Aiims 2014 PDF

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PART1
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Part
(Q.1) Whichofthefollowingisthetypeofjointbetweenearossicles?
(a)
Primarycartilaginous
(b)
Secondarycartilaginous
(c)
Synovial
(d)
Fibrous
YourResponse:
CorrectAnswer:
Exp:
Synovial.
TYPESOFJOINTSINBODY:HEADTOTOE:
JOINT
TYPE
SubjectTestSeries
Temporomandibularjoints
Condylar(Bicondylar)synovialjoint
2015
Cricothyroidandcricoareytenoidjoint
Synovialjoint
DNBSimplified
Atlantooccipitaljoint,Wristjointand
Metacarpophalangealjoint
Ellipsoidjoint
Sternoclavicularjoint
Saddle(sellar)joint
Earossicles
SaddletypeSynovialjoint
MelleoIncaljoint
BallandsockettypeSynovialjoint
Incudostapedialjoint
Syndesmosis
Stapesfootplate
JointbetweenalaofvomerandRostrumof
sphenoid
Schindylesis(Wedgeandgroovesuture)
Costovertebraljoint
Planesynovialjoint
Costotransversejoint
Synovialjoint
1stchondrosternaljoint,
Primarycartilaginousjoint/Synchondrosis/
Hyalinecartilaginousjoint.
AllCostochondraljoints,
Sphenooccipitaljoint
Jointbetweenepiphysisanddiaphysisof
growingbone
2nd7thchondrosternaljoint
Synovialjoint
5th9thcostalcartilagearticulation
Synovialjoint
10thcostalcartilageisunitedto9thcostal
cartilageby
Fibroustissue.
SuperiorandinferiorRadioulnarjoints
Pivot(Trochoid)joint
MedianAtlantoaxialjoint
http://dbmci.examonair.com/Result/ShowAllQuestionInHtml.aspx?testid=3572
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Middleradioulnarjoint
Syndesmosis
Sternoclavicularjoint
Saddlejoint
ElbowandAnklejoint
Hingesynovialjoint
Hipjoint
Ballandsocketsynovialjoint
Kneejoint
Compoundsynovialjoint
2condylarjointsbetweenmedialandlateral
condylesoffemurandtibia.
1saddlejointbetweenfemurandpatella.
SuperiorTibiofibularjoint
Planesynovialjoint
MiddleTibiofibularjoint
Fibrousjoint
InferiorTibiofibularjoint
Syndesmosis`
Talocalcaneal/Subtalarjoint
Planesynovialjoint
Calcaneocuboidjoint
Saddlejoint
Talocalcaneonavicularjoint
Ballandsocketsynovialjoint
Otherintertarsaljoints
Planesynovialjoint
Symphysispubis
Secondarycartilaginousjoint/Symphyses/
Fibrocartilagenousjoint
Sacrococcygealjoint
Manubriosternaljoint
Intervertebraljoints
(Q.2) Ipsilateralhorizontalgazeisimpairedinlesioninvolving
(a)
Oculomotornucleus
(b)
Abducensnucleus
(c)
Trochlearnucleus
(d)
Vestibularnucleus
YourResponse:
CorrectAnswer:
Exp:
Abducensnucleus(RefHarrisonsprinciplesofinternalmedicine16thed.Chapter25)
HorizontalGaze
Descendingcorticalinputsmediatinghorizontalgazeultimatelyconvergeatthelevelofthepons.
Neuronsintheparamedianpontinereticularformationareresponsibleforcontrollingconjugategazetoward
thesameside.
Theyprojectdirectlytotheipsilateralabducensnucleus.
Alesionofeithertheparamedianpontinereticularformationortheabducensnucleuscausesanipsilateral
conjugategazepalsy.
Lesionsateitherlocusproducenearlyidenticalclinicalsyndromes,withthefollowingexception:vestibular
stimulation(oculocephalicmaneuverorcaloricirrigation)willsucceedindrivingtheeyesconjugatelytothe
sideinapatientwithalesionoftheparamedianpontinereticularformation,butnotinapatientwitha
lesionoftheabducensnucleus.
(Q.3) Trojanigradingsystemisforwhichofthefollowingtumors?
(a)
Bonetumors
(b)
Softtissuesarcomas
(c)
Vasculartumor
(d)
Braintumor
YourResponse:
CorrectAnswer:
Exp:
Softtissuetumors
Baily&Love25thedition,page556
Trojanigradingisusedforgradingsofttissuesarcomas.
thisincludesfourparameters1.Tumordifferentiation,2.Mitoticcount,3.Tumornecrosis,4.Histologic
grade
BonetumorsEnnekingstagingsystem
Softtissuesarcoma:
Twocelltypescanbeseenmicroscopicallyinsynovialsarcoma.Onefibroustype,knownasaspindleor
sarcomatouscell,isrelativelysmallanduniform,andfoundinsheets.Theotherisepithelialinappearance.
Classicalsynovialsarcomahasabiphasicappearancewithbothtypespresent.Synovialsarcomacanalso
appeartobepoorlydifferentiatedortobemonophasicfibrous,consistingonlyofsheetsofspindlecells.
Someauthoritiesstatethat,extremelyrarely,therecanbeamonophasicepithelialformwhichcauses
difficultyindifferentialdiagnosis.Likeothersofttissuesarcomas,thereisnouniversalgradingsystemfor
reportinghistopathologyresults.InEurope,theTrojaniorFrenchsystemisgaininginpopularitywhile
theNCIgradingsystemismorecommonintheUnitedStates.TheTrojanisystemscoresthesample,
dependingontumourdifferentiation,mitoticindex,andtumournecrosis,between0and6andthenconverts
thisintoagradeofbetween1and3,with1representingalessaggressivetumour.TheNCIsystemisalsoa
threegradeone,buttakesanumberofotherfactorsintoaccount.
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(Q.4) Whichofthefollowingisthenucleusoftrigeminalnervewheretheafferentarch(impulses)formasseterreflexarecarried?
(a)
Spinalnucleus
(b)
Mesencephalicnucleus
(c)
Sensorynucleus
(d)
Motornucleus
YourResponse:
CorrectAnswer:
Exp:
Mesencephalicnucleus
TRIGEMINALNERVENUCLEI
MotorNucleus
ThemotornucleusofCNVislocatedintheponsjustmedialtothemainsensorynucleusofthetrigeminal
andadjacenttothepointofexitorentryofthetrigeminalnervefibers.Thesemotorfiberssupplythe
musclesofmastication(masseter,temporalis,andmedialandlateralpterygoid;
SensoryNucleus
Themainsensorynucleusislocatedjustlateraltothemotornucleus.
Themainsensorynucleusreceivestactileandpressuresensationsfromtheface,scalp,oralcavity,nasal
cavity,anddura.
SpinalTrigeminalNucleus
Thespinaltrigeminalnucleusisacaudalcontinuationofthemainsensorynucleus,extendingfromthemid
ponsthroughthemedullatothecervicalcord.Centralprocessesfromcellsinthetrigeminalganglion
conveyingpainandtemperaturesensationsfromthefacedescendinthespinaltractofVandsynapseon
cellsinthespinalnucleus.
MesencephalicNucleus
ThemesencephalicnucleusofCNVislocatedatthepointofentryofthefifthnerveandextendsintothe
midbrain.Itreceivesproprioceptiveinputfromjoints,musclesofmastication,extraocularmuscles,teeth,
andtheperiodontium.Someofthesefiberssynapsemonosynapticallyonthemotoneurons,formingthe
sensorylimbofthejawjerkreflex(Massetermuscle).
Thereisonlyoneareaofthenervoussystemwherethenucleiofprimarysensoryneuronsarelocatedwithin
theCNSratherthaninoutsideganglia.ThisisthemesencephalicnucleusofCN5whichcontainsthenucleiof
CN5proprioceptivefibers.
Locusceruleusisanorepinephrinecontainingbrainstemnucleusthatliesnearthemesencephalicnucleusof
CN5.Itprojectstowidespreadareasofthebrainandmayhaveageneraleffectonmodulatingbrainfunction
(Q.5) WagnerandGrossmanshypothesispertainsto?
(a)
Jointinnervation
(b)
Spinalintersegmantalmovements
(c)
Bonedensitychanges
(d)
Recurrentlaryngealnervepalsy
YourResponse:
CorrectAnswer:
Exp:
Recurrentlaryngealnervepalsy
Laws/Formulations/ConceptsinAnatomy:
Hiltonslaw:Nervesupplytoamusclewhichliesacrossajointnotonlysuppliesthatmusclebutalsosupllies
thejointunderneathandtheskinoverlyingthemuscle.
Lastsformulation:4contiguousspinalsegmentsregulatethemovementofajoint.Upper2segments
controlonemovementsandlower2segmentsregulatetheoppositemovement.
Wolffslaw:Alawstatingthatbonedensitychangesinresponsetochangesinthefunctionalforcesonthe
bone.Wolff(18361902)proposedthatchangesintheformandfunctionofbones,orchangesinfunction
alone,arefollowedbychangesintheinternalstructureandshapeoftheboneinaccordancewith
mathematicallaws.Thus,inmaturebonewherethegeneralformisestablished,theboneelementsplaceor
displacethemselves,anddecreaseorincreasetheirmass,inresponsetothemechanicaldemandsimposed
onthem.Thetheoryissupportedbytheobservationthatbonesatrophywhentheyarenotmechanically
stressedandhypertrophywhentheyarestressed.AlthoughWolff'sproposalrelatesspecificallytobone,the
lawhasalsobeenappliedtootherconnectivetissuessuchasligamentsandtendons.
Gardnersconceptofjointinnervation:Eachnerveinnervatesaspecificregionofthejointcapsuleandthat
thepartofthecapsulewhichismadetautbyagivenmuscleisinnervatedbythenervesupplyingits
antagonist.
DuBoisformula:forcalculatingsurfaceareaofthebody.
A=WxHx
71.84
whereW=weightinkg,H=heightincm.
NeurontheoryofWaldeyer:Contactbetweenneuronsisbycontiguityandnotbycontinuity.
Semonslaw:Inprogressivelesionsoftherecurrentlaryngealnerveabductormusclesoflarynx(Postcrico
arytenoid)are1sttobeparalysedlasttorecoverascomparedtoadductors.Infunctionalparalysisof
recurrentlaryngealnerveadductorsare1stparalysedandrecoverthelast.
Wallenslawofdegeneration:Ifaspinalnerveiscompletelydividedthedistalportionundergoesfatty
degeneration.
WagnerandGrossmanshypothesis:Inrecurrentlaryngealnerveparalysisthecricothyroidmuscleisspared
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whichkeepsthecordsinparamedianpositionduetoitsadductoraction.
(Q.6) Kegelexercisesareadvisedinwhichcondition?
(a)
JRA
(b)
Overactivebladder
(c)
Duchennemyopathy
(d)
Talardomefracture
YourResponse:
CorrectAnswer:
Exp:
Overactivebladder
RefNelson,18thedition,page2252
Kegelexercisesareusedtostrengthenpelvicfloormusclesinvolvedinurination.theseexercisestreatboth
stressincontinenceandurgeincontinence(overactivebladder).Theseexercisesarealsoadvicedto
pregnantfemalestopreventincontinence
IndicationsforFEMALES:
Factorssuchaspregnancy,childbirth,aging,beingoverweight,andabdominalsurgerysuchascesarean
section,oftenresultintheweakeningofthepelvicmuscles.Thiscanbeassessedbyeitherdigital
examinationofvaginalpressureorusingaKegelperineometer.Kegelexercisesareusefulinregainingpelvic
floormusclestrengthinsuchcases.
Urinaryincontinence
Pelvicfloorexercisesarerecommendedforwomenwithurinaryincontinenceofthestress,urge,ormixed
types.Thereistentativeevidencethatbiofeedbackmaygiveaddedbenefitwhenusedwithpelvicfloormuscle
training.
Pelvicprolapse
Thereissomeevidenceshowingapositiveeffectofpelvicfloorexercisesonthesymptomsofprolapseand
itsseverity
Sexualfunction
In1952,Dr.Kegelpublishedareportinwhichheclaimedthatthewomendoinghisexerciseswereorgasming
moreeasily,morefrequentlyandmoreintensely:"ithasbeenfoundthatdysfunctionofthepubococcygeus
existsinmanywomencomplainingoflackofvaginalfeelingduringcoitusandthatinthesecasessexual
appreciationcanbeincreasedbyrestoringfunctionofthepubococcygeus."Thereiscontroversyoverthe
preciseeffectsofthePCmuscleonorgasticresponsebutcertainbenefitsofastrongpelvicfloorarewell
accepted.
IndicationforMEN:
Thoughmostcommonlyusedbywomen,mencanalsouseKegelexercises.Kegelexercisesareemployedto
strengthenthepubococcygealmuscleandothermusclesofthepelvicdiaphragm.Kegelscanhelpmenachieve
strongererections,maintainhealthyhips,andgaingreatercontroloverejaculation.Theobjectiveofthismay
besimilartothatoftheexerciseinwomenwithweakenedpelvicfloor:toincreasebladderandbowel
controlandsexualfunction.
Urinaryincontinence
Afteraprostatectomythereisnoclearevidencethatteachingpelvicfloorexercisesalterstheriskofurinary
incontinence(leakageofurine).
Sexualfunction
Kegelworkoutscanprovidemenwithstrongererections.Researchpublishedin2005issueofBJU
Internationalhasshownthatpelvicfloorexercisescouldhelprestoreerectilefunctioninmenwitherectile
dysfunction.Therearesaidtobesignificantbenefitsfortheproblemofprematureejaculationfromhaving
moremuscularcontrolofthepelvis.
(Q.7) Facialcolliculusislocatedin?
(a)
Pons
(b)
Medulla
(c)
Midbrain
(d)
Interpeduncularfossa
YourResponse:
CorrectAnswer:
Exp:
Pons
Facialcolliculusisanelevatedarealocatedonthedorsalponsintheflooroffourthventricle,oneoneither
sideofmediansulcus.Itisformedbyfibersfromthemotornucleusoffacialnerveastheyloopoverthe
abducensnucleus
Facialcolliculussyndromeinvolveslesionofthesethree
facialnervefiberatgenucausingipsilateralfacialpalsy
abducensnervenucleus
mediallongitudinalfasciculus
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Nerve
Components
Function
OpeninginSkull
I.
Olfactory
Sensory
Smell
Openingsin
cribriformplateof
ethmoid
II.
Optic
Sensory
Vision
Opticcanal
III.
Oculomotor
Motor
Liftsuppereyelid,turnseyeball
upward,downward,andmedially;
constrictspupil;accommodateseye
Superiororbital
fissure
IV.
Trochlear
Motor
Assistsinturningeyeballdownward
andlaterally
Superiororbital
fissure
V.
Trigeminal
Sensory
Cornea,skinofforehead,scalp,eyelids, Superiororbital
andnose;alsomucousmembraneof fissure
paranasalsinusesandnasalcavity
Ophthalmic
division
Maxillarydivision Sensory
Skinoffaceovermaxillaandtheupper Foramenrotundum
lip;teethofupperjaw;mucous
membraneofnose,themaxillaryair
sinus,andpalate
Mandibular
division
Motor
Musclesofmastication,mylohyoid,
anteriorbellyofdigastric,tensorveli
palatini,andtensortympani
Sensory
Skinofcheek,skinovermandible,
lowerlip,andsideofhead;teethof
lowerjawandtemporomandibular
joint;mucousmembraneofmouthand
anteriortwothirdsoftongue
Foramenovale
VI.
Abducent
Motor
Lateralrectusmuscle:turnseyeball
laterally
Superiororbital
fissure
VII.
Facial
Motor
Musclesofface,cheek,andscalp;
stapediusmuscleofmiddleear;
stylohyoid;andposteriorbellyof
digastric
Internalacoustic
meatus,facialcanal,
stylomastoid
foramen
Sensory
Tastefromanteriortwothirdsof
tongue,floorofmouth,andpalate
Secretomotor
Submandibularandsublingualsalivary
parasympatheticglands,lacrimalgland,
andglandsofnoseandpalate
Vestibular
Sensory
Positionandmovementofhead
Cochlear
Sensory
Hearing
VIII.
IX.
X.
XI.
XII.
Vestibulocochlear
Glossopharyngeal Motor
Internalacoustic
meatus
Stylopharyngeusmuscle:assists
swallowing
Secretomotor
parasympathetic
Parotidsalivarygland
Sensory
Generalsensationandtastefrom
posteriorthirdoftongueandpharynx;
carotidsinusandcarotidbody
Motor
Constrictormusclesofpharynxand
Jugularforamen
intrinsicmusclesoflarynx;involuntary
muscleoftracheaandbronchi,heart,
alimentarytractfrompharynxto
splenicflexureofcolon;liverand
pancreas
Sensory
Tastefromepiglottisandvalleculaand
afferentfibersfromstructuresnamed
above
Cranialroot
Motor
Musclesofsoftpalate,pharynx,and
larynx
Spinalroot
Motor
Sternocleidomastoidandtrapezius
muscles
Hypoglossal
Motor
Musclesoftonguecontrollingitsshape Hypoglossalcanal
andmovement(exceptpalatoglossus)
Vagus
Jugularforamen
Accessory
Jugularforamen
(Q.8) Whichofthefollowingisnotafeatureofradialnerveinjuryatupperarm?
(a)
WeaknessofBrachioradialis
(b)
Inabilitytoextendfingers
(c)
Paralysisofextensorcarpiradialisbravis
(d)
Lossofsensationsoverdorsumofhand
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YourResponse:
CorrectAnswer:
Exp:
WeaknessofBrachioradialis
Radialnerveisknownasthegreatextensornerve.
Causesofinjury
Theradialnervemaybedamagedbytraumaorentrapped,especiallybetweentheheadsofmuscles.
Intheaxilla:
Withfeaturesofweaktriceps,wristdropandpossiblyalsomedianandulnarnerveinvolvement.Themost
commoncauseiscompression.
Theradialnervemaybedamagedintheaxillabyfractureordislocationoftheheadofthehumerus.
Saturdaynightsyndrome(sonamedbecauseitcanbeacquiredbysleepingwiththearmoverthebackofa
chairwhilstinadrunkenstupor,socompressingtheplexus):
Isduetocompressionofthelowerpartofthebrachialplexus.Asthisisreallyabrachialplexusinjury,the
medianandulnarnervesmayalsobeinvolved.
Itmayalsobecompressedbytheuseofshouldercrutches.
Nervefunctionusuallyfullyrecoverswithinafewweeks.
Intheupperarm(tricepsandbrachioradialisareoftenspared):
Maybeduetoacompressionlesionbutfractureistheusualcause.Injectionsgiveninthearmofsmall
babiescandamagetheradialnerve.
Asthenerveoftenpassesdowninthespiralgrooveofthehumerus,itmaybeinjuredwithafractureofthe
shaftofthehumerus.
Attheelbow:
Theradialnervemaybeentrappedattheelbowatanumberofsitesbutthemostcommonistheproximal
borderofthetendonofsupinatorcalledthearcadeofFrohse.
Checkfortendernessovertheradialtunnel.Theremaybepainwhenthefingersareextendedagainst
resistance.
Supinationfromapronatedpositionalongwithflexionofthewristmayreproducethesymptoms.
Lesionsatthewrist:
Causefingerdropwithanormalwristandintactsensation.
Causesincludefractureoftheradius,elbowdeformity,softtissuemassesandcompressionbytheextensor
carpiradialisbrevis.
Lesionsofthesuperficialnerves(causepainandsensorylossbutnomotorloss):
Attheelbow,rupturedsynovialeffusionisthemostcommoncause.Intheforearmtheremaybeanaberrant
coursethroughthemuscles.
Atthewrist,causesincludecompressionfromplastercasts,wristbandsorhandcuffs,especiallythetypethan
gettighterwithstruggling.Othercausesaresurgery,injectionsandnervetumours.
Injurytoradialnerveatdifferentlevelscausesdifferentsyndromeswithvaryingmotorandsensorydeficits.
Attheaxilla
Commonmechanismsofinjury:Saturdaynightpalsy,crutchpalsy
Motordeficit:
Lossofextensionofforearm,weaknessofsupination,andlossofextensionofhandandfingers.
Presenceofwristdrop,duetoinabilitytoextendthehandandfingers.
Sensorydeficit:
Lossofsensationinlateralarm,posteriorforearm,theradialhalfofdorsumofhand,anddorsalaspectof
radial3digits,excludingtheirnailbeds.
Atmidarm
Commonmechanismofinjury:Midshafthumeralfracture
Motordeficit:
Weaknessofsupination,andlossofextensionofhandandfingers.
Presenceofwristdrop,duetoinabilitytoextendthehandandfingers.
Sensorydeficit:Lossofsensationinposteriorforearm,theradialhalfofdorsumofhand,anddorsalaspectof
radial3digits,excludingtheirnailbeds.
Justbelowtheelbow
Commonmechanismofinjury:Neckofradiusfracture,elbowdislocationorfracture,tightcast,rheumatoid
nodules,injectionsduetotenniselbow,injuringthedeepbranchoftheradialnervethatpiercestheradial
head,causingposteriorinterosseousnervesyndrome
Motordeficit:
Weaknessinextensionofhandandlossofextensionoffingers.Presenceoffingerdrop,and
partialwristdrop,sincetheextensorcarpiradialislongusandbrachioradialismusclesareworking.
Sensorydeficit:None,assensationissuppliedbythesuperficialradialnerve
Soinlowlevelradialnerveinjurybrachioradialisisstillworkingsothereisonlypartialwristdrop.
RadialnerveprovidesinnervationoftheBrachioradialis,Extensorsofthewristandfingers,Supinator,and
Triceps.
SR.NERVEMUSCLEGROUPFUNCTIONALDEFICITORSIGN
1.LongthoracicSerratusanteriorWingingscapula
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2.SuprascapularSupraspinatusandDifficultyininitiatingarm
Infraspinatusabduction
3.AxillaryDeltoidandTeresminorInabilitytofullyabductarm
4.RadialExtensorsofforearms,Lossofarmextension,lossof
wristproximalphalanforeamsextension,supination,
gesandthumbabduction,lossofwristextension
(wristdrop),lossofproximal
phalangealextensionandthumbextension.
5.MusculoFlexorsofarmandWeakarmandforearmflexion,
cutaneousforearmweakforearmsupination.
6.MedianWristandhandflexorsParalysisofflexor,pronator,and
thenarmuscles,inabilitytofully
flextheindexandmiddlefingers
(signofbenediction),Pointing
indexfinger,Labourersnerve.
7.UlnarWristandhandflexorsInabilitytoextendthedistaland
middlephalanges(clawhand);
lossofthumbabduction,
Fromentsignpositive.
(Q.9) ThePhysiologicallockingoftheKNEEjointoccursasaresultof?
(a)
Medialrotationoftibiaoverthefixedfemur
(b)
Lateralrotationoffemuroverthetibia
(c)
Lateralrotationoftibiaoverthefemur
(d)
Medialrotationoffemuroverthefixedtibia
YourResponse:
CorrectAnswer:
Exp:
Medialrotationoffemuroverthefixedtibia(RefBDChaurasiaVol.II,3rded.130)
LOCKINGANDUNLOCKINGOFKNEEJOINT
Lockingofthekneejointoccursasaresultofmedialrotationofthefemurduringthelaststageofextension.
TheAPdiameterofthelateralfemoralcondyleislessthanthatofthemedialcondyle.Asaresult,whenthe
lateralcondylararticularsurfaceisfullyusedupbyextension,partofmedialcondylarsurfaceremains
unused.
Atthisstagethelateralcondyleactsasanaxisaroundwhichmedialcondylerotatesbackwards(i.e.medial
rotationofthefemuroccurs),sothattheremainingpartofthemedialcondylarsurfaceisalsotaken
up.Thismovementlocksthekneejoint.
*LockingisproducedbyactionofQuadricepsfemoris(italsoproducesextension).
*Unclockingisbroughtaboutbytheactionofthepopliteusmuscle(popliteusalsoprotectslateralmeniscus
bypullingitbackwards).
(Q.10) Stochasticeffectisseeninwhichcondition?
(a)
Cancerchemotherapy
(b)
Radiotherapy
(c)
Posttransplantimmunosuppressivetherapy
(d)
Aftercoronaryarterybypasssurgery
YourResponse:
CorrectAnswer:
Exp:
RadiotherapyRefNelson,18thedition,page2899
BIOLOGICEFFECTSOFRADIATION
Stochastic(random)effectsareofgreaterconcernbecausetheycanoccuratanydose;i.e.,thereisno
threshold,withtheprobabilityofaneffectincreasingwithincreasingdose.Theseeffectscanbecausedby
anyradiationstrikingvulnerabletissue(mostimportantlyDNA,butcytoplasmalsomaybeatrisk)and
causingirreversibledamage.Theseeffectsleadtothelinearnodosethreshold(LNT)concept,whichstates
thatradiationdamageincreaseswithincreasingdoseinalinearfashion.Thisconceptstressesthatnolevel
ofradiationexposurecanbeconsideredtobeabsolutelysafe
(Q.11) ThetermZeitgebersisusedinrelationto?
(a)
Intrinsiccircadianrhythm
(b)
Arrhythmias
(c)
GImotility
(d)
Nutrition
YourResponse:
CorrectAnswer:
Exp:
Intrinsiccircadianrhythm(RefNelson,18thedition,page9192)
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Theterm"zeitgeber"(Germanfor"timegiver"or"synchronizer")wasfirstusedbyJrgenAschoff,oneof
thefoundersofthefieldofchronobiology.Hisworkdemonstratedtheexistenceofendogenous(internal)
biologicalclocks,whichsynchronizebiologicalrhythms.Inaddition,hefoundthatcertainexogenous
(external)cues,whichhecalledzeitgebers,influencethetimingoftheseinternalclocks.
Intrinsiccircadianrhythms,whichgovernmanyphysiologicprocessesinadditiontosleepwakerhythms,areinturn
affectedtoadegreebyexternaltimecues,orzeitgebers(timingofmeals,alarmclocks),buttheyaremostsensitiveto
lightdarknesssignals,whichswitchtheproductionofthehormonemelatoninbythepinealglandoff(light)oron(dark).
(Q.12)
Falseregardingthe1stPharyngealarchis?
(a) MaxillaryandMandibulardivisionsoftrigeminalnervearetherelatednerves
(b) Musclesofmasticationdevelopfromit
(c) Mandibledevelopsfromit
(d) Stapedialarteryisthearchartery
YourResponse:
CorrectAnswer:
Exp:
Stapedialarteryisthearchartery
HEADANDNECKEMBRYOLOGY:SUMMARIZED:
Pharyngeal ArchArtery
CranialNerve
Skeletalelements
Muscles
Arch
1
TerminalBranch Maxillaryand
ofmaxillary
mandibular
artery
divisionof
trigemenial(V)
Derivedfromarch
cartilages(originating
fromneuralcrest):
Musclesof
mastication
(temporalis,masseter,
Frommaxillarycartilages: andpterygoids),
mylohyoid,anterior
Alispenoid,incus
bellyofdigastric,
Frommandibular:
tensortympani,tensor
velipalatini(originate
Meckels
fromcranial
cartilage,malleus
somitomere4)
Upperportionofexternal
ear(auricle)isderived
fromdorsalaspectof1st
pharyngealarch.
Derivedbydirect
ossificationfromarch
dermalmesenchyme:
Maxilla,zygomatic,
squamousportionof
temporalbone,mandible
Stapediusartery Facialnerve(VII)
(embryologic)
and
cortiotympanic
artery(adult)
Common
Glossopharyngeal Lowerrimandgreater
carotidartery, (IX)
hornofhyoid(derived
mostofinternal
fromthethirdarch
carotid
cartilage;originatefrom
neuralcrestcells)
Left:Archof
aorta;
Right:Right
subclavian
artery;
Stapes,styloidprocess,
Musclesoffacial
stylohyoidligament,lesser expression(orbicularis
hornsandupperrimof
oculi,orbicularisoris,
hyoid(derivedfromthe auricularis,platysma,
secondarchcartilage;
frontoooccipitalis,
originatefromneural
buccinator),posterior
crest).
bellyofdigastric,
Lowerportionofexternal stylohyoid,stapedius
(originatefromcranial
ear(auricle)isderived
somitomere6)
from2ndpharyngealarch.
Sytlopharyngeus
(originatefromcranial
somitomere7)
Superiorlaryngeal Laryngealcartilages
Constrictorsof
branchofvagus (Derivedfromthe4tharch pharynx,cricothyroid,
(X)
cartilage,originatefrom levatorvelipalatine
lateralplatemesoderm) (originatefrom
occipitalsomites24)
Originalsprouts
ofpulmonary
arteries
6
Ductus
arteriosus;
rootsof
definitive
pulmonary
arteries
Recurrent
laryngealbranch
ofvagus(X)
Laryngealcartilages
Intrinsicmusclesof
(derivedfromthe6tharch larynx(originatefrom
cartilage;originatefrom occipitalsomites1and
lateralplatemesoderm) 2)
Originsofcraniofacialmuscles:
MesodermalOrigin
Muscles
Innervation
Somitomeres1,2
Superior,medialandventralrecti
Oculomotor(III)
Somitomere3
Superioroblique
Trochlear(IV)
Somitomere4
Jawclosingmuscles
Trigeminal(V)
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Somitomere5
Lateralrectus
Abducens(VI)
Somitomere6
Jawopeningandother2ndarchmuscles
Facial(VII)
Somitomere7
Stylopharyngeus
Glossopharyngeal(IX)
Somites1,2
Intrinsiclaryngeals
Vagus(X)
Somites25
Tonguemuscles
Hypoglossal(XII)
Derivatesofpharyngealpouches:
Auditorytube,whichcomesincontactwithepitheliallineoffirst
pharyngealcleft,wherefutureexternalacousticmeatuswillform.
Firstpouch
Distalportionwillformtympaniccavity(liningwillbecomeeardrum)
Proximalportionwillbecomeauditorytube
Secondpouch
Formsbudsthatpenetratesurroundingmesenchyme,whichtogetherform
thepalatinetonsils
Thirdpouch
Formsthymusandinferiorparathyroidglands
Fourthpouch
Formssuperiorparathyroidglands
Fifthpouch
Formsutlimobranchialbody
Derivativesofpharyngealclefts/grooves:
Initially,fourcleftsexist;however,onlyonegivesrisetoadefinitestructureinadults.
st
1 pharyngealcleft
PenetratesunderlyingmesenchymeandformsEAM.Thebottomof
EAMformslateralaspectoftympaniccavity.
2ndpharyngealcleft
Undergoesactiveproliferationandoverlapsremainingclefts.It
mergeswithectodermoflowernecksuchthattheremainingclefts
losecontactwithoutside.Temporarily,thecleftsforman
ectodermallylinedcavity,thecervicalsinus,butthisdisappears
duringdevelopment.
Viscera/organdevelopment:
Tongue
Appearsat4thweek.
Musculaturederivedfrommesodermofoccipitalsomites.Precursormusclescells
migratetoregionoftongueandareinnervatedbygeneralsensoryefferentfibers
ofCNXII.
Mucosaderivedfromanteriorendodermliningarches14;accordingly,innervation
dependsonarchderivation:
Mucosaofanterior2/3oftonguecomesfromthefirstarchCNV
Mucosaofposterior1/3oftonguecomesfromthirdandfortharchCNIX,
X
Specialtasteofanterior2/3oftonguecomesfromCNVII.
Specialtasteofposterior1/3oftonguecomesfromCNX.
Tonguefreedfromfloorofmouthbyextensivedegenerationofunderlying
tissue.Midlinefrenulumcontinuestoanchortonguetofloorofmouth.
ThyroidGland Developsasingrowthofmucosalepitheliumlocatedinthemidlineofthetongue
(atforamencecum).Itdescendsalongfrontofpharyngealgut,butremains
connectedtotonguebythyrooglossalduct,whichisobliteratedlaterin
development.Thyroidglanddescendstoapointjustcaudaltolaryngealcartilages.
Facial
structures
(general)
a)medialnasalprominenceformsmidlineofnose,philtrumandprimarypalate
b)lateralnasalprominenceformsalaeofnose
c)maxillaryprominenceformscheekregionandlaterallip
d)cleftscanformatinterprominencefusionlines
Nose
Atthetimeofanteriorneuraltubeclosure,mesenchymearoundforebrain,
frontonasalprominence(FNP),hassmoothroundedextendedcontour.Nasal
placodes(thickeningofsurfaceectodermtobecomeperipheralneuraltissue)
developonfrontolateralaspectsofFNP.Mesenchymeswellsaroundnasalplacode
producingamedialandlateralnasalprominence(nasomedialandnasolateral
processes).Thesenasalprominencesformthenose.
Mouth
Stomadeum(primitiveoralcavity)formsbetweenfrontonasalprominenceandfirst
pharyngealarch.Thefirstpharyngealarchformsthedorsalmaxillaryprominence
andventralmandibularprominence.Themaxillaryprominencewillmergewith
medialnasalprominences,pushingthemclosertocausefusion.Fusedmedial
nasalprominenceswillformmidlineofnoseandmidlineofupperlip(philtrum)and
primarypalate(first4teeth).
Nasolacrimal Maxillaryandlateralnasalprominencesareseparatedbydeepfurrow,the
structures
nasolacrimalgroove.Ectoderminfloorofgrooveformsepithelialcord,which
detachesfromoverlyingectoderm.Theepithelialcordcanalizestoformthe
nasolacrimalduct.Theupperendoftheductwidenstoformthelacrimal
sac.Afterdetachmentofthecord,themaxillaryandlateralnasalprominences
mergewitheachother,resultingintheformationofanasolacrimalductthatruns
fromthemedialcorneroftheeyetotheinferiormeatusofthenasalcavity.
Themaxillaryprominencesenlargetoformthecheeksandmaxillae.
Thelateralnasalprominencesformthealaeofthenose.
Secondary
Mainpartofdefinitivepalateformedbytwopalatineshelvesderivedfrom
(hard)palate intraoralbilateralextensionsofthemaxillaryprominences.Theseappearatthe
6thweek.Theyaredirectedobliquelydownwardoneachsideofthetongue;they
movedownwhenmandiblegetsbigger.
Attheseventhweek,theyascendtoattainahorizontalposition,thenfusetoform
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thesecondarypalate.Atthetimethepalatineshelvesfuse,thenasalseptum(an
outgrowthofmediantissueofthefrontonasalprominence)growsdownandjoins
thecephalicaspectofthenewlyformedpalate
Anteriorly,shelvesfusewithtriangularprimarypalate.Theincisiveforamenmarks
themidlinebetweentheprimaryandsecondarypalate.
ExternalEar
Theauricleisderivedfrom6auricularhillocks(mesenchymalproliferations)along
thedorsalaspectofarches1(topofear)and2(bottomofear).Thesefusetoform
thedefinitiveauricle.Atthemandiblegrows,theearispushedupwardand
backwardfromitsinitialhorizontalpositionontheneck.
TheEAMisderivedfromthe1stpharyngealarch.
Theeardrum(tympanicmembrane)iscomposedof3layersofcells:1)ectodermal
epithelialliningofbottomofEAM;2)endodermalepitheliumliningoftympanic
cavity;3)intermediatelayerofconnectivetissue.
Theeardrumiscomposedofmultiplecelllayersbecauseitrepresentsthefirst
pharyngealmembrane,andthusliesatthejunctionofthefirstpharyngealpouch
andcleft.
MiddleEar
Themiddleearconsistsofanauditorytube(fromthe1stpharyngealpouch,along
withtympaniccavity)andtheossicles(frompharyngealarches1and2cartilage).
Thefirstarchcartilageformsthemalleusandincus.Thetensortympani(muscleof
themalleus)isderivedfromthefourthsomitomere(associatedwiththefirstarch)
andisthereforeinnervatedbyCNV.
Thesecondarchcartilageformsthestapes.Thestapedius(musclesofthestapes)
isderivedfromthesixthsomitomere(associatedwiththesecondarch)andis
thereforeinnervatedbyCNVII.
Theossiclesareinitiallyembeddedinmesenchyme,butinthe8thmonth,the
mesenchymedegeneratesandanendodermalepithelialliningofthetympanic
cavityenvelopstheossiclesandconnectsthemtothewallofthecavityina
mesenterylikefashion.
InnerEar
Theinnerearisderivedthickeningofsurfaceectodermonbothsidesofthe
hindbrain(oticplacodes).Theplacodesinvaginatetoformoticvesicles
(otocytes).Thevesiclesthendivideintoventralanddorsalcomponents.
Theventralcomponentformsthesacculeandcochlearduct.
Thedorsalcomponentformstheutricleandsemicircularcanalsandendolymphatic
duct.
CochlearDuct Derivedfromanoutgrowthofthesacculeduringthe6thweek.Theoutgrowth
penetratesthesurroundingmesenchymeinaspiralfashion.Thesurrounding
mesenchymeformsthecartilageandundergoesvacuolization.
Thescalavestibuleandscaletympaniformandsurroundthecochlearduct.They
arefilledwithperiplymptoreceivemechanicalvibrationsofossicles.The
mechanicalstimuliactivatessensory(ciliary)cellsinthecochlearduct.
Semicircular
canals
Theutricleisinitiallythreeflattenedoutpocketings,whichlosethecentral
core.Fromthisthreesemicircularcanalsareforms,eachat90degreeanglesfrom
oneanother.Sensorycellsariseintheampullaatoneendofeachcanal,inthe
utricleandsaccule.
Eye
Atweek4,twodepressionsareevidentoneachoftheforebrainhemispheres.As
theanteriorneuralfoldcloses,theopticpitselongatetoformtheoptic
vesicles.Theopticvesiclesremainconnectedtotheforebrainbyopticstalks.
Theinvaginationoftheopticvesiclesformsabilayeredopticcup.Thebilayered
cupbecomestheduallayeredretina(neuralandpigmentedlayer)
Surfaceectodermformsthelensplacode,whichinvaginateswiththeopticcup.
Theopticstalkisdeficientventrallytocontainchoroidsfissuretoallowblood
vesselsintotheeye(hyaloidartery).Thearteryfeedsthegrowinglens,butwillits
distalportionwilleventuallydegeneratesuchthattheadultlensreceivesno
hyaloidvasculature.
Atthe7thweek,thechoroidsfissureclosesandwallsfuseastheretinalnerveget
bigger.
Theanteriorrimoftheopticvesiclesformstheretinaandiris.Theirisisan
outgrowthofthedistaledgeoftheretina.
Opticvesiclesinduces/maintainsthedevelopmentofthelensvesicle,whichforms
thedefinitivelens.Followingseparationofthelensvesiclefromthesurface
ectoderm,thecorneadevelopsintheanterior1/5thoftheeye.
Thelensandretinaaresurroundedbymesenchymewhichformsatough
connectivetissue,thesclera,thatiscontinuouswiththeduramateraroundthe
opticnerve.
Iridopupillarymembraneformstoseparatetheanteriorandposteriorchambersof
theeye.Themembranebreaksdowntoallowforthepupil
Mesenchymesurroundingtheformingeyeformsmusculature(ciliarymusclesand
pupillarymusclesfromsomitomeres1and2;innervatedbyCNIII),supportive
connectivetissueelementsandvasculature.
Eyelids
Formedbyanoutgrowthofectodermthatisfusedatitsmidlineinthe2nd
trimester,butlaterreopen.
(Q.13) Pickthewrongmatchofcoronaryarteryinvolvementandmyocardialinfarctlocationbasedonthenormalpatternofbloodsupplyto
theheart:
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(a)
ProximalLADAnteriorwall
(b)
CircumflexarteryPosterolateralwall
(c)
DistalRightCoronaryarteryInferiorwall
(d)
Earlyobtuse,marginalarteryRightventricularmedialwall
YourResponse:
CorrectAnswer:
Exp:
Earlyobtuse,marginalartery
D.
Rightventricular
medialwall
ClinicalAnatomybyRegions;RichardSnell8thed,Chap3
CoronaryArteryLesions,InfarctLocation,andECGSignature
CoronaryArtery
InfarctLocation
ECGSignature
ProximalLAD
Largeanteriorwall
STelevation:I,L,V1,V6
MoredistalLAD
Anteroapical
STelevation:V2,V4
Inferiorwallifwraparound
LAD
STelevation:II,III,F
DistalLAD
Anteroseptal
STelevation:V1,V3
Earlyobtuse,marginal
Highlateralwall
STelevation:I,L,V4,V6
Moredistalmarginalbranch, Smalllateralwall
circumflex
STelevation:I,L,orV4,V6,ornoabnormality
Circumflex
Posterolateral
STelevation:V4,STdepression:V1,V2
DistalRCA
Smallinferiorwall
STelevation:II,III,F;STdepression:I,L
ProximalRCA
Largeinferiorwalland
posteriorwallSomelateral
wall
STelevation:II,III,F;STdepression:I,L,
V1,V3STelevation:VV6
RCA
Rightventricular
STelevation:V2,V4;someSTelevation:V1;or
STdepression:V2,V3
Usuallyinferior
STelevation:II,III,F
ECG,electrocardiographic;LAD,leftanteriordescending(interventricular);RCA,rightcoronaryartery.
(Q.14) Whichofthefollowingisnotdirectlyconnectedtothecavernoussinus?
(a)
Superficialmiddlecerebralvein
(b)
Superiorpetrosalsinus
(c)
Inferiorpetrosalsinus
(d)
Deepcerebralvein
YourResponse:
CorrectAnswer:
Exp:
Deepcerebralvein
*Eachcavernoussinusreceivesbloodfromsomeofthecerebralveins,ophthalmicveins,andthe
sphenoparietalsinus.
TRIBUTARIES:
Superiorandinferiorophthalmicveins
Sphenoparietalsinus
Superficialmiddlecerebralveins
DRAINAGE:
SuperiorPetrosalsinus
Iinferiorpetrosalsinuses
Emissaryveinsthroughtheforaminaoftheskull(mostlythroughforamenovale).
Therearealsoconnectionswiththepterygoidplexusofveinsviainferiorophthalmicvein,deepfacial
veinandemissaryveins.
(Q.15) Allofthefollowinghormonesareattheirpeaklevelduringthethirdtrimesterofpregnancyexcept?
(a)
hCG
(b)
Prolactin
(c)
Estradiol
(d)
Progesterone
YourResponse:
CorrectAnswer:
Exp:
GanongReviewofMedicalPhysiology23rdEdChap25
Inallmammals,thecorpusluteumintheovaryatthetimeoffertilizationfailstoregressandinstead
enlargesinresponsetostimulationbygonadotropichormonessecretedbytheplacenta.Theplacental
gonadotropininhumansiscalledhumanchorionicgonadotropin(hCG).Theenlargedcorpusluteumof
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pregnancysecretesestrogens,progesterone,andrelaxin.Therelaxinhelpsmaintainpregnancybyinhibiting
myometrialcontractions.Inmostspecies,removaloftheovariesatanytimeduringpregnancyprecipitates
abortion.Inhumans,however,theplacentaproducessufficientestrogenandprogesteronefrommaternal
andfetalprecursorstotakeoverthefunctionofthecorpusluteumafterthesixthweekofpregnancy.
Ovariectomybeforethesixthweekleadstoabortion,butovariectomythereafterhasnoeffectonthe
pregnancy.Thefunctionofthecorpusluteumbeginstodeclineafter8wkofpregnancy,butitpersists
throughoutpregnancy.hCGsecretiondecreasesafteraninitialmarkedrise,butestrogenandprogesterone
secretionincreaseuntiljustbeforeparturition.
HormoneLevelsinHumanMaternalBloodduringNormalPregnancy.
Hormone
ApproximatePeakValue
TimeofPeakSecretion
hCG
5mg/mL
Firsttrimester
Relaxin
1ng/mL
Firsttrimester
hCS
15mg/mL
Term
Estradiol
16ng/mL
Term
Estriol
14ng/mL
Term
Progesterone
190ng/mL
Term
Prolactin
200ng/mL
Term
HumanChorionicGonadotropin
hCGisaglycoproteinthatcontainsgalactoseandhexosamine.Itisproducedbythesyncytiotrophoblast.
Likethepituitaryglycoproteinhormones,itismadeupofandsubunits.hCGisidenticaltothe
subunitofLH,FSH,andTSH.ThemolecularweightofhCGis18,000,andthatofhCGis28,000.hCGis
primarilyluteinizingandluteotropicandhaslittleFSHactivity.Itcanbemeasuredbyradioimmunoassayand
detectedinthebloodasearlyas6dafterconception.Itspresenceintheurineinearlypregnancyisthe
basisofthevariouslaboratorytestsforpregnancy,anditcansometimesbedetectedintheurineasearlyas
14dafterconception.ItappearstoactonthesamereceptorasLH.hCGisnotabsolutelyspecificfor
pregnancy.Smallamountsaresecretedbyavarietyofgastrointestinalandothertumorsinbothsexes,and
hCGhasbeenmeasuredinindividualswithsuspectedtumorsasa"tumormarker."Italsoappearsthatthe
fetalliverandkidneynormallyproducesmallamountsofhCG.
(Q.16) MostofthefollowingGIsecretionshaveabasaloutputduringtheinterdigestiveperiod(betweenmeals).However,thesightand
smellofatastymealstimulatesGIsecretions.OfthevariousGIsecretions,whichisthemoststimulated?
(a)
Gastricsecretion
(b)
Intestinalsecretion
(c)
Pancreaticsecretion
(d)
Salivarysecretion
YourResponse:
CorrectAnswer:
Exp:
Salivarysecretion(RefGanongReviewofMedicalPhysiology23rdEdPage573)
Salivarysecretionisexclusivelyunderneuralcontrol.
Theothersneedbothneuralandhormonalstimulationandare,therefore,onlypartiallystimulatedbythe
sight,smell,andchewingoffood(cephalicphase).
Thesight,smell,andchewingoffoodstimulatetheparasympatheticnervoussystem,whichstimulates
salivarysecretion.
(Q.17) Bileaciduptakebyhepatocytesisdependenton
(a)
Calcium
(b)
Iron
(c)
Sodium
(d)
Potassium
YourResponse:
CorrectAnswer:
Exp:
SodiumRefGanongReviewofMedicalPhysiology23rdEdPage643
TheBileAcid:NaSymporter(BASS)Family
FunctionallycharacterizedmembersoftheBASSfamilycatalyzeNa:bileacidsymport.Thesesystemshave
beenidentifiedinintestinal,liverandkidneytissuesofanimals,andatleastthreeisoformsarepresentina
singlespeciessuchashumans.TheBASSfamilyisalsocalledtheSoluteCarrierFamily10.
ABASSintheapicalmembraneofthehumanilealintestinecatalyzestheelectrogenicuptakeofbileacids
withastoichiometryofbileacid:Naof1:2.Thisproteinisassociatedwiththe16kDasubunitcofthe
vacuolarprotonpump(Sunetal.,2004).Thismayaccountforitsapicallocation.Thus,thevacuolarproton
pumpassociatedapicalsortingmachinerymaybeusedtosorttheapicalNa:bilesymporter.Proteinsofthe
BASSfamilyvaryinsizefromabout340to480aminoacylresiduesandpossess7to10putative
transmembranespanners(TMSs).ThebileacidbindingsiteappearstobelocalizedtothelastTMS(last60
residues)(Krameretal.,2001).TheBASSfamilybelongstotheBARTsuperfamily(Mansouretal.,2007)
Thesesymportersexhibitbroadspecificity,takingupavarietyofnonbileorganiccompoundsaswellas
taurocholateandotherbilesalts.Homologuesarefoundinplants,yeast,archaeaandbacteria.Forexample,
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functionallyuncharacterizedhomologuesarepresentinSynechocystis(292aas;gbD90911)andBacillus
subtilis(283aas;spP55190;Z99104).Thebacterialhomologuesexhibit610putativeTMSs.Becausethe
familyisrepresentedinwidelydivergentorganisms,itisprobablyubiquitous.
