Defect in limb of Loop of Henle
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Dent's disease refers to heterogenous group of X-linked disorders.
It b characterized by manifestations of proximal tubule dysfunction
r.c
(PT) dysfunction associated with hypercalciuria nephrolithiasis,
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nephrocalcinosis and progressive renalfailure
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These features are found in males only.
tR
mutation in gene encoding CLS-S, a Voltage gated Chloide channel.
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427. All are true for transplanted kidney
except
a) Humoral antibody responsible for rejection
b) CMI is responsible for rejection
c) Previous blood transfusion
d) HLA identity similarity seen in 1:100 people
Correct Answer - D
Answer- D. HLA identity similarity seen in 1:100 people
om
Within any particular family, sibling's have a 7:4 chance of being
HLA identical. In contrast among unrelated
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people, the probabilities of HLA identity in several thousand
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depending upon phenotype involved' It is due to the fact that
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HLA complex is inherited intact as two haplotypes.
tR
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428. Best management after human bite -
a) Ampicillin plus sulbactam
b) Clindamycin plus TMP-SMX
c) Fibroquinolone
d) Doxycycline
Correct Answer - A
Answer- A. Ampicillin plus sulbactam
1. Ampicillin/sulbactam
2. Imipenem
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3. Cefoxitin in penicillin allergics
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429. Duroziez's sign is seen in
a) Aortic Regurgitation
b) Tricuspid RegurgitationMitral stenosis
c) Pericardial effusion
d) None
Correct Answer - A
Answer- A. Aortic Regurgitation
In severe aortic regurgitation, gradual pressure over the femoral
artery leads to a systolic and diastolic bruit.
om
Refers to systolic and distolic murmurs heard over the femoral artery
r.c
while partially compresslng the vessel with the diaphragm of the
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stethoscope.
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430. TTKG in hypokalemia is -
a) < 3-4
b) > 6-7
c) > 9-10
d) > 10-15
Correct Answer - A
Answer- A. < 3-4
A normal TTK in normal subjects on normal diet is 8-9
Without other disease, hypokalemia should produce a TTKG <3
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431. Most common cause of death in
diphtheria is due to
a) Airway compromise
b) Toxic cardiomyopathy
c) Sepsis
d) Descending polyneuropathy
Correct Answer - B
Answer- B. Toxic cardiomyopathy
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Most common cause of death in diphtheria cardiomyopathy
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432. Upper lobe bronchiectasis is seen in
which disease?
a) Cystic fibrosis
b) Aspergilloma
c) HIV
d) Bronchogenic carcinoma
Correct Answer - A
Answer- A. Cystic fibrosis
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Upper lobe bronchiectasis-
Cystic fibrosis
r.c
Tuberculosis
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Non tuberculous mycobacterial infections
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433. On medical check up of a Punjabi
student following findings were seen Hb
of 9.9gm/d1, RBC count of 5.1 million,
MCV of 62.5 fl and RDW of 13.51%. What
is the most probable diagnosis ?
a) HbD
b) Thalassemia trait
c) Iron deficiency anemia
d) Anemia of chronic disease
om
r.c
Correct Answer - B
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Answer- B. Thalassemia trait
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Normal RDW with low MCV is seen in--
tR
1. Anemia of chronic disease
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2. Heterozygous thalassemia (Thalassemia trait)
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3. Hemoglobin E trait.
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434. Risk factors associated with health care
associated pneumonia (HCAP)-
a) Acute care hospitalization for at least 2 days in the preceding
90 days
b) Home infusion therapy
c) Immunosuppressive disease or immunosuppressive therapy
d) Antibiotic therapy in the preceding 90 days
e) Hospitalization for > 48 h om
Correct Answer - A:B:C:D:E
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Answer- (A) Acute care hospitalization for at least 2 days in the
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preceding 90 days (B) Home infusion therapy
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(C) Immunosuppressive disease or immunosuppressive
tR
therapy (D) Antibiotic therapy in the preceding 90 days
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(E) Hospitalization for > 48 h
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Acute care hospitalization for at least 2 days in the preceding 90
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days
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Residence in a nursing home or extended care facility
Home infusion therapy, including chemotherapy, within the past 30
days
Long-term dialysis within the past 30 days
Home wound care
Family member with an infection involving a multiple drug resistant
pathogen
Immunosuppressive disease or immunosuppressive therapy
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435. Malignancy associated with
hypercalcemia:
a) Breast cancer
b) Small cell lung cancer
c) Non-small lung cancer
d) Prostate cancer
e) Multiple myeloma
om
Correct Answer - A:C:D:E
Answer- A,Breast cancer C,Non-small lung cancer D,Prostate
r.c
cancer E,Multiple myeloma
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Lung carcinoma, breast carcinoma, and multlple myeloma account
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for more than 50% of all cases of malignancy-associated
tR
hypercalcemia.
irs
Gastrointestinal tumars and prostate carcinoma are less common
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causes of hypercalcemia.
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436. Capnography helps to know the
following
a) Correct intubation
b) Pulmonary embolism
c) Adequate ventilation
d) Lung perfusion
e) Significant metabolic change
om
Correct Answer - A:B:C:D:E
Answer- A,Correct intubation B,Pulmonary
r.c
embolism C,Adequate ventilation D,Lung
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perfusion E,Significant metabolic change
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Conditions that affect ET CO2
tR
Increased
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Hypoventilation
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Rebreathing
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Malignant hyperthermia,
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Neuroleptic malignant syndrome
Increased skeletal muscle activity (shivering
Hypermetabolism
Hyperthyroidism & thyroid storm
Decreased
Hyperventilation
Pulmonary embolism
Hypoperfusion, hypotension, hypovalemia, shock
Hypothermia
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437. The severity of mitral stenosis can be
judged by-
a) Intensity of murmur
b) Duration of murmur
c) Left ventricular S3
d) Loud S1
Correct Answer - B
Answer- B. Duration of murmur
om
Duration depends on severity of MS.
In severe MS, the mid diastolic murmur is long and merges with the
r.c
presystolic murmur to produce holodiastolic murmur..
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438. Pure motor palsy seen in poisoning of
a) Lead poisoning
b) Arsenic poisoning
c) Cocaine poisoning
d) Cannabis poisoning
Correct Answer - A
Ans. is 'A' i.e., Lead poisoning
The peripheral neuropathy of lead toxicity is a pure motor
neuropathy affecting the upper limbs more than the lower limbs,
om
presenting as symmetric or asymmetric wrist drop. The weakness
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may also involve other muscle groups of the distal upper extremities,
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the involvement of lower extremities, including isolated foot drop,
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also may occur.
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439. Smokers are prone to which lung
infection
a) Mycobacterium tuberculosis
b) Pneumonia
c) Influenza
d) All the above
Correct Answer - D
Answer- D. All the above
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440. Some patients with severe form of
Idiopathic infantile hypercalcemia, presnt
with phenotypic features similar to which
of the following?
a) Williams syndrome
b) Potters syndrome
c) Angelman syndrome
d) VHL syndrome
om
Correct Answer - A
r.c
Answer- A. Williams syndrome
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In the severe form, Prenatal and postnatal growth failure are
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common and number of phenotypic features of Williams syndrome
tR
are observed in some of the patients include cardiovascular
irs
abnormalities (usually supravalvular aortic stenois and peripheral
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pulmonic stenosis), late psychomotor development, selective mental
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deficiency, a characteristic unusual facies and short stature.
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The serum calcium levels range between 12 - 19mg/ dL.
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441. Which liver disease/s is/are associated
with ductopenia?
a) Chronic graft rejection
b) Hepatic sarcoidosis
c) Paraneoplastic syndrome related to hodgkins lymphoma
d) All the above
Correct Answer - D
Answer- D. All the above
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Loss of bile ducts from the portal tracts is referred to as ductopenia.
Ductopenia is most commonly seen related to chronic allograft
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rejection and includes drug related injury, primary binary cirrhosis,
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primary sclerosing cholangitis, chronic graft-vs-host disease, hepatic
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sarcoidosis, paraneoplastic syndrome related to Hodgkin disease,
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and syndromic paucity of bile ducts (Alagille syndrome).
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442. Which of the following is not true about
metabolic syndrome?
a) It is also called Syndrome X
b) Acanthosis and signs of hyperandrogenism may be seen
c) Type A has autoantibodies against the insulin receptor
d) Insulin resistance increases the risk of type 2 DM in patients
with PCOS
Correct Answer - C
om
Answer- C. Type A has autoantibodies against the insulin
receptor
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It is an insulin resistance condition which comprises a spectrum of
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disorders, with hyperglycemia representing one of the most readily
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diagnosed features.
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The metabolic syndrome, the insulin resistance syndrome, or
irs
syndrome X are terms used to describe a constellation of metabolic
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derangements that includes insulin resistance, hypertension,
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dyslipidemia (decreased HDL and elevated triglycerides), central or
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visceral obesity, type 2 diabetes or IGT/IFG, and accelerated cardio-
vascular disease.
Acanthosis nigricans and signs of hyperandrogenism
(hirsutism, acne, and oligomenorrhea in women) are also
common physical features.
Two distinct syndromes-
1. type A, which affects young women and is characterized by severe
hyperinsulinemia, obesity, and features of hyperandrogenism; and
type A insulin resistance syndrome have an undefined defect in the
insulin-signaling pathway.
2. type B, which affects middle-aged women and is characterized by
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severe hyperinsulinemia, features of hyperandrogenism, and
autoimmune disorders.
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443. Metabolic syndrome diagnosis in men
based on NCEP ATP III criteria includes
the following except
a) Abdominal obesity > 40 inches
b) HDL < 50 mg / dL
c) BP >/= 130/85 mm Hg
d) Fasting glucoe > 110 mg/ dL
Correct Answer - B
om
Answer- B. HDL < 50 mg / dL
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444. Ejection click of pulmonary stenosis is
better heard in
a) Inspiration
b) Expiration
c) Patient bending forward
d) Patient lying in left lateral position
Correct Answer - B
Answer- B. Expiration
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It emanates from a stenotic pulmonary valve or a dilated pulmonary
artery.
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Its most characteristic feature is to disappear or become markedly
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softer with inspiration i.e. it is better heard in expiration.
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It is localized to 2nd and 3rd intercostal spaces.
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They may also be present in patients with pulmonary hypertention or
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the ones with dilated pulmonary artery.
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445. Reciprocal changes in ECG in patients
with inferior wall myocardial infarction
are seen in which leads
a) I
b) II
c) III
d) aVF
Correct Answer - A
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Answer- A. I
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446. All are features of aortic stenosis
except
a) Congestive heart failure due to systolic or diastolic dysfunction
b) Presence of ejection systolic murmur
c) Presence of pulsus tardus
d) Pressure in the aorta is the same as in left ventricle
Correct Answer - D
Answer- D. Pressure in the aorta is the same as in left ventricle
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Clinical Findings-
Systolic ejection murmur
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Carotid pulsus parvus et tardus
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Diminished aortic component of 2nd heart sound
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Sudden death in severe stenosis after exercise
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Classical triad-
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Angina
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Syncope
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Shortness of breath (heart failure)
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447. Which of the following is not true about
bicuspid aortic valve?
a) Usually undetected in early life
b) It is more common in females than in males
c) Post-stenotic dilatation of ascending aorta can be seen
d) Diagnosis is made by echocardiography
Correct Answer - B
Answer- B. It is more common in females than in males
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The congenital bicuspid aortic valve, which may initially be
functionally normal, is one of the most common congenital
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malformations of the heart and may go undetected in early life.
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More frequent in males (3:1)
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Diagnosis is made by echocardiography, which reveals the
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morphology of the aortic valve and aortic root and quantitates
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severity of stenosis or regurgitation.
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The ascending aorta is often dilated, misnamed "poststenotic"
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dilatation; this is due to histologic abnormalities of the aortic media
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similar to those in Marfan's syndrome and may result in aortic
dissection.
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448. Which of the following hemodynamic
changes is not evident in cardiac
tamponade during diastole?
a) Right atrial and ventricular collapse
b) Absent y wave on JVP
c) Biphasic venous return
d) Elevated pericardial pressure
Correct Answer - C
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Answer- C. Biphasic venous return
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During the diastole the pericardial pressure remains elevated.
It is greater than the intracavitary pressure thus there is no filling
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during the diastole
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The absence of venous return during the diastole leads to absence
tR
of "y" waves on the J.V.P. and the "diastolic collapse" of the right
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atria and ventricle.
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449. Major criteria for infective endocarditis
include which of the following
a) Injection drug user
b) Fever
c) Oslers nodes
d) Typical organism of infective endocarditis isolated from two
separate blood cultures
Correct Answer - D
om
Answer- D. Typical organism of infective endocarditis isolated
from two separate blood cultures
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450. Which of the following ECG features are
not seen in patients with ventricular
tachycardias?
a) Bizzare QRS complexes
b) Presence of AV dissociation [fusion beats]
c) Prolonged duration of QRS complexes
d) P pulmonale
Correct Answer - D
om
Answer- D. P pulmonale
r.c
AV dissociation (atrial capture, fusion beats)
QRS duration > 140 ms for RBBB type V1 morphology, VI > 160 ms
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for LBBB type VI morphology
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Frontal plane axis - 900 to 1800
tR
Delayed activation during initial phase of the QRS complex
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LBBB pattern - R wave in V1, V, > 40 ms
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RBBB pattern - onset of R wave to nadir of S > 100 ms
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Bizarre QRS pattern that does not mimic typical RBBB or LBBB
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QRS complex.
Concordance of QRS complex in all precordial leads
RS or dominant S in V6 for RBBB VT Q wave in V6 with LBBB QRS
pattern
Monophasic R or biphasic qR of R/S in V, with RBBB pattern
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451. Cerebro-occulo-genital syndrome has
the following features except
a) Microcephaly
b) Short stature
c) Agenesis of corpus callosum
d) Flaccid quadriplegia
Correct Answer - D
Answer- D. Flaccid quadriplegia
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Cerebro-occulo-genital syndrome is associated with microcephaly,
short stature, microophthalmia, agenesis of corpus callosum,
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hypospadias and spastic quadriplegia.
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452. Pulsus biseferians, which of the
following is not true
a) It is seen in aortic regurgitation
b) It is better felt in peripheral arteries
c) It has one peak in systole and one in diastole
d) It has two peaks
Correct Answer - C
Answer- C. It has one peak in systole and one in diastole
om
It is characterized by two systolic peaks.
It is seen in patients of aortic regurgitation.
r.c
The pulse wave upstroke rises rapidly and forcefully producing the
ke
first systolic peak (percussion wave). A brief decline in pressure is
an
followed by a smaller and somewhat slower rising positive pulse
tR
wave.
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In bisiferians pulse the second rise in systole is enhanced by
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reflection from peripheral arteries therefore it is more prominent in
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peripheral pulse.
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453. Square wave seen in ECG recording
denote
a) Atrial depolarization
b) Ventricular depolarization
c) Ventricular repolarization
d) Standardization of ECG
Correct Answer - D
Answer- D. Standardization of ECG
om
Each ECG machine has a provision for Standardization (STD) of
Calibration (CAL).
r.c
The standardization lever releases a current of 1 mV to the stylus of
ke
ECG machine that records a shift of 10 mm on the ECG paper.
an
The standardization current gives rise to a wave pattern called
tR
square wave pattern as depicted in the image below.
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454. Which of the following is not true about
Torsades de pointes?
a) Presence of prolonged QT interval on ECG
b) Presence of polymorphic QRS complexes
c) It is a type of supraventricular tachycardia
d) QRS complexes appear to rotate around the isoelectric
baseline of ECG
Correct Answer - C
om
Answer- C. It is a type of supraventricular tachycardia
The significance of the long QT syndrome is its association with the
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development of a specific type of ventricular tachycardia called
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Torsades de points or polymorphic ventricular tachycardia
an
A wide complex tachyarrythmia with QRS complexes of varying axis
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and morphology that appear to rotate around the iso electric
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baseline.
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455. Prolonged QT interval is seen in all of the
following except
a) Hypokalemia
b) Hypocalcemia
c) Use of macrolide antibiotitcs
d) Hypernatremia
Correct Answer - D
Answer- D. Hypernatremia
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Metabolic
Hypokalemia
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Hypocalcemia
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Hypomagnesemia
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456. Following are the clinical signs of
widened pulse pressure seen in patients
of aortic regurgitation except
a) Corrigans sign
b) De Mussets sign
c) Water Hammer pulse
d) Diastolic murmur
Correct Answer - D
om
Answer- D. Diastolic murmur
r.c
Corrigan’s pulse: A rapid and forceful distension of the arterial pulse
with a quick collapse
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De Musset’s sign: Bobbing of the head with each heartbeat (like a
an
bird walking)
tR
Muller’s sign: Visible pulsations of the uvula
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Quincke’s sign: Capillary pulsations seen on light compression of the
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nail bed
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Traube’s sign: Systolic and diastolic sounds heard over the femoral
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artery (“pistol shots”)
Duroziez’s sign: Gradual pressure over the femoral artery leads to a
systolic and diastolic bruit
Hill’s sign: Popliteal systolic blood pressure exceeding brachial
systolic blood pressure by ≥ 60 mmHg (most sensitive sign for aortic
regurgitation)
Water hammer pulse
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457. Episode of stable angina pectoris
typically lasts for
a) Less than 1 min
b) 2 - 5 mins
c) 5 - 10 mins
d) > 10 mins
Correct Answer - B
Answer- B. 2 - 5 mins
om
Angina is usually crescendo- decrescendo in nature, typically lasts 2
to 5 min, and can radiate to either shoulder and to both arms
r.c
(especially the ulnar surfaces of the forearm and hand).
ke
It also can arise in or radiate to the back, interscapular region, root
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of the neck, jaw, teeth, and epigastrium. Angina is rarely localized
tR
below the umbilicus or above the mandible.
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458. Not True about Prinzmetal's angina:
a) May present at rest
b) Occurs due atherosclerotic obstruction of coronary arteries
c) Smoking is a risk factor
d) Nitrates are used for treatment
Correct Answer - B
Answer- B. Occurs due atherosclerotic obstruction of coronary
arteries
This syndrome is due to focal spasm of an epicardial coronAry
om
artery, leading to severe myocardial ischemia leading to severe
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myocardial ischemia.
ke
The right coronary artery is the most frequent site, followed by the
an
left anterior descending coronary artery.
tR
Acetylcholine released by the parasympathetic system at rest will
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simply cause contraction of the vascular smooth muscle.
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It usually occurs at rest and is associated with transient ST- segment
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elevation.
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Etiology
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cigarette smokers
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459. Obstructive shock can be seen in
a) Pulmonary embolism
b) Tension pneumothorax
c) Pericardial tamponade
d) All the above
Correct Answer - D
Answer- D. All the above
Causes in trauma patients include pulmonary embolism, pericardial
tamponade, acute coronary syndromes, increased intrathoracic
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pressure as in tension pneumothorax, positive pressure ventilation
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and excessive PEEP.
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460. Pharmacological stress during stress
myocardial radionucleotide perfusion
imaging can be induced using
a) Dipyridamole
b) Adenosine
c) Dobutamine
d) All the above
Correct Answer - D
om
Answer- D. All the above
r.c
Dipyridamole or adenosine can be given to create a coronary "steal"
by temporarily increasing flow in nondiseased segments of the
ke
coronary vasculature at the expense of diseased segments.
an
Alternatively, a graded incremental infusion of dobutamine may be
tR
administered to increase MVO2.
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The development of a transient perfusion defect with a tracer such
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as thallium-201 or 99m-technetium sestamibi is used to detect
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myocardial ischemia.
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461. While treating patients with malignant
hypertention the maximum allowed
decrease in blood pressure in the first 2 -
6 hours should not exceed %
a) 15
b) 20
c) 25
d) 30
om
Correct Answer - C
r.c
Answer- C. 25
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Hypertension with systolic BP 180 mmHg and diastolic BP 120 mm
an
Hg is classified as "severe hypertension".
tR
Severe hypertension ( 180/120) does not necessarily mean
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hypertensive emergency or malignant hypertension. ? Patients with
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B.P. 180 / 120 may remain asymptomatic without causing any
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complications.
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The initial aim of treatment in malignant hypertension and
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hypertensive encephalopathy is to lower diastolic blood pressure to
about 100 to 105 mm Hg within minutes to, two- six hours with the
maximum fall in B.P. over this period of time not exceeding 25% of
the original value.
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462. Contraindication for percutaneous ballon
mitral valvotomy include the following
except
a) Presence of pulmonary hypertension
b) Left atrial thrombus
c) Severe mitral regurgitation
d) Commissural calcification
Correct Answer - A
om
Answer- A. Presence of pulmonary hypertension
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Patients with valvular calcification, thickened fibrotic leaflets with
decreased mobility and subvalvular fusion, have incidence of acute
ke
complications and higher rate of restenosis on followup. Such
an
patients are considered a contraindication for the procedure. Other
tR
contraind ications include more than moderate mitral regurgitation,
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presence of left atrial thrombi, and commissural calcification.
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463. Mitral valve replacement is
recommended in patients with
a) Moderate MS in NYHA class II
b) Moderate MS in NYHA class III
c) Severe MS in NYHA class II
d) Severe MS in NYHA class III
Correct Answer - D
Answer- D. Severe MS in NYHA class III
om
Since there are also long-term complications of valve replacement,
patients in whom preoperative evaluation suggests the possibility
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that MVR may be required should be operated on only if they have
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severe MS—i.e., an orifice area "1 cm2—and are in NYHA Class III,
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i.e., symptomatic with ordinary activity despite optimal medical
tR
therapy".
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464. HOCM is common in which age group?
a) 10 - 30 years
b) 20 - 40 years
c) 30 - 50 years
d) 40 - 60 years
Correct Answer - B
Answer- B. 20 - 40 years
Hypertrophic cardiomyopathy is characterized by marked left
ventricular hypertrophy in the absence of other causes, such as
om
hyper- tension or valve disease.
r.c
Earlier termed hypertrophic obstructive cardiomyopathy (HOCM)
ke
Hypertrophic cardiomyopathy is characterized hemodynamically by
an
diastolic dysfunction, originally attributed to the hyper¬trophy,
tR
fibrosis, and intraventricular gradient when present.
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Hypertrophic cardiomyopathy usually presents between the ages of
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20 and 40 years. Dyspnea on exertion is the most common
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presenting symptom, reflecting elevated intracardiac filling pressures
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465. Preferred vein for central venous
catheter insertion is
a) Right internal jugular vein
b) Left internal jugular vein
c) Right subclavian vein
d) Right antecubital vein
Correct Answer - A
Answer- A. Right internal jugular vein
om
Placement of the central venous catheter is indicated for the
monitoring of the central venous pressure and for prolonged drug
r.c
administration for parenteral nutrition.
ke
The preferred site for insertion of catheter into the superior venacava
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is from internal jugular vein of the neck. Other used sites are from
tR
the subclavian vein or from the peripheral vein in the antecubital
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fossa.
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Commonly used vein cannulation sites for central venous
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access include:
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Jugular vein
External jugular vein
Internal jugular vein (central, posterior, anterior approaches)
Subclavian vein (supraclavicular, infraclavicular, axillary
approaches)
Femoral vein
Basilic vein
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466. Kerley B lines seen in mitral stenosis
when the resting left atrial pressure
exceeds
a) 10 mm Hg
b) 20 mm Hg
c) 30 mm Hg
d) 40 mm Hg
Correct Answer - B
om
Answer- B. 20 mm Hg
r.c
Kerley B lines are fine, dense, opaque, horizontal lines that are most
prominent in the lower and mid-lung fields and that result from
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distention of interlobular septae and lymphatics with edema when
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the resting mean LA pressure exceeds approximately 20 mmHg.
tR
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467. Which of the following is the most
common anamoly in patients with
fanconi's anemia?
a) Hyperpigmentation of the trunk, neck and intertriginous areas
b) Absent radii and thumb
c) Weak radial pulse
d) Presence of horse shoe kidneys
Correct Answer - A
om
Answer- A. Hyperpigmentation of the trunk, neck and
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intertriginous areas
Fanconi anemia (FA) is primarily inherited in an autosomal recessive
ke
manner (one uncommon form is X-linked recessive).
an
The most common anomaly in FA is hyperpigmentation of the trunk,
tR
neck, and intertriginous areas, as well as café-au-lait spots and
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vitiligo, alone or in combination.
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Anomalies of the feet, congenital hip dislocation, and leg
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abnormalities are seen.
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468. Patients with which of the following
conditions are at greatest risk of pernio
a) Raynaud's phenomenon
b) Kawasaki disease
c) Henoch Schonlen purpura
d) Hepatitis C infection
Correct Answer - A
Answer- A. Raynaud's phenomenon
om
The two most common nonfreezing peripheral cold injuries are
chilblain (pernio) and immersion (trench) foot.
r.c
Chilblain results from neuronal and endothelial damage induced by
ke
repetitive exposure to dry cold.
an
Young females, particularly those with a history of Raynaud's
tR
phenomenon, are at greatest risk of pernio (chilblain).
irs
Persistent vasospasticity and vasculitis can cause erythema, mild
.F
edema, and pruritus. Eventually plaques, blue nodules, and
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ulcerations develop
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469. What is Tiffeneau - Pinelli index?
a) FEV1/FVC ratio
b) Body mass index
c) Quetlet index
d) Ventilation/Perfusion ratio
Correct Answer - A
Answer- A. FEV1/FVC ratio om
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470. Lights criteria is used for
a) Pleural effusions
b) Pericardial effusions
c) Ascites
d) Increased intracranial tension
Correct Answer - A
Answer- A. Pleural effusions
Light's critena for classification of unilateral pleural effusion
The pleural fluid is an exudate if one or more of the following citeria
om
are met.
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Pleural fluid protein divided by serum protein >0.5
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Pleural fluid lacato dehyoctogenase LDH divided by serum LDH >
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0.6
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471. Common cause of death in a patient with
chronic bronchieactasis is
a) Right sided heart fail
b) Infection
c) Hemoptysis
d) Carcinoma
Correct Answer - A
Answer- A. Right sided heart fail
om
In todays world, right sided heart failure in patients with diffuse long
standing bronchieactasis is a common cause of death in patients
r.c
with chronic bronchieactasis.
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Pneumonia and hemorrhage are less common causes of death.
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tR
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472. Leutriene inhibitors are used in asthma
for
a) Monotherapy for acute attack
b) Add-on therapy in patients not controlled by low dose inhaled
glucocorticoids
c) Status asthmaticus
d) None of the above
Correct Answer - B
om
Answer- B. Add-on therapy in patients not controlled by low
dose inhaled glucocorticoids
r.c
Cysteinyl-leukotrienes are potent bronchoconstrictors, cause
ke
microvascular leakage, and increase eosinophilic inflammation
an
through the activation of cys-LT1-receptors.
tR
Lukotriene inhibitors such as montelukast and zafirlukast, block cys-
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LT 1-receptors and provide modest clinical benefit in asthma.
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They are less effective than inhaled corticosteroids in controlling
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asthma and have less effect on airway inflammation, but are useful
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as an add-on therapy in some patients not controlled with low doses
of inhaled corticosteroids.
