Question: Earliest phenotypic manifestation of Idiopathic hereditary hemochromatosis is

Investigations in Primary Haemochromatosis Serum iron studies show a greatly increased ferritin, a raised plasma iron and saturated plasma iron-binding capacity. The serum iron level and percent saturation of transferrin are elevated early in the course, but their specificity is reduced by significant false-positive and false-negative rates. For example, serum iron concentration may be increased in patients with alcoholic liver disease without iron overload; in this situation, however, the hepatic iron index is usually not increased as in hemochromatosis (Table 407-1). In otherwise healthy persons, a fasting serum transferrin saturation >45% is abnormal and suggests homozygosity for hemochromatosis. Transferrin saturation of more than 45% is suggestive of iron overload. Significant liver disease is unusual in patients with ferritin lower than 1000 mg/L (100 mg/dL). The differential diagnoses for elevated ferritin are inflammatory disease or excess ethanol consumption for modest elevations (< 1000 mg/L (100 mg/dL). Very significant ferritin elevation can be seen in adult Still's disease. In terms of imaging techniques, MRI has high specificity for iron overload but poor sensitivity. Liver biopsy allows assessment of fibrosis and distribution of iron (hepatocyte iron characteristic of haemochromatosis). The Hepatic Iron Index (HII) provides quantification of liver iron (mmol of iron per g dry weight of liver/age in years). An HII of more than 1.9 suggests genetic haemochromatosis . Both the C282Y and the H63D mutations can be identified by genetic testing, which is now in routine clinical use . Ref Davidsons 23e p895 , Harrison 20e p2980

Post prandial increase in serum iron concentration


Question: The first virological marker following acute hepatic infection if he has


Question: Jejunal biopsy is diagnostic in

biopsy reveals characteristic findings in the following diseases which may cause steatorrhea: sprue, amyloidosis, Whipple's disease, lymphoma, a-beta-lipoproteinemia, and scleroderma. In nontropical sprue (and to a lesser degree in tropical sprue), microscopic examination of the jejunum reveals blunting or absence of the villi, substitution of cuboidal for columnar surface cells, infiltration of the lamina propria with lymphocytes and plasma cells, and increased mitotic activity in the crypts of the unusually deep intestinal glands. In amyloidosis, which affects the intestinal tract in 50% of cases, there is deposition of amyloid in the lamina propria and around blood vessels. In Whipple's disease, villi of the intestinal mucosa are thickened and have bulbous tips, and the laminae propria contain foamy histiocytes and lipid deposits; also the macrophages contain a carbohydrate-protein complex which is readily demonstrated by the periodic-acid, Schiff staining technic. In lymphoma, mucosal lesions may be identical to those seen in sprue; on the other hand, diagnostic nodules of lymphocytes or unusual cellular infiltrations may be seen in the lamina propria. In a-beta-lipoproteinemia, numerous vacuoles of fat are found in the epithelial cells Ref Davidson edition23rd pg 809


Question: Bilateral facial nerve palsy is seen in

(C) Gullian Barre syndrome # BILATERAL FACIAL PALSY occurs in Gullian Barre syndrome, in a form of sarcoidosis called uveoparotid fever (Heerfordt syndrome) & in bilateral acoustic neuroma,> Facial Neuropathy: An isolated facial palsy may occur in patients with HIV seropositivity, sarcoidosis, or Lyme disease. In the Ramsay Hunt syndrome, pain and vesicles appear in the external auditory canal, and patients lose their sense of taste in the anterior two-thirds of the tongue while developing ipsilateral facial palsy. The geniculate ganglion of the sensory branch of the facial nerve is involved. Tumors that invade the temporal bone (carotid body, cholesteatoma, dermoid) may produce a facial palsy, but the onset is insidious and the course progressive. Acoustic neuromas frequently involve the facial nerve by local compression. Infarcts, demyelinating lesions of multiple sclerosis, and tumors are the common pontine lesions that interrupt the facial nerve fibers; other signs of brainstem involvement are usually present. Bilateral facial paralysis (facial diplegia) occurs in Guillain-Barre syndrome and also in a form of sarcoidosis known as uveoparotid fever (Heerfordt syndrome). Lyme disease is a frequent cause of facial palsies in endemic areas. Rare Melkersson-Rosenthal syndrome consists of a triad of recurrent facial paralysis, recurrent--and eventually permanent-- facial (particularly labial) edema, and less constantly, plication of the tongue; its cause is unknown. Leprosy: Frequently involves the facial nerve, and facial neuropathy may also occur in diabetes mellitus.


Question: Radiotherapy is treatment of choice in


Question: Therapeutic hypothermia is useful in preventing neurological complication in

Therapeutic hypothermia (also called targeted temperature management) refers to deliberate reduction of the core body temperature, typically to a range of about 32deg to 34deg C (89.6deg to 93.2deg F) in patients who don't regain consciousness after return of spontaneous circulation following a cardiac arrest. Hypothermia also is used to treat newborns with perinatal asphyxia; however, this aicle focuses on its use in adults. Hypothermia counteracts neuroexcitation in brain cells by stabilizing calcium and glutamate release, reducing the degree of cell death. It also stabilizes the blood-brain barrier and suppresses the inflammatory process, reducing cerebral edema. Cerebral metabolism decreases 6% to 10% for every degree Celsius that body temperature drops. As cerebral metabolism declines, the brain needs less oxygen. In essence, hypothermia counteracts many of the destructive mechanisms of cardiac arrest. Its effects resemble those of cardiac defibrillation, which makes the hea stop and then reset itself to a normal rhythm. Similarly, hypothermia halts destructive brain mechanisms and lets the brain reset itself to normal functioning. Therapeutic hypothermia occurs in three phases--induction, maintenance, and rewarming. Clinicians must control hypothermia and rewarming to prevent potential adverse effects, such as arrhythmias and skin breakdown during the cold phases (induction and maintenance) and rapid electrolyte shifts during the rewarming phase. Temperature should be monitored with a method that measures core temperature, such as use of an esophageal, bladder, or pulmonary aery catheter. REF - pubmed.com , medlineplus.com


Question: Diagnostic of acute pulmonary embolism is

Ans. d (D-dimer assay). (Ref. Harrison, Medicine, 18th/Chapter 103; fig. 58-2)EVALUATION OF ACUTE PULMONARY EMBOLISM# ECG may show RV hypertrophy with strain, RBBB, increased HR and T-wave inversion in V1 to V4.# CXR is frequently normal. However Palla sign (enlarged right descending pulmonary artery) or Westermark's sign (decreased pulmonary vascular markings peripherally) or Hampton's hump.# If clinical likelihood is low, then d-dimer, ELISA and USG lower extremities are done# D-dimer is elevated in number of conditions other than pulmonary embolism, however, a negative D-dimer assay suggests that likelihood of PE is low. Patients with a low likelihood of DVT or a low-to-moderate likelihood of PE can undergo initial diagnostic evaluation with d-dimer testing alone without obligatory imaging tests. If the d-dimer is abnormally elevated, imaging tests are the next step# VP lung scans are done in any stable patient with suspicion of PE and are investigation of choice.# CT with contrast may be helpful, and may supplement VP Scan in coming days.# Pulmonary arteriography is 'gold-standard' and definitive


Question: Plantar reflex root value is

(B) Afferent S1, Efferent L5, S1 # PATHWAYS FOR PLANTAR REFLEX:> Afferent: Nociception detected in the S1 dermatome and travels up the tibial nerve to the sciatic nerve to roots of L5, S1 and synapse in the anterior horn to elicit the motor response.> Efferent: Motor response back through the L5, S1 roots to the sciatic nerve to its bifurcation. Toe flexors are innervated by tibial nerve. Toe extensors (extensor hallicus longus, extensor digitorum longus) are innervated by the deep peroneal nerve. Loss of normal adult descending pyramidal control of the reflex arc to suppress extensor withdrawl results in the up-going toes in the plantar reflex known as Babinski's sign. There is no such thing as a negative Babinski's sign.> Causes of an extensor plantar response: Pyramidal tract lesions; Normal children up to one year of age; Deep sleep; Coma; General Anaesthesia; Postictal stage of epilepsy; Electroconvulsive therapy (ECT); Hypoglycaemia; Alchol intoxication; Narcosis; Hypnosis; Following severe physical exhaustion; Head trauma with concussion.> Root values of Reflexes: Biceps reflex (C5, C6) Brachioradialis reflex (C5, C6, C7) Extensor digitorum reflex (C6, C7) Triceps reflex (C6, C7, C8) Patellar reflex or knee-jerk reflex L2, L3, L4) Ankle jerk reflex (Achilles reflex) (S1, S2) Plantar reflex or Babinski reflex (L5, S1, S2)


Question: The most impoant diagnositic feature for beta thalassemia trait


Question: Inclusions in oligodendrogliocytes is a feature of

Harrison's principles of internal medicine 17th edition. Pg 1249*Oligodendrocytes have enlarged,densely staining nuclei that contain viral inclusions formed by crystalline arrays of JC virus paicles.


Question: Deposition of anti ds DNA Ab in kidney, skin, choroid plexus and joints is seen

Ref - Harrison's internal medicine 20e p2517


Question: Short acting anticholinesterase is

(B) Edrophonium# Pyridostigmine:> Resembles neostigmine in all respects but is dose to dose less potent and longer acting, less frequent dosing is required in myasthenia gravis.# Edrophonium:> Resembles neostigmine in action, has a brief duration (10-30 min), suitable as a diagnostic agent for myasthenia gravis and for postoperative decurarization.# Tacrine:> It is a lipophilic acridine compound which interacts with ChE in a manner analogous to edrophonium.> It crosses blood-brain barrier and has a longer duration of action.# Donepezil:> Another centrally acting anti AChE that has produced cognitive and behavioral improvement in AD.> It is long acting and suitable for once daily administration.


Question: Hypernatremia is defined as a plasma sodium concentration more than

Hypernatremia is defined as a plasma Na+ concentration >145 mmol/L. Hypernatremia can develop following the loss of water both renal and nonrenal routes. Insensible losses of water may increase in the setting of fever, exercise, heat exposure, severe burns, or mechanical ventilation. Diarrhea is, in turn, the most common gastrointestinal cause of hypernatremia. Notably, osmotic diarrhea and viral gastroenteritides typically generate stools with Na+ and K+ <100 mM, thus leading to water loss and hypernatremia; in contrast, secretory diarrhea typically results in isotonic stool and thus hypovolemia with or without hypovolemic hyponatremia. Common causes of renal water loss include osmotic diuresis secondary to hyperglycemia, excess urea, postobstructive diuresis, or mannitol;Hypernatremia due to a water diuresis occurs in central or nephrogenic diabetes insipidus (DI). Ref: Harrison 19e pg: 302


Question: Commonest presentation of sickle cell anaemia is

Sickle cell anemis causes Vaso-occlusive crisis : This means plugging of small vessels in the bone produces severe bone pain. This affects areas of active marrow: the hands and feets in children(dactylitis) or femora, humeri, ribs, pelvis and veebrae in adults. Reference : Davidson, 23rd Edition, page no : 952.