(Q.18) Jcurvephenomenonisrelatedtowhichofthefollowing?
(a)
Hypertension
(b)
Diabetes
(c)
HIV
(d)
Alloftheabove
YourResponse:
CorrectAnswer:
Exp:
Hypertension
Jcurvephenomenon
PeoplewithhighBPand/orhighbloodcholesterollevelshaveagreaterriskofdevelopingcardiovascular
diseases(CVD).
Thehigherthebloodpressureand/orcholesterollevel,thegreatertherisk.Wealsoknowthatlowering
bloodpressureandcholesterollevelslowerstheriskforCVD.
Whenthebloodpressureorbloodcholesterollevelsoflargegroupsofpeopleareplottedonagraph
againstCVDmortality,itoftenresultsinaJshapedcurve.
Thiscurveshowsthatthosewithhigherbloodpressureand/orcholesterollevels,closertothetopofthe
curve,aremorelikelytodiefromCVD.
Thecurvealsoshowsthatthoseatthelowestendofthecurve(withverylowbloodpressureand/orlow
cholesterollevels)alsohavehigherCVDmortality.ThisaccountsfortheJshapeandisknownastheJcurve
phenomenon.(RefH18thPg2058)
ThetermJcurveisusedinseveraldifferentfieldstorefertoavarietyofunrelatedJshapeddiagramswhere
acurveinitiallyfalls,butthenrisestohigherthanthestartingpoint.
Inmedicine,the'Jcurve'referstoagraphinwhichthexaxismeasureseitheroftwotreatablesymptoms
(bloodpressureorbloodcholesterollevel)whiletheyaxismeasuresthechancethatapatientwilldevelop
cardiovasculardisease(CVD)
Itiswellknownthathighbloodpressureorhighcholesterollevelsincreaseapatient'srisk.
WhatislesswellknownisthatplotsoflargepopulationsagainstCVDmortalityoftentakestheshapeofaJ
curvewhichindicatesthatpatientswithverylowbloodpressureand/orlowcholesterollevelsarealsoat
increasedrisk
(Q.19) Carbonicanhydraseisanenzymethatoccursinplants,bacteria,andanimalsandisinvolvedintheformationofwhichchemical?
(a)
Carbondioxidefromcarbonandoxygen
(b)
Carbonicacidfromcarbondioxideandwater
(c)
Bicarbonateionfromcarbonicacid
(d)
Hydrochloricacid
YourResponse:
CorrectAnswer:
Exp:
CarbonicacidfromcarbondioxideandwaterRefGanongReviewofMedicalPhysiology23rdEdPage
816
Carbonicanhydrasecatalyzestheformationofcarbonicacidfromcarbondioxideandwater.Itisnot
involvedintheformationofcarbondioxidefromcarbonandoxygen,bicarbonateionfromcarbonicacid,
hydrochloricacid,orhypochlorousacid.
(Q.20) Parasympatheticstimulationinducessalivaryacinarcellstoreleasewhichofthefollowingprotease
(a)
Bradykinin
(b)
Kallikrein
(c)
Kininogen
(d)
Kinin
YourResponse:
CorrectAnswer:
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Exp:
KallikreinRefGanongReviewofMedicalPhysiology23rdEdPage757
Theproductionofsalivaisstimulatedbothbythesympatheticnervoussystemandtheparasympathetic.[10]
Thesalivastimulatedbysympatheticinnervationisthicker,andsalivastimulatedparasympatheticallyis
morewatery.
Sympatheticstimulationofsalivaistofacilitaterespiration,whereasparasympatheticstimulationisto
facilitatedigestion.
Parasympatheticstimulationleadstoacetylcholine(ACh)releaseontothesalivaryacinarcells.AChbinds
tomuscarinicreceptors,specificallyM3,andcausesanincreasedintracellularcalciumionconcentration
(throughtheIP3/DAGsecondmessengersystem).Increasedcalciumcausesvesicleswithinthecellstofuse
withtheapicalcellmembraneleadingtosecretion.AChalsocausesthesalivaryglandtoreleasekallikrein,
anenzymethatconvertskininogentolysylbradykinin.Lysylbradykininactsuponsbloodvesselsand
capillariesofthesalivaryglandtogeneratevasodilationandincreasedcapillarypermeabilityrespectively.
Theresultingincreasedbloodflowtotheaciniallowsproductionofmoresaliva.Inaddition,SubstanceP
canbindtoTachykininNK1receptorsleadingtoincreasedintracellularcalciumconcentrationsand
subsequentlyincreasedsalivasecretion.Lastly,bothparasympatheticandsympatheticnervousstimulation
canleadtomyoepitheiliumcontractionwhichcausestheexpulsionofsecretionsfromthesecretoryacinus
intotheductsandeventuallytotheoralcavity.
Sympatheticstimulationresultsinthereleaseofnorepinephrine.Norepinephrinebindingtoadrenergic
receptorswillcauseanincreaseinintracellularcalciumlevelsleadingtomorefluidvs.proteinsecretion.If
norepinephrinebindsadrenergicreceptors,itwillresultinmoreproteinorenzymesecretionvs.fluid
secretion.Stimulationbynorepinephrineinitiallydecreasesbloodflowtothesalivaryglandsdueto
constrictionofbloodvesselsbutthiseffectisovertakenbyvasodilationcausedbyvariouslocalvasodilators.
Salivaproductionmayalsobepharmacologicallystimulatedbysocalledsialagogues.Itcanalsobe
suppressedbysocalledantisialagogues.
(Q.21) Thefollowinggraphrepresentseffectofsubstrateconcentrationontheinitialvelocityofanenzyme
catalyzedreaction.Wrongstatementaboutthisgraphis?
(a) Thecurveishyperbolicinshape.
(b) ?hererepresentsKmoftheenzyme.
(c) AtpointConlyasmallamountoftheenzymeispresentastheEnzymeSubstratecomplex.
(d)
AtpointC,vidependssolelyontherapiditywithwhichproductdissociatesfromtheenzymesothatitmaycombinewithmore
substrate
YourResponse:
CorrectAnswer:
Exp:
AtpointConlyasmallamountoftheenzymeispresentastheEnzymeSubstratecomplex.
REF:Harper'sIllustratedBiochemistry,28e>Chapter8.Enzymes:Kinetics
Enzymereactionsaretreatedasiftheyhadonlyasinglesubstrateandasingleproduct.Forenzymeswith
multiplesubstrates,theprinciplesdiscussedbelowapplywithequalvalidity.Moreover,byemploying
pseudofirstorderconditions(seeabove),scientistscanstudythedependenceofreactionrateuponan
individualreactantthroughtheappropriatechoiceoffixedandvariablesubstrates.Inotherwords,under
pseudofirstorderconditionsthebehaviorofamultisubstrateenzymewillimitateonehavingasingle
substrate,Inthisinstance,however,theobservedrateconstantwillbeafunctionoftherateconstantk1for
thereactionaswellastheconcentrationofthefixedsubstrate(s).
Foratypicalenzyme,assubstrateconcentrationisincreased,viincreasesuntilitreachesamaximumvalue
Vmax.Whenfurtherincreasesinsubstrateconcentrationdonotfurtherincreasevi,theenzymeissaidto
be"saturated"withsubstrate.Notethattheshapeofthecurvethatrelatesactivitytosubstrate
concentrationishyperbolic.Atanygiveninstant,onlysubstratemoleculesthatarecombinedwiththe
enzymeasanEScomplexcanbetransformedintoproduct.Second,theequilibriumconstantforthe
formationoftheenzymesubstratecomplexisnotinfinitelylarge.Therefore,evenwhenthesubstrateis
presentinexcess(pointsAandB,onlyafractionoftheenzymemaybepresentasanEScomplex.Atpoints
AorB,increasingordecreasing[S]thereforewillincreaseordecreasethenumberofEScomplexeswitha
correspondingchangeinvi.AtpointC,essentiallyalltheenzymeispresentastheEScomplex.Sincenofree
enzymeremainsavailableforformingES,furtherincreasesin[S]cannotincreasetherateofthereaction.
Underthesesaturatingconditions,vidependssolelyonandthusislimitedbytherapiditywithwhich
productdissociatesfromtheenzymesothatitmaycombinewithmoresubstrate.
(Q.22) Agatstonscoreisusedfor?
(a)
Regionalwallmotionabnormality
(b)
Myocardialscar
(c)
Quantificationofcalcifiedplaque
(d)
Toknowejectionfraction.
YourResponse:
CorrectAnswer:
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Exp:
Quantificationofcalcifiedplaque
RecentAdvances:PathologyofPlaque.
I.Atheroscleroticplaquesbecomeprogressivelycalcifiedovertime,increaseswithage.
II.Forthisreason,methodsfordetectingcoronarycalciumhavebeendevelopedasameasureofthe
presenceofcoronaryatherosclerosis.
III.DetectionofcalciuminatheroscleroticplaquebyelectronbeanCTscan(EBCT).
IV.CoronarycalciumdetectedbytheseimagingtechniquesisquantifiedusingtheAgatstonscoremost
commonly,whichisbasedontheareaanddensityofcalcification.
TwomodesofcardiacCTareusedforCornonaryarteryCalcification(CAC)quantification.Formerly,electron
beamcomputedtomography(EBCT)andmorerecentlymultidetectorcomputedtomography(MDCT)have
beenusedforthisevaluation.Electronbeamcomputedtomographyallowedfasterimagingwithhigher
temporalresolution.However,MDCThavetheadvantageofhigherspatialresolutionandimagequality
especiallywithrecentscannergenerations,butoptimallyshouldbedonewithheartratecontroltolimit
motionartifactsfromhighheartrates.
CACisdefinedasahyperattenuatinglesion>130Hounsfieldunitswithanareaof3pixels.BaselineCAC
hasbeenquantifiedbyseveralmethods.TheAgatstonscoreiscalculatedbymultiplyingthelesionarea
(mm2)byadensityfactor(between1and4).Becauseofthestepwisenatureofthedensityfactor,changes
intheAgatstonscoremightnotaccuratelycapturechangesincoronarycalcium.IncontrasttotheAgatston
score,thecalciumvolumescore(CVS)representsanactualvolumeofCACandreducesvariabilitybetween
scansopposedtotheincreaseinAgatstonscorewhichmightjustrepresentanincreaseinplaque
attenuationratherthansizeovertime.Themassscorehasalsobeenadvocated,withlessinterscanner
variability,howeverlimitedoutcomedataisavailablewiththismeasure,soitisrarelyused.CACistypically
scannedinaprospectivelyECGtriggeredmodewith2.53.0mmthickaxialimages.Theradiationdoseis
low,withatypicaleffectivedoseof<1.5mSv.
CACscorehadbeenvalidatedinanoriginalhistopathologicalstudybyRumbergeretal.whichshowedahigh
correlationbetweenCACareabyEBCTandplaqueareain13autopsyhearts.EBCTCACScorewasalso
directlycomparedtocoronaryangiographyin213consecutivepatientsandacutpointAgatstonscoreof
371wasfoundtobeassociatedwithcoronaryarterialluminalstenosis>70%inatleastonecoronaryartery
withhighsensitivityandspecificity.Specificpatternsofcalcifications,namely;shelllikeanddiffusewere
showntobemoreassociatedwithseverestenosisratherthananodularpattern
(Q.23) Stabilityofanklejointmaintainedbyallexcept
(a)
Collateralligaments
(b)
Cruciateligaments
(c)
Tendonsofmusclescrossingthejoint
(d)
Closeappositionofarticularsurfacesofbones
YourResponse: b
CorrectAnswer: B
Exp:
Cruciateligaments
Ref1.Pg.150;BDChaurasia(4thEd.);Vol2,2.Pg.1443;Gray's
Anatomy(40thEd.)
Cruciateligamentsarepresentinthekneeandnottheanklejoint.
Anklejointisstabilizedbythefollowingfactors:
Closeappositionofarticularsurfacesofbones
Tendonsofmusclescrossingthejoint
Ligamentslikecollateralligamentsanddistaltibiofibularligaments
Gravityandgroundreactionforcesprovidedynamicstability.
(Q.24) Regardinggenitaldevelopment,trueis
(a)
Ychromosomeisassociatedwithovarydevelopment
(b)
Genitalridgestartsdevelopingat5thweek
(c)
Malegenitalsdevelopearlierthanfemalegenitals
(d)
ExternalGenitaldevelopmentiscompleteby10thweek
YourResponse:
CorrectAnswer:
Exp:
Genitalridgestartsdevelopingat5thweek
References:1.Pg.263,271;Thedevelopinghuman(KeithLMoore);8thEd.
ThekeytosexualdimorphismistheYchromosome,whichcontaintheTDF(TestesDeterminingFactor)
gene,calledastheSRYgeneonitsshortarm.
UndertheinfluenceofTDF,maledevelopmentoccurs;initsabsence,femaledevelopmentisestablished.
Hence,Ychromosomeregulatesmalesexualdevelopment.
Genitalridgesstartdevelopingatthe5thweek
Thegonadsdonotacquiremaleorfemalemorphologicalcharacteristicsuntilthe7thweekofdevelopment.
So,attheendof6thweekitisimpossibletodistinguishbetweenthetwosexesbylookingattheexternal
genitalia.
Distinguishingsexualcharacteristicsbegintoappearduringthe7thweekbuttheexternalgenitaliaarenot
fullydifferentiateduntilthe12thweek
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(Q.25) Pelvicsplanchnicnervessupplyallexcept
(a)
Vermiformappendix
(b)
Urinarybladder
(c)
Uterus
(d)
Rectum
YourResponse:
CorrectAnswer:
Exp:
Vermiformappendix
References:1.Pg.1045,1143;Gray'sAnatomy(40thEd.),2.Pg.258;BDChaurasia(4thEd.);Vol2
Pelvicsplanchnicnervesaretheparasympatheticnervestosupplythepelvicvisceralikeurinarybladder,
uterusandrectum.
AppendixisapartofMidgutandissuppliedbytheVagusnerve.
Parasympatheticnervoussystem
Functions:
Evacuationofbodytubesby
Increaseinperistalsis
Relaxationofsphincters
Erectionofgenitalia
Parasympatheticnervesupply:
Tillmidgut:Vagus
Hindgut:Pelvicsplanchnicnerves
Pelvicsplanchnicnerves(alsocalledasNervierigentes)arebranchesofsacralplexuscarrying
parasympatheticfibres.
Theyalsoprovidevasodilatorfibreserectiletissueofpenis&clitoriscausingerection.
Conusmedullarysyndrome:Pelvicsplanchnicnervesarelesionedleadingtourinaryretention,constipation
andimpotence(erectiledysfunction).
Sympatheticnervoussystem
Functions:
Retentionofthebodytubescontentsby
Decreaseinperistalsis
Constrictionofsphincters
Ejaculation
Sympatheticsupply:
Foregut:Greatersplanchnicnerve(T:59)
Midgut:Lessersplanchnicnerves(T10,11)
Kidney:Leastsplanchnicnerves(T12)
Hindgut:Lumbarsplanchnicnerves(L1,2)
Visceralpainisusuallycarriedbythesympatheticfibersandpainofacuteappendicitis(Midgut;T10)is
carriedbythelessersplanchnicnervesandreferredtothecorrespondingdermatome(Periumbilicalregion:
T10).
(Q.26) Urogenitaldiaphragmformedbyallexcept
(a)
Collesfascia
(b)
Deeptransverseperinei
(c)
Perinealmembrane
(d)
Sphincterurethrae
YourResponse:
CorrectAnswer:
Exp:
Collesfascia
Urogenitaldiaphragmcontainsthedeepperinealpouchandislinedinferiorlybytheperinealmembrane
(d)andnotCollesfascia(a).
Collesfasciaactuallyistheinferiorliningofsuperficialperinealpouch.
Urogenitaldiaphragmisatriangularmusculofascialdiaphragmintheanteriorpartofperineum.Itis
contributedbymainlytwomuscles:sphincterurethrae(d)anddeeptransverseperinei(b).
Thesemusclesareenclosedwithinasuperiorandinferiorfascia.Theinferiorfasciaisalsocalledasperineal
membrane.
Perinealbodyisafibromuscularbodyattachedattheposteriorborderofperinealmembraneinthe
midline.Boththefasciaofurogenitaldiaphragmareattachedtotheperinealbody.
Perinealbodyisagoodsupportofpelvicvisceraandisattachedbymanymusclesoftheperineumincluding
themusclesofurogenitaldiaphragmdeeptransverseperinei&sphincterurethrae.
References:
1.Pg.361;BDChaurasia(4thEd.);Vol2
2.Pg.10946;Gray'sAnatomy(40thEd.)
3.Pg.429;SnellsClinicalAnatomy(7thEd.)
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(Q.27) Hemivertebraisadefectof
(a)
Body
(b)
Transverseprocess
(c)
Spine
(d)
Posteriorvertebralarches
YourResponse:
CorrectAnswer:
Exp:
Body
Vertebralbodiesmainlydevelopfromventralsclerotome(VS)andthushemivertebraisadefectofVS.
Hemivertebracanleadtodefectsinthevertebralcolumnscoliosis.
Posteriorvertebralarches(PVA)contributemainlytothelamina&spines.PVAarecontributedbythedorsal
sclerotome.
Ahemivertebraistypeofvertebralanomalyandresultsfromalackofformationofonehalfofavertebral
body.Itcanbeacommoncauseofacongenitalscoliosis/kyphosisoralordosis.Theestimatedincidenceisat
~0.3per1000livebirths.
Itfallsunderthespectrumofsegmentationalanomaliesandcaninvolveoneormultiplelevels.A
hemivertebraactsasawedgewithinthevertebralcolumn,resultingincurvatureawayfromthesideon
whichitispresent.
Recognisedassociationsaremanyandinclude
Aicardisyndrome
cleidocranialdysostosis
gastroschisis3
Gorlinsyndrome
fetalpyelectasis3
JarchoLevinsyndrome
OEIScomplex
VACTERLassociation
Classification
Ahemivertebracanbeclassifiedaccordingtomanytypeswhichinclude
Attachment
fullysegmental(free):
notattachedtoeithervertebraaboveorbelow
mostconcerning
semisegmental:halfsegmentisfusedwithvertebraaboveorbelowwithnointerveningintervertebraldisc
nonsegemental:
notseperatedfrom(i.econnectedto)eitherlevelaboveorbelow
causeslessofaconcern
incarcerated:
joinedbypediclestolevelsaboveandbelow
causeslessofaconcern
Orientation
dorsalhemivertebra:classicallyresultsinakyphosis
lateralhemivertebra:classicallyresultsinascoliosis
ventralhemivertebra(extremelyrare):resultsinthelordosis
Radiographicfeatures
Antenatalultrasound
Ahemivertebramaybeseenasanasymmetricalvertebralbodyonsagittalorcoronalscanning,whileon
axialscanning,afocaldefectmaybeseenateithersideofthevertebralcolumn5.
Plainfilm/CT
Usuallydirectlyoutlinesthebonyanomalyandoftenseenasawedgeshapedvertebralbody.
Theprognosiscanbevariabledependantonthetypefrombeingaprogressivetononprogressive
deformity.Thestrongestnegativeimpactiswhenahemivertebraoccursatthelumbosacrallevel7.
Differentialdiagnosis:Forantenatalsonographicappearancesconsiderblockvertebra
(Q.28) Whichisanonessentialmineral
(a)
Copper
(b)
Manganese
(c)
Iron
(d)
Lead
YourResponse:
CorrectAnswer:
Exp:
Lead
(RefGanongReviewofMedicalPhysiology23rdEd,Chapter27.Digestion,Absorption,&Nutritional
Principles)
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Table273TraceElementsBelievedEssentialforLife.
ArsenicManganese
ChromiumMolybdenum
CobaltNickel
CopperSelenium
FluorineSilicon
IodineVanadium
IronZinc
Manganeseisanessentialtracenutrientinallformsoflife.
Theclassesofenzymesthathavemanganesecofactorsareverybroadandincludeoxidoreductases,
transferases,hydrolases,lyases,isomerases,ligases,lectins,andintegrins.
Thereversetranscriptasesofmanyretroviruses(thoughnotlentivirusessuchasHIV)containmanganese.
Thebestknownmanganesecontainingpolypeptidesmaybearginase,thediphtheriatoxin,andMn
containingsuperoxidedismutase(MnSOD).
(Q.29) Nitricoxideisreleasedfrom:
(a)
Pericytes
(b)
Smoothmusclecells
(c)
Endothelialcells
(d)
Mesenchymalcells
YourResponse:
CorrectAnswer:
Exp:
Endothelialcells
REFRobbins8thEdChap2.
NitricOxide
NOisashortlived,soluble,freeradicalgasproducedbymanycelltypesandcapableof
mediatingavarietyoffunctions.Inthecentralnervoussystemitregulatesneurotransmitter
releaseaswellasbloodflow.Macrophagesuseitasacytotoxicmetaboliteforkilling
microbesandtumorcells.Whenproducedbyendothelialcells(whereitwasoriginallynamed
endotheliumderivedrelaxationfactor),itcausessmoothmusclerelaxationandvasodilation.
NOissynthesizeddenovofromlarginine,molecularoxygen,andNADPHbytheenzyme
nitricoxidesynthase(NOS).TherearethreeisoformsofNOS,withdifferenttissue
distributions.TypeI(nNOS)isaconstitutivelyexpressedneuronalNOS,whichdoesnotplay
asignificantroleininflammation.TypeII(iNOS)isaninducibleenzymepresentin
macrophagesandendothelialcells;itisinducedbyanumberofinflammatorycytokinesand
mediators,mostnotablybyIL1,TNF,andIFN,andbybacterialendotoxin,andis
responsibleforproductionofNOininflammatoryreactions.iNOSisalsopresentinmany
othercelltypes,includinghepatocytes,cardiacmyocytes,andrespiratoryepithelium.Type
III(eNOS)isaconstitutivelysynthesizedNOSfoundprimarily(butnotexclusively)within
endothelium.
NOplaysmanyrolesininflammation,including(1)relaxationofvascularsmoothmuscle
(vasodilation),(2)antagonismofallstagesofplateletactivation(adhesion,aggregation,and
degranulation),(3)reductionofleukocyterecruitmentatinflammatorysites,and(4)action
asamicrobicidal(cytotoxic)agent(withorwithoutsuperoxideradicals)inactivated
macrophages.
(Q.30) ChediakHigashisyndromeisassociatedwithdefectin:
(a)
Chemotaxis
(b)
Phagocytosis
(c)
Absorption
(d)
BothAandB
YourResponse:
CorrectAnswer:
Exp:
BothAandB
Thebestanswershouldbeboth.
TheunderlyingdefectinChdiakHigashisyndromeremainselusive,butthedisordercanbeconsidereda
modelfordefectsinvesicleformation,fusion,ortrafficking.
Robins8theditionpage5556
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Chediakhigashisyndromeisautosomalrecessiveconditioncharacterizedbydefectivephagolysosome
function
defectivefusionofphagosomesandlysosomesinphagocytes(causingsusceptibilitytoinfections)
abnormalitiesinmelanocytes(leadingtoalbinism)
abnormalitiesincellsofnervoussystem(nervedefects)
defectiveplateletsfunction
neutropeniaanddefectivedegranulationdelayedmicrobialkilling
leukocytecontaingiantgranules(duetoabberantphagolysosomefusion)
(Q.31) Whichsugaristakenupbyenterocytesbyfacilitateddiffusion?
(a)
Glucose
(b)
Galactose
(c)
Fructose
(d)
Xylose
YourResponse:
CorrectAnswer:
Exp:
RefGanongReviewofMedicalPhysiology23rdEdPage608
Fructoseistakenupbyenterocytesbyfacilitateddiffusion.Bothglucoseandgalactosearetakenupby
enterocytesthroughasodiumdependenttransporter(secondaryactivetransport).Xyloseandsucroseare
nottakenupbyenterocytes.
(Q.32) Clottingfactorpresentinbothplasmaandserumis
(a)
Thrombin
(b)
FactorVIII
(c)
FactorV
(d)
FactorVII
YourResponse:
CorrectAnswer:
Exp:
FactorVII
Fluidportionofblood(Bloodminuscells)isknownasplasmaandifthewholebloodisallowedtoclotand
theclotisremoved,theremainingfluidiscalledserum.
SerumhasessentiallythesamecompositionasplasmaexceptthatfibrinogenandclottingfactorII,Vand
VIIIhavebeenremoved.
Italsohasahighserotonincontentduetobreakdownofplateletsduringclotting.
TiptoremembervitKdependentfactorsdonotgetconsumedduringclottingexceptfactorII.
(Q.33) ThefollowingaremostimportantFreeRadicalScavengersexcept:
(a)
Superoxidedismutase
(b)
Catalase
(c)
Glutathione
(d)
Glutamine
YourResponse:
CorrectAnswer:
Exp:
Glutamine.(RefRobbins8th/pg.20,21;Table13;Fig.120;HarperBiochemistry28th/pg.483)
RemovalofFreeRadicals:
Freeradicalsareinherentlyunstableandgenerallydecayspontaneously.,forexample,isunstableand
decays(dismutates)spontaneouslyintoO2andH2O2inthepresenceofwater.
Inaddition,cellshavedevelopedmultiplenonenzymaticandenzymaticmechanismstoremovefreeradicals
andtherebyminimizeinjury.
Theseincludethefollowing:
Antioxidantseitherblocktheinitiationoffreeradicalformationorinactivate(e.g.,scavenge)freeradicals.
Examples:
LipidsolublevitaminsEandAaswellasVitaminCandglutathioneinthecytosol.
IronandcoppercancatalyzetheformationofROS.Thelevelsofthesereactivemetalsareminimizedby
bindingoftheionstostorageandtransportproteins(e.g.,transferrin,ferritin,lactoferrin,and
ceruloplasmin),therebyminimizingtheformationofROS.
AseriesofenzymesactsasfreeradicalscavengingsystemsandbreaksdownH2O2includethefollowing:
Superoxidedismutases(SODs)OptionAarefoundinmanycelltypesandconvertoxygenfree
radicaltoH2O2.
oCatalase,OptionBpresentinperoxisomes,decomposesH2O2(2H2O2O2+2H2O).
GlutathioneperoxidaseOptionCalsoprotectsagainstinjurybycatalyzingfreeradicalbreakdown
(H2O2+2GSHGSSG[glutathionehomodimer]+2H2O,or2OH+2GSHGSSG+2H2O).Theintracellular
ratioofoxidizedglutathione(GSSG)toreducedglutathione(GSH)isareflectionoftheoxidativestateofthe
cellandisanimportantindicatorofthecell'sabilitytodetoxifyROS.
SummaryRemovaloffreeradicals:
Themajorantioxidantenzymes(freeradicalscavengingsystems)are:
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Superoxidedismutase(SOD):
oInmitochondriaoConvertsO2(superoxide)H2O2.
Catalase
oInperoxisomesoConvertsH2O2H2O+O2.
GlutathionePeroxidase
oInmitochondria.oConvertsOH(hydroxylradical)H2O2H2O+O2.
Peroxiredoxins
oCauseconversiontoHNO2.oIncytosolandmitochondria.
(Q.34) Proofreadingistheroleof?
(a)
DNAprimase
(b)
DNAPolymerase
(c)
ExonucleaseI
(d)
Restrictionendonuclease
YourResponse:
CorrectAnswer:
Exp:
DNAPolymerase.(RefHarperBiochemistry26th/pg.328,311)
PolymeraseII(polII)ismostlyinvolvedinproofreadingandDNArepair.PolymeraseI(polI)completes
chainsynthesisbetweenOkazakifragmentsonthelaggingstrand.Eukaryoticcellshavecounterpartsfor
eachoftheseenzymesplussomeadditionalones.
PROTEINFUNCTION
1DNApolymerasesDeoxynucleotidepolymerization
2HelicasesProgressiveunwindingofDNA
3TopoisomerasesRelievetorsionalstrainthatresultsfromhelicaseinducedunwinding
4DNAprimaseInitiatessynthesisofRNAprimers
5SinglestrandbindingproteinsPreventprematurereannealingofdsDNA
6DNAligaseSealsthesinglestrandnickbetweenthenascentchainandOkazakifragmentson
laggingstrand
(Q.35) ThetypeofmutationthatleadstoreplacementofValineforglutamateinSickleCellDiseaseis?
(a)
Pointmutation
(b)
Silentmutation
(c)
Nonsensemutation
(d)
None
YourResponse:
CorrectAnswer:
Exp:
Pointmutation.
Pointmutations
Pointmutationsresultfromthesubstitutionofasinglenucleotidebasebyadifferentbase,resultinginthe
replacementofoneaminoacidbyanotherintheproteinproduct.
(a).Missensemutations:
Themutationgivingrisetosicklecellanemiaisanexcellentexampleofapointmutationthataltersthe
meaningofthegeneticcode.
Suchmutationsaresometimescalledmissensemutations.
(b).Nonsense"mutations:
Incontrast,certainpointmutationsmaychangeanaminoacidcodontoachainterminationcodon,orstop
codon.
Such"nonsense"mutationsinterrupttranslation,andtheresultanttruncatedproteinsarerapidlydegraded.
Frameshiftmutations
Frameshiftmutationsoccurwhentheinsertionordeletionofoneortwobasepairsaltersthereadingframe
oftheDNAstrand.
Trinucleotiderepeatmutations
Trinucleotiderepeatmutationsbelongtoaspecialcategory,becausethesemutationsarecharacterizedby
amplificationofasequenceof3nucleotides.
Althoughthespecificnucleotidesequencethatundergoesamplificationdiffersinvariousdisorders,all
affectedsequencessharethenucleotidesguanine(G)andcytosine(C).
Forexample,infragileXsyndrome,prototypicalofthiscategoryofdisorders,thereare200to4000tandem
repeatsofthesequenceCGGwithinagenecalledFMR1.Innormalpopulations,thenumberofrepeatsis
small,averaging29.TheexpansionsofthetrinucleotidesequencespreventnormalexpressionoftheFMR1
gene,thusgivingrisetomentalretardation.
Anotherdistinguishingfeatureoftrinucleotiderepeatmutationsisthattheyaredynamic(i.e.,thedegreeof
amplificationincreasesduringgametogenesis).
(Q.36) ThefourPyroleringsinhemoglobinmoleculearejoinedtogetherby?
(a)
Disulphidebridges
(b)
Methylenebridges
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(c)
Hydrogenbonds
(d)
Alphabonds
YourResponse:
CorrectAnswer:
Exp:
Methylenebridges(RefHarpersBiochemistry26th/pg.270278)
StructureofHb
Hb=Heme+globulin(2+2chains)Q
TheironisinFe++stateinthehemeoffunctionalHb.
IroncanformsixCoOrdinatedBonds.
Ironisheldatthecentreofthehemeby4nitrogenofporphyrinrings(pyrrolerings).
Ironbindinternally(by5thlinkage)withaminoacidsofHistidine.Q
ThecoordinatedpositionofFe++isaavailabletobindtoO2.
ThefourPyroleringsarejoinedbyMethyleneorMethylidenebridge(C=bridge).
HbinternallycontainsmostlyHydrophobicaminoacids(formingHemepocket)andHydrophilicamino
acidsontheirsurfaces.
TheHemepocketofsubunitareadequateforentryofO2whilesubunitsHemepocketsblocksentry
ofO2byavalineresidues.
(Q.37) Followingarethephysiologicalactionsofinsulinexcept:
(a)
Increasedlipogenesis
(b)
Increasedaminoacidentryinthecell
(c)
ActivationofLipoproteinlipase
(d)
Activationofkeyenzymesofglycolysis
YourResponse:
CorrectAnswer:
Exp:
ActivationofLipoproteinlipase.(RefHarpersIllustratedBiochemistry26
editionTable191)
PATHWAYEFFECTOFINSULIN
1Glycogensynthesis+
2Glycolysis(liver)+
3Triacylglyccridesynthesis+
4Fattyacidsynthesis+
5Proteinsynthesis+
6Cholesterolsynthesis+
7Glycogenolysis+
8Gluconeogenesis(liver)
9Lipolysis
10Fattyacidoxidation
11Proteinbreakdown+/
12Ketogenesis(liver)
13Ketonebodyutilization(nonhepatictissues)
Themajoractionsofinsulinare:
1.Facilitationofglucosetransportthroughcertainmembranes(e.g.adiposeand
musclecells)
2.Stimulationoftheenzymesystemforconversionofglucosetoglycogen(liver
andmusclecells);
3.Slowdownofgluconeogenesis(liverandmusclecells);
4.Regulationoflipogenesis(liverandadiposecells);and
5.Promotionofproteinsynthesisandgrowth(generaleffect).
Noteinsulinactivateslipoproteinlipaseinadiposetissueanddecreaseslipoproteinlipase
activityinmuscles
(Q.38) Activityofallofthefollowingenzymesisincreasedindiabetesstateexcept?
(a)
Pyruvatecarboxylase
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(b)
PEPCarboxykinase
(c)
Pyruvatedehydrogenase
(d)
Glucose6phosphatase.
YourResponse:
CorrectAnswer:
Exp:
Pyruvatedehydrogenase.
RegulatoryandAdaptiveEnzymesAssociatedwithCarbohydrateMetabolism
Activityin
Carbo
hydrate
Feeding
Fasting Inducer
and
Diabetes
Repressor Activator
Inhibitor
Glycogenolysis,glycolysis,andpyruvateoxidation
Glycogensynthase
Increases Decreases
Hexokinase
Noeffecteither
Glucokinase
Increases Decreases Insulin
Phosphofructokinase Increases Decreases Insulin

1
Insulin,
glucose6
phosphate
Glucagon
Glucose6
phosphate
Glucagon
Glucagon 5'AMP,
Citrate,ATP,
fructose6
glucagon
phosphate,
fructose2,6
bisphosphate,
Pi
Pyruvatekinase
Increases Decreases Insulin,fructose Glucagon Fructose1,6 ATP,alanine,

bisphosphate, glucagon,
insulin
norepinephrine
Pyruvate
dehydrogenase
Increases Decreases
CoA,NAD+, AcetylCoA,
insulin,ADP, NADH,ATP
(fattyacids,
pyruvate
ketonebodies)
Gluconeogenesis
Pyruvatecarboxylase Decreases Increases Glucocorticoids, Insulin
glucagon,
epinephrine
AcetylCoA
Phosphoenolpyruvate Decreases Increases Glucocorticoids, Insulin

carboxykinase
glucagon,
epinephrine
Glucagon?
Glucose6
phosphatase
ADP
Decreases Increases Glucocorticoids, Insulin

glucagon,
epinephrine
(Q.39) Intermsofenzymekineticsthefollowingplotisof1/vi(vi=Velocityofenzymereaction)asyasafunctionof1/[S](S=Substrate
concentration)asx.Thisplotiscorrectlynamedas?
(a)
Doublereciprocalplot
(b)
Hillequationplot
(c)
LineweaverBurkplot
(d)
BothAandC.
YourResponse:
CorrectAnswer:
Exp:
REFHarper'sIllustratedBiochemistry,28eChapter8.Enzymes:Kinetics
Equation(35)istheequationforastraightline,y=ax+b,wherey=1/viandx=1/[S].Aplotof1/viasyasa
functionof1/[S]asxthereforegivesastraightlinewhoseyinterceptis1/VmaxandwhoseslopeisKm
/Vmax.SuchaplotiscalledadoublereciprocalorLineweaverBurkplot.Settingtheytermofequation
(36)equaltozeroandsolvingforxrevealsthatthexinterceptis1/Km.
ThegreatestvirtueoftheLineweaverBurkplotresidesinthefacilitywithwhichitcanbeusedtodetermine
thekineticmechanismsofenzymeinhibitors(seebelow).However,inusingadoublereciprocalplotto
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determinekineticconstants,itisimportanttoavoidtheintroductionofbiasthroughtheclusteringofdata
atlowvaluesof1/[S].Toachievethis,prepareasolutionofsubstratewhosedilutionintoanassaywill
producethemaximumdesiredconcentrationofsubstrate.Nowusethesamevolumeofsolutionsprepared
bydilutingthestocksolutionbyfactorsof1:2,1:3,1:4,1:5,etc.Thedatawillthenfallonthe1/[S]axisat
intervalsof1,2,3,4,5,etc.Alternatively,asinglereciprocalplotsuchastheEadieHofstee(viversusvi/[S])
orHanesWoolf([S]/viversus[S])plotcanbeusedtominimizeclustering.
(Q.40) EnzymedeficientinAlkaptonuria?
(a)
Phenylalaninehydroxylase
(b)
Cystathioninesynthase
(c)
Homogentisicacidoxidase
(d)
Tyrosinase
YourResponse:
CorrectAnswer:
Exp:
Homogentisicacidoxidase.(RefHarpersIllustratedBiochemistry26edition/pg.255)
TheprobablemetabolicdefectintypeItyrosinemia(tyrosinosis)isatfumarylacetoacetatehydrolase.
Therapyemploysadietlowintyrosineandphenylalanine.Untreatedacuteandchronictyrosinosisleadsto
deathfromliverfailure.AlternatemetabolitesoftyrosinearealsoexcretedintypeIItyrosinemia(Richner
Hanhartsyndrome),adefectintyrosineaminotransferase,andinneonataltyrosinemia,duetoloweredp
hydroxyphenylpyruvatehydroxylaseactivity.Therapyemploysadietlowinprotein.
Alkaptonuriawasfirstdescribedinthe16thcentury.Characterizedin1859,itprovidedthebasisfor
Garrodsclassicideasconcerningheritablemetabolicdisorders.Thedefectislackofhomogentisateoxidase.
Theurinedarkensonexposuretoairduetooxidationofexcretedhomogentisate.Lateinthedisease,there
isarthritisandconnectivetissuepigmentation(ochronosis)duetooxidationofhomogentisateto
benzoquinoneacetate,whichpolymerizesandbindstoconnectivetissue.
Alkaptonuria(ochronosis)
Congenitaldeficiencyofhomogentisicacidoxidaseinthedegradativepathwayoftyrosine.
Resultingalkaptonbodiescauseurinetoturnblackonstanding.
Also,theconnectivetissueisdark.
Benigndisease,butmayhavedebilitatingarthralgias.
ALLENZYMEDEFICIENCYDISEASES:
DISEASE
DEFICIENTENZYME
VonGierkesDiseaseIa
Glucose6phosphatase
VonGierkesDiseaseIb
Glucose6phosphatasetranslocase
PompesDisease
Acidmaltase/Lysosomalacidalphaglucosidase
CorisDisease/Forbes/Limitdextrinosis
Liverandmuscledebrancherenzyme
AndersonsDisease/Amylopectinosis
Branchingenzyme
McArdlesDisease
Musclephosphorylase
HersDisease
Hepaticphosphorylase
TaruiDisease
Phosphofructokinase
Fanconi/BickelsDisease
GlucosetransporterII
Albinism
Tyrosinase
NeimanPicksDisease
Acidsphingomyelinase
Metachromaticleukodystrophy
Arylsulphatase
GauchersDisease
Acidbetaglucosidase
Oroticaciduria
Oroticphosphoribosyltransferase
Galactosemia
Galactose1phosphateuridyltransferase
Galactokinase
UDPgalactose4epimerase
Fructoseintolerance
Fructose1,6biphosphatase
Essentialfructosuria
Fructokinase
KrabbesDisease
Betagalactosidase
FabrysDisease
Alphagalactosidase
FarbersDisease
Acidceramidase
ForbesDisease
Debranchingenzyme
MPSI
AlphaLIduronidase
MPSII
Iduronatesulphatase
TaysachsDisease
BetaHexosaminidaseA
Sandhoff;sDisease
BetaHexosaminidaseAandB
TyrosinemiaI
Fumarylacetoacetatehydrolase
TyrosinemiaII
Transaminase
MSUD
Branchedchainalphaketoaciddecarboxylase
HomocystinutiaI
Cystathioninesynthetase
HomocystinuriaII
N5MethylTHFmethyltransferase
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Sialidosis
Neuraminidase
GM1Gangliosidosis
Betagalactosidase
Essentialpentosuria
NADPDependantLXylitoldehydrogenase
RefsumsDisease
Phytanatealphaoxidase
cystinosis
Cysteinereductase
LeschNyhanSyndrome
HGPRTaseCompletedeficiency
KelleySeegmillersyndrome
HGPRTasePartialdeficiency
Acuteintermittentporphyria
UroporphyrinogenIsynthetase
Congenitalerythropoeticporphyria
UroporphyrinogenIIIsynthetase
Porphyriacutaneatarda
Uroporphyrinogendecarboxylase
Variegateporphyria
Protoporphyrinogenoxidase
Erythropoeticprotoporphyria
Ferrochelatase
HyperammonemiaI
CarbamoylphosphatasesynthetaseI
HyperammonemiaII
Transcarbamoylase
Citrullemia
Arginosuccinatesynthetase
Arginosuccinicaciduria
Arginosuccinase
Arginemia
Arginase
Fucosidosis
Alphafucosidase
CanavansDisease
NAspertoAcylase
Adrenoleucodystrophy
AcylCoAsynthetase
(Q.41) FalseregardingGroupItypeofhormonesis?
(a)
Theyarelipophilic
(b)
Haveaverylongplasmahalflife
(c)
Theirreceptorsaremainlylocatedontheplasmamembrane
(d)
SteroidhormonesareexamplesofGroupItype.
YourResponse:
CorrectAnswer:
Exp:
Theirreceptorsaremainlylocatedontheplasmamembrane
REF:Harper'sIllustratedBiochemistry,28eChapter41
GeneralFeaturesofHormoneClasses
GroupI
GroupII
Types
Steroids,iodothyronines,
calcitriol,retinoids
Polypeptides,proteins,glycoproteins,catecholamines
Solubility
Lipophilic
Hydrophilic
Transport
proteins
Yes
No
Plasmahalflife Long(hourstodays)
Short(minutes)
Receptor
Intracellular
Plasmamembrane
Mediator
Receptorhormonecomplex
cAMP,cGMP,Ca2+,metabolitesofcomplex
phosphinositols,kinasecascades
ThehormonesingroupIarelipophilic.Aftersecretion,thesehormonesassociatewithplasmatransportor
carrierproteins,aprocessthatcircumventstheproblemofsolubilitywhileprolongingtheplasmahalflifeof
thehormone.Therelativepercentagesofboundandfreehormonearedeterminedbytheamount,binding
affinityandbindingcapacityofthetransportprotein.Thefreehormone,whichisthebiologicallyactive
form,readilytraversesthelipophilicplasmamembraneofallcellsandencountersreceptorsineitherthe
cytosolornucleusoftargetcells.Theligandreceptorcomplexisassumedtobetheintracellularmessenger
inthisgroup.
Thesecondmajorgroupconsistsofwatersolublehormonesthatbindtotheplasmamembraneofthe
targetcell.Hormonesthatbindtothesurfacesofcellscommunicatewithintracellularmetabolicprocesses
throughintermediarymoleculescalledsecondmessengers(thehormoneitselfisthefirstmessenger),
whicharegeneratedasaconsequenceoftheligandreceptorinteraction.Thesecondmessengerconcept
arosefromanobservationthatepinephrinebindstotheplasmamembraneofcertaincellsandincreases
intracellularcAMP.ThiswasfollowedbyaseriesofexperimentsinwhichcAMPwasfoundtomediatethe
effectsofmanyhormones.Atrialnatriureticfactor(ANF),usescGMPasitssecondmessenger(groupII.B).
Severalhormones,manyofwhichwerepreviouslythoughttoaffectcAMP,appeartouseioniccalcium
(Ca2+)ormetabolitesofcomplexphosphoinositides(orboth)astheintracellularsignal.Theseareshownin
groupII.Cofthetable.TheintracellularmessengerforgroupII.Disaproteinkinasephosphatasecascade.
Severalofthesehavebeenidentified,andagivenhormonemayusemorethanonekinasecascade.Afew
hormonesfitintomorethanonecategory,andassignmentschangeasnewinformationisbroughtforward.
(Q.42) Vitamindeficiencyassociatedwithincreasexanthurenicacidexcretioninurine?
(a)
Thiamine
(b)
Pyridoxine
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(c)
Ascorbicacid
(d)
Niacin
YourResponse:
CorrectAnswer:
Exp:
Pyridoxine(RefHarper,Biochemistry,26thed.,258)
Conversionoftryptophanmetabolite3hydroxykinurenineto2hydroxyantranilateisimpairedinvitamin
B6deficiency;hencelargeamountofxanthinurateisformed.
ThisisbasicprinciplebehindconductingtryptophanloadtestwhichmainlyprecipitatesearlyvitaminB6
deficiency.
PYRIDIOXINEDEFICIENCY
Deficiency
CONVULSIONS,
Hyperirritability(deficiencyinduciblebyINHandoralcontraceptives),
Peripheralneuropathy.
Function
A.Convertedtopyridoxalphosphate,
B.Acofactorusedin:
1.Transamination(e.g.,ALTandAST),
2.Decarboxylationreactions,
3.Glycogenphosphorylase,and
4.Hemesynthesis.
C.Requiredforthesynthesisofniacinfromtryptophan.
Vitamin
Enzymesinwhichitactsascoenzyme
Deficiencydisease
1.Vit.B1(Thiamine)
Pyruvatedehydrogenasecomplex
BeriBeridisease
Oxidativedecarboxylationof
Wernickeencephalopathy
ketoacid
Transketolasereaction
Tryptophanpyrrolase
2.Vit.B2(Riboflavin)(heat
stablebutlightsensitive)
FMNandFADare2coenzymesofthisvit. Cheilosis
ConstituentofcytochromeC
Glossitis
reductase
Seborrheicdermatitis
Warburgyellowenzyme
Fumaratedehydrogenase
3.Vit.B3(Niacin)
NADandNADPareits
PellagraC/B3Ds
activeformswhich
Diarrhea
operateashydrogenand
Dermatitis
electrontransferagents
Dementia
Theyarecoenzymesforvarioustypesof
dehydrogenaseslike
Alcoholdehydrogenase
Lactatedehydrogenase
Malatedehydrogenase
Pyruvatedehydrogenase
4.Vit.B6(Pyridoxine)
Cotransaminase
Epileptiformconvulsionin
infants
Codecarboxylase
Deaminase
Sideroblasticanemia[Vit
B6isusedint/tofoxalate
InvolvedinsynthesisofCoA
stoneofkidneyand
homocystinuria]
CoenzymeforKynureninase
[vitB6deficiencyKynureninelevels,
whichisconvertedtoxanthurenicacid
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whichisareliablecriteriaforB6deficiency]
5.Pantothenicacid
ActiveformisCoA
G.I.symptoms
FormationofAcetylCoA
Changedsleeppatterns
FormationofsuccinylCoA
Easyfatigue
OxidationofFattyacids
Burningfootsyndrome
SynthesisofFattyacids
Carboxylaseenzyme
6.Biotin
Carboxylaseenzyme
Leinersdisease
Exfoliativedermatitis
7.Vit.B12(cyanocobalamine
ToconvertMethylmalonylCoA
Methylmalonylurea
Homocystinuria
Homocysteinemethionine
Perniciousanemia
SCID
Ribonucleotide
Deoxyribonucleotide
(Q.43) Whichofthefollowingarechaperones?
(a)
Amyloidprecursorprotein
(b)
BenceJonesprotein
(c)
Conjugatedprotein
(d)
Heatshockprotein
YourResponse:
CorrectAnswer:
Exp:
Heatshockprotein(RefHarperBiochemistry26thed.35,36)
Heatshockproteinanyofagroupofproteinsfirstidentifiedassynthesizedinresponsetohyperthermia,
hypoxia,orotherstressesandbelievedtoenablecellstorecoverfromthesestresses.Manyhavebeen
foundtobemolecularchaperonesandaresynthesizedabundantlyregardlessofstress.
CHAPERONES
Aretheproteinthatpreventfaultyfoldingandunproductiveinteractionsofotherproteins
Playaroleintheassemblyorproperfoldingofotherproteins.
ie.preventwrongfoldingandallowsfolding,onlyinthecorrectdirection.
