Miscellaneous

• 1. A 25 year old male presented to OPD with complains of fatigue for 1 month. He also complains of decreased sleep and decreased appetite. He mentioned that he could not concentrate well in his lecture classes. He feels emptiness in his life and tried ending his life twice in the past week. On asking further, he told that he was diagnosed as a case of Schizophrenia 5 years back and he is currently under regular medications. Lab investigations show; TSH 4.5, ESR 10, Hb 9.7, MCV 78, normal electrolytes, SGOT 52, SGPT 43 and ALP 50 (standard units are mentioned). His father also has been diagnosed as a case of Schizophrenia. What is the most likely diagnosis at this point of time in the patient?
• a. Schizophrenia
• b. Hypothyroidism
• c. Schizoaffective disorder
• d. Mood disorder with psychotic features

d. Mood disorder with psychotic features

(The patient already has Schizophrenia and still taking medications, so we can assume he may still have its symptoms as there is no mention in the question regarding its complete cure. So,this patient seems to have both depressive/mood symptoms and schizophrenic symptoms together (and not at different times). Hence we can tick “d. Mood disorder with psychotic features” as the best possible answer.)

• A. Schizoaffective disorder
• • Shares symptoms with both schizophrenia and mood disorders (major depressive or bipolar disorder).
• • To differentiate from a mood disorder with psychotic features, patient must have > 2 weeks of psychotic symptoms without a manic or depressive episode.

• B. Schizophrenia
• • Chronic illness causing profound functional impairment. Symptom categories include:
• • Positive—hallucinations, delusions, unusual thought processes, disorganized speech, bizarre behavior
• • Negative—flat or blunted affect, apathy, anhedonia, alogia, social withdrawal
• • Cognitive—reduced ability to understand or make plans, diminished working memory, inattention
• • Diagnosis requires ≥ 2 of the following active symptoms, including ≥ 1 from symptoms #1–3:
• 1. Delusions
• 2. Hallucinations, often auditory
• 3. Disorganized speech
• 4. Disorganized or catatonic behavior
• 5. Negative symptoms
• • Requires ≥ 1 month of active symptoms over the past 6 months; onset ≥ 6 months prior to diagnosis.

• C. MDD with psychotic features
• • MDD + hallucinations or delusions. Psychotic features are typically mood congruent (eg, depressive themes of inadequacy, guilt, punishment, nihilism, disease, or death) and occur only in the context of major depressive episode (vs schizoaffective disorder).
• • Treatment: antidepressant with atypical antipsychotic, ECT.

• 2. Drugs cause urticaria by direct degranulation of mast cells, interfering with arachidonic acid metabolism, IgE-mediated degranulation of mast cells or Complement-mediated degranulation of mast cells. Which of the following drugs cause urticarial by IgE-mediated degranulation of mast cells?
• a. Aspirin
• b. Penicillin
• c. Radioactive contrast
• d. Sulphonamide

b. Penicillin

• Transmitted Diseases, Neena Khanna, 4th edition, page no. 211
• Drugs causing Urticaria and Angioedema
• Pathogenesis
• • Drugs cause urticaria by:
• • Direct degranulation of mast cells.
• • Interfering with arachidonic acid metabolism.
• • IgE-mediated degranulation of mast cells.
• • Complement-mediated degranulation of mast cells.
• Clinical Features
• Urticaria and angioedema can occur independently or may also be part of a severe and generalized reaction (anaphylaxis), which includes bronchospasm and circulatory collapse.
• Drugs Implicated
• A. Drugs which directly direct degranulate mast cells:
• • Aspirin.
• • Indomethacin.
• B. Drugs which interfere with arachidonic acid metabolism:
• • Opiates: morphine and codeine.
• • Sulfonamides.
• • Curare.
• • Radioactive contrast.
• C. Drugs which mediate urticaria through IgE:
• • Penicillin.
• D. Drugs which mediate urticaria through complement system:
• • Blood products.

• 3. Secretin and CCK are important hormones which regulate secretion of Pancreatic juice. Which one of the following statements is true regarding this regulation?
• a. Secretin causes release of juice rich in enzymes but low in volume
• b. CCK causes release of juice rich in HCO3− and poor in enzymes
• c. Secretin acts on duct cells by increasing cAMP
• d. CCK acts on duct cells by increasing cGMP

c. Secretin acts on duct cells by increasing cAMP

• REGULATION OF THE SECRETION OF PANCREATIC JUICE
• • Secretion of pancreatic juice is primarily under hormonal control.
• • Secretin acts on the pancreatic ducts to cause copious secretion of a very alkaline pancreatic juice that is rich in HCO3− and poor in enzymes. The effect on duct cell is due to an increase in intracellular cAMP. Secretin also stimulates bile secretion.
• • CCK acts on the acinar cells to cause the release of zymogen granules and production of pancreatic juice rich in enzymes but low in volume. Its effect is mediated by phospho-lipase C. Thus, by acting together, CCK and secretin add enzymes to the pancreatic juice and ensure that they are washed into the intestine.

Ans : Median nerve

• • When the median nerve is severed in the elbow region, flexion of the proximal interphalangeal joints of the 1st–3rd digits is lost and flexion of the 4th and 5th digits is weakened. Flexion of the distal interphalangeal joints of the 2nd and 3rd digits is also lost. Flexion of the distal interphalangeal joints of the 4th and 5th digits is not affected because the medial part of the FDP, which produces these movements, is supplied by the ulnar nerve. The ability to flex the metacarpophalangeal joints of the 2nd and 3rd digits is affected because the digital branches of the median nerve supply the 1st and 2nd lumbricals. Thus, when the person attempts to make a fist, the 2nd and 3rd fingers remain partially extended (“hand of benediction”).
• • Thenar muscle function (function of the muscles at the base of the thumb) is also lost, as in carpal tunnel syndrome. When the anterior interosseous nerve is injured, the thenar muscles are unaffected, but paresis (partial paralysis) of the flexor digitorum profundus and flexor pollicis longus occurs. When the person attempts to make the “okay” sign, opposing the tip of the thumb and index finger in a circle, a “pinch” posture of the hand results instead owing to the absence of flexion of the interphalangeal joint of the thumb and distal interphalangeal joint of the index finger (anterior interosseous syndrome).

• Ans: B
• Ref: Harper Biochemistry 30th Edition, Page No: 639
• • Hurler disease: Mental retardation, coarse facial features, hepatosplenomegaly, cloudy cornea
• • Hunter disease: Mental retardation
• • Morquio syndrome A : Skeletal dysplasia, short stature
• • Natowicz syndrome: Joint pain, short stature

• 1. You are called urgently to see an 80-year-old man who is 6 days following open anterior resection for rectal carcinoma with defunctioning stoma. The patient reported seeing a gush of pink fluid from the central laparotomy wound. You notice that the small bowel is eviscerating from the wound. Following initial resuscitation, the next best step is to
• a. Cover the small bowel with a sterile saline-soaked gauze
• b. Administer intravenous cefuroxime 1.5 g
• c. Return the patient to theatre for deep-tension abdominal wall closure
• d. Apply vacuum-assisted closure therapy

• Ans: a
• The most appropriate next step following resuscitation is to protect the bowel from the atmosphere with a saline-soaked gauze. This should precede the subsequent management, which would include calling a senior colleague, administering intravenous antibiotics and returning the patient to theatre for immediate closure of the abdomen using deep tension sutures.
• Vacuum-assisted closure therapy can be used in cases of wound dehiscence, but not where the bowel is eviscerated.

• 2. Frost bite is treated by:
• a. Rapid rewarming
• b. Gentle rewarming
• c. IV pentoxyphiline
• d. Amputation

• Ans: b
• Ref: Bailey and Love 27th Edition, Page No: 422
• Frost bite and immersion injuries (trench foot)
• • Frost bite occurs when a part of the body freezes.
• • The cells are disrupted and the tissue dies. It is in effect a ‘cold’ burn and can be categorized according to the depth that it affects in the same way as a conventional burn. Other mechanisms at play include vasoconstriction caused by cold, capillary sludging and reperfusion injury with the release of free radicals, which occurs on rewarming the part. It commonly involves the fingers, toes, cheeks, the tip of the nose and the ears.
• • When frozen the tissue feels hard and cannot be indented. Immersion injury is a cold injury, which does not involve actual freezing of the tissue and is commonly caused by prolonged immersion in cold water (hence trench foot).
• • The patient may also be hypothermic. Warming should be gentle as the heat used may actually cause a burn! Rehydration with warm fluids and use of non-steroidal anti-inflammatory drugs like ibuprofen are beneficial.
• • Demarcation will occur between dead and viable tissue and at this stage no surgery should be undertaken as there is often considerable deep recovery. The injured area should be kept clean and dry and efforts made to prevent further injury, as well as to prevent infection. Definitive surgery to excise dead tissue can be left for many months.
• • Recent developments, such as the use of tissue plasminogen activator (TPA) and nerve blocks, show promising results in reducing amputations, but have to be started within 24 hours and are seldom possible in the field.

• 3. A 65-year old man presented with an episode of syncope. He said he felt dizzy during defecation and noticed gross bleeding in the pan. Fecal occult blood test done 3 months ago as a part of routine screening for colon cancer was negative. There is no history of recent weight loss. What is the likely colonoscopic finding?
• a. Early stage carcinoma colon
• b. Sigmoid diverticulitis
• c. Microscopic colitis
• d. Dilated mucosal and submucosal veins in the colon

• Ans: d
• Ref: Harrison 19th Edition, Page No: 731 ; Bailey 26th Edition, Page No:1174, 25th Edition, Page No:1157
• Diagnosis in a 65 year old patient of bleeding per rectum with syncope and negative fecal occult blood test and no history of recent weight loss is HEYDE’S Syndrome.
• The colonoscopic finding in Hyde’s syndrome is dilated mucosal and submucosal veins in the colon.
• HEYDE’S Syndrome: Triad of aortic stenosis, acquired coagulopathy and anaemia due to bleeding from intestinal angiodysplasia.

• 4. A 28 year old male presents with weight loss. On Barium study, pulled up cecum is seen. Likely diagnosis is?
• a. Ca colon
• b. Carcinoid
• c. Ileocecal tuberculosis
• d. Crohn’s disease

• Ans: c
• Ref: Bailey & Love 25th Edition, Page No: 1174
• TB of small intestine
• Clinical features:
• • Attacks of acute abdominal pain with intermittent diarrhea
• • Mass in right iliac fossa in a patient with vague ill health
• • Features of blind loop syndrome may develop due to stasis, distension and chronic infection in the segment of ileum proximal to obstruction.
• Barium meal radiography reveals:
• • Persistent narrowing of the affected segment in the terminal ileum and cecum
• • Caecum is pulled up and may become subhepatic

• 1. World Health Day 2020 marked acknowledgement of the role of:
• a. Doctors
• b. Midwives
• c. Pharmacist
• d. Research scientist

• Ans: b
• Happy World Health Day 2020
• 7 April 2020 is the day to celebrate the work of nurses and midwives and remind world leaders of the critical role they play in keeping the world healthy. Nurses and other health workers are at the forefront of COVID-19 response - providing high quality, respectful treatment and care, leading community dialogue to address fears and questions and, in some instances, collecting data for clinical studies. Quite simply, without nurses, there would be no response.

• 2. PFK -1 inhibitor:
• a. AMP
• b. Citrate
• c. ATP
• d. Both b and c

• Ans: D
• Ref: Harper biochemistry; 30th edition; Page No: 189
• Phosphofructokinase (phosphofructokinase-1) occupies a key position in regulating glycolysis and is also subject to feedback control. It is inhibited by citrate and by normal intracellular concentrations of ATP and is activated by 5′ AMP. At the normal intracellular [ATP] the enzyme is about 90% inhibited; this inhibition is reversed by 5′AMP.

• 3. Which of the following promotes high levels of HbF synthesis?
• a. Hydroxyurea
• b. Butyrates
• c. Cytarabine
• d. All of the above

• Ans: D
• Ref: Harrison 19th Edition, Page No: 639
• Reestablishing high levels of HbF synthesis can ameliorate symptoms of thalassemia.
• Hydroxyurea & cytarabine promote high levels of HbF synthesis by stimulating proliferation of F cell progenitors. Butyrates also stimulate HbF production.

• 4. A couple is using OCP for 3 years. They are hesitant about the daily use and missed pills. They want alternative long lasting contraception plan. You are explaining them about the other methods available. IUCD fascinates them. Characteristics of an ideal candidate for copper-T insertion include all of the following except:
• a. Has born at least one child
• b. Is willing to check IUD tail
• c. Has a history of ectopic pregnancy
• d. Has normal menstrual periods

• Ans: c
• Ref: Shaw Gynecology 16th Edition, Page No: 269
• IUCDs are a good contraceptive choice for the following groups of women:
• ��� Low risk of STD
• • Multiparous woman
• • Monogamous relationship
• • Desirous of long-term reversible method of contraception, but not yet desirous of permanent sterilization
• • Unhappy or unreliable users of oral contraception or barrier contraception

• Contraindications
• • Suspected pregnancy
• • Pelvic inflammatory disease (PID), lower genital tract infection
• • Presence of fibroids—because of misfit
• • Menorrhagia and dysmenorrhoea, if Copper T is used
• • Severe anaemia
• • Diabetic women who are not well controlled—because of slight increase in pelvic infection
• • Heart disease—risk of infection
• • Previous ectopic pregnancy
• • Scarred uterus
• • Preferably avoid its use in unmarried and nulliparous patients because of the risk of PID and subsequent tubal infertility
• • LNG IUCD in breast cancer
• • Abnormally shaped uterus, septate uterus

• 5. A one-week-old, full-term infant born by uncomplicated vaginal delivery is brought to a pediatrician by his mother, who notes that her daughter's skin appears yellow. She reports that the child cries several times per day and sleeps 7-8 hours at night, uninterrupted. She has been breastfeeding exclusively and feels that he has been feeding well. Which of the following is the best treatment for this condition?
• a. Phenobarbital administration
• b. Plasma exchange
• c. Switch from breast milk to formula
• d. Continue normal breast feeding

• Ans: d
• • The infant in this case most likely has breast milk jaundice. No intervention is needed, and the mother does not need to stop breast feeding.
• • Breast milk jaundice occurs because the infant liver is not mature enough to process lipids. It presents between the 4th and 7th day of life. If breast feeding stops, bilirubin levels fall rapidly; however, if breast feeding continues, bilirubin levels will fall slowly.
• • Distinct from breast milk jaundice, breastfeeding jaundice is the most common cause of neonatal jaundice in the first week of life and occurs in 10% of births. It is characterized by insufficient feeding, which leads to fewer bowel movements and, therefore, decreased bilirubin clearance. The infant in this vignette has been breastfeeding normally.
• • While switching to formula may improve the jaundice, mothers should be encouraged to continue breast feeding because of the improved health benefits of breast milk over formula.

• 1. Hotline number for ambulance services in Nepal is:
• a. 100
• b. 101
• c. 102
• d. 103

• Ans: c
• • In the event of an emergency, dial 100 to contact the police in Nepal.
• • Dial 101 for fire.
• • Dial 102 for ambulance service.
• • Dial 103 for traffic control.
• • Dial 197 for telephone inquiry.

• 2. Catecholamines are increased in:
• a. Neuroblastoma
• b. Retinoblastoma
• c. Medulloblastoma
• d. Nephroblastoma

• Ans: a
• Ref: Robbins Basic Pathology 10th Edition, Page No: 286, 289
• Neuroblastoma
• • The term neuroblastic includes tumors of the sympathetic ganglia and adrenal medulla that are derived from primordial neural crest cells populating these sites; neuroblastoma is the most important member of this family.
• • It is the second most common solid malignancy of childhood after brain tumors, accounting for 7% to 10% of all pediatric neoplasms, and as many as 50% of malignancies diagnosed in infancy.
• • About 90% of neuroblastomas, regardless of location, produce catecholamines (similar to the catecholamines associated with pheochromocytomas), which constitutes an important diagnostic feature (i.e., elevated blood levels of catecholamines and elevated urine levels of catecholamine metabolites such as vanillylmandelic acid [VMA] and homovanillic acid [HVA]). Despite the elaboration of catecholamines, hypertension is much less frequent with these neoplasms than with pheochromocytomas.
• Retinoblastoma
• • Most common primary intraocular malignancy of children.
• • Approximately 40% of the tumors are associated with a germline mutation in the RB gene and are therefore heritable.
• • The remaining 60% of the tumors develop sporadically, and these have somatic RB gene mutations. Familial cases typically are associated with development of multiple tumors that are bilateral, although they may be unifocal and unilateral.
• • All of the sporadic, nonheritable tumors are unilateral and unifocal.
• • Patients with familial retinoblastoma also are at increased risk for the development of osteosarcoma and other soft tissue tumors.

• 3. Rave drug is:
• a. Cannabis
• b. Cocaine
• c. Heroin
• d. Amphetamine

• Ans: d
• MDMA is also called Rave drug and ecstasy.
• Street names:
•  Gamma Hydroxy butyrate (GHB): Liquid ecstasy, Grievous bodily harm
•  Phencyclidine and Ketamin: Angel dust, Hog, Special K
•  Cocaine: Crack (vapour to be smoked), Rush, Coke, Snow, Blow, Peruvian marching Powder
•  Methylene dioxymethamphetamine (MDMA): Ecstasy, Rave drug
•  Lysergic acid diethylamide (LSD): Windowpane, Twenty-five

• 4. A child is below the third percentile for height.His growth velocity is normal,but chronological age is more than skeletal age. The most likely diagnosis is:
• a. Constitutional growth delay
• b. Hypopituitarism
• c. Familial short stature
• d. Cretinism

• Ans: a
• Ref: OP Ghai 9th edition page 33
• Constitutional growth delay:
• • These children are born with a normal length and weight and grow normally for the first 6-12 months of life. Their growth then shows a deceleration so that the height and weight fall below the 3rd centile.
• • By 3 Years of age, normal height velocity is resumed and they continue to grow just below and parallel to the 3rd centile with a normal height velocity.
• • The onset of puberty and adolescent growth spurt is also delayed in these children but final height is within normal limits.
• • Bone age is lower than chronological age and corresponds to the height age. History of delayed puberty and delayed height spurt is usually present in one or both parents.

• 5. The greatest risk factor for Necrotizing enterocolitis is
• a. Low birth weight
• b. Intestinal ischemia
• c. Enteral nutrition
• d. Prematurity

• Ans: d
• Ref: Nelson 20th edition page 869
• Although NEC is a multifactorial disease primarily associated with intestinal immaturity, the concept of “risk factors” for NEC is controversial. The triad of intestinal ischemia (injury), enteral nutrition (metabolic substrate), and bacterial translocation has classically been linked to NEC.
• The greatest risk factor for NEC is prematurity. The disorder probably results from an interaction between loss of mucosal integrity due to a variety of factors (ischemia, infection, inflammation) and the host’s response to that injury (circulatory, immunologic, inflammatory), leading to necrosis of the affected area. Coagulation necrosis is the characteristic histologic finding in intestinal specimens.

• 1. A 19-year-old woman in her first pregnancy presents to you with an outbreak of primary herpes simplex infection on her labia. She is 33 weeks pregnant. What is the best advice regarding her herpes?
• a. Acyclovir from 36 weeks until delivery
• b. Caesarean section should be performed if she labors within the next 8 weeks
• c. Reassure as the infection will pass and pose no further concern
• d. If she labors within 6 weeks, a caesarean should be recommended

• Ans: d
• If primary herpes develops in pregnancy it is imperative to consider risk of vertical transmission. If the herpes presents at the time of delivery or within 6 weeks of the due date a caesarean is the safest mode of delivery.
• If she labours within 6 weeks (not 8 weeks) of developing primary herpes she should consider a caesarean. If she refuses to have a caesarean then IV acyclovir during labour and close liaison with the neonatologist is recommended.
• You can reassure the woman but only if she delivers after 6 weeks when the herpes should have cleared. It would be wrong to tell her that all will be well regardless of the timing of delivery.

• 2. A 12-year-old boy presents to his GP with left-sided unilateral breast development stage III. He is very upset as he is being bullied at school. His mother is worried as her friend’s sister has just been diagnosed with breast cancer and wants to know if he could have breast cancer? What is the management?
• a. Refer for a breast ultrasound
• b. Test alpha fetoprotein
• c. Reassure and explain this is a normal part of puberty; it will resolve but the other breast may enlarge transiently as well
• d. Do a fine needle aspirate on his left breast

• Ans: c
• This is a common presentation for adolescent males and the correct answer is to reassure. Normal puberty for boys starts between 9 and 13 years old with increasing testicular volume above 4 mL. This is followed by penis enlargement, pubic hair growth and lastly the growth spurt. It is not uncommon for boys to develop transient gynaecomastia during puberty. He does not need investigation or intervention, unless the problem does not resolve.

• 3. Which of the following drug is not used in TOF?
• a. Isoprenaline
• b. Sodium bicarbonate
• c. Morphine
• d. Propranolol

• Ans: a
• Ref: OP Ghai Pediatrics 9th Edition, Page No: 408
• Cyanotic spells/ Tet spells are acute hypoxemic attacks in tetralogy of Fallot.
• Treatment of Tet spells is done by following methods
•  Knee chest positioning or squatting- increases systemic vascular resistance at femoral veins & decreases systemic venous return.
•  Morphine: suppress respiratory center & abolishes hyperpnea
•  Oxygen : Acidosis if any should be treated with NaHCO3 intravenously.
•  Propranolol: Propranolol by decreasing cardiac contractility may decrease infundibular obstruction of right ventricular outflow.
• Prevention
•  Counsel parents regarding the possibility of recurrence of spells and precipitating factors (dehydration, fever, pain)
•  Encourage early surgical repair

• 4. Expectant management in ectopic pregnancy is done if:
• a. Initial beta hCG level <1000 IU/ml & falling
• b. Initial beta hCG level <2000 IU/ml & falling
• c. Diameter of sac <5 cm
• d. All of the above

• Ans: a
• Ref: Dutta Obstetrics 8th Edition, Page No: 216
• Expectant management: where only observation is done hoping spontaneous resolution.
• Indications are:
•  Initial beta–hCG level < 1000 IU/ml & falling
•  Gestational sac size < 4 cm
•  No fetal heart beat on TVS
•  No evidence of bleeding or rupture

• 5. Pseudoparalysis In infant is suggestive of:
• a. Vitamin K deficiency
• b. Vitamin A deficiency
• c. Vitamin C deficiency
• d. Vitamin B deficiency

• Ans: c
• Ref: OP Ghai Pediatrics 8th Edition, Page No: 120
• Vitamin C (ascorbic acid), structurally related to glucose, has a striking capacity for reversible oxidation-reduction. Humans and other primates do not synthesize vitamin C.
• Sources
• • Dietary sources include vegetables (cauliflower, broccoli, cabbage) and fruits (berries, citrus). Much of vitamin C may be lost in cooking, but is stable in canned and frozen foods. Vitamin C in human and cow milk ranges from 5 to 15 mg/100 kcal and 0.2-2.0 mg/100 kcal respectively. Daily requirements are 30-40 mg for infants and 40-70 mg for children.
• Absorption and metabolism
• • Ascorbic acid is absorbed by an active, sodium-dependent process in the upper small intestine. The vitamin circulates in plasma in its free, anionic form, reaching high concentrations in adrenal and pituitary glands and in leukocytes. Vitamin C appears unchanged in the urine when renal threshold is exceeded.
• Biologic action
• • Vitamin C functions as a strong reducing agent or in electron transport within biological systems. Ascorbic acid is essential for normal function of leukocytes, fibroblasts, osteoblasts and microsomes and participates in metabolism of carnitine, serotonin and folate. Ascorbic acid affects the immune response, detoxification, collagen synthesis and wound healing.
• Deficiency
• • Prolonged vitamin C deficiency results in scurvy. It usually occurs in those who are deprived of citrus fruits, fresh vegetables or vitamins for some cultural or geographic reasons. In infancy, features of scurvy are anorexia, diarrhea, pallor, irritability and increased susceptibility to infections. Subperiosteal hemorrhages and long bone tenderness (pseudoparalysis of lower extremities) can occur; radiologic abnormalities are frequent. In older children, hemorrhagic signs predominate, with bleeding from gums, conjunctiva and intestinal tract.

• 6. What is the earliest most common presenting feature of anterior cervical fibroid?
• a. Frequency of urine
• b. Bleeding
• c. Acute abdomen
• d. Constipation

• Ans: a
• Ref: Dutta Gynecology 6th Edition, Page No: 284
• Cervical fibroid
• Symptoms
• In nonpregnant state, the symptoms are predominantly due to pressure effect on the surrounding structures.
• • Anterior cervical: Bladder symptoms like frequency or even retention of urine are conspicuous. The retention is more due to pressure than elongation of urethra.
• • Posterior cervical: Rectal symptom is in the form of constipation.
• • Lateral cervical: Vascular obstruction may lead to hemorrhoids and edema legs (rare). The ureter is pushed laterally and below the tumor.

• 1. What is the defect in Prader-Willi syndrome?
• a. Maternally derived chromosome 12
• b. Paternally derived chromosome 12
• c. Maternally derived chromosome 15
• d. Paternally derived chromosome 15

• Ans: d
• Ref: Nelson Pediatrics, 20th edition, page 602 – 603
• • The 2 copies of most autosomal genes are functionally equivalent. However, in some cases only 1 copy of a gene is transcribed and the other copy is silenced.
• • In imprinting, gene expression depends on the parent of origin of the chromosome. Imprinting disorders result from an imbalance of active copies of a given gene, which can occur for several reasons. Prader-Willi and Angelman syndromes, two distinct disorders associated with developmental impairment, are illustrative. Both can be caused by microdeletions of chromosome 15q11-12.
• • The microdeletion in Prader-Willi syndrome is always on the paternally derived chromosome 15, whereas in Angelman syndrome it is on the maternal copy.

• 2. Gartner's duct cyst is seen in:
• a. Vagina
• b. Cervix
• c. Hymen
• d. Labia minora

• Ans: a
• Ref: Shaw Gynecology 16th Edition, Page No: 388, 389
• Vaginal Cysts
• The vaginal cyst is rare, and most commonly located in the anterior vaginal wall. They are usually small, but may attain a size of 7.5 cm in diameter.
• • Gartner’s duct cyst arises from the remnants of the meso¬nephric duct and lies in the anterolateral aspect of the vaginal wall. A small cyst remains asymptomatic. A large cyst if causing dyspareunia requires excision.
• • Inclusion cyst is mainly seen at the lower end of the vagina on its posterior surface and is caused by tags of mucosa embedding inside the scar those later forms a cyst.
• • Bartholin cyst at times extends into the vagina and causes dyspareunia.
• • Endometriotic cyst appears as a bluish bulge in the posterior fornix. It behaves similar to endometriotic cyst of the vulva. It is treated with either danazol or surgical excision.

• 3. According to WHO, what does X2 denote in xerophthalmia in Vitamin A deficiency
• a. Conjunctival xerosis
• b. Corneal xerosis
• c. Bitot’s spot
• d. Corneal ulcer

• Ans: b
• Ref: AK khurana, 6thedition,page 468
• First clinical sign of Vitamin A deficiency is conjunctival xerosis
• First clinical symptom of Vitamin A deficiency is night blindness.
• WHO classification of xerophthalmia
• Class Signs
• X1A Conjunctival xerosis
• X1B Bitot’s spot
• X2 Corneal xerosis
• X3A Corneal xerosis with ulceration
• X3B Keratomalacia

• 4. If you were told by a colleague that their assessment of a patient’s Glasgow Coma Scale was E2, V3, M5, how would you interpret this?
• a. The patient’s eyes open to sound, they are orientated are able to obey commands
• b. The patient’s eyes open to pain, they can utter some words but do not form sentences, and they are able to localise to trapezius pinch.
• c. The patient’s eyes open spontaneously; they are orientated and able to obey commands
• d. The patient’s eyes open spontaneously; they are orientated and they are able to localise to trapezius pinch.

• Ans: b
• Ref: Bailey and Love Surgery, 27th Edition, Page 325
• If the colleague has used the numbers correctly they mean that the patient’s eyes open to pain, they can utter some words but do not form sentences, and they are able to localise to trapezius pinch. But you should ask them to confirm this is the case by using the words, which should be used in preference to numbers for this purpose.
• • Eye (E): 1-4: Does not open eyes ---Opens eyes in response to pain---Opens eyes in response to voice---Opens eyes spontaneously
• • Verbal ( V ) : 1-5: Makes no sounds---Makes sounds---Words---Confused, disoriented---Oriented, converses normally
• • Motor (M): 1-6: Makes no movements---Extension to painful stimuli (decerebrate response)---Abnormal flexion to painful stimuli (decorticate response)---Flexion / Withdrawal to painful stimuli---Localizes to painful stimuli---Obeys commands

• 5. Carvallo’s sign is related to which of the following:
• a. Aortic regurgitation
• b. Mitral regurgitation
• c. Tricuspid regurgitation
• d. Pericarditis

• Ans: c
• Ref: Harrison Medicine 19th Edition, Page No: 1548
• A prominent RV pulsation along the left parasternal region and a blowing holosystolic murmur along the lower left sternal margin, which may be intensified during inspiration & reduced during expiration or the strain of the Valsalva maneuver (Carvallo’s sign), are characteristic findings of TR.

☆ [@ ViT C ; Vitum sign and Carvello's sign seen in TR]

• 1. In systemic inflammatory response syndrome:
• a. Respiratory rate < 10/min
• b. Heart rate > 90/min
• c. White blood count < 6 × 109/L
• d. PaCO2 normal

• Ans: b
• Ref: Davidson’s Medicine 22ndd Edition, page No: 184
• Systemic inflammatory response syndrome (SIRS)
• • Defined by the presence of two or more of:
• o Respiratory rate > 20/min
• o Heart rate > 90/min
• o White blood count > 12 × 109/L or < 4 × 109/L
• o Temperature > 38.0°C or < 36.0°C
• o PaCO2 < 4.3 kPa (< 32 mmHg) or ventilated
• • A wide pulse pressure, e.g. 115/42 mmHg, may be an early pointer to systemic sepsis
• • Cause may be infection or a non-infective condition, e.g. pancreatitis, trauma, cardiopulmonary bypass, vasculitis etc.
• • Hypothermia and septic neutropenia indicate more severe infection

• 2. All of the following statements concerning the ureters are correct except:
• a. They are retroperitoneal.
• b. They cross the pelvic brim anterior to the bifurcation of the common iliac arteries.
• c. They are fibrous tubes connecting the kidneys to the urinary bladder.
• d. Their superior halves lie in the abdomen and the inferior halves lie in the pelvis.

• Ans: c
• Ref: Moore's Anatomy 7th Edition, Page No: 363
• The ureters are muscular tubes, 25 to 30 cm long, that connect the kidneys to the urinary bladder. They are retroperitoneal, with their superior halves in the abdomen and their inferior halves in the pelvis. The pelvic part of the ureters begins where it crosses the bifurcation of the common iliac artery.

• 3. The area is declared free of epidemic:
• a. Till last secondary case recovers
• b. No new case reported for the incubation period of disease since the last case
• c. No new case reported for twice the incubation period of disease since the last case
• d. No new case reported for six months since the last case

• Ans: c
• Ref: Park PSM 23rd Edition, Page No: 132
• The search for new cases (secondary cases) should be carried out every day, till the area is declared free of epidemic. This period is usually taken as twice the incubation period of the disease since the occurrence of last case.

• 4. Satellite lesion in keratitis occurs due to:
• a. Pneumococcus
• b. Aspergillus
• c. Herpes zoster
• d. Herpes simplex virus

• Ans: B
• Ref: AK Khurana Ophthalmology 6th Edition, Page No: 106
• A typical fungal corneal ulcer has following salient features :
• • Corneal ulcer is dry-looking, greyish white, with elevated rolled out margins.
• • Pigmented ulcer (brownish) may be caused by some species of fungi, e.g., dermatiaceous fungi.
• • Delicate feathery finger-like extensions are present into the surrounding stroma under the intact epithelium.
• • A sterile immune ring (yellow line of demarcation) may be present where fungal antigen and host antibodies meet.
• • Multiple, small satellite lesions may be present around the ulcer.
• • Usually a big hypopyon is present even if the ulcer is very small. Unlike bacterial ulcer, the hypopyon may not be sterile as the fungi can penetrate into the anterior chamber without perforation.
• • Endothelial plaque, composed of fibrin and leucocytes, may be located under the stromal lesion. It may be present in the absence of hypopyon.
• • Perforation in mycotic ulcer is rare but can occur.
• • Corneal vascularization is conspicuously absent in pure mycotic ulcer.

• 5. ATPase activity is present in
• a. Myosin head
• b. Myosin tail
• c. Actin filaments
• d. Desmin filaments

• Ans: a
• Ref: Ganong physiology 25th Edition, Page No: 104
• Before contraction begins, the heads of the cross bridges binds with ATP. The ATPase activity of the myosin head immediately cleaves the ATP but leaves the cleavage products, ADP plus phosphate ion, bound to the head. The sliding during muscle contractions occurs when the myosin heads bind firmly to actin, bend at the junction of the head with the neck, and then detach. The power stroke depends on the simultaneous hydrolysis of ATP.

• 6. Twitch of a single motor unit is called
• a. Myoclonic jerk
• b. Fasciculation
• c. Tremor
• d. Chorea

• Ans: b
• Ref: Ganong physiology 25th Edition, Page No: 110
• • Fasciculations are jerky, visible contractions of group of muscle fibres that occur as a result of pathologic discharge of spinal motor neurons.
• • Fibrillations are fine, irregular contractions of individual muscle fibres. They may occur due to denervation hypersensitivity resulting from LMN lesion. Usually the contractions are not visible grossly.
• • Myoclonic jerk or clonus is the regular, rhythmic contractions of a muscle subjected to sudde maintained stretch. It is due to increased Gamma efferent discharge.

• 1. Liver biopsy of biliary atresia shows:
• a. Proliferation of small bile ducts
• b. Atrophy of small bile ducts
• c. Fibrosis and calcifications of small bile ducts
• d. All of the above

Ans: a

• 2. DOG-1 is marker of tumour of which organ?
• a. Prostate
• b. Lung
• c. Liver
• d. Intestine

Ans: d

• 3. Vaginal pH after menopause is:
• a. 3-4
• b. 5
• c. 5-6
• d. 7

Ans: d

• 4. Lamellar cataract is seen in:
• a. Hypoglycemia
• b. Hyperglycemia
• c. Hypocalcemia
• d. Hypercalcemia

Ans: a

• 5. Rocher’s sign is helpful in differentiating:
• a. Breast abscess from mastitis
• b. Torsion of testis and epididymitis
• c. Appendicitis from Diverticulitis
• d. Intussusception from Hirschsprung disease

Ans: b

• 1. IV loading dose of MgSO4 Prophylaxis in Pre eclampsia is?
• a. 8 ml MgSO4 + 10 ml of NS
• b. 10 ml MgSO4 + 10 ml of NS
• c. 8 ml MgSO4 + 12 ml of NS
• d. 12 ml of MgSO4 + 8 ml of NS

• Ans: c
• Ref: Dutta Obstetrics 8th Edition, Page No: 273
• Pritchard regimen:
• Loading dose: IV: 4 gm (20 % solution)/IM 10 gm (50%), 5 gm in each buttock

• 1 vial of MgSO4 contains = 2 ml solution
• = 1 gm MgSO4 (w/v 50%)

• Question is asking about= IV loading dose, means: 4gm in 20 %
• 4 vials needed for 4 gm
• 4 vials = 8 ml of MgSO4 in 50 %
• = Add 12 ml NS to make it 20 % (simple calculation)

• 2. A 23-year-old male basketball player injured his foot during training and is admitted to the emergency department. An MRI examination reveals a hematoma in the medial malleolus. Upon physical examination the patient shows overeversion of his foot. Which of the following ligaments most likely has a tear?
• a. Plantar calcaneonavicular (spring)
• b. Calcaneofibular
• c. Long plantar
• d. Deltoid

• Ans: d
• Ref: Gray’s Anatomy for Students, 605, 606
• • One important function of the deltoid ligament is the prevention of overeversion of the ankle. The ligament is so strong that excessive eversion can cause the medial malleolus to be pulled off (an avulsion fracture) rather than tearing the deltoid ligament.
• • Deltoid ligament of the ankle: The complex of the medial collateral ligaments of the ankle joint is collectively called deltoid ligament. It attaches the medial malleolus to multiple tarsal bones.
• • The ligament is composed of two layers. The superficial layer has variable attachments and crosses two joints while the deep layer has talar attachments and crosses one joint: It is a strong triangular band attached to the apex and the anterior and posterior borders of the medial malleolus. The plantar calcaneonavicular ligament can be considered as part of the medial complex.

• 3. A patient tries to make a fist, but digits 2 and 3 remain partially extended. What nerve is injured?
• a. Ulnar nerve
• b. Radial nerve
• c. Median nerve
• d. Musculocutaneous nerve

• Ans: c
• Ref: Moore's Anatomy 7th Edition, Page No: 768
• • When the median nerve is severed in the elbow region, flexion of the proximal interphalangeal joints of the 1st–3rd digits is lost and flexion of the 4th and 5th digits is weakened. Flexion of the distal interphalangeal joints of the 2nd and 3rd digits is also lost. Flexion of the distal interphalangeal joints of the 4th and 5th digits is not affected because the medial part of the FDP, which produces these movements, is supplied by the ulnar nerve. The ability to flex the metacarpophalangeal joints of the 2nd and 3rd digits is affected because the digital branches of the median nerve supply the 1st and 2nd lumbricals. Thus, when the person attempts to make a fist, the 2nd and 3rd fingers remain partially extended (“hand of benediction”).
• • Thenar muscle function (function of the muscles at the base of the thumb) is also lost, as in carpal tunnel syndrome. When the anterior interosseous nerve is injured, the thenar muscles are unaffected, but paresis (partial paralysis) of the flexor digitorum profundus and flexor pollicis longus occurs. When the person attempts to make the “okay” sign, opposing the tip of the thumb and index finger in a circle, a “pinch” posture of the hand results instead owing to the absence of flexion of the interphalangeal joint of the thumb and distal interphalangeal joint of the index finger (anterior interosseous syndrome).

• 4. Microglia is derived from:
• a. Ectoderm
• b. Mesenchymal cells
• c. Neural crest cells
• d. Endoderm

• Ans: b
• Ref: Ginhoux F, Prinz M (July 2015). "Origin of microglia: current concepts and past controversies". Cold Spring Harbor Perspectives in Biology. 7
• For a long time it was thought that microglial cells differentiate in the bone marrow from hematopoietic stem cells, the progenitors of all blood cells. However, recent studies show that microglia originate in the yolk sac during a remarkably restricted embryonal period and populate the brain mesenchyme. Additionally, they continuously renew themselves and persist throughout life without replenishment from peripheral monocytic precursors.

• 5. Glucose transport by GLUT is an example of:
• a. Primary active transport
• b. Secondary active transport
• c. Facilitated diffusion
• d. Active transport

• Ans: c
• Ref: Ganong physiology 25th Edition, Page No: 48
• • Carriers are transport proteins that bind ions and other molecules and then change their configuration, moving the bound molecule from one side of the cell membrane to the other.
• • Molecules move from areas of high concentration to areas of low concentration (down their chemical gradient), and cations move to negatively charged areas whereas anions move to positively charged areas (down their electrical gradient).
• • When carrier proteins move substances in the direction of their chemical or electrical gradients, no energy input is required and the process is called facilitated diffusion. A typical example is glucose transport by the glucose transporter, which moves glucose down its concentration gradient from the ECF to the cytoplasm of the cell.
• • Other carriers transport substances against their electrical and chemical gradients. This form of transport requires energy and is called active transport. In animal cells, the energy is provided almost exclusively by hydrolysis of ATP. Not surprisingly, therefore, many carrier molecules are ATPases, enzymes that catalyze the hydrolysis of ATP.
• • One of these ATPases is sodium–potassium adenosine triphosphatase (Na, K ATPase), which is also known as the Na, K pump. There are also H, K ATPases in the gastric mucosa and the renal tubules. Ca2+ ATPase pumps Ca2+ out of cells.

• 1. A 22-year-old male is admitted to the hospital with groin pain and blood in the semen. An MRI examination and biopsy reveal testicular cancer. Which of the following lymph nodes will be first involved in case of metastasis?
• a. Internal iliac
• b. Superficial inguinal
• c. Deep inguinal
• d. Paraaortic and lumbar

• Ans: d
• Ref: Gray’s Anatomy for Students, 477, 496
• The paraaortic and lumbar nodes at the level of the kidneys will most likely be infiltrated by metastasis of testicular cancer because testicular lymphatics run in close association with the testicular vessels and drain the testicles and epididymis.
• Testicular cancer is said to be a disease that is especially dangerous for young men. The internal iliac nodes drain the inferior pelvis and deep perineal structures. The external iliac nodes drain all anterosuperior pelvic structures. The superficial inguinal nodes drain all of the superficial structures below the umbilicus. Finally, the deep inguinal nodes receive more superficial vessels and drain the glans penis in males.

• 2. The head of the pancreas is embraced by which of the following structures?
• a. Stomach
• b. Spleen
• c. Cecum
• d. C-shaped curve of the duodenum

• Ans: d
• Ref: Moore's Anatomy 7th Edition, Page No: 257
• The head of the pancreas is embraced by the C-shaped curve of the duodenum to the right of the superior mesenteric vessels.

• 3. The superior end of the vagina surrounds which of the following structures?
• a. Round ligament
• b. Urogenital hiatus
• c. Urethra
• d. Cervix

• Ans: d
• Ref: Moore's Anatomy 7th Edition, Page No: 371
• The superior end of the vagina surrounds the cervix; the lower end passes anteroinferiorly through the pelvic floor to open in the vestibule.

• 4. Pacemaker regulating the rate of respiration is:
• a. Pneumotaxic center
• b. Dorsal group of nucleus
• c. Apneustic center
• d. Pre-Bötzinger

• Ans: d
• Ref: Ganong Physiology 24th Edition, Page No: 658
• Pacemaker of respiration is pre-Bötzinger complex of neurons, which is a part of VRG in medulla
• • The main components of the respiratory control pattern generator responsible for automatic respiration are located in the medulla.
• • Rhythmic respiration is initiated by a small group of synaptically coupled pacemaker cells in the pre-Bötzinger complex (pre-BÖTC) on either side of the medulla between the nucleus ambiguus and the lateral reticular nucleus.
• • These neurons discharge rhythmically, and they produce rhythmic discharges in phrenic motor neurons that are abolished by sections between the pre-Bötzinger complex and these motor neurons. They also contact the hypoglossal nuclei, and the tongue is involved in the regulation of airway resistance.

• 5. Prime driving force for counter current multiplier system is:
• a. Medullary hyperosmolarity
• b. Reabsorption of Na+ in thick ascending limb
• c. Action of ADH via Aquaporin channels
• d. Urea recycling

• Ans: b
• Ref: Guyton and Hall, 13th Edition, Page No: 374
• The major factors that contribute to the buildup of solute concentration into the renal medulla are as follows:
• • Active transport of sodium ions and co-transport of potassium, chloride, and other ions out of the thick portion of the ascending limb of the loop of Henle into the medullary interstitium
• • Active transport of ions from the collecting ducts into the medullary interstitium
• • Facilitated diffusion of urea from the inner medullary collecting ducts into the medullary interstitium
• • Diffusion of only small amounts of water from the medullary tubules into the medullary interstitium— far less than the reabsorption of solutes into the medullary interstitium

• 1. Posterior herniation of the synovial membrane in the popliteal fossa is:
• a. Semi-membranous bursa
• b. Clergyman’s knee
• c. Housemaid’s knee
• d. Morrant-Baker's cyst

Ans: D

• Different bursae in relation to the knee, which may present as swelling are:
• • Semi-membranous bursa causes painless oval swelling at the postero-medial aspect of the knee;
• • Infra-patellar bursa (Clergyman’s knee) lying deep to the ligamentum patellae;
• • Pre-patellar bursa (Housemaid’s knee) lying in front of the patella;
• • Morrant-Baker's cyst – a posterior herniation of the synovial membrane in the popliteal fossa.

• 2. How should chest compressions be performed on an infant?
• a. With the heel of one hand and the other hand on top of the first
• b. With the heel of one hand only
• c. With 4 fingers of one hand
• d. With 2 fingers of one hand

• Ans: d
• Compressions: Infants (<1 year, excluding newborns)
• • Check pulse at brachial artery
• • Compression landmarks: lower third of sternum between the nipples
• • Compression method: two fingers if alone or thumb-encircling if multiple providers
• • Depth: at least one-third AP chest diameter
• • Depth: about 1.5 inches (4 cm)
• • Allow complete chest recoil after each compression.
• • Compression rate: 100-120 per minute
• • Compressions-to-ventilations ratio: 30:2 if single rescuer, 15:2 if multiple rescuers
• • Continuous compressions if advanced airway present and timed ventilation
• • Rotate compressor every 2 minutes or if fatigued.
• • Minimize interruptions in compressions to less than 10 seconds.
• • Avoid excessive ventilation.

