Question: Investigation of choice in clinical suspicion of stroke

After the clinical diagnosis of stroke is made, an orderly process of evaluation and treatment should follow. The first goal is to prevent or reverse brain injury. Attend to the patient's airway, breathing, and circulation (ABCs), and Treat hypoglycemia or hyperglycemia if identified. Perform an emergency noncontrast head CT scan to differentiate between ischemic stroke and hemorrhagic strokeRef: Harrison 19e pg: 2561


Question: Massive bleeding per rectum in a 70 yr old patient is due to

Hemorrhage from a colonic diveiculum is the most common cause of hematochezia in patients > 60years old.Most bleeds are self-limited and stop spontaneously with bowel rest. The lifetime risk of rebleeding is 25%.Acute uncomplicated diveiculitis characteristically presents with fever, anorexia, left lower quadrant pain and obstipation.A complicated diveicular disease is defined as a diveicular disease associated with an abscess or perforation and less commonly with a fistula.Barium enema or colonoscopy should not be performed in acute setting because of the higher risk of colonic perforation associated with insufflation or inseion of barium-based contrast material under pressure. (Ref: Harrison's 18/e p2502)


Question: Most common cause of hea block in infants is

Ans. is 'b' i.e., Surgery for congentital hea disease In children, the most common cause of permanent acquired complete AV block is surgery for congenital hea disease. Postsurgical completer atrioventricular block (A VB) is the most common cause for acquired AV block in children, resulting from trauma to the AV node at time of surgery (i.e., hemorrhage, ischemia, necrosis, inflammation, traumatic disruption). The second most common cause is congenital herat disease associated with complete AV block. Other etiologies of acquired AV block are often reversible and include : Digitalis and other drug intoxications. Viral myocarditis. Acute rheumatic fever, Lyme disease, and infectious mononucleosis.


Question: Brock's Syndrome is

Ans. is 'b' i.e., Middle Lobe Bronchiectasis Brock's Syndrome Right middle lobe bronchiectasis occurring as a late sequel ofprimaiy tuberculosis is known as Brock's syndrome or middle lobe syndrome. Brock's syndrome is believed to be caused by pressure of lymph nodes in primary tuberculosis on the middle lobe bronchus. It has been described as a typical outcome of hilar node involvement by tuberculosis in childhood. This term is also applied to recurrent atelectasis of the right middle lobe in the absence of endobronchial obstruction. Bronchiectasis develops after recurrent episodes of atelectasis and fibrosis


Question: According to the Glasgow Coma Scale (GCS), a verbal score of 1 indicates

. *Glasgow coma score -verbal (nonintubated). 5-oriented and talks 4-disoriented and talks 3-inappropriate words 2-incomprehensible words 1-no response. Ref Harrison20th edition pg 2677


Question: Shelf life of Platelets is

Shelf life of Platelets is < 5 days Cryoprecipitate is 2 years.


Question: Cause of dysphonia and hoarseness of voice includes

(A) Thiamine # WERNICKE-KORSAKOFF SYNDROME, which combines Wernicke encephalopathy and Korsakoff psychosis, occurs in some alcoholics who do not consume foods fortified with thiamin.> Wernicke encephalopathy consists of psychomotor slowing or apathy, nystagmus, ataxia, ophthalmoplegia, impaired consciousness, and, if untreated, coma and death. It probably results from severe acute deficiency superimposed on chronic deficiency.> Korsakoff psychosis consists of mental confusion, dysphonia, and confabulation with impaired memory of recent events. It probably results from chronic deficiency and may develop after repeated episodes of Wernicke encephalopathy.


Question: An elderly man with ataxic hemiparesis, diagnosis is

(A) Cerebellar hemorrhage # Ataxic hemiparesis> Fisher initially described and named this syndrome, and it consists of a combination of homolateral ataxia and crural paresis.> The usual clinical features include "weakness of the lower limb, especially the ankle and toes, and a Babinski sign, associated with striking dysmetria of the arm and leg on the same side".> Some of the patients also had transient paresthesias, with a stuttering course of symptoms noted. Fisher later renamed the syndrome "ataxic hemiparesis," meaning any combination of weakness and incoordination, out of proportion to weakness, on the same side of the body.> Ataxic hemiparesis occurs in as many as 18% of case series of lacunar infarctions.> Lesions that simultaneously interrupt pyramidal systems (weakness) and adjoining frontopontocerebellar systems (ataxia) produce ataxic hemiparesis. The corona radiata and the anterior limb of the internal capsule are common sites of injury.> Fisher reported 3 autopsied cases that showed contralateral lacunar infarcts in the upper basis pontis.> CT-based series of patients with ataxic hemiparesis have also shown lesions in the internal capsule (posterior limb), corona radiata, lentiform nucleus, and thalamus.> Overall, no distinct clinical features differentiate lacunar infarctions originating in the capsule from those in the pons.> In addition to small deep infarcts, larger anterior cerebral artery infarcts have been recognized as a cause of ataxic hemiparesis with leg-predominant weakness. Ataxic hemiparesis also has been described in several nonischemic lesions, particularly hemorrhages and tumors.> Overall, improvement occurs within days or weeks & occasionally, the hemiparesis improves and the ataxia remains.


Question: Most common cause of diffuse bronchiectasis is

(C) Cystic Fibrosis # DIFFUSE BRONCHIECTASIS develops most often in patients with genetic, immunologic, or anatomic defects that affect the airways. In developed countries, many cases appear initially to be idiopathic, probably partly because onset is so slow that the triggering problem cannot be identified by the time bronchiectasis is recognized.> With newer, improved genetic and immunologic testing, an increasing number of reports describe finding an etiology in these idiopathic cases after careful, systematic evaluation.> Cystic Fibrosis (CF) is the most common identified cause, and previously undiagnosed CF may account for up to 20% of idiopathic cases. Even heterozygous patients, who typically have no clinical manifestations of CF, may have an increased risk of bronchiectasis.> Immunodeficiencies such as common variable immunodeficiency (CVID) may also lead to diffuse disease, as may rare abnormalities in airway structure. Undernutrition and HIV infection also appear to increase risk.> Congenital defects in mucociliary clearance such as primary ciliary dyskinesia (PCD) syndromes may also be a cause, possibly also explaining some idiopathic cases.> Diffuse bronchiectasis sometimes complicates common autoimmune disorders, such as RAor Sjogren syndrome.> Allergic bronchopulmonary aspergillosis, a hypersensitivity reaction to Aspergillus spp. (Allergic Bronchopulmonary Aspergillosis (ABPA)) that occurs most commonly in people with asthma, but sometimes in patients with CF, can cause or contribute to bronchiectasis.> In developing countries, most cases are probably caused by TB, particularly in patients with impaired immune function due to undernutrition and HIV infection.> Focal bronchiectasis typically develops as a result of untreated pneumonia or obstruction (eg, due to foreign bodies, tumors, postsurgical changes, lymphadenopathy). Mycobacteria (tuberculous or nontuberculous) can both cause focal bronchiectasis and colonize the lungs of patients with bronchiectasis due to other disorders.


Question: Gerstmann syndrome occurs due to damage to

(A) Left inferior parietal region # Gerstmann's Syndrome is a combination of:1. Acalculia (impairment of simple arithmetic),2. Dysgraphia (impaired writing),3. Finger anomia (an inability to name individual fingers such as the index and thumb), &4. Right-left confusion (an inability to tell whether a hand, foot, or arm of the patient or examiner is on the right or left side of the body).> Diagnosis: it is important to establish that the finger and left-right naming deficits are not part of a more generalized anomia and that the patient is not otherwise aphasic.> Gerstmann's syndrome arises acutely & is commonly associated with damage to the inferior parietal lobule (especially the angular gyrus) in the left hemisphere.


Question: Lysosomal Storage disorders are associated with

(B) Loss of function # Lysosomal storage disorders (LSDs) are inherited diseases characterized by lysosomal storage and dysfunction.> Loss of lysosomal function is associated with severe neurodegeneration, which is the prominent pathological hallmark of LSDs.> Physical findings are disease-specific, and enzyme assays or genetic testing can be used to make a definitive diagnosis.


Question: Laminar necrosis and watershed infarcts are most suggestive of

Decreased brain perfusion may be generalized (global) or localized. Global ischemia results from generalized decreased blood flow, such as with shock, cardiac arrest, or hypoxic episodes (e.g., near drowning or carbon monoxide poisoning). Global hypoxia results in watershed (border zone) infarcts, which typically occur at the border of areas supplied by the anterior and middle cerebral aeries, and laminar necrosis, which is related to the sho, penetrating vessels originating from pial aeries. The Purkinje cells of the cerebellum and the pyramidal neurons of Sommer's sector in the hippocampus are paicularly sensitive to hypoxic episodes. Atherosclerosis, which predisposes to vascular thrombi and emboli, is related to regional ischemia. Hypeension damages parenchymal aeries and aerioles, producing small ischemic lesions (lacunar infarcts). Fat emboli, related to trauma of long bones, lodge in small capillaries to form petechiae. Venous sinus thrombosis is related to systemic dehydration, phlebitis, and sickle cell disease. Ref - Harrison's internal medicine 20e pg 1117, 2039-2040


Question: Lymph node metastasis is common in   a) Osteosarcoma  b) Fibrous histiocytoma  c) Angiosarcoma  d) Rhabdomyosarcoma


Question: Fulminant hepatitis is commonest with

In HDV, Fulminant viral hepatitis is 5-20%; HEV: 1-2%; HBV: 0.1-1%; HCV: 0.1%; HAV: 0.1%Reference: Harrison&;s Principles of Internal Medicine; 19th edition; Chapter 360; Acute Viral Hepatitis


Question: Loud S1 in mitral stenosis is seen in


Question: Treatment of choice for chronic ulcerative colitis is

In mild to moderate cases of ulcerative colitis, the combination of a once-daily oral and a topical 5-aminosalicylate preparation is effective. MOA of the drug is it modulate cytokine release from mucosa. Reference : Davidson, 23rd Edition, page no : 820.


Question: Spider neavi is a feature of

Spider naevi

Oral contraceptive loops
Chronic liver disease
Thyrotoxicosis.


Question: 'Shrinking lung' is a feature of

Shrinking lung syndrome (SLS) is a rare complication of systemic lupus erythematosus (SLE) characterized by unexplained dyspnea, a restrictive pattern on pulmonary function tests, and an elevated hemidiaphragm.. This disorder is seen primarily during the later stages of SLE Ref Davidson 23rd edition pg 533


Question: In an obese patient the most likely respiratory change is

Obesity hypoventilation syndrome is characterized by :

Obesity.
Hypoxemia.
Hyper carbia.
Respiratory acidosis.
Pulmonary hypertension.
Right ventricular failure.


Question: Most common extra articular manifestation seen in Ankylosing spondylitis

M/C extra articular manifestation - Acute anterior uveitis.