Theyhelpintheassemblyofthetertiaryandquantimetrystructureofproteins.
Theyarenotpartofthematureprotein,andtheyhaveATPaseactivity.
Somepropertiesofchaperoneproteins
Presentinawiderangeofspeciesfrombacteriatohumans.
Manyaresocalledheatshockprotein(Hsp)
Someareinduciblebyconditionsthatcauseunfoldingofnewlysynthesizedprotein(eg.temp.,and
variouschemicals)
Theybindstopredominantlyhydrophobicregionsofunfoldedandaggregatedproteins.
Theyactinpartasaqualitycontrolor,editingmechanism.Fordetectingmisfoldedorotherwisedefective
proteins.
MostchaperonsshowsassociatedATPaseactivity,withATPorADPbeinginvolvedintheprotein
chaperoneinteraction
Foundinvariouscellularcomponentssuchas,cytosol,mitochondriaandthelumenoftheendoplasmic
reticulum.
Somechaperonesandenzymesinvolvedinfoldingthatarelocatedintherough
endoplasmicreticulum:
BIP(Igheavychainbindingprotein
GRP94(glucoseregulatoryprotein)
Calnexin(Ca++bindingprotein)
Calreticulum(Ca++bindingprotein)
PDI(Proteindisulfideisomerase)
PPI(Peptidylprolylcistransisomerase)
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(Q.44) TruestatementsregardingVitaminB6arethefollowingEXCEPT:
(a) VitaminB6DeficiencyIsRare.
(b) VitaminB6Deficiencyresultsinabnormalitiesoftryptophanandmethioninemetabolism.
(c) VitaminB6StatusisAssessedbyAssayingErythrocyteAminotransferases.
(d) InExcess,VitaminB6CausesMotorNeuropathy.
YourResponse:
CorrectAnswer:
Exp:
(RefHarpersBiochemistry26thed.166,491)
VitaminB6DeficiencyIsRare.
Althoughclinicaldeficiencydiseaseisrare,thereisevidencethatasignificantproportionofthepopulation
havemarginalvitaminB6status.
Moderatedeficiencyresultsinabnormalitiesoftryptophanandmethioninemetabolism.
Increasedsensitivitytosteroidhormoneactionmaybeimportantinthedevelopmentofhormone
dependentcancerofthebreast,uterus,andprostate,andvitaminB6statusmayaffecttheprognosis.
VitaminB6StatusIsAssessedbyAssayingErythrocyteAminotransferases.
ThemostwidelyusedmethodofassessingvitaminB6statusisbytheactivationoferythrocyte
aminotransferasesbypyridoxalphosphateaddedinvitro,expressedastheactivationcoefficient.
InExcess,VitaminB6CausesSensoryNeuropathy.
Thedevelopmentofsensoryneuropathyhasbeenreportedinpatientstaking27gofpyridoxineperdayfor
avarietyofreasons(thereissomeslightevidencethatitiseffectiveintreatingpremenstrualsyndrome).
Therewassomeresidualdamageafterwithdrawalofthesehighdoses;otherreportssuggestthatintakesin
excessof200mg/dareassociatedwithneurologicdamage.
(Q.45) Presenceofwhichofthefollowingintheexpressionofvectorensuresincreaseintheyieldofrecombinantproteinproduced?
(a)
Induciblepromoter
(b)
Genecodingforproteaseinhibitor
(c)
Translationinitiationsignals
(d)
TranscriptionandTranslationterminationsignals
YourResponse:
CorrectAnswer:
Exp:
(RefHarperBiochemistry28th/pg.)
Theprimaryadvantageofaninduciblepromoterexpressionsystemisthatproductionoftherecombinant
proteincanbebiochemicallycontrolled,allowingfortheseparationofuniquegrowthandproduction
phasesoftheculture.Duringthegrowthphase,thecultureisrapidlygrowntohighcelldensitypriorto
inductionwithouttheextrametabolicburdenofexogenousproteinproduction,thusminimizingthe
nonproductiveperiodoftheculture.Inductionofthecultureathighcelldensityensuresthatthevolumetric
productionwillbemaximized.
Thus,aInduciblepromoterintheexpressionofvectorincreasestheyieldofrecombinantproteinproduced.
Giventheimportanceofproteaseinhibitors,characterizationofproteaseinhibitors,whichcanplayarolein
preventing,amelioratingorcorrectingduysfunctionsanddiseases.
(Q.46) Twoplantsgrowningardensoil,onetoexpressGreenFluoroscentProtein(GFP)andotherfireflyluciferase.Indark,whichofthe
followingwillbeseen?
(a)
PlantexpressingGPFwillglow
(b)
Plantexpressingfireflyluciferasewillglow
(c)
Boththeplantswillglow
(d)
Boththeplantswillnotglow
YourResponse:
CorrectAnswer:
Exp:
Plantexpressingfireflyluciferasewillglow.
Fireflyluciferaseisbyfarthemostcommonlyusedbioluminescentreported.Fireflyluciferaseisslightly
differentfromGFP,aphotoprotein.Luciferaseisagenerictermfortheclassofoxidativeenzymesusedin
bioluminescenceandisdistinctfromaphotoprotein.
Thegreenfluorescentprotein(GFP)isaproteincomposedof238aminoacidresidues(26.9kDa)that
exhibitsbrightgreenfluorescencewhenexposedtobluelight.Photoproteins(GPF)dontrequireanyspecial
pigments,enzymesorchemicalstosetitoff.Onceexpressed,itsimplyneedsmineralsubstratestoemit
fluorescence.GFPwasoriginallyrecruitedfromjellyfish.Ithasthesamepurposeastheluciferaseenzymein
molecularbiology,tomarktheexpressionofselectgenes.Atleastinthelab,itGFPalsorequirestoshine
bluelight(orsometimesUV)forittoemitthegreenfluorescence.Itssuchastandardtoolnow,inmice,
plants,flies,fishstudies.
(Q.47) Whichofthefollowingisrequiredfortransferofaminogroup?
(a)
Transferase
(b)
Oxidase
(c)
Transaminase
(d)
Anhydrase
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YourResponse:
CorrectAnswer:
Exp:
Transaminase.(RefHarperbiochemistry26th/pg.135)
Aminotransferase(transaminase)reactionsform:
Pyruvatefromalanine,
Oxaloacetatefromaspartate,and
ketoglutaratefromglutamate.
Becausethesereactionsarereversible,thecyclealsoservesasasourceofcarbonskeletonsforthe
synthesisoftheseaminoacids.
Otheraminoacidscontributetogluconeogenesisbecausetheircarbonskeletonsgiverisetocitricacidcycle
intermediates.
Alanine,cysteine,glycine,hydroxyproline,serine,threonine,andtryptophanyieldpyruvate;
Arginine,histidine,glutamine,andprolineyieldketoglutarate;
Isoleucine,methionine,andvalineyieldsuccinylCoA;
Tyrosineandphenylalanineyieldfumarate.
(Q.48) FalseregardingCytochomeP450s?
(a) Theyarehemoproteins
(b) Theyarepresentinhighestamountsinlivercellsandenterocytes
(c) AtleastsixdifferentspeciesofcytochromeP450arepresentintheendoplasmicreticulumofhumanliver
(d) NADHisinvolvedinthereactionmechanismofcytochromeP450
YourResponse:
CorrectAnswer:
Exp:
NADHisinvolvedinthereactionmechanismofcytochromeP450
REF:Harper'sIllustratedBiochemistry,28e>Chapter53.
RememberCytochromeP450isaveryimportanttopicforyourentrance.Hereisadetailedaccountof
thesewproteins:
Becauseofthelargenumberofisoforms(about150)thathavebeendiscovered,itbecameimportantto
haveasystematicnomenclatureforisoformsofP450andfortheirgenes.Thisisnowavailableandinwide
useandisbasedonstructuralhomology.TheabbreviatedrootsymbolCYPdenotesacytochromeP450.This
isfollowedbyanArabicnumberdesignatingthefamily;cytochromeP450sareincludedinthesamefamily
iftheyexhibit40%ormoreaminoacidsequenceidentity.TheArabicnumberisfollowedbyacapitalletter
indicatingthesubfamily,iftwoormoremembersexist;P450sareinthesamesubfamilyiftheyexhibit
greaterthan55%sequenceidentity.TheindividualP450sarethenarbitrarilyassignedArabicnumerals.
Thus,CYP1A1denotesacytochromeP450thatisamemberoffamily1andsubfamilyAandisthefirst
individualmemberofthatsubfamily.ThenomenclatureforthegenesencodingcytochromeP450sis
identicaltothatdescribedaboveexceptthatitalicsareused;thus,thegeneencodingCYP1A1isCYP1A1.
Likehemoglobin,theyarehemoproteins.
Theyarewidelydistributedacrossspecies,includingbacteria.
Theyarepresentinhighestamountinlivercellsandenterocytesbutareprobablypresentinalltissues.In
liverandmostothertissues,theyarepresentmainlyinthemembranesofthesmoothendoplasmic
reticulum,whichconstitutepartofthemicrosomalfractionwhentissueissubjectedtosubcellular
fractionation.Inhepaticmicrosomes,cytochromeP450scancompriseasmuchas20%ofthetotalprotein.
P450sarefoundinmosttissues,thoughofteninlowamountscomparedwithliver.Intheadrenal,theyare
foundinmitochondriaaswellasintheendoplasmicreticulum;thevarioushydroxylasespresentinthat
organplayanimportantroleincholesterolandsteroidbiosynthesis.ThemitochondrialcytochromeP450
systemdiffersfromthemicrosomalsysteminthatitusesanNADPHlinkedflavoprotein,adrenodoxin
reductase,andanonhemeironsulfurprotein,adrenodoxin.Inaddition,thespecificP450isoformsinvolved
insteroidbiosynthesisaregenerallymuchmorerestrictedintheirsubstratespecificity.
AtleastsixdifferentspeciesofcytochromeP450arepresentintheendoplasmicreticulumofhumanliver,
eachwithwideandsomewhatoverlappingsubstratespecificitiesandactingonbothxenobioticsand
endogenouscompounds.ThegenesformanyisoformsofP450(frombothhumansandanimalssuchasthe
rat)havebeenisolatedandstudiedindetailinrecentyears.Thecombinationoftherebeinganumberof
differenttypesandeachhavingarelativelywidesubstratespecificityexplainswhythecytochromeP450
familycanmetabolizethousandsofdifferentchemicals.
NADPH,notNADH,isinvolvedinthereactionmechanismofcytochromeP450.Theenzymethatuses
NADPHtoyieldthereducedcytochromeP450,shownatthelefthandsideoftheaboveequation,iscalled
NADPHcytochromeP450reductase.ElectronsaretransferredfromNADPHtoNADPHcytochromeP450
reductaseandthentocytochromeP450.Thisleadstothereductiveactivationofmolecularoxygen,and
oneatomofoxygenissubsequentlyinsertedintothesubstrate.Cytochromeb5,anotherhemoprotein
foundinthemembranesofthesmoothendoplasmicreticulum,maybeinvolvedasanelectrondonorin
somecases.
LipidsarealsocomponentsofthecytochromeP450system.Thepreferredlipidisphosphatidylcholine,
whichisthemajorlipidfoundinmembranesoftheendoplasmicreticulum.
MostisoformsofcytochromeP450areinducible.Forinstance,theadministrationofphenobarbitalorof
manyotherdrugscauseshypertrophyofthesmoothendoplasmicreticulumandathreetofourfold
increaseintheamountofcytochromeP450within45days.Themechanismofinductionhasbeenstudied
extensivelyandinmostcasesinvolvesincreasedtranscriptionofmRNAforcytochromeP450.However,
certaincasesofinductioninvolvestabilizationofmRNA,enzymestabilization,orothermechanisms(eg,an
effectontranslation).InductionofcytochromeP450hasimportantclinicalimplications,sinceitisa
biochemicalmechanismofdruginteraction.Adruginteractionhasoccurredwhentheeffectsofonedrug
arealteredbyprior,concurrent,orlateradministrationofanother.Asanillustration,considerthesituation
whenapatientistakingtheanticoagulantwarfarintopreventbloodclotting.Thisdrugismetabolizedby
CYP2C9.Concomitantly,thepatientisstartedonphenobarbital(aninducerofthisP450)totreatacertain
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typeofepilepsy,butthedoseofwarfarinisnotchanged.After5daysorso,thelevelofCYP2C9inthe
patient'sliverwillbeelevatedthreetofourfold.Thisinturnmeansthatwarfarinwillbemetabolizedmuch
morequicklythanbefore,anditsdosagewillhavebecomeinadequate.Therefore,thedosemustbe
increasedifwarfarinistobetherapeuticallyeffective.Topursuethisexamplefurther,aproblemcouldarise
lateronifthephenobarbitalisdiscontinuedbuttheincreaseddosageofwarfarinstaysthesame.The
patientwillbeatriskofbleeding,sincethehighdoseofwarfarinwillbeevenmoreactivethanbefore,
becausethelevelofCYP2C9willdeclineoncephenobarbitalhasbeenstopped.Anotherexampleofenzyme
inductioninvolvesCYP2E1,whichisinducedbyconsumptionofethanol.Thisisamatterforconcern,
becausethisP450metabolizescertainwidelyusedsolventsandalsocomponentsfoundintobaccosmoke,
manyofwhichareestablishedcarcinogens.Thus,iftheactivityofCYP2E1iselevatedbyinduction,thismay
increasetheriskofcarcinogenicitydevelopingfromexposuretosuchcompounds.
CertainisoformsofcytochromeP450(eg,CYP1A1)areparticularlyinvolvedinthemetabolismofpolycyclic
aromatichydrocarbons(PAHs)andrelatedmolecules;forthisreasontheywereformerlycalledaromatic
hydrocarbonhydroxylases(AHHs).ThisenzymeisimportantinthemetabolismofPAHsandin
carcinogenesisproducedbytheseagents.Forexample,inthelungitmaybeinvolvedintheconversionof
inactivePAHs(procarcinogens),inhaledbysmoking,toactivecarcinogensbyhydroxylationreactions.
Smokershavehigherlevelsofthisenzymeinsomeoftheircellsandtissuesthandononsmokers.Some
reportshaveindicatedthattheactivityofthisenzymemaybeelevated(induced)intheplacentaofa
womanwhosmokes,thuspotentiallyalteringthequantitiesofmetabolitesofPAHs(someofwhichcouldbe
harmful)towhichthefetusisexposed.
CertaincytochromeP450sexistinpolymorphicforms(geneticisoforms),someofwhichexhibitlow
catalyticactivity.Theseobservationsareoneimportantexplanationforthevariationsindrugresponses
notedamongmanypatients.OneP450exhibitingpolymorphismisCYP2D6,whichisinvolvedinthe
metabolismofdebrisoquin(anantihypertensivedrug)andsparteine(anantiarrhythmicandoxytocic
drug).CertainpolymorphismsofCYP2D6causepoormetabolismoftheseandavarietyofotherdrugsso
thattheycanaccumulateinthebody,resultinginuntowardconsequences.Anotherinteresting
polymorphismisthatofCYP2A6,whichisinvolvedinthemetabolismofnicotinetoconitine.Three
CYP2A6alleleshavebeenidentified:awildtypeandtwonullorinactivealleles.Ithasbeenreportedthat
individualswiththenullalleles,whohaveimpairedmetabolismofnicotine,areapparentlyprotected
againstbecomingtobaccodependentsmokers.Theseindividualssmokeless,presumablybecausetheir
bloodandbrainconcentrationsofnicotineremainelevatedlongerthanthoseofindividualswiththewild
typeallele.IthasbeenspeculatedthatinhibitingCYP2A6maybeanovelwaytohelppreventandtotreat
smoking.
(Q.49) TrueaboutmanagementofLungcancerisallexcept:
(a) SurgicalresectionisnotroutinelyrecommendedforNSCLC.
(b) PalliativeradiotherapyisavitalRxofSCLCpatients.
(c) ErlotinibisusedinsecondlinetherapyofNSCLC.
(d) ChemoradiationisthetreatmentofchoiceforbulkystageIIIAorIIIBdiseasewithoutpleuraleffusion.
YourResponse:
CorrectAnswer:
Exp:
SurgicalresectionisnotroutinelyrecommendedforNSCLC(NonSmallCellLungCancer).(RefHarrison
17th/pg.560)
RxofCaLung:
SurgicalresectionisnotroutinelyrecommendedforSCLC.(smallcelllungcancer).butitisdoneveryfrequentlyfornon
smallcell.
Onecanrememberthislikethatallsmalllungproblemsdosentneedknife.
ChemotherapyplusradiationtherapyisthetreatmentofchoiceforpatientswithbulkystageIIIAorIIIB
diseasewithoutpleuraleffusion(referredtoasdryIIIB).
PalliativeradiationtherapyisanimportantcomponentofthemanagementofSCLCpatients.
EGFRTargetedTherapy(ErlotinibanoralinhibitoroftheEGFRkinase)isusedinsecondlinetherapyof
NSCLC.
Squamouscell
CentralLocation(2/3),
Atelectasis,
Postobstructivepneumonia,
Maycavitate.
Adenocarcinoma
Usuallyperipheral,
Foundinscars,
Solitarynodule(52%),
Upperlobedistribution(69%).
Smallcell
Mediastinaladenopathy,
Hilarmass,
Smallorinvisiblelungnodule,
Highmetastaticpotential,
Rapidgrowth.
MaybeassociatedwithHypoglycemia,Cushing'ssyndrome,Inappropriate
secretionofADH,excessivegonadotropinsecretion.
Largecell
Largeperipheralmass
undifferentiated(10%) Pleuralinvolvement.
(Q.50) A51yearoldmanpresentswithbilateralenlargementofhisbreasts.Physicalexaminationisotherwiseunremarkable,andthe
diagnosisofgynecomastiaismade.Whichofthefollowinghistologicfeaturesismostlikelytobeseenwhenexaminingabiopsy
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specimenfromthismansbreasttissue?
(a)
Atrophicductalstructureswithincreasednumbersoflipocytes
(b)
Dilatedductsfilledwithgranular,necrotic,acidophilicdebris
(c)
Expansionoflobulesbymonotonousproliferationofepithelialcells
(d)
Proliferationofductsinhyalinizedfibroustissuewithperiductaledema
YourResponse:
CorrectAnswer:
Exp:
Proliferationofductsinhyalinizedfibroustissuewithperiductaledema
Gynecomastia(enlargementofthemalebreast)histologicallyrevealsepithelialhyperplasiawithinthe
ductsthatissurroundedbyhyalinizedfibroustissue.Itiscausedbyanincreaseintheestrogentoandrogen
ratio.Thisabnormalitymaysometimesbefoundinmalesatthetimeofpuberty.Othercausesof
gynecomastiaincludeKlinefelterssyndrome(decreasedsecretionoftestosterone),testicularfeminization
(androgeninsensitivity),testiculartumors,cirrhosisoftheliver,alcoholabuse,increasedgonadotropin
levels(suchaschoriocarcinomaofthetestis),increasedprolactinlevels,drugs(suchasdigoxin),or
hyperthyroidism.Testicularneoplasmsthatareassociatedwithgynecomastiaaretumorsthatsecrete
humanchorionicgonadotropin(hCG),whichincreasesthesynthesisofestradiol.Testiculartumorsassoci
atedwiththeproductionofhCGincludegermcelltumors(choriocarcinomaandseminoma),Leydigcell
tumors,andSertolicelltumors.
Notemalebreastdoesnthavelobulessonoterminalductlobarunit(TDLU)iseverseenin
malebreast
Nolobulessonolobularhyperplasia.malebreastenlargementmeans.ductandonlyductproliferation
alongwithstromalhyperplasiaandhyalinizationofstroma
(Q.51) Trueaboutprionsis?
(a)
Theyareencodedbyviralgenome
(b)
Associatedwithmisfoldingofproteins
(c)
NonInfectious
(d)
Immunogenic
YourResponse:
CorrectAnswer:
Exp:
Associatedwithmisfoldingofproteins.
(RefRobbinspathology8th/pg.1308;Harper28th/pg.3940;Ananthanarayan7th/pg.567)
Proteinaceousparticlesdevoidofnucleicacid,thatcausesslowlyevolvingspongiformdegenerationof
centralnervoussystemwithoutproductionofimmuneresponseandduetoabnormalityofproteinfolding.
Prionsareinfectiousagents,proteininnature,devoidofDNAandRNA,andunusuallyresistanttophysical
andchemicalagentslikeheat,irradiation,andformalin.
NormalPrPisa30kDcellularproteinpresentinneurons.DiseaseoccurswhenthePrPundergoesa
conformationalchangefromitsnormalhelixcontainingisoform(PrPc)toanabnormalpleatedsheet
isoform,usuallytermedPrPsc(forscrapie).Associatedwiththeconformationalchange,PrPacquires
resistancetodigestionwithproteases,suchasproteinaseK.AccumulationofPrPscinneuraltissueseemsto
bethecauseofthepathologyinthesediseases,buthowthismaterialinducesthedevelopmentof
cytoplasmicvacuolesandeventualneuronaldeathisstillunknown.Westernblottingoftissueextractsafter
partialdigestionwithproteinaseKallowsdetectionofPrPsc,whichisdiagnostic.
TheconformationalchangeresultinginPrPscmayoccurspontaneouslyatanextremelylowrate
(resultinginsporadiccases)oratahigherrateifvariousmutationsarepresentinPrPc,suchasoccursin
familialformsofCJDandinGSSandfatalfamilialinsomnia.PrPsc,independentofthemeansbywhichit
originates,thenfacilitates,inacooperativefashion,theconversionofotherPrPcmoleculestoPrPsc
molecules.ItisthisactivityofPrPscthataccountsforthenatureofpriondiseases.
ThegeneencodingPrP,termedPRNP,showsahighdegreeofconservationacrossspecies.Avarietyof
mutationsinPRNPhavebeenfoundtounderliefamilialformsofpriondiseases.
(Q.52) Anautopsydoneinapatientwhosuccumbedtomyocardialinfarctionrevealswelldevelopedphagocytosisofdeadcellsandearly
fotmationoffibrovasculargranulationtissueatmargins.Whatisthetimeofdeathsincetheeventofinfarction?
(a)
12to24hrs
(b)
1to3days
(c)
3to7days
(d)
7to10days
YourResponse:
CorrectAnswer:
Exp:
7to10days
REFRobbins8thEdChap11
Anotherveryfrequentlyaskedtopic.Youmustknowthefollowingtablebyheart.
EVOLUTIONOFMORPHOLOGICCHANGESINMI:
TIME
GROSS
FEATURES
LIGHTMICROSCOPY
ELECTRONMICROSCOPY
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REVERSIBLE
INJURY:
00.5hrs
None
None
Relaxationof
myofibrils,glycogenloss,mitochondrial
swelling
14hrs
None
Usuallynone,variablewavinessof
fibresatborder
Sarcollemaldisruption;
mitochondrialamorphousdensities
412hrs
Occaisionally Beginningcoagulation
darkmottling necrosis;edema;hemorrhage
1224hrs
Darkmottling Ongoingcoagulationnecrosis;
pyknosisofnuclei;
myocytehypereosinophilia;marginal
contractionbandnecrosis;beginning
neutrophilicinfiltrate
13days
Mottlingwith Coagulationnecrosiswithlossof
yellowtan
nucleiandstriations;interstitial
infarctcentre infiltrationofneutrophils
37days
Hyperemic
border;
centralyellow
tansoftening
710days
Maximally
Welldevelopedphagocytosisofdead
yellowtanand cells;earlyfotmationoffibrovascular
soft;with
granulationtissueatmargins
depressedred
tanmargins
1014days
Redgrey
Wellestablishedgranulationtissue
depressed
withnewbloodvesselsandcollagen
infarctborders deposition
23weeks
Graywhite
Increasedcollagendepositionwith
scar;
decreasedcellularity
progressive
fromborder
towardscore
ofinfarct
2monthsand
later
Scarring
complete
IRREVERSIBLE
INJURY
Beginningdisintegrationofdead
myofibres;withdeadneutrophils;
earlyphagocytosisofdeadcellsby
macrophagesatinfarctborder
Densecollagenousscar
(Q.53) CD4isnotimportantforwhichofthefollowing
(a)
Antibodyproduction
(b)
CytotoxicityofTcells
(c)
MemoryBcells
(d)
Opsonization
YourResponse:
CorrectAnswer:
Exp:
OpsonizationRefRobbins,8thed.,page395397
CD4performsthefollowinghelperfunctions
i.TheyhelpBcellsdevelopintoantibodyproducingplasmacells.SomeactivatedBcellsalsoformmemory
cells,whichcanremainquiescentforlongperiodsbutcapturebybeingactivatedrapidlyuponreexposure
toantigen
ii.TheyhelpCD8TcellstobecomeactivatedcytotoxicTcells
ThesefunctionareperformedbytwosubpopulationofCD4cells:ThlcellsactivatecytotoxicTcellsby
producingIL2andhelpinitiatedelayedhypersensitivityresponsebyproducingprimarilyIL2&yinterferon.
whereasTh2cellsperformBcellhelperfunctionbyproducingprimarilyIL4andIL5.
(Q.54) Ectopicrestofnormaltissueisknownas?
(a)
Choristoma
(b)
Hamartoma
(c)
Pseudotumor
(d)
Lymphoma
YourResponse:
CorrectAnswer:
Exp:
Choriostma.(RefRobbins8th/pg.174)
Hamartomaisamalformationthatpresentsasamassofdisorganizedtissueindigenoustotheparticular
site.Onemayseeamassofmaturebutdisorganizedhepaticcells,bloodvessels,andpossiblybileducts
withintheliver,ortheremaybeahamartomatousnoduleinthelungcontainingislandsofcartilage,
bronchi,andbloodvessels.Anothermisnomeristhetermchoristoma.Thiscongenitalanomalyisbetter
describedasaheterotopicrestofcells.Forexample,asmallnoduleofwelldevelopedandnormally
organizedpancreatictissuemaybefoundinthesubmucosaofthestomach,duodenum,orsmallintestine.
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ThisheterotopicrestmayberepletewithisletsofLangerhansandexocrineglands.ThetermChoristoma,
connotinganeoplasm,impartstotheheterotopicrestagravityfarbeyonditsusualtrivialsignificance.
Althoughtheterminologyofneoplasmsisregrettablynotsimple,itisimportantbecauseitisthelanguage
bywhichthenatureandsignificanceoftumorsarecategorized.
(Q.55) Schaumannbodiesareseenin?
(a)
Sarcoidosis
(b)
Chronicbronchitis
(c)
Asthma
(d)
Syphilis
YourResponse:
CorrectAnswer:
Exp:
Sarcoidosis.(RefRobbins8th/pg.738)
Sarcoidosisisasystemicdiseaseofunknowncausecharacterizedbynoncaseatinggranulomasinmany
tissuesandorgans.
AssociationwithcertainHLAgenotypes(e.g.,classIHLAA1andHLAB8).
Nounequivocalevidencetosuggestthatsarcoidosisiscausedbyaninfectiousagent.
Histologically,allinvolvedtissuesshowtheclassicnoncaseatinggranulomas,eachcomposedofan
aggregateoftightlyclusteredepithelioidcells,oftenwithLanghansorforeignbodytypegiantcells.Central
necrosisisunusual.Withchronicity,thegranulomasmaybecomeenclosedwithinfibrousrimsormay
eventuallybereplacedbyhyalinefibrousscars.
Twoothermicroscopicfeaturesareoftenpresentinthegranulomas:
laminatedconcretionscomposedofcalciumandproteinsknownasSchaumannbodiesand
stellateinclusionsknownasasteroidbodiesenclosedwithingiantcellsfoundinapproximately60%ofthe
granulomas.
Althoughcharacteristic,thesemicroscopicfeaturesarenotpathognomonicofsarcoidosisbecauseasteroid
andSchaumannbodiesmaybeencounteredinothergranulomatousdiseases(e.g.,tuberculosis).
Pathologicinvolvementofvirtuallyeveryorganinthebodyhasbeencitedatonetimeoranother.
REMEMBER:ListofvariousBODIESseeninvariousdiseases:
BODIES
DISEASE
Hematoxylinbody
LibmanSacsendocarditis
MeyersKouvenaarsbody
Filariasis
Ricebodies
FibrousloosebodiesinjointsinTBarthritis
MichalisGuttmanbody
Malakoplakia
Herringbody
Posteriorpituitarybodies
HalberstaedlerProwazekbody
Trachomatosis
Picksbody
FrontoTemporaldementia/Picksdisease
Moosersbody
Endemictyphus
Loforabody
Familialmyoclonicepilepsy
Tuftstonebody
Metachromaticleukodystrophy
Cystoidbody
CMVretinitis
Paschenbody
Elementarybodyofvariola(Smallpox)
Guarneribody
Inclusionbodyofvariolavaccinia
Molluscumbody
Inclusionbodyofmolluscumcontagiosum
LDbody
Leishmaniasis(Itisaamastigotewithinamacrophage)
Negribody
Rabies(Intracytoplasmic)
Bollingerbody
Fowlpox
HendersonPetersonbody
Molluscumcontagiosum
Torresbody
Yellowfever
WarthinFinkeledybody
Measles
Miyagawabody
LGV
LevinthalColeLillybody
Psittacosis
Copperpennybody
HistologiccharacteristicofChromoblastomycosis
Parappenheimerbody
Sideroblasticanemia
Gammagandybody
Sicklecellanemia
Massonbody
Cryptogenicorganizingpneumonia
Asteriodbody,Schaumannbody
Sarcoidosis
RusselandDutcherbody
Multiplemyeloma
Globoidbody
Krabbesdisease
Aschoffbody
Rheumaticheartdisease
(Q.56) LibmanSachsendocarditisisassociatedwith?
(a)
Rheumaticheartdisease
(b)
SLE
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(c)
Carcinoma
(d)
Fungalinfection
YourResponse:
CorrectAnswer:
Exp:
SLE(RefRobbinspathology8th/pg.408
LibmanSacksEndocarditis
LibmanSacksendocarditisreferstosterilevegetationsthatcandeveloponthevalvesofpatientswith
systemiclupuserythematosus.
Theselesionspresumablyoccurbecauseofimmunecomplexdepositionandthushaveassociated
inflammation.
Withincreasinguseofsteroidsfortreatmentoflupus,LibmanSacksendocarditishasbecomefairly
uncommon.
VARIOUSTYPESOFVEGETATIONSSEENONVALVES:
characterizedbymicrobialinvasionofheartvalvesormuralendocardiumoften
withdestructionoftheunderlyingcardiactissues(valveperforation,ring
abscess).
Infectiveendocarditis
Bulky,friablevegetationscomposedofnecroticdebris,thrombus,and
organisms.
Thromboemboismcommon.
LibmanSacks
endocarditis
SLEcanbeassociatedwithLibmanSacksendocarditis
inwhichtherearemanyflat,reddishtanvegetationsspreadingoverthemitral
valveandchordae.
vegetationsonbothsidesofvalve
donotembolize.
NBTE(nonbacterial
typicallyexhibitssmall,blandvegetations,usuallyattachedatthelineofclosure.
thromboticendocarditis) Easilydetachable.
NBTEindebilitatedcancerandsepsispatientsismaranticendocarditis.
Rheumaticcarditis
Vegetationslargerthan10mm(notwellpenetratedbyantibiotics)
Alongthelineofclosure
Aschoffbodies
(Q.57) VirchowsTriadincludethefollowingEXCEPT?
(a)
Hypercoagulability
(b)
Stasisofblood
(c)
Injurytovessels
(d)
VenousThrombosis
YourResponse:
CorrectAnswer:
Exp:
VenousThrombosis
FactorswhichleadtovenousthrombosisThesewereoriginallydescribedbyVirchowoveracenturyago.He
suggestedthatthefollowingfactorsmayleadtoclottingintheveins.
VIRCHOWTRIAD:
Changesinthevesselwallwithdamagetotheendotheliumduetoinjuryorinflammation.Thisisknownto
happenfollowingpreviousdeepveinthrombosis.
Diminishedrateofbloodflowintheveins.Inmodernmedicalpracticethisoccursduringandafter
operations,andindebilitatingconditionssuchasstrokesandmyo
cardialinfarction.
Increasedcoagulabilityoftheblood.Thisalsooccursfollowingsurgeryandinthepresenceofinfectionor
systemicmalignancy.
FEWCLASSICALTRIADS:
AUSTRIANTRIAD
TheAustriantriadisnamedafterRobertAustrianwhoinitiallyidentifiedand
describedit.It'scomponentsare:
1.Pneumococcalpneumonia2.Meningitis3.Endocarditis(classicallyaorticvalve
endocarditisassociatedwithaorticregurgitation)
WADDELsTRIAD
Waddell'striadisrecognizedinclinicalpracticeasassociatedwithhighvelocity
accidentssuchasmotorvehicle,autopedestrian,orbicyclecrashes
Waddell'striadconsistsof
1.Femurfracture2.Intraabdominalorintrathoracicinjury3.Headinjury,
CHARCOTsTRIAD
TherearetwosetsofCharcot'striadsrelatingtoquiteseparatediseases.
A.Charcot'striadformultiplesclerosis
1.Nystagmus2.Intentiontremor3.Scanningorstaccatospeech
Whilethistriadischaracteristicofmultiplesclerosis,itisnotconsidereddefinitely
diagnostic.
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B.Charcot'striadforascendingcholangitis
1.Jaundice2.Fever,usuallywithrigors3.Rightupperquadrantabdominalpain.
Charcot'striadforascendingcholangitisisaresultofascendingcholangitis(an
infectionofthebileductusuallycausedbybacteriaascendingfromitsjunction
withtheduodenum).Whenthepatientpresentsalsowithhypotensionandmental
statuschanges,itisknownasReynolds'pentad
Charcot'striadsarenamedfortheFrenchneurologistwhofirstdescribedthese
combinationsofsignsinrelationtothesediseases,JeanMartinCharcot(1825
1893.
VIRCHOWsTRIAD
Virchow'striadpresentsthethreebroadcategoriesoffactorsthatarethoughtto
contributetothrombosis.
Thetriadconsistsof:
1.Alterationsinnormalbloodflow2.Injuriestothevascularendothelium3.
Alterationsintheconstitutionofblood(hypercoagulability)
Alterationinbloodflowcanincludeturbulence,stasis,mitralstenosis,andvaricose
veins.Injuriestothevascularendotheliumcanbecausebydamagetotheveins
arisingfromshearstressorhypertension.Hypercoagubilitycanbeaconsequence
ofnumerouspossibleriskfactorssuchashyperviscosity,deficiencyofantithrombin
III,nephroticsyndrome,changesafterseveretraumaorburn,disseminatedcancer,
latepregnancyanddelivery,race,age,smoking,andobesity.
Virchow'striadwasfirstformulatedbytheGermanphysicianRudolfVirchow
(18211902)in1856.
BECKsTRIAD
Beck'striadwasdescribedbythethoracicsurgeonCaludeS.Beckin1935.It's
componentsare:
1.Distendedneckveins2.Distantheartsounds3.Hypotension
i.e.risingvenouspressure,fallingarterialpressure,anddecreasedheartsounds
foundinthepresenceofpericardialtamponade.
BERGMANsTRAID
Bergmanstriadisseenwithfatembolisyndrome.It'scomponentsare:
1.Mentalstatuschanges2.Petechiae(oftenintheaxilla/thorax)3.Dyspnea
CARCINOIDTRIAD
Theelementsofthecarcinoidtriadare:
1.Flushing2.Diarrhea3.Rightsidedheartfailure
Bronchospasmissometimesalsopresent.
CUSHINGsTRIAD
Cushing'striad(nottobeconfusedwiththeCushingreflex)isasignofincreased
intracranialpressure.Itisthetriadof:
1.Hypertension(progressivelyincreasingsystolicbloodpressure)
2.Bradycardia
3.Wideningpulsepressure(anincreaseinthedifferencebetweensystolicand
diastolicpressureovertime)
Cushing'striadsuggestsacerebralhemorrhageinthesettingoftraumaoranspace
occupyinglesion(e.g.braintumor)thatisgrowingandapossibleimpendingfatal
herniationofthebrain.Cushing'striadisnamedafteranAmericanneurosurgeon
HarveyWilliamsCushing(18691939).
HUTCHINSONTRIAD
Hutchinson'striadisacommonpatternofpresentationforcongenitalsyphilis.It
consistsof:
1.Interstitialkeratitis2.Hutchinsonincisors3.Eighthnervedeafness
Hutchinson'striadisnamedafterSirJonathanHutchinson(18281913).
MACDONALDTRIAD
TheMacdonaldtriadisasetofthreebehavioralcharacteristicswhichare
associatedwithsociopathicbehavior.Thesebehavioralcharacteristicsarefoundin
thechildhoodhistoriesofindividualswithsociopathicbehavior:
1.Enuresis(bedwetting)2.Firesetting3.Torturingsmallanimals
TheMacdonaldtriadisalsoknownasthetriadofsociopathy.Itwasfirstidentified
byaforensicpsychiatrist,JohnMarshallMacdonald(November7,1920
December16,2007),ina1963paperintheAmericanJournalofPsychiatrytitled
"TheThreattoKill".
TheMacdonalttriadisconsideredpredictiveoffuturecriminalbehavior.
Meltzerstriad
Purpura,arthralgiaandmyalgia.
IsgenerallyseenwithpolyclonalCryoglobulinemiasseeninessential,viral,
orconnectivetissuediseaseassociatedCryoglobulinemias.
(Q.58) Nitrobluetetrazolium(NBT)dyetestisdoneforassessingdefectin?
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(a)
Tcells
(b)
Bcells
(c)
Phagocytes
(d)
Platelets
YourResponse:
CorrectAnswer:
Exp:
Phagocytes(RefRobbinsPathology7thed.Pg.63)
NBT:
.Nitrobluetetrazoliumisusedinadiagnostictest,particularlyforchronicgranulomatousdisease
andotherdiseasesofphagocytefunction.WhenthereisanNADPHoxidasedefect,thephagocyte
isunabletomakereactiveoxygenspeciesorradicalsrequiredforbacterialkilling.Asaresult,
bacteriamaythrivewithinthephagocyte.Thehigherthebluescore,thebetterthecellisat
producingreactiveoxygenspecies.Normally,whitebloodcellscalledneutrophilsmakeachemicalthat
killsbacteria.Inchronicgranulomatousdisease,thischemicalismissing.Thechemicalthatkillsthebacteria
isthesameonethatcausesNBTtochangefromcleartodeepblue.Ifthechemicalismissing,thewhite
bloodcellswillnotchangecolorwhenNBTisadded.Nitrobluetetrazoliumisachemicalcompound
composedoftwotetrazolemoieties.Itisusedinimmunologyforsensitivedetectionofalkaline
phosphatase(withBCIP).NBTservesastheoxidantandBCIPistheAPsubstrate(andgivesalso
darkbluedye).
(Q.59) Duringoxidativeburstinphagocytosiswhichenzymesplayskeyrole?
(a)
Oxidase
(b)
Peroxidase
(c)
Carboxylase
(d)
Hydrolase
Your
Response:
Correct
Answer:
Exp:
A
Oxidase(RefRobbinsPathology7thed.Pg.63)
OXYGENDEPENDENTRESPIRATORYBURST:
NADPHoxidase(deficiency=chronicgranulomatous
disease)
Superoxidedismutase
Myeloperoxidase
Catalase
Glutathionereductase
Glucose6phosphatedehydrogenase(G6PD)
(Q.60) Incongenitaldystrophicepidermolysisbullosa,mutationisseeningenecodingfor?
(a)
Laminin4
(b)
CollagentypeVII
(c)
Alpha6integrin
(d)
Keratin14
YourResponse:
CorrectAnswer:
Exp:
CollagentypeVII(RefRobbinspathology7th/pg.106;table32)
COLLAGEN
TISSUEDISTRIBUTION
GENETICDISORDERS
TYPE
I
Ubiquitousinhardandsofttissues OsteogenesisImperfectaQ
EhlersDanlossyndromearthrochalasias
type
II
Cartilage,intervertebraldisk,
vitreous
AchondrogenesistypeII,spondyloepiphyseal
dysplasiasyndrome
III
Holloworgans,softtissues
VascularEhlersDanlossyndrome
IV
Basementmembranes
AlportsyndromeQ
Softtissues,bloodvessels
ClassicalEhlersDanlossyndrome
VI
Ubiquitousinmicrofibrils
Bethlemmyopathy
VII
Anchoringfibrilsatdermal
epidermaljunctions
DystrophicepidermolysisbullosaQ
IX
Cartilage,intervertebraldisks
Multipleepiphysealdysplasias
IX
Cartilage,vitreous
Sticklersyndrome
XVII
Transmembranecollagenin
epidermalcells
Benignatrophicgeneralizedepidermolysis
bullosa
XVandXVIII
Endostatinformingcollagens,
Knoblochsyndrome(typeXVIIIcollagen)
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endothelialcells
(Q.61) Filariformlarvaeareseenwith?
(a)
Enterobiusvermicularis
(b)
Ascarislumbricoides
(c)
Necatoramericans
(d)
Trichuristrichura
YourResponse:
CorrectAnswer:
Exp:
Ascarislumbricoides.(RefMedparasitologybyArora2nd/1321)
Filariformlarva:
Isinfectivethirdstagelarvaofthehookworm,Ascaris,andothernematodeswithpenetratinglarvaeorwith
larvaethatmigratethroughthebodytoreachtheintestine.
ExtraEdge:LaboratoryFindings(Harrison,17theditionpage1320)
MostcasesofascariasiscanbediagnosedbymicroscopicdetectionofcharacteristicAscariseggs(65by45
m)infecalsamples.Occasionally,patientspresentafterpassinganadultwormidentifiablebyitslarge
sizeandsmoothcreamcoloredsurfaceinthestoolorthroughthemouthornose.
Duringtheearlytranspulmonarymigratoryphase,wheneosinophilicpneumonitisoccurs,larvaecanbe
foundinsputumorgastricaspiratesbeforediagnosticeggsappearinthestool.
Theeosinophiliathatisprominentduringthisearlystageusuallydecreasestominimallevelsinestablished
infection.Adultwormsmaybevisualized,occasionallyserendipitously,oncontraststudiesofthe
gastrointestinaltract.
Aplainabdominalfilmmayrevealmassesofwormsingasfilledloopsofbowelinpatientswithintestinal
obstruction.
Pancreaticobiliarywormscanbedetectedbyultrasoundandendoscopicretrograde
cholangiopancreatography;thelattermethodalsohasbeenusedtoextractbiliaryAscarisworms.
(Q.62) AllofthefollowingserotypesofB.cereusareassociatedwithemetictypeoffoodpoisoningexcept?
(a)
(b)
(c)
(d)
10
YourResponse:
CorrectAnswer:
Exp:
10
DISEASESANDSPECIFICASSOCIATEDSEROTYPES
B.cereusfoodpoisoning
Emetic1,3,5
Diarrhoeal2,6,8,9,10,12
Humanbotulism
A,B,EandrarelyF.toxinproductionisdeterminedbybacteriophage
intypeC&D
Clostrialfoodpoisoning
Cl.PerfringestypeA
Enteritisnecroticans/
pigbel
Cl.PerfringestypeC(betatoxin)
Listeriamonocytogens
humaninfection
1/2a,1/2b,4b
Yersiniapseudotuberculosis 01
Yersiniaenerocolitica
03,08,09
S.pyogens
glomerulonephritis
49,5355,5964,1,12
Lateonsetneonatal
meningitisbygroupb
streptococcus
CapsulartypeIII
Pneumococcalpneumonia Type1totype8.Mostvirulenttype3
Meningococcalmeningitis A,B,C,W,Y
Legionellapneumophilla
Mostcommonserotype1.Hospitalacquireddiseaseand
poorprognosisserotype6
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Chlamydiatrachomatis
EndemicblindingtrachomaA.B.Bo,CInclusionconjunctivitis,
genitalinfection,infantpneumoniaDto
RLymphogranulomavenerumL1,L2,L3
Cryptococcusneoformans Immunocompromised=vargrubii(serotype
A)immunocompetent=vargatti(serotypeB
andC)
Poliovirus
Mostcommonandmostepidemictype1Mostantigenicand
endemictype2Vaccineinducedparalysismutatedtype3
Influenzavirus
AntigenicvariationA>B
NoAntigenicvariationC
Parainfluenzavirus
Mostcommongroupinchildrentype1
Mostcommongroupinlowerrespiratorytractinfectionininfants
type3
Rotavirus
Humanillness=A>B>C
Adultdiarrohealrotavirus=grpB
Smallpopulationofpediatricdiarrhoealdiseases=group
c
MostcommonserotypesofgroupAinhumans=G1toG4,G9
Astrovirus
Mostcommon=1
Rhabdoviridea
Rabiesvirus=1,rabiesrelatedvirus=2,3,4
Adenovirus
Follicular(swimmingpool)conjunctivitis=
3,7epidemickeratoconjunctivitis
(shipyardeye)=8,9,37
Respiratorydiseaseinchildren=1,2,5,6Sorethroat,
pneumonia=3,4,7,14,21
Acuterespiratorydistressinmilitaryrecruits=
4,7,21
Diarrhoea=40,41Hemmorhagiccystitis=11,21
H.influenza
Meningitis=Biotype1Invasivedisease=capsular
subtypeb
Coxsackievirus
Acutehemmorhagiccystitis=A24Generaliseddiseaseof
newborn=B2to5Handfootmouthdiseaseandherpangina=A>
B
Pleurodynia=B>AJuvenilediabetes=
B4
Postviralfatiguesyndrome=B
Enterovirus
Acutehemmorhagiccystitis=ent70
Handfootmouthdiseaseandherpangina=ent71
HPV
Commonwarts/verrucavulgaris=
1,2,3,4Condylomaacuminata=
6,11
CIN(LOWRISK)=6,11Carcinoma(HIGHRISK)=
16,18,31,33,45Epidermodyspl.Verruciformis=
5,8
(Q.63) WhichofthefollowingshowRegressivemetamorphosis?
(a)
Hydatidcyst
(b)
Cysticercoid
(c)
Cysticercusbovis
(d)
Cysticercuscellulosae
YourResponse:
CorrectAnswer:
Exp:
Hydatidcyst.(RefMedicalparasitologybyRajeshKaryakarte1sted/pg.117&256)
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RegressivemetamorphosisisshownbyHydatidcyst.
itisseeninhydatiddisease.....therupturedhydatidcystreleasesproscolicesintotissueswhichdonot
developintoadultformsaccordingtolawofmigrationofcystodes....buttheyformanewhydatidtissue
againstthelaw....thisiscalledregressivemetamorphosis.
Secondaryechinococcosisoccursasacomplicationofaprimarycyst.Theimportanceofoperative
techniqueduringtheremovaloftheprimarycystisemphasized,becausetheintraoperativedisemination
occursmostfrequentlyafterasurgicalperformance.Secondaryechinococcosisgeneratesbyasexual
regressivemetamorphosisoflarvalelementintrolarvalforms.
LAWOFMIGRATIONOFCYSTODE:Acystodehastocompleteitslifecyclewithalterationofgeneration
alongwithalterationofhosts.
Whichmeansnormalistoformadultafterlarvabutinechinococcus(hydatidcyst)whathappensis
regressivemetamorphosis,larvaformslarva.
Diagnosis(Harrison,17theditionpage1339)
Radiographicandrelatedimagingstudiesareimportantindetectingandevaluatingechinococcalcysts.Plain
filmswilldefinepulmonarycystsofE.granulosususuallyasroundedmassesofuniformdensitybutmay
misscystsinotherorgansunlessthereiscystwallcalcification(asoccursintheliver).