Question: The commonest intrabronchial cause of haemoptysis is


Question: Maximal deaths in MI occurs within

(A) 0-24 hrs > The vast majority of deaths due to ventricular fibrillation occur within the first 24 h of the onset of symptoms, and of these, over half occur in the first hour.> Therefore, the major elements of prehospital care of patients with suspected STEM I include Recognition of symptoms by the patient and prompt seeking of medical attention Rapid deployment of an emergency medical team capable of performing resuscitative maneuvers, including defibrillation Expeditious transportation of the patient to a hospital facility that is continuously staffed by physicians and nurses skilled in managing arrhythmias and providing advanced cardiac life support Expeditious implementation of reperfusion therapy


Question: Most common site of histiocytosis is

Ans. is 'a' i.e. bone Histiocytosis is a disorder of the mononuclear phagocytic system.Mononuclear phagocytic system consists of monoblasts, promonocytes, monocytes and tissue macrophages.Macrophages are transformed monocytes i.e. monocytes present in the tissues. Monocytes emigrate continuously from peripheral blood into the tissuesHistiocyteThe term histiocyte is synonymous with macrophage.In diseases of mononuclear phagocytic system the terms histiocyte and histiocytosis are used.Langerhans cellsLangerhans cell is macrophage and plays important role in immunity.It processes antigen and present it to T cells.Langerhans cells histiocytosis (LCH) is a clonal histiocytosis and the lesions are characterized by the presence of Langerhans cells, eosinophils and Lymphocytes in a variable number.The various features of Langerhans cells are:Presence of Birbeck granules (E/M - HX bodies)Presence of enzymes likea Naphthyl acetate esterasea Naphthyl butyrate esteraseAcid phosphataseMarkers likeS-100 positivityCD-I a positivityHCA-DR expressionEarlier the term histiocytosis X was used which includedLetterer-Siwe diseases (generalised disease)Hand schuller-christian diseaseEosinophilic granuloma (localised lesion)However, now the term Langerhans cell histiocytosis is preferred Langerhans cell histiocytosis includes 3 clinicopathologic entitiesAcute disseminated Langerhans cell histiocytosisMultifocal Langerhans cell histiocytosisUnifocal Langerhans cell histiocytosisAcute disseminated LCH (Letterer siewers disease)* This is the most severe form with systemic lesionsUsually affects children < 2 yearsSeborrheic type of skin rash is present over the front and back of the trunk and scalpHepatosplenomegaly is moderateLymphadenopathy is positivePulmonary lesions are not uncommonLytic lesions in bones are seenFever is of moderate degreeOtitis media andMastoiditis may be present Hematological findings of LCH CytopeniasAnemia, neutropenia and thrombocytopenia. These may occur in isolation or in combination.Cytopenias occur because hematopoietic cells in marrow get replaced by histiocytes.Bone marrowBone marrow shows infiltration by histiocytes which are large cells with abundant cytoplasm having a vesicular, oval or indented nucleus. These cells are loaded with cholesterol.E/M reveals Birbeck granulesS100, CD1a positiveMultifocal LCHMultiple lesions involving many systems.Prognosis is better than in the disseminated LCH.Usually affects children who presents with fever and skin eruptions on the scalp.Some of the patients demonstrate involvement of posterior pituitary stalk of hypothalamus resulting in diabetes insipidus.Some manifests proptosis of eye.There is evidence of osteolytic lesions in some of the bones like skull, orbit, jaw, femur, vertebrae and ribsHistomorphology of the lesion demonstrates histiocytes admixed with eosinophils.Unifocal LCHThis is characterized by a focal lesion amenable to treatment and carry a good prognosis.This focal disease affects the skeletal system.Commonly affected bones are calvaria, ribs and femur.The lesions may be asymptomatic or may cause pain, tenderness and pathological fractures.


Question: A child is exclusively fed on cow's milk. the  deficiency seen in

Cow's milk is a poor source of vitamin C and Iron.


Question: Metabolic alkalosis is seen in

Ans. is 'a' i.e., Primary mineralocorticoid excess * Mineralocorticoid excess increases net acid excretion, this leads to metabolic alkalosis.Also knowThe plasma potassium concentration changes with serum pH.If pH decreases the excess H+ tends to enter the body's cells in exchange for K+ and plasma increases.If the pH increases (alkalosis) H+ tends to leave cells and enters bloodstream to partly compensate for the alkalosis.In exchange for H\ K+ enters the cells and results in decreased plasma hypokalemic alkalosis.Causes of Metabolic AlkalosisExogenous HCO3' loadsAcute alkali administrationMilk-alkali syndromeEffective ECFV contraction, normotension, K+ deficiency, and secondary hyperreninemic hyperaldosteronismGastrointestinal originVomitingGastric aspirationCongenital chloridorrheaVillous adenomaCombined administration of sodium polystyrene sulfonate (Kayexalate) and aluminum hydroxide.Renal originDiureticsEdematous statesPost hypercapnic stateHypercalcemia/hypoparathyroidismRecovery from lactic acidosis or ketoacidosisNonabsorbable anions including penicillin, carbenicillinMg2+deficiencyK+ depletionBartter's syndrome (loss of function mutations in TALH)Gitelman' s syndrome (loss of function mutation in Na+-Cl- cotransporter in DCT)ECFV expansion, hypertension, K+ deficiency, and mineralocorticoid excessHigh reninRenal artery stenosisAccelerated hypertensionRenin-secreting tumorEstrogen therapyLow reninPrimary aldosteronismAdenomaHyperplasiaCarcinomaAdrenal enzyme defectslip - Hydroxylase deficiency17a - Hydroxylase deficiencyCushing's syndrome or diseaseOtherLicoriceCarbenoxoloneChewer's tobaccoLydia Pinkam tabletsGain of function mutation of renal sodium channel with ECFV expansion, hypertension, K+ deficiency, and hyporeninemic- hypoaldosteronismA.Liddle's syndromeThis is the complete list of metabolic alkalosis the list given in answer 32 is not complete.


Question: Most common symptom of lung carcinoma


Question: The mortality rate in Acute hemorrhagic pancreatitis is

(20%) (1896-H) (628-CMDT-09) (2011-H17th)* The term hemorrhagic pancreatitis is less meaningful in a clinical sense because variable amounts of interstitial hemorrhage can be found in pancreatitis as well as in other disorders such as pancreatic trauma, pancreatic carcinoma, and severe CHF (1896-H)* Prognosis (674-CMDT-05)Mortality rate for acute pancreatitis have declined from at least 10% to around 5% in the past 20 years, but the mortality rate of severe acute pancreatitis (more than three Ranson criteria) remains at least 20%, especially when hepatic cardiovascular or renal impairment is present in association with pancreatic necrosis.* Recurrence are common in alcoholic pancreatitis* Mortality rate for undrained pancreatic abscess approaches 100% (1900-H)


Question: Cerebral angiography was performed by


Question: Residul lung volume increased in

(B) Emphysema# FACTORS AFFECTING FRC> FRC Increases with: Increased height Erect position (30% more than in supine) Decreased lung recoil (E.g. emphysema)> FRC Decreases with: Obesity, Muscle Paralysis (especially in supine) Restrictive lung disease (E.g. Fibrosis, Pregnancy) Anaesthesia FRC does not change with age> Emphysema is a condition of the lung characterized by abnormal permanent enlargement of the airspaces distal to the terminal bronchiole, accompanied by destruction of their walls and without obvious fibrosis.> Principal antielastase activity in serum and interstitial tissue is alpha 1 -AT (others are secretory leukoprotease inhibitor in bronchial mucus and serum alphal -macroglobulin), and the principal cellular elastase activity is derived from neutrophils (other elastases are formed by macrophages, mast cells, pancreas, and bacteria). Neutrophil elastase is capable of digesting human lung, and this digestion can be inhibited by alphal-antitrypsin.> The most plausible hypothesis to account for the destruction of alveolar walls is the protease-antiprotease mechanism. This hypothesis is based on two important observations, one clinical and one experimental. The first is that homozygous patients with a genetic deficiency of the protease inhibitor alphal -AT have a markedly enhanced tendency to develop pulmonary emphysema, which is compounded by smoking.# Emphysema is classified into distinct pathologic types:> The most important types being centriacinar and panacinar.# Centriacinar emphysema, the type most frequently associated with cigarette smoking, is characterized by enlarged airspaces found (initially) in association with respiratory bronchioles.> Centriacinar emphysema is most prominent in the upper lobes and superior segments of lower lobes and is often quite focal.# Panacinar emphysema refers to abnormally large airspaces evenly distributed within and across acinar units.> Panacinar emphysema is usually observed in patients with a1 AT deficiency.> Pulmonary function testing shows airflow obstruction with a reduction in FEV1 and FEV1/FVC With worsening disease severity, lung volumes may increase, resulting in an increase in total lung capacity, functional residual capacity, and residual volume.> In patients with emphysema, the diffusing capacity may be reduced, reflecting the parenchymal destruction characteristic of the disease.


Question: Left Axis Detion is seen as

Answer is B (Positive in Lead I and Negative in Lead II) Left axis detion is seen as positive deflexion in Lead I and a Negative deflection in Lead II. Calculating the cardiac axis: Normal Axis Right axis detion Left axis detion Lead I Positive Negative Positive Lead II Positive Positive or negative Negative Lead III Positive or negative Positive Negative Note: Lead I : POSITIVE BETWEEN -90 TO +90 (CLOCKWISE) Lead II : POSITIVE BETWEEN -30 TO +150 (CLOCKWISE) Lead III : POSITIVE BETWEEN +30 TO -150 (CLOCKWISE)

Positive in Lead I and Positive in Lead II

Negative in Lead I and Negative in Lead II

Negative in Lead I and positive in Lead II


Question: The following feature is in our of ulcerative colitis over Crohn&;s disease

The major symptoms of UC are diarrhea, rectal bleeding, tenesmus, passage of mucus, and crampy abdominal pain.Ulcerative ColitisCrohn's diseaseClinical Gross blood in stoolYes OccasionallyMucusYesOccasionallySystemic symptomsOccasionallyFrequentlyPainOccasionallyFrequentlyAbdominal massRarelyYesSignificant perineal diseaseNoFrequentlyFistulasNoYesSmall intestinal obstructionNoFrequentlyColonic obstructionRarelyFrequentlyResponse to antibioticsNoYesRecurrence after surgeryNoYesEndoscopicRectal sparingRarelyFrequentlyContinuous diseaseYesOccasionally"Cobblestoning"NoYesGranuloma on biopsyOccasionallyRadiographicSmall bowel significantly abnormalNoYesAbnormal terminal ileumNoYesSegmental colitisNoYesAsymmetric colitisNoYesStrictureOccasionallyFrequentlyRef: Harrison 19e pg: 1956


Question: In a patient with bronchial asthma silent chest signifies

Ans. is 'c' i.e., Grave Prognosis Silent chest (Little/no air movement without wheezes in Bronchial Asthma suggests a grave prognosis/impending respiratory failure (Life threatening Asthma). Signs of impending respiratory failure include : Drowsiness or confusion Diaphoresis Bradycardia Paradoxical thoraco abdominal Signs of impending respiratory failure in Asthma Drowsiness or confusion Diaphoresis Bradycardia Paradoxical thracoabdominal movements PEFR < 33% Hypotension Pulsus paradoxus Hypercapnea Silent chest


Question: Minimum concentration of reduced hemoglobin required for cyanosis is

Cyanosis refers to a bluish discolouration of the skin and mucous membranes resulting from an increased quantity of reduced hemoglobin(I.e.,deoxygenated hemoglobin)or of hemoglobin derivatives(eg.,methemoglobin or sulfhemoglobin)in the small blood vessels of those tissues.Cyanosis becomes apparent when the concentration of reduced hemoglobin in capillary blood exceeds 5gm/dL. Ref:Harrison' s medicine-18th edition page no:288.


Question: The most common presentation of IgA nephropathy

The two most common presentations of IgA nephropathy are - Recurrent episodes of macroscopic hematuria during or immediately following an upper respiratory infection often accompanied by proteinuria . Persistent asymptomatic microscopic hematuria. Nephrotic syndrome is uncommon . Ref:Harrison 20 th edition pg no 2140


Question: Single gene autosomal recessive disease is

Single gene autosomal recessive disease is Wilson's disease.
Tuberous sclerosis, Huntington's disease are autosomal dominant disorder
Schizophrenia is a multifactorial disease.


Question: Most common cause of pleural effusion in HIV" patients includes

(D) Kaposi's sarcoma # AIDS> Pleural effusions are uncommon in such patients.> The most common cause is Kaposi's sarcoma, followed by parapneumonic effusion.> Other common causes are TB, cryptococcosis, and primary effusion lymphoma.> Pleural effusions are very uncommon with Pneumocystis carinii infection.


