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

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


Question: 'Teichopsia' is seen in

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


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

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


Question: Kussmaul's sign is NOT seen in

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


Question: Purpura fulminans is a feature of

Ans. c (Acute Meningococcemia) (Ref. Harrison 18th/ p 114)ACUTE MENINGOCOCCEMIA# Neisseria meningitidis# Petechiae rapidly becoming numerous, sometimes enlarging and becoming vesicular;# Trunk, extremities most commonly involved;# May appear on face, hands, feet;# May include Purpura fulminans reflecting disseminated intravascular coagulation;# Most common in children, individuals with asplenia or terminal complement component deficiency (C5-C8);# Hypotension, meningitis (sometimes preceded by upper respiratory infection) may occur.PURPURA FULMINANS# Feature of severe disseminated intravascular coagulation# Characterized by Large ecchymoses with sharply irregular shapes evolving into hemorrhagic bullae and then into black necrotic lesions# Individuals with sepsis (e.g., involving N. meningitidis), malignancy, or massive trauma; asplenic patients at high risk for sepsis are predisposed.Educational points: Organism (Gram)ToxinMode of actionRole in diseaseProtein synthesis inhibitorsCorynebacterium diphtheria (Th)Diphtheria toxin# ADP ribosyl transferase inactivates EF-2# Targets: heart, nerves, epitheliumInhibits eukaryotic cell protein synthesis Pseudomonas aeruginosa (- )Exotoxin A# ADP ribosyl transferase inactivates EF-2# Target: liverInhibits eukaryotic cell protein synthesis Shigella dysenteriae (-)Shiga toxinInterferes with 60S ribosomal subunit# Inhibits protein synthesis in eukaryotic cells# Enterotoxic, cytotoxic, and neurotoxic Enterohemorrhagic E coli (EHEC) (-)Verotoxin(Shiga-like)Interferes with 60S ribosomal sunbmitInhibits protein synthesis in eurokaryotic cellsNeurotoxinsClostridium tetani (Th)Tetanus toxinBlocks release of glycine and GABAInhibits neurotransmission in inhibitor synapses Clostridium botulinum (Th)Botulinum toxinBlocks release of acetylcholineInhibits cholinergic synapsesEndotoxin enhancersStaphylococcus aureus (Th)TSST-1# Pyrogenic, decreases liver clearance of LPS# SuperantigenFever, increased susceptibility to LPS, rash, shock, capillary leakage Streptococcus pyogenes (Th)Exotoxin A, also called erythrogenic or pyrogenic toxinSimilar to TSST-1Fever, increased susceptibility to LPS, rash, shock, capillary leakage, cardiotoxicityCAMP inducersEnterotoxigenicEscherichia coli (-)Heat labile toxin (LT)LT stimulates an adenylate cyclase by ADP ribosylation of GTP-binding proteinBoth LT and ST promote secretion of fluid and electrolytes from intestinal epithelium Vibrio cholerae (-)Cholera toxinSimilar to E. coli LTProfuse, watery diarrhea Bacillus anthracisAnthrax toxin (3 proteins make 2 toxins)# EF = edema factor= adenylate cyclase# LF - lethal factor# PA = protective antigen (B component for both)# Decreased phagocytosis# Causes edema, kill cells Bordetella pertussis (Th)Pertussis toxinADP ribosylates GI, the negative regulator of adenylate cyclase, leading to increased cAMP# Histamine sensitizing# Lymphocytosis promotion# Islet activationCytolysinsClostridium perfringens (Th)Alpha toxinLecithinase# Damages cell membranes# Myonecrosis Staphylococcus aureus (Th)Alpha toxinPore formerMembrane becomes leaky


Question: Carcinoid tumour is most common in

Answer is D (Appendix); Antong, the given option the most common site of carcinoid tumour is appendix. Carcinoid tumor location, Frequency of Metastases, and Association with the Carcinoid Syndrome Site Location (% of Total) Incidence of Metastases Incidence of Carcinoid Syndrome Foregut Esophagus <0.1 - - Stomach 4.6 10 9.5 Duodenum 2.0 - 3.4 Pancreas 0.7 71.9 20 Gallbladder 0.3 17.8 5 Bronchus, lung, trachea 27.9 5.7 13 Midgut Jejunum Ileum 1.8 14.9 158.4 9 9 Meckel's diveiculum 0.5 13 Appendix Colon Liver Ovary Testis Hindgut 4.8 8.6 0.4 1.0 <0.1 38.8 51 32.2 32 - <1 5 - 50 50 Rectum 13.6 3.9 -


Question: Biot's respiration is seen in

(D) Bulbar poliomyelitis # Biot's breathing is caused by brain damage, increased intracranial pressure and drug-induced respiratory depression.> Biot's respiration, sometimes also called ataxic respiration, is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. It generally indicates a poor prognosis. Biot's respiration is caused by damage to the medulla oblongata due to strokes or trauma or by pressure on the medulla due to uncal or tentorial herniation. It can be caused by opioid use.


Question: A 40 year old man was admitted to the hospital emergency with sudden onset of the symptoms and signs of severe left ventricular failure. Calculate the atrial rate of the patient.

Ventricular rate : 1500/10 = 150 ECG shows HR of 150/min with normal axis. Saw tooth waves are noted with 2:1 AV block. Ventricular rate is 150/min therefore the atrial rate would be 300/min.


Question: Non modifiable risk factor for hypertension

Cultural characteristic acquired over time


Question: A 40 years males presented with painful vesicular lesion in the forehead extending to the eyelids. Diagnosis is

(Herpes- Zoster) (52-Roxburg's 17th) (1182- CMDT-08)* Herpes simplex - manifest as acute gingivo-stomalitis, herpes labialis**, balanitis, vulvo-vaginitis, proctitis or kerato conjunctivitis* Intraepidermal vesicles around the mouth and lip (Type I) on the genitalia (Type II)* Herpes Zoster (Shingles) - Involvement of the branches of trigeminal ganglion, with lesions in the distribution of the maxillary, mandibular or ophthalmic sensory nerves as is involvement of dermatomes of the cervical and thoracic regions* H. Zoster affecting the opthalmic branch of the trigeminal nerve involving the right side of the forehead and eye and corneal ulcerations (.Hutchinson's sign)* The eruption consists of grouped tense vesicles or even bullae surrounded by a zone of erythema characteristically limited to a singe neural segment and is strictly unilateralMolluscum Contagiosum - transmitted by skin to skin contact* Typical lesion is a pink - coloured or skin coloured umbilicatedpapule** containing a greyish central plug, face and genital regions are commonly involved* A live attenuated VZV vaccine helps prevent herpes Zoster in persons 60 years and older


Question: An elderly male presents with pain in his shoulders and hips. Temporal arteries are tender to palpation. ESR is 105 mm/L.

The large vessel vasculitides include temporal (giant cell) arteritis and Takayasu arteritis. Temporal arteritis typically occurs in older patients and is accompanied by aching in the shoulders and hips, jaw claudication, and a markedly elevated ESR. Takayasu arteritis, a granulomatous inflammation of the aorta and its main branches, typically occurs in young women. Symptoms are attributed to local vascular occlusion and may produce arm or leg claudication. Systemic symptoms of arthralgia, fatigue, malaise, anorexia, and weight loss may precede the vascular symptoms. Surgery may be necessary to correct occlusive lesions.

Granulomatosis with polyangiitis (Wegener granulomatosis)


Question: Localisation of parathyroids in hyperparathyroidism is done best with


Question: For the following medical conditions, select the associated acid base disturbances.Sepsis.

Sepsis can cause cardiovascular insufficiency with lactic acidosis, whereas fever and endotoxemia stimulate the respiratory center, causing respiratory alkalosis.

metabolic acidosis and respiratory acidosis

metabolic acidosis and respiratory alkalosis

metabolic alkalosis and respiratory acidosis

metabolic alkalosis and respiratory alkalosis


Question: Philadelphia (Ph) chromosome

i.e. (Balanced translocation): (414-H17th) (493-94-CMDT-l1)The Philadelphia chromosome (Ph) is derived from a reciprocal translocation between chromosome 9 and 22 with the break point joining the sequence of ABL oncogene with the BCR gene. The fusion of these DNA sequences allows the generation of an entirely noval fusion protein with modified functionReciprocal translocation generates Ph chromosomes Fusion of BCR and ABL gene sequences Chimeric BCR-ABL *protein-- The first reproducible chromosome abnormality detected in human malignancy was the Philadelphia chromosomes detected in CMLOther example - Translocations of MYC in Burkitt's lymphoma


Question: Suprasellar aneurysms causes

(B) Bitemporal hemianopia # Sagittal (central) lesions of the chiasma.These are characterized by bitemporal hemianopia and bitemporal hemianopic paralysis of pupillary reflexes.> Lateral chiasmal lesions: Salient features of such lesions are binasal hemianopia associated with binasal hemianopic paralysis of the pupillary reflexes.> Lesions of optic tract:These are characterized by incongruous homonymous hemianopia associated with contralateral hemianopic pupillary reaction (Wernicke's reaction).


Question: Wilson's disease is characterized by

Wilson's disease (hepatolenticular degeneration) is a rare but impoant autosomal recessive disorder of copper metabolism caused by a variety of mutations in the ATP7B gene on chromosome 13. Total body copper is increased, with excess copper deposited in, and causing damage to, several organs. Normally, dietary copper is absorbed from the stomach and proximal small intestine and is rapidly taken into the liver, where it is stored and incorporated into caeruloplasmin, which is secreted into the blood. The accumulation of excessive copper in the body is ultimately prevented by its excretion, the most impoant route being bile. In Wilson's disease, there is almost always a failure of synthesis of caeruloplasmin; however, some 5% of patients have a normal circulating caeruloplasmin concentration and this is not the primary pathogenic defect. The amount of copper in the body at bih is normal but thereafter it increases steadily; the organs most affected are the liver, basal ganglia of the brain, eyes, kidneys and skeleton . Ref - Davidsons medicine 23e p896

Low serum ceruloplasmin and low urinary copper

Low serum ceruloplasmin and high urinary copper

High serum ceruloplasmin and low urinary copper

High serum ceruloplasmin and high urinary copper


Question: Anaemia due to antibodies against blood group antigens

Answer- C. Haemolytic disease of the newbornHemolytic disease of thefetus and newborn (HDFN), also known as alloimmune HDFN or erythroblastosis fetalis, is caused by the destruction of reil blood cells (RBCs) of the neonate or fetus by maternal IgG antibodies.


Question: Criteria for Brainstem death includes

Harrison's principles of internal medicine 17th edition. *Cardinal signs of death are cessation of cardiac function and respiration,pupils become fixed,body becomes cool,muscles and incontinence may occur

Absent pupillary light reflex and delated pupils


Question: Most common lung cancer due to tobacco


Question: In Wood's lamp examination, green fluorescence detects

(Pseudomonas) (287-88-H 16th) (312, 326-H17th)WOOD'S LIGHT - A wood's lamp generates 360 nm ultraviolet (or black) light that can be used to aid the evaluation of certain skin disorders- Examples.* Erythrasm caused by corynebacterium minutis-simum) to show characteristic coral red color.* Wound colonized by Pseudomonas to appear pale blue.* T.capitis caused by dermatophytes such as Microsporum canis or M. audouini exhibits a yellow fluorescence* Post inflammatory hyperpigmentation fades under Wood's light.* Vitiligo appears totally white under a Wood's lamp.* A Wood lamp may also aid in the demonstration of tinea versicolor and in recognition of ash led spots with tuberous sclerosis.