MRI,CT,andultrasoundrevealwelldefinedcystswiththickorthinwalls.Whenoldercystscontainalayer
ofhydatidsandthatisrichinaccumulatedprotoscolices,theseimagingmethodsmaydetectthisfluidlayer
ofdifferentdensity.However,themostpathognomonicfinding,ifdemonstrable,isthatofdaughtercysts
withinthelargercyst.
Thisfinding,likeeggshellormuralcalcificationonCT,isindicativeofE.granulosusinfectionandhelpsto
distinguishthecystfromcarcinomas,bacterialoramebicliverabscesses,orhemangiomas.Incontrast,
ultrasoundorCTofalveolarhydatidcystsrevealsindistinctsolidmasseswithcentralnecrosisandplaquelike
calcifications.
AspecificdiagnosisofE.granulosusinfectioncanbemadebytheexaminationofaspiratedfluidsforproto
scolicesorhooklets,butdiagnosticaspirationisnotusuallyrecommendedbecauseoftheriskoffluid
leakageresultingineitherdisseminationofinfectionoranaphylacticreactions.
Serodiagnosticassayscanbeuseful,althoughanegativetestdoesnotexcludethediagnosisof
echinococcosis.Cystsintheliverelicitpositiveantibodyresponsesin~90%ofcases,whereasupto50%of
individualswithcystsinthelungsareseronegative.Detectionofantibodytospecificechinococcalantigens
byimmunoblottinghasthehighestdegreeofspecificity.
Secondaryechinococcosisoccursasacomplicationofaprimarycyst.Theimportanceofoperativetechnique
duringtheremovaloftheprimarycystisemphasized,becausetheintraoperativediseminationoccursmost
frequentlyafterasurgicalperformance.Secondaryechinococcosisgeneratesbyasexual
regressivemetamorphosisoflarvalelementintrolarvalforms
(Q.64) Livepartofhydatidcyst?
(a)
Pericyst
(b)
Ectocyst
(c)
Endocyst
(d)
Noneoftheabove
YourResponse:
CorrectAnswer:
Exp:
Endocyst(RefBaileyandLove25th/pg.56)
EndocystisLivepartofhydatidcyst.
Etiology(Harrison,17theditionpage1338)
HydatiddiseaseisaparasiticinfectioncausedbyEchinococcusgranulosus.Thecystlodgesmost
commonlyintheliverandthelungs,respectively.
Morphologically,hydatidcystconsistsofthreelayersandhydatidfluid.Thefirstlayeristhepericystor
adventitiawhichisthehosttissueformedbythelungasareactiontotheforeignbody(parasite).The
othertwolayers,thelaminatedmembrane(externallayerofthecyst)andthegerminativelayer(inner
layerofthecyst),belongtotheparasite.Thecystfluidresembleswaterinappearancewhichmaycontain
daughtervesicles.
Theinnerlayerisalsocalledendocystwhichisthelivingpartwhichmeans,theyareinfectious.thatis
whyrupturedhydatidcystissuchaseriousproblem.thefluidinendocystisspilledinsurroundinghost
tissueanddaughtercystswilldevelopedinlarva.
Thecystsexistindifferentforms:intactorrupturedsingleormultiple,unilateralorbilateral,solely
locatedinthelungorconcomitantlyinotherorganlodgements(especiallyintheliver)
(Q.65) Informoletherconcentrationtechnique,whichlayercontaintheparasites?
(a)
Ether
(b)
Fecaldebris
(c)
Formalwater
(d)
Sediment
YourResponse:
CorrectAnswer:
Exp:
Sediment(RefMedicalparasitologybyRajeshKaryakarte1sted/pg.215;Fig.122)
Concentrationtechniquesinclude:
Sedimentationtechniques
Formoletherconcentrationtechnique
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Formoldetergentconcentrationtechnique
Floatationtechniques
Sodiumchloridefloatationtechniques
Zincsulphatefloatationtechnique
Sugarfloatationtechnique
Thediagnosisofparasiticinfectionsinhumansischallengingandrequirestherecognitionofparasitestages
basedonsize,morphology,color,andmovement.Sizeandmorphologyarethemajordiagnostic
parameters,(Foreyt,1989).Aconcentration
procedureshouldbeperformedasaroutinepartofacompleteexaminationforparasites.Concentration
permitsthedetectionoforganismspresentinsmallnumbers:thesemaybemissedbyusingdirectwet
mounts.Organismsthatcangenerallybeidentified
usingaconcentrationprocedureinclude:helmintheggsandlarvae;cystsofGiardialamblia,Entamoeba
histolytica/Entamoebadispar,Entamoebacoli,Endolimaxnana,Blastocystishominis,Iodamoebabutschii;
oocystsofIsosporabelli.twotofivegrams
ofstoolwereusedforeachtest.Thestoolwaspouredontoadoublelayerofwettedgauzetakingspecial
caretoincludeanybloodormucus.Tenmillilitersofapreparationofeithernormalsalineor0.1NNaOH
weremixed.Themixturewasleftfor1hourbeforecentrifugationfor5minutesat2,000rpm.The
supernatantwaspouredoffandmixedwiththereagentinstep2again.Repeatcentrifugation,atthesame
rateandforthesametime,wasconducted.Thesupernatantwaspouredoffand10mlof0.1%formalin
wereadded.Themixturewasleftfor10minutes.Threemillilitersofetherwereadded;thetubewasclosed
andmixingtookplacefor30seconds.Theupperseparatedsupernatantwaspouredoff;thesedimentwas
usedforslidepreparation.
(Q.66) InHotairOven,forholdingperiodofonehourtemperaturerequiredis?
(a)
100oC
(b)
120oC
(c)
140oC
(d)
160oC
YourResponse:
CorrectAnswer:
Exp:
160oC.
(RefTextbookofMicrobiologybyAnanthanarayan8thed.25)
Hotairovenismostwidelyusedmethodofsterilizationbydryheat.Holdingperiodof160ocforonehouris
usedtosterilizethefollowing:
a.Glasswaresb.Forcepsc.Scissord.Scalpele.Glasssyringe
f.Swabsg.Liquidparaffinh.Dressingpowderi.Fats,oilsandgrease.
ThesporesofanontoxigenicstrainofClostridiumtetaniareusedasmicrobiologicaltestofdryheat
efficiency.
(Q.67) WhichofthefollowingisthepathogenresponsibleforblindnessinadvancedHIVinfections?
(a)
Cytomegalovirus
(b)
EpsteinBarrvirus
(c)
Fungus
(d)
Toxoplasma
YourResponse:
CorrectAnswer:
Exp:
Cytomegalovirus
ThepredominantcausesofmorbidityandmortalityamongpatientswithlatestageHIVinfectionare
opportunisticinfections.
Thesearedefinedassevereinfectionsinducedbyagentsthatrarelycausediseaseinimmunecompetent
individuals.OpportunisticinfectionsusuallydonotoccuruntilCD4Tcellcountsdropfromnormal(1000
cellspermicroliter)tolessthan200cellspermicroliter.
ThecommonopportunisticinfectionsinuntreatedAIDSpatientsarecausedbyprotozoa,fungi,bacteria,
andotherviruses.CoinfectionwithDNAvirusesarereportedtoleadtoenhancedexpressionofHIVincells
invitro.
HerpesvirusinfectionsarecommoninAIDSpatients,andCytomegalovirus(CMV)hasbeenshownto
produceaproteinthatactsasachemokinereceptorandisabletohelpHIVinfectcells.CMVretinitisisthe
mostcommonsevereocularcomplicationsofAIDS.
(Q.68) TheFcpieceofwhichImmunoglobulinfixesC1complements?
(a)
IgA
(b)
IgG
(c)
IgM
IgE
(d)
YourResponse:
CorrectAnswer:
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Exp:
IgG
(RefH17th/Table30811pg.708)
Physical,Chemical,andBiologicPropertiesofHumanImmunoglobulins
Property
IgG
IgA
IgM
IgD
IgE
Usualmolecularform Monomer
Monomer,dimer Pentamer,
hexamer
Monomer Monomer
Otherchains
None
Jchain,SC
Jchain
None
None
Subclasses
G1,G2,G3,G4 A1,A2
None
None
None
Heavychainallotypes Gm(=30)
NoA1,A2m(2) None
None
None
Molecularmass,kDa 150
160,400
950,1150
175
190
Sedimentation
constant,Sw20
6.6S
7S,11S
19S
7S
8S
Carbohydrate
content,%
10
13
Serumlevelin
9.512.5
averageadult,mg/mL
1.52.6
0.71.7
0.04
0.0003
Percentageoftotal
serumIg
715
510
0.3
0.019
Serumhalflife,days 23
2.5
Synthesisrate,mg/kg 33
perday
65
0.4
0.016
Antibodyvalence
7585
2,4
10,12
Classicalcomplement +(G1,2?,3)
activation
++
Alternate
+(G4)
BindingcellsviaFc
Macrophages,
neutrophils,
largegranular
lymphocytes
Lymphocytes
Lymphocytes None
Biologicproperties
Placental
transfer,
secondaryAb
formost
antipathogen
responses
Secretory
PrimaryAb
immunoglobulin responses
complement
activation
Mastcells,
basophils,B
cells
Markerfor Allergy,
matureB antiparasite
cells
responses
(Q.69) TrueaboutC.jejuni:
(a)
Grampositivebacillus
(b)
Symptomsmayinitiallymimiccholecystitis
(c)
Mostoftenoccursseveraldaysafterconsumptionofundercookedchicken.
(d)
Penicillinindrugofchoice
YourResponse:
CorrectAnswer:
Exp:
Mostoftenoccursseveraldaysafterconsumptionofundercookedchicken.
Campylobacterspeciesaresmallmotile,nonsporeforming,commashaped,gramnegativebacilli,best
growninamicroaerophilicenvironmentat42C(107.6F).
GuillainBarreisarareneurologicalcomplicationofC.jejunigastroenteritis.
C.jejunigastroenteritisisusuallyselflimited;however,ifnecessary,erythromycinisthedrugofchoice.
Campylobacterinfectionmostoftenoccursseveraldays(upto7d)afterconsumptionofundercooked
chicken.
Symptomoffeverandabdominalpainmayinitiallymimicappendicitispseudoappendicitis.
(Q.70) HPVrelatedcervicalintraepithelialneoplasiacanbediagnosedbythepresenceofwhichofthefollowinghistologicfeatures?
(a)
Central,basophilicintranuclearcellularinclusions
(b)
CowdrytypeAintranuclearcellularinclusions
(c)
Enlargedmultinucleatedcells
(d)
Cytoplasmicvacuolizationandnuclearenlargementofcells
YourResponse:
CorrectAnswer:
Exp:
Cytoplasmicvacuolizationandnuclearenlargementofcells
HPVproducescharacteristiccytoplasmicvacuolizationandnuclearenlargementofsquamousepithelial
cells,referredtoaskoilocytosis.BothCowdrytypeAintranuclearinclusionsandenlargedmultinucleated
cellscanbeseenwithherpessimplexvirus(HSV)andvaricellazostervirus(VZV)infections;central,
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basophilicintranuclearinclusionbodiesareseeninCMVinfections,whereasthepresenceofatypical
lymphocytesisseenspecificallyinEpsteinBarrvirus(EBV)infections.
(Q.71) Whichofthefollowingviralfamiliesisknowntobecausallyassociatedwithtumorformationinhealthyappearinghumanadults?
(a)
Flaviviruses
(b)
Papovaviruses
(c)
Paramyxoviruses
(d)
Polyomaviruses
YourResponse:
CorrectAnswer:
Exp:
Papovaviruses
HPVisamemberofthePapovavirusfamilyandiscausallyassociatedwithcervicalcancerinotherwise
healthyindividuals;HepatitisCvirusisamemberoftheFlavivirusesfamilyandcauseschronichepatitisand
inseverecasesisafactorinlivercancerdevelopment;Paramyxovirusesincludeagentssuchasrespiratory
syncytialvirusandmeaslesvirusandarenotassociatedwithcarcinomas;humanpolyomavirusesincludeBK
andJCviruses,whichhavebeenassociatedwithimmunocompromisedpatients,andtheirroleinformation
ofhumantumorsisstillunderinvestigation.
(Q.72) Hemagglutinin,(AntiAandAntiB)arewhichtypeofantibodies?
(a)
IgG
(b)
IgM
(c)
IgA
(d)
IgE
YourResponse:
CorrectAnswer:
Exp:
IgM
(RefH17th/pg.708709;Wintrobe'sclinicalhematology13th/pg.979)
Isohemagglutinins,substancesthatagglutinatetheredbloodcellsofothersofthesamespecies,arealso
foundinhumans.Thus,therearefourmainbloodgroups,whichdifferwithrespecttotwoantigens,Aand
B,intheredbloodcellsandtwoisohemagglutinins,antiAandantiB,intheserum.Thus,inhumans,typeO
hasneitherantigenbutbothagglutinins,typeAhasAantigenandantiB.
AntiAandantiBantibodiesareusuallyIgManddonotpassthroughtheplacenta.
(Q.73) Cellfusionisaninnovativetechniqueofpreparingspecificantibodies.Techniquestoinducethecellfusionincludethefollowing
except:
(a)
Byadheringsomeinactivatedvirusestosurfacemembrane
(b)
Byaddingcomponentpolyethyleneglycol
(c)
Bymildelectricshock
(d)
Byreducingtheviscosityofthemembrane
YourResponse:
CorrectAnswer:
Exp:
Byreducingtheviscosityofthemembrane.
Cellfusionisaninnovativetechniqueofpreparingspecificantibodies.
Techniquestoinducethecellfusioninclude:
Byadheringsomeinactivatedvirusestosurfacemembrane
Byaddingcomponentpolyethyleneglycol
Bymildelectricshock.
(Q.74) Whichofthefollowingprecautionsisadvisablewhenusinglovastatin?
(a)
Serumtransaminasemeasurements
(b)
Renalfunctionstudies
(c)
Acousticmeasurements
(d)
Monthlycompletebloodcounts
YourResponse:
CorrectAnswer:
Exp:
Serumtransaminasemeasurements
Lovastatinshouldnotbeusedinpatientswithsevereliverdisease.Withroutineuseoflovastatin,serum
transaminasevaluesmayrise,andinsuchpatients,thedrugmaybecontinuedonlywithgreatcaution.
Lovastatinhasalsobeenassociatedwithlenticularopacities,andslitlampstudiesshouldbedonebefore
and1yearafterthestartoftherapy.Thedrugisnottoxictotherenalsystem,andreportsofbonemarrow
depressionareveryrare.Thereisasmallincidenceofmyopathy,andlevelsofcreatininekinaseshouldbe
measuredwhenunexplainedmusclepainoccurs.Combinationwithcyclosporineorclofibratehasledto
myopathy.Thereisnodangerinusewithbileacidsequestrants.
(Q.75) Allopurinolshouldbeavoided,orreduceddosesgivenifwhichofthefollowingchemotherapeuticagentisbeinggiven?
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(a)
Bleomycin
(b)
Cisplatin
(c)
Cyclophosphamide
(d)
Mercaptopurine
YourResponse:
CorrectAnswer:
Exp:
Mercaptopurine
Mercaptopurineandotherthiopurinesarepurineantimetabolitesthataremetabolicallyinactivated
(detoxified)byxanthineoxidase.Thispurinedegradationpathwayofmetabolismnotonlyleadsto
formationofuricacid,butalsoisimportanttoreducinghostcelltoxicitytothethiopurines.Thus,
concomitantuseofallopurinolincreasestheriskofhostcelltoxicityNotethatazathioprine(aninhibitorofB
andTlymphocyteproliferation,andtypicallyusedasanimmunosuppressant)ismetabolizedto
mercaptopurine.Asaresult,ittooisaninteractantwithallopurinol.Themetabolismoftheotherdrugs
listedisnotxanthineoxidasedependent.
(Q.76) DrugswhichinducecytochromeP450areallexcept:
(a)
Griseofulvin
(b)
Ketoconazole
(c)
Barbiturates
(d)
Phenytoin
YourResponse:
CorrectAnswer:
Exp:
Ketoconazole
Microsomalenzymeinhibitors
.Ketoconazole.Ciprofloxacin.Allopurinol.Omeprazole
.Erythromycin.Cimetidine.Phenylbutazone
Microsomalenzymeinduction
Anticonvulsant
Antitubercularsterid
Other
Phenobarbitone
Rifampicin
Chloralhydrate
Phenytoin
Isoniazid
Phenylbutazone
Glucocorticoids
Griseofulvin
DDT
(Q.77) DrugnotgiveninthecontinuationphaseofcategoryIIis:
(a)
Isoniazid
(b)
Rifampicin
(c)
Ethambutol
(d)
Pyrazinamide
YourResponse:
CorrectAnswer:
Exp:
Pyrazinamide
ThetreatmentregimernsfollowedinIndiaundertherevisednationaltuberculosiscontrolprogramme
(RNTCP1997)
TBCategory
Initialphase
Continuationphase
Totalduration
2H3R3Z3E3
4H3R3
II
2H3R3Z3E3S3+1H3R3Z3E3
5H3R3E3
III
2H3R3Z3
4H3R3
Thenumeralbeforeaphaseisthedurationofthatphaseinmonths.
Thenumeralinsubscript(e.gH3R3)isnumberofdosesofthatdrugperweek.Itthereisnosubscript
numeral,thenthedrugisgivendaily.
(Q.78) Whichofthefollowingdrugdoesnotreducespreload:
(a)
GTN
(b)
Captopril
(c)
Hydralazine
(d)
Nitroprusside
YourResponse:
CorrectAnswer:
Exp:
Hydralazine
HYDRALAZINEisadirectactingvasodilatorthatactsdirectlyonthearteriolesandreducestotalperipheral
resistance(afterloadreduction).Itincreasesheartrate,strokevolume,andcardiacoutput.
(Q.79) Chloroquineismosteffectiveagainstwhichstageofmalarialparasite:
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(a)
Merozoites
(b)
Tissueschizonts
(c)
Bloodschizonts
(d)
Gametocytes
YourResponse:
CorrectAnswer:
Exp:
Bloodschizonts
CHLOROQUINEinhibitstheerythrocyticstageofPlasmodium.Itinterruptserythrocyticschizogony(blood
schizonts).
Chloroquineinhibitsthepolymerizationofhaemtoinerthaemozoin.Freehaemmonomersarethoughtto
catalyzeoxidativedamagetothePlasmodiumspp.trophozoite,thestagewhenhaemoglobincatabolismis
maximal.bloodschizontsaremoresensitiveforhisdrugthantissueschizonts.
(Q.80) SodiumreabsorptioninPCTispreventedby:
(a)
Thiazide
(b)
Triamterene
(c)
Mannitol
(d)
Ethacrynicacid
YourResponse:
CorrectAnswer:
Exp:
Mannitol
Mannitolisapharmacologicallyinertsubstancethatisfreelyfilteredofglomerulusandnotabsorbedin
appreciableamount.Principalsiteofactionisproximalconvolutedtubule.PassivereabsorptionofNa+and
CIisdecreasedduetoprogressivelyincreasingconcentrationgradient.
(Q.81) Whichofthefollowingistrueregardingbromocriptine:
(a)
Dopamineagonist
(b)
Dopamineantagonist
(c)
Increasesprolactinlevel
(d)
Galactopoietic
YourResponse: a
CorrectAnswer:
Exp:
Dopamineagonist
Actionsofbromocriptine
1.Dopamineagonist2.Antidyskinetic3.Growthhormone
suppressant
4.Antihyperprolactinemic5.Lactationinhibitor6.Neuroleptic
malignantsyndrome
(Q.82) Trueaboutroutesofdrugadministration:
(a)
80%bioavailabilitybyI.V.injection
(b)
I/Dinjectionproduceslocaltissuenecrosisandirritation
(c)
Inhalationproducesdelayedsystemicbioavailability
(d)
S/Crouteisusedinthetreatmentofhypotensiveshockpatient.
YourResponse:
CorrectAnswer:
Exp:
Intradermalinjectionproduceslocaltissuenecrosisandirritation
ThroughIV.route,thedrugdirectlyreachesthesystemiccirculationandeffectsareproducedimmediately
(greatvalueinemergency).
Bioavailabilityis100%.
Theintimaofveinsisinsensitiveanddruggetsdilutedwithblood,Therefore,evenhighlyirritantdrugscan
beinjectedIV.
Onlyaqueoussolutions(notsuspensions)canbeinjectedIV.andtherearenopreparationsforthisroute.
Doseofthedrugrequiredissmallest.
NotonlyIV.,butalltheparenteralroutessuchassubcutaneous(S.C.),intramuscular(I.M.)intravenous(IV.)
andintradermal(I.D.)havethefollowingdisadvantages:
Preparationandtechniqueneedstobesterile.
Itiscostlier.
Itisinvasive,painfulandcancauselocaltissuenecrosisandirritation.
Assistanceofanotherpersonismostlyneeded.
Therearechancesoflocaltissueinjury.
Itisingeneral,morerisky.
Ininhalation,absorptiontakesplacefromthevastsurfaceofalveoliimmediatesystemicbioavailability
andveryrapidaction.
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Volatileliquidsandgasesaregivenbyinhalationforsystemicactione.g.,amylnitrate.
Whenadministrationisdiscontinued,thedrugdiffusesbackandisrapidlyeliminatedinexpiredair.
(Q.83) Carisoprodolactivationformswhichmetabolite:
(a)
Amphetamine
(b)
Meprobamate
(c)
Doxylamine
(d)
Dimethadione
YourResponse:
CorrectAnswer:
Exp:
.Meprobamate
Carisoprodolisarapidlyactingandisacentrallyactingmusclerelaxant.
Thedrugblockstheelectricalcommunicationamongthecentralnervesinbrain.
Thedrugstartsactingwithin20minutesandtheeffectslastfor26hours.
Itismetabolizedquicklybycytochromeenzymestomeprobamate,whichisanindependentmuscle
relaxant.
However,meprobamatehasabusepotential.Usualdoseofcarisoprodolis350mgdailyandsedationis
mainsideeffect.
Carisoprodolisbelievedtohavelessabusepotential.
Meprobamatewasusedinthepastasaselectiveantianxietydrugwithinsomnia.
However,nowadays,benzodiazepinesarethedrugsofchoiceforthiscondition.
Presently,though,carisoprodoltypeofdrugsareusedorallysometimesinorthopaedicconditions;theyare
oftengivenincombinationwithNSAIDsastopicalformulationsforbackpain,sprains,lumbagoetc.
(Q.84) Widmarksformulaisusedforestimationof:
(a)
Alcohol
(b)
Timesincedeath
(c)
Timessinceinjury
(d)
Consciousness
YourResponse:
CorrectAnswer:
Exp:
Alcohol.(RefReddy24thed.Pg.491)
WIDMARKFORMULA
Ittakesintoaccountthesizeandsexofthepersonandthetypeofalcoholic
liquorconsumed:
a=pre
Where:
a=wt.ofAlcoholinbodyingm
p=bodywtinkg.
e=conc.ofalcoholintheblood,inmg/kg
r=isaconstant0.6formen;0.5forwomen.
ForurineAnalvsis
A=%pr.qq=Alcoholicconc.inurineinmg/kg.
(Q.85) Incisedwoundresembles?
(a)
Splitlaceration
(b)
Stretchlacerations
(c)
Chopwounds
(d)
Internallacerations
YourResponse:
CorrectAnswer:
Exp:
Splitlaceration(RefParikhFMT6th/pg.4.10;4.13)
Incisedwound
Anincisedwoundisaninjurycausedbyaweaponwithasharpcuttingedgewhenitisdrawnacrossthe
skin.
Splitlacerationsthatareusuallyfoundinthepartsoverlyingboneswithoutmuchtissueinbetween(e.g.
scalp,face,hands,andlowerlegs)areincisedlikeorincisedlookingwounds.
(Q.86) Whichisnotacontentofblackgunpowder?
(a)
Sulphur
(b)
Charcoal
(c)
Sodiumnitrate
(d)
Potassiumnitrate
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YourResponse:
CorrectAnswer:
Exp:
Sodiumnitrate(RefParikhFMT6th/pg.4.29)
Blackpowderorthegunpowder
Theblackpowderorthegunpowderconsistof:
Charcoal(15%),
Sulphur(10%),and
Postassium(75%).
GenerallyBlackpowderisusedinmuzzleloaders,blankcartridges,refilledcartridges,andcountrymade
cartridges.
Smokelesspowdercontainsnitrocellulose,orsometimesnitroglycerine.Smokelesspowdrisusedinall
moderncartridgeslikeofshotgun,revolver,rifle,etc.
Ablackpowdersubstitute,Pyrodex,isrecentlymanufacturedforuseinoldfirearms.
(Q.87) Whichchelatingagentisobtainedfromorganisms?
(a)
Desferrioxamine
(b)
BAL
(c)
EDTA
(d)
DTPA
YourResponse
c
:
CorrectAnswer A
:
Exp:
Desferrioxamine(RefKDT,Pharmacology,6thed.,867)
Desferrioxamine
Itisobtainedfromactinomycete.
1gmofdesferrioxamineiscapableofchelating85mgof
elementaliron.
Use:
AcuteIronpoisoning
Topreventhemochromatosisinpatientreceivingmultipleblood
transfusion
Adverseeffects:
HistaminereleaseRetinopathy,cataractHypertension
Deferiprone:
Orallyactingironchelator
Mainsideeffectsarearthropathyandbonedepression.
(Q.88) Chocolatecoloredpostmortemstainingisseenin?
(a)
Carbonmonoxidepoisoning
(b)
KCNpoisoning
(c)
Phosphoruspoisoning
(d)
Potassiumchloratepoisoning
YourResponse:
CorrectAnswer:
Exp:
Potassiumchlorate(RefParikhFMT,p3.10)
LIVORMORTIS(HYPOSTASIS,POSTMORTEMLIVIDITY,POSTMORTEMSUGGILLATIONS)
Lividityisadarkpurplediscolourationoftheskinresultingfromthegravitationalpoolingofbloodinthe
veinsandcapillarybedsofthedependentpartsofthebodyfollowingcessationofthecirculation.
Theprocessbeginsimmediatelyafterthecirculationstops,andinapersondyingslowlywithcirculatory
failure,itmaybepronouncedveryshortlyafterdeath.
Thisisduetothereleaseoffibrinolysins,especiallyfromsmallcalibrevessels,e.g.capillaries,andfrom
seroussurfaces,e.g.thepleura.Clotsmaypersistwhenthemassofclotistoolargetobeliquifiedbythe
fibrinolysinavailableatthesiteofclotformation.
Insomedeathsassociatedwithinfectionandcachexia,thisfibrinolyticeffectmayfailtodevelop,explaining
thepresenceofabundantclotintheheartandlargecalibrevessels.
Thus,incasesofsuddendeaththebloodremainsspontaneouslycoagulableonlyduringabriefperiod
immediatelyfollowingdeath;itthenbecomescompletelyfreefromfibrinogenandwillneveragainclot.
Thisincoagulabilityofthebloodisacommonplaceobservationatautopsy.
Thenormalcolourofareasofpostmortemlividityisacyanotichue,butthisdescriptionshouldnotbeused
sinceitismisleading.
Thedevelopmentoflividityistoovariabletoserveasausefulindicatorofthetimeofdeath.
Typically,lividityhasa
Purpleorreddishpurple
colouration.
Carbonmonoxidepoisoning
Cherryred.
Potassiumchlorate,nitrates,andanilinepoisoning(Incaseswhere
methaemoglobinisformedinthebloodduringlife)
Chocolatebrown.
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Cyanidepoisoning
Pink,brightscarlet,and
violet.
Deathsfromexposuretocold
Brightpink
(Q.89) ThefollowingsectionsofIndianPenalCode(IPC)dealwithsexualoffencesexcept?
(a)
Sec375
(b)
Sec376
(c)
Sec377
(d)
Sec351
YourResponse:
CorrectAnswer:
Exp:
FEWIMPORTANTIPCsTOBEREMEMBERED:
Sec118IPC
Concealingdesigntocommitoffencepunishablewithdeath
orimprosonmentforlife.
Sec176,IPC
Omissiontogivenoticeorinformationtopublicservantby
personlegallyboundtogiveit.
Sec177IPC
Furnishingfalseinformation.
Sec182IPC
Falseinformationwithintenttocausepublicservanttouse
lawfulpowertotheinjuryofanotherperson.
Sec191IPC
Givingfalseevidence
Sec192IPC
Fabricatingfalseevidence.
Sec193IPC
Punishmentforfalseevidence
Sec197IPC
Issuingorsigningfalsecertificates.
Sec204IPC
Destructionofdocumenttopreventitsproductionas
evidence.
Sec284IPC
Negligentconductwithrespecttopoisonoussubstances.
Sec299IPC
Definesculpablehomicidenotamountingtomurder
Sec300IPC
Definesmurder
SEC302IPC
punishmentformurderdeath/life+fine
Sec304IPC
SECTION304AIPC:Causingdeathbynegligence2years/
fineorboth.
SECTION304BIPC:Dowrydeath.incaseofdeathofa
marriedwomanwithin7yearsofmarriage,duetoother
thannaturalcauses,withhistoryofcrueltyorharassment
priortodeath.thechargeisframedagainsttheaccused
undersection304BIPC.
Sec309IPC
Attempttocommitsuicide
Sec312316IPC
Dealswithcriminalabortion
Sec317IPC
Abandoningofchildbyparents
Sec318IPC
Concealmentofdeathofinfant
Sec313IPC
Causingmiscarriagewithoutwoman'sconsent
Sec320IPC
Definitionofgrievoushurt
SEC321IPC
Voluntarilycausinghurt
SEC325IPC
Grievoushurtispunishableundersection325IPC.
SEC338IPC:
Theactdonerashlyandnegligentlycausingminoroffenceor
grievoushurtwillbechargedundersection338IPC
Sec351IPC
Assault.
Sec354IPC
Molestation:Considerstheassaultorcriminalforceto
womanwiththeintentiontooutragehermodesty.This
offenseisconsideredlessseriousthanRape.
Sec362IPC
Abduction.
Sec375IPC
DefinitionofRape.
Sec376IPC
Section376A:PunishmentforRape
RestallclausesofSec376dealwithCustodialrape.
Section376B:dealswiththeintercourseofpublicservant
withwomaninhiscustody.
Section376C:dealswithintercourseofsuperintendentof
jail,remand,hostel,privatehousesetc.
Section376D:dealswithintercoursebyanymemberofthe
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managementorstaffofahospitalwithanywomaninthat
hospital.
Sec377IPC
Unnaturaloffences
Sec497IPC
Adultery.
Sec509IPC
Word,gestureoractintendedtoinsultthemodestyofa
woman.Whoever,intendingtoinsultthemodestyofany
woman,uttersanyword,makesanysoundorgesture,or
exhibitsanyobject,intendingthatsuchwordorsoundshall
beheard,orthatsuchgestureorobjectshallbeseen,by
suchwoman,orintrudesupontheprivacyofsuchwoman,
shallbepunishedwithsimpleimprisonmentforaterm
whichmayextendtooneyear,orwithfine,orwithboth.
(Q.90) ThepostmortemfindingseeninSmotheringincludes
(a)
Bruisingininneraspectofupperlip
(b)
Fracturebodyofhyoid
(c)
Fractureofcricoid
(d)
Curvedmarksontheneck
YourResponse:
CorrectAnswer:
Exp:
Bruisingininneraspectofupperlip
Thelips,gums&tonguemayshowbruisingorlaceration
Slightbruisingmaybefoundinthemouthandnose,whichshouldbeconfirmedbymicroscopy.
Theasphyxialsignsandsymptomsaresevere,becausedeathusuallyresultsduetoslowasphyxiaandoften
thefatalperiodisthreetofiveminutes
(Q.91) AllarecharacteristicsofEntrytypeFirearmwoundexcept?
(a)
Smallinsize
(b)
Invertededges
(c)
Abrasioncollarpresent
(d)
Leadringabsent
YourResponse:
CorrectAnswer:
Exp:
Leadringabsent
REFParikhs6thEdPage4.47
ENTRYWOUND
EXITWOUND
Smallinsize(exceptwhenatcontactrangeskin Sharplydefinedoutwardlysplitedges
tornedbyblast)
InflatboneCleancutonoutersurface,chipped InflatboneBevelledandeverted.
inward.
Edgesinverted,exceptinfattypersonsmaybe
evertedduetoprotrusionoffat.
Edgeseverted.
Abrasioncollarpresent.
Absentexceptinshoredexitwoundswhen
irregularabrasionwillbeseen.
Greasecollarmayormaynotbepresent
Absent
Burning,Blackening,Singeingandtattooingat
appropriatedistances.
Absentexceptwhenanotheroverlappingexit
woundcausesitsoverlappingpattern
Clothingturnedinandcarriedinward.
Mayormaynotbeturnedout.
Tracknearwoundmaybebrightpinkdueto
carboxyhemoglobin.
Notusuallyso.
Leadringonradiologicalormicrochemical
examination.
Absent
(Q.92) Whenusingtheplanemirrortechniqueduringretinoscopy,whichoneofthefollowingstatementsstandswrong?
(a)
A'with'movementisneutralizedwithapluslens
(b)
An'against'movementisneutralizedwithaminuslens
(c)
A'with'movementalwaysindicateshypermetropia
(d)
An'against'movementalwaysindicatesmyopia
YourResponse:
CorrectAnswer:
Exp:
A'with'movementalwaysindicateshypermetropia.
Withtheplanemirrortechnique,pluslensisusedtoneutralizewithmovementandminuslensforagainst
movement.Whileanagainstmovementalwaysindicatesmyopia,awithmovementmaybeseenin
myopicpatientifthemyopiaislessthanthedioptricvalueoftheobserver'sworkingdistance(forexample
atadistanceof2/3m,awithmovementisseenifthemyopiaislessthan1.50D.Theneutralpointoccurs
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whenthepatient'sfarpointcoincideswiththeobserver'snodalpoint..
(Q.93) CauseofEnlargedcornealnervesis?
(a)
Fuchscongenitaldystrophy
(b)
Congenitalglaucoma
(c)
Leprosy
(d)
Allofabove
YourResponse:
CorrectAnswer:
Exp:
Allofabove
Causesofcorneal
Anaesthesia(Neurotrophickeratopathy) Hyposthesia
Enlargednerves
Congenital
MnemonicFindoldcongenital
LINKtoRefsumsMEN
Familialdysautonomia(RileyDay
syndrome)
Anhidroticectodermaldysplasia
Absolute
glaucoma
Keratoconus
FuchsCornealdystrophy
anterior(Axenfeld
sign)
Oldage
Congenitalinsensitivitytopain
Congenitalglucoma
Acquired
Leprosy(Hensensdisease)
Alcoholblock,electrocoagulationor
sectionofgasserianganglionorsensory
rootoftrigeminalnervefortrigeminal
neuralgia
Icthyosis
Neurofibromatosis
Herpessimplex
Keratoconus
Herpeszoster
Trauma
Syphilitic(Luetic)neuropathy
Refsumsdisease
Leprosy
MENtypeIIB
Diabetes
Acousticneuroma
Abuseoftopicalanaesthetics
(Q.94) Inelectroretinogram(ERG),awave,largenegativewaveisgeneratedby:
(a)
Retinalpigmentepithelium
(b)
Rods&conesreceptoractivity.
(c)
Responseofamacrinecells
(d)
All
YourResponse:
CorrectAnswer:
Exp:
Rods&conesreceptoractivity.(RefBasak,Ophthalmology,2nded.,21)
ERG
Electroretinographymeansgrossrecordofelectricalpointial,changesintheretinaoften
stimulationwithlength.
InitialpositivedeflectionR1isfollowedbyR2isduetophotochemicalreactioninrods&
conesoutersegments.
Thisisfollowedbyalargenegativeawavewhichreflectsphotoreceptor(rods&cones)
activity.
Thenalargepositivebwavefollowsduetoresponseofbipolarcells.
Lastly,asmallpositivecwaveisgeneratedbyretinalpigmentepitheliallayer.
Ganglioncelllayer,nervefiberlayer&opticnerveplaynopart.
Durationofentireresponse<250ms.
USES:
Usefulindistinguishingretinalandopticnervedysfunctionfrommaculardiseases.
Assessesretinalfunctioninpresenceofopacityinmediainsiderosisbulbi.
Usefulin
Corticalandhystericalblindness,
Retinitispigmentosa,
Chorioretinitis,
Rodandconedysfunction,and
Toxicretinopathy.
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(Q.95) Retinoscopyisusedto?
(a)
TodeterminedegreeofametropiA.
(b)
ToknowconditionofRefraction
(c)
Testingvisualacuity
(d)
Tomeasureastigmatismofanteriorcornealsurface.
YourResponse:
CorrectAnswer:
Exp:
Forestimatingconditionofrefraction(RefBasak,Ophthalmology,2nded.,72)
RETINOSCOPY
Mostpracticalmethodofestimatingconditionofrefractionobjectively,withaccommodation
atrest.
Principleistomakeeveryobservingeyeemmetropic,sothatemergingraysshouldform
parallelbeam.
Streakretinoscopyeasilydeterminesaxisofastigmatism,canbedoneinanyposition,children
andpreoperatively.
Cycloplegiamayberequiredchildren,howevernotadvisableundercycloplegia.
Itshouldpreferablybeconductedinadarkroom.
Sourceoflightshouldbebehindthepatient.
Inhypermetropia,emmetropia&myopia<1Dreflexmoves,reflexsamedirection.
Inmyopiaof1Dnomovement.
Inmyopia>1Dshadowmovesoppositedirection.
(Q.96) Indacryocystorhinostomy(DCR)lacrimalsacsaredirectlyopenedinto:
(a)
Superiornasalmeatus
(b)
Middlenasalmeatus
(c)
Inferiornasalmeatus
(d)
Nasolacrimalduct
YourResponse:
CorrectAnswer:
Exp:
Middlenasalmeatus
(RefBasaks,Opthalmology,2nded.,pg,282,336)
DACROCYSTORHINOSTOMY(DCR)issurgicalprocedureofchoiceinchronicdacryocystitis,inwhicha
communicationismadebetweenlacrimalsacandmiddlemeatusofnose.
Contraindications:oDNSoAtrophicrhinitisoCarcinomaoflacrimalgland
(Q.97) Amongtheretinalganglioncells,thefastestsignaltransmissiontothebrainandpromptresponsivenessforrapidchangesinvisual
imageisthefunctionof:
(a)
Wcells
(b)
Ycells
(c)
Xcells
(d)
Horizontalcells
YourResponse:
CorrectAnswer:
Exp:
Ycells.(RefAldersphysiologyofeye10thed.718)
Theconesrespondtobrightlightandmediatehighresolutionvisionandcolorvision.
Therodsrespondtodimlightandmediatelowerresolution,blackandwhite,nightvision.
Humanshavethreedifferenttypesofcones(trichromaticvision).
Whenlightfallsonareceptoritsendsaproportionalresponsesynapticallytobipolarcells,whichinturn
signaltheretinalganglioncells.Thereceptorsarealsocrosslinkedbyhorizontalcellsandamacrinecells,
whichmodifythesynapticsignalbeforetheganglioncells.
Intheretinalganglioncellstherearetwotypesofresponse,dependingonthereceptivefieldofthecell.In
ONcells,anincrementinlightintensityinthecenterofthereceptivefieldcausesthefiringratetoincrease.
InOFFcells,itmakesitdecrease.Beyondthissimpledifference,chromaticsensitivityandthetypeofspatial
summationalsodifferentiateganglioncells.
GanglionCells
Theganglioncellsarethelastneuronsinthechain,beforetheoutputleavestheeyeandgoestothebrain.
Thereareseveraltypesofganglioncell,andit'sbelievedeachtypeisusedforadifferentpurposes.TheW
cellisexcitedmainlybyrods,anditsfunctionistoperceivedirectionalmovementallovertheretina.Asan
objectmovesacrossthefield,thewcellsarestimulatedandpasstheinformationonviatheintegration
chain.TheXcellsareresponsibleformostcolorvision.Theyreceiveinputfromthecones;andtheyarealso
themostnumeroustypeofganglioncell.Theyprobablyaccountforthepinpointingoftheimageinits
preciselocationontheretina.TheYcellsarethelargestandleastnumeroustypeofganglioncell.They
appeartobededicatedtotheperceptionofchangesinlightintensityandperhapsveryrapidmovement
ofanimageacrossthevisualfield.Ganglioncells,unliketheotherintegratorneurons,dohaveaction
potentials,andevenwhenunstimulatedtheyfireatamoreorlessconstantrate.Itisthechangesinlight
intensityandtheshiftingoftheimageoverthefieldofvisionthatcausesachangeinthefiringratein
ganglioncells.These"on"or"off"responsesofindividualganglioncells,whichtaketheformofchangesof
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frequencyoffiring,areinterpretedbythebrainasthefinaloutputofthesystem.Byswitchingtheganglion
cellsonoroffasdictatedbytheintegrationoftheimageintheretina,theeyehasanamazingabilityto
detectmotionofevenverysmallobjects.
(Q.98) TruestatementsaboutJacksonscrosscylinderareallEXCEPT:
(a)
Doesnotblurtheimagewhenplacedbeforeanemmetropiceye
(b)
Doesnotalterthesphericalequivalentofanametropiceye
(c)
Isusedtochecktheaxisofthecylindersubjectively
(d)
Isusedtocheckthepowerofthecylindersubjectively
YourResponse:
CorrectAnswer:
Exp:
Doesnotblurtheimagewhenplacedbeforeanemmetropiceye(RefKhurana3rded.683)
JACKSONSCROSSCYLINDER
Thecrosscylinderisusedforsubjectiverefinementofaxisandpowerofcylinderafterplacingthebest
availableestimateofrefractionbeforetheeye(retinoscopy,astigmaticdialtest,orpreviousrefraction).
Itisusedtochecktheaxisofthecylinderbeforeitspower.
Thepowerofthecylinderistwicethatofthesphereandofoppositesign.
A0.50Dcrosscylinderhasatotalcylindricalpowerof0.50D.A0.50Dcrosscylinderhasanetspherical
powerorsphericalequivalentpowerof0.A0.50Dcrosscylindercanbewrittenupas+0.25DS/0.50DCor
0.25DS/+0.50DC.Axisisnotspecified.
Placedbeforeanemmetropiceye,thecrosscylinderblurstheimage.
Placedbeforeanametropiceye,thecrosscylinderdoesnotalterthesphericalequivalent,butitwillenlarge
orcontracttheintervalofSturm,blurringorclarifyingtheimage,asitincreasesordecreasesthenet
astigmaticametropia.
(Q.99) Vagalstimulationcausesincreasein
(a)
Heartrate
(b)
RRintervalinEC
(c)
Cardiacoutput(COP)
(d)
Forceofcontraction
YourResponse: b
CorrectAnswer:
Exp:
RRinterval
RRintervalistheintervalbetweenthepeaksofRwaveof2consecutive
QRScomplexes.
Obviously,theRRintervalbearsaninverserelationshipwiththeheart
rate.
VagalstimulationcausesbradycardiaandthereforeanincreaseinRR
interval.
Vagalstimulationleadstobradycardia,hatiswhyinsymptomatic
bradycardiacases.
Patientsaretreatedbygivinginjectionatropine.
VagalstimulationleadstodecreaseCOP&ejectionfraction.
(Q.100) Mostcommonlocationofiriscoloboma:
(a)
12oClockposition
(b)
9oClockposition
(c)
6oClockposition
(d)
3oClockposition
YourResponse:
CorrectAnswer:
Exp:
6oClockposition
COLOBOMAOFTHEIRIS
Itisacongenital(presentsincebirth)defectoftheirisoftheeye.
Mostcommonlylocatedinferonasally.
Itisvisibleasahole,split,orcleftintheiris.
Colobomaoftheirismayappearasablack,roundholelocatedinoradjacenttotheiris(coloredportionof
theeye).
Itcanappearasablacknotchofvaryingdepthattheedgeofthepupil,givingthepupilanirregularshape.
Itcanalsoappearasasplitintheirisfromthepupiltotheedgeoftheiris.
Asmallcoloboma,especiallyifitisnotattachedtothepupil,mayallowasecondaryimagetofocusonthe
backoftheeye,causingaghostimage,blurredvision,ordecreasedvisualacuity.
Colobomamaybeassociatedwithhereditaryconditions,traumatotheeye,oreyesurgery.
Thedefectmayextendtotheretina,choroid,oropticnerve.
CommonCauses:
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Cateyesyndrome
Trisomy13
Trisomy18
Marfanssyndrome
RubinsteinTaybisyndrome
SturgeWeberdisease
Basalcellnevussyndrome
Normalvariant(canbeinheritedasanautosomaldominanttrait)
Colobomasaregenerallydiagnosedat,orshortlyafterbirth.
Childhaswhatappearstobeaholeintheirisoranunusualshapedpupil.
Visionbecomesblurred,ordecreasedvisionisnoted.
(Q.101) Mostreliablelandmarkinotoscopyis:
(a)
Coneoflight
(b)
Lateralprocessofmalleus
(c)
Handleofmalleus
(d)
Umbo
Your
Response:
Correct
Answer:
Exp:
B
Lateralprocessofmalleus
Mostreliablelandmarkinotoscopyislateralprocess
ofmalleus.
(Q.102) Semontmaneuver(MSM)andmodifiedEpleyprocedure(MEP)areusedfortreating:
(a)
BPPV
(b)
Barotrauma
(c)
Menieresdisease
(d)
Traumaticnystagmus
YourResponse:
CorrectAnswer:
Exp:
BPPV(RefPLDhingraENT,5th/pg.51)
EpleyprocedureortheSemontmaneuver
Benignparoxysmalpositionalvertigo(BPPV)occursasaresultofdisplacedotoconia,whicharesmall
crystalsofcalciumcarbonate(alsoreferredtoas"otoliths"orcanaliths)thatarenormallyattachedto
theotolithicmembraneintheutricleoftheinnerear.
Becauseoftrauma,infection,orevensimpleaging,canalithscandetachfromtheutricleandcollectwithin
thesemicircularcanals.Headmovementsshiftthedetachedcanalithsandstimulatesensitivenervehairs
tosendfalsesignalstothebrain,causingdizzinessandothersymptoms.Thegoalofthecanalith
repositioningprocedure(CRP),aformofvestibularrehabilitationtherapy,istomovethedisplaced
canalithstostopthesefalsesignalsandthedebilitatingsymptomstheycancause.
SingleapplicationsoftheEpleyprocedureortheSemontmaneuverhavebeenreportedtorelieve
symptomsinthemajorityofpatients.
Repeatedtreatmentsessionsmaybenecessarybeforesymptomsresolve.
(Q.103) Carhartsnotchisseenat:
(a)
1000Hz
(b)
2000Hz
(c)
4000Hz
(d)
6000Hz
YourResponse:
CorrectAnswer:
Exp:
2000Hz(RefPLDhingra5th/Pg.99,458)
OtosclerosisandAudiometry
AirConduction:decreasedmoreforlowerfrequency.
BoneConduction:
Normal
Insamecasesthereisdipinboneconductioncurvemaximumat2000Hzandiscalled
asCarhartznotch.
Itisduetoinertialpropertyofstapes.
ItdisappearsafterStapedectomy.
FrequencyNotchinboneconduction
2000Hz=Otosclerosis
3000Hz=AcousticNeuroma
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4000Hz=Noiseinduceddeafness
(Q.104) Vestibularfunctiontestedbyfollowingexcept:
(a)
Galvanicstimulation
(b)
Fistulatest
(c)
Impedanceaudiometry
(d)
Coldcalorictest
YourResponse:
CorrectAnswer:
Exp:
Impedanceaudiometry(RefPLDhingra5th/pg.28,47,49)
Galvanictestistheonlyvestibulartest,whichhelpsindifferentiatinganendorganlesionfromvestibular
nerve.
Fistulatest:
UsedtodetectfistulainbonywallofLabyrinth.
Increasingpressureinbonycanal;causesgiddinessandnystagmus;aspressureistransmittedtothe
labyrinththroughfistula(positiveFistulatest).