Question: Screening tests for B cell defects

T cell markers are unidigits (Eg: CD3) B cell markers are double digits (Eg: CD20)


Question: The clinical feature of normal pressure hydrocephalus is

(D) Gait disturbance # Causes Of Dementia# Normal-pressure hydrocephalus (NPH) is a relatively uncommon syndrome consisting of an abnormal gait (ataxic or apractic), dementia (usually mild to moderate), and urinary incontinence.> Historically, many individuals who have been treated as having NPH have suffered from other dementias, particularly AD, multi- infarct dementia, and DLB.> Neuroimaging findings in NPH are those of a communicating hydrocephalus with a patent aqueduct of Sylvius.> In many cases periventricular edema is present.> Lumbar puncture findings include an opening pressure in the high-normal range and normal CSF protein, sugar concentrations, and cell count.> NPH is presumed to be caused by obstruction to normal flow of CSF over the cerebral convexity and delayed absorption into the venous system.> Indolent nature of the process results in enlarged lateral ventricles but relatively little increase in CSF pressure.> There is presumably stretching and distortion of white matter tracts in the corona radiata, but the exact physiologic cause of the clinical syndrome is unclear.


Question: Best predictor for coronary artery disease

Elevated LDL cholesterol and decreased HDL cholesterol are independent predictors of coronary heart disease.
Although there is consensus regarding the benefits of lowering LDL cholesterol the value of elevating HDL
cholesterol remains controversial.
Low HDL and coronary risk
High serum HDL cholesterol is associated with a lower risk of CHD.
The incidence of CHD events in a normal population appears to be inversely related to serum HDL cholesterol with
low levels being associated with increased coronary risk.
Based upon data from the Framingham Heart study, the risk for myocardial infarction increases by about 2 5% for
every 5mg/dl (.13 mmol/l) decrement in serum HDL cholesterol.
Elevated LDL and coronary risk
Elevation in LDL cholesterol is a well-known risk factor for the development of coronary artery disease.
Association of elevated LDL with coronary artery disease has been established in various trials and studies.
There is linear reduction in cardiovascular disease with progressive lowering of the LDL cholesterol.
Traditionally LDL levels are considered to be the most important factor in the prediction of coronary artery disease.
The importance of LDL as a risk factor lies in the fact that effective therapies are available to lower it, while it is not
so in the case of HDL. So when treating dyslipidemia for reducing cardiovascular events, the first target is LDL and
not HDL.
Doubt and Controversy
What is creating doubts in our mind is a table from Braunwald 8th/e p1008 according to which ‘Low HDL’ appears to
be better marker for prediction of future cardiovascular disease than ‘High LDL’
According to this bar diagram in Braunnwald 8th/e pl008 - the adjusted hazard ratio for future cardiovascular events
for LDL is 1.62 while that of HDL is 2.32. But the text given in the book does clarify which one is better marker, (we
have given this table from Braunwald in our previous discussion on this topic in Nov 2009 Medicine).
We have tried to confirm this ‘Low HDL’ fact from various other books. But none of the texts clearly favored any one
between these 2 to be the better marker. Both LDL and HDL are mentioned to be important.
We have also consulted several cardiologist on this. All of them say that the answer should be LDL.
Well, Braunwald is text book of immense reputation, and any information or text given in the book does not need
confirmation from any other source. But what has added to the confusion is that the latest edition of Braunwald i.e.,
9th/e has eliminated that diagram from the book and in the text have not clarified which one is better marker.
Instead, the text states that Apolipo (a) and B 100 are better marker for predicting future cardiovascular events than
LDL and HDL.
We are not absolutely sure of the answer, but we would for the time being go with LDL.
Also Know
The following lipid and lipoprotein abnormalities are associated with increased coronary risk.
Elevated total cholesterol
Elevated LDL cholesterol
Low HDL cholesterol
Increased total to HDL cholesterol ratio
Increased non HDL cholesterol
Hypertriglyceridemia
Increased Lp(a)
Increased apolipoprotein B
Small dense LDL particles


Question: Most common cause of Thrombotic Pulmonary Embolism is

(B) Deep vein thrombosis# DEEP VENOUS THROMBOSIS in the leg or in the pelvis is most likely the cause of pulmonary embolism, but in about 80-90%, it occurs without any previous clinical manifestations.> Pulmonary embolism: Following dislodgement of venous thrombi generally from femoral and iliac veins.> Causes: Multiple trauma, tumor embolus, amniotic fluid.> Sign and symptoms: Pleurisy, haemoptysis, crackles, shortness of breath.> Sign and symptoms of right heat failure and raised CVP> Diagnosis: Ventilation perfusion scan (confirm the diagnosis). Contrast enhanced CT scan (most accurate technique).> Treatment: Thrombolytic agents (streptokinase, TP factors).> Pulmonary embolectomy (may be required).> Lung transplantations indicated in: End stage parenchymal or pulmonary vascular disease> Cystic fibrosis and irreversible pulmonary hypertension with right ventricular failure.


Question: An adult patient weighting 70 kg has fasting blood sugar 180 mg/dl. He is having


Question: Chronic Renal Diseases / failure is commonly associated with

Answer is A (Metabolic Acidosis): Chronic Renal Disease/Failure is commonly associated with metabolic acidosis. 'Metabolic acidosis is a common disturbance in advanced chronic Renal Disease '-


Question: Hyperphosphatemia is seen in

Hyperphosphatemia in chronic kidney disease (CKD) patients is a potentially life altering condition that can lead to cardiovascular calcification, metabolic bone disease (renal osteodystrophy) and the development of secondary hyperparathyroidism (SHPT). Ref Davidson 23rd edition pg 344


Question: Blink reflex is used for

Ans. a. Mid pontine lesions The Blink Reflex Test (B) is a neurophysiological examination used for evaluation of brainstem reflex circuits.: In veebrate anatomy the brainstem (or brain stem) is the posterior pa of the brain, adjoining and structurally continuous with the spinal cord. It is usually described as including the medulla oblongata (myelencephalon), pons (pa of metencephalon), and midbrain (mesencephalon). Pons: The pons contains nuclei that relay signals from the forebrain to the cerebellum, along with nuclei that deal primarily with sleep, respiration, swallowing, bladder control, hearing, equilibrium, taste, eye movement, facial expressions, facial sensation, and posture A number of cranial nerve nuclei are present in the pons Mid-pons: the 'chief' or `pontine' nucleus of the trigeminal nerve sensory nucleus (V) Mid-pons: the motor nucleus for the trigeminal nerve (V) Lower down in the pons: abducens nucleus (VI) Lower down in the pons: facial nerve nucleus (VII) Lower down in the pons: vestibulocochlear nuclei (vestibular nuclei and cochlear nuclei) (VIII) The corneal eye blink reflex neural circuit consists of Trigeminal 1deg afferent (free nerve endings in the cornea, trigeminal nerve, ganglion, root, and spinal trigeminal tract), which end on --> Trigeminal 2deg afferent in the spinal trigeminal nucleus, some of which send their axons to --> Reticular formation interneurons, which send their axons bilaterally to --> Facial motor neurons in the facial nucleus, which send their axons in the facial nerve to --* Orbicularis oculi, which functions to lower the eyelid


Question: Quincke's sign in  aortic regurgitation refers to

Sign
 Presentation

Becker's sign
Prominent retinal artery pulsation

Corrigan's sign
Prominent carotid pulsation

De Musset's sign
Head nodding in time with the heart beat

Duroziez's sign
Systolic and diastolic murmurs heard over the femoral artery while partially compressing the vessel with the diaphragm of the stethoscope

Gerhardt's sign
Pulsation of the spleen in time with the heart beat

Hill's sign
Higher blood pressure (>20mmHg) in the legs than in the arms.

Landolfi's sign
Rhythmic pupillary pulsation in time with the heart beat.

Lincoln sign
Excessive pulsation in the popliteal artery.

Mayne's sign
A fall in diastolic blood pressure (> 15mm Hg ) on raising the arm above the head

Muller's sign
Pulsation of the uvula in time with the heart beat

Quincke's sign
Prominent capillary nail bed pulsation

Rosenbach's sign
Pulsation of the liver in time with the heart beat

Traube's sign
A double sound heard over the femoral artery while compressing it distally

Ashrafian sign
Pulsatile pseudo proptosis.

Sherman's sign
An easily palpable dorsalis pedis pulse in a patient over the age of 75 years.

Pulsation of uvula in time with heart beat


Question: Bipolar II disorder characterized by

(B) Hypomania and severe depression # SUBTYPES OF BIPOLAR DISORDER1. Bipolar I: Characterized by episodes of severe mania and severe depression.2. Bipolar II: Characterized by episodes of hypomania (not requiring hospitalization) and severe depression.


Question: 10% Tumour is

Pheochromocytomas normally obey the “rule of 10”. Hence, they are also called the “10% tumor”. i.e. 10% of pheochromocytomas are:

Familial.
Malignant.
Bilateral.
Extra-adrenal.
Seen in children


Question: Most common cause of chronic kidney disease


Question: Brugada syndrome is associated with

Mutations involving car- diac sodium channels are identified in approximately 25% of cases. Distinction from patients with similar ST elevation owing to LV hyperophy, pericarditis, myocardial ischemia or MI hyperkalemia, hypothermia, right bundle branch block, and ARVC is often difficult Ref Harrison 20th edition pg 1423


Question: Emporiatrics deals with the health of the


Question: SA node is supplied by

Ans. a (Right coronary artery). (Ref. Harrison's Medicine, 18th ed/Chapter 230.)SA NODE# SA node lies at the junction of right atrium and SVC.# It measures 15 mm x 2-3 mm in size.# It is supplied by sinus node artery, which arises from right coronary (60%) or left circumflex coronary artery (40%).AV node# AV node lies at the bases of inter-atrial septum just above the tricuspid annulus and anterior to coronary sinus.# It is supplied by posterior descending coronary artery (90%).Bundle of His# Has dual blood supply (*AV nodal artery + branches of anterior descending coronary artery).


Question: A ventricular aneurysm has one of the following characteristic features

left ventricular aneurysm can be diagnosed on ECG when there is persistent ST segment elevation occurring 6 weeks after a known transmural myocardial infarction (usually an anterior MI). Without knowing the past medical history, the ECG changes of an aneurysm may mimic an acute anterior MI. Ref Davidson 23rd edition pg 465


Question: A patient with burns presents to the emergency room. He was started on intravenous fluids. The best method to assess the adequacy of volume replacement is

Answer: b) Urine output (Merck manual & Handbook of Evidence based critical care)Treatment of shock is directed at maintainingCVP of 8-12 mm HgMean arterial pressure of >65 mmHg (systolic pressure >90 mmHg)Cardiac index of 2-4 L/min/m2The urine output rate should be kept at >0.5 mL/kg per hourAdequate end-organ perfusion is best indicated by urine output of > 0.5 to 1 mL/kg/hHeart rate, mental status, and capillary refill may be affected by the underlying disease process and are less reliable markers.Because of compensatory vasoconstriction, mean arterial pressure (MAP) is only a rough guideline; organ hypoperfusion may be present despite apparently normal values.An elevated arterial blood lactate level reflects hypoperfusion; however, levels do not decline for several hours after successful resuscitation.HEMODYNAMIC SUPPORT IN SHOCKNS or RL (crystalloids) is the first choice for acute stage of resuscitationWhen fluid requirements are high, colloids (Dextran, gelatin, 5% albumin) are of usePacked RBC should be given at 10 mL/kg to maintain hematocrit at 30% or Hb 9 g/dLBolus of 20ml/Kg given rapidly over 5-10 mins; if no response - repeat bolusPatients who do not respond to rapid boluses of 40-60ml/Kg in the first hour are labeled as fluid refractory shock and inotrophic support (dopamine or dobutamine) should be givenUse insulin only if it is needed to maintain the blood glucose concentration below 150 mg/dLFirst line Vasopressor inAnaphylactic shock: EpinephrineSeptic shock, Cardiogenic shock, Vasodilatory shock: NorepinephrineRefractory shock: EpinephrineIf shock persists - catecholamine resistant shock - give Hydrocortisone if adrenal insufficiency is suspectedACTH stimulation test is not useful for detecting less profound degrees of corticosteroid deficiency in patients who are critically illVasodilators (nitroprusside, nitroglycerine) in children remaining hypodynamic with high SVR despite fluid and ionotropic supportChildren remaining normotensive with low output state and high SVR despite epinephrine and vasodilator - phosphodiesterase III inhibitors (Amrinone, Milrinone) are givenRecombinant activated protein C (aPC) - for severe sepsis or septic shock