• Compressions: Children aged 1 year to puberty
• • Check pulse at carotid artery.
• • Compression landmarks: lower half of sternum between the nipples
• • Compression method: heel of one hand, other hand on top if needed
• • Depth: at least one-third anteroposterior (AP) chest diameter
• • Depth: about 2 inches (5 cm)
• • Allow complete chest recoil after each compression
• • Compression rate: 100-120 per minute
• • Compressions-to-ventilations ratio: 30:2 if single rescuer, 15:2 if multiple rescuers
• • Continuous compressions if advanced airway present and asynchronous ventilation
• • Rotate compressor every 2 minutes or if fatigued.
• • Minimize interruptions in compressions to less than 10 seconds.
• • Avoid excessive ventilation.

• 3. Imperforate hymen is usually noticed at what age?
• a. Prenatally
• b. At birth
• c. 5 – 6 years
• d. 14 – 16 years

• Ans: d
• Ref: Dutta’s Gynecology, 6th Revised Edition, Page 41
• • Gross hymenal abnormality of significance is imperforate hymen. It is due to failure of disintegration of the central cells of the Müllerian eminence that projects into the urogenital sinus
• • The existence is almost always unnoticed until the girl attains the age of 14–16 years. As the uterus is functioning normally, the menstrual blood is pent up inside the vagina behind the hymen (cryptomenorrhea).
• • Depending upon the amount of blood so accumulated, it first distends the vagina (hematocolpos). The uterus is next involved and the cavity is dilated (hematometra). In the late and neglected cases, the tubes may also be distended after the fimbrial ends are closed by adhesions (Hematosalpinx)

• 4. What is the total conduction delay in A-V node &bundle system of heart?
• a. 0.04 second
• b. 0.09 second
• c. 0.13 second
• d. 0.16 second

• Ans: c
• Nodal delay: 0.09 s
• Nodal and bundle delay: 0.13 s
• Ref: Guyton’s Physiology 13th Edition, Page No: 125
• • The impulse generated in SA node after traveling through the intermodal pathways, reaches the A-V node in about 0.03 second.
• • Then there is a delay of another 0.09 second in the A-V node itself before the impulse enters the penetrating portion of the A-V bundle, where it passes into the ventricles.
• • A final delay of another 0.04 second occurs mainly in this penetrating A-V bundle, which is composed of multiple small fascicles passing through the fibrous tissue separating the atria from the ventricles.
• • Thus, the total delay in the A-V nodal and A-V bundle system is about 0.13 second.
• • This delay, in addition to the initial conduction delay of 0.03 second from the sinus node to the A-V node, makes a total delay of 0.16 second before the excitatory signal finally reaches the contracting muscles of the ventricle.

• 5. A 20-year-old man complains of difficulty in reading newspaper in the right eye 4 weeks after gunshot injury in the left eye. The likely diagnosis is:
• a. Macular edema
• b. Sympathetic ophthalmitis
• c. Optic nerve avulsion
• d. Delayed vitreous hemorrhage

• Ans: b
• Ref: Parson Ophthalmology 22nd Edition, Page No: 398
• Sympathetic ophthalmitis
• • This is a condition in which serious inflammation attacks the sound eye after injury (including intraocular surgeries) to the other.
• • Sympathetic ophthalmitis or ophthalmia almost always results from a penetrating wound, occurring in 0.2–0.5% of such cases.
• • Wounds involving the ciliary body and leading to its incarceration in the scar, have always been considered particularly dangerous.
• • Incarceration of the iris or lens capsule are also more likely to set up sympathetic ophthalmitis than others.

• 1. Duramater is supplied by all cranial nerves except:
• a. 12
• b. 10
• c. 5
• d. 4

• Ans: d
• Ref: Moore's Anatomy 7th Edition, Page No: 865, 872
•  The cranial dura mater (dura), a thick, dense, bilaminar membrane, is also called the pachymeninx (G. pachy, thick + G. menix, membrane).
•  It is adherent to the internal table of the calvaria. The two layers of the cranial dura are an external periosteal layer, formed by the periosteum covering the internal surface of the calvaria, and an internal meningeal layer, a strong fibrous membrane that is continuous at the foramen magnum with the spinal dura covering the spinal cord.
•  The external periosteal layer of dura adheres to the internal surface of the cranium; its attachment is tenacious along the suture lines and in the cranial base. The external periosteal layer is continuous at the cranial foramina with the periosteum on the external surface of the calvaria.
•  This outer layer is not continuous with the dura mater of the spinal cord, which consists of only a meningeal layer.
•  Innervation of dura mater is derived mainly from three sources:
• 1) Three divisions of trigeminal nerve
• 2) C2 & 3 spinal nerves and
• 3) Cervical sympathetic trunk.
•  Vagus and hypoglossal nerves, and possibly the facial and glossopharyngeal nerves may also supply duramater (less established).

• 2. Phlebotomus argentipes is killed by:
• a. Malathion
• b. Pyrethrum
• c. DDT
• d. Parathion

• Ans: c
• Ref: Park PSM 23rd Edition, Page No: 308
• Sandfly control
• • The application of residual insecticides has proved effective in the control of sand flies. DDT is the first choice since the vector of kala-azar, P. argentipes is susceptible to DDT. Insecticide spraying should be undertaken in human dwellings, animal shelters and all other resting places upto a height of 6 feet (2 metres) from floor level. DDT (two rounds per year) at the rate of 1-2 g per sq. metre is considered sufficient to control transmission. Spraying should be preceded and followed by an assessment of susceptibility. Any sign of resistance in vector should lead to an immediate change in insecticide. BHC should be kept as a second line of defence.
• • Spraying should be repeated at regular intervals to keep down the density of sandflies. For long-lasting results, insecticidal spraying should be combined with sanitation measures, viz elimination of breeding places (e.g., cracks in mud or stone walls, rodent burrows, removal of firewood, bricks or rubbish around houses), location of cattle sheds and poultry at a fair distance from human dwellings, and improvement of housing and general sanitation.

• 3. Coarse facies, hepatosplenomegaly and cloudy cornea are characteristic feature of:
• a. Morquio syndrome A
• b. Hurler’s disease
• c. Hunters disease
• d. Natowicz syndrome

• Ans: B
• Ref: Harper Biochemistry 30th Edition, Page No: 639
• • Hurler disease: Mental retardation, coarse facial features, hepatosplenomegaly, cloudy cornea
• • Hunter disease: Mental retardation
• • Morquio syndrome A : Skeletal dysplasia, short stature
• • Natowicz syndrome: Joint pain, short stature

• 4. A female neonate on 10th day presented with vaginal bleeding. What would be the next step of management?
• a. Estrogen
• b. Progesterone
• c. OCP
• d. Reassurance and do nothing

• Ans: d
• Ref: Dutta’s Textbook of Gynaecology including Contraception, 6th edition, page 543
• • Bleeding per vaginum (mostly blood stained to frank bleeding at times) usually occurs in newborns within 10 days following birth.
• • It occurs due to decline in level of estrogen, which is unable to support the endometrium, resulting in withdrawal bleeding.
• • There is no cause for concern and patient party can be simply reassured.

• 5. Pilon fracture is:
• a. Avulsion fracture of lateral tibial condyle; associated with ACL injury
• b. Intraarticular fracture of tibial condyle
• c. Intraarticular comminuted distal tibia fracture
• d. Salter-Harris III of lateral distal tibia (because of lateral epiphyseal fusion)

• Ans: c
• Ref: Apley’s Orthopedics, 9th Edition; Page No: 916
• PILON FRACTURES
• Unlike the twisting injuries that cause the common ankle fractures, this injury to the ankle joint occurs when a large force drives the talus upwards against the tibial plafond, like a pestle (pilon) being struck into a mortar. There is considerable damage to the articular cartilage and the subchondral bone may be broken into several pieces; in severe cases, the comminution extends some way up the shaft of the tibia.

• • Segond: Avulsion fracture of lateral tibial condyle; associated with ACL injury
• • Bumper: Intraarticular fracture of tibial condyle
• • Pilon: Intraarticular comminuted distal tibia fracture
• • Tillaux: Salter-Harris III of lateral distal tibia (because of lateral epiphyseal fusion)
• • Triplane: Salter III/IV fracture of distal tibia

• 1. A young patient presents with lethargy and malaise, bone pain, bleeding gums and impaired wound healing. Definitive sign of the disease in X-ray will be:
• a. Ringed epiphysis
• b. Ground glass appearance
• c. White line in metaphysis
• d. Thin cortex

• Ans: a
• Ref: OP Ghai 9th Edition, Page No: 121
• Diagnosis of scurvy: The diagnosis is made by presence of characteristic physical findings and history of inadequate dietary intake of vitamin C. X-rays of long bones show a ground glass appearance with thinning of cortex (pencil thin cortex). An irregular thickened white line appears at the metaphysis (white line of Frankel), representing the zone of well-calcified cartilage. There is a zone of rarefaction proximal to this line, which represents poorly formed trabeculae (Triimmerfeld zone). The lateral part of the rarefaction appears as a triangular defect called Pelken spurs. The epiphyses are surrounded by a thin white line (Wimberger ring sign)
• • Ringed epiphysis (Wimberger sign): It is white ring surrounding the epiphyseal centers of ossification. It is relatively specific for scurvy.
• • White line in metaphysis (Fraenkel) can be seen in scurvy, healing rickets, Plumbism, severe PEM, congenital syphilis and acute leukemia.

• 2. For a screening test, 90 percent specificity means that 90 % of non diseased person will give:
• a. True positive
• b. True negative
• c. False positive
• d. False negative

• Ans: b
• Ref: Park PSM; 23rd edition; Pg 139
• Sensitivity
• • The term sensitivity was introduced by Yerushalmyin 1940s as a statistical index of diagnostic accuracy.
• • It has been defined as the ability of a test to identify correctly all those who have the disease, that is "true-positive". A 90 percent sensitivity means that 90 per cent of the diseased people screened by the test will give a "true-positive" result and the remaining 10 per cent a "false-negative" result.
• Specificity
• • It is defined as the ability of a test to identify correctly those who do not have the disease, that is, "true-negatives".
• • A 90 per cent specificity means that 90 per cent of the non-diseased persons will give "true-negative" result, 10 percent of non-diseased people screened by the test will be wrongly classified as "diseased" when they are not.

• 3. Typical deformity in anterior hip dislocation is:
• a. Flexion, adduction, internal rotation
• b. Abduction, external rotation
• c. Flexion, abduction, internal rotation
• d. Abduction, internal rotation

• Ans: b
• Ref: Maheshwari Orthopedics 5th Edition Page No: 56
• Typical deformities in dislocations
• • Shoulder (anterior): Abduction
• • Elbow (posterior): Flexion
• • Hip:
•  Posterior: Flexion, adduction, internal rotation
•  Anterior: Abduction, external rotation
• • Knee: Flexion, external rotation
• • Ankle: Varus

• 4. Rose Waaler test is done in:
• a. SLE
• b. Rheumatic fever
• c. Rheumatoid arthritis
• d. Polymyositis

• Ans: C
• Ref: Surinder singh microbiology; 1st edition; Pg155
• Rose-Waaler Test
• A special type of passive agglutination test is the Rose-Waaler test. In rheumatoid arthriris, RA factor (an anti-gammaglobulin autoantibody) appears in the serum. It acts as antibody to human IgG. The RA factor is able to agglutinate red cells coated with globulins. The antigen used for the test is a suspension of sheep erythrocytes sensitized with a sub agglutinating dose of rabbit anti-sheep erythrocyte antibody (amboceptor).

• 5. Tuohy needle is used for:
• a. Spinal anesthesia
• b. CSF tapping
• c. Biopsy
• d. Epidural anesthesia

• Ans: D
• Ref: Morgan 5th edition Page No: 959
• Epidural Needles
• The standard epidural needle is typically 17–18 gauge, 3 or 3.5 inches long, and has a blunt bevel with a gentle curve of 15–30° at the tip. The Tuohy needle is most commonly used .The blunt, curved tip theoretically helps to push away the dura after passing through the ligamentum flavum instead of penetrating it. Straight needles without a curved tip (Crawford needles) may have a greater incidence of dural puncture, but facilitate passage of an epidural catheter. Needle modifications include winged tips and introducer devices set into the hub designed for guiding catheter placement.

• 1. Ankle sprain due to forced inversion of a plantar flexed foot is due to injury to:
• a. Posterior talofibular ligament
• b. Calcaneofibular ligament
• c. Posterior fibres of deltoid
• d. Anterior talofibular ligament

• Ans. d. Anterior talofibular ligament
• Ref: Apley 8/e p733-736

• Over 90% of ankle ligament injuries (twisted ankle or ankle sprain) involve the lateral ligament complex, usually the anterior tibiofibular ligament.
• A. Medial Collateral Ligament:
• I. Also known as deltoid ligament.
• II. It is a strong ligament and major stabilizer of the ankle joint
• III. Two components: Superficial: Resist eversion of hind foot (Talo-tibial, naviculo- tibial, calcaneo-tibial) and Deep (Intra-articular): Prevents external rotation of talus (Anterior and posterior talotibial)

• B. Lateral Collateral Ligament:
• I. It is a weak ligament, so involved in over 90% of ankle injuries.
• II. It has three parts:
• i. Anterior talofibular: Most commonly injued.
• ii. Middle calcaneofibular: 2nd most commonly injured.
• iii. Posterior talofibular: Torn in most severe injuries.

• 2. A 25-year-old man presents to his primary care physician with crampy abdominal pain for 2 days. He reports having loose stools and losing 15 lbs (6.8 kg) over a 3-month duration. He also reports increased fatigue. Further evaluation revealed Crohn’s disease. The earliest manifestation in Crohn’s disease is :
• a. Aphthous Ulcer
• b. Anal fistula
• c. Rose thorn appearance on Barium swallow
• d. Skip lesions

• Ans, a. Aphthous ulcer
• Ref: Harrison 19th edition/pg. 1952

• i. The earliest lesions are Aphthous ulcerations & focal crypt abscesses with loose aggregations of macrophages, which form non-caseating granulomas in all layers of the bowel wall.
• ii. In early mild Crohn’s disease, the colonic mucosa appears endoscopically normal or small.
• iii. Punched-out aphthous ulcers are often seen.
• iiii. Aphthous ulcers occur as a result of submucosal lymphoid follicle expansion.
• v. In moderate Crohn's Disease, aphthous ulcers coalesce into larger ulcers, which may take on the appearance of a star (stellate ulcers).
• vi. As Crohn's disease severity increases, submucosal edema and injury can result in cobblestoning of the mucosa, which is seen more often in Crohn’s disease than in ulcerative colitis.

• 3. Resistant hypertension is defined as:
• a. Resistance to aldosterone
• b. Resistance to Angiotension II receptors
• c. Resistance to 2 or more anti hypertensive drugs including thiazides
• d. Resistance to 3 or more anti-hypertensive drugs including thiazides

• Ans,d.Resistance to 3 or more anti-hypertensive drugs including thiazides
• Ref: Harrison 18th edition, chapter 247

• I. Resistant hypertension refers to patients with blood pressures persistently >140/90 mmHg despite taking three or more antihypertensive agents, including a diuretic, in a reasonable combination and at full doses.
• II. Resistant or difficult-to-control hypertension is more common in patients >60 years than in younger patients.
• III. Resistant hypertension may be related to:
• i. “Pseudoresistance” (high office blood pressures and lower home blood pressures), nonadherence to therapy.
• ii. Identifiable causes of hypertension (including obesity and excessive alcohol intake.
• iii. Use of any of a number of nonprescription and prescription drugs.

• Q1.Aqueous humour is produced by:
• a.Iris
• b.Lens
• c.Ciliary body
• d.Choroid

Ans: c ; Ciliary body

• Ref:AK Khurana 6th e/p 148
• • Ciliary body is forward continuation of the choroid at ora serrata. In cut-section, it is triangular in shape. The anterior side of the triangle forms the part of the angle of anterior and posterior chambers. In its middle the iris is attached.
• • The outer side of the triangle lies against the sclera with a suprachoroidal space in between. The inner side of the triangle is divided into two parts. The anterior part (about 2 mm) having finger-like ciliary processes is called pars plicata and the posterior smooth part (about 4 mm) is called pars plana.
• • Functions of ciliary body
• • Formation of aqueous humour.
• • Ciliary muscles help in accommodation.

• Q2.A 43-year-old man with diabetes has a 4-cm nonhealing foot ulcer. Culture of the ulcer yields Staphylococcus aureus, Bacteroides fragilis, and a gram-negative bacillus that swarms across the blood agar plate covering the entire surface of the agar after 36 hours. The gram-negative bacillus is a member of the genus:
• a.Escherichia
• b. Enterobacter
• c.Serratia
• d. Proteus

Ans:d,Proteus

• Ref: Jawetz Melnick and Adelberg’s medical microbiology 27th/e p 233
• • Proteus–Morganella–Providencia group—The members of this group deaminate phenylalanine, are motile, grow on potassium cyanide medium (KCN), and ferment xylose.
• • Proteus species move very actively by means of peritrichous flagella, resulting in “swarming” on solid media unless the swarming is inhibited by chemicals, such as phenylethyl alcohol or CLED (cystine-lactose-electrolytedeficient) medium.
• • Whereas Proteus species and Morganella morganii are urease positive, Providencia species usually are urease negative. The Proteus–Providencia group ferments lactose very slowly or not at all.

• Q3. A 3-month-old child presents with intermittent stridor aggravated on keeping the child supine. Most likely cause is:
• a. Laryngotracheobronchitis
• b. Laryngomalacia
• c. Respiratory obstruction
• d. Foreign body aspiration

Ans:b,Laryngomalacia

• Ref: Ghai 8th ed pg 369
• • Laryngomalacia is the most common congenital laryngeal anomaly, accounting for up to 60% and the most common cause of infant stridor.
• • Inspiratory stridor is the hallmark of the condition.
• • Symptoms are typically aggravated when the child is supine or crying.
• • Flexible endoscopy reveals partial collapse of a flaccid supraglottic airway with inspiration.
• • If present, gastroesophageal reflux, should be managed.
• • Laryngomalacia is generally benign and selflimited, as most cases resolve by 18 months of age.
• • Surgical intervention is advised for either respiratory distress or failure to thrive

• 1. Which radiological procedure is used for studying vesco-ureteric reflux?
• a. Ascending pyelogram
• b. Cystogram
• c. Intravenous urogram
• d. Micturition cystourethrogram

• Ans, D, Micturation cystourethrogram
• Ref, Smith’s General Urology, 17e, Chapter12
• Explanation
• The diagnosis of vesico-ureteric reflux is made using micturation cystourethrogram. Other techniques used in diagnosing vesico-ureteric reflux are simple or delayed cystography or voiding cine fluoroscopy.
• In a case of vesico-ureteric reflux, cystogram may show one of the following findings:
• Persistently dilated lower ureter, areas of dilatation in the ureter, ureter visualized throughout its entire length shows, presence of hydroureteronephrosis with a narrow
• juxtavesical ureteral segment or changes of healed pyelonephritis.

• 2. Light microscopic appearance of the PAS-stained specimen from a renal biopsy shows wire loop glomerular capillary lesions. Which of the following is specific marker of the condition?
• a. Scl-70
• b. Anti-Sm
• c. Jo-1
• d. Anti-HLA-B27

• Ans, B, Anti-Sm
• Ref, Robbins & Cotran, Pathologic basis of disease, 7e, p231-233
• Explanation
• Wire loop glomerular capillary lesions seen in lupus nephritis.
• Anti-Sm and anti–double stranded DNA are specific for systemic lupus erythematosus. Anti-Sm is present in only 25% of cases, however.
• Scl-70 isa marker for diffuse systemic sclerosis. Jo-1 is most specific for polymyositis.
• HLA-B27 is seen in ankylosing spondylitis.
• Anticentromere antibody is seen most often with limited scleroderma.

• 3. Central value of a set of 180 values can be obtained by
• a. 90th percentile
• b. 2nd tertile
• c. 9th decile
• d. 2nd quartile

• Ans, D, 2nd quartile
• Ref, Methods in Biostatistics by Mahajan, 7/e p45
• Explanation
• • Quartile: Divides a distribution into 4 equal parts, so the number of intercepts required will be 3, i.e. Q1, Q2, Q3
• – So, Zero – Q1 covers 25% values
• – Similarly, Q2 – Q1, Q3 – Q2 and 100 – Q3 all cover 25% values each
• – Thus, Q2 – Zero, 100 – Q2 and Q3 – Q1 all cover 50% values each
• – Q1 divides a distribution in a ratio of 25 : 75 OR 1 : 3
• – Q2 divides a distribution in a ratio of 50 : 50 OR 1 : 1, Thus second quartile is equivalent to median
• – Q3 divides a distribution in a ratio of 75 : 25 OR 3 : 1.

• In the given question, n = 180
• Thus Q2 which is equivalent to median, divides a distribution in a ratio of 50 : 50 OR 1 : 1.

Answers to yesterday's questions.

Ans, DCB

• 1. A 25 year old male presented to OPD with complains of fatigue for 1 month. He also complains of decreased sleep and decreased appetite. He mentioned that he could not concentrate well in his lecture classes. He feels emptiness in his life and tried ending his life twice in the past week. On asking further, he told that he was diagnosed as a case of Schizophrenia 5 years back and he is currently under regular medications. Lab investigations show; TSH 4.5, ESR 10, Hb 9.7, MCV 78, normal electrolytes, SGOT 52, SGPT 43 and ALP 50 (standard units are mentioned). His father also has been diagnosed as a case of Schizophrenia. What is the most likely diagnosis at this point of time in the patient?
• a. Schizophrenia
• b. Hypothyroidism
• c. Schizoaffective disorder
• d. Mood disorder with psychotic features

• Ans, D
• Ref. FA, USMLE step 1, 2020, Page no. 560,561

(The patient already has Schizophrenia and still taking medications, so we can assume he may still have its symptoms as there is no mention in the question regarding its complete cure. So,this patient seems to have both depressive/mood symptoms and schizophrenic symptoms together (and not at different times). Hence we can tick “d. Mood disorder with psychotic features” as the best possible answer.)

• A. Schizoaffective disorder
• • Shares symptoms with both schizophrenia and mood disorders (major depressive or bipolar disorder).
• • To differentiate from a mood disorder with psychotic features, patient must have > 2 weeks of psychotic symptoms without a manic or depressive episode.

• B. Schizophrenia
• • Chronic illness causing profound functional impairment. Symptom categories include:
• • Positive—hallucinations, delusions, unusual thought processes, disorganized speech, bizarre behavior
• • Negative—flat or blunted affect, apathy, anhedonia, alogia, social withdrawal
• • Cognitive—reduced ability to understand or make plans, diminished working memory, inattention
• • Diagnosis requires ≥ 2 of the following active symptoms, including ≥ 1 from symptoms #1–3:
• 1. Delusions
• 2. Hallucinations, often auditory
• 3. Disorganized speech
• 4. Disorganized or catatonic behavior
• 5. Negative symptoms
• • Requires ≥ 1 month of active symptoms over the past 6 months; onset ≥ 6 months prior to diagnosis.

• C. MDD with psychotic features
• • MDD + hallucinations or delusions. Psychotic features are typically mood congruent (eg, depressive themes of inadequacy, guilt, punishment, nihilism, disease, or death) and occur only in the context of major depressive episode (vs schizoaffective disorder).
• • Treatment: antidepressant with atypical antipsychotic, ECT.

• 2. Secretin and CCK are important hormones which regulate secretion of Pancreatic juice. Which one of the following statements is true regarding this regulation?
• a. Secretin causes release of juice rich in enzymes but low in volume
• b. CCK causes release of juice rich in HCO3− and poor in enzymes
• c. Secretin acts on duct cells by increasing cAMP
• d. CCK acts on duct cells by increasing cGMP

• Ans, C
• Ref, Textbook of Medical Physiology, Guyton and Hall, 13th edition, page no. 454

• REGULATION OF THE SECRETION OF PANCREATIC JUICE
• • Secretion of pancreatic juice is primarily under hormonal control.
• • Secretin acts on the pancreatic ducts to cause copi¬ous secretion of a very alkaline pancreatic juice that is rich in HCO3− and poor in enzymes. The effect on duct cells is due to an increase in intracellular cAMP. Secretin also stimulates bile secretion.
• • CCK acts on the acinar cells to cause the release of zymogen granules and production of pancreatic juice rich in enzymes but low in volume. Its effect is mediated by phospho-lipase C. Thus, by acting together, CCK and secretin add enzymes to the pancreatic juice and ensure that they are washed into the intestine.

• 3. Drugs cause urticaria by direct degranulation of mast cells, interfering with arachidonic acid metabolism, IgE-mediated degranulation of mast cells or Complement-mediated degranulation of mast cells. Which of the following drugs cause urticarial by IgE-mediated degranulation of mast cells?
• a. Aspirin
• b. Penicillin
• c. Radioactive contrast
• d. Sulphonamide

• Ans, B
• Ref, Illustrated Synopsis of Dermatology and Sexually

• Transmitted Diseases, Neena Khanna, 4th edition, page no. 211
• Drugs causing Urticaria and Angioedema
• Pathogenesis
• • Drugs cause urticaria by:
• • Direct degranulation of mast cells.
• • Interfering with arachidonic acid metabolism.
• • IgE-mediated degranulation of mast cells.
• • Complement-mediated degranulation of mast cells.
• Clinical Features
• Urticaria and angioedema can occur independently or may also be part of a severe and generalized reaction (anaphylaxis), which includes bronchospasm and circulatory collapse.
• Drugs Implicated
• A. Drugs which directly direct degranulate mast cells:
• • Aspirin.
• • Indomethacin.
• B. Drugs which interfere with arachidonic acid metabolism:
• • Opiates: morphine and codeine.
• • Sulfonamides.
• • Curare.
• • Radioactive contrast.
• C. Drugs which mediate urticaria through IgE:
• • Penicillin.
• D. Drugs which mediate urticaria through complement system:
• • Blood products.

• Q1. Fenestration operation falls into which type of tympanoplasty as classified by Wullstein?
• a. Type II
• b. Type III
• c. Type IV
• d. Type V

• Ans: d, Type V
• Ref: PL Dhingra, 6/e, p30
• Wullstein classified tympanoplasty into five types.
• ·Type I :
• ▪Defect is perforation of tympanic membrane which is repaired with a graft. It is also called myringoplasty.
• ·Type II :
• ▪Defect is perforation of tympanic membrane with erosion of malleus. Graft is placed on the incus or remnant of malleus.
• ·Type III :
• ▪Malleus and incus are absent. Graft is placed directly on the stapes head. It is also called myringostapediopexy or columella tympanoplasty.
• ·Type IV :
• ▪Only the footplate of stapes is present. It is exposed to the external ear, and graft is placed between the oval and round windows.
• ▪A narrow middle ear (cavum minor) is thus created to have an air pocket around the round window.
• ▪A mucosa-lined space extends from the Eustachian tube to the round window.
• ▪Sound waves in this case act directly on the footplate while the round window has been shielded.
• ·Type V :
• ▪Stapes footplate is fixed but round window is functioning. In such cases, another window is created on horizontal semicircular canal and covered with a graft. Also called fenestration operation.

• Q2. All of the following statements regarding inflammatory bowel disease are correct except?
• a. Ulcerative colitis affects colon; Crohn’s disease can affect any ;part of the GI tract
• b. Ulcerative colitis is associated with Perianal disease, whereas this is unusual in Crohn’s disease
• c. Crohn’s disease more commonly causes stricturing and fistulation
• d. Granulomas may be found on histology in Crohn’s disease, but not in Ulcerative colitis

• Ans: b, Ulcerative colitis is associated with Perianal disease, whereas this is unusual in Chron’s disease
• Ref: Bailey and Love 27/e, p1243

• Differences between ulcerative colitis (UC) and Crohn’s disease (CD)
• UC affects the colon; CD can affect any part of the gastrointestinal tract, but particularly the small and large bowel.
• UC is a mucosal disease, whereas CD affects the full thickness of the bowel.
• UC produces confluent disease in the colon and rectum, whereas CD is characterised by skip lesions.
• CD more commonly causes stricturing and fistulation.
• Granulomas may be found in histology in CD, but not in UC.
• CD is often associated with perianal disease, whereas this is unusual in UC.
• CD affecting the terminal ileum may produce symptoms mimicking appendicitis, but this does not occur in UC.
• Resection of colon and rectum cures the patients with UC, whereas recurrence is common after resection in CD.

• Q3. Commonest birth mark occurring most commonly on the head and neck and 70% of which gets resolved by 7 years of age is?
• a. Capillary haemangioma
• b. Port wine stain
• c. Salmon Patch
• d. Campbell de Morgan Spots

• Ans: a, Capillary haemangioma
• Ref: Bailey and Love, 27/e, p613

• Capillary haemangioma (strawberry naevus)
• ▪This is the commonest ‘birth mark’, occurring most commonly on the head and neck (Figure 40.43). 90% appear at birth, and, as a consequence of intravascular thrombosis, fibrosis and mast cell infiltration, 10% resolve each subsequent year, with 70% resolved by 7 years old.
• ▪White skin is affected most commonly and girls are affected three times more than boys.

• Campbell de Morgan spots
• ▪These are arteriovenous fistulae at the dermal capillary level in sun-exposed skin of older patients.

• Salmon patch
• ▪A salmon patch is a haemangioma that presents as a pinkish macule, usually at the nape of neck.
• ▪It is caused by an area of persistent fetal dermal circulation, which usually disappears at 1 year.

• Capillary vascular malformations ‘port-wine’ stains
• ▪Capillary vascular malformations [‘port-wine stains’ (PWS)] are 20 times less common than capillary haemangiomata and result from defective maturation of cutaneous sympathetic innervation during embryogenesis, leading to localised intradermal capillary vasodilatation.
• ▪They appear at birth as flat, smooth, intensely purple-stained areas, most frequently on the head and neck, often within the maxillary and mandibular dermatomes of the trigeminal nerve.
• ▪Treatment with intense pulsed light and pulse dye laser are successful. PWS may be associated with various syndromes.

• Q1.A simple febrile seizure is characterized by all of the following features except:
• a.occur between the ages of 6 and 60 mo with a temperature of 38°C (100.4°F) or higher.
• b.Last for a maximum of 15 min.
• c.Is not recurrent within a 24-hr period
• d.Focal in nature

• Ans:d,Focal in nature
• Ref:Nelson 21st e/p 12071
• •Febrile seizures are seizures that occur between the ages of 6 and 60 mo (peak 12-18 mo) with a temperature of 38°C (100.4°F) or higher, that are not the result of CNS infection or any metabolic imbalance, and that occur in the absence of a history of prior afebrile seizures.
• •A simple febrile seizure is a primary generalized, usually tonic-clonic, attack associated with fever, lasting for a maximum of 15 min, and not recurrent within a 24-hr period.
• •A complex febrile seizure is more prolonged (>15 min), and/or is focal, and/or recurs within 24 hr. Febrile status epilepticus is a febrile seizure lasting longer than 30 min.
• • Most patients with simple febrile seizures have a very short postictal state and usually return to their baseline normal behavior and consciousness within minutes of the seizure.
• •Febrile infection–related (or refractory ) epilepsy (FIRES) is a very different disorder seen predominantly in older (>5 yr) usually male children and associated with an encephalitis-like illness but without an identifiable infectious agent. Children with FIRES were previously normal but subsequently develop difficult-to-treat epilepsy.

• Q2. Arden index is related to:
• a.ERG(Electroretinogram)
• b.EOG(Electro-oculogram)
• c.VER(Visual evoked response)
• d.Perimetry
• Ans:b,EOG

• Ref: AK Khurana 6th e/p519
• Electro-oculography (EOG)
• •Electro-oculography is based on the measurement of resting potential of the eye which exists between the cornea (+ve) and back of the eye (-ve).
• •Interpretation of results. Results of EOG are interpreted by finding out the Arden ratio as follows:
• Arden ratio = Maximum height of light peak/ Minimum height of dark trough × 100
• •Normal curve values are 185 or above.
• •Subnormal curve values are less than 150.
• •Flat curve values are less than 125.
• •Uses. Since the EOG reflects the presynaptic function of the retina, any disease that interferes with the functional interplay between the retinal pigment epithelium (RPE) and the photoreceptors will produce an abnormal or absent light rise in the EOG. Thus, EOG is affected in diseases such as retinitis pigmentosa, vitamin A deficiency, retinal detachment and toxic retinopathies. Hence, EOG serves as a test that is supplementary and complementary to ERG and in certain states is more sensitive than the ERG, e.g. in diagnosis of Best’s disease.

• Q3. A teenager who plays with dogs developed skin rash, eosinophilia, and an enlarged liver and spleen for 1 year. The most likely cause of this infection is
• a. Trichinosis
• b. Schistosomiasis
• c. Toxoplasmosis
• d. Visceral larva migrans

Ans: d, visceral larva migrans

• Ref:Paniker 8th ed pg 167
• Visceral Larva Migrans
• This condition is caused by the migration of larvae of nonhuman species of nematodes that infect by the oral route.
• The most common cause is the dog ascarid, Toxocara canis and less often the cat ascarid, T. cati. Visceral larva migrans may also be caused by Anisakis, which are large ascarid parasites of marine animals and also by Gnathostoma spinigerum, Angiostrongylus cantonensis. Human nematodes like A. lumbricoides and S. stercoralis may produce visceral larva migrans, when they get lost in ectopic sites
• Clinical manifestations depend on the sites affected and the degree and duration of infection.
• • As children are more likely to swallow dirt, this condition is much more frequent in them.
• • Fever, hepatomegaly, pneumonitis, hyperglobulinemia and pica are th e common findings.
• • Patients may develop neurological disturbances (neural larva migrans) and endophthalmitis (ophthalmic larva migrans).
• • Marked leukocytosis occurs with persistently high eosinophilia.

• Points to Remember
• • Adult onset papilloma – seen in adults in the third decade
• • Ca which presents with neck nodes = supraglottis Ca
• • Highest lymphnode involvement occurs in – supraglottic Ca
• • Hoarseness is the presenting symptom – Glottic Ca
• • Stridor is the presenting symptom in Subglottic Ca.
• • Laryngeal cancer with worst prognosis = subglottic Ca
• • Ca with best prognosis = Glottic Ca

• 1. C3 level is decreased in:
• a. PSGN
• b. IgA nephropathy
• c. HSP
• d. Goodpasture syndrome

Ans, A, PSGN

• I. Decreased C3 may be seen in:
• A. Systemic diseases:
• ▪Lupus nephritis
• ▪SABE
• ▪Shunt nephritis,
• ▪Essential mixed cryoglobulinemia
• ▪Visceral abscesses

• B. Renal diseases:
• ▪PSGN
• ▪MPGN type

• II. Normal C3 is seen in:
• A. Systemic diseases:
• ▪PAN
• ▪Hypersensitivity vasculitis
• ▪HSP
• ▪Granulomatosis with polyangitis
• ▪Goodpasteur syndrome

• B. Renal diseases
• ▪IgA nephropathy
• ▪RPGN
• ▪Post infectious GN

• 2. 22-year-old Rama is being counseled after a first-trimester miscarriage. Her physical examination is unremarkable, no significant medical problems and in counseling her you explain in lay terms that the most likely cause of her miscarriage is chromosomal abnormality. The most common chromosomal abnormality causing miscarriage is?
• a. Trisomy 16
• b. 45,XO
• c. Triploidy
• d. Unbalanced translocation

Ans, B, 45,XO

• {This is a bit confusing. Over all the most common cause for miscarriage is aneuploidy (abnormal numbers of chromosome).
• Among them, the most common is trisomy i.e. 47 chromosomes, about 50%. Among which trisomy 16 on third of all trisomies i.e. around 16% of abortuses.
• Then comes monosomy but, 45,XO appears to be cause in 20% alone so, its the best answer in this question.}

• SPONTANEOUS ABORTION (MISCARRIAGE)
• DEFINITION:
• •Abortion is the expulsion or extraction from its mother of an embryo or fetus weighing 500 g or less when it is not capable of independent survival (WHO).
• •This 500 g of fetal development is attained approximately at 22 weeks (154 days) of gestation. The expelled embryo or fetus is called abortus.
• The word miscarriage is the recommended terminology for spontaneous abortion.

• GENETIC FACTORS RELATED TO MISCARRIAGE:
• •Majority (50%) of early miscarriages are due to chromosomal abnormality in the conceptus.
• •Autosomal trisomy is the commonest (50%) cytogenetic abnormality.
• •Trisomy for every chromosome has been reported.
• •The most common trisomy is trisomy 16 (30%). Polyploidy has been observed in about 22% of abortuses. (Polyploidy refers to the presence of three or more multiples of a haploid number of chromosome, e.g. 3n = 69, 4n= 92. Triploidy is more common than tetraploidy).
• •Monosomy X (45, X) is the single most common chromosomal abnormality in miscarriages (20%). Structural chromosomal rearrangements are observed in 2–4% of abortuses.
• •These include translocation, deletion, inversion and ring formation.
• •Other chromosomal abnormalities like mosaic, double trisomy, etc. are found in about 4% of abortuses.

• 3. A 30-year-old man has excessive sleep at work attributed to sleep discomfort at night. He also has recent history of falling while partying with friends. What are the other features that can be seen associated with his condition:
• a. Paralysis during sleep-wake transition with hallucinations
• b. Snoring with witnessed sleep apnea
• c. Pain in the legs before going to sleep
• d. Generalized seizures in the wake state

Ans, A, Paralysis during sleep-wake transition with hallucinations

• History of fall is highly suggestive of atonia/paralysis and may be due to Narcolepsy. In obstructive sleep apnea,patient usually falls asleep during daytime with no loss of postural tone. Narcolepsy is both a disorder of the ability to sustain wakefulness voluntarily and a disorder of REM sleep regulation. Paralysis during sleep-wake transition with hallucinations is seen in narcolepsy.
• Narcolepsy
• Narcolepsy is a common sleep disorder characterized by excessive day time sleepiness, cataplexy (episodes of muscle weakness triggered by emotions), hypnagogic hallucinations and sleep paralysis.
• Narcolepsy (Classic tetrad)
• • Excessive day time somnolence.
• • Sudden weakness or loss of muscle tone without loss of consciousness often elicited by emotions (cataplexy).
• • Hallucination at sleep onset (Hypnagogic hallucination).
• • Muscle paralysis upon awakening.

• 4. Which of the following structure in the spine is pain insensitive?
• a. Nucleus pulposus
• b. Dura
• c. Annulus fibrosus
• d. Longitudinal ligaments

Ans, A, Nucleus pulposus

• Pain sensitive structures of the spine are:
• ▪Facet joints
• ▪Periosteum of vertebrae
• ▪Annulus fibrosus of intervertebral disc
• ▪Dura
• ▪Epidural veins and arteries
• ▪Longitudinal ligaments
• Nucleus pulposus of intervertebral disk is not pain sensitive.

• 5. A previously diagnosed case (2 years old baby) of tubercular meningitis comes with delayed milestones and mental retardation. After examination and investigations, he was found to have increased ICP. This is because of decreased absorption of CSF with normal production of it from ventricles and choroid plexus. Production of CSF from walls of ventricles and the choroid plexus is about?
• a. 20ml/hr
• b. 40ml/hr
• c. 60ml/hr
• d. 80ml/hr

• Ans, A, 20ml/hr
• Explanation:
• The total CSF volume is normally about 150 mL. Production from the walls of the ventricles and the choroid plexus is about 20 mL per hour. Hydrocephalus refers to an increase in CSF volume with ventricular enlargement, often presenting symptoms of raised ICP.

• 1.Diffusion into gas-containing spaces is a problem with:
• a. Halothane
• b. Nitrous oxide
• c. Isoflurane
• d. Ether

• Ans: B,Nitrous Oxide
• Ref: Morgan 5/e p166
• Contraindications Of nitrous oxide
• •Although nitrous oxide is insoluble in comparision with other inhalation agents, it is 35 times more soluble than nitrogen in blood.
• •Thus, it tends to diffuse into air-containing cavities more rapidly than nitrogen is absorbed by the bloodstream.
• •For instance, if a patient with a 100-mL pneumothorax inhales 50% nitrous oxide, the gas content of the pneumothorax will tend to approach that of the bloodstream.
• •Because nitrous oxide will diffuse into the cavity more rapidly than the air (principally nitrogen) diffuses out, the pneumothorax expands until it contains 100 mL of air and 100 mL of nitrous oxide.
• •If the walls surrounding the cavity are rigid, pressure rises instead of volume.
• •Examples of conditions in which nitrous oxide might be hazardous include venous or arterial air embolism, pneumothorax, acute intestinal obstruction with bowel distention, intracranial air (pneumocephalus following dural closure or pneumoencephalography), pulmonary air cysts, intraocular air bubbles, and tympanic membrane grafting .
• •Nitrous oxide will even diffuse into tracheal tube cuffs, increasing the pressure against the tracheal mucosa.
• •Obviously, nitrous oxide is of limited value in patients requiring high inspired oxygen concentrations.

• 2. A lady presents after 2 days following complete perineal tear, best time for perineal repair is
• A.Immediately
• B.After 1 week
• C.No need to repair
• d.After 3 months

• Ans,d; after 3 months
• Ref dc dutta 8/e P490
• Timing of repair of perineal tear
• •Recent tear should be repaired immediately following the delivery of the placenta.
• •This reduces the chance of infection and minimizes the blood loss.
• •In cases of delay beyond 24 hours, the repair is to be withheld.
• •Antibiotics should be started to prevent infection.
• •The complete tear should be repaired after 3 months if delayed beyond 24 hours.
• •In case of any doubt to grade of 3rd degree tear, it is advisable to classify to the higher degree rather than lower degree.

• 3. You are a medical officer of Sukraraj tropical hospital, you are providing direct care to COVID-19 patients, you are not involved in Aerosol-generating procedures. According to WHO which of the following PPE is NOT necessary for you?
• A. Respirator N95 or FFP2 standard
• B. Gown
• C. Eye protection (goggles or face shield)
• D. All are recommended

• Ans A Respirator N95 or FFP2 standard
• Ref, WHO rational use of personal protective equipment for coronavirus disease 2019 (COVID-19)

• Q1. The action of which of the following muscles can displace bilateral fractures of the mandible in the canine region posteriorly?
• a. Thyrohyoid, genioglossus and geniohyoid muscles
• b. Anterior belly of digastric, geniohyoid and genioglossus muscles
• c. Mylohyoid, genioglossus and styloglossus muscles
• d. Mylohyoid, masseter and geniohyoid muscles

• Ans: b, Anterior belly of digastric, geniohyoid and genioglossus muscles
• Ref: Bailey and Love 25/e, p331
• Fractures of the mandible
• The condylar neck is the weakest part of the mandible and is the most frequent site of fracture, while other fractures tend to occur through unerupted teeth (the impacted wisdom tooth) or where the roots are long (the canine tooth). The mandible may fracture directly at the point of the blow, or indirectly where the force from the blow is transmitted and the mandible fractures at a point of weakness distant from the original blow. The latter is characteristically seen in the so called ‘guardsman’ fracture, where a blow to the chin point may cause a fracture of the symphysis or parasymphysis of the lower jaw, and indirect transmission of the kinetic energy causes a unilateral or bilateral fracture of the mandibular condyles. Individual sharp blows with a blunt instrument may fracture a segment away from the mandible. Blows from below may cause the mandible to be thrust upwards, fracturing the alveolus and teeth as they strike the maxillary dentition.
• Much has been made in the past of the ‘butterfly’ fracture of the mandible. Here, a segment of mandible is detached from the rest of the mandible in the canine regions. The segment of bone may include the anterior insertion of the tongue (genioglossus and geniohyoid). Theoretically, the tongue may fall back and occlude the airway.
• The muscles attached to the anterior mandible which can cause posterior displacement in a bilateral parasymphyseal mandibular fracture are the anterior belly of digastric, geniohyoid and genioglossus.

• Q2. Which of the following statements regarding the vertigo associated with Ménière’s disease are true?
• a. It lasts for days to weeks.
• b. It lasts for minutes to hours.
• c. It lasts for seconds to minutes.
• d. It is caused by recurrent infection.

• Ans: b, It lasts for minutes to hours
• Ref: Bailey and Love, 25/e, p699.
• Ménière’s disease describes an intermittent vertigo which lasts for minutes to hours and is associated with tinnitus, hearing loss and a feeling of aural fullness. The cause is unclear although it may be related to pressure changes within the inner ear. Investigation will include MRI to exclude mass lesions at the cerebellopontine angle, which may mimic the condition. Treatment includes diuretics which may help lower the inner ear pressure, injection of gentamicin to the middle ear to perform a pharmaceutical larbyrinthectomy or more destructive surgical interventions to destroy the labyrinth or the nerves that supply it.

• Q3. Which of the following is not true in relation to strangulated hernias?
• a. They present with local and then generalised abdominal pain and vomiting.
• b. A normal hernia can strangulate at any time.
• c. This is more common in femoral hernia.
• d. They can be reliably excluded in irreducible hernias on clinical examination.