Question: The drug of choice for the treatment of Pneumocystis jirovei (Pneumocystis carini) pneumonia is

Pneumocystis jirovecii pneumonia is characterised by progressive dyspnoea with dry cough and fever.Chest X ray shows bilateral interstitial infiltrate spreading out from hilar regions.High resolution CT scan is more sensitive,showing 'ground-glass' interstitial infiltrates.Diagnosis is made with silver stains,PCR,immunofluorescence of bronchoalveolar lavage(BAL)/induced sputum.Treatment is with high dose co-trimoxazole;together with adjunctive steroids if the patient is hypoxic. Reference: Davidson edition23rd pg 584


Question: Most common manifestation of Multiple Sclerosis is

(C) Optic neuritis # MANIFESTATIONS OF MULTIPLE SCLEROSIS in the eye include both the afferent and efferent visual pathways. Optic neuritis, the most common ocular manifestation of multiple sclerosis, may be the initial clinical disease manifestation.MANIFESTATION OF MULTIPLE SCLEROSIS* Sensory loss37* Optic neuritis36* Weakness35* Paresthesias24* Diplopia15* Ataxia11


Question: Chinese herb nephropathy is caused by

Aristolochic acid causes Chinese herb nephropathy and Balkan nephropathy.


Question: Continuous murmur is present in

A continuous murmur is predicated on a pressure gradient that persists between two cardiac chambers or blood vessels across systole and diastole.The murmurs
typically begin in systole, envelop the second heart sound (S 2 ), and continue through some portion of diastole.
They can often be difficult to distinguish from individual systolic and diastolic murmurs in patients with mixed valvular heart disease.
The classic example of a continuous murmur is that associated with a patent ductus arteriosus, which usually is heard in the second or third interspace at a slight distance from the sternal border. Other causes of a continuous murmur include a ruptured sinus of Valsalva aneurysm with creation of an aortic–right atrial or right ventricular fistula, a coronary or great vessel arteriovenous fistula, and an arteriovenous fistula constructed to provide dialysis access.


Question: Test for confirming H.pylori eradication is

The test of choice for documenting of H. pylori eradication is the laboratory-based validated monoclonal stool antigen test or a urea breath test (UBT).The patient must be off antisecretory agents when being tested for the eradication of H. pylori with UBT or stool antigen. Serologic testing is not useful for the purpose of documenting eradication because antibody titers fall slowly and often do not become undetectable.Ref: Harrison; 19th edition; Page no: 1924


Question: Most commonly associated with Conn&;s syndrome

The most common cause of mineralocoicoid excess is primary aldosteronism bilateral micronodular hyperplasia some what more common than unilaterl adrenal adenoma( Ref Harrison 20 th edition)

Bilateral micronodular adrenal hyperplasia


Question: In pseudogout, material deposited is

Ans: d (calcium pyrophosphate) Ref: Harrison 17th ed/p.2167.In Pseudogout, calcium pyrophosphate is depositedIn Gout, Monosodium urate crystal is depositedAssociations of CPPD (calcium pyrophosphate dihvdrate) crystal deposition:-* Ageing (most common)* Osteoarthritis* Familial* Metabolic diseases-HaemochromatosisHyperparathyroidismHypophosphatasiaHypomagnesaemiaWilson's diseaseCompensated polarised light microscopy of synovial fluids:-Monosodium urate crystals - Bright birefringence (negative sign) and needle shaped morphologyCalcium pyrophosphate crystals - Weak birefringence (positive sign) and rhomboid morphology.Note:-o Osteoarthritis- involvement of PIP, DIP and 1st carpometacarpal joint (base of thumb). Sparing of MCP and wrist.o Rheumatoid arthritis - involvement of any small joints of the hand i.e PIP, MCP, and wrist. Sparing of DIP.o Psoriatic arthritis - involvement of PIP, DIP, MCP and wrist. Sparing of any joint may or may not be present.


Question: During ventricular pressure pulses square root wave is seen in

Ref Harrison 19 th ed pg 1576 constrictive pericarditis, the ventricular pressure pulses in both ventricles exhibit characteristic "square root" signs during diastole. These hemodynamic changes, although characteristic, are not pathognomonic of constrictive pericarditis and may also be observed in restrictive cardiomyopathies.


Question: Loud pulmonary component of second heart sound heard in  a) Pulmonary hypertension  b) TOF  c) Eissenmenger's syndrome  d) Pulmonary stenosis  e) AS


Question: Vegetations on undersurface of A.V. valves are found in

Ref: R Alagappan - Manual of Practical Medicine 4th Edition.pg no:163 Endocarditis associated with SLE (Libman-Sachs endocarditis): The vegetations are 3-4 mm in size, composed of degenerating valve tissue; functional disability is minimal; ventricular surface of the mitral valve is commonly involved; aoic valve involvement is rare; entire valve apparatus can be involved.


Question: Earliest clinical indicator of sodium loss is

Ans. a (Altered sensorium) (Ref. Harrison's - 18th/pg. Ch. 45).Hyponatremia may be due to water excess, diabetes, lipidemia etc. Drugs known to release ADH will cause dilutional hyponatremia include morphine, tricyclics, nicotine, NSAIDs, etc. The individual present with confusion, anorexia, lethargy and cramps. When sodium drops abruptly, seizures, hemiparesis and coma can develop.CLINICAL FEATURES OF HYPONATREMIA# The clinical manifestations of hyponatremia are related to osmotic water shift leading to increased ICF volume, specifically brain cell swelling or cerebral edema.# The symptoms are primarily neurologic.# Patients may be asymptomatic or complain of nausea and malaise.# As the plasma Na+ concentration falls, the symptoms progress to include headache, lethargy, confusion, and obtundation.# Stupor, seizures, and coma do not usually occur unless the plasma Na+ concentration falls acutely below 120 mmol/L or decreases rapidly.# Loss of Na+ and K+, followed by organic osmolytes, from brain cells decreases brain swelling due to secondary transcellular water shifts (from ICF to ECF).# The net effect is to minimize cerebral edema and its symptoms.Composition of World Health Organization Oral Rehydration Solution (ORS) A,BConstituentConcentration, mmol/LNa+90K+20Cl-80Citrate10Glucose110Also know:*SLADH is characterized by hypotonic hyponatremia with euvolemia. Low plasma osmolality (<280 mOsm/Kg) with high urine osmolality (>100-150 mOsm/Kg) in suspected patients is diagnostic.* Pneumonia, hyponatremia and diarrhea are almost classic for Legionella.* Under most physiologic conditions, sodium, urea, and glucose generate the osmotic pressure of blood. Plasma osmolality is calculated according to the following expression: Posm = 2Na+ + Glu + BUN (all in mmol/L), or, using conventional laboratory values in which glucose and BUN are expressed in milligrams per deciliter: Posm = 2Na+ + Glu/18 + BUN/2.8. The calculated and determined osmolality should agree within 10-15 mmol/kg H20. When the measured osmolality exceeds the calculated osmolality by >15-20 mmol/kg H20, one of two circumstances prevails. Either the serum sodium is spuriously low, as with hyperlipidemia or hyperproteinemia (pseudohyponatremia), or osmolytes other than sodium salts, glucose, or urea have accumulated in plasma.


Question: A 25 year male presented with nausea, vomiting, epigastric pain, Na+ level is 125 meq/L. Treatment start with

(Give hypotonic saline) (758- 61 - CMDT- 08) (277-79, 2223-2224-Hl7th)* Treatment consist of replacement of lost volume with isotonic or half normal (0.45%) saline or lactated Ringer *s infusion in hypovolemic Hypotonic Hyponatremia* Asymptomatic hyponatremia - water restriction, 0.9% saline Demeclocycline. Fludrocortisone, selective renal vasopressin V2 antagonists (conivaptan. Mozavaptan, tolvaptan)* Hypervolemic hypotonic hyponatremia - water restriction Diuretics and V2 antagonists. Hypertonic (3%) saline


Question: Hepatitis C virus is associated with

Polyarteritis nodosa - Hepatitis B associated.
Cryoglobulinemic Vasculitis - Hepatitis C associated.


Question: Venous thrombosis In patients with paroxysmal nocturnal hemoglobinuria is observed in

Answer- C. Intrabdominal veinsVenous thrombosis is an inconstant but severe clinical manifestation of P.N.H.Thrombosis occcurs due to absence of CD59 which k a membrane attached proteinThrombosis usually occurs in abdominal veins. Intra-abdominal yeins are the most common site of thromosis in P.N.H.


Question: Most commonly involved organ in congenital tuberculosis is

Ans. Answer is B (Liver): Most common primary site- LIVER (primary complex in liver is suggestive of congenital TB) Most common site is- LUNG The form of disease is usually miliary with multiple organ involvement. Lungs are involved in almost all cases. Other sites frequently involved are liver, spleen, lymph nodes, the gastrointestinal tract and kidney'. -Textbook of Pulmonary Medicine by Behera 2"a/495


Question: Shelf life of blood in a blood bank in CPDA buffer

Answer- C. 35 daysCitrate phosphate dextrose-adenine (CPD-A )- 35 days


Question: Rupture of a berry aneurysm of the Circle of Willis would likely produce hemorrhage into the

Subarachnoid hemorrhage is much less common than hypeensive intracerebral hemorrhage, and most often it results from rupture of a berry aneurysm. Berry aneurysms are saccular aneurysms that result from congenital defects in the media of aeries. They are typically located at the bifurcations of aeries. They are not the result of atherosclerosis. Instead, berry aneurysms are called congenital, although the aneurysm itself is not present at bih. Berry aneurysms are most commonly found in the circle of Willis, typically either at the junction of the anterior communicating aery with the anterior cerebral aery or at the junction of the middle cerebral aery and the posterior communicating aery. The chance of rupture of berry aneurysms increases with age (rupture is rare in childhood). Rupture causes marked bleeding into the subarachnoid space and produces severe headaches, typically described as the "worst headache ever." Additional symptoms include vomiting, pain and stiffness of the neck (due to meningeal irritation caused by the blood), and papilledema. Death may follow rapidly. Ref - Harrison's internal medicine 20e pg 2073, 2084-2085


Question: Drug used in Acute Intermittent Porphyria is

(A) Opioids# A high-carbohydrate (10% glucose) infusion is recommended, which may aid in recovery.> If drugs have caused the attack, discontinuing the offending substances is essential.> Infection is one of the top causes of attacks and requires vigorous treatment.> Pain is extremely severe and almost always requires the use of opiates to reduce it to tolerable levels.> Pain should be treated early as medically possible due to its severity.> Nausea can be severe; it may respond to phenothiazine drugs but is sometimes intractable.> Hot water baths or showers may lessen nausea temporarily, but can present a risk of burns or falls.


Question: "Face of giant panda" sign on MRI brain is seen in

The "Face of the Giant Panda" sign, "Panda Sign of the Midbrain," or "Double-Panda Sign" refers to a characteristic "panda's face" appearance in MRI images of patients suffering from Wilson's disease. Along with Kayser-Fleischer rings, the sign is helpful in diagnosis ref - Researchgate.net


Question: Value of Pa02/ Fi02 chracteristic of ARDS is

Answer- A. < 200 mmHgAcute respiratory distress syndrome (ARDS) is a clinical symdrome of severe dyspnea of rapid onset, hypoxemia, and diffirse pulmonary infiltrates leading to respiratory failure.The aerial PaO, (in mmHg)/FiO, (inspiratory O, fraction) <200 mmHg is characteristic of ARDS, while a PaO, /FiO, between 200 and 300 identifies patients with ALI who are likely to benefit from aggressive therapy.