Question: Most common site of peptic ulcer is

The term 'peptic ulcer' refers to an ulcer in the lower oesophagus, stomach or duodenum, in the jejunum after surgical anastomosis to the stomach or, rarely, in the ileum adjacent to a Meckel's diveiculum. Ulcers in the stomach or duodenum may be acute or chronic; both penetrate the muscularis mucosae but the acute ulcer shows no evidence of fibrosis. Erosions do not penetrate the muscularis mucosae The prevalence of peptic ulcer (0.1-0.2%) is decreasing in many Western communities as a result of widespread use of Helicobacter pylori eradication therapy but it remains high in developing countries. The male-to-female ratio for duodenal ulcer varies from 5:1 to 2:1, while that for gastric ulcer is 2:1 or less. Chronic gastric ulcer is usually single; 90% are situated on the lesser curve within the antrum or at the junction between body and antral mucosa. Chronic duodenal ulcer usually occurs in the first pa of the duodenum and 50% are on the anterior wall. Gastric and duodenal ulcers coexist in 10% of patients and more than one peptic ulcer is found in 10-15% of patients. Ref Davidson edition23rd 798


Question: Xerophthalmia is a public health problem if prevalence of bitot spots is

Night blindness : > 1%.
Bitot spots : >0.5%.
Corneal ulcer : >0.05%.
Corneal xerosis : >0.01%.


Question: Helicobacter pylori is not associated with


Question: Intravenous fluid of choice in management of diabetic ketoacidosis

Answer-A. Normal salineTreatment of DKA1. InsulinA bolus of IV IM sho acting insulin (regular insulin) should be given immediately to reduce blood glucose level'Subsequent treatment should piovide continuous and adequate level ofcirculating insulin'2. IV fluidDue to vomiting, osmotic diuresis and hyperventilation, there is dehydration and Na. deficit in DKA which should be treated by iv saline infusion.Normal saline (0.9% saline) k the fluid of choice3. KCI4. Sodium bicarbonate5. Magnesium and phosphate


Question: Suramin is the drug of choice for


Question: Investigation of choice in bronchiectasis is

HRCT chest is more specific for bronchiectasis and is the imaging modality of choice for confirming the diagnosis.CT findings include airway dilation(detected as parallel "tram tracks" or as the "signet-ring sign"-a cross sectional area of the airway with a diameter at least 1.5 times that of the adjacent vessel),lack of bronchial tapering(including the presence of tubular structures within 1 cm from the pleural surface.),bronchial wall thickening in dilated airways,inspissated secretions (eg.,the " tree-in-bud" pattern ),or cysts emanating from the bronchial wall(especially pronounced in cystic bronchiectasis.) Reference:Harrison's medicine-18th edition,page no:2143.


Question: The most common cause of malignant adrenal mass is

Ans. is 'd' i.e., Metastasis from another solid tissue tumor The most common cause of adrenal tumors is metastasis from another solid tumor like breast cancer and lung cancer. Malignant Percentage Adrenocoical carcinoma 2-5% Malignant pheochromocytoma <I% Adrenal neuroblastoma <0- 1% Lymphomas (incl. primary adrena lymphoma) <1% Metastases (most frequent : Breast, lung) 15%


Question: Aoic regurgitation does NOT occur in

Aoic regurgitation Valvular Congenital (bicuspid) Endocarditis Rheumatic fever Myxomatous (prolapse) Traumatic Syphilis Ankylosing spondylitis Root disease Aoic dissection Cystic medial degeneration Marfan's syndrome Bicuspid aoic valve Nonsyndromic familial aneurysm Aoitis Hypeension ( Harrison&;s principle of internal medicine,18th edition,pg no.1930)


Question: Kerley B line are seen at

Ans. is 'd' i.e., Pleural surface Kerley's line Kerley's line is a linear opacity which, depending on its locaton, extent and orientation, may be be fuher classified as :? Kerley's A lines o These are thin, non-branching lines radiating from hilum. These lines are 2-6 cm in length. These lines are found in the mid and upper zones of the lung fields pleural. These lines are due to the thick interlobar septa. Kerley's B lines (septal lines) These are transverse (Horizontal) lines at the lung base pleural. These are 1-2 cm in length and are perpendicular to pleura. Kerley's B line is due to the thickening of interlobar septa due to edema caused by pulmonary venous hypeension (congestion), as occurs in left ventricular failure or mitral stenosis


Question: Most common lesion in diabetic nephropathy

m/c - Diffuse glomerulosclerosis
Pathognomonic - Kimmelstiel Wilson nodule


Question: ROME III criteria for Irritable bowel syndrome AE

Answer- B. Rectal bleedingROME II Diagnostic Criteria for Functional Bowel Disorders-Irritable Bowel SyndromeFunctional Abdominal BloatingFunctional ConstipationFunctional DiarrheaUnspecifed Functional Bowel Disorder

Onset associated with change in frequency of stool

Onset associated with change in form of stool


Question: The most sensitive test for diagnosis of myasthenia gravis is

Electromyography is most sensitive test for diagnosing myasthenia gravis


Question: Pyrazinamide acts on

(C) Tuberculous bacilli in macrophages # PYRAZINAMIDE A derivative of nicotinic acid, pyrazinamide is an important bactericidal drug used in short-course therapy for tuberculosis.> Mechanism of action: Pyrazinamide is similar to isoniazid in its narrow spectrum of antibacterial activity, which essentially includes only M.tuberculosis. The drug is bactericidal to slowly metabolizing organisms located within the acidic environment of the phagocyte or caseous granuloma; it is active only at a pH of <6.0. Pyrazinamide is considered a prodrug and is converted by the tubercle bacillus to the active form pyrazinoic acid. The target for this compound is thought to be a fatty acid synthase gene. Susceptible strains of M. tuberculosis are inhibited by 20p g/mL.

Interfering folic acid biosynthesis of mycobacteria

Bacteriostatic activity on growing organisms


Question: Type II Respiratory failure is characterised by (Davidson)

(Low PaO2/High PaCO2) (1684 -H17th)Respiratory failure - PaO2 <8.0 kPa (60mmHg) and PaCO2 > 6.5 kPa (50 mmHg)Type 1 - PaO2 low, PaCO2 normal or lowType II - PaCO2 raised, PaO2 low - Ventilatory failure* Most important - cause in chronic type II respiratory failure is - chronic bronchitis


Question: Most important drug used in the treatment of coronary artery disease is


Question: Best treatment for exercise induced asthma is

The stepwise approach to the management of asthma Step 1: Occasional use of inhaled sho-acting b2-adrenoreceptor agonist bronchodilators A variety of different inhaled devices are available and the choice of device should be guided by patient preference and competence its use. The metered-dose inhaler remains the most widely prescribed . For patients with mild intermittent asthma (symptoms less than once a week for 3 months and fewer than two nocturnal episodes per month), it is usually sufficient to prescribe an inhaled sho-acting b2-agonist, such as salbutamol or terbutaline, to be used as required. However, many patients (and their physicians) under-estimate the severity of asthma. A history of a severe exacerbation should lead to a step-up in treatment. (BUD), fluticasone, mometasone or ciclesonide) should be staed in addition to inhaled b2-agonists taken on an as-required basis for any patient who: * has experienced an exacerbation of asthma in the last 2 years * uses inhaled b2-agonists three times a week or more * repos symptoms three times a week or more * is awakened by asthma one night per week. For adults, a reasonable staing dose is 400 ug beclometasone dipropionate (BDP) or equivalent per day in adults, although higher doses may be required in smokers. Alternative but much less effective preventive agents include chromones, leukotriene receptor antagonists and theophyllines. The preferred asthma medications are sho-acting beta-2 agonists such asalbuterol. Taken 10 minutes before exercise, thesemedicationscan prevent the airways from contracting and help control exercise-induced asthma. Having good control of asthma in general will also help prevent exercise-induced symptoms Ref Davidson edition23rd pg 571


Question: The treatment of metastatic testicular carcinoma is

Standard chemotherapy for Germ Cell tumour is BEP regimen B- Bleomycin (30units) Day 2, 9, 16 E- Etoposide (100mg/m2) Day 15 P- Cisplatin (20mg/m2) Day 15 ref - Harrisons internal medicine 20e pg635-36,633


Question: A patient presented with thunder clap headache followed by unconsciousness with pregressive 111 ranial nerve palsy. Likely diagnosis is

davidson's principles and practices of medicine 22nd edition. *85% of SAH are caused by saccular or berry aneurysm arise from bifurcation of cerebral aeries *SAH typically presented with a sudden ,severe ,thunderclap headache (often occipital) , which lasts for hours or even days,often accompanied by vomitting , raised blood pressure and neck stiffness or pain. *there may be loos of consciousness at the onset ,so SAHshould be consider if patient is comatose *focal neurological signs like hemiparesis,aphasia may be present at onset if there is an associated intracerebral hematoma *a third nerve palsy present due to local pressure from an aneurysm of posterior communicating aery. Ref Harrison20th edition pg 2456


Question: A patient presented with high frequency SNHL, Ipsilateral cerebellar ataxia. The site of lesion is

(B) Cerebellopontine # Cerebellar limb ataxia results from disorders of the spinocerebellar and corticopontocerebellar inputs, the integrator of these inputs in the intermediate and lateral cerebellum, or the output to the spinal neurons (via the red nucleus and rubrospinal tract) or to the cortex. These pathways ensure adequate speed, fluency, and integration of limb movements. The lateral cerebellar hemisphe es coordinate a polysynaptic feedback circuit that modulates cortically initiated limb movement.


Question: The minimum dose of radiation to produce cerebral symptoms

(5000 rads) (2588-H 15th)OrganInjuryMinimum tolerance doseMaximum tolerance doseWhole or partial organ(Field size or length)Bone marrowAplasia250450Whole Pancytopenia300004000SegmentalLiverAcute hepatitis25004000*Whole Chronic hepatitis15002000Whole (Strip)StomachPerforation, ulcer, hemorrhage45005500100 cmIntestineUlcer, perforation45005500400 cm Haemorrhage50006500100 cmBrainInfarction necrosis5000*6000WholeSpinal cordInfarction necrosis4500550010 cmHeartPericarditis,4500550060% Pan carditis7000800025%LungAcute and chronic pneumonitis30003500100 cm 15002500WholeKidneyAcute and chronic nephrosclerosis15002000Whole (strip) 20002500WholeFetusDeath200400Whole


Question: SARS causative agent

Ans. a. Corona-virus SARS-associated coronavirus (SARS-CoV) caused epidemics of pneumonia from November 2002 to July 2003. Corona Virus SARS virus is corona virus. Corona virus infections in human beings usually remain limited to upper respiratory tract. In contrast, the outbreak of SARS in 2003 was characterized by serious respiratory illness, including pneumonia and progressive respiratory failure. In all likelihood, the SARS virus originated in a non-human host and acquired the ability to infect humans. Chinese horse-shoe bats are natural reservoirs of SARS-like Coronavirus. Incubation period of SARS Coronavirus: 6 days Death from progressive respiratory failure occurs in almost 10% of cases, with highest death rates among elderly.