Question: Systemic Millary TB spreads


Question: Marked decreased FEV1 and FEV1/ FVC ratio are seen in

In obstructive diseases like asthma,marked fall in FEV1 and FEV1/FVC ratio is present.In restrictive diseases like kyphoscoliosis and fibrosis,lung volumes like TLC,FRC,RV as well as FVC are lowered.Maximal expiratory flows like FEV1 are also reduced compared with normal values,but are relatively elevated when considered in relation to lung volumes.So FEV1/FVC ratio will be normal or slightly increased Ref:Harrison's medicine-18th edition,page no:2093.


Question: Relative risk of developing TB in patients already infected with TB bacilus is highest in

Ans. is 'c' i.e., Post transplantation Relative risk of developing T.B. Post transplantation 20-70 HIV 30 Silicosis 30 Recent infection 12 Diabetes 3-4 Malnutrition 2-3


Question: Most common cause of renal artery stenosis in  young females .

Elderly - m/c cause - Atherosclerosis.
Young females - m/c cause - Fibromuscular dysplasia.


Question: The best marker to diagnose thyroid related disorder is

Answer is C (TSH) : The enhanced sensitivity and specificity of TSH assays have greatly improved laboratory assessment of thyroid function - Harrison With rare exceptions a normal TSH level excludes a primary abnormality of thyroid function.- Harrison Approach to thyroid testing: Because TSH change dramatically in response to alteration of free T4 and T3, a logical approach to thyroid testing is to determine first whether TSH is suppressed, normal or elevated - Harrison


Question: Cystatin C is a novel marker of


Question: Duration of apnea in OSAS is


Question: Most common cause and the most common valve affected in Infective endocarditis in I.V drug abusers

In I.V drug abusers it is staph.aureus to cause Infective endocarditis most commonly and the right sided valves are more commonly affected than the left sided valves


Question: Hepatic secretory function is evaluated using

Answer- D. Prothrombin time (PT)The most widely used tests are those measuring the blood concentration of aspaate aminotransferase (AST) and alanine aminotransferase (ALT).Congulation proteins: The easiest way to estimate the concentration of the coagulation factors is by measuring the prothrombin time (PT), which is normally l0 to 13 seconds. Prolonged PT is a sensitive index of liver function loss.


Question: Sun damage causes malignant transformation of skin by

The most significant cause of BCC and SCC is UV exposure whether through direct exposure to sunlight or by aificial UV light sources (tanning beds). Both UVA and UVB can induce DNA damage through free radical formation (UV A) or induction of pyrimidine dimers (UVB). The sun emits energy across the UV spectrum whereas tanning bed equipment typically emits 97% UV A and 3% UVB Thymine Dimers and Skin Cancercauses of skin cancer : Pathophysiology: UV light causes a crosslink in the DNA The absorption of UV light by a molecule promotes an electron from a filled orbital, to an unfilled orbital such as a non-bonding orbital or antibonding orbital. This makes the molecule potentially very reactive, and in ceain situations can result in new bonds being made between different molecules. This is especially impoant for ceain molecules containing pi bonds such as the DNA bases. In paicular, when thymine absorbs UV light, is becomes reactive with an adjacent thymine molecule in the DNA double helix and can lead to formation of a cyclobutane dimer in which the two thymine residues are covalently linked. This makes it impossible for RNA polymerase to make an accurate mRNA from the DNA, so it effectively prevents the cell from being able to use the DNA to make the correct protein or even replicating. Cytosine residues can also form similar crosslinks. The general term used in the literature to describe these dimers is "cyclobutane pyrimidine dimers, or CPDs". Heavy exposure of your skin to UV light causes many such thymine crosslinks to form in the DNA. Founately, we have repair enzymes that can remove the thymine crosslinks and restore the DNA in your skin cells back to the correct sequence. When you get a sunburn, it is because you have caused more thymine crosslinks than can be repaired, so the cells generally just die. This results in the pain and dead skin you get with sunburns. However, in very rare cases, the thymine dimers interupt the funcions of just the right genes so that your skin cells become cancerous. In other words, they sta growing and do not stop like they should. You get tumors, and eventually the cancer cells invade vital organs and prevent an impoant function in your body and you could die. Reference: Harrisons Textbook of Internal Medicine; 19th edition


Question: Target BP before thrombolysis in ischemic stroke is below


Question: "Anhedonia" means

Defined as the inability to experience pleasure from activities usually found enjoyableAnhedonia can be characteristic of:Mood disordersSchizoaffective disorderBorderline personality disorderSchizoid personality disorderSchizophreniaRef: Ahuja 5/e p56, 58


Question: Mast cell stabilizer used in Bronchial Asthma is

Mast cells are impoant in initiating the acute bronchoconstrictor responses to allergens & several other indirectly acting stimuli like exercise and hyperventillation.Ketotifen is a mast cell stabilizer which reduces the stimulation of mast cells and mediator release is reduced(histamine,PGD2,leukotrienes). Dose:1-2 mg BD;children 0.5 mg BD Reference:Harrison' s medicine-18th edition,page no:2104;Textbook of pharmacology-K D Tripathi,7th edition,page no:229


Question: Brain death is said to occur if there is

(C) Absence of brainstem reflexes # BRAIN DEATH is present when there is irreversible loss of all brain function, both brain-stem function & cortical (hemisphere) function.> Brain death criteria - Loss of brainstem function & Absent cranial nerve reflexes - Pupillary light reflex; Corneal reflex; Oculoves-tibular reflex (cold caloric test; No gag reflex).> Absent respiratory brainstem reflexes is done by Apnea test: Loss of cortical function (No spontaneous movement; no response to external stimuli); Irreversibility.> Brain death is present when there is irreversible loss of brain function (criteria-loss of brainstem function) absent cranial nerve reflexes, pupillary light reflex, corneal reflex, oculovestibular reflex.

Cortical death following widespread brain injury

Core temperature of the body is below 35degC


Question: Caplan's syndrome is

Rheumatoid Arthritis + Pneumoconiosis nodules = Caplan's syndrome.
Neutropenia + Splenomegaly + Nodular RA = Felty's syndrome.


Question: Most effective medication in GERD

(A) PPI > They self-medicate with over the counter medicines such as simple antacids, antacid-alginate preparations and H2recepto' antagonists.> PPis, such as Omeprazole, lansoprazole and pantoprazole, are by far the most effective drug treatment for GERD.


Question: Punctuate yellow exudates in colon, found on endoscopic examiantion are indicative of


Question: Gradient in pulmonary aery wedge pressure and left ventricular end diastolic pressure is seen in

Answer is C (Left atrial myxoma) An increased gradient during diastole is suggestive of an obstructive lesion between Left atrium and Left ventricle that is not allowing pressures to normalize between the atria and ventricle such as atrial myxoma. Pulmonary aery wedge pressure represents Left atrial pressure. Left ventricular end diastolic pressure represents Left ventricular pressure. Gradient between Left atrial pressure (PCWP) and Left ventricular pressure during diastole: Normally there is no gradient during diastole as both pressures are equal. An increased gradient during diastole is suggestive of an obstructive lesion between Left atrium and Left ventricle that is not allowing pressures to normalize between the atria and ventricle. This may thus be seen in obstructive lesions between Left atria and ventricle such as : Mitral stcnosis Atrial myxomas


Question: Lyme disease is

diagnosed by demonstration of specific IgM antibody

the etiological agent can be grown in modified Kelley's medium


Question: Factor I and H deficiency causes

A typical HUS (Non - epidemic, diarrhea negative) : common cause factor H & I deficiency.


Question: Treatment therapy for Pneumocystis carinii infection is

(Co-trimoxazole) (1362-63-CMDT-09)Infection or MalignancyTreatmentPoenumocystis carinii/ JiroveciTrimethoprim-sulfamethoxazole orally or IV for 14-21 daysPentamidine, Trimethoprim, Primaquine, Atovaquone, TrimetrexateMycobacterium avium complex infectionClarithromycin with ethambutolToxoplasmosisPyrimethamine with sulfadiazine and Folinic acidLymphomaCombination chemotherapy (eg. Modified CHOP, M-BA COD, with or withoutG-CSF or GM-CSF)Central nervous system disease: radiation treatment with dexamethasone for edemaCryptococcal meningitisAmphotericin B, with or without flucytosineFluconazoleCytomegalovirus infectionValganciclovir, Ganciclovir, FoscametEsophageal candidiasis or recurrent vaginal candidiasisFluconazoleHerpes simplexAcyclovir, Famciclovir, Valacyclovir, FoscarnetHerpes zosterAcyclovir, Famciclovir, Valacyclovir, FoscarnetKaposis sarcoma Limited cutaneous diseaseObservation, intralesional VinblastineExtensive or aggressive cutaneous diseaseSystemic chemotherapy (eg. Liposomal Doxorubicin) Alpha interferon (For patients with CD4 > 200 cells/m/L and no constitutional symptoms).Radiation (amelioration of edema)Visceral disease(eg. Pulmonary)Combination chemotherapy (e.g. Daunorubicin, Bleomycin, Vinblastin)


Question: Cardioselective beta blockers is contraindicated in

(B) II & III degree heart block# Except for those drugs specifically approved for use in heart failure, beta blockers are contraindicated in heart failure patients> Side effects of beta-blockers are related to their cardiac mechanisms and include bradycardia, reduced exercise capacity, heart failure, hypotension, and atrioventicular (AV) nodal conduction block.> Beta-blockers are therefore contraindicated in patients with sinus bradycardia and partial AV block.> Non-selective beta-blockers are contraindicated in patients with asthma or chronic obstructive pulmonary disease which is not a contraindication for cardioselective beta blockers.


Question: Clubbing is not seen in


Question: Pyknolepsy is seen in

Pyknolepsy refers to a syndrome of typical absence seizures (both simple and complex) in otherwise normal, prepubeal children older than about 3 to 5 years. There is a strong genetic predisposition, and girls are more frequently affected. The absences are very frequent (occurring at least several times daily), and tend to cluster. The absences may remit during adolescence, but generalized tonic-clonic seizures may develop. The EEG reveals a bilateral, synchronous, symmetric 3-Hz spike-and-wave discharge with normal interictal background activity. No distinct clinical or EEG features completely differentiate childhood absence epilepsy from juvenile absent epilepsy Ref Harrison20th edition pg 2234


Question: A ventilator pressure relief valve stuck in closed position can result in

A ventilator pressure relief valve stuck in closed position can generate excessively high pressure in the patient's lung,resulting in barotrauma.Barotrauma and volutrauma overdistend and distrupt lung tissue;may be clinically manifest by interstitial emphysema,or pneumothorax;and can result in the liberation of cytokines from over distended tissues,fuher promoting tissue injury. Reference:Harrison's Medicine


Question: Treatment of choice for Echinococcus granulosus is.

Answer is A (Albendazole): The drug of choice for treatment of Echinococcus granulosus injection (Hydatid cyst) is Albendazole.


Question: Kussumauls breathing

Rapid,deep(Kussmaul) breathing usually implies metabolic acidosis but may also occur with pontomesencephalic lesions. Ref:Harrison's medicine -18th edition,page no:2251.