• Ans: d, They can be reliably excluded in irreducible hernias on clinical examination
• Ref: Bailey and Love 25/e, p969-70
• Strangulation is a genuine surgical emergency and requires prompt surgery. The clinical features may mimic gastroenteritis in a strangulated Richter’s hernia, which may delay diagnosis. The initial symptoms in a strangulated omentocele are similar to a strangulated bowel, but vomiting and constipation may be absent.

• 1. A couple has been experiencing discharge from their sex organs. The male partner also gives history of dysuria while the girl doesn’t have that. They have been indulged in sexual activities since their third date 1 month back. They deny use of condoms but has been strictly following calendar method of contraception. Both of them had previous relationship. On gram’s stain of discharge Gram –ve intracellular diplococci is revealed. What is the incubation period of the likely venereal disease?
• a. 1-2 days
• b. 1-5 days
• c. 1-30 days
• d. 5-14 days

• Ans, B, 1-5 days
• Ref, Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases, Neena Khanna, 4th edition, page no. 315
• Gonorrhea
• Etiology: Neisseria gonorrhoeae, transmitted sexually; sometimes vertically (from mother to child) causing ocular infection in neonates.
• Incubation period: 1–5 days.
• Males: Urethritis manifesting as profuse urethral discharge and dysuria.
• Females: Usually asymptomatic carriers; may have vaginal discharge.
• Complications:
• Infection of adjoining structures and glands.
• Late complications like urethral stricture (males) and pelvic inflammatory disease and infertility (females).
• Diagnosis: Clinical suspicion confirmed in males by demonstration of Gram-negative intracellular diplococci on Gram stain. And in females by culturing the organism.
• Treatment:
• Uncomplicated gonococcal infection: Single oral dose of cefixime (400 mg) or ciprofloxacin (500 mg) or intramuscular ceftriaxone (125 mg);
• Complicated infections: Need longer treatment.

• 2. Having very hard time raising a son, parents come to a pediatrician. They complain that their son turned 4 years of age recently and since that time around, has been developing undesirable symptoms. The boy has difficulty sitting still at a place for long time, doesn’t seem to listen to anybody, gets easily distracted, talks excessively and appears fidgety all the time. Attention deficit disorder with hyperactivity is the commonest type of ADD. Which of the following symptoms suggest poor attention of the child?
• a. Difficulty sitting still at a place for long time
• b. Appears fidgety all the time
• c. Doesn’t seem to listen
• d. Talks excessively

• Ans, C, Doesn’t seem to listen
• Ref, A Short Textbook of Psychiatry, Niraj Ahuja, 7th edition, page no. 166
• Attention deficit disorder (ADD)
• A relatively common disorder, it occurs in about 3% of school age children. Males are 6-8 times more often affected. The onset occurs before the age of 7 years and a large majority of patients exhibit symptoms by the 4th year of age.
• Attention deficit disorder (ADD) is of four clinical types:
• 1. Attention deficit disorder with hyperactivity (Hyperkinetic disorder)
• This is the commonest type. The characteristic clinical features are:
• a) Poor attention span with distractibility
• • Fails to finish the things started.
• • Shifts from one uncompleted activity to another.
• • Doesn’t seem to listen.
• • Easily distracted by external stimuli.
• • Often loses things.
• b) Hyperactivity
• • Fidgety.
• • Difficulty in sitting still at one place for long.
• • Moving about here and there.
• • Talks excessively.
• • Interference in other people’s activities.
• c) Impulsivity
• • Acts before thinking, on the spur of the moment.
• • Difficulty in waiting for turn at work or play.

• 2. Attention deficit disorder without hyperactivity
• It is a rare disorder with similar clinical features, except hyperactivity.

• 3. Residual type
• It is usually diagnosed in a patient in adulthood, with a past history of ADD and presence of a few residual features in adult life.

4. Hyperkinetic disorder with conduct disorder (Hyperkinetic conduct disorder).

• 3. A researcher observes pattern of sleep in a normal human being. One of the volunteers is asked to sleep in a dim-light room. He then observes for any movements or other findings he might find notable. Suddenly, after a while, the researcher notices rapid movement of the sleeper’s eyes which is clearly appreciated as wavy movement of eyelids. In a normal sleep, what is the average duration of a bout of Rapid Eye Movement sleep?
• a. 5-30 mins
• b. 30-60 mins
• c. Around 90 mins
• d. 2 hours

• Ans, A, 5-30 mins
• Ref, Textbook of Medical Physiology, Guyton and Hall, 13th edition, page no. 763
• Types of sleep
• Each night, a person goes through stages of two major types of sleep that alternate with each other. These types are called
• 1. Rapid eye movement sleep (REM sleep), in which the eyes undergo rapid movements even though the person is still asleep.
• • REM sleep occurs in episodes that occupy about 25 percent of the sleep time in young adults; each episode normally recurs about every 90 minutes.
• • In a normal night of sleep, bouts of REM sleep lasting 5 to 30 minutes usually appear on average every 90 minutes in young adults.
• • When a person is extremely sleepy, each bout of REM sleep is short and may even be absent. As the person becomes more rested through the night, the durations of the REM bouts increase.
• • This type of sleep is not so restful, and it is often associated with vivid dreaming.

• 2. Slow-wave sleep or non-REM (NREM) sleep, in which the brain waves are strong and of low frequency.
• • Most sleep during each night is of the slow-wave (NREM) variety, which is the deep, restful sleep that the person experiences during the first hour of sleep after having been awake for many hours.
• • This sleep is exceedingly restful.

• Q. Posterior inferior cerebellar artery is the branch of
• a. Vertebral artery
• b. Basilar artery
• c. Subclavian artery
• d. Internal carotid artery

• Ans: a. Vertebral artery
• Ref: Ref: Ref: Human anatomy BD Chaurasia 4th Vol 3 P202

Branches of vertebral artery

• a. Cervical branches
• 1. Spinal branches
• 2. Muscular branches

• b. Cranial branches
• 1. Meningeal branches
• 2. Anterior spinal artery
• 3. Posterior spinal artery ( usually a branch of posterior interior cerebellar artery )
• 4. Posterior inferior cerebellar artery ( largest branch )
• 5. Medullary arteries

• Q. Burning foot syndrome is caused by deficiency of:
• a. Riboflavin
• b. Niacin
• c. Pantothenic acid
• d. Folic acid

• Ans: c. Pantothenic acid
• Ref: Biochemistry U. Satyanarayana 4th e P 150
• Deficiency symptoms of pantothenic acid
• It is a surprise to biochemists that despite the involvement of pantothenic acid (as coenzyme A) in a great number of metabolic reactions, its deficiency manifestations have not been reported in humans. This may be due to the widespread distribution of this vitamin or the symptoms of pantothenic acid may be similar to other vitamin deficiencies. Dr. Gopalan, a world renowned nutritionist from India, linked the burning feet syndrome (pain and numbness in the toes, sleeplessness, fatigue etc.) with pantothenic acid deficiency.

• Q. Which of the following drug can cause thyroid dysfunction?
• a. Amiodarone
• b. Ampicillin
• c. Ibutilide
• d. Acyclovir

• Ans: a. Amiodarone
• Essentials of medical pharmacology KD Tripathee 7th e P 534
• Adverse effects of Amiodarone
• These are dose-related and increase with duration of therapy.
• • Fall in BP, bradycardia and myocardial depression occurs on i.v. injection and after drug cumulation.
• • Nausea, gastrointestinal upset may attend oral medication, especially during the loading phase.
• • Photosensitization and sun burn like skin pigmentation occurs in about 10% patients.
• • Corneal microdeposits are common with longterm use, may cause headlight dazzle, but are reversible on discontinuation.
• • Pulmonary alveolitis and fibrosis is the most serious toxicity of prolonged use, but is rare if daily dose is kept below 200 mg.
• • Peripheral neuropathy generally manifests as weakness of shoulder and pelvic muscles. Liver damage is rare.
• • Amiodarone interferes with thyroid function in many ways including inhibition of peripheral conversion of T4 to T3 and interaction with thyroid hormone receptor. Goiter, hypothyroidism and rarely hyperthyroidism may develop on chronic use.

• 1.All are true regarding Caroli’s disease except?
• A. Intrahepatic stone formation
• B. Biliary stasis
• C. Commonly presents with ascites
• D. Malignant change can occur

Correct answer : C. Commonly presents with ascites

CT scan of cholangiocarcinoma. Malignant change can occur in Caroli’s disease.

• Caroli’s disease is congenital dilatation of the intrahepatic biliary tree.
• This disease is complicated by presence of intrahepatic stone formation.
• Patients can present with abdominal pain or sepsis.
• Biliary stasis with stone formation can lead to biliary sepsis.
• Malignant change in the ductal system can lead to cholangiocarcinoma

• 2.Which of the following is not a component of Total Parenteral Nutrition?
• A. Amino acids
• B. Fats
• C. Vitamins
• D. Fiber

• Correct answer : D. Fiber
• Ref. Bailey and Love 27/e, p286-87

• COMPONENTS OF TOTAL PARENTERAL NUTRITION
• Total parenteral nutrition should provide both energy and other essential nutrients.
• Carbohydrates, lipids and amino acids provide energy.
• The other essential nutrients to be included are: minerals, vitamins and water.
• Dietary fiber is required only in case of enteral nutrition. It is not given as a part of parenteral nutrition.

• 3.Carcinoma of buccal mucosa commonly drain to the following lymph nodes sites:
• a. Submental
• b. Submandibular
• c. Supraclavicular
• d. Cervical

• Ans. is b i.e. Submandibular
• Ref. Dhingra 5/e, p 240; 6/e, p 227
• • M/C lymph node involved in any oral malignancy is Submandibular LN
• • Maximum LN metastases is seen in cancer tongue followed by floor of mouth.
• • Lymphatic metastasis is least in lip cancer followed by hard palate.
• Lymphatic drainage of tongue, Floor of mouth and Buccal mucosa:
• • Level I: Submandibular LN
• • Level II: Upper deep cervical LN
• • Level III: Middle deep cervical LN
• • Level IV: Lower deep cervical LN
• Lymphatic drainage of oropharyngeal tumors:
• • Level I: Jugulodigastric LN
• • Level II: Upper deep cervical LN
• • Level III: Jugulomohyoid or middle deep cervical LN
• • Level IV: Lower deep cervical LN

• 1. A young girl presents with abdominal pain and a recent change in bowel habit, with passage of mucus in stool. There is no associated blood in stool and symptoms are increased with stress. The most likely diagnosis is:
• a. Irritable bowel syndrome
• b. Ulcerative Colitis
• c. Crohn’s disease
• d. Amebiasis

• Ans, a. Irritable bowel syndrome
• Ref: Harrison’s 18/e p2496-97, 17/e p1899, 1900
• Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habits in the absence of detectable structural abnormalities. No clear diagnostic markers exist for IBS, thus the diagnosis of the disorder is based on clinical presentation.
• IBS is a disorder that affects all ages, although most patients have their first symptoms before age 45. Older individuals have a lower reporting frequency. Women are diagnosed with IBS two to three times as often as men and make up 80% of the population with severe IBS. Pain or abdominal discomfort is a key symptom for the diagnosis of IBS. These symptoms should be improved with defecation and/or have their onset associated with a change in frequency or form of stool. Painless diarrhea or constipation does not fulfill the diagnostic criteria to be classified as IBS. Supportive symptoms that are not part of the diagnostic criteria include defecation straining, urgency or a feeling of incomplete bowel movement, passing mucus and bloating.

• 2. Most common cause of death in primary amyloidosis is
• a. Respiratory failure
• b. Renal failure
• c. Cardiac failure
• d. Septicemia

• Ans, c. Cardiac failure
• Ref: Harrison’s 18/e p948
• Amyloidosis is the term for diseases caused by the extracellular deposition of insoluble polymeric protein fibrils in tissues and organs. These diseases are a subset of a growing group of disorders attributed to misfolding of proteins. Among these are Alzheimer’s disease and other neurodegenerative diseases, transmissible prion diseases, and genetic diseases caused by mutations that lead to misfolding, aggregation, and protein loss of function, such as certain of the cystic fibrosis mutations. Amyloid fibrils share a common beta pleated sheet structural conformation that confers unique staining properties.
• For patients with impaired cardiac function or arrhythmias due to amyloid involvement of the myocardium, median survival is only about 6 months without treatment, and stem cell mobilization and high-dose chemotherapy are dangerous. In these patients, cardiac transplantation can be performed, followed by treatment with HDM/SCT to prevent amyloid deposition in the transplanted heart or other organs.

• 3. A 55 year old female came with hip flexor contracture. What is the most likely test to be done in this case:
• a. Allis test
• b. Thomas test
• c. Ober test
• d. Trendelenburg test

• Ans, b.Thomas test
• Ref: Apley’s system of orthopaedics and fracture 9th ed., pg. 495
• Full name of the test is Hugh Owen well leg hip flexion Thomas test. This test is used to find out fixed flexion deformity of hip joint.
• Ober test is to determine Iliotibial band contracture
• Trendelenberg test is to find out abductor weakness of hip joint.
• Allis test or Galeazzi sign is used to diagnose DDH in children.

• 1) Bullet which is left in the body for very long time is known as?
• a. Tandem bullet
• b. War bullet
• c. Souvenir bullet
• d. Tracer bullet

Ans, C, Souvenir bullet

Ref, SK Singhal’s Forensics, 4th edition, page no. 188

• Types of bullet:
• i. Tandem bullet/piggy tail bullet: Bullet not released on first fire comes out with second bullet on second shot.

ii. Souvenir bullet : Bullet which is left in the body for long.

iii. Tracer bullet : Bullet that leaves a visible mark in path that a person can see.

iv. Ricocheting bullet : Bullet deviated from its path after coming in contact with a surface.

• 2) What is the maximum diameter of Tardieu spots that is seen in case of asphyxia?
• a. 0.5mm
• b. 1mm
• c. 2mm
• d. 5mm

Ans, C, 2mm

Ref, The Essentials of Forensic Medicine and Toxicology, Reddy, 33rd edition, page no.141

Tardieu spots are numerous where the capillaries are least firmly supported, as in sub-conjunctival tissues and under the pleural and pericardial membranes but they can appear almost anywhere if the degree of congestion and cyanosis is sufficient. Tardieu spots are usually rounded, dark and well-defined, varying in size from a pin's head to 2 mm. They may occur as isolated minute haemorrhages or present in large numbers, and at times fuse to form patches of red colour, especially at the back of the heart.

• 3) Chocolate agar is used for isolation of;
• a. N. gonorrhoea
• b. H. influenzae
• c. B. pertusis
• d. E.coli

Ans, B, H. influenza

Ref: First aid for USMLE Step 1 2020 pg170

• •H influenzae = Chocolate agar
• •N gonorrhoeae, N meningitidis=Thayer-Martin agar.
• •B pertussis= Bordet-Gengou agar (Bordet for Bordetella),Regan-Lowe medium
• •C diphtheriae =Tellurite agar, Löffler medium
• •M tuberculosis =Löwenstein-Jensen medium, Middlebrook medium
• •M pneumoniae= Eaton agar
• •E coli = Eosin–methylene blue (EMB)
• •Legionella=Charcoal yeast extract agar buffered with cysteine and iron
• •Fungi =Sabouraud agar

• 1) Which of the following formula can be used for calculation for mental age (MA) if chronological age (CA) is known?
• a. CA= (CA- MA)/IQ x 100
• b. IQ=MA/CA x 100
• c. CA=IQ/MA x 100
• d. IQ=CAx100/MA

Ans, B

Ref, Niraj Ahuja - A Short Textbook of Psychiatry, 20th Edition, Page no. 156

• A classification of mental retardation on the basis of IQ ( Intelligence Quotient, which is equal to mental age, i.e. MA, divided by chronological age, i.e. CA, multiplied by 100;
• i.e. IQ = MA/CA × 100), is provided in Table.

• 2) A 10 year old boy presented with a mild tibial swelling.On X-ray,lytic lesion with sclerotic margins was seen.What is the most likely diagnosis?
• a. Osteoid osteoma
• b. Fibrous cortical defect
• c. Osteosarcoma
• d. Fibrous dysplasia

Ans, A, Osteoid osteoma

(Ref: Apley 9th ed, pg 194-204)

-The most liekly diagnosis in a 10 year old boy who presents with a mild tibial swelling and lytic lesion with sclerotic margins on X-ray is Osteoid osteoma.

• 3) All of the followings are true about hernias except;
• a. All hernias require surgical repair
• b. Small hernias can be more dangerous than large
• c. Pain, tenderness and skin color changes imply high risk of strangulation
• d. Femoral hernia should always be repaired

Ans, A, All hernias require surgical repair

Ref: Bailey and love 27th edition, pg no.1026

• Explanation:
• Management principles of hernia
• Not all hernias require surgical repair.
• Small hernias can be more dangerous than large.
• Pain, tenderness and skin colour changes imply high risk of strangulation.
• Femoral hernia should always be repaired.

• 1) Which of the following about atherosclerosis is true?
• a. Intake of unsaturated fatty acid is associated with decreased risk
• b. Thoracic aorta involvement is more severe than abdominal aorta involvement
• c. Extent of lesion in veins is same as that in arteries
• d. Hypercholesterolemia does not always increase the risk of atherosclerosis

Ans, A, Intake of unsaturated fatty acid associated with decreased risk

Ref- Harrison 17th edition page no.2429

• · Atherosclerosis is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol.
• · It is a syndrome affecting arterial blood vessels, a chronic inflammatory response in the walls of arteries, caused largely by the accumulation of macrophage white blood cells and promoted by low-density lipoproteins without adequate removal of fats and cholesterol from the macrophages by functional high density lipoproteins (HDL),
• · It is commonly referred to as a hardening or furring of the arteries.
• · It is caused by the formation of multiple plaques within the arteries.
• The athermatous plaque is divided into three distinct components:
• ☆ The atheroma which is the nodular accumulation of a soft, flaky, yellowish material at the center of large plaques, composed of macrophages nearest the lumen of the artery
• ☆ Underlying areas of cholesterol crystals
• ☆ Calcification at the outer base of older/more advanced lesions.
• Role of PUFA
• · N-3 polyunsaturated fatty acids (n-3 PUFAs) are present in high concentration in fish and in flax seeds.
• · The most widely used n-3 PUFAs for the treatment of hyperlipidemias are the two active molecules in fish oil: eicosapentanoic acid (EPA) and decohexanoic acid (DHA).
• · N-3 PUFAs have been concentrated into tablets and decrease fasting triglycerides in doses of 3–4 g/d.
• · Fish oils can result in an increase in plasma LDL-C levels in some patients.
• · Fish oil supplements can be used in combination with fibrates, niacin, or statins to treat hypertriglyceridemia. In general, fish oils are well tolerated and appear to be safe, at least at doses up to 3–4 g.
• · Although fish oil administration is associated with a prolongation in bleeding time, no increase in bleeding has been seen in clinical trials.
• · A lower dose of omega 3 (about 1 g) has been associated with reduction in cardiovascular events in CHD patients and is used by some clinicians for this purpose.

• 2) SIADH is characterised by all except;
• a. Urine osmolarity > 100mOsm/kg
• b. Serum osmolarity >280mOsm/kg
• c. Serum sodium < 135mEq/l
• d. Urinary sodium > 30mEq/l

Ans, B, Serum osmolarity >280mOsm/kg

Ref: Nelson textbook of pediatrics 21st edition pg 2070

• Diagnostic Criteria for Syndrome of Inappropriate Antidiuretic Hormone Secretion
• • Absence of: Renal, adrenal, or thyroid insufficiency, Heart failure, nephrotic syndrome, or cirrhosis, Diuretic ingestion, Dehydration
• • Urine osmolality >100 mOsm/kg (usually > plasma)
• • Serum osmolality <280 mOsm/kg and serum sodium <135 mEq/L
• • Urine sodium >30 mEq/L
• • Reversal of “sodium wasting” and correction of hyponatremia with water restriction

• 3) Leucopenia is NOT seen in?
• a. New born
• b. Starvation
• c. Enteric Fever
• d. Viral or protozoal infection

Ans, D, Viral or protozoal infection

Ref: Robbins 10th Edition p582-83

• Leukocytosis is seen with Viral infections on account of increase in number of natural killer cells
• Leucopenia : MI, Sepsis, CLL, Lithium intoxication, Down's syndrome, Polyarteritis nodosa, Trauma, Cushing's disease

• 1) What is the correct sequence of stages of overcoming addiction?
• a. Contemplation, pre-contemplation, action, preparation, maintenance, relapse
• b. Preparation, pre-contemplation, contemplation, action, maintenance, relapse
• c. Pre-contemplation, contemplation, preparation, action, maintenance, relapse
• d. Pre-contemplation, contemplation, action, preparation, maintenance, relapse

Ans, C, Pre-contemplation, contemplation, preparation, action, maintenance, relapse

Ref. FA, USMLE step 1, 2020, Page no.568

• Stages of change in overcoming addiction
• Pre-contemplation—denying problem
• Contemplation—acknowledging problem, but unwilling to change
• Preparation/determination—preparing for behavioral changes
• Action/willpower—changing behaviors
• Maintenance—maintaining changes
• Relapse—(if applicable) returning to old behaviors and abandoning changes

• 2) Freiberg's disease is:
• a. Avascular necrosis of navicular
• b. Avascular necrosis of lunate
• c. Osteochondritis of the calcaneal apophysis
• d. Osteochondritis of the second metatarsals

Ans, D, Osteochondritis of the second metatarsals

(Ref: Apley 8th ed, pg 101-102)

-Frieberg's disease is a crushing type of osteochondritis of the second metatarsal head (rarely the third ) affects mostly young women.

• 3) Which artery is not the branch of internal carotid artery?
• a. Ophthalmic artery
• b. Caroticotympanic artery
• c. Middle cerebral artery
• d. Posterior cerebral artery

Ans, D, Posterior cerebral artery

• Branches of Internal carotid artery (10 branches)
• 1. Cervical part
• • No branches

• 2. Petrous part
• a) Caroticotympanic artery
• b) Pterygoid artery

• 3. Cavernous part
• a) Cavernous artery
• b) Hypophyseal artery
• c) Meningeal artery

• 4. Cerebral part
• a) Posterior communicating artery
• b) Ophthalmic artery
• c) Middle cerebral artery
• d) Anterior cerebral artery
• e) Anterior choroid artery

• 1) Which of the following radiological sign will be present in a young lady with symptoms suggestive of pulmonary embolism?
• a. Hampton's hump
• b. Westermark sign
• c. Fleischner sign
• d. All of the above

Ans, D, All of the above

• Pulmonary infarction may occur if the pulmonary venous pressure is elevated or the
• bronchial arterial supply to a region is deficient. The cone-shaped area of pulmonary
• infarction has been called a Hampton's hump. An area of radiolucency, corresponding to diminished pulmonary vascularity distal to a pulmonary embolism, is occasionally seen and is called the Westermark sign. There may also be an increase in the size of the pulmonary artery proximal to a large central pulmonary embolus (Fleischner sign).

• 2) What are pathognomic lesions of acne vulgaris?
• a. Tiny pustule
• b. Nodule
• c. Comedone
• d. Keratin accumulation

Ans, C, Comedone

Ref, Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases, Neena Khanna, 4th edition, page no.112

• &Comedones: Are pathognomonic lesions of acne vulgaris
• Two main types of comedones recognized:
• Open comedones (black heads):are dueto plugging of the pilosebaceous orificeby keratin and sebum on the skin surface.
• Closed comedones (white heads):are due to keratin and sebum accretions plugging the pilosebaceous ducts below the skin surface. Some closed comedones are deep seated (submarine comedones) and are best seen by stretching the skin.Submarine comedones respond poorly to medical treatment.

• 3) Congenital deficiency of which factor result in parahemophilia?
• a. Factor V
• b. Factor VIII
• c. Factor IX
• d. Factor XI

Ans: A, Factor V

Ref: Nelson textbook of pediatrics 21st edition pg 10194

• ☆ V Labile factor, proaccelerin Congenital deficiency (parahemophilia)
• ☆ VIII Antihemophilic factor Congenital deficiency is hemophilia A (classic hemophilia)
• ☆ IX Christmas factor Congenital deficiency is hemophilia B (sometimes referred to asChristmas disease)
• ☆ XI Plasma thromboplastinantecedentCongenital deficiency (sometimes referred to as hemophilia C)

• 1) Normal PT is found in patients with deficiency of factor(s)
• a. VIII
• b. VII
• c. IX
• d. Both a and c

Ans, D, Both a and c

Ref: Nelson textbook of pediatrics 21st edition pg 10203

In The laboratory, prothrombin time (PT) measures the activation of factor X by factor VII and is therefore normal in patients with factor VIII or factor IXdeficiency

• 2) With the patient lying in lithotomy position, the classical location of hemorrhoids are?
• a. 3, 9 and 12 o’clock position
• b. 3, 7 and 12 o’clock position
• c. 3, 7 and 11 o’clock position
• d. 3, 9 and 11 o’clock position

Ans: C, 3, 7 and 11 o’clock position

Ref: Bailey and Love 27th edition, Pg no. 1355

• Explanation:
• Haemorrhoids: clinical features
• Haemorrhoids or piles are symptomatic anal cushions. They are more common when intra-abdominal pressure is raised, e.g. in obesity, constipation and pregnancy. Classically, they occur in the 3, 7 and 11 o’clock positions with the patient in the lithotomy position.
• Symptoms of haemorrhoids: Bright-red, painless bleeding, mucus discharge, prolapse, pain only on prolapsed.

• 3) Upper part of the faucial pillars and most of the uvula are visible ,what is the malampatti grading of this patient;
• a. I
• b. II
• c. III
• d. IV

• Ans, B, II
• Ref: Text book of clinical anesthesiology, Morgan and Mikhail, 5th edition, page 313

• Mallampati classifi cation: a frequently performed test that examines the size of the tongue in relation to the oral cavity. The greater the tongue obstructs the view of the pharyngeal structures, the more difficult intubation may be.
• ■ Class I: the entire palatal arch, including the bilateral faucial pillars, are visible down to their bases.
• ■ Class II: the upper part of the faucial pillars and most of the uvula are visible.
• ■ Class III: only the soft and hard palates are visible.
• ■ Class IV: only the hard palate is visible.
• • Th yromental distance: the distance between the mentum and the superior thyroid notch. A distance greater than 3 finger breadths is desirable.
• • Neck circumference: a neck circumference of greater than 27 in is suggestive of difficulties in visualization of the glottic opening. Although the presence of these findings may not be particularly sensitive for detecting a difficult intubation, the absence of these findings is predictive for relative ease of intubation.

• Q 7) A transplant from one member to another in a common species is called?
• a. Autograft
• b. Isograft
• c. Xenograft
• d. Allograft

Ans, D, Allograft

Ref, Textbook of Medical Physiology, Guyton and Hall, 13th edition, page no.481

• Autografts, Isografts, Allografts, and Xenografts.
• A transplant of a tissue or whole organ from one part of the same animal to another part is called anautograft;
• from one identical twin to another, an isograft;
• from one human being to another or from any animal to another animal of the same species, an allograft;
• from a non-human animal to a human being or from an animal of one species to one of another species, a xenograft.

• Q 8 Marker specific for Myocardial infarction :
• a. Troponin I
• b. Troponin C
• c. Troponin T
• d. LDH

Ans, A, Troponin I

( Ref: Harrison 19th ed/ pg. 1600)

-The best test for diagnosis of MI is troponin I which can be quantified as value more than 0.04 ng/dl after 3 hours of onset of myocardia infarction.

• Q 9 All of the following antimicrobial drugs acts by binding to 50s subunit of ribosome EXCEPT
• a. Macrolides
• b. Chloramphenicol
• c. Tetracycline
• d. Clindamycin

Ans, C, Tetracycline

• Drugs Acting on 50S subunit
• • Macrolides (Azithromycin, Clarithromycin, Erythromycin)
• • Chloramphenicol
• • Clindamycin
• • Linezolid
• • Streptogramins
• - Quinuristin
• - Dalfopristin

• Q 4) UMN lesion causes facial nerve palsy:
• a. Contralateral upper face
• b. Contralateral lower face
• c. Ipsilateral upper face
• d. Ipsilateral lower face

Ans, B, Contralateral lower face

( Ref : Harrison 17th ed/ pg. 2487)

- Weakness of the lower two thirds of the face with preservation of upper third suggests UMN lesion, whereas weakness of an entire side suggests a LMN lesion.

• Q5) The little’s area is supplied by :
• a. Superior labial, anterior ethmoidal, greater palatine and spheno-ethmoidal arteries.
• b. Superior labial, posterior ethmoidal, greater palatine and spheno-ethmoidal arteries.
• c. Superior labial, anterior ethmoidal, lesser palatine and spheno-ethmoidal arteries.
• d. None of the above.

Ans: D, None of the above

Ref: PL Dhingra

• Explanation:
• Kiesselbach's plexus, which lies in Kiesselbach's area, Kiesselbach's triangle, or Little's area, is a region in the anteroinferior part of the nasal septum where four arteries anastomose to form a vascular plexus of that name. The arteries are:
• ● Anterior ethmoidal artery (from the ophthalmic artery)
• ● Sphenopalatine artery (terminal branch of the maxillary artery)
• ● Greater palatine artery (from the maxillary artery)
• ● Septal branch of the superior labial artery (from the facial artery)

• Q6) Which of the following condition gives the characteristic radiological finding "bone within a bone" appearance?
• a. Osteogenesisimperfecta
• b. Osteopetrosis
• c. Scurvy
• d. Rickets

Ans, B, Osteoporosis

• Reference: radiopedia.org
• Osteopetrosis also known as Albers-Schonberg disease or marble bone disease is an uncommon hereditary disorder that results from defective osteoclasts.

• Q 1) Limiting amino acids in Cereals & Pulses respectively:
• a. Lysine& Threonine
• b. Lysine& Cysteine
• c. Glycine& Methionine
• d. Lysine& Methionine

Ans, D, Lysine& Methionine

Cereal proteinsare deficient in lysine and threonine, and pulse proteins in methionine. These are known as "limiting" amino acids. Whentwo or more of vegetarian foods are eaten together (as for example, rice-dhal combination in India) their proteinssupplement one another and provide a protein comparable to animal protein in respect of EAA.

• Q 2) Which of the following is less likely correct regarding indications and use of ECT in a schizophrenic patient?
• a. Catatonia is one of the indications
• b. Used in acute exacerbation not controlled with drugs
• c. Preferred if severe side-effect with drugs occur
• d. Usually one to two ECT appointments is enough to treat the patient

Ans, D, Usually one to two ECT appointments is enough to treat the patient

• Electroconvulsive Therapy (ECT)
• Schizophrenia is not a primary indication for ECT. The indications for ECT in schizophrenia include:
• 1. Catatonic stupor.
• 2. Uncontrolled catatonic excitement.
• 3. Acute exacerbation not controlled with drugs.
• 4. Severe side-effect with drugs, in presence of untreatedschizophrenia.
• Usually 8-12 ECTs are needed (although up to 18have been given in poor responders), administered two or three times a week.

• Q 3) A complication of common cold:
• a. Otitis externa.
• b. Quinsy.
• c. Facial palsy.
• d. Maxillary sinusitis.

Ans, D, Maxillary sinusitis.

• ☆ Otitis media is a recognized complication of common cold.
• ☆ Quinsy is a recognized complication of acute tonsillitis.
• ☆ Facial palsy may be a complication of otitis media.
• ☆ Common cold is the most common cause of maxillary sinusitis.

• Q. Lateral boundary of cubital fossa is formed by?
• a. Brachioradialis
• b. Pronator teres
• c. Bicipital aponeurosis
• d. Supinator

Ans: a. Brachioradialis

• ☆ Boundaries of cubital fossa
• Laterally — medial border of the brachioradialis
• Medially — lateral border of the pronator teres. — is directed upwards, and is represented by an imaginary line joining the front of two epicondyles of the humerus.
• Apex — is directed downwards, and is formed by the meeting point of the lateral and medial boundaries.
• Roof:
• The roof of the cubital fossa is formed by: (a) Skin (b) superficial fascia containing the median cubital vein, the lateral cutaneous nerve of the forearm and the medial cutaneous of the forearm (c)deep fascia. (d) bicipital aponeurosis.
• Floor:
• It is formed by: (i) the brachialis and (ii) the supinator muscles

• Q. Injury to which part of the brachial plexus cause Erb's Paralysis?
• a. Root
• b. Upper trunk
• c. Lower trunk
• d. Posterior cord

Ans: b. Upper trunk

• Erb's Paralysis
• Site of injury :The region of the upper trunk of the brachial plexus is called Erb's point .Six nerves meet here. Injury to the upper trunk causes Erb's paralysis
• Causes of injury
• Undue separation of the head from the shoulder, which is commonly encountered in: (i) birth injury, (ii) fall on the shoulder, and (iii) during anaesthesia.
• Nerve roots involved
• Mainly C5 and partly C6. Muscles paralysed. Mainly biceps, deltoid, brachialis and brachioradialis. Partly supraspinatus, infraspinatus and supinator.
• Deformity (position of the limb) Arm:
• Hangs by the side; it is adducted and medially rotated. Forearm: Extended and pronated. The deformity is known as 'policeman's tip hand' or 'porter's tip hand'.
• Disability.
• The following movements are lost:
• 1 . Abduction and lateral rotation of the arm (shoulder)
• 2.Flexion and supination of the forearm.
• 3.Biceps and supinator jerks are lost.
• 4.Sensations are lost over a small area over the lower part of the deltoid.

• Q. An agent which prevents the action of an agonist on a receptor or the subsequent response, but does not have any effect of its own is called:
• a. Agonist
• b. Inverse agonist
• c. Antagonist
• d. Partial antagonist

Ans: c. Antagonist

• The following terms are used in describing drug-receptor interaction:
• Agonist : An agent which activates a receptor to produce an effect similar to that of the physiological signal molecule.
• Inverse agonist : An agent which activates a receptor to produce an effect in the opposite direction to that of the agonist.
• Antagonist : An agent which prevents the action of an agonist on a receptor or the subsequent response, but does not have any effect of its own.
• Partial agonist : An agent which activates a receptor to produce submaximal effect but antagonizes the action of a full agonist.
• Ligand : Any molecule which attaches selectively to particular receptors or sites.

• Q1. Depth perception and colour vision develops by age of:
• a.2 weeks
• b.1-2months
• c.3-4 months
• d.5-6 months

Ans: d, 5-6 months

• Q2.cANCAis associated with:
• a.Microscopic polyangitis
• b.Wegners granulomatosis
• c.SLE
• d.Polyarteritis nodusa

Ans: b, Wegners granulomatosis

• Q3. Pseudomembranous colitis is caused by
• a.Metronidazole
• b.Oral vancomycin
• c.Clindamycin
• d.All of the above

Ans: c, Clindamycin

• Clostridium difficile
• • Produces toxins A and B, which damage enterocytes. Both toxins lead to watery diarrhea= pseudomembranous colitis.Often 2° to antibiotic use, especially clindamycin or ampicillin; associated with PPIs.
• • Diagnosed by PCR or antigen detection of one or both toxins in stool.
• • Complications: toxic megacolon.
• • Treatment: oral vancomycin, metronidazole, or fidaxomicin. For recurrent cases, consider repeating prior regimen or fecal microbiota transplant.

• 1.Which of the following is not a risk factor for Carcinoma endometrium?
• a. Family history
• b. Early menopause
• c. Obesity
• d. Use of HRT

Ans.B Early menopause

• The following are found to be related to carcinoma endometrium
• • Estrogen—Persistent stimulation of endometrium with unopposed estrogen is the single most important factor for the development of endometrial cancer.
• • Age—About 75 percent are postmenopausal with a median age of 60 (c.f. Carcinoma cervix is more common in perimenopausal period). About 10 percent of women with postmenopausal bleeding have endometrial cancer.
• • Parity—It is quite common in unmarried and in married, nulliparity is associated in about 30 percent. (c.f. – Carcinoma cervix is associate more with multiparae).
• • Late menopause—The chance of carcinom increases, if menopause fails to occur beyond 52 years.
• • Corpus cancer syndrome — encompasses –obesity, hypertension and diabetes.
• • Obesity leads to high level of free estradiol as the sex hormone binding globulin level is low.
• • Unopposed estrogen stimulation in conditions such as functioning ovarian tumors (granulosa cell) or polycystic ovarian syndrome (PCOS) is associated with increased risk of endometrial cancer. Unopposed estrogen replacement therapy in postmenopausal women is associated with increased risk of endometrial cancer. Use of cyclic progestin reduces the risk. Prior use of combined oral contraceptives reduces the risk significantly (50%). Tamoxifen is antiestrogenic as well as weakly estrogenic. It is used for the treatment of breast cancer. Increased risk of endometrial cancer is noted when it is used for a long time due to its weak estrogenic effect. Family history or personal history of colon, ovarian or breast cancer increases the risk of endometrial cancer. Genetic inheritance (Lynch 11 syndrome family) is currently thought of. Fibroid is associated in about 30 percent cases. Endometrial hyperplasia precedes carcinoma in about 25 percent cases.

• 2.An 80-year-old female who has never taken estrogen,develops pink vaginal discharge. An endometrial biopsy shows an adenocarcinoma of the endometrium. Papanicolaou smear is negative. Of the following what is the most important indicator of prognosis?
• a. Body habitus
• b. Level of CA – 125
• c. Nutritional status
• d. Histologic type of tumour

Ans D.Histologic type of tumor

• Prognosis of endometrial carcinoma:
• The poorly differentiated tumor, the greater degree of myometrial penetration, lymphovascular space invasion and the advanced stages are prognostically poor. Aneuploid tumors are prognostically worst. Histologically non-endometrioid tumors are aggressive and carry increased risk of recurrence. The prognostic factors to be considered are
• • Age at diagnosis (older the patient poorer the prognosis).
• • Stage of the disease.
• • Histologic type (typical adenocarcinomas — better prognosis, papillary serous, clear cell carcinoma — poor prognosis).
• • Histologic differentiation.
• • Histologic grade ,grade 3 tumors have 5 times more risk of recurrence and low 5 year survival rate.
• • Myometrial penetration.
• • lymphovascular space invasion.
• • lymph node metastasis.
• • extension to cervix.
• • Peritoneal cytology.
• • Tumor size (>2 cm → more lymph node metastasis).
• • Hormone receptor status (receptor positive tumors have got better prognosis).
• • Ploidy status — aneuploid tumors have got poor prognosis compared to diploid tumors.
• • oncogene expression — HeR – 2/neu, poor prognosis .

• 3.what is the further investigation required for a follicular cyst of 3cm seen in USG?
• A.CA-125
• B.Laparoscopy
• C.Repeated ultrasound in 3 to 6 months
• D.No further investigation required

Ans.D ,No further investigation

• Follicular Cysts
• Follicular cysts are the commonest functional cyst.They are usually multiple and small as seen in cases of cystic glandular hyperplasia of the endometrium or in association of fibroid. Hyperestrinism is implicated as its cause. However, an isolated cyst may be formed in unruptured Graafian follicle, which may be enlarged but usually not exceeding 5 cm. The cyst is lined by typical granulosa cells without lutein cells or the cells may be flattened due to pressure In majority of cases, the detection is made accidentally on bimanual examination, sonography, laparoscopy or laparotomy. The cyst may remain asymptomatic or may produce vague pain.Management:
• A follicular cyst < 3 cm requires no further investigations. A simple cyst, < 8 cm,unilocular, echo free without solid areas or papillary projections, with normal serum CA 125 ,should be followed up with repeat ultrasound in 3 to 6 months time.Whenever a cyst persists or grow, it should be removed by laparoscopy/laparotomy.

• Q.1 Immediate life threatening injuries of the chest include all of the following except ?
• a. Airway obstruction
• b. Pericardial tamponade
• c. Flail chest
• d. Tracheo-bronchial injuries

Ans: d, Tracheo-bronchial

• Explanation:
• The ‘deadly dozen’ threats to life from chest injury;
• Immediately life threatening
• Airway obstruction
• Tension pneumothorax
• Pericardial tamponade
• Open pneumothorax
• Massive haemothorax
• Flail chest
• Potentially life threatening
• Aortic injuries
• Tracheobronchial injuries
• Myocardial contusion
• Rupture of diaphragm
• Oesophageal injuries
• Pulmonary contusion

• Q.2 A mass like lesion on the lateral side of the neck (upper one third of sternocleidomastoid muscle) is suspected as a case of Branchial cyst? From where does this cyst develop from?
• a. First pharyngeal cleft
• b. Second pharyngeal cleft
• c. First pharyngeal arch
• d. Second pharyngeal arch

Ans:b, second pharyngeal cleft

• Explanation:
• A branchial cyst develops from the vestigial remnants of the second branchial cleft, is lined by squamous epithelium and contains thick, turbid fluid. The cyst usually presents in the upper neck in early or middle adulthood and is found at the junction of the upper third and middle third of the sternomastoid muscle at its anterior border. It is a fluctuant swelling that may transilluminate and is often soft in its early stages so that it may be difficult to palpate.

• Q.3 All are the purpose of metabolic changes following injury except?
• a. Provide essential substrates for survival
• b. Postpone anabolism
• c. Optimize host defense
• d. Postpone catabolism

Ans: d, postpone catabolism

• Explanation:
• Purpose of neuro-endocrine changes following injury
• The constellation of neuro-endocrine changes following injury acts to:
• · Provide essential substrates for survival
• · Postpone anabolism
• · Optimize host defense
• These changes may be helpful in the short term, but may be harmful in the long term, especially to the severely injured patient who would otherwise not have survived without medical intervention.

• 1. Shilling’s test is used to determine deficiency of:
• a. Vitamin B12
• b. Vitamin B6
• c. Folic Acid deficiency
• d. Vitamin D deficiency

Ans.a, Vitamin B12

• The Schilling test is a medical investigation used for patients with vitamin B12 (cobalamin) deficiency.The purpose of the test is to determine how well the patient is able to absorb B12 from their intestinal tract.
• In this test, the patient will ingest tiny amount of radioactive Vit B12.Then the blood is checked whether the patient’s body had absorbed Vit B12 or not. After that, the patient will ingest the combination of Vit B12 and intrinsic factor. If the radioactive Vit B12 is absorbed only when taken with intrinsic factor, it shows that the patient lacks intrinsic factor.

• 2.Most common nephrotic syndrome in elderly patients:
• a. Minimal change GN
• b. Membranous GN
• c. IgA nephropathy
• d. None of the above

Ans.b, Membranous GN

Membranous glomerulonephritis (MGN) , or membranous nephropathy accounts for approximately 30% of cases of nephrotic syndrome in adults, with a peak incidence between the ages of 30 and 50 years and a male to female ratio of 2:1. It is rare in childhood and the most common cause of nephritic syndrome in the elderly. In 25–30% of cases, MGN is associated with a malignancy (solid tumors of the breast, lung, colon), infection (hepatitis B, malaria, schistosomiasis), or rheumatologic disorders like lupus or rarely rheumatoid arthritis.

• 3.The most common site of intestinal obstruction in gallstone ileus is:
• a. Duodenum
• b. Jejunum
• c. Ileum
• d. Sigmoid colon

Ans.c, Ileum

Gallstone ileus refers to mechanical intestinal obstruction resulting from the passage of a large gallstone into the bowel lumen. The stone customarily enters the duodenum through a cholecystoenteric fistula at that level. The site of obstruction by the impacted gallstone is usually at the ileocecal valve, provided that the more proximal small bowel is of normal caliber. The majority of patients do not give a history of either prior biliary tract symptoms or complaints suggestive of acute cholecystitis or fistulization. Large stones, >2.5 cm in diameter, are thought to predispose to fistula formation by gradual erosion through the gallbladder fundus. Diagnostic confirmation may occasionally be found on the plain abdominal film (e.g., small-intestinal obstruction with gas in the biliary tree and a calcified, ectopic gallstone) or following an upper gastrointestinal series (cholecystoduodenal fistula with small-bowel obstruction at the ileocecal valve).

• You are a first year resident in psychiatry department of TUTH and a patient came and you assessed him as Type A personality. All are cluster A personality disorders except which one of the following?
• a. Borderline
• b. Schizoid
• c. Schizotypal
• d. Paranoid

Ans, A, Borderline

• There are three types of personality disorders which are as follows.
• Cluster A: Paranoid, Schizoid, Schizotypal
• Cluster B: Antisocial, Histrionic, Borderline, Narcissistic
• Cluster C: Dependent, Anxious/Avoidant, Obsessive compulsive

• Romana's sign occurs in
• a. Babesiosis
• b. Leishmaniasis
• c. Trypanosomiasis
• d. Schisotosomiasis

• Ans: c
• Acute chagas disease:
• .Acute phase occurs soon after infection and may last for 1- 4 months
• . lt is seen often in children under 2 years of age.
• • First sign appears within a week after invasion of parasite.
• • "Chagoma" is the typical subcutaneous lesion occurring at the site of inoculation. Inoculation of the parasite in conjunctiva causes unilateral, painless edema of periocular tissues in the eye called as Romana's sign,. This is a classical finding of the acute Chagas disease.
• • In few patients, there may be generalized infection with fever, lymphadenopathy and hepatosplenomegaly.
• • The patient may die of acute myocarditis and meningoencephalitis.
• • Usually within 4-8 weeks, acute signs and symptoms resolve spontaneously and patients, then enter the asymptomatic or indeterminate phase of chronic T. cruzi infection.