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473. Apnea hypoapnea index indicating
obstructive sleep apnea is -
a) <1
b) 2 - 5
c) 5 - 8
d) >8
Correct Answer - A
Answer- A. <1
om
Normal preschool and school-age children generally have a total
AHI of less than 1.5 (obstructive AHI <1), and this is the most widely
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used cutoff value for Obstructive Sleep Apnea in children 12 yr and
ke
below; in older adolescents, the adult cutoff of an AHI 5 is generally
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used.
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474. Multiple episodes of acute chest
syndrome are associated with
a) Asthma
b) Bronchieactasis
c) SLE
d) Sjogrens syndrome
Correct Answer - A
Answer- A. Asthma
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Patient presents with recurrent episodes of acute chest syndrome.
The characteristic symptoms during an episode of asthma are
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wheezing, dyspnea, and coughing, which are variable, both
ke
spontaneously and with therapy.
an
Prodromal symptoms may precede an attack, with itching under the
tR
chin, discomfort between the scapulae, or inexplicable fear
irs
(impending doom).
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475. Triad of skin lesions, mononeuritis
multiplex, eosinophils seen in
a) Alports syndrome
b) Churg - Strauss syndrome
c) Cryoglobulinemia
d) Wegeners granulomatosus
Correct Answer - C
Answer- C. Cryoglobulinemia
om
Churg & Strauss is characterized by asthma, eosinophilla,
extravascular granuloma formation, vasculitis.
r.c
Clinical Features-Fever, malaise, anorexia, weight loss.
ke
Mononeuritis multiplex is the second most common features.
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Allergic rhinitis and sinusitis.
tR
Asthma
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Peripheral and tissue eosinophillia, extravascular necrotizing
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granuloma.
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476. Chronic bronchitis is said to be present
when patient has chronic cough
a) 3 consecutive months in at least two consecutive years
b) 2 consecutive months for 3 consecutive years
c) 3 consecutive months in one year
d) 1 month in a year for 2 consecutive years
Correct Answer - A
Answer-A. 3 consecutive months in at least 2 consecutive
om
years.
Cigarette smoking is the most important risk factor; air pollutants
r.c
also contribute.
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The dominant pathologic features are mucus hypersecre- tion and
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persistent inflammation.
tR
Histologic examination demonstrates enlargement of mucous-
irs
secreting glands, goblet cell hyperplasia, chronic inflammation, and
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bronchiolar wall fibrosis.
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477. Brocks syndrome is due to which lobe of
lung?
a) Right middle lobe
b) Right lower lobe
c) Left upper lobe
d) Left lower lobe
Correct Answer - A
Answer- A. Right middle lobe
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Brocks syndrome is due to collapse of right middle lobe of lung. It is
seen as an acute complication of pulmonary tuberculosis. It occurs
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secondary to hilar node involvement.
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478. Presence of Velcro crackles at the lung
base on auscultation is a sign of
a) Scleroderma
b) Systemic Lupus
c) Wegeners Granulomatosus
d) Polyarteritisnodosa
Correct Answer - A
Answer- A. Scleroderma
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CLINICAL FEATURES-
Skin- sclerodactyly, Ranaud’s phenomenon, calcinosis,
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telangiectasia, skin thickening. (inadvance stage fingers become
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claw like & face mask like)
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Musculoskeletal features- Arthralgia, flexor tenosynovitis
tR
GIT- oesophagitis, dysphagia, malabsorption
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Cardiorespiratory features- pulmonary fibrosis, pulmonary
.F
hypertension
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Renal features- hypertensive renal crisis
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Malignant hypertension
Physical examination may reveal "Velcro" crackles at the lung
bases.
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479. Type IV respiratory failure occurs due to
a) Alveolar flooding
b) Inability to eliminate CO2
c) Lung atelactasis
d) Hypoperfusion of respiratory muscles
Correct Answer - D
Answer- d. Hypoperfusion of respiratory muscles
Type IV Respiratory Failure: results from hypoperfusion of
respiratory muscles in patients in shock.
om
Commonly caused by cardiogenic shock, septic shock and
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hypovolemic shock.
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tR
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480. Tool/s which objectively asses the risk of
adverse outcomes in a patient with
pneumonia is/are
a) Pneumonia severity index [PSI]
b) CURB - 65 criteria
c) Apachee Score
d) Glasgow scale
Correct Answer - A:B
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Answer- (A) Pneumonia severity index [PSI] (B) CURB - 65
r.c
criteria
Tools that objectively assess the risk of adverse outcomes are the
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Pneumonia Severity Index (PSI), a prognostic model used to identify
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patients at low risk of dying; and the CURB-65 criteria, a severity-of-
tR
illness score.
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The CURB-65 criteria include five variables: confusion (C); urea >7
.F
mmol/L (U); respiratory rate 30/min (R); blood pressure, systolic "90
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mmHg or diastolic" 60 mmHg (B); and age 65 years (65).
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481. In ICU setting patients suffering from
which respiratory pathology are at risk of
CO2 narcosis?
a) Pneumonia
b) Asthma
c) Emphysema
d) Bronchieactasis
Correct Answer - C
om
Answer- C. Emphysema
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Hypoventilation syndrome occurs most frequently in patients with a
history of chronic CO, retention who are receiving oxygen therapy
ke
for emphysema or chronic pulmonary disease.
an
The elevated Paco, leading to CO, narcosis may have a direct
tR
anesthetic effect, and cerebral vasodilation from increased Paco,
irs
can lead to increased ICP
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482. Inspiratory squeaks are the physical
examination finding of
a) Bronchiolitis
b) Pulmonary hypertension
c) Pneumonia
d) Pulmonary edema
Correct Answer - A
Answer- A. Bronchiolitis
om
ILD associated with inflammation but are less likely to be heard in
the granulomatous lung diseases.
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Crackles may be present in the absence of radiographic
ke
abnormalities on the chest radiograph.
an
Scattered late inspiratory high-pitched rhonchi—so-called inspiratory
tR
squeaks—are heard in patients with bronchiolitis.
irs
Cyanosis and clubbing of the digits occur in some patients with
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advanced disease.
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483. Which of the following are the clinical
abnormalities of uremia?
a) Hyperphosphatemia
b) Uremic frost
c) Peptic ulcer
d) All the above
Correct Answer - D
Answer- D. All the above
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Volume expasion (I)
Hyperkalemia (I)
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Hyponatremia (1)
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Hyperphosphatemia (I)
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484. Which type of Bartter's syndrome is
associated with mutations in barttin?
a) Type 1
b) Type 2
c) Type 3
d) Type 4
Correct Answer - D
Answer- D. Type 4
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Bartter's syndrome may result from mutations affecting any of five
ion transport proteins in the TAL.
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The proteins affected include the apical loop diuretic-sensitive
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sodium-potassium-chloride co-transporter NKCC2 (type 1), the
an
apical potassium channel ROMK (type 2), and the basolateral
tR
chloride channel C1C-Kb (type 3).
irs
Bartter's type 4 results from mutations in barttin, an essential subunit
.F
of CIC-Ka and C1C-Kb that enables transport of the chloride
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channels to the cell surface. Barttin is also expressed in the inner
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ear; this accounts for the deafness invariably associated with
Bartter's type 4.
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485. Test used for screening for urinary tract
infection is
a) Nitrite test
b) Na nitropruss ide test
c) Paul Bunnel test
d) Fentons test
Correct Answer - A
Answer- A. Nitrite Test
om
Effective and rapid method used for screening urine for the presence
of bacterial infection.
r.c
Test is based on the fact that most bacteria present in the urine,
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have the capacity to reduce urine nitrate to nitrite.
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tR
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486. Patient with nephrotic syndrome has
decreased amount of which antibody
a) IgG
b) IgE
c) IgM
d) IgA
Correct Answer - A
Answer- A. IgG
om
The immunological abnormalities noted are very peculiar
IgG antibody is decrease
r.c
IgE and IgM antibody increase
ke
Reduced responses to PHA and Con A (Concanavalin A)
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Increase of beta microglobulinlevels
tR
Reduced production of IL 2
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Increased production of vascular permeability and
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immunosuppressor factors by CD4 T cells and CD 8 T cells
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respectively.
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487. RIFLE criteria is used for diagnosis of
a) Acute kidney injury
b) Acute splenic injury
c) Acute liver injury
d) Acute bowel injury
Correct Answer - A
Answer- A. Acute kidney injury
The RIFLE criteria, defines threes increasing levels of severity of
acute kidney injury on the basis of the increase in serum creatinine
om
concentration or decrease in urine output.
r.c
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tR
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488. Hemodynamically important lesions of
renal artery stenosis are predicted by
renal artery velocities more than on
Doppler ultrasound.
a) 100 cm/s
b) 125 cm/s
c) 150 cm/s
d) 200 cm/s
om
Correct Answer - D
r.c
Answer- D. 200 cm/s
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Renal artery velocities by Doppler ultrasound above 200 cm/s
an
generally predict hemodynamically important lesions (above 60%
tR
vessel lumen occlusion), although treatment trials require velocity
irs
above 300 cm/s to avoid false positives.
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Renal resistive index has predictive value regarding the viability of
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the kidney. It remains operator- and institution- dependent.
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489. Gitelman's syndrome resembles the
effects of which of the following drugs?
a) Thiazide
b) Furosemide
c) Spironolactone
d) Amiloride
Correct Answer - A
Answer- A. Thiazide
om
Gitelman's syndrome is due to mutations in the thiazide-sensitive
Na-Cl co-transporter, NCCT, in the distal convoluted tubule (DCT).
r.c
Defects in NCCT in Gitelman's syndrome impair sodium and chloride
ke
reabsorption in the DCT and thus resemble the effects of thiazide
an
diuretics. It remains unclear how this defect leads to severe
tR
magnesium wasting.
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490. Definition of complicated urinary tract
infection is, the infection which fail to
resolve or recur within week/s of
standard therapy.
a) 1 week
b) 2 weeks
c) 3 weeks
d) 4 weeks
om
Correct Answer - B
r.c
Answer- B. 2 weeks
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Complicated urinary tract infections refers to the infections that fail to
an
resolve or recur within 2 weeks of standard therapy.
tR
These are associated with bacteremia or sepsis and are assocated
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with periurethral abscess, obstructions and pyelonephritis
.F
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491. A patient presents with blunt trauma to
abdomen. On investigations patient is
found to have hepatic injury which has a
ruptured subcapsular hematoma with
active bleeding. What is the grade of liver
injury?
a) Grade I
b) Grade II
c) Grade III
d) Grade IV
om
r.c
ke
an
Correct Answer - C
Answer- C. Grade III
tR
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492. Excellent predictor of mortality and
morbidity in patients after hepatectomy
is
a) Serum lactate levels
b) Serum magnesium level
c) Serum iron level
d) Serum copper level
Correct Answer - A
om
Answer- A. Serum lactate levels
r.c
Hyperlactemia and hypophosphatemia are common derangements
in patients undergoing liver resection.
ke
Gluconeogenesis carried out by the liver normally consumes 40-
an
60% of lactate.
tR
When the liver is damaged, stressed or resected, it produces lactate
irs
rather than metabolizing it.
.F
Due to the additive effects of lactate-containing intravenous solution,
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non-lactate containing solutions are recommended for postoperative
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use after hepatectomy.
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493. Ascitic fluid SAAG < 1.1 what is the
disease associated with
a) Hepatic failure
b) Idiopathic portal fibrosis
c) Constrictive pericarditis
d) Peritoneal carcinomatosis
Correct Answer - D
Answer- D. Peritoneal carcinomatosis
om
Low albumin gradient (SAAG <1.1 g/dL)
Peritoneal carcinomatosis
r.c
Peritoneal tuberculosis
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Pancreatitis
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Serositis
tR
Nephrotic syndrome
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494. Gene associated with the development of
Peutz-Jeghers syndrome is
a) STK 11
b) PTEN
c) KRAS
d) BRCA 1
Correct Answer - A
Answer- A. STK 11
om
Germline heterozygous loss-of-function mutations in the gene STKil
are present in approximately half of individuals with familial Peutz-
r.c
Jeghers syndrome as well as a subset of patients with sporadic
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Peutz-Jeghers syndrome.
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495. Right hand dominant patient presents
with normal comprehension but speaks
with short utterances of a few words at a
time, comprised mostly of nouns. What
is the most probable location of the
lesion
a) Left inferior frontal gyrus
b) Right inferior frontal gyrus
c) Left superior temporal gyrus
d) Right superior temporal gyrus
om
r.c
ke
an
Correct Answer - A
Answer- A. Left inferior frontal gyrus
tR
Patient has normal comprehension but speaks with short utterances
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of a few words at a time, comprised mostly of nouns. These findings
.F
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are suggestive of brocas aphsia. It is seen in patients having
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affection of the inferior frontal gyrus of the dominant hemisphere.
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The patient is right handed so the left hemisphere, will the dominant
one. Thus most probable location of the lesion is left inferior frontal
gyrus.
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496. Pure word deafness is associated with
a) Middle cerebral artery stroke
b) Posterior cerebral artery stroke
c) Vertebral artery aneurysm
d) Basilar artery aneurysm
Correct Answer - A
Answer- A. Middle cerebral artery stroke
The most common causes are either bilateral or left-sided middle
cerebral artery (MCA) strokes affecting the superior temporal gyrus.
om
The net effect of the underlying lesion is to interrupt the flow of
r.c
information from the auditory association cortex to Wernicke's area.
ke
an
tR
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497. Global aphasia is seen due to
a) Strokes involving entire middle cerebral artery distribution in left
hemisphere
b) Strokes involving entire middle cerebral artery distribution in
right hemisphere
c) Strokes involving entire posterior cerebral artery distribution in
left hemisphere
d) Strokes involving entire posterior cerebral artery distribution in
right hemisphere
om
Correct Answer - A
r.c
Answer- A. Strokes involving entire middle cerebral artery
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distribution in left hemisphere
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This syndrome represents the combined dysfunction of Broca's and
tR
Wernicke's areas and usually results from strokes that involve the
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entire middle cerebral artery distribution in the left hemisphere.
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Related signs include right hemiplegia, hemisensory loss, and
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homonymous hemianopia.
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498. Lambert Eaton syndrome true is
a) It is a paraneoplastic syndrome associated with squamous cell
carcinoma of lung
b) IgM antibodies against ligand gated calcium channels
c) There is increase in release of presynaptic acetylcholine
d) With continuous stimulation there is marked increase in
amplitude of action potentials.
Correct Answer - D
Answer- D. With continuous stimulation there is marked
om
increase in amplitude of action potentials.
r.c
It is a paraneoplastic syndrome associated with cancer particularly
ke
small cell Ca of lung.
an
It is a disorder of neuromuscular junction transmission (Presynaptic)
tR
These IgG autoantibodies against the voltage sensitive calcium
irs
channels reduce the number of functioning channels.
.F
This causes decrease in release of presynaptic acetylcholine.
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Symptoms
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Muscles of the trunk shoulder girdle, pelvic girdle and muscles of
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lower extremities (muscles of the proximal leg are the most
commonly involved muscles)
Often the first symptoms are difficulty in arising from a chair,
climbing stairs and walking, the shoulder muscles are affected later
on.
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499. Which is not seen in Alzheimers disease
a) Gradual development of forgetfulness
b) Defective visuospatial orientation
c) Depression
d) Sequence of neurological abnormalities follows a described
order
Correct Answer - D
Answer- D. Sequence of neurological abnormalities follows a
described order
om
The sequence of neurological disabilities may not follow any
r.c
described order and one or another deficit may take preceedence
ke
but usually the disease preceedes in the following four observed
an
patterns.
tR
1) Korsakoff amnestic state
irs
2) Dysnomia
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3) Visuospatial orientation becomes defective
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4) Paranoia and other personality changes
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500. Which lobe is affected in the early course
of alzheimers disease
a) Frontal lobe
b) Parietal lobe
c) Medial temporal lobe
d) Lateral temporal lobe
Correct Answer - C
Answer- C. Medial temporal lobe
om
Structures of the medial temporal lobe, including hippocampus,
entorhinal cortex and amygdala, are involved early in the course and
r.c
are usually severely atrophied in the later stages.
ke
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tR
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501. Which is/are the usual first deformity/ies
to be seen in CMT disease?
a) Pes cavus
b) Club hand
c) Mannus valgus
d) Flexion deformity of knee
Correct Answer - A
Answer- A. Pes cavus
om
Charcot-Marie-Tooth (CMT) disease is the most common type of
hereditary neuropathy.
r.c
There is progressive muscle weakness and atrophy that usually
ke
begins in the first two decades of life.
an
The first signs of the disease are usually pes cavus, foot deformities
tR
and scoliosis.
irs
There is slowly progressive weakness and wasting, first of the feet
.F
and legs and then of the hands.
w
The most common form of CMT is type 1, a demyelinating
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neuropathy with autosomal dominant inheritance, mapped most
commonly to the short arm of chromosome 17.
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502. Huntingtons disease is commonly seen
in age group between
a) 15 - 35 years
b) 25 - 45 years
c) 35 - 55 years
d) 45 - 65 years
Correct Answer - B
Answer- B. 25 - 45 years
om
HD is a progressive, fatal, highly penetrant autosomal dominant
disorder characterized by motor, behavioral, and cognitive
r.c
dysfunction.
ke
Onset is typically between the ages of 25 and 45 years (range, 3-70
an
years) with a prevalence of 2-8 cases per 100,000 and an average
tR
age at death of 60 years.
irs
Huntigton's disease is characterized by triad of
.F
Autosomal dominant inheritence
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Choreoathetosis
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Dementia
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503. Which cranial nerve is involved in Weber
syndrome?
a) II
b) III
c) IV
d) V
Correct Answer - B
Answer- B. III
om
Weber's syndrome- Midbrain- Oculomotor nerve- Ipsilateral third-
nerve palsy
r.c
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tR
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504. Violent abnormal flinging movements
which are irregular and affecting one
side are called as -
a) Chorea
b) Athetosis
c) Dystonia
d) Hemiballismus
Correct Answer - D
om
Answer- D. Hemiballismus
r.c
It is defined as the dysfunction in the implementation of appropriate
targeting and velocity of intended movements, dysfunction of
ke
posture and abnormal involuntary movement, or the performance of
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normal appearing movements at inappropriate or unintended times.
tR
irs
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505. Wernickes encephalopathy develops
secondary to accumulation of which
substrate?
a) Glutamate
b) Aspartate
c) Lactate
d) Acetate
Correct Answer - A
om
Answer- A. Glutamate
r.c
Glutamate accumulates owing to impairment of a ketoglutamate
dehydrogenase activity and in combination with energy deficiency
ke
may result in excitotoxic cell damage.
an
tR
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506. Which of the following clinical test when
positive suggests presence of sensory
ataxia?
a) Romberg test
b) Adson test
c) Stinchfield test
d) Crossed SLR test
Correct Answer - A
om
Answer- A. Romberg test
r.c
The Romberg test is a test of the body's sense of positioning
(proprioception), which requires healthy functioning of the dorsal
ke
columns of the spinal cord.
an
The Romberg test is used to investigate the cause of loss of motor
tR
coordination (ataxia).
irs
A positive Romberg test suggests that the ataxia is sensory in
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nature, that is, depending on loss of proprioception.
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507. Todds paralysis is experience following
episode of
a) Focal seizure
b) Generalised seizure
c) After correction of hyponatremia
d) After correction of hypokalemia
Correct Answer - A
Answer- A. Focal seizure
om
Focal seizures arise from a neuronal network either discretely
localized within one cerebral hemisphere.
r.c
The routine interictal (i.e., between seizures) electroencephalogram
ke
(EEG) in patients with focal seizures is often normal or may show
an
brief discharges termed epileptiform spikes, or sharp waves.
tR
Second, patients may experience a localized paresis (Todd's
irs
paralysis) for minutes to many hours in the involved region following
.F
the seizure.
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508. Cerebro-occulo-genital syndrome has
the following features except
a) Microcephaly
b) Short stature
c) Agenesis of corpus callosum
d) Flaccid quadriplegia
Correct Answer - D
Answer- D. Flaccid quadriplegia
om
Cerebro-occulo-genital syndrome is associated with microcephaly,
short stature, microophthalmia, agenesis of corpus callosum,
r.c
hypospadias and spastic quadriplegia.
ke
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tR
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509. Frontal lobe syndrome consists
a) Euphoria
b) Indifference
c) Irritability
d) All the above
Correct Answer - D
Answer- D. All the above
Euphoria, indifference, disinhibition, and irritability are consequences
of frontal lobe lesions. These emotional and behavioural
om
disturbances are usually referred to as frontal lobe syndrome.
r.c
Other features are decreased social concern, jocularity,
ke
facetiousness, coarseness, hyperkinesia, disinhibition, loss of social
an
graces, inappropriate sexual advances, sexual exhibitionism,
tR
impulsiveness, restlessness, and grandiose delusions.
irs
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510. Flapping tremors are not seen in
a) CO2 toxicity
b) Hypomagnesemia
c) Subarachnoid hemorrhage
d) Carbolic acid poisoning
Correct Answer - D
Answer- D. Carbolic acid poisoning
It is an important clinical sign
It is not pathognomonic of any condition but it gives clue to serious
om
underlying disease process.
r.c
Flapping tremor is a motor disturbance marked by intermettent
ke
lapses of an assumed posture as a result of intermittency of
an
sustained contraction of group of muscles.
tR
irs
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511. Features which differentiate seizures
from syncope include the following
except
a) No immediate precipitating factors like stress, valsalva,
orthostatic hypotension
b) Immediate transition to unconciousness
c) Presence of cyanosis and frothing of mouth
d) Presence of premonitory symptoms like diaphoresis and
tunneling of vision om
r.c
Correct Answer - D
Ans. D. Presence of premonitory symptoms like diaphoresis
ke
and tunneling of vision
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512. Fine tremors are found in which
disorder
a) Mercury poisoning
b) Excess smoking
c) Hypoglycemia
d) All the above
Correct Answer - D
Answer- D. All the above
om
Fine tremors are noted when a limb is held in an antigravity posture
They are noted in situations of catecholamine excess such as
r.c
anxiety states, thyrotoxicosis, hypoglycemia and in alcoholism and
ke
excess smoking.
an
They are also noted after ingestion of drugs like caffeine,
tR
salbutamol, theophylline, amphetamine, tricyclic antidepressants,
irs
Lithium, valproate, steroids, and in mercury poisoning.
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513. True about electrophoresis in patients of
multiple myeloma
a) M component spike is for the alpha globulins
b) Monoclonal antibody must be present at a concentration of at
least 10 g/L [1.0 g/dL] to be accurately quantitated by
electrophoresis
c) M component is IgM in 53% of the patients
d) M component is IgA in 25% of the patients
om
Correct Answer - D
Answer- D. M component is IgA in 25% of the patients
r.c
The immunoglobulins move heterogeneously in an electric field and
ke
form a broad peak in the gamma region. The y globulin region of the
an
electrophoretic pattern is usually increased in the sera of patients
tR
with plasma cell tumors. There is a sharp spike in this region called
irs
an M component (M for monoclonal).
.F
The serum M component in multiple myeloma will be IgG in 53% of
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patients, IgA in 25%, and IgD in 1%; 20% ofMietits will have only
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light chains in serum and urine.
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514. All but one is true for beta thalassemia
major
a) Growth and development is impaired
b) Red cell count <4 x 10'2/L
c) Levels of HbA2 < 3.5%
d) Bone marrow iron is depleted
Correct Answer - D
Answer- D. Bone marrow iron is depleted
om
Anaemia Hb gm/dl- < 7 (severe)
Increased HbF, HbA2 and absence of HbA.
r.c
Severity of disease ++++
ke
Growth and development impaired
an
Splenomegaly ++++
tR
Skeletal changes +++
irs
Thalassemia facies
.F
B.M. Iron- decreased
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515. Immune thrombocytopenic puprpura
associated with
a) Hepatitis A infection
b) Hepatitis B infection
c) Hepatitis C infection
d) Hepatitis D infection
Correct Answer - C
Answer- C. Hepatitis C infection
om
Immune thrombocytopenic purpura (ITP; also termed idiopathic
thrombocytopenic purpura) is an acquired disorder in which there is
r.c
immune-mediated destruction of platelets and possibly inhibition of
ke
platelet release from the megakaryocyte.
an
ITP is termed secondary if it is associated with an underlying
tR
disorder; autoimmune disorders, particularly systemic lupus
irs
erythematosus (SLE), and infections, such as HIV and hepatitis C,
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are common causes.
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516. Which of the following is not a cause of
secondary Idiopathic thrombocytopenic
purpura?
a) Systemic lupus erythmatosus
b) Hepatitis C infection
c) Rheumatoid arthritis
d) HIV infection
Correct Answer - C
om
Answer- C. Rheumatoid arthritis
r.c
ITP is termed secondary if it is associated with an underlying
disorder; autoimmune disorders, particularly systemic lupus
ke
erythematosus (SLE), and infections, such as HIV and hepatitis C,
an
are common causes.
tR
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517. Drug/s used in management relapsed
multiple myeloma is
a) Bortezomib
b) Lenalidomide
c) Doxorubicin
d) All the above
Correct Answer - D
Answer- D. All the above
om
The combination of bortezomib and liposomal doxorubicin is active
in relapsed myeloma.
r.c
Thalidomide, if not used as initial therapy, can achieve responses in
ke
refractory cases.
an
High-dose melphalan and stem cell transplant, if not used earlier,
tR
also have activity in patients with refractory disease.
irs
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518. Treatment of chronic phase of CML in
pregnant women is -
a) Imatinib
b) Leukapheresis
c) Spleenectomy
d) Interferon therapy
Correct Answer - B
Answer- B. Leukapheresis
om
Intensive leukapheresis may control the blood counts in chronic-
phase CML; however, it is expensive and cumbersome.
r.c
It is useful in emergencies where leukostasis-related complications
ke
such as pulmonary failure or cerebrovascular accidents are likely.
an
Splenectomy was used in CML in the past because of the
tR
suggestion that evolution to the acute phase might occur in the
irs
spleen.
.F
Splenic radiation is used rarely to reduce the size of the spleen.
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519. Which of the following drug/s can be
used for immediate parenteral
anticoagulation in patients with venous
thromboembolism?
a) Unfractioned heparin
b) Low molecular weight heparin
c) Fondaparinux
d) All the above
om
Correct Answer - D
r.c
Answer- D.�All the above
ke
Immediately effective anticoagulation is initiated with a parenteral
an
drug: unfractionated heparin (UFH), low-molecular-weight heparin
tR
(LMWH), or fondaparinux.
irs
One should use a direct thrombin inhibitor�argatroban, lepirudin, or
.F
bivalirudin�in patients with proven or suspected heparin-induced
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thrombocytopenia.
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Warfarin requires 5-7 days to achieve a therapeutic effect.
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520. A patient presents with icterus, but there
is no evidence of bilirubin in urine. What
is the most likely cause of jaundice in
this patient?
a) Hemolysis
b) Gall stones
c) Carcinoma head of pancreas
d) Biliary atresia
om
Correct Answer - A
r.c
Answer- A. Hemolysis
ke
Hemolysis and hyperbilirubinemia
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Increased destruction of erythrocytes leads to increased bilirubin
tR
turnover and unconjugated hyperbilirubinemia; the
irs
hyperbilirubinemia is usually modest in the presence of normal liver
.F
function.