ImpedanceAudiometry:measuresresistanceinthemiddleearcavity.
Thecoldcalorictestisatestofthevestibuloocularreflexthatinvolvesirrigatingcoldorwarmwaterorair
intotheexternalauditorycanal
(Q.105) WhichofthefollowingisdifficulttovisualizeorexamineonIndirectlaryngoscopy?
(a)
Truevocalcord
(b)
Anteriorcommissure
(c)
Epiglottis
(d)
Falsevocalcord
YourResponse
d
:
CorrectAnswer: B
Exp:
Anteriorcommissure
(RefPLDhingra5th/pg.447;DiseasesofENTbyBhargava5thed.
270)
StructuresvisualizedbyIDLare:
Posteriorthirdofthetongue
Valleculae
Epiglottis
Aryepiglotticfolds
Inletoflarynx
Posteriorcommissure
Interioroflarynx
Truevocalcords
Posteriorpharyngealwall
MedialwallofPyriformfossa
Postcricoidregion.
Falsevocalcord
(Q.106) TobeyAyertestisusefulfordiagnosing:
(a)
Lateralsinusthrombosis
(b)
Cavernoussinusthrombosis
(c)
Serousotitismedia
(d)
Eustachiantubedefect
YourResponse:
CorrectAnswer:
Exp:
(Lateralsinusthrombosis)(RefPLDhingra5th/pg.94)
SIGMOIDORLATERALSINUSTHROMBOSIS
HecticPicketfencetypeoffeverwithrigors
Thisisduetosepticaemia,oftencoincidingwithreleaseofsepticemboliintobloodstream.Feverisirregularhaving
oneormorepeaksaday.Itisusuallyaccompaniedbychillsandrigors.Profusesweatingfollowsfalloftemperature.
Clinicalpictureresemblesmalariabutlacksregularity.
Inbetweentheboutsoffever,patientisalertwithasenseofwellbeing.Patientsreceivingantibioticsmaynotshow
thispicture.
Headache.Inearlystage,itmaybeduetoperisinusabscessandismild.Later,itmaybeseverewhenintracranial
pressurerisesduetovenousobstruction.
Progressiveanaemiaandemaciation.
Griesinger'ssign
Thisisduetothrombosisofmastoidemissaryvein.Oedemaappearsovertheposteriorpartofmastoid.
PapilloedemaItspresencedependsonobstructiontovenousreturn.Itisoftenseenwhenrightsinus(whichislarger
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thanleft)isthrombosedorwhenclotextendstosuperiorsagittalsinus.Fundusmayshowblurringofdiscmargins,
retinalhemorrhagesordilatedreins.Funduschangesmaybeabsentwhencollateralcirculationisgood.
TobeyAyertestThisistorecordCSFpressurebymanometerandtoseetheeffectofmanualcompressionofoneor
bothjugularveins.
Compressionofveinonthethrombosedsideproducesnoeffectwhilecompressionofveinonhealthysideproduces
rapidriseinCSFpressurewhichwillbeequaltobilateralcompressionofjugularveins.
CroweBecktestPressureonjugularveinofhealthysideproducesengorgementofretinalveins(seenby
ophthalmoscopy)andsupraorbitalveins.Engorgementofveinssubsideonreleaseofpressure.
TendernessalongjugularveinThisisseenwhenthrombophlebitisextendsalongthejugularvein.Theremaybe
associatedenlargementandinflammationofjugularchainoflymphnodesandtorticollis
(Q.107) Griesingerssignisseenin:
(a)
Lateralsinusthrombosis
(b)
Meningitis
(c)
Brainabscess
(d)
Mastoiditis
YourResponse:
CorrectAnswer:
Exp:
Lateralsinusthrombosis(RefPLDhingra5th/pg.94)
Griesingerssignisoneoftheclassicalsignoflateralsinusthrombosischaracterizedbyedemaover
mastoidprocessduetothrombosisofmastoidemissaryvein.
(Q.108) WhichofthefollowingisFalseaboutcholesteatomais:
(a)
Lymphaticpermeation
(b)
Boneerosion
(c)
Epithelialdesquamatedsinus
(d)
Deafness
YourResponse:
CorrectAnswer:
Exp:
Lymphaticpermeation(RefCurrentOtolaryngologyChapter49;PLDhingra5th/pg.75)
Cholesteatoma
Congenital/primaryAcquired/secondary
Cholesteatomaisthepresenceofsquamousepitheliuminthemiddleear,mastoid,orepitympanum.The
mostcommonformofcholesteatomaistheacquiredvariety,whichisclassifiedasprimaryandsecondary
acquiredcholesteatoma.
Primaryacquiredcholesteatomaisthemostcommonofthesetypesandformsasaretractionofthe
tympanicmembrane.Inmostcases,theretractionoccursintheparsflaccida,althoughparstensa
retractionscanalsooccur.
Secondaryacquiredcholesteatomaformsasaresultofeithersquamousepithelialmigrationfromthe
tympanicmembraneorimplantationofsquamousepitheliumintothemiddleearduringsurgery,suchas
ventilationtubeplacementortympanoplasty.
Themostcommonlocationofcholesteatomainthemiddleearisintheareaaroundthestapes
superstructureandincuslongprocess.Thisareaisusuallydifficulttodissectbecauseofthepresenceof
thefacialnerveandossicularchain.
(Q.109) Inobstructiveazoospermia
(a)
FSH&LHBothincrease
(b)
FSH&LHBothnormal
(c)
FSHdecreasebutLHincreases
(d)
FSH&LHbothdecrease
YourResponse:
CorrectAnswer:
Exp:
FSH&LHBothnormal
FSH&LHBothnormal.BothFSH&LHareamarkeroftesticularfunction,whichtendstobenormalinmostcases
ofobstructiveazoospermiaso,thechancesoffindingnormalFSH&LHlevelsaremaximum.Infactsomestudies
alsopinpointthesamefact.
Formostinfertilemen,thesemenanalysisistheonlytestwhichneedstobedoneafterall,theonlyjobofaman
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istoprovidespermtofertilizetheegg!Formenwithalowspermcount,thereisnoneedtodoanyothertests,
sincethesedonotprovideanyusefulinformation.
However,manydoctorsstilldobloodtestsformeasuringthelevelsofkeyreproductivehormones,suchas
prolactin,FSH,LHandtestosterone.
Thesearejustawasteoftimeandmoneysincetheyprovidenousefulinformationanddonotalterthetreatment
plan.
Formenwithazoospermia(zerospermcount),additionalbloodtestsmaybeuseful.
TheserumFSH(folliclestimulatinghormone)leveltestisausefuloneforassessingtesticularfunction.
Ifthereasonfortheazoospermiaistesticularfailure,thenthisisreflectedinaraisedFSHlevel.
Thisisbecause,inthesepatients,thetestisalsofailstoproduceahormonecalledinhibin(whichnormally
suppressesFSHlevelstotheirnormalrange).
AhighFSHlevelisusuallydiagnosticofprimarytesticularfailure,aconditioninwhichtheseminiferoustubulesin
thetestesdonotproducespermnormally,becausetheyaredamaged.
Thistestisdonebyaradioimmunoassayorchemiluminescentassay,andsinceitisasophisticatedtest,itisbest
doneinaspecializedlaboratory.
Abnormaltestresultsshouldberepeatedandrecheckedforconfirmation.
TheotherreasonforahighFSHlevelinsomemenistheconsumptionofclomiphene(amedicineoftenprescribed
fortheempirictreatmentofoligospermia).
Thisiswhythetestshouldbedoneonlywhennomedicationisbeingtaken.
WhileahighFSHlevelisdiagnosticoftesticularfailure,anormalFSHlevelprovidesnousefulinformation.
Thus,menwithcompletetesticularfailuremayalsohavenormalFSHlevels.
WhileahighFSHlevelsuggestsprimarytesticularfailure,itcannotdifferentiatebetweenpartialtesticularfailure
andcompletetesticularfailure.
ThismeansthatevenmenwithveryhighFSHlevelscanhaveoccasionalareasofspermproductionintheirtestes,
andthesetesticularspermcanbeusedforTESAICSI(testicularspermaspirationandintracytoplasmicsperm
injection)treatment.
Rarely,theFSHlevelmaybelow.AlowFSHlevelisfoundinpatientswithhypogonadotropichypogonadism.
Hypogonadotropichypogonadismisanuncommon(buttreatable!)causeofazoospermia.
AlongwithanFSHleveltest,mostdoctorsalsodoaLH(luteinizinghormone)leveltest,whichprovidesmostlythe
sameinformation.
Atestosteroneleveltestprovidesinformationonwhetherornotthetestesareproducingadequateamountsof
themalehormone,namely,testosterone.
Mostinfertilemenhavenormaltestosteronelevels,becausethecompartmentfortestosteroneproductionis
separatefromthecompartmentwhichproducessperm,andisusuallyintactininfertilemen.
Alowtestosteronelevelcausesadecreasedlibidoandthiscanbetreatedbytestosteronereplacementtherapyin
theformoftabletsorinjections.
Ofcourse,thistherapywillnotincreasethespermcount.
Formenwithazoospermiaanderectiledysfunction,measuringtheprolactinlevelwillhelptodetectmenwho
havehyperprolactinemia(highprolactinlevels).
Thoughthisisarareproblem,theycanbeeffectivelytreatedwithmedicaltherapywithbromocriptineandthe
resultsareverygratifying.
(RefMaleInfertilityTests.BeyondtheSemenAnalysis(Page2):HowtoHaveaBaby:OvercomingInfertilitybyDr.
AniruddhaMalpani,MDandDr.AnjaliMalpani,MD)
(Q.110) WhichofthefollowingisnotincludedintheWHOMemberStatesmandated"official"globalpublichealthcampaigns?
(a)
24thMarchWorldTBday
(b)
7thAprilWorldHealthday
(c)
1stDecemberWorldAIDSday
(d)
4thFebruaryWorldCancerday
YourResponse:
CorrectAnswer:
Exp:
4thFebruaryWorldCancerday
Globalpublichealthcampaignsoffergreatpotentialtoraiseawarenessandunderstandingabouthealth
issuesandmobilizesupportforaction,fromthelocalcommunitytotheinternationalstage.Therearemany
worlddaysobservedthroughouttheyearrelatedtospecifichealthissuesorconditionsfromAlzheimer's
tozoonoses.However,WHOfocusesparticularattentiononthesevendaysandoneweekthatWHO
MemberStateshavemandatedas"official"globalpublichealthcampaigns.Theseare:
WorldTBDay
24March
WorldHealthDay
7April
WorldImmunizationWeek
lastweekofApril
WorldMalariaDay
25April
WorldNoTobaccoDay
31May
WorldBloodDonorDay
14June
WorldHepatitisDay
28July
WorldAIDSDay
1December
OtherCommemorativedaysare
WorldCancerDay
February4
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InternationalDayofZeroTolerancetoFemale
GenitalMutilation
NationalScienceDay(India)
Zerodiscriminationday
InternationalWomen'sDay
InternationalDayfortheEliminationofRacial
Discrimination
WorldDownSyndromeDay
WorldWaterDay
WorldTuberculosisDay
Worldautismawarenessday
WorldHemophiliaDay
EarthDay
WorldMalariaDay
WorldThallasemiaDay
WorldHypertensionDay
WorldMilkDay
WorldEnvironmentDay
WorlddayagainstChildLabour
WorldBloodDonorDay
WorldPopulationDay
NelsonMandelaInternationalDay
WorldHepatitisDay
WorldBreastfeedingWeek
InternationalYouthDay
WorldHumanitarianDay
WorldContraceptionDay
WorldBreastCancerAwarenessMonth
WorldVegetarianDay
WorldMentalHealthDay
WorldFoodDay
UnitedNationsDay
WorldDiabetesDay
HumanRightsDay
February6
February28
1March
March8
March21
March21(RememberasDownsis21Trisomy(3rd
month)i;e21/03)
March22
March24
April2
April17
April22
April25
May8
May17
June1
June5
June12
June14
July11
July18
July28
August01to07
August12
August19
September26
October
October1
October10
October16
October24
November14
December10
(Q.111) MaximumabsorptionofHCO3occursis:
(a)
PCT
(b)
DCT
(c)
CT
(d)
ALH
YourResponse:
CorrectAnswer:
Exp:
PCT
About70%offilteredHCO3occuratPCT.70%offilteredwater.NaClabsorptionoccuratPCT.100%of
filteredglucoseandaminoacidoccuratPCT
(Q.112) WHOdefinitionofLowvision?
(a)
Visionmorethan6/60andlessthan6/18inbettereye
(b)
Visionmorethan6/60andlessthan3/60inbesteye
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(c)
Visionmorethan3/60andlessthan6/18inbettereye
(d)
Visionmorethan3/60andlessthan3/18inbesteye
YourResponse:
CorrectAnswer:
Exp:
Visionmorethan6/60andlessthan6/18inbettereye.(RefParkstextbookofPSM19thed.360)
VISION2020:
TheRighttoSightisthecommonagendalaunchedbytheWHOandTaskForceofInternational
organizationtocombatblindness,as80%ofglobalblindnessisavoidable.
FiveconditionsthathavebeenidentifiedasimmediateprioritieswithinVISION2020areCataract,
trachoma,Onchocerciasis,childhoodblindnessandrefractiveerrorsandlowvision.
TheSAFEstrategyhasbeendevelopedtocombatTRACHOMAandisbeingappliedinaffectedareas.
ItisexpectedthatthroughSAFEstrategyitwillbepossibletoeliminatetrachomabyyear2020.
CATEGORIESOFVISUAL MAXIMUMVISUALACUITYLESSTHAN
IMPAIRMENT
Lowvision
Blindness
MINIMUMVISUALACUITYEQUAL
TOORBETTERTHAN
6/18
6/60
6/60
3/60
3/60(fingercountingat3metres)
Lightperception
Nolightperecption
(Q.113) Accordingtotheconceptoftheicebergphenomenonofdisease,thewaterlinerepresentsthedemarcationbetweenwhichofthe
following?
(a)
Undiagnosedandundiagnosed
(b)
Symptomaticandpresymptomatic
(c)
Carrierandsufferers
(d)
Apparentandinapparent
YourResponse:
CorrectAnswer:
Exp:
Apparentandinapparent.(RefParkstextbookofPSM19thed.36)
ICEBERGOFDISEASE
Aconceptcloselyrelatedtothespectrumofdiseaseistheconceptoftheicebergphenomenonofthe
disease.
Accordingtothisconcept,diseaseinacommunitymaybecomparedwithaniceberg.
Thefloatingtipoftheicebergrepresentswhatthephysicianseesinthecommunityi.e.clinicalcases.
Thevastsubmergedportionofthehiddenmassofdisease,i.e.latent,inapparent,presymptomatic,and
underdiagnosedcasesandcarriersinthecommunity.
Thewaterlinerepresentsthedemarcationbetweenapparentandinapparent.
(Q.114) ThepowerfulconceptofKAPispracticedinIndiaforwhichofthefollowing?
(a)
HIV/AIDS
(b)
Familyplanning
(c)
Cancer
(d)
Malaria
YourResponse:
CorrectAnswer:
Exp:
Familyplanning(RefParkstextbookofPSM19thed.406)
Theconceptthateventuallybecameunmetneedforfamilyplanningwasfirstexploredin1960s,when
datafromsurveysofcontraceptiveknowledge,attitudeandpractices(KAP)showedagapbetweensome
womensreproductiveintensionandtheircontraceptivebehavior.
ThetermthatcametopopularusedescribingthisgroupwasKAPgap.
Oneofthefirstpublisheduseofthetermunmetneedappearedin1977.
In1978,basedonWorldFertilitySurveydatafromfiveAsiancountries,CharlesWestoffpublishedfirst
comparativeestimatesofunmetforlimitingbirths.
Unmetneedisdefinedonthebasisofwomensresponsetosurveyquestions.
Accordingtothenationalfamilyhealthsurvey2(19981999),about16%ofcurrentlymarriedwomenin
Indiahaveanunmetneedforfamilyplanning.
Unmetneedforfamilyplanningishighest(27%)amongwomenbelowage20yearsandisalmostentirely
forspacingbirthsratherthanforlimitingthebirth.
Itrangesfrom7%inPunjabto25%inUttarPradeshandBihar,amongthemajorstatesofIndia.
(Q.115) Standarderroris
(a)
S.D/n
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(b)
S.Dxn
(c)
SD/2n
(d)
S.D/squarerootofn
YourResponse:
CorrectAnswer:
Exp:
S.D/squarerootofn)(RefAnintroductiontomedicalstatisticsbyBland2nded.60)
Standarderror
Thestandarderrorofamethodofmeasurementorestimationistheestimatedstandarddeviationofthe
errorinthatmethod.
Thestandarderrorofthemeanofasamplefromapopulationisthestandarddeviationofthesampling
distributionofthemean,andmaybeestimatedbytheformula:
Where
isanestimateofthestandarddeviationofthepopulation,andnisthesize(numberofitems)ofthe
sample.
(Q.116) WhichofthefollowingareincludedinWHOGlobalTargetsinNutrition2025?
(a)
40%reductioninthenumberofchildrenunder5whoarestunted
(b)
30%reductioninlowbirthweight
(c)
noincreaseinchildhoodoverweight
(d)
Allofabove
YourResponse:
CorrectAnswer:
Exp:
Allofabove
REF:http://www.who.int/nutrition/topics/nutrition_globaltargets2025/en/index.html
WHO'sMemberStateshaveendorsedglobaltargetsforimprovingmaternal,infantandyoungchild
nutritionandarecommittedtomonitoringprogress.Thetargetsarevitalforidentifyingpriorityareas
foractionandcatalysingglobalchange.
40%reductioninthenumberofchildrenunder5whoarestunted
50%reductionofanaemiainwomenreproductiveage
30%reductioninlowbirthweight
noincreaseinchildhoodoverweight
increasetherateofexclusivebreastfeedinginthefirst6monthsuptoatleast50%
reduceandmaintainchildhoodwastingtolessthan5%
(Q.117) AboutASHA(AccreditedSocialHealthActivist)trueisallthefollowingEXCEPT:
(a)
Theyarepreferablyfemales.
(b)
ThereisoneASHAworkerper1000population.
(c)
TheyareSkilledbirthattendant
(d)
Providesprimarymedicalcareforminorailments
YourResponse:
CorrectAnswer:
Exp:
TheyareSkilledbirthattendant
ACCREDITEDSOCIALHEALTHACTIVIST(ASHA)
TheGovernmentofIndiahasdecidedtolaunchaNationalRuralHealthMission(NRHM)toaddressthe
healthneedsofruralpopulation,especiallythevulnerablesectionsofsociety.
TheSubcentreisthemostperipherallevelofcontactwiththecommunityunderthepublichealth
infrastructure.Thiscaterstoapopulationnormof5000,butiseffectivelyservingmuchlargerpopulation
attheSubcentrelevel,especiallyinEAGStates.Withonlyabout50%MPWbeingavailableintheseStates,
theANMisheavilyoverworked,whichimpactsoutreachservicesinruralareas.
CurrentlyAnganwadiWorkers(AWWs)undertheIntegratedChildDevelopmentScheme(ICDS)are
engagedinorganizingsupplementarynutritionprogrammesandothersupportiveactivities.Thevery
natureofherjobresponsibilities(withemphasisonsupplementaryfeedingandpreschooleducation)does
notallowhertotakeuptheresponsibilityofachangeagentonhealthinavillage.
Thusanewbandofcommunitybasedfunctionaries,namedasAccreditedSocialHealthActivist(ASHA)is
proposedtofillthisvoid.ASHAwillbethefirstportofcallforanyhealthrelateddemandsofdeprived
sectionsofthepopulation,especiallywomenandchildren,whofinditdifficulttoaccesshealthservices.
(Q.118) About,Aedesaegypti,falseis:
(a) Recognizedbywhitemarkingsonlegsandamarkingoftheformofalyreonthethorax.
(b) ThemalesofAedesspeciesofmosquitoesbitehumansandanimals.
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(c) Theireggscansurviveforverylongperiodsinadrystate
(d) Arenighttimebitersandpreferbreadinginflowingwater
YourResponse:
CorrectAnswer:
Exp:
Arenighttimebitersandpreferbreadinginflowingwater
Aedesaegyptiisamosquitothatcanspreadthedenguefever,Chikungunyaandyellowfeverviruses,and
otherdiseasesaswell.Themosquitocanberecognizedbywhitemarkingsonlegsandamarkingofthe
formofalyreonthethorax.
Theyarerecurrentdaytimebitersandbreedinstatgnantwater.
Aedesaegyptiissmallincomparisontoothers,usuallybetweenthreetofourmillimetresinlength
discountingleglength.
Itistotallyblackapartfromwhite'spots'onthebodyandheadregionsandwhiteringsonthelegs.The
thoraxisdecoratedwithawhite'Lyre'shapeofwhichthe'chords'aretwodullyellowlines.
Itswingsaretranslucentandborderedwithscales.
Themalesofallspeciesofmosquitoesdonotbitehumansoranimalsofanyspecies,theyliveonfruit.
Onlythefemalebitesforbloodwhichsheneedstomaturehereggs.
Theeggsofmostspeciesarelaidtogetherinaraftform,butAedeslayshereggsseparatelythusallowing
themtospreadoverlargesurfacesofwaterifconditionspermit,thiswaytheeggsstandabetterchanceof
survival.
Theeggscansurviveforverylongperiodsinadrystate,oftenformorethanayear.
Sincetheviruscanbepassedfromadulttoeggthenthevirustooisguaranteedsurvivaluntilthenext
summerandheavyrains.
Aedesaegyptibitesduringdaytimeandhencedaytimemosquitobiteisthemainreasonfortransmission.
Aedesisverydomesticated,asmuchasyourpetdogorcat,mostmosquitoescanliveinforestedareasa
longwayfromhumansandliveonanimalblood,notAedes.
(Q.119) Trueis:
(a)
Aldrineisanorganophosphate.
(b)
Tik20isaArylgroupcontainingphosphorouscompounD.
(c)
ACholineesteraseactivatorisusefulinRxofDichlorovaspoisoning
(d)
ThepopularBaygonSparyContainsanOrganophosphorouscompound
YourResponse:
CorrectAnswer:
Exp:
ACholineesteraseactivatorisusefulinRxofDichlorovaspoisoning.
AcarbamatePropoxuristhecontentofBAYGON.
Propoxur,Metformin,PhenforminareArylgroupcontainingphosphorouscompounds.
DichlorovasisaOrganophosphateandpralidoxime(2PAM),acholinesterasereactivatorisusefulinRx.
PAMisusefulforreversalofnicotinicsignsandsymptomsduetoorganophosphates,nervegasesor
unknownanticholineestrases
(Q.120) Integratedmanagementofchildhoodillness(IMCI)targetsthefollowingdiseasesEXCEPT
(a)
Malaria
(b)
Neonataltetanus
(c)
Otitismedia
(d)
HIV
YourResponse:
CorrectAnswer:
Exp:
Neonataltetanus(RefParkstextbookofPSM19thed.372;462)
Integratedmanagementofchildhoodillness(IMCI)
Theextentofchildhoodmorbidityandmortalitycausedbydiarrhoea,Acuterespiratoryinfection,malaria,
measlesandmalnutritionissubstantial.
IthasbeendecidedtolaunchIMCIinfourselecteddistrictseachinUttaranchal,MadhyaPradesh,Orissa,
Rajasthan,Maharashtra,Gujarat,Delhi,HaryanaandTamilNadu.
IMNCIwillbeimplementedinaphasedmannerthroughoutthecountry.
IntheIndiancontextthisstrategyisquitepertinentconsideringtherecentevidencefromNFHSIIreport
highlightingthatARI(17percent),diarrhoea(13percent),fever(27percent)andundernutrition(43per
cent)werethecommonestmorbiditiesobservedinthechildrenagedunder3years.
Coverageofmeaslesvaccinationinchildrenbetween1223monthsisalsolow.
ThemajorhighlightsoftheIndianadaptationare:
Inclusionof07daysageintheprogramme.
Incorporatingnationalguidelinesonmalaria,anaemia,vitaminAsupplementationandimmunization
schedule.
Trainingofthehealthpersonnelbeginswithsickyounginfantsupto2months;
Proportionoftrainingtimedevotedtosickyoungitandsickchildisalmostequal;and
isskillbased.
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(Q.121) AllofthefollowingareinheritedinXlinkedrecessivemannerexcept?
(a)
Hemophilia
(b)
Ducchenemusculardystrophy
(c)
G6PDdeficiency
(d)
Retinitispigmentosa
YourResponse:
CorrectAnswer:
Exp:
Retinitispigmentosa
AgainrememberthatthisisaveryveryfrequentlyaskedQuestiontypeinAIIMSexams.byjustbyhearting
themodeofinheritanceofvariousdiseasesitispossibletoscore1MCQcorrectineachandeveryAIIMS
exam.
IamprovidingyouwithanOvercomprehensivelistofvariousdiseasesandtheirmodeofinheritance.
Rememberingallofthemisimpracticalbutreviseitagainandagainandyouwillnotmissoutonitinthe
exam.
AUTOSOMALDOMINANT
AUTOSOMALRECESSIVE
Hyperlipoprotinemias(excepttypeI)
Abetalipoprotinemia
Achondroplasia
Cysticfibrosis
Neurofibromatosis
Hirshsprungdisease
Adenomatouspolyposiscoli
Phenylketonuria
Marfanssyndrome
Albinism
Retinoblastoma
Taysachsdisease
HereditarySpherocytosis
Alkaptonuria
Tuberoussclerosis
Galactosemia
Myotonicdystrophy
MapleSyrupurinedisease
VonWillebranddisease
Betathallasemia
Osteogenesisimperfecta
Homocystinuria
Acuteintermittentporphyria
Lysosomalstoragedisorders
Holtoramsyndrome
Alpha1Antitrypsindeficiency
MEN
Wilsonsdisease
VHLsyndrome
Hemochromatosis
Wilmstumour
Glycogenstoragedisorders
Otosclerosis
Sicklecelldisease
BRCA1andBRCAIIBreastcancers
Congenitaladrenalhyperplasia
Gardner,Peutzzeigersyndrome
Freidrichsataxia
Retinitispigmentosa
Spinalmuscularatrophy
ALS
HereditaryvitaminDResistantrickets
OslerWeberRendudisease
Kartagenersyndrome
Huntingtonschorea
Turcotssyndrome
ABOBloodgroupsystem
Polycysticliverdisease
Crouzonsyndrome
Fanconisyndrome
Myotonicdystrophy
Gauchersyndrome
Hypophosphatemicrickets(FGF23mutation)
FAXB(Fanconianemia,Ataxiatelangiectasia,Xeroderma
pigmentosum,Bloomsyndrome)
Hemiplegicmigraine
SwisstypeAgammaglobulinemia
CharcotMarieToothdisease
Nonketotichyperglycinemia
Pigmentaryglaucoma
Acrodermatitisenteropathica
Hypokalemicperiodicparalysis
Diaphysialaclasia
XLinkedRecessiveInheritance
XLinkedDominantInheritance
HemophilaAandB
VitaminDResistantrickets
Duchennemusculardystrophy
FamilialHypophosphatemia(PHEX)
G6PDdeficiency
BloodgroupXg
Hydrocephalus
Rettssyndrome
Retinitispigmentosa(mostseverelesscommon OroFacioDigitalsyndrome
form)
BrutonsAgammaglobulinemia
Incontinentiapigmentii
Hunterssyndrome
ChronicGranulomatousdisease
WiskottAldrichsyndrome
Diabetesinsipidus
LeschNyhansyndrome
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FragileXsyndrome
Dentsdisease
Kallmansyndrome
Androgeninsensitivitysyndrome
Fabrysdisease
Alportsyndrome
MITOCHONDRIALINHERITANCE(1QuestionwasaskedinAIIMSNOV09)
Mitochondrialmyopathy
LebersHereditaryOpticNeuropathy(LHON)
MELAS:MetabolicEncephalopathy+LacticAcidosis+Strokelikeepisodes
NARP:Neuropathy+Ataxia+RetinitisPigmentosa
Pearsonsyndrome:BonemarrowandPancreaticfailure
KearnsSayresyndrome:Ophthalmoplegia+Pigmentarydegenerationofretina+Cardiomyopathy
MERRFsyndrome:MyoclonicEpilepsy+RaggedRedFibres
MMC:MaternallyinheritedMyopathyandCardiomyopathy
CEOP:ProgressiveExternalOphthalmoplegia
ADMIMY:AutosomalDominantinheritedMitochondrialMyopathyandMitochondrialDeletion
Leighsdisease:movementdisorder+regression+respiratorydyskinesia
NavajoNeurohepatopathyandMDS
(Q.122) Decisionanalysesoftenincludeapatientsutilitiesinthedeterminationofthebestdecision.Theseutilitiesmeasure?
(a)
Whetherapatientfavorsonedecisionoveranother
(b)
Whetheraphysicianfavorsonedecisionoveranother
(c)
Thedifferencebetweenapatientsdecisionandthephysiciansdecision
(d)
Therelativevalueapatientplacesonaparticularoutcome
YourResponse:
CorrectAnswer:
Exp:
Therelativevalueapatientplacesonaparticularoutcome
Indecisionanalysis,utilitiesrefertotherelativevaluesplacedonvariousoutcomes.Forexample,perfect
healthmightbeassignedautilityof100,anddeathassignedoneof0.What,then,wouldtheutilitybefor
lifewithmoderatebackpain?Withcarefulquestioning,onefindsthatmostpatientsplaceahighervalue
onlifewithdisabilitythanwouldbeanticipated.
(Q.123) Theauthorsofastudystatethatcarefulautopsiesshowthat60percentofallpersonswhodiehaveevidenceofrecentorprevious
pulmonaryembolismandconcludethatpulmonaryembolismistheleadingcauseofdeathinIndiA.Possiblereasonsfordisagreeing
withtheconclusionincludeallthefollowingexcept:
(a)
Confounding
(b)
Selectionbias
(c)
Randomerror
(d)
Leadtimebias
YourResponse:
CorrectAnswer:
Exp:
Leadtimebias
Theexactproportionofdeathsduetopulmonaryembolismisnotknownandcouldonlybedeterminedby
astudyofarandomsampleofallpersonswhodied.Thiswouldavoidtheproblemofselectionbias(only
certainpersonsundergoautopsies).Thestudyshouldbelargeenoughtoavoidrandomerror(perhapsthe
citedstudyfoundemboliinthreeoffiveautopsies),andtheinvestigatorsshouldhavecarefulandprecise
definitionsofpulmonaryembolismtoavoidoverdiagnosisofthecondition.Theassociationbetween
pulmonaryembolismanddeathmaybeduetoconfoundingifsomeotherfactorcausesboth.Thus,
pulmonaryembolism,thoughpresent,maynotbethecauseofdeath.Leadtimebiasreferstoanapparent
increaseinsurvivalamongpersonswhosediseaseisdetectedbyscreening.Forexample,5yearsurvivalof
cancerpatientsidentifiedonscreeningmightappeartobeprolongedsimplyasaresultofstartingtocount
thesurvivaltimeearlierinthecourseofdisease.
(Q.124) Whichstatementistrueconcerningmeasuresofcentraltendency?
(a) Ifmoreoutlyingobservationsaresmallerthantherestofthevalues,thedataareskewedtotheright
(b) Ifmoreoutlyingobservationislargerthantherestofthevalues,themedianwillbesmallerthanthemean
(c) Ifthedataareskewedtotheleft,themeanislargerthanthemedian
(d) Themedianismoresensitivethanthemeanstoextremeobservation
YourResponse:
CorrectAnswer:
Exp:
Ifmoreoutlyingobservationislargerthantherestofthevalues,themedianwillbesmallerthanthe
mean
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Whenmoreoutlyingvaluesarelargerthantherestofthevalues,thedataaresaidtobeskewedtothe
right,andthemedianissmallerthanthemean.Ifmoreoutlyingvaluesaresmallerthantherest,thedata
aresaidtobeskewedtotheleft,andthemedianislargerthanthemean.Themedianismorerobustthan
themeanbecauseitislesssensitivetoextremeobservationsandisamoreappropriatemeasureofcentral
tendencywhenextremevaluesarepartofthedataset.Themode,themean,andthemedianareallthe
sameforasymmetricaldistributionofdata.Thesedistributionscanbeillustratedasfollows:
(Q.125) AccordingtorevisedRCHprogramme,CommunityHealthCentreisreferredas:
(a)
Firstreferralunit
(b)
IIFRU
(c)
IIIFRU
(d)
ItisnotincludedinaccordingtonewRCHprogramme
YourResponse:
CorrectAnswer:
Exp:
Firstreferralunit(RefParkstextbookofPSM19thed.367)
ThemainhighlightsofRCHprogrammeare:
Theprogrammeintegratesallinterventionsoffertilityregulation,maternalandchildhealthwith
reproductivehealthforbothmenandwomen.
Theservicestobeprovidedareclientoriented,demanddriven,highqualityandbasedonneedsof
communitythroughdecentralisedparticipatoryplanningandtargetfreeapproach.,
Theprogrammeenvisagesupgradationoftheleveloffacilitiesforprovidingvariousinterventionsand
qualityofcare.TheFirstReferralUnits(FRUs)beingsetupatsubdistrictlevelprovidecomprehensive
emergencyobstetricandnewborncare.SimilarlyRCHfacilitiesatPHCsaresubstantiallyupgraded.
Facilitiesofobstetriccare,MTPandIUDinsertioninthePHCslevelareimproved.IUDinsertionfacilitiesare
alsoavailableatsubcentres.
SpecialistfacilitiesforSTDandRTIareavailableinalldistricthospitalsandinafairnumberofsubdistric
hospitals.
RCHprogrammeisbasedonadifferentialapproach.Inputsinallthedistrictshavenotbeenkeptuniform.
Whilethecarecomponentsarethesameforalldistricts,theweakerdistrictsgetmoresupportand
sophisticatedfacilitiesareproposedforrelativelyadvanceddistricts.Onthebasisofcrudebirthrateand
femaleliteracyrate,allthedistrictshavebeendividedintothreecategories.CategoryAhaving58districts,
categoryBhaving184districtsandcategoryChaving265districts.Allthedistrictswerecoveredina
phasedmannerover.aperiodofthreeyears.Theprogrammewasformallylaunchedon15thOctober
1997.
(Q.126) TrueregardingNRHMis?
(a) SeekstorevitalizelocalhealthtraditionsandmainstreamAYUSHintothepublichealthsystem
(b) InfantMortalityRatereducedto30/1000livebirthsisanationalleveloutcomeindicator
(c) Itseeksdecentralizationofprogrammesfordistrictmanagementofhealth.
(d) Allofabove
YourResponse:
CorrectAnswer:
Exp:
Ans.D.Allofabove
NATIONALRURALHEALTHMISSION
THEVISION
TheNationalRuralHealthMission(200512)seekstoprovideeffectivehealthcaretoruralpopulation
throughoutthecountrywithspecialfocuson18states,whichhaveweakpublichealthindicatorsand/or
weakinfrastructure.
These18StatesareArunachalPradesh,Assam,Bihar,Chhattisgarh,HimachalPradesh,Jharkhand,Jammu
&Kashmir,Manipur,Mizoram,Meghalaya,MadhyaPradesh,Nagaland,Orissa,Rajasthan,Sikkim,Tripura,
UttaranchalandUttarPradesh.
TheMissionisanarticulationofthecommitmentoftheGovernmenttoraisepublicspendingonHealth
from0.9%ofGDPto23%ofGDP.Itaimstoundertakearchitecturalcorrectionofthehealthsystemto
enableittoeffectivelyhandleincreasedallocationsaspromisedundertheNationalCommonMinimum
Programmeandpromotepoliciesthatstrengthenpublichealthmanagementandservicedeliveryinthe
country.
Ithasasitskeycomponentsprovisionofafemalehealthactivistineachvillage;avillagehealthplan
preparedthroughalocalteamheadedbytheHealth&SanitationCommitteeofthePanchayat;
strengtheningoftheruralhospitalforeffectivecurativecareandmademeasurableandaccountabletothe
communitythroughIndianPublicHealthStandards(IPHS);andintegrationofverticalHealth&Family
WelfareProgrammesandFundsforoptimalutilizationoffundsandinfrastructureandstrengthening
deliveryofprimaryhealthcare.
ItseekstorevitalizelocalhealthtraditionsandmainstreamAYUSHintothepublichealthsystem.
Itaimsateffectiveintegrationofhealthconcernswithdeterminantsofhealthlikesanitation&hygiene,
nutrition,andsafedrinkingwaterthroughaDistrictPlanforHealth.
Itseeksdecentralizationofprogrammesfordistrictmanagementofhealth.
ItseekstoaddresstheinterStateandinterdistrictdisparities,especiallyamongthe18highfocusStates,
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includingunmetneedsforpublichealthinfrastructure.
Itshalldefinetimeboundgoalsandreportpubliclyontheirprogress.
Itseekstoimproveaccessofruralpeople,especiallypoorwomenandchildren,toequitable,affordable,
accountableandeffectiveprimaryhealthcare.
GOALS
ReductioninInfantMortalityRate(IMR)andMaternalMortalityRatio(MMR)
UniversalaccesstopublichealthservicessuchasWomenshealth,childhealth,water,sanitation&
hygiene,immunization,andNutrition.
Preventionandcontrolofcommunicableandnoncommunicablediseases,includinglocallyendemic
diseases
Accesstointegratedcomprehensiveprimaryhealthcare
Populationstabilization,genderanddemographicbalance.
RevitalizelocalhealthtraditionsandmainstreamAYUSH
Promotionofhealthylifestyles
OUTCOMES
NationalLevel:
InfantMortalityRatereducedto30/1000livebirths
MaternalMortalityRatioreducedto100/100,000
TotalFertilityRatereducedto2.1
Malariamortalityreductionrate50%upto2010,additional10%by2012
KalaAzarmortalityreductionrate:100%by2010andsustainingeliminationuntil2012
Filaria/Microfilariareductionrate:70%by2010,80%by2012andeliminationby2015
Denguemortalityreductionrate:50%by2010andsustainingatthatleveluntil2012
JapaneseEncephalitismortalityreductionrate:50%by2010andsustainingatthatleveluntil2012
CataractOperation:increasingto46lakhsperyearuntil2012.
Leprosyprevalencerate:reducefrom1.8/10,000in2005tolessthan1/10,000thereafter
TuberculosisDOTSservices:Maintain85%cureratethroughentireMissionperiod.
UpgradingCommunityHealthCenterstoIndianPublicHealthStandards
IncreaseutilizationofFirstReferralUnitsfromlessthan20%to75%Engaging250,000femaleAccredited
SocialHealthActivists(ASHAs)in10States.
CommunityLevel:
Availabilityoftrainedcommunitylevelworkeratvillagelevel,withadrugkitforgenericailments
HealthDayatAnganwadilevelonafixedday/monthforprovisionofimmunization,ante/postnatal
checkupsandservicesrelatedtomother&childhealthcare,includingnutrition.
AvailabilityofgenericdrugsforcommonailmentsatSubcentreandhospitallevel
Goodhospitalcarethroughassuredavailabilityofdoctors,drugsandqualityservicesatPHC/CHClevel
ImprovedaccesstoUniversalImmunizationthroughinductionofAutoDisabledSyringes,alternatevaccine
deliveryandimprovedmobilizationservicesundertheprogramme
(Q.127) AllofthefollowingareECGfeaturesofhypokalemiaexcept?
(a)
ProlongedPRinterval
(b)
ProminentUwave
(c)
STdepression
(d)
PeakedTwaves
YourResponse:
CorrectAnswer:
Exp:
PeakedTwaves
Thisisanextremelyhighyieldtopichavingatleast1questionineveryexam.
HereisalistofalmostallimportantconditionscausingspecificECGabnormalities.
ECGABNORMALITIES:
DIAGNOSTICECGFEATURES
CONDITION
QTshortening(Earliestfeature)
TherapeuticDigitalization
IncreasedPRinterval
Slowingofheartrate
Decreasedamplitude/invertedTwave
STdepression
ProlongedPRinterval,
Digitalistoxicity
VPCs,VT,VF,AVblock
Sinoatrialblock,
Ventricularbigeminy/trigeminy
Flattening/inversionofTwave
Earlyhypokalemia
STdepression
ProminentUwave
ProlongedQUinterval
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ProlongedPR
Severehypokalemia
DecreasedvoltageandwideningofQRS
Increasedriskofventriculararrhythmias
RarelySAblock
PeakedTwaves
Hyperkalemia
LossofPwave
SINEWAVEPATTERN
WideningofQRSandprolongedPR
Sinusarrest
Cardiacarrestasystole
Ventricularfibrillation
Bradycardia
Hypercalcemia
AVblock
ShortQT
ProlongedQT
Hypocalcemia
WidespreadSTelevationwithupwardconcavity STAGEIAcutePericarditis
involving23standardlimbleadsandV2V6
ReciprocaldepressiononlyinaVRand
sometimesinV1
PRdepressions/oAtrialinvolvement
STsegmentreturnstonormalafterseveraldays STAGEIIAcutePericarditis
OnlythenorevenafteritTwaveinversion
occurs
STAGEIIIAcutePericarditis
WeekstomonthsafteritECGreturnstonormal STAGEIVAcutePericarditis
JwaveorOsbornwave
Hypothermia
HighvoltagetallQRSwithshortPRinterval
Pompesdisease
CVATpattern:
IntracranialblledsespSAH.
MarkedQTprolongationwithdeepwideT
waveinversions
TotalElectricalAlternans
PericardialEffusionwithcardiactamponade
d/tswingingmotionofheartinthepericardial
cavityatafrequencyexactlyhalfthehrtrate
ReplarisationAlternans
Signofelectricalinstabilityandmaysuggest
impendingventriculartachyarrythmias
PeakedTwaves(d/thyperkalemia)
ECGTriadofchronivrenalfailure
LongQTd/tStsegment
lengthening(hypocalcemia)
Leftventricularhypertrophy(d/tsystemic
hypertension)
Rightaxisdeviation
TetralogyofFallot
RightventricularhypertrophywithinvertedT
wavesandPPulmonale
NormalPwavewithshortPR
WPWsyndrome
ASlurredthickenedinitialupstrokeofQRS
DELTAwave
MainQRSdeflection
SecondarySTandTwavechanges
Twavesuppression/inversion(most
characteristicchange)
Imipramine(TCA)toxicity
ProlongedQRS>100ms
RwavegreaterthanSwave
PolymorphicVTpreceededbymarkedQT
prolongation>0.6sec
Torsadesdepointes
BizzareandmultiformQRS
TransientSTdepression
Classicalangina
TransientStelevationwithoutQwave
Noninfarctiontransmural
ischemia(Prinzmetalsangina)
ParadoxicalTwavenormalization
STdepressionorTwaveinversionwithoutQ
wave
NSTEMI
STelevation
HyperacutephaseMI
TallwidenedTwaves
PathologicalQwave
FullyevolvedMI
STelevation
InvertedsymmetricTwave
PathologicalQwaveonly
Oldinfarct
(Q.128) Extinctionphenomenaisseenin?
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(a)
Alzheimerdisease
(b)
Hemispatialneglect
(c)
Antonionsyndrome
(d)
Wernickesencephalopathy
YourResponse:
CorrectAnswer:
Exp:
Hemispatialneglect
RefHarrison,17thedition,page167
HemispatialNeglect
Adaptiveorientationtosignificanteventswithintheextrapersonalspaceissubservedbyalargescale
networkcontainingthreemajorcorticalcomponents.Thecingulatecortexprovidesaccesstoalimbic
motivationalmappingoftheextrapersonalspace,theposteriorparietalcortextoasensorimotor
representationofsalientextrapersonalevents,andthefrontaleyefieldstomotorstrategiesforattentional
behaviors.Subcorticalcomponentsofthisnetworkincludethestriatumandthethalamus.Contralesional
hemispatialneglectrepresentsoneoutcomeofdamagetoanyofthecorticalorsubcorticalcomponentsof
thisnetwork.
Extinctionisaneurologicaldisorderthatimpairstheabilitytoperceivemultiplestimuliofthesametype
simultaneously.Extinctionisusuallycausedbydamageresultinginlesionsononesideofthebrain.Those
whoareaffectedbyextinctionhavealackofawarenessinthecontralesionalsideofspace(towardsthe
leftsidespacefollowingarightlesion)andalossofexploratorysearchandotheractionsnormallydirected
towardthatside.
(Q.129) A36yearoldmalecomestohisprimarycarephysiciancomplainingof3daysofworseningheadache,leftfrontalfacialpain,and
yellownasaldischarge.Thepatientreportsthathehashadnasalstuffinessandcoryzaforabout5days.Pastmedicalhistoryis
notableonlyforseasonalrhinitis.Thephysicalexaminationisnotableforatemperatureof37.9C(100.2F)andtendernessto
palpationovertheleftmaxillarysinus.Theoropharynxhasnoexudates,andthereisnolymphadenopathy.Whichofthefollowing
isthemostappropriatenextintervention?
(a)
Aspirationofthemaxillarysinus
(b)
Nasalfluticasone
(c)
Oralamoxicillin
(d)
Serumantineutrophilcytoplasmicantibodies
YourResponse:
CorrectAnswer:
Exp:
Nasalfluticasone
Thehistoryandclinicalpresentationsuggeststhatpatientisacaseofseasonalrhinitis(hayfever).
Thegoalofrhinitistreatmentistopreventorreducethesymptomscausedbyinflammationofaffected
tissue.
Avoidtheallergenasmuchaspossible
Intranasalcorticosteroidsareprefferedtreatmentegnasalfluticasone
Oralantibioticsareofnouseasitisallergicnotinfectiveetiology
Decongestents
Yogaanddeepbreathingexcercisesaregood
Aspirationshouldbeperformedwhenthereisknownopacificationofasinusandempiricaltherapyhasnot
beeneffectiveorthepatientisatriskofopportunisticinfection
(Q.130) Trueaboutasthma?
(a)
IncreasedFRCanddecreasedresidualvolume
(b)
IncreasedFRCandincreasedresidualvolume
(c)
ReducedFRCandreducedresidualvolume
(d)
DecreasedFRCandincreasedresidualvolume
YourResponse:
CorrectAnswer:
Exp:
increasedFRCincreasedresidualvolume
Asthma
PATHOPHYSIOLOGY
Thepathophysiologichallmarkofasthmaisareductioninairwaydiameterbroughtaboutbycontractionof
smoothmuscle,vascularcongestion,edemaofthebronchialwall,andthick,tenacioussecretions.Thenet
resultisanincreaseinairwayresistance,adecreaseinforcedexpiratoryvolumesandflowrates,
hyperinflationofthelungsandthorax,increasedworkofbreathing,alterationsinrespiratorymuscle
function,changesinelasticrecoil,abnormaldistributionofbothventilationandpulmonarybloodflowwith
mismatchedratios,andalteredarterialbloodgasconcentrations.Thus,althoughasthmaisconsideredto
beprimarilyadiseaseofairways,virtuallyallaspectsofpulmonaryfunctionarecompromisedduringan
acuteattack.
Inaddition,inverysymptomaticpatientstherefrequentlyiselectrocardiographicevidenceofright
ventricularhypertrophyandpulmonaryhypertension.Whenapatientpresentsfortherapy,the1sforced
expiratoryvolume(FEV1)orpeakexpiratoryflowrate(PEFR)istypically_40%ofpredicted.Inkeepingwith
thealterationsinmechanics,theassociatedairtrappingissubstantial.
Inacutelyillpatients,residualvolumefrequentlyapproaches400%ofnormal,whilefunctionalresidual
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capacitydoubles.
(Q.131) GasusedtomeasurediffusionLungCapacity?