• Larval forms of which parasite can be found in muscle biopsy
• a. Ascaris lumbricoides
• b. Taenia solium
• c. Trichuris trichiura
• d. Ancylostoma duodenale

• Ans: b
• MUSCLE BIOPSY
• Spiral larval form of Trichinella spiralis, larval form of T. solium (cyslicercus cellulosae) and
• amastigote ofTrypanosoma cruzi can be demonstrated in skeletal muscle biopsy. In trichinosis, muscle biopsy (gascrocnemius, deltoid and biceps) specimen must be examined by compressing thetissue be tween two slides and checking the preparation under low-power (lOX) objective. this method doesn' t become positive until 2-3 weeks after the illness.
• Ref: Panikers textbook of medical parasitology 8th edition pg243

• Q.3The current treatment of choice for a large antrochoanal polyp in a 10-year-old is:
• a. Intranasal polypectomy
• b.Caldwell Luc operation
• c. FESS
• d. Lateral rhinotomy and excision

Ans. is c i.e. FESS

• An antrochoanal polyp is easily removed by avulsion either through the nasal or oral route.
• Recurrence is uncommon after complete removal. In cases which do recur, Caldwell–Luc operation may be required to remove the polyp completely from the site of its origin and to deal with coexistent maxillary sinusitis.
• These days, endoscopic sinus surgery has superseded other modes of polyp removal. Caldwell–Luc operation is avoided.

• Q. 2 Most common cause of upper GI bleeding is?
• a. Oesophageal varices
• b. Erosions
• c. Vascular lesions
• d. Ulcers

Ans: d

• Explanation:
• Causes of upper gastrointestinal bleeding.
• Condition %
• Ulcers 60
• Oesophageal 6
• Gastric 21
• Duodenal 33
• Erosions 26
• Oesophageal 13
• Gastric 9
• Duodenal 4
• Mallory–Weiss tear 4
• Esophageal varices 4
• Tumour 0.5
• Vascular lesions 0.5
• Others 5

• Q.1 Treatment of high grade mucoepidermoid tumor of salivary gland is?
• a. Wide local excision.
• b. Wide local excision + Regional node dissection.
• c. Wide local excision + Regional node dissection + Radiotherapy.
• d. Wide local excision + Regional node dissection + Radiotherapy + Chemotherapy.

Ans: (c) Wide local excision + Regional node dissection + Radiotherapy.

• Explanation:
• - For Low grade malignant tumors excision of the tumor with complete parotid (with clear margins) is thenaim.
• - No adjuvant chemotherapy is required.
• - For high grade cancers after generous primary excision, for clinically palpable nodes radical or modified radical neck dissection is performed followed by radiotherapy in selected group.

• What is the maximum diameter of Tardieu spots that is seen in case of asphyxia?
• a. 0.5mm
• b. 1mm
• c. 2mm
• d. 5mm

Ans, C, 2mm

Ref, The Essentials of Forensic Medicine and Toxicology, Reddy, 33rd edition, page no.141

Tardieu spots are numerous where the capillaries are least firmly supported, as in sub- conjunctival tissues and under the pleural and pericardia membranes but they can appear almost anywhere if the degree of congestion and cyanosis is sufficient. Tardieu spots are usually rounded, dark and well-defined, varying in size from a pin's head to 2 mm. They may occur as isolated minute haemorrhages or present in large numbers, and at times fuse to form patches of red colour, especially at the back of the heart.

What is the correct sequence of stages of overcoming addiction?

• a. Contemplation, pre-contemplation, action, preparation, maintenance, relapse
• b. Preparation, pre-contemplation, contemplation, action, maintenance, relapse
• c. Pre-contemplation, contemplation, preparation, action, maintenance, relapse
• d. Pre-contemplation, contemplation, action, preparation, maintenance, relapse

Ans, C, Pre-contemplation, contemplation, preparation, action, maintenance, relapse

Ref. FA, USMLE step 1, 2020, Page no.568

• Stages of change in overcoming addiction
• i. Pre-contemplation—denying problem
• ii. Contemplation—acknowledging problem, but unwilling to change
• iii. Preparation/determination—preparing for behavioral changes
• iv. Action/willpower—changing behaviors
• v. Maintenance—maintaining changes
• vi. Relapse—(if applicable) returning to old behaviors and abandoning changes

• Elfin facies are seen in:
• a.Down syndrome
• b.William syndrome
• c.Mucopolysaccharidosis
• d.Cushing syndrome

• Ans : b
• .Mongoloid/Down facies
• Upward slant of eyes, epicanthic folds,
• hypertelorism, flattened nasal bridge,
• protuberant tongue.
• • Elfin facies
• Upromed nose, broad upper lip, small mandible, prominent maxilla, short statute.
• • Moon/steroid/cushingoid facies
• Rounded face, chubby and puffy look, double chin, hitsutism.
• • Hemolytic facies
• Pallor, malar prominence, frontal bossing, depressed nasal bridge.
• • Risus sa;dooicus
• Due to spasm of the platysma muscle, the
• cornets of the mouth move downwards and outwards, the lip is stretched across the incisor teeth.
• • Coarse facies
• Dry skin, thick tongue, thickened facial outlines
• • Potter facies
• Suborbital creases, depressed nasal tip, low set ears, retrognathia, associated with positional defonmities of limbs, like clubfeet.
• Ref:Clinical Methods in pediatrics 4th ed pg 186

• Q.1 Heineke–Mikulicz principle to ‘lengthen’ the frenulum is used in?
• a. Frenulum breve
• b. Paraphimosis
• c. Phimosis
• d. Peyronie´s disease
• Ans: a
• Explanation:
• Frenulum breve
• Phimosis should not be confused with this condition, where the frenulum is short, such that it causes pain when the fore-skin is retracted. Another possible presentation is tearing of the frenulum during sexual activity. Treatment is by frenu-loplasty, which utilises the Heineke–Mikulicz principle to ‘lengthen’ the frenulum.
• Ref: Bailey and love 27th edition , Pg no.1489

• Q.2 The adult prevalence of visible varicose veins is?
• a. 10-20%
• b. 20-30%
• c. 30-50%
• d. 50-60%
• Ans: c
• Explanation:
• The adult prevalence of visible varicose veins is between 30% and 50%. Factors affecting prevalence include:
• ● Gender: the vast majority of studies report a higher preva-lence in women than men, though community prevalence may differ.
• ● Age: the prevalence of varicose veins increases with age.
• In the Edinburgh Vein study, the prevalence of trunk vari-cosities in the age groups 18–24 years, 25–34 years, 35–44 years, 45–57 years and 55–64 years was 11.5%, 14.6%, 28.8%, 41.9% and 55.7%, respectively.
• ● Ethnicity: does seem to inf l uence the prevalence of vari-cose veins.
• ● Body mass and height: increasing body mass index and height may be associated with a higher prevalence of vari-cose veins.
• ● Pregnancy: increases the risk of varicose veins.
• ● Family history: evidence supports familial susceptibility to varicose veins.
• ● Occupation and lifestyle factors: there is inconclusive evi-dence regarding increased prevalence of varicose veins in smokers, patients who suffer constipation and occupations that involve prolonged standing.
• Ref: Bailey and love 27th edition, Pg no. 975

Secretory proteins are synthesized in

• a) First in cytoplasm and then in endoplasmic reticulum
• b) First in endoplasmic reticulum and then in cytoplasm
• c) Endoplasmic reticulum
• d) Cytoplasm

Ans, C, Endoplasmic reticulum

Ref, Harper’s Biochemistry, 26th edition, page no. 498-502

• The proteins which are meant to be transported or secreted are synthesized in ribosomes attached to the endoplasmic reticulum. But, proteins which have to be delivered in the cytosol are synthesized in free polyribosomes in cytosol.
• The secretory proteins and transport proteins contain signal peptides, which helps them to be transported into Golgi apparatus via endoplasmic reticulum.
• Golgi body is the organelle where sorting of proteins for their respective destination occurs. The proteins which enter the Golgi apparatus are segregated into two types when they reach the exit side of the Golgi apparatus. These two types are-
• i. Transport proteins- they are destined for plasma membrane. They are stored in transport vesicles and are secreted in constitutive manner.
• ii. Secretory proteins- They are destined for secretion and are stored in secretory vesicles.

• Bullet which is left in the body for very long time is known as?
• a) Tandem bullet
• b) War bullet
• c) Souvenir bullet
• d) Tracer bullet

Ans, C, Souvenir bullet

Ref, SK Singhal’s Forensics, 4th edition, page no. 188

• Types of bullet:
• i. Tandem bullet/piggy tail bullet: Bullet not released on first fire comes out with second bullet on second shot.
• ii. Souvenir bullet: Bullet which is left in the body for long.
• iii. Tracer bullet: Bullet that leaves a visible mark in path that a person can see
• iv. Ricocheting bullet:Bullet deviated from its path after coming in contact with a surface.

• Q.1 During repair of hernia using mesh, position of mesh can be?
• a. Just outside the muscle in the subcutaneous space.
• b. Between fascial layers in the abdominal wall.
• c. Immediately extraperitoneally, against muscle or fascia (also sublay).
• d. Any of the above.

• Ans: d
• Explanation:
• Positioning the mesh
• The strength of a mesh repair depends on host–tissue in-growth. Meshes should be placed on a firm, well vascularised tissue bed with generous overlap of the defect.
• The mesh can be placed:
• • Just outside the muscle in the subcutaneous space (onlay);
• • Within the defect (inlay) – only applies to mesh plugs in small defects;
• • Between fascial layers in the abdominal wall (intraparietal or sublay);
• • Immediately extraperitoneally, against muscle or fascia (also sublay);
• • Intraperitoneally.
• At open surgery all of these planes are used but laparoscopic surgeons currently use only intraperitoneal or extraperitoneal planes.
• Ref: Bailey and love 27th edition

• Q.3 To see the tympanic membrane, pinna has to be pulled?
• a. Upward, backward and laterally
• b. Upward, backward and medially
• c. Downward, backward and laterally
• d. Downward, front and laterally

• Ans: a
• Explanation: EAC is not a straight tube; its outer part is directed upwards, backwards and medially while its inner part is directed downwards, forwards and medially. Therefore, to see the tympanic membrane, the pinna has to be pulled upwards, backwards and laterally so as to bring the two parts in alignment.
• Ref: Diseases of ear, nose and throat and head and neck surgery, PL Dhingra,6th edition, Pg,no.2

• 1. The presence of nitrates in water indicates:
• A. Temporary hardness of water
• B. Permanent hardness of water
• C. Fresh faecal pollution
• D. Past faecal pollution

Ans: D. Past faecal pollution

Faecal and animal wastes products containing inorganic nitrogen and organic nitrogen are first decomposed to give ammonia, which is then oxidized to nitrite and nitrate later on.

• 2. Threshold radiation dose for haematological syndrome is?
• A. 1 Gy
• B. 5 Gy
• C. 25 Gy
• D. 50 Gy

Ans: A. 1 Gy

Threshold radiation of acute radiation syndromes:

• Hematological syndrome - 1Gy
• Gastrointestinal syndrome - 5Gy
• CNS syndrome - 20Gy

• 3. Which ONE of the following is not an endogenous mediator of increased vascular permeability?
• A. Angiotensin
• B. C3a and C5a
• C. 5-hydroxytryptamine
• D. Kallikrein9.

Ans: A. Angiotensin

☆ Angiotensin is produced by the action of renin on angiotensinogen and is involved in the secretion of aldosterone and in pressor effects.

• ☆ C3a and C5a (B) are part of the complement cascade and are activated C3 and C5;
• they act by liberating histamine from mast cells.

☆ 5-hydroxytryptamine(C)or serotonin causes increased vascular permeability in rodents but not in man.

☆ Kallikrein (D) is produced by the activation of Hageman factor (factor XII) producing prekallikrein activator which converts prekallikrein to kallikrein.

• 1. A patient is treated for a skin disease. Grattage test is seen when examined. Which is the disease?
• a) Psoriasis
• b) Erythema multiforme
• c) Lichen planus
• d) Tinea corporis

Ans, A

• Various bed side tests and signs are associated with psoriasis. They are as follows:
• i. Grattage test: scraping of psoriasis lesion causes accentuation of silvery scales, due to trapping of air.
• ii. Auspitz’s sign: scraping of psoriasis lesion causes accentuation of silvery scales but on continuing further, a glistening white membrane, punctate (pin-point) bleeding becomes visible, referred to as auspitz’s sign.
• iii. Woronoff’s ring: Occasionally a hypopigmented ring is seen surrounding the lesion, known as woronoff’s ring. Mostly associated with topical steroids.

• 2. Filigree burn is seen in
• a) Electrocution
• b) Lightning
• c) Fire
• d) Heat stroke

Ans, B, Lightning

Lightning strike causes arborescent or filigree burns or lichtenberg’s flowers which are superficial, thin, irregular and tortuous markings on the skin resembling the branches of a tree.

• 3. A patient comes to office with visual hallucinations. Which of the following is more likely cause?
• a) Depression
• b) Epilepsy
• c) Schizophrenia
• d) Drug intoxication

Ans, D, Drug intoxication

Ref. FA, USMLE step 1, 2018, Page no. 543

• Hallucinations Perceptions in the absence of external stimuli (eg, seeing a light that is not actually present). Contrast with illusions, misperceptions of real external stimuli. Types include:
• Visual – It is more commonly a feature of medical illness (e.g., drug intoxication) than psychiatric illness.
• Auditory—more commonly a feature of psychiatric illness (eg, schizophrenia) than medical illness.
• Olfactory—often occur as an aura of temporal lobe epilepsy (e.g., burning rubber) and in brain tumors.
• Gustatory—rare, but seen in epilepsy.
• Tactile—common in alcohol withdrawal and stimulant use (e.g., cocaine, amphetamines), delusional parasitosis, “cocaine crawlies.”
• Hypnagogic—occurs while going to sleep. Sometimes seen in narcolepsy.
• Hypnopompic—occurs while waking from sleep (“pompous upon awakening”). Sometimes seen in narcolepsy.

• Which of the following is the most common drug induced skin reaction?
• a) Papular rash
• b) Fixed drug eruption
• c) Morbilliform rash
• d) Photosentivity reaction

Ans, C, Morbiliform rash

Ref, Harrison’s Internal medicine, 18th edition, Chapter 55

• Morbilliform or maculopapular eruptions are the most common of all drug induced reactions, often start on the trunk or intertriginous areas, and consist of erythematous macules and papules that are frequently symmetric and may become confluent.
• Delayed hypersensitivity directed by drug specific T cells is probably the most important mechanism in the etiology of the most common drug eruptions, “morbilliform” (measles like) eruptions, and also of rare and severe forms such as hypersensitivity syndrome, acute generalized exanthematous pustulosis, Stevens Johnson syndrome and toxic epidermal necrolysis.

Eg. Penicillins, sulfonamides, phenytoin or gold will develop a maculopapular ruption.

Stapes footplate covers:

A. Round window.

B. Oval window.

C. Sinus tympani.

D. Aditus ad antrum.

Ans:B

The footplate of the stapes helps with hearing. The stapes bone notifies the ovalwindow when movement occurs. The stapes footplate proceeds into the oval window, sending the round window membrane out, allowing for the fluid in the cochlea to move, which leads to the cochlear inner hair cells’ movement, and finally, hearing.

• Retention of urine in Fowler´s syndrome is best treated by?
• a. Intermittent self catheterization
• b. Urethral dilatation
• c. Urethroplasty
• d. None

• Ans: a
• Explanation:
• Fowler’s syndrome
• This idiopathic condition, which was described by Fowler and Kirby, is associated with an abnormal myotonic discharge in the striated urethral sphincter that can be detected by sphincter electromyography. It is often associated with polycystic ovaries and causes urinary retention in women and should not be confused with a urethral stricture. Urethral dilatation is ineffective and the retention is best treated by intermittent self-catheterisation. There is some evidence that sacral neuro-modulation can be effective.
• Ref: Bailey and love 27th edition, Pg no.1485

• 1. A 13-year-old boy has been drinking large quantities of fluids and has an insatiable appetite. He is losing weight and has become more tired and listless for the past month. Laboratory findings include normal CBC and fasting serum glucose of 175 mg/dL. His parents, two brothers, and one sister are healthy. A maternal uncle is also affected. Which of the following is the probable inheritance pattern of his disease?
• a. Autosomal dominant
• b. Autosomal recessive
• c. Mitochondrial DNA
• d. Multifactorial

Ans: d

Type 1 diabetes mellitus has an increased frequency in some families, but the exact mechanism of inheritance is unknown. The risk is increased for offspring when first-order relatives are affected. HLA-linked genes and other genetic loci and environmental factors are considered important. This pat¬tern of inheritance is multifactorial. The other listed inheritance patterns are not seen with most cases of diabetes mellitus.

• 2. A 5-year-old child is exposed to Mycobacterium tubercu¬losis. A month later the child’s tuberculin skin test is positive. The child then develops fever, inspiratory stridor, and non¬productive cough. Which of the following findings is most likely to be present on the chest radiograph of this child?
• a. Hilar lymphadenopathy
• b. Miliary pulmonary nodules
• c. Pneumonic consolidation
• d. Upper lobe cavitation

Ans: a

• • The child has primary tuberculosis. Most healthy per¬sons have subclinical disease, and a minority develop clini¬cal manifestations; of those, most have limited pulmonary involvement without dissemination.
• • Primary tuberculosis is marked by the Ghon complex, which is a small subpleural granuloma at mid-lung along with prominent enlarged hilar lymph nodes. These nodes may impinge upon central airways. When the cell-mediated immune response is poor, then there can be numerous small granulomas scattered throughout the lungs, or disseminated to other organs, as a miliary pattern (granulomas that are the size of millet seeds).
• • Progressive pri¬mary tuberculosis can lead to more extensive lung involve¬ment with pneumonic infiltrates.
• • Upper lobe cavitary disease is characteristic for secondary tuberculosis (reactivation or reinfection) in persons who have previously mounted an im¬mune response.

• 3. Platelet aggregation is inhibited by all except:
• a. Aspirin
• b. Clopidogrel
• c. Thromboxane A2
• d. Eptifibatide

Ans: c

• Antiplatelet Drugs
• • Aspirin
• • Dipyridamole
• • Ticlopidine
• • Abciximab
• • Clopidogrel
• • Eptifibatide
• • Prasugrel
• • Tirofiban

• 4. Which drug is given in delayed vomiting after chemotherapy:
• a. Metoclopramide
• b. Hyoscine
• c. Domperidone
• d. Aprepitant

Ans: d

• Aprepitant
• • Selective, high affinity NK1 receptor antagonist that blocks the emetic action of substance P, with little effect on 5 HT3 and D2 or other receptors.
• • Gastrointestinal motility is not affected.
• • Oral aprepitant (125 mg + 80 mg + 80 mg over 3 days) combined with standard i.v. ondansetron + dexamethasone regimen significantly enhanced the antiemetic efficacy against high emetogenic cisplatin based chemotherapy.
• • Greater additional protection was afforded against delayed vomiting than against acute vomiting.
• • It was particularly useful in patients undergoing multiple cycles of chemotherapy.
• • Adjuvant benefit of aprepitant has also been demonstrated in cyclophosphamide based moderately emetogenic chemotherapy.

• The active form of Remdesivir, drug under clinical trial for treatment of COVID 19, is:
• a. GC-376
• b. GS-441524
• c. B-5701
• d. GS-5734

• Ans: b
• Ref: Agostini ML, Andres EL, Sims AC, Graham RL, Sheahan TP, Lu X, et al. (March 2018). "Coronavirus Susceptibility to the Antiviral Remdesivir (GS-5734) Is Mediated by the Viral Polymerase and the Proofreading Exoribonuclease
• • Remdesivir is a prodrug that metabolizes into its active form GS-441524.
• • An adenosine nucleotide analog, GS-441524 interferes with the action of viral RNA-dependent RNA polymerase and evades proofreading by viral exoribonuclease (ExoN), causing a decrease in viral RNA production.
• • Though in some viruses, such as the respiratory syncytial virus but not Ebola virus, it causes the RNA-dependent RNA polymerases to pause, its predominant effect is to induce an irreversible chain termination.
• • Unlike with many other chain terminators, this was not mediated by preventing addition of the immediately subsequent nucleotide, but is instead delayed, occurring after five additional bases have been added to growing RNA chain.
• • During 2020, several clinical trials were underway. The first placebo controlled trial of Remdesivir in China, according to a WHO report that was published early in error, showed that Remdesivir had no clinical or virological benefits, and the drug was stopped early in 11.6% of patients due to adverse effects. In the large industry sponsored study for Remdesivir, for severe COVID-19, the trial was modified, mid trial, increasing in size from 400 subjects to 2,400 participants. The primary end point of the trial was also changed during the trial.

• Deep Brain Stimulation done for Parkinson’s disease primarily targets
• a. Globus Pallidus internus
• b. Globus Pallidus externus
• c. Substantia Nigra compacta
• d. Substantia nigra reticulata

Ans: a

• • DBS for PD primarily targets the STN or the GPi. It provides dramatic results, particularly with respect to tremor and reducing both “off” time and dyskinesias, but does not provide superior clinical benefits or improve features that do not respond to levodopa such as freezing, falling, and dementia.
• • The procedure is thus primarily indicated for patients who suffer disability resulting from severe tremor, or levodopa-induced motor complications that cannot be satisfactorily controlled with drug manipulation. In such patients, DBS has been shown to provide benefits in comparison to best medical therapy.
• • Recent studies indicate that benefits following DBS of the STN and GPi are comparable, but that GPi stimulation may be associated with a reduced frequency of depression. Although not all PD patients are candidates, the procedure can be profoundly beneficial for many.

• Mantle cell lymphoma are positive for all except:
• a. CD 23
• b. CD 5
• c. CD 43
• d. CD 20

Ans: a

• • Almost all tumors have an (11;14) translocation that fuses the cyclin D1 gene to the IgH locus. This translocation leads to over expression of cyclin D1, which you will recall stimulates growth by promoting the progression of cells from the G1 phase to the S phase of the cell cycle.
• • The tumor cells express surface IgM and IgD, the B cell antigen CD20, and CD5, and they contain high levels of cyclin D1 protein.

• Achondroplasia is caused by point mutation of:
• a. TCIRG1
• b. Mutation in the genes that encode the α1 and α2 chains
• c. carbonic anhydrase 2
• d. FGFR3

Ans: d

• • Mutation in the genes that encode the α1 and α2 chains : Osteogenesis Imperfecta
• • TCIRG1 and carbonic anhydrase 2 mutation : Osteopetrosis
• • FGFR3 mutation : Achondroplasia and Thanatophoric Dysplasia

• Meniere’s disease is characterized by:
• a. Conductive hearing loss and tinnitus
• b. Vertigo ear discharge tinnitus and headache
• c. Vertigo, tinnitus hearing loss and headache
• d. Vertigo, tinnitus and hearing loss

Ans: c > d

• Cardinal symptoms of Ménière’s disease are
• (i) episodic vertigo
• (ii) fluctuating hearing loss
• (iii) tinnitus and
• (iv) sense of fullness or pressure in the involved ear.
• It is concluded that Ménière’s disease is associated with headache that can be handicapping, and tricyclic antidepressants with pain alleviating medication is often needed to treat the headache in MD whereas sumatriptan did not alleviate the headache of the non-migraine patients.

• • The corpus luteum continues to grow and forms the corpus luteum of pregnancy (corpus luteum graviditatis).
• • By the end of the third month, this structure may be one third to one half of the total size of the ovary.
• • Yellowish luteal cells continue to secrete progesterone until the end of the fourth month; thereafter, they regress slowly as secretion of progesterone by the trophoblastic component of the placenta becomes adequate for maintenance of pregnancy.
• • Removal of the corpus luteum of pregnancy before the fourth month usually leads to abortion.

• 1. Which of the following is important in patient-centered communication?
• a. Empathy
• b. Sympathy
• c. Kindness
• d. Attitude

• Ans: a
• Patient-centered communication is critical to good patient care. Patient-centered communication drives treatment planning through the transmission of information and provides a therapeutic and supportive environment for the patient. Empathy is of particular importance in effective patient-centered communication.
• A nurse’s ability to recognize patients’ empathic opportunities and respond to a patient empathically, communicating a desire to understand, can help patients understand and cope effectively with their illnesses.

• 2. Inferior thyroid vein drains into:
• a. External jugular vein
• b. Internal jugular vein
• c. Inferior venacava
• d. Brachiocephalic vein

Ans: d

• • The venous drainage of the thyroid gland is usually via superior, middle and inferior thyroid veins.The superior thyroid vein emerges from the upper part of the gland and runs with the superior thyroid artery towards the carotid sheath; it drains into the internal jugular vein.
• • The middle thyroid vein collects blood from the lower part of the gland; it emerges from the lateral surface of the gland and drains into the internal jugular vein. The inferior thyroid veins arise in a glandular venous plexus, which also connects with the middle and superior thyroid veins. These veins form a pretracheal plexus, from which the left inferior vein descends to join the left brachiocephalic vein, and the right descends obliquely across the brachiocephalic artery to join the right brachiocephalic vein at its junction with the superior vena cava.
• • The inferior thyroid veins often open via a common trunk into the superior vena cava or left brachiocephalic vein. They drain the oesophageal, tracheal and inferior laryngeal veins and have valves at their terminations.

• 3. Transient tachypnea of the newborn develops in:
• a. Term baby by spontaneous vaginal delivery
• b. Term baby by forceps
• c. Term baby by cesarean section
• d. Preterm with ventouse

Ans: c

• • Transient tachypnea is most common after term cesarean delivery.
• • It is characterized by the early onset of tachypnea, sometimes with retractions, or expiratory grunting and, occasionally, cyanosis that is relieved by minimal oxygen supplementation (<40%).
• • Most infants recover rapidly, usually within 3 days.
• • The chest generally sounds clear without crackles or wheeze, and the chest radiograph shows prominent pulmonary vascular markings, fluid in the intralobar fissures, overaeration, flat diaphragms, and, rarely, small pleural effusions.
• TTN (wet lung syndrome) is a clinical diagnosis. It is caused by a delayed resorption of intrauterine pulmonary liquids.
• Normally, pulmonary fluids are cleared by:
• • Bronchial squeezing during delivery, 30%
• • Absorption, 30%: lymphatics, capillaries
• • Suction, 30%

• 4. A 6-year-old boy is brought to the emergency department by his mother due to swelling around his eyes and legs. The mother reports that the patient recently recovered from an upper respiratory tract infection. Physical exam is significant for periorbital and lower extremity edema. Laboratory testing is significant for hypoalbuminemia and normal complement levels. Urinalysis demonstrates 4+ protein. Which of the following is false about the disease the children might have been suffering?
• a. Known as nil lesion
• b. Commonest cause of nephrotic syndrome in adults
• c. Acellular urinary sediment
• d. Selective proteinuria

Ans: b

Minimal change disease (MCD), sometimes known as nil lesion, causes 70–90% of nephrotic syndrome in childhood but only 10–15% of nephrotic syndrome in adults. Minimal change disease usually presents as a primary renal disease but can be associated with several other conditions, including Hodgkin’s disease, allergies, or use of nonsteroidal anti-inflammatory agents; significant interstitial nephritis often accompanies cases associated with nonsteroidal drug use.

• Coarse facies, hepatosplenomegaly and cloudy cornea are characteristic feature of:
• a. Morquio syndrome A
• b. Hurler’s disease
• c. Hunters disease
• d. Natowicz syndrome

Ans: B

• • Hurler disease: Mental retardation, coarse facial features, hepatosplenomegaly, cloudy cornea
• • Hunter disease: Mental retardation
• • Morquio syndrome A : Skeletal dysplasia, short stature
• • Natowicz syndrome: Joint pain, short stature

• A female neonate on 10th day presented with vaginal bleeding. What would be the next step of management?
• a. Estrogen
• b. Progesterone
• c. OCP
• d. Reassurance and do nothing

• Ans: d
• Ref: Dutta’s Textbook of Gynaecology including Contraception, 6th edition, page 543
• • Bleeding per vaginum (mostly blood stained to frank bleeding at times) usually occurs in newborns within 10 days following birth.
• • It occurs due to decline in level of estrogen, which is unable to support the endometrium, resulting in withdrawal bleeding.
• • There is no cause for concern and patient party can be simply reassured.

• Pilon fracture is:
• a. Avulsion fracture of lateral tibial condyle; associated with ACL injury
• b. Intraarticular fracture of tibial condyle
• c. Intraarticular comminuted distal tibia fracture
• d. Salter-Harris III of lateral distal tibia (because of later epiphyseal fusion)

• Ans: c
• Ref: Apley’s Orthopedics, 9th Edition; Page No: 916
• PILON FRACTURES
• Unlike the twisting injuries that cause the common ankle fractures, this injury to the ankle joint occurs when a large force drives the talus upwards against the tibial plafond, like a pestle (pilon) being struck into a mortar. There is considerable damage to the articular cartilage and the subchondral bone may be broken into several pieces; in severe cases, the comminution extends some way up the shaft of the tibia.

• • Segond: Avulsion fracture of lateral tibial condyle; associated with ACL injury
• • Bumper: Intraarticular fracture of tibial condyle
• • Pilon: Intraarticular comminuted distal tibia fracture
• • Tillaux: Salter-Harris III of lateral distal tibia (because of later epiphyseal fusion)
• • Triplane: Salter III/IV fracture of distal tibia

• 1. Which of the following is not correct about treatment of sunburn?
• a. Calamine lotion
• b. Topical steroid
• c. Allylamines
• d. NSAIDs

• Ans, C, Allylamines
• Ref, Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases, Neena Khanna, 4th edition, page no.192, 193
• Allylamines are antifungals, eg, Terbinafine.

• Sunburn
• Cause:
• Action spectrum: UVB which induces release of cytokines in skin, resulting in pain, redness, erythema edema and even blistering.
• Skin type: Most frequent and intense in individuals who are skin type I and II.
• Clinical features:
• • Seen in light skinned.
• • Areas overexposed to UVR become painful and deeply erythematous after several hours.
• • Redness peaks at 24 h and subsides over next 48–72 h, followed by sheet-like peeling of skin and then hyperpigmentation

• Treatment
• Prevention
• • Avoiding overexposure to sun (e.g., sunbathing), especially by light-skinned individuals.
• • Using protective clothing and sun shades.
• • Using UVB protective sunscreens.
• Symptomatic treatment
• • Calamine lotion provides comfort.
• • Topical steroids help, if used early.
• Nonsteroidal anti-inflammatory drugs like aspirin not only relieve pain but also the inflammation.

• 2. A 45 years old male comes with complains of very salty-tasting skin, persistent coughing, at times with phlegm, frequent past lung infections including pneumonia and bronchitis, frequent greasy, bulky stools and difficulty with bowel movements and infertility. This is typical of cystic fibrosis. What is the position of amino acid in the protein determined by CFTR gene mutated that caused this condition in the patient?
• a. 308
• b. 408
• c. 508
• d. 608

• Ans: C, 508
• Ref, Ganong’s Review of Medical Physiology, 26th edition, page no. 612
• Cystic Fibrosis
• • Among whites, cystic fibrosis is one of the most common genetic disorders; greater than 3% of the United States popula¬tion are carriers for this autosomal recessive disease.
• • The gene that is abnormal in cystic fibrosis is located on the long arm of chromosome 7 and encodes the cystic fibro¬sis transmembrane conductance regulator (CFTR), a regu¬lated Cl– channel located on the apical membrane of various secretory and absorptive epithelia.
• • The number of reported mutations in the CFTR gene that cause cystic fibrosis is large (> 1000) and the mutations are now grouped into five classes (I–V) based on their effects on cellular function.
• 1. Class I muta¬tions do not allow for synthesis of the protein.
• 2. Class II muta¬tions have protein processing defects.
• 3. Class III mutations have a block in their channel regulation.
• 4. Class IV mutations display altered conductance of the ion channel.
• 5. Class V mutations display reduced synthesis of the protein.
• The most common mutation causing cystic fibrosis is loss of the phenylalanine residue at amino acid position 508 of the pro¬tein (ΔF508), a Class II mutation that limits the amount of CFTR protein that gets to the plasma membrane.

• 3. You come across with a patient who says he wants to wear pink t-shirts, tight pants and female inner garments. He feels sexually aroused on doing so. What type of paraphilia does this patient seems to show?
• a. Exhibitionism
• b. Fetishistic transvestism
• c. Voyeurism
• d. Frotteurism

• Ans: B, Fetishistic transvestism
• Ref, A Short Textbook of Psychiatry, Niraj Ahuja, 7th edition, page no. 124-126
• Paraphilias (sexual deviations; perversions) are disorders of sexual preference in which sexual arousal occurs persistently and significantly in response to objects which are not a part of normal sexual arousal (e.g. nonhuman objects; suffering or humiliation of self and/or sexual partner; children or nonconsenting person). They are as follows:
• 1. Fetishism: In fetishism, the sexual arousal occurs either solely or predominantly with a nonliving object, which is usually intimately associated with the human body.
• 2. Fetishistic Transvestism: This disorder occurs exclusively in heterosexual males. The person actually or in fantasy wears clothes of the opposite sex (cross-dressing) for sexual arousal.
• 3. Sexual Sadism: In this disorder, the person (the ‘sadist’) is sexually aroused by physical and/or psycho logical humiliation, suffering or injury of the sexual partner (the ‘victim’).
• 4. Sexual Masochism: This is just the reverse of sexual sadism. Here the person (the ‘masochist’) is sexually aroused by physical and/or psychological humiliation, suffering or injury inflicted on self by others (usually ‘sadists’).
• 5. Exhibitionism: Exhibitionism is a persistent (or recurrent) and significant method of sexual arousal by the exposure of one’s genitalia to an unsuspecting stranger.
• 6. Voyeurism: This is a persistent or recurrent tendency to observe unsuspecting persons (usually of the other sex) naked, disrobing or engaged in sexual activity.
• 7. Frotteurism: This is a persistent or recurrent involvement in the act of touching and rubbing against an unsuspecting, nonconsenting person (usually of the other sex).
• 8. Paedophilia: Paedophilia is a persistent or recurrent involvement of an adult (age >16 years and at least 5 years older than the child) in sexual activity with prepubertal children, either heterosexual or homosexual.
• 9. Zoophilia (Bestiality): Zoophilia as a persistent and signifi cant involvement in sexual activity with animals is rare.
• Other Paraphilias: These include sexual arousal with urine (urophilia); faeces (coprophilia); enemas (klismaphilia); corpses (necrophilia), among many others.

• 1. The arteries supplying the pelvic part of ureter in a female includes all except
• a. Renal artery
• b. Vesical artery
• c. Middle rectal artery
• d. Uterine artery

Ans, A

• The ureter is supplied by three sets of long arteries:
• 1. The upper part receives branches from the renal artery. It may also receive branches from the gonadal, or colic vessels.
• 2. The middle part receives branches from the aorta. It may also receive branches from the gonadal, or iliac vessels.
• 3. The pelvic part is supplied by branches from the vesical, middle rectal, or uterine vessels

• 2. The resistance to isoniazid is associated with
• a. inhA gene
• b. katG gene
• c. ahpC gene
• d. All of the above

Ans, D

Resistance to isoniazid is associated with mutations resulting in overexpression of inhA, which encodes an NADH-dependent acyl carrier protein reductase; mutation or deletion of the katG gene; promoter mutations resulting in overexpression of ahpC, a gene involved in protection of the cell from oxidative stress; and mutations in kasA.

• 3. Which of the following is the protein complex II of the respiratory chain?
• a. NADH-Q oxidoreductase
• b. Cytochrome c oxidase
• c. Q-cytochrome c oxidoreductase
• d. Succinate-Q reductase

Ans, D

Components of the Respiratory Chain Are Contained in Four Large Protein Complexes Embedded in the Inner Mitochondrial Membrane

Electrons flow through the respiratory chain through a redox span of 1.1 V from NAD+/NADH to O2/2H2O, passing through three large protein complexes:

• ❖ NADH-Q oxidoreductase (Complex I), where electrons are transferred from NADH to coenzyme Q (Q) (also called ubiquinone)
• ❖ Q-cytochrome c oxidoreductase (Complex III), which passes the electrons on to cytochrome c; and

❖ Cytochrome c oxidase (Complex IV), which completes the chain, passing the electrons to O2 and causing it to be reduced to H2O.

• ❖ Some substrates with more positive redox potentials than NAD+/NADH (eg, succinate) pass electrons to Q via a fourth complex, succinate-Q reductase (Complex II), rather than Complex I.
• ❖ The four complexes are embedded in the inner mitochondrial membrane, but Q and cytochrome c are mobile.
• ❖ Q diffuses rapidly within the membrane, while cytochrome c is a soluble protein.

• Q.1.Detection of pulsations of the vaginal and uterine arteries in the vaginal fornices in early pregnancy is:
• A. Jacquemier’s sign
• B. Goodell’s sign
• C. Osiander’s sign
• D. Piskacek’s sign

Ans C ; Osiander’s sign

• Jacquemier’s or Chadwick’s sign : It is the dusky hue of the vestibule and anterior vaginal wall visible at about 8th week of pregnancy. The discoloration is due to local vascular congestion.

• • Vaginal sign:
• ☆ Apart from the bluish discoloration of the anterior vaginal wall
• ☆ The walls become softened and Copious non-irritating mucoid discharge appears at 6th week
• ☆ There is increased pulsation, felt through the lateral fornices at 8th week called Osiander’s sign.

• • Cervical signs:
• ☆ Cervix becomes soft as early as 6th week (Goodell’s sign), a little earlier in multiparae. The pregnant cervix feels like the lips of the mouth, while in the non-pregnant state, like that of tip of the nose.
• ☆ On speculum examination, the bluish discoloration of the cervix is visible. It is due to increased vascularity.
• • Uterine signs:
• ☆ Size, shape and consistency— The uterus is enlarged to the size of hen’s egg at 6th week, size of a cricket ball at 8th week and size of a fetal head by 12th week.
• ☆ The pyriform shape of the non-pregnant uterus becomes globular by 12 weeks.
• ☆ There may be asymmetrical enlargement of the uterus if there is lateral implantation. This is called Piskacek’s sign where one half is more firm than the other half.
• ☆ As pregnancy advances, symmetry is restored. The pregnant uterus feels soft and elastic.

• Q.2. Mapleson A circuit is?
• a. Ayre tube
• b. Jackson-Reese circuit
• c. McGill circuit
• d. Bain circuit
• Ans: C, McGill circuit

• • Mapleson A, also called McGill circuit, is the circuit of choice for spontaneous ventilation.
• • Mapleson B: is not common in clinical use.
• • Mapleson C: is the circuit of choice in post-operative recovery room.
• • Mapleson D: (Bain circuit) is most commonly used for controlled ventilation.
• • Mapleson E: (Ayre tube) is used for infants and young children.
• • Mapleson F: (Jackson & Reese circuit) is used for children <6 years of age and <20 kg weight

• Q.3 Adipocere formation starts under the influence of:
• a. Intrinsic lipase
• b. Lipase from bacteria
• c. Lecithinase
• d. Dehydrogenase
• Ans, A, Intrinsic lipase

• ADIPOCERE(SAPONIFICATION)
• Adipocere (cire=wax)
• • Is a modification of putrefaction.
• • In this, the fatty tissues of the body change into a substance known as adipocere.
• • It is seen most commonly in bodies immersed in water or in damp, warm environment.

• Mechanism:
• • The change is due to the gradual hydrolysis and hydrogenation of pre-existing fats, such as olein, into higher fatty acids, which combine with calcium and ammonium ions to form insoluble soaps, which being acidic, inhibit putrefactive bacteria.
• • Ultimately, the whole of the fat is converted into palmitic, oleic, stearic and hydroxystearic acid, together with some glycerol, and a mixture of these substances forms adipocere.
• • These form a matrix for remnants of tissue fibres, nerves and muscles.
• • At the time of death, body fat contains, about half percent of fatty acids, but in adipocere they rise to 20% within a month and over 70% in three months.
• • The process starts under the influence of intrinsic lipases, and is continued by the bacterial enzymes of the clostridia group, mainly Cl. perfringens, as the bacteria produce lecithinase, which facilitates hydrolysis and hydrogenation.
• • Water is essential for the bactetial and enzymatic processes involved in adipocere formation.

• 1. Ankle sprain due to forced inversion of a plantar flexed foot is due to injury to:
• a. Posterior talofibular ligament
• b. Calcaneofibular ligament
• c. Posterior fibres of deltoid
• d. Anterior talofibular ligament

• Ans. d. Anterior talofibular ligament
• Ref: Apley 8/e p733-736

• Over 90% of ankle ligament injuries (twisted ankle or ankle sprain) involve the lateral ligament complex, usually the anterior tibiofibular ligament.
• A. Medial Collateral Ligament:
• I. Also known as deltoid ligament.
• II. It is a strong ligament and major stabilizer of the ankle joint
• III. Two components: Superficial: Resist eversion of hind foot (Talo-tibial, naviculo- tibial, calcaneo-tibial) and Deep (Intra-articular): Prevents external rotation of talus (Anterior and posterior talotibial)

• B. Lateral Collateral Ligament:
• I. It is a weak ligament, so involved in over 90% of ankle injuries.
• II. It has three parts:
• i. Anterior talofibular: Most commonly injued.
• ii. Middle calcaneofibular: 2nd most commonly injured.
• iii. Posterior talofibular: Torn in most severe injuries.

• 2. A 25-year-old man presents to his primary care physician with crampy abdominal pain for 2 days. He reports having loose stools and losing 15 lbs (6.8 kg) over a 3-month duration. He also reports increased fatigue. Further evaluation revealed Crohn’s disease. The earliest manifestation in Crohn’s disease is :
• a. Aphthous Ulcer
• b. Anal fistula
• c. Rose thorn appearance on Barium swallow
• d. Skip lesions

• Ans, a. Aphthous ulcer
• Ref: Harrison 19th edition/pg. 1952

• i. The earliest lesions are Aphthous ulcerations & focal crypt abscesses with loose aggregations of macrophages, which form non-caseating granulomas in all layers of the bowel wall.
• ii. In early mild Crohn’s disease, the colonic mucosa appears endoscopically normal or small.
• iii. Punched-out aphthous ulcers are often seen.
• iiii. Aphthous ulcers occur as a result of submucosal lymphoid follicle expansion.
• v. In moderate Crohn's Disease, aphthous ulcers coalesce into larger ulcers, which may take on the appearance of a star (stellate ulcers).
• vi. As Crohn's disease severity increases, submucosal edema and injury can result in cobblestoning of the mucosa, which is seen more often in Crohn’s disease than in ulcerative colitis.

• 3. Resistant hypertension is defined as:
• a. Resistance to aldosterone
• b. Resistance to Angiotension II receptors
• c. Resistance to 2 or more anti hypertensive drugs including thiazides
• d. Resistance to 3 or more anti-hypertensive drugs including thiazides

• Ans,d.Resistance to 3 or more anti-hypertensive drugs including thiazides
• Ref: Harrison 18th edition, chapter 247

• I. Resistant hypertension refers to patients with blood pressures persistently >140/90 mmHg despite taking three or more antihypertensive agents, including a diuretic, in a reasonable combination and at full doses.
• II. Resistant or difficult-to-control hypertension is more common in patients >60 years than in younger patients.
• III. Resistant hypertension may be related to:
• i. “Pseudoresistance” (high office blood pressures and lower home blood pressures), nonadherence to therapy.
• ii. Identifiable causes of hypertension (including obesity and excessive alcohol intake.
• iii. Use of any of a number of nonprescription and prescription drugs.

• Q1.Aqueous humour is produced by:
• a.Iris
• b.Lens
• c.Ciliary body
• d.Choroid

• Ans:c,Ciliary body
• Ref:AK Khurana 6th e/p 148
• • Ciliary body is forward continuation of the choroid at ora serrata. In cut-section, it is triangular in shape. The anterior side of the triangle forms the part of the angle of anterior and posterior chambers. In its middle the iris is attached.
• • The outer side of the triangle lies against the sclera with a suprachoroidal space in between. The inner side of the triangle is divided into two parts. The anterior part (about 2 mm) having finger-like ciliary processes is called pars plicata and the posterior smooth part (about 4 mm) is called pars plana.
• • Functions of ciliary body
• • Formation of aqueous humour.
• • Ciliary muscles help in accommodation.

• Q2.A 43-year-old man with diabetes has a 4-cm nonhealing foot ulcer. Culture of the ulcer yields Staphylococcus aureus, Bacteroides fragilis, and a gram-negative bacillus that swarms across the blood agar plate covering the entire surface of the agar after 36 hours. The gram-negative bacillus is a member of the genus:
• a.Escherichia
• b. Enterobacter
• c.Serratia
• d. Proteus

• Ans:d,Proteus
• Ref: Jawetz Melnick and Adelberg’s medical microbiology 27th/e p 233
• • Proteus–Morganella–Providencia group—The members of this group deaminate phenylalanine, are motile, grow on potassium cyanide medium (KCN), and ferment xylose.
• • Proteus species move very actively by means of peritrichous flagella, resulting in “swarming” on solid media unless the swarming is inhibited by chemicals, such as phenylethyl alcohol or CLED (cystine-lactose-electrolytedeficient) medium.
• • Whereas Proteus species and Morganella morganii are urease positive, Providencia species usually are urease negative. The Proteus–Providencia group ferments lactose very slowly or not at all.