Question: An ophthalmoplegic migraine means

Ophthalmoplegic migraine is characterized by recurrent attacks of ophthalmoplegia, following severe migrainous headaches. The condition almost always begins in childhood, and is considered to be rare in adults. However, OM may occur for the first time in adult life. The typical clinical picture of OM includes a child with severe migraine that lasts for several days and is followed soon after, by ptosis and diplopia due to isolated oculomotor nerve palsy, as the headache remits. Pupillary involvement with a 'full blown' pupil is the rule in children.However, pupillary sparing is not uncommon, especially in adults. Abducens nerve involvement is uncommon and trochlear nerve palsy is rare. Recovery is the rule. Rarely, deficits persist after multiple attacks. ref - pubmed.com

When headache is followed by complete paralysis of the III rd and VI nerve on the same side as the hemicrania.

When the headache is followed by paial paralysis of the IIIrd nerve on the same side as the hemicrania with out any scotoma.

Headache associated with IIIrd, IVth and VIth nerve paralysis.


Question: ADAM TSB.13 deficiency is seen in

Answer- A. TTPTTP is included among group of diseases called thrombotic microangiopathic which are characterised by widespread thrombosis in microcirculation. The other disorder which is included in this group include hemolytic uremic syndrome (HUS)Small vessels like terminal aerioles and capillaries are involved.Pathogenesis of TTPPatients with TTP are deficient in an enzyme called ADAMTSB.T3 also known as vWF metalloprotease that degrades very high molecular weight multitimers of vWF.


Question: Followings are the symptoms of carcinoid symptoms  a) Wheezing  b) Flushing  c) Cyanosis  d) Clubbing  e) Diarrhoea


Question: Best diagnostic modality for rotavirus diarrhea


Question: Type B Lactic acidosis is due to

Lactic Acidosis:An increase in plasma l-lactate may be secondary to poor tissue perfusion (type A)--circulatory insufficiency (shock, cardiac failure), severe anemia, mitochondrial enzyme defects, and inhibitors (carbon monoxide, cyanide)--or to aerobic disorders (type B)-- malignancies, nucleoside analogue reverse transcriptase inhibitors in HIV, diabetes mellitus, renal or hepatic failure, thiamine deficiency, severe infections (cholera, malaria), seizures, or drugs/toxins (biguanides, ethanol, methanol, propylene glycol, isoniazid, and fructose).Reference: Harrison&;s Principles of Internal Medicine; 19th edition; Chapter 66; Acidosis and Alkalosis


Question: Most common cause of Cushing syndrome is

Steroid supplementation is the most common cause of question syndrome.


Question: A 35 years old man Ramu has fasting and post prandial blood sugar within normal limit but urine sugar is 3 plus (+++)* The diagnosis is.

Ans. is 'a' Renal Glycosuria. /Reference Harrison 15/e p 2315]Patient is excreting Glucose at normal blood glucose concentration. This feature is characteristics of renal glycosuria."It is characterized by urinary excretion of Glucose at normal concentrations of blood glucose"The condition is benign but occasionally glycosuria may be severe enough to cause polyuria and polydipsia.

High carbohydrate diet taken in the morning.

Diabites & Inappropriate Antidiuretic Hormone


Question: One of the following conditions is not associated with clubbing.


Question: Tumors most amenable (cured with) to chemotherapy.

Treatment of low-risk gestational trophoblastic neoplasia (GTN) (invasive mole or choriocarcinoma) may include the following: Chemotherapy with one or more anticancer drugs. Treatment is given until the beta human chorionic gonadotropin (b-hCG) level is normal for at least 3 weeks after treatment ends Ref Harrison 20th edition pg 540


Question: Choose the best Lab value for a patient with central diabetes insipidus

Diabetes insipidus is the reverse of SIADH, here the ADH level is decreased which leads to excessive water loss from the kidney resulting in hypertonic plasma associated with dilute urine.
It can be

- Central     → (due to impaired secretion of ADH from the neurohypophysis)
- Nephrogenic →   (due to renal insensitivity or nonresponsiveness to ADH).

In both circumstances. the serum osnzolality is increased with inappropriately low urine osmolalitv.
The two may be distinguished, however, by the response to either exogenous or endogenous vasopressin.
In neurogenic (central) DI,

- ADH levels are 100, and the kidney rapidly acts to conserve water once exogenous ADH is administered.

In contrast, in nephrogenic DI,

- ADH is associated with normal or increased ADHe levels and administration of additional ADH has no significant effect on renal water reabsorption.
Also known

Urinary Osmolality - 50, Serum Osmolality - 300

Urinary Osmolality - 500, Serum Osmolality - 260

Urinary Osmolality - 50, Serum Osmolality - 260

Urinary Osmolality - 500, Serum Osmolality - 100


Question: For the following causes of sexual dysfunction, select the most likely clinical feature.Rarely indicates organic disease.

An absent orgasm, when libido and erectile function are normal, invariably indicates that organic disease is absent. Loss of desire can also be caused by psychologic disturbance, but may indicate androgen deficiency or drug effect.

failure of erection with absent nocturnal penile tumescence (NPT)

absence of orgasm with normal libido and erectile function


Question: Commonest organism causing acute epiglotitis is


Question: Sarcoidosis

Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology that is characterised by the presence of non-caseating granulomas . The condition is more frequentlydescribed in colder pas of nohern Europe .The tendency for sarcoid to present in the spring and summer has led to speculation about the role of infective agents, including mycobacteria, propionibacteria and viruses, but the cause remains elusive. Genetic susceptibility is suppoed by familial clustering; a range of class II HLA alleles confer protection from, or susceptibility to, the condition. Sarcoidosis occurs less frequently in smokers. It may be associated with common variable immunodeficiency .Bilateral hilar lymphadenopathy (BHL) is often seen in young women .Alternatively, BHL may be detected in an otherwise asymptomatic individual undergoing a chest X-ray for other purposes. Ref - Davidsons 23e p630

Produces bilateral hilar lymphadenopathies in the absence of pulmonary symptoms


Question: Lung volume reduction surgery is used in the management of

Lung volume reduction surgery (LVRS) reduce volume of lung in emphysema. Patients with upper lobe-predominant emphysema and a low post-rehabilitation exercise capacity are most likely to benefit from LVRS. Patients are excluded if they have significant pleural disease, a pulmonary aery systolic pressure >45 mmHg, extreme deconditioning, congestive hea failure, or other severe comorbid conditions. Patients with an FEV1 <20% of predicted and either diffusely distributed emphysema on CT scan or diffusing capacity of lung for carbon monoxide (DlCO) <20% of predicted have an increased moality rate after the procedure and thus are not candidates for LVRS.Ref: Harrison 19e pg: 1706


Question: The minimum concentration of reduced hemoglobin required for cyanosis is

Cyanosis refers to a bluish colour of the skin and mucous membranes resulting from an increased quantity of reduced hemoglobin, or of hemoglobin derivatives, in the small blood vessels of those areas. It is usually most marked in the lips, nail beds, ears, and malar eminences.
The degree of cyanosis is modified by the colour of the cutaneous pigment and the thickness of the skin, as well as by the state of the cutaneous capillaries.
In some instances, central cyanosis can be detected reliably when the SaO2 has fallen to 85%; in others, particularly in dark-skinned persons, it may not be detected until it has declined to 75%.
The increase in the quantity of reduced hemoglobin in the mucocutaneous vessels that produces cyanosis may be brought about either by an increase in the quantity of venous blood as a result of dilation of the venules and venous ends of the capillaries or by a reduction in the Sa in the capillary blood. In sulhaemoglobmemia cyanosis occurs when its level exceeds 0.5gm/dl A methemogiobm level of 15% (i.e.,1.5gm/dl) 3 is associated with visible cyanosis-Nelson


Question: Most common cause of decrease in incidence of H.pylori in the western countries is due to


Question: The Most sensitive marker of cardiac injury is

(D) Troponin # Plasma biochemical markers: The biochemical markers that are most widely used in the detection of Ml are creatine kinase (CK), a most sensitive and cardiospecific isoform of this enzyme (CK-MB), and the cardiospecific proteins, troponins T and I.> The troponins are also released, to a minor degree, in unstable angina with minimal myocardial damage.


Question: The agent of choice for controlling heparin induced bleeding is


Question:
Carney triad consists of.
(A)Gastric carcinoma
(B)Paraganglioma
(C)Pulmonary Chordoma
(D)Carcinoma bronchus
(E)Chondromatosis

Gastric GIST Paraganglioma Pulmonary chondroma
"It describes the coexistence of several neoplasms, mainly in young women, including:
gastric epithelioid leiomyosarcoma (these are now known to actually be malignant gastrointestinal stromal tumours), pulmonary chondroma, and extra-adrenal paraganglioma"
Also Know: “Carney complex, also known as LAMB syndrome and NAME syndrome is an autosomal dominant condition comprising myxomas of the heart and skin, hyperpigmentation of the skin (lentiginosis), and endocrine overactivity.
It is distinct from Carney's triad. Approximately 7% of all cardiac myxomas are associated with Carney complex"


Question: American Heart Association standard pediatric dose of amoxicillin for antibiotic prophylaxis, in cases of endocarditis is


Question: Reversible myocardial stunning with ecg changes of acute myocardial infarction  is seen in

Takatsubo cardiomyopathy is stress induced infundibular spasm resulting in LV hypokinesia . ECG shows ST elevation


Question: V wave in left atrium is higher than in right atrium becasuse

Left atrial waveform is very similar to right atrium however a wave and v wave are larger because of lower compliance in left atrium v wave represents the passive filling of atria.

Left atrium good compliance with pulmonary vein

Something due to poor transit through lung for atrium


Question: Mast cell stabilizer used in ronchial Asthma is


Question: Dysmetria is due to lesion of

Answer is D (Cerebllum): Dysmetria is a typical feature of cerebellar dysfunction / disease. Dysmetria refers to errors in judging distance and gauging the distance, speed, power and direction of movement. It refers to inaccuracy of movement in which the desired target is either unde- reached (hypometria) or over-reached (hypermetria). Dysmetia is feature of cerebellar disease / dysfunction and is evident on finger chase' or 'toe to finger' tests. Features of Cerebellar Disease / Dysfunction Dysmetria (Inaccuracy of movement, disturbance of rate, range & force of movement) Dysahria (Ataxic dysahria results from disruption of timing, force, range and direction of movement needed to maintain normal aiculation) Ataxia (unsteady to stand or sit without suppo) Incoordination Pastpointing Intention tremor (Inability to coordinate fine motor activity) Dysdiadokinesia (Inability to perform rapid lternating movements) Hypotonia Cerebellar Nystagmus


Question: Infliximab is contraindicated in

(B) Intestinal tuberculosis # Infliximab is a drug used to treat autoimmune disorders.> Infliximab is known as a "chimeric monoclonal antibody" (the term "chimeric" refers to the use of both mouse (murine) and human components of the drug i.e. murine binding Fab domains and human constant Fc domains).> Case studies have been done into other uses of infliximab, such as to treat skin diseases.> Infliximab has been approved for treating ankylosing spondylitis, Crohn's disease, fistulizing Crohn's disease, pediatric Crohn's disease, psoriatic arthritis, psoriasis, rheumatoid arthritis, and ulcerative colitis.> Infliximab is also prescribed (out of indication) for the treatment of Behcet's disease and infusions of infliximab have been used successfully in the treatment of sciatica due to slipped discs


Question: An 18 year old boy while riding a motorbike without a helmet sustained a road traffic accident. He is brought to casualty and imaging studies done. He is diagnosed with left frontal skull fracture and cortical contusion. He has had no seizures and his GCS is 10. Antiepileptic drug therapy in this patient

Prophylactic phenytoin reduces incidence of seizures after head injury, though there is no reduction in long term risk

Indicated to reduce incidence of early onset post traumatic seizures

Is likely to cause increased cerebral edema

Indicated to reduce incidence of late onset post traumatic seizures


Question: Range of current used by biphasic defibrillator

Modern units deliver a biphasic shock, during which shock polarity is reversed mid-shock. This reduces the total energy required to depolarise the hea. The energy of first and second shocks should be 150joules and thereafter up to 200joules. Reference Harrison 20th edition pg 1576


Question: A 24 year old male presents with abdominal pain, rashes, palpable purpura and, ahritis. The most probable diagnosis is.