(a)
CO
(b)
NO
(c)
CO2
(d)
O2
YourResponse:
CorrectAnswer:
Exp:
CO(RefH17th/pg.1592)
DiffusingCapacity
Theabilityofgastodiffuseacrossthealveolarcapillarymembraneisordinarilyassessedbythediffusing
capacityofthelungforcarbonmonoxide(DLCO).
Inthistest,asmallconcentrationofcarbonmonoxide(0.3%)isinhaled,usuallyinasinglebreaththatis
heldfor~10s.Duringthebreathhold,thecarbonmonoxideisdilutedbythegasalreadypresentinthe
alveoliandisalsotakenupbyhemoglobinastheerythrocytescoursethroughthepulmonarycapillary
system.Theconcentraonofcarbonmonoxideisthenmeasuredinthegasexhaledaerthebreathhold,
andDLCOiscalculatedasthequantyofcarbonmonoxideabsorbedperminutepermmHgpressure
gradientfromthealveolitothepulmonarycapillaries.ThevalueobtainedforDLCOdependsonthe
alveolarcapillarysurfaceareaavailableforgasexchangeandonthepulmonarycapillarybloodvolume.In
addion,thethicknessofthealveolarcapillarymembrane,thedegreeofV
/Q
mismatching,andthe
paentshemoglobinlevelwillaectthemeasurement.Becauseofthiseectofhemoglobinlevelson
DLCO,themeasuredDLCOisfrequentlycorrectedtotakethepaentshemoglobinlevelintoaccount.The
valueforDLCO,ideallycorrectedforhemoglobin,canthenbecomparedwithapredictedvalue,based
eitheronage,height,andgenderoronthealveolarvolume(VA)atwhichthevaluewasobtained.
(Q.132) Apatientisevaluatedintheemergencydepartmentforperipheralcyanosis.Whichofthefollowingisnotapotentialetiology?
(a)
Coldexposure
(b)
Deepvenousthrombosis
(c)
Methemoglobinemia
(d)
Peripheralvasculardisease
YourResponse:
CorrectAnswer:
Exp:
Methemoglobinemia
Thelogicsaysanycausewhichreducesoxygencarryingtoalloverthebodywillbecausingcentral
cyanosisforexamplemethemoglobinemiabecauseitisinbloodcompetingwithnormalhemoglobinto
attatchwithoxygenandwhenmethhemoglobingetstheoxygenitdoesntleaveitsointheendbody
doesntgetoxygen=centralcyanosis
Incontrasttocentralcyanosisperipheralcyanosisoccurswhenthereissomelocalorpartofourbody
getslessoxygenforexampleobstructioninoneparticularbloodvesseletcsohereinthequestiongiven
allotherareperipheralcauseexceptmethemoglobin
CausesofCyanosis
CentralCyanosis
Decreasedarterialoxygensaturation
Decreasedatmosphericpressurehighaltitude
Impairedpulmonaryfunction
Alveolarhypoventilation
Unevenrelationshipsbetweenpulmonaryventilationandperfusion(perfusionofhypoventilatedalveoli)
Impairedoxygendiffusion
Anatomicshunts
Certaintypesofcongenitalheartdisease
Pulmonaryarteriovenousfistulas
Multiplesmallintrapulmonaryshunts
Hemoglobinwithlowaffinityforoxygen
Hemoglobinabnormalities
Methemoglobinemiahereditary,acquired
Sulfhemoglobinemaacquired
Carboxyhemoglobinemia(nottruecyanosis)
PeripheralCyanosis
Reducedcardiacoutput
Coldexposure
Redistributionofbloodflowfromextremities
Arterialobstruction
Venousobstruction
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(Q.133) A35yearoldmaleisseenintheclinicforevaluationofinfertility.Hehasneverfatheredanychildren,andafter2yearsof
unprotectedintercoursehiswifehasnotachievedpregnancy.Spermanalysisshowsanormalnumberofsperm,buttheyare
immotile.Pastmedicalhistoryisnotableforrecurrentsinopulmonaryinfections,andthepatientrecentlywastoldthathehas
bronchiectasis.Chestradiographyislikelytoshowwhichofthefollowing?
(a)
Bihilarlymphadenopathy
(b)
Bilateralupperlobeinfiltrates
(c)
Normalfindings
(d)
Situsinversus
YourResponse:
CorrectAnswer:
Exp:
Situsinversus
Thisparticularcasesuggesttwoclosediagnosisoronecangetconfusedbetweencysticfibrosisand
kartagenersyndromethekeytotheanswerisNormalspermcountandimmotilespermswhichismore
specificallyfoundinkartargenersyndrome.
Thecombinationofinfertilityandrecurrentsinopulmonaryinfectionsshouldpromptconsiderationofan
underlyingdisorderofciliarydysfunctionthatistermedprimaryciliarydyskinesia.Thesedisordersaccount
forapproximately5to10%ofcasesofbronchiectasis.Anumberofdeficiencieshavebeendescribed,
includingmalfunctionofdyneinarms,radialspokes,andmicrotubules.Allorgansystemsthatrequire
ciliaryfunctionareaffected.Thelungsrelyonciliatobeatrespiratorysecretionsproximallyand
subsequentlytoremoveinspiredparticles,especiallybacteria.Intheabsenceofthisnormalhostdefense,
recurrentbacterialrespiratoryinfectionsoccurandcanleadtobronchiectasis.Otitismediaandsinusitis
arecommonforthesamereason.Inthegenitourinarytract,spermrequireciliatoprovidemotilityso
spermsareimmotilealthoughspermcountisnormal.
Kartagenerssyndromeisacombinationofsinusitis,bronchiectasis,andsitusinversusandimmotile
spermswithnormalspermcounts.Itaccountsforapproximately50%ofpatientswithprimaryciliary
dyskinesia.
Cysticfibrosisisassociatedwithinfertilityandbilateralupperlobeinfiltrates,itcausesadecreasednumber
ofspermorabsentspermonanalysisbecauseofthecongenitalabsenceofthevasdeferens.butherein
thisparticularcasethespermcountisnormal
Sarcoidosis,whichisoftenassociatedwithbihilaradenopathy,isnotgenerallyacauseofinfertility.Water
balloonshapedheartisfoundinthosewithpericardialeffusions,whichonewouldnotexpectinthis
patient.
(Q.134) TrueaboutEnteralnutritionis?
(a) Resultsinreductionofinfectiouscomplicationsincriticallyillpatents.
(b) Ismoreexpensivethanparenteralnutrition
(c) Resultsinfasterreturnofbowelfunctioninhealthypatientsaftergastrointestinalsurgery.
(d) Hasahighercomplicationratethanparenteralnutrition.
YourResponse:
CorrectAnswer:
Exp:
Resultsinreductionofinfectiouscomplicationsincriticallyillpatents.
(RefSchwartz:Principlesofsurgery5theditionpageno.96100)
Mostprospectiverandomizedstudiesforsevereabdominal&thoracictrumademonstratessignificant
reductionsininfectiouscomplicationforpatientsgivenearlyenteralnutritionwhencomparedwiththose
whoareunfedorreceivingparenteralnutrition.
Enteralfeedingprovidesphysiologic,metabolic,safety,andcostbenefitsoverparenteralnutrition.
Therearevariouswaysenteralnutritionalisadministeredandscheduled.Themethodofadministration
mustbeindividualizedtoeachpatient'sspecificneeds.ThefunctioningandcapacityoftheGItract,
underlyingdiseasestatesandpatienttolerancemustbeassessedinordertodeterminetheappropriate
administrationmethod.
ENadmini
Indications
Advantages
Intactgagreflex
Easytubeinsertion
Disadvantages
strationroutes
Nasogastric
Noesophagealreflux
Normalgastricemptying
Stomachuninvolvedwith
primarydisease
Nasojejunal
Highestriskofpulmonary
Largerreservoircapacity aspiration
instomach
Patientselfconsciousdueto
appearanceofnasogastrictube
Gastroparesisorimpaired
gastricemptying
TFmaybeinitiated
PotentialGIintolerancetogoalTF
immediatelyafterinjury infusionrate
Esophagealreflux
Reducedaspirationrisk
comparedtoNG
Gastricdysfunctiondueto
tramaorsurgery
Mayrequireendoscopic
placementoftube
Patientselfconsciousdueto
appearanceofnasoenterictube
Tubedisplacementandpotential
aspiration
Jejunostomy
Longtermfeeding
Reducedriskofaspiration
Highriskofaspiration
PlacedadjunctlywithGI
surgery
PotentialGIintoleranceto
goalTFinfusionrate
Stomacareneeded;potential
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Esophagealreflux
Nosurgeryneededfor
InabilitytoaccessupperGI percutaneousendoscopic
tract
jejunostomy(PEJ)
Gastroparesisorimpaired PEJlesscostlythansurgical
gastricemptying
jejunostomy
Gastricdysfunctiondueto TFmaybeinitiated
tramaorsurgery
immediatelyafterinjury
infectionatstomasite
Potentialskinexcoriation
fromleakagesofdigestive
secretionsatstomasite
Potentialfistulaaftertube
removed
Tubeocclusionwithsmall
boretubeorneedlecatheter
Surgeryneededforsurgical
jejunostomies
(Q.135) Inapatientwithseverebullousemphysema,themostappropriatemethodformeasuringlungvolumesis
(a)
Bodyplethysmography
(b)
Diffusingcapacityofcarbonmonoxide
(c)
Spirometry
(d)
Heliumdilution
YourResponse:
CorrectAnswer:
Exp:
Bodyplethysmography
Spirometrydoesnotmeasuretotallungcapacitybecauseitcannotaccountforresidualvolumesoits
alreadyout
DLCOisaffectesinfectdecresasedincaseofCOPDandspeciallyemphysematouscasessothisalsocant
measuretotallungcapacityinbullousemphysema.
Themostfrequentlyusedandaccuratemeasuresoflungvolumesaresteadystateheliumdilutionlung
volumesandbodyplethysmography.
Inheliumdilutionthepatientinspiresaknownconcentrationofheliumfromaclosedcircuitofknown
volume.Afterthepatientrebreathesintheclosedcircuitforaperiodoftime,theconcentrationofhelium
equilibrates,andsubsequentlythelungvolumescanbecalculatedbyusingAvogadroslaw.This
calculationassumesthatgasinthecircuitwillrapidlyequilibratewiththeventilatedportionsofthelung.
However,ifthereareslowlyemptyingareasofthelung,asincysticfibrosispatients,orpartsofthelung
thatdonotparticipateingasexchangeatall,asinbullousemphysemapatients,heliumdilutionwill
underestimatetruelungvolumes.
Subsequently,bodyplethysmographyisthepreferredmethodforlungvolumemeasurementinthese
diseasestates.Toperformbodyplethysmography,thepatientsitsinasealedboxandpantsagainsta
closedmouthpiece.Pantingresultsinchangesinthepressureoftheboxthat,whencomparedwith
changesatthemouthpiece,canbeusedtocalculatelungvolumes.Thismethodmeasurestotalthoracic
gasvolumeandismoreaccuratethanheliumdilution.Heliumlungvolumesareeasiertoperformfor
patientsandstaffandgivereliableresultsinmostcircumstances.Manycentersmeasureasinglebreath
heliumdilutionlungvolumewhenmeasuringthediffusingcapacityofcarbonmonoxide,whichhasthe
sameorgreaterlimitationsastherebreathingmethod.Transdiaphragmaticpressureisusedtomeasure
respiratorymusclestrength,notlungvolumes.
(Q.136) Whatisthediagnosis?
(a)
Istdegreeheartblock
(b)
2nddegreeheartblock
(c)
Rightbundlebranchblock
(d)
Completeheartblock
YourResponse:
CorrectAnswer:
Exp:
Completeheartblock
REF:Ganong'sReviewofMedicalPhysiology>Chapter30.OriginoftheHeartbeat&theElectrical
ActivityoftheHeart
TheAVnodeandotherportionsoftheconductionsystemcan,inabnormalsituations,becomethecardiac
pacemaker.Inaddition,diseasedatrialandventricularmusclefiberscanhavetheirmembranepotentials
reducedanddischargerepetitively.
Asnotedabove,thedischargerateoftheSAnodeismorerapidthanthatoftheotherpartsofthe
conductionsystem,andthisiswhytheSAnodenormallycontrolstheheartrate.Whenconductionfrom
theatriatotheventriclesiscompletelyinterrupted,complete(thirddegree)heartblockresults,andthe
ventriclesbeatatalowrate(idioventricularrhythm)independentlyoftheatria.Theblockmaybedueto
diseaseintheAVnode(AVnodalblock)orintheconductingsystembelowthenode(infranodalblock).In
patientswithAVnodalblock,theremainingnodaltissuebecomesthepacemakerandtherateofthe
idioventricularrhythmisapproximately45beats/min.Inpatientswithinfranodalblockduetodiseasein
thebundleofHis,theventricularpacemakerislocatedmoreperipherallyintheconductionsystemandthe
ventricularrateislower;itaverages35beats/min,butinindividualcasesitcanbeaslowas15beats/min.
Insuchindividuals,theremayalsobeperiodsofasystolelastingaminuteormore.Theresultantcerebral
ischemiacausesdizzinessandfainting(StokesAdamssyndrome).Causesofthirddegreeheartblock
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includeseptalmyocardialinfarctionanddamagetothebundleofHisduringsurgicalcorrectionof
congenitalinterventricularseptaldefects.Whenconductionbetweentheatriaandventriclesisslowedbut
notcompletelyinterrupted,incompleteheartblockispresent.Intheformcalledfirstdegreeheartblock,
alltheatrialimpulsesreachtheventriclesbutthePRintervalisabnormallylong.Intheformcalledsecond
degreeheartblock,notallatrialimpulsesareconductedtotheventricles.Forexample,aventricularbeat
mayfolloweverysecondoreverythirdatrialbeat(2:1block,3:1block,etc).Inanotherformofincomplete
heartblock,therearerepeatedsequencesofbeatsinwhichthePRintervallengthensprogressivelyuntila
ventricularbeatisdropped(Wenckebachphenomenon).ThePRintervalofthecardiaccyclethatfollows
eachdroppedbeatisusuallynormaloronlyslightlyprolonged.
SometimesonebranchofthebundleofHisisinterrupted,causingrightorleftbundlebranchblock.In
bundlebranchblock,excitationpassesnormallydownthebundleontheintactsideandthensweepsback
throughthemuscletoactivatetheventricleontheblockedside.Theventricularrateisthereforenormal,
buttheQRScomplexesareprolongedanddeformed.Blockcanalsooccurintheanteriororposterior
fascicleoftheleftbundlebranch,producingtheconditioncalledhemiblockorfascicularblock.Left
anteriorhemiblockproducesabnormalleftaxisdeviationintheECG,whereasleftposteriorhemiblock
producesabnormalrightaxisdeviation.Itisnotuncommontofindcombinationsoffascicularandbranch
blocks(bifascicularortrifascicularblock).TheHisbundleelectrogrampermitsdetailedanalysisofthesite
ofblockwhenthereisadefectintheconductionsystem.
(Q.137) Maturityonsetdiabetesoftheyoung(MODY)isinheritedas:
(a)
Autosomaldominantdisease
(b)
Autosomalrecessivedisease
(c)
Xlinkeddominantdisease
(d)
Xlinkedrecessivedisease
YourResponse:
CorrectAnswer:
Exp:
Autosomaldominant
Althoughnoninsulindependentdiabetesmellitusdisease(nonketogenic)isfamilial,theexactmodeof
inheritanceisnotknownexceptforthespecificvariantknownasmaturityonsetdiabetesoftheyoung
(MODY),whichismanifestedbymildhyperglycemiawithoutketosis.Onthebasisoffamilystudies,this
diseaseisinheritedinanautosomaldominantfashionwithalmostcompletepenetrance.Therefore,50%of
thechildrenofadiabeticparentwithMODYwilldevelopthedisease.ThereislinkagebetweenMODYand
mutationsintheglucokinasegeneontheshortarmofchromosome7.Thisabnormalityisnotpresentin
ordinarynonketoticdiabetics.Unlikethecaseininsulindependentdiabetes,noHLArelationshipshave
beenidentified.Moreover,anautoimmuneetiologyforthediseaseisnotfelttobeimportant;thisisalsoa
distinctivefeaturecomparedwithtypicaljuvenileonsetinsulindependentdiabetes
(Q.138) A35yroldfemaleduringapreoperativeworkuphadaNormalPTandincreasedaPTTof48secwithnormalcontrol2628.There
wasprevioushistoryofuneventfulcholecystectomydone2yrsback.Nextinvestigationtobefurtherevaluation?
(a)
ClottingFactor8levels
(b)
PlateletAggregationtest
(c)
Russelvipervenomtest
(d)
Ristocetincofactorassay
YourResponse:
CorrectAnswer:
Exp:
Russelvipervenomtest(RefH17th/pg.1795,622,369
Clottingfactor8isnotneededorsayitwonthelpbecausesheisfemale.factor8deficiencyoccursin
malesplusshehaduneventfullcholecystectomy2yearsbackwhichexplainssheisnothavingany
abnormalityinfactor8productionsofar.
NowthisisacaseofisolatedprolongedaPTT.
IsolatedprolongaPTTindicatesdefectsinintrinsicpathwaythesearestandardpaneloftestoneshould
performtodetectthecause
Lupusanticoagulantdetection
Measurementoffactor8,9,11,12
VWFantigenlevels
OptionnumberBandDareoutbecauseplateletaggregationtestandristocetincofactorassaywontaffect
aPTTthisaffectbleedingtime.ifthereisabnormalityinaPTTtherehastobeabnormalityinclottingtime
andnotbleedingtime.
Soweareleftwithoptionrusselviporvenomtestwhichisdoneforlupusanticoagulantandoneshoulddo
itasitisacquiredcauseofaPTTabnormality.
ANTIPHOSPHOLIPID/ANTICARDIOLIPINANTIBODYSYNDROME(APLAS)
AntiphospholipidantibodiesisIgAorIgMagainstenzymesincoagulationcascade,whichareenhancedby
plateletmembraneorphospholipids.
AntibodiesbindtophospholipidsinvitroandprolongsPTT.
ProlongationofRusselvipervenomtimeismoresensitive,itisneutralizedbyaddingplateletmembrane
(lupusanticoagulant).
Bleedingmanifestsinpresenceofthrombocytopeniahypoprothrombinaemia.
Antibodypredisposestothrombosisbymaintainingplateletsininactivatedstateorbyinhibitingfibrinolytic
activityofendothelialcells.
Antiphospholipidsyndromedevelopsinpatientsexpressingantibodiestoanionicphospholipids,
particularly2glycoprotein1.
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Halfofthepatientshavenoobviouscause,afewarepregnant,somearealreadyreceivinghemodialysisor
havearenalallograft,andtheresthaveaprimaryglomerulonephritis(nillesionormembranous
nephropathy)orarheumatologicdiseasesuchasSLE.Lupuspatientsalsooftencoexpressalupus
anticoagulant,withelevationintheactivatedpartialtissuethromboplastintime.
Clinicalpresentationofthecatastrophicformofantiphospholipidsyndromeappearsasmixedthrombosis
ofthearterialandvenouscirculationwithvaryingdegreesofthrombocytopenia,hemolyticanemia,deep
veinthrombosis,transientischemicattacks,pulmonaryembolism,andspontaneousabortions;lesser
degreesofdiseasearemorecommon.
Diagnostictest
isRusselvipervenomPTT.
Treatment
Themainstayoftreatmentforantiphospholipidsyndromeiswarfarin.Thereisalsoevidenceofvasculitisin
manypatientsduetocomplementfixingantiphospholipidantibodies,whichrespondstotheadditionof
steroids.
Acuterenalfailuresometimesrespondstoremovalofantiphospholipidantibodieswithplasmapheresis
andadjustmentofimmunosuppressionwhereclinicallyindicated.
(Q.139) Apatientwithamyelodysplasticsyndrome(subtype,refractoryanemiawithringedsideroblasts)hasbeentransfusiondependent
forthepast2years.Thepatienthasreceivedatotalof50unitsofpackedredbloodcells.Hisphysicalexaminationisnormalexcept
forhyperpigmentation.Laboratoryevaluationrevealsmildglucoseintolerance.Atrialoferythropoietinwasunsuccessful.Whichof
thefollowingwouldbethemostimportanttherapeuticapproachatthistime?
(a)
Granulocytecolonystimulatingfactor(GCSF)
(b)
Phlebotomy
(c)
Ascorbicacid
(d)
Desferrioxamine
YourResponse:
CorrectAnswer:
Exp:
Desferrioxamine
Sinceeachunitoftransfusedbloodcontains200to250mgofironandnormalironexcretionisonly1
mg/d,apatientreceivingabout40unitsofbloodannuallywillaccumulateabout8gofiron,puttinghimor
heratriskforproblemsrelatedtotransfusionalironoverload.Inadditiontotherequirementformany
transfusions,thedisordermustalsohavealongnaturalhistorytoallowforthedevelopmentoftheclinical
sequelaeofchronicironoverload.Thalassemiamajor,myeloproliferativedisorders,myelodysplastic
syndromes(withoutexcessmyeloblasts),pureredcellaplasia,andmoderatelysevereaplasticanemiaare
diseasesthatmaybeassociatedwithtransfusionalironoverload.Thespectrumofproblemsproducedby
irondepositionintissuesincludescardiacdysfunction(arrhythmias,conductiondefects,andrestrictive
cardiomyopathy),hepaticcirrhosis,glucoseintolerance,gonadaldysfunction,andhyperpigmentationdue
toincreasedmelaninproductionsecondarytodermalirondeposition.Theonlyavailabletreatmentfor
transfusionassociatedhemochromatosis(phlebotomyisnotanoptionbecauseofchronicanemia)is
chelationwithdesferrioxamine,whichmustbegivensubcutaneouslyover12to16h/dbyaportable
pump.Whileoralascorbicacidmayenhanceironexcretioninpatientsreceivingdesferrioxamine,ithasno
roleasamonotherapyandmaybeassociatedwithdangerouscardiactoxicity.
(Q.140)
A39yearsoldpatientslaboratoryreportsrevealedaplateletcountof700x109/Lwithabnormalitiesinsize,shape,andgranularity
ofplatelets.WBCcountwas12x109/L,hemoglobinof11g/dlandtheabsenceofthePhiladelphiachromosome.Themostlikely
diagnosisis:
(a)
Polycythemiavera
(b)
Essentialthrombocythemia
(c)
CML
(d)
Leukemoidreaction
YourResponse:
CorrectAnswer:
Exp:
Essentialthrombocythemia
Thenormalhemoglobinlevelsvirtuallyexcludespolycythemiavera,andnormalcytogeneticswiththe
absenceofthePhiladelphiachromosomemakesthediagnosisofchronicmyelogenousleukemiamost
unlikely.
ThetermleukemoidreactionisusedtodescribepersistentneutrophiliawithWBCcountsofmorethanor
equalto30,00050,000/microLiterthatisnotleukemicinetiology.Thecirculatingneutrophilsareusually
matureandnotclonallyderived.Itisusuallyseeninresponsetoinfection,inflammation,ortherapeutic
agentssuchasgrowthfactorsandislesscommonlycausedbymalignancy.
Thusthepatientinthisquestionhasessentialthrombocythemia.
(Q.141) AutosomalDominantgastrointestinalpolyposissyndromeis?
(a)
Turcotsyndrome
(b)
Juvenilepolyposis
(c)
Lynchsyndrome
(d)
Alloftheabove.
YourResponse:
CorrectAnswer:
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Exp:
Alloftheabove.
REFHarrison17thEdChapter87.
Hereditable(AutosomalDominant)GastrointestinalPolyposisSyndromes
Syndrome
Distributionof HistologicType Malignant AssociatedLesions

Polyps
Potential
Familial
adenomatous
polyposis
Largeintestine Adenoma
Common
None
Gardner's
syndrome
Largeandsmall Adenoma
intestines
Common
Osteomas,fibromas,lipomas,
epidermoidcysts,ampullary
cancers,congenital
hypertrophyofretinalpigment
epithelium
Turcot's
syndrome
Common
Braintumors
Nonpolyposis
syndrome(Lynch (often
syndrome)
proximal)
Common
Endometrialandovarian
tumors
PeutzJeghers
syndrome
Smallandlarge Hamartoma
intestines,
stomach
Rare
Mucocutaneouspigmentation;
tumorsoftheovary,breast,
pancreas,endometrium
Juvenile
polyposis
Largeandsmall Hamartoma,
intestines,
rarely
stomach
progressingto
adenoma
Rare
Variouscongenital
abnormalities
(Q.142) CD19positive,CD22positive,CDI03positivemonoclonalBcellswithbrightkappapositivitywerefoundtocomprise60%ofthe
peripheralbloodlymphoidcellsonflowcytometricanalysisina55yearoldmanwithmassivesplenomegalyandatotalleucocyte
countof3.3x109/1.Themostlikelydiagnosis?
(a)
Spleniclymphomawithvillouslymphocytes
(b)
Mantlecelllymphoma
(c)
Bcellprolymphocyticleukemia
(d)
Hairycellleukemia
YourResponse:
CorrectAnswer:
Exp:
Hairycellleukemia(RefRobbinsPathology7thed./683)
Presenceofmassivesplenomegaly,andgranulocytopenia,alongwithcharacteristicimmunophenotypic
features(speciallyCD103)suggeststhediagnosisofHairycellleukemia.CD103isexclusivelypositivein
Hairycellleukemiaandthusleavesnodoubtasregardsthecorrectdiagnosis.
ImmunophenotypicfeaturesofHairycellleukemia:
CDmarkers
Surfaceimmunoglobulins
PanBcellmarkers:CD19,CD20
Heavychain:IgG
Monocyticassociatedantigen:CD11c,CD25,CD103
Lightchain:or
SIg
CD5
CD10
CD11c
CD19
CD20
CD22
CD23
CD25
CD103
Hairycell
leukemia
/+
/+
++
++
/+
++
Mantlecell
lymphoma
++
/+
CLL
+/
++
/+
+/
/+
++
/+
Prolymphocytic
leukemia
++
/+
+/
+/
Splenicmarginal +
lymphoma
/+
/+
+/
/+
Lympho
plasmacytoma
/+
+/
/+
+/
+/
REMEMBER:
AQuestionisalwaysaskedonLEUKEMIASandmustbesolvedcorrectlywiththehelpofthefollowing
ALLTEXTSCOMPILEDkeytoleukemiaidentification:
CHARECTERISTICFEATURES
LEUKEMIA
CD:5,19,23,20+
CLL
LowlevelexpressionofSurfaceIgheavychainandeitherkappa/lambda
chain
CD:19,20,5,43+ve
Mantlecelllymphoma
Cd:23ve
Middleageandelderly
ModeratetohighlevelofexpressionofsurfaceIgandeitherkappa/
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lambdachains
PositiveforcyclinD1.
CD:19,20,25(IL2receptoralphachain),103andotherPanBcell
markers+ve
Hairycellleukemia
PositiveforsurfaceIgheavyghain(IgG)andeitherkappaorlambda
chains
CD:5and23ve
FMC7+ve
TARTRATERESISTANTACIDPHOSPHATASE(TRAP)
CD:19,20,10+ve
Follicularlymphoma
SurfaceIg+ve
Translocation(14;18)
BCL2proteinandBCL6+ve
Ki67fractionislowerthaninrectivefollicles
CD43+ve
Myeloperoxidaseandlysozyme+ve
Granulocyticsarcoma/
Chloroma
CD:19,20,10+ve
Burkittlymphoma
BCL6+ve
BCL2ve
MatureBcellsexpressingsurfaceIgM
Monotypickappaorlambdachain
Translocation(8;14),(2;8),(8,22)
CD:20,45+ve
DiffuselatgeBcelllymphoma
CD:5,3ve
CD:3,30,+ve
Anaplasticlargecelllymphoma
CD:15,20ve
EMAandALK+ve
TdTandCD19,10+ve
PrecursorBcellALL
Aboveplus
EarlypreBcellALL
AbsentcytoplasmicIgMheavychain
Aboveplus
LatepreBcellALL
PresentcytoplasmicIgMheavychain
TdTandCD:1,2,5,7,+ve
PrecursorTcellALL
Aboveplus
EarlypreTcellALL
CD:3,4and8allve
Aboveplus
LatepreTcellALL
CD:3,4,8all+ve
CD:15,30+ve
ClassicalHodgkinsdisease
CD:15,30ve
LymphocytepredominantHD
CD:20,45+ve
AndGerminalcentrespecifictranscriptionfactorBCL6+ve
CD13,33,34+ve
AMLM0
CD:13,33,34,15+ve
AMLM2
GlycophorinA+ve
AMLM6Erythroleukemia
CD41,CD61
AMLM7Megakaryocytic
CD11b,14+ve
AMLwithmonocytic
differentiation(M4,M5)
CD;20,79bandsmig+ve
ProlymphocyticBcellleukemia
(Q.143) A63yearoldmanpresentedwithmassivesplenomegaly,lymphadenopathyandaTLCof17000permm3.Theflowcytometry
showedCD19positive,CD5positive,CD23negative,monoclonalBcellswithbrightkappapositivelycomprising80%ofthe
peripheralbloodlymphoidcells.Themostlikelydiagnosisis:
(a)
Mantlecelllymphoma
(b)
Spleniclymphomawithvillouslymphocytes
(c)
Follicularlymphoma
(d)
Hairycellleukemia
YourResponse:
CorrectAnswer:
Exp:
Mantlecelllymphoma
Mantlecelllymphoma
Presentsinthemiddleagedandtheelderly(MeanAge=63yrs)
ClinicalprofileconsistofPainlesslymphadenopathy,Splenomegaly,andOccasionalGIinvolvement.
ImmunocytochemicalmarkersofMantleCellLymphoma
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CDmarkers
SURFACEimmunoglobulins
CellsarepositiveforPANB
markersD19,CD2,CD22,
CD24
Moderatelyhighlevelsof
t(11;14)translocation14t(11;14)
surfaceimmunoglobulinsheavy translocationleadstoincreasedexpression
chainsIgMandIgD
ofcyclinD1
CellsarepositiveforCD5
BcellspresentbrightK
positivity(eitherKorlight
chainmaybepresent)
CellsarenegativeforCD23
CellsarenegativeforCD10
Translocation
(Q.144) Achildunderwentatonsillectomyat6yearsofagewithnocomplications.Heunderwentapreoperativescreeningforbleedingat
theageof12yearsbeforeanelectivelaparotomy,andwasfoundtohaveaprolongedpartialthromboplastintimebutnormalPT
andthrombintime.Therewasnofamilyhistoryofbleeding.Thepatientislikelytohave?
(a)
AcquiredvitaminKdeficiency
(b)
Acquiredliverdisease
(c)
FactorXIIdeficiency
(d)
MildhemophiliaA
YourResponse:
CorrectAnswer:
Exp:
FactorXIIdeficiency:
AcquiredvitaminKdeficiencywillcausereducedfactor2,7,9,10andcausebothraisedPTandaPTT
SimilarlyliverdiseasealsoaffectbothPTandaPTT
Weareleftwithfactor8deficiencyorfactorXIIdeficiency
IsolatedprolongationofPTTsuggestadefectintheintrinsicpathwayofcoagulationcascadeonly,and
leavesuswiththepossibilityofeitherfactorXIIdeficiencyorHemophiliaA(FactorVIIIdeficiency).
Absenceofclinicalbleedingevenaftermajorsurgeryliketonsillectomysuggestsaclassicaldeficiencyof
contactfactorXII.
IsolatedelongationofaPTTwithbleeding
manifestations
IsolatedprolongationofaPTTwithoutbleeding
manifestations
FactorVIIIdefect
FactorXIIdefect
FactorIXdefect
Prekallikreindefect
FactorXIdefect
HMWkininogendefect
Nonbleedingdisorder/Deficiencyofthecontactfactors:
Contactfactorsfunctionatthestrepofinitiationofintrinsicpathwayoftheclottingcascadeandinclude
thefollowing:
(Q.145) ADAMTS13deficiencyorinhibitionbytheblockingantibodiesisfoundin:
(a)
IdiopathicThrombocytopenicPurpura
(b)
ThromboticThrombocytopenicPurpura
(c)
Henochschoenleiniipurpura
(d)
Glanzmannsthrombasthenia
YourResponse:
CorrectAnswer:
Exp:
ThromboticThrombocytopenicPurpura
Theetiologyofthromboticthrombocytopenicpurpura(TTP)hasbeenlinkedtoabnormalitiesofthevon
WillebrandfactorcleavingmetalloproteaseknownasADAMTS13.
SinglegeneencodesamemberoftheADAMTS(adisintegrinandmetalloproteinasewiththrombospondin
motif)proteinfamily.TheenzymeencodedbythisgeneisthevonWillebrandFactor(vWF)cleaving
protease,whichisresponsibleforcleavingatthesiteofTyr842Met843ofthevWFmolecule.Adeficiency
ofthisenzymeisassociatedwiththromboticthrombocytopenicpurpura.
Earlydiagnosisandpromptinitiationofplasmaexchangeiscriticaltotheclinicaloutcomeinpatients
diagnosedwithTTP.
(Q.146) Whichofthefollowingstatementspertainingtoleukemiaiscorrect?
(a) BlastsofacutemyeloidleukemiaaretypicallySudanblacknegative.
(b) Blastsofacutelymphoblasticleukemiaaretypicallymyeloperoxidasepositive
(c) Lowleukocytealkalinephosphatasescoreischaracteristicallyseeninblastphaseofchronicmyeloidleukemia
(d) Tartarateresistantacidphosphatase(TRAP)positivityistypicallyseeninhairycellleukemia
YourResponse:
CorrectAnswer:
Exp:
TRAPpositivityistypicallyseeninhairycellleukemia
AML(acutemyeloidleukemia):
M0 Minimallydifferentiated 23%
MPOnegative
M1 Withoutdifferentiation
20%
>/=3%blastsareMPOpositive
M2 Withmaturation
3040%
Fullrangeofmyeloidmaturation;Auerrods+;
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t(8,21)
M3 Acutepromyelocytic
510%
Hypergranularpromyelocyteswithmanyauerrods
percell,youngerpatient,highincidenceofDIC;
M4 Acutemyelomonocytic
1520%
Myelocyticandmonocyticdifferentiation,NSE+
M5 Acutemonocytic
10%
Subtypesaandb,MonoblastsMPOnegative,
NSE+,occursinolderpatients,organomegaly,
lymphadenopathy,chloromasandtissue
infiltration.
M6 Acuteerythroleukemia
5%
Dysplasticerythroidprecursorspredominate;
>30%myeloblasts,occurinadvancedage
1%
Blastsofmegakaryocyticlineagepredominate;
BlastsreactwithplateletspecificabagainstGO
IIb/IIIaorvMF;Myelofibrosisorincreased
reticulin.
t(15,17)
(Dguglimossyndrome)
M7 Acutemegakaryocytic
A.NotallblastsofAMLarepositiveforsudanblack
BBlastofALLarePASpositive
C.LeucocytealkalineisalwayslowinCMLitsnotcharactersticofblastcrisis
(Q.147) WhichofthefollowingisnotanAcutePhaseReactant?
(a)
CRP
(b)
Fibrinogen
(c)
Tissuefactor
(d)
Serumamyloidaprotein
YourResponse:
CorrectAnswer:
Exp:
Tissuefactor.(RefRobbinspathology8th/pg.74;HarpersBiochemistry26th/pg.583)
CRP,FibrinogenandSerumamyloidAproteinarethreemostimportantacutephasereactants.
Acutephaseprotein:
Alsocalledanacutephasereactant.
Anyproteinwhoseplasmaconcentrationincreases(ordecreases)by25%ormoreduringcertain
inflammatorydisorders.TheacutephaseproteinsincludeCreactiveprotein(CRP),serumamyloidA(SAA),
fibrinogen,andalpha1acidglycoprotein.
PerhapsthebestknownoftheseacutephaseproteinsisCRP,aplasmaproteinthatrisesinthebloodwith
inflammation.ThelevelofCRPinbloodplasmacanriseashighas1000foldwithinflammation.Conditions
thatcommonlyleadtomarkedchangesinCRPincludeinfection,trauma,surgery,burns,inflammatory
conditions,andadvancedcancer.Moderatechangesoccurafterstrenuousexercise,heatstroke,and
childbirth.SmallchangesinCRPoccurafterpsychologicalstressandinseveralpsychiatricillnesses.
Creactiveproteinisatestofvalue.MarkedrisesinCRPreflectthepresenceandintensityofinflammation.
AnelevationinCRP,however,isnotatelltalesignpointingtojustonedisease.
AcutePhaseReactants:
1Acidglycoproteina
AlphaMacroglobulinCRP
CeruloplasminHaptoglobin
HemopexinLipopolysaccharidebindingprotein(LBP)
1inhibitor3oralphaXprotein)aMurinoglobulin
Thiostatin
Miscellaneous
Lactoferrins:Humanandbovineholoandapolactoferrin
InfectiousDiseaseAntigens:HepatitisBcoreandHepatitisBeantigens
HumanCardiacMarkers:
TroponinI,troponinT,troponinC,myoglobinandfattyacidbindingprotein(FABP).
(Q.148) Bananashapedgametocytesareseenin?
(a)
Pl.falciparum
(b)
Pl.vivax
(c)
Pl.malariae
(d)
Pl.ovale
YourResponse:
CorrectAnswer:
Exp:
Pl.falciparum
CharacteristicsFalciparumVivaxOvaleMalariae
Accoleforms+
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Durationofintrahepaticphase(days)5.58915
Merozoites/infectedhepatocytes30,00010,00015,00015,000
Durationoferythrocytecycle48485072
RedcellpreferenceYoungercellsReticsReticsBand
MorphologyRingformsRingformsEnlargedTropozoites
BananagameEnlargedRBCsRBCs
TococytesSchuffnerdotSchuffnerdot
PigmentcolorBlackYellowDarkbrownBlack
AbilitytocauserelapseNoYesYesNo
NephroticSyndromeNoNoNoYes
Drugswhich,attackexoerythrocyticstage(hypnozoites)giventogetherwithaclinicalcurativeachievetotal
eradicationofparasitefrompatientsbody,knownasradicalcure.
Aradicalcureisneededinrelapsingmalaria(plasmodiumalemalaria),whileinFalciparummalaria,
adequatetreatmentofclinicalattackleavesnoparasiteinthebody(thereisnosecondaryexoerythrocytic
tissuephase).
(Q.149) A70yrpatientwithlongstandingtype2DMpresentswithC/Opainintheleftearwithpurulentdrainage.O/E,thepatientis
afebrile.Thepinnaoftheleftearistender,andtheexternalauditorycanalisswollenandedematous.TLCisnormal.Theorganism
mostlikelytogrowfromthepurulentdrainageis?
(a)
Staphylococcusaureus
(b)
Moraxellacatarrhalis
(c)
Haemophilusinfluenzae
(d)
Pseudomonasaeruginosa
YourResponse:
CorrectAnswer:
Exp:
Pseudomonasaeruginosa
Malignantexternalotitis
Theswellingandinflammationoftheexternalauditorymeatusstronglysuggestthisdiagnosis.This
infectionusuallyoccursinolderdiabeticsandisalmostalwayscausedbyP.aeruginosa.H.influenzaeand
M.catarrhalisfrequentlycauseotitismedia,butnotexternalotitis.
(Q.150) Symptomsofanxietyandpanicareassociatedwithalowlevelofwhichneurotransmitter?
(a)
Cortisol
(b)
Dopamine
(c)
Gammaaminobutyricacid
(d)
Glutamate
YourResponse:
CorrectAnswer:
Exp:
Gammaaminobutyricacid.
DISEASE
ASSOCIATEDCHANGEINNEUOTRANSMITTER
Sucidalbehaviour
5HIAAandserotonin
Anxiety
NE,GABA,serotonin(5HT).
Depression
NEandserotonin(5HT).
Alzheimersdementia
ACh.
Huntingtonsdisease
GABA,ACh.
Schizophrenia
dopamine.
Parkinsonsdisease
dopamine,ACh.
(Q.151) Allofthefollowingarepathologicaldefensemechanismsexcept?
(a)
Conversion
(b)
Denial
(c)
Splitting
(d)
Displacement
YourResponse:
CorrectAnswer:
Exp:
Displacement
Vaillant'scategorizationofdefencemechanisms
LevelIpathologicaldefences(i.e.psychoticdenial,delusionalprojection)
LevelIIimmaturedefences(i.e.fantasy,projection,passiveaggression,actingout)
LevelIIIneuroticdefences(i.e.intellectualization,reactionformation,dissociation,displacement,
repression)
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LevelIVmaturedefences(i.e.humour,sublimation,suppression,altruism,anticipation)
Level1:Pathological
Themechanismsonthislevel,whenpredominating,almostalwaysareseverelypathological.Thesesix
defences,inconjunction,permitonetoeffectivelyrearrangeexternalexperiencestoeliminatetheneedto
copewithreality.Thepathologicalusersofthesemechanismsfrequentlyappearirrationalorinsaneto
others.Thesearethe"psychotic"defences,commoninovertpsychosis.However,theyarefound
indreamsandthroughoutchildhoodaswell.
Theyinclude:
DelusionalProjection:Delusionsaboutexternalreality,usuallyofapersecutorynature.
Conversion:Theexpressionofanintrapsychicconflictasaphysicalsymptom;someexamplesinclude
blindness,deafness,paralysis,ornumbness.Thisphenomenaissometimescalledhysteria.
Denial:Refusaltoacceptexternalrealitybecauseitistoothreatening;arguingagainstananxiety
provokingstimulusbystatingitdoesn'texist;resolutionofemotionalconflictandreductionofanxietyby
refusingtoperceiveorconsciouslyacknowledgethemoreunpleasantaspectsofexternalreality.
Distortion:Agrossreshapingofexternalrealitytomeetinternalneeds.
Splitting:Aprimitivedefence.Negativeandpositiveimpulsesaresplitoffandunintegrated.
Extremeprojection:Theblatantdenialofamoralorpsychologicaldeficiency,whichisperceivedasa
deficiencyinanotherindividualorgroup.
SuperiorityComplex:Apsychologicaldefencemechanisminwhichaperson'sfeelingsofsuperiority
counterorconcealhisorherfeelingsofinferiority.
InferiorityComplex:Abehaviourthatisdisplayedthroughalackofselfworth,anincreaseofdoubtand
uncertainty,andfeelingofnotmeasuringuptosociety'sstandards.
Level2:Immature
Thesemechanismsareoftenpresentinadults.Thesemechanismslessendistressandanxietyprovokedby
threateningpeopleorbyuncomfortablereality.Excessiveuseofsuchdefencesisseenassocially
undesirableinthattheyareimmature,difficulttodealwithandseriouslyoutoftouchwithreality.These
arethesocalled"immature"defencesandoverusealmostalwaysleadstoseriousproblemsinaperson's
abilitytocopeeffectively.Thesedefencesareoftenseeninmajordepressionandpersonalitydisorders.
Theyinclude:
Actingout:Directexpressionofanunconsciouswishorimpulseinaction,withoutconsciousawarenessof
theemotionthatdrivesthatexpressivebehaviour.
Fantasy:Tendencytoretreatintofantasyinordertoresolveinnerandouterconflicts.
Wishfulthinking:Makingdecisionsaccordingtowhatmightbepleasingtoimagineinsteadofbyappealing
toevidence,rationality,orreality
Idealization:Unconsciouslychoosingtoperceiveanotherindividualashavingmorepositivequalitiesthan
heorshemayactuallyhave.[19]
Passiveaggression:Aggressiontowardsothersexpressedindirectlyorpassivelysuchas
usingprocrastination.
Projection:Projectionisaprimitiveformofparanoia.Projectionalsoreducesanxietybyallowingthe
expressionoftheundesirableimpulsesordesireswithoutbecomingconsciouslyawareofthem;attributing
one'sownunacknowledgedunacceptable/unwantedthoughtsandemotionstoanother;includes
severeprejudice,severejealousy,hypervigilancetoexternaldanger,and"injusticecollecting".Itisshifting
one'sunacceptablethoughts,feelingsandimpulseswithinoneselfontosomeoneelse,suchthatthose
samethoughts,feelings,beliefsandmotivationsareperceivedasbeingpossessedbytheother.
Projectiveidentification:Theobjectofprojectioninvokesinthatpersonpreciselythethoughts,feelingsor
behavioursprojected.
Somatization:Thetransformationofnegativefeelingstowardsothersintonegativefeelingstowardself,
pain,illness,andanxiety.
Level3:Neurotic
Thesemechanismsareconsideredneurotic,butfairlycommoninadults.Suchdefenceshaveshortterm
advantagesincoping,butcanoftencauselongtermproblemsinrelationships,workandinenjoyinglife
whenusedasone'sprimarystyleofcopingwiththeworld.
Theyinclude:
Displacement:Defencemechanismthatshiftssexualoraggressiveimpulsestoamoreacceptableorless
threateningtarget;redirectingemotiontoasaferoutlet;separationofemotionfromitsrealobjectand
redirectionoftheintenseemotiontowardsomeoneorsomethingthatislessoffensiveorthreateningin
ordertoavoiddealingdirectlywithwhatisfrighteningorthreatening.Forexample,amothermayyellat
herchildbecausesheisangrywithherhusband.
Dissociation:Temporarydrasticmodificationofone'spersonalidentityorcharactertoavoidemotional
distress;separationorpostponementofafeelingthatnormallywouldaccompanyasituationorthought.
Hypochondriasis:Anexcessivepreoccupationorworryabouthavingaseriousillness.
Intellectualization:Aformofisolation;concentratingontheintellectualcomponentsofasituationsoasto
distanceoneselffromtheassociatedanxietyprovokingemotions;separationofemotionfromideas;
thinkingaboutwishesinformal,affectivelyblandtermsandnotactingonthem;avoidingunacceptable
emotionsbyfocusingontheintellectualaspects
(e.g.isolation,rationalization,ritual,undoing,compensation,magicalthinking).
Isolation:Separationoffeelingsfromideasandevents,forexample,describingamurderwithgraphic
detailswithnoemotionalresponse.
Rationalization(makingexcuses):Whereapersonconvinceshimorherselfthatnowrongwasdoneand
thatallisorwasallrightthroughfaultyandfalsereasoning.Anindicatorofthisdefencemechanismcanbe
seensociallyastheformulationofconvenientexcusesmakingexcuses.
Reactionformation:Convertingunconsciouswishesorimpulsesthatareperceivedtobedangerousor
unacceptableintotheiropposites;behaviourthatiscompletelytheoppositeofwhatonereallywantsor
feels;takingtheoppositebeliefbecausethetruebeliefcausesanxiety.Thisdefencecanworkeffectively
forcopingintheshortterm,butwilleventuallybreakdown.
Regression:Temporaryreversionoftheegotoanearlierstageofdevelopmentratherthanhandling
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unacceptableimpulsesinamoreadultway.(ex.Usingwhiningasamethodofcommunicatingdespite
alreadyhavingacquiredtheabilitytospeakwithappropriategrammar)
Repression:Theprocessofattemptingtorepeldesirestowardspleasurableinstincts,causedbyathreatof
sufferingifthedesireissatisfied;thedesireismovedtotheunconsciousintheattempttopreventitfrom
enteringconsciousnessseeminglyunexplainablenaivety,memorylapseorlackofawarenessofone'sown
situationandcondition;theemotionisconscious,buttheideabehinditisabsent.[citationneeded]
Undoing:Apersontriesto'undo'anunhealthy,destructiveorotherwisethreateningthoughtbyactingout
thereverseofunacceptable.Involvessymbolicallynullifyinganunacceptableorguiltprovokingthought,
idea,orfeelingbyconfessionoratonement.
Withdrawal:Withdrawalisamoresevereformofdefence.Itentailsremovingoneselffromevents,stimuli,
interactions,etc.underthefearofbeingremindedofpainfulthoughtsandfeelings.