• Q3. A 3-month-old child presents with intermittent stridor aggravated on keeping the child supine. Most likely cause is:
• a. Laryngotracheobronchitis
• b. Laryngomalacia
• c. Respiratory obstruction
• d. Foreign body aspiration

• Ans:b,Laryngomalacia
• Ref: Ghai 8th ed pg 369
• • Laryngomalacia is the most common congenital laryngeal anomaly, accounting for up to 60% and the most common cause of infant stridor.
• • Inspiratory stridor is the hallmark of the condition.
• • Symptoms are typically aggravated when the child is supine or crying.
• • Flexible endoscopy reveals partial collapse of a flaccid supraglottic airway with inspiration.
• • If present, gastroesophageal reflux, should be managed.
• • Laryngomalacia is generally benign and selflimited, as most cases resolve by 18 months of age.
• • Surgical intervention is advised for either respiratory distress or failure to thrive

• 1. Radiological appearance of thimble' bladder is seen in the following condition:
• a. Cystitis cystica
• b. Chronic tuberculous cystitis
• c. Neurogenic bladder
• d. Acute tuberculous cystitis

Ans: B

• Explanation
• Early tuberculosis of the bladder commences around the ureteric orifice or trigone, the earliest evidence being pallor of the mucosa due to submucosal oedema. Subsequently, tubercles may be seen and, in long standing cases, there is marked fibrosis and the capacity of the bladder is greatly reduced giving the radiological appearance of thimble bladder'.

• 2. Leucopenia is NOT seen in?
• a. New born
• b. Starvation
• C. Enteric Fever
• d. Viral or protozoal infection

• Ans : D
• Ref: Robbins 10th Edition p582-83
• Leukocytosis is seen with Viral infections on account of increase in number of natural killer cells
• Leucopenia: MI, Sepsis, CLL, Lithium intoxication, Down's syndrome, polyarteritis nodosa, trauma, Cushing's disease

• 3. Limiting amino acids in Cereals & Pulses respectively:
• a. Lysine & Threonine
• b.Lysine & Cysteine
• c.Glycine & Methionine
• d.Lysine & Methionine

• Ans: D, Lysine & Methionine
• Ref: Park PSM 23rd Edition, Page No: 610
• Cereal proteins are deficient in lysine and threonine, and pulse proteins in methionine. These are known as "limiting" amino acids. When two or more of vegetarian foods are eaten together (as for example, rice-dhal combination in India) their proteins supplement one another and provide a protein comparable to animal protein in respect of EAA.

• Most powerful sensitizer of helper T- cell is:
• a. Interleukins
• b. Mature dendritic cells
• c. Macrophages
• d. Interferons

• Ans: b
• Ref: Robbins Basic Pathology 10th Edition, Page No: 128
•  Dendritic cells act as antigen-presenting cells: they activate helper T-cells and killer T-cells as well as B-cells by presenting them with antigens derived from the pathogen, alongside non-antigen specific costimulatory signals.
•  Dendritic cells can also induce T-cell tolerance (unresponsiveness). Certain C-type lectin receptors (CLRs) on the surface of dendritic cells, some functioning as PRRs, help instruct dendritic cells as to when it is appropriate to induce immune tolerance rather than lymphocyte activation.
•  Dendritic cells (DCs) are the most important antigen presenting cells for initiating T-cell responses against protein antigens.
•  These cells have numerous fine cytoplasmic processes that resemble dendrites, from which they derive their name. Several features of DCs account for their key role in antigen capture and presentation.

• Mechanism of action of Stiripentol, though not a new molecule, was approved in Europe in 2007 for a very specific type of epilepsy, is:
• a. Enhance GABAergic transmission in the brain, partly through a barbiturate-like effect
• b. Prolongs inactivation of VG Na+ channels
• c. Enhances K+ channel opening
• d. Action on synaptic protein SV2A

• Ans: a
• Ref: Katzung Pharmacology 12th Edition, Page No: 415
• Stiripentol
• • The drug is used with clobazam and valproate in the adjunctive therapy of refractory generalized tonic-clonic seizures in patients with severe myoclonic epilepsy of infancy (SMEI, Dravet’s syndrome) whose seizures are not adequately controlled with clobazam and valproate.
• • The mechanism of action of stiripentol is not well understood but it has been shown to enhance GABAergic transmission in the brain, partly through a barbiturate-like effect, ie, prolonged opening of the Cl – channels in GABA A receptors.
• • It also increases GABA levels in the brain. It can increase the effect of other AEDs by slowing their inactivation by cytochrome P450.
• Drugs and Mechanism of Action:
• • Lamotrigine: Prolongs inactivation of VG Na+ channels; acts presynaptically on VG Ca2+ channels, decreasing glutamate release
• • Rufinamide: Prolongs inactivation of VG Na+ channels
• • Tiagabine: Blocks GABA reuptake in forebrain by selective blockade of GAT-1
• • Retigabine: Enhances K+ channel opening
• • Topiramate: Multiple actions on synaptic function, probably via actions on Phosphorylation
• • Levetiracetam: Action on synaptic protein SV2A

• α1 = α2; β1 >> β2 is seen with:
• a. Epinephrine
• b. Norepinephrine
• c. Phenylephrine
• d. Isoproterenol

• Ans: b
• Ref: Katzung Pharmacology 12th Edition, Page No: 133
• Alpha agonists
• • Phenylephrine, methoxamine α1 > α2 >>>>> β
• • Clonidine, methylnorepinephrine α2 > α1 >>>>> β
• Mixed alpha and beta agonists
• • Norepinephrine α1 = α2; β1 >> β2
• • Epinephrine α1 = α2; β1 = β2
• Beta agonists
• • Dobutamine1 β1 > β2 >>>> α
• • Isoproterenol β1 = β2 >>>> α
• • Albuterol, terbutaline, metaproterenol, ritodrine β2 >> β1 >>>> α
• Dopamine agonists
• • Dopamine D1 = D2 >> β >> α
• • Fenoldopam D1 >> D2

• A 66-year-old man with chronic cough has an episode of hemoptysis. On physical examination, there are no abnormal findings. A chest radiograph shows a 6-cm mass in the right lung. A sputum cytologic analysis shows neoplastic squamous cells. Metastases from his lung lesion are most likely to be found at which of the following sites?
• a. Cerebral hemisphere
• b. Chest wall muscle
• c. Hilar lymph nodes
• d. Splenic red pulp

• Ans: c
• Ref: Robbins Basic Pathology 9th Edition, Page No: 168–169
• Carcinomas metastasize through lymphatics most of¬ten, usually to regional nodes first. Hematogenous metastases are possible, however, to sites such as bone marrow, liver, or the opposite lung. About half of all cerebral metastases arise from lung primary carcinomas. Soft-tissue metastases to muscle, fat, and connective tissues are rare, as are splenic metastases.

• Atropine is most sensitive to:
• a. Mucous and pharyngeal secretions
• b. Heart
• c. Pupil
• d. GI tract motility

• Ans: a
• Ref: KDT Pharmacology, 7th Edition; Page No: 115
• The sensitivity of different organs and tissues to atropine varies and can be graded as:
• Saliva, sweat, bronchial secretion > eye, bronchial muscle, heart > smooth muscle of intestine, bladder > gastric glands and smooth muscle.
• • Atropine markedly decreases sweat, salivary, tracheobronchial and lacrimal secretion (M3 blockade). Skin and eyes become dry, talking and swallowing may be difficult.
• • Atropine decreases secretion of acid, pepsin and mucus in the stomach, but the primary action is on volume of secretion so that pH of gastric contents may not be elevated unless diluted by food.
• • Since bicarbonate secretion is also reduced, rise in pH of fasting gastric juice is only modest.

• Thiopentone is used for induction of anaesthesia. It shows marked redistribution which is a characteristic of:
• a. Highly lipid soluble drugs
• b. Highly water soluble drugs
• c. Weak electrolytes
• d. Highly plasma protein bound drugs

• Ans: a
• Ref: KDT Pharmacology, 7th Edition; Page No: 18
• Redistribution
• • Highly lipid-soluble drugs get initially distributed to organs with high blood flow, i.e. brain, heart, kidney, etc. Later, less vascular but more bulky tissues (muscle, fat) take up the drug—plasma concentration falls and the drug is withdrawn from the highly perfused sites.
• • If the site of action of the drug was in one of the highly perfused organs, redistribution results in termination of drug action.
• • Greater the lipid solubility of the drug, faster is its redistribution.
• • Anaesthetic action of thiopentone sod. Injected i.v. is terminated in few minutes due to redistribution.

• 1. 9th, 10th and 11th cranial nerves form nucleus ambiguus which is classified as
• a. Special visceral efferent
• b. General somatic efferent
• c. General visceral efferent
• d. General somatic afferent

• Ans: a
• Ref: Inderbir Singh embryology 12th edition; Pg 297-299

• Afferent columns in alar lamina: The four functional columns in alar lamina are:
• • General visceral afferent (GVA): concerned with visceral sensations conveyed through 9th and 10th cranial nerves.
• • Special visceral afferent (SVA): concerned with taste sensation conveyed through 7th, 9th and 10th cranial nerves from the tongue, pharynx and soft palate.
• • General somatic afferent (GSA): contains mesencephalic, chief and spinal nuclei of trigeminal nerve concerned with proprioception, touch, and pain and temperature sensations respectively from the head and neck region.
• • Special somatic afferent (SSA): contains vestibular and cochlear nuclei concerned with equilibrium and hearing.

• Efferent columns of basal lamina: The three functional columns in basal lamina are:
• • General somatic efferent (GSE): contains nuclei of cranial nerves (3rd, 4th, 6th and 12th) that supply the extraocular muscles of eyeball and musculature of tongue.
• • Special visceral efferent/Branchial efferent (SVE): contains the nuclei of cranial nerves (5th, 7th, 9th, 10th and 11th) that supply to musculature derived from pharyngeal arches.
• • General visceral efferent (GVE): contains the cranial nerve nuclei of origin for preganglionic neurons of peripheral parasympathetic ganglia.
• • Edinger-Westphal nucleus (3rd cranial nerve): Ciliary ganglion
• • Superior salivatory nucleus (7th cranial nerve): Pterygopalatine and submandibular ganglia
• • Inferior salivatory nucleus (9th cranial nerve): Otic ganglion
• • Dorsal nucleus of vagus (10th cranial nerve): for supply of thoracic and abdominal viscera.

• 2. In triage the second priority is given to which of the color coding
• a. Black
• b. Blue
• c. Yellow
• d. Green

• Ans: C
• Ref: Park PSM 23rd Edition, Page No: 796-797
• Triage
• When the quantity and severity of injuries overwhelm the operative capacity of health facilities, a different approach to medical treatment must be adopted. The principle of "first come, first treated", is not followed in mass emergencies. Triage consists of rapidly classifying the injured on the basis of the severity of their injuries and the likelihood of their survival with prompt medical intervention. It must be adopted to locally available skills. Higher priority is granted to victims whose immediate or long-term prognosis can be dramatically affected by simple intensive care. Moribund patients who require a great deal of attention, with questionable benefit, have the lowest priority. Triage is the only approach that can provide maximum benefit to the greatest number of injured in a major disaster situation.

• Although different triage systems have been adopted and are still in use in some countries, the most common classification uses the internationally accepted four colour code system.
• • Red indicates high priority treatment or transfer,
• • Yellow signals medium priority,
• • Green indicates ambulatory patients and
• • Black for dead or moribund patients.

Triage should be carried out at the site of disaster, in order to determine transportation priority, and admission to the hospital or treatment centre, where the patient's needs and priority of medical care will be reassessed. Ideally, local health workers should be taught the principles of triage as part of disaster training. Persons with minor or moderate injuries should be treated at their own homes to avoid social dislocation and the added drain on resources of transporting them to central facilities. The seriously injured should be transported to hospitals with specialized treatment facilities.

• 3. Infliximab is:
• a. IgG1 chimeric monoclonal antibody against TNF alpha
• b. IgG1 fully human monoclonal antibody against TNF alpha
• c. IgG4 chimeric monoclonal antibody against TNF alpha
• d. P75 TNF receptor fusion protein

• Ans: a
• Ref: Katzung Pharmacology 12th Edition, Page No: 993
• Infliximab
•  Human-mouse chimeric IgG 1 monoclonal antibody possessing human constant (Fc) regions and murine variable regions.
•  It is administered intravenously but has the same anti- TNF-α activity as adalimumab and etanercept. Infliximab is currently approved for use in Crohn’s disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, plaque psoriasis, and psoriatic arthritis.

• 4. Rugger Jersey spine is seen in
• a. Fluorosis
• b. Achondroplasia
• c. Renal osteodystrophy
• d. Marfan’s syndrome

• Ans: c
•  Rugger jersey spine describes the prominent endplate densities at multiple contiguous vertebral levels to produce an alternating sclerotic-lucent-sclerotic appearance.
•  This mimics the horizontal stripes of a rugby jersey. This term and pattern are distinctive for hyperparathyroidism.
•  Seen in osteopetrosis and renal osteodystrophy. In patient with renal osteodystrophy, this appearance is due to hyperparathyroidism and osteosclerosis.

• 5. Ormond’s disease is:
• a. Idiopathic lymphadenopathy
• b. Retractile testis
• c. Idiopathic retroperitoneal fibrosis
• d. Idiopathic mediastinitis

• Ans: c
• Ref: Bailey and Love 27th Edition, Page No: 1064-1065
• Retroperitoneal fibrosis
• • This is a relatively rare diagnosis characterized by the development of a flat grey/white plaque of tissue, which is found first in the low lumbar region but then spreads laterally and upwards to encase the common iliac vessels, ureters and aorta. Histological appearances vary from active inflammation with a high cellular content interspersed with bundles of collagen through to one of acellularity and mature fibrosis/calcification.
• • Its etiology is obscure in most cases (idiopathic-) being allied to other fibromatoses (others being Dupuytren’s contracture and Peyronie’s disease). In other patients the cause is known.
• • The clinical presentation may be one of ill-defined chronic backache or occur as a result of compromise to involved structures, e.g. lower limb or scrotal edema secondary to venous occlusion, or chronic renal failure secondary to ureteric obstruction. Treatment will be directed to the cause, the modification of disease activity when appropriate, e.g. immunomodulation with steroids, tamoxifen and restoration of flow in affected structures, e.g. ureteric stenting.

Causes of retroperitoneal fibrosis: Idiopathic (Ormond’s disease)

• Q13. The recommended treatment for Q-fever endocarditis is:
• a. Emergent surgery; antibiotics are not effective
• b. Levofloxacin monotherapy for 6 weeks
• c. 18 months of combination therapy with doxycycline and hydroxychloroquine
• d. Penicillin and gentamicin combination therapy using IgG titers to determine duration

• Ans: c, 18 months of combination therapy with doxycycline and hydroxychloroquine.
• Ref: Jawetz Melnick and Adelberg’s medical microbiology 27th/e p 347
• • C. burnetii is a small obligate organism that has a membrane similar to gram-negative bacteria, does not stain with Gram stain, multiplies within vacuoles, and causes the disease Q fever.
• • C burnetii exists in two antigenic forms called phase I and phase II. Phase I is the virulent form that is found in humans with Q fever and infected vertebrate animals, and it is the infectious form. Phase II is the avirulent form.
• • C burnetii is found in sheep, goats, cattle, and a variety of other animals, which are usually asymptomatic. Transmission to humans is by inhalation of contaminated dirt from animal feces, products of conception, or dust from animal products such as contaminated hides.
• • Q fever is characterized by acute and chronic infections. Acute pneumonia and hepatitis are associated with antibodies to phase II antigens; endocarditis is the most common form of chronic infection and is associated with antibodies to phase I antigens.
• • Diagnosis is clinically suspected and confirmed largely by serology or PCR performed in reference laboratories that have developed and verified their own assays.
• • Doxycycline is the drug of choice for the treatment of acute Q fever. The newer macrolides have also been shown to be effective in the treatment of acute pneumonia. Chronic Q fever requires prolonged treatment for 18 months or longer with a combination of doxycycline and hydroxychloroquine. Duration of treatment is long as mentioned earlier and should be determined by decrease in phase I antibody titers. In endocarditis, combination therapy is necessary to prevent relapse; occasionally, valve replacement is required and can prolong survival.

• Q14. Photodisruption is the basic mechanismof action of:
• a. Argon LASER
• b. Nd:YAG LASER
• c. Excimer LASER
• d. All of the above

Ans: b, Nd:YAG LASER

• Ref:AK Khurana 6th e/p 462
• MECHANISMS OF LASER EFFECT
• • Photocoagulation: Argon, diode, krypton and diode pump frequency doubled Nd:YAG lasers are based on this mechanism.
• • Photovaporization: Vaporization of tissue to CO2 and water occurs when temperature rises to 60–100 degree Centigrade or greater, e.g., CO2 absorbed by water of cells and heat generated causes cauterization or causes disintegration thereby incising the tissue.
• • Photodisruption: Nd:YAG laser and femtosecond laser are based on this mechanism.
• • Photoablation: Lasers based on this mechanism produce UV light of very short wavelength which breaks chemical bonds of biologic materials, converting them into small molecules that diffuse away. These lasers are collectively called excimer (excited dimer) lasers. These act by tissue modelling.
• • Photoradiation (Photochemical effect): Photochemical effect following visible/infrared particularly after administration of exogenous chromophore, e.g., hematoporphyrin or benzaporphyrin and is used for photodynamic therapy, treatment of ocular tumours and choroidal neovascularization.

• Q15. Dobutamine acts primarily on:
• a. D1 receptors
• b. D2 receptors
• c. Beta 1 receptors
• d. Beta 2 receptors

Ans:c, Beta 1 receptors

Ref:Ghai 8th e/p 718

• 1. Which of the following is not correct about treatment of sunburn?
• a. Calamine lotion
• b. Topical steroid
• c. Allylamines
• d. NSAIDs

Ans, C, Allylamines

Allylamines are antifungals, eg, Terbinafine.

• Sunburn
• Cause:
• Action spectrum: UVB which induces release of cytokines in skin, resulting in pain, redness, erythema edema and even blistering.
• Skin type: Most frequent and intense in individuals who are skin type I and II.
• Clinical features:
• • Seen in light skinned.
• • Areas overexposed to UVR become painful and deeply erythematous after several hours.
• • Redness peaks at 24 h and subsides over next 48–72 h, followed by sheet-like peeling of skin and then hyperpigmentation

• Treatment
• Prevention
• • Avoiding overexposure to sun (e.g., sunbathing), especially by light-skinned individuals.
• • Using protective clothing and sun shades.
• • Using UVB protective sunscreens.
• Symptomatic treatment
• • Calamine lotion provides comfort.
• • Topical steroids help, if used early.
• Nonsteroidal anti-inflammatory drugs like aspirin not only relieve pain but also the inflammation.

• 2. A 45 years old male comes with complains of very salty-tasting skin, persistent coughing, at times with phlegm, frequent past lung infections including pneumonia and bronchitis, frequent greasy, bulky stools and difficulty with bowel movements and infertility. This is typical of cystic fibrosis. What is the position of amino acid in the protein determined by CFTR gene mutated that caused this condition in the patient?
• a. 308
• b. 408
• c. 508
• d. 608

Ans: C, 508

• Cystic Fibrosis
• • Among whites, cystic fibrosis is one of the most common genetic disorders; greater than 3% of the United States popula¬tion are carriers for this autosomal recessive disease.
• • The gene that is abnormal in cystic fibrosis is located on the long arm of chromosome 7 and encodes the cystic fibro¬sis transmembrane conductance regulator (CFTR), a regu¬lated Cl– channel located on the apical membrane of various secretory and absorptive epithelia.
• • The number of reported mutations in the CFTR gene that cause cystic fibrosis is large (> 1000) and the mutations are now grouped into five classes (I–V) based on their effects on cellular function.
• 1. Class I muta¬tions do not allow for synthesis of the protein.
• 2. Class II muta¬tions have protein processing defects.
• 3. Class III mutations have a block in their channel regulation.
• 4. Class IV mutations display altered conductance of the ion channel.
• 5. Class V mutations display reduced synthesis of the protein.
• The most common mutation causing cystic fibrosis is loss of the phenylalanine residue at amino acid position 508 of the pro¬tein (ΔF508), a Class II mutation that limits the amount of CFTR protein that gets to the plasma membrane.

• 3. You come across with a patient who says he wants to wear pink t-shirts, tight pants and female inner garments. He feels sexually aroused on doing so. What type of paraphilia does this patient seems to show?
• a. Exhibitionism
• b. Fetishistic transvestism
• c. Voyeurism
• d. Frotteurism

Ans: B, Fetishistic transvestism

• Paraphilias (sexual deviations; perversions) are disorders of sexual preference in which sexual arousal occurs persistently and significantly in response to objects which are not a part of normal sexual arousal (e.g. nonhuman objects; suffering or humiliation of self and/or sexual partner; children or nonconsenting person). They are as follows:
• 1. Fetishism: In fetishism, the sexual arousal occurs either solely or predominantly with a nonliving object, which is usually intimately associated with the human body.
• 2. Fetishistic Transvestism: This disorder occurs exclusively in heterosexual males. The person actually or in fantasy wears clothes of the opposite sex (cross-dressing) for sexual arousal.
• 3. Sexual Sadism: In this disorder, the person (the ‘sadist’) is sexually aroused by physical and/or psycho logical humiliation, suffering or injury of the sexual partner (the ‘victim’).
• 4. Sexual Masochism: This is just the reverse of sexual sadism. Here the person (the ‘masochist’) is sexually aroused by physical and/or psychological humiliation, suffering or injury inflicted on self by others (usually ‘sadists’).
• 5. Exhibitionism: Exhibitionism is a persistent (or recurrent) and significant method of sexual arousal by the exposure of one’s genitalia to an unsuspecting stranger.
• 6. Voyeurism: This is a persistent or recurrent tendency to observe unsuspecting persons (usually of the other sex) naked, disrobing or engaged in sexual activity.
• 7. Frotteurism: This is a persistent or recurrent involvement in the act of touching and rubbing against an unsuspecting, nonconsenting person (usually of the other sex).
• 8. Paedophilia: Paedophilia is a persistent or recurrent involvement of an adult (age >16 years and at least 5 years older than the child) in sexual activity with prepubertal children, either heterosexual or homosexual.
• 9. Zoophilia (Bestiality): Zoophilia as a persistent and signifi cant involvement in sexual activity with animals is rare.
• Other Paraphilias: These include sexual arousal with urine (urophilia); faeces (coprophilia); enemas (klismaphilia); corpses (necrophilia), among many others.

• Q1. The recommended treatment for Q-fever endocarditis is:
• a. Emergent surgery; antibiotics are not effective
• b. Levofloxacin monotherapy for 6 weeks
• c. 18 months of combination therapy with doxycycline and hydroxychloroquine
• d. Penicillin and gentamicin combination therapy using IgG titers to determine duration

Ans: c, 18 months of combination therapy with doxycycline and hydroxychloroquine.

• • C. burnetii is a small obligate organism that has a membrane similar to gram-negative bacteria, does not stain with Gram stain, multiplies within vacuoles, and causes the disease Q fever.
• • C burnetii exists in two antigenic forms called phase I and phase II. Phase I is the virulent form that is found in humans with Q fever and infected vertebrate animals, and it is the infectious form. Phase II is the avirulent form.
• • C burnetii is found in sheep, goats, cattle, and a variety of other animals, which are usually asymptomatic. Transmission to humans is by inhalation of contaminated dirt from animal feces, products of conception, or dust from animal products such as contaminated hides.
• • Q fever is characterized by acute and chronic infections. Acute pneumonia and hepatitis are associated with antibodies to phase II antigens; endocarditis is the most common form of chronic infection and is associated with antibodies to phase I antigens.
• • Diagnosis is clinically suspected and confirmed largely by serology or PCR performed in reference laboratories that have developed and verified their own assays.
• • Doxycycline is the drug of choice for the treatment of acute Q fever. The newer macrolides have also been shown to be effective in the treatment of acute pneumonia. Chronic Q fever requires prolonged treatment for 18 months or longer with a combination of doxycycline and hydroxychloroquine. Duration of treatment is long as mentioned earlier and should be determined by decrease in phase I antibody titers. In endocarditis, combination therapy is necessary to prevent relapse; occasionally, valve replacement is required and can prolong survival.

• Q2. Photodisruption is the basic mechanismof action of:
• a. Argon LASER
• b. Nd:YAG LASER
• c. Excimer LASER
• d. All of the above

Ans: b, Nd:YAG LASER

• Ref:AK Khurana 6th e/p 462
• MECHANISMS OF LASER EFFECT
• • Photocoagulation: Argon, diode, krypton and diode pump frequency doubled Nd:YAG lasers are based on this mechanism.
• • Photovaporization: Vaporization of tissue to CO2 and water occurs when temperature rises to 60–100 degree Centigrade or greater, e.g., CO2 absorbed by water of cells and heat generated causes cauterization or causes disintegration thereby incising the tissue.
• • Photodisruption: Nd:YAG laser and femtosecond laser are based on this mechanism.
• • Photoablation: Lasers based on this mechanism produce UV light of very short wavelength which breaks chemical bonds of biologic materials, converting them into small molecules that diffuse away. These lasers are collectively called excimer (excited dimer) lasers. These act by tissue modelling.
• • Photoradiation (Photochemical effect): Photochemical effect following visible/infrared particularly after administration of exogenous chromophore, e.g., hematoporphyrin or benzaporphyrin and is used for photodynamic therapy, treatment of ocular tumours and choroidal neovascularization.

• Q3. Dobutamine acts primarily on:
• a. D1 receptors
• b. D2 receptors
• c. Beta 1 receptors
• d. Beta 2 receptors

Ans:c, Beta 1 receptors

Ref:Ghai 8th e/p 718

• 1. All are true regarding Zollinger Ellison syndrome, except:
• a. Diarrhoea
• b. Recurrence after operation
• c. Hypergastrinemia
• d. Decreased ratio of BAO to MAO

Ans,d. Decreased ratio of BAO to MAO

• Basic pathology in patients with Zollinger Ellison syndrome is increased secretion of gastrin from non Beta cell endocrine tumour. The increased level of gastrin causes increased basal acid output secretion which is 60% of the total acid output. Then the ratio of basal acid out to maximal acid output is increased in Zollinger Ellison syndrome.
• This increased level of gastrin and acid produces peptic ulcers and diarrhoea which are common manifestations of Zollinger Ellison Syndrome.
• Diagnosis of Zollinger Ellison Syndrome:
• • First step in the diagnosis is to obtain fasting Gastrin level which is elevated.
• • It is > 150 pg/ml in almost all cases.
• • A level of >1000 pg/ml almost confirms the diagnostic of Zollinger Ellison syndrome.
• • Second step is to assess acid secretion. Basal acid output is increased.
• • Gastrin provocative test are also helpful in the diagnosis of Zollinger Ellison Syndrome. Especially in patients with indeterminate acid secretion. These tests are :
• • Secretion stimulation test (Most sensitive & Specific)
• • Calcium infusion test
• • Standard meal test

• Treatment:
• • DOC → Proton pump inhibitors (Omeprazole and Lansoprazole)
• • Surgery → Recurrence rate is high as it is difficult to exactly localize the tumour.

• 2. A patient comes with thrombocytopenia, eczema and recurrent infections. What is the most probable diagnosis:
• a. Wiskott Aldrich syndrome
• b. Beta gammaglobulinemia
• c. Chediak Hegashi syndrome
• d. Lazy leukocyte syndrome

Ans,a. Wiskott Aldrich syndrome

• • This X-linked disease characterized by eczema, thrombocytopenia, and repeated infections is caused by mutations in WAS gene.
• • Affected male infants often presents with bleeding, and most do not survive childhood, dying of complications of bleeding, infection, or lymphoreticular malignancy.
• • The immunologic defects include low serum concentrations of IgM, while IgA and IgG are normal and IgE is frequently increased.
• • Although the number and class distribution of B lymphocytes are usually normal, these patients fail to make antibodies to polysaccharide antigens normally, and responses to protein antigens may be impaired late in the course of disease.
• • Most patients eventually acquire severe T cell deficiency, rendering them vulnerable to overwhelming infections with herpes simplex virus and other infectious agents.

• 3. Bennet fracture dislocation involves base of:
• a. 1st metacarpal
• b. 5th metacarpal
• c. 1st metatarsal
• d. 5th metatarsal

Ans,a.1st metacarpal

• • Benett’s fracture is an intra-articular fracture dislocation of the palmar base of first metacarpal bone of the thumb with either subluxation or dislocation of first carpometacarpal joint, i.e. trapezometacarpal joint.
• • The common mechanism of injury is an axial blow directed against the partially flexed metacarpal, in most cases during “Fist fights. Patient complains of pain, swelling and tenderness over the base of the thumb. Movements of thumb are restricted.

• Q1. Surgical landmark for endolymphatic sac during surgery is:
• a. Solid angle
• b. Trautman triangle
• c. Utelli's angle
• d. Donaldson line

Ans: d, Donaldson line

• Donaldson's line: This line is a surgical landmark for endolymphatic sac. It passes through horizontal bisecting the posterior semicircular canal. The endolymphatic sac that appears as thickening of the posterior cranial fossa dura is situated inferior to Donaldson's line.
• Also Know:
• • Citelli's angle (sinodural angle): It lies between the sigmoid sinus and middle fossa dura mater.
• • Bill's island: This thin plate of bone left on sigmoid sinus during mastoidectomy helps in retracting the sigmoid sinus. It should not be confused with Bill's bar, which lies in the fundus of internal auditory canal.
• • Solid angle: This area of bony labyrinth lies between the three semicircular canals.
• • Trautmann's triangle: This area is bounded by the bony labyrinth anteriorly, sigmoid sinus posteriorly and the superior petrosal sinus superiorly. Any infection in the posterior canal fossa can spread through this triangle and can be approached by removing the bone in between the triangle.

• Q2. Peritoneal loose bodies also known as peritoneal mice are mostly asymptomatic. They are composed of;
• a. cartilage surrounded by saponified fat
• b. fibrin and cartilage
• c. saponified fat surrounded by fibrin
• d. fat balls only

Ans: c, saponified fat surrounded by fibrin

• Peritoneal loose bodies (peritoneal mice)
• Peritoneal loose bodies (peritoneal mice) may be confused with a small tumour but almost never cause symptoms. One or more may be found in a hernial sac or in the pouch of Douglas. The loose body may come from an appendix epiploica that has undergone axial rotation followed by necrosis of its pedicle and detachment, but they are also found in those who have subacute attacks of pancreatitis. These hyaline bodies attain the size of a pea or bean and contain saponified fat surrounded by fibrin.

• Q3. Vicryl, an absorbable suture material used commonly in surgical practice is a:
• a. Homopolymer of polydiaxone
• b. Co-polymer of glycolide and lactide
• c. Homopolymer of glycolide
• d. Homopolymer of lactide

Ans: b. Co-polymer of glycolide and lactide

• • Vicryl, a polyglactin is a Synthetic, Absorbable, Multifilament, lubricant coated suture.
• • It is a copolymer of lactide and glycolide in a 90:10 ratio, coated with polyglactin and calcium stearate.
• • Complete absorption by 60-90 days; (increases in alkaline environment and high temps; don’t use to close bladder).

• Q4. For infection prevention and control, WHO calls to action on 5 may 2020, which action is meant for nurses?
• a. Clean and safe care starts with you
• b. Your hands make all the difference for mothers and babies
• c. Empower nurses and midwives in providing clean care
• d. Safer care for you, with you

Ans: a. Clean and safe care starts with you

SAVE LIVES: Clean Your Hands 5 May 2020

• Nurses and Midwives, clean care is in your hands!
• • Clean health care is recognized as one of WHO’s urgent challenges to be tackled in the next 10 years by the global community, in our race to meeting SDG deadline.
• • Therefore, clean care, including hand hygiene best practices, and the central role played by nurses and midwives in achieving this, is the focus of this year’s 5 May campaign.
• • The idea has been to partner with the Year of the Nurse and the Midwife that WHO has declared for 2020, and to recognize their crucial contribution to strengthening quality health systems.
• • We are calling all health care workers and other target audiences to join hands in celebrating and empowering nurses and midwives in the monumental work that they do to keep our patients, families, and their colleagues safe by preventing health care-associated infections.

• 5 MAY 2020 CALLS TO ACTION
• •Nurses: “Clean and safe care starts with you."
• •Midwives: “Your hands make all the difference for mothers and babies.”
• •Policy Makers: "Increase nurse staffing levels to prevent infections and improve quality of care. Create the means to empower nurses and midwives.”
• •IPC Leaders: "Empower nurses and midwives in providing clean care."
• •Patients and Families: "Safer care for you, with you."

• Q5. Adipocere formation starts under the influence of:
• a. Intrinsic lipase
• b. Lipase from bacteria
• c. Lecithinase
• d. Dehydrogenation

Ans, A, Intrinsic lipase

• ADIPOCERE(SAPONIFICATION)
• Adipocere (cire=wax)
• • Is a modification of putrefaction.
• • In this, the fatty tissues of the body change into a substance known as adipocere.
• • It is seen most commonly in bodies immersed in water or in damp, warm environment.
• Mechanism:
• • The change is due to the gradual hydrolysis and hydrogenation of pre-existing fats,such as olein, into higher fatty acids, which combine with calcium and ammonium ions to form insoluble soaps, which being acidic, inhibit putrefactive bacteria.
• • Ultimately, the whole of the fat is converted into palmitic, oleic, stearic and hydroxystearic acid, together with some glycerol, and a mixture of these substances forms adipocere.
• • These form a matrix for remnants of tissue fibers, nerves and muscles.
• • At the time of death, body fat contains, about half percent of fatty acids, but in adipocere they rise to 20% within a month and over 70% in three months.
• • The process starts under the influence of intrinsic lipases, and is continued by the bacterial enzymes of the clostridia group, mainly Cl. perfringes, as the bacteria produce lecithinase, which facilitates hydrolysis and hydrogenation.
• • Water is essential for the bacterial and enzymatic processes involved in adipocere formation.

• Q1. Effect of progestogens on lipid profile is
• a.Increase LDL
• b.Decrease HDL
• c.Both
• d.No effect on lipid profile
• .
• Ans.c.both
• SIDE EFFECTS OF PROGESTOGENS:
• nausea—subsides gradually
• • leg cramps
• • mastalgia
• • Weight gain due to salt and water retention
• • acne
• • scanty periods due to androgenic progestins
• • loss of libido
• • Virilism
• • Headaches—migraines should be excluded
• • Depression and mood changes—may be due to low level of pyridoxin as progestins alter the tryptophan metabolism.
• • lipid profile—increase in LDL and decrease inHDL level.

• Q2. A 40 years old man is accused of anal intercourse to a seven years old boy. An adult who repeatedly engages in sexual activities with children is called:
• a.Pedophile
• b. Catamite
• c. Paederasty
• d.Gerontophilia
• .
• Ans , a.Pedophile

• SODOMY
• • Sodomy is the anal intercourse between two males, or between a male and female.
• • This used to be practiced in a town called Sodom. It is also called buggery.
• • It is called
• o gerontophilia- when the passive agent is an adult
• o paederasty- when the passive agent is a child, who is known as catamite.
• •A pedophile-is an adult who repeatedly engages in sexual activities with children.
• •The Greeks of the "Golden Age" also practised it, and it is sometimes referred to as Greek love. It can be heterosexual or homosexual.
• •When practised between two men, they may alternately act as active and passive agents.

• Q3. You are a medical officer in Shukraraj Tropical & Infectious Disease Hospital,you are treating patients infected with COVID-19,which precaution is needed for you
• a.Standard precautions
• b.Transmission-Based precautions
• c.Basic precautions
• d.Both a and b

Ans d ,both a and b

• Infection Control Basics
• There are 2 tiers of recommended precautions to prevent the spread of infections in healthcare settings:
• Standard Precautions and Transmission-Based Precautions.
• Standard Precautions for All Patient Care
• Standard precautions are used for all patient care. They’re based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient.
• Transmission-Based Precautions
• Transmission-based precautions are used in addition to Standard Precautions for patients with known or suspected infections.

• 1. The neck- shaft angle of femur is:
• a. 15°
• b. 75°
• c. 125°
• d. 160°

• Ans: c.125°
• Ref: Human anatomy BD Chaurasia 4th edition Vol2 P16
• The neck-shaft angle is about 125° in adults. It is less in females due to their wider pelvis.
• The angle facilitates movements of the hip joint. It is strengthened by a thickening of bone called the calcar femorale present along its concavity.
• The angle of femoral torsion or angle of anteversion is formed between the transverse axes of the upper and lower ends of the femur. It is about 15°.

• 2. Which amino acid contains sulfur atoms in the side chain?
• a. Alanine
• b. Methionine
• c. Tyrosine
• d. Tryptophan

• Ans: b. Methionine
• Harper’s illustrated Biochemistry 31th edition P 51
• A. Amino acids with side chain containing Hydroxylic (OH) groups
• Serine
• Threonine
• Tyrosine
• B. Amino acids with side chain containing sulfur atoms
• Cysteine
• Methionine
• C. Amino acids with side chain containing acidic groups or their amides
• Aspartic acid
• Asparagine
• Glutamic acid
• Glutamine
• D. Amino acids with side chain containing basic groups
• Arginine
• Lysine
• Histidine

• 3. Which of the following drug is delivered through skin patch for the treatment of parkinsonism?
• a. Levadopa
• b. Rotigotine
• c. Apomorphine
• d. Arantil

• Ans: b. Rotigotine
• Ref: Basic and clinical Pharmacology, Katzung 14th P 499
• The dopamine agonist rotigotine, delivered daily through a skin patch, is approved for treatment of early Parkinson’s disease. It supposedly provides more continuous dopaminergic stimulation than oral medication in early parkinsonism; its efficacy in moreadvanced disease is less clear. Benefits and side effects are similar to those of other dopamine agonists but reactions may also occur at the application site and are sometimes serious.

• 1. What is involved in alopecia universalis?
• a. Whole scalp
• b. Whole body
• c. Whole body except armpits and pubis
• d. Whole scalp plus armpits and pubis

Ans, b, Whole body

• Alopecia areata
• Etiology: Immunologically mediated.
• Morphology: Noncicatricial, noninflammatory alope
• Presents as discoid areas of hair loss with exclamation mark hair at the edge.
• Course: Unpredictable; spontaneous recovery with regrowth initially of gray hair. Or progresses to
• Alopecia totalis (whole scalp) or Alopecia universalis (whole body).
• Site: Scalp, less frequently beard, eyebrows, and eye- lashes. Sometimes generalized.
• Treatment: Localized lesions: <6 months: no treatment; >6 months: topical steroids.
• Extensive lesions: Response to treatment unpredictable.
• Minoxidil, psoralens with UVA/UVA sol (topical and systemic) and steroids (topical and systemic).

• 2. A transplant from one to another twin is called?
• a. Autograft
• b. Isograft
• c. Xenograft
• d. Allograft

Ans, b, Isograft

• Autografts, Isografts, Allografts, and Xenografts.
• A transplant of a tissue or whole organ
• i. from one part of the same animal to another part is called an autograft;
• ii. from one identical twin to another, an isograft;
• iii. from one human being to another or from any animal to another animal of the same species, an allograft;
• iv. from a non-human animal to a human being or from an animal of one species to one of another species, a xenograft.

• 3. What is the correct sequence of stages of overcoming addiction?
• a. Contemplation, pre-contemplation, action, preparation, maintenance, relapse
• b. Preparation, pre-contemplation, contemplation, action, maintenance, relapse
• c. Pre-contemplation, contemplation, preparation, action, maintenance, relapse
• d. Pre-contemplation, contemplation, action, preparation, maintenance, relapse

Ans, c, Pre-contemplation, contemplation, preparation, action, maintenance, relapse

• Stages of change in overcoming addiction
• Pre-contemplation—denying problem
• Contemplation. —acknowledging problem, but unwilling to change
• Preparation/determination—preparing for behavioral changes
• Action/willpower—changing behaviors
• Maintenance. —maintaining changes
• Relapse. —(if applicable) returning to old behaviors and abandoning changes

• 1. Earliest radiological sign of Pulmonary Venous Hypertension in Chest X-ray is:
• a. Cephalization of pulmonary vascularity
• b. Pleural effusion
• c. Kerley B lines
• d. Alveolar pulmonary edema

• Correct Ans : a
• Explanation
• Ref:; Textbook of radiology and Imaging By David Sutton, 5th Edition, Pages 288-89
• The first radiographic sign of pulmoi ary venous hypertension is cephalization of the pulmonary vessels due to pulmonary vein and artery dilatation.
• In the normal individual, there is continuous passage of fluid from the pulmonary veins into adjacent interlobular lymphatics that return the fluid to the central mediastinal veins.
• If the lymphatic reserve is overcome by increased transudate as a result of elevated pulmonary venous pressure, the interlobular septa are thickened and become visible radiographically.
• The first radiologic sign of pulmonary venous hypertension is cephalization of the pulmonary vessels.

• 2. Which of the following is an autosomal recessive disorder?
• a. Duchenne muscular dystrophy
• b. Friedreich ataxia
• c. Wiskott Aldrich syndrome
• d. Lesch Nyhan syndrome

• Ans: b
• Ref: Robbins & Cotran, Pathologic basis of disease, South Asia edition, Vol 1, p141, 1
• Duchenne muscular dystrophy, Wiskott Aldrich syndrome and Lesch Nyhan syndrome are X-linked recessive disorders.
• Friedreich ataxia is an autosomal recessive disorder.
• Other autosomal recessive disorders include congenital adrenal hyperplasia, alkaptonuria, alpha 1 antitrypsin deficiency, phenylketonuria and Wilson disease.

• 3. Long term fluctuation is seen with
• a. cyclic trends
• b. epidemics
• c. secular trends
• d. seasonal trends

• Ans, C, secular trends
• Ref, Park’s Textbook of Preventive and Social Medicine 22nd edition, p62
• Explanation
• Long Term Fluctuations [Secular Trends]
• Implies changes in occurrence of a disease (progressive increase or decrease) over a long period of time, generally several years or decades.
• Is the consistent tendency to change in a particular direction or a definite movement in one direction.
• Examples:
• – Communicable diseases (Poliomyelitis, Diphtheria, and Pertussis) are reducing in past few decades
• – Non-communicable diseases (Diabetes, Hypertension, and Obesity) are increasing in past few decades.

• Q1.Bachman's test is done to diagnose infections with :
• a. Schistosoma japonicum
• b. Trichinella spiralis
• c. Trichuris trichiura
• d. Ancylostoma duodenale

Ans: b,Trichinella

•  Trichinella spiralis, tissue n ematode, is the causative agent of trichinosis.
•  Diagnosis of trichinosis can be made by direct and indirect methods
•  Bachman intra.dermal test: It uses a 1:5,000 or 1:10,000 dilution of the larval antigen. An erythematous wheal appears in positive cases within 15- 20 minutes. The rest remains positive for years after infection.

• Q2.A 6 years old boy presents with passage of frothy urine,anasarca.He was evaluated and diagnosed as Nephrotic Syndrome and was kept under prednisolone therapy however there was no remission at 8 weeks of therapy.What could be the most common cause?
• a.Minimal change disease
• b.Focal segmental glomerulosclerosis(FSGS)
• c.Membranoproliferative Glomerulonephritis
• d.IgA Nephropathy

• Ans:b, FSGS
• Ref:Nelson 21st ed pg 10823
• • Steroid resistance is defined as the failure to achieve remission(Remission consists of a urine protein:creatinine ratio of < 0.2 or < 1+ protein on urine dipstick testing for 3 consecutive days)after 8 wk of corticosteroid therapy.
• • Children with steroid-resistant nephrotic syndrome require further evaluation, including a diagnostic kidney biopsy, evaluation of kidney function, and quantitation of urine protein excretion (in addition to urine dipstick testing).
• • Steroid-resistant nephrotic syndrome is usually caused by FSGS (80%), MCNS, or membranoproliferative glomerulonephritis.

• Q3.Dendritic keratitis is associated with:
• a.Adeno virus keratitis
• b.Fungal keratitis
• c.Pseudomonas keratitis
• d.Herpes simplex keratitis

• Ans:d, Herpes simplex keratitis
• Ref:Nelson textbook of pediatrics 21st edition pg13021
• Dendritic Keratitis
• • Infection of the cornea with the herpes simplex virus produces a characteristic lesion of the corneal epithelium, referred to as a dendrite; it has a branching treelike pattern that can be demonstrated by fluorescein staining .
• • The acute episode is accompanied by pain, photophobia, tearing, blepharospasm, and conjunctival injection.
• • Specific treatment may include mechanical debridement of the involved corneal epithelium to remove the source of infection and eliminate an antigenic stimulus to inflammation in the adjacent stroma. Medical treatment involves the use of trifluridine, topical ganciclovir, or systemic acyclovir. In addition, a cycloplegic agent is useful to relieve pain from spasm of the ciliary muscle.
• • Overly aggressive topical antiviral treatment itself can be toxic to the cornea and should be avoided. Recurrent infection and deep stromal involvement can lead to corneal scarring and loss of vision.