Question: A patient develops Mitral Regurgitation following myocardial infarction. The likely cause for this complication is

(B) Rupture of chorda tendinae # MR is frequently secondary to ischemia.> Thus, it may occur as a consequence of ventricular remodeling or with fibrosis of a papillary muscle in patients with healed myocardial infarction.> It may develop acutely in patients with acute infarction involving the base of a papillary muscle.


Question: Mental retardation is NOT a feature of one of the mucopolysaccaridos

Mucopolysaccharidoses (MPS) The MPSs are a group of closely related syndromes that result from genetically determined deficiencies of enzymes involved in the degradation of mucopolysaccharides (glycosaminoglycans). Chemically, mucopolysaccharides are long-chain complex carbohydrates that are linked with proteins to form proteoglycans. They are abundant in the ground substance of connective tissue. The glycosaminoglycans that accumulate in MPSs are dermatan sulfate, heparan sulfate, keratan sulfate, and chondroitin sulfate. The enzymes involved in the degradation of these molecules cleave terminal sugars from the polysaccharide chains disposed along a polypeptide or core protein. In the absence of enzymes, these chains accumulate within lysosomes in various tissues and organs of the body. Several clinical variants of MPS, classified numerically from MPS I to MPS VII, have been described, each resulting from the deficiency of one specific enzyme. All the MPSs except one are inherited as autosomal recessive traits; the exception, Hunter syndrome, is an X-linked recessive trait. Within a given group (e.g., MPS I, characterized by a deficiency of a-l-iduronidase), subgroups exist that result from different mutant alleles at the same genetic locus. Thus, the severity of enzyme deficiency and the clinical picture even within subgroups are often different. In general, MPSs are progressive disorders, characterized by coarse facial features, clouding of the cornea, joint stiffness, and mental retardation. Urinary excretion of the accumulated mucopolysaccharides is often increased. Ref Robbins 9/e pg 154


Question: A boy is suffering from acute pyelonephritis. Most specific urinary finding will be

Ans. is 'a' i.e. W.B.C. casts RememberThey have specifically asked about pyelonephritis, not urinary tract infection. There are three basic forms of urinary tract infectionPyelonephritisCystitisAsymptomatic bacteriuriapyelonephritisUrinary tract infection involving the renal parenchyma, if there is no parenchymal involvement, the condition may be termed pyelitis.cystitisIt indicates bladder involvement.asymptomatic bacteriuriaIt refers to individuals who have a positive urine culture without any manifestation of infection and occur almost exclusively in girls. Remember that casts can only be formed in the kidney. The presence of cast is specific for kidney. Casts cannot be formed from anywhere else in the urinary tractCasts are the only elements found in urinary sediments which are unique to the kidney.Thus whenever WBC casts are present in a patient suspected of having urinary tract infection it confirms pyelonephritis.According to Harrison "leucocyte casts can be detected in urine of only selected patients but the detection of these casts is pathognomic"About "Bacteria in gram stain"Bacteria in gram stain can be positive in any type of urinary tract infection whether it is pyelonephritis, cystitis, or urethritis.Presence of bacteria confirms the urinary tract infection but the exact site is detected by W.B.C. casts.Still of am not sure of the answer, because on page 251 Harrison states "The presence of bacteria suggests infection and white blood cell casts with bacteria are indicative of pyelonephritis. White blood cells and or white blood cell casts may also be seen in tubulointerstitial processes such as interstitial nephritis, S.L.E and transplant rejection"Nitrite testMore than 90% of common urinary pathogen (gram negative rods) are nitrite producing bacteria.In the presence of infection urinary nitrate is converted to nitrite which can be detected in urine.A positive nitrite test indicates infection with nitrite producing bacteria.Leucocyte esterase testA positive test is seen in presence of WBC's in urine and suggestive of pyuria.A positive leucocyte esterase test results from the presence of WBC. A negative leucocyte esterase test indicates that an infection is unlikely and that without additional evidence of urinary tract infection urine culture need not be.Once again, make it clear"Although white cell casts may be observed in other conditions they are along with other features of UT1 specific for acute pyelonephritis "'

Urinary Tract Infections and Interstitial Cystitis


Question: The number of major hormones produced by the anterior pituitary gland is

Six major hormones produced by anterior pituitary gland are Prolactin (PRL), Growth hormone (GH), Adrenocoicotropin hormone (ACTH), Luteinizing hormone (LH), Follicle-stimulating hormone (FSH) & Thyroid-stimulating hormone (TSH).Reference: Harrison 19th edition 401e-1


Question: Most common cause of death in amyotropic lateral sclerosis is

Answer-B. Respiratory failureAmyotrophic lateral sclerosis (ALS) is the most cornmon form of progressive motor neuron disease. It is a prime example of a neurodegenerative disease and is arguably the most devastating ofthe neurodegenerative disorders.Respiratory failure is the leading cause of death in amyotrophic lateral sclerosis, and terminal dysnoea is a major fear in patients with amyotrophic lateral sclerosis.


Question: Bronchial asthma patient on artificial ventilation requires


Question: Amaurosis fugax is caused by occlusion of

(C) Central retinal artery # Amaurosis fugax> It refers to a sudden, temporary and painless monocular visual loss occurring due to a transient failure of retinal circulation.> Its common causes are: carotid transient ischaemic attacks (TIA), embolization of retinal circulation, papilloedema, giant cell arteritis, Raynaud's disease, migraine, as a prodromal symptom of central retinal artery or carotid artery occlusion, hypertensive retinopathy, and venous stasis retinopathy.> An attack of amaurosis fugax is typically described by the patients as a curtain that descends from above or ascends from below to occupy the upper or lower halves of their visual fields.> The attack lasts for two to five minutes and resolves in the reverse pattern of progression, leaving no residual deficit.> Due to brief duration of the attack, it is rarely possible to observe the fundus.> When observed shortly after an attack, the fundus may either be normal or reveal signs of retinal ischemia such as retinal oedema and small superficial haemorrhages.> In some cases, retinal emboli in the form of white plugs (fibrin-platelet aggregates) may be seen.)


Question: Moderate increase in serum aminotransferases with ASTiALT > 3 is suggestive of

Ans. c (Alcoholic liver disease) (Ref: Harrison's Internal medicine 18th/Table 307-2)AST, ALTPredictors of alcoholic liver diseaseMild to moderate increaseMarked increaseAST> ALT= 2:1- suggestive.Fatty Liver pregnancyDrug-induced hepatitisAST > ALT = 3:1- Highly suggestive.Alcoholic liver diseaseCCFr GTP- Raised in all alcoholicsChronic hepatitisViral hepatitis (Acute)ALP- Moderate TPOOR PREDICTORS OF ALCOHOLIC HEPATITIS# PMN > 55,00/c mm# Discriminant score > 32# D.S = 4.6 X Prothrombin time control + Serum Bilirubin# Drug used for treatment: Prednisolone (DOC)-preferred choice; others-Pentoxiphylline, TNF a InhibitorsLaboratory Diagnosis of Alcoholic Fatty Liver and Alcoholic HepatitisTestCommentASTIncreased two- to sevenfold, <400 U/L, greater than ALTALTIncreased two- to sevenfold, <400 U/LAST/ALTUsually >1GGTP (maglutamyl transpeptidase)Not specific to alcohol, easily inducible, elevated in all forms of fatty liverBilirubinMay be markedly increased in alcoholic hepatitis despite modest elevation in alkaline phosphatasePolymorphonuclear cellsIf >5500/L, predicts severe alcoholic hepatitis when discriminant function >32


Question: MELD score includes A/E

Ans. is 'a' i.e., Sr. creatinine The Model for End-stage Liver Disese (MELD) is a prospectively developed and validated chronic liver disease severity scoring system that uses a patient's laboratory values for - Li Serum bilirubin Serum creatinine The international normalized ratio (INR) for prothrombin time to predict three month survival. Patients with cirrhosis, and increasing MELD score is associated with increasing severity of hepatic dysfunction and increased three-month moality risk. Given its accuracy in predicting sho-term survival among patients with cirrhosis, MELD was adopted by the United network for organ sharing (UNOS) in 2002 for prioritization or patients awaiting liver trasplantation in the United states. Pediatric end stage liver disease (PELD) Serum bilirubin INR Serum albumin Age Nutritional status


Question: A patient was on antiepileptics. Hirsutism, coarsening of facial features, gingival hyperophy is noted in the patient. The epileptic could be

Long-term use of phenytoin is associated with untoward cosmetic effects (e.g., hirsutism, coarsening of facial features, gingival hyperophy) and effects on bone metabolism. Due to these side effects, phenytoin is often avoided in young patients who are likely to require the drug for many years.Ref: Harrison 19e 2552


Question: A 25 year old patient complains of Crushing chest discomfort for 45 minutes, no significant medical history. ECG is normal. His chest pain improved with sublingual nitroglycerin diagnosis is

DES →
Chest pain simulate that of MI
Pain can be precipitated by drinking cold liquids.


Question: Indication for prophylaxis in pneumocystis carini pneumonia include

Ans. is 'a' i.e., CD4 count < 200 PROPHYLAXIS OF PNEUMOCYSTIC CARINH PNEUMONL4 Primary prophylaxis is indicated for Patients with CD4- cell counts of< 200/4 History of oropharyngeal candidiasis Secondary prophylaxis is indicated for Both HIV infected and non HIV infected patients. Who have recovered from pneumocystosis. Primary and secondary prophylaxis may be discontinued in HIV infected persons once. CD4+ counts have risen to > 200/p1 and remained at that level for 3 months. Also know First choice agent for prophylaxis Trimethoprim, sulphamethoxazole. Other agents used in prophylaxis. Dapsone, pentamidine.


Question: A patient comes with sudden respiratory distress, on examination, bilateral basal crepts are present over chest suggestive of pulmonary edema with normal alveolar wedge pressure. The likely cause is

Answer is A (Narcotic overdose): Pulmonary edema with normal pulmonary capillary wedge pressure suggests a diagnosis of ARDS or non cardiogenic pulmonary edema. Narcotic overdose is the only non cardiogenic cause for pulmonary edema (ARDS) amongst the options provided and hence the answer here.


Question: The most common causative organism causing lobar pneumonia is

Although Streptococcus pneumoniae is most common, other organisms must also be considered in light of the patient&;s risk factors and severity of illness.(Ref: Harrison's 18/e p2131)


Question: Gamma Glutamyl Transferase is increased in

(A) Alcoholic hepatitis # Function of GGT:> It is involved in the transfer of amino acids across the cellular membrane and in glutathione metabolism.> Location> GGT is found in high concentrations in the liver, bile ducts and kidney.> Enzyme is also present in other tissues, such as the epididymis.> Clinical significance Congestive heart failure Cholestasis (congestion of the bile ducts) Cirrhosis of the liver Restricted blood flow to the liver Restricted venous outflow from liver like Budd-Chiari syndrome Necrosis of the liver Liver tumors Hepatitis Hepatotoxic drugs> Its levels are increased in chronic and acute alcohol abuse.


Question: AIDS was first diagnosed in patients suffering from


Question: CSF glucose level is


Question: Positive hepatojugular reflux is found in

As is the case for TS, the clinical features of TR result primarily from systemic venous congestion and reduction of CO. With the onset of TR in patients with PA hypeension, symptoms of pulmonary congestion diminish, but the clinical manifestations of right-sided hea failure become intensified. The neck veins are distended with prominent v waves and rapid y descents, marked hepatomegaly, ascites, pleural effusions, edema, systolic pulsations of the liver, and a positive hepatojugular reflex. ref : Harrison&;s principle of internal medicine,20th edition,pg no.1948


Question: 100% recurrence of disease in Down's syndrome

100% recurrence of disease in Down's syndrome is due to balanced translocation (21 : 21).