Answer is A (Henoch Schonlein Purpura) Palpable Purpura (most commonly distributed over the buttocks and lower extremities), ahralgias, and abdominal pain are all charachteristic features of Henoch-Schonlein purpura. Although H.S purpura is usually seen in a children and most patients range in age from 4-7 years, Harrisons text clearly mentions that this condition may also be seen in infants and adults. The charachteristic clinical manifestation of palpable purpura, ahralgia and abdominal pain in this young adult suggest the diagnosis of H-S purpura. Henoch Schonlein Purpura : Anaphylactoid Purpura : Review What is H. S. Purpura? H. S. Purpura is a vasculitis of small vesselsdeg The pathogenic mechanism for this vasculitis is iminune complex depositiondeg The most common class of antibodies seen in immune complexes of H.S purpura is IgAQ How does H. S. Purpura Present? Vasculitis Vasculitis of Skin Vasculitis of Toints Vasculitis of Gastrointesinal Vasculitis of (cutaneous) (Ahralgias) tract kidney Palpable purpura * Polyahralgiase in absence Colicky Abdominal paine is Mild glomerulonephritis2 Most commonly distributed over the of frank ahritis (Non deforming in nature) the most charachteristic manifestation . leading to proteinuria, microscopic haematuriaQ and buttocks and lower * Mainly involves large joints Other manifestations.. RBC cast in urine are the extremity of the lower extremity * Passage of blood & mucus charachteristic renal * Joint involvement is often migratory per rectum * Nausea/vomiting manifestation * Diarrhea / constipation


Question: A patient presents with Microcytic Hypochromic anemia. Serum iron levels and TIBC are decreased. Likely diagnosis is

Answer is B (Anemia of chronic disease) Hypochromic microcytic anemia with decreased serum iron and decreased TIBC is characteristic of anemia of chronic disease. Hypochromic microcytic anemia with 4.serum iron and TTIBC: iron Deficeincy Anemia Hypochromic microcytic anemia with fserum iron and TIBC : Anemia of Chronic disease Condition Iron deficiency Thalassemia Sideroblastic anemia Anemia of chronic disease Test (normal values) Serum iron Low (<30) Normal Normal ,l, (<50) (50-15014/d1) TIBC High (>360) Normal Normal ,l, (<300) (300-600 ug/dl) (Chandrasoma Taylor)


Question: Adenosine deaminase (enzyme) deficiency is associated with

Ten to 20% of SCID patients exhibit a deficiency in adenosine deaminase (ADA), an enzyme of purinemetabolism that deaminates adenosine (ado) and deoxyadenosine(dAdo). An ADA deficiency results in the accumulation of ado and dAdo metabolites that induce premature cell death of lymphocyte progenitors. The condition results in the absence of B and NK lymphocytesas well as T cells. The clinical expression of complete ADA deficiencytypically occurs very early in life. Since ADA is a ubiquitous enzyme,its deficiency can also cause bone dysplasia with abnormal costochondral junctions and metaphyses (found in 50% of cases) and neurologicdefects. The very rare purine nucleoside phosphorylase (PNP) deficiency causes a profound although incomplete T cell deficiency that isoften associated with severe neurologic impairments Ref - Harrison's internal medicine 20e pg 2392-2493

Transient hypogammaglobulinemia of infancy


Question: Total iron binding capacity is increased in

Iron deficiency anaemia.
Serum  ↓.
Serum ferritin ↓.
TIBC ↑.


Question: Kussumaul's sign is most commonly seen in


Question: A 40 years old female is came in the depament by describing "1 have worst headache of my life". The investigation of choice for this patient

Answer- B. Computed tomography (CT)It is a case of "acute subarachnoid hemorrhage".The explosive onset of severe, excruciating headache is a common feature of subarachnoid haemonhage (SAH).Diagnosis of Subarachnoid hemorrhageThe hallmark of aneurysmal rupture is blood in the cerebrospinalfluid.More than 95% cases have enough blood to be visualized on a high quality non contract CT scan obtained within 72h.MRI can also be used to diagnose subarachnoid hemorrhage but CT is more sensitive than MRI for acute blood


Question: Not a cause of hypernatremia

Ans. is 'b' i.e., Decreased insensible losses Major causes of hypernatremia Unreplaced water loss (which requires an impairment in either thirst or access to water) Insensible and sweat losses Gastrointestinal losses Central or nephrogenic diabetes insipidus Osmotic diuresis Glucose in uncontrolled diabetes mellitus Urea in high-protein tube feedings Mannitol Hypothalamic lesions impairing thirst or osmoreceptor function Primary hypodipsia Reset osmostat in mineralocoicoid excess Water loss into cells Severe exercise or seizures Sodioum overload Intake or administration of hypeonic sodium solutions


Question: Drug of choice for Mycoplasma pneumoniae is


Question: Nicotine dependence

(B) Physical dependence < psychic dependence PSYCHOACTIVE SUBSTANCE USE DISORDERSDrugUsual Route of AdministrationPhysical DependencePsychic DependenceTolerance1. AlcoholOral+ ++ ++2. OpioidsOral, Parental, Smoking+ + ++ + ++ + +3. Cannabis (Marihuana)Smoking Oral++ ++4. CocaineInhalation, Oral, Smoking Parental++ +--5. AmphetaminesOral, Parental+ ++ ++ + +6. Lysergic acidOral-++7. BarbituratesOral, Parental+ ++ ++ + +8. BenzodiazepinesOral, Parental+++9. Volatile solventsInhalation++ ++10. Phencyclidine (PCP)Smoking, Inhalation, Parental, Ora!+++11. CaffeineOral++ ++12. NicotineOral, Smoking++ ++-- = None; + = Probable/Little; + = Some / Mild; ++ = Moderate; +++ = Severe.

Physical dependence > psychic dependence

Physical dependence = psychic dependence


Question: In leprous neuritis, there is  a) Intracutaneous thickening of the nerve  b) Facial palsy  c) Occurs in warm and moist areas  d) Palpable peripheral nerves are present  e) > 10 lesions may be found


Question: Kerley B lines are due to

Pulmonary oedema is usually caused by a heart condition. Other causes include pneumonia, exposure to certain toxins and drugs, and being at high elevations.
Depending on the cause, pulmonary oedema symptoms may appear suddenly or develop over time. Mild to extreme breathing difficulty can occur. Cough, chest pain and fatigue are other symptoms.
Treatment generally includes supplemental oxygen and medication.


Question: Chances of veical transmission of Hepatitis B may be high as

Answer is D (90%) The rate of perinatal transmission of hepatitis B (HBV) essentially depends on the presence or absence of HBe Ag and viral replication. The rate of perinatal transmission of HBV may be as high as 90% in neonates born to mothers who are positive for HBe AG. 'The likelihood of perinatal transmission of HBV correlates with the presence of HBe Ag and high level viral replication. 90% of HBe Ag positive mothers but only 10-15% of Anti-HBe Ag negative mothers transmit HBV to their offspring' - Harrison 18th/2547 `Transmission of infection from an HBV carrier mother to her neonate accounts for the majority of new infections in the world today. Sixty to 90% of Hepatitis B surface antigen (HBs Ag) positive mothers who are Hepatitis B 'e' antigen (HBe Ag) positive transmit the disease to their offspring, whereas mothers who are positive for antibody to HBe Ag (Anti - HBe) do so less frequently (15-20%). -


Question: Abnormal function of epithelial chloride channel protein is the cause of


Question: Post transfusion hepatitis is common with


Question: Mentzer index more than 13 suggests a diagnosis of

Ans. is 'a' i.e., Iron deficiency Anemia Mentzer index more than 13 suggests a diagnosis of Iron-deficiency anemia. Mentzer index The Mentzer index is used to help in differentiating iron deficiency anemia from beta thalassemia. The index is calculated as the quotient of the mean corpuscular volume (MCV, in fL) divided by the red blood cell count (RBC, in millions per microleter). If the Mentzer index is less than 13, thallassemia is said to be more 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. In practice, the Mentzer index is not a reliable indicator and should not, by itself be used to differentiate the two conditions. Index Formula Value for iron deficiency anemia Value for iron thalassemia Mentzer index MC V/RBC count > 13 < 13 Shine and Lal index MCV2 x MCH x 0.01 > 1530 < 1530 England and Fraser index MCV - RBC - (5 x Hb) 5.19 > 0 < 0 Srivastava index MCH/RBC > 3.8 < 3.8 Green and king index MCV2 x RDW x Hb/100 > 65 < 65 Red cell distribution width index MCV x RDW/RBC > 220 < 220


Question: A person washes hands repeatedly with a fear of getting HIV, he is suffering from

(B) Obsessive-compulsive disorder # OBSESSIVE-COMPULSIVE DISORDER:> Washers:* This is commonest type. Here the obsession is of contamination with dirt, germs, body excretions and the like.* The compulsion is washing of hands or the whole body, repeatedly many times a day.* It usually spreads on to washing of clothes, washing of bathroom, bedroom, door knobs and personal articles gradually.


Question: Pneumothorax

In pneumothorax, the trachea will be deted to the opposite side. Resonant or hyperresonant note on percussion. Breath sounds will be reduced or absent. Tactile vocal fremitus will be decreased. Tactile vocal resonance will also be decreased. Option B: Dull note on percussion is seen in consolidation, collapse, pleural effusion. Reference: Davidson's Medicine-22nd edition, page no:645.


Question: Pulmonary hypertension in COPD is due toa) Constriction of pulm vesselsb) Hypoxiac) Interstitial fibrosisd) Bronchoconstriction


Question: Reverse Coarctation is seen in

Reverse Coarctation ;weak or absent pulse in upper limb + pulse present in lower limb.


Question: In significant bacteriuria, count will be

Ans (a) > 105/mlGrowth of >105 indicate infectionmost common organism causing UTI -E coliD O C of uncomplicated UTI- Trimethorprim


Question: Clinical finding inAV fistula is one of the following


Question: Investigation of choice to establish the diagnosis in case of nephrotic syndrome in adult is

Answer- A. Renal biopsyIn adults since steroid responsive disease is less likely (<30%), and a wide differential diagnosis ofnephrotic syndrome exists, renal biopsy is recommended to establish the diagnosis.