• 1. Most common complication of Shigellosis is:
• a. Hemolytic Uremic Syndrome (HUS)
• b. Reactive arthritis
• c. Pneumonia
• d. Meningitis

• Ans,a. Hemolytic Uremic Syndrome (HUS)
• Harrison 19th ed/pg.905,906
• Common complications:
• • Bacteremia
• • HUS : It occurs with S. dysenteriae type-1 infection. Manifestations of HUS usually develop at the end of first week of shigellosis.Oliguria, marked drop in hematocrit are the first signs & progresses to anuria with renal failure & severe anemia with congestive heart failure.
• Less common complications: Reactive arthritis
• Rare complications: Pneumonia; Meningitis; Vaginitis (in prepubertal girls);Keratoconjunctivitis & “rose spot” rashes.

• 2. Which one of the following act directly on thromboplastin to activate plasminogen:
• a. Streptokinase
• b. Urokinase
• c. Heparin
• d. rt-PA

• Ans,d. rt-PA
• Ref: Harrison’s 18th ed./p.1001
• • Streptokinase is obtained from cultures of Beta hemolytic streptococci. By itself, streptokinase has no PA activity, but when complexed with plasminogen, it can convert other plasminogen molecules to plasmin. It is not fibrin-selective in that the so-called lytic state resulting from its therapeutic use is due to lysis of fibrinogen as well as fibrin.
• • Recombinant tissue-type plasminogen activator (rt-PA) produced by recombinant technology demonstrates in vitro affinity for fibrin with which it forms a ternary complex with plasminogen. Despite reported fibrin-specificity, the lytic state is produced with dosages currently used. Bleeding complications with rt-PA are similar to those of streptokinase or urokinase.

• 3. If the fracture is intra-articular and extends through the epiphysis, physis and metaphysis,which type of Salter Harris classification does it fall under:
• a. Type II
• b. Type III
• c. Type IV
• d. Type V

• Ans,c. type IV
• Ref: Campbell’s 12th ed./p.1366
• Salter Harris classification : Epiphyseal / Physeal injuries
• • Type I: Complete separation of epiphysis from the metaphysis without fracture. Common in rickets, scurvy and osteomyelitis.
• • Type II: The fracture involves physis and a triangle of metaphyseal bone (Thurston Holland sign). This is the commonest type of epiphyseal injury accounting for 73 percent of cases over 10 years of age.
• • Type III: The fracture is intra- articular and extends along the physis and then along the growth plate. This injury is relatively uncommon.
• • Type IV: The fracture is intra-articular and extends through the epiphysis, physis and metaphysis. Perfect reduction is necessary and open reduction is more often necessary to prevent growth arrest.
• • Type V: Crushing of epiphysis. Growth arrest usually follows.
• • Type VI (Rang’s type) : There is a peripheral physis (perichondrial ring) injury.

• 1. Deep Brain Stimulation done for Parkinson’s disease primarily targets
• a. Globus Pallidus internus
• b. Globus Pallidus externus
• c. Substantia Nigra compacta
• d. Substantia nigra reticulata

• Ans: a
• Ref: Harrison 20th Edition, Page No: 3129
• • DBS for PD primarily targets the STN or the GPi. It provides dramatic results, particularly with respect to tremor and reducing both “off” time and dyskinesias, but does not provide superior clinical benefits or improve features that do not respond to levodopa such as freezing, falling, and dementia.
• • The procedure is thus primarily indicated for patients who suffer disability resulting from severe tremor, or levodopa-induced motor complications that cannot be satisfactorily controlled with drug manipulation. In such patients, DBS has been shown to provide benefits in comparison to best medical therapy.
• • Recent studies indicate that benefits following DBS of the STN and GPi are comparable, but that GPi stimulation may be associated with a reduced frequency of depression. Although not all PD patients are candidates, the procedure can be profoundly beneficial for many.

• 2. Mantle cell lymphoma are positive for all except:
• a. CD 23
• b. CD 5
• c. CD 43
• d. CD 20

• Ans: a
• Ref: Robbins Basic Pathology 10th Edition, Page No: 469
• • Almost all tumors have an (11;14) translocation that fuses the cyclin D1 gene to the IgH locus. This translocation leads to over expression of cyclin D1, which you will recall stimulates growth by promoting the progression of cells from the G1 phase to the S phase of the cell cycle.
• • The tumor cells express surface IgM and IgD, the B cell antigen CD20, and CD5, and they contain high levels of cyclin D1 protein.

• 3. Achondroplasia is caused by point mutation of:
• a. TCIRG1
• b. Mutation in the genes that encode the α1 and α2 chains
• c. carbonic anhydrase 2
• d. FGFR3

• Ans: d
• Ref: Robbins Basic Pathology 10th Edition, Page No: 800
• • Mutation in the genes that encode the α1 and α2 chains- Osteogenesis Imperfecta
• • TCIRG1 and carbonic anhydrase 2 mutation-Osteopetrosis
• • FGFR3 mutation-Achondroplasia and Thanatophoric Dysplasia

• 4. The use of genetic information to guide the choice of drug and dose on an individual basis:
• a. Pharmacogenetics
• b. Pharmacogenomics
• c. Pharmacovigilance
• d. Pharmacodynamics

• Ans: b
• Ref: KDT Pharmacology 7th Edition, Page No: 82,65,1-2
• Pharmacovigilance
• Pharmacovigilance has been defined by the WHO (2002) as the ‘science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other drug related problems.’

• Pharmacogenetics: The study of genetic basis for variability in drug response is called ‘Pharmacogenetics’.
• Pharmacogenomics: The use of genetic information to guide the choice of drug and dose on an individual basis.
• Pharmacodynamics (Greek: dynamis—power) —What the drug does to the body.
• • This includes physiological and biochemical effects of drugs and their mechanism of action at organ system/subcellular/macromolecular levels, e.g.—Adrenaline → interaction with adrenoceptors → G-protein mediated stimulation of cell membrane bound adenylyl cyclase → increased intracellular cyclic 3 ́,5 ́AMP → cardiac stimulation, hepatic glycogenolysis and hyperglycaemia, etc.
• Pharmacokinetics (Greek: Kinesis—movement)—What the body does to the drug.
• • This refers to movement of the drug in and alteration of the drug by the body; includes absorption, distribution, binding/localization/storage, bio- transformation and excretion of the drug, e.g. paracetamol is rapidly and almost completely absorbed orally attaining peak blood levels at 30–60 min; 25% bound to plasma proteins, widely and almost uniformly distributed in the body (volume of distribution ~ 1L/kg); extensively metabolized in the liver, primarily by glucuronide and sulfate conjugation into inactive metabolites which are excreted in urine; has a plasma half life (t1⁄2) of 2–3 hours and a clearance value of 5 ml/kg/min.

• 5. The active form of Remdesivir, drug under clinical trial for treatment of COVID 19, is:
• a. GC-376
• b. GS-441524
• c. B-5701
• d. GS-5734

• Ans: b
• Ref: Agostini ML, Andres EL, Sims AC, Graham RL, Sheahan TP, Lu X, et al. (March 2018). "Coronavirus Susceptibility to the Antiviral Remdesivir (GS-5734) Is Mediated by the Viral Polymerase and the Proofreading Exoribonuclease
• • Remdesivir is a prodrug that metabolizes into its active form GS-441524.
• • An adenosine nucleotide analog, GS-441524 interferes with the action of viral RNA-dependent RNA polymerase and evades proofreading by viral exoribonuclease (ExoN), causing a decrease in viral RNA production.
• • Though in some viruses, such as the respiratory syncytial virus but not Ebola virus, it causes the RNA-dependent RNA polymerases to pause, its predominant effect is to induce an irreversible chain termination.
• • Unlike with many other chain terminators, this was not mediated by preventing addition of the immediately subsequent nucleotide, but is instead delayed, occurring after five additional bases have been added to growing RNA chain.
• • During 2020, several clinical trials were underway. The first placebo controlled trial of Remdesivir in China, according to a WHO report that was published early in error, showed that Remdesivir had no clinical or virological benefits, and the drug was stopped early in 11.6% of patients due to adverse effects. In the large industry sponsored study for Remdesivir, for severe COVID-19, the trial was modified, mid trial, increasing in size from 400 subjects to 2,400 participants. The primary end point of the trial was also changed during the trial.

• 1. A 66-year-old man with chronic cough has an episode of hemoptysis. On physical examination, there are no abnormal findings. A chest radiograph shows a 6-cm mass in the right lung. A sputum cytologic analysis shows neoplastic squamous cells. Metastases from his lung lesion are most likely to be found at which of the following sites?
• a. Cerebral hemisphere
• b. Chest wall muscle
• c. Hilar lymph nodes
• d. Splenic red pulp

• Ans: c
• Ref: Robbins Basic Pathology 9th Edition, Page No: 168–169
• Carcinomas metastasize through lymphatics most of¬ten, usually to regional nodes first. Hematogenous metastases are possible, however, to sites such as bone marrow, liver, or the opposite lung. About half of all cerebral metastases arise from lung primary carcinomas. Soft-tissue metastases to muscle, fat, and connective tissues are rare, as are splenic metastases.

• 2. Thiopentone is used for induction of anaesthesia. It shows marked redistribution which is a characteristic of:
• a. Highly lipid soluble drugs
• b. Highly water soluble drugs
• c. Weak electrolytes
• d. Highly plasma protein bound drugs

• Ans: a
• Ref: KDT Pharmacology, 7th Edition; Page No: 18
• Redistribution
• • Highly lipid-soluble drugs get initially distributed to organs with high blood flow, i.e. brain, heart, kidney, etc. Later, less vascular but more bulky tissues (muscle, fat) take up the drug—plasma concentration falls and the drug is withdrawn from the highly perfused sites.
• • If the site of action of the drug was in one of the highly perfused organs, redistribution results in termination of drug action.
• • Greater the lipid solubility of the drug, faster is its redistribution.
• • Anaesthetic action of thiopentone sod. Injected i.v. is terminated in few minutes due to redistribution.

• 3. Atropine is most sensitive to:
• a. Mucous and pharyngeal secretions
• b. Heart
• c. Pupil
• d. GI tract motility

• Ans: a
• Ref: KDT Pharmacology, 7th Edition; Page No: 115
• The sensitivity of different organs and tissues to atropine varies and can be graded as:
• Saliva, sweat, bronchial secretion > eye, bronchial muscle, heart > smooth muscle of intestine, bladder > gastric glands and smooth muscle.
• • Atropine markedly decreases sweat, salivary, tracheobronchial and lacrimal secretion (M3 blockade). Skin and eyes become dry, talking and swallowing may be difficult.
• • Atropine decreases secretion of acid, pepsin and mucus in the stomach, but the primary action is on volume of secretion so that pH of gastric contents may not be elevated unless diluted by food.
• • Since bicarbonate secretion is also reduced, rise in pH of fasting gastric juice is only modest.

• 4. Major basic protein is formed from:
• a. Neutrophil
• b. Lymphocyte
• c. Basophil
• d. Eosinophil

• Ans: D
• Ref: Robbins Pathology; 10th edition; pg 84
• Eosinophils are abundant in immune reactions mediated by IgE and in parasitic infections. Their recruitment is driven by adhesion molecules similar to those used by neutrophils, and by specific chemokines (e.g., eotaxin) derived from leukocytes and epithelia cells. Eosinophils have granules that contain major basic protein, a highly cationic protein that is toxic to parasites but also injures host epithelial cells. This is why eosinophils are of benefit in controlling parasitic infections, yet also contribute to tissue damage in immune reactions such as allergies.

Answers and Winners of QUIZ for CEE MD/MS Based Online Model Test (Baisakh 17, 07:00 PM)

• 1. 9th, 10th and 11th cranial nerves form nucleus ambiguus which is classified as
• a. Special visceral efferent
• b. General somatic efferent
• c. General visceral efferent
• d. General somatic afferent

• Ans: a
• Ref: Inderbir Singh embryology 12th edition; Pg 297-299

• Afferent columns in alar lamina: The four functional columns in alar lamina are:
• • General visceral afferent (GVA): concerned with visceral sensations conveyed through 9th and 10th cranial nerves.
• • Special visceral afferent (SVA): concerned with taste sensation conveyed through 7th, 9th and 10th cranial nerves from the tongue, pharynx and soft palate.
• • General somatic afferent (GSA): contains mesencephalic, chief and spinal nuclei of trigeminal nerve concerned with proprioception, touch, and pain and temperature sensations respectively from the head and neck region.
• • Special somatic afferent (SSA): contains vestibular and cochlear nuclei concerned with equilibrium and hearing.

• Efferent columns of basal lamina: The three functional columns in basal lamina are:
• • General somatic efferent (GSE): contains nuclei of cranial nerves (3rd, 4th, 6th and 12th) that supply the extraocular muscles of eyeball and musculature of tongue.
• • Special visceral efferent/Branchial efferent (SVE): contains the nuclei of cranial nerves (5th, 7th, 9th, 10th and 11th) that supply to musculature derived from pharyngeal arches.
• • General visceral efferent (GVE): contains the cranial nerve nuclei of origin for preganglionic neurons of peripheral parasympathetic ganglia.
• • Edinger-Westphal nucleus (3rd cranial nerve): Ciliary ganglion
• • Superior salivatory nucleus (7th cranial nerve): Pterygopalatine and submandibular ganglia
• • Inferior salivatory nucleus (9th cranial nerve): Otic ganglion
• • Dorsal nucleus of vagus (10th cranial nerve): for supply of thoracic and abdominal viscera.

• 2. In triage the second priority is given to which of the color coding
• a. Black
• b. Blue
• c. Yellow
• d. Green

• Ans: C
• Ref: Park PSM 23rd Edition, Page No: 796-797
• Triage
• When the quantity and severity of injuries overwhelm the operative capacity of health facilities, a different approach to medical treatment must be adopted. The principle of "first come, first treated", is not followed in mass emergencies. Triage consists of rapidly classifying the injured on the basis of the severity of their injuries and the likelihood of their survival with prompt medical intervention. It must be adopted to locally available skills. Higher priority is granted to victims whose immediate or long-term prognosis can be dramatically affected by simple intensive care. Moribund patients who require a great deal of attention, with questionable benefit, have the lowest priority. Triage is the only approach that can provide maximum benefit to the greatest number of injured in a major disaster situation.

• Although different triage systems have been adopted and are still in use in some countries, the most common classification uses the internationally accepted four colour code system.
• • Red indicates high priority treatment or transfer,
• • Yellow signals medium priority,
• • Green indicates ambulatory patients and
• • Black for dead or moribund patients.

Triage should be carried out at the site of disaster, in order to determine transportation priority, and admission to the hospital or treatment centre, where the patient's needs and priority of medical care will be reassessed. Ideally, local health workers should be taught the principles of triage as part of disaster training. Persons with minor or moderate injuries should be treated at their own homes to avoid social dislocation and the added drain on resources of transporting them to central facilities. The seriously injured should be transported to hospitals with specialized treatment facilities.

• 3. Infliximab is:
• a. IgG1 chimeric monoclonal antibody against TNF alpha
• b. IgG1 fully human monoclonal antibody against TNF alpha
• c. IgG4 chimeric monoclonal antibody against TNF alpha
• d. P75 TNF receptor fusion protein

• Ans: a
• Ref: Katzung Pharmacology 12th Edition, Page No: 993
• Infliximab
•  Human-mouse chimeric IgG 1 monoclonal antibody possessing human constant (Fc) regions and murine variable regions.
•  It is administered intravenously but has the same anti- TNF-α activity as adalimumab and etanercept. Infliximab is currently approved for use in Crohn’s disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, plaque psoriasis, and psoriatic arthritis.

• 4. Rugger Jersey spine is seen in
• a. Fluorosis
• b. Achondroplasia
• c. Renal osteodystrophy
• d. Marfan’s syndrome

• Ans: c
•  Rugger jersey spine describes the prominent endplate densities at multiple contiguous vertebral levels to produce an alternating sclerotic-lucent-sclerotic appearance.
•  This mimics the horizontal stripes of a rugby jersey. This term and pattern are distinctive for hyperparathyroidism.
•  Seen in osteopetrosis and renal osteodystrophy. In patient with renal osteodystrophy, this appearance is due to hyperparathyroidism and osteosclerosis.

• 5. Ormond’s disease is:
• a. Idiopathic lymphadenopathy
• b. Retractile testis
• c. Idiopathic retroperitoneal fibrosis
• d. Idiopathic mediastinitis

• Ans: c
• Ref: Bailey and Love 27th Edition, Page No: 1064-1065
• Retroperitoneal fibrosis
• • This is a relatively rare diagnosis characterized by the development of a flat grey/white plaque of tissue, which is found first in the low lumbar region but then spreads laterally and upwards to encase the common iliac vessels, ureters and aorta. Histological appearances vary from active inflammation with a high cellular content interspersed with bundles of collagen through to one of acellularity and mature fibrosis/calcification.
• • Its etiology is obscure in most cases (idiopathic-) being allied to other fibromatoses (others being Dupuytren’s contracture and Peyronie’s disease). In other patients the cause is known.
• • The clinical presentation may be one of ill-defined chronic backache or occur as a result of compromise to involved structures, e.g. lower limb or scrotal edema secondary to venous occlusion, or chronic renal failure secondary to ureteric obstruction. Treatment will be directed to the cause, the modification of disease activity when appropriate, e.g. immunomodulation with steroids, tamoxifen and restoration of flow in affected structures, e.g. ureteric stenting.

Causes of retroperitoneal fibrosis: Idiopathic (Ormond’s disease)

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• 1. CABG is preferred over PCI for revascularization in the following situations except
• a. Severe left main disease
• b. Three vessel disease
• c. In patients with DM
• d. Favorable anatomy

• Ans: d
• CABG is preferred over PCI in most severe left main and three-vessel disease or those with diabetes.
• Otherwise PCI is preferred to CABG, specially when there is favorable anatomy.
• Reference: UpToDate

• 2. HDV RNA requires which of the following for its replication?
• a. Host RNA polymerase I
• b. Viral RNA polymerase I
• c. Host RNA polymerase II
• d. Viral RNA polymerase II

• Ans: c
• Ref: Harrison 19th Edition, Page No: 2009
• HDV RNA requires host RNA polymerase II for its replication via RNA-directed RNA synthesis by transcription of genomic RNA to a complementary antigenomic (plus strand) RNA. The antigenomic RNA, in turn, serves as a template for subsequent genomic RNA synthesis.

• 3. Trachea begins at the level of:
• a. Lower border of thyroid cartilage
• b. Lower border of cricoid
• c. Lower border of hyoid
• d. Fourth cervical vertebra

• Ans: b
• Ref: Snell Clinical Anatomy; 9th edition; Page No: 63
• o The trachea is a mobile cartilaginous and membranous tube. It begins in the neck as a continuation of the larynx at the lower border of the cricoid cartilage at the level of the 6th cervical vertebra. It descends in the midline of the neck.
• o In the thorax, the trachea ends below at the carina by dividing into right and left principal (main) bronchi at the level of the sternal angle (opposite the disc between the 4th and 5th thoracic vertebrae).
• o During expiration, the bifurcation rises by about one vertebral level, and during deep inspiration may be lowered as far as the 6th thoracic vertebra.

• 4. A 22 year old patient presents with excessive wax in both ears. This is due to secretion from the gland:
• a. Modified eccrine glands
• b. Modified apocrine glands
• c. Mucous gland
• d. Modified holocrine glands

• Ans: b
• Ref: PL Dhingra and Shruti Dhingra ENT and HNS 6th Edition, Page No: 53
• • Wax is composed of secretion of sebaceous glands, ceruminous glands, hair, desquamated epithelial debris, keratin and dirt.
• • Sebaceous and ceruminous (modified sweat glands) glands open into the space of the hair follicle.
• • Sebaceous glands provide fluid rich in fatty acids while secretion of ceruminous gland is rich in lipids and pigment granules. Secretion of both these glands mixes with the desquamated epithelial cells and keratin shed from the tympanic membrane and deep bony meatus to form wax.

• 1. A 6 year old child has briefly sustained flexion or extension of predominantly proximal muscles, including truncal muscles. The EEG usually shows diffuse, giant slow waves with a chaotic background of irregular, multifocal spikes and sharp waves. The type of seizure probably is
• a. Epileptic spasm
• b. Atonic seizure
• c. Myoclonic seizure
• d. Absence seizure

• Ans: a
• Ref: Harrison 20th Edition, Page No: 3052
• Epileptic spasms are characterized by a briefly sustained flexion or extension of predominantly proximal muscles, including truncal muscles. The EEG usually shows hypsarrhythmia, which consist of diffuse, giant slow waves with a chaotic background of irregular, multifocal spikes and sharp waves. During the clinical spasm, there is a marked suppression of the EEG background (the “electrodecremental response”). The electromyogram (EMG) also reveals a characteristic rhomboid pattern that may help distinguish spasms from brief tonic and myoclonic seizures. Epileptic spasms occur predominantly in infants and likely result from differences in neuronal function and connectivity in the immature versus mature CNS.

• 2. A 5-year-old child is noted to be iron deficient. Upon questioning, his family reports several episodes of grossly bloody (maroon) stools. Which of the following is a likely explanation for his anemia?
• a. Increased demands for iron due to accelerated growth
• b. Meckel diverticulum
• c. Infestation by hookworm
• d. Recurrent epistaxis

• Ans: b
• Ref: Nelson pediatrics, 20th Edition, Page No: 1804, 1805
•  Iron deficiency is most common between 6 months and 3 years of age. During this period, the need for iron is increased because of accelerated growth, and this need is often not met when the diet consists predominantly of cow’s milk, a uniquely iron-poor food. Growth plateaus during the preschool and preadolescent years and the mixed diets of children in this period are more likely to provide them with adequate iron. Chronic loss of blood from the intestinal tract or from nosebleeds can quickly deplete the iron stores of children. In adolescence, there are increased requirements for iron because of rapid growth. The adolescent female has the additional risk of becoming iron deficient from the loss of menstrual blood.
•  Grossly positive blood in the stool of this patient requires further evaluation. The Meckel diverticulum results from an embryologic remnant of the vitelline duct. Gastric tissue in the area ulcerates, causing intermittent bleeding. Blood can be microscopic or massive and grossly positive. The bleeding is often painless and is intermittent. The diverticulum can serve as a lead point for intussusception with resultant symptoms of obstruction. The diagnosis is with a Meckel scan (Tc99m pertechnetate nuclear scan), which demonstrates a lesion in the right lower quadrant.

• 3. What is true about Okazaki pieces?
• a. Continuously synthesized
• b. Fragments of RNA
• c. Synthesized by lagging strand
• d. Joined by endonuclease

• Ans: c
• Ref: Satyanarayan Biochemistry, 4th edition, Page No: 525 – 526
• • Okazaki pieces are small fragments of the discontinuously synthesized DNA.
• • These are produced on the lagging strand of the parent DNA.
• • Okazaki pieces are later joined to form a continuous strand of DNA. DNA polymerase I and DNA ligase are responsible for this process.

• 4. Neisseria gonorrhoeae attaches to host cells using which of the following?
• a. IgA1 protease
• b. Lipooligosaccharide
• c. Outer membrane protein
• d. Pili

• Ans: d
• Ref: Jawetz Microbiology, 27th edition, page 282
• • Pili (fimbriae) are hairlike appendages that extend up to several micrometers from the gonococcal surface. They enhance attachment to host cells and resist phagocytosis.
• • The pilins of almost all strains of N gonorrhoeae are antigenically different, and a single strain can make many antigentically distinct forms of pili.

• 5. Lancefield grouping of streptococci is done by using:
• a. M protein
• b. Group C carbohydrate antigen in cell wall
• c. Group C peptidoglycan cell wall
• d. M antigen

• Ans: b
• Ref: Surinder Microbiology; 1st edition; Page No: 241
• • The work of Rebecca Lancefield in 1933 laid the groundwork for the serological classification of B hemolytic streptococci. On the basis of group-specific carbohydrate (C) antigens in the cell wall, B hemolytic streptococci are divided into 21 serological groups from A to W (without I and J). These are known as Lancefield groups. Groups A, B, C, D, and G are most commonly found associated with human infections.
• Griffith Typing
• • Hemolytic streptococci of group A are known as Str. pyogenes. These are further divided into types based on the protein (M, T and R) antigens present on the cell surface (Griffith typing). About eighty types of Str. pyogenes have been recognized so far (types 1, 2, 3 and so on).

• 6. Which of the following helps in entry of SARS-CoV-2 entry into the cells?
• a. Transmembrane protease, serine 1
• b. Transmembrane protease, serine 2
• c. Transmembrane protease, thymine 1
• d. Transmembrane protease, thymine 2

• Ans: a
• • Each SARS-CoV-2 virion is approximately 50–200 nanometres in diameter.
• • Like other coronaviruses, SARS-CoV-2 has four structural proteins, known as the S (spike), E (envelope), M (membrane), and N (nucleocapsid) proteins; the N protein holds the RNA genome, and the S, E, and M proteins together create the viral envelope.
• • The spike protein, which has been imaged at the atomic level using cryogenic electron microscopy, is the protein responsible for allowing the virus to attach to and fuse with the membrane of a host cell.
• • Protein modeling experiments on the spike protein of the virus soon suggested that SARS-CoV-2 has sufficient affinity to the receptor angiotensin converting enzyme 2 (ACE2) on human cells to use them as a mechanism of cell entry.
• • Initial spike protein priming by transmembrane protease, serine 2 (TMPRSS2) is essential for entry of SARS-CoV-2. After a SARS-CoV-2 virion attaches to a target cell, the cell's protease TMPRSS2 cuts open the spike protein of the virus, exposing a fusion peptide. The virion then releases RNA into the cell and forces the cell to produce and disseminate copies of the virus, which infect more cells.
• • SARS-CoV-2 produces at least three virulence factors that promote shedding of new virions from host cells and inhibit immune response.

• 1. Which of the following is not microbial sensor?
• a. TLRs
• b. NOD-like receptors (NLRs)
• c. RIG-1 like helicases and MDA-5
• d. Transcriptase

• Ans: d
• Ref: Jawetz Microbiology 26th Edition, Page No: 124
• When a pathogen enters the skin, it is confronted with macrophages and other phagocytic cells possessing “microbial sensors.”
• There are three major groups of microbial sensors: (1) TLRs, (2) NOD-like receptors (NLRs), and (3) RIG-1 like helicases and MDA-5. The best studied of the microbial sensors are the TLR.

• 2. IL-12 is secreted by:
• a. Dendritic cells
• b. Macrophages
• c. B cells
• d. All of the above

• Ans: d
• Ref: Jawetz Microbiology 26th Edition, Page No: 130
• Cytokines, Primary cells and their Activity
• • IL-1: Most cells, macrophages, dendritic cells; Induces inflammation, fever and sepsis, activate TNF-α
• • IL-2: T cells; Induces proliferation and maturation of T cells
• • IL-6: Most cells; B cell stimulation, mediator of acute phase reactions
• • IL-10: T cells, monocytes/macrophages; Inhibits IFN-γ and IL-12 production
• • IL-11: Bone marrow stromal cells, mesenchymal cells; Synergistic effects on hematopoiesis and thrombopoiesis, cytoprotective effects on epithelial cells, induces immunosuppression
• • IL-12: Dendritic cells, macrophages, B cells; Induces production of IFN-γ , TNF-α, and IL-2 by resting and activated T and NK cells
• • IL-15: T cells, atrocytes, microglia, fibroblasts, epithelial cells; Biological activities similar to IL-2, induces proliferation of peripheral blood, mononuclear cells, maturation of NK cells (IL-1, IFN-γ, TNF-α)
• • IL-17 (6 members) (IL-17 A-F Th17 cells; Stimulates epithelial, endothelial, and fibroblastic cells to produce IL-6, IL-8, G-CSF, and ICAM-1
• • IL-23: Macrophages, dendritic cells; Similar to IL-12 (induces IFN-γ) helps to differentiate CD4 T cells to TH17

• 3. Replication of coronavirus occurs in:
• a. Cytoplasm
• b. Nucleus
• c. Cell membrane
• d. Mitochondria

• Ans: a
• Ref: Jawetz Microbiology 26th Edition, Page No: 613
• Properties of Coronaviruses
• • Virion: Spherical, 120–160 nm in diameter, helical nucleocapsid genome: Single-stranded RNA, linear, nonsegmented, positive-sense, 27–32 kb, capped and polyadenylated, infectious
• • Proteins: Two glycoproteins and one phosphoprotein. Some viruses contain a third glycoprotein (hemagglutinin esterase) envelope: Contains large, widely spaced, club- or petal-shaped spikes
• • Replication: Cytoplasm; particles mature by budding into endoplasmic reticulum and Golgi
• • Outstanding characteristics: Cause colds and SARS; Display high frequency of recombination; Difficult to grow in cell culture

• 4. The flow of electrons through the respiratory chain and the production of ATP are normally tightly coupled. The processes are uncoupled by which of the following?
• a. Cyanide
• b. Oligomycin
• c. Thermogenin
• d. Carbon monoxide

• Ans: c
• Ref: Harper Biochemistry 30th Edition, Page No: 264
• A thermogenic uncoupling protein, thermogenin, acts as a proton conductance pathway dissipating the electrochemical potential across the mitochondrial membrane.

• 5. In laryngeal trauma, which of the following structure is commonly involved?
• a. Thyroid cartilage
• b. Arytenoid cartilage
• c. Vocal cord
• d. Cricoid cartilage

• Ans: a
• Ref: Jacob Mandell; Visual Approach to Diagnostic Imaging; Core Radiology Page No: 289
• Blunt trauma to the neck may compress the larynx against the cervical spine. The thyroid cartilage and cricoid cartilage are susceptible to fracture, which may be difficult to detect in young patients with incomplete ossification of these structures.
• Laryngeal trauma may also result from intubation, which can cause arytenoid dislocation.

• 1. A change in the third nucleotide of a codon is likely to produce which type of mutation?
• a. Frameshift mutation
• b. Missense mutation
• c. Nonsense mutation
• d. Silent mutation

• Ans: d
• Ref: Harper’s Biochemistry, 30th edition, page 416 – 417

• Single base change mutation in the mRNA will have the following effects:
• ☆ Silent mutation: There may be no detectable effect because of the degeneracy of the code. This would be most likely if the changed base in mRNA molecule were to be at the third nucleotide of a codon. Because of wobble, the translation of a codon is least sensitive to a change at the third position.
• ☆A missense effect : will occur when a different amino acid is incorporated at the corresponding site in the protein molecule. This mistaken amino-acid – or missense, depending upon its location in the specific protein – might be acceptable, partially acceptable, or unacceptable to the function of that protein molecule.
• ☆A nonsense codon : may appear that would then result in the premature termination of translation and the production of only a fragment of the intended protein molecule. The probability is high that a prematurely terminated protein molecule or peptide fragment will not function in its normal role.

☆Frameshift mutations : result from deletion or insertion of nucleotides in DNA that generates altered mRNAs. The deletion of a single nucleotide from the coding strand of a gene results in an altered reading frame in the mRNA.

• 2. PFK -1 inhibitor:
• a. AMP
• b. Citrate
• c. ATP
• d. Both b and c

• Ans: d
• Ref: Harper biochemistry; 30th edition; Page No: 189
• Phosphofructokinase (phosphofructokinase-1) occupies a key position in regulating glycolysis and is also subject to feedback control. It is inhibited by citrate and by normal intracellular concentrations of ATP and is activated by 5′ AMP. At the normal intracellular [ATP] the enzyme is about 90% inhibited; this inhibition is reversed by 5′AMP.

• 3. Which of the following is not a step in PCR?
• a. Annealing
• b. Denaturation
• c. Transformation
• d. Synthesis

• Ans: c
• Ref: Satyanarayan biochemistry; 4th edition; Page No: 594
• The actual technique of PCR involves repeated cycles for amplification of target DNA.
• Each cycle has three stages.
• 1. Denaturation: On raising the temperature to about 95°C for about one minute, the DNA gets denatured and the two strands separate.
• 2. Renaturation or annealing: As the temperature of the mixture is slowly cooled to about 55°C, the primers base pair with the complementary regions flanking target DNA strands. This process is called renaturation or annealing. High concentration of primer ensures annealing between each DNA strand and the primer rather than the two strands of DNA.
• 3. Synthesis: The initiation of DNA synthesis occurs at 3c-hydroxyl end of each primer. The primers are extended by joining the bases complementary to DNA strands. The synthetic process in PCR is quite comparable to the DNA replication of the leading strand. However, the temperature has to be kept optimal as required by the enzyme DNA polymerase. For Taq DNA polymerase, the optimum temperature is around 75°C (for E. coli DNA polymerase, it is around 37°C). The reaction can be stopped by raising the temperature (to about 95°C).Each cycle of PCR takes about 3-5 minutes. In the normal practice, the PCR is carried out in an automated machine.

• 4. A 7-year-old boy has fallen on an outstretched hand and complains of a painful right elbow. When reviewing the radiographs for evidence of bony injury, which one of the following statements is true?
• a. A posterior fat pad may be a normal finding on a flexed lateral view.
• b. An anterior fat pad is always abnormal.
• c. The line from the anterior cortex of the humerus should pass through the anterior third of the capitellum.
• d. The radiocapitellar line should intersect on all views.

• Ans: d
• Ref: Grainger and Allison's Radiology, 5th Edition, Page No: 1614
• If a line does not intersect the capitellum on all views, a dislocation should be suspected.

• Plain radiograph in supracondylar humeral fracture:
• Lateral and AP radiographs are usually sufficient, and in many instances demonstrate an obvious fracture. Often, however, no fracture line can be identified. In such cases assessing for indirect signs is essential:
• • Anterior fat pad sign (sail sign : the anterior fat pad is elevated by a joint effusion and appears as a lucent triangle on the lateral projection
• • Posterior fat pad sign
• • Anterior humeral line should intersect the middle third of the capitellum in most children although, in children under 4, the anterior humeral line may pass through the anterior third without injury.

• 5. Which is a form of cold sterilization?
• a. Infrared rays
• b. Gamma rays
• c. Beta rays
• d. Autoclave

• Ans: b
• Ref: Surinder Singh microbiology;1st edition; Page No:46
• Ionizing Radiation
• These include X-rays, γ (gamma) rays and cosmic rays. These have very high penetrative power and are highly lethal to all cells including bacteria. Ionizing radiations damage the DNA by various mechanisms and include structural defects in microbial DNA synthesis, leading to cell death. Bacterial spores are generally more resistant than vegetative cells, and spores are among the most radiation resistant microorganisms known.

• Applications
• i. For sterilization in pharmacy and medicine.

ii. Sterilization of packaged disposable articles: Such as plastic syringes, intravenous lines, catheters and gloves that are unable to withstand heat.

• Cold Sterilization
• Since there is no appreciable increase in temperature in this method it is known as cold sterilization. Large commercial plants use gamma radiation emitted from a radioactive element, usually cobalt 60 for this type of sterilization.

iii. Use for antibiotics, hormones, sutures, and vaccines and to prevent food spoilage.

• 1. Coronavirus genome is:
• a. Segmented genome of positive-sense, single stranded RNA
• b. Unsegmented genome of positive-sense, single stranded RNA
• c. Segmented genome of negative-sense, single stranded RNA
• d. Unsegmented genome of negative-sense, single stranded RNA

• Ans: b
• Ref: Jawetz Microbiology 26th Edition, Page No: 412, 413
•  Coronaviruses are enveloped 120- to 160-nm particles containing an unsegmented genome of positive-sense, single stranded RNA, 27–32 kb in size; the nucleocapsid is helical, 9–11 nm in diameter. Coronaviruses resemble orthomyxoviruses but have petal-shaped surface projections arranged in a fringe, similar to a solar corona.
•  Coronavirus nucleocapsids develop in the cytoplasm and mature by budding into cytoplasmic vesicles. These viruses have narrow host ranges.

• 2. What is the source of secretion of erythropoietin?
• a. Bone marrow
• b. Liver
• c. Lungs
• d. Kidneys

• Ans: d
• Ref: Guyton & Hall Physiology, 13th edition, page 324
• The kidneys secrete erythropoietin, which stimulates the production of red blood cells by hematopoietic stem cells in the bone marrow. One important stimulus for erythropoietin secretion by the kidneys is hypoxia. The kidneys normally account for almost all the erythropoietin secreted into the circulation. In people with severe kidney disease or who have had their kidneys removed and have been placed on hemodialysis, severe anemia develops as a result of decreased erythropoietin production.

• 3. What is the commonest type of choanal atresia?
• a. Unilateral bony
• b. Unilateral membranous
• c. Bilateral bony
• d. Bilateral membranous

• Ans: a
• Ref: PL Dhingra and Shruti Dhingra ENT and HNS 7th Edition, Page No: 183
• Choanal atresia occurs due to persistence of bucconasal membrane and may be unilateral or bilateral, complete or incomplete, bony (90%) or membranous (10%). Unilateral atresia is more common and may remain undiagnosed until adult life. Bilateral atresia presents with respiratory obstruction as the newborn.

• 4. Receptors used by Rhinovirus is:
• a. Integrins
• b. CD21
• c. CXCR4
• d. ICAM-1

• Ans: d
• Ref: USMLE Step 1 First Aid 2020, Page No: 166
• Receptors used by viruses:
•  CMV: Integrins (heparan sulfate)
•  EBV: CD21
•  HIV: CD4, CXCR4, CCR5
•  Parvovirus B19: P antigen on RBCs
•  Rabies: Nicotinic AChR
•  Rhinovirus: ICAM-1

• 5. An immunologically mediated adverse effect producing a known set of symptoms & signs which are not related to the mechanism of action of the specific drug is known as:
• a. Intolerance
• b. Idiosyncrasy
• c. Hypersensitivity
• d. Toxicity

• Ans: c
• Ref: KDT Pharmacology 8th Edition, Page 94 - 96
• • Idiosyncrasy refers to genetically determined abnormal reactivity to a chemical.
• • Intolerance is the appearance of characteristic toxic effects of a drug in an individual at therapeutic doses.
• • Hypersensitivity is an immunologically mediated reaction producing stereotype symptoms which are unrelated to the pharmacodynamic profile of the drug.
• • Toxicity are the results of excessive pharmacological action of the drug due to overdosage or prolonged usage.

• 6. Carman’s meniscus sign is diagnostic of:
• a. Peptic ulcer
• b. Cholecystitis
• c. Meconium ileus
• d. Carcinoma of stomach

• Ans: d
• Ref: Jacob Mandell; Visual Approach to Diagnostic Imaging; Core Radiology Page No: 133
• Benign gastric ulcer
• Although less commonly encountered in the modern era of proton pump inhibitors and Helicobacter pylori treatment, benign gastric ulcers tend to have typical imaging findings:
• • Radiating gastric folds are smooth and symmetric.
• • Ulcer extends beyond the normal contour of the gastric lumen.
• • The Hampton line represents nonulcerated acid-resistant mucosa surrounding the ulcer crater.
• • Most benign ulcers occur along the lesser curvature of the stomach, although benign ulcers associated with aspirin ingestion can occur in the greater curvature and antrum, which are dependent locations.

• Gastric carcinoma
• Gastric carcinoma may present with malignant ulceration, which can usually be distinguished from a benign ulcer by the following features:
• • Asymmetric ulcer crater, with surrounding nodular tissue.
• • Abrupt transition between normal gastric wall and surrounding tissue.
• • Ulcer crater does not project beyond the expected location of gastric wall.
• • The Carman meniscus sign is considered pathognomonic for tumor. It describes the splaying open of a large, flat malignant ulcer when compression is applied.

• 1. Which of the following is ethically correct?
• a. A physician should not enter into any emotional or sexual relationship with patient
• b. A physician should not enter into any emotional or sexual relationship with patient but can do with member of patient's family at personal level
• c. A physician can enter into any emotional or sexual relationship with patient, if they have affair
• d. There is no ethical recommendation if the relationship is private

• Ans: a
• A physician should not enter into any emotional or sexual relationship with patient or a member of patient's family, which may disrupt the patient's life, damage, or distress the patient or his or her family.

• 2. The genetic testing in an asymptomatic child with positive family history of Huntington chorea is called:
• a. Predisposional testing
• b. Predictive testing
• c. Diagnostic testing
• d. Pharmacogenetic testing

• Ans: b
• Ref: Nelson pediatrics, 20th Edition, Page No: 581, 582
• Predictive testing
• Predictive genetic testing involves performing a test in a person who is at risk for developing a genetic disorder (presymptomatic), usually on the basis of family history, yet who does not manifest signs or symptoms. This is usually done for disorders that display age-dependent penetrance; the likelihood of manifesting signs and symptoms increases with age, as in cancer or Huntington disease.

• Predispositional testing
• It is expected that genetic tests will become available that will predict risk of disease. Common disorders are multifactorial in etiology; there may be many different genes that contribute to risk of any specific condition. Most of the genetic variants that have been found to correlate with risk of a common disease add small increments of relative risk, probably in most cases too little to guide management.

• Pharmacogenetic testing
• Polymorphisms in drug metabolism genes can result in distinctive patterns of drug absorption, metabolism, excretion, or effectiveness. Knowledge of individual genotypes will guide pharmacologic therapy, allowing customization of choice of drug and dosage to avoid toxicity and provide a therapeutic response. An example of this is testing for polymorphisms within the methylenetetrahydrofolate reductase (MTHFR) gene for susceptibility of potentially increased toxicity to methotrexate antimetabolite therapy for treatment of acute lymphoblastic leukemia.

• 3. The combination of trimethoprim and sulfamethoxazole is effective against which of the following opportunistic infections in the AIDS patient?
• a. Disseminated Herpes simplex
• b. Cryptococcal meningitis
• c. Pneumocystis jiroveci
• d. Tuberculosis

• Ans: c
• Ref: KDT Pharmacology 7th Edition, Page No: 706,707
• COTRIMOXAZOLE
• • The fixed dose combination of trimethoprim and sulfamethoxazole is called cotrimoxazole.
• • Trimethoprim is a diaminopyrimidine related to the antimalarial drug pyrimethamine which selectively inhibits bacterial dihydrofolate reductase (DHFRase).
• • Antibacterial spectra of trimethoprim and sulfonamides overlap considerably.
• • Additional organisms covered by the combination are—Salmonella typhi, Serratia, Klebsiella, Enterobacter, Yersinia enterocolitica, Pneumocystis jiroveci and many sulfonamide-resistant strains of Staph. aureus, Strep. pyogenes, Shigella, enteropathogenic E. coli, H.influenzae, gonococci and meningococci.

• 4. Tract present in middle cerebellar peduncle is:
• a. Dentato-thalamic
• b. Posterior spinocerebellar
• c. Olivocerebellar
• d. Pontocerebellar

• Ans: d
• Ref: USMLE Step 1 First Aid 2020, Page No: 499
• Input in cerebellum:
•  Contralateral cortex via middle cerebellar peduncle
•  Ipsilateral proprioceptive information via inferior cerebellar peduncle from spinal cord
•  Middle cerebellar peduncle has incoming (afferent) fibers from the contralateral pons (ponto-cerebellar) fibers.
•  Dentato-thalamic fibers pass through superior cerebellar peduncle from the dentate nucleus to synapse in thalamus.
•  Posterior spino-cerebellar and the olivo cerebellar fibers pass through the inferior cerebellar peduncle.

• 5. Forgarty’s catheter is used for:
• a. Embolectomy
• b. Angiography
• c. Drainage
• d. Suprapubic catheterization

• Ans: a
• Ref: Bailey & Love’s Surgery; 27th edition; Pg 955
• Embolectomy
• Local or general anaesthesia may be used. The artery (usually the femoral), bulging with clot, is exposed and held in silastic vessel loops. Through a transverse incision the clot begins to extrude and is removed, together with the embolus, with the help of a Fogarty balloon catheter. The catheter, with its balloon tip, is introduced both proximally and distally until it is deemed to have passed the limit of the clot. The balloon is inflated and the catheter withdrawn slowly,together with any obstructing material. The procedure is repeated until bleeding occurs. An angiogram may be performed in the operating theatre at the end of the procedure to ensure that flow to the distal leg has been restored. Postoperatively, heparin therapy is continued until long-term anticoagulation with warfarin is established to reduce the chance of further embolism.

Which of the following is not a component of Syndrome Z?