Question: Celiac sprue is associated with

The precise mechanism of mucosal damage is unclear but immunological responses to gluten play a key role . There is a strong genetic component, with around 10% of first-degree relatives of an index case affected, and there is strong (approximately 75%) concordance in monozygotic twins. There is a strong association with human leukocyte antigen (HLA)-DQ2/DQ8. Dysbiosis of the intestinal microbiota has been identified but it is unclear if this is pathological or a response to the underlying mucosal changes Ref Davidson edition23rd pg 805


Question: Most common cause of epidural abscess

Harrison's principles of internal medicine. * Staphylococci or gram negative organisms are the usual cause of an epidural abscess


Question: Earliest feature in Multiple sclerosis is

* Initial Symptoms and percent of cases Sensory loss -37% Optic neuritis- 36% Weakness -35% Ataxia-11%. Optic nerve Pain and temporary vision loss in one eye are common symptoms of optic neuritis. Optic neuritis is linked to multiple sclerosis (MS), a disease that causes inflammation and damage to nerves in your brain and spinal cord Ref Davidson edition23rd pg1110


Question: Mycosis fungoides is best described as

Ans d: (Cutaneous Lymphoma) Ref: Harrison 17th edition pg 697 Mycosis fungoides is a lymphoid neoplasm of mature T cell * Median age of presentation - mid fifties * Males > females * Indolent lymphoma with patient often having several years of eczematous or dermatitic skin lesions before diagnosis is established * Skin lesions progress from patch- plaque & cutaneous tumours * Advanced stage lymphoma spread to lymph node and viscera * Patient with this may develop generalised erythroderma and circulates tumour cells- Sezary syndrome Rx Localised early stage- radiotherapy often total skin electron beam radiation More advanced- Topical gluco- corticoid Topical N2 mustard Phototherapy Psoralen with UV A(PUVA) Interferon, antibodies etc


Question: Bence jones proteinuria is best detected by

Ans. is `d' i.e., Electrophoresis Bence Jones proteins are seen in multiple myeloma. Urinary protein electrophoresis will exhibit a discrete protein peak. In myeloma plasma cells produce immuno-globulin of a single heavy and light chain, a monoclonal protein commonly referred to as a paraprotein. Heat test is false negative in 50% of patients with light chain myeloma. Dipstick detects albumin and not paraproteins.


Question: Best natural source of iodine is

Best natural source of iodine is - Sea foods.


Question: Hampton's hump is associated with

(D) Pulmonary thromboembolism > Hampton's hump, also called Hampton hump, is a radiologic sign seen on chest radiographs indicating pulmonary infarction and atelectasis classically due to pulmonary embolism. It was first described by Aubrey Otis Hampton.> It consists of a pleura based shallow wedge-shaped consolidation in the lung periphery with the base against the pleural surface.> A normal or near-normal chest x-ray in a dyspneic patient suggests PE. Well-established abnormalities include focal oligemia (Westermark's sign), a peripheral wedged-shaped density above the diaphragm (Hampton's hump), or an enlarged right descending pulmonary artery (Palla's sign).


Question: Munchaussen syndrome is a

(A) Factitious disorder # FACTITIOUS DISORDERS are conditions in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms. Factitious disorder by proxy is a condition in which a person deliberately produces, feigns, or exaggerates symptoms in a person who is in their care. Munchausen syndrome is an older term for Factitious disorder. People with this condition may produce symptoms by contaminating urine samples, taking hallucinogens, injecting themselves with bacteria to produce infections, and other such similar behaviour. They might be motivated to perpetrate factitious disorders either as a patient or by proxy as a caregiver to gain any variety of benefits including attention, nurturance, sympathy, and leniency that are unobtainable any other way. Somatoform disorders are characterised by multiple somatic complaints. Conversion disorder is a condition in which you show psychological stress in physical ways. The condition was so named to describe a health problem that starts as a mental or emotional crisis -- a scary or stressful incident of some kind -- and converts to a physical problem. Malingering is a medical term that refers to fabricating or exaggerating the symptoms of mental or physical disorders for a variety of "secondary gain" motives, which may include financial compensation (often tied to fraud); avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply to attract attention or sympathy. Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person's normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from one's emotions, body and/or immediate surroundings.


Question: HbA1c reduction is maximum with use of

Mechanism of ActionExamplesHbA Reduction (%)Agent-Specific AdvantagesAgent-Specific DisadvantagesContraindicationsOralBiguanides|Hepatic glucose productionMetformin1-2Weight neutral, do not cause hypoglycemia, inexpensive, extensive experience, |CV eventsDiarrhea, nausea, lactic acidosisSerum creatinine> 15 mg/dL (men)>1.4 mg/dL (women)(see text), CHF, radio graphic contrast studies,hospitalized patients,acidosisRenal/liver diseasea-Glucosidase inhibitors|GI glucose absorptionAcarbose, miglitol, voglibose0.5-0.8Reduce postprandial glycemiaGI flatulence, liver function testsRenal/liver diseaseDipeptidyl peptidase IV inhibitorsProlong endogenous GLP-1 actionAlogliptin, Linagliptin, Gemigliptin, linagliptin, saxagliptin,sitagliptin, teneligliptin, vildagliptin0.5-0.8Well tolerated, donot cause hypoglycemia Reduced dose with renal disease; one associated with increase hea fail pure risk; possible association with ACE inhibitor-induced angioedemaInsulin secretagogues:Sulfonylureas|Insulin secretionGlibornuride, gliclazide, glimepiride,glipizide, gliquidone,glyburide,glyclopyramide1-2Sho onset of action, lower postprandial glucose, inexpensiveHypoglycemia, weight gainRenal/liver diseaseInsulin secretagogues:Nonsulfonylureas|Insulin secretionNateglinide, repaglinide, mitiglinide0.5-1.0Sho onset of action, lower postprandial glucoseHypoglycemiaRenal/liver diseaseSodium-glucose cotranspoer 2 inhibitors|Urinary glucose excretionCanagliflozin,dapagliflozin,empagliflozin0.5-1.0Insulin secretion and action independentUrinary and vaginal infections, dehydration, exacerbate tendency to hyperkalemiaLimited clinical experience; moderate renal insufficiencyThiazolidinediones|Insulin resistance,|glucose utilizationRosiglitazone, pioglitazone0.5-1.4Lower insulin requirementsPeripheral edema,CHF, weight gain,fractures, macularedemaCHF, liver disease Ref: Harrison 19e pg: 2414


Question: Sudden death can be due to

Ans. a (Ventricular fibrillation). (Ref. Harrison, Principles of Medicine, 18th/Chapter 233.)# Most common electrical mechanism of true cardiac arrest is ventricular fibrillation, responsible for 65-80% of cardiac arrests.# Episodes of cardiac arrest during Holter monitoring reveal that 3/4th of sudden deaths are due to VT/VF.# Treatment: Imparted cardioversion/defibrillator/amiodarone.VPCs in asymptomatic Young individual need no treatment.


Question: Condition with characteristic EEG finding

(A) SSPE # SSPE- Periodic discharges at 4 sec interval. Maximum at fronto central areas Giant slow waves mixed with several sharp waves.


Question: Bechterews disease also known as

Ans. is 'b' i.e., Ankylosing spondylitis ANKYLOSING SPONDYLITIS (MARIE - STRUMPELL DISEASE) Ankylosing spondylitis is a chronic progressive inflammatory disease of the sacroiliac joints and the axial skeleton. Prototype of seronegative (absence of rheumatoid factor) spondyloahropathies. Inflammatory disorder of unknown cause. Usually begins in the second or third decade with a median age of 23, in 5% symptoms begin after 40. o Male to female ratio is 2-3 : 1 Strong correlation with HLA-B27 90-95% of cases are positive for HLA B27. Joints involved in ankvlosing spondylitis Ankylosing spondylitis primarily affects axial skeleton. The disease usually begins in the sacro-iliac joints and usually extends upwards to involve the lumbar, thoracic, and often cervical spine. In the worst cases the hips or shoulders are also affected. Hip joint is the most commonly affected peripheral joint. o Rarely knee (Ebenzar 4thie 593) and ankle (Apley's 9th/e 67) are also involved. Clinical features Low back pain of insidious onset Duration usually less than 3 months Significant morning stiffness and improvement with exercise o Limited chest expansion Diffuse tenderness over the spine and sacroiliac joints Loss of lumbar lordosis, increased thoracic kyphosis Decreased spinal movements (especially extension) in all directions. Radiological features of ankvlosing spondvlitis Radiographic evidence of sacroiliac joint is the most consistent finding in ankylosing spondylitis and is crucial for diagnosis. The findings are :? Sclerosis of the aiculating surfaces of SI joints Widening of the sacroiliac joint space Bony ankylosis of the sacroiliac joints Calcification of the sacroiliac ligament and sacro-tuberous ligaments Evidence of enthesopathy - calcification at the attachment of the muscles, tendons and ligaments, paicularly around the pelvis and around the heel. o X-ray of lumbar spine may show :- Squaring of veebrae : The normal anterior concavity of the veebral body is lost because of calcification of the anterior longitudinal ligament. Loss of the lumbar lordosis Bridging `osteophytes' (syndesmophytes) Bamboo spine appearance


Question: Renal Calculi associated with Proteus infection is

Phosphate calculus Phosphate calculus is smooth and diy whiteIt tends to grow in alkaline urine, especially when urea-splitting Proteus organisms are present; As a result, the calculus may enlarge to fill most of the collecting system, forming a staghorn calculusStaghorn calculus may be clinically silent for years and may present with haematuria, urinary infection or renal failure(Ref: Harrison's 18/e p2387; Bailey 26/e p1293)


Question: . Beevor sign is Seen in

*Lesion at T9-T10 paralyse the lower,but not upper-abdominal muscles,resulting in upward movement of the umbilicus when the abdominal wall contracts. Beevor's sign is medical sign seen in the selective weakness of the lower abdominal muscles, involving the movement of the navel towards the head on flexing the neck Beevor's sign is characteristic of spinal cord injury between T9 and T10 levels. This occurs when the upper pa of the Rectus abdominis muscle is intact but the lower pa is weak because of the spinal injury. Thus when the patient is asked to raise his head as he lies supine on bed, only the upper pa of the muscle contracts pulling the umbilicus toward the head. The sign has also been observed in amyotrophic lateral sclerosis, a disease associated with progressive weakening of the muscles of multiple areas of the body, and in facioscapulohumeral muscular dystrophy, a disease of weakness of predominantly the facial, shoulder and upper arm muscles. Ref Harrison20th edition pg 2611


Question: Kimmelstiel Wilson disease is


Question: The Antiepileptic drug, Phenytoin therapeutic blood level is

(B) 10-19 mcg/ml# SERUM PHENYTOIN LEVELS:> Therapeutic range is 10-20 mcg/mL.# Total phenytoin levels (mcg/mL) - Typical corresponding Signs & Symptoms: Lower than 10- Rare Between 10 and 20 - Occasional mild nystagmus Between 20 and 30 - Nystagmus Between 30 and 40 - Ataxia, slurred speech, nausea, and vomiting Between 40 and 50 - Lethargy and confusion Higher than 50 - Coma and seizures


Question: A thiy five year old female has proximal weakness of muscles, ptosis and easy fatigability. The most sensitive test to suggest the diagnosis is.