Question: In primary immune deficiency, the following plasma protein fraction can be reduced

Agammaglobulinemia is a type of primary immunodeficiency of the adaptive immune systemAgammaglobulinemia is characterized by a profound defect in B cell development (<1% of the normal B cell blood count). In most patients, very low residual Ig isotypes can be detected in the serum. In 85% of cases, agammaglobulinemia is caused by a mutation in the BTK gene that is located on the X chromosome.Harrison 19e pg: 2107


Question: An individual is said to be 'overweight' if his BMI is in the range of


Question: Antibiotic associated diarrhea is caused by

Inflammation of the colon caused by the bacteria Clostridium difficile. Clostridium difficile colitis results from disruption of normal, healthy bacteria in the colon, often as a result of antibiotics. C. difficile can also be transmitted from person to person by spores. It can cause severe damage to the colon and even be fatal Antibiotic-associated diarrhoea is among the most common adverse events related to antibiotic use. Most cases are mild, but Clostridium difficile infection causes a spectrum of disease, ranging from occasional diarrhoea to colitis, toxic megacolon, and potentially death Ref Harrison20th edition pg 1123


Question: Renin plays impoant role in

Stimulation of the renin-angiotensin-aldosterone system leads to vasoconstriction, salt and water retention, sympathetic nervous system activation. This is mediated by angiotensin II, a potent constrictor of aerioles in both the kidney and the systemic circulation . Activation of the sympathetic nervous system may initially maintain cardiac output through an increase in myocardial contractility, hea rate and peripheral vasoconstriction. However, prolonged sympathetic stimulation leads to cardiac myocyte apoptosis, hyperophy and focal myocardial necrosis.renin also has an essential role in renovascular hypeension.Renovascular hypeension is another renin-mediated form of hypeension. Obstruction of the renal aery leads to decreased renal perfusion pressure, thereby stimulating renin secretion. Over time, as a consequence of secondary renal damage, this form of hypeension may become less renin dependent. ref:Harrison&;s principles of internal medicine,ed 18,pg no 2044


Question: Calcium Gluconate is not used in CPR by


Question: For the following cardiac abnormalities, select the characteristic JVP finding.Complete heart block.

Large a waves occur with increased resistance to filling (tricuspid stenosis, pulmonary hypertension) or when the right atrium contracts against a tricuspid valve closed by right ventricular systole (Cannon a waves) in complete heart block or other arrhythmias.


Question: Most common cause of hypernatremia

Ans. is `c' i.e., Renal losses Major causes of hypernatremia Unreplaced water loss (which requires an impairment in either thirst or access to water) Insensible and sweat losses Gastrointestinal losses Central or nephrogenic diabetes insipidus o Osmotic diuresis Glucose in uncontrolled diabetes mellitus Urea in high-protein tube feedings Mannitol Hypothalamic lesions impairing thirst or osmoreceptor function Primary hypodipsia Reset osmostat in mineralocoicoid excess Water loss into cells Severe exercise or seizures Sodioutn overload Intake or administration of hypeonic sodium solutions


Question: Anakinra, used in the treatment of rheumatoid arthritis is

(A) IL-1 # Recombinant IL-1 receptor antagonist (IL-1Ra) (anakinra): Inhibit IL-1 and is FDA approved for rheumatoid arthritis. Recombinant TNF-receptor-Ig fusion protein (etanercept): Inhibit TNF-alfa and is FDA approved for rheumatoid arthritis, juvenile rheumatoid arthritis, psoriasis Anti-TNF-alfa monoclonal antibody: Humanized mouse chimeric MAb, infliximab Fully humanized MAb, adalimumab inhibit TNF- alfa FDA approved for rheumatoid arthritis, Crohn's colitis (infliximab); FDA approved for rheumatoid arthritis (adalimumab). No TNF BETA inhibitors used. No IL-7 inhibitors used Anakinra is also useful in: Neonatal onset inflammatory disease, Muckle-Wells syndrome, and familial cold urticaria, Systemic juvenile onset inflammatory arthritis and adult onset Still's disease. Remember: Anakinra should not be combined with an anti-TNF drug (causes high rate of serious infections).


Question: Ectopic ACTH syndrome is seen most commonly with

* Ectopic ACTH production is predominantly caused by occult carcinoid tumors, most frequently in the lung, but also in thymus or pancreas. * Advanced small cell lung cancer can cause ectopic ACTH production. In rare cases, ectopic ACTH production has been found to originate from medullary thyroid carcinoma or pheochromocytoma, the latter co-secreting catecholamines and ACTH.


Question: The following are preventable risk factors for dementia

Many risk factors for dementia have been identified in recent years, most of which are common, and several are associated with both AD and VaD, as well as with atherosclerosis.These include age, hypeension, diabetes mellitus, dyslipidemia, hyperhomocysteinemia, obesity, smoking, coronary aery disease, and low level of education and occupational attainment. It is impoant to note that many of these risk factors seem to exe their critical effects already in midlife In senescence, the changes mayhave disappeared. Most elderly are not overweight any more, have stopped smoking (if they ever did), and even their cholesterol levels are lower than they have ever been. It is impoant to realize that an interaction exists between these factors. Ref Harrison20th edition pg 2297


Question: Minimal Babinski is

(A) Contraction of Hamstring muscles # True BABINSKI SIGN - includes all the components of the fully developed extensor plantar response.> Minimal Babinski sign - is characterised by contraction of the hamstring muscles and the tensor fasciae latae which can be detected by palpation of the thigh.> Spontaneous Babinski sign - is encountered in patients with extensive pyramidal tract lesions. Passive flexion of the hip and knee or passive extension of the knee may produce a positive Babinski sign in adults, as may foot manipulation in infants and children.> Crossed extensor response/bilateral Babinski sign - may be encountered in cases with bilateral cerebral or spinal cord disease. Unilateral foot stimulation elicits a bilateral response in such cases.> Tonic Babinski reflex - is characterised by a slow prolonged contraction of the toe extensors. It is encountered in patients with combined frontal lobe lesions and extrapyramidal involvement.> Exaggerated Babinski sign - may take the form of a flexor or extensor spasm. Flexor spasms can occur in patients with bilateral UMN lesion at the supraspinal or spinal cord level. Extensor spasms can occur in patients with bilateral corticospinal tract lesion but preserved posterior column function.> Babinski mimickers: 1. Pseudo Babinski sign 2.Inversion of plantar reflex 3. Withdrawal response> Pseudo Babinski sign: This sign may be encountered in patients with choreoathetosis where the upgoing toe is a manifestation of hyperkinesia.


Question: The principal impact indicator in Iodine Deficiency disorders

Urinary Iodine Levels - principal impact indicator.
Neonatal TSH levels - screening programme for hypothyroidism.


Question: Risk factors for coronary aery disease (CAD)

Answer is C Increased homocysteine levels Increased homocysteine levels and increased lipoprotein (a) levels are risk factors for cornonary aery disease Increased risk of coronary aery disease is also associated with: High LDL (not low LDL) Low HDL (not high HDL) Increased Fibrinogen levels (not decreased fibrinogen levels)


Question: CT scan is complementary to MRI in

(C) Posterior fossa tumour# Skull base anatomy is complex. Numerous vital neurovascular structures pass through multiple channels and foramina located in the base skull. With the advent of computerized tomography (CT) and magnetic resonance imaging (MRI), accurate preoperative lesion localization and evaluation of its relationship with adjacent neurovascular structures is possible.> It is imperative that the radiologist and skull base surgeons are familiar with this complex anatomy for localizing the skull base lesion, reaching appropriate differential diagnosis, and deciding the optimal surgical approach.> CT and MRI are complementary to each other and are often used together for the demonstration of the full disease extent> Diagnosis of Posterior Fossa Tumor is based on a thorough medical history and physical examination, followed by imaging tests. The best way to look at the posterior fossa is with an MRI scan. CT scans are usually not helpful to see that area of the brain.> CT scan is very much useful in traumatic lesions.> Hydrocephalus is best diagnosed by MRI scan and even Plain X-ray.


Question: HLA* 1502 is a genetic marker of

The HLA allele B*1502 as a marker for carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis .This allele is seen in high frequency in many Asian populations other than Han Chinese, but there are few data on whether the allele is a marker for this severe outcome in anyone other than Han Chinese. In fact, the association has not been found in Caucasian patients. Carbamazepine is an impoant treatment for seizure disorders, bipolar disorder, trigeminal neuralgia and chronic pain. However, carbamazepine is also associated with hypersensitivity reactions that range from benign uicaria to life-threatening cutaneous disorders, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) . Ref - harrison's internal medicine 20e p368


Question: Increased "Anion gap' is a characteristic feature


Question: In rheumatoid ahritis pathology stas in

Answer- C. SynoviumRA is a chronic multisystem disorder that may affect many tissues and organs, but principally attacks the joint, producing a nonsuppurative proliferative and inflammatory synovitis that often progresses to destruction of the aicular cailage and ankylosis ofthe joint.


Question: GH level increases during

(B) Hypoglycaemia # Stimulators of Growth Hormone (GH) secretion include:> Peptide hormones: GHRH (somatocrinin) through binding to the growth hormone-releasing hormone receptor (GHRHR) Ghrelin through binding to growth hormone secretagogue receptors (GHSR)> Sex hormones: Increased androgen secretion during puberty (in males from testis and in females from adrenal cortex)> Estrogen: Clonidine and L-DOPA by stimulating GHRH release a4b2 nicotinic agonists, including nicotine, which also act synergistically with clonidine. Hypoglycemia, arginine and propranolol by inhibiting somatostatin release Deep sleep Niacin as nicotinic acid (Vitamin B3) Fasting Vigorous exercise> Inhibitors of GH secretion include: GHIH (somatostatin) from the periventricular nucleus Circulating concentrations of GH and IGF-1 (negative feedback on the pituitary and hypothalamus) Hyperglycemia Glucocorticoids Dihydrotestosterone> In addition to control by endogenous and stimulus processes, a number of foreign compounds (xenobiotics such as drugs and endocrine disruptors) are known to influence GH secretion and function.


Question: A 45 year old female is diagnosed as a case of pneumococcal meningitis.Her blood sample were sent for culture sensitivity. In the mean time best drug to sta as an empirical treatment is

Harrison's textbook of internal medicine 17th edition . *Treatment of choice for pneumococcal meningitis is cetriaxone (2g q 12h) plus vancomycin (1g q 12h).


Question: Common presenting symptom of pneumocystis carini pneumonia Is

The key presenting symptom of PCP is progressive dyspnoea.Dry cough & fever are common.Physical findings include tachypnoea,tachycardia,and cyanosis.Chest X ray shows typical 'ground-glass' interstitial infiltrates in the perihilar regions.Pneumatoceles may occur and rupture,resulting in a pneumothorax. Reference: Davidson edition23rd pg 585


Question: Most common cause of acute arterial occlusion


Question: Increase in blood pressure occurs with

Low-potassium diet -- Low dietary potassium intake (below 40 mEq/day ) has been associated with an elevation in blood pressure and an increased risk of stroke , as well as an increase in risk of chronic kidney disease Ref Davidson 23rd edition pg 355


Question: Contraindication for PA in ischemic stroke is

Contraindications for administration of Intravenous Recombinant Tissue Plasminogen Activator (PA ) for Acute Ischemic Stroke (AIS)Sustained BP >185/110 mmHg despite treatmentPlatelets <100,000; HCT <25%; glucose <50 or >400 mg/dLUse of heparin within 48 h and prolonged PTT, or elevated INRRapidly improving symptomsPrior stroke or head injury within3 months; prior intracranial haemorrhageMajor surgery in preceding 14 daysMinor stroke symptomsGastrointestinal bleeding in preceding21 daysRecent myocardial infarctionComa or stuporRef: Harrison 19e pg: 2562


Question: Cause of nail bed infarctions  a) H.D  b)  Wegener's granulomatosis  c) Infective endocardities   d) Surge strauss syndrome  e) PAN


Question: Clinical finding in AV fistula is one of the following

The mechanism behind bradycardia associated with Branham sign is likely similar to the reflex arc that occurs during the Bezold-Jarisch reflex. Presence of an AV fistula results in increased cardiac output because of low resistance across the AV shunt. Ref Davidson 23rd edition pg 467


Question: Wing beating tremor is seen in


Question: Most common site of thrombosis in paroxysmal nocturnal hemoglobinuria

Intra abdominal veins are the most common site of thrombosis in PNH.