Upwardanddownwardsocialcomparisons:Adefensivetendencythatpeopleuseasameansofself
evaluation.Theseindividualswilllooktoanotherindividualorcomparisongroupwhoareconsideredtobe
worseoffinordertodissociatethemselvesfromperceivedsimilaritiesandtomakethemselvesfeelbetter
abouttheirselforpersonalsituation.
Level4:Mature
Thesearecommonlyfoundamongemotionallyhealthyadultsandareconsideredmature,eventhough
manyhavetheiroriginsinanimmaturestageofdevelopment.Theyhavebeenadaptedthroughtheyears
inordertooptimisesuccessinhumansocietyandrelationships.Theuseofthesedefencesenhances
pleasureandfeelingsofcontrol.Thesedefenceshelpustointegrateconflictingemotionsandthoughts,
whilststillremainingeffective.Thosewhousethesemechanismsareusuallyconsideredvirtuous.
Theyinclude:
Humility:Aqualitybywhichapersonconsideringhisowndefects,hasahumbleopinionofhimself.
Humilityisintelligentselfrespectwhichkeepsusfromthinkingtoohighlyortoomeanlyofourselves.
Mindfulness:Adoptingaparticularorientationtowardonesexperiencesinthepresentmoment,an
orientationthatischaracterisedbycuriosity,openness,andacceptance.
Acceptance:Aperson'sassenttotherealityofasituation,recognizingaprocessorcondition(oftena
negativeoruncomfortablesituation)withoutattemptingtochangeit,protest,orexit.Religionsand
psychologicaltreatmentsoftensuggestthepathofacceptancewhenasituationisbothdislikedand
unchangeable,orwhenchangemaybepossibleonlyatgreatcostorrisk.
Gratitude:Afeelingofthankfulnessorappreciation,involvesappreciationofawiderrangeofpeopleand
events.Peoplewhofeelmoregratitudearemuchmorelikelytohavehigherlevelsofhappiness,andlower
levelsofdepressionandstress.Throughouthistory,gratitudehasbeengivenacentralpositioninreligious
andphilosophicaltheories.
Altruism:Constructiveservicetoothersthatbringspleasureandpersonalsatisfaction.
Tolerance:Thepracticeofdeliberatelyallowingorpermittingathingofwhichonedisapproves.
Mercy:Compassionatebehavioronthepartofthoseinpower.
Forgiveness:Cessationofresentment,indignationorangerasaresultofaperceivedoffence,
disagreement,ormistake,orceasingtodemandpunishmentorrestitution.
Anticipation:Realisticplanningforfuturediscomfort.
Humour:Overtexpressionofideasandfeelings(especiallythosethatareunpleasanttofocusonortoo
terribletotalkabout)thatgivespleasuretoothers.Thethoughtsretainaportionoftheirinnatedistress,
buttheyare"skirtedround"bywitticism,forexampleSelfdeprecation.
Identification:Theunconsciousmodellingofone'sselfuponanotherperson'scharacterandbehaviour.
Introjection:Identifyingwithsomeideaorobjectsodeeplythatitbecomesapartofthatperson.
Sublimation:Transformationofnegativeemotionsorinstinctsintopositiveactions,behaviour,oremotion
(e.g.,playingaheavycontactsportsuchasfootballorrugbycantransformaggressionintoagame).
Thoughtsuppression:Theconsciousprocessofpushingthoughtsintothepreconscious;theconscious
decisiontodelaypayingattentiontoanemotionorneedinordertocopewiththepresentreality;making
itpossibletolateraccessuncomfortableordistressingemotionswhilstacceptingthem.
Emotionalselfregulation:Theabilitytorespondtotheongoingdemandsofexperiencewiththerangeof
emotionsinamannerthatissociallytolerable
(Q.152) Anadolescentboyissuspectedtobesufferingfromalcoholabuse.Whichofthemetabolitedetectedinhisurinewillhelpconfirm
thesuspicion?
(a)
Acetaldehyde
(b)
Cocaine
(c)
Formaldehyde
(d)
Acetaminophen
YourResponse:
CorrectAnswer:
Exp:
Acetaldehyde
UrineScreeningforDrugsCommonlyAbusedbyAdolescents
DRUG
MAJORMETABOLITE
APPROXIMATERETENTIONTIME
Alcohol(blood)
Acetaldehyde
710hr
Alcohol(urine)
Acetaldehyde
1013hr
Amphetamines
48hr
Barbiturates
Shortacting(24hr);longacting(23wk)
Benzodiazepines
Cannabinoids
3days
Carboxyand
310days(occasionaluser);12mo(chronicuser)
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hydroxymetabolites
Cocaine
Benzoylecgonine
24days
Methaqualone
Hydroxylatedmetabolites
2wk
Morphine
2days
Opiates
Heroin
Glucuronide
Morphine
Morphine
2days
Glucuronide
Codeine
Morphine
2days
Glucuronide
Phencyclidine
8days
ModifiedfromDrugsofabuseurinescreening[Physicianinformationsheet].LosAngeles,Pacific
Toxicology.FromMacKenzieRG,KipkeMD:Substanceuseandabuse.InFriedmanSB,FisherM,Schonberg
SK(editors):ComprehensiveAdolescentHealthCare.St.Louis,QualityMedicalPublishing,1992,p783.
(Q.153) Falseaboutbulimianervosais?
(a)
Onsetinearlyadulthood
(b)
Commoninmales
(c)
Weightisnormal
(d)
Mortalityislow
YourResponse:
CorrectAnswer:
Exp:
Commoninmales
CommonCharacteristicsofAnorexiaNervosaandBulimiaNervosa
AnorexiaNervosaa
BulimiaNervosa
Onset
Midadolescence
Lateadolescence/early
adulthood
Female:male
10:1
10:1
Lifetimeprevalencein
women
1%
13%
Weight
Markedlydecreased
Usuallynormal
Menstruation
Absent
Usuallynormal
Bingeeating
2550%
Requiredfordiagnosis
Mortality
5%perdecade
Low
ClinicalCharacteristics
PhysicalandLaboratoryFindingsa
Skin/extremities
Lanugo
Acrocyanosis
Edema
Cardiovascular
Bradycardia
Hypotension
Gastrointestinal
Salivaryglandenlargement
Salivaryglandenlargement
Slowgastricemptying
Dentalerosion
Constipation
Elevatedliverenzymes
Hematopoietic
Normochromic,normocyctic
anemia
Leukopenia
Fluid/Electrolyte
IncreasedBUN,creatinine
Hypokalemia
Hypokalemia
Hypochloremia
Alkalosis
Endocrine
Hypoglycemia
Lowestrogenor
testosterone
LowLHandFSH
Lownormalthyroxine
NormalTSH
Increasedcortisol
Bone
Osteopenia
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(Q.154) An8yroldboypresentedwithwelldefinedannularlesionoverthebuttockwithcentralscaringthatisgraduallyprogressiveover
thelast8months.Whatisthediagnosis?
(a)
Annularpsoriasis
(b)
Lupusvulgaris
(c)
Tineacorporis
(d)
Chronicgranulomatousdisease
YourResponse:
CorrectAnswer:
Exp:
LupusVulgaris(Ref.Rookstextbook7th/28.1030)
Annularpsoriasis:looselyadherentsilveryscales.Noscarring.
Tinea:itchingisveryimportant.
Lupusvulgaris:lesionsconsistoferythematous,induratedplaquewhichmayulcerate.Healingwithscar
formationinsomeareasandprogressionoflesioninotherdirectionisquitefrequent.Longdurationisalso
afavorablepoint.
(Q.155) Ayoungboypresentedwithalesionoverhisrightbuttock,whichhadperipheralscalingwithcentralscarring.Theinvestigationof
choicewouldbe?
(a)
Tzancksmear
(b)
KOHpreparation
(c)
Biopsy
(d)
Sabouraudsagar
YourResponse:
CorrectAnswer:
Exp:
Biopsy(Ref.Rookstextbook7th/28.1030)
Centralclearing:T.CorporisKOHsmear
Centralscaring:LupusvulgarisBiopsy(scarisvulgardobiopsy
Centralcrusting:LeishmaniasisLTbodydemonstration(crispycrustofleishmanianeedsLTbody
demonstration)
(Q.156) TrueaboutScrofuloderma:
(a)
ChronicinfectionbyStaphylococcusepidermidis
(b)
Tubercularsinuswithdischarge
(c)
Ruptureofalymphnodewithinvolvementofskin
(d)
Lesioninlupusvulgaris
YourResponse:
CorrectAnswer:
Exp:
Ruptureofalymphnodewithinvolvementofskin
Lymphnodetuberculosispresentsaspainlessswellingofthelymphnodes,mostcommonlyatcervicaland
supraclavicularsites,aconditionoftenreferredtoasscrofula.
SCROFULODERMA
Itresultsfromenlargement,coldabscessformation,andbreakdownofalymphnode,mostfrequentlyina
cervicalchain,withextensiontotheoverlyingskin.
Linearorserpiginousulcersanddissectingfistulasandsubcutaneoustractsstuddedwithsoftnodulesmay
develop.
Spontaneoushealingmaytakeyears,eventuatingincordlikekeloidscars;lupusvulgarismayalsodevelop.
Scrofulodermaofacervicallymphnodeoftenoriginatesinthelarynxandwaslinkedinthepastto
ingestionofmilkcontainingM.bovis.
Lesionsmayalsooriginatefromanunderlyinginfectedjoint,tendon,bone,orepididymis.
Thedifferentialdiagnosisincludessyphiliticgumma,deepfungalinfections,actinomycosis,and
hidradenitissuppurativa.
Thecourseisindolent,andconstitutionalsymptomsaretypicallyabsent.
Antituberculoustherapyisusuallyeffective.
(Q.157) A62yearoldfarmerpresentedwithawartyplaqueonthesoleoftherightfootsinceayear.Examinationrevealedalarge,warty,
hyperpigmentedplaqueonthesoleoftheinvolvedfoot.Whatistheprobablediagnosis?
(a)
Tuberculosisverrucosacutis
(b)
Verrucavulgaris
(c)
Mycetomafoot
(d)
Lichensimplexhypertrophicus
YourResponse:
CorrectAnswer:
Exp:
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(Ref.IADVLTextbookofDermatology3rd/pg.244;Robbins8th/pg.1200)
iscausedbyexogenousinoculationoftuberclebacilliintotheskinofindividualswithapreexisting
moderatelyhighdegreeofimmunitytotheorganism.
Intropicalclimates,tuberculosisverrucosacutisisgenerallyadiseaseaffectingchildrenoryoungadults
whocontractthebacteriabywalkingbarefootorawartyplaqueonthesoleofthefootsittingonground
contaminatedwithtuberculoussputum.
Insuchcases,lesionsdeveloponthesolesofthefeet,asinourcase,oronthebuttocks.
Achronicallypresentlarge,warty,hyperpigmentedplaqueispresentonthesoleofthefootissuggestive
ofTuberculosisverrucosacutis.
Skinhistopathologyshowsthedermalinflammation,whichincludesanepithelioidcellgranulomawitha
centralmultinucleatedLangerhansgiantcell.
Caseationnecrosisisnotpresentinthisgranuloma.
(Q.158) Falseabouttuberculoidformofleprosy?
(a) ResistancetoM.lepraeispoor,largenumbersoforganismsarepresentandskinlesionsareextensive.
(b) Pregnancyisarecognizedprecipitatingfactorduetoarelativelyreducedimmunity.
(c) SatellitepapulesareoftenfoundadjacenttothemainplaquesinBT.
(d) Lossofsensationinskinlesionsistheruleandregionalnerveinvolvementwithenlargementandpalsiesiscommon.
YourResponse:
CorrectAnswer:
Exp:
ResistancetoM.lepraeispoor,largenumbersoforganismsarepresentandskinlesionsareextensive
Tuberculoidformsofleprosy
Intuberculoidformsofleprosy,resistancetoM.lepraeishigh,smallnumbersoforganismsarepresent
andskinlesionsarefew,Histopathologyofaskinbiopsyrevealsgranulomatousinflammation,often
showingneurotropism.
Pregnancyisarecognizedprecipitatingfactorforleprosyduetoarelativelyreducedimmunity.Inthepost
partumperiodtypeIreactions(characterizedbysuddenenhancedinflammationofskinlesionsand
neuritis)canoccurwhennormalimmunefunctionisrestored.
Inborderlinetuberculoidleprosysatellitepapulesareoftenfoundadjacenttothemainplaques.
JustgothroughthefollowingtablefromHARRISON17thEdchapter152
Clinical,Bacteriologic,Pathologic,andImmunologicSpectrumofLeprosy
Feature
Tuberculoid(TT,BT)
Leprosy
Borderline(BB,BL)Leprosy Lepromatous(LL)Leprosy
Skinlesions
Oneorafewsharply
IntermediatebetweenBT
definedannular
andLLtypelesions;ill
asymmetricmaculesor definedplaqueswithan
plaqueswithatendency occasionalsharpmargin;
towardcentralclearing, fewormanyinnumber
elevatedborders
Nervelesions
Skinlesionsanesthetic Hypestheticoranesthetic Hypesthesiaalatesign;nerve

early;nervenearlesions skinlesions;nervetrunk
palsiesvariable;acral,distal,
sometimesenlarged;
palsies,attimessymmetric symmetricanesthesiacommon
nerveabscessesmost
commoninBT
Acidfastbacilli
(BIa)
01+
35+
46+
Lymphocytes
2+
1+
01+
Macrophage
differentiation
Epithelioid
EpithelioidinBB;usually
undifferentiated,butmay
havefoamychangesinBL
Foamychangetherule;maybe
undifferentiatedinearlylesions
Langhans'giant
cells
13+
Leprominskin
test
+++
Lymphocyte
transformation
test
Generallypositive
110%
12%
CD4+/CD8+Tcell 1.2
ratioinlesions
BB(NT);BL:0.48
0.50
M.lepraePGL1 60%
antibodies
85%
95%
Symmetric,poorlymarginated,
multipleinfiltratednodulesand
plaquesordiffuseinfiltration;
xanthomalikeor
dermatofibromapapules;leonine
faciesandeyebrowalopecia
(Q.159) Altemeiersprocedureisfor:
(a)
Solitaryrectalulcer
(b)
Rectalprolapse
(c)
Rectalstricture
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(d)
Rectalcarcinoma
YourResponse:
CorrectAnswer:
Exp:
Rectalprolapse.(Ref.LB25thpg.1225)
RECTALPROPLASE
Itmaybemucosalorfullthickness(wholewallincluded).
Commencesasrectalintussusception.
Inchildren,theprolapseisusuallymucosalanshouldbeRxedconservatively.
Intheadults,theprolapseisoftenfullthicknessandisfrequentlyasociatedwithincontinence.
Surgeryisnecessaryforfullthicknessreactlaprolpase.
Theoperationisperformedeitherviaperineum(Thierschoperation,Delormesoperation,&/orAltemeier
opeartion)orviatheabdomen(Wellsoperation,Ripsteinsoperation,orlaparosocpicapproach).
TreatmentofRECTALPROPLASE:
Surgeryisrequired,andtheoperationcanbeperformedviatheperinealortheabdominalapproaches.An
abdominalrectopexyhasalowerrateofrecurrencebut,whenthepatientiselderlyandveryfrail,a
perinealoperationisindicated.Asanabdominalprocedurerisksdamagetothepelvicautonomicnerves,
resultinginpossiblesexualdysfunction,aperinealapproachisalsousuallypreferredinyoungmen.
LISTOFIMPORTANTNAMEDOPERATIONSINGENERALSURGERY:
NAME
USEDFOR
Swensonsoperation,Duhamelsoperation,Soave
operation
Hirschsprungdisease
Nissenstotalfundoplication,Toupetspartial
fundoplication,Hillsprocedure,BelseymarkIV
operation,Angelchickprosthesis
GERD
Dohlmansoperation
Zenkersdiverticulum
Delormesprocedure
Perinealrepairofadultrectalprolapse
AndersonHynesdismemberedpyeloplasty
Cong.PUJobstruction
Nesbittsoperation
Peyroniesdiseaseofpenis
Jaboulaysoperation
Smallandmediumsizedhydrocele
Lordsoperation
Largehydrocele
Hadfieldsoperation
Periductalmastitis/Ductectasia
Trendelenbergoperation
GSVvaricosity
CokketsandDoddsoperation
Subfascialligationofvaricosities
Ivorlewisoperation,Mckeown3stage
operation,Orringerstranshiatalesophagectomy
CaEsophagus
FredetRamstedoperation
CHPS
Thierschoperation,Lockheartmummeryrectopexy
Childhoodrectalprolapse
Thierschoperation,Delormesoperation,Altemiers
operation
AdultrectalprolapsePerinealapproaches
Ripsteinsoperation,Wellsoperation,Lahauts
operation
AdultrectalprolapseAbdominalapproaches
Milesoperation/APR
CaLowerrectum
Hartmannsprocedure
Leftcacolon
Burrhennetechnique
RemovalofresidualstoneinCBD
Grahamsrepair
Perforatedduodenalulcer
Kockspouch
Chroniculcerativecolitis
Puestowsprocedure
Drainageprocedureforchronicpancreatitiswithduct
dilataion
Thomsonsprocedure,LeMuserier
operation,TennissonRandelloperation,Millers
rotationadvancementtechnique
Cleftlip
Allisonsrepair
Hiatushernia
Commandosoperation
CaTongue
Kraskeprocedure
Carectum(postproctotomysphinctersparing)
MiliganMorganoperation
Hemorrhoidectomy
Mayosoperation
Umbilicalhernia
Psoashitchoperation
Uretericreconstruction
Nesovicsoperation
Sportshernia
Cheatlehenryoperation
Obturatrhernia
Sebrocksoperation
Parotidductfistula
Bentallsoperation
Aorticrootaneurysmrepair
Hellerdorsoperation
Achalasiacardia
Laddsprocedure
Midgutvolvulus
LockwoodsoperationLowrepair
Femoralhernia
McEvedyoperationHighrepaiwithvertical
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incision
LotheissenoperationOpeninguinalcanal
Rovsingsoperation
Polcystickidneydis
Brunschwingsoperation
Pelvicexenterationincarectum
A.Perinealapproach
Theseprocedureshavebeenusedmostcommonly.
Thierschoperation
Thisprocedure,whichaimedtoplaceasteelwireor,morecommonly,aSilasticornylonsuturearoundthe
analcanal,hasbecomeobsolete.Thereasonsforitslackofpopularitywerethatthesuturewouldoften
breakorcausechronicperinealsepsis,orboth,ortheanalstenosissocreatedwouldproducesevere
functionalproblems.Delormesoperationisnowthepreferredperinealoperation.
Delormesoperation
Inthisprocedure,therectalmucosaisremovedcircumferentiallyfromtheprolapsedrectumoverits
length.Theunderlyingmuscleisthenplicatedwithaseriesofsutures,suchthat,whenthesearetied,the
rectalmuscleisconcertinaedtowardstheanalcanal.Theanalcanalmucosaisthensutured
circumferentiallytotherectalmucosaremainingatthetipoftheprolapse.Theprolapseisreduced,anda
ringofmuscleiscreatedabovetheanalcanal,whichpreventsrecurrence.
Altemeiersprocedure
Thisconsistsofexcisionoftheprolapsedrectumandassociatedsigmoidcolonfrombelow,and
constructionofacoloanalanastomosis.
(Q.160) Apatientwithleukemiaonchemotherapydevelopsacuterightlowerabdominalpainassociatedwithanemia,thrombocytopenia
andleukopeniA.Whichofthefollowingistheclinicaldiagnosis?
(a)
Appendicitis
(b)
Leukemiccolitis
(c)
Perforationperitonitis
(d)
Neutropeniccolitis
YourResponse:
CorrectAnswer:
Exp:
Neutropeniccolitis
Neutropeniccolitis(ileocecalsyndrome/typhlitis)
InGreektyphlos=blindsac=caecum
Acuteinflammationofcaecum,appendix,andoccasionallyterminalileum,mainlydescribedinchildren
withleukemiaandsevereneutropenia.
Predisposingfactors:
a.Childhoodleukemiab.Aplasticanemiac.Lymphoma
d.Immunosuppressivetherapye.Cyclicneutropeniaf.Myelodysplasticsyndromeg.
AIDS
Organismsresponsible:
a.CMVb.Pseudomonasc.Candidad.Klebsiellae.E.colif.B.fragilis
g.Enterobacter
Complications:perforationandabscessformation
(Q.161) A32yearoldadulthadabdominalinjuryfollowingavehicularinjury.Radiologicalinvestigationsrevealedsevereinjuryto
duodenum,theadjacentpancreaticheadandtheterminalbiliarytractinjury.Whichofthefollowingshallbethecorrectsurgical
approachformanagementofthispatient?
(a)
RouxenYsurgery
(b)
PrimaryDuodenoduodenostomy
(c)
SurgicalRepairofbileductanddamagedpartofduodenum
(d)
Pancreaticoduodenectomy
YourResponse:
CorrectAnswer:
Exp:
Pancreaticoduodenectomy
INTHISPATIENT,thepancreaticduodenalcomplexisseverelydisrupted(gradeVpancreaticinjury),hence
weshouldconsiderpancreaticoduodenectomyi.e.Whipplesoperationforthetreatment
ClassofPancreaticInjuryTreatment
IMinorcontusionsandlacerationsExternaldrainage
IIMajorcontusionsandlacerations(MPDintact)Externaldrainage
Distalpancreatectomy
IIIDistaltransectionormajorductinjuryDistalpancreatectomy(considerspleenpreservation)
IVProximalinjurywithmajorductinjuryExtendeddistalpancreatectomy
VMassivedisruptionofpancreaticheadResect(ordrain)pancreasexcludeduodenum;
pancreaticduodenal
complexconsiderpancreaticoduodenectomy.
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(Q.162) Whichofthefollowingcolonicpathologiesisthoughttohavenomalignantpotential?
(a)
Ulcerativecolitis
(b)
Villousadenomas
(c)
Familialpolyposis
(d)
PeutzJegherssyndrome
YourResponse:
CorrectAnswer:
Exp:
PeutzJegherssyndrome
Cancerofthecolon
Inpatientswithchroniculcerativecolitisis10timesmorefrequentthaninthegeneralpopulation.
Thechanceofdevelopmentofcarcinomaofthecoloninpatientswithfamilialpolyposisisessentially
100%.Treatmentofthepatientwithfamilialpolyposisgenerallyconsistsofsubtotalcolectomywith
ileoproctostomyandregularproctoscopicexaminationoftherectalstump.Villousadenomashavebeen
demonstratedtocontainmalignantportionsinaboutonethirdofaffectedpersonsandinvasive
malignancyinanotheronethirdofremovedspecimens.
PeutzJegherssyndromeischaracterizedbyintestinalpolyposisandmelaninspotsoftheoralmucosa.
Unliketheadenomatouspolypsseeninfamilialpolyposis,thelesionsinthisconditionarehamartomas,
whichhavenomalignantpotential.
(Q.163) A70yearoldwomanhasnausea,vomiting,abdominaldistention,andepisodic,crampymidabdominalpain.Shehasnohistoryof
previoussurgerybuthasalonghistoryofcholelithiasisforwhichshehasrefusedsurgery.Herabdominalradiographrevealsa
sphericaldensityintherightlowerquadrant.Correcttreatmentshouldconsistof?
(a)
Ileocolectomy
(b)
Cholecystectomy
(c)
Ileotomyandextraction
(d)
Nasogastrictubedecompression
YourResponse:
CorrectAnswer:
Exp:
Ileotomyandextraction
Gallstoneileusisduetoerosionofastonefromthegallbladderintothegastrointestinaltract(most
commonlyintotheduodenum).Thestonebecomeslodgedinthesmallbowel(usuallyintheterminal
ileum)andcausessmallbowelobstruction.Plainfilmsoftheabdomenthatdemonstratesmallbowel
obstructionandairinthebiliarytractarediagnosticofthecondition.
Treatmentconsistsofileotomy,removalofthestone,andcholecystectomyifitistechnicallysafe.Ifthere
issignificantinflammationoftherightupperquadrant,ileotomyforstoneextractionfollowedbyan
intervalcholecystectomyisoftenasaferalternative.Operatingonthebiliaryfistuladoublesthemortality
ratecomparedwithsimpleremovalofthegallstonefromtheintestine.
(Q.164) Whichofthefollowingisaproinflammatorymediatorofshock:
(a)
Interleukin4
(b)
Interleukin6
(c)
Interleukin10
(d)
Interleukin13
YourResponse:
CorrectAnswer:
Exp:
Interleukin6
ProinflammatoryAntiinflammatory
IL1/IL4
IL2IL10
IL6IL13
IL8ILIra
IFNPGE2
TNFTGF
PAF
Bacterialexotoxinsandendotoxinsbothstimulateproinflammatorymediatorsbutthecontributionofeach
individualtoxininthereleaseofmediatorscausinglethalshockisincompletelyunderstood.
staphylococcalenterotoxinB(SEB)orlipopolysaccharide(LPS)leadtotheshock.
SEBaloneinducedmoderatelevelsofIL2andMCP1
LPSinduceshighlevelsofIL6andMCP1.
Bacterialexotoxinsandendotoxinsareamongthemostcommonetiologicalagentsthatcausesepticshock
.
StaphylococcalenterotoxinB(SEB)andstructurallyrelatedexotoxinsarebacterialsuperantigensthat
potentlyactivateantigenpresentingcellsbybindingdirectlytomajorhistocompatibilitycomplex(MHC)
classIImolecules.
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TheseexotoxinsalsointeractwithspecificVregionsoftheTcellantigenreceptorsresultinginpolyclonal
Tcellactivation.
InteractionsofsuperantigenswithantigenpresentingcellsandTcellsleadtomassiveproinflammatory
cytokineandchemokinerelease,causingclinicalsymptomsthatincludefever,hypotension,andshock.
Incontrast,lipopolysaccharide(LPS)fromgramnegativebacteriabindstoadifferentreceptoron
monocytes/macrophages.
AnLPSbindingproteininserumfirstbindstoLPSandfacilitatesitsbindingtocellsurfaceproteinCD14on
monocytes/macrophagesandothercells.
ThesubsequentinteractionofLPS/CD14complexwithTolllikereceptor4onthesecellsinitiates
recruitmentofintracellularadaptorsanddownstreamsignalingpathwaysactivatingNFBandresultsin
hyperproductionofproinflammatorycytokinesandchemokines.
REF.SCHWARTZSURGERY8THEDNCHP3PG46
(Q.165) Thetreatmentofhydrofluoricacidskinburnis:
(a)
Injectionofsodiumbicarbonate
(b)
Irrigationwithsodiumbicarbonate
(c)
Applicationofcalciumcarbonategel
(d)
Localwoundcareonly
YourResponse:
CorrectAnswer:
Exp:
Applicationofcalciumcarbonategel
REF.BAILEYANDLOVE25THEDNPG372
1.Theinitialtreatmentaftercontactwiththeskiniscopiousirrigation,whichmustbecontinuedforat
least1530min.witheitherwaterornormalsaline.
2.Thesecondaspectoftreatmentaimstoinactivatethefreefluorideionbypromotingtheformationof
aninsolublefluoridesalt.
3.Topicalcalciumcarbonategelhasbeenshowntodetoxifythefluorideionandrelievepain.
4.Thetreatmentinvolvesmassageofa2.5%calciumcarbonategelintotheareaofexposureforatleast30
min.
(Q.166) AllofthefollowingareTissuespecificendpointsofResuscitationexcept?
(a)
Gastrictonometry
(b)
CO2level
(c)
Nearinfraredspectroscopy
(d)
Cardiacoutput
YourResponse:
CorrectAnswer:
Exp:
Cardiacoutput
RefSchwartz8thEdChapter4
EndpointsinResuscitation
Shockisdefinedasinadequateperfusiontomaintainnormalorganfunction.Withprolongedanaerobic
metabolism,tissueacidosisandoxygendebtaccumulate.Thusthegoalinthetreatmentofshockis
restorationofadequateorganperfusionandtissueoxygenation.Resuscitationiscompletewhenoxygen
debtisrepaid,tissueacidosisiscorrected,andaerobicmetabolismrestored.Clinicalconfirmationofthis
endpointremainsachallenge.
Resuscitationofthepatientinshockrequiressimultaneousevaluationandtreatment;theetiologyofthe
shockoftenisnotinitiallyapparent.Hemorrhagicshock,septicshock,andtraumaticshockarethemost
commontypesofshockencounteredonsurgicalservices.Tooptimizeoutcomeinbleedingpatients,early
controlofthehemorrhageandadequatevolumeresuscitation,includingbothredbloodcellsand
crystalloidsolutions,arenecessary.Expedientoperativeresuscitationismandatorytolimitthemagnitude
ofactivationofmultiplemediatorsystemsandtoabortthemicrocirculatorychanges,whichmayevolve
insidiouslyintothecascadethatendsinirreversiblehemorrhagicshock.Attemptstostabilizeanactively
bleedingpatientanywherebutintheoperatingroomareinappropriate.Anyinterventionthatdelaysthe
patient'sarrivalintheoperatingroomforcontrolofhemorrhageincreasesmortalitythustheimportant
conceptofoperatingroomresuscitationofthecriticallyinjuredpatient.
Recognitionbycareprovidersofthepatientwhoisinthecompensatedphaseofshockisequally
important,butmoredifficultbasedonclinicalcriteria.Compensatedshockexistswheninadequatetissue
perfusionpersists,despitenormalizationofbloodpressureandheartrate.Evenwithnormalizationof
bloodpressure,heartrate,andurineoutput,80to85%oftraumapatientshaveinadequatetissue
perfusionasevidencedbyincreasedlactateordecreasedmixedvenousoxygensaturation.100,101
Persistent,occulthypoperfusionisfrequentintheintensivecareunit,withresultantsignificantincreasein
infectionrateandmortalityinmajortraumapatients.Patientsfailingtoreversetheirlacticacidosiswithin
12hoursofadmission(acidosisthatwaspersistentdespitenormalheartrate,bloodpressure,andurine
output),developedaninfectionthreetimesasoftenasthosewhonormalizedtheirlactatelevelswithin12
hoursofadmission.Inaddition,mortalitywasfourfoldhigherinpatientswhodevelopedinfections.Both
injuryseverityscoreandocculthypotension(lacticacidosis)longerthan12hourswereindependent
predictorsofinfection.102,103Thusrecognitionofsubclinicalhypoperfusionrequiresinformationbeyond
vitalsignsandurinaryoutput.
Endpointsinresuscitationcanbedividedintosystemicorglobalparameters,tissuespecificparameters,and
cellularparameters.Globalendpointsincludevitalsigns,cardiacoutput,pulmonaryarterywedgepressure,
oxygendeliveryandconsumption,lactate,andbasedeficit(Table44).
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EndpointsinResuscitation
Systemic/global
Lactate
Basedeficit
Cardiacoutput
Oxygendeliveryandconsumption
Tissuespecific
Gastrictonometry
TissuepH,oxygen,carbondioxidelevels
Nearinfraredspectroscopy
Cellular
Membranepotential
Adenosinetriphosphate(ATP)
(Q.167) Thehalflifecobalt60is:
(a)
1.2years
(b)
2.3years
(c)
3.4years
(d)
5.3years
YourResponse:
CorrectAnswer:
Exp:
REF.SCHWARTZSURGERY8THEDNPG259263
Ahalflifeistheintervaloftimerequiredforonehalfoftheatomicnucleiofaradioactivesampletodecay
(changespontaneouslyintoothernuclearspeciesbyemittingparticlesandenergy),or,equivalently,the
timeintervalrequiredforthenumberofdisintegrationspersecondofaradioactivematerialtodecrease
byonehalf.
Theradioactiveisotopecobalt60,whichisusedforradiotherapy,has,forexample,ahalflifeof5.26years.
Thusafterthatinterval,asampleoriginallycontaining8gofcobalt60wouldcontainonly4gofcobalt60
andwouldemitonlyhalfasmuchradiation.Afteranotherintervalof5.26years,thesamplewouldcontain
only2gofcobalt60.Neitherthevolumenorthemassoftheoriginalsamplevisiblydecreases,however,
becausetheunstablecobalt60nucleidecayintostablenickel60nuclei,whichremainwiththestill
undecayedcobalt.
Halflivesarecharacteristicpropertiesofthevariousunstableatomicnucleiandtheparticularwayinwhich
theydecay.
Alphaandbetadecayaregenerallyslowerprocessesthangammadecay.
Halflivesforbetadecayrangeupwardfromonehundredthofasecondand,foralphadecay,upwardfrom
aboutonemillionthofasecond.Halflivesforgammadecaymaybetooshorttomeasure(around1014
second),thoughawiderangeofhalflivesforgammaemissionhasbeenreported.
(Q.168) Regardinguretericcalculi,untrueisare:
(a) Aremostoftencomposedofcalciumoxalateorphosphate
(b) Extracorporeallithotripsyisusefulforstonesintheupperthirdoftheureter
(c) About30%ofpatientsrequireopensurgerytoremovethestone
(d) Anobstructedureterinthepresenceofinfectionisasurgicalemergency
YourResponse:
CorrectAnswer:
Exp:
About30%ofpatientsrequireopensurgerytoremovethestone
Uretericcalculi
Factorsfavouringformation
Increasedurinaryconcentrationofconstituents
Presenceofpromotersubstances
Reductioninconcentrationofinhibitors
Lifetimeriskofdevelopingauretericcalculusisabout5%
Occurmostcommonlyinmenagedbetween3060years
90%areidiopathic
10%aredueto:
Hyperparathyroidism
VitaminDexcess
Primaryhyperoxaluria
Chemicalcomposition
Calciumoxalate(40%)
Calciumphosphate(15%)
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Mixedoxalatephosphate(20%)
Struvite(15%)
Uricacid(10%)
Clinicalfeatures
Stonesusuallypresentwithpainduetoobstructionofurinaryflow
Maycausefewsymptomsormaypresentwithtypicaluretericcolic
Uretericcolictypicallyisseverecolickylointogroinpain
Painmayradiateintoscrotuminmenandlabiainwomen
Mayalsocausefrequency,urgencyanddysuria
Painmaysettlewithpassageofthestoneorifstonefailstomigrate
Abdominalexaminationisusuallyunremarkable
Microscopichematuriaisoftenpresent
Investigation
Midstreamurinespecimen
KUBplusultrasound
Intravenousurography(IVU)
Complications
Obstruction
Uretericstrictures
Infection
Acuteinfectioninanobstructedkidneyisaurologicalemergency
Patientisusuallyunwellwithloinpain,swingingpyrexiaanddysuria
Withoutdrainage,rapidrenaldestructionmayoccur
Requiresemergencypercutaneousnephrostomy
Chronicinfectionwithureaseproducingorganisms(e.g.Proteus)precipitates
stoneformation
Magnesiumammoniumphosphateorstaghorncalculiresult
Largestaghorncalculimaybeasymptomatic
Staghorncalculicanleadtodeteriorationinrenalfunction
Management
Initialconservativetreatmentwithoralfluidsandadequateanalgesia
Checkserumelectrolytesandcalcium
Urinalysiswillnormallyshowmicroscopichematuria
IVUtoconfirmdiagnosisanduretericobstruction
Moststones<5mmindiameterpassspontaneously
Ifmorethan510mmindiameterandfailtopassspontaneouslyconsider:
Upperthirdofureterextracorporealshockwavelithotripsy(ESWL)
Lowerthirdofureterureteroscopy(USC)+lithotripsy
MiddlethirdofuretereitherESWLorUSC
Iftotalobstructionoccursinthepresenceofinfectedurineneedurgent
decompression
Decompressionusuallyachievedwithpercutaneousnephrostomy
Iflargestonesinrenalpelvisorupperureterconsiderpercutaneous
nephrolithotomy
Particularlyifstonemorethan3cmindiameterora'staghorncalculus'
Lessthan1%patientswithstonesrequireopensurgeryureteroor
nephrolithotomy
Lithotripsy
Istheuseofshockwavestobreakupstones
Lithotripsyrequires:
Anenergysourcesparkgapelectrodeorpiezoceramicarray
Acouplingdevicebetweenpatientandelectrodewaterbathorcushion
Amethodofstonelocalisationfluoroscopyorultrasound
(Q.169) Propertreatmentforfrostbiteconsistsof
(a)
Debridementoftheaffectedpartfollowedbysilversulfadiazinedressings
(b)
Administrationofcorticosteroids&vasodilators
(c)
Immersionoftheaffectedpartinwaterat4044C(104111.2F)
(d)
Rewarmingoftheaffectedpartatroomtemperature
YourResponse:
CorrectAnswer:
Exp:
(Greenfield,2/e,pp412414.)
Manymethodsoftreatingfrostbitehavebeentriedthroughouttheyears.Theseincludemassage,warm
waterimmersion,orcoveringtheaffectedarea.Rapidwarmingbyimmersioninwaterslightlyabove
normalbodytemperature(4044C)isthemosteffectivemethod;however,becausethefrostbittenregion
isnumbandespeciallyvulnerable,itshouldbeprotectedfromtraumaorexcessiveheatduringtreatment.
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Furthertreatmentmayincludeelevationtominimizeedema,administrationofantibioticsandtetanus
toxoid,anddebridementofnecroticskinasneeded.
REFHARRISON17thEdChapter20.
Frostbite:Treatment
Frozentissueshouldberapidlyandcompletelythawedbyimmersionincirculatingwaterat3740C.
Rapidrewarmingoftenproducesaninitialhyperemia.Theearlyformationoflargecleardistalblebsis
morefavorablethansmallerproximaldarkhemorrhagicblebs.Acommonerroristhepremature
terminationofthawing,sincethereestablishmentofperfusionisintenselypainful.Parenteralnarcoticswill
benecessarywithdeepfrostbite.Ifcyanosispersistsafterrewarming,thetissuecompartmentpressures
shouldbemonitoredcarefully.
Numerousexperimentalantithromboticandvasodilatorytreatmentregimenshavebeenevaluated.There
isnoconclusiveevidencethatdextran,heparin,steroids,calciumchannelblockers,hyperbaricoxygen,or
prostaglandininhibitorssalvagetissue.AtreatmentprotocolforfrostbiteissummarizedinTable204.
TreatmentforFrostbite
BeforeThawing
DuringThawing
AfterThawing
Removefrom
environment
Considerparenteralanalgesiaand
ketorolac
Gentlydryandprotectpart;elevate;
pledgetsbetweentoes,ifmacerated
Preventpartial
thawingand
refreezing
Administeribuprofen,400mgPO
Ifclearvesiclesareintact,aspirate
sterilely;ifbroken,debrideanddress
withantibioticorsterilealoevera
ointment
Stabilizecore
temperatureand
treathypothermia
Immersepartin3740C
(thermometermonitored)circulating
watercontaininganantisepticsoap
untildistalflush(1045min)
Leavehemorrhagicvesiclesintactto
preventdessicationandinfection
Protectfrozenpart Encouragepatienttogentlymovepart
nofrictionor
massage
Continueibuprofen400mgPO(12
mg/kgperday)q812h
Addressmedicalor
surgicalconditions
Considertetanusandstreptococcal
prophylaxis;elevatepart
Ifpainisrefractory,reducewater
temperatureto3537Cand
administerparenteralnarcotics
Hydrotherapyat37C
Considerphenoxybenzamineinsevere
cases
Unlessinfectiondevelops,anydecisionregardingdebridementoramputationshouldbedeferreduntil
thereisclearevidenceofdemarcation,mummification,andsloughing.Magneticresonanceangiography
maydemonstratethelineofdemarcationearlierthanclinicaldemarcation.Themostcommon
symptomaticsequelaereflectneuronalinjuryandthepersistentlyabnormalsympathetictone,including
paresthesias,thermalmisperception,andhyperhidrosis.Delayedfindingsincludenaildeformities,
cutaneouscarcinomas,andepiphysealdamageinchildren.
Managementofthechilblainsyndromeisusuallysupportive.Withrefractoryperniosis,alternativesinclude
nifedipine,steroids,orlimaprost,aprostaglandinE1analogue
(Q.170) A43yroldfemaleisdiagnosedhavingsuperficial,gradeIItransitionalcellcarcinomaoftheurinarybladder.Whichofthefollowing
isnottrueaboutregardingthispatient?
(a)
Smokingpredisposestothiscancer
(b)
Recurrencewilloccurforwhichshemayneedrepeatedfulguration
(c)
Therearenoeffectiveanticancerdrugsforbladdercancer
(d)
Thereis70%chancethatsheeventuallywillneedcystectomyinnext5yrs.
YourResponse:
CorrectAnswer:
Exp:
Therearenoeffectiveanticancerdrugsforbladdercancer.(Ref.Harrisons17th/pg.591)
Epidemiology
Cigarettesmokingisbelievedtocontributetoupto50%ofthediagnosedurothelialcancersinmenandup
to40%inwomen.Theriskofdevelopingaurothelialmalignancyinmalesmokersisincreasedtwoto
fourfoldrelativetononsmokersandcontinuesfor10yearsorlongeraftercessation.Otherimplicated
agentsincludetheanilinedyes,thedrugsphenacetinandchlornaphazine,andexternalbeamradiation.
Chroniccyclophosphamideexposuremayalsoincreaserisk,whereasvitaminAsupplementsappeartobe
protective.ExposuretoSchistosomahaematobium,aparasitefoundinmanydevelopingcountries,is
associatedwithanincreaseinbothsquamousandtransitionalcellcarcinomasofthebladder
AnumberofchemotherapeuticdrugsinUBcancerhaveshownactivityassingleagents;cisplatin,
paclitaxel,andgemcitabineareconsideredmostactive.Standardtherapyconsistsoftwo,three,orfour
drugcombinations.Overallresponseratesof>50%havebeenreportedusingcombinationssuchas
methotrexate,vinblastine,doxorubicin,andcisplatin(MVAC);cisplatinandpaclitaxel(PT);gemcitabine
andcisplatin(GC);orgemcitabine,paclitaxel,andcisplatin(GTC).MVACwasconsideredstandard,butthe
toxicitiesofneutropeniaandfever,mucositis,diminishedrenalandauditoryfunction,andperipheral
neuropathyledtothedevelopmentofalternativeregimens.Atpresent,GCisusedmorecommonlythan
MVAC,basedontheresultsofacomparativetrialofMVACversusGCthatshowedlessneutropeniaand
fever,andlessmucositisfortheGCregimen.AnemiaandthrombocytopeniaweremorecommonwithGC.
GTCisnotmoreeffectivethanGC.
Chemotherapyhasalsobeenevaluatedintheneoadjuvantandadjuvantsettings.Inarandomizedtrial,
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patientsreceivingthreecyclesofneoadjuvantMVACfollowedbycystectomyhadasignificantlybetter
median(6.2years)and5yearsurvival(57%)comparedtocystectomyalone(mediansurvival3.8years;5
yearsurvival42%).Similarresultswereobtainedinaninternationalstudyofthreecyclesofcisplatin,
methotrexate,andvinblastine(CMV)followedbyeitherradicalcystectomyorradiationtherapy.The
decisiontoadministeradjuvanttherapyisbasedontheriskofrecurrenceaftercystectomy.Indicationsfor
adjuvantchemotherapyincludethepresenceofnodaldisease,extravesicaltumorextension,orvascular
invasionintheresectedspecimen.AnotherstudyofadjuvanttherapyfoundthatfourcyclesofCMV
delayedrecurrence,althoughaneffectonsurvivalwaslessclear.Additionaltrialsarestudyingtaxaneand
gemcitabinebasedcombinations.
(Q.171) AGrayhackshuntis?
(a) Anastomosisofasaphenousveintooneofthecorporacavernosa
(b) Cavernosalspongiosumshunt
(c) Incisionontheglanswithcommunicationofthecorpospongiosumwiththecorpocavernosum
(d) Placementoftubeincorpospongiosum
YourResponse:
CorrectAnswer:
Exp:
Anastomosisofasaphenousveintooneofthecorporacavernosa(Ref.Swartz8th/1550)
Grayhackshuntissaphenousveincavernousshunt.
Priapismisararedisorderinwhichprolonged,painfulerectionoccurs,usuallynotassociatedwithsexual
stimulation.Thebloodinthecorporacavernosabecomeshyperviscousbutnotclotted.About25%ofcases
areassociatedwithleukemia,metastaticcarcinoma,sicklecellanemia,ortrauma.Inmostcases,thecause
isuncertain.
Rx:
Iftheerectiondoesnotsubside,needleaspirationofthesludgedbloodofthecorporafollowedbylavage
withalphaadrenergicagentssuchasphenylephrineshouldbeperformed.Delayedorunsuccessful
treatmentmayresultinimpotence.UnsuccessfultreatmentcallsfortheWinterprocedure,inwhicha
biopsyneedleispassedthroughtheglansintooneofthecorpora.Apieceoftunicaalbugineaisremoved,
creatingafistulabetweencorporacavernosaandcorpusspongiosum.Thissimpleprocedureishighly
successful,andpotencyisusuallymaintained.Otherproceduresincludecavernosalglandularshunt,
cavernosalspongiosumshunt,andsaphenousveincavernousshunt.Ifpriapismpersists,impotence
results.
Insicklecellanemia,hydrationandhypertransfusionoftengivereliefandshouldconstituteinitialtherapy.
Surgicalinterventionisusedonceitisapparentthatintracavernoustreatmenthasfailed.Surgicalshunting
asameansforblooddrainagefromthecorporacavernosainvolveseitherdistalorproximalapproaches.
Distalcavernoglanular(corporoglanular)shuntingisusuallyperformedfirstbecauseitislessinvasiveand
carriesalowerriskofcomplicationsthanproximalshunting.
Distalshuntingtechniquesincludeplacingalargebiopsyneedle(Wintershunt)orscalpel(Ebbehojshunt)
percutaneouslythroughtheglans,orexcisingthetunicaalbugineaatthetipofthecorpuscavernosum(El
Ghorabshunt).
Ifdistalshuntingfails,proximalcavernospongiosal(corporospongiosal)shuntingcanbeused.
Thisinvolvesthecreationofawindowbetweentherespectivecorporalbodies(QuackelsorSachershunt),
orananastomosisofasaphenousveintooneofthecorporacavernosa(Grayhackshunt).
(Q.172) Laparoscopicsterilizationiscontraindicatedin:
(a)
Postpartum
(b)
Gynecologictumors
(c)
FollowingMTP
(d)
Ifpatienthasmorethan3children.
YourResponse:
CorrectAnswer:
Exp:
Postpartum
Contraindicationsoflaparoscopicsterilization:
Patientwithcardiacorpulmonarydisease,headlowpositionandCo2arecontraindicated
Previousabdominalsurgeryexposesthepatienttotheriskofintestinaltraumaincaseparietaladhesions
arepresent.
Extremeobesity,diaphragmaticorumbilical.
InPID,fallopiantubesmaynotbeeasilyvisibleamongsttheadhesions.
Puerperalandvascular:Thefallopiantubesareedematousandvascularandmayeasilygettorn.The
uterusissoftandcaneasilygetperforatedwiththeuterinemanipulator
(Q.173) Forinducingtherapeuticabortion,Mifepristoneismosteffectivewhengivenwithin_______daysofpregnancy
(a)
120days
(b)
88days
(c)
72days
(d)
63days
YourResponse:
CorrectAnswer:
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Exp:
63days
(Ref.TextbookofGynaecology5th/pg.511,Duttaobstetrics6th/pg.175&550)
BuccaluseofMifepristoneisaseffectiveasvaginalininducedmedicalabortionupto63daysgestation.
RegimensfortreatmentofMedicalabortion
Themostcommonearlyfirsttrimestermedicalabortionregimensusemifepristoneincombinationwitha
prostaglandinanalog(i.e.misoprostol)upto63daysofgestationalage,methotrexateincombinationwith
aprostaglandinanalog(i.e.misoprostol)upto49daysgestation,oraprostaglandinanalog(i.e.
misoprostol)alonewhere.
Mifepristonemisoprostolcombinationregimensworkfasterandaremoreeffectiveatlatergestational
agesthanmethotrexatemisoprostolcombinationregimens.