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Therefore, hemolysis alone cannot result in a sustained
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hyperbilirubinemia of more than -68 umol/L (4 mg/dL).
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When hemolysis is the only abnormality in an otherwise healthy
individual, the result is a purely unconjugated hyperbilirubinemia.
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521. True about sideroblastic anemia
a) Severity of the disease depends on the residual erythroid ALA
synthase activity
b) Prussian blue staining sideroblasts are observed
c) Pyridoxine supplementation can be used for treatment
d) All the above
Correct Answer - D
Answer- D. All the above
XLSA results from the deficient activity of the erythroid form of ALA-
om
synthase and is associated with ineffective erythropoiesis,
r.c
weakness, and pallor.
ke
Typically, males with XLSA develop refractory hemolytic anemia,
an
pallor, and weakness during infancy.
tR
Peripheral blood smears reveal a hypochromic, microcytic anemia
irs
with striking anisocytosis, poikilocytosis, and polychromasia; the
.F
leukocytes and platelets appear normal.
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A variety of Prussian blue-staining sideroblasts are observed. Levels
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of urinary porphyrin precursors and of both urinary and fecal
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porphyrins are normal.
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522. Massive transfusion is defined as
transfusion of
a) 10/ 24 or more red cell products in hours.
b) 5/12 or more red cell products in hours.
c) 10/48 or more red cell products in hours.
d) 5/24or more red cell products in hours.
Correct Answer - A
Answer: A 10/ 24 or more red cell products in hours.
om
Various definitions of massive blood transfusion (MBT) have been
published in the medical literature such as:
r.c
Replacement of one entire blood volume within 24 h
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Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h
an
Transfusion of >4 units of PRBCs in 1 h when on-going need is
tR
foreseeable
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523. Which is the most common cause of
thrombocytopenia in an ICU patient?
a) Sepsis
b) Bone marrow failure
c) ITP
d) Drug induced
Correct Answer - A
Answer- A. Sepsis
om
Thrombocytopenia is a common laboratory abnormality that has
been associated with adverse outcomes in ICU patients.
r.c
Thrombocytopenia is defined as platelet count < 150 X 103 cells /
ke
mcL.
an
Common causes of thrombocytopenia in ICU patients:
tR
Sepsis
irs
Disseminated intravascular coagulation
.F
Consumption (eg, major trauma, cardiopulmonary bypass)
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Dilution (with massive transfusion)
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Myelosuppressive chemotherapy
Mechanical circulatory support devices (eg, intra-aortic balloon
pump)
Less common but important causes of thrombocytopenia that should
not be missed:
Heparin-induced thrombocytopenia
Hemophagocytic syndrome
Uncommon causes of thrombocytopenia that develop during ICU
admission
Drug-induced thrombocytopenia (other than heparin or cytotoxic
chemotherapy)
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Leukemia, myelodysplasia, aplastic anemia, etc, unless
abnormalities were already present before ICU admission
om
r.c
ke
an
tR
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524. What percentage of Multiple myeloma
patients have vertebral involvement?
a) 22%
b) 44%
c) 66%
d) 88%
Correct Answer - C
Answer- C. 66%
om
Bone lesions are most common in the vertebral column. The
following distribution was seen in a large series of cases:
r.c
Vertebral column → 66%
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Ribs- 44%
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Skull → 4%
tR
Pelvis → 28%
irs
Femur → 28%
.F
Clavicle → 10%
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525. Multiagent chemotherapy induces
remission in of the patients of acute
myelogenous leukemia
a) 65 - 70
b) 75 - 80
c) 85 - 90
d) 95 - 100
Correct Answer - C
om
Answer- C.�85 - 90
r.c
Aggressive multiagent chemotherapy is successful in inducing
remission in approximately 85-90% of patients.
ke
Prognostic features [t(8;21); t(15;17); inv(16); APL] and improved
an
outcome with chemotherapy, matched sibling stem cell
tR
transplantation is recommended only after a relapse
irs
Matched-sibling bone marrow or stem cell transplantation after
.F
remission achieves long-term disease-free survival in about two
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thirds of patients.
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526. HbA1C criteria for a patient to be
diagnosed with diabetes mellitus is
a) >4.5%
b) >5.5%
c) >6.5%
d) >7.5%
Correct Answer - C
Answer- C. >6.5%
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Fasting plasma glucose > (126 mg/dl)
Two hour plasma glucose > (200mg/d1) during an oral GTT
r.c
A/C > 6.5%
ke
an
tR
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527. Which of the following is not true about
the development of thyroid tumors in
nodular goiter?
a) Prevalence of thyroid carcinoma ranges between 5-15% in the
patients with multinodular goiter
b) Papillary carcinoma is the most common carcinoma developed
in patients with nodular goiter
c) Both benign and malignant neoplasms can be seen in patients
with nodular goiter
d) The risk of development of carcinoma is not correlated with the
level of TSH
om
r.c
ke
Correct Answer - D
an
Answer- D. The risk of development of carcinoma is not
tR
correlated with the level of TSH
irs
Thyroid tumors both benign and malignant can be seen in colloid
.F
goiter with both solitary and multiple nodules.
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The prevalence of thyroid carcinoma ranges from 5 – 15% in
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multinodular goiter and 8 – 17% in solitary colloid nodules.
The prevalence in higher in men compared to women and usually
occurs in older age group.
The most common malignant tumor arising in mutinodular goiter is
papillary carcinoma. Other like follicular carcinoma, hurthle cell
carcinoma and medullary carcinoma are also encountered
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528. Indication for giving liothyronine as
therapeutic management is
a) Resistant depression
b) Social phobia
c) Alzheimers disease
d) Cataplexy
Correct Answer - A
Answer- A. Resistant depression
om
It is the synthetic levorotatory isomer of triiodothyronine (T3).
Liothyronine is the most broadly used thyroid hormone for treatment
r.c
of depression.
ke
Liothyronine is used to accelerate the response to tricyclic
an
antidepressants particularly in women.
tR
It is known to augment response to antidepressants in patients with
irs
mood disorders, in those who failed to respond to a tricyclic
.F
antidepressant trialie. In patients with resistant depression.
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529. Medical management of
hyperparathyroidism includes which of
the following?
a) Bisphosphonates
b) Calcitonin
c) Plicamycin
d) All the above
Correct Answer - D
om
Answer- D. All the above
r.c
Expansion of intravascular volume, administration of loop diuretics,
pharmacotherapy which reduces osteoclastic bone resorption (like
ke
Bisphosphonates, Calcitonin, and Plicamycin) are useful in the
an
medical management of hyperparathyroidism.
tR
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530. Which of the following causes of
hypercalcemia is not associated with
high bone turnover?
a) Hyperthyroidism
b) Vitamin A intoxication
c) Vitamin D intoxication
d) Thiazides
Correct Answer - C
om
Answer- C. Vitamin D intoxication
r.c
Vitamin D related
Vitamin D intoxication
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Increased 1, 25 (OH)2D eg. Sarcoidosis
an
Idiopathic hypercalcemia of infancy
tR
Associated high bone turnover
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Hyperthyroidism
.F
Immobilization
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Thiazides
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Vitamin A intoxication
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531. Fasting hypoglycemia is caused by the
following except
a) Alcohol intake
b) Pentamidine therapy
c) Renal insufficiency
d) Chronic pancreatitis
Correct Answer - D
Answer- D. Chronic pancreatitis
om
Inappropriate (High) Insulin Level
Insulin reaction in patients with diabetes - This is the most common
r.c
cause of hypoglycemia, due to an imbalance between insulin supply
ke
and insulin requirements.
an
Insulin secretagogue overdose in type 2 diabetes patients - Insulin
tR
secretagogues are oral hypoglycemic agents that work by
irs
stimulating insulin release from beta islet cells and, herefore, have
.F
the potential to cause hypoglycemia. Sulfonylureas
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(the most commonly prescribed type of these medications) are
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cleared by the kidney, so elderly patients with compromised renal
function are at risk for developing hypoglycemia while on these
agents.
Factitious hypoglycemia (self induced or inadvertent)
Autoimmune hypoglycemia
Pentamidine - Pentamidine used for treatment/prophylaxis of PCP in
patients with AIDS can cause hypoglycemia by direct injury to the
beta islet cells causing hyperinsulinemia.
Excess Insulin Secretion (Insulinoma)
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532. Diabetes insipidus is said to be present
when
a) > 30ml/hr urine output in 24 hrs and < 260 mosml/L osmolarity
b) > 40ml/hr urine output in 24 hrs and < 280 mosml/L osmolarity
c) > 50ml/hr urine output in 24 hrs and < 300 mosml/L osmolarity
d) > 60ml/hr urine output in 24 hrs and < 320 mosml/L osmolarity
Correct Answer - C
Answer- C. > 50ml/hr urine output in 24 hrs and < 300 mosml/L
om
osmolarity
Decreased secretion or action of arginine vasopressin usually
r.c
manifests as diabetes insipidus, a syndrome characterized by the
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production of abnormally large volumes of dilute urine.
an
DI must be differentiated from other etiology of polyuria.
tR
The test should be started in the morning with careful supervision to
irs
avoid dehydration.
.F
Bodyweight, plasma osmolality, serum sodium, and urine volume
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and osmolality should be measured hourly.
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The test should be stopped when body weight decreases by 5% or
plasma osmolality/sodium exceed the upper limit of normal.
The 24-hour urine volume is >50 ml/kg body weight or urine
osmolality
Measurement of AVP levels before and after fluid deprivation may
be helpful to distinguish central and nephrogenic DI.
Occasionally, hypertonic saline infusion may be required if fluid
deprivation does not achieve the requisite level of hypertonic
dehydration, but this should be administered with caution.
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533. Chronic adrenal insufficiency is caused
by the following organisms except
a) Mycobacterium tubercle
b) Histoplasma capsulatum
c) Coccidioides immitis
d) Mycobacterium bovis
Correct Answer - D
Answer- D. Mycobacterium bovis
om
Infections, particularly tuberculosis and those produced by fungi,
cause primary chronic adrenocortical insufficiency.
r.c
When present, tuberculous adrenalitis is usually associated with
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active infection in other sites, particularly in the lungs and
an
genitourinary
tR
AIDS sufferers are at risk for developing adrenal insufficiency from
irs
several infectious (cytomegalovirus, Mycobacterium
.F
aviumintracellulare) and noninfectious (Kaposi sarcoma)
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complications.
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534. Which of the following is not a feature of
myxedema coma?
a) Reduced level of consciousness and seizures with other
features of hypothyroidism is seen
b) Hypoventilation leading to hypoxia and hypercapnia
c) Levothyroxine can be given via intravenous and nasogastric
route
d) Levothyroxine should not be used in the management
om
Correct Answer - D
Answer- D. Levothyroxine should not be used in the
r.c
management
ke
Myxedema coma is defined as severe hypothyroidism leading to
an
decreased mental status, hypothermia, and other symptoms of
tR
hypothyroidism.
irs
Reduced level of consciousness, sometimes associated with
.F
seizures may also be seen.
w
Factors that predispose to myxedema coma include cold exposure,
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trauma, infection, and administration of narcotics.
Therapy for myxedema coma should include levothyroxine (500 μg)
as a single IV bolus followed by daily treatment with levothyroxine
(50–100 μg/d), along with hydrocortisone (50 mg every 6 h) for
impaired adrenal reserve, ventilatory support, space blankets, and
treatment of precipitating factors.
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535. Acute adrenal insufficiency can present
as
a) Acute abdomen with abdominal tenderness, nausea,vomiting
and fever
b) Neurologic disease with decreased responsiveness progressing
to stupor and coma
c) Hypovolemic shock
d) All of the above
om
Correct Answer - D
Answer- D. All of the above
r.c
Postural hypotension may progress to hypovolemic shock.
ke
Adrenal insufficiency may mimic features of acute abdomen with
an
abdominal tenderness, nausea, vomiting, and fever.
tR
In some cases, the primary presentation may resemble neurologic
irs
disease, with decreased responsiveness, progressing to stupor and
.F
coma.
w
An adrenal crisis can be triggered by an intercurrent illness, surgical
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or other stress, or increased glucocorticoid inactivation (e.g.,
hyperthyroidism).
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536. Hypotonic solution given to correct
a) Dehydration secondary to diuretic therapy
b) Diabetic ketoacidosis
c) Hyperosmolar, hyperglycemic nonketotic syndrome
d) All the above
Correct Answer - D
Answer- D. All the above
Hypotonic solution has osmolarity lower than seum osmolarity.
When a patient receives hypotonic solution, fluid shifts out of the
om
blood vessels and into the cells and interstitial spaces, where
r.c
osmolarity is higher.
ke
Hypotonic solution hydrates cells while reducing fluid in the
an
circulatory system.
tR
Indications
irs
Dehydration secondary to diuretic therapy.
.F
Diabetic ketoacidosis
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Hyperosmolar, hyperglycemic nonketotic syndrome
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Examples of hypotonic solutions: half normal saline, 0.33% sodium
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chloride, dextrose 2.5% in water, dextrose 2.5%.
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537. All of the following are causes of acute
hyponatremia except
a) Glycine irrigation in TURP
b) Recent institution of thiazide therapy
c) MDMA ingestion
d) Liquorice ingestion
Correct Answer - D
Answer- D. Liquorice ingestion
om
causes of hyponatremia
Iatrogenic
r.c
Postoperative: premenopausal women
ke
Hypotonic fluids with causes of 1' vasopressin
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Glycine irrigation: TURP, uterine surgery
tR
Colonoscopy preparation
irs
Recent institution of thiazides
.F
Polydipsia MDMA ingestion
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Exercise-induced
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Multifactorial, e.g., thiazide and polydipsia
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538. Respiratory acidosis is recognized
primarily by increase in
a) Pa02
b) PaCO2
c) HCO3
d) None of the above
Correct Answer - B
Answer- B. PaCO2
om
Respiratory acidosis occurs when there is accumulation of CO2 due
to type II respiratory failure.it can also occur due to severe
r.c
pulmonary disease, respiratory muscle fatigue, or abnormalities in
ke
ventilatory control and is recognized by an increase in Paco2 and
an
decrease in pH
tR
This results in a rise in the PCO2, with a compensatory increase in
irs
plasma bicarbonate concentration, particularly when the disorder is
.F
of long duration and the kidney has fully developed its capacity for
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increased acid excretion
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539. Which of the following drug
administration is not associated with
hypomagnesemia?
a) Cisplatin
b) Valproate
c) Foscarnet
d) Cetuximab
Correct Answer - B
om
Answer- B. Valproate
r.c
Drugs causing hypomagnesemia
Ethanol
ke
Diuretics (loop, thiazide, osmotic)
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Cisplatin
tR
Pentamidine, foscarnetCyclosporine
irs
Amino glycosides, amphotericin B
.F
Cetuximab
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540. Dose of benzathaine penicillin G to be
given in patients of latent syphilis in
patients without penicillin allergy and
normal CSF findings is
a) 0.6mU IM / week for 3 weeks
b) 1.2mU IM / week for 3 weeks
c) 2.4mU IM / week for 3 weeks
d) 4.8mU IM / week for 3 weeks
om
Correct Answer - C
r.c
Answer- C. 2.4mU IM / week for 3 weeks
ke
Primary, secondary, or early latent- CSF normal or not examined:
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Penicillin G benzathine (single dose of 2.4 mU IM)
tR
CSF abnormal -Treat as neurosyphilis
irs
Late latent (or latent of uncertain duration), cardiovascular, or benign
.F
tertairy- CSF normal or not examined: Penicillin G benzathine (2.4
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mU IM weekly for 3 weeks).
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CSF abnormal : Treat as neurosyphilis
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541. SARS infection case fatality rate of >50%
is observed in patients of which age
group?
a) < 20 yrs
b) 20 - 40 years
c) 40 - 60 years
d) > 65 years
Correct Answer - D
om
Answer- D. > 65 years
r.c
The case fatality rate from SARS-CoV infection during the 2003
outbreak was 10-17%. No pediatric deaths were reported. The
ke
estimated case fatality rate according to age varied from <1% for
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those younger than 20 year of age to >50% for those older than 65
tR
yr of age.
irs
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542. Which of the following corroborates to
the presence of clostridium difficle
infection in patients taking antibiotics for
another cause?
a) Diarrhoea unformed stools per 12 h for 2 days with no other
recognized cause
b) Diarrhoea unformed stools per 24 h for 2 days with no other
recognized cause
c) Diarrhoea unformed stools per 24 h for 3 days with no other
recognized cause
d) Diarrhoea unformed stools per 24 h for 4 days with no other
om
recognized cause
r.c
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an
tR
Correct Answer - B
irs
Answer- B. Diarrhoea unformed stools per 24 h for 2 days with
.F
no other recognized cause
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Diarrhoea unformed stools per 24 h for 2 days with no other
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recognized cause.
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Toxin A or B detected in the stool by PCR or culture.
Pseudomembranes seen in colon by endoscopy.
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543. Following are the features of neuropathy
associated with varicella-zoster infection
except
a) Persistent infection in neurons of sensory ganglia
b) With reactivation virus transported along nerves to skin
c) Shingles are distributed along motor dermatomes
d) Intranuclear inclusions are not found in peripheral nervous
system
om
Correct Answer - C
r.c
Answer- C. Shingles are distributed along motor dermatomes
Varicella-zoster is one of the most common viral infections of the
ke
peripheral nervous system.
an
Following chickenpox, a latent infection persists within neurons of
tR
sensory ganglia.
irs
If the virus is reactivated, sometimes many years later, it may be
.F
transported along the sensory nerves to the skin.
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Here it infects keratinocytes, leading to a painful, vesicular skin
w
eruption (shingles) in a distribution that follows sensory dermatomes
Most common is the involvement of thoracic or trigeminal nerve
dermatomes.
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544. Which of the following is not true about
the epididymo¬orchitis of mumps?
a) It is the most common manifestation of mumps infection
b) Testicular enlargement usually resolves in 1 week
c) Bilateral testicular involvement seen in 10 - 30% of cases
d) Sterility rarely develops in these patients
Correct Answer - A
Answer- A. It is the most common manifestation of mumps
om
infection
Epididymo-orchitis is the second most common manifestation of
r.c
mumps, developing in 15–30% of cases in postpubertal males.
ke
– Orchitis, characterized by a painful, tender, fever and enlarged
an
testis, is bilateral in 10–30% of cases and resolves within 1 week.
tR
– Oophoritis (manifested by lower abdominal pain and vomiting)
irs
occurs in ~5% of women with mumps.
.F
– Sterility in mumps is rare.
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545. Most common nerve affected in leprosy
a) Posterior tibial
b) Ulnar
c) Median
d) Facial
Correct Answer - A
Answer- A. Posterior tibial
Leprosy affects peripheral mixed nerves and cutaneous nerves.
The most common peripheral nerves affected in the order of
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frequency are the posterior tibial>ulnar> median> lateral popliteal>
r.c
facial > radial
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546. Austrian syndrome is caused by which
infection
a) Staphylococcus aureus
b) Streptococcus pneumoniae
c) Staphylococcus epidermidis
d) Streptococcus viridans
Correct Answer - B
Answer- B. Streptococcus pneumoniae
om
Austrian syndrome is a medical condition first described by Robert
Austrian in 1957.
r.c
The classical triad consists of pneumonia, endocarditis, and
ke
meningitis, all caused by Streptococcus pneumoniae.
an
It is associated with alcoholism, due to the presence of hyposplenia
tR
(reduced splenic functioning), and can be seen in males between 40
irs
and 60 years old.
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547. Factors contributing to the development
of complications in measles are the
following except-
a) Age group 5-20 years
b) Higher case fatality with overcrowding
c) Severe malnutrition
d) Lower serum retinol levels
Correct Answer - A
om
Answer- A. Age group 5-20 years
r.c
Complications of measles are largely attributable to the pathogenic
effects of the virus on the respiratory tract and immune system.
ke
Morbidity and mortality from measles are greatest in patients
an
younger than 5 yr of age (especially <1 yr of age) and older than 20
tR
yr of age.
irs
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548. True about VHL syndrome is
a) It is an autosomal recessive condition
b) Central nervous system is not involved
c) Regular screening for clear cell carcinoma of kidneys is
essential
d) VHL is a growth promoter gene
Correct Answer - C
Answer- C. Regular screening for clear cell carcinoma of
kidneys is essential
om
Von Hippel-Lindau disease (VHL) is a rare autosomal dominant
r.c
disease characterized by abnormal angiogenesis with benign and
ke
malignant tumors that affect multiple tissues.
an
The disease is inherited as a mutation in one allele of the VHL
tR
tumor-suppressor gene.
irs
Somatic mutation of the normal allele leads to retinal angiomas,
.F
central nervous system (CNS) hemangioblastomas,
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pheochromocytomas and multicentric clear cell cysts,
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hemangiomas, and adenomas of the kidney.
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The hi h risk of renal cell carcinoma mandates i eriodic surveillance
usuall earl in adults b CT or MRI. Routine screening and awareness
of the natural history of lesions has enabled renal-sparing
approaches to disease management.
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549. Tuberous sclerosis is caused by
mutations in the following proteins
a) Hamartin
b) Tuberin
c) Merlin
d) Ankyrin
Correct Answer - A:B
Answer- A. Hamartin & B. Tuberin
om
It is caused by mutations in either the TSC1 gene, which maps to
chromosome 9q34, and encodes a protein termed hamartin, or
r.c
mutations in the TSC2 gene, which maps to chromosome 16p13.3
ke
and encodes the tuberin protein.
an
Hamartin forms a complex with tuberin, which inhibits cellular
tR
signaling through the mammalian target of rapamycin (mTOR), and
irs
acts as a negative regulator of the cell cycle.
.F
Patients with tuberous sclerosis have seizures, mental retardation,
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adenoma sebaceum (facial angiofibromas), shagreen patch,
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hypomelanotic macules, periungual fibromas, renal
angiomyolipomas, and cardiac rhabdomyomas.
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550. What characteristic finding of tuberous
sclerosis is present at birth but not later
in life?
a) Cardiac rhabdomyosarcoma
b) Facial angiofibroma
c) Periungal fibroma
d) Renal angiomyolipoma
Correct Answer - A
om
Answer- A. Cardiac rhabdomyosarcoma
r.c
Patients with tuberous sclerosis have seizures, mental retardation,
adenoma sebaceum (facial angiofibromas), shagreen patch,
ke
hypomelanotic macules, periungual fibromas, renal
an
angiomyolipomas, and cardiac rhabdomyomas.
tR
Cardiac rhabdomyosarcomas can be present at birth in upto 80% of
irs
the infants with tuberous sclerosis. These involute in the first three
.F
years of life and completely disappear by adulthood
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551. Following is not true about epinephrine
a) Has potent alpha and beta stimulating properties
b) It improves coronary perfusion pressure and myocardial blood
flow
c) Increases cerebral blood flow during CPR
d) Routine use of high dose epinephrine during resuscitation is
indicated
Correct Answer - D
Answer- D. Routine use of high dose epinephrine during
om
resuscitation is indicated
r.c
Epinephrine (adrenaline) is an endogenous catecholamine with
ke
potent a- and 11-adrenergic stimulating properties.
an
The adrenergic action (vasoconstriction) increases systemic and
tR
pulmonary vascular resistance. The resultant higher aortic diastolic
irs
blood pressure improves coronary perfusion pressure and
.F
myocardial blood flow even though it reduces global cardiac output
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during CPR.
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epinephrine also increases cerebral blood flow durin ood u uali
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CPR because peripheral vasoconstriction directs a greater
proportion of flow to the cerebral circulation.However, epinephrine
can decrease local cerebral microcirculatory blood flow at a time
when global cerebral flow is increased.
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552. Z track technique must be used for
administration of
a) Injection Iron Dextran deep IM
b) Injection Hydroxyzine hydrochloride deep IM
c) Injection Depomedroxyprogesterone iv
d) Injection erythromycin
Correct Answer - A:B
Answer- A. Injection Iron Dextran deep IM & B. Injection
om
Hydroxyzine hydrochloride deep IM
With intramuscular injections medications can leak upward into the
r.c
subcutaneous tissues causing staining, bruising and significant pain
ke
for several weeks or longer with some medications.
an
Nurses are encouraged to use the Z track technique (causing a
tR
needle track or pathway in the shape of Z) any time an intramuscular
irs
injection is given, to prevent leakage and associated pain.
.F
The Z track technique must be used whenever a deep intramuscular
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injection of iron dextran, and other irritating solutions such as
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hydroxyzine hydrochloride and several antipsychotic agents are
given.
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553. In man what quantity of ethyl alcohol
consumed daily for > 10 years increases
the relative risk of development of
alcoholic liver disease
a) 20g/d
b) 40g/d
c) 60g/d
d) 80g/d
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Correct Answer - D
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Answer- D. 80g/d
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80g/day x 10+ yr.
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554. Which of the following antineoplastic
agents is used in the management of
Hodgkins lymphoma, non Hodgkins
lymphoma and small cell carcinoma of
lung?
a) Cisplatin
b) Bleomycin
c) Paclitaxel
d) Doxorubicin
om
r.c
Correct Answer - A
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Answer- A. Cisplatin
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Cisplatin is used in the management of Hodgkins lymphoma, non
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Hodgkins lymphoma and small cell carcinoma of lung.
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555. Pierre robin syndrome following is true
except
a) Consists of micrognathia and cleft palate
b) Tongue is of normal size
c) Airway obstruction particularly during expiration
d) 30 - 50% patients have Stickler syndrome
Correct Answer - C
Answer C. Airway obstruction particularly during expiration
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Pierre Robin syndrome consists of micrognathia usually
accompanied by a high arched or cleft palate.
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The tongue is usually of normal size, but the floor of the mouth is
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foreshortened.
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The air passages can become obstructed, particularly on inspiration,
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usually requiring treatment to prevent suffocation.
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The infant should be maintained in a prone or partially prone position
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so that the tongue falls forward to relieve respiratory obstruction.
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Some patients require tra- cheostomy.
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Mandibular distraction procedures in the neonate can improve
mandibular size, enhance respiration, and facilitate oral feedings.
Sufficient spontaneous mandibular growth can take place within a
few months to relieve the potential airway obstruction.
Often the growth of the mandible achieves a normal profile in 4-6
year.
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556. Mantle field radiation was used for
management of -
a) Hodgkins lymphoma
b) Mantle cell lymphoma
c) Multiple myeloma
d) Cervical carcinoma
Correct Answer - A
Answer- A. Hodgkins lymphoma
om
Mantle field radiation is a type of radiation treatment used for
Hodgkin's lymphoma
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The term 'mantle' is derived from the name of a garment, much like
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a cloak, used many years back. The shape of the exposed area the
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radiation field has contours that resemble the shielding cloak.
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This type of large radiation field is not commonly used today.
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557. Alien limb syndrome seen in
a) Post neurosurgical cases
b) Alzheimers disease
c) Creutzfeldt-Jakob disease
d) All the above
Correct Answer - D
Answer- D. All the above
Alien hand syndrome (AHS) is a condition in which a person
experiences their limbs acting seemingly on their own, without
om
control over the actions.
r.c
The term is used for a variety of clinical conditions and most
ke
commonly affects the left hand.