• A. Obstructive sleep apnoea
• B. Blood pressure more than 130/85 mm Hg
• C. Fasting triglyceride more than 150mg/dl
• D. LDL more than 100mg/dl

Correct answer: D. LDL more than 100mg/dl

• Explanation:
• Syndrome Z is a combination of obstructive sleep apnoea and metabolic syndrome. Metabolic syndrome is diagnosed if any three of the following conditions are met:
• 1. Fasting plasma glucose level > 100mg/dl
• 2. Blood pressure > 130/85 mm Hg
• 3. Fasting triglyceride level > 150mg/dl
• 4. HDL cholesterol level < 40mg /dl (men) and < 50mg/dl (women)
• 5. Waist circumference > 102cm (men) and > 88cm (women)

• Which of the following helps in entry of SARS-CoV-2 entry into the cells?
• a. Transmembrane protease, serine 1
• b. Transmembrane protease, serine 2
• c. Transmembrane protease, thymine 1
• d. Transmembrane protease, thymine 2

• Ans: b
• • Each SARS-CoV-2 virion is approximately 50–200 nanometres in diameter.
• • Like other coronaviruses, SARS-CoV-2 has four structural proteins, known as the S (spike), E (envelope), M (membrane), and N (nucleocapsid) proteins; the N protein holds the RNA genome, and the S, E, and M proteins together create the viral envelope.
• • The spike protein, which has been imaged at the atomic level using cryogenic electron microscopy, is the protein responsible for allowing the virus to attach to and fuse with the membrane of a host cell.
• • Protein modeling experiments on the spike protein of the virus soon suggested that SARS-CoV-2 has sufficient affinity to the receptor angiotensin converting enzyme 2 (ACE2) on human cells to use them as a mechanism of cell entry.
• • Initial spike protein priming by transmembrane protease, serine 2 (TMPRSS2) is essential for entry of SARS-CoV-2. After a SARS-CoV-2 virion attaches to a target cell, the cell's protease TMPRSS2 cuts open the spike protein of the virus, exposing a fusion peptide. The virion then releases RNA into the cell and forces the cell to produce and disseminate copies of the virus, which infect more cells.
• • SARS-CoV-2 produces at least three virulence factors that promote shedding of new virions from host cells and inhibit immune response.

• 1. The most commonly diagnosed multiple sclerosis belongs to following category
• A.Relapsing-remitting MS (RRMS)
• B.Primary progressive MS (PPMS)
• C.Secondary progressive MS (SPMS)
• DProgressive-relapsing MS (PRMS)

Ans is A

Approximately 85% of all MS cases present as RRMS. The categories are based on frequency of clinical relapses, progression, and lesion development, as detected by MRI. RRMS is characterized by recurrent attacks of neurologic deficits referable to different parts of the central nervous system that resolve completely or almost completely over a short period of time with little to no residual deficit. Clinically isolated syndrome (CIS) and benign MS are sometimes counted as subgroups of RRMS. CIS describes a single episode of neurologic symptoms, whereas patients with benign MS achieve almost complete remission between relapses, with little or no accumulated physical disability over decades.

About half of patients diagnosed initially with RRMS will convert to a secondary progressive pattern within 10-15 years. Once patients have SPMS, they may or may not experience relapses but the disease will continually progress, with increasing disability. PPMS is associated with steady functional decline with no relapses; it accounts for 10%-15% of MS cases. Less than 5% of patients with MS have PRMS, in which the disease is progressive, with occasional relapses.

• 2. The duration of uncontrolled asthma required for the diagnosis of Severe asthma is
• A.1 month
• B.3-6 months
• C.6-9 months
• D.9+ months

Ans B

• According to the GINA report, a diagnosis of severe asthma should be made if difficult-to-treat asthma remains after about 3-6 months of management that includes:
• · Providing asthma education
• · Optimizing treatment
• · Treating comorbidities and modifiable risk factors
• · Considering nonbiologic add-on therapy, nonpharmacologic interventions, and a trial of high-dose inhaled corticosteroids

• 3.Which of the following statement is most accurate regarding deep vein thrombosis?
• A.DVT involving vena cava or pelvic veins produces unilateral leg edema rather than bilateral
• B.Pain and tenderness associated with DVT correlates with the size, location, and extent of thrombus
• C.DVT that is present without causing a net venous outflow obstruction is often asymptomatic
• D.DVT can often be diagnosed or excluded based solely on clinical findings

Ans is C

DVT classically produces pain and limb edema; however, in a given patient, symptoms may be present or absent, unilateral or bilateral, or mild or severe. A thrombus that does not cause a net venous outflow obstruction is often asymptomatic. DVT that involves the iliac bifurcation, pelvic veins, or vena cava produces leg edema that is usually bilateral rather than unilateral. High partial obstruction often produces mild bilateral edema that is mistaken for the dependent edema of right-sided heart failure, fluid overload, or hepatic or renal insufficiency.

Leg pain is commonly associated with DVT, but this is entirely nonspecific. Pain can occur on dorsiflexion of the foot (Homan sign). Tenderness occurs in most patients but is also found in many patients without objectively confirmed DVT. When tenderness is present, it is usually confined to the calf muscles or along the course of the deep veins in the medial thigh. Pain and/or tenderness away from these areas is not consistent with venous thrombosis and usually indicates another diagnosis. The pain and tenderness associated with DVT does not usually correlate with the size, location, or extent of the thrombus. DVT cannot be diagnosed or excluded based on clinical findings.

• 4.The most frequent cause of secondary hypertension is
• A.Hyperthyroidism
• B.Hypothyroidism
• C.Obstructive sleep apnea
• D.Aortic coarctation

Ans is C

• Although the vast majority of patients have primary or essential hypertension, secondary hypertension is identified in approximately 10% of adult patients. Common causes of secondary hypertension include the following:
• Renovascular disease
• Obstructive sleep apnea
• Renal parenchymal disease
• Primary aldosteronism
• Drug- or alcohol-induced

• Uncommon causes include the following:
• · Pheochromocytoma/paraganglioma
• · Cushing syndrome
• · Hypothyroidism
• · Hyperthyroidism
• · Aortic coarctation
• · Primary hyperparathyroidism
• · Congenital adrenal hyperplasia
• · Mineralocorticoid excess syndromes (other than primary aldosteronism)
• · Acromegaly

• 5. Which of the following is the cause for orthostatic hypotension in the patient with Sickle cell disease?
• A.Patients with SCD rarely drink any liquids
• B.Heart failure
• C.Inabality of urine concentration urine because of damage to the kidneys
• D.Pulmonary hypertension

• Ans : C
• Orthostatic hypotension can be common in patients with SCD. Patients with SCD may be susceptible to hypovolemia, leading to vaso-occlusive painful crises due to loss of renal concentrating capacity. Patients with SCD are taught early on about the need to drink a lot of fluids, and it is often the first thing a patient will try if they feel like a crisis is coming on.

Heart failure in patients with SCD is often underrecognized and diagnosed at a late congestive stage.

Pulmonary hypertension is associated with high mortality in patients with SCD.

• 1. A 25 year old boy presents with renal failure. His uncle died of renal failure three years ago. Slit lamp examination reveals Lenticonus / Keratoconus. The likely diagnosis is:
• a. Autosomal dominant polycystic kidney disease (ADPCKD)
• b. Autosomal recessive polycystic kidney disease (ARPCKD)
• c. Alport’s syndrome
• d. Denysh-Drash syndrome

• Ans: c
• Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1847
• ALPORT’S SYNDROME
• • Classically, patients with Alport’s syndrome develop hematuria, thinning and splitting of the GBMs, mild proteinuria (<1–2 g/24 h), which appears late in the course, followed by chronic glomerulosclerosis leading to renal failure in association with sensorineural deafness.
• • Some patients develop lenticonus of the anterior lens capsule, “dot and fleck” retinopathy, and rarely, mental retardation or leiomyomatosis.

• 2. Greater superficial petrosal nerve arises from:
• a. Meatal segment
• b. Labyrinthine segment
• c. Horizontal segment
• d. Vertical segment

• Ans: c
• Ref: PL Dhingra and Shruti Dhingra ENT and HNS 6th Edition, Page No: 90
• BRANCHES OF FACIAL NERVE
• • Greater superficial petrosal nerve : It arises from geniculate ganglion and carries secretomotor fibres to lacrimal gland and the glands of nasal mucosa and palate.
• • Nerve to stapedius : It arises at the level of second genu and supplies the stapedius muscle.
• • Chorda tympani : It arises from the middle of vertical segment, passes between the incus and neck of malleus, and leaves the tympanic cavity through petrotympanic fissure. It carries secretomotor fibres to submandibular and sublingual glands and brings taste from anterior two-thirds of tongue.

• 3. What is the duration needed to label a case of diarrhea as chronic?
• a. > 2 weeks
• b. > 4 weeks
• c. > 6 weeks
• d. > 8 weeks

• Ans: B, > 4 weeks
• Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 261
• • Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased frequency. For adults on a typical Western diet, stool weight >200 g/d can generally be considered diarrheal.
• • Diarrhea may be further defined as acute if <2 weeks, persistent if 2–4 weeks, and chronic if >4 weeks in duration.
• • Two common conditions, usually associated with the passage of stool totaling <200 g/d, must be distinguished from diarrhea, because diagnostic and therapeutic algorithms differ. Pseudodiarrhea, or the frequent passage of small volumes of stool, is often associated with rectal urgency, tenesmus, or a feeling of incomplete evacuation, and accompanies IBS or proctitis.
• • Fecal incontinence is the involuntary discharge of rectal contents and is most often caused by neuromuscular disorders or structural anorectal problems.

• 4. Which of the following is the most common cause of Cushing syndrome in a child is?
• a. Bilateral adrenal hyperplasia
• b. Exogenous administration of glucocorticoids
• c. Functioning adrenocortical tumor
• d. Pituitary adenoma

• Ans: b
• Ref: Nelson pediatrics, 20th Edition, Page No: 2723
• • The most common cause of Cushing syndrome is prolonged exogenous administration of glucocorticoid hormones, especially at the high doses used to treat lymphoproliferative disorders. This rarely represents a diagnostic challenge, but management of hyperglycemia, hypertension, weight gain, linear growth retardation, and osteoporosis often complicates therapy with corticosteroids.
• • Endogenous Cushing syndrome is most often caused in infants by a functioning adrenocortical tumor.

• 1. Radical mastoidectomy includes all except:
• a. Cochlea removed
• b. Ossicles removed
• c. Closure of the auditory tube
• d. Exteriorisation of mastoid
• Ans : a, Cochlea removed

• Ref: Diseases of Ear Nose and Throat, PL Dhingra, 6th edition, page no.405
• Radical mastoidectomy is a procedure to eradicate disease from middle ear and mastoid without any attempt to reconstruct hearing.
• It is rarely done these days – Its only indications are:
• •Malignancy of middle ear
• •When cholesteatoma cannot be removed safely e.g, if it invades eustachian tube, round window or perilabrynthine cells
• •If previous attempts to eradicate cholesteatoma have failed
• Following steps are done in radical mastoidectomy:
• •Posterior meatal wall is removed and the entire area of middle ear, attic, antrum and mastoid is converted into a single cavity, by removing the bridge and lowering the facial ridge.
• •All remnants of tympanic membrane, ossicles (except the stapes foot plate) and mucoperiosteal lining are removed (Not cochlea)
• •Eustachian tube is obliterated by a piece of muscle or cartilage
• .The diseased middle ear and mastoid are permanently exteriorised for inspection and cleaning.
• Remember: Bridge is the most posterosuperior part of bony meatal wall lateral to aditus and anturm, which overlies the Notch of Rivinus while facial ridge lies lateral to fallopian canal. Bridge is removed and ridge is lowered in radical or modified radical operation.

• 2.A known case of gall bladder stone landed up in emergency with complaints of pain over epigastric region since two days not relieved by proton pump inhibitors. On examination, you noticed bluish discoloration in the inguinal region. This sign is;
• a.Grey Turner’s sign
• b.Fox sign
• c.Cullen’s sign
• d.Hacking sign

• Ans :b Fox sign
• Ref: Short Practice of Surgery, Bailey and Love, 27th edition, page no.1223
• •Bleeding into the fascial planes can produce bluish discoloration of the flanks (Grey Turner’s sign) or umbilicus (Cullen’s sign). Neither sign is pathognomonic of acute pancreatitis; Cullen’s sign was first described in association with rupture of an ectopic pregnancy. Subcutaneous fat necrosis may produce small, red, tender nodules on the skin of the legs.
• •Fox's sign is a clinical sign in which bruising is seen over the inguinal ligament. It occurs in patients with retroperitoneal bleeding, usually due to acute hemorrhagic pancreatitis.

• 3. There are different types of cells in blood. Which of the following is less likely correct percentage regarding number of blood cells in a normal adult?
• a.Neutrophils around 60%
• b.Basophils around 0.5%
• c.Monocytes around 5%
• d.Lymphocytes around 60%

• Ans, D, Lymphocytes around 60%
• •Ref, Textbook of Medical Physiology, Guyton and Hall, 13th edition, page no.455
• •Lymphocytes are around 30% in a normal human body and not 60%
• •Concentrations of the Different White Blood Cells in the Blood.
• •The adult human being has about 7000 WBCs per microliter of blood (in comparison with 5 million red blood cells [RBCs] per microliter).
• •Of the total WBCs, the normal percentages of the different types are approximately the following:

• Polymorphonuclear neutrophils 62.0%
• Polymorphonuclear eosinophils 2.3%
• Polymorphonuclear basophils 0.4%
• Monocytes 5.3%
• Lymphocytes 30.0%

•The number of platelets, which are only cell fragments, in each microliter of blood is normally about 300,000.

• 4. Immediately following delivery uterus weighs about
• a.500gm
• b.1000gm
• c.60gm
• d.100gm

• Ans;b 1000gm
• Ref,dc dutta 8/e,p168,169
• INVOLUTION OF THE UTERUS:
• ANATOMICAL CONSIDERATION Uterus:
• •Immediately following delivery, the uterus becomes firm and retract with alternate hardening and softening.
• •The uterus measures about 20 × 12 × 7.5 cm3 (length, breadth and thickness) and weighs about 1,000 g.
• •At the end of 6 weeks, its measurement is almost similar to that of the nonpregnant state and weighs about 60 g.
• •The decrease in size of the uterus and cervix has been shown with serial MRI.
• •The placental site contracts rapidly presenting a raised surface which measures about 7.5 cm and remains elevated even at 6 weeks when it measures about 1.5 cm.
• Lower uterine segment:
• •Immediately following delivery, the lower segment becomes a thin, flabby and collapsed structure.
• •It takes a few weeks to revert back to the normal shape and size of the isthmus, i.e. the part between the body of the uterus and internal os of the cervix.
• Cervix:
• •The cervix contracts slowly; the external os admits two fingers for a few days but by the end of 1st week, narrows down to admit the tip of a finger only. The contour of the cervix takes a longer time to regain (6 weeks) and the external os never reverts back to the nulliparous state.

• 1. Most common complication of Shigellosis is:
• a. Hemolytic Uremic Syndrome (HUS)
• b. Reactive arthritis
• c. Pneumonia
• d. Meningitis

• Ans,a. Hemolytic Uremic Syndrome (HUS)
• Harrison 19th ed/pg.905,906
• Common complications:
• • Bacteremia
• • HUS : It occurs with S. dysenteriae type-1 infection. Manifestations of HUS usually develop at the end of first week of shigellosis.Oliguria, marked drop in hematocrit are the first signs & progresses to anuria with renal failure & severe anemia with congestive heart failure.
• Less common complications: Reactive arthritis
• Rare complications: Pneumonia; Meningitis; Vaginitis (in prepubertal girls);Keratoconjunctivitis & “rose spot” rashes.

• 2. Which one of the following act directly on thromboplastin to activate plasminogen:
• a. Streptokinase
• b. Urokinase
• c. Heparin
• d. rt-PA

• Ans,d. rt-PA
• Ref: Harrison’s 18th ed./p.1001
• • Streptokinase is obtained from cultures of Beta hemolytic streptococci. By itself, streptokinase has no PA activity, but when complexed with plasminogen, it can convert other plasminogen molecules to plasmin. It is not fibrin-selective in that the so-called lytic state resulting from its therapeutic use is due to lysis of fibrinogen as well as fibrin.
• • Recombinant tissue-type plasminogen activator (rt-PA) produced by recombinant technology demonstrates in vitro affinity for fibrin with which it forms a ternary complex with plasminogen. Despite reported fibrin-specificity, the lytic state is produced with dosages currently used. Bleeding complications with rt-PA are similar to those of streptokinase or urokinase.

• 3. If the fracture is intra-articular and extends through the epiphysis, physis and metaphysis,which type of Salter Harris classification does it fall under:
• a. Type II
• b. Type III
• c. Type IV
• d. Type V

• Ans,c. type IV
• Ref: Campbell’s 12th ed./p.1366
• Salter Harris classification : Epiphyseal / Physeal injuries
• • Type I: Complete separation of epiphysis from the metaphysis without fracture. Common in rickets, scurvy and osteomyelitis.
• • Type II: The fracture involves physis and a triangle of metaphyseal bone (Thurston Holland sign). This is the commonest type of epiphyseal injury accounting for 73 percent of cases over 10 years of age.
• • Type III: The fracture is intra- articular and extends along the physis and then along the growth plate. This injury is relatively uncommon.
• • Type IV: The fracture is intra-articular and extends through the epiphysis, physis and metaphysis. Perfect reduction is necessary and open reduction is more often necessary to prevent growth arrest.
• • Type V: Crushing of epiphysis. Growth arrest usually follows.
• • Type VI (Rang’s type) : There is a peripheral physis (perichondrial ring) injury.

• 1. Which of the following is/are Unprofessional action and misconduct?
• a. Using a 34x20 inch size signboard in front of your personal clinic
• b. Letters in signboard are yellow on a black background to make it look prominent
• c. Using Red Cross symbol in vehicle to make known the fact of being a physician
• d. All of the above

• Ans: d
• Unprofessional actions and misconducts
•  A physician should use an 18x14 inch size signboard and write his name, NMC number, qualification, titles, and name of his specialty.
•  The letters should be in blue on a white background.
•  S/he should not use the International Red Cross symbol to make known the fact of being a physician.
•  It is improper to affix a signboard on a chemist's shop.

• 2. What is seen in boxers hemorrhage?
• a. Fracture of base of skull
• b. Fractured orbits
• c. Hemorrhagic sinusitis
• d. Pontine hemorrhage

• Ans: d
• Ref: Reddy Forensic Medicine, 33rd Edition, Page No: 287
•  A wide range of injuries are produced from boxing, but the head is frequently injured.
•  Fracture of skull is rare, but subdural haemorrhage, usually within one of the middle cranial fossae, due to tearing of dural emissary veins, is the most common cause of death due to prolonged repetitive punching, occurs in about one-third of fatal cases.
•  Some victims may show pontine haemorrhage, the so-called "boxers haemorrhage".
•  Retinal detachment, choroidal tears and vitreous hemorrhages may occur. Deterioration in speed and coordination is the chief symptom of the onset of punchdrunk (traumatic encephalopathy or dementia pugilistica) condition, which may arise years after the last injury. Punchdrunk syndrome in its final form is recognized by slurred speech, defective memory, slow thought process, stiff limbs, ataxia, broad-based gait, outbursts of violence, Parkinsonian0-like facial appearance and dementia.
•  The intracranial findings in boxers are: subdural, subarachnoid and intracerebral haemorrhage, diffuse axonal injury, focal ischaemic lesions, dissecting aneurysms, cortical atrophy, slight hydrocephalus. thinning or tears of corpus callosum, scars or patches of gliosis, loss of neurons from the cerebellum and substantia nigra, and contusions of the brain. The changes are broadly similar to that in Alzheimer’s disease.

• Boxer fractures: Minimally comminuted, transverse fractures of the 5th metacarpal and are the most common type of metacarpal fracture. They typically occur (as the name suggests) when punching and are a common sight in all emergency departments on Friday nights.
• Boxer knuckle: Represents a tendinous and ligamentous disruption of the metacarpal phalangeal joint.

• 3. Whom of the following has the most total body water?
• a. Fetus
• b. Infant
• c. Preterm newborn
• d. Term new born

• Ans: a
• Ref: Nelson Pediatrics, 20th edition, page 346
• • Total body water (TBW) as a percentage of body weight varies with age.
• • The fetus has very high TBW, which gradually decreases to approximately 75% of birthweight for a term infant. Premature infants have higher TBW than term infants. During the 1st yr of life, TBW decreases to approximately 60% of body weight and basically remains at this level until puberty.
• • At puberty, the fat content of females increases more than that in males, who acquire more muscle mass than females. Because fat has very low water content and muscle has high water content, by the end of puberty TBW in males remains at 60%, but TBW in females decreases to approximately 50% of body weight.

• 4. What is the chromosomal location of the MEN1 gene?
• a. 11q13
• b. 12q13
• c. 13q11
• d. 13q12

• Ans: A, 11q13
• Ref: Harrison’s Principles of Internal Medicine, 20th edition, page 2649
• • The molecular basis of some endocrine tumors, such as the multiple endocrine neoplasia (MEN) syndromes (MEN1, 2A, 2B), has provided important insights into tumorigenesis.
• • MEN1 is characterized primarily by the triad of parathyroid, pancreatic islet, and pituitary tumors. The MEN1 gene, located on chromosome 11q13, encodes a putative tumor-suppressor gene, menin. Analogous to the paradigm first described for retinoblastoma, the affected individual inherits a mutant copy of the MEN1 gene, and tumorigenesis ensues after a somatic “second hit” leads to loss of function of the normal MEN1 gene (through deletion or point mutations).
• • MEN2 predisposes to medullary thyroid carcinoma, pheochromocytoma, and hyperparathyroidism. In contrast to inactivation of a tumor-suppressor gene, as occurs in MEN1 and most other inherited cancer syndromes, MEN2 is caused by activating mutations in a single allele.

• 5. A 28 year old sexually active lady presented with creamy white vaginal discharge with fishy odor. She has sexual relationship with multiple partners. Drug of choice is:
• a. Doxycycline
• b. Ofloxacin
• c. Metronidazole
• d. Clindamycin

• Ans: c
• Ref: Shaw Gynecology 16th Edition, Page No: 384
• Bacterial vaginosis is termed vaginosis rather than vaginitis, because it is associated with alteration in the normal vaginal flora rather than due to any specific infection.
• Characteristics of vaginal discharge are as follows according to Amsel’s criteria:
• • White, milky, non-viscous discharge adherent to the vaginal wall.
• • pH of the discharge is more than 4.5. (5–7 pH).
• • Fishy odor when mixed with 10% KOH is due to amino-metabolites from various organisms (amine or whiff rest).
• • Presence of clue cells—the epithelial cells have a fuzzy border due to adherence of bacteria.
• • Increased number of Gardnerella vaginalis and other organisms and reduced number of lactobacilli and leucocytes.
• • Gram-negative stain and culture are additional investigations.

• Treatment
• • The 7-day course of metronidazole 500 mg twice daily is effective in 85% cases, whereas a single dose of 2 g cures only 45%. Ampicillin 500 mg or cephalosporin 500 mg bid for 7 days is also effective. Tetracycline 500 mg four times a day, doxycycline 100 mg twice a day and sulphafurazole 1 g four times daily for 10–14 days are the alternative antibiotics.
• • Clindamycin 2% cream locally is effective in 85%. Oral clindamycin 300 mg daily for 7 days is effective. Ornidazole 500 mg vaginal tablet daily for 7 days is also effective.
• • Vaginal tablets avoid first-pass effect in liver seen with oral route.
• • Lacteal is a protein-free acidifying lactate gel which neutralizes the vaginal pH (lactic acid 5% W/V, 0.1% glycogen)—5 mL is applied daily for 7 days.

• Q.1. You are a first year resident of Thapathali maternity hospital, you got a call from labour room for retention of placenta for one hour. Cleavage of placental separation after birth of baby occurs through which layer?
• A. Superficial compact layer
• B. Deep spongy layer
• C. Nitabuch’s layer
• D. Basal layer

• Ans ,B, Deep spongy layer
• Ref: Ref: Dc Dutta Obstetrics 8th edition page number 122
• Mechanism of separation of placenta;
• Marked retraction reduces effectively the surface area at the placental site to about its half. But as the placenta is inelastic, it cannot keep pace with such an extent of diminution resulting in its buckling . A shearing force is instituted between the placenta and the placental site which brings about its ultimate separation. The plane of separation runs through deep spongy layer of decidua basalis so that a variable thickness of decidua covers the maternal surface of the
• separated placenta.
• There are two ways of separation of placenta
• (1) Central separation (Schultze) : Detachment of placenta from its uterine attachment starts at the center resulting in opening up of few uterine sinuses and accumulation of blood behind the placenta (retro placental hematoma). With increasing contraction, more and more detachment occurs facilitated by weight of the placenta and retro placental blood until whole of the placenta gets detached.
• (2) Marginal separation (Mathews-Duncan) : Separation starts at the margin as it is mostly unsupported. With progressive uterine contraction, more and more areas of the placenta get separated. Marginal separation is found more frequently.

• Q.2 A 24 year old postpartum female complaining of whitish color PV discharge, which was told to be normal by consulting doctor. What is her probable postpartum day?
• A.1-4 days
• B.5-9 days
• C.10-15 days
• D.15-20 days

• Ans C ,10-15 days
• Ref: Dc Dutta Obstetrics 7th edition page number 142

• In this case according to consulting doctor, the discharge is normal. The discharge which she complained of, is Lochia.
• LOCHIA
• for the first fortnight during puerperium. The discharge originates from the uterine body, cervix and vagina.
• Odor and reaction: It has got a peculiar offensive fishy smell. Its reaction is alkaline tending to become acid towards the end.
• Color: Depending upon the variation of the color of the discharge, it is named as: (1) Lochia rubra (red) 1-4 days. (2) Lochia serosa (5-9 days) — the color is yellowish or pink or pale brownish. (3) Lochia alba — (pale white) — 10-15 days.
• Composition: Lochia rubra consists of blood, shreds of fetal membranes and decidua, vernix caseosa, lanugo and meconium.
• Lochia serosa consists of less RBC but more leukocytes, wound exudate, mucus from the cervix and microorganisms (anaerobic streptococci and staphylococci). The presence of bacteria is not pathognomonic unless associated with clinical signs of sepsis.
• Lochia alba contains plenty of decidual cells, leukocytes, mucus, cholestrin crystals, fatty and granular epithelial cells and microorganisms.
• Amount: The average amount of discharge for the first 5–6 days, is estimated to be 250 mL.
• Normal duration: The normal duration may extend up to 3 weeks. The red lochia may persist for longer duration especially in women who get up from the bed for the first time in later period. The discharge may be scanty, especially following premature labors or may be excessive in twin delivery or hydramnios.
• Clinical importance: The character of the lochial discharge gives useful information about the abnormal puerperal state.
• The vulval pads are to be inspected daily to get information:
• • Odor: If malodorous, indicates infection. Retained plug or cotton piece inside the vagina Amount: Scanty or absent — signifies infection or lochiometra. If excessive — indicates infection.
• • Color: Persistence of red color beyond the normal limit signifies sub involution or retained bits of conceptus.
• • Duration: Duration of the lochia alba beyond 3 weeks suggests local genital lesion

• Q.3. A comatose patient with unidentified poison is brought to ER .You are planning to give coma-cocktail, which of the following is NOT the composition of Coma –cocktail?
• A. Glucose
• B. Thiamine
• C. Naloxone
• D. None

• Ans D,None
• Ref: Reddy, The essential of forensic medicine and toxicology 33rd edition, page number 586

• In a suspected poisoning case, when exact poison is not known, and patient is unconscious or in comatose condition, we give the mixture of glucose, thiamine, Naloxone –which is called COMA-COCKTAIL.
• Coma Cocktail: In comatose patients where the identity of poison is not known, 100 mi. 50% glucose, 100 mg. thiamine, and 2 mg. naloxone should be given i.v.

• 1. All of the following are the derivatives of dorsal mesogastrium except
• a. Lesser omentum
• b. Greater omentum
• c. Gastrophrenic ligament
• d. Gastrosplenic ligament

• Ans, A
• Ref: Human anatomy BD Chaurasia 4th edition Vol 2 Page no. 224
• The abdominal part of the foregut is suspended by mesenteries both ventrally and dorsally. The ventral mesentery of the foregut is called the ventral mesogastrium, and the dorsal mesentery is called the dorsal mesogastrium (gastrium-stomach).
• The fate of the dorsal mesogastrium is as follows.
• a) The greater or caudal part of the dorsal mesogastrium becomes greatly elongated and forms the greater omentum
• b) The spleen develops in relation to the cranial part of the dorsal mesogastrium, and divides it into dorsal and ventral parts. The ventral part forms the gastrosplenic ligament while the dorsal part forms the lienorenal ligament.
• c) The cranial most part of the dorsal mesogastrium forms the gastrophrenic ligament.
• The midgut and hindgut have only a dorsal mesentery, which forms the mesentery of the jejunum and ileum, the mesoappendix, the transverse mesocolon and the sigmoid mesocolon.
• The mesenteries of the duodenum, the ascending colon, the descending colon and the rectum are lost during development.

• 2. Which drug is used for the treatment of chronic hepatitis C infection?
• a. Ledipasvir
• b. Simeprevir
• c. Sofosbuvir
• d. All of the above

• Ans, D
• Ref: Basic and clinical pharmacology Katzung 14th e Page no 885
• (Please See the picture after this explanations)

• 3. All are third generation cephalosporins except
• a. Cefoperazone
• b. Cefotaxime
• c. Cefuroxime
• d. Moxalactam

• Ans, C
• Ref: Basic and clinical pharmacology Katzung 14th e Page no 802,803
• • Third-generation agents include cefoperazone, cefotaxime, ceftazidime, ceftizoxime, ceftriaxone, cefixime, cefpodoxime proxetil, cefdinir, cefditoren pivoxil, ceftibuten, and moxalactam.
• • Cefuroxime is a second generation cephalosporin.

• 1. Deja vu means [IOM 2018]
• a. Unfamiliarity of familiar situations
• b. Familiarity of unfamiliar situations
• c. Hearing of unfamiliar events
• d. Complete forgetfulness of past events

• Ans: b
• Ref: Kaplan and Sadock Psychiatry 11th Edition, Page No: 683
• Preictal events (auras) in complex partial epilepsy include autonomic sensations (e.g., fullness in the stomach, blushing, and changes in respiration); cognitive sensations (e.g., déjá vu, jamais vu, forced thinking, dreamy states); affective states (e.g., fear, panic, depression, elation); and, classically, automatisms (e.g., lip smacking, rubbing, chewing).
• • déjà entendu: Illusion that what one is hearing one has heard previously. See also paramnesia.
• • déjà pensé: Condition in which a thought never entertained before is incorrectly regarded as a repetition of a previous thought.
• • déjà vu: Illusion of visual recognition in which a new situation is incorrectly regarded as a repetition of a previous experience.

• 2. Commotio cordis is due to: [IOM 2019]
• a. Hypokalemia
• b. Blunt trauma to chest
• c. Hypomagnesemia
• d. Myocardial infarction

• Ans: b
• Ref: Link MS, Mark Estes NA 3rd, Maron BJ, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 13: Commotio Cordis: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation. 2015 Dec 1. 132 (22):e339-42.
• Sudden unexpected cardiac death that occurs in young people during sports participation is usually associated with previously diagnosed or undiagnosed structural or primary electrical cardiac abnormalities. Examples of such abnormalities include hypertrophic cardiomyopathy, anomalous origin of a coronary artery, arrhythmogenic right ventricular cardiomyopathy, and primary electrical disorders, such as congenital prolongation of the QTc interval and catecholaminergic, polymorphic ventricular tachycardia (CPVT).
• Sudden death due to ventricular fibrillation may also occur following a blunt, nonpenetrating blow to the chest, specifically the precordial area, in an individual with no underlying cardiac disease. This is termed commotio cordis.

• 3. Platelets act via [IOM 2013]
• a. cGMP
• b. cAMP
• c. IP3
• d. PIP2

• Ans: a
• Ref: cGMP Signaling in Platelets; Platelets, Haemostasis and Inflammation pp 231-252
• Platelets generate and degrade cGMP by the NO-activated soluble guanylate cyclase and several phosphodiesterases (PDE2, PDE3, and PDE5), respectively.
• An increase of the cGMP concentration activates cGMP-dependent protein kinase type I (cGKI), which phosphorylates several platelet proteins.

• 4. Pinna is not supplied by which one of the following nerve? [IOM 2015]
• a. Greater Auricular Nerve
• b. Posterior Occipital Nerve
• c. Glossopharyngeal Nerve
• d. Vagus Nerve

• Ans: c
• Ref: PL Dhingra and Shruti Dhingra ENT and HNS 7th Edition, Page No: 4
• Nerve supply of the pinna
•  Greater auricular nerve (C2, 3) supplies most of the medial surface of pinna and only posterior part of the lateral surface.
•  Lesser occipital (C2) supplies upper part of medial surface.
•  Auriculotemporal (V3) supplies tragus, crus of helix and the adjacent part of the helix.
•  Auricular branch of vagus (CN X), also called Arnold’s nerve, supplies the concha and corresponding eminence on the medial surface.
•  Facial nerve, which is distributed with fibres of auricular branch of vagus, supplies the concha and retroauricular groove.

• 5. Thickest layer of cornea is [IOM 2009]
• a. Stroma
• b. Descemet’s membrane
• c. Bowman's membrane
• d. Epithelium

• Ans: a
• Ref: AK Khurana Ophthalmology 6th Edition, Page No: 96 | Ref: Parson Ophthalmology 22ndEdition, Page No: 4, 262
• Stroma (substantia propria )
•  This layer is about 0.5 mm in thickness and constitutes most of the cornea (90% of total thickness).
•  It consists of collagen fibrils (type-I and type-V fibrillae interwined with filaments of type-VI collagen) embedded in hydrated matrix of proteoglycans (chondroitin sulphate and keratan sulphate).
• The sclera is the ‘white’ supporting wall of the eyeball and is continuous with the clear cornea. It is a dense white tissue, thickest in the area around the optic nerve.
• The lens capsule is a thick, collagenous basement membrane which is transparent, is thickest at the anterior pre equatorial region and thinnest at the posterior pole.

• 1. What is the minimum recommended body weight required for blood donation? [IOM 2017]
• a. 100 pounds
• b. 115 pounds
• c. 110 pounds
• d. 120 pounds

• Ans: a
• Ref: Nepal Red Cross Society. Blood donation: general information. Kathmandu: Nepal Red Cross Society Central Blood Transfusion Service; 2014. pp 44
• Eligibility for blood donation : Nepal Red Cross Society.
• • Age: 18 – 60 years of both male and female can donate blood.
• • Weight: More than 45 kg (99.2 pounds) can donate blood.
• • Hemoglobin: ≥ 12 g/ dl can donate blood
• • Blood pressure: 100/70 – 160/95 mm Hg can donate blood.
• • Person suffering from epilepsy, tuberculosis, diabetes, hypertension, and HIV/AIDS infected person should not donate blood.
• • Menstrual woman, lactating mother and pregnant women should not donate. Unsafe sex and multi sex partner having people should not donate blood. Substance and drug abused people should not donate blood.

WHO reference: 50 kg (110 pounds). WHO mentions the variability In some countries. Donors of whole blood donations should weigh at least 45 kg to donate 350 ml ± 10% .

Better we follow Nepalese guidelines.

• 2. Most common age group for Tinea capitis is: [IOM 2012]
• a. <10 yrs
• b. 10-20 yrs
• c. 20-30 yrs
• d. >30 yrs

• Ans: a
• Ref: Dermatology, Neena Khanna, 4th edition, Page No: 283
• Tinea capitis (tinea of scalp)
• • Age: Invariably a child. Tinea capitis occurs primarily in children and occasionally in other age groups. It is seen most commonly in children aged between 5 and 10 years. Mean age of onset is in patients aged 6.9-8.1 years
• • Discoid patch of partial alopecia from which the hair can easily and painlessly be plucked.
• • Degree of inflammation varies, depending on the strain of fungus, being more when tinea capitis is caused by zoophilic or geophilic species than with anthropophilic species.

• 3. How much percentage of total body weight is constituted by protein? [IOM 2009]
• a. 15%
• b. 20%
• c. 25%
• d. 30%

• Ans: a
• Ref: Assessment of Fluid Status and Body Composition and Control of Fluid Balance With Intermittent Hemodialysis in the Critically Ill Patient; Israel Campos, Peter Kotanko, in Critical Care Nephrology (Third Edition), 2019
• • Body composition can be viewed from five perspectives: atomic, molecular, cellular, tissue, and whole body levels. At the atomic level, six elements form 98% of the body mass: 61% oxygen, 23% carbon, 10% hydrogen, 2.6% nitrogen, and 1.4% calcium; the remaining 2% of the mass consists of 44 other elements.
• • Water, which accounts for about 60% of a 70-kg “reference male” and about 50% of a “reference female,” is the major chemical component of the body and essential for the interior milieu.
• • The total body water (TBW) is distributed between two major compartments, the intracellular volume (ICV) and the extracellular volume (ECV); the latter can be divided into the interstitial compartment, which constitutes the extracellular environment of the cells, and the vascular space.
• • Body fat depends heavily on nutrition and training status, ranging from less than 10% to more than 50%.
• • Protein and minerals account for 15% and 5% of body composition, respectively.

• 4. Median longitudinal arch is chiefly maintained by: [IOM 2011]
• a. Calcaneum
• b. Talus
• c. Medial cuneiform
• d. 1st metatarsal

• Ans: b
• Ref: Moore's Anatomy 7th Edition, Page No: 654
• • The longitudinal arch of the foot is composed of medial and lateral parts. Functionally, both parts act as a unit with the transverse arch of the foot, spreading the weight in all directions.
• • The medial longitudinal arch is higher and more important than the lateral longitudinal arch. The medial longitudinal arch is composed of the calcaneus, talus, navicular, three cuneiforms, and three metatarsals. The talar head is the keystone of the medial longitudinal arch. The tibialis anterior and posterior, via their tendinous attachments, help support the medial longitudinal arch. The fibularis longus tendon, passing from lateral to medial, also helps support this arch.
• • The lateral longitudinal arch is much flatter than the medial part of the arch and rests on the ground during standing. It is made up of the calcaneus, cuboid, and lateral two metatarsals.
• • The transverse arch of the foot runs from side to side. It is formed by the cuboid, cuneiforms, and bases of the metatarsals. The medial and lateral parts of the longitudinal arch serve as pillars for the transverse arch. The tendons of the fibularis longus and tibialis posterior, crossing under the sole of the foot like a stirrup, help maintain the curvature of the transverse arch. The integrity of the bony arches of the foot is maintained by both passive factors and dynamic supports.

• 1. What is the mechanism of pseudofolliculitis barbae?
• a. Infection
• b. Collection of sebum
• c. Ingrowing of hairs
• d. Obstruction of sweat glands

• Ans, C, Ingrowing of hairs
• Ref. Dermatology, Andrew’s Diseases of skin, 13th edition, page no. 767
• Pseudofolliculitis Barbae
• Pseudofolliculitis barbae (“razor bumps”) consists of hairs that, after appearing at the surface, curve back and pierce the skin as ingrowing hairs.
• This results in inflammatory papules and pustules, which may scar.
• In severe cases, large deforming keloids may result in the beard area.
• Pseudofolliculitis of the beard is seen in more than 50% of black men, who must sometimes give up shaving to alleviate the disorder.

• 2. Which of the following is true about stabbed wounds?
• a. The length of the wound is equal to the width of the weapon
• b. The length of the wound is slightly more than the width of the weapon
• c. The length of the wound is slightly less than the width of the weapon
• d. The length of the wound is equal to the width of the wound

• Ans, C, The length of the wound is slightly less than the width of the weapon
• Ref, The Essentials of Forensic Medicine and Toxicology, Reddy, 33rd edition, page no.210-211
• STAB OR PUNCTURED WOUNDS
• A stab wound is produced when force is delivered along the long axis of a narrow or pointed object, such as knife, dagger, sword, chisel, scissors, nail, needle, spear, screw driver, etc. into the depths of the body.
• Characters:
• (1) Margins: The edges of the wound are clean-cut and inverted. The margins can be everted when the wound is situated over the fatty area, such as portuberant abdomen or gluteal region.
• (2) Length: The length of the wound is slightly less than the width of the weapon up to which it has been driven in, because of stretching of the skin.
• (3) Width: By examining multiple stab wounds in the body, the length and width of the knife blade can be determined approximately.
• (4) Depth: The depth (length of track) is greater than the width and length of the external injury. It is not safe to find out the depth of a stab wound by introducing a probe, because it may disturb a loose clot and may lead to fatal haemorrhage, or cause serious damage and may produce multiple false wound tracks.

• 3. What is the approximate total surface area of respiratory membrane of normal adult human lungs?
• a. 10 sq meters
• b. 50 sq meters
• c. 70 sq meters
• d. 110 sq meters

• Ans, C, 70 sq meters
• Ref, Textbook of Medical Physiology, Guyton and Hall, 13th edition, page no.522
• The different layers of the respiratory membrane are:
• A layer of fluid containing surfactant that lines the alveolus and reduces the surface tension of the alveolar fluid
• The alveolar epithelium, which is composed of thin epithelial cells
• An epithelial basement membrane
• A thin interstitial space between the alveolar epithelium and the capillary membrane
• A capillary basement membrane that in many places fuses with the alveolar epithelial basement membrane
• The capillary endothelial membrane
• Despite the large number of layers, the overall thickness of the respiratory membrane in some areas is as little as 0.2 micrometer and averages about 0.6 micrometer, except where there are cell nuclei.
• From histological studies, it has been estimated that the total surface area of the respiratory membrane is about 70 square meters in the healthy adult human male, which is equivalent to the floor area of a 25 × 30 foot room.

• 1. In trigger finger the level of tendon sheath constriction is found at the level of:
• a. Middle phalanx
• b. Proximal interphalangeal joint
• c. Proximal phalanx
• d. Metacarpophalangeal joint

• Ans: d
• Ref: Gray’s anatomy, 41st Edition; Page No: 879.e1
• • Trigger finger is a stenosing tenovaginitis that affects the fibrous flexor sheaths of the fingers or thumb within the palm. The affected sheath thickens and entraps the contained tendons, which become constricted at the site of entrapment and bulge distal to it. This produces a distinct nodule in the palm of the hand and the finger now snaps as the tendon nodule passes through the constriction on flexing the finger. The corresponding extensor muscle is insufficiently powerful to extend the affected finger, so the patient does this passively, accompanied by a painful snap. Treatment frequently requires surgical division of the A1 pulley of the flexor sheath to relieve the stricture.
• • The most commonly affected level is at MCP joint but occasionally it may occur at distal joints also. The index finger is affected rarely.
• • De Quervain’s tenovaginitis is a stenosing tenovaginitis of unknown aetiology that occurs in the first dorsal compartment at the level of the radial styloid. It involves the common extensor sheath containing the tendons of abductor pollicis longus and extensor pollicis brevis. There is palpable thickening of the tendon sheath with painful limitation of extension of the thumb. Treatment frequently requires division of the thickened sheath, care being taken to avoid the adjacent superficial radial nerve; division of the sheath produces no functional impairment.

• 2. Atherosclerosis induced peripheral artery diseases primarily involves which artery?
• a. Iliac arteries
• b. Peroneal arteries
• c. Popliteal arteries
• d. Tibial arteries

• Ans: c
• Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 1923
• • Peripheral artery disease (PAD) is defined as a clinical disorder in which there is a stenosis or occlusion in the aorta or the arteries of the limbs. Atherosclerosis is the leading cause of PAD in patients >40 years old. Other causes include thrombosis, embolism, vasculitis, fibromuscular dysplasia, entrapment, cystic adventitial disease, and trauma. Segmental lesions that cause stenosis or occlusion are usually localized to large and medium-size vessels.
• • The pathology of the lesions includes atherosclerotic plaques with calcium deposition, thinning of the media, patchy destruction of muscle and elastic fibers, fragmentation of the internal elastic lamina, and thrombi composed of platelets and fibrin.
• • The primary sites of involvement are the abdominal aorta and iliac arteries (30% of symptomatic patients), the femoral and popliteal arteries (80–90% of patients), and the more distal vessels, including the tibial and peroneal arteries (40–50% of patients).
• • Atherosclerotic lesions occur preferentially at arterial branch points, which are sites of increased turbulence, altered shear stress, and intimal injury. Involvement of the distal vasculature is most common in elderly individuals and patients with diabetes mellitus.

• 3. Vitamin K is available as all forms except?
• a. Phytonadione
• b. Menaquinone
• c. Phytoquinone
• d. Acetomenapthone

• Ans: c
• Ref: KDT Pharmacology 8th Edition, Page No: 972
• The available forms of Vitamin K are:
• • Phytonadione (K1) (Phylloquinone)
• • Menaquinone (K2)
• • Menadione (K3)
• • Acetomenapthone

• 4. Neurovegetative symptoms best relate to?
• a. Depressive disorder
• b. Bipolar disorder
• c. Posttraumatic stress disorder (PTSD)
• d. Schizophrenia

• Ans: a
• Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 2715
• Neuroendocrine abnormalities that reflect the neurovegetative signs and symptoms of depression include:
• • increased cortisol and corticotropin-releasing hormone (CRH) secretion,
• • an increase in adrenal size,
• • a decreased inhibitory response of glucocorticoids to dexamethasone, and
• • a blunted response of thyroid-stimulating hormone (TSH) level to infusion of thyroid-releasing hormone (TRH).
• Antidepressant treatment leads to normalization of these abnormalities.
• Major depression is also associated with changes in levels of Proinflammatory cytokines and neurotrophins.