Question: Bilateral facial palsy is not seen in

(B) Ramsay Hunt syndrome # Bilateral facial palsy occurs in Gullian Barre syndrome, in a form of sarcoidosis called uveoparotid fever (Heerfordt syndrome) and in bilateral acoustic neuroma.> Facial Neuropathy> An isolated facial palsy may occur in patients with HIV seropositivity, sarcoidosis, or Lyme disease , but most often it is idiopathic (Bell's palsy)> In the Ramsay Hunt syndrome, pain and vesicles appear in the external auditory canal, and patients lose their sense of taste in the anterior two-thirds of the tongue while developing ipsilateral facial palsy. The geniculate ganglion of the sensory branch of the facial nerve is involved.


Question: Hyperpigmentation is seen with

Ref image - Davidson's medicine 23e p672


Question: A male patient presents with headache, profuse sweating and palpitations with a blood pressure of 180/120 mm Hg. The drug of choice would be

Answer is B (Labetalol) Symptomatic Hypeension with diastolic pressure of 120 suggest a diagnosis of Hypeensive Emergency. Labetalol (intravenous) is the drug of choice for management of Hypeensive Emergencies (amongst the options provided).


Question: In lobar pneumonia, the presence of fibrinosuppurative exudate with disintegration of red cells is seen in the stage of


Question: Beryllium expsore is associated with

Beryllium can produce a chronic granulomatous inflammatory disease that is similar to sarcoidosis.It is distinguished from sarcoidosis by evidence of a specific cell-mediated immune response(delayed hypersensitivity) to beryllium.Chest imaging shows nodules along septal lines.Pulmonary function tests show restrictive and /or obstructive ventilatory defects and decreased diffusing capacity. Ref:Harrison's medicine-18th edition,page no:2125.


Question: Features of neurogenic shock are


Question: Treatment of uncomplicated hydatid cyst in lung is


Question: Deficiency of Arylsulphatase is seen in

(B) Metachromatic leukodystrophy (MLD) # Metachromatic leukodystrophy (MLD) is a lysosomal storage diseases, which are progressive, inherited, and neurodegenerative disorders (MLD included).> 4 types of MLD occur with varying ages of onset and courses (i.e., 1. Late infantile, 2. Early juvenile, 3. Late juvenile, 4. Adu t).> All forms of MLD involve a progressive deterioration of motor & neurocognitive function.> The typing is somewhat arbitrary, as the types overlap, and some cases do not fall neatly within a single type. MLD actuall / describes a continuum of clinical severity. The presence of white matter abnormalities on brain images is characteristic.> Pathophysiology: In patients, the inability to degrade sulfated glycolipids, especially the galactosyl-3-sulfate ceramides, characterizes MLD. A deficiency in the lysosomal enzyme sulfatide sulfatase (arylsulfatase A) is present in MLD.


Question: Broca's aphasia is


Question: Nephrocalcinosis is seen in

Answer is A (Medullary sponge kidney) Medullary sponge kidney and Hyperparathyroidism are established causes ofNephrocaleinosis.


Question: Tadalafil should NOT be used in

(B) Patient on Nitrates therapy[?]Sildenafil, Tadalfil, Vardenafil & Avanafil are the only approved & effective oral agents for the treatment of Erectile Dysfunction.oThese 4 drugs markedly improved the management of erectile dysfunction, because they are effective for the treatment of a broad range of causes, including psychogenic, diabetic, vasculogenic, post-radical prostatectomy (nerve-sparing procedures), & spinal cord injury.oThese are Selective & Potent Inhibitors of PDE-5, the predominant phosphodiesterase isoform found in the penis.DrugOnset of ActionHalf-lifeDoseAdverse EffectsContraindicationsTadalafilTmax,30-60 min Duration, 12-36 h Plasma concentration Not affected by food or ETOH17.5 h10 mg, 20 mg; 2.5 or 5 mg or daily doseHeadache,dyspepsia,back pain,nasalcongestion,myalgiaNitratesHypotensionCardiovascular risk factorsRetinitis pigmentosaChange dose with some antiretroviralsShould be on stable dose of alpha blockers[?]Significant Drug Interactions & Contraindications:oPhosphodiesterase 5 (PDE5) inhibitors include Sildenafil (Viagra), Vardenafil (Levitra), & Tadalafil (Cialis).-The administration of any of these drugs with doses of any Nitrate is contraindicated.-The combination can cause dangerously low blood pressure.[?]Contraindications of Tadalafil Black 80 mg:oThe consumption of this drug is chiefly avoided due to some medical issues in men like:-Abnormal conditions or deformity of genitals-Hypersensitivity problem to any ingredient of this drug.-Heart related problems-Severe renal insufficiency-History of stroke & heart attack-Severe pulmonary disorders.-Patients with history of AMI/stroke/fatal arrhythmias <6 month Nitrates - total contraindication/PDEIs in small dose + spacing at least 24 hrs (48 hrs with Tadalafil) for fear of developing IHD/AMI due to severe hypotension.oPrecautions for Tadalafil:-With alpha blockers (except Tamsulosin) - orthostatic hypotension.-With hepato/renal insufficiency.-With Pyronie's disease-With bleeding tendencies (leukemia's, hemophilia, Vitamink K deficiency, Antiphospholipid syndrome... etc).-With quinidine, procainamide, amiodarone (class I & III antiarhtmics) (Vardenafil).-Dose adjustment; when using drugs that have interaction on hepatic livery microsomal enzymes i.e., inhibitors or inducers.-Retinitis pigmentosa.OTHER OPTIONS[?]Nitrates are vasodilators acts by producing vascular smooth muscle relaxation through cGMP pathway.-Cyclic GMP is hydrolyzed to 5 GMP by PDE5-Tadalafil is a Phosphodiesterase 5 (PDE5) inhibitors-Inhibition of PDE5 prolongs and accentuates the cGMP in smooth muscle causes relaxation.-Taking tadalafil with vasodilator drug like nitrate can cause sudden & serious decrease in blood pressure.oTadalafil in treatment of Pulmonary Arterial Hypertension is used to improve haemodynamics & excercise ability oTadalafil in treatment of Sexual dysfunction like Erectile dysfunction is treated by5-20 mg taken 1-2 h before sex, is now the standard treatment for maintaining erections.oRemember1-Combination with vasodilators results in sudden changes of blood pressure values:-Tadalafil relaxes muscles of the blood vessels and increases blood flow to particular areas of the body.-Used to treat erectile dysfunction, and symptoms of benign prostatic hypertrophy-Also in treatment of Pulmonary Arterial Hypertension is used to improve haemodynamics & excercise ability.oWhen given alone to men with severe coronary artery disease, these drugs have modest effects on blood pressure, producing >10% fall in systolic, diastolic & mean systemic pressures & in pulmonary artery systolic & mean pressures.oSildenafil, tadalafil & vardenafil all have a significant & potentially dangerous interaction with organic nitrates, the therapeutic actions of which are mediated via their conversion to NO with resulting increases in cyclic GMP.oIn the presence of a PDE5 inhibitor, nitrates cause profound increases in cyclic GMP and can produce dramatic reductions in blood pressure.


Question: Anti fodrin antibodies are positive in

Anti fodrin are directed against muscarinic receptors seen in sjogren. Sjogren&;s syndrome is a late onset chronic systemic autoimmune disease characterized by lymphocytic infiltration and destruction of the salivary and lacrimal glands resulting in dry mouth(xerostomia) and dryness and atrophy of conjunctiva and cornea (keratoconjunctivits sicca). This disease is caused by an immune-mediated inflammation of salivary,lacrimal and sweat glands as Sicca Syndrome or with internal organ involvement. Clinical Types PRIMARY SS - Alone. SECONDARY SS - associated underlying connective tissue diseases (RA / SLE / Scleroderma ) SICCA SYNDROME -- Xerophthalmia + Xerostomia --Internal Organ / Bone C/F * Glandular manifestation Dry mouth (Xerostomia) due to decreased production of saliva by salivary glands * Lacrimal Gland Involvement -- Dryness of eyes causes keratoconjuctivitis sicca. * Burning itchy sensation in the eyes. SKIN MANIFESTATIONS (50% Xeroderma, pruritus and scaling Annular erythema, Papular Erythema including Sweet&;s-like lesions. Raynaud&;s syndrome Hyperglobulinemic Purpura Vitiligo Sweating abnormalities Cutaneous Amyloidosis Alopecia diffuse and generalized Diagnosis SS patients of both primary and secondary Sjogren&;s syndrome have marked hypergammaglobulinemia (IgG>IgA>IgM),ANA(>50c)/0) elevated total protein and sedimentation rate. Anti-Ro and Anti-La Antibodies occur in approximately 60% of patients with Sjogren&;s syndrome * Histolgy of skin shows an absence of sebaceous glands and decrease in the sweat glands. Revised classification criteria for Sjogren&;s Syndrome Ocular symptoms : at least one of - * Dry eyes for more than 3 months * Sensation of sand or gravel in the eyes * Need for tear substitutes more than 3 times a day * Oral Symptoms : at least one of -- * Dry mouth for more than 3 months * Recurrently or Persistently swollen salivary glands * Need liquids to swallow dry food * Ocular Signs --at least one the following two tests positive * Schirmer&;s test * Rose Bengal score 4. Histopathology: in minor salivary glands, focal lymphocytic sialoadenitis (focus score ?A). 5. Salivary gland involvement: a positive result for at least one of the following diagnostic tests: 1 Unstimulated whole salivary flow (1.5 ml in 15 min) 2 Parotid sialography showing punctate, cavitary, or destructive pattern, without evidence of obstruction in the major ducts 3 Salivary scintigraphy showing delayed uptake, reduced concentration 6. Autoantibodies -- Anti Ro and Anti La Criteria For primary SS In patients without any potentially associated disease. primary SS may be defined as follows: a. The presence of any four of the six items is indicative of primary SS, as long as either item 4 (Histopathology) or 6 (Serology) is positive. b. The presence of any three of the four objective criteria items (that is, items 3, 4, 5, 6) For secondary SS In patients with a potentially associated disease. the presence of item 1 or item 2 plus any two from among items 3, 4, and 5 may be considered as indicative of secondary SS Treatment Symptomatic treatment for dryness of eyes -- by lubricating agents such as 0.5% methylcellulose eye drops for 4-5 times daily. Cyclosporine ocular drops Bromhexine 16 mg TDS has been found to increase the lacrimal secretion. Aificial saliva and cyclosporin(2.5-5mg/kg), for xerostomia. Routine dental care Steam inhalation may help dryness of the respiratory tract. ref - Harrisons internal medicine 20th ed pg2560


Question: The Hemoglobin A1c level indicates the patient's level of glycemic control during the previous

Measurement of glycated haemoglobin (HbA1c) is the standard method for assessing long-term glycemic control. When plasma glucose is consistently elevated, there is an increase in nonenzymatic glycation of haemoglobin; this alteration reflects the glycemic history over the previous 2-3 months because erythrocytes have an average lifespan of 120 days The glycemic level in the preceding month contributes about 50% to the HbA1c value.Harrison 19the pg: 2410


Question: A 70 years old male develops pneumonia and septicaemia. Patient goes into renal failure and has a B.P of 70/50 mm of Hg. Drug that should be used to maintain B.P is


Question: Tietze syndrome involves swelling of

Painful swelling of second or third Costo chondral joint.