Tensilon test (edrophonium test) is a pharmacological test used for the diagnosis of ceain neural diseases, especially myasthenia gravis. It is also used to distinguish a myasthenic crisis from a cholinergic crisis in individuals undergoing treatment for myasthenia gravis 10 mg edrophonium hydrochloride syringe and a 2 mg atropine syringe are prepared. Atropine is prepared for immediate use in case cholinergic crisis occurs. After a neurologic examination and recording of vital signs, first 2 mg edrophonium is injected intravenously. After waiting 30 seconds and ensuring that no adverse reactions occurred, the remaining 8 mg of edrophonium is also injected. A patient suffering from myasthenia gravis experiences improvement in muscle strength and endurance with repetitive movements, while normal persons do not feel any difference. The effects of edrophonium lasts around 10 minutes. The edrophonium allows accumulation of acetylcholine (ACh) in the neuromuscular junctions, and makes more ACh available to the muscle receptors, thereby increasing muscle strength in myasthenia gravis. In newborns, a 0.15 mg/kg edrophonium administered subcutaneously produces a response within 10 minutes. In infants, the drug is administered intravenously at a dose of 0.2 mg/kg. Improvement of diplopia is often used as an evaluation item because in this case, placebo effect can be excluded Ref Harrison20th edition pg 2456


Question: Birefringent crystals in urine is seen with

Uricosuria refers to uric acid in the urine. Urine levels of uric acid can be described as: Hyperuricosuria, an abnormally high level of uric acid in the urine. Hypouricosuria, an abnormally low level of uric acid in the urine.briskeffervence crystals are seen in urine Ref Harrison20th edition pg 277


Question: Dialysis disequilibrium is due to

Dialysis disequilibrium syndrome due to rapid shifts in urea levels which induce cerebral Odema.


Question: Osteitis fibrosa cystica is seen in

The clinical presentation of primary hyperparathyroidism is described on page 769. Parathyroid bone disease is now rare due to earlier diagnosis and treatment. Osteitis fibrosa results from increased bone resorption by osteoclasts with fibrous replacement in the lacunae. This may present as bone pain and tenderness, fracture and deformity. Chondrocalcinosis can occur due to deposition of calcium pyrophosphate crystals within aicular cailage. It typically affects the menisci at the knees and can result in secondary degenerative ahritis or predispose to attacks of acute pseudogout Skeletal X-rays are usually normal in mild primary hyperparathyroidism, but in patients with advanced disease characteristic changes are observed. In the early stages there is demineralisation, with subperiosteal erosions and terminal resorption in the phalanges. A 'pepper-pot' appearance may be seen on lateral X-rays of the skull. Reduced bone mineral density, resulting in either osteopenia or osteoporosis, is now the most common skeletal manifestation of hyperparathyroidism. This is usually not evident radiographically and requires assessment by DEXA (p. 1065). Primary hyperparathyroidism Primary hyperparathyroidism is caused by autonomous secretion of PTH, usually by a single parathyroid adenoma, which can vary in diameter from a few millimetres to several centimetres. It should be distinguished from secondary hyperparathyroidism, in which there is a physiological increase in PTH secretion to compensate for prolonged hypocalcaemia (such as in vitamin D deficiency, p. 1126), and from teiary hyperparathyroidism, in which continuous stimulation of the parathyroids over a prolonged period of time results in adenoma formation and autonomous PTH secretion (Box 20.39). This is most commonly seen in individuals with advanced chronic kidney disease (p. 483). The prevalence of primary hyperparathyroidism is about 1 in 800 and it is 2-3 times more common in women than men; 90% of patients are over 50 years of age. It also occurs in the familial MEN syndromes (p. 795), in which case hyperplasia or multiple adenomas of all four parathyroid glands are more likely than a solitary adenoma. Clinical and radiological features The clinical presentation of primary hyperparathyroidism is described on page 769. Parathyroid bone disease is now rare due to earlier diagnosis and treatment. Osteitis fibrosa results from increased bone resorption by osteoclasts with fibrous replacement in the lacunae. This may present as bone pain and tenderness, fracture and deformity. Chondrocalcinosis can occur due to deposition of calcium pyrophosphate crystals within aicular cailage. It typically affects the menisci at the knees and can result in secondary degenerative ahritis or predispose to attacks of acute pseudogout In nephrocalcinosis, scattered opacities may be visible within the renal outline. There may be soft tissue calcif ication in aerial walls and hands and in the cornea. DAVIDSONS PRINCIPLES AND PRACTICE OF MEDICINE 22ND EDITION PAGE NO-769


Question: Lesion is Alzheimer's disease are commonest at

Nucleus basalis of Meyne for Alzheimer's disease and Parkinson's disease dementia. The nucleus basalis of Meyne (NBM) is a large source of cholinergic innervation to widespread coical areas. There have been two repos of DBS of the NBM for either AD or PD. Ref Harrison20th edition pg 2456


Question: Tuberculides are seen in

(Lichen scrofulosorum) (202-Behl lCfh, 1756-Dorland 28th, 219- Neena khanna)TUBERCULIDES - Group of disease where the evidence for a tuberculous etiology is not definite {May be hypersensitivity reaction) but which show a tuberculous granuloma on histology and respond to ATT)Conditions included in TuberculidsCutaneous Tuberculosis (Non Tuberculides)* Lichen scrofulosorum* Lupus vulgaris* Erythema- induratum* Sacrofuloderma* Papulonecrotc tuberculides (Acne-scrafulosorum)* Tubercularis cutis verrucosus* Lupus miliaris disseminatus faciei* Miliary tuberculosis and metastatic tuberculosis* Rosaceous tuberculide* Miliary tuberculosis and metastatic tuberculosis abscess may also present as cutaneous tuberculosis(According to 'Behl' Erythema - nodosum is also a tuberculide while some texts do not include it as a tuberculide)Features of TB in AIDS patients* |Sputum positivity *** Little or no cavitation*** |ed extra pulmonary tuberculosis *** Negative PPD skin test*** Lack of classic granuloma* Atypical CXR- Diffuse interstitial or military infiltrate* Response to short course chemotherapy is similar*** but adverse effects may be more pronounced including severe or even fatal skin disease* High rate of reactivation Indications of pulmonary resection in tuberculosis / haemoptysis areAbsoluteRelative* Massive haemoptysis (600cc/24 hours)* Destroyed lung, positive sputum* Bronchopleural fistula* Suspicion of carcinoma* Haemoptysis* Bronchial stenosis* Persistent positive sputum* Open negative cavity* T.B. Empyema* Atypical tuberculus infections* Aspergilloma (Fungus balls)Lupus - vulgaris - is a form of cutaneous tuberculosis that is seen in previously infected and sensitized individualsLupus- pernio - is a particular type of sarcoidosis that involves the tip of nose & earlobes with lesions that are violaceous in colourSpino- ventosa - Tuberculosis of bone in which bone is expanded & the cortex thins eg digitsScrofuloderma - Tuberculosis first develops in a lymph node or a bone producing a swelling and subsequently ruptures through the overlying skinFalse negative tuberculin skin test - reactions may result from improper testing technique - concurrent infections, malnutrition advanced age, immunologic disorders, lymphoreticular malignancies, corticosteroid therapy, CRF, HIV infections and fulminant tuberculosis


Question: Oliguric phase of ARF is characterized by A/E


Question: Treatment of choice in neurocysticercoses of T. Solium

(B) (Albendazole) (3431-H 18th)* Albendazole 15 mg/kg daily for a minimum of 8 days has become the drug of choice for parenchymal neurocysticercosis (380- Davidson 22nd)* Approximately 85% of parenclymal cysts are destroyed by a single course fo albendazole and 75% are destroyed by a single course of praziquantel for 15 days (3431- H 18th)Drug of choice for CNS toxoplasmosis is combination of sulfadiazine plus pyrimethamine **


Question: Untoff phenomenon is

Harrison's principles of internal medicine 17th edition. *U/l visual blurring may occur following a hot shower or with physical exercise. Uhthoff's phenomenon (also known as Uhthoff's syndrome, Uhthoff's sign, and Uhthoff's symptom) is the worsening of neurologic symptoms in multiple sclerosis (MS) and other neurological, demyelinating conditions when the body gets overheated from hot weather, exercise, fever, or saunas and hot tubs. Ref Harrison20th edition pg 2345

Worsening of symptom with heat and exeion

Palsy of symptom with heat and excretion


Question: If a patient has to undergo cect chest prerequisite would be

Answer: (A) NPO FOR 6HRS &S. CREATININE NORMALIn preparation for a CT scan, patients are often asked to avoid food, especially when contrast material is to be used. Contrast material may be injected intravenously, or administered by mouth or by an enema in order to increase the distinction between various organs or areas of the body. Therefore, fluids and food may be restricted for several hours prior to the examination. If the patient has a history of allergy to contrast material (such as iodine), the requesting physician and radiology staff should be notified. All metallic materials and certain clothing around the body are removed because they can interfere with the clarity of the images.Because Contrast material has to be excreted without any metabolism, kidney functions are required to be normalCT scans have vastly improved the ability of doctors to diagnose many diseases earlier in their course and with much less risk than previous methods. Further refinements in CT scan technology continue to evolve which promise even better picture quality and patient safety. CT scans known as ''spiral" or "helical" CT scans can provide more rapid and accurate visualization of internal organs. For example, many trauma centers are using these scans to more rapidly diagnose internal injuries after serious body trauma. High resolution CT scans (HRCT) are used to accurately assess the lungs for inflammation and scarring. CT angiography is a newer technique that allows noninvasive imaging of the coronary arteries. Note that some CT scanners may not be able to accommodate pat ients that weigh over 400 pounds.

Blood sugar normal and no dietary restriction


Question: Not seen in hyperparathyroidism

Increase in 24 hr urinary calcium excretion > 250


Question: Best ventilator strategy for ARDS is

ARDS can be difficult to distinguish from fluid overload or cardiac failure.Occasionally, conditions may present in a similar way to ARDS but respond to alternative treatments; an example of this might be a glucocoicoid- responsive interstitial pneumonia . Management of ARDS is suppoive, including use of lung-protective mechanical ventilation, inducing a negative fluid balance and treating the underlying cause. Establishing the severity of ARDS is useful, as severe disease will require more proactive management such as prone positioning or extracorporeal membrane oxygenation (ECMO) Berlin definition of ARDS * Onset within 1 week of a known clinical insult, or new or worsening respiratory symptoms * Bilateral opacities on chest X-ray, not fully explained by effusions, lobar/lung collapse or nodules * Respiratory failure not fully explained by cardiac failure or fluid overload. Objective assessment (e.g. by echocardiography) must exclude hydrostatic oedema if no risk factor is present * Impaired oxygenation Ref Davidson edition23rd pg 199_198

Synchronised intermittent mandatory ventilation


Question: In primary pulmonary hypeension basic abnormality in genes lies in

Ref Harrison 19 th ed pg 1655 Abnormalities in multiple molecular pathways and genes that regu- late the pulmonary vascular endothelial and smooth muscle cells have been identified ). These abnormalities include decreased expression of the voltage-regulated potassium channel, mutations in the bone morphogenetic protein receptor-2, increased tissue factor expres- sion, overactivation of the serotonin transpoer, hypoxia-induced activation of hypoxia-inducible factor-1a, and activation of nuclear factor of activated T cells.