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Alien hand syndrome is best documented in cases where a person
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has had the two hemispheres of their brain surgically separated, a
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procedure sometimes used to relieve the symptoms of extreme
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cases of epilepsy.
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It also occurs in some cases after brain surgery,stroke,infection,
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tumor, aneurysm and specific degenerative brain conditions such as
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Alzheimer's disease and Creutzfeldt-Jakob disease.
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558. Osmolarity of Milk F-100 is
a) 399 mOsm/L
b) 409 mOsm/L
c) 419 mOsm/L
d) 429 mOsm/L
Correct Answer - C
Answer- C. 419 mOsm/L
UNICEF and WHO prepared two formula diets by modification of the
cows milk - Milk F-75 (starter 75 kcal/100 ml) and F-100 (followup
om
100 kcal/ 100 ml).
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559. Which of the following drugs can cause
seizures except?
a) Lithium
b) Phencyclindine
c) INH
d) Ketorolac
Correct Answer - D
Answer- D. Ketorolac
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Psychotropics
Antidepressants
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Antipsychotics
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Lithium
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Drugs of abuse Amphetamine Cocaine
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Phencyclidine Methylphenidate Flumazenil
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560. Riboflavin deficiency causes
a) Corneal vascularization
b) Anemia
c) Personality changes
d) All the above
Correct Answer - D
Answer- D. All the above
Riboflavin deficiency is manifested principally by lesions of the
mucocutaneous surfaces of the mouth and skin. In addition to the
om
mucocutaneous lesions, corneal vascularization, anemia, and
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personality changes have been described with riboflavin deficiency.
ke
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561. Soret band in which porphyrins absorb
light lie at what wavelength of the
spectrum of light?
a) 200nm
b) 300nm
c) 400nm
d) 500nm
Correct Answer - C
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Answer- C. 400nm
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Due to this structure porphyrins avidly absorb light in a region near
400 nm of the light spectrum. This part of the light spectrum is called
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the Soret band.
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562. Which of the following is not seen after
nerve transection?
a) Morphologic pattern of wallerian degeneration
b) Myelin ovoids
c) Painful neuroma
d) Neuroma in continuity
Correct Answer - D
Answer- D. Neuroma in continuity
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The morphologic hallmarks of axonal neuropathies produced by
cutting a peripheral nerve, results in a prototypical pattern of injury
r.c
described as Wallerian degeneration
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Within a day of injury, the distal axons begin to fragment and the
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associated myelin sheaths unravel and disintegrate into spherical
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structures (myelin ovoids).
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A failure of the outgrowing axons to find their distal target can
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produce a "pseudotumor" termed traumatic neuroma— a
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nonneoplastic haphazard whorled proliferation of axonal processes
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and associated Schwann cells that results in a painful nodule.
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563. Reactive nitrogen species for killing of
microbes are mainly derived from
a) Elemental nitrogen [N3]
b) Nitric Oxide [NO]
c) Nitrogen Dioxide [NO2]
d) Nitrous Oxide [N20]
Correct Answer - B
Answer- B. Nitric Oxide [NO]
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Killing of microbes is accomplished by reactive oxygen species
(ROS, also called reactive oxygen intermediates) and reactive
r.c
nitrogen species, mainly derived from nitric oxide (NO), and these as
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well as lysosomal enzymes destroy phagocytosed debris.
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This is the final step in the elimination of infectious agents and
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necrotic cells.
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564. During state of arousal in men relaxation
of smooth muscle in corpus cavernosum
is mainly caused by
a) Acethycholine
b) Nitric oxide
c) Bicarbonate ions
d) Calcium
Correct Answer - B
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Answer- B. Nitric oxide
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Erectile dysfunction (ED) refers to the inability of men to attain and
maintain an erect penis with sufficient rigidity to allow sexual
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intercourse.
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Nitric oxide (NO) released parasympathetic nonadrenergic
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noncholinergic (NANC) nerves andvascular endothelium is the major
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transmitter causing relaxation of smooth muscle in corpus
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cavernosum and blood vessels supplying it; ACh and PGs also play
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a role.
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565. Which of the following genes if affected
will sporadically cause Juvenile myeloid
leukemia?
a) NF1
b) PTEN
c) APC
d) SMAD2
Correct Answer - A
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Answer- A. NF1
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NF1 - Neurobiastoma, juvenile myeloid leukemia
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566. Chronic manifestations of Aspergillosis
are not evident in which of the following
organs?
a) Skin
b) Brain
c) Lung
d) Eye
Correct Answer - D
om
Answer- D. Eye
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Lung, sinus, brain, skin, heart,
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567. Oculogyric crisis is known to be
produced by all of the following drugs
except
a) Trifluoperazine
b) Atropine
c) Perchlorperazine
d) Perphenazine
Correct Answer - B
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Answer- B. Atropine
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Oculogyric crisis is one of the manifestations seen in acute dystonic
reaction (acute muscular dystonia).
ke
Other manifestations are facial grimacing, torticollis, locked jaw,
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abnormal contraction of spinal muscles (opisthotonus).
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It occurs within 1 to 5 days of antipsychotic therapy.
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Trifluperazine, perchlorperazine and perphenazine are antipsychotic
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568. Which metabolic derangement is seen in
pregnancy?
a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis
Correct Answer - D
Answer- D. Respiratory alkalosis
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Hyperventilation in pregnancy will lead to respiratory alkalosis.
The hyperventilation that occur during pregnancy is probably due in
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part to progesterone stimulating the centre.
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Lung volume changes and altered compliance may also contribute.
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The effect is a chronic respiratory alkalosis which is compensated by
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renal excretion of bicarbonate.
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569. Which of the following is not used for
investigation of fat malabsorption
a) 13C Trioctanoin
b) 13C Triolein
c) 13C Tripalmitin
d) 13C Triclosan
Correct Answer - D
Answer- D. 13C Triclosan
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Tests used for fat malabsorption
1. "C Triolene breath test
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2. '3C Tripalmitin breath test
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3. '3C Mixed-Triglyceride breath test
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4. "C-Trioctanoin breath test
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570. Vitamin E deficiency causes
a) Hemorrhagic stroke
b) Cardiac failure
c) Ataxia
d) Megalablastic anemia
Correct Answer - C
Answer- C. Ataxia
Clinical Manifestations
Axonal degeneration
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Hemolytic anaemia
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Peripheral neuropathy
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Spinocerebellar ataxia
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Dry skin
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Thrombocytosis
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Ataxia
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571. 1 year old male child is having a Heart
Rate 40/min, BP 90/60. His serum
Potassium = 6.5 what is the next best
management?
a) Ipratropium
b) Adrenaline
c) Sodium bicarbonate
d) Calcium chloride
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Correct Answer - C
r.c
Answer- C. Sodium bicarbonate
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For severe elevation 7 meq/L
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You need to shift potassium into the cells together with
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elimination of potassium from the body
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1. Stabilize the heart
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2. Shift potassium into cells
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3. Promotes potassium excretion
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Shift potassium into the cells
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Calcium Chloride : reduce the effect of potassium at the myocardial
cell membrane
Sodium bicarbonate
Glucose plus insulin
Nebulized albuterol
Promotes potassium excretion
Diuretics (Furosemide)
Kayexalate
Dialysis
[Ref Harrison's 18`51e chapter 45]
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572. Most common presentation of extra-
pulmonary TB
a) Tubercular lymphadenitis
b) Peritoneal TB
c) Pericardial TB
d) Tubercular meningitis
Correct Answer - A
Answer- A. Tubercular lymphadenitis
om
The most common presentation of extra-pulmonary TB in both HIV
sero-negative and HIV-infected patients to about 35% in general,
r.c
lymph node disease is particularly frequent among HIV infected
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patients and in children.
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573. Incorrect about takayasu arteritis
a) Spares pulmonary artery
b) Renovascular hypertension
c) Blood pressure difference between left and right limbs
d) Strongly positive mantoux
Correct Answer - A
Answer- A. Spares pulmonary artery
Takayasu arteritis is granulomatous vasculitis of large and medium
arteries. It is characterized principally by ocular disturbance and
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marked weakening of pulses in the upper extremities -> Pulseless
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disease.
ke
It is also characterized by a strong predilection for aortic arch and its
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branches - Aortic arch syndrome.
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Subclavian artery is involved most commonly
irs
Other vessels involved are common carotid, abdominal aorta,
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coeliac, superior mesenteric, renal, vertebral, iliac, pulmonary and
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coronary arteries.
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574. Which of the following is associated with
highest risk of Anaphylaxis
a) Iron dextran
b) Iron sucrose
c) Ferumoxytol
d) Iron Gluconate
Correct Answer - A
Answer- A. Iron dextran
om
The risk of anaphylaxis is maximally associated with high molecular
weight dextran (not so with low molecular weight dextran).
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575. Herpes simplex infection can lead to?
a) Frontal lobe infarction
b) Parietal lobe infarction
c) Temporal lobe infarction
d) Occipital neuralgia
Correct Answer - C
Answer- C. Temporal lobe infarction
Herpes simplex infection has a predilection for the involvement of
Temporal lobe.
om
The lesions in HSV encephalitis are intense hemorrhagic necrosis of
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the inferior and medial temporal lobe and the mediorbital part of
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frontal lobes.
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576. C V junction abnormalities are seen in all
of the following except
a) Rheumatoid arthritis
b) Ankylosing spondylitis
c) Odontoid dysgenesis
d) Basilar invagination
Correct Answer - B
Answer- B. Ankylosing spondylitis
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Developmental and acquired abnormalities
Atlanto axial instability
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1. Errors of metabolism (e.g. Morquio's syndrome)
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2. Infections (e.g. Grisel's syndrome)
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3. Inflammatory (e.g. rheumatioid arthritis, Psoriasis, Ankylosing
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Spondylitis)
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4. Traumatic atlanto-axial dislocation, Atlantal-dislocation, Down
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syndrome
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5. Malignancy (e.g. Chordoma, Plasmacytoma, Osteoblastoma,
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Neurofibromatosis)
6. Degenerative (e.g. fetal warfarin syndrome, Conradi's Syndrome,
Goldenhar syndrome
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577. Most common mechanism of arrhythmia
?
a) Re-entry
b) Early after depolarization
c) Late after depolarization
d) Automaticity
Correct Answer - A
Answer- A. Re-entry
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Re-entry appears to be basis for most abnormal sustained Supra
Ventricular Tachycardias (SVTs) and VTs.
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Examples of re-entry are :-
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VF due to acute myocardial ischemia and
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578. Which of the following is the common
cause of respiratory failure type 2 ?
a) Chronic bronchitis exacerbation
b) Acute attack asthma
c) ARDS
d) Pneumonia
Correct Answer - A
Answer- A. Chronic bronchitis exacerbation
om
Type II respiratory failure occurs due to alveolar hypoventilation
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579. Which of the following is seen in
sarcoidosis
a) Hypercalcemia
b) Hypocalcemia
c) Hyperphosphatemia
d) Hypophosphatemia
Correct Answer - A
Answer- A. Hypercalcemia
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Granuloma of sarcoidosis can secret 1-25 (OH)2 vitamin D.
Therefore, patients of sarcoidosis may develop hypercalcemia.
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580. In a patient with COPD, best
management option is
a) Quit smoking
b) Bronchodilators
c) Low flow oxygen
d) Mucolytics
Correct Answer - C
Answer- C. Low flow oxygen
om
Therapy is started with short-acting bronchodilator (beta-agonist or
anticholinergic).
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Long-term oxygen therapy is used in all patients with COPD who
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have chronic hypoxemia
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581. In a patient there is dyspnea in upright
position which is relieved in supine
position, Diagnosis ?
a) Tachypnea
b) Orthopnea
c) Paroxysmal nocturnal dyspnea
d) Platypnea
Correct Answer - D
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Answer- D. Platypnea
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Platyapnea (Orthodeoxia)
Dyspnoea when a patient moves to sitting or standing position from
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a recumbent position.
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582. After Road traffic accident a patient
presented to casualty with vitals
showing BP of 90/60 mm Hg with heart of
56 bpm. Which kind of shock occurs ?
a) Cardiogenic
b) Neurogenic
c) Distributive
d) Hypovolemia shock
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Correct Answer - B
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Answer- B. Neurogenic
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Neurogenic shock is a distributive type of shock resulting in low
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blood pressure, occasionally with a slowed heart rate, that is
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attributed to the disruption of the autonomic pathways within the
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spinal cord.
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It can occur after damage to the central nervous system such as
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spinal cord injury.
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583. Most common cause of idiopathic
interstitial pneumonia is
a) Sarcoidosis
b) Organizing pneumonia
c) Idiopathic pulmonary fibrosis
d) Lipoid pneumonia
Correct Answer - C
Answer- C. Idiopathic pulmonary fibrosis
om
Idiopatic pulmonary fibrosis
Idiopathic nonspecific interstitial pneumonia
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584. Man working in hot environment &
drinking lots of water without intake of
salts is liable to develop -
a) Heat hyperpyrexia
b) Heat cramps
c) Heat stroke
d) Heat encephalopathy
Correct Answer - B
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Answer- B. Heat cramps
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Heat cramps/Miner's cramps/Stoker's cramp/Firemen's cramp
These are painful spasm of voluntary muscles which follow sternous
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work in a hot atmosphere.
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These are caused by loss of water and salt in profuse prespiration
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(sweating).
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585. Clicking noise in Pneumomediastinum is
known as
a) Hamman sign
b) Trail sign
c) Kussmaul sign
d) None
Correct Answer - A
Answer- A. Hamman sign
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Crunching or clicking noise heard synchronously with the heart beat
on auscultation and best heard in the left lateral decubitus position. It
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is associated with "Pneumomediastinum".
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586. True abour drug induced SLE is except ?
a) Female: Male ratio=9:1
b) Anti-histone Antibodies
c) CNS involvement not common
d) Renal involvement not common
Correct Answer - A
Answer- A. Female: Male ratio=9:1
It is predominant in caucasians
It has less female preddiction than SLE
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It rarely involves kidneys or brain
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It is rarely associated with anti Ds DNA
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It is commonly associated with antibodies to histones
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It usually resolves over several weeks after discontinuation of the
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offending medication.
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587. Emphysema presents with all except
a) Cyanosis
b) Barrel shaped chest
c) Associated with smoking
d) Type I respiratory failure
Correct Answer - A
Answer- A. Cyanosis
Dyspnoea
Cough or wheezing (some patient)
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Weight loss
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Barrel-Chest
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FEVC and FEV1 are reduced. TLC, RC, and FRC are increased due
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to hyperinflation.
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Cyanosis is rare (in contrast to chronic bronchitis)
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Emphysema (COPD) causes type-1 respiratory failure
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588. All are seen in emphysema except
a) Decreased vital capacity
b) Hyperinflation
c) Rhonchi
d) Reduced Dlco
Correct Answer - C
Answer- C. Rhonchi
Cough or wheezing (some patient)
Weight loss
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Barrel-Chest
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FEVC and FEV1 are reduced. TLC, RC and FRC are increased due
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to hyperinfcation.
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Cyanosis is rare (in contrast to chronic bronchitis)
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Emphysema (COPD) causes type-1 respiratory failure
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589. Flushing with niacin in reduced by -
a) Laropiprant
b) Premedication with aspirin
c) Tachyphylaxis
d) All of the above
Correct Answer - D
Answer- D. All of the above
Laropiprant (selective prostaglandin D2 receptor antagonid)
Premedication with aspirin
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Flushing as subject to tachyphylaxis and often improves with time.
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590. Most common cause of lung abscess is
comatose patient
a) Staph aureus
b) Oral anaerobes
c) Klebsiella
d) Tuberculosis
Correct Answer - B
Answer- B. Oral anaerobes
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Most lung abscesses in moribund intubated patients are due to
anaerobic bacteria, like peptostreptococcus, Bacteroides etc. Lung
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abscess
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The term pulmonary abscess describes a local suppurative process
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within the lung, characterized by necrosis of lung tissues
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Etiology
irs
As aspiration of oropharyngeal secretions is the most common
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cause, organisms most commonly causing lung abscess are those
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normally found in oral cavity, i.e., Anaerobic bacteria (Bacteroides,
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Fusobacterium, peptococcus species). Other organisms are S.
aureus, Klebsiella, Nocardia and gram negative bacteria.
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591. Which can be give in hemorrhagic stroke
?
a) Normal saline
b) Colloids
c) Blood transfusion
d) Hypertonic fluids
Correct Answer - A
Answer- A. Normal saline
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Normal saline initially should be used for maintenance and
replacement fluids :
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Hypotonic fluids are contraindicated as they may exacerbate
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cerebral edema and intracranial pressure.
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Hypervolemia should be avoided as it may worsen cerebral edema.
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592. If a person is having ventriular
tachycardia, extra systoles appears to
a) P wave
b) QRS complex
c) T wave
d) R wave
Correct Answer - B
Answer- B. QRS complex
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Extra systole in ventricular tachycardia appears in QRS complex
when an irritable focus in any part of the ventricular myocardium
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activates the ventricles before the arrival of the next normal wave of
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depolarisation from the atria a ventricular extrasystole is produced.
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593. Most common arrhythmia in ICU patients
-
a) Atrial flutter
b) Atrial fibrillation
c) PSVT
d) NPAT
Correct Answer - B
Answer- B. Atrial fibrillation
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Most common arrhythmia in I.C.U. patient → Atrial fibrillation
Most common arrhythmia in a patient with Cardiac arrest →
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Ventricular fibrillation
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594. In a patient who was brought to casualty
after RTA with pulse rate 108, SBP 80.
Which fluid is to be given ideally?
a) Plasma
b) Normal Saline
c) Blood
d) 5% dextrose
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Correct Answer - B
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Answer- B. Normal Saline
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Initial resuscitation requires rapid reexpansion of the circulating
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intravascular blood volume along with interventions to control
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ongoing losses.
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Volume resuscitation is initiated with the rapid infusion of either
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isotonic saline or a balanced salt solution such as Ringer's lactate
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595. Patient of 1st degree heart block
complains of dizziness. Best treatment
for this patient is
a) Atropine
b) Isoprenaline
c) Adrenaline
d) Pacemaker
Correct Answer - D
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Answer- D. Pacemaker
r.c
The most definitive or reliable treatment for patient with symptomatic
A. V. conduction system is temporary or permanent pacing.
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596. Which of the following condition does
not cause multiple painful ulcers on
tongue?
a) TB
b) Sacroidosis
c) Herpes
d) Behcet disease
Correct Answer - B
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Answer- B. Sacroidosis
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Painful ulcers in mouth
Apthous ulcers
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Behcet disease
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Denture stomatitis
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Thermal burns
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Tuberculosis
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Herpes
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Carcinoma tongue
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Arsenic poisoning
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597. All are used for secondary prevention of
MI except
a) Aspirin
b) Statins
c) Beta blockers
d) Warfarin
Correct Answer - D
Answer- D. Warfarin
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Medicines used in the secondary prevention of M.I.
Long term dual antiplatelet therapy with aspirin and P2Y12 receptor
r.c
blocker.
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Statins (high intensity).
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Angiotensin converting enzyme inhibitors in patient with diabetes
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heart failure, left ventricular ejection fraction.
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f3 blockers.
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598. Which of the following substances is
primarily found in tendons?
a) Collagen
b) Fibrin
c) Fibrillin
d) Protedglycans
Correct Answer - A
Answer- A. Collagen
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Tendon is primarily made up of collagen.
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599. Not recommended in coronary artery
disease patients
a) Daily exercise
b) Potassium
c) Vitamin-E
d) Statins
Correct Answer - C
Answer- C. Vitamin-E
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Intervention studies using vitamin E to prevent cardiovascular
disease or cancer have not shown efficacy
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600. Number of barr bodies in klinfellter's
syndrome is -
a) 0
b) 1
c) 2
d) 3
Correct Answer - B
Answer- B. 1
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Found in female But -
Kleinefelter syndrome is male with one Barr body.
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Turner syndrome is female without Barr body.
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601. Digitalis is used in mitral stenosis when
patient develops
a) Atrial fibrillation
b) Right ventricular failure
c) Acute pulmonary edema
d) Myocarditis
Correct Answer - A
Answer- A. Atrial fibrillation
om
Drugs useful in slowing the ventricular rate of patients with AF
Beta blockers,
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Nondihydropyridine calcium channel blockers (e.g., verapamil or
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diltiazem), and
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Digitalis glycosides
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602. Incorrect about LAMB syndrome -
a) Lentigines
b) Atrial Myxoma
c) Myaesthenic syndrome
d) Blue Nevi
Correct Answer - C
Answer- C. Myaesthenic syndrome
LAMB syndrome is characterized by presence of :-
Lentigines
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Atrial Myxoma
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Blue nevi.
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603. Which one of the following is not an
early complication of acute myocardial
infarction ?
a) Papillary muscle dysfunction
b) Ventricular septal defect
c) Paricarditis
d) Dressler's syndrome
Correct Answer - D
om
Answer- D. Dressler's syndrome
r.c
Dressler's syndrome is a late complication of myocardial infarction. It
usually occurs 1-8 weeks after myocardial infarctions
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604. Most common malignant tumor of heart
in adults
a) Sarcoma
b) Rhabdomyoma
c) Lipoma
d) Paraganglioma
Correct Answer - A
Answer- A. Sarcoma
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Almost all primary cardiac malignancies are sarcomas.
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605. In which of causes of oral ulcer, Auto-
antibodies are not seen?
a) Behcet disease
b) SLE
c) Pemphigus
d) Celiac disease
Correct Answer - A
Answer- A. Behcet disease
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Behcet's disease is classified among the vasculitides laboratory
diagnostic does not include regularly autoantibodies associated with
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vascular manifestations of systemic autoimmune disease.
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606. Which is the best way to differentiate
between stable angina and NSTEMI?
a) ECG
b) Cardiac-biomarker
c) Trans thoracic Echocardiography
d) Multi uptake gated Acquisition scan
Correct Answer - B
Answer- B. Cardiac-biomarker
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The differentiating feature between Angina and MI is the elevation of
cardiac markers°.(no elevation is seen in Angina)
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607. Aetiology of Dressler Syndrome is
a) Viral
b) Autoimmune
c) Idiopathic
d) Toxin mediated
Correct Answer - B
Answer- B. Autoimmune
Immunological factors are thoughts to be of primary importance.
The immune complexes hat are generated are deposited into the
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pericardium, pleura and lungs.
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608. Murmur heard in aortic stenosis
a) Right 2nd intercistal, low pitch murmur
b) Apex, low pitch murmur
c) Left Sternal area, low pitch murmur
d) Pen-systolic murmur, high pitch murmur
Correct Answer - A
Answer- A. Right 2nd intercistal, low pitch murmur
Typically heard at the base of the heart in Aortic area (second
intercostal space).
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Harsh quality.
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Generally begins after Si and end S before S2.
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609. All are true about cross-matching of
blood except -
a) Mandatory in all cases except emergency
b) Recipient serum is tested against donor packed cells
c) Donor serum is tested against recipient packed cells
d) Involves visible agglutination
Correct Answer - C
Answer- C. Donor serum is tested against recipient packed
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cells
Cross matching involves testing the patients serum with donor cells
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to determine whether the patient has an antibody which may cause
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a hemolytic transfusion reaction
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610. Becks triad is seen in
a) Constrictive pericarditis
b) Restrictive cardiomyopathy
c) Cardiac tamponade
d) None of the above
Correct Answer - C
Answer- C. Cardiac tamponade
Beck's triad is characteristic of cardiac Tamponade, it includes
:
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Increased venous pressure
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Decreased arterial pressure
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Muffled heart sounds, silent heart (due to presence of fluid in
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pericardium).
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611. All are seen in Nephrotic syndrome
except
a) Atherosclerosis
b) Thrombo-embolism
c) Increased protein C levels
d) Lipiduria
Correct Answer - C
Answer- C. Increased protein C levels
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Nephrotic syndrome is a clinical complex characterized by a number
of renal and extrarenal features, most prominent of which are
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Proteinuria (in practice > 3.0 to 3.5gm/24hrs),
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Hypoalbuminemia, Edema
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Hypertension
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Hyperlipidemia, Lipiduria
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Hypercoagulabilty(result of Loss of Antithrombin III)
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612. All are seen in carney's triad except -
a) Atrial myxoma
b) GIST
c) Chondroma
d) Paraganglioma
Correct Answer - A
Answer- A. Atrial myxoma
Extra-adrenal paraganglioma (e.g. extra adrenal phaeo-
chromocytoma)
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Gastrontestinal stromal tumors previously known as gastric
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epithelioid leiomyosarcoma
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Pulmonary chondroma hamartoma only 2 of the 3 tumors are
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present at the time of diagnosis typically affects young people.
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613. Basket weave appearance of glomerular
basement membrane on electron
microscopy is seen in
a) Alport syndrome
b) Acute post stretptococcal GN
c) Polyarteritis nodosa
d) Giant cell arteritis
Correct Answer - A
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Answer- A. Alport syndrome
r.c
Basketweave appearance of glomerular basement membrane on
Electron Microscopy is seen in Alport's syndrome.
ke
In Alport's Syndrome, the glomerular basement membrane shows
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irregular thinning and thickening with a lamellated basket-weave
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appearance in the thickened area due to extensive remodeling and
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injury of the basement membrane.
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614. All of the following causes acute renal
failure except
a) Pyelonephritis
b) Snakebite
c) Rhabdomyolysis
d) Analgesic nephropathy
Correct Answer - D
Answer- D. Analgesic nephropathy
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Analgesic nephropathy causes chronic interstitial nephritis and
presents with chronic kidney disease.
r.c
AKI is a serious complication of snakebites by the viperidae family
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615. Martel sign is seen in -
a) Gout
b) Ankylosing spondylitis
c) Osteoarthritis
d) Rheumatoid arthritis
Correct Answer - A
Answer- A. Gout
Martel's sign is not present in all cases of gouty arthritis.
Martel's sign, which is a radiological sign (straight arrow) to describe
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the overhanging margin of the new bone alone the edge of erosion.
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616. All are true about GFR except
a) 30-40% decrease after 70 years of age
b) Best estimated by creatinine clearance
c) C.K.D is defied as GFR < 30 ml/min/1.732 for 4 weeks
d) GFR is dependent on height in children
Correct Answer - C
Answer- C. C.K.D is defied as GFR < 30 ml/min/1.732 for 4
weeks
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617. Manifestations of vitamin E.deficiency
are all except -
a) Hemolytic anemia
b) Posterior column abnormalities
c) Cerebellar ataxia
d) Autonomic dysfunction
Correct Answer - D
Answer- D. Autonomic dysfunction
om
The clinical manifestations are edema, hemolytic anemia (due to
fragile red cell's membrane as a result of lipid peroxidation) and
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thrombocytosis. Nerve and muscle membrane damage may occur.
ke
Vitamin E deficiency causes axonal degeneration of the large
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myelinated axons and results in posterior column and
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spinocerebellar symptoms.