(Q.174) Markerofopenneuraltubedefect?
(a)
Amnioticfluidacetylcholineesterase
(b)
Amnioticfluidacetylcholinekinase
(c)
AmnioticfluidHCG
(d)
Amnioticfluidpseudoacetylcholineesterase
YourResponse:
CorrectAnswer:
Exp:
Amnioticfluidacetylcholineesterase
(Ref.DuttaObstetrics6th/107;WilliamsObstetrics
22nd/Page278)
Ifpresentafter14weeksofgestation,amnioticfluidacetylcholinesteraseisconsidereddirectevidence
ofanopenneuraltubedefect.
Normalrangebymethod:
oPolyacrylamidegelelectrophoresis:Negative
oAE2immunoassay:Negative
oInhibitionassay:5.172.63milliunits/mL(5.172.63units/L)
(Q.175) Placentalalkalinephosphataseismarkerof
(a)
Thecacelltumour
(b)
Teratoma
(c)
Choriocarcinoma
(d)
Seminoma
YourResponse:
CorrectAnswer:
Exp:
i.e.seminoma
Recently,placentalalkalinephosphatasehasbeensuggestedastumormarkerinpatientwith
seminoma.
Someothertumourmarkersare
TumorMarkers
Cancer
NonneoplasticConditions
Humanchorionic
gonadotropin
Gestationaltrophoblasticdisease,
gonadalgermcelltumor
Pregnancy
Calcitonin
Medullarycancerofthethyroid
Catecholamines
Pheochromocytoma
TumorMarkers
Hormones
OncofetalAntigens
Fetoprotein
Hepatocellularcarcinoma,gonadal
germcelltumor
Cirrhosis,hepatitis
Carcinoembryonic
antigen
Adenocarcinomasofthecolon,
pancreas,lung,breast,ovary
Pancreatitis,hepatitis,
inflammatoryboweldisease,
smoking
Prostaticacid
phosphatase
Prostatecancer
Prostatitis,prostatic
hypertrophy
Neuronspecific
enolase
Smallcellcancerofthelung,
neuroblastoma
Enzymes
Lactatedehydrogenase Lymphoma,Ewing'ssarcoma
Hepatitis,hemolyticanemia,
manyothers
TumorAssociatedProteins
Prostatespecific
antigen
Prostatecancer
Prostatitis,prostatic
hypertrophy
Monoclonal
Myeloma
Infection,MGUS
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immunoglobulin
CA125
Ovariancancer,somelymphomas
Menstruation,peritonitis,
pregnancy
CA199
Colon,pancreatic,breastcancer
Pancreatitis,ulcerativecolitis
CD30
Hodgkin'sdisease,anaplasticlarge
celllymphoma
CD25
Hairycellleukemia,adultTcell
leukemia/lymphoma
(Q.176) Thefollowingaretruestatementsregardingsalicylatepoisoningexcept:
(a)
Hypokalemiaisafeature
(b)
Hypoventilationisanearlyfeature
(c)
Vasodilatationisafeature
(d)
Respiratoryalkalosisisseeninchildren
YourResponse:
CorrectAnswer:
Exp:
Hypoventilationisanearlyfeature
Hypoventilationisalatefeatureofsalicylatepoisoning,andtogetherwithcomaindicateseverpoisoning.
Theacidbasedisturbancesarecomplexandbothacidosisandalkalosismayoccur.Salicylateshaveadirect
stimulanteffectontherespiratorycentreresultinginhyperventilationandarespiratoryalkalosisseen
earlyon,thoughthisstagemaynotbeapparentinyounginfants.
(Q.177) Allofthefollowingaretypesofavascularnonunionoffractureexcept:
(a)
Torsionwedgenonunion
(b)
Oligotrophicnonunion
(c)
Comminutednonunion
(d)
Defectnonunion
YourResponse:
CorrectAnswer:
Exp:
Oligotrophicnonunion(Ref.TextbookofforthopedicsbyJohnEbnezar3rded.36)
Definition(FDApanel)ofnonunion:Itissaidtobeestablishedwhenaminimumof9monthshaselapsed
sinceinjuryandfractureshowsnoradiologicallyvisibleprogresssuggestiveofhealingcontinuouslyfor3
months.
Classification(MullerandWeber)ofNONUNION:
HypervasculartypesAvasculartypes
Hypertrophic(elephantfoot,exuberantcallus)Torsionwedge
HorsehoofComminuted
OligotrophicDefect
(Q.178) WhichofthefollowingisnottrueregardingMolluscacontagiosa?:
(a)
Causedbyapoxvirus
(b)
Seenasapearlypapulewithacentralumbilicus
(c)
Spontaneousresolutionisusualby6weeks
(d)
Cryotherapyessentialinalmostallcases
YourResponse:
CorrectAnswer:
Exp:
Cryotherapyessentialinalmostallcases
Molluscacontagiosaisacommoninfectionamongschoolchildrencausedbyapoxvirus.Itpresentsas
pearlypapuleswithacentralumbilicus.Spontaneousresolutionusuallyoccurswithin69months,though
thelesionscanlastforyears.Disseminatedinfectionmaybeseeninchildrenwithatopiceczemaandinthe
immunosuppressed.Notreatmentisusuallygivenasthiscanresultinscarring,however,cryotherapyisa
treatmentoptionifnecessary.
(Q.179) Falseaboutsynovialfluidis?
(a)
TypeBcellsproducesynovialfluiD.
(b)
Synovialfluidhasthixotropiccharacteristics
(c)
SynovialfluidexhibitsNewtonianflowcharacteristics
(d)
Containslubricin
YourResponse:
CorrectAnswer:
Exp:
SynovialfluidexhibitsNewtonianflowcharacteristics
Synovialtissueissterileandcomposedofvascularizedconnectivetissuethatlacksabasementmembrane.
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Twocellstype(typeAandtypeB)arepresent:TypeBproducesynovialfluid.
Synovialfluidismadeofhyaluronicacidandlubricin,proteinases,andcollagenases.
SynovialfluidexhibitsnonNewtonianflowcharacteristics;theviscositycoefficientisnotaconstantandthe
fluidisnotlinearlyviscous.
Synovialfluidhasthixotropiccharacteristics;viscositydecreasesandthefluidthinsoveraperiodof
continuedstress.
Normalsynovialfluidcontains34mg/mlhyaluronan(hyaluronicacid),apolymerofdisaccharidescomposed
ofDglucuronicacidandDNacetylglucosaminejoinedbyalternatingbeta1,4andbeta1,3glycosidic
bonds
Hyaluronanissynthesizedbythesynovialmembraneandsecretedintothejointcavitytoincreasethe
viscosityandelasticityofarticularcartilagesandlubricatethesurfacesbetweensynoviumandcartilage.
Synovialfluidcontainslubricinsecretedbysynovialcells.Itischieflyresponsibleforsocalledboundary
layerlubrication,whichreducesfrictionbetweenopposingsurfacesofcartilage.
Thereisalsosomeevidencethatithelpsregulatesynovialcellgrowth.
Itsfunctionsare:reducingfrictionbylubricatingthejoint,absorbingshocks,andsupplyingoxygenand
nutrientstoandremovingcarbondioxideandmetabolicwastesfromthechondrocyteswithinarticular
cartilage.
Italsocontainsphagocyticcellsthatremovemicrobesandthedebristhatresultsfromnormalwearand
tearinthejoint.
Synovialfluidcanbecollectedbysyringeinaproceduretermedarthrocentesis,alsoknownasjoint
aspiration.
Classification
Synovialfluidcanbeclassifiedintonormal,noninflammatory,inflammatory,septic,andhemorrhagic:
Classificationofsynovialfluidinanadultkneejoint
Normal
Noninflammatory
Inflammatory
Septic
Hemorrhagic
Volume(ml)
<3.5
>3.5
>3.5
>3.5
>3.5
Viscosity
High
High
Low
Mixed
Low
Clarity
Clear
Clear
Cloudy
Opaque
Mixed
Color
Colorless/straw
Straw/yellow
Yellow
Mixed
Red
WBC/mm3
<200
2002,000
2,00075,000
>100,000
Sameasblood
Polys(%)
<25
<25
>50
>75
Sameasblood
Gramstain
Negative
Negative
Negative
Oftenpositive Negative
(Q.180) Ketaminebelongstowhichofthefollowinggroupofdrug?
(a)
Phencyclidine
(b)
Phenols
(c)
Barbiturate
(d)
Benzodiazepine
YourResponse:
CorrectAnswer:
Exp:
Phencyclidine(Ref.AnaesthesiabyAjayYadav,3rded.,p78)
KETAMINE(dissociativeanaesthesia)
Phencyclidine(PCP)derivative.
Primarysiteofactionisthalamoneocorticalprojection.
Fastonset.
Doserelatedunconsciousnessanddissociativestateanalgesia.
Stronganalgesic.
Notasamnesticasbenzodiazepines.
Nosuppressionofthecardiovascularandrespiratorysystems.
Maycausehallucinationsanddisturbingdreams,especiallyinadultsandhallucinationisthemostcommon
sideeffectketamine.
Intracranialtensionishighlyincreased.
Potentbronchodilator.
Dilatespupilsandtriggersnystagmus.
Increasedsalivation.
Increasedmuscletoneandpurposelessmovementsoftheextremities
Increasedcerebralbloodflowandintracranialpressure.
(Q.181) Ahighpotassiumlevelisseeninwhichofthefollowingconditionwhenscolineisbeingusedforintubation
(a)
Renalfailure
(b)
Chronicparaplegia
(c)
Fracturefemur
(d)
Myocardialinfarction
YourResponse:
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CorrectAnswer:
Exp:
Chronicparaplegia(Ref.Leeanaesthesia12thed.220)
Scolin/succinylcholinehasbeenassociatedwithrapidmusclebreakdownandresultsinincreasein
potassiumlevelscausinglifethreateningheartrythumsandcardiacarrests.
Itisusedforintubationasamusclerelaxantbutoneshouldtakecarefulhistoryofpatient.
ChronicparaplagicshaveweakmusclesanditcanreleaseextremelevelsofK+withscolin
Fracturefemure/renalfailure/MIallhashighpotassiumbutthecauseisdifferentitsnotscolin
Scolincausesriseofchronicparaplegicsbycausingmusclebreakdown.
Certaingroupsofpatientsexperienceproliferationof"extrajunctional"acetylcholinereceptorswhich
occuroutsidethemarginsofthemotorendplate.Suxamethoniumcausesalargerthanusualriseinserum
potassium.Thisriseisoftheorderof23mmol/L,buthasbeenreportedashigher.Itvarieswiththe
natureoftheconditioninvolved,itsage,andseverity.
Theconditionsinwhichithasbeendescribedinclude:
BURNS.A1060dayrulehasbeendescribedsubsequenttoreportsofthephenomenonbetweendays14
66afterburns.Asinotherconditions,alatentphaseoccurs;"extrajunctional"receptorsdonotappear
immediatelyafterinjury.
ACUTEUPPERMOTORNEURONLESIONS&STRUCTURALBRAINDAMAGE.Theseincludespinalcordinjury,
anoxicbraindamage,encephalitis,subarachnoidhaemorrhage,andcerebrovascularaccidents.
PROGRESSIVENEUROLOGICALCONDITIONS.Demyelinatingdiseases,andbraintumoursmaybeassociated
withtheresponse.Againthiswillbegreaterifthediseaseisrapidlyprogressive,andingeneral,the
potentialforevokedreleaseofpotassiumisofalowermagnitudeandoccursoveralongerperiodoftime.
TherelationshipinParkinson'sdiseaseisnotclear.
CHRONICSTABLENEUROLOGICALCONDITIONS.Thesearegenerallyassociatedwitha"normal"response
only,includingcerebralpalsy.
LOWERMOTORNEURONDISEASE.Thephenomenomhasbeendescribedbetweendays42192following
acuteperipheralnervedamage,andcardiacarresthasbeenreportedfollwingsuxamethoniumwithdiffuse
neuropathies.
MUSCULARDYSTROPHIES.HyperkalemiahasbeenreportedinpatientswithDuchenne'smuscular
dystrophy,however,thiswasascribedtoMalignantHyperpyrexia.
TRAUMA.Aswithburns,thisoccursinmannerinfluencedbythetimefrominjury,andtheextentofnerve
andmuscledamage.
INFECTION.Again,thisresponsehasbeenseeninsevereinfectionincludingosteomyelitisandgangrene.
(Q.182) Siteofactionofvecuronium?
(a)
Cerebrum
(b)
Reticularformation
(c)
Motorneuron
(d)
Myoneuraljunction
YourResponse: d
CorrectAnswer: D
Exp:
Myoneuraljunction(Ref.KDT5thed.309)
Vecuronium
Excretedinbile
Notusedinbiliaryobstruction
CARDIOVASCULARstability,henceagentofchoiceincardiacpatients
Longtermuseresultsinpolyneuropathy
Longacting,Nondepolarisingmusclerelaxant.
pHofsolution4.Stablefor24hoursat25oc.(Muchmorestable
thanAtracurium)
Dose0.Img/kg.
Onsetofaction12min.
Durationofactionabout20min.
Siteofactionismyoneuraljunction.
(Q.183) Whichofthefolwoingindicatesradiographcontrastinducednephropathy?
(a)
Increasedcreatininelevels
(b)
Decreasedurineoutput
(c)
Increasedbilirubin
(d)
Decreasedbilirubin
YourResponse:
CorrectAnswer:
Exp:
Increasedcreatininelevels
REF:
1.http://emedicine.medscape.com/article/246751overview:ContrastInducedNephropathyAuthor:
RenuBansal,MD;ChiefEditor:VecihiBatuman,
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2.AmericanJournalofRoentgenology.2004;183:16731689.10.2214/ajr.183.6.01831673
Contrastinducednephropathy(CIN)isdefinedastheimpairmentofrenalfunctionandismeasuredas
eithera25%increaseinserumcreatinine(SCr)frombaselineor0.5mg/dL(44mol/L)increasein
absolutevalue,within4872hoursofintravenouscontrastadministration.
Forrenalinsufficiency(RI)tobeattributabletocontrastadministration,itshouldbeacute,usuallywithin
23days,althoughithasbeensuggestedthatRIupto7dayspostcontrastadministrationbeconsidered
CIN;itshouldalsonotbeattributabletoanyotheridentifiablecauseofrenalfailure.Atemporallinkisthus
implied.Followingcontrastexposure,SCrlevelspeakbetween2and5daysandusuallyreturntonormalin
14days.
Complications
CINisoneoftheleadingcausesofhospitalacquiredacuterenalfailure.Itisassociatedwithasignificantly
higherriskofinhospitaland1yearmortality,eveninpatientswhodonotneeddialysis.Nonrenal
complicationsincludeproceduralcardiaccomplications(eg,QwaveMI,coronaryarterybypassgraft
[CABG],hypotension,shock),vascularcomplications(eg,femoralbleeding,hematoma,pseudoaneurysm,
stroke),andsystemiccomplications(eg,acuterespiratorydistresssyndrome[ARDS],pulmonary
embolism).ThereisacomplicatedrelationshipbetweenCIN,comorbidity,andmortality.Mostpatients
whodevelopCINdonotdiefromrenalfailure.Death,ifitdoesoccur,ismorecommonlyfromeithera
preexistingnonrenalcomplicationoraproceduralcomplication.
Otherrenalfunctionmarkers
TheuseofSCrasamarkerofrenalfunctionhasitslimitations.Indicatorssuchastheestimatedglomerular
filtrationrate(eGFR)andcystatinCareincreasinglyconsideredtobemorereliableandaccuratereflectors
ofexistingrenalfunction
TheeGFRcanbecalculatedusingtheModificationofDietinRenalDisease(MDRD)formulaorthe
CockroftGaultformula.TheCockroftGaultformulacalculateseGFRusingage,sex,andbodyweight,which
arefactorsthat,independentofGFR,influenceSCr.TheMDRDequationalsoincludesbloodureanitrogen
(BUN)andserumalbumin.
TheeGFRworksbestatlowcreatininevalues.SCrandGFRshareacurvilinearrelationship.AtlowerSCr
values,doublingSCrisassociatedwithacorresponding50%decreaseinGFR.However,inelderlypatients
withchronickidneydisease(CKD)whohavehighSCrvaluesatbaseline,a25%riseinSCrisactually
indicativeofarelativelymodestreductioninGFR.Nonetheless,evena25%increaseinSCrinthissituation
hasbeenshowntohavegreatimpact,especiallyintermsofinhospitaland1yearmortality
SerumcystatinCisaserumproteinthatissecretedbynucleatedcells.Itisfreelyfilteredbytheglomerulus
andhasbeenfoundtobeanaccuratemarkerofGFR.ComparedwithSCr,cystatinCchangesmuchearlier
aftercontrastadministrationandisnotsubjecttoconfoundingfactors,suchage,sex,andmusclemass,
thatinfluenceSCrvaluesindependentoftheunderlyingGFR.CystatinCisincreasinglybeingusedasa
markerofrenalfunctionincardiacsurgicalpatients.
1.http://emedicine.medscape.com/article/246751overview:ContrastInducedNephropathyAuthor:
RenuBansal,MD;ChiefEditor:VecihiBatuman,
2.AmericanJournalofRoentgenology.2004;183:16731689.10.2214/ajr.183.6.01831673
Contrastinducednephropathy(CIN)isdefinedastheimpairmentofrenalfunctionandismeasuredas
eithera25%increaseinserumcreatinine(SCr)frombaselineor0.5mg/dL(44mol/L)increasein
absolutevalue,within4872hoursofintravenouscontrastadministration.
Forrenalinsufficiency(RI)tobeattributabletocontrastadministration,itshouldbeacute,usuallywithin
23days,althoughithasbeensuggestedthatRIupto7dayspostcontrastadministrationbeconsidered
CIN;itshouldalsonotbeattributabletoanyotheridentifiablecauseofrenalfailure.Atemporallinkisthus
implied.Followingcontrastexposure,SCrlevelspeakbetween2and5daysandusuallyreturntonormalin
14days.
Complications
CINisoneoftheleadingcausesofhospitalacquiredacuterenalfailure.Itisassociatedwithasignificantly
higherriskofinhospitaland1yearmortality,eveninpatientswhodonotneeddialysis.Nonrenal
complicationsincludeproceduralcardiaccomplications(eg,QwaveMI,coronaryarterybypassgraft
[CABG],hypotension,shock),vascularcomplications(eg,femoralbleeding,hematoma,pseudoaneurysm,
stroke),andsystemiccomplications(eg,acuterespiratorydistresssyndrome[ARDS],pulmonary
embolism).ThereisacomplicatedrelationshipbetweenCIN,comorbidity,andmortality.Mostpatients
whodevelopCINdonotdiefromrenalfailure.Death,ifitdoesoccur,ismorecommonlyfromeithera
preexistingnonrenalcomplicationoraproceduralcomplication.
Otherrenalfunctionmarkers
TheuseofSCrasamarkerofrenalfunctionhasitslimitations.Indicatorssuchastheestimatedglomerular
filtrationrate(eGFR)andcystatinCareincreasinglyconsideredtobemorereliableandaccuratereflectors
ofexistingrenalfunction
TheeGFRcanbecalculatedusingtheModificationofDietinRenalDisease(MDRD)formulaorthe
CockroftGaultformula.TheCockroftGaultformulacalculateseGFRusingage,sex,andbodyweight,which
arefactorsthat,independentofGFR,influenceSCr.TheMDRDequationalsoincludesbloodureanitrogen
(BUN)andserumalbumin.
TheeGFRworksbestatlowcreatininevalues.SCrandGFRshareacurvilinearrelationship.AtlowerSCr
values,doublingSCrisassociatedwithacorresponding50%decreaseinGFR.However,inelderlypatients
withchronickidneydisease(CKD)whohavehighSCrvaluesatbaseline,a25%riseinSCrisactually
indicativeofarelativelymodestreductioninGFR.Nonetheless,evena25%increaseinSCrinthissituation
hasbeenshowntohavegreatimpact,especiallyintermsofinhospitaland1yearmortality
SerumcystatinCisaserumproteinthatissecretedbynucleatedcells.Itisfreelyfilteredbytheglomerulus
andhasbeenfoundtobeanaccuratemarkerofGFR.ComparedwithSCr,cystatinCchangesmuchearlier
aftercontrastadministrationandisnotsubjecttoconfoundingfactors,suchage,sex,andmusclemass,
thatinfluenceSCrvaluesindependentoftheunderlyingGFR.CystatinCisincreasinglybeingusedasa
markerofrenalfunctionincardiacsurgicalpatients.
(Q.184) Lactatingwomenwithpainfulbreast,1stinvestigationtobedoneshouldbe?
(a)
USG.
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(b)
Mammography
(c)
CT
(d)
MRI
YourResponse:
CorrectAnswer:
Exp:
USG
CanaLactatingWomanHaveaMammogram?Patricia(Pat)A.Camillo,PhD
http://www.medscape.com/viewarticle/449395
AccuracyofDiagnosticMammographyandBreastUltrasoundDuringPregnancyandLactation.Read
More:http://www.ajronline.org/doi/full/10.2214/AJR.09.3662
Amammogramisnotthebestdiagnostictoolforalactatingwomanforthesamereasonsthatitisnot
generallyrecommendedformostwomenunderage35years.Youngwomentendtohaveverydense
breasts,makingitdifficulttofindradiographiclesions.Thelactatingbreastshowsanevengreaterincrease
inparenchymaldensity,withmorenodularandropelikecharacteristics,correspondingtoductal
distentionwithmilk.
Hereisanalternativeapproachtoconsiderforlactatingwomenwithsuspectedlesions[1]:
Beginwithanultrasoundifthereisapalpableabnormality.Ultrasoundcanclearlydemonstrateasolidvs
cysticmassorgalactocele.Thiswouldinitiallyeliminatetheneedforamammogram.
Fineneedleaspirationcanbeofferedifamassisdeterminedtobeacystorgalactocele,usuallywithno
furtherinterventionnecessary.
Ifthepalpablemassappearssolidonultrasound,abiopsyisindicated.Stereotacticguidanceforfine
needleaspirationorlargecorebreastbiopsycanbeusedsuccessfullyinthelactatingwoman.Tominimize
creationofamilkfistula,theaffectedbreastshouldbepumpedjustpriortotheprocedure.
Biopsyisalsoindicatedifthemassispalpablebuttheultrasoundisnegative.
Iftheabnormalityisfoundtobemalignant,thenabilateralmammogramisdone,thepurposeofwhichis
toexplorewhetherthereareothersuspiciouslesions.
Fortunately,breastcancersarenotcommoninlactatingwomen.Lactatingadenomasandfibroadenomas
arethemostcommonsolidpalpablemassesandthesearealwaysbenign.However,whenmalignanciesare
found,theyareofteninanadvancedstagewithapoorprognosis.Thishaslesstodowiththephysiologyof
theselesionsandmoretodowiththedelayinidentifyingthem.[3]Althoughroutinemammography
screeningisnotindicated,abaselineclinicalbreastexaminationisanimportantpartofinitialprenatal
care.Changesorabnormalitiesofanykindshouldbeinvestigatedwiththesamelevelofconcern
regardlessofwhetherawomanisbreastfeeding.
TheNationalComprehensiveCancerNetwork'sguidelinesoffirstusingbreastultrasoundfollowedby
mammographywhenthesonographicfindingsareinconclusiveorsuspiciousintheevaluationof
nonpregnantsymptomaticwomenyoungerthan30yearsappearstobeanappropriateapproachtothe
evaluationofsymptomaticpregnantorlactatingwomen
(Q.185) InvestigationofchoiceinDCIS:
(a)
Mammography
(b)
CT
(c)
MRI
(d)
PET
YourResponse:
CorrectAnswer:
Exp:
MRI(RefGraingerRadiology,4thEdition,22692273)
Ductalcarcinomainsitu(DCIS)andlobularcarcinomainsitu(LCIS)areconfinedtotheductsandacini,
respectively.TherearefoursubtypesofDCIS:comedocarcinoma,micropapillarycarcinoma,cribriform
carcinomaandsolidcarcinoma.Amongthesesubtypes,comedocarcinomaisthemostaggressive.DCIS
nowaccountsfor2040%ofallcancersdetectedbyscreeningmammography.
MRImustbeabletodemonstrateandcharacterizemammographicallydetectedlesions(includingDCIS)
and,ideally,revealmammographicallyoccultlesions.ThisrequiresMRItohavehighresolution
capabilities.
CTisveryrarelyusedinbreastimaging.MRIisusedasaproblemsolvingmodalitywhenUSG/
Mammographyfailstogiveadefinitivediagnosis.Henceifthe1stinvestigationinalactatingfemaleisthe
questionasked,USGshouldbethebestoption
(Q.186) Radiologically,increasedpulmonarybloodflowisindicatedbythefollowingexcept:
(a)
Descendingpulmonaryarterydiameter>16mm
(b)
Kerleyblines
(c)
Diameterof2peripheralarteries>accompanyingbronchiole
(d)
bloodvesselinouter1/3rd
YourResponse:
CorrectAnswer:
Exp:
Noneoftheabove
AfteraextensivesearchinRadiologyliteratureincludingSutton,Grainger,Felson,emedicine,AJRand
RSNAtheclosestreferenceIfoundwasthefollowing:
ClinicalDiagnosisofCongenitalHeartDiseaseByM.Satpathy
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FeaturesofincreasedPumonarybloodflow(PulmonaryPlethora):
Bloodvesselsbecomevisibleintheouterthirdofthelungfields.(Atleast6vesselscanbetracedtothe
outerthird).Whenhilarandintrapulmonaryvesselsareuniformlyenlargeditisverysuggestiveofshunt
lesions.
RatioofRightdescendingpulmonaryartery:Trachea>1.
Rightdescendingpulmonaryarterydiameter>14mmsuggestsincreasedflowand>17mmisvery
stronglysuggestive.
Prominentendonvesselsseenathilum
Enfacevesselsbelow10thposteriorrib.
Prominentvesselsseenbelowcrestofdiaphragm.
Ratioofvesselstoadjacentbronchus>2:1.
Sutton7thEdChap11Pg286says:
ThedifficultyintryingtodifferentiatePulmonaryarteriesfromveinsonchestxraysmeansthattheterm
PulmonaryvesselsorPulmonaryvascularityaremorepracticalthanpotentiallyhazardousattemptsto
distinguishbetweenthem.
SuttoninthesamechapteralsomentionsKerleylinesasbeingadistinctfindinginPulmonaryvenous
hypertension(Pg289).AccordingtoFelson(TheMOTHERBOOK)ofchestradiologyKerleylinesasactually
duetoprominenceoflymphaticchannels/Interlobulearseptaandcanbeseeninvariousdiseases.Most
importantamongthesearediseasesthatcausepulmonaryvenoushypertensionlikeCCF.ThusKerleyB
linescanstillbeconsideredasINDIRECTmarkersofincreasedpulmonarybloodflow.
Nowletusgotoouroptions:
OptionA:YES.Accordingtotheabovelistedcriteria.
OptionB:KERLEYLINES:Asperourabovediscussion,YEScouldbeanindirectindicator.
OptionD:YES.Againseethelistabove.
OptionC:WELL!ThespecificcriteriaaslistedaboveisRatioofVessel:Bronchus>2.1.Justsayingthatthe
vesselislargerthanthebronchusdoesnotfitthecriteria.ForegRatioof1.5:1willnotsatisfythe
criteriaabove.
HencemethinksCshouldbetheanswer.
(Q.187) ApatientofRTAwithinjuryoverchestandlimbshaslowspo2.MmodeUSofrightupperpartofchestshowsstratospheresign.
Whatisthediagnosis?
(a)
Haemothotax
(b)
Pneumothorax
(c)
Cardiactamponade,
(d)
Pulmonaryembolism
YourResponse:
CorrectAnswer:
Exp:
Pneumothorax
REF:BedsideUltrasonographyforPneumothoraxAuthor:ZinaSemenovskaya,MD
http://emedicine.medscape.com/article/1883608overview#showall
Findingssuggestiveofpneumothorax
Thepresenceofapneumothoraxischaracterizedbytheabsenceof2findings:(1)theabsenceofpleural
(lung)sliding,and(2)theabsenceofsocalledcomettailartifacts.[12]Thesocalledlungpointisarelatively
recentlydescribedsignthat,althoughdifficulttoidentify,ispathognomonicforapneumothoraxandcan
beusedtomeasurethesizeofthepneumothorax.
Absenceofpleuralsliding
Innormalpatients,thepleurallinerepresentsboththeparietalandviscerallayersofthepleura,andback
andforthslidingofthatlineiseasilyvisualizedduringtherespiratorycycle.Inthepresenceofa
pneumothorax,airaccumulatesbetweenthe2layersandblockstransmissionofsoundwaves,sothatthe
slidingisnotvisualized.Thisphenomenoncanbeseeninrealtimeinthe2Dmodebutismoreeasily
visualizedbyviewingastillimageinMmode(motionmode;seethevideobelow).
Theappearanceofnormallunghasbeendescribedastheseashoresign(seethefirstimagebelow).This
termreferstothechangeinappearancebetweensofttissueandlung,dividedbythepleuralline,achange
resemblingthatbetweensandandseawaves.Inthepresenceofapneumothorax,thisdemarcationislost,
andtheappearanceonMmodeimagingisdescribedasthestratospheresign
Absenceofcomettails
Comettailsareartifactsthatarethoughttobecreatedwhenultrasoundwavesbounceofftheinterface
betweentheapposingvisceralandparietallayersofthepleura.Theyappearashypoechoicverticalraylike
projectionsoffthepleurallineandareparalleltotheribshadowspreviouslynoted
Thepresenceofairinthepleuralspaceinhibitsthepropagationofsoundwaves,preventingthe
appearanceofcomettails.Comettailartifactsmaybehardtovisualize,requiringconsiderablepatience;
thetransducershouldbekeptinafixedlocationonthechestasthedynamiclungisobservedsliding
throughouttheexpiratorycycle.Thepresenceofcomettailsis60%specificfortheabsenceof
pneumothorax.Combinedwiththeabsenceoflungsliding,theabsenceofcomettailshasanegative
predictivevalueof100%andaspecificityof96.5%.
Lungpoint
Thelungpointisamorerecentlydescribedsignthatispathognomonicforthepresenceofa
pneumothorax.Thelungpointistheactualpointatwhichthenormallungpattern(ie,lungslidingand
comettailartifacts)isreplacedbyapatternconsistentwithapneumothorax(ie,nolungslidingandno
comettailartifacts).
Thelungpointisadynamicsignand,likethecomettails,canbevisualizedonlybykeepingthetransducer
inafixedpositionandwatchingthepleurathroughouttherespiratorycycle.Thispointshouldbesoughtby
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longitudinallyscanningtheanterior,lateral,andposteriorpositionsofthechestwall.Althoughitisthe
mostspecificsignofpneumothorax,itisalsothehardesttovisualizeandmayrequireanexperienced
operatortolocate.Findingbothtransitionzones(fromnormallungtopneumothoraxandthenbackagain)
allowscalculationofpneumothoraxsize.
(Q.188) RegardingKawasakidisease,trueis?
(a) ItisaPolyarteritis
(b) Afeverof>37.5cshouldbepresentfor5daystomakethediagnosis
(c) Untreated,nearly2%ofchildrenwilldevelopcoronaryarteryaneurysms
(d) Intravenousimmunoglobulinshouldbegivenwithin3weeksofonsetofdisease
YourResponse:
CorrectAnswer:
Exp:
ItisaPolyarteritis
Kawasakidiseaseisaninfantilepolyarteritis.Thediagnosticcriteriaareafeverof>38.5Cfor>5days
togetherwith4ofthefollowingfeatures:
*Bilateralnonpurulentconjunctivitis.
*Oralmucosalchanges.
*Cervicallymphadenopathywithonenode>1.5cm.
*Involvementofhandsandfeetwitherythema,swellingorpeelingofthepalmsandsoles.
*Rash(polymorphus).
Thechildisusuallyextremelyirritable,withcoughorcoryzalsymptoms,andmayhavewaterydiarrhea.
Cardiaccomplicationsaresignificantcauseofmorbidity:coronaryarteryaneurysmsoccurinupto20%of
childrenwhoarenottreated.
Athrombocythaemiaisseeninthesecondandthirdweeks,andahighWCCandanaemiamaybeseen.
Managementiswithhighdoseintravenousimmunoglobulinover12hours,whichshouldbegivenwithin
10daysofdiseaseonset.Aspirinisgivenfor6weeksoruntilthecoronaryaneurysmsaregone,whichis
assessedbyechocardiogramatfollowup.
(Q.189) FollowingareusefulinRxofPPHinwomenwithRheumaticheartdiseaseexcept:
(a)
Oxytocin
(b)
Misoprostol
(c)
Methylergometrine
(d)
Carboprost
YourResponse:
CorrectAnswer:
Exp:
Methylergometrine
(RefDuttaobst.6thed447&Tableno.19,Williams,Obstetrics,21sted.,620,635)
TreatmentofPPH:
Ifuterusflabby:
a.Massageuterus
b.IVmethargin
c.Oxytocin
d.Bladdercatheterization
e.Examineexpelledplacenta
Ifstillflabby,exploretheuterus.
Injectionergometrine0.25mgorMethargin0.2mgisgivenintravenouslyfollowingthebirthofanterior
shoulder.Itshouldnotbeusedincardiaccasesorseverepreeclampsiaforfearofprecipitatingcardiac
overloadintheformerandaggravationofbloodpressureinthelatter.
(Q.190) Aprimigravidfemaleat37weeksofgestationhasmilduterinecontractions.Onexaminationshehasnoeffacementofcervixand
cervixisonly1cmdilateD.Therearearound10uterinecontractionsperhour.Sheishemodynamicallystableandnotindistress.
Whatisthemostappropriatemanagement?
(a)
Waitandwatch
(b)
TakeherforLSCS
(c)
Amniotomy
(d)
Inductionoflaborwithruptureofmembrane
YourResponse:
CorrectAnswer:
Exp:
Waitandwatch
Thisprimigravidfemaleat37weeksofgestationhasmilduterinecontractions.Shehasnoeffacementof
cervixandcervixisonly1cmdilated.Therearearound10uterinecontractions/hr.Sheisnotindistress,
hencebestmanagementwouldbewaitandwatch.
(Q.191) DiagnosisofectopicpregnancycanbemadewithpredictedbetahCGlevelsofmorethan:
(a)
1000mIU/ml
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(b)
(c)
2000mIU/ml
(d)
2500mIU/ml
1500mIU/ml
YourResponse:
CorrectAnswer:
Exp:
1500mIU/mL
(RefTeLindesOperativeGynecology10th/pg.804)
Presently,transvaginalultrasonographyreliablydetectsintrauterinegestationsasearlyas1weekafter
missedmenses(hCG>1,500IU/L;56weeks'gestation).Barnhartandassociatesreportedthatwitha
hCGconcentrationof1,500IU/Lorhigher,anemptyuterusontransvaginalultrasonographyidentifiedan
ectopicpregnancywith100%accuracy.EvenusingadiscriminatoryserumhCGconcentrationof1,000
IU/L,Cacciatoreandassociatesidentifiedanintrauterinegestationinallintrauterinepregnanciesandin
noneoftheectopicpregnancies.Furthermore,theseinvestigatorsreportedthatthedetectionofan
adnexalmassincombinationwithanemptyuterushadasensitivityof97%,specificityof99%,positive
predictivevalueof98%,andnegativepredictivevalueof98%,providedthatserumhCGconcentrations
exceeded1,000IU/L.ThecouplingofhCGtiterswithtransvaginalultrasonographicfindingshastherefore
greatlyfacilitatedtheearlydiagnosisofectopicgestation.
(Q.192) Confinedbloodchimerismisseenin:
(a)
Monochorionicdizygotictwins
(b)
Dichorionicdizygotictwins
(c)
Singletonpregnancy
(d)
Vanishingtwin
YourResponse:
CorrectAnswer:
Exp:
Monochorionicdizygotictwins
Confinedbloodchimerismisfrequentlyseeninmonochorionicdizygotictwining.
Thewordchimerismisusedwhenanorganismcontainscellpopulationfromtwoormorezygote.Thismay
beoftruechimerismorconfinedchimerism.
Intruechimerismadmixtureof2ormorezygoteoccursveryearlyinembryoniclifeandeverytissueof
individualincludingplacentaarechimeric.
Typicalexampleistruehermaphroditewith46,XX/46,XYchromosomecomplement.Inconfinedchimerism
admixtureof2ormorezygoteislimitedtoonetypeoftissueviz.blood(confinedbloodchimerism;CBC)or
placenta(confinedplacentalchimerism;CPC).
Mechanismforchimerismcouldbeduetoplacentalvascularanastamosisoranadmixtureoftrophoblastic
cellsduringearlyblastocystdevelopment.
CBCfrequentlyseeninmonochorionicdizygotictwining.
(Q.193) Anambiguousgenitaliaina46XXfemaleisunlikelytobedueto?
(a)
Earlyantenatalexposuretoandrogensfromfetaladrenals
(b)
Placentalsteroidsulfatasedeficiency
(c)
Fetalaromatasedeficiency
(d)
FetalWnt4mutation.
YourResponse:
CorrectAnswer:
Exp:
Placentalsteroidsulfatasedeficiency.
Anambiguousgenitaliaina46XXfemaleisunlikelytobeduetoPlacentalsteroidsulfatasedeficiency.
Fetaladrenalsteroidogenesisisestablishedatleastasearlyas8weeks.Consequently,CAHgirlshave
prolongedexposuretohighfetalconcentrationsofandrogens,particularlyinassociationwithsevere
CYP21A2.
Placentalsteroidsulfatasedeficiency:Xlinkedichthyosis(XLI)isaskinconditioncausedbythehereditary
deficiencyofthesteroidsulfatase(STS)enzymethataffects1in2000to1in6000males.XLImanifests
withdry,scalyskinandisduetodeletionsormutationsintheSTSgene.XLIandcanalsooccurinthe
contextoflargerdeletionscausingcontiguousgenesyndromes.Treatmentislargelyaimedatalleviating
theskinsymptoms.ThemajorsymptomsofXLIincludescalingoftheskin,particularlyontheneck,trunk,
andlowerextremities.Theextensorsurfacesaretypicallythemostseverelyaffectedareas.
(Q.194) Mostaccuratefordiagnosisofpregnancyinfemalewith6wksamenorrhea?
(a)
Usgshowingfetalcardiacactivity
(b)
Doppler
(c)
UrineforHCG
(d)
Uterussize
YourResponse:
CorrectAnswer:
Exp:
USGshowingfetalcardiacactivity
REF:Diagnosticultrasound:Carolrumack4thEd,Chap4,Chap32:Firsttrimesterultrasound.
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NowthedilemmaisbetweenA.USGVsB.Dopplermodeultrasound.These2methodsinvolvedirect
visualizationofthegestationalsacandfetalpoleascomparedtoUrineforHCGandUterinesize
estimation.
Thesinglemostimportantfeatureforconfirmationofembryonicandfetallifeistheidentificationof
cardiacactivity.UsingTransabdominalultrasound,cardiacactivityisalwayspresentwhentheembryois
visualizedthatiswithTASitisabnormaltovisualizeanembryowithoutdemonstratingcardicactivity.
Thecaveatisthattheexaminationmustbeofhighquality,usingmodernequipmentandtheentire
embryomustbevisualized.Itisessentialtouseahighframerateandtheframeaveragingmodemustbe
turnedoff.
UsingTVStheembryoandembryoniccardiacactivitycanbereliablyandconsistentlyidentifiedearlierthan
withTAS.AlthoughitisabnormaltoidentifyanembryowithoutcardiacactivitywithTAS,TVScanidentify
anormalembryowithoutcardiacactivity.
NowthequestiondoesnotmentionaboutTASorTVS.Nonethelesswhatinevitablyhappenswhenweturn
ontheDopplermodeisthattheFramerateofdisplaygoesdownsignificantly.Alsoat6weeksamenorrhea
thefetalpolevisualisedisonlyafewmillimetersinsize.ThusputtingaDopplerwindowonastructure
under5mminsize,andexpectingittodetectcardiacmotionIsindeedaskingtoomuch.Henceat6weeks
amenorrheaconsideringvariousfactorslike
Verysmallsizeoffetalpole(Fewmillimeters).
Needofhighframerate,withoutframeaveragingforproperimaging.
HighresolutionofroutineBmodeTAS/TVSscanning
TheMOSTACCURATEfordiagnosisofpregnancywillbeA.USGshowingfetalcardiacactivity.
(Q.195) A22yearoldnewlymarriedwomanconsultsyoubecauseofpainfulcoitus,withthepainlocatedatthevaginalintroitus.Itis
accompaniedbypainfulinvoluntarycontractionofthepelvicmuscles.Othersthanconfirmationthesefindings,thepelvic
examinationisnormal.Ofthefollowing,whatisthemostcommoncauseofthiscondition?
(a)
Endometriosis
(b)
Psychogeniccauses
(c)
Bartholinsglandabscess
(d)
Vulvaratrophy
YourResponse:
CorrectAnswer:
Exp:
Psychogeniccauses
Thispatientpresentswithvaginismus,definedasinvoluntarypainfulspasmofthepelvicmusclesand
vaginaloutlet.Itisusuallypsychogenic.Itshouldbedifferentiatedfromfrigidity,whichimplieslackof
sexualdesire,anddyspareunia,whichisdefinedaspelvicand/orbackpainorotherdiscomfortassociated
withsexualactivity.Dyspareuniaisfrequentlyassociatedwithpelvicpathologysuchasendometriosis
pelvicadhesions,orovarianneoplasms.Thepainofvaginismusmaybepsychogenicinorigin,ormay
becausebypelvicpathologysuchasadhesions,endometriosis,orleiomyomas.Treatmentofvaginismusis
primarilypsychotherapeutic,asorganicvulvarorpelviccauses(suchasatrophy,Bartholin'sglandcyst,or
abscess)areveryrare.
(Q.196) Uterineheightmorethancorrespondinggestationalagewithcomplainsofvomitingandpervaginalbleedingfavorsthediagnosis
of?
(a)
H.Mole
(b)
Threatenedabortion
(c)
Placentapreviae
(d)
Abruptioplacentae
YourResponse:
CorrectAnswer:
Exp:
H.mole.(RefDuttaObst.5thEd.206)
Hydatidiformmole/vesicularmole:
Abnormalconditionofovumwithpartlydegenerationandpartyhyperplasticchangesinyoungchronicvilli.
Itisbenignneoplasiaofchronicwithmalignantpotential.
HighestincidenceinPhilippines/[SoutheastAsia]
InIndia1in400.
Canbecompleteorincomplete.
Completemoleshave46XXKaryotype,molarchromosomesderivedentirelyfromFather(androgenous).
VesiclefluidisinterstitialfluidrichinHCG.
Thereisnotraceofembryooramnioticsac.
Vaginalbleedingcommonestpresentation(90%)
Expulsionofgrapelikevesiclespervaginumdiagnostic.
Featuresofpreeclampsiapresentinabout50%.
Sizeofuterusmorethanexpectedforperiodofammenorrheain70%,correspondswithperiodof
ammenorrheain20%andsmallerin10%.
Unilateralorbilateralenlargementofovary
(ThecaluteinCyst)in2550%ofcases.
USGSnowstormappearance.
HCGinurinebetween1in200to1in500beyond100dayshighlysuggestive.
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FeatureCompletemolePartialmole
Karyotype46xx(46,xy)Triploid
VillousedemaAlivillisomevilli
TrophoblastproliferationDiffuseFocal
AtypiaOftenpresentAbsent
HCGintissue+++++
Behavior2%choriocarcinomaRare
(Q.197) Whichofthefollowingistheprimarytreatmentforpubertymenorrhagiaina16yrsoldgirlwith3gm%Hb?
(a)
DandCwithbloodtransfusion
(b)
Danazolwithbloodtransfusion
(c)
Progestogenwithbloodtransfusion
(d)
OestrogenandProgestogenwithbloodtransfusion
YourResponse:
CorrectAnswer:
Exp:
OestrogenandProgestogenwithbloodtransfusion
Pubertymenorrhagiaisathresholdbleedingofadolescencecausedbyexcessorunopposed
Oestrogenandabsenceofprogesteroneintheanovulatorycycle.Anaemiamaydemandbloodtransfusion
orhaematinictreatment.Oestrogentherapyyieldgoodresultsbutisnotrecommendedduetohighdose
andsideeffects.ProgestogenandOCpillsareusedduringanepisodeofbleedingaswellaslaterto
regularizeandcontrolthemenstrualbleeding.Danazoliscontraindicatedinyounggirlsbecauseitmay
causehirsutism.Ifagirlfailstorespondtohormonaltherapycurettageofendomentriumisnecessaryto
ruleoutgenitalTBwhichisseenin4%ofthesegirls.
(Q.198) A36yearsoldladywith4monthsamenorrhoeapresentswithc/oirritabilityandheadache.HerFSHandLHincreasedestradiollow
diagnosisis:
(a)
PCOD
(b)
Prematuremenopause
(c)
Ovariantumor
(d)
Pituitaryadenoma
YourResponse:
CorrectAnswer:
Exp:
Prematuremenopause
Prematuremenopauseisdefinedassecondaryamenorrhoeaforatleast3monthswithraisedFSH,raised
FSH/LHratioandlowestrogenlevelinawomenunder40yrsofage.
(Q.199) Contradiisyndromeresultsfromtheuseofwhichdruginpregnancy?
(a)
Warfarin
(b)
Lithium
(c)
Phenytoin
(d)
Penicillin
YourResponse:
CorrectAnswer:
Exp:
Warfarin
IMPORTANTDRUGSANDTHEIRTERATOGENICEFFECTS:
DRUG
EFFECT
Isotretinoin
Craniofacialdefects:Cleftlip,cleft
palate,microcephaly
CNS:NTDs,Microcephaly,hydrocephalus
CVS:ASD,Conotruncalandoutflowtracteffects
Thymicandrenalmalformations
Lithium
Ebstiensanomaly
Tricuspidatresia
Fetalgoiter
Alcohol
FetalAlcoholSyndrome:microcephaly,mental
retardation,maxillaryhypoplasia,growth
retardation,ASD,PDA,VSD,microphthalmia
Methanol
Craniofacial:microcephalyandmaxillary
hypoplasia
Mentalandgrowthretardation
Phenytoin
FetalHydantoinsyndrome:
Microcephaly,cleftlipandpalate
Hypoplasticphalanges
Warfarin
Contradiisyndrome:
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1sttrimester:craniofacialabnormalities,
chondrodysplasiapunctate
2ndtrimester:CNSmalformations
3rdtrimester:riskofbleeding
Barbiturates
Riskofneonataldependence,congenitalheart
disease,
Tetracycline
Discolorationofteeth,bonegrowthretardation
Valproate
NTDs
Indomethacin
Prematureclosureofductusarteriosus
Stilbesterol
Clearcellvaginalcarcinoma
ACEinhibitors
Renaldamage
Thalidomide
Phocomelia
Carbimazole
Choanalatresia,patchyscalphairdefects,trachea
esophagealfistula,psychomotordelay,fetal
goiter,hypoplasticphalanges,
(Q.200) Lorcaserinisa
(a)
5HT2Cagonist
(b)
GABAinhibitor
(c)
SNRI
(d)
Noneoftheabove
YourResponse: a
CorrectAnswer: A
Exp:
5HT2Cagonist
Thisisaweightlossdrug
Serotonergicpropertiesactasanorectic
A.ItisthedrugofchoiceforobesetypeIIdiabetes.Itdoesnotcause
hypoglycemia.Q
SideEffectsmostcommonisheadache.nauseaanddiarrhoea.
ItshouldnotbeusedinCRF,liverfailure&alcoholics(duetoriskof
lacticacidosis).
ProlongusecancauseVitB12deficiency.
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