Question: Drug of choice for social phobia is

(A) SSRIs # Social Phobia> This is an example of irrational fear of activities or social interaction, characterized by an irrational fear of performing activities in the presence of other people or interacting with others.>The patient is afraid of his own actions being viewed by others critically, resulting in embarrassment or humiliation.> There is marked distress and disturbance in daily functioning.> Examples are fear of blushing (erythrophobia), eating, public speaking, public performance (e.g. on stage), participating in groups, writing in public (e.g. signing a check), speaking to strangers (E.g. for asking for directions), dating, speaking to authority figures, and urinating in a public lavatory (shy bladder).> Sometimes, alcohol (and rarely other drugs is used to overcome the anxiety occurring in social situations.# Drug Treatment of phobia are:> Benzodiazepines are given to reduce the anticipatory anxiety.> Alprazolam is believed to have anti-phobic, anti-panic and anti-anxiety properties.> So, it is the drug of choice when benzodiazepines are used.> Long-term follow-up of double-blind trials are needed before it is firmly established as an anti-phobic.> The other drugs used include Clonazepam, lorazepam and diazepam.> Among the antidepressants, SSRIs are currently drugs of choice, with paroxetine being the most widely used and effective drug.> Other SSRIs, like fluoxetine and sertraline are also very effective.


Question: A child presents with massive hemetemesis and systemic hypotension. He has no fever or other significant history. Examination reveal massive splenomegaly but no hepatomegaly. Likely diagnosis is

Answer is D (Non cirrhotic poal fibrosis): NCPF is suspected in a patient presenting with symptoms of poal hypeension with: YOUNG AGE Moderate/Large Splenomegaly NO FEATURES SUGGESTIVE OF LIVER CELL FAILURE -No Jaundice (uncommon) - No Ascitis (uncommon) - No Hepatomegaly (uncommon) - No Stigmata of liver cell failure (uncommon) Non cirrhotic poal fibrosis is a condition of liver characterized by widespread fibrosis of the 1 ver (mainly poal, subcapsular and rarely perisinusuoidal) causing wide variation in the normal architecture but there is no true cirrhosis. NCPF is the most impoant causes of intrahepatic non cirrhotic poal hypeension in India


Question: Leisch nodules are seen in

(C) Neurofibromatosis type I # NEUROFIBROMATOSIS TYPES# TYPE 1 (NF-1) Peripheral neurofibromatosis Von Recklinghausen's disease Incidence 1 in 3 000 Gene on long arm of chromosome 17> Diagnostic criteria: Devised by National Institute of Health in 1987 Require 2 or more of the following> Cafe au lait spots 6 or more >5mm (prepubertal) >15mm (postpubertal)> Freckling Axillary or inguinal> Neurofibromas Two or more neurofibromas of any sort OR One plexiform neurofibroma> Optic glioma> Leisch nodules Two or more> Distinctive osseous lesion Sphenoid dysplasia Thinning of long bone cortex with pseudarthrosis> First degree relative with neurofibromatosis Parent, sibling or offspring# NEUROFIBROMATOSIS 2 Central neurofibromatosis Incidence 1 in 50 000 Gene on long arm of chromosome 22> Features Two types> Multiple CNS involvement Neuraxial neoplasia Meningoneuroplasia Cranial schwannoma> Bilateral acoustic neuromas Isolated Dermal lesions unusual


Question: Most common cause of unilateral pedal edema

Ans. is 'c' i.e., Venous insufficiency The most likely cause of leg edema in patients over age 50 is venous insufficiency. Venous insufficiency affects up to 30% of the population, whereas hea failure affects only approximately 1%. The most impoant cause of unilateral pedal edema is venous insufficiency. Milroys disease : The defect in Milroy's disease is present from bih and symptoms are usually first experienced in childhood. The most common problem is one-sided leg swelling, unilateral edema, which is progressive and can affect both legs. Impaired intestinal lymphatics can cause steatorrhea due to impaired transpo of chylomicrons


Question: Longest acting Insulin among the following

insulin degludec which has duration of action upto 42hours Ref Harrison 20th edi page no 2863, tab 397-4


Question: Chronic liver disease is caused by


Question: The "subclan steal syndrome" occurs due to

*Subclan steal:when the arm is used,blood is stolen from the brain the veebral aery .this lead to veebro-basilar ischemia ,which is characterised by dizziness ,coical blindness and/or collapse. Ref Harrison20th edition pg 2456

Occlusion of the subclan aery proximal to origin of veebral aery

Occlusion of the subclan aery distal to origin of veebral aery


Question: Proptosis is not seen in

Ans. is 'd' i.e., Myxoedema Proptosis occurs in thyrotoxicosis not in hypothyroidism Choices Logic Grave's Cytokines appear to play a major role in thyroid-associated ophthalmopathy There is infiltration of the extraocular muscles by activated T cells; the release of cytokines such as IFN-alpha and TNF results in fibroblast activation and increased synthesis of glycosaminoglycans that trap water, thereby leading to characteristic muscle swelling Sarcoidosis Approximately 20%, of patients with ophthalmic findings of sarcoid have soft tissue involvement of the orbit or lacrimal gland and present as a mass lesion with proptosis, ptosis, or ophthalmoplegia. Pituitary adenoma Macro-adenoma associated with pituitary apoplexy can lead to proptosis.


Question: Investigation of choice for leptomeningeal carcinomatosis

To detect leptomeningeal metastases, gadolinium-enhanced MRI is more sensitive than CT scanning. The sensitivity of MRI is nearly 70% while that of CT scan is around 30%. The most common MRI findings consist of typical nodules in the subarachnoid and parenchymal regions, parenchymal volume loss and sulcal/dural enhancement CT-myelography is not indicated due to low sensitivity, whereas the value of FDG PET ,SPECT scan is still under investigation Ref Harrison20th edition pg 2234


Question: Schober's sign is used to evaluate

Ans. is 'a' i.e., Flexion of lumbar spine Schober's test is used for the assessment of patients with ankylosing spondylitis. It is performed as follows :? Mark two points 10 cm above and 5 cm below a line joining the dimple of venus on the sacral promontory (the line passing along L5 and dimple indicates the site of posterior superior iliac spine). Ask the patient to bend forward as for as possible. Now measure the distance between upper and lower markings. Normally it in erases by > 5 cm below 50yrs of age If <5cm indicates limitation of the mobility of spine.


Question: Treatment of choice for seasonal influenza is

Early treatment of hospitalized adult influenza patients with oseltamivir has been repoed to reduce death in some observational studies. Clinical benefit is greatest when antiviral treatment is administered early, especially within 48 hours of influenza illness onset in clinical trials and observational studies Ref Harrison20th edition pg 980


Question: Criteria of cysts in USG to diagnose ADPKD at 40years of age

Diagnosis OF ADPKD: Diagnosis is typically made from a positive family history consistent with autosomal dominant inheritance and multiple kidney cysts bilaterally. Renal ultrasonography is often used for presymptomatic screening of at-risk subjects and for evaluation of potential living related kidney donors from ADPKD families. The presence of at least two renal cysts (unilateral or bilateral) is sufficient for diagnosis among at-risk subjects between 15 and 29 years of age with a sensitivity of 96% and specificity of 100%. The presence of at least two cysts in each kidney and the presence at least four cysts in each kidney are required for the diagnosis of at-risk subjects age 30 to 59 years and age 60 years or older, respectively, with a sensitivity of 100% and specificity of 100%. This is because there is an increased frequency of developing simple renal cysts with age.Reference: Harrison&;s Principles of Internal Medicine; 19th edition; Chapter 339; Polycystic Kidney Disease and Other Inherited Disorders of tubule growth and Development


Question: Most common site of intracranial metastasis is from primary carcinoma of

MC brain tumor is metastasis,arising from - (1) Oat cell Ca lung/small cell Ca lung (2) Ca Breast (3) M. Melanoma MC 1deg Brain tumour- Glioma MC benign brain tumour - Meningioma


Question: Features of restrictive lung disease is

Answer is D (FEVI/FVC increase and compliance decreases): Restrictive lung diseases are characterized by decreased compliance and increased FEVIFI"C FENT' & FVC Forced Vital Capacity (FVC) is decreased Forced expiratory flow rates are relatively preserved (FEV1 is preserved) FEV1 / FVC When FEVI is considered as a percentage of FVC, the flow rates tend to become supranormal or dispropoionately high relative to size of lungs. FEV", is preserved and FVC is decreased so FEV / IFTC is increased The hallmark of restrictive lung diseases is a decrease in lung volumes primarily TLC and V.C.' (FVC is decreased)-Harrison Compliance decreases in restrictive lung disease. Compliance is usually unaffected in obstructive lung diseases except in emphysema where it is increased.

FEV1/FVC decreases and compliance decreases

FEV1/FVC increases and compliance increases

FEV1/FVC decreases and compliance increases

FEV1/FVC increases and compliance decreases


Question: Phlegmonous gastritis occurs in

Phlegmonous gastritis( due to reflux of acid) is an uncommon form of gastritis caused by numerous bacterial agents, including streptococci, staphylococci, Proteus species, Clostridium species, and Escherichia coli. Phlegmonous gastritis usually occurs in individuals who are debilitated. It is associated with a recent large intake of alcohol, a concomitant upper respiratory tract infection, and AIDS. Phlegmonous means a diffuse spreading inflammation of or within the connective tissue. In the stomach, it implies infection of the deeper layers of the stomach (submucosa and muscularis). As a result, purulent bacterial infection may lead to gangrene. Phlegmonous gastritis is rare. The clinical diagnosis is usually established in the operating room, as these patients present with an acute abdominal emergency requiring immediate surgical exploration. Without appropriate therapy, it can progress to peritonitis and death. Ref Davidson edition23rd pg802


Question: A 45 year old man, known case of chronic renal failure develops rugger jersey spine. The probable cause is

Answer is B (Secondary Hyperparathyroidism): Rugger .Jersey Spine is characteristically found in secondary hyperparathyroidism (Renal osteodystrophy in CRF).


Question: Nosocomial pneumonia is most commonly caused by


Question: Most well differentiated thyroid tumor is

(A) Papillary carcinoma # Follicular cell origin: (A) Differentiated. (B) Undifferentiated.# DIFFERENTIATED:* Papillary carcinoma (60%);* Follicular carcinoma (15%);* Mixed papillary and follicular carcinoma.# UNDIFFERENTIATED:* Anaplastic carcinoma (13%).> Clinical features: It is the most slow growing among the malignant tumours of the thyroid.