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618. Dialysis indications
a) Hypertension
b) Hypokalemia
c) Pericarditis
d) Metabolic alkalosis
Correct Answer - C
Answer- C. Pericarditis
Indications of dialysis in chronic renal failure
Pericarditis or pleuritis (urgent indication).
om
Progressive uremic encephalopathy or neuropathy, with signs such
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as confusion, asterixis, myoclonus, wrist or foot drop, or,in severe
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cases, seizures (urgent indication).
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A clinically significant bleeding diathesis attributable to uremia
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(urgent indication).
irs
Persistent metabolic disturbances that are refractory to medical
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therapy;these include hyperkalemia, metabolic acidosis,
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hypercalcemia, hypocalcemia, and hyperphosphatemia.
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Fluid overload refractory to diuretics.
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Hypertension poorly responsive to antihypertensive medications.
Persistent nausea and vomiting.
Evidence of malnutrition.
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619. Which of the following microorganism is
incriminated in infection after
hemodialysis
a) Chlamydia
b) Gram positive organisms
c) Gram negative
d) Anaerobes
Correct Answer - B
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Answer- B. Gram positive organisms
r.c
Hemo-dialysis catheter-related bloodstream infections (CRBSIs) are
a major complication of long-term catheter us in HD. Gram positive
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organism are seen followed by gram negative organisms.
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620. Dietary deficiency of which vitamin
usually does not exist -
a) Vitamin-B6
b) Thiamine
c) Vitamin-E
d) Vitamin-D
Correct Answer - C
Answer- C. Vitamin-E
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Dietary deficiency of vitamin E does not exist.
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621. Low serum copper due to ATP 7A gene
is due to?
a) Dubin-johnson's syndrome
b) Wilson disease
c) Menke disease
d) Gilbert's disease
Correct Answer - C
Answer- C. Menke disease
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Menke's disease, also known as kinky hair disease, is an X-linked
neurodegenerative disease of impaired copper transport, due to ATP
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7A gene located on Xp12-13.
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622. I.R.I.S. is -
a) Immune reconstitution idiopathic syndrome
b) Immune reconstitution immunological syndrome
c) Immune reconstitution inflammatory syndroma
d) Inflammatory reconstitution immune syndrome
Correct Answer - C
Answer- C. Immune reconstitution inflammatory syndroma
The term "immune reconstitution inflammatory syndrome" (IRIS)
describes a collection of inflammatory disorders associated with
om
paradoxical worsening of preexisting infectious processes following
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the initiation of highly active antiretroviral therapy.
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623. Blood transfusion associated acute lung
injury occurs due to -
a) Nosocomial infections
b) HLA mediated
c) Auto-immune disorder
d) Genetic susceptibility
Correct Answer - B
Answer- B. HLA mediated
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TRALI usually results from the transfusion of donor plasma that
contains high titre anti HLA class II antibodies that bind recipient
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leucocytes.
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The leucocytes aggregate in the pulmonary vasculature and release
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mediators that increase capillary permeability.
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Testing the donor's plasma for Anti HLA antibodies can support this
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diagnosis.
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624. Rockall score is used for prognosis of
patients of
a) Upper GI bleeding
b) Lower GI bleeding
c) Hepatic encephalopathy
d) IBD
Correct Answer - A
Answer- A. Upper GI bleeding
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625. Which of the following is given to
decrease Serum Triglycerides?
a) Fibrates
b) Statine
c) Ezetimibe
d) Niacin
Correct Answer - A
Answer- A. Fibrates
om
Fibrates are drugs of choice for hypertriglyceridemia (type IV) and
chylomicronemia (type I).
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626. Streptococcus bovis infection is
associated with -
a) CLL
b) Hairy cell leukemia
c) Colorectal cancer
d) Multiple myeloma
Correct Answer - C
Answer- C. Colorectal cancer
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Colon and rectal tumors Streptococcus bovis (bacteremia)
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627. Which is a hormone dependent liver
tumor ?
a) Adenoma
b) Hemangioma
c) Hepatocellular carcinoma
d) Hemangiopericytoma
Correct Answer - A
Answer- A. Adenoma
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Adenomas are associated with contraceptive hormone use.
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628. Polyarticular onset JRA involves more
than how many joints -
a) 3
b) 4
c) 5
d) 6
Correct Answer - C
Answer- C. 5
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Polyarticular JRA
It is characterized by involvement of 5 or more joints.
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There are two subtypes :-
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i) Polyarticular RA positive
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It is characterized bysymmetrical joint involvement along with
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Uveitis, and rheumatoid nodules.
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RA factor and ANA are positive.
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ii) Polyarticular RA negative
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RA factor and rheumatoid nodules are not seen.
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629. Poikilocytosis and anisocytosis is seen
in
a) Megaloblastic anaemia
b) Iron deficiency anaemia
c) Nutritional deficiency anaemia
d) Thalassemia
Correct Answer - B
Answer- B. Iron deficiency anaemia
om
Anisocytosis means that RBC's are unequal in size indicating that
some of the RBC's are either too big or too small.
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Poikilocytosis means that some of the RBC's are abnormally
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shaped.
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630. Alzehiemer type II astrocyte are seen in -
a) Hepatic encephalopathy
b) Alzehiemer's
c) Parkinsonism
d) Biswanger disease
Correct Answer - A
Answer- A. Hepatic encephalopathy
Swollen astrocytes in hepatic encephalopathy are called Alzheimer
type II astrocytes. Their nuclei are large and appear clear in H & E
om
stains. They are also seen in Wilson disease.
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631. Which of the following antibodies is
highly specific for systemic lupus
erythematosus -
a) Anti-Sm
b) Anti-RO-1
c) Anti-UIRNP
d) Anti-Centromere
Correct Answer - A
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Answer- A. Anti-Sm
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Sensitive test for SLE → Antinuclear antibodies (ANA)
Specific test for SLE → Anti dsDNA, Anti Sm
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632. All of the following are characteristic
features of treatment of iron deficiency
anemia with oral iron supplements,
except
a) Bioavailability is enhanced with vitamin C
b) The proportion of iron absorbed reduces as hemoglobin
improves
c) The reticulocyte count should begin to increase in two weeks
and peak in 4 weeks this suggests good response to treatment
d) The treatment should be discontinued immediately once
hemoglobin normalizes to prevent side effects of iron
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Correct Answer - D
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Answer- D. The treatment should be discontinued immediately
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once hemoglobin normalizes to prevent side effects of iron
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The reticulocyte count begin to increase within 4-7 days after
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initiation of therapy and peak at 1.5 weeks.
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Typically for iron replacement therapy, up to 200mg of elemental
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iron per day is given, usually as three or four iron tablets (each
containing 50-65mg elemental iron) given over the course of the
day.
A dose of 200 mg of elemental iron per day should result in
absorption of iron upto 50 mg/day. This supports a red cell
production level of 2-3 times normal in an individual with a normally
functioning marrow and appropriate erythropoietin stimulus.
As the hemoglobin level rise, erythropoietin stimulation decreases,
and the amount of iron absorbed is reduced.
The goal of therapy in individuals with iron-deficiency anemia is not
only to repair the anemia, but also to provide stores of at least 0-5-1
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only to repair the anemia, but also to provide stores of at least 0-5-1
g of iron.
This sustained treatment for a period of 6-12 months after correction
of the anemia will be necessary.
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633. Which of the following is not expected in
a case of Microcytic Hypochromic
anemia
a) Reduced serum Iron
b) Reduced total RBC distribution width
c) Normal Ferritin levels
d) Increased TIBC
Correct Answer - B
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Answer- B. Reduced total RBC distribution width
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The first change in iron deficiency anemia is decreased in iron store,
which is manifested as decreased serum ferritin level.
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Bone marrow iron decreases earlier than serum iron.
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There is microcytic hypochromic anemia (microcytosis precedes
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hypochromia).
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634. A 23-year old woman has experienced
episodes of myalgias, pleural effusion,
pericarditis and arthralgias without joint
deformity over course of several years.
The best laboratory screening test to
diagnose her disease would be -
a) CD, lymphocyte count
b) Erythrocyte sedimentation rate
c) Antinuclear antibody
d) Assay for thyroid hormones
om
r.c
ke
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Correct Answer - C
Answer- C. Antinuclear antibody
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Sensitive test for SLE → Antinuclear antibodies (ANA)
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Specific test for SLE → Anti dsDNA, Anti Sm
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635. Zieve syndrome is characterized by all
except
a) Alcohol abuse
b) Hemolysis
c) Hypertriglyceridemia
d) Pancreatic lipase deficiency
Correct Answer - D
Answer- D. Pancreatic lipase deficiency
om
Zieve's syndrome is an acute metabolic condition that can occur
during withdrawal from prolonged alcohol abuse
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Zieve syndrome is a rare condition characterized by hemolytic
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anemia in conjunction with secondary hyperlipidemia in patients
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suffering from alcohol-related toxic liver damage.
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636. Which is the most common tumor
leading to death in adults?
a) Lung cancer
b) Prostate cancer
c) Colorectal cancer
d) Leukemia
Correct Answer - A
Answer- A. Lung cancer
om
Lung cancer constitutes upto29% of all cancer related deaths in
males and 26% of all cancer related death in woman.
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637. Hemoglobin with zeta 2 and gamma 2
chains are seen in which of the
following
a) Gower I
b) Gower II
c) Portland
d) Fetal Gb
Correct Answer - C
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Answer- C. Portland
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Hb Gower I → Zeta 2 / epsilon 2
Hb Portland → Zeta 2 /gamma 2
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Hb Gower H Alpha 2 / epsilon 2
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638. In long standing rheumatoid arthritis
which will be seen -
a) Milk alkali syndrome
b) Nephrolithiasis
c) Paradoxical aciduria
d) Secondary amylodosis
Correct Answer - D
Answer- D. Secondary amylodosis
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Reactive amyloid A (AA) amyloidosis, one of the most severe
complications of RA, is serious, potentially life threatening disorder
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caused by deposition of AA amyloid fibrils in multiple organs
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639. All are true about CNS leukemia except
a) CNS irradiation is given
b) Intrathecal methotrexate is given
c) Seen with acute myeloid leukemia
d) Single blast in CSF is sufficient for diagnosis
Correct Answer - C
Answer- C. Seen with acute myeloid leukemia
Most children with leukemia have subclinical CNS involvement at the
time of diagnosis.
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Few children show central nervous system involvement at the time
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of diagnosis, most are asymptomatic but some have features of
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raised intracranial tension.
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CNS involvement is mostly due to ALL. CNS involvement is more
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common in ALL than AML.
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640. Thrombocythemia is characterized by
a) Platelets elevation
b) Low platelets
c) Neutrophilia
d) Monocytosis
Correct Answer - A
Answer- A. Platelets elevation
Thrombocythemia or thrombocytosis is the elevation of platelets.
om
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641. Hyperuricemia can be caused by all
except -
a) Ethanol
b) Thiazide
c) Furosemide
d) None
Correct Answer - D
Ans. is. D. None
om
Causes of drug or diet induced hyperuricemia
Diuretics (thiazides and loop diuretics)
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Cyclosporine and tacrolimus
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Low dose salicylates.
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Ethambutol
tR
Pyrazinamide
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Ethanol
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Levodopa
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Methoxyflurane
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Laxative abuse (alkalosis)
Salt restriction
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642. Glucose fever is related with -
a) Glucagon
b) Parathyroid
c) GH
d) Aldosterone
Correct Answer - D
Answer- D. Aldosterone
Hypoglycemia in Addison disease is managed with
hydrocortisone/dexamethasone.
om
Administration of I.V. glucose in Addison leads to development of
r.c
fever and is called as "glucose fever".
ke
In patients with adrenal insufficiency, who have not received
an
glucocorticoids glucose infusion may cause high fever (glucose
tR
fever) followed by collapse and death.
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643. Patient on insulin in CKD stage 4. What
is the dose adjustment of insulin
required ?
a) Increased insulin
b) Decreased insulin
c) Normal insulin
d) Add DPP-4 inhibitors
Correct Answer - B
om
Answer- B. Decreased insulin
r.c
Insulin requirements show a biphasic course in diabetic patients with
renal disease. It is not uncommon for glucose control to deteriorate
ke
as renal function deteriorates, as increasing insulin resistance can
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affect both type I and type 2 diabetics.
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644. Most common cause of death in cancer
is -
a) Bleeding
b) Infection
c) Respiratory failure
d) Renal failure
Correct Answer - B
Answer- B. Infection
om
The most common causes of death in patients with cancer are
infection (leading to circulatory failure), respiratory failure, hepatic,
r.c
and renal failure. Intestinal blockage may lead to inanition and
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starvation.
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645. Which is the best indicator for short term
control (2-3 weeks] of blood glucose ?
a) Serum fructosamine
b) HbA lc
c) Blood sugar
d) Urine sugar
Correct Answer - A
Answer- A. Serum fructosamine
om
Serum fructosamine → Tells sugar fluctuations in 2-3 weeks
Glycosylated hemoglobin → Tells sugar fluctuations in previous 6-8
r.c
weeks.
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646. Post Prandial capillary glucose should
be mg/dl for adequate diabetes control
a) < 100mg / dl
b) < 140 mg / dl
c) < 180 mg/dl
d) < 200 mg/dl
Correct Answer - C
Answer- C. < 180 mg/dl
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HbA IC- two
Preprandial capillary plasma glucose- 70-130 mg/d1 <
r.c
Peak post prandial capillary plasma glucose -180 mg/d1 <
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Blood pressure- 130/80
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647. Mosaic pattern of coment line is
characteristically seen in -
a) Hyperthyroidism
b) Paget's disease of bone
c) Renal osteodystrophy
d) Osteomalacia
Correct Answer - B
Answer- B. Paget's disease of bone
om
Mosaic pattern of cement line is characteristically associated with
paget's disease of the bone
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648. Hyperpigmentation is seen with which
hormone?
a) FSH
b) LH
c) TSH
d) ACTH
Correct Answer - D
Answer- D. ACTH
om
Hyperpigmentation of the skin and mucous membranes often
precedes all other symptoms by months to years.
r.c
It is caused by the stimulant effect of excess adrenocorticotrophic
ke
hormone (ACTH) on the melanocytes to produce melanin.
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The hyperpigmentation is caused by high levels of circulating ACTH
tR
that bind to the melanocortin 1 receptor on the surface of dermal
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melanocytes.
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Other melanocyte-stimulating hormones produced by the pituitary
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and other tissues include alpha-MSH (contained within the ACTH
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molecule), beta-MSH, and gamma-MSH. When stimulated, the
melanocyte changes the color of the pigment to a dark brown or
black.
The increased MSH in Addison's causes melanocytes to disperse
melanin in the epidermis thus increasing pigmentation.
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649. Female with blood sugar of 600 mg% and
sodium of 110 mEq. Insulin was given,
what will happen to serum sodium levels
?
a) Sodium increase
b) Sodium decrease
c) Sodium unaffected
d) Relative sodium deficiency
om
Correct Answer - A
r.c
Answer- A. Sodium increase
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As the glucose level decreases, there is decrease in the osmolarity
an
of extracellular fluid. This causes movement of intracellular fluid
tR
back into the cellular compartment producing increase in serum
irs
sodium.
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650. Which of the following presents with
hypokalemia and metabolic acidosis ?
a) Diarrhea
b) Vomiting
c) Nasogastic suction
d) Nasogastic suction
Correct Answer - A
Ans- A. Diarrhea
om
Diarrhea causes hypokalemia with metabolic acidosis.
Vomiting nosogastric suction and conn's syndrome cause metabolic
r.c
alkalosis.
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651. Lafora's disease presents with -
a) G.T.C.S
b) Myoclonic epilepsy
c) Petit mal epilepsy
d) Partial seizures
Correct Answer - B
Answer- B. Myoclonic epilepsy
Lofora disease is an autosomal recessive poliencephalopathy of late
childhood or early adult life.
om
It is characterized by progressive dementia, dysarthria, visual loss,
r.c
pyramidal & cerebellar signs, and myoclonic & other seizures.
ke
The diagnostic pathological finding is lofora bodies.
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652. In cobalamin deficiency which is not
seen
a) Microcytic anemia
b) Long tract signs
c) Loss of proprioception
d) Rhomberg sign
Correct Answer - A
Answer- A. Microcytic anemia
om
Cobalmine deficiency causes megaloblastic (macrocytic) anemia
(not microcytic).
r.c
Cobalamine deficiency also causes subacute combined
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degeneration of spinal cord due to involvement of posterior column,
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affecting vibration, fine touch, and imbolance (Romberg sign).
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653. Hypernatremia causes all EXCEPT
a) Seizure
b) Thrombus
c) Brain hemorrhage
d) Central pontine myelinosis
Correct Answer - D
Answer- D. Central pontine myelinosis
Complication of hypernatremia are brain hemorrhage, seizures,
coma, thrombotic complications and raised ICT.
om
Central pontine myelinosis is classically associated with overlay
r.c
rapid correction of hyponatremia.
ke
Clinical features-
an
Patients are irritable, restless weak and lethargic
tR
Some have high pitched cry and hyperpnea.
irs
Alert patient are very thirsty.
.F
Hypernatremia causes fever although many patients have
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underlying process that contributes to the fever.
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654. All of the following are associated with
hyponatremia except
a) anorexia
b) Convulsions
c) Drowsiness
d) Myalgia
Correct Answer - D
Answer- D. Myalgia
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Anorexia, nausea & vomiting
Coma
r.c
Convulsions
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Drowsiness
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Headache
tR
Circulatory failure and hypotension
irs
Hyponatremia can also cause muscle cramps and weakness.
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655. Most common type of multiple sclerosis?
a) Relapsing remitting type
b) Secondry progressive multiple sclerosis
c) Progresive relapsing multiple scelrosis
d) Primary progresive multiple sclerosis
Correct Answer - A
Answer- A. Relapsing remitting type
Repapsing-remitting multiple sclerosis (RRMS)
This is the most common form of multiple sclerosis.
om
About 85% of people with M.S. are initially diagnosed with relapsing-
r.c
remitting multiple sclerosis.
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656. Aspirin decreases the risk of
development of which of the following -
a) Colorectal cancer
b) Stomach cancer
c) Carcinoid
d) MALToma
Correct Answer - A
Ans. A. Colorectal cancer
om
Regular aspirin use reduces the risk of colon adenomas and
carcinomas as well as death from large-bowel cancer
r.c
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657. Dermatitis may be a clinical
manifestation of deficiency states of all
of following nutrients except -
a) Biotin
b) Niacin
c) Pyridoxine
d) Thiamine
Correct Answer - D
om
Answer- D. Thiamine
r.c
Vitamin B3 (Niacin) deficiency causes dermatitis. Biotin and Vitamin
B6 (pyridoxin) deficiency causes seborrheic dermatitis.
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658. In EEG which type of waves are seen in
metabolic encephalopathy
a) Alpha
b) Beta
c) Gamma
d) Delta
Correct Answer - D
Answer- D. Delta
om
E.E.G. has been widely used to evaluate metabolic encephalopathy.
The E.E.G. findings are abnormal in acute encephalopathy stages
r.c
Metabolic
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'vthm
encephalopathy
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Grade I (almost Dominant activity is rhythm with minima, theta
tR
normal) activity
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Grade II (mildly Dominant theta background with some alpha
.F
abnormal) and delta activities
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Grade II
Continuous delta activety predominates, little
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(morderately
activity of faster frequencies
abnormal)
Grade IV (severely Low-amplitude delta activity or suppression-
abnormal) burst pattern
Grade V (extremely
Nearly "flat" tracing or electrocerebral inactivity
abnormal)
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659. Which vitamin toxicity is associated with
excessive sweating -
a) Choline
b) Biotin
c) Folic cid
d) Vitamin B
Correct Answer - A
Answer- A. Choline
om
Toxicity from choline results in -
Hypotension
r.c
Cholinergic sweating
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Diarrhea
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Salivation
tR
Fishy body odor
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660. Isaac syndroma is characterised by -
a) Peripheral nerve excitability
b) Opsoclonus
c) Encephalomyelitis
d) Limbic encephalitis
Correct Answer - A
Answer- A. Peripheral nerve excitability
Isacc syndrome (neuromyotonia)
Peripheral nerve hyperexcitability
om
Spontaneous and continuous muscle fiber activity of peripheral
r.c
nerve origin.
ke
Clinical features include cramps, muscle twitching (fasciculations or
an
myokymia)
tR
Stiffness
irs
Delayed
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Muscle relaxation (pseudomyotonia)
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Spontaneous or evoked carpal or pedal spasms.
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661. Glasgow coma scale motor 4
represents?
a) Withdrawal or flexion
b) Decorticate posturing
c) Decorticate posturing
d) Localise pain
Correct Answer - A
Answer- A. Withdrawal or flexion
om
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662. A patient after an accident was
unconscious. On physical examination
there was unilateral pupillary dilatation
Possible reason for the same is
a) Uncal herniation
b) Tonsillar herniation
c) Cingulate herniation
d) Transcalvarial herniation
om
Correct Answer - A
r.c
Answer- A. Uncal herniation
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Transtentorial herniation is the displacement of medial temporal lobe
an
into the tentorial opening it is usually seen after extradural
tR
hemorrhage.
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663. First Symptoms of parkinsons disease is
-
a) Postural instability
b) Rigidity
c) Tremors
d) Bradykinesia
Correct Answer - C
Answer- C. Tremors
om
Parkinsonism is a progressive degenerative, extrapyramidal disorder
of muscle movement, due to dysfunction in basal ganglia,
r.c
comprising four cardinal features
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Bradykinesia or hypokinesia
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Muscle rigidity
tR
Resting tremor
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664. Increased ICT is shown by
a) Miosis
b) Systemic hypotension
c) Tachycardia
d) Reduction in GCS
Correct Answer - D
Answer- D. Reduction in GCS
Increased ICT leads to bradycardia with Hypertension. Uncal
herniation of brain leads to ipsilateral pupillary dilatation. Reduction
om
in GCS due to damage to reticular activating system leads to
r.c
development of coma.
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665. Plaques jaunes are seen in
a) Syphilis
b) Head injury
c) Endocarditis
d) Atherosclerosis
Correct Answer - B
Answer- B. Head injury
Plaque Jaunes is a term used to describe the characteristic gross
appearance of old traumatic contusions on the surface of brain from
om
previous head injuries.
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666. Commonest cause of cerebro vascular
accident
a) Infarction
b) Infarction
c) Embolism
d) Aortic dissection
Correct Answer - A
Answer- A. Infarction
om
1. Ischemic (85%) (infarction) : Causes are embolism (75% of ischemic
stroke) and thrombosis (25% of ischemic stroke).
r.c
2. Hemorrhagic (15%) : Intraparenchymal, subdural, epidural,
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subarachnoid.
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667. This patient came to the casualty with
palpitations. His ECG has been shown
below. What is your diagnosis?
a) Ventricular tachycardia
b) A-V dissociation
c) Supraventricular tachycardia
d) Sinus tachycardia
Correct Answer - C
om
Answer- C. Supraventricular tachycardia
r.c
The overall rhythm is rapid and rgular. The R-R interval is almost
exactly 1.5 large boxes in duration - establishing the rate at 180-190
ke
beats per min this is an ECG showing narrow complex tachycardia
an
most probably due to AVNRT (Av Nodal Reentrant Tachycardia) aka
tR
supraventricular tachycardia.
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[Ref Harrison's 18th/e p.1888]
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668. What is Reifenstein syndrome?
a) Associated with gonadal dysgenesis
b) Partial androgen insensitivity syndrome due to receptor
mutation
c) Associated with mental retardation
d) 5-alpha reductase deficiendy associated with perineo¬scrotal
hypospadias
Correct Answer - B
Answer- B. Partial androgen insensitivity syndrome due to
om
receptor mutation
r.c
It is partial androgen insensitivity syndrome because of less severe
ke
androgen receptor mutation.
an
Patients often present in infancy with :
tR
1. Perineoscrotal hypospadias and small undescended testes.
irs
2. Gynecomastia at the time of puberty.
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3. Those individuals raised as males require hypospadias repair in
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childhood and breast reduction in adolescence.
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4. Supplemental testosterone rarely enhances androgenization
w
significantly, as endogenous testosterone is already increased.
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669. Following are absolute indication for
hemo-dialysis except
a) GI bleeding
b) Convulsions
c) Pericarditis
d) Hyperkalemia of 6.5 mEq/L
Correct Answer - D
Answer- D. Hyperkalemia of 6.5 mEq/L
om
Important indications for hemodialysis are:
1. Severe metabolic acidosis wher sodium bicarbonate cannot be used
r.c
(due to risk of fluid overload).
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2. Severe hyperkalemia
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3. Drug poisoning like lithium & aspirin
tR
4. Uremia (Uremic pericarditis, encephalopathy or GI bleeding).
irs
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670. In scleroderma features are all except:
a) Decrease in tone of LES
b) Restrictive cardiomyopathy
c) Syndactyly
d) Halitosis
Correct Answer - C
Answer- C. Syndactyly
Syndactyly is not associated with scleroderma.
Lower esophageal sphincter tone is decreased in scleroderma.
om
Scleroderma can cause restrictive cardiomyopathy.
r.c
Halitosis (bad smell in breath) can occur in scleroderma.
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671. Best for management of respiratory
alkalosis?
a) Rebreathing in paper bag
b) IPPV
c) Normal saline
d) Acetazolamide
Correct Answer - A
Answer- A. Rebreathing in paper bag
om
Changing ventilator setting may be used to prevent or treat
respiratory alkalosis in persons who are being mechanically
r.c
ventilated. Persons with hyperventilation syndrome may benefit from
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reassurance, rebreathing from a paper bag during symptomatic
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attacks, and attention to the psychological stress.
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672. Adrenal reserve is best tested by means
of infusion with
a) Glucocorticoids
b) ACTH
c) GnRH
d) Metyrapone
Correct Answer - B
Answer- B. ACTH
om
Glucocorticosteroid reserve can be evaluated by the ACTH
stimulation test
r.c
A more sensitive test of adrenal reserve is the standardised 24-hour
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ACTH infusion test. Under maximal ACTH stimulation the cortisol
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secretion increases tenfold. If gtucocorucoid coverage is required
tR
during the ACTH stimulation test, dexamethasone can be used
irs
because it does not interfere with the laboratory values of
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endogenous glucocorucoids.