Question: Mutation in alpha 5 chain of collagen 4, the diagnosis

Ans. is 'a' i.e. Alport's syndrome Alport's syndrome is a hereditary nephritis, characterized byMicroscopic hematuria (first symptom)QDeafness QPathology of Alport's syndromeAlport's syndrome is characterized by diffuse glomerular basement membrane thickening.The basement membrane of the glomerulus is made up of type IV collagen.Type IV collagen consists of six differenta chains i.e.a1and a2 located on chromosome 13 (col A4A1, col A4A4)a3 and a4 located on chromosome 2 (col A 4A3, col A 4A2)a5 and a6 located on chromosome 6 (col A 4A5 col A 4A6)a3 a4 and a5 form collagen network present inGlomerular basement membraneCochleaLens capsuleIn Alport's syndrome there is defect in the synthesis of type IV collagen Q because there is a mutation in the gene encoding a5 chain of collagen type IV (col 4A5)These mutations are heterogenous and affect all domains of a5 chain.Because of these defects the glomerular membrane is thin and on electron microscopy it demonstrates irregular foci of thickening alternating with thinning with pronounced splitting of the lamina densa often with "basket weave appearance Q"Also knowPathogenesis of Good pasture syndromeGood pasture syndrome is an uncommon autoimmune disease, characterized by the presence of circulating autoantibodies targeted against the noncollagenous domain of the a-3 chain of collagen IVQ.These antibodies initiate an inflammatory destruction of the basement membrane in kidney glomeruli and lung alveoli, giving rise to proliferative usually rapidly progressive glomerulonephritis Q and a necrotizing hemorrhagic interstitial pneumonitis Q.Clinical features of Alport's syndromeMicroscopic hematuria QHearing loss Q


Question: The following is a marker of acute hepatitis B infection

Ans. is 'a' i.e. DNA polymerase "DNA polymerase activity, HBVDNA, HBeAg which are representative of the viremic stage of hepatitis B occur early in the incubation period concurrently or shortly after the first appearance of HBsAg" -Jawetz - 19h/ep. 475.DNA polymerase is a marker for active viral replication.It is not exclusively associated with acute hepatitis B.It is also seen in chronic hepatitis B when there is active viral replication in chronic hepatitis (Chronic active hepatitis).But since active viral replication is usually associated with acute hepatitis, DNA polymerase is usually associated with seen in acute hepatitis B.Serological markers of Acute Hepatitis B infectionHBsAg appears before the onset of symptoms Q, peaks during overt disease and then declines to undetectable levels in 3-6 months.HBeAg, HBV-DNA and DNA polymerase appear in the serum soon after HBsAg and all signify active viral replication.IgM anti-HBc becomes detectable in serum shortly before the onset of symptoms, concurrent with the onset of elevation of serum aminotransferases. Over months the IgM antibody is replaced by IgG Anti HBc (when infection becomes chronic)Anti HBS is detectable shortly after the disappearance of HBeAg implying that the acute infection has peaked and the disease is on the wane.Hepatitis core antigen never appears in the serum.


Question: In Budd Chiari syndrome, the site of venous thrombosis is


Question: Rx of latent syphilis  a) Penicillin  b) Erythromycin  c) Tetracycline  d) Ciprofloxacin


Question: Drug of choice for maintenance therapy in PSVT is

Table 276-3 Verapamil 5-10 mg ,over 3-5 min , maintenance: 2.5-10 mg/h ,SVT, AF rate control Ref Davidson 20th edition pg 1532


Question: Feature of glomerular haematuria

Answer is A (Dysmorphic R.BO.) Presence of Dysmorphic RBC and RBC cast suggests hematuria of glomerular origin or a glomerular disease.


Question: The most common cause for chronic cor pulmonale is

Answer is B (COPD): The most common cause of chronic cor puhnonale is chronic. obstructive pulmonary disease - Rubin's pathology


Question: Most common cause of subarachnoid haemorrhage is

(C) Trauma # Most common cause of Subarachnoid haemorrhage is Berry aneurysm.> Most common cause of spontaneous subarachnoid haemorrhage is rupture of saccular aneurysm.> Autopsy has revealed 3-4% of population harbour aneurysm. According to Harrison "... .Excluding head trauma, the most common cause of SAH is rupture of a saccular aneurysm...." Head trauma is not a spontaneous cause of SAH.> Sudden severe headache is the commonest presentation of subarachnoid haemorrhage.> Mortality rate is about 50% in first month. Arteriovenous malformation presents as stroke in young person. 85% of the aneurysms occur in the anterior circulation of Willis. Prodromal symptoms help to localize unruptured aneurysm.> 3rd nerve palsy with loss of light reflex and pain above or behind eye: Aneurysm at junction of posterior communicating & internal carotid artery. 6th nerve palsy: Aneurysm at cavernous sinus.> Occipital or posterior cervical pain: Aneurysm at posterior inferior cerebellar artery or anterior inferior cerebellar artery. Four major causes of delayed neurological deficit are - rerupture, hydrocephalus, vasospasm and hyponatraemia. Vasospasm is the major cause of delayed neurological deficit.; The incidence of rerupture is maximum at 7th day. The signs of vasospasm are maximum at 7th day.> MC cause of CVA - Thrombosis> MC site of Hypertensive bleeds Putamen> MC site of berry aneurysm-Ant, cerebral- ant, communicating art, junction# This one has been repeated so many times. Excluding trauma, the most common cause of subarachnoid hemorrhag e is rupture of aneurysm# Causes of subarachnoid hemorrhage: Trauma (most common); Rupture of Berry's aneurysm; Rupture of A.V. malformation> Causes of subarachnoid haemorrhage: Aneurysms ... 70% Arteriovenous malformations ... 10% Idiopathic... 5% Other: Spinal AVM, Tumour, Coagulopathy


Question: As a result of a unilateral lower motor neuron lesion of the hypoglossal nerve

The genioglossus muscle is paralyzed on the side of the lesion in the hypoglossal nerve. When the tongue is protruded, the vector of the fully innervated muscles is unopposed by the muscle on the opposite side, thus producing the obvious detion of the tongue from the midline. Protrusion is still possible due to the normally innervated side. Taste is not related to the muscle innervation of the tongue; it is carried by the trigeminal and glossopharyngeal nerves. Spasticity is a sign of an upper motor neuron lesion. In a lower motor neuron lesion, atrophy of the affected side may be observed by the examiner. Ref - Harrison's internal medicine 20e pg 3028, 3171

The tongue would dete toward the same side as the lesion when protruded

The patient would not be able to protrude the tongue

Taste would be lost on one side of the tongue

The tongue would dete toward the opposit side of the lesion when protruded


Question: Chvostek’s sign is elicited by

The Clinical manifestations of hypocalcemia are mostly due to neuromuscular irritability.
 The patients complains of paresthesias which are typically perioral or of the hands and feets
 Tetany is the classic manifestation of hypocalcemia, the manifestations are :
 Corpopedal Spasm o Laryngospasm o Seizures Latent tetany occurs which can be manifested by
Chvostek sign and  Trousseau sign Electrocardiographic manifestations The classic E.C.G.
change with hypocalcemia is prolonged corrected QT interval Other possible E. C. G.
findings are o Prolonged ST interval o Peaked T waves o Arryhtmmias Heart block (hypocalcemia may impair cardiac contractility and decrease blood pressure) GI.
T manifestations o Intestinal cramps and malabsorption NOTE: Corpopedal spasm: o Contraction the muscels of the hand and feet.
The wrists are flexed and fingers extended, with the thumbs adducted over the palms. Chvostek sign:
Tapping the facial nerve anterior to the external auditory meatus elicits a twitch of the upper lip or entire mouth.
This is not a very specific sign because it is positive in about 10% of patients without hypocalcemia. Trousseau sign:
 A blood pressure cuff is inflated slightly above the systotic blood pressure for more than 3 minutes.
Corpopedal spasm occurs if hypocalcemia is present as a result of the ischemia of motor nerves.

Facial nerve stimulation by tapping over the parotid


Question: Pulsus Bigeminus is seen in therapy with

o Pulsus Bigeminus is recognized as a cause of digitalis toxicity.
o Pulsus Bigeminus is a disorder of rhythm (irregular rhythm; arrhythmia) most commonly caused by Premature Ventricular Contracons that results in a pulse with irregular rhythm that alternates in amplitude (pressure) from beat to beat.
The most common cause of Pulsus Bigeminus is Digitalis and Pulsus Bigeminus is recognized as a cause of digitalis toxicity :


Question: Feature of Torsade de pointes is

Polymorphic VT that occurs in the context of congenital or acquired prolongation of the QT interval often has a waxing and waning QRS amplitude creat- ing a "twisting about the points" appearance referred to as Torsade de Pointes Ref Harrison 20th edition pg 1443


Question: ST segment elevation on EKG is not seen in

Causes of ST-segment elevation are as follows: 1. Ischemia/myocardial infarction a. Noninfarction, transmural ischemia (Prinzmetal's angina, and Takotsubo syndrome) b. Acute MI c. Postmyocardial infarction (ventricular aneurysm) 2. Acute pancarditis 3. Normal variant (early repolarization pattern) 4. Left ventricular hyperophy/left bundle branch block 5. Rare causes a. Brugada pattern b. Class-1c antiarrhythmic drugs c. DC cardioversion d. Hypercalcemia e. Hyperkalemia f. Hypothermia (J wave/Osborne waves) g. Myocardial injury i. Myocarditis J. Tumor invading left ventricle K. Trauma to ventricles Ref - Harrison&;s principles of internal medicine 20th ed pg 1680


Question: Candle wax dripping sign is seen in

Answer- A. SarcoidosisCondle wax chipping sign is a feature of occular Sarcoidosis.


Question: In prolactinoma most common symptom other than galactorrhea is

Answer- B. AmennorheaAmenorrhoea and galactorrhoea are the major endocrine manifestation of prolactinoma.


Question: A patient underwent adrenalectomy in views of B/L pheochromocytoma , 1 day later developed lethargy ,fatigue, low BP and pulse normal No signs of volume deficit , likely course is

ADDISONIAN CRISIS PRESENTATION Sudden penetrating pain in the legs, lower back or abdomen Severe vomiting and diarrhea, resulting in dehydration Low blood pressure, Unexplained shock, usually refractory to fluid and pressor resuscitation Syncope (loss of consciousness) Hypoglycemia Confusion, psychosis, slurred speech Severe lethargy Hypercalcemia Convulsions Fever Rapid withdrawal of long-term steroid therapy " Hypehermia or hypothermia ref : harrisons 21st ed


Question: Cardiac biomarkers of choice for diagnosis of myocardial infraction 10 days after initial event

Ref Harrison 19 th ed pg 1594 addition to the clinical examination, three major noninvasive tools are used in the evaluation of NSTEMI-ACS: the electrocardiogram (ECG), cardiac biomarkers, and stress testing. CCTA is an additional emerging option The goals are to: (1) recognize or exclude myocardial infarction (MI) using cardiac biomarkers, preferably cTn;


Question: Ipsilateral VI & VII nerve palsy with contralateral hemiplegia is known as

Site of disease: PonsAery involved is AICAStructure involved are: 6th and 7th cranial nerve and coicospinal tract, so patient presents with ipsilateral 6 & 7 cranial nerve palsy and contralateral hemiparesis.


Question: Antibody in asthma treatment

Omalizumab o Omalizumab is an anti IgE agent approved by the (FDA)
for use in patients age 12 and above with moderate to severe persistent allergic asthma with
: - An IgE level of30-700 lu/ml. Positive allergen skin or specific IgE tests to a perenmial allergen and Incomplete symptom control
with inhaled glucocorticoid treatment. o Omalizumab is administered by “subcutaneous injecon ” every mo to four weeks in a dose that
is determined by- body weights and the level of serum IgE.
o Omalizumab produces 25% reduction in rate of asthma exacerbations.
 The response to omalizumab therapy is variable and dif icult to predict with overall response rates in patients with moderate to severe asthma averaging 30-50%.
 A minimum of 12 weeks of treatment is necessary to determine the efficacy 1 ofanti-IgE theraphy


Question: The following enzyme is not elevated in polymyositis

Polymyositis is a type of inflammatory myopathy, which refers to a group of muscle diseases characterized by chronic muscle inflammation and weakness. elevations of serum activities of the so called "liver enzymes", the transaminases and lactate dehydrogenase (LD) in myositis Ref Robbins 9/e pg 226


Question: Alpha,anti trypsin deficiency causes

Ans b (panacinar -emphysema) Ref Harrison 17th pg 1638Emphysema is classified into distinct pathologic types, the most important being centriacinar and panacinar.Centriacinar emphysema -cigarette smoking- enlarged airspaces in association with respiratory bronchioles- upper lobes and superior segments of lower lobes and is often quite focal.Panacinar emphysema - large airspaces evenly distributed within and across acinar units-Alpha! AT deficiency- lower lobes.Risk factors for the development of COPDTobacco smokeBiomass solid fuel firesOccupational -Coal miners & cadmiumAir pollutionLow birth weightChildhood infections & maternal smoking


Question: Christmas disease is treated by

Fresh frozen contains all the coagulation factors except platelets. Also erythrocytes and leukocytes are absent in it. The specific treatment is with factor9 concentrate. The new extended half life recombinant factor 9 products made by Fc fusion, albumin fusion and pegylation offer the possibility of prophylaxis on a once-weekly or even two-weekly schedule. Reference : Davidson, 23rd Edition, page no : 974.