Question: The drug used in the management of medullary carcinoma thyroid is

Ans.is 'a' i.e., Cabozantinib Medullary thyroid cancers (MTCs) are neuroendocrine tumors of thyroid paraf011icular cells that do not concentrate iodine. The primary treatment for MTC is extensive and meticulous surgical resection. There is a limited role for external-beam radiotherapy. For patients with asymptomatic metastatic tumors generally less than 1 to 2 cm in diameter, growing in diameter less than 20 percent per year Systemic therapy is not required Such patients should be monitored for disease progression. Known sites of metastatic disease should be imaged by CT or MRI every 6 to 12 months, and potential new sites of disease should be imaged every 12 to 24 months. For patients with metastatic tumors at least 1 to 2 cm in diameter, growing by at least 20 percent per year, or Or patients with symptoms related to multiple metastatic foci that cannot be alleted with surgery or external beam radiotherapy Administer systemic treatment as pa of a clinical trial. Forpatients with metastatic tumors at least I to 2 cm in diameter, growing by at least 20 percent per year, or for patients with .symptoms related to multiple metastatic foci who cannot paicipate in a clinical trial An oral tyrosine kinase inhibitor (TKI) is suggested, rather than traditional cytotoxic chemotherapy. For initial TKI therapy Cabozantinib or vandetanib rather than sorafenib or sunitinib. Cytotoxic chemotherapy, of which dacarbazine-based regimens such as cyclophosphamide-vincristinedacarbazine are preferable, is an alternative option for patients who cannot tolerate or who fail multiple TKIs Drugs used in medullary carcinoma thyroid Tyrosine kinase inhibitors Cvtotoxic chemotherapy Cabozanitib Cyclophosphamide Vandetanib Vincristine Sorafenib Dacarbazine Sunitinib


Question: The commonest of death in ARDS is

Moality estimates for ARDS range from 26 to 44%.Moality in ARDS is largely attributable to nonpulmonary causes,with sepsis and nonpulmonary organ failure accounting for >80% of deaths.Increasing age,chronic liver disease,cirrhosis,chronic alcohol abuse,chronic immunosuppression,sepsis,chronic renal disease,any nonpulmonary Organ failure have been linked to increased ARDS moality. Ref:Harrison's disease-18th edition,page no:2209/


Question: Massive hemoptysis seen in

Answer- A. Mitral stenosisLarge volume hemoprysis, referred to as massive hemoptysis , is variably defined as hemoptysis of greater than 200-600 cc in 24 h. Massive hemoptysis should be considered a medicai emersency.Hemoptysis does not occur from hea failure itself. Most commonly it is due to mitral valve diseases like or mitral mitral stenosis regurgitation.


Question: The pathogenesis of hypochromic anemia in lead poisoning is due to

Lead interferes with the synthesis of Heme. Deficiency of heme causes microcytic hypochromic anemia because heme is an integral part of hemoglobin and it is well known that hemoglobin deficiency causes microcytic hypochromic anaemia.

Inhibition of enzymes involved in heme biosynthesis

Binding of lead to transferrin, inhibiting the transport of iron

Binding of lead to cell membrane of erythroid precursors

Binding of lead to ferritin inhibiting their breakdown into hemosiderin


Question: Onion skin spleen is seen in

Onion skin patten is due to Concentric Fibrosis seen in SLE.


Question: MIDAS question are is used in assessment of

Once a diagnosis of migraine has been established, it is impoant to assess the extent of a patient's disease and disability. The Migraine Disability Assessment Score (MIDAS) is a well-validated, easy-to-use tool . Migraine Disability Assessment Score Five questions related to headache severity are used in assessment Grade I--Minimal or Infrequent Disability: 0-5 Grade II--Mild or Infrequent Disability : 6-10 Grade III--Moderate Disability : 11-20 Grade IV--Severe Disability : > 20 Ref Harrison 20th edition page 3098, 3100(table 422-4)


Question: In a normal electrocardiogram (ECG or EKG),

B: The QRS complex consists of three individual waves: the Q, R, and S waves. The QRS complex results from depolarization of the ventricles, and the beginning of the QRS complex precedes ventricular contraction.
A: The P wave results from depolarization of the atrial myocardium, and the beginning of the P wave precedes the onset of atrial contraction.
C: The T wave represents the repolarization of the ventricles, and the beginning of the T wave precedes ventricular relaxation.
D: During the P-R interval, the atria contract and begin to relax.

The P wave results from repolarization of the atria.

The QRS complex results from depolarization of the ventricles.

The T wave represents repolarization of the auricles.

During the P-R interval, the ventricle contract.


Question: Treatment of choice in intractable ulcerative colitis ;

Indications for surgery in ulcerative colitis Intractable disease Fulminant disease Toxic megacolon Colonic perforation Massive colonic hemorrhage Extracolonic disease Colonic obstruction Colon cancer prophylaxis Colon dysplasia or cancer

Mucosal proctectomy - Ileoanal pouch anastomosis


Question: Most common clinical presentation of juvenile myoclonic epilepsy

Ans. c. Myoclonus Most common clinical presentation of juvenile myoclonic epilepsy is myoclonus. "Juvenile myoclonic epilepsy (JME) is a generalized seizure disorder of unknown cause that appears in early adolescence and is usually characterized by bilateral myoclonic jerks that may be single or repetitive. The myoclonic seizures are most frequent in the morning after awakening and can be provoked by sleep deprivation. Consciousness is preserved unless the myoclonus is especially Juvenile Myoclonic Epilepsy Juvenile myoclonic epilepsy (JME) is a generalized seizure disorder of unknown cause that appears in early adolescence Characterized by bilateral myoclonic jerks that may be single or repetitiveQ. Clinical Features: Myoclonic seizures are most frequent in the morning after awakening and can be provoked by sleep deprivationQ. Consciousness is preserved unless the myoclonus is especially severe. Many patients also experience generalized tonic-clonic seizures, and up to one-third have absence seizures. Although complete remission is relatively uncommon, the seizures respond well to appropriate anticonvulsant medication. There is often a family history of epilepsy, and genetic linkage studies suggest a polygenic cause Juvenile Myoclonic Epilepsy Treatment: Valproate is often used to treat juvenile myoclonic epilepsy. Other epilepsy drugs are effective in juvenile myoclonic epilepsy: - LevetiracetamQ - TopiramateQ - LamotrigineQ For most people with JME, treatment is long-term, and often lifelongQ. However, treatment is effective, allowing most people with juvenile myoclonic epilepsy to go five years or more between seizures.

Generalised tonic clonic seizures in sleep

Generalised tonic clonic seizures in awake state


Question: The most common cause of seizures in a patient of AIDS is

Ans. is 'a' i.e., Toxoplasmosis Neurological manifestations of H.I.V. AIDS dementia complex (HIV encephalopathy) is a result of direct effects of HIV on CNS (not an oppounistic disease). It is subcoical dementia. Most common cause of seizures --> Toxoplasma Most common cause of meningitis --> Cryptococcus M.C. cause of focal neurological deficit --> Toxoplasma Toxoplasmosis is the most common CNS infection in AIDS. CNS lymphoma and prograssive multifocal leukoencephalopathy may occur.


Question: A ventrolateral cordotomy is performed to produce relief of pain from the right leg. It is effective because effective because it interrupts the

The lateral spinothalamic tract conveys pain and temperature. In the spinal cord, the spinothalamic tract has somatotopic organization. The pathway crosses over (decussates) at the level of the spinal cord, rather than in the brainstem like the dorsal column-medial lemniscus pathway and lateral coicospinal tract. Cordotomy (or chordotomy) is a surgical procedure that disables selected pain-conducting tracts in the spinal cord, in order to achieve loss of pain and temperature perception Ref Harrison20th edition pg 2366


Question: The earliest muscle to be involved in dermatomyositis is

Dermatomyositis (DM) is a long-term inflammatory disorder which affects muscles. Its symptoms are generally a skin rash and worsening muscle weakness over time.These may occur suddenly or develop over months.Other symptoms may include weight loss, fever, lung inflammation, or light sensitivity.Complications may include calcium deposits in muscles or skin. People with DM experience progressively worsening muscle weakness in the proximal muscles (for example, the shoulders and thighs).Tasks that use these muscles: standing from sitting, lifting, and climbing stairs, can become increasingly difficult for people with dermatomyositis .(quadriceps are first effected) Ref Robbins 9/e pg 172


Question: Disease only transmitted to females

Hunter disease (MPS II) is an X-linked disorder due to a deficiency in iduronate sulfate sulfatase and has manifestations similar to those ofMPS I, including neurologic degeneration. There is no corneal clouding or other eye diseases. Hematopoietic stem cell transplantation has not been successful in treating CNS disease associated with MPS II. The FDA and the European Medicines Agency (EMA) have approved enzyme therapy for the visceral manifestations of MPS II. References: Harrison's Principles of Internal Medicine; 19th edition; CHAPTER 432e; Lysosomal Storage Diseases


Question: Felty syndrome

Felty's syndrome is an extra aicular manifestation of rheumatoid ahritis.It is the association of splenomegaly & neutropenia with RA. Common features include spmenomegaly, lymphadenopathy,weight loss,skin pigmentation ,recurrent infections ,nodules,vasculitis,leg ulcers.

Nodules in upper lobe of lung and difficulty in breathing


Question: Prolonged intake of PPI does not cause

Long-term acid suppression, especially with PPIs, has been associated with A higher incidence of community-acquired pneumonia Community and hospital acquired Clostridium difficile associated disease. Long-term use of PPIs was associated with the development of hip fractures in older women. PPIs may exe a negative effect on the anti-platelet effect of clopidogrel. The mechanism involves the competition of the PPI and clopidogrel with the same cytochrome p450 (CYP2C19).


Question: Proliferative glomerular deposits in the kidney are found in

IgA nephropathy or Berger's disease: immune complex-mediated glomerulonephritis defined by the presence of diffuse mesangial IgA deposits often associated with mesangial hypercellularity. Male preponderance, peak incidence in the second and third decades of life.Clinical and laboratory findings: Two most common presentations recurrent episodes of macroscopic hematuria during or immediately following an upper respiratory infection often accompanied by proteinuria or persistent asymptomatic microscopic hematuriaIgA deposited in the mesangium is typically polymeric and of the IgA1 subclass. IgM, IgG, C3, or immunoglobulin light chains may be codistributed with IgAPresence of elevated serum IgA levels in 20-50% of patients, IgA deposition in skin biopsies in 15-55% of patients, elevated levels of secretory IgA and IgA-fibronectin complexesIgA nephropathy is a benign disease mostly, 5-30% of patients go into a complete remission, with others having hematuria but well preserved renal functionAbout 25-30% of patients have progressive disease and developmental failure slowly over 20-25 yearsPersistent proteinuria for 6 months or longer is found to be associated with adverse renal outcomesLight microscopy may reveal lesions such asDPGN; segmental sclerosis; and rarely, segmental necrosis with the cellular crescent formation, which typically presents as RPGNHenoch-Schonlein purpura is distinguished clinically from IgA nephropathy by prominent systemic symptoms, a younger age (<20 years old), preceding infection, and abdominal complaintsRef: Harrison's 18/e p2342


Question: Obstructive sleep apnoea syndrome

(A) Associated with sudden cardiac death > In severe and prolonged cases there is | in pulmonary prssure that are transmitted to right side of heart - this results in CHF - significantly lower levels of nitrate - CVS complications.