Question: Retinal output is mainly from

(A) Ganglion cell layer # Retina:> Layer of rods & cones: These are the end organs of vision & are also known as photoreceptors> Outer nuclear layer: It consists of nuclei of the rods and cones.> Outer plexiform layer: It consists of connections of rod spherules and cone pedicles with the dendrites of bipolar cells and horizontal cells.> Inner nuclear layer: It mainly consists of cell bodies of bipolar cells.* It also contains cell bodies of horizontal & muller's cells & capillaries of central artery of retina* The bipolar cells constitute the 1 st order neurons> Ganglion cell layer. It mainly contains the cell bodies of ganglion cells (the second order neurons of visual pathway).


Question: In the treatment of megaloblastic anemia, vitamin B12 and folic acid should be given together because

Ans. is 'b' i.e., Folic acid alone causes improvement of anemic symptoms but neurological dysfunction continues Percentage absorption of iron falls progressively as iron deficiency is corrected." As the hemoglobin levels rise, erythropoietin stimulation decreases and the amount of iron reabsorbed is reduced" Oral therapy for iron deficiency anemia A dose of 300 mg of elemental iron given per day in divided doses. 300 mg of elemental rion gives about 50 mg of absorbed iron per day (and not 100 mg of absorbed iron). Typically the Hb levels should be fully corrected within I month of initiating therapy in the absence of continuing blood loss (and not after six months). Treatment should not be stopped after normalizing of Hb, but continued for an additional 4 to 6 months to replenish body iron stores.

Vitamin B12 acts as a cofactor for digydrofolate reductase

Vitamin B12 deficiency may result in methylfolate trap

Folic acid is required for conversion of methymalonyl-CoA to succinyl Co-A


Question: Acute uraemic syndrome causes disturbance in

(B) Consciousness # Clinical Abnormalities in Uremiaa> Neuromuscular disturbances Fatigue Sleep disorders Headache Impaired mentation Lethargy Asterixis Muscular irritability Peripheral neuropathy Restless legs syndrome Paralysis Myoclonus Seizures Coma Muscle cramps Dialysis disequilibrium syndrome Myopathy


Question: Normal parent with 2 siblings having osteogenesis imperfecta. Pattern of inheritance is

D i.e. Germline mosacism Differential expression of same gene depending on parent of origin is referred to as genomic imprinting. Germline (Gonadal) mosaicism results from a mutation only affecting cells destined to form gonads - postzygotically during early embryonic development. So the individual (parent) is phenotypically normal but can transmit the disease to offsprings through mutant gametesQ. And because the progenitor cells of gametes carry mutation, there is a high possibility that more than 1 child of such parent would be affected.


Question: Lupus pernio is seen in


Question: Decremental response on EMG is seen in

Ans. is 'a' i.e., Myasthenia gravisDiagnosis of myaesthenia gravis 1Several special diagnostic Tests for mysthenia gravisElectrophysiological Testing: (Repetitive nerve stimulation test)* Characteristic of myasthenia on electrophysiological testing is rapid reduction in the amplitude of muscle action potentials evoked during a series of repetitive stimulations of a peripheral nerve at a rate of 3 per second (decrementing response)* The traditional and simple method is to stimulate the nerve at 3 Hz and to measure the compound muscle action potential (a decrement of more than 10% when comparing the fifth to the first response is abnormal)Single fibre electromyography:* This is more sensitive but technically more difficult than electrophysiological testing* Confirmatory but not specific.* This technique demonstrates an inconstancy in the firing offibres connected to the same motor unit or a blocking of successive discharges from single muscle fibre belonging to the same motor unit.Edrophonium and Neostigmine test/Tensilon test:* When edrophonium and neostigmine are given intravenously, it produces a transient improvement in strength in patients with myasthenia.* Edrophonium and neostigmine are anticholinesterase so they prolong and exaggerate the effect of acetylcholine in the synapse and therefore provide an increment in muscle power in patient with myasthenia.* It is highly sensitive with 85%Q sensitivity in ocular and 95% sensitivity in systemic myaesthenia.Measurement of receptor antibodies in the blood:* Measurement of antiacetylcholine receptor antibodies provides a sensitive and highly specific test for the diagnosis of myasthenia. Presence ofAch antibodies is virtually diagnostic of Myaesthenia graves.* Sensitivity is limited to about 50% in purely occular myasthenia and about 85% in generalized myasthenia.* Definitive if positive but negative test does not rules out the diagnosis.Also knowMost specific test to diagnose myaesthenia gravis - Anti - AchR antibody test (presence of Anti - AchR antibody is virtuallyDiagnostic of myaesthenia gravis)Most sensitive test to diagnose myaesthenia gravis - Single fibre electromyography


Question: Selenium deficiency causes

(A) Cardiomyopathy DEFICIENCIES OF METALSElementDeficiencyBoronNo biologic function determinedCalciumReduced bone mass, osteoporosisCopperAnemia, growth retardation, defective keratinization and pigmentation of hair, hypothermia, degenerative changes in aortic elastin, osteopenia, mental deteriorationChromiumImpaired glucose toleranceFluorideDental cariesIodineThyroid enlargement, T4, cretinismIronMuscle abnormalities, kilonychia, pica, anemia, work performance, impaired cognitive development, premature labor, perinatal maternal mortalityManganeseImpaired growth and skeletal development, reproduction, lipid and carbohydrate metabolism; upper body rashMolybdenumSevere neurologic abnormalitiesSeleniumCardiomyopathy, heart failure, striated muscle degenerationPhosphorousRickets (osteomalacia), proximal muscle weakness, rhabdomyolysis, paresthesia, ataxia, seizure, confusion, heart failure, hemolysis, acidosisZincGrowth retardation, taste and smell, alopecia, dermatitis, diarrhea, immune dysfunction, failure to thrive, gonadal atrophy, congenital malformations


Question: The Prevalence of the following with its degree may correlate with Disease activity in SLE

(B) Lymphopenia # Autoimmune Hemolytic Anemia (AIHA) It is characterized by elevated reticulocyte counts, low haptoglobin levels, increased indirect bilirubin concentration and a positive direct Coombs' test. It has been noted in up to 10% of patients with SLE. Presence of hemolytic anemia may associate with manifestations of severe disease such as renal disease, seizures and serositis. Presence of both immunoglobulin and complements on red blood cells is usually associated with some degree of hemolysis, while presence of complements alone (C3 and /or C4) is often not associated with hemolysis AIHA responds to steroids (1 mg/kg per day prednisone or its equivalent in divided doses) in 75 to 96% of patients. Once the hematocrit begins to rise and the reticulocyte count falls, steroids can be rapidly tapered.SLICC CLASSIFICATION CRITERIA FOR SYSTEMIC LUPUS ERYTHEMATOSUSRequirements: > criteria (at least 1 clinical and 1 laboratory criteria. Or Biopsy-proven lupus nephritis with positive ANA or Anti-DNAClinical CriteriaImmunologic Criteria* Acute Cutaneous Lupus* ANA* Chronic cutaneous Lupus* Anti-DNA* Oral or nasal ulcers* Ant-Sm* Non-Scarring alopecia* Antiphospholipid Ab* Arthritis* Low complement (C3, C4, CH50)* Serositis* Direct Coomb's test* Renal * Neurologic* Hemolytic anemia* Leukopenia* Thrombocytopenia (<100,000/mm3)> Leucopenia It is a typical feature of SLE which may occur as a result of lymphopenia, neutropenia or a combination of both. Prevalence of lymphopenia in SLE ranges from 20 to 81% and its degree may correlate with disease activity. Both T and B lymphocytes are reduced, while natural killer cells are typically increased. Reduced surface expression of complement regulatory proteins CD55 and CD59 has been found in leucopenic patients with SLE. Deficiency of these proteins may make these cells susceptible to complement-mediated lysis. There is increasing evidence that endogenous production of type 1 interferons (IFNs) is implicated in the pathogenesis of neutropenia and lymphopenia in SLE. Elevated serum levels of IFN-a in SLE correlate inversely with leucocyte numbers# Neutropenia It is a common feature of SLE, with a prevalence rate of 47%, it may be mediated by anti-neutrophil antibodies. Increased levels of TNF-related apoptosis-inducing ligand (TRAIL) in SLE and may contribute to Neutropenia (through excessive neutrophil apoptosis mediated neutropenia).# Thrombocytopenia It has a reported prevalence ranging from 7 to 30% in large series of patients with SLE. Increased peripheral destruction of platelets and presence of anti-platelet antibodies, is the most likely pathogenic mechanism. Thrombocytopenia is an independent risk factor for increased mortality in SLE.


Question: Chorea is NOT seen in

(D) Tourette Syndrome # TOURETTE SYNDROME is a neurological disorder characterised by sudden rapid, involuntary movements called tics, which occur repeatedly. Tourette Syndrome is also linked to other behaviours, most often OCD and Attention Deficit Disorder (ADHD).> Symptoms can include bouts of motor and vocal tics and the focus of these tics tends to wax and wane over time.> Typically tics increase as a result of stress or tension, and may decrease when relaxed or absorbed in a task.> Chorea is seen with: Huntington's disease, a group of neurodegenerative diseases such as Creutzfeldt-Jakob disease and Kuru, children and adolescents with rheumatic fever develop Sydenham's chorea as a complication, drugs like levodopa, anti-convulsants, anti-psychotics, Wilsond disease and Chorea gravidarum is rare type of chorea which is a complication of pregnancy.


Question: The most common electrolyte abnormality found in patients with normal anion gap metabolic acidosis is

Ans. A. Hyperchloremia.In a normal anion gaps metabolic acidosis there is by definition a rise in the serum chloride equivalent to the fall in the serum bicarbonate such that the anion gap (Na-Cl-HCO3 ) remains unchanged.


Question: Following an attack of myocardial infarction the moality and morbidity of the patient is indicated by

Answer is B (Left ventricular ejection fraction) Pump failure is now the primary cause of in hospital death following MI. The degree of pump failure relates well with moality. The most sensitive index of cardiac function amongst the options provided is 'ejection fraction' i.e. the ratio of stroke volume to end diastolic volume. This is thus the best indicator of moality & morbidity following ML

Percentage of narrowness of coronary aery


Question: Thymoma commonly presents with

Thymus is abnormal in 75% patients with MG; 65%is hyperplastic and 10 % have thymic rumours or thymomas These patients may present with cough, chest pain, superior vena cava (SVC) syndrome, dysphagia, and hoarseness if the recurrent laryngeal nerve is involved. One third of cases are found incidentally on radiographic examinations during a workup for myasthenia gravis (MG). Ref Harrison20th edition pg 2789


Question: Graham Steel's murmur is an ausultatory finding of

(B) Pulmonary regurgitation > Graham Steell's murmur: a high-pitched diastolic murmur caused by pulmonary regurgitation secondary to severe pulmonary hypertension; it is heard at the left sternal edge, level with the second or third costal cartilage.> Duroziez's murmur: a double murmur over the femoral or other large peripheral artery, due to aortic insufficiency.> Cruveilhier-Baumgarten murmur: a venous murmur heard at the abdominal wall over veins connecting the portal and caval systems.> Carey Coombs murmur: a rumbling apical mid-diastolic cardiac murmur occurring in the acute phase of rheumatic fever and disappearing afterward.> Austin Flint murmur: a presystolic or mid-diastolic murmur heard at the cardiac apex in aortic regurgitation, originating at the mitral valve when blood enters simultaneously from both the aorta and the left atrium.> Gibson murmur or Machinary murmur: a long rumbling sound occupying most of systole and diastole, usually localized in the second left interspace near the sternum, and usually indicative of patent ductus arteriosus> Seagull murmur: a raucous murmur with musical qualities resembling the call of a seagull such as that heard occasionally in aortic insufficiency, and attributed specifically to eversion or retroversion of the right anterior aortic cusp.