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673. Graham steel murmur is seen in
a) PS
b) PR
c) TR
d) TS
Correct Answer - B
Answer- B. PR
Graham steel's murmur
A diastolic murmur audible along the left sternal border due to
om
pulmonaryregurgitation in patients with pulmonary hypertension.
r.c
Graham steel murmur is a high pitched decressendo murmur
ke
loudest during inspiration
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Grahm steel's- Early DM- PR
tR
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674. CVP is monitored in A/E
a) Anterior jugular vein
b) Internal jugular vein
c) External jugular vein
d) Inferior venacava
Correct Answer - D
Answer- D. Inferior venacava
Commonly used vein cannulation sites for central venous
access include:
om
Jugular vein
r.c
External jugular vein
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Internal jugular vein (central, posterior, anterior approaches)
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Subclavian vein (supraclavicular, infraclavicular, axillary
tR
approaches)
irs
Femoral vein
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Basilic vein
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675. Central venous monitoring is done for all
except
a) Regulating the speed and amount of fluid infusion
b) Administering thrombolytics
c) Deciding the need for plasma infusion
d) Deciding the requirement for blood transfusion
Correct Answer - B
Answer- B. Administering thrombolytics
om
1) Administration of noxious medications
2) Hemodynamic monitoring-
r.c
Blood transfusion or plasma transfusion
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3) Plasmapheresis, apheresis, hemodialysis, or continuous renal
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replacement therapy
tR
4) Poor peripheral venous access
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676. Thrombosis is most commonly
associated with what site in CVP
a) Internal jugular vein
b) Subclavian vein
c) Femoral vein
d) External jugular vein
Correct Answer - C
Answer- C. Femoral vein
om
Advantages-
Rapid access with high success rate
r.c
Does not interfere with CPR
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Does not interfere with intubation
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No risk of pneumothorax
tR
Trendelenburg position not necessary during insertion
irs
Disadvantages-
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Delayed circulation of drugs during CPR Prevents patient
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mobilization
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Difficult to keep site sterile
Difficult for PA catheter insertion
Increased risk of iliofemoral thrombosis
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677. Serum ascitic fluid gradient of 1.5
(SAAG) with ascitic fluid protein of
2.8gm/d1. the most likely cause is
a) Nephritic syndrome
b) Cardiac failure
c) TB
d) Portal hypertension
Correct Answer - B
om
Answer- B. Cardiac failure
r.c
Serum to ascites albumin gradient >1.5 suggests either cirrhosis or
cardiac failure.
ke
The total protein concentration >2.5 suggests ascites due to cardiac
an
cause
tR
The total protein concentration helps to differentiate uncomplicated
irs
ascites from cirrhosis from cardiac ascites both of which have a
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SAAG 1.1 g/dL.
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678. Coronary steal phenomenon caused due
to
a) Arterial dilation
b) Coronary microvessel dilation
c) Epicardial vessel dilation
d) Capacitance vessel dilation
Correct Answer - B
Answer- B. Coronary microvessel dilation
om
Coronary steal is the term given to blood being stolen from one
region of the coronary tree by another.
r.c
It is also called coronary steal syndrome.
ke
It is commonly seen with powerful coronary dilator drugs like
an
dipyridamole or hydralazine.
tR
These drugs are potent arteriolar dilators and dilates resistance
irs
vessels too.
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The obstructed branch has significant arteriolar dilation even when
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oxygen demand is low because of the accumulation of metabolites
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in the ischemic tissue.
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679. Decreased CVP is seen in
a) Pneumothorax
b) PEEP
c) Bacterial sepsis
d) Heart failure
Correct Answer - C
Answer- C. Bacterial sepsis
Decreased
Hypovolemia
om
Septic shock
r.c
Deep inhalation (transient)
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Increased venous compliance
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680. Lemierre's syndrome is
a) Carotid sinus aneurysm
b) Thromobophlebitis of IJV
c) Traumatic occlusion of IJV
d) Any of the above
Correct Answer - B
Answer- B. Thromobophlebitis of IJV
Rare thrombophlebitis of the jugular veins with distant metastatic
sepsis in the setting of initial oropharyngeal infections (pharyngitis,
om
t/-peritonsillar abscess).
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681. Wide QRS duration is -
a) > 0.8sec
b) > 0.9 sec
c) > .12 sec
d) None
Correct Answer - C
Answer- C. > .12 sec
QRS duration → 0.08 - 0.12 sec.
QT interval
om
0.40 sec.
r.c
PR interval
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0.12 - 20 sec.
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QRS Axis range → + 90 to -30°
tR
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682. Torsades de pointes is seen in all
except
a) Hyponatremia
b) Hypocalcemia
c) Hypomagnesemia
d) Hypokalemia
Correct Answer - A
Answer- A. Hyponatremia
om
HypokalemiaQ
HypocalcemiaQ
r.c
Hypomagnesemia
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683. Sinus bradycardia with MI treatment
a) Atropine
b) Digoxin
c) Calcium channel blocker
d) Propranolol
Correct Answer - A
Answer- A. Atropine
The SA node rate generally increases after the administration of a
vagolytic drug, such as "atropine".
om
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684. In COPD which is true
a) FEV 1 /FVC < 0.7
b) FEV1/FVC
c) RV4
d) TLV1
Correct Answer - A
Answer- A. FEV 1 /FVC < 0.7
Spirometry findings in COPD includes reduced FEV1 and a reduced
FEV1 / FVC ratio. Diffusion capacity for carbon monoxide reflects
om
the ability of lung to transfer gas across alveolar/capillary interface.
r.c
Diffusion capacity is low in patients with emphysema and infiltrative
ke
lung diseases. It is increased in patients with pulmonary
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hemorrhage, congestive heart failure and asthma.
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685. Which of the following is markedly
decreased in restrictive lung disease
a) FVC
b) FEV I
c) FEV I /FVC
d) RV
Correct Answer - A
Answer- A. FVC
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Forced vital capacity (FVC)- Decreased (more than obstruction)
Forced expiratory volume in 1 second (FEV,)- Decreased in
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proportion to FVC
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FEVi/FVC- Near normal or increased
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Forced mid expiratory flow rate- Reduced
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Total lung capacity- Decreased
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Residual volume- Generally decreased
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Functional residual capacity- Decreased
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686. Cepacia syndrome fulminant illness seen
in
a) Sarcoidosis
b) Cystic fibrosis
c) Tuberculosis
d) Immotile cilia sydrome
Correct Answer - B
Answer- B. Cystic fibrosis
om
Capacea syndrome is a rapid clinical deterioration in patients with
cystic fibrosis due to new acquisition of or chronic colonization with
r.c
Burkholderia cepacia complex and carries a very high mortality.
ke
In chronically colonized patients the deterioration is often triggered
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by an intercurrent illness.
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687. Empyema thoracis is most commonly
caused by which organism
a) Streptococcus pneumoniae
b) Pseudomonas
c) Mycoplasma
d) Stapylococcus aureus
Correct Answer - A
Answer- A. Streptococcus pneumoniae
om
Empyema thoracic is commonly caused by those bacterias that
cause pneumonias such as streptococcus pneumoniae and
r.c
staphlococcus aureus. E.coli, FLinfluenzas, Klebsiella pneumoniae.
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688. Most common cause of lobar
consolidation
a) Mycoplasma
b) Chlamydia
c) Streptococcus
d) Legionela
Correct Answer - C
Answer- C. Streptococcus
om
Lobar pneumonias typically occurs with primary pneumonias caused
by virulent agents, most commonly pneumococci.
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689. Clinical feature of Bronchiestasis are all
except
a) Hemoptysis
b) Night sweats
c) Chest pain
d) Productive cough
Correct Answer - B
Answer- B. Night sweats
om
The classic clinical manifestations of bronchiectasis are cough and
the daily production of mucopurulent and tenacious sputum lasting
r.c
months to years.
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complaints include dyspnea, wheezing hemoptysis, and pleuritic
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chest pain.
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690. All of the following are features of
interstitial lung disease except
a) Exertional dyspnea
b) Early productive cough
c) Digital clubbing
d) Coarse crepitation during clubbing
Correct Answer - B
Answer- B. Early productive cough
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Cough is usually nonproductive, a productive cough is unusual
Hemoptysis
r.c
Wheezing
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Chest pain
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Clubbing can occur with interstitial lung disease.
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691. Chest X-ray shows B/L lung infiltrates
next investigation is
a) Sputum examination
b) CT
c) Bronchoscopy
d) Antibiotics
Correct Answer - B
Answer- B. CT
om
Presence of B/L lung infiltrates suggests interstitial lung disease.
High resolution computed tomography (HRCT) is obtained in almost
r.c
all patients with diffuse pulmonary parenchymal disease.
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692. Drug of choice in interstitial lung disease
is
a) Antibiotics
b) Steroid
c) Bronchodilators
d) Aspirin
Correct Answer - B
Answer- B. Steroid
om
The usual initial treatment is "oral prednisolone".
For severe disease, - "Pulse methylprednisolone" is used.
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693. Last stage of acute asthma is
a) Hypocapnia
b) Hypercapnia
c) Hyperoxia
d) Alkalosis
Correct Answer - B
Answer- B. Hypercapnia
Late stages of Asthma are characterized by "hypercapnia".
In asthma patients with impending respiratory failure the CO, level
om
exceeds 45 mmHg.
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694. AGN (acute glomerulonephritis) is
diagnosed by
a) Hyaline cast
b) WBC cast
c) RBC cast
d) Granular cast
Correct Answer - C
Answer- C. RBC cast
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Presence of RBC casts in urine is characteristic of nephritic
syndrome due to glomerulonephritis.
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695. Cystatin C levels are used in urology for
a) Detecting UTI
b) Estimating GFR
c) Estimating difference betwen CRF and ARF
d) Screening of Rena Ca
Correct Answer - B
Answer- B. Estimating GFR
GFR estimations determined by creatinine based equations are not
precise, so other substances such as "cystatin C" are being explored
om
to estimate GFR.
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696. Which is not seen in distal RTA
a) Urine pH < 5.5
b) Hypokalemia
c) Hypercalciuria
d) Nephrolithiasis
Correct Answer - A
Answer- A. Urine pH < 5.5
Normal anion gap metabolic acidosis/acidemia
Hypokalemia
om
Urinary stone formation (related to alkaline urine, hypercalciuria, and
r.c
low urinary citrate).
ke
Nephrocalcinosis (deposition of calcium in the substance of the
an
kidney)
tR
Bone demineralisation (causing rickets in children and osteomalacia
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in adults)
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697. Which of the following is not a feature of
distal renal tubular acidosis
a) Normal anion gap
b) Renal hypercalciuria
c) Alkaline urine
d) Hyperkalemia
Correct Answer - A
Answer- A. Normal anion gap
om
Normal anion gap metabolic acidosis/acidemia
Hypokalemia
r.c
Urinary stone formation (related to alkaline urine, hypercalciuria, and
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low urinary citrate).
an
Nephrocalcinosis (deposition of calcium in the substance of the
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kidney)
irs
Bone demineralisation (causing rickets in children and osteomalacia
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in adults)
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698. Hyperkalemia aciduria is seen in
a) Type I RTA
b) Type II RTA
c) Type IV RTA
d) Sigmoidocolostomy
Correct Answer - C
Answer- C. Type IV RTA
Type 4 RTA is due either to a deficiency of Aldosterone or to a
resistance to its effects.
om
It was included in the classification of renal tubular acidoses as it is
r.c
associated with a mild (normal anion gap) metabolic acidosis
ke
(hyperchloremic acidosis) due to a physiological reduction in
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proximal tubular ammonium excretion (impaired ammoniagenesis),
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which is secondary to hypoaldosteronism, and results in a decrease
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in urine buffering capacity.
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699. A patient with diabetes, hyperkalemia,
urinary pH < 5.5 Cause is
a) Uremia
b) Pseudohyperaldosteronism
c) Type I Renal tubular acidosis
d) Type IV RTA
Correct Answer - D
Answer- D. Type IV RTA
om
Hyperkalemia with urinary pH < 5.5 along with diabetes suggests
type IV renal tubular acidosis.
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700. Calciphylaxis is a severe life threatening
condition which occurs is
a) Parathyroidectomy
b) Medullary carcinoma thyroid
c) Hyperthyroidism
d) End stage Renal disease
Correct Answer - D
Answer- D. End stage Renal disease
om
Calciphylaxis is a rare and serious disorder characterized by
systemic medial calcification of the arterioles that leads to ischemia
r.c
and subcutaneous necrosis.
ke
Calciphylaxis is one of several types of extra-osseous calcification
an
(which also includes intimal, medial, and valvular calcification) that
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may occur in patients with end-stage renal disease (ESRD).
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Calciphylaxis most common occurs in patients with ESRD who are
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on hemodialysis.
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701. The hallmark of henoch schonlein
purpura is
a) Palpable purpura
b) Abdominal pain
c) Arthritis
d) Renal dysfunction
Correct Answer - A
Answer- A. Palpable purpura
om
Palpable purpura is essential for diagnosis.
Diagnosis is confirmed by presence of palpable purpura with normal
r.c
platelet count along with one or more of the following : abdominal
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pain, arthralgia/arthritisand mesangial deposition of IgA.
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702. A:G maintained in
a) Nephritic syndrome
b) Cirrhosis
c) Protein losing enteropathy
d) Multiple myeloma
Correct Answer - A
Answer- A. Nephritic syndrome
Decreased albumin/Globulin ratio is seen :
Multiple myeloma or metastatics disease
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AIDS
r.c
Renal disease
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Liver disease (cirrhosis)
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Intestinal disease (Protein losing enteropathy)
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Cachexic patient
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CHF
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A/G ratio is decreased in nephrotic syndrome.
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703. Which is not a stroke
a) TIA
b) Hemiplegia
c) SAH
d) Intracerebral hemorrhage
Correct Answer - A
Answer- A. TIA
Stroke occurs when poor blood flow to brain results in death of brain
cells.
om
Stroke is of two types :-
r.c
1. Ischemic stroke: It is the most common type and occurs due to
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thrombosis of cerebral blood vessels.
an
2. Hemorrhagic stroke: It occurs due to hemorrhage either in brain
tR
tissue (Intracerebral hemorrhage) or in subarachnoid space
irs
(subarachnoid hemorrhage).
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Symptoms of stroke are :-
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1. Sudden onset of hemiparesis / hemiplagia
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704. The features of Cushing triad are all
except
a) Bradycardia
b) Hypotension
c) Irregular breathing
d) Hypertension
Correct Answer - D
Answer- D. Hypertension
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Cushing's triad is a sign of increased intracranial pressure.
It is the triad of : - Hypertension, Bradycardia and Irregular breathing
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705. Alice in wonderland syndrome occurs
in
a) SSPE
b) Epilepsy
c) Cerebral hemorrhage
d) Multiple sclerosis
Correct Answer - B:C
Answer- (B) Epilepsy & (C) Cerebral hemorrhage
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Infectious : CMV, EBV (IMN), Influenza A encephalitis, coxsackie B1
encephalitis, scarlet fever, typhoid encephalopathy, VZV
r.c
encephalitis.
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CNS lesions :- Acute disseminated encephalomyelitis, cavernous
an
angioma, cerebral arteriosclerosis, brain tumor, cerebral
tR
hemorrhage.
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Paroxysmal neurological disorders : Epilepsy (temporal lobe
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epilepsy), migraine1
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706. Water shed infarct in brain
a) Occurs in the proximal portion of main arteries
b) Occurs in the central portion of main arteries
c) Occurs in the terminal portion of main arteries
d) Any of the above
Correct Answer - C
Answer- C. Occurs in the terminal portion of main arteries
Border zone or watershed infarcts are ischemic lesion that occurs in
characteristic location at the junction between two main arterial
om
territories.
r.c
Watershed strokes are named that way because they affect the
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watershed areas of the brain.
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These areas are thin strips of brain which are sandwiched in
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between the farthest end branches of two adjacent vascular
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territories.
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707. In Wilsons disease copper deposition
occurs in
a) Pons
b) Medulla
c) Cerebellum
d) Basal ganglia
Correct Answer - D
Answer- D. Basal ganglia
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In brain, the toxic injury primarily affects the basal ganglia
particularly the putamen which demonstrates atrophy and cavitation.
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708. Abdominojugular reflex appears after
compressing abdomen for
a) 5 sec
b) 10 sec
c) 15 sec
d) 30 sec
Correct Answer - C
Answer- C. 15 sec
om
This is done by applying firm pressure with the palm of the hand to
the right upper quadrant of the abdomen for 10-15 seconds with the
r.c
patients breathing quietly while the jugular vein is observed.
ke
A positive abdominojugular reflux sign is defined by an increase in
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the jugular venous pressure of greater than 3 cm, sustained for
tR
greater than 15 seconds.
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709. Genitourinary complication of ulcerative
colitis
a) Cystitis
b) Pyelonephritis
c) Urinary calculi
d) Urethritis
Correct Answer - C
Answer- C. Urinary calculi
om
Urinary calculi (oxalate stones in ileal disease), local extension of
Crohn disease involving ureter or bladder, amyloidosis, drug-related
r.c
nephrotoxicity.
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710. Liver biopsy indication is all except
a) Amoebic hepatitis
b) Wilson's disease
c) Chronic hepatitis B and C
d) Autoimmune hepatitis
Correct Answer - A
Answer- A. Amoebic hepatitis
Grading and staging of chronic hepatitis B and C
Diagnosis of :
om
Hemochromatosis (quantitative estimation of hepatic iron)
r.c
Wilson's disease (quantitative hepatic copper)
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Focal liver lesions
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Evaluation of :
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Cholestatic liver disease : Primary biliary cirrhosis, primary
irs
sclerosing cholangitis
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Abnormal liver biochemical tests in a patient with a negative or
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inconclusive serologic work-up
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Treatment efficacy
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Side effects of treatment regimens (such as methotrexate for
rheumatoid arthritis)
Post liver transplant by protocol or for evaluation of abnormal liver
biochemical tests
Donor liver
Fever of unknown origin
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711. Use of spironolactone in liver cirrhosis
is
a) Decrease edema
b) Improves liver function
c) Decrease afterload
d) Decrease intravascular volume
Correct Answer - A
Answer- A. Decrease edema
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Treatment of ascites in patient with cirrhosis is aimed at the
underlying cause of the hepatic disease and at the sodium water
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retention
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Diuretic therapy typically consists of treatment with spironolactone
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and furosemide in a ratio of 100: 40 mg/day with doses titrated
tR
upward as needed (upto 400 mg spironolactone and furosemide in a
irs
ratio of 100 : 40 mg/day).
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712. Pea soup diarrhea is seen in -
a) Cholera
b) Typhoid
c) Yersinosis
d) Hepatitis
Correct Answer - B
Answer- B. Typhoid
Pea Soup diarrhoea is characteristic of salmonella infection.
About 2 weeks after infection with salmonella typhi most people
om
suffering from typhoid develop a yellow green foul liquid stool that
r.c
resembles pea soup in appearance i.e., pea soup stool.
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713. Most significant risk factor for
development for gastric carcinoma is
a) Paneth cell metplasia
b) Pyloric metaplasia
c) Intestinal metaplasia
d) Ciliated metaplasia
Correct Answer - C
Answer- C. Intestinal metaplasia
om
A) Environmental factors
B) Host factors : Chronic gastritis (causing hypochlorhydria or
r.c
intestinal metaplasia), partial gastrectomy, gastric adenoma,
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Barrett's esophagus, and Menetrier disease.
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Intestinal metaplasia is the most significant precursor lesion for
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Gastric cancer
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C) Genetic factors
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714. Adult male with chronic atrophic
gastritis, growth on skirrows medium &
rapid urease test positive. Diagnosis is
a) H pylori
b) H. influnzae
c) K pneumonia
d) V. Cholarae
Correct Answer - A
om
Answer- A. H pylori
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All favor the diagnosis of H pylori infection.
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715. Seen in SIADH
a) Generalized edema
b) Ascites
c) Normal BP
d) Dry mucous membrane
Correct Answer - C
Answer- C. Normal BP
Hyponatremia (dilutional hyponatremia with Net' < 135 mmol/L)
Decreased plasma osmolality (<280 m osm/kg) with inappropriately
om
increased urine osmolality > 150 m osm).
r.c
High urine sodium (over 20 meq/1)
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Low blood urea nitrogen <10 mg/L
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Hypouricemia (<4 mg/dL)
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Clinical euvolemia
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716. A diabetic patient having sensory
involvement, tingling, numbness, ankle
swelling, no pain. Diagnosis is
a) Charcots joint
b) Gout
c) Rheumatoid arthritis
d) Ankylosing spondylitis
Correct Answer - A
om
Answer- A. Charcots joint
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It is a progressive destructive arthritis associated with loss of pain
sensation°, proprioception° or both, in addition normal muscular
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reflexes that modulate joint movements are decreased.
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It is most commonly caused by diabetes mellitus.
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[Ref Harrison 18`5/e p. 2855, 2856; 17th/e p. 2180-2181]
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717. Patient having Cushing syndrome due to
adrenal tumor. Drug to be given
a) Cortisol
b) Betamethasone
c) Ketoconazole
d) Fludrocortisones
Correct Answer - C
Answer- C. Ketoconazole
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TREATMENT-
Treatment of choice- removal of pituritary corticotrope tumour
r.c
(transphenoidal approach)
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Pituitary irradiation
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Metyrapone and ketoconazole
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Adrenocortical carcinoma- mitotane
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718. Metabolic change in severe vomiting is
a) Metabolic alkalosis
b) Respiratory alkalosis
c) Metabolic acidosis
d) Hyperkalemia
Correct Answer - A
Answer- A. Metabolic alkalosis
Persistent gastric vomiting leads to
Hyponatremia
om
Hypokalemia
r.c
Hypochloremia
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Alkalosis
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719. Treatment of hypercalcemia includes all
except
a) Steroids
b) Bisphosphonates
c) Phosphate
d) Strontium
Correct Answer - D
Answer- D. Strontium
om
Treatment of acute hypercalcemia
Hydration with saline
r.c
Forced diuresis: Saline plus loop diuretics (furosemide)
ke
Bisphosphonates (pamidronate, zoledronate)
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Calcitonin
tR
Special therapies: Phosphate (oral), glucocorticoids, dialysis
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720. Myelodysplastic syndrome is common in
which age group
a) 2-10yrs
b) 15-20yrs
c) 25-40 yrs
d) > 50yrs
Correct Answer - D
Answer- D. > 50yrs
om
Myelodysplastic syndrome occurs most commonly in older adults
with median age at diagnosis in most cases of 65 years and a male
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preponderance. Onset of the disease earlier than age 50 is unusual.
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721. The best drug to lower prolactin level in
a female with infertility is
a) Bromocriptine
b) GnRH
c) Testosterone
d) Corticosteroid
Correct Answer - A
Answer- A. Bromocriptine
om
The treatment of choice for prolactinoma is "bromocriptine".
Bromocriptine is a dopamine agonist which inhibits the secretion and
r.c
synthesis of prolactin.
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722. Which of the following is not commonly
seen in Polycythemia Vera
a) Thrombosis
b) Hyperuricemia
c) Prone for acute leukemia
d) Spontaneous severe infection
Correct Answer - D
Answer- D. Spontaneous severe infection
om
Clinical features-
Hyperviscosity, hypovolaemia, hypermetabolism, erythocytosis,
r.c
thrombosis.
ke
Headache, vertigo, tinnitus, syncope or even coma, transient visual
an
loss
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Splenomegaly, haemtemesis and melena, bleeding.
irs
Pruritis & peptic ulceration (basophilia with histamine release)
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Hyperuricaemia- urate stones and gout
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723. Evans syndrome is
a) Anemia and thrombocytopenia
b) Pancytopenia
c) Lymphopenia and anemia
d) Thrombocytosis and lymphocytosis
Correct Answer - A
Answer- A. Anemia and thrombocytopenia
Evans syndrome (ES) refers to the combination of Coombs-positive
warm autoimmune hemolytic anemia (AIHA) and immune
om
thrombocytopenia (ITP), although, less commonly, some patients
r.c
will also have autoimmune neutropenia (15 percent in one series).
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724. All are major complications of massive
transfusion except
a) Hypokalemia
b) Hypothermia
c) Hypomagnesemia
d) Hypocalcemia
Correct Answer - A
Answer- A. Hypokalemia
om
Complications of Massive transfusion : -
Coagulopathy
r.c
Citrate toxicity
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Hypothermia
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Metabolic alkaptosis
tR
Hyperkalemia
irs
Acute respiratory distress syndrome
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Coagulation factor depletion
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725. Regarding MSUD which is not true
a) Deficiency of branched chain amino acid enzymes
b) Hyperaminoaciduria
c) Asymptomatic
d) FeC13 turns navyblue
Correct Answer - C
Answer- C. Asymptomatic
It is an inherited (autosomal recessive) disorder of branched chain
amino acid i.e. - Valine, Leucine and Isoleucine.
om
Maple syrup urine disease (MSUD) is d/t defect in enzyme - a-keto
r.c
acid dehydrogenase.
ke
Diagnosis
an
The keto acids may be detected by adding a few drops 2-4 din
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itrophenylhydrazine (DNPH) reagent which produces a yellow
irs
precipitate in positive test.
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Ferric chloride gives navy blue colour with the patients urine.
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726. Result of liquorice ingestion
a) Hyperkalemic alkalosis
b) Hypokalemic alkalosis
c) Hypokalemic acidosis
d) Hypermalemic acidosis
Correct Answer - B
Answer- B. Hypokalemic alkalosis
Liquorice (Licorice) ingestion causes apparent mineralocorticoid
excess (pseudohyperaldosteronism) due to inhibition of enzyme 11-
om
13-HSD.
r.c
This causes metabolic alkalosis, hypokalemia and volume overload.
ke
an
tR
irs
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727. Most common carcinoma associated
with RA
a) Diffuse large B cell lymphoma
b) Large granular lymphocytic leukemia
c) Chronic lymphocytic leukemia
d) None of the above
Correct Answer - B
Answer- B. Large granular lymphocytic leukemia
om
Lymphogranular proliferation may be present in patients with
Rheumatoid arthritis and in minority it will proceed to "large granular
r.c
lymphocytic leukemia" in Rheumatoid arthritis
ke
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tR
irs
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728. Systemic sclerosis shows all except
a) Acroosteolysis
b) Tufting
c) Calcinosis cutis
d) Digital ulcers
Correct Answer - B
Answer- B. Tufting
Skin involvement in systemic sclerosis
Pruritus in the early stages
om
Edema in the early stages
r.c
Sclerodactyly
ke
Digital ulcers
an
Pitting at the fingertips
tR
Telangiectasia
irs
Calcinosis cutis
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729. Tetany is seen in
a) Hypocalcemia
b) Hypercalcemia
c) Hypoparathyroidism
d) Hyperparathyroidism
Correct Answer - A
Answe- A. Hypocalcemia
Acute hypocalcemia directly increases peripheral neuromuscular
irritability.
om
Tetany consists of repetitive high frequency discharges after a single
r.c
stimulus.
ke
Hyperexcitability ofperipheralneurons is probably the most important
an
pathophysiologic effect of hypocalcemia.
tR
irs
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730. In inflammatory myopathy, which group
of muscles is not affected
a) Ocular
b) Facial
c) Proximal muscles of limb
d) Distal muscles of limb
Correct Answer - C
Answer- C. Proximal muscles of limb
om
Inflammatory myopathies represent the largest group of acquired
and potentially treatable cause of skeletal muscle weakness.
r.c
They are classified into three major groups :
ke
1. Polymyositis
an
2. Dermatomyositis
tR
3. Inclusion body myositis
irs
These disorders present as progressive often symmetric muscle
.F
weakness.
w
The proximal muscles are involved predominantly, first of the lower
w
w
limb or girdle followed by proximal muscles of upper limb.
Occular muscles are spared.
Distal muscles of the limb are involved rarely.