Question: Keshan disease is an endemic cardiomyopathy found in deficiency of

(Selenium) (410-H) (449-H17th)Keshan disease - found in children and young women residing in regions of china where dietary intake of selenium is low (< 20 mg/d)* Concomitant deficiencies of iodine and selenium may worsen the clinical manifestations of cretinism.


Question: Faget sign is

Answer- B. Bradycardia with hypehermiaThe Faget sign (sphygmotheric dissociation) is the unsual pairing of fever and bradycardia.Often seen in -Yellow feverTyphoid feverTularaemiaBrucellosisColorado tick fever


Question: Characteristic feature of korsakoff psychosis is


Question: The most common translocation seen in patients with Multiple Myeloma is

Answer is A (t(11;14)) The most common translocation seen in patients with Multiple Myeloma is 01;14). `The most common translocation seen in patients with Multiple Myeloma is t(11;14)(q13;q32) involving the BCL1 locus on chromosome 11g13 and the immunoglobulin heavy (IgH) chain locus on chromosome 14q13 which leads to overexpression of Cyclin D1 '- The Washington Manual of Surgical Pathology `The two most common translocation seen in patients with Multiple Myeloma are t(11;14)and t(4; 14). Both these translocations occur with almost similar frequencies, however the incidence of translocation 1(11; 14) appears to be marginally higher. Patients with t(4; 14) fall within a poor prognosis subgroup, while those with 1(11; 14) have a standard risk' - The Principles of Clinical Cytogenetics The two most common translocation seen in patients with Multiple Myeloma t(11;14)(q13;q32) : Associated with standard prognosis t(4;14) (p16;q32) : Associated with aggressive behaviour and poor prognosis The most common translocation in multiple myeloma associated with a poor prognosis is translocation t(4;14)


Question: Comment on the diagnosis

ECG shows hea rate of 70/min with T wave inversion noted in leads V1 to V4. Indicates possible Myocardial ischemia. Choice A and D are ruled out as there is no ST elevation. Pulmonary embolism leads to "S1Q3T3 pattern" (McGinn-White Sign)


Question: 30 year old female patient complains of breath less ness since 5 month, Her pulmonary function tests report is as follows

Among the given options pulmonory fibrosis fits into restrictive lung disease.


Question: According to American diabetes association, HbAlc levels in diabetes patients under control are


Question: Gegenhalten (paratonia) indicates lesion in

Ans. c (Frontal lobe) (Ref. Harrison 18th/Fig 370-9).PARATONIA: | tone that varies irregularly in a manner that may seem related to a degree of relaxation, is present throughout the range of motion, affects flexors and extensors equally, usually results from lesion of bilateral frontal lobes or dominant frontal lobe.RIGIDITY: | Tone, affects flexors and extensors equally; seen in extrapyramidal lesionsSPASTICITY: | tone, affects mainly extensors and seen in pyramidal tract lesions.Signs and symptomsStructures involved# Paralysis of opposite foot and leg# A lesser degree of paresis of opposite arm# Cortical sensory loss over toes, foot, and legMotor leg areaArm area of cortex or fibers descending to corona radiateSensory area for foot and leg# Urinary incontinenceSensorimotor area in paracentral lobule# Contralateral grasp reflex, sucking reflex, gegenhaiten (paratonic rigidity)Medial surface of the posterior frontal lobe; likely supplemental motor area# Abulia (akinetic mutism), slowness, delay, intermittent interruption, lack of spontaneity, whispering, reflex distraction to sights and soundsUncertain localization--probably cingulate gyrus and medial inferior portion of frontal, parietaland temporal lobes# Impairment of gait and stance (gait apraxia)Frontal cortex near leg motor area# Dyspraxia of left limbs, tactile aphasia in left limbsCorpus callosumDeficit/feature of lesion of a particular area of brainLobesImportant regionsDeficit after lesionFrontalPrimary motor and premotorFrontal eye fieldsBroca speech area*Contralatera spastic paresis (region depends on area of homunculusEyes deviate to ipsilateral sideBroca aphasia (expressive, nonfluent aphasia): patient can understand written and spoken language, but speech and writing are slow and effortful; patients are aware of their problem; often associated with contralateral facial and arm weaknessPrefrontal cortexFrontal lobe syndrome: symptoms can include poor judgement, difficulty concentrating and problem solving, apathy, inappropriate social behaviorParietalPrimary somatosensory cortexSuperior parietal lobuleInfrerior parietal lobuleContralateral hemihypesthesia (region depends on area homunculus affected)Contralateral asteroegnosis and sensory neglect, apraxiaGerstmann syndrome (if dominant hemisphere): right/left: confusion, dyscalculia and dysgraphia, finger agnosia, contralateral hemianopia or lower quadrantanopiaTemporalPrimary auditory cortexBilateral damage deafnessUnilateral leads to slight hearing lossWernicke area*Wernicke aphasia (receptive, fluent aphasia); patient cannot understand any form of language; speech is fast and fluent, but not comprehensibleHippocampusAmygdalaOlfactory bulb, tract, primary cortexMeyer loop (visual radiations)Bilateral lesions lead to inability to consolidate short-term to long-termKluver-Bucy syndrome: hyperphagia, hypersexuality, visual agnosia Ipsilateral anosmiaContralateral upper quadrantanopia ("pie in the sky")OccipitalPrimary visual cortexBlindnessAlso Remember: Parietal lobe lesions | | | Dominant lobe Non dominant lobe | | Multinodal complex motor activities affected Multinodal complex sensory disabilities | | # Ideational# Ideomotor# Alexia}Apraxia Visuospatial disorders(Hemiattention) AnosognosiaDressing and constructionalApraxia# Gerstamann's syndrome


Question: Low haptoglobin in haemorrhage is masked by concurrent presence of

D i.e Liver parenchymal disease Haptoglobin (Hp) binds extracorpuscular (i.e. extracellular) hemoglobin (Hb), preventing free Hb from entering the kidney. Hp-Hb complex is removed from plasma by haptocytes. Levels of haptoglobin falls rapidly in situations where hemoglobin is constantly being released from RBC such as occurs in hemolytic anemia (haemorrhage). But in case of parenchymal liver disease, Hp-Hb complex removal is deranged so reduction in haptoglobin level is masked. Haptoglobin It is a plasma glycoprotein that binds extracapsular hemoglobin (Hb) in a tight non-covalent complex. Its amount ranges from 40mg- 180 mg of hemoglobin binding capacity / deciliter. Only 10% of degraded hemoglobin is released in circulation (i.e. extra corpuscular) the remaining 90% is present in old damaged RBCs, which are degraded by histiocytic system. Free Hb (molecular mass 65KDa) passes through glomerulus and precipitate in tubules. However, after binding with haptoglobin (90 KDa) the Hb-Hp complex (155KDa) becomes too large to pass through glomerulus. So the function of haptoglobin is to prevent loss of free hemoglobin into kidney and conserve the valuable iron present in hemoglobin, which would otherwise be lost to the body. Humans have 3 polymorphic forms, k/a Hp 1-1, Hp 2-1, Hp 2-2. Low levels of haptoglobins are found in patients with hemolytic anemia. This is explained by the fact that where the life of Hp is 5 days, the t1/2 of Hb-Hp complex is 90 minutes, the complex being rapidly removed by hepatocytes. So when the hepatoglobin is bound to Hb, it is cleared from plasma about 80 times faster than normally. Hb is an acute phase protein & is elevated in variety of inflammatory states. * Haptoglobin related protein binds hemoglobin; hemopexin binds free heme; and albumin binds metheme (ferric heme)


Question: Drug of choice in the treatment of onchocerciasis is

(B) Ivermectin # Ivermectin, a semisynthetic macrocyclic lactone active against microfilariae, is the first-line agent for the treatment of onchocerc asis.> It is given orally in a single dose of 150 pg/kg, either yearly or semiannually.


Question: In essential hypertention changes seen in the heart are

Ans. is 'b' i.e., Cardiac cell hypertrophy Hypertrophy - It's increase in size of a tissue d/t increase size of individual cells.Hyperplasia - Increase in size of a tissue as a result of increased no. of component cells . It's the principle mechanism for increased size in tissue composed of labile & stable cells.Hypertrophy is seen in following tissues #Tissue - Cause of increased demandsSkeletal muscle hypertrophy - physical activity, weight lifting*Cardiac muscle hypertrophy - Increased pressure load (Hypertension)*Increased volume load *("Valve incompetence causing regurgitation of blood")Smooth muscle hypertrophy - obstructive lesions (Wall of intestine & urinary bladder)Renal hypertrophy - Unilateral disease of one kidneyRemoval of one kidneyHyperplasia* is seen in - Breast growth* (during pregnancy & lactation)Both hypertrophy and hyperplasia* is seen in - uterine growth during pregnancy*


Question: Giant V wave on examination of the jugular venous pulse is suggestive of

(B) tricuspid incompetence # Tricuspid regurgitation causes the v wave to be more prominent; when tricuspid regurgitation becomes severe, the combination of a prominent v wave and obliteration of the x descent results in a single large positive systolic wave.> After the v wave peaks, the right atrial pressure falls because of the decreased bulging of the tricuspid valve into the right atrium as right ventricular pressure declines and tricuspid valve opens# Jugular venous pulse> Normal: 3 +ve pulse waves -a, c and v 2 -ve pulse waves -x and y> 'a'wave: Due to right atrial contraction Synchronous with carotid artery pulse> Absent'a'wave : Atrial fibrillation> Diminished 'a' wave: Tachycardia Prolonged PR interval> 'a' Wave Fused with (c' Wave: Supra ventricular tachycardia> Large 'a' Waves : Pulmonary hypertension Pulmonary stenosis Tricuspid stenosis Tricuspid atresia AV dissociation> Cannon Waves (Giant 'a' Waves) : Complete heart block when right atrium occasionally contracts against closed tricuspid valve Ventricular tachycardia Ectopic beats> Regular 'a' Waves : AV junctional rhythm 10AV block 2 : 1 AV block Atrial tachycardia> Irregular 'a' Waves: Premature systoles: Atrial Ventricular AV junctional Complete AV dissociation: Complete AV block AV junctional tachycardia Ventricular tachycardia Atrial flutter> Non-conducted 'a' waves: Atrial tachycardia Atrial flutter with block> 'c' Wave : Produced by Impact of carotid artery to jugular vein Retrograde transmission of positive wave in right atrium (by ventricular systole and bulging of tricuspid valve into right atrium). Carotid artefact Systolic bulging of tricuspid valve into RA> V Wave: Absent 'x' wave: Constrictive pericarditis Restrictive cardiomyopathy ASD (sometimes)> v Wave : during ventricle contraction caused by atrial filling and occurs with and just after carotid pulse.# Large V Waves: Tricuspid regurgitation ASD Anomalous pulmonary venous drainage, Right sided heart failure> 'y' Wave: Slow Descent y Wave : Tricuspid stenosis Sharp Descent y Wave : Constrictive pericarditis Rapid Descent y wave : Constrictive pericarditis (Friedreich's sign) Severe heart failure Tricuspid regurgitation


Question: Anti ds DNA antibody is specific for

Ref image- Harrison's internal medicine 20e p2517


Question: Electric alternans is seen in

Rrf Harrison 19 th ed pg 1573 There may be reduction in ampli- tude of the QRS complexes, and electrical alternans of the P, QRS, or T waves should raise the suspicion of cardiac tamponade . the features that distinguish acute cardiac tampon- ade from constrictive pericarditis.