• 5. Boxer’s fracture is?
• a. Radial styloid fracture
• b. Reverse Colles fracture
• c. 5th metacarpal fracture
• d. 1st metacarpal fracture

• Ans: c
• Ref: Maheshwari Orthopedics 5th Edition Page No: 118
• • Monteggia’s fracture:- fracture of proximal third of ulna with radial head dislocation
• • Galeazzi fracture:- fracture of the distal third of radius with dislocation of distal radio-ulnar joint
• • Colles fracture:- fracture of distal end of radius with dorsal tilt
• • Smith’s fracture:- reverse Colles fracture
• • Boxers fracture:- fracture through neck of 5th metacarpal

• 1. Piezoelectricity technique is used in:
• a. Ultrasound
• b. MRI
• c. CT Scan
• d. PET Scan

Ans, A, Ultrasound

Ref, Diagnostic Ultrasound Rumack e5/ p7

• Explanation
• Ultrasound transducers use piezoelectricity, a principle discovered by Pierre and Jacques Curie in 1880. Piezoelectric materials have the unique ability to respond to the action of an electric field by changing shape. They also have the property of generating electric potentials when compressed. Changing the polarity of a voltage applied to the transducer changes the thickness of the transducer, which expands and contracts as the polarity changes. This results in the generation of mechanical pressure waves that can be transmitted into the body. The piezoelectric effect also results in the generation of small potentials across the transducer when the transducer is struck by returning echoes.

2. Artificial surfactant is most likely to be used in the treatment of an infant with

• a. Hemolytic disease of the newborn
• b. Hyaline membrane disease
• c. Physiologic jaundice of the newborn
• d. Retrolental fibroplasia

Ans, B , Hyaline membrane disease

Ref, Robbins & Cotran, Pathologic basis of disease, 7e, p 471-473

Explanation

A disorder in newborns that is histologically identical to ARDS is called neonatal respiratory distress syndrome [hyaline membrane disease (HMD)]. HMD, which accounts for 20% of all deaths in the first 28 days of life, is basically a disease of premature infants; most affected infants weigh 1000 to 1500 g. Contributing factors in the development of HMD include diabetes in the mother (maternal diabetes with increased glucose causes increased fetal secretion of insulin, which inhibits the effects of steroids such as lung maturation and production of surfactant) and cesarean section. Infants who develop HMD appear normal at birth, but within minutes to hours their respirations become labored. Grossly the lungs are a mottled, red-purple color, while microscopically there are hyaline membranes in air spaces, similar to those of ARDS.

3. Disease elimination means:

• a. Cure of the disease
• b. Preventing the transmission totally
• c. Eradication of the vector
• d. Complete termination of infective organism

Ans, B, Preventing the transmission totally

Ref, Park’s Textbook of Preventive and Social Medicine 22nd edition, p38

• Explanation
• • Concepts of control of disease:

• – Disease control: Is reducing the transmission of disease agent to such a low level that it ceases to be a public health problem; it aims at reducing,
• 1. Incidence of the disease
• 2. Duration of the disease
• 3. Effects of infection
• 4. Financial burden to the community

• – Disease elimination: Is complete interruption of transmission of disease in a defined geographical area, but the causative organism may be persisting somewhere
• Disease elimination is a ‘geographical term’, i.e. can be used only for a country or a region

• – Disease eradication: Is complete ‘extermination’ of organism
• 1. Is ‘tearing out by roots’ of a disease
• 2. Exhibits ‘All or none phenomenon’
• 3. Disease eradication is a ‘global term’, i.e. can be used only for whole planet
• 4. World has eradicated ONLY 1 disease till date: Small pox (declared eradicated on 8 May, 1980)
• 5. 3 next target diseases for eradication, globally:
• i. Poliomyelitis
• ii. Measles
• iii. Guinea worm

• Q1.Condition in which corneal scar results in slight opacification allowing the details of the iris to be seen through the opacity is known as:
• a.Macula
• b.Leucoma
• c.Nebula
• d.Adherent leucoma

• Ans: c
• Ref: Parsons diseases of eye 22nd edition page no: 213

• Corneal Opacity
• • Nebula or a nebular corneal opacity: If the corneal scar results in slight opacification allowing the details of the iris to be seen through the opacity.
• • Macula or a macular corneal opacity: If rather more dense, through which the details of the iris cannot be seen but the iris and pupillary margins are visible.
• • Leucoma or a leucomatous corneal opacity: If very dense and white and totally opaque obscuring the view of the iris and pupil.Old central leucomata sometimes show a horizontal pigmented line in the palpebral aperture, the nature of which is obscure but may be due to deposition of iron from the pre-corneal tear film.
• • Adherent leucoma: If the iris is adherent to the back of a leucoma following healing of a perforated corneal ulcer.

• Q2.Which of the following stages of Ancylostoma duodenale is infective to human beings ?
• a. Rhabditiform larva
• b. Filariform larva
• c. Eggs
• d. Adult worm

• Ans: b
• Ref:Panikers textbook of medical parasitology 8th edition pg203

• Infective Form
• Third-stage filariform larva.
• • Adult worm inhabiting the small intestine of man attach themselves to the mucous membrane by means of their mouth parts. The female worm lays eggs.
• • The eggs containing segmented ova with four blastomeres, are passed out in the feces of infected person. Eggs freshly passed in feces are not infective for humans.
• • When deposited in the soil, the embryo develops inside the eggs. Its development takes place optimally in sandy loamy soil with decaying vegetation under a moist, warm, shady environment.
• • In about 2 days, a rhabditiform larva, measuring 250 mcm in length hatches out of the egg. It feeds on bacteria and other organic matter in the soil and grows in size .
• • It moults twice, on the 3rd and 5th days after hatching to become the third-stage infective filariform larva .
• • Filariform larva is about 500-600 µm long, with a sharp pointed tail. The filariform larva is nonfeeding. They can live in the soil for 5-6 weeks, with their heads waving in the air, waiting for their hosts. They can also ascend on blades of grass or other vegetation, being carried in capillary water films on their surface. Direct sun light, drying, or salt water can kill the larva.

• Q3.The greatest risk factor for Necrotizing enterocolitis is with:
• a. Low birth weight
• b. Intestinal ischemia
• c. Enteral nutrition
• d. Prematurity

• Ans: d
• Ref: Nelson’s textbook of pediatrics 20th edition page no:869

• • Although NEC is a multifactorial disease primarily associated with intestinal immaturity, the concept of “risk factors” for NEC is controversial.
• • The triad of intestinal ischemia (injury), enteral nutrition (metabolic substrate), and bacterial translocation has classically been linked to NEC.
• • The greatest risk factor for NEC is prematurity. The disorder probably results from an interaction between loss of mucosal integrity due to a variety of factors (ischemia, infection, inflammation) and the host’s response to that injury (circulatory, immunologic, inflammatory), leading to necrosis of the affected area.
• • Coagulation necrosis is the characteristic histologic finding in intestinal specimens.

• 1. MRP 2 associated with which of the following?
• a. Rotor syndrome
• b. Dubin-Johnson syndrome
• c. Crigler-Najjar syndrome
• d. Gilbert syndrome

• Ans: b
• Ref: Nelson pediatrics, 20th Edition, Page No: 1938
• Dubin-Johnson Syndrome
• • Dubin-Johnson syndrome is an autosomal recessive inherited defect with variable penetrance in hepatocyte secretion of bilirubin glucuronide.
• • The defect in hepatic excretory function is not limited to conjugated bilirubin excretion but also involves several organic anions normally excreted from the liver cell into bile.
• • Absent function of multiple drug-resistant protein 2 (MRP2), an adenosine triphosphate–dependent canalicular transporter, is the responsible defect.
• • More than 10 different mutations, including compound heterozygous mutation in the CMOAT gene, have been identified and either affect localization of MRP2 with resultant increased degradation or impair MRP2 transport activity in the canalicular membrane.
• • Bile acid excretion and serum bile acid levels are normal. Total urinary coproporphyrin excretion is normal in quantity but coproporphyrin I excretion increases to approximately 80% with a concomitant decrease in coproporphyrin III excretion.

• 2. Linear deposition of immunocomplex is seen in examination of lung or renal tissue by immunofluorescent techniques in?
• a. Systemic lupus erythematous
• b. Goodpasture syndrome
• c. Henoch Schonlein purpura
• d. Wegner granulomatosis

• Ans: b
• Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1715
• Goodpasture Syndrome
• • Clinical manifestations Pulmonary hemorrhage and glomerulonephritis are features in most patients with this disease.
• • Autoantibodies to renal glomerular and lung alveolar basement membranes are present.
• • This syndrome can present and recur as DAH without an associated glomerulonephritis. In such cases, circulating anti-basement membrane antibody is often absent, and the only way to establish the diagnosis is by demonstrating linear immunofluorescence in lung tissue.
• • Histologic findings: The underlying histology may be bland hemorrhage or DAH associated with capillaritis.
• • Treatment Plasmapheresis has been recommended as adjunctive treatment.

• 3. Fuch’s spots are seen in:
• a. Fuch’s dystrophy
• b. High myopia
• c. Hypertensive retinopathy
• d. Best disease

• Ans: b
• Ref: Kanski Ophthalmology 8th Edition, Page No: 632
• A Fuchs spot: is a raised, circular, pigmented lesion at the macula developing after a subretinal hemorrhage has absorbed. Seen in high myopia.

• 4. In an in-vitro fertilization, embryo transfer should be done how many times?
• a. 3
• b. 4
• c. 5
• d. no limit

• Ans: a
• Ref: Dutta Gynecology 6th Edition, Page No: 253, 251
• Embryo transfer
• The fertilized ova at the 6–8 blastomere stage are placed into the uterine cavity close to the fundus about 3 days after fertilization through a fine flexible soft catheter transcervically.
• Not more than three embryos are transferred per cycle to minimize multiple pregnancy.

• Principal steps of an Assisted Reproductive Technology (ART) cycle:
•  Down regulation using GnRH agonist.
•  Controlled ovarian hyperstimulation (COH).
•  Monitoring of follicular growth.
•  Oocyte retrieval.
•  Fertilization in vitro (IVF, ICSI, GIFT).
•  Transfer of gametes or embryos.
•  Luteal support with Progesterone

• Nepal has long term goal to end tuberculosis epidemic by:
• a. 2025
• b. 2045
• c. 2050
• d. 2075

• Ans: c
• Ref: Annual Health Report 73/74; Page No: 163-164

Vision, goal, strategy and target of the National TB Programme

Vision: Nepal free of tuberculosis.

Long term goal: End the tuberculosis epidemic by 2050.

Short term goal: Reduce TB incidence by 20% by 2021 compared to 2015 and increase case notifications by a cumulative total of 20,000 from July 2016 to July 2021.

• Objectives:
• • Increase case notification through improved health facility-based diagnosis.
• • Maintain the treatment success rate at 90% of patients (for all forms of TB) through to 2021.
• • Provide drug resistance diagnostic services for 50% of persons with presumptive drug resistant TB by 2018 and 100% by 2021 and successfully treat at least 75% of diagnosed drug resistant patients.
• • Further expand case finding by engaging the private sector.
• • Strengthen community systems for the management, advocacy, support and rights of TB patients in order to create an enabling environment to detect and manage TB cases in 60% of all districts by 2018 and 100% of districts by 2021.
• • Contribute to health system strengthening through TB human resource management, capacity development, financial management, and infrastructure, procurement and supply management.
• • Develop a comprehensive TB surveillance, monitoring and evaluation system
• • Develop a plan to continue NTP services in the aftermath of natural disasters and public health emergencies.

• Guttmann’s sign is:
• a. Flushing of the conjunctiva
• b. Engorged veins of the arm
• c. Stuffiness of the nostril
• d. Warmth of the face

• Ans: c
• Ref: Lee’s Synopsis of Anaesthesia. 13th edition Page No: 444.
• Guttmann’s sign is stuffiness of the nostril which is a sign of successful stellate ganglion block.
• The other signs of successful stellate ganglion block include Horner’s syndrome, engorged veins of the arm, flushing of the conjunctiva and sclera, increase in skin temperature and anhidrosis of the face and neck.

• You are working as a Medical Officer in district hospital in Rupandehi. You are about to screen a patient for COVID 19. What will you ask?
• a. Do you have cough, fever or shortness of breath?
• b. Have you recently returned from, travel in, or been living in India?
• c. Have you been in close contact with anyone with fever or respiratory illness of unknown cause?
• d. All of the above

• Ans: d
• Screening questionnaire for COVID 19: Nepali Guidelines
• All individuals presenting to the OPD or ER entrance should be screened with the following questions:
• a. Symptoms: Do you have any of the following symptoms?
• • Cough? Fever? Shortness of breath? (common)
• • Sore throat, headache or body ache? (less common)
• b. Travel history or contact with traveler: Have you?
• • Recently returned from, travel in, or been living in, an affected area in the past 2 weeks?
• • Been in close contact in the past 2 weeks with someone returning from an affected area?
• c. Exposures: Did you have any exposures to any of the following in last 2 weeks?
• • Close contact with anyone with fever or respiratory illness of unknown cause
• • Known or suspected COVID-positive contact

• Which of the following is not the discharge criterion of COVID 19 patient?
• a. Afebrile >72 hours without antipyretics
• b. Improvement in respiratory symptoms/signs
• c. More than 7 days since the onset of symptoms
• d. Negative RT-PCR from at least two specimens collected ≥ 6 hrs apart

• Ans: d
• Discharge Criteria:
• Clinical
• • Afebrile >72 hours without antipyretics
• • Improvement in respiratory symptoms/signs
• • More than 7 days since the onset of symptoms
• Laboratory
• • Afebrile >72 hours
• • Negative RT-PCR from at least two specimens collected ≥ 24hrs apart

• Atherosclerosis induced peripheral artery diseases primarily involves which artery?
• a. Iliac arteries
• b. Peroneal arteries
• c. Popliteal arteries
• d. Tibial arteries

• Ans: c
• Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 1923
• • Peripheral artery disease (PAD) is defined as a clinical disorder in which there is a stenosis or occlusion in the aorta or the arteries of the limbs. Atherosclerosis is the leading cause of PAD in patients >40 years old. Other causes include thrombosis, embolism, vasculitis, fibromuscular dysplasia, entrapment, cystic adventitial disease, and trauma. Segmental lesions that cause stenosis or occlusion are usually localized to large and medium-size vessels.
• • The pathology of the lesions includes atherosclerotic plaques with calcium deposition, thinning of the media, patchy destruction of muscle and elastic fibers, fragmentation of the internal elastic lamina, and thrombi composed of platelets and fibrin.
• • The primary sites of involvement are the abdominal aorta and iliac arteries (30% of symptomatic patients), the femoral and popliteal arteries (80–90% of patients), and the more distal vessels, including the tibial and peroneal arteries (40–50% of patients).
• • Atherosclerotic lesions occur preferentially at arterial branch points, which are sites of increased turbulence, altered shear stress, and intimal injury. Involvement of the distal vasculature is most common in elderly individuals and patients with diabetes mellitus.

• 1. Birbeck granule is found in:
• a. Langerhans cell
• b. Langhans giant cell
• c. Lepra cell
• d. Clue cell

• Ans: a
• Ref: Robbins Basic Pathology 10th Edition, Page No: 484
• Langerhans cell proliferations take on different clinical forms, but all are believed to be variations of the same basic disorder. The proliferating Langerhans cells express MHC class II antigens, CD1a, and langerin.
• Langerin is a transmembrane protein found in Birbeck granules, cytoplasmic pentalaminar rod-like tubular structures that in electron micrographs have a characteristic periodicity and sometimes a dilated terminal end (“tennis racket” appearance).
• Under the light microscope, the proliferating Langerhans cells do not resemble their normal dendritic counterparts.
• Instead, they have abundant, often vacuolated cytoplasm and vesicular nuclei, an appearance more akin to that of tissue macrophages (called histiocytes by morphologists)—hence the term Langerhans cell histiocytosis.

• 2. Guttmann’s sign is:
• a. Flushing of the conjunctiva
• b. Engorged veins of the arm
• c. Stuffiness of the nostril
• d. Warmth of the face

• Ans: c
• Ref: Lee’s Synopsis of Anaesthesia. 13th edition Page No: 444.
• Guttmann’s sign is stuffiness of the nostril which is a sign of successful stellate ganglion block.
• The other signs of successful stellate ganglion block include Horner’s syndrome, engorged veins of the arm, flushing of the conjunctiva and sclera, increase in skin temperature and anhidrosis of the face and neck.

• 3. What volume of urine is required to be collected in a normal human adult to elicit reflex contraction of bladder?
• a. 50 – 100 ml
• b. 200 – 300 ml
• c. 300 – 400 ml
• d. 500 – 600 ml

• Ans: c
• Ref: Ganong Review of Medical Physiology, Lange; 25th Edition, Page No: 692
• • The bladder smooth muscle has some inherent contractile activity; however, when its nerve supply is intact, stretch receptors in the bladder wall initiate a reflex contraction that has a lower threshold than the inherent contractile response of the muscle.
• • Fibers in the pelvic nerves are the afferent limb of the voiding reflex, and the parasympathetic fibers to the blad¬der that constitute the efferent limb also travel in these nerves.
• • The reflex is integrated in the sacral portion of the spinal cord.
• • In the adult, the volume of urine in the bladder that normally initiates a reflex contraction is about 300–400 ml.

• 4. Nepal has long term goal to end tuberculosis epidemic by:
• a. 2025
• b. 2045
• c. 2050
• d. 2075

• Ans: c
• Ref: Annual Health Report 73/74; Page No: 163-164

Vision, goal, strategy and target of the National TB Programme

Vision: Nepal free of tuberculosis.

Long term goal: End the tuberculosis epidemic by 2050.

Short term goal: Reduce TB incidence by 20% by 2021 compared to 2015 and increase case notifications by a cumulative total of 20,000 from July 2016 to July 2021.

• Objectives:
• • Increase case notification through improved health facility-based diagnosis.
• • Maintain the treatment success rate at 90% of patients (for all forms of TB) through to 2021.
• • Provide drug resistance diagnostic services for 50% of persons with presumptive drug resistant TB by 2018 and 100% by 2021 and successfully treat at least 75% of diagnosed drug resistant patients.
• • Further expand case finding by engaging the private sector.
• • Strengthen community systems for the management, advocacy, support and rights of TB patients in order to create an enabling environment to detect and manage TB cases in 60% of all districts by 2018 and 100% of districts by 2021.
• • Contribute to health system strengthening through TB human resource management, capacity development, financial management, and infrastructure, procurement and supply management.
• • Develop a comprehensive TB surveillance, monitoring and evaluation system
• • Develop a plan to continue NTP services in the aftermath of natural disasters and public health emergencies.

• 5. You are working as a Medical Officer in district hospital in Rupandehi. You are about to screen a patient for COVID 19. What will you ask?
• a. Do you have cough, fever or shortness of breath?
• b. Have you recently returned from, travel in, or been living in India?
• c. Have you been in close contact with anyone with fever or respiratory illness of unknown cause?
• d. All of the above

• Ans: d
• Screening questionnaire for COVID 19: Nepali Guidelines
• All individuals presenting to the OPD or ER entrance should be screened with the following questions:
• a. Symptoms: Do you have any of the following symptoms?
• • Cough? Fever? Shortness of breath? (common)
• • Sore throat, headache or body ache? (less common)
• b. Travel history or contact with traveler: Have you?
• • Recently returned from, travel in, or been living in, an affected area in the past 2 weeks?
• • Been in close contact in the past 2 weeks with someone returning from an affected area?
• c. Exposures: Did you have any exposures to any of the following in last 2 weeks?
• • Close contact with anyone with fever or respiratory illness of unknown cause
• • Known or suspected COVID-positive contact

• 6. Which of the following is not the discharge criterion of COVID 19 patient?
• a. Afebrile >72 hours without antipyretics
• b. Improvement in respiratory symptoms/signs
• c. More than 7 days since the onset of symptoms
• d. Negative RT-PCR from at least two specimens collected ≥ 6 hrs apart

• Ans: d
• Discharge Criteria:
• Clinical
• • Afebrile >72 hours without antipyretics
• • Improvement in respiratory symptoms/signs
• • More than 7 days since the onset of symptoms
• Laboratory
• • Afebrile >72 hours
• • Negative RT-PCR from at least two specimens collected ≥ 24hrs apart

• 1.True statement about gliobastoma multiforme:
• a. Common in 3rd decade
• b. Most common location is supratentorial
• c. Mostly located in posterior fossa
• d. It has good prognosis

• Ans,b. Most common location is supratentorial
• Ref:Harrison 19th/p.91,17thed./p.2603
• Glioblastoma Multiforme (GBM)
• • GBM is the most common and most aggressive type of primary brain tumor in humans, involving glial cells and accounting for 52% of all parenchymal brain tumor cases and 20% of all intracranial tumors.
• • Excepting the brainstem gliomas, glioblastoma has the worst prognosis of any CNS malignancy
• • Composed of a heterogenous mixture of poorly differentiated neoplastic astrocytes, glioblastomas primarily affect adults, and they are located preferentially in the cerebral hemispheres (so supratentorial)
• • It occurs most often in the subcortical white matter of the cerebral hemispheres. The most frequently affected sites are the temporal (31%), parietal (24%), frontal (23%), and occipital (16%) lobes. Combined fronto-temporal location is particularly typical.
• • Sites for glioblastomas that are much less common are the brainstem (which often is found in affected children), the cerebellum, and the spinal cord.

• 2.Which is the best investigation best to confirm diagnosis of anaphylaxis:
• a. IgA levels
• b. IgD levels
• c. Serum tryptase
• d. Serum precipitins

• Ans,c. Serum Tryptase
• Ref: Harrison 19th ed./p.2116
• • Elevations of tryptase levels in serum implicate mast cell activation in a systemic reaction and are particularly informative for anaphylaxis with episodes of hypotension during general anesthesia or when there has been a fatal outcome.
• • However, because of the short half-life of tryptase, elevated levels are best detected within 4 hours of a systemic reaction
• • Immunoassays using purified antigens can demonstrate the presence of specific IgE in the serum of patients with anaphylactic reactions, and intracutaneous skin testing may be performed after the patient has recovered to elicit a local wheal and flare in response to the putative antigen.

• 3.All of the following are the causes of sudden increase in pain in osteochondroma, except:
• a. Sarcomatous change
• b. Fracture
• c. Bursitis
• d. Degenerative changes

• Ans. is ‘d’ i.e. Degenerative changes
• Ref: Maheshwari, 3rd ed./p.225
• • Osteochondroma usually presents as a painless swelling.
• • Occurrence of pain suggests some complications such as : bursitis at the tip of the swelling, fracture through stalk of the osteochondroma, impingement on or tethering of neighbouring structures such as a tendon, muscle or nerve, malignant transformation
• • A malignant transformation of osteochondroma should be suspected if the osteochondroma continues to grow after skeletal maturity or shows a rapid increase in the size or appearance of sudden pain.
• • The malignancy associated with osteochondroma is most often chondrosarcoma, although malignant fibrous histiocytoma and osteosarcoma have also been reported.

• 1. Reversibility of asthma is defined as an increase in FEV1 15 minutes after inhaled short-acting beta2-agonist of:
• a. 12 % or 50 mL
• b. 12 % or 100 mL
• c. 12 % or 150 mL
• d. 12 % or 200 mL

Ans: d

Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 1675

 The diagnosis of asthma is usually apparent from the symptoms of variable and intermittent airways obstruction, but must be confirmed by objective measurements of lung function.

 Lung Function Tests Simple spirometry confirms airflow limitation with a reduced FEV1, FEV1/FVC ratio, and PEF.

 Reversibility is demonstrated by a >12% and 200-mL increase in FEV1 15 min after an inhaled short-acting β2-agonist or in some patients by a 2- to 4-week trial of oral corticosteroids (OCS) (prednisone or prednisolone 30–40 mg daily).

 Measurements of PEF twice daily may confirm the diurnal variations in airflow obstruction.

 Flow-volume loops show reduced peak flow and reduced maximum expiratory flow.

 Further lung function tests are rarely necessary, but whole-body plethysmography shows increased airway resistance and may show increased total lung capacity and residual volume.

 Gas diffusion is usually normal, but there may be a small increase in gas transfer in some patients.

• 2. A 7-year-old child is brought to the emergency room by his parents in severe pain. They state that he fell on his outstretched right arm while playing with his friends. He is unable to move his right arm which is being supported by his left. On exam, his vitals are normal. His right extremity reveals normal pulses without swelling in any compartments, but there is crepitus above the elbow upon movement. The child is able to flex and extend his wrist, but this is limited by pain. The child has decreased sensation along his thumb and is unable to make the "OK" sign with his thumb and index finger. What is the most likely diagnosis?
• a. Mid humerus fracture
• b. Scaphoid fracture
• c. Distal radius fracture
• d. Supracondylar humerus fracture

Ans: d

This patient has a clinical presentation suggestive of a supracondylar humerus fracture with concomitant median nerve palsy. Patients are typically treated non-operatively with closed reduction or operatively with open reduction and internal fixation with pinning.

 Pediatric patients with falls on outstreched hands commonly present with supracondylar fractures of the humerus. These fractures are important to diagnose because they can often concur with neurovascular injuries. Specifically, the anterior interosseous nerve, a branch of the median nerve, can be stretched due to traction and lead to a palsy preventing thump opposition and making the "OK" sign. Additionally, injuries to vasculature can lead to permanent ischemic contracture.

 A midhumerus fracture is associated with a radial nerve palsy that results in wrist drop and sensory deficits in the posterior compartments of the arm.

 A scaphoid fracture is a common injury in falls and is typically characterized by pain over the anatomic snuffbox (dorsal aspect of the proximal thumb).

 Distal radial and ulnar fractures would present with crepitus below the elbow and would not results in extensive pain above the arm.

• 3. Lining epithelium of vagina is:
• a. Pseudostratified columnar epithelium
• b. Keratinized stratified squamous epithelium
• c. Non keratinized stratified squamous epithelium
• d. Ciliated columnar epithelium

Ans: c

Ref: Gray’s anatomy, 41st Edition; Page No: 1291

VAGINA

• The vagina is a fibromuscular tube lined by non-keratinized stratified epithelium. It extends from the vestibule (the opening between the labia minora) to the uterus. The upper end of the vagina surrounds the vaginal projection of the uterine cervix. The anular recess between the cervix and vagina is the fornix; the different parts of the fornix are given separate names, i.e. anterior, posterior and right and left lateral, but they are continuous.

• The apex of the vagina is directed posteriorly towards the ischial spines. The width of the vagina increases as it ascends. The inner surfaces of the anterior and posterior vaginal walls are in contact with each other, forming a transverse slit. The vaginal mucosa is attached to the uterine cervix higher on the posterior cervical wall than on the anterior; the anterior wall is approximately 7.5 cm long and the posterior wall is approximately 9 cm long.

• The fibromuscular anterior wall of the vagina supports the base of the bladder in its middle and upper portions, and the urethra (which is embedded in it) inferiorly. The fibromuscular posterior wall of the vagina supports the rectum.

• The upper quarter of the posterior vagina is separated from the rectum by the peritoneum of the recto-uterine pouch, and by moderately dense fibromuscular tissue (Denonvilliers’s fascia) in its middle half.

• In its lower quarter, it is separated from the anal canal by the fibromuscular perineal body.

• The upper part of the vagina is supported laterally by levator ani, together with the transverse cervical, pubocervical and uterosacral ligaments. Pubovaginalis provides a U-shaped muscular sling around the mid-vagina.

• The lower vagina is surrounded by the skeletal muscle fibres of bulbospongiosus. As the ureters pass anteromedially to reach the fundus of the bladder, they pass close to the lateral Fornices, where care must be taken to avoid damage during hysterectomy. As they enter the bladder, the ureters are usually anterior to the vagina; at this point, each ureter is crossed transversely by a uterine artery.

• 4. Luxatio erecta is:
• a. Tear of the glenoid labrum
• b. Inferior dislocation of shoulder
• c. Anterior dislocation of shoulder
• d. Defect in the humeral head

Ans: b

Ref: Maheshwari Orthopedics 5th Edition Page No: 367

DISLOCATIONS WITH EPONYMS:

• Chopart’s: dislocation through talo-navicular joints

• Divergent: elbow dislocation where ulna and radius dislocate in opposite directions

• Lisfranc’s: dislocation through inter tarsal joint

• Lunate: wrist injury where lunate bone comes out to lie in front of other carpal bones

• Luxatio erecta: inferior dislocation of shoulder

• Otto pelvis: gradual shift of the acetabulum into the pelvis (e.g. in osteomalacia)

• Perilunate: wrist injury where the lunate remains in its place and the other carpal bones dislocate around it dorsally

• Spondylolisthesis: movement of one vertebra over another (usually L4 over L5)

• Sprain: A break in the continuity of a ligament

• Strain: A break in muscle fibres

• Q1.Vascular resistance is low in which type of shock?
• a. Hypovolemic shock
• b. Distributive shock
• c. Cardiogenic shock
• d. Obstructive shock

• Ans: b, Distributive shock
• Ref: Short Practice of Surgery, Bailey and Love, 27th edition, page no.15

• Explanation:
• Cardiovascular and metabolic characteristics of shock
• Hypovolaemic vs Cardiogenic vs Obstructive vs Distributive
• Cardiac output : Low vs Low vs Low vs High
• Vascular resistance : High vs High vs High vs Low
• Venous pressure : Low vs High vs High vs Low
• Mixed venous saturation : Low vs Low vs Low vs High
• Base deficit : High vs High vs High vs High

• Q2. The anterior group of axillary lymph nodes lies;
• a. Along the axillary vein
• b. Along the lateral thoracic vessels
• c. Along the subscapular vessels
• d. Embedded in fat in the centre of the axilla

• Ans: b, Along the lateral thoracic vessels
• Ref: Short Practice of Surgery, Bailey and Love, 27th edition, page no.860-61
• Explanation:
• The lymphatics of the breast drain predominantly into the axillary and internal mammary lymph nodes. The axillary nodes receive approximately 85% of the drainage and are arranged in the following groups:
• • lateral, along the axillary vein;
• • anterior, along the lateral thoracic vessels;
• • posterior, along the subscapular vessels;
• • central, embedded in fat in the centre of the axilla; interpectoral, a few nodes lying between the pectoralis major and minor muscles;
• • apical, which lie above the level of the pectoralis minor tendon in continuity with the lateral nodes and which receive the efferents of all the other groups.

• Q3. A final year MBBS student is asked by the examiner to perform abdominal examination during his final year assessment. While palpating the abdomen, the examiner asked him the direction of enlargement of spleen which is;
• a. Downwards, forwards and medially
• b. Downwards, backwards and medially
• c. Downward, forward and laterally
• d. Downward, backward and laterally

• Ans: a, Downwards, forwards and medially
• Ref: Short Practice of Surgery, Bailey and Love, 27th edition, page no.1021

• Examination of Spleen
• •In a healthy patient the spleen is not normally palpable.
• •An enlarged spleen descends downwards, forwards and medially.
• •Palpation for an enlarged spleen is best performed in a supine patient. The examining hand should start in the right lower abdomen, with the tips of the fingers pointing upwards and pressed inwards. The patient is then asked to take a deep breath, and if the spleen is enlarged the lower edge with the characteristic notch will touch the fingers. If it is not palpable, then the hand is gradually moved upwards in the direction of the position of the edge of the normal-sized spleen with each breath.
• •If the spleen is still not palpable, the patient is moved to the right lateral position and the examination repeated.

• Q4. You are doing autopsy examination of a 45 years old male body, who died due to lightening stroke, you find filigree burns over his body. Filigree burns are:
• a. Deep, thick, regular markings on the skin
• b. Deep, thick, irregular markings on the skin
• c. Superficial, thin, regular markings on the skin
• d. Superficial, thin, irregular markings on the skin

• Ans: d, Superficial, thin, irregular markings on the skin
• Ref: Reddy, The essential of forensic medicine and toxicology 33rd edition, page number 334
• Arborescent or Filigree Burns: (Lichtenberg's flowers):
• •They are superficial, thin, irregular and tortuous markings on the skin.
• •These markings have a general pattern resembling the branches of a tree.
• •This fern-like pattern of erythema in the skin is usually found over the shoulders or the flanks.
• •It appears within few minutes to one hour of accident.

• Mechanism:
• •The mechanism by which this pattern hi occurs is not known.
• •It may be caused due to the slight staining of the tissues by haemoglobin from lysed red blood cells along the path of the electric current or rupture of smaller blood vessels at several places giving rise to ecchymoses.
• •They may be superficial bums producing mere erythema of skin which indicate the path taken by the current.
• •They are also said to be due to minute depositions of copper in the dermis or from boiling of the intercellular fluid following the fascial planes.

• Insular carcinoma is a variety of
• a. Papillary
• b. Medullary
• c. Anaplastic
• d. Follicular

• Ans: d
• Ref: Harrison’s Principles of Internal Medicine; 19th Edition, Page No: 2303

• Q1.Termination of pregnancy by Menstrual regulation method consists of aspiration of the contents of the uterine cavity by means of a plastic cannula (Karman’s cannula). It is carried out effectively within:
• a 14 days of the beginning of the last menstrual period (LMP)
• b.72 hours of the beginning of the last menstrual period (LMP)
• c. 28 days of the beginning of the last menstrual period (LMP)
• d. 42 days of the beginning of the last menstrual period (LMP)

Answer d. 42 days of the beginning of the last menstrual period (LMP)

• Ref: Shaw’s text book of gynecology, 15th edition, page number 288
• Menstrual Regulation method for termination of pregnancy:
• • Menstrual regulation consists of aspiration of the contents of the uterine cavity by means of a plastic cannula (Karman’s cannula).
• • It has a plastic 50 mL syringe capable of creating a vacuum of of 65 cm Hg.
• • It has a simple thumb-operated pressure control valve and piston locking handle.
• • It is independent of electricity, is portable and washable.
• • It is carried out effectively within 42 days of the beginning of the last menstrual period (LMP).
• • A paracervical local anaesthetic block or preoperative sedative alone usually suffices but sometimes
• • in an apprehensive patient, general anaesthesia with intravenous thiopentone sodium may be necessary.
• • This procedure can be performed in an office set-up, outpatient clinic, or day-care centre.
• • Since 1972, this method has been extensively evaluated and found to be efficient, safe, and easy to use in terminating early pregnancy.
• • It is a good practice to examine the products of conception.
• • The occasional complications encountered include failure to evacuate leading to continuation of pregnancy, incomplete evacuation, haemorrhage, cervical laceration, perforation, infection and anaesthetic complications.
• A failure to evacuate is due to:
• 1. Too early pregnancy.
• 2. Ectopic pregnancy.
• 3. Uterus bicornuate, aspiration being carried out in nonpregnant horn. Sometimes, tip of the cannula breaks but comes out in the next menstrual bleeding—and it may not be necessary to retrieve it.
• • RH anti-D globulin 100 mcg IM should be given to a RH negative non-immunized woman.

• Q2. The incidence of heterotopic pregnancy is higher in IVF programmes. Heterotopic pregnancy is:
• a. Ectopic pregnancy at two different site
• b. Combined abdominal and tubal pregnancy
• c. Twin pregnancy of different sex
• d. Combined uterine and ectopic tubal pregnancy

Answer d. Combined uterine and ectopic tubal pregnancy

Ref: Shaw’s text book of gynecology, 15th edition, page number 309

• Heterotopic Pregnancy
• • Heterotopic pregnancy, i.e. combined uterine and ectopic tubal pregnancy, is very rare in spontaneous conception cycles; the incidence is not more than 1:4000 to 1:7000 pregnancies.
• • The incidence is however higher in IVF programmes because of the higher number of embryo transfer, with one embryo migrating to the tube.
• • The incidence is also related to the amount of fluid injected with the embryo.
• • At present, IVF centres present an incidence of 1–3% of heterotopic pregnancy.
• The diagnosis is not easy.
• • The serum b-hCG may not be proportionately high.
• • Ultrasound can visualize multiple pregnancy in early pregnancy.
• • It is therefore mandatory to search for adnexal mass when pregnancy occurs in ART.
• Treatment
• • Medical treatment with mTX, mifepristone and prostaglandin are contraindicated because of their adverse effects on the normal uterine pregnancy.
• • Glucose and KCl may be used or surgery performed.
• • The treatment is preferably laparoscopic minimal invasive surgery, allowing uterine pregnancy to grow.
• In IVF programme, the following prophylactic measures have been suggested:
• • Bilateral tubectomy prior to IVF.
• • Transfer of not more than two embryos
• • A small amount of fluid medium to be transferred.
• • A routine ultrasound scanning in early pregnancy, incase conception follows

• Q3. A 65-year-old male is fall from tree and suddenly collapses. He is Unresponsive, you are doing cardiopulmonary resuscitation. What method should be used to open his airway if you suspect he had neck injury?
• a. Chin-lift
• b. Jaw thrust
• c. Head-tilt/ chin-lift
• d. Head-tilt

Answer b. Jaw thrust

Ref: Basic life support provider hand book (2015-2020 guidelines and standards) page number 10

• The jaw thrust is the maneuver of choice to open this patient’s airway given the concern of a fall and potential for traumatic injuries.
• Cardiopulmonary resuscitation steps:
• 1. Check for the carotid pulse on the side of the neck. Keep in mind to not waste time trying to feel for a pulse; feel for no more than 10 seconds. If you are not sure you feel a pulse, begin CPR with a cycle of 30 chest compressions and two breaths (Figure a).
• 2. Use the heel of one hand on the lower half of the sternum in the middle of the chest (Figure b).
• 3. Put your other hand on top of the first hand (Figure c).
• 4. Straighten your arms and press straight down (Figure d). Compressions should be at least two inches into the person’s chest and at a rate of 100 to 120 compressions per minute.
• 5. Be sure that between each compression you completely stop pressing on the chest and allow the chest wall to return to its natural position. Leaning or resting on the chest between compressions can keep the heart from refilling in between each compression and make CPR less effective.
• 6. After 30 compressions, stop compressions and open the airway by tilting the head and lifting the chin (Figure e & f).
• a. Put your hand on the person’s forehead and tilt the head back
• b. Lift the person’s jaw by placing your index and middle fingers on the lower jaw; lift up.
• c. Do not perform head-tilt/ chin lift if you suspect the person may have a neck injury. In that case the jaw-thrust is used.
• d. For the jaw-thrust maneuver, grasp the angles of the lower jaw and lift it with both hands, one on each side, moving the jaw forward. If their lips are closed, open the lower lip using your thumb.
• 7. Give a breath while watching the chest rise. Repeat while giving a second breath. Breaths should be delivered over one second.
• 8. Resume chest compressions. Switch quickly between compressions and rescue breaths to minimize interruptions in chest compressions.

• 1. Multiple motor tics often accompanied by vocalization, predominantly in males and patient can voluntarily suppress tics for short period of time but then experience an irresistible urge to express them. This is seen in:
• a. Tardive dyskinesia
• b. Huntington's disease
• c. Tourette's syndrome
• d. Psychogenic disorder

• Ans: c
• Ref: Harrison’s Principles of Internal Medicine; 20th Edition, Page No: 3138
• • TS is a neurobehavioral disorder named after the French neurologist Georges Gilles de la Tourette.
• • TS is characterized by multiple motor tics often accompanied by vocalizations (phonic tics).
• • Patients characteristically can voluntarily suppress tics for short periods of time, but then experience an irresistible urge to express them.
• • Tics vary in intensity and may be absent for days or weeks only to recur, occasionally in a different pattern.
• • Tics tend to present between ages 2 and 15 years (mean 7 years) and often lessen or even disappear in adulthood, particularly in males.
• • Associated behavioral disturbances include anxiety, depression, attention deficit hyperactivity disorder, and obsessive-compulsive disorder.

• 2. Inspiratory stridor is found in what kind of lesions:
• a. Supraglottic
• b. Subglottic
• c. Tracheal
• d. Bronchus

• Ans: a
• Ref: PL Dhingra and Shruti Dhingra ENT and HNS 7th Edition, Page No: 333
•  Inspiratory stridor is often produced in obstructive lesions of supraglottis or pharynx, e.g. laryngomalacia or retropharyngeal abscess.
•  Expiratory stridor is produced in lesions of thoracic trachea, primary and secondary bronchi, e.g. bronchial foreign body, and tracheal stenosis.
•  Biphasic stridor is seen in lesions of glottis, subglottis and cervical trachea, e.g. laryngeal papillomas, vocal cord paralysis and subglottis stenosis.

• 3. Glycogenin is a:
• a. Polypeptide
• b. Polysaccharide
• c. Lipid
• d. Glycosaminoglycan

• Ans: a
• Ref: Harper Biochemistry 30th Edition, Page No: 177
• • Glycogenin is a protein
• • 37 K Da protein
• • Glycogenin catalyzes transfer of 7 glucosyl residues from UDPGlucose, in alpha 1 → 4 linkage
• • Glucosyl residues are added on specific tyrosine residues of Glycogenin
• • Glycogenin remains at the core of Glycogen granule.

• 4. Empyema necessitans is defined as so when -
• a. Plural empyema is under pressure
• b. Pleural empyema has ruptured into bronchus
• c. Pleural empyema has ruptured into the pericardium
• d. Pleural empyema is showing extension to the subcutaneous tissue

• Ans: d
• Ref: SRB's Manual of Surgery; 5th Edition, Page No: 1120
• It is a complication of empyema thoracis, where in empyema which is not drained perforates through the chest wall presenting as subcutaneous collection of pus communicating directly or often with a tortuous route with the pleural cavity.
• Causes
• • Neglected empyema of tuberculous or non tuberculous etiology.
• • Following incomplete aspiration of pus of empyema through thin needle—needle track itself allows pus to form a track and leads to empyema necessitans.

• 1. Pricking injury to finger leads to: [KU 2019]
• a. Implantation dermoid
• b. Sequestration dermoid
• c. Sebaceous cyst
• d. Corn

• Ans: a
• Ref: SRB's Manual of Surgery; 5th Edition, Page No: 77
• Implantation dermoid is due to minor pricks or trauma, epidermis gets buried into the deeper subcutaneous tissue which causes reaction and cyst formation (trauma is forgotten often). It is an acquired cyst. It is common in fingers (common in tailors, gardeners), toes and feet.

• 2. KatG mutation occurs in: [KU 2018]
• a. Rifampicin
• b. Isoniazid
• c. Pyrazinamide
• d. Ethambutol

• Ans: b
• Ref: Katzung Pharmacology 12th Edition, Page No: 840
• Isoniazid inhibits synthesis of mycolic acids, which are essential components of mycobacterial cell walls. Isoniazid is a prodrug that is activated by KatG, the mycobacterial catalase-peroxidase. The activated form of isoniazid forms a covalent complex with an acyl carrier protein (AcpM) and KasA, a beta-ketoacyl carrier protein synthetase, which blocks mycolic acid synthesis and kills the cell.
• Resistance to isoniazid is associated with mutations resulting in overexpression of inhA , which encodes an NADH-dependent acyl carrier protein reductase; mutation or deletion of the katG gene; promoter mutations resulting in overexpression of ahpC , a putative virulence gene involved in protection of the cell from oxidative stress; and mutations in kasA . Overproducers of inhA express low-level isoniazid resistance and cross-resistance to ethionamide.
• KatG mutants express high-level isoniazid resistance and often are not cross-resistant to ethionamide.

• 3. Intercalary staphyloma is [KU 2011]
• a. Ectasia of sclera with incarceration of root of iris
• b. Ectasia of sclera with incarceration of choroid
• c. Ectasia of sclera with incarceration of ciliary body
• d. Ectasia of sclera with incarceration of iris

• Ans: a
• Ref: Parson Ophthalmology 22ndEdition, Page No: 229
• Intercalary Staphyloma
• • This is located at the limbus and is lined by the root of the iris and the anteriormost part of the ciliary body.
• • It is seen externally from the limbus to up to 2 mm behind the limbus.
• • The usual causes are lesions that produce weakening of the globe in this region such as perforating injuries of the peripheral cornea, marginal corneal ulcer, anterior scleritis, scleromalacia perforans, complicated cataract surgery with poor wound apposition and secondary glaucoma.

• 4. Zinc phosphide is a: [KU 2013]
• a. Contact poison
• b. Respiratory poison
• c. Stomach poison
• d. Hemotoxin

• Ans: b
• Ref: Gautam Biswas Forensic Medicine, 3rdEdition, Page No: 512
• • Zinc is normally present in our body. Poisonous salts are compounds of chloride, phosphide, sulfate (white vitriol), oxide and stearate.
• • Zinc chloride is used to clean metals before soldering. Zinc phosphide is used as rodenticide. Zinc stearate is used as a cosmetic (baby powder).
• • Zinc phosphide releases phosphine gas under acidic conditions in the stomach (similar to aluminum phosphide). In addition to the above features, the vomitus gives the smell of garlic. Dyspnea, lethargy, hypotension, cardiac arrhythmias, pulmonary edema, metabolic acidosis, convulsions, circulatory collapse, coma and death may be occur.
• • Zinc phosphide is hydrolyzed by the gastric acid and is transformed into phosphine gas. Phosphine is a respiratory toxin that inhibits cytochrome C oxidase system.