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731. Signs of Bartter's syndrome -
a) Hypokalemia
b) Hypernatremia
c) Hyperkalemia
d) Acidosis
Correct Answer - A
Answer- A. Hypokalemia
Inherited forms of hypochloremic metabolic alkalosis and
hypokalemia without hypertension are due to genetic mutations of
om
various ion transporters and channels of the thick ascending limb of
r.c
Henle's loop (TAL) and distal convoluted tubule (DCT).
ke
[Ref: Harrisons Principles of Internal Medicine, 18th Edition, Pages
an
2360, 61]
tR
irs
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732. Description of Waterhouse Friedrich
syndrome
a) Adrenal hemorrhage post malignancy
b) Congenital adrenals deficiency
c) Adrenal hemorrhage after meningococcal infection
d) Adrenal hemorrhage after corticosteroid withdrawal
Correct Answer - C
Answer- C. Adrenal hemorrhage after meningococcal infection
om
Waterhouse Friderichsen syndrome or massive adrenal hemorrhage
is an uncommon usually fatal consequence of overwhelling sepsis.
r.c
It is most frequently seen as a result of "meningococcal infection".
ke
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733. In total parenteral nutrition, no need to
measure daily
a) Electrolyte
b) Fluid intake and output
c) LFT albumin
d) Magnesium
Correct Answer - C
Answer- C. LFT albumin
om
Monitoring of parenteral nutrition daily :-
Measurement of fluid intake and output
r.c
Serum electrolyte
ke
Glucose
an
Calcium
tR
Magnesium
irs
Phosphate
.F
Monitor the following parameters weekly :-
w
Aminotransferase
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Bilirubin
Triglycerides
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734. Drug of choice for kala-azar is
a) Antimonials
b) Amphotericin B
c) Quinine
d) Parmomycin
Correct Answer - A
Answer- A. Antimonials
First line : Pentavalent antimony (Sodium stibogluconateis the drug
of choice), and amphotericin-B.
om
Alternatives : Paromomycin, pentamidine, miltefosine, sitamoquine
r.c
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735. DMD not seen is
a) Muscle pseudo hypertrophy
b) Weakness
c) Tenderness
d) Cardiomyopathy
Correct Answer - C
Answer- C. Tenderness
DMD, also called peudohypertrophic mucular dystrophy, is the most
common hereditary neuromuscular dystrophy. It is an X-linked
om
recessivedisorder.
r.c
It is caused by a mutation in gene responsible for producing
ke
dystrophin (a sarcolemmal protein).
an
There is progressive muscle weakness affecting proximal muscles of
tR
limbs.
irs
Child walks clumsily, has difficulty in climbing stairs and the gait is
.F
waddling (Trendelenburg).
w
Scoliosis, epilepsy and mild mental retardation
w
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736. Most sensitive test for myaesthenia
gravis
a) Edrophonium test
b) Single fibre EMG
c) Multiple fibre EMG
d) Repetitive nerve stimulation
Correct Answer - B
Answer- B. Single fibre EMG
om
Diagnosis-
Anti- AchR radioimmunoassay
r.c
Electrophysiological testing
ke
Single- fibre electromyography (most sensitive)
an
tR
irs
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737. Dyslipidemia associated with alcohol
consumption
a) Decreased HDL
b) Increased HDL
c) Decreased triglycerase
d) Decreased lipoprotein
Correct Answer - B
Answer- B. Increased HDL
om
Serem HDL cholesterol increases by 4.0 mg/dl (.1mmol/L)
Serum apolipoprotein A.1 increase by 8.8 mg/dl
r.c
Serum Triglyceride increases by 5-4 mg mg/dl
ke
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738. Migraine is due to
a) Dilatation of cranial arteries
b) Constriction of cranial arteries
c) Cortical spreading depression
d) Meningial inflammation
Correct Answer - C
Answer- C. Cortical spreading depression
Cortical spreading depression is a self propagating wave of neuronal
and glial depolarization that spreads across the cerebral cortex.
om
The activation of trigeminal afferents by cortical spreading
r.c
depression in turn causes inflammatory changes in the pain-
ke
sensitive meninges that generate the headache of migraine through
an
central and peripheral reflex mechanisms.
tR
irs
.F
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739. -30° to -60° left axis deviation is seen in
a) Left ventricular hypertrophy
b) Right ventricular hypertrophy
c) Aortic stenosis
d) Left atrial enlargement
Correct Answer - A
Answer- A. Left ventricular hypertrophy
Normally, QRS axis ranges from -30° to 90°C
An axis more negative than -30° is referred to as left axis deviation
om
and an axis more positive than +100° is called right axis deviation
r.c
Left axis deviation
ke
Axis more negative than -30°
an
Associated with
tR
Left ventricular hypertrophy
irs
Left anterior fascicular block
.F
Inferior M.I.
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740. Which is increased in plasma of chronic
heart disease pts
a) BNP
b) Endothelin 1
c) Cortisol
d) None
Correct Answer - A
Answer- A. BNP
om
The plasma concentrations of both hormones are increased in
patients with asymptomatic and symptomatic left ventricular
r.c
dysfunction, permitting their use in diagnosis.
ke
BNP levels are simple and objective measures of cardiac function.
an
These measures can be used to diagnoose heart failure including
tR
diastolic function.
irs
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741. In asthma diagnosis is by
a) FEVi
b) Measurement of tidal volume
c) End expiratory flow rate
d) Total lung capacity
Correct Answer - A
Answer- A. FEVi
Asthma is classified according to the frequency of symptoms, forced
expiratory volume in one second (FEV1), and peak expiratory flow
om
rate.
r.c
Spirometry is recommended to aid in diagnosis and management. It
ke
is the single best test for asthma. If the FEV1 measured by this
an
technique improves more than 12% and increases by at least 200
tR
milliliters following administration of a bronchodilator such as
irs
salbutamol, this is supportive of the diagnosis.
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742. A person has asthma attacks more than
once during day and once during night
a) Mild intermittent asthma
b) Mild persistent asthma
c) Moderate asthma
d) Severe asthma
Correct Answer - D
Answer- D. Severe asthma
om
Severe asthma
Symptoms- Throughout day
r.c
Night awakenings- Daily
ke
Short-acting B2-agonist use for symptom control-Several times per
an
day
tR
Interference with normal activity- Extreme limitation
irs
FEV1- < 60%
.F
FEV1 /FVC= > 5% reduced
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743. A child presents with recurrent
pulmonary infections for hemoptysis due
to associated bronchiectasia and on
imaging characterized by unilateral loss
of lung volume with hyperlucency on
chest radiograph, reduction in
vascularity on CT scan of the chest. The
abdominal organs are normally place (d)
most lilkely cause is
a) Kartagener's syndrome
b) Swyer-James-MacLeod syndrome
om
c) Mendelson's syndrome
r.c
ke
an
d) Immotile cilia syndrome
tR
irs
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Correct Answer - B
w
Answer- B. Swyer-James-MacLeod syndrome
w
Swyer-James-MacLeod syndrome or unilateral h erlucent lun
ndrome is a rare entity associated with postinfectious bronchiolitis
obliterans occurring in childhood.
It is characterized by hypoplasia and/or agenesis of the pulmonary
arteries resulting in pulmonary parenchyma hypoperfusion, showing
a characteristic radiological pattern, such as translucent or
hyperlucent unilateral lung.
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744. Fibrosis of upper lobe is due to
a) Pneumonia
b) ABPA
c) Bronchiectasis in COPD
d) Rheumatoid arthritis
Correct Answer - B
Answer- B. ABPA
Silicosis (Progressive massive fibrosis
Sarcoidosis
om
Coal worker pneumoconiosis
r.c
Ankylosing spondylitis
ke
Radiation
an
Allergic bronchopulmonary aspergillosis
tR
Tuberculosis
irs
Extrinsic allergic alveolitis
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745. What is not seen in CRF
a) Hypercalcemia
b) Hyperkalemia
c) Hyperphosphatemia
d) Hypocalcemia
Correct Answer - A
Answer- A. Hypercalcemia
Abnormalities seen in CRF
Acidosis
om
Hyperkalemia
r.c
Anemia
ke
Hypernatremia
an
Hyperphosphatemia
tR
Hyperlipidemia
irs
Hyponatremia
.F
Hypocalcemia
w
Uremia
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746. Maximum urinary catheter induced
infection
a) E.coli
b) Pseudomonas
c) Staphylococcus epidermidis
d) Proteus
Correct Answer - A
Answer- A. E.coli
om
Catheter associated urinary tract infections represent the most
common type of nosocomial infection.
r.c
Most common organism causing catheter associated urinary tract
ke
infections are E.coli.
an
tR
irs
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747. Most common symptom of genitourinary
TB
a) Renal colic
b) Increased frequency
c) Hematuria
d) Painful micturition
Correct Answer - B
Answer- B. Increased frequency
om
The clinical manifestations are variable.
The onset of clinically evident genitourinary tuberculosis is usually
r.c
insidious.
ke
The most common symptoms are :-
an
Dysuria, increased frequency of urination and gross hematuria
tR
irs
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748. Anominal aphasia is due to defect in
a) Left inferior frontal
b) Parietal
c) Temporal occipital
d) Cerebellum
Correct Answer - C
Answer- C. Temporal occipital
Anomia can be genetic or caused by damage to various parts of the
parietal lobe or the temporal lobe of the brain by an accident or
om
stroke, or a brain tumor.
r.c
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tR
irs
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749. Unable to consolidate long term memory.
Which lobe of the brain is involved
a) Frontal
b) Parietal
c) Temporal
d) Occipital
Correct Answer - C
Answer- C. Parietal
om
Medial temporal lobe is the area of brain responsible for
consolidation, i.e. processing of short term memory into long term
r.c
memory.
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irs
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750. Gerstmanns syndrome all except
a) Acalculia
b) Agraphia
c) Aphasia
d) Agnosia
Correct Answer - C
Answer- C. Aphasia
Gerstmann syndrome consists of :
1. Agraphia
om
2. Acalculia
r.c
3. Finger agnosia
ke
4. Left right disorientation
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751. Pontine hemorrhage most common
cause is
a) Hypertension
b) Diabetes
c) Trauma
d) Aneurysmal rupture
Correct Answer - A
Answer- A. Hypertension
om
Most common cause of pontine hemorrhage is hypertension.
r.c
ke
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tR
irs
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752. Daily temperature variation in remmitent
fever is
a) < 0.5 C
b) > 1°C
c) < 1.0 C
d) > 2 C
Correct Answer - B
Answer- B. > 1°C
om
Continuous fever
Temperature remains above normal throughout the day and does
r.c
not fluctuate more than 1°C in 24 hours. Intermittent fever
ke
The temperature elevation is present only for a certain period, later
an
back to normal e.g. malaria, kala azar septicaemia.
tR
irs
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753. Hyperthermia
a) Temperature > 41.5
b) > 40 with autonomic dysfunctuion
c) No change in hypothalamic thermostat
d) Failure of thermoregulation
Correct Answer - D
ANswer- D. Failure of thermoregulation
Hyperthermia is defined as elevation of core body temperature
above the normal diurnal range of 36 to 37.5°C due to failure of
om
thermoregulation at the level of hypothalamus.
r.c
Hyperthermia is not synonymous with the more common sign
ke
offever, which is induced by cytokine activation during inflammation,
an
and regulated at the level of the hypothalamus.
tR
irs
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754. Myasthenia gravis is associated with
a) Antibodies against Ach receptors
b) Decreased myosin
c) Absent troponin C
d) Increased myoneural junction transmission
Correct Answer - A
Answer- A. Antibodies against Ach receptors
The characteristic pathological feature of myasthenia gravis is
presence of antibodies against acetyl choline receptors.
om
These autoantibodies against the acetylcholine receptors lead to
r.c
loss of functional acetylcholine receptors at the neuro muscular
ke
junction.
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irs
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755. Eaton Lambert syndrome is seen with -
a) Ca breast
b) Ca liver
c) Ca lung
d) CNS tumors
Correct Answer - C
Answer- C. Ca lung
Paraneoplastic syndrome
Associated with
om
Small cell carcinoma lung
r.c
Certain autoimmune diseases
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756. Lesion of globus pallidus causes
a) Chorea
b) Athetosis
c) Hemibalismus
d) Flexion dystonia
Correct Answer - B
Answer- B. Athetosis
Athetosis- Globus pallidus (mainly) and Subthalamic nucleus.
Lesion at the globus pallidus and
om
striatum cause athetosis, which is characterized by
r.c
continuous, slow writhing movements.
ke
Chorea: rapid, involuntary dancing movements → Most commonly,
an
the lesion is in the striatum.
tR
Ballism: involuntary flailing, intense and violent movements. The
irs
movements are of large amplitude and predominantly involves
.F
proximal muscles.
w
The lesion in the subthalamic nucleus.
w
Athetosis: continuous, slow writhing movements → Lesion at globus
w
pallidus and striatum.
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757. Most common tumor associated with NF
1
a) Optic glioma
b) 2nd nerve schwannoma
c) Astrocytoma
d) Bilateral acoustic neuroma
Correct Answer - A
Answer- A. Optic glioma
om
"Optic pathway gliomas" are the predominant type of neoplasm
associated with neurofibromatosis type I but other central nervous
r.c
system and non CNS tumours can occur.
ke
an
tR
irs
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758. CSF picture in viral meningitis
a) Lymphocytic pleocytosis
b) WBC count > 1500/mL
c) Sugar is reduced
d) Protein is decreased
Correct Answer - A
Answer- A. Lymphocytic pleocytosis
Normal Bacterial Viral
Opening
om
7-18 >30 Normal or Mildly Increased
Pressure
r.c
Clear,
ke
Appearance Turbid Clear
Colorless
an
tR
Protein
23-38 Increased Normal to Decreased
irs
(mg/dl)
.F
2/3rds
w
Glucose
Serum Decreased Normal
w
(mmol/L)
w
Glucose
Positive 160-90% of
Gram Stain Negative Negative
Cases)
Glucose
CSF: Serum 0.6 <0.4 >0.6
Ratio
White Cell
cells Predominately NeutrophilsPredominately Lymphocytes
Count
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759. In herpes encephalitis A/E
a) Focal symptoms common
b) Temporal lobe involved
c) MRI is diagnostic
d) EEG not diagnostic
Correct Answer - D
Answer- D. EEG not diagnostic
Diagnosis
Most sensitive and specific investigation for HSV-1 encephalitic is
om
MRI
r.c
In contrast, cranial CT scans have only 50% sensitivity and that too
ke
early in the disease. EEG findings in HSV-1 encephalitis
an
tR
irs
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760. Which of the following provide
protection against malaria all except
a) Duffy blood group
b) Sickle cell anemia
c) Thalassemia
d) PNH
Correct Answer - D
Answer- D. PNH
om
Red cell surface antigen that offer protection against malaria
Duffy blood group system
r.c
ABO (H) blood group system
ke
Glycophorins
an
Gerbich antigen
tR
Complement receptor type I
irs
Knops blood group
.F
Abnormalities of the red cell cytoskeleton which may offer
w
protection include
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South-east asia ovalocytosis Hereditary elliptocytosis
Hereditary spherocytosis Sickle cell HbA/S
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761. Richner-Hanhart syndrome is
a) Autosomal dominant
b) Occular and cutaneous features
c) Associated with abnormality in lipid metabolism
d) Normal mental function
Correct Answer - B
Answer- B. Occular and cutaneous features
Rare autosomal recessive disorder of tyrosine metabolism due to
deficiency of the cytosolic fraction of hepatic tyrosine amino
om
transferase.
r.c
Occurs due to deficiency of "Tyrosine amino transferase".
ke
Mental retardation.
an
The patient has high urinary tyrosine levels along with high plasma
tR
tyrosine levels.
irs
These patients responds dramatically to dietary restriction of the
.F
amino acids phenylalanine and tyrosine
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762. Fabry's disease affects
a) ER
b) Lysosome
c) Mitochondria
d) Cell membrane
Correct Answer - B
Answer- B. Lysosome
Fabry disease, also called Anderson-Fabry disease, is the second
most prevalent lysosomal storage disorder after Gaucher disease.
om
It is an X-linked inborn error of the glycosphingolipid metabolic
r.c
pathway. This results in accumulation of globotriaosylceramide
ke
(Gb3) within lysosomes in a wide variety of cells, thereby leading to
an
the protean manifestations of the disease.
tR
irs
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763. Calcium homeostasis disturbance is
seen in
a) Malignant hyperthermia
b) DMD
c) Tibial muscular dystrophy
d) Limb girdle muscle dystrophy
Correct Answer - A
Answer- A. Malignant hyperthermia
om
Malignant hyperthermia is a pharmacogenetic condition caused due
to mutation of the "Ryanodine receptor gene".
r.c
Ryanodine receptor gene controls the level of "cytosolic calcium"
ke
and therefore skeletal muscle contraction.
an
tR
irs
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764. Tetany is seen in
a) Respiratory alkalosis
b) Respiratory acidosis
c) Metabolic acidosis
d) Hyperkalemia
Correct Answer - A
Answer- A. Respiratory alkalosis
In alkalosis tetany occurs because of the decreased concentration of
free ionized calcium.
om
It is the free ionized calcium that is physiologically more important.
r.c
[Ref Harrison 18th/e p. 362, 360; Guyton 10thie p. 342]
ke
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765. Hypomagnesemia is not seen in
a) Barters syndrome
b) Diabetes mellitus
c) Diarrhea
d) Gitelman syndrome
Correct Answer - A
Answer- A. Barters syndrome
Hypomagnesemia may occur in Barter's syndrome but usually the
serum magnesium level is normal in Barters syndrome.
om
r.c
ke
an
tR
irs
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766. Primary Sjogrens syndrome true is
a) Can be seen in children
b) Increased complement C4 leads to thymoma
c) Associated with rheumatoid arthritis
d) Salivary gland enlargement
Correct Answer - D
Answer- D. Salivary gland enlargement
Sjogren syndrome is a chronic disease characterized by dry eyes
(keratoconjuctivitis sicca) and dry mouth (xerostomia) resulting from
om
immunological mediated destruction of the lacrimal and salivary
r.c
glands.
ke
It occurs in two forms
an
1. Primary form (SICCA SYNDROME) → Occurs as an isolated
tR
disorder.
irs
2. Secondry form → When it occurs in association with other
.F
autoimmune disorder. It is more common.
w
Autoimmune diseases associated with sjogren syndrome
w
Symptoms result from inflammatory destruction of the exocrine
w
glands.
1. Keratoconjunctivitis
2. Xerostomia
3. Parotid gland enlargement
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767. Prophylaxis for HIV is optimally effective
if started upto ..... hrs of exposure
a) 1
b) 2
c) 4
d) 12
Correct Answer - A
Answer- A. 1
om
goal is to start within one to two hours or earlier after exposure often
using a starter pack with appropriate drugs as immediately available.
r.c
The median time to initiation of postexposure prophylaxis is 1.8 hrs.
ke
The centre for disease control and prevention (CDC)
an
recommendations are to offer prophylaxis upto 24-36 hrs after
tR
exposure, for longer time lapses, the recommendations is to seek
irs
advice from an expert
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768. Odd pair
a) Erythema marginatum-rheumatic fever
b) Erythema gyrens ripens-malignancy
c) Necrotic acral erythema-HCV
d) Erythema chronicum migrans malignancy
Correct Answer - D
Answer- D. Erythema chronicum migrans malignancy
"Erythema gyratum repens" is a rare and characteristic rash strongly
associated with malignancy .
om
Erythema chromicum nigrans
r.c
Ergthema marginatum
ke
It is a characteristic cutaneous manifestation of rheumatic fever.
an
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769. Yellow-nail syndrome consists of
a) Knee joint effusion and lymphedema, associated with
discolored nails
b) Pericardial and lymphedema, associated with discolored nails
c) Peritoneal effusion and lymphedema, associated with
discolored nails
d) Pleural effusion and lymphedema, associated with discolored
nails
Correct Answer - D
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Answer- D. Pleural effusion and lymphedema, associated with
r.c
discolored nails
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Yellow nail syndrome is a rare disorder of the nail, which is usually
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accompanied by
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Lymphoedema
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It may also be associated with :
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Recurrent pleural effusions
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Bronchiectasis
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770. Not to be given in malignant malaria is -
a) Quinolone
b) Quinine
c) Doxycycline
d) Artesunate
Correct Answer - A
Answer- A. Quinolone
Artemisinin derivative : Artesunate
Quinine or Quinidine
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Plus one of the following : Doxycycline, Tetracycline and
r.c
Clindamycin
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771. Muir–Torre syndrome shows
a) Sebaceous keratomas
b) Lisch nodules
c) Intestinal polyp
d) Hyperelastic joints
Correct Answer - A
Answer- A. Sebaceous keratomas
Muir - Torre syndrome is an autosomal skin condition of genetic
origin characterized by tumors of the sebaceous gland or
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keratoacanthoma that are associated with visceral malignant
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disease
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Cutaneous characteristic
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Adenoma
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Epithelioma
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Carcinoma
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Multiple keratoacanthomas
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772. First symptom of leprosy
a) Decreased vibration & position sense
b) Decreased pain
c) Decreased temperature
d) Decreased light touch
Correct Answer - B
Answer- B. Decreased pain
In 90% of patients the first sign of the disease is a feeling of
numbers which may preceedes skin lesions by a number of years .
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Temperature is the first sensation lost followed by light tourch pain
r.c
and then deep pressure.
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[Ref Harrison 18thie p. 1363-1364]
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773. Migraine is due to
a) Dilatation of cranial arteries
b) Constriction of cranial arteries
c) Cortical spreading depression
d) Meningial inflammation
Correct Answer - C
Answer- C. Cortical spreading depression
Cortical spreading depression is a self propagating wave of neuronal
and glial depolarization that spreads across the cerebral cortex.
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The activation of trigeminal afferents by cortical spreading
r.c
depression in turn causes inflammatory changes in the pain-
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sensitive meninges that generate the headache of migraine through
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central and peripheral reflex mechanisms.
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774. Which of the following is endogenous
pyrogen
a) PG E2
b) PG D2
c) PGF2 alpha
d) PG I2
Correct Answer - A
Answer: -A. PG E2
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Pyrogen
Pyrogens are substances that cause fever.
r.c
Pyrogens may be exogenous or endogenous
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Exogenous → Bacterial toxins
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Endogenous → IL-1, TNF-a, IL-6, Interferons, Ciliary neurotrophic
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factor
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These pyrogens increase the level of PGE, in the hypothalamus that
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elevates the thermoregulatory set point and causes fever.
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775. In Bartter syndrome defect is seen in:
a) Defect in PCT
b) Defect in DCT
c) Defect in thick ascending limb of loop of henle
d) None
Correct Answer - C
Answer: C - Defect in thick ascending limb of loop of henle
Autosomal recessive disorder.
Genetic defect in the thick ascending limb of the loop of henle
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Defects in Na-K-2C/ coLtransporter, K or Cl
r.c
channels result in lack of concentrating ability
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776. Not seen in allergic pulmonary
aspergillosis is
a) High IgE level
b) Recurrent pneumonia
c) Occurrence in patients with old cavitary lesions
d) Pleural effusion
Correct Answer - B
Answer: B-Recurrent pneumonia
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Allergic bronchopulmonary aspergillosis is a pulmonary
hypersensitivity disorder caused by allergy to fungal antigens that
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colonize the tracheobronchial tree.
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It most commonly occurs in atopic asthmatic individuals in response
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to antigen of aspergillus species.
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Main diagnostic criteria
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Clinical history of Asthma Q
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Pulmonary infiltrates (transient /fleeting or fixed)Q
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Peripheral eosinophilia (> 1000 /,uL)Q
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Immediate skin reactivity to Aspergillus antigen (wheal and flare
response)
Serum precipitins to A. fumigatus
Elevated serum IgE levels(>100Ong/ml)
Central /proximal bronchiectasis
Secondary diagnostic criteria
History of brownish plugs in sputum
Identification / culture of A., fumigatus from sputum
Late skin reactivity to aspergillus antigen - CMDT
Elevated IgE (and IgG) class antibodies specific for A. fumigatus -
Harrisons
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Note
Elevated IgE (and IgG) class antibodies specific for A. fumigatus has
been mentioned as a secondary diagnostic criteria in Harrison's
textbook while Fishman's textbook includes this as a main/major
diagnostic criteria.
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777. Pseudo P Pulmonale
a) Hypokalemia
b) Hyponatremia
c) Hypocalcemia
d) Hypercalcemia
Correct Answer - A
Answer: A. Hypokalemia
In some cases there can be a notched (or bifid) p-wave known as “p
mitrale”, indicative of left atrial hypertrophy which may be caused by
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mitral stenosis. There may be tall peaked p-waves. This is called “p-
r.c
pulmonale” and is indicative of right atrial hypertrophy often
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secondary to tricuspid stenosis or pulmonary hypertension.
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A similar picture can be seen in hypokalemia (known as “pseudo p-
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pulmonale”).
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778. Automatic Implantable Cardioverter
Defibrillator, (AICD) implantation is done
for which of following conditions:
a) Brugada syndrome
b) Ventricular fibrillation
c) Acute coronary syndrome with low EF
d) All of the above
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Correct Answer - D
r.c
Answer: D. All of the above
An Automatic Implantable Cardioverter Defibrillator, (AICD), is a
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small electronic device that is implanted into your chest to monitor
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and correct an abnormal heart rhythm, or arrhythmia. These devices
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are used to treat serious and life-threatening arrhythmias and are
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the most effective way of doing so.
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Brugadasyndrome is a condition that causes a disruption of the
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heart's normal rhythm.
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Ventricular fibrillation is a heart rhythm problem that occurs when
the heart beats with rapid, erratic electrical impulse.
Acute coronary syndrome is a term used to describe a range of
conditions associated with sudden, reduced blood flow to the heart.
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779. What is the line of treatment for
intractable Sydenham chorea?
a) Haloperidol
b) Valproate
c) Warfarin
d) Risperidone
Correct Answer - B
Answer: B. Valproate
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Sydenham's chorea (SC) / Chorea minor / Rheumatic chorea
(RC) / St. Vitus’ s Dance
r.c
Major diagnostic criteria for rheumatic disease
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Most common acquired chorea during childhood
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Characterized by rapid, uncoordinated jerking movements primarily
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affecting the face, hands and feet
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Benzodiazepines facilitate the action of GABA and valproate
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enhances the action on GABA, hence these agents are used to treat
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chorea
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780. Neurofibromatosis 1 criteria except
a) Brain tumor
b) Acoustic neuromas
c) Pseudoarthrosis
d) Cafe-au-lait spots
Correct Answer - B
Answer: B - Acoustic neuromas
Clinical diagnosis requires presence of at least 2 of 7 criteria to
confirm presence of neurofibromatosis, type 1.
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Despite suspicion, most signs do not appear until late childhood /
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adolescent
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The 7 clinical criteria used to diagnose NF1 are as follows:
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Six or more café-au-lait spots / hyperpigmented macules greater
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than or equal to 5 mm in diameter in prepubertal children & 15 mm
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postpubertal
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Axillary or inguinal freckles (>2)
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Two or more typical neurofibromas or one plexiform neurofibroma
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Optic nerve glioma
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Two or more iris hamartomas (Lisch nodules) (often identified only
through slit-lamp examination)
Sphenoid dysplasia or typical long-bone abnormalities such as
pseudarthrosis
Strong family history (1st degree relative with NF1)
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781. Most common site of chronic gastric
ulcer
a) Pyloric antrum
b) Upper part of lesser curvature
c) Lower part of lesser curvature
d) Segment of large intestine
Correct Answer - A
Answer: A - Pyloric antrum
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A major causative factor (60% of gastric& up to 50–75% of
duodenal ulcers) is chronic inflammation due to Helicobacter
r.c
pylori that colonizes the antral mucosa.