Question: Late onset of puberty in the male is defined as

"The diagnosis of delayed puberty is made when signs of sexual development, such as an increase in the volume of the testis are not evident even by the age of 14years in boys and breast budding by 13 years in Girls".
Some important causes of delayed puberty

Hypothyroidism
Hyperprolactinemia
Noonan syndrome
Klinefelter syndrome


Question: A common cause of Primary hyperparathyroidism is


Question: A patient with HIV has diarrhoea with AF +ve organism in stool. The most likely organism is

Surprised,

Usually, the mycobacterium is associated with respiratory tract infection.
In HIV infections mycobacterium is an important cause of diarrhoeas.
The incidence of the extrapulmonary disease is increased in patients with HIV.

Work up in an HIV patient with diarrhoea.

The initial evaluation of a patient with HIV infection and diarrhoea includes:-
A set of stool examination including culture, examination for ova and parasites. and
Examination for Clostridium difficile toxin.
Approximately 50% of the time this workup will demonstrate infection with pathogenic bacteria, mycobacteria or protozoa.
AFB +ve organism suggests the presence of Mycobacterium.
We have two options to choose from either mycobacterium. T.B. or mycobacterium avium intracellulare.
Both mycobacterium T.B. and M.A.C. can cause diarrhoea in patients with HIV and obviously, both of them are acid-fast, So, which one to choose from.
I am in favour of Mycobacterium avium intracellular.
MAC infections are more likely to cause diarrhoea.
The presumed portals of entry in MAC are respiratory and gastrointestinal tract.
While discussing HIV patients with diarrhoea.  Harrison Says -"Abdominal pain and diarrhoea may be seen with MAC infection."
Thus it seems MAC infection is more likely to cause diarrhoea.
But still, I am not sure of the answer.
The incidence of Mycobacterium T.B. is more than the incidence of MAC in HIV, so mycobacterium T.B. should account for the greater number of diarrhoeal cases in H.I.V.


Question: For the following medical conditions, select the associated acid base disturbances.Hepatic cirrhosis complicated by AKI.

Hepatic cirrhosis frequently results in chronic respiratory alkalosis. AKI with metabolic acidosis is common in patients with cirrhosis.

metabolic acidosis and respiratory acidosis

metabolic acidosis and respiratory alkalosis

metabolic alkalosis and respiratory acidosis

metabolic alkalosis and respiratory alkalosis


Question: The following drug is used recently in Alcohol dependence patients

(B) Naltrexone # Rehabilitation of Alcoholics> While the mainstay of alcoholic rehabilitation involves counseling, education, and cognitive approaches, several medications might be useful.> The first is the opioid-antagonist drug Naltrexone, 50 to 150 mg/d, which has been reported in several small-scale, short-term studies to decrease the probability of a return to drinking and to shorten periods of relapse.> However, at least one longer-term large-scale trial questioned the superiority of naltrexone to placebo, and more studies are required before the cost-effectiveness of this approach can be established.> A second medication, acamprosate (Campral), 2 g/d, has been tested in >5000 patients in Europe, with results that appear similar to those reported for naltrexone.> Several long-term trials of naltrexone and acamprosate, used individually and in combination, are in progress, and early results are promising.> A third medication, which has historically been used in the treatment of alcoholism, is the ALDH inhibitor disulfiram.> In doses of 250 mg/d this drug produces an unpleasant (and potentially dangerous) reaction in the presence of alcohol, a phenomenon related to rapidly rising blood levels of the first metabolite of alcohol, acetaldehyde.


Question: The test used to diagnose Dubin Johnson syndrome is

Answer is B (Bromsulphalein / Sulfobromophthalein) The appearance of late rise in plasma level of Bromsulphalein, BSF / Sulfobromophthalein in the clearance of this dye has been considered as a oathormontie sign of Dubin Johnson syndrome - Metabolism of Bromsulphalein in D-J syndrome; Digestive diseases and Sciences Vol/17 numbers 6. Patients with D - J syndrome exhibit a characteristic rise in plasma concentration of Bromsulphalein at 90 minutes after injection due to reflux of conjugated BSP into circulation from Hepatocyte. - Harrison Bromsulphalein test for Dubin Johnson syndrome : Harrison 16th / 1821 Dubin Johnson syndrome is characterized by a Familial / Autosomal Recessive defect in Hepatic excretory function (fom hepatocyte to biliary canaliculi ) Biliary excretion of a number of anionic compounds is compromised including that of sulfohromphthalein (Bromsulphalein, BSP), a synthetic dye (cholecystographic agent). To test for D -- J syndrome, the role of disappearance of BSP from plasma is determined after its bolus intravenous administration. Patients with D - J syndrome exhibit a characteristic rise in its plasma concentration at 90 minutes after injection due to reflux of conjugated BSP into circulation from Hepatocyte. -- Harrison Dubin Johnson Syndrome : Review During Johnson syndrome is an autosomal recessive() hereditary disorder presenting with conjugated hyperbilirubinemiaQ due to defect in hepatic excretory function across the canalicular membrane of hepatocyte.() Clinical presentation * Most patient are asymptomatic (subclinical chemical hyperbilirubinemia) * Unexplained low grade jaundice during teenage years Often exacerbated by : -- Oral contraceptive use -- Pregnancy -- Intercurrent illness * Physical examination is usually normal (occasional patient may have hepatosplenomegaly) Laboratory studies * Coniuifated Ilvperbilirubinemia :Total bilirubin is typically between 2 -- 5 mg/dl (34 -- 85 ymol/L) May occasionally he Normal or as high as 20-25 mg/dI(340-430 ,umol/L) * Bilirubinitria :Typically present as hyperbilirubinemia is conjugated * Other Routine Liver Function Tests including Serum Transaminases and Alkaline Phosphatase are essentially Normal Diagnosis Bromsulphalein test :Elaborated above Histology : Corporphyrin test Deposition of melanin like pigment occurs in the (Preferential urinary excretion of corporphyrin-l) liver causing liver to appear dark or completely black. Corporphrins are byproducts of heme biosnthesis There are two naturally occurring corporphyrins -- I & III Pigment is thought to be derived from epinephrine Normally approx. 75 % of corporpyrin in urine is isomer III metabolites that are not excreted normally In urine of patients with D-J Syndrome total corporphyrin content in urine is norma but > 80 % is Isomer I


Question: Indications for use of cyclophosphamide in SLE is

Cytotoxic therapy is a cornerstone for patients with severe systemic lupus erythematosus (SLE). High-dose cyclophosphamide, 200 mg/kg, can induce a complete remission without the need for stem cell rescue in patients with autoimmune illnesses.High dose cyclophosphamide is a therapy capable of decreasing disease severity in poor prognosis SLE patients. Future study is warranted for both refractory patients as well as primary therapy for patients with moderate to severe disease presentations . Ref Davidson 23rd edition pg 941


Question: In AIDS patients, CD4 count >75 lymphocyte count, cotton wool spots in eye examination reveales infection of

(CMV) (1154, 1158- CMDT-08) (1180-CMDT-09)Relationship of CD4 count to development of opportunistic infections || 500 - Bacterial infections TuberculosisH. simplex, Zoster, Hairy leukoplakia Kaposis* sarcoma ||| |||||||||||||||||| 200 -Pneumocytosis Toxoplasmosis Cryptococcosis Coccidiodomycosis Cryptosporidiosis ||| |||||||||| 50 - Disseminated. Mycoavium complex- Histoplasmosis- CMV retinitis- CNS- Lymphoma ||**Cotton wool spots - seen in CMV retinitis** White fluffy exudates is the most common retinal infection in AIDS*Hypogonadism is probably the most common endocrine abnormalities in HIV infected man*Toxoplasmosis is the most common space- occupying lesion in HIV infected patients**Pneumocystis jivoveci pneumonia is the most common opportunistic infection associated with AIDS* Definitive diagnosis can be obtained in 50- 80% of cases by Wright- Giemsa stain or Direct fluorescence antibody (DFA) test of induced sputum* Community acquired pneumonia is the most common cause of pulmonary disease in HIV infected persons


Question: Rh factor is

A i.e. IgM antibody - Rheumatoid (Rh) factor in rheumatoid ahritis is an autoantibody of IgM class directed against Fc fragment of IgGQ. - Antibodies (immunoglobins) are glycoproteins. And Rh factors is an autoantibody of any immunoglobin class directed against Fc fragment of IgG immunoglobin (Davidson).


Question: Hypersensitivity vasculitis involve

Hypersensitivity vasculitis, which is usually represented histopathologically as leukocytoclastic vasculitis (LCV), is a term commonly used to denote a small-vessel vasculitis. There are many potential causes of hypersensitivity vasculitis; however, up to 50% of cases are idiopathic. Hypersensitivity vasculitis may present clinically as cutaneous disease only or it may be a cutaneous manifestation of systemic disease. The internal organs most commonly affected in hypersensitivity vasculitis are the joints, gastrointestinal tract, and kidneys. Hypersensitivity vasculitis may be acute and self-limited, recurrent, or chronic. Overall, hypersensitivity vasculitis has a orable prognosis, paicularly when no internal involvement is present . Hypersensitivity vasculitis tends to affect the skin and occasionally the kidney. The loss of integrity of the capillaries and post capillary venules results in extravasation of red blood cells, usually causing purpura and a burning or minimally pruritic sensation. Hypersensitivity vasculitis is thought to be mediated by immune complex deposition.In this form of vasculitis, circulating antigens in the body (produced by factors such as medications, infections, and neoplasms) induce antibody formation. These antibodies bind to the circulating antigen and create immune complexes, which then deposit within vessels, activating complement and inducing inflammatory mediators. Inflammatory mediators, adhesion molecules, and local factors may affect the endothelial cells and play a role in the manifestations of this disease. Additionally, autoantibodies, such as antineutrophil cytoplasmic antibody (ANCA), may be associated with disease manifestations. In ANCA-mediated vasculitis, intracellular proteins from neutrophils become expressed on the cell surface, leading to formation of antibodies (ANCA). These autoantibodies then bind neutrophils, subsequently leading to neutrophil adhesion to vessel walls and cellular activation. Ref - medscape.com


Question: Most common extraintestinal complication of ulcerative colitis is

M/c Arthritis
Peripheral arthritis - responds to treatment
Axial arthritis -does not responds to treatment.


Question: Persistent priapism in childhood is due to

(A) Sickle cell anaemia # Priapism in childhood commonly presents as a common symptom of Sickle Cell Disease especially after puberty, mainly as low flow or as a complication of penile trauma (normally high flow, non-ischemic episodes).> This phenotypic manifestation of SCD can cause persistent impotence, erectile dysfunction and behavioral problems in the sexual realm, as affected individuals fear the induction of an episode of painful erection in the course of normal sexual activity, which is the most common cause of priapism episodes after puberty.> The causative mechanisms are poorly understood but involve complex neurological and vascular factors.>Priapism may be associated with 1. Haematological disorders, especially sickle-cell disease, sickle-cell trait, and 2. Other conditions such as leukemia, thalassemia, and Fabry's disease, and 3. Neurologic disorders such as spinal cord lesions and spinal cord trauma (priapism has been reported in hanging victims; death erection).> Priapism is also found to occur in extreme cases of rabies,>. Priapism can also be caused by reactions to medications.


Question: The prognosis of rapidly prolifeating glomerulonephritis (Crescentric GN) depends upon

Answer is A (Number of crescents) The prognosis of crescentric glonzerulonephritis relates to the number of crescents Prognosis can he roughly related to the number of crescents' - Robbins


Question: Age related dementia has been associated with increased levels of

Identification of modifiable risk factors provides a crucial approach to the prevention of dementia.. The findings are consistent with moderately raised plasma total homocysteine (>11 mmol/L), which is common in the elderly, being one of the causes of age-related cognitive decline and dementia Ref Harrison20th edition pg 2445


Question: Dengue shock syndrome occurs due to