Question: Uretheritis is seen in

Sexually acquired reactive ahritis (SARA) is predominantly a disease of young men, with a male preponderance of 15 : 1. This may reflect a difficulty in diagnosing the condition in young women, in whom Chlamydia infection is often asymptomatic and is hard to detect in practical terms. Between 1% and 2% of patients with non-specific urethritis seen at genitourinary medicine clinics have SARA . The syndrome of chlamydial urethritis, conjunctivitis and reactive ahritis was formerly known as Reiter's disease . The diagnosis is usually made clinically but joint aspiration may be required to exclude crystal ahritis and aicular infection. ESR and CRP are raised, urethritis may be confirmed in the 'two-glass test' by demonstration of mucoid threads in the first-void specimen that clear in the second. High vaginal swabs may reveal Chlamydia on culture. Except for post-Salmonella ahritis, stool cultures are usually negative by the time the ahritis presents but serology may help confirm previous dysentery. RF, ACPA and ANA are negative Ref - Davidsons 23e p1031


Question: Type I Respiratory failure is seen in

(B) Emphysema # RESPIRATORY FAILURE may be classified as hypoxic or hypercapnic and may be either acute or chronic.# Hypoxemic respiratory failure (Type I) is characterized by a Pa02of less than 60 mmHg with a normal or low PaCO2.> Most common form of respiratory failure, and it can be associated with virtually all acute diseases of the lung, which generally involve fluid filling or collapse of alveolar units.> Some examples of Type I respiratory failure are cardiogenic or noncardiogenic pulmonary edema, pneumonia, and pulmonary hemorrhage..> Common causes of Type I (hypoxemic) respiratory failure Pneumonia Pulmonary edema Pulmonary fibrosis Asthma Pneumothorax Pulmonary embolism Pulmonary arterial hypertension Pneumoconiosis Granulomatous lung diseases Cyanotic congenital heart disease Bronchiectasis Adult respiratory distress syndrome Fat embolism syndrome Kyphoscoliosis Obesity# Hypercapnic respiratory failure (Type II) is characterized by a PaCO2 of more than 50 mm Hg.> Hypoxemia is common in patients with hypercapnic respiratory failure who are breathing room air.> The pH depends on the level of bicarbonate, which, in turn, is dependent on the duration of hypercapnia.> Common etiologies include drug overdose, neuromuscular disease, chest wall abnormalities, and severe airway disorders < e.g., asthma, chronic obstructive pulmonary disease)# Common causes of Type II (hypercapnic) respiratory failure Chronic bronchitis and emphysema (COPD) Severe asthma Drug overdose Poisonings Myasthenia gravis Polyneuropathy Poliomyelitis Primary muscle disorders Porphyria Cervical cordotomy Head and cervical cord injury Primary alveolar hypoventilation Obesity hypoventilation syndrome Pulmonary edema Adult respiratory distress syndrome Myxedema Tetanus Guillain-Barre syndrome


Question: Oral lesions in Immunocompromised state


Question: For diagnosis of acute rheumatic fever, essential feature is

The diagnosis, according to the revised Jones criteria, is based upon two or more major manifestations, or one major and two or more minor manifestations; evidence of preceding streptococcal infection is also required.
JONES CRITERIA FOR THE DIAGNOSIS OF RHEUMATIC FEVER
Major manifestations

Carditis
Polyathritis
Chorea
Erythema marginatum
Subcutaneous nodules Minor manifestations
Fever
Arthralgia
Previous rheumatic fever
Raised ESR or CRP
Leucocytosis
First – degree AV block PLUS
Supporting evidence of preceding streptococcal infection: recent scarlet fever, raised antistreptolysin 0 or other streptococ-cal antibody titre, positive throat culture

N. B. Evidence of recent streptococcal infection.


Question: Comment on the diagnosis based on spirometry repo TLC= 75% FRC= 100% RV = 120 % FEV1 = 60% DLco = 80%

Acute asthma and Emphysema- TLC| due to air trapping Pulmonary Fibrosis - TLC| RV| Myasthenia Gravis - TLC| RV| Extraparenchymal Restrictive Lung Disease


Question: Alternating RBBB with Left anterior hemiblock is seen in

Ans. is 'd' i.e., Bi-fascicular block Bifascicular block - combination of RBBB with either left anterior hemiblock or left posterior hemiblock. Tri fascicular block - RBBB plus either LAHB/LPHB+ first degree AV block. Complete hea block destruction of - AV node leading to AV dissociation


Question: Dose of MgSO4 in asthma is

Bronchodilators Bronchodilator therapy is central to the management of breathlessness. The inhaled route is preferred and a number of different agents delivered by a variety of devices are available. Choice should be informed by patient preference and inhaler assessment. Sho-acting bronchodilators may be used for patients with mild disease but longer-acting bronchodilators are usually more appropriate for those with moderate to severe disease. Significant improvements in breathlessness may be repoed despite minimal changes in FEV1, probably reflecting improvements in lung emptying that reduce dynamic hyperinflation and ease the work of breathing. Oral bronchodilator therapy, such as theophylline preparations, may be contemplated in patients who cannot use inhaled devices efficiently but their use may be limited by side-effects, unpredictable metabolism and drug interactions; hence the requirement to monitor plasma levels. Orally active, highly selective phosphodiesterase inhibitors remain under appraisal. Combined inhaled glucocoicoids and bronchodilators The fixed combination of an inhaled glucocoicoid and a LABA improves lung function, reduces the frequency and severity of exacerbations and improves quality of life. These advantages may be accompanied by an increased risk of pneumonia, paicularly in the elderly. LABA/inhaled glucocoicoid combinations are frequently given with a long-acting muscarinic antagonist (LAMA). LAMAs should be used with caution in patients with significant hea disease or a history of urinary retention. Oral glucocoicoids Oral glucocoicoids are useful during exacerbations but maintenance therapy contributes to osteoporosis and impaired skeletal muscle function, and should be avoided. Oral glucocoicoid trials assist in the diagnosis of asthma but do not predict response to inhaled glucocoicoids in COPD. Pulmonary rehabilitation Exercise should be encouraged at all stages and patients reassured that breathlessness, while distressing, is not dangerous. Multidisciplinary programmes that incorporate physical training, disease education and nutritional counselling reduce symptoms, improve health status and enhance confidence. Most programmes include two to three sessions per week, last between 6 and 12 weeks, and are accompanied by demonstrable and sustained improvements in exercise tolerance and health status. Oxygen therapy Long-term domiciliary oxygen therapy (LTOT) improves survival in selected patients with COPD complicated by severe hypoxaemia (aerial PaO2 < 7.3 kPa (55 mmHg)). It is most conveniently provided by an oxygen concentrator and patients should be instructed to use oxygen for a minimum of 15 hours/ day; greater benefits are seen in those who use it for more than 20 hours/day. The aim of therapy is to increase the PaO2 to at least 8 kPa (60 mmHg) or SaO2 to at least 90%. Ambulatory oxygen therapy should be considered in patients who desaturate on exercise and show objective improvement in exercise capacity and/or dyspnoea with oxygen. Oxygen flow rates should be adjusted to maintain SaO2 above 90%. Surgical intervention Bullectomy may be considered when large bullae compress surrounding normal lung tissue. Patients with predominantly upper lobe emphysema, preserved gas transfer and no evidence of pulmonary hypeension may benefit from lung volume reduction surgery (LVRS), in which peripheral emphysematous lung tissue is resected with the aim of reducing hyperinflation and decreasing the work of breathing. Both bullectomy and LVRS can be performed thorascopically, minimising morbidity. Lung transplantation may benefit carefully selected patients with advanced disease (p. 567). Other measures Patients with COPD should be offered an annual influenza vaccination and, as appropriate, pneumococcal vaccination. Obesity, poor nutrition, depression and social isolation should be identified and, if possible, improved. Mucolytic agents are occasionally used but evidence of benefit is limited. Palliative care Addressing end-of-life needs is an impoant, yet often ignored, aspect of care in advanced disease. Morphine preparations may be used for palliation of breathlessness in advanced disease and benzodiazepines in low dose may reduce anxiety. Decisions regarding resuscitation should be addressed in advance of critical illnes Magnesium sulfate is a bronchodilator. It relaxes the bronchial muscles and expands the airways, allowing more air to flow in and out of the lungs. This can relieve symptoms of asthma, such as shoness of breath. initial loading dose 2 gm over a period of 20 minutes where infused Ref Davidson edition23rd pg 577


Question: Diagnostic criteria of Metabolic syndrome includea) High serum homocysteineb) High serum triglyceridec) Low HDL cholesterold) High LDL cholesterol


Question: In Burkitts lymphoma, translocation seen is chromosome

Answer is B (8 - 14 translocation) Presence oft (8; 14) or one of its variants t (2; 8) or t (8; 22) can be confirmatory - Harrison 16th/ 652. Impoant translocation to be remembered


Question: Enzyme raised in myopathies is

Ans. a (CPK), (Ref. Harrison, Principles of Medicine, 18th/Chapter 246.)# CPK is raised in many myopathies and in AMI.

Disorder of Metabolism & Connective Tissue


Question: Doughy skin and woody induration of tongue is seen in

Hypernatremia is defined as a serum sodium concentration of greater The skin can feel doughy or velvety due to intracellular water loss and Woody indurations on tongue are seen Ref Davidson 23rd edition pg 345


Question: Strawberry gingivitis seen in

Wegener's granulomatosis is a rare multi-system disease characterized by the classic triad of necrotizing granulomas affecting the upper and lower respiratory tracts, disseminated vasculitis and glomerulonephritis. Oral lesions as a presenting feature are only encountered in 2% of these cases. Hyperplastic gingival lesions or strawberry gingivitis, is a characteristic sign of Wegener's granulomatosis. The latter consists of reddish-purple exophytic gingival swellings with petechial haemorrhages thus resembling strawberries. Recognition of this feature is of utmost impoance for timely diagnosis and definitive management of this potentially fatal disease. Ref - pubmed.com


Question: Cause of death in diabetic ketoacidosis in children

Ans. is 'a' i.e., Cerebral edema High blood sugar will cross the blood brain barrier and simultaneously will draw water inside leading to cerebral edema. Cerebral edema accounts for 60-90% of all DKA related deaths in children. Infection is a precipitator for development of DKA. Other precipitating factor can be tissue ischemia, inadequate insulin administration, drugs (cocaine) and pregnancy.