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782. Approximate time interval between HIV
infection & manifestation of AIDS is?
a) 7.5 yr
b) 10 yr
c) 12 yr
d) 11 yr
Correct Answer - B
Answer: B - 10 years
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The approximate time frame required for incubation is usually 10
years.
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median time from infection to the development of AIDS in adults is
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about 9 years. A small proportion of untreated HIV-infected people
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are long-term non-progressors, with CD4 counts in the reference
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range for 10 years or more. Some long-term non-progressors have
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undetectable viral loads and are known as ‘elite controllers’.
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783. Heller's myotomy is done for
a) Zenker's diverticulum
b) Achalasia cardia
c) Bunions
d) Knee arthroscopy
Correct Answer - B
Answer: B - Achalasia cardia
Achalasia, a disorder of esophagus characterized by progressive
inability to swallow solids & liquids.
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Causes include weakened esophageal muscles & issues with lower
r.c
esophageal sphincter relaxation
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Heller Myotomy, surgical procedure offers long term symptomatic
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relief to these patients.
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It involves weakening of muscles at gastroesophageal junction,
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allowing the valve between oesophagus & stomach to remain open.
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784. Myocardial stunning pattern not
matching the ECG. What is the
diagnosis.
a) Takotsubo cardiomyopathy
b) Restrictive cardiomyopathy
c) Brigade's cardiomyopathy
d) Pericardial something
Correct Answer - A
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Answer: A -Takotsubo cardiomyopathy
r.c
“Myocardial Stunning” is a state where certain segments of
myocardium (corresponding to area of major coronary
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occlusion) shows forms of contractile abnormality.
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A segmental dysfunction persisting for a variable period of time,
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about two weeks, even after ischemia has been relieved (by for
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instance angioplasty or coronary artery bypass surgery).
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Takotsubo cardiomyopathy / Takotsubo syndrome, a temporary
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condition where your heart muscle becomes suddenly weakened or
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'stunned'.
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785. Alternative drug for cardiac arrest in
place of epinephrine is?
a) Amiodarone infusion
b) Atropine
c) High dose vasopressin
d) Adenosine
Correct Answer - C
Answer: C - High dose vasopressin
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Vasopressin is an alternative vasopressor at high doses, causes
vasoconstriction by directly stimulating smooth muscle V1
r.c
receptors.
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American Heart Association (AHA) guidelines states “Vasopressin is
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a reasonable first-line vasopressor in patients with ventricular
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fibrillation or pulseless ventricular tachycardia. Additionally, the
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guidelines comment that one dose of vasopressin 40 U may replace
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the first or second dose of epinephrine in all pulseless sudden
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cardiac arrest scenarios, including asystole and pulseless electrical
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activity.
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786. Patient presenting with cutaneous
vasculitis, glomerulonephritis, peripheral
neuropathy, Which investigation is to be
performed next that will help you
diagnose the condition?
a) ANCA
b) RA factor
c) Hbsag
d) MIF
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r.c
Correct Answer - A
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Answer: A - ANCA
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Anti-neutrophil cytoplasmic antibodies (ANCAs):
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Group of autoantibodies
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IgG type mainly,
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Produced against antigens in cytoplasm of neutrophil granulocytes &
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monocytes.
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Particularly associated with systemic vasculitis, so called “ANCA-
associated vasculitis”.
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787. Cryoglobulinemia
a) Hepatitis c
b) Ovarian cancer
c) Diabetes
d) Leukemia
Correct Answer - A
Answer: A. Hepatitis C
Cryoglobulinemia / Cryoglobulinemic disease with large amounts of
cryoglobulins in blood
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Cryoglobulins are proteins (mostly immunoglobulins themselves)
r.c
Become insoluble at reduced temperatures.
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Mixtures of monoclonal or polyclonal IgM, IgG, and/or IgA & blood
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complement proteins like C4 are associated with cases of infectious
tR
diseases, particularly Hepatitis C infection,
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788. Causes of hypokalemic metabolic
alkalosis with hypertension
a) Liddle syndrome
b) Bartter syndrome
c) Gitelman syndrome
d) Renal tubular acidosis
Correct Answer - A
Answer: A. Liddle syndrome
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Liddle syndrome - Rare hereditary disorder
Increased activity of the epithelial sodium channel (E-Na Ch)
r.c
Activating kidneys to excrete potassium retaining excessive sodium
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& water, leading to hypertension.
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789. Gold criteria for very severe COPD
a) Fev1/Fvc <70 and Fev1 < 30
b) Fev1/Fvc <70 and Fev1 < 70
c) Fev1/Fvc <70 and Fev1 < 50
d) Both A and C
Correct Answer - A
Answer: A. Fev1/Fvc <70 and Fev1 < 30
COPD should be considered in any patient who has dyspnea,
chronic cough or sputum production, and/or a history of exposure to
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risk factors for the disease.
r.c
Spirometry is required to make the diagnosis.
ke
Presence of post-bronchodilator FEV1/FVC < 0.70 confirms the
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presence of persistent airflow limitation.
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Stage IV / Very Severe COPD
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Severe airflow limitation (FEV1/FVC < 70%; FEV1 <. 30% predicted)
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or FEV1 < 50% predicted plus chronic respiratory failure.
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Patients may have Very Severe (Stage IV)COPD even if FEV1 is >
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30% predicted.
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790. ABPI increases artificially in
a) Arteriosclerosis calcified arteries
b) Ischemic ulcers
c) Intermittent claudication
d) DVT
Correct Answer - A
Answer: A. Arteriosclerosis calcified arteries
The ankle-brachial pressure index (ABPI) / Ankle-Brachial index
(ABI):
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Ratio of blood pressure at ankle to blood pressure in upper arm
r.c
(brachium).
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Compared to arm, lower blood pressure in leg suggests blocked
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arteries due to peripheral artery disease (PAD).
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Ankle brachial pressure index (ABPI) is a method for the
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quantification of peripheral vascular disease that results from
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advanced atherosclerosis.
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791. Minimal dysfunction syndrome seen in
a) Dyslexia
b) ADHD
c) Mental subnormality
d) Down’s syndrome
Correct Answer - A
Answer: A. Dyslexia
Clinical feature of Minimal dysfunction syndrome includes dyslexia.
Minimal brain dysfunction:
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Neurodevelopmental disorder.
r.c
Characterized by evidences of immaturity involving control of
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activity, emotions, & behavior
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Specific learning disabilities involving the communicating skills
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needed in reading, writing, and mathematics.
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Inability to maintain attention & concentration
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Inability to skillfully blend the auditory & visual functions essential in
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language performance
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792. The earliest feature of 3rd cranial nerve
involvement in diabetes mellitus patient
is -
a) Normal light reflex
b) Abnormal light reflex
c) Normal light and accommodation reflex
d) Abnormal light and accommodation reflex
Correct Answer - A
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Answer: A. Normal light reflex
r.c
The oculomotor nerve is the third cranial nerve. It enters the orbit
via the superior orbital fissure and innervates muscles that enable
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most movements of the eye and that raise the eyelid. The nerve also
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contains fibers that innervate the muscles that enable pupillary
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constriction and accommodation (ability to focus on near objects as
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in reading). The oculomotor nerve is derived from the basal plate of
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the embryonic midbrain.In people with diabetes and older than 50
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years of age, an oculomotor nerve palsy occurs.
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793. Mobitz type 2 second degree AV block is
seen in all except:
a) Hypothyroidism
b) Coronary Artery Disease
c) Sarcoidosis
d) Cushing syndrome
Correct Answer - D
Ans: D. Cushing syndrome
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Delay or lack of conduction through the atrioventricular (AV) node
and below has multiple causes. Degenerative changes (eg, fibrosis,
r.c
calcification, or infiltration) are the most common cause of non-
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ischeamic AV block. Idiopathic fibrosis or calcification of the AV
an
conduction system, commonly seen in the elderly, can cause
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complete AV block.
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Causes of Mobitz type 2 second degree AV block are -
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Damage of the conduction system from coronary artery disease,
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valve surgery, myocardial infarction, myocarditis, infiltrative
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cardiomyopathies (sarcoidosis, hemochromatosis), myxedema,
Lyme disease, neuromuscular disease, and AV junction ablation [6]
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794. Which drug regimen is given in a
pregnant woman with HIV infection?
a) Tenofovir disoproxil fumarate with emtricitabine
b) Tenofovir disoproxil fumarate with lamivudine
c) Abacavir with lamivudine
d) All
Correct Answer - D
Ans. D. All
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Preferred Regimens for HIV Antiretroviral Therapy (ART) in
Pregnancy
r.c
Two-NRTI backbone
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Regimens include the following:
an
Tenofovir disoproxil fumarate with emtricitabine (TDF/FTC co-
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formulated) or tenofovir disoproxil fumarate with lamivudine (3TC)
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once daily (use with caution in renal insufficiency) or
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Abacavir with lamivudine (ABC/3TC) once daily (only if HLA-B5701–
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negative); avoid combination with ritonavir-boosted atazanavir if the
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pretreatment HIV viral load exceeds 100,000 copies/mL.
For women who have never taken HIV medicines, the preferred HIV
regimen should include two nucleoside reverse transcriptase
inhibitors (NRTIs) plus an integrase strand transfer inhibitor
(INSTI), a non-nucleoside reverse transcriptase inhibitor
(NNRTI), or a protease inhibitor (PI) with low-dose ritonavir (brand
name: Norvir).
The regimen generally should include at least one of the
following NRTIs that pass easily across the placenta:
abacavir (brand name: Ziagen)
emtricitabine (brand name: Emtriva)
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lamivudine (brand name: Epivir)
tenofovir disoproxil fumarate(brand name: Viread)
zidovudine (brand name: Retrovir)
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795. Nutcracker esophagus, the correct
statement is
a) There is extremely forceful peristaltic activity leading to
episodes of chest pain and dysphagia
b) There is no medical t/t available
c) Type of oesophageal Malignancy
d) None
Correct Answer - A
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Ans: A. There is extremely forceful peristaltic activity leading to
episodes of chest pain and dysphagia
r.c
NutCracker Oesophagus is a hypermotility disorder with high
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amplitude peristalsis. It is a condition in which extremely forceful
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peristaltic activity leads to episodic chest pain and dysphagia.
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Treatment is with nitrates or nifedipine.
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Ref. davidsons principles and practice 23rd edition page no.795
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796. Which of the following criteria is used to
assess the prognosis of the liver
condition as represented in the picture
below?
a) Child pugh score
b) Milan score
c) Meld score
d) Alvarado score
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Correct Answer - A
r.c
Ans: A. Child pugh score
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the liver condition as represented in the picture above demonstrates
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liver cirrhosis.
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Child-Pugh score (or the Child–Turcotte–Pugh score or Child
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Criteria) is used to assess the prognosis of chronic liver disease,
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mainly cirrhosis.
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It is now used to determine the prognosis, as well as the required
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strength of treatment and the necessity of liver transplantation.
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Factor 1 2 points 3 points
point
Total bilirubin <34 34-50 >50
(μmol/L)
Serum albumin >35 28-35 <28
(g/L)
PT INR <1.7 1.71-2.30 >2.30
Ascites None Mild Moderate to
Severe
Hepatic None Grade I-II (or suppressed Grade III-IV (or
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Hepatic None Grade I-II (or suppressed Grade III-IV (or
encephalopathy with medication) refractory)
Interpretation:
Points Class One year survival Two-year survival
5–6 A 100% 85%
7–9 B 81% 57%
10–15 C 45% 35%
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797. Sudden onset headache with neck
rigidity?
a) Intraparenchymal hemorrhage
b) Sah
c) Meningitis
d) None of the above
Correct Answer - B
Ans: b. Sah
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sudden onset of a severe headache (often described as "the worst
headache of my life")
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nausea and vomiting
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stiff neck
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sensitivity to light (photophobia)
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blurred or double vision
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loss of consciousness
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seizures
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798. Vegetation in mitral valve seen in which
condition
a) Libman sacks
b) Infective endocarditis
c) NBTE
d) Rheumatic fever
Correct Answer - B
Ans: B. Infective endocarditis
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Infective endocarditis is characterized by lesions, known as
vegetations, which is a mass of platelets, fibrin, microcolonies of
r.c
microorganisms, and scant inflammatory cells. In the subacute form
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of infective endocarditis, the vegetation may also include a center of
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granulomatous tissue, which may be fibrosed or calcified.
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799. Water hammer pulse is seen in
a) Aortic regurgitation
b) Mitral stenosis
c) Aortic stenosis
d) Left ventricular failure
Correct Answer - A
Ans: A. Aortic regurgitation
Water hammer pulse
It is a large bounding pulse, associated with an increased stroke
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volume of the left ventricle and a decrease in the peripheral
r.c
resistance, leading to wide pulse pressure.
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The pulse strikes the palpating finger with a rapid, forced jerk and
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quickly disappears.
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It is best felt in the radial artery with the patient's arm elevated.
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It is seen in aortic regurgitation.
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800. What will you do when 3 yrs old child
parents come to phc with fever, cough
since 5 days with chest indrawing
present under mnci classification
a) Give antipyretics only
b) Give antibiotics and follow up
c) Refer urgently to tertiary care
d) Give antibiotics and refer to tertiary care
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Correct Answer - D
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Ans: D. Give antibiotics and refer to tertiary care
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801. What poison will you detect in skeleton
even after emaciation
a) Lead
b) Arsenic
c) Mercury
d) Cadmium
Correct Answer - B
Ans: B. Arsenic
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Arsenic can be detected even in conflagrated human bones. Hence,
it is possible to detect poisoning by arsenic even when the body has
r.c
been burnt for a long time.
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FMT 2nd edition Page no. 184
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802. Ph7.2, HCO3 - (10 or 12), pco2-35 ,
metabolic acidosis due to
a) K+ excretion by the kidney
b) Co2 expiration by lungs
c) H+excretion by the kidney
d) Hco3 loss by kidney
Correct Answer - D
Ans: D. Hco3 loss by kidney
om
In the question, pH is decreased (acidosis) & pCO2 is decreased
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(Normal= 40-45 mm Hg).
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A decreased pCO2 will try to increase pH, hence it must be a
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secondary compensating mechanism.
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So, the primary mechanism causing the acid-base imbalance must
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be a decrease in serum bicarbonate concentration i.e. metabolic
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acidosis.
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803. Impaired function of Aquaporin results in
a) Liddel syndrome
b) Nephrogenic DI
c) Cystic fibrosis
d) Barter syndrome
Correct Answer - B
Ans: B. Nephrogenic DI
Aquaporins, also called water channels, are integral membrane
proteins from a larger family of major intrinsic proteins that
om
form pores in the membrane of biological cells, mainly facilitating the
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transport of water between cells.
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Genetic defects involving aquaporin genes have been associated
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with several human diseases including nephrogenic diabetes
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insipidus and neuromyelitis optica.
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804. The most common cause of death in SLE
in children
a) Lupus nephritis
b) Lupus cerebritis
c) Libman sacks endocarditis
d) Anemia and infections
Correct Answer - A
Ans: A. Lupus nephritis
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Major causes of death in pediatric SLE include :
1. Renal disease (lupus nephritis)
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2. Severe disease flare
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3. Infections
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805. A patient having multiple Gall stones and
shows 8 mm dilation and 4 stones in
CBD, best treatment modalities are –
a) Cholecystectomy with choledocholithotomy at the same setting
b) ESWL
c) Cholecystectomy and wait for ERCP
d) All
Correct Answer - A
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Ans: A. Cholecystectomy with choledocholithotomy done at the
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same sitting
Management of suspected or proven CBD stones associated with
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gall bladder stones
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For gallstones - laparoscopic cholecystectomy is the procedure of
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choice.
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For CBD stones two things can be done:
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1) If the surgeon is experienced in laparoscopic techniques of
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CBD stone removal then both cholecystectomy and
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choledocholithotomy are done in the same sitting.
CBD stones are first confirmed by an intraoperative cholangiogram
then the stones are removed laparoscopically via the cystic duct or
by choledochotomy.
2) If the surgeon is not experienced with laparoscopic methods of
CBD stone removal, preoperative endoscopic sphincterotomy with
stone removal and later laparoscopic cholecystectomy is done.
Laparoscopic cholecystectomy with choledocholithotomy in the
same sitting is the preferred technique (provided the surgeon is
experienced)
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But one must keep in mind here that
"for elderly, poor-risk patients with gallstones and CBD stones, some
have recommended ERCP and sphincterotomy as the sole
treatment, leaving gallbladder and stones in situ". - Maingot's 10/e
Usually the gallstones in these patients remain asymptomatic and if
the need arises can be managed by cholecystectomy
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806. Pulmonary plethora is seen with all
except:
a) TGS
b) Ebstein anomalies
c) Hypoplastic left heart syndrome
d) Double outlet right ventricle
Correct Answer - B
Ans: B. Ebstein anomalies
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Pulmonary plethora is seen in
TOF
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TA
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Ebstein's anomaly
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Pulmonary atresia
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807. Hemodynamically unstable patient with
SVT
a) IV IBUTILIDE
b) IV DILTIAZEM
c) CARDIOVERSION
d) Iv beta-blockers
Correct Answer - C
Ans: C. CARDIOVERSION
om
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808. A Female patient was on lithium for
bipolar disorder for 6 months.she fasted
for some days due to religious condition
and later presented with
seizures,tremors, confusion and
weakness. What investigations have to
be done to diagnose her condition
a) serum electrolytes
b) serum lithium
c) ECG
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d) MRI
r.c
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Correct Answer - B
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Ans: B. serum lithium
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Because of its effects on multiple body systems, including but not
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limited to renal, hematologic, and thyroid systems, appropriate
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baseline studies must precede the start of lithium therapy.
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The minimal tests to be done include serum creatinine, electrolytes,
thyroid function tests, and a complete blood count with differential.
Additionally, because of its cardiac effect, an ECG is indicated. Any
woman thought to be pregnant should have a pregnancy test.
Ref: Nurcombe B. (2008). Chapter 12. Diagnostic Formulation,
Treatment Planning, and Modes of Treatment in Children and
Adolescents. In M.H. Ebert, P.T. Loosen, B. Nurcombe, J.F.
Leckman (Eds), CURRENT Diagnosis & Treatment: Psychiatry, 2e.
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809. Lithium causes:
a) Hypokalemia
b) Hyperkalemia
c) Hypocalcemia
d) Hypercalcemia
Correct Answer - A
Ans: A. Hypokalemia
Side effects of lithium
1. Neurological: - Tremor is the commonest side effect of lithium. Other
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CNS side effects are giddiness, ataxia, motor incoordination,
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hyperreflexia, mental confusion, nystagmus.
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2. Renal: - Nephrogenic diabetes insipidus with polyuria & polydipsia.
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Amiloride is the DOC for Lithium induced nephrogenic DI.
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3. Cardiovascular: - Effects are similar to hypokalemia. The most
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common ECG change is T wave depression.
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4. Endocrine: - Goitre, hypothyroidism
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5. GIT: - Nausea, vomiting, diarrhea, metallic test, abdominal pain.
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6. Dermatological : - Acneiform eruptions, papular eruption,
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exacerbation of psoriasis.
7. Teratogenicity: - Ebstein's anomaly in the fetus.
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810. A 50-year-old man presents with
paresthesia. HB-6.8g/dl. Peripheral
smear shows macrocytosis and
neutrophils with hypersegmented
nuclei.endoscopy reveals atrophic
gastritis. a most probable diagnosis is
a) Folate deficiency
b) Vitamin B12 deficiency
c) Riboflavin deficiency
d) Iron deficiency
om
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Correct Answer - B
Ans: B. Vitamin B12 deficiency
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Macrocytosis and hyper segmented neutrophils on peripheral smear,
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poor absorption(Atrophic gastritis) suggest the diagnosis of B12
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deficiency.
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The presence of anemia (Hb= 6gm%) Macrocytosis (MCV=104) and
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decreased vitamin B12 levels (B12=60 pg/ml) suggests a diagnosis
of megaloblastic anemia due to vitamin B12 deficiency.
The patient in question thus has macrocytic anemia due to vitamin
B12 deficiency.
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811. All trans retinoic acid is used in the
treatment of tumour associated with
a) BCR-ABL
b) PML-RARA
c) CMYC
d) CEBPA
Correct Answer - B
Ans: B. PML-RARA
om
All-trans retinoic acid (ATRA) is an active metabolite of vitamin A
under the family retinoid.
r.c
Retinoids, through their cognate nuclear receptors, exert potent
ke
effects on cell growth, differentiation and apoptosis, and have
an
significant promise for cancer therapy and chemoprevention.
tR
Differentiation therapy with ATRA has marked a major advance and
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become the first choice drug in the treatment of acute promyelocytic
.F
leukemia (APL).
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All-trans retinoic Acid is used in the treatment for Acute
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Promyelocytic Leukemia (PML)
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812. Renal tubular acidosis with ABG value
pH = 7.24 P02=80; PaCO2= 36 Na = 131;
HCO3 = 14 Cl= 90; BE = -13 Glucose =
135 above ABG picture suggest –
a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis om
Correct Answer - C
r.c
Ans: C. Metabolic acidosis
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The given values have low pH, and low HCo3 Indicate metabolic
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acidosis
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PCO2 in lower normal range (normal value 35-45 mm/hg)
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813. Patient with pulmonary fibrosis. Which
antiarrhythmic drug should not be given
a) Amiodarone
b) Flecainide
c) Iv ibutilide
d) lidocaine
Correct Answer - A
Ans: A. Amiodarone
om
Amiodarone and its metabolites can produce lung damage directly
by a cytotoxic effect and indirectly by an immunological reaction.
r.c
The latter is supported by the finding of cytotoxic T cells in
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bronchoalveolar lavage (BAL) fluid from patients with diagnosed
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APT. Amiodarone may induce the production of toxic O2 radicals,
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which can directly damage cells
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814. A 42-year-old patient with obstructive
jaundice. Alp, Ggt, haptoglobin all
increased. The most likely cause is:
a) Alcohol
b) Lead
c) Chronic rf
d) None of the above
Correct Answer - A
om
Ans: A. Alcohol
r.c
An indicator that should make the clinician highly suspicious of
alcohol-related liver injury is AST: ALT ratio of 2:1 or more.
ke
Gamma-glutamyl transferase (GGT) is another sensitive but non-
an
specific marker for the hepatic injury which cannot be used solely to
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diagnose alcohol-related hepatic insult.
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Levels of GGT greater than twice the normal values in addition to
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AST:ALT ratio >2 strongly indicate alcohol-induced liver injury as
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well.
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815. The differentiating feature between IBS
and organic GI disease is:
a) Diarrhea
b) Stool calprotectin
c) Pain abdomen
d) Mucus in stools
Correct Answer - B
Ans: B. Stool calprotectin
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Both organic IBD and non-organic functional disorders like IBS
exhibit very similar symptoms researchers have identified several
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stool-based biomarkers to differentiate between IBD and IBS. These
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become especially crucial when taking the next step towards
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deciding how to manage the disease (e.g. therapeutic intervention,
tR
etc.). Those biomarkers include the following:
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Calprotectin
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Alpha-1 Antitrypsin
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Lysozyme
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Secretory IgA
Albumin
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816. Atient has fatigue. But not gaining
weight. Body was warm. Investigation
will show:
a) Low TSH with more t3 or t4
b) High TSH with normal t3 or t4
c) High TSH with euthyroid
d) Increased uptake of t3, but decrease t4
Correct Answer - A
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Ans: A. Low TSH with more t3 or t4
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817. Warming in Frost frostbite should be
done at what temperature:
a) 37 degree
b) 42 degree
c) 44 degree
d) 46 degree
Correct Answer - A
Ans: A. 37 degree
om
At temperature below freezing (dry-cold condition) frostbite occurs
the tissue freeze & ice crystals form in between the cells
r.c
Affected part should be warmed using water at 44 °is under
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Criticism, Warming should last about 20 minutes at a time, Intake of
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hot fluids promotes general rewarming
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818. Which of the following is not seen in
Pituitary apoplexy
a) Headache
b) Hypertension
c) Hypotension
d) Vomiting
Correct Answer - C
Ans: C. Hypotension
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Following are seen in Pituitary apoplexy
Severe hypoglycemia
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Severe headache (usually retro-orbital)
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Impaired consciousness
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Fever
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Visual disturbances (visual field defect, visual acuity)
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Ophthalmoplegia (ocular paresis) → Causing diplopia
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Hypotension & shock
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Nausea/vomiting
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Meningeal sign
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819. Loss of pain/temperature sensation on
ipsilateral face & C/L body due to
thrombosis in
a) PICA
b) Posterior cerebellar artery
c) Superior cerebellar artery
d) None of the above
Correct Answer - A
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Ans: A. PICA
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.Most cases result from ipsilateral vertebral artery occlusion;
occlusion of the posterior inferior cerebellar artery is responsible for
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it.
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Vessel occlusion that results in Lateral Medullary syndrome:
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Vertebral (most common)
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Posterior inferior cerebellar (2nd most common)
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Superior, middle or Inferior lateral medullary arteries
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Lateral medullary syndrome (Wallenberg syndrome):
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Vertigo
Numbness of ipsilateral face and contralateral limbs
Diplopia
Dysphagia
Dysarthria
Ataxia
Hoarseness
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820. All found in LVF except
a) Lung oligemia
b) Kerley b lines
c) Rales
d) Pedal edema
Correct Answer - A
Ans: A. Lung oligemia
Chest X-ray Features of Left ventricular failure:
Cardiomegaly
om
Kerley lines
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Prominent upper lobe veins
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Bat’s wings shadow
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Pleural effusion
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Kerley B line is due to interstitial edema.
irs
Prominent right descending pulmonary artery is seen in acute
.F
pulmonary embolism.
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821. A 25 years old lady with a history of fever
for 1 month presents with headache and
ataxia.Brain imaging shows dilated
ventricles and significant basal
exudates. Which of the following will be
the most likely CSF finding:
a) Lymphocytosis, Low Glucose, High protein
b) Lymphocytosis, Normal Glucose, High protein
c) Lymphocytosis, Low Glucose, Normal protein
d) Neutrophilia, Low glucose, Low Protein
om
r.c
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Correct Answer - A
Ans: A. (Lymphocytosis, Low Glucose, High protein)
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Presence of significant basal exudates, together with dilated
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ventricles (hydrocephalus) in a young female with
.F
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a prolonged history of fever and headache suggests a diagnosis of
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Tubercular Meningitis.
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Tubercular Meningitis is characterized by Lymphocytic Pleocytosis,
Low Glucose and High Protein within the CSF.
The pathological hallmark of Tubercular Meningitis is the
predominant involvement of basal cisterns that are observed by the
presence of basal inflammatory tissue exudate.
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