Question: Ahritis is not a pa of

Lupus has non-erosive, intermittent polyahritis. Diagnostic criteria for ahritis in SLE includes non-erosive ahritis involving two or more peripheral joints characterised by tenderness, swelling or effusion.Psoriatic ahritis involves PIP, DIP, MCP and wrist. Sparing of any joint may or may not be present.Reiter's syndrome and reactive ahritis are regarded as a spectrum of the same disease. (Triad of ahritis, urethritis, and conjunctivitis - Fiessenger-Leroy-Reiter syndrome)Ref: Harrison's 18/e p2728, 2780, 2790, 2847


Question: Primary complex in Liver in Congenital tuberculosis occurs through

Answer is B (Haematogenous Spread): Primary Complex in Liver in cases of Congenital Tuberculosis occurs when infection enters the fetus through the umbilical veins (Trans-placental; Haematogenous Infection). Liver is the most common Primary site of infection in Congenital Tuberculosis caused by Trans placental or Haematogenous route Lung is the most common Primary site of infection in Congenital Tuberculosis caused by aspiration of infected amniotic fluid Gastrointestinal Tract is the most common Primary site of infection in Congenital Tuberculosis caused by ingestion of infected amniotic fluid Since Lungs are eventually involved in most cases of congenital tuberculosis where Liver is the primary site of infection, Lungs are overall the most commonly involved sites in Congenital Tuberculosis


Question: The MOST sensitive 24 hour urinary biochemical test to suggest pheochromocytoma among the following is

Table 343-2 Biochemical Tests Used for Pheochromocytoma Diagnosis Diagnostic Method Sensitivity Specificity 24-h urinary tests Vanillylmandelic acid ++ ++++ Catecholamines +++ +++ Fractionated metanephrines ++++ ++ Total metanephrines +++ ++++ Ref: Harrisons Principles of Internal Medicine, 18th Edition, Page 2963


Question: Prophylaxis for migraine

K.D Tripathy essentials of medical pharmacology 7th edition . *Drugs for prophylaxis of migraine are beta blockers(propranalol ),TCA(amitriptyline ), calciumchannelblockers(flunarizine),anticonvulsants (valproate),5HT antagonist. Ref Harrison20th edition pg 2234


Question: NARP Syndrome is a

NARP SYNDROME NARP syndrome is a mitochondrial function disorder. The main components of NARP syndrome are: Neuropathy (peripheral neuropathy which mostly affects sensory nerves) Ataxia Retinitis pigmentosa Other features include seizures, hearing loss and cardiac conduction defects. It occurs due to a mutation in the MT-ATP6 gene, which results in altered structure or function of mitochondrial ATP synthase leading to decreased ATP production. As it involves a mutation of mitochondrial DNA, it is inherited from mother to child (maternal inheritance). Other maternally inherited mitochondrial DNA disorders include: Leigh syndrome, Leber's hereditary optic neuropathy & Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes ( MELAS ) Ref :Harrison's Principles of Internal Medicine 21st ed .


Question: Drug used in irritable bowel syndrome with constipation


Question: Long term control of diabetes is assessed by


Question: Dissociative sensory loss is not seen in

Dissociated sensory loss is a pattern of neurological damage caused by a lesion to a single tract in the spinal cord which involves preservation of fine touch and proprioception with selective loss of pain and temperature. Understanding the mechanisms behind these selective lesions requires a brief discussion of the anatomy involved. Loss of pain and temperature are due to damage to the lateral spinothalamic tracts, which cross the central pa of the cord close to the level where they enter it and travel up the spinal column on the opposite side to the one they innervate (i.e. they ascend contralaterally). Note that a lesion of the lateral spinothalamic tract at a given level will not result in sensory loss for the dermatome of the same level; this is due to the fibers of the tract of Lissauer which transmit the neuron one or two levels above the affected segment (thus bypassing the segmental lesion on the contralateral side). Loss of fine touch and proprioception are due to damage to the dorsal columns, which do not cross the cord until the brainstem, and so travel up the column on the same side to the one they innervate (i.e. they ascend ipsilaterally). This means that a lesion of the dorsal columns will cause loss of touch and proprioception below the lesion and on the same side as it, while a lesion of the spinothalamic tracts will cause loss of pain and temperature below the lesion and on the opposite side to it. Dissociated sensory loss always suggests a focal lesion within the spinal cord or brainstem. The location of cord lesions affects presentation--for instance, a central lesion (such as that of syringomyelia) will knock out second order neurons of the spinothalamic tract as they cross the centre of the cord, and will cause loss of pain and temperature without loss of fine touch or proprioception. Other causes of dissociated sensory loss include: Diabetes mellitus Syringomyelia Brown-Sequard syndrome Lateral medullary syndrome aka Wallenberg's syndrome Anterior spinal aery thrombosis Tangier disease Subacute combined degeneration Multiple sclerosis Tabes dorsalis Friedreich's ataxia (or other spinocerebellar degeneration) Ref Harrison20th edition pg 2756


Question: In a patient with myocardial infarction the valvular lesion commonly seen is


Question: Punched out appearance in skull seen in

i.e. (Multiple myeloma): (679-Robbins 7th)MULTIPLE MYELOMA - presents as multifocal destructive bone tumours composed of plasma cells throughout the skeletal system* The bone lesions appears radiographically as punched out defects usually 1 -4 cm in diameter and grossly consists of gelatinous soft red tumour masses* Hyperparathyroidism - "pepper pot skull", The mandible a common site for Frown ' tumours* Moth - eaten appearance - syphilis* Rugor Jersy spine - Osteopetrosis* Beheadedscortish terrior sign - Spondylolisthesis


Question: Treatment for genotype 1a of hepatitis C

- Hepatitis C genotypes and their treatment Genotype 1a Ledipasvir + sofosbuvir Genotype 1b Ledipasvir + sofosbuvir Genotype 2 Sofosbuvir + velpatasvir Genotype 3 Sofosbuvir + velpatasvir Genotype 4 Sofosbuvir + velpatasvir Genotype 5,6 Sofosbuvir + velpatasvir


Question: Most common cause of subarachnoid hemorrhage IS

*Commonly result from rupture of congenital berry aneurysms in the interpeduncular cistern Ref Harrison20th edition pg 2344


Question: Single best test for diagnosis of hypothyroidism is estimation of

Ans. c (TSH). (Ref. Harrison, Principles of Medicine, 15th ed. 2066)# A normal TSH level excludes primary (but not secondary) hypothyroidsm.# If TSH is elevated, a free T4 level is needed to confirm presen ce of clinical hypothyroidism, but free T4 is inferior to TSH when used as screening test, as it will not detect subclinical or mild hypothyroidsm.# Circulating free T3 levels are normal in about 25% patients, reflecting adaptive response to hypothyroidism. T3 levels are therefore not indicated.# For congenital hypothyroidism even TSH/T4 levels in heel-prick blood specimens are used for neonatal screening.# Note: Iodine deficiency remains the most common cause of hypothyroidsm.


Question: Autoimmune hemolytic anemia is seen in

Answer is B (Chronic lymphatic leukemia) Leukemias especially of the CLL type are associated with Autoimmune hemolytic anemia - Harrison Hemolvsis due to Antibodies: Warm-Antibody immunohemolytic anemia Cold-Antibody immunohemolytic Anemia 1. 2. 3. 4. 5. 6. Idiopathic Lymphomas: Chronic lymphocytic leukemia, non-Hodgkin's lymphomas, Hodgkin'd disease (infrequent) SLE and other collagen-vascular diseases Drugs (a) a-Methyldopa type (autoantibody to Rh antigens) (b) Penicillin type (stable hapten) (c) Quinidine type (unstable hapten) Postviral infections Other tumors (rare) I. 2. Cold agglutinin disease (a) Acute: Mycoplasma infection, infectious mononucleosis (b) Chronic: Idiopathic, lymphoma Paroxysmal cold hemoglobinuria


Question: Rome II criteria are used for

Rome II criteria for the diagnosis of Irritable Bowel SyndromeRecurrent abdominal pain or discomfo at least 3 days per month in the last 3 months associated with two or more of the following:Improvement with defecationOnset associated with a change in frequency of stoolOnset associated with a change in form (appearance) of stoolRef: Harrison 19e pg: 1965


Question: The Drug of Choice for Sydenham chorea is

(D) Sodium Valproate[?]SYDENHAM'S CHOREA:oSydenham's chorea (SC)/Chorea minor/Rheumatic chorea (RC)/St Vitus' s Dance:-Major diagnostic criteria for rheumatic disease-Most common acquired chorea during childhood-Characterized by rapid, uncoordinated jerking movements primarily affecting the face, hands and feet.[?]Treatment of Chorea:oMay be difficult to treat.oTaper or discontinue any medications that can cause or worsen chorea.oIn adults, the mainstay of treatment in adults is Neuroleptics, including Haloperidol & Pimozide.oIn children the incidence of side effects in children is high.oTherefore, treatment is usually:-Benzodiazepine, particularly Clonazepam, Diazepam or Clobazam.-Valproate Is the drug of choiceoSydenham chorea generally responds to dopamine-blocking agents - Valproic acid & carbamazepine.oBenzodiazepines facilitate the action of GABA and valproate enhances the action on GABA, hence these agents are used to treat choreaoBut it is self limited, and treatment generally restricted to those with severe chorea.oSydenham chorea with recurrence in lateral life as pregnancy (Chorea gravidarum) or treatment with sex hormones.[?]Treatment Hyperkinetic Movement Disorders:oDystonia:-Anticholinergic, baclofen, botulinum toxin, globus pallidus internus DBS.oHemifacial spasm:-Botulinum toxinoEssential tremor:-Propranolol, primidone, topiramate, botulinum toxin, ventral intermediate nucleus DBS.oTics (Tourette's syndrome):-Fluphenazine, risperidone, botulinum toxin.oChorea (huntington's Disease):-TetrabenazineoMyoclonus:-Clonazepam, levetiracetam, piracetam, sodium valproate.oTardive dyskinesia:-Withdrawal of the causative treatment, tetrabenazine (for tardive stereotypy, chorea, tremor), botulinum toxin (for tardive dystonia).GENETIC & NON-GENETIC CAUSES OF CHOREAGenetic causesNon-genetic causes* Huntington's Disease* Sydenham's chorea* Neuroacanthocytosis* Metabolic causes* Benign hereditary chorea* Chorea gravidarum* Wilson's disease* Drug induced chorea* Dentatorubropallidolusian atrophy* Senile chorea* Spinocerebellar ataxia type 2* Vascular chorea* McLeod Syndrome* Infective causes[?]CAUSES OF CHOREA:oDrugs:-Levodopa in Parkinson's patients-Oral contraceptive pills-Many psychiatric drugsoVascular disease of the basal ganglia:-Atheroma-Systemic lupus erythematosusoDegeneartive disease:-Huntington's diseaseoPost-infectious:-Sydenham's choreaoOther causes: Thyrotoxicosis


Question: Treatment of acute cardiac tamponade is

Initial management in hospital is by pericardiocentesis. This involves the inseion of a needle through the skin and into the pericardium and aspirating fluid under ultrasound guidance preferably. This can be done laterally through the intercostal spaces, usually the fifth, or as a subxiphoid approach.A left parasternal approach begins 3 to 5 cm left of the sternum to avoid the left internal mammary aery, in the 5th intercostal space. Often, a cannula is left in place during resuscitation following initial drainage so that the procedure can be performed again if the need arises. If facilities are available, an emergency pericardial window may be performed instead] during which the pericardium is cut open to allow fluid to drain. Following stabilization of the person, surgery is provided to seal the source of the bleed and mend the pericardium. In people following hea surgery the nurses monitor the amount of chest tube drainage. If the drainage volume drops off, and the blood pressure goes down, this can suggest tamponade due to chest tube clogging. In that case, the person is taken back to the operating room for an emergency reoperation. If aggressive treatment is offered immediately and no complications arise (shock, AMI or arrhythmia, hea failure, aneurysm, carditis, embolism, or rupture), or they are dealt with quickly and fully contained, then adequate survival is still a distinct possibility. Ref Davidson 23rd edition pg 453


Question: Bart hemoglobin is a tetramer of

Bart Hb is a tetramer of excess γ globin.