Question: Benefits ofEnteric feeding Vs parenteral feeding

ENTERAL NUTRITION cheaper. simpler. fewer complications. for efficient use of nutrients. stimulates intestinal blood flow. maintain GI mucosal barrier (prevents bacterial translocation and poal endotoxemia) reduced gut associated lymphoid system (GALT) -> becomes a source of activated cells and proinflammatory stimulants Ref Davidson 23rd edition pg 763


Question: Condition associated with prolonged muscle contraction followed by slow muscle relaxation includes

(A) Myotonia # Myotonia is a symptom of a small handful of certain neuromuscular disorders characterized by delayed relaxation (prolonged contraction) of the skeletal muscles after voluntary contraction or electrical stimulation.> Myotonia may present in the following diseases with different causes related to the ion channels in the skeletal muscle fiber membrane (Sarcolemma).> Myotonia is present in Myotonia congenita, Paramyotonia Congenita and myotonic dystrophy.


Question: Testicular descent is controlled in pa by

Testicular descent through the inguinal canal is controlled in pa by Leydig cell production of insulin-like factor 3 (INSL3), which acts a receptor termed GREAT ( G protein-coupled receptor affecting testis descent). Ref Harrison 20th edi page no 2769


Question: Best marker for drug induced lupus is

Ref image - Harrison's internal medicine 20e p2517


Question: A patient complains of intermittent claudication, dizziness and headache, likely cardiac lesion is


Question: "Sleep apnoea", is defined as a temporary pause in breathing during sleep lasting at least


Question: Most common anterior mediastinal tumour is

(Thymoma): {2181- H 18th edition)MEDIASTINAL MASSESAnterior mediastinumThymoma (Most common)***LymphomaTeratomatous neoplasmsThyroid massesMiddle mediastinum- Vascular masses (Most common)**- Lymph node enlargement from metastasis or granulomatous disease- Pleuropericardial and bronchogenic cystsPosterior mediastinum- Neurogenic tumours (Most common)**- Meningoceles, meningomyelocele- Gastroenteric cysts- Esophageal diverticula* Investigation of choice - CT-scan* Definite diagnosis - Mediastinoscopy or anterior mediastinotomy


Question: Sudden onset of cough followed by increasing dyspnoea is characteristic of

Pneumonia,paicularly lobar pneumonia,usually presents as an acute illness with sudden onset fever,chills,rigor,cough and malaise.Cough is characteristically sho,painful and dry,but later accompanied by the expectoration of mucopurulent sputum(rusty coloured in case of Strep.pneumoniae),with pleuritic chest pain.The patients also presents with increasing dyspnoea with increased respiratory rate(>30/min) and use of accessory muscles of respiration. Pleural effusion has got an insidious onset with breathlessness,with or without cough and pleuritic chest pain.In pneumothorax,the most common symptoms are sudden- onset unilateral pleuritic chest pain or breathlessness.In MI,pain is the cardinal symptom with breathlessness,vomiting & collapse. Reference:Davidson's Medicine-22nd edition,page no:683,661,729,590.


Question: Multifactorial inheritance Is known in

These benign tumors usually develop in or under the skin, but can also grow inside the body. Sometimes, a growth will involve multiple nerves (plexiform neurofibroma). Plexiform neurofibromas, when located on the face, can cause disfigurement. Neurofibromas may increase with age. Bone deformities Neurofibromas arise from nonmyelinating Schwann cells that only express the inactive version of the NF1 gene, which leads to a complete loss of expression of functional neurofibromin. While one defective allele may be inherited, loss of heterozygosity (LOH) must occur before a neurofibroma can form; this is called the 'two-hit hypothesis'. This LOH happens by the same mechanisms, such as oxidative DNA damage, that causes mutations in other cells. Once a nonmyelinating Schwann cell has suffered inactivation of its NF1 genes, it begins to proliferate rapidly. This condition is called hyperplasia, which is cell growth beyond what is normally seen. However, despite increased numbers of nonmyelinating Schwann cells, there is no neurofibroma yet. In order for the neurofibroma to develop, cells that are heterozygous for the NF1 gene must be recruited to the site. It has been hypothesized that the proliferating nonmyelinating Schwann cells secrete chemoattractants such as the KIT ligand, and angiogenic factors such as the heparin-binding growth factor midkine. These chemicals promote the migration of different kinds of cells that are heterozygous for the NF1 gene into the hyperplastic lesions created by the nonmyelinating Schwann cells. These cell types include fibroblasts, perineurial cells, endothelial cells, and mast cells. The mast cells then secrete mitogens or survival factors that alter the developing tumor microenvironment and result in neurofibroma formation.it has multifactorial inheritance Ref Robbins 9/e pg 174


Question: Following is indicative of hypercalcemia on ECG

(A) Short QT interval ECG OF HYPERCALCEMIAECG OF HYPOCALCEMIA* Marked shortening of Q-T interval* Prolongation of Q-T interval* ST segment is eliminated* Lengthening of ST segment# ECG of HYPERCALCAEMIA:> Short QT interval> Serum calcium > 15 mg% occurs in malignancy.> > 200 mg/day of urinary calcium suggest hypercalcaemia.> < 100 mg/day Hypocalcaemia> ECG shows a shortened QT interval, measurements of PTH and PTH-related protein (PTHrP) help distinguish between maligncmcy- associated by hypercalcaemia (elevated PTHrP) and hypoerparathyroidism (elevated PTH).# Q-T Interval: 'Measurement from the beginning of the Q wave to the end of the T wave.> Normal Q-T interval: is from 0,32 to 0.4 sec.> Shortened Q-T interval: Hyperkalemia; Hypercalcemia; Digitalis and Diphenyhydantoin sodium; Tachycardia.> Prolonged Q-T interval: Bradycardia-complete A-V book Hypokalemia, Hypocalcaemia and hypomagnesemia Drugs--Quinidine, procainamide, phenothiazines, tricyclic antidepressants. IHD, Mitral valve prolapse, CNS disease.


Question: Murmur increasing with Valsalva manouvre

Ref: Harrison's 19th E pg 1568 All murmurs decreases with valsalva maneuver except that of HOCM and MVP. In hocm, blood acts as a physical barrier between hyperophied septum and anterior mitral leaflet. During valsalva, there is decreased venous return and subsequently decreased blood reaching LV. As blood flow reduces, there is more chances of obstruction, it increases the murmur (ejection systolic murmur)


Question: In benign hypeension commonest vascular pathology is

In smaller aeries (< 1 mm), hyaline aeriosclerosis occurs in the wall, the lumen narrows and aneurysms may develop. Widespread atheroma develops and may lead to coronary and cerebrovascular disease, paicularly if other risk factors (e.g. smoking,diabetes, hyperlipidaemia,) are present.These structural changes in the vasculature often perpetuate and aggravate hypeension by increasing peripheral vascular resistance and reducing renal blood flow, thereby activating the renin-angiotensin-aldosterone axis. ref:davidson&;s principles and practices medicine,ed 21,pg no 624


Question: In LVH, SV1 +RV6 is more than mm

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. To diagnose the left ventricular hyperophy on ECG one of the following criteria should be met :? The sokolow-lyon criteria is most often used - R in V, or V6 + 5 in V > 35 mm in men The cornell-criteria has different values R in aVL and S in V3 > 28 mm in men R in aVL and S in V3 > 20 mm in women As the left ventricular wall becomes thicker QRS complexes are larger in leads V1-V6 S wave is deep in V, R wave is high in V4 ST depression in V,,-V, (strain pattern)


Question: Cryptococcus neoformans has significant predilection for


Question: A 32 year old carpenter presented to you with history of recurrent attacks of chest pain . You prescribe him sublingual nitroglycerin  and advise him to take it at the time of pain. The patient revisits the hospital again after 2weeks and tells that the intensity of chest pain has increased on taking nitroglycerin.  The patient is most likely suffering from

Nitrates are vasodilator drugs which aggravate condition of HOCM , so it is generally not used in HOCM

Hypertrophic obstructive  cardiomyopathy


Question: In Wilsons disease copper deposition occurs in

Wilson's disease (hepatolenticular degeneration) is a rare but impoant autosomal recessive disorder of copper metabolism caused by a variety of mutations in the ATP7B gene on chromosome 13. Total body copper is increased, with excess copper deposited in, and causing damage to, several organs. Normally, dietary copper is absorbed from the stomach and proximal small intestine and is rapidly taken into the liver, where it is stored and incorporated into caeruloplasmin, which is secreted into the blood. The accumulation of excessive copper in the body is ultimately prevented by its excretion, the most impoant route being bile. In Wilson's disease, there is almost always a failure of synthesis of caeruloplasmin; however, some 5% of patients have a normal circulating caeruloplasmin concentration and this is not the primary pathogenic defect. The amount of copper in the body at bih is normal but thereafter it increases steadily; the organs most affected are the liver, basal ganglia of the brain, eyes, kidneys and skeleton . Ref - Davidsns internal medicine 23e p89


Question: Vitamin B level in chronic myeloid leukemia is

Ans. is 'a' i.e., Elevated CML there will be rise in B1, level LDH level And decreased levels of ALP.


Question: If a person has a hea rate of 70 beats/min, a left ventricular end diastolic volume of 100 ml, and an ejectionfraction of 0.50, then the cardiac output is

Cardiac output = hea rate x stroke volume. The ejection fraction = stroke volume/left ventricular end- diastolic volume (LVEDV). Therefore, stroke volume ejection fraction x L VEDV, or 0.50 x 100 ml = 50 nit Cardiac output = 50 ml x 70 beats/mm = 3500 mI/minute, or 3.5 liters/mm.


Question: 'Teichopsia' is seen in

Ans. B. Migrane. (Ref Victor Adams Neurology, pg. 182-183.)Classic migraine is usually familial, involves a unilateral, throbbing head pain, and diminishes in fre- quency with age. The blind spot, or scotoma, that may develop as part of the aura of a classic migraine attack will involve the same visual field in both eyes. This defect usually changes over the course of minutes. It typically enlarges and may intrude on the central vision. The margin of the blind spot is often scintillating or dazzling. If this margin has a pattern like the battlement of a castle, it is called a fortification spectrum, or teichopsia. Homonymous hemianoptic defects of the sort that develop during the aura of a classic migraine indicate an irritative lesion that is affecting one part of the occipital cortex in one hemisphere of the brain. The changes in the scotoma over the course of minutes indicate that the irritative phenomenon sets off a cascade of events in the visual cortex that temporarily disturbs vision in a progressively larger area. Other focal neurologic phenomena may precede classic migraine; the most common are tingling of the face or hand, mild confusion, transient hemiparesis, and ataxia. Fatigue, irritability, and easy distractibility often develop before a migraine. Affected persons usually also have hypersensitivity to light and noise during an attack.


Question: Most common extra renal manifestation of autosomal dominant polycystic kidney disease .

Most common extra renal manifestation of ADPCKD  - Cysts in liver (Hepatomegaly).


Question: Kussmaul's sign is NOT seen in

Answer is C (Cardiac tamponade) most probably Kussmaul's sign is absent in cardiac tamponade. Presence of Kussmaul's sign in cardiac tamponade suggests an organizing process and presence of epicardial constriction (constrictive pericarditis) in addition to effusion. Kussmaul's sign is not a feature of isolated cardiac tamponade. Kussmaul's sign is absent inisolated cardiac tamponade It is frequent with constrictive pericarditis and R.V.MI. Not so frequent in R.C.MP. but definitely present Rare (absent) in Cardiac Tamponade